To the entomologist all insects have six legs; the layman tends to use the term "insect" to include the eight-legged spiders and mites. All these creatures are correctly classified as arthropods. Many thousands of the hundreds of thousands of recognised species of arthropods are found in the human environment-domestic, occupational and rec reational. Those species which are obligate parasites of man, the human scabies mite and the head and body lice, produce familiar clinical syndromes. They remain important in medical practice and have been the subject of a great deal of recent research. This is beginning to throw much light on the immunological mechanisms which largely determine the reactions of the host. Dr. Alexander has provided a detailed survey of this work. The wasps, bees, ants and other Hymenoptera which may sting man in self-defence can cause painful, even fatal reactions. The recent work on this important subject has also been thoroughly reviewed. Every dermatologist of experience will admit that he sees many patients in whom he makes a diagnosis of "insect bites," if he has the confidence to do so, or of "papular urticaria" or "prurigo" when he lacks such confidence, mainly because he is at a loss to know which arthropod is likely to be implicated. In his survey of the enormous literature in the entomological, public health and dermatology journals Dr. Alexander has provided an invaluable guide in which the solutions to these clinical mysteries can be sought."

Drawing on the expertise of a nationally recognized group of family practice educators affiliated with the University of California, Drs. Little and Midtling are able to present many specific examples on meeting the challenges of becoming a family physician. Also included are chapters that draw out the differences between inpatient and outpatient service, discuss the teaching of practice management, and touch on the impact of specialists in ethics and cross cultural communication on family practice teams. The concluding chapters examine how family physicians have survived in the "medical community," and examine the future of family practice.

The Oxford English Dictionary defines diagnosis as: 'Identification of a disease by careful investigation of its symptoms and history' . Regrettably, the value of the history in the diagnosis of disease often seems to be neglected in both undergraduate and postgraduate medical education. The considerable advances in medical technology have made it easy to carry out a multiplicity of tests. As a result, there is frequently an unfortunate tendency to rely on the results of tests before decisions are taken on diagnosis and treatment, even though such tests are often of limited value in the manage ment of the patients. This book is an attempt to redress the balance and place the proper emphasis on the diagnostic value of a well-taken and perspicacious history. The main purpose of the book is to show that most of the clinical problems encountered in daily practice can be dealt with effectively and satisfactorily on the basis of a good clinical history. This should be supplemented by a prob lem-orientated clinical examination, the primary function of which is either to confirm and amplify the diagnosis provided by the history, or to refute it."

High blood pressure (BP) (with fats and smoking) is one of the three roots of cardio-cerebro-renovascular disease affecting up to 25% of the adult population. Hence, high blood pressure should be recognized and treated, to reduce any complications and prolong life, as noted by Michael Weber of the Veterans Administration Hospital in Long Beach, California. He further emphasizes the need for monitoring before one starts the treatment of high blood pressure. Indeed, he refers to the results of the Australian study on mild hypertension with a large percentage of placebo responders and rightly suggests that many people are treated who should not be because of 'white-coat-associated high blood pressure'. He also points to the lack of standardization of techniques for data analysis and of methods of BP measurement. Ambulatory monitoring under usual condi tions without concomitant recording of events does not allow even a qualitative assessment of the impact of varying stimuli, in weber's opinion."

Systemic Method Mark B. Mengel, M. D. , M. P. H. Learning Objectives 3 The Biomedical Model 6 A New Framework: The Systemic Patient-Centered Method 9 Physician Roles Patient Roles 22 Patient-Centered Clinical Decision-Making Data Base Responding to Patient Cues Constructing a Mutually Agreeable Plan The Systemic Patient-Centered Method: Other Concerns Changing Larger Systems Ethics of the Systemic Patient-Centered Method Efficacy of the Systemic Patient-Centered Method 32 Safety of the Systemic Patient-Centered Method Conclusion Cases for Discussion Recommended Readings XV 36 34 32 32 31 30 30 27 25 23 16 10 Patient-Centered The 1: Chapter !iiiii!i !ili !iil !i!i !iii !iii iiii !iiiii!i !iii !iil !iii!ii! !i!i!iiiiiii !i!i !i!i!iil ii!i !i!i !iii iiii!iiiiiii !ill !i!i!iii !iii !i!i !i!ilili!iii iiii !iil i!ii iili iii! i!ii ii!i i!ii iiii iiil iiiiiii! iiii iiiiii!iiiiiiiiiii!iiii!iiii iiii iiii ii!i iiiiii!i!i!iiiiiiiii !iii iiii iiiiiiiiii!i iiiiiiiiiiii iiiiiiii iiiiiiiiiiiiii!i iiii iiii iiiiiiii iiiiiiil iii!iiii iii! iiii iiii i!i! ilil iiii iiii iiii iiii iiii iiii iiii iiiiiiii iiii!iiiiiii iiii !iiiiiii iiii iiiiii!i iiii !iii !iiii!iii!i ii!i ii!i iiil iiii !i!i!iiiii!i!ill iiiiiiii! i!i iiii iili ii!i iiiiii!i iliiii!i iili iiiiiiiiiiililil iiii iiil ilil iliiiiiiiiiiiiii ilii ilii iiii iiii iiii iiii iiii iiiiiiii ilil i!il iiil iiii ii ii iiiiiiii iiiiiiii iiii !i !i!i !i!i !i!i !i!i !i!i !i!i !i!i !i!i !ill !i!i !i!iii!iii!i !i!i !i!i !!ii !iil !iii !iii !iii !i!i iiiiiiiiiiiiiiiiiiiiii!iii!i ililili! iii iiii iiii iiiil iii iiiil iiii iiii iiii xvi Part II.

This book is designed to be a physician's guide for those interested in diving and hyperbaric environments. It is not a detailed document for the erudite researcher; rather, it is a source of information for the scuba-diving physician who is searching for answers put to him by his fellow nonmedical divers. Following the publication of The Underwater Handbook: A Guide to Physiology and Performance for the Engineer there were frequent requests for a companion volume for the physician. This book is designed to fill the void. Production of the book has been supported by the Office of Naval Research and by the Bureau of Medicine and Surgery, Research and Development Command, under Navy Contract No. NOOOOI4-78-C-0604. Our heartfelt thanks go to the many authors without whose contributions the book could not have been produced. These articles are signed by the responsible authors, and the names a e also listed alphabetically in these preliminary pages. Every chapter was officially reviewed by at least one expert in the field covered and these reviewers are also listed on these pages. Our thanks go to them for their valuable assistance. We are grateful to Marthe Beckett Kent for editing Chapter III. Our thanks also go to Mrs. Carolyn Paddon for typing and retyping the manuscripts, and to Mrs. Catherine Coppola, who so expertly handled the many fiscal affairs.

Obesity in affluent countries continues to be a serious problem. When one runs an Obesity Clinic there appears to be an unending series of patients who need help. Our understanding of weight control has been advanced not only by the studies of obese patients but also by our investigation of the problems of weight gain in young women with anorexia nervosa. Just as among obese patients there is the group of 'efficient metabolizers' who can maintain their excessive weight with a calorie intake occasion ally as low as 600 kcal per day, so we have demonstrated that among anorexic women there are a few who may fail to gain normal weight with 3500 kcal per day. Some of the latter group may in fact develop T3 (tri-iodothyronine) thyrotoxicosis. One of the major unknown factors is still what determines when patients may be at these extremes. If we knew how to control these extremes we would like, for a time, to switch each to the opposite end of the spectrum. One factor which is becoming apparent from studying people in the machine which continually plots metabolic rate is that the metabolic response to food is a' major factor in determining a person's weight. In general terms there is a tendency for those who are below their ideal weight to have an increased metabolic response to food and those who are above ideal weight to have a reduced metabolic response to food."

Guide to Fitness After Fifty presents basic and applied research data, authoritative advice and tested techniques for professional workers who want to learn more about physical exercise, fitness and health for aging people and for all who seek to become more physically and mentally fit. The editors and contributors believe that physical activity and exercise following the pri ciples and practices utlined in this inter disciplinary volume can improve the health and quality of life by increasing en durance and cardiovascular fitness, strengthening the musculoskeletal system, im proving mobility, posture and appearance, and relaxing emotional tensions. Evidence at hand and discussed in this book demonstrates that properly prescribed physical activity or exercise can raise the level of physical fitness and health, both physical and mental, at any age, delay the ravages of aging, and prevent or reduce disability from musculoskeletal and circulatory disorders. Section I, Perspectives on Exercise and Aging, surveys the fundamental problems and relationships of exercise to aging and health and provides historical insights and philosophic perspectives on the significance and importance of physical fitness and exercise through the centuries and in contemporary society. Section II, Evaluation and Physiology of Exercise, presents objective scientific and medical evidence that reasonable improvement in fitness and other bodily func tions may be achieved by people of all ages who follow well designed exercise and relaxation routines for at least 30 minutes three or more times weekly."

A concise summary of the most important medical and scientific topics concerning cardiovascular medicine in the primary care environment, this new edition of Cardiology in Family Practice has been updated with cutting-edge information and useful tips. Written in an easy-to-read format (background, diagnosis and disease management) and emphasizing practical techniques for evaluation and treatment, the authors explain the basic mechanisms underlying cardiovascular disease states and the treatment strategies that arise from them. Topics include stable angina, acute coronary syndromes, arrythmias, hypertension, pericardial and valvular diseases, and hyperlipidemia. New figures have been added to each chapter in this edition. This book is a must-have for primary care physicians who wish to keep up to date with the rapidly changing field of cardiology.

The original Beecham Manual for General Practice was produced by Dr Selwyn Carson, of Christchurch, New Zealand, whose objective was a set of instructions for patient care for his practice team. Beecham Research Laboratories published and distributed it. Dr Ed Gawthorn of Melbourne, Australia, edited an Australian version again published and distributed by Beecham Research Laboratories. We were invited to adapt the New Zealand and Australian editions for British readers -but we decided that we should produce an entirely new Manual. This was done and it was published and distributed to general practitioners by Beecham Research Laboratories. This latest edition has been revised and updated. The Manual is a ready reference on planned care of certain age groups and situations; specific procedures and emergencies; and clinical care in general practice of important conditions. We have intentionally adopted a concise didactic style that should be helpful for trainers, trainees and members of the practice team. We thank Beecham Research Laboratories, and especially Ed Stanford and Bill Burns, for their support and help over many years. John Fry (Editor) June 1982 viii Section A PLANNED CARE Family Planning A1 Discuss with the individual patient the advantages and disadvantages of all the methods. Keep in mind individual needs, wishes and religious beliefs. In Great Britain * 2.5 million women are registered with their G.P.'s for contraception. -100 per G.P. * 95% of G.P.'s provide contraceptive services.

Infections of Leisure provides a thorough yet concise examination of the infectious risks and diseases of leisure time activity. Encompassing a wide range of medical and social interests, chapters provide practical, clinical guidelines for the diagnosis and management of various infectious risks in the garden, at the shore, on fresh water, on camping trips, traveling abroad, and on the farm. Additional chapters include up-to-date information on foodborne illnesses, and on animal-associated infections, with particular attention given to housepets. The rising prevalence of Lyme Disease, hepatitis and food poisoning make this volume vitally important. Family practitioners, internists, infectious disease specialists, pediatricians, and emergency room physicians will all benefit from the indispensable and practical information presented in this unique, groundbreaking volume.

Decision making is the physician's major activity. Every day, in doctors' offices throughout the world, patients describe their symptoms and com plaints while doctors perform examinations, order tests, and, on the basis of these data, decide what is wrong and what should be done. Although the process may appear routine-even to the physicians in volved-each step in the sequence requires skilled clinical judgment. Physicians must decide: which symptoms are important, whether any laboratory tests should be done, how the various items of clinical data should be combined, and, finally, which of several treatments (including doing nothing) is indicated. Although much of the information used in clinical decision making is objective, the physician's values (a belief that pain relief is more important than potential addiction to pain-killing drugs, for example) and subjectivity are as much a part of the clinical process as the objective findings of laboratory tests. In recent years, both physicians and psychologists have come to realize that patient management decisions are not only subjective but also prob abilistic (although this is not always acknowledged overtly). When doc tors argue that an operation is fairly safe because it has a mortality rate of only 1 %, they are at least implicitly admitting that the outcome of their decision is based on probability."

Herewe offer anew approach to understanding and managing common medical conditions. With the needs of our readers in mind we present clearer, more extensive and more expansive views on them. Traditional medical textbooks are wordy tomes with well worn patterns dealing in set order with 'causes, symptoms and signs, diagnosis and treatment'. They offer formal instant snapshots of diseases. We have devised an economic synoptic style, and we have endeavoured to give acomprehensive and an on-going long term movepicture ofeach condition and to relate this to the analysisofsymptoms and signs, to diagnostic assessment and to management and treatment. We have selected 22 important conditions and for eachhave followed the same sequence of questions and answers: * What is it? giving a brief summary of the current understanding of the nature of the condition. * Who gets it when? showing the age-sex distributions and influence ofother factors such as social class, international comparisons, andtheirlikelyfrequency ingeneralpractice and at the district general hospital. * What happens? analysing the significance of symptoms and signs, the likely course and outcome and how these influence care. * What to do? an appreciation of the nature and presentation of the condition, and their relevance to diagnosis and management.

Primary care medicine is the new frontier in medicine. Every nation in the world has recognized the necessity to deliver personal and primary care to its people. This includes first-contact care, care based in a posi tive and caring personal relationship, care by a single healthcare pro vider for the majority of the patient's problems, coordination of all care by the patient's personal provider, advocacy for the patient by the pro vider, the provision of preventive care and psychosocial care, as well as care for episodes of acute and chronic illness. These facets of care work most effectively when they are embedded in a coherent integrated approach. The support for primary care derives from several significant trends. First, technologically based care costs have rocketed beyond reason or availability, occurring in the face of exploding populations and diminish ing real resources in many parts of the world, even in the wealthier nations. Simultaneously, the primary care disciplines-general internal medicine and pediatrics and family medicine-have matured significantly."

ALLEN W. ROOT On November 11 and 12, 1988, a "Festschrift" was held to honor "our Chief;' Lewis A. Barness. Who is our Chief, and why was such an occasion held? I will not attempt to describe him in terms of his scientific and scholarly accomplish ments, which have spanned more than four decades. Rather, I will describe the characteristics of an individual whose concern for humanity has made him the quintessential role model for countless students, residents, and graduate pediatri cians around the world. The Chief's concern is manifested by his love for chil dren and his tireless efforts on their behalf, as well as his genuine affection for his colleagues, all of whom are also his friends. During the 2-day celebration, many of these friends had an opportunity to make comments which I believe capture portions of the essence of this remark able human being: Many of us are better persons because of our association with the "Chief . . .: ' Many of us have chosen pediatrics as a career as an unspoken act of tribute to him . . . . We love you and we thank you for making the world a better place to spend some time. (F. Oski) Lew fulfilled all our dreams . . . We all wish we could have done half so well. (R. Klein) Your] ever-present evidence of concern for your fellow man . . . it is the quality of car ing. (T."

Volume 5 of Contemporary Nephrology summarizes major advances in 15 different areas of nephrology. As in previous volumes the different chapters constitute up- of the discipline contributed by individuals dates in both basic and clinical aspects with in-depth expertise in their respective areas. We are grateful to the authors for their outstanding contributions to this fifth volume. Drs. Reuss and Cotton review in Chapter 1 new advances in our understanding of water transport in epithelial tissues responsive to antidiuretic hormone. In Chap- ters 2 and 3 Dr. Knox and Dr. Schoolwerth and their associates summarize respec- tively new information in the areas of renal hemodynamics and electrolyte excre- tion, and renal metabolism. Chapter 4, written by Drs. Laski and Kurtzman, updates recent developments in the regulation of acid-base balance in health and disease. Chapter 5, contributed by Drs. Sutton and Cameron, provides the reader with a detailed account of progress in the area of mineral metabolism. In Chapter 6, Dr. Campese examines the contribution of sodium, calcium, and neurogenic factors in the pathogenesis of essential hypertension. The immunological aspects of renal disease are clearly discussed by Dr. Couser in Chapter 7. New developments in this field are emphasized and should provide the reader with a clear understanding of the direction in which this field is moving. Drs. Humes and Messana (Chapter 8) discuss selected areas in which new developments have occurred in our understand- ing of acute renal failure and toxic nephropathy.

Proceedings of the NATO Advanced Study Institute, San Miniato, Italy, September 2-13, 1985

Here is a practical guide giving you systematic strategies for correctly diagnosing heart disease. The emphasis is on the patient's history and the physical examination, the two cornerstones of medical diagnosis. These are correlated with knowledge of the natural history of disease and the physical findings of subsequent examination techniques. The role of current examination technology - both invasive and noninvasive - is discussed. Important advances in the field, including procedures such as echocardiography, transesophageal probe, exercise electrocardiography, nuclear ventriculography and magnetic resonance imaging, are taken into consideration. The book covers all major heart diseases and is liberally illustrated.

Comprehensive Management of Menopause is a balanced, authoritative, and state-of-the-art approach to the treatment of all medical issues of the menopausal patient, strongly emphasizing clinical and practical applications for comprehensive care. The book is edited by leaders in the field and contains an impressive array of internationally recognized contributors. Divided into five easily referenced sections: Physiology, Diagnosis and Epidemiology; Medical Aspects of the Menopause; Gynecologic Aspects of the Menopause; Management and Therapeutic Guidelines; and The Future; this outstanding volume contains the most up-to-date information on diagnosis, treatment, and management of: - osteoporosis and musculo-skeletal pain; - cardiovascular disease and lipid and metabolism disorders; - all gynecologic aspects of menopause, including the newest technology and advances in hormone therapies; - breast problems and skin care. It also includes preventive medicine and general health care guidelines. Comprehensive Management of Menopause is the definitive text comprising all aspects of menopause and is indispensable to every physician providing medical care to women.

Thoroughly illustrated, this second edition provides the primary care physician with detailed information on the most commonly encountered clinical situations and the most frequently asked questions. The chapters address everything the primary care physician will regularly face and will need to know about the breast, pregnancy, sexually transmitted diseases, contraception, infertility, gynecologic cancers, urogynecology and gynecology.

The Tenth International Conference on Intracellular Protein Catabolism was held in Tokyo Japan, October 30-November 3, 1994. under the auspices of the International Committee on Proteolysis (lCOP). ICOP meetings have been held biennially in the USA, Europe, and Japan in turn. The previous three ICOP meetings (7th to 9th) were held in Shimoda, Japan, in 1988. in WildbadKreuth, Germany, in 1990, and in Williamsburg. Virginia, in 1992. Previous meetings were held in resort areas, this was the first meeting held in a large city. Attendance has grown every year so that nearly 400 participants from 19 different countries attended the Tokyo meeting. At the meeting, novel and updated results on the structure-function. physiology, biology, and pathology of proteases and inhibitors were discussed, together with cellular aspects of proteolysis and protein turnover. Thirty-nine invited papers and eight selected posters were presented orally and 171 poster presentations were discussed. This book documents almost all of the lectures and some selected posters. Since the world of proteolysis and protein turnover is expanding very rapidly. far beyond our expectations, it is impossible to cover all the new aspects of this field. However, this book will give an idea of the current status, trends. and directions of the field, and information necessary to understand what is and will be important in this field. Further. the editors hope that the novel ideas, approaches. methodologies, and important findings described in this book will stimulate further study on proteolysis and protein turnover.

Evidence-based Clinical Practice (EBCP) is the conscientious, explicit, and judicious use of current best external evidence in making decisions about the care of individual patients. In neurology, practice has shifted from a rich, descriptive discipline to one of increasingly diagnostic and therapeutic interventions. Providing a comprehensive review of the current best evidence, Neurology: An Evidence-Based Approach presents this type of evidence in a concise, user-friendly and easily accessible manner. The three co-editors of this important volume are linked in their passion for evidence-based clinical practice in the clinical neurological sciences, connected to a common historical origin at the University of Western Ontario (UWO), London, Ontario Canada and influenced directly by Evidence-Based Medicine teachings of McMaster University, Hamilton, Ontario Cananda. The book is organized in three sections: Basics of Evidence-Based Clinical Practice, with an introduction to the topic, a chapter on the evolution of the hierarchy of evidence, and another chapter on guidelines for rating the quality of evidence and grading the strength of recommendation. The second section, Neurological Diseases, provides an illuminating overview of evidence-based care in ten of the most common areas in neurologic practice. The final, third section provides an outstanding roadmap for teaching evidence-based neurology with a chapter on the Evidence-Based Curriculum. A superb contribution to the literature, Neurology: An Evidence-Based Approach offers a well designed, well written, practical reference for all providers and researchers interested in the evidence-based practice of neurology.

Sudden death is probably the greatest challenge facing modem cardiology today. This is mainly due to the impact of its brusque appearance and the socioeconomic implications. The incidende is presently decreasing somewhat, mainly due to the decline in new cases of ischemic heart disease on one hand, and to better preven tion in risk patients on the other. Nevertheless, the figures are still high and represent over 300.000 patients per year in the United States alone. This book is an updating of the problem of sudden death from a multifactorial standpoint. It includes not only electrophysiologic data but also covers aspects ranging from epidemiology to prevention. Risk markers and triggering mechanicsms of sudden death are reviewed, with special emphasis on the role of electrical instability, ischemia and depressed ventricular function. The book includes the contributions from many experts, often pioneers in their respective fields. It is our hope that the book serves as an Updating for those cardiologist who are not specialized in these subjects, but may also be of interest to the expert. We wish to express our sincerest gratitude to the authors for sending in their work so promptly, and also Kluwer Academic Publishers for their exactitude and perfection in this edition."

The secretion of bioactive products by tumors of the gastroenteropancreatic system results in the development of watery diarrhea that can lead to death in a very short period if not brought under control. Even if the consequences are less dramatic, the patients' ability to lead a normal daily life is seriously impaired, and they may become severely depressed. SandostatinR alleviates the condition by inhibiting peptide release, and its long duration of action makes it an effective and rational adjunct to therapy at all stages. Last year a consensus Round Table Meeting was held in Scottsdale, Arizona, to discuss the optimal use of SandostatinR in this indication. These guidelines offer the results of clinical research and the dosage recommendations arising from them, together with a critical summary of the points of view presented.

This volume comes from manuscriptscontributed by invited speakers to the NATO AdvancedStudyInstitute on Biopolymers, which was held in Izmir, during August 27th - September 5th, 1984. Many more detailshave been added to the manuscripts as a resultof the interchange of ideas during the symposium. This book includes 16 papers which were originallypresented at the meeting by some of the world'sforemostinvestigators. In this volume, the existing basic knowledgeacross the wholefieldof polymericbiomaterials is reviewed.Classification, structure, composition, synthesis, modification and fabrication of these novel materialsis included in detail. Fundamental phenomena involved in the interactionof polymers with the biological environmentand resultingresponses of blood and tissue components are discussed. Modification of polymers physically, chemicallyor biochemically, in order to improve their biocompatibility is included. Selected applications of polymeric biomaterialsin Medicine, Dentistry, Biotechnology, Pharmacology and otherrelated fieldsarealsocovered. We stronglyhope thatthis book will be agreatcontribution to the rapidly expanding field of biomaterialsand willhelp to stimulate an even more excitingfuturefor th is field. ErhanPiskin AllanS. Hoffman VI ACKNOWLEDGEMENTS NATO Advanced Study Institute on "Biopolymers" was held in Izmir during August 27th - September 5th, 1984. I would like to ex press my deepest appreciation and gratitude to NATO Scientific Affairs Division, that our meeting has been accepted as a NATO ASI, and has been supported by their programmes. I wish to thank also to all the other supporting firms and organizations, especially to Hacettepe University and Turkish Scientific and Technical Research Council."