bluuebunny/crossref_metadata_2025 huggingface dataset:
Consequences of model assumptions when projecting habitat suitability: a caution of forecasting under uncertainties
Authors: Hodgdon Cameron T , Mazur Mackenzie D , Friedland Kevin D , Willse Nathan , Chen Yong
Published: May 2021

Climate change is continuing to influence spatial shifts of many marine species by causing changes to their respective habitats. Habitat suitability as a function of changing environmental parameters is a common method of mapping these changes in habitat over time. The types of models used for this process (e.g. bioclimate models) can be used for projecting habitat if appropriate forecasted environmental data are used. However, the input data for this process must be carefully selected as less reliable results can incite mis-management. Thus, a knowledge of the organism and its environment must be known a priori. This paper demonstrates that these assumptions about a species’ life history and the environment are critical when applying certain types of bioclimate models that utilize habitat suitability indices. Inappropriate assumptions can lead to model results that are not representative of environmental and biological realities. Using American lobster (Homarus americanus) of the Gulf of Maine as a case study, it is shown that the choice of extrapolation data, spatial scale, environmental parameters, and appropriate subsetting of the population based on life history are all key factors in determining appropriate biological realism necessary for robust bioclimate model results.
Influence of Music Therapy and Music-Based Interventions on Dementia: A Pilot Study
Authors: Dahms Rebecca , Eicher Cornelia , Haesner Marten , Mueller-Werdan Ursula
Published: May 2021

According to national dementia plan in many countries, the music implementation into the daily routine as an adjunctive therapy to medication treatment is common. However, the ability of long-term care facilities to implement individualized music therapy (MT) and music-based interventions is not sufficiently taken into account. This pilot study examined the frequency of use and acceptance of MT and technology-based music interventions (TBMI) as well as the influence of high and low usage of both interventions of dementia on behavioral and psychological symptoms (BPSD) at two timepoints. Furthermore, the influence on the combination of MT and TBMI of dementia within the nursing home setting on BPSD with a focus on agitation, apathy, depression, and quality of life at all timepoints was considered. In the present study, data from 30 people with dementia (PwD) aged on average 81 years were analyzed within an eight-week noncontrolled intervention study, including four-week follow-up. Initial outcome data indicated significant decreases at times T2 and T3 in agitation and apathy among PwD with a high usage of MT and TBMI than among those with a low usage. In general, reductions were obtained from all observed BPSD at all timepoints. Significant results were found only for agitation over time. Considering the demonstrated results, a long-term implementation of music within daily routines in nursing homes for PwD should be strived for.
Neuraxial Anesthesia
Authors: Cardenas Paulina
Published: May 2021

Neuraxial anesthesia is the preferred method of anesthetic care for the parturient. This chapter will discuss the different neuraxial techniques and how they are used for both labor and cesarean delivery. It will discuss single-shot spinal anesthesia, continuous spinal anesthesia (CSA), epidural anesthesia, and combined spinal-epidural (CSE) anesthesia. It will also discuss the relevant anatomy and physiology to consider when placing a neuraxial anesthetic. The pain pathways for the first and second stages of labor will be described. Common equipment used while placing a neuraxial anesthetic is reviewed. The recent addition of neuraxial ultrasonography to aid in placing neuraxial anesthesia is discussed.
Non-Opioid Analgesic Techniques for Labor and Vaginal Delivery
Authors: Nguyen Anvinh , Deng Yi , Nikolaidis Melissa A.
Published: May 2021

This chapter will review non-opioid analgesic techniques for vaginal delivery. There are three stages of vaginal delivery, and the different dermatomal coverage required for adequate relief of labor pain will be reviewed for each stage. As labor progresses through its predictable stages, different nerves are involved in the transmission of pain. The location of pain can be described by the spinal nerve roots that are carrying the noxious stimuli. The chapter will discuss epidural and regional techniques as well as the use of non-opioid oral medications, non-opioid intravenous medications, and inhalational medications for alleviating pain during vaginal delivery.
Obstetric Hemorrhage
Authors: Khan Faiza A. , Mhyre Jill M.
Published: May 2021

Obstetric hemorrhage remains a major cause of maternal morbidity and mortality. It is important to recognize that excessive bleeding may become life threatening if not identified early. Importance must be paid to recognition of the cause of bleeding and appropriate intervention. Hemorrhage can be antepartum or postpartum. Effective management requires a multidisciplinary approach for positive outcomes including collaboration of anesthesiologists with the obstetrician, neonatologist, and interventional/surgical services. Anesthesiologists should be involved in the management of all stages of hemorrhage for an effective approach. Use of national guidelines and checklists is recommended to ensure timely diagnosis and management. In this chapter, we review the different types of obstetric hemorrhage, the stages of hemorrhage, the general management plan, as well as specific considerations for each cause. We include multidisciplinary guidelines and algorithms that can be used to guide management.
Neonatal Assessment and Resuscitation
Authors: Kromah Fatoumata , Bhatt Darshna , Chahin Nayef , Yitayew Miheret , Khoury Joseph
Published: May 2021

Neonatal care is complex, multifactorial, and multidisciplinary. The provider has to take into consideration physiologic, clinical, ethical, and technological factors that will impact the long-term neonatal outcome. This is an important consideration, as the US infant mortality rate remains higher than any other developed nation.1 The decrease in the rate of neonatal mortality in the US has been mainly attributed to better understanding of neonatal assessment, advances in neonatal resuscitation, and risk mitigation of birth-related neurological injuries. Understanding risk factors for poor fetal outcomes, neonatal assessment, and resuscitation is essential to the practice of obstetric anesthesia.
Anesthesia and Assisted Reproductive Techniques
Authors: Martin Nora , Farah Fadi , Reddy Shamantha
Published: May 2021

This book chapter covers the anesthetic management and associated challenges involved in assisted reproductive techniques. The average age of women starting their families has increased, which has led to a rise in infertility and assisted reproductive procedures. Ambulatory surgeries and office-based procedures for infertility are also becoming more prevalent given the new business models of healthcare. Understanding the various steps starting from hormonal stimulation to embryo transfer will help the anesthesiologist in not only administering safe care but also showing empathy towards these patients who go through an emotional roller coaster of conception. We will also discuss the different anesthetic techniques and their implications for the success of the assisted reproductive techniques.
Medicolegal Issues in Obstetric Anesthesia
Authors: Onyewu Samuel , Kromah Fatoumata
Published: May 2021

This chapter highlights medicolegal issues in obstetric anesthesia and reviews expectations for the anesthesiologist involved in the care of obstetric patients. Obstetric anesthesia is a unique subspecialty in anesthesiology. It is the only subspecialty where the anesthesiologist is primarily responsible for two patients at the same time (while performing one anesthetic). In this era of tremendous medical advancements in patient care, women with debililating medical conditions live long enoughto childbearing age, hence the obstetric anesthesiologist is often involved in the management of high-risk pregnant patients with complex medical history. Pregnant patients with complex medical conditions have increased risk for severe maternal and fetal/neonatal mortality and morbidity. Therefore, when dealing with high-risk obstetric patients, the potential for medicolegal issues is greater compared to nonpregnant or healthy pregnant patients. Trends in medical liability claims for obstetric anesthesiologists have changed over the years. There has been a reduction in maternal death, neonatal death, and brain damage claims; however, maternal nerve and minor-injury claims are increasing. The most common reasons for anesthesia-related malpractice liability claims are anesthesia delay, substandard care, inadequate or inaccurate documentation, poor communication, and medication errors.
Vesicular Trafficking
Authors: Benarroch Eduardo E.
Published: May 2021

Normal cell function depends on the appropriate synthesis, maturation, sorting, and delivery of fully processed proteins and other macromolecules to specific intracellular compartments; uptake of material from the cell exterior; and regulated intracellular processing and degradation of proteins, lipids, complex carbohydrates, abnormal aggregates, and senescent organelles. These fundamental functions involve secretory, endocytic, and autophagic pathways. The secretory pathway is responsible for protein maturation, sorting, and delivery of transmembrane and secreted proteins from their site of synthesis to their final destinations. Synaptic vesicle exocytosis is a special form of secretion that allows rapid communication between neurons. The endocytic pathway starts with the internalization of material via endosomes. Endosomal content can be transported back to the cell body, recycled to cell compartments, or delivered for degradation by the lysosome. Abnormal protein aggregates or damaged organelles undergo autophagy, which involves formation of an autophagosome and degradation by the lysosome. Impaired vesicular trafficking is a fundamental mechanism in a large number of neurodegenerative disorders, including hereditary spastic paraplegia, lower motor neuron syndromes, and Parkinson disease.
Neurotransmission, Neuromodulation, and Plasticity
Authors: Benarroch Eduardo E.
Published: May 2021

Neurochemical signals released at synapses or by perisynaptic glial cell processes include excitatory and inhibitory amino acids, acetylcholine, monoamines, neuropeptides, purines, lipid mediators, nitric oxide, growth factors, cytokines, and extracellular matrix proteins. These signals produce three fundamental effects on their target: classical neurotransmission, neuromodulation, and plasticity. Classical neurotransmission is the rapid, precise transmission of excitatory or inhibitory signals. Neuromodulation affects the probability of neurotransmitter release or responsiveness of the postsynaptic cells to the neurotransmitter. Synaptic plasticity refers to the use-dependent changes in efficacy of transmission of excitatory signals, eventually associated with change in dendritic structure and connectivity. Plasticity also involves interactions among synapses, glial cell, and the extracellular matrix. Abnormalities of synaptic transmission and plasticity are common disease mechanisms in neurologic disorders and are therapeutic targets.
Glutamatergic Transmission and Synaptopathies
Authors: Benarroch Eduardo E.
Published: May 2021

L-glutamate is the primary excitatory neurotransmitter in the adult central nervous system (CNS). Glutamatergic inputs are critical for fast synaptic excitation, use-dependent synaptic plasticity, shaping of activity of local circuits and networks, neuron–astrocyte interactions, and myelination by oligodendrocytes. Plasticity of glutamatergic synapses is critical for development and maintenance of synaptic connections and for mechanisms of learning and adaptation in the CNS. Induction of these forms of glutamatergic synaptic plasticity depends on the activity-dependent expression and recycling of glutamate receptor subunits. Impaired plasticity of glutamatergic synapses is a major disease mechanism in neurodevelopmental intellectual disability, Alzheimer disease, limbic encephalitis, and cerebellar ataxia.
Astrocytes and Astrocyte–Neuron Interactions
Authors: Benarroch Eduardo E.
Published: May 2021

Astrocytes constitute approximately 30 percent of cells in the CNS and are the most abundant glial cells. They constitute a structural and functionally heterogeneous population and are critically involved in development, homeostasis, synaptic and neuronal network activity, and response to injury and repair in the CNS. They have a major role in synaptic formation during development and maintenance of extracellular fluid and potassium homeostasis, antioxidant protection, metabolic support to active neurons and oligodendrocytes, local regulation of cerebral blood flow, uptake and recycling of synaptic glutamate and γ-aminobutyric acid (GABA), synaptic plasticity, and coordination of activity in neuronal networks in the adult CNS. Astrocytes are primarily affected in metabolic, genetic, and immune astrocytopathies and have a major role in the pathophysiology of epilepsy and in vascular, immune, inflammatory, and neurodegenerative disorders.
Sleep–Wake Cycle and Circadian Rhythms
Authors: Benarroch Eduardo E.
Published: May 2021

Wake and sleep states are defined by behavioral and electrophysiological biomarkers such as the electroencephalogram and electromyogram. Studies using selective neuronal activation and inactivation in experimental animals show that the control of the wake–sleep cycle primarily depends on glutamatergic and GABAergic neurons distributed in the basal forebrain, hypothalamus, and brainstem. These neurons receive modulatory influence of cholinergic, monoaminergic, and peptidergic neurons. Whereas arousal depends on brainstem and basal forebrain mechanisms, the maintenance of the waking states and the transition from wakefulness to sleep depend on the hypothalamus. The sleep–wake cycle is primarily regulated by the circadian rhythm and homeostatic sleep pressure. Sleep has a critical role in memory consolidation, synaptic plasticity, and maintenance of homeostasis in CNS. Disturbances of circadian regulation and sleep architecture are major manifestations of genetic, neurodegenerative, and autoimmune disorders.
Behavioral State Control
Authors: Benarroch Eduardo E.
Published: May 2021

Information processing, cognition, and behavior are dynamically modulated by several groups of cholinergic and monoaminergic neurons that provide widespread but functionally distinct inputs to the cerebral cortex and subcortical areas. These neurons are active during wakefulness and increase their activity in response to behaviorally relevant environmental stimuli. Via different presynaptic and postsynaptic receptors located in principal neurons and local interneurons, these cholinergic and monoaminergic systems participate in the maintenance of arousal and have a major role in sensory processing, selective attention, motivation, and action selection. These systems are selectively vulnerable in neurodegenerative disorders and also have a major role in psychiatric disorders.
Spinal Motor Control
Authors: Benarroch Eduardo E.
Published: May 2021

Motor neurons in the spinal cord brainstem motor nuclei (motoneurons) are the final effectors of central motor control and provide the output to skeletal muscles, forming motor units. The activity of spinal motoneurons is controlled by descending cortical and brainstem inputs largely via premotor circuits involving excitatory or inhibitory interneurons. These circuits elicit specific patterns of motoneuron activation controlling muscle synergies under the influence of descending corticospinal and brainstem motor pathways. Central pattern generators are interneuron circuits that can autonomously generate activation of motoneurons in the absence of descending commands or afferent feedback and include those involved in locomotion, respiration, and swallowing. Disorders affecting motor neurons or their control by afferent, cortical, or cerebellar influences constitute a large proportion of neurological diseases.
Cerebellar Circuits
Authors: Benarroch Eduardo E.
Published: May 2021

The cerebellum has a critical role in control of timing and coordination of movement, acquisition of skills, and cognitive and affective functions. It participates in motor control via both immediate online adjustments of motor performance and long-term adaptive motor learning, referred to as supervised or error-based learning. Most of the cerebellum is interconnected with association areas of the cerebral cortex. The cerebellum is a major target of genetic, degenerative, metabolic, and immune disorders. Experimental evidence indicates that disrupted Purkinje cell pacemaking activity and synaptic plasticity in the cerebellum have a major role in the pathophysiology of ataxia. The cerebellar circuits also have a major role in the pathophysiology of different types of tremor.
Autonomic Control and Survival
Authors: Benarroch Eduardo E.
Published: May 2021

The autonomic nervous system controls the moment-to-moment activity of visceral organs and has a critical in survival, homeostasis, and adaptations to internal or external challenges. The autonomic outputs are mediated by the sympathetic, parasympathetic, and enteric nervous systems under the influence of several interconnected areas distributed throughout the central nervous system (CNS). They include lower brainstem areas mediating autonomic reflexes, and upper brainstem areas that integrate autonomic and respiratory control with behavioral arousal. These areas are also the effectors of descending commands from the hypothalamus, amygdala, and cerebral cortex and provide feedback inputs to these areas. Disorders affecting autonomic control may manifest with autonomic failure that severely affects quality of life, and sometimes with life-threatening impaired control of blood pressure and respiration during sleep.
Executive Control
Authors: Benarroch Eduardo E.
Published: May 2021

Attention, working memory, decision-making, and executive control are fundamental cognitive functions that involve large-scale networks largely defined on the basis of functional magnetic resonance imaging (fMRI) studies. These networks include areas of the lateral and medial prefrontal, orbitofrontal, anterior, and midcingulate cortices, anterior insula, and lateral and medial posterior parietal cortices as well as areas of the temporal lobe and temporoparietal junction. These networks include the dorsal and ventral attention networks, frontoparietal, cingulo-opercular and salience control networks, and the default mode network. These networks are located along a hierarchical gradient of cortical organization. Dysfunction of large-scale cortical networks is a cardinal feature of neurodegenerative dementias and psychiatric disorders.
Regional Anesthesia
Authors: Berg Kent B. , Kiley Sean , Buchanan Patrick J. , Robicsek Steven A.
Published: May 2021

Major vascular surgical procedures are commonly performed on patients with significant comorbidities. Regional anesthetic techniques may be used as the primary mode of anesthesia or to supplement general anesthesia for open or endovascular surgical procedures. This chapter focuses on the management of thoracic and abdominal aortic repair, as well as revascularization of the lower extremities. Although general anesthesia is still used in a majority of these surgeries, neuraxial and regional options allow for the reduction of opioid administration and provide hemodynamic stability while maintaining safety. An understanding of vascular anatomy, the surgical procedure, as well as neuraxial or regional anesthesia technique, is critical for success. Finally, anticoagulant medication management, coordination of the timing of the procedure, and postoperative management are crucial to reduce the risk of complications in this challenging patient population.
Normal Respiratory Physiology
Authors: Renschler Jordan S. , Jeha George M. , Kaye Alan D.
Published: May 2021

Patient positioning should optimize exposure for surgery while minimizing potential harm to the patient. Concerns for patient positioning include interfering with respiration or circulation, compressing peripheral nerves of skin, and causing musculoskeletal discomfort. This chapter will review basic respiratory physiology and introduce physiological and anatomical considerations during thoracic anesthesia, including the supine position and the lateral decubitus, both closed and open chest. It will cover lung isolation techniques, including anatomical landmarks, double-lumen tubes, bronchial blocker, bronchoscopy. with consideration of specific indications and basic lung mechanics and pulmonary function. It will also examine different types of equipment for thoracic anesthesia, such as the double-lumen tube and the bronchial blocker, and their uses.
Patient Positioning and Surgical Considerations
Authors: Ho Phi , Deng Yi , Nikolaidis Melissa
Published: May 2021

It is a collaborative effort among all operating room personnel to ensure safety and well-being of the patient while providing optimal surgical exposure. Lateral positioning is the most common position for most thoracic surgeries. Proper assessment of patient positioning is of utmost importance to mitigate peripheral nerve injuries. Understanding physiologic changes with changes in position is prudent in treatment of hemodynamic changes. This chapter discusses numerous positionings to ensure surgical access that mitigate risks for neurological injuries such as damage to the ulnar nerve. In addition to lateral positioning, the authors examine the flexed lateral decubitus (kidney), supine, and lateral semiprone positions.
Anesthetic Management Techniques in Thoracic Surgery
Authors: Liu Henry , Chen Xiangdong , Kaye Alan D. , Urman Richard D.
Published: May 2021

Although anesthetic management for thoracic surgery can be challenging, ventilation and hemodynamic monitoring are critical. In this chapter, we begin with a brief history of the pneumothorax challenge that surgeons and anesthesiologists needed to overcome during intrathoracic surgical procedures. They then discuss the intraoperative ventilation and hemodynamic monitoring approaches, as well as management strategies for intraoperative hypoxemia. There are newer anesthetic approaches such as nonintubating techniques for thoracic surgical procedures, and a greater emphasis on the application of goal-directed fluid therapy and the multimodal analgesic strategies.
Anesthesia for Pleural Space Procedures
Authors: Arora Harendra , Smeltz Alan
Published: May 2021

A variety of conditions can involve the pleural space that may require surgical intervention. Diseases that involve the pleura include pleurisy, pneumothorax, pleural effusion, hemothorax, chylothorax, empyema, and pleural tumors, as well as alveolopleural or bronchopleural fistula. Surgical interventions for treatment of pleural diseases include catheter drainage, debridement, decortication, pleurodesis, and thoracic duct ligation or repair of bronchopleural or alveolopleural fistula. Aside from overall patient assessment and workup, the preanesthetic evaluation should focus on cardiopulmonary risks to determine patients’ tolerance to one-lung ventilation. Anesthetic plan typically includes general anesthesia with or without one-lung isolation techniques. There are specific cases that may benefit from awake anesthetic techniques in order to allow maintenance of spontaneous ventilation. Most patients undergoing surgery for pleural disease can be extubated at the end of the procedure unless their cardiopulmonary status is rather tenuous. Postoperative analgesia is best addressed through a multimodal approach with certain cases benefiting from epidural or paravertebral analgesia.
Lung Transplantation
Authors: Francis Loren , McKinnon Jared
Published: May 2021

Anesthesia for lung transplant surgery involves careful preoperative assessment, close intraoperative monitoring, prompt evaluation and treatment of hemodynamic and respiratory instability, and clear communication with the surgical team. This chapter discusses key elements of lung transplant surgery and offers clinical guidance for the cardiothoracic anesthesiologist. It details preoperative, intraoperative, and postoperative management considerations and offers a focused overview of mechanical support strategies. Specifically, pulmonary artery catheter placement is explained, relevant transesophageal echocardiography anatomy is reviewed, and ventilator and fluid management strategies are discussed. The chapter begins with the preoperative assessment and then moves to intraoperative management. The chapter ends with a discussion of mechanical support and posttransplant management.
Minimally Invasive Thoracic Surgery
Authors: Capone Joseph , Tharian Antony
Published: May 2021

This chapter on novel approaches to minimally invasive thoracic surgery explores the latest techniques being utilized in thoracic surgery. It reviews anesthetic considerations including patient positioning, intraoperative monitoring, and temperature management. It also reviews commonly utilized anesthetic approaches to thoracic surgery such as general endotracheal anesthesia with lung isolation as well as nonintubated anesthesia, regional anesthetic techniques, and approaches to postoperative pain management. This chapter also provides an up-to-date review of the latest approaches being utilized for thoracic surgery including single port video assisted thoracic surgery, robot-assisted thoracic surgery, and single port robotic surgery.
Enhanced Recovery in Thoracic Surgery
Authors: Zhao Manxu , Xia Zhongyuan , Liu Henry
Published: May 2021

With the development and improvement of enhanced recovery after surgery protocol over the past 20 years, there is an increasing acceptance and application of enhanced recovery after surgery in many surgical subspecialties. Thoracic surgery has also started adopting the practice of enhanced recovery after surgery, and some hospitals have already implemented elements of enhanced recovery after surgery pertinent to thoracic surgical patients such as optimization of preoperative pulmonary rehabilitation, increasing application of regional anesthesia in multimodal analgesia, single chest tube placement, and early removal of chest tube. Enhanced recovery in thoracic surgery has resulted some improved clinical outcomes with multidisciplinary multimodal perioperative approach.
Memory and Attention Adaptation Training
Authors: Ferguson Robert , Gillock Karen
Published: May 2021

Memory and Attention Adaptation Training (MAAT) is a cognitive-behavioral therapy (CBT) designed to help cancer survivors self-manage and mitigate the late and long-term effects of cancer and cancer therapy on memory function. Cancer-related cognitive impairment (CRCI) is a set of mild to moderate memory and attention impairments that can have an adverse influence on quality of life. CRCI symptoms tend to present during active treatment, but for some individuals cognitive changes can persist for years. While the exact prevalence of CRCI is unknown, review of the literature estimates that nearly half of all survivors may experience some form of CRCI. Causes of CRCI are multiple and are the subject of continued research. Chemotherapy, genetic vulnerability, neurovascular damage, inflammation, and hormonal/endocrine disruption have all been identified as candidate mechanisms of persistent cognitive change. Given the multiple causal mechanisms, finding a biomedical treatment for CRCI remains elusive. MAAT was developed as a CBT to help cancer survivors make adaptive behavioral and cognitive changes to improve performance in the valued activities that CRCI hinders. MAAT consists of eight visits and has been designed for administration through telehealth technology, improving access to the survivorship care that so many cancer survivors may lack after the time and expense of cancer treatment. Survivors can use this workbook to reinforce their in-session learning and continue to build adaptive coping.
Visit 1
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

During Visit 1, Clinicians and survivors review the introduction and overview of MAAT and the eight-session training schedule. The education component covers cancer background, significance, and causes topics as well as helping survivors recognize that not all memory/attention failures are cancer/treatment related (re-attribution). MAAT highlights the important rationale that, while we can’t know at the causes of cancer-related memory problems, we do know that factors such as stress, fatigue, and the divided attention of busy, daily life also contribute to memory problems—and we can change environment, stress response, and manage fatigue through the use of compensatory strategies aimed a minimizing the effects of memory failures. Self-awareness is introduced, and self-monitoring forms are explained and assigned for homework in order to identify the environmental, affective, and cognitive antecedents of memory failures in daily life. Survivors are guided through a Progressive Muscle Relaxation procedure and instructed for home practice with a provided recording.
Visit 2
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

In Visit 2, the survivor and clinician review homework from Visit 1. Any difficulty in applying compensatory strategies is reviewed and problem-solved. A review of memory and attention problem records is aimed at identifying themes in memory and attention failures (e.g., verbal-auditory, visual-attention, recall of written or auditory information, ability to follow instruction) while acknowledging the role of environmental factors and inner physical and emotional states (e.g., anxiety, frustration, fatigue, hunger, pain, etc.). A review of progressive muscle relaxation sets the stage for learning quick relaxation. An important internal strategy—self-instructional training—is reviewed and rehearsed so that the survivor can apply it in daily life in a practical way.
Visit 7
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

The first goal of the penultimate visit is to review active listening and verbal rehearsal skills for socializing by asking about what strategies were used, for what, when, and where and modifying as needed. The second goal is to review fatigue management and sleep quality improvement by asking what strategies were used, for what, when, and where and modifying as needed. The third goal is to introduce the internal strategy of visualization, including the rationale and reviewing visual–auditory associations. Emphasizing novelty and humor to evoke emotion and deepen memory is also covered. The strategies taught are simple visualization, name–face mnemonic, and the method of loci. The final goal, as customary, is to assign homework, including identifying, practicing, and applying relevant visualization strategies “in the real world.”
Opioid pharmacology in obese patients
Authors: Mulier Jan P. , Wouters Ruben
Published: May 2021

A primary goal in the care of surgery patients is adequate treatment of their perioperative pain. The guidelines from The Joint Commission described the measurement of pain as the ‘fifth vital signal’. Consequently, pain alleviation is a top priority in postoperative management. Most anaesthesiologists worldwide use opioids as one of the primary components of general anaesthesia for achieving haemodynamic stability and for postoperative pain relief. There are medical conditions associated with obesity that must be considered when using postoperative opioids to avoid deleterious effects in these patients. The intraoperative use of opioids is less dangerous but induces rapid tolerance and hyperalgesia, requiring higher postoperative opioid dosages. The physiological differences between obese and non-obese patients can have repercussions on the pharmacokinetics and pharmacodynamics of opioid drug use for this patient population.
Ventilatory strategies in obesity and obesity hypoventilation syndrome
Authors: Venkataramani Ranjani , Coleman Scott R. , Sinha Ashish C.
Published: May 2021

Ventilating obese patients under general anaesthesia can be quite challenging. In addition to altered lung mechanics, increased abdominal adiposity, surgical positioning, and creation of pneumoperitoneum adds complexity to the situation.
Healthy obese
Authors: Wadhwa Anupama , Obal Detlef
Published: May 2021

At least 30% of the surgical population consists of ‘obese’ patients, mirroring the obesity epidemic in the general population in the United States. Nearly 74% of participants in the American College of Surgery’s National Surgical Quality Improvement Program had an abnormally high body mass index, including 17% of patients under the age of 18 years. This development is particularly concerning as obesity is associated with increased risk of metabolic syndrome, hypertension, coronary artery disease, and diabetes mellitus. However, physicians, nutritionists, and the general public struggle with definitions of obesity based only on total body weight proportionate to height and, therefore, body mass index. This leads to the question of whether body mass index is adequate to describe the physical condition and potential risk of our patients.
Tissue oxygenation in the obese patient
Authors: Singh Shubhangi , Singh Prashant , Singh Preet M.
Published: May 2021

Tissue oxygenation refers to the amount of oxygen available at the level of the tissues for cellular metabolism. Due to a much higher increase in the subcutaneous fat volume as compared to the blood volume, obese patients at baseline are at a lower level of tissue oxygenation as compared to their lean counterparts. Increased basal metabolism (higher oxygen need), decreased functional residual capacity, and propensity for obstructive sleep apnoea (lower oxygen supply) increase their risk of hypoxic injury further. Tissue oxygenation is further adversely affected by pathological conditions such as sepsis and haemorrhage that have higher incidences in the obese patient. This leads to further increased expression of proinflammatory cytokines and downregulation of the anti-inflammatory cytokines in the obese patient. This chapter deals with the current knowledge of the concept of tissue oxygenation with a special focus on the obese population.
Guidelines and equipment in obese patients
Authors: Balabanoff-Acosta Christian , Fleckenstein Clint , Gewirtz Eric
Published: May 2021

This chapter of the textbook aims to improve the reader’s understanding of the term ‘difficult airway’ in the obese patient and provides personal insight about and general perioperative recommendations for assessing the airways of, using equipment on, and monitoring obese, morbidly obese, and super-morbidly obese patients. Coupling the suggestions in this chapter with the guidelines of the reader’s home institution will ensure that surgeries for obese, morbidly obese, and super-morbidly obese patients will go as smoothly and as safely as is possible.
Historical background, classification, and diagnostic criteria
Authors: Shiboski Caroline H. , Daniels Troy E.
Published: May 2021

The objective of this chapter is to describe the evolution of, and critically assess, the various diagnostic and classification criteria for Sjögren’s syndrome (SS) first published in 1965. This chapter provides a historical perspective on the natural history of SS and the various diagnostic tests that have proven useful over time and are individual criteria items within the classification criteria set for SS most recently approved by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR). We also summarize the guidelines and important steps recommended by the relevant ACR and EULAR committees for the development and validation of criteria for the rheumatic diseases. Finally, we describe the development and validation of the 2016 ACR-EULAR classification criteria for SS as part of a large international collaborative effort.
Biomarkers in primary Sjögren’s syndrome
Authors: Berardicurti Onorina , Smith Charlotte G. , Giacomelli Roberto , Price Elizabeth J. , Barone Francesca
Published: May 2021

Primary Sjögren’s syndrome (pSS) is an autoimmune disease characterized by lymphocytic infiltrates in exocrine glands and a heterogeneous presentation with a wide spectrum of clinical and serological manifestations. Early diagnosis, treatment choice, and prognostic stratification are all unmet needs in pSS. Biomarkers - objective items measurable or quantifiable in an accurate, reproducible and easy manner - could improve patient identification and treatment. In this review, we summarize the state of the art of ‘traditional’ recognized clinical, serological, and histologic biomarkers for pSS. We also discuss some of the ‘novel’ biomarkers, presenting the evidence in favour of their use in disease assessment. Finally, we highlight biomarkers’ relevance and limitations in current clinical practice and future perspectives.
Autoantibodies and autoantigens in Sjögren’s syndrome
Authors: Ambrosi Aurélie , Björk Albin , Wahren-Herlenius Marie
Published: May 2021

Autoantibodies are a key serological feature of Sjögren’s syndrome (SS). The presence of Ro/Sjögren’s syndrome-related antigen A (SSA) autoantibodies is one of the items with the highest weight in the 2016 joint ACR/EULAR SS classification criteria. Autoantibodies appear before overt clinical disease manifestations, and patient autoantibody profiles seem stable over time, even after B-cell depleting therapy. Expression of Ro/SSA and La/Sjögren’s syndrome-related antigen B (SSB), the major autoantigens in SS, in the target organs (exocrine glands), local autoantibody production, and the capacity of autoantigen-containing immune complexes to induce interferon production all point to a central involvement of autoantibodies in disease pathogenesis. Here, we review the main autoantibody specificities reported in SS, their clinical associations, the current understanding of how autoantibody production is initiated and maintained, and how autoantibodies may exert pathogenic effects. We provide a comprehensive overview of the nature and biological function of the three main autoantigens, Ro52, Ro60, and La (Ro/SSA and La/SSB) found in SS.
Dental-related disease
Authors: Fuller Jennifer , Shahdad Shakeel
Published: May 2021

Saliva contains a complex mixture of organic and inorganic molecules, enabling it to play many roles within the oral cavity, including lubrication, protection of the mucosa and maintenance of dental hard tissues, antibacterial activity, digestion, and taste perception. Hyposalivation in Sjögren’s syndrome (SS) patients leads to dry mouth, rampant dental caries, increased risk of oral infections, difficulty in speaking and swallowing food, and dysgeusia (altered taste perception). SS patients have higher rates of decayed, missing, and filled teeth and increased rates of edentulousness. Rehabilitation with dental prosthesis for these patients can be problematic, as this can increase the risk of plaque stagnation and further dental disease, leading to failure of treatment. Saliva is pivotal in retention of certain types of dental prosthesis and protection of mucosal damage. SS patients may benefit from implant-retained prosthesis. In this chapter dental disease in SS patients and appropriate management are discussed.
Gynaecologic and obstetric aspects in Sjögren’s syndrome
Authors: Priori Roberta , Minniti Antonina , Colafrancesco Serena
Published: May 2021

Although primary Sjögren’s syndrome (SS) mainly affects women, its gynaecological, obstetric, and sexual aspects have been largely overlooked. Data regarding the impact of the disease on pregnancy and vice versa are scant. Primary SS can occur in all age groups but usually starts after the fifth decade, often beyond the childbearing age; however, at least in the Western world, the age of first pregnancy is increasingly delayed, so pregnancy in SS is being encountered more frequently. Vaginal dryness represents the main cause of dyspareunia, which seriously affects individuals’ quality of life, but data regarding this aspect of the disease are scarce. In this chapter we review the main gynaecologic complications of SS, focusing on their prevalence and impact on daily life. In addition we review pregnancy outcome in primary SS including obstetric complications, pregnancy outcome, and manifestations of neonatal lupus.
Sjögren’s syndrome–associated lymphoma
Authors: Rassam Saad M. B.
Published: May 2021

Non-Hodgkin’s lymphoma (NHL), predominantly of the B-cell type, affects a significant proportion of patients with Sjögren’s syndrome (SS). SS carries the highest NHL risk among all systemic autoimmune diseases. Although marginal zone lymphomas (MZL) of the mucosa-associated lymphoid tissue (MALT) type of the salivary glands is the commonest histological type, other indolent and more aggressive subtypes can occur. NHL and its treatment adds to the morbidity and mortality in SS. Early detection and management can improve survival and quality of life in SS patients. This chapter will review some basics of the immune system; expand on NHL incidence and predictive risk factors, pathogenesis, and subtypes of NHL seen in SS; clinical presentation; diagnosis; management; treatment modalities; and complications of therapy. Recent advances in therapy using our expanding knowledge of the molecular pathways seen in NHL will be discussed, as well as novel molecules and innovative immunotherapy.
Sjögren’s syndrome overlaps
Authors: Waller Arabella , Sutcliffe Nurhan
Published: May 2021

Up to one-third of those with Sjögren’s syndrome (SS) have at least one additional autoimmune disease, and 8% have more than two such conditions. The most commonly seen additional autoimmune disease is autoimmune thyroid disease. Systemic lupus erythematosus represents the most closely related systemic autoimmune disease to SS, with significant overlap in clinical and immunological expression. The clinical phenotype of these ‘overlap’ patients often differs considerably from those with ‘pure’ disease. This chapter discusses the epidemiological, clinical, and laboratory features of the commonly seen overlap syndromes with SS, including that with systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, autoimmune liver and thyroid disease, and coeliac disease.
Experimental therapies in primary Sjögren’s syndrome
Authors: Fisher Benjamin
Published: May 2021

Recently there has been a large increase in the number of clinical trials assessing systemic immunomodulatory drugs in Sjögren’s syndrome. This has occurred for a number of reasons including a growing appreciation of the direct and indirect costs and quality-of-life impairment associated with Sjögren’s syndrome, as well as the development of validated outcome measures. Early studies with antitumour necrosis factor demonstrated that a greater understanding of the pathogenic role of a putative target is required since some typically proinflammatory cytokines may also have a negative regulatory role in a context-dependent fashion. Despite the disappointing results of two phase 3 studies of rituximab, novel approaches to B-cell depletion are currently being studied, alongside trials targeting IL-6, intracellular signalling, and co-stimulation pathways.
Breathlessness
Authors: Robinson Chapman
Published: May 2021

Clinical assessment and causes, specific situations. Dyspnoea refers to the abnormal and uncomfortable awareness of breathing. Its physiological mechanisms are poorly understood; possible afferent sources for the sensation include receptors in respiratory muscles, juxta-capillary (J) receptors (sense interstitial fluid), and chemoreceptors (sensing iCO2 and dO2).
Chest pain
Authors: Robinson Chapman
Published: May 2021

The majority of patients with chest pain referred for a respiratory opinion have either acute pleuritic pain or persistent, well-localized pain. Within the respiratory system, pain may arise from the parietal pleura, major airways, chest wall, diaphragm, and mediastinum; the lung parenchyma and visceral pleura are insensitive to pain. Processes involving the upper parietal pleura cause a pain localized to that part of the chest. The lower parietal pleura and outer region of the diaphragmatic pleura are innervated by the lower six intercostal nerves, and pain here may be referred to the abdomen. The central region of the diaphragm is supplied by the phrenic nerve, and pain may be referred to the ipsilateral shoulder tip. Tracheobronchitis tends to be associated with retrosternal pain.
Pleural effusion
Authors: Robinson Chapman
Published: May 2021

The most common causes of pleural effusion include cardiac failure, pneumonia, malignancy, and pulmonary embolism (PE). The priority is to make a diagnosis and relieve symptoms while keeping the number of invasive procedures to a minimum. The majority of patients do not require a chest drain and can be managed as outpatients. Procedures, such as therapeutic thoracentesis, may be performed readily on a day unit.
Acute respiratory distress syndrome
Authors: Robinson Chapman
Published: May 2021

Acute respiratory distress syndrome (ARDS) is not a single entity but represents the severe end of a spectrum of acute lung injury due to many different insults. Manifests as acute and persistent lung inflammation with increased vascular permeability. Most commonly seen on the ITU where about 10–20% of such patients will have ARDS depending on the definition.
Pulmonary hypertension (PHT)
Authors: Robinson Chapman
Published: May 2021

PHT is a haemodynamic and pathophysiological state that can be found in multiple clinical conditions. Each group has differing characteristic pathological features, but vasoconstriction, remodelling of the pulmonary vessel wall, medial hypertrophy of distal pulmonary arteries ± fibrotic change, and thrombosis lead to raised pulmonary vascular resistance and ultimately right heart failure. The symptoms of PHT are primarily due to RV dysfunction. The symptoms are non-specific, often leading to a delay in diagnosis from first symptoms, which include exertional breathlessness, due to the inability to increase cardiac output with exercise. WHO functional assessment classification is used to quantify the condition. Other symptoms include chest pain (right heart angina), fatigue and weakness, syncope or pre-syncope, due to a fall in systemic BP on exercise, palpitations, peripheral oedema and other signs of right-sided fluid overload.
Respiratory infection—bacterial
Authors: Chapman Stephen J. , Robinson Grace V. , Shrimanker Rahul , Turnbull Chris D. , Wrightson John M.
Published: May 2021

Includes: Community-acquired pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, aspiration pneumonia, lung abscess, nocardiosis, actinomycosis, anthrax, tularaemia, melioidosis, leptospirosis.
Sickle cell disease and the lung
Authors: Chapman Stephen J. , Robinson Grace V. , Shrimanker Rahul , Turnbull Chris D. , Wrightson John M.
Published: May 2021

Sickle cell disease is an autosomal recessive condition resulting in a substitution of a valine for glycine in the β‎-globin subunit of Hb, forming HbS. HbS is less soluble under reduced O2 tensions and leads to deformation of red blood cells (sickling) when deoxygenated (e.g. in atelectatic lung), resulting in chronic haemolysis and vascular occlusion with tissue infarction in individuals homozygous for the β‎-globin gene mutation (sickle cell anaemia/disease).