bluuebunny/crossref_metadata_2025 huggingface dataset:
Problems with Doctors Invoking the Best Interest Standard
Authors: Rhodes Rosamond
Published: April 2020

Although the “best interest standard” has been widely accepted as a benchmark for decisions made on behalf of others, this chapter explains why medical professionals should eschew the phrase. Decisions by medical professionals are different from decisions by patients and surrogates, and their duty to care for patients and promote their interests is markedly different from acting in the patient’s best interest. Doctors must distinguish their professional fiduciary responsibilities from the concept of best interest because confusing the two can lead to blunders with unfortunate consequences. This chapter responds to supporters of the best interest standard, like Kopelman, and critics, like Veatch, who object to its being subjective and vague. It also explains why introducing the phrase into the language of medical professionals can be misleading or irrelevant and lead to behavior that is intolerant, polarizing, and unjust. Instead, the chapter offers the “three-box model” for guiding doctors’ responses to surrogate decisions.
Hot and Bothered
Authors: Perry Christopher , Sonenthal Nechama
Published: April 2020

Pediatric fever is both an extremely common and yet highly challenging scenario faced regularly by emergency medicine physicians. A high degree of concern must always exist for the presence of a serious bacterial infection (SBI). This is especially true for infants due to their immature immune systems as well as to the limitations involved in obtaining a reliable history and physical exam. Evidence-based guidelines can assist the clinician in performing an appropriate work-up and treatment plan. However, clinical judgement always remains the physician’s most valuable tool. In areas where the guidelines are not clear, clinicians should exercise the highest degree of caution that a febrile child may have an SBI or other potentially life-threatening infectious pathology.
What Goes Down, Might Come Up!
Authors: Mace Sharon E.
Published: April 2020

In infants, vomiting is usually benign, but it can also portend significant underlying illness or injury. It is important to remember that although vomiting is commonly from the gastrointestinal (GI) tract itself, it may also be due to more generalized, systemic disorders or injuries (non-GI causes). As with most pediatric complaints a comprehensive history and physical exam is critical to direct both diagnostic testing and management. Remember the past medical history in infants includes neonatal history, growth and developmental history (include weight gain), social and family history. A history of bilious vomiting in an infant should always raise concerns occurs with obstruction, therefore, bilious vomiting always warrants evaluation.
Was It Something I Ate?
Authors: Firnberg Maytal , Malia Laurie , Rabiner Joni E.
Published: April 2020

This chapter discusses a pediatric case of acute appendicitis. Appendicitis is a challenging yet important diagnosis for clinicians to make and is based on a combination of history, physical examination, laboratory work, and diagnostic imaging findings. This chapter reviews up-to-date recommendations of recent changes in imaging technology, antibiotic management, and surgical techniques that affect outcomes in acute appendicitis. Overall, children with acute appendicitis who are diagnosed and treated appropriately have good outcomes. With appropriate antibiotic administration and advances in surgical technique, children may no longer be rushed to the operating room and instead may go to the operating room in the next available opening or the next day with no increase in rate of complications, often with same day or next day discharge from the hospital.
Tummy Ouchie
Authors: Orajiaka Nkeiruka , Dishong Meghan
Published: April 2020

Intussusception is one of the most common abdominal emergencies in children. The classic triad of symptoms involves colicky abdominal pain, an abdominal mass, and red currant jelly stools, but this is seen in only about 15% of cases of children with intussusception. Early diagnosis and management reduce morbidity, risk for complications, and surgical intervention. Abdominal ultrasound is generally accepted as the gold standard for diagnosis. Treatment typically involves an air or hydrostatic enema; however, variability and controversies still exist in treatment and post-care management for nonsurgical cases. Variability also still exists in post-reduction care of children with intussusception. Feeding and monitoring times after nonoperative management differ between institutions. Some patients are advanced to feeds as tolerated while some others are placed in fasting to rest the bowel and prevent recurrence.
Another Day, Another GI Bug
Authors: Mukherji Pinaki , Libov Dana
Published: April 2020

This chapter presents 3 cases of vomiting in children and explores less common diagnoses not to be missed by the astute clinician. The first case of a child with recurrent progressive vomiting has unusual lab abnormalities which leads to the final diagnosis of an inborn error of metabolism. The second case presents a child with several Emergency Department visits for vomiting and a skin finding leads to a final diagnosis of non-accidental trauma. The final case reviews a vomiting child with electrolyte abnormalities and an abnormal radiograph, leading to a diagnosis of malrotation with volvulus. Each case gives the clinician key pearls to distinguish these high risk cases from everyday gastroenteritis.
What’s This Pounding in My Head?
Authors: Sojar Sakina , Allister Lauren
Published: April 2020

Headaches are a common chief complaint within the pediatric emergency department. They can be a source of significant morbidity in the pediatric population causing severe pain, cognitive dysfunction, and missed school days. It is critical that the physician delineates between life-threatening versus non-life-threatening etiologies of headache and obtain imaging of the head when appropriate. Computed tomography and magnetic resonance imaging are the modalities of choice. Each imaging modality presents advantages and disadvantages. Common causes of headaches in the pediatric emergency department include migraine, tension headaches, and viral illness. Physicians must be aware of more serious etiologies (such as space occupying lesions) that may warrant further investigation.
Sugar and Spice . . . Not Always Nice
Authors: Cerrone Crista , Stoner Michael J.
Published: April 2020

The case of a tachypneic 8-year-old exemplifies the diversity of etiologies for tachypnea and is a good reminder to avoid conformation bias given a patient’s history. In this case, the child has new onset diabetes and is in diabetic ketoacidosis (DKA). DKA is due to a deranged metabolism given the lack of insulin, leading to hyperglycemia, ketosis, and acidosis as well as dehydration. The chapter highlights the treatment including diligent rehydration and correction of acidosis. This is accomplished by restoring typical metabolic pathways with insulin all while closely monitoring and correcting changes in glucose and electrolytes. Finally, clinical symptoms are monitored closely to avoid pitfalls, which can include altered metal status, respiratory failure, cerebral edema, coma, and death.
Diagnostic neuroimaging in migraine
Authors: Kruit Mark C. , May Arne
Published: April 2020

This chapter focuses on diagnostic clinical neuroimaging in migraine. In most migraine cases, patient history, details of symptoms, and careful clinical neurological examination are together the most important tools in diagnosing and treating migraine, and, consequently, there is mostly no need for further laboratory tests or neuroimaging. In selected non-acute headache cases, neuroimaging is warranted, and recommendations are provided. Good understanding of the migraine pathophysiology allows better interpretation of neuroimaging findings, notably when patients present acutely, in or outside an attack. The neuroradiological findings relevant in understanding the complex relationship between migraine and stroke will therefore be discussed. Similarly, knowledge of the epidemiological findings that have set migraine as a risk factor for (progressive) subclinical brain lesions is relevant in everyday neuroradiological practice.
Non-vascular comorbidities and complications
Authors: Louter Mark A. , Scher Ann I. , Terwindt Gisela M.
Published: April 2020

This chapter discusses non-vascular comorbidities and complications. Comorbidity is used mostly for associations between disorders that are greater than could be expected based on the usual individual prevalence of both diseases in the given population. Migraine comorbidities have been investigated in both clinical and population-based studies and most are cross-sectional, complicating the causal interpretation of the results. The number of suggested migraine comorbidities, as reported in scientific literature, has increased immensely over the past decades, and can range from psychiatric disorders through to cancer.
Cluster headache
Authors: de Coo Ilse F. , Wilbrink Leopoldine A. , Haan Joost
Published: April 2020

Cluster headache is a primary headache disorder characterized by attacks of severe-to-very severe unilateral pain, located in the orbital, supraorbital, and/or temporal regions, with ipsilateral autonomic symptoms and/or restlessness. By definition, cluster headache attacks last between 15 and 180 minutes. Based on the temporal course, cluster headache can be categorized into episodic and chronic. A subdivision can also be made in primary and secondary chronic and secondary episodic. The cause of cluster headache is unknown, but probably the hypothalamus, trigeminal sensory system, some cranial blood vessels, and the autonomic nervous system are involved. A combination of acute (oxygen inhalation and/or subcutaneous sumatriptan) and prophylactic (first choice verapamil) treatment is usually necessary. For treatment-resistant patients, some experimental invasive options exist.
Hemicrania continua
Authors: Lim Johan , Haan Joost
Published: April 2020

Hemicrania continua is an uncommon primary headache characterized by continuous, unilateral cranial pain of moderate intensity, more painful exacerbations with cranial autonomic features, and an absolute response to indomethacin. It is considered one of the trigeminal autonomic cephalalgias. Activation of the trigeminal–autonomic reflex and the contralateral posterior hypothalamic grey is thought to play an important role in its pathophysiology. The mean age of onset is in the third decade and there is a female preponderance of 2:1. Hemicrania continua can be divided into a remitting and an unremitting type; most patients suffer from the unremitting type. Any part of the head or neck can be affected, and pain is mainly described as throbbing. Many patients experience migrainous features during exacerbations. Physical and supplementary investigations are mostly normal. Other trigeminal autonomic cephalalgias and migraine are the main differential diagnostic alternatives for consideration.
Primary stabbing headache
Authors: Halker Rashmi B. , Dilli Esma , Starling Amaal
Published: April 2020

Primary stabbing headache is a unique headache disorder, also known as idiopathic stabbing headache, ice pick headache, and jabs and jolts syndrome. The headache is described as a sharp, stabbing pain, lasting seconds to minutes, with no associated symptoms, including any autonomic features. It is more common in women by a 3:1 ratio and is comorbid with migraine, with some studies reporting that up to 40% of migraineurs also have primary stabbing headache. Performing magnetic resonance imaging of the brain is reasonable in patients who present with stabbing headache, as there are secondary causes. Meningiomas, hemorrhages, and giant cell arteritis have all been reported to present in this manner. As primary stabbing headache is a benign disorder, infrequent attacks do not require treatment and patients can be counselled accordingly. For more frequent attacks, indomethacin is the prophylactic drug of choice. Other treatment options include melatonin and cyclooxygenase-2 inhibitors.
Cough headache
Authors: Pascual Julio , van den Berg Peter
Published: April 2020

Cough headache exists in a primary and secondary form. The latter is due to tonsillar descent or, more rarely, to other space-occupying lesions in the posterior fossa/foramen magnum. Up to 40% of patients have an underlying structural lesion. Most patients with primary cough headache respond to indomethacin and suboccipital craniectomy with posterior fossa reconstruction can relieve cough headache in Chiari type I malformation.
Exertional and sex headache
Authors: Chen Shih-Pin , Pascual Julio , Wang Shuu-Jiun
Published: April 2020

Exertional headache and sexual headache are headache disorders that share some clinical and pathophysiological characteristics. These two headache disorders are both provoked by specific triggers and are highly comorbid with migraine. They account for a small proportion of headache consultations, but potentially devastating secondary causes such as subarachnoid haemorrhage or reversible cerebral vasoconstriction syndromes should be considered. Structural neuroimaging studies, as well as comprehensive vascular imaging of head and neck, are necessary to exclude secondary causes. The diagnosis of primary exertional headache and primary sexual headache should be based on the criteria proposed in the International Classification of Headache Disorders, 3rd edition (beta version). Impaired cerebral autoregulation or venous stenosis has been proposed as possible pathophysiology. Beta blocker and indomethacin might be effective treatment, but large-scale randomized placebo-controlled studies are required to provide solid evidence.
Hypnic headache
Authors: Holle Dagny , Dodick David W.
Published: April 2020

Hypnic headache (HH) is a rare primary headache disorder. Its main clinical features are strict sleep-related headache attacks that awaken patients from sleep. As headache attacks often occur at the same time at night, HH has also been referred to as ‘alarm clock headache’. Currently, 225 cases have been reported in the literature. Patients are generally older than 50 years of age at headache onset, but occurrence in younger patients and even children has been described. More women than man are affected. The headache may be bilateral or unilateral. Some migrainous features, such as nausea or photophobia, or mild cranial autonomic symptoms, such as lacrimation, may accompany HH and create diagnostic uncertainty. While most patients display some motor activity during the headache attacks, the agitation and motor restlessness that is characteristic of cluster headache does not appear. The pathophysiology of HH is still enigmatic. Hypothalamic involvement has been considered on the basis of the circadian rhythmicity, relationship with sleep, and imaging evidence of a decrease in grey matter volume within the posterior hypothalamus. Caffeine, lithium carbonate, and indomethacin may be effective for the prevention of attacks, but randomized, placebo-controlled trials are not yet available.
New daily persistent headache
Authors: Peng Kuan-Po , Robbins Matthew S. , Wang Shuu-Jiun
Published: April 2020

New daily persistent headache (NDPH) is a rare headache syndrome affecting both paediatric and adult populations. In the latest revision of International Classification of Headache Disorders, 3rd edition (ICHD-3 beta), it is defined by the onset of daily and unremitting headaches within 24 hours lasting for more than 3 months. Common triggers include flu-like symptoms and stressful life events; however, the pathophysiology is largely unknown. Regarding headache features, in the ICHD-3 beta, migrainous features are allowed in comparison with ICHD-2. Different triggers and heterogeneous clinical presentations suggest that NDPH is more likely a syndrome, rather than a disease entity. Secondary aetiologies must be carefully excluded, especially meningitis, high and low intracranial pressure headaches, medication overuse headache, or reversible cerebral vasoconstriction syndrome. There are no randomized placebo-controlled trials for NDPH; thus, the treatment is mostly empirical. Most patients have persistent headache despite treatment, but approximately one-quarter of them reached remission, usually within 24 months. However, a subgroup of those who reached remission initially might experience relapse after months or years free from pain.
Frequent headaches with and without acute medication overuse
Authors: Sun-Edelstein Christina , Rapoport Alan M.
Published: April 2020

The term ‘chronic daily headache’ (CDH) encompasses those headache disorders in which headaches are present on at least 15 days per month. CDH is a significant problem worldwide. Compared to episodic headache disorders, it is associated with more disability, lower health-related quality of life and greater health care resource utilization. However, it remains under-recognized and undertreated. This chapter provides a summary of the management of several CDH subtypes, including chronic migraine, medication overuse headache and chronic cluster headache. International differences in CDH management, as documented in the medical literature and through comments from headache specialists around the world, are also discussed. In order to increase the awareness and treatment of CDH and reduce the associated societal and economic costs, further education, research and public health policies are needed.
Nummular headache
Authors: Pareja Juan A. , Robertson Carrie E.
Published: April 2020

Nummular headache is characterized by head pain exclusively felt in a sharply contoured, rounded, or elliptical area of the scalp, fixed in size and shape, and typically 1–6 cm in diameter. The affected area may show variable combinations of hypoaesthesia, dysaesthesia, paraesthesia, allodynia, and/ or tenderness. The symptomatic area may be localized in any part of the head but mostly in the parietal region. Rarely, the disorder may be multifocal, with each symptomatic area retaining all the characteristics of nummular headache. The pain is continuous or intermittent, and generally chronic. Nummular headache is a primary condition.
Thunderclap headache
Authors: Koppen Hille , van Sonderen Agnes , de Bruijn Sebastiaan F.T.M.
Published: April 2020

Severe headache of sudden onset is relatively common, especially in emergency departments, and has an extensive differential. Neurovascular disorders often present with thunderclap headache. Although the initial work-up is focused to exclude subarachnoid haemorrhage, several other serious life-threatening disorders must be considered, such as cerebral venous sinus thrombosis and stroke. Furthermore, other causes like reversible cerebral vasoconstriction syndrome are recognized more and more. In this chapter the work-up of alert, neurologically intact patients presenting with an acute and severe headache, not related to trauma, will be described.
Headache associated with systemic infection, intoxication, or metabolic derangement
Authors: Lagman-Bartolome Ana Marissa , Gladstone Jonathan P.
Published: April 2020

This chapter discusses headaches attributed to exposure to a substance, disorders of homeostasis, high altitude, airplane travel, diving, sleep apnoea, dialysis, cardiac cephalalgia, hypertension, metabolic derangement, and systemic infection.
Headache associated with intracranial infection
Authors: Brouwer Matthijs C. , Gladstone Jonathan P.
Published: April 2020

Headache is a common presenting symptom in patients with intracranial infections, such as bacterial meningitis, viral encephalitis, brain abscess, and tuberculous meningitis, and may be the only symptom. The headache during intracranial infections is caused by several factors, such as increased intracranial pressure, stimulation of meningeal nociceptors by bacterial products, mediators of inflammation, and reactive oxygen species, and intracranial complications, such as hydrocephalus, subdural empyema, cerebral abscess, cerebral infarctions, and cerebral haemorrhages. As intracranial infections constitute a medical emergency, the initial management will be directed at diagnosis and management of the infection. Upon treatment of the infection, headache will resolve in most patients, although a proportion of patient will have persisting or chronic headache. Diagnostic criteria have been developed to categorize patients with headache following intracranial infection. The type and incidence of headache following intracranial infection does not appear to differ from that in the common population.
Orofacial pain
Authors: Graff-Radford Steven B. , Newman Alan C.
Published: April 2020

Orofacial pain involves pain conditions associated with the hard and soft tissues of the head, face, neck, and all the intra-oral structures. The field of orofacial pain encompasses diagnosis and treatment of primary headaches, temporomandibular disorders, neuropathic pain, cervical pain, and myofascial pain. The evaluation and treatment of orofacial pain has evolved into a shared responsibility between the dentist and physician, with considerable overlap, distinguished only by the practitioner’s knowledge and training.
Headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL) syndrome
Authors: Morís Germán , Pascual Julio
Published: April 2020

Headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL) is a rare, self-limited syndrome that is characterized by 1–12 episodes of headache with temporary neurological deficits and cerebrospinal fluid lymphocytosis within a period of 3 months. HaNDL syndrome is more frequent in males (3:1) around their third and fourth decades of life. As HaNDL is commonly preceded by a viral illness, a possibility is that this syndrome is autoimmune in origin. Headache is usually described as severe and bilateral, and lasts from a few hours to a few days. Accompanying temporary deficits typically are restricted to one hemisphere and last an average of 5 hours. Sensory symptoms, language disorders, and hemiparesis, in this order, are the more frequent focal deficits. Contrary to migraine aura, visual symptoms are rare. While neuroimaging discloses no abnormalities, lumbar tap demonstrates lymphocytic pleocytosis with normal glucose levels and negative microbiological results. Electroencephalography and brain single photon emission computed tomography show hemispheric slowing or decrease uptake within the acute episodes. There is no specific treatment, but the syndrome does not leave any sequel.
Giant cell arteritis and primary central nervous system vasculitis as causes of headache
Authors: Shibata Mamoru , Suzuki Norihiro , Hunder Gene
Published: April 2020

Giant cell arteritis (GCA) is a granulomatous vasculitic disorder that affects cranial arteries, as well as large arteries, including the aorta. The possibility of GCA should always be considered in headache developing in elderly people. Temporal artery biopsy is usually required to establish the diagnosis. Prompt institution of steroid therapy reduces the risk of complications, such as visual loss and major ischaemic events. Primary central nervous system vasculitis (PCNSV), or primary angiitis of the central nervous system (PACNS), causes headache and neurological symptoms. Patients affected by PCNSV can exhibit thunderclap headache. In such cases, scrutiny for subarachnoid haemorrhage, pituitary apoplexy, and venous thrombosis is warranted. Differential diagnosis between PCNSV and reversible cerebral vasoconstriction syndrome can be challenging. However, this differentiation is important, because they require distinct therapeutic strategies. Steroid and cyclophosphamide are used to treat PCNSV.
Headache related to an intracranial neoplasm
Authors: Leroux Elizabeth , Maurice Catherine
Published: April 2020

Patients presenting for headache often worry about having a brain tumour. Specific tumours may induce headache by varied mechanisms, producing different phenotypes. Virtually all headache and facial pain phenotypes can be secondary to a brain tumour, but clinical clues to a secondary aetiology are often present. Headaches may also be related to the treatment of intracranial neoplasms such as intrathecal chemotherapy, radiotherapy, and craniotomy. The ICHD-3 therefore includes several codes related to brain tumours, illustrating this diversity. Although not specifically represented in the classification, the association of trigeminal autonomic cephalalgias with pituitary tumours is now supported by the literature and is discussed in a specific section.
Headache and Chiari malformation
Authors: Holle Dagny , Pascual Julio
Published: April 2020

Chiari malformation is a rare medical condition that is characterized by downward displacement of the cerebellar tonsils through the foramen magnum. The clinical presentation of Chiari malformation is diverse, but headache is the most often reported symptom. The typical Chiari malformation headache is localized in the occipital part of the head and aggravated by coughing, other Valsalva manoeuvres, or physical exertion. The prevalence of other episodic primary headache disorders such as tension-type headache and migraine is not increased in patients with Chiari malformation. The underlying pathophysiology of headache in Chiari malformation is still enigmatic, but alteration of intrathecal pressure was suggested to be involved. Controlled treatment trials for CM-related headaches are not available and treatment recommendations are mainly based on case reports, small case series and clinical experience. Therefore, no firm recommendation regarding surgical treatment can be made.
Headaches in the elderly
Authors: Smith Jonathan H. , Straube Andreas , Swanson Jerry W.
Published: April 2020

There is a non-controversial definition about who is an elderly patient. The age group above 85 years is the fastest growing segment in the total population. Persisting pain is not rare in this patient group and the prevalence for persisting pain is 40–79%. Migraine prevalence declines gradually after the age of 40 years, but even in the age group of 60 years and older up to 5% complain of migraine and in some patients the symptoms change towards more tension type-like headaches. Tension-type headaches are thought to be the most prevalent primary headaches in the elderly, with a 1-year prevalence of about 36%; secondary headaches often present as tension type-like headaches. A typical age-bounded headache is hypnic headache, which is only seen in patients older than 55 years of age. In the treatment of headaches in the elderly, the pharmacokinetic changes with age should be considered; the distribution volume and elimination kinetics are different in the elderly. Therefore, treatment should be initiated as ‘slow and low’.
Headache and psychiatry
Authors: Pompili Maurizio , Lamis Dorian A. , Andrasik Frank , Martelletti Paolo
Published: April 2020

Patients suffering from different types of headache typically complain of numerous associated symptoms (e.g. behavioural and somatic), which may be partially related to psychiatric comorbidity. Somatic symptoms have been demonstrated to be more common in patients with chronic migraine, especially for severe headaches with accompanying depression or anxiety. Moreover, chronic migraine may be considered as distinct from an episodic type of migraine with aura, migraine without aura, and migraine aura without headache (without a history of characteristic migraine headaches). Accordingly, the present chapter explores the prevalence and impact of mental illness in patients diagnosed with migraine headache.
Headache and sport
Authors: Kernick David P. , Goadsby Peter J.
Published: April 2020

Headache is prevalent within the community and can have an impact on sport in both the amateur and the elite player. Initiatives to increase activity levels in the population make this an important area. Against a background of a limited evidence base, this chapter suggests how headache can be classified within this context and offers guidance for treating both the amateur and the elite athlete. The impact of headache in sport may be unrecognized and undertreated, and further research is needed in this area.
Headache attributed to airplane travel
Authors: Mainardi Federico , Zanchin Giorgio
Published: April 2020

Headache attributed to airplane travel, also named ‘airplane headache’ (AH) is a recently described clinical entity characterized by the sudden onset of a severe head pain, which appears exclusively in relation to airplane flights, mainly during the landing phase. Secondary causes, such as upper respiratory tract infections or acute sinusitis, must be ruled out. Although its pathophysiology is not completely understood, a causative role is attributed to an imbalance of the intrasinus pressure, consequent to a change of external air pressure not paralleled with an adequate compensation inside the cranial sinuses. In the International Classification of Headache Disorders, second edition (ICHD-2) AH is not mentioned. On the basis of an extended investigation, AH diagnostic criteria were proposed, which have been introduced for the first time in the recently published ICHD-3B version. Its formal recognition will favour further studies aimed at improving knowledge about AH and implementing preventative measures.
Headache and sleep
Authors: Evers Stefan , Jensen Rigmor
Published: April 2020

Headache and sleep share some clinical and physiological features. In ancient times good sleep was regarded as a cure for headache. The neuroanatomical links between the two conditions is the hypothalamus and one of the physiological links is the orexin metabolism. In the clinical setting, there are headache disorders predominantly occurring during sleep, such as cluster headache, or often occur in the early morning, such as migraine attacks. On the other side, sleep disorders can trigger headache such as sleep apnoea syndrome or bruxism. Recently, a significant association has been described between migraine and restless legs syndrome. Drugs used in headache and migraine treatment can lead to sleep disturbances such as vivid dreams caused by betablockers or hypersomnia caused by tricyclic antidepressants. A specific condition is hypnic headache, which exclusively occurs during the sleep.
Ethics and research in psychiatry: Consent, capacity, and bioethics
Authors: Lalanie Fernando Buddhika , Sumathipala Athula
Published: April 2020

This chapter provides an overview of the principles underlying ethical procedures in psychiatric research, with a specific focus on populations with mental disorders and research conducted in people who may lack capacity to consent to take part in research. Key topics covered in the chapter include the principles underlying ethical clinical research in psychiatry, the procedural elements of obtaining valid consent to take part in research from participants (including specific consent procedures), the principles underlying assessment of whether individuals have the capacity to consent to research and tools/instruments which may aid determining this, the procedures which should be observed when consent is sought for research in instances where capacity to consent may be absent, and protecting the best interests of vulnerable research participants. The chapter includes a separate section outlining additional considerations for assessing capacity in children to take part in research.
Ecological studies
Authors: Das-Munshi Jayati
Published: April 2020

Ecological studies use aggregated data to infer correlation of exposures with outcomes over time, or by place. One of the first examples of an ecological study was Emile Durkheim’s exploration of country-level factors underlying suicide, first published in 1897. Ecological studies have continued to hold an important place in psychiatry, particularly for developing hypotheses. They can also be used to assess the impact of policies on health outcomes over time. There are important limitations associated with ecological study designs, in particular the ability to make causal inferences at the individual level. Multilevel modelling approaches are an important analytic development in the field, which allow the possibility of using group-level information alongside individual-level attributes in analyses. In the first part of this chapter, some examples of ecological studies and their advantages and disadvantages will be introduced. In the second part of this chapter, multilevel modelling techniques will be briefly introduced and discussed with respect to their use in overcoming some of the limitations of geographical ecological studies.
Cohort studies
Authors: Goodwin Laura , Fear Nicola
Published: April 2020

This chapter begins by defining a cohort and describing what is meant by a cohort study. It then discusses the different types of cohort, some of the key considerations for their design and interpretation, and the key advantages and disadvantages of this type of study. It ends by describing some of the analytical techniques and statistical outcomes that can be generated from these studies and provides some practical exercises. By the end of this chapter, the reader should be able to describe the major features of a cohort study and to identify their strengths and weaknesses.
Research synthesis: Systematic reviews and meta-analyses
Authors: Purgato Marianna , Ostuzzi Giovanni , Barbui Corrado
Published: April 2020

In everyday clinical practice, the choice of the best treatment to be delivered to each individual patient should be based on the integration of three main aspects: the patient’s psychopathological status, the clinical experience, and the best scientific knowledge available about efficacy and safety of interventions. The approach that integrates these three aspects is known as evidence-based medicine. The aim of this chapter is to describe the main methodological characteristics of what constitutes an evidence base, in order to assist mental health professionals in the compelling world of scientific evidence. We present randomized controlled trials as a tool for evaluating efficacy and tolerability of treatments, systematic reviews of randomized trials, and meta-analysis, a statistical approach that allows the calculation of a weighted pooled estimate of treatment efficacy and tolerability. Finally, two innovative methods to statistically summarize data using meta-analytical techniques are described: individual patient data meta-analysis and multiple treatment meta-analysis.
Inference 1: Chance, bias, and confounding
Authors: Stewart Robert
Published: April 2020

Inference describes the process of deriving conclusions from observations to generalizations and is a key activity in all research. This chapter commences with considering how the findings from a research sample can be applied to the population from which that sample was drawn—that is, the role of chance in accounting for observed findings, and the possibility that they might have arisen because of errors in the design of the study (bias)—whether relating to the people in the sample (selection bias) or the measurements applied (information bias). The chapter then begins to consider the extent to which a causal relationship can be inferred from an observed association, by considering the role of confounding factors as alternative explanations and ways in which these are addressed in statistical analyses.
Inference 2: Causation
Authors: Stewart Robert
Published: April 2020

Most epidemiological research, beyond the simple descriptive study, is attempting to elucidate a causal relationship. This chapter continues the consideration of causal inference in a broader context, covering the principles of inductivism and refutationism that emerged in seventeenth-century Western philosophy and which have had profound influences on modern science. However, life sciences cannot rely on perfectly controlled experimental conditions and consequently a number of other principles have had to be developed to allow knowledge to accumulate despite uncertainties in hypothesis testing. For epidemiology, these include the principle of consensus (repeated experiments contributing to a ‘verdict of causality’) and the causal criteria outlined by Bradford Hill. Finally, the potential combinations of variables under investigation (causal, confounding, mediation, effect modification) are considered in relation to analysis designs.
Genetic epidemiology: Overview
Authors: Rijsdijk Frühling , O’Reilly Paul F.
Published: April 2020

This chapter demonstrates the principles behind some of the major genetic study designs used in psychiatry research. The first part focuses on behavioural genetic designs, while the second part describes designs for ‘gene mapping’. Behavioural genetics examines the genetic basis of behavioural phenotypes, including both disorders and ‘normal’ dimensional traits. The theoretical basis is derived from population genetics, including properties such as segregation ratios, random mating, genetic variance, and genetic correlation between relatives. The second part of the chapter deals with gene mapping designs, in which specific genetic variants or genomic regions associated with a disorder or trait are identified. A brief outline of the most popular current approaches to the analysis of the genetics of complex human disorders is also provided.
Bio-informatics and psychiatric epidemiology
Authors: Voyle Nicola , Kerz Maximilian , Kiddle Steven , Dobson Richard
Published: April 2020

This chapter highlights the methodologies which are increasingly being applied to large datasets or ‘big data’, with an emphasis on bio-informatics. The first stage of any analysis is to collect data from a well-designed study. The chapter begins by looking at the raw data that arises from epidemiological studies and highlighting the first stages in creating clean data that can be used to draw informative conclusions through analysis. The remainder of the chapter covers data formats, data exploration, data cleaning, missing data (i.e. the lack of data for a variable in an observation), reproducibility, classification versus regression, feature identification and selection, method selection (e.g. supervised versus unsupervised machine learning), training a classifier, and drawing conclusions from modelling.
The molecular basis of cardiac embryogenesis
Authors: Torres Miguel
Published: April 2020

The heart is the first organ to function in the mammalian embryo; however, heart development spans the whole intrauterine period and is only completed during the postnatal period. The ability of the mammalian fetal heart to provide circulatory support while preserving its proliferative and regenerative ability has stimulated interest in the molecular and cellular pathways underlying cardiac development and how they might be exploited in the design of regenerative strategies in the adult heart. Cardiac cell lineage specification and differentiation is regulated by an intricate network of molecular pathways that involve extracellular signals, transcription factors, and chromatin regulators. This chapter outlines current knowledge and the latest advances in understanding the molecular basis of cardiac lineage specification and differentiation during embryonic development.
Gastroenterology
Authors: Frise Charlotte , Collins Sally
Published: April 2020

This chapter covers the common gastroenterological symptoms associated with pregnancy (e.g. constipation, gastro-oesophageal reflux, nausea, and the less common hyperemesis gravidarum). Common inflammatory bowel conditions (e.g. ulcerative colitis and Crohn’s disease) and their management in pregnancy are discussed, and drug interactions with breastfeeding are covered. Coeliac disease and associated risks to the pregnancy are covered, as well as bariatric procedures both pre and post pregnancy.
Liver disease
Authors: Frise Charlotte , Collins Sally
Published: April 2020

This chapter covers pregnancy-related liver changes, and the differing normal ranges for liver function tests during pregnancy and the postpartum period. It then describes various liver disease, including those caused by pregnancy (jaundice, acute fatty liver, and intrahepatic cholestasis of pregnancy), as well as hepatitis, cirrhosis, and non-alcoholic fatty liver disease. Hereditary liver problems are covered, alongside biliary atresia and primary and secondary biliary cholangitis. Management appropriate to pregnancy for each condition is covered, including any modifications due to changes in pregnancy.
Neurology
Authors: Frise Charlotte , Collins Sally
Published: April 2020

This chapter considers the effects of neurological conditions in the pregnant patient. This includes epilepsy, the use of antiepileptic drugs and any contraindications and problems for the fetus, and the management of seizures both pre- and postnatally. Ischaemic stroke, intracranial and subarachnoid haemorrhage, cervical artery dissection, moyamoya, headaches, migraine, and neonatal effects of myasthenia gravis are all discussed, along with management strategies. Inherited and acquired neuropathies are also covered, along with other neurological conditions.
Haematology
Authors: Frise Charlotte , Collins Sally
Published: April 2020

This chapter begins by describing the normal haematological and physiological changes that occur in pregnancy, and biochemical markers at different trimester stages. It then covers the diagnosis, management, and complications for a range of haematological disorders, which may either pre-exist (such as sickle cell disease, thalassaemia, and other inherited conditions) or develop in pregnancy, including their potential risks to fetal development. Blood products and antithrombotic drugs in both pregnancy and lactation are described.
Diabetes mellitus
Authors: Frise Charlotte , Collins Sally
Published: April 2020

This chapter covers all issues of diabetes mellitus in relation to pregnancy. Type 1 and type 2 diabetes are defined, alongside gestational and monogenic diabetes. Advice for the pregnant patient with diabetes is given for every stage, from preconception to ante- and postnatal care. Practical aspects such as target capillary glucose levels, glucose monitoring, and types of insulin are all described. Complications and emergencies, including hypoglycaemia and diabetic ketoacidosis, are also explained, along with their management.
Dermatology
Authors: Frise Charlotte , Collins Sally
Published: April 2020

This chapter covers the common skin changes in pregnancy, as well as atopic and polymorphic eruptions of pregnancy, pemphigoid gestationis, erythema nodosum, psoriasis, and more. For each condition, the background, symptoms, and potential effects on the fetus are described, as well as management strategies.
Ophthalmology
Authors: Frise Charlotte , Collins Sally
Published: April 2020

This chapter covers the general considerations regarding the eyes in pregnancy (normal physiological changes and general messages, topical antibiotics for ocular use, etc.), disorders that can affect the neonate (ophthalmia neonatorum), and other associated issues such as glaucoma, uveitis, and miscellaneous other conditions that may have symptoms that result in eye problems.
Pelvic organ prolapse
Authors: Jefferis Helen , Price Natalia
Published: April 2020

Pelvic organ prolapse (POP) is where the pelvic organs (uterus/vaginal apex/bladder/bowel) herniate into or beyond the vagina from their normal anatomical position. This chapter provides both the classification and grading of pelvic organ prolapse, alongside assessment and examination of the patient. Management is split into conservative, pessaries, and surgery. Different types of surgery and their techniques are described, with indications and variants for various prolapses.
Urology
Authors: Jefferis Helen , Price Natalia
Published: April 2020

This chapter covers various issues to do with urology in women. It begins by listing different investigation methods and what conditions they are best prepared to show. It then goes through various urological problems that may be encountered, such as ureteric stenting, haematuria, urinary tract infections and non-bacterial cystitis, and bladder pain syndrome. Urethral conditions and injuries to the urinary tract are both covered, including mechanism of injury and repair. Catheters, vesicovaginal fistulae, and urinary diversion are also described and given techniques for management.
Neurology
Authors: Jefferis Helen , Price Natalia
Published: April 2020

This chapter describes the various neurological conditions that can have an effect on bladder function and the upper renal tract. Brain lesions and effect on continence are described, alongside spinal cord lesions, sacral cord injuries, and peripheral neuropathies like diabetes and Herpes zoster.
Laparoscopic urogynaecology
Authors: Jefferis Helen , Price Natalia
Published: April 2020

Laparoscopic surgery is well-established in the management of benign gynaecological conditions, and is increasing in use in urogynaecology. This chapter provides an overview of the advantages and disadvantages to laparoscopic surgery for both the surgeon and the patient, and then outlines key considerations in patient selection. Methods of entry are described and compared, and a list of laparoscopic procedures is included, alongside tips for training.
Pharmacologic treatment of negative symptoms
Authors: Czobor Pál , Bitter István
Published: April 2020

During the last decade negative symptoms in schizophrenia became a legitimate indication for potential drug targets. Significant progress has been made to improve measurement of negative symptoms, to distinguish between primary and secondary negative symptoms, and the importance of predominant negative symptoms was underlined. However, few clinical trials focused on primary and/or predominant negative symptoms. A large meta-analysis found that second-generation antipsychotics (SGA) had the greatest efficacy for negative symptoms, followed by first-generation antipsychotics (FGA), combination treatments, antidepressants, and glutamatergic medications. The included studies, however, were not specifically designed to measure negative symptoms. With respect to patients with predominant negative symptoms, in the largest trial conducted so far, the SGA cariprazine was superior to its comparator, risperidone. For medication classes other than antipsychotics and antidepressants, no reliable support was found that would substantiate evidence-based recommendations for using these agents in the treatment of negative symptoms in clinical practice.
Case 6
Authors: Ramasamy Maheshi
Published: April 2020

Community-acquired pneumonia (CAP) commonly presents as a syndrome of cough and breathlessness and is a leading cause of morbidity and death globally. The most common causative organism of CAP in adults is the bacterium Streptococcus pneumoniae. Microbiological investigations to identify causative agents include blood cultures, viral throat swabs for polymerase chain reaction (PCR), and urinary antigen tests. Scoring tools such as CURB-65 can help determine whether a patient with CAP can be safely managed in the community or needs admission to hospital. Most patients respond to β‎-lactam antibiotics, but in patients with atypical causative organisms, alternative classes of antibiotics may be required.