bluuebunny/crossref_metadata_2025 huggingface dataset:
Palliative care and end-stage liver disease
Authors: Patel Arpan , Walling Anne
Published: September 2021

End-stage liver disease is associated with significant morbidity, disability, and suffering. Over the past few decades, there have been notable advances in managing complications of portal hypertension, including ascites, encephalopathy, and variceal haemorrhage. Similarly, there are more management options available for burdensome symptoms that negatively affect health-related quality of life, such as fatigue, insomnia, pain, depression, cramps, and pruritus. A subset of patients with end-stage liver disease, however, continue to deteriorate despite optimal management of their condition. For these patients, liver transplantation can greatly improve survival and health-related quality of life; however, it remains the only curative option and a limited resource internationally. There are critical gaps in managing disability and end of life care for patients with end-stage liver disease. Applying palliative care principles to the management of patients with end-stage liver disease can have significant benefits to their overall care and meet an unmet need.
Palliative care in catastrophic disasters and humanitarian crises
Authors: Wilkinson Anne , Matzo Marianne
Published: September 2021

Both catastrophic disasters and humanitarian crises can have widespread, long-term, and often unpredictable negative impacts, causing shortages of safe water, food, shelter, transportation, and sanitation as well as the displacement of large numbers of people and the loss of many lives. Routinely ignored in disaster and humanitarian planning are those socially and medically vulnerable populations living in the affected community who are dependent on the existing healthcare system for survival, making them particularly predisposed to the risk of harm or death due to the event. Because of their unique needs, extra steps need to be taken in order to reduce the likelihood that vulnerable populations will suffer injury, disease, or even death. Serious health-related suffering resulting from illness or injury stemming from a natural or man-made crisis could be ameliorated by the inclusion of palliative care services in planning and response activities. While the primary goal of disaster medicine is to maximize the number of lives saved and to ensure the best outcomes for the community as a whole, a holistic and fully compassionate response necessitates a secondary goal of minimizing the physical and psychological suffering of those whose lives may be shortened by a crisis event. In order to effectively provide palliative care services in crisis situations, all care delivery sites, especially triage and alternative care sites, will need clearly articulated protocols, trained staff (including personnel with palliative care, mental health, and spiritual counselling skills), supplies (including those necessary for appropriate pharmacological treatment), and appropriate space for dying patients.
Management of the actively dying patient
Authors: Lacey Judith , Cherny Nathan I.
Published: September 2021

Few issues so encapsulate the palliative care as the skilled care of the dying patient and their family members. How patients die is a matter of supreme consequence in the human life cycle and for the surviving family. This chapter presents a multidisciplinary approach to highlighting challenges in identifying the terminal phase, approaches to help the clinician address the needs of patients and their family members, the management of common symptoms at the end of life including the management of refectory symptoms at the end of life. Tabulated information highlights some of the special issues including practical ways family members can participle in the care of their loved ones. The chapter concludes with some of the challenging issues related to hydration and nutrition, difficult deaths and staff coping and support.
Medical and ethical considerations in palliative sedation at the end of life
Authors: Krakauer Eric L.
Published: September 2021

Among patients with an advanced terminal illness whose primary goal is comfort, severe suffering occurs occasionally that is refractory even to intensive palliative care with standard medicines and techniques. Controlled deep sedation, sometimes to unconsciousness, may be the only effective means of protecting patients from end of life suffering in these unusual situations. Thus, it is ethically imperative that deep palliative sedation be accessible for these rare situations. Ethical provision of deep palliative sedation requires that the main goal of care agreed upon with the patient or the patient’s surrogate be comfort, that there be agreement to withhold or withdraw life-sustaining treatments, that informed consent be obtained from the patient or surrogate, that all staff members actively involved in caring for the patient be informed in advance of the plan, that the clinical intention be demonstrated by using the minimum doses of medicine needed to achieve an adequate degree of comfort, and that dose titration be based on close observation of the patient. Deep palliative sedation may be used to assure comfort during terminal discontinuation of mechanical ventilation. Deep palliative sedation is ethically fundamentally different from euthanasia and physician-assisted suicide and should not be confused with these practices.
Quality of life and patient-reported outcome measures
Authors: Loge Jon Håvard , Kaasa Stein
Published: September 2021

To improve or sustain patients’ quality of life (QoL) is the main goal of palliative care. In palliative care as in healthcare in general, QoL is commonly conceptualized as health-related quality of life (HRQoL) which is the self-perceived health status of an individual and encompasses measurable components that are related to health, disease, illness, and medical interventions. Patient-reported outcome (PRO) measures is the term presently used for any measure that collects responses directly from the patients and includes measures on QoL, HRQoL, functions, and symptoms. In spite of substantial evidence on the positive outcomes of using PRO instruments (questionnaires) in the clinic, such use still faces barriers from the health system and the healthcare providers. The content and the measurement capabilities of present PRO instruments can also be a barrier. The selection of PRO instruments is recommended to follow a sequential approach. Define overall aim(s), define the research question(s), agree upon the key outcome(s), and select the appropriate set of questions/questionnaires guided by the primary and secondary outcomes. In general, it is recommended to use a generic or a disease-specific questionnaire and supplement with domain-specific questionnaire(s) for measurement of fatigue, pain, anxiety, depression, or other symptoms/functions reflecting the purpose(s) of the data collection.
Characteristics and impact of cognitive dysfunction
Authors: Baune Bernhard T.
Published: September 2021

The chapter characteristics and impact of cognitive dysfunction describes in depth the key features of the domains of cognitive abilities impaired across a broad range of functions. It examines the clinical impact and meta-analytic evidence of cognitive dysfunction both as a state marker of acute depression and a trait marker of depression as an illness. Importantly, it highlights the long-lasting psychosocial and workplace-related impairments in major depressive disorder. In addition to the functional outcomes, it draws the interconnectedness of life domains, subjective experiences of cognitive impairment, and objective measures of cognitive dysfunction, as well as with the course of major depressive disorder.
Characteristics and impact of impaired emotion processing
Authors: Baune Bernhard T.
Published: September 2021

Characteristics and impact of impaired emotion processing demonstrates that the experience of sustained negative affect and diminished positive emotions are cardinal symptoms of major depressive disorder (MDD). It explores how patients diagnosed with MDD show reduced approach motivation and increased avoidance motivation and demonstrate a mood-congruent negative processing bias. It deepens our understanding that patients might exhibit an elevated sensitivity to negative feedback and show an altered thinking style referred to as rumination. Importantly, it explains that depressed patients preferentially attend to mood-congruent stimuli, recall more unpleasant memories, and tend to interpret (ambiguous) information in a negative manner. It highlights that emotional-cognitive dysfunctions are closely related information processing and hence impair cognitive performance of MDD patients.
Assessment of cognitive dimensions
Authors: Baune Bernhard T.
Published: September 2021

Assessment of cognitive dimensions underscores the importance of following standard quality and test performance criteria during the assessment of cognitive function in major depressive disorder (MDD). The chapter explains the relevance of high-quality and -standard assessments as these are used for purposes of diagnosis and the evaluation of treatment efficacy. It highlights the role of the assessment of social cognitive function as an important tool to capture cognitive function in the context of emotion processing and social interaction. The chapter supports the notion for best practise guidance for the assessment of cognition in MDD. It reviews meta-analytic studies, characterizes paper-and-pencil and digital test platforms, evaluates screening tools for cognitive impairment in MDD, and estimates the efficacy of cognitive change in clinical trials in MDD. It also reviews a broad range of tests for social cognitive function.
Apathy and Schizophrenia
Authors: Faerden Ann , Aleman André
Published: September 2021

Apathy was considered a core feature of schizophrenia by Kraepelin. Studies show that apathy contributes considerably to the functional disability in patients with schizophrenia and constitutes a major challenge for recovery. Understanding this has been a target for researchers and clinicians. Schizophrenia presents itself with a multitude of symptoms, organized into positive and negative symptoms, and of the two, negative symptoms have been found to have the strongest association to functioning. Negative symptoms are made up of five sub-symptoms, of which apathy is one. The study of apathy is closely linked to the study of the negative symptoms, but it is only during the last 15 years that apathy has been studied separately. Investigation of putative underlying mechanisms in recent years has enhanced understanding of apathy in schizophrenia and novel interventions are being developed to enhance motivation in different ways, including psychosocial and brain-based approaches.
Brain Reward Systems and Apathy
Authors: Kaiser Stefan , Schlagenhauf Florian
Published: September 2021

Reward is essential for motivating goal-directed behaviour. Impairment in the processing of reward is therefore a promising candidate for understanding apathy which has been defined as a loss of motivation and a quantitative reduction of goal-directed behaviour. This chapter employs the recently updated Research Domain Criteria framework for positive valence systems to provide an overview of reward system functions that have been associated with apathy, including reward anticipation, reward consumption, learning and prediction error, value representation, and integration of effort. For each construct, the concept and the measures on the behavioural and neural level are discussed. The chapter then provides examples from the schizophrenia literature on the association of apathy with these functions and gives a transdiagnostic perspective on the role of reward system dysfunction.
Psychosocial Approaches to the Treatment of Apathy
Authors: Riehle Marcel , Kasanova Zuzana , Lincoln Tania M.
Published: September 2021

This chapter examines how apathy, that is, reduced goal-directed behaviour, can be treated with psychological therapies, in particular cognitive behavioural therapy, cognitive remediation, and social skills training. A variety of specific and integrative approaches and treatment programmes are discussed. The chapter elaborates on the psychological processes underlying apathy, explains the rationale and main techniques for each therapeutic approach, and reviews evidence regarding the efficacy of the different approaches. In every part, the chapter translates research from specific symptom areas in mental disorders, particularly negative symptoms in schizophrenia and anhedonia in major depression, to the transdiagnostic concept of apathy. The chapter ends with an outlook detailing how refined therapeutic techniques, such as shared decision-making and treatment personalization, and technological advancements, such as digital and mobile health applications, can help to improve existing psychological treatments.
Hepar uterinum
Authors: Obladen Michael
Published: September 2021

The means of fetal nutrition has been debated for over two millennia, with the controversy of oral versus parenteral nutrition already in the Corpus Hippocraticum. In 1587, Aranzio rejected connections between maternal and fetal blood vessels, and coined the term hepar uterinum for the placenta. From the 16th to 18th century, fervent debate focused on the type and extent of connection between maternal and fetal vessels. But up to the middle of the 19th century, an important nutritive function was attributed to amniotic fluid. When with the discovery of oxygen the placenta’s respiratory function became understood, its nutritional function fell from grace. Most scientists realized reluctantly that the organ had numerous functions. As late as the 19th century, the advent of microscopy allowed cell theory to develop, and analytical chemistry furthered the understanding of the transport of nutrients across the placenta. The identification of the syncytiotrophoblast made passive diffusion unlikely. Radioisotopes, molecular biology, and the fluid mosaic model of the cell membrane revealed active transport mechanisms for nearly all macronutrients.
Resuscitation 3
Authors: Obladen Michael
Published: September 2021

Endotracheal intubation was applied by Scheel in 1798 to resuscitate neonates. A century before endotracheal anaesthesia was developed, inventive obstetricians constructed devices for the endotracheal intubation of infants and mastered their insertion, localization, and airtight sealing. Fell’s laryngoscope, Magill’s intubation forceps, and tissue-friendly materials were significant 20th-century contributions to endotracheal intubation of the newborn. The striking absence of scientific studies on the most efficient resuscitation techniques for neonates is attributable to the difficulty of adjusting for personal skills of the resuscitator.
Postverta, Agrippa, Caesarea
Authors: Obladen Michael
Published: September 2021

The frequency of breech presentation at term is 3% among singletons. Greek physicians dreaded those births, as they frequently led to the death of mother, infant, or both. In Rome, surviving infants were named Agrippa (born with difficulty), and the goddess Postverta was revered for presiding over breech deliveries. To the antique procedures of embryotomy and hook for the dead infant, the Middle Ages added manoeuvres to turn and extract a living, albeit often traumatized infant. These manoeuvres were associated with asphyxia from cord prolapse or compression, fracture of legs, arms, or clavicles, cerebral haemorrhage, trauma to the cerebellum, tentorium, or pituitary stalk, and with torticollis and arm plexus palsy. The prototype of difficult birth, infants born feet-first were considered dangerous, and were neglected or killed in many cultures. Even after Caesarean section had lost most of its risk, conservative obstetricians still propagated vaginal delivery from breech presentation. Finally, at the beginning of the 21st century, large randomized trials and population-based studies proved that Caesarean delivery was safe for the mother and highly beneficial for the child, making vaginal delivery from breech presentation obsolete.
Respiratory distress
Authors: Obladen Michael
Published: September 2021

Remarkable insight into disturbed lung mechanics of preterm infants was gained in the 18th and 19th centuries by the founders of obstetrics and neonatology who both observed respiratory failure and designed devices to treat it. Pathological anomalies in the immature lung were described in Germany by Virchow in 1854 and by Hochheim in 1903. The Swiss physiologist von Neergard fully understood surfactant function in 1929, but his paper was ignored for 25 years. The physical properties of surfactants were identified in the early 1950s through research on warfare chemicals by Pattle in Britain and by Radford and Clements in the US. The causal relationship between respiratory distress syndrome and surfactant deficiency was established in the US by Avery and Mead in 1959. The Australian obstetrician Liggins induced lung maturity with glucocorticoids in 1972, but his discovery was not fully accepted for another 20 years.
Persisting patency of the ductus arteriosus in the preterm infant
Authors: Obladen Michael
Published: September 2021

By 1769, it was known to Morgagni that the ductus arteriosus may persist until adulthood. In 1835, Jörg linked delayed postnatal closure with disturbed respiration, a discovery that afterwards was forgotten for a century. When blood gas analysis became available, the association between persisting patency and diminished oxygenation resurfaced. When it became known that prostaglandins played a role in maintaining ductal patency, the development of pharmacologic intervention with cyclooxygenase inhibitors immediately followed. This rapid progress was due to the interaction between basic science, paediatric cardiology, and neonatology disciplines at the Cardiovascular Research Institute in San Francisco, coordinated by Julius Comroe, as well as President Kennedy’s foundation of the National Institute of Child Health and Development. This series of events exemplifies how clinical research became an integrated managed multidisciplinary endeavour in the 20th century.
Unequal but monozygotic
Authors: Obladen Michael
Published: September 2021

Twin–twin transfusion is the major cause of mortality and morbidity in monochorionic twins. Its pathogenesis has been gradually elucidated over the last three centuries. There was a long-lasting controversy among obstetricians regarding the existence of placental anastomoses and whether or not to tie the placental end of the firstborn infant’s cord. However, a twin pregnancy practically never could be ruled out. Stalpart van der Wiel described a twin–twin vessel connection in 1687. Studies on interfetal anastomoses by injecting dyes into placental vessels were published by Smellie in 1752, Osiander in 1781, and Brachet in 1821. Different types of anastomoses, and their associated fetal disorders were classified by Schatz in a series of papers in the late 19th century. With the advent of ultrasound and laser techniques, prenatal diagnosis and treatment became available in the last decade of the 20th century.
Lethal lullabies
Authors: Obladen Michael
Published: September 2021

Poppy extract accompanied the human infant for more than three millennia. Motives for its use included excessive crying, suspected pain, and diarrhoea. In antiquity, infantile sleeplessness was regarded as a disease. Dabbing maternal nipples with bitter substances and drugging the infant with opium were used to hasten weaning. Opiates joined the treatment of difficult teething in the 17th century. Foundling hospitals and wet nurses used them extensively. With industrialization, private use was rampant among the working class. In German-speaking countries, poppy extracts were administered in soups and pacifiers. In English-speaking countries, proprietary drugs containing opium were sold at the doorstep or in grocery stores. Opium’s toxicity for infants was common knowledge, but the willingness to use it in infants persisted and physicians continued to prescribe it for babies. Intoxication became a significant factor in infant mortality. As late as 1912, the International Opium Convention signed at The Hague forced governments to implement legislation which effectively curtailed the access to opium and broke the dangerous habit of sedating infants.
Yellow brains and blue light
Authors: Obladen Michael
Published: September 2021

Fetal dropsy and neonatal jaundice were well known in the 17th century, but considered to be different diseases. Basal brain ganglia stained yellow were observed by Antoine Dugès in 1821, who also suggested that this finding may be associated with seizures. From observing kernicterus to understanding haemolytic disease of the newborn, 140 years passed, and the entire field of immunology had to develop. Only 25 years passed from understanding isoimmunization to the availability of effective prevention. With exchange transfusions, an effective but risky treatment for haemolytic disease and severe jaundice evolved in the 1940s. With some hesitation in the US, phototherapy followed in the 1950s. Rhesus haemolytic disease was practically eradicated during the 1960s by anti-D immunoglobulin. Kernicterus returned in the 1990s because of lessened awareness, and difficulty in monitoring bilirubin values after early discharge from maternity wards.
Despising the weak
Authors: Obladen Michael
Published: September 2021

In Germany, paediatrics evolved at the end of the 19th century in an atmosphere of social Darwinism and nationalism which paved the way towards elimination of handicapped infants. Killing handicapped children was organized in Hitler’s Chancellery from 1939, targeting infants with idiocy and mongolism, micro- or hydrocephaly, malformed limbs, head, or spine, and palsies. A system of reporting and rating such infants was established, leading to their admission to one of 30 ‘Special Children’s Departments’. There, sedatives were applied in a dose depressing respiration which led to a slow death disguised as natural. A hundred physicians were directly involved in killing, and many more including eminent paediatricians in reporting infants. After the war, court trials were initiated, but usually discontinued. Physicians involved in murdering children continued to teach and to conduct research on the victims’ brains. Their textbooks conveyed little compassion for the weak, malformed, and handicapped. There was widespread unwillingness to keep preterm infants alive. When from 1960 artificial ventilation of neonates became possible, opposition against it persisted. Despising the weak was an enduring legacy of Nazism that may have delayed the introduction of modern neonatology in Europe.
For whom no bell tolled
Authors: Obladen Michael
Published: September 2021

This chapter describes infant burials and their history. When cities were established in Mesopotamia in the fifth millennium b.c.e., particular burial places evolved: adults and older children were interred in cemeteries outside the dwelling sites, infants were disposed of within their natal homes. On the Greek island of Astypalaia, a specific cemetery for newborns was used from 750 b.c.e. At the Athenian Agora, 449 fetal and neonatal skeletons were uncovered in a well. In Roman Italy, deceased infants were mostly disposed of in mass graves. From the 5th century, burial in church-associated cemeteries became the usual pattern in Anglo-Saxon Britain. Funeral rites included viewing of the deceased, prayer and religious service, procession to the gravesite, and burial. For deceased newborn infants, the adult rite was often practised in a simplified form. During the 19th century, burial clubs providing funds for funeral expenses were abused to make money from infanticide. The maintenance of unique mortuary practices lasting millennia suggests that newborns, especially when preterm or malformed, were considered unfinished, and of little societal importance.
Tissue healing
Authors: McGrouther Gus
Published: September 2021

This chapter describes in detail the processes of acute and chronic wound healing, and how these can be influenced by the plastic surgeon. Wound healing as it is relevant to graft take is also described. The chapter also discusses hypertrophic and keloid scar formation.
Sarcoma
Authors: Smith Ian M. , Itte Vinay
Published: September 2021

Sarcomas are malignant tumours of the soft tissues or bone. Epidemiology, aetiology, pathology, clinical features, investigations, diagnosis, staging, classification, and management of soft tissue sarcomas are described in this chapter. These tumours are relatively uncommon but require a systematic approach to treatment involving a multidisciplinary team.
Chronic postsurgical pain and complex regional pain syndrome
Authors: Colvin Lesley A. , Bourn Sebastian
Published: September 2021

Pain is defined by the International Association for the Study of Pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. Acute pain is predictable following surgical intervention; chronic pain is less so. Chronic pain, persisting for longer than 3 months, or beyond expected wound healing, is a worldwide problem affecting around 20% of the adult population. Chronic postsurgical pain is multifactorial, although it often involves some form of nerve damage, with clinical signs consistent with this. Neuropathic pain may have a greater impact on quality of life than other chronic pain syndromes. It is important, therefore, to identify neuropathic pain as early as possible, in order to initiate appropriate management and reduce longer-term impact. This chapter focuses on two types of neuropathic pain: chronic postsurgical pain and complex regional pain syndrome.
Classification of lower limb trauma
Authors: Khan Umraz
Published: September 2021

Accurate, simple, and reproducible classification of lower limb injuries facilitates communication between healthcare professionals, allows application of a standard treatment algorithm, and provides a platform for conducting detailed audit. The Gustilo and Anderson grading is widely used and is relatively simple but has poor inter-rater reliability and is best applied after wound excision. Other more comprehensive classifications (such as the AO system) are best used for audit and in outcomes databases.
Principles of acute management of lower limb trauma
Authors: Kelly Michael
Published: September 2021

The morbidity of lower limb trauma can be significant and a combination of orthopaedic and plastic surgery expertise is required from the initial assessment through to completion of treatment for these complex injuries. Guidelines have been established in the United Kingdom that address assessment, timing of treatment, and the management of soft tissue and skeletal components of injury. This chapter outlines these principles of treatment.
Microvascular cover in the lower limb
Authors: Arnež Zoran M.
Published: September 2021

Providing adequate and timely soft tissue cover is essential in the treatment of injuries to the lower extremity. Microvascular free tissue transfer is a part of the algorithm of treatment. Free flaps provide the desired quantity and quality of well-vascularized tissue from numerous potential donor sites all over the body, tailored to each specific defect. Microvascular surgery allows single-stage reconstruction of composite defects and is best done early, where possible in the first 24 hours or failing this, during the first week after injury. Free tissue transfer is a complex interdisciplinary procedure and can fail in up to 5% of cases. It is not appropriate for all patients. Free muscle, or musculocutaneous, flaps are ideal for coverage of diaphyseal defects whereas free fasciocutaneous flaps are better for coverage of metaphyseal defects. Perforator free flaps experience little donor site morbidity.
Management of bone loss
Authors: Jackson Mark
Published: September 2021

Bone defects in the lower limb are the result of trauma, tumour resection, infection, or congenital defects. They can be classified by cause or extent. The management depends on the extent. Options for treatment include allowing the defect to heal, augmenting a partial defect with bone graft, or in the case of segmental defects either shortening the bone to allow direct healing or replacing the segmental defect by techniques of bone transport, the Masquelet technique of membrane induction of bone graft incorporation, massive allograft replacement, or using the variety of vascularized bone flaps available.
How the foot and ankle works (mechanics of the foot)
Authors: Winson Ian
Published: September 2021

This chapter examines the mechanics of the foot from the clinician’s perspective. The kinematics, kinetics, muscle balance, and stability of the foot and ankle are complex, as the foot has evolved to provide shock absorption, stability, propulsion, and accommodation. It does this by maintaining a stable, balanced structure in all positions of the foot. The mobility of the joints together with their stabilizing structures (the ligaments of the foot), and the complex balance between muscle tension and tendon position relative to the axis of rotation of the joints, are responsible for this function. As a consequence of this complex dynamic structure, the foot stores a significant amount of energy during ambulation, and its efficient use of this is a major reason for the ability of humans to travel long distances.
Introduction to orthognathic surgery, the assessment of facial disproportion, and orthognathic treatment planning
Authors: Bates Claire , Hodge Trevor , Mannion Christopher J. , Carter Lachlan M.
Published: September 2021

Facial deformity associated with jaw malalignment and malocclusion can be addressed with orthognathic surgery to reposition the maxilla or mandible, or both, in combination with dental alignment with orthodontic treatment. Careful assessment of facial proportion and treatment planning allows precise repositioning of the facial skeleton and teeth to restore appearance and occlusion.
Preoperative imaging for autologous breast reconstruction
Authors: Ashton Mark , Whitaker Iain
Published: September 2021

A complete understanding of vascular anatomy is now integral to planning most, if not all, vascularized flaps in plastic surgery. Recent advances in preoperative imaging have provided an unheralded ability to investigate the vascular anatomy of planned donor and recipient sites for plastic surgical reconstruction, and as such, have been associated with a significant decrease in operative morbidity, operative time, and surgeon stress. This chapter provides a comprehensive review of the most recent advances in preoperative planning investigations for plastic surgery in the thorax and abdomen and autologous breast reconstruction.
Alternative flaps for microsurgical breast reconstruction
Authors: Rakhorst Hinne A.
Published: September 2021

Microsurgery in general has made dramatic improvements over the past decades. This applies to microsurgery in general and to breast reconstructive surgery especially. The demand for autologous breast reconstruction has risen. Since the introduction of the free transverse rectus abdominis myocutaneous (TRAM) flaps, through the muscle-sparing TRAM, flaps designs have evolved into the current gold standard, the deep inferior epigastric perforator (DIEP) flap. From experiences and increasing numbers of flap procedures performed by surgeons, techniques became more familiar and part of standard care. These factors gave rise to the development of a growing number of areas of the body where tissues of interest can be harvested using perforator flap-based techniques. This chapter discusses the most common as well as the ‘rising stars’ in terms of flaps to be used as alternative flaps to the DIEP flap for breast reconstruction. It discusses practical issues on dissection as well as donor site morbidity.
Hypospadias
Authors: Wharton Simon , Khan Khurram , Coleman David
Published: September 2021

Hypospadias is a congenital developmental penile anomaly characterized by a ventral ectopically sited meatus and a ventrally split foreskin, with or without ventral curvature. It occurs in about 1 in 125 live male births with both genetic and environmental aetiological factors. Hypospadias is corrected to allow micturition while standing, to achieve a natural appearance, and to allow normal sexual function. Operations to achieve this involve a combination of urethroplasty, glansplasty, and skin cover. Hypospadias repair should result in a straight, symmetrical penis with a natural slit-shaped terminal meatus. Normal function and appearance should be maintained with growth. It may be acceptable to complete the reconstruction by discarding the prepuce to give a circumcised appearance. However, in some cultures most boys are not circumcised and a prepuce reconstruction will be more appropriate.
Anatomy, physiology, and pathology of body fat
Authors: Teo Isabel , Soldin Mark
Published: September 2021

Subcutaneous body fat is a distinct anatomical entity with unique physiology, metabolism, and disease. The main roles of fat are energy storage, hormone production, and insulation. Free fatty acids and glycerol can be assembled into triglycerides, and conversely triglycerides can undergo lipolysis. Insulin is the key hormone that controls this fine balance. Pregnancy is associated with increased truncal body fat and breast ptosis. Cellulite is the padded appearance of fat and there is currently no single proven treatment. Lipomas are the most common soft tissue tumour and can be treated with excision or liposuction. Lipodystrophies are disorders characterized by the selective loss of body fat and lipofilling is a useful treatment modality. Panniculitis is the inflammation of subcutaneous fat and treatment involves dealing with the precipitating cause. The plastic surgeon should be familiar with the anatomy, physiology, and pathology of fat in order to treat this wide array of adipose-related conditions.
Abdominoplasty
Authors: Abela Christopher , Soldin Mark
Published: September 2021

The abdominoplasty or ‘tummy tuck’ is one of the most commonly requested aesthetic procedures and refers to a variety of surgical techniques. A detailed understanding of the surgical anatomy, deformity, the components that need redress, and the clinical decision-making algorithms are essential. Meticulous attention to perioperative optimization mitigates risk and complications. The evolution of the surgical techniques is ongoing particularly following the increased demand from massive weight-loss patients.
The extensor tendons
Authors: Majumder Sanjib
Published: September 2021

The extensor tendon system of the hand includes the forearm-based extrinsic extensors that power wrist and finger extension as well as the hand-based intrinsic extensors that stabilize the digits in extension. The anatomy and interaction of these tendons are described with reference to the topographic classification system of Verdan’s zones. The injuries of the extensors can be either closed or open and the treatment is injury and site specific. The approaches to the individual injuries and treatment are described.
Bone lesions in the upper limb and hand
Authors: Hooper Geoffrey
Published: September 2021

A wide variety of bony swellings may occur in the upper limb, although individually each is uncommon. Not all are neoplastic and many present not as palpable, swellings but as incidental findings on radiographs taken for other reasons. The surgeon must then establish a diagnosis and decide whether treatment is required. In the presence of pain or a pathological fracture this decision may be easier than in the asymptomatic lesion. This chapter describes the most common bony swellings in the upper limb and hand. Information about their diagnosis and management is given.
Dupuytren’s disease
Authors: Milner Richard
Published: September 2021

Dupuytren’s disease is benign fibromatosis affecting primarily the fascia of the hand and fingers. The epidemiology, pathology, and clinical presentation are described in this chapter. Non-surgical treatments, including clostridial collagenase injection, and a variety of surgical techniques are discussed. Expected outcomes are also described together with the author’s preferred treatment algorithm.
The burned patient
Authors: Wood Fiona , Judkins Keith
Published: September 2021

The pathophysiology of the burn patient is complex with far-reaching effects on virtually all tissues and organ systems. Management of the many different tissue disturbances is best in a multidisciplinary team—with clinicians dealing with their particular area of expertise as part of an organized and coordinated association. An understanding of the inflammatory response is key to understanding the effect of burn injury on different organ systems, and how this can be best modulated to improve patient outcomes. The effects of burn injury are local and systemic—with growing evidence that the long-term sequelae are equally widespread and lifelong.
Fillers and dermabrasive therapies
Authors: Archer Brett
Published: September 2021

Facial ageing involves several key processes: loss of volume; laxity of tissues; and surface skin changes of wrinkles, pigmentation, vascular lesions, and textural changes. Surgery remains the mainstay of treating laxity or sagging of tissues. Fillers are an increasingly popular and effective method of replacing lost volume, or preventing it, and there are a myriad of options for dealing with the surface skin changes. This chapter deals with the principles of the appropriate use of fillers by looking at the patient suitability, the products available, and the proficiency of the injector. Steps to avoid complications are outlined and the management of these rare complications are discussed. A brief discussion is given of the place of chemical peels, dermabrasion, topical agents, and lasers in the improvement of the appearance of ageing skin.
Primary management of cleft lip and palate
Authors: Neil-Dwyer Jason
Published: September 2021

Cleft lip and palate is a condition with the potential to impact the lifetime of a patient, affecting overall health, appearance, communication, facial growth, hearing, eating, dental health, and psychological well-being. To effectively manage these multiple effects, the treatment of cleft lip and/or palate requires involvement of multiple healthcare specialists. This multidisciplinary management is difficult to coordinate so is often delivered by extended multidisciplinary healthcare teams. The early management of a child with a cleft lip and/or palate centres on the well-being of the child. The focus is on feeding, breathing, and managing medical comorbidities. Care can require extensive input from paediatric medical specialists, and needs to occur prior to any surgical management of the cleft lip or palate. This chapter discusses the surgical and perisurgical management of the primary cleft lip and/or palate including manipulation of the cleft lip prior to definitive surgery, primary lip surgery, primary palate surgery, and primary closure of the alveolar cleft with an assumption of medical well-being.
Tumours of the nasopharynx, oropharynx, and hypopharynx
Authors: Iqbal Isma Z. , Balasubramanian Anusha , Paleri Vinidh
Published: September 2021

The pharynx (Greek for throat) is a 12 cm fibromuscular tube extending from the base of the skull above and fusing with the oesophagus below. The pharynx is the common entrance point for respiration and digestion and is divided into the three regions based on its anterior communications—the nasopharynx, the oropharynx and the laryngopharynx. Akin to three cups stacked one on top of the other, it is composed of three constrictor muscles inserting one into the other from superior to inferior, and three longitudinal muscles enabling elevation and dilatation. The pharynx serves the dual purpose of channelling food via the oesophagus into the digestive tract and enabling air to be directed via the larynx and trachea into the respiratory system. The pharyngeal structures also assist in vocalization of sounds and equalization of pressure within the middle ear. Management of pharyngeal neoplasia is challenging and is described in greater detail in published guidelines. This chapter summarizes the management of benign and malignant neoplastic diseases of the pharynx based on its anatomical subdivisions.
Anatomy and physiology of the facial nerve and aetiology of facial nerve palsy
Authors: Gilleard Onur , Tzafetta Kalliroi
Published: September 2021

Facial paralysis can have significant functional and social consequences and presents a challenging reconstructive problem for plastic surgeons. Detailed knowledge of facial nerve anatomy and an understanding of the natural history of the different conditions which result in facial palsy is a prerequisite for clinicians who are involved in the management of this devastating affliction.
Aesthetic surgery of the genitalia
Authors: Mughal Maleeha , Soldin Mark
Published: September 2021

Genital aesthetic surgery is a rapidly growing subspecialty in plastic surgery. Concerns about self-esteem and sexual identity issues have resulted in an increased demand from individuals seeking corrective or enhancing procedures. The surgeon must be able to understand the psychological, technical, and ethical issues linked with surgery to the external genitalia.
Transition of the initial mass function in the metal-poor environments
Authors: Chon Sunmyon , Omukai Kazuyuki , Schneider Raffaella
Published: September 2021

We study star cluster formation in a low-metallicity environment using three-dimensional hydrodynamic simulations. Starting from a turbulent cloud core, we follow the formation and growth of protostellar systems with different metallicities ranging from 10−6 to 0.1 Z⊙. The cooling induced by dust grains promotes fragmentation at small scales and the formation of low-mass stars with M* ∼ 0.01–0.1 M⊙. While the number of low-mass stars increases with metallicity, when Z/Z⊙ ≳ 10−5, the stellar mass distribution is still top-heavy for Z/Z⊙ ≲ 10−2 compared to the Chabrier initial mass function (IMF). In these cases, star formation begins after the turbulent motion decays and a single massive cloud core monolithically collapses to form a central massive stellar system. The circumstellar disc preferentially feeds the mass to the central massive stars, making the mass distribution top-heavy. When Z/Z⊙ = 0.1, collisions of the turbulent flows promote the onset of the star formation and a highly filamentary structure develops owing to efficient fine-structure line cooling. In this case, the mass supply to the massive stars is limited by the local gas reservoir and the mass is shared among the stars, leading to a Chabrier-like IMF. We conclude that cooling at the scales of the turbulent motion promotes the development of the filamentary structure and works as an important factor leading to the present-day IMF.
Giant cell arteritis with spontaneous remission
Authors: Álvarez-Lario Bonifacio , Lorenzo-Martín José Andrés , Colazo-Burlato María , Macarrón-Vicente Jesús Luis , Alonso-Valdivielso José Luis
Published: September 2021

The case of a 75-year-old woman diagnosed with polymyalgia rheumatica (PMR), treated with low doses of prednisone, and with clinical and analytical remission is reported. Two years later, she presented with a clinical picture of giant cell arteritis (GCA), including headache, diplopia, jaw pain, feeling of swelling in both temples, and elevation of acute phase reactants. Symptoms spontaneously subsided 2 weeks later, while analytical parameters improved without any treatment. A high-resolution colour Doppler ultrasound showed thickening of the intima–media complex with ‘halo’ sign in the right temporal artery. A biopsy of the right temporal artery was performed, although it was not successful, as no artery could be found, and the procedure became more complicated with an eyebrow ptosis due to a lesion in the frontal branch of the facial nerve. GCA diagnosis was based on the clinical, laboratory, and ultrasound findings. The patient was treated with prednisone and methotrexate, without clinical or analytical relapse. Comments are presented on the described cases of GCA with spontaneous remission, and the most appropriate treatments in these cases are discussed. Other peculiarities of the case, such as the progression to GCA more than 2 years after the onset of PMR, and the complications from the temporal artery biopsy are also mentioned.
A rare case of a patient with systemic lupus erythematosus who presented with Rowell syndrome responding to treatment with hydroxychloroquine and prednisone with 1 year of relapse-free survival on belimumab
Authors: Loghmani Arya , Ford Barrett , Derbes Stephen
Published: September 2021

Rowell syndrome, first described in 1963 by Rowell et al., is an infrequently reported and unique syndrome occurring in patients with systemic lupus erythematosus (SLE). This syndrome characteristically presents with erythema-multiforme-like lesions as well as other specific immunologic and histopathological manifestations. Since Rowell’s original description, diagnostic criteria have been proposed and modified to better describe the syndrome. We describe a 32-year-old African American female patient with a previous history of SLE who presented with dermatologic, immunologic, and histopathological manifestations that fit the modified diagnostic criteria for Rowell syndrome.
A unique salvage operation strategy: implantation of the ulnar total elbow component to the radius to overcome large ulnar bone defect caused by infection after total elbow arthroplasty
Authors: Tomizawa Takuya , Ito Hiromu , Murata Koichi , Matsuda Shuichi
Published: September 2021

The elbow joints of patients with rheumatoid arthritis (RA) are often destroyed, and total elbow arthroplasty (TEA) is one treatment for these patients. However, patients with RA tend to develop surgical site infections due to immunosuppression. Once an implant is infected, reoperation may be difficult because of the risk of reinfection. In such patients, the infected site must be debrided thoroughly, although this might reduce the bone scaffold needed for re-TEA. We used a unique method to manage a large ulnar bone defect and an infected implant. The patient with RA had undergone TEA 15 years earlier. Etanercept was initiated to control disease activity; however, this treatment led to infection of the elbow prosthesis. Several surgical debridements were performed to eradicate the bacteria, which improved the symptoms of infection. However, most of the proximal ulna was lost, and it seemed impossible to fix the prosthesis using the remaining small ulna after debridement. Therefore, we planned to implant the ulnar component into the radius as a salvage technique. With this procedure, we provided the patient with elbow mobility and eradicated the infection. This is an alternative method for restoring function in an elbow with a massive bone defect in the ulna.