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Mayookha Mitra-Majumdar and Aaron Kesselheim reflect on steps taken to combat reporting bias in clinical trials over the last two decades.

In 2018, the United Nations General Assembly convened the first-ever high-level meeting (HLM) on tuberculosis (TB). Since that time news on the world’s most lethal infectious disease is not good—the 2019 WHO TB report shows 1.2 million people died from TB, a number that has fallen just 11% since 2015, less than one-third of the way towards the End TB Strategy milestone of a 35% reduction (to about 850 million deaths) by 2020. The same number of people, 10.0 million, are estimated to have fallen ill with TB in 2018 as in 2017. The stubborn persistence of TB is attributable to glaring gaps in case detection and treatment. While case detection has increased in recent years, there is still a significant gap between the 7 million new cases reported and the 10 million incident cases estimated in the most recent WHO data—and treatment success continues to hover at only 85%. There has long been a call for a shift toward a “human rights-based approach” in TB—building policies and programs explicitly on the norms and values set out in international human rights law, treating people with TB as rights holders in their interaction with the state and the health system, and working to overcome stigma and discrimination. Yet laws in high TB-burden countries (HBCs) have not been reformed to include basic rights protections. This helps explain the lack of progress, as individuals who fear discrimination and coercion may avoid diagnosis and treatment. Thus, TB stands in stark contrast to HIV/AIDS, for which the international community has moved far more decisively to recognize and protect key rights, even as more progress is needed. At the UN, heads of state committed to removing discriminatory laws and policies against people with TB, protecting and promoting their human rights and dignity, as a key part of a strategy to improve the TB response and end the epidemic. Here, we analyze key areas of law with particular importance for TB, focusing on five aspects of compulsory public health powers in law and on laws related to migration. We identify significant gaps between core human rights norms and existing legal environments.

Background The rapidly increased spending on insulin is a major public health issue in the United States. Industry marketing might be one of the upstream determinants of physicians’ prescription of long-acting insulin—the most commonly used and costly type of insulin, but the evidence is lacking. We therefore aimed to investigate the association between industry payments to physicians and subsequent prescriptions of long-acting insulin. Methods and findings Using the databases of Open Payments and Medicare Part D, we examined the association between the receipt of industry payments for long-acting insulin in 2016 and (1) the number of claims; (2) the costs paid for all claims; and (3) the costs per claim of long-acting insulin in 2017. We also examined the association between the receipt of payments and the change in these outcomes from 2016 to 2017. We employed propensity score matching to adjust for the physician-level characteristics (sex, years in practice, specialty, and medical school attended). Among 145,587 eligible physicians treating Medicare beneficiaries, 51,851 physicians received industry payments for long-acting insulin worth $22.3 million. In the propensity score–matched analysis including 102,590 physicians, we found that physicians who received the payments prescribed a higher number of claims (adjusted difference, 57.8; 95% CI, 55.8 to 59.7), higher costs for total claims (adjusted difference, +$22,111; 95% CI, $21,387 to $22,836), and higher costs per claim (adjusted difference, +$71.1; 95% CI, $69.0 to $73.2) of long-acting insulin, compared with physicians who did not receive the payments. The association was also found for changes in these outcomes from 2016 to 2017. Limitations to our study include limited generalizability, confounding, and possible reverse causation. Conclusions Industry marketing payments to physicians for long-acting insulin were associated with the physicians’ prescriptions and costs of long-acting insulin in the subsequent year. Future research is needed to assess whether policy interventions on physician–industry financial relationships will help to ensure appropriate prescriptions and limit overall costs of this essential drug for diabetes care., Author summary Why was this study done? The financial relationships between physicians and pharmaceutical companies have received increased attention due to their potential to influence clinical decision-making. Although Medicare spending on insulin increased 840% over the last decade, empirical evidence about whether the physician–industry financial relationship contributes to physicians’ prescriptions and costs of long-acting insulin, the most commonly used and most costly type of insulin, is lacking. To address this knowledge gap, we aimed to investigate the association between physicians’ receipt of industry payments and their subsequent prescription of long-acting insulin in the United States. What did the researchers do and find? Among 145,587 physicians treating Medicare beneficiaries included in our study by linking databases of the Open Payments and the Medicare Part D, 51,851 physicians received industry payments for long-acting insulin worth $22.3 million. Using the propensity score–matched analysis adjusting for physician characteristics, we found that physicians who received the payments prescribed a higher number of claims, higher costs for total claims, and higher costs per claim of long-acting insulin, compared with physicians who did not receive the payments. The association was also found for changes in these outcomes from 2016 to 2017. Meals constituted 96% of the total number of industry payments for long-acting insulin, and we found the dose–response relationship between the number of meals received in 2016 and the utilization of long-acting insulin in 2017. What do these findings mean? Our findings indicate that industry marketing related to long-acting insulin, even those at relatively low dollar amounts such as meals, may influence physicians’ prescriptions of long-acting insulin in clinical practice. Future research is needed to investigate whether policy interventions on the financial relationships between physicians and industry are effective to ensure appropriate prescriptions and save overall costs of long-acting insulin.

On our 15th anniversary, the PLOS Medicine editors discuss progress in open access, medical publishing and the journal's mission over the years.

Background Schizophrenia is a leading cause of disability, and a shift from facility- to community-based care has been proposed to meet the resource challenges of mental healthcare in low- and middle-income countries. We hypothesized that the addition of mobile texting would improve schizophrenia care in a resource-poor community setting compared with a community-based free-medicine program alone. Methods and findings In this 2-arm randomized controlled trial, 278 community-dwelling villagers (patient participants) were randomly selected from people with schizophrenia from 9 townships of Hunan, China, and were randomized 1:1 into 2 groups. The program participants were recruited between May 1, 2015, and August 31, 2015, and the intervention and follow-up took place between December 15, 2015, and July 1, 2016. Baseline characteristics of the 2 groups were similar. The patients were on average 46 years of age, had 7 years of education, had a duration of schizophrenia of 18 years with minimal to mild symptoms and nearly one-fifth loss of functioning, and were mostly living with family (95%) and had low incomes. Both the intervention and the control groups received a nationwide community-based mental health program that provided free antipsychotic medications. The patient participants in the intervention group also received LEAN (Lay health supporters, E-platform, Award, and iNtegration), a program that featured recruitment of a lay health supporter and text messages for medication reminders, health education, monitoring of early signs of relapses, and facilitated linkage to primary healthcare. The primary outcome was medication adherence (proportion of dosages taken) assessed by 2 unannounced home-based pill counts 30 days apart at the 6-month endpoint. The secondary and other outcomes included patient symptoms, functioning, relapses, re-hospitalizations, death for any reason, wandering away without notifying anyone, violence against others, damaging goods, and suicide. Intent-to-treat analysis was used. Missing data were handled with multiple imputations. In total, 271 out of 278 patient participants were successfully followed up for outcome assessment. Medication adherence was 0.48 in the control group and 0.61 in the intervention group (adjusted mean difference [AMD] 0.12 [95% CI 0.03 to 0.22]; p = 0.013; effect size 0.38). Among secondary and other outcomes we noted substantial reduction in the risk of relapse (26 [21.7%] of 120 interventional participants versus 40 [34.2%] of 117 controls; relative risk 0.63 [95% CI 0.42 to 0.97]; number needed to treat [NNT] 8.0) and re-hospitalization (9 [7.3%] of 123 interventional participants versus 25 [20.5%] of 122 controls; relative risk 0.36 [95% CI 0.17 to 0.73]; NNT 7.6). The program showed no statistical difference in all other outcomes. During the course of the program, 2 participants in the intervention group and 1 in the control group died. The limitations of the study include its lack of a full economic analysis, lack of individual tailoring of the text messages, the relatively short 6-month follow-up, and the generalizability constraint of the Chinese context. Conclusions The addition of texting to patients and their lay health supporters in a resource-poor community setting was more effective than a free-medicine program alone in improving medication adherence and reducing relapses and re-hospitalizations. Future studies may test the effectiveness of customization of the texting to individual patients. Trial registration Chinese Clinical Trial Registry ChiCTR-ICR-15006053., Wenjie Gong and colleagues show that mobile messaging can increase medication adherence and reduce relapses in schizophrenia patients in rural China., Author summary Why was this study done? Schizophrenia is a leading cause of disability, but in low- and middle-income countries (LMICs) the treatment gap remains high, and even when treatment is available, adherence to antipsychotics is low. Mobile text messaging has been shown to be useful to strengthen community- and family-based care in resource-poor settings due to its availability, reliability, and ease of use. However, there has been no clear evidence that texting improves treatment adherence, symptoms, and functioning in people with schizophrenia. What did the researchers do and find? We developed an intervention called LEAN, involving the recruitment of lay health supporters; an electronic platform with mobile texting for medication reminders, health education, and monitoring; the awarding of token gifts for positive behavioral improvement, and integration of the texting with the health system. In this 2-arm randomized controlled trial, the control group received a free antipsychotic medication program (the 686 Program) while the intervention group received the 686 Program plus LEAN. We found significant improvement in medication adherence (0.48 in the control group versus 0.61 in the intervention group) and a substantial reduction in the risks of relapse and re-hospitalization with the intervention. What do these findings mean? LEAN demonstrated a 27% improvement in adherence, which is larger than the 15%–18% range reported in other text message interventions. Two unique features may have contributed to the relative superiority of LEAN: active engagement of lay health supporters and the use of texting to connect the entire treatment team from patients to lay health supporters to village doctors to psychiatrists, all in support of the patient. Texting effectively addressed the low adherence at marginal cost, and LEAN’s experiences may be useful for other LMICs with resource constraints. However, an adaptation of LEAN should fully consider some implementation details including keeping the program simple and integrated into routine care, maintaining low cost, and choosing existing texting platforms if available.

In this month's editorial, the PLOS Medicine Editors discuss the role of preprints in human health research and propose a 3-part framework for ensuring benefit.

In this month's editorial, PLOS Medicine's Chief Editor Larry Peiperl discusses the relevance of patient care to a journal editor's work.

Background In February 2011, an Ohio law took effect mandating use of the United States Food and Drug Administration (FDA)-approved protocol for mifepristone, which is used with misoprostol for medication abortion. Other state legislatures have passed or enacted similar laws requiring use of the FDA-approved protocol for medication abortion. The objective of this study is to examine the association of this legal change with medication abortion outcomes and utilization. Methods and Findings We used a retrospective cohort design, comparing outcomes of medication abortion patients in the prelaw period to those in the postlaw period. Sociodemographic and clinical chart data were abstracted from all medication abortion patients from 1 y prior to the law’s implementation (January 2010–January 2011) to 3 y post implementation (February 2011–October 2014) at four abortion-providing health care facilities in Ohio. Outcome data were analyzed for all women undergoing abortion at ≤49 d gestation during the study period. The main outcomes were as follows: need for additional intervention following medication abortion (such as aspiration, repeat misoprostol, and blood transfusion), frequency of continuing pregnancy, reports of side effects, and the proportion of abortions that were medication abortions (versus other abortion procedures). Among the 2,783 medication abortions ≤49 d gestation, 4.9% (95% CI: 3.7%–6.2%) in the prelaw and 14.3% (95% CI: 12.6%–16.0%) in the postlaw period required one or more additional interventions. Women obtaining a medication abortion in the postlaw period had three times the odds of requiring an additional intervention as women in the prelaw period (adjusted odds ratio [AOR] = 3.11, 95% CI: 2.27–4.27). In a mixed effects multivariable model that uses facility-months as the unit of analysis to account for lack of independence by site, we found that the law change was associated with a 9.4% (95% CI: 4.0%–18.4%) absolute increase in the rate of requiring an additional intervention. The most common subsequent intervention in both periods was an additional misoprostol dose and was most commonly administered to treat incomplete abortion. The percentage of women requiring two or more follow-up visits increased from 4.2% (95% CI: 3.0%–5.3%) in the prelaw period to 6.2% (95% CI: 5.5%–8.0%) in the postlaw period (p = 0.003). Continuing pregnancy was rare (0.3%). Overall, 12.6% of women reported at least one side effect during their medication abortion: 8.4% (95% CI: 6.8%–10.0%) in the prelaw period and 15.6% (95% CI: 13.8%–17.3%) in the postlaw period (p < 0.001). Medication abortions fell from 22% (95% CI: 20.8%–22.3%) of all abortions the year before the law went into effect (2010) to 5% (95% CI: 4.8%–5.6%) 3 y after (2014) (p < 0.001). The average patient charge increased from US$426 in 2010 to US$551 in 2014, representing a 16% increase after adjusting for inflation in medical prices. The primary limitation to the study is that it was a pre/post-observational study with no control group that was not exposed to the law. Conclusions Ohio law required use of a medication abortion protocol that is associated with a greater need for additional intervention, more visits, more side effects, and higher costs for women relative to the evidence-based protocol. There is no evidence that the change in law led to improved abortion outcomes. Indeed, our findings suggest the opposite. In March 2016, the FDA-protocol was updated, so Ohio providers may now legally provide current evidence-based protocols. However, this law is still in place and bans physicians from using mifepristone based on any new developments in clinical research as best practices continue to be updated., In this retrospective cohort study, Ushma Upadhyay and colleagues compare outcomes from medication abortions performed in Ohio before and after a law mandating use of the FDA-approved protocol., Author Summary Why Was This Study Done? An Ohio law went into effect in 2011 that required abortion providers to use a protocol for medication abortion that had been approved by the US Food and Drug Administration (FDA) in 2000. This protocol conflicted with the protocol supported by several international guidelines and used by most abortion providers throughout the US. The protocol approved by the FDA in 2000 required a higher, more expensive dose of oral mifepristone, a lower dose of oral misoprostol administered only at a provider’s office 48 h later, and limited use up to 49 d after a woman’s last menstrual period. This research was conducted to explore the abortion outcomes for women who received medication abortion before the 2011 law went into effect compared with outcomes after the law was in place. What Did the Researchers Do and Find? Using chart data from 2,783 women who obtained a medication abortion between 2010 and 2014 collected retrospectively from four clinics in Ohio, we examined the proportion of women who received an additional medical intervention to complete the abortion, the experience of side effects, and the rate of medication abortion versus aspiration abortion in Ohio. The data showed that women who had medication abortions in the postlaw period were three times as likely to need additional interventions to complete their abortion compared to women in the prelaw period. In addition, side effects such as nausea and vomiting were significantly more likely among women after the law change, and there was an 80% decline in medication abortion in Ohio between 2010 and 2014. What Do These Findings Mean? These results suggest that after the 2011 law was enacted, there was a greater need for additional intervention, as well as more visits, more side effects, and higher costs for women compared to before the law. Although the FDA updated the medication abortion protocol in March 2016 to match the evidence, this protocol may also become outdated in the future, and health providers in Ohio will be required to provide care based on legislation, rather than the most up-to-date research and evidence-based practice.

John Ioannidis argues that problem base, context placement, information gain, pragmatism, patient centeredness, value for money, feasibility, and transparency define useful clinical research. He suggests most clinical research is not useful and reform is overdue.

In this month’s editorial, the PLOS Medicine editors note recent progress towards data sharing as the community norm in medical research and the barriers that remain.

Writing from personal experience, physician and author Danielle Ofri asks what evidence is needed to justify trying to humanize medical training via the power of literature.

Aaron Kesselheim and colleagues compared US medical students' survey responses regarding pharmaceutical company interactions with the schools' AMSA PharmFree scorecard and Institute on Medicine as a Profession's (IMAP) scores. Please see later in the article for the Editors' Summary, Background Professional societies use metrics to evaluate medical schools' policies regarding interactions of students and faculty with the pharmaceutical and medical device industries. We compared these metrics and determined which US medical schools' industry interaction policies were associated with student behaviors. Methods and Findings Using survey responses from a national sample of 1,610 US medical students, we compared their reported industry interactions with their schools' American Medical Student Association (AMSA) PharmFree Scorecard and average Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database score. We used hierarchical logistic regression models to determine the association between policies and students' gift acceptance, interactions with marketing representatives, and perceived adequacy of faculty–industry separation. We adjusted for year in training, medical school size, and level of US National Institutes of Health (NIH) funding. We used LASSO regression models to identify specific policies associated with the outcomes. We found that IMAP and AMSA scores had similar median values (1.75 [interquartile range 1.50–2.00] versus 1.77 [1.50–2.18], adjusted to compare scores on the same scale). Scores on AMSA and IMAP shared policy dimensions were not closely correlated (gift policies, r = 0.28, 95% CI 0.11–0.44; marketing representative access policies, r = 0.51, 95% CI 0.36–0.63). Students from schools with the most stringent industry interaction policies were less likely to report receiving gifts (AMSA score, odds ratio [OR]: 0.37, 95% CI 0.19–0.72; IMAP score, OR 0.45, 95% CI 0.19–1.04) and less likely to interact with marketing representatives (AMSA score, OR 0.33, 95% CI 0.15–0.69; IMAP score, OR 0.37, 95% CI 0.14–0.95) than students from schools with the lowest ranked policy scores. The association became nonsignificant when fully adjusted for NIH funding level, whereas adjusting for year of education, size of school, and publicly versus privately funded school did not alter the association. Policies limiting gifts, meals, and speaking bureaus were associated with students reporting having not received gifts and having not interacted with marketing representatives. Policy dimensions reflecting the regulation of industry involvement in educational activities (e.g., continuing medical education, travel compensation, and scholarships) were associated with perceived separation between faculty and industry. The study is limited by potential for recall bias and the cross-sectional nature of the survey, as school curricula and industry interaction policies may have changed since the time of the survey administration and study analysis. Conclusions As medical schools review policies regulating medical students' industry interactions, limitations on receipt of gifts and meals and participation of faculty in speaking bureaus should be emphasized, and policy makers should pay greater attention to less research-intensive institutions. Please see later in the article for the Editors' Summary, Editors' Summary Background Making and selling prescription drugs and medical devices is big business. To promote their products, pharmaceutical and medical device companies build relationships with physicians by providing information on new drugs, by organizing educational meetings and sponsored events, and by giving gifts. Financial relationships begin early in physicians' careers, with companies providing textbooks and other gifts to first-year medical students. In medical school settings, manufacturers may help to inform trainees and physicians about developments in health care, but they also create the potential for harm to patients and health care systems. These interactions may, for example, reduce trainees' and trained physicians' skepticism about potentially misleading promotional claims and may encourage physicians to prescribe new medications, which are often more expensive than similar unbranded (generic) drugs and more likely to be recalled for safety reasons than older drugs. To address these and other concerns about the potential career-long effects of interactions between medical trainees and industry, many teaching hospitals and medical schools have introduced policies to limit such interactions. The development of these policies has been supported by expert professional groups and medical societies, some of which have created scales to evaluate the strength of the implemented industry interaction policies. Why Was This Study Done? The impact of policies designed to limit interactions between students and industry on student behavior is unclear, and it is not known which aspects of the policies are most predictive of student behavior. This information is needed to ensure that the policies are working and to identify ways to improve them. Here, the researchers investigate which medical school characteristics and which aspects of industry interaction policies are most predictive of students' reported behaviors and beliefs by comparing information collected in a national survey of US medical students with the strength of their schools' industry interaction policies measured on two scales—the American Medical Student Association (AMSA) PharmFree Scorecard and the Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database. What Did the Researchers Do and Find? The researchers compared information about reported gift acceptance, interactions with marketing representatives, and the perceived adequacy of faculty–industry separation collected from 1,610 medical students at 121 US medical schools with AMSA and IMAP scores for the schools evaluated a year earlier. Students at schools with the highest ranked interaction policies based on the AMSA score were 63% less likely to accept gifts as students at the lowest ranked schools. Students at the highest ranked schools based on the IMAP score were about half as likely to accept gifts as students at the lowest ranked schools, although this finding was not statistically significant (it could be a chance finding). Similarly, students at the highest ranked schools were 70% less likely to interact with sales representatives as students at the lowest ranked schools. These associations became statistically nonsignificant after controlling for the amount of research funding each school received from the US National Institutes of Health (NIH). Policies limiting gifts, meals, and being a part of speaking bureaus (where companies pay speakers to present information about the drugs for dinners and other events) were associated with students' reports of receiving no gifts and of non-interaction with sales representatives. Finally, policies regulating industry involvement in educational activities were associated with the perceived separation between faculty and industry, which was regarded as adequate by most of the students at schools with such policies. What Do These Findings Mean? These findings suggest that policies designed to limit industry interactions with medical students need to address multiple aspects of these interactions to achieve changes in the behavior and attitudes of trainees, but that policies limiting gifts, meals, and speaking bureaus may be particularly important. These findings also suggest that the level of NIH funding plays an important role in students' self-reported behaviors and their perceptions of industry, possibly because institutions with greater NIH funding have the resources needed to implement effective policies. The accuracy of these findings may be limited by recall bias (students may have reported their experiences inaccurately), and by the possibility that industry interaction policies may have changed in the year that elapsed between policy grading and the student survey. Nevertheless, these findings suggest that limitations on gifts should be emphasized when academic medical centers refine their policies on interactions between medical students and industry and that particular attention should be paid to the design and implementation of policies that regulate industry interactions in institutions with lower levels of NIH funding. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001743. The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice document, which describes what is required of all registered doctors in the UK Information about the American Medical Student Association (AMSA) Just Medicine campaign (formerly the PharmFree campaign) and about the AMSA Scorecard is available Information about the Institute on Medicine as a Profession (IMAP) and about its Conflicts of Interest Policy Database is also available “Understanding and Responding to Pharmaceutical Promotion: A Practical Guide” is a manual prepared by Health Action International and the World Health Organization that medical schools can use to train students how to recognize and respond to pharmaceutical promotion The US Institute of Medicine's report “Conflict of Interest in Medical Research, Education, and Practice” recommends steps to identify, limit, and manage conflicts of interest The ALOSA Foundation provides evidence-based, non-industry-funded education about treating common conditions and using prescription drugs

Over the past decade, several scholars have advocated for international standards in medical ethics and human rights [1–3]. Others have countered that such standards risk ignoring important cultural differences in the way people conceptualize medical decision-making [4–8]. Within this debate hangs a question for international bioethics: as developing countries build allopathic medical systems, what should their bioethics be? In this essay, we explore possible answers to this question, ultimately arguing that Western bioethics is insufficient to solve the problems that arise in the practice of allopathic medicine in non-Western contexts. As an example, we discuss recent conflicts over the use of mechanical ventilators in Thailand. Thailand is a center of cutting-edge allopathic medical care in Asia. It has a universal health-care system, which provides many Thais with access to mechanical ventilation. So many Thais are placed on mechanical ventilators at the end of life that it has become one of the largest drains on Thailand's universal health-care system [9]. Furthermore, the use of ventilators has become a source of vehement national debate, mostly as a result of several prominent political figures who received overly aggressive medical care at the end of life [10,11]. As in Western hospitals, the ascension of mechanical ventilation has introduced a host of difficult ethical dilemmas for doctors, families, and patients [12,13]. How will Thais go about solving these dilemmas? On which principles of bioethics will they rely? Most hospitals in Thailand have temples nearby where patients and families can grapple with the karmic landscape of illness and medicine To answer these questions, we start with a case that illustrates a common ethical dilemma about withdrawal of mechanical ventilation in Thai intensive care units. We then explore some concepts from Western bioethics to see if they help resolve this dilemma. Finally, we explain some of the local ethics behind the case and discuss the concept of a Thai bioethics to address the use of ventilators in Thailand.

Background to the Debate All of the major international medical journals are now available both in print and online. Being online increases the potential for these journals to have a more global distribution. With the rise of these online international journals, what functions do local journals serve?., All of the major international medical journals are now available both in print and online. With the rise of these online, international journals, what functions do local journals serve?

The humanistic principles of the medical profession are nicely condensed in Oliver Wendell Holmes's old maxim stating that the key role of the physician is “to comfort always.” Thus, beyond the specificity of diagnoses and the effectiveness of treatments, the traditional practice of medicine gave high importance to bedside manner and interpersonal issues. In contrast, 21st century medicine, with its reliance on technology and the changes in practice patterns (e.g., managed care), leaves little time for face-to-face interactions, gradually eroding the doctor–patient relationship. In this transition towards technological medicine, it would appear that we have switched from “comforting” our patients (where “to comfort” means “to give strength and hope; to ease the grief or trouble; to cheer” [1]) to simply “reassuring” them (where “to reassure” means “to assure anew; or restore to confidence” [1]). In this modern context, “reassurance” simply means to let patients know that their symptoms do not appear to be caused by physical disease. In primary care, the de facto mental health system [2], large numbers of patients with common mental disorders such as depression or anxiety present with medically unexplained physical symptoms (MUPS). These somatic presentations have been well documented throughout the years, have always baffled the medical establishment, and metamorphose with cultural evolution and the changing perspectives of medical paradigms [3]. In all their forms, patients presenting with MUPS are the bane of modern medicine. Not fitting anywhere, they land in the vortex of the centuries-old mind–body debate. In primary and specialty care nowadays, a number of “functional labels” [4] are a convenient though imprecise way to frame certain types of MUPS. These functional labels seem more acceptable to patients than receiving no diagnosis or having their symptoms attributed to a mental disorder, often viewed as a moral infirmity. MUPS add complexity to other physical or psychiatric disorders and lead to additional impairment and complications, so it is imperative that these presenting symptoms be properly addressed. Patients presenting with medically unexplained physical symptoms are the bane of modern medicine.

Background Nigeria has an estimated 3.6 million people with HIV/AIDS and is home to one out of every 11 people with HIV/AIDS worldwide. This study is the first population-based assessment of discrimination against people living with HIV/AIDS in the health sector of a country. The purpose of this study was to characterize the nature and extent of discriminatory practices and attitudes in the health sector and indicate possible contributing factors and intervention strategies. The study involved a cross-sectional survey of 1,021 Nigerian health-care professionals (including 324 physicians, 541 nurses, and 133 midwives identified by profession) in 111 health-care facilities in four Nigerian states. Methods and Findings Fifty-four percent of the health-care professionals (550/1,021) were sampled from public tertiary care facilities. Nine percent of professionals reported refusing to care for an HIV/AIDS patient, and 9% indicated that they had refused an HIV/AIDS patient admission to a hospital. Fifty-nine percent agreed that people with HIV/AIDS should be on a separate ward, and 40% believed a person's HIV status could be determined by his or her appearance. Ninety-one percent agreed that staff and health-care professionals should be informed when a patient is HIV-positive so they can protect themselves. Forty percent believed that health-care professionals with HIV/AIDS should not be allowed to work in any area of health-care that requires patient contact. Twenty percent agreed that many with HIV/AIDS behaved immorally and deserve the disease. Basic materials needed for treatment and prevention of HIV were not adequately available. Twelve percent agreed that treatment of opportunistic infections in HIV/AIDS patients wastes resources, and 8% indicated that treating someone with HIV/AIDS is a waste of precious resources. Providers who reported working in facilities that did not always practice universal precautions were more likely to favor restrictive policies toward people with HIV/AIDS. Providers who reported less adequate training in HIV treatment and ethics were also more likely to report negative attitudes toward patients with HIV/AIDS. There was no consistent pattern of differences in negative attitudes and practices across the different health specialties surveyed. Conclusion While most health-care professionals surveyed reported being in compliance with their ethical obligations despite the lack of resources, discriminatory behavior and attitudes toward patients with HIV/AIDS exist among a significant proportion of health-care professionals in the surveyed states. Inadequate education about HIV/AIDS and a lack of protective and treatment materials appear to contribute to these practices and attitudes., Results of a survey of attitudes and actions of over 1000 Nigerian health care professionals (doctors, nurses, and midwives).

Al-Ubaydli shares some useful tips for making the most of search engines.

Meeting the challenge of providing health care for a multicultural population is now a major movement that is impacting health care worldwide.