Evidence-based Facts Research Articles

Introduction to Mindfulness: Evidence-Based Medicine Lecture and Active Session.

There is a growing body of evidence regarding the effectiveness of mindfulness practices and the benefits for the resilience of patients and medical professionals. Thus, there is a need to educate medical students in this technique and its benefits, but there are no readily available resources that emphasize the current evidence. We developed an introductory session for the mindfulness technique as an evidenced-based medicine lecture combined with an active mindfulness exercise. This session consisted of a PowerPoint lecture overview of mindfulness, a topic unknown to most students, with an emphasis on evidence-based facts, as well as an active practical mindfulness exercise. The effectiveness of the lecture was assessed using a survey instrument, which was designed to assess the learners' knowledge and interest in learning and using mindfulness (before and after the session) and their interest in integrating mindfulness into the medical school curriculum. The survey contained six multiple-choice questions. Participation was voluntary and anonymous, with the use of Turning Point technology (an audience response system). The session was administered to and evaluated by first- and second-year medical students with no prior instruction in mindfulness. The session was held by a physician who uses mindfulness in the clinic. After the session, 90% of students were interested in learning more about mindfulness, and the majority were interested in having mindfulness integrated into the medical curriculum. The results suggest the session can be effectively used as is in other medical teaching institutions to introduce students to mindfulness and to assess students' perception of knowledge in the area and their interest in both having more comprehensive training on the subject and practicing mindfulness in medical care.

Rapid maxillary expansion: a review of appliance designs, biomechanics and clinical aspects

Rapid maxillary expansion (RME) is an orthopaedic procedure that utilizes heavy forces to correct transverse maxillary arch discrepancies. There is a substantial body of literature relating to the various designs of RME devices and their clinical indications. CPD/Clinical Relevance: To provide the dental practitioner and orthodontist with evidence-based facts about types, designs and uses of RME appliances and to promote understanding of their biomechanical effects.

Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique.

The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach. During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified. We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6% (range 49-79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications. The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and "non-touch" oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.

Airway management for cervical spine surgery.

Cervical spine surgery is one of the most commonly performed spine surgeries in the United States, and 90% of the cases are related to degenerative cervical spine disease (the rest to cervical spine trauma and/or instability). The airway management for cervical spine surgery represents a crucial step in the anesthetic management to avoid injury to the cervical cord. The crux for upper airway management for cervical spine surgery is maintaining the neck in a neutral position with minimal neck movement during endotracheal intubation. Therefore, the conventional direct laryngoscopy (DL) can be unsuitable for securing the upper airway in cervical spine surgery, especially in cases of cervical spine instability and myelopathy. This review discusses the most recent evidence-based facts of the main advantages and limitations of different techniques available for upper airway management for cervical spine surgery.

A Conceptual Technique for Laparoscopic Right Hepatectomy Based on Facts and Oncologic Principles: The Caudal Approach.

To evaluate a new conceptual technique of laparoscopic right hepatectomy. Despite significant improvements in surgical care in the last decades, morbidity is still high after major hepatectomy. Blood loss and transfusions are known to significantly increase the risk of postoperative complications and cancer recurrence after liver resection. A laparoscopic approach may improve perioperative outcomes in these cases, but data in literature are limited and the surgical technique is not yet standardized. A new conceptual technique of right hepatectomy was designed using evidence-based facts and oncologic rules: laparoscopy with pneumoperitoneum, low central venous pressure, intermittent pedicle clamping, anterior approach without mobilization, and parenchymal section with ultrasonic dissector. Thirty patients were prospectively enrolled between October 2011 and September 2013. Primary endpoint was intraoperative blood loss. Eighty percent of patients underwent surgery for malignant disease and cirrhosis was present in 11 patients. Benign lesions accounted for 13% of indications, whereas living liver donation was performed in 2 cases. Median blood loss was 100 mL (50-700) and transfusion rate was 7%. Five patients (16.6%) required conversion to laparotomy, including 2 using hybrid technique. The median operative time was 360 minutes (210-510). R0 resection rate was 87% (21/24). Postoperative morbidity rate was 23% (7/30) with 8 complications including 6 Clavien III-IV. No respiratory complication occurred. The median hospital stay was 8 days. No patient died. This study showed that several evidence-based facts could be combined to define a new conceptual technique of laparoscopic right hepatectomy allowing for low blood loss and morbidity.

Don't Forget the Doctor: Gastroenterologists' Preferences on the Development of mHealth Tools for Inflammatory Bowel Disease.

BackgroundInflammatory bowel disease (IBD) encompasses a number of disorders of the gastrointestinal tract. Treatment for IBD is lifelong and complex, and the majority of IBD patients seek information on the Internet. However, research has found existing digital resources to be of questionable quality and that patients find content lacking. Gastroenterologists are frontline sources of information for North American IBD patients, but their opinions and preferences for digital content, design, and utility have not been investigated. The purpose of this study is to systematically explore gastroenterologists’ perceptions of, and design preferences for, mHealth tools.ObjectiveOur goal was to critically assess these issues and elicit expert feedback by seeking consensus with Canadian gastroenterologists.MethodsUsing a qualitative approach, a closed meeting with 7 gastroenterologists was audio recorded and field notes taken. To synthesize results, an anonymous questionnaire was collected at the end of the session. Participant-led discussion themes included methodological approaches to non-adherence, concordance, patient-centricity, and attributes of digital tools that would be actively supported and promoted.ResultsSurvey results indicated that 4 of the 7 gastroenterologists had experienced patients bringing digital resources to a visit, but 5 found digital patient resources to be inaccurate or irrelevant. All participants agreed that digital tools were of increasing importance and could be leveraged to aid in consultations and save time. When asked to assess digital attributes that they would be confident to refer patients to, all seven indicated that the inclusion of evidence-based facts were of greatest importance. Patient peer-support networks were deemed an asset but only if closely monitored by experts. When asked about interventions, nearly all (6/7) preferred tools that addressed a mix of compliance and concordance, and only one supported the development of tools that focused on compliance. Participants confirmed that they would actively refer patients and other physicians to digital resources. However, while a number of digital IBD tools exist, gastroenterologists would be reluctant to endorse them.ConclusionsGastroenterologists appear eager to use digital resources that they believe benefit the physician-patient relationship, but despite the trend of patient-centric tools that focus on concordance (shared decision making and enlightened communication between patients and their health care providers), they would prefer digital tools that highlight compliance (patient following orders). This concordance gap highlights an issue of disparity in digital health: patients may not use tools that physicians promote, and physicians may not endorse tools that patients will use. Further research investigating the concordance gap, and tensions between physician preferences and patient needs, is required.

Early recognition of fatigue in Parkinson's disease

Fatigue in Parkinson's disease (PD) remains under-recognised and under-treated by health-care professionals (HCPs). A PD patient suffering from fatigue can have an antagonistic outcome despite the best drug management given with the greatest quality of care. Untreated fatigue can cause unnecessary anxiety, concerns with employment, financial hardship, difficulties with relationships, increased need for care provision and poor quality of life. It is imperative that fatigue in PD is recognised, diagnosed, treated and managed effectively so that PD patients with fatigue can manage their time more resourcefully. Poor understanding among HCPs on this matter may result in a bad reputation and cause frustration among service users, mistrust and needless costs to the health-care system. This article highlights the importance of early recognition of fatigue in PD. It provides evidence-based clinical information and facts gained from clinical studies and research to help enhance HCPs' knowledge and understanding the subject and how to manage fatigue in PD effectively.

OrphanAnesthesia – anesthesia recommendations for patients suffering from rare diseases

Anesthesia is becoming safer over the past decades. This process was driven by the development of new anesthetics and the establishment of modern safety concepts. On the other hand anesthetists benefit from profound pathophysiological knowledge and the competence of translating patient specific conditions into individual perioperative risk. But in case of rare diseases this concept is often lacking specific knowledge about the patient conditions and its importance for anesthesia. OrphanAnesthesia is a common project of the Scientific Working Group of Paediatric Anaesthesia of the German Society of Anaesthesiology and Intensive Care Medicine in cooperation with the European Society for Paediatric Anaesthesia. The aim of OrphanAnesthesia is the publication of anaesthesia recommendations for patients suffering from rare diseases with the target of improving patients’ safety. When it comes to the management of rare diseases, there are only spare evidence-based facts and even far less knowledge in the anaesthetic outcome. OrphanAnesthesia would like to merge this knowledge based on scientific publications and proven experience of specialists and make it available for physicians worldwide. All OrphanAnesthesia recommendations are standardized and need to pass a peer review process. They are being reviewed by at least one anaesthesiologist and another disease expert involved in the treatment of this group of patients. The project OrphanAnesthesia is internationally orientated. Our recommendations will be published in English on the OrphanAnesthesia website as well as in the medical journal “Anaesthesiologie und Intensivmedizin” basically. At a later time we are going to make most of the translations available to attract a larger number of readers. The first recommendations have already been published online on http://www.orphananesthesia.eu. Authors and reviewers are from all over the world. We have received a great feedback and are convinced to be able to increase the patients’ safety. Of course we also would like to increase the number of recommendations, considering the facts that there are about 8,000 diagnosed rare diseases.

CMV

Exclusively for TheHearingJournal.com AUGUST 2013 After two-year-old Daisy Doutre developed profound bilateral hearing loss from a common herpes virus she had at birth, her grandmother, Utah Rep. Ronda Rudd Menlove, R-Garland, took steps to raise public awareness of one of the leading causes of hearing loss in children. Rep. Menlove successfully sponsored House Bill 81, leading to the July launch of a cytomegalovirus (CMV) education and prevention initiative in Utah—the first of its kind in the country. The new law requires the Utah Department of Health (UDOH) to educate pregnant women and women who may become pregnant about the health complications of CMV and how to prevent the virus. It also requires medical practitioners to test newborns for congenital CMV before they’re 21 days old if they fail two hearing tests. This public health movement is very important because it deals with a virus that can easily be avoided with good hygiene, said Stephanie McVicar, AuD, director of UDOH Early Hearing Detection and Intervention. “The education component is carried out in two ways: through an active conversation with patients and through the distribution of informative flyers. “Our department assembled a committee of experts to produce a set of evidence-based facts on CMV. It includes topics like risks and prevention, and tells mothers to wash their hands after changing diapers and feeding. “The other part involves doctors and nurses talking to their patients about CMV because many of them have never heard of it before.” Most children and adults with strong immune systems don’t show any signs or symptoms after being infected with CMV. Serious health complications, however, such as hearing loss and developmental disabilities can arise if an infected pregnant woman transmits the virus to her unborn baby. Of the 30,000 babies born with congenital cytomegalovirus in the United States every year, about 5,000 develop permanent problems because of it, according to the Centers for Disease Control and Prevention (CDC). “While the screening process is a step in the right direction, about half of the babies infected with CMV will pass the hearing tests and initially go undiagnosed because of its frequent late onset,” Dr. McVicar said. Even though the campaign won’t identify every newborn with congenital CMV, it will make a difference in the fight against a leading cause of hearing loss, said Karen Fowler, DrPH, of the University of Alabama at Birmingham. “There are certainly some precautionary steps we can take like conducting additional hearing screenings throughout a child’s adolescence to make sure nothing has changed,” she said. “While there is still no vaccine for CMV today, there is an increased awareness, and maybe someday soon we Stephanie McVicar

The Neglected Mandate: Teaching Science as Part of Our Culture

I have been asked to introduce for your consideration a matter which is as urgent as the time given to me here is brief. I do so gladly, chiefly for two reasons: One is that by experiment on a national and international scale it has been proven that teaching science with the inclusion of a measure of history and philosophy can be done, with success, even though with much labor. The other reason is that this way of improving science teaching is urgently needed just now. For let us be frank here: While we all know exemplary cases of fine science teaching, the results on average in this country are abysmal, by national and international comparisons. You all know the facts. For our profession as educators, this is a deeply sobering matter. Moreover, it is coming just at the time in history when, on many measures, the U.S. lags far behind those of many of our ambitious and well-organized foreign opponents— regarding the knowledge of science by students and the wider public, even regarding the respect for scientific reasoning and evidence-based facts. On this front, one may still say that ours is ‘‘A Nation at Risk’’. Thus I earnestly believe that there is an urgent need to upgrade the teaching of science now. For the nation faces a challenge not very different from that, many decades ago, when the Soviet Union launched Sputnik. At that time we woke up, realizing how we had failed in many crucial ways, and seriously experimented with greatly improved science teaching. Many at this conference will have had some experience with those efforts. I feel sure that from the results of the experiments which succeeded then there are valuable lessons for our own situation today. I have been invited to speak about one of them, in which I was and still am involved. In a nutshell, it started with an approach to me from the National Science Foundation. The Foundation had supported a large-scale introductory physics course (Physical Science Study Committee) developed by distinguished physicists at MIT. It was imaginative and successful; but the Foundation was concerned that despite its excellence it was reaching a

Ambitions and Responsibilities: A Textual Analysis of the Norwegian National Curriculum Regulations for Nursing Education

Society assigns professional educational programs the responsibility to aid students in learning and dedicate expert knowledge to furthering the well-being of citizens. This demand calls for addressing the how educational policies prioritize learning professionals' responsibility. Inspired by the theory of Jacques Derrida, we deconstruct the national curriculum text for Norwegian nursing education. Our findings indicate that, despite highlighting ethics and a holistic view on human beings, “hard evidence-based facts” remain the main navigation tool for responsible behavior. Additionally, by introducing “operational preparedness” as a learning goal, the texts partly renounce the obligation to educate for essential dimensions of responsibility by distributing the obligation to the future employer and the individual student.

Transparency and accountability in mass media campaigns about organ donation: a response to Morgan and Feeley

We respond to Morgan and Feeley's critique on our article "Mass Media in Organ Donation: Managing Conflicting Messages and Interests." We noted that Morgan and Feeley agree with the position that the primary aims of media campaigns are: "to educate the general public about organ donation process" and "help individuals make informed decisions" about organ donation. For those reasons, the educational messages in media campaigns should not be restricted to "information from pilot work or focus groups" but should include evidence-based facts resulting from a comprehensive literature research. We consider the controversial aspects about organ donation to be relevant, if not necessary, educational materials that must be disclosed in media campaigns to comply with the legal and moral requirements of informed consent. With that perspective in mind, we address the validity of Morgan and Feeley's claim that media campaigns have no need for informing the public about the controversial nature of death determination in organ donation. Scientific evidence has proven that the criteria for death determination are inconsistent with the Uniform Determination of Death Act and therefore potentially harmful to donors. The decision by campaign designers to use the statutory definition of death without disclosing the current controversies surrounding that definition does not contribute to improved informed decision making. We argue that if Morgan and Feeley accept the important role of media campaigns to enhance informed decision making, then critical controversies should be disclosed. In support of that premise, we will outline: (1) the wide-spread scientific challenges to brain death as a concept of death; (2) the influence of the donor registry and team-huddling on the medical care of potential donors; (3) the use of authorization rather than informed consent for donor registration; (4) the contemporary religious controversy; and (5) the effects of training desk clerks as organ requestors at the Department of Motor Vehicles offices. We conclude that organ donation is a medical procedure subject to all the ethical obligations that the medical profession must uphold including that of transparency and truthfulness.

Message formats and their influence on perceived risks of tobacco use: a pilot formative research project in India

In India, tobacco kills 900,000 people every year though the burden of tobacco is faced disproportionately in poorer states such as Bihar. Teachers may be a particularly influential group in setting norms around tobacco use in the Indian context. However, tobacco use among teachers remains high and perceptions of tobacco-related health risks are unexplored. To qualitatively explore perceptions about tobacco use among teachers in Bihar and to examine how risk information may be communicated through a variety of message formats, 12 messages on tobacco health risks varying in formats were tested in focus groups with teachers from Bihar. Participants stated that teachers were already aware of tobacco-related health risks. To further increase awareness of these risks, the inclusion of evidence-based facts in messages was recommended. Communicating risk information using negative emotions had a great appeal to teachers and was deemed most effective for increasing risk perception. Messages using narratives of teachers' personal accounts of quitting tobacco were deemed effective for increasing knowledge about the benefits of quitting. To conclude, messages using evidence-based information, possibly with negative emotions, testimonials with role models and those messages emphasizing self-efficacy in the format of narratives appear to appeal to teachers in Bihar.

Corrigendum

Glimepiride: evidence-based facts, trends, and observationsBasit A, Riaz M, Fawwad A Vascular Health and Risk Management 2012, 8:463–472The title of the paper should have read "Glimepiride: evidence-based facts, trends, and observations (GIFTS)."Read the original article

Glimepiride: evidence-based facts, trends, and observations

Glimepiride: evidence-based facts, trends, and observations Abdul Basit, Musarrat Riaz, Asher FawwadDepartment of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, PakistanAbstract: Type 2 diabetes mellitus is characterized by insulin resistance and progressive β cell failure; therefore, β cell secretagogues are useful for achieving sufficient glycemic control. Glimepiride is a second-generation sulfonylurea that stimulates pancreatic β cells to release insulin. Additionally, is has been shown to work via several extra pancreatic mechanisms. It is administered as monotherapy in patients with type 2 diabetes mellitus in whom glycemic control is not achieved by dietary and lifestyle modifications. It can also be combined with other antihyperglycemic agents, including metformin and insulin, in patients who are not adequately controlled by sulfonylureas alone. The effective dosage range is 1 to 8 mg/day; however, there is no significant difference between 4 and 8 mg/day, but it should be used with caution in the elderly and in patients with renal or hepatic disease. In clinical studies, glimepiride was generally associated with lower risk of hypoglycemia and less weight gain compared to other sulfonylureas. Glimepiride use may be safer in patients with cardiovascular disease because of its lack of detrimental effects on ischemic preconditioning. It is effective in reducing fasting plasma glucose, post-prandial glucose, and glycosylated hemoglobin levels and is a useful, cost-effective treatment option for managing type 2 diabetes mellitus.Keywords: antihyperglycemic agents, diabetes, glimepiride, sulfonylurea

Glimepiride: evidence-based facts, trends, and observations (GIFTS). [corrected

Type 2 diabetes mellitus is characterized by insulin resistance and progressive β cell failure; therefore, β cell secretagogues are useful for achieving sufficient glycemic control. Glimepiride is a second-generation sulfonylurea that stimulates pancreatic β cells to release insulin. Additionally, is has been shown to work via several extra pancreatic mechanisms. It is administered as monotherapy in patients with type 2 diabetes mellitus in whom glycemic control is not achieved by dietary and lifestyle modifications. It can also be combined with other antihyperglycemic agents, including metformin and insulin, in patients who are not adequately controlled by sulfonylureas alone. The effective dosage range is 1 to 8 mg/day; however, there is no significant difference between 4 and 8 mg/day, but it should be used with caution in the elderly and in patients with renal or hepatic disease. In clinical studies, glimepiride was generally associated with lower risk of hypoglycemia and less weight gain compared to other sulfonylureas. Glimepiride use may be safer in patients with cardiovascular disease because of its lack of detrimental effects on ischemic preconditioning. It is effective in reducing fasting plasma glucose, post-prandial glucose, and glycosylated hemoglobin levels and is a useful, cost-effective treatment option for managing type 2 diabetes mellitus.

The Pain of Chronic Lyme Disease: Moving the Discourse Backward?

Phillip Baker has taken “Lyme denialism” to new depths (1). According to the Institute of Medicine, there are at least 116 million people living with acute and chronic pain in the United States. According to Baker, not one of those individuals suffers from chronic Lyme disease as a result of persistent infection with the Lyme spirochete, Borrelia burgdorferi. What is the basis for his opinion? Baker claims that “there is no evidence to indicate that chronic Lyme disease is due to a persistent infection” or that “extended antibiotic therapy is beneficial and safe”. This denialist statement about a disease that causes pain and suffering equivalent to that of diabetes or congestive heart failure ignores a growing body of evidence from the peer-reviewed medical literature that contradicts his opinion (2–5). Baker starts by attacking “Lyme-literate” physicians who use a “Lyme disease specialty laboratory” to diagnose tick-borne disease in a manner that is inconsistent with the surveillance case definition established by the Centers for Disease Control and Prevention (CDC). What Baker fails to tell us is that the CDC admits that its surveillance case definition “was developed for national reporting of Lyme disease” and was “not intended to be used in clinical diagnosis” (6). Thus, the diagnostic approach that Baker endorses is inappropriate for diagnosis of Lyme disease. Furthermore, the 46 patented commercial laboratory tests that Baker recommends for Lyme disease diagnosis have a sensitivity of only 46% and appear to yield results that are biased against women (7–9). Consequently, these commercial tests miss more than one-half of the patients with chronic Lyme disease in the United States. In contrast, the maligned “Lyme disease specialty laboratory” uses diagnostic criteria based on evidence from the peerreviewed medical literature (10, 11), and its “genderneutral” testing has a sensitivity and specificity of 90% (12). Clearly, this testing is preferable for the diagnosis of Lyme disease. As for Baker’s pat statement that “there is no evidence to indicate that chronic Lyme disease is due to a persistent infection,” numerous reports of veterinary cases and animal models confirm persistent infection with the Lyme spirochete in gerbils, hamsters, mice, dogs, monkeys, birds, and horses (13– 15). Among these cases, persistent pathology was seen in mice, dogs, and horses after the animals failed short-course treatment for their infection. Furthermore, there are at least 27 reports of persistent symptoms and failure to eradicate B. burgdorferi infection in humans treated with short-course antibiotic therapy for their tick-borne disease (5). Why does Baker deny these reports? He does so because they do not fit his limited view of Lyme disease. Baker also attacks the safety and efficacy of prolonged antibiotic therapy for chronic Lyme disease, stating that “all of the evidence obtained thus far...indicates no significant benefit as well as serious safety problems” with extended antibiotic therapy for these patients. What Baker fails to tell us is that the number of patients in controlled trials of Lyme disease treatment totals a mere 221 highly selected subjects who do not represent the vast majority of patients with chronic Lyme disease (3–5). Further analysis of these studies reveals that they were “of questionable quality”, lacked the power to detect potentially positive treatment effects, and failed to report predefined endpoints (16). Even so, in two of the four controlled trials, a significant benefit was seen in fatigue and cognition with the limited antibiotic regimen that was used, and safety problems were minimal (17, 18). In larger studies of extended antibiotic therapy, the safety of this treatment was shown to be acceptable, and the benefit of extended therapy was significant in terms of cognition, fatigue, and myalgic pain, although it took 6 –12 months of i.v. therapy to achieve this benefit (19, 20). In summary, Baker’s denialist view of the Lyme disease epidemic ignores significant evidence from the peer-reviewed medical literature that contradicts his opinion. It follows that practitioners who subscribe to his narrow view are abandoning the multitude of patients with acute and chronic pain who would benefit from treatment for their persistent spirochetal infection.

Plagiarism in scientific writing: words or ideas?

Plagiarism in scientific writing: words or ideas?

Chronic renal failure from lead: myth or evidence-based fact?

In this mini review, we would like to challenge the well-established 'fact' that lead exposure causes chronic renal failure (CRF). Even though only scarce evidence exists of the relationship between lead and renal failure, a World Health Organization Environmental Health Criteria document summarizes that 'Lead has been a very common cause of acute or chronic renal failure'. It is also written and cited in textbooks and numerous publications that chronic lead nephropathy causes a slowly progressive interstitial nephritis manifested by a reduced glomerular filtration rate, and that there is a growing consensus that lead contributes to hypertension in the general population. We will argue that, when published reports are carefully scrutinized, such statements on lead and CRF are not evidence based but are rather founded on a few narrative reports on lead-exposed individuals and statistical associations between lead and serum creatinine (or urea) in a few population studies. We will, however, not argue that lead is not toxic and that lead does not cause other types of severe health effects where the evidence is unquestionable, but we do not believe that the kidneys are an early victim after lead exposure.

Evaluating botulinum toxin products for clinical use requires accurate, complete, and unbiased data

Evaluating botulinum toxin products for clinical use requires accurate, complete, and unbiased data