bluuebunny/crossref_metadata_2025 huggingface dataset:
Karyotypic polymorphism ofCrocidura tanakae(Eulipotyphla: Soricidae) and revision of the karyotype ofC. attenuatain mainland China
Authors: Li Haotian , Mo Xinmin , Sun Huimei , Wang Jing , Motokawa Masaharu , Harada Masashi , Wu Yi , Li Yuchun
Published: August 2020

Conventional karyotypes of Crocidura tanakae and C. attenuata collected from mainland China were examined by bone marrow and cell culture methods along with identification to species using molecular data. In contrast to C. tanakae from Taiwan, populations from mainland China were karyotypically polymorphic, varying in diploid number (2n) from 24 to 40 and fundamental number (FN) from 45 to 56. Autosomes are composed of 6–20 metacentric or submetacentric chromosomes, 0–8 subtelocentric chromosomes, and 0–24 telocentric chromosomes. These polymorphic karyotypes indicate the presence of two geographically separated races. The ancestral karyotype of C. tanakae potentially is the same as currently found on Taiwan: 2n = 40 and FN = 56. In contrast to C. tanakae, C. attenuata had a uniform karyotype (2n = 40, FN = 54) in mainland China, suggesting that previously reported karyotypic polymorphism in this species was an error due to the morphological crypsis between C. tanakae and C. attenuata in mainland China. The intricate karyotypic polymorphism of C. tanakae may be indicative of this species undergoing speciation.
The Legal Context
Authors: Kavanaugh Antoinette , Grisso Thomas
Published: August 2020

The chapter begins with a brief introduction, describing the scope and types of evaluations for juvenile sentencing in criminal court, offering the reader relevant terminology and an introduction to the book’s purpose. The primary focus of the chapter is on the relevant law for these evaluations. It describes relevant U.S. Supreme Court cases, especially Miller v. Alabama, which abolished mandatory life without parole sentences for juveniles and required developmental analysis to inform juvenile sentencing, as well as Montgomery v. Louisiana, which required resentencing for persons previously receiving mandatory life without parole sentences as juveniles. Miller’s definitions for the standards to be applied in juvenile sentencing and resentencing are then introduced and discussed: the legal concept of “irreparable corruption” and the five “Miller factors” defining characteristics of immaturity relevant for sentencing. Finally, the chapter describes the legal process for juvenile sentencing, identifying the role of Miller evaluations within that process.
ACT in Steps
Authors: Twohig Michael P. , Levin Michael E. , Ong Clarissa W.
Published: August 2020

This book is a guide for new therapists on the use of acceptance and commitment therapy (ACT) for any psychological disorder that involves some level of struggle with inner experiences; it is not targeted to any particular diagnosis. The book is suitable for graduate students who are seeing their first client, for clinicians with years of experience who have never done ACT or are just learning about ACT, and for anyone who is interested in applying ACT across a range of presentations. The book also includes exercises and worksheets that will continue to be useful for sessions after the therapist is competent in ACT. The chapters walk therapists through a recommended sequence of ACT sessions, including creative hopelessness, control as the problem, acceptance, defusion, mindfulness, values, and committed action. They also contain accompanying materials for clients. The book provides information on assessment, case conceptualization, treatment planning, and intervention that therapists can use as a starting point for practicing ACT. The book is intended to serve as a more structured framework from which therapists can learn and experiment with ACT concepts as they begin to get more experience with the therapy.
What Is Acceptance and Commitment Therapy (ACT)?
Authors: Twohig Michael P. , Levin Michael E. , Ong Clarissa W.
Published: August 2020

This chapter provides a broad overview of acceptance and commitment therapy (ACT), including empirical evidence for its effectiveness, how it fits with other cognitive-behavioral therapies, and defining features of ACT. The chapter also explains the theory and scientific philosophy underlying ACT so that readers have a framework to which to refer as they learn how to implement ACT in practice. In addition, the chapter describes the model of psychological inflexibility that underpins assessment and intervention in ACT. This chapter also gives readers an introduction to terms associated with ACT and what they mean.
Session 1
Authors: Twohig Michael P. , Levin Michael E. , Ong Clarissa W.
Published: August 2020

This chapter outlines how a first session of acceptance and commitment therapy (ACT) might go. This first session typically includes two components: (1) orienting clients to what to expect from therapy generally and ACT specifically, and (2) beginning work on creative hopelessness. Key points emphasized in this chapter are learning about clients’ perception of therapy, clarifying clients’ treatment goals, collaboratively setting therapeutic expectations, exploring the effects and effectiveness of trying to control thoughts and feelings, and introducing an alternative to controlling thoughts and feelings (willingness). This content sets the stage for concepts to be covered in Chapter 5.
Sessions 7 and 8
Authors: Twohig Michael P. , Levin Michael E. , Ong Clarissa W.
Published: August 2020

This chapter opens with teaching therapists how to lead a brief mindfulness exercise at the start of therapy sessions to increase clients’ present-moment awareness. The chapter describes the NOTE acronym as a means to help clients remember the skills they have learned up to this point: to notice what is happening, observe thoughts and feelings for what they are, turn toward their values, and engage in what matters. If clients have sufficiently built up acceptance and defusion skills, therapist may begin work on self-as-context. The chapter concludes with explaining how to introduce self-as-context to clients and provide metaphors to illustrate this tricky concept.
Session 9
Authors: Twohig Michael P. , Levin Michael E. , Ong Clarissa W.
Published: August 2020

This chapter describes a session focused on values work within the context of acceptance and commitment therapy (ACT). Values work or talking about values can help increase engagement in therapy, but the ultimate goal of clarifying values is to increase clients’ awareness of what truly matters to them so they have a meaningful direction in which to move. Specifically, values work entails defusing from external rules and expectations, defining values, providing examples of values, clarifying clients’ personal values, assessing consistency of current actions with values, setting goals consistent with values, and following through on chosen goals. Measures used to aid in doing values work include the Bull’s Eye Values Survey (BEVS) and the Values Living Questionnaire (VLQ).
Session 10
Authors: Twohig Michael P. , Levin Michael E. , Ong Clarissa W.
Published: August 2020

This chapter builds on previous chapters that covered acceptance, defusion, mindfulness, self-as-context, and values in acceptance and commitment therapy (ACT). The emphasis in therapy now turns to using values as a foundation for behavior change and skill maintenance. It is possible that clients did not fully grasp the function of values in the previous session, so it is worth reviewing values again. The chapter also provides an outline for discussing how to structure values-consistent behavioral commitments. Some areas to cover in this discussion include emphasizing that any size step is great as long as it is a step in a valued direction, not basing the activity on distress level, and being present while engaging in the activity.
What’s the Problem?
Authors: Aunger Robert
Published: August 2020

The first chapter sets up the current situation: why is behavior change considered hard, and what do people recommend be done? I present a novel perspective on public health problems, arguing that they all derive from inabilities to learn appropriate responses due to recent changes to the environments in which we live that have occurred through technological evolution. This is a “mismatch” hypothesis common in evolutionary psychology applied to behavior change. Different types of mismatch occur between particular structures of public health problems (as learning problems). This is actually a theory of public health—why certain kinds of health problems arise in the first place.
Deliver
Authors: Aunger Robert
Published: August 2020

Perhaps the most crucial, but also most overlooked, step in planning behavior change programs is actually implementing it. Often, it is assumed that this will simply happen with great fidelity and reach everyone being targeted. However, logistical problems can abound. Planning in advance can obviously help with minimizing such problems. While the details of such planning will vary according to circumstance, certain goals of the planning process can be identified to guide it. Various ways in which one can monitor implementation and measure aspects of program delivery on the ground are also covered. Identifying process and outcome indicators can be crucial.
Evaluate
Authors: Aunger Robert
Published: August 2020

Evaluating how well a program has worked—has it actually achieved the goal of changing behavior significantly?—is also highly desirable if the field of behavior change is to advance conceptually and become more effective. For this reason, efforts to evaluate programs should be undertaken, not just for research projects. This chapter provides a discussion of how this can be achieved with scientific rigor. Standard research designs are covered, such as Randomized Controlled Trials, as well as less common models. It is also noted that while evaluating whether the desired outcomes were achieved (such as improved public health indicators), it is equally important to understand how those outcomes arose—was it through the activities of the intervention? Can the observed improvements be assigned to the intended effects (e.g., on how people behave and think)?
The Old Medicine and the New: Why Did Barker Write This Manuscript, for Whom Was It Written, and Why Was It Not Published?
Authors: Kahn Richard J.
Published: August 2020

This section begins with a very brief overview of early medical philosophies leading up to Barker’s time, when science was developing an important place in American intellectual life. There was a gradual increase in the cultural authority of “regular” medical education by preceptorship, didactic medical school lectures, and medical licensure, as opposed to self-help or domestic medicine, sectarian medicine, the Thomsonians, homeopaths, and others. William Cullen, Benjamin Rush, and John Brown influenced medicine at the end of the eighteenth century. Pierre Louis in Paris, who had become a major influence on American medicine during the first third of the nineteenth century, believed that “medicine is a science of observation” and a “rigid method” is essential for medicine to improve. Careful case reports, necessary for practice and teaching, were facilitated by the numerical method. The Physician’s Case Book, published by Allen & Ticknor, Boston, in 1832, was an attempt to help physicians to record and organize their case reports. Possible reasons Barker failed to publish his manuscript include finances, competition from other books, and the rapidly changing medical beliefs during the first third of the nineteenth century. A comparison is made to Noah Webster’s 1832 decision to abandon the revised edition of his 1799 book on epidemics.
“Alkaline Doctor” and “A Dangerous Innovator”
Authors: Kahn Richard J.
Published: August 2020

In 1795 Barker read Lavoisier’s chemistry, experimented on tainted meat made edible by soaking in alkalis, and began using alkaline therapy such a limewater. He wrote about this to Samuel Mitchill and Benjamin Rush, telling them that he had been called a “dangerous innovator.” A brief history of the acid/alkali debates of the seventeenth and eighteenth centuries includes information about Otto Tachenius, John Colbatch, Hermann Boerhaave, George Ernst Stahl, William Cullen, Joseph Black, and Antoine Lavoisier. Barker wrote about his experiments, azotic air (nitrogen), and his difficulty understanding the mechanism of this apparently successful therapy. His results were published in the Medical Repository, beginning a correspondence with Samuel Latham Mitchill, professor of chemistry at Columbia University. Contributors to the discussion of alkalis included David Hosack, Thomas Beddoes and James Watt, Humphry Davy, and Matthew Carey. Comments by Charles Rosenberg, John Harley Warner, Lester King, and others help us make sense of medical science and the acid/alkali battle.
**30** Chap. 3d4.th
Authors: Kahn Richard J.
Published: August 2020

Barker gives clinical descriptions and therapy of the 1784–1785 epidemic of throat distemper that occurred in Cumberland County, Maine. He cites authorities and includes a long excerpt from “Observations and Remarks on the Putrid Malignant Sore-throat, from 1784 to 1786” by Hall Jackson of Portsmouth, New Hampshire, who also quotes from numerous authorities. Therapies considered include Bark (cinchona/quinine), marsh rosemary, blisters, and mercury.
Chap. Hydrophobia.
Authors: Kahn Richard J.
Published: August 2020

Barker presents several cases of hydrophobia, or rabies, written by physicians in the United States and abroad, with two apparent “cures.” For example, Joseph Gallup of Vermont apparently cured a case of a twenty-eight-year-old male bitten in the arm by a dog known to be mad because other animals bitten by it had “died within 21 days, a dog, two hogs and a sheep, with all the symptoms of canine madness”; two other dogs on being taken sick were killed.
Chap. 10. [marked 9] May 30th. 1798
Authors: Kahn Richard J.
Published: August 2020

This first page of this chapter is the letter Barker wrote on May 30, 1798, to Samuel L. Mitchill of New York City. The letter was later published with the title, “On Febrifuge Virtues of Lime, Magnesia and Alkaline Salts in Dysentery, Yellow-Fever and Scarlatina Angiosa. In a Letter from Dr. Jeremiah Barker, of Portland, (Maine) Dated May 30, 1798” in the Medical Repository 2, no. 2 (1798): 147–52. Barker wrote of the communications preceding this publication at the very end of the previous chapter.
**C10** Chap. 1.
Authors: Kahn Richard J.
Published: August 2020

The etymology of the word “consumption” is followed by a discussion of the anatomy of the respiratory system and a quote by William Cullen on the frequency of hemoptysis (coughing up blood) in the disease. Barker reports on the incidence of consumption in women and concludes that the disease was much more frequent in both sexes than in former years, owing in part to neglect and delay on the part of the patient, changes in mode of living and dress, and the increased use of spiritous liquors among both sexes. He argues that consumption was more common in New England in part due to “the cold changeable air of our variable climate” and to hereditary differences between the populations of New England and states further south. He considers heredity the issue in his loss of two children, at three weeks and at six months, both born of consumptive mothers.
Phthisis Pulmonalis, or pulmonary consumption.
Authors: Kahn Richard J.
Published: August 2020

Barker defines pulmonary consumption as a wasting disease with destruction of the lungs, explaining that the poor results of treatments by the ancients was due to medical instruction “destitute of anatomical knowledge.” He cites Thomas Reid and quotes David Ramsay, that from 1700 to 1800, thousands of dissections led to improved treatments. Barker’s experience includes his careful observations on consumption, having lost three wives and two children to the disease, when the nature of this disease was “involved in obscurity.” He knows that he had been called “an unskillful and unsuccessful practitioner in consumption,” but feels that he has learned from his own sad experience. He comments on consumption in pregnancy and parturition as well as in young females whose “customary evacuations” fail to take place, followed by a hectic fever and often death. “Exposure to evening air, in the parade of parties, and the ball room, clad in cobweb muslin, has laid the foundation for consumption in many fashionable young females, and consigned them to an untimely grave!” Phthisis pulmonalis frequently takes place in consequence of neglected pneumonia, influenza, and measles.
**C59** Chap. 4.
Authors: Kahn Richard J.
Published: August 2020

Barker describes cases of consumption during in his preceptorship as well as the loss to this disease of his own wives in 1775, 1794, and 1799, portraying his early “defective practice” that improved with the advancing state of medical knowledge succeeding years. He comments on the death of Dr. Ezekiel Hersey in 1770, of his preceptor, Dr. Bela Lincoln in 1774, and of Rev. John Hall, a missionary to the Indians, and presents a number of his other patients with consumption.
**C225** Chap. 8.
Authors: Kahn Richard J.
Published: August 2020

Barker explains that the Medical Museum (Philadelphia) and the Medical Repository (New York City) were rare books in Maine that could not conveniently be purchased by young physicians. Because he was known to have an unusually good personal library, Barker was asked to excerpt some of the most extraordinary cases of consumption from those journals. For example, a twenty-year-old West Indian seaman died at New York Hospital with a diagnosis of phthisis pulmonalis manifested by extreme emaciation, cough, catarrh, and fever. On dissection the lungs showed no adhesions, no traces of organic lesions, and no inflammation. The physician was of the opinion that phthisis pulmonalis was “not always attended with tubercles and ulcers,” and that death was due to another cause. He suggested that in some cases the disease yielded to calomel, symptoms disappeared, but the patient still died.
**C252** Chap. 9.
Authors: Kahn Richard J.
Published: August 2020

This chapter includes a series of unusual cases from Maine, New Hampshire, Massachusetts, Georgia, London, and Paris. A twenty-five-year-old Maine woman with the usual symptoms of pulmonary consumption developed postpartum chest pains and a swollen leg, was treated, and all symptoms resolved. A twenty-year-old physician from New Hampshire was subject to frequent and profuse hemoptysis, up to a pint of blood at a time. Besides frequent bloodletting to obviate plethora, he conceived of the idea of the efficacy of breast milk. Of every nursing woman whom he met, he solicited permission to draw her breasts. After a year of little or no other nourishment, except cow’s milk when he could not find a supply of breast milk, he had become nearly free from hemoptysis. He died at the age of fifty-seven. An 1822 case of chest surgery and rib-resection for infection in Augusta, Georgia, was reported in the New England Journal of Medicine.
Assessing Patients’ Unmet Palliative Care Needs With Tools for Assessment
Authors: Thomas Chandra , Halpin Amanda
Published: August 2020

High symptom burden of living with kidney disease negatively impacts patients’ health-related quality of life, making it important to routinely screen for symptoms to identify their unmet needs. Research shows that clinicians are inaccurate at estimating symptoms of their patients; therefore, validated tools called patient-reported outcome measures have been developed to improve screening for and identification of troublesome symptoms patients are experiencing. Routinely incorporating patient-reported outcome measures will likely require some change to many current practices; utilizing a change management plan with appointed champion(s) and a supporting multidisciplinary team can help ensure the success of this practice transformation.
Establishing Relationships With Specialty Palliative Care for More Complex Patient Needs
Authors: Schueller Kate , Rotella Joseph D.
Published: August 2020

Interdisciplinary palliative care teams can improve quality of life by addressing the needs and experience of the whole person with chronic kidney disease, including physical, psychological, social, spiritual, cultural, end-of-life, ethical, and practical concerns. Nephrology teams can develop the essential skills to provide primary palliative care for uncomplicated problems, but consultation with a specialty palliative care team is warranted for more severe, complex, or refractory problems. Although specialty palliative care can be delivered in any care setting, it may be a scarce resource outside of a hospital or hospice. Nephrology teams should identify all the specialty palliative care resources available in their community and consider engaging palliative care experts not only in patient care but also in advisory, educational, and quality improvement activities.
Physician Wellness in Nephrology and Palliative Care
Authors: Ramer Sarah , Koncicki Holly
Published: August 2020

Among many threats to physician wellness is burnout, which is associated with negative outcomes for patients and the healthcare system, in addition to the impact it has on physicians. Data on the prevalence, predictors, and consequences of burnout among nephrologists are very limited, but evidence from various sources suggests it might be a major issue. The prevalence of burnout among palliative care physicians is better-studied and appears to vary by country, with up to 60% of palliative care physicians in the United States suffering from burnout in a recent study. Various interventions for prevention and treatment of burnout have been tried, and some have been found to be effective. Controversy exists, however, over whether the individual or the system in which the individual works is more appropriately targeted for intervention. Learning palliative care skills, such as symptom management and advanced communication techniques, might lessen burnout and increase resilience in nephrologists.
Advance Care Planning to Elicit and Respect Patient Values and Preferences
Authors: Holley Jean L. , Yasunaga J. April
Published: August 2020

Advance care planning (ACP) is a patient-centered process to elicit patient and family goals and values that shape medical decision-making and form the basis for completing written advance directives. Advance directives such as healthcare power of attorney, surrogate decision-maker identification, and living wills are executed by the patient. These may be supplemented by provider orders such as resuscitation status (do not resuscitate/do not attempt resuscitation) and provider orders for life-sustaining treatment. Provider input into ACP is required as patients and families need information on prognosis and risks and benefits of interventions to make informed decisions. Because health states influence decisions for ongoing care, ACP is a process that requires revisiting wishes and goals via discussions at stages throughout a patient’s life. All healthcare systems through which a patient passes will need to be involved and cognizant of advance directives to ensure a patient’s wishes are honored. Dialysis units are an integral part of the healthcare system for end-stage kidney disease patients and need to be engaged in the ACP process. Consensus statements, guidelines, and tools exist to facilitate ACP in end-stage kidney disease and chronic kidney disease patients.
The System to Implement Advance Care Planning and Make Proxies, Advance Directives, and Portable Medical Orders Available and Actionable Across Care Settings
Authors: Satkoske Valerie , Moss Alvin H.
Published: August 2020

Few would debate that thoughtful advance care planning conversations between providers, patients, and patients’ loved ones reflect a respect for the right to direct one’s end-of-life care based upon personal values, preferences, and goals. Previous research suggests that advance directives and medical orders are the vehicles to enable patient wishes to be known. However, without ensuring clinician access to those documents, the chances that a patient will receive the desired level of treatment at the end of life diminish significantly. This chapter explores the impediments to accessing and acting upon advance directives and medical orders and suggests a comprehensive system that improves access to completed advance care planning documents for providers and patients. It reviews the successes with such a system in a state—West Virginia—and the positive outcomes with employing components of the proposed system with chronic kidney disease and dialysis patients.
The Role of Estimating and Communicating Prognosis in Kidney Supportive Care
Authors: Thorsteinsdottir Bjorg , Germain Michael J.
Published: August 2020

Most patients with advanced chronic kidney disease and end-stage kidney disease want to know their prognosis. Nephrologists report discomfort in communicating prognostic information to their patients and tend to avoid these discussions. This contributes to prognostic misperceptions among patients and overtreatment for patients for whom treatment benefit is questionable. Decisional regret and withdrawal rates are very high, especially among elderly dialysis patients. Prognosis lies at the center of good discussions about treatment goals that, in turn, facilitate shared decision-making. Good prognostic discussions thus have the potential to promote patient autonomy and facilitate goal concordant care. Several validated tools and frameworks are available to guide clinicians in these important conversations.
Systematic Pain Assessment and Management
Authors: Davison Sara N.
Published: August 2020

Patients with chronic kidney disease suffer from high rates of pain. Pain is a highly complex, multidimensional, and personal phenomenon with far reaching physical and psychosocial consequences if the pain progresses to become a chronic disorder. Systematic integration of global symptom screening needs to be incorporated into routine kidney care, followed by a comprehensive pain assessment for those with clinically significant pain, keeping in mind the overall goal is to promote functionality and quality of life and not to necessarily completely resolve the pain. There is tremendous variability within and between countries in the management of pain, including the prescribing patterns of analgesics. This chapter outlines a systematic approach to the assessment and management of acute and chronic pain with both nonpharmacologic and pharmacologic interventions.
Systematic Psychosocial and Spiritual Needs Assessment and Management
Authors: Cukor Daniel , Kozlov Elissa
Published: August 2020

The mental healthcare and spirituality of patients is an important and often undermanaged aspect of holistic palliative care for patients with end-stage kidney disease (ESKD). Assessment for psychological problems should be a standard part of dialysis patient care. Studies show that some form of depression is prevalent in about 30-% to 40% of ESKD patients being treated with hemodialysis, with about 10-% to 20% with a major depressive disorder. Anxiety is also prevalent in dialysis, but it is less well studied. Treatment for both entails both pharmacologic and non-pharmacologic approaches with cognitive behavioral therapy being one of the most effective of the latter. The goals of this chapter are to outline the major psychological and spiritual reactions to living with ESKD, to suggest an approach to a systematic assessment strategy, and to summarize treatment issues in the management of common comorbid psychiatric disorders.
Palliative Considerations for the Patient With Acute Kidney Injury in the Intensive Care Unit
Authors: Rubenzik Tamara , Moss Alvin H.
Published: August 2020

Acute kidney injury is a common occurrence in the intensive care unit and one that is associated with a high morbidity and mortality. One role for palliative care is to guide medical decision-making regarding management of patients with acute kidney injury. This role can be fulfilled as part of primary palliative care by the intensive care unit and nephrology teams or by specialist palliative care clinicians if there is a need for assistance with conflict resolution. In such discussions, it is important to understand the patient’s prognosis and values, preferences, and goals to inform the shared decision-making discussion about whether to initiate or continue renal replacement therapy. This chapter reviews the literature and guideline recommendations on a palliative care approach to managing critically ill patients with acute kidney injury.
Coordination of Care and Care Transitions With Primary Care Clinicians, Specialty Palliative Care, and Hospice
Authors: Jawed Areeba , Rotella Joseph D.
Published: August 2020

Patients with chronic kidney disease typically have needs that cut across a range of services, including nephrology, other specialties, primary care, and palliative care. This chapter proposes a model of integrated supportive care from diagnosis to end of life that coordinates the efforts and maximizes the benefits of different healthcare teams. Supportive care teams can learn primary kidney supportive care skills to manage symptoms, provide emotional support, and facilitate conversations that focus on what matters most to patients and families. Applying best practices of care coordination, they can facilitate seamless transitions as the patient’s condition evolves.
Palliative Dialysis
Authors: Grubbs Vanessa
Published: August 2020

Dialysis is typically thought of as a life-saving treatment for patients with end-stage kidney disease (ESKD), but for a subset of older patients with dementia or ischemic heart disease or other advanced comorbidities it may not confer a survival benefit, stop the ESKD trajectory, and be life-extending despite achieving standard quality metrics. Providers should consider palliative dialysis for patients with ESKD who have a life expectancy of less than one 1 year, symptoms that might be ameliorated by dialysis, and values such that they would consider a trial of dialysis. Offering palliative dialysis should be considered part of a patient-centered approach for some patients with ESKD with a poor prognosis even with dialysis. In this broadened view of choices for patients with ESKD, decision-making need not only include forgoing or withdrawing dialysis as options. Dialysis is a care plan that strives to achieve hopes while minimizing fears. This balance of the positives and negatives of dialysis can be thought of as palliative dialysis.
Process of Dialysis Withdrawal for Patients Failing to Thrive on Dialysis
Authors: Lam Daniel , Schmidt Rebecca J.
Published: August 2020

Dialysis therapy should be aligned with patient goals, values, and preferences. Withdrawal from dialysis is common, requiring kidney care professionals to recognize when the burden of dialytic therapies outweighs its benefit for any given patient. Informing patients early of the option to withdraw as part of periodic advance care planning can ease future conversations around withdrawal. A systematic approach to discussing withdrawal will address patient and family needs and includes assessing decision-making capacity, eliciting values, clarifying preferences, and educating patients and families about the physical, psychosocial, spiritual, and legal aspects of end-of-life care. All are key components of shared decision-making and the process of withdrawing from dialysis.
What Diagnosis Is—And What It Isn’t
Authors: Paris Joel
Published: August 2020

Diagnosis in psychiatry is not based on a deep understanding of disease mechanisms. Rather, it is a practical way of classifying what clinicians can observe and what patients can describe. Attempts to root diagnosis in neuroscience have all, up to now, failed. There are also no reliable biomarkers or genetic markers for mental disorders. Psychiatric categories can be overdiagnosed or underdiagnosed, but overdiagnosis is the more serious problem. The most frequently overdiagnosed categories these days are bipolar disorder, attention-deficit hyperactivity disorder, and post-traumatic disorder. A history of changes in the diagnosis of schizophrenia is presented to illustrate some of these problems.
The DSM and Its Discontents
Authors: Paris Joel
Published: August 2020

The DSM-5, published in 2013, met with a mixed reaction. This chapter reviews the history of this edition of the manual, examining its overall strengths and weaknesses. Since DSM-5 was not very different from its predecessors, more radical changes using alternative models have been proposed, such as a fully dimensional system (HITOP) and a system based largely on neuroscience (RDoC). However, the real problems lie in our lack of knowledge about the causes of mental disorders. The series of manuals were always intended to be provisional, but the flaws of the DSM system make it all too easy to overdiagnose its categories.
Overdiagnosis and Overtreatment
Authors: Paris Joel
Published: August 2020

Psychiatry has embraced overdiagnosis both because it does not understand the causes of mental disorders and because clinicians are keen to use the tools they already have for treatment. These trends have most notable effects on the overprescription of antidepressant drugs. Overdiagnosis has also infiltrated psychiatric epidemiology, since most studies are DSM-based. All these factors have supported diagnostic epidemics, in which identification of certain categories increases dramatically over relatively brief periods of time. When drugs are believed to be the main form of treatment, these trends have been further encouraged by the pharmaceutical industry, and by opinion leaders who are sponsored by Big Pharma.
Science, Philosophy, and Diagnosis
Authors: Paris Joel
Published: August 2020

Diagnosis in psychiatry is not well based in science, mainly because we do not know the causes of most mental disorders, and are forced to identify them by their signs and symptoms, Diagnosis could be made more scientific by using external sources of validity, such as biomarkers for endophenoypes, but there is not enough knowledge do so. In general, attempts to apply reductionist models to the mind are limited in principle because neuroscience studies mental phenomena on a different level, and tends to exclude psychosocial factors. In practice, diagnoses tend to be used largely as heuristics leading to treatments believed to be effective. Moreover, there is no well-defined boundary between psychopathology and normality.
How Major Is Major Depression?
Authors: Paris Joel
Published: August 2020

Major depression is not a coherent diagnostic entity. Moreover, its definition is problematic, particularly the very low bar in symptoms and time course required to make the diagnosis. Major depression is not always that major, and is seriously overdiagnosed, particularly in patients whose depressive symptoms are related to categories. The unitary theory of mood disorders that has adopted also fails to distinguish between melancholia and non-melancholic depression, each of which respond to different forms of treatment. Finally, there is no clear boundary between depression and normal sadness. The result has been a major overuse of antidepressant drugs and of problematic polypharmacy.
Bipolar Disorders
Authors: Paris Joel
Published: August 2020

Bipolar disorder is currently undergoing a diagnostic epidemic. This is because proponents of a broad bipolar spectrum, who can be called “bipolar imperialists” see latent bipolarity in a wide spectrum of other diagnoses. Thus bipolar disorders are being overdiagnosed in patients who are depressed, in patients who have affective instability related to personality disorders, and in children who mainly present with irritability. None of these patients demonstrate manic episodes or the hypomanic episodes required to diagnose bipolar-II. There are no biological markers to support this expansion of the original concept of bipolarity. The result has been a vast over-prescription of “mood stabilizers” and antipsychotics, both in adults and in children.
Attention Deficit Hyperactivity Disorder
Authors: Paris Joel
Published: August 2020

Attention deficit hyperactivity disorder (ADHD), once considered fairly uncommon, is now being diagnosed at historically high levels. Moreover, because problems with attention are very common in the community, the frequency of the diagnosis in adults has exploded. Yet many adult patients who seem to have ADHD lack a childhood history of the disorder, as required by DSM-5. There is now evidence that adult ADHD frequently appears without such a history and may be an entirely different disorder. Moreover, many other diagnoses cause problems with attention, and stimulant drugs can increase focus in almost anyone. The driving force behind this diagnostic epidemic appears to be the wish to prescribe stimulants, even though these agents could have \ long-term side effects.
Other Disorders in Which Overdiagnosis Is a Risk
Authors: Paris Joel
Published: August 2020

This chapter will examine other disorders that tend to be overdiagnosed. Autism spectrum disorders (ASD), long considered to rather rare, have been much more frequently diagnosed in recent years. This increase may be largely due to the reassignment of patients previously seen as filling within other categories to ASD. Although there are few highly effective treatments for these patients, increase in diagnosis may also reflect a greater availability of services for patients if the seen as lying “on the spectrum.” The chapter will also make briefer mention of other categories, including social anxiety disorder, binge eating disorder, and neurocognitive disorders, all of which have an unclear boundary with normality.
The Rise of Aggressive Psychopharmacology
Authors: Paris Joel
Published: August 2020

Aggressive psychopharmacology describes the current practice of prescribing a large number of medications to patients with almost any mental disorder. While there is some evidence for this approach in severe and, persistent mental disorders, it has spread to common disorders, most particularly major depression. Clinical practice guidelines, which offer a wide range options for patients who are resistant to standard treatments, are being interpreted as promoting polypharmacy for a very broad group of patient. These practices have a surprisingly weak evidence base, and tend to take psychotherapy options off the table. Aggressive psychoharmacology is driven by overdiagnosis and is strongly encouraged by the pharmaceutical industry.
Transdiagnostic Approaches
Authors: Paris Joel
Published: August 2020

Transdiagnostic approaches in psychiatry aim to replace qualitative categories with quantitative dimensional ratings. This chapter examines their advantages and disadvantages. The advantage is that dimensional scales could address the misleading levels of comorbidity that result from overlap between multiple diagnoses in the DSM-5 system. While transdiagnostic methods have thus far studied most extensively in personality disorders, they can, as proposed by a system called HITOP, be applied to any other group, The review in this chapter concludes that we lack the empirical data that would support such a radical change in diagnostic practices, and that given the complexity of these systems, and their unfamiliarity to clinicians brought up in medical models, they are not yet ready for prime time.
Vascular access
Authors: Mitchell Andrew , De Maria Giovanni Luigi , Banning Adrian
Published: August 2020

This chapter discusses different types of vascular access in cardiac catheterization. It starts by describing the Seldinger technique, then goes on to explain which arterial access route to use, including difficulties and reasons for choosing an alternative approach and trends in vascular access. The ways of obtaining arterial access (both radial and femoral) are covered, and venous access is examined for the femoral, internal jugular, and subclavian veins. Anticoagulation issues including warfarin and direct oral anticoagulants are then discussed, and the chapter ends by describing compression devices and arterial closure devices.
Cardiac catheterization
Authors: Mitchell Andrew , De Maria Giovanni Luigi , Banning Adrian
Published: August 2020

Cardiac catheterization allows the invasive acquisition of haemodynamic data using direct and indirect pressure measurements and oxygen saturations, and provides anatomical information using contrast angiography. Right heart catheterization used to be a routine part of an invasive cardiac study. The increased accessibility and accuracy of non-invasive imaging (in particular, echocardiography and Doppler techniques), however, has reduced the need to perform right heart catheterization. This chapter describes the principal uses of cardiac catheterization, the basics of pressure waveforms, equipment required, accessing the left and right heart, left and right heart pressures and waveforms, how to perform calculations, and the techniques of ventriculography and aortography.
Coronary angiography
Authors: Mitchell Andrew , De Maria Giovanni Luigi , Banning Adrian
Published: August 2020

This chapter describes coronary angiography. It starts by describing coronary anatomy, and then the choice of catheters and catheter manipulation, including engaging the left and right coronary arteries and the use of radial catheters. Next, imaging planes for the left and right coronary arteries are described, with clinical images and schematic illustrations included to aid understanding. The use of nitrates and coronary spasm are then covered, along with the quantification of stenoses, tips for interpretation, common pitfalls in coronary angiography. Finally, unusual coronary anatomy is described, including some tips for selective intubation of anomalous coronaries.
Percutaneous coronary intervention
Authors: Mitchell Andrew , De Maria Giovanni Luigi , Banning Adrian
Published: August 2020

This chapter covers percutaneous coronary intervention. It starts with the history of the procedure, indications, and techniques for imaging the lesion, and describes different systems of lesion classification. The equipment required for percutaneous coronary intervention, including guiding catheters, angioplasty guide wires, angioplasty balloons, and intracoronary stents (drug-eluting stents, bioabsorbable scaffolds, etc.) are all covered. The percutaneous coronary intervention procedure is then explained. Intravascular ultrasound is compared and contrasted to optical coherence tomography. Antiplatelet and anticoagulant therapies are described in detail, and finally specific techniques in complex PCI are covered.
Complications
Authors: Mitchell Andrew , De Maria Giovanni Luigi , Banning Adrian
Published: August 2020

Cardiac catheterization is an invasive study that involves real risks to the patient. The risks increase with patient age and co-morbidity. Though vascular complications (particularly haematoma formation) and vasovagal reactions are more common, the risk of serious complications from diagnostic cardiac catheterization and coronary angiography remains low. This chapter covers complications that may arise, including death, myocardial infarction, pulmonary oedema, stroke, hypotension, cardiac tamponade, contrast reactions, vasovagal reactions, arrhythmias, vascular complications, limb ischaemia, coronary dissection (including left main stem dissection and iatrogenic type A aortic dissection), air embolism, coronary perforation, renal failure, contrast nephropathy, and cholesterol embolization.
History of the myeloproliferative neoplasms
Authors: Mughal Tariq I. , Barbui Tiziano
Published: August 2020

The history of haematological malignancies appears to have begun in the sixteenth century as a result of astute clinical observations and the invention of medical microscopy. In the nineteenth century, the use of aniline-based dyes to stain human tissues facilitated the initial recognition of leukaemias, lymphomas, and myelomas as distinct nosological entities. The first detailed description of what is now referred to as chronic myeloid leukaemia, appeared in 1845, and the other ‘classic’ myeloproliferative neoplasms thereafter. Major progress in the therapy and the understanding of these malignancies, however, did not occur until the mid-twentieth century. Since the mid-1990s, these efforts have accelerated remarkably, resulting in the successful introduction of molecularly targeted therapies, and along with increased affordability and reliability of genomic profiling, have helped to usher in the era of precision medicine. In this chapter, we present a brief history of the biological and therapeutic milestones pertaining to myeloproliferative neoplasms.
Genomic landscape of myeloproliferative neoplasms
Authors: Tantravahi Srinivas K. , Khorashad Jamshid S. , Deininger Michael W.
Published: August 2020

The discovery of the Philadelphia chromosome (Ph) and BCR-ABL1 fusion gene in chronic myeloid leukaemia (CML) was a first step in understanding the genetic basis of myeloproliferative neoplasms (MPN), but it took more than 20 years until the molecular basis of Ph– MPN was unravelled with the identification of mutually exclusive mutations in JAK2, MPL, and CALR. The common effect of these mutations, activation of JAK/STAT signalling, informed the therapeutic development of JAK kinase inhibitors. Additional mutations in epigenetic modifier, mRNA splicing, and transcriptional regulator genes are present in many MPN cases. Elucidating the prognostic and functional significance of these mutations is the focus of intense ongoing studies. Given that JAK kinase inhibitors have limited impact on the mutant allele burden these additional pathways may offer much needed additional therapeutic targets. In this chapter, we discuss in detail the genetic landscape of MPN in the context of prognostication and therapy.
Haematopathology of classic myeloproliferative neoplasms
Authors: Kvasnicka Hans Michael , Thiele Jürgen
Published: August 2020

The classification of the World Health Organization (WHO) continues to advocate the diagnostic importance of bone marrow (BM) morphology in the diagnostic workup of myeloproliferative neoplasms (MPN). In this regard, distinctive histological BM patterns characterize specific subtypes of MPN and are the key to a meaningful clinical and molecular-defined risk stratification of patients. In this regard, the morphological denominator includes a characteristic megakaryocytic proliferation along with variable changes in the granulopoiesis and erythropoiesis. Importantly, diagnosis of MPN requires absence of relevant dysgranulopoiesis or dyserythropoiesis. In terms of clinical practice, the concept of precursor stages provides the possibility of an early intervention by appropriate therapeutic regimens that might prevent fatal complications like thrombosis and haemorrhage, especially in early stages of polycythaemia vera or in primary myelofibrosis. However, the WHO classification is not aimed to capture all biological true cases of MPN or guarantee a complete diagnostic specificity and thus might be in need of continuous improvement following clinical experience.