bluuebunny/crossref_metadata_2025 huggingface dataset:
Segmental Analysis of R/S-Methamphetamine and R/S-Amphetamine in Abusers’ Head Hair
Authors: Wang Ting , Shen Baohua , Wu Hejian , Gu Jun , Shen Min , Xiang Ping
Published: October 2019

In this study, the relationships between the concentrations of R/S-methamphetamine (MA) and its metabolite R/S-amphetamine (AP), the AP/MA ratio in hair samples, and MA dependence were investigated by performing segmental hair analysis in MA users. Authentic hair samples collected from 10 chronic MA abusers were cut into 1-cm sections (a total of 120 segments). The concentrations of MA and AM enantiomers were quantitatively measured by the LC–MS-MS method. The S-MA concentrations ranged from 1.17 to 256.41 ng/mg and the S-AP concentrations ranged from 0.11 to 23.31 ng/mg in the 120 segments. S-MA and S-AP were the most common analytes identified in hair; no R-MA or R-AP was found. The S-AP/S-MA ratios ranged from 0.03 to 0.32, indicating that the subjects primarily consumed S-MA rather than R-MA or AP. The S-AP/S-MA ratios in the long hair of all chronic MA abusers showed some variation, but there was an overall trend of gradual increase from the distal to the proximal end. This trend was independent of the drug concentrations. Therefore, we could conclude that the AP/MA ratios increased with the duration of MA abuse, and a higher AP/MA ratio suggested high MA dependence. There was no chiral conversion of MA or AP in the hair matrix. The segmental hair analysis showed that all subjects continuously used S-MA, and some users showed an increase in drug dose or the frequency of use.
Candidatus Rickettsia senegalensis in Cat Fleas (Siphonaptera: Pulicidae) Collected from Dogs and Cats in Cauca, Colombia
Authors: Betancourt-Ruiz Paola , Martínez-Díaz Heidy-C , Gil-Mora Juliana , Ospina Catalina , Olaya-M Luz-Adriana , Benavides Efraín , Bolaños Eliana , Cuervo Claudia , Blanton Lucas , Hidalgo Marylin
Published: October 2019

Rickettsia typhi and Rickettsia felis (Rickettsiales: Rickettsiaceae) are flea-transmitted pathogens. They are important causes of acute febrile illness throughout the world. We, therefore, sought to identify the rickettsial species present in the fleas of dogs and cats in the department of Cauca, Colombia. In this study, we collected 1,242 fleas from 132 dogs and 43 fleas from 11 cats. All fleas were morphologically identified as Ctenocephalides felis (Bouché) adults and organized in pools for DNA extraction (234 pools from dogs and 11 from cats). The gltA gene from rickettsiae was targeted for screening amplification using conventional PCR. In total, 144 of the 245 pools (58.7%) were positive. The positive samples were then processed for the amplification of the 17kDa antigen gene (144/144; 100% positive) and sca5 gene (140/144; 97.2% positive). In addition, restriction enzyme length polymorphism analysis using NlaIV on the amplified product of the sca5 gene demonstrated several organisms: 21/140 (15%) were R. felis, 118/140 (84.3%) were Rickettsia asemboensis, and 1/140 (0.7%) were Candidatus Rickettsia senegalensis. Subsequent sequencing confirmed Candidatus Rickettsia senegalensis in C. felis collected from dogs the first reported from Colombia.
The Power Puzzle: When Exclusion Increases Security and Inclusion Reduces It
Authors: Hazelton Jacqueline L
Published: October 2019

The empirical research in this issue explores sources of security and insecurity to reveal paradoxical relationships and dangerous assumptions. Drawing on this research and earlier findings about international and intra-state security, I argue that inclusion can drive insecurity and exclusion can support security. It is normatively appealing to believe that inclusion increases security in ways that benefit humans and polities and that exclusion decreases security. Authors here, however, find that it is not necessarily so. The key to increasing security as a positive good lies in understanding the actors' interests and goals. Some states and non-state actors may want to increase security in ways that do not benefit all. Others may profit by increasing insecurity. Some actors may seek inclusion while others prefer exclusion of self or other. The articles in this issue underline the importance of accurately identifying and examining assumptions in scholarship and policymaking.
Examining Differences in Parent Knowledge About Pediatric Food Allergies
Authors: Luke Anna K , Flessner Christopher A
Published: October 2019

Objective

Pediatric food allergy (FA) is a serious health condition that has become increasingly prevalent. Parents often play a primary role in assessing and managing risk for their child’s FAs, making it critical that they remain informed of the most recent guidelines for FA management. This study aimed to examine if diagnostic source (i.e., pediatrician vs. allergist) and child- and parent-level variables predicted parental FA knowledge using a comprehensive measure.

Methods

The Food Allergy Knowledge Test (FAKT) was administered to parents (N = 518) of children aged 3–17 years with (n = 349) and without (n = 169; i.e., control group) FAs using internet-sampling procedures. The sample was further partitioned into parents of children diagnosed by an allergist or a pediatrician, and control group parents who did or did not endorse knowing someone with an FA.

Results

Significant group differences were found with respect to the overall FAKT score and diagnostic source. Among the FA group, parental relationship to child, income, identification with a minority status, parental anxiety, and child possession of an emergency action plan were significant predictors of FAKT scores.

Conclusions

Knowledge of FA was poor across all groups. Education for caregivers both with and without food-allergic children is important to ensure FA safety in multiple settings. Future directions and limitations are discussed.
Prognostic impact of immunohistopathologic features in definitive radiation therapy for nasopharyngeal cancer patients
Authors: Murakami Naoya , Mori Taisuke , Kubo Yuko , Yoshimoto Seiichi , Ito Kimiteru , Honma Yoshitaka , Ueno Takao , Kobayashi Kenya , Okamoto Hiroyuki , Boku Narikazu , Takahashi Kana , Inaba Koji , Okuma Kae , Igaki Hiroshi , Nakayama Yuko , Itami Jun
Published: October 2019

Our previous study by Murakami N, Mori T, Nakamura S, Yoshimoto S, Honma Y, Ueno T, Kobayashi K, Kashihara T, Takahashi K, Inaba K, Okuma K, Igaki H, Nakayama Y, Itami J. (J Radiat Res. 2019 Jul 30. pii: rrz053. doi: 10.1093/jrr/rrz053. [Epub ahead of print]) showed that strong expression of epithelial cell adhesion molecule (EpCAM) was associated with radiation resistance in head and neck squamous cell cancer patients (SCC). In this study, the prognostic impact of histopathologic features including EpCAM for nasopharyngeal cancer (NPC) patients was investigated. Since 2009, our institution has performed chemoradiation for locally advanced NPC patients with intensity modulated radiation therapy (IMRT). Tri-weekly adjuvant cisplatin (CDDP, 80 mg/m2) was administered concurrently with definitive radiation therapy 70 Gy in 35 fractions. One month after radiation therapy, adjuvant chemotherapy of three cycles of CDDP/5 fluorouracil (5-FU) was administered. Using a pretreatment biopsy specimen, EBV-encoded small RNA in situ hybridization (EBER-ISH), EpCAM, p16 and p53 were assessed by immunohistochemical analysis. Between May 2009 and September 2017, 51 NPC patients received definitive radiation therapy. Five, 13, 17 and 16 patients were staged as I, II, III and IV, respectively. The median follow-up period for alive patients was 31.1 months (12.4–109.7 months). Three-year overall survival (OS), progression-free survival (PFS) and locoregional control (LRC) were 87.1, 57.1 and 85.7%, respectively. EpCAM, p16 and p53 were not associated with PFS, OS nor LRC. Three-year PFS for patients with keratinizing and non-keratinizing SCC were 25 and 60.5%, respectively (P = 0.033, hazard ratio 4.851 (95% confidence interval 1.321–17.814)).Prognosis of NPC patients with keratinizing SCC was worse than non-keratinizing SCC patients, suggesting a biological difference between the two types of tumor.
Transcriptome sequencing reveals hotspot mutation regions and dwarfing mechanisms in wheat mutants induced by γ-ray irradiation and EMS
Authors: Xiong Hongchun , Zhou Chunyun , Guo Huijun , Xie Yongdun , Zhao Linshu , Gu Jiayu , Zhao Shirong , Ding Yuping , Liu Luxiang
Published: October 2019

Induced mutation is an important approach for creating novel plant germplasms. The introduction of dwarf or semi-dwarf genes into wheat has led to great advancements in yield improvement. In this study, four elite dwarf wheat mutants, named dm1–dm4, induced from γ-ray irradiation or ethyl methanesulfonate (EMS) mutagenesis, were used to identify transcriptome variations and dwarfing mechanisms. The results showed that the hotspot regions of mutations distributed on the chromosomes were consistent among the four mutant lines and these regions were mainly located around the 50, 360 and 400 Mb positions of chromosome 1A and the distal regions of chromosomes 2A and 2BL. Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses suggested that ‘protein processing in endoplasmic reticulum’ was the most common significantly enriched pathway based on the differentially expressed genes (DEGs) between wildtype (WT) and the mutants. Notably, 18 out of 20 genes involved in this process encode heat shock proteins (HSPs). The results implied that HSPs might participate in wheat dwarfism response and function in the dwarfism process through protein folding and/or degradation. Moreover, seven genes in dm4 involved in modulating auxin levels were down-regulated and dm4 was more sensitive to auxin treatment compared with WT, indicating the important roles of auxin in regulation of dwarf phenotype in dm4. This study not only identified transcriptome sequence variation induced by physical and chemical mutagenesis but also revealed potential dwarfing mechanisms in the wheat mutant lines.
The Effect of Information Technology on the Information Exchange between Laboratories and Ambulatory Care Centers: A Systematic Review
Authors: Seyyedi Negisa , Moghaddasi Hamid , Asadi Farkhondeh , Hamidpour Mohsen , Shoaie Kamal
Published: October 2019

Laboratory services form an integral part of medical care in the decision-making of physicians, including those working at ambulatory care centers. Information exchange is essential between ambulatory care centers and laboratories. Inevitable errors have always existed in the exchange of such information on paper, which can be to some extent avoided by developing appropriate computer-based interfaces. Therefore, this review aimed to examine studies conducted to determine the effect of electronic communication between ambulatory care centers and laboratories. This systematic review was conducted on the basis of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were searched in the PubMed, Embase, Cochrane, and Web of Science, and those written in English and published between 2000 and February 2019 with full texts available were selected. From a total of 3898 papers retrieved from the studied databases, 24 papers were eligible for entering this study after removing similar and nonrelated studies. Electronic exchanges between ambulatory care centers and laboratories can have numerous benefits in terms of financial, organizational, and quality. This evidence for the value of electronic communications is an important factor contributing to its local investment and adoption.
Designing Babies
Authors: Klitzman Robert
Published: October 2019

Since the first “test tube baby” was born over 40 years ago, in vitro fertilization and other assisted reproductive technologies (ARTs) have advanced in extraordinary ways, producing millions of babies. About 20% of Americans use infertility services, and that number is growing. ARTs enable gay and lesbian couples, single parents, and now others to have offspring. Prospective parents can also use preimplantation genetic diagnosis to avoid passing on certain mutations to their children and to avoid abortions of fetuses with these mutations. Other future parents routinely choose the sex of their child and whether to give birth to twins. In the United States, these procedures are largely unregulated, and a large commercial market has rapidly grown, using “egg donors,” buying and selling human eggs and sperm, and using gestational surrogates. Potential parents; policymakers; doctors, including reproductive endocrinologists; and others thus face critical complex questions about the use—or possible misuse—of ARTs. This book examines ethical, social, and policy questions about these crucial technologies. Based on in-depth interviews, Robert Klitzman explores how doctors and patients struggle with quandaries of whether, when, and how to use ARTs. He articulates the full range of these crucial issues, from economic pressures to moral and social challenges of making decisions that will profoundly shape these offspring. The book explores, too, broader social and moral questions regarding gene editing, CRISPR, and eugenics. Klitzman argues for closer regulation of these technologies, which are altering future generations and the human species as a whole.
Becoming an Infertility Patient
Authors: Klitzman Robert L.
Published: October 2019

For many patients, the first step in using these technologies is getting a referral to an infertility specialist, yet even that step can pose challenges. Several types of healthcare provider can serve as gatekeepers and refer patients to fertility specialists—obstetricians and gynecologists, general practitioners, oncologists, and genetic counselors. Yet these clinicians often have knowledge gaps regarding infertility and thus delay or fail to make referrals. Patients encounter financial barriers as well. Patients may postpone or not seek treatment because they fail to appreciate how much age can diminish fertility. Both doctors and patients can feel awkward discussing sexual activity, reproduction, and infertility because of stigma. Usually, infertile patients who pursue treatment first undergo tests to determine whether the infertility stems from the man, the woman, or both. Before proceeding to in vitro fertilization, women ordinarily attempt medications and intrauterine insemination but face a range of challenges and questions.
“Family Balancing”
Authors: Klitzman Robert L.
Published: October 2019

Doctors and patients confront decisions of whether to perform “positive selection”—to choose embryos for various socially desired characteristics—most commonly sex but also deafness and dwarfism. Physicians routinely screen embryos for sex not only to prevent the transmission of serious sex-associated diseases (e.g., autism) but also for “family balancing”—though differing widely in how they define this concept. University-affiliated clinics tend to consult formal external ethics committees about these issues, while free-standing private clinics do not. While many countries explicitly prohibit social sex selection, US providers regularly perform it, raising concerns about a possible “slippery slope” toward eugenics. In the near future, screening for genes associated with other non-medical “desired traits” such as blond hair and blue eyes will probably also be developed and requested. Providers and patients wrestle with whether certain types of embryo selection might restrict a child’s “open future” and ability to make key choices for him- or herself, as well as how to uphold the child’s best interests.
“Two Kids for the Price of One?”
Authors: Klitzman Robert L.
Published: October 2019

Providers and patients grapple, too, with how many offspring to produce. A California woman who gave birth to octuplets through in vitro fertilization, whom the media labeled “Octomom,” brought worldwide attention to the problems of multiple births from these technologies. Many patients and providers still seek twins to save time and money, fueling an “epidemic of twins.” Yet even with twins, the risks of complications rise significantly. In over 40% of twin births, the infants encounter medical complications. Commentators have argued that single embryo transfer should become the standard of care, but patients frequently oppose it. If more than one fetus develops, providers and patients also confront dilemmas of whether to abort all but one of the fetuses. Decisions about such fetal reduction can excruciate both doctors and patients. Even many pro-choice patients are wary of such partial abortions.
Choosing Wombs
Authors: Klitzman Robert L.
Published: October 2019

Many would-be parents face quandaries about whether to pay a woman to carry their fetus in her womb as a gestational surrogate—so-called renting wombs—and, if so, what woman. Many prospective mothers cannot carry a fetus themselves due to medical reasons. Single and gay men who want a biological child have no choice but to use a surrogate. Celebrity actresses such as Sarah Jessica Parker have also hired a surrogate to avoid undergoing pregnancy themselves. The market for such surrogates grows enormously, but debates rage about it due to fears of exploiting women as surrogates. US states range considerably in whether they permit, prohibit, or limit surrogacy and in how they enforce whatever laws they have. Like all pregnant women, surrogates face potential short- and long-term risks. Many parents seek gestational surrogates abroad to save money but may face medical and legal risks regarding the pregnancy and bringing the children into the United States.
Choosing Children
Authors: Klitzman Robert L.
Published: October 2019

Prospective parents who fail to get pregnant using these technologies frequently consider adoption of infants or foster children as an alternative but can then encounter various obstacles as well. Many infertility patients investigate adoption as a backup plan, offering hope. But they face quandaries of how long to keep trying in vitro fertilization before pursuing this alternative or accepting childlessness—whether having a biologically unrelated child is better than not having a child at all. Varied financial, administrative, and other logistical obstacles to adoption can prove daunting. Adopting babies from both the United States and abroad has become harder. Due to costs and trade-offs, many individuals consider but finally reject these options.
Choosing Doctors
Authors: Klitzman Robert L.
Published: October 2019

Patients struggle with how to pick doctors, wanting success and patient-centered care but often facing difficulties assessing and weighing these qualities. Many patients feel dissatisfied and disappointed and grapple with how to gauge and weigh communication against technical skills, success rates, financial resources, and hope—whether to shop around and, if so, how much and how to decide. Providers generally receive little, if any, training on how best to address the difficult emotions, profound uncertainties, and complex statistics involved with assisted reproductive technologies. After treatment failures, many patients consult more than one physician and/or seek more holistic, patient-centered approaches, including unproven, alternative approaches.
“Will They Be Good Enough Parents?”
Authors: Klitzman Robert L.
Published: October 2019

Physicians often wrestle with whether patients will be “good enough” parents and how much responsibility providers have toward the well-being of the future child—whether to treat all patients and, if not, whom to reject and how to decide. Providers see not only married heterosexual couples but “nontraditional” families, including single-parents-by-choice; lesbian, gay, transgender, or HIV-infected parents; and more “unconventional” types of reproductive arrangements, including gamete donations between sisters and brothers as well as mothers and daughters serving as surrogates for each other. Other couples may seem “highly neurotic” or emotionally unstable. Yet eventual child-raising abilities are tricky to predict. Over time, social attitudes toward certain types of nontraditional families have also been changing. Providers face questions about future blurry and confusing roles in families, children’s welfare, and competing medical, personal, moral, scientific, and social considerations.
“Meant to Be?”
Authors: Klitzman Robert L.
Published: October 2019

Religious and spiritual beliefs can help patients cope and/or prevent them from pursuing certain treatments. Major religions all contain myths about the creation of life—including human beings. Clergy, families, and friends may sanction certain procedures but prohibit others and vary widely, even within any one faith. Religious leaders may oppose a variety of procedures from small to large. Patients can follow or avoid such prohibitions. Patients, family, friends, and providers can misunderstand a religion’s perspectives, making incorrect assumptions and/or disagreeing about whether a particular couple is “meant” to have children. Providers may be unsure how to interact with patients’ beliefs and clergy, especially when the latter, not the patient, is making the decisions.
Perspectives and Paradigms
Authors: Fedoroff J. Paul
Published: October 2019

Abstract: Paraphilias are sexual interests that differ from “normal.” There is a widespread belief that paraphilias cannot be changed and therefore can be at best, managed, with no hope of successfully treatment. This chapter reviews how problematic sexual interests have been dealt with by clinicians and the courts. It introduces the concepts of genes, gender, orientation, drive, and interests. The chapter also presents reasons for the persistence of the unproven belief that paraphilic interests cannot change. It concludes with an alternative paradigm in which paraphilic interests are seen as variants of non-paraphilic interests and therefore equally modifiable. This means that paraphilic disorders can be effectively treated, and the establishment of persistent harmful sexual interests can be prevented.
Exhibitionistic Disorder
Authors: Fedoroff J. Paul
Published: October 2019

Abstract: This chapter provides a brief description of the key diagnostic features of exhibitionistic disorder in addition to a historic review of changes in the criteria in the Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases. This is followed by a review of the differential diagnosis and the ways in which the disorder can take different forms or be confused with other disorders. The recent scientific literature on the disorder is summarized. A description of recommended approaches to the assessment and treatment of this disorder, including differential diagnosis and psychotherapeutic and pharmacologic treatments, is presented.
Frotteuristic Disorder
Authors: Fedoroff J. Paul
Published: October 2019

Abstract: Frotteuristic disorder is a condition defined as recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors, or by rubbing against non-consenting people for sexual stimulation. It has been reported that up to 30% of adult males in the general population may have committed frotteuristic acts. This chapter reviews the Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases criteria for frotteurism. Conditions for consideration in the differential diagnosis are discussed. Treatment and prognosis are discussed, and the recent literature on these topics is reviewed.
Models of Care Delivery and Quality Measurement
Authors: Lee Katherine , Cooper Zara
Published: October 2019

Two main models of care delivery have emerged for palliative care delivery to surgical patients: the consultative model, which relies on triggers for palliative care consultations, and the integrative model, which delivers palliative care alongside standard treatments. While both these models have shown success among nonsurgical populations, only a few studies have examined their utilization among surgical patients. Even though these models provide palliative care delivery to patients, indicators of quality are also necessary to ensure that palliative delivery improves quality of care. However, the most relevant and important indicators of quality for surgical palliative care remain undefined. Presently, there is no national surgical quality improvement program for palliative care, hindering attempts to measure quality and improve performance. However, the surgical specialties can adapt and learn from related specialties, such as critical care, geriatrics, oncology, and palliative and hospice medicine, to develop quality indicators for surgical palliative care. Capitalizing on existing quality structures, such as the American College of Surgeons quality improvement programs, can also help ensure integration of quality improvement efforts into standard practice.
Self-Care and the Surgeon
Authors: Siegel Timothy R.
Published: October 2019

Physician burnout in general, and surgeon burnout in particular, can have profound negative effects on individual practitioners, their patients, and healthcare systems. This chapter defines the terms physician burnout and compassion fatigue, including their associated risk factors, prevalence, and effects on physician well-being, patient care, and patient outcomes. Strategies for dealing with burnout, with emphasis on individual and workplace stressors, are reviewed. Individual self-care techniques, including self-awareness and mindfulness mediation, are emphasized. Institutional engagement around this issue is discussed, and recommendations for undergraduate and graduate medical education curriculum development are made. A summary of the benefits of attention to burnout and self-care is provided.
Spirituality and Surgery
Authors: Hinshaw Daniel B.
Published: October 2019

Increasing evidence has demonstrated the importance of spirituality and spiritual care for patients with life-threatening illnesses. With the growth of scientific medicine from the nineteenth century, a medical dualism has developed with an intense focus on identifying and treating disease almost to the exclusion of caring for the suffering of the person with the disease. This chapter provides surgeons with an understanding of human suffering and its close connection to spirituality, reviews studies highlighting the importance of spirituality and spiritual care to critically ill patients, and outlines some basic skills surgeons can develop to address the spiritual needs of their patients.
Preoperative Palliative Care Assessment, Frailty, and Prognostication
Authors: Fahy Bridget N. , Shinall Myrick C.
Published: October 2019

Preoperative assessment involves assessing a patient’s physiologic fitness for surgery; counseling patients about risks, benefits, and alternatives to surgical intervention; and prognosticating about anticipated postoperative outcomes. The most challenging scenarios involve patients who are marginal surgical candidates, when the outcome of the operation is uncertain, or when the goals of the operation are not well defined. Under these circumstances, applying the key tenets of surgical palliative care is essential. Surgeons must be able to address goals of care by incorporating patient values, preferences, hopes, and fears. With this information, surgeons are then prepared to ensure that the right patient undergoes the correct operation at the right time. Tools available to surgeons as they perform these aspects of preoperative assessment and prognostication include frailty indices and surgical risk calculators.
Palliative Care for the Trauma Patient
Authors: Ballou Jessica H. , Zonies David H.
Published: October 2019

Trauma results in acute and chronic physical, spiritual, and emotional injuries for patients and their families that can be as devastating as their new physical limitations. Trauma patients have palliative care needs and benefit from early palliative care assessments to meet their multidisciplinary needs. Palliative care, with its focus on multidisciplinary symptom management and coordinated care, is an integral component of trauma care. Identifying persons in need of specialty palliative care, such as frail persons at the extremes of age, spinal cord injuries, traumatic brain injuries, or complex comorbidities or social circumstances allows for better allocation of palliative care resources.
Palliative Care in Transplantation
Authors: Rivet Emily B. , Stern Jeffrey M. , Mahadevan Karunasai , Noreika Danielle
Published: October 2019

Organ transplantation is a field where patients often have significant palliative care needs but frequently lack access to palliative care due to a variety of barriers, including some commonly encountered as well as others specific to this patient population. Organ system failure is necessary to qualify for transplantation. Morbidity and mortality of the particular organ failure syndrome have a profound impact on quality of life. Also, the donor process adds another patient group that may benefit from palliative care. For solid-organ transplant candidates, long waiting times on organ transplant lists and limited organ availability shape the patient experience. Death while waiting for transplant for some conditions is not unusual. Furthermore, there is variability in the ability to replace organ function and how these modalities impact quality of life and end-of-life care. An integrated approach introducing end-of-life planning and palliative care early in the course for patients with organ failure awaiting transplant would improve patient knowledge and possibly symptom management and empower patient decision-making at the end of life.
Principles, Assessment, and Evaluation for Palliative Surgery
Authors: Cohen Joshua T. , Miner Thomas J.
Published: October 2019

Palliative surgery requires the highest level of surgical decision-making. The surgeon must evaluate the severity of the patient’s symptoms, the patient’s priorities, the available options for treatment, and the morbidity the patient can incur by undergoing an operation. Indications for palliative surgery are influenced by symptom severity and are disease and patient specific. It is a necessity that patients are managed by a multidisciplinary team, which can include surgeons, palliative specialists, endoscopists, interventional radiologists, medical teams, case managers, social workers, nurses, and chaplains. Communication is the cornerstone of successful palliation and can be facilitated by utilizing the palliative triangle. Patient selection requires a deliberate and thoughtful assessment of the specific circumstances and needs of each individual patient. In evaluating outcomes, emphasis should be placed on symptom and quality-of-life improvement, which is subsequently weighed against the morbidity of the operation in the context of anticipated recovery and survival time.
Palliative Gastrointestinal Surgery
Authors: Badgwell Brian
Published: October 2019

Palliative surgical consultation is a critical component of multidisciplinary gastrointestinal cancer care. For many types of gastrointestinal malignancies, the majority of patients are not able to achieve cure and develop symptoms attributable to their advanced or incurable malignancy. The most common diagnosis is bowel obstruction, but diagnoses such as bowel perforation, hemorrhage, neutropenia and abdominal pain, and anorectal infections are also included. Safe utilization of surgical intervention can be difficult due to the increased risks of surgery, limited therapeutic options for these complex palliative care situations, and the progressive nature of incurable gastrointestinal cancer. In selected patients, surgical palliation can improve symptoms and quality of life with acceptable reported rates of morbidity and mortality. Even in situations where surgery is not offered, an understanding of the disease processes and outcomes can inform patients and other providers in the optimal management strategy.
Palliation in Head and Neck Surgery
Authors: McCammon Susan D.
Published: October 2019

Head and neck surgery treats lesions from the skull base to the thoracic inlet. While most of these are malignant and require multimodal oncologic management, many are benign, but their treatment can be quite morbid due to their location. This anatomic area encompasses the special sense organs of sight, smell, taste, and hearing as well as the essential social function of speech and the vital processes of breathing and swallowing. The appearance of the face is often affected, and this can affect personal identity. In many clinical situations, survival outcomes are equal between radically different treatment paradigms, and medical decisions are predicated on anticipated survival and quality of life. Thus, it is critical to elicit accurate values and goals of care from patients and families facing these decisions. Narrative competence in describing and quantifying likely outcomes is an important skill for clinicians to cultivate, as is awareness of unconscious biases and the use of directive counsel. Even successful head and neck surgery has symptomatic sequelae that can be minimized with prehabilitation and managed with ongoing supportive care.
Palliative Care and Cardiovascular Surgery
Authors: Chauhan Dhaval , Mosenthal Anne C.
Published: October 2019

Advances in cardiovascular surgery and technology over the last 50 years have improved survival and quality of life for those with acute and chronic heart and vascular disease and have significantly increased life expectancy. However, cardiovascular disease remains a leading cause of death, and while surgical advances have changed the end-of-life trajectory, palliative care remains an important component and adjunct in cardiovascular surgery. Two advances in particular, placement of a destination therapy–left ventricular assist device (DT-LVAD) and transcatheter aortic valve replacement (TAVR), bring complex decision-making, ethical dilemmas, and high symptom burden for patients and their caregivers. Concurrent palliative care over the whole trajectory of illness is an essential part of this care. In this chapter, the role of palliative care for DT-LVAD and TAVR is described, starting with a case scenario, problem statement, and assessment of prognosis from beginning to end of life.
The Family Conference
Authors: Hoffman Melissa Red
Published: October 2019

The family conference chapter explores, in detail, one of the primary interventions performed by palliative care providers. A successful meeting can actually be viewed as time saving as it offers an opportunity for many issues to be reviewed and for multiple important decisions to be made in a relatively short period of time. By describing the conference in terms of a surgical procedure, during which we prepare, do, and close, this chapter offers specific guidance in a way most likely to resonate with a surgeon. It reviews the steps necessary to prepare for a family conference and describes how such steps may aid the family and the treatment team in managing uncertainty. It introduces the ask-tell-ask model of communication and discusses how this model can help to facilitate shared decision-making.
Pharmacopalliation of Pain
Authors: Ray James B.
Published: October 2019

Pain is one of the most common symptoms that a surgeon may encounter in their patients with palliative care needs. Pain no longer serves an adaptive, protective mechanism but one that is maladaptive and has no redeeming purpose except to add to the patient’s suffering. Effective management requires the surgeon to consider the bio-psychosocial-spiritual impact of the underlying disease when assessing the patient’s self-report of pain. This chapter is a primer and provides an overview of the most common factors that a surgeon may want to consider in providing primary pharmacopalliation of pain, including analgesic selection and adverse effect management.
Nonpain Symptom Management
Authors: Pruskowski Jennifer
Published: October 2019

Along with pain, surgical palliative care patients often suffer from both physical and psychosocial symptoms in the weeks to months before death. They can have a variety of nonpain symptoms due to their serious illness. Literature suggests these symptoms can be more debilitating than pain, but patients are less likely to self-report. Surgical palliative care providers have an important opportunity to manage these nonpain symptoms to improve a patient’s quality of life. This chapter briefly reviews the principles of nonpain symptom management and focuses on the management of six common nonpain symptoms experienced by surgical palliative care patients: dyspnea, delirium, nausea, constipation, anorexia, and anxiety.
Transitions of Care—Disposition Planning
Authors: Kopecky Kimberly , Miller Pringl
Published: October 2019

Care transitions are a hot topic in healthcare delivery, research, and policy today because national patient quality and safety data have identified transition of care as a critical time during a patient’s care continuum when both quality and safety are potentially compromised. Poorly executed transitions of care are associated with preventable adverse events and hospital readmissions that are burdensome to patients and their caregivers, correlating to suboptimal outcomes and exorbitant costs. Therefore, reducing both adverse events during a care transition and hospital readmission rates is a matter of clinical and policy priority. High-risk surgical patients are particularly vulnerable to preventable adverse events and readmissions during care transitions because of the complexity of their care needs. To address this problem, governmental and other healthcare organizations are allocating resources and investing in research initiatives to improve, refine, and standardize the transition-of-care process in order to optimize quality of care throughout a patient’s care continuum.
Care of the Family
Authors: Fiorentino Michele
Published: October 2019

This chapter discusses the key points of the care of the family in the surgical setting and palliative care. In critically ill patients, to provide the best possible care we must also care for the needs of the family. This chapter discusses the needs of the family in respect to the critically ill patients, dying patients, withdrawal of life support, and the death of a child. In the critically ill, family members are often placed in the role of surrogate decision maker. The need to identify surrogate decision makers, their role, and the challenges they face is discussed in detail. Family presence during resuscitation is also discussed, including benefits for patients, families, and the medical team. The keys elements of implementing family presence during resuscitation are described. Grief and bereavement are also discussed, along with the surgeon’s role in facilitating healthy grieving and recognizing complicated grief.
The history of neurosurgery
Authors: Marsh Henry , Marts Eleni
Published: October 2019

The history of neurosurgery falls naturally into the premodern era, where it is essentially the history of surgery to the skull and of head injuries, and the modern era, where it is the history of surgery to the brain itself, made possible by cerebral localization theory, antisepsis, and anaesthesia, all of which developed in the nineteenth century. The first known neurosurgical procedures were skull trephines, seemingly carried out on both the living and the dead. It is unclear whether these were performed for therapeutic or ritualistic reasons. There are many trepanned skulls dating back thousands of years to the Neolithic era, and perhaps to even earlier, from sites all over the world.
The operating theatre environment
Authors: Kitchen Neil , Shapey Jonathan
Published: October 2019

The modern neurosurgical theatre is a vastly different environment to what Victor Horsley and other early neurosurgical pioneers were accustomed to at the turn of the twentieth century. This chapter details the essential equipment used in the modern-day operating theatre including the microscope, endoscope, drills, retractors, diathermy, and haemostatic agents. Commonly used surgical positions are described and illustrated. The history and evolution of stereotactic neurosurgery and neuronavigation is discussed and intraoperative imaging techniques such as X-ray, ultrasound, and magnetic resonance imaging are explained. Intraoperative neurophysiological monitoring techniques are also reviewed including somatosensory evoked potentials, motor evoked potentials, electromyography, and intraoperative cortical mapping.
Perioperative care of the neurosurgical patient
Authors: Budohoski Karol P , Scudellari Alessandro , Karcheva Sylvia , Duane Derek
Published: October 2019

Perioperative care of the neurosurgical patient describes the processes required to facilitate safely and professionally neurological operative interventions and outcomes. An account is given of the systematic preoperative evaluation needed to optimize a patient’s medical conditions before surgery, the intraoperative anaesthetic management, the postoperative care, and the possible complications that may be encountered. Anaesthetic considerations for specific neurosurgical interventions are also described. Overall, emphasis is placed on the importance of requesting the appropriate investigations, adhering to strategies for the correction of coagulation disorders along with the prevention of venous thromboembolic complications, understanding the effect of anaesthesia on cerebrovascular haemodynamics and providing specialist postoperative facilities and expertise.
Intracranial metastases
Authors: Brodbelt Andrew , Zakaria Rasheed
Published: October 2019

The incidence of brain metastases is increasing due to better management of the systemic primary disease, a lack of chemotherapeutic agents that cross the blood–brain barrier, and more sensitive imaging methods. Presenting symptoms include seizures, headache, and neurological deficit caused by the tumour and associated oedema. Steroids and antiepileptic drugs assist in initial symptom control, and allows assessment of the patient’s performance which remains an important determinant of treatment and outcome. Assessment starts with history and examination, contrast-enhanced MRI brain, and whole-body staging. Newer multimodal MRI techniques can help in diagnostic and treatment dilemmas. Definitive treatments include surgery, radiosurgery, whole-brain radiotherapy, and chemotherapy. The optimal combination and timing of these therapies remains controversial, however there are principles of management that can help the physician guide the patient on the best course. A true multidisciplinary approach is required to optimize treatment and care in an efficient and effective manner.
Primary central nervous system lymphoma
Authors: Quah Boon Leong , Munusamy Thangaraj , Watts Colin
Published: October 2019

Primary central nervous system lymphoma (PCNSL) is a rare form of Non-Hodgkin’s lymphoma (NHL) confined to the central nervous system, which continues to be a challenging malignancy to treat. The reason behind this lies in the fact that its systemic counterpart carries a more favourable prognosis with a cure rate of approximately 70%, whereas the prognosis of PCNSL remains poor in the immunocompetent and even poorer in HIV-associated PCNSL. Fortunately, the median overall survival has nearly doubled since the 1970s reflecting a better understanding, and more effective management of this disease. In this chapter, we will explore the many reasons behind this increased survival as well as current management options from a neurosurgical perspective.
Glioneuronal and other epilepsy-associated tumours
Authors: Simon Matthias , Grote Alexander
Published: October 2019

Patients with (glio)neuronal brain tumours are rare. The most common variants, hat is, gangliogliomas and dysembryoplastic neuroepithelial tumours (DNTs), frequently present with pharmacoresistant epilepsy. Together with certain other tumour types associated with chronic epilepsy (including selected cases with diffuse gliomas WHO grade II/III) these entities have historically been referred to as LEATs (long-term epilepsy-associated tumours). LEATs share a very benign clinical course and rarely recur following a gross total resection. More than 80% of patients can expect to become seizure-free following epilepsy surgery (i.e. resection of the epileptogenic zone rather than tumour removal only). Hippocampal resections may improve the seizure outcome in cases with mesial temporal lobe epilepsy, but may also carry a concurrent risk of neuropsychological deficits. In contrast, oncological issues dominate the clinical course of LEATs and glioneuronal tumour variants if encountered outside the setting of refractory epilepsy. The dysplastic cerebellar gangliocytoma (L’Hermitte-Duclos disease, LDD) is the major central nervous system manifestation of Cowden disease. Its neoplastic nature is questionable.
Chemotherapy for brain tumours
Authors: Brown Nicholas F. , Krell Daniel , Mulholland Paul
Published: October 2019

Chemotherapy can prolong survival of patients with brain tumours. Temozolomide with radiotherapy is the standard of care in glioblastoma following surgery. Elderly patients with MGMT-promotor methylated tumours benefit more from chemotherapy than radiotherapy. Localized delivery of chemotherapy-soaked wafers (Gliadel®) inserted at surgery has being investigated. At recurrence, modest survival advantage has been shown with chemotherapy. Chemotherapy has an established role in lower grade tumours. Stratification of tumours by their molecular profiles allows identification and selection of patients more likely to benefit from chemotherapy. Increased understanding of brain tumours and their microenvironment have led to the investigation of targeted therapies and immunotherapy, which are likely to form the basis of future treatment regimens.
Surgical techniques in the management of intrinsic tumours
Authors: Hervey-Jumper Shawn , Berger Mitchel
Published: October 2019

Surgical resection plays a central role in the management of intrinsic brain tumours, and there is a growing body of evidence concerning the value of extent of resection to improve patient outcome and quality of life. Maximal resection can be difficult to achieve due to tumour proximity to eloquent structures and uncertainty as to tumour margins. Direct stimulation mapping, functional neuronavigation, intraoperative MRI, and fluorescence-guided surgery are all useful tools to improve the extent of tumour resection while minimizing morbidity. Current evidence suggests that a more extensive surgical resection is associated with longer survival and improved quality of life for patients with either low- or high-grade gliomas. This chapter emphasizes the evidence supporting the role of surgery for intrinsic brain tumours, their surgical neuroanatomy, and techniques to maximize the extent of resection while minimizing morbidity.
Malignant skull base tumours
Authors: Helmy Adel , Panizza Benedict
Published: October 2019

Malignant skull base tumours are a rare and diverse group of histological entities that cross the skull base. Their management requires a multidisciplinary approach that aims to achieve microscopically clear margins, dural reconstitution to avoid cerebrospinal fluid (CSF) leak, soft tissue reconstruction and where possible, an en bloc resection. Both traditional craniofacial and more modern endoscopic techniques can be utilized, if the surgical and management goals can be achieved successfully. This is then combined with adjuvant therapy, typically radiotherapy, to maximize prognosis. We discuss both anterior and lateral skull base tumours as well as consider the special case of perineural spread as an example of complex disease at the skull base.