Current Controversies Research Articles

Prevalence of ocular toxicity induced by antimalarial drugs in patients with rheumatic diseases

Several studies have reported the possibility of ocular toxicity with the use of antimalarial drugs by patients with rheumatic diseases. Thus, the present study intended to investigate the prevalence of such toxicity in these patients and the feasibility of the regression of changes after medication discontinuation. The present retrospective study included the medical records of 598 patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and mixed connective tissue disorders (MCTDs) who took chloroquine (CQ) or hydroxychloroquine (HCQ) and underwent routine ophthalmologic examinations. Moreover, if a patient had any ocular abnormality reported by the examining ophthalmologist, he/she was referred to another ophthalmologist to confirm the primary findings. Also, the patients with abnormal ocular findings who discontinued the drugs were re-examined 12 months after the drug discontinuation to evaluate the rate of regression of the ocular changes. According to our findings, 81 out of 598 patients (13.6%) had ocular toxicity in routine ophthalmologic examinations. However, ocular changes were ruled out in 49 (8.2%) patients using a second examination by another ophthalmologist. Therefore, retinopathy was confirmed in 32 out of 598 (5.4%) cases. Moreover, the patients with eye complications were significantly older than those without ocular toxicity (P = 0.03), while no significant relationship was found between ocular toxicity and other variables. Finally, of 32 patients with ocular toxicity, 12 patients were re-examined 12 months after the drug discontinuation, revealing normal findings in 7 (58%) patients, while 5 (42%) had irreversible ocular abnormalities. According to our findings, the prevalence of HCQ- and CQ-induced retinopathy was quite considerable in patients receiving these drugs. Therefore, despite the current controversies, we recommend that all patients receiving antimalarial drugs undergo screening for ocular toxicity.

Stuck Behind the Times: How Current Controversies Related to Domestic Violence Intervention Programs are Addressed in U.S. State-Specific Documents

ABSTRACT This research assesses the extent to which current treatment-related controversies are addressed in state documents related to Domestic Violence Intervention Programs (DVIP). Specifically, we consider state-specific guidance on conducting treatment with female-identifying perpetrators, perpetrators in LGBTQ+ relationships, perpetrators located within relationships with bi-directional violence and perpetrators with a trauma history. Relevant DVIP governing documents were obtained from all U.S. states, as available (n = 47, 94%). Documents were coded with good interrater reliability (IRR = 82.4%). Although most states have gender-neutral or gender-non-specified DVIP guidelines (n = 31, 66%), 16 states (24%) have documents that specify they can only be applied to male perpetrators. Only two states (4%) provide detailed guidance for work with LGBTQ+ perpetrators. Of note, 44% of states (n = 22) exclude addressing bidirectional violence within their programs, despite its prevalence among violent couples. Only one state currently advises its DVIPs to assess for bidirectional violence at intake. While a substantial minority of states (n = 20, 40%) advise DVIPs to assess for perpetrator trauma, only a few state documents specifically endorse a trauma-informed approach (n = 6, 12%) even fewer require DVIP facilitators to include trauma information in their curriculum (n = 2, 4%). Problematically, many states’ DVIP guidelines have not been updated recently, with only 17 states having guidelines updated in the last five years. State policies must address the needs, motivations, and experiences of all DVIP perpetrators by acknowledging violence-related dynamics, incorporating a strength-based perspective, providing trauma-informed care, and enacting gender and LGBTQ±specific treatment recommendations.

Stem cell-derived embryo models: moral advance or moral obfuscation?

Stem cell-derived embryo models (SCEMs) are model embryos used in scientific research to gain a better understanding of early embryonic development. The way humans develop from a single-cell zygote to...

Twenty Years of Blast-Induced Neurotrauma: Current State of Knowledge.

Blast-induced neurotrauma (BINT) is an important injury paradigm of neurotrauma research. This short communication summarizes the current knowledge of BINT. We divide the BINT research into several broad categories-blast wave generation in laboratory, biomechanics, pathology, behavioral outcomes, repetitive blast in animal models, and clinical and neuroimaging investigations in humans. Publications from 2000 to 2023 in each subdomain were considered. The analysis of the literature has brought out salient aspects. Primary blast waves can be simulated reasonably in a laboratory using carefully designed shock tubes. Various biomechanics-based theories of BINT have been proposed; each of these theories may contribute to BINT by generating a unique biomechanical signature. The injury thresholds for BINT are in the nascent stages. Thresholds for rodents are reasonably established, but such thresholds (guided by primary blast data) are unavailable in humans. Single blast exposure animal studies suggest dose-dependent neuronal pathologies predominantly initiated by blood-brain barrier permeability and oxidative stress. The pathologies were typically reversible, with dose-dependent recovery times. Behavioral changes in animals include anxiety, auditory and recognition memory deficits, and fear conditioning. The repetitive blast exposure manifests similar pathologies in animals, however, at lower blast overpressures. White matter irregularities and cortical volume and thickness alterations have been observed in neuroimaging investigations of military personnel exposed to blast. Behavioral changes in human cohorts include sleep disorders, poor motor skills, cognitive dysfunction, depression, and anxiety. Overall, this article provides a concise synopsis of current understanding, consensus, controversies, and potential future directions.

Donation after circulatory death: a narrative review of current controversies, attitudes, and the evolving role of regional perfusion technology

Donation after circulatory death: a narrative review of current controversies, attitudes, and the evolving role of regional perfusion technology

Choosing home: discharge to assess and the Health and Care Act 2022

In the early stages of the coronavirus pandemic National Health Service hospitals were instructed to rapidly discharge patients from wards with consequences which, in the case of some care homes, has been claimed to be catastrophic due to lack of effective testing and isolation. These tragic events also highlight a longer-term issue, namely hospital discharge policies and their relationship with obligations placed on local authorities to assess needs of individuals under the Care Act 2014. Concerns have been expressed for some time regarding the delays in getting patients discharged from hospitals – with them being labelled inappropriately as ‘bed blockers’. The Health and Care Act 2022 includes new statutory measures concerning discharge to facilitate rapid discharge of patients from hospitals. This can be seen as a solution to a major resource problem, but could this ultimately undermine choice and respect for individual wellbeing?The article explores the background to the recent controversies concerning hospital discharge decisions and their relationship with the Care Act 2014. It demonstrates that, while the current debates and controversies regarding hospital discharge decisions are nothing new and pre-date the pandemic by decades, hospital discharge processes accelerated during the pandemic and have left a problematic legacy. It interrogates the Health and Care Act 2022 discharge provisions and whether these will be an effective integration of health and social care provision going forward or whether there is a real risk of undermining individual autonomy, the Care Act 2014 obligations concerning promotion of well-being and a person’s choice of their ‘home’.

Pain Management for Ambulatory Surgery: Current Controversies and Concerns

Pain Management for Ambulatory Surgery: Current Controversies and Concerns

Power to Detect What? Considerations for Planning and Evaluating Sample Size

Academic In the wake of the replication crisis, social and personality psychologists have increased attention to power analysis and the adequacy of sample sizes. In this article, we analyze current controversies in this area, including choosing effect sizes, why and whether power analyses should be conducted on already-collected data, how to mitigate the negative effects of sample size criteria on specific kinds of research, and which power criterion to use. For novel research questions, we advocate that researchers base sample sizes on effects that are likely to be cost-effective for other people to implement (in applied settings) or to study (in basic research settings), given the limitations of interest-based minimums or field-wide effect sizes. We discuss two alternatives to power analysis, precision analysis and sequential analysis, and end with recommendations for improving the practices of researchers, reviewers, and journal editors in social-personality psychology. Public Recently, social-personality psychology has been criticized for basing some of its conclusions on studies with low numbers of participants. As a result, power analysis, a mathematical way to ensure that a study has enough participants to reliably “detect” a given size of psychological effect, has become popular. This article describes power analysis and discusses some controversies about it, including how researchers should derive assumptions about effect size, and how the requirements of power analysis can be applied without harming research on hard-to-reach and marginalized communities. For novel research questions, we advocate that researchers base sample sizes on effects that are likely to be cost-effective for other people to implement (in applied settings) or to study (in basic research settings). We discuss two alternatives to power analysis, precision analysis and sequential analysis, and end with recommendations for improving the practices of researchers, reviewers, and journal editors in social-personality psychology.

Stock buybacks in the spotlight

Theoretical Basis The theoretical basis for the case is information asymmetry and signaling theory, with buybacks providing a mechanism for reducing information asymmetry between management and investors. The controversy surrounding buybacks has led to political and regulatory scrutiny, which, consistent with evidence from academic research, may affect corporate behavior. Research methodology The compact case is based on secondary, public information about stock buybacks. All sources used are cited in-text, with full citations included in the references section at the end of the teaching note. Case Overview/Synopsis Stock buybacks, a means of providing returns to shareholders, have recently received increased scrutiny by politicians, media and shareholder activists. Proponents have argued that buybacks result in efficient allocation of capital by returning funds to shareholders, whereas opponents have criticized buybacks for enriching executives, providing tax advantages to shareholders and contributing to income inequality. Corporations did not curtail their use of buybacks after the Inflation Reduction Act of 2022 imposed an excise tax. The case frames the buyback debate in current events and focuses on the buyback activity of Apple. The case provides students the opportunity to analyze alternative ways that companies can provide returns to shareholders, evaluate impacts of buybacks on corporate stakeholders and appraise the reasons for, and implications of, current controversy regarding buybacks. Complexity/Academic Level This compact case is appropriate for upper-level undergraduate or graduate courses in financial accounting, tax and finance. This case provides an opportunity to analyze and evaluate stock buyback decisions in the context of the current controversy related to buybacks.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): contemporary advances and current controversies.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory syndrome with characteristic clinical, radiological, and pathological features, and can be effectively treated with corticosteroid-based immunotherapies. The exact pathogenesis of CLIPPERS remains unclear, and specific diagnostic biomarkers are not available. According to the 2017 diagnostic criteria, probable CLIPPERS should be considered in middle-aged patients with subacute onset of pontocerebellar symptoms and typical punctuate and curvilinear gadolinium enhancement lesions ("salt-and-pepper" appearance) located in the hindbrain (especially pons) on magnetic resonance imaging. In addition, CLIPPERS-mimics, such as central nervous system (CNS) lymphoma, and several antibody-associated autoimmune CNS diseases (e.g., myelin oligodendrocyte glycoprotein antibody-associated disease, autoimmune glial fibrillary acidic protein astrocytopathy, and anti-N-methyl-D-aspartatereceptor encephalitis), should be extensively excluded. The prerequisite for definite CLIPPERS is the perivascular T-cell-predominant inflammatory infiltration observed on pathological analysis. A biopsy is strongly suggested when clinical/radiological red flags are present. Most patients with CLIPPERS respond well to corticosteroids and have a good prognosis. Long-term low-dose corticosteroid maintenance therapy or corticosteroids coupled with immunosuppressants are recommended to prevent the recurrence of the syndrome. The potential progression of CLIPPERS to lymphoma has been suggested in some cases; therefore, at least 2-year clinical and radiological follow-up is essential. Here, we critically review the recent developments and provided an update on the clinical characteristics, diagnostic criteria, differential diagnoses, and therapeutic management of CLIPPERS. We also discuss the current controversies in this context that can be resolved in future research studies.

Impostor Phenomenon in Racially/Ethnically Minoritized Groups: Current Knowledge and Future Directions.

In recent years there has been a surge of research conducted on the impostor phenomenon, with approximately half of all impostor phenomenon articles being published between 2020 and 2022 and growing interest in understanding how the impostor phenomenon affects racially and ethnically minoritized individuals. Questions around intersectionality remain about how to apply the impostor phenomenon to the experiences of minoritized individuals. In this review, we revisit the historical context of the impostor phenomenon. We address issues of nomenclature and current controversies regarding whether the impostor phenomenon (a) blames the victim, (b) should be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and (c) is beneficial for individuals. In addition, we address the limitations of current research on racially and ethnically minoritized individuals, especially women of color. Finally, we conclude by discussing the need for a reconceptualized racialized impostor phenomenon as well as the need to establish new impostor phenomenon measures, conduct more quantitative research with diverse samples, and create culturally tailored interventions.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and currentcontroversies.

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Postmastectomy radiotherapy in breast reconstruction: Current controversies and trends.

Breast cancer is the most common cancer among women worldwide. Postmastectomy radiotherapy (PMRT) is an essential component of combined therapy for early-stage, high-risk breast cancer. Breast reconstruction (BR) is often considered for patients with breast cancer who have undergone mastectomy. There has been a considerable amount of discussion about the optimal approach to combining PMRT with BR in the treatment of breast cancer. PMRT may increase the risk of complications and prevent good aesthetic results after BR, while BR may increase the complexity of PMRT and the radiation dose to surrounding normal tissues. The purpose of this review is to give a broad overview and summary of the current controversies and trends in PMRT and BR in the context of the most recent literature available.

The Role of Endocrine Disruptors Bisphenols and Phthalates in Obesity: Current Evidence, Perspectives and Controversies.

Excess body weight constitutes one of the major health challenges for societies and healthcare systems worldwide. Besides the type of diet, calorie intake and the lack of physical exercise, recent data have highlighted a possible association between endocrine-disrupting chemicals (EDCs), such as bisphenol A, phthalates and their analogs, and obesity. EDCs represent a heterogeneous group of chemicals that may influence the hormonal regulation of body mass and adipose tissue morphology. Based on the available data from mechanistic, animal and epidemiological studies including meta-analyses, the weight of evidence points towards the contribution of EDCs to the development of obesity, associated disorders and obesity-related adipose tissue dysfunction by (1) impacting adipogenesis; (2) modulating epigenetic pathways during development, enhancing susceptibility to obesity; (3) influencing neuroendocrine signals responsible for appetite and satiety; (4) promoting a proinflammatory milieu in adipose tissue and inducing a state of chronic subclinical inflammation; (5) dysregulating gut microbiome and immune homeostasis; and (6) inducing dysfunction in thermogenic adipose tissue. Critical periods of exposure to obesogenic EDCs are the prenatal, neonatal, pubertal and reproductive periods. Interestingly, EDCs even at low doses may promote epigenetic transgenerational inheritance of adult obesity in subsequent generations. The aim of this review is to summarize the available evidence on the role of obesogenic EDCs, specifically BPA and phthalate plasticizers, in the development of obesity, taking into account in vitro, animal and epidemiologic studies; discuss mechanisms linking EDCs to obesity; analyze the effects of EDCs on obesity in critical chronic periods of exposure; and present interesting perspectives, challenges and preventive measures in this research area.

The direct Z-scheme character and roles of S vacancy in BiOCl/Bi2S3-(001) heterostructures for superior photocatalytic activity: a hybrid density functional investigation.

Given some current speculations and controversies regarding the type of BiOCl/Bi2S3-(001) heterostructure in experiments, it is of great importance to clarify these controversies and further explain the relevant experimental results. In this work, based on first-principles hybrid density functional calculations, it is verified that the BiOCl/Bi2S3-(001) heterostructure is a direct Z-scheme photocatalyst with high photo-generated carrier separation efficiency and strong redox ability that can react with O2 and OH- to produce photocatalytic active species of superoxide ions (˙O2-) and hydroxyl radicals (˙OH), respectively. This is consistent with the experimental findings and explains the excellent photocatalytic performance of the BiOCl/Bi2S3-(001) heterostructure in experiments. Besides, excitingly, it is found that the optical absorption, built-in electric field intensity, interlayer recombination probability, hydrogen evolution reaction ability, and the difference in electron-hole mobility are further enhanced via S vacancy introduction in BiOCl/Bi2S3-(001). Therefore, the significant roles of S vacancy in further improving the photocatalytic properties of the BiOCl/Bi2S3-(001) heterostructure are profoundly revealed. This work can provide valuable theoretical insights for designing the superior direct Z-scheme BiOCl/VS-Bi2S3-(001) heterostructure with promising photocatalytic properties.

Current Challenges and Controversies in Colorectal Carcinoma Pathologic Staging-A Practical Guide.

The pathologic assessment of colorectal carcinoma specimens plays a crucial role in the therapeutic management of patients and disease prognostication. The TNM staging system is used globally and is a critical component of colorectal carcinoma pathology reporting. However, our experience informs us that there are significant variations in the assignment of the TNM stage, both between pathologists and between hospital centers. We identify several potential reasons for this, among them suboptimal gross and microscopic assessment of colorectal resection specimens and, later, nonuniformity in applying criteria set forth in pathologic TNM staging guidelines. In addition, some defining characteristics of the staging system remain poorly defined. We aim to enlist those issues with potential remedies to improve reproducibility and, therefore, multidisciplinary discussion.

Robotic radical hysterectomy for cervical cancer: current trends and controversies.

Minimally invasive radical hysterectomy (MIRH) is widely performed as a treatment for early-stage cervical cancer. However, in 2018, a randomized controlled trial (RCT) called the Laparoscopic Approach to Cervical Cancer (LACC) trial showed that MIRH had poorer oncologic outcomes compared to laparotomy. Since then, several clinical studies have supported this finding, and most surgeons now perform MIRH with limited surgical indications. However, most of the reported studies evaluated laparoscopic radical hysterectomy rather than robotic radical hysterectomy (RRH). Robotic surgery has advantages for complex surgical procedures in the deep and narrow pelvic cavity in cervical cancer, making it necessary to evaluate the benefits and potential harms of RRH individually. Based on this systematic review, RRH is a safe and effective alternative to abdominal approach for early-stage cervical cancer. RRH offers significant perioperative benefits, including reduced blood loss, shorter hospital stays, and fewer complications, without compromising oncologic outcomes such as overall survival and progression-free survival. Additionally, surgeons should aim to minimize tumor cell spillage into the peritoneal cavity by eliminating the use of uterine manipulators or vaginal colpotomy. Ongoing RCTs will reveal whether we can perform RRH without oncologic compromise in cervical cancer.

Unlocking the pathological pathway in urinary tract infection-induced brain fog: A literature review

Brain fog is a common and bothersome symptom caused by urinary tract infections. Along with other symptoms like delirium, memory issues, confusion, and disorientation, this cognitive impairment may include trouble thinking clearly. Sudden confusion or delirium can be brought on by urinary tract infections, especially in elderly or dementia patients. It is hypothesized that urinary tract infections affect hippocampal neurogenesis and other aspects of brain homeostasis, which may be linked to their effects on cognitive function. Moreover, mental anguish and confusion are linked to urinary tract infections, though not all symptoms that resemble urinary tract infections are caused by urinary tract infections. Our search turned up articles about delirium, brain fog, and urinary tract infections in PubMed, Google Scholar, Scopus, and other online databases. Urinary tract infections (UTIs) can cause a variety of symptoms, including brain fog, confusion, and delirium. These symptoms can impair cognitive function and require a thorough diagnosis. This review describes the various symptoms that are linked to urinary tract infections, ranging from traditional indications like fever and frequent urination to non-specific symptoms like delirium and confusion. It emphasizes how important it is to diagnose and comprehend non-specific symptoms by including assessment tools such as the Glasgow Coma Scale, DSM-V, and the Brief Confusion Assessment Method. In addition, it discusses the current controversy regarding the management of individuals with asymptomatic bacteriuria or urinary tract infections, emphasizing the difficulties in avoiding and treating urinary tract infections -related mental impairment. Confusion and delirium brought on by urinary tract infections are better understood when underlying causes, such as immunological, genetic, and microbiological factors, are investigated. Evaluating underlying factors such as immunological, genetic, microbiological aspects can lead to a better understanding of the confusion and uncertainty caused by UTI. This knowledge can help healthcare professionals in conditions, in order to improve diagnostic, therapeutic and management strategies for patients experiencing UTI and possibly cognitive impairment.

Poetry, Philosophy, and Smart AI

Abstract: Here I look at sundry aspects of the current controversy about Generative AI and, in particular, the implications of this new and rapidly evolving technology for poetry, the arts, and human creativity in general. My essay looks at earlier episodes in the history of thought, from Descartes on, that I take to have prefigured this latest debate around 'the human' in relation to its various physical, 'artificial,' or (presumptively) prosthetic means of extension and refinement. I also discuss its bearing on literary-critical issues concerning the formal or structural aspects of poetry, the role (if any) of authorial intent, and the extent to which criticism enters into– and might lay claim to a stake in–what counts as human creativity. A central point of reference is William Empson's 1930 book, Seven Types of Ambiguity, where these issues are raised in a strikingly prescient way through his practice of close-focused textual analysis allied to great philosophical acuity. I conclude that a priori attitudinizing, pro or con, is not much use in this context, but that poets, critics, philosophers, cognitive scientists, and AI researchers need to cooperate in the reexamination of many long-standing but now highly contestable distinctions.

The contribution of metal allergy to the failure of metal alloy implants, with special reference to titanium: Current knowledge and controversies.

After almost three-quarters of a century during which contact dermatologists have often struggled to comprehend the relationship between metal allergy and failure of metal-alloy containing implant, it is possible to say that a relationship does exist, particularly for cobalt and chromium, but also for nickel. There is still debate as to whether allergy develops as a consequent of failure but thenceforth contributes to it, or whether sensitisation starts first and induces failure secondarily-opinion probably favours the first. Metal-on-polypropylene articulations were associated with few metal allergic problems but now are less favoured by orthopaedists due to plastic wear products causing osteolysis and pseudotumour formation through local inflammation. New metal alloys are regularly being introduced such that interested dermatologists need to stay on top of the situation. The jury is still out as to whether the recent favouring of titanium-containing alloys will confirm them to be more inert allergenically. Case reports do show some clinical reactions to titanium-containing implants and patch test series have inferred sometimes quite a high background rate of allergy, but interpretation must be tempered by the awareness that titanium salts on patch testing have a tendency to cause irritant reactions. Blood monitoring of metal ion values is now recommended in certain situations after joint replacement and increasing levels may be an indication that allergy with joint failure can develop, in which case patch testing is indicated, and suggested series are available. Predictive patch testing, whilst generally not recommended in the past, has been introduced into some protocols often by non-dermatologists, such that it is now needed for temporo-mandibular joint and Nuss bar insertion, and it can be anticipated that this may become more commonplace in the future. One of the major current deficits for patch testers is standardised guidance on which preparation or preparations to use for suspected titanium allergy. One suggestion is 0.5% titanium sulphate in petrolatum, though experience in at least one centre suggests the use of a battery of titanium salts might be desirable.