bluuebunny/crossref_metadata_2025 huggingface dataset:
Depressive Symptoms are Associated with Heart Rate Variability Independently of Fitness: A Cross-Sectional Study of Patients with Heart Failure
Authors: Walter Fawn A , Gathright Emily , Redle Joseph D , Gunstad John , Hughes Joel W
Published: April 2019

Background

Depression is associated with reduced heart rate variability (HRV) in healthy and cardiac samples, which may be accounted for by physical fitness. In a small sample of cardiac patients, activity and fitness levels attenuated the relationship between HRV and depression. In the current study of heart failure (HF) patients, we hypothesized that depressive symptoms and HRV would be inversely related and physical fitness would attenuate this association.

Purpose

To determine if previous associations among depressive symptoms, physical fitness, and HRV would replicate in a sample of HF patients.

Methods

The sample consisted of HF patients (N = 125) aged 68.55 ± 8.92 years, 68.8% male, and 83.2% Caucasian. The study was cross-sectional and a secondary analysis of a nonrandomized clinical trial (Trial Identifier: NCT00871897). Depressive symptoms were evaluated using the Beck Depression Inventory (BDI)-II, fitness with the 2 min step test (2MST), and HRV during a 10 min resting laboratory psychophysiology protocol. The dependent variable in hierarchical linear regressions was the root mean square of successive differences.

Results

Controlling for sex, age, β-blocker use, hypertension, and diabetes, higher BDI-II scores significantly predicted lower HRV, β = −.29, t(92) = −2.79, p < .01. Adding 2MST did not attenuate the relationship in a follow-up regression.

Conclusion

Depressive symptoms were associated with lower HRV in HF patients, independent of physical fitness. Given the prevalence of depression and suppressed HRV common among HF patients, interventions addressing depressive symptoms and other predictors of poor outcomes may be warranted.
Use of continuous infusion ceftolozane–tazobactam with therapeutic drug monitoring in a patient with cystic fibrosis
Authors: Elizabeth Davis Sarah , Ham Jared , Hucks Jennifer , Gould Alyssa , Foster Rachel , Ann Justo Julie , Nicolau David P , Bookstaver P Brandon
Published: April 2019

Purpose

The safe and effective use of ceftolozane–tazobactam delivered via continuous infusion in a cystic fibrosis (CF) patient with reduced body weight and presumed augmented renal clearance is reported.

A 30-year-old woman with CF was admitted for acute pulmonary exacerbations with positive respiratory cultures for Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing Escherichia coli. Susceptibility testing confirmed multidrug resistance, and the patient was transitioned to ceftolozane–tazobactam for definitive therapy. A novel strategy of administering ceftolozane–tazobactam 6 g by continuous i.v. infusion over 24 hours was initiated during hospitalization and continued at discharge for a total of 10 days. Therapeutic drug monitoring over the first 36 hours of the continuous infusion confirmed adequate exposure. The patient had clinical resolution with return to baseline of pulmonary function tests and no noted adverse drug events.

Conclusion

A continuous infusion regimen of ceftolozane–tazobactam was successfully used in a CF patient with augmented renal clearance.
Cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation procedures
Authors: Parkin Scott R , Negrelli Jenna M , Van Gorder Charles M , Brooks Tyson W A
Published: April 2019

Purpose

A cost-reduction strategy for isoproterenol use in radiofrequency catheter ablation procedures was evaluated.

A medication-use evaluation at a 454-bed tertiary medical center revealed that the cardiac catheterization laboratory was the highest user of isoproterenol. Isoproterenol was removed from all AcuDose-Rx machines Omnicell, Mountain View, CA, and compounding was performed by pharmacy personnel. It was initially provided to the cardiac catheterization laboratory as an 8-µg/mL concentration in 20-mL 0.9% sodium chloride injection syringes with a 24-hour beyond-use date. This resulted in an initial cost savings but with an unacceptably high rate of wastage. Isoproterenol was then compounded as a 4-µg/mL concentration in 30 mL 5% dextrose in water syringes with a 9-day beyond-use date after a thorough literature search supported longer stability with this admixture. After 12 months of our current process, isoproterenol use during radio frequency catheter ablations (RFCAs) in the cardiac catheterization laboratory was reduced by 85%, decreasing the number of ampules used from 11.15 to 1.66 per week.

Conclusion

A pharmacy-initiated process to mitigate an extraordinary increase in isoproterenol acquisition cost resulted in a reduction in usage in a tertiary care community hospital. Isoproterenol usage was reduced 85% after two different interventions were implemented, which is estimated to save $1,839 per procedure.
Sex-Specific Relationship Between Long-Term Maintenance of Physical Activity and Cognition in the Health ABC Study: Potential Role of Hippocampal and Dorsolateral Prefrontal Cortex Volume
Authors: Barha Cindy K , Best John R , Rosano Caterina , Yaffe Kristine , Catov Janet M , Liu-Ambrose Teresa
Published: April 2019

Background

Physical activity (PA) is a promising strategy for the promotion of brain health, although substantial variation exists in the effects of PA at the individual level. Given the greater prevalence and faster progression of Alzheimer’s disease in women compared to men, and known sex differences in brain architecture, analysis of sex differences in the relationship between PA, cognition, and brain region volumes is warranted.

Methods

To address this, we conducted secondary analyses of data from the Health, Aging, and Body Composition study. To determine whether longitudinal changes in PA over 10 years predicted declines in global cognitive functioning and executive functions and processing speed differently in males and females, latent growth curve modeling was utilized. Magnetic resonance imaging was performed at year 10, and the hippocampus and dorsolateral prefrontal cortex were identified as regions of interest.

Results

Maintaining PA over 10 years predicted less declines in executive functions and processing speed in females but not males. Maintaining PA over 10 years was significantly associated with greater volume of the left dorsolateral prefrontal cortex, a brain region involved in executive functions, in year 10 in females only. Maintaining physical activity was associated with better global cognitive function in both males and females, and also predicted volume of the left hippocampus, albeit in different directions with females showing a negative relationship and males showing a positive relationship.

Conclusions

These findings suggest that the relationship of PA with cognition and its neurobiological correlates differ by sex, with females apparently benefiting from PA to a greater extent than males. Development of personalized, tailored exercise recommendations to promote healthy brain aging should account for sex differences.
Forms of selenium in vitamin-mineral mixes differentially affect serum alkaline phosphatase activity, and serum albumin and blood urea nitrogen concentrations, of steers grazing endophyte-infected tall fescue
Authors: Jia Yang , Son Kwangwon , Burris Walter R , Bridges Phillip J , Matthews James C
Published: April 2019

The goal of this study was to test the hypothesis that sodium selenite (ISe), SEL-PLEX (OSe), vs. a 1:1 blend (MIX) of ISe and OSe in a basal vitamin-mineral mix would differentially affect serological and hepatic parameters of growing steers grazing toxic endophyte-infected tall fescue-mixed forage pasture. Predominately Angus steers (BW = 183 ± 34 kg) were randomly selected from herds of fall-calving cows grazing endophyte-infected tall fescue-mixed pasture and consuming vitamin-mineral mixes that contained 35 ppm Se as ISe, OSe, and MIX forms. Steers were weaned, depleted of Se for 98 d, and subjected to summer-long common grazing of an endophyte-infected tall fescue-mixed pasture (0.51 ppm total ergovaline + ergovalinine; 10.1 ha). Steers were assigned (n = 8 per treatment) to the same Se form treatments upon which they were raised. Se treatments were administered by daily top-dressing 85 g of vitamin-mineral mix onto 0.23 kg soyhulls, using in-pasture Calan gates. The PROC MIXED procedure of SAS was used to assess the effect of Se form treatments on serum parameters at day 0, 22, 43, 64, and 86. After slaughter, the effect of Se treatment on hepatic alkaline phosphatase (tissue nonspecific isoform, TNALP) mRNA, protein, and albumin protein content was assessed using the PROC GLM procedure of SAS. Fisher’s protected LSD procedure was used to separate treatment means. Partial correlation analysis was used to evaluate the relationship among whole blood Se concentration and serum parameters, accounting for the effect of time. Across periods, MIX steers had more (P ≤ 0.04) serum albumin than OSe and ISe steers, respectively. However, the relative hepatic bovine serum albumin protein content was not affected (P = 0.28) by Se treatments. Serum alkaline phosphatase activity was greater (P ≤ 0.01) in MIX and OSe steers. Similarly, hepatic TNALP protein content in MIX steers was greater (P = 0.01) than ISe steers. Partial correlation analysis revealed that serum albumin, blood urea nitrogen, and alkaline phosphatase activity were correlated (r ≥ 0.23, P ≤ 0.02) with whole blood Se concentration. In summary, consumption of 3 mg Se/d as OSe or MIX forms of Se in vitamin-mineral mixes increased serum albumin concentration and alkaline phosphatase activity, the reduction of which is associated with fescue toxicosis. We conclude that the organic forms of Se ameliorated the depression of 2 of known serological biomarkers of fescue toxicosis.
Effects of Hypoxia on Acoustic Activity of Two Stored-Product Pests, Adult Emergence, and Grain Quality
Authors: Njoroge Anastasia W , Mankin Richard W , Smith Bradley , Baributsa Dieudonne
Published: April 2019

Modified atmospheres such as hermetic storage are widely used for the control of stored grain insect pests. To improve their effectiveness, there is need to better understand insect responses to low-oxygen environments. Adult Callosobruchus maculatus F. (Coleoptera: Chrysomelidae: Bruchinae) on cowpea and Sitophilus oryzae L. (Coleoptera: Curculionidae) on wheat were exposed to hypoxia treatments consisting of 1, 3, and 5% oxygen levels for 14 d. Acoustic activity was monitored during the experiment, and insect mortality and grain quality were examined immediately after the hypoxia treatments. Adult emergence was assessed 45 d post-treatment. All three hypoxia treatments eliminated acoustic activity of both species within 4 d. There was neither insect survival for both species nor significant grain damage immediately after 14-d exposure to hypoxia treatments. No adult insects emerged 45 d post-exposure on grains maintained at 1% oxygen level for 14 d. However, at 3 and 5% oxygen levels, there were eggs on cowpea, holes in wheat, and emerging adults for both insect species 45 d post-exposure. Although insect activity ceased within 4 d when hypoxia was maintained below 5%, there is need to explore exposure beyond 14 d for 3 and 5% oxygen levels, to ensure to avoid potential adult emergence from eggs and other insect life stages post-treatments. Maintaining 3–5% hypoxia conditions for a longer duration would ensure insufficient oxygen is available for progeny development.
Non–High-Density Lipoprotein Cholesterol and Guidelines for Cholesterol Lowering in Recent History
Authors: Levinson Stanley S
Published: April 2019

Background

The National Cholesterol Education Program (NCEP) released guidelines for treating cholesterol in 1988, 1994, and 2002. After a hiatus, the guidelines were released again in 2013, 2016, 2017, and 2018.

Methods

In this article, I review these guidelines, factors that affected their release, how they evolved, and why recommended treatment targets are reasonable. Also, to aid reader understanding, I briefly discuss biochemical mechanisms and the pathophysiology of beta-lipoproteins, focusing on the importance on non–high-density cholesterol (non-HDLC) in assessing risk and as a target for treatment. The concepts discussed are important to laboratory clinicians because those workers inscribe target values on the reports and may consult with medical staff members.

Conclusions

The newest recommendations, released in 2018, are an extension of the 2017 guidelines that defined non-HDLC as equivalent to low-density lipoprotein cholesterol (LDLC). For the reasons discussed herein, non-HDLC has advantages over LDLC. Laboratories reporting cholesterol results should include non-HDLC values and cutoffs in their reports.
Application of High-Resolution Melting PCR to Detect the Genomic Fungal ITS 2 Region
Authors: Nawar Nada N , Behiry Iman K , Yousef Reham H A , Emara Mohamed A
Published: April 2019

Background

Invasive fungal infections (IFIs) are a main cause of morbidity and mortality. High-resolution melting polymerase chain reaction (HRM PCR) is promising for the identification of fungal species via the detection of internal transcribed spacer 2 (ITS2).

Objectives

To assess the sensitivity and specificity of HRM PCR in diagnosing IFIs, compared with blood culture.

Methods

Our study included 100 patients who were suspected of having IFIs; we analyzed their specimens via blood culture and HRM PCR.

Results

Blood culture results were positive in 57 cases and negative in 43 cases. HRM PCR results were positive in 14 cases and negative in 86 cases. The 14 cases with positive results included 4 with Candida tropicalis, 4 with Candida glabrata, and 6 with Candida krusei. HRM PCR sensitivity was 24.6%, specificity was 100%, positive predictive value (PPV) was 100%, and negative predictive value (NPV) was 50%.

Conclusions

HRM PCR is specific but not sensitive. Blood culture is more sensitive and cannot be replaced by HRM PCR.
Culture as a Multidimensional Construct
Authors: Emmerich Anne , Tarver Leslie
Published: April 2019

Despite years of training about how to care for others, many health care providers know little about themselves. This is nowhere more relevant than when caring for patients who come from cultures other than our own because in these clinical encounters, we may not recognize our own implicit biases. Our cultural identity as health care workers is multifaceted, including attitudes shaped by our life experience and those shaped by the culture of our health care system. This chapter discusses the concepts of culture and cultural self-awareness and introduces strategies that health care workers can use to understand their own cultural influences and consider how these may be impacting their clinical work. We present a case example that exemplifies the principles outlined in the chapter.
Culture in the DSM-5
Authors: Trinh Nhi-Ha T. , Son Maya , Chen Justin A.
Published: April 2019

This chapter focuses on the revision of the DSM-IV to DSM-5, including an increased emphasis on the role of culture in psychopathology. The DSM-5, published in 2013, includes a revision of DSM-IV’s Outline for Cultural Formulation and includes the newly added standardized and manualized Cultural Formulation Interview (CFI), the 12 supplementary modules to the CFI, and a Glossary of Cultural Concepts of Distress. With these changes, DSM-5 strives to provide clinicians with a practical interpretive framework to explore patients’ varied experiences and expression of mental distress, increasing the clinical significance of each patient’s ethnic and cultural context. This chapter explores these additions to and revision of the DSM-5, reviews some of its criticism, and offers best practices for using these tools in the evaluation and management of diverse patients.
Social Determinants of Psychiatric Illness
Authors: Nishimi Kristen , Howe Esther , Dunn Erin C.
Published: April 2019

The social determinants of health refer to the ways in which societal conditions impact the etiology, course, and treatment of health outcomes. This chapter summarizes four main topics related to the social determinants of mental health in order to provide a framework for clinicians to understand the major social determinants of mental illness and help them incorporate insights about the social determinants of health into their clinical practice. First, we demonstrate how social determinants are related to the field of public health and population health frameworks. Second, we describe how knowledge of social determinants can inform psychiatric clinical practice. Third, we summarize research on four major social determinants—gender, socioeconomic status, childhood adversity, and school and neighborhood environments—with respect to depression risk. Last, we show how information about social determinants can be integrated with more individual-level factors, including genetic variation.
Identifying and Working with Diverse Explanatory Models of Mental Illness
Authors: Benning Tony B. , Chen Justin A.
Published: April 2019

Derived from research undertaken in various cultural settings, and encompassing spiritual, traditional, religious, and folk beliefs, the knowledge base on diverse explanatory models of mental illness is burgeoning. Unfortunately, there is a dearth of literature that examines these explanatory models from the sort of overtly clinical perspective that would be of practical relevance to clinicians. To be able to identify, honor, and work with a diverse range of explanatory models of mental illness is an ethical imperative in an increasingly globalized and culturally diverse society. The purpose of this chapter is to address this gap in the literature by exploring diverse explanatory models from a clinical perspective to inform the work of psychiatrists and other mental health clinicians. We propose that David Bohm’s concept of dialogue is a potentially useful communication framework that can aid clinicians working with patients with diverse explanatory models of mental illness.
Gender and Sexuality
Authors: Cruz Andrew , Torrence Julianne , Palmer Christopher M.
Published: April 2019

The psychiatric encounter provides an opportunity to discuss sexuality and sexual behaviors with patients. Often patients are reluctant to discuss sexual matters with clinicians, as shame can often be associated with sexual behaviors and fantasies. Clinicians, therefore, need to be aware of both common and uncommon fantasies and behaviors and be willing to initiate conversations with patients in a safe and respectful manner. Sexual behaviors can be associated with some psychiatric disorders and can sometimes be a psychiatric disorder unto themselves. Therefore, a sexual history and assessment is often a required portion of a complete psychiatric evaluation. However, there is tremendous variability in what is considered normal and abnormal, posing challenges for clinicians. This chapter sets out to provide a framework for approaching some of these challenging situations.
Case 5: Syncope, Neurally Mediated Vasodepressor with Cerebral Autoregulatory Failure
Authors: Novak Peter
Published: April 2019

This chapter describes a unique vasodepressor syncope with minimal prodromes associated with loss of cerebral autoregulation.
Case 9: Postural Tachycardia Syndrome, Neuropathic Type
Authors: Novak Peter
Published: April 2019

Postural tachycardia syndrome (POTS) can be associated with mixed small fiber neuropathy in which both epidermal and autonomic fibers are affected. Damage of sensory fibers leads to sensory symptoms (pain, numbness) while dysfunction of autonomic fibers (in this case, with adrenergic dysfunctions as detected by the Valsalva maneuver and sudomotor deficit as detected by sudomotor testing and confirmed by abnormal sweat gland nerve fibers on the skin biopsy) leads to POTS. Hypocapnia is common in POTS and reduces the cerebral blood flow velocity due to its vasoconstrictive effect.
Case 10: Postural Tachycardia Syndrome with Hyperventilation
Authors: Novak Peter
Published: April 2019

Postural tachycardia syndrome (POTS) patients exhibit signs of cerebral hypoperfusion, which is related to a decline in cerebral blood flow velocity (CBFv). End tidal CO2 has profound effects on CBFv. A decline in CBFv in POTS is mainly due to hypocapnia. This is a common finding in POTS.
Case 13: Postural Tachycardia Syndrome with Syncope
Authors: Novak Peter
Published: April 2019

The tilt provoked most of the patient’s symptoms, including dizziness, nausea and loss of consciousness, which was consistent with postural tachycardia syndrome and neurally mediated syncope of mixed type.
Case 25: Inappropriate Sinus Tachycardia
Authors: Novak Peter
Published: April 2019

Autonomic testing is useful to assess inappropriate sinus tachycardia (ISA).
Case 30: Hypocapnic Cerebral Hypoperfusion with Paced Breathing
Authors: Novak Peter
Published: April 2019

In this patient, cerebral blood flow velocity (CBFv) was reduced by 38% during the tilt. Decline in CBFv was due to hypocapnia-induced cerebral vasoconstriction, typical for hypocapnic cerebral hypoperfusion (HYCH). Patient reported dizziness, shortness of breath, and confusion during the tilt. Blood pressure during tilt showed prominent oscillations characteristic of hypovolemia.
Case 31: Hypocapnic Cerebral Hypoperfusion with an Artifact
Authors: Novak Peter
Published: April 2019

In this patient, the initial decline in blood pressure at the tilt onset was physiologic since it was accompanied by the decline in cerebral blood flow velocity and heart rate responses. The testing revealed normal autonomic functions. It is important always to check the raw data. Blood pressure from the finger cuff is not always accurate.
Case 32: Small Fiber Neuropathy, Orthostatic Hypertension, and Hypocapnic Cerebral Hypoperfusion
Authors: Novak Peter
Published: April 2019

In this patient, testing showed several findings including small fiber neuropathy, orthostatic hypertension, and hypocapnic cerebral hypoperfusion. Elevated orthostatic blood pressure is commonly seen in painful neuropathies.
Case 35: Initial Orthostatic Hypotension
Authors: Novak Peter
Published: April 2019

Initial orthostatic hypotension (IOH)is characterized by a rapid decrease in blood pressure in response to standing up quickly, with restoration of blood pressure in less than a minute. IOH is not associated with autonomic failure.
Case 37: Severe Dyspnea and Preload Failure
Authors: Novak Peter
Published: April 2019

An older patient presents with fatigue, exertional dyspnea, exertional chest tightness, and palpitations. Cardiopulmonary exercise testing (CPET) showed low biventricular filling pressure and poor peripheral oxygen extraction as a cause of dyspnea, consistent with preload failure. Tilt test demonstrated postural tachycardia syndrome (POTS), neuropathic form.
Case 38: Dizziness and Elevated Cerebral Blood Flow Velocity
Authors: Novak Peter
Published: April 2019

The tilt test reproduced several of a patient’s complaints, including dizziness and palpitations. Her symptomatic episodes were positive for elevated cerebral blood flow velocity (CBFv), with prominent oscillations, but tilt did not show tachycardia or hypotension.
Case 41: Atypical Parkinsonism
Authors: Novak Peter
Published: April 2019

The testing for this patient showed minimal dysautonomia, small fiber neuropathy, and orthostatic cerebral hypoperfusion syndrome (OCHOS). Small fiber neuropathy can be due to vitamin B12 deficiency. Mild dysautonomia is not suggestive of Parkinson’s disease or multiple system atrophy.
Case 49: Dizziness Due to Multiple Sclerosis or Due to Dysautonomia?
Authors: Novak Peter
Published: April 2019

The tilt provoked syncope. Patient confirmed that the symptoms of dizziness during the tilt test were very similar to her complaints. Small fiber neuropathy can be associated with multiple sclerosis.
Case 52: Painful Small Fiber Neuropathy
Authors: Novak Peter
Published: April 2019

This case presents characteristic symptoms of painful small fiber neuropathy which was confirmed by abnormal skin biopsy. Painful small fiber neuropathy can have autoimmune cause and may respond to intravenous immunoglobulin (IVIG).
Case 58: Small Fiber Neuropathy and Orthostatic Cerebral Hypoperfusion Syndrome with Positive Autoantibodies to N-type Calcium Channel
Authors: Novak Peter
Published: April 2019

Small fiber neuropathy, mixed, length-dependent, is associated with antibodies against the N-type calcium channel. Tilt showed hypocapnic cerebral hypoperfusion.
Case 60: Small Fiber Neuropathy, Seronegative, Treated with Immune Globulins
Authors: Novak Peter
Published: April 2019

Small fiber neuropathy, mixed, length-dependent can be autoimmune even if no antineuronal antibodies can be found. Yet the seronegative small fiber neuropathy may still respond to therapy with immune globulins.
Case 68: Unknown Connective Tissue Disorder and Postural Tachycardia Syndrome
Authors: Novak Peter
Published: April 2019

The testing showed a typical postural tachycardia syndrome (POTS) pattern but was negative for small fiber neuropathy. Although the patient has marfanoid habitus, she tested negative for the fibrillin-1 gene mutation which underlies the Marfan syndrome; she is more likely for positive for Ehlers-Danlos syndrome.
Case 70: Small Fiber Neuropathy and Generalized Hypermobility Spectrum Disorder
Authors: Novak Peter
Published: April 2019

Autonomic testing showed mixed small fiber neuropathy, which can be responsible for both sensory complaints and dysautonomia. Dysautonomia was generalized but mild. The patient has generalized hypermobility spectrum disorder (GHSD).
Case 73: Dysautonomia Due to Mast Cell Activation Syndrome or Psoriatic Arthritis?
Authors: Novak Peter
Published: April 2019

The patient presents with fatigue, postprandial nausea, diarrhea, food allergies, and nighttime tachycardia. She was diagnosed with mast cell syndrome (MCAS). Autonomic testing has shown anxiety; mild postural tachycardia syndrome (POTS), neuropathic form; and small fiber neuropathy, mixed, length-dependent.
Case 74: Small Fiber Neuropathy and Lyme Disease
Authors: Novak Peter
Published: April 2019

Dizziness, numbness, and pain can be associated with small fiber neuropathy and hypocapnic hyperventilation. Lyme disease can be the underlying cause.
Case 76: Small Fiber Neuropathy, Hypocapnic Cerebral Hypoperfusion, and Posttreatment Lyme Disease Syndrome
Authors: Novak Peter
Published: April 2019

This chapter describes posttreatment Lyme disease syndrome (PLDS) that can be associated with mild adrenergic failure, small fiber neuropathy, and hypocapnic cerebral hypoperfusion during the tilt.
Case 84: Intermittent Confusion
Authors: Novak Peter
Published: April 2019

Short episodes confusion, dizziness, and shortness of breath can be associated with intermittent declines in cerebral blood flow velocity (CBFv). CBFv decline without orthostatic hypotension or decline in end tidal CO2 can be seen in orthostatic cerebral hypoperfusion syndrome (OCHOS) associate with abnormal cerebral vasoconstriction due to cerebral autoregulatory failure.
Case 85: Rhythmic Dizziness
Authors: Novak Peter
Published: April 2019

Episodic decrease in cerebral blood flow velocity triggered by a deep breath can be associated with dizziness.
Case 88: Intermittent Vision Loss After Cervical Spine Injury
Authors: Novak Peter
Published: April 2019

Cervical spine injury may result in postural tachycardia syndrome and autonomic dysreflexia.
Case 91: Primary Cerebral Autoregulatory Failure
Authors: Novak Peter
Published: April 2019

Recurrent hypertensive crisis, dizziness, and headaches may be associated with cerebral autoregulatory failure, which can be detected by a transcranial Doppler.
Case 98: Repetitive Psychogenic Pseudosyncope
Authors: Novak Peter
Published: April 2019

Cerebral blood flow velocity monitoring can be useful to diagnose psychogenic pseudosyncope.
Case 99: Mixed Tilt Patterns in Rheumatoid Arthritis
Authors: Novak Peter
Published: April 2019

Autonomic testing may reveal combined initial orthostatic hypotension and orthostatic hypotension due to a combination of volume depletion and adrenergic failure, presyncope with prominent vasodepressor component, and small fiber neuropathy.
Case 100: Dizziness After Concussion
Authors: Novak Peter
Published: April 2019

Low cerebral blood flow velocity (CBFv) can be associated with signs of cerebral hypoperfusion with dizziness in concussion. The tilt test with CBFv monitoring can be helpful to differentiate this from other causes of dizziness.
Bartlett's Medical Management of HIV Infection
Authors: Bartlett John G. , Redfield Robert R. , Pham Paul A.
Published: April 2019

With more than 30 million people living with HIV, nearly 2 million new HIV infections, and 1 million deaths in 2017 globally, the HIV epidemic continues to exert a considerable deleterious impact on the health of individuals, communities, and the economic growth of nations. However, remarkable advances have also been achieved: improvements in our scientific understanding of the biology of HIV, how it causes disease, and its prevention and treatment, coupled with unprecedented multi-sectoral global efforts, have resulted in rendering HIV infection essentially a manageable chronic disease. The 17th edition of Bartlett’s Medical Management of HIV Infection offers the best-available clinical guidance for treatment of patients with HIV, all in a portable, quick-reference format. Edited by preeminent and pioneering authorities in HIV research and clinical care, it has earned its status as the definitive work for physicians, physician assistants, nurse practitioners, pharmacists, and anyone working in the care of persons with HIV.
Systems Review
Authors: Bartlett John G. , Redfield Robert R. , Pham Paul A.
Published: April 2019

Abstract: This chapter is a systems overview involving people living with HIV, and covers cardiovascular disease, dermatologic complications, gastrointestinal complications, hematologic complications, immune reconstitution inflammatory syndrome (IRIS), liver and pancreatic disease, hepatitis B and C, Kaposi sarcoma, non-Hodgkin lymphoma (NHL), neurologic complications, ophthalmic complications, psychiatric complications, pulmonary disorders, and renal complications.
Beckwith-Wiedemann Syndrome
Authors: Mussa Alessandro , Kalish Jennifer M. , Cerrato Flavia , Riccio Andrea , Ferrero Giovanni Battista
Published: April 2019

This chapter provides a thorough overview of Beckwith-Wiedemann syndrome, which is considered to be the most common of the overgrowth syndromes and imprinting disorders. It starts with a description of the clinical aspects of the condition, including diagnostic criteria, differential diagnosis, risk of malignancy, and management. This is followed by an in-depth description of the genetic causes of the syndrome and of the molecular pathways involved in the pathogenesis of this disorder. The complexities of the etiology, which involves two neighboring loci, each one regulated by finely tuned imprinting mechanisms, are clearly delineated. The chapter also touches on the reported association between in vitro fertilization and risk of conceiving a baby with this syndrome.
Sotos Syndrome
Authors: Lapunzina Pablo , Tenorio Jair A.
Published: April 2019

This chapter describes Sotos syndrome as a clinical entity characterized, in addition to overgrowth, by distinctive craniofacial manifestations that include macrocephaly, a tall forehead, and an elongated face with pointed chin. This clinical aspect is illustrated by photographs of patients. The differential diagnosis between Sotos and other overgrowth syndromes can be particularly difficult and is therefore described in detail, with the aid of a summary table. The genetic cause and inherent pathogenic mechanisms are clearly delineated. Even though malignancies are reported in less than 1% of patients with Sotos syndrome, this potential risk is not to be disregarded and is the object of a thorough discussion.
Simpson-Golabi-Behmel Syndrome
Authors: Neri Giovanni
Published: April 2019

Simpson-Golabi-Behmel syndrome was described independently by three groups of authors and eventually received its current designation by the author of this chapter. Among all the conditions described in this book, it is the only one to have X-linked inheritance, with possible expression in some carrier females. Therefore, the description of the clinical phenotype is subdivided into two parts, one pertaining to males, the other to females. Typically present in both affected males and females is a “coarseness” of the facial traits, in addition to a number of congenital malformations that can affect the heart, the diaphragm, and the skeleton. Differential diagnosis and recurrence risks are clearly delineated. The genetic cause is described in detail and the pathogenic mechanism is illustrated by an explanatory cartoon.
Perlman Syndrome
Authors: Neri Giovanni
Published: April 2019

This chapter describes Perlman syndrome, which is an autosomal recessive overgrowth syndrome that presents with a severe phenotype, usually resulting in early postnatal death. Overgrowth is extended to the internal organs, liver, pancreas, and especially kidneys, with histologic findings of focal hamartomas and nephroblastomatosis. These dysplasias predispose to the development of Wilms tumor, a very common occurrence in Perlman syndrome. The condition seems to be very rare, even though mild cases, if any exist, may go undiagnosed. The causal mutation affecting the DIS3L2 gene was discovered only recently and it is not known if this is the only causal gene.
PTEN-Related Overgrowth Syndromes
Authors: Yehia Lamis , Ngeow Joanne , Eng Charis
Published: April 2019

Individuals carrying germline mutations in the tumor suppressor gene phosphatase and tensin homolog (PTEN) may present with diverse clinical phenotypes, grouped under the term of PTEN hamartoma tumor syndrome (PHTS). This chapter will focus on two PHTS conditions: Bannayan-Riley-Ruvalcaba syndrome and Cowden syndrome. The first condition is an autosomal dominant disorder characterized by macrocephaly, intestinal hamartomatous polyposis, vascular malformations, lipomas, hemangiomas, and genital freckling. Other features include developmental delay, hypotonia, and scoliosis. Cowden syndrome is also an autosomal dominant disorder, mainly characterized by multiple hamartomas and high risk of breast, thyroid, and other cancers. PTEN encodes the main inhibitor of the PI3K-AKT pathway, regulating cell growth and proliferation, and protein synthesis. Therefore, germline loss-of-function mutations in this gene lead to excessive growth, particularly affecting connective tissues. Detection of PTEN mutations is critical for clinical management and treatment strategies.
Proteus Syndrome
Authors: Biesecker Leslie G.
Published: April 2019

Proteus syndrome is an exceedingly rare disorder, perhaps the least common of all overgrowth syndromes but one of the most distinctive because of its segmental nature and unrelenting progression. Proteus syndrome occurs sporadically and was the first of the segmental overgrowth syndromes found to be caused by somatic mosaicism. The discovery of an activating mutation in AKT1 by Les Biesecker and colleagues at the National Institutes of Health provided the initial molecular proof for somatic mosaicism in Proteus syndrome. Overgrowth in Proteus syndrome can involve nearly any tissue or part of the body. Presumably a germline mutation that would affect all tissues of the body would be lethal. Overgrowth of a tissue or a body part is the distinctive manifestation of Proteus syndrome but in most cases will be accompanied by other cutaneous, skeletal, vascular, or soft tissue findings. Although the possibility of an increased risk for developing neoplastic disease is a concern in any overgrowth disorder, this has not been demonstrated in Proteus syndrome.
Vascular Anomalies
Authors: Lee Lara Wine , Trenor Cameron C.
Published: April 2019

The chapter provides a description of the main anomalies characterized by excessive proliferation of the vascular tissue and the major syndromes associated with them. The predominant types of vascular anomalies are vascular tumors and vascular malformations. Vascular tumors are further subdivided in benign, locally aggressive, and malignant, according to the clinical course of the lesions, while vascular abnormalities are classified as simple (capillary, lymphatic, venous, arteriovenous, and arteriovenous fistula) or combined. For each subgroup of vascular anomalies, clinical presentation and diagnostic procedures are discussed, as well as pathogenic mechanisms and potential comorbidities. The management of vascular anomalies may be oriented to treat the aesthetic discomfort as well as the functional impairment and may involve both pharmaceutical and surgical approaches.
Transoesophageal echocardiography, sonoanatomy, and standard views
Authors: Fletcher Nick
Published: April 2019

This chapter will describe the omniplane probe (with its scan planes) and indications, contraindications, and complications of transoesophageal echocardiography (TOE), before defining a scheme for focused TOE assessment in a critically ill patient. It will highlight the cardiac structures that are best imaged using either transthoracic echocardiography or TOE, and outline specific clinical applications (including suspected aortic dissection, left atrial appendage thrombus, mitral disease, and right ventricular failure) that lend themselves to TOE assessment.
Aortic valve assessment
Authors: Peck Marcus , Scheuermann-Freestone Michaela
Published: April 2019

This chapter will cover in detail the two-dimensional sonoanatomy and pathophysiology of common aortic valve lesions and explain step by step how to image the aortic valve and detect significant disease. The advanced section will introduce how to use colour and spectral Doppler to recognize acute and severe pathology that requires immediate management.
Dyspnoea and hypoxaemia
Authors: Miller Ashley
Published: April 2019

Lung ultrasound can be used to diagnose most pathologies which cause respiratory failure. This chapter will outline a systematic approach to assessing the patient presenting with acute respiratory failure. In addition, the role of ultrasound in assessing ventilated patients with established respiratory failure, monitoring fluid balance and pleural effusions, identifying ventilator-associated pneumonia, and monitoring lung recruitment will be reviewed.
Advanced echocardiography: sepsis
Authors: Price Susanna , Tavazzi Guido
Published: April 2019

This chapter will introduce the key features to address in sepsis using echocardiography, including: volaemic status (requirement for, and tolerance to, volume); alteration in myocardial function; when sepsis is associated with acute respiratory distress syndrome and assessment of right heart function for potential extracorporeal support; differentiation of pulmonary oedema from acute respiratory distress syndrome; changes in pulmonary artery systolic pressures and/or pulmonary vascular resistance; and exclusion/diagnosis of the underlying cause of sepsis, including endocarditis.
Pericardial drainage
Authors: Alam Shirjel , Gillies Michael
Published: April 2019

This chapter will explain how this potentially lifesaving procedure can be done using echocardiographic guidance, discussing indications, contraindications, monitoring and equipment, positioning and approach, technical aspects of the procedure using ultrasound, and post-procedure care.
Physiology of exercise
Authors: D’Silva Andrew , Sharma Sanjay
Published: April 2019

When we exercise we are accessing the same potential as the physical activity that our ancestors depended on for survival. Humans are adapted for high performance locomotor function, and exercise physiology studies the integration of neurological, respiratory, circulatory, endocrine, and metabolic systems coordinating a response to energy and oxygen demand. From rest to exercise cardiac output increases up to five- to sevenfold and pulmonary ventilation increases over 16-fold in order to enhance oxygen transport for unlocking energy in respiring muscle cells. Furthermore, a symphony of changes in cellular respiration, vascular resistance, and adrenergic stimulation is required to support the necessary transformation of chemical energy to kinetic energy for prolonged muscle activity. This chapter describes these processes in detail and relates physiological changes during exercise to the findings of the normal cardiopulmonary exercise test.
Impact of sporting discipline, gender, ethnicity, and genetics on the athlete’s heart
Authors: Sheikh Nabeel
Published: April 2019

Participation in regular exercise is associated with several electrical and structural cardiac adaptations collectively termed the ‘athlete’s heart’. The nature and extent of these changes are influenced by several demographic factors, including the sporting discipline, gender, and ethnicity of the athlete. Knowledge of these influences is crucial for the correct interpretation of data from pre-participation cardiac evaluation of athletes and prevention of erroneous diagnoses. The greatest adaptations are usually observed in male athletes, those competing in endurance exercise, and those of African/Afro-Caribbean (black) ethnicity. In particular, much attention has recently been given to cardiac remodelling in black athletes, a significant proportion of whom exhibit profound electrical and structural cardiac changes in response to exercise. Data on the influence of genetic factors on the athlete’s heart are now emerging, which may aid our understanding of the complex mechanisms underlying this process and ultimately help differentiation of normal physiology from cardiac pathology.
Vascular remodelling
Authors: Gielen Stephan , Laughlin M. Harold , Duncker Dirk J.
Published: April 2019

Vascular remodelling plays an important role in the adaptation of the athlete to increased exercise duration and intensity. Endurance exercise improves endothelium-dependent flow-mediated vasodilation and leads to increases in conduit artery lumen diameter after regular exercise, typically in the trained limb. These changes result in a reduced vascular stiffnes. On the contrary strength training (e.g. for weight-lifting) produces increased vascular stiffness and enlarged central vessels (e.g. aortic root diameters), while the diameters of peripheral vessels are unchanged. In the skeletal muscle, endurance training increases capillary density and improves oxygen exchange, thus adding further functional reserves to the aerobic exercise capacity. Aerobic exercise leads to a large increase in cardiac functional reserves, hence myocardial perfusion is increased in line with metabolic demands. In addition to improved endothelium-dependent vasodilation, coronary arterioles also exhibit an increased myogenic tone.
History and physical examination
Authors: Schiavon Maurizio , Zorzi Alessandro , Corrado Domenico
Published: April 2019

Personal and family history are invaluable components in pre-participation screening of athletes. Both the American Heart Association and the European Society of Cardiology recommend administering a questionnaire about family and personal history and performing a physical examination focused on the common signs of heart disease in the young. However, it should be kept in mind that the screening history questions that are currently recommended are based on expert opinion and enquire about common symptoms that are not specific to cardiac diseases. Moreover, many athletes show innocent cardiac murmurs which may trigger further unnecessary cardiovascular examination. Hence, the education and experience of screening physicians are critical for improving the effectiveness of history-taking and physical examination in pre-participation evaluation.
Class 1 anti-arrhythmic drug provocation test
Authors: Antz Matthias
Published: April 2019

The Brugada syndrome is associated with potentially lethal arrhythmias and sudden cardiac death. The diagnosis is made from the surface ECG. In suspicious but not typical ECGs, intravenous administration of class 1 anti-arrhythmic drugs (i.e. sodium channel blocking agents such as ajmaline, flecainide, or procainamide) can be performed for diagnostic reasons.
Echocardiogram: morphological and functional evaluation including new echocardiographic techniques
Authors: Caselli Stefano , D’Ascenzi Flavio
Published: April 2019

Echocardiography is the most important imaging technique for the characterization of athlete’s heart as it allows evaluation of morphological and functional cardiac adaptations induced by exercise. It is usually performed when abnormalities are found on clinical examination and/or on resting or stress echocardiograms, and is particularly helpful for differential diagnosis of pathological conditions at risk for sudden cardiac death such as hypertrophic, dilated, arrhythmogenic, or non-compaction cardiomyopathies. This chapter reviews useful methods for performing a standard echocardiographic examination in competitive athletes and for correct interpretation of findings by discussing determinants and upper limits of cardiac adaptations, reference values, and specific clues for the differential diagnosis of pathological conditions.
Coronary computed tomography
Authors: Möhlenkamp Stefan
Published: April 2019

Coronary computed tomography (CCT) allows high resolution imaging of coronary atherosclerosis, coronary artery stenosis, and other coronary pathology or anomaly, such as abnormal origin of coronary arteries or myocardial bridging. Coronary artery calcium (CAC) imaging to quantify calcified plaque or CT angiography (CTA) to detect calcified, mixed, or non-calcified plaque may help to improve risk stratification and exclusion of coronary artery disease, especially in master athletes with present or past cardiovascular risk factors or athletes with atypical chest pain. Initial data suggest that the extent of subclinical atherosclerosis may be underestimated in athletes and that an increased atherosclerosis burden is associated with impaired prognosis. Careful risk–benefit assessment of radiation exposure, contrast agent, and costs of the test is necessary, particularly for asymptomatic athletes with risk factors and young athletes.
Coronary angiography
Authors: Möhlenkamp Stefan
Published: April 2019

Invasive coronary angiography is used in symptomatic athletes with clinical suspicion of coronary artery disease which presumably requires interventional therapy, i.e. mainly in acute coronary syndrome and myocardial infarction. Because of its invasive nature, it is not used in asymptomatic athletes. Advanced intra-coronary artery imaging, including intra-vascular ultrasound (IVUS), intra-coronary Doppler ultrasound (ICDUS) and assessment of fractional flow reserve (FFR), can help to improve understanding of epicardial and intra-myocardial microvascular causes of symptoms. Plaque rupture, plaque erosion, coronary vasospasm, and thrombotic coronary occlusion have been demonstrated subsequent to athletic activities, but it is uncertain to what extent exhaustive exercise triggered the symptoms that led to invasive angiography. Because of radiation exposure, use of contrast agent, and the costs of the test careful risk–benefit assessment is necessary, especially in asymptomatic athletes with risk factors and in young athletes.