bluuebunny/crossref_metadata_2025 huggingface dataset:
Incubation Temperature Affects Duckling Body Size and Food Consumption Despite No Effect on Associated Feeding Behaviors
Authors: Hope S F , Kennamer R A , Grimaudo A T , Hallagan J J , Hopkins W A
Published: February 2020

Synopsis

Developmental conditions can have consequences for offspring fitness. For example, small changes (<1°C) in average avian incubation temperature have large effects on important post-hatch offspring phenotypes, including growth rate, thermoregulation, and behavior. Furthermore, average incubation temperatures differ among eggs within the same nest, to the extent (i.e., >1°C) that differences in offspring phenotypes within broods should result. A potential consequence of within-nest incubation temperature variation is inequality in behaviors that could cause differences in resource acquisition within broods. To investigate this, we incubated wood duck (Aix sponsa) eggs at one of two ecologically-relevant incubation temperatures (35°C or 36°C), formed mixed-incubation temperature broods after ducklings hatched, and conducted trials to measure duckling behaviors associated with acquisition of heat (one trial) or food (three trials). Contrary to our predictions, we found no effect of incubation temperature on duckling behaviors (e.g., time spent occupying heat source, frequency of feeding bouts). However, we found evidence that ducklings incubated at the higher temperature consumed more food during the 1-h feeding trials, and grew faster in body mass and structural size (culmen and tarsus) throughout the study, than those incubated at the lower temperature. Apparent food consumption during the trials was positively related to culmen length, suggesting that differences in food consumption may be driven by structural size. This could result in positive feedback, which would amplify size differences between offspring incubated at different temperatures. Thus, our study identifies incubation temperature as a mechanism by which fitness-related phenotypic differences can be generated and even amplified within avian broods.
The Role of Autologous PRP on Deep Partial-Thickness Burn Wound Healing in Bama Pigs
Authors: Sun Yanwei , Cao Yongqian , Zhao Ran , Xu Famei , Wu Dan , Wang Yibing
Published: February 2020

In this study, we aimed to evaluate the therapeutic effects of autologous platelet-rich plasma (PRP) on deep partial-thickness burns in Bama pigs. Deep partial-thickness burn wounds were created on the back of Bama pigs. The reepithelialization time was compared between the PRP and control groups. The mean score of Ki67 (+) cells and α-SMA (+) vessels, the mean thickness of epidermis and dermis of the healing wounds were determined via H&E staining and immunohistochemical assay. The levels of the growth factors epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF) were examined by ELISA. Our data showed that the time to wound reepithelialization was shorter in the PRP group compared with the control group. The thickness of the epidermis was larger in the PRP group compared with the control group. On the 7th and 14th days after the treatment, the mean score of Ki67 (+) cells and α-SMA (+) vessels were higher in the PRP group compared with the control group. The PRP group showed higher levels of growth factors (EGF, bFGF, and VEGF) compared with the control group by ELISA. The results indicated that PRP could improve wound healing process of deep partial-thickness burns in Bama pigs. The PRP increased the thickness of epidermis of the healed wounds, cell proliferation, and angiogenesis. We demonstrated that applying PRP had a greater potential for the treatment of deep partial-thickness burns.
Paris court grants an SEP anti-anti-suit injunction in IPCom v Lenovo: a worrying decision in uncertain times?
Authors: Bonadio Enrico , McDonagh Luke
Published: February 2020

IPCom v Lenovo, Tribunal de Grande Instance de Paris, Case No RG 19/59311, 8 November 2019

The Tribunal de Grande Instance de Paris has granted an anti-anti-suit injunction in favour of SEP-holder IPCom against Lenovo, requiring the latter to withdraw an anti-suit injunction action filed before the US District Court for the Northern District of California.
Parallel Proceedings under Chinese BITs: The Case of Hela Schwarz GmbH v PR China
Authors: Wei Shen
Published: February 2020

Classic issues in international commercial arbitration such as parallel proceedings also emerge in international investment arbitration. The parallel existence of international investment arbitration and domestic litigation deserves careful analysis for the sake of international legal certainty and security. Given a small number of international investment arbitration cases involving China and its bilateral investment treaties (BITs), the issue of parallel proceedings in Chinese BIT law and practice is underinvestigated. This article tries to look into this issue by reference to the case of Hela Schwarz GmbH v PR China, an ongoing BIT arbitration case registered with the International Centre for Settlement of Investment Disputes. Some improvements have been made to relevant jurisdictional clauses in China’s more recent free trade agreements filling the gap in this grey area.
How the Traumatic Experiences of Students Manifest in School Settings
Authors: Hertel Ron , Johnson Mona M.
Published: February 2020

Throughout their lifetimes, people can face challenges from toxic stress and trauma that influence their lives at any place, at any time. To be most effective, educators must understand the impact of trauma on neurobiology and brain development, academic and cognitive skills, behavior, and social-emotional functioning. They must learn to adapt the learning environment and strategies for instruction accordingly with these elements in mind. This chapter presents evidence-based and researched strategies that educators can employ to address the impact of trauma. From an educator’s point of view, the most helpful approach is twofold: firstly, an educator must be self-aware of his or her ability to manage his or her own challenges before, secondly, beginning to address challenges in the lives of students and their families.
Instructional Strategies for a Trauma-Informed Classroom
Authors: Grossman Hannah M.
Published: February 2020

Teachers have many roles in the classroom, one of which is to support children who have experienced trauma. This chapter aims to help teachers and school-based professionals develop a shared understanding about trauma-informed classrooms and how to support them. This chapter is structured as a problem-based learning case about how a traumatic situation can influence a classroom culture. It can be read through by an individual or in groups. The case is enhanced with conceptual exploration questions, personal practice options, and group activities. Using the Simplified 12 Core Concepts for Understanding Traumatic Stress Responses in Children and Families, learners will process through the case to explore the complexity and interwoven factors in a traumatic situation.
Students Affected by Child Maltreatment
Authors: Collin-Vézina Delphine
Published: February 2020

Child maltreatment constitutes all forms of child abuse including physical, emotional, or sexual abuse and neglect, resulting in actual or potential harm to the child’s health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power. Child maltreatment represents one of the most influential determinants of mental health and academic functioning. This chapter will review the definitions of different forms of child maltreatment as well as their prevalence, risk factors, and associated negative outcomes. Developmental and cultural considerations will be discussed and illustrated through several case vignettes. Finally, the chapter presents several strategies that apply to all forms of child maltreatment, along with recommendations of children’s literature and external resources.
Supporting Students Following Crises and Natural Disasters
Authors: Fernandez Benjamin S.
Published: February 2020

Acute traumatic events have the potential to significantly disrupt the learning environment as well as the psychological functioning of students, staff, and the school community. Such events range in size and intensity, though all require careful planning to address the comprehensive safety and recovery needs of a school. Such planning includes considerations of prevention and preparedness, establishing crisis teams and crisis communications, and the selection and delivery of appropriate interventions given demonstrated need. This chapter discusses best practices in school safety planning and approaches to recovery after an incident to address crisis-generated problems, prevent trauma, and help restore the learning environment.
Trauma Screening and Assessment
Authors: Eklund Katie , Koriakin Taylor A. , Chafouleas Sandy M. , Dodge Sophia C. F.
Published: February 2020

Adversity, stress, and trauma can have a negative impact on students’ academic, behavioral, and social-emotional functioning. Screening and identification of students who have potential symptoms from experiencing traumatic stress may help schools provide services within an integrated model of service delivery. Successful implementation of a trauma-informed approach to school-based service delivery requires identification of early indicators of risk, followed by careful planning and decision-making regarding follow-up care. The current chapter provides an overview of strategies for assessing trauma symptoms within schools, discusses the differences between screening for trauma exposure versus symptomatology, and provides a brief list of trauma screening measures. This list includes the scope and focus, the practicality associated with administration, and the psychometric properties (e.g., validity, reliability, diagnostic accuracy) of each measure. The chapter concludes with an overview of important ethical, legal, and procedural considerations to guide schools in the selection and implementation of trauma screening.
Effective Implementation and Evaluation of Trauma-Informed Schools
Authors: Cook Elizabeth , Black Pamela
Published: February 2020

In any given year, educators are inundated with innumerable products and processes that promise to advance the academic or social-emotional development of their students. Publishers often describe the great potential benefits of implementing a new approach or process yet often do not discuss how to sustainably implement in a way that fits the specific context. Thoughtful program implementation and evaluation remain essential to ensuring success, especially when a district or school decides to take up the challenges of becoming a trauma-informed school, an innovation with myriad strategies and programs that, when implemented and evaluated with intention, can make a meaningful impact on students, staff, and families. Using the phases of implementation, this chapter discusses the importance of program evaluation and lays out a framework to support district and school efforts in the transformative process of becoming a trauma-informed system.
C—Connect
Authors: Wittenberg Elaine , Goldsmith Joy V. , Ragan Sandra L. , Ann Parnell Terri
Published: February 2020

To connect is to achieve shared understanding in communication. Patients and families facing serious, chronic, or terminal illness have a story to share. Most of them want to communicate their journey and want to believe that the providers in their midst know them. Patients and families desire a connection with their nurse and the need to be understood, especially in terms of the challenges in their illness journey. Learning to listen deeply to patient/family stories and capture important information about what they value can lead to connecting with patient/family. Encouraging storytelling, listening to quality of life issues, and practicing person-centered communication are cornerstones of communication in palliative nursing. These principles work together to accomplish narrative clinical practice.
M—Making Meaning
Authors: Wittenberg Elaine , Goldsmith Joy V. , Ragan Sandra L. , Ann Parnell Terri
Published: February 2020

Making meaning is predicated on the notion that helping patients and families make meaning of their suffering is a valuable contribution that palliative care nurses can make. The Voice of the Lifeworld of the patient/family is juxtaposed with the Life of Medicine to help the reader recognize the powerful meaning of the life lived outside of the illness. The chapter explores the patient’s quality of life and the spiritual and/or religious life spaces of patients/families. Presence is that quality of being there for the patient or family member, either physically or psychologically, or both, and being nonjudgmental, unscripted, and spontaneous. Thus, a mindful presence means that the nurse is totally dedicated to the circumstances of the here and now, regardless of what has gone before or what is predicted to follow. It is a valuing of “being” over “doing,” in the belief that compassionately bearing witness to a patient’s/family’s suffering may be the greatest gift a provider can offer.
T—Team
Authors: Wittenberg Elaine , Goldsmith Joy V. , Ragan Sandra L. , Ann Parnell Terri
Published: February 2020

The interdisciplinary team is central to the labors of the palliative care nurse. Nurses need team communication skills to lead the palliative care team or establish leadership within the team. Team-building skills include encouraging other team members to actively contribute during team decision-making, fostering opposing viewpoints when they arise in care planning, and evaluating team goals and communication processes. This chapter presents an overview of team communication, focusing on interdisciplinary collaboration and interprofessional practice and warning against communication processes that lead to groupthink. In truly collaborative teams, intellectual resources are utilized; there is a commitment to interprofessional care, respect among team members, inclusion of individuals with diverse perspectives, effective meeting leadership, systems of mutual support and accountability, and productive time management focused on new information relevant to patient/family care.
Anita’s Vision
Authors: Josephs Debra
Published: February 2020

Epilepsy education and awareness are brought to the forefront in the following stories through innovative outreach, research, and marketing efforts.
You Can
Authors: Busing Meg
Published: February 2020

This section emphasizes the empowerment of others through the arts, employment, camping, and the Americans with Disabilities Act.
Definition and Classification of Involuntary Movements
Authors: Shibasaki Hiroshi , Hallett Mark , Bhatia Kailash P. , Reich Stephen G. , Balint Bettina
Published: February 2020

Involuntary movements, also called hyperkinetic movement disorders, are defined as abnormal, unintended movements. They are defined as “abnormal” because not all unintended movements are pathological (reflexive or spontaneous movements also occur but are part of normal function; these include breathing, yawning, blinking, and the like). Involuntary movements can be classified into several categories according to their phenomenological characteristics and then according to the etiology and/or pathophysiology for each kind of involuntary movement. Involuntary movements include tremor, chorea, ballism, athetosis, dystonia, myoclonus, dyskinesia, tics, asterixis, and motor stereotypy. Many of the involuntary movements can occur as side effects of pharmaceutical drugs. Functional or psychogenic involuntary movements are not infrequently encountered.
Myoclonus
Authors: Shibasaki Hiroshi , Hallett Mark , Bhatia Kailash P. , Reich Stephen G. , Balint Bettina
Published: February 2020

Myoclonus is defined as brisk, shock-like, involuntary movements. Hiccup and nocturnal myoclonus are physiological myoclonus. Myoclonus is usually caused by abrupt, instantaneous contraction of muscles (positive myoclonus), but it can be also caused by transient interruption of the ongoing muscle contraction (negative myoclonus, asterixis). Myoclonus is usually irregular, but some myoclonus may occur at certain intervals (rhythmic or periodic myoclonus). Myoclonus is caused by excessive excitation of motor neurons in the motor cortex (cortical myoclonus, epileptic myoclonus), in the brainstem, or in the spinal cord (spinal myoclonus). Cortical myoclonus is commonly associated with convulsive seizures and is also called epileptic myoclonus. Syndromes characterized by myoclonus, generalized convulsion, and cognitive impairment are coined the progressive myoclonus epilepsies and are caused by multiple neurodegenerative diseases.
Chorea and Ballism
Authors: Shibasaki Hiroshi , Hallett Mark , Bhatia Kailash P. , Reich Stephen G. , Balint Bettina
Published: February 2020

Chorea comprises irregular, apparently random movements of varying speeds involving hands, feet, mouth, and tongue. Particularly at the outset of the disorder, the movement may appear purposeful and can be easily imitated. Chorea is seen in association with various medical diseases such as cerebrovascular diseases (hemichorea), autoimmune diseases like Sydenham chorea, thyrotoxicosis, pregnancy, drug intoxication, and hereditary disorders like Huntington disease, neuroacanthocytosis, and dentato-rubro-pallido-luysian atrophy (DRPLA). Treatment with D2-blockers is effective in some cases. Ballism entailsgross violent movements of extremities that look like throwing or kicking. It is commonly caused by a vascular lesion of the subthalamic nucleus or striatum and thus involves contralateral upper and lower limbs (hemiballism). Vigorous muscle contractions irregularly involve the shoulder and pelvic girdles and the proximal limbs. In the chronic stage, each movement becomes less violent and resembles chorea, although it still involves primarily the proximal muscles. Ballism usually responds to medication with diazepam or D2-blockers like haloperidol.
Concussion
Authors: Hainline Brian , Gurin Lindsey J. , Torres Daniel M.
Published: February 2020

Concussion is a type of mild traumatic brain injury, is common, and occurs both in sport and as a result of falls or accidents. Concussion has become an increasingly recognized public health concern, largely driven by prominent media coverage of athletes who have sustained concussion. Although much has been written about this condition, its natural history is still not well understood, and practitioners are only now beginning to recognize that concussion often manifests in different clinical domains. These may require targeted treatment in and of themselves; otherwise, persistent post-concussive symptoms may develop. Although most individuals who sustain a concussion recover, and although concussion is a treatable condition, it is important that concussion be managed early and comprehensively to avoid a more prolonged clinical trajectory. A relatively recent term often used in the setting of concussion is repetitive head impact exposure—a biomechanical force applied to the head that does not generate a clinical manifestation of concussion, but may result in structural brain changes. Although it is often assumed that repetitive head impact exposure leads to long-term neurological sequelae, the science to document this assumption is in its infancy. Repeated concussions may lead to depression or cognitive impairment later in life, and there is an emerging literature that repeated concussion and repetitive head impact exposure are associated with chronic traumatic encephalopathy or other neurodegenerative diseases. Currently there is no known causal connection between concussion, repetitive head impact exposure, and neurodegeneration, although this research is also still in its infancy.
Acute Concussion versus Catastrophic Brain Injury
Authors: Hainline Brian , Gurin Lindsey J. , Torres Daniel M.
Published: February 2020

Concussion is considered a type of mild traumatic brain injury, and may exist on a continuum with moderate and severe brain injury. If an individual has suffered an injury severe enough to cause a concussion, there should be a low threshold for also suspecting a more severe traumatic brain injury. In contact/collision sports, it is desirable to have an emergency action plan in place for catastrophic injuries that include moderate or severe traumatic brain injuries. Emergency medical services should be activated for suspected moderate and severe traumatic brain injuries.
Post-Concussion Syndrome
Authors: Hainline Brian , Gurin Lindsey J. , Torres Daniel M.
Published: February 2020

Post-concussion syndrome is no longer an accepted medical term and has been replaced by the phrase “persistent post-concussive symptoms” or simply “persistent symptoms.” Post-concussion syndrome had been used to identify individuals with prolonged symptoms following concussion, but the term assumed that concussion is a homogeneous process and that persistent symptoms were always a manifestation of the original brain injury. Concussion often manifests in different clinical domains, and it is important that these domains be managed more specifically. Domain-specific interventions seek to address the somatic, cognitive, and emotional issues that are common following concussion. Such specific interventions mitigate the development of persistent symptoms.
Migraine and Other Headache Disorders Following Concussion
Authors: Hainline Brian , Gurin Lindsey J. , Torres Daniel M.
Published: February 2020

Headache is an exceedingly common symptom following concussion, and post-traumatic headache may evolve into a persistent post-concussion manifestation. Migraine and post-traumatic headache share similar pathophysiologic mechanisms, and both can considerably decrease quality of life. The development of post-traumatic headache or post-traumatic migraine must be differentiated from concussion, and requires specific management to address headache manifestations. Although there are no approved pharmacologic treatments specific to post-traumatic headache, emerging strategies focus on treatment paradigms similar to migraine management. Failure to address post-traumatic headache and post-traumatic migraine will lead to prolonged post-concussive symptoms and the misunderstanding that such prolonged symptoms are a result of incomplete recovery from concussion.
Concussion and Attention-Deficit/Hyperactivity Disorder
Authors: Hainline Brian , Gurin Lindsey J. , Torres Daniel M.
Published: February 2020

Individuals with attention-deficit/hyperactivity disorder (ADHD) self-report more concussions than those without this diagnosis. Individuals with ADHD have higher symptom scores at baseline relative to their non-ADHD counterparts. Individuals with ADHD who sustain a concussion may have more prolonged post-concussion symptoms, and worsening of their ADHD. It is important to differentiate between persistent symptoms linked to underlying ADHD and more severe brain injury. ADHD-specific pharmacologic and nonpharmacologic strategies will help to mitigate the development of persistent post-concussive symptoms in this population. Importantly, individuals who are taking stimulant medication at the time of concussion should not have this medication withdrawn post-concussion, but rather adjusted as warranted.
Autonomic Dysfunction Following Concussion
Authors: Hainline Brian , Gurin Lindsey J. , Torres Daniel M.
Published: February 2020

Autonomic dysfunction is increasingly recognized as a manifestation of concussion, and may result from disruption of the central network of control of autonomic function, which is widespread throughout the brain. Individuals with autonomic dysfunction commonly experience dizziness, lightheadedness, or the perception of a racing heart. Autonomic dysfunction can mimic vestibular dysfunction and anxiety. Prolonged autonomic dysfunction can lead to persistent symptoms following concussion. It is important to suspect autonomic dysfunction in patients who complain of persistent symptoms such as dizziness or lightheadedness. Targeted management should be used, and often includes aerobic exercise below the threshold that elicits symptoms.
Mental Health Symptoms and Disorders Following Concussion
Authors: Hainline Brian , Gurin Lindsey J. , Torres Daniel M.
Published: February 2020

Mental health symptoms are common following acute concussion, but most individuals recover from these symptoms. However, a link has been reported between repetitive concussions and/or repetitive head impact exposure and development of later-life depression. Athletes who have transitioned out of sport are also at risk of developing mental health symptoms and disorders independent of concussion or repetitive head impact exposure. When athletes present with later-life manifestations of depression, it is important to evaluate for all risk factors of depression, and not to assume that depression is a manifestation of concussion alone. Irrespective of the underlying cause of depression, the individual should receive appropriate, targeted management.
The Global Burden of Disease: Measuring the health of populations
Authors: Vos Theo , Lopez Alan , Murray Christopher
Published: February 2020

To make the best decisions to improve health, policymakers need reliable, up-to-date information on the major challenges facing their country. The Global Burden of Disease study facilitates this by providing comprehensive and scientifically rigorous estimates of the causes of death and illness across the globe. It examines a total of 79 risk factors and the amount of health loss attributable to each or combinations of them. Analysis over time reveals a shift from disease burden dominated by communicable, maternal, neonatal, and nutritional causes to a burden increasingly made up of non-communicable diseases and injuries. By making comparisons between countries or subnational units like states or counties, the Global Burden of Disease can highlight areas of particular success or challenge, providing opportunities to examine what is working, or what is not.
Medicine quality, physicians, and patients
Authors: Newton Paul N.
Published: February 2020

Poor-quality medicines negate the enormous advantages of modern pharmaceuticals and lead to avoidable morbidity and mortality; loss of confidence in medicines and healthcare systems; economic losses for patients, their families, governments, and the pharmaceutical industry; and—for anti-infectives—engender pathogen drug resistance.

There are many examples of both falsified (due to fraudulent production) and substandard (due to in-factory negligence) medicines, vaccines, diagnostic tests, and devices. New portable diagnostic devices offer hope that they could empower medicine inspectors and pharmacists to obtain objective evidence for selection of suspicious samples for formal analysis. Much greater international effort is needed for the reporting of poor-quality medicines so that detection can be acted upon and patients protected.
The cell
Authors: Banting George , Luzio J. Paul
Published: February 2020

The cell is a dynamic entity. Cells are not simply building blocks that are linked together to create an organism: each cell comprises a dynamic network of interacting macromolecules. Just how dynamic has been brought home by recent advances in cell imaging technologies. A host of multisubunit molecular structures must assemble and disassemble in a highly coordinated, exquisitely regulated, and beautifully choreographed manner to ensure the integrity of the cell and provide its ability to function correctly as a single unit within a large multicellular organism. This chapter explains how the cell is the fundamental unit of all forms of independent life on this planet, from the simplest single-celled prokaryote to the most complex multicellular eukaryote.
Circulating DNA for molecular diagnostics
Authors: Dennis Lo Y.M. , Chiu Rossa W.K.
Published: February 2020

Short fragments of cell-free DNA are released into the plasma when cells die. In patients with cancer some of this circulating DNA is released by tumour cells; in pregnant women some is derived from the fetus; and increased amounts are found in many pathological conditions associated with cell death. In each of these circumstances, analysis of cell-free DNA can provide useful clinical information (e.g. detection or monitoring of cancer, determination of mutation status of a fetus). With further improvement in analytical technologies and developments of new markers, it is likely that the application of circulating cell-free DNA and cell-free RNA species in molecular diagnostics will increase in the future.
Principles of transplantation immunology
Authors: Wallin Elizabeth , Wood Kathryn J.
Published: February 2020

Since the first successful transplant of a kidney between identical twins in 1954, transplantation has progressed from being an experimental procedure to a routine clinical therapy offering immense benefits for patients with organ failure. However, the survival of transplanted organs remains limited by the body’s immune responses, and many of the complications of transplantation result from the crude nature of our attempts to suppress these. This chapter explains how the survival of transplanted organs remains limited by the body’s immune responses, which are designed to discriminate between ‘self’ and ‘non-self’ or ‘altered-self’, and how many of the complications of transplantation result from the crude nature of our attempts to suppress these.
Frailty and sarcopenia
Authors: Clegg Andrew , Patel Harnish
Published: February 2020

Sarcopenia and frailty are inter-related expressions of ageing which identify people at risk of important adverse health events such as falls, disability, and mortality, and the consequent health and social care needs such as hospitalization or care home admission.

Sarcopenia is the progressive and generalized loss of skeletal muscle mass and function with age. It has a complex aetiology involving neurohormonal, immunological, and nutritional mechanisms, and is a core component of frailty, which is characterized by reduced biological reserves across a range of physiological systems that increase vulnerability to adverse outcomes following minor stressor events. Detection of frailty should be an essential part of assessment of older people, and the Clinical Frailty Scale is a simple tool based on comprehensive geriatric assessment that enables assignment of a frailty category based on clinical judgement.
Older people and urgent care
Authors: Conroy Simon , Banerjee Jay
Published: February 2020

Older people, especially those with frailty, are increasingly becoming the main users of urgent care services, despite efforts to promote care at home. This is a global issue. Older people with frailty will usually present with non-specific presentations, multiple morbidities, functional decline, and differential challenge (those most in need are least able to access the services they require) a constellation that challenges the traditional paradigm of urgent care responses. Comprehensive geriatric assessment is a useful evidence-based, overarching framework to guide assessment and management of older people with frailty presenting with crises. Geriatric teams should be excellent at delivering comprehensive geriatric assessment, but all clinicians throughout the health and social care system need to be able to apply its principles.
Introduction to palliative care
Authors: Salt Susan
Published: February 2020

Palliative care shifts the focus of care from managing the underlying pathophysiological processes to one that looks at the individual and the impact of life-threatening illness on them and those important to them. It aims to prevent and relieve suffering by means of early identification, assessment, and treatment of pain and other problems, physical, psychosocial, and spiritual. It focuses on interventions which might improve an individual’s quality of life rather than alter the underlying disease process, and routinely extends support to those important to the individual both during that individual’s lifetime and into bereavement. Challenges to the provision of effective palliative care include prognostic uncertainty, the necessity for engaging in difficult conversations, and the need to deal with a variety of ethical issues.
Colorado tick fever and other arthropod-borne reoviruses
Authors: Warrell Mary J. , Warrell David A.
Published: February 2020

Human pathogens are found in six genera of Reoviridae: Reovirus, Rotavirus, Orthoreovirus, and three arthropod-borne genera: Coltivirus (Colorado tick fever, Salmon River virus, and Eyach viruses); Orbivirus (Kemerovo, Changuinola, Orungo, and Lebombo); and Seadornavirus (Banna virus). Colorado tick fever is common in parts of north-western North America; acquired from tick (ixodid) bites, most often by hikers and campers, presenting 3–6 days later with sudden fever, rigors, generalized aches, myalgia, headache and backache, rashes (12%), and gastrointestinal symptoms (20%). Diagnosis is confirmed by detection of viral antigen in erythrocytes or serum, or by serodiagnosis. Management is symptomatic. Illness usually resolves in 10–14 days, but convalescence may be prolonged. Prevention is by avoiding, repelling, and rapidly removing ticks; no vaccines are available.
Rubella
Authors: Tookey Pat , Best J.M.
Published: February 2020

Rubella is caused by an enveloped RNA virus, for which humans are the only known host. Transmission is by airborne droplet spread, with infection seen predominantly in spring and early summer in temperate zones. Postnatally acquired infection presents after incubation of 14–21 days with rash (maculopapular, usually beginning on the face before spreading to the trunk and extremities), lymphadenopathy (suboccipital and posterior cervical), and mild fever. Sore throat, coryza, cough, conjunctivitis, and arthralgia may be seen. The illness is usually mild. Management is symptomatic. With rubella in pregnancy, in the first 10 weeks of gestation this is associated with a 90% risk of congenital fetal abnormalities, most typically comprising sensorineural hearing loss, alone or combined with cataracts and/or cardiac anomalies. Clinical diagnosis is unreliable, hence rapid investigation is essential when a woman develops a rubella-like illness in the first 16 weeks of pregnancy.
Dengue
Authors: Wills Bridget , Leo Yee-Sin
Published: February 2020

Dengue is the most important mosquito-borne viral infection to affect humans. It is an RNA virus in the Flavivirus genus, family Flaviviridae. There are four closely related but serologically distinct viral serotypes, all of which may cause disease. Following infection with one serotype there is lifelong immunity to that serotype but the possibility of more severe disease during a subsequent infection with a different serotype. The primary mosquito vector is Aedes aegypti. Recent estimates suggest around 100 million symptomatic, and many more asymptomatic, infections occur annually worldwide. The disease is hyperendemic in many large Asian cities, and is also a significant problem in the Pacific region and in the Americas.
Hepatitis C virus
Authors: Klenerman Paul , Jeffery Katie J.M. , Barnes Ellie J. , Collier Jane
Published: February 2020

Hepatitis C virus is a major cause of liver disease worldwide. It is estimated that globally 170 million people are affected. Infection is parenteral. In many countries most recent acquisition is in people who inject drugs, but transmission worldwide also occurs in in healthcare settings due to the reuse or inadequate sterilization of medical equipment and the transfusion of unscreened blood and blood products. Sexual transmission also occurs, particularly in men who have sex with men. The virus has a tendency to become persistent in most of those infected. However, a substantial minority (around 25%) do clear the virus as a result of effective innate and adaptive immune responses at the times of acute infection. In those with persistent infection, the clinical course is quite variable. Treatment with directly acting antiviral drugs is well tolerated and leads to very high cure rates in chronic disease.
Orf and Milker’s nodule
Authors: Aarons Emma , Warrell David A.
Published: February 2020

This chapter covers orf and milker’s nodule, which are characteristic nodular skin lesions caused by parapox viruses of sheep and goats, or cattle, respectively. These viruses are epitheliotropic and able to suppress the host’s immune response. The infections are occupational zoonoses of people working with ruminants. A single or small number of somewhat painful pustules develops, usually on the hand, at the site of contact with an animal’s lesions. Fever is unusual, but local lymphadenopathy, erythema multiforme, or secondary infection may occur. Spontaneous resolution within 6 weeks is usual. Multiple, giant lesions may develop in the immunosuppressed. Topical cidofovir is effective in severe cases.
Streptococci and enterococci
Authors: Stevens Dennis L. , Hobdey Sarah
Published: February 2020

The term streptococcus was first used by Billroth in 1874 to describe chain-forming cocci found in infected wounds. The streptococci are a diverse group of Gram-positive pathogenic cocci that cause clinical disease in humans and domestic animals. They are traditionally classified on the basis of serological reactions, particularly Lancefield grouping based on cell-wall carbohydrates, and haemolytic activity on blood agar. Six groups can be defined by genetic analysis: pyogenic streptococci, milleri or anginosus group, mitis group, salivarius group, mutans group, and bovis group. Since the medically important members of the mitis, salivarius, and mutans groups are all oral streptococci and are of clinical relevance predominantly in endocarditis, they will be considered together in this chapter.
Typhoid and paratyphoid fevers
Authors: Parry Christopher M. , Basnyat Buddha
Published: February 2020

Typhoid and paratyphoid fever (the enteric fevers) are caused by specific serovars of the Gram-negative bacillus, Salmonella enterica. Sources of typhoid transmission are excreting chronic or convalescent carriers and the acutely infected, with transmission occurring through contamination by carriers of food or water by effluents containing infected faeces or urine. Global estimates have varied between 12 and 27 million cases of enteric fever in the world each year, almost all in low- and middle-income countries, with about 200,000 deaths. Aside from supportive care, antibiotic therapy reduces mortality and complications and shortens the illness. Antibiotic resistance is a common and increasing problem, hence the choice of antibiotic should be informed by knowledge of likely local susceptibility.
Anaerobic bacteria
Authors: Venugopal Anilrudh A. , Hecht David W.
Published: February 2020

Anaerobic bacteria will not grow when incubated with 10% CO2 in room air, but they vary in their tolerance of different levels of oxygen. Anaerobic bacteria are important commensal flora of the skin and oral, intestinal, and pelvic mucosae, and are classified according to their Gram-staining characteristics and ability to produce spores: (1) Gram-positive—cocci, non-spore-forming bacilli, and spore-forming bacilli (notably the Clostridium spp.); (2) Gram-negative—cocci and bacilli. Many anaerobic bacteria possess virulence factors that facilitate their pathogenicity (e.g. histolytic enzymes and various toxins). A putrid odour of the affected tissue or drainage is highly suggestive of an anaerobic infection, as is the presence of gas in tissues. Aside from supportive care, treatment requires drainage of abscesses and resection of devitalized tissue; and antibiotics—agents that are active against anaerobes include clindamycin, metronidazole, vancomycin, β-lactam/β-lactamase inhibitor combinations, carbapenems, moxifloxacin, tigecycline, chloramphenicol, and even macrolides.
Legionellosis and legionnaires’ disease
Authors: Viasus Diego , Carratalà Jordi
Published: February 2020

Legionellaceae are Gram-negative bacilli, of which Legionella pneumophila is the principal cause of human infections. Their natural habitats are freshwater streams, lakes, thermal springs, moist soil, and mud, but the principal source for large outbreaks of legionellosis is cooling systems used for air conditioning and other cooling equipment. Legionella spp. are principally transmitted to humans through contaminated water aerosols. Middle-aged men, smokers, regular alcohol drinkers, and those with comorbidity are most at risk. Aside from supportive care, the first-choice antibiotics are macrolides (mainly azithromycin) and/or fluoroquinolones (especially levofloxacin). Case fatality is 5–15% in previously well adults, but much higher in those who are immunocompromised or develop respiratory failure. Prognosis is improved by early administration of effective anti-legionella antibiotic therapy. Prevention is by the correct design, maintenance, and monitoring of water systems.
Cryptococcosis
Authors: Powderly William G. , Campbell J. William , Shapiro Larry J.
Published: February 2020

Cryptococcus neoformans, which is found worldwide as a soil organism and thought to be transmitted by inhalation, most often causes disease in patients with abnormal cell-mediated immunity, notably patients with HIV infection and solid-organ transplant recipients, but the infection also occurs rarely in apparently immunocompetent people in restricted geographical areas, especially involving C. neoformans var. gattii. The most common presentation is with subacute meningoencephalitis, but other manifestations (e.g. isolated pulmonary disease or disseminated infection, are well described). Diagnosis is usually by culture or serology. Untreated cryptococcal meningitis is fatal: aside from supportive care (including monitoring for raised intracranial pressure), the therapy of choice is an initial period (at least two weeks) of amphotericin B (ideally with flucytosine), followed by at least 3 months of fluconazole. Most immunocompromised patients subsequently require maintenance suppressive therapy, usually with fluconazole.
Coccidioidomycosis
Authors: Anstead Gregory M.
Published: February 2020

Coccidioidomycosis results from inhalation of arthroconidia of Coccidioides spp., which are soil fungi endemic to the south-western United States of America and parts of Latin America. Most infections are asymptomatic, but primary infection may resemble community-acquired pneumonia, sometimes with hypersensitivity manifestations such as erythema nodosum, erythema multiforme, and arthritis. Acute pulmonary infection usually resolves spontaneously, but—especially in immunocompromised patients, African Americans, and Filipinos—it may progress to persistent pulmonary disease or disseminate to skin, soft tissues, the osteoarticular system, and the central nervous system. Diagnosis is by culture, histopathology, or serology. Fluconazole and itraconazole are usually the initial drugs of choice, with amphotericin B reserved for severe pulmonary and disseminated disease, and in pregnancy. In refractory cases, posaconazole, voriconazole, and isavuconazole are alternative antifungal agents.
Angiostrongyliasis
Authors: Knight Richard
Published: February 2020

The rat lungworm Angiostrongylus cantonensis causes outbreaks of eosinophilic meningitis in parts of Southeast Asia, East Asia, Oceania, and the Caribbean. Human infections follow ingestion of raw snails (the primary intermediate hosts), food contaminated by snail mucus, or one of several paratenic hosts. Clinical manifestations include headache, meningism, vomiting, cranial nerve, ocular, lesions, and rarely seizures. Lumbar puncture reveals eosinophilic meningitis and sometimes larval worms. Treatment is usually with prednisolone alone, or with albendazole and prednisolone. Mortality is usually below 2%. Prevention is by avoidance of raw high-risk dietary items and unwashed salads. Another species A. costaricensis causes granulomatous bowel and hepatic lesions in some tropical American countries. Rats are the definiitive hosts, human infection follows ingestion of small slugs. Treatment is surgical.
Diseases of high terrestrial altitudes
Authors: Albert Tyler , Swenson Erik R. , Pollard Andrew J. , Basnyat Buddha , Murdoch David R.
Published: February 2020

Ascent to altitudes above 2,500 m leads to exposure to hypobaric hypoxia. This affects performance on first arrival at high altitude and disturbs sleep, but physiological changes occur over time to defend arterial and tissue oxygenation and allow the individual to adjust. This process of acclimatization includes (1) an increase in the rate and depth of breathing; and (2) an increase in red cell mass, and in red cell 2,3-diphosphoglycerate. Acclimatization is no longer possible at extreme altitude (>5,800 m) and the exposed individual will gradually deteriorate. Altitude illness results from a failure to adjust to hypobaric hypoxia at altitude. Risk is increased by ascent to higher altitudes, by more rapid gain in altitude, and (in some people) genetic predisposition; the condition may be avoided in most cases by slow, graded ascent.
Bioterrorism
Authors: Green Manfred S.
Published: February 2020

Bioterrorism is the deliberate use of biological agents to cause illness, death, and fear for ideological or personal purposes. The agents might be disseminated through aerosolization, food, human carriers, infected insects, or water. The incubation periods of these agents can vary from hours to weeks, with early symptoms mimicking many other infectious diseases. The diagnosis might not be suspected unless cases occur in clusters. Early identification of outbreaks will depend largely on the ability of primary care and emergency room physicians to identify and promptly report cases to the public health authorities. Specific treatment (if available) of affected individuals will depend on the pathogen, and for contagious diseases such as smallpox and plague, isolation of patients and their contacts, barrier nursing, quarantine, and restriction of the movements and social interactions of people are important control measures.
Obesity
Authors: Farooqi I. Sadaf
Published: February 2020

Obesity is defined as an excess of body fat that is sufficient to affect health adversely. While the quantification of fat mass is usually only performed in the research setting, body mass index (weight in kg/height in metres2) is a useful surrogate marker for fat mass. Using the World Health Organization definition of a body mass index more than 30 kg/m2 to define obesity, 30% of Americans and 10–20% of Europeans are classified as obese, with the prevalence rising in many developing countries. As body mass index increases, so does the relative risk of type 2 diabetes, hypertension, and cardiovascular disease. As such, obesity is associated with disability, mortality, and substantial health costs. At an individual level, severe obesity can be associated with sleep disturbance and respiratory difficulties, joint and mobility disorders, as well as considerable social stigma which can affect quality of life, educational attainment, and employment opportunities.