bluuebunny/crossref_metadata_2025 huggingface dataset:
Radiotherapy In The Management Of Muscle-Invasive Bladder Cancer
Authors: Harrington K J , Sikora K
Published: October 2023

The patient population that presents with bladder cancer offers a number of specific challenges. These patients are frequently elderly, with a poor performance status and a number of concurrent medical conditions, often related to prior or ongoing tobacco smoking. Such patients are often unfit for radical surgery, either by virtue of the extent of the disease or the risk posed by the anaesthesia, and may not tolerate combined bladder-conserving therapeutic approaches using radiotherapy and chemotherapy. Careful selection of the most appropriate treatment strategy can result in effective palliation of symptoms and even complete resolution of the disease process before death due to an inter-current illness intervenes (1–3).
Integration Of Cytotoxic Chemotherapy Into Management Of Muscle-Invasive Bladder Cancer
Authors: Raghavan Derek , Andavolu Murthy
Published: October 2023

Approximately 10 000 cases of invasive bladder cancer are diagnosed in the United States each year, representing about 20% of incident cases of urothelial malignancy (1). Invasive bladder cancer is now considered to be a systemic disease as more than half of the presenting cases will eventually relapse with distant metastases (2), presumably because micrometastases are present early in the course of the disease. With this in mind, systemic chemotherapy has been added to locoregional treatment in an attempt to improve cure rates (3).
Palliative Care For Patients With Bladder Cancer
Authors: Harrington K J , Syrigos K N
Published: October 2023

To many the term palliative care is synonymous with the treatment of patients in the terminal phase of a disease process, usually cancer. However, this is a narrow view and fails to embrace the wide variety of clinical scenarios which can justifiably be included under this heading. It is more useful to consider that palliative care is the specific treatment given to patients with incurable disease with the aim of relieving disease-related symptoms and promoting physical, psychological, and spiritual well-being. In the sphere of malignant disease, palliative care legitimately includes active therapeutic manoeuvres such as the use of surgery, chemotherapy, and radiotherapy, as well as the more widely recognized palliative therapies such as pain relief. Many patients present with disease too advanced to allow for the possibility of cure and others may have concomitant medical conditions that preclude the use of aggressive therapy which might, under different circumstances, have offered the chance of a cure. In these patients the aim of treatment from the very outset is to achieve symptom palliation and, if possible, prolongation of their lives. Therefore, palliative care of patients with cancer is a challenging and diverse discipline in which palliative care physicians, oncologists, and surgeons can play an important part. In addition, the involvement of a variety of healthcare professionals including nurses, social workers, counsellors, physiotherapists, and occupational therapists as part of a multidisciplinary team allows important psychosocial issues to be addressed as part of the overall care package.
The Role Of The Research Nurse In The Management Of Bladder Cancer Patients
Authors: Bowerbank M M
Published: October 2023

As previous chapters have already suggested, the treatment of bladder cancer depends on the extent of the patient’s disease, as does the overall aim of treatment. For some, one treatment modality is enough, for others, a combination of surgery, chemotherapy or radiotherapy will be needed. Although advances have been made in the treatment of bladder cancer, overall management of this disease in all its stages, remains controversial. Unless current treatment modalities for this disease are evaluated within the auspices of large scale, prospective, randomized clinical trials, treatment is likely to remain controversial (1,2).
Your Spinal Pain —Top To Toe
Authors: Burn Loïc
Published: October 2023

There are two important, potentially confusing facts about the spine and pain. Firstly, problems in the spine can, and frequently do, lead to pain felt in almost any part of the body. When such pain is felt at a distance from its true source it is called ‘referred’ pain. With spinal pain this is very common indeed and, unfortunately, can make the diagnosis difficult. Tenderness can be referred in exactly the same way, and is as unreliable in indicating its source. The problems created by referred pain are discussed in the next chapter.
Self-Help —What You Can Do About Your Chronic Pain
Authors: Burn Loïc
Published: October 2023

In Chapter 8 we showed how crucial self, help is in the management of acute back and neck pain. Many believe it to be, together with manipulation, the main way to prevent loss of work and chronic pain. In the last chapter we demonstrated how pain clinics manage, basically by programmes of increasing exercise and activity, to often relieve chronic pain and, much more significantly, to reduce the level of disability caused by it. Thus, the same methods are used nowadays in the management of both acute and chronic pain-and for thesame reasons (less time off work, less pain, and less disability).
Treatments That May Help You
Authors: Burn Loïc
Published: October 2023

We have seen that it is difficult both to find the cause of back or neck pain and to give an accurate diagnosis. This means that it is also difficult to plan treatment. Indeed treatment is often a matter of trial and error! It is important that you are aware of and consider all the available treatments, particularly if surgery is contemplated. There are many treatments on offer; the one you are given will depend largely on to whom you go for help. (The next chapter looks at the people who may help you.)
Clinical interventions for fatigue
Authors: Ream Emma , Stone Paddy
Published: October 2023

Healthcare professionals are becoming increasingly aware of the difficulties patients with cancer face when they experience fatigue. A growing body of research portrays the relentlessness of this symptom for this group of patients, and describes the challenges associated with its successful management. Clinicians themselves have reported difficulties with assisting patients to cope with fatigue, and allude to their frustration when their intervention fails (Copp and Dunn 1993).
Fatigue and everyday function in people living with cancer
Authors: Mallinson Trudy , Cella David
Published: October 2023

Fatigue is becoming recognized as one of the most common and most devastating side-effects from cancer treatment. Previous research has identified that 70–80% of cancer patients will experience debilitating fatigue during the course of treatment (Portenoy et al. 1994). Further, fatigue does not always resolve with the termination of cancer therapy (Ferrell et al. 1996). Its impact on patients’ daily lives can range from difficulty completing simple tasks such as shopping, to resuming productive roles such as working and childcare (Messias et al. 1997).
Muscular dystrophy - an evolving concept
Authors: Emery Alan E H
Published: October 2023

Muscular dystrophy is one of the fastest growing fields in medicine, at both the clinical and laboratory level. Over the last 50 years or so, many important innovations in medical science have actually been initiated in studies of muscular dystrophy (Emery and Emery 1995). For example, the first application in medicine of discriminant function statistical analysis was in the 1950s for resolving clinical and genetic heterogeneity in these diseases. A little later the first application of Bayseian statistics was in risk calculations in muscular dystrophy, a statistical method of reverse genetics or, more precisely, positional cloning. This technique has subsequently been applied with great success to other forms of dystrophy as well as to many other genetic disorders.
Developing a role for counselling in the primary health care team
Authors: Dammers Jane , Wiener Jan
Published: October 2023

This chapter describes our view of past, present and possible future directions for counselling and its relationship to general practice. We have worked together as GP and psychotherapist for two decades, exploring how to build bridges across our two professions to bring medical and psychological models of work together to help patients with mental health problems. Our thinking, writing and the conferences and workshops we have helped to convene have emerged from a common starting point a belief in the value of a psychodynamic approach to work in a general practice set ting. GPs and psychodynamic counsellors share a longitudinal approach to acquiring information and understanding about their patients relatively slowly over time.
Counselling across social, sexual and ethnic differences
Authors: Zarbafi Ali
Published: October 2023

In this setting, the GP is the ‘gatekeeper’. By this I mean the key decision-maker, who either treats the patient or decides where the patient should go for tests or more specialized help. As the GP has very little time, there is a sense of speed. The short time spent on individual consultations, and the medical model, which prioritizes checking for physical symptoms for any complaint, defends the doctors from being overwhelmed and thus contains their anxieties and enables them to work effectively.
Ethical theory and principles
Authors: Miller Ronald Baker
Published: October 2023

The purpose of this chapter is twofold: (1) to provide an overview of ethical issues of concern to patients with kidney disease and to the physicians and other health care professionals who care for them; and (2) to review both theoretical and practical approaches for the analysis and resolution of clinical ethical problems. It is only in the 1980s and 1990s that ethics has been taught explicitly in medical schools, internal medicine residencies, and nephrology training programs.
India
Authors: Jha Vivekanand , Chugh Kirpal S
Published: October 2023

Organ transplantation in India is mostly confined to transplantation of kidneys using living-related and unrelated donors and, in a small number of patients, cadaver donors. With the recent development of split transplant technique, a few liver trans plants have also been performed successfully in some centers using living-related donors. The lack of infrastructure for harvesting cadaver organs has not only pre vented the growth of cadaver renal donor transplant programs but also of unpaired vital organs like heart, pancreas and liver. This communication highlights the ethical aspects of kidney transplantation in developing countries in general and India in particular.
Developmental dysplasia of the hip: natural history, results of treatment, and controversies
Authors: Morcuende Jose A , Weinstein Stuart L
Published: October 2023

Developmental dysplasia of the hip (DOH) is one of the most common problems in paediatric orthopaedics, and one of the most fascinating. DOH represents a spectrum of conditions that range from a simple neonatal instability to an established dislocation. The term developmental is now preferred to congenital because it is more encompassing as it is taken in the literal sense of organ growth and differentiation, which includes fetal, neonatal, and infantile periods.
Decision analysis: utility for everyday use?
Authors: Elwyn Glyn , Edwards Adrian , Eccles Martin , Rovner David
Published: October 2023

The final chapter in this section examines some of the background and issues arising from the decision making approach known as ‘decision analysis’. It is conceptually quite different from the other models or approaches just presented, ·although it includes the values of both professional and patient. Patient-centred medicine, shared decision making, and risk communication concern either the skills to engage the patient more directly in decisions about their treatment or care, or the nature of the information which may be most usefully provided or discussed with the patient. These approaches entail a transfer of responsibility from the professional more towards the patient.
Education and training of health care professionals
Authors: Towle Angela , Godolphin William
Published: October 2023

Hope (1996) defines the focus of evidence-based patient choice (EBPC) as the use of evidence-based information to help people make choices when they, or those close to them, are in need of health care. Neither he, nor other writers, have identified the knowledge, skills, and attitudes which health professionals require in order to practice EBPC nor described the ways in which EBPC can be implemented within the doctor-patient encounter. Our work has been based on the concept of informed shared decision making. We believe there are many similarities in terms of the knowledge, skills, and attitudes needed for both. We will therefore use our work on shared decision making as a model for exploring the teaching and learning of EBPC, the problems likely to be encountered, and possible solutions. In this chapter we focus particularly on the education and training of physicians. However, our preliminary work with dentists, pharmacists, physiotherapists, and occupational therapists suggests that the competences required for physicians are generalizable to other health care professionals.
Moving to the mainstream
Authors: Holmes-Rovner Margaret , Llewellyn-Thomas Hilary , Elwyn Glyn
Published: October 2023

Evidence-based patient choice (EBPC) may well be the future framework for health care, but it is definitely not yet in place in the clinical settings we observe. Evidence-based medicine (EBM) has had unparalleled influence over medicine, but its recent extension to encompass the realm of patient choice has not yet gained widespread acceptance. It may be an even more arduous journey than that faced by the pioneers of EBM.
The future
Authors: Coulter Angela
Published: October 2023

In September 1999 the British Medical Journal published a special theme issue entitled ‘Embracing patient partnership’. Following its publication visitors to the BMJ’s website were asked to respond to a brief questionnaire asking their views on consulting styles (BMJ 16/10/99). The survey ran over a two-week period from 17 September to 4 October. The results are shown in Table 18.1.
Managing thoughts, stress, and pain
Authors: Crossman Jane
Published: October 2023

In the sport psychology literature there is a well-known adage that states: “how you think is how you perform’. For injured athletes, the phrase can be translated to ‘how you think can affect how you progress in rehabilitation’. The thoughts that injured athletes have regarding their injury will influence their perception of it and its potential impact on their future athletic careers, their lives, and the length of time it takes to make a successful return to action. Negative mental preoccupations almost always affect stress levels and may lead to physical reactions such as muscle tension and pain.
The Role of Significant Others: Social Support During Injuries
Authors: Udry Eileen
Published: October 2023

Certain teammates were there through the injury ... they would fax me from wherever they were and let me know what the team was doing. That was really cool. But, definitely only some teammates-it’s just the people that are closest to you.
Editors’ note to Chapter 5
Authors: Downie R S , Macnaughton Jane , Randall Fiona
Published: October 2023

To illustrate the applicability of our central thesis—that evidence and judgement form a seamless garment—we invited a hospital consultant to consider how far this thesis might be relevant to a currently controversial area of health care: resource management, prioritizing, or rationing. We are particularly grateful to Dr Fiona Randall for agreeing to write this chapter. First, she is able to offer the perspective of a hospital consultant, and it is hospital consultants who are perhaps most aware of resource constraints. Second, we were interested to see how our general line of argument would work out in an area at the rock-face of current controversy. Her views on this important topic are much wider than can be expressed within the constraints we have imposed on her. No doubt she will have occasion to publish a more extended version of them.
Educating judgement: the humanities
Authors: Downie R S , Macnaughton Jane , Randall Fiona
Published: October 2023

This book has so far attempted to describe the knowledge, skills, and attributes required for someone to make good clinical judgements. It is clear that the doctor needs to understand his patient through a scientific knowledge of how the body works and appreciate how scientific research can help him make decisions about how best to treat a patient. But we have also discussed the ways in which this evidence-base must be modified in the clinic; a ‘humane’ doctor is required with the understanding (the interpretative ability and insights), governed by ethical sensitivity, to apply, in the particular clinical situation, scientific evidence and skills. As we shall see, a broad education is also required. This chapter is concerned with providing more detail on this capacity for humane judgement, and with considering how far it can be learned. Before we embark on this we should note that little will be said here directly about education for scientific judgement. This is because it is a large and important topic on its own, with a large literature.
Bandolier’s Little Book of Pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Acute and chronic pain place a huge burden on our society. Approximately 10% of the population in Western countries report suffering from chronic pain, and both chronic and acute pain are responsible for high absenteeism in the workplace. It is therefore crucial that we have effective ways of treating pain. Unfortunately though, we have no objective measures of pain - no blood tests, no urine dipsticks. We have to rely on what the patient tells us. So how then do we know what are and what are not effective pain treatments? It is here that the principles of evidence-based medicine have been of great value - helping us to understand the most effective forms of pain treatment. Bandolier’s Little Book of Pain is a unique portable guide to evidence-based pain treatments. For each possible treatment, the book provides the evidence supporting the efficacy of the treatment, along with a clinical bottom line, for those requiring immediate information. Written by world leaders in the field of evidenced-based pain treatments, the book will be indispensable for the multi-disciplinary professionals managing acute and chronic pain in primary and secondary care.
Clinical trial methods
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

If trials are not done properly, any results they produce will be worthless. We call this validity. What constitutes a valid trial depends on many factors, and so there are no absolute hard and fast rules that can cover every clinical eventuality. But for pain, we can make some important observations about what to look for in a valid clinical trial. We randomise trials to exclude selection bias. Trials are usually performed where there is uncertainty as to whether a treatment works (is better than no treatment or placebo), or whether one treatment is better than another. We start from a position of intellectual equipoise. But trials are often done by believers, and belief, even subconscious belief, might influence our choice of patients to have one treatment or another if we could choose.
Systematic review and meta-analysis
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Systematic reviews identify and review all the relevant studies, and are more likely to give a reliable answer. They use explicit methods and quality standards to reduce bias. Their results are the closest we are likely to get to the truth in the current state of knowledge. We will see (section 1.6) that even the best trials designed to tell us that an analgesic is better than placebo can give the wrong result just by the random play of chance. Systematic reviews (and meta-analysis, the statistical combining of information from many trials) are our best defence against making incorrect decisions based on inadequate data.
Injected morphine in postoperative pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. A 10-mg intramuscular dose of morphine is an effective analgesic. It has an NNT of 2.9 (2.6–3.6) for at least 50% pain relief over 4–6 h compared with placebo in pain of moderate to severe intensity. The incidence of minor adverse effects is significantly higher with 10 mg intramuscular morphine compared with placebo. Few trials of acceptable quality have been carried out. This is especially true for subcutaneous and intravenous studies. Morphine is the archetypal analgesic for use in moderate or severe pain. It is the principle alkaloid of opium, and is given by many different routes. Morphine is the ‘gold standard’ against which other injected analgesics are tested.
Dihydrocodeine in postoperative pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. A single 30 mg oral dose of dihydrocodeine does not provide effective analgesia. A 60-mg dose is significantly less effective than ibuprofen 400 mg. Quality data do not exist for a placebo comparison. Patients should be offered a more effective analgesic in the treatment of postoperative pain. Dihydrocodeine is a synthetic opioid analgesic which was developed in the early 1900s. Its structure and pharmacokinetics are similar to codeine, and it is used for the treatment of postoperative pain and as an antitussive. Nearly one tenth of all analgesic preparations issued in England were for dihydrocodeine in 1995.
Intramuscular pethidine in postoperative pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. Intramuscular pethidine is an effective analgesic. A single dose of intramuscular pethidine 100 mg had an NNT of 2.9 (2.3–3.9) for at least 50% pain relief over 4–6 h in patients with moderate or severe pain compared with placebo. This is similar to intramuscular morphine 10 mg which has an NNT of 2.9 (2.6–3.6). Based on small numbers of patients, pethidine 50 mg does not appear to offer effective pain relief. Pethidine 100 mg was associated with significantly more adverse effects than placebo. The NNH for a single intramuscular dose of pethidine 100 mg was 2.6 (2.1–3.6).
Topically applied non-steroidal anti-inflammatory drugs in acute pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. Topical NSAIDs are effective in the relief of pain caused by soft tissue injury, sprains, strains and trauma. Ketoprofen, felbinac, ibuprofen and piroxicam have proven efficacy. The NNT was 3.9 (3.4–4.3) for at least 50% pain relief after one week of topical NSAID use compared with placebo. Benzydamine and indomethacin did not appear to be effective. No significant local or systemic adverse effects are associated with topical NSAID use. Oral NSAIDs are associated with increased risk of adverse effects such as gastrointestinal problems. The question arises therefore whether topical NSAIDs, which are widely available without prescription, are more suitable for a number of conditions. However, it has also been argued that topical NSAIDs have no action other than as rubefacients.
Other acute pain interventions without evidence of efficacy
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

This section looks at a number of other interventions for acute pain where there is some evidence that they do not work. What is not included are interventions that could come under the heading of complementary therapy, which are dealt with in a later section. The format is a title, clinical bottom line, reference, and a brief commentary for each. Clinical bottom line. In renal colic NSAIDs act faster when given intravenously compared with intramuscular or rectal routes. This may be clinically relevant. In all other pain conditions there is no evidence that injected NSAIDs were better than oral. There is, however, increased reporting of adverse effects with intravenous and rectal administration.
Introduction
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

In chronic pain relief, just as in other therapeutic areas, there are often many ways to tackle a particular problem. There may be more or less evidence of benefit for each of the alternatives. The task facing us is to have a way of ranking the relative effectiveness of these interventions, and to couple that with knowledge of any hazards, minor or major. Then we can make informed decisions about which should be offered to patients. In an ideal world there would be large randomised trials comparing the various interventions. In practice what we have is a relatively small number of small studies. This section is not about how clinical trials are performed in chronic pain, but rather to set a scene in which the available evidence may be placed.
TENS for chronic pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Inclusion criteria were randomised trials in which the analgesic effect of repeated or continuous use of TENS was studied in patients with chronic pain (defined as pain of at least three months’ duration). Various sorts of TENS were included, with sham-TENS, or no treatment controls, or comparisons between different sorts of TENS, with different voltage, frequency or type of machine. Parallel, cross-over, or partial cross-over designs were accepted. Trial quality was generally poor because blinding was deemed impossible (active TENS causes tingling sensations). Studies were generally small, with poorly defined treatments and outcomes. Duration of use was variable.
Epidural corticosteroids for back pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. Epidural administration of corticosteroids is effective in the management of sciatica, with a NNT of 7.3 (4.7–16) for greater than 75% pain relief in the short-term (1–60 days), and a NNT of 13 (6.6–314) for greater than 50% pain relief in the long-term (12 weeks to one year). Epidural corticosteroids are commonly used in the treatment of low back pain and sciatica, although steroids are not currently licensed for epidural use in the UK. Steroids have a number of anti-inflammatory properties and an inhibitory effect on C-fibre conduction.
Cannabis for pain relief and for spasticity
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Chronic non-malignant pain. Two trials in two patients (both N of 1 trials with one patient in each) tetrahydrocannabinol 5 or 10 mg was better than placebo and about equivalent to codeine 50 mg. Cancer pain. Five trials with 128 patients. Tetrahydrocannabinol was roughly equivalent to codeine 60 mg in one trial.An analogue was also found to be equivalent to codeine 60 mg. Higher doses of tetrahydrocannabinol produced many adverse effects. At lower doses adverse effects were still more frequent than with standard analgesics.
NSAIDs for treating Osteoarthritis
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. NSAIDs effectively relieve pain by about half and increase mobility in about 60% of people with osteoarthritis. There is insufficient information to rank their effectiveness, but what information we have suggests that daily doses of diclofenac (100–150 mg) and naproxen (500–750 mg) are more effective than low doses of ibuprofen, and more effective than paracetamol. Non-steroidal anti-inflammatory drugs (NSAIDs) have become the common choice for treating rheumatological conditions like osteoarthritis, rheumatoid arthritis and gout.About 25 million prescriptions are written in the UK every year and most general practitioners will write a number of prescriptions every day because these are common conditions.
Paracetamol (acetaminophen) for Osteoarthritis
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

There were only four trials that fulfilled these inclusion criteria, and the main results are outlined in Table 5.7.1. Paracetamol 4000 mg daily was better than placebo in one trial, about the same as ibuprofen, but inferior to diclofenac and rofecoxib at usual daily doses. Total discontinuations in 345 patients over 4–6 weeks were 27%, 8% because of adverse events and 9% because of lack of efficacy. Based on this paucity of information it is hard to draw any sensible conclusions, other than such trials as we have broadly confirm clinical judgement, that paracetamol 4000 mg daily is effective for some patients, but will generally be inferior to top doses of NSAIDs.
Fish oil for rheumatoid Arthritis
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

The main inclusion criteria were that trials had to be randomised and double blind, to have a placebo control with results reported at baseline and follow up, and with a parallel or cross-over design. One quasirandomised study was included. This study used a search of MEDLINE from 1991, supplemented with additional searches and contacts to manufacturers. The review also obtained individual patient results and looked at results from an analysis of mean results of published material, and from an individual patient basis.
Strontium 89 therapy for painful bony metastases
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. Strontium 89 is useful in prostatic and breast cancer. Although it may not necessarily reduce pain from existing bony metastases, it appears to decrease the number of new sites developing. Strontium 89 appears to have similar clinical response rates to other radiopharmaceuticals with selective bone localisation. Most secondary bone lesions arise from primary carcinoma of the prostate, breast or lung, and external beam radiation therapy palliates 70% of lesions. However, this is not always adequate treatment for patients with multiple lesions and end-stage disease. In such cases pain relief is an important aspect of treatment.
Intracerebroventricular opioid therapy compared with epidural and subarachnoid opioids for intractable cancer pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. Intracerebroventricular (ICV) opioid therapy appears to be at least as effective as epidural or subarachnoid opioid therapy in patients with intractable cancer pain. Adverse effects and catheter/system related problems do not clearly favour one route. These should be carefully weighed when making a decision about method of delivery, but more rigorous data are needed in order to assess whether ICV is an appropriate first-line neuraxial treatment. Central or neuraxial opioid treatments have been used for the small number of cancer patients who do not respond to systemic treatment.
Complementary therapy at the end of life
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Six electronic databases were searched for papers about pain, dyspnoea, and nausea and vomiting at the end of life. The intention was to find papers that clearly studied interventions for these conditions, rather than surveys. The authors found 21 studies, 11 of which were randomised trials, two non-randomised controlled studies, and eight case series. Most of the studies investigated highly individual treatments in highly individual situations, so the likelihood of data pooling was low.
Efficiency-motivated responses to market failures
Authors: Dolan Paul , Olsen Jan Abel
Published: October 2023

Public intervention in the market for health care is based on two quite separate reasons: ‘market failures’ and equity. This chapter seeks to analyse the nature of market failures, emphasizing people’s selfish motivations for various forms of regulation in the distribution of health care.
Pyschodynamic theories in conversion hysteria
Authors: Shoenberg P J
Published: October 2023

A 19-year-old girl with an alteration in the pattern of her epileptic fits was admitted to a neurology ward. Originally these had been grand mal fits in childhood; more recently she developed a new form of fit: she appeared to suddenly lose consciousness and become lifeless or else become violent. Sometimes during an attack she put her hands up to her throat as if to strangle herself. Physical examination was normal. On the ward her fits increased in frequency. We moved her into a room where she was placed beside an oxygen cylinder and given oxygen whenever she had a fit. We increased her dose of anti- convulsants. One day during a ward round she had a fit in front of the consultant neurologist, who surprised us all by speaking to her.
Introduction
Authors: Szarewski Anne , Guillebaud John
Published: October 2023

Despite St Augustine, contraceptive methods of one sort or another have been used for thousands of years. Many ancient remedies were poorly effective and some downright dangerous. However, even with all our modern technology no one has yet managed to produce the perfect contraceptive method. In an ideal world, a contraceptive would provide complete protection against pregnancy, be entirely free of health risks and side-effects, not involve any action either during or immediately before intercourse, be completely reversible, not rely on the user’s memory, and not involve the medical profession. Nowadays it would be welcome if, in addition to all these things, it prevented the transmission of sexually transmitted diseases. It is likely to take a very long time before this ideal becomes a reality.
How the pill was developed
Authors: Szarewski Anne , Guillebaud John
Published: October 2023

Hormonal contraception is not a new idea, although the earliest experimenters did not realize that was what they were trying to achieve. Swallowing things as contraceptives, rather than using barriers, was advocated in many ancient civilizations. In China, for example, women were advised to swallow live tadpoles! In India one prescription among many suggested that large quantities of three-year-old molasses should be eaten every day for a fortnight. If any woman succeeded in doing this she was supposed to remain childless for the rest of her life. Another way of becoming permanently childless was to drink a potion made up of the Kallambha plant mixed with the feet of jungle flies.
Which pill will suit me best?
Authors: Szarewski Anne , Guillebaud John
Published: October 2023

In this chapter we will consider the so-called ‘minor’ side-effects of the pill, which are of course not at all minor to those who experience them. Indeed, women often do stop the pill not because of worries about health risks, but precisely because they are fed up with some nagging, ‘trivial’ side-effect. So, in fact, these side-effects are of great importance. In most cases the balance of oestrogen and progestogen in a particular pill formulation is responsible: we saw in Chapter I that each of these hormones has its own specific effects in the body, although these are modified when the two are combined in the pill. Your experience of any given brand will depend on which of the two hormones is dominating the combination.
Injectable progestogens and implants
Authors: Szarewski Anne , Guillebaud John
Published: October 2023

Injectable progestogens consist of the hormone progestogen given in the form of an injection. Because no oestrogen is contained in them people often believe that they must work and behave like the progestogen-only pill (POP); however, although some similarities exist, there are also some very significant differences. How do injectable progestogens work? The method is exactly the same as that of the combined pill; they stop ovulation. You may find this surprising, since the POP is, after all, also a progestogen-only method, but depends more heavily on thickening the cervical mucus so that it becomes impenetrable to sperm, and on making the lining of the womb thin, so that the fertilized egg cannot implant itself. Injectable progestogens perform both these functions, but since they work primarily by preventing ovulation, they are far more effective, having a failure rate of only 0.1 per hundred woman-years. This means that if 1,000 women used this method for a year, only one would be expected to become pregnant.
The neuropathophysiology of delirium
Authors: Trzepacz Paula , Mast Roos van der
Published: October 2023

Introduction

Multiple higher cortical functions and neural circuits are affected in delirium, hence Lipowski’s description of the disorder as ‘acute brain failure’. With its characteristic abrupt onset and fluctuating symptom severity, delirium is a severe neuropsychiatric disorder. It is usually associated with generalized EEG slowing, consistent with widespread cortical dysfunction causing a range of symptoms arising from different functional brain regions. Additionally, evoked potential abnormalities suggest involvement of subcortical areas including the brainstem and thalamus (Trzepacz 1994). Lack of primary motor and sensory signs (unless related to specific aetiologies, like asterixis) suggests that association cortices (secondary and tertiary), limbic structures and ascending neurotransmitter systems are principally affected in delirium. Neuroimaging and lesion reports suggest that prefrontal cortex, anterior thalamus, non-dominant parietal and fusiform cortex are also involved (Trzepacz 1999).
Oh to be a volunteer
Authors: Tyrrell David , Fielder Michael
Published: October 2023

The founding of the CCU somehow caught the public imagination. And this, of course, was because of the volunteers. There was nothing like it, or them, anywhere else in the world. When the Crown Film Unit produced a series of wartime films entitled Britain can make it, one of the last of these featured the CCU. It began with a woman sneezing at a conveyer belt in an armaments factory and ended with cheerful volunteers in their rooms, and a scientist handling vials of possible virus.
Musculoskeletal and autoimmune manifestations of non-rheumatic disorders
Authors: Peterson Karin S
Published: October 2023

The aim of this chapter is to provide a comprehensive discussion of disorders that may occasionally manifest with secondary musculoskeletal complaints and mimic Juvenile Idiopathic Arthritis. Musculoskeletal pain, arthritis or autoimmune phenomena are some- times encountered in a child already diagnosed with another disorder, such as diabetes, cystic fibrosis, or an immunodeficiency. In most instances this is not the occurrence of a second disease but a symptom related to the underlying disorder or, occasionally, its treatment.
Rheumatoid Factor Negative Polyarthritis
Authors: Martini Alberto
Published: October 2023

According to the revised International League of Associations for Rheumatology (ILAR) classification criteria [1] (Table 2.5.1), Rheumatoid Factor (RF) Negative Polyarthritis is defined as any form of arthritis which meets criteria for Juvenile Idiopathic Arthritis (JIA) (unknown origin, onset before the 16th birthday, at least 6 week duration), lacks circulating RF, and affects five or more joints during the first 6 months of disease. It is the least defined and possibly the most heterogeneous form of JIA. Patients who meet the criteria for the diagnosis of Systemic Arthritis, RF Positive Polyarthritis, Psoriatic Arthritis, and Enthesitis Related Arthritis are excluded.
Environmental factors in the pathogenesis of Juvenile Idiopathic Arthritis
Authors: Prakken Berent J , Albani, Salvatore , Kuis Wietse
Published: October 2023

The aim of this chapter is to provide an overview of the importance of the environment (especially the microbial environment) and its inter- action with the immune system in immunopathogenesis and disease susceptibility in Juvenile Idiopathic Arthritis (JIA). Juvenile Idiopathic Arthritis (JIA) consists of a complex of diseases with a multi-factorial pathogenesis [1]. Although genetic predisposition does play a role in disease susceptibility, JIA is not a monogenetic disease [2–4] (See Part 2, Chapter 2.10 “Genetic and Cytokine Associations in JIA”). Aside from genetic susceptibilities, environmental factors play an additional role in the pathogenesis of the disease.
Introduction
Authors: Malleson Peter N
Published: October 2023

Juvenile Idiopathic Arthritis (JIA) is a difficult condition to treat for a number of reasons. As has been discussed in the previous section JIA is not a single disease, but several conditions linked by the presence of a chronic arthritis affecting one or more joints in a child. A child with Oligoarthritis who has one inflamed knee is going to require a different management approach to a child who has Systemic Arthritis associated with severe daily fevers and pericarditis. Even within any particular subtype, the management may vary substantially for different individuals.
Physiotherapy and occupational therapy
Authors: Kuchta Gay , Davidson Iris
Published: October 2023

The aim of this chapter is to discuss the multiple roles of phyiotherapists and occupational therapists in the assessment and management of children with JIA as the disease evolves over time. The chapter emphasizes that the role of therapists is not only to address the physical functioning of the child, but working with other health care professionals to help optimize the child’s overall wellbeing and psychosocial health. Occupational therapists (OTs) and physiotherapists (PTs) comple- ment the drug therapy of Juvenile Idiopathic Arthritis (JIA), by focusing on the symptoms of rheumatic diseases and attempting to prevent disability.
The Mediterranean in the Age of the Renaissance 1200-1500
Authors: Denley Peter
Published: October 2023

In 1202 a learned hermit, Joachim of Fiore, died in his native Calabria. His writings were to rank amongst the most influential of the later Middle Ages. Joachim envisaged a reclassification of the ‘ages of the world’. To the conventional two ages of the Father and of the Son he added a third, that of the Spirit, which would be the equivalent of Paradise on earth. According to Joachim’s calculations man was coming to the end of the second age. The transition to the third age, scheduled for the year r 260, would come about through a monumental struggle between the forces of good and evil, and would involve the appearance of the Antichrist. Interest in apocalyptic soon grew with the diffusion of these texts, which of course were capable of many interpretations, making them just as influential when r 260 had come and gone.
Greek Drama
Authors: Levi Peter
Published: October 2023

There is plenty of drama in everyday life, and the experience of life is the source of everything that succeeds in the theatre. Almost every human society has formal drama of one kind or another, if we define the word loosely. We know the Greeks sat on theatre benches to watch sacred rituals. The ceremonies of state and of religion, and the moments of birth, death, marriage, harvest, and so on, have a great deal in common with theatrical drama, but we recognize drama strictly speaking because it uses actors, takes place in something like a theatre, an area defined by an audience, and probably has a plot, and more importantly an inner form, that we have learnt to expect. Once there is a theatre, there will be many other conventions: applause, competition, a style of speech, maybe the mask and the dance.
Cicero and Rome
Authors: Griffin Miriam
Published: October 2023

If we know more about these years than about any other period of Roman history, it is due principally to one man, Marcus Tullius Cicero. We have an abundance of speeches and letters written when he was deeply involved in day-to-day politics, either holding the highest offices of state or in contact with the men who were settling the future of the Mediterranean world. But it is not only political history that his works illuminate so brilliantly. When not at the centre of the stage, Cicero turned to literature of a more reflective sort and composed a corpus of theoretical works on philosophy and rhetoric richly adorned with contemporary examples and redolent of contemporary attitudes. Precisely because he was not an original thinker, Cicero helps us to recapture the intellectual habits of his generation.
Introduction: Remembering the Second World War in Italy
Authors: Morgan Philip
Published: October 2023

Most continental European countries, with the exception of the neutrals Sweden and Switzerland, have lived through one or all of the experiences of fascist dictatorship, and war, defeat, and foreign occupation. Even though West European countries had not become fascist before the outbreak of war, they suVered military defeat and Nazi German occupation. Some people collaborated with the occupier, some resisted, and the reasons for collaboration and resistance varied greatly. In other Nazi-occupied countries, as in Italy, during and after liberation, the resisters and the people took sometimes bloody revenge on those who collaborated with the Nazis.
Fascist Italy at War, 1940–1943: Propaganda and Reality
Authors: Morgan Philip
Published: October 2023

Italy’s ‘Fascist’ war, from June 1940 to July 1943, used to be something of a blank in the country’s historical consciousness. Most writing—and certainly most written-up memoirs—has tended to give more attention and significance to the events of 1943 to 1945 than to the events of 1940 to 1943. There are good reasons for giving preferential treatment to how the country left the Second World War, ahead of how Italy entered and fought a Fascist war. For the country as a whole, the years 1940 to 1943 were ones of almost continuous military defeat, a national humiliationfelt by all Italians.
Fascist Italy at War, 1940–1943: Collapse of the Home Front
Authors: Morgan Philip
Published: October 2023

Measured in terms of the physical, psychological, and political damage they inflicted, the Allied bombings of Italy during the Second World War must count as one of the most successful bombing campaigns ever. It would be pushing things too far to say that Allied bombing was responsible for the downfall of Mussolini in July 1943. But the bombings, together with the food situation, certainly caused a widespread loss of confidence in Mussolini and the Fascist regime and turned many Italians against the war.
Life Cheapens: The Descent into War
Authors: Mulholland Marc
Published: October 2023

As early as 1966 a shadowy paramilitary group, the Ulster Volunteer Force (named after the 1912 UVF), with some connections to the extremes of mainstream unionism, attempted to scupper O’Neillism by imitating republican violence. The UVF hoped to entrench existing polarities between communities and destroy illusions that Catholics could be loyal to the state. This coolly rational plan collapsed due to the sectarian enthusiasm of its members. In May it targeted a Catholic pub, mistakenly killing a Protestant woman; when in June it assassinated a Catholic man, Terence O’Neill declared the UVF illegal.
Conclusion
Authors: Mulholland Marc
Published: October 2023

Who won and who lost? Certainly, unionists cannot hope to return to an Ulster of old, securely British in all manifestations of state culture. The Troubles have locked Northern Ireland irreversibly into an Irish paradigm. Institutional recognition of this, in all-Ireland bodies, is likely to be permanent. Nor can nationalists have faith that Ireland will become ‘Gaelic and free’, shunning its community with Great Britain. The principle that only Northern Ireland can consent to fundamental constitutional change is more firmly enshrined now than when the violence began.