The Neurological Study Unit: "A Combined Attack on a Single Problem from Many Angles".

In the 1920s, neurology was a fledgling discipline. Various attempts were made to establish programs relating to neurological care and research. One such initiative was the Neurological Study Unit (NSU) at the Yale School of Medicine. My aim is to chronicle the early years of the NSU (1924-40): the motivations for establishing the unit, its structure, its challenges, and its evolution. I have studied all documents related to the NSU at Manuscripts & Archives, Yale University Library. The NSU was heralded as a "combined attack on a single problem from many angles." It was slow to develop, however, and had a number of missing elements. While some of this may have been due to a lack of funds and the absence of a dedicated neurologist, it was also the result of a failure to conceptualize a neurological unit, the slow evolution-into-existence of a nascent and fledgling medical discipline, growing pains and frictions within the leadership, a university-based rather than a hospital-based model of operation, and turf wars between neurology and allied disciplines.

Madeline Earle Stanton (1898-1980): Librarian and Consultant of the Medical Historical Library at Yale University, Research Assistant in Bibliography in the Yale Department of the History of Medicine, Associate Editor of the Journal of the History of Medicine and Allied Sciences, and Secretary and Protégé of Harvey Cushing.

BACKGROUND: This historical account reviews the course and lasting impact of Madeline Earle Stanton (1898-1980) in neurosurgery. METHODS: The writing of this project was sparked by the discovery of original scientific and bibliographical information about Stanton. It is a thorough review of literature on Stanton and reflects the scope and depth of these prior works. RESULTS: Beginning with Madeline Stanton's venture with Dr. Harvey Cushing at Harvard and Peter Bent Brigham Hospital in Boston, this project follows the transformation of her role as Cushing's secretary to the secretary of the Medical Historical Library at Yale. Stanton played an integral role in the development of the Yale Medical Historical Library, becoming the librarian of the Historical Collections and remaining a historical consultant after retirement. Stanton served as an assistant and associate editor for the Journal of the History of Medicine and Allied Sciences. Stanton's work created an access point to valuable medical literature for the furthering of medical education and development. CONCLUSIONS: Our article provides glimpses into the personality of Madeline Stanton and her marked impact on neurosurgery.

Yale announces plan to handle charges of fraud.

KIE: In the aftermath of a controversy over the handling of a fraud investigation involving Yale Medical School professor Philip Felig, Yale has become the first university to announce a formal plan for dealing with allegations of fraudulent research. The September 1982 Yale Bulletin carried the full text of the policy, which centers on administrative mechanisms whereby deans, the president, or a university tribunal might investigate charges of misconduct.^ieng

Coping with fraud.

The tardiness of actions by Harvard officials when faced with confessed fraudulent research conducted by John Darsee is contrasted with the more rapid responses by authorities in the cases of William T. Summerlin (Sloan-Kettering) and Vijay Soman (Yale).

Paul Beeson (1908-2006), Distinguished Physician.

Paul Bruce Beeson (1908-2006) was a preeminent academic physician in both the United States and Great Britain. He attended medical school at McGill University in Canada and then trained at the University of Pennsylvania and Harvard University. During his career, he was Chairman of the Departments of Medicine at Emory University and at Yale University and then became Nuffield Professor at Oxford University. He ended his career at the Veterans Administration in Seattle as a Distinguished Physician. He was a skilled administrator and an excellent and admired clinician. He was also a productive scientist, who discovered interleukin-1, studied the pathogenesis of urinary tract infections and endocarditis, and delineated the causes of prolonged fever of unknown origin.

Use of recombinant human bone morphogenetic protein-2 in spine surgery.

Bone morphogenetic proteins are osteoinductive factors which have gained popularity in orthopaedic surgery and especially in spine surgery. The use of recombinant human bone morphogenetic protein-2 has been officially approved by the United States Food and Drug Administration only for single level anterior lumbar interbody fusion, nevertheless it is widely used by many surgeons with off-label indications. Despite advantages in bone formation, its use still remains a controversial issue and several complications have been described by authors who oppose their wide use.

A comprehensive assessment of the risk of bone morphogenetic protein use in spinal fusion surgery and postoperative cancer diagnosis.

The risk of postoperative cancer following the use of recombinant human bone morphogenetic protein (BMP)-2 in spinal fusion is one potential complication that has received significant interest. Until recently, there has been little clinical evidence to support the assertion of potential cancer induction after BMP use in spinal surgery. This report aims to summarize the findings from clinical data available to date from the Yale University Open Data Access (YODA) project as well as more recently published large database studies regarding the association of BMP use in spinal fusion and the risk of postoperative cancer. A detailed review was based on online databases, primary studies, FDA reports, and bibliographies of key articles for studies that assessed the efficacy and safety of BMP in spinal fusion. In an analysis of the YODA project, one meta-analysis detected a statistically significant increase in cancer occurrence at 24 months but not at 48 months, and the other meta-analysis did not detect a significant increase in postoperative cancer occurrence. Analysis of 3 large health care data sets (Medicare, MarketScan, and PearlDiver) revealed that none were able to detect a significant increase in risk of malignant cancers when BMP was used compared with controls. The potential risk of postoperative cancer formation following the use of BMP in spinal fusion must be interpreted on an individual basis for each patient by the surgeon. There is no conclusive evidence that application of the common formulations of BMP during spinal surgery results in the formation of cancer locally or at a distant site.

Guidelines for deciding care of critically ill or dying patients.

Medical technology is usually beneficial in the care of sick or injured persons, sometimes dramatically so. However, since it is often intrusive, occasionally cruel, sometimes of little or no value, and almost always expensive, its use must be assessed critically, particularly in ICUs. Guidelines for doing this are proposed. To ensure the most caring approach to patient care and family support, the values and autonomy of patients and their families, one by one, are emphasized in all decision making and the roles of nurses and social workers as well as those of physicians are considered central. If these guidelines are used, many, perhaps most, of the ethical and legal issues and the problems of human relationships in ICUs will be resolved.

Divided loyalties in adolescent psychiatry: late adolescence.

The paper discusses problems that arise in psychotherapy with late adolescent patients when other individuals somehow become indirectly involved in ways that require or suggest some exchange of information. These individuals may be parents or administrative and teaching personnel within an institution. The differences between confidentiality, privileged communication, and privacy are discussed, and specific difficulties discussed in the therapy of late adolescents who are in the process of psychologically (as well as legally) attempting to achieve the independent status of a young adult.

KIE: Arnstein, a member of the staff of the Yale University Health Services, discusses problems that arise in psychotherapy with college students relating to the exchange of information with third parties. He is concerned with maintaining a physician patient relationship of trust and cooperation while fulfilling obligations to parents and the institution. After providing brief information on the legal aspects of confidentiality, privileged communication, and privacy in Connecticut, Arnstein describes Yale's policy on disclosing student psychiatric information to parents, university personnel, other universities, and potential employers, and on resolving problems created by psychologically disturbed students.

A decade beyond medical school: a longitudinal study of physicians' attitudes toward death and terminally-ill patients.

Physicians were surveyed soon after graduation from medical school in 1976 to determine their attitudes toward death and terminally-ill patients and their families. A follow-up survey of the 1093 respondents was made in 1986 to ascertain if changes had occurred in their attitudes. Eight of the eleven Likert-type items showed statistically significant differences over time and by attitudes toward terminally-ill patients and their families. These data present evidence to suggest that physicians in 1986 were more open in telling dying patients their prognosis than in 1976.

Attitudes of IVF parents regarding the IVF experience and their children.

PURPOSE: to assess parental attitudes regarding the IVF experience, the IVF pregnancy, and issues associated with raising their IVF child(ren). METHOD: parents (184 couples) of IVF children born between 1982 and 1992 were mailed individual anonymous questionnaires. RESULTS: (31%) parents responded: 62 mothers and 41 fathers. One hundred-three (41%) of the mothers felt that our staff could have been more helpful during their pregnancy. Half the women subjects (52%) stated that they wished they had contact with other IVF couples during pregnancy. Fifty-two percent of the mothers reported that IVF created special feelings of attachment to the child, causing some difficulty with their initial separation. This was comparatively less an issue for fathers, with only 19% reporting similar difficulties (chi 2 = 8.39, P < 0.01). Ninety-eight percent of the subjects have told someone else about the IVF experience. Interestingly, 25% of the parents remained uncertain about whether they would tell the child. Sixteen couples (15%) had already told the child, and of the 57 (66%) who intended to tell the child later, they varied greatly in their views about which age would be appropriate (mean, 7.3 years; SD, 6.5 years; range, 2-21 years). CONCLUSIONS: The results suggest that women undergoing IVF might profit from greater contact with staff during pregnancy and, again, later when dealing with issues of separation. A substantial proportion of couples expressed some concerns about the issue of disclosure to the child and might profit from counseling when they feel the issue is current.