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A strong evidence-based case is made for a reduction in the drink driving blood alcohol concentration (BAC), currently in the UK 80 mg to 50 mg per 100 ml which worldwide has been shown to decrease the number of drink driving including fatal accidents. An even lower BAC of 20 mg per 100 ml is recommended for the younger novice representing 7% of driving licence holders in the UK but involved in 20% of fatal and serious collisions. The danger of binge drinking and of combining alcohol with other drugs such as cannabis and marijuana is emphasised and the harmful influence of simple energy drinks when combined with alcohol. The review also emphasises the need for enhanced police enforcement and more public awareness campaigns which to date have indicated growing public support for reducing the drink driving limits.

Background The United States (US) Expanded Access Program (EAP) to coronavirus disease 2019 (COVID-19) convalescent plasma was initiated in response to the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19. While randomized clinical trials were in various stages of development and enrollment, there was an urgent need for widespread access to potential therapeutic agents. The objective of this study is to report on the demographic, geographical, and chronological characteristics of patients in the EAP, and key safety metrics following transfusion of COVID-19 convalescent plasma. Methods and findings Mayo Clinic served as the central institutional review board for all participating facilities, and any US physician could participate as a local physician–principal investigator. Eligible patients were hospitalized, were aged 18 years or older, and had—or were at risk of progression to—severe or life-threatening COVID-19; eligible patients were enrolled through the EAP central website. Blood collection facilities rapidly implemented programs to collect convalescent plasma for hospitalized patients with COVID-19. Demographic and clinical characteristics of all enrolled patients in the EAP were summarized. Temporal patterns in access to COVID-19 convalescent plasma were investigated by comparing daily and weekly changes in EAP enrollment in response to changes in infection rate at the state level. Geographical analyses on access to convalescent plasma included assessing EAP enrollment in all national hospital referral regions, as well as assessing enrollment in metropolitan areas and less populated areas that did not have access to COVID-19 clinical trials. From April 3 to August 23, 2020, 105,717 hospitalized patients with severe or life-threatening COVID-19 were enrolled in the EAP. The majority of patients were 60 years of age or older (57.8%), were male (58.4%), and had overweight or obesity (83.8%). There was substantial inclusion of minorities and underserved populations: 46.4% of patients were of a race other than white, and 37.2% of patients were of Hispanic ethnicity. Chronologically and geographically, increases in the number of both enrollments and transfusions in the EAP closely followed confirmed infections across all 50 states. Nearly all national hospital referral regions enrolled and transfused patients in the EAP, including both in metropolitan and in less populated areas. The incidence of serious adverse events was objectively low (, In an observational study of registry data, Jonathon Senefeld and colleagues study factors related to patient enrollment in the Expanded Access Program for use of COVID-19 convalescent plasma in the United States., Author summary Why was this study done? There was a public health need to provide expedited and broad access to convalescent plasma for the treatment of coronavirus disease 2019 (COVID-19) during the early stages of this public health emergency in the United States. Convalescent plasma was initially administered through regulatory pathways that required per-patient approval, resulting in substantial administrative time. The Expanded Access Program (EAP) was initiated to provide broad access to COVID-19 convalescent plasma and to provide a framework for standardized collection of data describing the safety profile of convalescent plasma. What did the researchers do and find? The EAP provided rapid and broad access to convalescent plasma throughout the US and some US territories and was effective at providing therapy for demographic groups that were severely affected by COVID-19. In addition, the data provide evidence supporting that transfusion of convalescent plasma is safe in hospitalized patients with COVID-19. What do these findings mean? The study design of the EAP may serve as an example for future efforts in response to a rapidly developing infectious disease when broad access to a treatment is needed in areas and demographic groups that are often poorly represented in clinical trials.

A recurring issue in (mid-career) master programs Public Administration is to get students to become (more) reflexive (conf. e.g. special issue of Teaching Public Administration 2013). As academic graduates they should not merely apply public administration theories and methods in standardized ways but always think critically about what they do and why. Moreover they should be able to make sensible, situated connections between ‘theory’ and ‘praxis’ and critically and creatively derive new modes of professional action from these. To achieve this students should approach their study with the main intention to develop personal understanding (e.g. Marton & Säljö, 1976; Trigwell, 2010). In this article the redesign of a course in a two year mid-career master program from a traditional instructional mode to blended learning, will be discussed and analyzed to see if the redesign attributed to more reflexive working methods in the course and a more reflexive attitude in students.

Aims: To test the hypothesis that regional variations in the prevalence of alcoholic liver disease are contributed to by regional variations in ‘softness’ of drinking water, i.e. its mineral content. Methods: Annual hospital admission rates for alcoholic liver disease per 100,000 population in the 28 Strategic Health Authorities (SHAs) existing in England over the period 2003–2006 were compared with regional measures of water hardness, alcohol consumption and social deprivation. As corroborative evidence, the same relations were examined for hospital admission rates for osteoporosis, a disorder with an already established link with calcium deficiency in drinking water (as well as with heavy drinking). Results: Hospital admissions rates for alcoholic liver disease were higher in predominant-soft-water SHAs than with hard water SHAs. These areas, with one exception, were also associated with high alcohol consumption, but not with greater social deprivation. Hospital admission rates for osteoporosis were found to vary in a way similar to that for alcoholic liver disease, with significant correlations with soft water and alcohol consumption. Conclusion: Given experimental evidence that magnesium deficiency can aggravate liver damage from alcohol, soft water with its low magnesium concentration may be a factor additional to alcohol consumption in the development of liver damage. The parallel findings with osteoporosis admissions, explainable by low calcium and magnesium levels present in soft water, along with the known effect of heavy drinking on bone metabolism, provide corollary support for the hypothesis linking soft water with the pathogenesis of these two diseases.

OBJECTIVE: One of the major and devastating complications of the coronary artery bypass grafting (CABG) is the stroke. Avoiding cardiopulmonary bypass (CPB) may reduce this neurological complication. In the past years there was an increased interest in the off-pump coronary artery grafting (OPCAB). The benefit of this method of revascularization in term of stroke and mortality is controversially discussed. METHODS: A retrospective analysis of collected data from 252 patients were operated without cardiopulmonary bypass out of 1516 CABG procedures from January 2004 through May 2006. The mean age of the patient population was 70±11years, within a range of 27-88 years. Forty-eight (19%) patients were older than 80 years and there were 172 (69%) males. Mean graft per patient was 1.78±0.79. The internal mammary artery (IMA) graft was used in 95% of the patients. For eight (3.17%) patients this was the second procedure. RESULTS: Hospital mortality was 3.17%; Mean EuroSCORE in these patients was 10.36±6.67. No neurological complications occurred, six (2.38%) patients had temporary psycho syndrome. Postoperative myocardial infarction occurred in three (1.19%) patients. Two patients required rethoracotomy as a result of bleeding. Thirty-eight (15%) patients needed postoperative therapy for atrial fibrillation. CONCLUSION: CABG with OPCAB technique has the benefit of low mortality and morbidity in terms of stroke. The advantages of this technique depends on the patient's general condition at the time of the operation, the sufficiency of pump function and coronary morphology, as well as on the surgeon's experience. OBJETIVO: Uma das principais e devastadoras complicações da revascularização do miocárdio é o acidente cerebrovascular. Evitar a circulação extracorpórea (CEC) pode reduzir essa complicação neurológica. No passado, houve um interesse crescente na cirurgia de revascularização do miocárdio sem circulação extracorpórea. O benefício deste método de revascularização com relação ao acidente cerebrovascular e à mortalidade ainda é discutido de forma controversa. MÉTODOS: Uma análise retrospectiva dos dados coletados de 1.516 pacientes submetidos à cirurgia de revascularização do miocárdio, de janeiro de 2004 a maio de 2006, dos quais 252 pacientes que foram operados sem circulação extracorpórea. A média de idade da população da amostra foi de 70±11 anos, variando de 27 a 88 anos. Quarenta e oito pacientes (19%) tinham mais de 80 anos e 172 pacientes (69%) eram homens. O número médio de transplante por paciente foi de 1,78±0,79. A artéria torácica interna (ATI) foi usada em 95% dos pacientes, enquanto que para oito pacientes a ATI foi o segunda procedimento. RESULTADOS: A mortalidade hospitalar foi de 3,17%; o EuroScore médio nesses pacientes foi de 10,36±6,67. Não ocorreram complicações neurológicas, porém, seis pacientes (2,38%) tiveram psicossíndrome temporária. Infarto do miocárdio ocorreu em três pacientes (1,19%) após a cirurgia. Dois pacientes precisaram fazer uma nova toracotomia por motivo de sangramento e 38 (15%) de tratamento para fibrilação atrial após a cirurgia. CONCLUSÃO: A cirurgia de revascularização do miocárdio sem circulação extracorpórea apresenta o benefício da baixa mortalidade e morbidade com relação ao acidente cerebrovascular. As vantagens dessa técnica dependem da condição geral do paciente na época da cirurgia, da suficiência da função da bomba e da morfologia coronária, bem como da experiência do cirurgião.

Mr Thakore and colleagues (March 2002 JRSM1) conclude that 55% of calls for emergency ambulances did not merit an immediate response. As they acknowledge, the design of the study was not ideal. The initial reason for the request was determined from ambulance crew and accident and emergency (A&E) data after the patient had been seen. This will almost inevitably introduce bias when applying the triage criteria, and the assessment should have been blinded. Also, it is much easier to make such determinations in hindsight, with additional time and clinical information, than when faced with a real call when one has to consider the consequences of the decision reached. It is surprising that this paper makes no reference to priority-based dispatch systems, such as the Advanced Medical Priority Dispatch System (AMPDS), as these are currently used by most ambulance services in the UK. These systems have been shown to have a low risk of serious under-prioritization of life-threatening episodes2. However, work that we have undertaken in Nottingham suggests that they may not be very effective in predicting low-priority 999 calls3. The NHS Executive has stressed the importance of developing telephone prioritization systems that will free ambulance services from having to respond to ‘patients who dialled 999 but who do not need emergency care’4. We believe this may be difficult to achieve. Appropriate and effective telephone triage on non-emergency 999 calls requires a greater understanding of the relationship between the initial telephone assessment by ambulance control and the subsequent outcome of the individual call. Without these data we will not be able to ensure that such a system could operate safely and we endorse the authors' views that prospective studies are essential to assess the feasibility of accurately identifying lower priority calls.

Granular cell myoblastoma is an uncommon tumor in the respiratory tract. It usually occurs in the tongue, skin, breast, or subcutaneous tissue. When it occurs in the respiratory tract, it is usually located in the bronchus or larynx. Primary tracheal location is rare with only nine such cases reported in the literature. This report describes a 26-year-old woman with granular cell myoblastoma of the trachea. She presented with a four-year history of bronchial asthma. The tumor was surgically excised by tracheal resection and reconstruction. The patient has remained well and free of obstructive airway symptoms, without recurrence of the tumor for more than one year.

Ten patients with acromegaly, six with active acromegaly and four with inactive acromegaly were studied with regard to the possible relationship between aldosterone metabolism and hypertension. It was noted that tetrahydroaldosterone-3-glucuronide levels were highest in those cases which exhibited the highest prolactin levels. It was in these cases that hypertension was present and they were active as judged by clinical and biochemical parameters. On administration of bromocryptine there was a reduction of tetrahydroaldosterone-3-glucuronide, prolactin and also a significant reduction of blood pressure. The significance of these results is discussed.

Ten patients with hypertension and obesity were studied during a program of weight loss on an unrestricted sodium diet. The study showed that weight loss during the ten month period was accompanied by a significant decrease in urinary aldosterone, tetrahydroaldosterone -3-glucuronide and plasma renin activity values. It was also demonstrated that successful reduction in body weight was associated with a reduction in blood pressure. It is postulated that blood pressure reduction in obese patients during weight reduction may depend on decreases in aldosterone and plasma renin activity. The reduction in levels of tetrahydroal-dosterone-3-glucuronide is due to an energy related depression of the glucuronidation process caused by carbohydrate deficiency. It is postulated that the lowered rate of metabolism of aldosterone as measured by the diminished formation of the metabolite tetrahydroaldosterone-3-glucuronide is an important determinant of blood pressure status during weight reduction.

Summary Two cases are described who developed epileptic seizures whilst taking maprotiline hydrochloride in therapeutic dosage. In both cases the electroencephalogram was normal and the fits stopped on withdrawal of the drug.

Summary Two cases of severe thyrotoxicosis are described. They both exhibited choreo-athetoid movements which were abolished by successful treatment of the thyrotoxicosis. It is suggested that the tremor of mild thyrotoxicosis is one end of a spectrum at which choreo-athetosis is at the most severe end. A tentative explanation of this hypothesis is given in the discussion.

Out of 102 patients with cardiac infarction admitted to the coronary care unit at this hospital and not treated with anticoagulants 30 (29%) developed isotopic evidence of deep vein thrombosis. Of the 65 smokers only 7 (11%) developed a deep vein thrombosis, whereas of the 37 non-smokers 23 (62%) developed a deep vein thrombosis. This difference is highly significant (P < 0·00001).

Ten patients with severe myxœdema were treated with regular increments of thyroxine. The urine aldosterone excretion rate and plasma-aldosterone level increased with each increasing dose of thyroxine. Two patients in whom the serum-aldosterone rose to abnormally high levels had cardiac failure which resolved when the thyroxine dose was reduced.

A case of aspiration pneumonia due to incoordination of swallowing is described. Its aetiology lies in the myopathy of thyrotoxicosis and a tentative hypothesis as to its causation is suggested.