bluuebunny/crossref_metadata_2025 huggingface dataset:
Competition, the State, and Public Undertakings: Article 106 TFEU
Authors: Jones Alison , Sufrin Brenda
Published: July 2014

All books in this flagship series contain carefully selected substantial extracts from key cases, legislation, and academic debate, providing able students with a stand-alone resource. This chapter examines how competition law applies to the actions of the State when it intervenes in the market through undertakings that it controls or owns or which it places in a privileged position. The discussions include the limits of competition law; Article 4 TEU; Article 106; the direct effect of Article 106(1) and (2); Article 106(3); and services of general economic interest and state aid.
Public Enforcement by the Commission and the National Competition Authorities of the Antitrust Provisions
Authors: Jones Alison , Sufrin Brenda
Published: July 2014

All books in this flagship series contain carefully selected substantial extracts from key cases, legislation, and academic debate, providing able students with a stand-alone resource. This chapter discusses the following: the change in the enforcement regime for EU antitrust rules on 1 May 2004; the system under Regulation 17 that applied before then; the reasons for, and salient features of, the ‘modernisation’ in Regulation 1/2003; the powers of the Commission; the role of EU Courts; enforcement by national competition authorities and the relationship between EU and national law; the possibility of sanctions against individuals; and the position of those who make complaints about alleged infringements of the competition rules.
Private Enforcement
Authors: Jones Alison , Sufrin Brenda
Published: July 2014

All books in this flagship series contain carefully selected substantial extracts from key cases, legislation, and academic debate, providing able students with a stand-alone resource. This chapter focuses on the private civil enforcement of EU antitrust rules through claims made by private litigants in the national courts and tribunals of the individual Member States. The discussions cover the principle of direct effect and national procedural autonomy; why there has been relatively little antitrust litigation in the EU; the relationship between public and private enforcement; the Commission's policy towards private enforcement, the initiatives it has taken to encourage private litigation, and mechanisms for cooperation between the Commission and national courts; and the obligations of national courts when dealing with cases that raise the issue of whether a contract in violation of Article 101 or Article 102 is enforceable and whether, and if so when, damages and injunctions should be available to remedy such violations.
Probability of stochastic depletion: an easily interpreted diagnostic
for stock assessment modelling and fisheries management
Authors: Thorson James T. , Jensen Olaf P. , Hilborn Ray
Published: July 2014

Marine fish populations have high variation in cohort strength, and the production of juveniles (recruitment) may have persistent positive or negative residuals (autocorrelation) after accounting for spawning biomass. Autocorrelated recruitment will occur whenever average recruitment levels change between oceanographic regimes or due to predator release, but may also indicate persistent environmental and biological effects on shorter time-scales. Here, we use estimates of recruitment variability and autocorrelation to simulate the stationary distribution of spawning biomass for 100 real-world stocks when unfished, fished at FMSY, or fished following a harvest control rule where fishing mortality decreases as a function of spawning biomass. Results show that unfished stocks have spawning biomass (SB) below its deterministic equilibrium value (SB0) 58% of the time, and below 0.5SB0 5% of the time on average across all stocks. Similarly, stocks fished at the level producing deterministic maximum sustainable yield (FMSY) are below its deterministic prediction of spawning biomass (SBMSY) 60% of the time and below 0.5SBMSY 8% of the time. These probabilities are greater for stocks with high recruitment variability, positive autocorrelation, and high natural mortality—traits that are particularly associated with clupeids and scombrids. An elevated probability of stochastic depletion, i.e. biomass below the deterministic equilibrium expectation, implies that management actions required when biomass drops below a threshold may be triggered more frequently than expected. Therefore, we conclude by suggesting that fisheries scientists routinely calculate these probabilities during stock assessments as a decision support tool for fisheries managers.
Tropical Infections
Authors: Maguire James H.
Published: July 2014

Diseases endemic to the tropics and subtropics remain major causes of morbidity and mortality in resource-poor areas of the world and are a challenge for practitioners in industrialized countries who care for returning travelers and immigrants. As a rule, the infectious diseases of travelers are different from or present differently than those of persons who have lived for long periods of time in endemic areas. For example, hepatitis A is rare among immigrants arriving from the tropics, who typically acquired infection and lasting immunity early in life, whereas travelers from industrialized countries lack immunity unless vaccinated and are at high risk of becoming infected during travel. In this review several of the most common clinical syndromes and the tropical infectious diseases that cause them are discussed.
Non-Hodgkin and Hodgkin Lymphoma
Authors: Odejide Oreofe O. , LaCasce Ann S.
Published: July 2014

Lymphomas are malignancies of lymphoid cells. These neoplasms originate from cells in the B lymphocyte and T lymphocyte/natural killer (NK) cell lineages. Broadly they are categorized into non-Hodgkin (NHL) and Hodgkin lymphomas (HL). The World Health Organization (WHO) recognizes over 40 major types of NHL and five major types of HL.
Oncologic Emergencies
Authors: DeAngelo Daniel J. , Alyea Edwin P.
Published: July 2014

Medical emergencies related to cancer are often related to: (1) the anatomic localization of the tumor resulting in obstruction or mass effect, (2) metabolic or hormonal derangements, or (3) complications of cancer therapy. Common presentations of severe oncologic complications and their treatment are discussed in this chapter.
Anemia and Hemoglobinopathies
Authors: Okam Maureen M.
Published: July 2014

Anemia is defined as a hemoglobin (or hematocrit) below the lower limit of the normal range for age and sex of an individual. About 40 years ago, a World Health Organization expert committee suggested 12 g/dL as the lower limit of normal for nonpregnant women and 13 g/dL as the lower limit for adult men, values that have been used in many studies as the definition of normal. The “right” values for the upper and lower limits of normal remain a subject of intense debate, but they certainly vary according to age, race, and gender.
Mechanical Ventilation
Authors: Kritek Patricia A.
Published: July 2014

Patients receive mechanical ventilation for a variety of reasons. The general practitioner should understand the broad categories for initiation of mechanical ventilation as well as be able to determine when a patient can be liberated from a ventilator. The majority of this chapter focuses on the common modes of ventilation, the difference between pressure- and volume-cycled breath delivery and how these different modes are monitored.
Interstitial Lung Diseases
Authors: Mihalek Andrew D. , Goldberg Hilary J.
Published: July 2014

This chapter provides 20 Critical Care Board Review Questions.
Adrenal Disorders
Authors: Trikudanathan Subbulaxmi , Dluhy Robert G.
Published: July 2014

Calcium is vital for the regulation of a vast array of human physiological processes including cell division, cell adhesion, plasma membrane integrity, protein and hormone secretion, muscle contraction, neuronal excitability, glycogen metabolism, platelet aggregation, and blood coagulation. Given this list, it is not surprising that calcium levels are very tightly regulated. This chapter discusses disorders of calcium metabolism.
Dialysis and Transplantation
Authors: Hundert Joshua S. , Tucker J. Kevin
Published: July 2014

The magnitude of the public health problem due to chronic kidney disease (CKD) in the United States is gaining recognition. More than 19 million adult Americans, or 11%, have CKD, the majority with stage 1–3 disease. Many of the complicating features traditionally described in the end-stage kidney patient (ESRD) population are increasingly being noted in chronic kidney disease patients. It is now understood that complications of CKD develop earlier in the course and lead to adverse outcomes in their own right. CKD thus becomes a systemic disorder as it progresses. The major complications of CKD to be discussed—hypertension, cardiovascular disease, anemia, and bone-mineral disorders—are consistently found and are to a degree independent of the primary cause of the kidney disease.
Chronic Kidney Disease
Authors: Singh Ajay K.
Published: July 2014

Chronic kidney disease (CKD) is defined by the National Kidney Foundation (NKF) as either (1) a glomerular filtration rate (GFR) of 〈60 mL/min with or without kidney damage for 3 or more months or (2) the presence of kidney damage for 3 or more months demonstrated by pathologic abnormalities, markers of kidney damage (e.g., blood or urine composition), or imaging tests. In the United States it is estimated that CKD affects 7–10% of the adult population or 15–20 million individuals, although specific subgroups such as African Americans and Hispanics are at especially high risk. Chapter 60 in this section of the volume reviews the complications of CKD.
Essential and Secondary Hypertension
Authors: Singh Karandeep , Singh Ajay K.
Published: July 2014

Hypertension is one of the most common chronic diseases confronting humanity. The worldwide prevalence is estimated to be approximately 26%, or approximately 1 billion individuals. The World Health Organization estimates that high blood pressure causes one in every eight deaths, making hypertension the third leading source of mortality in the world. In the United States, the National Health and Nutrition Educational Survey (NHANES) survey reports an incidence of approximately 30% in individuals 18 years and older. The prevalence is higher in older individuals, non-Hispanic blacks, and women. Essential hypertension is the most prevalent hypertension type, affecting 90–95% of hypertensive patients.
Nephrology Board Review Questions
Authors: Denker Bradley M.
Published: July 2014

This chapter provides 15 Nephrology Board Review Questions.
Peptic Ulcer Disease
Authors: Berzin Tyler M. , Falchuk Kenneth R.
Published: July 2014

Peptic ulcer disease (PUD) involves the stomach or duodenum and is a significant cause of morbidity and mortality both in the United States and worldwide, with a lifetime prevalence estimated at 5–15%. For a good part of the 20th century PUD was felt to be a condition related to stress and dietary factors. More recently, our understanding of PUD has been advanced by research into the role of gastric acid secretion and the benefits of various classes of antisecretory medications and, perhaps most importantly, in 1984, by Warren and Marshall, who identified Helicobacter pylori (H. pylori) as a pathogenic agent in this disease. Proton pump inhibitor (PPI) therapy and H. pylori eradication regimens have altered the natural history of what once was a chronic disease, and they have also reduced peptic ulcer complications, limiting the need for surgery.
Pericardial Disease
Authors: Lilly Leonard S.
Published: July 2014

The pericardium is a two-layered sac that surrounds the heart. It is composed of an outer stiff fibrous coat (the parietal pericardium) and a thin inner membrane that is adherent to the external surface of the heart (the visceral pericardium). The visceral pericardium reflects back at the level of the great vessel origins to form the inner lining of the parietal layer. The space between these two layers normally contains 15–50 mL of serous pericardial fluid, which permits the heart to contract in a minimum-friction environment. The major diseases of the pericardium are acute pericarditis, cardiac tamponade, and constrictive pericarditis.
Arrhythmias
Authors: Chiravuri Murali , Tadros Thomas M. , Tedrow Usha B.
Published: July 2014

In the normal heart the sinoatrial (SA) node serves as the principal pacemaker and determines the heart rate. The SA node consists of groups of pacemaker cells marked by their ability to spontaneously depolarize and are located at the junction of the right atrium and the superior vena cava. The blood supply to the SA node is variable with the sinus nodal artery arising from the right coronary artery in 60% percent of cases and from the left circumflex artery in 40% of cases. Following depolarization of the SA nodal cells, the signal traverses the atrium before arriving at the atrioventricular (AV) node. The AV node is marked by its ability to delay impulse propagation, which allows for coordinated contraction of the atria and ventricles. The AV nodal artery arises from the right coronary artery in 90% of cases and from the left circumflex artery in 10% of cases. After exiting the AV node, the impulse is transmitted through the bundle of His, the right and left bundle branches, and ultimately exits the terminal Purkinje fibers of the conduction system into the myocardium near the apex of the heart.
Peripheral Vascular Disease
Authors: Creager Mark A.
Published: July 2014

Atherosclerosis is a systemic disorder with regional manifestations in the heart, limbs, brain, and other organs. Advances in vascular biology, diagnostic imaging, pharmacotherapeutics, and intervention have provided physicians with greater opportunities to evaluate and manage patients with atherosclerotic vascular diseases. This chapter reviews several of these peripheral vascular diseases, including peripheral artery disease, abdominal aortic aneurysm, and carotid artery disease.
Cardiology Board Review Questions
Authors: Lewis Eldrin Foster
Published: July 2014

This chapter provides 20 Cardiology Board Review Questions.
The Neurologic Examination
Authors: Henderson Galen V.
Published: July 2014

The neurological examination is not challenging or complex. It does have many components and includes a number of skills that can be mastered only through repetition of the same techniques on a large number of individuals with and without neurological disease. Please remember that the purpose of the examination is to simply localize the lesion. Based on patient history alone, 80% of lesion locations should be known, and then a very specific neurological examination is performed to confirm the location. The examination is the less time consuming of the two parts of the patient's neurological evaluation.
Basic Principles of Epidemiology and Biostatistics
Authors: Buring Julie E. , Lee I-Min
Published: July 2014

One hundred women over the age of 50 received mammograms at a mobile breast cancer screening unit. Twenty-seven women had findings suspicious for malignancy on the mammogram; 19 of these women were confirmed as having breast cancer by biopsy. One woman had a negative mammogram but in the subsequent year developed breast cancer and is assumed to have had the disease at the time of screening. What is the sensitivity of the mammogram? The specificity? And the predictive value of a positive screening test?
Contraception
Authors: Sillman Jane S. , Singh Ajay K.
Published: July 2014

The general internist needs to be up to date in contraception management. Each year nearly half of all pregnancies in the United States are unintended. Counseling about contraceptive options, provision of a back-up method, and information about emergency contraception can decrease the risk of unintended pregnancy. This chapter focuses on the aspects of contraception emphasized in Medical Knowledge Self-Assessment Program (MKSAP) 14: hormonal contraception, use of barrier methods, intrauterine devices, and emergency contraception.
Psychiatry Essentials for the Internist
Authors: Phull Brijmohan K. , Phull Rattna K.
Published: July 2014

Mood disorders, anxiety disorders, and somatoform disorders are common psychiatric conditions confronting general physicians in the outpatient setting. In the inpatient setting, the most common problems are delirium, dementia, mood and anxiety disorders, adjustment reactions to illness, and substance abuse. Mood disorders include various depressive disorders and bipolar disorder.
Communication skills
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Introduction

Essential considerations

General principles

Body language: an introduction

Interpreters

Communicating with deaf patients

Telephone communication

Other specific situations

Breaking bad news

Law, ethics, and consent
The nervous system
Authors: Thomas James , Monaghan Tanya
Published: July 2014

History

Presenting symptoms

The rest of the history

Examination

The outline examination

General inspection and mental state

Cognitive function

Speech and language

Cranial nerve examination

Cranial nerves II, III, IV, and VI

Cranial nerve I: olfactory

Cranial nerve V: trigeminal

Cranial nerve VII: facial

Cranial nerve VIII: vestibulocochlear

Cranial nerves IX and X

Cranial nerve XI: accessory

Cranial nerve XII: hypoglossal

Motor: applied anatomy

Motor: inspection and tone

Motor: upper limb power

Motor: lower limb power

Tendon reflexes

Other reflexes

Primitive reflexes

Sensory: applied anatomy

Sensory examination

Coordination

Some peripheral nerves

Gait

The unconscious patient

Important presenting patterns

The elderly patient
The female reproductive system
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Introduction

History

The gynaecological history

Abnormal bleeding

Pelvic pain and dyspareunia

Vaginal discharge

Vulval symptoms

Urinary incontinence

Genital prolapse

Examination

Outline gynaecological examination

Pelvic examination

Speculum examination

Bimanual examination

Taking a cervical smear

The elderly patient
The paediatric assessment
Authors: Thomas James , Monaghan Tanya
Published: July 2014

History taking

Approaching the examination

The respiratory system

Ear, nose, and throat

The cardiovascular system

The abdomen and external genitalia

Examining the external genitalia

The nervous system

Assessment of a squint

Developmental assessment

The newborn
Clinical data interpretation
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Electrocardiography

Electrocardiography (ECG)

Other clinical data
Mortality after Critical Illness
Authors: Baldwin Matthew , Wunsch Hannah
Published: July 2014

Many critically ill patients now survive what were previously fatal illnesses, but long-term mortality after critical illness remains high. While study populations vary by country, age, intervention, or specific diagnosis, investigations demonstrate that the majority of additional deaths occur in the first 6 to 12 months after hospital discharge. Patients with diagnoses of cancer, respiratory failure, and neurological disorders leading to the need for intensive care have the highest long-term mortality, while those with trauma and cardiovascular diseases have much lower long-term mortality. Use of mechanical ventilation, older age, and a need for care in a facility after the acute hospitalization are associated with particularly high 1-year mortality among survivors of critical illnesses. Due to challenges of follow-up, less is known about causes of delayed mortality following critical illness. Longitudinal studies of survivors of pneumonia, stroke, and patients who require prolonged mechanical ventilation suggest that most debilitated survivors die from recurrent infections and sepsis. Potential biologic mechanisms for increased risk of death after a critical illness include sepsis-induced immunoparalysis, intensive care unit-acquired weakness, neuroendocrine changes, poor nutrition, and genetic variance. Studies are needed to fully understand how the severity of the acute critical illness interacts with comorbid disease, pre-illness disability, and pre-existing and acquired frailty to affect long-term mortality. Such studies will be fundamental to improve targeting of rehabilitative, therapeutic, and palliative interventions to improve both survival and quality of life after critical illness.
Patterns of Recovery after Critical Illness
Authors: Sekaran Nishant K , Iwashyna Theodore J
Published: July 2014

There are at least as many ways to recover from critical illness as there are to become critically ill. This chapter argues that, to understand recovery, we need to understand both its trajectory and the different domains in which recovery occurs. An adequate description of recovery should include pre-illness characteristics, depth of problems during the acute illness, the rate and duration of recovery, the extent of peak recovery, and long-term differences in post-illness trajectory. It should also take seriously the distinct domains mapped out in the World Health Organization’s International Classification of Functioning (ICF): tissue impairment, activity limitations, participation restriction, and health-related quality of life. These domains each represent distinct and important facets, and separately assessing each leads to deeper understanding and opportunities for intervention.
Costs and Resource Utilization in Prolonged Critical Illness
Authors: E Cox Christopher
Published: July 2014

Patients who have chronic critical illness, operationally defined as those requiring prolonged mechanical ventilation, are markedly increasing in number and commonly experience profound, persistent physical and psychological debilitation. This patient population consumes an extraordinary amount of health care resources attributed to both the acute hospitalization as well as complex post-discharge treatments provided across multiple post-acute care facilities. Currently, the US health care system incentivizes these patient flow dynamics. Health care policy changes addressing post-acute care payment are inevitable. This chapter highlights potential patient, family, physician, and systems targets for current and future interventions, designed to improve quality and reduce costs for this patient population.
Severe Burn Injuries and Their Long-Term Implications
Authors: C Diaz Eva , C Finnerty Celeste , Herndon David N
Published: July 2014

Burn injury is notable for the degree and duration of pathophysiological alterations that it induces. Burn triggers profound changes in metabolism, immune function, and endocrine function, leading to a host of negative effects, including catabolism of muscle and bone and insulin resistance. These changes may persist or evolve for years after the injury has occurred, delaying recovery. This chapter discusses all of these consequences of burn injury, along with other adverse outcomes, specifically growth delay in children and hypertrophic scarring. Particular attention is placed on what is known about the mechanisms underlying each of these pathological changes and, in some cases, current practice in their management. A description is also provided of some of the pharmacologic (i.e. oxandrolone and recombinant human growth hormone) and non-pharmacologic (i.e. exercise therapy) approaches that hold promise in the treatment of burn injury and its consequences.
Cognitive Impairment Following Critical Illness
Authors: Hopkins Ramona O , C Jackson James
Published: July 2014

Millions of individuals each year survive critical illness, many of whom will develop post-intensive care syndrome which includes new or worsening impairments in physical, psychiatric, or cognitive functioning. Cognitive impairments are common in survivors of critical illness, are often severe, and persist years after hospital discharge. Cognitive impairments improve in some patients and, in others, appear stable over time, rather display a pattern of progressive decline. Cognitive impairment contributes to clinically significant functional decrements as well as decreased quality of life. The biological mechanisms of cognitive impairment are not well defined, although numerous risk factors have been identified. As the number of ICU survivors increases, there is a growing population of patients with cognitive impairments following critical illness, underscoring the need to address cognitive impairments through prevention, treatment, and rehabilitation. Interventions to prevent or reduce the severity of cognitive impairments (i.e. sedation, delirium, and early mobility protocols) need to be investigated. Although there are very limited examples in which rehabilitation is used in ICU populations, it may hold the potential to facilitate improvements in cognition, particularly among individuals with deficits in memory, attention, and executive functioning. Despite over a decade of focused investigation, fundamental questions pertaining to cognitive impairments after critical illness exist. Research is needed on methods to proactively identify those at risk for cognitive impairment and to develop methods which will robustly prevent and improve deficits in ICU survivors.
Sleep Disorders and Recovery from Critical Illness
Authors: Hoff Scott , Collop Nancy A
Published: July 2014

Many factors contribute to sleep disruption in critically ill patients. Sleep is a complex process, with broad effects on diverse physiologic systems. Environmental factors, such as light exposure, noise from diverse sources, and sleep interruptions related to patient care, have all received considerable investigational attention. Critical illness can affect elements involved in sleep initiation and maintenance. The various modes of mechanical ventilation may have different effects on sleep fragmentation and on the propensity to cause central apnoeas, thereby potentially prolonging the time on the ventilator. Pharmacologic agents, especially sedatives, can directly affect sleep architecture and may contribute to the incidence of intensive care unit delirium. Additional research is needed on the biological effects of critical illness on sleep, how sleep disruption affects systemic physiology and outcomes, and how these interactions can be modulated for therapeutic purposes.
Sepsis-Associated Encephalopathy
Authors: Magalhaes Eric , Polito Angelo , Polito Andréa , Sharshar Tarek
Published: July 2014

Brain dysfunction is a major complication of sepsis and is characterized by alteration of consciousness, ranging from delirium to coma and marked electroencephalographic changes. It reflects a constellation of dynamic biological mechanisms, including neurotransmitter imbalance, macro- and microcirculatory dysfunction resulting in ischaemia, endothelial activation, alteration of the blood-brain barrier impairment with passage of neurotoxic mediators, activation of microglial cells within the central nervous system, cumulatively resulting in a neuroinflammatory state. Sepsis-associated brain dysfunction is associated with increased mortality and long-term cognitive decline, whose mechanisms might include microglial activation, axonopathy, or cerebral microinfarction. There is no specific treatment, other than the management of the underlying septic source, correction of physiological and metabolic abnormalities, and limiting the use of medications with neurotoxic effects.
Skeletal Muscle Mass Regulation in Critical Illness
Authors: Puthucheary Zudin , Montgomery Hugh , Hart Nicholas , Harridge Stephen
Published: July 2014

Muscle is a dynamic, plastic, and malleable tissue that is highly sensitive to mechanical and metabolic signals. Muscle mass is regulated by protein homeostasis, with protein being continually turned over, reflecting a balance between synthesis and breakdown. This chapter discusses the effect of critical illness on skeletal muscle mass, protein homeostasis, and the intracellular signalling driving anabolism and catabolism. The focus will be on the unique challenges to which the skeletal muscle are exposed, such as inflammation, sepsis, sedation, and inadequate nutrition, which, in combination with the disuse signals of immobilization and bed rest, engender dramatic changes in muscle structure and function. The mechanisms regulating muscle loss during critical illness are being unravelled, but many questions remain unanswered. Detailed understanding of these mechanisms will help drive strategies to minimize or prevent intensive care-acquired muscle weakness and the long-term consequences experienced by ICU survivors.
Ventilator Liberation Strategies
Authors: Nava Stefano , Fasano Luca
Published: July 2014

The weaning process should ideally begin as soon as the patient is intubated and continue through the treatment of the cause inducing acute respiratory failure. Weaning includes the assessment of readiness to extubate, extubation, and post-extubation monitoring; it also includes consideration of non-invasive ventilation which has been shown to reduce the duration of invasive mechanical ventilation in selected patients. Weaning accounts for approximately 40% of the total time spent on mechanical ventilation and should be achieved rapidly, since prolonged mechanical ventilation is associated with increased risk of complications and mortality and with increased costs. During mechanical ventilation, medical management should seek to correct the imbalance between respiratory load and ventilatory capacity (reducing the respiratory and cardiac workload, improving gas exchange and the ventilatory pump power). Ventilator settings delivering partial ventilatory pump support may help prevent ventilator-induced respiratory muscles dysfunction. Daily interruption of sedation has been associated with earlier extubation. Critically ill patients should be repeatedly and carefully screened for readiness to wean and readiness to extubate, and objective screening variables should be fully integrated in clinical decision making.
Sleep-Promoting Strategies
Authors: Fanelli Vito , Mirabella Lucia , Italiano Stefano , Dambrosio Michele , Ranieri V Marco
Published: July 2014

The architecture of sleep is profoundly altered in critically ill patients. Up to 60% of ICU survivors report poor sleep quality or sleep deprivation. Sleep in ICU patients is characterized by a longer onset and a poorer sleep efficiency, as demonstrated by the prevalence of light sleep (N1 and N2 stages), a reduction or absence of deep phase (N3 stage) and REM sleep, and increased sleep fragmentation. The amount of total sleep time (TST) in 24-hour period is generally preserved, but this reflects abnormal daytime sleep (up to the 40–50% of TST) with short periods of nocturnal sleep. Disruption of sleep architecture has deleterious consequences on the homeostasis of cardiovascular, respiratory, and nervous systems, exposing patients to an increased risk of myocardial infarction, prolonged mechanical ventilation, and cognitive dysfunction. Factors associated with sleep disruption in the ICU include noise, lighting, nursing care interventions, pain, discomfort, mechanical ventilation, medications, and delirium. Although clinical trials are lacking, potentially valuable approaches to ameliorate sleep quality in the ICU include reducing noise and pain, promoting patient ventilator synchrony, and managing delirium.
Physical and Occupational Therapy in the ICU
Authors: Schweickert William D , Kress John P
Published: July 2014

Mechanically ventilated patients in the ICU are commonly immobilized for prolonged time periods due to factors that include the underlying illness, encephalopathy, or sedation. In this setting, severe ICU-acquired weakness is common and may represent both a cause and consequence of immobilization. Physical and occupational therapy is feasible in ICU patients, even very early during mechanical ventilation. This intervention requires a coordinated effort between physicians, nurses, respiratory therapists, and the physical/occupational therapy team. Early physical and occupational therapy can lead to improved strength and functional status, reduced ventilator days and length of stay, and fewer days of ICU delirium.
Neuromuscular Electrical Stimulation: A New Therapeutic and Rehabilitation Strategy in the ICU
Authors: Gerovasili Vasiliki , Nanas Serafim N
Published: July 2014

Many critically ill patients undergo a period of immobilization with detrimental effects on skeletal muscle, effects which seem most pronounced in the first days of critical illness. Diagnosis of intensive care unit muscle weakness (ICUAW) is often made after discontinuation of sedation when significant nerve and/or muscle damage may already have occurred. Recently, there has been interest in early mobilization during the acute phase of critical illness, with the goal of preventing ICUAW. Neuromuscular electrical stimulation (NEMS) is an alternative form of exercise that has been successfully used in patients with advanced chronic obstructive pulmonary disease (COPD) and chronic heart failure. NEMS is a rehabilitation tool that can be used in critically ill, sedated patients, does not require patient cooperation, and is therefore a promising intervention to prevent muscle dysfunction in the critically ill. When applied early during the course of critical illness, NEMS can preserve muscle morphology and function. Available evidence suggests that NEMS may have a preventive role in the development of ICUAW and could even contribute to a shorter duration of weaning from mechanical ventilation. Studies are needed to evaluate the long-term effect of NEMS and to explore NEMS settings and delivery characteristics most appropriate for different subgroups of critically ill patients.
Exercise and Early Rehabilitation in the Intensive Care Unit
Authors: Gosselink Rik
Published: July 2014

Exercise and early rehabilitation have an important role in the management of patients with critical illness. The assessment and treatment of critically ill patients focuses on deconditioning (limb and respiratory muscle weakness, joint stiffness, impaired functional exercise capacity, physical inactivity) and weaning failure as targets for rehabilitation. A variety of modalities for exercise training and early mobility have been tested in clinical studies and can be implemented, depending on the stage of critical illness, comorbid conditions, and alertness and cooperation of the patient. Successful mobilization plans and exercise prescription for the patient is a team endeavour, involving physiotherapist, occupational therapist, intensivist, and nursing staff.
Introduction: Therapeutic and Rehabilitation Strategies in the Post-ICU Period
Authors: Griffiths Richard D.
Published: July 2014

Chapter 46 provides an outline to therapeutic and rehabilitation strategies in the post-ICU period, and examines conflict in care between patient and family experiences, types of recovery pathways, relatives' coping strategies, risk assessment and support, and a clinical review of issues that may include drug withdrawal, cessation of unwanted medication, optimization of cardiorespiratory function, and screening for the associated physical problems of immobility. It also covers elements of physical, psychological, and social recoveries, as well as cognitive dysfunction and social challenges.
Models of Rehabilitative Care after Critical Illness
Authors: Herridge Margaret S , Cameron Jill I
Published: July 2014

Critical illness is transformative. Patients and caregivers are traumatized and acquire new mood disorders and disability. These are costly and consequential. Knowledge of current rehabilitation theory may help to inform emerging models of care for our critically ill patients and families. The International Classification of Functioning, Disability, and Health (ICF) model is presented as a candidate construct for patients and families after critical illness. It highlights the complexity and interdependence of factors that determine outcome and incorporates multiple facets of the individual experience. ICF may facilitate the development of a novel framework of aetiologically neutral clinical phenotypes with distinct recovery trajectories after critical illness. This informs tailored interventions for distinct patient and family groupings, independent of initial diagnostic groups, and acknowledges the similar themes of ICUAW, cognitive dysfunction, and mood disorders following complex critical illness.
Pyrexia of unknown origin: the use of PET and PET-CT
Authors: Storrar Neill , Bleeker-Rovers Chantal
Published: July 2014

Pyrexia of unknown origin, PUO, is a medical syndrome that is frequently managed by infectious disease teams. The differential diagnoses are vast, and must encompass both infective and non-infective conditions such as malignancy and inflammatory conditions. This chapter will describe a case study along with a discussion of the role of positron emission tomography in elucidating the cause of PUO.
HIV: antiretroviral treatment and emergence of resistance
Authors: Bradshaw Daniel , Arnold Amber , Carr Andrew
Published: July 2014

HIV resistance continues to pose a problem in the choice for effective regimens despite the arrival of newer antiretroviral agents. The emergence of resistance is dependent on both physician factors (for example, interpreting resistance information appropriately and prescribing medications at the correct dose and in effective combinations) as well as patient-related factors relating to adherence. This chapter presents a case where both areas were not ideal. The role of genotypic assays is evaluated and the interpretation of resistance data and choices of antiretroviral agents discussed.
Disseminated aspergillosis after bone marrow transplantation
Authors: Lambourne Jonathan , Hemsley Carolyn
Published: July 2014

Aspergillus species have the capacity to cause devastating infection. More efficacious antifungal agents and improved diagnostics have improved survival from invasive Aspergillus, but mortality is still 30% and approaches 100% for Aspergillus infection of the central nervous or cardiovascular systems. A case of disseminated Aspergillus infection is presented in a patient following bone marrow transplantation and risk factors, testing, and management are discussed.
Hepatitis B reactivation
Authors: Chakrabarty Gayatri , Forton Daniel
Published: July 2014

There is a significant risk of relapse with chronic hepatitis B during periods of immunosuppression. Prophylaxis with antiretroviral agents has the potential to prevent relapse and complications such as liver fibrosis, and is strongly supported in the hepatology community and through professional guidelines. A case is presented where the patient was not offered prophylaxis despite risk factors and suffered a significant relapse after chemotherapy for malignancy. The testing, management, and treatment of hepatitis B are discussed with particular attention to the role of prophylaxis.
Hospital-acquired Legionella pneumonia
Authors: Roberts Catherine , Newsholme William
Published: July 2014

Legionellosis provides a classic example of the need for an understanding of the ecology of an organism, as well as its clinical behaviour, in order to identify possible sources of infection. This chapter describes a case of hospital-acquired legionellosis focusing on its diagnosis and management. The chapter also focuses on the infection control issues surrounding nosocomial acquisition of the organism and the infection control implications, investigations, and management. The case highlights how all water sources to which a patient may have been exposed, both in and outside the hospital, must be considered as potential sources and involvement of the infection control team, the estates department and public health departments must occur at an early stage.
Contracts
Authors: Simon Chantal , Everitt Hazel , van Dorp Françoise , Burkes Matt
Published: July 2014

Partnership agreements

General Medical Services Contract

GP pay under the GMS Contract

Carr-Hill Allocation Formula

Quality and Outcomes Framework

Other provider contracts

Commissioning

Partnership disputes are common. A properly drafted partnership agreement may prevent disputes and, if they do occur, may lessen their impact.

A partnership without an up-to-date written agreement is a ‘partnership at will’, governed by the 1890 Partnership Act. A ‘partnership at will’ is a very unstable situation as:...
Consulting and certification
Authors: Simon Chantal , Everitt Hazel , van Dorp Françoise , Burkes Matt
Published: July 2014

The consultation

Consultation models

Patient records

Telephone consulting and home visits

Referral letters and electronic media

Organization of out-of-hours services

The doctor’s bag

Social factors in general practice

Benefits for people on low income

Multicultural medicine

Breaking bad news

Confirmation and certification of death

Organ donation...
Healthy living
Authors: Simon Chantal , Everitt Hazel , van Dorp Françoise , Burkes Matt
Published: July 2014

Prevention and screening

Prevention of travel-related illness

Diet

Obesity

Exercise

Smoking

Alcohol

Management of alcohol misuse

Assessment of drugs misuse

Management of drugs misuse

Insomnia

In all disease, the goal is prevention.

• Primary prevention Prevention of disease occurrence

• Secondary prevention Controlling disease in early form (e.g. carcinoma in situ)...
Mental health
Authors: Simon Chantal , Everitt Hazel , van Dorp Françoise , Burkes Matt
Published: July 2014

Mental health assessment

Mental health symptoms and signs

Psychological therapies

Anxiety

Other anxiety-type disorders

Chronic stress

Depression

Drugs for treating depression

Psychosis

Schizophrenia and mania

Acute delirium

Dementia

Eating disorders

Other psychological conditions

Assessing a patient with mental health problems in primary care can be challenging. Aims (may need >1 appointment to achieve):...
Emergencies in general practice
Authors: Simon Chantal , Everitt Hazel , van Dorp Françoise , Burkes Matt
Published: July 2014

Emergency patient encounters

Managing a resuscitation attempt outside hospital

Adult basic life support

Adult advanced life support

Paediatric basic life support

Paediatric advanced life support

Resuscitation of the newborn

Coma

The fitting patient

Anaphylaxis

Shock

Gastrointestinal bleeding

Meningitis and encephalitis

Chest pain and palpitations

Acute coronary syndrome...
Case 1.15
Authors: Lee Christine U. , Glockner James F.
Published: July 2014

39-year-old man with a 6-month history of epigastric and right upper quadrant discomfort with associated intermittent right shoulder pain and nausea. Laboratory tests were unremarkable; specifically, the AFP level was within normal limits. A hepatic mass was seen on CT

Axial fat-suppressed FSE T2-weighted (...
Periodic flare of the 6.7-GHz methanol maser in IRAS 22198+6336
Authors: Fujisawa Kenta , Takase Genta , Kimura Saki , Aoki Nozomu , Nagadomi Yoshito , Shimomura Tadashi , Sugiyama Koichiro , Motogi Kazuhito , Niinuma Kotaro , Hirota Tomoya , Yonekura Yoshinori
Published: July 2014

We have detected periodic flares of the 6.7-GHz methanol maser from an intermediate-mass star-forming region IRAS 22198+6336. The maser was monitored daily in 2011, 2012, and 2013. Six flares were observed with a period of 34.6 d. The variation pattern is intermittent, and the flux ratio of the flaring and the quiescent states exceeds 30. Such intermittent variation with the short period uniquely characterizes the variation of the IRAS 22198+6336 maser. At least five spectral components were identified. The spectral components varied almost synchronously, but their peak times differed by 1.8 d. These characteristics can be explained by the colliding-wind binary model.
Alcanivorax xenomutans sp. nov., a hydrocarbonoclastic bacterium isolated from a shrimp cultivation pond
Authors: Rahul K. , Sasikala Ch. , Tushar L. , Debadrita R. , Ramana Ch. V.
Published: July 2014

Two bacterial strains (JC109T and JC261) were isolated from a sediment sample collected from a shrimp cultivation pond in Tamil Nadu (India). Cells were Gram-stain-negative, motile rods. Both strains were positive for catalase and oxidase, hydrolysed Tween 80, and grew chemo-organoheterotrophically with an optimal pH of 6 (range pH 4–9) and at 30 °C (range 25–40 °C). Based on 16S rRNA gene sequence analysis, strains JC109T and JC261 were identified as belonging to the genus

Alcanivorax

with

Alcanivorax dieselolei

B-5T (sequence similarity values of 99.3 and 99.7 %, respectively) and

Alcanivorax balearicus

MACL04T (sequence similarity values of 98.8 and 99.2 %, respectively) as their closest phylogenetic neighbours. The 16S rRNA gene sequence similarity between strains JC109T and JC261 was 99.6 %. The level of DNA–DNA relatedness between the two strains was 88 %. Strain JC109T showed 31±1 and 26±2 % DNA–DNA relatedness with

A. dieselolei

DSM 16502T and

A. balearicus

DSM 23776T, respectively. The DNA G+C content of strains JC109T and JC261 was 54.5 and 53.4 mol%, respectively. Polar lipids of strain JC109T included diphosphatidylglycerol, phosphatidylglycerol, phosphatidylethanolamine, two unidentified aminophospholipids, two unidentified phospholipids and two unidentified lipids. The major fatty acids were C10 : 0, C12 : 0, C16 : 0, C12 : 0 3-OH, C16 : 1ω7c, C18 : 1ω7c and C19 : 0 cyclo ω8c. Both strains could utilize diesel oil and a variety of xenobiotics as carbon and energy sources. The results of physiological, biochemical, chemotaxonomic and molecular analyses allowed the clear differentiation of strains JC109T and JC261 from all other members of the genus

Alcanivorax

. Strains JC109T and JC261 are thus considered to represent a novel species, for which the name Alcanivorax xenomutans sp. nov. is proposed. The type strain is JC109T ( = KCTC 23751T = NBRC 108843T).
Sro7 and Sro77, the yeast homologues of the Drosophila lethal giant larvae (Lgl), regulate cell proliferation via the Rho1–Tor1 pathway
Authors: Liou Liang-Chun , Ren Qun , Gao Qiuqiang , Zhang Zhaojie
Published: July 2014

Saccharomyces cerevisiaeSro7 and Sro77 are homologues of theDrosophilatumour suppressor lethal giant larvae (Lgl), which regulates cell polarity inDrosophilaepithelial cells. Here, we showed that double mutation ofSRO7/SRO77was defective in colony growth. The colony of theSRO7/SRO77double deletion was much smaller than the WT and appeared to be round with a smooth surface, compared with the WT. Analysis using transmission electron microscopy revealed multiple defects of the colony cells, including multiple budding, multiple nuclei, cell lysis and dead cells, suggesting that the double deletion caused defects in cell polarity and cell wall integrity (CWI). Overexpression ofRHO1, one of the central regulators of cell polarity and CWI, fully recovered thesro7Δ/sro77Δ phenotype. We further demonstrated thatsro7Δ/sro77Δ caused a decrease of the GTP-bound, active Rho1, which in turn caused an upregulation ofTOR1. Deletion ofTOR1insro7Δ/sro77Δ (sro7Δ/sro77Δ/tor1Δ) recovered the cell growth and colony morphology, similar to WT. Our results suggested that the tumour suppressor homologueSRO7/SRO77regulated cell proliferation and yeast colony development via the Rho1–Tor1 pathway.