bluuebunny/crossref_metadata_2025 huggingface dataset:
Dementia
Authors: Widera Eric , Bernacki Rachelle
Published: April 2015

Dementia is caused by a variety of disorders that result in a progressive loss of both cognitive and functional abilities. Despite the heterogeneity of disorders, there is a common set of problems that patients and families face living with this syndrome. Symptoms such as pain, eating difficulties, depression, and agitation are all common. As the disease progresses to the advanced stages, the different disorders share a common functional trajectory that includes persistently severe disability with complete dependence on others for basic activities of daily living. Care for individuals with dementia should involve a number of important palliative interventions. Advance care planning should occur early on in the disease process as it is anticipated that an individual will lose capacity to make medical and financial decisions at some point in their illness; specialized programmes for end-of-life care, such as hospice, should be considered for all patients with advanced dementia.
Care of children with advanced illness
Authors: Collins John J. , Campbell Kirsty , Edmonds Wendy , Frost Judith , Mherekumombe Martha F. , Samy Natasha
Published: April 2015

The World Health Organization supports the global application of the principles of palliative care to every child with a life-limiting illness, irrespective of geographical location whilst acknowledging that treatment options are limited in some countries. The care of the child with advanced and progressive illness and their family requires a holistic approach to the often complex physical, social, psychological, and spiritual needs as well as support in bereavement. This inevitably requires a paediatric palliative care team with diverse skills and abilities to meet these needs. This chapter discusses the global perspective of paediatric palliative care and the role of the team, nursing, and volunteers in that care. The significant physical and psychosocial issues for the child with advanced illness are discussed, as well as bereavement support of families. The necessity of quality improvement and strategies for setting up such a programme are outlined.
Spiritual issues in palliative medicine
Authors: McClement Susan E.
Published: April 2015

The focus of palliative care is the whole person, including biopsychosocial, cultural, and spiritual dimensions of patient needs. The burgeoning literature examining the topic of spirituality within health care in general, and within palliative care in particular, underscores the notion that attending to patients’ spiritual care needs is a vital part of providing optimal palliative care. Yet health-care providers frequently report that they feel ill equipped to provide spiritual care at the end of life and wrestle with many questions and uncertainties: What is spiritual care? What is spiritual suffering? Who should provide spiritual care? How is a spiritual assessment conducted? What are some spiritual interventions for end of life care? What are some future research directions in the area of spiritual care? Answers to these questions form the basis of this chapter.
Depression, demoralization, and suicidality
Authors: Kissane David W. , Doolittle Matthew
Published: April 2015

The development of clinical depression is common during palliative care, adversely affects quality of life and adherence to medical treatments, yet regrettably can pass unrecognized. Screening for distress as the sixth vital sign is therefore highly recommended. Demoralization is another form of distress where the apparent pointlessness of continued life may lead to suicidal thinking. As the mental condition deteriorates, co-morbid states of anxiety, depression, and demoralization become more likely. Rates of suicide are increased with advanced cancer and poor symptom control. Fortunately, combined treatment with medication and counselling is effective in ameliorating depression, demoralization, and suicidality. Meta-analyses of psychotherapy trials confirm clear benefits, with behavioural activation, supportive, interpersonal, and cognitive behavioural therapies all making contributions. Group, couple, and family therapies optimize support for all involved. All members of the multidisciplinary team contribute to the active treatment of depression, demoralization, and the prevention of suicide.
Adjustment disorders and anxiety
Authors: Wein Simon , Amit Limor
Published: April 2015

Adjustment disorders and anxiety are two of the more common responses to stressors in palliative care. At one end of the spectrum, adjustment and anxiety are normal defences. However, when coping mechanisms fail these responses can become pathological. Judging when a response is pathological is based on two principles: the severity of symptoms and the extent of disruption of normal functioning or homeostatic adaptation. The intimate two-way relationship between physical and psychological symptoms in palliative care means that physical symptoms have to be well controlled and that psychological symptoms can be masked by physical complaints. Management principles include talking therapies, psychopharmacology, and complementary treatments. Examples of innovative psychological treatments are dignity therapy and meaning-centred therapy. Every palliative care intervention requires consideration of the family and it is also important to monitor anxiety and adjustment of the staff who are also prone to burn-out, compassion fatigue, and difficulties in adjusting to stressors.
Bereavement
Authors: Kissane David W. , Zaider Talia I.
Published: April 2015

The phenomena and trajectory of mourning as a normal adaptive process are differentiated from clinical depression, avoidant and complicated grief, post-traumatic distress disorder, and other forms of pathological grief. Anticipatory grief can be a particular challenge during palliative care. The family is recognized as the major source of social support and the environment in which grief is shared with others. Key risk factors for pathological bereavement outcomes can be identified on admission to palliative care, permitting preventive models of psychological care to be used through palliative care into bereavement. Models of therapy include supportive-expressive, interpersonal, cognitive behavioural, family focused, and specific therapy for complicated grief. Pharmacotherapy can judiciously accompany psychotherapy. Life-cycle issues include bereaved children, siblings, parents, and grief for the very elderly. Grief can be stigmatized and ambiguous in special circumstances, yet positive growth is a desirable outcome from any loss.
Management of the actively dying patient
Authors: Lacey Judith
Published: April 2015

The period leading to death is characterized by increasing prevalence and intensity of physical, psychological, existential, and social concerns, and it is often a challenging time for patients, their families, and health-care providers. This chapter specifically addresses the most prevalent symptoms and concerns encountered when managing the actively dying patient. Symptoms affecting dying patients’ comfort, including pain, dyspnoea, delirium, terminal secretions, and refractory symptoms and suffering require different clinical management as death approaches. Other topics included are recognizing the dying phase; communication with and preparation of patient, family, and staff; anticipating dying-advanced care planning and approach to resuscitation; addressing psychosocial and existential concerns; and approach to difficult end-of-life scenarios. This chapter aims to provide the health-care practitioner with a good overview and approach to the whole-person care needs of the dying patient and their family and carers to enable health practitioners to feel comfortable in providing this important care with confidence.
Understanding clinical trials in palliative care research
Authors: Farrar John T.
Published: April 2015

Advances in basic science, translational, and clinical research have led to rapid improvements in our understanding of many disease processes. The randomized clinical trial (RCT) has played an important role in validating the benefits and harms of therapies thought to be potentially useful based on scientific theory or clinical observation, and has become the ‘gold standard’ for the demonstration of efficacy. As in all clinical study designs, the RCT has strengths and weaknesses that must be understood to appropriately interpret the study results. While randomization of the intended study population is the primary strength of such trials, choice of the study population, control condition, outcome measures, analysis procedure, and procedures for blinding the study participants can all affect the results. Understanding the requirements of a valid RCT and what can potentially go wrong will improve the conduct of palliative care research and the usefulness of published information in the care of patients.
Qualitative research
Authors: Flemming Kate
Published: April 2015

This chapter outlines the importance of qualitative research as a method to provide answers to clinical questions arising in palliative medicine. Rather than being a chapter about how to ‘do’ qualitative research, it is a chapter that seeks to outline the role and purpose of qualitative research for palliative care by looking at the kind of questions qualitative research can answer, exploring qualitative research and its relationship to evidence-based practice, the role of qualitative research within mixed methods research, and the developing area of the synthesis of qualitative research. It addresses some of the more practical aspects of searching for qualitative research and undertaking an appraisal of its quality, whilst acknowledging that these are contested areas undergoing methodological development. In exploring these issues it firmly establishes a place for qualitative research within evidence-based practice and for palliative medicine in particular.
Research into psychosocial issues
Authors: Kissane David W. , Street Annette F. , Schweers Erin E. , Atkinson Thomas M.
Published: April 2015

Psychological, existential, spiritual, and social issues cause much suffering and deserve extensive study to understand these concerns more fully and to intervene more effectively. Themes that abound include communication, coping, ethics, the family, caregiving, quality of life, death and dying, psychiatric disorders, suffering, and the many expressions of distress. Many study designs are possible to explore these themes, often with complementary quantitative and qualitative components. This chapter summarizes the psychometric properties of many of the instruments that are commonly employed in such studies and the computer-assisted software packages that assist qualitative analyses. The goal is to strengthen research design and optimize research outcomes to benefit the discipline.
Ethical issues in palliative care research
Authors: Casarett David
Published: April 2015

Recent growth in palliative care research has created a heterogeneous field that encompasses both qualitative and quantitative techniques, and descriptive as well as interventional study designs. Despite the valuable knowledge that has been produced by this research, and the promise of future important advances, its progress has been impeded by a persistent uncertainty about the ethics of these studies. For instance, there have been concerns raised about whether patients near the end of life should ever be asked to participate in research, although others have objected to this extreme position. Nevertheless, the combination of ethical and practical issues can create substantial barriers to palliative care research. This chapter discusses five ethical aspects of palliative care research that investigators and clinicians should consider in designing and conducting palliative care research. These include (1) the study’s potential benefits to future patients, (2) the study’s potential benefits to subjects, (3) the study’s risks to subjects, (4) subjects’ decision-making capacity, and (5) the voluntariness of subjects’ choices about research participation.
Health services research in palliative care and end-of-life care
Authors: Smets Tinne , Deliens Luc
Published: April 2015

Health services research in palliative care and end-of-life care involves the study of palliative care needs, access and quality of palliative care, and the feasibility, effectiveness, and cost of palliative and end-of-life care services and interventions. The evaluation of services and interventions involving patients with advanced illness presents unique challenges, both ethical and methodological. In this chapter, several research designs that are useful for the service evaluation of complex interventions in palliative care and end-of-life care are discussed and examples of studies using these designs are described. The designs that are described include both experimental and non-experimental designs. The problems and challenges that doing research with dying patients presents are subsequently described and possible solutions proposed. The challenges dealt with in this chapter include defining the intervention, determining relevant outcome measures, randomization of patients to intervention and control group, achieving recruitment and minimizing attrition, heterogeneity of the patient group, and obtaining informed consent.
Dysphagia, dyspepsia, and hiccup
Authors: Clark Katherine
Published: April 2015

Dysphagia, or difficulty swallowing, is a complex problem that is identified as a common occurrence in palliative care. Although people may present with dysphagia as an issue that requires palliation, other people may develop dysphagia as a complication of progressive disease and increasing debilitation. The diagnosis of dyspepsia requires people to be experiencing one or more of the following four problems: epigastric pain, epigastric burning, postprandial fullness, or early satiety. Dyspepsia may occur either as a functional disorder where the cause is not clear or as a secondary disorder. Hiccup, or more correctly singultus, is a problem where people experience a sharp and involuntary contraction of the muscles of inspiration which causes a sudden sharp inspiration and closure of the glottis. Although this is often a short-lived experience, for some people, it may be more prolonged.
This chapter discusses the definition, prevalence, pathophysiology, causes, presenting problems, investigations, and management of dysphagia, dyspepsia, and hiccup.
Jaundice, ascites, and encephalopathy
Authors: Keen Jeremy
Published: April 2015

For many people, jaundice will occur as part of an episode of acute, self-limiting, viral hepatitis but in the context of chronic hepatic disease or malignancy, the development of jaundice or ascites is usually an ominous indicator of advanced disease. In two reported studies of individuals admitted to hospital with jaundice, 24% and 42% of patients with malignancy and 23% with cirrhosis died during their first admission. The necessity of a willingness to adopt a ‘palliative approach’ to the care of such individuals is obvious. This chapter discusses three features of liver impairment that may be encountered in those for whom palliative care is appropriate but the review of ascites concentrates on causes other than cirrhosis and portal hypertension.
The contribution of art therapy to palliative medicine
Authors: Wood Michèle J.M.
Published: April 2015

In the United Kingdom, and several other European countries, Canada, Australia, and the United States, art therapy is a state-registered health-care profession and its practitioners complete a postgraduate training for 2 years full-time or equivalent. The training encompasses models of psychotherapy, psychiatry, psychology, and the role and function of aesthetics and creativity in health care. Art therapy training consists of three core elements: the theoretical underpinnings of the practice, experiential engagement in artistic and interpersonal activities (so that trainees develop their capacity for self-reflection and insight and continue to engage in their own art-making) and clinical placements. Clinical placements are central to the training of art therapists, and in this way practitioners also learn about the roles of other health professionals, the function of interdisciplinary teamwork, and art therapy’s contribution to this. Professional registration of art therapists ensures that practitioners continue to maintain the standards of proficiency and professional practice established on qualification. In the United Kingdom, art therapy had its beginnings in the tuberculosis sanatoria of the 1940s but quickly developed within psychiatric and educational settings. Integrated with other care, it has since been widely incorporated into the fields of mental health and learning disabilities. However, there is a growing interest in art therapy with the medically and terminally ill. One recent survey in the UK found over 50% of art therapists in adult cancer care working with people in the palliative phase.
Psychological and psychiatric interventions in pain control
Authors: Price Julie R. , Hawkins Alric D. , Adams Michael L. , Breitbart William S. , Passik Steven D.
Published: April 2015

Pain is a common problem in populations with advanced illness and has been best characterized in those with cancer or AIDS. Despite the high prevalence of pain in populations with advanced illness, there is evidence that pain is frequently under-diagnosed and inadequately treated. Undertreatment has multiple causes, one of which is the complex presentation of pain in these populations. Pain is not a purely physical experience, but involves many aspects of human functioning, including personality, affect, cognition, behaviour, and social relations. This complexity is best managed using a multimodality approach, including psychiatric and psychological interventions. These interventions may be psychotherapeutic, cognitive behavioural, or psychopharmacologic.
Complementary therapies in pain management
Authors: Deng Gary , Cassileth Barrie R.
Published: April 2015

Complementary therapies are modalities that are not traditionally part of Western medical care. Some of these therapies have demonstrated a favourable benefit:risk ratio in recent research and many can be incorporated into a multimodality pain management plan. In general, complementary therapies reduce pain by interfering with the processing of pain signals or lessen the impact of pain on the patient’s emotional state. Mind-body therapies, such as hypnosis, meditation, yoga/qigong, and music therapy, can reduce anxiety, depression, and stress-all common in patients experiencing pain. Acupuncture appears to have direct analgesic effects and reduce nausea and vomiting, which are potential side effects from opioid therapy. Massage therapy may reduce anxiety, and to a lesser degree, depression and pain. Complementary therapies are generally safe when provided by trained practitioners, although certain safety precautions still need to be exercised. The origin of pain, the factors complicating it, burdens and risks to patient, and each patient’s belief system and cultural background should all be considered when selecting from among the complementary modalities for pain.
Paediatric pain control
Authors: McCulloch Renée , Collins John
Published: April 2015

Our understanding regarding pain in children has grown significantly in the past few decades; however, we still find reluctance to acknowledge and treat pain in children. Many myths prevail, and coupled with poor understanding, can undermine the effective treatment of pain in children. Understandably many health-care professionals are apprehensive and fearful about working with very sick and dying children; perhaps there is a sense of failure for being unable to ‘cure’. However, as pain is one of the most common symptoms in this group of children, relieving pain and distress can be an extremely rewarding experience. This chapter outlines the background and principles of understanding, evaluating, and treating pain in children with palliative care needs. It offers an overview of current evidence and hopes to support health-care professionals working in this challenging discipline.
The International Classification of Functioning, Disability, and Health
Authors: Playford Diane
Published: April 2015

The International Classification of Functioning, Disability and Health (ICF), provides a framework for the description of health and health-related states and offers a biopsychosocial model of disability. The ICF was introduced by the World Health Organization in 1999 as a response to the conceptual and practical difficulties posed by its predecessor, the International Classification of Functioning, Disability and Health. The ICF lists body functions and structure, and activity and participation. The relationship between impairment, activity, and participation is not linear, and can be further moderated by contextual factors, including personal and environmental factors. There are a wide range of potential applications of the ICF.It has been adopted most widely within rehabilitation services to describe individual functioning, but can also be used at a service and national policy level to describe, monitor, and evaluate different activities.This chapter outlines the use of the ICF, considers its strengths, and highlights its function in a range of settings.
The economic benefits of rehabilitation for neurological conditions
Authors: O’Connor Rory
Published: April 2015

A rehabilitation programme may initially appear expensive, resulting in a lack of enthusiasm to develop them by funding bodies and commissioners. Therefore, demonstrating the long-term cost-effectiveness of rehabilitation is extremely important. Many people with long-term neurological conditions will live for many years and investment in their physical and psychological functioning early in the course of the condition will, over the lifetime of the patient, potentially result in substantial savings.However, calculating economic evaluations can be complicated and the correct measure must be chosen to identify the change produced by the rehabilitation intervention. These data must then be handled appropriately and all ancillary costs included. The economics are wider than this and will include potential earnings and reduced costs to social care. The economic analyses will also include housing, education, and vocational outcomes and the impact on family members who may have a caring role.
Predicting activities after stroke
Authors: Kwakkel Gert , Kollen Boudewijn
Published: April 2015

Knowledge about the functional prognosis of stroke patients admitted to a stroke unit has increased substantially over the past years. Prospective cohort studies suggest that a return of some finger extension and voluntary activity in the shoulder abductors within days post-stroke onset predicts a favourable recovery of the upper extremity function at 6 months. The Barthel Index and the ability to sit unsupported are the main predictors for recovery of gait and ADL independency. Almost all developed prediction models identify patients with a favourable prognosis but are less suitable to accurately predict individuals who will not regain dexterity, mobility, and ADL independence following stroke. In individuals with an unfavourable prognosis, this entails measuring clinical determinants frequently and longitudinally during the post-stroke course. Moreover, future research should focus on cross-validating prediction models, which should also incorporate presently excluded stroke subtypes, such as brain stem strokes, intraparenchymal and subarachnoid haemorrhages.
Designing a clinical trial for neurorehabilitation
Authors: Dobkin Bruce , Dorsch Andrew
Published: April 2015

The design, implementation, and analysis of clinical trials for the types of complex therapies needed to lessen impairments and disabilities that result from neurological diseases are reviewed. A multistep progression from feasibility testing in small groups of selected participants to the demonstration of efficacy in large-scale, multicentre randomized clinical trials is presented. Designs other than the ‘gold standard’ parallel-group trial can be used to optimize the contents of a new therapeutic strategy. Emphasis is placed on defining clinical characteristics and establishing a stable functional baseline for study participants. How the choices of outcome measure and comparison intervention affect the statistical and clinical significance of trial results are highlighted. Discussion of methodological concerns about randomization and blinded outcome assessment is followed by a review of common statistical confounders in neurorehabilitation trials. The use of consensus standards about trial reporting provides a valuable checklist for basic decisions in trial design.
Autonomic nervous system dysfunction
Authors: Gall Angela , Craggs Mike
Published: April 2015

This chapter delivers an overview of autonomic functions, their control and pathophysiology, reviews the most important and specific autonomic system disorders, their causes, management, and assessment, and future directions for neurorehabilitation following autonomic failure. The autonomic nervous system (ANS)regulates responses to exercise, environmental challenges, and emotional responses.The system has two main divisions, sympathetic and parasympathetic, continuously monitoring and controlling the visceral organs. Many brain structures are essential to the ANS.ANS disorders can affect a single organ or whole systems and can result in neuropathies.Alterations in ANS function can impair the ability of the circulatory system to maintain blood flow and pressure, impair gastrointestinal function, lead to metabolic disturbances, and aberrant supraspinal affects can lead to urogenital dysfunction.In acute stroke the pathophysiology is not always immediately clear somanagement has to be guided by sound assessment. Modern techniques in neurorehabilitation are continually being explored and tested to address these dysfunctions.
Functional recovery in CNS disease: impact of animal models
Authors: Franz Steffen , Hug Andreas , Weidner Norbert
Published: April 2015

Animal models of central nervous system (CNS) diseases such as ischaemic stroke and spinal cord injury (SCI) are well suited for the analysis of tissue damage and functional impairment. Caveats, with respect to preclinically observed spontaneous or elicited functional recovery, and the extrapolation into the clinical setting, are related to the animal species, respective disease models, the administration of the therapy under investigation, and the applied outcome measures in comparison to the clinical situation. SCI and ischaemic stroke share characteristics but differ in terms of therapeutic approaches. In ischaemic stroke innovative therapy concepts aim to protect CNS tissue at risk of degeneration, whereas in SCI efforts are made to regenerate damaged spinal cord tissue and to reinstall neuronal connectivity. This chapter examines components of animal models, the integration of clinical standard therapy concepts, the precise translation of experimental therapy administration, and the transferability of chosen structural and functional readouts in preclinical disease models of stroke and SCI.
Stem cell application in neurorehabilitation
Authors: Jessberger Sebastian , Curt Armin , Barker Roger
Published: April 2015

Several diseases of the brain and spinal cord are associated with substantial neural cell death and/or disruption of neural networks. A�variety of therapeutic strategies to rescue these systems has been proposed along with agents to induce functional plasticity within the remaining central nervous system (CNS) structures. In the case of injury or neurodegenerative disease these approaches have only met with limited success, indicating the need for novel approaches to treat diseases of the adult CNS. Recently, the idea of recruiting stem cells to replace lost structures within the adult brain or spinal cord has gained significant attention and opened up novel therapeutic avenues. Here, recent advances in our understanding of endogenous stem cells are reviewed and new clinical and preclinical data suggesting that stem cell-based therapies hold great promise as a future treatment option in a number of diseases disrupting the proper function of the adult CNS are summarized.
Treatment of arm and hand dysfunction after CNS damage
Authors: Ward Nick
Published: April 2015

Residual upper limb dysfunction after injury to the central nervous system is a major clinical, socioeconomic and societal problem. Upper limb dysfunction can occur in many disorders of the central nervous system including cervical spinal cord injury and multiple sclerosis, but therapeutic approaches for upper limb dysfunction after stroke are the most thoroughly investigated. General approaches to treatment require:�(i)�avoidance of complications such as spasticity, pain, and loss of range; (ii) early high-dose engaging functional motor training; (iii) consideration of how neuroplastic processes might be engaged to enhance the effects of training. The evidence to deliver optimal personalized treatment strategies for all patients is lacking, but there is evidence that higher doses and intensity of upper limb therapy will be beneficial to most patients. Recent work has focused on how technological innovation might be used to promote recovery of upper limb function.
The clinical neurology of problems with oral feeding
Authors: Hughes Tom
Published: April 2015

Oral feeding comprisesa number of composite functions, all of which have to be coordinated to ensure adequate nutrition and hydration.Voluntary swallowing is central to the process, but without adequate pulmonary functionthe airway isvulnerable.Medical and surgical problems, and the environment in which the patient is nursed also determine the success of attempted oral feeding.Using this framework of thinking may help structure the clinical approach to oral feeding failure and facilitate discussion of issues other than just swallowing and dysphagia when forming opinions about the diagnosis and prognosis of the underlying disease, the mechanism of the feeding problem, and the most appropriate therapy.The goals of any intervention should be informed by a detailed appreciation of clinical issues and a working knowledge of the relevant ethical and legal issues. The MEALTIME approach is suggested as an aide memoire to help ensure thatthe relevant issues are addressed.
Management of bladder, bowel, and sexual dysfunction
Authors: Mehnert Ulrich
Published: April 2015

This chapter provides an overview of the pathophysiological basis of bladder, bowel, and sexual dysfunction, relevant therapy principles, and treatment options. These dysfunctions are frequent sequelae of neurotrauma and neurodegenerative diseases that require adequate management and treatment. Knowledge of basic neurophysiological and pathophysiological processes involved is important for understanding and interpretation of clinical symptoms and findings and for understanding current treatment concepts. Treatment is mandatory and therapy options range from simple conservative measures to major surgery. The main therapeutic principles include protection of kidney function, reduction of urinary and/or faecal incontinence, independent management of bladder and bowel function, ability to sustain a satisfactory sexual relationship, fertility support, and improvement of quality of life. To comply with such principles and to select, initiate, maintain, and eventually adapt the ‘optimal’ treatment regimen for each patient requires a specialized multidisciplinary team.
The assessment and treatment of pain syndromes in neurorehabilitation
Authors: Widerström-Noga Eva
Published: April 2015

Persistent pains associated with injuries or disease involving the central nervous system (CNS), are common. In order to optimally manage persistent pain the primary underlying mechanisms need to be determined and the treatment targeted to these. A�comprehensive pain evaluation including symptoms, sensory function/dysfunction, and psychosocial factors is critical to the translation of research into the clinical pain management, to increasing the understanding of the contributory mechanisms and factors, and to the development of effective pain management. This chapter focuses on the assessment of pain and sensory status, associated psychosocial factors, and pharmacological and non-pharmacological pain management after CNS injury and disease. Principles and utility of the various types of pain-related assessments and examinations including pain report, pain classification, quantitative sensory testing, and psychological factors are discussed. Finally, both pharmacological and non-pharmacological treatment options for these persistent pain conditions are reviewed and discussed in the context of putative mechanisms.
Neuropalliative rehabilitation—managing neurological disability in the context of a deteriorating illness
Authors: Eva Gail , Bayly Jo , Playford Diane
Published: April 2015

Although the concepts of ‘rehabilitation’ and ‘palliative care’ may seem paradoxical, the two approaches have a great deal in common. Rehabilitation for people with deteriorating, life-limiting neurological conditions can be organized into four distinct but overlapping categories: preventative, restorative, supportive, and palliative.Patients with neurological conditions can report palliative care needs from diagnosis; neuropalliative rehabilitation needs to be available within the context of whatever services are most appropriate for the patient’s circumstances at the time, requiring excellent coordination of care between neurology, palliative care, and rehabilitation services. Neuropalliative rehabilitation follows the same process that would be used in other conditions, but is underpinned by specific palliative care skills which include the ability to work flexibly with rapidly changing conditions, as well as understanding and being able to manage the tension between the patient’s active engagement in life and acknowledging loss and death.
Recognition and management of functional (non-organic) symptoms after CNS damage
Authors: Ricciardi Lucia , Carson Alan , Edwards Mark
Published: April 2015

Patients witha recognized neurological disease or a structural damage to the central nervous system (CNS), may present with or later develop symptoms unexplained by that disease or damage (functional overlay). This chapter considers the relevance of functional overlay to management of patients with CNS damage.There are only few studies focusing on functional symptoms occurring specifically in the setting of CNS damage,nevertheless, there is an extensive literature on those patients who have an inexplicably catastrophic outcome after minor traumatic brain injury (mTBI). This evidence is reviewed as well as evidence for the diagnosis, pathophysiology, and treatment of functional symptoms.The wide phenomenology of possible symptoms is discussed as well as clinical tools for arriving at a positive diagnosis. We discuss the importance of giving and explaining the diagnosis in a suitable way to patients and their caregivers as well as management and treatment options.
Application of orthoses and neurostimulation in neurorehabilitation
Authors: Carpaneto Jacopo , Micera Silvestro
Published: April 2015

Electrical stimulation can allow the recruitment of muscles to achieve functional movements. This approach is therefore very interesting to restore motor functions in subjects who have lost them because of neurological problems. In this chapter the main approaches to restoration of grasping and of locomotor functions using electrical stimulation and also the combined use of electrical stimulation and mechanical orthoses are presented.The potentials and limits related to the use of these different non-invasive or invasive techniques are highlighted and examined. Finally, a brief description of future trends and current limitations is also provided.
Overview of Localization of Function and Neurological Diagnosis
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

The main information on disease in the human nervous system is determined by a careful workup of the patient using the neurological exam and the mini mental exam. The modern investigation of disease in the central nervous system is added by the technology of electroencephalography, computerized tomography, magnetic resonance imaging, and magnetic resonance angiography.
Skeletal Muscle and Nerve-Muscle Junction
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

The bulk of the body is formed by the skeletal and smooth muscles. The molecular architecture of the muscles permits them to function. The nerve-muscle junction, the endplate, is where the nerve controls the muscle by means of the chemical acetylcholine with other chemicals acting as neuromodulators. Diseases of muscles include dystrophies, metabolic myopathies, congenital myopathies, and disease of the neuromuscular junction, including myasthenia gravis and toxins.
Spinal Cord
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

The spinal cord is protected by the vertebra and many skeletal muscles, and it demonstrates the simplest organization in the nervous system with the white matter on the outside and the neurons on the inside. The white matter is divided into three major columns: a dorsal, lateral, and anterior column, which contains the major ascending and descending pathways. The gray matter is organized into a dorsal/sensory horn, a ventral/motor horn, and an intermediate/association region. In the thoracic and lumbar level, there is an intermediolateral column containing the preganglionic sympathetic neurons.
Spinal Cord
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

Extrinsic compression of the spinal cord with resulting dysfunction can be caused by trauma, tumors, and disease in the disc. Intrinsic disease of the spinal cord can be divided into local disease affecting one or more segments (infarction or trauma), system disease (e.g., amyotrophic lateral sclerosis) affecting one or more fiber systems, and multifocal disorders (e.g., multiple sclerosis) affecting various levels of the cord.
Case History Problem Solving
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

This chapter includes problem solving involving the spinal cord with illustrations to label and cases to solve from spinal cord and nerve root
The Cranial Nerves
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

There are 12 cranial nerves in the brain. Each cranial nerve is listed with a Roman numeral. Cranial nerve I is associated with the base of the frontal lobe; cranial nerve II is associated with the diencephalon; cranial nerves III and IV are found in the midbrain; cranial nerves V–VII in the pons; cranial nerves VIII–XII in medulla; with cranial nerve XI also originating in the upper cervical levels of the spinal cord. The special somatic sensory cranial nerves are I (olfactory), II (optic), and VIII (auditory-vestibular). The special visceral sensory (taste) are VII, IX, and X. Cranial nerves III, IV, and VI are involved with eye movements, cranial nerve IX initiates swallowing, cranial nerve XI permits one to turn one’s head to the side or to shrugs the shoulders, while with cranial nerve XII one can move the tongue. Cranial nerve X, the vagus, forms the bulk of the parasympathetic control to the heart, lungs, glands, GI, and urinary system, and it controls the pharynx and larynx. The arterial blood supply is from the vertebral, basilar, and posterior cerebral.
Diencephalic Nuclei, Functional Localization, and Atlas of the Diencephalon
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

The thalamic nuclei of the diencephalon is the major subcortical region that supplies input onto the cerebrum. There are many nuclei in the thalamus, but they can be divided into an anterior, medial, and lateral nuclear group. And then divided functionally into sensory and motor relay (ventrobasal and lateral posterior nuclei), limbic (anterior, medial lateral dorsal, midline and intralaminar nuclei), specific associational-multimodal somatic nuclei (pulvinar complex), special sensory (lateral geniculate nucleus and medial geniculate nucleus), and nonspecific associational (reticular and intralaminar nuclei). A case demonstrating the effects of a thalamic lesion is included.
Hypothalamus, Neuroendocrine System, and Autonomic Nervous System
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

The hypothalamic region of the diencephalon is a small region, but it is functionally very potent as it controls the hypophysis and has ascending and descending fibers which control the sympathetic and parasympathetic ganglia in the thorax, abdomen, perineum, and pelvis and is also a very important part of the Papez memory and emotion circuit. The hypothalamus is divided into a medial and lateral zone, each of which has subnuclei. There are many afferent pathways into the hypothalamus from the reticular system, thalamus, optic nerve, and even temporal lobe of the cerebrum. The major efferent fiber tracts that leave the hypothalamus are the mammillothalamic, periventricular system, mammillotegmental tract, the medial forebrain bundle and dorsal longitudinal fasciculus, the hypothalamic-hypophyseal tracts, and the hypothalamic hypophyseal tract. With all these major circuits and nuclei it is not surprising that the hypothalamic provides the stability to control many vital body functions, including the biological clock, temperature, water balance, neurosecretion, food intake, sexual reproduction, sleep, and the autonomic nervous system.
Limbic System
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

The following quote from Shakespeare summarizes the functions of the limbic system, which includes the many cortical and subcortical centers that control our emotional response to our environment: “Cure her of that: canst thou not minister to a mind diseased, pluck from the memory a rooted sorrow; raze out the written troubles of the rain and with some sweet oblivious antidote cleanse the stuff’d bosom of that the perilous stuff which weighs upon the heart” (Macbeth, Act V, scene iii).
Alterations in Consciousness
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

Coma is an abnormal state of altered consciousness. It may be caused by many factors, including trauma, bleeding into the brain, infections, and so on. The MRI or the electroencephalogram is commonly used to determine whether there are abnormalities in the electrical activity in the brain. Epilepsy is commonly seen in younger patients and is caused by many factors, including dysgenesis, trauma, infections, and drug overdose. Alzheimer’s disease and other degenerative disorders are commonly found in the elderly.
Targeting chromatin binding regulation of constitutively active AR variants to overcome prostate cancer resistance to endocrine-based therapies
Authors: Chan Siu Chiu , Selth Luke A. , Li Yingming , Nyquist Michael D. , Miao Lu , Bradner James E. , Raj Ganesh V. , Tilley Wayne D. , Dehm Scott M.
Published: April 2015

Androgen receptor (AR) variants (AR-Vs) expressed in prostate cancer (PCa) lack the AR ligand binding domain (LBD) and function as constitutively active transcription factors. AR-V expression in patient tissues or circulating tumor cells is associated with resistance to AR-targeting endocrine therapies and poor outcomes. Here, we investigated the mechanisms governing chromatin binding of AR-Vs with the goal of identifying therapeutic vulnerabilities. By chromatin immunoprecipitation and sequencing (ChIP-seq) and complementary biochemical experiments, we show that AR-Vs display a binding preference for the same canonical high-affinity androgen response elements (AREs) that are preferentially engaged by AR, albeit with lower affinity. Dimerization was an absolute requirement for constitutive AR-V DNA binding and transcriptional activation. Treatment with the bromodomain and extraterminal (BET) inhibitor JQ1 resulted in inhibition of AR-V chromatin binding and impaired AR-V driven PCa cell growth in vitro and in vivo. Importantly, this was associated with a novel JQ1 action of down-regulating AR-V transcript and protein expression. Overall, this study demonstrates that AR-Vs broadly restore AR chromatin binding events that are otherwise suppressed during endocrine therapy, and provides pre-clinical rationale for BET inhibition as a strategy for inhibiting expression and chromatin binding of AR-Vs in PCa.
The Statistics of Causal Inference: A View from Political Methodology
Authors: Keele Luke
Published: April 2015

Many areas of political science focus on causal questions. Evidence from statistical analyses is often used to make the case for causal relationships. While statistical analyses can help establish causal relationships, it can also provide strong evidence of causality where none exists. In this essay, I provide an overview of the statistics of causal inference. Instead of focusing on specific statistical methods, such as matching, I focus more on the assumptions needed to give statistical estimates a causal interpretation. Such assumptions are often referred to as identification assumptions, and these assumptions are critical to any statistical analysis about causal effects. I outline a wide range of identification assumptions and highlight the design-based approach to causal inference. I conclude with an overview of statistical methods that are frequently used for causal inference.
A Randomized, Double-blinded Trial of a “Rule of Threes” Algorithm versus Continuous Infusion of Oxytocin during Elective Cesarean Delivery
Authors: Kovacheva Vesela P. , Soens Mieke A. , Tsen Lawrence C.
Published: April 2015

AbstractAbstract

In 60 women randomized to treatment at cesarean delivery, a single intravenous bolus of 3 IU at delivery was as effective as continuous, wide-open infusion of oxytocin, 30 IU/500 ml despite less total oxytocin delivered. Groups did not differ in side effects associated with oxytocin.

Background:

The administration of uterotonic agents during cesarean delivery is highly variable. The authors hypothesized a “rule of threes” algorithm, featuring oxytocin 3 IU, timed uterine tone evaluations, and a systematic approach to alternative uterotonic agents, would reduce the oxytocin dose required to obtain adequate uterine tone.

Methods:

Sixty women undergoing elective cesarean delivery were randomized to receive a low-dose bolus or continuous infusion of oxytocin. To blind participants, the rule group simultaneously received intravenous oxytocin (3 IU/3 ml) and a “wide-open” infusion of 0.9% normal saline (500 ml); the standard care group received intravenous 0.9% normal saline (3 ml) and a “wide-open” infusion of oxytocin (30 IU in 0.9% normal saline/500 ml). Uterine tone was assessed at 3, 6, 9, and 12 min, and if inadequate, additional uterotonic agents were administered. Uterine tone, total dose and timing of uterotonic agent use, maternal hemodynamics, side effects, and blood loss were recorded.

Results:

Adequate uterine tone was achieved with lower oxytocin doses in the rule versus standard care group (mean, 4.0 vs. 8.4 IU; point estimate of the difference, 4.4 ± 1.0 IU; 95% CI, 2.60 to 6.15; P < 0.0001). No additional oxytocin or alternative uterotonic agents were needed in either group after 6 min. No differences in the uterine tone, maternal hemodynamics, side effects, or blood loss were observed.

Conclusion:

A “rule of threes” algorithm using oxytocin 3 IU results in lower oxytocin doses when compared with continuous-infusion oxytocin in women undergoing elective cesarean delivery.