Split (1)

train · 72.2k rows

text stringlengths 11 320k	source stringlengths 26 161
Electrodiagnosis ( EDX ) is a method of medical diagnosis that obtains information about diseases by passively recording the electrical activity of body parts (that is, their natural electrophysiology ) or by measuring their response to external electrical stimuli ( evoked potentials ). [ 1 ] The most widely used methods of recording spontaneous electrical activity are various forms of electrodiagnostic testing ( electrography ) such as electrocardiography (ECG), electroencephalography (EEG), and electromyography (EMG). Electrodiagnostic medicine (also EDX) is a medical subspecialty of neurology , clinical neurophysiology , cardiology , and physical medicine and rehabilitation . Electrodiagnostic physicians apply electrophysiologic techniques, including needle electromyography and nerve conduction studies to diagnose , evaluate, and treat people with impairments of the neurologic, neuromuscular , and/or muscular systems. The provision of a quality electrodiagnostic medical evaluation requires extensive scientific knowledge that includes anatomy and physiology of the peripheral nerves and muscles , the physics and biology of the electrical signals generated by muscle and nerve, the instrumentation used to process these signals, and techniques for clinical evaluation of diseases of the peripheral nerves and sensory pathways. [ 2 ] In the United States, neurologists receive training in performing needle electromyography and nerve conduction studies during a fellowship in clinical neurophysiology or neuromuscular medicine. [ 3 ] [ 4 ] Physical medicine and rehabilitation physicians receive this training during their residency. [ 5 ] and can get further training in a neuromuscular fellowship. The American Board of Electrodiagnostic Medicine certifies US physicians in electrodiagnostic medicine. [ 6 ] In Europe, nerve conduction studies and electromyography training may be part of neurology, physical medicine and rehabilitation, or clinical neurophysiology training. In the United States, there is also a certification in neuromuscular medicine. This certification is open only to neurologists and physical medicine and rehabilitation specialists that have completed a fellowship in neuromuscular medicine. The neuromuscular medicine examination includes electrodiagnostic testing as part of the certification examination but also includes broader topics such as genetics, biopsy, and rehabilitation. [ 7 ] [ 8 ] Technologists sometimes assist in the performance of the NCSs but not the interpretation. In the United States, the Current Procedural Terminology code of the American Medical Association, states ""Waveforms must be reviewed on site in real time..." In addition, it states that the "Reports must be prepared on site by the examiner, and consists of the work product of the interpretation of numerous test results...along with summarization of clinical and electrodiagnostic data, and physician or other qualified health care professional interpretation. [ 9 ] Patients will typically be referred to a specialist in electrodiagnostic medicine if they have numbness, tingling, pain, weakness or spasms. Common muscle and nerve disorders seen by these types of specialists include pinched nerves in the neck or back ( radiculopathy ), carpal tunnel syndrome , and neuropathies. More uncommon diseases include ALS , myasthenia gravis , and chronic inflammatory demyelinating polyneuropathy . Using their broader training, physicians in electrodiagnostic medicine, often perform more detailed evaluations which may include laboratory tests, CT or MRI scans, genetic evaluation, biopsy of nerve, skin, or muscle, or perform neuromuscular ultrasound. A more complete listing of disorders and testing can be found under neuromuscular medicine . [ citation needed ] Clinical neurophysiology , is a broader field that includes EEG , intraoperative monitoring , nerve conduction studies , EMG and evoked potentials . [ 10 ] The American Board of Psychiatry and Neurology provides certification examination in clinical neurophysiology. The American Board of Electrodiagnostic Medicine provides certification in EDX medicines. [ 11 ] The American Board of Clinical Neurophysiology certifies in electroencephalography (EEG), Evoked Potentials (EP), Polysomnography (PSG), Epilepsy Monitoring, and Neurologic Intraoperative Monitoring (NIOM). [ 12 ] In the US physicians typically specialize in EEG or EDX medicine but not both. [ citation needed ] Electrodiagnostic medicine traces its origin back to a 1791 experiment by Luigi Galvani . Galvani depolarized frog leg muscles by using metal rods to make contact with the leg muscles. The development of the oscilloscope in 1897 significantly enhanced the ability of scientists to record signals from nerve and muscle. However, it was the needs of those with severe injuries during World War II that created the field of modern electrodiagnostic medicine. In the early 1950s, the first society dedicated to the development of this field, the AAEE, was founded in Chicago by a group of interested specialists in neurology and physical medicine and rehabilitation. James Golseth was instrumental in creating this organization. [ 13 ] Over time, newer techniques, such as somatosensory evoked potentials, single fiber electromyography, autonomic testing, and neuromuscular ultrasound have evolved as useful complementary techniques to nerve conduction studies and elecytromyography, which remain the core of electrodiagnostic medicine. [ citation needed ]	https://en.wikipedia.org/wiki/Electrodiagnostic_medicine
Electromyoneurography (EMNG) is the combined use of electromyography and electroneurography [ 1 ] This technique allows for the measurement of a peripheral nerve's conduction velocity upon stimulation (electroneurography) alongside electrical recording of muscular activity (electromyography). Their combined use proves to be clinically relevant by allowing for both the source and location of a particular neuromuscular disease to be known, and for more accurate diagnoses. Electromyoneurography is a technique that uses surface electrical probes to obtain electrophysiological readings from nerve and muscle cells. The nerve activity is generally recorded using surface electrodes, stimulating the nerve at one site and recording from another with a minimum distance between the two. The time difference of the potential is a measure of the time taken for the potential to travel the distance across the two sites and is a measure of the conduction velocity along the nerve. The amplitude of the potential , measured baseline to peak, or peak to peak, is a measure of the number of fibers conducting the response. Abnormality in data obtained from nerve measurements, such as absent or low amplitude, indicates potential nerve damage. [ 2 ] This technique is used in many medical fields today. One example of its use is to detect neuropathy due to diseases like diabetes mellitus . [ 3 ] It can also be used to detect muscle weakness or paralysis due to sepsis or multi-organ failure in comatose patients. [ 4 ] This method remains a largely used medical technique due to its efficiency and relative simplicity. It is especially attractive due to the lack of special precautions or preparation involved with this procedure. There is minimal pain and no significant risks except those associated with needle use. [ 5 ] The technique of electromyoneurography was first practiced in the late 1970s by the American Academy of General Practice . The use of this technique enhances diagnostic capability by defining and localizing the target site. In 1978, Milton B. Spiegel, research physician with The Rehabilitation Institute of South Florida, wrote one of the first major academic papers surrounding the uses and benefits of electromyoneurography. It was in this paper that Dr. Spiegel suggested that pre-examination of the patients' range of motion and reflexes would eliminate time and exploration of nerve entrapments during the electromyoneurographic procedure. [ 1 ] In the early 1980s, the practice of utilizing electromyoneurography became more widely accepted in the medical community, specifically aiding in the diagnoses of neuropathy , radiculopathy , and axonopathy . As to more recent use, electromyoneurography has been employed throughout the 21st century, aiding in the diagnosis of carpal tunnel syndrome, abnormal glucose levels, and many other myopathies. This procedure now analyzes the nerve conduction and muscle potentials through the use of H-Reflex and F-Wave studies. Combined with a pre-examination, electromyoneurography is utilized to detect neuromuscular abnormalities. [ 6 ] Electromyoneurography has a variety of modern applications. The high level of sensitivity that electromyoneurography employs makes it ideal for detecting peripheral nerve damage as well as a variety of myopathies in their early stages. This electrophysiological data obtaining technique has been able to heighten diagnostic capabilities when looking at peripheral neuropathy disorders like radiculopathy , and axonopathy in addition to myopathies such as muscular dystrophy , myotonia , and myasthenia gravis . [ 1 ] Electromyoneurography was the main technique used in a study to detect diabetic polyneuropathy, a serious condition that is progressive in nature. [ 7 ] Electromyoneurography can also be used to measure patient recovery from surgical procedures, such as nerve repair. A study conducted on patients with proximal radial nerve injuries used the procedure to indicate the degree of both pre- and postoperative nerve damage. [ 8 ] In this particular study, electromyoneurography was the preferred method of measuring recovery, chosen over magnetic resonance imaging ( MRI ) and computed tomography ( CT ) scans. When looking at the sample data table, one can see that postoperative patients generally see an increase in mean radial nerve amplitude, a decrease in mean radial nerve latency and increases in nerve motor conduction velocity. These results are all general trends that would be expected when operating on damaged nerves in effort to increase their performance. [ citation needed ] Electromyoneurography's unique combination of recording in muscle and nerve simultaneously typically results in a higher level of diagnostic ability in the field of medicine. This heightened utility often results in a lesser demand for more invase techniques for acquiring electrophysiological data, such as myelography, [ 1 ] a procedure where complications are not uncommon and the amount of attention required for post-operative care is more involved. Electromyoneurography has been found to be particularly useful in diagnosing the following neuromuscular conditions, though it is not an exhaustive list: In an electromyoneurography procedure, recording of the muscle is done by insertion of a needle. The recordings are taken when the muscle is at rest and when the muscle is contracting; the muscle will contract based on the directions of the one performing the test (instructing the patient to move certain body parts in certain directions forming muscle contractions). Various regions of muscle on the body are examined in an electromyoneurography test and the procedure lasts anywhere between 30 and 60 minutes (2–5 minutes per muscle). In addition to examining the muscles, the conduction velocity of nerve signals are measured. The nerve's ability to transmit signals is tested by inserting recording electrodes to capture the data and signal electrodes to initiate signals down a nerve by applying a small shock. Self-generated potentials also occur naturally for recording, in addition to the artificial "shock". Evaluating a nerve's conduction velocity, together with testing potentials, allows for a beneficial diagnosis that can detect pain and sensory problems at the neuromuscular level. [ 5 ] The needle is normally attached to a recording device known as an electromyography machine. The results show the appearance of action potential or graded potential spikes. While interpretation of the results requires background knowledge, irregular data can be used to diagnose many diseases. If the activity of the nerves at rest is abnormal, this may indicate nerve lesion , radiculopathy , or lower motor nerve degeneration . The amplitude or duration of the potential spike may also be used to gather information. A decreased amplitude or duration may indicate nerve damage due to a muscle diseases, whereas an increase in these demonstrates reinervation, or repair by new nerve connections to the muscles, has occurred. [ 5 ]	https://en.wikipedia.org/wiki/Electromyoneurography
The Electronic Medicines Compendium is a provider of information on medicines, produced by Datapharm . It lists summaries of product characteristics and patient information leaflets . [ 1 ] [ 2 ] This medical article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Electronic_Medicines_Compendium
An electronic apex locator is an electronic device used in endodontics to determine the position of the apical constriction and thus determine the length of the root canal space. The apex of the root has a specific resistance to electrical current, and this is measured using a pair of electrodes typically hooked into the lip and attached to an endodontic file . The electronic principle is relatively simple and is based on electrical resistance; when a circuit is complete (tissue is contacted by the tip of the file), resistance decreases markedly and current suddenly begins to flow. Various devices signal this event by a beep, a buzz, a flashing light, digital readouts, or a pointer on a dial. The original electronic apex locators operated on the direct current principle. A problem with these devices was that conductive fluids such as hemorrhage, exudate, or irrigant in the canal would permit current flow and therefore a false reading. Newer devices are impedance-based, using alternating current of two frequencies;these measure and compare two electrical impedances that change as the file moves apically. The benefit is that these devices are much less affected by fluid conductive media in the canal. The impedance type apex locators have been demonstrated to be 80 to 95% accurate in identifying the apical foramen. Therefore after obtaining a reading, 1 to 2 mm is subtracted as the corrected working length. Electronic apex locators have been shown to be more accurate than radiography when determining the position of the apical foramen. All apex locators have two electrodes , one is connected to an endodontic instrument, the other is connected to the patient's body (on the lip or an electrode in his hand). The electrical circuit is completed, when the instrument is introduced into the root canal in an apical direction, and touches the periodontal tissues. [ citation needed ] Adaptive Apex Locator overcomes as the disadvantages of the popular 4th generation apex locators – low accuracy on working in wet canals, as well the disadvantages of devices from previous generations. Though, fifth generation locators can experience difficulty when working in dry canals and require additional wetting. [ 1 ] Adaptive Apex Locator continuously defines humidity of the canal and immediately adapts for dry or wet canal. On this way is possible to be measured as in dry and in additional wetted canals as well, canals with blood or exudates, canals with still not-extirpated pulp. This dentistry article is a stub . You can help Wikipedia by expanding it . This article related to medical equipment is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Electronic_apex_locator
Electronic prescription ( e-prescribing or e-Rx ) is the computer-based electronic generation, transmission, and filling of a medical prescription , taking the place of paper and faxed prescriptions. E-prescribing allows a physician , physician assistant , pharmacist , or nurse practitioner to use digital prescription software to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy . It outlines the ability to send error-free, accurate, and understandable prescriptions electronically from the healthcare provider to the pharmacy. E-prescribing is meant to reduce the risks associated with traditional prescription script writing. It is also one of the major reasons for the push for electronic medical records . By sharing medical prescription information, e-prescribing seeks to connect the patient's team of healthcare providers to facilitate knowledgeable decision making. [ 1 ] An e-prescribing system used in the United States must be capable of performing all of the following functions: [ 2 ] [ 3 ] [ 4 ] The basic components of an electronic prescribing system are the: [ 3 ] The PBM and transaction hub work closely together. The PBM works as an intermediate actor to ensure the accuracy of information, although other models may not include this to streamline the communication process. In addition to pharmacies, medical tests can also be prescribed. The prescriber, generally a clinician or healthcare staff, is defined as the electronic prescribing system user and sign into the system through a verification process to authenticate their identity. [ 3 ] The prescriber searches through the database of patient records by using patient-specific information such as first and last name, date of birth, current address etc. Once the correct patient file has been accessed, the prescriber reviews the current medical information and uploads or updates new prescription information to the medical file. [ 3 ] The transaction hub provides the common link between all actors (prescriber, pharmacy benefit manager, and pharmacy). It stores and maintains a master patient index for quick access to their medical information as well as a list of pharmacies. [ 3 ] When the prescriber uploads new prescription information to the patient file, this is sent to the transaction hub. The transaction hub will verify against the patient index. This will automatically send information about this transaction to the PBM, who will respond to the hub with information on patient eligibility, formulary, and medication history back to the transaction hub. The transaction hub then sends this information to the prescriber to improve patient management and care by completing and authorizing the prescription. Upon which, the prescription information is sent to the pharmacy that the patient primarily goes to. [ 3 ] When a pharmacy receives the prescription information from the transaction hub, it will send a confirmation message. The pharmacy also has the ability to communicate to the prescriber that the prescription order has been filled through the system. Further system development will soon allow different messages such as a patient not picking up their medication or is late to pick up medication to improve patient management. [ 3 ] When an imaging center receives the prescription, the imaging center will then contact the patient and schedule the patient for his/her scan. The advantage of ePrescribing radiology is that often when a patient is handed a paper script, the patient will lose the prescription or wait to call and schedule. This can be disastrous for patients with severe underlying conditions. The imaging center will call and schedule the patient as soon as the referral arrives. There are mobile ePrescribing portals as well as web portals that handle this well, and there are advantages. [ 5 ] Compared to paper-based prescribing, e-prescribing can improve health and reduce costs because it can: [ 2 ] [ 6 ] Safety improvements are highly desirable; in 2000, the Institute of Medicine identified medication errors as the most common type of medical error in health care, estimating that this leads to several thousand deaths each year. [ 8 ] Illegibility from handwritten prescriptions is eliminated, decreasing the risk of medication errors while simultaneously decreasing risks related to liability. Oral miscommunications regarding prescriptions can be reduced, as e-prescribing should decrease the need for phone calls between prescribers and dispensers. Causes of medication errors include mistakes by the pharmacist incorrectly interpreting illegible handwriting or ambiguous nomenclature, and lapses in the prescriber's knowledge of desired dosage of a drug or undesired interactions between multiple drugs. Electronic prescribing has the potential to eliminate most of these types of errors. Warning and alert systems are provided at the point of care. E-prescribing systems can enhance an overall medication management process through clinical decision support systems that can perform checks against the patient's current medications for drug-drug interactions, drug-allergy interactions, diagnoses, body weight, age, drug appropriateness, and correct dosing. Based on these algorithms, the system can alert prescribers to contradictions, adverse reactions, and duplicate therapies. The computer can also ensure that clear and unambiguous instructions are encoded in a structured message to the pharmacist, and decision support systems can flag lethal dosages and lethal combinations of drugs. [ 7 ] E-prescribing allows for increased access to the patient's medical records and their medication history. Having access to this information from all health care providers at the time of prescribing can support alerts related to drug inappropriateness, in combination with other medications or with specific medical issues at hand. Electronic prescribing has been shown to reduce prescribing errors by up to 30%. [ 9 ] According to estimates, almost 30 percent of prescriptions require pharmacy callbacks. [ 10 ] This translates into less time available to the pharmacist for other important functions, such as educating consumers about their medications. In response, E-prescribing can significantly reduce the volume of pharmacy call-backs related to illegibility, mistaken prescription choices, formulary and pharmacy benefits, decreasing the amount of time wasted on the phone. This ultimately impacts office workflow efficiency and overall productivity in a positive manner. Both prescribers and pharmacists can save time and resources spent on faxing prescriptions through a reduction in labor costs, handling costs, and paper expenses waste due to unreliability. With e-prescribing, renewal authorization can be an automated process that provides efficiencies for both the prescriber and pharmacist. Pharmacy staff can generate a renewal request (authorization request) that is delivered through the electronic network to the prescriber's system. The prescriber can then review the request and act accordingly by approving or denying the request through updating the system. With limited resource utilization and just a few clicks on behalf of the prescriber, they can complete a medication renewal task while enhancing continuous patient documentation. It is estimated that 20% of paper-based prescription orders go unfilled by the patient, partly due to the hassle of dropping off a paper prescription and waiting for it to be filled. By elimination or reducing this waiting period, e-prescribing may help reduce the number of unfilled prescriptions and hence, increasing medication adherence. Allowing the renewal of medications through this electronic system also helps improve the efficiency of this process, reducing obstacles that may result in less patient compliance. Availability of information on when patient's prescriptions are filled can also help clinicians assess patient adherence. Improved prescriber convenience can be achieved when using mobile devices, that work on a wireless network, to write and renew prescriptions. Such mobile devices may include laptops, PDAs, tablet computers, or mobile phones. This freedom of mobility allows prescribers to write/renew prescriptions anywhere, even when not in the office. E-prescribing systems enable embedded, automated analytic tools to produce queries and reports, which would be close to impossible with a paper-based system. Common examples of such reporting would be: finding all patients with a particular prescription during a drug recall, or the frequency and types of medication provided by certain health care providers. Although e-prescribing has the ability to streamline workflow process and increase the system's efficiency, challenges and limitations that may hinder the widespread adoption of e-prescribing practices include: [ 2 ] The vast majority of community medical prescriptions in Australia continue to be delivered on paper, either in printed or hand-written format. Electronic prescription in Australia is currently provided by two service providers, MediSecure and eRx. Both services can be integrated into many of the existing clinical and pharmacy prescribing software systems. Since December 1991, they have become interoperable allowing bilateral transfer of information. [ 17 ] [ 18 ] [ 19 ] Private companies started working with electronic prescriptions. On 2017 July easypres.com launched Bangladesh's [ 20 ] first cloud-based electronic prescription and patient management software for Doctors in Bangladesh. [ 21 ] Within a year, more than a thousand doctors registered for the software out of 83 thousand registered MBBS doctors in Bangladesh for this Digital prescription writing software. High court of Bangladesh issued a rule that doctors need to write the prescription in readable format meaning they need to use software of ALL caps later while writing prescription. This software also stores the medical history of patients and doctors can access these data easily from anywhere using the Internet. On March 22, 2016, the Government of Canada allocated funds to Canada Health Infoway to develop an e-prescribing service. [ 22 ] Infoway is working with Health Canada, the provinces and territories and industry stakeholders to create PrescribeIT, a multi-jurisdiction e-prescribing service. Infoway will create, operate and maintain the service, along with its partners. The service will be financially self-sustaining and is designed to be scaled across the country and will enable prescribers to electronically transmit a prescription to a patient's pharmacy of choice. [ 23 ] Physicians, physician assistants, nurse practitioners and other prescribers will be able to use the system either through their existing electronic medical record or through a standalone application. Health Canada included supporting better prescribing practices, including e-prescribing, as part of its Action on Opioid Misuse plan. [ 24 ] Until recently in Canada, it was the position of Health Canada that, to allow for e-prescribing, amendments to Part C of the Food and Drugs Regulations made under the Food and Drugs Act, regulations made under the Controlled Drugs and Substances Act and possibly regulations made under Personal Information Protection and Electronic Documents Act would be required. After further review, Health Canada has concluded that there are currently no regulatory impediments to moving ahead with electronically generated and transmitted prescriptions and that these are permissible to the extent that they achieve the same objectives as written prescriptions. Provinces and territories wishing to proceed with e-prescribing are obligated to ensure that electronic prescriptions meet existing regulatory requirements and achieve the same objectives as written prescriptions. For example, there must be evidence of a genuine practitioner/patient relationship, and in the case of controlled substances, pharmacists filling prescriptions must verify prescriptions are signed by the practitioner before selling or providing drugs containing controlled substances to a patient. Health Canada has collaborated with Canada Health Infoway on the development of a technical document entitled Ensuring the Authenticity of Electronic Prescriptions, in order to provide advice about how to ensure the authenticity of electronic signatures. [ 25 ] The Czech healthcare system is moving towards a mandatory electronic prescribing system to take effect in 2020. Patients and clinicians will have access to the prescribing records. Codes and names of medications are allocated by the State Institute for Drug Control . [ 26 ] Electronic prescriptions were introduced in Estonia in January 2010 [ 27 ] and by mid-2013, 95% of all prescriptions in the country were being issued electronically. [ 28 ] e-Prescription, is a centralized paperless system for issuing and handling medical prescriptions. When a doctor prescribes medicine using the system, he or she does so electronically, with the aid of an online form. At the pharmacy, all a patient needs to do is present an ID-card. The pharmacist then retrieves the patient's information from the system and issues the medicine. Because the e-Prescription system draws on data from the national health insurance fund, any state medical subsidies that the patient is entitled to, also appear, and the medicine is discounted accordingly. Another major advantage of the system is that doctor visits are no longer needed for repeat prescriptions. A patient can contact the doctor by e-mail, Skype or phone, and the doctors can issue repeats with just a few clicks, and the patient can collect the medicine from their closest pharmacy. 99% of all prescriptions in the country are issued electronically. This frees up time for patients and doctors, and reduces administrative strain on hospitals. The use of electronic prescription has been designated as an important strategic policy to improve health care in Europe. The aim of the European Union is to have a cross-border electronic healthcare system in Europe which will enable EU citizens to obtain e-Prescriptions anywhere in Europe. The Scandinavian countries are leading Europe in deploying e-Prescription. Other countries which use the prescription process routinely are Norway, Denmark, Finland, Sweden, Belgium, [ 29 ] the Netherlands, Italy, [ 30 ] Iceland, Greece, England, Scotland, Wales and Northern Ireland. The European Union is pushing for more cross border health data exchange. Multiple perceived barriers impede its incorporation in clinical practice. There are varying interpretations and implementations of data protection and confidentiality laws in the 27 member states. Infrastructures are not in place to support the system and stakeholders in some jurisdictions are reluctant to embrace e-health due to the high cost and the lack of security of the systems. Interoperability of different systems is only a partial solution. Security and enforcement of privacy must also be equally enforced. [ 31 ] In India some private hospitals started using electronic prescription. But a major step was taken by government of West Bengal in August 2014 when they started the process of issuing e-prescriptions instead of hand-written instructions in top government hospitals. The biggest advantage of the system is that a patient has all his medical data stored in the server of state health department which can be referred to in future. In the private sector, a number of companies have started initiatives to build software to support e-prescriptions. With the development and implementation of electronic technologies in Russian healthcare system, electronic prescription became part of the project called EMIAS . EMIAS is the digital system designed to increase the quality and access of the medical aid in the public health facility. The project was designed and being implemented as part of «Digital city» program in execution of the Moscow Government's order from April 7, 2014 (as Moscow government amended on 21.05.2013 No. 22-PP). The system offers special portal Emias.Info , that provides appointment service to the patients and client area with different services including e-Prescription. Government social program allows getting pharmaceutical products for free or with the discount, depending on the category of the citizen. About 420 million repeat prescriptions are generated in the UK each year - about 200 for each general practitioner each week. They account for about 80% of the cost of medication in primary care. Paper based Repeat Dispensing Services were introduced by the NHS in 1991, and in 1992 it became possible to use the NHS Electronic Prescription Service for this purpose. In 2017 awareness of the scheme among patients was low. [ 32 ] In October 2017 Keith McNeil, NHS England 's chief clinical information officer demanded that NHS hospitals should be moved rapidly onto electronic prescribing in the light of research showing it would cut serious prescribing errors by more than half. There was no information about the extent to which it is happening in hospitals. [ 33 ] After successful pilots in London and the East Midlands it was agreed in April 2018 that electronic prescribing should be introduced in all urgent care settings in England, including NHS 111 and other Out-of-hours services so that dispensed medication can be ready for collection at a pharmacy when patients arrive. [ 34 ] £78 million was allocated in December 2018 to encourage progress with implementing electronic prescribing in NHS organisations which were struggling. [ 35 ] Electronic prescribing is to start in English hospitals in the summer of 2022, using the IC24 system which was piloted at Midlands Partnership NHS Foundation Trust from 2020. [ 36 ] In the United States, the HITECH Act promotes adoption of this technology by defining e-prescribing as one meaningful use of an electronic medical record . [ 37 ] Standards for transmitting, recording, and describing prescriptions have been developed by the National Council for Prescription Drug Programs , in particular the SCRIPT standard, which describes data formats. Elsewhere in the world, health care systems have been slower to adopt e-prescribing standards. [ 38 ] Adoption of e-prescribing technology has accelerated in the United States, in large part, due to the arrival of Stage 2 of meaningful use. One of the Stage 2 core measures is: "Generate and transmit permissible prescriptions electronically (e-Rx.)" In order to meet this measure, practices must prescribe and transmit at least 50 percent of permissible prescriptions electronically. [ 39 ] According to data released in May 1991 by Surescripts, a company which operates the nation's largest health information (e-prescribing) network, roughly 317,000 office-based physicians now e-prescribe in the United States. [ 40 ] A more recent report released by the Office of the National Coordinator for Health IT in June 2012 finds that 48 percent of U.S. physicians use e-prescribing systems. National growth in e-prescribing over the period September 2008 through June 2012 increased over 40 percent, with individual states increasing adoption anywhere from 28 percent to 70 percent. [ 41 ] In 2019, the Federal Trade Commission sued Surescripts, alleging that the company employed unlawful restraints in order to maintain its monopolies over electronic prescribing. [ 42 ] [ 43 ] Starting from April 2019, ePrescription is one of the key components of the reimbursement system in Ukraine. [ 44 ] The e-prescription module integrates all primary care physicians (over 23,000 doctors) and almost 50% of pharmacies across the country. [ 45 ] [ 46 ] While the launch of e-prescription was done quickly, the quality was not compromised. The development of the tool was completed according to international standards as well as HL7 FHIR medical data requirements. Ukrainian eHealth system is a two layer system with central core component developed as storage of dictionaries and rules and private IT-companies who offers e-prescription's functionality through interfaces of the doctors and pharmacists. [ 47 ] [ 48 ] The e-prescription code is open and available. [ 49 ] As a next step of expansion of eRx functions in Ukraine, Ministry of Health of Ukraine develop the technical requirement for substitution of oldfashion, paper-based prescriptions with digital eRx for all applicable medicines. [ 50 ] A study in the UK tested the Salford Medication Safety Dashboard (SMASH), a web application to help GPs and pharmacists find people in their electronic health records who might face safety hazards due to prescription errors. The dashboard was successfully used in identifying and helping patients with already registered unsafe prescriptions and later it helped monitoring new cases as they appeared. [ 51 ] [ 52 ]	https://en.wikipedia.org/wiki/Electronic_prescribing
Electronic visit verification ( EVV ) is a method used to verify home healthcare visits to ensure patients are not neglected and to cut down on fraudulently documented home visits. Beginning January 1, 2020, home care agencies that provide personal care services must have an EVV solution in place or risk having their Medicaid claims denied, under a mandate included in the 21st Century Cures Act. [ 1 ] While the federal mandate sets key data points that must be collected and electronically verified, states create their own systems. State governments decide how to gather and report data that EVV vendors use, and whether to include additional EVV compliance rules. [ 2 ] Electronic visit verification was created to help cut down on fraud and ensure that people receive the documented care they need. EVV was designed to help verify that services billed for home healthcare are for actual visits made. [ 3 ] The passing of the Affordable Care Act signed into law in 2010 made provisions for the cut down of fraud and over-payments, requiring states to stop Medicaid payments to providers when there is credible evidence of fraud. [ 4 ] At least 10 states implemented an office of inspector general to oversee Medicaid fraud investigations, with many moving towards a system of verifying home healthcare visits in order to help reduce fraud. [ 4 ] Several states have introduced electronic visit verification with some mandating it for home healthcare. [ 5 ] In January 2014, Illinois became the first state to mandate the use of EVV when the Department of Human Services required it for its home services program. [ 6 ] As of June 1, 2015, the Texas Health and Human Services Commission mandates that electronic visit verification be used for all home healthcare visits billed to the state. [ 3 ] The state of Ohio began the process of implementing an electronic verification system that would be used starting in 2016. [ 7 ] It estimated the use of EVV will save the state approximately $9.5 million in its first two years of use. [ 8 ] Other states that use but do not mandate EVV include Louisiana , [ 9 ] Alaska , [ 10 ] and Tennessee . [ 4 ] Electronic visit verification is widely used throughout the healthcare industry, not solely by government entities. Companies use it for compliance and quality assurance. [ 11 ] Employers of home healthcare providers use it to verify employee's locations as well as document patient care. [ 12 ] It can also be used to verify hours of work and document time sheets for healthcare workers. [ 12 ] Health care fraud includes health insurance fraud, drug fraud , and medical fraud . Health insurance fraud occurs when a company or an individual defrauds an insurer or government health care program, such as Medicare (United States) or equivalent State programs. The manner in which this is done varies, and persons engaging in fraud are always seeking new ways to circumvent the law. Damages from fraud can be recovered by use of the False Claims Act , most commonly under the qui tam provisions which rewards an individual for being a " whistleblower ", or relator (law) . [ 13 ] Electronic visit verification is mainly done through the use of GPS tracking and computer software. It can also include the use of telephone based systems where healthcare workers can call-in from each location. [ 7 ] GPS can be used to track the location of nurses, or a "check-in" system can be used requiring healthcare providers to clock in when they are at a home visit. [ 14 ] EVV is also used by employers to track employees and determine their compensation. Electronic visit verification software integrates with payroll systems that allow companies to verify payroll of its nurses. [ 6 ] Many EVV software providers employ a cloud-based system that integrates with a mobile app to coordinate schedules, billing, payroll, communication, and patient documentation. [ 15 ] Nurses can update patient files with the system while also submitting working hours to their employers. [ 15 ] In contrast, companies such as First Data provide a telephone and computer-based system for verification, [ 9 ] similar to the system implemented in the state of Texas in 2015. [ 16 ]	https://en.wikipedia.org/wiki/Electronic_visit_verification
A cardiac electrophysiology study ( EP test or EP study ) is a minimally invasive procedure using catheters introduced through a vein or artery to record electrical activity from within the heart . [ 1 ] This electrical activity is recorded when the heart is in a normal rhythm ( sinus rhythm ) to assess the conduction system of the heart and to look for additional electrical connections ( accessory pathways ), and during any abnormal heart rhythms that can be induced. [ 2 ] EP studies are used to investigate the cause, location of origin, and best treatment for various abnormal heart rhythms, and are often followed by a catheter ablation during the same procedure. [ 3 ] It is important for patients not to eat or drink for up to 12 hours before the procedure. This is to prevent vomiting, which can result in aspiration, and also cause severe bleeding from the insertion site of the catheter. Failure to follow this simple preparation may result in dangerous consequences. In general, small amounts of water can be consumed up to 2 hours before the exam. Patients should try to schedule the exam at a time when they will be having symptoms and will not need to drive for 2 to 3 days. If the reason for the EP study is for an arrhythmia, then antiarrhythmic drugs may be held to increase the likelihood of being able to induce the rhythm. Additionally, beta blockers or calcium channel blockers may be held as well. Anticoagulants may be held or continued depending on the scenario. An EP study is typically performed in an EP lab (a specialized cath lab ). These are specially equipped operating rooms that usually contain: [ 3 ] The procedure may be performed awake under local anaesthetic , or under general anaesthetic . Monitoring equipment is attached including an automated blood pressure cuff and a pulse oximeter to measure the oxygen saturation of the blood. A peripheral venous cannula is generally inserted to allow medication to be given such as sedatives , anesthesia , or drugs. [ 3 ] An access site that will allow catheters to be passed to the heart via an artery or vein is shaved and cleaned, usually in the groin . The blood vessels used to reach the heart (the femoral or subclavian veins , and sometimes the femoral artery ) are punctured before a guidewire and plastic sheath are inserted into the vessel using the Seldinger technique . [ 3 ] Once the catheter is in and all preparations are complete elsewhere in the lab, the EP study begins. The X-ray machine will give the doctor a live view of the heart and the position of the electrodes. He will guide the (steerable) electrodes to the correct position inside the heart. The electrophysiologist begins by moving the electrodes along the conduction pathways and along the inner walls of the heart, measuring the electrical activity along the way. The next step is pacing the heart, this means he/she will speed up or slow down the heart by placing the electrode at certain points along the conductive pathways of the heart and control the depolarization rate of the heart. The doctor will pace each chamber of the heart one by one, looking for any abnormalities. Then the electrophysiologist tries to provoke arrhythmias and reproduce any conditions that have resulted in the patient's placement in the study. This is done by injecting electric current into the conductive pathways and into the endocardium at various places. Last, the electrophysiologist may administer various drugs ( proarrhythmic agents ) to induce arrhythmia (inducibility of VT/VF [ 4 ] ). If the arrhythmia is reproduced by the drugs (inducible), the electrophysiologist will search out the source of the abnormal electrical activity. The entire procedure can take several hours. If at any step during the EP study the electrophysiologist finds the source of the abnormal electrical activity, they may try to ablate the cells that are misfiring. This is done using high-energy radio frequencies (similar to microwaves ) to effectively heat up the abnormal cells, to form scar tissue. This can be painful with pain felt in the heart itself, the neck and shoulder areas. A more recent method of ablation is cryoablation , which is considered less risky and less painful. [ 5 ] When the necessary procedures are complete, the catheter is removed. Firm pressure is applied to the site to prevent bleeding. This may be done by hand or with a mechanical device. Other closure techniques include an internal suture and plug. If the femoral artery was used, the patient will probably be asked to lie flat for several hours (3 to 6) to prevent bleeding or the development of a hematoma . Trying to sit up or even lift the head is strongly discouraged until an adequate clot has formed. The patient will be moved to a recovery area where he/she will be monitored. For patients who had a catheterization at the femoral artery or vein (and even some of those with a radial insertion site), in general recovery is fairly quick, as the only damage is at the insertion site. The patient will probably feel fine within 8 to 12 hours after the procedure, but may feel a small pinch at the insertion site. After a short period of general rest, the patient may resume some minor activity such as gentle, short, slow walks after the first 24 hours. If stairs must be climbed, they should be taken one step at a time and very slowly. All vigorous activity must be postponed until approved by a physician. It is also important to note that unless directed by a doctor, some patients should avoid taking blood thinners and foods that contain salicylates, such as cranberry-containing products until the clot has healed (1–2 weeks). As with any surgical procedure, cardiac catheterizations come with a generic list of possible complications. One of the complications that are sometimes reported involves some temporary nerve involvement. Sometimes a small amount of swelling occurs that can put pressure on nerves in the area of the incision. Venous thrombosis is the most common complication with an incidence ranging between 0.5 and 2.5%. [ 6 ] There have been reports of patients feeling like they have hot fluid like blood or urine running down their leg for up to a month or two after the incision has healed. This usually passes with time, but patients should tell their doctor if they have these symptoms and if they last. More severe but relatively rare complications include: damage or trauma to a blood vessel, which could require repair; infection from the skin puncture or from the catheter itself; cardiac perforation, causing blood to leak into the sac around the heart and compromising the heart's pumping action, requiring removal using a needle under the breast bone (pericardiocentesis); hematoma at the site(s) of the puncture(s); induction of a dangerous cardiac rhythm requiring an external shock(s); a clot may be dislodged, which may travel to a distant organ and impede blood flow or cause a stroke; myocardial infarction; unanticipated reactions to the medications used during the procedure; damage to the conduction system, requiring a permanent pacemaker; death.	https://en.wikipedia.org/wiki/Electrophysiology_study
Electrosurgery is the application of a high-frequency (radio frequency) alternating polarity, electrical current to biological tissue as a means to cut, coagulate , desiccate , or fulgurate tissue. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] (These terms are used in specific ways for this methodology—see below.) Its benefits include the ability to make precise cuts with limited blood loss. Electrosurgical devices are frequently used during surgical operations helping to prevent blood loss in hospital operating rooms or in outpatient procedures. [ 8 ] In electrosurgical procedures, the tissue is heated by an electric current . Although electrical devices that create a heated probe may be used for the cauterization of tissue in some applications, electrosurgery refers to a different method than electrocautery . Electrocautery uses heat conduction from a probe heated to a high temperature by a direct electrical current (much in the manner of a soldering iron). This may be accomplished by direct current from dry-cells in a penlight-type device. Electrosurgery, by contrast, uses radio frequency (RF) alternating current to heat the tissue by RF induced intracellular oscillation of ionized molecules that result in an elevation of intracellular temperature. When the intracellular temperature reaches 60 degrees C, instantaneous cell death occurs. If tissue is heated to 60–99 degrees C, the simultaneous processes of tissue desiccation (dehydration) and protein coagulation occur. If the intracellular temperature rapidly reaches 100 degrees C, the intracellular contents undergo a liquid to gas conversion, massive volumetric expansion, and resulting explosive vaporization. Appropriately applied with electrosurgical forceps, desiccation and coagulation result in the occlusion of blood vessels and halting of bleeding. While the process is technically a process of electrocoagulation , the term "electrocautery" is sometimes loosely, nontechnically and incorrectly used to describe it. The process of vaporization can be used to ablate tissue targets, or, by linear extension, used to transect or cut tissue. While the processes of vaporization/ cutting and desiccation/coagulation are best accomplished with relatively low voltage, continuous or near continuous waveforms, the process of fulguration is performed with relatively high voltage modulated waveforms. Fulguration is a superficial type of coagulation, typically created by arcing modulated high voltage current to tissue that is rapidly desiccated and coagulated. The continued application of current to this high impedance tissue results in resistive heating and the achievement of very high temperatures—enough to cause breakdown of the organic molecules to sugars and even carbon, thus the dark textures from carbonization of tissue. Diathermy is used by some as a synonym for electrosurgery but in other contexts diathermy means dielectric heating , produced by rotation of molecular dipoles in a high frequency electromagnetic field. This effect is most widely used in microwave ovens or some tissue ablative devices which operate at gigahertz frequencies. Lower frequencies, allowing for deeper penetration, are used in industrial processes. RF electrosurgery is commonly used in virtually all surgical disciplines including dermatological, gynecological, cardiac, plastic, ocular, spine, ENT, maxillofacial, orthopedic, urological, neuro- and general surgical procedures as well as certain dental procedures. RF electrosurgery is performed using a RF electrosurgical generator (also referred to as an electrosurgical unit or ESU) and a handpiece including one or two electrodes—a monopolar or bipolar instrument. All RF electrosurgery is bipolar so the difference between monopolar and bipolar instruments is that monopolar instruments comprise only one electrode while bipolar instruments include both electrodes in their design. The monopolar instrument called an "active electrode" when energized, requires the application of another monopolar instrument called a "dispersive electrode" elsewhere on the patient's body that functions to 'defocus' or disperse the RF current thereby preventing thermal injury to the underlying tissue. This dispersive electrode is frequently and mistakenly called a "ground pad" or "neutral electrode". However virtually all currently available RF electrosurgical systems are designed to function with isolated circuits—the dispersive electrode is directly attached to the ESU, not to "ground". The same electrical current is transmitted across both the dispersive electrode and the active electrode, so it is not "neutral". The term "return electrode" is also technically incorrect since alternating electrical currents refer to alternating polarity, a circumstance that results in bidirectional flow across both electrodes in the circuit. Bipolar instruments generally are designed with two "active" electrodes, such as a forceps for sealing blood vessels. However, the bipolar instrument can be designed such that one electrode is dispersive. The main advantage of bipolar instruments is that the only part of the patient included in the circuit is that which is between the two electrodes, a circumstance that eliminates the risk of current diversion and related adverse events. However, except for those devices designed to function in fluid, it is difficult to vaporize or cut tissue with bipolar instruments. Neural and muscle cells are electrically-excitable, i.e. they can be stimulated by electric current. In human patients such stimulation may cause acute pain, muscle spasms, and even cardiac arrest . Sensitivity of the nerve and muscle cells to electric field is due to the voltage-gated ion channels present in their cell membranes . Stimulation threshold does not vary much at low frequencies (so called rheobase -constant level). However, the threshold starts increasing with decreasing duration of a pulse (or a cycle) when it drops below a characteristic minimum (so called chronaxie ). Typically, chronaxie of neural cells is in the range of 0.1–10 ms, so the sensitivity to electrical stimulation (inverse of the stimulation threshold) decreases with increasing frequency in the kHz range and above. (Note that frequency of the alternating electric current is an inverse of the duration of a single cycle). To minimize the effects of muscle and neural stimulation, electrosurgical equipment typically operates in the radio frequency (RF) range of 100 kHz to 5 MHz. Operation at higher frequencies also helps minimizing the amount of hydrogen and oxygen generated by electrolysis of water . This is especially important consideration for applications in liquid medium in closed compartments, where generation of gas bubbles may interfere with the procedure. For example, bubbles produced during an operation inside an eye may obscure a field of view. [ citation needed ] There are several commonly used electrode configurations or circuit topologies: With "bipolar" instruments the current is applied to the patient using a pair of similarly-sized electrodes. For example, special forceps , with one tine connected to one pole of the RF generator and the other tine connected to the other pole of the generator. When a piece of tissue is held by the forceps, the RF alternating polarity electrical current oscillates between the two forceps tines, heating the intervening tissue by the previously described synchronous oscillation of intracellular ions. [ citation needed ] In monopolar configuration the patient is attached to the dispersive electrode, a relatively large metal plate or a flexible metalized plastic pad which is connected to the RF generator or electrosurgical unit (ESU). The surgeon uses a pointed or blade shaped electrode called the "active electrode" to make contact with the tissue and exert a tissue effect - vaporization, and its linear propagation called electrosurgical cutting, or the combination of desiccation and protein coagulation used to seal blood vessels for the purpose of Hemostasis. The electric current oscillates between the active electrode and the dispersive electrode with the entire patient interposed between the two. Since the concentration of the RF current reduces with distance from the active electrode the current density rapidly (quadratically) decreases. Since the rate of tissue heating is proportional to the square of current density, the heating occurs in a very localized region, only near the portion of the electrode, usually the tip, near to or in contact with the target tissue. On an extremity such as a finger, there is limited cross-sectional area to disperse the current, a circumstance which might result in higher current density and some heating throughout the volume of the extremity. Another bipolar instrument is characterized with both electrodes on the same design, but the dispersive electrode is much larger than the active one. Since current density is higher in front of the smaller electrode, the heating and associated tissue effects take place only (or primarily) in front of the active electrode, and exact position of the dispersive electrode on tissue is not critical. Sometimes such configuration is called sesquipolar , even though the origin of this term in Latin ( sesqui ) means a ratio of 1.5. [ 9 ] Relatively low-powered high frequency electrosurgery can be performed on conscious outpatients with no grounded machines without a dispersive electrode . [ 10 ] Operating at low currents with no dispersive electrode is possible because, at the medium RF frequencies (usually 100 – 500 kHz) that the machines generate, the self- capacitance of the patient's body (which is between the patient's body and the machine's ground) is large enough to allow the resulting displacement current to act as a virtual "circuit completion path." One example of such a machine is called a hyfrecator . This term began in 1940 as a Birtcher Corporation brand name Hyfrecator for " Hi gh Fre quency Eradi cator ", but now serves generically to describe a general class of single-electrode, non-isolated (earth-referenced) low-powered electrosurgical machines intended mainly for office use. An accidental circuit completion path through an earth-ground creates the danger of a burn at a site far away from the probe electrode, and for this reason single-electrode devices are used only on conscious patients who would be aware of such complications, and only on carefully insulated tables. In such a setting, hyfrecators are not used to cut tissue, but to destroy relatively small lesions, and also to stop bleeding in surgical incisions made by blade instruments under local anesthesia. In cutting mode electrode touches the tissue, and sufficiently high power density is applied to vaporize its water content. Since water vapor is not conductive under normal circumstances, electric current cannot flow through the vapor layer. Energy delivery beyond the vaporization threshold can continue if sufficiently high voltage is applied (> +/-200 V) [ 11 ] to ionize vapor and convert it into a conductive plasma. Vapor and fragments of the overheated tissue are ejected, forming a crater. [ 12 ] Electrode surfaces intended to be used for cutting often feature a finer wire or wire loop, as opposed to a more flat blade with a rounded surface. [ citation needed ] Coagulation is performed using waveforms with lower average power, generating heat insufficient for explosive vaporization, but producing a thermal coagulum instead. Electrosurgical desiccation occurs when the electrode touches the tissue open to air, and the amount of generated heat is lower than that required for cutting. The tissue surface and some of the tissue more deep to the probe dries out and forms a coagulum (a dry patch of dead tissue). This technique may be used for treating nodules under the skin where minimal damage to the skin surface is desired. In fulguration mode, the electrode is held away from the tissue, so that when the air gap between the electrode and the tissue is ionized, an electric arc discharge develops. In this approach, the burning to the tissue is more superficial, because the current is spread over the tissue area larger than the tip of electrode. [ 13 ] Under these conditions, superficial skin charring or carbonization is seen over a wider area than when operating in contact with the probe, and this technique is therefore used for very superficial or protrusive lesions such as skin tags. Ionization of an air gap requires voltage in the kV range. Besides the thermal effects in tissue, the electric field can produce pores in the cellular membranes – a phenomenon called electroporation . This effect may affect cells beyond the range of thermal damage. There are wet and dry field electrosurgical devices. Wet field devices operate in a saline solution, or in an open wound. Heating is as a result of an alternating current that passes between two electrodes. Heating is usually greatest where the current density is highest. Therefore, it is usually the smallest or sharpest electrode that generates the most heat. Cut/Coag Most wet field electrosurgical systems operate in two modes: "Cut" causes a small area of tissue to be vaporized, and "Coag" causes the tissue to "dry" (in the sense of bleeding being stopped). "Dried" tissues are killed (and will later slough or be replaced by fibrotic tissue) but they are temporarily physically intact after electrosurgical application. The depth of tissue death is typically a few millimeters near the contact of the electrode. Cut If the voltage level is high enough, the heat generated can create a vapour pocket. The vapour pocket typically reaches temperatures of approximately 400 degrees Celsius, which vaporizes and explodes a small section of soft tissue, resulting in an incision. Coag When the system is operating in "coag mode" the voltage output is usually higher than in cut mode. Tissue remains grossly intact, but cells are destroyed at the point of contact, and smaller vessels are destroyed and sealed, stopping capillary and small-arterial bleeding. Different waveforms can be used for different electrosurgical procedures. For cutting, a continuous single frequency sine wave is often employed. Rapid tissue heating leads to explosive vaporization of interstitial fluid . If the voltage is sufficiently high (> 400 V peak-to-peak) [ 11 ] the vapor sheath is ionized, forming conductive plasma . Electric current continues to flow from the metal electrode through the ionized gas into the tissue. Rapid overheating of tissue results in its vaporization, fragmentation and ejection of fragments, allowing for tissue cutting. [ 11 ] In applications of a continuous wave the heat diffusion typically leads to formation of a significant thermal damage zone at the edges of the lesion. Open circuit voltage in electrosurgical waveforms is typically in the range of 300–10,000 V peak-to-peak. Higher precision can be achieved with pulsed waveforms. [ 11 ] [ 12 ] Using bursts of several tens of microseconds in duration the tissue can be cut, while the size of the heat diffusion zone does not exceed the cellular scale. Heat accumulation during repetitive application of bursts can also be avoided if sufficient delay is provided between the bursts, allowing the tissue to cool down. [ 12 ] The proportion of ON time to OFF time can be varied to allow control of the heating rate. A related parameter, duty cycle , is defined as the ratio of the ON time to the period (the time of a single ON-OFF cycle). In the terminology of electrical engineering , the process of altering this ratio to achieve an average amplitude, instead of altering the amplitude directly is called pulse-width modulation . For coagulation, the average power is typically reduced below the threshold of cutting. Typically, sine wave is turned on and off in rapid succession. The overall effect is a slower heating process, which causes tissue to coagulate. In simple coagulation/cutting mode machines, the lower duty cycle typical of coagulation mode is usually heard by the ear as a lower frequency and a rougher tone than the higher frequency tone typical of cutting mode with the same equipment. Many modern electrosurgical generators provide sophisticated wave forms with power adjusted in real time, based on changes of the tissue impedance. For the high power surgical uses during anesthesia the monopolar modality relies on a good electrical contact between a large area of the body (Typically at least the entire back of the patient) and the return electrode or pad (also known as dispersive pad or patient plate). Severe burns (3rd degree) can occur if the contact with the return electrode is insufficient, or when a patient comes into contact with metal objects serving as an unintended (capacitative) leakage path to Earth/Ground. To prevent unintended burns, the skin is cleaned and a conductive gel is used to enhance the contact with the return electrode. Proper electrical grounding practices must be followed in the electrical wiring of the building. It is also recommended to use a modern ElectroSurgical Unit that includes a return electrode monitoring system that continuously tests for reliable and safe patient contact. These systems interrogate the impedance of a split or dual-pad return electrode and will alarm out, disabling further generator output in case of fault. Prior generators relied on single pad return electrodes and thus had no means of verifying safe patient connection. Return electrodes should always have full contact with the skin and be placed on the same side of the body and close to the body part where the procedure is occurring. If there is any metal in the body of the patient, the return electrode is placed on the opposite side of the body from the metal and be placed between the metal and the operation site. This prevents current from passing selectively through metal on the way to the return electrode. For example, for a patient who has had a right sided hip replacement who is scheduled for surgery, the return electrode is placed on the left side of the body on the lateral side of the lower abdomen, which places the return electrode between the location of the metal and the surgical site and on the opposite side from the metal. If there is metal on both sides of the body, the return electrode is placed between the metal and the procedure site when possible. Common return electrode locations include lateral portions of the outer thighs, abdomen, back, or shoulder blades. [ 8 ] The use of the bipolar option does not require the placement of a return electrode because the current only passes between tines of the forceps or other bipolar output device. Electrosurgery should only be performed by a physician who has received specific training in this field and who is familiar with the techniques used to prevent burns. Concerns have also been raised regarding the toxicity of surgical smoke produced by electrosurgery. This has been shown to contain various volatile organic compounds (VOCs) , including formaldehyde , [ 14 ] which may cause harm by inhalation by the patients, surgeon or operating theatre staff. [ 15 ] [ 16 ] Electrical knives should not be used around flammable substances, like alcohol-based disinfectants. [ 17 ] Development of the first commercial electrosurgical device is credited to William T. Bovie , who developed the first electrosurgical device while employed at Harvard University . [ 8 ] [ 18 ] The first use of an electrosurgical generator in an operating room occurred on October 1, 1926 at Peter Bent Brigham Hospital in Boston , Massachusetts . The operation—removal of a mass from a patient’s head—was performed by Harvey Cushing . [ 19 ] The low powered hyfrecator for office use was introduced in 1940.	https://en.wikipedia.org/wiki/Electrosurgery
An electuary is a medicine consisting of a powder or other ingredient mixed with something sweet such as honey to make it more palatable. [ 1 ] In German and Swiss cultures, electuary ( German : Latwerge or Latwerg ) is also more generally a thickened juice and honey preparation with a thick, viscous consistency that is used in for culinary purposes, such as a (bread) spread or as a sauce ingredient. [ 2 ] [ 3 ] In the Indian Ayurveda tradition, electuaries are called Lēhya (लेह्य) [ 4 ] (literally, "lickable"). There are several different types of electuary: laxative electuary, joyful electuary, etc . The fermentation of mixed herbs in honey and their effects on each other are said to increase the medical properties already present and to create new ones. [ 5 ] This medical article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Electuary
Elizabeth Adkins-Regan (née Kocher ; born July 1945) is an American comparative behavioral neuroendocrinologist best known for her research on the hormonal and neural mechanisms of reproductive behavior and sexual differentiation in birds. She is currently a professor emeritus in the Department of Psychology and the Department of Neurobiology and Behavior at Cornell University . [ 1 ] Adkins-Regan received her B.S. in Psychology from the University of Maryland, College Park in 1967. [ 1 ] She earned her Ph.D. in Physiological Psychology from the University of Pennsylvania in 1971. [ 1 ] She was one of the first graduate students of Norman T. Adler . Her dissertation research focused on the hormonal control of mating behavior in Japanese quail . [ 2 ] After receiving her graduate degree, she was an assistant professor at Bucknell University from 1972-1974 and then at the State University of New York College at Cortland from 1974–1975. [ 1 ] She joined the faculty at Cornell University as an assistant professor in the Department of Psychology and the Department of Neurobiology and Behavior in 1975. [ 1 ] She became an associate professor at Cornell in 1981. In 1986, she received a Fulbright Research Scholar Award to work as a visiting scientist at the French National Institute for Agricultural Research (INRA) , [ 1 ] where she studied the sexual differentiation of behavior in pigs. [ 3 ] She became a full professor in the Department of Psychology and Department of Neurobiology and Behavior at Cornell University in 1988. [ 1 ] In 2005, she published the book Hormones and Animal Social Behavior , [ 4 ] a major synthesis of the study of animal social behavior and steroid and peptide hormones . She served as the Editor-in-Chief of the journal Hormones and Behavior from 2008-2011 and was the President of the Society for Behavioral Neuroendocrinology from 2015–2017. [ 1 ] In her early research using the Japanese quail , Adkins-Regan performed a number of fundamental experiments on the mechanisms of sexual differentiation of behavior in birds, which have a ZW sex determination system . Her work demonstrated that, unlike what is observed in mammalian sexual differentiation , female-typical reproductive behavior can be activated in both male and female Japanese quail by estrogen treatment. [ 5 ] [ 6 ] She also demonstrated that treatment of male Japanese quail embryos with estrogens de-masculinizes behavior, resulting in adult males that fail to show male-typical courtship behavior even when later treated with testosterone. [ 7 ] These experimental findings suggested a model of sexual differentiation for birds in which the steroid hormone estradiol secreted by the heterogametic sex (in this case, females) is responsible for the process of differentiation. Thus, the absence of male-type sexual behavior in adult females would result from their early exposure to endogenous estrogens, a process that would be experimentally reproduced in males by the injection of exogenous estradiol. [ 7 ] [ 8 ] [ 9 ] In the 1980s her research program expanded to include research in both Japanese quail and zebra finches . In the socially-monogamous zebra finches, she performed a series of parallel experiments demonstrating the effects of steroid hormones on the development sexually differentiated behaviors in these songbirds. [ 10 ] [ 11 ] Adkins-Regan's later research focused on the hormonal and neural mechanisms of a broader range of reproductive and social behaviors in birds, including courtship, mate choice , pair formation, mating behavior, parental behavior and aggression. She also published research in 2016 demonstrating that King quail , a closely related species to the Japanese quail, form monogamous pair bonds. [ 12 ] On 7 August 2005, she published Hormones and Animal Social Behavior . [ 13 ] Adkins-Regan has been married to the Cornell University social psychologist Dennis T. Regan since 1980.	https://en.wikipedia.org/wiki/Elizabeth_Adkins-Regan
The Elizabeth Blackwell Medal is awarded annually by the American Medical Women's Association . The medal is named in honor of Elizabeth Blackwell , the first woman to receive a medical degree in the United States and a pioneer in promoting the education of women in medicine . Established by Elise S. L'Esperance in 1949, 100 years after Blackwell received her medical degree, [ 1 ] the medal is granted to a woman physician "who has made the most outstanding contributions to the cause of women in the field of medicine." Before 1993, the medal was only awarded to members of the AMWA. [ 2 ] Source: AMWA	https://en.wikipedia.org/wiki/Elizabeth_Blackwell_Medal
Elizabeth Courtauld (1867–1947) was a pioneer British physician and anaesthetist, practising in India. She was a volunteer doctor at a field hospital run by women ( Scottish Women's Hospital ) close to the front line in France during the First World War. Elizabeth Courtauld was the third child of industrialist and politician George Courtauld and Susanna Elizabeth Savill, born on 2 December 1867 in Gosfield, Essex . Her elder siblings were Katherine Courtauld , farmer and suffragist, and Samuel Augustine Courtauld , who became a director of the family firm. Her mother died when she was a teenager. Courtauld completed her formal education at a residential school at Edge Hill, Wimbledon. She then returned to live at home aged 16 where she received private tuition in a range of subjects including botany, music, drawing, geography, French, German, geology, 'sums' and Euclid. By age 19 she still received music and drawing lessons but she also had responsibilities for some housekeeping and teaching her younger siblings. [ 1 ] In her early 20s Courtauld began taking extended trips to visit friends in Germany, and commenced nursing studies at the Deaconesses Institute of Kaiserswerth in the Dusselforf area, established by Theodor Fliedner . The Institute provided care for the needy sick and provided education for women in nursing skills and theology. Florence Nightingale had previously studied there. She began considering training to become a doctor but her father strongly disapproved of the idea, and she began work as a nurse in Cheltenham hospital in January 1891. She worked as a nurse for four years until she entered the London School of Medicine for Women in 1895, aged 28. She studied alongside Frances Ivens and Augusta Lewin, who she would later work alongside in France. In 1901 she qualified by sitting for the licentiate of the Society of Apothecaries , which entitled her to be entered on the Medical Register . She followed this with a degree of Doctor of Medicine of Brussels ('Brussels MD') in 1903. [ 2 ] She did not have the qualifications to sit for a medical degree in London and the Brussels MD had become an established route for several hundred other medical practitioners in similar circumstances in England and Wales in recent years. [ 3 ] After qualifying she worked at the Church of England Zenana Mission Hospital in Bangalore, established by the Church of England Zenana Missionary Society The zenana missions were made up of female missionaries who could visit Indian women in their own homes with the aim of converting them to Christianity. The purdah system made it impossible for many Indian women, especially high status women, to access health care. By training as doctors and nurses, the women of the zenana missions were accepted by the women of India into their homes. The zenana missions expanded over time from home visits to mobile clinics in rural areas, women only hospitals and all-girl schools, staffed and run by women both recruited in Britain and those recruited and trained locally in India. Courtauld described herself as "an independent worker, not a missionary". [ 4 ] She worked in Bangalore for the rest of her professional career apart from her service in Europe during the First World War. Courtauld was on leave from India after the outbreak of the First World War when Frances Ivens invited her to join the Scottish Women's Hospital unit at Royaumont , an auxiliary hospital with 200 beds established in 1915. She worked there from January 1916 to March 1919. Courtauld was a supporter of the National Union of Women's Suffrage Societies 17 September 1915 [ 5 ] which was active in fundraising for the Scottish Women's Hospitals. Courtauld and other members of the Courtauld family were generous contributors to the funding of the hospital at Royaumont in particular [ 6 ] The hospital came under most pressure during the German advance on the Aisne in May 1918. Courtauld was working in a unit at Villers-Cotterêts , continuing to conduct operations on the wounded day and night in the face of German bombardment and described the situation in a letter to her father: "there came an order for the hospital to evacuate ... Then came an order that heaps of terribly wounded were expected, and we could stay on. We were glad. It seemed horrid to be told to go and leave things behind us. All the night we were hard at it and working under difficulties. Terrible cases came in. Between 1030 and 330 or 4 AM we had to amputate six thighs and one leg, mostly by the light of bits of candle, held by the orderlies, and as for me giving the anaesthetic, I did it more or less in the dark at my end of the patient ... Air raids were over us nearly all night" [ 7 ] Courtauld was a devout Anglican and conducted a daily morning service for hospital staff until this was abandoned due to the volume of work in 1918. She also conducted funeral services in the local cemetery when a Protestant clergyman could not be found. [ 8 ] After leaving Royaumont she worked for a time in the devastated areas of northern France before returning to Bangalore. She was awarded the Croix de Guerre [ 9 ] [ 10 ] for her war service. Courtauld left Bangalore and retired to Greenstead Green , Essex in 1927, aged 60 and was Churchwarden for her parish church until 1946. She was wealthy throughout her life and a generous benefactor to many causes. These included funding the building of an out-patients' block at Halstead Hospital in memory of her father, who had founded the hospital in 1884. She was elected the first life vice-president of the hospital and served on the committee for many years. During her residence at Greenstead Green she took an interest in the welfare of the village. She erected several houses in the village and provided a children's playing field near the village green. [ 11 ] She died in 1947, aged 81.	https://en.wikipedia.org/wiki/Elizabeth_Courtauld
Elizabeth Louise Hartland AM , who publishes as Elizabeth L. Hartland , is a microbiologist and immunologist, and Eureka prize judge. [ 1 ] She was appointed a Member of the Order of Australia in 2024, [ 2 ] for service to "medical research, particularly microbiology, and to tertiary education". [ 3 ] She is CEO and Director of the Hudson Institute of Medical Research within Monash University. [ 4 ] Hartland received a Bachelor of Science (Hons), in 1990, a PhD in Microbiology and Immunology in 1996 for her thesis, "The genetic basis of virulence in Yersinia enterocolitica ". [ 5 ] She was then awarded a Bachelor of Arts from the University of Melbourne in 1997, and a Graduate Certificate in Higher Education in 2004, from Monash University . [ 6 ] [ better source needed ] Hartland worked at the Department of Biochemistry at Imperial College , at London, with a Royal Society/NHMCR Howard Florey Fellowship. She was one of the first ARC Future Fellows at the University of Melbourne. Hartland was the Head of department for the Department of Microbiology and Immunology at the University of Melbourne. She then was employed as the deputy director of the Doherty Institute. Hartland was also the president of the Association of Australian Medical Research Institutes (AAMRI). [ 7 ] As at 2024, Hartland is the Director of the Hudson Institute of Medical Research. [ 8 ] Hartland's research interests include pathogenesis and infections which are involved with Gram-negative pathogens. She also has research interests in immune evasion and bacterial colonisation. Her main areas of expertise include cell intrinsic immunity, intestinal bacterial pathogens and human microbiota and immune responses. [ 9 ] Hartland has an oration at the Victorian Infection and Immunity Network named after her, where the winner receives prize money, and delivers a speech at the Lorne conference. [ 10 ] She is also the chair of the Victorian Premier's award, for the selection panel of Health and Medical Research. [ 11 ] Hartland has over 165 publications, with an H-index of 58 and over 10,000 citations as at July 2024, according to Google Scholar. [ 12 ]	https://en.wikipedia.org/wiki/Elizabeth_Hartland
Elize Matsunaga: Once Upon a Crime (Elize Matsunaga: Era uma Vez um Crime) is a 2021 docuseries released on Netflix on July 8, 2021, starring Stephanie Sherry and Elize Matsunaga. [ 1 ] [ 2 ] Matsunaga shot and dismembered her husband, Marcos Matsunaga, [ 3 ] [ circular reference ] who was a member of the family that formerly owned the Yoki [ 4 ] [ circular reference ] food company in Brazil. Matsunaga is from Chopinzinho .	https://en.wikipedia.org/wiki/Elize_Matsunaga:_Once_Upon_a_Crime
The Ellison–Cliffe Lecture is held annually by the Royal Society of Medicine . The lecture series, which commenced in 1987 is named after Percy Cliffe and his wife, Carice Ellison , who endowed the lecture to be given on a subject connected with the contribution of fundamental science to the advancement of medicine. [ 1 ] The Lecturer is also awarded a medal in honour for their presentation. [ 2 ]	https://en.wikipedia.org/wiki/Ellison–Cliffe_Lecture
Dr. George Washington Corner Dr. George Whipple Elmer Belt (April 10, 1893 – May 17, 1980) was an American urologist. He was an early practitioner of gender-affirming surgery , an advocate for the founding of UCLA School of Medicine , and a book collector known for assembling a library of research materials about Leonardo da Vinci—the Elmer Belt Library of Vinciana —which he donated to the University of California, Los Angeles between 1961-66. Arthur Elmer Belt was born in Chicago, Illinois, on April 10, 1893. His parents worked for the United States Postal Service . The family moved to Southern California when Belt was nine. Elmer Belt (the form of name he preferred) received his early education in Orange County, California, and attended Los Angeles High School , traveling there on horseback. During high school he took courses in Latin, a medical school prerequisite, and met Ruth Smart, whom he married in 1918. Belt started a small book-and-supplies store at the school. [ 1 ] This enterprise led him to become acquainted with some of the city's leading booksellers, including Ernest Dawson . Recounting his high school years in a 1979 letter, Belt wrote, "As a Freshman in High School, I learned what an Aldine was and about Gutenberg and his woes and all of the wonderful world of books. [ 2 ] When he was a teenager, Belt's father died after undergoing abdominal surgery. When the surgeon informed the family, Belt noticed the smell of alcohol on him and believed the surgeon had botched the surgery while under the influence. This experience led Belt to vow never to drink alcohol. [ 3 ] Belt attended the University of California, Berkeley , obtaining a B.A. in 1916 and an M.A. in 1917. (He was a member of the first class taught by Herbert McLean Evans . [ 4 ] ) Belt then attended UCSF School of Medicine , where he was chosen to be a fellow of the Hooper Institute for Medical Research, working in urology with Dr. George Whipple and Dr. Frank Hinman . After completing medical school in 1920, Belt began a residency in Urology under Dr. Hinman. However, when Belt's young son, Charles, was seriously injured in a car accident, Belt sought treatment for him from renowned orthopedist Robert W. Lovett at Harvard Medical School . To be closer to his son and provide better care, Belt applied for a residency in General Surgery at the Peter Bent Brigham Hospital and spent a year working under Harvey Cushing . [ 5 ] [ 3 ] ) While in medical school, Belt took a non-credit elective course in the History of Medicine taught by George W. Corner . It was during this class that Belt developed his lifelong interest in Leonardo da Vinci. [ 6 ] In 1923, Elmer and Ruth Belt moved to Los Angeles, where he began a private practice. In 1936 he established the Elmer Belt Urologic Group, located in its own building at 1893 Wilshire Boulevard. The second floor of the building housed Belt's growing library. During this time, his growing reputation in the field earned him positions as a staff, attending, or consulting urologist at numerous hospitals in Los Angeles County. In addition to specializing in urology, Belt was an advocate for public health and, from 1939 through 1954, served as the President of the State Board of Public Health. [ 7 ] First appointed to this position by California Governor Culbert Olsen , Belt was reappointed by Governor Earl Warren for each of the latter's three terms in office. [ 8 ] In public health, Belt worked to establish the Hyperion Water Reclamation Plant . He also advocated for the care and rights of refugees from the Dust Bowl who had settled in Tulare County . During World War II, he advocated for funding to treat sexually transmitted diseases and to address prostitution, which he viewed as significant issues near military camps in the state. [ 9 ] Belt was the author of numerous publications about both urology [ 10 ] [ 11 ] and Leonardo da Vinci [ 12 ] [ 13 ] From the time he returned to California from Massachusetts in 1923, Belt advocated for the establishment of a medical school at UCLA. [ 14 ] [ 15 ] Despite his rising status and influence, Belt's efforts were hindered by the economic and political upheavals of the Great Depression and World War II. However, in 1945, after the war, he launched a lobbying campaign with the State Legislature's Appropriations Committee. As Governor Earl Warren’s personal physician, Belt seized the opportunity during a consultation to passionately advocate for the establishment of a medical school under UCLA’s administration. [ 16 ] Before leaving Belt's office, Warren pulled out a notebook and outlined a ten-step plan to move the project forward and secure approval from the state legislature. For the final step, he wrote, "Be there to stand behind me when I sign this legislation ." [ 17 ] On February 19, 1946, Belt stood alongside other dignitaries as Governor Warren signed a bill allocating $7 million to establish a medical school at UCLA. [ 18 ] After the approval of a medical school for UCLA, the next challenge was determining its location—on-campus or off-campus. The Regents' committee on location concluded that no suitable on-campus site was available. Concerned that the school might be placed far away, possibly at the county hospital downtown, Belt took it upon himself to scout Westwood, Los Angeles for viable land. He identified a nearly vacant 33-acre tract stretching from Wilshire Boulevard to Strathmore Drive and from the western edge of Westwood Village to Veteran Avenue. Dr. Belt consulted Dr. Edward Janss, the developer who had donated the land for UCLA’s campus, and discovered the property was owned by the Veterans Hospital Association. Securing the land would require an act of Congress, which meant drafting a bill to transfer ownership to the University of California. However, the university’s central administration was reluctant to make the request. After persistent efforts, UCLA Chancellor Clarence Dykstra finally agreed to facilitate the transfer with the Veterans Hospital Administration. The bill reached the 81st Congress as the final item on the docket. At this critical juncture, Dr. Belt sought the help of Edwin W. Pauley . Belt didn’t know Pauley personally, he reached out through Pauley’s wife, who arranged a meeting at their home. After hearing Dr. Belt’s appeal, Pauley called President Truman directly and persuaded him to sign the legislation. This act secured the land transfer from the Veterans Administration to the University of California, paving the way for the medical school’s construction. [ 19 ] Belt helped recruit the School of Medicine's first dean, Stafford L. Warren , who was appointed in 1947. In the fall of 1951, the medical school enrolled its first class, which consisted of 30 students—28 men and two women. [ 20 ] At this time, there were 15 faculty members, including Belt, who served as Clinical Professor of Surgery (Urology). In 1955 the university completed work on the UCLA Medical Center, giving the Medical School a permanent home. [ 21 ] Not long afterwards, University of California President Robert Gordon Sproul characterized Belt as "The Life Belt of the UCLA Medical School." [ 22 ] Belt remained a staunch supporter of the School for the rest of his life. Belt may have been the first surgeon in the United States to perform gender-affirming surgery , which he was likely doing by 1950. [ 23 ] [ 24 ] However, ascertaining exactly when he did them is not possible because a fire in Belt's medical office in 1958 destroyed many, if not all, records prior to that year. The surgeries were performed at Good Samaritan Hospital, where Belt's Urologic Group's surgical practice was conducted; he did not perform them at UCLA. [ 25 ] Belt was the uncle of Willard Elmer Goodwin, M.D. (1915-1998) who, in 1951, was the founding chair of the Division of Urology in the Department of Surgery at the UCLA School of Medicine. [ 26 ] [ 27 ] [ 28 ] Belt trained his nephew in the techniques of gender-affirming surgery. In 1954 a committee of UCLA doctors, including Goodwin and members of the Psychiatry Department, decided that these surgeries should no longer be performed under the aegis of the university. [ 23 ] However, Goodwin continued to perform them quietly. [ 23 ] At the end of 1954, Belt temporarily ceased his transgender surgeries, but resumed them in the late 1950s. [ 23 ] Belt received referrals from Harry Benjamin ; Dr. LeMon Clark, professor of Gynecology at the University of Arkansas and editor of Sexology Magazine ; and others. Many prospective corresponded directly with Belt. [ 29 ] Belt performed male-to-female operations. One of his best known patients was Patricia Morgan . [ 30 ] In early 1962, facing pressure from his wife, his son Bruce, and his office manager, Belt decided to stop performing gender-affirming surgery. Along with these pressures, he feared the risk of a lawsuit from a dissatisfied patient that could jeopardize his practice. Additionally, it was becoming increasingly difficult to find hospitals willing to accommodate gender-affirming surgeries. Knowing that other doctors, such as Goodwin and Georges Burou , could take on these patients, Belt ultimately chose to refer them elsewhere. [ 23 ] A lifelong bibliophile, Belt began collecting books as a child. By his mid-teens, he had assembled a prized collection of comic books and dime novels. Belt's mother discarded the collection when he went to college—a loss he lamented for the rest of his life. [ 31 ] Belt also collected works by his patient Upton Sinclair and, in 1934, supported Sinclair's campaign for governor of California. Belt donated his Upton Sinclair collection to Occidental College Library. [ 32 ] In addition, Belt formed collections around Silas Weir Mitchell and Florence Nightingale . He donated both collections to the Louise M. Darling Biomedical Library at UCLA. [ 33 ] In 2014 the remainder of Belt's collection was sold at auction including an illuminated manuscript by Dante Gabriel Rossetti of The Blessed Damozel by Alberto Sangorski; California mission etchings by Henry Ford ; a handwritten manuscript by Bertrand Russell and a signed Sierra Nevada: The John Muir Trail by Ansel Adams . [ 34 ] Belt’s Leonardo da Vinci collection was his most significant undertaking as a collector, with the goal of creating the world’s most comprehensive collection on Leonardo.His efforts focused on acquiring facsimiles of Leonardo’s works in all available editions, as well as books that Leonardo is known to have consulted, specifically in the same editions that the artist himself used—an assemblage referred to as "Leonardo’s Library." He also collected early art history books, including key works like Lives of the Most Excellent Painters, Sculptors, and Architects , as well as modern scholarly literature exploring Leonardo’s influence in the arts and sciences. Among the highlights of his collection were all printed editions of A Treatise on Painting , two manuscript versions predating the first printed edition, and a selection of graphic arts materials, such as prints inspired by Leonardo’s "grotesques." Beginning in the 1930s, Dr. Belt worked closely with Jacob Zeitlin , who acted as Belt's agent in sourcing and acquiring materials for this collection. By 1945, the Leonardo collection had grown to the extent that Belt hired a full-time librarian, his former patient Kate Steinitz , to manage it. In installments between 1961 and 1966, Belt donated his Leonardo da Vinci collection to UCLA on the condition that the University maintain his collection and not integrate it with the rest of the library's holdings. In 2011, a fiftieth anniversary tribute to Belt was held at the Department of Special Collections. [ 35 ] From 1966 to 2002, the Elmer Belt Library of Vinciana was housed in a suite of rooms within the Art Library in Dickson Art Center. The wood-paneled rooms were furnished with Renaissance furniture, antiques, artwork, and art objects donated by the Kress Foundation and Norton Simon . In 2002, counter to the terms of the gift, the Elmer Belt Library of Vinciana was integrated into UCLA Library Special Collections. [ 36 ] Belt married the former Mary Ruth Smart (1892-1983) in 1918. Like her husband, Ruth (her preferred name), attended the University of California, Berkeley. After graduating, she attended a full-time program in library science organized by the University Library and offered under the College of Letters and Science. After they settled permanently in Los Angeles in 1923, she became a social and cultural leader in the city. She served on the Los Angeles Library Commission and the Opera Guild of Southern California. She also was president of the UCLA Art Council and helped launch major fundraising events for that group. In 1959, she led a drive to add 35 cents for the city tax rate to help support the city's public elementary schools. She was as well a founding director of the World Affairs Council and national vice president of the Travelers Aid Society. She died on January 9, 1983. [ 37 ] The Belts had two sons, Charles Elmer Belt (1919-1994), and Bruce Gregory Belt (1926-2012), who also became a urologist, practicing medicine in the Elmer Belt Urological Group for 20 years before leaving medicine in 1977 to teach at the Brentwood School . [ 38 ] Belt's sister Olive married Willard Goodwin, Sr. Their son Willard Goodwin, M.D. (1915-1998), was founding chair of the Division of Urology in the Department of Surgery at the UCLA School of Medicine. Like his uncle, Goodwin performed gender-affirming surgeries. [ 39 ] He was also known for his work in organ and graft transplantation. [ 40 ] The Belt Residence was located at 2201 Fern Dell Place in Los Feliz, California . Not long after suffering a stroke, Belt died on May 17, 1980, at age 87. [ 41 ] Arthur, Ransom. By the Old Pacific's Rolling Water: Birth of the UCLA School of Medicine. Los Angeles: School of Medicine, University of California, 1992. Belt, Elmer. "Elmer Belt." In There Was Light: Autobiography of a University, Berkeley: 1868-1968, edited by Irving Stone, 353-367. New York: Doubleday, 1970. Marmor, Max. "The Elmer Belt Library of Vinciana." The Book Collector, 38, no. 3 (Autumn 1989): 1-23. Meyerowitz, Joanne. How Sex Changed: A History of Transsexuality in the United States. Cambridge, MA: Harvard University Press, 2002. Pedretti, Carlo. Leonardo da Vinci: Studies for a Nativity and the 'Mona Lisa Cartoon' with Drawings after Leonardo from the Elmer Belt Library of Vinciana: Exhibition in Honour of Elmer Belt, M.D. on the Occasion of his Eightieth Birthday. Los Angeles: University of California, 1973. Surgeon and Bibliophile: Elmer Belt. Oral History Transcript; interviewed by Esther de Vécsey between 1974-75. Los Angeles: Oral History Program, University of California, Los Angeles, 1983.	https://en.wikipedia.org/wiki/Elmer_Belt
Elmex is a brand of toothpaste that has been sold since 1962. [ 1 ] It is manufactured by GABA International AG, a Swiss manufacturer of branded oral care products located in Therwil . GABA was acquired by the Colgate-Palmolive company of the United States in 2004 for US$841 million. [ 2 ] Elmex was the first toothpaste to contain the organic Amine Fluoride (AmF) olaflur as an active ingredient for protection against dental caries . [ citation needed ] Elmex is often sold together with Aronal which should be used in the morning. [ 3 ] Aronal contains vitamin A and zinc to protect the gums against inflammation. The brand had a 25% market share in the German market as of 2008 and is noted for having used the same packaging appearance since its 1962 introduction. [ 3 ] Elmex was the sponsor of the Dutch basketball club "Elmex Leiden" from 1982 to 1985 (now ZZ Leiden ). This dentistry article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Elmex
Under the Geneva Conventions , the emblems of the International Red Cross and Red Crescent Movement are to be worn by all medical and humanitarian personnel and also displayed on their vehicles and buildings while they are in an active warzone, and all military forces operating in an active warzone must not attack entities displaying these emblems. [ 1 ] The International Red Cross and Red Crescent Movement recognizes four protection emblems, three of which are in use: the Red Cross (recognized since 1864), the Red Crescent (recognized since 1929), the Red Lion and Sun (recognized since 1929; unused since 1980), and the Red Crystal (recognized since 2005). The Red Cross was the original protection symbol declared at the First Geneva Convention in 1864. The Red Crescent, which was first used by the Ottoman Empire in the 1870s, and the Red Lion and Sun , which had been used only in Iran between 1924 and 1980, were both formally recognized as protection symbols following a 1929 amendment to the Geneva Conventions. Controversy stemming from the movement's successive rejections of the Red Star of David , which was established in 1899 and has been used only in Israel , led to the creation of the Red Crystal as the fourth protection symbol by a vote in 2005. In 2006, the movement announced that it was officially adopting the Red Crystal as a neutral symbol and that it was also granting formal recognition to Israel's Magen David Adom alongside the Palestine Red Crescent Society . In popular culture, the red cross symbol came to be a recognizable generic emblem for medicine, commonly associated with first aid , medical services, products, or professionals; it has been unlawfully used in toys, movies, and video games, outside of its defined context. After objections from the movement, derivatives and alternatives have come to be used instead. Additionally, Johnson & Johnson has registered the symbol for their medicinal products. The appropriation of the symbol has led to further irritation due to the practice of hospitals, first aid teams, and ski patrols in the United States reversing the symbol to a white cross on a red background—so undoing the original idea of the Red Cross emblem, namely reversing the Swiss flag —thus inappropriately suggesting an affiliation with Switzerland . [ 2 ] The symbols described below have two distinctively different meanings. On one hand, the visual symbols of the Red Cross , the Red Crescent , the Red Lion with Sun and the Red Crystal serve as protection markings in armed conflicts, a denotation which is derived from and defined in the Geneva Conventions. This is called the protective use of the symbols. On the other hand, these symbols are used as distinctive logos by those organizations which are part of the International Red Cross and Red Crescent Movement. This is the indicative use of the emblems, a meaning which is defined in the statutes of the International Movement and partly in the third Additional Protocol. As a protection symbol, they are used in armed conflicts to mark persons and objects (buildings, vehicles, etc.) which are working in compliance with the rules of the Geneva Conventions . In this function, they can also be used by organizations and objects which are not part of the International Red Cross and Red Crescent Movement, for example the medical services of the armed forces, civilian hospitals, and civil defense units. As protection symbols, these emblems should be used without any additional specification (textual or otherwise) and in a prominent manner which makes them as visible and observable as possible, for example by using large white flags bearing the symbol. Four of these symbols, namely the Red Cross, the Red Crescent, the Red Lion with Sun and the Red Crystal, are defined in the Geneva Conventions and their Additional Protocols as symbols for protective use. When used as an organizational logo, these symbols only indicate that persons, vehicles, buildings, etc. which bear the symbols belong to a specific organization which is part of the International Red Cross and Red Crescent Movement (like the ICRC, the International Federation or the national Red Cross and Red Crescent societies). In this case, they should be used with an additional specification (for example "American Red Cross") and not be displayed as prominently as when used as protection symbols. Three of these symbols, namely the Red Cross, the Red Crescent and the Red Crystal, can be used for indicative purposes by national societies for use in their home country or abroad. In addition to that, the Red Shield of David can be used by the Israel society Magen David Adom for indicative purposes within Israel, and, pending the approval of the respective host country, in combination with the Red Crystal when working abroad. The Red Cross on white background was the original protection symbol declared at the 1864 Geneva Convention. The ideas to introduce a uniform and neutral protection symbol as well as its specific design originally came from Dr. Louis Appia , a Swiss surgeon, and Swiss General Henri Dufour , founding members of the International Committee. The red cross symbolizes as an identifier for medical personnel during wartime. The Red Cross is defined as a protection symbol in Article 7 of the 1864 Geneva Convention, Chapter VII ("The distinctive emblem") and Article 38 of the 1949 Geneva Convention ("For the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field"). There is an unofficial agreement within the Red Cross and Red Crescent Movement that the shape of the cross should be a cross composed of five squares. [ 3 ] However, regardless of the shape, any Red Cross on white background should be valid and must be recognized as a protection symbol in conflict. Of the 190 National Societies which are currently recognized by the ICRC, 154 are using the Red Cross as their official organization emblem. According to the ICRC , the emblem adopted was formed by reversing the colours of the flag of Switzerland . [ 4 ] This was officially recorded in the 1906 revision of the convention. [ 5 ] However, according to jurist and Red Cross historian Pierre Boissier, no clear evidence of this origin has been found; the concept that the design was chosen to complement the country in which the convention at which it was adopted was held, was also promoted later to counter the objections of Turkey that the flag was a Christian symbol . [ 6 ] Some Christian religious orders , and organizations descended from these orders, lay claim to symbols that resemble, but are unrelated to, the Red Cross. These include the Order of Santiago , which uses a red Cross of Saint James ; [ 7 ] the Camillians , who use a red Latin cross ; [ 8 ] and descendant organizations of the Knights Hospitaller , which often use a white Maltese cross . [ 9 ] Some of these organizations, like the Camillians and Sovereign Military Order of Malta , are engaged in humanitarian or medical work. [ 8 ] [ 9 ] During the Russo-Turkish War from 1877 to 1878, the Ottoman Empire used a Red Crescent instead of the Red Cross because its government believed that the cross would alienate its Muslim soldiers. When asked by the ICRC in 1877, Russia committed to fully respect the sanctity of all persons and facilities bearing the Red Crescent symbol, followed by a similar commitment from the Ottoman government to respect the Red Cross. After this de facto assessment of equal validity to both symbols, the ICRC declared in 1878 that it should be possible in principle to adopt an additional official protection symbol for non-Christian countries. The Red Crescent was formally recognized in 1929 when the Geneva Conventions were amended (Article 19). [ 4 ] After the collapse of the Ottoman Empire, the Red Crescent was first used by its successor nation Turkey , followed by Egypt . From its official recognition to today, the Red Crescent became the organizational emblem of nearly every national society in countries with majority Muslim populations except Indonesia . The national societies of some countries such as Pakistan (1974), Malaysia (1975), and Bangladesh (1989) have officially changed their name and emblem from the Red Cross to the Red Crescent. The Red Crescent is used by 33 of the 190 recognized societies worldwide. The introduction of an additional neutral protection symbol had been under discussion for a number of years, with the Red Crystal (previously referred to as the Red Lozenge or Red Diamond ) being the most popular proposal. However, amending the Geneva Conventions to add a new protection symbol requires a diplomatic conference of all 192 signatory states to the Conventions. The Swiss government organized such a conference to take place on December 5–6, 2005, to adopt a third additional protocol to the Geneva Conventions introducing the Red Crystal as an additional symbol with equal status to the Red Cross or Red Crescent. Following an unplanned extension of the conference until December 7, the protocol was adopted after a vote successfully achieved the required two-thirds majority. From the countries which attended the conference, 98 voted in favour and 27 against the protocol, while 10 countries abstained from voting. In the third Protocol the new symbol is referred to as "the third Protocol emblem". [ 10 ] The rules for the use of this symbol, based on the third additional protocol to the Geneva Conventions, are the following: On 22 June 2006, the ICRC announced that the International Red Cross and Red Crescent Movement adopted the Red Crystal as an additional emblem for use by the national societies. The ICRC also announced the recognition of the Palestine Red Crescent Society (PRCS) and the Israeli National Society, Magen David Adom (MDA). [ 11 ] On 14 January 2007, the third additional protocol entered into force. From 1924 to 1980, Iran used a Red Lion and Sun symbol for its national society, the Red Lion and Sun Society , based on the flag and emblem of Iran. The Red Lion with Sun was formally recognized as a protection symbol in 1929, together with the Red Crescent. The symbol was introduced at Geneva in 1964. [ 12 ] Despite the country's shift to the Red Crescent in 1980, Iran explicitly maintains the right to use the symbol. Magen David Adom , the national society of Israel , has used the Red Shield of David as its organization emblem since its foundation. The Red Shield of David was initially proposed as an addition to the Red Cross, Red Crescent, and Red Lion with Sun in 1931. The proposal was rejected by the ICRC, like the Mehrab-e-Ahmar ( Red Archway ) symbol of the national aid society of Afghanistan four years later, as well as a wide range of other proposals, due to concerns about symbol proliferation. [ 13 ] Israel again tried to establish the emblem as a third protection symbol in the context of the Geneva Conventions, but a respective proposal was narrowly defeated when the Geneva Conventions were adopted by governments in 1949. As the Red Shield of David is not a recognized protection symbol under the Geneva Conventions, Magen David Adom's recognition as a national society by the ICRC was long delayed. It was not until 2006 that the ICRC officially recognized Magen David Adom. [ 14 ] The adoption of the third protocol emblem paved the way for the recognition and admission of Magen David Adom as a full member of the International Federation, as the rules of the third protocol allow it to continue using the Red Shield of David when operating within Israel and provide a solution for its missions abroad. Though the organization only recently gained official recognition, it took part in many international activities, in cooperation with both the ICRC and the Federation, prior to its official recognition. Various other countries have also lobbied for alternative symbols, which have been rejected because of concerns of territorialism. [ 13 ] [ 15 ] In 1922, a Red Swastika Society was formed in China during the Warlord era . The swastika is used in East, South and Southeast Asia as a symbol to represent Dharma . While the organization has set up philanthropic relief projects (both domestic and international), as a religious body it is ineligible for recognition and membership into the International Committee of Red Cross and Red Crescent. The Red Swastika Society's headquarters are now in Taiwan. The original motto of the International Committee of the Red Cross was Inter Arma Caritas ("In War, Charity"). This Christian-spirited slogan was amended in 1961 with the neutral motto Per Humanitatem ad Pacem or "With humanity, towards peace". While Inter Arma Caritas is still the primary motto of the ICRC (as per Article 3 of the ICRC statutes), Per Humanitatem ad Pacem is the primary motto of the Federation (Article 1 of the Constitution of the Federation). Both organizations acknowledge the alternative motto, and together both slogans serve as the combined motto of the International Movement. The mission statement of the International Movement as formulated in the "Strategy 2010" document of the Federation is "to improve the lives of vulnerable people by mobilizing the power of humanity". From 1999 to 2004, the common slogan for all activities of the International Movement was "The Power of Humanity". In December 2003, the 28th International Conference in Geneva adopted the conference motto "Protecting Human Dignity" as the new Movement slogan. The 16th International Conference which convened in London in 1938 officially decided to make May 8, the birthday of Henry Dunant , as the official annual commemoration and celebration day of the Movement. Since 1984, the official name of the celebration day has been " World Red Cross and Red Crescent Day ". In Solferino, a small museum describes the history of the Battle of Solferino and of the Risorgimento , the long and bloody Italian struggle for independence and unity. In the Ossario di Solferino (Solferino Ossuary) in close proximity to the museum, a moving display shows the horrors of war. Inside the chapel, 1,413 skulls and many more bones from thousands of French and Austrian troops who died during the battle are shown. Solferino is also host to the International Red Cross Memorial inaugurated in 1959 on the centennial of the Battle of Solferino. The memorial contains stone plaques identifying each recognized national society. In Castiglione delle Stiviere , a small town near Solferino , the International Museum of the Red Cross was also opened in 1959. Moreover, another museum, the International Red Cross and Red Crescent Museum stands in Geneva in close proximity to the headquarters of the ICRC. Finally, in the Swiss village of Heiden , the Henry Dunant Museum was opened to preserve the memory and legacy of Dunant himself. The Geneva Conventions specifies that the emblems recognized by the Convention may only be used for: In order to ensure universal respect for the emblems, the Geneva Conventions obliged their signatories to forbid any other use of the names and emblems in wartime and peacetime. Nevertheless, the illegal usage of the emblem is widespread and it is often used as a general symbol to indicate first aid , medical supplies and civilian medical services especially in walk-in clinics. Such uses appear in movies (a notable example is The Living Daylights , [ 18 ] [ 19 ] wherein narcotics were disguised as Red Cross care packages, as a plot device), on television, and in computer software and games. Service companies, such as those for car repair or lawn maintenance, tout themselves as service "doctors" and incorporate medical symbols to promote themselves. Prior to 1973, ambulances in the United States and elsewhere in the Western Hemisphere were typically marked with a safety orange cross, differing from the red cross only in its hue. Toys and paintings of ambulances commonly ignored even that nuance, instead using a red cross. After protests from the American Red Cross that the safety orange cross was insufficiently distinguishable from the protected Red Cross symbol, the U.S. Department of Transportation developed the blue Star of Life as a replacement for the safety orange cross. The blue Star of Life has since been adopted throughout much of the world on ambulances and in other related applications. But in most post-Soviet countries , inherited from the Soviet Union , the Red Cross still remains a symbol of medicine, used on first-aid kits and ambulances . In 2006, the Canadian Red Cross issued a press release asking video game makers to stop using the red cross in their games; it is an especially common sight to see first aid kits and other items which restore the player character's health marked with a red cross. [ 20 ] In 2017, Introversion Software , creators of indie game Prison Architect , were contacted by the British Red Cross regarding usage of red cross on the hoods of ambulances and backpacks of paramedics in the game; the emblem was subsequently modified. [ 21 ] In order to avoid this conflict, other generic alternatives are used, such as a green cross, a white cross on a red background, or the letter H. [ 22 ] Pre-existing trademarks are protected in the implementing legislation of other countries, including Australia , [ 23 ] New Zealand , [ 24 ] and the United Kingdom and its dependencies. [ 25 ] In many countries, it is a violation of the rule of law to seize intellectual property lawfully created prior to a ban without compensating its owner through eminent domain , with limited exceptions for offensive or dangerous uses. (For example, a red cross on a building conveys a potentially false and dangerous impression of military presence in the area to enemy aircraft, although the building itself would not be attacked; thus the U.S. reservations to the 1949 Geneva Conventions, as noted below , effectively ban that use.) In recognition of this fact, Protocol III expressly preserves most pre-2005 trademarks containing the Red Crystal, as long as they cannot be confused with military uses. Trademarks from after 2005 bearing the emblem are banned as there is no longer an issue of retroactive law . The flag of Tonga designed in 1862 happened to be a red cross on a white field; in 1866, when the similarity to the Red Cross flag was noted, the Tonga flag was changed to put the red cross in a canton . [ 26 ] The protected status of these images was established in the First Geneva Convention which states: [ 27 ] The Red Cross, Red Crescent, Red Crystal, and Red Lion and Sun emblems are protected under the Trade-marks Act , section 9(1), paragraphs f, g, g.1, and h, respectively: [ 28 ] Prohibited marks The Hong Kong Red Cross Ordinance ( Cap. 1129 ), in Section 3(c) "Unauthorized distribution of badges and products", states: No person shall, except with the authority of the Hong Kong Red Cross, distribute or sell or expose for sale ... any product which contains the emblem of the Geneva Convention, with or without additional words, characters or designs [ 29 ] This restriction on the use of the emblem was added in 1995. The use of the emblems in Singapore is governed by the Geneva Conventions Act (Cap 117) . The use of the emblems in the United Kingdom are governed by the Geneva Conventions Act 1957 [ 30 ] as amended by Geneva Conventions (Amendment) Act 1995 and several Orders as Statutory Instruments . Geneva Conventions and United Nations Personnel (Protocols) Act 2009 extended the protection to the Red Crystal. The unauthorised use of the Red Cross on a pantomime costume in Glasgow in 2011 resulted in a request for its removal. [ 31 ] A similar situation occurred in Norwich in 2015. [ 32 ] A notable exception to this [ clarification needed ] is the United States where, although the United States first ratified the Geneva Conventions in 1882, for 18 years no legislation was passed to enact treaty obligations regarding the protection of the Red Cross symbol. On 6 June 1900, the bill to charter the American National Red Cross (ARC) was signed into law. Section 4, which ultimately was codified as 18 U.S.C. §706, protected the Greek red cross symbol by making it a misdemeanor for any person or association to use the Red Cross name or emblem without the organization's permission. Penalties included imprisonment not to exceed one year and a fine between $1 and $500, payable to the ARC. There had been seven trademark registrations for Greek red crosses by entities unrelated to the Red Cross at the time the ARC was incorporated. The existence of these users was recognized in congressional discussion of the act. However, lawmakers took no action to prohibit the rights of these earlier users. In 1905, when Congress was revising the ARC's charter, the issue of pre-existing rights to use the emblem was again raised. Lawmakers reiterated Congress' intent that the prohibitions on use of the Red Cross name and emblem did not make unlawful the use of the Greek red cross by those with otherwise established rights. However, these sentiments were again not reflected in the Red Cross charter revision. At the time of the 1905 revision, the number of trademark registrations with a Greek red cross had grown to 61, including several by Johnson & Johnson . Concerned over potential pre-emption, commercial users lobbied for codification of their existing trademark rights. In 1910, Congress formally established that lawful use of the Red Cross name and emblem that began prior to 5 January 1905, could continue, but only if that use was "for the same purpose and for the same class of goods". Later, the U.S. ratified the 1949 revisions to the Geneva Conventions with a specific reservation that pre-1905 Red Cross trademarks would not be disturbed as long as the Red Cross is not used on "aircraft, vessels, vehicles, buildings or other structures, or upon the ground", all of which are likely to be confused with military uses. [ 33 ] Until 2007, U.S. law protected only the Red Cross, and permitted its use only by the ARC and U.S. armed forces; though its use by non-U.S. organizations would normally be implied by the ARC's membership in IFRC and the standard protocols of the military and the Red Cross & Red Crescent movement, the ARC's withholding of IFRC dues from 2000 to 2006 over the Magen David Adom (MDA) issue raised concerns. Both to implement Protocol III (which had received advice and consent from the United States Senate in 2006; the U.S. formalized its ratification in March 2007) and to address these concerns, the Geneva Distinctive Emblems Protection Act of 2006 (Public Law 109–481) was signed into law 12 January 2007, two days before Protocol III went into effect. [ 34 ] The law, codified as 18 U.S.C. §706a, extended full legal protection to the Red Crescent and Red Crystal (but not the Red Lion and Sun) in the U.S., subject to private uses prior to the signing of Protocol III that cannot be confused with military uses; permitted the use of all appropriate emblems under the Conventions by the ICRC, the IFRC, all national Red Cross & Red Crescent societies (including MDA by this time), and "(t)he sanitary and hospital authorities of the armed forces of State Parties to the Geneva Conventions"; and permitted the United States Attorney General to obtain injunctions against improper use of the Red Cross, Red Crescent, and Red Crystal in the U.S. U.S. law still does not specifically protect the right of military chaplains to use the emblems under the Geneva Conventions; however, military chaplains that are part of their armed forces' "sanitary and hospital authorities" would have the right to use the emblems in the U.S. The ARC and other Red Cross & Red Crescent entities also employ chaplains; they are entitled to use the emblems through their employment. On 9 August 2007, in the United States District Court for the Southern District of New York , Johnson & Johnson (J&J) filed suit against the American Red Cross alleging trademark infringement. [ 35 ] The suit sought to halt the placement of the Red Cross emblem on all first aid, safety and disaster preparedness products not specifically licensed by Johnson & Johnson. The suit also asked for the destruction of all currently existing non-J&J Red Cross emblem-bearing products of this type, and demanded the American Red Cross pay punitive damages and J&J's legal fees. J&J released a statement to the public on 8 August 2007, detailing its decision to file suit, [ 36 ] claiming prior rights to the emblem. On the same date, the American Red Cross issued a press release of its own, [ 37 ] stating some of the reasons behind its decision to license the Red Cross emblem to first aid and disaster preparedness product manufacturers. It issued a further press release two days later, disputing several of J&J's claims and asserting that "The Red Cross has been selling first aid kits commercially in the United States since 1903." [ 38 ] In a statement, the American Red Cross said it had worked since 2004 with several licensing partners to create first aid, preparedness and related products that bear the Red Cross emblem. The charity said that all money it received from the sale of these products to consumers was reinvested in its humanitarian programs and services. "For a multi-billion dollar drug company to claim that the Red Cross violated a criminal statute that was created to protect the humanitarian mission of the Red Cross—simply so that J&J can make more money—is obscene", said Mark Everson, the chief executive of the charity. [ 39 ] Johnson & Johnson responded, stating that the American Red Cross's commercial ventures were outside the scope of historically well-agreed usage, and were in direct violation of federal statutes. [ 40 ] The federal court rejected Johnson & Johnson's position and ruled for the American Red Cross, holding that federal law authorizes the American Red Cross to use the Red Cross emblem in the sale of mission-related items like first aid and disaster preparedness kits and to license other firms to use its name and emblem to sell such products. The court noted in particular that the American Red Cross had been doing so for over a century, and that Johnson & Johnson had once itself sought to be a licensee of the American Red Cross. After the court rejected the substance of Johnson & Johnson's complaint, the parties ultimately settled their differences, and the American Red Cross remains free to use its emblem commercially. [ 41 ]	https://en.wikipedia.org/wiki/Emblems_of_the_International_Red_Cross_and_Red_Crescent_Movement
Embolic stroke of undetermined source (ESUS) is an embolic stroke , a type of ischemic stroke , with an unknown origin, [ 1 ] defined as a non- lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. [ 2 ] As such, it forms a subset of cryptogenic stroke, which is part of the TOAST-classification. [ 3 ] The following diagnostic criteria define an ESUS: [ 2 ] The following factors are suggested as pathogenesis of ESUS: [ 4 ] ESUS is a diagnosis of exclusion based on radiological and cardiological examinations. For exclusion of haemorrhagic or lacunar strokes CT or MRI imaging is needed. Both procedures also allow detection of embolic pattern of ischemic lesions. 12-lead ECG and cardiac monitoring for at least 24 h with automated rhythm detection are mandated to exclude atrial fibrillation; echocardiography (TTE and/or TEE) is used to detect other major-risk cardioembolic sources (e.g., intracardiac thrombi, or ejection fraction <30%). For imaging of both the extracranial and intracranial arteries supplying the area of brain ischaemia, examination methods like catheter , MR/CT angiography or cervical duplex plus transcranial Doppler ultrasonography are required. They allow an exclusion of large vessel stenosis (≥ 50%). [ 2 ] Cryptogenic stroke is also an ischemic stroke with more than one probable cause or strokes with incomplete diagnostic workup. [ 3 ] ESUS has a clearer definition, with an established minimum diagnostic requirements; this is not required in defining a cryptogenic stroke. ESUS is an embolic stroke for which no probable cause can be identified after a standard diagnostic evaluation. [ citation needed ] Due to the lack of data, there are no specific treatment guidelines for ESUS. Current guidelines recommend antiplatelet therapy for patients with non-cardioembolic ischemic stroke. [ 8 ] [ 9 ] [ 10 ] However, it is widely believed that there is a substantial overlap between ESUS and cardioembolic stroke, clinical trials have assessed the benefit of anticoagulation versus antiplatelet agents for preventing recurrent stroke. [ 2 ] [ 11 ] Although the existing data does not favor the use anticoagulation in patients with ESUS, current hypotheses suggest there may be subgroups who do benefit from anticoagulation. [ 12 ] On average, ESUS accounts for about 1 in 6 ischemic strokes (17% (range 9 – 25%)) according to a systematic literature review of 9 studies. [ 13 ] Patients with ESUS tend to be relatively young and experience mild strokes. However, ESUS is associated with high recurrence rates. Of 2045 ESUS patients (identified by 8 studies) The stroke recurrence rate was 29.0% over 5 years in patients with ESUS, which is similar to patients with cardioembolic stroke (26.8%), but significantly higher than all types of non-cardioembolic stroke. However, mortality was significantly lower in patients with ESUS than cardioembolic stroke. [ 14 ] [ 15 ]	https://en.wikipedia.org/wiki/Embolic_stroke_of_undetermined_source
Embolization refers to the passage and lodging of an embolus within the bloodstream. It may be of natural origin ( pathological ), in which sense it is also called embolism , for example a pulmonary embolism ; or it may be artificially induced ( therapeutic ), as a hemostatic treatment for bleeding or as a treatment for some types of cancer by deliberately blocking blood vessels to starve the tumor cells. In the cancer management application, the embolus, besides blocking the blood supply to the tumor, also often includes an ingredient to attack the tumor chemically or with irradiation . When it bears a chemotherapy drug, the process is called chemoembolization. Transcatheter arterial chemoembolization (TACE) is the usual form. When the embolus bears a radiopharmaceutical for unsealed source radiotherapy , the process is called radioembolization or selective internal radiation therapy (SIRT). Embolization involves the selective occlusion of blood vessels by purposely introducing emboli , in other words deliberately blocking a blood vessel. Embolization is used to treat a wide variety of conditions affecting different organs of the human body. Embolization is commonly used to treat active arterial bleeding. Embolization is rarely used to treat venous bleeding as venous bleeding can stop on its own or with packing or compression. [ 1 ] [ 2 ] The treatment is used to occlude: The treatment is used to slow or stop blood supply thus reducing the size of the tumour: It could be useful for managing malignant hypertension due to end stage kidney failure . [ 6 ] First developed by Sadek Hilal in 1968, embolization is a minimally invasive surgical technique. [ 8 ] The purpose is to prevent blood flow to an area of the body, which can effectively shrink a tumor or block an aneurysm. The procedure is carried out as an endovascular procedure by an interventional radiologist in an interventional suite. It is common for most patients to have the treatment carried out with little or no sedation, although this depends largely on the organ to be embolized. Patients who undergo cerebral embolization or portal vein embolization are usually given a general anesthetic . Access to the organ in question is acquired by means of a guidewire and catheter(s). Depending on the organ this can be very difficult and time-consuming. The position of the correct artery or vein supplying the pathology in question is located by digital subtraction angiography (DSA). These images are then used as a map for the radiologist to gain access to the correct vessel by selecting an appropriate catheter and or wire, depending on the 'shape' of the surrounding anatomy. Once in place, the treatment can begin. The artificial embolus used is usually one of the following: Once the artificial emboli have been successfully introduced, another set of DSA images are taken to confirm a successful deployment. Liquid embolic agents – Used for AVM, these agents can flow through complex vascular structures so the surgeon does not need to target the catheter to every single vessel. Sclerosing agents – These will harden the endothelial lining of vessels. They require more time to react than the liquid embolic agents. Therefore, they cannot be used for large or high-flow vessels. Particulate embolic agents – These are only used for precapillary arterioles or small arteries. These are also very good for AVM deep within the body. The disadvantage is that they are not easily targeted in the vessel. None of these are radioopaque, so they are difficult to view with radiologic imaging unless they are soaked in contrast prior to injection. Mechanical occlusion devices – These fit in all vessels. They also have the advantage of accuracy of location; they are deployed exactly where the catheter ends.	https://en.wikipedia.org/wiki/Embolization
In dentistry , embrasures are V-shaped valleys between adjacent teeth . They provide a spill way for food to escape during chewing [ 1 ] which essentially aids in the self-cleansing process. They also prevent food from being forced through the contact area which might cause food packing and periodontal pain and permit a slight amount of stimulation to the gingiva . When two teeth in the same arch are in contact, their curvatures adjacent to the contact areas form spillway spaces which are known as embrasures. This dentistry article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Embrasure_(dentistry)
Embryocardia is a condition in which S 1 and S 2 ( the two heart sounds that produce the typical " lubb-dubb " sound of the heart) become indistinguishable and equally spaced. [ 1 ] Thus the normal "lubb-dubb" rhythm of the heart becomes a "tic-toc" rhythm resembling the heart sounds of a fetus . This indicates a serious loss of natural fluctuation and often precedes a fatal collapse. [ 2 ] [ 3 ] This condition is observed in myocarditis . [ 4 ] This medical sign article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Embryocardia
Embryoma is a mass of rapidly growing cells believed to originate in embryonic ( fetal ) tissue. [ 1 ] Embryonal tumors may be benign or malignant , and include neuroblastomas and Wilms tumors . Also called embryoma. Embryomas have been defined as: "Adult neoplasms expressing one or more embryo-exclusive genes." [ citation needed ] Embryomas can appear in the lungs. [ 2 ] It is not a precise term, and it is not commonly used in modern medical literature. Embryomas have been defined as: "Adult neoplasms expressing one or more embryo-exclusive genes". [ citation needed ] This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute . This oncology article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Embryoma
Emergence delirium is a condition in which emergence from general anesthesia is accompanied by psychomotor agitation . Some see a relation to pavor nocturnus [ 1 ] while others see a relation to the excitement stage of anesthesia . The Pediatric Anesthetic Emergence Delirium (PAED) scale or the Cornell Assessment of Pediatric Delirium may be used to measure the severity of this condition in children . [ 2 ] [ 3 ] In this patient population, emergence delirium is typically identified within the first 30 minutes of recovery from anesthesia. It terminates within five to fifteen minutes with spontaneous resolution. [ 4 ] Emergence delirium occurs with similar frequency after anesthesia with desflurane and isoflurane . [ 5 ] It has been hypothesized that rapid awakening from these inhaled anesthetics may worsen the child's natural apprehension upon suddenly finding him/herself in an unfamiliar environment. [ 6 ] ED in children has been associated with the type of surgery, anesthesia, and the use of adjunct medication, but the identification of its underlying cause remains elusive. [ 4 ] Elderly people are more likely to experience confusion or problems with thinking following surgery, which can occur up to several days postoperatively. These cognitive problems can last for weeks or months, and can affect the patients’ ability to plan, focus, remember, or undertake activities of daily living. A review of intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery showed little or no difference in postoperative delirium according to the type of anaesthetic maintenance agents from five studies (321 participants). The authors of this review were uncertain whether maintenance of anaesthesia with propofol-based total intravenous anaesthesia (TIVA) or with inhalational agents can affect incidences of postoperative delirium. [ 7 ] Emergence delirium has been associated long-term changes neurocognitive dysfunction after cardiac surgery. [ 8 ] A cohort study which included 560 adults aged 70 years and older for a period of 6 years revealed that delirium represents the most common post-operative complication and is associated with long-term cognitive decline and increased incidence of dementia. [ 9 ] The overall incidence of emergence delirium is 5.3%, with a significantly greater incidence (12–13%) in children. The incidence of emergence delirium after halothane , isoflurane , sevoflurane or desflurane ranges from 2–55%. [ 10 ] Most emergence delirium in the literature describes agitated emergence. Unless a delirium detection tool is used, it is difficult to distinguish if the agitated emergence from anesthesia was from delirium or pain or fear, etc. A research study of 400 adult patients emerging from general anesthesia in the PACU were assessed for delirium using the Confusion Assessment Method for the ICU (CAM-ICU) found rates of emergence delirium of 31% at PACU admission with rates declining to 8% by 1 hour. [ 11 ]	https://en.wikipedia.org/wiki/Emergence_delirium
An emergency care instructor is a person who provides training in emergency care to civilians or military personnel. In order to qualify, a person must undergo appropriate courses, and have a certification level not lower (usually at least one level higher) than that to be taught. [ 1 ] Often, experience with the provision of such care is required. If these requirements are met, the applicant will receive a certificate after completing training and fulfilling possible additional conditions. Typically, upon certification it is necessary to hold a certain number of classes under the supervision of other instructors, and only after that may a new instructor teach courses on their own. The certificate must be renewed periodically. [ 2 ] Many first aid and medical care courses exist. They differ by: This job-, occupation-, or vocation-related article is a stub . You can help Wikipedia by expanding it . This medical article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Emergency_care_instructor
In the United States, the licensing of prehospital emergency medical providers and oversight of emergency medical services are governed at the state level. Each state is free to add or subtract levels as each state sees fit. Therefore, due to differing needs and system development paths, the levels, education requirements, and scope of practice of prehospital providers varies from state to state. Even though primary management and regulation of prehospital providers is at the state level, the federal government does have a model scope of practice including minimum skills for EMRs, EMTs, Advanced EMTs and Paramedics set through the National Highway Traffic Safety Administration (NHTSA). [ 1 ] While states are able to set their own additional requirements for state certification, a quasi-national certification body exists in the form of the National Registry of Emergency Medical Technicians (NREMT). The NREMT offers a national certification based on the NHTSA National Standard curriculum for the levels of EMR, EMT, Advanced EMT and Paramedic. [ 2 ] Individual states are allowed to use NREMT certification as part of their certification process, but are not required to. As of 2011, 38 states use the NREMT examination for EMT certification and 45 states use the NREMT examination for Paramedic certification. [ 3 ] These levels are denoted below using an asterisk (*). At present time, use of the NREMT examination for EMT-Intermediate 85 and 99 have not been included in this list. Any provider between the levels of Emergency medical technician and Paramedic is either a form of EMT-Intermediate or an Advanced EMT . The use of the terms "EMT-Intermediate/85" and "EMT-Intermediate/99" denotes use of the NHTSA EMT-Intermediate 1985 curriculum and the EMT-Intermediate 1999 curriculum respectively. In addition, not all states use the "EMT" prefix for all levels (e.g. Texas uses EMT-Paramedic and Licensed Paramedic). Finally, some states have levels that have partially been phased out. While no new certifications are provided at this level, providers can sometimes be grandfathered in provided they meet recertification requirements. Any level that has been completely phased out (i.e. not used for new or continuing providers) is not listed. In some states there are also EMS-RN's which is a Registered Nurse trained in Pre-Hospital response. In the list, each state's certification levels are provided from most basic at the top to most advanced at the bottom. Colorado EMS Scope of Practice and Education Standard Comparison Archived 2017-02-15 at the Wayback Machine Transition to new levels began January 2011, and finished in March 2015. [ 24 ] (Endorsements are listed below each level, are optional and can be achieved in any order and combination.) Now have been phased out of the state of Utah: Source: [ 65 ] Wyoming has adopted the National Registry model with an addition of IEMT. The IEMT has all of the skills of an AEMT with the addition of additional medications, endotracheal intubation, cardiac drugs and skills (manual defibrillator, epi 1:10000, etc.) chest darts and pain management. National Registry is NOT required, and not accepted for licensing in Wyoming. [ 68 ]	https://en.wikipedia.org/wiki/Emergency_medical_responder_levels_by_U.S._state
Emergency psychiatry is the clinical application of psychiatry in emergency settings. [ 1 ] [ 2 ] Conditions requiring psychiatric interventions may include attempted suicide , substance abuse , depression , psychosis , violence or other rapid changes in behavior . Psychiatric emergency services are rendered by professionals in the fields of medicine , nursing , psychology and social work . [ 2 ] The demand for emergency psychiatric services has rapidly increased throughout the world since the 1960s, especially in urban areas . [ 3 ] [ 4 ] Care for patients in situations involving emergency psychiatry is complex. [ 3 ] Individuals may arrive in psychiatric emergency service settings through their own voluntary request, a referral from another health professional, or through involuntary commitment . Care of patients requiring psychiatric intervention usually encompasses crisis stabilization of many serious and potentially life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions. [ 2 ] Symptoms and conditions behind psychiatric emergencies may include attempted suicide , substance dependence , alcohol intoxication , acute depression , presence of delusions , violence, panic attacks , and significant, rapid changes in behavior. [ 5 ] Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric conditions. In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms. A physician 's or a nurse's ability to identify and intervene with these and other medical conditions is critical. [ 1 ] A psychiatric emergency is a disturbance in thought, mood and/or action which causes sudden distress to the individual/others and sudden disability or death, thus requiring immediate management. The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric Emergency Services, Psychiatric Emergency Care Centers, or Comprehensive Psychiatric Emergency Programs. Mental health professionals from a wide area of disciplines, including medicine , nursing , psychology , and social work in these settings alongside psychiatrists and emergency physicians . [ 2 ] The facilities, sometimes housed in a psychiatric hospital , psychiatric ward, or emergency department , provide immediate treatment to both voluntary and involuntary patients 24 hours a day, 7 days a week . [ 6 ] [ 7 ] [ 8 ] Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity, find appropriate alternatives to psychiatric hospitalization for the patient, and to treat those patients whose symptoms can be improved within that brief period of time. [ 9 ] Even precise psychiatric diagnoses are a secondary priority compared with interventions in a crisis setting. [ 2 ] The functions of psychiatric emergency services are to assess patients' problems, implement a short-term treatment consisting of no more than ten meetings with the patient, procure a 24-hour holding area, mobilize teams to carry out interventions at patients' residences, utilize emergency management services to prevent further crises, be aware of inpatient and outpatient psychiatric resources, and provide 24/7 telephone counseling . [ 10 ] Since the 1960s, the demand for emergency psychiatric services has endured a rapid growth due to deinstitutionalization both in Europe and the United States . Deinstitutionalization, in some locations, has resulted in a larger number of severely mentally ill people living in the community. There have been increases in the number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric medication . [ 3 ] [ 4 ] [ 11 ] The actual number of psychiatric emergencies has also increased significantly, especially in psychiatric emergency service settings located in urban areas . [ 5 ] Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless and other disenfranchised populations. Emergency psychiatry services have sometimes been able to offer accessibility, convenience, and anonymity. [ 3 ] While many of the patients who have used psychiatric emergency services shared common sociological and demographic characteristics, the symptoms and needs expressed have not conformed to any single psychiatric profile. [ 12 ] The individualized care needed for patients utilizing psychiatric emergency services is evolving, requiring an always changing and sometimes complex treatment approach. [ 3 ] As of 2000, the World Health Organization estimated one million suicides in the world each year. [ 13 ] There are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of suicide or suicide attempts. Mental health professionals in these settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide can stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment. [ 2 ] Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system . This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve both suicide and homicide. [ 14 ] Violence is also associated with many conditions such as acute intoxication, acute psychosis, paranoid personality disorder , antisocial personality disorder , narcissistic personality disorder and borderline personality disorder . Additional risk factors have also been identified which may lead to violent behavior. Such risk factors may include prior arrests, presence of hallucinations, delusions or other neurological impairment, being uneducated, unmarried, etc. [ 2 ] Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient. [ 2 ] Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. [ 2 ] Sometimes patients brought into the setting in a psychotic state have been disconnected from their previous treatment plan. While the psychiatric emergency service setting will not be able to provide long-term care for these types of patients, it can exist to provide a brief respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication. A visit to a crisis unit by a patient with a chronic mental disorder may also indicate the existence of an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition. These considerations can play a part in an improvement to an existing treatment plan. [ 2 ] An individual could also be experiencing an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination , conducting psychological testing , obtaining neuroimages , and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. As with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention according to Shubham kumar. The lack of identification and treatment can result in suicide, homicide, or other violence. [ 3 ] Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition. [ citation needed ] Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions. [ 2 ] [ 3 ] Acting as a depressant of the central nervous system , the early effects of alcohol are usually desired for and characterized by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short-term memory loss which could result in behavioral change causing injury or death, levels of alcohol below 60 milligrams per deciliter of blood are usually considered non-lethal. However, individuals at 200 milligrams per deciliter of blood are considered grossly intoxicated and concentration levels at 400 milligrams per deciliter of blood are lethal, causing complete anesthesia of the respiratory system . [ 3 ] Beyond the dangerous behavioral changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations , increased aggressiveness, rage, agitation and violence. Chronic alcoholics may also have alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics are often used to treat these symptoms. [ 3 ] Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine , caffeine , tetrahydrocannabinol , cocaine , phencyclidines , or other inhalants , opioids , sedatives , hypnotics , anxiolytics , psychedelics, dissociatives and deliriants . Clinicians assessing and treating substance abusers must establish therapeutic rapport to counter denial and other negative attitudes directed towards treatment. In addition, the clinician must determine substances used, the route of administration, dosage, and time of last use to determine the necessary short and long-term treatments. An appropriate choice of treatment setting must also be determined. These settings may include outpatient facilities, partial hospitals, residential treatment centers, or hospitals. Both the immediate and long-term treatment and setting is determined by the severity of dependency and seriousness of physiological complications arising from the abuse. [ 2 ] Overdoses , drug interactions , and dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics. [ 11 ] If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death. [ 11 ] Serotonin syndrome can result when selective serotonin reuptake inhibitors or monoamine oxidase inhibitors mix with buspirone . [ 2 ] Severe symptoms of serotonin syndrome include hyperthermia , delirium, and tachycardia that may lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency department or medicine service for increased monitoring. [ citation needed ] Disorders manifesting dysfunction in areas related to cognition , affectivity , interpersonal functioning and impulse control can be considered personality disorders . [ 15 ] Patients with a personality disorder will usually not complain about symptoms resulting from their disorder. Patients with an emergency phase of a personality disorder may showcase combative or suspicious behavior, have brief psychotic episodes, or be delusional. Compared with outpatient settings and the general population, the prevalence of individuals with personality disorders in inpatient psychiatric settings is usually 7–25% higher. Clinicians working with such patients attempt to stabilize the individual to their baseline level of function. [ 2 ] Patients with an extreme case of anxiety may seek treatment when all support systems have been exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalized anxiety disorder , or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder . Clinicians usually attempt to first provide a "safe harbor" for the patient so that assessment processes and treatments can be adequately facilitated. [ 3 ] The initiation of treatments for mood and anxiety disorders are important as patients with anxiety disorders have a higher risk of premature death. [ 2 ] Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the event. Emergency management often includes psychiatric emergency services designed to help victims cope with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks, or dysphoria. [ 3 ] Due to the typically disorganized and hazardous environment following a disaster, mental health professionals typically assess and treat patients as rapidly as possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and basic survival considerations are managed first. Soon after a disaster clinicians may make themselves available to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent upon the scale of the disaster, many victims may develop either chronic or acute post-traumatic stress disorder . Patients affected severely by this disorder often are admitted to psychiatric hospitals to stabilize the individual. [ 3 ] Incidents of physical abuse , sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may have extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be required to report criminal activity to a police force. Mental health professionals will usually gather identifying data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical treatment may include a physical examination , collection of medicolegal evidence, and determination of the risk of pregnancy , if applicable. [ 3 ] Treatments in psychiatric emergency service settings are typically transitory in nature and only exist to provide dispositional solutions and/or to stabilize life-threatening conditions. [ 3 ] Once stabilized, patients with chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation . [ 3 ] Prescribed treatments within the emergency service setting vary dependent upon the patient's condition. [ 16 ] Different forms of psychiatric medication, psychotherapy , or electroconvulsive therapy may be used in the emergency setting. [ 16 ] [ 17 ] [ 18 ] The introduction and efficacy of psychiatric medication as a treatment option in psychiatry has reduced the utilization of physical restraints in emergency settings, by reducing dangerous symptoms resulting from acute exacerbation of mental illness or substance intoxication. [ 17 ] With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration. [ 17 ] Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the route of administration , absorption , distribution and metabolism of the medication. [ 11 ] [ 19 ] A common route of administration is oral administration, however if this method is to work the drug must be able to get to the stomach and stay there. [ 11 ] In cases of vomiting and nausea this method of administration is not an option. Suppositories can, in some situations, be administered instead. [ 11 ] Medication can also be administered through intramuscular injection , or through intravenous injection . [ 11 ] The amount of time required for absorption varies dependent upon many factors including drug solubility , gastrointestinal motility and pH . [ 11 ] If a medication is administered orally the amount of food in the stomach may also affect the rate of absorption. [ 11 ] Once absorbed medications must be distributed throughout the body, or usually with the case of psychiatric medication, past the blood–brain barrier to the brain . [ 11 ] With all of these factors affecting the rapidity of effect, the time until the effects are evident varies. Generally, though, the timing with medications is relatively fast and can occur within several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after haloperidol , an antipsychotic, is administered intramuscularly. [ 17 ] Antipsychotics , especially Haloperidol , [ 20 ] as well as assorted benzodiazepines are the most frequently used drugs in emergency psychiatry, especially agitation. [ 21 ] Other treatment methods may be used in psychiatric emergency service settings. Brief psychotherapy can be used to treat acute conditions or immediate problems as long as the patient understands his or her issues are psychological, the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change, the physician is aware of the psychopathological history of the patient, and the patient understands that their confidentiality will be respected. [ 17 ] The process of brief therapy under emergency psychiatric conditions includes the establishment of a primary complaint from the patient, realizing psychosocial factors, formulating an accurate representation of the problem, coming up with ways to solve the problem, and setting specific goals. [ 17 ] The information gathering aspect of brief psychotherapy is therapeutic because it helps the patient place his or her problem in the proper perspective. [ 17 ] If the physician determines that deeper psychotherapy sessions are required, he or she can transition the patient out of the emergency setting and into an appropriate clinic or center. [ 17 ] Electroconvulsive therapy is a controversial form of treatment which cannot be involuntarily applied in psychiatric emergency service settings. [ 17 ] [ 18 ] Instances wherein a patient is depressed to such a severe degree that the patient cannot be stopped from hurting himself or herself or when a patient refuses to swallow, eat or drink medication, electroconvulsive therapy could be suggested as a therapeutic alternative. [ 17 ] While preliminary research suggests that electroconvulsive therapy may be an effective treatment for depression, it usually requires a course of six to twelve sessions of convulsions lasting at least 20 seconds for those antidepressant effects to occur. [ 11 ] There are other essential aspects of emergency psychiatry: observation and collateral information. The observation of the patient's behavior is an important aspect of emergency psychiatry as it allows the clinicians working with the patient to estimate prognosis and improvements/declines in condition. Many jurisdictions base involuntary commitment on dangerousness or the inability to care for one's basic needs. Observation for a period of time may help determine this. For example, if a patient who is committed for violent behavior in the community, continues to behave in an erratic manner without clear purpose, this will help the staff decide that hospital admission may be needed. Collateral information or parallel information is information obtained from family, friends or treatment providers of the patient. Some jurisdictions require consent from the patient to obtain this information while others do not. For example, with a patient who is thought to be paranoid about people following him or spying on him, this information can be helpful discern if these thoughts are more or less likely to be based in reality. Past episodes of suicide attempts or violent behavior can be confirmed or disproven. Patient receive emergency services often on a time limited basis such as 24 or 72 hours. After this time, and sometimes earlier, the staff must decide the next place for the patient to receive services. This is referred to as disposition. This is one of the essential features of emergency psychiatry. The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they can be safely discharged to the community after a period of observation and/or brief treatment. [ citation needed ] Initial emergency psychiatric evaluations usually involve patients who are acutely agitated, paranoid , or who are suicidal. Initial evaluations to determine admission and interventions are designed to be as therapeutic as possible. [ 2 ] Involuntary commitment , or sectioning, refers to situations where police officers , health officers, or health professionals classify an individual as dangerous to themselves, others, gravely disabled , or mentally ill according to the applicable government law for the region. After an individual is transported to a psychiatric emergency service setting, a preliminary professional assessment is completed which may or may not result in involuntary treatment . [ 2 ] Some patients may be discharged shortly after being brought to psychiatric emergency services while others will require longer observation and the need for continued involuntary commitment will exist. While some patients may initially come voluntarily, it may be realized that they pose a risk to themselves or others and involuntary commitment may be initiated at that point. [ citation needed ] In some locations, such as the United States, voluntary hospitalizations are outnumbered by involuntary commitments partly due to the fact that insurance tends not to pay for hospitalization unless an imminent danger exists to the individual or community. In addition, psychiatric emergency service settings admit approximately one third of patients from assertive community treatment centers. [ 2 ] Therefore, patients who are not admitted will be referred to services in the community.	https://en.wikipedia.org/wiki/Emergency_psychiatry
Emerson Colon Angell (1822–1903) was an American dentist who is known as the father of the rapid maxillary expansion. [ 1 ] He published a paper in Dental Cosmos in 1860 in which he described this technique. [ 2 ] [ 3 ] He was born and grew up in Scituate, Rhode Island . He was the 7th generation of his family from Rhode Island. He was a descendant of Thomas Angell . Emerson learned agriculture and mechanics from his father. He began studying dentistry in 1846, under mentorship of people in the community due to the lack of any formal education available at that time. He eventually practiced in Rhode Island, New York City and San Francisco. Emerson first published a paper on expansion of palate in San Francisco Medical Press (SFMP) in January 1860. [ 4 ] This initial paper described the expansion of palate with deciduous teeth, which was later followed by another paper on the permanent teeth dentition in SFMP. His first paper was a case report which focused on a 14-year-old patient with a posterior Crossbite . Emerson fitted this patient with an appliance in his maxillary arch and gave patients instructions to turn the screw every day. Emerson claimed that expansion was achieved in 2 weeks by separation of maxilla along the Midpalatal suture . Dr. Angell faced much criticism from people in the field of dentistry at that point. [ 5 ] This dentistry article is a stub . You can help Wikipedia by expanding it . This biographical article related to medicine in the United States is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Emerson_C._Angell
Emil Wilhelm Georg Magnus Kraepelin ( / ˈ k r ɛ p əl ɪ n / ; German: [ˈeːmiːl 'kʁɛːpəliːn] ; 15 February 1856 – 7 October 1926) was a German psychiatrist . H. J. Eysenck 's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. His theories dominated psychiatry at the start of the 20th century and, despite the later psychodynamic influence of Sigmund Freud and his disciples, enjoyed a revival at century's end. While he proclaimed his own high clinical standards of gathering information "by means of expert analysis of individual cases", he also drew on reported observations of officials not trained in psychiatry. His textbooks do not contain detailed case histories of individuals but mosaic-like compilations of typical statements and behaviors from patients with a specific diagnosis. He has been described as "a scientific manager" and "a political operator", who developed "a large-scale, clinically oriented, epidemiological research programme". He developed racist psychiatric theories. [ 2 ] [ 3 ] Kraepelin, whose father, Karl Wilhelm, was a former opera singer, music teacher, and later successful story teller, [ 4 ] was born in 1856 in Neustrelitz , in the Duchy of Mecklenburg-Strelitz in Germany . He was first introduced to biology by his brother Karl , 10 years older and, later, the director of the Naturhistorisches Museum Hamburg. [ 5 ] Kraepelin began his medical studies in 1874 at the University of Leipzig and completed them at the University of Würzburg (1877–78). [ 1 ] At Leipzig, he studied neuropathology under Paul Flechsig and experimental psychology with Wilhelm Wundt . Kraepelin would be a disciple of Wundt and had a lifelong interest in experimental psychology based on his theories. While there, Kraepelin wrote a prize-winning essay, "The Influence of Acute Illness in the Causation of Mental Disorders". [ 6 ] At Würzburg he completed his Rigorosum (roughly equivalent to a PhD level viva-voce examination , literally "rigorous exam") in March 1878, his Staatsexamen (licensing examination) in July 1878, and his Approbation (his license to practice medicine; roughly equivalent to an MBBS ) on 9 August 1878. [ 1 ] From August 1878 to 1882, [ 1 ] he worked with Bernhard von Gudden at the University of Munich . Returning to the University of Leipzig in February 1882, [ 1 ] he worked in Wilhelm Heinrich Erb 's neurology clinic and in Wundt's psychopharmacology laboratory. [ 6 ] He completed his habilitation thesis - major postdoc publication and process - at Leipzig; [ 1 ] it was entitled "The Place of Psychology in Psychiatry". [ 6 ] On 3 December 1883 he completed his umhabilitation ("habilitation" at another institution than originally applied for = habilitation recognition procedure) at Munich. [ 1 ] Kraepelin's major work, Compendium der Psychiatrie: Zum Gebrauche für Studirende und Aerzte ( Compendium of Psychiatry: For the Use of Students and Physicians ), was first published in 1883 and was expanded in subsequent multivolume editions to Ein Lehrbuch der Psychiatrie ( A Textbook: Foundations of Psychiatry and Neuroscience ). In it, he argued that psychiatry was a branch of medical science and should be investigated by observation and experimentation like the other natural sciences. He called for research into the physical causes of mental illness, and started to establish the foundations of the modern classification system for mental disorders. Kraepelin proposed that by studying case histories and identifying specific disorders, the progression of mental illness could be predicted, after taking into account individual differences in personality and patient age at the onset of disease. [ 6 ] In 1884, he became senior physician in the Prussian provincial town of Leubus , Silesia Province , and the following year he was appointed director of the Treatment and Nursing Institute in Dresden . On 1 July 1886, [ 1 ] at the age of 30, Kraepelin was named Professor of Psychiatry at the University of Dorpat (today the University of Tartu ) in what is today Tartu, Estonia (see Burgmair et al., vol. IV). Four years later, on 5 December 1890, [ 1 ] he became department head at the University of Heidelberg , where he remained until 1904. [ 6 ] While at Dorpat he became the director of the 80-bed University Clinic , where he began to study and record many clinical histories in detail and "was led to consider the importance of the course of the illness with regard to the classification of mental disorders". In 1903, Kraepelin moved to Munich to become Professor of Clinical Psychiatry at the University of Munich . [ 7 ] In 1908, he was elected a member of the Royal Swedish Academy of Sciences . [ citation needed ] In 1912, at the request of the DVP (Deutscher Verein für Psychiatrie; German Association for Psychiatry), [ 8 ] of which he was the head from 1906 to 1920, he began plans to establish a centre for research. Following a large donation from the Jewish German-American banker James Loeb , who had at one time been a patient, and promises of support from "patrons of science", the German Institute for Psychiatric Research was founded in 1917 in Munich. [ 9 ] [ 10 ] Initially housed in existing hospital buildings, it was maintained by further donations from Loeb and his relatives. In 1924 it came under the auspices of the Kaiser Wilhelm Society for the Advancement of Science . The German-American Rockefeller family 's Rockefeller Foundation made a large donation enabling the development of a new dedicated building for the institute along Kraepelin's guidelines, which was officially opened in 1928. [ 6 ] Kraepelin spoke out against the barbarous treatment that was prevalent in the psychiatric asylums of the time, and crusaded against alcohol, capital punishment and the imprisonment rather than treatment of the insane. For the sedation of agitated patients, Kraepelin recommended potassium bromide . [ 11 ] He rejected psychoanalytical theories that posited innate or early sexuality as the cause of mental illness, and he rejected philosophical speculation as unscientific . He focused on collecting clinical data and was particularly interested in neuropathology (e.g., diseased tissue). [ 6 ] He also firmly rejected the assumption of natural difference in relation to homosexuality, which he regarded as a vice caused by masturbation. In 1918 he called for "educational discipline" such as those introduced by the Nazi party after 1933: severe punishments for the crime of 'corruption' (seduction), applicable to any act related to sexual gratification. This extended the anti-gay policy of the time, which only punished sexual intercourse between men. These ideas eventually went on to lend legitimacy to Nazi policies that persecuted gay people, allowing the Nazi party to do so under the guise of conforming to scientific opinions. His work legitimized the persecution and inhumane treatment of gay people in Nazi Germany. [ 12 ] In the later period of his career, as a convinced champion of social Darwinism , he actively promoted a policy and research agenda in racial hygiene and eugenics . [ 13 ] Kraepelin retired from teaching at the age of 66, spending his remaining years establishing the institute. The ninth and final edition of his Textbook was published in 1927, shortly after his death. It comprised four volumes and was ten times larger than the first edition of 1883. [ 6 ] In the last years of his life, Kraepelin was preoccupied with Buddhist teachings and was planning to visit Buddhist shrines at the time of his death, according to his daughter, Antonie Schmidt-Kraepelin. [ 14 ] Kraepelin announced that he had found a new way of looking at mental illness, referring to the traditional view as "symptomatic" and to his view as "clinical". This turned out to be his paradigm -setting synthesis of the hundreds of mental disorders classified by the 19th century, grouping diseases together based on classification of syndrome —common patterns of symptoms over time—rather than by simple similarity of major symptoms in the manner of his predecessors. Kraepelin described his work in the 5th edition of his textbook as a "decisive step from a symptomatic to a clinical view of insanity. . . . The importance of external clinical signs has . . . been subordinated to consideration of the conditions of origin, the course, and the terminus which result from individual disorders. Thus, all purely symptomatic categories have disappeared from the nosology ". [ 15 ] Kraepelin is specifically credited with the classification of what was previously considered to be a unitary concept of psychosis , into two distinct forms (known as the Kraepelinian dichotomy ): Drawing on his long-term research, and using the criteria of course, outcome and prognosis , he developed the concept of dementia praecox , which he defined as the "sub-acute development of a peculiar simple condition of mental weakness occurring at a youthful age". When he first introduced this concept as a diagnostic entity in the fourth German edition of his Lehrbuch der Psychiatrie in 1893, it was placed among the degenerative disorders alongside, but separate from, catatonia and dementia paranoides . At that time, the concept corresponded by and large with Ewald Hecker 's hebephrenia . In the sixth edition of the Lehrbuch in 1899 all three of these clinical types are treated as different expressions of one disease, dementia praecox. [ 17 ] One of the cardinal principles of his method was the recognition that any given symptom may appear in virtually any one of these disorders; e.g., there is almost no single symptom occurring in dementia praecox which cannot sometimes be found in manic depression. What distinguishes each disease symptomatically (as opposed to the underlying pathology ) is not any particular ( pathognomonic ) symptom or symptoms, but a specific pattern of symptoms. In the absence of a direct physiological or genetic test or marker for each disease, it is only possible to distinguish them by their specific pattern of symptoms. Thus, Kraepelin's system is a method for pattern recognition, not grouping by common symptoms. It has been claimed that Kraepelin also demonstrated specific patterns in the genetics of these disorders and patterns in their course and outcome, [ 18 ] but no specific biomarkers have yet been identified. Generally speaking, there tend to be more people with schizophrenia among the relatives of schizophrenic patients than in the general population, while manic depression is more frequent in the relatives of manic depressives. Though, of course, this does not demonstrate genetic linkage, as this might be a socio - environmental factor as well. He also reported a pattern to the course and outcome of these conditions. Kraepelin believed that schizophrenia had a deteriorating course in which mental function continuously (although perhaps erratically) declines, while manic-depressive patients experienced a course of illness which was intermittent, where patients were relatively symptom-free during the intervals which separate acute episodes. This led Kraepelin to name what we now know as schizophrenia, dementia praecox (the dementia part signifying the irreversible mental decline). It later became clear that dementia praecox did not necessarily lead to mental decline and was thus renamed schizophrenia by Eugen Bleuler to correct Kraepelin's misnomer. In addition, as Kraepelin accepted in 1920, "It is becoming increasingly obvious that we cannot satisfactorily distinguish these two diseases"; however, he maintained that "On the one hand we find those patients with irreversible dementia and severe cortical lesions. On the other are those patients whose personality remains intact". [ 19 ] Nevertheless, overlap between the diagnoses and neurological abnormalities (when found) have continued, and in fact a diagnostic category of schizoaffective disorder would be brought in to cover the intermediate cases. Kraepelin devoted very few pages to his speculations about the etiology of his two major insanities, dementia praecox and manic-depressive insanity. However, from 1896 to his death in 1926 he held to the speculation that these insanities (particularly dementia praecox) would one day probably be found to be caused by a gradual systemic or "whole body" disease process, probably metabolic , which affected many of the organs and nerves in the body but affected the brain in a final, decisive cascade. [ 20 ] In the first through sixth edition of Kraepelin's influential psychiatry textbook, there was a section on moral insanity , which meant then a disorder of the emotions or moral sense without apparent delusions or hallucinations, and which Kraepelin defined as "lack or weakness of those sentiments which counter the ruthless satisfaction of egotism". He attributed this mainly to degeneration. This has been described as a psychiatric redefinition of Cesare Lombroso 's theories of the "born criminal", conceptualised as a " moral defect", though Kraepelin stressed it was not yet possible to recognise them by physical characteristics. [ 21 ] In fact from 1904 Kraepelin changed the section heading to "The born criminal", moving it from under "Congenital feeble-mindedness" to a new chapter on "Psychopathic personalities". They were treated under a theory of degeneration. Four types were distinguished: born criminals (inborn delinquents), pathological liars , querulous persons, and Triebmenschen (persons driven by a basic compulsion, including vagabonds , spendthrifts , and dipsomaniacs ). The concept of " psychopathic inferiorities" had been recently popularised in Germany by Julius Ludwig August Koch , who proposed congenital and acquired types. Kraepelin had no evidence or explanation suggesting a congenital cause, and his assumption therefore appears to have been simple " biologism ". Others, such as Gustav Aschaffenburg , argued for a varying combination of causes. Kraepelin's assumption of a moral defect rather than a positive drive towards crime has also been questioned, as it implies that the moral sense is somehow inborn and unvarying, yet it was known to vary by time and place, and Kraepelin never considered that the moral sense might just be different. Kurt Schneider criticized Kraepelin's nosology on topics such as Haltlose for appearing to be a list of behaviors that he considered undesirable, rather than medical conditions, though Schneider's alternative version has also been criticised on the same basis. Nevertheless, many essentials of these diagnostic systems were introduced into the diagnostic systems, and remarkable similarities remain in the DSM-5 and ICD-10. [ 21 ] The issues would today mainly be considered under the category of personality disorders , or in terms of Kraepelin's focus on psychopathy . Kraepelin had referred to psychopathic conditions (or "states") in his 1896 edition, including compulsive insanity, impulsive insanity, homosexuality , and mood disturbances. From 1904, however, he instead termed those "original disease conditions, and introduced the new alternative category of psychopathic personalities. In the eighth edition from 1909 that category would include, in addition to a separate "dissocial" type, the excitable, the unstable, the Triebmenschen driven persons, eccentrics, the liars and swindlers, and the quarrelsome. It has been described as remarkable that Kraepelin now considered mood disturbances to be not part of the same category, but only attenuated (more mild) phases of manic depressive illness; this corresponds to current classification schemes. [ 22 ] Kraepelin postulated that there is a specific brain or other biological pathology underlying each of the major psychiatric disorders. [ 23 ] As a colleague of Alois Alzheimer , he was a co-discoverer of Alzheimer's disease , and his laboratory discovered its pathological basis. Kraepelin was confident that it would someday be possible to identify the pathological basis of each of the major psychiatric disorders. [ citation needed ] Upon moving to become Professor of Clinical Psychiatry at the University of Munich in 1903, Kraepelin increasingly wrote on social policy issues. He was a strong and influential proponent of eugenics and racial hygiene . His publications included a focus on alcoholism , crime , degeneration and hysteria . [ 2 ] Kraepelin was convinced that such institutions as the education system and the welfare state , because of their trend to break the processes of natural selection , undermined the Germans' biological "struggle for survival". [ 13 ] He was concerned to preserve and enhance the German people, the Volk , in the sense of nation or race. He appears to have held Lamarckian concepts of evolution, such that cultural deterioration could be inherited. He was a strong ally and promoter of the work of fellow psychiatrist (and pupil and later successor as director of the clinic) Ernst Rüdin to clarify the mechanisms of genetic inheritance as to make a so-called " empirical genetic prognosis ". [ 2 ] Martin Brune has pointed out that Kraepelin and Rüdin also appear to have been ardent advocates of a self-domestication theory, a version of social Darwinism which held that modern culture was not allowing people to be weeded out, resulting in more mental disorder and deterioration of the gene pool. Kraepelin saw a number of "symptoms" of this, such as "weakening of viability and resistance, decreasing fertility, proletarianisation, and moral damage due to "penning up people" [ Zusammenpferchung ]. He also wrote that "the number of idiots, epileptics, psychopaths, criminals, prostitutes, and tramps who descend from alcoholic and syphilitic parents, and who transfer their inferiority to their offspring, is incalculable". He felt that "the well-known example of the Jews , with their strong disposition towards nervous and mental disorders, teaches us that their extraordinarily advanced domestication may eventually imprint clear marks on the race". Brune states that Kraepelin's nosological system "was, to a great deal, built on the degeneration paradigm ". [ 24 ] Kraepelin's great contribution in classifying schizophrenia and manic depression remains relatively unknown to the general public, and his work, which had neither the literary quality nor paradigmatic power of Freud's, is little read outside scholarly circles. Kraepelin's contributions were also to a large extent marginalized throughout a good part of the 20th century during the success of Freudian etiological theories. However, his views now dominate many quarters of psychiatric research and academic psychiatry. His fundamental theories on the diagnosis of psychiatric disorders form the basis of the major diagnostic systems in use today, especially the American Psychiatric Association 's DSM-IV and the World Health Organization 's ICD system, based on the Research Diagnostic Criteria and earlier Feighner Criteria developed by espoused "neo-Kraepelinians", though Robert Spitzer and others in the DSM committees were keen not to include assumptions about causation as Kraepelin had. [ 15 ] [ 25 ] Kraepelin has been described as a "scientific manager" [ 26 ] [ 27 ] and political operator, who developed a large-scale, clinically oriented, epidemiological research programme. In this role he took in clinical information from a wide range of sources and networks. Despite proclaiming high clinical standards for himself to gather information "by means of expert analysis of individual cases", he would also draw on the reported observations of officials not trained in psychiatry. The various editions of his textbooks do not contain detailed case histories of individuals, however, but mosaiclike compilations of typical statements and behaviors from patients with a specific diagnosis. Kraepelin wrote in a knapp und klar (concise and clear) style that made his books useful tools for physicians. Abridged and clumsy English translations of the sixth and seventh editions of his textbook in 1902 and 1907 (respectively) by Allan Ross Diefendorf (1871–1943), an assistant physician at the Connecticut Hospital for the Insane at Middletown, inadequately conveyed the literary quality of his writings that made them so valuable to practitioners. [ 28 ] Among the doctors trained by Alois Alzheimer and Emil Kraepelin at Munich at the beginning of the 20th century were the Spanish neuropathologists and neuropsychiatrists Nicolás Achúcarro and Gonzalo Rodríguez Lafora , two distinguished disciples of Santiago Ramón y Cajal and members of the Spanish Neurological School . In the Heidelberg and early Munich years he edited Psychologische Arbeiten , a journal on experimental psychology. One of his own famous contributions to this journal also appeared in the form of a monograph (105 pp.) entitled Über Sprachstörungen im Traume ( On Language Disturbances in Dreams ). [ 29 ] Kraepelin, on the basis of the dream- psychosis analogy, studied for more than 20 years language disorder in dreams in order to study indirectly schizophasia . The dreams Kraepelin collected are mainly his own. They lack extensive comment by the dreamer. In order to study them the full range of biographical knowledge available today on Kraepelin is necessary (see, e.g., Burgmair et al., I-IX). For biographies of Kraepelin see: For English translations of Kraepelin's work see:	https://en.wikipedia.org/wiki/Emil_Kraepelin
Emily Blackwell (October 8, 1826 – September 7, 1910) was an American physician and women's rights activist. She was the second woman to earn a medical degree at what is now Case Western Reserve University , after Nancy Talbot Clark . She made major advancements in the medical scene, assisting in the start of the New York Infirmary for Indigent Women and Children [ 1 ] and creating the Women's Central Association of Relief . [ 2 ] Blackwell, along with her sister Elizabeth , established the Women's Medical College in New York City. [ 3 ] Shortly after, she helped form the London School of Medicine for Women . [ 3 ] In 1993, she was inducted into the National Women's Hall of Fame . Blackwell was born on October 8, 1826, in Bristol , England. She was the sixth of nine surviving children of Samuel and Hannah Lane Blackwell. The Blackwell family had been very prosperous for the time, educating Emily with private tutors. The Blackwell household was said to be very intelligent and stimulating. Especially because her father Samuel was many things including a dissident, reformer, and a lay preacher. At a young age Emily was shy but extremely intelligent, she would perform different experiments in her family attic. Also in her youth Emily became an "amateur expert" in certain fields like flowers and birds. She gained this title through reading extensively about and observing different flowers and birds around the family's house. [ 4 ] Blackwell's parents were considered to be liberal in their view of education and pushed mathematics and science on her at a young age. In 1832, Blackwell and her family emigrated to the United States. They spent time living in New York City , NY and Jersey City , New Jersey before her family finally settled near Cincinnati , Ohio in 1837. [ 5 ] Her father passed shortly after this move, in 1838, when Emily was at the age of eleven, and by 1844, the family was living at Lane Theological Seminary in Walnut Hills . It was here that the children made friends with Henry Ward Beecher and Harriet Beecher Stowe , whose father had founded the seminary. [ 6 ] Inspired by the example of her older sister, Elizabeth , Blackwell applied to study medicine at Geneva Medical College in Geneva , New York, from which her sister graduated in 1849, but was rejected. After being rejected by several other schools, she was finally accepted in 1853 by Rush Medical College in Chicago , where she studied for a year. However, in 1853, when male students complained about having to study with a woman, the Illinois Medical Society vetoed her admission. Eventually, she was accepted to the Medical College of Cleveland, Ohio, Medical Branch of Western Reserve University , earning her Doctor of Medicine in 1854 with honors . [ 7 ] At Western Reserve University , the medical education of women began at the urging of Dean John Delamater, who was backed by the Ohio Female Medical Education Society , formed in 1852 to provide moral and financial support for the women medical students. Despite their efforts, the Western Reserve faculty voted to put an end to Delamater's policies in 1856, finding it "inexpedient" to continue admitting women. (The American Medical Association also adopted a report in 1856 advising against coeducation in medicine.) Western Reserve resumed admitting women in 1879, but did so only sporadically for five years. Admission of women at Western Reserve recommenced on a continuous basis in 1918. After earning her medical degree, Blackwell pursued further studies in Edinburgh under Sir James Young Simpson , in London under Dr. William Jenner , and in Paris , Berlin , and Dresden . In 1857, Blackwell, along with her sister Elizabeth and Marie Zakrzewska , established the New York Infirmary for Indigent Women and Children . Also Emily raised $50,000 to start a medical school in 1859. And in 1860 the infirmary began to train women as assistant physicians. [ 1 ] From the beginning, Emily Blackwell took responsibility for the management of the infirmary and for the raising of funds. For the next forty years, she managed the infirmary, overseeing surgery, nursing, and bookkeeping . Blackwell traveled to Albany to convince the legislature to provide the hospital with funds that would ensure long-term financial stability. She transformed an institution housed in a rented 16-room house into a full-fledged hospital. In 1871 the New York County Medical Society accepted Emily as a member. [ 8 ] By 1874, the infirmary served over 7,000 patients annually. Emily Blackwell is largely responsible for the long term survival of the New York Infirmary for Indigent Women and Children . [ 4 ] With Blackwell's assistance, the infirmary was able to provide medical care to underserved women and children in the community. [ 4 ] During the American Civil War , Blackwell helped organize the Women's Central Association of Relief , which selected and trained nurses for service in the war. The WCAR had trained close to 4000 American women in order to distribute life-saving supplies across the United States. Between the years 1861 to 1863, the group had distributed over 470,000 articles of clothing and close to 300,000 bedding items. Emily and Elizabeth Blackwell and Mary Livermore also played an important role in the development of the United States Sanitary Commission . [ 9 ] After the war, in 1868 the Blackwell sisters established the Women's Medical College in New York City . For 30 years Emily served as a professor for over 300 women in studies of obstetrics and gynecology before co-ed medical schools were a common practice, and in 1869, when Elizabeth moved to London to help form the London School of Medicine for Women , became dean of the college. In 1876 it became a three-year institution, and in 1893 it became a four-year college, ahead of much of the profession. By 1899 the college had trained 364 women doctors. Among those on staff at the college during this time was Mary Putnam Jacobi , who taught materia medica and therapeutics. [ 10 ] From 1883, Blackwell lived with Elizabeth Cushier , who also served as a doctor at the infirmary. [ 11 ] When Blackwell was 44, she adopted a baby named Nanny. [ 12 ] Blackwell and Cushier retired at the turn of the century. Blackwell had viewed her retirement as an opportunity to focus her efforts on the expansion of social formalities by addressing more broad social issues and pushing for continuous societal change. [ 13 ] Following Emily's retirement in 1900, the infirmary still stands and does excellent work under a new name, the NYU downtown hospital. [ 1 ] After traveling abroad in Europe for a year and a half, they spent the next winters at their home in Montclair , New Jersey, and summers in York Cliffs, Maine . [ 14 ] She also frequently traveled to California and parts of Southern Europe for her health. Emily was able to see her sister Elizabeth one final time in 1906 before the eldest Blackwell fell down a flight of stairs and never fully recovered and ended up passing in May 1910. [ 1 ] Emily Blackwell died due to enterocolitis on September 7, 1910, in York Cliffs , Maine, a few months after her sister Elizabeth's death in England. [ 15 ]	https://en.wikipedia.org/wiki/Emily_Blackwell
Eminectomy is a surgical procedure that reduces the articular eminence to correct chronic dislocation or closed lock of the mandible. The temporoparietal fascia , which is the most superficial fascia layer beneath the subcutaneous fat, is the galea's lateral extension and is continuous with the superficial musculoaponeurotic layer (SMAS). Divide the dissection into thirds. The upper third of the body is completed first. The second section of the dissection is contained within the incision's lower third. [ 1 ] When bilateral eminectomy is required, the procedure is repeated on the contralateral side. The third section of the dissection connects the incision's middle third to the dissection's superior and inferior thirds. Ice packs are applied to the surgical area for 24 hours following eminectomy. Appropriate patient selection is critical for a successful eminectomy procedure. [ 2 ] [ 3 ]	https://en.wikipedia.org/wiki/Eminectomy
Emotions Anonymous ( EA ) is a twelve-step program for recovery from mental and emotional illness . [ 1 ] It is modeled after Alcoholics Anonymous . Founded in 1971, it is a self-help organization that offers peer support to people experiencing a wide range of emotional and mental health challenges, including depression, anxiety, grief, anger, and relationship problems. The program follows the same twelve steps and twelve traditions as other recovery programs, with adaptations focusing on emotional well-being rather than substance addiction. Emotions Anonymous operates through local support groups that meet regularly across numerous countries worldwide, providing a space where members can share their experiences and work toward emotional sobriety in a confidential environment. The organization is self-supporting through member contributions and publishes literature to assist in the recovery process. There are approximately 300 Emotions Anonymous groups active in the United States and another 300 around the world in 30 countries. [ 2 ] Marion Flesch (July 24, 1911 – October 10, 2004) is responsible for creating the groups that would later become known as Emotions Anonymous. Marion was a graduate of St. Cloud State Teachers College (now St. Cloud State University ) and at various times worked as a teacher , secretary , clerk , accountant , bookkeeper and office manager . Later in life she became a certified chemical dependency counselor through the University of Minnesota and started work on a master's degree, but stopped at age 80 due to health concerns. Marion originally went to Al-Anon meetings at the advice of a friend to help cope with panic attacks . [ 3 ] Later Marion learned of another twelve-step program, Neurotics Anonymous and she started the first such meeting in Minnesota held April 13, 1966, at the Merriam Park Community Center in St. Paul . Neurotics Anonymous grew quickly in Minnesota, and by fall of 1966 there were thirty active groups in the state. [ 4 ] Differences developed between the Minnesota groups and the central offices of Neurotics Anonymous. The Minnesota Intergroup Association separated from Neurotics Anonymous on July 6, 1971. After unsuccessful attempts to reconcile differences with Neurotics Anonymous, the Minnesota groups later adopted the name Emotions Anonymous. They wrote to Alcoholics Anonymous World Services for permission to use the Twelve Steps and Twelve Traditions . Permissions were eventually granted. Emotions Anonymous officially filed articles of incorporation on July 22, 1971. [ 4 ] EA is not intended to be a replacement for psychotherapy , psychiatric medication , or any kind of professional mental health treatment. [ 5 ] People may find useful as a complement to mental health treatment, as a personal means to better mental health in general, or when psychiatric treatment is not available or they have resistance to psychiatric treatment. [ 6 ] EA does not attempt to coerce members into following anyone's advice. [ 7 ] Jim Voytilla of the Ramsey County, Minnesota , Human Services Department created EA groups for intellectually disabled substance abusers in 1979. Voytilla noted when this particular demographic of substance abusers attended AA meetings in the surrounding community, they felt uncomfortable and made others attending the meetings uncomfortable. Voytilla's EA meetings were created to avoid these problems, and address the illnesses of his clients other than substance abuse. [ 8 ] Since then, four articles have narrowly defined EA as a program specifically for intellectually disabled substance abusers. [ 9 ] [ 10 ] [ 11 ] [ 12 ] In a similar way, EA has also been incorrectly described as an organization either specifically or primarily for those who have been discharged from psychiatric hospitals. [ 13 ] EA does not discriminate against any demographic. All that is needed to join EA is a desire to become emotionally well. EA is not, and never has been, a program specifically for people of any particular background or treatment history. [ 14 ] It is not uncommon for individuals in recovery from addictions or former patients in psychiatric hospitals to seek help in EA after being discharged. [ 15 ] Emotions Anonymous views mental and emotional illness as chronic and progressive, like addiction . EA members find they "hit bottom" when the consequences of their mental and emotional illness cause complete despair. [ 16 ] Twelve-step groups symbolically represent human structure in three dimensions: physical, mental, and spiritual. The illnesses the groups deal with are understood to manifest themselves in each dimension. The First Step in each twelve-step group states what members have been unable to control with their willpower . In some cases the emphasis is on the experience in the physical dimension; in AA the First Step suggests admitting powerlessness over alcohol , in Overeaters Anonymous (OA) it is powerlessness over food . In other groups the First Step emphasizes the experience in the mental dimension; in NA the First Step suggests admitting powerlessness over addiction, in EA (as well as Neurotics Anonymous), it is powerlessness over emotions. Emotions Anonymous focuses on deviant moods and emotions , not just a craving for mood alteration. The subjective experience of powerlessness over one's emotions can generate multiple kinds of behavioral disorders, or it can be a cause of mental suffering with no consistent behavioral manifestation (such as affective disorders). [ 17 ] In the Third Step members surrender their will to a Higher Power , this should not be understood as encouraging passiveness, rather its purpose is to increase acceptance of reality. [ 16 ] The process of working the Twelve Steps is intended to replace self-centeredness with a growing moral consciousness and a willingness for self-sacrifice and unselfish constructive action; this is known as a spiritual awakening, or religious experience . [ 18 ] [ 17 ] Emotions Anonymous publishes three books approved for use in the organization. Emotions Anonymous is the primary book, the Today book contains 366 daily meditation readings related the EA program, and It Works If You Work It discusses EA's tools and guidelines in detail. All twelve-step programs use the Twelve Steps and Twelve Traditions , but most have their own specialized tools and guidelines emphasizing the focus of their program. EA developed the "Twelve Helpful Concepts," [ 19 ] and "What EA Is...and Is Not." [ 5 ] the "Just for Todays," [ 19 ] as well as a slightly modified version of AA's Twelve Promises. [ 19 ] The EA "Just For Todays" were adapted by a twelve-step organization for female victims of domestic violence with substance abuse histories, Wisdom of Women (WOW). [ 20 ]	https://en.wikipedia.org/wiki/Emotions_Anonymous
An empyema ( / ˌ ɛ m p aɪ ˈ iː m ə / ; from Ancient Greek ἐμπύημα (empúēma) ' abscess ' ) is a collection or gathering of pus within a naturally existing anatomical cavity. The term is most commonly used to refer to pleural empyema , [ 1 ] which is empyema of the pleural cavity . It is similar or the same in meaning as an abscess , but the context of use may sometimes be different. For instance, appendicular abscess is also formed within a natural cavity as the definition of empyema. Empyema most commonly occurs as a complication of pneumonia but can also result from other infections or conditions that lead to the collection of infected fluid in a body cavity. [ 2 ] Empyema occurs in: Chest X-rays or computed tomography (CT) scans can reveal the presence of fluid within the pleural space and help assess its characteristics. Once a fluid-filled cavity has been identified, it is often partially or fully drained with a needle, so that the fluid may be analyzed. This helps determine whether the fluid is infected and allows for the identification of the causative microorganisms. Blood tests may also be performed, which can identify both an elevated neutrophil count, which is indicative of an infection, or bacteremia . [ 2 ] In addition to CT, suspected cases of empyema in and around the brain are often subjected to more rigorous neuroimaging techniques, including MRI . In these cases, fluid samples are obtained via stereotactic needles rather than lumbar puncture , because unlike most cases of meningitis , a lumbar puncture will most often not reveal anything about the causative microorganisms. [ 3 ] This immunology article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Empyema
Enamel lamellae are a type of hypomineralized structure in teeth that extend either from the dentinoenamel junction (DEJ) to the surface of the enamel , or vice versa. In essence, they are prominent linear enamel defects, but are of no clinical consequence. [ 1 ] These structures contain proteins , proteoglycans , and lipids. Enamel lamellae should not be confused with two similar entities, enamel tufts and enamel spindles . Enamel tufts are small branching defects that are found only at the DEJ, and so differ from lamellae which can be facing either direction and are strictly linear. Enamel spindles are also linear defects, but they too can be found only at the DEJ, because they are formed by entrapment of odontoblast processes between ameloblasts prior to and during amelogenesis . They may be classified as Type A, Type B and Type C, based on its extension, cause of formation and contents. Based on time of development, they may be classified as pre-and post-eruptive enamel lamellae. This dentistry article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Enamel_lamellae
Enamel microabrasion is a procedure in cosmetic dentistry used to improve the appearance of the teeth. Like tooth whitening it is used to remove discolorations of the tooth surface but microabrasion is both a mechanical and chemical procedure. In the past, teeth with stains or other color changes were made to look better through the use of restorative materials, such as dental porcelain . These materials would create a thin veneer over the outer surface of the tooth. Although veneers looked better, these materials did not match the structure or characteristics of the tooth enamel and replacement was frequently needed. As far back as 1916, some researchers were advocating instead removing a thin layer of the outermost enamel to expose the (presumably) undamaged layer underneath. [ 1 ] The first practical application of enamel microabrasion was developed by Theodore Croll and Richard Cavanaugh in 1986, who used a combination of weak hydrochloric acid and pumice to remove a few tenths of millimeters of the enamel. [ 2 ] [ 3 ] Contemporary enamel microabrasion uses a combination of mechanical and chemical means to remove of a small amount of tooth enamel (not more than a few tenths of a millimeter) to eliminate superficial discoloration. [ 4 ] These discolorations can result from either from extrinsic factors (such as tobacco, dental plaque, certain foods, etc.) or intrinsic ones (most commonly dental fluorosis ). Dental fluorosis is the most common indication where it ranges in severity from mild to severe, microabrasion should be considered the first option in treating mild and moderate cases of fluorosis. [ 5 ] Removal of intrinsic enamel stains, correction of surface irregularities and defects in enamel caused either after removal of orthodontic appliances or during tooth formation. [ 6 ] [ 7 ] The patients' age is not a limiting factor for the enamel microabrasion technique but in cases of not fully erupted teeth , it may be difficult to place rubber dam for the microabrasion process [ 8 ] Microabrasion is not indicated when discoloration is located in dentin such as in dentigenous imperfecta or tetracycline discoloration. Should be delayed or not used in patients with deficient labial seal because enamel surfaces are extremely dry which makes stains more obvious.so, Sundfeld, et al in 2007, found that orthodontic lip repositioning should be done first to make removal of these stains more effective. [ 9 ] Patients can benefit from combined microabrasion and bleaching techniques as microabrasion causes reduction in the enamel surface and sometimes the tooth surface appear yellowish or darker due to exposure of dentin surface and thinning of enamel layer over it. In this condition, correction of this yellow color can be achieved by using tooth whitening technique to mask the color. [ 8 ] Fragoso, et al. (2011) found that applying fluoride paste on enamel surface after microabrasion process provides higher hardness & more enamel smoothness. [ 10 ] in addition, Segura et al found that the treated enamel surface become more resistant to demineralisation than untreated enamel and less colonisation of bacteria occur. [ 11 ]	https://en.wikipedia.org/wiki/Enamel_microabrasion
Enamel spindles are "short, linear defects, found at the dentinoenamel junction (DEJ) and extend into the enamel , often being more prevalent at the cusp tips." [ 1 ] The DEJ is the interface of the enamel and the underlying dentin . Because they are "formed by entrapment of odontoblast processes between ameloblasts prior to and during amelogenesis ," they cannot be found at the enamel surface protruding inward, as enamel lamellae are often located. Enamel spindles are often confused with two other entities: enamel lamellae and enamel tufts . Lamellae are linear enamel defects that extend from the surface of the enamel towards the DEJ, or vice versa. Enamel tufts are "small, branching defects that are found only at the DEJ, protruding into the enamel towards the enamel surface. Enamel spindles however, are in fact odontoblast processes that extend into the enamel. [ 1 ] [ 2 ] This dentistry article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Enamel_spindles
10117 13801 ENSG00000132464 ENSMUSG00000029286 Q9NRM1 O55196 NM_031889 NM_001368133 NM_017468 NP_114095 NP_001355062 NP_059496 Enamelin is an enamel matrix protein (EMPs), that in humans is encoded by the ENAM gene . [ 5 ] [ 6 ] It is part of the non- amelogenins , which comprise 10% of the total enamel matrix proteins. [ 7 ] It is one of the key proteins thought to be involved in amelogenesis (enamel development). The formation of enamel's intricate architecture is thought to be rigorously controlled in ameloblasts through interactions of various organic matrix protein molecules that include: enamelin, amelogenin , ameloblastin , tuftelin , dentine sialophosphoprotein, and a variety of enzymes. Enamelin is the largest protein (~168kDa) in the enamel matrix of developing teeth and is the least abundant (encompasses approximately 1-5%) of total enamel matrix proteins. [ 6 ] It is present predominantly at the growing enamel surface. Enamelin is thought to be the oldest member of the enamel matrix protein (EMP) family, with animal studies showing remarkable conservation of the gene phylogenetically. [ 8 ] All other EMPs are derived from enamelin, such as amelogenin. [ 9 ] EMPs belong to a larger family of proteins termed 'secretory calcium-binding phosphoproteins' (SCPP). [ 10 ] Similar to other enamel matrix proteins, enamelin undergoes extensive post-translational modifications (mainly phosphorylation), processing, and secretion by proteases. Enamelin has three putative phosphoserines (Ser 54 , Ser 191 , and Ser 216 in humans) phosphorylated by a Golgi-associated secretory pathway kinase ( FAM20C ) based on their distinctive Ser-x-Glu (S-x-E) motifs. [ 11 ] The major secretory product of the ENAM gene has 1103 amino acids (post-secretion), and has an acidic isoelectric point ranging from 4.5–6.5 (depending on the fragment). [ 12 ] At the secretory stage, the enzyme matrix metalloproteinase-20 ( MMP20 ) proteolytically cleaves the secreted enamelin protein immediately upon release, into several smaller polypeptides; each having their own functions. However, the whole protein (~168 kDa) and its largest derivative fragment (~89 kDa) are undetectable in the secretory stage; these are existent only at the mineralisation front. [ 7 ] Smaller polypeptide fragments remain embedded in the enamel, throughout the secretory stage enamel matrix. These strongly bind to the mineral and arrest seeded crystal growth. The primary function of the proteins acts at the mineralisation front; growth sites where it is the interface between the ameloblast plasma membrane and lengthening extremity of crystals. The key activities of enamelin can be summarised: It is speculated that this protein could interact with amelogenin or other enamel matrix proteins and be important in determining growth of the length of enamel crystallites. The mechanism of this proposed co-interaction is synergistic (" Goldilocks effect "). With enamelin enhancing the rates of crystal nucleation via the creation of addition sites for EMPs, such as amelogenin, to template calcium phosphate nucleation. [ 14 ] It is best thought to understand the overarching function of enamelin as the proteins responsible for correct enamel thickness formation. Mutations in the ENAM gene can cause certain subtypes of amelogenesis imperfecta (AI), a heterogenous group of heritable conditions in which enamel in malformed. [ 15 ] Point mutations can cause autosomal-dominant hypoplastic AI, and novel ENAM mutations can cause autosomal-recessive hypoplastic AI. [ 16 ] [ 17 ] However, mutations in the ENAM gene mainly tend to lead to the autosomal-dominant AI. [ 13 ] The phenotype of the mutations are generalised thin enamel and no defined enamel layer. [ 7 ] A moderately higher than usual ENAM expression leads to protrusive structures (often, horizontal grooves) on the surface of enamel, and with high transgene expression, the enamel layer is almost lost. [ 18 ]	https://en.wikipedia.org/wiki/Enamelin
Encephaloduroarteriosynangiosis (abbreviated EDAS ) surgery is a neurosurgical procedure performed to treat moyamoya syndrome . [ 1 ] [ 2 ] This surgery article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Encephaloduroarteriosynangiosis
End-of-life care is health care provided in the time leading up to a person's death . End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotional needs, physical comfort, spiritual needs, and practical tasks. [ 1 ] [ 2 ] End-of-life care is most commonly provided at home, in the hospital, or in a long-term care facility with care being provided by family members, nurses, social workers, physicians, and other support staff. Facilities may also have palliative or hospice care teams that will provide end-of-life care services. [ 2 ] Decisions about end-of-life care are often informed by medical, financial and ethical considerations. [ 3 ] [ 4 ] [ 1 ] In most developed countries, medical spending on people in the last twelve months of life makes up roughly 10% of total aggregate medical spending, while those in the last three years of life can cost up to 25%. [ 5 ] Advances in medicine in the last few decades have provided an increasing number of options to extend a person's life and highlighted the importance of ensuring that an individual's preferences and values for end-of-life care are honored. [ 6 ] Advanced care planning is the process by which a person of any age is able to provide their preferences and ensure that their future medical treatment aligns with their personal values and life goals. [ 7 ] It is typically a continual process, with ongoing discussions about a patient's current prognosis and conditions as well as conversations about medical dilemmas and options. [ 8 ] A person will typically have these conversations with their doctor and ultimately record their preferences in an advance healthcare directive . [ 9 ] An advance healthcare directive is a legal document that either documents a person's decisions about desired treatment or indicates who a person has entrusted to make their care decisions for them. [ 10 ] The two main types of advanced directives are a living will and durable power of attorney for healthcare. A living will includes a person's decisions regarding their future care, a majority of which address resuscitation and life support but may also delve into a patient's preferences regarding hospitalization, pain control, and specific treatments that they may undergo in the future. The living will will typically take effect when a patient is terminally ill with low chances of recovery. [ 11 ] A durable power of attorney for healthcare allows a person to appoint another individual to make healthcare decisions for them under a specified set of circumstances. Combined directives, such as the "Five Wishes", that include components of both the living will and durable power of attorney for healthcare, are being increasingly utilized. [ 12 ] Advanced care planning often includes preferences for CPR initiation, nutrition (tube feeding), as well as decisions about the use of machines to keep a person breathing, or support their heart or kidneys. [ 6 ] [ 10 ] Advanced care planning can be a complex and intimidating change for the patient. Often, when the patient must make a significant change, they will undergo the five stages of change. This theory includes: precontemplation, contemplation, preparation, action, and maintenance. [ 13 ] Many studies have reported benefits to patients who complete advanced care planning, specifically noting the improved patient and surrogate satisfaction with communication and decreased clinician distress. However, there is a notable lack of empirical data about what outcome improvements patients experience, as there are considerable discrepancies in what constitutes as advanced care planning and heterogeneity in the outcomes measured. [ 14 ] Advanced care planning remains an underutilized tool for patients. Researchers have published data to support the use of new relationship-based and supported decision making models that can increase the use and maximize the benefit of advanced care planning. [ 6 ] [ 15 ] End-of-life care conversations are part of the treatment planning process for terminally ill patients requiring palliative care involving a discussion of a patient's prognosis, specification of goals of care, and individualized treatment planning. [ 16 ] A recent Cochrane review (2022) set forth to review the effectiveness of interpersonal communication interventions during end-of-life care. [ 17 ] Research suggest that many patients prioritize proper symptom management, avoidance of suffering, and care that aligns with ethical and cultural standards. [ 18 ] Specific conversations can include discussions about cardiopulmonary resuscitation (ideally occurring before the active dying phase as to not force the conversation during a medical crisis/emergency), place of death, organ donation, and cultural/religious traditions. [ 19 ] [ 20 ] As there are many factors involved in the end-of-life care decision-making process, the attitudes and perspectives of patients and families may vary. [ 16 ] For example, family members may differ over whether life extension or life quality is the main goal of treatment. As it can be challenging for families in the grieving process to make timely decisions that respect the patient's wishes and values, having an established advanced care directive in place can prevent over-treatment, under-treatment, or further complications in treatment management. [ 21 ] [ 22 ] The Shared Decision-Making Theory (SDM) is crucial to end-of-life care conversations between patients, families, and providers. The Shared Decision-Making Theory allows patients and providers to collaborate on their treatment plans and efforts to ensure the patient's voice is heard. This model fosters a collaborative conversation between healthcare providers and patients that focuses on the patient's goals and beliefs, with the provider's expertise and medical knowledge to formulate a co-developed care plan. [ 23 ] For instance, a terminally ill patient may prioritize quality of life and seek to formulate an effective plan with their trusted provider. Patients and families may also struggle to grasp the inevitability of death, and the differing risks and effects of medical and non-medical interventions available for end-of-life care. [ 24 ] People might avoid discussing their end-of-life care, and often the timing and quality of these discussions can be poor. For example, the conversations regarding end-of-life care between chronic obstructive pulmonary disease (COPD) patients and clinicians often occur when a person with COPD has advanced stage disease and occur at a low frequency. [ 25 ] To prevent interventions that are not in accordance with the patient's wishes, end-of-life care conversations and advanced care directives can allow for the care they desire, as well as help prevent confusion and strain for family members. [ 9 ] [ 16 ] Applying the SDM Theory aids in making sure patients and providers are on the same page about the patient's plans and goals to promote mutual respect and communication. It ensures that all parties involved have their needs and wishes met and respected. In the case of critically ill babies, parents are able to participate more in decision making if they are presented with options to be discussed rather than recommendations by the doctor. Utilizing this style of communication also leads to less conflict with doctors and might help the parents cope better with the eventual outcomes. [ 26 ] [ 27 ] The National Cancer Institute in the United States advises that the presence of some of the following signs may indicate that death is approaching: [ 28 ] [ 29 ] The following are some of the most common potential problems that can arise in the last days and hours of a patient's life: [ 33 ] Constipation Other symptoms that may occur, and may be mitigated to some extent, include cough , fatigue , fever , and in some cases bleeding . [ 40 ] A subcutaneous injection is one preferred route of delivery of medications when it has become difficult for patients to swallow or to take pills orally, and if repeated medication is needed, a syringe driver (or infusion pump in the US) is often likely to be used, to deliver a steady low dose of medication. In some settings, such as the home or hospice, sublingual routes of administration may be used for most prescriptions and medications. [ 43 ] Another means of medication delivery, available for use when the oral route is compromised, is a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route . The catheter was developed to make rectal access more practical and provide a way to deliver and retain liquid formulations in the distal rectum so that health practitioners can leverage the established benefits of rectal administration . Its small flexible silicone shaft allows the device to be placed safely and remain comfortably in the rectum for repeated administration of medications or liquids. The catheter has a small lumen , allowing for small flush volumes to get medication to the rectum. Small volumes of medications (under 15mL) improve comfort by not stimulating the defecation response of the rectum and can increase the overall absorption of a given dose by decreasing pooling of medication and migration of medication into more proximal areas of the rectum where absorption can be less effective. [ 44 ] [ 45 ] Integrated care pathways are an organizational tool used by healthcare professionals to clearly define the roles of each team-member and coordinate how and when care will be provided. [ 46 ] These pathways are utilized to ensure best practices are being utilized for end-of-life care, such as evidence-based and accepted health care protocols, and to list the required features of care for a specific diagnosis or clinical problem. Many institutions have a predetermined pathway for end of life care, and clinicians should be aware of and make use of these plans when possible. [ 47 ] [ 48 ] Integrated care pathways should also focus on standardizing healthcare processes while tailoring individual patient needs. For example, integrated pathways can be complex and promote a major change within the patient's lifestyle. in this case, it is essential to create a pathway that will allow for an individual to maintain autonomy and their current lifestyle without having to make drastic changes. These factors can be evaluated from the Social Ecological Model. This model can be broken down into individual, interpersonal, organizational, community, and societal/ political factors. All of which can impact how an integrated pathway will be implemented. [ 49 ] In the United Kingdom, end-of-life care pathways are based on the Liverpool Care Pathway. Originally developed to provide evidence based care to dying cancer patients, this pathway has been adapted and used for a variety of chronic conditions at clinics in the UK and internationally. [ 50 ] Despite its increasing popularity, the 2016 Cochrane Review, which only analyzed one trial, showed limited evidence in the form of high-quality randomized clinical trials to measure the effectiveness of end-of-life care pathways on clinical outcomes, physical outcomes, and emotional/psychological outcomes. [ 51 ] [ 52 ] The BEACON Project group developed an integrated care pathway entitled the Comfort Care Order Set, which delineates care for the last days of life in either a hospice or acute care inpatient setting. This order set was implemented and evaluated in a multisite system throughout six United States Veterans Affairs Medical Centers, and the study found increased orders for opioid medication post-pathway implementation, as well as more orders for antipsychotic medications, more patients undergoing palliative care consultations, more advance directives, and increased sublingual drug administration. The intervention did not, however, decrease the proportion of deaths that occurred in an ICU setting or the utilization of restraints around death. [ 53 ] While not possible for every person needing care, surveys of the general public suggest most people would prefer to die at home. [ 54 ] In the period from 2003 to 2017, the number of deaths at home in the United States increased from 23.8% to 30.7%, while the number of deaths in the hospital decreased from 39.7% to 29.8%. [ 55 ] Home-based end-of-life care may be delivered in a number of ways, including by an extension of a primary care practice, by a palliative care practice, and by home care agencies such as Hospice. [ 56 ] High-certainty evidence indicates that implementation of home-based end-of-life care programs increases the number of adults who will die at home and slightly improves their satisfaction at a one-month follow-up. [ 57 ] There is low-certainty evidence that there may be very little or no difference in satisfaction of the person needing care for longer term (6 months). [ 57 ] The number of people who are admitted to hospital during an end-of-life care program is not known. [ 57 ] In addition, the impact of home-based end-of-life care on caregivers, healthcare staff, and health service costs is not clear, however, there is weak evidence to suggest that this intervention may reduce health care costs by a small amount. [ 57 ] Not all groups in society have good access to end-of-life care. A systematic review conducted in 2021 investigated the end of life care experiences of people with severe mental illness , including those with schizophrenia , bipolar disorder , and major depressive disorder . The research found that individuals with a severe mental illness were unlikely to receive the most appropriate end of life care. The review recommended that there needs to be close partnerships and communication between mental health and end of life care systems, and these teams need to find ways to support people to die where they choose. More training, support and supervision needs to be available for professionals working in end of life care; this could also decrease prejudice and stigma against individuals with severe mental illness at the end of life, notably in those who are homeless. [ 58 ] [ 59 ] In addition, studies have shown that minority patients face several additional barriers to receiving quality end-of-life care. Minority patients are prevented from accessing care at an equitable rate for a variety of reasons including: individual discrimination from caregivers, cultural insensitivity, racial economic disparities, as well as medical mistrust. [ 60 ] Furthermore, these disparities can be understood through the Social Ecological Model. This model discusses how different factors, such as personal, environmental, political, and societal, influence a persons lifestyle. The model highlights how the different levels can intersect and influence a patient's ability to carry out their treatment plan. [ 61 ] Family members are often uncertain as to what they should be doing when a person is dying. Many gentle, familiar daily tasks, such as combing hair, putting lotion on delicate skin, and holding hands, are comforting and provide a meaningful method of communicating love to a dying person. [ 62 ] Family members may be suffering emotionally due to the impending death. Their own fear of death may affect their behavior. They may feel guilty about past events in their relationship with the dying person or feel that they have been neglectful. These common emotions can result in tension, fights between family members over decisions, worsened care, and sometimes (in what medical professionals call the " Daughter from California syndrome ") a long-absent family member arrives while a patient is dying to demand inappropriately aggressive care. Family involvement in end-of-life care can be both beneficial and detrimental to patients, depending on the shape that involvement takes. On the one hand, family involvement is associated with reduced patient distress when the goals of the patient and the family are convergent. Loved ones can engage the patient in discussions about their care preferences, aid communication with the medical team, and offer social, emotional, and financial support. However, family involvement can also be detrimental when the goals of the patient and family are divergent. Emotionally charged decision-making and differing opinions on medical decisions like terminal sedation, withdrawing of treatment, and transitioning to hospice can lead to arguments, conflict, and poor communication. End-of-life decisions can be explained by the Theory of Reasoned Action (TRA), which balances personal values and the opinions and beliefs of family members. In the context of end-of-life cancer care, some key themes regarding familial conflict at the end-of-life include patients and family members being on different pages regarding the illness prognosis, familial strife, cultural differences, and the general stress that accompanies caregiving. [ 63 ] In addition to these, family can be a major predictor of whether or not the person engages in the behavior, and all parties have a mutual understanding of the end-of-life care plan. [ 64 ] Research on patient and family preferences have elucidated some key findings. In intensive care units, good communication, coordination between different arms of the care team, and spiritual support were found to be important to both patients and their families. [ 65 ] When patients receive subpar end-of-life care – like recurring emergency room visits, chemotherapy administered at the end-of-life, or failure to be admitted to hospice – the well-being of their loved ones can suffer. In cases where the patient did not receive appropriate end-of-life care, families and loved ones experienced more depression and regret than families and loved ones with patients who experienced appropriate end-of-life care. [ 66 ] In research done into shared decision-making (SDM) in regards to cancer patients receiving palliative care, it has been found that most patients rely on the physician to initiate some form of SDM, leading to family and friends being involved in the decision making process along with the patient and physician. However, this can also result in lapses of judgment, as physicians in these studies have typically showed intent to preserve a patient's "hope". This brings up a whole different case on whether or not it is physician's jobs to promote "hope", but obviously it seems like most do try to. Patients rely on their physician as an expert opinion, but in palliative care circumstances, the physician may want to involve the patient and their family more, since any medical interventions may be ineffective at that point. However, this again proves to be a slippery slope, as some patients facing existential uncertainty do not want a large part in the decision making process, instead defaulting to the previously mentioned expert opinion of doctors. The study suggests that SDM in regards to palliative cancer care is a challenging and constantly evolving situation, with it mostly revolving around the relationship between the patient, the patient's family, and the physicians in charge. Facilitating and building up the relationship between these parties is the best way to encourage positive SDM in palliative care cancer patients. [ 67 ] [ 68 ] Spirituality is thought to be of increased importance to an individual's wellbeing during a terminal illness or toward the end-of-life. [ 69 ] For example, most cancer patients report some level of spirituality or religiosity, but nearly half report some degree of spiritual struggle at the end-of-life. [ 70 ] Pastoral/spiritual care has a particular significance in end of life care, and is considered an essential part of palliative care by the WHO. [ 71 ] [ 69 ] In palliative care, responsibility for spiritual care is shared by the whole team, with leadership given by specialist practitioners such as pastoral care workers. The palliative care approach to spiritual care may, however, be transferred to other contexts and to individual practice. [ 72 ] [ 73 ] Spiritual, cultural, and religious beliefs may influence or guide patient preferences regarding end-of-life care. [ 74 ] Healthcare providers caring for patients at the end of life can engage family members and encourage conversations about spiritual practices to better address the different needs of diverse patient populations. [ 74 ] Studies have shown that people who identify as religious also report higher levels of well-being. This leads to a higher level of self-efficacy and provides the person with the skills to make and execute decisions relating to end-of-life care. Evidence supports that people who practice religion tend to have a more positive outlook on life and can help patients deal with stress associated with growing older. [ 75 ] On the other hand religion has also been shown to be inversely correlated with depression and suicide. While religion provides some benefits to patients, there is some evidence of increased anxiety and other negative outcomes in some studies. [ 76 ] Religiosity, for example, has been associated with poorer advanced care planning. [ 77 ] Additionally, while spirituality has been associated with less aggressive end-of-life care, religion has been associated with an increased desire for aggressive care in some patients. Despite these varied outcomes, spiritual and religious care remains an important aspect of care for patients. Studies have shown that barriers to providing adequate spiritual and religious care include a lack of cultural understanding, limited time, and a lack of formal training or experience. [ 76 ] [ 78 ] There is nuance to the relationship between religiosity or spirituality and end-of-life care, because different trends emerge based on factors like religious denomination and geographical location. For example, Catholics are significantly less likely to have a do not resuscitate (DNR) order compared to non-Catholics. Compared to Christians, Buddhists and Taoists in Singapore are more likely to receive aggressive, life-prolonging care. [ 77 ] At the same time, people belonging to a particular religious or ethnic group should not be treated as a monolith. Within these groups, beliefs and end-of-life care preferences can vary quite widely, highlighting the need for open-minded, adaptable, and culturally competent end-of-life care. In the Western world, many health care providers lack knowledge about culturally and spiritually informed end-of-life care and report discomfort when engaging in religious discussions with people whose beliefs differ from their own. This is one hypothesis as to why minorities access end-of-life care at lower rates than white people. At the same time, engagement with end-of-life care services can improve when clinicians are educated on culturally and spiritually diverse beliefs, which can foster better relationships and communication between health care providers, patients, and families. Currently, web-based educational programs that center stories, dialogue, and personal reflection are showing promise at improving cultural and spiritual competence amongst providers. [ 79 ] Many hospitals, nursing homes, and hospice centers have chaplains who provide spiritual support and grief counseling to patients and families of all religious and cultural backgrounds. [ 80 ] The World Health Organization defines ageism as "the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) towards others or ourselves based on age." [ 81 ] A systematic review in 2017 showed that negative attitudes amongst nurses towards older individuals were related to the characteristics of the older adults and their demands. This review also highlighted how nurses who had difficulty giving care to their older patients perceived them as "weak, disabled, inflexible, and lacking cognitive or mental ability". [ 82 ] Another systematic review considering structural and individual-level effects of ageism found that ageism led to significantly worse health outcomes in 95.5% of the studies and 74.0% of the 1,159 ageism-health associations examined. [ 83 ] Studies have also shown that one's own perception of aging and internalized ageism negatively impacts their health. In the same systematic review, they included this factor as part of their research. It was concluded that 93.4% of their total 142 associations about self-perceptions of aging show significant associations between ageism and worse health. [ 83 ] End-of-life care is an interdisciplinary endeavor involving physicians, nurses, physical therapists, occupational therapists, pharmacists and social workers. Depending on the facility and level of care needed, the composition of the interprofessional team can vary. [ 84 ] Health professional attitudes about end-of-life care depend in part on the provider's role in the care team. Physicians generally have favorable attitudes towards Advance Directives, which are a key facet of end-of-life care. [ 85 ] Medical doctors who have more experience and training in end-of-life care are more likely to cite comfort in having end-of-life-care discussions with patients. [ 86 ] Those physicians who have more exposure to end-of-life care also have a higher likelihood of involving nurses in their decision-making process. [ 87 ] A systematic review assessing end-of-life conversations between heart failure patients and healthcare professionals evaluated physician attitudes and preferences towards end-of-life care conversations. The study found that physicians found difficulty initiating end-of-life conversations with their heart failure patients, due to physician apprehension over inducing anxiety in patients, the uncertainty in a patient's prognosis, and physicians awaiting patient cues to initiate end-of-life care conversations. [ 88 ] Although physicians make official decisions about end-of-life care, nurses spend more time with patients and often know more about patient desires and concerns. In a Dutch national survey study of attitudes of nursing staff about involvement in medical end-of-life decisions, 64% of respondents thought patients preferred talking with nurses than physicians and 75% desired to be involved in end-of-life decision making. [ 89 ] The ethics of end-of-life care revolve around dignity and respect for the patient by minimizing their suffering, enhancing their quality of life, and honoring any wishes or advance directives they may have put forth. In practice, however, these goals can be complicated by factors like patient competence, family influence, and the absence of advanced care planning. Decisions about CPR, intubation, tube feeding, terminal sedation, physician-assisted suicide, and the stopping of life-prolonging treatment can all present ethical dilemmas for doctors and caregivers as they try to strike a balance between prolonging a patient’s life and preventing unnecessary pain. Four universal ethical principles can guide healthcare providers as they navigate difficult end-of-life care decisions: [ 90 ] Confusion surrounding the difference between euthanasia and withdrawing or withholding treatment is a distinction that can be distressing for family members and doctors alike. For family members, the concern is often ethical and philosophical in nature: "If I stop life-prolonging care, am I killing my loved one?" For doctors, this concern can go one step further: "If I stop providing life-prolonging care, is that euthanasia?" In addition to the ethical implications, doctors can fear legal ramifications since physician assisted suicide must be a voluntary decision on the part of the patient and is only legal in specific places under specific circumstances. Not only can this conflict be unpleasant for doctors, it can also lead to poorer outcomes for patients. Thus, clear directives are needed to identify when it is acceptable to withdraw or withhold treatment at the end of life. One argument contends that there is no ethical distinction between stopping a life-prolonging medical intervention once it has begun, and refusing to start it all together. If the intervention is medically futile, contrary to the best interest of the patient, or unwanted by the patient (either in the moment or in an advance directive), then it is ethically acceptable to withdraw or withhold treatment. [ 91 ] In 2012, Statistics Canada 's General Social Survey on Caregiving and care receiving [ 94 ] found that 13% of Canadians (3.7 million) aged 15 and older reported that at some point in their lives they had provided end-of-life or palliative care to a family member or friend. For those in their 50s and 60s, the percentage was higher, with about 20% reporting having provided palliative care to a family member or friend. Women were also more likely to have provided palliative care over their lifetimes, with 16% of women reporting having done so, compared with 10% of men. These caregivers helped terminally ill family members or friends with personal or medical care, food preparation, managing finances or providing transportation to and from medical appointments. [ 95 ] End of life care has been identified by the UK Department of Health as an area where quality of care has previously been "very variable," and which has not had a high profile in the NHS and social care. To address this, a national end of life care programme was established in 2004 to identify and propagate best practice, [ 96 ] and a national strategy document published in 2008. [ 97 ] [ 98 ] The Scottish Government has also published a national strategy. [ 99 ] [ 100 ] [ 101 ] In 2006 just over half a million people died in England, about 99% of them adults over the age of 18, and almost two-thirds adults over the age of 75. About three-quarters of deaths could be considered "predictable" and followed a period of chronic illness [ 102 ] [ 103 ] [ 104 ] – for example heart disease , cancer , stroke , or dementia . In all, 58% of deaths occurred in an NHS hospital, 18% at home, 17% in residential care homes (most commonly people over the age of 85), and about 4% in hospices. [ 102 ] However, a majority of people would prefer to die at home or in a hospice, and according to one survey less than 5% would rather die in hospital. [ 102 ] A key aim of the strategy therefore is to reduce the needs for dying patients to have to go to hospital and/or to have to stay there; and to improve provision for support and palliative care in the community to make this possible. One study estimated that 40% of the patients who had died in hospital had not had medical needs that required them to be there. [ 102 ] [ 105 ] In 2015 and 2010, the UK ranked highest globally in a study of end-of-life care. The 2015 study said "Its ranking is due to comprehensive national policies, the extensive integration of palliative care into the National Health Service , a strong hospice movement, and deep community engagement on the issue." The studies were carried out by the Economist Intelligence Unit and commissioned by the Lien Foundation , a Singaporean philanthropic organisation. [ 106 ] [ 107 ] [ 108 ] [ 109 ] [ 110 ] The 2015 National Institute for Health and Care Excellence guidelines introduced religion and spirituality among the factors which physicians shall take into account for assessing palliative care needs. In 2016, the UK Minister of Health signed a document which declared people "should have access to personalised care which focuses on the preferences, beliefs and spiritual needs of the individual." As of 2017, more than 47% of the 500,000 deaths in the UK occurred in hospitals. [ 111 ] In 2021 the National Palliative and End of Life Care Partnership published their six ambitions for 2021–26. These include fair access to end of life care for everyone regardless of who they are, where they live or their circumstances, and the need to maximise comfort and wellbeing. Informed and timely conversations are also highlighted. [ 112 ] Research funded by the UK's National Institute for Health and Care Research (NIHR) has addressed these areas of need. [ 113 ] Examples highlight inequalities faced by several groups and offers recommendations. These include the need for close partnership between services caring for people with severe mental illness, [ 114 ] [ 115 ] improved understanding of barriers faced by Gypsy, Traveller and Roma communities, [ 116 ] [ 117 ] the provision of flexible palliative care services for children from ethnic minorities or deprived areas. [ 118 ] [ 119 ] Other research suggests that giving nurses and pharmacists easier access to electronic patient records about prescribing could help people manage their symptoms at home. [ 120 ] [ 121 ] A named professional to support and guide patients and carers through the healthcare system could also improve the experience of care at home at the end of life. [ 122 ] [ 123 ] A synthesised review looking at palliative care in the UK created a resource showing which services were available and grouped them according to their intended purpose and benefit to the patient. They also stated that currently in the UK palliative services are only available to patients with a timeline to death, usually 12 months or less. They found these timelines to often be inaccurate and created barriers to patients accessing appropriate services. They call for a more holistic approach to end of life care which is not restricted by arbitrary timelines. [ 124 ] [ 125 ] As of 2019, physician-assisted dying is legal in eight states ( California , Colorado , Hawaii , Maine , New Jersey , Oregon , Vermont , Washington ) and Washington D.C . [ 126 ] Spending on those in the last twelve months accounts for 8.5% of total aggregate medical spending in the United States. [ 5 ] When considering only those aged 65 and older, estimates show that about 27% of Medicare 's annual $327 billion budget ($88 billion) in 2006 goes to care for patients in their final year of life. [ 127 ] [ 128 ] [ 129 ] For the over-65s, between 1992 and 1996, spending on those in their last year of life represented 22% of all medical spending, 18% of all non-Medicare spending, and 25 percent of all Medicaid spending for the poor. [ 127 ] These percentages appears to be falling over time, as in 2008, 16.8% of all medical spending on the over 65s went on those in their last year of life. [ 130 ] Predicting death is difficult, which has affected estimates of spending in the last year of life; when controlling for spending on patients who were predicted as likely to die, Medicare spending was estimated at 5% of the total. [ 131 ] Belgium's first palliative home care team was established in 1987, and the first palliative care unit and hospital care support teams were established in 1991. A strong legal and structural framework for palliative care was established in the 1990s, which divided the country into areas of 30, where palliative care networks were responsible for coordinating palliative services. Home care was provided by palliative support teams, and each hospital and care home recognized to have a palliative support team. In 1999, Belgium ranked second (after the United Kingdom) in the number of palliative care beds per capita. In 2001, there was an active palliative care support team in 72% of hospitals and a specialized nurse or active support team in 50% nursing homes . Government resources for palliative care doubled in 2000, and in 2007 Belgium was ranked third out of 52 countries worldwide in terms of resources for palliative care. (Together with the United Kingdom and Ireland) to raise public awareness under the auspices of EoL 6 According to the Lien Foundation report, Belgium ranks 5th (out of 40 countries worldwide) for the overall level of mortality . [ 132 ]	https://en.wikipedia.org/wiki/End-of-life_care
End organ damage is severe impairment of major body organs due to systemic disease. Commonly this is referred to in diabetes , high blood pressure , or states of low blood pressure or low blood volume. [ 1 ] This can present as a heart attack or heart failure , pulmonary edema , neurologic deficits including a stroke , or acute kidney failure . [ 2 ] End organ damage typically occurs where systemic disease causes cell death in most or all organs. When blood pressures are critically high (>180/120 mm Hg) or the rate of rise in blood pressure is rapid, a large volume of blood circulating in a small space creates turbulence and can damage the inner lining of blood vessels. The body’s repair systems are activated by damage and circulating blood components, like platelets , work on repair. The deposition of platelets can clutter the vessel space and impair the body’s natural ability to produce nitrous oxide , which would dilate blood vessels and help lower blood pressure. When high pressure is pushing on the walls of narrowed blood vessels, fluid leaves the inside of blood vessels and moves to the space just outside. This impairs necessary blood flow and cuts off circulating oxygen, which can lead to tissue death and permanent damage to the brain, heart, arteries, and kidneys. This may occur as a result of chronic or poorly controlled hypertension, illicit drug use, or as a complication of pregnancy. [ 3 ] Recent studies have shown that activation of the immune system may also be closely involved with the development of end organ damage in hypertensive states. [ 4 ] Shock is when the body does not have adequate circulation to provide oxygen to body tissues. Hypovolemic shock occurs due to low circulating volume of fluids in the blood vessels. Distributive shock , which can occur due to anaphylaxis or sepsis, results in widespread dilation of blood vessels in the body resulting in lower blood pressure. In cases of extremely low circulating volume or inability to maintain an adequate blood pressure, body tissues do not receive enough oxygen and nutrients. [ 5 ] When tissues lack oxygen and adequate circulation, organs can fail. [ 6 ] In diabetes , the dysregulation of insulin and blood glucose levels damages end organ cells and as the body compensates through regulating fluid volume to adjust glucose concentration, it also incurs collateral damage to organs. Microvascular and macrovascular complications include nephropathy, retinopathy, neuropathy, and ASCVD events . [ 7 ] In diabetic neuropathy , glucose promotes oxidative stress leading to nerve damage. [ 8 ] Chronically high insulin levels are also associated with early development of atherosclerotic plaques inside blood vessel walls. [ 9 ] Source: [ 3 ] Source: [ 11 ] End organ damage can occur at any diagnostic stage of diabetes, including pre-diabetes . [ 12 ] Source: [ 13 ] When there is concern for the presence or development of end organ damage, blood pressure should be lowered emergently with intravenous antihypertensive medications. Patients should be admitted to the hospital to be closely monitored for complications of end organ damage, notably strokes. Blood pressure should be lowered a maximum of 10% over the first hour and 25% over the first two hours as rapid lowering of blood pressure can lead to decreased blood flow in the brain and cause the development of an ischemic stroke. Once blood pressure is stabilized, patients can be changed from intravenous medications to oral. [ 3 ] For patients with long-standing hypertension, patient education on the importance of consistently taking prescribed medications and keeping blood pressure well-controlled is critical. [ 2 ] Additionally, future treatments may focus not only on blood pressure control but also the reduction of local inflammation that can lead to end organ damage. [ 4 ] In pregnant patients where there is concern for pre-eclampsia, patients should be given magnesium sulfate and admitted. Urine output, breathing, and reflexes should be monitored closely with concern for the development of worsening kidney function and magnesium toxicity . Systolic blood pressure should be treated with antihypertensive medications only if it is higher than 160 mm Hg. [ 2 ] When a patient is in shock, the development of end organ damage is typically due to circulating blood volume or blood pressure that is not high enough to maintain oxygen and nutrient supply to vital organs. Initial treatment is focused on stabilizing the patient. Fluids are given to increase circulating blood volume. Vasopressors , medications that constrict blood vessels, can also be given in order to maintain a higher blood pressure and help vital organs receive enough oxygen and nutrients. High-dose steroids, like hydrocortisone , may also help maintain blood pressures in patients. Close monitoring in the critical care unit is often necessary to measure blood pressures. [ 10 ] The next step in treating end organ damage due to septic shock is to identify the source of the infection and treat it. Broad-spectrum antibiotics can be started that will treat many potential bacteria before cultures grow the specific bacteria that is causing the infection. Once cultures identify the culprit of the infection, the antibiotic therapy can be changed so that it is only covering what needs to be treated. Treatment of the source of infection should resolve low blood pressures that compromise vital organ function. Complications, including acute respiratory distress syndrome , acute kidney injury , and electrolyte abnormalities , can be treated proactively and managed on an individual basis. [ 10 ] Lifelong treatment and monitoring is often necessary for glucose control. Glucose levels should be maintained at 90 to 130 mg/dL and HbA1c at less than 7%. [ 7 ] Medical treatment includes use of insulin and/or other medications to control glucose levels. Monitoring for end organ damage complications is recommended on guidelines by different regional medical bodies. [ 7 ]	https://en.wikipedia.org/wiki/End_organ_damage
Endarterectomy is a surgical procedure to remove the atheromatous plaque material, or blockage, in the lining of an artery constricted by the buildup of deposits. It is carried out by separating the plaque from the arterial wall. It was first performed on a subsartorial artery in 1946 by a Portuguese surgeon, João Cid dos Santos, at the University of Lisbon . In 1951, E. J. Wylie, an American, performed it on the abdominal aorta . The first successful reconstruction of the carotid artery was performed by Carrea, Molins, and Murphy in Argentina, later in the same year. [ 1 ] An endarterectomy of the carotid artery in the neck is recommended to reduce the risk of stroke when the carotid artery is severely narrowed, particularly after a stroke to reduce the risk of additional strokes. [ citation needed ] Coronary endarterectomy involves removing atheroma from the wall of blocked blood vessels (coronary) supplying the heart muscle. The concept was first introduced by Bailey [ 2 ] in the 1950s prior to the advent of coronary artery bypass surgery to help patients with angina and coronary artery disease . It is still used today when coronary artery bypass surgery proves difficult. Livesay [ 3 ] in Texas and Nair [ 4 ] in Leeds have published the largest series in the world. A femoral endarterectomy is also frequently used as a supplement to a vein bypass graft at the sites of surgical anastomosis . Pulmonary hypertension caused by chronic thromboembolic disease (CTEPH) may be amenable to pulmonary thromboendarterectomy of the pulmonary artery . This procedure was refined by Jamieson over the last two decades and his technique has become the standard worldwide. [ 5 ] This surgery article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Endarterectomy
Endaural phenomena are sounds that are heard without any external acoustic stimulation. Endaural means "in the ear". Phenomena include transient ringing in the ears (that sound like sine tones ), white noise -like sounds, and subjective tinnitus . Endaural phenomena need to be distinguished from otoacoustic emissions , in which a person's ear emits sounds. The emitter typically cannot hear the sounds made by his or her ear. [ citation needed ] Endaural phenomena also need to be distinguished from auditory hallucinations , which are sometimes associated with psychosis . [ 1 ] This article about a disease of the ear and mastoid process is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Endaural_phenomena
Endeavors , formerly known as Family Endeavors , is a non-profit organization that provides programs and services towards community, disaster relief, employment, housing, mental health, and veteran family services in the United States. [ 3 ] In 1969, several of San Antonio’s inner-city churches banded together to launch "Urban Ministries", and initiated programs such as food bank and housing for seniors and runaway youths. [ 4 ] In 1977, the scope of housing programs was expanded to include individuals with mental illness . [ 4 ] In 1992, employment programs were initiated for those with disabilities. In 1995, after school programs for youth were launched. [ 4 ] In 2007, Urban Ministries was rebranded initially as San Antonio Family Endeavors with the scope of the organization covering supportive housing, job training, employment, case management, homeless prevention, group and individual counseling, and youth development services. [ 2 ] As the organization expanded their services nationally the name was shortened to Family Endeavors in 2013 and then to just Endeavors in 2018. [ 3 ] [ 4 ] Since 2011, Endeavors has been receiving federal funding in an effort to end veteran homelessness. Federal funding of $4 million was renewed again by congressman Joaquin Castro in 2016. [ 5 ] On May 20, 2016, Family Endeavors expanded their mental health services by formally opening their first of three mental health clinic which operate under the banner of Steven A. Cohen Military Family Clinic operating from within their San Antonio office. [ 6 ] The second Military family Clinic was opened in El Paso and the third in Killeen on July 15, 2017, and May 15, 2018, respectively. [ 7 ] In addition, to in house care the Cohen Clinics also provide online video counseling services. [ 8 ] Children and youth services include on demand case management, clinical and social work and direct care that staff provides on a national scope to evacuation centers, foster homes, corporations, community centers and families. [ 9 ] Employment services are provided under the Endeavors Unlimited label for individuals with disabilities specifically Commercial Grounds Maintenance and Custodial Services. [ 9 ] Housing Programs are the longest running program from Endeavors with a goal of providing permanent supportive housing to individuals and families with mental illness, disabilities, and female Veterans. [ 10 ] They follow the Fairweather Lodge model with case management, professional counseling, life skills training, and employment opportunities. [ 9 ] The most notable institution are the Fairweather Lodge/ Family Fairweather lodge located in Bexar county, San Antonio, Texas. [ 11 ] Additional homelessness prevention programs for veterans are present in Comberville County and Fayetville, North Carolina. [ 12 ] [ 13 ] Steven A. Cohen Military Family Clinics operate in San Antonio, El Paso and Killeen. [ 6 ] In addition, to onsite care for veterans telehealth services in the form of online face to face therapy services our available to post 9/11 veterans.	https://en.wikipedia.org/wiki/Endeavors_(non-profit)
Endemic goitre is a type of goitre that is associated with dietary iodine deficiency. [ 1 ] [ 2 ] Some inland areas, where soil and water lacks iodine compounds and consumption of marine foods is low, are known for higher incidence of goitre . In such areas goitre is said to be " endemic ". [ citation needed ] This type of goitre is easily preventable. In most developed countries regulations have been put into force by health policy institutions requiring salt, flour or water to be fortified with iodine. [ citation needed ] Treatment of endemic goitre is medical with iodine and thyroxine preparations. Surgery is only necessary in cases that are complicated by significant compression of nearby structures. [ citation needed ]	https://en.wikipedia.org/wiki/Endemic_goitre
An endobronchial valve ( EBV ) is a small, one-way valve, which may be implanted in an airway feeding the lung or part of lung. The valve allows air to be breathed out of the section of lung supplied, and prevents air from being breathed in. This leaves the rest of the lung to expand more normally and avoid air-trapping. Endobronchial valves are typically implanted using a flexible delivery catheter advanced through a bronchoscope in minimally invasive bronchoscopic lung volume reduction procedures in the treatment of severe emphysema . The valves are also removable if they are not working properly. The one-way endobronchial valve is typically implanted such that on exhalation air is able to flow through the valve and out of the lung compartment that is fed by that airway, but on inhalation , the valve closes and blocks air from entering that lung compartment. Thus, an implanted endobronchial valve typically helps a lung compartment to empty itself of air. This has been shown to be beneficial in the treatment of emphysema , where lungs lose their elasticity and thus cannot contract sufficiently to exhale air, leading to air trapping and hyperinflation. When one or more diseased portions of an emphysematous lung are made to deflate and collapse, other healthier portions of the lung have more room in the chest cavity to inhale and exhale, pressure is removed from the diaphragm , and even the heart may function better as the hyperinflated lung becomes smaller. [ 1 ] The amount of residual volume reduction achieved, correlates with the effects on FEV1 , quality of life and exercise capacity. [ 2 ] Endobronchial valves have also been shown to be beneficial in treatment of persistent air leaks in the lungs. Their use in the treatment of tuberculosis and its complications has been studied resulting in promising outcomes but further studies are needed. [ 3 ] Endobronchial valves may be the first successful medical device treatment of emphysema, a disease that affects millions of people worldwide and has no known cure, being managed traditionally by lung transplantation and/or lung volume reduction surgery (though some people do not meet the eligibility requirements for one or both of these invasive procedures). [ 4 ] [ 5 ] Although endobronchial isolation techniques for emphysema were developed in the early 2000s, [ 6 ] specific valves were developed primarily by the start-up medical device company Emphasys Medical (now Pulmonx - Redwood City, California) as a minimally invasive alternative to lung volume reduction surgery for emphysema. In lung volume reduction surgery, one or more diseased portion(s) of a lung are excised . Endobronchial valves were designed to replicate the effects of that procedure without requiring incisions, by simply allowing the most diseased portions of the lung to collapse. Emphasys was purchased by Pulmonx in 2009, and Pulmonx currently markets the Zephyr® endobronchial valve (developed by Emphasys) in Europe, Australia, China and many other locations outside the U.S. Pulmonx also sells the Chartis® Pulmonary Assessment System, which is an assessment tool used with endobronchial valves to help physicians target appropriate lung compartments for treatment. [ 2 ] Another company, Spiration (Seattle, Washington), developed a different type of endobronchial valve and was acquired by Olympus in 2010.	https://en.wikipedia.org/wiki/Endobronchial_valve
Endocardial fibroelastosis ( EFE ) is a rare heart disorder usually occurring in children two years old and younger. [ 1 ] It may also be considered a reaction to stress, not necessarily a specific disease. [ 2 ] It should not be confused with endomyocardial fibrosis . [ citation needed ] EFE is characterized by a thickening of the innermost lining of the heart chambers (the endocardium ) due to an increase in the amount of supporting connective tissue and elastic fibres. It is an uncommon cause of unexplained heart failure in infants and children, and is one component of HEC syndrome . Fibroelastosis is strongly seen as a primary cause of restrictive cardiomyopathy in children, along with cardiac amyloidosis , which is more commonly seen in progressive multiple myeloma patients and the elderly. [ citation needed ] A review cites references to 31 different diseases and other stresses associated with the EFE reaction. [ 2 ] These include infections, cardiomyopathies, immunologic diseases, congenital malformations, even electrocution by lightning strike. EFE has two distinct genetic forms, each having a different mode of inheritance . An X-linked recessive form, [ 3 ] and an autosomal recessive form [ 4 ] have both been observed. A Cardiac MRI can show eccentric patchy thickening of endocardium which is a non-specific finding. Myocardial biopsy is a definitive test. [ citation needed ] The cause should be identified and, where possible, the treatment should be directed to that cause. A last resort form of treatment is heart transplant . [ 5 ] An infant with dilated, failing heart was no rarity on the pediatric wards of hospitals in the mid-twentieth century. On autopsy, most of these patients' hearts showed the thickened endocardial layer noted above. This was thought to be a disease affecting both the heart muscle and the endocardium and it was given various names such as: idiopathic hypertrophy of the heart, endocardial sclerosis, cardiac enlargement of unknown cause, etc. Some of these hearts also had overt congenital anomalies, especially aortic stenosis and coarctation of the aorta. [ citation needed ] The term "endocardial fibroelastosis" was introduced by Weinberg and Himmelfarb in 1943. [ 6 ] In their pathology laboratory they noted that usually the endocardium was pearly white or opaque instead of normally thin and transparent and microscopically showed a systematic layering of collagenous and elastic fibers . They felt their new term was more adequately descriptive, and, indeed it was quickly and widely adopted. Clinicians began applying it to any infant with a dilated, failing heart, in spite of the fact that the only way to definitively establish the presence of EFE was to see it at autopsy. EFE had quickly become the name of a disease, and it continues to be used by many physicians in this way, though many patients with identical symptoms do not have the endocardial reaction of EFE. [ citation needed ] In the latter decades of the twentieth century, new discoveries and new thinking about heart muscle disease gave rise to the term "cardiomyopathy". Many of the cases of infantile cardiac failure were accordingly called "primary cardiomyopathy" as well as "primary EFE", while those with identifiable congenital anomalies stressing the heart were called "secondary EFE". In 1957 Black-Schaffer proposed a unitary explanation that stress on the ventricle, of any kind, may trigger the endocardial reaction, so that all EFE could be thought of as secondary. [ 7 ] Evidence gradually accumulated as to the role of infection as one such type of stress. The studies of Fruhling and colleagues in 1962 were critical. [ 8 ] They followed a series of epidemics of Coxsackie virus infection in their part of France. After each epidemic there were increased numbers of cases with EFE coming to autopsy. On closer study there were cases of pure acute myocarditis, cases of mixed myocarditis and EFE, and cases where myocarditis had healed, leaving just EFE. They were able to culture Coxsackie virus from the tissues of many of the cases at all stages of this apparent progression. A similar progression from myocarditis to EFE was later observed at Johns Hopkins but no virology was done. [ 9 ] Noren and colleagues at the University of Minnesota , acting on an idea floated at a pediatric meeting, were able to show a relation between exposure to maternal mumps in fetal life, EFE, and a positive skin test for mumps in infants. [ 10 ] This brought on a large ongoing controversy and finally prompted a virologist colleague of theirs to inject embryonated eggs with mumps virus . [ 11 ] The chicks at first showed the changes of myocarditis, about a year later, typical EFE, and transitional changes in between. Despite this, the controversy about the role of mumps continued as the actual incidence of EFE plummeted. The proponents of mumps as a cause pointed to this as the effect of the recent implementation of widespread mumps immunization. [ citation needed ] Evidence that viral infection may play a role as a cause or trigger of EFE was greatly reinforced by the study directed by Towbin in the virus laboratory of Texas Children's Hospital . [ 12 ] They applied the methods of today's genetics to old preserved specimens from autopsies of patients with EFE done well before mumps immunization began and found mumps genome in the tissues of over 80% of these patients. It seems undeniable that transplacental mumps infection had been in the past the major cause of EFE, and that immunization was indeed the cause of EFE having become rare. [ citation needed ] Non-infectious causes of EFE have also been studied, spurred by the opening of new avenues of genetics research. Now there are specific named genes associated with certain cardiomyopathies, some of which show the characteristic reaction of EFE. A typical example is Barth syndrome and the responsible gene, tafazzin. [ 13 ] Developments in echocardiography, both the technology of the machines and the skill of the operators, have made it no longer necessary to see the endocardium at autopsy. EFE can now be found non-invasively by the recording of increased endocardial echos. Fetal echocardiography has shown that EFE can begin to accumulate as early as 14 weeks of gestation, and increase with incredible rapidity [ 14 ] and even that it can be reversed if the stress can be removed early in fetal life. [ 15 ] The North American Pediatric Cardiomyopathy Registry was founded in 2000 and has been supported since by the National Heart, Lung and Blood Institute. Because of the logic of the diagnostic tree, where EFE applies to many branches of the tree and thus cannot occupy a branch, it is not listed by the Registry as a cause but rather, "with EFE" is a modifier that can be applied to any cause. [ 16 ] Thus, the past half-century has seen EFE evolve from a mysterious but frequently observed disease to a rare but much better understood reaction to many diseases and other stresses. [ citation needed ]	https://en.wikipedia.org/wiki/Endocardial_fibroelastosis
An endoclip , also referred to as a hemostatic clip or a hemoclip , [ 1 ] [ 2 ] is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing . Its function is similar to a suture in gross surgical applications, as it is used to join together two disjointed surfaces, but, can be applied through the channel of an endoscope under direct visualization. Endoclips have found use in treating gastrointestinal bleeding (both in the upper and lower GI tract ), in preventing bleeding after therapeutic procedures such as polypectomy , and in closing gastrointestinal perforations . Many forms of endoclips exist of different shapes and sizes, including two and three prong devices, which can be administered using single use and reloadable systems, and may or may not open and close to facilitate placement. The endoclip was first described by Hayashi and Kudoh in 1975, [ 3 ] and was termed the "staunch clip". Initial attempts to incorporate the clip into applications in endoscopy (such as clipping bleeding blood vessels ) were limited by the applicator system of the clip. [ 3 ] However, by 1988, an easy to use applicator delivery system was developed, and a functional reloadable endoclip system was described. [ 4 ] This consisted of a stainless steel clip (of size approximately 6 mm long and 1.2 mm wide at the prongs) with a metal deployment device (that could be used to insert the clip into the endoscopic camera, and deployed outside the camera) enclosed in a plastic sheath. [ 3 ] These clips were initially reloadable. [ citation needed ] Endoclips in use today have a variety of additional shapes and sizes than the original. Clips with two and three prongs (TriClip, Cook Medical [ 5 ] ) have been described and used for various applications. [ 6 ] Rotatable clips have been devised to improve localization of deployment. [ 7 ] Also, clips that open and close (as opposed to single-deployment) have also been developed (Resolution Clip, Boston Scientific [ 8 ] ), and also facilitate the appropriate location of deployment. [ 9 ] When a treatable lesion is identified on endoscopy (such as a bleeding vessel), an endoclip can be inserted through the channel of the endoscope until the sheathed clip is visible on the endoscopic image, and the handle for deployment handed to the nurse assistant. The clip is unsheathed by retraction at the handle, positioned, and "fired" by the assistant to treat the lesion. [ citation needed ] Endoclips have found a primary application in hemostasis (or the stopping of bleeding) during endoscopy of the upper (through gastroscopy ) or lower (through colonoscopy ) gastrointestinal tract . [ 3 ] Many bleeding lesions have been successfully clipped, including bleeding peptic ulcers , [ 6 ] Mallory-Weiss tears of the esophagus , [ 10 ] Dieulafoy's lesions , [ 11 ] stomach tumours , [ 12 ] and bleeding after removal of polyps . [ 13 ] Bleeding peptic ulcers require endoscopic treatment if they show evidence of high risk stigmata of re-bleeding, such as evidence of active bleeding or oozing on endoscopy or the presence of a visible blood vessel around the ulcer. [ 14 ] [ 15 ] The alternatives to endoscopic clipping of peptic ulcers are thermal therapy (such as electrocautery to burn the vessel causing the bleeding), or injection of epinephrine to constrict the blood vessel. Comparative studies between endoclips and thermal therapy make the point that endoclips cause less trauma to the mucosa around the ulcer than electrocautery, [ 16 ] but no definitive advantage to either approach has reached consensus by gastroenterologists . [ 17 ] [ 18 ] Endoclips have also found an application in preventing bleeding when performing complicated endoscopic procedures. For example, prophylactic clipping of the base of a polyp has been found to be useful in preventing post- polypectomy bleeding, especially in high-risk patients or patients on anticoagulant medications. [ 19 ] In addition, clips can be used to close gastrointestinal perforations that may have been caused by complicated therapeutic endoscopy procedures, such as polypectomy , or by the endoscopic procedure itself. [ 20 ] Clips have also been used to secure the placement of endoscopic feeding tubes , [ 21 ] and to orient the bile duct to assist with endoscopic retrograde cholangiopancreatography , a procedure used to image to bile duct. [ 22 ] Endoclips have been seen to dislodge between 1 and 3 weeks from deployment, [ 23 ] although lengthy clip retention intervals of as high as 26 months have been reported. [ 3 ] [ 11 ] Endoclips are believed to be safe and no major complications (such as perforation or impaction) have been reported with them, although concern has been raised about blocking the outflow of the bile duct if clips are deployed in the duodenum . [ 3 ]	https://en.wikipedia.org/wiki/Endoclip
Endocrine-Related Cancer is a monthly peer-reviewed medical journal covering cancers in endocrine organs — such as the breast , prostate , pituitary , testes , ovaries , and neuroendocrine system — and hormone-dependent cancers occurring elsewhere in the body. Its scope covers basic , translational , clinical and experimental studies. The journal is published by Bioscientifica on behalf of the Society for Endocrinology . It is also an official journal of the North American Neuroendocrine Tumor Society, the Endocrine Society of Australia and the Japanese Hormone and Cancer Society . The editor-in-chief is Matthew Ringel MD, PhD (Ralph W. Kurtz Professor of Medicine, and Director of the Division of Endocrinology and Metabolism at The Ohio State University, USA) and, according to the ISI Journal Citation Reports , the journal has a 2022 impact factor of 3.9. [ 1 ] Endocrine-Related Cancer was founded as Reviews on Endocrine-Related Cancer , the in-house journal of Zeneca (now AstraZeneca ) published by its parent company ICI Pharmaceuticals . It was taken over by the Society for Endocrinology in 1994 when it was renamed, and the remit was extended to include a limited number of original research articles to complement the existing reviews. The numbers of research articles gradually increased over time. The editor-in-chief of the journal at the time of the name change and remit extension was Vivian H.T. James, who took the journal's precursor and set Endocrine-Related Cancer on a firm footing for development and expansion. Marc Lippman took over leadership in 2000 and managed the fourfold increase in published pages. He also oversaw an impact factor increase from 0.933 in 1999 to 4.597 in 2004. [ 2 ] In 2006, Endocrine-Related Cancer was adopted as an official journal by the European Society of Endocrinology, in 2015 by the Japan Hormone and Cancer Society and in 2021 by the Endocrine Society of Australia. James Fagin held the role of editor-in-chief from 2006 to 2010. During this time the impact factor rose to 5.236. [ 3 ] [ 4 ] There were four annual issues of the journal from 1994 to 2010. From 2011 to 2015 Endocrine-Related Cancer was published bimonthly and, as of 2017, is published monthly. Endocrine-Related Cancer was first published online in March 1998 in PDF format. From September 2004, the online offering was extended to include the HTML full text version of articles and separate figures. All peer-reviewed editorial and review content is free to access from publication. Research articles are under access control for the first 12 months before being made available to the public. During the first 12 months the content is accessible for those at subscribing institutions and members of the Society for Endocrinology and the European Society of Endocrinology. The journal automatically deposits articles to PubMed Central on behalf of authors who are funded by the National Institutes of Health (NIH), for release 12 months from publication, enabling authors to comply with the NIH Public Access Policy . Endocrine-Related Cancer is a hybrid open access journal , offering a 'gold' open access option whereby authors can pay an article publishing charge upon acceptance to have their article made freely available online immediately upon publication. These articles are automatically deposited into PubMed Central. [ 5 ] All journal content is included in the World Health Organization 's HINARI scheme, which offers free or reduced-price access for institutions in certain developing countries to health-related research . The archive of published content from 1994 to 1997 is available to purchase by institutions as part of the Society for Endocrinology Archive. Endocrine-Related Cancer is abstracted and indexed in:	https://en.wikipedia.org/wiki/Endocrine-Related_Cancer
The Endocrine Society is a professional, international medical organization in the field of endocrinology and metabolism , founded in 1916 [ 1 ] as The Association for the Study of Internal Secretions. [ 2 ] The official name of the organization was changed to the Endocrine Society on January 1, 1952. It is a leading organization in the field and publishes four leading journals. It has more than 18,000 members from over 120 countries in medicine , molecular and cellular biology , biochemistry , physiology , genetics , immunology , education , industry, and allied health . The Society's mission is: "to advance excellence in endocrinology and promote its essential and integrative role in scientific discovery, medical practice, and human health." It is said to be "the world's oldest, largest and most active organization devoted to research on hormones and the clinical practice of endocrinology." [ 3 ] Annual Meetings have been held since 1916 except in 1943 and 1945 during World War II when meetings were cancelled at the request of the United States government. Realizing the increasing importance of endocrinology to general medicine, the Council, in 1947, established an annual post graduate assembly now known as the Clinical Endocrinology Update. The Society publishes Endocrinology , the first issue of which was published in January 1927 and edited by Henry Harrower . Another publication, The Journal of Clinical Endocrinology (JCEM), was established in 1941, and the name of the journal was changed to The Journal of Clinical Endocrinology & Metabolism on January 1, 1952. [ 4 ] Current publications include: Endocrine Reviews , JCEM Case Reports , and Journal of the Endocrine Society [ 5 ] (JES). Each year, the Endocrine Society hosts three major meetings throughout the course of a calendar year: ENDO, Clinical Endocrinology Update (CEU), and Endocrine Board Review (EBR). ENDO is the top global meeting on endocrinology research and clinical care. This annual conference gathers world-renown speakers in the endocrine space to showcase cutting-edge science. Clinical Endocrinology Update (CEU) provides practicing endocrinologists with the latest updates through the latest expert guidelines in hormone care. Endocrine Board Review (EBR) is the leading online training program for fellows, residents and physicians preparing for board certification exams. EBR offers a comprehensive preparation course for the Endocrinology, Diabetes, & Metabolism Exam. The Endocrine Society influences a wide range of policies affecting endocrine-related research and practice. The organization’s priorities include: increased funding for the National Institutes of Health (NIH); ensuring access to adequate, affordable healthcare; improved regulation of endocrine-disrupting chemicals (EDCs) [ 6 ] in the United States and internationally, realigning physician payment to recognize the value endocrinologists bring to the health care system; reduction in the prevalence of diabetes and obesity, protecting access to care for women and transgender patients; improved research policy; and increased awareness of the impact of climate change on endocrine health. Insulin affordability has become an increasingly prevalent issue for people living with diabetes. The Endocrine Society's advocacy team supports insulin affordability for all, the Endocrine Society advocates for the Inflation Reduction Act to limit cost-sharing to a copay of no more than $35 and capping costs at no more than $100 per month. [ 7 ] In August 2022, the Inflation Reduction Act was passed. Then Endocrine Society President Ursula B. Kaiser, explained the impact of this legislation on the lives of everyday Americans who live with diabetes. Additionally, the Endocrine Society has partnered with IPEN to raise awareness of health risks associated with endocrine-disrupting chemicals. Experts in the field have developed a guide [ 8 ] for public interest organization and policy makers urging them to prioritize specific actions on EDCs, including a coherent identification process linked to control measures to reduce widespread exposures. In 2023, Delia M. Sosa and other members of the American Medical Association’s Medical Student Section authored a resolution with the Endocrine Society that led to the American Medical Association strengthening its position on protecting gender-affirming care. This resolution advocated against legislation criminalizing access to gender-affirming healthcare and supported efforts to oppose discriminatory policies. [ 9 ] [ 10 ] The Endocrine Society and its membership have developed and showcased new research in a swath of topical areas that has garnered media attention for its clinical significance. In 2019, clinical practice guidelines addressing Treatment of Diabetes in Older Adults. [ 11 ] These guidelines recommendations included higher glucose and A1c targets for older people with diabetes, particularly those with several other chronic illnesses and cognitive impairment. A 2021 study found that eating breakfast earlier in the morning, before 8:30 AM, can potentially reduce the risk of type 2 diabetes. [ 12 ] Endocrine Society publicized this study, looking at eight years of data on 10,575 adults, at ENDO. During the COVID-19 pandemic, one study published in Endocrine Society Journals suggested that vitamin D helped reduce the effects of COVID. [ 13 ] Endocrine Society members unveiled research about the promise of male birth control pills [ 14 ] This new contraception proved safe in the testing phases. An ENDO 2023 study examined the obesity vastly underestimate the prevalence of obesity using BMI and there are many people with normal BMI who still have obesity. [ 15 ] In 2023, the Endocrine Society released a scientific statement on aging. [ 16 ] This statement offered data and available therapies for older individuals with growth hormone, adrenal, ovarian, testicular, thyroid, osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism. The Endocrine Society provides a forum for other related societies to discuss, interact and share views in the field of endocrinology. The list of related societies is as follows: [ 17 ] The Endocrine Society publishes the following journals: [ 18 ]	https://en.wikipedia.org/wiki/Endocrine_Society
An endocrine bone disease is a bone disease associated with a disorder of the endocrine system . [ 1 ] An example is osteitis fibrosa cystica . [ citation needed ] The thyroid, parathyroid, pituitary, or adrenal glands, and the pancreas are parts of the endocrine system, and, therefore are associated with the endocrine bone disease. [ 2 ] Some common endocrine disorders are hypothyroidism, hyperthyroidism, Paget's disease , [ 1 ] Osteoporosis, and diabetes. [ 3 ] The thyroid gland produces thyroxin (T3, and T4) which is necessary for normal development of the nervous system. Its functions include: promoting growth, increasing basal metabolic rate and controlling body temperature. [ 3 ] Adequate iodine intake is necessary for the production of thyroid hormone. According to Payton R. G. et al., a common disorder of the thyroid gland is hypothyroidism, which is more prevalent in women than in men. Symptoms of hypothyroidism include cold intolerance, weight gain, fatigue, anemia, difficulty concentrating, amenorrhea, bradycardia (low heart rate) and goiter. [ 2 ] Another hormone that is secreted by Para follicular cells of the thyroid gland is calcitonin. [ 2 ] Calcitonin works in an antagonistic fashion with parathyroid hormone (PTH): both regulate the level of calcium in the blood. [ 3 ] Blood calcium level is tightly regulated by these two hormones. The cells of our bone that is involved in bone formation and bone breakdown is osteoblast and osteoclast respectively. Osteoclasts are cells of bones that promote bone demineralization or bone resorption . [ 3 ] In contrast, Osteoblast promotes calcium absorption by the bone therefore, promoting bone mineralization and formation of new bones. [ 2 ] Thus Calcitonin activates osteoblasts, therefore decrease blood calcium levels by decreasing bone breakdown (resorption) by inhibiting osteoclast. Whereas, PTH activates osteoclast and thereby increases blood calcium. The hormone produced by the thyroid gland has big impact on bone density, blood calcium levee. [ 4 ] Abnormalities of the thyroid gland impact bone disease such as osteoporosis, a condition that is common in women but men can be diagnosed with this silent disease as well as it mainly affects elderly individual. [ citation needed ] In addition to the thyroid gland, Vitamin D plays a crucial role in the absorption of calcium. [ 2 ] In fact, Vitamin D is needed for efficient absorption of calcium and therefore proper bone health. [ 2 ] Vitamin D is a fat-soluble vitamin, as well, it is unique because it is considered as a hormone; synthesized endogenously in the liver in form of Cholecalciferol . [ 2 ] The endogenous inactive form of Vitamin D is Cholecalciferol or Vitamin D3 which is converted to active form of Vitamin D– Calcitriol also known as 1, 25-Dihydroxycholecalciferol in the Kidney upon exposure to UV ray of sun light. [ 2 ] Deficiency in Vitamin D or renal disease contributes to bone disorder such as in Osteomalacia in adult and Rickets in children. [ 2 ] Osteomalacia is the softening of bones due to poor bone mineralization which is in turn due to poor calcium absorption. [ 2 ] Ultimately, these hormonal changes in body; such as function of thyroid, parathyroid, liver and kidney disrupts metabolic changes as well as function of specific organs, which in turn leads to condition that are not desirable such as bone disorders or other endocrine related diseases. [ 3 ] Bone disease is common among the elderly individual, but adolescents can be diagnosed with this disorder as well. There are many bone disorders such as osteoporosis , Paget's disease , hypothyroidism . [ 2 ] Although there are many forms of bone disorders, they all have one thing in common; abnormalities of specific organs involved, deficiency in vitamin D or low Calcium in diet, which results in poor bone mineralization . [ 2 ] Endocrine disorder is more common in women than men, as it is associated with menstrual disorders. [ 2 ]	https://en.wikipedia.org/wiki/Endocrine_bone_disease
Endocrine diseases are disorders of the endocrine system . The branch of medicine associated with endocrine disorders is known as endocrinology . Broadly speaking, endocrine disorders may be subdivided into three groups: [ 1 ] Endocrine disorders are often quite complex, involving a mixed picture of hyposecretion and hypersecretion because of the feedback mechanisms involved in the endocrine system. For example, most forms of hyperthyroidism are associated with an excess of thyroid hormone and a low level of thyroid stimulating hormone . [ 2 ] In endocrinology, medical emergencies include diabetic ketoacidosis , hyperosmolar hyperglycemic state , hypoglycemic coma , acute adrenocortical insufficiency , phaeochromocytoma crisis, hypercalcemic crisis , thyroid storm , myxoedema coma and pituitary apoplexy . [ 7 ] Emergencies arising from decompensated pheochromocytomas or parathyroid adenomas are sometimes referred for emergency resection when aggressive medical therapies fail to control the patient's state, however the surgical risks are significant, especially blood pressure lability and the possibility of cardiovascular collapse after resection (due to a brutal drop in respectively catecholamines and calcium, which must be compensated with gradual normalization). [ 8 ] [ 9 ] It remains debated when emergency surgery is appropriate as opposed to urgent or elective surgery after continued attempts to stabilize the patient, notably in view of newer and more efficient medications and protocols. [ 10 ] [ 11 ] [ 12 ]	https://en.wikipedia.org/wiki/Endocrine_disease
Endocrine oncology refers to a medical speciality dealing with hormone-producing tumors, i.e. a combination of endocrinology and oncology . Few centres are specializing in hormone producing tumors only, due to the relatively low incidence . Most centres have gastroenterologists, oncologist or endocrinologists who deal with other diseases as well. One exception is the Uppsala Centre of Excellence in Neuroendocrine Tumors [ 1 ] at Uppsala University Hospital in Sweden , where doctors treat only endocrine tumors. There are many different kinds of endocrine tumors, some of which are listed below:	https://en.wikipedia.org/wiki/Endocrine_oncology
Endocrinology (from endocrine + -ology ) is a branch of biology and medicine dealing with the endocrine system , its diseases, and its specific secretions known as hormones . It is also concerned with the integration of developmental events proliferation, growth, and differentiation, and the psychological or behavioral activities of metabolism , growth and development , tissue function, sleep , digestion , respiration , excretion , mood , stress , lactation , movement , reproduction , and sensory perception caused by hormones . Specializations include behavioral endocrinology and comparative endocrinology . [ 1 ] The endocrine system consists of several glands , all in different parts of the body, that secrete hormones directly into the blood rather than into a duct system. Therefore, endocrine glands are regarded as ductless glands. Hormones have many different functions and modes of action; one hormone may have several effects on different target organs, and, conversely, one target organ may be affected by more than one hormone. Endocrinology is the study of the endocrine system in the human body . [ 2 ] This is a system of glands which secrete hormones. Hormones are chemicals that affect the actions of different organ systems in the body. Examples include thyroid hormone , growth hormone , and insulin . The endocrine system involves a number of feedback mechanisms, so that often one hormone (such as thyroid stimulating hormone ) will control the action or release of another secondary hormone (such as thyroid hormone ). If there is too much of the secondary hormone, it may provide negative feedback to the primary hormone, maintaining homeostasis . [ 3 ] [ 4 ] [ 5 ] In the original 1902 definition by Bayliss and Starling (see below), they specified that, to be classified as a hormone, a chemical must be produced by an organ, be released (in small amounts) into the blood, and be transported by the blood to a distant organ to exert its specific function. This definition holds for most "classical" hormones, but there are also paracrine mechanisms (chemical communication between cells within a tissue or organ), autocrine signals (a chemical that acts on the same cell), and intracrine signals (a chemical that acts within the same cell). [ 6 ] A neuroendocrine signal is a "classical" hormone that is released into the blood by a neurosecretory neuron (see article on neuroendocrinology ). [ citation needed ] Griffin and Ojeda identify three different classes of hormones based on their chemical composition: [ 7 ] Amines, such as norepinephrine , epinephrine , and dopamine ( catecholamines ), are derived from single amino acids , in this case tyrosine. Thyroid hormones such as 3,5,3'-triiodothyronine (T3) and 3,5,3',5'-tetraiodothyronine (thyroxine, T4) make up a subset of this class because they derive from the combination of two iodinated tyrosine amino acid residues. [ 8 ] Peptide hormones and protein hormones consist of three (in the case of thyrotropin-releasing hormone ) to more than 200 (in the case of follicle-stimulating hormone ) amino acid residues and can have a molecular mass as large as 31,000 grams per mole. All hormones secreted by the pituitary gland are peptide hormones, as are leptin from adipocytes, ghrelin from the stomach, and insulin from the pancreas . [ citation needed ] Steroid hormones are converted from their parent compound, cholesterol . Mammalian steroid hormones can be grouped into five groups by the receptors to which they bind: glucocorticoids , mineralocorticoids , androgens , estrogens , and progestogens . Some forms of vitamin D , such as calcitriol , are steroid-like and bind to homologous receptors, but lack the characteristic fused ring structure of true steroids. Although every organ system secretes and responds to hormones (including the brain , lungs , heart , intestine , skin , and the kidneys ), the clinical specialty of endocrinology focuses primarily on the endocrine organs , meaning the organs whose primary function is hormone secretion. These organs include the pituitary , thyroid , adrenals , ovaries , testes , and pancreas . An endocrinologist is a physician who specializes in treating disorders of the endocrine system, such as diabetes , hyperthyroidism , and many others (see list of diseases ). The medical specialty of endocrinology involves the diagnostic evaluation of a wide variety of symptoms and variations and the long-term management of disorders of deficiency or excess of one or more hormones. [ 9 ] The diagnosis and treatment of endocrine diseases are guided by laboratory tests to a greater extent than for most specialties. Many diseases are investigated through excitation/stimulation or inhibition/suppression testing. This might involve injection with a stimulating agent to test the function of an endocrine organ. Blood is then sampled to assess the changes of the relevant hormones or metabolites. An endocrinologist needs extensive knowledge of clinical chemistry and biochemistry to understand the uses and limitations of the investigations. A second important aspect of the practice of endocrinology is distinguishing human variation from disease. Atypical patterns of physical development and abnormal test results must be assessed as indicative of disease or not. Diagnostic imaging of endocrine organs may reveal incidental findings called incidentalomas , which may or may not represent disease. [ 10 ] Endocrinology involves caring for the person as well as the disease. Most endocrine disorders are chronic diseases that need lifelong care. Some of the most common endocrine diseases include diabetes mellitus, hypothyroidism and the metabolic syndrome . Care of diabetes, obesity and other chronic diseases necessitates understanding the patient at the personal and social level as well as the molecular, and the physician–patient relationship can be an important therapeutic process. Apart from treating patients, many endocrinologists are involved in clinical science and medical research , teaching , and hospital management . Endocrinologists are specialists of internal medicine or pediatrics . Reproductive endocrinologists deal primarily with problems of fertility and menstrual function—often training first in obstetrics. Most qualify as an internist , pediatrician , or gynecologist for a few years before specializing, depending on the local training system. In the U.S. and Canada, training for board certification in internal medicine, pediatrics , or gynecology after medical school is called residency. Further formal training to subspecialize in adult, pediatric , or reproductive endocrinology is called a fellowship. Typical training for a North American endocrinologist involves 4 years of college, 4 years of medical school, 3 years of residency, and 2 years of fellowship. In the US, adult endocrinologists are board certified by the American Board of Internal Medicine (ABIM) or the American Osteopathic Board of Internal Medicine (AOBIM) in Endocrinology, Diabetes and Metabolism. [ citation needed ] Endocrinology also involves the study of the diseases of the endocrine system. These diseases may relate to too little or too much secretion of a hormone, too little or too much action of a hormone, or problems with receiving the hormone. Because endocrinology encompasses so many conditions and diseases, there are many organizations that provide education to patients and the public. The Hormone Foundation is the public education affiliate of The Endocrine Society and provides information on all endocrine-related conditions. Other educational organizations that focus on one or more endocrine-related conditions include the American Diabetes Association , Human Growth Foundation , American Menopause Foundation, Inc., and American Thyroid Association. [ 12 ] [ 13 ] In North America the principal professional organizations of endocrinologists include The Endocrine Society, [ 14 ] the American Association of Clinical Endocrinologists , [ 15 ] the American Diabetes Association, [ 16 ] the Lawson Wilkins Pediatric Endocrine Society, [ 17 ] and the American Thyroid Association. [ 18 ] In Europe, the European Society of Endocrinology (ESE) and the European Society for Paediatric Endocrinology (ESPE) are the main organisations representing professionals in the fields of adult and paediatric endocrinology, respectively. In the United Kingdom, the Society for Endocrinology [ 19 ] and the British Society for Paediatric Endocrinology and Diabetes [ 20 ] are the main professional organisations. The European Society for Paediatric Endocrinology [ 21 ] is the largest international professional association dedicated solely to paediatric endocrinology. There are numerous similar associations around the world. The earliest study of endocrinology began in China. [ 22 ] The Chinese were isolating sex and pituitary hormones from human urine and using them for medicinal purposes by 200 BC. [ 22 ] They used many complex methods, such as sublimation of steroid hormones. [ 22 ] Another method specified by Chinese texts—the earliest dating to 1110—specified the use of saponin (from the beans of Gleditsia sinensis ) to extract hormones, but gypsum (containing calcium sulfate ) was also known to have been used. [ 22 ] Although most of the relevant tissues and endocrine glands had been identified by early anatomists, a more humoral approach to understanding biological function and disease was favoured by the ancient Greek and Roman thinkers such as Aristotle , Hippocrates , Lucretius , Celsus , and Galen , according to Freeman et al., [ 23 ] and these theories held sway until the advent of germ theory , physiology, and organ basis of pathology in the 19th century. In 1849, Arnold Berthold noted that castrated cockerels did not develop combs and wattles or exhibit overtly male behaviour. [ 24 ] He found that replacement of testes back into the abdominal cavity of the same bird or another castrated bird resulted in normal behavioural and morphological development, and he concluded (erroneously) that the testes secreted a substance that "conditioned" the blood that, in turn, acted on the body of the cockerel. In fact, one of two other things could have been true: that the testes modified or activated a constituent of the blood or that the testes removed an inhibitory factor from the blood. It was not proven that the testes released a substance that engenders male characteristics until it was shown that the extract of testes could replace their function in castrated animals. Pure, crystalline testosterone was isolated in 1935. [ 25 ] Graves' disease was named after Irish doctor Robert James Graves , [ 26 ] who described a case of goiter with exophthalmos in 1835. The German Karl Adolph von Basedow also independently reported the same constellation of symptoms in 1840, while earlier reports of the disease were also published by the Italians Giuseppe Flajani and Antonio Giuseppe Testa, in 1802 and 1810 respectively, [ 27 ] and by the English physician Caleb Hillier Parry (a friend of Edward Jenner ) in the late 18th century. [ 28 ] Thomas Addison was first to describe Addison's disease in 1849. [ 29 ] In 1902 William Bayliss and Ernest Starling performed an experiment in which they observed that acid instilled into the duodenum caused the pancreas to begin secretion, even after they had removed all nervous connections between the two. [ 30 ] The same response could be produced by injecting extract of jejunum mucosa into the jugular vein, showing that some factor in the mucosa was responsible. They named this substance " secretin " and coined the term hormone for chemicals that act in this way. Joseph von Mering and Oskar Minkowski made the observation in 1889 that removing the pancreas surgically led to an increase in blood sugar , followed by a coma and eventual death—symptoms of diabetes mellitus . In 1922, Banting and Best realized that homogenizing the pancreas and injecting the derived extract reversed this condition. [ 31 ] Neurohormones were first identified by Otto Loewi in 1921. [ 32 ] He incubated a frog's heart (innervated with its vagus nerve attached) in a saline bath, and left in the solution for some time. The solution was then used to bathe a non-innervated second heart. If the vagus nerve on the first heart was stimulated, negative inotropic (beat amplitude) and chronotropic (beat rate) activity were seen in both hearts. This did not occur in either heart if the vagus nerve was not stimulated. The vagus nerve was adding something to the saline solution. The effect could be blocked using atropine , a known inhibitor to heart vagal nerve stimulation. Clearly, something was being secreted by the vagus nerve and affecting the heart. The "vagusstuff" (as Loewi called it) causing the myotropic (muscle enhancing) effects was later identified to be acetylcholine and norepinephrine . Loewi won the Nobel Prize for his discovery. Recent work in endocrinology focuses on the molecular mechanisms responsible for triggering the effects of hormones . The first example of such work being done was in 1962 by Earl Sutherland . Sutherland investigated whether hormones enter cells to evoke action, or stayed outside of cells. He studied norepinephrine , which acts on the liver to convert glycogen into glucose via the activation of the phosphorylase enzyme. He homogenized the liver into a membrane fraction and soluble fraction (phosphorylase is soluble), added norepinephrine to the membrane fraction, extracted its soluble products, and added them to the first soluble fraction. Phosphorylase activated, indicating that norepinephrine's target receptor was on the cell membrane, not located intracellularly. He later identified the compound as cyclic AMP ( cAMP ) and with his discovery created the concept of second-messenger-mediated pathways. He, like Loewi, won the Nobel Prize for his groundbreaking work in endocrinology. [ 33 ]	https://en.wikipedia.org/wiki/Endocrinology
Endocrinology of parenting has been the subject of considerable study with focus both on human females and males and on females and males of other mammalian species. Parenting as an adaptive problem in mammals involves specific endocrine signals that were naturally selected to respond to infant cues and environmental inputs. [ 1 ] [ 2 ] Infants across species produce a number of cues to inform caregivers of their needs. These include visual cues, like facial characteristics, or in some species smiling, auditory cues, such as vocalizations, olfactory cues, and tactile stimulation. [ 3 ] A commonly mentioned hormone in parenting is oxytocin , [ 1 ] however many other hormones relay key information that results in variations in behavior. These include estrogen , progesterone , prolactin , cortisol , and testosterone . While hormones are not necessary for the expression of maternal behavior, they may influence it. [ 4 ] Based on cross species evidence, some aspects of these mechanisms have been phylogenetically conserved from rodents to humans, [ 5 ] meaning that these mechanisms are adaptive for mammalian parenting and that the environment of evolutionary adaptedness of some parenting mechanisms may have evolved when mammals first evolved. The importance of these mechanisms are to regulate parental investment and to inform offspring about their environment, primarily those involving responsiveness and sensitivity. These are commonly mentioned in humans as important parenting characteristics that inform their infants about their environments. [ 6 ] [ 7 ] [ 2 ] Many nonhuman studies can be used as both potential models for humans and to show the phylogenetic conservation of some endocrine signals. [ 1 ] Estrogen and progesterone released by ovaries during pregnancy make oxytocin receptors more sensitive in female rats [ 8 ] and is associated with the onset of maternal behaviors in other species as well. [ 4 ] [ 9 ] [ 10 ] Maestripieri found a very similar relationship in which estrogen and progesterone are increased during pregnancy whereas oxytocin was increased postpartum . [ 11 ] The presence of estrogen, progesterone, and estradiol in pregnant mammals in some species appears to exhibit a correlation to maternal behavior in the mammals before and after the birth of their offspring as well as in interactions with other offspring [ 4 ] However, an increase in hormones influences maternal behavior, but it is not always the cause of the onset of maternal behavior in females. Some studies on primates in which increased estrogen and progesterone have a negative or absent correlation with maternal responsivity are in black tufted-ear marmosets , [ 12 ] common marmosets, [ 13 ] lowland gorillas , [ 14 ] and baboons . [ 15 ] Alternatively, one experimental study showed that nulliparous rats, which tend to avoid pups, were transfused with postpartum rat blood that is high in estrogen and progesterone which resulted in responsiveness to the pups’ cues. [ 16 ] Due to this variation between species, the effects of the hormones listed does not give much weight to the phylogenetic conservation of these neuroendocrine mechanisms; although Saltzman points out that the social structure of some species may be significant. [ 4 ] In social species, previous exposure to infants relies less on these hormones to activate mechanisms and more on modulating maternal behavior, because parenting behaviors are not always dependent on hormones. [ 4 ] On the other hand, in non-human primates, specifically lactating females of multiple species, there is an alarming correlation with increased estrogen, progesterone, and prolactin. [ 4 ] These species include black tufted-ear marmosets, [ 12 ] baboons, [ 15 ] rhesus macaques , [ 17 ] and gorillas. [ 14 ] Endogenous signals such as an increase in estrogen compared to a decrease in progesterone, causes an increase in the levels of prolactin, the “lactating hormone,” in the bloodstream. Furthermore, exogenous cues from infants such as suckling induces this mechanism. [ 18 ] The hormone oxytocin, similarly to prolactin, has been found to increase with an increase in estrogen and the presence of infant cues such as suckling. [ 19 ] Oxytocin has been found in other non-human species to inhibit the rejection of offspring; [ 4 ] oxytocin is essential for responsive and sensitive caregiving. [ 20 ] [ 21 ] [ 4 ] [ 22 ] Some specific examples include Francis's study on female rats which linked high amount of oxytocin receptors to increased grooming, [ 23 ] and another study by Maestripieri which linked oxytocin levels in free-ranging macaques to increased nursing and grooming. [ 11 ] However, experimental results are less conclusive. As aforementioned, nulliparous mice do not respond to pup calls, but when administered with oxytocin, they do. [ 24 ] A similar study conducted by Holman and Goy tested nulliparous rhesus females, where their behavior post injection did not elicit a drastic response to infants, however, the adults presented a change in their behavior with a notable increase in proximity and touching. [ 25 ] Oxytocin is more often described as a hormone that facilitates bonding and not one that directly increases care. [ 26 ] [ 25 ] [ 27 ] [ 11 ] Also, the mice were responding to pup calls and the rhesus macaque infants weren't necessarily providing cues that would induce maternal care and support. Saltzman proposes that this is due to primates living socially and having a slower developmental trajectory, in which learning is more important. [ 4 ] The function of oxytocin may lead to an increase in maternal behavior by subsequently reducing anxiety as it has been found to regulate anxiety, social recognition, and coping with stress. [ 28 ] Early studies have found that oxytocin influenced maternal behavior of mother rats depending on the environment in which they were placed. Oxytocin seemed to have an opposing effect on anxiety so that when placed in a novel environment as opposed to a familiar one, mother rats were better able to cope with their higher levels of stress due to their increased oxytocin levels. [ citation needed ] Like in many nonhuman animals, human mothers go through a period of high progesterone during pregnancy that is followed by a decrease in progesterone and a subsequent increase in estrogen, prolactin and oxytocin near parturition. During pregnancy and postpartum, a high estradiol to progesterone ratio is associated with mothers reporting higher feelings of attachment. [ 29 ] High levels of progesterone, which are associated with pregnancy, inhibits prolactin and therefore lactation. [ 30 ] Prolactin increases during the initial stages of lactation and can be stimulated by estrogen but not progesterone. [ 30 ] Research, however, focuses on the role of prolactin for breastfeeding and less on other behaviors. [ 30 ] Prolactin increases with infant suckling, but not other forms of infant contact. [ 31 ] Oxytocin on the other hand increases with both suckling, and physical contact in human females. [ 30 ] Oxytocin levels in human females are associated with the degree of physical affection and bonding. Feldman (2010) found that mothers who displayed “high affectionate contact” had increased oxytocin levels post interaction, but not mothers who displayed “low affectionate contact. [ 22 ] ” Oxytocin is believed to provide a feedback loop, meaning that maternal-infant contact increases oxytocin and oxytocin increases maternal behavior and facilitates bonding. [ 32 ] In one study oxytocin also played a role on mother reported attachment to her fetus. [ 33 ] Studies have shown that plasma oxytocin in pregnant women is higher compared to non-pregnant women. [ 28 ] Wynne-Edwards and Timonin recognize that paternal care is not primed in the same way as maternal care simply because males do not undergo pregnancy. Therefore, males do not go through the same hormonal changes as women. [ 34 ] The simplest way, through natural selection, for paternal care to evolve or be maintained is to use the same or similar pathways as females. [ 35 ] Wynne and Reburn (2001) suggest that fathers who are pair bonded and spend time with the soon to be mother may activate paternal pathways through various cues. [ 35 ] Estradiol increases just before their offspring's birth in black-tufted-ear marmosets and dwarf hamsters and possibly activates certain pathways involved in paternal behavior. [ 36 ] [ 37 ] This is similar to estrogen and progesterone in pregnant females. However, the manipulation of estradiol does not increase or decrease paternal behaviors. [ 34 ] This may be similar to the finding that women who do not breastfeed or do not have vaginal births still responds to their infants. [ 20 ] Like expecting and new mothers, fathers in multiple mammals have elevated prolactin levels compared to non-fathers. These species include California mice, [ 38 ] Mongolian gerbils , [ 39 ] dwarf hamsters , [ 40 ] meerkats , [ 41 ] marmosets, [ 42 ] and cotton-top tamarins . [ 43 ] However, the previously listed studies have different cues and are associated with different paternal behaviors, and this may be due to species specific mechanisms or simply different contexts. The above species are biparental and the elevated prolactin levels in males were not exclusive to fathers. [ citation needed ] There are variable results in between the effects of oxytocin on paternal care between males of different species. Oxytocin levels are unchanged in California mice before and after becoming fathers, [ 44 ] but the amount of paternal exposure to rats is associated with an increase in oxytocin and increased care. [ 43 ] However, multiple studies on biparental species show an association between paternal care and oxytocin. [ 44 ] [ 45 ] [ 35 ] [ 46 ] Since the species in these studies are biparental, excluding rats, it is unclear as to why California mice do not have a change in oxytocin postpartum. In human mothers, oxytocin is associated with high physical contact and affection. However, studies on fathers show that oxytocin is related to high stimulatory contact and exploratory play. [ 22 ] [ 47 ] This supports three hypotheses: One study exhibited the proposed effects that oxytocin had on Tsimane men who had been hunting for varying periods of time. [ 48 ] Once the men returned home, it was found that oxytocin levels were higher in those men who had hunted for longer periods of time. As a result of the longer time period spent hunting, the increased levels of oxytocin were thought to be interconnected with familial social contact dating back to humans’ evolutionary past. [ citation needed ] Across multiple species and in some cases across sexes, there is evidence for the phylogenetic conservation of parental hormones. These include the relationships between the hormones estrogen, progesterone, prolactin, and oxytocin. In males across species, including humans, increased prolactin levels are associated with fatherhood. [ 38 ] [ 39 ] [ 40 ] [ 41 ] [ 42 ] [ 43 ] [ 49 ] [ 50 ] In both non-human primates and humans, the increase in estrogen and progesterone during pregnancy is often followed by a decrease in progesterone and an increase in prolactin, postpartum. [ 12 ] [ 15 ] [ 14 ] [ 25 ] [ 30 ] One study utilized Silastic implants containing estradiol and progesterone which were implanted in nulliparous rats that either maintained the function of their pituitary glands or underwent a hypophysectomy to determine the length of time for maternal care to ensue. [ 51 ] The rats with hypophysectomies exposed to these conditions for 5-6 days were not affected by the treatment and consequently did not induce any maternal behavior. However, it was found that those rats with functioning pituitary glands exhibited maternal behavior within about 3-4 days. In some studies on females across species, estrogen and progesterone prepartum is also related to oxytocin. [ 8 ] [ 4 ] [ 9 ] [ 10 ] [ 11 ] Although, the relationships between these hormones is similar across species, there is variation in the degree to how oxytocin effects behavior. For example, in some species, like rats, an increase in oxytocin greatly increases interactions with infants, [ 24 ] but an increase in oxytocin in macaques only mildly increased interactions. [ 25 ] However, the importance here is that oxytocin increased interactions in all of the relevant cited studies for females, [ 8 ] [ 4 ] [ 9 ] [ 10 ] [ 25 ] as well as the majority of studies cited for males. [ 44 ] [ 45 ] [ 35 ] [ 46 ] In fathers across species the effects of oxytocin are more variable, however in general oxytocin is associated with increased paternal care. [ 44 ] [ 45 ] [ 35 ] [ 46 ] In human fathers increased oxytocin is linked to increased involvement, however the type of involvement is different between fathers and mothers, where fathers focus more on stimulatory contact and exploratory play. [ 22 ] [ 47 ] In human mothers oxytocin is associated with general care and affection. [ 22 ] One study examined the effects that intranasal oxytocin spray administration has in relation to individuals' childhood experiences of punishment by maternal love withdrawal. [ 52 ] It was found that oxytocin effects were absent in individuals who experienced high maternal love withdrawal indicating that the parental behavior associated with withdrawal causes alterations in the genetic expression of endogenous oxytocin levels which affects their children into adulthood. Contrary to the positive effects of oxytocin on maternal behavior, heightened levels of cortisol postpartum has been linked to a decrease in maternal care in nonhuman species, including the western lowland gorilla, [ 53 ] baboons, [ 54 ] Japanese macaques , [ 55 ] and rhesus macaques. [ 11 ] However, there has been some evidence to support that the increase in cortisol levels during pregnancy results in an increased maternal care in two baboon species. [ 56 ] [ 15 ] This variation possibly shows an ontogenetic difference in the role of cortisol. The functions of prolactin have been extensively studied on rats which has revealed its effects and profound role in maternal care. The role of prolactin has been found to induce the maternal behavior in nulliparous rats exposed to a hypophysectomized steroid treatment as noted in which prolactin secreting pituitary implants were placed under the kidney capsule which caused a shortened latency to participate in maternal behavior towards foster pups. [ 28 ] The functions of prolactin have been extensively studied on rats which has revealed its effects and profound role in maternal care. The role of prolactin has been found to induce the maternal behavior in nulliparous rats exposed to a hypophysectomized steroid treatment as noted in which prolactin secreting pituitary implants were placed under the kidney capsule which caused a shortened latency to participate in maternal behavior towards foster pups. A different study used non-hypophysectomized, steroid-treated nulliparous rats were exposed to a dopamine D2 agonist, called bromocriptine, used to decrease the release of prolactin. [ 28 ] Bromocriptine, in turn, consequently lowered the maternal behavioral tendency to foster the young pups. Conversely, when bromocriptine was used in conjunction with prolactin, the maternal behavior returned. Another experiment also utilized bromocriptine to inhibit the release of prolactin in mother rats who were lactating to their pups during a 2-5-day period. [ 57 ] The inhibition of prolactin release appears to indicate a critical period of the development of prolactin mechanisms within the pups. One study demonstrated that a deficiency in prolactin during the postnatal period in rats has the potential to affect their maternal behavior. [ 57 ] In this study bromocriptine-treated juvenile rats exhibited hyperactivity and distractibility from the pups during the maternal behavior test suggesting the importance of prolactin to promote maternal behavior. Adult rats also treated with bromocriptine showed similar differences when exposed to pups as opposed to control rats that exhibited maternal tendencies towards the pups. It was determined that prolactin deficiency may lead to disruptions in maternal behavior in adulthood, affect the neural substrates that promote maternal behavior, and that behavioral deficits are not only caused by a developmental delay in the systems regulating maternal behavior. [ 57 ] Cortisol in human mothers is elevated during pregnancy. [ 58 ] Human mothers with elevated cortisol during pregnancy more easily recognized, and were more attracted to, their own infant's odors postpartum, but this did not affect maternal attitudes toward their infants. [ 29 ] Behaviorally, mothers with higher levels of cortisol postpartum displayed higher levels of affectionate approach. [ 29 ] Women with higher cortisol levels were also more alert and sympathetic to infant crying. [ 59 ] Fleming and colleagues discovered that there was variation in how cortisol affected mothers with only one offspring and those with more than one offspring. [ 29 ] When cortisol levels were high, women with one offspring displayed more affectionate contact, and women with multiple offspring spent more time in caretaking activities. However, the authors did not report whether or not the two groups of women had significantly different levels of cortisol. If they were different, the specific levels of cortisol may be a contributing factor in the different behaviors. Couvade syndrome , or sympathy pregnancy, is defined by Masoni and colleagues as fathers having two or more pregnancy symptoms. [ 60 ] Human fathers with couvade syndrome have higher levels of prolactin, and cortisol levels than fathers without. [ 49 ] Cross-culturally couvade syndrome is associated with how close the mother and father are just prior to birth; in the postpartum period, these fathers invested more in direct care. [ 61 ] Increased paternal care is likely associated with offspring survival. A study on Canadian fathers found that, just before the birth of their infant, the fathers had significantly higher prolactin and cortisol levels. [ 49 ] The father's prolactin and cortisol levels correlated with the mothers, although her levels were significantly higher. This provides evidence for Wynne and Reburn's hypothesis that mothers may provide cues to the father to activate paternal care pathways. [ 35 ] In a separate study, fathers with higher prolactin compared to other fathers responded more positively to infant crying. [ 50 ] These levels also positively correlated with father experience. In the same study, cortisol levels in response to infant cries were negatively correlated with father experience. Higher cortisol levels was associated with higher father alertness and responsiveness to infant crying. Increased levels of cortisol in response to infant cries was greater in inexperienced fathers. [ 50 ] The behaviors associated with elevated cortisol levels appears to be more related to whether or not the mother was pre or postpartum, however the behaviors varied across species. In multiple studies on nonhuman females across species, found that high levels of cortisol postpartum was linked to low levels of maternal care. [ 53 ] [ 15 ] [ 55 ] [ 11 ] However, when cortisol levels were high during pregnancy there was an increase in maternal care. [ 56 ] [ 15 ] This difference did not hold true for humans of females and first time fathers. Increased cortisol levels in general increased maternal care. [ 29 ] [ 59 ] Increased cortisol levels in first time human fathers correlated with an increase in responsiveness to their infant's crying, but not in fathers with more than one offspring. [ 50 ] Studies have been conducted that show an interaction between brain circuits that respond to baby-stimuli, such as infant cries, and testosterone and oxytocin pathways. [ 62 ] It has been found that when acute amounts of testosterone and oxytocin are administered to nulliparous women exposed to infant cries, they cause decreased responses in the amygdala and increased insula and inferior frontal gyrus responses. The alterations in responses within those brain regions have been seen to induce maternal behaviors. As such, there is speculation that increasing the availability of testosterone and oxytocin alters the maternal brain to induce a non-aversive response to infant cries. The most commonly associated hormone with males is testosterone. It is believed to be the “anti-parental hormone”; it inhibits the activation of paternal mechanisms. [ 1 ] In many cases testosterone levels decrease when fathers have or actively care for their infants in non-humans. [ 49 ] [ 63 ] [ 50 ] [ 34 ] However, testosterone can be converted into estradiol, which supports paternal behavior. [ 34 ] [ 64 ] Testosterone is converted into estradiol through the process of aromatization . [ 64 ] Stated previously, with the repeated presence of pups to non-parental rats, caregiving mechanisms can inhibit other mechanism, like the avoidance mechanism; [ 16 ] similar inhibitions occur in male marmosets. [ 65 ] When male marmosets hold their infants, they did not have an increased testosterone response to novel females when they otherwise would. In other words, holding the infant inhibited the mating mechanisms. This could mean that caregiving supersedes mating in some situations. For example, it may be adaptive to continue to invest in your current offspring rather than potentially create another. Multiple studies on fathers have shown that a reduction in testosterone results in increased responsiveness to infant cues [ 66 ] [ 67 ] [ 68 ] and that fathers in general have lower testosterone than non-fathers. [ 68 ] [ 69 ] [ 70 ] Testosterone in human males decreases with the number of offspring human males have. [ 68 ] However, human males with higher level testosterone had greater activation of neural mechanisms when interacting with their own infants, [ 71 ] [ 72 ] this may be due to the activation of a paternal protection mechanism. [ 73 ] Between species variation in behaviors associated with testosterone in biparental species was not noted. Across species father experience was negatively correlated with testosterone [ 65 ] [ 68 ] and lower levels of testosterone was associate with an increase in care. [ 66 ] [ 49 ] [ 68 ] Testosterone is more commonly studied in males than females. However, one study on human females found that lower testosterone is associated with increased maternal care. [ 29 ]	https://en.wikipedia.org/wiki/Endocrinology_of_parenting
Hormonal regulation occurs at every stage of development . A milieu of hormones simultaneously affects development of the fetus during embryogenesis and the mother, including human chorionic gonadotropin (hCG) and progesterone (P4). Human chorionic gonadotropin (hCG), progesterone , 17β-estradiol , endorphins and gonadotropin-releasing hormone (GnRH) synthesis are rapidly upregulated by the developing embryo following fertilization of the ovum. [ 1 ] [ 2 ] [ 3 ] During early embryonic development, paracrine / juxtacrine signaling of hCG induces blastulation and neurulation . An in vitro model of early human embryogenesis ( human embryonic stem cells (hESCs)) has demonstrated that hCG promotes cell proliferation via the LH/hCG receptor (LHCGR). hCG signaling upregulates the expression of steroidogenic acute regulatory protein (StAR)-mediated cholesterol transport and the synthesis of progesterone in hESC. The production of progesterone at this time induces embryroid body (akin to blastulation) and rosette (akin to neurulation) formation in vitro. Progesterone induces the differentiation of pluripotent hESC to neural precursor cells. [ 4 ] [ 5 ] Suppression of P4 signaling following withdrawal of progesterone, or treatment with the progesterone receptor antagonist RU-486 ( mifepristone ), inhibits the differentiation of hESC colonies into embryoid bodies ( blastulation ) or rosettes ( neurulation ). RU-486, a drug commonly used to terminate pregnancy in its early stages, acts not only to abort the embryo, but also to inhibit normal embryonic development. [ 4 ] [ 5 ] Pregnancy -associated hormones such as hCG and sex steroids regulate numerous biological processes in the maternal system prior to and during pregnancy. The embryo orchestrates biological changes that occur in both the embryo and the mother. The embryo upregulates hCG, drives growth of the cell, and upregulates P4 production driving development. hCG and P4 direct changes in the mother to enable successful pregnancy (see below) via upregulation of specific hormones that act to direct both endocrinological and biological changes within the mother for successful pregnancy. [ citation needed ] The early embryo has 1–2 weeks in order to produce sufficient hCG in order to stabilize the endometrial lining to allow for blastocyst attachment. The dramatic increase in trophoblastic and corpus luteal hCG synthesis signals both blastocyst [ 5 ] and corpus luteal [ 6 ] production of P4, crucial for the maintenance of the endometrium . hCG secreted by cytotrophoblastic cells of the blastocyst controls endometrial tissue remodeling by both activation of matrix matalloproteinases (MMPs) that control the maternal extracellular matrix and inhibition of tissue-inhibitors of matrix-metalloproteinases (TIMP). hCG mediates invasion and attachment to the endometrium. [ 7 ] Low levels of hCG increase risk of pre-eclampsia . [ 8 ] Uterine angiogenesis is upregulated by human chorionic gonadotropin and progesterone and downregulated by estrogen. The balance of influences of progesterone and estrogen determine the state of angiogenesis in the uterus during early pregnancy. [ 9 ] [ 10 ] High levels of progesterone produced by the embryonic placenta regulate lymphocyte proliferation at the maternal-fetal interface, locally suppressing maternal immune response against the developing embryo. [ 11 ] Negative feedback of progesterone inhibits hypothalamic pulsatile GnRH neurosecretion, ovulatory GnRH release and pituitary gonadotropin surges thereby effectively preventing further follicular maturation. [ 12 ] [ 13 ] [ 14 ] Progesterone regulates metabolism of carbohydrates , proteins , and lipids , resulting in physiological changes associated with pregnancy. The mix of hormones characteristic of early pregnancy promote natural growth of maternal tissues and weight gain. [ 15 ] In the second half of pregnancy, progesterone and prolactin prepare the mammary glands for lactation. [ 16 ] Estrogens and progesterone promote mammary epithelial cell proliferation resulting in the formation of the primary and secondary ductal structure. Progesterone induces formation of tertiary side-branches in the mammary glands during puberty and during the luteal phase of the menstrual cycle upon which lobuloalveolar structures form under the influence of prolactin . Prolactin stimulates lactogenesis . [ 16 ] [ 17 ] hCG appears to be soporific during pregnancy; levels of hCG correlate with sleep changes during pregnancy, and administration of hCG increases sleep in rats likely via neuronal LHCGR. [ 18 ]	https://en.wikipedia.org/wiki/Endocrinology_of_reproduction
Endodontic files and reamers are surgical instruments used by dentists when performing root canal treatment . These tools are used to clean and shape the root canal , with the concept being to perform complete chemomechanical debridement of the root canal to the length of the apical foramen . Preparing the canal in this way facilitates the chemical disinfection to a satisfactory length but also provides a shape conducive to obturation (filling of the canal). Hand files can provide tactile sensation when cleaning or shaping root canals. This allows the dentist to feel changes in resistance or angulation, which can help determine curvature, calcification and/or changes in anatomy, which two dimensional radiographs may not always identify. This information can help determine strategies or avoid complications before moving on to rotary instruments. The cutting edge of K type files is made up of twisted squares of stainless steel alloy. The K-flex file differs for the fact it has a rhomboid shaped cross-section and has an increased flexibility compared to traditional K-files. [ 1 ] C-files are stiffer than K-files, and are recommended for calcified canals and ones that are curved and narrow. [ 2 ] Nickel-titanium is a superelastic alloy which allows it to undergo greater stresses compared to stainless steel therefore files have a reduced risk of file fracture. It also has the characteristic of 'shape memory' which allows it to return to its initial shape through heating after strain. This reduces the risk of deformation within the root canal as forces of compression and tension are absent. The superelasticity allows an increase in taper (between 4–8%) compared to stainless steel. This allows an adequate taper of the root canal which takes less time to prepare than with stainless steel and less files needed. The super elasticity also means the risk of zipping and apical transportation is reduced. Many Nickel-titanium files are available. The files can be used within rotary systems or manually for a higher level of control. Watch winding and circumferential filing technique The use of the file in a forwards and backwards motion, as if watch winding, with slight apical pressure. This allows the file to effectively debride the canal dentine by moving slowly down the canal. For K-type files, once the file has reached the desired working length, a push and pulling action is used around the circumference of the canal, while only maintaining contact with the canal wall on the outstroke to minimise a debris blockage apically. The balanced force technique This is the most widely used technique and especially good for working with curved canals. [ 3 ] Files used for this technique need to be non-cutting edge and flexible. The file is rotated 60 degrees clockwise in the canal when a slight resistance is felt. The file is then rotated 360 degrees anticlockwise to pick up the dentine in the flutes that was made during the first rotation. This should be done no more than three times before the file is removed and cleaned and the canal system irrigated before reinsertion. [ 4 ] The cross-section of a Hedstrom file (H-file) is made up of a continuous sequence of cones. They are very sharp with a cutting tip. Their use in a push-pull fashion results in a high level of debridement on removal from the root canal. They should not be rotated more than 30 degrees as they are narrow and vulnerable to fracture. They are also used for removal of root canal filling materials e.g. gutta percha during secondary root canal treatment. This file is used to remove pulp tissue (extirpation) during root canal treatment. There are sharp barbs on the file to engage the pulp tissue and remove this efficiently. These files are not used to shape the RCS. The handles of the ISO instruments are colour coded and are available in three different lengths of 21mm, 25mm and 31mm where the extra length is non-cutting shaft. This extra length is particularly useful for posterior teeth where access and visibility is impaired. ISO files are made of stainless steel. This can be useful in smaller files (<20) but larger files have increased rigidity which can result in procedural errors. At smaller sizes the files can be pre-curved which is a major advantage for the debridement of roots with sharp curvatures. Their rigidity also has an advantage in calcified root canals in the initial stages of debridement. The ISO stainless steel files on the market today include K-Flex, K-Flexofile and Hedström where the tip size and taper is standardised. ISO normed hand files have a standardised taper of 2% that equates to 0.02mm increase in diameter per mm of file. This standardised taper allows you to calculate the diameter of any given stainless steel file at any given point. Where the 2% taper means that there is an increase in diameter by 0.02mm every 1mm of file (moved in a coronal direction). The most apical point of any file is deemed D 0 , so moving coronal on the file by 1mm brings you to D 1 and so on, up to D 16 as there is a 16mm cutting surface on all files. For example, an ISO K file size 25 has a D 0 value of 0.25mm diameter at its tip. If you were to move 6mm coronally on this file from D 0 , the cross sectional diameter would be: 0.25mm + (6mmx0.02mm)=0.37mm The range of files are available as hand and rotary. The first files in the series are termed SX, S1 and S2. These are used to improve access to the canals by first creating a coronal flare in the crown-down technique. SX files are typically used first as they are shorter in overall length 19mm and so are good in cases of restrictive space. The canal is prepped in the coronal 2/3 with these files as part of the crown-down technique. After this, files named F1, F2, F3 etc. are used with increasing D0 values. These are used to shape the canal. Between each of these finishing files, you should recapitulate the canal using the corresponding (with the same D0 value) K file. This prevents procedural errors, confirms the canal remains patent and prevents dentine swarf build up in within the canal. Complete copious irrigation in between each file. The introduction of Nickel Titanium in dentistry has allowed the use of rotary systems to be used to prepare root canals safely and predictably. Rotary instrumentation is known to have an improved cutting efficiency when compared with hand filing techniques. It is advisable to use a dedicated electric endodontic motor where torque and speed can be easily controlled dependent on the system chosen. Despite the advantages of rotary systems, it is always recommended to create a glide path with hand files in each canal prior to rotary instrumentation. There are numerous rotary files available on the market, including a variety of systems from different manufacturers. Reciprocating systems involve rotation of the file in both anti-clockwise and clockwise directions. This is similar to the ‘balanced force’ mechanism used with hand files. When the file is used in an anti-clockwise direction, it engages dentine and is quickly followed by a clockwise turn before re-engaging the root canal wall and shearing the dentine. Benefits of a reciprocating system include: Self-adjusting file systems have been developed to overcome complications that arise due to complex anatomy and canal configurations. These files are used in a rotary hand piece and consist of a flexible, thin NiTi lattice with a hollow centre that adapt three-dimensionally to the shape of a given root canal, including its cross section . [ 5 ] The files are operated with vibratory in-and-out motion, with continuous irrigation of disinfectant delivered by a peristaltic pump through the hollow file. [ 6 ] A uniform layer of dentin is removed from the whole circumference of the root canal, thus achieving the main goals of root canal treatment while preserving the remaining root dentin. [ 7 ] The 3D scrubbing effect of the file, combined with the fresh irrigant, result in clean canals, which in turn facilitate better obturation. [ 5 ] More effective disinfection of flat-oval root canals is another goal that is simultaneously attained. [ 8 ] D files are a selection of bespoke rotary files that are commonly used in re-treatment cases for the efficient removal of gutta percha . They are used in sequence to remove the coronal (D1), mid (D2) and apical (D3) ⅓ root filling material more efficiently before the final shaping with conventional instruments. D1 is 16mm in length with a cutting end tip to engage the filling material in the canal. D2 and D3 are 18mm and 22mm in length respectively, both are non end cutting and aim to not remove remaining dentine from canal walls in the process. [ 1 ] In 2007, new legislation documenting the possible risk of prion disease transmission via endodontic files/reamers during root canal treatment was published via the BDJ . [ 9 ] The conclusions made were such that there was no significant risk associated but the implementation of single use instruments was introduced to take all possible precautions. This was primarily due to the shape and relative surface area of the files making thorough disinfection and sterilisation very difficult. Instrumentation of the root canal systems (RCS) can lead to procedural errors including ledging, zipping, canal perforation and apex transportation all of which can be somewhat successfully resolved through further manual corrective techniques. However, file separation whereby the instrument breaks in the canal, is the most concerning and problematic procedural error, with fractured endodontic instruments being the most commonly found object in the RCS. The incidence of file fracture has been found to range between 0.25-6% of cases. File separation will create an obstruction within the canal preventing adequate cleaning and shaping of the canal at and beyond the obstruction as well as under-filling of the RCS. This may ultimately lead to endodontic failure depending on the location at which the file fractured in the RCS. The cause fracture of instruments can be divided into different factors, operator/ technique, anatomy and instrument. i.e. the lack of flexibility of the instruments when negotiating particularly curved canals. The more curved the canal, the greater the cyclical fatigue placed on the instrument, as it is undergoing repetitive tensile and compressive stresses upon rotation no matter the flexibility of the alloy. Pre-curving of the stainless steel files for canal negotiation will work-harden them, rendering them more brittle and therefore are more likely to fracture. Such files should also not be twisted in an anticlockwise manner, as this may also lead to brittle fracture especially when there is increased torque. NiTi files have been designed with increased flexibility for canal negotiation, however this does not entirely negate the event of file separation. NiTi files undergo cyclic fatigue due to a change in the crystalline structure of the file whilst under stress resulting in the alloy becoming more brittle. i.e. overuse of the file. It is safe to assume that the more a file is used, the greater the risk of separation. However, one cannot dictate a specific number of times for use nor predict when a file is going to fracture. The introduction of single use files has reduced this risk somewhat, yet it is vital to regularly inspect the files upon removal from canals for damage. The problem comes when files separate without there being any visible sign of damage. Torque relates to the required force needed in order for an instrument to carry on rotating upon encountering frictional forces. A file may bind the wall of the root canal apically due to a larger diameter of the file compared with the canal causing friction. If rotational forces are still in motion, torque may reach a critical level and the file will fracture. The torque generated from smaller canals will be greater than in larger canals, as files will bind to the canal walls more readily through friction. The greater the diameter of the instrument, the more force it can withstand despite needing increased torque however, the less resistant it becomes to cyclic fatigue. Torsional fatigue can be somewhat limited through creation of a glide path and adopting the Crown-Down technique in a bid to reduce frictional forces. Beware of surface defects arising from the manufacture of the files, which can propagate under fatigue by creating stress concentrations and ultimately lead to fracture. This holds especially true for NiTi files, which are manufactured via milling of alloy blanks using CAD-CAM, as opposed to twisting of the blanks like with stainless steel. Deeper cutting flutes will also create stress concentrations. File failure could be attributed to the skill and chosen technique used for instrumentation by the operator. It is more often the way in which an instrument is used, as opposed to the number of times it has been used that causes fracture e.g. due to overloading. Aggressively inserting instruments into canals should be avoided, as this will increase the friction created between the canal walls and the file. Evidence shows that hand instrumentation will result in a lower risk of file fracture compared with rotary and this may be attributed to increased rotational speed, which enhances the effects of cyclic fatigue. Therefore, when using electric motors with rotary instruments, a low speed and low torque concept is recommended.	https://en.wikipedia.org/wiki/Endodontic_files_and_reamers
Endogenous anesthetics are analogs of anesthetics the body makes that have the properties and similar mode of action of general anesthetics. [ 1 ] [ 2 ] Carbon dioxide (CO 2 ) is an abundant gas produced as the final product of glucose metabolism in animals. CO 2 anesthesia is most frequently used for anesthetizing flies. [ 3 ] But it has also been considered as a fast acting anesthetic in small laboratory animals and in humans. [ 4 ] [ 5 ] In the 1900s, CO 2 anesthesia, known as CO 2 therapy was used by psychiatrists for the treatment of anxiety. The patients would receive 70% CO 2 in combination with 30% oxygen causing rapid and reversible loss of continuousness. [ 6 ] Ammonia has also been shown to have anesthetic properties. [ 7 ] It is released during protein catabolism, and its presence reduced the requirement for inhaled anesthetics. Whether the endogenous release of the ammonia is contributing to an anesethetic effect in vivo has not yet been established. The most abundant endogenous anesthetics are small hydrophobic gaseous metabolites of catabolism and likely work through a membrane-mediated mechanism of general anesthesia. In the 1800s anoxia was considered the mechanism of CO 2 anesthesia. [ 8 ] However, studies in humans showed the opposite, oxygenation of the brain tissue increases with increase CO 2 in the lung. [ 9 ] More recent studies have shown in bees that anoxia is also not the mechanism. [ 10 ] In humans, CO 2 raises the threshold of stimulation of the nerve cell, decreases the speed of conduction of impulses along the nerve, and increases the height and prolonged duration of the action potential. [ 11 ] While the endogenous anesthetics appear to have a similar mechanism of action to inhaled anesthetics, their rapid endogenous metabolism complicates their use in humans. Apart from flies, exogenous compounds have proven more useful for maintaining general anesthesia . The first private demonstration of an anesthetic was carbon dioxide by Henry Hill Hickman in a dog cerca 1823.	https://en.wikipedia.org/wiki/Endogenous_anesthetic
Endolymphatic hydrops is a disorder of the inner ear . It consists of an excessive build-up of the endolymph fluid, which fills the hearing and balance structures of the inner ear. Endolymph fluid, which is partly regulated by the endolymph sac, flows through the inner ear and is critical to the function of all sensory cells in the inner ear. In addition to water, endolymph fluid contains salts such as sodium, potassium, chloride and other electrolytes. If the inner ear is damaged by disease or injury, the volume and composition of the endolymph fluid can change, causing the symptoms of endolymphatic hydrops. [ 1 ] The symptoms of endolymphatic hydrops include the feeling of pressure or fullness in the ears, hearing loss , tinnitus (ringing in the ears) and balance problems . Individuals who have Ménière's disease have a degree of endolymphatic hydrops that is strong enough to trigger the symptoms of this disease, but individuals with endolymphatic hydrops do not always progress to Ménière’s disease. [ 1 ] Endolymphatic hydrops may occur as a result of trauma such as a blow to the head, infection, degeneration of the inner ear, allergies, dehydration and loss of electrolytes or in extremely rare circumstances a benign tumor such as an endolymphatic sac tumor . [ 2 ] In many cases, it is not clear what causes the disorder. Ménière’s attacks occur when there is an increase in endolymphatic volume in the inner ear, causing a temporary leak in the membrane separating the perilymph (potassium poor fluid) and the endolymph (potassium rich fluid). The mix of these two fluids surrounding the vestibular sensory cells can lead to a temporary electrical blockade and loss of sensory function. The sudden change in the rate of the vestibular nerve firing results in a disturbance of signal processing in the corresponding brain regions, and thus to acute sensations of imbalance, otherwise known as vertigo . [ 3 ] Posthumous diagnosis can be done using petrous bone autopsy , although fixation artifacts during tissue preparation might artificially skew hydrops diagnosis rates. In-vivo hydrops analysis can be performed using time delayed inner ear MRI with contrast agent . [ 4 ] Low salt, low sugar diet and keeping hydrated. [ 5 ] Medications may include corticosteroids and/or diuretics. [ 5 ] Caffeine should be avoided. [ 6 ]	https://en.wikipedia.org/wiki/Endolymphatic_hydrops
The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus . The tissue subsequently undergoes a histologic evaluation which aids the physician in forming a diagnosis. [ citation needed ] There are a number of indications for obtaining an endometrial biopsy from a non-pregnant woman: [ citation needed ] Transvaginal ultrasonography is generally done before obtaining an endometrial biopsy as it may help in the gynecologic diagnosis, or even make the taking of a biopsy superfluous if the lining is thin. If the endometrial lining is less than 5 mm thick on sonography, it is highly unusual to encounter endometrial cancer. [ 1 ] The test is usually done in women over age 35. [ 2 ] A more thorough histologic evaluation can be obtained by a dilatation and curettage , which requires anesthesia. The procedure is contraindicated in pregnancy. [ 1 ] Therefore, women in the reproductive years may need a pregnancy test before a biopsy is taken to assure that the test is not done during a pregnancy. Other contraindications are pelvic inflammatory disease and coagulopathies. [ 1 ] An endometrial biopsy usually cannot be done as an office procedure in children, young women, women with vaginismus , or women with cervical stenosis . If necessary, an examination under anesthesia could be performed at which time a biopsy could be taken. [ citation needed ] While procedure is generally considered safe, cramps or pelvic pain is a common if short-lived side effect. After the procedure, the patient may experience some bleeding. A uterine perforation or an infection are rare complications. [ 2 ] Endometrial biopsy pain [ 3 ] is quite common. The reason that doctors spray the lidocain is to help to deal with some of the pain from the procedure. The lidocain spray can burn when it is sprayed into the area. The clamp that is put onto the cervix may be another cause of pain and the procedure itself, with the doctor procuring a piece of the lining with the tube potentially being painful. Most of the time, this will only be required once, but sometimes the procedure can entail two or three instances of procuring a piece of the endometrium. [ citation needed ] Generally, an endometrial biopsy follows this process: Both the application of the tenaculum as well as the removal of tissue by the biopsy may cause pain. Patients, in general, may want to take some pain medication (such as ibuprofen ) before the procedure and inquire about local anesthesia . [ citation needed ] A number of biopsy instruments are in use. The Novak curette is a thin metallic tube with a side opening at the tip; suction with attached syringe can be applied to help to remove tissue. The Pipelle is a more flexible plastic tube with a side opening at the tip. A smaller tube (internal piston) inside the Pipelle is withdrawn to create suction. Meanwhile, the pipelle is rotated and moved outwards from the fundus to the internal os to collect small pieces of endometrial tissue. [ 5 ] Recently, the TruTest has been introduced as an alternative method of endometrial biopsy. Rather than using a suction tube, this method uses the Tao Brush to gently brush the lining of the uterus. Generally, this method has been found to be less painful than the traditional suction method. [ citation needed ]	https://en.wikipedia.org/wiki/Endometrial_biopsy
Endomyocardial biopsy (EMB) is an invasive procedure used routinely to obtain small samples of heart muscle , primarily for detecting rejection of a donor heart following heart transplantation . It is also used as a diagnostic tool in some heart diseases . [ 1 ] A bioptome is used to gain access to the heart via a sheath inserted into the right internal jugular or less commonly the femoral vein . [ 1 ] Monitoring during the procedure consists of performing ECGs and blood pressures. [ 1 ] Guidance and confirmation of correct positioning of the bioptome is made by echocardiography or fluoroscopy . [ 1 ] The risk of complications is less than 1% when performed by an experienced physician in a specialist centre. [ 1 ] Serious complications include perforation of the heart with pericardial tamponade , haemopericardium , AV block , tricuspid regurgitation and pneumothorax . [ 2 ] EMB, sampling myocardium was first pioneered in Japan by S. Sakakibra and S. Konno in 1962. [ 1 ] [ 3 ] The main reason for performing an EMB is to assess allograft rejection following heart transplantation and sometimes to evaluate cardiomyopathy , some heart disease research and ventricular arrhythmias , [ 4 ] or unexplained ventricular dysfunction . [ 5 ] [ 6 ] Visualising the microscopic appearance of the heart muscle allows the detection of cell-mediated or antibody-mediated rejection and is recommended episodically during the first year after heart transplantation. Occasionally, monitoring continues beyond one year. [ 1 ] The use of EMB in heart transplant rejection surveillance remains the gold standard test , although the pre-test predictors of rejection cardiac magnetic resonance imaging (CMR) and gene expression profiling , are increasingly used. [ 1 ] EMB has a role in the diagnosis of viral myocarditis and inflammatory myocarditis. [ 1 ] EMB of the right ventricle via the internal jugular vein is standard after heart transplant. [ 4 ] A bioptome is used to gain access to the heart via a sheath inserted into the right internal jugular or less commonly the femoral vein . [ 1 ] Monitoring during the procedure consists of performing ECGs and blood pressures. Guidance and confirmation of correct positioning of the bioptome is made by echocardiography or fluoroscopy [ 1 ] before the biopsy specimen is taken and in the case of transplants, usually three [ 4 ] or four or more samples are taken. [ 1 ] Endomyocardial fibrosis can occur if biopsies are performed repeatedly. This risk is reduced if the operator is experienced. Unlike for rejection detection, for diagnosing heart disease, different biopsy sites within the heart are targeted. [ 4 ] It is possible but less common to biopsy the left ventricle via the femoral arteries . [ 1 ] The accuracy of diagnosis by EMB depends on whether the correct site is biopsied. There is a risk that a diagnosis can be missed if the biopsy misses the diseased part of heart muscle, particularly with myocardial inflammation or fibrosis. [ 5 ] [ 7 ] An experienced pathologist trained in biopsy analysis and interpretation also reflects EMB’s reliability. Variability between pathologists has been observed. [ 4 ] A frequent concern regarding EMB has been its safety. [ 1 ] However, it has a low risk of less than 1% when performed by an experienced physician in a specialist centre. [ 1 ] [ 3 ] Possible complications, which almost all occur at time of procedure, [ 4 ] include rupture of the right intraventricular septum , conduction block, arrhythmias, pneumothorax , tricuspid regurgitation , atrioventricular fistula , [ 8 ] and pulmonary embolism . Death has been reported, but is rare. [ 1 ] Early heart biopsies, sampling pericardium , in the latter half of the 1950s were performed through a cut in the left intercostal space at the costochondral junction . [ 6 ] However this method risked lung and coronary blood vessel damage, cardiac tamponade and arrhythmias . [ 3 ] EMB, sampling myocardium , has evolved since it was first pioneered in Japan by S. Sakakibra and S. Konno in 1962. [ 1 ] The concept of introducing a biopsy needle through the right internal or external jugular vein to reach the right intraventricular septum for the purpose of sampling the heart muscle was initiated in 1965 by R. T. Bulloch. In 1972, the bioptome and procedure was modified by Philip Caves . This was to allow access percutaneously . [ 6 ]	https://en.wikipedia.org/wiki/Endomyocardial_biopsy
Endoscopic carpal tunnel release (ECTR) refers to a method of performing carpal tunnel surgery using an endoscope or an arthroscopic device to provide visualization of the anatomic structures. Endoscopic techniques for carpal tunnel release involve one or two smaller incisions (less than half inch each) through which instrumentation is introduced including a synovial elevator, probes, knives, and an endoscope used to visualize the underside of the transverse carpal ligament. [ 1 ] [ unreliable medical source? ] The endoscopic methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open method does. [ 2 ] Many studies have been done to determine whether the perceived benefits of a limited endoscopic or arthroscopic release are significant. Many surgeons have embraced limited incision methods. It is considered to be the procedure of choice for many of these surgeons with respect to idiopathic carpal tunnel syndrome. Supporting this are the results of some of the previously mentioned series that cite no difference in the rate of complications for either method of surgery. Thus, there has been broad support for either surgical procedure using a variety of devices or incisions. For ECTR or any carpal tunnel release surgery while there are many different blades and techniques the primary goal is to release the transverse carpal ligament (TCL) that overlies and compresses the median nerve within the carpal tunnel. It is this compression on the median nerve that leads to the characteristic 'pins and needles' paresthesia in the thumb, index, long and ring fingers. The primary benefit of endoscopic releases versus traditional open carpal tunnel release is often perceived to be the smaller incision size. ECTR incisions are commonly less than 1 cm (0.39 in) compared to a 2–4 in (51–102 mm) longitudinal incision with a traditional carpal tunnel release. However, the incision size is not the only factor that differentiates the two methods. The principle behind the endoscopic release is that the Palmar aponeurosis , a thick tough layer of tissue that lines the palm, is not divided with endoscopic methods. In addition, the endoscopic methods offer less dissection and interruption of tissue planes than the open methods because the endoscopic methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open method does. [ 3 ] Thus, a more rapid recovery is generally touted with ECTR as the normal skin above the TCL is not incised. Surgery, either open or endoscopic is a way to treat Carpal Tunnel Syndrome . A meta-analysis supports the conclusion that endoscopic carpal tunnel release is favored over the open carpal tunnel release in terms of a reduction in scar tenderness and increase in grip and pinch strength at a 12-week follow-up [ 4 ] The use of an endoscope to release the carpal tunnel was first described in 1989 by Okutsu et al. [ non-primary source needed ] [ 5 ] Here a flexible clear plastic tube was used with a standard endoscope to identify the transverse carpal ligament and release it with a retrograde knife. Many variations of the endoscopic or arthroscopic methods have been described, each with its own unique apparatus and surgical protocol. The two more common and popular devices were referred to early on as the Chow device and the 3M Agee device. The Chow device is a two-portal device, while the 3M Agee endoscopic carpal tunnel release system is a single-portal device. The Chow device was produced by Dyonics and early papers documented its success. It was heralded by its corporate manufacturer as a breakthrough in carpal tunnel surgery. The Agee 3M device used a single, transverse incision in the area of the proximal wrist flexion crease. The Chow two-portal or two-incision device has had other manifestations, and the Agee device was bought by MicroAire Surgical Instruments. Both methods are still in use today. Additional modifications in technique for a smaller or limited incision have been accompanied by many variations of knives, rasps and tubes through which these instruments and the imaging arthroscope or endoscope are passed. Despite the many manifestations of these devices they are all either a single or two portal system. Athrex, Brown-Instratek, Linvatek and other manufacturers modified the original one or two portal systems for endoscopic carpal tunnel release. Most of these methods utilize an endoscope to visualize the under surface of the transverse carpal ligament while others simply rely on instrumentation that allows for a smaller incision and instrumentation that aids in guiding the surgeon's modified blade or knife. Lastly, several years later a distal portal or single incision in the distal palm was advocated by a group from Louisville. Many studies have been done to determine whether the perceived benefits of a limited endoscopic or arthroscopic release are truly significant. One prospective, randomized, multi-center study found no significant differences between the two groups with regard to the secondary quantitative outcome measurements. However, the open technique resulted in more tenderness of the scar than did the endoscopic method. A prospective randomized study using the MicroAire system was conducted in 2002 by Trumble and Diao et al. and revealed that good clinical outcomes and patient satisfaction are achieved more quickly when the endoscopic method of carpal tunnel release is used. Their study concluded that single-portal Endoscopic carpal tunnel release surgery is a safe and effective method of treating carpal tunnel syndrome. There was no significant difference in the rate of complications or the cost of surgery between the two groups. However, the open technique resulted in greater scar tenderness during the first three months after surgery as well as a longer time until the patients could return to work. [ 6 ] It has been shown in recent literature that there is a learning curve for a hand surgeon who begins to use an endoscopic technique to release the transverse carpal ligament. [ 7 ] However this same recent study also showed no significant morbidity associated with the endoscopic method. Brown et al. conducted a prospective, randomized, multi-center study and found no significant differences between the two groups with regard to secondary quantitative outcome measurements. [ 8 ] However, the open technique resulted in more tenderness of the scar than the endoscopic method. A prospective randomized study done in 2002 by Trumble revealed that good clinical outcomes and patient satisfaction are achieved more quickly with the endoscopic method. Single-portal endoscopic surgery is a safe and effective method of treating carpal tunnel syndrome. There was no significant difference in the rate of complications or the cost of surgery between the two groups. However, the open technique caused greater scar tenderness during the first three months after surgery, and a longer time before the patients could return to work. [ 9 ] In addition, in patients without workers compensation issues, the single-incision endoscopic carpal tunnel release led to less palmar tenderness and a quicker return to work compared to the two-incision endoscopic carpal tunnel release [ 10 ] Despite these views, some surgeons have suggested that in their own hands endoscopic carpal tunnel release has been associated with a higher incidence of median nerve injury, and for this reason, it has been abandoned at several centers in the United States. At the 2007 meeting of the American Society for Surgery of the Hand, a former advocate of endoscopic carpal tunnel release, Thomas J. Fischer, MD, retracted his advocacy of the technique, based on his own personal assessment that the benefit of the procedure (slightly faster recovery) did not outweigh the risk of injury to the median nerve. Contrary to this one or any one opinion of any individual surgeon it has been shown that while there is a learning curve for a hand surgeon who begins to use an endoscopic technique to release the transverse carpal ligament no significant safety issues or morbidity associated with the endoscopic method exist. [ 11 ] The use of endoscopic carpal tunnel release has continued to spread around the world and clinical and nerve electrophysiological states are significantly improved at the long-term follow-up after endoscopic carpal tunnel release. [ 12 ] A meta-analysis supports the conclusion that endoscopic carpal tunnel release is favored over the open carpal tunnel release in terms of a reduction in scar tenderness and increase in grip and pinch strength at a 12-week follow-up [ 13 ] [ 14 ] A study comparing the open method and endoscopic method resulted in a longer interval until the patient could return to work (median, twenty-eight days, compared with fourteen days for the open-release and endoscopic-release groups). [ 15 ] A recent study regarding outcome of Endoscopic carpal tunnel release has shown that clinical and nerve electrophysiological states are significantly improved at the long-term follow-up after endoscopic carpal tunnel release. [ 16 ] Further evidence supports that carpal tunnel release done endoscopically offers benefits in the early post operative period beyond that of open carpal tunnel syndrome. This came in the form of level 1 evidence as a meta-analysis that supports the conclusion that endoscopic carpal tunnel release is favored over the open carpal tunnel release in terms of a reduction in scar tenderness and increase in grip and pinch strength at a 12-week follow-up [ 17 ]	https://en.wikipedia.org/wiki/Endoscopic_carpal_tunnel_release
Endoscopic endonasal surgery is a minimally invasive technique used mainly in neurosurgery and otolaryngology . A neurosurgeon or an otolaryngologist, using an endoscope that is entered through the nose, fixes or removes brain defects or tumors in the anterior skull base . Normally an otolaryngologist performs the initial stage of surgery through the nasal cavity and sphenoid bone ; a neurosurgeon performs the rest of the surgery involving drilling into any cavities containing a neural organ such as the pituitary gland . The use of endoscope was first introduced in Transsphenoidal Pituitary Surgery by R Jankowsky, J Auque, C Simon et al. in 1992 G (Laryngoscope. 1992 Feb;102(2):198-202). Antonin Jean Desomeaux, a urologist from Paris, was the first person to use the term, endoscope. [ 1 ] However, the precursor to the modern endoscope was invented in the 1800s when a physician in Frankfurt, Germany by the name of Philipp Bozzini , developed a tool to see the inner workings of the body. [ 2 ] Bozzini called his invention a Light Conductor, or Lichtleiter in German, and later wrote about his experiments on live patients with this device that consisted of an eyepiece and a container for a candle. [ 1 ] Following Bozzini's success, The University of Vienna starting using the device to test its practicality in other forms of medicine. After Bozzini's device received negative results from live human trials, it had to be discontinued. However, Maximilian Nitze and Joseph Leiter used the invention of the light bulb by Thomas Edison to make a more refined device similar to modern day endoscopes. This iteration was used for urological procedures, and eventually otolaryngologists began to use Nitze and Leiter's device for eustachian tube manipulation and removal of foreign bodies. [ 2 ] The endoscope made its way to the US when Walter Messerklinger began teaching David Kennedy at Johns Hopkins Hospital. [ citation needed ] The transsphenoidal and intracranial approaches to pituitary tumors began in the 1800s but with little success. Gerard Guiot popularized the transphenoidal approach which later became part of the neurosurgical curriculum, however he himself discontinued the use of this technique because of inadequate sight. [ 1 ] In the late 1970s, the endoscopic endonasal approach was used by neurosurgeons to augment microsurgery which allowed them to view objects out of their line of sight. Another surgeon, Axel Perneczky , is considered to be a pioneer of the use of an endoscope in neurosurgery. Perneczky said that endoscopy, "improved appreciation of micro-anatomy not apparent with the microscope." [ 1 ] The surgery was pioneered in Algeria by Bouyoucef Kheireddine and Faiza Lalam . [ 3 ] [ 4 ] The endoscope consists of a glass fiber bundle for cold light illumination, a mechanical housing, and an optics component with four different views: 0 degree for straight forward, 30 degrees for forward plane, 90 degrees for lateral view, and 120 degrees for retrospective view. [ 5 ] For endoscopic endonasal surgery, rigid rod-lens endoscopes are used for better quality of vision, since these endoscopes are smaller than the normal endoscope used colonoscopies . [ 2 ] The endoscope has an eyepiece for the surgeon, but it is rarely used because it requires the surgeon to be in a fixed position. Instead, a video camera broadcasts the image to a monitor that shows the surgical field. [ citation needed ] Several specialties need to be involved to determine the complete surgical plan. These include: an Endocrinologist, a Neuroradiologist, an Ophthalmologist, a Neurosurgeon, and an Otolaryngologist. An endocrinologist is only involved in preparation for an endoscopic endonasal surgery, if the tumor is located on the pituitary gland. The tumor is first treated pharmacologically in two ways: controlling the levels of hormones that the pituitary gland secretes and reducing the size of the tumor. If this approach does not work, the patient is referred to surgery. The main types of pituitary adenomas are: A neuroradiologist takes images of the defect so that the surgeon is prepared on what to expect before surgery. This includes identifying the lesion or tumor , controlling the effects of the medical therapy, defining the spatial situation of the lesions, and verifying the removal of the lesions. [ 5 ] The lesions associated with endoscopic endonasal surgery include: Some suprasellar tumors invade the chiasmatic cistern , causing impaired vision. In these cases, an ophthalmologist maintains optic health by administering pre-surgical treatment, advising proper surgical techniques so that the optic nerve is not in danger, and managing post-surgery eye care. Common problems include: [ citation needed ] The transnasal approach is used when the surgeon needs to access the roof of the nasal cavity, the clivus , or the odontoid . This approach is used to remove chordomas , chondrosarcoma , inflammatory lesions of the clivus, or metastasis in the cervical spine region. The anterior septum or posterior septum is removed so that the surgeon can use both sides of the nose. One side can be used for a microscope and the other side for a surgical instrument, or both sides can be used for surgical instruments. [ 2 ] This approach is the most common and useful technique of endoscopic endonasal surgery and was first described in 1910 concurrently by Harvey Cushing and Oskar Hirsch . [ 6 ] [ 7 ] This procedure allows the surgeon to access the sellar space, or sella turcica . The sella is a cradle where the pituitary gland sits. Under normal circumstances, a surgeon would use this approach on a patient with a pituitary adenoma. The surgeon starts with the transnasal approach prior to using the transsphenoidal approach. This allows access to the sphenoid ostium and sphenoid sinus. The sphenoid ostium is located on the anterosuperior surface of the sphenoid sinus. The anterior wall of the sphenoid sinus and the sphenoid rostrum is then removed to allow the surgeon a panoramic view of the surgical area. [ 2 ] This procedure also requires the removal of the posterior septum to allow the use of both nostrils for tools during surgery. There are several triangles of blood vessels traversing this region, which are just very delicate areas of blood vessels that can be deadly if injured. [ 2 ] [ 8 ] A surgeon uses stereotactic imaging and a micro Doppler to visualize the surgical field. The invention of the angled endoscope is used to go beyond the sella to the suprasellar (above the sellar) region. This is done with the addition of four approaches. First the transtuberculum and transplanum approaches are used to reach the suprasellar cistern . The lateral approach is then used to reach the medial cavernous sinus and petrous apex . Lastly, the inferior approach is used to reach the superior clivus . Endoscopic endonasal transclival approaches are often described according to which segment of the clivus is involved in the approach, with the clivus typically divided into three regions. [ 9 ] Depending on which segment of the clivus is involved in the surgical approach, different neurovascular structures are placed at risk. The upper third lies inferior to the dorsum sellae and posterior clinoid processes and superior to the petrous apex, the middle third lies at the level of the petrous segments of the internal carotid artery (ICA), and the inferior third extends from the jugular tubercle to the foramen magnum. [ 9 ] It is important that the Perneczky triangle is treated carefully. This triangle has optic nerves, cerebral arteries, the third cranial nerve , and the pituitary stalk . Damage to any of these could provide a devastating post-surgical outcome. [ 2 ] [ 10 ] The transpterygoidal approach enters through the posterior edge of the maxillary sinus ostium and posterior wall of the maxillary sinus. This involves penetrating three separate sinus cavities: the ethmoid sinus , the sphenoidal sinus , and the maxillary sinus. Surgeons use this method to reach the cavernous sinus , lateral sphenoid sinus , infra temporal fossa , pterygoid fossa , and the petrous apex . Surgery includes a uninectomy (removal of the osteomeatal complex), a medial maxillectomy (removal of maxilla), an ethmoidectomy (removal of ethmoid cells and/or ethmoid bone), a sphenoidectomy (removal of part of sphenoid), and removal of the maxillary sinus and the palatine bone. The posterior septum is also removed at the beginning to allow use of both nostrils. [ 2 ] This approach makes a surgical corridor from the frontal sinus to the sphenoid sinus . This is done by the complete removal of the ethmoid bone, which allows a surgeon to expose the roof of the ethmoid, and the medial orbital wall. This procedure is often successful in the removal of small encephaloceles of the ethmoid osteomas of the ethmoid sinus wall or small olfactory groove meningiomas . However, with larger tumors or lesions, one of the other approaches listed above is required. [ 2 ] For removal of a small tumor, it is accessed through one nostril. However, for larger tumors, access through both nostrils is required and the posterior nasal septum must be removed. Then the surgeon slides the endoscope into the nasal choana until the sphenoid ostium is found. Then the mucosa around the ostium is cauterized for microadenomas and removed completely for macroadenomas. Then the endoscope enters the ostium and meets the sphenoid rostrum where the mucosa is retracted from this structure and is removed from the sphenoid sinus to open the surgical pathway. At this point, imaging and Doppler devices are used to define the important structures. Then the floor of the sella turcica is opened with a high speed drill being careful to not pierce the dura mater . Once the dura is visible, it is cut with microscissors for precision. If the tumor is small, the tumor can be removed by an en bloc procedure, which consists of cutting the tumor into many sections for removal. If the tumor is larger, the center of the tumor is removed first, then the back, then the sides, then top of the tumor to make sure that the arachnoid membrane does not expand into the surgical view. This will happen if the top part of the tumor is taken out too early. After tumor removal, CSF leaks are tested for with fluorescent dye, and if there are no leaks, the patient is closed. [ 2 ] This technique is the same as to the sellar region . However the tuberculum sellae is drilled into instead of the sella. Then an opening is made that extends halfway down the sella to expose the dura, and the intercavernous sinuses is exposed. When the optic chiasm , optic nerve , and pituitary gland are visible, the pituitary gland and optic chasm are pushed apart to see the pituitary stalk . An ethmoidectomy is performed, [ 2 ] the dura is then cut, and the tumor is removed. These types of tumors are separated into two types: When there is a tumor, injury, or some type of defect at the skull base whether the surgeon used an endoscopic or open surgical method, the problem still arises of providing separation of the cranial cavity and cavity between the sinuses and nose to prevent cerebrospinal fluid leakage through the opening referred to as a defect. [ 11 ] For this procedure, there are two ways to start: with a free graft repair or with a vascularized flap repair. The free grafts use secondary material like cadaver flaps or titanium mesh to repair the skull base defects, which is very successful (95% without CSF leaks) with small CSF fistulas or small defects. [ 12 ] The local or regional vascularized flaps are pieces of tissue relatively close to the surgery site that have been mostly freed up but are still attached to the original tissue. These flaps are then stretched or maneuvered onto the desired location. When technology advanced and larger defects could be fixed endoscopically, more and more failures and leaks started to occur with the free graft technique. The larger defects are associated with a wider dural removal and an exposure to high flow CSF, which could be the reason for failure among the free graft. [ 12 ] This surgery is turned from a very serious surgery into a minimally invasive one through the nose with the use of the endoscope. For instance craniopharyngiomas (CRAs) are starting to be removed via this method. Dr. Paolo Cappabianca described the perfect CRA for this surgery to be a median lesion with a solid parasellar component (beside the sellar) or encasement of the main neuromuscular structures that are localized in the subchiasmatic (below the optic chiasm ) and retrochiasmatic (behind the optic chiasm) regions. He also says that when these conditions are met, endoscopic endonasal surgery is a valid surgical option. [ 13 ] For a case study on large adenomas, the doctors showed that out of 50 patients, 19 had complete tumor removal, 9 had near complete removal, and 22 had partial removal. The partial removal came from the tumors extending into more dangerous areas. They concluded that endoscopic endonasal surgery was a valid option for surgery if the patients used pharmacological therapy after surgery. [ 14 ] Another study showed that with endoscopic endonasal surgery 90% of microadenomas could be removed, and that 2/3 of normal macroadenomas could be removed if they did not go into the cavernous sinus , which means fragile blood vessel triangles would have to be dealt with so only 1/3 of those patients recovered. [ 15 ] Endoscopic endonasal approach has been shown even among young patients to be superior to traditional microscopic transsphenoidal surgery. [ 16 ] The newer 3-D technique is gaining ground as the ideal way to do surgery because it gives the surgeon a better understanding of the spatial configuration of what they are seeing on a computer screen. Dr. Nelson Oyesiku at Emory University helped develop the 3-D technique. In an article he helped write, he and the other authors compared the effects of the 2-D technique vs the 3-D technique on patient outcome. It showed that the 3-D endoscopy gave the surgeon more depth of field and stereoscopic vision and that the new technique did not show any significant changes in patient outcomes during or after surgery. [ 17 ] In a case study from 2013, they compared the open vs endoscopic techniques for 162 other studies that contained 5,701 patients. [ 18 ] They only looked at four tumor types: the olfactory groove meningiomas (OGM), tuberculum sellae meningiomas (TSM), craniopharyngiomas (CRA), and clival chordomas (CHO). They looked at gross total resection and cerebrospinal fluid (CSF) leaks, neurological death, post-operative visual function, post operative diabetes insipidus , and post-operative obesity. The study showed that there was a greater chance of CSF leaks with endoscopic endonasal surgery. The visual function improved more with endoscopic surgery for TSM, CRA, and CHO patients. Diabetes insipidus occurred more in open procedure patients. The endoscopic patients showed a higher recurrence rate. In another case study on CRAs, [ 19 ] they showed similar results with the CSF leaks being more of a problem in endoscopic patients. Open procedure patients showed a higher rate of post operative seizures as well. Both of these studies still suggest that despite the CSF leaks, that the endoscopic technique is still an appropriate and suitable surgical option. Otologic surgery, which is traditionally performed via an open approach using a microscope, may also be performed endoscopically, and is called Endoscopic Ear Surgery or EES. [ citation needed ]	https://en.wikipedia.org/wiki/Endoscopic_endonasal_surgery
Endoscopic laser cordectomy , also known as Kashima operation , [ 1 ] is an endoscopic laser surgical procedure performed for treating the respiratory difficulty caused as a result of bilateral abductor vocal fold paralysis . Bilateral vocal fold paralysis is basically a result of abnormal nerve input to the laryngeal muscles , resulting in weak or total loss of movement of the laryngeal muscles. Most commonly associated nerve is the vagus nerve (10th cranial nerve) or in some cases its distal branch, the recurrent laryngeal nerve . Paralysis of the vocal fold may also result from mechanical breakdown of the cricoarytenoid joint . [ 2 ] It was first described in by Kashima in 1989. Bilateral abductor paralysis of the vocal folds being the main indication, Kashima operation is also done to treat vocal cord malignancies and dysplastic lesions of vocal cords. [ 3 ] This surgical management is usually undertaken with a target of decannulation in tracheotomy-dependent patients. [ 4 ] [ 5 ] The procedure being short and easy to perform makes it the treatment of choice for management of the same. [ 6 ] Due to minimal invasiveness during the procedure, the time of anesthesia is reduced and good functional results such as swallowing and good voice quality can be obtained. The main objective of the procedure being enlarging the airway, it has become an alternative to tracheotomy, as here the airway is enlarged by making a wedge shaped resection in the posterior vocal cord and retracting the tissue after freeing the vocal ligament and the vocal muscle from the vocal processes. [ 6 ] Kashima Operation should be avoided in cases when a tumour is diffused throughout the thyroid cartilage, because operating in such cases may damage the tumour which may lead to its metastasis. The procedure should be avoided in patients with history of bradycardia, aneurysms or recent infarcts where general anesthesia may become a threat to patient's life. In patients with fractured cervical spine it is not possible to perform this laser surgery because proper positioning of the patient would not be possible. Similarly in cases of severe ankylosing spondylitis, due to complete fusion and rigidity of the spine, movements are not possible which again hampers the proper positioning of the patient. [ 7 ] Circulatory and respiratory disorders may arise due to general anesthesia. [ 7 ] Injury to teeth, laceration of palate, hematoma and laceration of tongue or lips may occur during introduction of the laryngoscopes. [ 8 ] During the cordotomy, larynx might get injured and bleeding can occur. [ 7 ] As a normal body response to any injury, Granuloma and scar formation may take place. [ 9 ] Post operative edema might occur as the surrounding structures are also slightly affected during the procedure. [ 10 ] Surgery is performed under the effect of general anesthesia. The correct position of the patient is mandatory for the ideal introduction of laryngoscope. Preferably the patient should lie flat on the operating table without any head ring or sand bag beneath the shoulders. Before introduction of the laryngoscope, dental plate should be put in place. [ 7 ] After tracheotomy, with a laser-safe endotracheal tube the patient is intubated with an ample exposition of the glottis. A small laser-protected endotracheal tube is placed in case there is no pre-existing tracheotomy. [ 11 ] A modification to this technique is made by using endoscopic CO 2 laser posterior cordotomy without tracheotomy to not compromise respiration by minimising the postoperative edema. [ 9 ] This modified procedure involves a judicious excision of 3.5–4 mm C-shaped wedge in posterior vocal cord from the open edge of the membranous cord using carbon dioxide laser. Excision is made anteriorly to the vocal process, continuing 4 mm laterally on to the ventricular band without exposing the cartilage. A 6–7 mm transverse opening is created at the posterior larynx by the surgical resection. [ 12 ] To avoid unwanted effects of general anesthesia and prevent any infection during the operation, antibiotics, steroids, and H2 blockers are administered intraoperatively. [ 13 ] The procedure begins with orotracheal intubation using a laser-safe endotracheal tube. The eyes of the patient are padded and taped followed by draping of the head and application of upper tooth guard. [ 14 ] When the patient is anesthetized sufficiently and full relaxation is seen. The largest feasible laryngoscope is introduced, to obtain a good view of the larynx. After positioning of the laryngoscope, it is fixed in place with the help of the chest holder. The light carrier is withdrawn after the adjustment of scope in desired position and then the operating microscope is introduced. [ 7 ] The head and face of the patient is protected with moist towels. Then the operating microscope fitted with 400 mm lens and a microspot CO 2 laser is brought in position. The endotracheal tube cuff is protected by a moist cottonoid sponge placed in subglottis. [ 14 ] The site for the cordotomy is determined at the preoperative examination. If any one of the vocal fold seems to have a slightest degree of motion, then cordotomy is performed on the other one. Using CO 2 laser with a spot size of 0.2 mm and power of 3-5 Watts, a cordotomy is performed 1-2mm anteriorly to the vocal process. This is then carried laterally to the thyroid lamina through the width of the vocal ligament and vocalis muscle. The cordotomy provides access to the arytenoid cartilage as well as opens the airway posteriorly. After the operation, the patient is slightly immunocompromised, so to avoid infection by opportunistic organisms, oral antibiotic therapy is given for 1 week. [ 7 ] Anti -gastroesophageal reflux treatment is given for 8 weeks to avoid the gag reflex occurring due to post operative edema. The patient should be advised to take absolute voice rest by avoiding coughing, singing and clearing of the throat. Coughing can be treated with cough suppressing and mucolytic agents. Inhalation of steam is advised twice daily. Follow-up endoscopy with flexible endoscopes is performed 3 days after the procedure, to clean up the fibrous residues. Once the mucosal healing is complete, the patients with tracheotomy can be decannulated within 6 weeks of the procedure. [ 6 ]	https://en.wikipedia.org/wiki/Endoscopic_laser_cordectomy
Endoscopic nasopharyngectomy is a form of endoscopic surgery to treat nasopharyngeal carcinoma . [ 1 ] This type of cancer is commonly treated with radiation therapy and chemotherapy , but endoscopic operation offers an alternative treatment especially when the radiation therapy fails. [ 2 ] In the early stages oncology, endoscopic surgeries were considered to be radical treatment [ 3 ] despite the surgery being minimally invasive. [ 4 ] The surgery is effective the treatment of recently diagnosed localized nasopharyngeal cancer for stage I patients. Patient selection is extremely important in order to avoid surgical complications. Patients diagnosed with rT1 or rT2 tumors, and some rT3 tumors may be candidates for the surgery. [ 5 ] This medical treatment –related article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Endoscopic_nasopharyngectomy
Endoscopic submucosal dissection ( ESD ) is an advanced surgical procedure using endoscopy to remove gastrointestinal tumors that have not entered the muscle layer. ESD may be done in the esophagus, stomach or colon. Application of endoscopic resection (ER) to gastrointestinal (GI) neoplasms is limited to lesions with no risk of nodal metastasis . Either polypectomy or endoscopic mucosal resection (EMR) is beneficial for patients because of its low level of invasiveness. However, to ensure the curative potential of these treatment modalities, accurate histopathologic assessment of the resected specimens is essential because the depth of invasion and lymphovascular infiltration of the tumor is associated with considerable risk for lymph node metastasis. For accurate assessment of the appropriateness of the therapy, en bloc resection is more desirable than piecemeal resection. For a reliable en bloc resection of GI neoplasms, a new method of ER called endoscopic submucosal dissection (ESD) has been developed. The ESD technique has developed from one of the EMR techniques, namely endoscopic resection after local injection of a solution of hypertonic saline-epinephrine (ERHSE). [ 1 ] Initially, the ESD technique was called by various names such as cutting EMR, exfoliating EMR, EMR with circumferential incision etc. However, a new name was proposed to this technique in 2003, as a treatment positioned between EMR and laparoscopic surgery, since this technique is innovative and enables complete resection of neoplasms that were impossible to resect en bloc by EMR. At present, numerous electrosurgical knives such as insulation-tipped diathermic knife (IT-knife)–, needle knife, hook knife, flex knife–, triangle-tipped knife, flush knife, mucosectomy , splash needle and a special device called a small-caliber tip transparent (ST) hood are available for this technique. One or two of these electrosurgical knives are used in combination with a high frequency electrosurgical current (HFEC) generator with an automatically controlled system). New types of endoscopes are available for ESD, such as an endoscope with a water jet system, an endoscope with a multi-bending system to facilitate the ESD procedure–. As another approach to successful ESD, investigations of submucosal injection solutions have been actively done. It was reported that a hyaluronic acid solution makes a better long-lasting submucosal cushion without tissue damage than other available solutions,–. As a further improvement of hyaluronic acid solution, usefulness of a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar has also been reported,. ESD is characterized by three steps: injecting fluid into the submucosa to elevate the lesion from the muscle layer, circumferential cutting of the surrounding mucosa of the lesion, and subsequent dissection of the connective tissue of the submucosa beneath the lesion. The major advantages of this technique in comparison with polypectomy or EMR are as follows. The resected size and shape can be controlled, en bloc resection is possible even in a large neoplasm, and neoplasms with submucosal fibrosis are also resectable. So this technique can be applied to the resection of complex neoplasms such as large neoplasms, ulcerative non-lifting neoplasms, and recurrent neoplasms. The disadvantages of this technique are the requirement of two or more assistants, it is time-consuming, there is a higher risk of bleeding and perforation than EMR. In Japan, ESD is now gaining acceptance as the standard endoscopic resection technique for stomach neoplasms in an early stage, especially for large or ulcerative neoplasms. Recently, the ESD technique is applied to esophageal or colorectal neoplasms in some institutions, although it is still controversial considering the technical difficulty, associated risks, and favorable outcomes by EMR.	https://en.wikipedia.org/wiki/Endoscopic_submucosal_dissection
An endotype is a subtype of a health condition , which is defined by a distinct functional or pathobiological mechanism. [ 1 ] This is distinct from a phenotype , which is any observable characteristic or trait of a disease , such as development, biochemical or physiological properties without any implication of a mechanism. It is envisaged that patients with a specific endotype present themselves within phenotypic clusters of diseases. One example is asthma , which is considered to be a syndrome , consisting of a series of endotypes. [ 2 ] This is related to the concept of disease entity. The main concept in nosology is the disease entity. Normally there are two ways to define a disease entity: Manifestational criteria and causal criteria. [ 3 ] Following Fred Gifford , [ 4 ] these criteria lead one to view any disease entity in three different forms: [ 5 ] Following again F. Gifford, in fact each of the previous definitions can include the aetiology or can be aetiologically agnostic. Other authors simply continue with the classification of Whitbeck, leaving just three kinds of definition (clinical, pathological and aetiological). [ 6 ] It is important to note that a real-world definition is normally a hybrid between these above kinds, and an endotype should use all three of the descriptors - including aetiology - to ensure specificity .	https://en.wikipedia.org/wiki/Endotype
An enema , also known as a clyster , is the rectal administration of a fluid by injection into the lower bowel via the anus . [ 1 ] The word enema can also refer to the liquid injected, [ 2 ] [ 3 ] as well as to a device for administering such an injection. [ 4 ] In standard medicine, the most frequent uses of enemas are to relieve constipation and for bowel cleansing before a medical examination or procedure; [ 5 ] also, they are employed as a lower gastrointestinal series (also called a barium enema), [ 6 ] to treat traveler's diarrhea , [ 7 ] as a vehicle for the administration of food, water or medicine, as a stimulant to the general system, as a local application and, more rarely, as a means of reducing body temperature, [ 1 ] as treatment for encopresis , and as a form of rehydration therapy (proctoclysis) in patients for whom intravenous therapy is not applicable. [ 8 ] The principal medical usages of enemas are: As bowel stimulants, enemas are employed for the same purposes as orally administered laxatives : to relieve constipation ; to treat fecal impaction ; to empty the colon before a medical procedure such as a colonoscopy . When oral laxatives are not indicated or sufficiently effective, enemas may be a sensible and necessary measure. [ 9 ] A large volume enema [ 10 ] can be given to cleanse as much of the colon as possible of feces. [ 11 ] [ 12 ] However, a low enema is generally useful only for stool in the rectum, not in the intestinal tract. [ 13 ] Such enemas' mechanism consists of the volume of the liquid causing a rapid expansion of the intestinal tract in conjunction with, in the case of certain solutions, irritation of the intestinal mucosa which stimulates peristalsis and lubricates the stool to encourage a bowel movement. [ 14 ] An enema's efficacy depends on several factors including the volume injected and the temperature and the contents of the infusion. [ 9 ] For the enema to be effective, the patient should retain the solution for five to ten minutes, as tolerated. [ 5 ] [ 14 ] or, as some nursing textbooks recommend, for five to fifteen minutes or as long as possible. [ 15 ] For emptying the entire colon as much as feasible [ 12 ] deeper and higher enemas are utilized to reach large colon sections. [ 9 ] The colon dilates and expands when a large volume of liquid is injected into it. The colon reacts to that sudden expansion with general contractions, peristalsis , propelling its contents toward the rectum. [ 5 ] Soapsuds enema is a frequently used synonym for a large volume enema (although soap is not necessary for effectiveness). [ 5 ] A large volume enema may be used in a home setting to relieve occasional constipation, although medical care may be required for recurring or severe cases of constipation. [ 5 ] Plain water can be used, functioning mechanically to expand the colon, thus prompting evacuation. Normal saline is least irritating to the colon. Like plain water, it simply functions mechanically to expand the colon, but having a neutral concentration gradient, it neither draws electrolytes from the body, as happens with plain water, nor draws water into the colon, as occurs with phosphates. Thus, a salt water solution can be used when a longer retention period is desired, such as to soften an impaction. Castile soap is commonly added because its irritation of the colon's lining increases the defecation urgency. [ 15 ] However, liquid handsoaps and detergents should not be used. [ 5 ] Glycerol is a specific bowel mucosa irritant serving to induce peristalsis via a hyperosmotic effect . [ 16 ] It is used in a dilute solution, e.g., 5%. [ 17 ] The 2-4-6 Enema: Consists of 2 ounces of glycerin, 4 ounce of Epsom salt, mixed with 6 ounces of water, injected into the rectum, retained for five minutes. This small injection will produce several copious movements. Equal parts of milk and molasses were heated to slightly above normal body temperature. [ 18 ] Neither the milk sugars and proteins nor the molasses are absorbed in the lower intestine, thus keeping the water from the enema in the intestine. [ 19 ] Studies have shown that milk and molasses enemas have a low complication rate when used in the emergency department [ 20 ] and are safe and effective with minimal side effects. [ 21 ] Mineral oil functions as a lubricant and stool softener, but may have side effects including rectal skin irritation and oil leakage. [ 22 ] ATC code A06 Drugs for constipation is a therapeutic subgroup of the Anatomical Therapeutic Chemical Classification System , a system of alphanumeric codes developed by the World Health Organization (WHO) for the classification of drugs and other medical products. [ 23 ] [ 24 ] [ 25 ] Subgroup A06 is part of the anatomical group A Alimentary tract and metabolism . [ 26 ] Codes for veterinary use ( ATCvet codes ) can be created by placing the letter Q in front of the human ATC code: for example, QA06 . [ 27 ] National issues of the ATC classification may include additional codes not present in this list, which follows the WHO version. In alphabetical order In alphabetical order of the original brand names Klyx contains docusate sodium 1 mg/mL and sorbitol solution (70%)(crystallising) 357 mg/mL and is used for faecal impaction or constipation or colon evacuation prior medical procedures, [ 44 ] developed by Ferring B.V. Micralax (not to be confused with MICROLAX®) [ 45 ] MICROLAX® (not to be confused with Micralax) combines the action of sodium citrate , a peptidising agent which can displace bound water present in the faeces, with sodium alkyl sulphoacetate, a wetting agent, and with glycerol, an anal mucosa irritant and hyperosmotic. However, also sold under the name "Micralax", is a preparation containing sorbitol rather than glycerol; [ 46 ] which was initially tested in preparation for sigmoidoscopy . [ 47 ] Micolette Micro-enema® contains 45 mg sodium lauryl sulphoacetate, 450 mg per 5 ml sodium citrate BP, and 625 mg glycerol BP [ 48 ] and is a small volume stimulant enema suitable where large-volume enemas are contra-indicated. [ 28 ] TAI , also termed retrograde irrigation , is designed to assist evacuation using a water enema [ 49 ] as a treatment for persons with bowel dysfunction, including fecal incontinence or constipation, especially obstructed defecation . By regularly emptying the bowel using transanal irrigation, [ 50 ] controlled bowel function is often re-established to a high degree, thus enabling a consistent bowel routine development. [ 50 ] Its effectiveness varies considerably, some individuals experiencing complete control of incontinence but others reporting little or no benefit. [ 49 ] An international consensus on when and how to use transanal irrigation for people with bowel problems was published in 2013, offering practitioners a clear, comprehensive and straightforward guide to practice for the emerging therapeutic area of transanal irrigation. [ 50 ] The term retrograde irrigation distinguishes this procedure from the Malone antegrade continence enema , where irrigation fluid is introduced into the colon proximal to the anus via a surgically created irrigation port. [ 51 ] Patients who have a bowel disability, a medical condition which impairs control of defecation , e.g., fecal incontinence or constipation, [ 52 ] can use bowel management techniques to choose a predictable time and place to evacuate. [ 52 ] Without bowel management, such persons might either suffer from the feeling of not getting relief or soil themselves. [ 52 ] While simple techniques might include a controlled diet and establishing a toilet routine, [ 52 ] a daily enema can be taken to empty the colon, thus preventing unwanted and uncontrolled bowel movements that day. [ 53 ] In a lower gastrointestinal series an enema that may contain barium sulfate powder or a water-soluble contrast agent is used in the radiological imaging of the bowel. Called a barium enema , such enemas are sometimes the only practical way to view the colon relatively safely. [ 6 ] Failure to expel all of the barium may cause constipation or possible impaction [ 54 ] and a patient who has no bowel movement for more than two days or is unable to pass gas rectally should promptly inform a physician and may require an enema or laxative. [ 55 ] The administration of substances into the bloodstream. This may be done in situations where it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-angiogenic agents, which work better without digestion, can be safely administered via a gentle enema. Topical administration of medications into the rectum, such as corticosteroids and mesalazine , is used in the treatment of inflammatory bowel disease . Administration by enema avoids having the medication pass through the entire gastrointestinal tract , therefore simplifying the delivery of the medication to the affected area and limiting the amount that is absorbed into the bloodstream. Rectal corticosteroid enemas are sometimes used to treat mild or moderate ulcerative colitis. They may also be used along with systemic (oral or injection) corticosteroids or other medicines to treat severe disease or mild to moderate disease that has spread too far to be effectively treated by medicine inserted into the rectum alone. Improper administration of an enema can cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues which can be unnoticed as the rectum is insensitive to pain, [ 66 ] resulting in internal bleeding . However, these occurrences are rare in healthy, sober adults. Internal bleeding or rupture may expose the individual to infections from intestinal bacteria. Blood resulting from tears in the colon may not always be visible, but can be distinguished if the feces are unusually dark or have a red hue. If intestinal rupture is suspected, medical assistance should be obtained immediately. [ 14 ] Frequent use of enemas can cause laxative dependency. [ 67 ] The enema tube and solution may stimulate the vagus nerve , which may trigger an arrhythmia such as bradycardia . Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture . There are arguments both for and against colonic irrigation in people with diverticulitis , ulcerative colitis , Crohn's disease , severe or internal hemorrhoids or tumors in the rectum or colon . Its usage is not recommended soon after bowel surgery (unless directed by one's health care provider ). Regular treatments should be avoided by people with heart disease or kidney failure . Colonics are inappropriate for people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel perforation . [ 68 ] Recent research has shown that ozone water, which is sometimes used in enemas, can immediately cause microscopic colitis . [ 69 ] A recent case series [ 70 ] of 11 patients with five deaths illustrated the danger of phosphate enemas in high-risk patients. Enema entered the English language c. 1675 from Latin in which, in the 15th century, [ 3 ] it was first used in the sense of a rectal injection, [ 2 ] from Greek ἔνεμα (énema), "injection", itself from ἐνιέναι (enienai) "to send in, inject", from ἐν (en), "in" + ἱέναι (hienai), "to send, throw". [ 71 ] Clyster entered the English language in the late 14th century from Old French or Latin, from Greek κλυστήρ (klyster), "syringe", itself from κλύζειν (klyzein), "to wash out", [ 72 ] also spelled glister in the 18th century. [ 73 ] It is a generally archaic word used more particularly for enemas administered using a clyster syringe . The first mention of the enema in medical literature is in the Ancient Egyptian Ebers Papyrus ( c. 1550 BCE). One of the many types of medical specialists was a Nery-Pehuyt, the Shepherd of the Anus. Enemas administered many medications. [ 74 ] There was a Keeper of the Royal Rectum [ 75 ] who may have primarily been the pharaoh's enema maker. According to Egyptian mythology, the god Thoth invented the enema. [ 76 ] In parts of Africa, the calabash gourd is used traditionally to administer enemas. On the Ivory Coast the narrow neck of the gourd filled with water is inserted the patient's rectum and the contents are then injected by means of an attendant's forcible oral inflation, or a patient may self-administer the enema by using suction to create a negative pressure in the gourd, placing a finger at the opening, and then upon anal insertion, removing the finger to allow atmospheric pressure to effect the flow. In South Africa, Bhaca people used an ox horn to administer enemas. [ 77 ] Along the upper Congo River an enema apparatus is made by making a hole in one end of the gourd for filling it, and using a resin to attach a hollow cane to the gourd's neck. The cane is inserted into the anus of the patient who is in a posture that allows gravity to effect infusion of the fluid. [ 78 ] The Olmec used trance-inducing substances ceremonially from their middle preclassic period (10th through 7th centuries BCE) through the Spanish Conquest. These were ingested via enemas administered using jars, among other routes. As further described below in religious rituals , the Maya in their late classic age (7th through 10th centuries CE) used enemas for, at least, ritual purposes, Mayan sculpture and ceramics from that period depicting scenes in which, injected by syringes made of gourd and clay, ritual hallucinogenic enemas were taken. [ 79 ] In the Xibalban court of the God D, whose worship included ritual cult paraphernal, the Maya illustrated the use of a characteristic enema bulb syringe by female attendants administering clysters ritually. [ 80 ] [ 81 ] For combating illness and discomfort of the digestive tract, the Mayan also employed enemas, as documented during the colonial period, e.g., in the Florentine Codex . [ 79 ] The indigenous peoples of North America employed tobacco smoke enemas to stimulate respiration, injecting the smoke using a rectal tube. [ 82 ] [ 83 ] A rubber bag connected with a conical nozzle, at an early period, was in use among the indigenous peoples of South America as an enema syringe, [ 84 ] and the rubber enema bag with a connecting tube and ivory tip remained in use by them; in contrast, in Europe a syringe was still the usual means for conducting an enema. [ 85 ] In Babylonia, by 600 BCE, enemas were in use. However, it appears that initially they were in use because of a belief that the demon of disease would be driven out of the body by utilizing an enema. [ 86 ] Babylonian and Assyrian tablets c. 600 BCE bear cuneiform inscriptions referring to enemas. [ 87 ] In China, c. 200 CE, Zhang Zhongjing was the first to employ enemas. "Secure a large pig's bile and mix with a small quantity of vinegar. Insert a bamboo tube three or four inches long into the rectum and inject the mixture" are his directions, according to Wu Lien-teh . [ 88 ] In India, in the fifth century BCE, Sushruta enumerates the enema syringe among 121 surgical instruments described. Early Indian physicians' enema apparatus consisted of a tube of bamboo, ivory, or horn attached to the scrotum of a deer, goat, or ox. [ 86 ] In Persia, Avicenna (980–1037 A. D.) is credited with the introduction of the "clyster-purse" or collapsible portion of an enema outfit made from ox skin or silk cloth and emptied by squeezing with the hands. [ 87 ] Hippocrates (460–370 BCE) frequently mentions enemas, e.g., "if the previous food which the patient has recently eaten should not have gone down, give an enema if the patient be strong and in the prime of life, but if he be weak, a suppository should be administered, should the bowels be not well moved on their own accord." [ 89 ] In the first century BCE the Greek physician Asclepiades of Bithynia wrote "Treatment consists merely of three elements: drink, food, and the enema". [ 90 ] Also, he contended that indigestion is caused by particles of food that are too big and his prescribed treatment was proper amounts of food and wine followed by an enema which would remove the improper food doing the damage. [ 91 ] In the second century CE the Greek physician Soranus prescribed, among other techniques , enemas as a safe abortion method, [ 92 ] and the Greek philosopher Celsus recommended an enema of pearl barley in milk or rose oil with butter as a nutrient for those with dysentery and unable to eat, [ 93 ] and also Galen mentions enemas in several contexts. [ 61 ] In medieval times appear the first illustrations of enema equipment in the Western world , a clyster syringe consisting of a tube attached to a pump action bulb made of a pig bladder. [ citation needed ] A simple piston syringe clyster was used from the 15th through 19th centuries. This device had its rectal nozzle connected to a syringe with a plunger rather than to a bulb. [ citation needed ] Beginning in the 17th century, enema apparatus was chiefly designed for self-administration at home, and many were French as enemas enjoyed wide usage in France. [ 93 ] In 1694 François Mauriceau in his early-modern treatise, The Diseases of Women with Child, records midwives and man-midwives commonly administered clysters to labouring mothers just before their delivery. [ 94 ] Clysters were administered for symptoms of constipation and, with more questionable effectiveness, stomach aches and other illnesses. [ when? ] [ citation needed ] [ 95 ] In 1753, Johann Jacob Woyts described an enema bag prepared from a pig's or beef's bladder attached to a tube as an alternative to a syringe. [ 96 ] In the 18th century Europeans began emulating the indigenous peoples of North America's use of tobacco smoke enemas to resuscitate drowned people. [ 97 ] Tobacco resuscitation kits consisting of a pair of bellows and a tube were provided by the Royal Humane Society of London and placed at various points along the Thames. [ 93 ] Furthermore, these enemas came to be employed for headaches, respiratory failure, colds, hernias, abdominal cramps, typhoid fever, and cholera outbreaks. [ 97 ] Clysters were a favourite medical treatment in the bourgeoisie and nobility of the Western world up to the 19th century. As medical knowledge was fairly limited at the time, purgative clysters were used for a wide variety of ailments , the foremost of which were stomach aches and constipation. [ 9 ] According to the duc de Saint-Simon , clysters were so popular at the court of King Louis XIV of France that the duchess of Burgundy had her servant give her a clyster in front of the King (her modesty being preserved by an adequate posture) before going to the comedy . However, he also mentions the astonishment of the King and Mme de Maintenon that she should take it before them. [ 98 ] In the 19th century, many new types of enema administration equipment were devised. Devices allowing gravity to infuse the solution, like those mentioned above used by South American indigenous people and like the enema bag described by Johann Jacob Woyts, came into common use. These consist of a nozzle at the end of a hose that connects a reservoir, either a bucket or a rubber bag filled with liquid and held or hung above the recipient. [ 93 ] In the early 20th century the disposable microenema , a squeeze bottle, was invented by Charles Browne Fleet . [ 99 ] The term "colonic irrigation" is commonly used in gastroenterology to refer to the practice of introducing water through a colostomy or a surgically constructed conduit as a treatment for constipation. [ 100 ] The Food and Drug Administration has ruled that colonic irrigation equipment is not approved for sale for general well-being [ 101 ] and has taken action against many distributors of this equipment, including a Warning Letter . [ 102 ] The same term is also used in alternative medicine where it may involve the use of substances mixed with water to detoxify the body. Practitioners believe the accumulation of fecal matter in the large intestine leads to ill health. [ 103 ] This resurrects the old medical concept of autointoxication which was orthodox doctrine until the end of the 19th century but has now been discredited. [ 104 ] [ 105 ] [ 106 ] In the late 19th century, Dr. John Harvey Kellogg made sure that every patient's bowel was plied with water, from above and below. His favorite device was an enema machine ("just like one I saw in Germany") that could run fifteen gallons of water through a person's bowel in seconds. Every water enema was followed by a pint of yogurt—half was eaten, the other half was administered by enema "thus planting the protective germs where they are most needed and may render most effective service." The yogurt served to replace "the intestinal flora" of the bowel, creating what Kellogg claimed was a completely clean intestine. [ 107 ] Chlorine dioxide enemas have been fraudulently marketed as a medical treatment, primarily for autism . This has resulted, for example, in a six-year-old boy needing to have his colon removed and a colostomy bag fitted, [ 108 ] [ 109 ] complaints to the FDA reporting life-threatening reactions, [ 110 ] and even death. [ 111 ] Proponents falsely claim that administering enemas to autistic children results in the expulsion of parasitic worms (" rope worms "), which are fragments of damaged intestinal epithelium that are misinterpreted as being human pathogens. [ 112 ] [ 113 ] Oral and rectal use of the solution has also been promoted as a cure for HIV , malaria , viral hepatitis , influenza , common colds , acne , cancer , Parkinson's , and much more. Chlorine dioxide is a potent and toxic bleach [ 114 ] that is relabeled for "medicinal purposes" to a variety of brand names including, but not limited, to MMS, Miracle Mineral Supplement , and CD protocol. [ 115 ] For oral use, the doses recommended on the labeling can cause nausea, vomiting, diarrhea, and potentially life-threatening dehydration. [ 116 ] No clinical trials have been performed to test the health claims made for chlorine dioxide, which originate from former Scientologist Jim Humble [ 117 ] in his 2006 self-published book, The Miracle Mineral Solution of the 21st Century [ 118 ] and from anecdotal reports. Humble coined the name MMS. Sellers sometimes describe MMS as a water purifier to circumvent medical regulations. [ 119 ] The International Federation of Red Cross and Red Crescent Societies rejected "in the strongest terms" reports by promoters of MMS that they had used the product to fight malaria. [ 120 ] Well documented as having no proven benefits and considered by medical authorities as rash and potentially dangerous is an enema of coffee . [ 104 ] [ 121 ] A coffee enema can cause numerous maladies including infections , sepsis (including campylobacter sepsis), severe electrolyte imbalance , colitis , polymicrobial enteric sepsis, proctocolitis , salmonella , brain abscess , and heart failure, [ 122 ] [ 123 ] [ 124 ] [ 125 ] [ 126 ] [ 127 ] [ 128 ] [ 129 ] [ 130 ] [ excessive citations ] and deaths related to coffee enemas have been documented. [ 131 ] Gerson therapy includes administering enemas of coffee, [ 132 ] as well as of castor oil and sometimes of hydrogen peroxide or of ozone . [ 133 ] Some proponents of alternative medicine have claimed that coffee enemas have an anti- cancer effect by "detoxifying" metabolic products of tumors [ 122 ] but there is no medical scientific evidence to support this. [ 121 ] [ 123 ] [ 134 ] Enjoyment of enemas is known as klismaphilia , which medically is classified as a paraphilia . [ 135 ] [ 136 ] A person with klismaphilia is a klismaphile . Both women and men may enjoy sexual enema play, heterosexually and homosexually, experiencing sexual arousal from enemas which they find gratifying or sensual [ 137 ] [ 138 ] and which can be an auxiliary to, or even a substitute for, genital sexual activity . [ 137 ] [ 138 ] Klismaphiles may perceive pleasure from a large, water-distended belly, or the feeling of internal pressure. An enema fetish may include sexual attraction to the involved equipment, processes, environments, situations, or scenarios. [ 139 ] Klismaphiles can gain satisfaction of enemas through fantasies, by actually receiving or giving one, or through the process of eliminating steps to being administered one (e.g., under the pretence of being constipated). [ 138 ] That some women use enemas while masturbating was documented by Alfred Kinsey in Sexual Behavior in the Human Female : "There were still other masturbatory techniques which were regularly or occasionally employed by some 11 percent of the females in the sample... Douches, streams of running water, vibrators, urethral insertions, enemas, other anal insertions, sado-masochistic activity, and still other methods were occasionally employed, but none of them in any appreciable number of cases." [ 140 ] Besides klismaphilia, the intrinsic enjoyment of enemas, there are other uses of enemas in sexual play. [ 141 ] Enemas are sometimes used in sadomasochistic activities [ 142 ] [ 143 ] for erotic humiliation [ 144 ] or for physical discomfort. [ 145 ] Another sexual use for enemas is to empty the rectum as a prelude to other anal sexual activities such as anal sex , [ 146 ] possibly reducing risk of infection. This is different from klismaphilia, in which the enema is enjoyed for itself and as a part of sexual arousal and gratification. [ 146 ] Rectal douching is a common practice among people who take a receptive role in anal sex [ 147 ] although rectal douching before anal sex may increase the risk of transferring HIV , [ 148 ] hepatitis B , [ 149 ] and other diseases. [ 150 ] Noting that deaths have been reported from alcohol poisoning via enemas, [ 151 ] an alcohol enema can be used to very quickly instill alcohol into the bloodstream, absorbed through the membranes of the colon. However, great care must be taken as to the amount of alcohol used. Only a small amount is needed as the intestine absorbs the alcohol far more quickly than the stomach. When enema is prescribed for the administration of drugs or alcohol, a cleansing enema may first be used to clean the colon to help increase the rate of absorption. [ 152 ] All across Mesoamerica ritual enemas were employed to consume psychoactive substances, e.g., balché , alcohol , tobacco , peyote , and other hallucinogenic drugs and entheogens , most notably by the Maya , thus attaining more intense trance states more quickly. Mayan classic-period sculpture and ceramics depict hallucinogenic enemas used in rituals. [ 79 ] Some tribes continue the practice today. [ 153 ] With historical roots in the Indian subcontinent , enemas in Ayurveda , called Basti or Vasti, form part of Panchakarma procedure in which herbal medicines are introduced rectally. [ 154 ] Enemas have also been forcibly applied as a means of punishment. Political dissenters in post-independence Argentina were given enemas of chili pepper and turpentine . [ 155 ] Turpentine enemas are very harsh purgatives. [ 156 ] In the Guantanamo Bay Detention Camp , the Senate Intelligence Committee report on CIA torture documented instances of enemas being used by the Central Intelligence Agency to ensure "total control" over detainees. [ 157 ] Enemas, officials said, are uncomfortable and degrading. [ 158 ] The CIA forced nutrient enema on detainees who attempted hunger strikes, documenting "With head lower than torso … sloshing up the large intestines … [what] I infer is that you get a tube up as you can … We used the largest Ewal [ sic ] tube we had" wrote an officer, [ 159 ] and "violent enemas" is how a detainee described what he received. [ 160 ] In the Dionysus ' satyr play Limos , Silenus attempts to give an enema to Heracles . [ 161 ] In Shakespeare 's play Othello (Act II, Scene I) Iago says: "Yet again your fingers to your lips? would they were clyster-pipes for your sake!" [ 162 ] In Cervantes ' Don Quixote , a narrative to Sancho includes "The Knight of the Sun ... bound hand and foot ... was administered a clyster of snow water and sand that almost disracted him" [ 163 ] In the 17th century, satirists made physicians a favorite target, resembling Molière 's caricature whose prescription for anything was "clyster, bleed, purge," or "purge, bleed, clyster". [ 164 ] In Molière's play The Imaginary Invalid , Argan, a severe hypochondriac , is addicted to enemas as indicated by such lines as when Bĕralde asks, "Can't you be one moment without a purge?" [ 165 ] In George Orwell 's novel Nineteen Eighty-Four , the narrator notes, "Sexual intercourse was to be looked on as a slightly disgusting minor operation, like having an enema." [ 166 ] In Grace Metalious 's novel Peyton Place , the town doctor tells of "a young boy with the worst case of dehydration I ever saw. It came from getting too many enemas that he didn't need. Sex, with a capital S-E-X.". [ 167 ] As a teenager, the boy enjoys receiving enemas from his mother. [ 168 ] In Flora Rheta Schreiber 's book Sybil , Sybil's psychiatrist asks her "What's Mama been doing to you, dear?... I know she gave you the enemas." [ 169 ] TORCH SONG by Anne Roiphe, Farrar Straus & Giroux, RELEASE DATE: Jan. 1, 1976 In The Right Stuff , during flight training astronaut Alan Shepard retains a barium enema, [ 170 ] given two floors away from a toilet, embarrassedly riding a public elevator wearing a hospital gown and holding the enema bag with its tip still inserted in him. [ 171 ] [ 172 ] Water Power is a Pornographic film by Gerard Damiano loosely based on the real-life exploits of Michael H. Kenyon , an American criminal who pleaded guilty to a decade-long series of armed robberies of female victims, some of which involved sexual assaults in which he would give them enemas. [ 173 ] The lyrics of Frank Zappa 's song "The Illinois Enema Bandit" are concerned with Michael H. Kenyon 's sexual assaults which included administering involuntary enemas. [ 174 ] The album Enema of the State by blink-182 is titled with the word in it. It features a nurse on the cover. A 365-kilogram (805-pound) brass statue of a syringe enema bulb held aloft by three cherubs stands in front of the "Mashuk" spa in the settlement of Zheleznovodsk in Russia. Inspired by the 15th century Renaissance painter Botticelli, it was created by a local artist who commented, "An enema is an unpleasant procedure as many of us may know. But when cherubs do it, it's all right." When unveiled on 19 June 2008, a banner on one of the spa's walls declared "Let's beat constipation and sloppiness with enemas." The spa lying in the Caucasus Mountains region, known for dozens of spas that routinely treat digestive and other complaints with enemas of mineral spring water, the director commented "An enema is almost a symbol of our region." [ 175 ] [ 176 ] It is the only known monument to the enema. [ 177 ] Sources "A professional nursing instructional video demonstrating administering a cleansing enema" . Taber's Medical Dictionary . K. A. Davis Company . Retrieved 17 July 2014 .	https://en.wikipedia.org/wiki/Enema
To classify postoperative outcomes for epilepsy surgery , Jerome Engel proposed the following scheme, [ 1 ] the Engel Epilepsy Surgery Outcome Scale , which has become the de facto standard when reporting results in the medical literature: [ 2 ] Surgery for epilepsy patients has been used for over a century, but due to technological restrictions and insufficient knowledge of brain surgery , this treatment approach was relatively rare until the 1980s and 90s. [ 3 ] Prior to the 1980s, no classification system existed due to the lack of operations performed up until the time. As surgery as a treatment grew more prevalent, a classification system became a necessity. The appropriate evaluation of patients following epilepsy surgery is extremely important, as medical professionals must know the appropriate course of action to follow in order to achieve seizure freedom for patients. [ 4 ] Accordingly, the Engel classification guidelines were devised by UCLA neurologist Jerome Engel Jr. in 1987 and made public at the 1992 Palm Desert Conference on Epilepsy Surgery. [ 5 ] [ 6 ] The Engel classification system has since become the standard in reporting postoperative outcomes of epilepsy surgery. [ 1 ] In Engel's 1993 summary of the 1992 Palm Desert Conference on Epilepsy Surgery, he annotated his classification system with more detail. [ 1 ] The annotation was as follows: The subjectivity of the Engel system leaves much of the postoperative class assignment process to the patients. While many have noted the disadvantages of a classification system where the patients are involved in determining the evaluation, others have praised it. [ 4 ] Proponents of the Engel classification guidelines argue that the patients are best able to perceive the worth of the operation because they are the ones experiencing the seizures before and after the treatment. [ citation needed ] As is the case for all current methods of reviewing epilepsy surgery outcomes, the Engel classification system has subjective components. [ 6 ] A "disabling seizure" is subjective and can vary in definition from person to person. While one epileptic experiencing a seizure when driving a car may find the seizure "disabling", the same magnitude of seizure may be interpreted as mild, and thus "nondisabling", by an epileptic resting in bed. Every class other than class I is also subjective because there is no quantitative definition of what determines a rare occurrence or method to measure worthwhileness. One doctor and patient may consider two seizures in a year as a rare occurrence while another doctor may consider ten in a year as rarely occurring. The worthwhileness of the operation is ambiguous because worth can be interpreted differently by various patients and healthcare professionals. [ 7 ] Keeping those caveats in mind, most neurologists and neurosurgeons who specialize in epilepsy would most likely agree, as would many persons with epilepsy and even laypeople, that any seizure that leads to a period of status epilepticus (seizure activity, especially of the tonic-clonic, or grand mal, type, for longer than about five to ten minutes, or more – some now say it should be as little as two – without an intervening return to normal, or any repeat seizures without a return to consciousness) is a medical emergency, objectively a major problem, and cannot be considered a satisfactory outcome (unless perhaps if the person had a fatal or very severe form of a neurodegenerative syndrome or other disease where such severe repeat seizures are not unusual, and there are a number of these diseases; even then, such an outcome is usually still not a cure, just an amelioration of a fatal condition or a very disabling condition). Continuing to have to endure a large number of tonic-clonic seizures (grand mal seizures) over a period of days, months, or even over the course of a year or two, would make it impossible to drive and very hard to hold a job away from home entailing much stress, and would pose limits on one's abilities to safely carry out the activities of daily living without at least some monitoring or assistance. [ citation needed ] The Engel classification system has been thought of as a cross-sectional grading system by medical professionals because it does not account for long term changes in patients. [ 7 ] It has been proposed that it would be more beneficial to reevaluate patients on an annual basis, and the International League Against Epilepsy (ILAE) devised a separate rating scale in 2001 that reevaluates patients on every annual anniversary of their surgery. [ 4 ] The ILAE also developed their system in hopes of avoiding many of the subjective components found in the Engel system. [ 4 ]	https://en.wikipedia.org/wiki/Engel_classification
The enhanced permeability and retention ( EPR ) effect is a controversial concept [ 1 ] [ 2 ] by which molecules of certain sizes (typically liposomes , nanoparticles , and macromolecular drugs) tend to accumulate in tumor tissue much more than they do in normal tissues. [ 3 ] [ 4 ] The general explanation that is given for this phenomenon is that, in order for tumor cells to grow quickly, they must stimulate the production of blood vessels. VEGF and other growth factors are involved in cancer angiogenesis . Tumor cell aggregates as small as 150–200 μm , start to become dependent on blood supply carried out by neovasculature for their nutritional and oxygen supply. These newly formed tumor vessels are usually abnormal in form and architecture. They are poorly aligned defective endothelial cells with wide fenestrations, lacking a smooth muscle layer, or innervation with a wider lumen , and impaired functional receptors for angiotensin II . Furthermore, tumor tissues usually lack effective lymphatic drainage . All of these factors lead to abnormal molecular and fluid transport dynamics, especially for macromolecular drugs. This phenomenon is referred to as the "enhanced permeability and retention (EPR) effect" of macromolecules and lipids in solid tumors. The EPR effect is further enhanced by many pathophysiological factors involved in enhancement of the extravasation of macromolecules in solid tumor tissues. For instance, bradykinin , nitric oxide / peroxynitrite , prostaglandins , vascular permeability factor (also known as vascular endothelial growth factor VEGF), tumor necrosis factor and others. One factor that leads to the increased retention is the lack of lymphatics around the tumor region which would filter out such particles under normal conditions. The EPR effect is usually employed to describe nanoparticle and liposome delivery to cancer tissue. [ 5 ] One of many examples is the work regarding thermal ablation with gold nanoparticles . Halas, West and coworkers have shown a possible complement to radiation and chemotherapy in cancer therapy, wherein once nanoparticles are at the cancer site they can be heated up in response to a skin penetrating near IR laser ( Photothermal effect ). This therapy has shown to work best in conjunction with chemotherapeutics or other cancer therapies. [ 6 ] Although the EPR effect has been postulated to carry the nanoparticles and spread inside the cancer tissue, only a small percentage (0.7% median) of the total administered nanoparticle dose is usually able to reach a solid tumor. [ 7 ]	https://en.wikipedia.org/wiki/Enhanced_permeability_and_retention_effect
Enteric neuropathy is a degenerative neuromuscular condition of the digestive system. [ 1 ] In simple terms the gut stops functioning, due to degradation of the nerves and muscles. The condition affects all parts of the digestive tract . There is no known cure or treatment for enteric neuropathy at this time; it is only possible to work on symptom management. The name enteric neuropathy only seems to be used for diagnosis within the UK. The most common name worldwide for this condition is Intestinal pseudoobstruction . The main symptom of enteric neuropathy is severe and constant pain. Other symptoms include nausea , vomiting , diarrhoea , constipation , bloating and abdominal abnormalities. In addition malabsorption and poor nutrition are common, as the digestive system begins to fail. Symptom management is very important and the main priority is usually to get on top of the pain. However, as most people may have been waiting for years for a diagnosis they are often already addicted to painkillers (such as tramadol and oramorph ) and these have adverse effects on the primary condition. [ citation needed ] The diagnosis of enteric neuropathy is rather difficult, in that many symptoms present in ways that are common to many other bowel- and gut -related diseases. It is common that many people undergo many surgeries , sometimes over several years, to attempt to combat other possible diseases. The diagnosis itself is conducted by a physician based on multiple tests and is subjective rather than definitive, which for those who have enteric neuropathy will show signs of severe abnormalities in the movement of the gut. An operation to take a section of muscle for biopsy which, if it shows signs of nerve degradation, assists in the diagnosis. [ citation needed ]	https://en.wikipedia.org/wiki/Enteric_neuropathy
Entero-oxyntin is a hormone released from intestinal endocrine cells which stimulates gastric acid secretion in the stomach . It has been isolated from animals [ 1 ] and is hypothesised to exist in humans. This medical article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Entero-oxyntin
An enterostomal therapist is a health professional trained in the care of persons with stomas , such as colostomies or urostomies. An enterostomal therapy nurse, or ET nurse, is specialized in treating patients who have ostomies, wounds, or incontinence. This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute . This oncology article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Enterostomal_therapist
Enterotomy is the surgical incision into an intestine. It may be purposeful or a complication of an abdominal surgery , such as exploratory laparotomies or hernia repair . [ citation needed ] An enterotomy can be done to remove an obstruction or foreign body from the intestine. [ 1 ] If an accidental enterotomy is not noticed during surgery, it can take days to become apparent. Surgical repair is required. [ 2 ] This surgery article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Enterotomy
In the field of molecular biology , enterotoxin type B , also known as Staphylococcal enterotoxin B ( SEB ), is an enterotoxin produced by the gram-positive bacteria Staphylococcus aureus . It is a common cause of food poisoning , with severe diarrhea , nausea and intestinal cramping often starting within a few hours of ingestion. [ 1 ] Being quite stable, [ 2 ] the toxin may remain active even after the contaminating bacteria are killed. It can withstand boiling at 100 °C for a few minutes. [ 1 ] Gastroenteritis occurs because SEB is a superantigen , causing the immune system to release a large amount of cytokines that lead to significant inflammation. Additionally, this protein is one of the causative agents of toxic shock syndrome . The function of this protein is to facilitate the infection of the host organism. It is a virulence factor designed to induce pathogenesis . [ 3 ] One of the major virulence exotoxins is the toxic shock syndrome toxin (TSST), which is secreted by the organism upon successful invasion . It causes a major inflammatory response in the host via superantigenic properties, and is the causative agent of toxic shock syndrome. It functions as a superantigen through activation of a significant fraction of T-cells (up to 20%) by cross-linking MHC class II molecules with T-cell receptors . TSST is a multisystem illness with several symptoms such as high fever , hypotension , dizziness, rash and peeling skin. [ 3 ] All of these toxins share a similar two-domain fold (N and C-terminal domains) with a long alpha-helix in the middle of the molecule, a characteristic beta-barrel known as the "oligosaccharide/oligonucleotide fold" at the N-terminal domain and a beta-grasp motif at the C-terminal domain. Each superantigen possesses slightly different binding mode(s) when it interacts with MHC class II molecules or the T-cell receptor. [ 4 ] The N-terminal domain is also referred to as OB-fold , or in other words the oligonuclucleotide binding fold. This region contains a low-affinity major histocompatibility complex class II ( MHC II ) site which causes an inflammatory response . [ 5 ] The N-terminal domain contains regions involved in Major Histocompatibility Complex class II association. It is a five stranded beta barrel that forms an OB fold . [ 6 ] [ 7 ] [ 8 ] The beta-grasp domain has some structural similarities to the beta-grasp motif present in immunoglobulin-binding domains, ubiquitin, 2Fe-2 S ferredoxin and translation initiation factor 3 as identified by the SCOP database.	https://en.wikipedia.org/wiki/Enterotoxin_type_B
Entropy monitoring is a method of assessing the effect of certain anaesthetic drugs on the brain's EEG. It was commercially developed by Datex-Ohmeda, which is now part of GE Healthcare . Entropy is a quantitative EEG device which captures a single-lead frontal EEG via a 3-electrode sensor applied to the patient's forehead. The system calculates the " spectral entropy " of the electroencephalogram (EEG) signals, which is a measure of the degree that the power spectrum is uniform. Increasing brain levels of anaesthetic drugs causes the predominant frequencies in the EEG to be lower than when awake, and this is reflected in a decrease in the spectral entropy. [ 1 ] [ 2 ] Entropy monitors generate two numbers that are derived from different frequency bands used. The state entropy (SE) is calculated from the 0.8 Hz to 32 Hz range, whereas the response entropy (RE) uses frequencies up to 47 Hz. Electromyogram activity is more predominant in those higher frequencies, and so the Response Entropy may respond more quickly when muscle activity is present. Published studies show that entropy values do relate to clinical levels of anaesthetic depth. Most of the commonly used anaesthetic drugs are detectable by entropy monitoring, a notable exception being nitrous oxide , in common with BIS monitoring. Other vital signs such as pulse , heart rate , blood pressure , and movement are indirect indicators of consciousness , but are unreliable. When these are combined with expired gas analysis of inhalational anaesthetic agents, an experienced anaesthetist can be confident a patient is unconscious and not aware of their surroundings. However, the direct measurement of brain activity using a basic EEG is purported to measure effects of anaesthetics more comprehensively. Unlike the bispectral index monitor, the algorithm of the entropy monitor has been fully disclosed. [ 2 ]	https://en.wikipedia.org/wiki/Entropy_monitoring
Entrustable professional activity (EPA) refers to a framework within medical education where trainees are evaluated on their ability to perform certain critical clinical tasks without direct supervision. Originating from the medical education domain, the success of EPAs has sparked interest in its application across other professional sectors. The last decades of the 20th century saw a pronounced shift in medical education, with a growing emphasis on competency-based medical education (CBME). Especially in English-speaking countries like the USA, UK, Canada, and Australia, there was an increasing call to ensure that medical graduates had specific competencies to guarantee patient safety and effective medical care. This led to institutions framing their curricula around competency frameworks, such as the Accreditation Council for Graduate Medical Education (ACGME) in the USA, which defined core competencies for all medical specialties. [ 1 ] However, while CBME provided a structured approach, educators and policymakers noticed some limitations. Competencies, though crucial, were often too granular or abstract for direct assessment. This raised concerns about how to determine a trainee's readiness for independent practice. Was it enough to be competent in isolated skills, or was there a need to demonstrate capability in integrating these skills in real-world contexts? Professor Olle Ten Cate from the Netherlands introduced the concept of EPAs in this backdrop. The idea was to bridge the gap between competency acquisition and real-world clinical responsibilities. Instead of asking if a trainee had acquired a list of skills, the focus shifted to whether they could be "entrusted" with specific professional activities that integrated multiple competencies. [ 2 ] This framework quickly gained traction, not just in the Netherlands, but also in various English-speaking countries. In the United States, for instance, the Association of American Medical Colleges (AAMC) explored the implementation of EPAs for undergraduate medical education. By 2014, the AAMC had defined a set of 13 core EPAs that all medical school graduates should be able to perform on day one of residency without direct supervision. [ 3 ] The UK, Canada, and Australia also saw discussions and pilot implementations of the EPA framework, recognizing the need for a more holistic approach to assessing trainee readiness for clinical practice. [ 4 ] [ 5 ] The transition to EPAs from the traditional competency-based approach bore several advantages:	https://en.wikipedia.org/wiki/Entrustable_professional_activity
As a general surgical technique, enucleation refers to the surgical removal of a mass without cutting into or dissecting it. Enucleation refers to the removal of the eyeball itself, while leaving surrounding tissues intact. In the context of oral pathology , enucleation involves surgical removal of all tissue (both hard and soft) involved in a lesion . [ 1 ] Enucleation is the removal of fibroids without removing the uterus ( hysterectomy ), which is also commonly performed. This surgery article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Enucleation_(medicine)
An environment-wide association study , also known as an environmental-wide association study (abbreviated EWAS ), is a type of epidemiological study analogous to the genome-wide association study , or GWAS. The EWAS systematically examines the association between a complex disease and multiple individual environmental factors, controlling for multiple hypothesis testing . [ 1 ] [ 2 ] [ 3 ] This medical article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Environment-wide_association_study
Environmental noise is an accumulation of noise pollution that occurs outside. This noise can be caused by transport, industrial, and recreational activities. [ 1 ] Noise is frequently described as 'unwanted sound'. Within this context, environmental noise is generally present in some form in all areas of human, animal, or environmental activity. The effects in humans of exposure to environmental noise may vary from emotional to physiological and psychological. [ 2 ] Noise at low levels is not necessarily harmful. Environmental noise can also convey a sense of liveliness in an area, which can be desirable. The adverse effects of noise exposure (i.e. noise pollution ) could include: interference with speech or other 'desired' sounds, annoyance, sleep disturbance, anxiety, hearing damage and stress-related cardiovascular health problems. [ 3 ] As a result, environmental noise is studied, regulated, and monitored by many governments and institutions around the world. This creates a number of different occupations. The basis of all decisions is supported by the objective and accurate measurement of noise . Noise is measured in decibels (dB) using a pattern-approved sound level meter . The measurements are typically taken over a period of weeks, in all weather conditions. Noise from transportation is typically emitted by machinery (e.g. the engine or exhaust) and aerodynamic noise (see aerodynamics and aircraft noise ) caused by the compression and friction in the air around the vessel during motion. Environmental noise from the railway specifically is variable depending on the speed and quality of the tracks used for transportation. [ 4 ] Industrial and recreational noise could be generated by a multitude of different sources and processes. Industrial noise can be generated by factories and plants (i.e., product fabrication or assembly), power generation ( hydroelectricity or wind turbines ), construction activities, or agricultural and meat processing facilities. Sources of recreational noise vary widely but they can include music festivals , [ 5 ] shooting ranges , sporting events, car racing, woodworking, pubs, [ 6 ] people's activities on the street, [ 7 ] etc. Sound propagation outdoors is subject to meteorological effects (e.g. wind, temperature) that affect the distance, speed, and direction with which environmental noise travels from a source to a listener. Children and adolescents are just as susceptible to environmental noise exposure as adults. Similar to adults, with the exposure to noise there can be damaging outcomes on mental health. [ 8 ] The environmental noises that children can be exposed to are traffic noise, aircraft, trains, and more. [ 8 ] There are some pieces of evidence that show a small correlation between environmental noise and reading and oral comprehension. [ 8 ] Environmental noise in children is most commonly by people around them whether that be siblings crying or friends screaming. Then children are mostly exposed to animal noises and traffic noise. [ 9 ] When researchers asked children how they felt when it came to environmental noises around them, more felt negative emotions as compared to positive emotions. The negative emotions were tied to environmental sound, for example, traffic noise, industrial noises, sirens, and alarms. [ 9 ] The positive emotions were tied to winds, fans, and everyday household noises. [ 9 ] Noise and quality of life are correlated. The increase of environmental noise, especially for those living near railways and airports, has created conflict. Getting adequate and quality sleep is difficult for those who live in areas of high noise exposure. When the body is at rest, noise stimuli is continually being presented in the environment. The body responds to these sounds which can negatively affect sleep. [ 4 ] High exposure to environmental noise can play a role in cardiovascular disease . Noise can raise blood pressure, change heart rate, and release stress hormones. Consistent changes in these health statistics can lead to risks for hypertension, arteriosclerosis, and even more serious events such as a stroke or myocardial infarction. [ 10 ] [ 11 ] Sleep deprivation is another aspect of health that is affected by environmental noise. In order for our bodies to function properly, we need sleep and for some people having excessive environmental noise around them can cause difficulties sleeping. [ 12 ] For many, even ambient noise can affect their sleep state which can then affect their quality of life and outlook. [ 12 ] Those with misophonia may be particularly affected by environmental noise, especially when the sounds produced are repetitive or continuous over a long period of time. [ 13 ] The Noise Control Act of 1972 established a U.S. national policy to promote an environment for all Americans to be free from noise that jeopardizes their health and welfare. In the past, Environmental Protection Agency (EPA) coordinated all federal noise control activities through its Office of Noise Abatement and Control. [ 14 ] The EPA phased out the office's funding in 1982 as part of a shift in federal noise control policy to transfer the primary responsibility of regulating noise to state and local governments. The Noise Control Act of 1972 and the Quiet Communities Act of 1978 were never rescinded by Congress and remain in effect today, although essentially unfunded. [ 15 ] Today, in the absence of a national guidance and enforcement by the EPA, states, cities, and municipalities have had little or no guidance on writing competent and effective noise regulations . Since the EPA last published its Model Community Noise Ordinance in 1974, communities have struggled to develop their ordinances, often relying on copying guidance from other communities, and sometimes copying their mistakes. [ 16 ] Noise laws and ordinances vary widely among municipalities though most specify some general prohibition against making noise that is a nuisance and the allowable sound levels that can cross a property line. Some ordinances set out specific guidelines for the level of noise allowable at certain times of the day and for certain activities. [ 17 ] The Federal Aviation Administration (FAA) regulates aircraft noise by specifying the maximum noise level that individual civil aircraft can emit through requiring aircraft to meet certain noise certification standards. These standards designate changes in maximum noise level requirements by "stage" designation. The U.S. noise standards are defined in the Code of Federal Regulations (CFR) Title 14 Part 36 – Noise Standards: Aircraft Type and Airworthiness Certification (14 CFR Part 36). [ 18 ] The FAA also pursues a program of aircraft noise control in cooperation with the aviation community. [ 19 ] The FAA has set up a process to report aviation-related noise complaints for anyone who may be impacted by Aircraft noise. The Federal Highway Administration (FHWA) developed noise regulations to control highway noise as required by the Federal-Aid Highway Act of 1970. The regulations requires promulgation of traffic noise-level criteria for various land use activities, and describe procedures for the abatement of highway traffic noise and construction noise. [ 20 ] The U.S. Department of Transportation 's Bureau of Transportation Statistics has created a National Transportation Noise Map Archived 21 January 2018 at the Wayback Machine to provide access to comprehensive aircraft and road noise data on national and county-level. The map aims to assist city planners, elected officials, scholars, and residents to gain access to up-to-date aviation and Interstate highway noise information. [ 21 ] The European Union has a special definition based on the European directive 2002/49/EC article 10.1. This directive gives a definition for environmental noise. The main goal is to create an integrated noise management system. The Environmental Noise Directive (END) was created in the European Union to provide guidelines, laws, and standards in the management of environmental noise. The END has created noise mapping, noise action plans, and quiet areas to control environmental noise and the negative effects it can have on individuals. [ 22 ] The implementation is divided into phases: In the first phase, the member states shall inform about major roads with more than six million vehicles a year, major railways with more than 60,000 trains per year, major airports with more than 50,000 movements per year and metropolitan areas with more than 250,000 inhabitants. In the second phase, these numbers are halved; only the criteria for airports remains unchanged. In the third and the following phases, the methods for calculation of the noise levels will change while the criteria remains unchanged. Each phase consists of three steps: the collection of the data from the main sources of noise, strategic noise maps and action plans . The countries listed below follow the guidelines of the European Union. There are many groups of people affected by environmental noise within the European Union. Shift workers, older adults, and those without proper insulation in their homes are just some of those affected. [ 23 ] Within the European Union 40% of people are exposed to environmental noise in their daily commutes on the road which exceeds 55 dB(A). During the daytime, approximately 20% of people are exposed to environmental noise levels above 65 dB(A) and during the nighttime, 30% of people are exposed to environmental noise above 55 dB(A). [ 23 ] In Austria the institution which is responsible for the noise sources is also responsible for the noise maps concerning these sources. This means that the Federation is responsible for the federal roads and each state is responsible for the country's roads. France reported 24 metropolitan areas. Paris was the biggest with 9.6 million inhabitants and 272 square kilometres. Many of France's residents are exposed to high levels of noise. Previously it was estimated that 10% of the population, approximately 2 million people, were exposed to above 70 dB Leq. That number is estimated higher today. [ 12 ] Aircraft plays a major role in environmental noise. A study conducted in 2018 found that while aircraft noise in decibel level cannot cause any psychological-illness , there is a link to how aircraft noise causes an annoyance to residents which then leads to psychological illness. [ 24 ] The sensitivity of noise among people has an association with environmental noise and those affects. [ 24 ] Germany implemented national regulations in 2005 and 2006 and reported 27 metropolitan areas in the first phase. Berlin was the most populated with 3.39 million inhabitants and 889 square kilometres, Hamburg was considered the largest with 1,045 square kilometres and 2 million inhabitants. The smallest was Gelsenkirchen with 270,000 inhabitants and 105 square kilometres. In the national legislation, noise resulting from recreational activities like sports and leisure is not considered as environmental noise. The United Kingdom has 28 metropolitan areas, and London is the largest with 8.3 million inhabitants. Most are in England. Three are in Northern Ireland, Scotland and Wales. Within the United Kingdom, researchers revealed that approximately 55% of the population lived where the sound level exceeded the recommended level of 55 dB Leq in the daytime and 67% lived where the sound level exceeded the recommended level of 45 dB Leq at night. [ 25 ] About 20% of London residents were exposed to environmental noise near their home that was above 60 dBA Leq. All of these environmental noise exposures have led to higher increases in blood pressure within the UK population. [ 25 ]	https://en.wikipedia.org/wiki/Environmental_noise
Eosinophilic (Greek suffix -phil , meaning eosin -loving ) describes the staining of tissues , cells , or organelles after they have been washed with eosin , a dye commonly used in histological staining. Eosin is an acidic dye for staining cell cytoplasm , collagen , and muscle fibers . [ 1 ] [ 2 ] Eosinophilic describes the appearance of cells and structures seen in histological sections that take up the staining dye eosin. [ 2 ] Such eosinophilic structures are, in general, composed of protein . [ 3 ] Eosin is usually combined with a stain called hematoxylin to produce a hematoxylin- and eosin-stained section (also called an H&E stain , HE or H+E section). It is the most widely used histological stain for a medical diagnosis. [ 3 ] When a pathologist examines a biopsy of a suspected cancer, they will stain the biopsy with H&E. Some structures seen inside cells are described as being eosinophilic; for example, Lewy and Mallory bodies . [ 4 ] Some cells are also described as eosinophilic, such as Leukocytes . [ 5 ] This article related to pathology is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Eosinophilic
Eosinophilic myocarditis is inflammation in the heart muscle that is caused by the infiltration and destructive activity of a type of white blood cell , the eosinophil . Typically, the disorder is associated with hypereosinophilia , i.e. an eosinophil blood cell count greater than 1,500 per microliter (normal 100 to 400 per microliter). It is distinguished from non-eosinophilic myocarditis , which is heart inflammation caused by other types of white blood cells, i.e. lymphocytes and monocytes , as well as the respective descendants of these cells, NK cells and macrophages . This distinction is important because the eosinophil-based disorder is due to a particular set of underlying diseases and its preferred treatments differ from those for non-eosinophilic myocarditis. [ 1 ] [ 2 ] Eosinophilic myocarditis is often viewed as a disorder that has three progressive stages. The first stage of eosinophilic myocarditis involves acute inflammation and cardiac cell necrosis (i.e. areas of dead cells); it is dominated by symptoms characterized as the acute coronary syndrome such as angina , heart attack and/or congestive heart failure . The second stage is a thrombotic stage wherein the endocardium (i.e. interior wall) of the diseased heart forms blood clots which break off, travel in, and block blood through systemic or pulmonary arteries; this stage may dominate the initial presentation in some individuals. The third stage is a fibrotic stage wherein scarring replaces damaged heart muscle tissue to cause a clinical presentation dominated by a poorly contracting heart and cardiac valve disease . [ 3 ] [ 4 ] [ 5 ] Perhaps less commonly, eosinophilic myocarditis, eosinophilic thrombotic myocarditis, and eosinophilic fibrotic myocarditis are viewed as three separate but sequentially linked disorders in a spectrum of disorders termed eosinophilic cardiac diseases. [ 1 ] The focus here is on eosinophilic myocarditis as a distinct disorder separate from its thrombotic and fibrotic sequelae. Eosinophilic myocarditis is a rare disorder. It is usually associated with, and considered secondary to, an underlying cause for the pathological behavior of the eosinophils such a toxic reaction to a drug (one of its more common causes in developed nations), the consequence of certain types of parasite and protozoan infections (a more common cause of the disorder in areas with these infestations), or the result of excessively high levels of activated blood eosinophils due to a wide range of other causes. [ 6 ] The specific treatment (i.e. treatment other than measures to support the cardiovascular system) of eosinophilic myocarditis differs from the specific treatment of other forms of myocarditis in that it is focused on relieving the underlying reason for the excessively high numbers and hyperactivity of eosinophils as well as on inhibiting the pathological actions of these cells. [ 6 ] [ 7 ] [ 8 ] Symptoms in eosinophilic myocarditis are highly variable. They tend to reflect the many underlying disorders causing eosinophil dysfunction as well as the widely differing progression rates of cardiac damage. Before cardiac symptoms are detected, some 66% of cases have symptoms of a common cold and 33% have symptoms of asthma , rhinitis , urticarial , or other allergic disorder. Cardiac manifestations of eosinophilic myocarditis range from none to life-threatening conditions such as cardiogenic shock or sudden death due to abnormal heart rhythms . More commonly the presenting cardiac symptoms of the disorder are the same as those seen in other forms of heart disease: chest pain , shortness of breath, fatigue, chest palpitations , light headedness, and syncope . [ 7 ] In its most extreme form, however, eosinophilic myocarditis can present as acute necrotizing eosinophilic myocarditis, i.e. with symptoms of chaotic and potentially lethal heart failure and heart arrhythmias . This rarest form of the disorder reflects a rapidly progressive and extensive eosinophilic infiltration of the heart that is accompanied by massive myocardial cell necrosis . [ 1 ] [ 9 ] Hypereosinophilia (i.e. blood eosinophil counts at or above 1,500 per microliter) or, less commonly, eosinophilia (counts above 500 but below 1,500 per microliter) are found in the vast majority of cases of eosinophilic myocarditis and are valuable clues that point to this rather than other types of myocarditis or myocardial injuries. However, elevated blood eosinophil counts may not occur during the early phase of the disorder. Other, less specific laboratory findings implicate a cardiac disorder but not necessarily eosinophilic myocarditis. These include elevations in blood markers for systemic inflammation (e.g. C reactive protein , erythrocyte sedimentation rate ), elevations in blood markers for cardiac injury (e.g. creatine kinase , troponins ); and abnormal electrocardiograms ( mostly ST segment - T wave abnormalities). [ 7 ] There are many causes of eosinophilia that may underlie eosinophilic myocarditis. These causes are classified as primary (i.e. a defect intrinsic to the eosinophil cell line), secondary (induced by an underlying disorder that stimulates the proliferation and activation of eosinophils), or idiopathic (i.e. unknown cause). Non-idiopathic causes of the disorder are sub-classified into various forms of allergic , autoimmune , infectious , or malignant diseases and hypersensitivity reactions to drugs, vaccines, or transplanted hearts. While virtually any cause for the elevation and activation of blood eosinophils must be considered as a potential cause for eosinophilic myocarditis, the following list gives the principal types of eosinophilia known or thought to underlie the disorder. [ citation needed ] Primary conditions that may lead to eosinophilic myocarditis are: Secondary conditions that may lead to eosinophilic myocarditis are: The DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) is a severe immunological drug reaction . It differs from other drug reactions in that it: a) is caused by a particular set of drugs; b) typically occurs after a delay of 2 to 8 weeks following intake of an offending drug; c) presents with a specific set of signs and symptoms (i.e. modest or extreme elevations in blood eosinophil and atypical lymphocyte counts; acute onset of a skin rash; lymphadenopathy ; fever; neuralgia ; and involvement of at least one internal organ such as the liver, lung, or heart; d) develops in individuals with particular genetic predispositions; and e) involves reactivation of latent viruses , most commonly human herpesvirus 6 or more rarely human herpes virus 5 (i.e. human cytomegalovirus), human herpesvirus 7 , and human herpesvirus 4 (i.e. Epstein–Barr virus). These viruses usually become dormant after infecting humans but under special circumstances, such as drug intake, are reactivated and may contribute to serious diseases such as the DRESS syndrome. [ 20 ] [ 21 ] Eosinophils normally function to neutralize invading microbes, primarily parasites but also certain types of fungi and viruses. In conducting these functions, eosinophils normally occupy the gastrointestinal tract, respiratory tract, and skin where they produce and release on demand a range of toxic reactive oxygen species (e.g. hypobromite , hypobromous acid , superoxide , and peroxide ) and also release on demand a preformed armamentarium of chemical signals including cytokines , chemokines , growth factors , lipid mediators (e.g. leukotrienes , prostaglandins , platelet activating factor , 5-oxo-eicosatetraenoic acid ), and toxic proteins (e.g. metalloproteinases , major basic protein , eosinophil cationic protein , eosinophil peroxidase , and eosinophil-derived neurotoxin ). These agents serve to orchestrate robust inflammatory responses that destroy invading microorganisms . Eosinophils also participate in transplant rejection , Graft-versus-host disease , the destruction or walling off of foreign objects, and the killing of cancer cells . In conducting these functions, eosinophils enter tissues that they do not normally occupy. [ citation needed ] When overproduced and over-activated, such as in cases of eosinophilic myocarditis, eosinophils behave as though they were attacking a foreign or malignant tissue: they enter a seemingly normal organ such as the heart, misdirect their reactive oxygen species and armamentarium of preformed molecules toward seemingly normal tissue such as heart muscle, and thereby produce serious damage such as heart failure. [ 1 ] [ 22 ] [ 23 ] [ 24 ] Animal model studies suggest reasons why eosinophils are directed to and injure the heart muscle. Mice made hypereosinophilic by the forced overexpression of an interleukin-5 transgene ( interleukin 5 stimulates eosinophil proliferation, activation, and migration) develop eosinophilic myocarditis. A similar eosinophilic endocarditis occurs in mice immunized with the cardiac muscle protein, mouse myosin. In the latter model, endocarditis is reduced by inhibiting the cytokine interleukin-4 or eosinophils and is exacerbated by concurrently blocking two cytokines, interferon gamma and interleukin-17A . Finally, certain eosinophil- attracting agents, viz., eotaxins , are elevated in the cardiac tissue of myosin-immunized mice that are concurrently depleted of interferon-gamma and interleukin-17A. Eotaxins are also elevated in the cardiac muscle biopsy specimens of individuals with eosinophilic myocarditis compared to their levels in non-eosinophilic myocarditis. These findings suggest that eosinophilic myocarditis is caused by the abnormal proliferation and activation of eosinophils and that their directional migration into the heart is evoked by a set of cytokines and chemoattractants in mice and possibly humans. [ 3 ] In eosinophilic myocarditis, echocardiography typically gives non-specific and only occasional findings of endocardium thickening, left ventricular hypertrophy , left ventricle dilation, and involvement of the mitral and/or tricuspid valves . However, in acute necrotizing eosinophilic myocarditis, echocardiography usually gives diagnostically helpful evidence of a non-enlarged heart with a thickened and poorly contracting left ventricle . Gadolinium -based cardiac magnetic resonance imaging is the most useful non-invasive procedure for diagnosing eosinophilic myocarditis. It supports this diagnosis if it shows at least two of the following abnormalities: a) an increased signal in T2-weighted images ; b) an increased global myocardial early enhancement ratio between myocardial and skeletal muscle in enhanced T1 images and c) one or more focal enhancements distributed in a non-vascular pattern in late enhanced T1-weighted images. Additionally, and unlike in other forms of myocarditis, eosinophilic myocarditis may also show enhanced gadolinium uptake in the sub-endocardium. [ 1 ] [ 7 ] However, the only definitive test for eosinophilic myocarditis is cardiac muscle biopsy showing the presence of eosinophilic infiltration. Since the disorder may be patchy, multiple tissue samples taken during the procedure improve the chances of uncovering the pathology but in any case, negative results do not exclude the diagnosis. [ 5 ] [ 7 ] Eosinophilic coronary periarteritis is an extremely rare heart disorder caused by extensive eosinophilic infiltration of the adventitia and periadventitia, i.e. the soft tissues, surrounding the coronary arteries . The intima , tunica media , and tunica intima layers of these arteries remain intact and are generally unaffected. Thus, this disorder is characterized by episodes of angina , particularly Prinzmetal's angina , and chaotic heart arrhythmias which may lead to sudden death. The disorder is considered distinct from eosinophilic myocarditis as well as other forms of inflammatory arterial disorders in that it is limited to the coronary artery system. [ 1 ] [ 25 ] Due to its rarity, no comprehensive treatment studies on eosinophilic myocarditis have been conducted. Small studies and case reports have directed efforts towards: a) supporting cardiac function by relieving heart failure and suppressing life-threatening abnormal heart rhythms ; b) suppressing eosinophil-based cardiac inflammation; and c) treating the underlying disorder. In all cases of symptomatic eosinophilic myocarditis that lack specific treatment regimens for the underlying disorder, available studies recommend treating the inflammatory component of this disorder with non-specific immunosuppressive drugs , principally high-dosage followed by slowly tapering to a low-dosage maintenance corticosteroid regimens. It is recommended that affected individuals who fail this regimen or present with cardiogenic shock be treated with other non-specific immunosuppressive drugs viz., azathioprine or cyclophosphamide , as adjuncts to, or replacements for, corticosteroids. However, individuals with an underlying therapeutically accessible disease should be treated for this disease; in seriously symptomatic cases, such individuals may be treated concurrently with a corticosteroid regimen. Examples of diseases underlying eosinophilic myocarditis that are recommended for treatments directed at the underlying disease include [ 6 ] [ 7 ] [ 12 ] [ 26 ] The prognosis of eosinophilic myocarditis is anywhere from rapidly fatal to extremely chronic or non-fatal. Progression at a moderate rate over many months to years is the most common prognosis. [ 1 ] [ 9 ] In addition to the speed of inflammation-based heart muscle injury, the prognosis of eosinophilic myocarditis may be dominated by that of its underlying cause. For example, an underlying malignant cause for eosinophilia may be survival-limiting. [ 6 ] [ 9 ] In 1936, the famed Swiss physician Wilhem Löffler first described heart damage that appeared due to massive cardiac eosinophil infiltrations and was associated with excessively high levels of blood eosinophils. Subsequent cases of this disorder, termed Loeffler endocarditis , were found to occur in about 20% of individuals diagnosed with the hypereosinophilic syndrome . Loeffler's and the latter cases had pathological features of eosinophil infiltrations not only into the heart's myocardium but also its epicardium (i.e. lining of the heart chambers). Although eosinophilic myocarditis due to other underlying causes may show little or no eosinophil infiltrations into the endocardium, Loeffler endocarditis is considered an important form of the disorder. [ 4 ]	https://en.wikipedia.org/wiki/Eosinophilic_myocarditis
Eosinophiluria is the abnormal presence of eosinophils in the urine . It can be measured by detecting levels of eosinophil cationic protein . [ 1 ] It can be associated with a wide variety of conditions, including: Eosinophiluria (>5% of urine leukocytes ) is a common finding (~90%) in antibiotic-induced allergic nephritis, however, lymphocytes predominate in allergic interstitial nephritis induced by NSAIDs. Eosinophiluria is a feature of atheroembolic ARF. [ citation needed ] This article related to pathology is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Eosinophiluria
Epicanthoplasty is a rare eye surgery to modify the epicanthal folds . It can be a challenging procedure because the epicanthal folds overlay the lacrimal canaliculi (tear drainage canals). [ 1 ] Although an epicanthic fold can also be associated with a less prominent upper eyelid crease (a feature commonly termed "single eyelids" as opposed to "double eyelids"), the two features are distinct; a person may have both epicanthal folds and an upper eyelid crease, one and not the other, or neither. [ 2 ] Single eyelids are reshaped using East Asian blepharoplasty . [ citation needed ] Epicanthoplasty may leave visible post-surgical scar lines. A common corrective technique involves using Z-plasty . [ citation needed ] This surgery article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Epicanthoplasty
An epidural blood patch ( EBP ) is a surgical procedure that uses autologous blood, meaning the patient's own blood, in order to close one or many holes in the dura mater of the spinal cord , which occurred as a complication of a lumbar puncture or epidural placement. [ 1 ] [ 2 ] The punctured dura causes cerebrospinal fluid leak (CSF leak). [ 1 ] The procedure can be used to relieve orthostatic headaches , most commonly post dural puncture headache (PDPH). This procedure carries the typical risks of any epidural procedure. EBP are usually administered near the site of the cerebrospinal fluid leak (CSF leak), but in some cases the upper part of the spine is targeted. [ 3 ] An epidural needle is inserted into the epidural space like a traditional epidural procedure. The blood modulates the pressure of the CSF and forms a clot, sealing the leak. [ 4 ] [ 5 ] [ 6 ] EBPs were first described by American anesthesiologist Turan Ozdil and surgeon James B Gormley around 1960. [ 7 ] EBPs are an invasive procedure but are safe and effective—further intervention is sometimes necessary, and repeat patches can be administered until symptoms resolve. [ 6 ] [ 4 ] [ 8 ] It is considered the gold standard treatment for PDPH. Common side effects include back pain and headache. Rebound intracranial hypertension in people with spontaneous intracranial hypotension (SIH) is common, and people with SIH may have less success with EBPs. While the procedure uses blood, it does not carry a significant infectious risk, even in immunocompromised people. [ 9 ] The procedure is not entirely benign—seven cases of arachnoiditis have been reported as a result of administration. [ 10 ] EBPs are administered for treatment-related or spontaneous orthostatic headaches . [ 11 ] The procedure is most often used to relieve PDPH following an epidural injection or lumbar puncture . Post dural puncture headache (PDPH) is a side of effect of spinal anesthesia, where the clinician accidentally punctures the dura with the spinal needle and causes leakage of CSF. Factors such as pregnancy, having a low body mass index, being a female and young, increase the risk of dural puncture. [ 12 ] [ 7 ] The most common population at risk are pregnant patients, as they are usually young females, who commonly undergo epidural placements for pain control. It is estimated that the likelihood of a dural puncture occurring as a result of epidural catheter placement is 1.5%, with PDPH occurring in as much as 50% of these cases. [ 6 ] [ 3 ] Dural punctures usually present with a headache or backache within 3 days of the procedure. [ 13 ] The headache causes pain over the forehead and the back of the head. A distinguishing feature between PDPH and other types of headaches is the exacerbation of the headache with standing, and is non-throbbing like the common tension headaches. [ 13 ] As a result, many clinicians advise patients to lay flat and hydrate well to minimize the risk, but the efficacy of this practice has been questioned. [ 3 ] Most PDPHs are self-limiting, so epidural blood patches are only used for people with moderate to severe cases who do not respond to conservative treatment. [ 2 ] [ 9 ] In these patients, the headache is usually so severe that it affects the patient's ability to carry out normal daily tasks, and in cases of postpartum women, the concern is they are unable to care for themselves or their newborns. [ 13 ] EBP is also used to treat spontaneous intracranial hypotension (SIH). [ 5 ] [ 9 ] EBP has been used to treat pseudomeningoceles and leaks around intrathecal pumps . [ 14 ] For SIH, the same administration technique is used but at a different location with a different amount of blood injected. [ 15 ] An epidural is injected into the epidural space, inside the bony spinal canal but just outside the dura . In contact with the inner surface of the dura is another membrane called the arachnoid mater , which contains the cerebrospinal fluid. In adults, the spinal cord terminates around the level of the disc between L1 and L2, while in neonates it extends to L3 but can reach as low as L4. [ 16 ] Below the spinal cord there is a bundle of nerves known as the cauda equina or "horse's tail". Hence, lumbar epidural injections carry a low risk of injuring the spinal cord. Insertion of an epidural needle involves threading a needle between the bones, through the ligaments and into the epidural space without puncturing the layer immediately below containing CSF under pressure. [ 16 ] For administration of an EBP due to PDPH, the level of prior epidural puncture is targeted; [ 15 ] blood injected for the most part spreads cranially. [ 4 ] For SIH with unidentified leakage spots, L2 and L3 are targeted initially. [ 15 ] For EBPs, autologous blood is drawn from a peripheral vein; [ 2 ] [ 17 ] the procedure uses a typical epidural needle . [ 2 ] 20 mL of blood is recommended for EBPs, though injection should stop if not tolerated by the patient. [ 9 ] This amount of blood is also recommended for people in obstetrics . [ 18 ] Targeted EBP is performed under real-time fluoroscopy if the location of the CSF leak is known. [ 9 ] This fluoroscopic approach is standard, [ 15 ] but with cases of SIH two-site blind injection has similar outcomes. No randomized clinical trials have been conducted for this due to the rarity of SIH. [ 1 ] CT scanning can also be used. [ 9 ] Blood from EBPs is spread throughout several segments within the epidural space, so it does not need to be injected at the same level as the puncture. [ 17 ] For treatment of SIH, medication with acetazolamide before an EBP and administration in the Trendelenburg position is effective. [ 19 ] When an EBP is administered a mass effect occurs which compresses the subarachnoid space , thereby increasing and modulating the pressure of the CSF, which translates intracranially. Blood maintains a pressures surge for a longer time than crystalloid fluids . Simultaneously, an "epidural plug" is formed as a result of clot formation ; the clot adheres to the thecal sac , potentially becoming a permanent plug. [ 9 ] [ 15 ] [ 8 ] After about half a day the mass effect stops, and a mature clot is left. [ 8 ] Epidural blood patches are contraindicated in people with bleeding disorders , infection at the puncture site, fever , and bloodstream infections or sepsis . [ 9 ] Some clinicians recommend obtaining blood cultures before administration of EBP to ensure the absence of infections. [ 8 ] EBP may be contraindicated in people with a spinal deformity , HIV/AIDS , and leukemia . Epidurals are recommended for perioperative COVID-19 patients over general anesthesia—EBPs have an extremely low risk of transferring an infection to the central nervous system even with an ongoing infection but are a last resort after conservative treatments and nerve blocks. [ 9 ] Though little large-scale clinical studies have been conducted, and no adverse effects have been reported thus far, EBP are a relative contraindication in patients with malignancies. [ 17 ] Common side effects are headache, back pain , neck pain, and mild fever. Back pain is reported in approximately 80% of people, which might be a result of increased pressure. Radicular pain may also occur. [ 9 ] Rebound intracranial hypotension is very common in people with SIH after an EBP, and can be treated with acetazolamide , topiramate , or in severe cases therapeutic lumbar puncture ; most cases are not severe. Rare side effects include subdural or spinal bleeding, infection, and seizure, [ 9 ] though EBPs do not carry a significant infectious risk even in immunocompromised people. [ 14 ] Neurological symptoms occasionally develop as a result of administration. [ 4 ] Seven cases of arachnoiditis have been documented. [ 10 ] As a result of the procedure, additional dural puncture can occur, which may increase the chance of inadvertently injecting blood intrathecally . [ 9 ] EBPs are invasive [ 8 ] but are highly effective with a 50-80% success rate, and are relatively low risk, except the risks associated with epidural administration. [ 2 ] [ 4 ] Waiting 24 hours before administration reduces the failure rate of it significantly, [ 8 ] though performing it within 48 hours after puncture is associated with a higher need for repeat patches. [ 4 ] Successful treatment of PDPH with EBP has been reported months after onset. [ 14 ] Success rates may be higher than 96% with repeated EBP, even in the pediatric population. [ 17 ] EBPs are more likely to be successful with more than 22.5 mL of blood injected, and in people with less severe spinal CSF leakage. In people with severe leakage, treatment outcome does not depend on the amount of blood injected. [ 20 ] An ineffective EBP is more likely to occur in people with SIH where the CSF leak was not identified and a repeat EBP may be necessary. Nerve compression can also occur which can result in transient neurologic damage; less frequently, this may be permanent. [ 15 ] Some people may benefit from fibrin glue mixed with the blood. [ 21 ] EBP may cause more side effects than a topical nerve block of the sphenopalatine neuron cell group in postpartum women though no large-scale clinical trials have been conducted. [ 22 ] Multiple EBPs can be administered as necessary; this is more likely to happen with people with spontaneous headache or multiple leakages. [ 11 ] About 20% of people need a second EBP, and up to 20% of women do not have their symptoms resolved. [ 4 ] Studies have shown that Prophylactic EBPs do not decrease the risk of getting PDPH. [ 2 ] The use of EBPs as a treatment for PDPH, although historically considered aggressive, is increasing in adolescents as they are less likely to have their headaches resolved by conservative treatment. [ 17 ] Fluoroscopic EBPs are more successful than blindly administered ones as it allows for real-time visualization. The failure rate is around 15-20%, [ 9 ] though this can get as high as 30%. [ 8 ] The treatment of PDPH was historically uncertain—49 recommendations existed for the treatment of it. It was originally thought to be more of a psychogenic disease , which may have delayed the development of EBPs. Turan Ozdil, an anesthesiology instructor at the University of Tennessee , hypothesized how clotted blood could plug a hole in the dura while observing a car tire repair. [ 14 ] He worked with his associate W. Forrest Powell, leading to trials on dog models and then on humans around 1960. [ 14 ] James B. Gormley, a general surgeon, first observed how bloody lumbar punctures led to reduced rates of PDPH also in 1960; [ 9 ] Gormley would use only 2 to 3 mL of blood for experimenting with EBP, and he was not trained in epidural administration. Ozdil was unaware of Gormley's work, and Ozdil designed his technique to be prophylactic. Anesthesiologist Anthony DiGiovanni refined Ozdil and Powell's technique, using 10 mL of blood to treat a person with unknown leakage locations. DiGiovanni's staff member Burdett Dunbar wanted to more widely disseminate their technique, though their study was initially rejected by Anesthesiology until publication in Anesthesia & Analgesia in 1970. Detractors such as Charles Bagley at Johns Hopkins University provided evidence against the treatment since 1928 as according to their studies blood in the CSF had significant side effects up to "severe convulsive seizures"; DiGiovanni disproved this in 1972. [ 14 ] J. Selwyn Crawford discovered in 1980 that using a larger volume of blood was more successful. [ 9 ] The procedure would be widely accepted at the end of the 1970s. [ 14 ]	https://en.wikipedia.org/wiki/Epidural_blood_patch
Epidural steroid injection ( ESI ) is a technique in which corticosteroids and a local anesthetic are injected into the epidural space around the spinal cord in an effort to improve spinal stenosis , spinal disc herniation , or both. It is of benefit with a rare rate of major side effects. [ 1 ] [ 2 ] The Food and Drug Administration (FDA) has not approved ESI for pain management, and has raised concerns about rare, but serious, side effects. [ 3 ] Epidural steroid injection for sciatica and spinal stenosis is of unclear effect. [ 1 ] The evidence to support use in the cervical spine is not very good. [ 4 ] When medical imaging is not used to determine the proper spot for injection, ESI benefits appear to be of short-term benefit when used in sciatica . [ 5 ] It is unclear if ESI is useful for chronic pain after spinal surgery. [ 6 ] Steroids are included in ESI based on the belief that steroids reduce inflammation , but clinical practice has indicated that steroids plus lidocaine ( anesthetic ) produces no greater reduction in pain than lidocaine alone. [ 7 ] The fact that there is no association between quantity of steroid and reported pain reduction has caused speculation of a placebo effect for steroids. [ 8 ] Major side effects are rare. [ 2 ] These include loss of vision, stroke , paralysis , or death when the corticosteroids are infected, as in a 2012 meningitis outbreak . [ 2 ] [ 9 ] Another study found an increased odds of developing epidural lipomatosis, independent of body mass index (BMI) or other factors. [ 10 ] Locally injected glucocorticoids can have systemic effects, including loss of bone mineral density , suppression of the immune system as well as effects on the central nervous system and cardiovascular system. [ 11 ] Elective spinal injections should be performed with imaging guidance, such as fluoroscopy or the use of a radiocontrast agent , unless that guidance is contraindicated. [ 12 ] Imaging guidance ensures the correct placement of the needle and maximizes the physician's ability to make an accurate diagnosis and administer effective therapy. [ 12 ] Without imaging, the risk increases for the injection to be incorrectly placed, and this would in turn lower the therapy's efficacy and increase subsequent risk of need for more treatment. [ 12 ] Epidural steroid injections can be given in different areas of the spine, which include the lower back (lumbar), neck (cervical), or mid-back (thoracic). [ 13 ] The way the needle is inserted can vary. It can be interlaminar, which means it's placed between the lamina (the protective layers of the spine). It can be transforaminal, meaning it's inserted across the foramen (the openings on the sides of your vertebrae where the nerves exit). Or it can be caudal, which means it's inserted through the sacrum (the large, triangular bone at the base of the spine). [ 13 ]	https://en.wikipedia.org/wiki/Epidural_steroid_injection
Epikeratophakia [ 1 ] (also known as epikeratoplasty and onlay lamellar keratoplasty [ 2 ] ) is a refractive surgical procedure in which a lamella of a donor cornea is transplanted onto the anterior surface of the patient's cornea. A lamellar disc from a donor cornea is placed over the de-epithelialized host cornea and sutured into a prepared groove on the host cornea. Indications include treatment of keratoconus , refractive errors like myopia and high hypermetropia including aphakia , which cannot be corrected with conservative methods. [ 2 ] Common complications of epikeratophakia include delayed post operative visual recovery, reduced best corrected visual acuity , prolonged epithelial defects and irregular astigmatism . [ 3 ] [ 2 ] In 1949, José Barraquer introduced refractive procedure of inclusion of a lenticule within the corneal stromal layer. In 1980s, based on Barraquer's procedure, Werblin, Kaufman and Klyce at the LSU Eye Center introduced epikeratophakia. [ 4 ] This surgery article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Epikeratophakia
An epiphenomenon (plural: epiphenomena ) is a secondary phenomenon that occurs alongside or in parallel to a primary phenomenon. The word has two senses : one that connotes known causation and one that connotes absence of causation or reservation of judgment about it. [ 1 ] [ 2 ] In the philosophy of causality , an epiphenomenon is any effect of a cause apart from the effect under primary consideration. In situations in which an event of interest E is caused by (or, is said to be caused by) an event C , which also causes (or, is said to cause) an event F , then F is an epiphenomenon. The problem of epiphenomena is often a counterexample to theories of causation. For example, take a simplified Lewisian counterfactual analysis of causation that the meaning of propositions about causal relationships between two events A and B can be explained in terms of counterfactual conditionals of the form "if A had not occurred then B would not have occurred". Suppose that C causes E and that C has an epiphenomenon F . We then have that if E had not occurred, then F would not have occurred, either. But then according to the counterfactual analysis of causation, the proposition that there is a causal dependence of F on E is true; that is, on this view, E caused F . Since this is not in line with how we ordinarily speak about causation (we would not say that E caused F ), a counterfactual analysis seems to be insufficient. [ citation needed ] An epiphenomenon can be an effect of primary phenomena, but cannot affect a primary phenomenon. In the philosophy of mind , epiphenomenalism is the view that mental phenomena are epiphenomena in that they can be caused by physical phenomena, but cannot cause physical phenomena. In strong epiphenomenalism, epiphenomena that are mental phenomena can only be caused by physical phenomena, not by other mental phenomena. In weak epiphenomenalism, epiphenomena that are mental phenomena can be caused by both physical phenomena and other mental phenomena, but mental phenomena cannot be the cause of any physical phenomenon. The physical world operates independently of the mental world in epiphenomenalism; the mental world exists as a derivative parallel world to the physical world, affected by the physical world (and by other epiphenomena in weak epiphenomenalism), but not able to have an effect on the physical world. Instrumentalist versions of epiphenomenalism allow some mental phenomena to cause physical phenomena, when those mental phenomena can be strictly analyzable as summaries of physical phenomena, preserving causality of the physical world to be strictly analyzable by other physical phenomena. [ 3 ] In the more general use of the word, a causal relationship between the phenomena is implied; [ 1 ] [ 2 ] the epiphenomenon is a consequence of the primary phenomenon. [ 1 ] [ 2 ] This is the sense that is related to the noun epiphenomenalism . However, in medicine, this relationship is typically not implied, and the word is usually used in its second sense: an epiphenomenon may occur independently, and is called an epiphenomenon because it is not the primary phenomenon under study or because only correlation , not causation , is known or suspected. In this sense, saying that X is associated with Y as an epiphenomenon is preserving an acknowledgment that correlation does not imply causation . Signs , symptoms , syndromes (groups of symptoms), and risk factors can all be epiphenomena in this sense. For example, having an increased risk of breast cancer concurrent with taking an antibiotic is an epiphenomenon. It is not the antibiotic that is causing the increased risk, but the increased inflammation associated with the bacterial infection that prompted the taking of an antibiotic. The metaphor of a tree is one way of helping to explain the difference to someone struggling to understand. If the infection is the root of the tree, and the inflammation is the trunk, then the cancer and the antibiotic are two branches; the antibiotic is not the trunk. Although electronics is said to be due to the influence of electrons , the standard approach to the study of electrical phenomena due to James Clerk Maxwell views these particles as secondary: In Maxwell's theory , charge and current are 'epiphenomena' (secondary appearances) of underlying processes in what he termed, following Faraday , the electric and magnetic fields . Indeed, Maxwell's mature theory stays completely away from microstructure of matter and from any consideration of ‘electric substance’. Instead he proposed that certain quantities should be defined at every point in space, such that relations between them (the Maxwell equations ) and functions of them (such as energy functions) determine phenomena. These quantities (the fields ) may depend on microphysical events, and indeed Maxwell did expend some effort in his early papers on attempting to explain qualitatively how their relations could result in mechanical motions. However, the theory explains only large-scale phenomena, and it is not necessary to have the microscopic model in mind in order to work successfully with it. [ 4 ] Zenon Pylyshyn suggested a propositional model of cognition where people do not conceptualize ideas in images but rather in meaningful relationships. In this theory, epiphenomena refer to images because they are merely products people conceptualize from their actual thought processes. [ 5 ] Pylyshyn defends his claim by explaining that we only see images when we envision the form of an object. While visualizing objects or actions is a frequent process in our mind, it does not occur when we are considering the meaning behind an action or the non-visual properties of an object. There are many concepts we simply cannot envision. [ 6 ] Additionally, when envisioning an image, it changes based on our preconceived notions, suggesting that semantic relations precede visual images. Unfortunately, the idea of epiphenomena in propositional theory is largely subjective and not falsifiable . [ 7 ]	https://en.wikipedia.org/wiki/Epiphenomenon
Epiphysan is an extract derived from the pineal glands of cattle , historically used by veterinarians for rut suppression in mares and cows. Between 1954 and 1987 it was notoriously used in child research at the Kinderbeobachtungsstation in Innsbruck , Austria , which housed a children's psychiatric facility. [ 1 ] First developed for veterinary medicine, Epiphysan had been tested on humans in Vienna in the 1930s. Prisoners who were given the drug, temporarily exhibited a reduction in their masturbation impulse. [ 1 ] Maria Nowak-Vogl , a psychologist affiliated with the University of Innsbruck , oversaw the Kinderbeobachtungsstation until her retirement in 1987. [ 2 ] Her treatments included the administration of various potent sedatives including Rohypnol . Some children were given Epiphysan to suppress their sexual feelings and discourage masturbation . Nowak-Vogl was the first to administer it to children. According to hundreds of medical records reviewed by Ina Friedmann, a historian of medicine at the University of Innsbruck, nearly thirty cases of Epiphysan being administered were documented. After the 1980 documentary Problemkinder exposed some of the practices at the villa, Kornelius Kryspin-Exner, its new supervisor, ordered an end to the use of Epiphysan. [ 3 ] No research has been done to study the long-term effects of Epiphysan. [ 1 ]	https://en.wikipedia.org/wiki/Epiphysan
Episodic ataxia ( EA ) is an autosomal dominant disorder characterized by sporadic bouts of ataxia (severe discoordination) with or without myokymia (continuous muscle movement). There are seven types recognized but the majority are due to two recognized entities. [ 1 ] Ataxia can be provoked by psychological stress or startle , or heavy exertion, including exercise. Symptoms can first appear in infancy. There are at least six loci for EA, of which 4 are known genes. Some patients with EA also have migraine or progressive cerebellar degenerative disorders, symptomatic of either familial hemiplegic migraine or spinocerebellar ataxia . Some patients respond to acetazolamide though others do not. Typically, episodic ataxia presents as bouts of ataxia induced by startle, stress, or exertion. Some patients also have continuous tremors of various motor groups, known as myokymia . Other patients have nystagmus , vertigo , tinnitus , diplopia or seizures . [ citation needed ] The various symptoms of EA are caused by dysfunction of differing areas. Ataxia, the most common symptom, is due to misfiring of Purkinje cells in the cerebellum . This is either due to direct malfunction of these cells, such as in EA2, or improper regulation of these cells, such as in EA1. Seizures are likely due to altered firing of hippocampal neurons (KCNA1 null mice have seizures for this reason). [ citation needed ] Type 1 episodic ataxia (EA1) is characterized by attacks of generalized ataxia induced by emotion or stress, with myokymia both during and between attacks. This disorder is also known as episodic ataxia with myokymia (EAM), hereditary paroxysmal ataxia with neuromyotonia and Isaacs-Mertens syndrome. Onset of EA1 occurs during early childhood to adolescence and persists throughout the patient's life. Attacks last from seconds to minutes. Mutations of the gene KCNA1 , which encodes the voltage-gated potassium channel K V 1.1, are responsible for this subtype of episodic ataxia. K V 1.1 is expressed heavily in basket cells and interneurons that form GABAergic synapses on Purkinje cells . The channels aid in the repolarization phase of action potentials, thus affecting inhibitory input into Purkinje cells and, thereby, all motor output from the cerebellum . EA1 is an example of a synaptopathy . There are currently 17 K V 1.1 mutations associated with EA1, Table 1 and Figure 1. 15 of these mutations have been at least partly characterized in cell culture based electrophysiological assays wherein 14 of these 15 mutations have demonstrated drastic alterations in channel function. As described in Table 1, most of the known EA1 associated mutations result in a drastic decrease in the amount of current through K V 1.1 channels. Furthermore, these channels tend to activate at more positive potentials and slower rates, demonstrated by positive shifts in their V½ values and slower τ activation time constants, respectively. Some of these mutations, moreover, produce channels that deactivate at faster rates (deactivation τ), which would also result in decreased current through these channels. While these biophysical changes in channel properties likely underlie some of the decrease in current observed in experiments, many mutations also seem to result in misfolded or otherwise mistrafficked channels, which is likely to be the major cause of dysfunction and disease pathogenesis. It is assumed, though not yet proven, that decrease in K V 1.1 mediated current leads to prolonged action potentials in interneurons and basket cells. As these channels are important in the regulation of Purkinje cell activity, it is likely that this results increased and aberrant inhibitory input into Purkinje cells and, thus, disrupted Purkinje cell firing and cerebellum output. [ citation needed ] Type 2 episodic ataxia (EA2) is characterized by acetazolamide-responsive attacks of ataxia with or without migraine. Patients with EA2 may also present with progressive cerebellar atrophy, nystagmus , vertigo, visual disturbances and dysarthria. These symptoms last from hours to days, in contrast with EA1, which lasts from seconds to minutes. Attacks can be accompanied by increased heart rate and blood pressure, moderate to severe shaking, and stuttering. Like EA1, attacks can be precipitated by exercise, emotional stress/agitation, physical stress, or heat (overheated body temperature) but also by coffee and alcohol . EA2 is caused by mutations in CACNA1A , which encodes the P/Q-type voltage-gated calcium channel Ca V 2.1, and is also the gene responsible for causing spinocerebellar ataxia type-6 and familial hemiplegic migraine type-1. EA2 is also referred to as episodic ataxia with nystagmus, hereditary paroxysmal cerebellopathy, familial paroxysmal ataxia and acetazolamide-responsive hereditary paroxysmal cerebellar ataxia (AHPCA). There are currently 19 mutations associated with EA2, though only 3 have been characterized electrophysiologically, table 2 and figure 2. Of these, all result in decreased current through these channels. It is assumed that the other mutations, especially the splicing and frameshift mutations, also result in a drastic decrease in Ca V 2.1 currents, though this may not be the case for all mutations. CACNA1A is heavily expressed in Purkinje cells of the cerebellum where it is involved in coupling action potentials with neurotransmitter release. Thus, decrease in Ca 2+ entry through Ca V 2.1 channels is expected to result in decreased output from Purkinje cells, even though they will fire at an appropriate rate. The tottering mouse is a widely used model to study EA2, as it developed a spontaneous homologous mutation in Cacna1a in the early 1960s. [ 20 ] Alternatively, some CACNA1A mutations, such as those seen in familial hemiplegic migraine type-1, result in increased Ca 2+ entry and, thereby, aberrant transmitter release. This can also result in excitotoxicity, as may occur in some cases of spinocerebellar ataxia type-6 . Episodic ataxia type-3 (EA3) is similar to EA1 but often also presents with tinnitus and vertigo . Patients typically present with bouts of ataxia lasting less than 30 minutes and occurring once or twice daily. During attacks, they also have vertigo, nausea, vomiting, tinnitus and diplopia . These attacks are sometimes accompanied by headaches and precipitated by stress, fatigue, movement and arousal after sleep. Attacks generally begin in early childhood and last throughout the patients' lifetime. Acetazolamide administration has proved successful in some patients. [ 31 ] As EA3 is extremely rare, there is currently no known causative gene. The locus for this disorder has been mapped to the long arm of chromosome 1 (1q42). [ 32 ] Also known as periodic vestibulocerebellar ataxia, type-4 episodic ataxia (EA4) is an extremely rare form of episodic ataxia differentiated from other forms by onset in the third to sixth generation of life, defective smooth pursuit and gaze-evoked nystagmus. Patients also present with vertigo and ataxia. There are only two known families with EA4, both located in North Carolina . The locus for EA4 is unknown. [ citation needed ] There are two known families with type-5 episodic ataxia (EA5). [ citation needed ] These patients can present with an overlapping phenotype of ataxia and seizures similar to juvenile myoclonic epilepsy . In fact, juvenile myoclonic epilepsy and EA5 are allelic and produce proteins with similar dysfunction. [ citation needed ] Patients with pure EA5 present with recurrent episodes of ataxia with vertigo. Between attacks they have nystagmus and dysarthria . These patients are responsive to acetazolamide . Both juvenile myoclonic epilepsy and EA5 are a result of mutations in CACNB4 , a gene that encodes the calcium channel β 4 subunit. This subunit coassembles with α-subunits and produces channels that slowly inactivate after opening. [ citation needed ] EA5 patients have a cysteine to phenylalanine mutation at position 104. [ citation needed ] Thus results in channels with 30% greater current than wild-type. As this subunit is expressed in the cerebellum , it is assumed that such increased current results in neuronal hyperexcitability Coding and noncoding variation of the human calcium-channel beta4-subunit gene CACNB4 in patients with idiopathic generalized epilepsy and episodic ataxia. Type-6 episodic ataxia (EA6) is a rare form of episodic ataxia, identified initially in a 10-year-old boy who first presented with 30 minute bouts of decreased muscle tone during infancy. He required "balance therapy" as a young child to aid in walking and has a number of ataxic attacks, each separated by months to years. These attacks were precipitated by fever. He has cerebellar atrophy and subclinical seizures. During later attacks, he also presented with distortions of the left hemifield, ataxia, slurred speech, followed by headache. After enrolling in school, he developed bouts of rhythmic arm jerking with concomitant confusion, also lasting approximately 30 minutes. He also has presented, at various times, with migraines. This patient carries a proline to arginine substitution in the fifth transmembrane-spanning segment of the gene SLC1A3 . This gene encodes the excitatory amino acid transporter 1 (EAAT1) protein, which is responsible for glutamate uptake. In cell culture assays, this mutation results in drastically decreased glutamate uptake in a dominant-negative manner. This is likely due to decreased synthesis or protein stability. As this protein is expressed heavily in the brainstem and cerebellum , it is likely that this mutation results in excitotoxicity and/or hyperexcitability leading to ataxia and seizures. [ 33 ] Mutations in EAAT1 (GLAST) have subsequently been identified in a family with episodic ataxia. [ 34 ] Depending on subtype, many patients find that acetazolamide therapy is useful in preventing attacks. In some cases, persistent attacks result in tendon shortening, for which surgery is required. [ citation needed ]	https://en.wikipedia.org/wiki/Episodic_ataxia
Epizootiology , epizoology , or veterinary epidemiology is the study of disease patterns within animal populations. [ 1 ] This veterinary medicine –related article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Epizootiology
Eprinomectin is an avermectin used as a veterinary topical endectocide . [ 1 ] [ 3 ] It is a mixture of two chemical compounds, eprinomectin B1a and B1b. [ 4 ] This antiinfective drug article is a stub . You can help Wikipedia by expanding it .	https://en.wikipedia.org/wiki/Eprinomectin
An equianalgesic chart is a conversion chart that lists equivalent doses of analgesics (drugs used to relieve pain). Equianalgesic charts are used for calculation of an equivalent dose (a dose which would offer an equal amount of analgesia ) between different analgesics. [ 1 ] Tables of this general type are also available for NSAIDs , benzodiazepines , depressants , stimulants , anticholinergics and others. Equianalgesic tables are available in different formats, such as pocket-sized cards for ease of reference. [ 1 ] A frequently-seen format has the drug names in the left column, the route of administration in the center columns and any notes in the right column. [ 2 ] [ 3 ] There are several reasons for switching a patient to a different pain medication. These include practical considerations such as lower cost or unavailability of a drug at the patient's preferred pharmacy, or medical reasons such as lack of effectiveness of the current drug or to minimize adverse effects. Some patients request to be switched to a different narcotic due to stigma associated with a particular drug (e.g. a patient refusing methadone due to its association with opioid addiction treatment ). [ 4 ] Equianalgesic charts are also used when calculating an equivalent dosage of the same drug, but with a different route of administration . [ citation needed ] An equianalgesic chart can be a useful tool, but the user must take care to correct for all relevant variables such as route of administration, cross tolerance , half-life and the bioavailability of a drug. [ 5 ] For example, the narcotic levorphanol is 4–8 times stronger than morphine , but also has a much longer half-life. Simply switching the patient from 40 mg of morphine to 10 mg of levorphanol would be dangerous due to dose accumulation, and hence frequency of administration should also be taken into account. There are other concerns about equianalgesic charts. Many charts derive their data from studies conducted on opioid-naive patients. Patients with chronic (rather than acute) pain may respond to analgesia differently. Repeated administration of a medication is also different from single dosing, as many drugs have active metabolites that can build up in the body. [ 6 ] Patient variables such as sex, age, and organ function may also influence the effect of the drug on the system. These variables are rarely included in equianalgesic charts. [ 7 ] [ 3 ] [ 8 ] Opioids are a class of compounds that elicit analgesic (pain killing) effects in humans and animals by binding to the μ-opioid receptor within the central nervous system . The following table lists opioid and non-opioid analgesic drugs and their relative potencies . Values for the potencies represent opioids taken orally unless another route of administration is provided. As such, their bioavailabilities differ, and they may be more potent when taken intravenously . [ 9 ] This chart measures pain relief versus mass of medication. Not all medications have a fixed relationship on this scale. Methadone is different from most opioids because its potency can vary depending on how long it is taken. Acute use (1–3 days) yields a potency about 1.5× stronger than that of morphine and chronic use (7 days+) yields a potency about 2.5 to 5× that of morphine. [ 10 ] [ 11 ] Similarly, the effect of tramadol increases after consecutive dosing due to the accumulation of its active metabolite and an increase of the oral bioavailability in chronic use. [ 12 ] [ 13 ] 300 mg ( PO ) ( IV / IM ) or other parenteral administrations apart from spinal administration ( IV / IM ) or other parental administrations apart from spinal administration IV / IM ) or other parental administrations apart from spinal administration [ 51 ] 2–2.5 (insufflated) [ 52 ] (morphine prodrug ) [ 53 ] ( IV , IM ) (morphine prodrug ) [ 53 ] 62% Buccal: 28% Sublingual: 37.5% Intranasal: 43% IV, IM & IT: 100% 2–6 hours parenteral Explanatory notes Citations Bibliography	https://en.wikipedia.org/wiki/Equianalgesic
Erb's palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5–C6 nerves. These form part of the brachial plexus , comprising the ventral rami of spinal nerves C5–C8 and thoracic nerve T1. [ 1 ] [ 2 ] [ 3 ] These injuries arise most commonly, but not exclusively, from shoulder dystocia during a difficult birth. [ 4 ] Depending on the nature of the damage, the paralysis can either resolve on its own over a period of months, necessitate rehabilitative therapy, or require surgery. [ 5 ] The paralysis can be partial or complete; the damage to each nerve can range from bruising to tearing. The most commonly involved root is C5 (aka Erb's point : the union of C5 & C6 roots) [ 6 ] as this is mechanically the furthest point from the force of traction, therefore, the first/most affected. [ 7 ] Erb–Duchenne palsy presents as a lower motor neuron syndrome associated with sensibility disturbance and vegetative phenomena. [ 8 ] The most commonly involved nerves are the suprascapular nerve , musculocutaneous nerve , and the axillary nerve . [ 9 ] [ 10 ] The signs of Erb's palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid , biceps , and brachialis muscles. [ 6 ] "The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm". [ 7 ] The resulting biceps damage is the main cause of this classic physical position commonly called "waiter's tip". [ citation needed ] If the injury occurs at age early enough to affect development (e.g. as a neonate or infant), it often leaves the patient with stunted growth in the affected arm with everything from the shoulder through to the fingertips smaller than the unaffected arm. This also leaves the patient with impaired muscular, nervous and circulatory development. The lack of muscular development leads to the arm being much weaker than the unaffected one, and less articulate, with many patients unable to lift the arm above shoulder height unaided, as well as leaving many with an elbow contracture. [ citation needed ] The lack of development to the circulatory system can leave the arm with almost no ability to regulate its temperature, which often proves problematic during winter months when it would need to be closely monitored to ensure that the temperature of the arm was not dropping too far below that of the rest of the body. However the damage to the circulatory system also leaves the arm with another problem. It reduces the healing ability of the skin, so that skin damage takes far longer than usual to heal, and infections in the arm can be quite common if cuts are not sterilized as soon as possible. [ citation needed ] The neurological damage is often the most problematic aspect of Erb's palsy, but it is also the most varying. There have been cases of patients who have lost complete sensory perception within the arm after procedures whereas they had full sensory perception before. The most common area for a loss of sensory perception (except where the arm faces a total loss) is between the shoulder and the elbow, since the nerves which provide information from that area to the brain are also those first damaged in the initial causative trauma. [ citation needed ] The most common cause of Erb's palsy is dystocia , an abnormal or difficult childbirth or labor. [ 11 ] For example, it can occur if the infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal . The condition can also be caused by excessive pulling on the shoulders during a cephalic presentation (head first delivery), or by pressure on the raised arms during a breech (feet first) delivery. [ 4 ] [ 7 ] Erb's palsy can also affect neonates affected by a clavicle fracture unrelated to dystocia. [ 12 ] A similar injury may be observed at any age following trauma to the head and shoulder, which cause the nerves of the plexus to violently stretch, with the upper trunk of the plexus sustaining the greatest injury. Injury may also occur as the result of direct violence, including gunshot wounds and traction on the arm, or attempting to diminish shoulder joint dislocation. The level of damage to the constituent nerves is related to the amount of paralysis. [ citation needed ] The appearance of the affected arm (or arms) depends on the individual case. In some cases the arm may lack the ability to straighten or rotate but otherwise function normally giving the overall appearance of the arm to be stiff and crooked. Whereas in other circumstances the arm has little to no control and has a "loose" appearance. Treatment such as physiotherapy, massage and electrical stimulation can help to prevent this early on (or throughout) the patient's life by strengthening the arm. [ citation needed ] In some cases, individuals may experience significant discomfort. For instance, they might suffer from severe cramping pain that persists for a while and is especially intense after sleeping, radiating from the shoulder down to the wrist. While not everyone with Erb's palsy experiences pain, it can be extremely distressing for those who do, sometimes leading to physical sickness or fainting. This severe nerve pain is most common during the final stages of growth and generally subsides over time. Other types of pain that people with Erb's palsy might experience include muscle strain, stiffness, circulatory issues, and cramping. Different factors are dependent on the severity of the condition and can vary, so whilst some patient experience a lot of pain, some patients may experience no pain at all and for their affected arm to simply be visually crooked. [ citation needed ] Discomfort with the shoulder blade is also extremely common in Erb's palsy as the shoulder is often at risk of dislocation. This can result, again, in sickness or lack of sleep. [ citation needed ] Some babies recover on their own; however, some may require specialist intervention. [ citation needed ] Neonatal/pediatric neurosurgery is often required for avulsion fracture repair. Lesions may heal over time and function return. Physiotherapeutic care is often required to regain muscle usage. Although range of motion is recovered in many children under one year in age, individuals who have not yet healed after this point will rarely gain full function in their arm and may develop arthritis . [ citation needed ] The three most common treatments for Erb's palsy are nerve transfers (usually from the opposite arm or limb), subscapularis releases and latissimus dorsi tendon transfers. [ citation needed ] Nerve transfers are usually performed on babies under the age of 9 months since the fast development of younger babies increases the effectiveness of the procedure. They are not usually carried out on patients older than this because when the procedure is done on older infants, more harm than good is done, and it can result in nerve damage in the area from which the nerves were taken. Scarring can vary from faint scars along the lines of the neck to full "T" shapes across the whole shoulder depending on the training of the surgeon and the nature of the transplant. [ citation needed ] Subscapularis releases, however, are not time limited. Since it is merely cutting a "Z" shape into the subscapularis muscle to provide stretch within the arm, it can be carried out at almost any age and can be carried out repeatedly on the same arm; however, this will compromise the integrity of the muscle. [ citation needed ] Latissimus dorsi tendon transfers involve cutting the latissimus dorsi in half horizontally in order to pull part of the muscle around and attach it to the outside of the biceps. This procedure provides external rotation with varying degrees of success. A side effect may be increased sensitivity of the part of the biceps where the muscle will now lie, since the latissimus dorsi has roughly twice the number of nerve endings per square inch of other muscles. [ citation needed ] The renowned British obstetrician William Smellie is credited with the first medical description of an obstetric brachial plexus palsy. In his 1768 treatise on midwifery, he reported a case of transient bilateral arm paralysis in a newborn after difficult labour. [ citation needed ] In 1861, Guillaume Benjamin Amand Duchenne coined the term "obstetric palsy of the brachial plexus" after analyzing four infants with paralysis of identical muscles in the arm and shoulder, after publishing his initial findings in 1855. [ 13 ] [ 14 ] In 1874, Wilhelm Heinrich Erb concluded in his thesis on adult brachial plexus injuries that associated palsies of the deltoid, biceps and subscapularis are derived from a radicular lesion at the level of C5 and C6 rather than isolated peripheral nerve lesions. [ 15 ] Notable individuals with Erb's palsy include Emperor Wilhelm II of Germany, King of Prussia , [ 16 ] the Palestinian psychiatrist Samah Jabr , and the Canadian journalist Barbara Frum . [ citation needed ] Martin Sheen was injured during birth and developed the condition in his left arm. [ 17 ] Brittni Mason , a gold-medalist American Paralympian, was born with Erb's palsy in her left arm. [ 18 ] Military brace has also caused Erb's palsy in military school cadets. [ 19 ]	https://en.wikipedia.org/wiki/Erb's_palsy
Erethism , [ n 1 ] also known as erethismus mercurialis , mad hatter disease , or mad hatter syndrome , is a neurological disorder which affects the whole central nervous system, as well as a symptom complex, derived from mercury poisoning . Erethism is characterized by behavioral changes such as irritability, low self-confidence, depression, apathy, shyness [ 2 ] [ 3 ] and timidity, and in some extreme cases with prolonged exposure to mercury vapors, by delirium , personality changes and memory loss. People with erethism often have difficulty with social interactions. Associated physical problems may include a decrease in physical strength, headaches, general pain, and tremors, [ 4 ] as well as an irregular heartbeat . Mercury is an element that is found worldwide in soil, rocks, and water. People who get erethism are often exposed to mercury through their jobs . Some of the higher risk jobs that can lead to occupational exposure of workers to mercury are working in a chlor-alkali , thermometer , glassblowing , or fluorescent light bulb factory, and working in construction , dental clinics , or in gold and silver mines . [ 5 ] [ 6 ] [ 7 ] In factories, workers are exposed to mercury primarily through the base products and processes involved in making the final end consumer product. In dental clinics it is primarily through their interaction and installation of dental amalgams to treat dental caries . [ 7 ] In the case of mining, mercury is used in the process to purify and completely extract the precious metals. [ 8 ] Some elemental and chemical forms of mercury (vapor, methylmercury , inorganic mercury) are more toxic than other forms. The human fetus and medically compromised people (for example, patients with lung or kidney problems) are the most susceptible to the toxic effects of mercury. [ 9 ] Mercury poisoning can also occur outside of occupational exposures including in the home. Inhalation of mercury vapor may stem from cultural and religious rituals where mercury is sprinkled on the floor of a home or car, burned in a candle, or mixed with perfume. Due to widespread use and popular concern, the risk of toxicity from dental amalgam has been exhaustively investigated. It has conclusively been shown to be safe [ 10 ] although in 2020 the FDA issued new guidance for at-risk populations who should avoid mercury amalgam. [ 11 ] Historically, this was common among felt-hat makers in England who had long-term exposure to vapors from the mercury they used to stabilize the wool in a process called felting, where hair was cut from a pelt of an animal such as a rabbit. The industrial workers were exposed to the mercury vapors, giving rise to the expression "mad as a hatter". [ 12 ] Some believe that the character the Mad Hatter in Lewis Carroll 's Alice in Wonderland is an example of someone with erethism, but the origin of this account is unclear. The character was almost certainly based on Theophilus Carter , an eccentric furniture dealer who was well known to Carroll. [ 13 ] Acute mercury exposure has given rise to psychotic reactions such as delirium, hallucinations, and suicidal tendency. Occupational exposure has resulted in erethism, with irritability, excitability, excessive shyness, and insomnia as the principal features of a broad-ranging functional disturbance. With continuing exposure, a fine tremor develops, initially involving the hands and later spreading to the eyelids, lips, and tongue, causing violent muscular spasms in the most severe cases. The tremor is reflected in the handwriting which has a characteristic appearance. In milder cases, erethism and tremor regress slowly over a period of years following removal from exposure. Decreased nerve conduction velocity in mercury-exposed workers has been demonstrated. Long-term, low-level exposure has been found to be associated with less pronounced symptoms of erethism, characterized by fatigue, irritability, loss of memory, vivid dreams, and depression (WHO, 1976). The man affected is easily upset and embarrassed, loses all joy in life and lives in constant fear of being dismissed from his job. He has a sense of timidity and may lose self control before visitors. Thus, if one stops to watch such a man in a factory, he will sometimes throw down his tools and turn in anger on the intruder, saying he cannot work if watched. Occasionally a man is obliged to give up work because he can no longer take orders without losing his temper or, if he is a foreman, because he has no patience with men under him. Drowsiness, depression, loss of memory and insomnia may occur, but hallucinations, delusions and mania are rare. The most characteristic symptom, though it is seldom the first to appear, is mercurial tremor. It is neither as fine nor as regular as that of hyperthyroidism . It may be interrupted every few minutes by coarse jerky movements. It usually begins in the fingers, but the eyelids, lips and tongue are affected early. As it progresses it passes to the arms and legs, so that it becomes very difficult for a man to walk about the workshop, and he may have to be guided to his bench. At this stage the condition is so obvious that it is known to the layman as "hatter's shakes." Effects of chronic occupational exposure to mercury, such as that commonly experienced by affected hatters, include mental confusion, emotional disturbances, and muscular weakness. [ 15 ] Severe neurological damage and kidney damage can also occur. [ 16 ] Signs and symptoms can include red fingers, red toes, red cheeks, sweating, loss of hearing, bleeding from the ears and mouth, loss of appendages such as teeth, hair, and nails, lack of coordination, poor memory, shyness, insomnia, nervousness, tremors, and dizziness. [ 16 ] A survey of exposed U.S. hatters revealed predominantly neurological symptomatology, including intention tremor . [ 14 ] After chronic exposure to the mercury vapours, hatters tended to develop characteristic psychological traits, such as pathological shyness and marked irritability (see box). [ 17 ] Such manifestations among hatters prompted several popular names for erethism, including "mad hatter disease", [ 15 ] "mad hatter syndrome", [ 18 ] [ 19 ] "hatter's shakes" and " Danbury shakes". While hatters in the past were diagnosed with erethism through their symptoms, it was sometimes harder to prove that erethism was the result of mercury exposure, as seen in the case of the hatters of New Jersey below. Today, although erethism from the hat making industry is no longer an issue, it persists in other high-risk occupations. As a result, methods have been established to measure the mercury exposure of workers more accurately. They include the collection and testing of mercury levels in blood, hair, nails, and urine. [ 20 ] Most of these biomarkers have a shorter half-life for mercury (e.g. in blood the half-life is usually only around 2–4 days), which makes some of them better for testing acute, high doses of mercury exposure. [ 21 ] [ 22 ] However, mercury in urine has a much longer half-life (measured in weeks to months), and unlike the other biomarkers is more representative of the total body burden of inorganic and elemental mercury. [ 21 ] [ 22 ] This makes it the ideal biomarker for measuring occupational exposure to mercury because it is suitable to measuring low, chronic exposure, and specifically exposure to inorganic and elemental mercury (i.e. mercury vapor), which are the two types most likely to be encountered in a higher risk occupation. [ 21 ] [ 22 ] Especially in the 19th century, inorganic mercury in the form of mercuric nitrate was commonly used in the production of felt for hats. [ 23 ] During a process called carroting , in which furs from small animals such as rabbits, hares or beavers were separated from their skins and matted together, an orange-colored solution containing mercuric nitrate was used as a smoothing agent. The resulting felt was then repeatedly shaped into large cones, shrunk in boiling water and dried. [ 17 ] In treated felts, a slow reaction released volatile free mercury. [ 24 ] Hatters (or milliners ) who came into contact with vapours from the impregnated felt often worked in confined areas. [ 16 ] Use of mercury in hatmaking is thought to have been adopted by the Huguenots in 17th-century France, [ 17 ] [ 25 ] at a time when the dangers of mercury exposure were already known. This process was initially kept a trade secret in France, where hatmaking rapidly became a hazardous occupation. At the end of the 17th century the Huguenots carried the secret to England, following the revocation of the Edict of Nantes . During the Victorian era the hatters' malaise became proverbial, as reflected in popular expressions like " mad as a hatter " (see below ) and "the hatters' shakes". [ 17 ] [ 25 ] [ 26 ] The first description of symptoms of mercury poisoning among hatters appears to have been made in St Petersburg , Russia, in 1829. [ 14 ] In the United States, a thorough occupational description of mercury poisoning among New Jersey hatters was published locally by Addison Freeman in 1860. [ 27 ] [ 28 ] Adolph Kussmaul 's definitive clinical description of mercury poisoning published in 1861 contained only passing references to hatmakers, including a case originally reported in 1845 of a 15-year-old Parisian girl, the severity of whose tremors following two years of carroting prompted opium treatment. [ 27 ] In Britain, the toxicologist Alfred Swaine Taylor reported the disease in a hatmaker in 1864. [ 27 ] In 1869, the French Academy of Medicine demonstrated the health hazards posed to hatmakers. Alternatives to mercury use in hatmaking became available by 1874. In the United States, a hydrochloride -based process was patented in 1888 to obviate the use of mercury, but was ignored. [ 29 ] In 1898, legislation was passed in France to protect hatmakers from the risks of mercury exposure. By the turn of the 20th century, mercury poisoning among British hatters had become a rarity. [ 26 ] [ 30 ] In the United States, the mercury-based process continued to be adopted until as late as 1941, when it was abandoned mainly due to the wartime need for the heavy metal in the manufacture of detonators. [ 27 ] [ 29 ] Thus, for much of the 20th century mercury poisoning remained common in the U.S. hatmaking industries, including those located in Danbury, Connecticut (giving rise to the expression the "Danbury shakes"). [ 14 ] [ 26 ] Another 20th-century cohort of affected hatmakers has been studied in Tuscany , Italy. [ 31 ] [ 32 ] The experience of hatmakers in New Jersey is well documented and has been reviewed by Richard Wedeen. [ 27 ] In 1860, at a time when the hatmaking industry in towns such as Newark , Orange and Bloomfield was growing rapidly, a physician from Orange called J. Addison Freeman published an article titled "Mercurial Disease Among Hatters" in the Transactions of the Medical Society of New Jersey . This groundbreaking paper provided a clinical account of the effects of chronic mercury poisoning among the workforce, coupled with an occupational description of the use of mercuric nitrate during carroting and inhalation of mercury vapour later in the process (during finishing, forming and sizing). Freeman concluded that "A proper regard for the health of this class of citizens demands that mercury should not be used so extensively in the manufacture of hats, and that if its use is essential, that the hat finishers' room should be large, with a high ceiling, and well ventilated." [ 28 ] Freeman's call for prevention went unheeded. In 1878, an inspection of 25 firms around Newark conducted by Dr L. Dennis on behalf of the Essex County Medical Society revealed "mercurial disease" in 25% of 1,589 hatters. Dennis recognized that this prevalence figure was probably an underestimate , given the workers' fear of being fired if they admitted to being diseased. Although Dennis did recommend the use of fans in the workplace he attributed most of the hatters' health problems to excessive alcohol use (thus using the stigma of drunkenness in a mainly immigrant workforce to justify the unsanitary working conditions provided by employers). [ 27 ] [ 33 ] The surprise is that men can be induced to work at all in such death producing enclosures. It is hard to believe that men of ordinary intelligence could be so indifferent to the ordinary laws of health... It does not seem to have occurred to them that all the efforts to keep up wages... [are] largely offset by the impairment of their health, due to neglect of proper hygienic regulations of their workshops... And when the fact of the workmen in the sizing room, who stand in water, was mentioned, and the simple and inexpensive means by which it could be largely avoided was spoken of, the reply was that it would cost money and hat manufacturers did not care to expend money for such purposes, if they could avoid it. Some voluntary reductions in mercury exposure were implemented after Lawrence T. Fell, a former journeyman hatter from Orange who had become a successful manufacturer, was appointed Inspector of Factories in 1883. In the late nineteenth century, a pressing health issue among hatters was tuberculosis . This deadly communicable disease was rife in the extremely unhygienic wet and steamy enclosed spaces in which the hatters were expected to work (in its annual report for 1889, the New Jersey Bureau of Labor and Industries expressed incredulity at the conditions—see box). Two-thirds of the recorded deaths of hatters in Newark and Orange between 1873 and 1876 were caused by pulmonary disease, most often in men under 30 years of age, and elevated death rates from tuberculosis persisted into the twentieth century. Consequently, public health campaigns to prevent tuberculosis spreading from the hatters into the wider community tended to eclipse the issue of mercury poisoning. For instance, in 1886 J. W. Stickler, working on behalf of the New Jersey Board of Health , promoted prevention of tuberculosis among hatters, but deemed mercurialism "uncommon", despite having reported tremors in 15–50% of the workers he had surveyed. [ 27 ] [ 35 ] While hatters seemed to regard the shakes as an inevitable price to pay for their work rather than a readily preventable disease , their employers professed ignorance of the problem. In a 1901 survey of 11 employers of over a thousand hatters in Newark and Orange, the head of the Bureau of Statistics of New Jersey, William Stainsby, found a lack of awareness of any disease peculiar to hatters apart from tuberculosis and rheumatism (though one employer remarked that "work at the trade develops an inordinate craving for strong drink"). [ 27 ] [ 36 ] By 1934, the U.S. Public Health Service estimated that 80% of American felt makers had mercurial tremors. Nevertheless, trade union campaigns (led by the United States Hat Finishers Association, originally formed in 1854) never addressed the issue and, unlike in France, no relevant legislation was ever adopted in the United States. Instead, it seems to have been the need for mercury in the war effort that eventually brought to an end the use of mercuric nitrate in U.S. hatmaking; in a meeting convened by the U.S. Public Health Service in 1941, the manufacturers voluntarily agreed to adopt a readily available alternative process using hydrogen peroxide . [ 27 ] Although the expression "mad as a hatter" was associated with the syndrome, [ 37 ] the origin of the phrase is uncertain. Lewis Carroll 's iconic Mad Hatter character in Alice's Adventures in Wonderland displays markedly eccentric behavior, which includes taking a bite out of a teacup. [ 38 ] Carroll would have been familiar with the phenomenon of dementia among hatters, but the literary character is thought to be directly inspired by Theophilus Carter , an eccentric furniture dealer who did not show signs of mercury poisoning. [ 17 ] The actor Johnny Depp has said of his portrayal of a carrot-orange haired Mad Hatter in Tim Burton 's 2010 film, Alice in Wonderland that the character "was poisoned ... and it was coming out through his hair, through his fingernails and eyes". [ 39 ]	https://en.wikipedia.org/wiki/Erethism
Ergotism (pron. / ˈ ɜːr ɡ ə t ˌ ɪ z ə m / UR -gət-iz-əm ) is the effect of long-term ergot poisoning , traditionally due to the ingestion of the alkaloids produced by the Claviceps purpurea fungus—from the Latin clava "club" or clavus "nail" and -ceps for "head", i.e. the purple club-headed fungus—that infects rye and other cereals , and more recently by the action of a number of ergoline -based drugs. It is also known as ergotoxicosis , ergot poisoning , and Saint Anthony's fire . Ergotism is the effect of long-term ergot poisoning . [ 1 ] The symptoms can be roughly divided into convulsive symptoms and gangrenous symptoms. [ 1 ] Ergot alkaloids, the active compounds produced by the ergot fungus, can cause severe vasoconstriction , leading to symptoms like gangrene and convulsions. Additionally, ergot alkaloids can mimic neurotransmitters and hormones in the human body, causing hallucinations and affecting hormonal balance. Chronic exposure to ergot alkaloids has been linked to reproductive issues, such as spontaneous abortions and infertility, due to their action on the pituitary gland. [ 1 ] Convulsive symptoms include painful seizures and spasms , diarrhea , paresthesias , itching, mental effects including mania or psychosis , headaches, nausea , and vomiting. Usually the gastrointestinal effects precede central nervous system effects. [ citation needed ] The dry gangrene is a result of vasoconstriction induced by the ergotamine - ergocristine alkaloids of the fungus. [ citation needed ] It affects the more poorly vascularized distal structures, such as the fingers and toes. Symptoms include desquamation or peeling, weak peripheral pulses , loss of peripheral sensation, edema and ultimately the death and loss of affected tissues . Vasoconstriction is treated with vasodilators . [ 2 ] Historically, eating grain products, particularly rye , contaminated with the fungus Claviceps purpurea was the cause of ergotism. [ 3 ] The toxic ergoline derivatives are found in ergot-based drugs (such as methylergometrine , ergotamine or, previously, ergotoxine ). The deleterious side effects occur either under high dose or when moderate doses interact with potentiators such as erythromycin . [ citation needed ] The alkaloids can pass through lactation from mother to child, causing ergotism in infants. [ citation needed ] Dark-purple or black grain kernels, known as ergot bodies, can be identifiable in the heads of cereal or grass just before harvest. In most plants the ergot bodies are larger than normal grain kernels, but can be smaller if the grain is a type of wheat. [ citation needed ] Removal of ergot bodies is done by placing the yield in a brine solution; the ergot bodies float, while the healthy grains sink. [ 4 ] Infested fields must be deep-ploughed; ergot cannot germinate if buried more than one inch (2.5 cm) in soil [ citation needed ] and therefore will not release its spores into the air. Rotating crops using non-susceptible plants helps reduce infestations, since ergot spores live only one year. [ citation needed ] Crop rotation and deep tillage, such as deep mold-board ploughing , are important components in managing ergot, as many cereal crops in the 21st century are sown with a "no-till" practice (new crops are sown directly into the stubble from the previous crop to reduce soil erosion). Wild and escaped grasses and pastures can be mown before they flower to help limit the spread of ergot. Chemical controls can also be used but are not considered economical, especially in commercial operations, and germination of ergot spores can still occur under favourable conditions even with the use of such controls. Throughout history, outbreaks of ergotism have been documented, particularly in Europe. One of the most notable incidents occurred in 944 AD in France, where ergot poisoning led to widespread hallucinations, gangrene, and convulsions. Another significant case is associated with the Salem witch trials in 1692, where some historians believe ergotism may have contributed to the symptoms reported by the accusers. [ 5 ] Epidemics of the disease were identified throughout history, though the references in classical writings are inconclusive. Rye, the main vector (route) for transmitting ergotism, was not grown much around the Mediterranean . When Fuchs separated references to ergotism from erysipelas and other conditions in 1834, he found the earliest reference to ergotism in the Annales Xantenses for the year 857: "a great plague of swollen blisters consumed the people by a loathsome rot, so that their limbs were loosened and fell off before death". [ citation needed ] In the Middle Ages the gangrenous poisoning was known as "holy fire" or "Saint Anthony's fire", named after monks of the Order of St. Anthony , who were particularly successful at treating this ailment. According to Snorri Sturluson in his Heimskringla , King Magnus II of Norway , son of King Harald Sigurtharson , who was the half-brother of Saint King Olaf Haraldsson , died from ergotism shortly after the Battle of Hastings . The 12th-century chronicler Geoffroy du Breuil of Vigeois recorded the mysterious outbreaks in the Limousin region of France, where the gangrenous form of ergotism was associated with the local Saint Martial . Likewise, an outbreak in Paris around 1129 was reported to be cured by the relics of Saint Genevieve , a miracle commemorated in the 26 November "Feast of the Burning Ones". [ 6 ] The blight, named cockspur [ 7 ] owing to the appearance of infected grains, was identified and named by Denis Dodart , who reported the relation between ergotized rye and bread poisoning in a letter to the French Royal Academy of Sciences in 1676 ( John Ray mentioned ergot for the first time in English the next year). "Ergotism" in this modern sense was first recorded in 1853. [ citation needed ] Notable epidemics of ergotism occurred into the 19th century. Fewer outbreaks have occurred since then owing to rye being carefully monitored in developed countries. However, a severe outbreak of something akin to ergot poisoning occurred in the French village of Pont-Saint-Esprit in 1951, resulting in five deaths. [ 8 ] The outbreak and the diagnostic confusion surrounding it are vividly described in John Grant Fuller 's book The Day of St Anthony's Fire . [ 9 ] Ergot sclerotiums were found in the gut of the Grauballe Man , a bog body dated the late 3rd century BC. [ 10 ] When milled, the ergot is reduced to a red powder, [ 11 ] obvious in lighter grasses but easy to miss in dark rye flour. In less wealthy countries, ergotism still occurs; an outbreak in Ethiopia occurred in mid-2001 from contaminated barley . Whenever there is a combination of moist weather, cool temperatures, delayed harvest in lowland crops and rye consumption, an outbreak is possible. Poisonings due to consumption of seeds treated with mercury compounds are sometimes misidentified as ergotism. [ 12 ] [ 13 ] There have been numerous cases of mass-poisoning due to consumption of mercury-treated seeds. [ 14 ] The convulsive symptoms from ergot-tainted rye may have been the source of accusations of bewitchment that spurred the Salem witch trials . This medical explanation for the theory of "bewitchment" was first propounded by Linnda R. Caporael in 1976 in an article in Science . [ 15 ] In her article, Caporael argues that the convulsive symptoms such as crawling sensations in the skin , tingling in the fingers , vertigo , tinnitus aurium , headaches , disturbances in sensation, hallucination , painful muscular contractions , vomiting , and diarrhea , as well as psychological symptoms such as mania , melancholia , psychosis , and delirium , were all symptoms reported in the Salem witchcraft records. Caporael also states that there was an abundance of rye in the region, as well as climate conditions that could support the tainting of rye. [ 15 ] In 1982, historian Mary Matossian raised Caporael's theory in an article in American Scientist , in which she argued that symptoms of "bewitchment" resemble the ones exhibited in those affected by ergot poisoning. [ 16 ] The hypothesis that ergotism could explain cases of bewitchment has been subject to significant debate and has been criticized by several scholars. Within a year of Caporael's article, historians Nicholas Spanos and Jack Gottlieb refuted the idea in the same journal. [ 17 ] In Spanos and Gottlieb's rebuttal to Caporael's article, they concluded that there are several flaws in the explanation. They noted that if ergotism was present in Salem, the symptoms would have occurred by household, not individual. Whole families, and particularly all the young children in a household, would have shown symptoms, but this was not the case. In general, the proportion of children affected was significantly less than in a typical ergotism epidemic. Spanos and Gottlieb also state that most of ergot poisoning's symptoms, like crawling and tingling sensations, vertigo, tinnitus, vomiting, and diarrhea, do not appear in the records of events in Salem. Lastly, they note that convulsive ergotism epidemics only take place in communities suffering from vitamin A deficiencies; they argued that residents of Salem, living in a farming community with ample access to dairy , would have had no reason to be deficient in vitamin A . Therefore, an outbreak of ergotism as the cause of the Salem epidemic was unlikely. Historians published in the early 21st century continue to stand by Spanos and Gottlieb's conclusion. [ 18 ] Historian Leon Harrier has argued that only some members of a household might have shown symptoms because they had underlying conditions. Being chemically similar to lysergic acid diethylamide (LSD), ergot would not survive in the acidic environment of a typical human's stomach, especially in properly cooked food. [ citation needed ] But if some residents of a household were malnourished and had bleeding stomach ulcers, those individuals would have had a heightened risk of absorbing the toxin (even with properly cooked food items) through the stomach lining, offering a direct route to the bloodstream. Only those with these preexisting conditions would have been affected by ingesting contaminated grains, leaving the majority unaffected. Anthropologist H. Sidky noted that ergotism had been known for centuries before the Salem witch trials and argued that its symptoms would have been recognizable during the time of the Salem witch trials. [ 19 ] In 2003 it was pointed out that ergots produced by different strains of Claviceps purpurea , as well as those growing in different soils, may produce different ergot alkaloid compositions. This may explain the different manifestations of ergotism in different outbreaks. For example, an alkaloid present in high concentrations in ergots from Europe east of the Rhine may have caused convulsive ergotism, while ergot from the west caused epidemics of gangrenous ergotism. [ 20 ] In medieval Europe, outbreaks of ergotism were sometimes interpreted as divine punishment or witchcraft. The condition's symptoms, particularly hallucinations and convulsions, often led to accusations of demonic possession. The disease's association with St. Anthony's Fire is linked to the Order of St. Anthony, a medieval Christian order that provided care for ergotism sufferers. [ 21 ] The prevalence of ergotism was closely linked to environmental conditions, such as cold, damp weather, which promoted the growth of the ergot fungus. Poor storage of grain also contributed to the risk of contamination. Changes in agricultural practices and the introduction of disease-resistant crop varieties have largely eliminated ergotism in modern times. [ 22 ]	https://en.wikipedia.org/wiki/Ergotism
Erich Seligmann Fromm ( / f r ɒ m / ; German: [fʁɔm] ; March 23, 1900 – March 18, 1980) was a German-American social psychologist , psychoanalyst , sociologist , humanistic philosopher , and democratic socialist . He was a German Jew who fled the Nazi regime and settled in the United States. He was one of the founders of The William Alanson White Institute of Psychiatry, Psychoanalysis and Psychology in New York City and was associated with the Frankfurt School of critical theory . [ 1 ] [ n 1 ] Erich Fromm was born on March 23, 1900, at Frankfurt am Main , the only child of Rosa (Krause) and Naphtali Fromm. [ 2 ] He started his academic studies in 1918 at the University of Frankfurt am Main with two semesters of jurisprudence . During the summer semester of 1919, Fromm studied at the University of Heidelberg , where he began studying sociology under Alfred Weber (brother of sociologist Max Weber ), psychiatrist-philosopher Karl Jaspers , and Heinrich Rickert . Fromm received his Ph.D. in sociology from Heidelberg in 1922 with a dissertation under the title Das jüdische Gesetz. Ein Beitrag zur Soziologie des Diaspora-Judentums ( The Jewish Law: A Contribution to the Sociology of Jewish Diaspora ). Fromm at the time became strongly involved in Zionism , under the influence of the religious Zionist rabbi Nehemia Anton Nobel. [ 3 ] He was very active in Jewish Studentenverbindungen and other Zionist organisations. But he soon turned away from Zionism, saying that it conflicted with his ideal of a "universalist Messianism and Humanism". [ 4 ] During the mid-1920s, he trained to become a psychoanalyst through Frieda Reichmann 's psychoanalytic sanatorium in Heidelberg . They married in 1926, but separated shortly after and divorced in 1942. He began his own clinical practice in 1927. In 1930 he joined the Frankfurt Institute for Social Research and completed his psychoanalytical training. After the Nazi takeover of power in Germany, Fromm moved first to Geneva and then, in 1934, to Columbia University in New York. Together with Karen Horney and Harry Stack Sullivan , Fromm belongs to a Neo-Freudian school of psychoanalytical thought. Horney and Fromm each had a marked influence on the other's thought, with Horney illuminating some aspects of psychoanalysis for Fromm and the latter elucidating sociology for Horney. Their relationship ended in the late 1930s. [ 5 ] After leaving Columbia, Fromm helped form the New York branch of the Washington School of Psychiatry in 1943, and in 1946 co-founded the William Alanson White Institute of Psychiatry, Psychoanalysis, and Psychology. He was on the faculty of Bennington College from 1941 to 1949, and taught courses at the New School for Social Research in New York from 1941 to 1959. When Fromm moved to Mexico City in 1949, he became a professor at the National Autonomous University of Mexico (UNAM) and established a psychoanalytic section at the medical school there. Meanwhile, he taught as a professor of psychology at Michigan State University from 1957 to 1961 and as an adjunct professor of psychology at the graduate division of Arts and Sciences at New York University after 1962. He taught at UNAM until his retirement, in 1965, and at the Mexican Society of Psychoanalysis (SMP) until 1974. In 1974, he moved from Mexico City to Muralto , Switzerland, and died at his home in 1980, five days before his eightieth birthday. All the while, Fromm maintained his own clinical practice and published a series of books. Fromm was reportedly an atheist [ 6 ] [ n 2 ] but described his position as " nontheistic mysticism ". [ 7 ] Beginning with his first seminal work of 1941, Escape from Freedom (known in Britain as The Fear of Freedom ), Fromm's writings were notable as much for their social and political commentary as for their philosophical and psychological underpinnings. Indeed, Escape from Freedom is viewed as one of the founding works of political psychology . His second important work, Man for Himself: An Inquiry into the Psychology of Ethics , first published in 1947, continued and enriched the ideas of Escape from Freedom . Taken together, these books outlined Fromm's theory of human character, which was a natural outgrowth of Fromm's theory of human nature. Fromm's most popular book was The Art of Loving , an international bestseller first published in 1956, which recapitulated and complemented the theoretical principles of human nature found in Escape from Freedom and Man for Himself —principles which were revisited in many of Fromm's other major works. Central to Fromm's world view was his interpretation of the Talmud and Hasidism . He began studying Talmud as a young man under Rabbi J. Horowitz and later under Rabbi Salman Baruch Rabinkow, a Chabad Hasid . While working towards his doctorate in sociology at the University of Heidelberg , Fromm studied the Tanya by the founder of Chabad, Rabbi Shneur Zalman of Liadi . Fromm also studied under Nehemia Nobel and Ludwig Krause while studying in Frankfurt. Fromm's grandfather and two great-grandfathers on his father's side were rabbis , and a great uncle on his mother's side was a noted Talmudic scholar. However, Fromm turned away from orthodox Judaism in 1926, towards secular interpretations of scriptural ideals. The cornerstone of Fromm's humanistic philosophy is his interpretation of the biblical story of Adam and Eve 's exile from the Garden of Eden . Drawing on his knowledge of the Talmud, Fromm pointed out that being able to distinguish between good and evil is generally considered to be a virtue, but that biblical scholars generally consider Adam and Eve to have sinned by disobeying God and eating from the Tree of Knowledge . However, departing from traditional religious orthodoxy on this, Fromm extolled the virtues of humans taking independent action and using reason to establish moral values rather than adhering to authoritarian moral values. Beyond a simple condemnation of authoritarian value systems, Fromm used the story of Adam and Eve as an allegorical explanation for human biological evolution and existential angst, asserting that when Adam and Eve ate from the Tree of Knowledge, they became aware of themselves as being separate from nature while still being part of it. This is why they felt "naked" and "ashamed": they had evolved into human beings , conscious of themselves, their own mortality, and their powerlessness before the forces of nature and society, and no longer united with the universe as they were in their instinctive , pre-human existence as animals. According to Fromm, the awareness of a disunited human existence is a source of guilt and shame , and the solution to this existential dichotomy is found in the development of one's uniquely human powers of love and reason. However, Fromm distinguished his concept of love from unreflective popular notions as well as Freudian paradoxical love (see the criticism by Marcuse below ). Fromm considered love an interpersonal creative capacity rather than an emotion , and he distinguished this creative capacity from what he considered to be various forms of narcissistic neuroses and sado-masochistic tendencies that are commonly held out as proof of "true love". Indeed, Fromm viewed the experience of "falling in love" as evidence of one's failure to understand the true nature of love, which he believed always had the common elements of care , responsibility , respect , and knowledge . Drawing from his knowledge of the Torah , Fromm pointed to the story of Jonah , who did not wish to save the residents of Nineveh from the consequences of their sin, as demonstrative of his belief that the qualities of care and responsibility are generally absent from most human relationships . Fromm also asserted that few people in modern society had respect for the autonomy of their fellow human beings, much less the objective knowledge of what other people truly wanted and needed. Fromm believed that freedom was an aspect of human nature that we either embrace or escape. He observed that embracing our freedom of will was healthy, whereas escaping freedom through the use of escape mechanisms was the root of psychological conflicts. Fromm outlined three of the most common escape mechanisms: The word biophilia was frequently used by Fromm as a description of a productive psychological orientation and " state of being ". For example, in an addendum to his book The Heart of Man: Its Genius For Good and Evil , Fromm wrote as part of his humanist credo : "I believe that the man choosing progress can find a new unity through the development of all his human forces, which are produced in three orientations. These can be presented separately or together: biophilia, love for humanity and nature, and independence and freedom." [ 9 ] Erich Fromm postulated the following basic needs: Fromm's thesis of the "escape from freedom" is epitomized in the following passage. The "individualized man" referenced by Fromm is man bereft of the "primary ties" of belonging (such as nature, family, etc.), also expressed as "freedom from": There is only one possible, productive solution for the relationship of individualized man with the world: his active solidarity with all men and his spontaneous activity, love and work, which unite him again with the world, not by primary ties but as a free and independent individual.... However, if the economic, social and political conditions... do not offer a basis for the realization of individuality in the sense just mentioned, while at the same time people have lost those ties which gave them security, this lag makes freedom an unbearable burden. It then becomes identical with doubt, with a kind of life which lacks meaning and direction. Powerful tendencies arise to escape from this kind of freedom into submission or some kind of relationship to man and the world which promises relief from uncertainty, even if it deprives the individual of his freedom. In his book Man for Himself , Fromm spoke of " orientation of character ". He differentiates his theory of character from that of Freud by focusing on two ways an individual relates to the world. Freud analyzed character in terms of libido organization, whereas Fromm says that in the process of living, we relate to the world by: 1) acquiring and assimilating things—"Assimilation", and 2) reacting to people—"Socialization". Fromm asserted that these two ways of relating to the world were not instinctive, but an individual's response to the peculiar circumstances of his or her life; he also believed that people are never exclusively one type of orientation. These two ways of relating to life's circumstances lead to basic character-orientations. Fromm lists four types of nonproductive character orientation, which he called receptive, exploitative, hoarding, and marketing, and one positive character orientation, which he called productive. Receptive and exploitative orientations are basically how an individual may relate to other people and are socialization attributes of character. A hoarding orientation is an acquiring and assimilating materials/valuables character trait. The marketing orientation arises in response to the human situation in the modern era. The current needs of the market determine value. It is a relativistic ethic. In contrast, the productive orientation is an objective ethic. Despite the existential struggles of humanity, each human has the potential for love, reason and productive work in life. Fromm writes, "It is the paradox of human existence that man must simultaneously seek for closeness and for independence; for oneness with others and at the same time for the preservation of his uniqueness and particularity. ...the answer to this paradox – and to the moral problems of man – is productiveness." Fromm's four non-productive orientations were subject to validation through a psychometric test, The Person Relatedness Test by Elias H. Porter, PhD in collaboration with Carl Rogers , PhD at the University of Chicago's Counseling Center between 1953 and 1955. Fromm's four non-productive orientations also served as basis for the LIFO test, first published in 1967 by Stuart Atkins, Alan Katcher, PhD, and Elias Porter , PhD and the Strength Deployment Inventory , first published in 1971 by Elias H. Porter, PhD. [ 13 ] Fromm also influenced his student Sally L. Smith who went on to become the founder of the Lab School of Washington and the Baltimore Lab School. [ 14 ] Fromm examined the life and work of Sigmund Freud at length. He identified a discrepancy between early and later Freudian theory: namely that, prior to World War I, Freud had described human drives as a tension between desire and repression, but after the end of the war, began framing human drives as a struggle between biologically universal Life and Death ( Eros and Thanatos ) instincts. Fromm charged Freud and his followers with never acknowledging the contradictions between the two theories. Fromm also criticized Freud's dualistic thinking. According to Fromm, Freudian descriptions of human consciousness as struggles between two poles were narrow and limiting. Fromm also condemned Freud as a misogynist unable to think outside the patriarchal milieu of early 20th century Vienna. However, in spite of these criticisms, Fromm nonetheless expressed a great respect for Freud and his accomplishments. Fromm contended that Freud was one of the "architects of the modern age", alongside Albert Einstein and Karl Marx , but emphasized that he considered Marx both far more historically important than Freud and a finer thinker. [ 15 ] Fromm's best known work, Escape from Freedom , focuses on the human urge to seek a source of authority and control upon reaching a freedom that was thought to be an individual's true desire. Fromm's critique of the modern political order and capitalist system led him to seek insights from medieval feudalism . In Escape from Freedom , he discerned a certain value in the lack of individual freedom, rigid structure, and obligations required of the members of medieval society: What characterizes medieval in contrast to modern society is its lack of individual freedom…But altogether a person was not free in the modern sense, neither was he alone and isolated. In having a distinct, unchangeable, and unquestionable place in the social world from the moment of birth, man was rooted in a structuralized whole, and thus life had a meaning which left no place, and no need for doubt… There was comparatively little competition. One was born into a certain economic position which guaranteed a livelihood determined by tradition, just as it carried economic obligations to those higher in the social hierarchy. [ 16 ] The culmination of Fromm's social and political philosophy came in his 1955 book The Sane Society , which argued in favor of a humanistic and democratic socialism . Building primarily upon the early works of Karl Marx , Fromm sought to re-emphasise the ideal of freedom, missing from most Soviet Marxism and more frequently found in the writings of libertarian socialists and liberal theoreticians. Fromm's brand of socialism rejected both Western capitalism and Soviet communism , which he saw as dehumanizing, and which resulted in the virtually universal modern phenomenon of alienation . Fromm became one of the founders of socialist humanism , promoting the early writings of Marx and his humanist messages to the US and Western European public. He engaged with a Christian-Marxist intellectual dialogue group organized by Milan Machovec and others in 1960s Communist Czechoslovakia . [ 17 ] In the early 1960s, Fromm published two books dealing with Marxist thought ( Marx's Concept of Man and Beyond the Chains of Illusion: My Encounter with Marx and Freud ). In 1965, working to stimulate the Western and Eastern cooperation between Marxist humanists, Fromm published a series of articles entitled Socialist Humanism: An International Symposium . In 1966, the American Humanist Association named him Humanist of the Year. For a period, Fromm was also active in U.S. politics. He joined the Socialist Party of America in the mid-1950s, and did his best to help them provide an alternative viewpoint to McCarthyist trends in some US political thought. This alternative viewpoint was best expressed in his 1961 paper May Man Prevail? An Inquiry into the Facts and Fictions of Foreign Policy . However, as a co-founder of SANE , Fromm's strongest political activism was in the international peace movement , fighting against the nuclear arms race and U.S. involvement in the Vietnam War . After supporting Senator Eugene McCarthy 's losing bid for the Democratic presidential nomination , Fromm more or less retreated from the American political scene, although he did write a paper in 1974 entitled Remarks on the Policy of Détente for a hearing held by the U.S. Senate Committee on Foreign Relations . Fromm was awarded the Nelly Sachs Prize in 1979. In Eros and Civilization , Herbert Marcuse is critical of Fromm: In the beginning, he was a radical theorist, but later he turned to conformity. Marcuse also noted that Fromm, as well as his close colleagues Sullivan and Karen Horney, removed Freud's libido theory and other radical concepts, which thus reduced psychoanalysis to a set of idealist ethics, which only embrace the status quo . [ 18 ] Fromm's response, in both The Sane Society [ 19 ] and in The Anatomy of Human Destructiveness , [ 20 ] argues that Freud indeed deserves substantial credit for recognizing the central importance of the unconscious, but also that he tended to reify his own concepts that depicted the self as the passive outcome of instinct and social control, with minimal volition or variability. Fromm argues that later scholars such as Marcuse accepted these concepts as dogma, whereas social psychology requires a more dynamic theoretical and empirical approach. In reference to Fromm's leftist political activism as a public intellectual, Noam Chomsky said "I liked Fromm's attitudes but thought his work was pretty superficial". [ 21 ]	https://en.wikipedia.org/wiki/Erich_Fromm
Alfred Ernest Jones FRCP MRCS (1 January 1879 – 11 February 1958) was a Welsh neurologist and psychoanalyst . A lifelong friend and colleague of Sigmund Freud from their first meeting in 1908, he became his official biographer. Jones was the first English-speaking practitioner of psychoanalysis and became its leading exponent in the English-speaking world. As President of both the International Psychoanalytical Association and the British Psycho-Analytical Society in the 1920s and 1930s, Jones exercised a formative influence in the establishment of their organisations, institutions and publications. [ 1 ] Ernest Jones was born in Gowerton (formerly Ffosfelin), Wales, an industrial village on the outskirts of Swansea , the first child of Thomas and Ann Jones. His father was a self-taught colliery engineer who went on to establish himself as a successful businessman, becoming accountant and company secretary at the Elba Steelworks in Gowerton. His mother, Mary Ann (née Lewis), was from a Welsh-speaking Carmarthenshire family which had relocated to Swansea. [ 2 ] Jones was educated at Swansea Grammar School , Llandovery College , and Cardiff University in Wales . Jones studied at University College London and meanwhile he obtained the Conjoint diplomas LRCP and MRCS in 1900. A year later, in 1901, he obtained an M.B. degree with honours in medicine and obstetrics . Within five years he received an MD degree and a Membership of the Royal College of Physicians (MRCP) in 1903. He was particularly pleased to receive the University's gold medal in obstetrics from his distinguished fellow-Welshman, Sir John Williams . [ 3 ] After obtaining his medical degrees, Jones specialised in neurology and took a number of posts in London hospitals. It was through his association with the surgeon Wilfred Trotter that Jones first heard of Freud's work. Having worked together as surgeons at University College Hospital , he and Trotter became close friends, with Trotter taking the role of mentor and confidant to his younger colleague. They had in common a wide-ranging interest in philosophy and literature, as well as a growing interest in Continental psychiatric literature and the new forms of clinical therapy it surveyed. By 1905 they were sharing accommodation above Harley Street consulting rooms with Jones's sister, Elizabeth, installed as housekeeper. Trotter and Elizabeth Jones later married. Appalled by the treatment of the mentally ill in institutions, Jones began experimenting with hypnotic techniques in his clinical work. [ 4 ] Jones first encountered Freud's writings directly in 1905, in a German psychiatric journal in which Freud published the famous Dora case-history. It was thus he formed "the deep impression of there being a man in Vienna who actually listened with attention to every word his patients said to him...a revolutionary difference from the attitude of previous physicians..." [ 5 ] Jones's early attempts to combine his interest in Freud's ideas with his clinical work with children resulted in adverse effects on his career. In 1906 he was arrested and charged with two counts of indecent assault on two adolescent girls whom he had interviewed in his capacity as an inspector of schools for "mentally defective" children. At the court hearing Jones maintained his innocence, claiming the girls were fantasising about any inappropriate actions by him. The magistrate concluded that no jury would believe the testimony of such children and Jones was acquitted. [ a ] [ 6 ] In 1908, employed as a pathologist at a London hospital, Jones accepted a colleague's challenge to demonstrate the repressed sexual memory underlying the hysterical paralysis of a young girl's arm. Jones duly obliged but, before conducting the interview, he omitted to inform the girl's consultant or arrange for a chaperone . Subsequently, he faced complaints from the girl's parents over the nature of the interview and he was forced to resign his hospital post. [ 7 ] Jones's first serious relationship was with Loe Kann, a wealthy Dutch émigré referred to him in 1906 after she had become addicted to morphine during treatment for a serious kidney condition. Their relationship lasted until 1913. It ended with Kann in analysis with Freud and Jones, at Freud's behest, undergoing analysis with Sándor Ferenczi . [ 8 ] A tentative romance with Freud's daughter, Anna , did not survive the disapproval of her father. Before her visit to Britain in the autumn of 1914, which Jones chaperoned, Freud advised him: She does not claim to be treated as a woman, being still far away from sexual longings and rather refusing man. There is an outspoken understanding between me and her that she should not consider marriage or the preliminaries before she gets 2 or 3 years older. [ 9 ] In 1917, Jones married the Welsh musician Morfydd Llwyn Owen . They were holidaying in South Wales the following year when Morfydd became ill with acute appendicitis . Jones hoped to get his former colleague and brother-in-law, the leading surgeon Wilfred Trotter , to operate but when this proved impossible emergency surgery was carried out at his father's Swansea home by a local surgeon, with chloroform administered as the anaesthetic. [ 10 ] [ 11 ] As Jones recounts: "after a few days [she] became delirious with a high temperature. We thought there was blood poisoning till I got Trotter from London. He at once recognized delayed chloroform poisoning ... We fought hard, and there were moments when we seemed to have succeeded, but it was too late." [ 12 ] Jones arranged for his wife to be buried in Oystermouth Cemetery on the outskirts of Swansea with her gravestone bearing an inscription from Goethe's Faust : Das Unbeschreibliche, hier ist's getan . [ b ] [ 13 ] Following some inspired matchmaking by his Viennese colleagues, in 1919 Jones met and married Katherine Jokl, a Jewish economics graduate from Moravia. She had been at school in Vienna with Freud's daughters. They had four children in what proved to be a long and happy marriage, though both struggled to overcome the loss of their eldest child, Gwenith, at the age of 7, during the interwar influenza epidemic. [ 14 ] Their son Mervyn Jones became a writer. Whilst attending a congress of neurologists in Amsterdam in 1907, Jones met Carl Jung , from whom he received a first-hand account of the work of Freud and his circle in Vienna. Confirmed in his judgement of the importance of Freud's work, Jones joined Jung in Zürich to plan the inaugural Psychoanalytical Congress. This was held in 1908 in Salzburg , where Jones met Freud for the first time. Jones travelled to Vienna for further discussions with Freud and introductions to the members of the Vienna Psychoanalytic Society . Thus began a personal and professional relationship which, to the acknowledged benefit of both, would survive the many dissensions and rivalries which marked the first decades of the psychoanalytic movement, and would last until Freud's death in 1939. [ 15 ] With his career prospects in Britain in serious difficulty, Jones sought refuge in Canada in 1908. He took up teaching duties in the Department of Psychiatry of the University of Toronto (from 1911, as Associate Professor of Psychiatry). In addition to building a private psychoanalytic practice, he worked as pathologist to the Toronto Asylum and Director of its psychiatric outpatient clinic. Following further meetings with Freud in 1909 at Clark University in Worcester, Massachusetts , where Freud gave a series of lectures on psychoanalysis, and in the Netherlands the following year, Jones set about forging strong working relationships with the nascent American psychoanalytic movement. He gave some 20 papers or addresses to American professional societies at venues ranging from Boston, to Washington and Chicago. In 1910 he co-founded the American Psychopathological Association and the following year the American Psychoanalytic Association , serving as its first Secretary until 1913. [ 16 ] Jones undertook an intensive programme of writing and research, which produced the first of what were to be many significant contributions to psychoanalytic literature, notably monographs on Hamlet and On the Nightmare . A number of these were published in German in the main psychoanalytic periodicals published in Vienna; these secured his status in Freud's inner circle during the period of the latter's increasing estrangement from Jung. In this context in 1912 Jones initiated, with Freud's agreement, the formation of a Committee of loyalists charged with safeguarding the theoretical and institutional legacy of the psychoanalytic movement. [ c ] This development also served the more immediate purpose of isolating Jung and, with Jones in strategic control, eventually manoeuvring him out of the Presidency of the International Psychoanalytical Association , a post he had held since its inception. When Jung's resignation came in 1914, it was only the outbreak of the Great War that prevented Jones from taking his place. [ 17 ] Returning to London in 1913, Jones set up in practice as a psychoanalyst, founded the London Psychoanalytic Society, and continued to write and lecture on psychoanalytic theory. A collection of his papers was published as Papers on Psychoanalysis , the first account of psychoanalytic theory and practice by a practising analyst in the English language. By 1919, the year he founded the British Psychoanalytical Society , Jones could report proudly to Freud that psychoanalysis in Britain "stands in the forefront of medical, literary and psychological interest" (letter 27 January 1919 (Paskauskas 1993)). As President of the Society – a post he would hold until 1944 – Jones secured funding for and supervised the establishment in London of a Clinic offering subsidised fees, and an Institute of Psychoanalysis, which provided administrative, publishing and training facilities for the growing network of professional psychoanalysts. Jones went on to serve two periods as President of the International Psychoanalytic Association from 1920 to 1924 and 1932 to 1949, where he had significant influence. In 1920 he founded the International Journal of Psychoanalysis , serving as its editor until 1939. The following year he established the International Psychoanalytic Library, which published some 50 books under his editorship. Jones soon obtained from Freud rights to the English translation of his work. In 1924 the first two volumes of Freud's Collected Papers was published in translations edited by Jones and supervised by Joan Riviere , his former analysand and, at one stage, ardent suitor. [ 18 ] After a period in analysis with Freud, Riviere worked with Jones as the translation editor of the International Journal of Psychoanalysis. She then was part of a working group Jones set up to plan and deliver James Strachey 's translations for the standard edition of Freud's work . [ 19 ] Largely through Jones' energetic advocacy, the British Medical Association officially recognised psychoanalysis in 1929. The BBC subsequently removed him from a list of speakers declared to be dangerous to public morality. In the 1930s Jones and his colleagues made a series of radio broadcasts on psychoanalysis. [ 20 ] After Adolf Hitler took power in Germany, Jones helped many displaced and endangered Jewish analysts to resettle in England and other countries. Following the Anschluss of March 1938, Jones flew into Vienna at considerable personal risk to play a crucial role in negotiating and organising the emigration of Freud and his circle to London. [ d ] [ 21 ] Jones's early published work on psychoanalysis had been devoted to expositions of the fundamentals of Freudian theory, an elaboration of its theory of symbolism, and its application to the analysis of religion, mythology, folklore and literary and artistic works. Under the influence of Melanie Klein , Jones' work took a new direction. Klein had made an impact in Berlin in the new field of child analysis and had impressed Jones in 1925 when he attended her series of lectures to the British Society in London. At Jones's invitation she moved to London the following year; she soon acquired a number of devoted and influential followers. Her work had a dramatic effect on the British Society, polarising its members into rival factions as it became clear that her approach to child analysis was seriously at odds with that of Anna Freud, as set out in her 1927 book An Introduction to the Technique of Child Analysis . The disagreement centred around the clinical approach to the pre-Oedipal child; Klein argued for play as an equivalent to free association in adult analyses. Anna Freud opposed any such equivalence, proposing an educative intervention with the child until an appropriate level of ego development was reached at the Oedipal stage. Klein held this to be a collusive inhibition of analytical work with the child. [ 22 ] Influenced by Klein, and initiating what became known as the Jones–Freud controversy, Jones set out to explore a range of interlinked topics in the theory of early psychic development. These included the structure and genesis of the superego and the nature of the feminine castration complex. [ 23 ] He coined the term phallocentrism in a critique of Freud's account of sexual difference. He argued together with Klein and her Berlin colleague, Karen Horney , for a primary femininity, saying that penis envy arose as a defensive formation rather than arising from the fact, or "injury", of biological asymmetry. In a corresponding reformulation of the castration complex, Jones introduced the concept of " aphanisis " to refer to the fear of "the permanent extinction of the capacity (including opportunity) for sexual enjoyment". [ 24 ] These departures from orthodoxy were noted in Vienna and were topics that were featured in the regular Freud–Jones correspondence, the tone of which became increasingly fractious. Faced with accusations from Freud of orchestrating a campaign against him and his daughter, Jones sought to allay Freud's concerns without abandoning his new critical standpoint. Eventually, following a series of exchange lectures between the Vienna and London societies, which Jones arranged with Anna Freud, Freud and Jones resumed their usual cordial exchanges. With the arrival in Britain of refugee German and Viennese analysts in the 1930s, including Anna Freud in 1938, the hostility between the orthodox Freudians and Kleinians in the British Society grew more intense. Jones chaired a number of "extraordinary business meetings" with the aim of defusing the conflict, and these continued into the war years. The meetings, which became known as the controversial discussions , were established on a more regular basis from 1942. By that time, Jones had removed himself from direct participation, owing to ill health and the difficulties of war-time travel from his home in Elsted , West Sussex. He resigned from the presidency of the British Society in 1944, the year in which, under the presidency of Sylvia Payne , there finally emerged a compromise agreement which established parallel training courses providing options to satisfy the concerns of the rival groups that had formed: followers of Anna Freud, followers of Melanie Klein and a non-aligned group of Middle or Independent Group analysts. It was agreed further that all the key policy making committees of the BPS should have representatives from the three groups. [ 25 ] After the end of the war, Jones gradually relinquished his many official posts whilst continuing his psychoanalytic practice, writings and lecturing. The major undertaking of his final years was his monumental account of Freud's life and work, published to widespread acclaim in three volumes between 1953 and 1957. In this he was ably assisted by his German-speaking wife, who translated much of Freud's early correspondence and other archive documentation made available by Anna Freud . His uncompleted autobiography, Free Associations , was published posthumously in 1959. Always proud of his Welsh origins, Jones became a member of the Welsh Nationalist Party, Plaid Cymru . He had a particular love of the Gower Peninsula , which he had explored extensively in his youth. Following the purchase of a holiday cottage in Llanmadoc, this area became a regular holiday retreat for the Jones family. He was instrumental in helping secure its status in 1956, as the first region of the UK to be designated an Area of Outstanding Natural Beauty . [ 26 ] Both of Jones's main leisure pursuits resulted in significant publications. A keen ice skater since his schooldays, Jones published an influential textbook on the subject. [ 27 ] His passion for chess inspired a psychoanalytical study of the life of American chess genius, Paul Morphy . [ 28 ] Jones was made a Fellow of the Royal College of Physicians (FRCP) in 1942, Honorary President of the International Psychoanalytical Association in 1949, and was awarded an Honorary Doctor of Science degree at Swansea University (Wales) in 1954. Jones died in London on 11 February 1958, and was cremated at Golders Green Crematorium . His ashes were buried in the grave of the oldest of his four children in the churchyard of St Cadoc's Cheriton on the Gower Peninsula . [ 29 ] Maddox (2006) includes a comprehensive bibliography of Jones' writings.	https://en.wikipedia.org/wiki/Ernest_Jones
Ernesto Contreras (1915–2003) served as a Mexican medical doctor. He operated the Oasis of Hope Hospital in Tijuana for over 30 years, claiming to "treat" cancer patients with amygdalin (also called "laetrile" or, erroneously, "vitamin B 17 ") which has been found completely ineffective. His practices have been widely condemned. Contreras received post-graduate training at the Children's Hospital Boston in Boston . He served as the chief pathologist at the Army Hospital in Mexico City and was Professor of Histology and Pathology at the Mexican Army Medical School. About extreme terminal cancer cases, Contreras alleged: "The palliative action [the ability of laetrile to improve comfort of patient] is in about 60% of the cases. Frequently, enough to be significant, I see arrest of the disease or even regression in some 15% of the very advanced cases." [ 1 ] There is no evidence to support Contreras' statements. Many of Contreras' patients came from the United States , where use of laetrile is not approved by the Food and Drug Administration . [ 2 ] Since the 1970s, the use of Laetrile to treat cancer has been described in the scientific literature as a canonical example of quackery and has never been shown to be effective in the treatment or prevention of cancer. [ 2 ] [ 3 ] [ 4 ]	https://en.wikipedia.org/wiki/Ernesto_Contreras_(physician)
The Ernst Jung Prize is a prize awarded annually for excellence in biomedical sciences. The Ernst Jung Foundation, funded by Hamburg merchant Ernst Jung in 1967, has awarded the Ernst Jung Prize in Medicine, now €300,000, since 1976, and the lifetime achievement Ernst Jung Gold Medal for Medicine since 1990. [ 1 ] [ 2 ] Source: Jung Foundation Source: Jung Foundation	https://en.wikipedia.org/wiki/Ernst_Jung_Prize
Ernst Rüdin (19 April 1874 – 22 October 1952) [ 1 ] was a Swiss-born German psychiatrist , geneticist , eugenicist and Nazi , rising to prominence under Emil Kraepelin and assuming the directorship at the German Institute for Psychiatric Research in Munich. While he has been credited as a pioneer of psychiatric inheritance studies, he also argued for, designed, justified and funded the mass sterilization and clinical killing of adults and children. Rüdin was born on 19 April 1874 in St. Gallen , Switzerland, the son of Conrad Rüdin, a textile salesman. [ 2 ] From 1893 until graduating in 1898, he studied medicine in Geneva , Lausanne , Naples , Heidelberg , Berlin , Dublin and Zürich . [ 2 ] In 1899, at the Burghölzli in Zürich, Rüdin worked as an assistant to psychiatrist Eugen Bleuler , who coined the term schizophrenia . [ 2 ] He completed his PhD, then a psychiatric residency at a prison in Moabit , Berlin. [ 2 ] From 1907, Rüdin worked at the University of Munich as an assistant to Emil Kraepelin , the highly influential psychiatrist who had developed the diagnostic split between 'dementia praecox' ('early dementia' – reflecting his pessimistic prognosis – renamed schizophrenia) and 'manic-depressive illness' (including unipolar depression), and who is considered by many to be the father of modern psychiatric classification. [ 3 ] He became senior lecturer in 1909, as well as senior physician at the Munich Psychiatric Hospital , succeeding Alois Alzheimer . [ 4 ] Kraepelin and Rüdin were both ardent advocates of a theory that the German race was becoming overly 'domesticated' and thus degenerating into higher rates of mental illness and other conditions. [ 5 ] Fears of degeneration were somewhat common internationally at the time, but the lengths to which Rüdin took them may have been unique, and from the very beginning of his career he made continuous efforts to have his research translate into political action. He also repeatedly drew attention to the financial burden of sick and disabled people. [ 6 ] Rüdin developed the concept of "empirical genetic prognosis" of mental disorders . He published influential initial results on the genetics of schizophrenia (known as dementia praecox) in 1916. [ 7 ] Rüdin's data did not show a high enough risk in siblings for schizophrenia to be due to a simple recessive gene as he and Kraepelin thought, but he put forward a two-recessive-gene theory to try to account for this. [ 8 ] This has been attributed to a "mistaken belief" that just one or a small number of gene variations caused such conditions. [ 9 ] Similarly his own large study on mood disorders correctly disproved his own theory of simple Mendelian inheritance and also showed environmental causes, but Rüdin simply neglected to publish his data while continuing to advance his eugenic theories. [ 10 ] Nevertheless, Rüdin pioneered and refined complex techniques for conducting studies of inheritance, was widely cited in the international literature for decades, and is still regarded as "the father of psychiatric genetics". [ 11 ] Rüdin was influenced by his then brother-in-law, and long-time friend and colleague, Alfred Ploetz , who was considered the 'father' of racial hygiene and indeed had coined the term in 1895. [ 12 ] This was a form of eugenics , inspired by social darwinism , which had gained some popularity internationally, as would the voluntary or compulsory sterilization of psychiatric patients, initially in America. Rüdin campaigned for this early on. At a conference on alcoholism in 1903, he argued for the sterilisation of 'incurable alcoholics', but his proposal was roundly defeated. [ 12 ] In 1904, he was appointed co-editor in chief of the newly founded Archive for Racial Hygiene and Social Biology , and in 1905 was among the co-founders of the German Society for Racial Hygiene (which soon became International), along with Ploetz. [ 13 ] He published an article of his own in Archives in 1910, in which he argued that medical care for the mentally ill, alcoholics, epileptics and others was a distortion of natural laws of natural selection, and medicine should help to clean the genetic pool. [ 5 ] In 1917, a new German Institute for Psychiatric Research was established in Munich (known as the DFA in German; renamed the Max Planck Institute of Psychiatry after World War II), designed and driven forward by Emil Kraepelin. The Institute incorporated a Department of Genealogical and Demographic Studies (known as the GDA in German) – the first in the world specialising in psychiatric genetics – and Rüdin was put in charge by overall director Kraepelin. In 1924, the Institute came under the umbrella of the prestigious Kaiser Wilhelm Society . Rüdin returned to Switzerland in 1925, where he spent three years as full Professor of Psychology and director of the psychiatric clinic of the University of Basel . [ 13 ] [ 2 ] He returned to the Institute in 1928, with an expanded departmental budget and new building at 2 Kraepelinstrasse, financed primarily by the American Rockefeller Foundation . The institute soon gained an international reputation as leading psychiatric research center, including in hereditary genetics. In 1931, a few years after Kraepelin's death, Rüdin took over the directorship of the entire Institute as well as remaining head of his department. [ 6 ] [ 9 ] [ 14 ] [ 15 ] Rüdin was among the first to write about the "dangers" of hereditary defectives and the supposed value of the Nordic race as "culture creators". [ 16 ] By 1920, his colleague Alfred Hoche published, with lawyer Karl Binding , the influential "Allowing the Destruction of Life Unworthy of Living". [ 17 ] In 1930, Rüdin was a leading German representative at the First International Congress for Mental Hygiene, held in Washington, US, arguing for eugenics. [ 13 ] In 1932, he became President of the International Federation of Eugenics Organizations . He was in contact with Carlos Blacker of the British Eugenics Society, and sent him a copy of pre-Nazi voluntary sterilization laws enacted in Prussia; a precursor to the Nazi forced sterilization laws that Rüdin is said to have already prepared in his desk drawer. [ 18 ] From 1935 to 1945, he was President of the Society of German Neurologists and Psychiatrists (GDNP), later renamed the German Association for Psychiatry, Psychotherapy and Neurology (DGPPN). [ 19 ] The American Rockefeller Foundation funded numerous international researchers to visit and work at Rüdin's psychiatric genetics department, even as late as 1939. These included Eliot Slater and Erik Stromgren , considered the founding fathers of psychiatric genetics in Britain and Scandinavia respectively, as well as Franz Josef Kallmann , who became a leading figure in twins research in the US after emigrating in 1936. [ 6 ] Kallmann had claimed in 1935 that 'minor anomalies' in otherwise unaffected relatives of schizophrenic people should be grounds for compulsory sterilization. Rüdin's research was also supported with manpower and financing from the German National Socialists . In 1933, Ernst Rüdin, Alfred Ploetz , and several other experts on racial hygiene were brought together to form the Expert Committee on Questions of Population and Racial Policy under Reich Interior Minister Wilhelm Frick . The committee's ideas were used as a scientific basis to justify the racial policy of Nazi Germany and its " Law for the Prevention of Hereditarily Diseased Offspring " was passed by the German government on 1 January 1934. Rüdin was such an avid proponent that colleagues nicknamed him the "Reichsfuhrer for Sterilization" [ 4 ] [ 20 ] In a speech to the German Society for Rassenhygiene published in 1934, Rüdin recalled the early days of trying to alert the public to the special value of the Nordic race and the dangers of defectives. He stated: "The significance of racial hygiene did not become evident to all aware Germans until the political activity of Adolf Hitler and only through his work has our 30-year-long dream of translating racial hygiene into action finally become a reality." Describing it as a 'duty of honour' for society to help implement the Nazi policies, Rüdin declared: "Whoever is not physically or mentally fit must not pass on his defects to his children. The state must take care that only the fit produce children. Conversely, it must be regarded as reprehensible to withhold healthy children from the state." [ 16 ] From early on, Rüdin had been a 'racial fanatic' for the purity of the 'German people'. [ 21 ] However, he was also described in 1988 as "not so much a fanatical Nazi as a fanatical geneticist". [ 22 ] His ideas for reducing new cases of schizophrenia would prove a total failure, despite between 73% and 100% of the diagnosed being sterilised or killed. [ 9 ] Rüdin joined the Nazi Party in 1937. [ 23 ] In 1939, on his 65th birthday, he was awarded a 'Goethe medal for art and science' handed to him personally by Hitler, who honoured him as the 'pioneer of the racial-hygienic measures of the Third Reich '. In 1944, he received a bronze Nazi eagle medal ( Adlerschild des Deutschen Reiches ), with Hitler calling him the 'pathfinder in the field of hereditary hygiene'. [ 13 ] In 1942, speaking about 'euthanasia', Rüdin emphasised "the value of eliminating young children of clearly inferior quality". He supported and financially aided the work of Julius Duessen at Heidelberg University with Carl Schneider , clinical research which from the beginning involved killing children. [ 6 ] [ 20 ] [ 24 ] [ 25 ] At the end of the war in 1945, Rüdin claimed he had only ever engaged in academic science, only ever heard rumours of killings at the nearby insane asylums, and that he hated the Nazis. However, some of his Nazi political activities, scientific justifications, and awards from Hitler were already uncovered in 1945 (as were his lecture handouts praising Nordics and disparaging Jews). Investigative journalist Victor H. Bernstein concluded: "I am sure that Prof. Rüdin never so much as killed a fly in his 74 years. I am also sure he is one of the most evil men in Germany." [ citation needed ] In 1945, Rüdin was stripped of his Swiss citizenship, which he had held jointly with German since 1912, [ 2 ] and two months later was placed under house arrest by the Munich Military Government. However, interned in the US, he was released in 1947 after a ' denazification ' trial where he was supported by former colleague Kallmann (a eugenicist himself) and famous quantum physicist Max Planck [ verification needed ] ; his only punishment was a 500 ℛ︁ℳ︁ fine. [ 26 ] Speculation about the reasons for his early release, despite having been considered as a potential criminal defendant for the Nuremberg trials , include the need to restore confidence and order in the German medical profession; his personal and financial connections to prestigious American and British researchers, funding bodies and others; and the fact that he repeatedly cited American eugenic sterilization initiatives to justify his own as legal (indeed the Nuremberg trials carefully avoided highlighting such links in general). Nevertheless, Rüdin has been cited as a more senior and influential architect of Nazi crimes than the physician who was sentenced to death, Karl Brandt , or the infamous Josef Mengele , who had attended his lectures and been employed by his Institute. [ 27 ] After Rüdin's death in 1952, the funeral eulogy was delivered by Kurt Pohlisch [ de ] , a close friend who had been professor of psychiatry at Bonn University, director of the second-largest genetics research institute in Germany, and expert Nazi advisor on Action T4 . [ 28 ] Rüdin's connections to the Nazis were a major reason for criticisms of psychiatric genetics in Germany after 1945. [ 7 ] He was survived by his daughter, Edith Zerbin-Rüdin , who became a psychiatric geneticist and eugenicist herself [ citation needed ] . In 1996, Zerbin-Rüdin, along with Kenneth S. Kendler , published a series of articles on his work which were criticised by others for whitewashing his racist and later Nazi ideologies and activities ( Elliot S. Gershon also notes that Zerbin-Rüdin acted as defender and apologist for her father in private conversation and in a transcribed interview published in 1988). [ 29 ] [ 23 ] Kendler and other leading psychiatric genetic authors have been accused as recently as 2013 of producing revisionist historical accounts of Rüdin and his 'Munich School'. Three types of account have been identified: "(A) those who write about German psychiatric genetics in the Nazi period, but either fail to mention Rüdin at all, or cast him in a favorable light; (B) those who acknowledge that Rüdin helped promote eugenic sterilization and/or may have worked with the Nazis, but generally paint a positive picture of Rüdin's research and fail to mention his participation in the "euthanasia" killing program; and (C) those who have written that Rüdin committed and supported unspeakable atrocities." [ 30 ] [ 31 ]	https://en.wikipedia.org/wiki/Ernst_Rüdin

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.