bluuebunny/crossref_metadata_2025 huggingface dataset:
Seeing the History of Neuroscience in Turin through the Lenses of Its Instruments/Part 2
Authors: Galloni Marco R.
Published: February 2022

In the second half of the 19th century, the physiologist Angelo Mosso and the anatomist Carlo Giacomini collaboratively investigated the pulsation of the brain blood vessels and the variations of the brain surface temperature. Mosso invented the human circulation balance to measure the blood distribution throughout the human body. In the attempt to correlate cerebral activity and energy supply, he tried to explore the relationship between the blood distribution to the brain and various types of stimulation. At the beginning of the 20th century, Turin became the capital of silent movies, and Camillo Negro used this new technique to document clinical cases of neurological disorders in mental hospitals. In the 1930s, Giuseppe Levi brought in-vitro cell culture to Italy and used time-lapse cinematography to study the behavior of neurons.
The neurobiological basis of sleep
Authors: Rosenzweig Ivana
Published: February 2022

Despite the prevalence of sleep disorders, and our growing understanding of the bidirectional relationship between sleep and physical and mental health, most clinicians have little training or expertise in sleep medicine. The aim of this book is to provide a starting point for the theoretical and practical aspects of clinical sleep medicine, including the diagnosis and management of common and rare sleep disorders. It is aimed at all doctors likely to encounter patients with sleep disorders in their clinical practice, and also those embarking upon a career in sleep medicine.
Psychological therapies for insomnia
Authors: O’Regan David
Published: February 2022

Insomnia is the most common sleep disorder, and frequently coexists with other medical, psychiatric and sleep conditions. It is associated with significant personal and socioeconomic burden. The clinical features, diagnosis, differential diagnosis, assessment, epidemiology and consequences of insomnia are discussed within this chapter.
Sleep-disordered breathing and its associations
Authors: Kent Brian
Published: February 2022

Respiratory function is significantly altered by sleep. People with entirely normal breathing when awake can develop very significant respiratory compromise during sleep. Following sleep onset, central motor neuron output falls. This means that diminished upper airway dilator muscle function leads to a narrower upper airway, while reduced inspiratory muscle activity causes a shallower breathing pattern compared to the awake state.
Within this chapter, we discuss the classification of sleep-disordered breathing, its epidemiology, clinical features and associated co-morbidities.
Medical management of sleep-disordered breathing
Authors: Williams Adrian J.
Published: February 2022

People with obstructive sleep apnoea can be affected by a huge variety of unpleasant symptoms, ranging from broken nocturnal sleep and nocturia, to overwhelming daytime sleepiness and low mood. They also are more likely to be involved in car crashes, and to have significantly impaired concentration and daytime functioning.
However, a combination of sleepiness, cognitive or psychological symptoms, and an incremental reduction in overall economic productivity are unlikely to cause undue public or scientific excitement. Where OSA becomes more relevant from a population health perspective is in its relationship with long-term illness and death, a relationship largely mediated through an apparent effect of OSA on the likelihood of people developing cardiovascular and metabolic disease, and possibly also cancer. Longitudinal observational studies consistently show that increasing OSA severity is associated with excess morbidity and mortality, above and beyond the expected effects of confounding factors such as obesity.
Dental approaches to the management of sleep-disordered breathing
Authors: Desai Aditi
Published: February 2022

Barriers to the effective management of obstructive sleep apnoea are multiple, and included underdiagnosis. However, once the diagnosis has been established, several options exist for its treatment. These include effective elimination of contributing factors, such as obesity and nasal obstruction, as well as mechanical splinting of the upper airway through the use of continuous positive airway pressure.
This chapter focuses on the gold standard treatment of CPAP, indications for its use, hurdles to adherence, and strategies to improve tolerability.
Novel approaches for the treatment of obstructive sleep apnoea
Authors: Steier Joerg
Published: February 2022

Sleep related breathing disorders includes patients suffering from primary snoring, upper airway resistance syndrome and obstructive sleep apnoea (OSA). In these patients the turbulent airflow from the nose to the larynx is due to various anatomical obstructive segments resulting in snoring and apnoeic episodes.
The standard recommended treatment for moderate and severe OSA is continuous positive airway pressure, but the compliance and adherence of this form of therapy is somewhat poor. Surgical rectification of the obstructive upper airway may be an option, and may result in lowering the pressure requirement for CPAP thus improving compliance and adherence rates and occasionally may well alleviate the need of CPAP therapy.
Careful patient selection is the key in attaining good surgical outcomes and this certainly applies to patients with SDB. Assessment of the upper airway both during wakefulness and whilst asleep is important, as the muscle tone and obstructive events would differ in these two states.
This chapter discusses the proper evaluation of the upper airway, how suitable candidates for surgery are identified, and the surgical options available for the management of sleep-disordered breathing.
Other hypersomnias
Authors: Leschziner Guy
Published: February 2022

Narcolepsy is a chronic neurological disorder characterised by excessive daytime sleepiness and features of REM-sleep dissociation. It affects approximately 1 in 2000 people, and it may take up to 10-15 years from the onset of symptoms until the diagnosis is made. According to the latest International Classification of Sleep Disorders (ICSD3), Narcolepsy type 1 (NT1) and Narcolepsy type 2 (NT2) have replaced the previous diagnostic groups of narcolepsy with or without cataplexy respectively. The primary reason is the well pathophysiologically defined and homogenous group of NT1 patients who suffer from low or absent hypocretin (orexin) in the cerebrospinal fluid irrespective of the presence of cataplexy.
This chapter describes the classification, diagnosis and management of this archetypal neurological sleep disorder.
Gaining Insight of the Problem
Authors: Fava Giovanni A.
Published: February 2022

The chapter describes how the problem of withdrawal syndromes during tapering and/or after discontinuation of antidepressant medications emerged in the literature and clinical practice. Withdrawal reactions were promptly renamed as discontinuation syndromes, unlike with other psychotropic drugs, to avoid any inference to issues of dependence. Both physicians and patients were taught that the problem manifests itself only with abrupt discontinuation of antidepressant medications and that, if symptoms arise, they have to be considered signs of relapse, with prompt re-administration of the antidepressant. The chapter outlines how the author’s findings of the persistence of withdrawal symptoms were in sharp contrast to key opinion of the time.
The Clinical Manifestations of Withdrawal Following Discontinuation of Antidepressant Drugs
Authors: Fava Giovanni A.
Published: February 2022

Tapering and discontinuation of antidepressant medications are associated with a variety of clinical manifestations that, in many cases, reach the threshold of a withdrawal syndrome. Selective serotonin reuptake inhibitors (SSRI) and serotonin-noradrenaline reuptake inhibitors (SNRI) are the antidepressants that appear to be mostly associated with these manifestations. The clinical manifestations of withdrawal following discontinuation of antidepressant medications, and the findings of a number of systematic reviews on such manifestations, are discussed in this chapter. The definition of clinical phenomena following such discontinuation, the diagnostic criteria for withdrawal syndromes and persistent postwithdrawal disorders, and the qualitative experience of withdrawal are all described.
Pharmacological Strategies and Options
Authors: Fava Giovanni A.
Published: February 2022

The treatment strategy for discontinuing antidepressant medications is presented in this chapter. The various pharmacological options are reviewed as to their advantages and disadvantages, with particular reference to staging and methods of discontinuation. Rapid and slow taperings are compared; and potential interactions with other medications are reviewed. There is a lack of appropriate randomized controlled studies comparing different methods. Treatment choices are based entirely on clinical judgment and decision sharing with the patient. In this chapter, the author outlines the dilemmas and potential solutions that the clinician encounters, referring to both the literature that is available on various aspects of antidepressant medications and his own clinical and conceptual appraisal of the problem.
Synaptic Properties
Authors: Martin Usrey W. , Murray Sherman S.
Published: February 2022

In this chapter, the authors survey synaptic properties, especially as regards thalamic and cortical circuitry. Most attention is given to chemical synapses that dominate thalamic and cortical circuitry, but rare electrical synapses are found in both structures and are mentioned. The main neurotransmitters and their postsynaptic receptors are described. Regarding the latter, both ionotropic and metabotropic receptors are present, and the authors emphasize the point that many, but not all, glutamatergic afferents can activate both types of receptor. Finally, the chapter describes the presence of receptors found on synaptic terminals (i.e., presynaptic receptors) and the likely role they play in control of transmitter release.
Classification of Thalamocortical and Corticothalamic Motifs
Authors: Martin Usrey W. , Murray Sherman S.
Published: February 2022

There is great variety in the types of thalamocortical and corticothalamic projections, and a prerequisite to any deep understanding of these critical parts of brain circuitry is developing a proper classification of their elements. The thalamus and cerebral cortex are richly interconnected with an array of feedforward and feedback circuit motifs. Reflective of the history of investigation into thalamocortical relationships and the diversity of investigators studying these relationships, there is an array of classification schemes for thalamocortical and corticothalamic motifs. This chapter explores the properties of these classification schemes and their limitations, considers homologous relationships between apparently similar classes of cells and circuits between species, and emphasizes the need for a complete classification.
Parallel Processing of Sensory Signals to Cortex
Authors: Martin Usrey W. , Murray Sherman S.
Published: February 2022

Parallel pathways convey distinct information from periphery to cortex and serve to broaden the range of sensory signals conveyed to cortex. In the visual system, separate channels are evident at the level of retinal bipolar cells, with some cells conveying increases in luminance and others conveying decreases in luminance. One synapse downstream, multiple classes of retinal ganglion cells are further specialized to convey specific visual features. This chapter examines the functional organization of parallel processing in the retino-geniculo-cortical pathway of primates, felines, and rodents and considers evolutionary relationships between cell classes across species. Parallel pathways are evident not only in the feedforward projections to cortex, but also in the feedback projections from cortex to thalamus, thus allowing for stream-specific interactions between thalamus and cortex.
Gastroparesis, Chronic Intestinal Pseudo-obstruction, and Functional Dyspepsia
Authors: Camilleri Michael
Published: February 2022

Traditionally, gastroparesis is a syndrome characterized by delayed gastric emptying of solids and key upper gastrointestinal symptoms in the absence of mechanical obstruction of the stomach. However, in recent years, the spectrum has been broadened to gastroparesis and related disorders with recommendation to reconsider the syndrome a broader spectrum of gastric neuromuscular dysfunction. The principal symptoms of gastroparesis include postprandial fullness (early satiety), nausea, vomiting, bloating, belching, and upper abdominal pain. The most common causes of gastroparesis are idiopathic, diabetic, and iatrogenic (medications and postsurgical). Symptoms attributable to gastroparesis are reported by 5% to 12% of patients with diabetes mellitus.
Pathophysiologic Mechanisms of Appetite, Obesity, and Gut Hormones
Authors: Camilleri Michael
Published: February 2022

Multiple peripheral mechanisms regulate appetite, including the rate of gastric emptying and fasting and accommodation gastric volumes. The stomach is one of the organs that convey symptoms of satiation to the brain. Several peripherally released peptides and hormones originating from the stomach, small bowel, and pancreas provide feedback on arrival of nutrients in different regions of the gut. In the overall control of appetite, one cannot underestimate the important roles of motivation and behavioral aspects of feeding, the interaction with input of hypothalamic peptidergic circuits to vagal nuclei, and hormones derived from adipose tissue.
Irritable Bowel Syndrome: Peripheral Mechanisms, Biomarkers, and Management
Authors: Camilleri Michael
Published: February 2022

Several peripheral mechanisms result in symptoms of irritable bowel syndrome. They include abnormal colonic transit and rectal stool evacuation; intraluminal irritants such as short-chain fatty acids, bile acids, or gluten; microbiome changes; enteroendocrine cell products; and genetic susceptibility. Irritants can increase mucosal permeability, cause immune activation, activate local reflexes to alter intestinal motility or secretion, and induce visceral hypersensitivity and pain. IBS management is based on predominant symptom relief rather than targeting specific mechanisms. However, biomarkers are being identified and introduced into practice, such as colonic transit and fecal BA excretion and should lead to individualized, specific treatments of IBS.
Visceral Sensation
Authors: Camilleri Michael
Published: February 2022

Visceral sensation is one of the important mechanisms that are upregulated, a process resulting in hypersensitivity in functional gastrointestinal disorders. However, it is also relevant when other mechanisms, such as inflammation or altered motor function, result in signaling the abnormal functions such as stasis or accelerated transit from the gut to the brain. Thus, it is important to understand the physiologic basis of visceral sensation. The factors influencing visceral sensation are the neural pathways and transmitters, viscus compliance and tone, sex, level of attention, and unpleasantness of the sensation.
Ringworm of the scalp
Authors: Bursztein Ciro
Published: February 2022

This chapter describes different aspects of the classification, categorization, and treatment of ringworm of the scalp, presenting different key figures in the research and treatment of this disease. The chapter is divided into two periods. The first covers ringworm from ancient times until the advent of modern medicine in the 17th century. The second runs from the 17th century up to 1897, when Roentgen rays (x-rays) were introduced as a cure for the disease—a protocol that became known as the Kienböck–Adamson technique. This chapter also describes in great detail the health and economic burden and the cost in terms of social stigma that ringworm imposed upon society in different countries.
“Think before you act”
Authors: Sadetzki-Jackobson Siegal
Published: February 2022

A comprehensive follow-up study of a cohort composed of children who were treated with ionizing radiation for ringworm and two comparison groups was initiated in Israel in 1965. Over the years, these studies assessed the association between radiation exposure and the development of cancer, mortality, psychiatric illness, cognitive impairment, dental health, and vascular diseases. Genetic studies to identify inherited sensitivity to radiation were also conducted. Since 2001, the research activity has been performed in accordance with Clause 7a of the Ringworm Victims Compensation Law of 1994. The law mandates follow-up of individuals who were irradiated for ringworm in the 1950s and provides compensation for those who were affected by one of the diseases defined as being causally related to the treatment. Beyond Israel, the results contribute to the global data on health damages caused by ionizing radiation. This chapter presents the study methods and results from the period 1965 to 1995. The later studies conducted during 1995–2021 as well as The Ringworm Victims Compensation Law that was passed in 1994 are not described in this book.
Serious Pediatric Illness
Authors: Clark Jonna D. , Lewis-Newby Mithya , Kon Alexander A. , Morrison Wynne
Published: February 2022

Shared decision making, or collaborative decision making, in pediatric serious illness occurs when health care decisions are made through an exploration of the patient’s and family’s goals, preferences, and values, and potential options are weighed using guidance from clinicians. The foundation for successful collaborative decision making requires a partnership built on trust and transparent, nonjudgmental, and empathetic communication. Using eight clinical cases as examples, this chapter describes an ethically permissible spectrum of clinician directiveness, ranging from low to near complete. Internal influences, such as uncertainty in disease prognosis, benefits and burdens of treatment, and the family’s desire for clinician guidance, and external influences, such as institutional policy and societal values, often impact the approach utilized. Titrating clinician directiveness in collaborative decision making is an important tool that honors and supports families and their children when navigating serious illnesses.
Principles of imaging
Authors: Yip Connie , Jane Taylor N. , Chambers Anthony , Goh Vicky
Published: February 2022

Chapter 2 discusses how imaging is fundamentally important to the management of the cancer patient, how anatomical imaging is the mainstay for patient evaluation, and how functional and hybrid (combined functional–anatomical) imaging have acquired an increasing role. Additionally, it offers guidance on obtaining the most accurate and reliable information possible with the most appropriate imaging modality and why the relative performance of the imaging test has to be defined. Staging and prognosis is discussed, as well as therapeutic uses and image-guided radiotherapy. The chapter concludes by looking at how imaging is used in response assessment and future directions in imaging.
MRI and functional imaging in radiotherapy planning, delivery, and treatment
Authors: Yang Huiqi , Ajithkumar Thankamma
Published: February 2022

Abstract: This chapter describes the features, advantages, and challenges associated with multi-modality imaging in radiotherapy planning. Reasons are given behind the challenges facing on current imaging technology, and some of the possible resolutions. The application of MRI and PET imaging across different tumour sites within the scope of radiation practice is reviewed, including the current status, utility, and future perspective. The use of dose escalation and dose painting is described. The incorporation of MRI and PET/CT imaging has dramatically altered radiotherapy planning practices recently. There is ongoing research into the exploitation of information acquired through multi-parametric MRI and PET imaging for advancing dose delivery techniques, especially where there is strong evidence of a biological rationale and improved outcomes. Another field of work includes radiomics.
Breast
Authors: Geropantas Dinos , Ames Victoria
Published: February 2022

Chapter 4 discusses breast cancer, and includes incidence, screening, diagnosis and staging, radiological staging, radiotherapy planning, therapeutic assessment, and follow-up. Breast mortality has shown a decrease in recent years and advances in imaging have played a significant role in this. Although mammography and ultrasound remain key in breast cancer diagnosis, new techniques such as contrast-enhanced spectral mammography (CESM) and dynamic contrast-enhanced breast MRI have led to improvements in detection and local staging. PETCT is increasingly used in breast cancer diagnosis and management as it can in some cases complement the combination of CT and bone scan in identifying distant disease and also in assessing response to systemic therapy. Radiotherapy contouring and planning are now CT-based and specific guidelines on how to draw clinical target volumes have been published aiming to reduce errors and homogenize treatment.
Head and neck cancers
Authors: Barnett Gill , Das Tilak
Published: February 2022

Imaging plays a pivotal role in the management of head and neck cancer (HNC). CT and MRI are used as initial staging investigations, whilst PET-CT is performed if the primary tumour is not evident. PET-CT is also recommended in patients with more advanced stage HNC to assess for mediastinal disease or metastases. Ultrasound (US) with fine needle aspiration cytology (FNAC) is a useful adjunct to CT and MRI for the detection of involved lymph nodes. PET-CT is used to assess response to definitive treatment with chemoradiation. The combination of US, CT, and MRI is also used to assess salivary gland tumours. MRI is particularly useful for detecting perineural invasion. US is the imaging modality of choice for both diagnosis and follow up of thyroid cancer, usually with FNAC or core biopsy. CT or MRI is reserved only for locally advanced disease to assess whether surgery is feasible. CT may be used to assess for pulmonary metastases.
Endocrine tumours
Authors: Aloj Luigi
Published: February 2022

Chapter 19 discusses endocrine tumours and covers neuroendocrine neoplasms, and tumours of the adrenal medulla and adrenal cortex. Given the distinctive biochemical properties of these tumours, radionuclide methods targeting specific biomarkers are applied in many settings. Progress in radionuclide based imaging has been mostly focused on new applications of positron emission tomography (PET) through development of new radiolabelled compounds. This has also prompted clinical research in radionuclide therapy utilizing the same principles to deliver lethal radiation to tumours which have provided approved treatments in specific areas. X-ray computed tomography (CT) and magnetic resonance imaging (MRI) have well established roles in whole body staging (CT) and high sensitivity for small lesions (MRI) in specific settings. MRI methods utilizing spectroscopic imaging are expected to allow additional biochemical characterization of tumours in the future.
International progress in the development of palliative medicine
Authors: Centeno Carlos , Payne Sheila , Garralda Eduardo
Published: February 2022

Between 40 and 80 million patients with advanced disease need access to palliative care, 78–95% of them living in low- and middle-income countries. However, palliative care development is progressing slowly and unevenly across the globe, and health-related suffering remains greatly unaddressed. The global development of palliative care requires a public health approach, capable of addressing the establishment of policies, education, availability and accessibility of pain medicines, as well as the implementation of palliative care services. Although thus far palliative care has concentrated upon provision of palliative care for adults, in recent times, the scientific community has also called to tackle the nearly total lack of palliative care provision for children. This chapter traces the history, definitions, and concepts of palliative care; describes global advances of palliative care according to the four dimensions of the World Health Organization public health strategy; and provides recent information for all regions across the world. It concludes with a section dedicated to promotion initiatives carried out by diverse international organizations.
Barriers to the delivery of palliative care
Authors: Laird Barry , Haraldsdottir Erna , Hall Charlie
Published: February 2022

Palliative care should be available to all, irrespective of geography, social circumstance, place of care, illness, and ethnicity. Yet this is sadly not the case and key barriers remain which can impede effective palliative care. In this chapter, some of these barriers are described with a focus on World Health Organization-led initiatives to break the barriers down. The chapter argues that the World Health Organization is the key group necessary to develop palliative care worldwide and, together with international palliative care organizations, to help countries advance their palliative care services.
Palliative care in the nursing home
Authors: Phillips Jane , Hosie Annmarie
Published: February 2022

Nursing homes are increasingly the place where many older, frail adults with multiple comorbidities and varying levels of disability and cognitive impairment live out the final stages of their lives Adopting a palliative approach optimizes these older people’s functional capacity, maintains dignity, minimizes discomfort and suffering, and attends to the family’s supportive care needs. A palliative approach helps to optimize the quality of life for older people with any life-limiting condition, and their families, by reducing suffering through early identification, impeccable assessment, and treatment of pain and physical, psychological, social, cultural, and spiritual needs. Initiating a palliative approach on a person’s admission into a nursing home ensures that the symptoms they experience don’t go undetected or undertreated, and any progressive illness needs, disability, impaired communication, or dementia is acknowledged and addressed. Embedding a palliative approach into nursing homes requires changes at the consumer, provider, and systems levels. The Innovative Care for Chronic Conditions Framework assists nursing homes to systematically address these challenges by focusing on (1) policies that promote the delivery of a palliative approach and the executive support and sponsorship required to embed the changes; (2) building the workforce’s geriatric and palliative care capabilities; (3) fostering collaborative partnerships across care settings to better meet the needs of residents; (4) promoting access to decision support tools; (5) increasing access to clinical information systems, including point-of-care evidence, electronic health records, and electronic prescribing systems; and (6) actively engaging residents with capacity and their families in care planning and decision-making.
The core team and the extended team
Authors: Haugen Dagny Faksvåg , Nauck Friedemann , Witt Sherman Deborah
Published: February 2022

Interdisciplinary collaboration is an inherent feature of palliative care and is based on the tenet of teamwork. A team is defined as a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable. Efficient teams are characterized by good leadership, efficient communication, a strong sense of cohesion, and good decision-making and conflict resolution skills. A palliative care team usually consists of core and extended members. All members operate in close relation to the patient and family, but while core members are full-time members governed by the team policy and managed by the team leader, associate or extended members are usually part-time in the team and not involved with every patient. The team needs to be named and defined, but must also be flexible and integrate the health professionals and skills needed in the individual case, as well as the patient and family members. The palliative care consult team has a unique role as the interface between palliative medicine and other medical specialties in the acute hospital, and has several levels of intervention. Every team should audit its own performance with respect to structure, processes, and outcomes. Interdisciplinary teamwork in palliative care has been shown to have positive benefits to organizations, health professionals, and most importantly to the quality of care offered to patients and their families.
Parenteral nutrition
Authors: Arends Jann , Strasser Florian
Published: February 2022

Parenteral nutrition (PN) is an invasive approach that aims to supply energy and nutrients when food intake in patients with an advanced disease is inadequate to the degree that it impairs quality of life, reduces mobility, enhances fragility, and shortens survival. The use of PN is complicated by serious risks and substantial logistic burdens for the patient and their care providers. Since maintaining body resources and performance is of major importance early in the trajectory but much less so as the patient approaches the end of life, decision-making must take into account the evolution of the underlying illness as well as the prevailing circumstances, prognosis, and goals of care. These decisions require balancing the possible benefits and risks and communicating these considerations with the patient and their caregivers and within the therapeutic team. It is of critical importance to differentiate pure starvation, due to an inability to take in, digest, or absorb nutrients, from cachexia, that is, anorexia and catabolism produced by cancer-associated systemic inflammation. PN is the technique of choice when intestinal failure develops in a patient with an otherwise stable condition, motivated and able to be physically active, and with an expected survival of at least several weeks or months. Supplying PN to patients with a working gut has not been shown reliably to be beneficial and other options for feeding should generally be pursued. In all circumstances, the patient’s consent to nutritional interventions is required. In situations when both tube feeding and PN are options, frequently, patients prefer the intravenous route. Composition, application, and follow-up of PN should follow rigorous procedures. Accepting the inevitability of disease progression, artificial nutrition should always be seen as one tool among others, which may support the patient during some episodes but will lose relevance during the final stages of an incurable disease.
Endocrine and metabolic complications of advanced cancer
Authors: Ryan Richella , Casey Ruth
Published: February 2022

This chapter reviews the epidemiology, pathogenesis, clinical features, and management of endocrine and metabolic complications of advanced cancer. Broadly, these complications may arise in three ways due to (1) direct tumour invasion of organs or tissues; (2) non-metastatic systemic effects resulting from secretion of hormones, cytokines, or growth factors either by the tumour itself or by normal cells in response to tumour invasion (‘paraneoplastic effects’); and (3) treatments targeted at cancer or its symptoms. The chapter is divided into four sections. First, it describes the three most common endocrine manifestations of advanced cancer, including hypercalcaemia, Cushing’s syndrome, and syndrome of inappropriate antidiuresis. Second, it discusses the endocrine manifestations resulting from rare but important secretory endocrine tumours, including hypoglycaemia secondary to islet-cell and non-islet cell tumours, enteropancreatic hormone syndromes, carcinoid syndrome, phaeochromocytoma, adrenocortical carcinoma, and medullary thyroid carcinoma. Third, it briefly describes miscellaneous rare endocrine manifestations of cancer, including gynaecomastia, hypo- and hyperthyroidism, hypothalamic–pituitary dysfunction, and adrenal insufficiency. Finally, it concludes with a brief discussion of metabolic complications that may arise in association with malignancy, including paraneoplastic pyrexia, hyperglycaemia, and metabolic bone disease. Renal failure and hepatic failure are dealt with separately in the volume.
Palliative care issues in head and neck cancers
Authors: Mayland Catriona R. , Rogers Simon N.
Published: February 2022

This chapter focuses on the key palliative care issues involved in the care of people with head and neck cancer, where both the cancer and the subsequent treatment can have a profound impact on the individual and their family carers. Initially, the prevalence and impact of head and neck cancer on a global basis is outlined. An overview of the recent developments in anticancer therapies for recurrent or palliative disease are given, along with the complexities that can arise relating to these and other ethical issues in terms of decision-making. Symptom control and the specific issues related to head and neck cancer are discussed with guidance provided for the practical management of these. With the emerging benefit of early palliative care, the challenges and complexities relating to the best way to integrate this approach into the routine oncological care for head and neck cancer patients is discussed.
Advanced heart disease
Authors: Pantilat Steven , Davidson Patricia , Psotka Mitchell
Published: February 2022

Heart disease is the leading cause of death in the developed world and causes significant morbidity and repeated hospitalization. Heart failure (HF) is the final common pathway for many cardiovascular diseases. Although optimal medical management and targeted use of devices improve survival and quality of life for people with HF, symptom distress and other types of illness burden are common. High illness burden and the risk of sudden death at every stage of HF means that palliative care treatments should be integrated into care for all patients. Palliative care should enhance communication among clinicians and with the patient and family, and should provide options for treatment of symptoms and deactivation of devices. Simultaneous care by a cardiologist and a palliative care specialist may optimize outcomes, and palliative care specialists must be aware that referral to HF specialists may be necessary for patients with advanced HF. Integrating palliative care alongside HF care can improve quality of life, decrease suffering and healthcare costs, and enhance quality of care.
Palliative medicine and care of the elderly
Authors: Agar Meera , Phillips Jane
Published: February 2022

Palliative care in the older person often occurs in the context of both chronic disease and multimorbidity. Coexisting conditions may include musculoskeletal, psychiatric, cognitive, and chronic pain-related problems, each associated with substantial symptomatology and disability. It is important to have an approach to palliative care that avoids management within disease ‘silos’, to ensure all treatments are integrated by considering the combined benefits and risks including impacts of polypharmacy; to respond to preference and choice of the older person; and to consider outcomes from symptom, function, and social domains. The complexity of older people’s care demands the formation of a collaborative partnership between primary care, geriatric, palliative care and social care services, other healthcare providers and the community in which they live on the basis of needs. The caregiver of the older person warrants specific mention, who is often an older spouse with their own medical problems or an adult child juggling other life and work commitments. Planning for care in advance is crucial to avoid decisions being made in crisis, more so if cognitive decline is expected. Physiological changes and the frequency of falls, frailty, depression, and delirium are important when planning care and prescribing.
Ethics in paediatric palliative care
Authors: Hain Richard D. W.
Published: February 2022

Professional competence is a necessary but insufficient representation of how an individual healthcare professional should properly behave in relation to a patient. Medical ethics addresses the further question of how to decide what actions taken by professionals in the context of that relationship are morally right. The ways in which children are distinct from adults are relevant to that question. Children are part of a family, their autonomy is limited in principle—and even more in practice—and, because they are often unable to communicate, children’s interests are easily ignored or annexed to others. The two ways in which ethical questions are currently usually addressed in practice are by appealing to principlism or to rights-based arguments. The ethical theories behind those approaches (deontology, utilitarian consequentialism, and virtue ethics) are problematic in children. While all are helpful, none provides a comprehensive or consistent account that is both ethically argued and child specific. This chapter reviews the strengths and weaknesses of existing ways of looking at ethics in end of life care for children and considers two important, specific, contemporary ethical debates in medical ethics in children’s palliative care: the principle of double effect and withholding or withdrawal of life-sustaining treatment.
Understanding clinical trials in palliative care research
Authors: Klepstad Pål , Kaasa Stein
Published: February 2022

Clinical studies encompass clinical trials and observational studies. Clinical trials assign participants to specific health-related interventions while observational studies assess health outcomes in studies where the investigators do not decide therapy. Shared properties in both designs is that the researcher should raise a relevant research question, include a relevant cohort of participants, and select a relevant outcome. The studies must also be performed with statistical rigour and be ethically sound. The studies should use instruments in general use that are validated for use in the study population, and adhere to recommendations for the performance and report of each study design such as the CONSORT rules for randomized controlled trials or STROBE statement for observational studies. Finally, for all clinical studies attention must be paid to the practicalities related to inclusion, follow-up, handling of samples, and organization. Based upon the methods used in clinical studies, the quality of evidence for a specific research question can be assessed following recommendations such as the GRADE system or the Oxford Centre for Evidence-Based Medicine levels of evidence. These assessments are the basis for clinical advice in guidelines and, thereafter, implementation in clinical practice.
Qualitative research
Authors: Flemming Kate
Published: February 2022

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 in the evaluation of complex interventions, and the importance to palliative medicine of undertaking systematic reviews of qualitative research. It addresses practical aspects of searching for qualitative research and how to assess for methodological strengths and limitations. In exploring these issues, it firmly establishes a place for qualitative research within evidence-based practice and for palliative medicine in particular.
The FRCEM OSCE
Authors: Goss Rachel , McMaster Emma , Rennie Stephanie
Published: February 2022

This chapter is an introduction to the Fellowship of the Royal College of Emergency Medicine (FRCEM) Objective Structured Clinical Examination (OSCE). It contains an explanation of the examination structure and scoring systems used. It provides a revision strategy, with advice and pointers to maximise marks. It provides knowledge and a guide to structuring revision.
Communication
Authors: Goss Rachel , McMaster Emma , Rennie Stephanie
Published: February 2022

This chapter contains 11 different communication skills sample cases for the Fellowship of the Royal College of Emergency Medicine (FRCEM) Objective Structured Clinical Examination (OSCE). In this chapter, candidates are invited to use advanced communication skills to deal with conflict and difficult situations. Communication skills are used in a variety of scenarios with patients and colleagues. The cases reflect a range of common presentations that are pertinent to the Royal College of Emergency Medicine (RCEM) curriculum and that are seen in real-life emergency departments. Each case contains instructions for the candidate and the patient actor, as well as a sample mark scheme breakdown and a mark scheme. Key learning points are highlighted after each case.
Proposing a diagnosis: classifications, formulation, and investigations
Authors: O'Dwyer Anne-Marie , Campion Mariel
Published: February 2022

Information gathered in the history and mental state examination must be collated to generate a ‘working’ diagnosis—a framework to understand why the patient has presented in this way at this moment. This requires an understanding of frameworks for diagnoses, relevant investigations to support or refute the proposed diagnosis, and a framework to look at stressors, vulnerabilities, and protective factors in each person (an approach to a formulation). The chapter also provides information on how to construct a biopsychosocial formulation (understanding an individual patient’s presentation from biological, psychological, and social perspectives).
This chapter provides knowledge about:
• The main diagnostic classification systems and how to use them.
• The meaning of a formulation and how to construct one.
• Key investigations and when to use them.
• The multi-disciplinary team.
Practical tips include:
• A summary of the advantages and disadvantages of diagnoses.
• A distinction between diagnosis and formulation.
• A practical grid to construct a formulation using a bio-psycho-social approach.
Eating disorders
Authors: O'Dwyer Anne-Marie , Campion Mariel
Published: February 2022

The core features of eating disorders include preoccupations with food, weight and body shape causing distress, functional impairment, and, often, physical as well as mental illness. Eating disorders can, therefore, present in a range of settings and can be challenging to recognize and manage. The best-described eating disorders are anorexia nervosa and bulimia nervosa. More recently, binge-eating disorder has been described, as has an ‘other’ category where features are not specific to any other diagnosis. This chapter focuses on the prominent disorders, anorexia and bulimia nervosa, and presents the key features of eating disorders with a focus on anorexia nervosa and bulimia nervosa.
This chapter provides knowledge about:
• How to diagnose anorexia nervosa and bulimia nervosa.
• Physical and psychological complications of eating disorders.
• Specific features, course and treatment of these disorders.
Practical tips include:
• A table highlighting key physical and psychological complications in these disorders.
• Indicators for urgent medical admission.
• A table highlighting key differences between anorexia nervosa and bulimia nervosa.
Psychiatry of later life
Authors: O'Dwyer Anne-Marie , Campion Mariel
Published: February 2022

Psychiatry of later life (old age, psychiatry for the elderly) provides mental health care to older people with new-onset psychiatric illness (after age 65) and people with dementia complicated by behavioural and psychological symptoms (BPSD). This chapter discusses mood, anxiety, and psychotic disorders as they present in an older age group. It begins with a review of delirium and dementia. These are challenging syndromes that frequently present to physicians. Basic assessment and management of these disorders should be familiar to all doctors. Psychiatry helps manage significant behavioural disturbance and more complex cases. This chapter therefore provides key information about psychiatry of later life, including:
• Presenting features of delirium and dementia.
• Assessment and management of delirium and dementia.
• Cognitive testing.
• Specific features of mood and psychosis in later life.
Practical tips include how to diagnose and manage dementia, key features of dementia sub-types.
Child, adolescent, and perinatal psychiatry
Authors: O'Dwyer Anne-Marie , Campion Mariel
Published: February 2022

This chapter focuses on the impact of mental illness in children at all stages—directly (child and adolescent psychiatry) and indirectly (perinatal psychiatry). Assessment of children raises specific issues, not just with respect to disorders of childhood, but also important areas such as consent and safety. Interventions in children will necessarily focus on the wider family. Psycho-social interventions, provided by a well-functioning MDT, are key in all mental illness, but particularly in this group. The complexities of prescribing medication for this age group means that if medications are required, you are likely to need expert advice. The post-natal period is a time of particular psychological vulnerability for women (and their babies) and an ability to detect problems and intervene early is essential. Key information presented about child, adolescent, and perinatal psychiatry, includes:
• Specific aspects of assessment and consent in children.
• Key features of childhood disorders, including pervasive developmental disorders, anxiety, and mood disorders.
• Mental illness in pregnancy and the postnatal period.
Practical tips include:
• Psychological interventions in childhood.
• Important considerations in assessment.
Psychological treatments
Authors: O'Dwyer Anne-Marie , Campion Mariel
Published: February 2022

At its simplest, psychotherapy is any intervention which aims to help a person’s psychological distress using psychological techniques. Typically, this involves ‘words’ (talking, listening, and reflecting) but set within a specific framework. Psychotherapies may be classified according to the number of patients taking part or the principles on which they are based. Even though many practitioners will never use a specific psychotherapy, an understanding of the principles optimizes care of patients by helping practitioners more meaningfully engage with colleagues for referring psychological treatments, matching patients’ needs to appropriate interventions and promoting best use of resources. Like all interventions in mental health, these are given within the context of a multi-disciplinary team (MDT). A bio-psycho-social approach to formulation (see Chapter 4) provides the framework for a bio-psycho-social approach to intervention. This chapter presents psycho-social interventions and the multi-disciplinary team, with a particular focus on psychological treatments.
This chapter provides knowledge about:
• The multi-disciplinary team (MDT).
• A model for delivery of psychological care.
• Psycho-education.
• Common elements of all psychotherapies and a history of how they evolved.
• Behavioural therapy, cognitive-behavioural therapy and dialectical behavioural therapy.
Practical tips include:
• A model for the delivery of psychological care in a medical setting.
• A model to understand classical conditioning.
• Key psycho-dynamic concepts used in everyday practice.