bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Ambulatory Surgery
Authors: McCormick Megan Rodgers
Published: March 2023

Children are often excellent candidates for outpatient surgery since they are generally healthy individuals undergoing brief surgeries with few complications. This chapter focuses on a brief overview of managing an outpatient pediatric anesthesia patient from preoperative to postoperative care. It reviews preoperative fasting guidelines, preoperative anxiolysis and premedication, and parental presence for induction. Inclusion and exclusion criteria for appropriate candidates are outlined, including postconceptual age and apnea concerns. Different types of induction techniques and intraoperative management and monitoring are reviewed. Common postoperative complications such as postoperative nausea and vomiting (PONV) are mentioned. Postoperative discharge criteria and the scales used to evaluate patients are described.
Cesarean Section
Authors: Al-Jindi Piotr , Attali Ami
Published: March 2023

Cesarean delivery is the most common surgical procedure performed worldwide. There are various indications related to maternal, fetal, uterus, or placental pathology. Preoperative evaluation includes review of past medical and obstetric history, including physical examination of airway, heart, and lungs. A blood type and crossmatch, intravenous access, aspiration prophylaxis, postoperative nausea and vomiting (PONV) management, and prophylactic antibiotics are integrals part of a preoperative plan. Neuraxial anesthesia is the preferred method of anesthesia for caesarian section unless there is an absolute contraindication. Advantages of neuraxial anesthesia include decreasing maternal mortality, limited neonatal drug transfer, ability of the parents to be awake and take part in the delivery during the birth of their child, and avoiding airway manipulation in patients who have both a potentially difficult airway and an aspiration risk. Different neuraxial techniques used for caesarian section include epidural, single-shot spinal, combined spinal-epidural, and spinal catheter. In case of general anesthesia, all equipment should be readily available with standard American Society of Anesthesiologist monitoring, including pulse oximetry, electrocardiography (ECG), capnography, and noninvasive blood pressure (NIBP). Rapid sequence induction and intubation with cricoid pressure are preferred after preoxygenation. All airway instruments should be available for a potential difficult airway, including an awake intubation plan if indicated. Anesthetic complications include intraoperative awareness and recall, dyspnea following neuraxial anesthesia, hypotension, failure of neuraxial blockade, high neuraxial blockade, difficult airway/trauma to the airway, and nausea and vomiting. Some of the important aspects of postoperative management include postoperative pain, pruritus, hypothermia, hemorrhage, and thromboembolic events.
Anesthesia for Cerclage or Nonobstetric Surgery
Authors: Ibrahim Rowaa , Attali Ami
Published: March 2023

Anesthetic management of pregnant women can be challenging, with multiple factors affecting the decision-making process, especially when considering nonobstetric surgery. The well-being of the mother and the fetus are a priority; therefore, clear communication between the multidisciplinary team is crucial. Guidelines have been recommended by both the American College of Obstetricians and Gynecologists and American Society of Anesthesiologists for management in both elective and emergent scenarios. A thorough preoperative assessment is needed and can help mitigate the risks associated with anesthesia for both the mother and baby. Intraoperative management must consider the physiological changes, fetal gestational age, as well as concomitant surgical risks that occur with pregnancy. The recovery period postoperatively focuses on multimodal management as well as avoiding possible complications of surgery. With a comprehensive perioperative plan, the gestation can return to its natural course.
Gestational Trophoblastic Disease
Authors: Younger Joshua D.
Published: March 2023

Gestational trophoblastic disease (GTD) is a spectrum of diseases that arise from the maldevelopment of trophoblastic tissue. Trophoblastic tissue develops as early as 4 days after fertilization. The tissue serves to feed and nourish the developing embryo. GTD can range from benign to lethal consequences. Included in this disease spectrum is a partial hydatiform molar pregnancy, complete molar pregnancy, invasive molar pregnancy, placental site trophoblastic tumor, and gestational choriocarcinoma. There can be multiple medical and specific anesthetic considerations that need to be appreciated. A thorough understanding of the disease processes and their complications allows for optimal anesthetic preparation and administration.
Autoimmune Disorders
Authors: Bhatia Anuschka , Chung Kevin W.
Published: March 2023

Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by autoantibody formation, multisystem immune complex deposition, and organ inflammation. Overall prevalence is approximately 50 per 100,000, and approximately 1 in every 1200 deliveries in the United States is affected. Pregnancy in patients with SLE is associated with a higher incidence of lupus-associated complications, as well as adverse maternal and obstetrical outcomes, such as preterm labor, unplanned cesarean delivery, maternal hypertension, preeclampsia, and eclampsia. Antiphospholipid syndrome (APS) is an acquired hypercoagulable state common among patients with SLE. Both SLE and APS require a multidisciplinary approach and specific anesthetic considerations in the peripartum period.
Hypertension
Authors: Ahmed Muhammad Fayyaz , Kamel Ihab
Published: March 2023

Hypertension complicates 5% to 10% of all pregnancies, and it is a major cause of maternal morbidity and mortality worldwide. Hypertensive disorders complicate pregnancy and can lead to significant maternal and fetal complications. Hypertensive disorders are classified into clinical classes that include chronic hypertension, gestational hypertension, hypertension with superimposed preeclampsia, and preeclampsia. During treatment of hypertensive disorders, attention should be given to fetal effects of antihypertensive medications and to maintenance of adequate uteroplacental perfusion. Intense sympathetic stimulation due to labor pain or direct laryngoscopy and intubation may lead to acute severe hypertension, which can then lead to life-threatening maternal complications.
Embolic Disorders
Authors: Ahmed Muhammad Fayyaz , Kamel Ihab
Published: March 2023

Embolic disorders are a major cause of maternal mortality in the United States, accounting for approximately 20% of all maternal deaths. It comprises mainly amniotic fluid embolism, venous thromboembolism, and venous air embolism. Each of the disorders has a different clinical course and management. Early recognition and management are necessary to reduce morbidity and mortality. High-risk patients with history of thrombosis, acquired or inherited thrombophilias, or patients with a mechanical heart valve should be anticoagulated during pregnancy as well as the postpartum period. Anesthetic considerations of the embolic disorders include preoperative assessment of high-risk patients for safe neuraxial anesthesia administration and management of intraoperative cardiovascular collapse that may result from massive embolism.
Retained Placenta
Authors: Ahmed Muhammad Fayyaz , Kamel Ihab
Published: March 2023

Retained placenta is a failure to deliver the placenta completely within 30 minutes (active management of labor) or 60 minutes (physiologic management of labor) after the delivery of the fetus. Reported incidence ranges from 0.01% to 6.3% of vaginal deliveries. The retained placenta can lead to various complications, including life-threatening postpartum hemorrhage. Treatment involves early extraction of the retained placenta while preparing for resuscitation if hemodynamic instability ensues. General and neuraxial anesthesia can be considered for the extraction procedure, bearing in mind that neuraxial anesthesia is best suited for hemodynamically stable patients. Uterine relaxation with pharmacological means is usually required to facilitate extraction.
Patient Selection and Preoperative Management
Authors: Moskal Anna
Published: March 2023

The development of minimally invasive surgery, improvement in surgical technique and pain control, as well as better patient selection and preoperative management contribute to significant expansion of ambulatory anesthesia. Nearly two-thirds of all operations are performed in outpatient facilities according to the Centers for Disease Control and Prevention. The surgical procedures suitable for same-day surgery are characterized by modest surgical trauma, no likelihood of continuing blood loss or large perioperative fluid shifts, or no need for complex postoperative care. Ambulatory surgery is being offered to a variety of patients with significant coexistent diseases. The suitability of ambulatory surgery in patients with obstructive sleep apnea (OSA) remains controversial; therefore, the Society for Ambulatory Anesthesia (SAMBA) developed a consensus statement. The recommendations include the use of the STOP-Bang questionnaire for preoperative OSA screening and considering patients’ comorbid conditions in the selection process. Ambulatory surgery is very safe, with low perioperative mortality. Predictors for morbidity and mortality are obesity, prolonged operative time, prior cardiac surgical intervention, hypertension, and a history of transient ischemic attack or stroke. In elderly patients, the presence of comorbidities, disability, and frailty are associated with postoperative complications.
Discharge Criteria and Postoperative Follow-up
Authors: Connolly Matthew T. , Abd-Elsayed Alaa
Published: March 2023

The objective of this chapter is to provide a concise overview of high-yield requirements and associated relevant topics for discharge from the postanesthesia care unit (PACU), phase II, and discharge home as well as home follow-up. The Modified Aldrete Scoring System and Post-Anesthetic Discharge Scoring System (PADSS) are the two most common criteria used for PACU discharge; both include the general principles based on updated American Society of Anesthesiologists guidelines that should serve as a supplement to the individual anesthesia providers’ overall evaluation of discharge readiness. Specialty topics related to anesthesia discharge and follow-up addressed include fast tracking and discharge/follow-up in the pediatric population.
Office-Based Anesthesia (OBA)
Authors: Heidari Afshin , Aquino Ben
Published: March 2023

Office-based anesthesia (OBA) examines one of the most significant changes in medicine and surgery in recent years. This has been driven by new medical knowledge about inpatient and outpatient medicine, improvement in surgical and anesthetic techniques, and the administrative need to maximize efficiency and minimize cost. Cholecystectomy, for example, an operation once done open with a weeklong hospital stay, is now done laparoscopically and, in some centers, as an outpatient procedure. Procedures that were previously done at an outpatient surgery center are now given in office-based settings. As more complex and invasive procedures are being done on patients with more comorbidities, it is essential for the anesthesia provider to understand the need and importance of safe OBA.
Malpractice
Authors: Ghosh Priyanka
Published: March 2023

Malpractice is an important concept in every physician’s practice, including the anesthesiologist. Malpractice broadly refers to medical negligence that was caused directly by the physician’s actions. Malpractice lawsuits must prove direct damages to the patient. In order to prove negligence, the situation must include four discrete elements, often referred to as “the four D’s” of medical negligence: duty, dereliction, direct causation, and damage. Over time, anesthesiology has become increasingly safe for patients, with a decrease in overall severity and number of malpractice claims. However, there continue to be malpractice claims made in anesthesiology; this is discussed in depth in this chapter.
Initial Certification, Recertification, Maintenance of Certification, and Related Issues
Authors: Chiong Katya H. , Abouhassan Soozan S.
Published: March 2023

The American Board of Anesthesiology (ABA) has transitioned to a new assessment of competency-based training and promotion mirroring the evaluation of anesthesia residents across the Accreditation Council of Graduate Medical Education (ACGME) system. Instead of the Traditional Part 1 (written) and Traditional Part 2 (Oral) Examination, candidates are now expected to complete a three-part examination: the BASIC, ADVANCED, and APPLIED Exams. The APPLIED Exam now includes elements of Objective Structured Clinical Examinations (OSCEs) in addition to the traditional Standardized Oral Examination (SOE) questions of the Traditional Part 2 (Oral) Examination. Candidates must satisfy all requirements for initial certification within 7 years of the last day of the year in which they completed their residency training. If a candidate does not satisfy all requirements for certification within the allotted time period, the candidate must reestablish eligibility with the ABA examination system. To maintain certification and meet recertification requirements, all newly certified diplomates participate in the ABA’s Maintenance of Certification in Anesthesiology™ (MOCA®) program, currently MOCA 2.0®. This program is designed to promote lifelong learning, maintain current medical knowledge, and promote patient safety.
Quality Improvement
Authors: McComb Joseph J. , Wong Corinne K.
Published: March 2023

Despite lagging other US industries, effective healthcare quality improvement (QI) programs are expected by patients, insurers, government agencies, and hospital leadership. Quality is important in any field, but even more so in medicine, where life and death are at stake. As the finances of medicine become more important, it is stressed more that we should look to produce quality medicine with fewer resources. The chapter looks at quality improvement projects to help streamline and provide better patient care while reducing expenses and increasing productivity. Anesthetists need to look at their culture, teamwork, current safety guidelines to help guide us and develop new methods for achieving quality and safe medicine.
The Greeks
Authors: Berman Carol W.
Published: March 2023

Starting from the ancient Greeks, plays have demonstrated basic psychiatric principles. For example, Sophocles’ Oedipus Rex shows Oedipus’s journey from marrying his mother to killing his father. Psychological studies revealed that boys of about three years old desire to be with their mothers and want to eliminate their fathers. We call this principle the Oedipus complex after Sophocles’s play. Similarly, girls at three yearn to be with their fathers and rid themselves of their mothers. Sophocles’s play Electra illustrates this psychiatric concept. Many other Greek plays portray fundamental truths in psychology. In Euripides’s Medea the extreme emotions of revenge of a woman betrayed by her husband are witnessed.
Reich’s Ideas
Authors: Berman Carol W.
Published: March 2023

Wilhelm Reich’s contributions to psychiatry include the study of character structure, studies of the psychology of fascism, and studies of sexuality. In opposition to Freud, Reich argued that every neurosis is the result of the damming up of sexual energy. He stressed character formation as a result of a human being dealing with instinctual conflicts. For him, the body armored itself in ways that therapists could read in body language and utilize for patients’ benefits. According to Reich, there are hysterical characters, compulsive characters, and impulsive ones. Blanche DuBois, in Tennessee Williams’s A Streetcar Named Desire is an example of a hysterical, impulsive character. When people watch this play, they usually empathize with Blanche and thereby achieve a catharsis.
Klein’s Positions
Authors: Berman Carol W.
Published: March 2023

Melanie Klein is famous for her work in object relations theory. Klein’s object relations theory is a variation of psychoanalytic theory. It places less emphasis on biological-based drives and more importance on interpersonal relationships. People are always dealing with relationships to objects (which can also be people). Her concepts of the “good breast” (mother providing nourishment) versus the “bad breast” (no nourishment from mother) established paranoid or depressed positions that patients could take. In Romeo and Juliet, the lovers become good and bad “breasts” to each other at different times and ultimately commit suicide when they feel the loss of each other as “objects.”
Telemedicine for Headache: Welcome to the Virtual World
Authors: Bernstein Carolyn , de Dhaem Olivia Begasse
Published: March 2023

The chapter “Telemedicine for Headache: Welcome to the Virtual World” reviews tips to optimize virtual headache medicine visits. The first step of virtual visits consists in ensuring a conducive, calm, confidential, comfortable, and safe environment for both parties. Identity should be confirmed, consent should be obtained, and rules (such as no recording) should be stated. Providers must make a conscious effort to adapt to telemedicine to build trust, show their presence, and ensure that the virtual setting does not dehumanize the patients’ experiences. Looking at the camera to make virtual eye contact, making pauses, and providing written supporting information for reference can help. Telemedicine is not an excuse to skip the neurological exam; this article provides tips on performing the examination. Further development is necessary regarding vital signs, funduscopic exam, and reflexes.
Primary Stabbing Headache: “Sticking Out the Pain”
Authors: Joshi Shivang , Harrington Carly E.
Published: March 2023

Primary stabbing headache, previously referred to as “ice-pick headache,” is a headache condition that causes short-lived but excruciating pain in the extratrigeminal regions. It is diagnosed through careful patient examination as well as testing to rule out conditions with similar presentation: clinicians should not discredit the importance of a detailed patient history while caring for individuals suffering from headaches. When primary stabbing headache is suspected, clinicians must exclude giant cell arteritis, glaucoma, cluster headache, thunderclap headache, and reversible cerebral vasoconstriction syndrome. Once diagnosis of primary stabbing headache has been established, possible treatment options include long-acting NSAIDs, gabapentin, and botox injections. The aim of this case review is to guide the reader through a complex case study in which a clinician is faced with the challenge of navigating both patient history and diagnostic testing to establish the most appropriate headache diagnosis.
Let’s Talk About Jaw Overuse
Authors: Hernández-Nuño de la Rosa María F.
Published: March 2023

The chapter “Let’s Talk about Jaw Overuse” examines the diagnosis, anatomy and etiology, evaluation and examination, work-up, and management of temporomandibular disorders. Temporomandibular disorders (TMDs) are a heterogeneous group of musculoskeletal conditions that affect the masticatory muscles, the temporomandibular joint, and the associated structures. They have a high prevalence in the general population, particularly in women. The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) describes the 12 most common types, including among them the headache attributed to TMD. The International Classification of Headache Disorders 3rd edition (ICHD-3) is another validated tool for the screening and the diagnosis of headache attributed to TMD. Mandibular parafunctional habits such as bruxism, in some cases secondary to long-standing life stressors, might play a very important role in the precipitation and/or perpetuation of this condition. Thus, it is advised to use a battery of standardized and validated questionnaires for behavioral screening as part of a comprehensive psychosocial assessment when encountering these patients. The management of headache attributed to TMD will require a multidisciplinary approach involving a combination of physical therapy, pharmacotherapy, and an intraoral orthotic device. The treatment plan might also include a referral to a clinical psychologist. For refractory pain, trigger point or even botulinum toxin injection therapy will be used. A comprehensive differential diagnosis should be performed to rule out the presence of giant cell arteritis, a condition that untreated can lead to blindness.
My Right Eye Is On Fire
Authors: de Dhaem Olivia Begasse
Published: March 2023

The chapter “My Right Eye Is On Fire” examines the diagnosis, work-up, and management of neuropathic eye pain. The first step to eye pain and photophobia is to determine whether the etiology is central or peripheral. The pain is likely peripheral if monocular, with no red flags on history, no abnormalities on neurological exam, and abates with a topical anesthetic. If there is a concern for a central etiology, further work-up with imaging and possibly lumbar puncture depending on the history and exam findings is warranted. Once established to be peripheral, a thorough ophthalmologic evaluation is necessary. Especially if the Schirmer test is positive, it is important to ask about other rheumatologic, endocrinologic, dermatologic, and autonomic symptoms. Management of neuropathic eye pain includes preservative-free artificial tears, omega-3 rich diet, riboflavin, systemic antidepressants such as amitriptyline or duloxetine, systemic anticonvulsants such as gabapentin, topical immunosuppressants, autologous serum tears. Medical optimization of comorbidities such as migraine, other chronic pain disorders, insomnia, and mood disorders is crucial. FL-41 or grey tinted glasses help with the blue-light sensitivity and photophobia without causing dark adaptation. Topical NSAIDs can also be helpful for acute bouts of eye pain and may help prevent progression to a full-blown migraine. Reversibly, triptans and other migraine acute treatments can also help with the photophobia associated with migraine attacks.
Headache Following a New Medication
Authors: Ostrem Bridget LaMonica
Published: March 2023

The chapter “Headache Following a New Medication” examines how to evaluate and manage and decrease the risk of vision loss due to idiopathic intracranial hypertension (IIH). IIH is a disorder of increased intracranial pressure (ICP) of unclear cause that primarily affects young women of childbearing age. Risk factors include obesity, family history, and certain medications. Patients often present with headaches and visual changes; funduscopic exam typically demonstrates papilledema. By definition, brain imaging cannot reveal an alternative cause for elevated ICP. Management includes large-volume lumbar puncture(s), weight loss, and carbonic anhydrase inhibitors. IIH can lead to persistent headaches and permanent vision loss. Prompt recognition and treatment of this disorder are needed to mitigate these risks.
Is It All About Mass?
Authors: Melnick Kaitlyn , Ghiaseddin Ashley Parham , Orlova Yulia
Published: March 2023

New or changed headache in a patient with abnormal neurological exam should raise the suspicion of space-occupying lesion and requires neuroimaging. Headache is rarely an isolated symptom of brain tumor, and new neurological signs can be usually found on thorough neurological exam that should include fundoscopy. Headache secondary to brain tumor is nonspecific and can present with various phenotypes. It is more common in children, young adults, those with primary headache disorders, large size or infratentorial location of tumor, and midline shift. Mechanisms of acute and chronic headache in patients with brain tumor are reviewed, including headache that changed or emerged after treatment of brain tumor. Treatment strategies of acute and chronic headache in patients with brain tumor are discussed.
Day-in, Day-out
Authors: de Dhaem Olivia Begasse , Bernstein Carolyn
Published: March 2023

The chapter “Day-in, Day-out” discusses the diagnosis and management of medication overuse headache. Medication overuse headache, preferably called medication adaptation headache, is hypothesized to originate from a combination long-term frequency acute medication use and preexisting headache disorder. The frequent acute medication use is thought to cause calcitonin gene-related peptide system–related sensitization of the trigeminal nociceptive process. The treatment mainly focuses on starting or optimizing preventive treatment (both pharmacologic and nonpharmacologic) and keeping track of headache days and medication use. A bridge therapy may be needed when weaning off butalbital- or opiate-containing agents due to initial headache worsening.
Principles of radiotherapy
Authors: Ajithkumar Thankamma
Published: March 2023

This chapter discusses the evolution of cancer and the basic principles of treatment. While DNA damage predominates the radiation-induced cell kill, there are other mechanisms which might influence radiation damage. This chapter also discusses types of radiations and their interaction with tissues, and the fundamental principles of radiotherapy. Radiotherapy cannot distinguish between multiplying cancer and normal cells and therefore results in damage of both cells. However, fractionation of radiotherapy governed by the 5Rs (redistribution of cells, reoxygenation, repair of sublethal damage, repopulation and radiosensitivity) is helpful to maximise tumour kill with acceptable normal tissue toxicities. The concepts of tumour control and normal tissue complication probabilities and clinical application of altered fractionations are also included.
Practical radiotherapy
Authors: Ajithkumar Thankamma
Published: March 2023

This chapter begins with a discussion of the intent of radiotherapy and clinical decision-making. Practical radiotherapy planning and delivery include a series of steps to ensure the highest quality of treatment. After informed consent, patients proceed with imaging for target volume definition in the optimal position with comfortable immobilisation. The concepts of various target volumes and the importance of appropriate windowing of planning CT scan for target and organs at risk delineation are emphasised. It also discusses treatment plan evaluation, modifications during treatment including gap corrections, and care after radiotherapy. There are sections on contouring of organs at risk, normal tissue tolerance, and treatment verification.
Gastrointestinal tumours
Authors: Ajithkumar Thankamma
Published: March 2023

The role of radiotherapy for gastrointestinal cancers depends on the site of the primary tumour and the stage of disease. There is global variation in the management of gastrointestinal cancers. For example, locally advanced operable oesophageal cancers are treated with neoadjuvant chemotherapy followed by surgery in the UK whereas it is treated with neoadjuvant chemo-radiotherapy in Europe and the US. This chapter discusses the clinical and imaging features of cancers occurring in different parts of the gastrointestinal tract, the role of radiotherapy for tumours arising in different sites, and practical details on radiotherapy planning. It also summarizes the evidence underpinning current clinical practice and mentions about global variations in the management.
Oligometastatic and oligoprogressive extracranial disease
Authors: Ajithkumar Thankamma
Published: March 2023

With the advent of modern imaging and frequent surveillance, some patients are shown to have progressive metastatic disease with or without symptoms. Some of these patients with limited sites of metastatic disease are often classified as oligometastatic, though a strict definition does not exist. Recently, there has been an increasing interest in the use of stereotactic ablative radiotherapy for patients with oligometastatic and oligoprogressive diseases. This chapter discusses the imaging features of oligometastatic and oligoprogressive diseases and their radiotherapy management. It also summarizes the evidence underpinning current clinical practice. Readers should be aware that it is an area where clinical practice is rapidly evolving.
Is it a stroke?
Authors: Harwood Rowan H. , Huwez Farhad Umer , Guyler Paul , Alam Sajid , Gaynor Catherine
Published: March 2023

This chapter describes the definition and diagnosis of stroke. Stroke is a type of brain injury triggered by the sudden interruption of blood flow. Diagnosis depends on history, examination, and the results of imaging studies. Stroke physicians must also have a good working knowledge of alternative diagnoses (mimics), and understand underlying pathological mechanisms in order to make investigation logical and systematic.
The first 2 weeks
Authors: Harwood Rowan H. , Huwez Farhad Umer , Guyler Paul , Alam Sajid , Gaynor Catherine
Published: March 2023

This chapter looks at the first weeks of stroke care Different trajectories of recovery, stability or deterioration can be seen, and care should be appropriate to each. The chapter explores neurological problems such as hemiparesis, neglect, aphasia, and emotional lability. It discusses complications, functional problems, co-existing medical problems, neurological deterioration, and pain. The chapter also covers the options for rehabilitation and specialist services.
Making difficult decisions
Authors: Harwood Rowan H. , Huwez Farhad Umer , Guyler Paul , Alam Sajid , Gaynor Catherine
Published: March 2023

This chapter focuses on medical decision-making, which is governed by law, professional regulations, ethics, and culture. It explains the ethical framework of principlism that considers the benefits and burdens of a proposed intervention, and respect for autonomy and justice. Most healthcare interventions require consent or agreement from an appropriate consultee when a patient lacks mental capacity. It describes the options for advanced care planning and some specific examples of difficult decision-making in stroke care.
Hospital discharge
Authors: Harwood Rowan H. , Huwez Farhad Umer , Guyler Paul , Alam Sajid , Gaynor Catherine
Published: March 2023

Hospital discharge requires careful planning. A hospital admission can serve valuable functions, but a person should remain in hospital only when necessary care cannot be delivered elsewhere. This determines when discharge should occur. Many patients rehabilitate better when nursing and rehabilitation are delivered at home. Community support divides into therapeutic services that try to improve a patient’s function, and prosthetic services that make up for things the patient cannot do themselves. The chapter explains the features to consider at the level of the person, their abilities, and their environment when considering fitness for discharge.
Longer-term problems and their management
Authors: Harwood Rowan H. , Huwez Farhad Umer , Guyler Paul , Alam Sajid , Gaynor Catherine
Published: March 2023

This chapter discusses the longer-term problems of stroke patients and their management. Some patients feel abandoned after leaving hospital. Services for stroke patients should identify and address longer-term needs. Some problems that occur early after stroke persist. Issues that emerge following hospital discharge include: difficulty in returning to work, driving, re-establishing interests, hobbies, and civic participation. Aphasia needs specialist long-term management and support that targets impairment, compensation, adjustment, and carer support. Community rehabilitation teams or stroke support workers can help reduce psychological distress.
Retrospective Analysis of the Safety and Efficacy of Fecal Microbiota, Live-jslm (REBYOTATM) Administered Under Enforcement Discretion to Patients With Clostridioides difficile Infection
Authors: Feuerstadt Paul , Harvey Adam , Yoho David S , Garcia-Diaz Julia B , Knapple Whitfield L , Bancke Lindy
Published: March 2023

Background

Fecal microbiota, live-jslm (RBL; REBYOTA™), the first microbiota-based live biotherapeutic approved by the US Food and Drug Administration to prevent recurrent Clostridioides difficile infection (rCDI) in adults, has been evaluated in 5 prospective clinical trials. A retrospective analysis considered the safety and efficacy of RBL administered under US Food and Drug Administration enforcement discretion to patients with rCDI and broad eligibility criteria mimicking real-world practice.

Methods

We retrospectively identified adults with rCDI treated with RBL under enforcement discretion between November 1, 2015, and September 30, 2019, across 5 study sites. CDI diagnosis was based on site-specific practice. The primary safety set (PSS) included all patients who were naïve to previous RBL treatment and had continuously comprehensive medical records for 6 months following treatment.

Results

The primary treatment cohort had 94 patients; the PSS included 64 patients with common comorbidities receiving diverse chronic therapeutics. Most treatment-emergent adverse events were mild to moderate in severity and comparable between comorbidity subgroups and the overall population. There were no serious adverse events related to RBL or the administration procedure. In the PSS, 82.8% of RBL-treated patients responded at 8 weeks, of whom 88.7% had sustained response through 6 months. The number of RBL doses administered had no marked effect on outcome.

Conclusions

Together with prospective clinical trial outcomes, these findings support the efficacy and safety of RBL to prevent rCDI, with diagnostics and comorbidities representative of real-world clinical practice.
Readability of Online Patient Educational Materials in Pediatric Orthopaedics: A Systematic Review
Authors: Hecht Christian J. , Burkhart Robert J. , McNassor Ryan , Mistovich R. Justin
Published: March 2023

Background:

As most patients and their families utilize online education materials, ensuring that their readability is at or below the recommended reading level of sixth grade is imperative to enhance informed consent, patient involvement, and shared decision-making. We evaluated and compared the readability of online patient education materials (PEMs) about pediatric orthopaedics for academic-sponsored websites and search-engine result websites.

Methods:

Following the PRISMA-P guidelines, we performed a systematic review to answer our study question (PROSPERO registration of the study protocol: CRD42022352323, August 8, 2022). PubMed, EBSCOhost, Medline, and Google Scholar electronic databases were utilized to identify all studies evaluating the readability of pediatric orthopaedic online PEMs between January 1, 2000 and September 9, 2022. We included studies with full-text manuscripts in English addressing the readability of pediatric orthopaedic online patient education materials. We excluded general reviews, papers, case reports, duplicate studies between databases, grey literature, and publications in languages other than English. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) tool for cross-sectional studies.

Results:

Our initial search yielded 196 candidate publications. Of these, 11 studies met inclusion criteria. These included a total of 893 PEMs assessed for readability between January 2001 to December 2021. The mean JBI score was 7.3±1.1. Each of the seven studies assessing PEMs from academic-sponsored sources reported mean readability scores of at least an eighth-grade level. Among the 5 studies assessing the readability of PEMs accessed through search engines, 3 studies reported ninth-grade reading level whereas the other 2 reported 10th-grade. Academic and search-engine website readability scores remained constant between 2001 and 2021.

Conclusions:

Our analysis showed poor readability scores for both academic-sponsored website PEMs and those accessed through search engines. In addition, the readability scores remained constant between 2001 and 2021, indicating that revisions to orthopaedic online PEMs are needed. Supplementation with visuals should be included to educate patients with lower health literacy.

Level of Evidence:

III.
Risk Factors for Multisystem Inflammatory Syndrome in Children: A Case-control Investigation
Authors: Zambrano Laura D. , Wu Michael J. , Martin Lora , Malloch Lacy , Chen Sabrina , Newhams Margaret M. , Kucukak Suden , Son Mary Beth , Sanders Cameron , Patterson Kayla , Halasa Natasha , Fitzgerald Julie C. , Leroue Matthew K. , Hall Mark , Irby Katherine , Rowan Courtney M. , Wellnitz Kari , Sahni Leila C. , Loftis Laura , Bradford Tamara T. , Staat Mary , Babbitt Christopher , Carroll Christopher L. , Pannaraj Pia S. , Kong Michele , Schuster Jennifer E. , Chou Janet , Patel Manish M. , Randolph Adrienne G. , Campbell Angela P. , Hobbs Charlotte V.
Published: March 2023

Background:

In a 2020 pilot case-control study using medical records, we reported that non-Hispanic Black children were more likely to develop multisystem inflammatory syndrome in children (MIS-C) after adjustment for sociodemographic factors and underlying medical conditions. Using structured interviews, we investigated patient, household, and community factors underlying MIS-C likelihood.

Methods:

MIS-C case patients hospitalized in 2021 across 14 US pediatric hospitals were matched by age and site to outpatient controls testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within 3 months of the admission date. Caregiver interviews queried race/ethnicity, medical history, and household and potential community exposures 1 month before MIS-C hospitalization (case-patients) or after SARS-CoV-2 infection (controls). We calculated adjusted odds ratios (aOR) using mixed-effects multivariable logistic regression.

Results:

Among 275 case patients and 496 controls, race/ethnicity, social vulnerability and patient or family history of autoimmune/rheumatologic disease were not associated with MIS-C. In previously healthy children, MIS-C was associated with a history of hospitalization for an infection [aOR: 4.8; 95% confidence interval (CI): 2.1–11.0]. Household crowding (aOR: 1.7; 95% CI: 1.2–2.6), large event attendance (aOR: 1.7; 95% CI: 1.3–2.1), school attendance with limited masking (aOR: 2.6; 95% CI: 1.1–6.6), public transit use (aOR: 1.8; 95% CI: 1.4–2.4) and co-resident testing positive for SARS-CoV-2 (aOR: 2.2; 95% CI: 1.3–3.7) were associated with increased MIS-C likelihood, with risk increasing with the number of these factors.

Conclusions:

From caregiver interviews, we clarify household and community exposures associated with MIS-C; however, we did not confirm prior associations between sociodemographic factors and MIS-C.
Cryptococcal Necrotizing Fasciitis in a Patient With Sarcoidosis
Authors: Killblane Tiffany , Milsap Dominique , Vetos Develyn , Grantham David C. , Hagan Margaret
Published: March 2023

Necrotizing fasciitis, a severe soft tissue infection that rapidly destroys the fascial layer through necrosis and inflammation, is often caused by Streptococcus pyogenes, gram-negative bacteria, Clostridium, and, rarely, fungal organisms. We present a case of necrotizing fasciitis caused by Cryptococcus neoformans in a patient with sarcoidosis on oral prednisone therapy.
Laparoscopic versus open repeat hepatectomy for recurrent hepatocellular carcinoma: a systematic review and meta-analysis of propensity score-matched cohort studies
Authors: Xiang Zhi-Qiang , Zhu Feng-Feng , Zhao Si-Qi , Li Hua-Jian , Long Zhang-Tao , Wang Qian , Dai Xiao-Ming , Zhu Zhu
Published: March 2023

Objective:

The effectiveness of laparoscopic repeat hepatectomy (LRH) versus open repeat hepatectomy (ORH) on recurrent hepatocellular carcinoma (RHCC) is unclear. We compared the surgical and oncological outcomes of LRH and ORH in patients with RHCC with a meta-analysis of studies based on propensity score-matched cohorts.

Methods:

A literature search was conducted on PubMed, Embase, and Cochrane Library with Medical Subject Headings terms and keywords until 30 September 2022. The quality of eligible studies was evaluated with the Newcastle–Ottawa Scale. Mean difference (MD) with a 95% CI was used for the analysis of continuous variables; odds ratio (OR) with 95% CI was used for binary variables; and hazard ratio with 95% CI was used for survival analysis. A random-effects model was used for meta-analysis.

Results:

Five high-quality retrospective studies with 818 patients were included; 409 patients (50%) were treated with LRH and 409 (50%) with ORH. In most surgical outcomes, LRH was superior to ORH: less estimated blood loss, shorter operation time, lower major complication rate, and shorter length of hospital stay (MD=−225.9, 95% CI=[−360.8 to −91.06], P=0.001; MD=66.2, 95% CI=[5.28−127.1], P=0.03; OR=0.18, 95% CI=[0.05−0.57], P=0.004; MD=−6.22, 95% CI=[−9.78 to −2.67], P=0.0006). There were no significant differences in the remaining surgical outcomes: blood transfusion rate and overall complication rate. In oncological outcomes, LRH and ORH were not significantly different in 1-year, 3-year, and 5-year overall survival and disease-free survival.

Conclusions:

For patients with RHCC, most surgical outcomes with LRH were superior to those of ORH, but oncological outcomes with the two operations were similar. LRH may be a preferable option for the treatment of RHCC.
The research on the treatment of primary immunodeficiency diseases by hematopoietic stem cell transplantation: A bibliometric analysis from 2013 to 2022
Authors: Hu Siqi , Xu Shixia , Lu Wei , Si Yingjian , Wang Ya , Du Zhenlan , Wang Yi , Feng Zhichun , Tang Xiangfeng
Published: March 2023

Hematopoietic stem cell transplantation (HSCT) is curative in patients with primary immunodeficiency syndrome. The safety and efficacy of HSCT as a therapeutic option for primary immunodeficiency diseases (PID) have been studied by many research groups. The purpose of our study was to perform a bibliometric analysis of research on HSCT for the treatment of PID, to assess research trends in this field, and note future research priorities. The Web of Science Core Collection (WOSCC) was used to identify relevant publications. VOSviewer and CiteSpace software were used to analyze bibliometric parameters, such as yearly records, authors, grouped authors, countries, institutions, categories and keywords. There are 602 relevant records for the last decade (2013–2022). The top 5 productive authors and high-quality paper journals are listed. Reference co-citations analysis demonstrated recent research trends were “inborn errors of immunity,” “gene editing,” and “enteropathy.” Research on HSCT for the treatment of PID has increased rapidly in the last decade, and bibliometrics are valuable for researchers to obtain an overview of hot categories, academic collaborations and trends in this study field.
Sphingomonas cremea sp. nov., isolated from ginseng soil
Authors: Park Yuna , Liu Qingzhen , Maeng Soohyun , Oh Hyejin , Yun Chan-Seok , Choe Hanna , Lee Hyang Burm , Im Wan-Taek
Published: March 2023

A novel Gram-stain-negative, aerobic, rod-shaped, non-motile, cream-coloured strain (G124T) was isolated from ginseng soil collected in Yeongju, Republic of Korea. Phylogenetic analysis based on 16S rRNA gene sequences revealed that strain G124T belongs to a distinct lineage within the genus

Sphingomonas

(family

Sphingomonadaceae

, order

Sphingomonadales

and class

Alphaproteobacteria

). Strain G124T was closely related to

Sphingomonas rhizophila

THG–T61T (98.5 % 16S rRNA gene sequence similarity),

Sphingomonas mesophila

SYSUP0001T (98.3 %),

Sphingomonas edaphi

DAC4T (97.6 %) and

Sphingomonas jaspsi

TDMA–16T (97.6 %). The strain contained ubiquinone 10 as the major respiratory quinone. The major polar lipid profile of strain G124T comprised phosphatidylethanolamine, diphosphatidylglycerol, phosphatidylglycerol, phosphatidylcholine and sphingoglycolipids. The predominant cellular fatty acids of strain G124T were summed feature 8 (C18 : 1
 ω7c/C18 : 1
 ω6c; 33.4 %), summed feature 3 (C16 : 1
 ω6c/C16 : 1
 ω7c; 27.2 %) and C16 : 0 (18.3 %). The genome size of strain G124T was 2 549 305 bp. The genomic DNA G+C content is 62.0 mol%. The average nucleotide identity and digital DNA–DNA hybridization values between strain G124T and other

Sphingomonas

species were in the range of 71.2–75.9 % and 18.7–19.9 %, respectively. Based on the polyphasic analysis such as biochemical, phylogenetic and chemotaxonomic characteristics, strain G124T represents a novel species of the genus

Sphingomonas

, for which the name Sphingomonas cremea sp. nov. is proposed. The type strain is G124T (=KACC 21691T=LMG 31729T).
Genomic surveillance identifies SARS-CoV-2 transmission patterns in local university populations, Wisconsin, USA, 2020–2022
Authors: Ramaiah Arunachalam , Khubbar Manjeet , Bauer Amy , Scott Samantha , Lentz Jennifer , Akinyemi Katherine , Skillman Addie , Weiner Joshua , Balakrishnan Nandhakumar , Bhattacharyya Sanjib
Published: March 2023

Novel variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to emerge as the coronavirus disease 2019 (COVID-19) pandemic extends into its fourth year. Understanding SARS-CoV-2 circulation in university populations is vital for effective interventions in higher education settings and will inform public health policy during pandemics. In this study, we performed whole-genome sequencing of 537 of 1717 SARS-CoV-2-positive nasopharyngeal/nasal swab samples collected over a nearly 20-month period from two university populations in Wisconsin, USA. We observed that the viral sequences were distributed into 57 lineages/sub-lineages belonging to 15 clades, of which the majority were from 21K (omicron, 36.13 %) and 21J (delta, 30.91 %). Nearly 40 % (213) of the sequences were omicron, of which BA.1 and its eight descendent lineages accounted for 91 %, while the remaining belonged to BA.2 and its six descendent lineages. Independent analysis of the sequences from these two universities revealed significant differences in the circulating SARS-CoV-2 variants. Phylogenetic analysis of university sequences with a global sub-dataset demonstrated that the sequences of the same lineages from the university populations were more closely related. Genome-based analysis of closely related strains, along with phylogenetic clusters and mutational differences, identified that potential virus transmission occurred within and between universities, as well as between the university and the local community. Although this study improves our understanding of the distinct transmission patterns of circulating variants in local universities, expanding genomic surveillance capacity will aid local jurisdictions not only in identifying emerging SARS-CoV-2 variants, but also in improving data-driven public health mitigation and policy efforts.