bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Karl Jaspers’ General Psychopathology: the range of appraisal
Authors: Mundt Christoph
Published: November 2017

Growing unease in the scientific community has stimulated reception of classical authors as Karl Jaspers. By drawing on existential philosophy Jaspers has given GP a depth which allows reflecting the methodological premises of psychopathology. Anthropologic phenomenology of Edmund Husserl was received with scepticism by Jaspers as was V. v. Weizsäcker’s psychosomatic medicine and Mitscherlich`s psychoanalysis. Jaspers refined mainstream psychopathology by understanding their nature and defining precise criteria. Delusion and psychotic symptoms are examples. The observation of patient`s and psychiatrist`s “vicarious self-representations” gained acceptance although low reliability was expected. Substantial critique on GP is rare. Some authors consider Jaspers’ work as replica of French psychiatrists. However, Jaspers’ work is unique in getting in touch philosophy and psychiatry. The comprehensiveness of the material is one merit of GP. Amazing that in times when psychopathological concepts are short lived a book published one hundred years ago still exerts influence. This steady interest may be an indication that GP touches upon the very roots of mental life.
Karl Jaspers’ General Psychopathology in the framework of clinical practice
Authors: Doerr-Zegers Otto , Pelegrina-Cetrán Héctor
Published: November 2017

Jaspers Psychopathology (1913) encompasses all areas of psychiatry and delves deeply into psychology and philosophy. From the beginning it has had a great repercussion in European, Japanese, Latin American and finally, in the English speaking psychiatry. Jaspers greatest achievement was to establish psychopathology as a hard science and the basis of psychiatry as professional practice. He did this from strictly methodological perspective. Besides, he aspired to consider the patient and his psychopathological manifestations on the horizon of the totality of existence. To summarize his contributions would be practically impossible. Therefore, these authors have focused this chapter on some particular topics of his work, such as the introduction of phenomenological method; the development of the method of understanding in contrast to explanation; the concepts of process and development; the overcoming of stimulus/response scheme for conceptualizing the man-world relationship and its replacement by his revolutionary concept of “situation”; and finally, the introduction of dialectical thinking in psychopathology and psychiatry.
The self in schizophrenia: Jaspers, Schneider, and beyond
Authors: Fuchs Thomas
Published: November 2017

The concept of self-disorders has always played a major role for the psychopathology of the psychoses. In his General Psychopathology, Jaspers distinguished what he called ego-consciousness from object-consciousness and characterized it by the sense of activity, unity, identity and ego-demarcation. On this basis, Kurt Schneider later coined the term “Ich-Störungen” (ego-disorders) for the schizophrenic experience of alien control. In contrast, ICD 10 and DSM IV regard these experiences as bizarre delusions. The chapter analyses the possible connection of ego-disorders with more basic disorders of self-awareness. It argues that delusions of alien control are based on a more fundamental disturbance of the intentionality of thinking, feeling and acting. These disturbances may be traced back to a lack of pre-reflexive self-awareness which has been emphasized by recent phenomenological approaches to schizophrenia.
Cardiovascular system
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter covers the assessment and investigation of perioperative cardiac risk, the principles of perioperative haemodynamic monitoring and physiological changes in cardiac comorbidity with their relevance to anaesthetic management. Perioperative cardiovascular risk includes assessment of cardiac risk factors, functional capacity and evidence-based guidelines for preassessment. Cardiovascular investigations such as cardiopulmonary exercise testing and scoring systems for cardiac risk are included. Management of the cardiac patient for non-cardiac surgery is detailed.
Invasive monitoring with arterial, central venous and pulmonary artery catheters is described. Cardiac output measurement systems including dilution techniques, pulse contour analysis and Doppler are compared. The physiological changes, management and implications for anaesthesia of common cardiac comorbidity including ischaemic heart disease, heart failure, valvular heart disease, pacemakers and pulmonary hypertension are described.
Nutrition
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This important aspect of patient care, particularly in critical illness and ITU, is often overlooked. Nutritional assessment with body composition and biochemical assessment is explained with evaluation of requirements and monitoring. The link between nutrition and patient outcome is also explored. Nutritional support via enteral and parenteral methods is described including methods, complications, and patient monitoring.
Airway management and anaesthesia for ENT, maxillofacial, and dental surgery
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter covers airway assessment and management with the conduct of anaesthesia for ENT and maxillofacial procedures, both elective and emergency. Airway assessment allows some prediction of the difficult airway. Management of the anticipated difficult airway is discussed with techniques including awake fibreoptic intubation. Management of the unanticipated difficult airway and the obstructed airway is discussed following Difficult Airway Society algorithms. Emergency airway management includes cricothyroidotomy and jet ventilation. Indications for tracheostomy, descriptions of surgical and percutaneous procedures and guidelines for the emergency management of tracheostomy/laryngectomy airway emergencies are included. Anaesthesia for ENT covers the common anaesthetic considerations in the pre-assessment and perioperative period during management of patients for common ENT procedures. The special considerations for laser airway surgery and emergency surgery (such as bleeding tonsils and epiglottitis) are described. Most maxillofacial trauma is performed on a semi-elective basis and the airway management planning for lower, mid and upper-face fractures is included.
Cardiac anaesthesia
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter, written by Anaesthetists from the Heart Hospital, describes the general principles in cardiac anaesthesia. Patient pre-assessment, perioperative monitoring, management of anticoagulation, methods of patient cooling and rewarming, cardiopulmonary bypass and postoperative complications such as tamponade and neurological dysfunction are all discussed in detail. The principles of intra-aortic balloon pump counterpulsation with indications and practical aspects of use are included. The principles of providing anaesthesia for the adult patient with congenital heart disease follow a description of the physiological considerations in these patients.
Regional anaesthesia
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

The regional anaesthesia chapter discusses the pharmacology of local anaesthetic agents, techniques of nerve localisation, practical aspects of ultrasound-guided blocks and the advantages and complications of regional anaesthesia. Common, and clinically useful, blocks for the upper and lower limb are described in detail with pictures of anatomical landmarks and ultrasound appearance to compliment the description. Indications, technique, volumes required and complications are described for each block.
Paediatric anaesthesia
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter, written by consultant anaesthetists from Great Ormond Street Hospital, London, summarizes the physiological and developmental changes, perioperative considerations, and modification to anaesthetic techniques used for anaesthesia in neonates, infants, and children. Emergency surgery for neonatal conditions such as pyloric stenosis is discussed, as well as care of the critically ill child with immediate resuscitation and safe transfers. Legal aspects of paediatric practice are covered within this chapter including consent, restraint, and child protection.
Biological effects of ionizing radiation
Authors: Andrzej Wojcik , Martin Colin J
Published: November 2017

Biological effects of radiation have been interpreted based on the assumption that DNA is the primary target, but recent research has shown that non-targeted mechanisms may affect cells that are not directly exposed. The most important effect in humans from low doses of radiation is the induction of cancer, but risks of other effects such as cataract and cardiac or circulatory disease are becoming apparent. Epidemiological studies of Japanese survivors of atomic bombs demonstrate a clear linear relationship between solid cancer incidence and organ dose. This is supported by other epidemiological data. This has become the gold standard for prediction of malignancy based on a linear no-threshold ‘LNT’ extrapolation, which links risk directly to radiation dose. However, the risk calculations involve many assumptions and approximations. They are designed to provide guidance on which a workable protection framework can be based. It is important that practitioners are aware of their limitations.
Radiation measurement
Authors: Green Stuart , Zamenhof Robert G , Delahunty Denise E
Published: November 2017

The ability to make accurate and reproducible measurements requires a detailed knowledge of radiation detection mechanisms, quantities to be measured, basic measurement techniques, and assessment of measurement uncertainties. The chapter begins with an overview of the operational dose quantities and the mechanisms by which measurements are traced to a suitable primary standard. This is followed by some tips on detector selection for both dose rate and contamination applications, before a more detailed description of the basic functional characteristics of gas detectors, scintillation detectors, and semiconductor detector. In each case, suggestions are made on typical areas of use, limitations of performance along with practical examples. Detector resolution issues are discussed for active detectors before a brief overview of passive detector systems including film (photographic and radiochromic) and thermoluminescent dosimetry. The chapter concludes with some common issues in practical measurement and describes the role and importance of the annual instrument test.
Radiation protection legislation
Authors: Martin Colin J , Le Heron John , Allisy-Roberts Penelope
Published: November 2017

Radiation protection standards and practice have been developed through the cooperationof international organizations able to call upon experts from around the world. The ICRP hasbeen central to this development, establishing through its recommendations the principles ofjustification, optimization, and dose limitation that have been the foundations of radiationprotection practice for over 30 years. The IAEA, under the auspices of the UN, establishessafety standards based on ICRP recommendations which all countries can use in developingtheir own regulations and codes. Other groupings of countries such as the EU develop theirown standards or directives which are then enacted in the national legislation of memberstates. Brief descriptions of the legislative structure in a selection of countries are included toprovide an indication of the range of systems in place.
Operational radiation protection
Authors: Sutton David G
Published: November 2017

The fundamental practical principles applied to any radiation protection problem are discussed. Types of radiation that may be encountered include α‎-particles, β‎-particles, γ‎-rays, neutrons, X-rays, or a combination. Each presents its own particular practical problems in terms of radiation protection, and the properties and practical principles that should be considered for each are outlined. The framework required to manage radiation protection and the practical techniques important in restricting exposure are discussed. The practical control measures of time, distance, and shielding that are invoked to restrict exposure from external radiation are considered for each type of radiation. Methods for limiting intake of radioactive material through ingestion, inhalation, and absorption to minimize internal exposure are described.
Personal monitoring
Authors: Temperton David H
Published: November 2017

Personal dose monitoring provides the important check and reassurance that radiation doses to those working with radiation are at a level that complies with dose constraints. The quantity which is relevant to external personal monitoring is the personal dose equivalent Hp(d) defined by the ICRU. Values at different depths d are equated to effective dose or doses to the skin or eye lens. This chapter contains the basic information that the radiation protection practitioner needs on personal monitoring, and the requirements for running a personal dose-monitoring service, including dosimeter calibration, performance testing, and record keeping. Techniques used in different types of dosemeters such as thermoluminescent dosimetry and optically stimulated luminescence, as well as neutron detection are explained, together with practical considerations for eye dose and extremity monitoring. Use of electronic personal dosemeters is discussed and techniques for monitoring internal exposure are described.
Diagnostic radiology equipment
Authors: Williams Jerry R
Published: November 2017

The chapter is concerned with the features of radiographic and fluoroscopic equipment that
present radiation protection issues for both patients and staff. These are managed through
regulation, manufacturing standards, and adherence to safe working practices. It is different
for patients who are deliberately irradiated in accordance with justification protocols not
considered here. Radiation protection is based on the ALARP principle which requires the
resultant dose to be minimized consistent with image quality is sufficient to provide accurate
and safe diagnosis. Dose minimization is critically dependent on detector efficiency. Quality
control of dose for individual examinations is particularly important to provide assurance of
ALARP. It should include not only patient dose assessment but also detector dose
indicators, particularly in radiography. These issues are discussed in detail together with
other dose-saving features and discussion on objective methods of image quality
assessment. Commissioning and lifetime tests are required for quality assurance
programmes. These are described.
Radiotherapy: brachytherapy and unsealed radionuclide therapy
Authors: Horton Patrick , Peet Deborah J , Sutton David G , Martin Colin J
Published: November 2017

The facilities and safe procedures required for afterloading (remote low, pulsed, and high dose-rate and manual), permanent seed implants, external plaques, intraoperative radiotherapy with X-ray sources, and unsealed radionuclide therapy (inpatient and outpatient) are described. Treatment room design makes particular reference to the shielded rooms required for high dose-rate afterloading and unsealed radionuclide therapy with I-131 and examples are included for calculating shielding thickness to achieve required dose constraints. Room location, layout, good practice, and engineering controls are also described, together with radiation surveys of completed facilities. The storage, handling, and record-keeping for both sealed and unsealed sources is discussed. The need for risk assessments and contingency plans is emphasized. Data for calculating shielding thickness and X-ray scatter for maze design are provided.
Recovery room routines
Authors: Hatfield Anthea
Published: November 2017

In this chapter patients are followed from the operating theatre to the recovery room. Their care is discussed and routine procedures described. Nurse and anaesthetist handovers are outlined, and the transfer of the patient back to the ward is explained.
Postoperative nausea and vomiting
Authors: Hatfield Anthea
Published: November 2017

Postoperative nausea and vomiting commonly occur after surgery and anaesthesia. Patients find it very distressing and this chapter sets out ways in which you can alleviate their symptoms: first by understanding the physiology and the causes of the problem and then by applying simple remedies and using well-tried and safe drugs. Mendelson’s syndrome of aspiration pneumonia is also described.
Regional analgesia
Authors: Hatfield Anthea
Published: November 2017

This chapter discusses the care of patients with nerve blocks. These may be epidural, spinal, or other local blocks. Epidural analgesia with its risks and complications, advantages and problems is thoroughly explained.
Pharmacology
Authors: Hatfield Anthea
Published: November 2017

Pharmacology is the study of the action and effect of drugs. This is an important subject, one that will require attentive study. Once understood, pharmacology makes the prescription of drugs both practical and meaningful. Anaesthetic drugs and their actions are described and patient factors in the metabolism of drugs are explained.
Cardiovascular physiology
Authors: Hatfield Anthea
Published: November 2017

This is a difficult chapter but read it carefully and you will be rewarded with a clear understanding of how the heart works. ECGs are revisited and there are sections on caring for patients with pacemakers and stents.
Crisis management
Authors: Hatfield Anthea
Published: November 2017

This chapter will give you the fundamental information to prepare your recovery room for any crisis. Crisis protocols and guidelines will help you to prepare for and conduct a full resuscitation. The management of anaphylaxis and seizures is described in detail.
The kidney
Authors: Hatfield Anthea
Published: November 2017

Renal failure after surgery does occur and carries a high mortality. The immediate postoperative management of the patient’s fluids is an important part of their recovery. This chapter will teach you the physiology of kidney function, how and why things go wrong, and how to anticipate and prevent renal failure from developing. Conditions that can lead to renal problems are discussed and also the effects of the drugs given to the patients during and after the operation.
Fluid balance
Authors: Hatfield Anthea
Published: November 2017

This chapter will tell you how surgery affects fluid balance and how the body controls fluids. Fluid compartments in the body and the nature of fluids are described. Disorders of fluid balance, the use of fluids to restore blood volume, and extra cellular fluid volume are all discussed. Management of fluid deficit, fluid overload, and pulmonary oedema and how to correct electrolyte balance are all clearly set out. Recommendations for fluids after different types of surgery and fluids for patients with renal and cardiac failure are given.
Metabolism
Authors: Hatfield Anthea
Published: November 2017

This chapter tells you how homeostasis in the body is achieved. Contributing factors such as stress, hormones, and the automatic nervous system are integrated into the discussion in a thoughtful way. The problem of cold postoperative patients is thoroughly referenced to modern investigation. Diabetes, how surgery destabilizes diabetics, and how to use insulin is explained. Malignant hyperthermia, thyroid storm, and acid—base disorders are all problems that can occur in the recovery room and guidelines for the management of these patients are outlined. Hydrogen ions affect haemoglobin and biochemical reactions and can cause acidosis and alkalosis—this chapter outlines how to interpret the blood gas results. How to distinguish between respiratory and metabolic causes of acid—base disorders is simply and clearly explained.
Infection control
Authors: Hatfield Anthea
Published: November 2017

Hand washing is the main subject of this chapter. The importance of hand hygiene cannot be too strongly emphasized. How infections occur and the chain of infection are described. Important organisms such as HIV/AIDS, tuberculosis, vancomycin-resistant Enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and hepatitis viruses are all included. What to do about needlestick injuries, using the N95 mask, and information about recent advances in hand hygiene using alcohol are all to be found here.
Palaeopathology of osteoarthritis
Authors: Rogers Juliet , Dieppe Paul
Published: November 2017

Palaeopathology is the study of disease in the past. Various different types of data can be used, including literature, paintings, and sculpture. In addition, for the rheumatic diseases, skeletal remains offer a particularly rich source of information for the palaeopathologist. This chapter only discusses the skeletal palaeopathology of osteoarthritis (OA). OA leaves characteristic imprints on the skeleton, such as osteophytes and bony sclerosis, which survive death, burial, and the recovery of skeletons. This has allowed researchers to compare the prevalence and distribution of OA within and between joints in skeletal collections obtained from different ancient populations in various countries. The data have shown that while OA has been common in all human populations studied, the nature, prevalence, and intra-articular distribution of the disease in different joints have probably changed over time. A high prevalence of elbow OA has been observed in many collections of human skeletons, suggesting that this joint may be more prone to the disease than generally thought, but that it might remain asymptomatic in the majority of people affected. In addition, skeletal palaeopathologists have found an association between osteophyte formation and enthesophytes, suggesting that some people may have a predisposition to osteoarticular changes characterized by new bone formation. OA has also been described and studied in different primate and other animal skeletons, providing further fascinating insights into the condition.
Cartilage (including meniscus)
Authors: van der Kraan Peter M. , Blaney Davidson Esmeralda N.
Published: November 2017

This chapter provides an overview of tissues unique to synovial joints, articular cartilage, and meniscus. The development and cellular and (bio)chemical composition are described, as well as the role of mechanical stimuli. In addition, the role of growth factors in cartilage and meniscus homeostasis, cellular differentiation, and chondrocyte hypertrophy are discussed. Furthermore, the involvement of aggrecanases and matrix metalloproteinases in cartilage and meniscus matrix degradation and osteoarthritis are described. Finally, the current status of repair of articular cartilage and meniscus is provided. This chapter reflects the changes in cellular differentiation, growth factor signalling, and altered matrix composition that contribute to osteoarthritis.
Age, gender, race/ethnicity, and socioeconomic status in osteoarthritis and its outcomes
Authors: Jordan Joanne M. , Allen Kelli D. , Callahan Leigh F.
Published: November 2017

Osteoarthritis (OA) is the most common joint condition worldwide. It can impair mobility and result in significant disability, need for total joint replacement, and healthcare utilization. OA is unusual in those younger than 40 years, then commonly the result of an underlying metabolic disorder or a prior joint injury. Some geographic and racial/ethnic variation exists in the prevalence and incidence of OA for specific joints, likely due to variation in genetics, anatomy, and environmental exposures. Many OA outcomes vary by socioeconomic status and other social factors. This chapter describes demographic and social determinants of knee, hip, and hand OA, including how these factors impact radiographic and symptomatic OA, OA-related pain and function, and its treatment.
Contextual aspects of pain: why does the patient hurt?
Authors: Walsh David A.
Published: November 2017

The context in which osteoarthritis (OA) pain is experienced moderates and, to an extent, mediates its severity and impact. Context is both internal to the patient (e.g. genes, gender, age, comorbidities, psychological distress, and catastrophizing), and a consequence of external factors (e.g. social, healthcare, and work environment). Context influences how people report their pain, and also how the nervous system processes nociceptive information. Treatment contexts moderate and mediate therapeutic effectiveness, dependent on treatment expectations, beliefs, and risk evaluation. Uptake of treatments, both in primary and secondary care, is further influenced by the contexts in which they are offered. Understanding the nature and consequences of context helps explain heterogeneity between different people with OA pain, and opens avenues for potentially powerful interventions that could improve their quality of life. Context can be adjusted through the clinician–patient relationship and by targeting risk factors for poor outcome. Concurrent weight reduction, and psychological and physiotherapeutic interventions illustrate the use of combination therapy to address multiple contextual aspects of OA pain.
Radiography and computed tomography imaging of osteoarthritis
Authors: Hayashi Daichi , Guermazi Ali , Roemer Frank W.
Published: November 2017

Osteoarthritis (OA) is the most prevalent joint disorder in the elderly worldwide and there is still no effective treatment, other than joint arthroplasty for end-stage OA, despite ongoing research efforts. Imaging is essential for assessing structural joint damage and disease progression. Radiography is the most widely used first-line imaging modality for structural OA evaluation. Its inherent limitations should be noted including lack of ability to directly visualize most OA-related pathological features in and around the joint, lack of sensitivity to longitudinal change and missing specificity of joint space narrowing, and technical difficulties regarding reproducibility of positioning of the joints in longitudinal studies. Magnetic resonance imaging (MRI) is widely applied in epidemiological studies and clinical trials. Computed tomography (CT) is an important additional tool that offers insight into high-resolution bony anatomical details and allows three-dimensional post-processing of imaging data, which is of particular importance for orthopaedic surgery planning. However, its major disadvantage is limitations in the assessment of soft tissue structures compared to MRI. CT arthrography can be useful in evaluation of focal cartilage defects or meniscal tears; however, its applicability may be limited due to its invasive nature. This chapter describes the roles and limitations of both conventional radiography and CT, including CT arthrography, in clinical practice and OA research. The emphasis is on OA of the knee, but other joints are also mentioned where appropriate.
Placebo, nocebo, and contextual effects
Authors: Abhishek Abhishek , Doherty Michael
Published: November 2017

Placebo effect is an example of ‘contextual’ effect and is the symptomatic improvement experienced by patients who have unknowingly received a placebo (inactive treatment) instead of an active drug. It occurs due to patient-specific factors such as expectation of improvement and is influenced by the context in which the treatment is delivered. Nocebo effect is the opposite of placebo effect and includes worsening of symptoms or incident adverse effects due to expectancy or negative contextual or practitioner influence. Placebo effect has been demonstrated in a range of musculoskeletal conditions, including osteoarthritis (OA), as well as other conditions such as Parkinson’s disease, irritable bowel syndrome, and asthma. In OA, the placebo effect is strongest for subjective outcomes like pain. In fact, the effect size (ES) of placebo analgesia in OA clinical trials (0.51) is clinically significant and higher than the ES (defined by the additional improvement above placebo) obtained from non-pharmacological (0.25) and pharmacological (0.39) treatments. A number of patient- and intervention-specific and contextual factors influence the magnitude of placebo-induced improvements. Placebo analgesia is real, not a ‘trick of the mind’, and results from central mechanisms that increase descending inhibition of pain. Contextual effects are an integral part of everyday clinical practice. While patient- and intervention-specific determinants cannot be changed easily, healthcare practitioners should optimize the physician-specific factors that enhance positive contextual response and minimize nocebo response. Such a strategy that will increase the overall improvement is particularly relevant for OA where there is no ‘cure’ and a predominance of negative beliefs.
Other surgical approaches in the management of osteoarthritis
Authors: Thorlund Jonas Bloch , Stefan Lohmander L.
Published: November 2017

Joint replacement is often considered the surgical treatment for patients with osteoarthritis (OA). However, several other surgical treatments, of which some are more frequently performed, have been advocated for patients with OA in order to relieve symptoms, stall progression, and avoid or postpone joint replacement. This chapter briefly describes the most common procedures such as knee and hip arthroscopy and knee and hip osteotomy. It also reviews the evidence for the efficacy of these treatments compared with non-surgical alternatives, which is frequently insufficient due to lack of controlled low-risk-of-bias studies. The risk of adverse events is also reported when data is available. Some of the more recent surgical techniques such as implantation of chondrocytes or stem cells are also described and discussed but their utility for treating osteoarthritis remains uncertain. There is a great need for continued innovation and development of surgical techniques for managing in particular the earlier stages of osteoarthritis. To reduce the risk of future costly failures, a stepwise introduction of new surgical procedures and devices must be encouraged.
Pathophysiology of gout
Authors: Dalbeth Nicola
Published: November 2017

The clinical features of gout occur in response to monosodium urate (MSU) crystals. Gout should be considered a chronic disease of MSU crystal deposition. A number of pathophysiological checkpoints are required for development of gout. First, elevated urate concentrations are required: urate overproduction and underexcretion contribute to total urate balance. Overproduction occurs due to alterations in the purine synthesis and degradation pathways. Renal underexcretion is an important cause of elevated serum urate concentrations (hyperuricaemia), and occurs through alterations in the urate transporters within the renal tubule (collectively known as the urate transportasome). Gut underexcretion (extrarenal urate underexcretion) also contributes to development of hyperuricaemia. The next checkpoint is MSU crystal formation. In some individuals with evidence of MSU crystal deposition, symptomatic gout develops. The acute inflammatory response to MSU crystals represents a self-limiting sterile acute auto-inflammatory response which is mediated by the innate immune system activation. Interleukin 1 beta is the key cytokine that contributes to the acute inflammatory response to MSU crystals. In some patients, advanced gout may occur with structural joint damage. Joint damage in gout is mediated both by direct effects of MSU crystals on joint tissue and by indirect effects of joint inflammation. In addition to their central role in pathogenesis of gout, MSU crystals have a physiological role, particularly as an adjuvant or ‘danger signal’ in immune surveillance.
Clinical presentation of gout
Authors: Jansen Tim L.
Published: November 2017

Gout most typically presents as an acute monoarthritis in characteristic joints (first metatarsophalangeal joint, midfoot and ankle). These acute inflammatory attacks are accompanied by severe pain, swelling, and commonly by erythema over the affected joint. Such attacks are often incapacitating and fully develop within 12 hours resulting in a level of approximately 80% of maximum pain. Such attacks may resolve shortly during the first few gout attacks, but after having had more attacks they may take more than 5 days to resolve. In some patients with persistent hyperuricaemia, tophaceous disease with chronic gouty arthropathy may also occur. In this chapter, characteristics of such a clinical presentation are described.
Laboratory investigations in gout
Authors: Pascual Eliseo , Sivera Francisca
Published: November 2017

Gout is a consequence of hyperuricaemia and the treatment goal is to dissolve the crystals by reducing serum urate levels. The first section of this chapter focuses on laboratory investigations on gout, reviewing serum urate levels and its determinants, methods of measurement, and urate renal handling. Additionally it reviews the use of inflammatory markers and synovial fluid cell counts. The second section of the chapter deals with the identification of monosodium urate and calcium pyrophosphate crystals in synovial fluid. It reviews the use of an optic microscope fitted with polarized filters and an analyser. A clear step-by-step process with useful tips is provided.
Clinical features of calcium pyrophosphate crystal deposition
Authors: Abhishek Abhishek , Doherty Michael
Published: November 2017

Calcium pyrophosphate deposition (CPPD) occurs in the elderly, and is commonly asymptomatic. However, it can cause acute calcium pyrophosphate (CPP) crystal arthritis, chronic CPP crystal inflammatory arthritis, and is frequently present in joints with osteoarthritis (OA). Acute CPP crystal arthritis presents with rapid onset of acute synovitis, which frequently affects the knees, wrists, shoulders, and elbows. It can mimic sepsis in the elderly, and may require hospital admission. Patients with CPPD plus OA may have more inflammatory signs and symptoms (e.g. joint swelling, stiffness) than those with OA alone. Additionally, patients with CPPD plus OA may also have intermittent attacks of acute CPP crystal arthritis. Some patients with CPPD may have more chronic inflammatory joint involvement and are classified as chronic CPP crystal inflammatory arthritis. This chapter describes the clinical features and differential diagnosis of common clinical manifestations of CPPD and outlines some of its rarer manifestations.
Oculoplastics
Authors: Gupta Tarang , Ezra Daniel
Published: November 2017

This chapter explores oculoplastics. It first details eyelid and nasolacrimal system anatomy and physiology. It then discusses lash abnormalities, covering trichiasis, distichiasis, madarosis, eyelash ptosis, hypertrichosis, and poliosis. Next, it discusses entropion, covering congenital entropion, involutional entropion, and cicatricial entropion. Next, ectropion is discussed, including congenital ectropion, paralytic ectropion, involutional ectropion, cicatricial ectropion, and mechanical ectropion. Ptosis is covered in two sections, and benign lid lesions, malignant lid lesions, epiphora, acquired nasolacrimal system abnormalities, and congenital nasolacrimal system abnormalities are also discussed. In addition, practical skills in oculoplastics are outlined, such as ptosis examination, syringing and probing, removing sutures, surgical repair of lid trauma, lateral tarsorraphy, and emergency lateral canthotomy/cantholysis.
Cornea and conjunctiva
Authors: Cleary Georgia , Barsam Allon , Tuft Stephen
Published: November 2017

This chapter focuses on the cornea and conjunctiva. It first discusses corneal anatomy and physiology, corneal nutrition, and conjunctival anatomy and physiology. Next, it outlines history taking for anterior segment disease. It then discusses clinical knowledge areas, including blepharitis, staphylococcal hypersensitivity disorders, dry eye disease, conjunctivitis, cicatrizing conjunctival disease, conjunctival degeneration, conjunctival neoplasia, corneal degeneration, infectious keratitis (bacterial, fungal, and viral), interstitial keratitis, peripheral ulcerative keratitis, metabolic and drug induced keratopathies, corneal dystrophies, contact lenses, corneal ectasia, keratoplasty, anterior uveal tumours, anterior segment trauma, chemical injury, and refractive surgery. Practical skills, such as the removal of a corneal foreign body, and corneal sutures, are also discussed.
Vitreoretinal surgery
Authors: Liyanage Sidath E. , Chen Fred K. , Bainbridge James W.
Published: November 2017

This chapter explores vitreoretinal surgery. It starts off with a detailed examination of retinal anatomy, including a discussion of retinal embryology, and then discusses the physiology of the retina. Next, it outlines the clinical skills of posterior segment history taking and examination. It then discusses the use of diagnostic lenses, which enable visualization of the fundus by neutralizing the optical power of the eye (direct lenses) or increasing the refractive power of the eye to create an inverted real image of the fundus anterior to the eye (indirect lenses). It then continues with a discussion of the practical skills of optical coherence tomography, ultrasonography, and retinal photocoagulation. The chapter also outlines clinical knowledge areas of vitreous disorders, retinal detachment, peripheral retinal abnormalities, macular surgery, submacular surgery, retinal tumours, choroidal tumours, vitreoretinopathies, and posterior segment trauma.
Cicely Saunders and her early associates: A kaleidoscope of effects
Authors: Clark David
Published: November 2017

This chapter explores the singular influence of Dr Cicely Saunders on the emerging field of interest in terminal care, together with that of her collaborators and associates. It shows how she began to articulate new ideas about the care of the dying, building on the inspiration of the terminal care homes. This required the adoption of new methods and a modern approach based on the three dimensions of clinical care, teaching, and research. These were embodied in the work of the first of the ‘modern’ hospice, St Christopher’s, which Saunders opened in 1967. Its influence was to quickly spread worldwide.
Defining the clinical realm
Authors: Clark David
Published: November 2017

To gain serious traction in the wider world of medicine, the terminal care protagonists needed to move from a loose web of activism to a concerted body of knowledge and practice. This chapter shows how a focus on cancer pain was a key line in this development. Hospice studies explored and pulled apart some of the prevailing orthodoxies about pain relief. A new confidence emerged in the use of morphine and other drugs. The concept of ‘total pain’ was coined by Saunders as a key perspective on the multi-faceted nature of suffering at the end of life. Clinical studies raised awareness of the hospice movement’s ambitions and began to demonstrate its efficacy. This in turn fuelled further investment and a rapid growth in hospice services.
Specialty recognition and global development
Authors: Clark David
Published: November 2017

The growing number of doctors working in hospices began to seek formal recognition for the specialist nature of their work. Discussions began with the Royal Colleges about how this could be achieved. There were workforce issues to be considered, as well as matters of training, development, and accreditation. The creation of specialist journals to disseminate research and clinical practice, the endorsement of the World Health Organization, and the growth of international networks of collaboration, all began to define a new field of activity. Formal recognition for palliative medicine happened first in the United Kingdom—100 years after the publication of Munk’s classic work. In time, other countries followed suit. This chapter shows how the field was now poised for an expanding role, with global dimensions. However, at the same time it faced challenges about boundaries, definition, and focus.
Working with vulnerable populations
Authors: Betancourt Theresa S. , Beardslee William , Kirk Catherine , Hann Katrina , Zombo Moses , Mushashi Christine , Kanyanganzi Fredrick , Munyana Morris , Bizimana Justin I.
Published: November 2017

We discuss key issues to consider when conducting clinical trials with vulnerable children, youths, and families, with particular attention to groups affected by communal violence/war and families affected by HIV/AIDS. Across these settings, there is an overlap of several forms of adversity and vulnerability which require careful research attention. We also discuss ethical practices with vulnerable groups, including the use of qualitative methods to enhance understanding of local perspectives and language around mental health problems and resilience, planning for risk of harm referral networks, and applications of community-based participatory research (CBPR) techniques.  Such approaches can raise community awareness and increase engagement for addressing mental health in vulnerable populations while also informing and promoting practice and policy change. Drawing from examples of work in Sub-Saharan Africa and with refugees in the US, we conclude with a series of recommendations for advancing sensitive research practices with vulnerable populations.
Trials of interventions for people with depression
Authors: Chowdhary Neerja , Rahman Atif , Verdeli Helena , Patel Vikram
Published: November 2017

Depression is a global health priority. Despite the evidence on burden and effective treatments, the vast majority of individuals affected by depression do not receive these treatments. Major challenges exist for implementation of evidence-based treatments, especially in LAMIC. A number of clinical trials have shown the effectiveness of treatment for depression across a range of low-resource settings and the common threads running through these trials. MANAS is one such trial conducted in Goa, India, which provided evidence that trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorder, suicidal behaviour, psychological morbidity, and disability days among those attending public primary care facilities. Despite the additional resources required for the intervention, costs incurred over follow-up were similar across the two arms. The role that lay health workers can play in reducing the treatment gap has important implications for mental health care in low-resource settings.
Trials for people with mental disorders and conditions associated with stress
Authors: Tol Wietse A. , Jordans Mark J.D. , Susanty Dessy , de Jong Joop T.V.M.
Published: November 2017

Exposure to negative life events is associated with worse mental health outcomes. The chapter provides an overview of mental disorders and conditions specifically associated with stress. It discusses proposals for a new category of conditions and disorders specifically associated with stress (e.g. symptoms of acute stress, post-traumatic stress disorder (PTSD), complex PTSD, prolonged grief disorder, adjustment disorder) and summarizes recent guidance for interventions. A preventive school-based intervention with children affected by armed conflict and cluster randomized trial in Indonesia is described and findings compared with trials in Burundi, Nepal, and Sri Lanka. These studies showed diverse effects of the same preventive intervention in different contexts and for different sub-populations. In accordance with a socioecological framework, intervention results were dependent on the extent to which children were exposed to ongoing events and the level of support they could draw on.
The importance of causal relationships in medicine and health care
Authors: Elwood Mark
Published: November 2017

This shows the importance and relevance of causal relationships in clinical medicine, public health, and wider healthcare and social issues. It gives a definition of causation, and distinguishes necessary, sufficient, and general quantitative causation. Randomised trials are discussed as showing a direct test of causation. Epidemiological methods of counting disease are explained, showing mortality, incidence, prevalence, disease duration, the relationship between these, and cumulative incidence.
Study designs which can demonstrate and test causation
Authors: Elwood Mark
Published: November 2017

This chapter presents study designs which can test and show causation. Cohort and intervention studies compare people exposed to an agent or intervention with those unexposed or less exposed. Case-control studies compare people affected by a disease or outcome with a control group of unaffected people or representing a total population. Surveys select a sample of people, not chosen by exposure or outcome. Cohort studies may be prospective or retrospective; case-control studies are retrospective; surveys are cross-sectional in time, but retrospective or prospective aspects can be added. In part two, strengths, weaknesses and applications of these designs are shown. Intervention trials, ideally randomised, are the prime method of assessing healthcare interventions; special types include crossover trials and community-based trials. Non-randomised trials are noted. The strengths and weaknesses of cohort studies, case-control studies, and surveys are shown.
Confounding
Authors: Elwood Mark
Published: November 2017

This chapter gives the definition of confounding, a central issue in epidemiology and its dependence on two associations, with exposure and with outcome. It explains confounding in trials, cohort and case-control studies, and Simpson’s paradox. It explains the five methods of controlling confounding: restriction, randomisation, stratification, matching and multivariate methods. For randomised trials, the limits of randomisation, residual confounding, pre-stratification, intention-to-treat, management and explanatory trials, pragmatic trials are explained. It shows the Mantel–Haenszel risk ratio or odds ratio, direct and indirect standardisation, and effect modification. Frequency and individual matching, their value and limitations, over matching, confounding by indication, and calculation of matched odds ratio are shown. It explains multivariate methods, including linear, logistic, Poisson, and Cox’s proportionate hazards models, including the relationship between coefficients and odds ratios, dummy variables, conditional methods, and propensity scores.
Critical appraisal in action
Authors: Elwood Mark
Published: November 2017

This short chapter introduces the next six chapters, each of which shows a published paper and presents a critical assessment of the study, with comments on further research since. Each critical assessment follows the system set out in chapter 10.
Critical appraisal of a prospective cohort study
Authors: Elwood Mark
Published: November 2017

This chapter presents a prospective cohort study with active follow-up over many years, assessing the relationship between breastfeeding and atopy and asthma. This shows the logistic issues involved and the analysis. The results conflict with some other studies, and the question has yet to be fully answered. The critical assessment follows the scheme set out in chapter 10: describing the study, assessing the non-causal explanations of observation bias, confounding, and chance variation; assessing time relationships, strength, dose-response, consistency and specificity, and applying the results to the eligible, source, and target populations; and then comparing the results with evidence from other studies, considering consistency and specificity, biological mechanisms, and coherence with the distribution of exposures and outcomes. The chapter gives a summary and table of the critical assessment and its conclusions; and comments on the impact of the study and research carried out since.