bluuebunny/crossref_metadata_2025 huggingface dataset:
A Prospective Study of Serum Vitamin E and 28-Year Risk of Lung Cancer
Authors: Huang Jiaqi , Weinstein Stephanie J , Yu Kai , Männistö Satu , Albanes Demetrius
Published: May 2019

Background

Epidemiologic data are inconsistent regarding the vitamin E-lung cancer association, and no study to our knowledge has examined serologic changes in vitamin E status in relation to subsequent risk.

Methods

In a cohort of 22 781 male smokers in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study, we ascertained 3184 lung cancer cases during up to 28 years of observation. Cox proportional hazards models examined whether higher serum alpha-tocopherol concentrations at baseline, 3 years, or the interval change were associated with lower lung cancer risk. All statistical tests were two-sided.

Results

After adjustment for age, body mass index, smoking intensity and duration, serum total cholesterol, and trial intervention group, we found lower lung cancer risk in men with high baseline alpha-tocopherol (fifth quintile [Q5] vs Q1, hazard ratio [HR] = 0.76, 95% confidence interval [CI] = 0.66 to 0.87, Ptrend < .001). A similar reduction in risk was seen for serum alpha-tocopherol at 3 years (Q5 vs Q1, HR = 0.78, 95% CI = 0.67 to 0.91, Ptrend = .004). The inverse risk association appeared stronger for younger men and those who had smoked fewer years but was similar across trial intervention groups. We also found reduced risk among men not supplemented with vitamin E who had a lower serum alpha-tocopherol at baseline and greater increases in concentrations at 3 years (third tertile vs first tertile of serum alpha-tocopherol change, HR = 0.74, 95% CI = 0.59 to 0.91, P = .005).

Conclusions

Higher vitamin E status, as measured by serum alpha-tocopherol concentration, as well as repletion of a low vitamin E state, was related to decreased lung cancer risk during a 28-year period. Our findings provide evidence supporting the importance of adequate physiological vitamin E status for lung cancer risk reduction.
Exposure to air pollution is associated with adverse cardiopulmonary health effects in international travellers
Authors: Vilcassim M J Ruzmyn , Thurston George D , Chen Lung-Chi , Lim Chris C , Saunders Eric , Yao Yixin , Gordon Terry
Published: May 2019

Background

With the number of annual global travellers reaching 1.2 billion, many individuals encounter greater levels of air pollution when they travel abroad to megacities around the world. This study’s objective was to determine if visits to cities abroad with greater levels of air pollution adversely impact cardiopulmonary health.

Methods

A total of 34 non-smoking healthy adult participants who travelled abroad to selected cities from the New York City (NYC) metropolitan area were pre-trained to measure lung function, blood pressure and heart rate (HR)/HR variability (HRV) and record symptoms before, during and after travelling abroad. Outdoor particulate matter (PM)2.5 concentrations were obtained from central monitors in each city. Associations between PM exposure concentrations and cardiopulmonary health endpoints were analysed using a mixed effects statistical design.

Results

East and South Asian cities had significantly higher PM2.5 concentrations compared with pre-travel NYC PM2.5 levels, with maximum concentrations reaching 503 μg/m3. PM exposure–related associations for lung function were statistically significant and strongest between evening Forced Expiratory Volume in the first second (FEV1) and same-day morning PM2.5 concentrations; a 10-μg/m3 increase in outdoor PM2.5 was associated with a mean decrease of 7 mL. Travel to a highly polluted city (PM2.5 > 100 μg/m3) was associated with a 209-ml reduction in evening FEV1 compared with a low polluted city (PM2.5 < 35 μg/m3). In general, participants who travelled to East and South Asian cities experienced increased respiratory symptoms/scores and changes in HR and HRV.

Conclusions

Exposure to increased levels of PM2.5 in cities abroad caused small but statistically significant acute changes in cardiopulmonary function and respiratory symptoms in healthy young adults. These data suggest that travel-related exposure to increased PM2.5 adversely impacts cardiopulmonary health, which may be particularly important for travellers with pre-existing respiratory or cardiac disease.
Restriction
Authors: Nicholson Nigel , Selden Nathan R.
Published: May 2019

Chapter 4 examines the physician’s relationship to the broader political life of the community. The Hippocratic corpus mostly frames health in terms of an individual and seems to exclude physicians from involvement in policy and politics. Yet some physicians sought to establish a less restrictive understanding of their work that would not inhibit political engagement. Modern professionals increasingly recognize a broad range of social determinants of healthcare, with a scope that exceeds the purview of traditional physicians. Accordingly, medicine should be recognized as a profession that has real relevance to public service and qualifies its practitioners for political office.
Autonomy
Authors: Nicholson Nigel , Selden Nathan R.
Published: May 2019

Chapter 5 explores an idea central to the medical profession, that a physician should be an autonomous agent. In the archaic and early classical period, physicians faced being associated with servility and a lack of autonomy. The autonomy of modern physicians is also threatened by a system that frames patients as customers and applies increasing pressure to make medical decisions based on broad outcomes data. Physicians should seek to regain their professional autonomy not by resisting data-based decision-making but rather by designing and leading the collection and analysis of the data, as well as creating and implementing evidence-based guidelines.
Mentoring
Authors: Nicholson Nigel , Selden Nathan R.
Published: May 2019

Chapter 6 explores tensions surrounding the mentoring of trainee physicians. Victory odes articulate an ideal of mentoring as an enduring, influential, and even transformational relationship focused on building character and moral judgment rather than technical skill. At the same time, the odes expose concerns that actual mentoring can fail to achieve this ideal, and instead prove to be elitist or more focused on obtaining immediate results than fostering independent agents. Mentorship has re-emerged as a key factor in the development of modern physicians as increased attention is paid to measuring the outcomes of medical education and humanistic competencies within medicine are revalued. Mentorship should certainly be fostered, but care must be taken to design mentorship programs that are inclusive and that develop independent agents.
Self
Authors: Nicholson Nigel , Selden Nathan R.
Published: May 2019

Chapter 7 explores elements in the rhetoric of medicine that impede physicians’ assessments of their own health, wellness, and competence to practice. The Hippocratic texts are shaped by a rhetoric of disembodiment. In case studies, physicians appear as narrators of sickness rather than participants in efforts to combat it. The idea of the disembodied physician also plays a significant role in the rhetoric of modern medicine, obscuring the physician’s own physicality and impeding proper assessment of physical capacities. In order to provide excellent healthcare, physicians must recognize, assess, and ameliorate burnout and aging in their trainees, their peers, and themselves.
Conclusion
Authors: Nicholson Nigel , Selden Nathan R.
Published: May 2019

The conclusion emphasizes the importance of attending to the rhetoric of medicine in achieving the best health care and system outcomes for patients, physicians, and society as a whole. The negative portrait of a physician doing something immoral for money was created by the poet Pindar as an effort to shield himself from criticism that he himself was trading in commodities, not as part of a concerted attack on physicians per se. This chapter proposes that physicians should work actively on their self-presentation, not through artificial marketing strategies but by shaping a practice and profession that clearly puts patients’ welfare at its center.
Disorders of Higher Visual Function
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

A disorder of higher visual function should be considered when visual complaints are out of proportion to examination findings. Such disorders can remain undiagnosed until other cognitive deficits develop. In this chapter, we begin by reviewing the various disorders of higher visual function, which include visual agnosias, simultanagnosia, ocular motor apraxia, and optic ataxia. We next discuss practical strategies to detect these disorders. We then discuss common causes of these disorders and their diagnostic evaluation. We focus our discussion on the clinical features and imaging findings in the visual variant of Alzheimer disease, where the parieto-occipital lobes are preferentially affected in the early stages of the disease.
Transient Vision Loss
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Transient vision loss is common and often results from a transient loss of blood supply to the afferent visual system, although there are many other potential causes. In this chapter, we begin by listing the common causes of transient vision loss. We next discuss the approach to transient vision loss. We emphasize the importance of the history, since physical examination and workup may be unrevealing. We then review the diagnostic evaluation, with a focus on investigations for transient vision loss that is vascular in etiology. Lastly, we discuss the management approach for patients with a cardiac source of embolism or internal carotid artery stenosis.
Fourth Nerve Palsy
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Fourth nerve palsy is a common cause of binocular vertical diplopia. However, it can be difficult to diagnose because the clinical signs are often subtle. In this chapter, we begin by reviewing the symptoms of fourth nerve palsy. We next discuss clinical maneuvers for diagnosing fourth nerve palsy, including the Parks-Bielschowsky three-step test. We list the common causes for isolated fourth nerve palsy and review its differential diagnosis, which includes skew deviation and myasthenia gravis. We then discuss the indications for neuroimaging in a patient with fourth nerve palsy. Lastly, we discuss management options for fourth nerve palsy, which include prisms and strabismus surgery.
Gaze-Evoked Nystagmus
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Gaze-evoked nystagmus is the one of the most common types of nystagmus encountered in clinical practice, but it is poorly localizing. It is often confused with physiologic “end-point” nystagmus. In this chapter, we begin by discussing the pathogenesis of gaze-evoked nystagmus. We next describe its clinical features as well as features that help distinguish it from “end-point” nystagmus, which is physiologic and of no concern. We then review common causes of gaze-evoked nystagmus, which include drugs (especially anticonvulsants), cerebellar degenerations, multiple sclerosis, and episodic ataxias. Lastly, we discuss the diagnostic approach to the patient with gaze-evoked nystagmus and basic management strategies.
Infantile Nystagmus
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Formerly known as congenital nystagmus, infantile nystagmus can occur in isolation or in association with other ophthalmic, neurologic, and endocrine abnormalities. It is predominantly horizontal and conjugate in most patients. It can have a sinusoidal (pendular) or jerk waveform with accelerating slow phases. While it does not usually cause oscillopsia, it can cause blurred vision. In this chapter, we begin by reviewing the clinical features of infantile nystagmus. We next discuss the diagnostic approach to identify conditions that can be associated with infantile nystagmus. We then present a contemporary approach to the management of infantile nystagmus, which includes optical, medical, and surgical strategies.
Anisocoria
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

A difference in the size of the pupils (anisocoria) is a frequent finding on physical examination. While often a cause for alarm, it is not uncommonly physiologic. In this chapter, we begin by reviewing the innervation of the iris sphincter and dilator muscles. We next introduce clinical strategies that can help to determine the etiology of anisocoria. We describe the components of the pupil examination, which includes an evaluation of pupil size in bright light compared to darkness, as well as evaluation of the pupil shape, response to light, and response to near. We include an algorithm that summarizes the clinical approach to anisocoria. Lastly, we review the clinical features of physiologic anisocoria, which occurs in up to 20% of the normal population and does not require further diagnostic testing.
Horner Syndrome
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Horner syndrome can be caused by a lesion anywhere along the oculosympathetic pathway. Although there may be other signs that help with localization of the lesion, the syndrome often occurs in isolation. In this chapter, we begin by reviewing the anatomy of the oculosympathetic pathway. We next describe the clinical features of Horner syndrome, which include ipsilateral miosis and eyelid ptosis. We then discuss the role and potential pitfalls of pharmacologic pupil testing in the diagnostic evaluation of Horner syndrome. We review the potential causes for Horner syndrome, with a focus on causes for acute isolated painful Horner syndrome, such as internal carotid artery dissection. Lastly, we discuss the workup, management, and potential complications of internal carotid artery dissection.
Tonic Pupil
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

A tonic pupil is caused by a lesion affecting the postganglionic parasympathetic innervation of the pupil. It can be an incidental finding on examination or associated with visual symptoms, such as photophobia. In this chapter, we begin by briefly reviewing the differential diagnosis of photophobia. We next review the characteristic features of tonic pupil, which include poor pupil reaction to light, segmental palsy of the iris sphincter muscle, accommodation palsy, and tonic pupil reaction to near. We then review the causes of tonic pupil, which include viral infections, trauma, orbital surgery, or neurologic diseases, such as Miller Fisher syndrome. We then go on to discuss the clinical features, diagnostic evaluation, and prognosis of idiopathic tonic pupil, which is also known as an Adie pupil. Lastly, we briefly discuss the management options for tonic pupil, which include use of sunglasses and dilute pilocarpine eye drops.
Syndromes of the Orbital Apex, Superior Orbital Fissure, and Cavernous Sinus
Authors: Thurtell Matthew J. , Tomsak Robert L.
Published: May 2019

Lesions in the orbital apex, superior orbital fissure, and cavernous sinus can give rise to characteristic combinations of cranial nerve palsies. In this chapter, we begin by reviewing the clinical features and common causes of syndromes of the orbital apex, superior orbital fissure, and cavernous sinus. We go on to discuss the pathogenesis and clinical features of rhino-orbital mucormycosis in detail, because it has a grave prognosis if it is not diagnosed and treated in a timely fashion. We then describe the roles and importance of imaging and tissue biopsy for its diagnosis. Lastly, we review the management of rhino-orbital mucormycosis, which includes rapid reversal of predisposing factors (such as diabetic ketoacidosis), immediate initiation of empiric antifungal treatment, and early surgical debridement of infected tissue.
Paternal Responsibility for Children and Pediatric Hospital Policies in Romania
Authors: Cutaș Daniela , Gheauș Anca
Published: May 2019

This case study explores one instance of how gender norms continue to inform institutional treatment of parents regarding care for children—specifically, how the exercise of fathers’ responsibilities for their children can be discouraged or altogether blocked. Expectations about fatherhood have changed significantly in Europe in the last decades in the direction of closer involvement in the lives and hands-on care of their children. At the same time, moral and political philosophers have for many years been stressing the value of family relationships, and some offer accounts of why individuals of any sex are entitled to have opportunities to develop flourishing relationships with their children
Autism, Family Life, and Epistemic Injustice
Authors: Ashcroft Richard
Published: May 2019

This case study explores the experiences of the father of a child with autism.
Handbook of Pediatric Infection Prevention and Control
Authors: PIDS Pediatric Infectious Diseases S...
Published: May 2019

In the fields of healthcare epidemiology and infection prevention, evidence to guide pediatric practice has been lacking for quite some time. However, in the past few decades, more and more pediatric clinicians, researchers, epidemiologists, and infection preventionists have been contributing to this important field. This textbook discusses topics that pediatric providers must tackle in many settings: in ambulatory clinics, emergency departments, community hospitals, and freestanding university children’s hospitals. Each chapter opens with a clinical scenario (perhaps you have dealt with a few of these scenarios in real life), and follows with questions that are frequently raised when a solution is sought.
Pathogens Spread via Respiratory Route
Authors: Poole Claudette , Nyquist Ann-Christine
Published: May 2019

This chapter covers common and epidemiologically significant pediatric respiratory pathogens, and provides recommendations for preventing transmission in the healthcare setting. Respiratory infections in children are one of the most common reasons for evaluation by a healthcare provider in all healthcare settings. These infections pose significant challenges for infection prevention and contribute to the burden of healthcare-associated infections (HAIs). In addition, family members, who may be less aware about disease transmission, provide direct hands-on care for their children while hospitalized, and then move freely throughout the hospital. Strategies for post-exposure prophylaxis are described for pertussis, varicella, measles, and influenza. Special considerations for pregnant and breastfeeding women are described, with an emphasis on healthcare personnel.
Surgical Site Infections
Authors: Shakoor Aqsa , Middlesworth William , Saiman Lisa
Published: May 2019

Surgical site infections (SSIs) not only increase morbidity and healthcare costs, they also impose emotional and physical burdens on patients and families. The SSI risk for patients undergoing a surgical procedure is specific to the type of surgery, degree of contamination of the operative field, and underlying patient risk factors (both modifiable and non-modifiable. This chapter reviews strategies to prevent surgical site infections in pediatric patients following general surgery, spine surgery for scoliosis, neurosurgical ventricular shunts, and cardiovascular surgery. Best practices and bundles used in leading pediatric healthcare facilities are described, including recommendations for perioperative antibiotic prophylaxis.
Drivers and Dilemmas of Female Genital Cosmetic Surgery
Authors: Shaw Dorothy , Todd Nicole
Published: May 2019

Female genital cosmetic surgery includes many procedures undertaken at the request of the woman and is the fastest-growing area of cosmetic surgery, despite calls for avoidance or extreme caution from professional organizations responsible for women’s health. Low genital self-image is presumed to drive requests, but root causes have not been studied. The vast majority of these surgeries are not indicated medically, have unknown long-term effects, and are being performed in a private-pay environment in a context of significant ethical concerns regarding informed consent, autonomy and beneficence, and conflict of interest. This chapter explores normal physiologic development of female genitalia as it pertains to knowledge of what is “normal,” self-image and the drivers of genital self-image, concerns about specific procedures, and statements of professional organizations. Ethical tensions and dilemmas for clinicians highlight physicians’ ethical responsibility to provide accurate information about potential harms and benefits of these procedures.
Sex Work, Ethics, and Healthcare
Authors: Bungay Victoria , Casey Lauren
Published: May 2019

Women engaged in sex work often face a myriad of barriers (including stigma and discrimination) in accessing and receiving care within the healthcare system. The narratives of 51 women engaged in sex work within indoor settings in a large western Canadian city are used to examine their experiences of stigma and discrimination in health care encounters and how stigma, discrimination, and ideologies of deviance underpin healthcare service programming and clinical encounters among this population. These issues are further nuanced in an analysis that illustrates the consequential and significant ethical concerns for clinicians and health service programming and the devastating effects for women’s health, their rights to healthcare, and their opportunities to be active agents in decisions affecting their care.
Perinatal Mental Health
Authors: d’Agincourt-Canning Lori , Ryan Deirdre
Published: May 2019

This chapter reviews ethical issues pertaining to the care of women with mental illness during pregnancy and the postpartum period. The incidence of perinatal depression and anxiety and psychotic disorders and their respective treatments are described. Ethics principles and perspectives that guide perinatal mental health care are discussed critically. Relational autonomy is shown to be a key principle to guide treatment decisions for these women. The value of relational autonomy in addressing ethical challenges is illustrated by three cases in reproductive mental health: psychotropic medication decisions during pregnancy; enforced treatment; and disclosure of medication use to fathers. A fourth case addresses social justice considerations of mother–baby units for women experiencing a perinatal mental health crisis. This analysis calls for a notion of self-determination that accounts for how autonomy occurs and is enacted within specific relational, social, cultural, and political contexts.
Research with Pregnant Women
Authors: Little Margaret Olivia , Wickremsinhe Marisha N. , Jaffe Elana , Lyerly Anne Drapkin
Published: May 2019

Despite progress in representing various populations in clinical research, one group has been left behind: pregnant women. Though millions of pregnant women annually need to use medication, whether to treat chronic illness or prevent infectious disease, pregnant women have been systematically excluded from the social investment in clinical research required to generate evidence to inform their care. This chapter articulates three models that have been advanced for morally framing research with pregnant women: an unfettered protectionist model, in which pregnant women are categorized as a “vulnerable population” for purposes of clinical research; a model of unrestricted deference to the pregnant woman’s autonomy; and a model that construes the fetus as a pediatric research subject. Each, it is argued, is critically flawed. With lessons learned from their respective limitations, the chapter points toward ways in which research during pregnancy must be given unique consideration, and toward development of an adequate framework.
Policies, Laws, Regulations, Contracts, and Procedures
Authors: Frisse Mark E. , Misulis Karl E.
Published: May 2019

Healthcare in the United States is heavily regulated; a host of often-confusing policies, laws, and regulations impact care delivery and care reimbursement. Because of the breadth of society’s health issues; the diversity of personal, religious, philosophical, or societal goals; and the conflicts that arise among concerned stakeholders, policies or their execution through procedures are almost always controversial. Policies are positions, statements, and courses of action that reflect an organization’s goals and values and are the products of government, business, or other authorities. Collectively, the arguably undue complexity of these regulatory efforts place enormous burdens on both those who develop clinical systems and those who must use them. Clinical informatics professionals must understand these complexities and seek ways of simplifying care and administrative processes.
Clinician Interface and Experience
Authors: Weaver Paul , Dickey Douglas J. , Misulis Karl E. , Frisse Mark E.
Published: May 2019

Clinical applications are evolving from purely transactional systems to systems more capable of providing cognitive support; particularly in the area of decision support, user-centered design and iterative development approaches are leading to improvements. But, at the same time, growing administrative and quality reporting requirements are providing new burdens on clinician time and threaten the clinician-patient experience. Efficiency, usability, and effective workflow integration remain primary concerns. The focus in this chapter is on the user experience, how the electronic health record vendors are working with users and experts to improve this experience. Among the enlisted personnel are not only software and hardware engineers, but also psychologists, physiologists, cognitive neuroscientists, data scientists, stakeholders, and users.
Analytics
Authors: Frisse Mark E. , Misulis Karl E.
Published: May 2019

Healthcare analytics is a subject important to all informatics professionals, from providers to payers to regulators. The analysis of clinical and administrative data is essential to quality improvement, cost management, and research. With the advent of large data sets and sophisticated machine learning techniques, options are growing. Often, the weakness of an analytic approach is more due to a failure to ask a question that leads to clinical action or an inability to answer a question because the data available are not sufficient in either quality or quantity to address the primary concerns. Effective clinical informatics professionals focus on questions for which the data are sufficient and where answers can yield to improved actions.
Decision Support
Authors: Lehmann Christoph U. , Misulis Karl E. , Frisse Mark E.
Published: May 2019

Decision support is a broad technique that seeks to bring information to bear at the time a clinician is taking actions that are driven by other data. Clinical decision-making methodology depends on the complexity of the patient’s case, the certainty of a diagnosis, available treatment and diagnostic resources, reliability of information resources, training of the clinician, and psychological makeup of the clinician. Most clinical decision support efforts seek to improve workflow, enforce best clinical practices, or mitigate adverse drug events. Clinical decision support can reduce medical errors, improve nutrition, prevent orders on the wrong patient, and reduce costs. Clinical and administrative decision support can lead to more effective outcomes, improved quality, and lower costs.
Body, Home, and Community
Authors: Frisse Mark E. , Misulis Karl E.
Published: May 2019

Sensors worn on the person (e.g., smartwatches), sensors in the home, and community-based resources are providing new data and connecting individuals in ways that promise to improve care. The rapid growth of mobile devices that can be worn or integrated into the immediate environment satisfies a need most humans have for connection and convenience. Through these devices, families and clinicians can develop greater insights into behaviors and, through social networks and other resources, connect individuals sharing common health interests. These resources often originate from commercial products and not from traditional healthcare delivery systems. Their availability is also providing new opportunities for health plans and other stakeholders to participate in care.
On the Horizon
Authors: Misulis Karl E. , Frisse Mark E.
Published: May 2019

Clinical informatics professionals are facing unparalleled challenges and opportunities. Our growing and aging population will face a greater burden of illness, often with inadequate financial and social support. Rising costs are placing a burden on government, employers, individuals, and others who pay for healthcare. In response, consumers are embracing new technologies to meet their needs. Clinical information systems will have to evolve to patient-focused collaborative technologies that effectively support care across every possible setting, from the waiting room to the living room. A changing focus and skill set will be essential for the healthcare operations to transcend these many settings.
Staying Current
Authors: Misulis Karl E. , Frisse Mark E.
Published: May 2019

Clinical informatics professionals must remain current with rapid changes in technology, expectations, payment methods, organizational management, and regulations. Fundamental principles in medicine, psychology, computer science, informatics, and economics will serve as a vital foundation; the application of these principles through people, organizations, data, processes, and technologies will change with rapidity. Clinical informatics professionals must remain current to understand and implement meaningful next steps as their organizations evolve. This currency can only be obtained through professional engagement with the broader informatics community and through study of new findings and innovations. Like clinical medicine and many other fields, the body of literature in informatics is growing far too rapidly to remain current in every professional interest. To face the challenges ahead, informatics professionals must employ a range of technologies and resources to collaborate and learn across the many applicable disciplines.
Mitral Valve Surgery
Authors: Mahboobi Sohail K.
Published: May 2019

The mitral valve consists of the mitral annulus, anterior and posterior mitral leaflets, anterolateral and posteromedial papillary muscles attached to mitral leaflets with chordae tendineae, and the left ventricle. Any condition or pathological process involving one or more of these components will affect proper functioning of the valve. A degenerative mitral valve disease process is commonly followed by functional mitral regurgitation. Rheumatic heart disease involving the mitral valve is not common in developed countries but is the most common cause of mitral disease in developing countries. A surgical procedure involving the mitral valve requires a thorough understanding of the physiology of a normally functioning valve as well as the mechanism of pathological processes affecting the valve. Mitral regurgitation is more common than mitral stenosis, and mitral valve repair is a preferable technique over replacement of the valve due to less chance of endocarditis, no thrombolytic therapy requirement, and maintenance of normal physiology of the valve. Anesthesiologists providing care for these patients in the operating room play a pivotal role in successful mitral valve procedures by determining the primary mechanism of the pathology, recommending if the valve is repairable, and evaluating the success of the surgical intervention.
Robotic Mitral Valve Surgery
Authors: Ghia Samit
Published: May 2019

Robotic mitral valve surgery is the most commonly performed robotic cardiac surgery. The first robotic mitral valve surgery took place in 1998. Differences from traditional mitral valve surgery include thoracic access via ports and peripheral cannulation for cardiopulmonary bypass (CPB). Although new techniques result in new complications, the robotic approach has many benefits: no need for sternotomy, reduced postoperative pain, and decreased hospital length of stay. The advent of robotic mitral valve surgery has resulted in drastic implications for anesthetic management: incorporation of regional techniques to address analgesia, need for lung isolation to optimize surgical exposure, and placement of catheters to assist in CPB or cardiac arrest. After a case presentation, this chapter details the surgical technique for robotic mitral valve surgery and the anesthetic implications.
Cardiac Tamponade
Authors: Novak Todd , Hoxie Silas
Published: May 2019

Cardiac tamponade is a life-threatening condition that occurs when accumulating pericardial fluid results in impaired cardiac filling and hemodynamic instability. Most of the clinical features of tamponade are subtle and nonspecific and may not be appreciated until cardiovascular collapse is imminent. Understanding the physiological changes that occur during tamponade are essential for early recognition and intervention. While cardiac tamponade is a clinical diagnosis, echocardiography is the modality of choice in facilitating the prompt identification of extraneous pericardial contents and the determination of the hemodynamic significance. This chapter discusses the presentation, pathophysiology, and echocardiographic signs of tamponade, as well the differential diagnosis and confounding conditions most pertinent to the anesthesiologist. Both medical and surgical management are also addressed, including a review of perioperative and anesthetic techniques.
Pulmonary Thromboendarterectomy
Authors: Ross Michael , Banks Dalia A.
Published: May 2019

Chronic thromboembolic pulmonary hypertension (CTEPH) is an important and often underappreciated cause of severe pulmonary hypertension. The disease is a result of incomplete resolution or recurrent pulmonary emboli. It is imperative to identify patients with CTEPH because it is one of the only causes of pulmonary hypertension that is curable. The treatment of choice is pulmonary thromboendarterectomy. The procedure involves removing any chronic thrombotic material and removing the intimal layer of the vasculature. Patients with CTEPH can be particularly challenging to manage in the perioperative setting and often present to the operating room with significant right heart dysfunction, severely elevated pulmonary vascular resistance, and reduced cardiac output.1 Increased knowledge about the unique disease and procedure can aid in optimizing the management of these patients in the perioperative period.2
Adult Congenital Heart Disease
Authors: Peterson Carly , Joffe Denise
Published: May 2019

The incidence of congenital heart disease is about 1 in 150 live births. In the United States, there are comprehensive healthcare programs that care for the pediatric patient with congenital heart disease; however, there are far fewer resources available for the adult patient. In fact, the majority of adult congenital heart disease patients are cared for in centers without specific expertise in congenital heart disease, which often results in worse outcomes for many of these complex patients. Therefore, it is preferable for patients with anything more than simple congenital heart disease to be treated in centers with specialized programs that have a full spectrum of providers. This chapter will review some of the medical, anesthetic and surgical challenges in caring for these patients.
Off-Pump Coronary Artery Bypass (OPCAB) Surgery
Authors: Feider Andrew
Published: May 2019

Off-pump coronary artery bypass grafting is a type of open-heart surgery whereby coronary grafts are performed without the use of cardiopulmonary bypass (CPB) and cardioplegia. Although not performed as frequently as on-pump coronary artery bypass grafting, it is still utilized in certain situations. Because CPB is not used, anesthetic management has many unique considerations, including temperature management and anticoagulation. Proper monitoring of cardiac output, mixed venous oxygen saturation, and wall motion abnormalities via transesophageal echocardiography are very important during intraoperative management, and there are many anesthetic and surgical techniques that are utilized to limit the degree of myocardial ischemia during surgical construction of the coronary anastomoses.
Chronic Pain After Cardiac Surgery
Authors: Hansen Jennette D. , Chaney Mark A.
Published: May 2019

Chronic pain after cardiac surgery can impair quality of life and rehabilitation. Chronic pain is difficult to study, and depending on how patients are questioned, the incidence of chronic pain after sternotomy is between 17% and 56%, and chronic pain after thoracotomy is between 15% and 80%. Several risk factors are independent predictors for the development of chronic pain. In recent years, minimally invasive techniques have been utilized in cardiac surgery patients to potentially minimize pain and to decrease length of stay in the hospital. At this point in time, no single regimen has been proven superior at preventing chronic pain. An aim to treat acute pain without delaying extubation has been the recent focus of pain management, with research in neuraxial and peripheral nerve blocks. In addition, multimodal analgesia is key for treatment of acute pain to allow patients to deep breathe, cough, and ambulate comfortably without respiratory depression. Some believe treatment of acute pain leads to less development of chronic pain; however, this has not yet been definitively proven.
Transcatheter Aortic Valve Replacement
Authors: Liu Melanie Mei , Mackensen Georg Burkhard
Published: May 2019

Transcatheter aortic valve replacement (TAVR) has revolutionized the management of patients with severe symptomatic aortic stenosis deemed high risk for surgery or inoperable, and its use has recently expanded to the treatment of intermediate-risk patients with severe symptomatic aortic stenosis as well as high-risk patients with a failing aortic valve bioprosthesis. As a key member of the interdisciplinary heart valve team involved in the care of the TAVR patient, the anesthesiologist must be familiar with the currently available devices, procedural steps, and intraoperative imaging requirements in order not only to provide the appropriate level of anesthesia and analgesia for any given patient and procedure but also to anticipate and treat the hemodynamic changes and possible complications that accompany it.
Percutaneous Mitral Valve Procedures
Authors: Cole Sheela Pai
Published: May 2019

As the population ages, more patients are presenting with symptomatic mitral valve disease that requires risk-prohibitive cardiac surgery. In the last decade, advances in valve technology have generated valves that can be inserted via a minimally invasive percutaneous approach. Nonetheless, patients must fulfill specific criteria in order to be considered for a percutaneous mitral intervention. From an anesthesiologist’s perspective, these cases are unique as they require both a detailed understanding of complex patient physiology and the need to be planned as fast-track procedures. Echocardiography is the cornerstone to success for these procedures, and typically a separate team of echocardiographers may be involved in the conduct of the case. This review discusses patient selection, complications of the procedure, and perioperative considerations for this technique.
Ventricular Assist Devices
Authors: Togashi Kei
Published: May 2019

Left ventricular assist devices (LVADs) have found increasing use since their initial approval in 1994. They can be used as bridge therapy to heart transplantation or as destination therapy for patients in whom transplants are not possible. The increasing number of LVAD implants, combined with longer life expectancies, has resulted in growth in this patient population. This has also resulted in the development of additional complications, and these patients often present for noncardiac interventions. Anesthesiologists must be familiar with currently available devices, LVAD physiology, common perioperative complications, and effects of anesthesia on LVAD physiology when they manage these patients intraoperatively.
Pulmonary Hypertension
Authors: Ferreira Renata G. , Schuler Andreas
Published: May 2019

Pulmonary hypertension (PHTN) is a rare yet devastating disease. PHTN is defined as a mean pulmonary artery pressure of 25 mm Hg or greater at rest, measured during right heart catheterization. The survival without therapy is only 2.8 years. Its estimated prevalence ranges from 0.001 to 0.01. In noncardiac surgery, PHTN is considered to be an important predictor of complications, with perioperative morbidity ranging from 14% to 24%. Given this potential morbidity, careful preoperative evaluation and understanding of risks and management of these patients is strongly encouraged as it may improve outcomes after surgery. The perioperative risk and management among patients with PHTN undergoing noncardiac surgery may differ. Therefore, it is important for the anesthesiologist to understand the underlying disease process causing elevation of the pulmonary artery pressure when evaluating the risks and benefits of the proposed procedure.
Anesthesia for Cardiac Transplantation
Authors: Lombaard Stefan , Reed Heather , Arzillo Samantha
Published: May 2019

Heart transplantation is indicated when other treatment options for patients with heart failure are no longer effective or when a heart transplant would improve survival. There are currently a variety of treatment options for these patients; the options range from medical therapy to full mechanical support. Heart transplantation remains the definitive therapy for end-stage heart failure. This discussion focuses on the management of a patient who presents for a heart transplant as well as some of the challenging clinical issues that may present during this period. Anesthetic induction agents may depress cardiovascular function and result in cardiovascular collapse. Drugs should be chosen that have limited hemodynamic effects.
Thoracic Aortic Aneurysm
Authors: Dahl Aaron B. , Fagley R. Eliot
Published: May 2019

Thoracic and thoracoabdominal aortic aneurysms often require surgical repair depending on the size of the aneurysm and the acuity of progression. The involvement of the aortic arch makes consideration of surgical approaches challenging, as it contains the vessels that provide cerebral perfusion. Risk factors for growth and rupture of thoracoabdominal aneurysms include aneurysm size, rapid aneurysm growth, aortic dissection, older age, female sex, chronic obstructive pulmonary disease, cigarette smoking, pain, and a positive family history. Without surgical repair, there is a risk of fatal rupture. Planning the appropriate surgical approach is complex, and protection of the spinal cord from ischemic complications is of paramount importance.
Robotic Thoracic Surgery
Authors: Stombaugh D. Keegan , Dalton Allison
Published: May 2019

Minimally invasive thoracic surgery has improved outcomes, including reduced length of postoperative admission, reduced postoperative pain, shorter postoperative stay, reduced wound complications, reduced blood loss, improved cosmesis, and improved equivalent oncological outcomes compared to traditional thoracotomy. Robotic thoracic surgery (RTS) is an improvement on video-assisted thoracoscopic surgery in that it allows the surgeon a greater degree of freedom with instrument movement and better surgical field visualization. Thoracic insufflation and one-lung ventilation both significantly alter and compromise the patient’s baseline cardiopulmonary physiology. Due to this, adequate preoperative workup, deftness at double-lumen endotracheal tube management, and advanced understanding of how RTS affects cardiopulmonary physiology are essential.
The Obstetric Patient for Cardiac Surgery
Authors: Powlovich Lauren , Kleiman Amanda M.
Published: May 2019

Cardiac disease is the second leading cause of morbidity and mortality in pregnancy behind peripartum hemorrhage. In developed countries, a majority of cardiac disease in pregnancy is secondary to congenital heart defects, whereas in developing countries, mitral stenosis secondary to rheumatic fever prevails as the leading cause of cardiac disease during pregnancy. There is added workload on the heart during pregnancy due to the increased blood volume and cardiac output of the parturient. In patients with preexisting cardiac disease, this added workload may lead to decompensated congestive heart failure. Alternatively, such physiologic changes may unmask an unknown cardiac lesion in an unsuspecting patient. Medical management is always the first-line treatment of the pregnant patient with decompensated heart failure. However, if medical management has failed, cardiac surgery with cardiopulmonary bypass may be necessary. Due to the unique maternal physiology and the presence of not only one but also two patients, anesthesia, cardiac surgery, and cardiopulmonary bypass come with specific challenges, hemodynamic goals, and ethical dilemmas.
Rehabilitation of the cancer patient
Authors: Eva Gail
Published: May 2019

Disability is a major, but often under-recognized, problem for people with cancer. Rehabilitation engages patients and their families in an active process of achieving meaningful goals, so that decline does not have to be associated with helplessness and hopelessness. It aims to maximize social participation and well-being, to achieve personal satisfaction and adaptation to disability, and to minimize carer stress and distress. Rehabilitation is a multiprofessional activity carried out by a range of allied health professionals (AHPs) and other health and social care professionals. The AHPs involved include occupational therapists, physiotherapists, speech and language therapists, dieticians, therapy radiographers, and lymphoedema therapists. In inpatient settings, discharge planning might supersede rehabilitation as the focus of care. Once the patient is at home, it is important to consider their longer-term rehabilitation needs and to make appropriate referrals to community-based primary care rehabilitation teams. Nurses play an active part in the rehabilitation process and can contribute by making appropriate rehabilitation referrals and by working with AHPs to enable patients to maintain independence and control in their daily activities. Patients’ rehabilitation needs vary from straightforward to complex, and the National Institute for Health and Care Excellence (NICE) has produced a 3-level model of the roles and responsibilities of different members of the multidisciplinary team.
Palliative care
Authors: Lund Susi
Published: May 2019

Palliative care improves the quality of life of patients and their families with life-threatening illness, through the prevention and relief of suffering by early assessment and treatment of pain and other problems. It can be provided as part of a more general role, or by specialist palliative care staff who have particular expertise. Referrals for specialist care will often be for pain or symptom management, family support, or spiritual support. End-of-life care aims to enable the person to die with dignity and to manage pain and distressing symptoms. Recognizing the end of life helps practitioners to meet the patient’s needs and prepares their family for the reality of death. Good practice in end-of-life care focuses on effective communication and provision of information, ensuring that patients and their families are fully involved in decision-making and respecting the personal wishes, preferred care setting, and current and anticipated care needs of the patient. Bereavement is frequently encountered in the families of patients prior to, and after, death. Common features of grief can include pining for, and being preoccupied with, the lost loved one, feelings of shock, disbelief, sadness, anger, and anxiety. Complicated grief involves an extended period of grieving, beyond 6 months, with intense feelings and disruption of usual life and activities. The majority of bereaved people do not require specialist support, so screening and assessment identify those at risk or in need of specialist interventions.