bluuebunny/crossref_metadata_2025 huggingface dataset:
Extra-articular manifestations: inflammatory bowel disease
Authors: Elewaut Dirk , Cypers Heleen , Stoll Matthew L. , Elson Charles O.
Published: November 2017

A significant overlap exists between spondyloarthritis (SpA) and inflammatory bowel disease (IBD), particularly in the IL-23/IL-17 pathway. Shared immunologic mechanisms include aberrant innate immune responses, an excess of Th1/Th17-mediated immunity, and inadequate immune regulation. Many genetic factors associated with IBD are involved in host–pathogen interactions and intestinal barrier function, and the intestinal microbiota do appear to play an important role in disease development. Hence the current hypothesis for IBD pathogenesis is that it stems from a dysregulated immune response to intestinal microbiota in a genetically susceptible host. In SpA, evidence for a role of intestinal microbiota is less abundant, but given the overlap with IBD, it is plausible that gut microbiota are important players in SpA pathogenesis as well. However, there are significant genetic differences between these two conditions, as well as differing responses to biologic therapy.
Extra-articular manifestations: psoriasis
Authors: Boehncke Wolf-Henning , Gladman Dafna D.
Published: November 2017

Psoriasis is a chronic, recurrent inflammatory skin disease, affecting about 2% of the world’s population. In 2014, the World Health Organization’s member states adopted a resolution on psoriasis, recognizing it as ‘a chronic, non-communicable, painful, disfiguring, and disabling disease for which there is no cure’. The resolution acknowledges the psychosocial burden of the disease and that many people with psoriasis suffer due to lack of awareness and access to sufficient treatment. Psoriasis is a multifaceted disease including not only a variety of skin lesions, but also joint manifestations and comorbidities. This chapter focuses on the clinical features of psoriasis of the skin and its underlying pathogenesis, taking into account the current status of genetic research in the field. It also describes psoriatic arthritis, as well as the association of psoriasis with spondyloarthritis.
Treatment: NSAIDs
Authors: Chan Jonathan , Haroon Nigil
Published: November 2017

Non-steroidal anti-inflammatory drugs (NSAIDs) constitute a diverse group of medications that inhibit prostaglandin synthesis. NSAIDs form the first-line pharmacological therapy in ankylosing spondylitis (AS). A number of randomized controlled trials (RCTs) support the efficacy of NSAIDs in reducing pain and improving patient function. Head-to-head comparisons have demonstrated equivalent effect of different NSAIDs in symptom control. The proposed disease-modifying potential of regular NSAID therapy is debatable and recent literature provides evidence to the contrary. Several safety concerns have been raised regarding long-term use of NSAIDs, especially an increase in cardiovascular risk. This chapter discusses the pharmacology, efficacy in treatment of AS, disease-modifying potential, and safety concerns of NSAIDs.
Treatment: DMARDs
Authors: Poddubnyy Denis , Haibel Hildrun
Published: November 2017

In axial spondyloarthritis (axSpA) there is little evidence to support use of classical synthetic disease-modifying antirheumatic drugs (DMARDs), with the majority of studies performed in advanced ankylosing spondylitis. Sulfasalazine is the best investigated DMARD in axSpA. Its positive clinical effect, if any, seems to be more prominent in the presence of peripheral arthritis, although a certain proportion of patients with axial disease might benefit from sulfasalazine therapy. Available data indicate that there is no evidence that methotrexate might be effective in axial disease, and only marginal evidence exists in support of methotrexate use in case of peripheral involvement. No true disease-modifying properties (e.g. retardation of structural damage progression in the spine) have been demonstrated for DMARDs in axSpA to date. Efficacy of a combination therapy (e.g. methotrexate plus sulfasalazine) as well as benefits of methotrexate (or other DMARDs) in addition to tumour necrosis factor α‎ inhibitors in axSpA remain uncertain.
Physical functioning and work ability
Authors: Ward Michael M.
Published: November 2017

Similar to most musculoskeletal diseases, ankylosing spondylitis (AS) has the potential to impact physical functioning and work ability. Physical functioning refers to the ability to move to accomplish a task, and includes activities such as self-care, mobility, and doing chores. Physical functioning provides the foundation for the ability to work. Both physical functioning and work ability can be impacted by specific aspects of AS, as well as by barriers in the environment. Although patients with AS tend to have fewer functional limitations than patients with other rheumatic diseases, most patients are affected to some degree on occasion, and some patients can be profoundly and persistently affected.
Axial spondyloarthritis in Latin America
Authors: Sampaio-Barros Percival , Valle-Oñate Rafael
Published: November 2017

Latin American countries are often characterized by a significant miscegenation among whites, blacks, and Amerindians. These heterogeneous populations frequently represent a challenge for the design of studies analysing the genetics, incidence, and prevalence of rheumatic diseases. In this setting, axial spondyloarthritis (axSpA) frequently shows an increased associated peripheral involvement, compared with the homogeneous population. Genetic and socioeconomic factors can be associated with this clinical presentation, although further studies are necessary to confirm this hypothesis. Regarding treatment, Latin American spondyloarthritis (SpA) patients also show a higher prescription of corticosteroids, methotrexate, and sulfasalazine than European series. This chapter presents and discusses the many aspects related to the presentation of axSpA in Latin America.
Seven steps to sustainability based on precision medicine
Authors: Barker Richard
Published: November 2017

Bioscience is producing tools that can streamline and focus the medical innovation process. Drawing on these tools we can and must make seven specific changes of mindset and practice. These are: (1) basing discovery on a molecular taxonomy of disease within a systems understanding of biology; (2) high impact academic-industry partnerships; (3) adaptive and collaborative product development and approval; (4) more creative reward and financing systems; (5) the engineering of faster adoption and better adherence; (6) real world data-driven learning; (7) bringing patients into the decision-making mainstream. Together they have the potential to transform life science translation, from a new approach to discovery, through faster, more targeted therapy development, to a better use of health data. Together these changes spell a new era of precision medicine.
Conclusion: New roles and relationships in a new innovation ecosystem
Authors: Barker Richard
Published: November 2017

The result of the proposals in this book is a new ecosystem for medical innovation in which many of the participants play new roles. Life science academics will focus to a greater extent on the potential impact of their work. Companies in industry will see more collaborations and partnerships both with academia and with each other. Patient groups and research charities will increasingly be drivers of innovation. Health systems will move from being passive recipients of innovation to being active participants in development. New entrants, mainly from the IT world, will carve out new businesses in patient selection and support and in treatment analysis. To bring all this about, we need ambitious 5- and 10-year goals covering areas from global convergence on evidence needs to a new concordat on patient data access and security.
Error, bias, and confounding in epidemiology
Authors: Bhopal Raj S.
Published: November 2017

Epidemiological studies are prone to error, because they usually study complex matters in human populations in natural settings and not in laboratory conditions. Bias may be thought of as error which affects comparison groups unequally or leads to inappropriate inferences about one group compared with another. Three broad problems confront epidemiologists: selection of study populations, quality of information, and confounding. Selection and imperfect information cause biases. Confounding is not an error or bias as normally understood, but it leads to errors of data interpretation. The different epidemiological research designs have similar problems with error and bias, which are mostly inherent in the survey and disease registration methods. Principles which apply to all studies and help to minimize these errors are also similar. The chronology and structure of a research project offers a pragmatic framework for the systematic analysis of error bias and confounding.
Cause and effect: The epidemiological approach
Authors: Bhopal Raj S.
Published: November 2017

Cause and effect understanding is the highest form of scientific knowledge. In epidemiology, demonstrating causality is difficult because of the long and complex natural history of many human diseases and because of ethical restraints. Epidemiologists should: hold the attitude that all judgements of cause and effect are tentative; understand that causal thinking demands a judgement; be alert for the play of chance, error, and bias; always consider reverse causality and confounding, utilize the power of causal models that broaden causal perspectives; apply guidelines for causality as an aid to thinking and not as a checklist; and look for corroboration of causality from other scientific frameworks for assessment of cause and effect. The ultimate aim of epidemiology is to use knowledge of cause and effect to break links between disease and its causes and to improve health. The application of erroneous knowledge has serious repercussions.
The concept of risk and fundamental measures of disease frequency: Incidence and prevalence
Authors: Bhopal Raj S.
Published: November 2017

In epidemiology, risk refers to the likelihood, or in statistical language probability, of an individual in a defined population developing a disease or other adverse health problem. The prime measures of disease frequency, including probability of outcomes, in epidemiology are incidence rates and prevalence proportions. The incidence rate is the number of new cases in relation to a population, time, and place. Prevalence proportion measures all disease or a risk factor in a population, either at a particular time (point prevalence) or over a time period (period prevalence, lifetime prevalence). Rates and proportions are most accurately presented by age and sex groups (‘specific’ rates and proportions), but for ease of interpretation they may be grouped as overall, actual (crude) rates. The collection of both disease, risk factor and population data to achieve accurate figures of incidence rates and prevalence proportions is problematic, and remains a major challenge.
Summarizing, presenting, and interpreting epidemiological data: Building on incidence and prevalence
Authors: Bhopal Raj S.
Published: November 2017

Basic epidemiological data on disease occurrence and population structure can be manipulated and presented in many ways. Epidemiological summary measures, broadly, estimate absolute or relative frequency of outcomes. Usually, relative measures are more useful in causal enquiry while absolute measures are better in health planning and policy. These measures, usually in association with risk factor prevalence data, allow estimation of the risk attributable to a risk factor in those exposed and in the entire population. Avoidable mortality (and morbidity) refers to the potential to avoid death (or morbidity) from a number of specified causes if the best possible health care actions were taken. Years of life saved measures help to measure the impact of avoidable mortality in the population. Epidemiological data on diseases can be combined with other information, such as socio-economic circumstances, social values and attitudes, and behaviours relevant to health, to build up a community health profile.
What is health protection?
Authors: Ghebrehewet Sam , Stewart Alex G. , Rufus Ian
Published: November 2017

Health Protection is one of the core fields of public health work. It can be defined as: “The protection of individuals, groups and populations through expert advice and effective collaboration to prevent and mitigate the impact of infectious disease, environmental, chemical and radiological threats.” This chapter concisely sets out the breadth and nature of health protection practice across its three domains: communicable disease control, emergency preparedness, resilience and response (EPRR), and environmental public health. The development of these domains and the scope of health protection are illustrated by a brief history of its development in England. The role of a specialist health protection service is also described.
The basics of infection microbiology
Authors: Shears Paul , Harvey David
Published: November 2017

This chapter outlines the natural history of infections caused by a variety of organisms. These organisms may already colonize a patient (endogenous) or come from another source (exogenous). They vary in the time it takes to cause symptoms (incubation period). Some are more infective than others, and the infective period varies depending on the organism. A range of diagnostic methods are used to identify the disease, from growing the organism (culture) to using molecular techniques to identify characteristics unique to the organism. Understanding what is causing an infection is important in public health management to support outbreak identification and management. Advanced techniques can identify whether the organism is likely to be transmitted from one individual to another. Antimicrobial resistance is becoming more and more problematic and can lead to difficulties of treatment of even simple infections.
Vero cytotoxigenic Escherichia coli (VTEC) O157
Authors: Lamden Ken , Rowell Sam , Fox Andrew
Published: November 2017

This chapter describes a cluster of diarrhoeal disease caused by E.coli O157 in a case scenario involving infection following a farm visit, and possible subsequent spread within a nursery. Background information on the epidemiology of E.coli O157 indicates the role of farm contact in infection, and the risk factors for transmission. In addition to providing clear case definitions, the risk groups of contacts are described in detail. ‘Top tips’ are given, to assist the health protection practitioner take timely and appropriate action, and ‘tools of the trade’ list the laboratory, epidemiological, and veterinary components of the investigation. The statutory safety legislation required at the source farm is explained, and the importance of communication with the affected families is emphasized. The final part of the chapter considers other possible scenarios, including the possibility of food from the farm café being the source.
Hepatitis B
Authors: Huyton Rita , Ghebrehewet Sam , Baxter David
Published: November 2017

This chapter describes an acute hepatitis B case and scenario involving a paramedic with a pregnant woman as close sexual contact and potential risk of transmission to the unborn baby. Background information on the epidemiology of Hepatitis B, markers of hepatitis B infection (both acute and chronic), and the risk factors for transmission are discussed. There are clear case definitions of acute, chronic, and those susceptible and at high risk for hepatitis B plus detailed interpretation of hepatitis B markers. ‘Top tips’ are given to assist the relevant clinicians or public health/health protection practitioner/specialist to take timely and appropriate action. The laboratory, epidemiological, and infection prevention and control components of the investigation are listed. The importance of confidentiality and communication with the affected individual and close contacts is emphasized. Other possible scenarios, including the public health response to a cluster/outbreak are considered.
Hospital multi-resistant infections
Authors: Harvey David , Ledgerton Andrea
Published: November 2017

This chapter outlines common pathogens responsible for neonatal infections. It describes the processes that should be undertaken when dealing with a hospital outbreak caused by a multi-drug-resistant organism, including understanding the clinical picture, epidemiology, and laboratory results to control the outbreak. The tools and control measures required to manage a hospital outbreak caused by a multi-drug resistant organism are described. Some of the challenges in managing a hospital outbreak caused by a multi-drug resistant organism are outlined and briefly discussed. Outbreaks in neonatal units can be amongst the most challenging to control. As such, the principles outlined in this chapter can be applied to other organisms and settings within the hospital.
Legionnaires’ disease
Authors: Phin Nick , Naik Falguni , Stanford Elaine , Ghebrehewet Sam
Published: November 2017

This chapter describes Legionnaires’ disease and its importance as a preventable cause of severe pneumonia—one that mainly affects older people and has a high mortality rate. The background information and epidemiology of Legionnaires’ disease describe the salient points succinctly. The approach to surveillance and public health management is described in detail, as, unlike many infectious diseases, the source of infection is in the environment and infection is not spread from person to person. A case study is used to describe a typical scenario, the principles used in the investigation, as well as the management and control of such incidents. Top tips are provided to reinforce key and essential activities.
Business continuity: Illustrated by hospital ward closures
Authors: Stewart Alex G. , Ghebrehewet Sam , Baxter David
Published: November 2017

This chapter describes the strategies for business continuity when a significant challenging event affects a hospital or other healthcare provider: the scenario is a norovirus outbreak affecting several wards and staff. The strategy includes business impact analysis and a disaster recovery plan. The importance of developing a generic response plan, rather than a response for each type of incident, is emphasized. The early involvement of the infection control team, isolating or cohorting patients, and liaison with the community are essential components of the response. The chapter describes how a ‘less serious event’ (a few reported cases) may rapidly escalate into a major incident. The business continuity plan should be implemented early, and should identify which services can be stopped, and which must continue. Finally, the importance of holding a multi-agency and multi-professional debrief meeting as soon as the incident is declared over is emphasized, with revision of the plan accordingly.
Hospital and community infection prevention and control (IPC)
Authors: Shears Paul , Ledgerton Andrea , Huyton Rita
Published: November 2017

This chapter outlines the key principles of infection prevention and control (IPC) in both hospital and community settings. This includes understanding the structures surrounding infection prevention and control in these two different environments. It outlines some of the practical components including hand hygiene, infection surveillance, personal protective equipment, decontamination, and policies and guidelines. The chapter also covers the investigation and management of clusters/outbreak, and provides an outline of situations that require local health protection team input. Finally, the interface between community and hospital IPC is discussed, along with the importance of providing a seamless IPC service in all geographical areas.
Essential statistics and epidemiology
Authors: Cleary Paul , Ghebrehewet Sam , Baxter David
Published: November 2017

This chapter provides a grounding in basic statistics, descriptive epidemiology, analytical epidemiology, and hypothesis testing appropriate for health protection practitioners. The analysis of categorical data using frequency distributions, and charts, and the interpretation of epidemic curves is described. The description of quantitative data including central tendency, standard deviation, and interquartile range is concisely explained. The role of geographical information systems and different disease map types is used to demonstrate how disease clusters may be detected. Determining possible association between specific risk factors and outcome is described in the section on analytical epidemiology, using the risk ratio and the odds ratio. The use of these in different study/investigation types is explained. The importance of confounding, matching, and standardization in study design is described. The final part of the chapter covers hypothesis testing to distinguish between real differences and chance variation, and the use of confidence intervals.
New and emerging environmental hazards and situations
Authors: Dobney Alec , Hodgson Greg
Published: November 2017

Environmental public health scientists and health protection practitioners are constantly challenged to respond to new or poorly understood hazards. Practitioners might also be required to address well-characterized hazards that have either increased in magnitude or re-emerged in different situations. Developing technological advances and new and emerging industrial processes (such as fracking, nanotechnology, shale gas, waste fires) can raise difficult questions for the public health practitioner, especially where research and health-related evidence is lacking. In these cases, public health science has a key role in undertaking and communicating risks and in providing the most accurate available scientific evidence and public health advice. The field of environmental public health is crowded with complex problems demanding our attention. It is impossible to devote sufficient clinical, research, and advocacy energies to all of these problems at once. Clinicians, public health professionals, and environmental public health scientists have to choose which health issues take priority.
Should the bipolar disorders be modelled dimensionally or categorically?
Authors: Parker Gordon , Paterson Amelia
Published: November 2017

Historically, there have been categorical models of bipolar disorder and dimensional models of bipolar disorder. This chapter seeks to outline the history of these models as well as some recent supporting research. The models are evaluated in two ways; how well they reflect the underlying nature of bipolar disorder, and how useful they are to the patient and to the clinician in undertaking treatment decisions. The dimensional model posits that depression and bipolar lie on a continuum with pure unipolar depression at one end, bipolar disorder at the other, and some experience of highs without diagnosable (hypo)mania in-between. The categorical model posits that depression and bipolar are entirely separate conditions and that bipolar I and II are separate conditions. It is the position of the authors that the categorical model is a better reflection of the underlying nature of bipolar disorder and has proved more useful in clinical practice.
Evidence-based maintenance treatment of bipolar disorder
Authors: Popovic Dina , Vieta Eduard
Published: November 2017

Due to the episodic and chronic nature of bipolar disorder, maintenance therapy represents a critical part of treatment. However, there is a paucity of studies comparing effectiveness of available long-term treatments. In this chapter, the efficacy and safety of pharmacological treatments for maintenance treatment of bipolar disorder, as deriving from the results of randomized controlled trials, will be critically reviewed. These include second-generation antipsychotics aripiprazole, olanzapine, quetiapine, risperidone long-acting injection, ziprasidone, paliperidone, and mood stabilizers lamotrigine, lithium, valproate, carbamazepine, and oxcarbazepine. In general, if a patient has responded satisfactorily to a certain drug during the acute phase, the same treatment should be maintained during maintenance treatment. This was confirmed in two randomized controlled trials. This chapter summarizes the characteristics of the placebo-controlled randomized controlled trials for all the antipsychotics used for maintenance treatment of bipolar disorder.
The treatment of bipolar II disorder
Authors: Yatham Lakshmi N. , Kesavan Muralidharan
Published: November 2017

Diagnosis and management of bipolar II disorder (BD II) remains a significant challenge for clinicians. Early diagnosis of BD II requires a step-wise approach to systematically probe for previous hypomanic episodes and look for other indicators of bipolarity. Emphasis must be laid on ruling out common clinical conditions that could be potential differential diagnoses for BD II. The evidence base from controlled trials for management of various phases of BD II is sparse. The role of antidepressants in treating BD II remains unclear. Hence, the treatment recommendations are formulated based not only on the limited data but also on the extrapolation of data from trials of bipolar I disorder and expert opinion. Further controlled studies are urgently needed to improve treatment of BD II.
The impact of psychiatric co-morbidity in the treatment of bipolar disorder: focus on co-occurring attention deficit hyperactivity disorder and eating disorders
Authors: Guerdjikova Anna I. , Keck Paul E. , McElroy Susan L.
Published: November 2017

Bipolar disorder (BD) commonly co-occurs with attention deficit hyperactivity disorder (ADHD) and eating disorders (EDs) in adolescents and in adults. The aim of this chapter is to summarize the available data regarding prevalence, clinical presentation, and psychological and pharmacological treatment of such complicated cases. Results of randomized controlled and open-label trials and case reports are reviewed. The main therapeutic goal when treating BD co-morbid with ADHD or ED is selecting a treatment strategy effective in the management of both syndromes, or at the minimum, selecting one that treats one syndrome without exacerbating the other. Controlled data are scarce. Various classes of medications, including stimulants, atomoxetine, bupropion, and wakefulness-provoking agents, might hold promise as adjunctive medication in improving ADHD symptoms in euthymic BD patients. The specificities of the ED, namely the predominance of undereating or overeating, need to be considered when selecting agents in the treatment of BD co-morbid with EDs.
Novel therapeutic targets for bipolar disorder
Authors: Henter Ioline D. , Machado-Vieira Rodrigo
Published: November 2017

The long-term course of bipolar disorder (BD) comprises recurrent depressive episodes and persistent residual symptoms for which standard therapeutic options are scarce and often ineffective. Glutamate is the major excitatory neurotransmitter in the central nervous system, and glutamate and its cognate receptors have consistently been implicated in the pathophysiology of mood disorders and in the development of novel therapeutics for these disorders. Since the rapid and robust antidepressant effects of the N-methyl-D-aspartate (NMDA) antagonist ketamine were first observed in 2000, other NMDA receptor antagonists have been studied in major depressive disorder (MDD) and BD. This chapter reviews the clinical evidence supporting the use of novel glutamate receptor modulators for treating BD—particularly bipolar depression. We also discuss other promising, non-glutamatergic targets for potential rapid antidepressant effects in mood disorders, including the cholinergic system, the melatonergic system, the glucocorticoid system, the arachidonic acid (AA) cascade, and oxidative stress and bioenergetics.
The genetics of axial spondyloarthritis
Authors: Siebert Stefan , Raj Sengupta , Tsoukas Alexander
Published: November 2017

Family and twin studies have long suggested a large genetic component in ankylosing spondylitis (AS). The genetic association with HLA-B27 remains one of the strongest single gene variant associations reported in any complex polygenic disease. The exact mechanism by which HLA-B27 contributes to AS remains unknown, with three main theories proposed: the arthritogenic peptide, endoplasmic reticulum stress with unfolded protein response, and homodimerization theories. Genome-wide association studies have identified a number of other important susceptibility genes for AS, several of which overlap with other spondyloarthritis conditions. Of these, ERAP1 and IL-23R, are covered in more detail, highlighting their functional importance.
The pathophysiology and immunology of axial spondyloarthritis
Authors: Siebert Stefan , Raj Sengupta , Tsoukas Alexander
Published: November 2017

Ankylosing spondylitis (AS) is a heterogeneous and complex disease. While the exact pathophysiology remains unclear, significant advances have recently been made in the understanding of several implicated processes. The potential role and interplay of genetic susceptibility, biomechanics, the microbiome, and key cytokines in axial spondyloarthritis (axSpA) is described in this chapter, with particular focus on the IL-23/IL-17 pathway.
Inflammatory back pain
Authors: Siebert Stefan , Raj Sengupta , Tsoukas Alexander
Published: November 2017

Inflammatory back pain (IBP) refers to a collection of symptoms that may help identify patients with possible inflammatory spinal disease. A number of criteria sets have been proposed for IBP, which share common features such as: onset of symptoms aged <40 years, alternating buttock pain, improvement with exercise, worsening with rest, gradual onset, early morning stiffness, and improvement with NSAIDs. The IBP criteria were initially developed and validated in patients with ankylosing spondylitis, but have subsequently been shown to perform similarly in patients with axial spondyloarthritis (axSpA). The Berlin criteria demonstrated the highest specificity (84%) and the Calin criteria the highest sensitivity (92%). IBP criteria have been used in primary and secondary care referral strategies to facilitate the identification of patients with potential axSpA. It is important to note that IBP does not equate to a diagnosis of axSpA and many patients with IBP will not have axSpA.
Non-pharmacological treatment of axial spondyloarthritis
Authors: Siebert Stefan , Raj Sengupta , Tsoukas Alexander
Published: November 2017

While drugs play a key role in reducing disease activity, non-pharmacological therapies are crucial in maintaining function, flexibility, and quality of life. Therefore, non-pharmacological therapy remains a key component in the optimal management of axial spondyloarthritis (axSpA), even in the era of biologics. Regular physical therapy allows patients to capitalize on the benefits of drug therapy and maintain optimal functional ability. Self-management and education strategies, supported by patient-support groups, facilitate independence and quality of life in chronic diseases. A proportion of patients with severe disease may require hip or spinal surgery. It is hoped that the availability of more effective drug therapies to control disease activity in axSpA will reduce the requirement for surgery in future. The optimal management of axSpA requires a combination of non-pharmacological and pharmacological treatments, for both initial and long-term management.
The current and future outlook for patients with axial spondyloarthritis
Authors: Siebert Stefan , Raj Sengupta , Tsoukas Alexander
Published: November 2017

There have been major advances in axial spondyloarthritis (axSpA) over the past decade. The current and future outlook for patients with axSpA is therefore much improved and largely positive. Despite this, there is still significant unmet need in pathophysiology, prevention, diagnosis, and treatment. While several new therapeutic agents are expected to reach the clinic over the next few years, the treatment of individual patients is likely to remain largely empiric. There is a need for the development of biomarkers and rationale stratified treatment approaches in order to capitalise on previous gains for the benefit of our patients.
Respiratory therapy techniques
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Oxygen therapy 2

Ventilatory support: indications 6

IPPV—description of ventilators 8

IPPV—modes of ventilation 10

IPPV—adjusting the ventilator 12

IPPV—barotrauma 14

IPPV—weaning techniques 16

High-frequency ventilation 18

Positive end-respiratory pressure 22

Continuous positive airway pressure ventilation (CPAP) 24

Recruitment manoeuvres 26

Prone position ventilation 28...
Gastrointestinal therapy techniques
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Insertion of a Sengstaken–Blakemore tube in critical care 74

Upper gastrointestinal endoscopy 76

Nasojejunal feeding in critical care patients 78

The Sengstaken–Blakemore tube is very effective at controlling torrential bleeding from oesophago-gastric varices. Its use is associated with serious complications such as oesophageal ulceration, oesophageal perforation and aspiration pneumonia in 15–20% of cases. Up to 50% of patients will re-bleed once the balloon is deflated. so its primary function is to control bleeding initially prior to further definitive treatment....
Respiratory monitoring
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Pulmonary function tests in critical illness 90

End-tidal CO2 monitoring 92

Pulse oximetry 94

Pulmonary function test results in critically ill patients can be important prognostically and guide ventilatory and weaning strategies. However, they are not straightforward to measure in mechanically ventilated patients and remain limited to dynamic volumes. Fortunately, most modern mechanical ventilators are able to calculate and display static and dynamic lung volumes, together with derived values for airway resistance, compliance and flow/volume/time curves. The ability to monitor these changes after altering ventilatory parameters has enabled more sophisticated adjustments of ventilation, to prevent potentially damaging mechanical ventilation....
Neurological drugs
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Opioid and non-opioid analgesics in the ICU 206

Sedation management in ICU 208

Muscle relaxants 210

Anticonvulsant drugs 212

Cerebroprotective agents 214

Mannitol and hypertonic saline 216

Opioid analgesic drugs remain the mainstay of pain relief in the Critical Care Unit. Abnormal GI function in the critically sick consequently makes enteral administration undesirable. IV administration remains the mainstay. Pharmacokinetic considerations consequent upon organ dysfunction leading to altered absorption, distribution and metabolism usually play the most important role in the choice of agent....
Miscellaneous drugs
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Antibiotics 228

Antifungals 230

Antiviral agents 232

N-Acetylcysteine 234

Activated protein C 236

Infection is a common reason for admission to an ICU and a common complication of stay in an ICU. The presence of infection in patients in ICU is an important risk factor for increased mortality and morbidity....
Renal disorders
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Prevention of acute renal failure 312

Diagnosis of acute renal failure 314

Acute kidney injury (AKI) often complicates the course of critical illness and was previously considered as a marker rather than a cause of adverse outcomes, it is independently associated with an increase in both morbidity and mortality. The major causes of AKI in the ICU include hypoperfusion, sepsis and direct nephrotoxicity, with the common aetiology believed to be a change in intrarenal haemodynamics with resultant acute tubular dysfunction and oxidant stress. Treatment of established acute renal failure in the ICU entails the use of RRT by means of various modalities, although this therapy itself carries an inherent morbidity and risk. Therefore, preventing or minimizing renal injury should confer a benefit to patients. Consequently, several pharmacological interventions have been tried to treat AKI. These interventions can be separated into measures influencing renal perfusion and measures modulating intrarenal pathophysiology....
Neurological disorders
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Agitation and confusion 360

Status epilepticus 362

Meningitis 364

Intracerebral haemorrhage 366

Subarachnoid haemorrhage 368

Ischaemic stroke 370

Guillain–Barre syndrome 372

Myasthenia gravis 374

ICU neuromuscular disorders 376

Tetanus 378

Botulism 380

Neurorehabilitation 382

Hyperthermias 384

Agitation and confusion are common features in critical illness. Agitation is a symptom or sign of numerous acute and chronic disease states that include pain, anxiety and delirium. Agitation is present in around half of ICU patients, with 15% experiencing severe agitation. Confusion may also be chronic or acute and arise from an overlapping set of pathological processes that includes hypoxia, hypotension, hypoglycaemia and dementia. It is possible to be agitated and not confused, and vice versa. Recognition and treatment of the underlying condition is of utmost importance, rather than treating the symptoms alone....
Shock
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Shock: definition and diagnosis 446

Hypovolaemic shock 450

Cardiogenic shock 452

Anaphylactic shock 456

Septic shock: pathogenesis 458

Shock, or acute circulatory failure, defines a state in which the delivery of oxygen and nutrients to the tissue is insufficient to meet basal metabolic needs, leading to tissue hypoxia, and, if persistent, to MOF and death. Shock results from tissue hypoperfusion and microcirculatory dysfunction, and should thus not be restricted to hypotension. Although frequent, hypotension is not mandatory for the diagnosis of shock. In the absence of hypotension, increased lactate levels may indicate tissue hypoper-fusion and can be used to diagnose shock (at least at its initiation)....
Obstetric emergencies
Authors: Waldmann Carl , Soni Neil , Rhodes Andrew
Published: November 2017

Pre-eclampsia 518

Eclampsia 520

HELLP syndrome 522

Postpartum haemorrhage 524

Amniotic fluid embolism 526

Pre-eclampsia is a common complication of pregnancy, UK incidence is 3–5%, with a complex hereditary, immunological and environmental aetiology.

Abnormal placentation is characterized by impaired myometrial spiral artery relaxation, failure of trophoblastic invasion of these arterial walls and blockage of some vessels with fibrin, platelets and lipid-laden macrophages. There is a 30–40%, reduction in placental perfusion by the uterine arcuate arteries as seen by Doppler studies at 18–24 weeks gestation. Ultimately the shrunken, calcified, and microembolized placenta typical of the disease is seen. The placental lesion is responsible for fetal growth retardation and increased risks of premature labour, abruption and fetal demise. Maternal systemic features of this condition are characterized by widespread endothelial damage, affecting the peripheral, renal, hepatic, cerebral, and pulmonary vasculatures. These manifest clinically as hypertension, proteinuria and peripheral oedema, and in severe cases as eclamptic convulsions, cerebral haemorrhage (the most common cause of death due to pre-eclampsia in the UK), pulmonary oedema, hepatic infarcts and haemorrhage, coagulopathy and renal dysfunction....
CNS tumours
Authors: Ajithkumar Thankamma , Barrett Ann , Hatcher Helen , Cook Natalie
Published: November 2017

Tumours of the CNS are characterized by a remarkable diversity of pathological type and behaviour. Although rare, they affect people of all ages and hence have a disproportionate influence on the number of years of life lost to cancer. With few exceptions there is a marked consistency of incidence worldwide. Some types of brain tumour are increasing in incidence and, after many years of therapeutic stagnation, there have recently been some important improvements in treatment and outcome. For both of these reasons the subdiscipline of neuro-oncology is of increasing relevance in cancer medicine....
Breast cancer
Authors: Ajithkumar Thankamma , Barrett Ann , Hatcher Helen , Cook Natalie
Published: November 2017

It is estimated that more than one million women are diagnosed with breast cancer every year and more than 410,000 women die from breast cancer representing 14% of female cancer deaths.

Breast cancer is the most common female malignancy in the UK and USA. In the UK, 30,000 new cases and 15,000 deaths occur each year due to breast cancer. In the USA, there are 192,000 new cases and 43,300 breast cancer deaths every year. The lifetime risk of developing breast cancer for a woman is 1 in 12 in the UK and 1 in 8 in the USA....
Skin cancer
Authors: Ajithkumar Thankamma , Barrett Ann , Hatcher Helen , Cook Natalie
Published: November 2017

Basal cell carcinoma (BCC) is a slow growing, locally invasive (hence called rodent ulcer) malignant epidermal skin tumour. The exact incidence is difficult to obtain although there is a worldwide trend in increasing incidence. Approximately 1 million new cases are diagnosed per year in the USA....
Paediatric malignancies
Authors: Ajithkumar Thankamma , Barrett Ann , Hatcher Helen , Cook Natalie
Published: November 2017

Leukaemia is the commonest cancer (accounting for >40% of cases) in children. It is a clonal proliferation of stem cells which leads to bone marrow failure and tissue infiltration.

• Acute lymphoblastic leukaemia (ALL): 4/100,000

• Acute myeloid leukaemia (AML): 0.7/100,000

• Chronic myeloid leukaemia (CML): 0.2/100,000...
HIV related tumours
Authors: Ajithkumar Thankamma , Barrett Ann , Hatcher Helen , Cook Natalie
Published: November 2017

Kaposi's sarcoma (KS) is a low-grade multifocal vascular tumour associated with human herpesvirus 8 (HHV8)/Kaposi's sarcoma herpes virus (KSHV) infection.

KS lesions of all epidemiological forms are similarly comprised of HHV8-positive (LNA-1 immunoreactive) spindle-shaped tumour cells, vessels, and chronic inflammatory cells. Lesions evolve from early patch, to plaque, and later tumour nodules....
Diagnosis and Assessment of Schizophrenia and Related Psychoses
Authors: Rosenstock Jason B.
Published: November 2017

It can be difficult assessing patients who present with psychotic symptoms. In this chapter, we will present a framework for how to make (and share) a definitive diagnose that will inform future treatment. In our approach, assessment requires both detailed cross-sectional and longitudinal components. Presentations may be heterogeneous, although diagnosis is grounded in key DSM-5 criteria, based on history and clinical assessment. Providers must rule out other psychiatric and medical conditions that can cause psychosis, before settling on a primary psychotic disorder. Finally, we must be careful when making a diagnosis of a psychotic disorder: it takes time, and when the news is delivered to patients and families, providers must be encouraging and hopeful about possibilities for recovery.
Course, Prognosis, and Outcomes of Schizophrenia and Related Disorders
Authors: Prasad Konasale M.
Published: November 2017

Course and outcome in schizophrenia and related disorders historically depend on diagnostic conceptualizations, with significant variability even across individuals with the exact same diagnosis. In this chapter, we will review the heterogeneity of course and outcome, providing some context in terms of factors that affect prognosis. Generally speaking, current outcomes are better than previously thought, with three-quarters of individuals having a good prognosis. Although these illnesses cannot be cured, we know that recovery is possible. The best predictors of outcome in schizophrenia are cognitive and negative symptoms (not positive symptoms), along with premorbid functioning, duration of untreated psychosis, and treatment adherence over time. Finally, we will touch on functional outcomes such as risk of violence and suicide, as well as issues around treatment discontinuation.
National consensus project for quality palliative care
Authors: Dahlin Constance M.
Published: November 2017

The National Consensus Project for Quality Palliative Care’s Clinical Practice Guidelines for Quality Care is a significant resource that offers the nurse a framework for quality care in all settings. The Clinical Practice Guidelines are appropriate to a range of populations from neonates to children to adults and older adults; a range of chronic progressive and serious life-threatening illnesses, injuries, and trauma; and a range of vulnerable and underresourced populations. The Clinical Practice Guidelines are appropriate for any setting because they facilitate partnerships for caring for patients with debilitating and life-limiting illnesses and offer support for the nurse in delivering the care, particularly for long-term patients.
Hospital-based palliative care
Authors: Maani-Fogelman Patricia , Bakitas Marie A.
Published: November 2017

The structure, clinical processes, and measurement of outcomes of specialized palliative and hospice services, organized as hospital-based palliative care (HBPC) programs, have grown in sophistication in response to documented, poor end-of-life care; growth of the elderly and advanced, chronic illness populations; and documented successes of pilot and maturing clinical palliative care programs. Standards, guidelines, and other resources are now available to assist health systems to develop, sustain, or expand palliative care services for persons of all ages and stages of illness, along the entire care continuum. All hospitals and healthcare systems should develop palliative care services that are consistent with these standards and the mission, size, and scope of the health system.
Dysphagia, xerostomia, and hiccups
Authors: Dahlin Constance M. , Cohen Audrey Kurash
Published: November 2017

Dysphagia, xerostomia, and hiccups are common problems that have not garnered much interest in research. A multidisciplinary approach incorporating nurses, speech and language pathologists, nutritionist, dietitians, and social workers will promote successful treatment. Nurses at the bedside may be the first to identify the presence of these symptoms and understand the negative impact on quality of life. The mere act of listening to a patient’s distress offers affirmation of the existence of the symptoms and validation that the symptoms will be taken seriously. Working with a team can offer relief to patients and their families.
Pruritis, fever, and sweats
Authors: Larkin Philip J.
Published: November 2017

Pruritus, fever, and sweats are complex and debilitating symptoms. This chapter addresses each of these symptoms separately for clarity; however patients may experience them in combination. The chapter discusses appropriate nursing responses and the use of measures beyond the biomedical framework to alleviate the discomfort imposed by symptoms. A case history is used to focus the discussion around each symptom and its appropriate medical management. This is followed by a review of the nursing response and care of the patient.
Neurological disorders
Authors: Schwartz Margaret A.
Published: November 2017

The palliative care nurse is likely to encounter a patient with advanced neurological disorder or with a medical condition with neurological complications. It behooves the palliative care nurse to prepare for the variety of symptoms and diagnoses that he or she will clinically encounter. This chapter aims to lead the palliative care nurse to the appropriate, evidence-based interventions for the patient with neurological disturbances. It addresses broad symptom categories as well as common neurological diseases with heavy symptom burden deserving of special attention.