Obvious Cases Research Articles

New classification of the penoscrotal positional anomalies.

The aspect of sexual differentiation and the mechanism controlling the position of genitalia, which represents one of the most substantial differences between the sexes, is still poorly understood. Minor cases and some variants of penoscrotal transposition (PST) are unreported, and obvious cases were classified broadly and confused with other unrelated anomalies. Relevant literature published till 2022 were reviewed then organized, recapitulated, and presented in comparison with the findings and data of 65 child diagnosed with PST. So, an integrated comprehensive approach to this uncommon condition enabled a new classification including few unreported variant cases, which were complemented. PST is classified herein into a cephalic or caudal scrotal migration, the cephalic type subdivided into major and minor subtypes the latter type subdivided into bilateral, unilateral or central subtypes. Cases of caudal scrotal regression is an unreported anomaly in which the scrotum located caudally, as constant association with epispadias/exstrophy anomalies leaving a wide distance between the fixed penis and the scrotal sacs. PST is not rare as it was believed, it occurs in two directions; cephalic and caudal directions. Scrotal caudal regression anomaly was not described before, as well the PST presented as an inguinal hernia.

Catch me if you can: free-living mice show a highly flexible dodging behaviour suggestive of intentional tactical deception.

Intentional tactical deception, the employment of a tactic to intentionally deceive another animal, is a complex behaviour based on higher-order cognition, that has rarely been documented outside of primates and corvids. New laboratory-to-field assays, however, provide the opportunity to investigate such behaviour among free-living mice. In the present study, we placed laboratory-style test chambers with a single entrance near a forest outside Warsaw, where we observed the social interactions of two territorial murids, black-striped and yellow-necked mice, under food competition for seven months. Notably, among the social interactions, we video-recorded 21 instances of deceptive pursuer evasion. In the most obvious cases, an individual inside the chamber, to avoid an incoming mouse, hid by the chamber opening (the only means to enter or exit), paused until the pursuer entered and passed by, and then exploited the distraction of the back-turned pursuer by fleeing through the opening in a direction opposite to the one the pursuer came from. This deceptive dodging is the first evidence of a behaviour suggestive of intentional tactical deception among mice. As such, this deceptive behaviour may be of interest not only for rodent psychology but also, more generally, for the fields of non-human intentionality and theory of mind.

Non-belief as self-deception?

Abstract The suppression thesis is the theological claim that theistic non-belief results from culpable mistreatment of one's knowledge of God or one's evidence for God. The thesis is a traditional one but unpopular today. This article examines whether it can gain new credibility from the philosophy of self-deception and from the cognitive science of religion. The thesis is analysed in terms of the intentionalist and the non-intentionalist model of self-deception. The first proposed model views non-belief as intentional suppression of one's implicit knowledge of God. It is less feasible psychologically but has a good theological fit with Paul's and Calvin's versions of the thesis. This model also helps the argument for the culpability of non-belief. The second model views suppression as a process of subconscious motivated reasoning driven by a desire to avoid an uncomfortable truth. It fits Pascal's view that one's desire for or against God determines whether one sees general revelation as providing sufficient evidence for God. There is some empirical and anecdotal evidence for both models, but obvious cases of non-resistant non-belief present a major problem for the suppression thesis. Also, it is hard to see what might motivate anyone to deceive oneself about God's existence.

Pulse selection algorithm for NM64 neutron detector

We propose an algorithm to sepearate pile-up pulses in neutron detectors by utilizing a standard pulse. For this method to be effective, the data must consist mostly of isolated pulses. First, we define a reference pulse by averaging a sample of clearly isolated pulses. Then, for an arbitrary signal, we calculate a shape deviation by summing up the squared residuals between it and the reference pulse. The pulse with the greatest shape deviation is removed from the process. We then recalculate the reference pulse and repeat until the remaining pulses have shape deviation within a threshold. These remaining pulses exhibit a very good linear trend between area and height, allowing us to screen those suspected as pile-ups. A pulse much higher than the final reference pulse, despite being in the area-height-trend and having low shape deviation, is considered a pile-up of two identical pulses. The final reference pulse is fitted to a function defined by two pieces of Gaussian-multiplied polynomial, normalized, and called the standard pulse. We attempted to fit the pile-up pulse with one standard pulse to separate pile-up pulses. If the sum of squared normalized residuals is higher than some threshold, we add one more pulse, try fitting again, and repeat up to three pulses. We apply this algorithm to the pulses collected from one counter at the Princess Sirindhorn Neutron Monitor station at the summit of Doi Inthanon Mountain, Chiang Mai, Thailand, measured by an oscilloscope. The algorithm correctly separates obvious pile-up cases, allowing to record individual pulse timing with improved accuracy. However, we found small pulses, usually belong to gamma rays, that blend with neutron pulse and pass 100 mV output filtration. After removing those under 100 mV, the pulse area distribution of the separated pile-up is consistent with that of single pulses except at very small pulse sizes.

Social Justice in Nigeria: A Dialectical Discourse

This paper examined the nexus between social justice, national development, and nation-building in Nigeria. It adopted the qualitative and historical descriptive method of analysis because, by its nature, the topic was not amenable to quantitative analysis. One of the important findings of the paper is that though Nigerian citizens have remained together within the same political space in spite of many challenges, there are obvious cases of inequality and glaring examples of the negation of the principles of social justice by the leadership class. The result of the breaches of the constitutional provision for social justice is Nigeria’s inability to consolidate its diversity to achieve national development and nation-building, as is the case in other heterogenous federations like the United States. The paper concluded that a possible way out of this quagmire is for the federal government to adopt concrete official measures to encourage attitudinal and behavioural changes among both the leaders and ordinary Nigerians in order to ensure faithful adherence to social justice, which is considered a panacea for the challenges of national development and nation-building.

Direct Dependence on Philo in the Epistle to the Hebrews

Abstract The near consensus opinion that the author of Hebrews was not directly influenced by Philo needs to be reevaluated. Even though there are no obvious cases of borrowing, the cumulative weight of the evidence indicates a more linear relationship than what may be accounted for by situating them both within Hellenistic Judaism. A number of parallels are sufficiently detailed to suggest direct dependence. These parallels are of a formal character, such as the metaphor of the dagger and the particular use of the terms ὑπόστασις, ἀρχηγός, τελειόω, ἄθλησις, τεχνίτης, and δημιουργός, as well of a material nature, concerning the development of key ideas, such as the eternal nature of the Son, his Melchizedekian high-priesthood, and the perception of the heavenly sanctuary.

Profile of autopsy cases at tertiary care centre during pandemic

The profile of autopsy cases are necessary for taking necessary preventive measures in future. New civil hospital is a government tertiary care center in south Gujarat where annually approximately 2500 cases are brought for postmortem examination. Forensic medicine department conducts postmortem examination of expert level cases which are directly brought by investigating officer or referred from medical officers. Manner of death is very important to determine the nature of investigation. The present study is a retrospective study. It includes all the total 131 expert autopsy cases conducted from 1 Jan 2020 to 31 Dec 2020. The emphasis was given on age, sex, cause of death, manner of death, mode of death, causative weapons. All these data were collected and analyzed. In the year 2020 total 131 expert cases out of them 89 male, 41 female and 1 unknown. Among them mode of death 26.72 % asphyxia, 20.61% coma, 33.59% syncope, 9.16% pending and 9.92% undetermined, 48.09% homicidal, 14.5% suicidal, 6.11% accidental, 12.98% natural death cases, 9.92% negative autopsy, 15.26% cases the time since death was within 12 hours. Present study evaluates the expert and referred autopsy cases conducted in a tertiary center, majority of the cases are of allegation and highly suspicious nature. So very few cases of road traffic accident and natural deaths or obvious suicidal death cases are brought to our department. So sometimes it becomes a challenging work to determine manner of the death, causative weapon and time since death.

A SHIELD OR A SWORD? MIGRATION LAW AND POLICY AND MODERN SLAVERY IN AUSTRALIA

How might migration legislation and policies contribute to modern enslavement of migrants in Australia? Migration law and policy are a shield in the sense that they have been used and have the potential to be used to shield or protect trafficked individuals and those subject to modern slavery. Nevertheless, the state could be complicit in modern slavery through its migration law and policies exemplified by English language requirements for visas and for entering into certain professions. By placing the English language barrier between migrants and their economic and professional aspirations in obvious cases when a demand for proof of English language proficiency must not be made in the first place, the Australian Government and institutions create the environment conducive for excluding migrants from the professions and exposing them to economic abuse and exploitation. The stated basis of the English language requirements for Australian visas is that English language ‘is critical to getting a job’ and safely practising a profession and participating in Australian society. Yet migrants from non-exempt countries are required to sit for an English test when they apply for permanent resident visas (such as Subclass 186) and temporary visas (such as Subclass 485), even when they are present and already employed in Australia. Educational qualifications in English awarded by Australian and non-Australian tertiary educational institutions that satisfy the Australian study and qualification requirements are not the acceptable proof of competency in the English language. The effect of non-recognition of educational qualifications in English as proof of the English language ability is that visa applicants from non-exempt countries, even those present and working in Australia and/or who have completed a course of study in Australia, have to sit for an English language test. The content of this test bears no connection whatsoever with the English language used in practice. The test has an expiry date thereby tying migrants’ English language ability to the test expiry date, suggesting that once the test expires, so does their competency in English. Failing one component of the test requires resitting all the four components. Whereas an Australian educational qualification in English is required for admission to the legal, medical and nursing professions, the English language competence of migrants from non-exempt countries who hold the qualification is extracted from this qualification. Therefore, migrants cannot rely on the qualification as prove of their competency in English, even though the practice boards accept this same qualification as meeting the standards for admission to practise. The evidence disallowed or required to prove the English language capability both for Australian visas and to enter into the professions thus belies the stated purposes of the English language requirements. English is a global language that is spoken by different nationalities in different parts of the world. Therefore, taking a blanket approach that proficient speakers of English originate in the nations that are exempt from the English language requirements ignores the reality of English language usage. In these circumstances, the English language would seem a disguised legal and policy tool for gatekeeping, exclusion and nationality-based discrimination. The deliberate denial of the English language abilities of certain migrants and the stipulation of absurd and inexplicable evidentiary requirements as proof of the English language competency deprive such migrants of opportunity to enter into professions of their choice, ridicule and expose them to exploitation and modern slavery contrary to Australian values and legislation on equality and fair play.

THEMES OF GRAMMATICAL FORMS IN THE NOMINATIVE SYSTEM

<p><span>The grammatical phenomenon of transforming a grammatical form into a new topic, as a representative form of speech or as a topic within a paradigm, we will call grammatical thematization. This phenomenon has been quite widespread in the historical development of the morphological structure of Albanian language. It is spread throughout the morphological system of variable parts of speech. Thematizations of grammatical forms are new linguistic states obtained for psychological, social, and linguistic reasons. In the noun system, the most numerous and obvious cases of thematization of grammatical forms are observed in the grammatical category of number. The most common process has been to use many grammatical plural forms as singular. These conversions from the plural form to the singular are generally called singularized plurals. Due to the occurrence of this phenomenon in different periods - often even in very old periods - they have completely replaced the singular and formed a new plural. The thematization of grammatical forms should not only be ascertained but should also be followed historically. However, the paper deals with special issues that can serve as a starting point for further studies and in-depth studies.</span></p><p><span><strong>Keywords:</strong> Thematization, grammatical form, noun system, grammatical category.</span></p>

On the absence of structure factors in concentrated colloidal suspensions and nanocomposites.

Small-angle scattering is a commonly used tool to analyze the dispersion of nanoparticles in all kinds of matrices. Besides some obvious cases, the associated structure factor is often complex and cannot be reduced to a simple interparticle interaction, like excluded volume only. In recent experiments, we have encountered a surprising absence of structure factors (S(q) = 1) in scattering from rather concentrated polymer nanocomposites (Genix et al. in ACS Appl Mater Interfaces 11(19):17863-17872, 2019). In this case, quite pure form factor scattering is observed. This somewhat "ideal" structure is further investigated here making use of reverse Monte Carlo simulations in order to shed light on the corresponding nanoparticle structure in space. By fixing the target "experimental" apparent structure factor to one over a given q-range in these simulations, we show that it is possible to find dispersions with this property. The influence of nanoparticle volume fraction and polydispersity has been investigated, and it was found that for high concentrations only a high polydispersity allows reaching a state of S = 1. The underlying structure in real space is discussed in terms of the pair-correlation function, which evidences the importance of attractive interactions between polydisperse nanoparticles. The calculation of partial structure factors shows that there is no specific ordering of large or small particles, but that the presence of attractive interactions together with polydispersity allows reaching an almost "structureless" state.

THEMES OF GRAMMATICAL FORMS IN THE NOMINATIVE SYSTEM

The grammatical phenomenon of transforming a grammatical form into a new topic, as arepresentative form of speech or as a topic within a paradigm, we will call grammatical thematization. Thisphenomenon has been quite widespread in the historical development of the morphological structure ofAlbanian language. It is spread throughout the morphological system of variable parts of speech.Thematizations of grammatical forms are new linguistic states obtained for psychological, social, and linguisticreasons. In the noun system, the most numerous and obvious cases of thematization of grammatical forms areobserved in the grammatical category of number. The most common process has been to use many grammaticalplural forms as singular. These conversions from the plural form to the singular are generally calledsingularized plurals. Due to the occurrence of this phenomenon in different periods - often even in very oldperiods - they have completely replaced the singular and formed a new plural. The thematization ofgrammatical forms should not only be ascertained but should also be followed historically. However, the paperdeals with special issues that can serve as a starting point for further studies and in-depth studies.

A Scoping Review of Diagnosis of Autism Spectrum Disorder in Primary Care

This scoping review was performed to collect, examine, and present literature on interventions promoting the diagnosis of Autism Spectrum Disorder (ASD) in U.S. primary health care settings. The literature searched was from 2011-2022, in the English language, in PubMed, CINAHL, Psych INFO, Cochrane, and Web of Science, for persons with autism or ASD aged ≤ 18 years. Six studies met the search criteria, including a quality improvement project, a feasibility study, a pilot study, and three primary care provider (PCP) intervention trials. Measured outcomes included: accuracy of diagnosis (n=4), practice change maintenance (n=3), time to diagnosis (n=2), specialty clinic appointment wait time (n=1), PCP comfort making ASD diagnosis (n=1), and increased ASD diagnosis (n=1). Results inform future implementation of PCP ASD diagnosis for the most obvious cases of ASD and research evaluating PCP training, using longitudinal measures of PCP knowledge of ASD and intention to diagnose.

Ontology as ideology: A critique of Butler's theory of precariousness

Ontology as ideology: A critique of Butler's theory of precariousness

Acupuncture and Chinese herbal medicine for menopausal mood disorder: a randomized controlled trial

Objective This study aimed to analyze the effectiveness of acupuncture combined with Chinese herbal medicine (CHM) on mood disorder symptoms for menopausal women. Methods A total of 95 qualified Chinese participants were randomly assigned to one of three groups: 31 in the acupuncture combined with CHM group (combined group), 32 in the acupuncture combined with CHM placebo group (acupuncture group) and 32 in the CHM combined with sham acupuncture group (CHM group). The patients were treated for 8 weeks and followed up for 4 weeks. The data were collected using the Greene Climacteric Scale (GCS), self-rating depression scale (SDS), self-rating anxiety scale (SAS) and safety index. Results The three groups each showed significant decreases in the GCS, SDS and SAS after treatment (p < 0.05). Furthermore, the effect on the GCS total score and the anxiety domain lasted until the follow-up period in the combined group (p < 0.05). Within the three groups, there was no difference in GCS and SAS between the three groups after treatment (p > 0.05). However, the combined group showed significant improvement in the SDS, compared with both the acupuncture group and the CHM group at 8 weeks and 12 weeks (p < 0.05). No obvious abnormal cases were found in any of the safety indexes. Conclusions The results suggest that either acupuncture, or CHM or combined therapy offer safe improvement of mood disorder symptoms for menopausal women. However, the combination therapy was associated with more stable effects in the follow-up period and a superior effect on improving depression symptoms.

Periapical Radiography versus Cone Beam Computed Tomography in Endodontic Disease Detection: A Free-response, Factorial Study

AimTo assess and compare reader performance in interpreting digital periapical (PA) radiography and cone beam computed tomography (CBCT) in endodontic disease detection, using a free-response, factorial model. Materials and MethodsA reader performance study of 2 image test sets was undertaken using a factorial, free-response design, accounting for the independent variables: case type, case severity, reader type, and imaging modality. Twenty-two readers interpreted 60 PA and 60 CBCT images divided into 5 categories: diseased–subtle, diseased–moderate, diseased–obvious, nondiseased–subtle, and nondiseased–obvious. Lesion localization fraction, specificity, false positive (FP) marks, and the weighted alternative free-response receiver operating characteristic figure of merit were calculated. ResultsCBCT had greater specificity than PA in the obvious nondiseased cases (P = .01) and no significant difference in the subtle nondiseased category. Weighted alternative free-response receiver operating characteristic values were higher for PA than CBCT in the subtle diseased (P = .02) and moderate diseased (P = .01) groups with no significant difference between in the obvious diseased groups. CBCT had higher mean FPs than PA (P < .05) in subtle diseased cases. Mean lesion localization fraction in the moderate diseased group was higher in PA than CBCT (P = .003). No relationships were found between clinical experience and all diagnostic performance measures, except for in the obvious diseased CBCT group, where increasing experience was associated mean FP marks (P = .04). ConclusionsReader performance in the detection of endodontic disease is better with PA radiography than CBCT. Clinical experience does not impact upon the accuracy of interpretation of both PA radiography and CBCT.

Effect of VEGF on neurological impairment and prognosis of acute cerebral infarction patients: A retrospective case-control study.

Due to the complex pathological mechanism of acute cerebral infarction, the role of vascular endothelial growth factor (VEGF) on the disease is not clear. Therefore, a retrospective case-control study was performed to explore the effect of VEGF on neurological impairment and prognosis of acute cerebral infarction patients. A total of 100 patients with acute cerebral infarction admitted to our hospital from April 2021 to April 2022 were selected. Blood samples from all patients would be routinely collected to detect the expression of serum VEGF. Pearson chi-square, Spearman correlation and univariate Logistic regression were used to analyze the clinical data to explore the relationship between VEGF expression and basic information, stroke degree, quality of life, and prognosis of patients. To determine whether VEGF can provide relevant basis for the early prevention and prognostic treatment of acute cerebral infarction. And multivariate logistic regression was used to calculate the odds ratio between each variable and VEGF expression. Pearson chi-square test and Spearman correlation coefficient showed that sex, degree of stroke, limb convulsions, loss of consciousness, hemiplegia, aphasia, mental functioning score, overall quality of life score, and short-term prognosis were significantly correlated with VEGF expression in 100 patients. Univariate logistic regression was used to describe the ORs and 95% confidence interval of subjects at the univariate level, and the degree of stroke (OR = 83.333, P < 0.001), tic of limbs (OR = 26.316, P < 0.001), loss of consciousness (OR = 23.256, P < 0.001), hemiplegia (OR = 62.500, P < 0.001), aphasia (OR = 76.923, P < 0.001), mental functioning score (OR = 7.937, P < 0.001), overall quality of life score (OR = 5.464, P < 0.001), short-term prognosis (OR = 37.037, P < 0.001) was significantly correlated with the high expression of VEGF. The level of serum VEGF was positively correlated with neurological impairment degree and prognosis in patients with acute cerebral infarction, the more severe the degree of stroke and the worse the prognosis.

A deep learning approach for rapid detection of soil liquefaction using time–frequency images

Soil liquefaction – a common hazard during earthquakes – can cause severe damage to infrastructure systems. The excessive pore water pressure induced by underground shaking can result in a sudden loss of soil stiffness and strength, which renders the soil–water mixture to behave temporarily as “liquid”. Identifying liquefaction events and extracting their time of initiation and duration from recorded data are critical capabilities for validating and improving predictive models, and ultimately, effectively mitigating this hazard. The current approach is to conduct on-site investigations or simplified statistical analyses, which are generally time-consuming and bear high uncertainties, except for the most obvious cases. In this study, we utilize a convolutional neural network (CNN), a deep learning method, to predict both the occurrence of a liquefaction event and its triggering time (if it occurred). For this purpose, first, more than one million high-fidelity nonlinear site response simulations with different soil profiles and ground motions are performed. The surface acceleration time-histories are then converted into time–frequency distribution images, which are fed into a CNN as the training inputs. The trained CNN exhibits high prediction accuracy for both training and validation sets, another suite of independent site response simulations, as well as real-life earthquake data.

A PCA-AHC Approach to Provenance Studies of Non-Ferrous Metals with Combined Pb Isotope and Chemistry Data

This paper discusses the applicability of the Principal Component Analysis-Agglomerative Hierarchical Clustering (PCA-AHC) approach to provenance studies of non-ferrous metals using combined Pb isotope and chemistry data. Pb isotopic ratios were converted to the natural abundance of individual isotopes and then to weight units. Next, all relevant variables (Pb isotopes and trace elements) were processed with PCA and AHC to examine the relationships between observations. The method is first verified on three literature-based case studies (1, 2, and 3). It is argued that, as is the case in archaeological iron provenance studies, the PCA-AHC method is also viable for non-ferrous metals. This method can greatly facilitate research, compared to conventional biplots with ratios of Pb isotopes and trace elements. Additionally, PCA-AHC can become part of the initial deposit selection process, and it can help clarify less obvious classification cases. The main problem with a practical application of this approach is insufficient deposit datasets with complete Pb isotopic and chemistry data. In such cases, it is possible to use the PCA-AHC method separately on Pb isotopic and chemistry data and then to compare and contrast results. Alternatively, the proposed approach can be used solely with Pb isotopic data. This application is shown in two additional case studies (4 and 5), which demonstrate the method’s application for tracing artefacts to their parent ores using datasets with a few thousand observations.

The effect of clinical history on diagnostic performance of endodontic cone-beam CT interpretation

To assess the effect of clinical history on the interpretation of endodontic disease in dental cone-beam computed tomography (CBCT). A reader performance study of an image test-set was undertaken using a factorial, free-response, crossover design, accounting for the independent variables: case type, case severity, reader type, and reading modality. Twenty-three readers interpreted 60 CBCT images twice over two reading sessions using a balanced design, once with access to clinical history and once without, where 30 in each session included history. Lesion localisations, specificity, false-positive marks and the weighted alternative free-response receiver operating characteristic (wAFROC1) figure of merit were calculated. Clinical history had no significant effect on specificity and false-positive rates in non-diseased cases (p>0.05), but improved lesion localisation in subtle and obvious diseased cases (p<0.01). wAFROC1 values were higher with clinical history for subtle (0.58 versus 0.48; p<0.001) and obvious (0.77 versus 0.71; p=0.006) diseased categories. No associations were observed between clinical history and both readers' years of experience and reading volume in the non-diseased categories. Readers with fewer (p=0.03) and moderate (p=0.008) years of experience and low (p=0.002) CBCT reading volume demonstrated better lesion localisation in subtle diseased cases when clinical history was available. Clinical history improved the interpretation of CBCT images with disease without affecting the interpretation of images without disease. Less and moderately experienced readers and low-volume readers benefitted more from availability of clinical history.

S-55-1: PRIMARY ALDOSTERONISM – WHERE TO FROM HER E?

Over the past decade there have been remarkable advances in the pathophysiology of primary aldosteronism (PA); in contrast, there has been little if any change in the clinical management of PA for over 20 years. A patient suspected of PA is referred to an expert center, and their medications withdrawn for 4–6 weeks, with CCBs/alpha blockers used if needed to control blood pressure (BP).They undergo a single blood draw for plasma aldosterone concentration (PAC) and plasma renin activity or concentration (PRA/PRC), to establish the aldosterone to renin ratio (ARR). If the ARR 'suggests’ PA, the patient then undergoes confirmatory testing by one of at least five different procedures – to ensure no patient who does not have PA ever slips through the net. There are multiple reasons for change. First, in no country are more than 1% of hypertensives ever screened for PA. Secondly, a single blood draw for PAC is a very imperfect index of a patient’s actual aldosterone status; among those referred many are excluded on the basis of their PAC who in fact have PA. Third, the current work up – in addition to being exclusionary - is demanding and clunky. Fourth, the prevailing attitude among those treating hypertension is that if the BP is controlled all will be well, when in fact patients with PA have a three-fold higher risk profile than matched essential hypertensives with the same BP. What we are thus facing is a major public health crisis. There is finally increasing recognition that the current estimate of PA prevalence (5% - 10% of hypertensives) is far too low, and the actual prevalence in hypertensives is of the order of at least 30% (and of 10% in normotensives). The current protocols are useless facing figures such as these; what is needed are much simpler and inclusive measures to diagnose probable PA – rather than excluding all but the most obvious cases. This will require input not only from endocrinologists, but also from hypertension specialists, internists, primary care and public health physicians. It is important to distinguish newly presenting and established hypertension. When a patient is newly diagnosed with an elevated BP eschew immediate antihypertensive(s) and order a PRA/PRC assay. If renin is not suppressed, onto antihypertensives. If the renin is suppressed coach the patient to provide a 24 h urine collection for Na, K, and urinary excretion of aldosterone (UEA). If the UEA is &lt; 6 mcg/24 h the patient does not have PA; if the UEA is 6–12, the patient may have PA; if the UEA is &gt; 12 the patient has PA. For these two latter categories order 25 mg/d spironolactone and review at four weeks. If BP falls by &lt; 10mmHg onto antihypertensives; if BP falls by &gt; 10 mmHg continue spironolactone. Established hypertension is rather simpler. Add spironolactone 25 mg/d to current medication and review at 4 weeks. If BP falls &lt; 10mmHg, discontinue; if BP falls &gt; 10mmHg order a UEA. If UEA and BP are moderately elevated continue spironolactone, as such patients very probably have bilateral hyperaldosteonism; if UEA and BP are high, refer to an expert center. What this is calling for is a radical reassessment of how physicians should address hypertensive patients. The rationale is to save them from the double jeopardy of hypertension and PA, and the attendant increased morbidity and premature mortality. The time is now.