bluuebunny/crossref_metadata_2025 huggingface dataset:
A Bayesian level set method for identifying subsurface geometries and rheological properties in Stokes flow
Authors: Holbach Lukas , Gurnis Michael , Stadler Georg
Published: May 2023

We aim to simultaneously infer the shape of subsurface structures and material properties such as density or viscosity from surface observations. Modelling mantle flow using incompressible instantaneous Stokes equations, the problem is formulated as an infinite-dimensional Bayesian inverse problem. Subsurface structures are described as level sets of a smooth auxiliary function, allowing for geometric flexibility. As inverting for subsurface structures from surface observations is inherently challenging, knowledge of plate geometries from seismic images is incorporated into the prior probability distributions. The posterior distribution is approximated using a dimension-robust Markov-chain Monte Carlo sampling method, allowing quantification of uncertainties in inferred parameters and shapes. The effectiveness of the method is demonstrated in two numerical examples with synthetic data. In a model with two higher-density sinkers, their shape and location are inferred with moderate uncertainty, but a trade-off between sinker size and density is found. The uncertainty in the inferred is significantly reduced by combining horizontal surface velocities and normal traction data. For a more realistic subduction problem, we construct tailored level-set priors, representing “seismic” knowledge and infer subducting plate geometry with their uncertainty. A trade-off between thickness and viscosity of the plate in the hinge zone is found, consistent with earlier work.
Resilience of front-line facilities during COVID-19: evidence from cross-sectional rapid surveys in eight low- and middle-income countries
Authors: Peters Michael A , Ahmed Tashrik , Azais Viviane , Amor Fernandez Pablo , Baral Prativa , Drouard Salomé , Neill Rachel , Bachir Kante , Bassounda Poidinguem , Dube Queen , Flora Sabrina , Montufar Edwin , Nzelu Charles , Tassembedo Mahamadi , Sanford Wesseh Chea , Alam Bushra , Rusatira Jean de Dieu , Hashemi Tawab , Karibwami Alain-Desire , Moscosco Virginia , Ogunlayi Munirat , Ortiz de Zunigalo Tania , Ruel-Bergeron Julie , Sieleunou Isidore , Hansen Peter M , Shapira Gil
Published: May 2023

Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks.
A radiation box domain truncation scheme for the wave equation
Authors: Schweizer B , Schäffner M , Tjandrawidjaja Y
Published: May 2023

We consider the wave equation in an unbounded domain and are interested in domain truncation methods. Our aim is to develop a numerical scheme that allows calculations for truncated waveguide geometries with periodic coefficient functions. The scheme is constructed with radiation boxes that are attached to the artificially introduced boundaries. A Dirichlet-to-Neumann operator $N$ is calculated in these radiation boxes. Efficiency of the scheme is obtained by calculating $N$ not with an iteration, but with a single run through the time interval. We observe speed-up factors of up to $20$ in comparison to calculations without domain truncation.
Assessing the impact of rainwater harvesting infrastructure and gardening trends on microbial indicator organism presence in harvested rainwater and garden soils
Authors: Moses Arthur , Ramírez-Andreotta Mónica D , McLain Jean E T , Cortez Luz Imelda , Kilungo Aminata
Published: May 2023

Aim

To assess the microbial water quality of harvested rainwater infrastructure used to supplement household water uses for homegrown produce.

Methods and Results

Using a co-created community science methodology, between 2017 and 2020, a total of 587 harvested rainwater samples and 147 garden soil samples irrigated with harvested rainwater were collected from four Arizona communities and analyzed for coliform, Escherichia coli, and/or Salmonella. Participants also completed a home description survey regarding their home and surrounding area, water harvesting infrastructure, and gardening habits.

Conclusion

Chi-Square tests revealed that the quality of harvested rainwater is affected by proximity to a waste disposal or incineration facility, animal presence, cistern treatment, and cistern age (P < 0.05), while soil samples were associated with community (P < 0.05). Coliform and E. coli concentrations in both sample types were greater in the monsoon season.
Parameterizing and simulating from causal models
Authors: Evans Robin J , Didelez Vanessa
Published: May 2023

Many statistical problems in causal inference involve a probability distribution other than the one from which data are actually observed; as an additional complication, the object of interest is often a marginal quantity of this other probability distribution. This creates many practical complications for statistical inference, even where the problem is non-parametrically identified. In particular, it is difficult to perform likelihood-based inference, or even to simulate from the model in a general way. We introduce the ‘frugal parameterization’, which places the causal effect of interest at its centre, and then builds the rest of the model around it. We do this in a way that provides a recipe for constructing a regular, non-redundant parameterization using causal quantities of interest. In the case of discrete variables, we can use odds ratios to complete the parameterization, while in the continuous case copulas are the natural choice; other possibilities are also discussed. Our methods allow us to construct and simulate from models with parametrically specified causal distributions, and fit them using likelihood-based methods, including fully Bayesian approaches. Our proposal includes parameterizations for the average causal effect and effect of treatment on the treated, as well as other causal quantities of interest.
A giant low-grade appendiceal mucinous neoplasm (LAMN) presenting as ileocecal intussusception: a case report
Authors: Liapis Stavros C , Perivoliotis Konstantinos , Psarianos Kyriakos , Chatzinikolaou Charito , Moula Amalia I , Skoufogiannis Pavlos , Balogiannis Ioannis , Lytras Dimitrios
Published: May 2023

We report the rare case of a giant low-grade appendiceal mucinous neoplasm (LAMN), presenting as ileocecal intussusception. An 80-year-old woman presented in the emergency department of our institution with progressively worsening diffuse abdominal pain during the last 24 h. A CT scan revealed a giant abdominal mass (98.7 × 127.3 × 107.6 mm) with air-fluid level and imaging characteristics of ileocecal intussusception. An emergency exploratory laparotomy was performed, and a well-circumscribed cystic mass deriving from the appendix was found. A right hemicolectomy was performed, and the histopathological examination confirmed the diagnosis of LAMN. This report aims to raise awareness among surgeons and radiologists, about LAMNs as a differential diagnosis of right iliac fossa masses presenting as acute abdomen.
Pseudomyxoma peritonei and an incidental low-grade appendiceal mucinous neoplasm and neuroendocrine appendiceal collision tumour: a case report
Authors: Gupta Ankit , Mirpuri Lavesh , Malik Faizan , Hassan Hussain , Amtul Nasira
Published: May 2023

Appendiceal collision tumours are extremely rare, with most reported cases describing tumours consisting of a mucinous component and a neuroendocrine component. Low-grade appendiceal mucinous neoplasms, in some cases, have a tendency to rupture and disseminate their mucin-producing cells throughout the abdominal cavity, leading to a clinical syndrome known as pseudomyxoma peritonei (PMP). We present the case of a 64-year-old male who initially presented with acute appendicitis and was subsequently found to have PMP and appendiceal malignancy. After several years of scans, surgical intervention and histological analysis, it became apparent that the appendiceal malignancy was comprised of distinct cell types. The patient underwent two rounds of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, which resulted in a 2-year disease-free period. Unfortunately, the PMP recurred, having morphological changes consistent with a more aggressive disease process.
Papillary thyroid carcinoma arising from a mature ovarian teratoma coexisting with stromal luteoma: the first case report in the literature
Authors: Al-janabi Moatasem H , Khaddour Tariq , Salloum Rabab
Published: May 2023

Mature cystic teratomas are the most common ovarian tumors in women of reproductive age. The malignant transformation of mature cystic teratomas is a rare entity. The most common malignant tumor in mature cystic teratomas is squamous cell carcinoma, whereas papillary thyroid carcinoma is an exceptional event. On the other hand, stromal luteoma is an uncommon benign steroid cell tumor of the ovary that occurs mostly in postmenopausal females. The coexistence of different ovarian tumor subtypes is an extremely rare pathological event. In this report, we describe a case of papillary thyroid carcinoma arising in mature cystic teratomas coexisting with stromal luteoma. To the best of our knowledge, this is the first report in English literature. Both mature cystic teratoma (with papillary thyroid carcinoma) and stromal luteoma are very rare entities. Pathologists should be aware of malignant transformation and exclude it when investigating mature cystic teratomas, especially in older patients.
Atovaquone and Proguanil Hydrochloride for Treatment of Malaria
Authors: Kremsner Peter G. , Looareesuwan Somchai , Chulay Jeffrey D.
Published: May 2023

Background: Safe and effective new drugs are needed for treatment of malaria. Atovaquone and proguanil hydrochloride is a new antimalarial combination that has recently become available in many countries.

Methods: Data from clinical trials evaluating atovaquone/proguanil for treatment of malaria were reviewed.

Results: In 10 open-label clinical trials, treatment of uncomplicated falciparum malaria with 1000 mg atovaquone and 400 mg proguanil hydrochloride (or the equivalent based on body weight in patients <40 kg) once daily for 3 days achieved cure in 514 of 521 (99%) evaluable patients. Treatment-limiting adverse events occurred in < 1 % of patients (vomiting in four, anaphylaxis in one). Atovaquone/proguanil has been used to provide radical cure of asymptomatic Plasmodium falciparum infections prior to initiation of placebo-controlled trials of malaria prophylaxis. Recurrent parasitemia occurred within 28 days in 0 of 99 subjects who subsequently received prophylaxis with atovaquone/proguanil and 1 of 81 subjects who subsequently received placebo. Atovaquone/proguanil is also effective for treatment of malaria caused by the other three Plasmodium species that cause malaria in humans. For treatment of vivax malaria, therapy with primaquine in addition to atovaquone/proguanil is needed 1o prevent relapse from latent hepatic hypnozoites.

Conclusion:Atovaquone and proguanil hydrochloride is a safe and effective combination for treatment of malaria.
Quantitation of Mycoplasma genitalium using droplet digital PCR
Authors: Peh Cheng Rui , Danielewski Jennifer , Chua Teck Phui , Bodiyabadu Kaveesha , Machalek Dorothy A , Garland Suzanne M , Bradshaw Catriona S , Murray Gerald L
Published: May 2023

Mycoplasma genitalium is a sexually transmitted infection with increasing concerns around antimicrobial resistance. Droplet digital PCR (ddPCR) is a rapid quantification method with high precision that may be useful for absolute quantitation of bacteria in samples. This study aimed to develop a ddPCR assay for the quantification of M. genitalium. ddPCR targeting the gene mgpB was established and analysed using the QX100 ddPCR system. The assay was evaluated against quantitated DNA standards, and then in comparison to an established quantitative PCR performed on the Lightcycler 480 II. DNA template of increasing complexity was used, including synthetic double stranded DNA, DNA extracts from laboratory-cultured M. genitalium strains (n = 17) and DNA from M. genitalium-positive clinical samples (n = 21). There was a strong correlation between ddPCR concentration estimates and measured DNA standards (r2 = 0.997), and between ddPCR and qPCR quantitation for different templates (r2 ranging from 0.953 to 0.997). ddPCR reliably detected template in a range from <10 copies per reaction to >104 copies per reaction and demonstrated linearity over dilution series. Concentration estimates by ddPCR were reproducibly less than those determine by qPCR. ddPCR demonstrated precise and reproducible quantitation of M. genitalium with a variety of templates.
Apologies Matter
Authors: Lemma Alessandra
Published: May 2023

This chapter explores what constitutes an ethical response ‘when things go wrong’. The Duty of Candour is discussed along with the intrapsychic and interpersonal functions of making an apology, drawing on the philosophical literature to tease out the constituent elements of an apology. Emphasis is placed on the importance of approaching errors with humility and recognizing both the moral and clinical value of apologizing when things go wrong. The public’s expectation is that therapists—like any other person involved in the helping professions—will always behave ethically. When there is a breakdown in this expectation, the breach of trust has grave consequences not just for the patient but also for the standing of the profession.
Diagnostic tests and principal investigations
Authors: Werner Yuki B.
Published: May 2023

This chapter provides an overview of the different methods to evaluate a disease including invasive, non-invasive, and functional tests. It is divided into ten sections and explains the principles of each test for use in clinical routine based on the current literature. It contains not only memorable but also useful image examples and exemplifies practical classifications. Technological progress and subtle test protocols expand the value of the established methods. Newer functional tests, such as high-resolution manometry and the endoluminal functional lumen imaging probe (EndoFLIP), extend the diagnostic spectrum for symptomatic patients. Functional imaging technologies enable clinicians to identify and differentiate the causes of dysphagia and the severity grades of motility disorders. The use of diagnostic tests will improve the ability to indicate necessary interventions and to predict the therapeutic response. Nevertheless, the introduction of new diagnostic methods into the clinical routine should be based on validated data from controlled clinical trials.
Benign diseases of the stomach
Authors: Aridome Kuniaki
Published: May 2023

Most benign diseases of the stomach are attributed to functional dyspepsia and acid-related disorders such as peptic ulcer disease. Dyspepsia is also the main manifestation of these acid-related conditions of the stomach. Functional dyspepsia comprises three subtypes: postprandial distress syndrome, epigastric pain syndrome, and a subtype with overlapping postprandial distress syndrome and epigastric pain syndrome features. Peptic ulcer disease is characterized by a non-malignant lesion in the gastrointestinal mucosa that may be acute, subacute, or chronic. Proton pump inhibitors significantly improve the management options available for patients with functional dyspepsia or peptic ulcer disease. Reduction of inappropriate prescribing of proton pump inhibitors in inpatient and outpatient settings can minimize the potential for adverse events.
Oesophageal cancer
Authors: van Boxel Gijsbert , van der Sluis Pieter C. , Grimminger Peter P. , van Hillegersberg Richard
Published: May 2023

Surgical resection of the oesophagus and its surrounding lymph nodes in an en bloc manner remains the mainstay treatment in the curative management of oesophageal cancer, with or without neoadjuvant oncological treatment. Evidence in favour of the minimally invasive approach for oesophagectomy is increasing, including that for the use of robotic surgery. The past two decades have seen an increasing uptake in minimally invasive Ivor Lewis oesophagectomy (MIO)—laparoscopic mobilization of the stomach with abdominal lymph node dissection and formation of the gastric conduit, followed by the thoracoscopic resection of the oesophagus and its surrounding lymph nodes and formation of an intrathoracic anastomosis. Several multicentre randomized controlled trials and large-scale meta-analyses have shown a reduction in cardiopulmonary complications with equivalent long-term disease-free and overall survival when comparing MIO to open oesophagectomy. Robot-assisted minimally invasive oesophagectomy (RAMIO) is fast becoming a preferred approach to oesophagectomy. Its principles are similar to MIO, although the evidence available suggests that the increased dexterity, magnification, tremor reduction, and three-dimensional vision permitted by the robotic platform allows for greater lymph node yields and reduced cardiopulmonary complications. This chapter reviews the history and variety of operative approaches to the surgical resection of the oesophagus and the rationale for each approach. The steps involved and the current available evidence for both MIO and RAMIO are described.
Oesophageal cancer
Authors: Goetze Thorsten Oliver , Al-Batran Salah-Eddin
Published: May 2023

Gastric and oesophageal carcinomas, including adenocarcinomas of the oesophagogastric junction, were responsible for more than 1 million deaths worldwide in 2018. Surgery remains the primary curative treatment method for these carcinomas. The overall prognosis for this condition treated with surgery alone, however, is unsatisfactory. Consequently, perioperative multimodal concepts are standard to improve the overall survival according to the FLOT4 and CROSS trials. However, more than 50% of patients continue to die from the disease in a curative setting. Several ongoing clinical trials are investigating the further optimization of perioperative therapies. In the palliation of gastric and oesophagogastric junction adenocarcinomas, there have been some innovations and changes in the conventional treatment, as well as in immunotherapy.
Gastric cancer
Authors: Bang Chang Seok
Published: May 2023

Gastric cancer remains a health-related burden worldwide and is the third leading cause of cancer-related mortality. Endoscopic submucosal dissection is indicated for superficial gastrointestinal neoplasms with negligible risk of lymph node metastasis. This procedure has an advantage of achieving en bloc resection of tumours irrespective of the size and location of the lesions, and the stomach can be preserved. It has evolved through an improvement in endoscopic skills, expertise, and equipment, reaching a better understanding of the indications, short-term and long-term outcomes, and management of adverse events. In this chapter, the indications, procedure, therapeutic outcomes, management of adverse events, and post-endoscopic submucosal dissection surveillance strategy are discussed.
Gastric cancer
Authors: Biebl Matthias , Kröll Dino , Chopra Sascha , Pratschke Johann
Published: May 2023

This chapter summarizes surgical treatment options for adenocarcinomas of the stomach (gastric cancer) as well as the oesophagogastric junction (AOG tumours). Anatomically, the cardia is the anatomical transition zone of the two-layered oesophageal musculature into the three-layered stomach defined by the end of the longitudinal gastric folds. The sharp transition of the oesophageal squamous epithelium into the cylindric gastric mucosa (the Z-line) is a well-defined landmark. It is, however, variable in height and, due to its potential for oral translocation in patients with acid reflux, not suitable for exact anatomical determination of the AOG junction. Siewert coined a classification regarding this junction, of the transitional zone between the oesophagus and stomach extending from 5 cm proximal to the histological cardia to 5 cm of the proximal stomach. Tumours arising within the distal 5 cm of the oesophagus (formally distal oesophageal adenocarcinomas) are defined as AOG I tumours, tumours arising within 2 cm cranial to and less than 2 cm below the anatomical cardia are defined as AOG II tumours. Tumours below 2 cm and within 5 cm distal to the cardia (formally subcardial gastric cancer) are defined as AOG III tumours. However, according to the current classification of the ‘Union international Contre le Cancer’ (UICC), there is no specified classification for AOG tumours, and AOG tumours are classified as oesophageal tumours. This has been criticized by several authors, who attribute to AOG II and III tumours a biological behaviour and lymphatic spread pattern similar to gastric cancers. Tumours distal to the 5 cm line from the cardia are defined according to their position in the stomach as upper-third gastric cancers (proximal tumours), mid-third gastric cancers (corpus carcinomas), and tumours of the distal third of the stomach (antral tumours).
Gastric cancer
Authors: Hikage Makoto , Terashima Masanori
Published: May 2023

Minimally invasive gastrectomy is becoming the mainstay surgical treatment for gastric cancer. Large-scale clinical studies have confirmed the safety and oncological feasibility of laparoscopic gastrectomy. Moreover, robotic systems, which have been introduced to overcome the disadvantages of laparoscopic surgery, are expected to further improve surgical outcomes, even in complicated procedures or highly advanced cases. This chapter provides a histological outline and describes the development of these minimally invasive surgeries with existing evidence. In addition, it comments on the future prospects of these techniques and concludes that that endoscopic surgery will play a leading role in gastric cancer therapy in the near future.
Fundamental Skills and Education for the Generalist and Specialist Palliative APRN
Authors: Wholihan Dorothy , Tilley Charles , Rudden Adrienne
Published: May 2023

Advanced practice registered nurses (APRN) have played a pivotal role in palliative care over the past 15 years and will continue to shape the future of hospice and palliative care. Broadly defined and practice-focused, advanced practice nursing includes interventions that influence healthcare outcomes, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and healthcare organizations, and the development and implementation of health policy. There are specific requirements for education delineated by the American Association of Colleges of Nursing (AACN) and the National Council of State Boards of Nursing (NCSBN) Consensus Model as per Licensure, Accreditation, Certification, and Education (LACE) standards. Palliative nursing is a necessary aspect of all specialty tracks. This chapter reviews graduate requirements for APRNs and both primary and specialty palliative care content in graduate curricula.
The Palliative APRN in Policy and Payment Models
Authors: Grant Marian
Published: May 2023

Palliative care achieves all the key objectives of health reform and health policy revisions, and recent federal legislation and regulation is improving access to palliative care services. In addition, healthcare payment is shifting toward paying for outcomes and value, and palliative care can contribute to achieving those goals. Health policy and payment policy affect patient care and access to care, what palliative advanced practice registered nurses (APRNs) can do clinically, and what they can be reimbursed for. Palliative care is attractive to policymakers because it improves care for serious illness while also controlling costs. This chapter reviews how palliative care meets policy goals, recent developments in federal legislation and regulation for serious illness, new payment models for that population, and how palliative APRNs can play a role in policy development and implementation.
The Palliative APRN in Research and Evidence-Based Practice
Authors: Linton Janice , Carpenter Joan G.
Published: May 2023

Advanced practice palliative nursing is grounded in research and guided by evidence-based practice (EBP). Research is a systematic approach aimed at developing new knowledge through science. EBP is a structured mechanism for solving health-related issues based on the triad of best research (external evidence), clinical expertise (internal evidence), and patient preferences and values to support clinical decision-making for best outcomes. This chapter defines the advanced practice registered nurse (APRN)’s role in conducting research and translating evidence into clinical practice. Case studies are integrated throughout to demonstrate the stepwise approach for conducting high-quality research and applying EBP processes. Supportive statements from leading organizations in the palliative care industry add credence to the APRN’s role in research and EBP. The future of high-quality care for persons living with a serious or life-threatening illness lies in delivering expert palliative care grounded in research and EBP.
The Palliative APRN in the Palliative Care Clinic
Authors: Smith Brooke , Stephens Lisa A.
Published: May 2023

This chapter discusses the role of the advanced practice registered nurse (APRN) in providing symptom management, psychosocial support, and collaborative decision-making support across the disease trajectory. It describes communication, assessment, and management of symptoms; psychosocial and spiritual support; and coordination of care as integral skills that the nurse brings to the care of palliative care patients in the clinic. It details outpatient palliative care clinic models and the APRN role within each model, its financing and scheduling, and the roles of other team members. It also reviews the evidence for the nurse’s role in enhancing patient satisfaction and reducing healthcare utilization. It describes the longitudinal support of the palliative APRN in fostering resilience in patients, family members, and other members of the healthcare team. Finally, it describes the necessity of care coordination to promote quality care.
The Palliative APRN in Primary Care
Authors: Gorman Rosemary , Wholihan Dorothy , Bender Sarah
Published: May 2023

Primary care is defined by the National Academy of Medicine (previously the Institute of Medicine) as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” A patient will see his or her primary care provider for routine physicals, preventive care, care of stable chronic illness, and common health-related issues. Advanced practice registered nurses (APRNs), most commonly nurse practitioners, frequently act in the role of primary care providers. The APRN who assumes this role acts as the initial contact point for patients who have a health-related problem. The primary care provider directs and coordinates specialist care as needed. Primary care providers aim for continuity of care that leads to the development of long-standing relationships. Since primary care takes a long-term, life span approach, the implementation of palliative care may be appropriate intermittently in a patient’s health trajectory. It is imperative that the APRN in primary care have primary palliative care skills.
LGBTQ+ Inclusive Palliative Care
Authors: Nymeyer Jessica
Published: May 2023

The palliative advanced practice registered nurse (APRN) cares for individuals who represent the spectrum of gender and sexual identities. Clinicians must be aware of the unique issues facing the LGBTQ+ population, including a history of discrimination in society at large and in healthcare institutions as well. In order to provide patient centered care and meet each patient’s medical and psychosocial needs, the palliative APRN should be familiar with the concerns, issues, and policies that affect the care of LGBTQ+ individuals. Moreover, there are unique concerns at end of life that must be addressed.
The Pediatric Palliative APRN in the Acute Care Setting
Authors: Kinnear Faith , Santucci Gina
Published: May 2023

The role of the pediatric palliative advanced practice registered nurse (PP APRN) in the acute care or inpatient setting encompasses a wide breadth including providing initial consults, managing acute pain and distressing symptoms, assisting families with complex medical decision-making, providing longitudinal support across multiple admission, ensuring goals are communicated among specialty team members, and providing expert care at the end of life. The APRN needs to be aware of the barriers that still exist to providing good pediatric palliative care and how providing primary palliative care education to colleagues can help overcome these barriers. This chapter highlights some of the nuances of inpatient pediatric palliative care and evidenced-based symptom management by utilizing case examples.
The Pediatric Palliative APRN in the Community
Authors: Chrastek Joan “Jody” , Hensel Jaime
Published: May 2023

This chapter provides an overview of pediatric palliative care in the community setting, where care can be complex and multilayered. The chapter describes the role of the pediatric palliative advanced practice registered nurse (PP APRN) in this setting. This includes the transition of care for a child with serious illness from hospital discharge, to care at home, to managing a home death. At times, community palliative care can be intimidating for families, caregivers, and professionals. However, with education and support, families are empowered as experts about their children and can provide the care their children need in a community setting. The PP APRN, along with the team, guides and helps the family care for their child in the place they feel most comfortable. Additional resources and checklists throughout the chapter are provided for more information.
Advance Care Planning
Authors: Farfour Hannah N.
Published: May 2023

Advance care planning (ACP) is a process that supports individuals at any stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal is to help ensure that people receive medical care that is consistent with their beliefs during serious and chronic illness. Advanced practice registered nurses (APRNs) are in a unique position to initiate, facilitate, and support patients and their families with the advance care planning process. They also ensure that these preferences are documented in accessible formats. This chapter discusses such topics as healthcare decision-making, advance directives, living wills, durable powers of attorney, and surrogate decision-making, as well as the important role the APRN plays in this process.
Ensuring Quality Spiritual Care
Authors: Ferrell Betty
Published: May 2023

The National Consensus Project for Quality Palliative Care identifies spiritual, religious, and existential care as one of the eight essential domains of quality care. Spiritual care becomes especially important when patients are facing serious illness or end of life. While all palliative care nurses should be trained in the provision of spiritual care, advanced practices registered nurses (APRNs) need advanced spiritual care training so that they are equipped to perform spiritual assessments, assist patients as they conduct life reviews, coordinate care, and work collaboratively with chaplains to address patients’ complex spiritual needs that may arise at the end of life. APRNs have an important role to play in modeling spiritual care skills, developing policies and procedures, and creating structures and processes of spiritual care as interprofessional palliative care teams assume the important work of spiritual care.
Fatigue
Authors: Pandey Shila
Published: May 2023

Fatigue is a common symptom in patients with cancer as well as in patients with other chronic diseases. Palliative advanced practice registered nurses (APRNs) have the specialized training to synthesize data so they can provide care that is centered on patients’ goals in the areas of health, quality of life, and function. Subjective in nature, fatigue requires that the advance practice nurse assess how much it interferes with the patient’s functional status and quality of life. Assessment should include underlying etiologies as well as contributing factors. The palliative APRN’s role includes educating patients about self-management of fatigue. Palliative APRNs work collaboratively with the interdisciplinary team to provide pharmacologic and nonpharmacologic interventions.
Nausea and Vomiting
Authors: DeMarco Katherine E.
Published: May 2023

This chapter provides an overview of the assessment and management of nausea and vomiting and data on their prevalence for the adult population. The chapter reviews comprehensive symptom assessment that focuses on describing the patient’s experience and an understanding of the physiological pathways of nausea and vomiting, and their common etiologies, including bowel obstruction. It concludes with a review of the evidence base for management strategies, including patient education, lifestyle changes, selected integrative therapies, and a review of the mechanisms of action of antiemetics. This chapter can guide general pediatric palliative advanced practice registered nurse (APRN) practice considerations but it is not inclusive of specialty pediatric antiemetic care plans.
Cognitive Impairment
Authors: Brody Abraham A. , McCabe Donna E.
Published: May 2023

Cognitive impairment in its many forms can bring about devastating symptoms for the person living with the condition as well as for their family. This chapter provides the advanced practice palliative care nurse with an overview of the common conditions that cause cognitive impairment, with a focus on dementia. Assessment and management strategies are described in the context of understanding unmet needs and ameliorating symptoms while optimizing quality of life and preventing functional decline. A systematic assessment tool for identifying the underlying causes of behavioral and psychological symptoms of dementia (BPSD) is included to assist the palliative care advanced practice nurse utilize effective nonpharmacological, patient-centered interventions and, where needed, evidence-based pharmacologic interventions.
Serious Mental Illness
Authors: Pellecchia Kristyn , Murphy Ryan
Published: May 2023

Serious mental illness (SMI) is a chronic, often life-limiting illness that is inherently accompanied by significant psychosocial and spiritual distress. Since SMI is prevalent, it is not uncommon that individuals are concurrently diagnosed with other life-limiting illnesses, for example, cancer. This specialty population presents with unique needs, challenges, and difficulties when trying to navigate the healthcare system. By reviewing SMI diagnoses and treatments, this chapter aims to educate the palliative advanced practice registered nurse (APRN) to better serve patients with both SMI and other palliative diagnoses. The content includes introductions to trauma-informed care, harm reduction, and palliative psychiatry.
Patients with Substance Use Disorders and Dual Diagnoses
Authors: Brant Jeannine M. , Edwards Tonya
Published: May 2023

Substance use disorders (SUDs) are a growing concern in the United States. Often, a mental health concern co-occurs in many patients, creating a dual diagnosis. Palliative care advanced practitioners often manage patients with a SUD or dual diagnosis in the midst of trying to diligently manage pain and other deleterious symptoms that accompany serious illness. This chapter provides an overview of some of the challenges when working with patients with SUDs and a dual diagnosis and provides guidelines for best practice to optimally manage these patients. The use of universal precautions can serve as a guide for assessing patients and managing care in this population. Guidance is provided for a comprehensive assessment, including the use of the prescription drug monitoring program and urine drug testing. Management considerations including risk stratification of patients, pain management for patients with SUDs, the use of opioid treatment agreements, and novel interdisciplinary models of care are described and provide the advanced practice registered nurse (APRN) with a foundation to provide safe and compassionate care.
Anxiety
Authors: Stalhandske Kira
Published: May 2023

Anxiety is common for persons with advanced, serious, and/or life-limiting illness. Anxiety impacts psychoemotional and physical aspects of life. Anxiety is more common for people with higher physical symptom burden. Anxiety is specifically identified in the National Consensus Project for Quality Palliative Care Clinical Practice Guidelines Domain 3 under Psychological and Psychiatric Aspects of Care. The interdisciplinary team assesses and addresses psychological and psychiatric aspects of care based on the best available evidence to maximize patient and family coping and quality of life. The palliative advanced practice registered nurse (APRN) must identify and understand etiologies for anxiety across populations and disease states. Both pharmacological and nonpharmacological strategies can be implemented to improve quality of life.
Discontinuation of Cardiac Therapies
Authors: Fogelman Patricia Maani , Gerringer Janine A.
Published: May 2023

Advanced practice registered nurses (APRNs) play a key role in the care of the cardiac patient. They order and interpret diagnostic data, perform physical examinations, make diagnoses, and formulate individualized treatment plans. This may include education about lifestyle modifications, the introduction and titration of cardiac medications, and referral for more advanced cardiac treatments, such as vasoactive or inotropic medications, cardiovascular implantable electronic devices, extracorporeal membrane oxygenation, and ventricular assist devices. Often patients decide to discontinue these therapies. This chapter reviews the factors surrounding the decision-making process for managing end-stage heart failure, ethical considerations for device discontinuation, processes for cessation, and aggressive symptom management to assure comfort, dignity, and freedom from suffering.
Discontinuation of Other Life-Sustaining Therapies
Authors: Plakovic Kathy , Donoghue Jennifer
Published: May 2023

Technological advances allow healthcare providers to delay the dying process for critically and terminally ill patients. For patients lingering between life and death, decisions frequently need to be made regarding withholding or withdrawing life-sustaining treatments such as antibiotics, blood products, dialysis, and medically administered nutrition. The ethical principle of autonomy gives patients or their healthcare power of attorney/surrogate decision-maker the right to accept or reject any treatment. This chapter reviews these treatments and the decision-making process that must be part of any discussion to discontinue treatments.
An Initial Approach to the Emergency Evaluation
Authors: Richmond Janet
Published: May 2023

The emergency psychiatric interview combines rapid and accurate diagnostic and risk assessments with a biopsychosocial formulation and, optimally, treatment. This is all done in a brief evaluation while simultaneously building and sustaining rapport within a chaotic environment that may require the clinician to attend to multiple patients and tasks simultaneously. This requires flexibility and awareness of one’s biases and countertransference reactions so that the clinician can then use them to facilitate empathic connections with patients. There are unique interviewing skills that help the clinician make rapid clinical decisions. These techniques are different yet draw from those of the traditional psychotherapist.
Telepsychiatry and Beyond
Authors: Maloy Katherine
Published: May 2023

Telemedicine has expanded rapidly in the context of the global COVID-19 pandemic, and psychiatry is no exception. Telepsychiatry in the emergency setting can be a way to expand access to care, particularly in rural or understaffed settings. Federal and local regulations should be considered, as well as issues of privacy and technology requirements. These legal and regulatory requirements continue to evolve and change. Clinicians need training and practice in performing a telepsychiatry evaluation. Overall, telepsychiatry has been shown to be well-accepted by patients, and it has been used in a variety of settings to expand access. Future directions should include exploration of provision of crisis services, aftercare, and supervision via telepsychiatry.
Altered Mental Status and Neurologic Syndromes
Authors: Heinrich Thomas W. , Steele Ian , Brady Sara
Published: May 2023

A patient presenting to the emergency department often represents a diagnostic enigma. The patient may present with a single pathognomonic symptom or sign or a myriad of vague, inconclusive signs and symptoms. The differential diagnosis for patients presenting to the emergency department with signs and symptoms suggestive of a psychiatric condition should include various medical conditions, delirium, and/or complications of psychiatric pharmacotherapy. This chapter addresses some of the more common etiologies of neuropsychiatric presentations in the emergency department, including delirium, catatonia, seizures, serotonin syndrome, and neuroleptic malignant syndrome. These disorders should be among those considered in an informed differential diagnosis of various patients in the emergency department.
Intoxication, Withdrawal, and Symptoms of Substance Use Disorders
Authors: Shumate Annaliese Koller
Published: May 2023

Substance Use disorders are quite common leading to significant morbidity and mortality. Over 19.3 million people aged 18 and older had a substance use disorder, in the US alone. Substance use, and psychiatric illness are commonly comorbid. The etiology of substance use disorders are a multifactorial interplay between nature and nurture drawing on genetics, neuronal circuitry reinforcement and environmental factors. Substance use of any kind triggers the brain’s meso-limbic dopaminergic reward pathway and reinforcement occurs both as a result of acute intoxication but also becomes hardwired into the brain by activating the amygdala. Unfortunately, those with substance use disorders (SUD) continue to be a highly stigmatized patient population and deserve non-judgemental treatment and access to pharmacologic treatment and therapy. Substance use, though prevalent, is treatable and early intervention and action in places like a psychiatric emergency service (PES) can lead to improved long term sequalae in patients with substance use disorders.
Psychosis, Psychotic Disorders, and the Schizophrenia Spectrum
Authors: Wolf Chelsea , Winston Helena
Published: May 2023

Psychosis is common among patients presenting to an emergency department with mental health concerns and should be considered a medical emergency. Although many of these patients may indeed have a long-standing psychiatric history, others may present with a new, acute onset of psychotic symptoms. The possible etiologies of psychosis are broad and include substance-induced, psychiatric, and other medical causes. It is important that emergency providers be able to appropriately evaluate and manage patients who present with psychotic symptoms. This chapter provides information regarding the initial assessment and management of patients with psychosis, the diagnostic workup and differential diagnosis, as well as the treatment of psychotic symptoms.
Personality Disorders
Authors: Bond Joseph B. , Smith Nicole R.
Published: May 2023

This chapter provides an overview of the prevalence, assessment, and management of personality disorders (PDs) in the emergency department (ED). Patients with PDs are often seen in the ED, and their complex clinical features and challenging behaviors can pose significant difficulties for ED staff. The chapter begins defining PDs and dividing them into clusters. Whether they are evident in the chief complaint or comorbid with another condition, ED clinicians are likely to encounter the symptoms of PDs. The chapter highlights the importance of a comprehensive evaluation that includes a thorough history, mental status examination, and consideration of comorbid conditions. Using case examples and clinical pearls, the chapter also discusses the various management strategies available to ED staff when caring for patients with PDs including de-escalation techniques, crisis management tools, guidance in using empathy in difficult encounters.
Children and Adolescents
Authors: Burns Heidi , Biermann Bernard , Malas Nasuh
Published: May 2023

Pediatric behavioral emergencies are an increasingly prevalent and important aspect of emergency psychiatric care. The incidence of mental illness in the United States is rising with limited access to preventative and mental health resources in the community. The result is an increasing number of youth seeking out emergency psychiatric services in the emergency department (ED) setting. Presentations in youth can be more undifferentiated, atypical, and more challenging to assess and manage due to developmental, familial, and systems-based factors. There is a dearth of training and education among primary care providers, ED providers, and general psychiatrists in the care of pediatric behavioral emergencies and a limited number of child and adolescent psychiatrists available to address these concerns. This can lead to missed opportunities to intervene, misdiagnosis, delays in care, or challenges in management. Given the breadth and volume of need, and the limited access to resources, it is incumbent on providers who interface with youth at risk for psychiatric emergencies to develop an improved understanding of the factors influencing these presentations in youth and how to address them. This chapter describes evidence-based evaluation and management strategies, as well as practical clinical pearls and expert opinion, regarding the care of youth presenting to the ED setting for emergency psychiatric care.