bluuebunny/crossref_metadata_2025 huggingface dataset:
A Failure to Oxygenate: A Case for Venovenous Extracorporeal Membrane Oxygenation
Authors: Agerstrand Cara , Pellet Andrew
Published: November 2020

This chapter explains the utilization of venovenous extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS). Venovenous ECMO provides respiratory support and is the most common ECMO configuration used during ARDS. Patient selection is of the utmost importance for successful use of ECMO. Patients being considered for venovenous ECMO for ARDS should meet criteria for severe ARDS. Best guidance can be taken from the Extracorporeal Life Support Organization recommendations and the multicenter Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome trial. The main contraindication to ECMO is any condition or organ dysfunction that would limit the overall benefit of ECMO, such as severe brain injury, metastatic cancer, or decompensated cirrhosis. Once the ECMO circuit is operational, ventilator settings must be optimized to protect the injured lungs by adhering to an ultra-lung-protective “lung rest” strategy.
Intra-aortic Balloon Pump
Authors: Choi Christopher , Masoumi Amirali
Published: November 2020

This chapter describes the intra-aortic balloon pump (IABP), which is the single most widely used mechanical circulatory assist device available today. Counterpulsation refers to balloon inflation in diastole and deflation in early systole: this results in increased coronary blood flow, left ventricular afterload reduction, and increased end-organ perfusion. Other uses of balloon counterpulsation include refractory ventricular arrhythmias, inability to wean from cardiopulmonary bypass, bridge to intervention in severe/critical aortic stenosis, and refractory pulmonary edema from decompensated heart failure. However, the absolute contraindications for IABP placement are aortic dissection, clinically significant aortic aneurysm, severe peripheral artery disease, significant aortic regurgitation, uncontrolled bleeding, and/or sepsis. The chapter then explains the optimal positioning for IABP. It also looks at complications associated with IABPs. These include thrombocytopenia and vascular complications, such as limb ischemia, bleeding, dissection, and hematoma/pseudoaneurysm formation. The presence of blood in the balloon tubing suggests the possibility of balloon rupture and gas embolism, an extremely uncommon but catastrophic event.
Endocarditis
Authors: Boylan Ruth , Conrick-Martin Ian
Published: November 2020

In this chapter we describe the case of a patient presenting with signs and symptoms of infective endocarditis following a recent mitral valve replacement. We describe the epidemiology of infective endocarditis and discuss its features including echocardiographic features. We discuss diagnosis, treatment (both medical and surgical), complications and prognosis with a focus and emphasis on the ICU patient. The clinical presentation of IE in the ICU setting may be atypical and classic features may be masked by critical care interventions and concomitant pathology. Echocardiography can be particularly challenging in the ICU setting. There should be a low threshold for TEE in critically ill patients with Staphylococcus aureus catheter-related bloodstream infection because of its high propensity to cause IE.
Postoperative Cardiogenic Shock
Authors: Hogan Maurice
Published: November 2020

Postoperative cardiogenic shock describes the management of a postoperative coronary artery bypass graft patient who develops early postoperative shock; after a brief discussion of the different potential causes, the chapter focuses on postoperative myocardial infarction due to graft failure. It reviews the assessment and treatment of patients with postoperative myocardial ischemia causing shock; it then outlines the immediate steps to take for diagnosis and patient stabilization, before discussing the definitive management strategy. A stepwise discussion covering fluids and pharmacological and mechanical support is provided to help guide management decisions. The chapter then outlines revascularization as the optimal treatment and fundamental goal.
Cardiac Surgery–Associated Acute Kidney Injury
Authors: Smyth Coilin , Galvin Sinead
Published: November 2020

This chapter on the topic of cardiac surgery–associated acute kidney injury (CS-AKI) examines the risk factors for and the prevention, diagnosis, and management of this serious and common consequence of cardiothoracic surgery. The chapter follows the clinical course of a patient with a moderate risk of CS-AKI undergoing an aortic valve replacement and coronary artery bypass grafting. The risk factors, both patient- and surgery-specific, are demonstrated in tabular form. Methods to mitigate against these risk factors are explained, including optimizing the timing of surgery. The most up-to-date diagnostic criteria for AKI are compared. It also recommends the most accurate formulae to evaluate the severity of CS-AKI. The value of medical therapies prior to renal replacement therapy (RRT) is examined. The clinical decisions regarding the mode of RRT, timing of RRT, anticoagulation methods, and vascular access are highlighted. Patients with already established end-stage renal disease are discussed as a separate cohort. The chapter concludes by discussing the short- and longer-term prognosis associated with CS-AKI.
“All of the above”
Authors: Moukouri Kouch Anna B. , Schweizer Nicolas P. , Treisman Glenn
Published: November 2020

The emphasis of holistic care, especially in persons living with HIV (PLWH) has moved to the forefront of healthcare. HIV was previously considered a death sentence, but with innovative antiretroviral therapy (ART), it is now considered a chronic condition. With patients consistently living longer, there is also an increasing burden of neuropsychiatric disorders that necessitate vigilance on the part of providers. HIV as a chronic health condition often co-occurs with the diseases of addiction and mental illnesses. The patients often present with some of the most common psychiatric mental health conditions: mood disorders, schizophrenia, and substance use disorder, with psychosis sometimes a component of all of them. This burden of comorbid conditions in combination with risk factors and other vulnerabilities can further impair ART adherence and increases the risk of risk-taking behaviors in PLWH, all of which worsen mortality. Treating these patients in a multidisciplinary environment has been shown to be the most effective way to deliver quality care.
Historical epistemology of the “unitary psychosis”
Authors: Berrios German E. , Marková Ivana S.
Published: November 2020

This chapter identifies and discusses the central and supporting concepts that seem to have participated in the construction of the concept of unitary psychosis. It proposes that concepts can be organized in terms of a simplified three-strata model that includes (1) a bottom-layer whose nature is mostly organic and includes causality generators; (2) a middle-layer whose nature in the past was considered as “functional” but which now can be redefined as a sort of translator or compiler, able to transfer information from the bottom layer to the top layer; and (3) a top or surface layer that contains the expressive forms and mechanisms required to communicate the signs and symptoms of disease.
Dimensional conceptualization of psychosis
Authors: Altınbaş Kürşat , Guloksuz Sinan , Os Jim van
Published: November 2020

Psychosis has traditionally been conceptualized as a distinct categorical disease entity. However, evidence from experimental, psychopathological, neurobiological, and genetic studies indicate overlapping symptoms, treatments, outcomes, and biological and genetic markers, suggesting a multidimensional spectrum encompassing nonaffective and affective domains. Outside the realm of clinical psychosis, epidemiological evidence from population cohorts has revealed an extended psychosis phenotype of subtle psychotic experiences, co-occurring with affective, motivational, and cognitive features, with prevalence rates of 5%–15%. The extended psychosis phenotype in the general population appears to pertain, phenomenologically, temporally and etiologically, to the same spectrum as clinical psychosis. Psychosis thus represents a multidimensional spectrum phenotype, transcending not only the distinction between diagnostic categories but also between health and illness. Research and practice in clinical and nonclinical samples can benefit from the explanatory power that is offered by conceptualizing psychosis as a multidimensional transdiagnostic spectrum phenotype. Models linking the impact of environmental and genetic influences, and their interactions, to severity and type of dimensional psychopathology have yielded promising results, as have studies researching psychosis as a developmental phenotype progressing from subthreshold psychosis proneness, to increasing levels of persistence over time and, finally, transition to a psychotic disorder.
Schizophrenia, schizoaffective disorder, bipolar disorder
Authors: Kern Barrett , Keedy Sarah K.
Published: November 2020

Schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features include varying degrees of psychosis and mood symptoms. As such, these disorders may represent three points on a spectrum rather than three categorically distinct disorders. This chapter outlines the key role of psychosis in characterizing these disorders and reviews the conceptual history of this characterization as embodied in the different editions of the Diagnostic and Statistical Manual of Mental Disorders. The inherent practical and conceptual problems associated with a categorical system for these diagnoses and for defining psychosis symptoms are emphasized. Finally, specific symptoms and their qualitative and quantitative features are compared and contrasted among schizophrenia, schizoaffective disorder, and psychotic bipolar disorder.
First-episode psychosis
Authors: Nordentoft Merete , Albert Nikolai
Published: November 2020

Psychosis in the schizophrenia spectrum constitutes a major public health problem. There is convincing evidence for positive effects of 2-year specialized early intervention programs with intensive care, assertive outreach, and family involvement. Follow-up studies indicate a risk of loss of positive clinical effects after termination of specialized programs, but clinical effects can be sustained or even improved with prolonged specialized treatment or transfer to standard treatment, including assertive community treatment (ACT) for the most disabled patients. Long-term studies show substantial heterogeneity in clinical and functional outcomes, resulting in a very diverse picture. Ten-year follow-up studies of the OPUS and the AESOP cohort indicate that more than half of the patients will achieve stable remission of psychotic symptoms and that half of those patients can maintain remission in the long run without antipsychotic medication.
Kynurenic acid in brain function and dysfunction
Authors: Schwarcz Robert , Erhardt Sophie
Published: November 2020

The essential amino acid tryptophan is degraded primarily by the kynurenine pathway, a cascade of enzymatic steps leading to the generation of several neuroactive compounds. Of those, kynurenic acid (KYNA), an antagonist at N-methyl-D-aspartate (NMDA) and alpha7-nicotinic receptors, has gained much attention in schizophrenia research. The concentrations of both KYNA and its precursor, kynurenine, have been repeatedly found significantly elevated both in the postmortem cerebral cortex and in the cerebrospinal fluid of schizophrenia persons as compared to healthy control subjects. Studies in experimental animals have demonstrated that KYNA tightly controls dopaminergic, cholinergic, glutamatergic, and GABAergic neurotransmission, and elevated brain levels appear related to psychotic symptoms and cognitive impairments. The kyurenine pathway is highly inducible by immune activation, and studies have shown that the pro-inflammatory cytokines interleukin (IL)-1β‎ and IL-6 are elevated in schizophrenia and stimulate the production of KYNA. Another mechanism that may account for the abnormally high central kynurenine and KYNA levels seen in schizophrenia might be the observed reduced expression and activity of the enzyme kynurenine 3-monooxygenase (KMO), shunting the synthesis of kynurenine toward KYNA. In line with these studies and concepts, preclinical results suggest that inhibition of kynurenine aminotransferase (KAT) II, by reducing the synthesis and function of KYNA in the brain, offers a novel approach to ameliorate psychosis and to improve cognitive performance in persons with schizophrenia.
Migration, ethnicity, and psychoses
Authors: Morgan Craig
Published: November 2020

The incidence of psychotic disorders is increased, to varying extents, in many migrant and minority ethnic populations in several countries. This chapter briefly reviews the evidence on disparities in incidence between minority and majority populations and then discusses possible explanations. It is unlikely that methodological artifact, including misdiagnosis, can fully account for the high incidence rates observed in some populations. Further, there is no evidence that established neurodevelopmental risk factors for psychosis explain disparities among ethnic groups. It is, then, most likely—and there is growing evidence to support this—that the high rates are a consequence of greater exposure to adverse social conditions and experiences, particularly those involving threat and violence, over the life course among minority ethnic groups. In other words, psychosis occurs more often in some minority populations via a socio-developmental pathway.
Pharmacological approaches to treatment
Authors: Leucht Stefan , Cipriani Andrea , Furukawa Toshi A.
Published: November 2020

Antipsychotic drugs should be efficacious for all psychotic symptoms, whether they occur in schizophrenia, depression, mania, or any other psychotic disorder. All currently marketed antipsychotic drugs are dopamine antagonists or partial agonists, making the role of dopamine blockade in this context the most likely mechanism of action. Antipsychotics show efficacy in treatment and in maintenance across the common psychosis diagnoses, especially when looking across large metanalyses. Yet, there is an important imbalance as to how well the pharmacological treatment of the different psychotic disorders have been addressed in the literature, with schizophrenia being predominant.
Peer support for people with psychiatric illness
Authors: Bellamy Chyrell D. , Klee Anne S. , Cornejo Xavier , Guy Kimberly , Costa Mark , Davidson Larry
Published: November 2020

This chapter focuses on peer support: when individuals with lived experience of mental illness provide support to others with similar lived experiences. It specifically explores peer support in the behavioral health workforce. It offers a comprehensive overview of peer support by addressing what peer support is, why it is needed, and what it does to effect change. It also provides a review of the effectiveness research on peer support, specific roles of peer supporters in practice, and ways to more effectively partner with peer supporters in the behavioral health field. Last a case example is given to highlight the efforts and lessons learned implementing peer supporters in the US Department of Veterans Affairs.
Noninvasive brain stimulation techniques in psychosis
Authors: Mondino Marine , Haesebaert Frédéric , Brunelin Jérôme
Published: November 2020

Noninvasive brain stimulation techniques are safe tools to modulate the brain activity and connectivity in vivo. They offer promise to alleviate psychotic symptoms, mainly in patients with schizophrenia. Evidence suggests that low-frequency repetitive transcranial magnetic stimulation (rTMS) targeting the left temporoparietal junction may decrease auditory verbal hallucinations with a moderate effect size. High-frequency rTMS targeting the left dorsolateral prefrontal cortex yields encouraging results to alleviate negative symptoms of schizophrenia, but recent findings have diminished the enthusiasm raised by the first studies. Transcranial direct current stimulation (tDCS) is an emerging field that shows promises to decrease hallucinations and negative symptoms in schizophrenia, but it suffers from a lack of large randomized controlled studies to confirm its interest in psychosis. Overall, electromagnetic techniques are promising techniques, offering new perspectives for treating psychotic symptoms but further studies are needed to draw a clear-cut conclusion.
Treatment approaches in the psychosis prodrome
Authors: Auther Andrea M. , Cornblatt Barbara A.
Published: November 2020

Interest in intervening prior to the onset of psychosis, in the prodromal or clinical high-risk (CHR) phase of illness, gained momentum in the 1990s. Initial treatment trials were conducted with the goal of preventing psychosis, but results to date have been equivocal. Only a few trials have found partial benefit of specific treatments over control conditions on transition rates, and even fewer show long-term gains. Challenges include high attrition and feasibility issues, especially for antipsychotic medication and cognitive remediation trials. While better tolerated, psychosocial therapy trials have mixed results, though when combined, meta-analyses show advantages compared to other treatments. Integrated treatment approaches lack specificity and the promising initial Omega-3 trial has not been replicated. Aside from conversion, early intervention appears to improve clinical outcomes including positive symptoms, depression, and anxiety. Importantly, treatment trials have not had a notable impact on functional outcomes, making this a crucial area for future research.
Management of the airway, analgesia, and anaesthesia
Authors: Greaves Ian , Porter Keith
Published: November 2020

Pain management is an essential part of effective pre-hospital care. The provision of analgesia should be regarded as normal practice that requires careful patient assessment, appropriate analgesic selection, and careful monitoring of the patient for both clinical effectiveness and adverse reactions. The method and choice of analgesia will vary depending on the skills of the practitioner. The chapter covers choices of analgesia, management of the airway (including moving the cervical spine) and anaesthesia.
The hostile environment
Authors: Greaves Ian , Porter Keith
Published: November 2020

Pre-hospital care and emergency medicine in the hostile environment poses particular challenges for those providing care to the patient. This chapter covers hypothermia, cold injury, avalanche rescue, heat-related illness, drowning and near drowning, diving emergencies, and electrocution injury. For each environment, mechanisms, diagnosis, and management are listed.
Major incident management and triage
Authors: Greaves Ian , Porter Keith
Published: November 2020

The management of major incidents and disasters is complex and requires the effective engagement and integration of a great number of responding organizations and individuals. This section offers an introduction to the subject, clarifying the key principles and giving some basic organizational information. The chapter classifies major incidents, defines the specific phases, the process of declaring a major incident, how to set the scene (including command structures and responsibilities), explains the role of the health services, the roles of the other emergency services and the armed forces. It covers radio voice procedure and approved communication shorthand, triage, trauma scoring, and mass gathering medicine.
Emergency obstetrics, gynaecology, and care of the newborn
Authors: Greaves Ian , Porter Keith
Published: November 2020

This chapter starts with the anatomy and physiology of pregnancy and the approach to managing a severely ill or injured pregnant patient. It covers taking a history and examination, before describing the management of specific issues. These include shock, ectopic pregnancy, miscarriage, toxic shock syndrome, antepartum haemorrhage, placental abruption, hypertensive disorders (eclampsia and pre-eclampsia), pre-term labour, trauma in pregnancy, and normal labour. The chapter goes on to goes on to describe the retained placenta, abnormal labour, and normal birth. Neonatal resuscitation, and the circumstances in which it should be stopped, are explained.
Clinical pharmacology and toxicology
Authors: Webb Andrew , Archer John
Published: November 2020

This chapter outlines the basic science and theory of clinical pharmacology, and pharmacology and toxicology for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables and boxes to highlight key facts.
Drug development and clinical trials translational medicine
Authors: Ciurtin Coziana , Mant Tim
Published: November 2020

This chapter outlines the basic science and theory of drug development and clinical trials translational medicine required for MRCP Part 1, before addressing the clinical aspects of drug development and clinical trials translational medicine for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables, and boxes to highlight key facts.
Haematology
Authors: Prasannan Nita , Ademokun Christine O. , Radia Deepti H.
Published: November 2020

This chapter outlines the basic science and theory of Haematology required for MRCP Part 1, before addressing the clinical aspects of Haematology for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables, and boxes to highlight key facts.
Critical Care
Authors: Frise Matthew C. , Welters Ingeborg
Published: November 2020

This chapter outlines the basic science and theory of critical care required for MRCP Part 1, before addressing the clinical aspects of critical care for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables and boxes to highlight key facts.
Gastroenterology
Authors: Cheriyan Danny , Ford Charlotte , Patchett Stephen
Published: November 2020

This chapter outlines the basic science and theory of gastroenterology required for MRCP Part 1, before addressing the clinical aspects of gastroenterology for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables, and boxes to highlight key facts.
Hepatology
Authors: Atkinson Stephen R. , Dhar Ameet
Published: November 2020

This chapter outlines the basic science and theory of hepatology required for magnetic resonance cholangiopancreatography (MRCP) Part 1, before addressing the clinical aspects of hepatology for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables, and boxes to highlight key facts.
Nephrology
Authors: Afzali Ben , Gökmen Refik
Published: November 2020

This chapter outlines the basic science and theory of nephrology required for MRCP Part 1, before addressing the clinical aspects of nephrology for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables and boxes to highlight key facts.
Psychiatry
Authors: Tandy Rob , Norton Kingsley
Published: November 2020

This chapter outlines the basic science and theory of psychiatric disorders and their treatment required for MRCP Part 1, before addressing the clinical aspects of psychiatric disorders and their treatment for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables, and boxes to highlight key facts.
Epidemiology and Public Health
Authors: Coltart Cordilia E.M. , Maryon-Davis Alan
Published: November 2020

This chapter outlines the basic science and theory of epidemiology and public health required for MRCP Part 1, before addressing the clinical aspects of epidemiology and public health for MRCP Part 2. To ensure effective revision, material is presented in short sections with bullet lists, tables, and boxes to highlight key facts.
Cancers in children, teenagers, and young adults
Authors: Boterberg Tom , Dieckmann Karin , Gaze Mark
Published: November 2020

Chapter 1 introduces the topic of cancer in children, teenagers, and young adults. Cancer in children and young people is rare: less than 1% of total cancer incidence. There is a wide variety of tumour types, and these are often different from the common adult cancers. Leukaemia, brain tumours, and malignancies of embryonal origin are most common in younger children. Genetic predisposition is important. Environmental causes are less common than in adults. Treatments have improved significantly and, currently, about three out of four children and young people are cured of their cancer. Multimodality protocols including chemotherapy, surgery, and, more frequently now, biological treatment, in addition to selective use of more sophisticated radiotherapy techniques, is the norm. Increasing personalization of treatment based on risk stratification has allowed for improved cure rates with a reduction in treatment-related morbidity.
Radiotherapy preparation and treatment
Authors: Alexander Rhonda , Boterberg Tom , Dieckmann Karin , Gaze Mark , King Hannah , Woodman Helen
Published: November 2020

Chapter 4 discusses radiotherapy preparation and treatment. There are many ways of delivering radiotherapy, and the best technique should be chosen for each child, teenager, or young adult for whom irradiation is indicated. Image-guided, intensity-modulated radiotherapy techniques are gradually replacing three-dimensional conformal approaches. Proton beam radiotherapy offers the advantage of lower normal tissue radiation doses in many circumstances, and its availability and use is growing. Highly specialized techniques including hypofractionated stereotactic radiotherapy, molecular radiotherapy, and brachytherapy offer important advantages in a small number of cases. Anaesthetic teams are essential for the immobilization of infants and most younger children requiring radiotherapy. Play specialists may reduce the need for anaesthesia in some cases, and greatly facilitate treatment of older children. Good imaging is essential for accurate target volume delineation, and careful prospective quality assurance of this process will help to improve outcomes.
Aftercare
Authors: Boterberg Tom , Chang Yen-Ch’ing , Dieckmann Karin , Gaze Mark , Woodman Helen
Published: November 2020

Chapter 5 discusses care during and after radiotherapy for children and young people. During and immediately after treatment, children and young people receiving radiotherapy need monitoring for acute complications of treatment and may require supportive care. Following completion of treatment, a response assessment is needed, followed by ongoing surveillance for recurrence. If relapse occurs, consideration can be given to further treatment, which may be radical or palliative in intent. With the passing of time, the risks of relapse recede and monitoring for the late effects of treatment becomes more important. As the majority of patients will have some long-term sequelae, some of which can be ameliorated by timely intervention, patients should be followed in a multidisciplinary clinic. A detailed treatment summary will help predict the risk of complications and guide long-term follow-up. Patients, when they reach adult life, should be aware of possible problems, including fertility issues and second malignant neoplasms.
Pain
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

This chapter answers many questions, for example, ‘What is pain?’ and ‘Why pain is harmful?’. How we perceive pain and the physiology of pain are discussed. Plasticity and wind-up and the role of ketamine in preventing chronic pain are also included in this fascinating chapter.
Analgesics
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Analgesics are drugs used to relieve pain. They are divided into groups: opioids, non-steroidals, and adjuvants. This chapter gives you detailed information on their pharmacology. Once you fully understand the chemistry of these drugs you can go on to understand their clinical properties, how they react differently in different groups of people, and their side effects.
Postoperative nausea and vomiting
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Postoperative nausea and vomiting commonly occur after surgery and anaesthesia. Patients find it very distressing and this chapter sets out ways in which you can alleviate their symptoms: first by understanding the physiology and the causes of the problem and then by applying simple remedies and using well-tried and safe drugs. Mendelson’s syndrome of aspiration pneumonia is also described.
Special problems
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Allergy, prolonged drug reactions, and delayed emergence and problems, large and small, that do not have a special chapter are covered in Chapter 10. The effect of residual relaxant drugs, and the management of these patients, is covered in these pages. Patients with brain damage, headache, or emergent delirium and violent or crying patients are described. Awareness, and its ongoing implication, is discussed. Treatment for extravasation and arterial injections are prescribed. Hiccups, shaking and shivering, pressure areas, care of the eyes, shoulder tip pain, sweating, mouth care, and urinary retention are all covered in this chapter.
Pharmacology
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Pharmacology is the study of the action and effect of drugs. This is an important subject, one that will require attentive study. Once understood, pharmacology makes the prescription of drugs both practical and meaningful. Anaesthetic drugs and their actions are described and patient factors in the metabolism of drugs are explained.
Mothers and babies
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

This chapter looks at pregnant mothers and the physiology of pregnancy. It describes how to look after these patients after operations they experience during their pregnancy as well as after Caesarean section. Instructions are given for the special care of newborn infants. Problems of postpartum haemorrhage, eclampsia, air and amniotic embolism, and aspiration pneumonia are discussed.
The elderly patient
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Elderly patients have special problems and these are extensively described in this chapter. The changes in their physiology and metabolism are correlated with their drug requirements and comorbidities.
Cardiovascular disease
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Cardiovascular disease is common and patients coming to recovery room with any of these common problems will need special care. The essential signs and symptoms of hypertension, cardiac failure, ischaemic heart disease, and valvular heart disease are outlined. The actions and side-effects of the drugs that these patients take to control their symptoms are described. Recognizing and treating hypotension and myocardial ischaemia are very important and relevant, and they are fully discussed in this chapter.
The kidney
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Renal failure after surgery does occur and carries a high mortality. The immediate postoperative management of the patient’s fluids is an important part of their recovery. This chapter will teach you the physiology of kidney function, how and why things go wrong, and how to anticipate and prevent renal failure from developing. Conditions that can lead to renal problems are discussed and also the effects of the drugs given to the patients during and after the operation.
Fluid balance
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

This chapter will tell you how surgery affects fluid balance and how the body controls fluids. Fluid compartments in the body and the nature of fluids are described. Disorders of fluid balance, the use of fluids to restore blood volume, and extra cellular fluid volume are all discussed. Management of fluid deficit, fluid overload, and pulmonary oedema and how to correct electrolyte balance are all clearly set out. Recommendations for fluids after different types of surgery and fluids for patients with renal and cardiac failure are given.
Infection control
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Hand washing is the main subject of this chapter. The importance of hand hygiene cannot be too strongly emphasized. How infections occur and the chain of infection are described. Important organisms such as HIV/AIDS, tuberculosis, vancomycin-resistant Enterococcus (VRE), meticillin-resistant Staphylococcus aureus (MRSA), and hepatitis viruses are all included. What to do about needlestick injuries, using the N95 mask, and information about recent advances in hand hygiene using alcohol are all to be found here.
Working with people
Authors: Craig Anne , Hatfield Anthea
Published: November 2020

Staffing your recovery unit, having meetings, emphasizing communication, and trust are all important parts of running a successful recovery room. Above all, the patients must feel safe and this calm atmosphere will be enhanced when all the staff are happy at work. Cultural and religious sensitivities are important; these are addressed here as well as the way to involve carers and relatives in the early stages of the patient’s awakening.
Intracranial Aneurysms: Does Size Really Matter?
Authors: Majeed Kashif , Boddu Srikanth R , Carnevale Joseph , Cenberlitas Elif Ezgi , Williams Nicholas , Patsalides Athos , Gobin Yves Pierre , Knopman Jared , Stieg Philip E
Published: November 2020

BACKGROUND

To stratify the risk of aneurysmal rupture, size remains the primary criterion as proposed by 2 ISUIA (International Study of Unruptured Intracranial Aneurysms) trials that recommend the observation of ≤7 mm aneurysms because of their low propensity to rupture. These recommendations are controversial, given the severe outcomes following hemorrhage.

OBJECTIVE

To retrospectively assess whether size correlates with aneurysmal rupture, and to analyze outcomes of endovascular and microsurgical procedures.

METHODS

All aneurysms presenting between 2016 and 2019 were reviewed. Age, gender, comorbidities, ruptured status, modes of treatment, and their outcomes were noted. Regression analysis was performed to correlate size with rupture. The type of intervention was based on clinical and aneurysmal characteristics and the likelihood of obliteration.

RESULTS

Of the 668 aneurysms, 116 had ruptured. In size groups 0 to 6 mm,  7 to 12 mm,  13 to 18 mm,  18 to 24 mm, and giant, the ruptured aneurysms were 60.3%, 30.2%, 1.7%, 0.9%, and 6.9%, respectively. The majority (423) were managed endovascularly, of which 84 (19.9%) were ruptured. A total of 97 (14.5%) underwent clipping, of which 31 were ruptured. The mean modified Rankin Scale for both treated groups was zero. One death in each group and a single brainstem stroke in the coiled group were noted. A total of 139 were followed, of which none had ruptured. The mean modified Raymond-Roy classification for endovascular therapy was 1.1, with 380 completely occluded; 15 had a score of 2, and 28 of score 3.

CONCLUSION

The ruptured aneurysms were mostly smaller than reported previously. Surgical clipping was at equipoise with endovascular treatments. Further studies to correlate aneurysmal characteristics to the risk of rupture are needed.
Introduction
Authors: Müller Andreas
Published: November 2020

The introduction sets the stage for what follows. Constructivism is presented as a position that seeks to explain why some considerations are reasons for or against certain actions. It thus disagrees with fundamentalist views which deny that a general, yet informative explanation of this kind is available. Constructivism also differs from Humean views that offer such an explanation in terms of the agent’s actual or hypothetical desires. By contrast, constructivism suggests that reasons can be explained as an upshot of our capacity to reason. The introduction also highlights that the constructivist view to be developed in the book is a meta-ethical, rather than a first-order normative position, and that it offers an account only of practical reasons, leaving, e.g., epistemic reasons aside.
Examination Under Anesthesia Improves Agreement on Mechanical Stability: A Survey of Experienced Pelvic Surgeons
Authors: Tucker Douglass , Carney John , Nguyen Aileen , Alluri Ram K. , Lee Adam , Marecek Geoffrey
Published: November 2020

Objectives:

To assess agreement among experts in pelvic fracture management regarding stability and need for operative repair of lateral compression-type pelvic fractures with static radiographs compared to static radiographs and examination under anesthesia (EUA).

Setting:

Online survey.

Patients/Participants:

Ten patients who presented to our level-1 trauma center with a pelvic ring injury were selected. Vignettes were distributed to 11 experienced pelvic surgeons.

Intervention:

Examination under anesthesia.

Main Outcome Measurements:

Agreement regarding pelvic fracture stability and need for surgical fixation.

Results:

Agreement on stability was achieved in 4 (40%) cases without EUA compared to 8 (80%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.207 vs. 0.592). Agreement on need to perform surgery was achieved in 5 (50%) cases compared to 6 (60%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.250 vs. 0.432). For reference cases with agreement, surgeons were able to predict stability or instability using standard imaging in 57 of a possible 88 reviewer choices (64.8%) compared to 82 of 88 choices (93.2%) with the addition of EUA (P < 0.0001).

Conclusions:

EUA increased agreement among experienced pelvic surgeons regarding the assessment of pelvic ring stability and the need for operative intervention. Further research is necessary to define specific indications for which patients may benefit from EUA.
Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation
Authors: Tan Jiong Hao , Wu Tian Yi , Tan Joel Yong Hao , Sharon Tan Si Heng , Hong Choon Chiet , Shen Liang , Loo Lynette Mee-Ann , Iau Philip , Murphy Diarmuid P. , O'Neill Gavin Kane
Published: November 2020

Objectives:

We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures, early (within 4 days) definitive stabilization (EDS) can be performed without an increase in postoperative ventilation and postoperative complications.

Design:

Retrospective cohort study.

Setting:

Level 1 trauma center.

Patients:

In total, 103 patients were included in this study; of whom, 18 (17.5%) were female and 85 (82.5%) were male. These patients were borderline trauma patients who had the following parameters before definitive surgery, normal coagulation profile, lactate of <2.5 mmol/L, pH of ≥7.25, and base excess of ≥5.5.

Intervention:

These patients were treated according to Early Total Care, definitive surgery on day of admission, or Damage Control Orthopaedics principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (>4 days).

Main Outcome Measures:

Primary outcome measured was the duration of ventilation more than 3 days post definitive surgery and presence of postoperative complications.

Results:

Thirty-five patients (34.0%) received Early Total Care, whereas 68 (66.0%) patients were treated with Damage Control Orthopaedics. In total, 51 (49.5%) of all patients had late definitive surgery, whereas 52 patients (50.5%) had EDS. On logistic regression, the following factors were found to be predictive of higher rates of postoperative ventilation ≥ 3 days, units of blood transfused, and time to definitive surgery > 4 days. Increased age, head abbreviated injury score of 3 or more and time to definitive surgery were found to be associated with an increased risk of postoperative complications.

Conclusions:

Borderline polytrauma patients with no severe soft tissue injuries, such as chest or head injuries, may be treated with EDS if adequately resuscitated with no increase in need for postoperative ventilation and complications.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
A Biomechanical Comparison of Trochanteric Versus Piriformis Reconstruction Nails for Femoral Neck Fracture Prophylaxis
Authors: Shieh Alvin K. , Bravin Daniel A. , Shelton Trevor J. , Garcia-Nolen Tanya C , Lee Mark A. , Eastman Jonathan G.
Published: November 2020

Objectives:

To compare piriformis fossa to greater trochanteric entry cephalomedullary implants in an evaluation of femoral neck load to failure when the device is used for femoral shaft fractures with prophylaxis of an associated femoral neck fracture.

Methods:

Thirty fourth-generation synthetic femur models were separated into 5 groups: intact femora, entry sites alone at the piriformis fossa or greater trochanter, and piriformis fossa and greater trochanteric entry sites after the insertion of a cephalomedullary nail. Each model was mechanically loaded with a flat plate against the superior femoral head along the mechanical axis and load to failure was recorded.

Results:

Mean load to failure was 5487 ± 376 N in the intact femur, 3126 ± 387 N in the piriformis fossa entry site group, 3772 ± 558 N in the piriformis entry nail, 5332 ± 292 N for the greater trochanteric entry site, and 5406 ± 801 N for the greater trochanteric nail group. Both piriformis groups were significantly lower compared with the intact group. Both greater trochanteric groups were similar to the intact group and were statistically higher than the piriformis groups.

Conclusions:

A piriformis fossa entry site with or without an intramedullary implant weakens the femoral neck in load to failure testing. A greater trochanteric entry yields a load to failure equivalent to that of an intact femoral neck. Instrumentation with a greater trochanteric cephalomedullary nail is significantly stronger than a piriformis fossa cephalomedullary nail during axial loading in a composite femur model.
Particulate Juvenile Articular Cartilage Transfer for Talar Osteochondral Lesions
Authors: McDonald Matthew R. , Cerrato Rebecca A. , Schon Lew C.
Published: November 2020

Osteochondral lesions of the talus present a challenge to the foot and ankle surgeon with regards to treatment. Although most bone marrow stimulation (BMS) procedures have relatively good outcomes, those patients who do not improve or present with large lesions (>1.5 cm2) are candidates for a range of more involved procedures. All of these treatments focus on improving pain and function by restoring cartilage at the lesion site. Treatment options are generally classified as either BMS or restorative. Histologic studies have found that BMS leads to infill by fibrocartilage that has physical properties inferior to that of native hyaline cartilage. The goal of restorative treatments is to create hyaline or hyaline-like cartilage. This category includes a variety of techniques each with their own advantages and disadvantages. This paper focuses specifically on one of these techniques, particulate juvenile articular cartilage transfer. A brief overview of BMS and restorative treatment options is provided. A detailed description of the surgical technique for particulate juvenile articular cartilage transfer and a review of published clinical results are discussed.

Level of Evidence: Level V—expert opinion. See Instructions for Authors for a complete description of levels of evidence.
Should Donors Consent to Export Their Corneas? Examination of Eye Tissue and Eye Care Sector Opinion
Authors: Machin Heather , Sutton Gerard , Baird Paul N.
Published: November 2020

Purpose:

Corneal tissue international activity is only possible because of the willingness of export populations to donate their corneas on their death. Current predonation public education campaigns and at-the-point-of-donation consent practice generally includes consent for transplantation, research, and/or training. It is unclear whether a consent-for-export step is universally included in the consent process or, indeed, whether it should. We interviewed eye tissue and eye care professionals from around the world, who exported, imported, or did neither to understand current consent-for-export awareness and determine opinion on future practice.

Method:

During wider qualitative grounded-theory semistructured interviews with sector experts, to determine whether Australia should export, we captured sector opinion on consent-for-export. We used saturation and sentiment methods to determine opinion and χ2 correlation coefficients to examine association, using an α of P = 0.05.

Results:

We interviewed 92 individuals, 83 of whom discussed consent-for-export. Of those, 51% (42/83) demonstrated some awareness of the practice; however, there were contradictions between interviewees from the same location. Regardless of current awareness, 57% (41/72) believed donors should be informed or consented for export. Their approval did not extend to donor-directed decisions, which would allow donors to decide which nation their donation should be sent, with 62.5% (45/72) opposing that notion.

Conclusions:

Our research indicates that the consent-for-export practice is not universally applied by exporting nations and that eye tissue and eye care professionals have limited awareness of the practice. Universally implementing a consent-for-export step within general consent practice would improve awareness, reduce confusion, and support donor wishes.
Stigmatization and Social Functioning Levels of Patients With Alcohol Use Disorders
Authors: Baysan Arabaci Leyla , Ayakdaş Dağli Dilek , Taş Gülsenay , Büyükbayram Arslan Ayşe
Published: November 2020

Aim

The aim of this stu dy was to determine the levels of internalized stigma and social functioning of patients with alcohol use disorders.

Method

The study is cross-sectional and descriptive. The data were collected between August 2017 and August 2018 using face-to-face interviews with 104 alcohol-dependent patients who were undergoing inpatient treatment. The data collection was done so through personal information forms, the Internalized Stigma of Mental Illness Scale (ISMIS), and the Social Functioning Scale (SFS). Descriptive statistics, t test, and correlation analysis were used in evaluating data.

Results

Analysis of the sociodemographic characteristics of the patients showed that the mean age was 47.28 ± 10.10 years and 92.3% of the patients were male. The mean age of patients when they first started drinking alcohol is 19.37 ± 6.25 years. It was determined that 85.5% of the patients were also cigarette smokers, 37.5% were previously treated because of alcohol dependence, and 34.6% are currently having legal problems. Patients' ISMIS mean score was 71.99 ± 13.78, and the mean scores of subscales were moderate. In SFS, the mean scores of the “preliminary social activity” and “leisure activities” subscales and the total scale scores were at a moderate level and those of the other subscales (social withdrawal, interpersonal functionality, independent competence, independent performance, job-profession) were below average. As the ISMIS mean score increases, the SFS subscales' mean scores decrease (p < .05).

Conclusion

Alcohol-dependent patients negatively stigmatize themselves, and the functionality of their prosocial activity skills, along with their recreational activities, is inadequate. Furthermore, as ISMIS tends to increase, SFS (interpersonal functioning, prosocial activities, recreational activities, independence-performance) levels decrease.