bluuebunny/crossref_metadata_2025 huggingface dataset:
Goose Bumps and Memory Loss
Authors: Britton Jeffrey W. , Narapureddy Bhavya , Dubey Divyanshu
Published: November 2021

A 46-year-old man had an episode of loss of awareness while driving home. He was found in a cul de sac by his neighbor and was acting confused. He was brought to the emergency department; while there, he started having recurrent episodes of goose bumps (goose flesh) involving half of his body associated with a “wavelike” sensation that would typically begin in the lower extremities and spread upward. He also had some speech difficulty. Physical and neurologic examinations were unremarkable, except for mild cognitive deficits.

Video electroencephalographic monitoring showed frequent independent left and right temporal ictal and interictal discharges. Magnetic resonance imaging of the brain showed fluid-attenuated inversion recovery hyperintensity in the bilateral hippocampi. Cerebrospinal fluid analysis showed a mildly increased total protein concentration but no supernumerary oligoclonal bands and normal nucleated cell count and immunoglobulin G index. Serum autoimmune epilepsy evaluation was remarkable for leucine-rich, glioma-inactivated protein 1-immunoglobulin G seropositivity.

The patient was diagnosed with leucine-rich, glioma-inactivated protein 1- immunoglobulin G antibody–associated autoimmune seizures presenting with pilomotor seizures.

Before autoimmune work-up, the patient had been treated with a gradual escalation of antiseizure medications. The seizures continued. He was subsequently started on intravenous methylprednisolone. He was seizure free and was transitioned to an oral prednisone taper. He was subsequently started on a 6-week regimen of intravenous immunoglobulin. He was also started on mycophenolate mofetil.

On follow-up clinic visits, the patient had no recurrence of seizures and disclosed no cognitive dysfunction except for mild inattention. Three years after the patient’s initial episode, the antiseizure medications and mycophenolate mofetil were gradually tapered, without recurrence.

Leucine-rich, glioma-inactivated protein 1-immunoglobulin G–associated autoimmunity is typically seen among older patients (>50 years), more commonly men. Symptoms commonly include seizures and cognitive dysfunction, presenting as memory loss and disorientation.
A Patient With Headache and Progressive Tremor
Authors: Zekeridou Anastasia
Published: November 2021

A 50-year-old man with no prior medical history sought care for new-onset daily headaches persisting for 3 months that did not improve after taking over-the-counter analgesics. He described asymmetric upper extremity action tremor and clumsiness affecting predominantly the right side. The patient’s wife also noted personality changes, anxiety, and depression. The review of systems was pertinent for a flulike syndrome in the weeks before his symptoms started.

Neurologic examination showed reduced digit span, pyramidal signs with asymmetric hyperreflexia (right greater than left), and bilateral subtle lower extremity spasticity. He also had cerebellar ataxia and postural and action tremor of the upper extremities (right predominant). Ophthalmologic examination indicated mild bilateral optic disc edema with normal visual acuity.

Brain magnetic resonance imaging showed linear radial perivascular enhancement in both cerebral hemispheres without associated T2 hyperintensities. Magnetic resonance imaging of the spine showed some hazy T2 hyperintensity in the thoracic cord with subtle gadolinium enhancement.

Cerebrospinal fluid examination showed an opening pressure of 21 cm H2O, 63 white blood cells/µL with lymphocytic predominance, increased protein concentration of 130 mg/dL, and no oligoclonal bands.

The patient’s cerebrospinal fluid was positive for immunoglobulin G antibodies specific for glial fibrillary acidic protein; no other neural autoantibodies were found in the serum or cerebrospinal fluid.

The patient was diagnosed with autoimmune glial fibrillary acidic protein astrocytopathy.

The patient was treated with high-dose intravenous corticosteroids followed by oral prednisone. The patient improved, the headaches disappeared, and he had only mild persistent tremor. After the corticosteroids were discontinued, he had an early relapse with increased headaches, confusion, and ataxia. Cerebrospinal fluid reevaluation showed reoccurrence of lymphocytic pleocytosis, and the patient was treated with oral prednisone. The corticosteroids were tapered over 6 months. Repeated imaging showed resolution of the abnormalities. At 3-year follow-up, the patient was relapse free.

Autoimmune glial fibrillary acidic protein astrocytopathy is defined by the presence of glial fibrillary acidic protein-immunoglobulin G in the cerebrospinal fluid.
Body Spasms in a Woman With Thyroid Disease
Authors: McKeon Andrew
Published: November 2021

A 46-year-old woman with a history of autoimmune Hashimoto thyroiditis sought care for a 6-month history of spasms affecting her back and bilateral proximal lower extremities.

On examination, the patient appeared anxious, and her whole body seemed to stiffen when the examiner entered the room. Her cognitive, cranial nerve, and upper extremity examinations were normal, except for brisk deep tendon reflexes. Examination of the patient’s spine indicated hyperlordosis of the lumbar region. There was visible hypertrophy of the lumbar paraspinal muscles. When asked to walk, the patient took short, tentative steps, despite having normal strength in her lower extremities. Her lower extremity tone demonstrated diffuse rigidity.

Cerebrospinal fluid evaluation showed isolated increased protein concentration. Autoantibody testing of the serum and cerebrospinal fluid showed markedly increased levels of glutamic acid decarboxylase 65-kDa isoform–immunoglobulin G antibody in serum and in cerebrospinal fluid. Neurophysiologic studies in a movement disorders laboratory indicated a nonhabituating, exaggerated, acoustic startle response.

Stiff-person syndrome was diagnosed.

The patient received diazepam for symptomatic relief. At her follow-up visit, the patient reported reduction in frequency and severity of spasms but persistent stiffness throughout the lower back and lower extremities. Intravenous immunoglobulin was. After 3 months, the patient reported a 50% further improvement in stiffness and spasms but still required a walking aid. Physical therapy sessions focused on gait and safety, the patient was able to resume ambulation with a cane, without further falls.

Stiff-person syndrome was described by Moersch and Woltman at Mayo Clinic in 1956. It most commonly arises in women of middle age but can affect men, women, and children. It is an autoimmune disorder of brainstem and spinal cord inhibitory interneuronal pathways, leading to what is termed central hyperexcitability.
Orthostatism, Constipation, and Early Satiety
Authors: Shouman Kamal , Benarroch Eduardo E.
Published: November 2021

A 65-year-old woman with a history of Graves disease, status post radioactive iodine therapy, and a biopsy-proven benign calcified breast nodule sought care for evaluation of multiple symptoms. She had constipation for 8 years, with prior fecal urgency, and intermittent diarrhea for the previous year. She was diagnosed with irritable bowel syndrome. Her weight remained stable until 1 1/2 years earlier, and she had lost 6.8 kg. For the previous 3 years, the patient had experienced multiple urinary symptoms including hesitancy, urgency, incontinence, and retention. She was diagnosed with a cystocele, the correction of which did not help. She had noted difficulty focusing her eyes when moving from a dark to a well-lit environment, or vice versa. She also reported orthostatic light-headedness for 1½years, which worsened on exposure to a hot environment. Neurologic examination showed abnormally dilated pupils with prominently sluggish constriction in response to light. Autonomic reflex screening indicated patchy postganglionic sympathetic sudomotor, marked cardiovagal, and cardiovascular adrenergic failure, with neurogenic orthostatic hypotension. Thermoregulatory sweat testing showed 82% anhidrosis. A nuclear medicine gastric-emptying study indicated delayed gastric emptying and colonic hypomotility. Serum testing was markedly positive for ganglionic (alpha 3) acetylcholine receptor autoantibodies. The patient was diagnosed with autoimmune autonomic ganglionopathy. The patient received intravenous immunoglobulin. She returned and reported 80% improvement in all symptoms, and neurologic examination showed normal pupillary response to light. Autonomic reflex screening indicated improvement of her adrenergic function, and thermoregulatory sweat testing showed an impressive improvement of her sudomotor function. Her postganglionic sympathetic sudomotor and cardiovagal function remained impaired. Gastric emptying remained mildly delayed. She was maintained on intravenous immunoglobulin, which was later tapered after azathioprine was started. Autoimmune autonomic ganglionopathy usually presents subacutely, much like other autoimmune neurologic diseases. Typical features of this disorder are the impaired pupillary reaction to light and prominent sicca symptoms, indicating prominent cranial parasympathetic (cholinergic) impairment. Also consistent with this diagnosis are the prominent gastrointestinal tract symptoms. Prominent cholinergic failure helps distinguish autoimmune autonomic ganglionopathy from peripheral autonomic neuropathy or neurodegenerative disorders such as pure autonomic failure.
Constipation and Syncope
Authors: Devine Michelle F. , Pittock Sean J.
Published: November 2021

A 43-year-old woman sought care for severe constipation associated with syncopal episodes. Her constipation alternated with explosive diarrhea. Chronic left-sided abdominal pain and severe bloating developed after eating. She was diagnosed with irritable bowel syndrome. After the initial onset of symptoms, nausea, bloating, and intractable vomiting developed. Symptoms were exacerbated by food and were partially relieved with vomiting. She had multiple episodes of bilious, undigested emesis per day. Trials of antiemetics and motility agents provided no substantial relief. She adopted a liquid diet, avoided solid foods, and eventually had a gastrostomy tube placed. She lost at least 15.9 kg over 2 years. Review of systems was significant for generalized fatigue and a burning sensation in her hands and feet. Her medical history was pertinent for Graves disease previously treated with remote thyroid radioablation, and she was now taking thyroid hormone replacement therapy. Neurologic examination findings were normal except for unreactive pupillary light reflexes. A gastrointestinal tract transit study showed persistently delayed colonic transit with mildly delayed gastric emptying. Autonomic reflex screening showed diffuse postganglionic sympathetic sudomotor, severe cardiovagal, and severe cardiovascular adrenergic impairment. Thermoregulatory sweat testing showed diffuse anhidrosis. Creatinine value was mildly increased. The serum was strongly positive for ganglionic (alpha 3) acetylcholine receptor-immunoglobulin G. The findings strongly suggested an autonomic autoimmune polyganglionopathy, with autoimmune gastrointestinal dysmotility as the predominant phenotype. She received intravenous immunoglobulin. She had complete resolution of her previous constipation, nausea, and vomiting. She regained 22.7 kg. Her gastrostomy tube was removed. Repeated gastrointestinal tract transit studies approached normal findings. Repeated autonomic testing and thermoregulatory sweat testing showed improvement. Over several months, the intravenous immunoglobulin dose was tapered. The patient remained asymptomatic for 8 years on long-term immunosuppression with azathioprine, she had a recurrence of her previous symptoms. Repeated gastrointestinal tract transit studies again showed delayed gastrointestinal tract emptying. Another intravenous immunoglobulin course controlled her symptoms, with normalization of gastrointestinal tract transit studies. Autoimmune gastrointestinal dysmotility can manifest as either hypomotility or hypermotility but most often presents as gastroparesis or pseudo-obstruction. Symptoms include nausea, vomiting, bloating, early satiety, diarrhea, constipation, and involuntary weight loss. It can be idiopathic or paraneoplastic. Risk factors for idiopathic cases include personal or family histories of autoimmunity.
Difficulty Climbing the Stairs
Authors: Zekeridou Anastasia , Lennon Vanda A.
Published: November 2021

A 72-year-old woman with a history of rheumatoid arthritis and chronic obstructive pulmonary sought care for a 3-month history of progressive difficulty walking on uneven terrain and climbing stairs. In the 2 preceding weeks, she also noted difficulty standing up from a seated position. She reported no sensory symptoms but recently noticed dry mouth and new-onset constipation with decreased appetite. Electromyography showed diffusely low-amplitude compound muscle action potential responses to single-nerve stimuli at rest, with normal sensory nerve action potentials. Studies of the ulnar and femoral motor nerves demonstrated a decrement to low-frequency repetitive stimulation (12%) and substantial postexercise facilitation (200%) and decrement repair. The serum was positive for cyclic citrullinated peptide antibody, rheumatoid factor, and P/Q-type voltage-gated calcium channel antibody. Computed tomography of the chest showed subcarinal and right hilar lymphadenopathy without evidence of a primary lesion, with avidity on 18F-fludeoxyglucose–positron emission tomography/computed tomography. Transbronchial fine-needle aspiration biopsy of the lymph node revealed small cell lung carcinoma. The patient was diagnosed with Lambert-Eaton myasthenic syndrome and small cell lung carcinoma. Concurrent chemotherapy and radiation were administered for the small cell lung carcinoma, with some improvement of the patient’s weakness. Symptomatic treatment for Lambert-Eaton myasthenic syndrome was initiated. Therapy with 3,4-diaminopyridine improved the patient’s weakness, but her daily activities were limited by persistent, moderate, lower extremity weakness. The weakness objectively improved with intravenous immunoglobulin therapy. Two years later, the patient was maintained on 3,4-diaminopyridine and monthly intravenous immunoglobulin, with minimal persistent weakness and no evidence of cancer recurrence. Lambert-Eaton myasthenic syndrome was first described at Mayo Clinic in 1956 as a “myasthenic syndrome associated with malignant tumors” that had characteristic electromyographic findings, later shown to be presynaptic by microelectrophysiologic testing.
A Woman With Progressive Gait Difficulty and White Matter Abnormalities
Authors: Budhram Adrian , Gavrilova Ralitza H.
Published: November 2021

A 45-year-old woman was assessed for slowly progressive gait difficulty. Eight years earlier, she first noticed dragging of her right foot and stumbling on uneven surfaces. She also described difficulty bending the right knee and intermittent spasms of the right leg. She reported bilateral, mild hand weakness when she was doing repetitive tasks such as using scissors. She reported increasing urinary urgency and frequency over the past 3 years. Magnetic resonance imaging of the spinal cord showed continuous, relatively symmetric, T2 hyperintensity of the dorsal columns and, to a lesser extent, the lateral columns, as well as medullary pyramids. Brain magnetic resonance imaging showed T2 hyperintensity in the corticospinal tracts bilaterally extending from the precentral gyrus through the corona radiata and again seen in the pons. Review of the magnetic resonance imaging pattern of white matter abnormalities led to specific clinical suspicion for leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation, an autosomal recessive condition due to DARS2 gene sequence variation. Brain magnetic resonance spectroscopy did not show lactate peaks. Genetic testing findings were abnormal and showed compound heterozygous DARS2 sequence variations. The presence of DARS2 sequence variations confirmed the diagnosis of leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation. The patient was counseled that gradual progression of her gait difficulties could be expected. The following year she reported increasing urinary urgency and several episodes of urge incontinence. She was referred to the urology clinic. Leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation is a leukodystrophy that most commonly presents clinically with spasticity, dorsal column dysfunction, cerebellar ataxia, and sometimes mild cognitive decline. Leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation classically has a childhood onset and therefore may not be included in the differential diagnosis of chronic progressive white matter disease in adults.
Subacute Cognitive Decline in an 86-Year-Old Woman With Prior Lobar Intracerebral Hemorrhage
Authors: English Stephen W. , Klaas James P.
Published: November 2021

An 86-year-old woman with a history of hypertension, hyperlipidemia, coronary artery disease, and hypothyroidism sought care for subacute, progressive cognitive decline. Five months earlier, she was hospitalized for a small, left temporal, lobar, intracerebral hemorrhage with associated receptive aphasia. Over the next several months, she had a precipitous cognitive decline. She was prescribed memantine by her primary physician because of concern for dementia. One month before seeking care, she was found unconscious in her bathroom, which was believed to be an unwitnessed seizure. Brain magnetic resonance imaging 1 month before the current evaluation showed a prior, small, left temporal hemorrhage and diffuse lobar microhemorrhages on gradient echo imaging, focal leptomeningeal gadolinium enhancement in the left temporal lobe, and multifocal T2 hyperintensity with mass effect, maximal in the left temporal lobe. Electroencephalography showed multifocal, independent epileptiform discharges. She underwent open biopsy of the left temporal lobe, which indicated focal granulomatous inflammation causing vascular destruction, with β‎-amyloid plaques within the cortical and leptomeningeal vessels. The findings were consistent with a diagnosis of amyloid-β‎-related angiitis in the setting of severe cerebral amyloid angiopathy. Because of concern for subclinical seizures and epileptiform discharges on electroencephalography, the patient was started on levetiracetam without substantial change in her mental status. After the biopsy findings demonstrated inflammatory changes consistent with amyloid-β‎-related angiitis, she was started on intravenous methylprednisolone, followed by transition to prednisone. After 6 months of treatment, she had significant clinical and radiographic improvement. Follow-up magnetic resonance imaging at that time showed interval improvement in the T2 hyperintensity and mass effect in the left temporal lobe. She was again independent with her activities of daily living, and memantine was discontinued. Cerebral amyloid angiopathy encompasses a heterogeneous group of diseases characterized by amyloid-β‎ peptide deposition. The most common clinical manifestation of cerebral amyloid angiopathy is lobar intracerebral hemorrhage, which can be multifocal and recurrent but can also result in cerebral ischemia and ischemic leukoencephalopathy.
A Woman With Headaches and a Tumefactive Brain Lesion
Authors: McKeon Andrew
Published: November 2021

A 65-year-old woman sought care for a 6-month history of confusion and emotional disturbance that was initially ascribed to stress. She then had development of headaches over several weeks, which prompted brain magnetic resonance imaging with contrast. Imaging showed a mass emanating bilaterally from the splenium of the corpus callosum with heterogeneous T1 postgadolinium enhancement. Neurologic examination indicated left homonymous hemianopia, but she was otherwise normal. She had neither alexia nor other language deficit that may appear with a splenial corpus callosum lesion. A biopsy of the brain mass was performed. Histologic analysis of the biopsy specimen revealed glioblastoma multiforme. Corticosteroid treatment was prescribed, which relieved her headache. Radiation therapy and chemotherapy (temozolomide) were recommended. No further follow-up information was available. In neurologic clinical practice, a large corpus callosum–based lesion is sometimes encountered. The localization of such lesions is not specific for any one diagnosis, but radiologic characteristics can aid clinical decision making. Although the radiologic appearance of a lesion spreading out into both hemispheres from the corpus callosum can indicate butterfly glioma, the differential diagnosis also includes tumefactive demyelinating disease and lymphoma, which can also have a callosal localization and produce mass effect.
Headache, Uveitis, and Leptomeningeal Enhancement
Authors: Kantarci Orhun H.
Published: November 2021

A 35-year-old man sought care for a severe, acute-onset, pounding, bifrontal headache, photopsias, and nausea for 1 day. Initially, bilateral red eyes developed, and within 24 hours he had central blurred vision problems in the left eye. He reported that objects had a yellow tint with the left eye and looked “wavy” supranasally. An emergent evaluation documented bilateral red eyes, and an initial diagnosis of bilateral panuveitis was given. By 48 hours after symptom onset, he started vomiting. He also was feeling feverish and off-balance. He reported no tinnitus or hearing loss, any change in color of his eyelashes or eyebrows, alopecia, poliosis, or cognitive difficulties. An initial work-up for infectious processes was negative. Given the patient’s ethnic background, including Chinese, Japanese, and Filipino origin, and typical findings of uveomeningitis, he was diagnosed with probable Vogt-Koyanagi-Harada syndrome. There is no specific diagnostic test for this entity, and the diagnosis remains reliant on a combined interpretation of clinical and ancillary testing. The patient was kept on oral prednisone daily, and azathioprine was initiated, as well as prophylaxis against Pneumocystis carinii pneumonia and gastrointestinal tract hemorrhage. During the tapering phase of prednisone, liver function test abnormalities were found, so azathioprine was discontinued. At 1-year follow-up, he had some mild skin flaking and weight gain from the corticosteroid therapy but no other symptoms, despite having discontinued azathioprine for 3 months. He continued to taper off prednisone. He had development of bilateral hip pain; imaging showed bilateral aseptic hip necrosis. A decision was made to initiate tumor necrosis factor (TNF)-α‎ inhibitors. He lost all the weight gained and recovered from the aseptic necrosis of the hip to be able to continue running. The final diagnosis was recurrent Vogt-Koyanagi-Harada syndrome. Vogt-Koyanagi-Harada syndrome is an idiopathic inflammatory disease with panuveitis and neurologic involvement in the form of aseptic meningitis and/or hearing loss. Although the full spectrum of the disorder may involve many skin changes and additional findings, most patients have incomplete disease because they are urgently treated with corticosteroids and the disorder is steroid responsive.
A Septuagenarian With Progressive Lower Extremity Weakness and Pain
Authors: Zalewski Nicholas L.
Published: November 2021

A 75-year-old man was referred for evaluation of treatment-resistant transverse myelitis. His medical history included hypertension, coronary artery disease, benign prostatic hyperplasia, and chronic kidney disease. Eight years earlier, the patient noted development of radiating pain down the left lower extremity during long drives, lower extremity weakness and pain, on the left greater than right. He received epidural lumbar corticosteroid injections. Nine months before the current evaluation, his symptoms became refractory, and he underwent surgical decompression with laminectomy at L3-L5. This provided substantial relief for the lower extremity pain. Review of outside magnetic resonance imaging indicated multilevel lumbar stenosis before his surgery and possible, faint, T2-hyperintense cord signal extending into the conus. At the time his symptoms worsened, magnetic resonance imaging of the thoracic spine showed longitudinally extensive T2 hyperintensity extending from the thoracic cord into the conus without contrast enhancement. Evaluation in our department included cerebrospinal fluid analysis, which showed an increased protein concentration of 92 mg/dL, 1 total nucleated cell/µL, normal immunoglobulin G index, and no supernumerary oligoclonal bands. Magnetic resonance angiography of the spinal canal showed mild prominence of vascularity at T10-T12 but no clear spinal dural arteriovenous fistula. However, given the strong suspicion for spinal dural arteriovenous fistula in an older man with progressive myelopathy worsening with corticosteroids, longitudinally extensive lesion extending into the conus, and no evidence of inflammation, spinal digital subtraction angiography was performed. The spinal digital subtraction angiography confirmed the diagnosis of left spinal dural arteriovenous fistula at T11. A T11-12 laminectomy and ligation of the spinal dural arteriovenous fistula was successfully performed without complication. The patient followed up with his local providers for rehabilitation. Spinal dural arteriovenous fistula is the most common spinal arteriovenous malformation, arising from an acquired abnormal connection between a radicular artery and radiculomedullary vein. Progressive congestion and cord edema lead to neurologic deficits over time. Cases are commonly seen in older men with a history of back surgery or trauma. A delay in diagnosis of 1 to 3 years is common.
Progressive Myelopathy After Neck Pain
Authors: Flanagan Eoin P.
Published: November 2021

A 36-year-old woman with a history of hypothyroidism, gout, fibromyalgia, depression, substance use disorder, and nephrolithiasis had development of neck pain. Three months later, she noted numbness in the left leg, which slowly worsened over the course of several months, spreading to involve the right leg and eventually forming a sensory level across the trunk at T8. At that time she also noted numbness in both hands. She had stiffness and weakness in both legs and had trouble emptying her bladder.

Neurologic examination showed mild weakness restricted to the bilateral iliopsoas and hyperreflexia in the upper and lower extremities. Hoffmann and Babinski signs were positive bilaterally. There was moderate spasticity in both lower extremities and mild distal vibratory sensation loss, with a sensory level across the trunk at T8. Her gait examination indicated a spastic gait, and she had a mildly positive Romberg sign. On re-evaluation of her previous magnetic resonance image, a transverse band or pancakelike enhancement pattern was noted at the center of a moderate to severely stenotic region of the cervical spine sparing gray matter on axial sequences.

The magnetic resonance imaging findings were highly suggestive of cervical spondylotic myelopathy.

A neurosurgical referral was made, and the patient underwent anterior cervical discectomy with decompression and fusion from C4-C7. At her follow-up visit 4 months after surgery, the patient reported improvement in her strength and walking. Her neurologic examination showed normal lower extremity strength, resolution of spasticity, and negative Babinski sign bilaterally but persistent sensory deficits. Magnetic resonance imaging of the cervical spine at that time showed a decrease in the degree of T2 hyperintensity and enhancement, consistent with interval response to surgery.

The presence of a progressive myelopathy over many months in this case patient argued against a diagnosis of transverse myelitis. Furthermore, the cerebrospinal fluid was noninflammatory, which also favored cervical spondylosis over idiopathic transverse myelitis. However, the gadolinium enhancement pattern was the key diagnostic feature that strongly suggested cervical spondylotic myelopathy as the diagnosis and ultimately led to neurosurgical referral for decompression.
Paediatric and adolescent gynaecology
Authors: Cloke Brianna
Published: November 2021

This chapter discusses aspects of women’s health in children and adolescents. It starts with the normal and abnormal features of puberty, the basics of the menstrual cycle, and labial development. Congenital abnormalities and difference in sexual development are covered. Vaginal bleeding, vaginal discharge, and adolescent endometriosis and PCOS are outlined. Contraceptive choices for teenagers are shown. Pregnancy and sexual health in the adolescent is explained, alongside resources for both the healthcare professional and the patient. Eating disorders and child protection are also covered.
Thyroid
Authors: Vanderpump Mark
Published: November 2021

This chapter covers the anatomy and physiology of the thyroid, and the molecular action of the thyroid hormone. It explains tests of hormone concentration and homeostatic control, and rare genetic disorders associated with thyroid hormone metabolism. It covers antibody screens and screening for thyroid disease, ultrasound scanning, fine needle aspiration cytology, computed tomography, positron emission tomography, and other laboratory investigations. It then covers various thyroid-associated diseases, their treatment (medical and surgical when necessary), and any follow-up management programmes.
Neuroendocrine disorders
Authors: Bradley Karin
Published: November 2021

This chapter begins by covering the neuroendocrine system, then neuroendocrine tumours. Carcinoid syndrome, insulinomas, gastrinomas, glucagonomas, and VIPomas are all described, as well as other rare functional pancreatic NETs.
Practical and nursing aspects of endocrine conditions
Authors: Marland Anne , Tadman Mike
Published: November 2021

Endocrinology nursing is an ever-evolving specialty. This chapter provides expert and innovative practice-based nursing information. It provides nursing care for thyroid surgery and disorders, facilitating investigation and education about pituitary function and specialist nurse management of different conditions. Education on visual field deficits and minimum driving standards are covered. The full roles of the nurse in pituitary surgery is explained, from pre-op to post-op care. Diabetes insipidus is covered. Responsibilities and possible pathways for managing male fertility, testosterone replacement, and gender dysphoria are all described. Finally, role development and nurse led clinics are examined.
Hepatic disease
Authors: Williams Ashleigh , Christie John
Published: November 2021

This chapter describes the anaesthetic management of the patient with liver disease and its sequelae. Acute liver failure and chronic liver failure are discussed, together with their anaesthetic implications on coagulation and drug metabolism. Major sequelae of liver disease are discussed, including portal hypertension, varices, and hepatorenal syndrome. The pre-operative investigation and optimisation, treatment, and anaesthetic management of the patient with liver failure are described. The investigation and management of postoperative liver dysfunction are described.
Endocrine and metabolic disease
Authors: Poole Joanna , Blanshard Hannah
Published: November 2021

This chapter describes the anaesthetic management of the patient with endocrine and metabolic disease. Topics covered include diabetes mellitus, thyroid and parathyroid disease, acromegaly, adrenocortical disease, steroid therapy, Cushing’s and Conn’s syndromes, apudoma (including phaeochromocytoma) and abnormalities of sodium and potassium. For each topic, pre-operative investigation and optimisation, treatment, and anaesthetic management are described. The perioperative management of the diabetic patient is discussed in detail, including insulin and oral hypoglycaemic therapy. Perioperative steroid management is described.
Haematology
Authors: Valentine Peter , Ford Pete
Published: November 2021

This chapter describes the anaesthetic management of the patient with a haematological disorder. Topics covered include anaemia; sickle-cell disease; porphyria; coagulation disorders; haemophilia and related disorders; platelet disorders and hypercoagulability syndromes. For each topic, pre-operative investigation and optimisation, treatment, and anaesthetic management are described. There is detailed discussion about the perioperative management of the patient taking a drug which affects the coagulation system, including anticoagulants, antiplatelet drugs, fibrinolytic and antifibrinolytic drugs. Coagulation tests are discussed in detail, and the haematological management of the bleeding patient is described.
Orthopaedic surgery
Authors: Griffiths Richard , Brooks David
Published: November 2021

This chapter discusses the anaesthetic management of orthopaedic surgery. It begins with general principles of the anaesthetic management of orthopaedic surgical patients, including the management of fat embolism syndrome (FES), bone cement implantation syndrome (BCIS), and the use of tourniquets. Surgical procedures covered include total hip joint replacement (THJR) (including revision THJR); femoral neck fracture surgery; total knee joint replacement (TKJR); arthroscopy; cruciate ligament repair; ankle surgery; foot surgery; spinal surgery (including the cervical spine); shoulder surgery (including total shoulder joint replacement (TSJR)); elbow replacement surgery and hand surgery.
Plastic and burns surgery
Authors: Chen Brian , Davis Simon , Maguire Fynn
Published: November 2021

This chapter discusses the anaesthetic management of plastic and burns surgery. It begins with general principles of the anaesthetic management of plastic surgical patients. Surgical procedures covered include breast augmentation, reconstruction and reduction surgery; free flap surgery; liposuction; skin grafting and burns reconstructive surgery. The chapter includes pertinent anaesthetic features for a series of additional miscellaneous plastic surgical operations.
Urological surgery
Authors: Catolico Mark , Campbell Jeremy
Published: November 2021

This chapter discusses the anaesthetic management of urological surgery. Surgical procedures covered include cystoscopic procedures; transurethral resection of the prostate (TURP) (including TURP syndrome); transurethral resection of bladder tumour (TURBT); prostatectomy (including radical prostatectomy); nephrectomy and partial nephrectomy; radical cystectomy; robot-assisted laparoscopic prostatectomy (RALP); percutaneous stone removal; extracorporeal shockwave lithotripsy, testicular surgery and renal transplantation. It includes pertinent anaesthetic features for a series of additional miscellaneous urological procedures.
The major trauma patient
Authors: Dodd Oliver , Wickham Alex , Dodd Oliver , Wickham Alex , Dodd Oliver , Wickham Alex , Clitheroe Edwin , Cantle Fleur , Freeman Nicholas
Published: November 2021

This chapter describes the anaesthetic management of the major trauma patient. It begins with immediate trauma care, the patient journey, primary survey and resuscitation. The management of head and traumatic brain injury, thoracic injury, abdominal and pelvic injuries, spinal injury, limb and extremity injury, blast injury and gunshot wounds and traumatic cardiac arrest are discussed. The specific management of burns, paediatric trauma and silver trauma are covered. Anaesthesia for major trauma, including damage control resuscitation and damage control surgery are discussed.
Anaesthetic emergencies
Authors: Kane Andrew , Armstrong Richard , Nolan Jerry P , Soar Jasmeet , Evans Sorcha , Bulger Terasa , Barneto Lisa , Hopkins Phil
Published: November 2021

This chapter discusses anaesthetic emergencies. It begins with a description of adult basic life support (BLS) and advanced life support (ALS). It goes on to describe post resuscitation care; severe bradycardia; tachycardia; severe hypo- or hypertension; severe hypoxia; laryngospasm; air/ gas embolism; gastric aspiration; severe bronchospasm; pulmonary oedema; anaphylaxis; latex allergy; intra-arterial injection; incomplete reversal of neuromuscular blockade; local anaesthetic toxicity; failed intubation; the can’t-intubate-can’t-oxygenate (CICO) scenario and malignant hyperthermia (MH).
Acute pain
Authors: Dashfield Adrian , Kibblewhite David
Published: November 2021

This chapter discusses the management of acute pain. It begins with an introduction which describes the benefits of acute pain management and the measurement of pain. Analgesic drugs are then described, including paracetamol; non-steroidal anti-inflammatory drugs (NSAIDs), and opioids (including their comparative efficacy). Patient-controlled analgesia (PCA), epidural analgesia, and continuous peripheral nerve blockade are described. Transcutaneous electrical nerve stimulation (TENS) and acupuncture are discussed. The management of the patient with persistent pain and a substance misuse disorder is also discussed. The chapter concludes with a discussion of non-opioid adjuvant analgesics.
Smoothing transition to dialysis to improve early outcomes after dialysis initiation among old and frail adults—a narrative review
Authors: Schaeffner Elke
Published: November 2021

The number of patients ≥65 years of age suffering from advanced chronic kidney disease and transitioning to end-stage kidney disease (ESKD) is increasing. However, elderly patients often have poor outcomes once haemodialysis is initiated, including high mortality within the first year as well as fast cognitive and functional decline and diminished quality of life. The question is how we can smooth this transition to ESKD in older patients who also exhibit much higher proportions of frailty when compared with community-dwelling non-dialysis older adults and who are generally more vulnerable to invasive treatment such as kidney replacement therapy. To avoid early death and poor quality of life, a carefully prepared smooth transition should precede the initiation of treatment. This involves pre-dialysis physical and educational care, as well as mental and psychosocial preparedness of the patient to enable an informed and shared decision about the individual choice of treatment modality. Communication between a healthcare professional and patient plays a pivotal role but can be challenging given the high rate of cognitive impairment in this particular population. In order to practise patient-centred care, adapting treatment tailored to the individual patient should include comprehensive conservative care. However, structured treatment pathways including multidisciplinary teams for such conservative care are still rare and may be difficult to establish outside of large cities. Generally, geriatric nephrology misses data on the comparative effectiveness of different treatment modalities in this population of old and very old age on which to base recommendations and decisions.
The Icon
Authors: Corrie Rebecca W.
Published: November 2021

Perhaps no form of visual culture is more closely associated with the history and religious life of the Byzantine Empire than the painted icon. Known from the Early Byzantine period in encaustic images, its theological and liturgical functions are usually understood in light of theory that emerged in the wake of the Iconoclastic Controversy. As the imprinting of sacred form on matter, icons provide access to the sacred. Although often characterized as static and unchanging, they were produced in a variety of media, and over time new formats and new image types appeared. Recent discussions of Byzantine icons have successfully employed anthropological theory. Continued investigation of the reception of icons beyond the empire’s borders will similarly illuminate the history of their meaning and form.
Bodily Adornment and Modification in Byzantium
Authors: Walker Alicia
Published: November 2021

Focusing on Early and Middle Byzantine (fourth-to-twelfth-century) objects, images, and texts, this essay explores the tension between, on the one hand, efforts of the Byzantine church and state to discourage and control bodily adornment and modification and, on the other hand, the extensive evidence of widespread and immoderate engagement with these practices. The enhancement and manipulation of Byzantine bodies is considered as both a real and a metaphoric phenomenon. Evidence culled from secular and sacred, written and material sources demonstrates the importance of bodily adornment and modification to our understanding of Byzantine material and visual culture.
Byzantine Art and Perception
Authors: Pentcheva Bissera V.
Published: November 2021

Byzantine art preferred chameleonic materials such as gold, glass, jewels, and variegated marbles with which to make images and shape architectural space. When set in shifting diurnal light and the flicker of candles, the variegated surfaces of the icon and ecclesiastical interiors produced a spectacle of shifting appearances, or poikilia. Both before and after Iconoclasm, ekphrasis explicitly trained the viewer’s perception to interpret these phenomena as manifestations of the ephemeral dwelling of the metaphysical in matter. Focusing on three examples—the ambo and apse mosaics in Hagia Sophia and the portable icon of the Archangel—this essay explores how the perception of animation of the icons and architectural interior emerge out of the synergy among material images, imagined visions, and ekphrasis.
Mosaics
Authors: James Liz
Published: November 2021

Although frequently identified as a Byzantine medium, mosaic was used throughout the Mediterranean, Christian and Islamic, during the Middle Ages. This chapter traces that use, highlighting key areas for research including questions of manufacture and possible reasons for mosaic’s popularity and longevity. It begins with a brief discussion about the making of mosaics and of the glass for mosaics, as well as the relationship between wall and floor mosaics, moving to explore a chronology of mosaic-making in Byzantium and beyond in two blocks, from Late Antiquity to the ninth century and from the ninth century to the fifteenth. In the process, apparent peaks and troughs in the quantities of mosaics manufactured are brought to the fore.
Jewelry and Enamels
Authors: Bosselmann-Ruickbie Antje
Published: November 2021

This chapter surveys jewelry and enamels. Byzantine jewelry has survived in small numbers. Early Byzantine rings, bracelets, necklaces, and earrings were made with gold, gemstones, and pearls, often in the opus interrasile openwork technique. From the tenth century, enamels could also adorn (imperial) gold jewelry. Inscribed and engraved rings were common in the Middle and Late Byzantine period. Bronze pieces attest to everyday jewelry. Increased exchange with other areas, especially the West, is noticeable in post-Crusader times.
This Can’t Be Legal? Queer Masculinities in the 1940s Hollywood Musical
Authors: Cohan Steven
Published: November 2021

This chapter looks at exemplary musicals of the 1940s to show how they can readily be read as “queer” even when they are not openly “gay.” For, despite the predominance of conservative romance plots clinching the future of a male-female couple, many 1940s musicals registered the incoherence characterizing the culture’s understanding of effeminacy in relation to manliness, of homosexuality in relation to heterosexuality, and of deviance in relation to normality. Although today we may see those relations as homologous, in the 1940s they foregrounded fissures in the dominant ideology as it classified sexual dissidence by making it invisible and illegal. The chapter looks at examples of sexual dissidence in show numbers, a military pairing, homosocial buddy pairings, and comedic drag sequences. The films examined are Down to Earth, Up in Arms, Anchors Aweigh, Two Guys from Texas, Road to Morocco, and Bathing Beauty.
Trances, Myth, Bachelor Machines, and Abstractions: Queer Experimental Film in the Cold War Era (1943–1962)
Authors: Suárez Juan Antonio
Published: November 2021

This chapter surveys the emergence and development of a queer experimental cinema in the United States between the early 1940s and the early 1960s. It locates queer experimental film within post–World War II culture, explores the conceptions of sexuality that subtend it, and discusses its main thematic concerns, stylistic gestures, and subgenres. Against earlier readings that stress the subjective, introspective character of this body of work, the chapter argues that these films are also forms of subcultural material practice: they sexualize public and private space, upend traditional myths, articulate heterodox conceptions of the body, and make peculiar uses of everyday objects and substances. In the process, they cast sexuality and desire as a series of unclassifiable impulses and affects that attach to varied gender and corporeal configurations indiscriminately. The chapter considers well-known filmmakers such as Kenneth Anger, Gregory Markopoulos, Harry Smith, and Marie Menken, along with lesser-known figures such as Willard Maas, Theodor Huff, Sara Katryn Arledge, and Jim Davis.
Andy and Me (It’s Not Real and It’s Not Fiction)
Authors: Kalin Tom
Published: November 2021

This chapter charts the influence of Andy Warhol on filmmaker Tom Kalin and provides an overview of Kalin’s films as well as his activism. From experimental videos such as They are lost to vision altogether (1989) to his features, Swoon (1992) and Savage Grace (2007), Kalin has drawn on Warhol’s cinematic language and bold sexual and gender politics. The chapter also depicts Kalin’s work with the activist collectives ACT UP and Gran Fury. Gran Fury formed to give voice to the political issues surrounding AIDS in America. This eleven-person collective devised appropriation strategies to simultaneously utilize and critique Madison Avenue vernaculars, and circumnavigate questions of access. Named for the automobile used by the New York City police (and also sounding like “big anger”), Gran Fury created public works that drew attention to medical, moral, and political issues related to AIDS.
Brother to Brother and the “Place” of Film in Black Queer History
Authors: Keeling Kara
Published: November 2021

This chapter considers the ways in which Black film enlists the past when engaging in present struggles. It demonstrates how Rodney Evans’s film Brother to Brother (2004) redresses the elision of queer history from accounts of the Harlem Renaissance. Through a close reading of the film’s spatial metaphors, sound design, and visual form, the chapter shows how realism and the disruption of habituation exist side by side as mechanisms for new visions of Black queer life. It concludes that Evans harnesses the power of sound and image to remake history and to account for Black queer desire and erotic life.
Syndromes and a Century: Contemporary Queer Thai Cinema
Authors: Fuhrmann Arnika
Published: November 2021

This chapter concentrates on the conceptual possibilities that new Thai cinema and media open up for how we understand—and inhabit—queer personhood. It draws these films into relation to a wider political context and delineates recent shifts in understandings of sexual personhood in the country. Investigating Thai and Thai-coproduced feature films, documentaries, as well as queer occupations of social media, the article pays special attention to the (nondoctrinal) ways in which Buddhism informs contemporary sexualities. What results are globally informed yet locally rooted models of queerness and transness that take us beyond the dominant liberal models of sexual identity and economic mobility, as trans videos, lesbian films, and queer documentaries model a kind of personhood that is ordinary, though not obedient, and socially central, though not assimilated.