Published histories of bacteriology concentrate on the scientific concepts, exemplified by Louis Pasteur and Robert Koch. Arguably, the early British bacteriological studies are headed by Lord Lister, whereas other notables such as Ronald Ross, Robert Bruce and Patrick Manson are honoured for their discoveries of ‘tropical’ microbes, accomplished abroad. What then was happening in Great Britain? The introduction of bacteriology into the medical school curriculum is examined according to the published lectures in The Lancet between 1889 and 1901 and the dates are reviewed in light of other published sources. The names of the people delivering bacteriology at the medical schools in Great Britain and Ireland provide a guide to the relevance of crediting Lister as the leading light for microbiology in the UK. The diversity of names and backgrounds suggests that a critical reassessment of the perceived late and limited start of UK medical bacteriology is needed.

This review seeks to map the appearance of bacteriology in the medical schools of England. The established histories of bacteriology1 mostly concentrated on the scientific breakthroughs, understandably then, dealing mostly with the work of Pasteur and Koch. A recent exception to this is the detailed analysis of bacteriology in Britain by Worboys,2 in which he addresses the impact of the growing awareness of bacteria in medical and veterinary conditions. However, with the recent exception of Worboys, the literature does not represent the appearance of bacteriologists in the UK.

At a time when university microbiology departments have mostly been incorporated into larger units, if not closed entirely, this review seeks to identify the chronology of the introduction of bacteriology into the medical schools and to highlight the people carrying the torch. Worboys2 demonstrates how several of the early bacteriologists were surgeons who only temporarily explored bacteriological research in the laboratory. It is shown here that there were a number of professors in universities that remained advocates of the discipline up to 1900.

The framework of the review compiles information on bacteriology departments within medical schools (listed alphabetically) taken from the published lists of lectures at the medical schools in England, Scotland and Ireland in The Lancet (Tables 1 and 2). Between 1899 and 1900, medical school curricula were given in tabular form for the academic year in the educational issues of The Lancet. During this period, bacteriology appears as a distinct lecture programme in most but not all of the medical schools and thus offers a picture of the key people who introduced the discipline to the medical curricula.

However, bacteriology was taught within other contexts (most frequently as pathology) and hence the introduction of bacteriology has been corroborated (or not, as the case may be) by examining other published sources. Hence, in those medical schools listed where bacteriology does not appear, the teaching of the subject is discussed. While it is apparent that The Lancet lecture listings are not always in agreement with other sources, this review seeks to provide a reference for discussion on the development of medical bacteriology in the UK. For perspective, the first Chair of Bacteriology at the medical school is provided (Table 3).

It is apparent that the bacteriologists employed are mostly located within departments of pathology. As most pathologist positions were a temporary but necessary component of the medical training (and do not reflect a strategic career choice) the data may over-represent bacteriological interests.

For the following listings, the title of bacteriologist at a hospital does not necessarily mean that the person holds a lectureship (or Chair) in bacteriology at the related medical school. Equally, a Chair at a university may be an entirely academic post, with no related hospital appointment. It was common to hold more than one appointment at a time. For example, one may be pathologist at hospital X and a physician to hospital Y.

The people mentioned are given mostly without biographical information. The criteria for inclusion is evidence of working and contributing to the published studies of laboratory-based bacteriology (mycology has, regrettably, been ignored as it is too broad, and virology as a distinct discipline mostly falls outside the time frame covered). I have not sought to identify infectious disease physicians (unless they published laboratory studies in significant volume). Neither have superintendents of tuberculosis sanatoria and fever hospitals been included.

Prior to 1900 it was common for medical schools to employ physicians as pathologists for a year as part of their training, mostly to obtain dissection and morbid anatomy experience. As these were fleeting appointments, such people also have not been included.

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NEW YORK — An article in the Aug. 22 Journal of the American Medical Association reported patients taking Celebrex (celecoxib) and Vioxx (rofecoxib) may run a higher risk of getting cardiovascular disease, a charge each drug maker vehemently denies.

The contents of the JAMA article were picked up by many news organizations.

“Pharmacia and Pfizer believe the conclusions drawn by the analysis in the JAMA article were flawed and unsound,” Pfizer, a co-marketer of Celebrex (celecoxib), reported in a statement issued the same day the study was published. “It contains no new clinical information and is based on an inappropriate re-analysis of several older clinical studies containing data that were not suitable for combination and comparison.”

Merck reportedly agreed with some of the study’s conclusions, but maintained that data exists that shows no increase in cardiovascular risk in patients taking its drug, Vioxx (rofecoxib). Celebrex and Vioxx, both used to treat arthritis, account for a combined $6 billion in annual prescription sales.

Dr. Eric J. Topol, chairman of cardiovascular medicine at the Cleveland Clinic Foundation, used data from two major clinical trials each company had run previously in an attempt to demonstrate their respective stomach-safety profiles. In Topol’s cardiac study, Merck’s Vioxx fared slightly worse and had more cardiac problems associated with it than Pfizer/Pharmacia’s Celebrex. Both Celebrex and Vioxx are cox-2 inhibitors.

“Our findings suggest a potential increase in cardiovascular event rates for the presently available cox-2 inhibitors,” Topol wrote. “It is possible that concomitant use of aspirin may not fully offset the risk of selective cox-2 inhibitors. However, definitive evidence of such an adverse effect will require a prospective randomized clinical trial.”

Topol acknowledged the limits of his study and even suggested cox-2s might alleviate atherosclerosis. “On the other hand, the inflammatory component of atherosclerosis has recently been emphasized and may be suppressible by cox-2 inhibitors,” Topol said. Still, Topol said the “remarkable exposure and popularity” of cox-2 inhibitors should compel researchers to conduct a randomized trial of their long-term effect on cardiovascular health. “Until then,” he said, “we urge caution in prescribing these agents to patients at risk for cardiovascular morbidity.”

For medical companies and their clients, calling back a product can sometimes be a matter of life and death. On March 29, a group of experts discussed several of the most publicized medical-product problems at a forum on managing risk.

CNY MedTech, a regional trade association for medicaltechnology and device companies, sponsored the event along with the Chubb Group and First Niagara Risk Management. One of the best-known cases of a medical recall came in 2004 when Merck & Co. Inc. recalled its pain drug Vioxx after evidence showed patients taking the medication were more susceptible to heart attacks. In that case, Merck failed to act in a timely fashion on knowledge it had, said John Powers, an attorney with Hancock & Estabrook LLP.

It’s likely, Powers said, that communication problems played a role somewhere in Merck’s Vioxx problems, which include a number of lawsuits accusing the company of negligence.

Open, effective, accurate communication is critical in any company, but especially those in the health-care industry, Powers said. Problems companies face in product lawsuits often stem from an employee making casual reference to a product being defective in an email or other exchange.

The term “defective” has specific legal connotations, and so it’s better for workers to be trained to describe potential problems specifically and in detail, rather than using terms they might not fully understand, Powers said.

“The problems are usually created when people don’t explain themselves or use a poor choice of words,” he said.

Determining what research to do on products is also critical, said William Grant, a research professor at the State University of New York Upstate Medical University in Syracuse. In the case of Vioxx, the data that initially indicated potential heart problems was contained in a study to learn whether the drug caused stomach ailments.

When designing studies, companies need to consider all reasonable and rational side effects that could be caused by their products, Grant said.

“It’s an art as much as a science in trying to figure out what you need to look at,” he said. “But I’m a firm believer that if you have data, you report it somewhere.”

CNY MedTech’s forum also discussed Guidant Corp.’s recall of more than 100,000 implantable heart defibrillators last year. The devices were malfunctioning after being implanted in patients.

After Guidant became aware of the problem, it fixed it, but did not tell the U.S. Food and Drug Administration or anyone else and continued to sell the defective inventory, panel members said.

“It should have been [taken] off the shelf immediately,” Grant said. “They could have saved themselves a whole lot of trouble if they had been assertive and aggressive in responding initially.”

Grant said the company should have replaced all the devices that were already implanted in patients as well.

Companies can even get into trouble before their products hit the market. Plenty of medical-device companies and pharmaceutical manufacturers are sued because of problems patients have during clinical trials.

One of the best ways to prevent those problems is to make sure patients understand what they’re getting into at the beginning of the trial, Grant said. Well-designed consent forms are just the beginning, he added.

Many companies are now taking steps like testing patients on consent forms after they read them.

“Sometimes the risk we have in a study … are not the risks we think about,” Grant said. “There are medical risks, but there are also often psychological risks and mental-health risks that we don’t think about. We need to consider all those things and make patients aware of them.”

In all cases, companies should try to go beyond what’s required of them in clinical trials, said Dana Jennings, a specialty underwriter with Chubb’s Technology Insurance Specialty Department.

“We’re going to look for them to exceed FDA guidelines,” she said. “It improves your defensibility.”

A terrible accident occurred recently when a car driving on an interstate highway suddenly veered across the median and smacked head-on into an 18-wheel truck. The entire family in the car was killed instantly. An investigation determined that the car’s driver had fallen asleep at the wheel. Family members later said the car’s occupants were on their way home from a vacation and had decided to drive all night to avoid paying for a motel room. This tragedy occurred because of sleep deprivation, and it should not have happened.

Although this is an example of an extreme consequence of sleep deprivation that luckily does not happen often, lack of sleep has been identified as a major contributing factor to accidents. Indeed, people with sleep apnea leading to loss of sleep have been found to have as high an incidence of traffic accidents as people who are under the influence of alcohol. (1) Drivers who have not had enough sleep can have driving problems that are comparable to those experienced by people with modest blood alcohol levels. The loss of as little as three hours of usual sleep affects an individual’s ability to maintain a consistent speed and a stable road position. (2)

Safety is a factor wherever loss of sleep exists. Sleep deprivation has been related to an increase in industrial accidents, poor academic performance, delays in recovery from hospitalization, and misdiagnoses mad errors in health care settings. For example, one study found that attending physicians were slower in performing intubations and had slower general reaction times when they were sleep deprived. This was especially evident as the physicians rotated through the night shift. (3)

Sleep deprivation is the absence of sleep during a period of time that is determined by an individual’s need. The Cochrane Database of Systematic Reviews lists many studies about sleep deprivation that have been conducted across a wide variety of situations. Participations include students, health care professionals, patients, pilots, astronauts, and others. Sleep deprivation’s effects can be mild to severe, depending on the length of time a person goes without sleep and the recuperative abilities of the individual. Everyone who has ever been a student (and that includes every nurse) remembers pulling at least one “all-nighter” when studying for exams or finals. Unfortunately, as it turns out, that was exactly the wrong time to be sleep deprived. (4)

After graduation, nurses have jobs and schedules that lead to sleep deprivation. This includes rotating shifts, being on call all night and then working regularly assigned shifts the next day, or working double shifts and having home responsibilities that prevent them from sleeping during precious free hours. (5)

EFFECTS OF SLEEP DEPRIVATION

Effects of sleep loss are fairly well recognized and include slower reaction times, decreased ability to perform fine psychomotor skills, mood changes, cognitive changes, and memory problems. (6) Physiological changes also can result if loss of sleep continues for an extended period of time. Although short-term sleep deprivation does not affect the immune system, some studies have shown that prolonged lack of sleep produces changes in cortisol levels and the immune system, as well as decreases in insulin sensitivity. (7)

Loss of sleep adversely affects the ability to perform tasks that require sustained and continuous attention. (8) It also appears to affect the neural auditory system by slowing the response time between hearing something and reacting to it. Even vocal intonations are affected by sleep deprivation, with tones becoming slower and flatter. (9)

IMPLICATIONS FOR PERIOPERATIVE NURSES

For a surgical team, loss of sleep potentially can create many safety and work problems, including

* risk of increased accidents,

* risk of increased errors,

* decreased ability to quickly solve problems,

* slower reaction and performance time in psychomotor skills, (10) and

* negative impact on the work environment because of mood swings and the decreased ability of sleep-deprived personnel to cope with workplace stress. (11)

The treatment for sleep deprivation is simple–get some sleep. Like most things, however, this is easier said than done. Physicians often have a room in the hospital where they can catch a short nap, but there is no place or time for others on the surgical team to do likewise.

Effects of sleep loss also can be counteracted the old fashioned way; that is, by drinking a couple of cups of strong coffee. (12) Unfortunately, other pharmacological agents also have been used to counteract the effects of sleepiness, which may contribute to safety problems in the OR.

CONCLUSION

Sleep deprivation is an old problem that has resurfaced because of the nursing shortage, decreased financial ability to hire adequate staff, and greatly increasing workloads. Staffing assignments should be evaluated to identify situations that contribute to sleep deprivation, and those situations should be corrected. Managers should be aware of the potential for accidents and consider increased risks for error when they schedule work shifts and call. Safety is a major concern for both patients and staff members, and simple, inexpensive solutions can counteract the risk of an accident occurring because of sleep deprivation. With some attention, sleep deprivation should not be a major problem in the OR.

Incorporating the launch of The Diabetic Foot journal’s pathway of care for people with diabetic foot problems (supported by an unrestricted educational grant from KCI Medical Ltd)

‘For the eighth year, we at The Diabetic Foot journal will be staging conferences in both Glasgow and London. These represent the largest diabetic foot gatherings worldwide, with 700 delegates across the two venues. The programme for 2007 focuses on some of the key clinical practice issues relating to diabetic foot care and best care treatment pathways. We will also be launching The Diabetic Foot journal’s pathway of care for people with diabetic foot problems. We promise to focus on these issues and more.

[ILLUSTRATION OMITTED]

We will again be featuring masterclasses–these interactive break-out sessions in five core areas of diabetic foot management will enable you to tailor your conference programme to match your own particular interest in the diabetic foot. The programme promises another exciting conference–we look forward to seeing you.’

Matthew Young, Conference Programme Director and Consultant Physician, Edinburgh Royal Infirmary

DAY 1

09.00-09.30  Registration
09.30-10.30  Smith + Nephew Breakfast Symposium: The health economics
and clinical impacts of the Versajet debridement system
10.30-11.00  Registration, coffee and exhibition viewing

SESSION 1

11.00-11.15  Introducing a revolutionary ‘best care’ pathway for
diabetic foot patients: from ‘at risk’ to ‘ulceration’ to
‘healing’ to ‘aftercare’
* Why do we need a new pathway of care?
* Problems with old pathways
* Why this is different?
* How it was set up
Matthew Young, Consultant Physician, Edinburgh
11.15-11.50  Pathway 1: The at-risk foot
* How, when and why
* New ulcer risk category
Duncan Stang, Chief Podiatrist, Lanarkshire
11.50-12.30  Pathway 2: The ulcerated foot
* As per published best care pathway document
* The how, when, where and why of ulcer prevention
* Classification as a guide to treatment
Matthew Young, Consultant Physician, Edinburgh
12.30-13.45  Lunch and exhibition viewing

SESSION 2

13.45-14.45  Masterclasses (1st rotation)
1. Wound (management)
Hands on demonstrations
* How to dress wounds and with what
* Tricky dressings and areas
Lynne Watret, Tissue Viability Nurse, Glasgow
2. Ischaemic foot
* Recognition
* Why is it special?
* What to do about it
* Preventative care
* When to refer
Cliff Shearman, Consultant Vascular Surgeon, Southampton
3. Charcot foot
* Recognition
* Why is it special?
* What to do about it
Fran Game, Consultant Physician, Nottingham (Glasgow)
William Jeffcoate, Consultant Endocrinologist, Nottingham
(London)
4. Litigious foot
* Why do things go wrong?
* Documentation
* Communication
* Dealing with errors
* Dealing with complaints
* What to do if you get sued
Louise Stuart, Consultant Podiatrist/Lecturer, Manchester
and Salford
5. Neuropathic foot
* Recognition
* Why is it special?
* Preventative care
* When to refer
Paul Chadwick, Principal Podiatrist, Salford
14.45-15.45  Masterclasses (2nd rotation)
15.45-16.15  Tea and exhibition viewing

SESSION 3    THE FOURTH ANNUAL DIABETIC FOOT JOURNAL LECTURE 2007

16.15-17.00  Antibiotics: should we or shouldn’t we?
* Infection and its role in tissue loss
* Is there any evidence for antibiotic use?
* If not what can we do to reduce infection?
* If yes, then which ones and for how long?
Featuring guest speaker from the US, Ben Lipsky, Professor
of Medicine
17.00-18.00  Satellite symposium
18.00-18.30  Foot in Diabetes UK (FDUK) meeting

DAY 2

08.45-09.45  Satellite symposium and breakfast
09.45-10.15  Registration, coffee and exhibition viewing

SESSION 4

10.15-10.50  Pathway 3 — Healing
* The how, when and why of strategies to heal ulcers
* Definition of the non-healing ulcer and its treatment
Speaker to be confirmed
10.50-11.30  Pathway 4 — Aftercare
* The how, when and why of strategies to keep patients
healed
Alistair McInnes, Senior Lecturer, Eastbourne
11.30-12.00  ‘Question time’ panel debate on the primary/secondary care
role in diabetic foot care: Is everyone a specialist now?
Chaired by Matthew Young, Consultant Physician, Edinburgh
Plus a panel of experts
12.00-13.15  Lunch and exhibition viewing

SESSION 5

13.15-14.15  Masterclasses (3rd rotation)
14.15-15.15  Masterclasses (4th rotation)
Rotations as per day one
15.15-15.45  Tea and exhibition viewing

SESSION 6    KEYNOTE LECTURE

15.45-16.30  The diabetic foot–past, present and future
Mike Edmonds, Consultant Diabetologist, London

A recent randomized, controlled trial conducted in Italy sheds new light on the use of spinal manipulation in the treatment of acute back pain and sciatica with disc protrusion. Results of the study, published in a recent issue of The Spine Journal, indicate that active spinal manipulation relieves pain more effectively than a sham simulation, leading to fewer days of localized pain and fewer days of radiating pain, and with no side-effects.

The study population consisted of 102 adults seen in two medical rehabilitation centers in Rome. All of the patients demonstrated the following characteristics: moderate to severe low back pain, moderate to severe radiating pain in one leg, and MRI evidence of disc protrusion in the spinal segments believed to be associated with the pain. Obese patients with acute LBP were excluded, as were patients with chronic LBP, disc protrusion with a ruptured annulus, and those who had already received spinal manipulation.

Upon admission to the study, each patient was interviewed and given a complete physical examination. During the interview, researchers collected detailed information on low back pain and leg pain (using a pair of visual analog scores), including the location of pain and the patient’s overall quality of life with the pain.
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Participants were randomized into two types of manipulation groups active and simulated. Individuals in the active manipulation group received a maximum of 20 sessions over a 30-day period, with each session lasting five minutes. Active manipulation consisted of examining the range of motion in the patient’s back, followed by soft-tissue manipulation and “brisk rotational thrusting away from the greatest restriction.” The purpose of manipulation was to restore movement to the “physiological motor unit” (with each motor unit consisting of two vertebrae, disc and surrounding structures). Subjects in the simulated manipulation group received soft muscle pressing that was similar to manipulation, but did not follow any specific patterns or involve rapid thrusts. All manipulations were performed by two experienced chiropractors with similar formal training from a U.S. chiropractic college.

During the treatment period, patients in both groups were asked to track the number of days they were in pain, the number and type of nonsteroidal antiinflammatory drugs (NSAIDs) they took, and the number of drug prescriptions. In addition, patients were assessed at 15, 30, 45, 90 and 180 days to document changes in pain.

Among the variables the researchers measured were the number of patients who were free of pain at the end of the study period, along with treatment failure (the number of patients who stopped receiving care because it failed to relieve the pain). Changes in visual analog scores at both anatomical locations and in the number of patients experiencing a reduction in disc protrusion (at 45 days) also were recorded.

Results

At the end of the follow-up period, the authors noted “a significant difference” in the percentage of patients between manipulation groups who were pain-free. Fifty-five percent of patients in the active treatment group were free of radiating pain, compared to only 20 percent of patients who received simulated manipulations. Moreover, 28 percent of the active manipulation patients were free of local pain, versus 6 percent of simulated manipulation patients.

In addition, there were significant differences between groups in terms of the number of days patients suffered pain. Active manipulation patients experienced an average of 23.6 days with pain (including 13.9 days experiencing moderate or severe pain). Among patients who received simulated manipulations, the average number of days with pain was higher (27.4), as was the number of days they experienced moderate or severe pain (17.9). Patients who received active manipulations also reported taking fewer NSAIDs and for fewer days than simulated-manipulation patients, although these results were considered nonsignificant. No adverse events were reported by patients.

Two limitations were noted by the study authors: the lack of an exit interview (which precluded the researchers from ascertaining whether the patients were truly “blinded” with regard to treatment) and the specificity of the condition being treated (pain with disc protrusion). Because of these limits, the authors stated that their study “needs to be replicated in other settings to verify its findings.”

Limitations aside, active chiropractic manipulation appeared to have a greater effect on overall pain relief than simulated chiropractic manipulation, with secondary benefits such as reduced use of pain medication, and without causing any adverse effects. As the researchers noted in the study’s conclusion:

“Patients receiving active manipulations enjoyed significantly greater relief of local and radiating acute LBP, spent fewer days with moderate-to-severe pain, and consumed fewer drugs for the control of pain. … Thus, manipulations may relieve acute back pain and sciatica with disc protrusion, although the results of subgroup analyses must be interpreted with caution.”

* Don’t be afraid of needles–especially if you suffer from arthritis pain. A study published in the British Medical Journal shows that acupuncture may be an effective treatment for osteoarthritis of the knee. Researchers gave 97 patients older than age 45, who had never received acupuncture, the anti-inflammatory medication diclofenac and either authentic or placebo acupuncture treatments. The same certified professional performed all acupuncture procedures, using needles with adhesive ends that didn’t penetrate the skin during the placebo procedures. Those who received the true acupuncture took less medication and reported better knee function at the end of 12 weeks.

A recent randomized, controlled trial conducted in Italy sheds new light on the use of spinal manipulation in the treatment of acute back pain and sciatica with disc protrusion. Results of the study, published in a recent issue of The Spine Journal, indicate that active spinal manipulation relieves pain more effectively than a sham simulation, leading to fewer days of localized pain and fewer days of radiating pain, and with no side-effects.

The study population consisted of 102 adults seen in two medical rehabilitation centers in Rome. All of the patients demonstrated the following characteristics: moderate to severe low back pain, moderate to severe radiating pain in one leg, and MRI evidence of disc protrusion in the spinal segments believed to be associated with the pain. Obese patients with acute LBP were excluded, as were patients with chronic LBP, disc protrusion with a ruptured annulus, and those who had already received spinal manipulation.

Upon admission to the study, each patient was interviewed and given a complete physical examination. During the interview, researchers collected detailed information on low back pain and leg pain (using a pair of visual analog scores), including the location of pain and the patient’s overall quality of life with the pain.

Participants were randomized into two types of manipulation groups active and simulated. Individuals in the active manipulation group received a maximum of 20 sessions over a 30-day period, with each session lasting five minutes. Active manipulation consisted of examining the range of motion in the patient’s back, followed by soft-tissue manipulation and “brisk rotational thrusting away from the greatest restriction.” The purpose of manipulation was to restore movement to the “physiological motor unit” (with each motor unit consisting of two vertebrae, disc and surrounding structures). Subjects in the simulated manipulation group received soft muscle pressing that was similar to manipulation, but did not follow any specific patterns or involve rapid thrusts. All manipulations were performed by two experienced chiropractors with similar formal training from a U.S. chiropractic college.

Last June the New England Journal of Medicine, one of the country’s premier medical journals, ended its practice of not soliciting review articles or editorials by authors who have relationships with drug companies. Review articles and editorials summarize published articles and synthesize their conclusions but do not present original research.

Formerly, the journal insisted that authors not have any financial interest in a company that makes a product discussed in an article. The new policy advises that authors should not have a “significant” interest in such a company. According to the journal’s editors, they could no longer find authors without ties to drug companies who could provide comprehensive, up-to-date information, especially on recent advances in therapeutics. “In the past two years we have been able to solicit and publish only one drug therapy article on a novel form of treatment,” they wrote in a June 13 editorial in the journal. “Without authoritative review articles written for scholarly journals by the best possible authors, physicians may find that pharmaceutical companies become their chief source of information about new therapies. This situation is not in the best interest of either physicians or patients.”

Moreover, they write, not all financial associations are the same: “Honorariums for occasional lectures sponsored by biomedical companies, … may be appropriately viewed as minor and unlikely to influence an author’s judgment…. It is our intent to focus on the financial relationships that, in our judgment, could produce bias, or the perception of bias, in an article.” Under the new policy, authors can receive up to $10,000 a year from a drug company before a relationship is automatically considered significant. “We also regard as a significant interest any holding in which the potential for profits is not limited, such as stock, stock options, and patent positions,” the editors wrote. They noted that information about financial relationships below the $10,000 limit but relevant to an article will be disclosed in the journal.