bluuebunny/crossref_metadata_2025 huggingface dataset:
Hyperreflexia
Authors: Shaibani Aziz
Published: March 2018

Hyperactive deep tendon reflexes (DTRs) is a sign of upper motor neuron (UMN) lesions. It is also commonly seen in normal but anxious people. The proper technique of deep tendon reflex examination and experience play a major role in eliciting and categorizing DTRs. Sustained clonus is the highest degree of hyperreflexia. The most important neuromuscular disease associated with hyperreflexia is amyotrophic lateral sclerosis (ALS) due to degeneration of the cortical motor neurons. Diagnostic difficulty occurs when hyperreflexia and spasticity are the only findings. In these cases, primary lateral sclerosis (PLS), hereditary spastic paraplegia (HSP), and other causes of myelopathies should be entertained. Compressive myelopathies are easily excludable by neuroimaging.
Muscle Twitching
Authors: Shaibani Aziz
Published: March 2018

Muscle twitching is an involuntary movement of the muscles that is usually focal and transient. Patients confuse it with restlessness of the legs and jerking of the extremities unless they are specifically asked. Tremor is also commonly mixed with twitching, but its regular nature should be noticed. Fasciculation and rippling are the most important neuromuscular causes of twitching. Reproduction of the symptoms in the clinic, if possible, is very useful for the diagnosis. Otherwise, a video showing these twitching is equally sufficient to provide evidence of the condition.
Muscle Stiffness and Cramps
Authors: Shaibani Aziz
Published: March 2018

Muscle stiffness as a nonspecific term means limited muscle mobility. Muscle and joint pain may be described as stiffness. Painful, sustained muscle cramps are usually associated with muscle stiffness. A careful history is paramount. Exercise-induced muscle cramps are usually myopathic (metabolic or mitochondrial myopathy) while resting, and nocturnal cramps are neurogenic [neuropathy, motor neuron disease (MND), etc.]. Metabolic cramps are electrically silent. Focal or generalized stiffness is typically seen in stiff person syndrome (SPS). Upper motor neuron (UMN) lesions are associated with spasticity and stiffness [hereditary spastic paraplegia (HSP), primary lateral sclerosis (PLS), myelopathies, etc.]. Painful cramps and fasciculation are important clues to peripheral nerve hyperexcitability disorder, which may also present with neuromyotonia. Not unusually, no cause is found for muscle cramps and stiffness. Symptomatic treatment frequently helps.
Numbness
Authors: Shaibani Aziz
Published: March 2018

Sensory symptoms are the most common symptoms in neuromuscular clinics, yet it is hard to capture them via video unless they have a very specific pattern and they are associated with objective loss of sensation. Distal sensory loss is a common neuropathic finding. It follows gloves and stocks distribution. Sensory neuropathies may present with ataxia which results in falls, or severe pain. Neuropathic pain with normal ankle reflexes and sural responses suggest small fiber neuropathy. Multifocal sensory loss is usually vascular. It can also be infectious (leprosy). Migratory neuritis is a poorly understood condition. Intercostal pain and numbness is usually due to radiculopathy (diabetic, zoster, or compressive radiculopathy). Foots ulcers and unfelt mosquito bites are markers for sensory loss. Loss of corneal sensation may led to keratitis and blindness.
Deformities
Authors: Shaibani Aziz
Published: March 2018

Deformities are important markers for congenital and hereditary neuromuscular disorders. For example, kyphosis, scoliosis, and pes cavus are common in Charcot-Marie-Tooth (CMT) disease and hereditary ataxias. Deformities such as high feet arches may also result from long-time weakness and asymmetry. Other types of deformities may be related to connective tissue pathology, which can be associated with neuromuscular disorders. Examples include multiple lipomatosis, scleroderma, and nephrogenic systemic sclerosis (NSS). Charcot joint is a result of lack of proprioceptive sensation and is usually associated with severe chronic neuropathy. Deformity of the nose can result from syphilis and leprosy. This chapter shows examples of these deformities and their treatments.
Electromyogram (EMG) Findings
Authors: Shaibani Aziz
Published: March 2018

While this chapter, and even this book, are not intended to be a textbook in electrodiagnosis, we have chosen video samples of typical abnormal discharges that often are faced by neuromuscular specialists, such as myopathic units, myotonic discharges, myokymia, fibrillation, and neurogenic firing. Other electromyogram (EMG) clips are embedded in other chapters. Firing frequency of the motor unit potentials can be calculated and it is increased in denervation. Observation for 40–60 seconds may be needed to detect infrequent fasciculations after needle placement. Mixed short and long duration is a features of chronic myopathy and can be confused with chronic denervation.
The Neurobiology of Meditation and Stress Reduction
Authors: Newberg Andrew B. , Yaden David B.
Published: March 2018

Meditation is a complex mental process that involves changes in cognition, sensory perception, emotions, hormones, and autonomic activity. Several brain regions are involved in these practices, particularly as they relate to improvements in brain function and psychological parameters, including the thalamus, frontal lobes, limbic system, and parietal lobes. Additionally, many different neurotransmitter systems are likely affected by meditation practices. Meditation programs have become widely used, either alone or combined with other therapies, for stress reduction depression, anxiety, and posttraumatic stress disorder. There has been an increasing understanding of the overall biological mechanism of meditation practices in terms of their effects on both the brain and body. Recent studies using clinical tools and functional neuroimaging have substantially augmented the knowledge of the biology of meditative practices. This chapter reviews current understanding regarding the physiological and neurophysiological effects of meditation practices as they pertain to brain health.
The Interaction of Religion and Health
Authors: Yaden David B. , Newberg Andrew B.
Published: March 2018

Religion and spirituality are an important part of many patients’ lives and influence healthcare and healthcare-related decisions. Measuring religious and spiritual beliefs is difficult and relies mostly on self report. As concepts, religion and spirituality overlap but also are distinct concepts. Religions often have specific rules or guidelines regarding sexual behavior, diet, drugs, and alcohol. These in turn may also affect psychological health and well-being. Religiousness has generally correlated with improved overall physical and mental health outcomes. Furthermore, religion and spirituality are sources of support and coping for many people. But religiousness can sometimes have negative influences such as in the case of cults or terrorism. Specific spiritual practices such as prayer, meditation, and yoga can have a direct effect on the brain and body. This chapter reviews the current understanding of how religious and spiritual beliefs and practices affect the brain and overall psychological health.
Botanicals of Interest to Psychiatrists
Authors: Monti Daniel A. , Newberg Andrew B.
Published: March 2018

There are many herbal and botanical substances that are currently used by patients with psychiatric disorders such as anxiety or depression. Because each botanical derives from a different source, contains different active components, and has a different application, each must be studied thoroughly and used carefully. The use of herbal medicines differs from that of chemical pharmaceuticals, which are usually tested, packaged, and administered as single agents in defined dosages. Clinical evidence of effectiveness and toxicity of natural agents varies greatly as do methods for assessing their efficacy. The regulation, legality, standards, and control of the use of botanicals also vary greatly throughout the world. An account of the most frequently used phytopsychopharmaceuticals with their biologic effects, indications, side effects, and interactions can be useful to the clinician and are described in this chapter. Some ingredients covered include St. John’s wort, panax ginseng, kava, valerian, cannabis, and lavender.
Neuromodulation in Psychiatric Disorders
Authors: Herring Christina
Published: March 2018

Quantitative electroencephalogram (qEEG) is the transformation of the EEG by spectral analysis in which the amount of electrical activity at a particular frequency is determined and compared against a normative data base. EEG findings are specific for different psychiatric problems and help reveal brain abnormalities associated with psychological symptoms. Repetitive transcranial magnetic stimulation (rTMS) is a system of delivering multiple pulses within a short time period that induce changes that outlast the stimulation period. Operant conditioning involves providing a reward to increase the probability of a certain behavior. Neurofeedback involves recording, analyzing, and presenting results of qEEG analyses in near real-time to patients in order to promote changes in brain electrical activity. This chapter reviews how neuromodulation works both clinically and from a neurophysiological perspective. This chapter also reviews current clinical data on the use of neuromodulation approaches for improving mental health and well-being.
Integrative Treatment of Emotional Traumas
Authors: Tobia Anna
Published: March 2018

This chapter examines the heterogeneity of posttraumatic stress disorder (PTSD), reviews the controversy over traumatic triggering events, and explores the complexities of the disease including clinical presentation, comorbidity, and the role of social support. Conceptual models for PTSD are also detailed. PTSD has a highly individualistic clinical presentation, which lends itself to the holistic nature of complementary and alternative medicine (CAM). In this chapter, CAM treatments that have demonstrated clinical utility and research support are reviewed. These approaches include mindfulness, Chinese medicine, the Neuro-Emotional Technique, biofeedback, animal-assisted therapy, yoga, plant-based medicines, and cannabis. The chapter addresses those who want to understand and treat PTSD.
Addictions: Evidence for Integrative Treatment
Authors: Morrison Mary F. , Lin Karen , Gersh Susan
Published: March 2018

Legal and illicit substance use disorders are common conditions associated with substantial impairment in health as well as social and occupational functioning. Integrative medicine proposes modalities that offer promise for increasing the likelihood of undertaking treatment for substance use as well as retaining individuals in treatment. Of the integrative therapies discussed, mindfulness-based therapies have both the greatest number of and most rigorous studies for substance use disorders. Mindfulness-based therapies can significantly reduce the consumption of tobacco, alcohol, and other substances compared to control conditions. Complementary therapies reviewed include acupuncture, mindfulness-based practices, exercise, yoga, biofeedback and neurofeedback, art and music therapy, as well as diet and dietary supplements, both herbal and vitamin. Given the high acceptability and low cost of integrative medicine interventions, studies employing these techniques as adjunctive therapies to conventional treatments should be more vigorously supported if they are well-designed and include adequate numbers of subjects.
Epidemiology and burden
Authors: Lam Raymond W.
Published: March 2018

Depression is a common condition with a lifetime prevalence of about 15%. People with depression experience significant impairment in psychosocial functioning, particularly in those with a recurrent or chronic course. Depression is now the leading cause of years lived with disability worldwide. Depression is also associated with increased risk of developing a medical illness and an increased risk of overall mortality, even when deaths from suicide are excluded. The economic costs of depression are staggering, largely owing to indirect costs associated with occupational impairment leading to work absence and reduced productivity. Depression remains undertreated, particularly in lower- and middle-income countries, but the World Health Organization has estimated that scaling up of depression treatment returns US$5 for every US$1 spent.
Special populations
Authors: Lam Raymond W.
Published: March 2018

The keys to optimal management of treatment-resistant depression (TRD) and depression in special populations include careful assessment, selection of evidence-based treatments tailored to the individual, and ongoing monitoring of response and outcome. For TRD, pharmacological strategies include switching antidepressants or adding an adjunctive agent. Adjunctive agents include second-generation (atypical) antipsychotics, other antidepressants, lithium, thyroid hormone, and psychostimulants. There is still a limited evidence base for pharmacotherapy and psychotherapy in special populations such as elderly patients, those with other medical illnesses, pregnant and breastfeeding women, and children and adolescents. For these patients, use and selection of antidepressants depends on an individual risk-benefit assessment.
Gardner and Sutherland’s Chromosome Abnormalities and Genetic Counseling
Authors: Gardner R.J. McKinlay , Amor David J.
Published: March 2018

Medical geneticists and genetic counselors regularly see families attending the genetic counseling clinic with questions about chromosome abnormalities. These families may themselves have had a child affected with a chromosome condition; or, there may have been a history elsewhere in the family. The presentation may have been due to infertility or reproductive loss. Questions may include the following: What is known about this condition? What caused this to happen? Is it likely to happen again? If so, is there a way to prevent it from happening again? The power of molecular approaches to chromosome analysis, coming to be routinely available in this second decade of the twenty-first century, has brought to our knowledge many new “chromosomal syndromes” to add alongside those long known from the days of classical cytogenetics. This new knowledge has increased our ability to answer the questions that families may have; but equally, it has raised challenges in interpretation, as molecular karyotyping has revealed more complexity in the way the human genome is constructed. This book distils the knowledge that has evolved in recent and olden times, and it presents the information in a way that will be helpful to the practitioner. In particular, the risks of recurrence, or of occurrence, of a particular chromosome disorder are clearly set forth. The application of chromosomal knowledge to reproductive conditions, both diagnostically and in management, is rehearsed.
Chromosome Analysis
Authors: McKinlay Gardner R. J , Amor David J
Published: March 2018

For the first half-century of clinical cytogenetics, analysis of chromosomes was an exercise in microscopy. This century, molecular methodologies are holding sway. However, it behoves the counselor to have a good understanding of how things used to be, not least because one often needs to make reference to the historical literature; albeit that it goes without saying, one must keep abreast of new developments. Modern cytogenomic reports are sophisticated documents, and those who read them, and who interpret them to patients and families, need to be well informed. This chapter provides a basic overview of the ways in which chromosomes may be analyzed. The particular distinction is made between the classical methodologies of the twentieth century, and the new molecular approaches largely developed in the twenty-first century.
Autosomal Reciprocal Translocations
Authors: McKinlay Gardner R. J , Amor David J
Published: March 2018

This chapter reviews in detail the question of carriers of autosomal reciprocal translocations and the genetic risks implied for potential offspring of theirs. Examples are offered of the various possibilities due to malsegregation in gametes of theirs: adjacent-1, adjacent-2, 3:1, and the (very rare) 4:0 malsegregation. The chapter provides advice on determining the most likely modes of segregation, according to the different forms of translocation (length of centric segment, length of translocated segment, sizes of derivative chromosomes). The chapter discusses the practical problem of the apparently balanced translocation but which is associated with phenotypic abnormality. Associations with infertility are noted.
Insertions
Authors: McKinlay Gardner R. J , Amor David J
Published: March 2018

Insertions are a type of translocation, and indeed they are sometimes referred to as “insertional translocation,” “interstitial translocation,” or “nonreciprocal translocation.” Here, a segment of one chromosome is removed and inserted within another chromosome (in contradistinction to the usual translocation, in which the translocated segment is attached to the end of a recipient chromosome). It is, essentially, a one-way translocation; that is, there is no reciprocal movement back to the originating chromosome. Insertions are rare rearrangements, at the level of detection according to classical cytogenetics. Insertions have their own specific qualities that influence risk assessment, and these are discussed in this chapter.
Down Syndrome, Other Full Aneuploidies, Polyploidy, and the Influence of Parental Age
Authors: McKinlay Gardner R. J , Amor David J
Published: March 2018

This chapter reviews the archetypical chromosome disorder, namely Down syndrome (DS; trisomy 21), and the various different chromosomal forms that may be the basis of it: standard trisomy 21, translocation trisomy, both de novo and inherited, and other rare forms. The concept of dosage imbalance as the basis of the pathogenesis is reviewed, and the “DS critical region” on chromosome 21 is examined. Reproductive risks associated with each of these DS types are discussed. The chapter considers the other full autosomal trisomies, T13 and T18, and also (mosaic) T9. Triploidy, as the basis of hydatidiform mole, is reviewed. Also reviewed are the influence of parental, mostly maternal, age, in the genesis of these aneuploidies, and the effect of secular change on these observations. Tables provide precise age-related risk figures for recurrence risk of T21 and more general figures for other trisomies.
Autosomal Structural Rearrangements
Authors: McKinlay Gardner R. J , Amor David J
Published: March 2018

This chapter considers the question of autosomal deletions and duplications, first from the aspect of presumed mechanisms by which they may arise, and then followed by a lengthy (but not encyclopedic) listing of specific imbalances. This listing is informed by the increased knowledge enabled by modern molecular karyotyping, and a number of conditions are those only of twenty-first century discovery. Conditions are listed by the chromosome involved, and each section is headed by a diagram showing the specific segments under consideration. In each, wherever known, a comment is made on possible de novo versus inherited forms, and inferences are drawn as to any recurrence risk in a future pregnancy.
Alcohol Use Among Incarcerated Individuals
Authors: Seal David Wyatt , Yancey Sarah , Reddy Manasa , Kinner Stuart A.
Published: March 2018

This chapter examines alcohol use among individuals who experience incarceration. It reviews the epidemiology of alcohol use before prison, in prison, and after release from prison, and discusses the role of treatment and policy reform in reducing the health and social harms associated with alcohol use in this population. Finally, it summarizes key conclusions, including the lack of data from resource-poor settings where neither routine surveillance nor epidemiological research is common; the failure of much surveillance to distinguish between alcohol use and drug use; and the wide variability in the measurement of alcohol use, misuse, or dependence across studies. The chapter discusses the difficulties in assessing the effectiveness of alcohol use reduction programs in correctional systems, given that many programs prioritize drug use reduction as a primary goal, and that there are wide differences across correctional settings in the availability and quality of these services.
Substance Use After Release from Prison
Authors: Larney Sarah , Stoové Mark , Kinner Stuart A.
Published: March 2018

This chapter discusses the substantial proportion of prisoners globally who have a history of alcohol, tobacco, and other drug use and dependence. Incarceration usually provides a period of abstinence or reduced substance use, but this reduction is often transientand many ex-prisoners rapidly return to pre-incarceration levels of substance use. Substance use after release from prison is affected by both individual factors, such as substance use history and personal expectations, and interpersonal factors, such as social networks. Released prisoners often return to environments in which drugs are readily available and substance use is accepted or normative. Structural factors, such as poor access to substance use treatment and other health services, unstable housing and limited employment options, can create additional stressors that increase the risk of harmful substance use. Given the paucity of epidemiological evidence, the natural history of substance use after release from prison remains poorly understood. In particular, there is a dearth of evidence relating to resumption of alcohol, tobacco, and non-injecting illicit drug use following release from prison. Furthermore, although substance use in ex-prisoners is affected by structural and interpersonal factors, interventions to address problematic substance use typically focus on the individual. Additional research in this area is urgently needed to inform evidence-based policies and interventions.
The Perfect Storm
Authors: Al-Darraji Haider A. , Altice Frederick L.
Published: March 2018

Globally, tuberculosis (TB) is a major cause of morbidity and mortality among people who use drugs (PWUD), particularly those co-infected with HIV. This chapter describes how TB is prevalent in several prison systems by virtue of the concentration of PWUD and people living with HIV. TB is further amplified within this system through overcrowding, poor ventilation, and delayed access to quality prevention and treatment services. In many countries, individuals cycling through prisons are inadequately screened and treated for TB, and affected individuals may have frequent treatment interruptions. For PWUD, relapse to drug use immediately after release from custody can impede continuity of care, which may contribute to the development of drug-resistant TB. Particularly in countries with high incarceration rates, prisons act as amplifiers of TB and drug-resistant TB in the community. The World Health Organization’s recommendations for integration of TB, HIV, and addiction treatment are seldom achieved, especially within prisons. Other factors contributing to poor TB outcomes among PWUD interfacing with prisons include insufficient support to promote medication adherence and co-morbidities, like viral hepatitis that potentiate hepatic toxicity, both of which are prevalent among PWUD.
Drug Use and Prison
Authors: Csete Joanne , Lines Rick , Jürgens Ralf
Published: March 2018

This chapter discusses protections of the health-related rights of prisoners that are encoded in widely ratified human rights instruments and in guidelines for which there is broad international consensus. People who use drugs while detained or incarcerated, however, rarely enjoy the standard of care to which they are entitled, which includes HIV prevention activities and other services that are available in the community. In some countries, people accused of minor drug infractions may be detained for long periods in centers that purport to provide treatment for drug dependence but are effectively labor camps that do not provide health care and where “patients” face physical abuse and denial of due process. There is an urgent need to establish and scale up health services for people who use drugs in custodial environments, with independent monitoring of the existence and quality of care and measures to ensure that health professionals working with people who use drugs in prison and pre-trial detention can work without interference. More important, however, drug dependence and minor drug infractions that often accompany it should be managed through health and social services rather than criminal sanctions. Reducing the use of prison and pretrial detention as a response to drug use and minor possession may be the most important measure for respecting, protecting and fulfilling the health-related rights of people who use drugs. Compulsory “treatment” centers should be closed in favor of humane care provided in the community.
Drug Treatment for Prisoners
Authors: Dolan Kate , Alam-Mehrjerdi Zahra , Moazen Babak
Published: March 2018

Globally more than 10.2 million people are held in prisons on any given day, of whom 10% to 48% of males and 30% to 60% of females are estimated to be drug-dependent. Rates of incarceration for people with drug-related problems have increased in the past couple of decades. The preponderance of people who use or inject drugs in prisons, high rates of drug-related harm in prison and after release, and the high level of re-incarceration among drug users after release from prison are the main reasons for providing drug treatment in prisons. This chapter provides an overview of the rationale for prison drug treatment programs in prison., It describes three main forms of treatment: opioid substitution treatment (OST), therapeutic communities or drug free units, and cognitive behavioral therapy. A review of the evidence on the effectiveness of each treatment is presented, and the chapter concludes with recommendations for drug treatment in the prison setting.
Preventing Drug-Related Death in Recently Released Prisoners
Authors: Brummer Julie , Møller Lars , Enggist Stefan
Published: March 2018

The mortality risk for recently released prisoners is alarmingly high. These individuals, especially in the first 2 weeks following release, are at an increased risk for death compared with an age- and gender-matched general population, with the majority of fatalities attributed to overdoses. Although a number of factors contribute to these incidents, the decreased tolerance resulting from a period of abstinence during incarceration is believed to be especially important. Other important factors are the concurrent use of multiple drugs, the lack of pre-release counseling and post-release follow-up, and the failure to identify those at greatest risk. This chapter describes studies conducted in various countries on post-release drug-related deaths. The literature review supports the finding that there is a significantly heightened risk of overdose death during the initial post-release period and suggests a number of prevention and harm reduction responses that may be applied at various levels of the criminal justice system to reduce drug-related deaths in ex-prisoners. Some identified potential preventive responses are the provision of opioid substitution therapy delivered in combination with psychosocial intervention for opioid-dependent prisoners and a continuity of care and stability of treatment through all stages of the criminal justice system, including during community integration, which can be supported by close linkages between prison-health and public-health systems. Take-home naloxone programs are another promising strategy to prevent overdose deaths among people recently released from prison.
Drug Use in Prisoners
Authors: Kinner Stuart A. , Rich Josiah D.
Published: March 2018

Drug use and crime seem inextricably linked. Law enforcement responses to drug use tend to funnel people who use drugs into the criminal justice system rather than treatment, and those drug users who are imprisoned often have multiple, co-occurring mental health problems and/or suffer from infectious diseases including HIV, hepatitis C, and tuberculosis. Prisons provide a rare but regrettable opportunity to identify and respond to these needs, but correctional policies with respect to drug use and related harms often diverge from the evidence. Where such responses are evidence-based, they are rarely delivered at scale. Drug use in prison remains common and, in the absence of evidence-based harm reduction measures, is high risk. Relapse to drug use after release from prison is normative, such that incarceration can at best be conceived of as an interruption in drug use. People released from prison are at markedly increased risk of drug-related harms including fatal drug overdose and preventable hospitalisation, and are at increased risk of reincarceration. Greater investment in independent, rigorous research on the epidemiology of substance use and related harms in people who cycle through prisons, and a renewed commitment to aligning correctional policy and practice with the evidence, will have measurable benefits for public health, public safety, and the public purse.
Orbit and lacrimal apparatus
Authors: Anbarasu Arangasamy , Lane Jack I.
Published: March 2018

This section discusses Orbital and Lacrimal Apparatus. Anatomy, Embryology, and Pathology is explored alongside the imaging techniques used in this area. More specific infections and traumas are looked at in detail also.
Paranasal sinuses and nasal cavity
Authors: Anbarasu Arangasamy , Lane Jack I.
Published: March 2018

Anatomy and Pathology of the Nasal Cavities and Paranasal Sinuses are discussed in this section. The anatomy and pathology is considered in great detail alongside imaging on the sinuses and disease states.
Temporal bone and skull base
Authors: Anbarasu Arangasamy , Lane Jack I.
Published: March 2018

In this section the temporal base is covered in detail. The skull, Cerebellopontine angle, External Auditory Canal, and areas of the ear are all discussed. Various issues and problems are detailed with imagining techniques for each area.
Ultrasound of the neck
Authors: Anbarasu Arangasamy , Lane Jack I.
Published: March 2018

Section 7 of this title covers Ultrasound of the neck. Equipment and techniques are discussed in depth linked with the various regions of the neck.
Thyroid and parathyroid
Authors: Anbarasu Arangasamy , Lane Jack I.
Published: March 2018

This section covers the Thyroid and Parathyroid in more detail. Various imaging texnigues are discussed. Anatomy, diagnosis, and pathology are all considered too.
The Role of Physical Activity in the Association Between Smoking Status and Quality of Life
Authors: Nduaguba Sabina O , Ford Kentya H , Rascati Karen
Published: March 2018

Objectives

Nonsmoking status and physical activity have, individually, been shown to be associated with health-related quality of life (HRQoL). The objective of this study was to assess whether the relationship between smoking status and HRQoL is modified or influenced by physical activity.

Methods

Data were extracted from the 2014 Behavioral Risk Factor Surveillance Survey dataset (N = 332680) in 2015. Logistic regression models were used to address study objectives. Health-related quality of life (HRQoL), measured using eight domains (general health, physical health, mental health, activity limitations, pain, depressive symptoms, anxiety, and vitality), was regressed on smoking status without and with adjustment for age, race, gender, education, marital status, income, employment, healthcare coverage, comorbidity, body mass index, flu vaccination, alcohol use, and physical activity. Smoking status by physical activity interaction term was added to the adjusted model and evaluated for significance.

Results

There were significant smoking status by physical activity interaction effects on general health, physical health, activity limitations, and depressive symptoms domains. Among those who exercised, relative differences in the odds of a high HRQoL was smaller between former smokers and nonsmokers and larger between current smokers and nonsmokers when compared to those who did not exercise. Similarly, there were sharper relative differences between those who exercised and those who did not exercise among former smokers than among current smokers.

Conclusions

Smokers who successfully quit smoking (former smokers) may benefit from enhanced HRQoL that tends towards that of nonsmokers if they adopt physical activity in their daily routine.

Implications

Behavioral interventions that combine smoking cessation and physical activity may be more effective than either smoking cessation or physical activity alone in improving the quality of life measures such as overall, physical and mental health, and degree of limitation to activities due to poor health. Health care providers can support patients who successfully quit smoking to add exercise to their daily routine with the expectation of enhanced HRQoL.
Infectious Diseases Consultation Reduces 30-Day and 1-Year All-Cause Mortality for Multidrug-Resistant Organism Infections
Authors: Burnham Jason P , Olsen Margaret A , Stwalley Dustin , Kwon Jennie H , Babcock Hilary M , Kollef Marin H
Published: March 2018

Background

Multidrug-resistant organism (MDRO) infections are associated with high mortality and readmission rates. Infectious diseases (ID) consultation improves clinical outcomes for drug-resistant Staphylococcus aureus bloodstream infections. Our goal was to determine the association between ID consultation and mortality following various MDRO infections.

Methods

This study was conducted with a retrospective cohort (January 1, 2006–October 1, 2015) at an academic tertiary referral center. We identified patients with MDROs in a sterile site or bronchoalveolar lavage/bronchial wash culture. Mortality and readmissions within 1 year of index culture were identified, and the association of ID consultation with these outcomes was determined using Cox proportional hazards models with inverse weighting by the propensity score for ID consultation.

Results

A total of 4214 patients with MDRO infections were identified. ID consultation was significantly associated with reductions in 30-day and 1-year mortality for resistant S. aureus (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.36–0.63; and HR, 0.73, 95% CI, 0.61–0.86) and Enterobacteriaceae (HR, 0.41; 95% CI, 0.27–0.64; and HR, 0.74; 95% CI, 0.59–0.94), and 30-day mortality for polymicrobial infections (HR, 0.51; 95% CI, 0.31–0.86) but not Acinetobacter or Pseudomonas. For resistant Enterococcus, ID consultation was marginally associated with decreased 30-day mortality (HR, 0.81; 95% CI, 0.62–1.06). ID consultation was associated with reduced 30-day readmission for resistant Enterobacteriaceae.

Conclusions

ID consultation was associated with significant reductions in 30-day and 1-year mortality for resistant S. aureus and Enterobacteriaceae, and 30-day mortality for polymicrobial infections. There was no association between ID consultation and mortality for patients with resistant Pseudomonas, Acinetobacter, or Enterococcus, possibly due to small sample sizes. Our results suggest that ID consultation may be beneficial for patients with some MDRO infections.
Application of Lean Principles to Neurosurgical Procedures: The Case of Lumbar Spinal Fusion Surgery, a Literature Review and Pilot Series
Authors: Liu Jesse J , Raskin Jeffrey S , Hardaway Fran , Holste Katherine , Brown Sarah , Raslan Ahmed M
Published: March 2018

BACKGROUND

Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed.

OBJECTIVE

To apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases.

METHODS

Process maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability.

RESULTS

Temporal variabilities in duration of decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and instrument defects accounted for 15% and 66% of all waste, respectively.

CONCLUSION

This pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.
Next Generation Case Report: Supraorbital Craniotomy for Anterior Communicating Artery Aneurysm Clipping in Annotated Virtual Reality Environment
Authors: Tucker Alexander M , Beckett Joel S , Martin Neil A
Published: March 2018

BACKGROUND AND IMPORTANCE

Recent years have seen significant advancements in virtual reality. Implementation of this technology in combination with traditional learning methods is a powerful tool for medical teaching.

CLINICAL PRESENTATION

This is a 60-yr-old woman who presented with a history of headaches and was found to have an unruptured 4-mm anterior communicating artery aneurysm. After discussion, the patient elected to have the aneurysm treated by surgical clipping. The aneurysm was completely occluded through a supraorbital craniotomy with a single clip. The patient was discharged home in good condition on postoperative day 2. This case was imported into a virtual reality environment with annotated slides and operative video for resident teaching.

CONCLUSION

As virtual reality technology continues to grow, library of interactive case reports could revolutionize neurosurgical education.
Fungicide and Cultivar Management of Leaf Spot Diseases of Winter Wheat in Western Canada
Authors: Kutcher H. R. , Turkington T. K. , McLaren D. L. , Irvine R. B. , Brar G. S.
Published: March 2018

A complex of leaf-spotting diseases—tan spot, the Septoria complex, spot blotch, and powdery mildew—are frequently observed on winter wheat in western Canada; however, there are few studies indicating varietal differences in reaction to these diseases or the benefit of fungicide application. To determine the benefit of varietal improvement and multiple fungicide treatments and application timings, field experiments were conducted at six site-years in western Canada. Two cultivars varying in reaction to leaf spot diseases were used in combination with fungicide treatments. Disease severity ranged from trace to 64% of the combined flag and penultimate leaf area diseased, differed between cultivars, and was reduced from the check by some fungicide treatments. Yield improvement by fungicide treatment varied from 3.3 to 13.2% greater than the nontreated check. At two site-years, the split application of two half rates of fungicide resulted in the greatest yield; however, in both cases, the yield benefit did not differ from a single application at the flag leaf growth stage. Cultivar selection and fungicide use under environments conducive to disease are beneficial components of an integrated leaf spot disease management program for winter wheat in western Canada.
Does Cannabis Use Influence Opioid Outcomes and Quality of Life Among Buprenorphine Maintained Patients? A Cross-sectional, Comparative Study
Authors: Bagra Igam , Krishnan Vijay , Rao Ravindra , Agrawal Alok
Published: March 2018

Objectives:

Use of various psychoactive substances can influence outcomes of patients on opioid agonist treatment (OAT). While use of alcohol and cocaine has shown to adversely affect OAT results, associated cannabis use shows mixed results. This study aimed to assess the pattern of cannabis use among opioid-dependent patients maintained on buprenorphine. Additionally, the study compared the dose of buprenorphine, opioid-related craving and withdrawals, productivity, and also quality of life between those with and without recent (past 90-day) cannabis use.

Methods:

We collected data on demographic and drug use details in 100 randomly selected adult male patients attending a community drug treatment clinic, who were stabilized on buprenorphine for more than 3 months. Other measures included scores on World Health Organization (WHO)-Alcohol, Smoking and Substance Involvement Screening Tool and WHO-Quality of Life-Brief (WHOQOL-Bref) version.

Results:

The average duration of maintenance treatment with buprenorphine was 96 months, with excellent compliance for buprenorphine (86.92 ± 9.58 days in 90 days). Thirty-five per cent had used cannabis in past 90 days, with lifetime use of cannabis in 77%. Participants using cannabis currently were on lower doses of buprenorphine (mean dose per day: 7.9 mg vs 8.9 mg; P = 0.04). Yet, there was no significant difference in the rates of opioid use or opioid withdrawals and craving between the 2 groups. Compliance to OAT, number of days of employment, daily earning, and WHOQOL-Bref scores in all domains were comparable between those with and without cannabis use. Duration of cannabis use, current use of alcohol, and dose of buprenorphine predicted current cannabis use in multivariable logistic regression analysis.

Conclusions:

Cannabis use does not negatively influence opioid outcomes among patients receiving buprenorphine maintenance treatment. There is no difference in productivity and quality of life between individuals maintained on buprenorphine with and without current cannabis use.
Tattoos in Nursing
Authors: Williams Barbara Miller , Wright Cindy , Leigh Katherine H. , Armstrong Brittney , Kelley Sabrina
Published: March 2018

Tattoos have become increasingly popular in the United States among the general population. Furthermore, the popularity of body art, primarily tattoos, among nursing students generates issues about professionalism in academics and in clinical settings. Nursing faculty are faced with conflicting views on cultural awareness, professionalism, and self-expression. With nursing viewed as one of the most trusted professions, the policy of covering tattoos should be discussed, and more research is necessary.
Total Ambient Dose Equivalent Buildup Factor Determination for Nbs04 Concrete
Authors: Duckic Paulina , Hayes Robert B.
Published: March 2018

Buildup factors are dimensionless multiplicative factors required by the point kernel method to account for scattered radiation through a shielding material. The accuracy of the point kernel method is strongly affected by the correspondence of analyzed parameters to experimental configurations, which is attempted to be simplified here. The point kernel method has not been found to have widespread practical use for neutron shielding calculations due to the complex neutron transport behavior through shielding materials (i.e. the variety of interaction mechanisms that neutrons may undergo while traversing the shield) as well as non-linear neutron total cross section energy dependence. In this work, total ambient dose buildup factors for NBS04 concrete are calculated in terms of neutron and secondary gamma ray transmission factors. The neutron and secondary gamma ray transmission factors are calculated using MCNP6™ code with updated cross sections. Both transmission factors and buildup factors are given in a tabulated form. Practical use of neutron transmission and buildup factors warrants rigorously calculated results with all associated uncertainties. In this work, sensitivity analysis of neutron transmission factors and total buildup factors with varying water content has been conducted. The analysis showed significant impact of varying water content in concrete on both neutron transmission factors and total buildup factors. Finally, support vector regression, a machine learning technique, has been engaged to make a model based on the calculated data for calculation of the buildup factors. The developed model can predict most of the data with 20% relative error.
Relationship Between Central Epithelial Thickness and Central Corneal Thickness in Healthy Eyes and Eyes After Laser In Situ Keratomileusis
Authors: Maltsev Dmitrii S. , Kudryashova Elena V. , Kulikov Alexei N. , Mareichev Artem Yu.
Published: March 2018

Purpose:

To study the relationship between central epithelial thickness (CET) and central corneal thickness (CCT) in healthy individuals and to evaluate their changes after laser in situ keratomileusis (LASIK).

Methods:

In this study, we included 150 patients (150 eyes) who underwent LASIK and 83 healthy individuals (83 eyes). In all patients, CET and CCT were measured using anterior segment optical coherence tomography with Copernicus REVO on B-scans. Statistical analysis was performed using the Spearman rank test, t test, and receiver operating characteristic curve analysis.

Results:

In healthy individuals, CET positively correlated with CCT (r = 0.5, P < 0.001), the CET-to-CCT ratio being 0.100 ± 0.006. The CET-to-CCT ratio increased to 0.111 ± 0.009 (P < 0.001) and to 0.132 ± 0.021 (P < 0.001) at 1 day and 1 month postoperatively, respectively. The area under the curve for the CET-to-CCT ratio as a diagnostic criterion for previously performed myopic LASIK was 0.97 (sensitivity 93.5% and specificity 91.6%).

Conclusions:

In healthy individuals, the corneal epithelium contributes a mean of 10.0% of corneal thickness. The CET-to-CCT ratio has a highly predictive value for indication of previously performed myopic LASIK. It seems that clinical application of epithelial thickness measurement can be improved by adjusting CET for CCT.