bluuebunny/crossref_metadata_2025 huggingface dataset:
Acute cardiac failure: definitions, investigation, and management
Authors: Clark Andrew L , Cleland John G. F
Published: April 2017

Presentations of acute heart failure fall into three overlapping categories: (1) acute breathlessness and pulmonary oedema, (2) chronic fluid retention and peripheral oedema (anasarca), and (3) cardiogenic shock.
Examination features include tachycardia, hypotension, a raised venous pressure, basal crackles, and peripheral oedema. Auscultation may reveal a third heart sound or features of precipitating valvular heart disease. Initial management focuses on confirming the diagnosis and identification of the immediate precipitant (e.g. arrhythmias, myocardial infarction, decompensating valvular heart disease).
Initial investigations include a 12-lead electrocardiogram (ECG), chest radiograph, full blood count, biochemical screen, troponin and thyroid function. Brain natriuretic peptide (BNP) is useful in confirming the diagnosis where clinical features are present and a normal BNP is helpful in excluding the diagnosis. All patients should undergo echocardiographic assessment early in the course of a hospital admission to assess left ventricular function and to look for underlying valvular heart disease.
In patients with acute pulmonary oedema investigation and management should proceed simultaneously. Intravenous loop diuretics and nitrates are commonly used therapies and may be combined with ventilatory support with oxygen and continuous positive airways ventilation. Mechanical support may be appropriate as a bridge to definitive therapy in potentially reversible causes. Inotropes are often used but without convincing evidence that they improve outcome.
In patients with features are of peripheral oedema and low cardiac output, fluid retention (usually >5 litres) is the predominant feature. Management is principally with bed rest, loop diuretics (usually by intravenous infusion), and, where appropriate, aldosterone antagonists. Thiazide diuretics can be added in resistant cases. Prophylactic low molecular weight heparin should be prescribed. Careful monitoring of fluid balance with daily weights and daily electrolytes is essential. Angiotensin converting enzyme (ACE) inhibitors and subsequently β‎-blockade can be introduced once a satisfactory diuresis has been achieved.
Management of cardiogenic shock is usually determined by the cause. Fluid status should be assessed and an adequate left ventricular filling pressure ensured by the administration of intravenous fluids where required (particularly in the case of right ventricular infarction). Revascularization is the mainstay of therapy in acute myocardial infarction. Circulatory support with intra-aortic balloon counter-pulsation (IABP), inotropic agents, ventricular assist devices (VADs), and extracorporeal membrane oxygenation should be considered for reversible causes (e.g. ventricular septal rupture, papillary muscle rupture, acute myocarditis and postpartum cardiomyopathy).
Hospital admission with acute heart failure caries a poor prognosis with an average in-hospital mortality of 10–15% rising to up to 60% at 30 days in cases of cardiogenic shock.
Circulation and circulatory support in the critically ill
Authors: Pinsky Michael R.
Published: April 2017

Cardiovascular dysfunction is common in the critically ill patient and is the primary cause of death in a vast array of illnesses. The prompt identification and diagnosis of its probable cause, coupled to appropriate resuscitation and (when possible) specific treatments, are cornerstones of intensive care medicine....
Cystic fibrosis
Authors: Bush Andrew , Elston Caroline
Published: April 2017

Cystic Fibrosis (CF) is a recessively inherited disease caused by mutations in the cystic fibrosis gene, located on the long arm of chromosome 7, which codes for a membrane protein—the cystic fibrosis transmembrane regulator protein (CFTR)—that is a chloride channel. Around 1300 CF mutations have been identified, with the ...
Pulmonary haemorrhagic disorders
Authors: Hendrick D.J. , Spickett G.P.
Published: April 2017

There are many causes of bleeding within the lung and haemoptysis, but the term ‘pulmonary haemorrhagic disorder’ applies only to diffuse bleeding from pulmonary alveolar capillaries. The condition is characterized by haemoptysis (not invariable), breathlessness, diffuse air space shadowing on the chest radiograph, anaemia (normochromic normocytic if acute, iron deficient with chronicity), and elevated carbon monoxide gas transfer (...
Eosinophilic pneumonia
Authors: Hendrick D.J. , Spickett G.P.
Published: April 2017

Eosinophilic pneumonia occurs when alveolar spaces are consolidated because of eosinophil inflammation/infiltration, usually with an accompanying eosinophilia of peripheral blood. The diagnosis should be considered when infiltrates on a chest radiograph, often migratory, are associated with blood eosinophilia, and confirmed by demonstrating an excess of eosinophils in bronchoalveolar lavage fluid....
Lymphangioleiomyomatosis
Authors: Bourke S.J. , Hendrick D.J.
Published: April 2017

Lymphangioleiomyomatosis is caused by mutations (usually sporadic, sometimes in tuberous sclerosis) of the TSC1 or TSC2 genes and results in cystic destruction of the lungs, with CT features being sufficiently characteristic to establish the diagnosis in many cases. Two-thirds of patients suffer pneumothoraces. Hormonal therapy with progesterone or tamoxifen is usually given for progressive disease; medical or surgical pleurodesis is advisable; lung transplantation is the main option for advanced disease....
Pulmonary alveolar proteinosis
Authors: Hendrick D.J. , Bourke S.J.
Published: April 2017

Pulmonary alveolar proteinosis is caused by failure, usually due to autoimmune antibodies, of GM-CSF to stimulate surfactant catabolism by alveolar macrophages. Presentation is with progressive shortness of breath, or with pneumonic illness due to superimposed infection. Chest radiography characteristically shows a picture simulating pulmonary oedema. Computed tomography shows a characteristic ‘crazy paving’ pattern and the demonstration of anti-GM CSF antibodies in the serum is useful in diagnosis. Bronchoalveolar lavage or lung biopsy demonstrates alveolar secretions that are strongly PAS-positive but contain no organisms and no excessive cellular response. In 30 to 50% of cases the disease improves spontaneously or fails to progress. When intervention is necessary the most effective measure is physical removal of secretions by whole-lung bronchoalveolar lavage. GM-CSF has been given to a few patients, with half seeming to respond. Eradication of infection may be difficult when opportunistic organisms are involved. Survival is about 70% at 10 years....
Lung cancer
Authors: Spiro S.G.
Published: April 2017

Lung cancer remains the commonest killing cancer in both men and women in the developed world, and is increasingly common in developing countries, although as a result of decreased tobacco consumption in Western countries there has been a considerable reduction in the incidence amongst men over the last 20 years, and a slowing down in incidence in women over the last few years. Nevertheless, lung cancer in women is commoner than breast cancer in some Western countries. There are several important industrial associations with lung cancer, in particular asbestos, but tobacco remains by far the most important cause....
Behçet’s syndrome
Authors: Yazici Hasan , Yurdakul Sebahattin , Fresko Izzet
Published: April 2017

Behçet’s syndrome is an inflammatory disorder of unknown aetiology that involves arteries and veins of all sizes. Most cases are from the countries around the Mediterranean basin, the Middle East and east Asia, with the highest prevalence in Turkey.

Clinical features—the disease typically presents in the second and third decades with recurrent oral ulcers (98% of cases), genital ulcers (85%), acneiform lesions (85%), pathergy reaction (60% in some countries), erythema nodosum (50%), uveitis (50%), arthritis (50%), thrombophlebitis (30%), and less commonly with arterial occlusion/aneurysm, central nervous system involvement or gastrointestinal lesions. A relapsing/remitting course is usual. Disease is more severe and mortality is higher in men. The diagnosis is clinical, laboratory findings are nonspecific and there is no specific diagnostic test for Behçet’s syndrome....
Skeletal disorders—general approach and clinical conditions
Authors: Smith R. , Wordsworth B.P.
Published: April 2017

Bone is made up of (1) cells—osteoblasts, osteoclasts, and ostoecytes; and (2) extracellular mineralized matrix—roughly one-third organic (90% type I collagen) and two-thirds inorganic (mainly hydroxyapatite). Bone modelling occurs during growth and remodelling throughout life due to the constant processes of osteoclastic bone resorption and osteoblastic bone formation, which are closely linked and regulated within bone multicellular units. In the adult, the replacement of old bone with new occurs at an annual turnover rate of 25% in cancellous bone, and 2 to 3% in cortical bone....
Osteoporosis
Authors: Compston Juliet
Published: April 2017

Osteoporosis is characterized by a reduction in bone mass and disruption of bone architecture, resulting in increased bone fragility and fracture risk, with fractures of the distal radius (Colles’ fracture), spine and proximal femur being most characteristic. One in two women and one in five men over the age of 50 years will suffer an osteoporotic fracture during their remaining lifetime, with massive cost to health care services....
Immunoglobulin A nephropathy and Henoch–Schönlein purpura
Authors: Barratt Jonathan , Feehally John
Published: April 2017

Immunoglobulin A nephropathy (IgAN) is the commonest pattern of glomerulonephritis identified in areas of the world where renal biopsy is widely practised. It is defined pathologically by IgA deposition in the glomerular mesangium accompanied by a mesangial proliferative glomerulonephritis which may vary greatly in severity. Aetiology is uncertain, but abnormalities of IgA1 hinge-region ...
Acute interstitial nephritis
Authors: Roger Simon D
Published: April 2017

Acute interstitial nephritis (AIN) is inflammation of the tubules and interstitium within the kidney, associated with a relatively sudden onset and a rapid decline in renal function. It is usually secondary to drugs [antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors being most commonly incriminated], with other causes being infections (classically streptococcal, but this is now less common) and immune disorders (systemic lupus erythematosus, sarcoidosis, and tubulointerstitial nephritis with uveitis)....
Diabetes mellitus and the kidney
Authors: Bilous Rudolf
Published: April 2017

Diabetic nephropathy is the commonest cause of endstage renal disease in the developed world, causing 44% of prevalent cases requiring renal replacement therapy in the United States of America in 2012 and 25% in the United Kingdom in 2013. Incident rates have increased slightly in the UK at 25% of all new patients accepted onto RRT in 2013. Most patients have type 2 diabetes, and in most countries the proportion with endstage renal disease who have type 1 diabetes is falling....
Megaloblastic anaemia and miscellaneous deficiency anaemias
Authors: Hoffbrand A.V. , Provan Drew
Published: April 2017

Megaloblastic anaemias are characterized by red blood cell macrocytosis. They arise because of inhibition of DNA synthesis in the bone marrow, usually due to deficiency of one or other of vitamin B12 (cobalamin) or folate, but sometimes as a consequence of a drug or a congenital or acquired biochemical defect that disturbs their metabolism, or affects DNA synthesis independent of vitamin B...
Disorders of the synthesis or function of haemoglobin
Authors: Weatherall D.J.
Published: April 2017

The inherited disorders of haemoglobin are the commonest single-gene disorders in the world. They cause much morbidity and mortality in those individuals who are severely affected, and place a major burden on health services in some places, in particular the Mediterranean region, sub-Saharan Africa, and South-East Asia, when economic conditions improve and infant and childhood death rates fall. Mass migrations of populations from high-incidence areas for the haemoglobin disorders, together with the general ease of international travel, means that these conditions are being seen with increasing frequency in parts of the world where they have not been recognized previously....
Cutaneous vasculitis, connective tissue diseases, and urticaria
Authors: Burge Susan , Ogg Graham S.
Published: April 2017

Vasculitis (angiitis) denotes necrotizing inflammation of the blood vessels; occlusive vasculopathy implies vascular occlusion without significant vascular inflammation. A small-vessel cutaneous vasculitis is the most common vasculitis affecting the skin, and may be the first sign of a systemic vasculitis, but 50% of patients have no systemic disease. The clinical findings must be integrated with the results of serological, pathological, and imaging studies to reach a diagnosis....
Infections and the skin
Authors: Hay Roderick
Published: April 2017

A huge variety of different organisms exist on healthy skin. Under certain circumstances, microbes can actively infect the skin as a primary or secondary event in cutaneous or systemic disease.

The most common causes of bacterial infection of the skin are Staphylococcus aureus or β...
Cutaneous reactions to drugs
Authors: Friedmann Peter S. , Healy Eugene
Published: April 2017

Adverse drug reactions (ADR) are responsible for about 5% of all hospital admissions, and 10 to 20% of hospital inpatients develop ADRs, many of which involve the skin. ADRs are classified into five groups: (1) type A (augmented)—the most common form of drug reaction, and predictable from the normal pharmacological effects of the drug or its metablite; (2) type B (bizarre)—are not predictable and reflect patient individuality; most cutaneous drug reactions, including hypersensitivity reactions, are of this type; (3) type C (chemical)—can often be predicted from the structure of the drug or its metabolites; some cutaneous reactions are of this type; (4) type D (delayed)—e.g. teratogenicity; (5) type E (end of dose)—withdrawal reactions....
Management of skin disease
Authors: Sinclair Rod
Published: April 2017

Topical therapy employs a vehicle (ointments, creams, lotions, gels) to deliver an active ingredient to the skin, to provide a protective barrier, or to hydrate and moisturize the skin. There are many types of topical treatments, including (1) antipruritics, e.g. calamine, are used to relieve itching; (2) keratolytics, e.g. salicylic acid, urea, are used to remove hyperkeratotic skin; (3) tars act by reducing the thickness of the epidermis; (4) corticosteroids have anti-inflammatory and immunosuppressive effects that are useful in treating many skin disorders; (5) calcipotriol (an analogue of 1,25-dihydroxycholecalciferol) reduces epidermal proliferation and is used in local treatment of plaque psoriasis; (6) retinoids influence immune function and have some anti-inflammatory activity and are used in acne; (7) antiseptics, e.g. benzoyl peroxide, chlorhexidine; (8) antifungal agents; (9) sunscreens; (10) anaesthetics/analgesics....
Mind and brain: building bridges linking neurology, psychiatry, and psychology
Authors: Zeman A.
Published: April 2017

‘The great regions of the mind correspond to the great regions of the brain.’

Paul Broca

‘… the master unsolved problem of biology: how the hundred million nerve cells of the brain work together to create consciousness …’

E.O. Wilson, Consilience, 1998

Here is one view of the relationship between medicine and psychiatry. Physicians study, diagnose, and treat disorders of the body; psychiatrists (by contrast) study, diagnose, and treat disorders of the mind. Medicine has to do mainly with processes in objects, such as the circulation of blood to the kidneys; psychiatrists concern themselves mainly with the experiences of subjects, such as auditory hallucinations. Medical disorders are ‘organic’; psychiatric disorders are ‘functional’. Medicine is mainly a science; psychiatry mainly an art. The brain, on this view, occupies an ambiguous position, poised between body and mind: it is an ambiguous intermediary, a skilful interpreter between the languages of mind and body. Nevertheless, disorders of body and mind can and should be rigorously distinguished....
Subcortical structures: the cerebellum, basal ganglia, and thalamus
Authors: Edwards Mark J. , Talelli Penelope
Published: April 2017

For video material relating to movement disorders, please go to Movement Disorders Videos.

Less is known of the function of the cerebellum, thalamus and basal ganglia than of other structures in the brain, but there is an increasing appreciation of their complex role in motor and nonmotor functions of the entire nervous system. These structures exercise functions that far exceed their previously assumed supporting parts as simple ‘relay stations’ between cortex and spinal cord....
Ataxic disorders
Authors: Wood Nicholas
Published: April 2017

For video material relating to movement disorders, please go to Movement Disorders Videos.

Ataxia is a feature of disorders of the cerebellum and its connections. It may be found in a large range of neurological conditions, in some of which it is the principal or main feature, but clinical assessment is complicated by the fact that few ataxic patients have disease restricted to the cerebellum alone....
Cardiac and vascular physiology in anaesthetic practice
Authors: Sidhu Kulraj S. , Essiet Mfonobong , Cannesson Maxime
Published: April 2017

This chapter discusses key components of cardiovascular physiology applicable to clinical practice in the field of anaesthesiology. From theory development to ground-breaking innovations, the history of cardiac and vascular anatomy, as well as physiology, is presented. Utilizing knowledge of structure and function, parameters created have allowed adequate patient clinical assessment and guided interventions. A review of concepts reveals the impact of multiple physiological variables on a patient’s haemodynamic state and the need for more accurate and efficient measurements. In particular, it is noted that a more reliable index of ventricular contractility is the end-systolic elastance rather than the ejection fraction. Constant direct preload assessment has not yet been achieved but continues to be determined through surrogate variables, and continuous cardiac output monitoring for oxygen delivery, although advancing, has limitations. Considering the effect of compound factors perioperatively, especially heart failure, modifies the goals and interventions of anaesthetists to achieve improved outcomes. Therefore, medical management prior to surgery and complete assessment through history, physical examination, and diagnostic tests are a priority. This chapter also details the expectations following volume expansion to augment haemodynamics during surgery, the concept of functional haemodynamic monitoring, and limitations to the parameters applied in assessing fluid responsiveness. Challenging the accuracy of conventional indices to predict volume status led to the use of goal-directed therapy, reducing morbidity and minimizing length of hospital stay. The mainstay of this chapter is to reinforce the relevance of advances in haemodynamic monitoring and homeostasis optimization by anaesthetists during surgery, using fundamental concepts of cardiovascular physiology.
Kidney and acid–base physiology in anaesthetic practice
Authors: Ho Kwok M.
Published: April 2017

Anatomically the kidney consists of the cortex, medulla, and renal pelvis. The kidneys have approximately 2 million nephrons and receive 20% of the resting cardiac output making the kidneys the richest blood flow per gram of tissue in the body. A high blood and plasma flow to the kidneys is essential for the generation of a large amount of glomerular filtrate, up to 125 ml min−1, to regulate the fluid and electrolyte balance of the body. The kidneys also have many other important physiological functions, including excretion of metabolic wastes or toxins, regulation of blood volume and pressure, and also production and metabolism of many hormones. Although plasma creatinine concentration has been frequently used to estimate glomerular filtration rate by the Modification of Diet in Renal Disease (MDRD) equation in stable chronic kidney diseases, the MDRD equation has limitations and does not reflect glomerular filtration rate accurately in healthy individuals or patients with acute kidney injury. An optimal acid–base environment is essential for many body functions, including haemoglobin–oxygen dissociation, transcellular shift of electrolytes, membrane excitability, function of many enzymes, and energy production. Based on the concepts of electrochemical neutrality, law of conservation of mass, and law of mass action, according to Stewart’s approach, hydrogen ion concentration is determined by three independent variables: (1) carbon dioxide tension, (2) total concentrations of weak acids such as albumin and phosphate, and (3) strong ion difference, also known as SID. It is important to understand that the main advantage of Stewart over the bicarbonate-centred approach is in the interpretation of metabolic acidosis.
Inhaled anaesthetics
Authors: Hendrickx Jan F. A. , van Zundert André , Wolf Andre De
Published: April 2017

Inhaled anaesthetic drugs are administered via the lungs to provide ‘general anaesthesia’. They are considered complete anaesthetics because they in and by themselves can in most patients ensure all clinical end-points that are required for ‘general anaesthesia’ (unconsciousness, immobility, and haemodynamic stability). The dose–response curve of each clinical end-point is conveniently defined by its mid-point, the end-expired concentration Fa that ensures response suppression in 50 % of the patients (MACawake, MAC, and MACBAR). By understanding the dose–response curves and the factors that influence them (pharmacodynamics), the target Fa and the dose of other drugs can be selected in each individual patient. This target Fa is achieved by adjusting the carrier fresh gas flow (O2, air, N2O) and agent vaporizer setting Fd. ‘Pharmacokinetics’ is the study of the factors that affect the partial pressure cascade from the vaporizer down to the site of action. Because IADs are transported down a partial pressure gradient, Fa will always try to approach the inspired concentration Fi, a process that is described by the Fa/Fi ratio over time. Both Fa and Fi are routinely measured. N2O remains widely used, with scientific scrutiny rather than belief finally delineating its advantages and disadvantages. Xenon, the near-ideal agent, is discussed briefly because it may enter clinical practice despite its cost because of its potential advantages in a yet to be defined subgroup of high-risk patients. The carrier gas N2 is often overlooked, but deserves careful analysis to help the reader understand how rebreathing affects its kinetics in a circle breathing system.
Drug interactions in anaesthetic practice
Authors: Olkkola Klaus T. , Vereecke Hugo E. M. , Luginbühl Martin
Published: April 2017

When two or more drugs are administered simultaneously, the pharmacological response may be greater or less than the sum of the effects of the individual drugs. One drug may antagonize or potentiate the effects of the other and there may be also qualitative differences in response. Although some drug interactions increase the toxicity or result in loss of therapeutic effect, others are beneficial. Indeed, modern anaesthetic techniques depend on beneficial drug interactions. A sound combination of drugs helps clinicians to increase both the efficacy and safety of drug treatment. Drugs may interact on a pharmaceutical, pharmacodynamic, or pharmacokinetic basis. Many pharmacodynamic interactions are predictable and can be avoided by the use of common sense. However, it is much more difficult to predict the likelihood of pharmacokinetic and pharmaceutical interactions despite good prior knowledge of pharmacokinetics and chemical properties of individual drugs. Pharmaceutical drug interactions usually occur before the drug is given to the patient and they are caused by chemical (such as acid–base, salt formation, oxidation–reduction, hydrolysis, or epimerization) or physical (such as adsorption/absorption or emulsion breaking) reactions. When drugs have a pharmacokinetic interaction, one drug alters the absorption, distribution, or the elimination of the other drug. Many pharmacokinetic drug interactions are due to inhibition or induction of cytochrome P450 enzymes. Pharmacodynamic drug interactions are caused by drugs having an effect on the same receptors or the same physiological system. This chapter gives anaesthetists an overview of clinically relevant perioperative drug interactions.
Adverse drug reactions in anaesthesia
Authors: Hopkins Philip M.
Published: April 2017

Adverse drug reactions are implicated in more than 40% of anaesthesia-related deaths. Undoubtedly, many more patients experience morbidity from adverse drug reactions. Widely cited definitions of adverse drug reactions encompass common side-effects but this chapter focuses on those that are unexpected reactions to drugs administered by anaesthetists and that occur at normal drug doses. The chapter includes a comprehensive account of malignant hyperthermia, which remains a major contributor to anaesthesia related to deaths. Malignant hyperthermia is a pharmacogenetic condition triggered by potent inhalational anaesthetics and possibly also suxamethonium. The genetic basis, pathophysiology, clinical presentations, and management of malignant hyperthermia are discussed. The chapter covers two other pharmacogenetic conditions: the acute porphyrias and butyrylcholinesterase (plasma cholinesterase) deficiency. Drug-induced anaphylaxis is another cause of perioperative morbidity and mortality. Recent data indicate that anaphylaxis during anaesthesia may be much more common than previously thought. The other type of adverse drug reaction covered in the chapter is serotonin syndrome. Perioperative serotonin syndrome is most likely to occur when patients who are already taking serotonergic drugs, such as selective serotonin reuptake inhibitor antidepressants or ‘triptan’ antimigraine treatments, are given a second drug with serotonergic properties, such as tramadol.
Assessment of the components of anaesthesia
Authors: Luginbühl Martin , Yli-Hankala Arvi
Published: April 2017

In modern anaesthesia practice, hypnotic drugs, opioids, and neuromuscular blocking agents (NMBAs) are combined. The introduction of NMBAs in particular substantially increased the risk of awareness and recall during general anaesthesia. Hypnotic drugs such as propofol and volatile anaesthetics act through GABAA receptors and have typical effects on the electroencephalogram (EEG). During increasing concentrations of these pharmaceuticals, the EEG desynchronization is followed by gradual synchronization, slowing frequency, and increasing amplitude of EEG, thereafter EEG suppressions (burst suppression), and, finally, isoelectric EEG. Hypnotic depth monitors such as the Bispectral Index™, Entropy™, and Narcotrend® are based on quantitative EEG analysis and translate these changes into numbers between 100 and 0. Although they are good predictors of wakefulness and deep anaesthesia, their usefulness in prevention of awareness and recall has been challenged, especially when inhalation anaesthetics are used. External and patient-related artifacts such as epileptiform discharges and frontal electromyography (EMG) affect the signal so their readings need careful interpretation. Their use is recommended in patients at increased risk of awareness and recall and in patients under total intravenous anaesthesia. Monitors of analgesia and nociception are not established in clinical practice but mostly remain experimental although some are commercially available. Some use EEG changes induced by noxious stimulation (EEG arousal) or quantify the frontal EMG in relation to EEG, while others are based on the sympathoadrenergic stress response. Various other devices are also discussed in this chapter.
Preoperative assessment and optimization
Authors: van Lier Felix , Stolker Robert Jan
Published: April 2017

Perioperative cardiovascular complications (including myocardial ischaemia and myocardial infarction) are the predominant cause of morbidity and mortality in patients undergoing non-cardiac surgery. The pathophysiology of perioperative myocardial infarction is complex. Prolonged myocardial ischaemia due to the stress of surgery in the presence of a haemodynamically significant coronary lesion, leading to subendocardial ischaemia, and acute coronary artery occlusion after plaque rupture and thrombus formation contribute equally to these devastating events. Perioperative management aims at optimizing the patient’s condition by identification and modification of underlying cardiac risk factors and diseases. The first part of this chapter covers current knowledge on preoperative risk assessment. Current risk indices, the value of additional testing, and new preoperative cardiac risk makers are investigated. During recent decades there has been a shift from the assessment and treatment of the underlying culprit coronary lesion towards a systemic medical therapy aiming at prevention of myocardial oxygen supply–demand mismatch and coronary plaque stabilization. In the second part of this chapter, risk-reduction strategies are discussed, including β‎-blocker therapy, statins, and aspirins. A central theme in this chapter will focus on long-term cardiovascular risk reduction. Patients who undergo non-cardiac (vascular) surgery are particularly prone to long-term adverse cardiac outcomes. The goal of perioperative cardiovascular risk identification and modification should not be limited to the perioperative period, but should extend well into the postoperative period.
Hazards in anaesthetic practice: body systems and occupational hazards
Authors: Merry Alan F. , Mitchell Simon J. , Hardman Jonathan G.
Published: April 2017

“Can’t intubate, can’t oxygenate” crises and aspiration of gastric contents are important hazards in anaesthesia, and may result in the death of relatively young and healthy patients. Airway difficulties may manifest at the end of anaesthesia as well as at induction and are commoner in emergency departments and intensive care settings than during anaesthesia in operating rooms. Elements of poor management characterize the majority of airway complications. Emergency cricothyroidotomy performed by anaesthetists is associated with a high rate of failure. Other important hazards associated with anaesthesia may involve excessive or inadequate levels of oxygen or carbon dioxide in the blood, hypertension or hypotension, hypothermia or hyperthermia (including malignant hyperpyrexia), hypovolaemia, embolism of gas or thrombus, awareness, infection, and injury to the peripheral or central nervous system, or the eyes. Stroke and postoperative cognitive dysfunction may be particularly devastating for patients. These hazards are typically increased in low- and middle-income countries. The World Federation of Societies of Anaesthesiologists and the World Health Organization have endorsed international standards for a safe practice of anaesthesia, which are structured to reflect different levels of resource. The Lifebox Foundation seeks to improve the safety of surgery and anaesthesia in resource-constrained areas, notably by closing the substantial global gap in pulse oximetry. Several hazards are integral to the occupation of anaesthesia, including certain infections, increased rates of suicide, and medico-legal risks. In the end, the best way to mitigate these risks is through focusing on the safety of our patients.
Post-surgical analgesia and acute pain management
Authors: Bonnet Francis , Gentili Marc E. , Aveline Christophe
Published: April 2017

Postoperative and acute pain remains uncontrolled in many instances, leading to the risk of development of chronic pain syndromes. After tissue damage, activation of postsynaptic NMDA receptors, also induced by opioid administration, plays a key role in postoperative pain sensitization, allodynia, and hyperalgesia. Pain intensity may depend on sex, age, anxiety, and genetic factors but in clinical practice, surgical procedure is the main determinant of pain, although pain may vary from one patient to one another. Serial pain measurements are mandatory to assess pain intensity and to guide pain treatment. They are based on unidimensional simple pain scales. Multimodal analgesia combining opioid and non-opioid agent and regional block or infiltration is the rule postoperatively, although evidence is sometimes lacking to support all the combinations commonly used. Opioids should be used on demand while other agents are administered systematically. Non-steroidal anti-inflammatory drugs decrease opioid demand as well as paracetamol although to a less extend. Antihyperalgesic agents including NMDA blockers (ketamine) and α‎2-δ‎ ligands (gabapentin, pregabalin) have an opioid-sparing effect and may prevent the occurrence of chronic pain syndrome after surgery. Regional blocks and infiltration provide good quality analgesia but the balance between advantages and drawbacks of central block need to be evaluated carefully for each surgical procedure.
Blood conservation and transfusion in anaesthesia
Authors: Thomas Dafydd , Beard Katy
Published: April 2017

Over the last three decades, avoidance of allogeneic transfusion in order to decrease adverse events within the recipient has become a part of clinical care. Although the main driver was an avoidance of transfusion-transmitted disease, other immunological consequences have been noted, and it is widely regarded as desirable to avoid the use of allogeneic component transfusion unless there is an essential physiological need. Of course this attempt at decreasing allogeneic blood component use has a potentially beneficial effect of blood component supply, leading to decreased use within the surgical specialties, while allowing increased use in clinical cases where there is currently no alternative to the transfusion of allogeneic components, such as those cases who have received chemotherapy and marrow suppression. The development of an array of techniques and treatments to decrease dependence of blood component transfusion has led to a care pathway that attempts to treat preoperative anaemia, minimize operative blood loss, and withhold allogeneic transfusion in the postoperative period according to clinical need. Many questions remain about the appropriate level of haemoglobin depending upon the comorbidities suffered by the patient, which is why patient blood management has gained popularity, as each patient deserves an individual care plan according to need.
Regional anaesthesia of the trunk
Authors: Berrill Andrew , Jones Will , Pegg David
Published: April 2017

Analgesia of the thorax and abdomen can be challenging. Surgical incisions are commonly associated with severe postoperative pain. Whilst continuous epidural analgesia remains the ‘gold standard’ in terms of postoperative pain relief after major surgery, there remain concerns regarding rare serious side effects. It has been difficult to demonstrate conclusive evidence of improvement in outcomes when epidural analgesia is used. Superior pain relief and a reduction in postoperative respiratory morbidity are, however, clear advantages of regional anaesthesia. Interest has increased in techniques such as paravertebral and rectus sheath blocks in part due to the ready availability of high-definition portable ultrasound equipment, but also in response to concerns regarding neuraxial blockade and the development of enhanced recovery pathways. In addition, novel approaches to analgesia of the trunk, such as the transversus abdominis plane block, have been developed and are now widely used as part of a multimodal analgesic regimen. In this chapter, techniques of neuraxial and peripheral nerve block are discussed along with their indications and complications.
Anaesthesia for abdominal surgery
Authors: Fawcett William J.
Published: April 2017

Care of patients undergoing major gastrointestinal surgery has been revolutionized in the last decade. The widespread adoption of laparoscopic surgery has bought benefits but also new challenges. Anaesthetic techniques, particularly refinements in analgesic regimens and fluid management, have also brought benefits to patients. However, many more elderly and frail patients are undergoing major surgery which is a challenge in both expertise and resources. Anaesthesia for patients undergoing gastrointestinal surgery has evolved into a package of perioperative care, with the anaesthetist increasingly viewed as the perioperative physician. Anaesthetists are now involved not only within the operating theatre, but with assessing risk for patients, optimizing them prior to surgery, and supervising postoperative care and in particular early recognition and treatment of complications. Liver surgery has become routine for patients particularly with secondary colorectal metastases. Previously, 5-year survival was very rare in these groups of patients, but now approximately half of patients are alive at 5 years. Colorectal surgery has also been transformed and the enhanced recovery programme has typified the way in which many years of dogma have been challenged, to be replaced by evidence-based pathways. Overall, for major elective surgery, results have improved and in general, morbidity, mortality, complications, and length of hospital stay for patients have reduced. For emergency patients, although there have been improvements too, there is still widespread concern about high mortality and marked variation in care between centres.
Anaesthesia for urological surgery and for robotic surgery in urology and gynaecology
Authors: Odeberg-Wernerman Suzanne , Mure Margareta
Published: April 2017

Laparoscopic and robot-assisted laparoscopic surgical procedures are commonly used in both urology and gynaecology. These minimally invasive techniques result in early mobilization and short hospital stay and robot-assisted operations are increasingly favoured by patients and surgeons. A complex physiological response is created by the combined effects of carbon dioxide pneumoperitoneum, elevated intra-abdominal pressure, and sometimes a profound Trendelenburg position. Healthy patients tolerate this situation well, but compromised patients are at risk of developing heart failure, ischaemia, or both. Correct interpretation of vital signs can be challenging in this situation. This chapter gives an overview of the physiology during laparoscopic and robot-assisted laparoscopic surgery and gives recommendations for anaesthesia and monitoring. The field of urology and gynaecology also includes major open surgery as well as transurethral surgery and techniques for the management of urinary tract stones. The anaesthetic management and perioperative care of major open surgery, including the increasingly adopted ‘enhanced recovery after surgery’ concept, are also covered. The syndrome of transurethral resection of the prostate can still place patients at risk despite increased knowledge and improved selection of irrigation fluid.
Pre-hospital care for the anaesthetist
Authors: Crombie Nicholas , Eindhoven G. Boukes , Dercksen Bert
Published: April 2017

Pre-hospital care is arguably the newest medical specialty having evolved from the introduction of portable defibrillators in the 1970s to the advanced critical care and interventions delivered today. The specialty draws heavily on anaesthesia and emergency medicine along with an understanding of and familiarity with the pre-hospital environment and infrastructure. Rather than being an expansive text on the specialty, this chapter sets out the history, the challenges, and the practice of pre-hospital care relevant to anaesthetists. The inclusion of pre-hospital care in the Oxford Textbook of Anaesthesia further reinforces the point that this exciting area of medicine has moved from the peripheries into an established and important component of the care of the critically ill.
Endocrine disease and anaesthesia
Authors: Farling Peter A. , James Michael F. M.
Published: April 2017

Anaesthesia for patients with endocrine disorders involves the management of both extremely common and extremely rare conditions. There is a high incidence of diabetes, hypothyroidism, and hyperthyroidism in the population but pituitary apoplexy, phaeochromocytoma, and insulinoma may never be encountered during the career of the general anaesthetist. Whenever possible, elective surgery should await normalization of abnormal endocrine function. For example, patients with uncontrolled hyperthyroidism are at risk of developing a thyroid crisis so elective surgery should be delayed until they are euthyroid. This chapter discusses the anatomy, physiology, and anaesthetic management for surgery on the pituitary, thyroid, parathyroid, and adrenal glands. Anaesthetic issues relating to patients with diabetes mellitus and carcinoid tumours are covered in detail. Endocrine emergencies may mimic other causes of cardiovascular collapse and successful management requires a multidisciplinary approach involving anaesthetists, endocrinologists, surgeons, accident and emergency, and intensive care specialists.
Healthcare Resource Utilization and Patient-Reported Outcomes Following Elective Surgery for Intradural Extramedullary Spinal Tumors
Authors: Chotai Silky , Zuckerman Scott L. , Parker Scott L. , Wick Joseph B. , Stonko David P. , Hale Andrew T. , McGirt Matthew J. , Cheng Joseph S. , Devin Clinton J.
Published: April 2017

BACKGROUND

Healthcare resource utilization and patient-reported outcomes (PROs) for intradural extramedullary (IDEM) spine tumors are not well reported.

OBJECTIVE

To analyze the PROs, costs, and resource utilization 1 year following surgical resection of IDEM tumors.

METHODS

Patients undergoing elective spine surgery for IDEM tumors and enrolled in a single-center, prospective, longitudinal registry were analyzed. Baseline and postoperative 1-year PROs were recorded. One-year spine-related direct and indirect healthcare resource utilization was assessed. One-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost).

RESULTS

A total of 38 IDEM tumor patients were included in this analysis. There was significant improvement in quality of life (EuroQol-5D), disability (Oswestry and Neck Disability Indices), pain (Numeric rating scale pain scores for back/neck pain and leg/arm pain), and general physical and mental health (Short-form-12 health survey, physical and mental component scores) in both groups 1 year after surgery (P < .0001). Eighty-seven percent (n = 33) of patients were satisfied with surgery. The 1-year postdischarge resource utilization including healthcare visits, medication, and diagnostic cost was $4111 ± $3596. The mean total direct cost was $23 717 ± $7412 and indirect cost was $5544 ± $4336, resulting in total 1-year cost $29 177 ± $9314.

CONCLUSION

Surgical resection of the IDEM provides improvement in patient-reported quality of life, disability, pain, general health, and satisfaction at 1 year following surgery. Furthermore, we report the granular costs of surgical resection and healthcare resource utilization in this population.
Crop Fertilization Impacts Epidemics and Optimal Latent Period of Biotrophic Fungal Pathogens
Authors: Précigout Pierre-Antoine , Claessen David , Robert Corinne
Published: April 2017

Crop pathogens are known to rapidly adapt to agricultural practices. Although cultivar resistance breakdown and resistance to pesticides have been broadly studied, little is known about the adaptation of crop pathogens to fertilization regimes and no epidemiological model has addressed that question. However, this is a critical issue for developing sustainable low-input agriculture. In this article, we use a model of life history evolution of biotrophic wheat fungal pathogens in order to understand how they could adapt to changes in fertilization practices. We focus on a single pathogen life history trait, the latent period, which directly determines the amount of resources allocated to growth and reproduction along with the speed of canopy colonization. We implemented three fertilization scenarios, corresponding to major effects of increased nitrogen fertilization on crops: (i) increase in nutrient concentration in leaves, (ii) increase of leaf lifespan, and (iii) increase of leaf number (tillering) and size that leads to a bigger canopy size. For every scenario, we used two different fitness measures to identify putative evolutionary responses of latent period to changes in fertilization level. We observed that annual spore production increases with fertilization, because it results in more resources available to the pathogens. Thus, diminishing the use of fertilizers could reduce biotrophic fungal epidemics. We found a positive relationship between the optimal latent period and fertilization when maximizing total spore production over an entire season. In contrast, we found a negative relationship between the optimal latent period and fertilization when maximizing the within-season exponential growth rate of the pathogen. These contrasting results were consistent over the three tested fertilization scenarios. They suggest that between-strain diversity in the latent period, as has been observed in the field, may be due to diversifying selection in different cultural environments.
Profile
Authors: Howe Michelle
Published: April 2017

Last November, Nursing Management Congress2016 attendees experienced a one-of-a-kind keynote address when Zubin Damania, MD, took the stage. Through self-produced song and video, he explored the ethics of delivering compassionate care in our challenging healthcare system. Here, read about the Iora Health model that Dr. Damania celebrates as “having it right.”
Integrative medicine in cancer survivors
Authors: Viscuse Paul V. , Price Katharine , Millstine Denise , Bhagra Anjali , Bauer Brent , Ruddy Kathryn J.
Published: April 2017

Purpose of review

Due to medical advances and an aging population, the number of cancer survivors continues to rise. Survivors often experience late and long-term sequelae of cancer and its treatment (e.g., fatigue, pain, fear of recurrence, and stress). As a result, some patients have utilized or expressed interest in integrative medicine (IM) modalities for prevention of recurrence, optimizing health, enhancing quality of life, and managing symptoms. The purpose of this review is to focus on research published during the past year that informs our understanding of the utility of IM for cancer survivors.

Recent findings

Physical activity, diet, dietary supplements, mind–body modalities, acupuncture, and massage therapy all may play a role in the management of the physical (e.g., fatigue and pain) and emotional (e.g., anxiety and fear) issues faced by cancer survivors.

IM therapies are appealing to and utilized by many cancer survivors and may reduce symptom burden. Clinicians who provide cancer survivorship care may improve patient care by understanding the evidence for and against their use.