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5.  Quicksilver & Gold: Mercury Pollution from Artisanal and Small-Scale Gold Mining 
Environmental Health Perspectives  2012;120(11):a424-a429.
PMCID: PMC3556620  PMID: 23117138
6.  Mercury. A history of quicksilver 
Medical History  1977;21(4):461.
PMCID: PMC1082118
7.  Quick fixes for quicksilver. 
Environmental Health Perspectives  1998;106(2):A74-A76.
Mercury pollution is a persistent and increasing problem in the environment. Along with some natural sources of the metal, major man-made sources of mercury pollution include incinerators, fossil fuel plants, and municipal sewage systems. The EPA estimated that in 1989, approximately 643,000 kg of mercury was discarded as municipal solid waste, with 84% of it landfilled.
PMCID: PMC1533006  PMID: 9456343
9.  QuickSilver Clinical Tracker – a Risk-Management Approach 
While many guidelines strive to automate the high-granular clinical thought process, the resulting risk stratification is often a lowgranular management class (i.e. low, medium or high risk). Furthermore, the “low hanging fruit” of guidelines is not in decision support, rather in the subsequent action tracking. Therefore, we believe that only a small amount of data is required to produce significant reminders. In our approach, the clinician risk-stratifies the patient and enters the guideline at the management level. We do not attempt to replicate the clinical thought process; rather we ask the question, “Now that you have decided, how can we help track your decisions?” A risk-management approach encapsulates salient guideline features and provides a framework for basic decision support and data tracking.
PMCID: PMC1479974  PMID: 14728492
10.  Thomas McKeown, Meet Fidel Castro: Physicians, Population Health and the Cuban Paradox 
Healthcare Policy  2008;3(4):21-32.
About 40 years ago, Thomas McKeown demonstrated that the historic decline in the great killer diseases owed little or nothing to progress in medicine. A generation of research on population health followed, highlighting the large social gradients in health within populations. These vary greatly across societies, but appear largely unrelated to medical care. Medicine was acknowledged as “powerful, but within limits”; the major determinants of health lie elsewhere.
We may have missed something. Cuba has achieved “first world” population health status despite a minimal economic base. Far from marginalizing medicine, Cuba has by far the world's largest physician workforce. But doctors' roles are significantly expanded. The system seems to work.
PMCID: PMC2645168  PMID: 19377323
11.  A gift from Oxford: the Osler-Thomas connection 
In June 1926, Dr. Henry M. Thomas Jr. (“Hal”) received as a gift from Grace Osler in Oxford an Einhorn Duodenal Bucket Set that had belonged to Sir William Osler. The Thomases were a distinguished multigenerational physician family of Baltimore with high educational standards and major accomplishments in medicine and medical education. An extraordinary number of the Thomas women earned doctorates and made significant contributions in an era when this was a pioneering achievement. This is exemplified by Martha Carey Thomas, who earned a PhD in 1882 and served as dean and president of Bryn Mawr College for women. As a leading feminist and member of the Women's Fund Committee, she was a major force in providing the endowment that permitted the opening of the Johns Hopkins School of Medicine under the strict stipulations that admission requirements include an undergraduate degree and that women be admitted on the basis of total equality with men. Osler established relationships that extended over three generations of the Thomas family during his Baltimore tenure, an influence that proved mutually beneficial.
PMCID: PMC3448570  PMID: 23077379
12.  Thermal Preference of Juvenile Dover Sole (Solea solea) in Relation to Thermal Acclimation and Optimal Growth Temperature 
PLoS ONE  2013;8(4):e61357.
Dover sole (Solea solea) is an obligate ectotherm with a natural thermal habitat ranging from approximately 5 to 27°C. Thermal optima for growth lie in the range of 20 to 25°C. More precise information on thermal optima for growth is needed for cost-effective Dover sole aquaculture. The main objective of this study was to determine the optimal growth temperature of juvenile Dover sole (Solea solea) and in addition to test the hypothesis that the final preferendum equals the optimal growth temperature. Temperature preference was measured in a circular preference chamber for Dover sole acclimated to 18, 22 and 28°C. Optimal growth temperature was measured by rearing Dover sole at 19, 22, 25 and 28°C. The optimal growth temperature resulting from this growth experiment was 22.7°C for Dover sole with a size between 30 to 50 g. The temperature preferred by juvenile Dover sole increases with acclimation temperature and exceeds the optimal temperature for growth. A final preferendum could not be detected. Although a confounding effect of behavioural fever on temperature preference could not be entirely excluded, thermal preference and thermal optima for physiological processes seem to be unrelated in Dover sole.
PMCID: PMC3632572  PMID: 23613837
13.  Portrayal of negative qualities in a doctor as a potential teaching tool in medical ethics and humanism: Journey to the End of Night by Louis‐Ferdinand Céline 
Postgraduate Medical Journal  2006;82(964):154-156.
Fictional stories about physicians and patients are increasingly used as a powerful teaching resource for medical students. Very often, but not exclusively, stories of physicians as positive role models are selected to teach students virtues and ethical values. Negative role models are rarely used and if so, physicians are rather described as medical quacks in such fiction then exhibiting primarily a corrupted character. I suggest that a fictional story that presents exclusively a negative role model of a physician could also be a valuable, admittedly difficult, teaching resource to demonstrate the consequences of absolute loss of ethical standards and virtues in physicians. A not widely known example of this genre is Louis‐Ferdinand Céline's (1894–1961) novel Voyage au bout de la nuit (Journey to the End of the Night), published in 1932. Having a strong autobiographical background, the novel described the adventures of the medicine student, Ferdinand Bardamu, during the first world war, in the African colonies as a trader, in the United States of America as factory worker, and later after finishing his education, as a doctor for the poor. Unfortunately, Dr Bardamu develops an unprofessional, even criminal behaviour, and may serve as a negative role model for the virtues of physicians. This article will familiarise the reader with the novel and its physician author.
PMCID: PMC2596693  PMID: 16461481
literature; medical education; ethics; professional development
14.  How primary care physicians' attitudes toward riskand uncertainty affect their use of electronicinformation resources 
Objective: The research sought to determine if primary care physicians' attitudes toward risk taking or uncertainty affected how they sought information and used electronic information resources when answering simulated clinical questions.
Methods: Using physician-supplied data collected from existing risk and uncertainty scales, twenty-five physicians were classified as risk seekers (e.g., enjoying adventure), risk neutral, or risk avoiders (e.g., cautious) and stressed or unstressed by uncertainty. The physicians then answered twenty-three multiple-choice, clinically focused questions and selected two to pursue further using their own information resources. Think-aloud protocols were used to collect searching process and outcome data (e.g., searching time, correctness of answers, searching techniques).
Results: No differences in searching outcomes were observed between the groups. Physicians who were risk avoiding and those who reported stress when faced with uncertainty each showed differences in searching processes (e.g., actively analyzing retrieval, using searching heuristics or rules). Physicians who were risk avoiding tended to use resources that provided answers and summaries, such as Cochrane or UpToDate, less than risk-seekers did. Physicians who reported stress when faced with uncertainty showed a trend toward less frequent use of MEDLINE, when compared with physicians who were not stressed by uncertainty.
Conclusions: Physicians' attitudes towards risk taking and uncertainty were associated with different searching processes but not outcomes. Awareness of differences in physician attitudes may be key in successful design and implementation of clinical information resources.
PMCID: PMC1852627  PMID: 17443246
15.  Thomas Arthur Kemp 
BMJ : British Medical Journal  2005;330(7488):422.
Consultant physician who twice captained England at rugby
PMCID: PMC549126
16.  Bulimia: A Comment on an Old Case Report by Sir Thomas Browne 
Canadian Family Physician  1989;35:395-397.
This paper offers a brief review of recent literature on the incidence and age of onset of bulimia in the light of a 17th century description of a female centenarian with bulimia, together with a brief account of the physician, Sir Thomas Browne (1605-1682), and the etymology and early usage of the term.
PMCID: PMC2280231  PMID: 21248899
bulimia; incidence; age; etymology; Sir Thomas Browne; history
17.  THOMAS: Building Bayesian Statistical Expert Systems to Aid in Clinical Decision Making 
Previous knowledge-based systems for statistical analysis separate the numeric knowledge needed for data analysis from the heuristic knowledge employed in using the results of the analysis. In contrast, a Bayesian framework for building biostatistical expert systems allows for the integration of the data-analytic and decision-making tasks. The architecture of such a framework entails enabling the system (1) to make its recommendations on decision-analytic grounds; (2) to update a statistical model based on the user's prior beliefs and on data from, and methodological concerns evinced by, the study; (3) to construct statistical models dynamically. This architecture permits the knowledge engineer to represent a variety of types of statistical and domain knowledge, such as methodological knowledge. Construction of such systems requires that the knowledge engineer reinterpret traditional statistical concerns, such as by replacing the notion of statistical significance with that of a pragmatic clinical threshold. The user of such a system can interact with the system at the level of general methodological concerns, rather than at the level of statistical details. We demonstrate these issues with a prototype system called THOMAS which helps a physician decision maker to interpret the results of a published randomized clinical trial.
PMCID: PMC2245418
Statistical and probabilistic analysis; Knowledge-based systems; Expert systems for decision support
18.  Stress in migraine: personality-dependent vulnerability, life events, and gender are of significance 
Upsala Journal of Medical Sciences  2011;116(3):187-199.
Background and aim
The individual's experiences of stress as well as constitutional factors, including high neuroticism and female gender, are known determinants for migraine. The present aim was to further elucidate factors of personality and stress, including life events, in relation to gender in migraine.
A cross-sectional study was performed on 150 persons, 106 women and 44 men, suffering from at least two migraine attacks a month. All obtained a doctor-defined migraine diagnosis based on a structured face-to-face interview concerning their health situation and current and prior stress. All of them also answered validated questionnaires regarding personality traits (SSP), life events, and perceived ongoing stress.
The personality trait inventory showed high mean scores for stress susceptibility and low mean scores for aggressiveness and adventure seeking, both for women and for men, as well as high mean scores for psychic and somatic anxiety in women. Stress susceptibility, the overall most deviant trait, correlated strikingly with current level of stress in both sexes. In women, stress susceptibility also correlated strongly with experiences of negative life events. Tension-type headache, anxiety, and depression were approximately twice as prevalent in women compared to men.
The present study confirms previous research, showing that stress is an important factor in migraine. Stress susceptibility, life events, and concomitant psychosomatic illnesses should be considered important when evaluating individuals with migraine, and gender aspects need to be taken into account.
PMCID: PMC3128723  PMID: 21668386
Gender; life event; migraine; personality; stress
19.  A children’s asthma education program: Roaring Adventures of Puff (RAP), improves quality of life 
It is postulated that children with asthma who receive an interactive, comprehensive education program would improve their quality of life, asthma management and asthma control compared with children receiving usual care.
To assess the feasibility and impact of ‘Roaring Adventures of Puff’ (RAP), a six-week childhood asthma education program administered by health professionals in schools.
Thirty-four schools from three health regions in Alberta were randomly assigned to receive either the RAP asthma program (intervention group) or usual care (control group). Baseline measurements from parent and child were taken before the intervention, and at six and 12 months.
The intervention group had more smoke exposure at baseline. Participants lost to follow-up had more asthma symptoms. Improvements were significantly greater in the RAP intervention group from baseline to six months than in the control group in terms of parent’s perceived understanding and ability to cope with and control asthma, and overall quality of life (P<0.05). On follow-up, doctor visits were reduced in the control group.
A multilevel, comprehensive, school-based asthma program is feasible, and modestly improved asthma management and quality of life outcomes. An interactive group education program offered to children with asthma at their school has merit as a practical, cost-effective, peer-supportive approach to improve health outcomes.
PMCID: PMC2866218  PMID: 20422062
Asthma education; Childhood asthma; Program evaluation; Quality of life; School-based program
20.  Thomas Graham Brown (1882–1965): Behind the Scenes at the Cardiff Institute of Physiology 
Thomas Graham Brown undertook seminal experiments on the neural control of locomotion between 1910 and 1915. Although elected to the Royal Society in 1927, his locomotion research was largely ignored until the 1960s when it was championed and extended by the distinguished neuroscientist, Anders Lundberg. Puzzlingly, Graham Brown's published research stopped in the 1920s and he became renowned as a mountaineer. In this article, we review his life and multifaceted career, including his active neurological service in WWI. We outline events behind the scenes during his tenure at Cardiff's Institute of Physiology in Wales, UK, including an interview with his technician, Terrence J. Surman, who worked in this institute for over half a century.
PMCID: PMC3259622
physiology; spinal cord; locomotion; motoneurones; interneurones; neural control; mountaineering; sailing; medical school politics
21.  Description of the karyotype of Rhagomys rufescens Thomas, 1886 (Rodentia, Sigmodontinae) from Southern Brazil Atlantic forest 
Genetics and Molecular Biology  2010;33(3):479-485.
Rhagomys rufescens (Rodentia: Sigmodontinae) is an endemic species of the Atlantic forest from Southern and Southeastern Brazil. Some authors consider Rhagomys as part of the tribe Thomasomyini; but its phylogenetic relationships remain unclear. Chromosomal studies on eight specimens of Rhagomys rufescens revealed a diploid number of 2n = 36 and a number of autosome arms FN = 50. GTG, CBG and Ag-NOR banding and CMA3 /DAPI staining were performed on metaphase chromosomes. Eight biarmed and nine acrocentric pairs were found in the karyotype of this species. The X and Y chromosomes were both acrocentric. Most of the autosomes and the sex chromosomes showed positive C-bands in the pericentromeric region. The X chromosome showed an additional heterochromatic block in the proximal region of the long arm. Nucleolus organizer regions (NORs) were located in the pericentromeric region of three biarmed autosomes (pairs 4, 6 and 8) and in the telomeric region of the short arm of three acrocentrics (pairs 10, 12 and 17). CMA 3 /DAPI staining produced fluorescent signals in many autosomes, especially in pairs 4, 6, and 8. This study presents cytogenetic data of Rhagomys rufescens for the first time.
PMCID: PMC3036123  PMID: 21637420
Rhagomys rufescens; Thomasomyini; Rodentia; Atlantic forest; karyotype
22.  First record of the genus Gratia Thomas (Ephemeroptera, Baetidae) from China with the description of a new species 
ZooKeys  2015;129-137.
A new species of Baetidae, Gratia baibungensis sp. n., is described and illustrated based on nymphal stage collected from the southeastern Tibet (Xizang) and the genus is reported for the first time from China. This new species can be readily differentiated from its congeners by the absence of a protuberance on the posterior margin of the abdominal tergum X, glabrate simple submarginal setae on the labrum, and the posterior margin of sterna VI–IX having much longer spatulate setae.
PMCID: PMC4319053
Mayfly; Gratia; new species; Oriental Region; Eastern Himalayas; Tibet
23.  Patients with suspected Lassa fever in London during 1984: problems in their management at St Thomas's Hospital. 
During 1984, 23 patients in whom a diagnosis of viral haemorrhagic fever was considered presented to the accident and emergency department at St Thomas's Hospital. There were no confirmed cases of viral haemorrhagic fever. Nine patients were transferred to Coppett's Wood Hospital, the nearest specially designated high security isolation unit. Malaria was the final diagnosis in 14, and in six this diagnosis was confirmed only after examining repeated smears at Coppett's Wood Hospital. Transferral of patients to such units is time consuming, expensive, and often unnecessary. Specially designated isolation units in district general hospitals and all teaching hospitals would simplify and improve the care not only of patients with a possible viral haemorrhagic fever but also patients with tuberculosis, multiply resistant staphylococcal infections, and viral infections that may be hazardous if transmitted to immunocompromised patients.
PMCID: PMC1418167  PMID: 3933748
24.  A case of Lassa fever: experience at St Thomas's Hospital. 
An 18-year-old Nigerian girl, normally resident in Jos, was admitted to hospital for five days before she was diagnosed as having Lassa fever. There were several atypical features in the early stages of here illness, notably the absence of prostration, pharyngitis, or bradycardia and the development of appreciable leucocytosis. Consequent control and surveillance measures required checks for 21 days on 173 people who had had contact with as first line if they had handled her or specimens without taking precautions to avoid direct skin contact with her excretions, secretions, and blood; other contacts were categorised as second line. During her time in hospital she was managed in a single room on a general ward. She visited a number of investigative departments within the hospital, and her specimens were examined in five clinical laboratories. Despite this no secondary cases occurred among either first- or second-line contacts, and there was no serological evidence of subclinical infection among any of the contacts tested (159 people).
PMCID: PMC1500309  PMID: 6812717
25.  Characteristics and Impact of Drug Detailing for Gabapentin 
PLoS Medicine  2007;4(4):e134.
Sales visits by pharmaceutical representatives (“drug detailing”) are common, but little is known about the content of these visits or about the impact of visit characteristics on prescribing behavior. In this study, we evaluated the content and impact of detail visits for gabapentin by analyzing market research forms completed by physicians after receiving a detail visit for this drug.
Methods and Findings
Market research forms that describe detail visits for gabapentin became available through litigation that alleged that gabapentin was promoted for “off-label” uses. Forms were available for 97 physicians reporting on 116 detail visits between 1995 and 1999. Three-quarters of recorded visits (91/116) occurred in 1996. Two-thirds of visits (72/107) were 5 minutes or less in duration, 65% (73/113) were rated of high informational value, and 39% (42/107) were accompanied by the delivery or promise of samples. During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the “main message” of the visit involved at least one off-label use. After receiving the detail visit, 46% (50/108) of physicians reported the intention to increase their prescribing or recommending of gabapentin in the future. In multivariable analysis, intent to increase future use or recommendation of gabapentin was associated with receiving the detail in a small group (versus one-on-one) setting and with low or absent baseline use of the drug, but not with other factors such as visit duration, discussion of “on-label” versus “off-label” content, and the perceived informational value of the presentation.
Detail visits for gabapentin were of high perceived informational value and often involved messages about unapproved uses. Despite their short duration, detail visits were frequently followed by physician intentions to increase their future recommending or prescribing of the drug.
Visits from pharmaceutical representatives regarding gabapentin "detailing" were frequently followed by physician intentions to increase their future activity with the drug.
Editors' Summary
In the US, before a pharmaceutical company can market a drug to doctors for use in a specific “indication” (meaning the treatment for a particular disease and group of patients), the drug has to be approved as safe and effective for that use by a government agency, the Food and Drug Administration. Once approved, doctors are allowed to use a drug for whatever nonapproved indications they think are appropriate, but the drug company cannot actively promote the drug for anything other than its approved use. However, many people are concerned that drug companies indirectly try to promote use of drugs for indications that are not approved. Such illegal activity would help a drug company increase its market share and sell more drugs. One tactic that drug companies use to sell drugs is “detailing.” Detailing involves direct visits from drug company representatives to individual doctors, during which the representative would provide information about their company's drugs. However, not a great deal is known about detail visits and the effect that they have on doctors' attitudes towards the drugs that are being promoted.
Why Was This Study Done?
The researchers carrying out this study wanted to learn more about what happens during detail visits and what impact these visits have on prescribing behavior. An opportunity for researching this came about as a result of a lawsuit during which drug company documents were subpoenaed (i.e., required by the court to be made available). In that lawsuit, it was alleged that a drug company, Parke-Davis, had promoted a drug, gabapentin, for many nonapproved uses. The company that subsequently took over Parke-Davis eventually made an out-of-court settlement. During the relevant time period, the only approved use of gabapentin was for treatment of partial seizures in adults with epilepsy, in combination with other drugs. However, gabapentin was used for many other conditions such as treatment of psychiatric disorders and management of pain. These researchers therefore used the documents available as a result of the lawsuit to research detailing and what impact detailing had on doctors' attitudes towards the drug being promoted.
What Did the Researchers Do and Find?
The documents analyzed in this study were produced by Verispan, a market research company. Verispan asked doctors who had been visited by Parke-Davis sales representatives to fill out a standard form after each detail visit. These forms were then subpoenaed as part of the lawsuit against Parke-Davis. The researchers here focused specifically on data relating to visits made by a single sales representative to a doctor or small group of doctors, and collected 116 forms. The data available from these forms included the doctors' ratings and comments regarding the main message associated with the products; the informational value of the visit; the quality of the presentation; and whether the doctor currently prescribed or planned to prescribe the product. The researchers classified the information available from the forms, identifying whether the “main message” related to approved uses of the drug or not; and extracting data relating to whether doctors planned to increase, maintain, or decrease their use of the drug. The majority of the visits studied were to doctors who were not neurologists, and would therefore be unlikely to prescribe gabapentin for its approved use. Doctors reported that a substantial proportion of the detail visits contained messages relating to nonapproved uses of gabapentin. Nearly half the doctors stated in the forms that their use of gabapentin would increase in the future, and no doctors said that their use would decrease following the visit. Doctors' intention to increase their use of gabapentin in the future was similar regardless of whether the message of the visit involved an approved or unapproved use.
What Do These Findings Mean?
This study shows that in the case of gabapentin, detail visits by drug company representatives frequently promoted nonapproved uses of the drug; these visits often resulted in doctors planning to increase their use of gabapentin. However, it is not clear whether these findings are also true for other drugs and drug companies, in part because these data came about as a result of a unique opportunity granted by the lawsuit against Parke-Davis.
Additional Information.
Please access these Web sites via the online version of this summary at
Medline Plus (provided by the US National Library of Medicine) has an entry about gabapentin
Introductory information is available from the US FDA Center for Drug Evaluation and Research about the drug approvals process in the USA
Wikipedia has an entry on pharmaceutical marketing (Note that Wikipedia is an internet encyclopedia anyone can edit)
The Drug Industry Document Archive is available at University of California, San Francisco; this internet archive holds documents relating to the lawsuit against Parke-Davis and from which the data presented in this paper derives
Guidance is available from the International Federation of Pharmaceutical Manufacturers and Associations regarding ethical promotion of medicines
PMCID: PMC1855692  PMID: 17455990

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