bluuebunny/crossref_metadata_2025 huggingface dataset:
Intraventricular Tumors
Authors: Obiorah Samanthalee C. S. , Dowd Richard S. , Toms Steven A.
Published: June 2023

Intraventricular tumors encompass lesions that develop within the ventricular system of the central nervous system, comprising the lateral, third, and fourth ventricles. This chapter discusses the development, imaging characteristics, symptomatology, management options, and prognosis of common intraventricular tumors. Colloid cysts, choroid plexus tumors, intraventricular meningiomas, ependymomas, subependymomas, astrocytomas, central neurocytomas, subependymal giant cell tumors, intraventricular lymphomas, and metastases are described in the chapter. In addition, the notable imaging features on computed tomography as well as various categories of magnetic resonance imaging are included in a table to allow for both comparison and contrast among these lesions. The discussion of these lesions presented here will further the knowledge surrounding their complexities.
Metastatic Disease in the Central Nervous System
Authors: Wilcox Jessica A. , Boire Adrienne A.
Published: June 2023

As many one-third of all patients with cancer will harbor central nervous system metastases, with the majority of brain metastases arising from lung, breast, melanoma, renal, and colorectal primary malignancies. Circulating tumor cells gain entry to the brain and leptomeninges through multiple mechanisms, hijack vascular supply and nearby nutrients, and flourish in these unfamiliar microenvironments through a cascade of malignant evolution. Despite multidisciplinary treatment strategies involving surgery, focal radiation, and systemic therapies, the morbidity and mortality afflicting those with CNS metastases remain grim. As scientific discoveries enable improved diagnosis, genomic sequencing from tumor and cerebrospinal fluid specimens, and targeted treatments based on specific cancer and mutation subtypes, we are beginning to appreciate a trend toward increased overall survival and quality of life.
Epidemiology and General Overview of Pediatric Central Nervous System Tumors
Authors: Coven Scott L.
Published: June 2023

This chapter examines tumors of the central nervous system (CNS) that may be encountered in childhood. It reviews the basic understanding of glioma, medulloblastoma, ependymoma, and other less common CNS tumors. This chapter discusses the evolution of molecular characteristics, current treatment strategies, and potential pitfalls for the selected tumor types. It also briefly reviews inherited syndromes linked to childhood CNS tumors, including neurofibromatosis, tuberous sclerosis, and Li-Fraumeni syndrome. It also discusses potential late effects that may manifest as a consequence of primary management of childhood CNS tumors. Many differences exist between childhood and adult CNS tumors, and this content is written to provide a basic understanding of the pertinent issues related to childhood central nervous system tumors.
Neurosurgical Management of Pediatric Central Nervous System Tumors
Authors: Shimony Nir , Noureldine Mohammad Hassan A. , Brimley Cameron , Jallo George I.
Published: June 2023

Pediatric brain and spinal cord tumors are the cause of significant morbidity in children. While pediatric spinal cord tumors are rare, brain tumors are the most common solid tumor in the pediatric population. Often, these tumors have a limited response to medical therapies or patients might have contraindications for radiation. Hence maximal surgical removal of these tumors is a common primary method of treatment. Furthermore, maximal safe tumor resection offers decompression, which might lead to clinical improvement and is crucial to establish a pathological diagnosis and inform further treatment recommendations. Secondary spinal cord involvement of tumors in the pediatric population is rare because primary systemic cancer metastases occur infrequently in this age group. Primary spinal cord tumors are encountered infrequently, have limited treatment options, and require careful neurosurgical and treatment considerations. There is growing research interest in pediatric nervous system tumors with multiple ongoing trials, many with promising results for better oncologic therapies. Advanced imaging as well as advances in genetic and molecular understanding of pediatric central nervous system tumors have also helped to broaden therapeutic options for tumors that were previously deemed inoperable or otherwise difficult to manage. With many gaps remaining in the field of pediatric neuro-oncology and neurosurgical oncology, there is a need for continued patient enrollment into clinical trials to advance the field through improved evidence-based management options.
Pediatric Embryonal Tumors
Authors: Mochizuki Aaron , Partap Sonia
Published: June 2023

This chapter on pediatric embryonal tumors encompasses the diagnoses of medulloblastoma, atypical teratoid/rhabdoid tumor (ATRT), pineoblastoma, embryonal tumor with multilayered rosettes (ETMR), and other embryonal tumors as delineated by the World Health Organization’s 2016 central nervous system tumor classification system. Each section reviews the epidemiology, clinical presentation, imaging, and pathological characteristics as well as principles of management informed by the most recent available medical literature. Additionally, the chapter describes the evolving understanding of each tumor that has been enabled by modern molecular characterization, including the latest consensus on medulloblastoma subtypes wingless ([WNT]-activated, sonic hedgehog [SHH]-activated, Group 3, and Group 4) and the emerging insights in other entities.
Neurosurgical Management of Adult Central Nervous System Tumors
Authors: Gogos Andrew J. , Morshed Ramin A. , Hervey-Jumper Shawn L.
Published: June 2023

With more than 100 histologically distinct primary central nervous system (CNS) tumors in addition to metastatic disease, tumors within the brain and spine each have their own distinct symptom profile and outcomes. Neurosurgical management of CNS tumors has evolved in tandem with advances in medical and radiation oncology. For most tumors, neurosurgical intervention remains the primary method for definitive diagnosis and the first line of treatment. This chapter describes the rationale for neurosurgical intervention for specific considerations for common tumor types in adults and details surgical techniques relevant to neuro-oncology practice.
Device-Based Treatments in Neuro-Oncology
Authors: Fonkem Ekokobe , Azadi Amir , Tadipatri Ramya
Published: June 2023

Glioblastoma heterogeneity has posed significant challenges in developing therapies. Although it is a diffusely infiltrative tumor, it almost never metastasizes and is therefore potentially suitable for regional therapy. A major limitation of many systemic cancer treatments is poor therapeutic index given the side-effect profile of many chemotherapeutic agents. Medical devices that provide loco-regional therapy include tumor-treating fields (TTFields), carmustine wafers, GammaTile, Nativis Voyager, NeuroBlate, Visualase, and Tumor Monorail. These devices have shown much promise overall and in some cases have significantly improved survival in glioblastoma patients, in addition to often having fewer side effects than systemic therapies. This chapter provides a comprehensive overview of these devices, along with indications for their use, possible contraindications, and side-effect profiles.
Designing and Deciphering Clinical Trials
Authors: Glantz Michael , Mansouri Alireza
Published: June 2023

This chapter distills the essential components required for designing clinical trials of high methodological quality and reproducibility into a user-friendly instruction manual complete with checklists, charts, and algorithms. Because these are the same components and procedures required for evaluating the strength of published research, the practice of critical appraisal also is considered. To accomplish these parallel goals, the authors focus on a “baker’s dozen” design features: asking the right question, randomization, allocation concealment, masked assessment, baseline patient characteristics, inclusion and exclusion criteria, accounting for clinical trial participants, intention-to-treat, primary and secondary outcomes, sample size calculation, evaluating benefits and harms, interpreting results, and managing conflict of interest. The chapter concludes with a hope and a prayer.
The Neuro-Oncology of Women (NOW)
Authors: Gatson Na Tosha N. , Taylor Kerianne R. , Boccia Maria L. , Woodard Terri L.
Published: June 2023

Adult females account for nearly 60% of all intracranial tumors reported in the United States. Despite a female predominance, clinical trial and brain tumor guideline development that explore potential differences in the management of brain tumors in women are limited. This chapter brings awareness to several common concerns pertaining to the care of women with CNS tumors, reviews the supporting data for best practices, and offers important context around the neuro-oncology of women (NOW). Neuro-oncology providers have difficult conversations with their female patients about the impact that cancer and/or cancer therapies have on their survival and quality of life (QOL). These discussions often require a multidisciplinary clinical approach when addressing sex, sexuality, fertility preservation, pregnancy maintenance, pregnancy prevention, and exogenous hormone exposure risks. Key gap-issues in NOW are covered in this chapter including current treatment and surveillance guidelines as well as special considerations for pregnant women with central nervous system (CNS) tumors. Also included is information about common primary brain tumors in women, women’s sexuality, quality of life issues, and considerations of fertility preservation. As significant percentage of intracranial tumors harbored by women are hormone-dependent, more research should be dedicated to addressing NOW-related topics to best inform our patients and providers. Issues of transgender health, cross-sex hormone exposure, family planning options, and limiting sexual risks for exposure to chemotherapy in body fluids are not addressed here. We address a critical portion of the expansive subject matter relevant to NOW and hope you enjoy this review.
Acute Confusional State in the Intensive Care Unit
Authors: Wijdicks Eelco F.M.
Published: June 2023

There is a high prevalence of acute confusion and delirium in critical illness, and patients admitted to the intensive care unit are at high risk for these disorders. As well, patients in a florid delirium are at additional risk of medical complications for which a confusional state or delirium can be very relevant. This chapter defines acute confusional state and delirium and explains the major diagnostic considerations and laboratory tests that are necessary to evaluate these patients thoroughly. Recognition of risk factors or triggers is important so that they can be mitigated or removed when possible. The best management of agitated and delirious patients also is discussed.
Coma and Other States of Altered Awareness in the Intensive Care Unit
Authors: Wijdicks Eelco F.M.
Published: June 2023

On a daily basis intensivists encounter comatose patients with a variety of presentations and causes. Coma may occur from a number of reasons such as drug or alcohol intoxication, traumatic brain injury, or after cardiopulmonary resuscitation. The first course of action is to rapidly determine whether the patient is comatose. Then one should determine whether the lesion is in one hemisphere causing mass effect (fixed dilated pupil same side of the lesion with decorticate or decerebrate motor response opposite side of the lesion), in both hemispheres (no asymmetries and often brainstem reflexes intact early on), or in the posterior fossa (pupil anisocoria and skew deviation of eye position, spontaneous vertical eye movements). If there is no vascular occlusion, mass lesion, brain edema, or acute hydrocephalus, an MRI with gadolinium should be considered urgently. This chapter provides a detailed template for evaluation.
Generalized Weakness in the Intensive Care Unit
Authors: Wijdicks Eelco F.M.
Published: June 2023

Generalized weakness following long-term bed rest is expected in the patient recovering from critical illness or injury. This weakness becomes of great concern to intensivists when patients have marked wasting of muscle, are unable to signal with their arms, are not weaned from the ventilator despite several attempts, or are exhibiting new-onset weakness. In these cases, determining whether a critically ill patient has, in fact, a neuromuscular disorder can be difficult to assess. The major diagnostic approach in new-onset ICU weakness is to evaluate for a neurologic disorder, and this is done exclusively clinically. This chapter provides an overview of the causes of generalized weakness associated with a myelopathy, neuropathy, neuromuscular junction disorder, or myopathy in the ICU.
Acute Movement Abnormalities in the Intensive Care Unit
Authors: Wijdicks Eelco F.M.
Published: June 2023

Although their true prevalence is unknown, unusual movements seem common in critically ill patients, and neurologists are therefore frequently asked to interpret and treat. A neurologic consultation is triggered when these adventitious movements are recurrent, spreading throughout different parts of the body, display a rhythmicity, involve abnormal grimacing mimicking pain, or interfere with care or mechanical ventilation. Movement disorders can lead to a host of secondary complications. Dystonic involvement of the chest wall, neck, and respiratory muscles may cause acute respiratory compromise requiring mechanical ventilation. Excess (hyperkinetic) movements sustained over a period of time increase the risk of muscle breakdown. In this chapter, the clinical semiology of movement disorders seen in the ICU is described to aid recognition.
Neurologic Manifestations of Acute Hepatic Failure
Authors: Wijdicks Eelco F.M.
Published: June 2023

In critically ill patients, acute hepatic failure occurs in the course of multiorgan failure, acute hypotension, or cardiac resuscitation. Acute hepatic failure as a primary presenting emergency is less common in medical intensive care units (ICUs), but patients may be admitted with sudden onset of hepatic encephalopathy from acute gastrointestinal hemorrhage that causes rapid hyperammonemia. A particularly challenging management problem in the ICU is the presentation of a patient with fulminant hepatic failure. This chapter illustrates the clinical characteristics of acute hepatic encephalopathy but concentrates on the management of fulminant hepatic failure and treatment of cerebral edema. Survival of fulminant hepatic failure is now possible as a result of urgent liver transplantation.
Neurologic Complications in the Critically Ill Pregnant Patient
Authors: Wijdicks Eelco F.M.
Published: June 2023

Pregnancy-specific disorders such as eclampsia; the hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; amniotic fluid embolism; and neurologic manifestations of tocolytic agents are the most common causes of admission to the intensive care unit (ICU). Obstetric admissions to the ICU are peripartum emergencies and include obstetric hemorrhage due to uterine atony or uncontrolled hypertension. Recent rupture of an aneurysm or arteriovenous malformation is sometimes seen. Some pregnancy-related disorders of the nervous system are very uncommon; others, such as eclampsia, are seen relatively frequently. Seizure control is often a reason for consultation, and the approach to management is different from that used in other conditions.
Neurologic Complications of Aortic Surgery
Authors: Wijdicks Eelco F.M.
Published: June 2023

Extensive surgical reconstructive repairs of the aorta increase the risk of ischemic injury not only to the viscera but also to the spinal cord. Several pathologic types of spinal cord infarction have been reported, but anterior spinal artery syndrome or complete spinal cord infarction at the mid-thoracic to low thoracic level is most frequent. The management of these patients often involves diversion of CSF and blood pressure augmentation, and consulting neurologists can be closely involved. Other complications may involve acute stroke management. This chapter reviews the scope of the problem of spinal cord infarction, its neurologic features and diagnostic evaluation; therapeutic options; plexopathies; and the sequelae of aortic dissection.
Neurologic Complications of Trauma to the Spine, Spinal Cord, and Nerves
Authors: Wijdicks Eelco F.M.
Published: June 2023

Trauma to the spinal cord presents first in the emergency department, but after stabilization in the field. A large number of surgical services (trauma, spine, orthopedic, neurosurgery) are immediately involved to assess the extent of injury and determine the need for emergent surgery. The role of the neurologist is initial confirmatory assessment and assistance with obtaining a detailed and full neurologic examination. Trauma to single nerves or plexus may occur and need to be recognized. This chapter provides a full overview of various types of stable and unstable spine and pelvis fractures and how to support traumatic spinal cord injury. Fat embolism to the brain is rare but important to recognize.
The Neurologist and End-of-Life Care in the Intensive Care Unit
Authors: Wijdicks Eelco F.M.
Published: June 2023

The time may come when physicians cannot be realistically hopeful, and intensive care is replaced by comfort and palliation. Neurologists are commonly involved in these decisions to de-escalate life support, and that is partly a reflection of the high prevalence of neurologic catastrophes in patients with a critical illness. This chapter deals with withdrawal of intensive care unit intervention in neurologic disease and its different ramifications. Withdrawal of treatment is less complicated in comatose patients. Some patients are eligible for organ donation, and these include any patient in which withdrawal of support is decided upon. In many instances, this is determined after a consensus agreement between physician and family members.
Clinical and social aspects of crime
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter begins with a description of crime to the forensic psychiatrist, and the prevalence and measurement of crime. It then begins to outline the psychology and philosophy of volition. The rest of the chapter covers both violent crime and sexual crime, with a rationale for dividing violent and sexual offending in forensic psychiatry. Under violent offences it covers the social factors associated with offending, the neurobiology of violence, adverse childhood experiences, unconscious factors, a developmental perspective, gang crime, extremism, terrorism, and radicalisation, and aims to answer the question on whether mental disorders cause violence. It also covers homicide, non-fatal assaults, and fire-setting behaviours. Under sexual crime, it covers stalking, sexual offending in its social context, offences against adults, children, and other types of sexual offending.
Assessment in forensic psychiatry
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter covers assessments in forensic psychiatry. It begins with an overview of the forensic psychiatric assessment, then goes on to assessments of personality and sexual attitudes and behaviour. It outlines psychological testing and test domains, then provides a list of specific psychological tests along with caveats around their use. The use of biological investigations is described. Information gathering and liaison, diagnosis, and formulation are outlined. Special issues in assessment are then covered, including in the prison setting, and working with women, children and youths, witnesses, and victims. Finally, issues relating to suggestibility and compliance are covered.
Treatment
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter covers treatment in forensic psychiatry. It begins with the aims of treatment, and settings in which treatment is carried out. Coercion and treatment and the therapeutic use of security are both included, along with the DUNDRUM toolkit along with seclusion and restraint. Physical treatments, pharmacology, physical health in the secure setting, and psychotherapies are all outlined. The chapter then goes on to specific treatment modalities, including CBT, DBT, MBT, SFT, arts psychotherapies and psychodynamic psychotherapies, and group therapy. Therapeutic communities are also discussed. The chapter goes on to nursing, relational security, social work, occupational therapy, and vocational rehabilitation. Finally, evaluation of treatment and the treatment of victims are outlined.
Clinical matters raising ethical issues
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter raises ethical issues within clinical matters. It begins with the concepts of mental disorders, and defines values and diversity in forensic practice, including how to avoid person prejudices. It goes on to the importance of autonomy and self-determination. Consent to treatment, and treatment during incapacity are both covered, alongside when patients refuse treatment. The chapter goes on to ask who forensic psychiatrists should treat, what counts as treatment, and consent to risk assessments and research/documentary procedures. It finishes with prosecution of patients.
Legal systems
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter begins with an overview of law in society, and then jurisprudence and legal interpretation. It goes on to explain sources of law, and the differences between civil law and common law systems. It goes on to explain the courts and tribunals of the UK, and Scotland. Judicial review, roles within the court, court procedures, and the burdens and standards of proof are all explained, alongside rules of evidence. The court systems within England, Wales, and Northern Ireland, the Republic of Ireland are all outlined, as well as a brief overview of systems in the EU and other countries. Finally, professional regulatory structures, inquests, and inquiries are all included.
The criminal justice system
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter covers the criminal justice system. It outlines social services, police services, the police station, and the handling of vulnerable suspects. Investigative psychology and prison services are both described, along with adolescent secure services. Parole boards, and probations services are included, alongside offender management and managing the restricted patient. Safeguarding, public protection arrangements, the risk management authority are all explained, and the chapter concludes with crime prevention, PREVENT, and homicide and suicide inquiries.
Legal tests relevant to psychiatry
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter provides a general overview of the legal tests relevant to psychiatry. It begins with fitness to plead and fitness to give evidence, and the validity of confessions. Capacity for form intent, automatism, and both voluntary and involuntary intoxication are all covered, as is intoxication and specific defences. The chapter moves on to insanity, diminished responsibility, loss of control and provocation, and duress coercion and necessity in legal defences and forensic psychiatry. Amnesia, aggravating and mitigating factors, and legal tests in personal injury cases are all outlined. Finally, fitness to practice professionally, tests in family law, fitness for work and dismissal, and fitness for extradition and deportation are explained.
Applied ethics and testimony
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter covers applied ethics and supplying testimony in court. It begins with judicial ethics and legal philosophy, and discusses avoiding addressing the ultimate issue in court. It then has an overview of giving expert advice to one side. Tips and tricks on how to convey controversial clinical concepts in court are outlined, and the importance of having opinions in sentencing is covered. The courts’ assessments of dangerousness is explained, and finally bias influencing opinion (including unconscious bias) is covered.
Providing reports
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán , Williams Hannah Kate
Published: June 2023

This chapter provides guides for providing reports in forensic psychiatry. It begins with the aims and methods of report-writing, then goes on to preparation, taking instructions, issues that should be considered before writing the report, and general aspects to do with the task at hand. It provides a suggested outline for report structure, and follow-up actions after writing. The remainder of the chapter provides specific instructions for different types of report: mental health tribunals, criminal cases, parole boards, family courts, civil compensation cases, clinical negligence, professional regulatory cases, employment tribunals, deportation and extradition, and inquests. Finally reporting without giving oral evidence is covered.
Decision-making theories
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán
Published: June 2023

Good, effective, ethical decisions in the assessment, treatment, and management of patients in clinical contexts and defendants or litigants in legal contexts depend upon the strengths and weaknesses of the decision-making process used. Explicit reflection helps good decision-making in any area of medicine (and far beyond medicine), but is particularly necessary in forensic psychiatry and psychology. Before the Enlightenment of the eighteenth century, decision-making rested largely upon the time-worn pillars of faith, hope, and experience. As the Age of Reason progressed, however, scientists, philosophers, and mathematicians, who prided themselves on their rationalism, turned their attention to decision-making, and developed theories that reflected their assumption that it was no more than a purely cognitive reasoning process. This chapter provides an overview of decision-making theories. It includes rational decision-making; nonrational decision-making; dual processes (system 1 and system 2); values at the heart of decision-making; ease, bias, and heuristics; and values-based decision-making.
Ethical cases
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán
Published: June 2023

This chapter covers twenty-four ethical cases with accompanying reflection questions to guide the forensic psychiatrist through difficult ethical issues. It begins with the right or duty to disclose defence reports in a criminal law context, and the right or duty to breach confidence in a civil law context. The duty to supervise a patient in the community is covered, alongside what information to share with patients. Treating the psychiatrist and therapist as an expert witness in criminal trials and civil litigation are both explained, alongside the role professional versus expert witnesses, and professional versus contractual duty and medically relevant but legally inadmissible information. The role of personal values in expert decision-making is discussed, and how to navigate uncertainty about your opinion and resisting legal pressure is explained. Disputes within forensic mental health teams and presenting evidence to a tribunal is related, and what to do when there is a clash between clinician and organisational values is explained. The role of personal values in risk-formulation, monitoring ‘treatment’, assisting police and the prosecution of a patient, measuring ‘good-enough’ treatment outcomes for patient progression, and assisting the detection, prevention, or prosecution of a serious crime are all covered. Professional boundary violations and workplace discrimination, how to weigh the benefits of treatment against detrimental side-effects, and finally what to do when all options present ethical issues are included.
Criminal law cases
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán
Published: June 2023

In this chapter thirty-one cases provide examples of criminal law, along with guided questions to help the forensic psychiatrist navigate the patient under criminal charges. The chapter begins with the preparation of an expert report on a vulnerable defendant, and how to perform an assessment for suggestibility and compliance on the patient. Next it covers fitness to plead in circumstances of intellectual disability and psychosis, and how to use psychological test results. Diminished responsibility is discussed with cases that include psychosis, neurotic illness, personality disorders, recognised medical conditions, and substance dependence and intoxication. It then covers the difference between loss of control and diminished responsibility, the concept of ‘slow burn’, and woundability and malingering, and joint enterprise and the role of encouraging or assisting a crime. Cases in the capacity to form specific intent in the presence of intoxication, intent to kill in the presence of drugs and alcohol, and the capacity to reform when there is the potential for the death sentence to be carried out are then included. Insanity as an appeal against verdict, and infanticide by an adolescent are both covered. Duress using drug importation is included, alongside vulnerability short of duress in the presence of personality disorder, and self-defence in attempted murder are all included. Cases on automatism in intoxication, brain injury, and dissociation; amnesia, dementia, and retracted confession in intellectual disability; and reliability of witness evidence, extradition and autism, appeal against murder convictions in emerging psychotic depression, and requests to alter court reports for sentencing.
A case study of critiquing clinical decision-making within multiple paradigms
Authors: Eastman Nigel , Adshead Gwen , Fox Simone , Latham Richard , Whyte Seán
Published: June 2023

The well-known case of a higher trainee paediatrician Dr Bawa-Garba, who was convicted of manslaughter as a result of her role in the death of a young boy with Down’s syndrome, illustrates the differences of process and outcome between prosecution for gross negligence manslaughter, civil legal negligence, professional regulatory proceedings, and internal service inquiries. All the material given in the description that follows is in the public domain, released by the inquiries concerned. This chapter provides a real-world case of critiquing clinical decision-making in a manslaughter trial. It presents the clinical case, the legal case, and reflections on how the case was handled.
Randomized controlled trials
Authors: Cook Jonathan A.
Published: June 2023

Randomized controlled trials (RCTs) are the preferred study design for assessing efficacy in clinical trials. This chapter describes the standard (two arm parallel-group) RCT design. In this chapter, why RCTs are considered the ‘gold’ standard design for comparing medical treatments is reviewed. The benefits of random allocation of treatments are considered. What is meant by random allocation, along with different methods of randomization (simple, random permuted blocks, stratification, minimization, and outcome-adaptive) are described. How randomization can be carried out in a clinical trial is also considered, and guidance on how to choose the randomisation method for a trial is given.
Choosing the sample size for a clinical trial
Authors: Cook Jonathan A.
Published: June 2023

Getting the sample size right is crucial for ensuring the clinical trial can meet its objectives. It also has practical, financial, and ethical considerations. Why getting the sample size right matters is addressed in this chapter. The chapter explains the purpose of the sample size calculation, and to how to determine the required sample size for binary, continuous and time-to-event outcomes. The inputs needed for each are covered along with what values to use, and worked example calculations are used. Different approaches to sample size determination when assessing safety is the main focus, or a precision-based or Bayesian approach are also described.
Reporting and disseminating the findings of a clinical trial
Authors: Cook Jonathan A.
Published: June 2023

The findings of a clinical trial need to be reported and disseminated so that they can be used by others and improve clinical practice. Why the quality of study reporting matters and the consequences of poor reporting are addressed in this chapter. Common limitations in reporting are considered along with potential remedies. The vital role of reporting guidelines in facilitating good reporting in journal articles is reviewed. The many possible audiences who might be interested in trial results and means of dissemination that can reach them are addressed, as is how to communicate to them. Sharing trial data and the related challenges are also considered.
A Denial a Day Keeps the Doctor Away
Authors: Dunn Abe , Gottlieb Joshua D , Shapiro Adam Hale , Sonnenstuhl Daniel J , Tebaldi Pietro
Published: June 2023

Who bears the consequences of administrative problems in health care? We use data on repeated interactions between a large sample of U.S. physicians and many different insurers to document the complexity of health care billing, and estimate its economic costs for doctors and consequences for patients. Observing the back-and-forth sequences of claim denials and resubmissions for past visits, we can estimate physicians’ costs of haggling with insurers to collect payments. Combining these costs with the revenue never collected, we estimate that physicians lose 18% of Medicaid revenue to billing problems, compared with 4.7% for Medicare and 2.4% for commercial insurers. Identifying off of physician movers and practices that span state boundaries, we find that physicians respond to billing problems by refusing to accept Medicaid patients in states with more severe billing hurdles. These hurdles are quantitatively just as important as payment rates for explaining variation in physicians’ willingness to treat Medicaid patients. We conclude that administrative frictions have first-order costs for doctors, patients, and equality of access to health care. We quantify the potential economic gains—in terms of reduced public spending or increased access to physicians—if these frictions could be reduced and find them to be sizable.
Radiotherapy Infrastructure Shielding Calculations: software development for shielding calculations in a linear accelerator radiotherapy room
Authors: Ganou Charalampia , Ganos Aristotelis , Papatheodorou Spiridon , Metaxas Vasileios , Dimitroukas Christos , Panayiotakis George
Published: June 2023

This work aimed to develop and validate software that calculates the shielding thickness required for a radiotherapy room with a linear accelerator utilising geometric and dosimetric data. The software “Radiotherapy Infrastructure Shielding Calculations” (RISC) was developed using MATLAB programming. It does not require the installation of the MATLAB platform, and the user only needs to download and install the application, which displays a graphical user interface (GUI). The GUI includes empty cells to insert numerical values for several parameters to calculate the proper shielding thickness. The GUI comprises two main interfaces, one for the primary and one for the secondary barrier calculation. The interface of the primary barrier is divided into four tabs: (a) primary radiation, (b) patient scattered and leakage radiation, (c) IMRT techniques and (d) the shielding cost calculations. The interface of the secondary barrier includes three tabs: (a) patient scattered and leakage radiation, (b) IMRT techniques and (c) the shielding cost calculations. Each tab consists of two sections: one for input and one for output of the necessary data. The RISC is based on the methods and formulae of the NCRP 151 and calculates the primary and secondary barrier thickness for ordinary concrete with a density of 2.35 g/cm3 and the cost for a radiotherapy room with a linear accelerator that performs conventional or IMRT techniques. Calculations can be performed for photon energies of 4, 6, 10, 15, 18, 20, 25 and 30 MV of a dual-energy linear accelerator, while instantaneous dose rate (IDR) calculations are also performed. The RISC has been validated using all comparative examples of NCRP 151 and the calculations from shielding reports of the Varian IX linear accelerator at Methodist Hospital of Willowbrook and Elekta Infinity at the University Hospital of Patras. The RISC is accompanied by two text files: (a) “Terminology,” extensively describing all parameters, and (b) “User’s Manual,” providing useful instructions to the user. The RISC is user-friendly, simple, fast and precise, providing accurate shielding calculations and quickly and easily reproducing different shielding scenarios for a radiotherapy room with a linear accelerator. Additionally, it could be used during the educational process of shielding calculations by graduate students or trainee medical physicists. As a future work, the RISC will be updated with new features such as skyshine radiation, door shielding, and other types of machines and shielding materials.
Identification of Bone Morphometric Protein-Related Hub Genes and Construction of a Transcriptional Regulatory Network in Patients With Ossification of the Ligamentum Flavum
Authors: Tuo YiFan , Hu Lihong , Gu Wenbo , Yuan Xiaoya , Ma Da , Wu Jide , Luo Di , Zhang Xiao , Li Xusheng , Yang Shengsen , Yuan Haifeng
Published: June 2023

Study Design:

Basic science laboratory study.

Objective:

To identify hub genes related to bone morphogenetic proteins (BMP) in ossification of the ligamentum flavum (OLF) and analyze their functional characteristics.

Summary of Background Data:

The exact etiology and pathological mechanism of OLF remain unclear. BMPs are pleiotropic osteoinductive proteins that may play a critical role in this condition.

Methods:

The GSE106253 and GSE106256 datasets were downloaded from the Gene Expression Omnibus database. The mRNA and lncRNA expression profiles were obtained from GSE106253. The miRNA expression profiles were obtained from GSE106256. Differentially expressed genes (DEGs) were identified between OLF and non-OLF groups and then intersected with BMP-related genes to obtain differentially expressed BMP-related genes (DEBRGs). The least absolute shrinkage selection operator (LASSO) and support vector machine recursive feature elimination (SVM-RFE) were used to screen hub genes. Furthermore, a competing endogenous RNA (ceRNA) network was constructed to explain the expression regulation of the hub genes in OLF. Finally, the protein and mRNA expression levels of the hub genes were verified using western blot and real-time polymerase chain reaction (RT-PCR), respectively.

Results:

We identified 671 DEGs and 32 DEBRGs. Hub genes ADIPOQ, SCD, SCX, RPS18, WDR82, and SPON1, identified via LASSO and SVM-RFE analyses, showed high diagnostic values for OLF. Furthermore, the ceRNA network revealed the regulatory mechanisms of the hub genes. RT-PCR showed that the mRNA expression of the hub genes was significantly downregulated in the OLF group compared with the non-OLF group. Western blot showed that the protein levels of ADIPOQ, SCD, WDR82, and SPON1 were significantly downregulated, whereas those of SCX and RPS18 were significantly upregulated in the OLF group compared with the non-OLF group.

Conclusion:

This study is the first to identify BMP-related genes in OLF pathogenesis through bioinformatics analysis. ADIPOQ, SCD, SCX, RPS18, WDR82, and SPON1 were identified as hub genes for OLF. The identified genes may serve as potential therapeutic targets for treating patients with OLF.
Physician Burnout and Medical Errors: Exploring the Relationship, Cost, and Solutions
Authors: Li Chris J. , Shah Yash B. , Harness Erika D. , Goldberg Zachary N. , Nash David B.
Published: June 2023

Physician burnout has demonstrated risks to providers and patients through medical errors. This review aims to synthesize current data surrounding burnout and its impacts on quality to inform targeted interventions that benefit providers and patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review methodology was utilized to identify studies of quantitative metrics for burnout and medical errors. Three independent reviewers conducted screening, study selection, and data extraction. Of 1096 identified articles, 21 were analyzed. Overall, 80.9% used the Maslach Burnout Inventory to evaluate for burnout. Moreover, 71.4% used self-reported medical errors as their primary outcome measure. Other outcome measures included observed/identified clinical practice errors and medication errors. Ultimately, 14 of 21 studies found links between burnout and clinically significant errors. Significant associations exist between burnout and medical errors. Physician demographics, including psychological factors, well-being, and training level, modulate this relationship. Better metrics are necessary to quantify errors and their impacts on outcomes. These findings may inform novel interventions that target burnout and improve experiences.
Reevaluating the Significance of Infection Preventionists and Infection Prevention and Control Departments in the Post-COVID-19 Era
Authors: Amaefule Adaeze Q. , Litvintchouk Alexander , de Cordova Pamela , Maio Vittorio , Pogorzelska-Maziarz Monika
Published: June 2023

Infection preventionists are specialized health care professionals tasked with developing and implementing infection control policies, educating staff and patients on prevention practices, and investigating outbreaks. Infection preventionists role in developing effective measures for infection prevention and control and ensuring public health and safety became even more vital given the emergence of the COVID-19 pandemic. It is important for health care systems and institutions to incorporate lessons learned, enhance infection prevention and control resources, and grow the infection preventionists workforce to prepare for future pandemic events.
Novel agents for treating IgA nephropathy
Authors: Kunter Uta , Seikrit Claudia , Floege Jürgen
Published: June 2023

Purpose of review

In the past, the treatment of IgA nephropathy (IgAN), which is the most common glomerulonephritis worldwide, mostly relied on blockade of the renin–angiotensin system as a central component of so-called supportive therapy as well as on high-dose systemic corticosteroid therapy.

Recent findings

The supportive treatment arm has been expanded by the addition of sodium-glucose cotransporter-2 inhibitors, hydroxychloroquine, and, most recently, endothelin A receptor blockers. Treatment with high-dose systemic corticosteroids has become more controversial, with some studies observing no benefit and others documenting the protection of kidney function. However, all recent studies on systemic corticosteroids consistently found significant toxicity. An important novel approach to IgAN, therefore, is therapy with a targeted release formulation of budesonide with preferential release in the distal small intestine, given the mounting evidence for a gut–kidney axis in the pathophysiology of IgAN. In addition, emerging new therapeutic options include a variety of complement inhibitors as well as agents targeting B-cell proliferation and differentiation.

In recent years, IgAN has become the focus of a considerable number of clinical studies that will significantly advance the development of new therapy strategies.
High-grade Serous Carcinoma can Show Squamoid Morphology Mimicking True Squamous Differentiation
Authors: Tomonobe Hiroshi , Ohishi Yoshihiro , Hachisuga Kazuhisa , Yahata Hideaki , Kato Kiyoko , Oda Yoshinao
Published: June 2023

Tubo-ovarian high-grade serous carcinoma (HG-SC) and ovarian endometrioid carcinoma (EC) can show overlapping morphologic features, such as glandular and solid patterns. The differential diagnosis of these subtypes is thus sometimes difficult. The existence of “squamous differentiation” tends to lead to a diagnosis of EC rather than HG-SC. We noticed that HG-SC can contain a “squamoid component,” but its nature has been poorly investigated. This study was thus established to clarify the nature of this “squamoid component” in HG-SC by investigating its frequency and immunohistochemical features. We reviewed hematoxylin and eosin–stained slides of 237 primary untreated cases of tubo-ovarian HG-SC and identified 16 cases (6.7%) of HG-SC with “squamoid component.” An immunohistochemical staining panel (CK5/6, CK14, CK903, p40, p63, WT1, ER, and PgR) was used to analyze all of these 16 cases. We also selected 14 cases of ovarian EC with “squamous differentiation” as a control. The “squamoid component” in HG-SC was completely p40-negative and showed significantly lower expression of CK5/6, CK14, CK903, and p63 than the “squamous differentiation” in EC. The immunophenotype of the “squamoid component” in HG-SC was concordant with the conventional HG-SC component (WT1-positive/ER-positive). Furthermore, all 16 tumors were confirmed to be truly “HG-SC” by the findings of aberrant p53 staining pattern and/or WT1/p16 positivity, and the lack of mismatch repair deficiency and POLE mutation. In conclusion, HG-SC can on rare occasions show a “squamoid component” mimicking “squamous differentiation.” However, the “squamoid component” in HG-SC does not represent true “squamous differentiation.” The “squamoid component” is one part of the morphologic spectrum of HG-SC, which should be interpreted carefully for the differential diagnosis of HG-SC and EC. An immunohistochemical panel including p40, p53, p16, and WT1 is a useful adjunct to achieve a correct diagnosis.
The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization
Authors: Cepeda Alfredo , Johnson Madysen L. , Kelagere Kavya , Obinero Chioma G. , Nguyen Phuong D. , Greives Matthew R.
Published: June 2023

Background:

Patients undergoing primary palatoplasty rely on narcotics for pain control, but narcotics can lead to sedation and respiratory depression. Recent research into Enhanced Recovery After Surgery (ERAS) pathways utilizing multimodal pain therapy has yielded promising results for patients undergoing palatoplasty in terms of decreased hospital length of stay (LOS), increased oral intake, and decreased narcotic usage. Despite the potential benefit of ketorolac after palatoplasty, there is a paucity of data regarding its use.

Methods:

A single-center cohort study of patients undergoing primary palatoplasty was performed using 2 cohorts: a retrospective cohort treated with our institution’s prior ERAS protocol from 2016 to 2018 and a prospective group of patients who also received ketorolac (ERAS+K) postoperatively from 2020 to 2022.

Results:

A total of 85 patients (57 ERAS and 28 ERAS+K) were included. Compared with the ERAS group, the ERAS+K cohort had significantly decreased LOS (31.8 versus 55 h, P=0.02), decreased morphine milligram equivalents administered at 24 hours (1.5 versus 2.5, P=0.003), 48 hours (0 versus 1.5, P<0.001), and total inpatient morphine milligram equivalents (1.9 versus 3.8, P=0.001). The ERAS+K group also had a significant decrease in the prescribed narcotic rate (32.1% versus 61.4%, P=0.006). No bleeding issues, blood transfusions, or reoperations were noted in either cohort.

Conclusions:

This study illustrates many potential benefits of using ketorolac as a pain management adjunct in combination with a multimodal pain regimen. Our results demonstrated favorable outcomes, including decreased narcotic usage and LOS as well as increased hourly oral intake, without increasing bleeding complications.