bluuebunny/crossref_metadata_2025 huggingface dataset:
Research on Solution of Ship Low Sulphur Fuel based on IMO Sulphur Limitation Regulation
Authors: Wang Zihui , Zhang Honggang , Gan Xuezhen
Published: November 2019

In recent years, the density of both domestic and international routes is generally at a high level. Intensive ship navigation frequency and ship number operations have brought many sulfur oxides, nitrogen oxides and other particulate matter to the port, resulting in increasingly serious port pollution, which has become one of the main sources of air pollution, and ship exhaust emissions are causing environmental pollution in coastal areas. As well as the main sources of port pollution, the pollution problem should not be underestimated. “Air pollution from maritime transport causes about 1450 to 37500 premature deaths each year and brings short-term and long-term changes to the climate system,” the IMO reiterated in response to the seriousness of the problem that all ship fuels should meet sulfur content below 0.5% starting from January 1,2020[1]. In view of this regulation, this paper systematically analyses three low-sulfur fuel solutions at present, and summarizes the optimal solution from the aspects of economy, feasibility and sustainability, and the comparative study of three different types of the optimal solution is carried out, that is, to refine the optimal solution again and put forward the applicable technology in the optimal solution.
Return Period of Low Tide Level in the Yangtze Estuary based on Nonstationarity Analysis
Authors: Zhou Yicen , Li Qi , Liu Shuguang , Lou Sha
Published: November 2019

Due to the influence of climate change and human activities, stationarity of hydrologic time series is being challenged. The Yangtze Estuary is a region with highly developed hydraulic structures and shipping. Stationarity analysis of water level in the Yangtze Estuary is of great significance. In this study, the return period of low tide level in the Yangtze Estuary is estimated with nonstationarity considered. Conventional frequency analysis and the time-varying moment method are used to analyze the annual minimum tide level (AMTL) records of Wusongkou Station and Baozhen Station on the basis of temporal change analysis. Abrupt changes are detected at 1996 and 1990 for Wusongkou Station and Baozhen Station separately. The GEV distribution with linear time-varying parameter fits best for Wusongkou Station and Baozhen Station. The AMTL series of both stations reveal a slight increasing trend. The 100-year low tide level of Wusongkou Station is approximately 0.261 meters, which is about -0.041 meters for Baozhen Station. The corresponding return period is 150 years and 119 years respectively, which indicates the existing channel standard more secure and the recalculation of design water level necessary in the Yangtze Estuary.
Study on Water Related Music Works—A Case Study in Gaomei Wetland
Authors: Chen Chen , Huang Guangwei
Published: November 2019

Wetland environment plays an essential role in integrated watershed management and has been studied from different perspectives ranging from ecology to tourism. However, there is still little research on the relationship between wetland environmental characteristics and music works. On the belief that music works can be part of wetland environment conservation, the present research explored the possibility to characterize wetland environments with music works. It was focus on the perception of local residents towards to a wetland in terms of music works. It was a case study in Gaomei Wetland, Taiwan, which is a coastal wetland. There are 3 hypotheses in this work: (1) there is a significant difference in the music types selected for the image of the wetland by the locals in different ages and living with different distances from the wetland; (2) there a significant difference in the music speed and rhythm selected by the locals in different ages and living with different distances from the wetland; (3) there is a preference on the music segments by the locals who are older and living closer to the wetland. Through survey conducted on-site, some interesting findings were obtained and presented in this paper.
Reviewing papers as you would like your papers to be reviewed
Authors: Baum Buzz
Published: November 2019

Peer review can seem like a barrier we have to scale in order to publish. In this Perspective, we ask what would happen if, instead, the focus of peer review was to help everyone in the field improve the quality of their papers.
Leaf trichomes in Metrosideros polymorpha can contribute to avoiding extra water stress by impeding gall formation
Authors: Amada Gaku , Kobayashi Keito , Izuno Ayako , Mukai Mana , Ostertag Rebecca , Kitayama Kanehiro , Onoda Yusuke
Published: November 2019

Background and Aims

Plants inhabiting arid environments tend to have leaf trichomes, but their adaptive significance remains unclear. Leaf trichomes are known to play a role in plant defence against herbivores, including gall makers. Because gall formation can increase water loss partly through increased surface area, we tested the novel hypothesis that leaf trichomes could contribute to avoiding extra water stress by impeding gall formation, which would have adaptive advantages in arid environments.

Methods

We focused on Metrosideros polymorpha, an endemic tree species in the Hawaiian Islands, whose leaves often suffer from galls formed by specialist insects, Hawaiian psyllids (Pariaconus spp.). There is large variation in the amount of leaf trichomes (0–40 % of leaf mass) in M. polymorpha. Three gall types are found on the island of Hawaii: the largest is the ‘cone’ type, followed by ‘flat’ and ‘pit’ types. We conducted laboratory experiments to quantify the extent to which gall formation is associated with leaf water relations. We also conducted a field census of 1779 individuals from 48 populations across the entire range of habitats of M. polymorpha on the island of Hawaii to evaluate associations between gall formation (presence and abundance) and the amount of leaf trichomes.

Key Results

Our laboratory experiment showed that leaf minimum conductance was significantly higher in leaves with a greater number of cone- or flat-type galls but not pit-type galls. Our field census suggested that the amount of trichomes was negatively associated with probabilities of the presence of cone- or flat-type galls but not pit-type galls, irrespective of environmental factors.

Conclusion

Our results suggest that leaf trichomes in M. polymorpha can contribute to the avoidance of extra water stress through interactions with some gall-making species, and potentially increase the fitness of plants under arid conditions.
Fiscal Policy with Limited-Time Commitment
Authors: Clymo Alex , Lanteri Andrea
Published: November 2019

We propose a theory of optimal fiscal policy with ‘Limited-Time Commitment’. In our framework, successive governments have commitment only over finite, overlapping horizons. We first show that key results in the ‘Full Commitment’ literature can often be sustained with a single period of commitment. We then solve a calibrated model in which ‘Limited-Time Commitment’ fails to implement the ‘Full Commitment’ policy, and find that one year (three years) of commitment recovers one-third (two-thirds) of the welfare losses relative to ‘No Commitment’. Finally, we investigate the trade-off between commitment and flexibility in response to shocks.
Comparative efficacy and safety of antithrombotic therapy for transcatheter aortic valve replacement: a systematic review and network meta-analysis
Authors: Zhu Yuexin , Zou Ziyuan , Huang Yusi , Zhang Lei , Chen Huiting , Li Yang , Liu Cheng , Li Xinrui , Xu Dingli , Zeng Qingchun
Published: November 2019

OBJECTIVES

We sought to determine the optimal antithrombotic therapy after transcatheter aortic valve replacement.

METHODS

Related scientific databases were searched until December 2018. We conducted a pairwise and a network meta-analysis within a frequentist framework, measuring 30-day bleeding, stroke and all-cause mortality. The surface under the cumulative ranking (SUCRA) curve was estimated to rank the therapies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was performed. The protocol was registered with PROSPERO (CRD42018111163).

RESULTS

Eight studies comprising 2173 patients were analysed. The risk of 30-day bleeding was higher for dual antiplatelet therapy (DAPT) than single antiplatelet therapy (SAPT) [odds ratio (OR) 1.90 (1.10–3.28); P = 0.02], whereas there was no difference in the risk of 30-day stroke [OR 1.27 (0.38–4.20); P = 0.69] and mortality [OR 1.46 (0.67–3.22); P = 0.34] between DAPT and SAPT. In the network meta-analysis, DAPT + oral anticoagulant (OAC) increased the risk of 30-day bleeding compared with SAPT [OR 6.21 (1.74–22.17); P = 0.005], DAPT [OR 3.27 (1.04–10.32); P = 0.043], SAPT + OAC [OR 4.87 (2.51–9.45); P < 0.001] and OAC [OR 14.4 (1.3–154.7); P = 0.028]. Additionally, patients receiving DAPT + OAC had the highest risks for 30-day bleeding (SUCRA 1.0%). OAC seemed to be superior to SAPT and DAPT in terms of 30-day bleeding (SUCRA OAC: 86.3%, SAPT: 72.3%, DAPT: 32.3%) and stroke (SUCRA 54.2%, 47.4%, 40.5%), but not mortality (SUCRA 69.6%, 74.1%, 43.4%).

CONCLUSIONS

There is a trend towards less bleeding with the application of SAPT, but no mortality benefit with the application of DAPT is shown. The comparison of SAPT, DAPT and OAC shows that OAC may improve the balance between stroke and bleeding, which can reduce the risk of mortality. In addition, the application of DAPT + OAC was ranked the worst amongst all treatment modalities and should be avoided due to an increased risk of bleeding.

Clinical trial registration number

PROSPERO (International Prospective Register of Systematic Reviews, CRD42018111163).
Complicated chylous pericardial and thoracic effusion as the first clinical manifestation of thoracic lymphatic malformation
Authors: Wiesner Sigrid , Uller Wibke , Hofmann Hans-Stefan , Ried Michael
Published: November 2019

Lymphatic malformations are benign focal proliferations of lymphatic vessels with a congenital origin. We present a case of an 18-year-old patient with post-traumatic chylopericardium and recurrent left-sided chylothorax, who was unresponsive to a variety of therapeutic measures until he was diagnosed with a complicated thoracic lymphatic malformation.
Topology of the Nodal Set of Random Equivariant Spherical Harmonics on 𝕊3
Authors: Jung Junehyuk , Zelditch Steve
Published: November 2019

We show that real and imaginary parts of equivariant spherical harmonics on ${{\mathbb{S}}}^3$ have almost surely a single nodal component. Moreover, if the degree of the spherical harmonic is $N$ and the equivariance degree is $m$, then the expected genus is proportional to $m \left (\frac{N^2 - m^2}{2} + N\right ) $. Hence, if $\frac{m}{N}= c $ for fixed $0 < c < 1$, then the genus has order $N^3$.
Exclusionary conduct in data-driven markets: limitations of data sharing remedy
Authors: Kathuria Vikas , Globocnik Jure
Published: November 2019

The natural consequence of finding an infringement of Article 102 TFEU is to offset the harm to consumer welfare by restoring competition through effective remedies. As big data constitutes the most vital resource in data-driven markets, a dominant undertaking can exclude its rivals from accessing user data and thus deprive them of scale in markets that are characterized by network effects. Indeed, the European Commission found Google guilty of excluding its rivals in the Android licencing case by adopting this strategy. The Commission, however, did not impose any data sharing remedy. This article analyses the viability of mandatory data sharing as a remedy to restore competition in the affected market. It approaches this research question from both theoretical and practical standpoints. It analyses the viability of a mandatory data sharing remedy from a legal, economic, and technological perspective. A separate section makes an assessment of such a remedy within the framework of the GDPR. Based on this investigation, this article concludes that mandatory data sharing is not the optimal solution to remedy loss to consumer welfare.
Systematic review of pre-operative planning modalities for correction of acetabular dysplasia
Authors: Acuña Alexander J , Samuel Linsen T , Mahmood Bilal , Kamath Atul F
Published: November 2019

Acetabular dysplasia, related to developmental dysplasia of the hip, causes the abnormal distribution of hip joint forces. Surgical correction of acetabular dysplasia involves repositioning the acetabulum to achieve improved coverage of the femoral head. However, ideal placement of the acetabular fragment is challenging, and has led to an increased interest in pre-operative planning modalities. In this study, we used the PubMed and EBSCO host databases to systematically review all the modalities for pre-operative planning of acetabular dysplasia proposed in the current literature. We included all case-series, English, full-text manuscripts pertaining to pre-operative planning for congenital acetabular dysplasia. Exclusion criteria included: total hip arthroplasty (THA) planning, patient population mean age >35, and double/single case studies. A total of 12 manuscripts met our criteria for a total of 186 hips. Pre-operative planning modalities described were: Amira (Thermo Fischer Scientific; Waltham, MA, USA) 12.9%, OrthoMap (Stryker Orthopaedics; Mahwah, NJ, USA) 36.5%, Amira + Biomechanical Guidance System 5.9%, Mills et al. method 16.1%, Klaue et al. method 16.1%, Armand et al. method 6.5%, Tsumura et al. method 3.8% and Morrita et al. method 2.2%. As a whole, there was a notable lack of prospective studies demonstrating these modalities’ efficacy, with small sample sizes and lack of commercial availability diminishing their applicability. Future studies are needed to comprehensively compare computer-assisted planning with traditional radiographic assessment of ideal osteotomy orientation.
Early separation of omphalopagus conjoined twins: a case report from Syria
Authors: Omran Ammar , Nassif Mhmmad , Salhab Nabila , Abdo Aras , Almahmod Alkhalil Mohammad Ahmad , Taishori Norma , Dayoub Adnan
Published: November 2019

Omphalopagus twins are one of many forms of conjoined twins sharing part of the gastrointestinal system and abdominal wall. This type of twins has the best chance of survival if successfully separated. Surgical approaches in these cases are generally preferably elective, but sometimes separation may be urgently needed due to life-threatening complications, such as hemodynamic instability, death of either twin, necrotizing enterocolitis, among many others. We report a case of successfully separated omphalopagus twins at day two of life.
Why Do People Get Better With Exposure Therapy?
Authors: Becker Carolyn Black , Farrell Nicholas R. , Waller Glenn
Published: November 2019

This chapter outlines a theoretically based rationale for using exposure consistently in the treatment of individuals with eating disorders. Due to the substantial overlap between eating disorders and anxiety disorders (both in symptom content and in comorbidity between the conditions), exposure therapy is a sound choice for therapeutic intervention. Indeed, the most evidence-based treatments for eating disorders contain a number of exposure-based strategies that drive much of the therapeutic benefit. The chapter discusses habituation, systematic desensitization, and inhibitory learning and differentiates exposure therapy from systematic desensitization. Using a case study to consider how exposure therapists can help patients learn to tolerate their anxiety by leaning into it rather than engaging in safety behaviors, this chapter lays the foundation for the application of exposure therapy to patients with eating disorders.
Why Exposure for Eating Disorders?
Authors: Becker Carolyn Black , Farrell Nicholas R. , Waller Glenn
Published: November 2019

This chapter provides the rationale for using exposure therapy for eating disorders. Exposure is a very intuitive, albeit anxiety-provoking, intervention. Over the years, a number of models have been proposed to explain how exposure works. Although no one knows for sure exactly how exposure works, the recent inhibitory learning model offers a number of concrete, and logical, strategies for strengthening safety learning. Importantly, many of these strategies (e.g., varying the context of exposure and anxiety tolerance) have been clinically used by experienced exposure therapists for a long time. As such, they are backed by both the science (and logic) of the inhibitory learning model and clinical wisdom.
Planning Exposure Therapy With Your Patients
Authors: Becker Carolyn Black , Farrell Nicholas R. , Waller Glenn
Published: November 2019

Clinicians should strive to change their patients’ responses to anxiety via exposure therapy so that key symptoms are reduced. When planning exposure therapy, clinicians should (a) consider their patients’ everyday lives and how anxiety is generating problems in eating, body image, etc.; (b) aim to teach patients, via exposure activities, that their fears are likely unfounded and that they have the ability to endure distress, even at higher levels; (c) help patients discover that if fears do come true (e.g., progressive weight gain in malnourished patients), such outcomes are more tolerable and controllable than expected; (d) ensure that the treatment setting is diverse and that neither the environment nor the clinician’s own concerns limit the diversity of change needed to maximize learning; (e) make the mixture of settings, tasks, and intensity relatively unpredictable; and (f) use homework as a very active part of therapy, stressing the patient’s need to undertake exposure in different ways.
Embarking on Exposure
Authors: Becker Carolyn Black , Farrell Nicholas R. , Waller Glenn
Published: November 2019

The aim of this chapter is to help clinicians think through some of the nuts and bolts of doing exposure. Exposure clinicians have many choices to make throughout the therapy process. This chapter considers questions related to the use of hierarchies in exposure, the speed at which patients progress through feared stimuli, the titration of anxiety, and the concept of exposure as a lifestyle. The chapter also considers the ways in which exposure interacts with other strategies used in evidence-based treatments of eating disorders and encourages clinicians to realize that forced contact with feared stimuli may not create optimal conditions for safety learning.
Dealing With Clinicians’ Fears About Using Exposure
Authors: Becker Carolyn Black , Farrell Nicholas R. , Waller Glenn
Published: November 2019

In addition to the institutional barriers to exposure that are often present in higher levels of care for eating disorders, there are also clinician-level barriers that need to be addressed across clinical settings. In particular, there is a well-documented tendency for clinicians to endorse concerns about the safety and tolerability of exposure therapy, and these concerns are unfortunately predictive of suboptimal delivery of the treatment. This chapter provides guidance for clinicians in effectively navigating their concerns, with remedial strategies pulled from empirical research on reducing clinician concerns about exposure-based therapy. Clinical supervisors are also encouraged to be mindful of the potential for their own concerns about exposure to negatively influence their supervisory style.
Delivering Psychological Services to Refugees Resettled in the United States
Authors: Nilsson Johanna E. , Stratmann Sally , Molitoris Aurora , Beaumont Marcella A. , Horine Jessica
Published: November 2019

Approximately 25 million refugees have fled their homelands internationally, and about 3 million have been resettled in the United States. The mental health needs of a population that has fled oppression, violence, and instability are diverse. This chapter seeks to provide a holistic overview of these needs. The introduction covers what defines the status of a refugee, current resettlement policies, and pre- and post-migration experiences and concerns among refugees, including barriers to basic services. Effective mental health treatment options and areas of competence for mental health professionals working with these individuals are discussed, along with future considerations for best meeting the mental health needs of refugees.
Bringing Psychotherapy to Immigrants
Authors: Mirsalimi Hamid
Published: November 2019

Immigrants have unique mental health challenges and treatment needs. This chapter attempts to shed light on the challenges, barriers, and potential solutions to providing psychotherapy to immigrant populations. Topics covered are language barriers, financial barriers, insurance barriers, intimate partner violence issues, cultural variables regarding disclosure issues, fear of involvement with immigration authorities, trust issues regarding political matters, limited knowledge about psychotherapy, stigma about psychotherapy, lack of knowledge about provider types, differences in symptom expression, lack of cultural sensitivity on the part of the psychotherapist, lack of adequate literature and research, and limitations posed by state licensing boards. Additionally, effective strategies and empirically supported treatments for providing mental health services to immigrants are reviewed. Future steps are recommended and reviewed, for individual clinicians and mental health professions, to reduce barriers and ensure that immigrants receive the mental health services they need and deserve.
Psychotherapy with the Underserved Older Adult Population
Authors: Whitbourne Susan Krauss , Martins Bruna
Published: November 2019

The older adult population is steadily growing in number, and by 2050, over 20% of the U.S. population is expected to be over the age of 65. Ageism may affect both patients and providers and may limit access to mental health services. This chapter reviews the prevalence of major mental health conditions in older adults, empirically supported treatments for these conditions, and how best to tailor interventions for use with older patients. The authors suggest that psychoeducational training, increasing availability of specialty training programs for providers, intergenerational programs to promote empathy from as early as primary school to hospital staff training, and shifts in policy may boost interactions with older persons in health care settings and decrease avoidance of assessment and treatment for mental health conditions.
Psychotherapy for Developmental Disabilities
Authors: Campbell Jonathan M. , Scarpa Angela
Published: November 2019

Psychological disorders commonly co-occur in individuals with developmental disabilities, yet mental health disorders are under-identified and mental health services are underutilized for this group. Within the larger population of individuals with developmental disabilities, this chapter focuses on individuals with intellectual disability (ID) and autism spectrum disorder (ASD). The authors review defining characteristics of ID and ASD and then describe common psychological disorders for each group, including anxiety, depression, and behavioral dysregulation disorders. A selective review is provided of evidence-based interventions, such as cognitive behavioral therapy, that address mental health concerns for both groups. Barriers to access and utilization of services are identified and potential solutions are offered to these barriers. The authors identify the important role of stigmatizing attitudes toward individuals with developmental disabilities as contributing to poor experiences with mental health providers. The intersectionality of developmental disability and mental illness is highlighted as contributing to barriers to access to mental health treatment.
Pain Management
Authors: Waldman Elisha , Friedrichsdorf Stefan J.
Published: November 2019

Effective pain management plays a frequent and central role in palliative care, regardless of setting. This chapter addresses assessment of pain in both children and adults, as well as approaches to thoughtful and ongoing management of pain, including basic analgesics, opioid analgesics, adjuvant medications, and integrative therapies.
Care of the Dying Patient
Authors: Doherty Megan , Hauser Joshua
Published: November 2019

This chapter addresses the management of children and adults who are in the last hours or days of life, by providing details on the management of pain and other physical symptoms as well as suggestions for how to ensure psychosocial and spiritual support for the patient and their family. Providing palliative care during this time will not hasten death but is essential to ensure comfort and dignity for the patient. In the last hours and days of life, pain and other symptoms can be challenging to control. They may require frequent reassessment and rapidly escalating doses of medications.
Palliative Care Emergencies in Humanitarian Crises
Authors: Williscroft David M.
Published: November 2019

Addressing medical emergencies that may arise during a humanitarian crisis is usually the greatest priority. What becomes more difficult is when patients with a palliative diagnosis or trajectory present with urgent needs and how to prioritize this unique population. Discomfort and lack of training in the area of palliative care may contribute to a lack of timely care for these patients. In this chapter, medical emergencies pertaining to patients with these discrete palliative issues are discussed. Bleeding, seizures, dyspnea, superior vena cava syndrome, and malignant spinal cord compression are reviewed, with a focus on patients who have a life-limiting diagnosis.
Essential Medicines
Authors: Habashy Catherine , Comolli Sarah L. , Baker Justin N.
Published: November 2019

The concept of essential medicines (EM) was developed by the World Health Organization (WHO) to promote equitable access to safe, effective, and low-cost medicines. Access to EM is considered part of the right to health and is critical to the provision of palliative care. Access to EM is often disrupted in the setting of humanitarian crises, leading to further physical and psychological suffering. The recently published WHO document, Integrating Palliative Care and Symptom Relief into the Response to Humanitarian Emergencies and Crises, provides guidance on the prioritization and utilization of EM as part of an essential package of care. This chapter draws on the recommendations of the WHO as well as those of other expert committees and multilateral organizations. It provides an overview of commonly used medicines in palliative care and is applicable to the delivery of palliative care in humanitarian crises. It also provides general dosage guidelines.
A Time for All Things
Authors: Miller Craig A.
Published: November 2019

Born in 1908 in Lake Charles, Louisiana, Michael DeBakey is the eldest of six children of Lebanese immigrants. He enjoys conspicuous academic success as a youth and then medical school, displaying intelligence and originality. DeBakey comes under the tutelage of surgery professor Alton Ochsner. He also spends a year training in Europe. Debakey and Ochsner publish important research papers. In World War Two DeBakey is assigned to the Office of the Army Surgeon General, where he excels in administration, rising to the rank of Colonel. He serves beyond the war’s end, contributing to the foundation of postwar federal medical research and veterans’ care. In 1948 he becomes Chair of Surgery at Baylor University medical school in Houston. The department focuses clinical and research efforts on vascular diseases, and leads a revolution in the surgical approach to these problems. DeBakey’s own family suffers from his devotion to his work. In the 1960s DeBakey’s fame grows. His lab pursues an artificial heart. Colleague Denton Cooley implants the first artificial heart with a device taken from DeBakey’s lab, and a forty-year rift between these two giants ensues. DeBakey becomes President, then Chancellor of the Baylor medical school. After the death of his first wife, he remarries in the 1970s. His fame and influence are worldwide. DeBakey operates on the Shah of Iran, and is consulted on the heart surgery of Boris Yeltsin. He is awarded the Congressional Gold Medal in 2008, and dies shortly afterward at age 99, a universally-admired legend.
Tulane University: 1926–1935
Authors: Miller Craig A.
Published: November 2019

Michael moves to New Orleans, has eye-opening experiences in the French Quarter, and his first-semester grades suffer. Influential professors shape his love of learning and research. He encounters Alton Ochsner, Chief of Tulane Department of Surgery and a highly influential future mentor. He has dramatic and defining clinical experiences at New Orleans’ Mercy and Charity Hospitals. While still a medical student, Michael invents a new transfusion syringe. The legendary surgeon and polymath Rudolph Matas befriends the eager young Michael, becoming another revered role model. DeBakey graduates from medical school at the top of his class and decides to become a surgeon, training under Ochsner.
Houston: 1948–1951
Authors: Miller Craig A.
Published: November 2019

DeBakey decides to move from New Orleans and take up the reins of the new Department of Surgery at Baylor School of Medicine in 1948. The medical school is understaffed, and the local surgeons are unqualified. There is no University Hospital. After soul-searching, DeBakey opts to remain in Houston. Fortune turns, and with his connections in Washington, D.C., DeBakey obtains the VA Hospital for Baylor as a teaching institution. He befriends local philanthropist Ben Taub, who delivers the Charity Hospital to DeBakey’s teaching service. Grants from the federal government and other local philanthropists help to fund the Surgery Department’s research.
Before Psychiatry
Authors: Horwitz Allan V.
Published: November 2019

This chapter explores the three major conceptions of mental illness—supernatural, biological, and psychological—that developed among the ancient Greeks and that formed the major templates for madness that have continually resurfaced in Western thought through the present. During the long period between the fall of the Roman Empire and the European Renaissance and Reformation, physicians became subordinate to theologians and medical thought itself languished. Nevertheless, the Hippocratic psychiatric corpus remained virtually undisturbed. The chapter then considers views of madness that developed in the 16th century in the works of Robert Burton, Richard Napier, and William Shakespeare. Finally, it turns to how mental illness became increasingly likely to be viewed within medical, as opposed to spiritual or moral, frameworks over the course of the 17th and 18th centuries. Within medicine, the influence of humoral pathology, which had dominated medical thinking since ancient times, gradually waned as mechanistic notions grounded in nerves, fibers, and organs arose.
Freud’s Transformation of Normality
Authors: Horwitz Allan V.
Published: November 2019

From the beginning of the 20th century onward, Freud’s writings concentrated on elucidating the common processes—repression, the unconscious, childhood sexuality, and the libido—that gave rise to both normal and neurotic phenomena. World War I then turned his attention to external traumas and the role of the ego in mediating between the conflicting demands of the id on one side and the superego and civilization on the other. Freud’s lasting contribution to thinking about mental illness was to successfully expand the range of disorders well beyond conditions thought to have an organic basis or the psychoses. Neuroses resulted from interactions between individuals and their human environments: no physical defect needed to be present. Psychiatrists came to have legitimate claims to treat distressing states that had previously been viewed as purely psychogenic in nature and therefore outside of the medical or neurological realm. Moreover, his blurring of the boundaries between the neuroses and normality created a zone of ambiguity that mental health professionals came to exploit. They came to treat a vast expanse of common occurrences including interpersonal conflicts, the psychic results of traumas, and everyday problems of living.
Diagnostic Psychiatry
Authors: Horwitz Allan V.
Published: November 2019

Psychiatry faced a major predicament as it entered the 1970s: it lacked the disease conditions that would provide the field with medical legitimacy. The publication of the DSM-III by the American Psychiatric Association in 1980 marked a thoroughgoing change in thinking about mental illness. In one stroke, psychiatry discarded one intellectual paradigm that had little concern with diagnosis and adopted an entirely new system of classification that imported a model from medicine where diagnosis is “the keystone of medical practice and clinical research.” The promulgators of the DSM-III overthrew the broad, vague, and often etiologically oriented concepts that were embodied in the DSM-I and DSM-II, reclaiming the diagnostic tradition that dominated 19th-century psychiatry. The fundamental principle of the new manual was to define distinct mental disorders through using observable clusters of symptoms without reference to their causes. The DSM-III created a powerful standardized system of diagnoses that reigned virtually unchallenged for the following three decades. It allowed psychiatry to reorganize itself from a discipline where diagnosis played a marginal role to one where it was the basis of the specialty. The DSM-III revolutionized conceptions of mental disorder through transforming conditions that had been thought to be distinctively psychosocial into ones that were disease-like states.
The Past and Future of Mental Illness
Authors: Horwitz Allan V.
Published: November 2019

The puzzles that mental illnesses present have perennially beguiled both professional and lay observers. Throughout history they have asked questions regarding what qualities of madness distinguish it from sanity, the extent to which mental and physical pathologies are similar or different, the kinds of factors that lead people to become mentally ill, and the sorts of treatments that might restore their sanity. Across time, knowledge about these issues does not show any steady growth or, arguably, much progress. The immense recent technological advances in brain science have not yet led to corresponding improvements in understandings of and treatments for mental illnesses. These perplexing phenomena remain almost as mysterious now as they were millennia ago.
Chronic Subdural Hematoma
Authors: Toop Nathaniel , McGahan Benjamin , Shah Varun , McGregor John
Published: November 2019

Chronic subdural hematomas are collections of blood in the subdural space. They can present variably in size and age. They can present as a single hemorrhage event or with evidence of repeated hemorrhages. They tend to be more common in an aging population. The associated trauma can be surprisingly minimal. The brain atrophy associated with old age allows for more room for subdural blood to pool prior to causing significant neurological dysfunction. They may occur spontaneously, and the symptoms relate to mass effect and irritation of the cortical surface. Treatment varies depending on presenting symptoms, size, chronicity, and degree of septations. Care should be taken in surgical cases to avoid disruption of the cortical surface, assure hemostasis prior to closure, and consider placement of a subdural drain. Growing evidence suggests there is a roll for conservative management in select presentations.
Diffuse Axonal Injury
Authors: Zeineddine Hussein A. , Lewis Cole T. , Kitagawa Ryan S.
Published: November 2019

Diffuse axonal injury (DAI) is a type of traumatic brain injury (TBI) that results from a blunt head injury. In this particular subtype, accelerating-decelerating motions cause white matter tract damage and preferentially impact regions including the corpus callosum and brainstem. The neurological compromise therefore relates to the severity of the axonal insult. The most common mechanism for DAI is high-speed motor vehicle accidents, and the clinical presentation is typically out of proportion to the CT findings. As a result, MRI is the modality of choice. Currently, there are limited therapeutic options, and management is identical to other forms of TBI including intracranial pressure and cerebral perfusion pressure management. As this disease is heterogeneous, survivors have a wide range of functional outcomes.
Blunt Intracranial Cerebrovascular Injury
Authors: Kafka Benjamin , Plitt Aaron R. , Rickert Kim
Published: November 2019

Intracranial cerebrovascular injury is more common in penetrating trauma than in blunt trauma, but it carries a high morbidity and mortality when left undiagnosed. The vessels are at highest risk of injury at transition points from a fixed segment to a mobile segment (e.g., along the skull base); therefore, patients presenting with skull base fractures should undergo an intracranial vascular imaging study. The gold standard imaging study is digital subtraction angiography (DSA) but can be supplanted with CT or MR angiography for expediency. Any patient with a traumatic head injury who develops a delayed neurological decline should undergo cerebrovascular imaging. Injuries to the cerebral vasculature are graded I–V. The modalities of treatment include endovascular therapy, open surgical intervention, or antiplatelet/anticoagulant therapy. The treatment strategy should be individualized to the patient and the location of the injury. Overall, patients presenting with skull base fractures should undergo cerebrovascular imaging, with treatment dependent on presentation; additionally, the patient should undergo surveillance imaging thereafter to assess for progression.
Evaluation and Management of Frontal Sinus Fractures
Authors: Peitz Geoffrey , Miller Mark A. , Hawryluk Gregory W. J. , Grandhi Ramesh
Published: November 2019

Frontal sinus fractures are usually associated with traumatic brain injury and nasoorbitoethmoidal fractures. Much of the available evidence is retrospective, and management algorithms vary. In general, nondisplaced fractures without nasofrontal outflow tract (NFOT) obstruction may be managed with clinical and radiographic follow-up whereas fracture displacement, NFOT obstruction, and persistent CSF leaks are indications for operative management. The bicoronal incision and bifrontal craniotomy allow for proper access to the frontal sinus. If there is NFOT obstruction, the sinus should be cranialized or possibly obliterated if only the anterior table is fractured. The NFOT and sinus are packed with bone chips, fat, or muscle and then sealed with a pericardial graft, fascial graft, or synthetic dural substitute. Inadequate cranialization or obliteration can result in mucocele or mucopyocele, intracranial extension of which can lead to brain abscess or meningitis. Complications can occur years after the initial injury so long-term follow-up is necessary.
Penetrating Brain Injuries
Authors: Hickman Zachary L. , Margetis Konstantinos
Published: November 2019

Penetrating brain injury (PBI) may result from missiles (high velocity) or non-missiles (low velocity), with the latter having a better prognosis and more frequently resulting in favorable patient outcomes. Certain risks, complications, and management principles are common across all types of PBI. These include the potential for the development of mass lesions, cerebral edema, and neurological deterioration, as well as a high risk of concomitant cerebrovascular injury, CSF leak, infection, and posttraumatic seizures. In most cases, urgent surgical treatment is warranted to mitigate these associated risks. This chapter will focus primarily on the assessment, diagnostic workup, decision making, and management of non-missile and low-velocity PBI.
The ENT examination
Authors: Corbridge Rogan , Steventon Nicholas
Published: November 2019

The chapter outlines the clinical examination techniques and skills used in assessing patients with ear, nose, and throat (ENT) problems. The basic and advanced equipment required in a clinic or ward setting is detailed. Examination of the ear, nose, throat, and neck is discussed, along with assessment of hearing through tuning fork testing and free field tests of hearing. Full otoneurological assessment of the vertiginous patient is outlined. Special tests of vestibular function are described, along with the use of endoscopes to evaluate the ear, nasal cavity, and larynx.
The oesophagus
Authors: Corbridge Rogan , Steventon Nicholas
Published: November 2019

This chapter describes the anatomy, function, and common conditions affecting the oesophagus. The symptoms of globus, feeling of something in the throat, and their relation to gastro-oesophageal reflux and laryngopharyngeal reflux are discussed. Neurological conditions, along with achalasia and pharyngeal pouch, are explored. The staging and treatment of oesophageal malignancies are outlined.
Practical procedures
Authors: Corbridge Rogan , Steventon Nicholas
Published: November 2019

This chapter provides detailed instructions for performing a wide variety of practical ear, nose, and throat (ENT) procedures. These procedures are commonly performed in the emergency department or on the ward. Each procedure has the indications for performing the procedure, a list of essential equipment required, and a step-by-step practical guide.
Clinical Assessment of Pain
Authors: Hogans Beth B.
Published: November 2019

Chapter 6 addresses the clinical assessment of patients with pain, including the pain-focused clinical interview (history of present illness), the patient’s illness narrative, boundary issues and precautions in examining patients with pain, and details of the basic pain-focused examination. Additionally, specific maneuvers for evaluation of common pain-associated conditions are described, including palpating for trigger points, palpation of the spine, straight leg raise testing, evaluations for radiculopathy, sacroiliac dysfunction, peripheral neuropathy, neuromas, and headache. The chapter applies the principles of patient-centered medicine, the structured clinical interview, the therapeutic alliance, and trauma-informed care to provide the health professions trainee with a useful introduction to the pain-focused clinical interview and examination.
Professionalism in Pain Care
Authors: Hogans Beth B.
Published: November 2019

Chapter 8 focuses on the recent enhancements to clinical processes that improve the patient–provider experience and increase successful long-term outcomes. Professionalism has at times been criticized as not being genuine, but clinical care is like an Olympic sport, it takes a lot of training to become effortless and natural. By actively incorporating essential components of the biopsychosocial model, patient-centered care, interprofessional collaboration, motivational interviewing, the stages of change model, healthcare ethics, and model strategies from clinical psychology, it is possible to engage in more successful and satisfying outcomes with patients. Because most chronic problems are not truly best served by a series of injections or surgeries, we need to increase knowledge of, motivation toward, and competence in the range of chronic condition management approaches that are evidence-based, safe, and effective in clinical practice.
Urgent Pain Problems
Authors: Hogans Beth B.
Published: November 2019

Chapter 15 addresses conditions that require prompt evaluation but are not generally in the group of conditions that are true emergencies. Included in this chapter are acute migraine, other severe nonemergent headaches, facial pain, severe low back pain, acute severe neuropathies such as shingles and diabetic amyotrophy, abdominal pain, and acutely painful muscle conditions requiring prompt attention, such as myositis and rhabdomyolysis. The differential diagnosis of headache with visual impairment is reviewed, as is the differential diagnosis of facial pain. Strategies for the evaluation, diagnosis, and treatment of atypical focal pains that can represent unusual presentations of common problems as well as uncommon conditions are discussed.
Extremes of Pain
Authors: Hogans Beth B.
Published: November 2019

Chapter 17 covers the range of extreme and unusual pain-associated conditions by highlighted selected conditions that illustrate the extent of severe pain and informative aberrations in pain signaling, including congenital insensitivity. Multiple forms of severe intractable pain are addressed, including trigeminal neuralgia, postherpetic neuralgia, phantom limb pain, complex regional pain syndrome, peripheral nerve vasculitis, fibromyalgia, Ehlers-Danlos syndrome, stiff-person syndrome, endometriosis, and erythromelalgia. The preponderance of these conditions are neuropathic in nature, and all require coordinated pharmacologic and nonpharmacologic treatment. Pharmacologic therapies may include neuromodulating agents, and nonpharmacologic approaches may include clinical psychology, psychologically informed physical therapy, daily moderate exercise, stress management, sleep optimization, and mind–body approaches. These extreme pain conditions range from fairly prevalent but poorly understood (e.g., fibromyalgia) to rare but associated with specific molecular processes, as in erythromelalgia.
Pain in Older Patients
Authors: Booker Staja Q. , Herr Keela A.
Published: November 2019

Chapter 19 discusses the complexities of pain assessment and treatment in older adults and provides best practice recommendations for comprehensive pain management. Pain in older patients is a common, yet significant quality-of-life issue necessitating accurate assessment and safe multimodal treatment. The assessment and treatment of older adults in pain pose distinct challenges and unique opportunities to provide proactive and patient-centered care for a high-risk population with complex health needs. Thus, it is important that providers are prepared to identify these challenges and implement an effective and safe pain management plan.
Opioid Misuse and Addiction Among Patients With Chronic Pain
Authors: Martel Marc O. , Jamison Robert N.
Published: November 2019

Chapter 20 provides an introduction to understanding the prevalence and risk factors as well as screening tools for assessing opioid misuse and addiction in patients with chronic pain. In the era of the opioid epidemic in North America and beyond, the use of prescription opioid medications to help improve function in chronic noncancer pain is frequently debated. Out of fear of iatrogenic addiction, litigation, and/or potential medication misuse, some clinicians are refusing to prescribe opioids for chronic pain. Evidence indicates that rates of opioid misuse and addiction are fairly high among chronic pain patients prescribed long-term opioid therapy, but there is consensus that opioids can be safe and effective for carefully selected and monitored patients.