Although the subject matter to be protected Since they are a form of monopoly cheap 10mg zyrtec with mastercard allergy forecast dallas today, and because largely dictates what type of protection is available monopolies have been subject to abuse (e cheap zyrtec 5 mg with mastercard allergy treatment pipeline. Another severe limitation out risk of being back-engineered zyrtec 5 mg lowest price allergy symptoms after quitting smoking, then the on patent rights is simply prohibiting the grant of innovator should consider not seeking a patent at patents on certain types of inventions. Al- the secret is inadvertently revealed, or when some though their numbers are diminishing, many coun- analytical tool is developed which allows back- tries have allowed only limited patent protection on engineering of the invention. In the area of pharmaceuticals; typically, what can be patented is pharmaceuticals, trade secret protection is not the processes to synthesize the compounds, but not likely to be sought by the innovator, since a new on the compounds per se. Two types of pharmaceutical tage if they were to grant compound per se protec- inventions, however, are often kept as trade secrets: tion, because they do not have the in-house manufacturing process improvements, and screen- infrastructure to invent/patent such compounds ing assays. The subtleties of this essentially the more desirable chair without an accommoda- economic debate are beyond the scope of this dis- tion with the other. Patents as described above between the first patentee and are limited geographically, temporally, and by the the manufacturer, does not protect the manufac- rights of others. However, he cannot make such a chair naturally occurring articles, scientific principles, because there is already a patent which, very and some inventions related to atomic energy and broadly, claims a chair having a flat sitting surface nuclear material. The since (a) it may be very difficult to prove that a first patentee has the right to exclude others, includ- particular process is being used by the alleged in- ing the later patentee, from making a four-legged fringer; and (b) other manufacturing processes may chair with a flat sitting surface, but it cannot itself have been developed which do not infringe. In this case, the manufacturer can chemical entity and a pharmaceutically acceptable attempt to negotiate a license from the first pa- carrier or two chemical entities), life forms (e. Two types of invention that tend to with multiple substituents on a core structural fail the utility test are perpetual motion machines element, but which does not specifically show the (the Patent and Trademark Office wants to see now-claimed compound. The matter is made worse by the organ- references cited against the applicant teaches an ization of patent applications, which are usually alkyl group at the same position of 4±7 carbons, drafted by first stating the background of the in- the second reference teaches 10±15 carbons, and vention, which may include a description of the the latest reference teaches 20±30 carbons). It should not be too surprising that an Exam- It brings in such secondary considerations as the iner, presented with both a statement of a problem commercial success of the invention, that there and the solution to the problem, would respond by was a long-felt need in the art, the failure of others concluding that the solution is obvious. Failing to convince by mere argumentation, shown the solution to a trivial geometric puzzle, the applicant may choose to introduce tangible which of course, up to that moment, had com- evidence, which is typically in the form of a signed pletely baffled us. Note that, The first and most important of these treaties is the since the rejection is based on what is disclosed in Paris Convention for the Protection of Industrial the prior art, the applicant can use what is disclosed Property of 1883. If the application is applicant and the Examiner, usually in the form successfully prosecuted, the applicant is then of written communications, which results in granted a patent by each of the designated coun- granting or denying the grant of a patent), or by tries; i. There is also a great economic is the simplest, since there is only one filing, one advantage to this arrangement, since the applicant prosecution, and essentially one set of allowed need only file one application to stop the prior art. If there is an adverse decision, or if decision-making process within a pharmaceutical the subject matter of the application is no longer of company varies from organization to organization interest, there are no translation costs. If an invention requires such a cell, However, the maximum advantage, in both time the applicant cannot meet the obligation to disclose and cost, results from deferring national filing until the invention in a patent specification; i. If the applicant no way to put the invention in the hands of the decides to defer national filing to 30 months, he/she public without also giving the cell to the public. A solution to this patentability (novelty, obviousness, and utility) as problem is to make a restricted deposit of the cell they apply to the claims, and possibly comments on in a public depository, which will provide an acces- other matters. Prosecution of each application is Treaty resolves these issues by providing a list of then handled by each country independently of approved depositories throughout the world and what any other country may be doing with a cor- one set of deposit conditions, including restricted responding application. The inventor need make only one deposit of that country, the Written Opinion cannot con- under one set of rules to enable the invention, and trol, and there can be a broad range of reactions the public gets disclosure of the invention under from the national patent offices to the Written certain restricted conditions prior to patent grant. Therefore, the 20 year patent has a ject matter or that there is some fundamental error slightly longer (by about 1 year) patent life than the in the first application, e. Rather, are still in prosecution, but it can also occur if one many of these are just the first of a string of related has already been granted and a patient has issued. Ultimately, a decision is made by a panel of invention, thus leveling the international playing Administrative Patent Judges as to which party is field. Each type of biotech invention pre- Issue Fee is paid and the patent is granted) or the sents it own technological difficulties, which must Examiner issues a Final Rejection, to which the be resolved using whatever tools are available when response is an Appeal. In these About 9±10 months after filing the application, a countries, when the Examiner decides there is pa- decision is made by the Patent Committee about if, tentable subject matter, the allowed claims are Pub- where, and how to foreign file the application, lished for Opposition. That there are so many effective standards must be set for clinical research, to treatments available for the cure or control of so which all interested parties should adhere. How- many diseases is largely the outcome of decades of ever, procedures must also be in place if fraud is research, stretching throughout the second half of suspected, despite the existence of these standards. However, there is still a very Within the pharmaceutical industry, the standards long way to go to master many diseases, including needed for the conduct of clinical research already cancers, psychoses, dementias and many others, exist, and have been adopted by all regulatory which are currently untreatable. Clinical research bodies licensing medicines, international pharma- must therefore continue, including genetic and bio- ceutical companies, and contract research organiza- technological research, recognizing that the welfare tions. Research fraud distorts the beginning of this chapter are therefore in place, database on which many decisions may be made, there is no such harmonization when it comes to possibly adversely affecting the health of thousands dealing with fraud and misconduct in the context of of others. Indeed, even within Europe there rifyingly dangerous; if licensing decisions were to be is as yet no agreed attitude towards tackling the made based on efficacy and safety data that are problem. Fortunately able aspect of clinical research must be tackled if we there is no strong evidence that such a sequence of are to achieve and maintain confidence in scientific events has yet occurred, but the importance of the integrity and in the clinical research process. Extrapolating this to the rest of the worldÐ trials to determine the thalidomide effect, but had and there is no evidence that the incidence of fraud at least accurately observed its toxicity. It took a decade to data being generated is fraudulent, where investi- demonstrate publicly that such studies did not gators are making up some of the data to be sub- exist, and almost another decade (1996) before mitted to a company andÐworst of allÐmaybe McBride was publicly denouncedÐall of which exploiting their patients in the process. This definition of an eminent public figure whose reputation was includes all of the components of fraud: the such that it was unthinkable that he might be tell- making-up of information that does not exist, and ing lies. Furthermore, this case demonstrates the intending to do so flagrantly in order to deceive messianic complexoccasionally seen in fraudsters, others into believing that the information is true. Adjuvant Breast and Bowel Project, regarding a The first example is that of John Darsee, a re- number of multicenter clinical studies on breast search cardiologist, first at Emory University, then and bowel cancer. He pleaded guilty to 13 counts of commit- have had to be retracted from the prestigious jour- ting `acts derogatory to the honour and dignity of nals in which they first appeared. He was found fraudulent articles have subsequently been re- by an astute pharmaceutical company clinical trial tracted by the editors of the journals in which monitor to have invented some of the laboratory they were published. Indeed, it was worried that it for some time there has been an impression would lose the confidence of doctorsÐand thus amongst pharmaceutical physicians, clinical re- prescriptionsÐif it was seen to be taking such an search associates, and quality assurance profes- action. Sadly, no action followed the publication against the company by banning it from the local of its report (Royal College of Physicians of postgraduate medical center, to which all pharma- London 1991) and it was consequently left to the ceutical companies normally had access for the Association of the British Pharmaceutical Industry sponsoring of meetings. Scientific re- greed (and here it is important to have a recognized search, outside the context of clinical research, is tariff for the involvement of investigators); emo- not subject to any agreed standards, and it is there- tional disturbance or mental illness; and vanity. This is profession throughout most of the world to take generally accepted by pharmaceutical companies as seriously allegations that fraud is occurring. Al- days when clinics would not be expected to be open; ternatively, the doctor may be prosecuted for the and similar handwriting appearing to have been criminal offence of deception. Any sus- police or of the Crown Prosecution Service where a picion raised by a monitor justifies consideration criminal offence may have been committed. The partner discovered a number of who, during 1995, claimed to have performed a consent forms that were not signed by the patients pioneering operation, when a subsequent enquiry in question, and who were not aware of their in- found that he had not done so. Furthermore, the prac- transplanted successfully an ectopic pregnancy and tice nurse was required to alter the dates printed by achieved a successful full-term vaginal delivery. Second, both these reports were published in ician in Edinburgh who, in his time, had been the British Journal of Obstetrics and Gynaecology; Secretary of the Royal College of Physicians of the article on relocation of the ectopic pregnancy Edinburgh (Dyer, 1997).
Thrombin and ﬁbrin glue are used surgically to treat bleeding and to throm- bose aneurysms generic 5 mg zyrtec otc allergy medicine safe pregnancy. Warfarin (and related coumarins) and heparin are the most commonly used anticoagulants zyrtec 10mg low cost allergy zantac. Aspirin cheap zyrtec 10mg online allergy testing tulsa, clopidogrel, dipyridamole and ticlopidine are among the anti-platelet agents. A newer class of drug, the direct thrombin inhibitors, are under development; some members (such as lepirudin) are already in clinical use. Focus on: anaemia Anaemia is deﬁned as a qualitative or quantitative deﬁciency of haemoglobin, which may lead to hypoxia (lack of oxygen) in organs. The three main ways in which anaemia may arise are: • excessive blood loss (acutely, such as a haemorrhage, or chronically through low-volume loss, e. Anaemia is the most common disorder of the blood; there are several kinds, produced by a variety of underlying causes. Anaemia may be classiﬁed by a ‘kinetic’ approach, which involves evaluating the production, destruction and loss of red blood cells, or a ‘morphologic’ approach, based on red blood cell size. Anaemia often goes undetected; signs and symptoms can be related to the anaemia itself or to the underlying cause. Types of anaemia Microcytic anaemia is primarily a result of a failure or deﬁciency of haemoglobin synthesis, which may be caused by several aetiologies: • Haem synthesis defect, for example iron-deﬁciency anaemia and anaemia of chronic disease (more commonly presenting as normocytic anaemia). Red blood cells often appear hypochromic (paler than usual) and microcytic (smaller than usual). Iron-deﬁciency anaemia is caused by insufﬁcient dietary intake or absorption of iron, or by loss of blood, for example bleeding lesions of the gastrointestinal tract. Worldwide the most common cause of iron-deﬁciency anaemia is parasitic infestation (hookworm, amoebiasis, schistosomiasis and whipworm). Macrocytic anaemia is deﬁned as one in which the red blood cells are larger than normal. Megaloblastic anaemia is the most common cause of macrocytic anaemia, caused by a deﬁciency of either vitamin B12 or folic acid (or both). Deﬁciency in folate and/or vitamin B12 may result from either inadequate intake or malabsorption. Pernicious anaemia is caused by a lack of intrinsic factor, which is required to absorb vitamin B12 from food (see below). Macrocytic anaemia can also be caused by removal of the functional portion of the stomach, such as during gastric bypass surgery, leading to reduced vitamin B12 and folate absorption. Macrocytic anaemia can be further divided into ‘megaloblastic anaemia’ and ‘non- megaloblastic macrocytic anaemia’. Pernicious anaemia is a megaloblastic anaemia, caused by a deﬁciency of vitamin B12; it is associated with both haematopoietic and neurological disorder. In the stomach, vitamin B12 is bound to one of two B12 binding proteins present in gastric juice; in the less acidic environment of the small intestine, these proteins dissociate from the vitamin. It is then bound by intrinsic factor, produced by the parietal cells of the gastric mucosa; the B12–intrinsic factor complex is speciﬁcally bound by epithelial receptors in the ileum, where the vitamin B12 is then absorbed. The most common cause for impaired binding of vitamin B12 by intrinsic factor is autoimmune atrophic gastritis. Autoantibodies are directed against parietal cells, which atrophy and cannot make intrinsic factor, and consequently cannot transport vitamin B12. Less frequently, loss of parietal cells may simply be part of a widespread atrophic gastritis of non-autoimmune origin, such as that frequently occurring in elderly people affected with long-standing chronic gastritis (including H. Treatment of pernicious anaemia has traditionally involved the parenteral delivery of vitamin B12 to ensure absorption. Oral replacement is now an accepted route, using large doses of vitamin B12, 1–2 mg daily. Normocytic anaemia occurs when the overall haemoglobin levels are decreased, although red blood cell volume remains normal. Treating anaemia • Mild to moderate iron-deﬁciency anaemia is treated by iron supplementation with ferrous sulphate or ferrous gluconate. A diagnosis of iron deﬁciency may indicate other potential sources of iron loss, such as gastrointestinal bleeding from ulcers or colon cancer. Blood transfusions for anaemia are generally to be avoided due to adverse clinical outcomes, but in severe, acute bleeding, transfusions of donated blood are often lifesaving. Focus on: angiogenesis Angiogenesis is the physiological growth of new blood vessels from pre-existing vessels. It is a normal process in growth and development, as well as in wound healing, but is also a fundamental step in the transition of tumours from a dormant to a malignant state. Receptor activation gives rise to a signal transduction cascade that leads to gene activation and diverse biological responses, including cell differentiation, proliferation and matrix dissolution, thus initiating a process of mitogenic activity critical for the growth of endothelial cells, ﬁbroblasts and smooth- muscle cells. This has been demonstrated to be a major contributor to angiogenesis, increasing the number of capillaries in a given network. These are protein growth factors that promote angiogenesis (as demon- strated by mouse knock-out studies). There are four identiﬁed angiopoietins, Ang1–4; in addition there are a number of proteins that are closely related to angiopoietins. This proteolysis allows the endothelial cells to escape into the interstitial matrix, as seen in sprouting angiogenesis. Angiogenesis as a therapeutic target Angiogenesis may be a target for combating diseases in which there is either poor vascu- larisation or abnormal vasculature. These proteins mainly originate as speciﬁc fragments to pre-existing structural proteins such as collagen or plasminogen. Angiogenesis represents an excellent thera- peutic target for the treatment of cardiovascular disease, namely the production of new collateral vessels to overcome the ischaemic insult. However, despite the large num- ber of pre-clinical trials in animal models of cardiac ischaemia, no therapy designed to stimulate angiogenesis in underperfused tissue has yet become viable in man. White adipose tissue is vascularised, much like a tumour, and growth of adipose tissue is highly dependent on the building of new blood vessels (angiogenesis). Recent studies with obese mice models have shown that proapoptotic peptide, directed against blood vessels, results in decreased food intake and signiﬁcant fat loss. Besides an adequate supply of calcium, a close cooperation is required between these two types of cell. Mature osteoblasts synthesise type 1 collagen, osteocalcin, cell attachment proteins (thrombospondin, ﬁbronectin, bone sialoprotein, osteopontin), proteoglycans and growth-related proteins. Vitamin D stimulates synthesis of alkaline phosphatase, matrix and bone-speciﬁc proteins. Osteoclast resorption of bone releases collagen peptides, pyridinoline cross-links and calcium from the bone matrix, through the action of lysosomal enzymes (collagenases and cathepsins).
Classification order generic zyrtec line allergy medicine decongestant,pathogenesis zyrtec 5mg cheap allergy symptoms to alcohol, clinical features order generic zyrtec from india allergy medicine you can take with high blood pressure, histological findings, diagnosis, treatment 3h. Сomparison of the histological findings in the kidneys with the clinical features.. Treatment - glucocorticosteroids, Cyclophosphamide, Cyclosporine, high doses of immunovenin. Glinical features of the different types based on immunofluorescence microscopy (deposits of IgG, 3h. Membranoproliferative (mesangiocapillary) glomerulonephritis Histological findings – specific changes on light microscopy, immunofluorescence microscopy and 2h. Acute interstitial nephritis – etiology,pathogenesis,clinical features, diagnosis, treatment. Obligatory tests for the donor and the recipient before proceeding kidney transplantation. General description of glomerular syndromes- proteinuria, hematuria, nephrotic syndrome, anemia. Minimal Change Glomerulopathy- epidemiology, pathogenesis, clinical features and natural history. Membranoproliferative Glomerulonephritis (Mesangial Capillary Glomerulonephritis)- pathology, clinical features, laboratory findings, treatment. Rapidly Progressive Glomerulonephritis and Crescentic Glomerulonephritis- pathogenesis, pathology, clinical features, treatment. Lupus Nephritis-epidemiology, pathogenesis, classification of Lupus Nephritis, pathology (Immunofluorescence, Electron Microscopy). Lupus Nephritis-clinical manifestations, serologic tests, drug-induced lupus, management of Lupus Nephritis, course and prognosis of Lupus Nephritis. Diabetic nephropathy- pathology of diabetic nephropathy, clinical features, laboratory findings, treatment. Diabetic nephropathy- microalbuminuria, extrarenal complications in diabetic nephropathy, treatment (blood pressure control, glucose control, dietary protein restriction). Acute interstitial nephritis-causative factors, pathology, cilinical manifestations and diagnosis, prognosis and management. Balkan Endemic Nephropathy- clinical features, diagnosis and treatment,chronic urate nephropathy. Chronic pyelonephritis-classification, etiology, clinical features, diagnosis, general principles of antimicrobial therapy. Autosomal Dominant Polycystic Kidney Disease - diagnosis, clinical features, complications, treatment. Acute kidney failure (indury) - definition, classification, clinical manifestations, course, complications,management. Chronic kidney disease - definition, risk factors, history, physical examination, clinical manifestations, course. Chronic kidney disease - staging, management of chronic kidney disease: dietary protein restriction; treatment of hypertension, anemia, hyperkalemia, hyperphosphatemia, metabolic acidosis. Stewart; Grunfeld, Jean-Pierre; Ponticelli, Claudio; Ritz, Eberhard; Winearls, Christopher G. Special features of the treatment of chronic gastritis of the corpus (chronic gastritis type A) and chronic gastritis of the antrum (chronic gastritistype B). Basic symptoms in gastroenterology - Examination of a patient, a brief oral exam Exercise № 2 - 2 hours Examination of the stomach. Liver cirrhoses – clinical signs, complications, diagnosis, differential diagnosis. Semesters of education: 9-th / 10-th semesters Auditorium classes: 20 hours of thelecture course, 50 hours of the practical course Technical equipment applied in the training: Practical work with patients с пациенти при леглото на болния (анамнеза, клиничен статус, диагностичен и терапевтичен план, методи на изследване, тълкуване на биохимични, хор- монални, имунологични и пр. Control and evaluation: Ongoing evaluation – tests, oral examinations, colloquia on different syllabus sections Final evaluation – practical and theoretical examination Score assessment Participation in practical exercises, tests, colloquia Semester exam: Yes /test, written and oral examination/ State Exam: Yes (part of the exam in Internal diseases) Lecturer: Full Professor from the Section of Endocrinology and metabolic diseases (Prof. Principles of the hormonal diagnosis and the feed-back mechanisms in endocrinology. Hypopituitarism – definition, causes, forms, pathogenesis, clinical presentation, syndromes, isolat- ed forms – hyposomatotropism, hypogonadism. Diabetes insipidus – causes, pathogenesis, clinical presentation, types of diabetes insipidus, differ- ential diagnosis and treatment. Cushing’s syndrome – ethi- opathogenesis, clinical presentation, diagnosis, differential diagnosis, treatment. Cushing’s syndrome (primary hyperglucocorticism) - clinical presentation, diagnosis, differential diagnosis and treatment. Primary hyperaldosteronism (Conn’s syndrome) – ethiopath- ogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Diseases of the adrenal cortex – primary adrenal insufficiency (Addison’s disease) - causes, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Учебна програма за специалност “Медицина” 3 Biosynthesis and metabolism of catecholamines. Diseases of the adrenal medulla: pheochromocy- toma – incidence, pathogenesis, classification, clinical presentation, diagnosis, differential diagno- sis and treatment. Endemic and sporadic goiter – incidence, etiology, clinical presentation, diagno- sis and treatment. Hypothyroidism – types, etiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Acute infectious, subacute, granulomatous, chronic lympho- cytic, silent, fibrous thyroiditis - etiology, clinical presentation, diagnosis, differential diagnosis and treatment. Graves’ disease - etiology, pathogenesis, clinical presentation, course, clinical forms and complications (ТАО, thyrotoxic crisis), treatment. Toxic adenoma - eti- ology, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Toxic multinodular goiter - etiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis and treatment. Carcinoma of the thyroid gland – incidence, etiology, classification, clinical presen- tation, differential diagnosis and treatment. Parathyroid and diseases of bone and mineral metabolism – regulation of metabolism. Hypopara- thyroidism – types, acute and chronic forms, clinical presentation, diagnosis, differential diagnosis and treatment. Primary hyperparathyroidism - etiology, pathogenesis, pathological morphology, clinical presentation, diagnosis, differential diagnosis and treatment. Disorders of the metabolism of carbohydrates and the endocrine pancreas – diabetes mellitus and prediabetes, metabolis syndrome.
The National Comorbidity Survey (Kessler ea buy generic zyrtec 10mg on-line allergy forecast florida, 1994) estimated lifetime and twelve-month prevalences of social anxiety disorder at over 13% and 7 purchase zyrtec us allergy shots regimen. The only commoner psychiatric disorders were major depression and alcohol abuse/dependence discount zyrtec online allergy partners of the midlands. Social phobia is often divided into generalised/diffuse (2 out of 3 cases) and 1720 specific/focal types, the former being more severe and potentially disabling. This generally comes on in the teens, but later onset, in the present author’s experience, should prompt a search for some other disorder, such as depression. According to Marks and Mataix-Cols,(2004) marked shyness in childhood may persist into adulthood but 1721 most focal social phobias commence in young adulthood. Fear of urinating/defecating in public toilets or of being incontinent when a toilet is not available are sometimes called ‘sphincteric phobia’. Marks and Mataix-Cols (2004) point out that sphincteric phobics are free of other social phobias. Functional neuroimaging suggests increased activity in amygdala and insula in social phobia. Role-playing may be of benefit in social phobias, and this might include, for example, talking to an opposite-sexed partner on a date. According to Reichborn-Kjennerud ea (2007), a common genetic vulnerability underlies both disorders in female twin pairs with differing life events determing final expression (common environmental effects could not be ruled out). Venlafaxine,(Kelsey, 1995) bupropion, and gabapentin may be worth trying in resistant cases. Many patients remain symptomatic despite treatment responses that are superior to placebo. Psychoanalysts have explained agoraphobia as stemming from early maternal deprivation or traumatic separations in early life. McGennis ea (1977) divided agoraphobia into primary (‘an abnormal fear of going out unaccompanied’) and secondary (depression or schizophrenia) cases. Some authors stress the fear of a second panic attack leading to agoraphobic behaviour and write that agoraphobia without a history of panic disorder is very rare in clinical practice. Each case should be subjected to careful assessment with collateral information gathering. Brief episodes of depression during the course of chronic agoraphobia may prompt a visit to the doctor. Ghosh ea (1988) found that, when treating phobias, self-exposure (to the feared stimulus) treatment was equally effective if a psychiatrist, a computer, or a book was used by the patient, and all held the same effect at six-months follow-up. Space phobia is a fear of falling made worse by the absence of any immediate source of support and is especially common in open spaces. It has a later age of onset than agoraphobia, with a mean onset at 55 years of age, and it does not respond to behaviour therapy. However, the housebound person may take on extra household chores so that the rest of the household becomes discommoded when treatment is aimed at helping the patient break out of this mould. Roy-Byrne ea (2002), using data from a highly selected small twin sample, suggest that chronic fatigue may more closely resemble atypical, anxious forms of depression than ‘classic’ depression. Indian women with chronic fatigue were found to have an excess of poor mental health and gender disadvantage, notably sexual violence by the husband. There may be little pathological basis for calling it an encephalomyelitis or a myopathy. Indeed, a study in primary care found that people who complained of fatigue for more than six months following an infection were more likely to been fatigued prior to the infection. Cockshell and Mathias (2010) performed a meta-analysis and found mainly problems with attention, memory, and reaction time. The widely held belief that antibiotics cause fatigue was not upheld in a double blind, randomised crossover trial in healthy volunteers of amoxycillin v placebo. Among patients attending an infectious diseases clinic with idiopathic fatigue, many improve spontaneously but functional impairment is associated with belief in a viral cause, reduction in exercise, avoidance of alcohol, a change in job, quitting work, belonging to a self-help group, or having a current emotional disorder on follow up. Diagnostic uncertainty on the part of the physician and the provision of a sick note may be 1743 unwitting contributors to an adverse outcome. Psychological factors are more important predictors of outcome than 1744 immunological or demographic variables. People in support groups, those currently emotionally distressed, receipt of sickness benefits and an exclusive belief in a physical aetiology were associated with adverse outcomes. Various treatments have enjoyed transient period of popularity such as magnesium supplementation. Iron supplementation for unexplained fatigue in the absence of anaemia only seems beneficial if the patient has low or borderline serum ferritin concentration. Wessely ea (1988) reported an improvement in myalgic encephalomyelitis using a combination of cognitive-behavioural methods and graded exercise. They suggested that instead of resting after influenza one should start taking regular gentle exercises to get going again. Neuroses: general considerations Those without personality disorder may be more likely to respond to psychological treatment methods, whereas those with personality disorder may respond better to medication, particularly antidepressants. They are often not seen by doctors and may be missed or misdiagnosed, or simply put down to advanced age or somatic illness. The clinical picture may be complicated by alcohol abuse or by dependence on or side effects from therapeutic drugs. Hysterical disorders may arise as a result of missed physical illness or they may be due to the release of dissociative tendencies in vulnerable people by organic brain disease or functional psychiatric illnesses. Many experts doubt the possibility that one can develop dissociative amnesia for traumatic events and warn us to outrule organic causes like head injury or intoxication. Various forms of backlash against ‘recovered memories’ have occurred on both sides of the Atlantic, both by those who say they have been falsely accused by these recollections and by insurance companies who refuse to pay therapists who harvest them. They submit to potentially hazardous investigations and treatments, and discharge themselves against medical advice if challenged when tests or observation negate their complaints. He wrote about soldiers who mimicked of induced illness in themselves and women who ‘assume the semblance of disease’. Negligible iodine uptake + high T4/T3 ratio + low/undetectable thyroglobulin = factitious. Non-nuclear cases (90% of cases) may be more common in women who are mostly socially conforming, of a higher socioeconomic status than the peregrinating, alias-using nuclear group, and may be intelligent and educated, and are frequently employed in a medically related field. Mothers in such cases may give histories of insecure attachment in their own childhood. The patient may be ingratiating and ‘helpful’ initially, profuse in thanks, but later becoming clinging and demanding. An apparent high pain threshold may be accompanied by demands for opiate analgesia. Pseudologia phantastica (pathological lying) refers to a free and effortless flow of lies that are immediately plausible. However, pathological lying may be associated with a deficiency of prefrontal grey matter relative to prefrontal white matter. A high index of suspicion and knowledge of the profile described in bare outline above are required for a working diagnosis.