دانلود کتاب راهنمای ایمونولوژی بالینی و آلرژی آکسفورد

Welcome to the fourth edition of the Oxford Handbook of Clinical Immunology and Allergy. Thanks are due to Michael Hawkes for his persistence in prodding me to work faster! As always, the errors are all mine. Despite being ‘flexibly retired’, i.e. retired but continuing to work part- time, I still enjoy the challenge of putting together the Handbook, and I hope that readers will also still find it useful. Re- reading my introduction to the third edition, nothing that has happened in the intervening years has made me believe that anything that I said then was incorrect. As I have been writing, the NHS has celebrated its 70th birthday and like many elderly people it is beginning to show its age. There is a desperate need for new solutions. The NHS is no longer able to cope with winter demand, or even now summer demand. We have had a junior doctors’ strike in the NHS against an imposed contract. The pyrrhic victory of the Health Secretary in this dispute has driven more and more junior doctors to leave the country or, worse, leave medicine altogether. We have seen a junior doctor convicted of medical negligence manslaughter, when in fact she was working in a failed system, with IT failures and staff shortages. We have seen an outpouring of anger against the GMC. We are seeing financial meltdown in the NHS, but also significant failures of private companies used to outsource NHS tasks such as GP records and payment of GP trainees. We have had a referendum in the UK in favour of leaving the European Union (EU). This has further destabilized staffing in the NHS, with EU healthcare professionals either deciding to leave or not coming in the first place. The increasing rate of retirement of senior doctors, driven by the tax and pension system, means that the NHS faces an unprecedented skills shortage. This is not, as in the 1960s, going to be filled by migration from Asia, particularly in view of the Home Office’s unhelpful cap on visas. How Brexit will affect drug licensing and regulation, drug supply, as well as key biomedical research collaboration and funding is still completely opaque. We have had yet another iteration of junior doctor training in the UK, in the form of ‘Shape of Training’ which reinvents the old senior registrar position (although for political reasons this is now a junior consultant!). More trainees will be forced to do general medicine. As surveys by the RCP have shown that 60% of trainees would rather not do general medicine and 45% of consultants don’t enjoy it either, there is clearly a problem. General physicians are sadly lacking now, but being a general physician is deemed synonymous with doing acute medicine, which it isn’t. Training itself is driven by a tick- box mentality, rather than working on the basis that learning to be a good doctor is an apprenticeship! Virtually no hospital trust in the UK is now able to operate at a profit, even the best run organizations. Temporary funding of £20 billion has been promised, but this in fact simply restores the £20 billion of ‘efficiency savings’ removed from the system over the last 5 years, and with inflation, probably doesn’t even restore the position. The inflation of the cost of medical care outstrips general inflation and is compounded by the swathes of new therapies. Comparing the section on biologicals in the first edition of the Handbook with the chapter on immunotherapeutics today, there was just OKT3 and Campath®. Now there are literally hundreds of biological therapies with new ones being licensed all the time. Some of the new genebased therapies of diseases such as cystic fibrosis are being marketed at $0.5 million per patient. The problem here is that the treatment is curative, so the pharma companies do not benefit from long- term retreatment, so must recover their development costs upfront. These treatments, needless to say, are currently unaffordable and a new funding model is required. The biggest change over the last 5 years is the impact of genetic technology. Most of the revision of this edition has been to update the genetics of old diseases and incorporate information on the ‘new’ genetic diseases. This has applied particularly to the primary immune deficiencies and to the autoinflammatory diseases. Even during the writing process, dozens of new genetic immunological diseases have been described. So readers beware— you absolutely need to monitor the literature regularly! This Handbook contains as much as is practical, but is not encyclopedic in coverage. For PIDs, the IUIS publishes regular (now yearly) updates on the recognized immunodeficiencies.