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A bioethicist argues that two journal articles about quality of life-adjusted years research oversimplifies the issue and do not take into consideration people's abilities to adapt to disability and disease. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Nooneneedsa reminderof the cost to taxpayers andconsumers forhealth careeachyear, bothhere in theUnitedStates and abroad.Legislators and taxpayers arealso concernedabout the returnon investment inhealth care research, andwhether this investment is furtheringorevenhindering theeffort toachieve 3objectives that are frequently in conflictwith eachother: improving quality, access, and cost-effectiveness. Muchevidencehasaccumulatedover the last coupleofdecades that the timebetweenaccumulationof evidence that an intervention or therapy does or does not work and its incorporation or removal from practice is measured in years if not decades. Simply implementing what we knowworks and desisting from what we know does not would have an enormous impact on health and health care. Investigators, clinicians, administrators, andgovernment agencies have learned that the translationofevidencetopolicyandpractice is far from simple and never assured. A new field of inquiry, implementation science, has developed that recognizes and addresses the multitude of gaps that impede evidence-based interventions fromproducingoptimal health outcomes. These knowledge and practice gaps include: • “Research-to-program”gaps,whichexistwhen researchevidence is not adequately or appropriately considered and integrated in the development of health outcomes. • “Research-to-policy” gaps, which exist when research evidence is not adequately or appropriately considered and integrated in the development of health policy. Implementation science is the study ofmethods to promote the integrationof research findingsandevidence intohealth care policy and practice. It seeks to understand the behavior of health careprofessionals andother stakeholders as a keyvariable in the sustainable uptake, adoption, and implementation of evidence-based practice. It also examines system issues for barriers to implementation and new methods to overcome these. A newer component of this science is starting to focusondeimplementation, thediscontinuanceof things proven not to be effective or safe. JAMAPediatricswill devote an entire issue in spring 2015 to implementation science research in childhealth, both in the United States and abroad, in high-resource aswell as lowand middle-resource countries.Aspediatric carebecomes increasingly focusedonchildren, adolescents, andyoungadultswith chronic illness, who account for the largest part of our health care expenditures, our hospital beds, and our specialty care, implementation research for these children and adolescents is of particular interest. Research on how to implement evidence-based practice is needed at all levels of care: the intensivecareunit, theemergencydepartment, thewards, theclinic, the home, and sites in the community including schools and neighborhoods. Implementationcanbe inall forms: frompractice to policy. We are interested in rigorous studies that test hypotheses about methods to close these gaps, to translate research in those stepsbetweenefficacy trials andpopulationhealth.This will include randomized clinical trials including cluster randomizedclinical trials,adaptiveresearchdesigns,carefullyconducted time series analyses, longitudinal studies, interrupted time series, andqualitative research.Weare interested aswell in cost-effectiveness analyses and systematic reviews on themost effective strategies to changeprofessional behavior; create informed, activated consumers; and guide the behavior of administrators and health care organizations and policy makers. Manuscripts submitted before October 2014 will have the bestchanceofacceptance.Fulldetailsonsubmissionandauthor guidelines are available at http://archpedi.jamanetwork.com.

To coincide with the American Diabetes Association Scientific Sessions in June 2014, JAMA will publish a theme issue on diabetes research. Our goals are to inform readers about the latest research in both type 1 and type 2 diabetes and to provide useful reviews of the current state of basic and clinical science underlying diabetes treatments. The World Health Organization estimates that 350 million people worldwide have diabetes.1 The international obesity epidemic has certainly accelerated the need to better understand the epidemiology, identification, and treatment of diabetes. We invitemanuscripts that address the identification and management of this complex chronic disease. We are especially interested in clinical trials of prevention, treatment, and delivery of care for people with diabetes. Care requirements and treatment goals for diabetes vary by age, and we welcome studies of patient populations of any and all ages, from children to the elderly. We recognize that diabetes is a global health problem, and we encourage submission of manuscripts that address aspects of diabetes thatmay be unique to a specific regional population, such as Asia or Africa. For example, a recent study indicated that approximately 114 million individuals in China have type 2 diabetes and an additional 493 million have prediabetes.2 A recent meta-analysis estimated a 5.7% prevalence rate of diabetes associated with impaired glucose tolerance among adults in sub-Saharan Africa.3 Bothof these studieshighlight theburdenofnoncommunicable diseases, especially diabetes, which is among the most common,withmore than 80%of the 3.4million annual deaths from diabetes occurring in lowand middle-income countries.4 We encourage authors to submit reports of original research, review articles, and Viewpoints for consideration for this theme issue. We are particularly interested in reports of randomized clinical trials that represent advances in the treatment of diabetes and interventions aimed at prevention. Authors who are interested in submitting a manuscript for the diabetes theme issue should indicate this in the cover letter accompanying their manuscript submission. Manuscripts received before January 15, 2014, will have the best chance of consideration for the theme issue. Exceptions may be granted for late-breaking randomized clinical trials to be presented at the American Diabetes Association Scientific Sessions. In these cases, we recommend that authors contact us as early as possible to discuss the trial and to allow coordination of timing of publication with the scientific presentation. We also welcome questions about this theme issue. Authors should consult the JAMA Instructions for Authors for guidelines on manuscript preparation and submission.5 Highquality manuscripts submitted to JAMA that are not of sufficiently high priority for publication in JAMA may be referred to another journal in The JAMA Network. We look forward to receivingyourmanuscripts for the2014 diabetes theme issue of JAMA.

To the Editor: —Since the publication of my article entitled "A Delicate Test for Bile in the Gastric Contents," inThe Journal, May 20, 1909, p. 1758, my attention has been called to Rosenbach's test for bile in the urine. This consists in filtering the urine several times through the same filter paper and applying nitrous acid to the filter paper after drying, to obtain the reaction for bile. I have never used the Rosenbach test for bile in the urine, but, working entirely independently of that method or other methods, I have found that the filter paper test for bile in gastric contents as described by me, will detect the presence of bile, when no reaction for bile will be obtained when nitrous acid is applied to the filtered gastric contents themselves.

St. Louis, Mo., May 15, 1897. To the Editor: — I herewith send you a few crumbs in answer to your call for a discussion of the paper on which theJournalshould be printed, because I am convinced that it will be calculated to do good service by directing attention to very important questions, which must be of great practical interest to the human race both in this and future generations. The question of the size and form of printing type, and the color of the material for background, is not only of great importance to the comfort of adults, but it is of far greater importance to children and those who quite naturally look to the typographical and mechanical features of theJournalfor a model. What constitutes readable print? The most readable print is that by which one may obtain the maximum of reading, with the minimum

To the Editor By an error, "ethyl acetate" appears in place of the correct name, "ethyl aceto-acetate" in my paper on "The Acidosis Index," which appeared inThe Archives of Internal Medicine(March, 1911, p. 369). This unfortunate mistake, which escaped my attention both in the typewritten manuscript and in the proofs, invalidates the whole paper. The sentence should read as follows: The "standard solution" consists of ethyl aceto-acetate, 1 c.c.; alcohol 25 c.c.; and distilled water to 1,000 c.c.

To the Editor: In theAmerican Journal of Diseases of Children, June, 1911, I published, with Zeiler, a report of two cases of influenzal meningitis. We stated that Wollstein in her paper on the same subject ( Am. Jour. Dis. Children , January, 1911) had failed to include one of her own cases in her summary of the literature. Dr. Wollstein in a recent conversation with me pointed out that she had included the case under the names of Agar and Avery, who had previously made a report of it, as she stated elsewhere in her paper. I regret very much that the oversight on my part occurred, and shall be obliged if you will publish this correction.

South Bethlehem, Pa., Dec. 18, 1895. To the Editor: —As Secretary of the Surgical Section of theAssociation, I am now engaged in arranging a program for the Atlanta meeting. We have selected " The Surgery of the Cerebro-spinal Axis and its Bony Encasement," as the special subject for discussion. I am anxious to obtain as full and as representative a discussion on this important subject as practicable. Will you permit me through theJournalto call the attention of our surgical members to this subject, and to request from them a liberal contribution of papers, and careful preparation for discussing the subject. Besides this special subject there will be room on the program for papers on other subjects. I solicit the active assistance and contribution of the members. Members who desire to contribute papers to the Surgical Section will please notify me and send the title of their papers to

To the Editor: —At the April meeting of the National Academy of Sciences, Dr. I. S. Kleiner and I presented a communication entitled "Retention in the Circulation of Dextrose in Normal and Depancreatized Animals, and the Effect of an Intravenous Injection of an Emulsion of Pancreas upon This Retention." This paper was published in the June issue of the Proceedings of the National Academy of Sciences , a publication which has only a small circulation. A few weeks ago we were surprised to find an article in the New York American stating that we have discovered the cause of diabetes and a cure for it. A day later a writer on foods published in an evening paper (in quotation marks) a statement, purporting to have been made by us: Glucose in its natural form may be detrimental, but when manufactured is often fatal. That article contains many other nonsensical remarks. I

San Jose, Cal., July 8, 1897. To the Editor: —Since I penned a few thoughts in the April 24 issue of theJournal, on the subject of glossy paper for periodical and bookmaking purposes, I have been thinking more on the subject, and the more I think the more I am convinced that the matter needs thorough agitation all round. If one will call to mind the large number of periodicals and books now printed on paper of high glossy finish he will conclude that this style of paper is becoming a " fad." A journal published in St. Louis entitled The American Medical Journalist , notices my former article and makes the following comments: "Dr. Simonton of San Jose, Cal., objects to the high finish of the paper upon which theJournal of the American Medical Associationis being printed, and claims that the 'gloss,' as he terms it, is injurious

Paper caps in place of linen caps for surgeons are becoming very popular for a number of reasons. They are cheap, costing less than the laundering and depreciation of linen caps, are cool and light, are automatically adjustable and are free from lint. While there are probably several types of paper hats on the market, the one which has an elastic crape paper insertion in the back is the one to be recommended because it adheres firmly to the head, preventing the dropping of dust on the wound. This hat is made over a block the shape of the head by pasting a paper band of glacine paper to a crown piece composed of any type of paper. In the back of the paper band is an elastic insert composed of crape paper which permits the hat to be stretched sufficiently to conform to heads of any size. A piece

San Jose, Cal., April 20, 1897. To the Editor: —It is not often that one will complain of receiving something that is too good, but I do wish to thus complain at present. While the matter and make up, generally, of theJournal of the Associationhave improved to a high point of excellence, the paper-maker has been endeavoring not to be left in the rear; and he has brought up the excellence of the paper on which theJournalis printed to a degree of perfection altogether too high to be acceptable to many readers of theJournal. As sanitarians and hygienists we ought to practice what we preach. There is not a medical man who will not say at once, when his attention is called to it, that printed matter intended to be read by human eyes—and it is mostly thus intended— should not be impressed on paper

Recent work on the basal metabolism of infants and adults has revived interest in Rubner's law that heat production in different individuals and species of animals is proportional to the surface area. This law was first definitely formulated by Rubner 1 in 1883, although suggested by Bergman 2 many years before. At the time the experimental work in support of this theory was done no record was kept of body movements and men and animals were allowed to move during the periods of investigation. The average heat production per square meter of body surface was about 1,000 calories per day. In modern work, where the influence of muscular activity is absolutely excluded, the figure is in the neighborhood of 830 calories per square meter per day, as has been shown in Paper 4 of this series. With these new figures it is not unnatural that many

METHODS FOR DETECTING HEATED MILK Numerous methods have been proposed to test quickly and simply whether or not a given sample of milk has been heated. The methods suggested fall into three main groups: Those based on the changes which the protein undergoes when milk is heated. These have not proved applicable in practice. Those which depend on the presence of oxidizing enzymes in milk. Of these, Storch's test is generally regarded as most satisfactory. This, however, as is well known, can be used only on milk heated from 78 to 80 C. (172.4 to 176 F.). It cannot, therefore, be applied to milk heated to the temperatures employed for pasteurization in this country. A microscopic test devised by myself and described in a paper by Frost and Ravenel in 1911 (A Microscopic Test for Heated Milk, Proc. Am. Assn. Med. Milk Commissions, May, 1911, p. 127). Two features of

The title of this paper may seem rather an ambitious one, since the study of vital and social statistics, and their application to the comparative study of races and nations, is almost too new to furnish many principles that may serve as bases of induction. However, I purpose to state in a fragmentary way a few notes and observations bearing on the subject. More than usual experience as a traveller has brought me in contact with various races of men under different mesological conditions. Experience and observation in this line show that, in spite of physical and moral varieties, there exists practically, for the physician, but one people, since there are no wide differences, biologically or medically speaking, in the human species; and the infirmities of men, notwithstanding their physical inequalities and the extensive range of the nosological table, are much the same the world over, no matter whether they

Ridgway, Pa., Sept. 20, 1902. To the Editor: —This last summer I drafted and presented to the official board of the First M. E. Church of this place, being a member of the board, a set of resolutions, drawing attention to the falseness of statements and dishonesty of purpose of various advertisers of "patent" medicines, and condemning the publication of such advertisements by the publishers of our church periodicals. The resolutions were passed, but two members of the official board voting against them. I took the ground that it was detrimental to the interests of the church that the papers should receive a profit from so false a business. Copies of the resolutions were sent to the various church publications circulating in this district. If necessary this move can be followed up to the annual and general conferences.

Mr. President and Gentlemen of the Association of Medical Colleges:—The paper of Dr. Vaughan, which has interested us so much, suggests great changes in medical education. During the past year my attention has been called to some of the details of laboratory work which must be faced by every one of you. Allow me to very briefly speak of some of the results of my thoughts and studies.Laboratory rooms must be light and roomy. Forty square feet of floor is the least amount which will accommodate a single student, and then only in the chemical laboratory. In all other laboratories at least sixty square feet of floor space, not including aisles, must be allowed each student. In the chemical laboratory students' desks may be placed twenty feet from the windows; in laboratories in which microscopes are to be used, fourteen feet is a maximum.The ordinary medical class in

In the course of other work on metabolism in typhoid fever it became advisable to analyze the feces of the patients. While these analyses constitute only a part of the problem in hand, the paucity of studies on the absorption of food in the febrile state appears to warrant publication of the results as a separate communication. For a complete discussion of the absorption of food in typhoid fever the reader is referred to the paper of Du Bois. 1 Seven cases in all have been studied. The diets administered were modifications of the high calory diet employed in this clinic, that is, the proportions of fat and carbohydrate were varied to satisfy the requirements of the problem under investigation. METHODS OF CHEMICAL ANALYSIS Urine and feces were collected in the manner described by Gephart and Du Bois. 2 The analysis consisted in the determination of fat and

CONTENTS Previous investigations. 2. Methods used. 3. Case histories. 4. Experimental data. 5. Discussion of results. A. The law of the conservation of energy in fever. B. The basal metabolism in typhoid fever. C. The specific dynamic action of food in typhoid fever. D. The relationship of heat production and heat elimination. E. A comparison of caloric intake and caloric output. F. Summary and conclusions. PREVIOUS INVESTIGATIONS In a previous communication 1 the respiratory metabolism of typhoid patients as determined by means of the small Benedict respiration apparatus was discussed in detail. The literature of the subject was also reviewed, making repetition here unnecessary. Following this earlier work it was possible to continue the study of the typhoid patients by using the respiration calorimeter of the Russell Sage Institute of Pathology in Bellevue Hospital. In the immediately preceding papers of the series 2 the calorimeter and

In presenting the subject of non-absorbent gauze for your consideration I am not offering a new topic for discussion; non-absorbent gauze takes its origin contemporaneously with the antiseptic dressings of Lister. Lister's 1 earlier dressings were distinctly non-absorbent; the manner of their production secured it, for muslin was soaked in a heated mixture of paraffin 16 parts, resin 4 parts and carbolic acid crystal 1 part; while still warm the excess of the compound was wrung out. Lister 2 shortly thereafter even suggested an 8 per cent. carbolic gauze made in the same manner. The paraffin counteracted the adhesiveness of the resin, and together they precluded a capillarity in gauzes thus treated. The faults of this carbolized gauze were early recognized and were its non-absorbence and its tendency to cake into a solid mass. In turn, Lister 2 experimented with corrosive sublimate and cyanid of mercury; the former, he found, combined

HISTORICAL A respiration calorimeter is an apparatus designed for the measurement of the gaseous exchange between a living organism and the atmosphere which surrounds it, and the simultaneous measurement of the quantity of heat produced by that organism. The first contrivance of this nature was described by Lavoisier in 1780. It will be remembered that Lavoisier was the first to comprehend the significance of the then newly discovered oxygen. Primitive though the apparatus, yet intellectually inspiring was the mind which so early grasped the principles and understood many of the difficulties. Apparatus for the measurement of the respiratory exchange was perfected before that for the measurement of heat production. Thus, Regnault and Rieset 1 in 1850 designed an air-tight apparatus in which an animal was placed; the carbonic acid formed in it was removed by pumping the air into flasks filled with potash, and oxygen was added

CONTENTS Previous descriptions of calorimeters. The calorimeter room. The wooden frame. The copper walls and the insulating wall. The absorber table, spirometer and heat absorbing system. Rheostat board and observer's table. Electric thermometers. Telephone, fan and bed. Electric and alcohol control experiments. Limits of error in measuring heat, carbon dioxid and oxygen. Determination of water elimination. Adaptability of calorimeter to varying conditions. Summary and conclusions. During the short time in which the Sage calorimeter has been in operation there have been several requests for the technical details of the construction of the apparatus. It has therefore seemed advisable to publish a brief article for those interested in calorimeters. A complete description of the Atwater-Rosa-Benedict type of apparatus will be found in the monograph by Benedict and Carpenter. 1 A number of valuable improvements are

Mr. President and Fellow-members of the Ohio State Medical Society: The subject of fever—in its general aspect—has been deemed worthy of so much labor and study on the part of the physiologist, the pathologist and the clinician, and is of such practical import to all who practice our art in any of its branches, that no apology is necessary, I trust, for bringing one of its numerous phases before this society for consideration. Looking at its most constant and evident symptom—the pyrexia—the physiologist points out, and the pathologist, and clinician confirm the probable •existence of heat-producing, heat controlling and heat dissipating areas, situated in the central nervous system, and influencing by their abnormal action the production of this particular symptom. That the pyrexia, however, does not constitute the disease is quite evident, since, it may be absent, controlled or even eliminated, and yet the patient be far from well. While

Chronic catarrhal laryngitis is a continuous passive inflammation of the laryngeal mucous membrane. Its etiology is multifarious. The most influential causes are nasal stenosis, liquor drinking, tobacco smoking, vitiated air, and an intemperate use of the vocal organs. Nasal stenosis necessitates mouth breathing—an abnormal respiration, by which we have carried into the laryngeal cavity an air pregnant with dust, that soon begets an inflammatory process. Chronic alcoholism produces an abnormal activity of the mucous glands of the mouth and fauces, which, during sleep, drops depraved excretions into the larynx, thereby producing a permanent inflammation. Tobacco smoking causes to be deposited daily in the air passages the liquid alkaloid nicotina, which produces partial paralysis of the vasomotor nerves of this locality, and a resultant permanent injury to the mucous texture. Vitiated air, in illy ventilated apartments, is one of the commonest causes of chronic laryngitis. Air reeking with noxious vapors poisons

[Your attention is invited to a subject which from the humanitarian standpoint is of the greatest importance and of practical value to us as surgeons. Much of the effort of our profession is directed toward the relief or prevention of pain. Distinct advances in our art followed the introduction of the various narcotics, and the science of surgery took a long step forward when the use of sulphuric ether for anesthesia was discovered Sept. 30, 1846, by Dr. Wm. T. G. Morton, of Wellesley, Mass., and chloroform by Sir James Simpson, of Edinburgh, on Nov. 4, 1847; and these names will ever live in our memory. But the great boon of narcosis is not unalloyed. Thousands have died from the effects of the volatile anesthetics, and every time we administer them we take upon ourselves the responsibility of a human life. Ether kills once in 15,000 administrations; chloroform once in

In a spirit that cannot be too highly commended, Dr. E. S. Kilgore has submitted to me the first draft of his manuscript together with a letter stating that "it would be decidedly to the advantage of the truth-seeking medical public if, after reading my manuscript, you would present your criticism in the form of an article to appear in the same journal number. . . . If you will do this I should like to have the privilege of reading your manuscript and, if indicated, altering my own, and we would then exchange manuscripts again until there were no further changes to make." Convinced by my experience as well as that of others, with the graphic oscillatory method of determining the blood pressure; by the satisfactory check to which it has been subjected by the experiments on animals, performed by myself and others, and by observations made both by

The subject of fibroid tumor of the uterus is too broad to be considered in all its aspects, in the time allotted, before this Society. I have therefore thought it advisable to speak of but two phases of the subject: 1, what cases require operation; 2, methods of operating. Clinical experience demonstrates that only a small percentage of those suffering from fibroids require operative interference for relief. This is so well known that the profession at large have come to regard them as purely innocent growths. This is true in the majority of cases. My experience, based upon more than two hundred carefully recorded cases, justifies me in saying that the majority of women from thirty-six to forty-five years of age suffering from fibroid tumors, do not require operative interference; but this fact increases our responsibility in determining early the cases really requiring operation. A great many women who are

All investigators who have attempted to carry on metabolism experiments in hospitals have experienced more or less difficulty in the administration of the diets and the collection of the excreta. The necessity for a special metabolism ward became evident as soon as it was decided to build a respiration calorimeter in Bellevue Hospital. Through the generosity of the trustees of the hospital and the attending staff of the Second Medical Division a small ward holding four or five beds was placed in charge of the medical director of the Russell Sage Institute of Pathology, 1 who was also one of the junior members of the attending staff of the hospital. He is directly responsible to the attending physician for the welfare of the patients, and there has always been a spirit of active cooperation between the small metabolism ward and the large medical wards of the service The

TABLE OF CONTENTS Introduction. Review of literature on basal metabolism. Review of literature on specific dynamic action of foods. Experimental procedure. Description of subjects and details of experiments. Tables of experimental data. Discussion of results: Introduction. Comparison of direct and indirect calorimetry. Comparison of surface and rectal temperature. Selection of the average normal standard. Variations from this standard found in normal individuals. Calories per square meter versus calories per kilogram. Increased metabolism following the ingestion of protein and carbohydrate. Summary and conclusions. The importance of the normal control has been emphasized so strongly by the serologists and the management of the control has been developed by them to such an art that it has seemed advisable to apply some of their methods of critique to the study of the respiratory metabolism. Serologists insist that

During the past twelve years the writer has embraced every opportunity to test various means for the purpose of devising some method of treating these injuries successfully, without resort to operations. A very large proportion of females suffering from these afflictions have neither the means nor the opportunity of seeking the aid of the specialist. The writer believes that he has perfected a simple method which can be used by all practitioners of intelligence for the treatment of these cases successfully with time and care without the necessity of operation. The agents resorted to in this method are entirely of a local character. Concealed fissures are often found after labor in the mucous membrane of the cervical canal, and are the cause of an infinite amount of local disease in the form of endocervicitis, hypertrophy of the adjacent tissues, inflammation of the submucous fibrous tissue, leucorrhœa, and often painful menstruation.

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To test the efficacy of adhesive paper tape in the closure of clean-contaminated wounds following elective colorectal resection.A prospective, nonrandomized controlled study.A medical center that offers a mixture of primary, secondary, and tertiary care services.The group undergoing skin closure with paper tape (PT group) consisted of 150 patients. The group undergoing skin closure with interrupted suture (IS group) also comprised 150 patients. All 300 patients underwent elective colorectal resection in 1997.The duration of skin closure, wound complication rate, and cosmetic appearance of the scar at 6 months after operation were compared using the chi(2)test or t test.The mean +/- SD average duration of skin closure was 116 +/- 23 seconds for the PT group and 457 +/- 64 seconds for the IS group (P.01). The wound complication rate was 3.3% (3 cases with wound infection; 2 with wound separation) for the PT group and 3.3% (5 cases with wound infection) for the IS group (P = 1.0). No significant differences were found between the narrowest width (mean +/- SD, 2.2 +/- 0.9 mm vs 2.3 +/- 1.0 mm) and widest width (mean +/- SD, 4.7 +/- 2.0 mm vs 4.3 +/- 1.8 mm) of scar formation between the 2 groups at 6 months after the operation. Ninety-eight percent of patients in the PT group reported satisfaction with their scar, compared with 92% in the IS group (P =.03).Compared with the traditional suture method, paper tape closure in the treatment of clean-contaminated wounds was less time consuming and produced greater patient satisfaction with no increased rate of wound complications.

Human exposure to bisphenol A (BPA) has been associated with adverse health outcomes, including reproductive function in adults1 and neurodevelopment in children exposed perinatally.2 Exposure to BPA is primarily through dietary ingestion, including consumption of canned foods.3 A less-studied source of exposure is thermal receipt paper,4 handled daily by many people at supermarkets, ATM machines, gas stations, and other settings. We hypothesized that handling of thermal receipts significantly increases BPA exposure, but use of gloves during handling minimizes exposure.

Context.—Review articles are important sources of information to help guide decisions by clinicians, patients, and other decision makers. Ideally, reviews should include strategies to minimize bias and to maximize precision and be reported so explicitly that any interested reader would be able to replicate them.Objective.—To compare the methodological and reporting aspects of systematic reviews and meta-analyses published by the Cochrane Collaboration with those published in paper-based journals indexed in MEDLINE.Data Sources.—The Cochrane Library, issue 2 of 1995, and a search of MEDLINE restricted to 1995.Study Selection.—All 36 completed reviews published in the Cochrane Database of Systematic Reviews and a randomly selected sample of 39 meta-analyses or systematic reviews published in journals indexed by MEDLINE in 1995.Data Extraction.—Number of authors, trials, and patients; trial sources; inclusion and exclusion criteria; language restrictions; primary outcome; trial quality assessment; heterogeneity testing; and effect estimates. Updating by 1997 was evaluated.Results.—Reviews found in MEDLINE included more authors (median, 3 vs 2; P

Purpose Macular schisis or detachment is frequently observed in eyes with optic pits or colobomas. Although spontaneous resolution of the maculopathy has been reported, concurrent changes in the optic nerve coloboma have not. We report three cases of atypical optic nerve colobomas in which dynamic optic nerve changes coincide with the development and subsequent resolution of the associated maculopathy. Methods We reviewed the records of three patients with dynamic optic nerve changes associated with maculopathy. All patients were observed for at least 6 months. Fundus photography and fluorescein angiography were used to document the optic nerve and macular changes. Results Three patients were noted to have macular detachments without apparent optic nerve excavation. With observation, the maculopathy spontaneously resolved in each case. We documented concurrent optic nerve changes whereby atypical optic nerve colobomas became apparent over several months in all cases. In one case, we noted the simultaneous development of maculopathy in association with obscuration of a prior disc anomaly. None of the eyes had a posterior vitreous detachment. We could not identify any associated systemic conditions or reproduce the findings with external stimulation. Initial Snellen acuity ranged from 20/60 to 20/200. Final Snellen acuity ranged from 20/20 to 20/40. Conclusions Fluctuating optic nerve changes may occur in the setting of atypical optic nerve coloboma and associated maculopathy. In cases of macular schisis or detachment where an optic nerve coloboma is not readily apparent, and no other causes are identified, consideration of a period of observation prior to therapeutic intervention seems appropriate.

THE PROPER use of adrenal corticosteroids and corticotropin in ocular diseases has been clarified gradually, so that ophthalmologists have become aware of many of the limitations inherent in this type of therapy. The purpose of this paper is to present information obtained from the treatment of a large series with a view to establishing a therapeutic regimen in certain types of ocular lesions. A number of the ocular complications we have encountered seem to have resulted from overtreatment or from an untoward response to steroid therapy. Therefore it is deemed advisable to emphasize the nature of some lesions and to discuss the undesirable effects resulting from the injudicious use of such therapy in specific types of disease. A brief description of the characteristics of each of the hormones commonly used in ophthalmology will be given, together with a discussion of their correct and incorrect therapeutic use. ADRENAL CORTICOSTEROIDS Cortisone (Compound

PRIMARY chorioretinal aberrations with night blindness was the subject of a symposium 1 at the 1949 meeting of the American Academy of Ophthalmology and Otolaryngology. The first abnormality considered in that symposium, and the subject of this paper, was characterized by one of us (F. D. C.) as night blindness present at birth, stationary, occurring in an approximately equal number of males and females, and with no associated abnormalities. Bell 2 collected 19 pedigrees of this disease. 3 A few sporadic cases have probably been encountered in the examination of candidates for the air force in this country 4 and in Canada, 5 and Langdon, 6 in 1915, reported the cases of a father and daughter in Philadelphia who had a reduced light sense and normal fundi. Except for Langdon's observation, however, we believe that the following report is the first to record a family affected typically with this abnormality

In 1887, Majocchi for the first time observed, and in 1896 for the first time published, a report of a hitherto undescribed dermatosis, "purpura annularis teleangiectodes," and enlarged on it, in 1898, in the Archiv fur Dermatologie und Syphilis , as a contribution to the Festschrift for Pick. In a memoir to the Royal Academy of Sciences of Bologna, in 1904, he collected reports of his cases, seven in all, and published them in book form in honor of Pick's anniversary. In 1912, at the International Congress of Dermatology and Syphilis at Rome, he reported a further series of six cases, 1 so that the first observer of this unrecorded skin malady had a collection of thirteen cases to report within a period of twenty-five years. This rather small number evidences the comparative rarity of the disease. It was fully eight years before another observer, Brandweiner, published an exhaustive paper based

Objective. —To develop a new method to improve the detection and characterization of adverse drug events (ADEs) in hospital patients. Design. —Prospective study of all patients admitted to our hospital over an 18-month period. Setting. —LDS Hospital, Salt Lake City, Utah, a 520-bed tertiary care center affiliated with the University of Utah School of Medicine, Salt Lake City. Patients. —We developed a computerized ADE monitor, and computer programs were written using an integrated hospital information system to allow for multiple source detection of potential ADEs occurring in hospital patients. Signals of potential ADEs, both voluntary and automated, included sudden medication stop orders, antidote ordering, and certain abnormal laboratory values. Each day, a list of all potential ADEs from these sources was generated, and a pharmacist reviewed the medical records of all patients with possible ADEs for accuracy and causality. Verified ADEs were characterized as mild, moderate, or severe and as type A (dose-dependent or predictable) or type B (idiosyncratic or allergic) reactions, and causality was further measured using a standardized scoring method. Outcome Measure. —The number and characterization of ADEs detected. Results. —Over 18 months, we monitored 36 653 hospitalized patients. There were 731 verified ADEs identified in 648 patients, 701 ADEs were characterized as moderate or severe, and 664 were classified as type A reactions. During this same period, only nine ADEs were identified using traditional detection methods. Physicians, pharmacists, and nurses voluntarily reported 92 of the 731 ADEs detected using this automated system. The other 631 ADEs were detected from automated signals, the most common of which were diphenhydramine hydrochloride and naloxone hydrochloride use, high serum drug levels, leukopenia, and the use of phytonadione and antidiarrheals. The most common symptoms and signs were pruritus, nausea and/or vomiting, rash, and confusion-lethargy. The most common drug classes involved were analgesics, anti-infectives, and cardiovascular agents. Conclusion. —We believe that screening for ADEs with a computerized hospital information system offers a potential method for improving the detection and characterization of these events in hospital patients. ( JAMA . 1991;266:2847-2851)

THE VALUE of individualized preanesthetic medication to produce effective sedation and analgesia for eye surgery is well recognized. This is particularly true of intraocular surgery done with local anesthesia. It is difficult to exaggerate the importance of good anesthesia and akinesia, and to obtain them careful attention to the details of the preanesthetic preparation of the patient is essential. Although the need for this is well known, many surgeons fail to give it the attention it deserves. Thus many operations are made more hazardous and eyes are needlessly damaged. With the improved anesthesia and operative technique now generally practiced. it becomes increasingly difficult to decrease appreciably the number of mishaps in operations, such as those for cataract extraction. However, any measure that will improve our percentage of good results by even a fraction of 1% seems worthy of consideration. Hartmann 1 has recently emphasized the importance of careful psychologic preparation

ALTHOUGH congenital absence of tears is a rare defect, its existence has been known since Thurnam's 1 report of two cases in 1848. Under the title of alacrimia congenita Sjogren and Eriksen, 2 in 1950, discussed this subject, and in 1952 Sjogren 3 reviewed 14 of the cases reported in the ophthalmic literature without establishing a common etiologic factor. Among the ascribed causes were (1) persistence of the physiologic condition of the newborn, (2) hypoplasia or absence of the lacrimal gland, and (3) disturbance of innervation of the lacrimal gland. In addition to the previously reported cases, there is a condition in which congenital alacrima is a constant finding. Credit for the recognition of this clinical entity goes to Riley 4 and his co-workers, who in 1949 reported five such cases under the title of "Central Autonomic Dysfunction with Defective Lacrimation." Largely as the result of subsequent studies by Riley

Paralysis of the third cranial nerve presents a discouraging problem from a clinical standpoint, for too often, even after intensive investigation, the cause remains obscure.1Even when a cause is found, the exact manner in which conduction through the nerve is interrupted remains uncertain. In order to clarify the mechanism by which the third cranial nerve is interrupted and to establish the site of involvement in various diseases, we examined the brains of a number of patients seen at the Mayo Clinic who had exhibited impaired function of the nerve during life. We shall present a few representative examples of the more frequent causes of third-nerve paralysis. Anatomic Aspects To comprehend the pathogenesis of paralysis of the third cranial nerve, complete cognizance of its course and relationships is necessary. The oculomotor nerves extend from the midbrain into the orbits (Fig. 1a). They leave the midbrain between the cerebral

CYSTINOSIS is a metabolic disorder that is better known to pediatricians than to ophthalmologists. The reason is that all of the victims are infants and children and do not live to become adults. Most of the discussion concerning the condition is in the pediatric literature, where the disorder may be known by various names, such as the de Toni-Fanconi syndrome, renal rickets, or intractable rickets. McCune and associates, 1 in discussing the group of cases with hypophosphatemic rickets, renal glycosuria, and acidosis, occasionally accompanied by cystinosis, remarked, "The state of the subject remains confused; it is, however, not quite chaotic." It is certainly confusing to one who is not skilled in biochemistry. At this writing only three cases have been reported in the American ophthalmic literature—those of Walsh and his co-workers 2 and that of Kennedy. 3 We wish to add two cases, as it seems certain that the condition

In a recent report 1 on the responses of the ocular tissues to injury an analysis was made of the role the various components of connective tissue play in wound repair. These studies, which clearly indicate the importance of the initial events, aroused further interest in the nature of these responses. With suspicion that the normal cell constituents of connective tissue adjacent to an injury play a vital part in repair, the healing of wounds in normal and devitalized corneas was investigated. The purpose of this study is twofold: to evaluate the importance to healing of those cell constituents at the edge of a fresh wound and to describe the time and site of formation of sulfated mucopolysaccharides in a cornea recovering from injury. Methods Maumenee's 2 method of killing corneal cells by freezing was used because it is believed this technique does not directly degrade the chemical constituents of

I have not attempted an academic paper on the treatment of interstitial keratitis, but have rather endeavored to give a paper based on clinical observations; and in order to get the conclusions and opinions of others, the following questions were addressed to thirty representative ophthalmologists in as many different sections of the country: What local measures other than those for the alleviation of symptoms have you used in the treatment of interstitial keratitis? To what extent have any of them contributed to the shortening of the inflammatory stage? Do you administer iodids during the inflammatory stage? In your opinion do iodids, given during the inflammatory stage, aid or retard recovery? What, in your opinion, is the best method of administering mercury? What is the average duration of the inflammatory stage in your practice? The answers to questions one and two were surprisingly uniform. Subconjunctival injections, cold water dropping, massage, ointment

At the close of the last meeting of the Association, held in St. Louis, I promised Dr. Miller, the Chairman-elect of this Section, to write a short paper on this subject, which had been pressing itself upon my mind for several years, and with growing force since the discussion in the Academy of Medicine, of Paris, of Gautier's paper on the result of the very important—not to say startling—investigations of Selmi in 1877, including much original matter as presented by himself. Continued researches in this direction have only confirmed the principles enunciated by earlier workers. The discovery of tyrotoxicon by Prof. Vaughan, with the increasing number of suggestive cases and reports, seemed to me to justify the contribution I proposed to offer to this Section. Since commencing the preparation of this paper Dr. Emmet Holt has given us a valuable article on the same subject published in the New York

While refraction is a science based on mathematical principles and theoretically very exact, yet there are other questions involved besides that of measuring the radius of curvature, finding the far and near points, range of accommodation, etc. What I shall have to say in this short paper will not be new to many, but it is a phase of refraction about which very little has been said or written. Hence my excuse for presenting this paper. Has psychology any practical bearing on the subject of refraction? In many cases perhaps very little, while in other cases quite a good deal. If all brains were of the same quality, all minds trained to think alike, all nervous systems equally well balanced, every individual reared in a pure atmosphere with proper and healthful environments, refraction would in a measure be reduced to the simple question of accurate observation and correct measurements. It

In presenting my paper on the surgical treatment of acute peritonitis I have not thought it necessary to review my experimental work, or to report all my cases operated upon. Neither is it possible in a short paper to enter into a discussion of the anatomy, etiology, pathology and the various clinical phases found in this formidable disease, because inflammation of this membrane may have so many different causes and assume such varied clinical aspects that it is difficult to formulate a uniform and satisfactory classification. Suffice it to say that, anatomically and physiologically considered, the peritoneal cavity may be said to be a large lymph-sac, and noted for its capacity of absorption. This capacity is not surprising when we take into consideration that in its parietal and visceral enfoldings, it presents nearly as large a surface as the entire integumentary covering of the body. Idiopathic peritonitis is considered doubtful by most modern pathologists, and it has become an established practice to search for a local cause in all cases of peritonitis. I believe in every instance, micro-organisms from some source or other have gained access to the