bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergency Vascular Access (DRAFT)
Authors: Padmanabhan Rajagopala , Murray Holt N.
Published: April 2018

Emergency resuscitation and stabilization of the critically ill patient is a cornerstone of patient care during a rapid response team (RRT) call. The establishment of vascular access, along with airway, breathing, and circulation management is pivotal for the delivery of fluid, blood products, and life-saving medications that can directly impact the morbidity and mortality of critically ill patients. Unfortunately, peripheral venous access may be difficult, if not impossible, to get in some patients. In these, and other select situations, excess time spent attempting to insert a peripheral line can delay essential therapies. In this chapter, the indications, types, and methods of establishing vascular access will be reviewed briefly.
Point-of-Care Testing (DRAFT)
Authors: Morgan Douglas E.
Published: April 2018

Point-of-care testing (POCT) is defined as medical diagnostic testing performed outside the clinical laboratory in close proximity to where the patient is receiving care. POCT is typically performed by non-laboratory personnel and the results are used for clinical decision making. When used appropriately, point-of-care testing (POCT) is a valuable resource during the rapid response system (RRS) activation. Advantages include shortened time between acquiring a sample from the patient and analysis of that sample and a subsequent decrease in time to clinical decision making. Disadvantages revolve largely around the cost of POCT. Driving forces behind the movement towards POCT include care process optimization, improvement of patient outcomes, changing regulatory requirements, and changes in the face of the workforce.
Hospital Policy (DRAFT)
Authors: Scholle Carol Curio
Published: April 2018

Establishing a successful rapid response system (RRS) requires policy and procedure that supports the system. The purpose of the policy is to outline organizational resources, process of care for patients, employees, and other non-hospitalized persons who experience a crisis or life-threatening circumstance while on the hospital campus. The policy should define the scope of the system, provide definition for terminology associated with the team, define the types of emergencies that will be addressed by the team, and any special circumstances to be considered. The associated procedure should provide detail on all aspects of the system including the criteria for calling the team, responsibilities of team personnel, and identification of any necessary specialty resources and equipment and how to access them. In this chapter, we will explore the elements of creating a policy, detailing a corresponding procedure, establishing and maintaining competence of the team, and monitoring quality of the RRS.
Patient Safety and Quality Improvement (DRAFT)
Authors: Painter Lisa M. , Janov Cheryl , Simmons Richard L.
Published: April 2018

Patients expect safe accountable care from their healthcare providers. Quality is doing the right thing, in the right way, at the right time, for the right reason, and to the right person. A number of governmental and non-governmental organizations have emerged to set standards for quality and safety. Rapid response systems (RRSs) are an important part of safety structure and this chapter aims to provide a basic understanding of the patient safety and quality movement, medical error and adverse events, and the role of the rapid response team (RRT) in identifying and reporting threats to patient safety. It offers a brief introduction of just culture, disclosure, and second victim.
The Neurology Video Primer
Authors: Kaplan Tamara B. , Milligan Tracy A.
Published: April 2018

The Neurology Video Primer breaks down and illustrates difficult and dense topics in short concise concept videos, providing an overview of the most common neurologic symptoms and diseases, including stroke, epilepsy, headache, neurologic emergencies, demyelinating diseases, neurodegenerative disease, exploring pertinent clinical findings, epidemiology, disease mechanisms, pathophysiology, differential diagnoses, key steps in making the diagnosis and important concepts in treatment.
Introduction (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

This chapter presents an introduction to the Neurology Video Primer. It outlines the aims of the title, and presents an overview of the topics covered, as well as the video formats of the chapters.
Cerebrovascular Disease 1: Vascular Territories (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores cerebrovascular disease, and focuses on vascular territories. It discusses the middle cerebral artery (MCA), posterior cerebral artery (PCA), and anterior cerebral artery (ACA), along with the portions of the brain they supply, as well as the different presentations of stroke in the three territories - contralateral weakness, sensory loss, and aphasia in MCA stroke, contralateral homonymous hemianopia in PCA stroke, and contralateral leg weakness and sensory changes in ACA stroke.
Cerebrovascular Disease 2: Stroke (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores cerebrovascular disease, and focuses on stroke. It discusses the definition of stroke as a sudden focal neurologic deficit that persists for more than 24 hours, as well as ischemic strokes (embolic, thrombotic, or due to hypoperfusion), and intraparenchymal hemorrhagic strokes.
Cerebrovascular Disease 3: Brainstem Syndromes (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores cerebrovascular disease, and focuses on brainstem syndromes. It includes the hallmark ‘crossed signs’ feature of brainstem syndromes (ipsilateral cranial nerve deficits, contralateral long track signs), the characteristics of lateral medullary syndrome due to a PICA stroke, and palsies that may result from a ventral pontine stroke, and medical midbrain stroke.
Movement Disorders 1: Tourette’s Syndrome, Essential Tremor, and Parkinson’s Disease (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores movement disorders, and focuses on Tourette’s Syndrome, Essential tremor, and Parkinson’s Disease. It outlines the characteristics of each, such as motor and vocal tics in Tourette’s Syndrome, postural or kinetic tremor in Essential tremor, and the four hallmark features of Parkinson’s Disease (bradykinesia, resting tremor, cogwheel rigidity, and postural instability).
Traumatic Brain Injury (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores traumatic brain injury (TBI), including common causes and injuries (coup, and contre-coup injuries, diffuse axonal injury, hemorrhages), as well as the use of the Glasgow Coma Scale to evaluate TBI.
The Optimal Delivery of Palliative Care (DRAFT)
Authors: Yoong Jaclyn , Poon Peter
Published: April 2018

This study aimed to compare the effect of palliative care consultation teams with that of dedicated palliative care units on the quality of end-of-life care. This was a telephone-base survey conducted in 77 Veterans Affairs medical centers that had provided both models of care. Deceased patients from July 2008 to December 2009 were identified. A family member of the decedent was invited to participate in the survey which consisted of one global rating item and nine core items pertaining to patient’s end-of-life care. Families of patients who received care in a palliative care unit were more likely to report “excellent” care compared to families of those who received at least one palliative care consultation; families of those who received at least one palliative care consultation in turn where more likely to report “excellent” care compared to families of those who received usual care.
The Edmonton Symptom Assessment System (DRAFT)
Authors: Hannon Breffni
Published: April 2018

The Edmonton Symptom Assessment System (ESAS) consists of eight common symptoms presented as visual analog scales ranging from 0 to 100mm. Patients score the ESAS independently where possible; the scores are summed to form an overall distress score and graphed to create a longitudinal visual representation of symptom burden. This study describes the use of the ESAS for patients with advanced cancer (n = 101) admitted to a palliative care unit in Edmonton, Canada. The ESAS was completed twice daily. In 84% of cases, patients completed the ESAS independently initially; 83% ultimately required nurse or family member completion as the patient’s clinical status deteriorated. Distress scores improved over time following admission (mean at Day 1 410+/–95, falling to 362+/–83 by Day 5). There were significant differences between patient, nurse, and family member distress scores. This paper demonstrates for the first time the routine clinical utility of the ESAS.
Haloperidol, Chlorpromazine, and Lorazepam for Delirium (DRAFT)
Authors: Tenorio Anna Cecilia , de la Cruz Maxine
Published: April 2018

This chapter provides an overview of the first randomized double-blind trial looking at the efficacy and safety of neuroleptics and benzodiazepines in the treatment of delirium in hospitalized AIDS patients. Thirty patients of patient who developed delirium were randomized into three treatment arms: haloperidol, chlopromazine, and lorazepam. This chapter includes commentary on study design as well the implications of the results in current practice in the treatment of delirium. Improvement in delirium symptoms and cognition were noted in a patient who received haloperidol and chlopromazine. Lorazepam had no effect on the delirium symptoms and cognition at any point in the study, and six patients who received the medication developed treatment-limiting side effects such as oversedation, disinhibition, ataxia, and worsening confusion resulting in drug discontinuation. A short case is including to illustrate how this study has impacted the authors’ clinical practice in palliative care.
Opioid Rotation for Toxicity Reduction (DRAFT)
Authors: Tenorio Anna Cecilia , Reddy Akhila
Published: April 2018

This chapter discusses the de Stoutz et al. retrospective review of patients with cancer pain who developed dose-limiting toxicities and underwent opioid rotation that resulted in improvement of symptoms related to opioid induced neurotoxicity, uncontrolled pain, and reduction in morphine equivalent daily dose. This study is the first to establish that opioid rotation, which is substituting one opioid with another using established equianalgesic conversion ratios, is a valuable tool in cancer pain management. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Duloxetine for Chemotherapy-Induced Peripheral Neuropathy (DRAFT)
Authors: Burke Rebecca , Reddy Akhila
Published: April 2018

This chapter discusses the Smith et al. randomized, double-blind, placebo-controlled crossover trial determining the effectiveness of duloxetine compared to placebo in reducing painful chemotherapy-induced peripheral neuropathy. Patients were divided into the duloxetine-first or placebo-first group, then subsequently crossed over to the alternate group. The study particularly examined changes in pain severity, quality of life, interference with daily function, and adverse events. The study demonstrated that patients receiving duloxetine first reported a statistically significant decrease in pain, improvement in quality of life, and decreased pain interference with daily functioning. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Enteral Tube Feeding Dysphagic Stroke Patients (DRAFT)
Authors: Loaiciga Francisco , Dev Rony
Published: April 2018

This chapter discusses the results of randomized controlled trials evaluating the benefits of early feeding for patients who suffered an acute stroke. The study was divided in two different groups: the first one compared early feeding versus avoiding nutrition, and the second compared percutaneous endoscopic gastrostomy versus nasogastric tube feeding in dysphagic stroke patients. The authors conclude that early tube feeding might reduce case fatality, but at the expense of increasing the proportion of patients surviving with poor outcome. This chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Feeding Tube and Survival Among Patients with Severe Cognitive Impairment (DRAFT)
Authors: Adile Claudio
Published: April 2018

This chapter provides an overview and commentary on the study published by Teno and colleagues in 2012 that analyzed if feeding tube insertion and its timing affect survival in patients with advanced dementia. The study concluded that insertion of feeding tubes, irrespective of the timing of insertion, does not confer a survival benefit. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Treatment of Opioid-Induced Constipation in Advanced Illness (DRAFT)
Authors: Zhukovsky Donna S.
Published: April 2018

Opioid-induced constipation is a major problem for patients with advanced medical illness despite aggressive use of bowel regimens. Methylnaltrexone is an opioid antagonist with limited ability to cross the blood–brain barrier and thus is thought to induce opioid withdrawal at the level of the gastrointestinal tract without causing central withdrawal and flare of pain. This chapter describes and evaluates a randomized controlled trial of methylnaltrexone versus placebo and an open label extension study for patients with advanced illness and opioid-induced constipation. Primary outcomes are efficacy and safety. The chapter concludes with a discussion of the possible role of methylnaltrexone in the therapeutic armamentarium of opioid induced constipation.
Doctors’ Prognostic Accuracy in Terminally Ill Patients (DRAFT)
Authors: Desai Anjali , Epstein Andrew S.
Published: April 2018

“Doctors’ Prognostic Accuracy in Terminally Ill Patients” reviews one of Christakis and Lamont’s landmark articles, which investigated the factors associated with prognostic accuracy (and prognostic error) in doctors’ prognoses for terminally ill patients. The article explored the extent and determinants of optimistic errors, pessimistic errors, and correct predictions among doctors who were estimating prognoses for their terminally ill patients. This chapter offers a concise breakdown of the study’s design and salient study results while also pointing out study limitations. The chapter summarizes other relevant studies exploring prognostic estimates and prognostic disclosure by physicians to terminally ill cancer patients. Finally, the chapter provides a clinical case to illustrate some of the study’s practical implications for patient care.
Expectations about Effects of Chemotherapy in Patients with Advanced Cancer (DRAFT)
Authors: Agarwal Rajiv , Epstein Andrew S.
Published: April 2018

This chapter reviews the Weeks et al. secondary analysis of data from the Cancer Care Outcomes Research and Surveillance (CanCORS) prospective cohort, evaluating the expectations of patients who receive chemotherapy for incurable metastatic lung or colorectal cancer. Patients’ understanding of the effectiveness of chemotherapy for providing cure, life extension, and symptom relief were measured. The researchers also investigated the clinical, sociodemographic, and health system factors that were associated with inaccurate expectations on the curative potential of chemotherapy. The study demonstrated that most patients with metastatic lung or colorectal cancer believed that chemotherapy was likely to cure their disease. Colorectal cancer, non-white race, nonintegrated health care networks, and high physician communication scores were independently associated with inaccurate expectations. These findings highlight that understanding the goals of chemotherapy is both important and necessary for patients with incurable cancers to make informed treatment decisions.
End-of-Life Discussions and Aggressiveness of Care Received Near Death (DRAFT)
Authors: Schenker Yael , Yu Justin
Published: April 2018

This chapter summarizes Mack and colleagues’ 2012 Associations Between End-of-Life (EOL) Discussion Characteristics and Care Received Near Death, which investigates the relationship between EOL discussion characteristics and the aggressiveness of EOL medical care received by patients with advanced cancer (stage IV lung or colorectal cancer). It reviews the frequency of which EOL discussions occur in this population and explores EOL discussion characteristics including timing, location, and involved providers. It then examines how these characteristics are associated with various markers of aggressive EOL care such as chemotherapy in last 14 days of life (DOL), acute or intensive care unit care in last 30 DOL, and initiation of hospice in last seven DOL.
Quality End-of-Life CarePatients’ Perspectives (DRAFT)
Authors: Soodalter Jesse A. , Schenker Yael
Published: April 2018

This chapter summarizes Singer and colleagues’ 1999 “Quality End-of-Life Care: Patients’ Perspectives,” which investigates elements of quality end-of-life (EOL) care from patients’ perspectives. The study uses content analysis of previously conducted interviews with 126 dialysis and HIV patients and long-term care residents to identify five domains of quality EOL care: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones. The authors compare these with three other, non-patient-derived taxonomies, finding the study’s domains to be simpler and more specific, less conceptually driven (e.g., “processes of care”), and more outcome-focused. This study pioneered patient-centered research into quality of EOL care, which has since expanded to many other populations
Factors Associated with Outcomes of Cardiopulmonary Resuscitation (DRAFT)
Authors: Mehta Dutt , Prommer Eric
Published: April 2018

Failed in-hospital resuscitations consume substantial health care resources. Accurate prediction of who will survive an in-hospital arrest is difficult. Identifying pre arrest factors associated with poor resuscitation outcomes facilitates and enhances cardiopulmonary resuscitation (CPR) discussions. Using a large CPR database, several preexisting factors associated with poor CPR outcome were identified and analyzed using statistical methods. The statistical model identifies factors associated with poor outcomes such as black race, advancing age, and multiple pre-existing conditions using the National Registry for Cardiopulmonary Resuscitation. The chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
The Modern Healthcare Environment (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Management has become more demanding and difficult considering the fierce competition, increased complexity, and diversity of services. Hospitals and clinics face increased demand for their services along with pressure to contain costs. This chapter suggests that the solution is the implementation of novel managerial approaches to identify and improve relevant value drivers. These innovative approaches include the theory of constraints (TOC), Lean, and Six Sigma. These managerial approaches are based on common sense, have evolved from field practice, and negate the input–output myth (“To do more, you more resources”). Instead, these approaches emphasize “doing more with what you have.”
Constraint Management under a Market Constraint (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Having a market constraint means that the system has excess capacity. For such cases, this chapter shows how the seven steps of the theory of constraints (TOC) can help in increasing demand for healthcare organizations’ services. The chapter adds two other important issues: peak management and the three strategic questions for constraint management. Peak management provides tools for managing systems that are characterized by peaks and dips in demand. The three strategic questions determine whether we should design the healthcare organization with excess capacity or with a bottleneck. In the latter case, the chapter analyzes where the constraint should be located in the long run.
Resolving Managerial Conflicts (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Managerial conflicts are contradicting alternatives with a common objective. However, many managerial conflicts can be resolved via win–win solutions. This chapter presents a graphical tool, the conflict resolution diagram, which displays the conflict and then generates effective ideas for conflict resolution. Using the conflict resolution diagram, the conflict can be resolved by differentiation, globalization, and by breaking some basic assumptions. In some cases, the conflict resolution diagram can identify an alternative that is irrelevant; thus, there is no conflict. A short recipe for constructing a conflict resolution diagram and generation of resolution ideas is provided. The chapter also provides examples of managerial conflicts and the caregiver conflict.
The “Evils” of Long Response Times (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

The “evils” of long response times, similar to the “evils” of excess work in process, are responsible for diminished quality and customer satisfaction. There is also an effect of diminishing throughput, control, and cash flow. Long response times (or high level of work in process) add to increase in operating expenses. Shortening response times and reducing the level of work in process are attainable and serve as leverage for significant improvement in organizational performance. Excess work in process can be caused by the efficiencies syndrome, viewing inventory as assets, and ignorance. The methods for reducing the level of work in process and shortening response times are detailed in the chapter 11.
Reducing Response Times (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

This chapter introduces practical tools for reducing response times significantly. Using the approaches and techniques presented in the chapter can reduce response time several folds. This is a strategic and tactical goal for every organization to reduce response times. The significant contribution of Lean/just in time to management is manifested in focusing on short response and introducing the perception that work in process is a burden, not an asset. This chapter presents tools and techniques such as the small batch concept, group technology, tactical gating, the “traffic lights” system, Superzoufing, working with a complete kit, and the shortest processing time.
The Complete Kit Concept (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

The complete kit (CK) concept is a well-established concept that offers considerable improvement potential for healthcare systems. It enables faster response times, lower costs, and improved quality. Working with incomplete kits leads to more work in process, longer response times, poor quality and customer dissatisfaction. The CK concept can be applied in all departments of healthcare systems including, among others, operating rooms, emergency departments, and outpatient clinics. To implement the CK concept, the healthcare system must train and educate executives, managers, physicians, nurses, and paramedical staff. Even though the concept is intuitively appreciated and accepted by people, there is a need to reinforce some formal frameworks as an infrastructure for implementing the CK concept.
Performance Measures (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Performance measures are a control tool used to navigate and guide managers in the organization. In many situations, an appropriate change of performance measures can bring upon fast and significant improvements in the organization’s performance, thus enhancing its value. This chapter presents the global performance measures that can help managers to focus on activities that need to be improved, which include throughput, operating expenses, inventory, response time, quality, and due-date performance. The global performance measures can be used to measure the whole organization as well as its departments. In organizations where local performance measures such as efficiencies exist, it is essential to implement a set of global performance measures.
The “Evils” of Traditional Cost Accounting (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Traditional cost accounting lost its relevance, and those who use it for decision-making may cause damages to their organizations. Traditional cost accounting is no longer valid because of the changes in healthcare cost structures and changes in the competitive environment. The chapter shows that the assumptions of traditional cost accounting that were valid at the beginning of the 20th century are no longer valid for analyzing costs of healthcare service organizations. Reliance on the cost of the product or the cost of the service may lead to the loss of business opportunities on the one hand and interference in the decision-making processes on the other hand. Chapter 16 will present alternatives for traditional cost accounting that are appropriate for healthcare organization in the modern business environment.
Global Decision-Making (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

The global decision-making methodology is a simple and effective tool for decision-making. It bypasses the need to determine the cost of service or cost of product as well as the product’s or service’s profit. Global decision-making methodology works well for pricing decisions, make-or-buy decisions, termination of services, bid pricing, determining service mix, and investment decisions. The methodology consists of three stages and provides practical tools for decision-making such as the measurement profile and the cost-utilization diagram. The methodology takes into consideration economic benefits as well as strategic benefits and intangible ones. It is simple to use, intuitive, and clear to communicate.
Quality Management and Process Control (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

In healthcare systems, more than in any other system, there is an urgent need for quality management and process control. Quality improvement and process control are a means that every healthcare organization must employ to achieve quality healthcare for the patients. It is also a necessary condition to survive in the competitive healthcare environment. The chapter shows that quality improvement and process control are a must for any healthcare organization. The chapter classifies the three stages of quality management and shows how tools such as constraint management, Lean/just in time, the complete kit concept, and the Pareto methodology can all enhance organizational value without substantial (if at all) financial investments. In the chapter, we break some quality improvement myths concerning quality management in healthcare organizations.
Success Stories (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

This chapter describes some success stories that show how the tools, methods, and philosophies were used in a variety of healthcare systems. The cases presented here include successful implementations in the United States, United Kingdom, and Israel. Each story highlights the objectives and the results of the organization. Objectives include reducing emergency room wait times, reducing delayed admissions, improving emergency department and operating room throughput, improving quality and customer satisfaction. Although the cases use a variety of methods, approaches include eliminating dummy constraints, using specific contribution for prioritization, and working with complete kits, focusing on the theory of constraints, and reducing work in progress.
UGI surgery (DRAFT)
Authors: Owers Corinne , Ackroyd Roger
Published: April 2018

The upper gastrointestinal (UGI) tract comprises of the oesophagus, stomach, and duodenum. Although some emergency management of UGI pathology may fall to the remit of the gastroenterologists, this chapter focuses specifically on surgical management of both benign and malignant pathology of these organs. UGI pathology contributes a significant amount to the on-call emergency workload for the general surgeon, as well as the UGI specialist. Subjects covered include the diagnosis and management of common pathologies in the upper gastrointestinal tract that are clinically relevant to those working in general surgery, including: gastro-oesophageal reflux (GORD) and ulcer disease, UGI bleeding, oesophagogastric cancer and bariatric surgery.
Colorectal surgery (DRAFT)
Authors: Webster Peter , Ritchie Judith , Garimella Veerabhadram
Published: April 2018

This chapter seeks to illustrate the interesting and diverse nature of adult colorectal surgery with a number of presentations of both benign and malignant conditions of the colon, rectum, and anus. The cases represent a wide variety of colorectal conditions that most junior surgical trainees will encounter from this specialty electively at outpatient clinic, including constipation, colorectal cancer, fissure-in-ano and fistulas, haemorrhoids, faecal incontinence, and pilonidal disease. Cases also feature emergency presentations commonly encountered on the acute surgical take such as acute diverticulitis, anorectal and pilonidal abscesses, large bowel obstruction, and rectal bleeding. Each case uses a question-based approach to cover relevant information about each complaint, including approaches to investigation and management.

haemorrhoids, anal fissure, constipation, cancer, fistula, anorectal sepsis, rectal bleeding, prolapse, ischaemic bowel
History of the concept of adjustment disorders (DRAFT)
Authors: Casey Patricia
Published: April 2018

Adjustment disorder (AD) was introduced by ICD-9 in 1978 and by DSM-III in 1980. Until recently it was neglected in research and in clinical practice. It has withstood the early controversies suggesting that it was a manufactured condition to facilitate the reimbursement of clinicians for treating mild conditions which otherwise would not be covered by insurance. Others argue that it medicalized problems of living. More recent controversies concern its status as a subthreshold disorder, disbarring it from being diagnosed when the threshold for other disorders is reached. Its status has been enhanced by its new positioning in DSM-5 in the Trauma and Stressor-Related Disorders category, similar to ICD-10. However, ICD-11 is proposing making AD a full-threshold disorder with specific criteria for diagnosis, unlike DSM-5. This radical proposal will put ICD-11 and DSM-5 at variance with each other and will require a reappraisal of the research, to date, on AD.
How common is adjustment disorder? (DRAFT)
Authors: Casey Patricia
Published: April 2018

Most of the large-scale epidemiological studies have neglected AD, although there are some recent smaller studies that have included it. The diagnostic tools in common use, such as SCAN or SCID, either omit AD or only allow the diagnosis to be made when all other disorders have been considered. Studies using these have found a prevalence of less than 2% in the general population or among those attending primary care. Two instruments specific for AD have been published in recent years. The ADNM is a screening instrument based on the proposed ICD-11 criteria, while the DIAD is a diagnostic tool. With these instruments, the prevalence has been shown to be much higher than earlier studies indicated, and in some settings such as liaison psychiatry its frequency eclipsed that of major depression. It is likely that the enhanced status of AD will result in more epidemiological studies that incorporate AD as well as other common disorders.
The diagnostic quagmire: Philosophical issues (DRAFT)
Authors: Casey Patricia
Published: April 2018

As currently defined, adjustment disorder (AD) lies in the hinterland between non-pathological behaviour/distress on one side and full-blown common mental disorders (CMDs) on the other. However, considerable symptom overlap exists, such that AD is frequently misdiagnosed as one of the other CMDs, and vice versa. Given the universality of life events which are stressful, clearly delineating AD from normal adaptive responses is particularly prescient if all human experience is not to be medicalized. DSM-III attempted to deal with this by requiring that the symptoms be ‘clinically significant’, yet this construct is a subjective one. It is not used in ICD-10 but it requires both symptoms and dysfunction, unlike DSM. The heterogeneity of symptoms that constitute a specific diagnosis where no one symptom is essential and all are given equal weight (the polythetic approach) can add to diagnostic uncertainty. The National Institute of Mental Health has made a suggestion for approaching this diagnostic maelstrom.
Making the diagnosis in clinical practice (DRAFT)
Authors: Casey Patricia
Published: April 2018

Neither ICD-10 nor DSM-5 has clinical criteria for making the diagnosis of AD. The only requirement is a stressor, either psychosocial or traumatic. The onset of symptoms within 1 month (ICD) and 3 months (DSM) is not evidence based. The symptoms may be depressive, anxious, behavioural, or a mixture of these. A useful clinical indicator that the event was the trigger is that the intensity of the symptoms increases when it is being recalled or recounted and diminishes when the person is removed from it. A number of differentials should also be considered. ICD-11 proposes specific criteria for ICD-11 that include preoccupation with the stressor and difficulty adapting, as evidenced by impaired concentration, sleep disturbance, and so on, causing impairment in functioning. It is unclear whether those diagnosed with AD using the new criteria will be the same clinically as those currently so diagnosed.
Adjustment disorders in legal settings (DRAFT)
Authors: Rix Keith
Published: April 2018

Sitting uncomfortably at the end or, as some might assert, off the end of the spectrum of mental disorder and in that grey area between normality and abnormality, adjustment disorders are already a challenge when they arise in legal settings. The challenge will be all the greater when reliance is placed on ICD-11 and DSM-5. This chapter analyzes cases from the civil and criminal jurisdictions to show the often pragmatic approaches taken by the courts in cases of adjustment disorder. These cases are used to suggest an approach as to how medical experts should report in cases where the diagnosis of adjustment disorder is an issue.
Ethics and Palliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

While ethics and palliative care have always been core components of the practice of medicine, each was only recently recognized as a distinct field. Both emerged from the twentieth-century shift of emphasis from paternalism (more inclusively termed parentalism) to patient autonomy, as well as the technological explosion that prompted many novel questions. With evolving recognition that patient wishes were not always honored—and patient suffering insufficiently addressed—the two fields attempted to empower patients and ameliorate suffering. Given the overlap between the two fields, there may be areas of conflict which—when viewed in a more positive light—may actually be opportunities for collaboration.
Advance Care Planning and Surrogate Decision-Making (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Adult patients are presumed to possess decision-making capacity, but when they are unable to make their own decisions—which is especially frequent in the context of serious illness—ideally a surrogate decision-maker will be able to determine what the patient would have wanted (i.e., substituted judgment). Only when this is not possible is it necessary to fall back on what seems to be in the patient’s best interests. To foster patient autonomy, goals and values should be identified and documented in advance, such as in an advance directive, as well as a surrogate decision-maker named. This helps guide the medical team in critical and often uncertain times, given the challenges in accurate prognostication (which are lessening with the advent of evidence-based tools).
Specific Ethical Issues at the End of Life (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

A specific application of advance care planning has to do with determining the “code status” of a patient. Many of the terms used to document this status are misunderstood or carry unfortunate connotations, such as “DNR.” It is more appropriate to refer to a “Do Not Attempt Resuscitation” (DNAR), to emphasize the uncertainty as to whether attempted resuscitation will be successful. Code status is especially relevant to patients who “want everything,” which may include high-burden and low-benefit procedures. Time-limited trials and Do Not Escalate Treatment orders may be considered in those situations. There may also be situations when a patient’s refusal should be overridden, when the patient’s decision-making capacity is compromised.
Pain and Symptom Management at the End of Life (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

The pendulum of pain treatment has swung from stoic acceptance before the widespread availability of opioids, to embrace of opioids as pain became the “fifth vital sign,” to significant concern in light of the current opioid epidemic. The use of opioids for chronic pain should be differentiated from their use in palliative care, where there still exists significant concern for hastened death when high doses are used (i.e., opiophobia). While clinicians should be familiar with the Rule of Double Effect to justify such use, the rule is not truly needed because of the rarity of respiratory depression when opioids are used appropriately. Appropriate pain treatment is a human right, and as such surrogates should not be able to refuse it based on their own views, and global inequities prompt significant justice concerns.
Palliative Sedation (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Palliative sedation refers to lowering a patient’s level of consciousness so that she no longer suffers from intolerable and refractory symptoms. Some forms of palliative sedation are ethically uncontroversial, such as emergency or respite sedation. Continuous sedation to unconsciousness (CSU) is controversial in that a patient in such a state is unable to eat or drink and may not be able to protect her airway. Ethically relevant considerations include the inability to participate in subsequent decision-making, the uncertain quality of an unconscious life, and the impact on life expectancy (which is often misunderstood). Special cases of CSU for existential distress and in children demand in-depth analysis.
Overview of Pediatric Ethics and Palliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Significant differences exist between adult and pediatric palliative care, including distinct diagnoses, divergent trajectories of illness, unique aspects of treatment, unique social contexts, and the simple fact that “children aren’t supposed to die.” Similarly, pediatric ethics is distinct from adult ethics by virtue of the shifted locus of decision-making, the lack of choice of one’s surrogate, the prevalence of the best interest standard, and the triadic clinical relationship. A more helpful paradigm by which to evaluate the appropriateness of parental decision-making is the harm principle, which recognizes the greater latitude granted to parents (compared to other surrogates) in deciding for the patient.
Ethics of Prenatal Palliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Palliative care can begin before birth, as parents wrestle with a prenatal diagnosis of a serious condition. The options are not limited to terminating the pregnancy or providing maximal treatment upon delivery. Prenatal interventions and focusing on comfort following delivery are also options. This also impacts the method of delivery, for if a pregnant woman’s values demand respect, so also should a request for caesarean section for fetal distress, even in the context of a serious fetal condition. The language one uses also impacts management and outlook, with terms such as “incompatible with life” both inaccurate and misleading. This chapter discusses these issues in the context of palliative care.
Ethics of Neonatal Palliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Neonatal palliative care is unique by virtue of some of the treatment methods only utilized in this age group and also the increasingly recognized uncertainty of prognosis. Often neonates will achieve the ability to breathe independently before their prognosis becomes clear, creating a “window of opportunity” where forgoing certain forms of medical treatment is temporarily an option. After that point the only treatment the patient may be dependent on is medically administered nutrition and hydration, which takes on additional ethical complexity because of the developmental stage of the neonate. There may be situations where parental requests for treatment are not honored—or their refusals not respected—based on the balance of benefits and burdens.
Requests for Nonbeneficial Treatment (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

The 1990s were termed the “futility decade” because of greater interest in cases where the patient demands treatment that the physician is reluctant to provide. In many ways this was the converse of the “right to die” movement of the 1970s and 1980s, except it did not lead to resolution because of definitional and practical barriers. The concept of nonbeneficial treatment—a more acceptable term—has recently received additional attention in the context of soaring health care costs. Some states have proposed clear and definitive mechanisms for adjudicating such disputes (such as the Texas Advance Directives Act). Each institution should have its own policy that can be modeled after a recent consensus statement on the topic.
Clinical Practice of Palliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Communication, cultural sensitivity, and respect for spirituality undergird the practice of palliative care. Clinicians must appreciate the nuance of communicating complex diagnoses and often grim prognoses and know how to respond when patients express a desire to not be fully informed (or their family demands that they not be). Across cultures there is significant variation in how prognosis is communicated, who makes decisions for a patient, and attitudes toward end-of-life care. Many patients and families also rely on their religious or spiritual beliefs in making medical decisions, and expectation of a “miracle” and perceived religious “mandates” for continued treatment demand spiritually-nuanced responses.
Body Structure, Function, Activity, and Participation in 3- to 6-Year-Old Children Born Very Preterm: An ICF-Based Systematic Review and Meta-Analysis
Authors: FitzGerald Tara L , Kwong Amanda K L , Cheong Jeanie L Y , McGinley Jennifer L , Doyle Lex W , Spittle Alicia J
Published: April 2018

Background

The World Health Organization's International Classification of Functioning, Disability, and Health framework, Children and Youth Version (ICF-CY), provides a valuable method of conceptualizing the multidomain difficulties experienced by children born very preterm (VP). Reviews investigating motor outcomes at preschool age across ICF-CY domains are lacking.

Purpose

The purpose of this review is to identify and compare motor outcomes of 3- to 6-year-old children born VP and children born full-term (FT) within the ICF-CY framework.

Data Sources

Four electronic databases and reference lists of included and key articles were searched.

Study Selection

Studies comparing motor outcomes of 3- to 6-year-old children born VP (<32 weeks’ gestation or birth weight <1500 g) with peers born FT were included.

Data Extraction

Two independent authors extracted data and completed quality assessments.

Data Synthesis

Thirty-six studies were included. Activity motor performance of children born VP was consistently poorer compared with peers born FT: standardized mean difference (SMD) was –0.71 (95% CI = –0.80 to –0.61; 14 studies, 2056 participants). Furthermore, children born VP had higher relative risk (RR) of motor impairment (RR = 3.39; 95% CI = 2.68 to 4.27; 9 studies, 3466 participants). Body structure and function outcomes were largely unable to be pooled because assessment tools varied too widely. However, children born VP had higher RR of any neurological dysfunction (Touwen Neurological Examination) (RR = 4.55; 95% CI = 1.20 to 17.17; 3 studies, 1363 participants). There were no participation outcome data.

Limitations

Limitations include the lack of consistent assessment tools used in VP follow-up at preschool age and the quality of the evidence.

Conclusions

Children born VP experience significant motor impairment across ICF-CY activity and body structure and function domains at preschool age compared with peers born FT. Evidence investigating participation in VP preschool-age populations relative to children born at term is sparse, requiring further research.