bluuebunny/crossref_metadata_2025 huggingface dataset:
Initiation of Antiretroviral Therapy
Authors: Ajmal Saira , Temesgen Zelalem
Published: March 2020

Upon completion of this chapter, the reader should be able to

• Discuss categories of regimens for first-line antiretroviral therapy.

• Recognize the basis for the US Department of Health and Human Services (USDHHS) guidelines for initial antiretroviral therapy.

• Recognize and apply recommended regimens for initiation of antiretroviral therapy....
Future Antiretrovirals, Immune-Based Strategies, and Therapeutic Vaccines
Authors: Jakharia Niyati , Majid Adrian , Gilliam Bruce L. , Talwani Rohit
Published: March 2020

Upon completion of this chapter, the reader should be able to to gain knowledge about new antiretroviral drugs in development, different strategies to restore the immune system and eliminate the latent HIV reservoir, and also discuss the role and current research of preventive and therapeutic vaccines....
Solid Organ Transplantation in Persons Living with HIV
Authors: Lopes Eurides , Husson Jennifer
Published: March 2020

The arrival of combination antiretroviral therapy (ART) in 1996 resulted in increased life expectancy for HIV-positive patients. Consequently, end-organ failure and associated disease has become a major cause of morbidity and mortality in this population. Up to 30% of HIV-positive individuals have end-stage renal disease (ESRD) as a direct consequence of HIV infection (HIV-associated nephropathy [HIVAN]), drug toxicities, or other comorbidities (...
Psychiatric Illness and Treatment in HIV Populations
Authors: David Elizabeth , Wilkins Rakel Beall
Published: March 2020

Upon completion of this chapter, the reader should be able to

• Discuss the psychiatric concomitants of HIV illness and the role of psychiatric care in the overall treatment of HIV populations.

From the earliest recognized AIDS deaths in 1981 to the commencement of highly active antiretroviral therapy (HAART) in the mid-1990s and the simpler combination ART regimens now available, HIV has remained a disease and an epidemic in constant evolution. For many years a near-certain death sentence, it has become a treatable chronic condition, with issues of HIV-associated dementia and rapid death by opportunistic infection generally replaced by treatment of “premature” aging and slow neurological decline and questions of maximizing adherence to treatment. Issues that have not changed include the tremendous psychosocial burden to the individual and family and the economic cost to the patient and society, as well as factors of stigmatization and marginalization of HIV populations. Many HIV-positive individuals were already stigmatized before contracting this illness. The prevalence of HIV infection is much higher in gay/bi/transsexual populations, in people of color, in substance abusers, in prison populations, in the homeless, in individuals with histories of physical and emotional trauma, and in people with mental illness (...
HIV and Hepatitis Coinfection
Authors: Monczor Ana , Hoffman-Terry Margaret , Vigil Karen J.
Published: March 2020

Upon completion of this chapter, the reader should be able to

• Discuss the clinical presentation, diagnosis, treatment, and treatment complications of hepatitis B and hepatitis C in HIV-infected patients.

Hepatitis B (HBV) infection is common in people living with HIV, and all patients with HIV should be screened for HBV infection. The most common route of transmission worldwide is through perinatal or early childhood exposure, but adult transmission of HBV is often by routes similar to those for HIV, including sexual contact and injection drug use. Although it varies by exposure route, approximately 10% of people living with HIV also have chronic HBV infection, and up to 90% have serologic evidence of past exposure to HBV (...
Cardiovascular Disease
Authors: Wohl David A. , Kirchner Jeffrey T.
Published: March 2020

Upon completion of this chapter, the reader should be able to

• To gain a greater understanding of the pathophysiology of CVD and myocardial infarction in persons living with HIV infection.

• To understand the link of chronic HIV infection as it relates to increased risk of CVD and myocardial infarction....
HIV-Associated Lipodystrophy and Lipoatrophy
Authors: Sekhar Rajagopal V.
Published: March 2020

Upon completion of this chapter, the reader should be able to

• Understand about HIV associate lipodystrophy and lipoatrophy.

The advent of combination antiretroviral therapy (ART) in the mid to late 1990s resulted in significant health benefits for patients infected with HIV by reducing AIDS-related mortality and increasing life expectancy. Additional collateral benefits were an improvement in nutritional status and a reduction in HIV-associated opportunistic infections. In parallel with these benefits, HIV patients began to develop unusual changes in body habitus with variable combinations of loss of peripheral fat in the limbs, buttocks, and face (termed ...
Research Design and Analysis
Authors: Ramers Christian B.
Published: March 2020

Upon completion of this chapter, the reader should be able to

• Demonstrate basic knowledge regarding the interpretation of results of medical research related to HIV in order to better incorporate emerging scientific concepts into the provision of optimal patient care.

• Differentiate between on-treatment (OT) and intent-to-treat (ITT) analyses and between time-to-loss of virologic response (TLOVR) analysis and a US Food and Drug Administration (FDA) SNAPSHOT analysis....
Reflecting on the Inevitable
Authors: Adams Peter J.
Published: March 2020

Death studies have, over the past twenty years, witnessed a flourishing of research and scholarship particularly in areas such as dying and bereavement, cultural practices and fear of dying. But, despite its importance, a specific focus on the nature of personal mortality has attracted surprisingly little attention. Reflecting on the Inevitable: Mortality at the Crossroads of Psychology, Philosophy, and Health breaks new ground by bringing together available ideas and research on the meaning of one’s own death. Its content is organized around the question of how an ongoing relationship might be possible when the threat of consciousness coming to an end points to an unthinkable and unspeakable nothingness. The book then argues that, despite this threat, an ongoing relationship with one’s own death is still possible by means of conceptual devices that help shape personal mortality into a relatable object. Four of these devices, or “enabling frames,” are examined: essential structures, passionate suffusion, point-of-transition, and self-generative process. While each frame conceptualizes mortality differently, they share a capacity to move it from unintelligibility to something we can think and speak about, thereby enabling us to maintain an ongoing engagement. The final chapters explore ways in which pursuing a relationship with our own deaths could become a normal and acceptable activity throughout our lives.
A Constant Companion
Authors: Adams Peter J.
Published: March 2020

This chapter starts by asking “If we struggle to speak and think about my-death, how is it possible to engage with it in an ongoing fashion?” It explores the advantages of switching from individualized conceptions of self-identity to relational or social conceptions. In doing so, the focus shifts from individual attributes to the importance of relationships. In applying this to death, the prospect of my-death shifts from being viewed as an aspect or an attribute of being alive to being viewed as an ongoing relationship, a constant presence, that persists from birth and throughout life. The discussion finishes by pointing out that, in the face of ongoing fear of death, for a relationship to form, some way of conceptualizing death through what is referred to as an “enabling frame” is needed before a relationship with my-death becomes achievable.
Point-of-Transition
Authors: Adams Peter J.
Published: March 2020

This chapter provides a third example of an enabling frame based on an intense belief in dying as a transition to some form of afterlife. An intense mystical experience can provide the catalyst for a profound realization that death is not the end of life but a transition into another form of being. Confidence in this belief reduces a person’s fear of death, and regular contact with markers of finitude further strengthens this understanding and reinforces a sense of connection to death as a gateway to the afterlife. This, then, leads on to a discussion of philosophical positions, both pro and anti, regarding life after death and its relationship to what is happening when a person has a near-death experience.
Self-Generative Process
Authors: Adams Peter J.
Published: March 2020

This chapter introduces the final and philosophically more complex enabling frame based on a shift away from looking at all experience, including experience of my-death, as representational. The three earlier enabling frames each assumed a something existing separate from death that underpins its reality, whether that be an underlying structure, a primal impulse, or a divinity. Instead, death can be seen as not requiring anything beyond itself because, through its interconnections with everything else and its performance in everyday living, it becomes sufficient in itself. Finitude again becomes the contact point for connecting with my-death on a daily basis.
Dialogue
Authors: Adams Peter J.
Published: March 2020

This chapter brings together the four enabling frames and reviews their relative strengths in the light of points of conflict and agreement. Points of conflict include whether life continues after death, whether death is intrinsic to the structures of life, and whether my-death represents something beyond itself. Points of agreement include improvements in the ability to think and speak about my-death, improvements in quality of life, and the positive contribution of markers of finitude to my-death awareness. This chapter’s discussion also highlights how engagement with my-death can enhance a sense of vibrancy and meaning in life.
Applications
Authors: Adams Peter J.
Published: March 2020

This chapter, explores ways in which the understandings of my-death developed in this book could be integrated into broader death awareness strategies. It turns first to the contribution of the death awareness movement and explores whether strategies used to promote death awareness could be extended to advancing my-death awareness. These include the death awareness movement’s use of the internet and self-help networks and professional education and training initiatives. For example, content from this book could be integrated into education sessions with health professionals. It also explores future opportunities for research and scholarship into the positive contributions of engaging with my-death.
Presentation of stroke in the older person
Authors: Sharma Jagdish
Published: March 2020

‘Presentation of stroke in the older person’ outlines the varied patterns of clinical presentation of stroke in the older person, looking at common and the less common syndromes. Symptoms and signs in older people can be very subtle, often difficult to diagnose, and challenge even the most astute of clinicians. Most stroke presentations in older patients are similar to those in younger patients with respect to Oxford Community Stroke Project classification. However, atypical presentations can lead to diagnostic challenges in older patients due to the interaction between age-related cerebral and circulatory changes and comorbidities. The presentation of ischaemic stroke with its different vascular patterns, is discussed. Cerebral haemorrhage is explored in the context of its presentation patterns.
Transient ischaemic attack (TIA) in the older person
Authors: Hagan Marissa , Shetty Ashit K.
Published: March 2020

‘Transient ischaemic attack (TIA) in the older person’ explores the new definitions of TIA (transient ischaemic attack) especially in the context of modern imaging methods, epidemiology of this common condition and its implications for everyone, the pathophysiology, common and less common clinical presentations, the differential diagnoses (including transient mono-ocular blindness, transient global amnesia, migraine, amyloid spells, and others), the risk factors (modifiable and non-modifiable), prognosis, risk scoring (ABCD2, ABCD2i, ABCD3i), investigation methods, and various pharmacological, non-pharmacological, and surgical methods of treatment. Lastly, this chapter discusses issues about TIA in the real world and the issues facing various stroke services around the world.
Stroke mimics: Transient focal neurological events
Authors: Stephen Christopher D. , Caplan Louis R.
Published: March 2020

‘Stroke mimics: Transient focal neurological events’ explores the important stroke-like symptoms that are due to non-cerebrovascular causes. Stroke mimics account for up to 31% of code stroke presentations, and up to 60% of potential TIAs. The most common stroke mimics are seizures, migrainous auras, and functional neurological disorders. Making an astute clinical decision based on the history and examination is particularly important as imaging cannot definitely rule out stroke. The chapter includes interesting case vignettes and discusses differential diagnoses like migraine, seizures, transient global amnesia, vertigo, functional neurological disorders, neuromuscular disorders, tumours, syncope, primary ophthalmic problems, and some other rare conditions.
Early management of acute ischaemic stroke
Authors: Guyler Paul
Published: March 2020

This chapter, ‘Early management of acute ischaemic stroke’, addresses all the basic issues of thrombolysis as it has evolved over the last three decades. More importantly the journey and controversy concerning thrombolysis in older people is discussed at length with excellent trial evidence from specialist research. A review of all-important thrombolysis trials is succinctly described. New national clinical guidelines are analysed. Endovascular mechanical thrombectomy, which is rapidly developing, is described in detail with a review of the latest trials too. The author also highlights the importance of establishing cerebral blood flow as quickly and as completely and safely as possible.
Early and late complications of stroke
Authors: Subramanian Ganesh
Published: March 2020

‘Early and late complications of stroke’ refers to the medical complications of acute stroke and the importance of these in the context of the outcome, morbidity, dependency, and mortality in these individuals. It explores the temporal profile of these complications. Infections, neurological, cardiac, pulmonary, gastrointestinal urinary, thrombotic, spasticity, sexual, and perceptual complications are described. A quarter of all stroke patients suffer at least one serious medical complication (defined as prolonged, immediately life-threatening, or resulting in hospitalization or death). Approximately 85% of patients suffered from a medical complication during their hospital stay. Depression, emotionalism, and anxiety are the common psychological syndromes encountered. Long-term complications are related to patient dependency and duration after stroke. Medical complications account for approximately half of stroke mortality.
Physiotherapy of the older stroke patient
Authors: Hicklin Dawn , Finnemore Clair
Published: March 2020

‘Physiotherapy of the older stroke patient’ introduces the role of physiotherapy in stroke and the older person. The authors have provided an insight into the influencing factors for stroke management from a therapy perspective, identified the challenges surrounding the perception of the older person and facilitated understanding of the treatments available. The chapter reviews the invisible burden of stroke, impact of age, neurological changes with ageing affecting motor function, evidence from research trials, frailty, falls, common and uncommon therapy approaches, neuroplasticity, extended roles of the physiotherapist, spasticity and controversial issues. Ongoing technological advancement and the ever-increasing developments in treatment options continue to inspire clinicians worldwide. Physiotherapists maximize function, and enhance quality of life, and form a core component of the stroke multidisciplinary team. Six excellent case vignettes are presented.
Assessing capacity and decision-making
Authors: McGowan Thomas , Blundell Adrian
Published: March 2020

This chapter, ‘Assessing capacity and decision-making’, explores mental capacity and the practical, legal, and ethical components of this common situation; the MCA (Mental Capacity Act) and its five statutory principles: the stages of capacity assessment; assessment of capacity in the context of cognitive problems; making decision for patients lacking capacity; determining patient’s best interests. Determining a patient’s best interests is often a complex area, and one in which family and friends can be uniquely placed to help you make this judgement. However, the relatives’ views have no legal standing in English law, and the decision must be made by the responsible professionals. With the help of excellent case vignettes, this chapter describes advance care planning, lasting power of attorney, IMCA (independent mental capacity advocate), DOLS (deprivation of liberty safeguards), The Court of Protection, and the implications of mental capacity on medical research.
Psychological and emotional issues after stroke
Authors: Morris Reg C.
Published: March 2020

‘Psychological and emotional issues after stroke’ explores these symptoms in great detail. These symptoms are common, disabling, and increase the costs of healthcare. Psychological conditions can occur at any age, and a person’s age is just one of many factors to be considered when assessing, formulating, and treating these complications. The commonest and most salient psychological conditions after stroke are anxiety, depression, fatigue, and emotionalism. Other more subtle presentations include low self-esteem, low confidence, reduced self-efficacy, altered identity, and post-traumatic stress. In approaching psychological conditions, it is important to be mindful that most are not limited to the acute phase. The delivery of psychological care is not necessarily the domain of specialists alone; service models such as stepped care may engage a range of staff in helping with less severe presentations. The ubiquitous nature of psychological conditions requires approaches that enable large numbers to be assessed and treated cost-effectively. Group-based approaches and self-management are particularly important additions to resource-intensive one–to-one therapy.
Readmission to hospital after stroke
Authors: Maddula Mohana , Munshi Sunil K.
Published: March 2020

‘Readmission to hospital after stroke’ explores the important area of hospital readmissions after a stroke. The authors examine the importance of hospital readmissions, the worldwide data, the influence of healthcare on readmissions, the current evidence and limitations of the available data, and the reasons for readmissions. The authors also discuss some illustrative case vignettes, how to identify patients at risk of readmissions, predicting risk of readmissions, strategies for prevention, implications for patients and healthcare workers, and the implications of stroke readmissions for health services and healthcare providers. There is a significant resource implication and consequent economic burden from stroke hospitalization, especially if this becomes a recurrent issue. While there is no doubt that readmissions are necessary in a cohort of patients who require urgent and specialized hospital care, a significant proportion of readmissions of stroke survivors may be preventable.
Basic Doppler principles
Authors: Huang Stephen
Published: March 2020

Basic two-dimensional echocardiography alone is inadequate for advanced diagnosis and treatment monitoring in critically ill patients because of haemodynamic complexities. To cope with such demands, a critical care physician will also need to be competent in Doppler echocardiography, which provides accurate measurements of blood flows. Experienced echocardiographers are able to draw inference about the cardiac function, intracardiac and intravascular pressures, and other abnormalities from the Doppler flow spectra. Doppler echocardiography also provides objective measurements that can be used for bedside diagnosis or for longitudinal monitoring. Learning Doppler echocardiography has a steep learning curve and has several hurdles to overcome. First, one needs to develop high-level transducer navigation skills to make sure a proper insonation angle is obtained for all Doppler measurements. Second, an understanding of medical ultrasound physics is required not only for knobology purposes, but also for appreciation of the pros and cons of various Doppler modalities. Third, recognition of the limitations of Doppler echocardiography is necessary to avoid misapplications and misinterpretations. Fourth, the operator needs to be able to identify Doppler artefacts so as not to mistake artefacts for real findings. Finally, an understanding of haemodynamic principles is important to execute proper interpretations of Doppler measurements. This chapter will cover mainly the second and third aspects of these. Doppler artefacts will be covered in Chapter 2 and haemodynamic principles in Chapter 3.
Heart–lung interactions
Authors: Zaidi Gulrukh , Mayo Paul H.
Published: March 2020

Echocardiography is the most clinically practical method of visualizing cardiac structures and directly observing changes of cardiac function during the respiratory cycle. This chapter will review heart–lung interactions and will focus on the effects of intrathoracic pressure variation on cardiac function that can be measured with advanced critical care echocardiography. These measurements are derived from observing respirophasic variation of stroke volume (SV) and help the intensivist to guide management of haemodynamic failure. The heart–lung interactions that occur with changes in intrathoracic pressure variation have utility in identification of preload sensitivity and adverse patient ventilator interaction. Measurement of the systolic velocity envelope with pulsed-wave Doppler is a requisite skill in order to identify SV variation, as is the recognition that the measurements may be difficult with transthoracic echocardiography.
Right ventricular function
Authors: Chew Michelle S.
Published: March 2020

The right ventricle (RV) has historically been given less importance than the left. There are important anatomical differences, including several intracardiac structures that may complicate echocardiographic assessments. The right heart is sensitive to changes in pressure and its function is affected by common interventions in critical care such as fluid loading and positive pressure ventilation. Right and left ventricular functions are inextricably linked, and both systolic and diastolic ventricular interdependence occur. The echocardiographic examination of the RV includes an assessment of size and dimensions, systolic and diastolic function, estimation of intracardiac and pulmonary pressures. These should be interpreted in the context of the clinical interventions that the patient was subjected to at the time of imaging, as well as left ventricular function. RV failure is associated with poorer outcomes in several disease states including congestive cardiac failure and acute myocardial infarction. In critically ill patients, acute respiratory distress syndrome (ARDS) has significant implications for right heart function, where there is a necessary balance between respiratory mechanics and haemodynamics.
Cardiac output measurement
Authors: Huang Stephen
Published: March 2020

Cardiac output (CO) is an important measurement in intensive care unit, especially in the management of patients with shock. The main utility of CO measurement is for the evaluation of the type of shock, and for evaluating the response of patients to fluid or inotropes. Traditionally, to measure CO, clinicians rely mostly on thermodilution method using pulmonary artery catheter. Apart from being invasive, the method only measures CO indirectly by temperature change and its accuracy is subjected to various factors (e.g. speed and during of injection of the cold saline, the presence of tricuspid regurgitation and intracardiac shunts, and output state of the patient). On the other hand, CO measurement by echocardiography, especially transthoracic echocardiography (TTE), provides a non-invasive alternative to thermodilution. There are two TTE methods: Simpson’s method of disc summation and Doppler echocardiography. To date, nearly all stroke volume (SV) and CO measurements are performed using Doppler TTE as the method is less reliant on image quality and various assumptions. Apart from assuming that the cross-section of the left ventricular outflow tract is circular in shape, Doppler TTE accuracy depends only on the skills and experience of echocardiographers. This chapter will cover the theories and pitfalls of both Simpson’s method and Doppler echocardiographic of SV and CO measurements.
Dynamic left ventricular outflow tract obstruction
Authors: Backer Daniel de
Published: March 2020

Left ventricular outflow tract (LVOT) obstruction is often clinically unrecognized unless echocardiographic assessment is performed. Its occurrence is favoured by anatomical factors (i.e. concentric or asymmetrical hypertrophy, excess tissue in mitral valve), hypovolemia and adrenergic stimulation and can occur in various conditions including postoperative setting (especially but not exclusively, after cardiac surgery), stress cardiomyopathy, and sepsis. A high flow in a narrow LVOT generates a Venturi effect in the LVOT which results in the attraction of the anterior mitral leaflet towards the interventricular septum causing LVOT obstruction. Not only this generates an intraventricular (left ventricle to LVOT) pressure gradient but can also be accompanied by mitral regurgitation that can sometimes be severe. Prompt echocardiographic assessment is warranted in order to adequately manage the patient. Typical echocardiographic findings include systolic aliased flow in LVOT on colour Doppler and dagger-shaped or double-peak Doppler flow in LVOT. The systolic anterior movement of the anterior leaflet of the mitral valve should be carefully searched. In some cases mitral regurgitation can be observed. Therapy may include fluid administration, weaning of adrenergic agents, and, whenever possible, beta-blockade administration.
Valvular stenosis
Authors: Martinez-Naharro Ana , Price Susanna
Published: March 2020

Evaluation of valve stenosis in the critical care setting can be challenging, as the clinical status of the patient may preclude the gold standard for assessment (multimodality imaging), demanding reliance on echocardiographic parameters that are not well-validated in the intensive care unit. Valve stenosis is common, and where it precipitates intensive care admission is likely to be severe, and affecting the left-sided valves. On occasion, however, stenosis may be an incidental finding in a critically ill patient with a variable impact on their clinical status. Right-sided lesions are rare (outside the grown-up congenital patient population) and only very infrequently lead to acute haemodynamic deterioration. Echocardiography is indicated in any intensive care unit (ICU) patient where there is suspicion of valvular heart disease. This chapter outlines how to assess valvular stenosis and define its severity in the critical care setting according to integrated echocardiographic parameters. It highlights how critical care pathophysiology may complicate this evaluation, and any potential pitfalls that may exist.
Valvular regurgitation
Authors: Choi Gordon YS , Yip Yu-Yeung
Published: March 2020

Valvular regurgitation can be classified according to the involvement of the specific valve and the rate of development of the disease process. Two-dimensional (2D) transthoracic echocardiography (TTE) is recommended as first-line imaging in valvular regurgitation and is often sufficient for diagnosis. A transoesophageal echocardiography (TOE) is indicated when TTE is inadequate or when further diagnostic refinement is required. The aetiology and mechanism of the regurgitant lesion should be determined with the use of 2D, M-mode, and colour-flow imaging. Specific quantification techniques include vena contracta (VC), proximal isovelocity surface area (PISA), pulsed-wave (PW) and continuous-wave (CW) Doppler measurements. Haemodynamic consequences may vary, depending on the valve affected and the rate of development of the regurgitation. It is vital for the clinician to accurately determine the degree of valvular regurgitation and its contribution to the overall clinical presentation of the patient.
Echocardiography in a patient with chest pain—an integrated approach
Authors: McLean Anthony
Published: March 2020

Investigating the cause of chest pain relies much upon history, and in particular a clear description of the nature of the pain itself. An intubated ventilated patient is usually unable to provide a precise description of chest pain and the physician depends more on ancillary aids including a chest X-ray and electrocardiogram (ECG). Echocardiography can add vital information in a rapid and non-invasive manner, either contributing directly to the diagnosis or else directing the physician to the most appropriate investigation for which the patient requires transfer beyond the intensive care unit. Underlying coronary artery lesions leading to myocardial ischaemia, pericardial pathology, and thoracic aorta anomalies usually require prompt attention but other conditions including pathologies of the lung, oesophagus, and chest wall may also be identified.
Echocardiography in post-cardiac surgery
Authors: Price Susanna
Published: March 2020

Echocardiography following cardiac surgery can be regarded as a subspecialty of critical care echocardiography, as it requires knowledge of the specifics of each surgical intervention and potential complications, as well as in-depth knowledge of cardiac anatomy and physiology. It has a significant overlap with intraoperative transoesophageal echocardiography (TOE) but they are not synonymous. This chapter outlines the general approach to evaluate the postoperative cardiac surgical patient using echocardiography, as well as specific considerations for common cardiac surgical procedures, and some of the potential pitfalls that exist. As there are increasing numbers of transcatheter/hybrid interventions now being undertaken, this chapter additionally includes a section on postcatheter complications. The final section addresses areas where echocardiography can be used to guide the use of extracorporeal support on the surgical cardiac intensive care unit.
Haemodynamic assessments in mechanically ventilated patients
Authors: Vieillard-Baron Antoine
Published: March 2020

Knowledge of heart–lung interactions is key to manage haemodynamics in mechanically ventilated patients (see also Chapter 5). It allows intensivists to understand the meaning of blood and pulse pressure respiratory variations (PPV). Unlike spontaneous breathing, positive pressure ventilation increases blood pressure and pulse pressure during inspiration following by a decrease during expiration. This is called reverse pulsus paradoxus and includes a ‘d-down’ and a ‘d-up’ effect. No variation means no effect of mechanical ventilation on the heart and especially on the right heart. In case of significant PPV, tidal volume usually reduces right ventricular stroke volume by way of reducing preload where systemic venous return is decreased (fluid expansion is useful to restore haemodynamics, when impaired) or increasing afterload (obstruction of pulmonary capillaries due to alveolar inflation and, in this case, fluid expansion is useless or even sometimes deleterious). Clinical examination as well as evaluation of respiratory variations of superior vena cava by echo, helps to distinguish between these two situations. By studying the beat-by-beat changes in echo parameters induced by positive pressure ventilation heartbeat by heartbeat, echocardiography is perfectly suited to study heart–lung interactions and then to propose an appropriate optimization in case of haemodynamic impairment.
Strain, twist, and torsion in left ventricular assessment
Authors: Huang Stephen
Published: March 2020

Although speckle tracking is increasingly used to study left ventricular strain, twist and torsion, there is a general lack of interest among clinicians. The main reasons for the lack of enthusiasm can be summarized as: (1) inadequate understanding of how to measure and analyse; (2) the clinicians cannot see the values of these measurements in their practices; (2) the measurements require offline analysis and are time-consuming, hence are not suitable for bedside assessments; (3) there are large inter- and intraobserver variabilities in measurements; and (4) different manufacturers use different speckle tracking algorithms resulting in incomparable results. To overcome some of the problems, this chapter explains the physiology and physics of strain, twist, and torsion, followed by an introduction to speckle tracking technology and measurements, a discussion on the interpretations of the results, and finally a brief summary of potential applications of strain and twist.
Surgery for urological cancer
Authors: Biers Suzanne , Armenakas Noel , Lamb Alastair , Mark Stephen , Reynard John , Sullivan Mark , Turner Kevin , Turney Ben
Published: March 2020

This chapter covers various surgical procedures for dealing with different urological cancers. For each method, it takes the reader through diagnosis, indications for the procedure, assessment and staging, patient preparation, and surgical approaches, then closure, and any other potential issues. Each topic is highly illustrated, to aid understanding for unfamiliar procedures.
Surgery for male factor infertility
Authors: Biers Suzanne , Armenakas Noel , Lamb Alastair , Mark Stephen , Reynard John , Sullivan Mark , Turner Kevin , Turney Ben
Published: March 2020

A male factor alone is responsible for infertility in 20% of couples and is contributory in another 30%. Evaluation of both partners is an essential part of the assessment of any infertile couple. After describing the aetiology and evaluation of male infertility, the chapter goes over surgical management techniques and approaches. It also has topics on testicular semen retrieval techniques, epididymal biopsy, and varicocele repair.
Growth (including short stature and tall stature)
Authors: Butler Gary , Kirk Jeremy
Published: March 2020

• Growth occurs in three separate phases, all of which are under different nutritional and/or hormonal controls:

◦ infantile (mainly nutritional)

◦ childhood (hormonal, mainly growth hormone (GH))

◦ pubertal (hormonal; GH and sex steroids acting synergistically).

• Height:

◦ should be measured supine up until 2 years of age, and standing after that, and plotted on appropriate charts

◦ is a normally distributed variable, with extremes (0.4th/2nd centiles and 99.6th/98th centiles) arbitrarily defined as short and tall stature respectively.

• Two major sets of genes determine height and rate of development; the first is assessed using mid-parental and target height, and the second using bone age.

• Short stature:

◦ Failure to achieve an acceptable height can be due to a primary growth problem, or secondary to an underlying disorder.

◦ Causes include familial, genetic disorders (syndromic), small birth size, chronic illness, psychological, environmental, and endocrine.

◦ Generally, short stature due to a hormonal issue is associated with (relative) overweight, and that due to an underlying chronic disorder with (relative) underweight.

◦ GH therapy is licensed for short stature in children in the following situations: GH deficiency, Turner syndrome, chronic renal insufficiency, children born small for gestational age, Prader–Willi syndrome, and SHOX deficiency.

• Tall stature:

◦ Although in theory this should present as frequently as short stature, in practice this is not the case.

◦ The commonest cause of tall stature is constitutional, although other forms include:

■ syndromic: e.g. Klinefelter, Marfan, and Sotos syndromes

■ hormonal: GH, sex steroid excess.

◦ Therapy (sex steroids, GH blockade, epiphyseal stapling) is less effective than in short stature.
The pituitary and hypopituitarism
Authors: Butler Gary , Kirk Jeremy
Published: March 2020

• The pituitary is formed of two anatomically and embryologically distinct lobes:

◦ anterior pituitary: which secretes growth hormone (GH), gonadotropins (luteinizing hormone (LH) and follicle-stimulating hormone (FSH)), adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), and prolactin

◦ posterior pituitary: which secretes vasopressin and oxytocin.

• Hypopituitarism is deficiency of one or more pituitary hormones. Some hormones, e.g. GH (LH/FSH), are more likely to present with isolated deficiencies, while others, e.g. TSH, ACTH, are more often found as part of multiple pituitary hormone deficiency (MPHD).

• Deficiencies may be congenital (including genetic) or acquired; secondary to tumour, trauma, infiltration, infection, or irradiation.

• GH deficiency:

◦ diagnosed using a combination of clinical, radiological, and biochemical assessment (including GH stimulation testing)

◦ treatment is with GH (including if necessary into adulthood).

• LH/FSH deficiency:

◦ If acquired, often one of the first anterior pituitary hormones to be lost.

◦ Congenital forms:

■ present with cryptorchidism and/or micropenis in males

■ may occur in isolation, or in association with anosmia (Kallmann and CHARGE syndromes).

◦ Treatment: sex steroid therapy to induce secondary sexual characteristics, and recombinant FSH/LH to induce fertility potential.

• ACTH deficiency:

◦ Unlike primary adrenal problems, hyperpigmentation does not occur.

◦ Although mineralocorticoid production is preserved, hyponatraemia may still occur.

◦ Treatment is with hydrocortisone.

• TSH deficiency:

◦ TSH may be low, normal, or raised (but inappropriate for free thyroxine level).

◦ Treatment is with thyroxine.

• Vasopressin deficiency:

◦ produces cranial diabetes insipidus

◦ treatment is with DDAVP (orally or nasally).

• Prolactin and oxytocin deficiency rarely produce clinical problems.
Obesity
Authors: Butler Gary , Kirk Jeremy
Published: March 2020

• Obesity is defined as: ‘An excess of body fat frequently resulting in a significant impairment of health and longevity’.

• In most cases obesity is not due to an underlying endocrine disorder, although it may produce endocrine morbidity such as type 2 diabetes.

• Although there are a number of different methods to assess overweight and obesity, the most common is body mass index (BMI): weight (kg)/height (m)2.

• Classification is:

• primary: exogenous or ‘simple’ obesity

• secondary:

■ identified genetic syndromes, e.g. Prader–Willi, Bardet–Biedl, pseudohypoparathyroidism

■ monogenic disorders, e.g. leptin deficiency, leptin/melanocortin receptor defects

■ CNS disease, e.g. hypothalamic obesity

■ endocrine disorders, e.g. hypothyroidism, Cushing syndrome, growth hormone deficiency, precocious puberty

■ immobility, e.g. cerebral palsy

■ iatrogenic.

• Generally, children with obesity which is:

• primary often have a family history, tall stature, advanced bone age, and no dysmorphic features

• secondary often have short stature, delayed bone age, dysmorphic features, and developmental delay.

• Complications of obesity are multisystem: metabolic, cardiovascular, respiratory, gastrointestinal/hepatic, orthopaedic, neurological, dermatological, gynaecological, and psychological.

• Therapy is aimed at modifiable factors restoring the balance between energy intake (e.g. dietary) and expenditure (e.g. exercise), and preferably a combination of both along with counselling and behaviour modification. There is currently only limited data on the benefits of pharmacotherapy and bariatric surgery.
Differences of sex development (DSD)
Authors: Butler Gary , Kirk Jeremy
Published: March 2020

• Embryology: the gonad is initially bipotential.

• The testes develop under active control of SRY and other genes.

Disorders of sex development (DSDs) are classified according to the karyotype:

• 46,XY DSD (incomplete masculinization of a male fetus):

◦ The commonest cause is androgen insensitivity syndrome (AIS):

■ mutations in androgen receptor (AR) gene on X chromosome in complete forms

■ alterations in androgen binding in partial forms.

◦ Abnormalities of testosterone synthesis and conversion, may be:

■ isolated, e.g. 17β‎HSD, 5α‎RD

■ occur in association with defects in steroid biosynthesis, e.g. StAR, 3β‎HSD.

• Pure 46,XY gonadal dysgenesis (Swyer syndrome):

◦ phenotype unambiguously female; may present with delayed puberty

◦ Müllerian structures are present but only streak gonads are seen.

• Mixed gonadal dysgenesis:

◦ usually asymmetrical, e.g. ovary/streak gonad or ovotestis

◦ karyotype is 45,X/46,XY or 46,XX/46,XY.

• Pure 46,XX gonadal dysgenesis:

◦ absent puberty in a phenotypically normal female

◦ intact Müllerian structures but streak ovaries; normal genitalia.

• 46,XX DSD (masculinization of a female fetus):

◦ the commonest cause is congenital adrenal hyperplasia, with the vast majority (>90%) due to 21-hydroxylase deficiency (21OHD).

• Ovotesticular DSD is rare:

◦ aetiology is unknown, and karyotype usually 46,XX

◦ asymmetrical gonad development; ovary and testis or ovotestis.

• DSD may also be part of other genetic syndromes, e.g. Antley–Bixler, Smith–Lemli–Opitz, trisomy 13.

• Management requires careful evaluation and counselling, working as part of a multidisciplinary team.
Endocrine investigations and laboratory reference ranges
Authors: Butler Gary , Kirk Jeremy
Published: March 2020

While baseline testing may be appropriate in some endocrine disorders (e.g. hyper/hypothyroidism), many hormones are not secreted in a constant fashion (e.g. pulsatile (growth hormone), diurnal (cortisol)), and are also age (IGF-1) and pubertal stage (Luteinizing hormone/follicle-stimulating hormone/testosterone/oestradiol) dependent. In these circumstances, stimulation (or suppression) testing including using hypothalamic/pituitary hormones may be required. Testing can either be performed to identify occult endocrine dysfunction in high-risk groups, or alternatively to confirm (or exclude) endocrine disorders in conjunction with careful clinical assessment. These tests are, however, often complex and difficult to perform, with both false-positive and false-negative results, so careful and appropriate timing and choice of tests is required to ensure optimal outcomes.
Severe traumatic brain injury
Authors: Newcombe Virginia , Cooper Jamie
Published: March 2020

This chapter is centred on a case study on traumatic brain injury. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images (e.g. chest X-rays and computed tomography scans), making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.
Post-cardiac arrest care and prognostication
Authors: Barnett Justine , Nolan Jerry
Published: March 2020

This chapter is centred on a case study on brain injury after cardiac arrest. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.
Subarachnoid haemorrhage
Authors: Kirkman Matthew A. , Smith Martin
Published: March 2020

This chapter is centred on a case study on subarachnoid haemorrhage. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.
Acute-on-chronic respiratory failure
Authors: Hunt Richard , MacNaughton Peter
Published: March 2020

This chapter is centred on a case study on acute-on-chronic respiratory failure. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.
Feeding, access, and thromboprophylaxis
Authors: Huntley Martin , Moonesinghe Ramani
Published: March 2020

This chapter is centred on a case study on feeding, access and thromboprophylaxis. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.
Malignancy and critical illness
Authors: Desai Nishita , Wares Gary
Published: March 2020

This chapter is centred on a case study on malignancy. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.
Major burns
Authors: Moxham Sian Alys , Young Amber E.
Published: March 2020

This chapter is centred on a case study on burns. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.