bluuebunny/crossref_metadata_2025 huggingface dataset:
Challenging Conversations in Palliative Care
Authors: Tanco Kimberson , Epner Daniel
Published: August 2018

Palliative care specialists manage a variety of difficult medical and psychosocial situations across a wide spectrum of medical conditions. Patient–physician communication is a critical element for the provision of quality palliative care and improving patient satisfaction. It is essential for palliative care clinicians to be aware of the various challenging conversions they will encounter in their routine clinical care and to develop the necessary skill set to adequately address these. Several communication techniques, such as a sitting posture during a conversion, proper use of silence, listening, and recognizing emotional movements and responding to them, are important so as to improve clinical care for patients and their families.
Geriatric Issues in Palliative Care
Authors: Guay Marvin Omar Delgado , Yennurajalingam Sriram
Published: August 2018

The proportion of patients aged 65 years or older is steadily increasing within United States. Older patients reaching end of life frequently have multiple chronic debilitating diseases. The approach to managing palliative care issues in the geriatric population is similar to that for younger adults except that assessment and management is more complex due to the presence of a higher frequency of comorbid illness, prolonged course of illness, and functional impairment. Management of palliative care issues in patients with advanced dementia is complex and often involves comprehensive geriatric assessment and interdisciplinary care. This chapter reviews various geriatric issues in palliative care.
Human Immunodeficiency Virus and Palliative Care
Authors: Weru John
Published: August 2018

Palliative care is an interdisciplinary care to relieve suffering and improve quality of life for patients and their families. The development of effective combination antiretroviral therapy has transformed HIV from a terminal to a chronic condition, with patients living longer but also experiencing more extensive symptoms that significantly impact quality of life. As a result, the role of palliative care has evolved to ameliorating distressing symptoms including pain while at the same time offering psychosocial and spiritual support for patients and families and preparing them for a dignified death. This chapter discusses some of the challenges and symptoms that patients and families encounter as they face this life-limiting disease.
Burnout in Palliative Care
Authors: Mackey Regina M. , Reddy Suresh
Published: August 2018

Recent studies have shown that increasing numbers of palliative care clinicians are feeling stress and burnout and also feeling dissatisfied with their professional life. Stress was high in the initial hospice movement, but it was low compared to that in other specialties. This was possibly due to early recognition and help seeking and possibly because palliative care clinicians were good at handling difficult situations. Stress in palliative care is mostly due to lack of organizational and social support and increased workload with no decision-making capacity. However, in recent research, burnout among palliative care specialists was found to be high (62%)—even higher than that for oncologists (45%). This may be due to the rapid growth of palliative care after it was recognized as a subspecialty, an increasing body of knowledge, evidence for the benefits of palliative care, and demand for palliative care service.
Research in Terminally Ill Patients
Authors: Yennurajalingam Sriram
Published: August 2018

It is important to conduct quality palliative care research so as to improve care in this distressed population. However, research in palliative care is challenging due to the high symptom burden and issues related to it, including poor accrual, and higher dropout rates compared to those of patients with chronic disease states. Additionally, patients receiving palliative care are considered a vulnerable population due to the presence of severe symptom distress and limited treatment options available. It is therefore important to address all ethical issues related to participation in a clinical trial. This chapter reviews key concepts with regard to research in terminally ill patients.
Palliative Care in the Intensive Care Unit
Authors: Isaac Margaret L. , Curtis J. Randall
Published: August 2018

Palliative care is increasingly recognized as an important component of care for all critically ill patients and should include both improving the primary palliative care skills of all clinicians working in the intensive care unit (ICU) as well as incorporating palliative care specialists for patients and families with unmet palliative care needs. This chapter highlights the key issues related to palliative care in ICU and evidence-based strategies to manage these issues. Topics covered include screening criteria to help identify patients with a high likelihood of unmet palliative care needs, withdrawal of life support (checklist and communication), providing prognostic information, quality indicators for end-of-life care in the ICU, and symptom assessment and management in the ICU.
We’re All in This Together
Authors: Krauter Cheryl
Published: August 2018

This chapter highlights and endorses a focus on continued progress in the area of integrative cancer care that assists the needs of the patients and also includes attention to the well-being of clinicians in cancer survivor care. Introducing a simple, relational structure that allows for both patients and clinicians to create a healing connection is one workable solution to the issues of quality survivorship care that can provide meaning and satisfaction to all concerned. The chapter provides evidence-based material on the vital importance of providing clinicians with meaningful support in their professional lives. It addresses their work–life balance and the importance of restoring their sense of personal meaning and quality of life to prevent burnout.
The Healing Power of Authenticity
Authors: Krauter Cheryl
Published: August 2018

This chapter translates a humanistic therapeutic approach to cancer survivorship care. Being seen, heard, and understood for who you are and where you are in the given moments of your life is a basic human need; this essential aspect of relationship is the bedrock of effective communication. To present practical approaches in clinical practice to enhance relationships with patients, topics in this chapter include engagement with patients; utilization of here-and-now communication; use of empathy in interactions; the powerful uses of bringing presence into the work of helping patients face emotional distress; the existential dilemma of meaning; the differences between fixing a problem and being present; doing versus being. This chapter illustrates the importance of developing the practice of listening as a guide for assessment and making appropriate referrals to psychotherapy or other integrative practices.
Taking Care of Each Other
Authors: Krauter Cheryl
Published: August 2018

This chapter discusses the acceptance of professional competence that allows for compassion toward oneself as well as toward other professionals. This chapter addresses how to recognize distress in others, offer support and assistance to those in distress, validate the setting of appropriate boundaries—for one’s self and for others—and reduce the conflict that arises between work and family life. This chapter promotes dialogue between providers by challenging the stigma that providers should be wary of sharing their emotional concerns and by supporting an open dialogue between colleagues as well as advocating for the request for help and support. A primary focus is on open communication and teamwork, and readers are supported to create a viable plan that supports clarity in cancer navigation.
Crisis Management in the Perioperative Setting
Authors: Clavijo Claudia F. , Zeidan Ronnie , Riveros-Perez Efrain
Published: August 2018

Anesthesiologists play a fundamental role in patient safety, particularly in emergent situations or during a crisis in the perioperative setting. Adequate knowledge and constant preparation is required to manage these events appropriately. This chapter discusses the common intraoperative crises that anesthesia residents encounter, especially during the first few months of residency; these include laryngospasm, oxygen failure, anaphylaxis, local anesthetic systemic toxicity, malignant hyperthermia, surgical site infections, and operating room fires. We also review the presentation and pathophysiology and provide step-by-step corrective actions to manage these crises until help arrives, including the use of medications, supplies, and equipment. A stepwise therapeutic approach to cardiac arrest in the operating room is also addressed.
Postanesthesia Care on the Day of Surgery
Authors: Van Drunen Lindsey , Dwarakanath Sanjay
Published: August 2018

This chapter presents key aspects to help those early in their anesthesia career to provide safe and efficient care to patients. It includes tips for safe transport of patients after surgery, effective hand-off reporting to the next level of care, and criteria to assess readiness of a patient to be discharged from the postanesthesia care unit (PACU). It also discusses common PACU complications such as pain and postoperative nausea and vomiting and approaches to treating them. Finally, it discusses PACU discharge instructions for patients after ambulatory surgery, with special attention paid for elderly patients or those with obstructive sleep apnea.
Evaluating rheumatological and musculoskeletal symptoms
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

General rheumatological assessment is for musculoskeletal pain, stiffness or swelling, weakness, fever, rashes, and fatigue. This chapter describes both the nature of those symptoms helpful in making a diagnosis and also the subjective elements influenced by exertion, loss of function, anxiety, cultural norms, and other symptoms. In children and adolescents, symptoms are also influenced by developmental stage and may present simply as a limp or loss of limb function. Other referrals are for symptom complexes (such as Raynaud’s disease) or isolated abnormal investigations (such as elevated erythrocyte sedimentation rate or antinuclear antibody). Both paediatric and adult assessment requires the effective use of the (p)GALS screening examination tool described here. The nature of symptoms requiring rheumatological assessment varies according to diagnosis and has a subjective element influenced by exertion, impact, anxiety, cultural norms, and associated symptoms. They include musculoskeletal pain and stiffness, weakness or loss of limb function, fever, and also fatigue. Other referrals require assessment of symptom complexes or isolated abnormal investigations.
Musculoskeletal assessment and patterns of disease: making a working diagnosis
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

The key to a rheumatological diagnosis and formulation of an effective management plan is a structured history and thorough examination that assesses the extent or impact of disease, screens for asymptomatic components, and tests for any red flags and incongruence. This, in turn, focuses the use of investigations, which alone rarely provide a diagnosis. Our structured approach aims to identify (1) those conditions not be missed; (2) normal variants; (3) inflammatory and non-inflammatory causes of pain, including chronic pain; (4) mono/oligo articular diagnoses; (5) multi/polyarticular or widespread presentations; and (6) diagnoses with systemic features. Assessment of the child and adolescent acknowledges the impact of musculoskeletal development on presentation and a parental-derived history. All assessment includes evaluation of infectious causes of musculoskeletal pain, gait, limp, muscle weakness and polysymptomatology.
Regional musculoskeletal symptoms: making a working diagnosis
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

This extensive chapter facilitates a focused regional musculoskeletal assessment with additional detail specific to children and adolescents. Taking each region or joint in turn, the reader is supported with (1) tables of differential diagnoses; (2) detailed descriptions of anatomy including reference ranges; (3) lines of enquiry that identify work- or sport-related injury; (4) examination that recognizes radiation, neuropathy, impingement, myopathy, and stress; (5) functional assessment; and (6) specific tests. In children, there is an additional focus on developmental or normal variants and dysplasia. The chapter also draws attention to common errors in assessment and mimics, the relative merits of investigation, and, when not covered elsewhere, treatments of joint-specific problems. The chapter is thorough, although not exhaustive, and supplements general enquiry.
Osteoarthritis
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

This chapter describes the epidemiology, aetiopathogenesis, presenting features, clinical manifestations, and management of osteoarthritis. Commonly used investigations for osteoarthritis, their indication, and interpretation are described. A summary of the commonly used drugs for the treatment of osteoarthritis, their mechanism of action, and key points for starting are included. Non-pharmacological holistic management is also discussed. Exciting emerging therapies that could change the future landscape of osteoarthritis management are introduced.
Systemic lupus erythematosus
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

The multisystem, autoimmune nature of systemic lupus erythematosus (SLE) and its broad spectrum of presenting clinical manifestations are explored in detail in this chapter. Important comorbidities and associations between SLE and the antiphospholipid syndrome and pregnancy are also discussed. The chapter details the various autoantibodies associated with the disease, along with their prevalence and associated clinical features. In addition, it provides a detailed review of the management of SLE, starting from conservative measures through to disease-modifying, immunosuppressive therapy to plasma exchange and stem cell transplantation. Novel therapeutic agents are also summarized, along with a note on prognosis. The chapter includes a section on childhood and neonatal SLE, covering presentation, relevant investigations, and treatment.
Systemic sclerosis and related disorders
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

This chapter focuses on systemic sclerosis, a generalized autoimmune connective tissue disease. It describes the epidemiology and classification of systemic sclerosis, along with its pathophysiology and potential triggers of disease. It also discusses the condition’s broad spectrum of clinical manifestations and highlights its potential for multiorgan involvement and life-threatening complications. Furthermore, the chapter provides insights into the definitions for related conditions such as morphoea and its different subtypes. Complexities around the treatment and a discussion on the prognosis and outcomes of systemic sclerosis and related conditions are also included.
Idiopathic inflammatory myopathies including polymyositis and dermatomyositis
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

This chapter explores the epidemiology and pathophysiology of idiopathic inflammatory myopathies. The chapter takes a focus on polymyositis and dermatomyositis and describes relevant diagnostic criteria, clinical presentations, investigations, and therapeutic options. Other inflammatory myopathies discussed include inclusion-body myositis and other (adult) inflammatory myopathies such as those induced by drugs. The chapter closes with a description of juvenile idiopathic inflammatory myopathies, a heterogeneous group of inflammatory muscle conditions affecting young people and consisting of juvenile dermatomyositis and amyopathic juvenile dermatomyositis among others.
Metabolic bone diseases
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

The Oxford Handbook of Rheumatology, 4th edition, includes a chapter on metabolic bone diseases with an extensive review of the modern management of all forms of osteoporosis and fracture risk assessment including glucocorticoid-induced osteoporosis, idiopathic juvenile osteoporosis, and DXA scanning. The chapter outlines the salient features of other less common and occasionally encountered bone diseases found in rheumatological practice including vitamin D deficiency, osteomalacia and rickets, hypercalcaemia, parathyroid disease, Paget’s disease of bone, SAPHO syndrome, osteochondroses, osteonecrosis, fibrous dysplasia, sclerosing bone dysplasias, and bone tumours. New to this Handbook edition is a section on the main childhood autoinflammatory conditions manifest as skeletal disease under the umbrella term chronic non-bacterial osteomyelitis.
Infection and rheumatic disease
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

Infectious agents have been linked directly and indirectly to a number of acute and chronic inflammatory rheumatological diseases. This chapter introduces some examples of the organism-specific and autoimmune responses leading to rheumatic disease. The epidemiology, aetiopathogenesis, classification criteria, clinical presentation, and management of septic arthritis (pyogenic non-gonococcal arthritis and gonococcal arthritis), Mycobacterium tuberculosis arthritis, osteomyelitis, Lyme disease, rheumatic fever, septic bursitis, and atypical mycobacterial infection are presented.
Rare autoinflammatory and miscellaneous diseases
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

This chapter provides a systematic approach to rare autoimmune and autoinflammatory or monogenetic genetic conditions. These conditions typically present with characteristic fevers such as familial Mediterranean fever, TRAPS, cryopyrin-associated periodic syndromes, and adult-onset Still’s disease; characteristic skin manifestations such as panniculitis, neutrophilic dermatoses, and eosinophilic fasciitis; or with refractory synovial disease or polychondritis. Rare multisystem conditions of unknown aetiology including sarcoidosis, Behçet’s disease, amyloidosis, and immunoglobulin G4-related disease are described in terms of organ or system involvement.
Hereditary disorders of connective tissue
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

The Oxford Handbook of Rheumatology, 4th edition, includes a chapter on the hereditary diseases of connective tissue. Of importance, up-to-date genetic information and classification of subtypes of osteogenesis imperfecta is reviewed. There is a summary of a broad range of diseases of connective tissue including Marfan syndrome, Stickler disease, and arthrogryposis—conditions encountered occasionally by the rheumatologist. The chapter details the new 2017 criteria for Ehlers–Danlos syndrome and outlines the new classification for the hypermobility spectrum disorders and the distinction between generalized, localized, and regional hypermobility and hypermobility Ehlers–Danlos syndrome, both in adults and in children.
Spinal disorders and back pain
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

The Oxford Handbook of Rheumatology, 4th edition, chapter on ‘Spinal disorders and back pain’ brings together a pragmatic approach to categorizing back pain, how to investigate disorders presenting with back pain, and how to treat adults, children, and adolescents with back pain. In the chapter, the management of back pain is separated into acute, subacute, and chronic presenting scenarios and the text makes reference to other chapters in the book where there may be some additional useful information (e.g. spondyloarthritis-associated back pain in Chapter 8 and chronic pain syndromes in Chapter 22). Notably the chapter is best read in conjunction with relevant sections in Chapter 3 (‘Regional musculoskeletal symptoms: making a working diagnosis’). The chapter makes reference to the need for a rigorous diagnostic approach to all the conditions which cause back pain, and at whatever age. There are subsections on how to assess paediatric spinal disorders and how to take a broad holistic approach to managing chronic back pain where there is no specific diagnosis.
Glucocorticoid injection therapy
Authors: Clunie Gavin , Wilkinson Nick , Nikiphorou Elena , Jadon Deepak R.
Published: August 2018

The Oxford Handbook of Rheumatology, 4th edition, includes a chapter on glucocorticoid (‘steroid’) injection therapy. Soft tissue, tendon sheath, tendon insertion (enthesis), and joint injections are commonly carried out by rheumatologists in outpatient clinics. The chapter outlines the principles of injection techniques referring to the utility of both image-guided and non-imaging-guided injection procedures and cross-refers to line drawings of joint and tendons elsewhere in the book. The chapter focuses also on the use of injections in the context of managing specific disorders such as tennis elbow, plantar fasciitis, carpal tunnel syndrome, and greater trochanter pain syndrome, thus placing injection therapy in the context of alternatively available therapies.
Principles of evidence-based medicine
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Evidence-based medicine (EBM) is an effective tool for identifying and critically appraising quality research findings, and allowing the best to be integrated within clinical practice. EBM requires familiarity with evidence grading systems, key statistical methods, and requires a good understanding of how to review and critique scientific papers to guide the clinical practice. This chapter introduces these tools and provide an easy-to-use layout for reading academic papers in hand.
Principles of good surgical practice
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

The importance of the surgeon’s professional responsibilities goes beyond immediate good clinical practice into the wider purpose and values that underpin the profession. Acceptable levels of good surgical practice, as detailed in the GMC Good Medical Practice, requires a good understanding and a proper application of relationship and responsibilities with patients and colleagues, as well as other issues, safety and quality, clinical governance framework, providing references, and advising on sensitive issues, such as end of life management. Maintaining boundaries with patients should also be respected all the time.
Principles of admission management
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Effective management of emergency and elective admissions is a multi-disciplinary process involving doctors, nurses, and hospital management. A safe and effective admission process should include a concise medical assessment by the admitting physician alongside evaluation of the patient’s social, nutritional, and functional status. Multi-disciplinary input should also be sought to ensure patients are discharged to a safe and supported environment when they are medically fit. All aspects of the patient pathway should be routinely evaluated through audit to ensure quality standards are maintained.
Good consent practice
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Patients consenting to a procedure must be able to appreciate and understand the implications of the proposed action. Physicians obtaining consent from patients must therefore possess the knowledge to present sufficient information to the patient to allow them to make an informed decision based on the risks and benefits of the procedure. It is best practice for the performing clinician to obtain consent; however, delegation of this task to appropriately trained staff is acceptable. Patients should be presented with all information required to make an informed decision except in exceptional cases where disclosure of information could result in serious harm to the patient. An assessment of capacity should be undertaken prior to obtaining consent for any procedure.
Preoperative assessment
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

All patients scheduled for procedures should undergo preoperative assessment. The process should aim to identify, evaluate, and optimize medical comorbidities that may otherwise have an adverse effect on outcome. In addition, it provides an opportunity to ensure that the patient comprehends the proposed procedure and is happy to proceed. A complete assessment including history, examination, ASA grade, and consideration of functional status should be performed by an appropriate health professional. Investigations should be performed only if they contribute to the preoperative process and subsequent management of the patient. Physicians should be vigilant of pre-existing cardiac or respiratory disease as these two systems are the most common cause of perioperative complications. A more thorough workup may be indicated in these cases and risk reduction strategies put in place.
Perioperative fasting
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Adequate perioperative fasting should aim to keep patients comfortable and hydrated whilst allowing for a safe anaesthesia. Instructions for fasting should be clearly communicated to both patients and care providers. The practice of complete abstention from food and drink for 8–12 hours should be avoided in favour of updated recommendations such as the ‘2 and 6 rule’ for healthy adults and the ‘2, 4 and 6 rule’ in children. Measures should be taken to mediate the risk of aspiration or regurgitation in patients who are considered high risk and can include the use of nasogastric tubes, proton pump inhibitors, and gastrokinetic agents. Oral fluid intake should be encouraged early in the post-operative period providing it is not contraindicated.
Preoperative assessment of bleeding risk
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Unselected coagulation testing is less evidenced based in assessing bleeding risk, prior to surgery. This not only delays surgery inappropriately but also causes unnecessary concern in patients who are found to have ‘abnormal’ tests. In addition, it is associated with a significant cost. Patients with a negative bleeding history do not require routine coagulation screening prior to surgery. Patients undergoing surgery should have a screening bleeding history taken. This should include structured detailed history, personal and family history, previous surgery and trauma, and detail of anti-thrombotic medication. Based on a detailed history, a few selected tests should be undertaken. In addition, liaise with the haematologist in the presence of positive bleeding history, significant comorbidities, and when high risk surgery is planned.
Venous thromboembolism (VTE) prophylaxis
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Venous thromboembolism is a common but largely preventable complication following surgery. However, fatal complications can occur as a result of pulmonary embolism following deep vein thrombosis. A structured risk assessment should be performed preoperatively in all surgical patients and thromboprophylaxis measures should be tailored according to patient- and procedure-related factors. These measures include anticoagulation with low molecular weight heparin and the use of mechanical compression devices.
Principles of trauma management
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Major trauma is defined as an injury or a combination of injuries that are life-threatening and could be life changing because it may result in long-term disability. The impact of trauma is huge. Injuries from accidental trauma worldwide causes moderate to severe disability in > 45m people each year. Trauma is the biggest killer of people age < 45y. UK annual trauma cost is ~£0.35b in immediate treatment; subsequent financial costs are unknown. UK annual lost economic output due to major trauma is ~£3.5b. Trauma management is challenging. Up to 40% of trauma patients have injuries that are initially missed, and up to 20% of these are clinically significant. The trauma team should be appropriately formed to achieve the assigned level of care and prioritize management. Guidelines for specific organ trauma management should be followed and practice standardized to ensure the best outcome.
Principles of infection control
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

The control and prevention of hospital-acquired infection is a legal obligation. Identifying high-risk patients and isolating them is very necessary. High-risk patients who are on multiple antibiotics, had previous MRSA infection, are HIV positive, are on haemodialysis, and general patients on high-risk units should be screened regularly for MRSA and C. diff-associated diarrhoea. Strict antibiotic prescribing policy, early isolation of infected patients, appropriate use of personal protective devices, hand hygiene, and staff education and training are mandatory for prevention of infection.
Gastro-oesophageal reflux disease (GORD)
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Gastro-oesophageal reflux disease is common, and may lead to debilitating symptoms as well as being a cancer risk. The chapter provides recommendations on investigations including endoscopy, medical management, and the place of anti-reflux surgery.
Ingestion of foreign bodies
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Foreign body ingestion presents an infrequent dilemma to the surgeon in the emergency setting. Essentially the risk of perforation and obstruction has to be weighed against the risk of intervention and retrieval. Differing objects also have differing guidelines for management and available recommendations are summarized in this chapter.
Achalasia
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Achalasia is an unusual motility disorder and is poorly understood. Accurate diagnosis is essential with a management plan tailored to severity of disease. The chapter describes diagnosis and management pathways including the place of dilatation, management of difficult cases with surgical myotomy, as well as a summary of newer treatments.
Oesophageal cancer
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Management of oesophageal cancer is a demanding sub-specialist surgical area and requires early diagnosis and optimum accurate staging for best outcomes. Patient selection for interventional treatment is also at the heart of appropriate management. The place of chemotherapy and chemoradiotherapy within current guidelines are discussed as well as oesophagectomy/ cardiooesophagectomy. Endoscopic therapies which have emerged for very early disease are also highlighted.
Management of oesophageal variceal haemorrhage
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Haemorrhage from oesophageal varices is potentially life-threatening and occurs unpredictably. Risk reduction can be achieved by identifying varices in cirrhotic patients and employing a surveillance strategy for low-risk cases, or pharmacological prophylaxis in higher-risk cases. This chapter sets out a summary of current national/international guidelines and includes detailed recommendations for management of acute haemorrhage including terlipressin, endoscopic EVL/sclerotherapy and Sengastaken tube therapy and TIPS.
Peptic ulcer disease
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Identification of H.pylori as a major risk factor for peptic ulcer disease has clearly revolutionized management and prevention of this condition. This has lead to production of clear guidelines for risk assessment, appropriate investigation including endoscopy and eradication therapy. H.pylori testing can be through a CLO test, carbon breath testing, or a stool antigen test. Second-line treatment and follow-up guidelines are also covered.
Neuroendocrine tumours (NETs)
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Neuroendocrine tumours (NETs) are rare GI tract tumours and most are asymptomatic. Understanding the pathobiology, genetic aspects, and possible clinical presentations is essential for management. The chapter discusses carcinoid syndrome, insulinoma, gastrinoma, glucagonoma and other NETs, as well as recommendations on investigation/localization, surgical resection, and peri-operative preparation of patients.
Surgery for obesity
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

In the UK, about 22% of adults are clinically obese. This has brought with it increased incidence of diabetes, hypertension, and ischaemic heart disease. Assessment of degree of obesity and health risk needs to be defined. Effective management then involves a multidisciplinary team. Lifestyle interventions, pharmaceutical management, and the principles of bariatric surgery are covered in this chapter, including gastric band, gastric bypass, vertical banded gastroplasty, and biliopancreatic diversion.
Acute appendicitis
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Appendicitis is the most common general surgical emergency. Pathogenesis is likely due to obstruction of the appendix lumen. Accurate diagnosis has always been a challenge. The use of C-reactive protein (CRP) estimation increases accuracy, as does focused ultrasound scanning, CT scanning, and MRI. The use of laparoscopy and laparoscopic appendicectomy are compared to the open approach. Conservative management with antibiotics is also covered, as well as appendicitis in pregnancy.
Pancreatic cancer
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Pancreatic cancer is the tenth most common cancer in the UK and is most often incurable at diagnosis. Presentation is generally with weight loss, jaundice, and or abdominal pain. Abdominal ultrasound, CT and MRI may be diagnostic. Tissue diagnosis is not usually necessary, but endoscopic ultrasound can obtain fine needle samples. The serum marker CA19-9 may be raised, but is not a screening test. Potentially curable lesions need careful multidisciplinary assessment for resectability, and a thorough assessment of patient fitness. The Whipple procedure is discussed as well as laparoscopic pancreatectomy. Adjuvant chemotherapy and palliative gemcitabine therapy are also covered.
Surgical management of liver metastasis
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

The liver is the most common site for metastases. Perioperative investigations are explored and are critical to the decision as to whether liver metastases should be treated with curative intent. Careful preoperative staging and discussion at a multidisciplinary team meeting is standard practice in established units. This chapter examines surgical management options as well as the neoadjuvant therapies. It details a treatment algorithm for synchronous metastatic colon cancer. It explores newer techniques for improving resectability.
Chronic limb ischaemia
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Chronic limb ischaemia or peripheral arterial disease is a common condition that is caused by the build-up of atheroma. This chapter examines the risk factors for developing this condition and describes non-invasive and invasive diagnostic investigations. The management of this condition depends on the severity of the presentation. Intermittent claudication is largely managed conservatively with risk factor modification and lifestyle adjustment unless walking limitation is severe. Critical limb ischaemia is treated in a more aggressive fashion by an endovascular or surgical approach. This chapter examines how the Transatlantic Society Consensus (TASC) relates to the optimum treatment options for occlusive disease in the lower limb.
Abdominal aortic aneurysm (AAA)
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Abdominal aortic aneurysms (AAA) are mostly asymptomatic and incidental findings on routine scans. The national screening programme currently offers scans to 65-year-old men. This chapter explores the risk factors and natural history of AAA. It describes the recommended investigations and management of AAA according to the presentation if symptomatic or size if asymptomatic. Treatment of AAA includes both traditional surgical repair or endovascular stents.
Benign breast diseases
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Benign breast lesions (fibroadenoma, breast cysts, breast pain, gyanecomastia, and breast infection) are common, and affect different age groups. Presentation ranges from well-defined breast lumps into spreading infection and nipple discharge. Triple assessment is the mainstay of diagnosis (clinical history and examination, breast imaging, and pathological assessment of biopsy). Management options include conservative wait and watch policy, into surgical excision and ultrasound-guided aspiration.
Principles of skin malignancies management
Authors: Jibawi Abdullah , Baguneid Mohamed , Bhowmick Arnab
Published: August 2018

Melanoma is the second most common cancer in the age group 15–34: more than two young adults in the UK are diagnosed with melanoma every day. Cutaneous squamous cell carcinomas (SCCs) are common, arise from the keratinizing cells of the epidermis or its appendages, and have a curative rate following local therapy of >90%. Basal cell carcinomas (BCC) are slow-growing, locally invasive malignant epidermal skin tumours, predominantly affecting Caucasians. Clinical suspicion should always arise where risk factors and clinical behaviour of a skin lesion exist (abnormal change in colour, size, or shape for example). Excisional biopsies are usually required. Staging and further treatment plans should follow accepted protocols.
Rationales for using qualitative research with RCTs
Authors: O'Cathain Alicia
Published: August 2018

The focus of this chapter is on why researchers may want to use qualitative research with randomized controlled trials (RCTs) to generate evidence of effectiveness. The chapter starts by offering definitions of qualitative research and randomized controlled trials. It then moves on to exploring the types of interventions and contexts where qualitative research may be of most value. Ten rationales for combining qualitative research with RCTs are explored, followed by exploration of concerns researchers have expressed about this endeavour. Finally, the relevance of qualitative research to different fields of health research is considered.
How qualitative research can contribute to generating evidence of effectiveness
Authors: O'Cathain Alicia
Published: August 2018

Qualitative research can make a large number of contributions to generating evidence of effectiveness. The same contributions can be described in different ways. Contributions depend on the rationale for undertaking the qualitative research, are often multiple, and may emerge as the study progresses. In this chapter, the range of contributions qualitative research can make is described, including how it can help to understand and improve the intervention, RCT processes such as recruitment, the outcomes of the RCT, and the measures used in the RCT. Reading about the range of contributions qualitative research can make to RCTs will enhance researchers’ understanding and help them to maximize the value of using qualitative research with RCTs.
Paradigms
Authors: O'Cathain Alicia
Published: August 2018

A paradigm is a world view held by members of a research community. It determines what humans can know and how to undertake research to generate knowledge. It shapes how research is undertaken and how quality is judged. In mixed methods evaluations combining qualitative research and RCTs, the implicit paradigm is often post-positivism. There are alternative paradigms such as participatory action research and realist evaluation. The status of qualitative research within a mixed methods evaluation may depend on the paradigm adopted. Researchers undertaking qualitative research may adopt a different philosophical stance from those undertaking the RCT. It is important to have team discussions about paradigms throughout a mixed methods evaluation to understand the variety of stances within the team. This chapter focuses on the range of paradigms researchers adopt and some of the challenges researchers face when combining qualitative research and RCTs within different paradigms.
Publishing journal articles
Authors: O'Cathain Alicia
Published: August 2018

The focus of this chapter is on reporting the qualitative research in peer-reviewed journal articles. Researchers may publish the qualitative data in a standalone journal article, or combine quantitative and qualitative process evaluation data in the same article, or combine the qualitative and RCT research in the same article. Writing these articles can be challenging, even when focusing solely on the qualitative research. Researchers need to consider the number of articles to be published from the whole study, the focus of each article, selecting a journal, and communicating implications for the RCT. Guidance is offered on the key issues to report in journal articles that focus solely on the qualitative research undertaken with an RCT.
White blood cell abnormalities
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Theodoulou Angela
Published: August 2018

Neutrophilia - Neutropenia - Lymphocytosis and lymphopenia - Eosinophilia - Basophilia and basopenia - Monocytosis and monocytopenia - Mononucleosis syndromes
Haemostasis and thrombosis
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Theodoulou Angela
Published: August 2018

Assessing haemostasis - The coagulation system - Laboratory tests - Platelets - Bleeding - Bleeding: laboratory investigations - Bleeding: therapeutic products - von Willebrand disease - Haemophilia A and B - Rare congenital coagulation disorders - Congenital thrombocytopenias - Congenital platelet function defects - Congenital vascular disorders - Haemorrhagic disease of the newborn - Thrombocytopenia (acquired) - Specific thrombocytopenic syndromes - Disseminated intravascular coagulation - Liver disease - Renal disease - Acquired anticoagulants and inhibitors - Treatment of spontaneous FVIII inhibitor - Acquired disorders of platelet function - Henoch–Schönlein purpura - Perioperative bleeding and massive blood loss - Massive blood loss - Heparin - Heparin induced thrombocytopenia/with thrombosis (HIT/T) - Oral anticoagulant therapy (warfarin, VKAs) - New oral anticoagulant drugs - Thrombosis - Risk assessment and thromboprophylaxis - Example of VTE risk assessment - Heritable thrombophilia - Acquired thrombophilia - Thrombotic thrombocytopenic purpura (TTP) - Haemolytic uraemic syndrome (HUS) - Heparin-induced thrombocytopenia (HIT)
Haematological emergencies
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Al-Sader Hassan
Published: August 2018

Septic shock/neutropenic fever - Acute transfusion reactions - Delayed transfusion reaction - Post-transfusion purpura - Hypercalcaemia - Hyperviscosity - Disseminated intravascular coagulation - Overdosage of thrombolytic therapy - Heparin overdosage - Heparin-induced thrombocytopenia - Warfarin overdosage - Massive blood transfusion - Paraparesis/spinal collapse - Leucostasis - Thrombotic thrombocytopenic purpura - Sickle crisis
Ethics and responsibilities
Authors: Winser Shane , Moore James , Bond Jim , Harris Rebecca , Hughes Amy , Moore James , Lewis Nick
Published: August 2018

Ethics of expeditions - Clinical competence - Care of local staff - Interacting with local communities - Working with other expeditions - Environmental impact - Assessing an expedition’s environmental footprint - Working with the media - Disaster medicine
Treatment: abdomen
Authors: Imray Chris , Anderson Sarah R. , Campbell-Smith Tim , Wilson-Howarth Jane
Published: August 2018

Acute abdominal pain - Upper abdominal pain - Lower abdominal pain - Gastrointestinal bleeding - Diarrhoea and vomiting - Other gastrointestinal problems - Urological problems - Acute scrotal pain - Gynaecological problems
Treatment: limbs and back
Authors: Dallimore Jon , Blackham Jules , Dallimore Jon , McClellan Carey M. , Pynn Harvey , Calder James , Watson James
Published: August 2018

Limb injuries - Fractures - Dislocations - Shoulder and upper arm injuries - Elbow and forearm injuries - Wrist injuries - Hand injuries - Finger injuries - Nail injuries - Pelvic and hip injuries - Knee injuries - Lower leg injuries - Achilles tendon disorders - Ankle injuries - Foot fractures and dislocations - Spinal injury - Low back pain - Physiotherapy
Cold climates
Authors: Imray Chris , Davis Ian , Johnson Chris , Johnson Clive , Oakley Howard , Roberts Barry
Published: August 2018

The polar environment - Travel in cold climates - Whiteout - Humans in polar areas - Preparations for a polar trip - Infectious diseases in polar areas - Hypothermia - Freezing cold injuries - Non-freezing cold injury - Snow blindness (photokeratitis) - Skin problems - Problems of prolonged polar travel
Timing of Infectious Disease Clinical Rotation Is Associated With Infectious Disease Fellowship Application
Authors: Blyth Dana M , Barsoumian Alice E , Yun Heather C
Published: August 2018

Background

With declining interest in infectious disease (ID) noted among internal medicine (IM) residents, national attention has been directed at methods to recruit more prospective ID applicants. The factors driving the recent decline in ID fellowship applications have thus far only been evaluated in survey studies. Since 2008 at our institution, all IM interns were required to complete a 4-week inpatient ID rotation. We evaluated this rotation to determine if any experiential factors could be linked to future ID interest.

Methods

Categorical IM interns rotating on the mandatory ID rotation at our institution between July 1, 2008, and June 30, 2015, were included. Interns were grouped by eventual application to ID fellowship (IDA) and nonapplication (non-IDA). Consult numbers and types and characteristics of team members during the rotation were compared.

Results

Between July 2008 and June 2015, 143 IM interns met inclusion criteria. Ten (7%) were IDA. There was no difference in number of consults seen, intern, team member, faculty, or fellow characteristics among groups. However, 90% of IDA compared with 46% of non-IDA rotated during the first 6 months of internship (P = .01).

Conclusions

During a 7-year period, those interns randomly assigned to rotate on ID in the first 6 months of their intern year were more likely to become future ID applicants. This supports prior self-reported survey data that early exposure to the field may impact future career choice and suggests that incorporating ID early into the intern experience may increase recruitment.