bluuebunny/crossref_metadata_2025 huggingface dataset:
The Unified Protocol for Use with Adolescents with or at Risk for Serious Mental Illness
Authors: Weintraub Marc J. , Zinberg Jamie
Published: September 2021

Youths with or at high risk for serious mental illness (SMI; i.e., psychotic or bipolar disorders) have heterogeneous psychiatric symptoms, including significant overlap with more common depressive and anxiety disorders. There are also heterogeneous illness trajectories, as some youth go on to develop chronic and debilitating SMIs while a large proportion have symptoms that remit or remain relatively milder. This chapter presents the rationale for using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) as a first-line, transdiagnostic, cognitive-behavioral treatment for youth with early SMI symptoms. This treatment is delivered in a group format including parents in an effort to reduce stigma, increase social support, and improve skill acquisition. Preliminary feasibility and efficacy data are presented as well as a case vignette. Recommendations are offered on how to deliver this treatment and troubleshoot common difficulties.
Whole-Person Assessment of the Patient
Authors: Ferrell Betty , Battista Vanessa
Published: September 2021

Comprehensive assessment provides the foundation for enhancing the quality of life of a seriously ill patient, forms the basis of care, and helps in the coordination of care across disciplines. A whole-person assessment in palliative care extends beyond basic patient evaluation by recognizing the unique needs of patients who face serious illness and the needs of their family members. It provides additional information on symptoms and physical and psychological concerns often present in advanced disease and assists in the evaluation of social factors such as family caregiver needs and the assessment of spirituality, which is recognized as an important aspect of patient and family support in serious illness.
Clinical Interprofessional Model of Spiritual Care
Authors: Puchalski Christina M.
Published: September 2021

To standardize and institutionalize spirituality as a component of whole-patient care, the biopsychosocial-spiritual model must be integrated across the continuum of care for all patients. This chapter explores the clinical interprofessional model of spiritual care. The biopsychosocial-spiritual model recognizes the distinct dimensions—biological, psychological, social, and spiritual—of a person and the fact that no dimension can be left out when caring for the whole person. This chapter describes a consensus- and evidence-based model that enables clinicians to fully attend to the spiritual needs and the spiritual distress that patients and their families may experience. The chapter is rounded out by two case examples.
Gastrointestinal Symptoms
Authors: Curseen Kimberly Angelia , Rizzolo Denise , Deutchman Mark
Published: September 2021

Patients with advanced illness often carry a high gastrointestinal symptom burden. These patients are at risk for poor oral health secondary to polypharmacy and limited access to appropriate dental care. Oral health directly correlates with overall health of patients. Nausea, vomiting, and constipation are common symptoms that initiate referrals to palliative care. Patients at the end of life and/or with advanced illness will likely experience gastrointestinal dysmotility related to their underlying illness and medications. Providers need to be adept at recognizing symptoms and starting the appropriate palliative measures. Addressing these symptoms appropriately can result in improved quality of life and significant reduction in morbidity for patients. A stepwise evidence-based approach is required to successfully manage these symptoms in patients undergoing curative, maintenance, and/or palliative therapy.
Genitourinary Issues in Palliative Care
Authors: Kim Min Ji , Tanco Kimberson
Published: September 2021

Genitourinary problems in palliative care can be very distressing to patients and require prompt management and alleviation of symptoms. Examples include urinary tract obstruction, which can lead to pain and kidney injury, as well as infection, hematuria, renal colic, and bladder spasm-related pain. This chapter addresses relevant aspects of palliative care in patients with genitourinary issues, including consideration for context of symptoms and subsequent practical management. Options for symptom management may range from medications to procedural interventions. In deciding between treatment options, factors such as the patient’s preexisting comorbidities, performance status, goals of care, and anticipated benefit in symptom control and in quality of life versus potential burden of treatment must be considered.
Family Stress
Authors: Snow Denis , Lasala Mary Ellen
Published: September 2021

Serious illness creates a need for financial and legal support for individuals and their families. Nonmedical issues are often as pressing on them as their medical concerns. Clinicians must have a basic understanding of meeting those needs of advance planning, income and family maintenance, access to insurance, and family preservation within the context of culturally appropriate care. Knowledge of community and faith-based resources to meet the nonmedical needs of the palliative care patient is an essential aspect of care. Since these are often unknown to patients and their families, the clinician must know how to guide patients through the morass of cultural and legal requirements for this purpose.
Ethical and Legal Issues
Authors: Cole-Gifford Bonnie K. , Wohlrabe Kathlyn F.
Published: September 2021

The sections of this chapter discuss both evaluation and management of legal and ethical aspects of the physician assistant (PA) profession, taking into consideration that the PA practice flows out of an interconnected relationship between the PA, the physician, and the patient. PAs are called to fulfill not only the law when practicing but also rise to uphold ethical principles. There are a variety of situations a provider can encounter throughout a career. Some topics are present in every patient encounter, such as confidentiality and informed consent. Some topics may only be present in certain cases, such as advanced directives and futile treatment. Nevertheless, the provider should be knowledgeable about each of these legal and ethical situations and understand the evaluation and management of them.
A look at vision, and a touch more
Authors: Arbib Michael A.
Published: September 2021

Le Corbusier’s distinction between engineering and architectural aesthetics introduces the challenges of balancing the practical and the aesthetic, and introduces his dictum, “A house is a machine for living in.” Here, beauty is just one aspect of the emotional impact of a building. Early visual processing in the frog is action-oriented, while in the primate it is general-purpose. These support different approaches to aesthetic judgment of visual form and suggest deep evolutionary underpinnings of aesthetic judgment. Neuroscientists distinguish working memory, episodic memory, procedural memory, and semantic memory. The VISIONS model exemplifies some of these, as well as principles of brain operation, including competition and cooperation of schema instances in constructing an interpretation of a visual scene. What people attend to is influenced by task and motivation. After assessing how a blind artist developed the ability to paint pictures, the chapter outlines MULTIMODES, a cognitive model that extends the principles of VISIONS to multimodal action-oriented perception of episodes.
The Militarized Arena of Medicine
Authors: Fuks Abraham
Published: September 2021

The predominant metaphor in the discourse of medicine is that of war and the military. American presidents of the past century have defined important social policies in terms of battles to be fought and foes to be vanquished, physicians and patients “wage war on cancer,” and cookbooks offer recipes to fight disease. These military tropes are not innocent depictions of medical care—they shape our understanding of illness, disease, and health. Patients become battlegrounds on which doctors fight disease, yet may shoulder the responsibility for “losing.” Obituaries are replete with tributes to heroic patients and valiant battles. This chapter describes different models of medical wars with varying combinations of protagonists and enemies and the effects of such metaphors on how we perceive epidemics and practice public health. It describes the social pressures that force patients to “fight to the end” and the frequent loneliness experienced by those with serious illness.
Adapting to the Diagnosis
Authors: Jacobsen Juliet , Jackson Vicki , Greer Joseph , Temel Jennifer
Published: September 2021

This chapter describes the first challenge of serious illness, adapting to the diagnosis. It explores the beginnings of prognostic awareness (the patient’s understanding of his or her most likely disease trajectory and life expectancy) and discusses the seemingly confusing way that patients cope with a new cancer diagnosis: by swinging, as if they are on a pendulum, between moments of hope and moments of worry. It outlines how palliative care clinicians can help patients adapt to and cope with this life-changing news, thereby developing a partnership. The chapter also describes how palliative care clinicians can build an effective collaboration with oncology colleagues. It focuses on how to manage role overlap and the interpretive role of the palliative care clinician in helping the patient and the oncologist to understand each other.
COVID's Impact on Health and Healthcare Workers
Authors: Goldenberg Don
Published: September 2021

The symptoms, risk factors and typical course of mild, moderate and severe COVID-19 infections are detailed, focusing on correlations with hospitalization and death. The physical and emotional toll on healthcare workers is described, as well as the innovations and sacrifices made by physicians, nurses, and hospitals during the pandemic. Present and enduring changes in primary care and mental healthcare, including increased utilization of telemedicine, are explained. The misinformation and disinformation raging during the pandemic and their adverse effect on public health and patient recovery are uncovered. There is a focus on persistent symptoms, long after the initial COVID infection, including long-COVID syndrome. The book concludes with recommendations to best move forward, addressing public health, healthcare inequities, long-term care facilities, primary care, healthcare worker well-being, and following science and truth.
A Stepwise Framework for Shared Decision Making in Pediatrics
Authors: Sawyer Kimberly E. , Opel Douglas J.
Published: September 2021

It is poorly understood when and how to use shared decision making (SDM) in pediatrics. To address this gap, this chapter presents a practical stepwise framework for putting SDM into practice in pediatrics. This framework includes four steps. The first three steps pose a question to the physician, with the answers directing the physician further along the framework: Step 1 (Medical Reasonableness): Does the decision include more than one medically reasonable option? Step 2 (Benefit-Burden): Does one option have a favorable medical benefit–burden ratio compared to other options? Step 3 (Preference Sensitivity): How preference sensitive are the options? Step 4 (Calibration): This step provides direction on the specific SDM approach to use for the decision under consideration based on the answers to Steps 1 through 3 as well as other decisional characteristics present. For each step, we expound on its rationale, application, and potential issues.
Dimensions of Externalizing Problems
Authors: Lahey Benjamin B.
Published: September 2021

Unlike the internalizing domain of psychological problems, externalizing problems are not defined by the experience of inherently distressing emotions such as anxiety or sadness. Rather, they are defined by patterns of behavior that interfere with living a successful and satisfying life. People with high levels of externalizing problems are often very distressed, but they are mostly distressed by the consequences of their actions. Their inattentive, hyperactive, impulsive, irritable, oppositional, antisocial, callous, psychopathic, narcissistic, and histrionic behaviors and their abuse of, and dependence on, psychoactive substances interfere with functioning in school, work, and other settings; alienate peers and family members; and can lead to serious social consequences such as family conflict, being fired from employment, or incarceration.
‘Those first forgotten particles’
Authors: Compston Alastair
Published: September 2021

Chapter 5. ‘Those first forgotten particles: Diatribae duae medico-philosophicae (1659–1687)’ provides a detailed bibliography, using the system described in chapter 4, of sixteen copies of Willis’s first published book in which are included three treatises: 1. De fermentatione; 2. De febribus; and 3. De urinis. The treatises on fermentation and fevers were translated and published in Dutch, together with the short work on scurvy (first published in 1667); and, alone amongst Willis’s writings, the treatise on urines was translated and published in French. These descriptions are preceded by a narrative highlighting the main bibliographic issues that characterize the various editions, states, and issues of these copies. Of these, some are already known but others newly identified. {117 words}
‘Satisfying a mind desirous of truth’
Authors: Compston Alastair
Published: September 2021

Chapter 13, ‘Satisfying a mind desirous of truth: Dr Willis’s practice of physick (1679–1684)’ provides a detailed bibliography, using the system described in chapter 4, of eleven copies of Willis’s treatises in English, books nine to twelve, intended as a single work, variously including treatises 1–13: made up as three copies of treatises 12–13, 7 (Pharmaceutice rationalis, 1679); three copies of treatises 1–6, 9–10 (The remaining medical works, 1681); one copy of treatises 1–7, 9–10, 12–13 (Dr Willis’s practice of physick, 1681); one copy of treatise 11 (Two discourses concerning the soul of brutes, 1683); and three copies of treatises 1–7, 9–13 (Dr Willis’s practice of physick, 1684). These descriptions are preceded by a narrative highlighting the main bibliographic issues that characterize the various editions, states, and issues of these copies. Of these, some are already known but others newly identified. {149 words}
Essential medicines for palliative care
Authors: Radbruch Lukas , De Lima Liliana
Published: September 2021

The World Health Organization defines essential medicines as those which satisfy the primary healthcare needs of the population. In 2013, the World Health Organization introduced a new section on medicines for pain and palliative care in the 18th edition of the Model List of Essential Medicine including 15 medicines for the most common symptoms in life-limiting health conditions. More recently, the Lancet Commission on palliative care developed an essential package which also includes equipment and human resources in addition to the essential medicines. The Lancet Commission specified that in order to achieve universal health coverage, coverage of the essential package is recommended by dedicated, pro-poor, public or publicly mandated funding and for all relevant health conditions. However, in many regions of the world, all or some of the essential medicines are not available at all, or if they are available in the country, they are regularly out of stock in the local pharmacy, out-of-pocket costs are so high that patients cannot afford the medicines, or whole families become impoverished buying treatment for their loved one. Problems with accessibility, affordability, and availability are particularly evident with opioid analgesics such as morphine. However, accessibility, affordability, and availability of essential medicines is a pivotal prerequisite for the delivery of quality palliative care.
Burnout, compassion fatigue, and moral distress in palliative care
Authors: Cherny Nathan I. , Ziff-Werman Batsheva , Kearney Michael
Published: September 2021

Work in palliative care and, in particular, end of life care is associated with inherent stressors that affect the well-being of clinicians working in the field. Work stressors may have diverse impacts on the emotional and professional lives of palliative care and hospice staff, including every member of the clinical team, volunteers, and administrators. They may negatively affect professional function and adversely influence the effectiveness and quality of care. They also may compromise the ability to sustain a career in palliative care. This chapter reviews issues related to burnout, compassion fatigue and moral distress, exploring contributing factors, describing the impact of these phenomena, and presenting strategies to prevent and to manage them.
Occupational therapy in palliative care
Authors: Denise Pessoa Silva Maria , Rolls Fiona , White Lynne , Longley Tamsin , Murphy Jane , Cooper Jill
Published: September 2021

Occupational therapy in palliative care aims to help patients achieve their optimum independence for as long as possible in activities that are important to them. There is a wide range of difficulties and symptoms experienced by palliative patients with which occupational therapy can intervene, which may include physical disabilities and functional impairments, extreme fatigue, anxiety, shortness of breath, and cognitive deficits. This chapter describes the broad range of areas in which the occupational therapist works in palliative care together with the multidisciplinary team. They take a key role in assessing and treating functional difficulties, organizing and facilitating safe discharge and care at home, with the aim of achieving best quality of life and avoiding admission to hospital whenever possible. The occupational therapist analyses and assesses specific problems and provides a treatment programme or solution to help the patient remain as independent as possible, using clinical reasoning and evidence-based practice.
Opioid therapy
Authors: Pergolizzi Joseph V. , LeQuang Jo Ann , Coluzzi Flaminia , Mariano Dean , Nicolaou Andrew , Gharibo Christopher
Published: September 2021

Opioid use disorder (OUD) is a prevalent condition associated with substantial morbidity, mortality, and healthcare utilization. Prescribers must rely on multiple tools and tactics to help reduce the risk of OUD. These include identification of risk factors for OUD and risk stratification, which must be individualized for each patient. Opioid diversion must be considered distinct from OUD and it has some unique risk factors. Aberrant drug-related behaviours may be observed in those taking opioids and may or may not suggest OUD; risk factors for OUD are dynamic. However, many aberrant drug-related behaviours may be harmless or misinterpreted. A variety of validated risk assessment tools are available to better quantify risk for OUD. An important factor in thwarting OUD remains patient and prescriber education as well as specialized resources such as patient–prescriber agreements, abuse-deterrent formulations of opioids, urine drug screens, and prescription drug monitoring programmes. There is no single, easy way to reduce OUD; instead, prescribers must be aware and make use of the many tools at their disposal to better pre-emptively identify those at elevated risk for OUD and to offer help to those who develop OUD over the course of prescribed opioid therapy.
Integrative medicine therapies in pain management
Authors: Samuels Noah , Ben-Arye Eran
Published: September 2021

Pain is a common and often debilitating symptom in both oncology and non-cancer settings, with conventional medical treatments often limited by adverse effects. Integrative medicine provides non-conventional therapies in a conventional setting, offering an additional option for the treatment of symptoms, including pain. Clinical research supports modalities such as acupuncture, touch therapies, and mind–body medicine (yoga, meditation, music therapy, hypnosis, etc.) in the treatment of pain, most significantly when provided as an ‘add-on’ to conventional palliative and supportive care. The Society for Integrative Oncology’s evidence-based guidelines on the use of integrative medicine in patients with breast cancer include the treatment of pain and exacerbating factors such as anxiety and stress. These guidelines have been endorsed by the American Society for Clinical Oncology and are in keeping with those recommended by the National Comprehensive Cancer Network. This chapter examines the effectiveness of integrative medicine in the treatment of pain in both oncology and non-cancer settings. An open and effective collaboration is needed among integrative physicians, who understand both paradigms of care, and palliative care professionals. Ways in which this collaboration can be advanced and future directions for research in the treatment of pain in palliative care are discussed.
Nausea and vomiting
Authors: Dorman Saskie
Published: September 2021

Nausea and vomiting are common, distressing symptoms, with significant impacts on physical functioning, psychological state, and social interaction. There are numerous causes including gastrointestinal, metabolic, treatment-related, vestibular, cranial, and psychological causes. Vomiting is mediated through pathways involving the nucleus of the solitary tract in the brainstem, with inputs from the gastrointestinal tract, viscera, vestibular system, area postrema, and higher centres. Nausea involves more complex connections between gut and brain. The roles of non-pharmacological strategies and medications (including levomepromazine, olanzapine, haloperidol, metoclopramide, domperidone, hyoscine hydrobromide, serotonin (5-HT3) antagonists, neurokinin antagonists, and others) are discussed. Emerging evidence in palliative care will facilitate optimum treatment.
Constipation and diarrhoea
Authors: Larkin Philip J.
Published: September 2021

Constipation is a common problem for palliative care patients, notably due to opioid-based pain management which physiologically impacts gut motility. Idiopathic diarrhoea is far less common in palliative care patients given opioid management. If present, it should be investigated, although it is often related to suboptimal constipation treatment. The management and treatment of both symptoms is largely a balance between pharmacological and non-pharmacological interventions. New treatments for the management of constipation using peripherally acting mu-opioid antagonists (PAMORAs) offer effective solutions as part of a range of clinical interventions to prevent and manage the problem successfully. A clear descriptive history is essential for optimal treatment of both constipation and diarrhoea.
Fatigue
Authors: Yennurajalingam Sriram , Bruera Eduardo
Published: September 2021

Fatigue is the most frequent, complex, multidimensional, and debilitating symptom in patients with advanced life-limiting diseases. In cancer patients, it is defined as ‘distressing persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning’. In the majority of patients receiving palliative care, the aetiology of fatigue is multifactorial. The most common factors associated with fatigue include anorexia/cachexia, pain, anxiety, depression, shortness of breath, sleep disturbances, anaemia, and inflammation. Routine screening for fatigue is essential for optimal assessment of fatigue. Initial management should aim towards identification and treatment of the reversible/underlying causes However, if there are no reversible causes identified or if the fatigue is not responsive to specific treatments, symptomatic treatment should be considered.
Sexuality in palliative care
Authors: Kadwell Lauren , Ussher Jane , Gilbert Emilee , Perz Janette , Hordern Amanda
Published: September 2021

Experiencing a life-limiting illness has the potential to radically transform every aspect of a person’s life, including how they feel about themselves, their body, and their sense of self within intimate and sexual relationships. For many people with a life-limiting illness, intimate and sexual moments are a vital aspect of their life, providing a sense of connectedness and assisting the person to explore and find meaning to living, dying, and death. Few health professionals view patients in their care as sexual beings and if they do, they struggle to know what and how to raise the topic of sexuality and intimacy within their clinical roles. This chapter defines patient sexuality and intimacy in the context of palliative care, explores the impact of natural ageing and treatment for cancer and chronic illnesses, and provides an introduction to opening communication and providing practical strategies to support the patient through intimate and sexual changes.
Radiotherapy in symptom management
Authors: Hoskin Peter
Published: September 2021

Radiotherapy has a major role in symptom control and over 40% of all radiation treatments are given with palliative intent. In the palliative setting, radiotherapy will usually be delivered using high-energy external beam treatment from a linear accelerator. Bone metastases may be treated with intravenous systemic radioisotopes and dysphagia with endoluminal brachytherapy. A general principle of palliative radiotherapy is that it should be delivered in as few treatment visits as possible and be associated with minimal acute toxicity. The main indications for palliative radiotherapy are in the management of symptoms due to local tumour growth and infiltration. These include pain from bone metastases, visceral pain from soft tissue metastases, and neuropathic pain from spinal, pelvic, and axillary tumour. Local pressure symptoms are particularly onerous and potentially dangerous when they affect the nervous system; thus, spinal canal compression remains one of the few true emergency situations in which radiotherapy is indicated. Similarly, brain, meningeal, or skull base metastases require urgent assessment and can be helped with local radiotherapy. Obstruction of a hollow tube or drainage channels can lead to significant symptoms and again local radiotherapy can be valuable in addressing this scenario. Such indications would include dysphagia, bronchial obstruction, leg or arm oedema, vena cava obstruction, or hydrocephalus. Finally, haemorrhage can be distressing if rarely life-threatening. Local radiotherapy to bleeding tumours in the lung, bronchus, bowel, genitourinary tract, and skin is very effective at control of bleeding.
Ethical issues in physician aid-in-dying
Authors: Materstvedt Lars Johan
Published: September 2021

According to international convention, physician aid-in-dying includes euthanasia and physician-assisted suicide, both of which are voluntarily requested forms of medicalized killings. In the former, a physician injects the patient with lethal drugs, whereas in the latter, the patient self-administers such drugs. The two practices differ fundamentally from non-treatment decisions and from the last-resort treatment, palliative sedation, and details of the differences are outlined in the chapter. Physician aid-in-dying differs considerably in appearance, depending on which normative ethical theory is taken as the point of departure and how various theories can be used either to reject or to defend physician aid-in-dying. The chapter also discusses alternative ways for palliative care physicians to relate to physician aid-in-dying.
Teaching and training in palliative social work, chaplaincy, and pharmacy
Authors: Glajchen Myra , Handzo George , Ahmed Ebtesam
Published: September 2021

As specialist-level palliative care evolves in developed and developing countries, increasing numbers of social workers, chaplains, and pharmacists are participating as members of interdisciplinary teams. These disciplines are faced with a workforce that may be inadequately trained to meet increasingly complex patient needs. As a result, systematic efforts to provide education, training, and certification are appearing. In some countries, these efforts gain support and legitimization through legislative and reimbursement practices. In other countries, there are few opportunities for training as the disciplines involved struggle for recognition as core providers of palliative care. Countries with professional associations that have embraced the role in palliative care have produced more defined training curricula and a stronger presence, but the growth is uneven. This chapter explores the state of the science in teaching and training for specialist palliative social work, chaplaincy, and pharmacy.
Research into psychosocial issues
Authors: Kissane David W. , Grossman Christopher H. , O’Callaghan Clare
Published: September 2021

Psychological, existential, spiritual, and social issues cause much suffering and deserve extensive study to understand these concerns more fully and to intervene more effectively. Themes that abound include communication, coping, ethics, the family, caregiving, quality of life, death and dying, psychiatric disorders, suffering, and the many expressions of distress. Many study designs are possible to explore these themes, often with complementary quantitative and qualitative components. This chapter summarizes the psychometric properties of many of the instruments that are commonly employed in such studies, and describes quantitative, qualitative, and mixed methods designs used. The goal is to strengthen research design and optimize research outcomes to benefit the discipline.
Health services research in palliative and end of life care
Authors: Smets Tinne , Deliens Luc
Published: September 2021

Clear information about the effectiveness of services and interventions is often lacking in palliative care service planning. The development of palliative care services and interventions should be based on evidence that they will increase the likelihood of desired outcomes, but also understanding the process of the intervention and how it might work in practice are vital in building an evidence base that informs policy and practice. Health services research in palliative care covers topics such as palliative care needs, access to palliative care, quality of care and feasibility, effectiveness, and cost of palliative care services and interventions. Patients needing palliative care often have complex needs and require complex services and interventions. The Medical Research Council guidance for developing, evaluating, and implementing complex interventions, the MORECare statement on ‘best practice’ methods for research evaluating end of life care, and the Medical Research Council guidance on process evaluation offer useful support for researchers undertaking health services research. To evaluate complex services and interventions, a wide ranch of study designs can be used. Studies that enrol patients with advanced illness present unique challenges, both ethical and methodological.
Measurement of Apathy
Authors: Mortby Moyra , Mele Bria , Ismail Zahinoor , Miller David
Published: September 2021

Apathy, whether considered a syndrome or a symptom, is increasingly being diagnosed. Marin and colleagues first described apathy as a syndrome characterized by deficits in goal-directed behaviour, goal-directed cognitive activity, and emotions. Diagnostic criteria for apathy have since been published and are used in clinical and research settings to assess apathy in neurodegenerative and neuropsychiatric disorders. Apathy is assessed using a variety of methods, including diagnostic criteria-based clinical interviews, administration of assessment scales, and observational ratings of behaviours by a trained specialist. A number of assessment tools are available to assess severity and change of apathy symptoms and to distinguish apathy from other comorbid syndromes commonly observed in neurocognitive disorders. This chapter provides a detailed overview of apathy measures in neurocognitive disorders, focusing on diagnostic criteria and commonly used assessment tools.
Anatomy and spontaneous closure of the ductus arteriosus
Authors: Obladen Michael
Published: September 2021

The ductus arteriosus and foramen ovale were described by Galen without understanding their functions. His beliefs in soul localization and spiritization within the left ventricle established religious pneumatology which became a theological need in the Middle Ages. Pulmonary transit was recognized by Servetus and Colombo after the Reformation around 1550. This prompted Harvey’s full understanding of the fetal circulation. Botallo did not describe the ductus arteriosus, but in 1564 redescribed the foramen ovale, making his way into the Nomina Anatomica by mistake. Most authors of the 19th and 20th centuries believed ductal patency to be passive, and postnatal closure to be an active process, explained by mechanical theories. After the discovery of prostaglandins by Bergstrom and Vane, Coceani proved that ductal patency is maintained by the relaxant action of prostaglandins.
From monster to reversed perfusion
Authors: Obladen Michael
Published: September 2021

A human being born without heart and head, the acardius/acranius malformation, has been described since antiquity. Superstition and fear made it a mystical disorder, a sign of God’s wrath. The inquisition ruled that acranic infants should not be baptized and located the soul in the brain. Acardia was not associated with twin gestation until the reports of Méry (1720) and Winslow (1740) were published in Paris. In 1850, Meckel identified the pathogenetic mechanism as reversed perfusion due to large arterioarterial and venovenous anastomoses; he believed the heart would fail to develop or stop during development, and the acardiac fetus would be maintained by arterial perfusion from the pump twin. In 1859, Claudius articulated that after normal initial development, the heart degenerates when backwards flow in the aorta leads to thrombosis. Today, it is assumed that both mechanisms may exist. With the advent of prenatal ultrasound diagnosis and radiofrequency ablation of the acardiac twin’s circulation, it became possible to save the pump twin.
Crooked limbs
Authors: Obladen Michael
Published: September 2021

This chapter describes thalidomide embryopathy as a paradigm of exogenous malformation. Previously, 1 in 1000 newborns had a limb anomaly, dreaded by agrarian societies that valued their offspring according to their bodily fitness. During the Middle Ages, malformations were attributed to cohabitation with animals or maternal imagination. Thalidomide, produced by the German company Chemie Grünenthal, was a popular sleeping pill marketed in Germany from 1957, in Britain from 1958, and in many other countries. With a 9-month delay and until 1962, over 10,000 severely malformed infants were born worldwide, the most frequent defects being limb reductions, ear and eye anomalies, and heart malformations. The drug’s toxicity was species specific and acted from 24 to 33 days after fertilization, when many women did not yet know they were pregnant. The epidemic was the greatest disaster in the history of pharmacology, and revealed severe shortcomings in German drug legislation. In the aftermath of this catastrophe, drug laws were tightened and patient safety has improved. The price was that in European countries, it became difficult to develop new drugs for infants.
A wretched condition
Authors: Obladen Michael
Published: September 2021

Although rare, cleft bladder was known to the ancients: the infants did not die after birth, but grew up incontinent. Combined with abnormal genitalia, the malformation was confused with hermaphroditism, the most loathed congenital anomaly. Three grades were discerned in the 17th century: epispadias, where the urethra opens at the anterior side of the penis; bladder exstrophy with open anterior bladder wall; and cloacal exstrophy with common outlet for stool and urine. Explanations of its origin included obstructed urethra, short umbilical cord, and bursting allantois, bladder, abdominal wall, or cloacal membrane. As the incontinent children suffered from painful inguinal eczema, urine collecting devices were constructed from copper and tin, and from rubber once vulcanization was invented. Correcting operations were attempted from 1852 with limited success. Today, stepwise corrective surgery begins by closing the bony pelvis, bladder, and the abdominal wall, followed by epispadias repair and penis remodelling. No controlled trials or international protocols have come forth, and the long-term prognosis is all but satisfying.
Bad milk
Authors: Obladen Michael
Published: September 2021

Throughout history, philosophical and medical authorities seemed to reinforce breastfeeding, but with limited success. It is probable that medical doctrines created a hostile environment for breastfeeding. According to Aristotle, Soranus, and Galen, milk was believed to derive from retained menstrual blood in the uterus and to be transferred to the breasts via specific vessels. From this theory, the doctrines emerged that: (1) lactating women had to abstain from sexual intercourse; (2) breastfeeding should be delayed as colostrum would poison the infant; (3) unwholesome milk would cause disease, especially convulsions, in the infant; (4) frequent and prolonged breastfeeding would spoil the infant; and (5) breastfeeding would destroy maternal health and beauty. As hormones were unknown, virtually all medical textbooks reiterated these doctrines. Medical doctrines impeded rather than promoted breastfeeding for over two millennia. Misinformation and indoctrination persisted well into the 19th century and may persist secretly in many people’s prejudices.
Cot death
Authors: Obladen Michael
Published: September 2021

Since antiquity, cot death was explained as accidental suffocation, overlaying, or smothering. Parents were blamed for neglect or drunkenness, and a cage called arcuccio was invented around 1570 to protect the sleeping infant. Up to the 19th century, accidents were registered as natural causes of death. From 1830, accidental suffocation became unacceptable for physicians and legislators, and ‘natural’ explanations for the catastrophe were sought, with parents being consoled rather than blamed. Prone sleeping originated in the 1930s and from 1944 was associated with cot death. However, from the 1960s many authors recommended prone sleeping for infants, and many countries adopted the advice. A worldwide epidemic followed, peaking at 2% in England and Wales and 5% in New Zealand in the 1980s. Although epidemiological evidence was available by 1970, the first intervention was initiated in the Netherlands in 1989. Cot death disappeared almost entirely wherever prone sleeping was avoided. This strongly supports the assumption that prone sleeping has the greatest influence on the disorder, and that the epidemic resulted from wrong advice.
Theirs is the kingdom of heaven
Authors: Obladen Michael
Published: September 2021

For many centuries, one in three newborns did not survive up to their first birthday, and details and causes of their death were unknown. Pioneers of vital statistics were Graunt and Petty in Britain, Süßmilch in Prussia, Berg in Sweden, Quetelet in Belgium, Villermé in France, Bodio in Italy, and Woodbury in the US. Since 1860, halfway reliable records were available, and infant mortality, at that time ranging from 100 to 300 per 1000 live births, was perceived as a humanitarian and political problem. Variables identified as associated with infant mortality included artificial feeding, poor sanitation, parental social and marital status, male sex, ethnicity, prematurity, and others, although their precise mechanisms often remained unclear. Since 1860, a dramatic and sustained decline in infant mortality caused a demographic revolution. Recent infant mortality rates ranged from 2 to 12 per 1000 live births in developed countries. Most of this reduction was achieved through public health measures and improved sanitation. Only since prematurity became the major cause of mortality could medicine claim to have enabled most of this progress.
Neurobiology of injury (compression, traction, laceration) and repair, and grading of injuries
Authors: Hart Andrew
Published: September 2021

The functioning nervous system is an integrated system including conscious and subconscious pathways in the brain and spinal cord, the peripheral nerves, and specialized target organs. Efferent and afferent feedback pathways integrate at multiple levels, and there is interplay with mood, life function, growth, and development. The peripheral nervous system provides homeostatic and pain functions, and links the virtual world of our consciousness to the physical body that senses and manipulates the world around us. Injury disconnects the central nervous system from physical reality and induces profound, time-dependent changes at all levels of the system that mostly impede functional restitution after nerve reconstruction. For surgery to optimize outcomes it must be timely, and applied with precision, neurobiological awareness, and aided by adjuvant therapies or technologies that modulate responses within the central nervous system, primary motor and sensory neurons, repair site, distal nerve stump, and target organs.
Brachial plexus injury in the child
Authors: Bains Robert , Kay Simon
Published: September 2021

Obstetric brachial plexus palsy (OBPP) was first described by the Scottish obstetrician William Smellie in 1779 who described, in a newborn, a case of unilateral arm paralysis which rapidly recovered. He attributed this palsy to compression of the axillary nerve against the humerus, probably wrongly in light of subsequent knowledge. The main risk factor for OBPP is high birth weight (>4000 g) and intrapartum shoulder dystocia causing traction on the brachial plexus. It has been demonstrated in cadaveric models that traction on the arm with the neck laterally flexed in the opposite direction causes rupture or avulsion of the brachial plexus. Upper roots are more likely to rupture due to strong ligamentous attachment to the spine whereas the lower roots are more likely to be avulsed. For unknown reasons, however, in the rare circumstance of small babies born breech, upper root avulsion is common. Other risk factors for OBPP include a previous child affected, prolonged labour, instrumented delivery, and multiparity, although each of these may be a surrogate for large birth weight.
Lower limb trauma outcome measures
Authors: Wallace David
Published: September 2021

The management of lower limb-threatening injuries is complex. Advances over the last few decades have provided the ability to salvage complex limb trauma but also have raised concerns that successful complex salvage surgery may not result in overall benefit for the patient. Surgical factors such as bony union, flap success, and a lack of complications are important but are not the sole factors upon which one can guide the patient toward their decision. The patient needs to know how the different treatments may affect their recovery, rehabilitation, return to work, and outcome. This chapter examines the indications and evidence for amputation and salvage by considering the importance of patient and injury-specific factors, biological and physiological variables, quality of life, patient satisfaction, and cost to the individual, hospital, and healthcare provider.
Fractures of the mandible
Authors: Carter Lachlan M.
Published: September 2021

The mandible forms the lower face and supports the teeth, the diaphragm of the floor of mouth, and the mobile tongue. It articulates with the skull base via the temporomandibular joints and is controlled by the muscles of mastication. Fractures of the mandible are common and require accurate reduction and stable fixation, particularly in the dentate patient. The anatomy, pathology, and management of mandible fractures are described in this chapter.
Latissimus dorsi breast reconstruction
Authors: Lee Mark A.
Published: September 2021

The latissimus dorsi flap provides a predictable, reliable, and safe breast reconstruction, and the original description and use of this flap was a defining moment in plastic surgery. It can replace skin loss, soften contours, produce a natural ptotic shape, provide vascularized protection of prosthetic devices, and even be fashioned as a complete reconstruction without implants. Partial breast defects can also be effectively reconstructed with this flap. It can be used in immediate, skin-sparing mastectomy reconstruction or equally in delayed reconstruction. While free tissue transfer, perforator flaps, and modern acellular dermal matrix techniques have been refined over the past decade, the latissimus dorsi flap has provided a safe alternative with the potential for excellent reconstructive results.
The open abdomen
Authors: Khan Omar A. , McGlone Emma Rose , Reddy Marcus
Published: September 2021

This chapter introduces the concept of the open abdomen and describes the various aetiologies of this complex condition, including the rationale for elective laparostomy in damage control surgery and as a treatment for abdominal compartment syndrome. The significance of the open abdomen is described in terms of its local and systemic complications, which form the basis of the established classification. Important considerations in the acute systemic management of patients with this condition are outlined, and methods of temporary abdominal closure are described. Advantages and disadvantages of these alternatives, including the use of negative-pressure wound therapy, are discussed.
Pilonidal disease
Authors: Echlin Kezia , Fleming Andrew
Published: September 2021

Pilonidal disease presents with a range of signs and symptoms: asymptomatic pits in the natal cleft, acute abscesses, chronic disease with persistent, discharging sinuses, or recurrent disease following previous attempts at treatment. It primarily affects the sacrococcygeal region and is a disease of young adults, generally male, and leads to pain, disability, and time lost from work. The treatment for an acute pilonidal abscess is widely accepted to be incision and drainage with the incision placed out of the natal cleft. The treatment of chronic and recurrent disease is contentious with excision and then either healing by secondary intention, primary closure, or flap closure all being suggested alongside other less aggressive approaches aimed at conserving tissue. Currently none of these treatments is ideal, although primary closure in the midline has been shown to be inferior and should not be performed.
Differences in sex development
Authors: Wood Dan
Published: September 2021

Disorders of sexual development are a complex group of conditions with anomalies of the internal and external genitalia due to abnormal chromosomal and hormonal influences during development. Diagnosis and management, including timing of intervention, and both long-term cosmetic and functional outcomes are discussed in this chapter.
Primary aesthetic rhinoplasty
Authors: Ion Lucian
Published: September 2021

Rhinoplasty is the aesthetic surgical intervention that covers the reshaping of the external nasal pyramid. It includes aesthetic and functional aspects, and addresses developmental or acquired pathology. Characteristically, it is associated with significant psychological overlay and due to the complex three-dimensional nasal structure it is the object of intense patient scrutiny involving fine detail from multiple angles. Nasal physiology characteristics dictate that aesthetic alterations can have profound physiological effects that need to be considered carefully in the design and execution of rhinoplasty surgery.