bluuebunny/crossref_metadata_2025 huggingface dataset:
Les Projets du hérisson oreillard: l’écriture anti-référentielle d’Éric Chevillard
Authors: Piguet Raphaël
Published: January 2017

Cet article analyse l’écriture d’Éric Chevillard, considérée comme problématique par la critique contemporaine, sous un angle économique. Il montre que son œuvre entière, conçue comme dépense somptuaire de signifiants, refusant toute logique référentielle et s’inscrivant de fait dans une certaine tradition (Georges Bataille notamment), connaît un bouleversement significatif lorsque l’auteur se trouve confronté au réel (voyage au Mali) et veut en rendre compte avec
Oreille rouge
(2005). Contraint de faire du référentiel, Chevillard opte pour une stratégie qui lui permet de surmonter l’obstacle (mise en abyme par l’interpolation du personnage d’Oreille rouge, figure d’auteur partant en Afrique pour en tirer un poème), mais qui dévoile aussi les rouages de son œuvre: écrire pour publier, c’est
projeter
le vécu dans l’économique. Cette effraction du réel dans le système clos de son écriture affecte la production subséquente de l’auteur:
Démolir Nisard
(2006) s’attaque à un personnage double, écrivain-voyageur et critique littéraire, et cette lutte se prolonge dans
L’Auteur et moi
(2012): la problématique de la littérature référentielle rejoint celle du travail critique. Dans les deux cas, il s’agit toujours d’accumuler un capital référentiel à faire fructifier, et c’est précisément le propre de l’écriture de Chevillard que d’échapper à ce mode de production.
Modelling indices of abundance and size-based indicators of cod and flounder stocks in the Baltic Sea using newly standardized trawl survey data
Authors: Orio Alessandro , Florin Ann-Britt , Bergström Ulf , Šics Ivo , Baranova Tatjana , Casini Michele
Published: January 2017

Standardized indices of abundance and size-based indicators are of extreme importance for monitoring fish population status. The main objectives of the current study were to (i) combine and standardize recently performed trawl survey with historical ones, (ii) explore and discuss the trends in abundance, and (iii) the trends in maximum length (Lmax) for cod (Gadus morhua) and flounder (Platichthys flesus) stocks in the Baltic Sea. Standardization of catch per unit of effort (CPUE) from trawl surveys from 1978 to 2014 to swept area per unit of time was conducted using information on trawling speed and horizontal opening of the trawls. CPUE data for cod and flounder stocks were modelled using generalized additive models (GAMs) in a delta modelling approach framework, while the Lmax data were modelled using ordinary GAMs. The CPUE time series of the Eastern Baltic cod stock closely resembles the spawning stock biomass trend from analytical stock assessment. The results obtained furnish evidence of the cod spill-over from Subdivisions (SD) 25–28 to SD 24. The decline of Lmax in recent years was evident for both species in all the stocks analysed indicating that the demersal fish community is becoming progressively dominated by small individuals. It is concluded that the standardization of long time series of fisheries-independent data constitutes a powerful tool that could help improve our knowledge on the dynamics of fished populations, thus promoting a long-term sustainable use of these marine resources.
Towards automating underwater measurement of fish length: a comparison of semi-automatic and manual stereo–video measurements
Authors: Shafait Faisal , Harvey Euan S. , Shortis Mark R. , Mian Ajmal , Ravanbakhsh Mehdi , Seager James W. , Culverhouse Philip F. , Cline Danelle E. , Edgington Duane R.
Published: January 2017

Underwater stereo–video systems are widely used for counting and measuring fish in aquaculture, fisheries, and conservation management. Length measurements are generated from stereo–video recordings by a software operator using a mouse to locate the head and tail of a fish in synchronized pairs of images. This data can be used to compare spatial and temporal changes in the mean length and biomass or frequency distributions of populations of fishes. Since the early 1990s stereo–video has also been used for measuring the lengths of fish in aquaculture for quota and farm management. However, the costs of the equipment, software, the time, and salary costs involved in post processing imagery manually and the subsequent delays in the availability of length information inhibit the adoption of this technology.

We present a semi-automatic method for capturing stereo–video measurements to estimate the lengths of fish. We compare the time taken to make measurements of the same fish measured manually from stereo–video imagery to that measured semi-automatically. Using imagery recorded during transfers of Southern Bluefin Tuna (SBT) from tow cages to grow out cages, we demonstrate that the semi-automatic algorithm developed can obtain fork length measurements with an error of less than 1% of the true length and with at least a sixfold reduction in operator time in comparison to manual measurements. Of the 22 138 SBT recorded we were able to measure 52.6% (11 647) manually and 11.8% (2614) semi-automatically. For seven of the eight cage transfers recorde,d there were no statistical differences in the mean length, weight, or length frequency between manual and semi-automatic measurements. When the data were pooled across the eight cage transfers, there was no statistical difference in mean length or weight between the stereo–video-based manual and semi-automated measurements. Hence, the presented semi-automatic system can be deployed to significantly reduce the cost involved in adoption of stereo–video technology.
Therapeutic Vaccine for Genital Herpes Simplex Virus-2 Infection: Findings From a Randomized Trial
Authors: Bernstein David I. , Wald Anna , Warren Terri , Fife Kenneth , Tyring Stephen , Lee Patricia , Van Wagoner Nick , Magaret Amalia , Flechtner Jessica B. , Tasker Sybil , Chan Jason , Morris Amy , Hetherington Seth
Published: January 2017

Background.

Genital herpes simplex virus type 2 (HSV-2) infection causes recurrent lesions and frequent viral shedding. GEN-003 is a candidate therapeutic vaccine containing HSV-2 gD2∆TMR and ICP4.2, and Matrix-M2 adjuvant.

Methods.

Persons with genital herpes were randomized into 3 dose cohorts to receive 3 intramuscular doses 21 days apart of 10 µg, 30 µg, or 100 µg of GEN-003, antigens without adjuvant, or placebo. Participants obtained genital swab specimens twice daily for HSV-2 detection and monitored genital lesions for 28-day periods at baseline and at intervals after the last dose.

Results.

One hundred and thirty-four persons received all 3 doses. Reactogenicity was associated with adjuvant but not with antigen dose or dose number. No serious adverse events were attributed to GEN-003. Compared with baseline, genital HSV-2 shedding rates immediately after dosing were reduced with GEN-003 (from 13.4% to 6.4% for 30 μg [P < .001] and from 15.0% to 10.3% for 100 µg [P < .001]). Lesion rates were also significantly (P < .01) reduced immediately following immunization with 30 µg or 100 µg of GEN-003. GEN-003 elicited increases in antigen binding, virus neutralizing antibody, and T-cell responses.

Conclusions.

GEN-003 had an acceptable safety profile and stimulated humoral and cellular immune responses. GEN-003 at doses of 30 µg and 100 µg reduced genital HSV shedding and lesion rates.

Clinical Trials Registration.

NCT01667341 (funded by Genocea).
The spleen is the site where mast cells are induced in the development of food allergy
Authors: Toyoshima Shota , Wakamatsu Ei , Ishida Yasuo , Obata Yuuki , Kurashima Yosuke , Kiyono Hiroshi , Abe Ryo
Published: January 2017

It has been reported that splenic immune responses play pivotal roles in the development of allergic diseases; however, the precise role of the spleen remains unclear. Herein, we demonstrated a novel role of the spleen in the pathogenesis of food allergy (FA). We found that mast cells (MCs) developed from progenitor cells present in spleen during an antigen-specific T-cell response in vitro. In a Th2 response-mediated FA model, significant expansion of MCs was also observed in spleen. The incidence of allergic diarrhea was profoundly reduced in splenectomized mice, whereas adoptive transfer of in vitro-induced splenic MCs into these mice restored allergic symptoms, suggesting that the splenic MCs functioned as the pathogenic cells in the development of FA. The in vitro-generated MCs required not only IL-3 but also IFN-γ, and treatment of FA-induced mice with anti-IFN-γ antibody suppressed expansion of MCs in spleen as well as diarrhea development, highlighting that IFN-γ in the spleen orchestrated the development of FA, which was followed by a Th2 response in the local lesion. Overall, we propose that the role of the spleen in the development of FA is to provide a unique site where antigen-specific T cells induce development of pathogenic MCs.
Design and evaluation of a pharmacogenomics information resource for pharmacists
Authors: Romagnoli Katrina M , Boyce Richard D , Empey Philip E , Ning Yifan , Adams Solomon , Hochheiser Harry
Published: January 2017

Objective: To develop and evaluate a pharmacogenomics information resource for pharmacists.

Materials and Methods: We built a pharmacogenomics information resource presenting Food and Drug Administration (FDA) drug product labelling information, refined it based on feedback from pharmacists, and conducted a comparative usability evaluation, measuring task completion time, task correctness and perceived usability. Tasks involved hypothetical clinical situations requiring interpretation of pharmacogenomics information to determine optimal prescribing for specific patients.

Results: Pharmacists were better able to perform certain tasks using the redesigned resource relative to the Pharmacogenomic Knowledgebase (PharmGKB) and the FDA Table of Pharmacogenomic Biomarkers in Drug Labeling. On average, participants completed tasks in 107.5 s using our resource, compared to 188.9 s using PharmGKB and 240.2 s using the FDA table. Using the System Usability Scale, participants rated our resource 79.62 on average, compared to 53.27 for PharmGKB and 50.77 for the FDA table. Participants found the correct answers for 100% of tasks using our resource, compared to 76.9% using PharmGKB and 69.2% using the FDA table.

Discussion: We present structured, clinically relevant pharmacogenomic FDA drug product label information with visualizations to help explain the relationships between gene variants, drugs, and phenotypes. The results from our evaluation suggest that user-centered interfaces for pharmacogenomics information can increase ease of access and comprehension.

Conclusion: A clinician-focused pharmacogenomics information resource can answer pharmacogenomics-related medication questions faster, more correctly, and more easily than widely used alternatives, as perceived by pharmacists.
Comparison of three commercial knowledge bases for detection of drug-drug interactions in clinical decision support
Authors: Fung Kin Wah , Kapusnik-Uner Joan , Cunningham Jean , Higby-Baker Stefanie , Bodenreider Olivier
Published: January 2017

Objective: To compare 3 commercial knowledge bases (KBs) used for detection and avoidance of potential drug-drug interactions (DDIs) in clinical practice.

Methods: Drugs in the DDI tables from First DataBank (FDB), Micromedex, and Multum were mapped to RxNorm. The KBs were compared at the clinical drug, ingredient, and DDI rule levels. The KBs were evaluated against a reference list of highly significant DDIs from the Office of the National Coordinator for Health Information Technology (ONC). The KBs and the ONC list were applied to a prescription data set to simulate their use in clinical decision support.

Results: The KBs contained 1.6 million (FDB), 4.5 million (Micromedex), and 4.8 million (Multum) clinical drug pairs. Altogether, there were 8.6 million unique pairs, of which 79% were found only in 1 KB and 5% in all 3 KBs. However, there was generally more agreement than disagreement in the severity rankings, especially in the contraindicated category. The KBs covered 99.8–99.9% of the alerts of the ONC list and would have generated 25 (FDB), 145 (Micromedex), and 84 (Multum) alerts per 1000 prescriptions.

Conclusion: The commercial KBs differ considerably in size and quantity of alerts generated. There is less variability in severity ranking of DDIs than suggested by previous studies. All KBs provide very good coverage of the ONC list. More work is needed to standardize the editorial policies and evidence for inclusion of DDIs to reduce variation among knowledge sources and improve relevance. Some DDIs considered contraindicated in all 3 KBs might be possible candidates to add to the ONC list.
Placenta and uteroplacental perfusion
Authors: Bonnet Marie-Pierre , Chantry Anne Alice
Published: January 2017

The placenta is a complex and changing organ necessary for normal fetal growth and development and for maintenance of a healthy pregnancy. It has three major functions: a protective function of the fetus, an endocrine function, and a metabolic function. The main functional unit of the placenta is the chorionic villous, responsible for the majority of the fetal–maternal exchanges. Migration of trophoblastic cells induces a remodelling of the uterine arteries, with vasodilatated and compliant vessels, unresponsive to maternal vasomotor control. Therefore, any significant change in maternal blood pressure, in particular in the context of general or regional anaesthesia, can directly impact on uteroplacental perfusion. Most anaesthetic drugs cross the placental barrier, but without significant consequences on the fetal well-being.
Maternal, fetal, and neonatal pharmacokinetics
Authors: Allegaert Karel , Van Calsteren Kristel
Published: January 2017

Most drugs are not thoroughly evaluated for use during pregnancy, delivery, or postpartum (e.g. breastfeeding). The same holds true for early infancy, and results in extensive off-label, unlicensed pharmacotherapy in these specific subpopulations. At present, most drug labels do not contain any instructions for use during pregnancy, in infancy, or during breastfeeding, yet these are the main concerns of healthcare providers considering medical treatment. Anaesthetists commonly treat pregnant women with similar dosing regimens recommended for use in adults and subsequently titrate to effect. The (dis)continuation of breastfeeding in the postpartum period following anaesthesia is commonly based on opinions instead of scientific evidence. This chapter describes the alterations in pharmacokinetics (absorption, distribution, metabolism, elimination) in pregnant women with specific emphasis on placental drug transport, and in neonates, with additional emphasis on breastfeeding. Drugs commonly administered by anaesthetists to women in the peripartum period are discussed with particular reference to the changed pharmacodynamics in both mother and infant.
Antenatal and intrapartum fetal evaluation
Authors: Jacquemyn Yves , Kwee Anneke
Published: January 2017

Antenatal and intrapartum fetal monitoring aim to identify the beginning of the process of fetal hypoxia before irreversible fetal damage has taken place. Fetal movement counting by the mother has not been reported to be of any benefit. The biophysical profile score, incorporating ultrasound and fetal heart rate monitoring, has not been proven to reduce perinatal mortality in randomized trials. Doppler ultrasound allows the exploration of the perfusion of different fetal organ systems and provides data on possible hypoxia and fetal anaemia. Maternal uterine artery Doppler can be used to select women with a high risk for intrauterine growth restriction and pre-eclampsia but does not directly provide information on fetal status. Umbilical artery Doppler has been shown to reduce perinatal mortality significantly in high-risk pregnancies (but not in low-risk women). Adding middle cerebral artery Doppler to umbilical artery Doppler does not increase accuracy for detecting adverse perinatal outcome. Ductus venosus Doppler demonstrates moderate value in diagnosing fetal compromise; it is not known whether its use adds any value to umbilical artery Doppler alone. Cardiotocography (CTG) reflects the interaction between the fetal brain and peripheral cardiovascular system. Prelabour routine use of CTG in low-risk pregnancies has not been proven to improve outcome; computerized CTG significantly reduces perinatal mortality in high-risk pregnancies. Monitoring the fetus during labour with intermittent auscultation has not been compared to no monitoring at all; when compared with CTG no difference in perinatal mortality or cerebral palsy has been noted. CTG does lower neonatal seizures and is accompanied by a statistically non-significant rise in caesarean delivery. Fetal blood sampling to detect fetal pH and base deficit lowers caesarean delivery rate and neonatal convulsions when used in adjunct to CTG. Determination of fetal scalp lactate has not been shown to have an effect on neonatal outcome or on the rate of instrumental deliveries but is less often hampered by technical failure than fetal scalp pH. Analysis of the ST segment of the fetal ECG (STAN®) in combination with CTG during labour results in fewer vaginal operative deliveries, less need for neonatal intensive care, and less use of fetal blood sampling during labour, without a change in fetal metabolic acidosis when compared to CTG alone.
Fertility treatment in the modern age: possibilities and anaesthesia
Authors: De Neubourg Diane , Devroe Sarah
Published: January 2017

As up to 4% of all pregnancies and deliveries are the result of assisted reproductive technology treatment in developed countries, fertility treatment in general has become an important activity for gynaecologists. Particularly in in vitro fertilization/intracytoplasmic sperm injection cycles, the oocyte aspiration procedure can be painful and requires analgesia. The method used should be safe and comfortable for the woman with minimal side effects, easy to administer and monitor, short acting, easily reversible, and with minimal to no effect on oocytes and embryos. Most fertility clinics have chosen their method depending on patients’ demands, staffing, and available facilities in the hospital or centre.
Medicolegal issues
Authors: Combeer Elizabeth , Iqbal Rehana , Yentis Steve
Published: January 2017

Medical law relating to obstetric anaesthesia has unique issues. There are legal implications of caring for two patients simultaneously, mother and fetus, and issues may arise when the welfare of one is in conflict with that of the other. This chapter addresses the extent to which a woman can be forced to consider the needs of her fetus, case law relating to enforced caesarean sections, and the current legal position. Although the majority of expectant mothers have capacity, there are situations where this may not be the case. Law concerning the care of teenage obstetric patients, the difficult areas of capacity and consent in labour, and the role of birth plans are therefore explored. Fundamental topics in medical law such as battery, negligence, manslaughter, and confidentiality are addressed, in addition to law relating to the teaching and supervision of junior medical staff, and clinical research and its publication. The chapter also considers areas of developing importance such as the legal implication of clinical guidelines and the degree to which these may be viewed as a standard of care. Finally, the chapter offers, where possible, the obstetric anaesthetist some practical guidance on incorporating the current legal position in these key areas of medical law into everyday practice.
High dependency and intensive care
Authors: Barclay Philip , Scholefield Helen
Published: January 2017

The development of maternal critical care is essential in reducing morbidity and mortality due to a substandard level of care. The level of critical care should depend upon the patient’s severity of illness, not their physical location. Escalation to level 3 (intensive) care is uncommon in pregnancy, with a median admission rate of 2.7 per 1000 births, mainly due to hypertensive disorders of pregnancy and haemorrhage. Maternal ‘near misses’ occur more frequently, with 6.5 per 1000 births meeting Mantel’s criteria, of which 85% is due to major obstetric haemorrhage. The admission rate to maternal high dependency units (level 2 care) varies from 1% to 5%. Acute physiological scoring systems have been found to be reliable when applied to parturients receiving level 3 care but overestimate mortality. Maternal early warning scores have been derived from simplified versions of these systems, with allowance made for physiological changes seen in pregnancy. There are many different maternity scoring systems in use throughout England and Wales. All share the same principle that parameters should be recorded regularly during the hospital stay, with deviations from normal quantified, recorded, and acted upon. A chain of response is then required to ensure that suitably qualified staff, possessing appropriate critical care competencies, attend in a timely fashion. Appropriate resources must be available with equipment readily to hand and suitably trained staff so that invasive monitoring can be used. Clear admission criteria are required for level 2 care within the delivery suite and escalation to level 3, with suitable arrangements for transfer.
Maternal mortality and morbidity
Authors: Halder Suni , Yentis Steve
Published: January 2017

The risk to women’s health is increased during pregnancy, and maternal mortality is used as an indicator of general healthcare provision as well as a target for improving women’s health worldwide. Morbidity is more difficult to define than mortality but may also be used to monitor and improve women’s care during and after pregnancy. Despite international efforts to reduce maternal mortality, there remains a wide disparity between the rate of deaths in developed (maternal mortality ratio less than 10–20 per 100,000 live births) and developing (maternal mortality ratio as high as 1000 or more per 100,000 live births in some countries) areas of the world. Similarly, treatable conditions that cause considerable morbidity in developed countries but uncommonly result in maternal death (e.g. pre-eclampsia (pre-eclamptic toxaemia), haemorrhage, and sepsis) continue to be major causes of mortality in developing countries, where appropriate care is hampered by a lack of resources, skilled staff, education, and infrastructure. Surveillance systems that identify and analyse maternal deaths aim to monitor and improve maternal healthcare through education of staff and politicians; the longest-running and most comprehensive of these, the Confidential Enquiries into Maternal Deaths in the United Kingdom, was halted temporarily after the 2006–2008 report but is now active again. Surveillance of maternal morbidity is more difficult but systems also exist for this. The lessons learnt from such programmes are thought to be important drivers for improved maternal outcomes across the world.
Thromboembolic disorders in pregnancy
Authors: Ballal Salma , Greer Ian A.
Published: January 2017

Thromboembolism in pregnancy remains a major cause of direct maternal mortality in the Western world. Thromboembolic events in pregnancy are spread across the three trimesters but the puerperium is the time of greatest risk with a relative risk of around 20-fold compared to the non-pregnant patient. When compared to the non-pregnant population where distal deep vein thrombosis is most common, most events in pregnancy are iliofemoral and left sided. Given the multi-hit nature of the problem, awareness of risk factors is important. The two most significant single risk factors in pregnancy for thromboembolism are history of previous venous thromboembolism and thrombophilia. The identification of risk factors will guide the use of thromboprophylaxis and assist diagnosis; however, objective diagnosis is required. Prophylaxis and treatment focuses on low-molecular-weight heparin, which is considered safe in pregnancy.
The obese parturient
Authors: Denison Fiona C. , Milne Alistair
Published: January 2017

Maternal obesity is the most common pre-existing morbidity in pregnant women in the United Kingdom. Obesity is associated with increased risk of maternal and offspring morbidity and mortality. Increased maternal morbidity is multifactorial. There is an increased incidence of coexisting medical conditions. Adverse physiological changes related to obesity also contribute to risk. In addition to this, there is an increased risk of many complications developing de novo during pregnancy. There are many practical and technical challenges for the multidisciplinary team that must be addressed in order to care for the morbidly obese parturient effectively. Many items of equipment designed for use with the morbidly obese will need to be available. Due to the complexity of their care and increased risks, all women with a body mass index over 40 kg/m2 should be seen prior to labour and delivery by an anaesthetist. This allows for timely planning of their care, involvement of appropriate personnel and equipment, and expectation management. The use of neuraxial analgesia and anaesthesia, whilst prone to increased technical difficulties and failure rates, has significant advantages for many morbidly obese parturients. There are many increased risks associated with general anaesthesia in the morbidly obese, but this may be the only option for operative delivery in some super morbidly obese parturients who cannot tolerate a tilted supine position. The care of the morbidly obese parturient is truly multidisciplinary which should be coordinated by a named consultant obstetrician.
Acquired heart disease
Authors: Peacock Linzi , Hignett Rachel
Published: January 2017

Heart disease in pregnancy is a leading cause of maternal death worldwide. In the United Kingdom and United States, heart disease in pregnancy is the commonest cause of maternal death. In Europe, over 1% of maternal deaths are attributable to structural heart disease. In addition, heart disease in pregnancy is a significant cause of severe maternal and fetal morbidity. Whilst the vast majority of women with heart disease in pregnancy have underlying congenital heart disease, most maternal deaths are due to acquired heart disease (AHD). As the risk factors for AHD become ever more prevalent, the expectation is that disease burden from AHD in pregnancy will also increase. Women with AHD benefit from preconception or early assessment in pregnancy by a multidisciplinary team including obstetricians, cardiologists, and obstetric anaesthetists. Risk assessment using the modified World Health Organization classification of cardiac disease in pregnancy will inform frequency of review in pregnancy. A detailed plan for delivery should be agreed in the third trimester. Where possible, a vaginal delivery is advised: caesarean delivery is reserved for women with obstetric indications or with specific severe underlying cardiac conditions. Slow incremental epidural analgesia is usually recommended to reduce the cardiorespiratory work of labour and an assisted second-stage delivery will limit exertion due to pushing. Neuraxial anaesthesia for operative delivery is becoming a more familiar approach and techniques such as low-dose spinal component combined spinal–epidural or slow incremental epidural top-up maximize haemodynamic stability. Invasive monitoring is often beneficial. Post-delivery care is safely delivered in a high dependency or intensive therapy setting. This chapter looks at the general principles of management of women with AHD, and then examines in detail ischaemic heart disease, arrhythmias, cardiac transplantation, aortic pathology and aortic dissection, cardiomyopathy, valvular heart disease, and infective endocarditis.
Neurological disease
Authors: Griffiths James , Drummond Kate
Published: January 2017

This chapter predominantly focuses on the provision of obstetric anaesthesia and analgesia for the parturient with neurological disease. Diseases of the central nervous system are an important cause of maternal morbidity and mortality. Maternal deaths may occur from such conditions as subarachnoid haemorrhage, intracerebral haemorrhage, thrombosis, and epilepsy. Neurological disease may impact on maternal well-being during pregnancy and pregnancy has the potential to exacerbate many neurological diseases. Many neurological conditions also have important implications for the safe conduct of neuraxial anaesthesia and analgesia, such as spina bifida and hydrocephalus. Management of these conditions may require care to be coordinated by a multidisciplinary team including the obstetrician, neurologist, neurosurgeon, and anaesthetist.
Musculoskeletal disorders
Authors: Brown James P. R. , Douglas M. Joanne
Published: January 2017

This chapter describes the major musculoskeletal diseases stating manifestations, associations, and their implications for pregnancy, delivery, and obstetric anaesthesia. It reviews and summarizes the literature, presenting the available evidence for methods of mitigating risks to the parturient. The chapter starts by discussing the pathophysiology, presentation, diagnosis, and management of malignant hyperthermia. The following conditions are then introduced in turn: backache, scoliosis, myopathies (including myotonic dystrophy), Ehlers–Danlos syndrome, rheumatoid arthritis, ankylosing spondylitis, achondroplasia, and osteogenesis imperfecta. The chapter aims to provide a pragmatic resource to allow obstetric anaesthetists to make informed decisions and management plans when faced with caring for a parturient with an uncommon musculoskeletal condition.
Endocrine and autoimmune disorders
Authors: Kendrisic Mirjana , Pujic Borislava
Published: January 2017

Advanced maternal age and increasing numbers of women of childbearing age with endocrine and autoimmune disorders have become the challenge for both anaesthetists and obstetricians. Genetic studies have provided new insight into underlying causes of endocrine disorders and prenatal prediction of inheritance. The expression of endocrine disease may influence the interpretation of diagnostic laboratory testing during pregnancy. Better understanding of the pathophysiological mechanisms enables new therapeutic approaches which can compromise pregnancy outcome. Although only a small number of drugs have been shown through clinical studies to be safe for use in pregnancy, intensive therapy for chronic disease is usually needed. Thus, anaesthetic management of women with endocrine disorders in pregnancy has become more complex. The most frequently encountered endocrine disorders during pregnancy include gestational diabetes mellitus and thyroid and adrenal disorders. Gestational diabetes has become increasingly common in pregnant women. Not only does it influence pregnancy outcome, but it also carries a risk for mother and offspring of developing type 2 diabetes later in life. Intensive glucose control may prevent maternal and fetal complications and improve long-term outcome. Pregnancy itself has been found to influence the course of autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus. However, autoimmune diseases may have adverse consequences for maternal, fetal, and neonatal health. There is a relative paucity of literature concerning anaesthetic management of autoimmune diseases. Early recognition and immediate treatment of the common complications have been the key elements to achieving the ultimate goal—good pregnancy outcome.
Genetics
Authors: Landau Ruth , Ortner Clemens
Published: January 2017

Phenotyping is key in all genetic association studies and designing clinical studies to assess the genetic contribution to pain and analgesic response in general, and in the context of obstetric pain is even more challenging. In addition, interpreting results, particularly when multiple genes are evaluated, requires large sample sizes and appropriate statistical analysis to avoid misconstrued finding. The genetic contribution to labour pain or even that of pharmacogenetics to explain differences in analgesic response is probably not simple and straightforward and we are at the beginning of our explorations. Firm recommendations to tailor opioid regimens based on patients’ individual genetic profile are not available and are unlikely to become available in the near future other than for the prescription of codeine. To help explore genetic variants that influence the progress of labour and other various obstetric outcomes, the concept of mathematical modelling of labour progress is extremely promising and may in the future allow identification of some important genetic contributions and will perhaps one day predict labour outcome and labour pain perception.
Simulation
Authors: Wigginton Mark , Garcia Miguel , Draycott Timothy J. , Muchatuta Neil A.
Published: January 2017

Simulation can be a powerful tool in obstetric anaesthesia, driving forwards the education of clinicians for the benefit of patients. Simulation has been closely linked with obstetrics since its inception. Today’s modern technology and educational theory have combined to make it a more powerful and accessible learning tool than ever, allowing both clinical skills and human factors to be effectively taught and assessed in combination. Since becoming more widely validated, simulation is also being used in research, to identify latent threats and for summative assessment. Setting up a simulation programme, whether in situ or at a dedicated centre, requires preparation, planning, and an appreciation of its limitations. The simulation should be evidence based, target the learner’s needs, and be of benefit to patients. The challenge for trainers and trainees is to ensure both that the training provided achieves these goals, and that they can deliver evidence to demonstrate that it has.
The case for social marketing in public health
Authors: French Jeff
Published: January 2017

This chapter explores the influence of paternalistic conceptions of public health fostered by more generic state paternalism that stresses the responsibility of the state to influence health and the conditions that create it. The limitations of such an approach are reviewed. The chapter also explores the growing realization that governments and their agencies cannot deliver the significant shifts in population-level behaviour change alone, and the implications of this realization. The second half of the chapter sets out the case for a new citizen-informed model of public health practice informed by social marketing principles. The rationale and practical implications of this new citizen-focused model are explored, including the added value contribution that can be made to public health programmes and policy through the application of social marketing principles. The chapter ends with a review of why social marketing is being increasingly applied as standard practice in many parts of the world.
Behaviour and how to influence it
Authors: French Jeff
Published: January 2017

This chapter focuses on the development of a more systematic approach to social behaviour change (Michie et al,2011) and the examination of a growing body of research in the public health world (CDC, 2000) that goes beyond just communication- and enforcement-based approaches to influencing health behaviour (McQuail, 2009; Rothschild, 1999). This understanding has been developing rapidly over recent years (NICE, 2007; 2014). Intervention organizing and planning systems such as social marketing (French et al., 2010), co-creation (Cottam and Leadbeater, 2004), and community engagement (Hills, 2004) are examples of how this new science is being operationalized in social policy delivery. This development, along with more general improvement in social policy implementation (Public Administration Select Committee, 2009), planning, and review (Australian Public Service Commission, 2007) has resulted in a growing consensus about how to establish, deliver, and evaluate more successful behavioural interventions focused on social good.
Social marketing on a small budget
Authors: French Jeff
Published: January 2017

It is often assumed that social marketing can only be conducted by big organizations with large budgets and lots of accumulated marketing expertise and experience. This chapter makes the case that a real strength of the social marketing approach is that it can be adapted and used by almost anyone who wants to help people behave in a socially responsible way. The key to effective social marketing on a small budget is to start by thinking like a marketer: thinking about the needs of citizens and how you can create value for them; not worrying about not having enough money to run a big, flashy campaign. The chapter gives examples of how people with limited or no budgets can still apply a social marketing mind-set and procedures to solve social problems. It also gives details of sources of free help and support for anyone who has access to the Internet.
Ethical issues in social marketing
Authors: Eagle Lynne , Dahl Stephan , Low David
Published: January 2017

Many social marketers assume that because they are focusing on positive behaviour change they may expect fewer ethical issues arising from their work than conventional, commercial marketing. However, such a view is sadly too simplistic. This chapter focuses on the ethical issues facing social marketing. It argues that social marketers face an even greater potential for ethical issues and gives examples of these by focusing on targeting, stigmatization, victim blaming, coercion, and the use of financial incentives, among others. Recognizing the manifold potential for ethical challenges, and the lack of a decisive manner in which to resolve them easily, it then discusses ethical frameworks which can aid social marketers in formulating a response to potential issues and arriving at a considered decision. The chapter concludes by discussing the potential role of a professional code of ethics, and how this can aid future ethical decision-making.
Preoperative assessment and preparation of elderly patients undergoing major surgery
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

The benefits to the elderly of current surgical advances are as good as or better than to younger patients. Preassessment serves to individualize operative decisions to optimize the patient’s condition and improve the outcome. These processes require experienced surgical and anaesthetic input. General patient factors are detailed, including communication skills, behavioural adaptation, functional reserve, cognitive function, and frailty. Systematic comorbidities, such as cardiovascular, neurological, respiratory, renal and nutritional status are discussed. The risk/benefit of the proposed procedure, which is often assessed using risk-stratification systems, is reviewed. Time to full recovery and the duration of convalescence are identified as lacking appropriate data at present. Finally, the emerging data on active, multidisciplinary ‘prehabilitation’ before surgery to improve and optimize the general fitness, chronic disease states, and medication of elderly patients in the weeks before elective surgery are examined.
Day-case anaesthesia in the elderly
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

Successful outcome from day surgery depends on good preoperative preparation, education of patients, day-surgery pathways, informed decisions regarding planned procedures, and postoperative care. Day surgery is widely accepted as the default position for the vast majority of patients requiring surgery, with inpatient stay chosen only by exclusion. Day surgery remains a good choice in the elderly, subject to appropriate home care after surgery. Patients should be assessed sufficiently ahead of the surgery to allow preparation, management of associated chronic diseases, and optimization. General anaesthesia may be associated with higher incidence of postoperative cognitive dysfunction, and it should be avoided as much as possible. Regional anaesthesia is the preferred choice when applicable because it provides good postoperative analgesia. Spinal anaesthesia is useful, but it can be associated with delayed discharge. A multimodal approach to pain relief and management of postoperative nausea and vomiting (PONV) are essential because inadequate management can significantly delay discharge.
Anaesthesia for orthopaedic surgery in the elderly
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

Arthritis and falls are common in the elderly and hence lead to major bone and joint surgery. Elderly patients may suffer from significant cardiorespiratory, renal, and neurologic dysfunction, and they may be malnourished; therefore, preoperative assessment is essential. Both general and regional anaesthesia techniques are commonly used, but regional anaesthesia, with or without sedation, is preferred. The use of cement during surgery is known to be associated with intraoperative morbidities, as is the use of a tourniquet. Antibiotics are routinely used, but they must be administered before the tourniquet is inflated. The incidence of deep vein thrombosis and pulmonary embolism is high, and prophylaxis should be considered. Blood loss may be excessive, especially during revision surgery; measures should be taken to minimize blood loss. Regional technique, with or without opioids, provides good analgesia. Patient-controlled analgesia (PCA) with an opioid remains a useful method where possible.
Urological and gynaecological surgery in the elderly
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

Urological and gynaecological procedures are commonly performed in the elderly. Usually, urinary tract endoscopy and surgery should only be performed if the urine is made sterile. Infection of the urinary tract is always a threat, specifically in obstructive diseases and in patients with permanent bladder catheters. Simple measures may prevent most of the transurethral resection of the prostate (TURP) syndrome cases. The elderly patient taking anti-platelet or anticoagulant drugs and presented for endoscopic urological surgery are at special risk because these may lead to life-threatening haemorrhage, and stopping these drugs can lead to life-threatening cardiovascular and embolic phenomenon. For most of these procedures, the choice between general and regional (mainly spinal) anaesthesia must be influenced by the specific medical condition of the patient, his/her wishes, and the planned procedure.
Ethics and the law involving the elderly
Authors: Dodds Chris , Kumar Chandra M. , Servin Frédérique
Published: January 2017

The role of ethics in the care of the elderly is discussed, and some of the aspects of importance to anaesthesia are reviewed. Ethical principles are commonly viewed as either consequential, where the risk/benefit balance between necessary harm (surgery) provides improved quality of life, or deontological, where it is simply the action that is judged and not the outcome. The lack of individualized outcome data is identified as a major issue for the consequential process. Consent for surgery (and anaesthesia) is described in the context of the UK, but it is applicable worldwide. The validity of informed consent is reviewed against the criteria of competence, lack of duress, and appropriately provided information. The capacity to give consent and the use of legal alternatives such as health attorneys is detailed. Finally, the debate on excellent palliative care rather than assisted death is reviewed.
Stroke Medicine (Oxford Specialist Handbooks in Neurology)
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

Recent years have seen a revolution in the profile of stroke. Often thought of as an untreatable disease we now realize that not only can many strokes be prevented, but acute treatment can have a major impact on outcome. There has been great recent interest in thrombolysis and thrombectomy but other aspects of stroke care including organized stroke unit care, and effective secondary prevention and rehabilitation also have a major impact on outcome. Clinicians looking after stroke patients need rapid access to up-to-date practical information on how to look after stroke patients. This handbook of Stroke Medicine is aimed to provide a ready source of information for both stroke trainees and consultants. It covers diagnosis and investigation of the stroke patient, as well as treatment ranging from primary and secondary prevention, to acute care and rehabilitation. It also covers rarer causes of stroke and the increasing important area of vascular cognitive impairment. It is written to cover the syllabus of the UK stroke specialist training programme and other similar programmes worldwide.
Epidemiology and stroke risk factors
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

In this opening chapter on the epidemiology and risk factors for stroke, the ‘size of the problem’ in public health terms both in the United Kingdom and worldwide is set out. Incidence, prevalence, and mortality of stroke are discussed. Epidemiological terms and definitions as applied to stroke care are reviewed and illustrated, including absolute and relative risk reduction and numbers needed to treat. This chapter also discusses aetiological subtyping of stroke which represents a syndrome caused by multiple different underlying pathologies. It ends with a comprehensive review of the major and minor modifiable and non-modifiable risk factors for stroke disease.
History-taking in the stroke patient
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

In this history-taking in the stroke patient chapter, general principles of how to approach history taking are outlined. Clinical definitions of both stroke and transient ischaemic attack are discussed, and pointers given as to how to diagnose stroke mimic conditions. Symptoms and signs associated with anterior and posterior circulation stroke are covered as well as how to systematically assess the underlying aetiological cause of stroke in an individual patient.
Investigation of the stroke patient
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

In the investigation of the stroke patient chapter, investigations to confirm or refute the diagnosis of stroke are discussed including brain imaging with computed tomography and magnetic resonance imaging and blood test laboratory investigations. The importance of vascular and cardiac investigations is discussed, especially with regard to diagnosing the aetiological cause of stroke. Investigations performed to anticipate potential complications from stroke are also reviewed.
Acute stroke treatment
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

In this chapter the use of thrombolysis and the more recent application of thrombectomy in acute ischaemic stroke are covered. Organized stroke unit care has a major impact on both reducing mortality and improving outcome, and the chapter describes the evidence for this. It also covers other components of supportive acute stroke care, including the importance of instituting measures to avoid complications and to prevent early recurrent stroke.
Cerebral haemorrhage
Authors: Markus Hugh , Pereira Anthony , Cloud Geoffrey
Published: January 2017

This chapter covers the several types of cerebral haemorrhage: extradural, subdural, subarachnoid, and intracerebral. Subarachnoid haemorrhage (SAH) is an important cause of neurological disability and mortality, although only occasionally present with focal stroke symptoms. Intracerebral haemorrhage usually presents with a stroke, which can only be reliably distinguished from ischaemic stroke by brain imaging. The chapter discusses the diagnosis, investigation, and management of both SAH and intracerebral haemorrhage.