bluuebunny/crossref_metadata_2025 huggingface dataset:
Session 4: Can Pulling-Related Inner Experiences Be Controlled?
Authors: Woods Douglas W. , Twohig Michael P.
Published: January 2023

This chapter covers the fourth session of the Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-T) treatment package. It outlines ways to help the client see their struggle with urges, other unpleasant inner experiences, or cravings for pleasurable sensory experiences more clearly. The therapist emphasizes that attempts to stop one’s private experiences are ineffective, so other means of dealing with them are needed. The therapist explains why the urge to pull and the feelings associated with it often show up larger than necessary. Examples are provided to illustrate what is meant by finding a way to live with the urge to pull, as well as finding a way to live with something that is a little difficult and how life might improve if one can do so.
Case 15
Authors: Frise Charlotte , Bhalsod Krupa , Scott Rebecca , Gibson Harry
Published: January 2023

A 30-year-old woman presented to her GP with a two-day history of dysuria, urinary frequency, and an offensive smell to her urine. She was 28 weeks pregnant in her first pregnancy. Her pregnancy had been uncomplicated apart from a previous urinary tract infection with similar symptoms 6 weeks prior to this presentation. A urine culture at this time had confirmed E. coli, sensitive to amoxicillin, so she was given a 5-day course, which led to resolution of her symptoms. She was otherwise fit and well with no past medical history, and was not taking any regular medications. She lived with her husband, worked as an accountant, and had never smoked.
Case 16
Authors: Frise Charlotte , Bhalsod Krupa , Scott Rebecca , Gibson Harry
Published: January 2023

A 25-year-old woman attended her 16-week antenatal appointment with her midwife and mentioned she had developed intermittent pain affecting the small joints of both hands and wrists 10 months prior to this appointment, but they had become more problematic in the preceding 5 weeks. In addition, she had developed a facial rash, intermittent chest discomfort, and shortness of breath. This was her first pregnancy. Her booking BP was 117/70 mmHg and BMI was 27 kg/m2. She took no medication, and she had no significant past medical history or family history. She did not smoke or drink alcohol. She was referred for urgent review.
Case 23
Authors: Frise Charlotte , Bhalsod Krupa , Scott Rebecca , Gibson Harry
Published: January 2023

A 45-year-old woman in her second pregnancy presented to the maternity assessment unit at 35 weeks of gestation. She reported flashing lights in her eyes as well as a dark spot in the periphery of her vision. The symptoms started when she woke in the morning and had progressed so that the vision in her left eye was very blurred. She also had a dull frontal headache and a swollen face and ankles. Her first pregnancy 5 years previously was uncomplicated. Her past medical history included type 2 diabetes mellitus and she was taking metformin and insulin in pregnancy as well as aspirin. Her blood pressure at booking had been normal (118/70 mmHg). Home blood pressure monitoring during this pregnancy had not identified any high readings. Her sister had suffered with hypertension in pregnancy, but there was no other family history of note. She was a non-smoker.
Case 25
Authors: Frise Charlotte , Bhalsod Krupa , Scott Rebecca , Gibson Harry
Published: January 2023

A 21-year-old woman with type 1 diabetes mellitus attended the obstetric diabetes clinic at 35 weeks of gestation. She reported that she had been woken by the alarm on her continuous glucose monitor on four occasions over the last week due to early morning hypoglycaemia. She had also had two hypoglycaemic episodes during the day over the last 2 days, despite a reduction in basal insulin rate on her pump over the last week. Other medications included regular aspirin and vitamin D. Her HbA1c at the start of pregnancy was 53 mmol/mol and was 49 mmol/mol at 28 weeks of gestation. She had no other medical conditions.
Test Accuracy, Sensitivity, and Specificity
Authors: Boyles Tom
Published: January 2023

This chapter explains how to use a 2×2 table to calculate test accuracy, sensitivity, and specificity, with the latter being calculated from the columns. It then explains the drawbacks of each statistic including that none answer questions that are directly relevant to patients, rather focusing on the performance of tests in populations already known to either have, or not have, the condition. It then explains that these statistics retain some value, particularly when approaching 100%, but otherwise it is not intuitively obvious what test results mean for patients. The chapter then describes the receiver operator characteristic (ROC) curve, which illustrates the accuracy of a test with continuous, rather than binary, outputs and can be summarized with the area under the ROC (AUROC or C-statistic). It explains that AUROCs are unhelpful when a population is imbalanced between those with and without the condition, in which case a precision–recall curve may be more appropriate.
Decision Thresholds
Authors: Boyles Tom
Published: January 2023

This chapter draws on the classic papers by Pauker and Kassirer to describe a basic method of determining whether a test is likely to influence the management of a patient and is therefore worthwhile. It begins by defining the therapeutic threshold which is the probability of disease at which the clinician experiences equipoise between treating and not treating the patient when no more tests are available. It explains the major influencers of therapeutic threshold and how it might be calculated either empirically or using experience. The chapter then explains how therapeutic threshold relates to testing by informing the test threshold and test–treatment threshold, which describe the probability above and below which a test result will not change the decision to treat or not treat a patient.
Frameworks for Evaluating Medical Tests
Authors: Boyles Tom
Published: January 2023

This chapter describes ways of evaluating tests so that they can be assessed for inclusion in public health programmes, rather than for use on individuals. It details the key principle of medical test evaluation, which is to show improved health outcomes, or other benefits such as reducing costs, or simplifying healthcare delivery without compromising the well-being of patients. It uses the example of the standard four-phase approach to drug evaluation to highlight the lack of such a consensus for test evaluation. Instead, multiple frameworks have been suggested, notably by Fryback and Thornbury and by Sackett and Haynes. Rather than choose a proposed framework, the chapter explains that three basic phases of test evaluation will be covered: ‘test research’ as outlined in Chapter 1, ‘diagnostic research’ which draws together as much relevant information about a patient as possible to develop diagnostic strategies, and ‘diagnostic intervention research’ to determine if diagnostic strategies improve real-world outcomes of patients and at what cost.
Impact Studies
Authors: Boyles Tom
Published: January 2023

This chapter describes studies designed to determine how well the outputs of diagnostic and prognostic research can improve patient outcomes and reduce costs. It explains the differences between assistive and directive methods of influencing healthcare provider and patient behaviours. It then covers multiple possible trial designs beginning with cheap and fast methods such as cross-sectional studies measuring changes in healthcare provider behaviours, through decision analytic modelling studies to randomized controlled trials drawing on the example of the High-STEACS study of high-sensitivity cardiac troponin. Potential complications with trial design are then discussed using theoretical examples of test/treatment combinations.
Healing and Whole-Person Care
Authors: Hutchinson Tom A. , Hutchinson Nora
Published: January 2023

When Cicely Saunders set up St. Christopher’s Hospice in 1967, she created whole-person care for patients who were dying and a model for the transformation of healthcare. This model of care, which combined healing and curing, has key aspects that needed to be addressed if the full potential of palliative medicine is to be realized. (1) Healing is a complex powerful process that is unpredictable and difficult to measure. (2) Curing is a radically different process, the impact of which is easier to quantify. These two processes synergize, but, in the tension between them, curing tends to be favored over healing. (3) The efficiency promoted by most healthcare institutions focuses primarily on the measurable actions and outcomes related to curing, further decreasing the time and attention to healing. (4) The authors have taught an approach to care based on mindfulness and congruence (mindful clinical congruence) to all medical students in all 4 years at McGill University that promotes a way of relating to patients that makes space for both healing and curing. (5) For this approach to succeed, both in palliative care and healthcare generally, will require a new kind of medical professionalism, where healing is seen as the bedrock of practice and curing as the context in which healing takes place. Communities of trust will be necessary for this transformation, which the authors believe will benefit both professional caregivers and the patients to whom they deliver care.
Diagnosis and Management of Depression in Palliative Care
Authors: Fairman Nathan , Irwin Scott A.
Published: January 2023

Depression occurs frequently in individuals with advanced disease, and its consequences can be serious. A profoundly painful experience, depression can cause significant physical, emotional, and social disability. It can deprive patients of the ability to experience joy and pleasure; it can create feelings of worthlessness and meaninglessness; it can cause distress for loved ones; it can amplify physical symptoms and undermine the response to disease treatment; it even has the power to make death itself appealing. This chapter provides a succinct review of the approach to identifying and addressing depression in palliative care settings. Because several different conditions share the common feature of depressed mood, distinguishing among these different conditions requires a careful approach to assessment. Fortunately, even in the context of serious illness, including near the very end of life, individuals with depression can often experience relief through management strategies that include psychosocial interventions, various psychotherapies, and a variety of evidence-based medication treatments.
Suicide and Desire for Hastened Death in the Terminally Ill
Authors: Walsh Leah E. , Polacek Laura C. , Heule Marjorie , Rosenfeld Barry
Published: January 2023

Patients in the palliative care setting are often faced with thoughts of a threatened or limited life expectancy due to their illness. The transition from curative to palliative treatment can signify to the patient that recovery from the illness is no longer possible and the most that medical care can offer is physical comfort. In some patients, this realization can lead to a desire for a more rapid death or even thoughts of suicide, as evidenced by elevated rates of suicide in patients with advanced medical illnesses. Understanding a patient’s expressions of the wish to hasten death in the context of serious medical illness has become more complicated over the past decades, particularly given the growing trend toward legalization of physician-assisted dying. Thus, it is crucial for healthcare providers to understand the risk factors for suicide and desire for hastened death in order to properly assess and respond to these patients. This chapter provides a broad overview of the reasons behind and risk factors for suicide and desire for hastened death, as well as how to assess and respond to these expressions in patients with advanced medical illness.
Palliative Care in the Patient with Substance Use Disorder
Authors: Amaram-Davila Jaya S. , Arthur Joseph A.
Published: January 2023

Opioids remain the mainstay for the treatment of pain among patients with advanced disease. Unfortunately, its nonmedical use and associated substance use disorder (SUD) have become of utmost concern among the medical community, especially in this era of the opioid crisis. There is an emerging need for palliative care among this subset of patients who develop these comorbid conditions. Current evidence suggests that nonmedical opioid use may be more prevalent among patients with advanced illness than previously thought. Data suggest that pain continues to be undertreated even among patients at the end of life. Clinicians therefore face the challenge to prescribe opioids to alleviate patients’ symptom burden while making all efforts to safeguard its appropriate use and mitigate the development of SUD. To overcome these challenges, clinicians can utilize a universal precautions approach while prescribing opioids. This chapter describes the scope of nonmedical use and SUD among patients with advanced disease and outlines practical strategies to ensure safe opioid prescribing practice. These may include obtaining comprehensive patient histories, screening all patients receiving opioid therapy using validated risk assessment questionnaires, and intensifying patient education on safe use, storage, and disposal of opioids. Best practices recommend using urine drug tests and prescription drug monitoring programs to monitor inappropriate opioid-related behaviors during routine chronic opioid therapy. Ultimately, the goal of all healthcare providers is to achieve the optimal risk-benefit ratio in opioid prescribing and provide improved quality care for palliative care patients with SUD.
Bereavement in Palliative Care
Authors: Lichtenthal Wendy G. , Fadalla Carol , Singer Jonathan , Roberts Kailey E. , Rosa William E. , Watsula Amanda , Prigerson Holly G.
Published: January 2023

Grieving often begins at the time of a diagnosis, continuing as the patient faces numerous role and functional losses, surging when death is anticipated, and most often manifesting most intensely for the family after the patient’s death. This chapter focuses on how palliative care clinicians may support those who are grieving, describing adaptive and pathological grief reactions and risk factors for poor bereavement outcomes. Additional information is provided on how to identify family members at greatest risk for debilitating grief reactions and how to assess and diagnose different bereavement-related mental disorders. The impact of patient loss among professionals is also reviewed.
Physical Symptom Management in the Terminally Ill
Authors: Portenoy Russell K. , Bruera Eduardo
Published: January 2023

Physical symptoms, such as pain, breathlessness, and fatigue, are highly prevalent in all populations with serious chronic illness. The distress accompanying symptoms that remain poorly controlled as disease progresses commonly affects both the patient and family. Symptom management is a key objective of palliative care, and all clinicians involved in the care of those with chronic illness can contribute by recognizing symptom distress, participating in a comprehensive assessment, and guiding the safe and effective use of both nonpharmacologic and pharmacologic therapies. This chapter describes the principles of symptom assessment and the management of a common group of physical symptoms based on the best evidence available.
Eating Issues in Palliative Cancer Patients
Authors: Hopkinson Jane B. , Amano Koji , Baracos Vickie E.
Published: January 2023

Eating issues are common in palliative care cancer patients. They accompany cancer cachexia, the debilitating syndrome associated with muscle wasting, involuntary weight loss, physical decline, fatigue, and poor appetite. These symptoms have emotional and social impact. They can adversely affect health-related quality of life in patients with advanced and progressing disease. The health and well-being of family members of patients with the syndrome can also be adversely affected. This chapter gives a brief overview of cancer cachexia syndrome, considers treatments, its emotional and social impact, and the measurement of associated distress. The authors draw on a systematic search of literature about psychosocial support for patients with cachexia to present a framework of factors that can influence quality of life and present a measure of cachexia-related distress in patients with advanced cancer. The chapter concludes by considering the implications for palliative care clinicians. In the absence of treatment for cancer cachexia, attention to psychosocial factors affecting cachexia-related quality of life is key to improvement in cachexia care.
Fatigue at End of Life
Authors: Hays Meredith , Santisi Han Le , Mahon Margaret M.
Published: January 2023

Fatigue is common in people with serious illness but is greatly underrecognized. Fatigue has been studied most commonly in people with cancer, although it has also been described (albeit still underrecognized) in people with HIV/AIDS, heart disease, lung disease, and others. Though people with fatigue tire easily, the symptom is much broader, typically including physical weakness and mental fatigue (difficulty concentrating and emotional lability). Fatigue limits one’s ability to participate in activities of daily living, and the implications for family or other caregivers are significant. Fatigue is poorly understood by clinicians, which undoubtedly contributes to lack of understanding by patients and families. Researchers have developed multiple tools to assess fatigue, some unidimensional, some multidimensional. Given the complex nature of the condition, while multidimensional tools may more accurately capture the patient’s experience. Fatigue can be caused by disease or treatment. Though incompletely understood, hypothesized causes include immune, inflammatory, hematologic, endocrine, and other causes. It is unlikely that any single treatment, nonpharmacologic or pharmacologic, will completely relieve fatigue. Many nonpharmacologic interventions have been studied: exercise and energy conservation have been most successful. Data about the efficacy of pharmacologic modalities are similarly mixed: methylphenidate, corticosteroids, and placebo have been beneficial in some studies. Patients and families will benefit from an interdisciplinary approach, enabling exposure to experts with expertise in a range of areas and tools.
Human Development and Personal Well-Being in Life-Threatening Conditions
Authors: Byock Ira
Published: January 2023

In common with the other disciplines within Western medicine, psychiatry responds to the fundamental human problems of illness and injury. Psychiatry contributes a distinct knowledge base and set of therapeutic interventions to advancing medicine’s principal goals of cure, longevity with chronic illness, rehabilitation, and alleviation of symptoms and suffering. Psychiatric practice historically has been organized around defined categories of suffering which fall within its purview: serious affective and thought disorders, disorders of personality or character, and responses to medical illness or physical injury. Consistent with the problem-based orientation of mainstream medicine, less attention has been devoted to concepts of health and well-being within the context of physical or psychiatric illness. Positive personal experiences, satisfying interpersonal dynamics, personal growth, and well-being are infrequently discussed in medical, psychiatric, and clinical psychology contexts. Important exceptions can be found within existential psychology and developmental psychology. Existential psychology is oriented toward living as fully as possible in whatever circumstances life presents. Developmental psychology recognizes crises as sources of suffering as well as stimuli for personal growth. The perspectives and insights of existential and developmental psychology open therapeutic opportunities in caring for and counseling people with life-threatening conditions that are foreclosed by problem-based medical models. Concepts of personal growth, quality of life, health, and well-being during advanced illness can enhance the specificity of psychosocial and spiritual interventions and contribute to the science and practice of palliative medicine.
The Right to Pain Relief and Other Deep Roots of the Opioid Epidemic
Authors: Sullivan Mark , Ballantyne Jane
Published: January 2023

The Right to Pain Relief and Other Deep Roots of the Opioid Epidemic aims to reach beneath popular narratives that blame profit-seeking pharmaceutical companies and healthcare practitioners for opioid overprescribing and the resulting epidemic of opioid addiction, overdose, and death. This book argues that the opioid epidemic arises from serious misunderstandings of both opioids and pain. Based on opioid use for acute pain, clinicians believed that opioids were specific “painkillers” that relieved pain but left the person alone. Recent research has shown that opioids have diverse functions within the human brain to modulate many forms of stress and support emotional function and socialization. We have also misunderstood the role of pain in human life. Over the past millennium, Western society has shifted from considering pain a religious problem, then a social problem, and now a medical problem. Innovations in the care of patients at the end of life led us to consider pain control to be an important medical responsibility independent of disease control, and to consider opioids to be safe and effective. Even though we understand chronic pain as a biopsychosocial condition, we have built mechanical causal models of chronic pain that support a moral model of pain as a form of passive and innocent suffering for which it is appropriate to claim a right to pain relief. To end our current opioid epidemic and prevent future epidemics, we need to reintegrate pain with the rest of human suffering as a necessary part of a full human life.
Occupational Therapy for Older Adults with Dementia and Their Caregivers
Authors: Martínez Jenny
Published: January 2023

This study investigated the effects of community-based occupational therapy on the daily functioning of older adults with dementia and caregivers’ sense of competence. Adults 65 years or older with a diagnosis of mild to moderate dementia and their caregivers were assigned to a control or an intervention group. The intervention group received 5 weeks of home-based occupational therapy focused on the older adult with dementia–caregiver dyad. Primary outcomes included 1) daily functioning as measured by the Assessment of Motor and Process Skills (AMPS), 2) performance in daily activities as measured by the Interview of Deterioration of Daily Activities in Dementia (IDDD), and 3) caregiver sense of competence as measured by the Sense of Competence Questionnaire. Results at 6 weeks showed improvement in AMPS and IDDD scores for older adults with dementia; caregivers’ sense of competence also increased. Improvements were sustained over 12 weeks. The findings support the benefits of occupational therapy in dementia care.
Occupational Therapy to Improve Clinical, Behavioral, and Psychosocial Outcomes among Young Adults with Diabetes
Authors: Fritz Heather
Published: January 2023

The Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) intervention is an individually tailored treatment delivered by occupational therapists that applies activity analysis to health management tasks necessary to prevent and manage chronic conditions. In a randomized controlled trial conducted among 81 ethnically diverse young adults with low socioeconomic status who had type 1 or type 2 diabetes, the REAL Diabetes treatment resulted in improved glycemic control, diabetes-related quality of life, and habit strength for checking blood glucose compared with participants who did not receive the intervention. The results of the REAL Diabetes study suggest the potential of occupation-based treatments founded on the principles of Lifestyle Redesign for reducing the impact of diabetes on health and quality of life.
Occupational Rehabilitation for Work-Related Musculoskeletal Disorders
Authors: Snodgrass Jeff
Published: January 2023

The chapter examines the role of occupational rehabilitation for work-related musculoskeletal disorders by reviewing and critiquing the study by Hardison and Roll titled “Factors Associated with Success in an Occupational Rehabilitation Program for Work-Related Musculoskeletal Disorders.” It examines factors that are predictive of success for clients participating in inpatient occupational rehabilitation programs. It identifies new factors associated with success in rehabilitation by highlighting the importance of session length and number of sessions of therapy and occupation-based activities for this population. It also provides a brief review of other relevant studies and a clinical case study based on the best available evidence.
Supported Education for Adults with Psychiatric Disabilities
Authors: Nagata Rashelle
Published: January 2023

This chapter describes a study analyzing the effectiveness of a supported education program for adults with psychiatric disabilities in achieving educational and vocational goals. Thirty-eight adults with psychiatric diagnoses were assigned at random to either an experimental group that received supported education services (n = 21) or a control group that received treatment as usual through their mental health facilities (n = 17). The 6-week intervention included 12 sessions that targeted a variety of topics to support academic and career success, in addition to individualized mentorship. Statistically significant findings were captured by the observational and self-report measures gathered by pre- and posttests in both the experimental and control groups. This chapter discusses the importance of occupational therapy support for adults with psychiatric disabilities in community reintegration through either formal education participation or employment.
Adapting the Environment for Improved Oral Care among Children on the Autism Spectrum
Authors: Benevides Teal W. , Pfeiffer Beth
Published: January 2023

Many children with autism spectrum disorder (ASD) have difficulty with sensory processing that impacts their cooperation and success with routine dental care. The purpose of this study was to examine the feasibility and pilot a sensory adapted dental environment (SADE) on distress, sensory discomfort, and perception of pain during oral cleanings for children with and without ASD between the ages of 6 and 12. There were a total of 44 participants (22 with ASD and 22 without ASD) who received dental cleanings in both a regular dental environment (RDE) and a SADE in an experimental crossover design. Both children with and those without ASD demonstrated decreased physiological anxiety as measured by electrodermal responses in the SADE. Additionally, both groups reported lower sensory discomfort and perceived pain in the SADE in comparison to the RDE.
Early Occupational and Physical Therapy for Critically Ill Patients Requiring Mechanical Ventilation
Authors: Nguyen Phuong
Published: January 2023

This chapter reviews a randomized controlled trial examining the effect of occupational and physical therapy initiated early post-intubation on mechanically ventilated, critically ill patients’ health outcomes compared to standard care. Critical illness and intensive care unit stays have a multitude of short- and long-term deleterious effects, including immobility secondary to sedation. This study examined the effect of early mobilization combined with daily sedation interruption on patient outcomes including functional status, delirium duration, mechanical ventilation duration, and intensive care unit and hospital lengths of stay. A comprehensive rehabilitation strategy working in concert with the medical sequelae was found to be safe and well tolerated and resulted in improved physical, cognitive, psychosocial, and functional outcomes.
Culturally Engaged Supervision
Authors: MacFarlane Ian M. , Redlinger-Grosse Krista
Published: January 2023

With the prioritization of justice, equity, diversity, and inclusion in the genetic counseling profession, culturally engaged supervision practices become increasingly important. This chapter first equips supervisors with background definitions and theory to provide common language and frameworks (e.g., cultural humility, professional development, and professionalism) to understand what culturally engaged clinical supervision entails. Through scenarios and self-reflective questions, it illustrates opportunities and barriers that can arise in culturally engaged supervision and offers strategies supervisors can begin to integrate into their supervision. Specifically, it includes discussions and application regarding self-awareness, communication of feedback and evaluation, culture sharing, and identifying and addressing microaggressions. Learning activities at the end of the chapter walk supervisors through steps to becoming more aware, reflective, and engaged in cultural issues in their supervision practice.
Setting Goals in Supervision
Authors: Veach Patricia McCarthy
Published: January 2023

Goals serve several functions in supervision. They clarify what a supervisor expects of a student and provide a framework for the supervision relationship, the student’s learning activities, and learning outcomes. This chapter defines the term goal, describes the functions and usefulness of goals in genetic counseling supervision, identifies characteristics of viable goals, and suggests strategies for establishing a goal-setting process and promoting goal accomplishment. It includes a description of the Discrimination Model and Bloom’s Taxonomy as resources for helping determine goal content and provides illustrative examples of genetic counseling goals that align with each model. This chapter discusses common goal-setting pitfalls and ways to manage them. Experiential learning activities provide opportunities to practice being systematic and selective when engaging in setting goals with student supervisees.
Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE)
Authors: Al Shakarchi Julien
Published: January 2023

This chapter provides a summary of a landmark study in the management of patients with atherosclerotic vascular disease. The Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial assessed whether clopidogrel decreased major adverse cardiovascular events compared to aspirin. The CAPRIE trial demonstrated better efficacy for clopidogrel in patients with peripheral arterial disease. This chapter describes the basics of the study, including funding, study location, who was studied, how many patients were recruited, study design, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary, and concludes with a relevant clinical case.
Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients with Symptomatic Stenosis of the Internal Carotid Artery
Authors: Al Shakarchi Julien
Published: January 2023

This chapter provides a summary of a landmark study in vascular surgery assessing whether carotid stenting improved outcomes compared to carotid endarterectomy in patents with symptomatic carotid artery disease. The study, which involved a meta-analysis of data from four randomized controlled trials, demonstrated an increased periprocedural stroke risk with stenting, especially in the first 7 days after the event. This chapter describes the basics of the study, including funding, number of studies included, inclusion and exclusion criteria, how many patients were recruited, study design, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and, concludes with a relevant clinical case.
Prospective Randomized Trial of Carotid Endarterectomy with Primary Closure and Patch Angioplasty with Saphenous Vein, Jugular Vein, and Polytetrafluoroethylene
Authors: Al Shakarchi Julien
Published: January 2023

This chapter provides a summary of a landmark study in vascular surgery assessing whether patching improved outcomes compared to primary closure in patients undergoing carotid endarterectomy. The study, a prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene, demonstrated that patch closure was less likely to cause perioperative stroke and led to a decrease in late recurrent stenoses. This chapter describes the basics of the study, including funding, study location, inclusion and exclusion criteria, how many patients were recruited, study design, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary, and concludes with a relevant clinical case.
Recurrent urinary tract infection
Authors: Harding Christopher K.
Published: January 2023

This case details a very common presentation that most urologists will see regularly. Recurrent urinary tract infection affects both pre- and postmenopausal women and although the case presented describes a postmenopausal woman, the evidence quoted is applicable to all women with recurrent uncomplicated cystitis. The case is used to highlight the current global issue of antimicrobial resistance and consequently explores several non-antibiotic options for urinary tract infection prevention. The evidence for low-dose daily prophylactic antibiotics is also provided. This case provides an overview of a range of preventative treatments and includes a summary of relevant reviews from Cochrane. It will enable readers to plan thorough consultations with patients who present with recurrent urinary tract infection by summarizing the evidence-based treatments while underlining the importance of antibiotic stewardship.
Ureteric stones
Authors: Bibby Lisa , Sheba Mostafa , Lavinio Andrea , Winterbottom Andrew , Wiseman Oliver
Published: January 2023

This case looks at one of the commonest emergency surgical presentations, ureteric colic. It covers the initial management of such patients in the emergency room, including the evidence behind which analgesia to use and which imaging to undertake. The patient discussed then re-presents with urosepsis, and the discussion centres around management of this, including the options for emergency drainage, with expert comment from an interventional radiology point of view regarding the nephrostomy, and an intensive therapy unit point of view for the identification and management of sepsis. Further management of this patient is with a ureteroscopy, and some of the tips and tricks of ureteroscopy are covered, including the evidence of whether to insert a JJ stent. The case finishes with discussion about metabolic work up and medical management of these patients, who often have a high stone recurrence rate.
Oligometastatic prostate cancer
Authors: Claps Francesco , Traunero Fabio , Pavan Nicola , Sooriakumaran Prasanna
Published: January 2023

Around 10–20% of men with newly diagnosed prostate cancer present with metastatic prostate cancer where the benefit of surgery is unknown. A case is presented of a man with low-volume metastatic (oligometastatic) prostate cancer who was eligible for the TRoMbone trial and who was randomized into the surgical arm. Robotic surgery for locally advanced prostate cancer is considered a possible therapeutic option as part of a multimodal approach. For metastatic disease, surgery of the primary tumour is a well-established concept in the treatment of several malignancies including ovarian tumours, various gastrointestinal tumours, and renal cell carcinoma; hence, there is a rationale to consider local treatment also in metastatic prostate cancer. Preliminary results of TRoMbone brought to light that it is feasible to randomize men with synchronous oligometastatic prostate cancer to standard of care systemic therapy versus that plus local treatment of the primary tumour. Moreover, the robot-assisted approach for oligometastatic cases was shown to be technically feasible and early results demonstrated acceptable perioperative and short-term oncological outcomes. Radical prostatectomy in patients with oligometastatic disease needs to be reserved for expert surgeons in tertiary care settings. These cases can present technical difficulties intraoperatively that only experienced surgeons can manage. Rectal injuries and high rates of positive surgical margins are possible sequelae of this surgery.
Localized renal cancer with inferior vena cava tumour thrombus
Authors: Klatte Tobias , Riddick Antony C.P. , Stewart Grant D. , Karam Jose A.
Published: January 2023

This case discusses the management of locally advanced renal cell carcinoma with associated inferior vena cava tumour thrombus. High-quality, up-to-date computed tomography and magnetic resonance imaging should be obtained before intended surgical resection, and the thrombus level should be assigned according to a surgical venous tumour thrombus classification. Several additional imaging parameters such as the anteroposterior diameter of the inferior vena cava can assist in surgical planning. Surgical resection without presurgical systemic treatment is the standard of care and is adapted according to thrombus level and intraoperative findings. Postoperative risk stratification depends on pathology and performance status. Adjuvant therapy is currently not recommended for high-risk disease, and postoperative risk-adapted surveillance remains the standard of care.
Localized penile cancer
Authors: Eardley Ian
Published: January 2023

This case describes a 48-year-old man with a clinically and radiologically localized penile cancer (T2G3) who was treated by glansectomy and skin grafting with preservation of normal micturition and some erectile function. Although he was clinically and radiologically node negative, sentinel node biopsy showed micro-metastasis in the right groin, requiring inguinal lymphadenectomy on that side. Over 5 years of follow-up there was no evidence of tumour recurrence.
Testicular torsion controversies
Authors: Vyas Lona , Noureldin Mohamed , Minhas Suks
Published: January 2023

Testicular torsion is a urological emergency, resulting in testicular ischaemia owing to twisting of the spermatic cord, which jeopardizes the blood supply of the testis. It necessitates urgent intervention, as it risks testicular viability and may lead to catastrophic consequences such as orchidectomy if the intervention is delayed. Despite the fact that testicular torsion one of the most frequent urological emergencies in men, there is uncertainty and discrepancies between guidance and practice. These can lead to delayed management. This case reviews and assesses controversial aspects of testicular torsion including aetiology, diagnosis, and management.
Bladder and ureteric trauma
Authors: Mantica Guglielmo , Spies Pieter V. , Van der Merwe André
Published: January 2023

A case of penetrating ureteric and bladder injury is reported. The principles of management of ureteric and bladder trauma are demonstrated by the tissue loss in this particular case. Emphasis is placed on the early diagnosis and then careful management of the injuries to allow tissue tension-free healing. The importance of anatomical expertise is demonstrated in the blood supply of the ureter. The case discusses the fragile nature of ureteric tissue needing gentle dissection techniques, respectful handling, and fine sutures. Ureter and bladder injuries have to be repaired in a watertight fashion and drained internally and externally. Urine accumulating in the tissue is toxic and can affect the critically ill trauma patient negatively, therefore, adequate drainage for a length of time allowing healing of tissue is essential.
The Effectiveness of Utilizing HRV Indices as a Predictor of ACFT Performance Outcomes
Authors: Torres Ricardo E , Heileson Jeffrey L , Richardson Kathleen A , Chapman-Lopez Tomas J , Funderburk LesLee K , Forsse Jeffrey S
Published: January 2023

Background

The Army Combat Fitness Test (ACFT) is a performance assessment used by the U.S. Army to assess a cadet’s strength, endurance, and agility with a series of six events to ensure that cadets are combat ready. Heart rate variability (HRV) is an instrument that measures cardiac autonomic modulation and has been incorporated to predict the performance of athletes in daily training and competition since acute bouts of exercise alter HRV variables.

Purpose

To assess the applicability of using HRV to predict ACFT score performance outcomes in cadets.

Methods

Fifty army cadets (n = 36 male; n = 14 female; age = 20.60 ± 3.61 years; height = 173.34 ± 10.39 cm; body mass = 76.33 ± 14.68 kg; body fat percentage  = 17.58 ± 5.26%) completed the ACFT and reported for HRV assessment. HRV assessment had the participant lay supine for 5 minutes, and traditional time and frequency domain variables were assessed. A Pearson’s correlation and multiple linear regressions were run.

Results

HRV time and frequency domains were not significantly correlated in linear regression models except the stress index (SI) and the 2-mile run (2MR). The standing power throw and sprint drag carry were significantly correlated with traditional HRV variables.

Conclusions

HRV was not a predictor of ACFT performance for individual events or overall ACFT. The SI presented predictive properties only for 2MR, with no other significant correlations between HRV variables with standing power throw and sprint drag carry. The SI ability to predict 2MR performance outcome via HRV is a promising tool to assess army cadet performance and recovery.
Towards a reliable calculation of relic radiation from primordial gravitational waves
Authors: Giarè William , Forconi Matteo , Di Valentino Eleonora , Melchiorri Alessandro
Published: January 2023

Inflationary gravitational waves, behaving as additional radiation in the Early Universe, can increase the effective number of relativistic species (Neff) by a further correction that depends on the integrated energy-density in gravitational waves over all scales. This effect is typically used to constrain (blue-tilted) models of inflation in light of the bounds resulting from the big bang nucleosynthesis. In this paper, we recompute this contribution, discussing some caveats of the state-of-the-art analyses. Through a parametric investigation, we first demonstrate that the calculation is dominated by the ultraviolet frequencies of the integral and therefore by the behaviour of the tensor spectrum on scales corresponding to modes that cross the horizon very close to the end of inflation, when the slow-roll dynamics breaks down and the production of gravitational waves becomes strongly model dependent. Motivated by these results, we realize a theoretical Monte Carlo and, working within the framework of the Effective Field Theory of inflation, we investigate the observable predictions of a very broad class of models. For each model, we solve a system of coupled differential equations whose solution completely specifies the evolution of the spectrum up to the end of inflation. We prove the calculation of $\Delta N_{\rm eff}^{\rm GW}$ to be remarkably model dependent and therefore conclude that accurate analyses are needed to infer reliable information on the inflationary Universe.
Tilted discs in six poorly studied cataclysmic variables
Authors: Stefanov Stefan Y , Stefanov Atanas K
Published: January 2023

In this work, we search for negative superhumps (nSHs) in poorly studied cataclysmic variables using Transiting Exoplanet Survey Satellite data. We find three eclipsing binaries with nSH signatures: HBHA 4204−09, Gaia DR3 5931071148325476992, and SDSS J090113.51+144704.6. The last one exhibits IW And-like behaviour in archival Zwicky Transient Facility data, and appears to have shallow, grazing eclipses. In addition, we detect nSH signatures in two non-eclipsing systems: KQ Mon and Gaia DR3 4684361817175293440, by identifying the orbital period from the superorbital-dependent irradiation of the secondary. We discover nSH signatures in one more system, [PK2008] HalphaJ103959, by using an orbital period from another work. An improved mass ratio–nSH deficit relation q(ε−) is suggested by us, which agrees with independent measurements on nova-like variables. With this relation, we estimate the mass ratios of all systems in our sample, and determine the orbital inclinations for the three that are eclipsing. All systems with discovered nSHs in this work are excellent targets for follow-up spectroscopic studies.
The excitation of CO in CO-dominated cometary comae
Authors: Żółtowski M , Lique F , Loreau J , Faure A , Cordiner M
Published: January 2023

An abundance of CO significantly surpassing the abundance of H2O is observed in the comae of comets at large heliocentric distances. In these environments, CO molecules can be the most abundant species and they may be therefore the dominant projectiles inducing collisional excitation of the cometary molecules. It is thus of high interest to investigate the excitation of CO by CO. This article provides a new set of CO–CO collisional rate coefficients for temperatures up to 150 K and for CO rotational levels j1 up to 10. These data are obtained from quantum scattering calculations using the coupled states approximation. They are used in a simple radiative transfer model in order to test their impact on the excitation of cometary CO. Because mutual (de-)excitations of the target and projectile are important, the CO projectile was assumed to be thermalized at the kinetic temperature. We found that the non-local thermodynamical equilibrium regime extends for CO densities in the range 103–107 cm−3. We also observed that as soon as the CO/H2O ratio is larger than 70 per cent/30 per cent, the contribution of H2O collisions can be neglected. Similarly, the excitation of CO by CO may be ignored for relatively low CO/H2O density ratios (≤30 per cent/70 per cent). Finally, when the coma is a ∼50 per cent/50 per cent mixture of CO and H2O, the contribution of both colliders is similar and has to be considered.
Single-centre, cross-sectional study on the factors and reasons for non-vaccination among patients with rheumatoid arthritis
Authors: Miyake Hirofumi , Sada Ryuichi Minoda , Tsugihashi Yukio , Hatta Kazuhiro
Published: January 2023

Objectives

We aimed to investigate the vaccination coverage and the factors associated with non-vaccination for vaccine-preventable diseases among patients with rheumatoid arthritis.

Methods

This single-centre, cross-sectional study was conducted in a 715-bed regional tertiary-care teaching hospital in Japan from 1 September to 30 November 2020. Vaccination status and the factors and reasons for not receiving the influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPSV23), 13-valent pneumococcal conjugate vaccine (PCV13), and varicella vaccine live (VVL) were investigated.

Results

Among 991 patients, the vaccination coverage for the influenza vaccine, PPSV23, PCV13, and VVL was 62%, 46%, 14%, and 3%, respectively. The most common reasons for vaccine hesitancy were efficacy concerns for the influenza vaccine, safety concerns for the PPSV23 and PCV13, and both efficacy and safety concerns for the VVL. Younger age, no use of biologics or other hospital visits, and public assistance were factors significantly associated with non-vaccination for the influenza vaccine; younger age, short disease duration, and no visits to other hospitals for PPSV23; younger age, no hospitalisation, more experienced doctor, and no medical immunodeficiency for PCV13.

Conclusions

We found that the factors associated with non-vaccination varied by vaccine type; therefore, vaccinations should be promoted with individualised strategies.