bluuebunny/crossref_metadata_2025 huggingface dataset:
Like Clockwork
Authors: Neme-Mercante Silvia , Alsheikhtaha Zahreddin , Foldvary-Schaefer Nancy
Published: August 2019

Sleep-related hypermotor epilepsy, previously known as nocturnal frontal lobe epilepsy, is a focal epilepsy with seizures arising from sleep, typically involving activation of ventromesial frontal, insular, or frontoparietal networks. The etiology may be genetic or due to structural pathology but in most cases is unknown. Seizures are characterized by hypermotor activity with violent proximal limb movements or tonic-dystonic posturing, usually short in duration and often in clusters during non–rapid-eye-movement (NREM) sleep and sleep/wake transitions. The differentiation of seizures from physiologically arousals or pathological arousals (NREM parasomnias) is often challenging, and misdiagnosis is common. Video electroencephalography-polysomnography recording typical events is often required to confirm the diagnosis.
Turn Up the Volume
Authors: Walia Harneet K. , Mansukhani Meghna P. , Grigg-Damberger Madeleine
Published: August 2019

Insufficient sleep syndrome is highly prevalent and an important sleep problem. It occurs when an individual persistently fails to obtain the amount of sleep required to maintain normal levels of alertness and wakefulness. The patient’s ability to initiate and maintain sleep is unimpaired or above average. This chapter outlines the relevant literature linking sleep deprivation and adverse wide-ranging consequences and plausible mechanisms linking them. One of the most striking of these consequences is drowsy driving, which many times is caused by sleep deprivation. Insufficient sleep is an important cause of motor vehicle crashes and carries a high socioeconomic burden. Dissemination and implementation research strategies are needed to inform public health policy initiatives to address insufficient sleep syndrome and drowsy driving.
Figuring Out Fitful Feet
Authors: Valentino Roxanne , Ibrahim Sally
Published: August 2019

This chapter describes a case of alternating leg muscle activation (ALMA) followed by discussion of this condition and the related hypnagogic foot tremor (HFT). HFT and ALMA are benign sleep-related movements of unknown etiology, typically found incidentally on polysomnography. Both HFT and ALMA are characterized by bursts of tibialis anterior activity occurring in sequences with an inter-burst interval shorter than found in periodic limb movements in sleep. There is no specific treatment for HFT and ALMA. Rather, treatment should focus on the other comorbid sleep disorders such as obstructive sleep apnea, as HFT and ALMA motor activity associated with respiratory events may be responsive to positive airway pressure therapy. In this chapter the diagnostic criteria and clinical features are summarized, and polysomnographic tracings and video samples are provided.
Whoever Wanted to Catch a Worm, Anyway?
Authors: Hiensch Robert , Shah Neomi
Published: August 2019

Delayed sleep/wake phase disorder (DSWPD) is the most common circadian rhythm disorder. It is characterized by persistently delayed sleep onset and wake times relative to conventional norms. Individuals usually present in young adulthood with symptoms of sleep-onset insomnia, sleep inertia, and excessive daytime sleepiness due to sleep deprivation when societal commitments require significantly earlier than desired sleep and wake times. Sleep quality itself is normal. The diagnosis can usually be made by history and sleep diaries. The exact cause of DSWPD is unknown, but genetics, abnormal circadian physiology, and perpetuating behaviors all contribute. Treatment consists of morning phototherapy and evening melatonin at times individualized to the patient’s circadian rhythm. Strict adherence to standard sleep hygiene practices increases the chance of success.
Stimulation Ultimately Prevails
Authors: Kominsky Alan , Waters Tina E.
Published: August 2019

This chapter discusses the role of neuromodulation in the treatment of obstructive sleep apnea (OSA). Various forms of hypoglossal nerve stimulation (HNS) have been researched, and one commercially available form of stimulation was approved for treatment of moderate to severe OSA by the U.S. Food and Drug Administration in 2014. Because of the novelty of this treatment and subgroup responsiveness, inclusion and exclusion criteria have been developed. The treatment is reserved for select patients who have been deemed to fail or are intolerant of positive airway pressure therapy. The nature of the therapy requires multidisciplinary care from both otolaryngology and sleep medicine specialists. Of the available outcome data, the therapy is effective at not only reducing the severity of OSA but also improving patient-reported outcomes of daytime sleepiness and quality of life.
Mr. Potato Head
Authors: Foldvary-Schaefer Nancy , Somboon Thapanee , Alsheikhtaha Zahreddin
Published: August 2019

This case illustrates diagnostic challenges in patients with epilepsy and suspected sleep disorders. Specifically, the symptomatic generalized epilepsy Lennox-Gastaut syndrome is an age-related epileptic encephalopathy characterized by developmental delay; multiple seizure types, including tonic seizures in drowsiness and sleep; and generalized slow spike-wave complexes on electroencephalography (EEG). Tonic seizures in sleep can be unrecognized or can be confused with sleep disorders such as sleep apnea. The case demonstrates how to identify generalized epileptic abnormalities and seizures on the limited EEG montage used in routine polysomnography and expanded EEG using the 10-20 system of electrode placement.
“Wakeup” to Reality!
Authors: Grigg-Damberger Madeleine
Published: August 2019

A small-vessel left paramedian pontine ischemic infarction on awakening from sleep in a 74-year-old woman with hypercholesterolemia triggered an evaluation for untreated severe obstructive sleep apnea (OSA). This case illustrates how the clinical presentation of OSA is different in older and younger adults. Older adults with OSA are more likely to report not feeling well rested in the morning, to have higher scores on the Epworth Sleepiness Scale, and to have greater frequency of nocturia. It is important to consider untreated OSA in patients who have ischemic stroke on awakening from sleep. Most strokes occur between 6 a.m. and noon, but strokes during sleep warrant consideration of untreated OSA. OSA is highly prevalent in patients after stroke or transient ischemic attack. OSA is associated with poorer outcomes after ischemic strokes.
Unwanted Overtures by Night, Remorse by Day
Authors: Irfan Muna , Howell Michel J.
Published: August 2019

Sexual behavior in sleep has only recently been recognized as a variant of non–rapid-eye-movement (NREM) arousal parasomnias. This chapter discusses a case of sexsomnia precipitated by obstructive sleep apnea, the ensuing impact on the subject and his bed partner, and evaluation and management strategies. Sexsomnia is suspected to be highly underreported and carries significant physical, psychosocial, and forensic ramifications. Polysomnography with expanded electroencephalography can help identify concurrent sleep disorders and exclude other etiologies such as epilepsy. Treatment of comorbid sleep disorders such as obstructive sleep apnea and sleep deprivation is highly effective in controlling the abnormal sexual behavior. There is a pressing need for research and expansion of current understanding to develop a standardized approach to evaluation and management of sexsomnia.
There Was a Crooked Man Who Could Not Breathe Day or Night
Authors: Jaimchariyatam Nattapong , Aboussouan Loutfi S.
Published: August 2019

Charcot-Marie-Tooth disease (CMT) is the most common hereditary motor and sensory polyneuropathy. Patients with CMT are prone to develop vocal cord palsy, diaphragmatic dysfunction, sleep disorders, and hypoventilation. Sleep disorders in CMT result mainly from comorbid sleep disordered breathing (SDB), including obstructive sleep apnea and sleep-related hypoventilation, and restless leg syndrome. Diaphragmatic dysfunction and pharyngeal neuropathy are the main pathogenetic mechanisms of SDB in patients with CMT. Similar to others, the diagnosis and treatment of SDB in patients with CMT are mainly based on polysomnography and nocturnal noninvasive ventilation, respectively.
The Chicken and/or the Egg?
Authors: Deoras Ketan , Oliver Jonathan , Deoras Mita S.
Published: August 2019

This chapter covers the bidirectional relationship between depression and insomnia. Patients with insomnia are more likely to develop depression; the prevalence of depression in people with comorbid insomnia is almost 10 times greater than in those without insomnia. Conversely, depression itself has sleep disturbance as a symptom 80% of the time. Treatment of comorbid insomnia and depression should aim at treating both conditions. While cognitive-behavioral therapy for insomnia (CBT-i) should always be considered in the treatment of chronic insomnia, instances may arise when medications are required. Sedative–hypnotics derive from a wide variety of classes of medications and may need to be used in conjunction with antidepressants in the depressed insomniac.
Not for the Faint of Heart
Authors: May Anna M. , Mehra Reena
Published: August 2019

This chapter evaluates strategies for obstructive sleep apnea (OSA) testing and discusses the risk for arrhythmia in patients with OSA. Arrhythmia generation has been associated with sleep apnea, and the case presented here highlights that particularly in heart failure, respiratory events can be a ventricular arrhythmia trigger secondary to OSA-related physiologic consequences such as autonomic nervous system fluctuations, intrathoracic pressure alterations, and upregulation of pathways of systemic inflammation. Untreated OSA increases the risk for sudden cardiac death, particularly between midnight and 6 a.m. Individuals with heart failure, even if they do not report sleepiness, should be evaluated for OSA, as nearly half will have this disorder. Limited data suggest that OSA treatment can decrease arrhythmogenesis in heart failure and may be a potential avenue to decrease morbidity in patients with heart failure.
The Curious Incident of the Toddler Who Wakes and Flails in Pain in the Night
Authors: Ievers-Landis Carolyn E. , Rosen Carol L.
Published: August 2019

Difficulty falling asleep and frequent nocturnal awakenings are common sleep problems in young children. These are highly influenced by parent choices about sleep schedules, bedtime routines, and psychosocial factors but are usually very treatable with effective behavioral interventions. Parents may respond with actions that actually end up perpetuating sleep problems based on their beliefs about the nature of the sleep disturbances. Parents may misattribute the sleep disturbance to other medical problems or misinterpret benign sleep disturbances such as confusional arousals. Even if these conditions are ruled out or identified, the learned negative sleep-onset associations can be challenging to alter. Fortunately, children’s sleep habits are amenable to change when caregivers apply empirically supported behavioral sleep medicine strategies. Sleep physicians and psychologists specializing in behavioral sleep medicine can work collaboratively to solve the mystery of complex toddler sleep problems, tailoring parent guidance and behavioral treatments to the individual child and family dynamics.
Terror at Northfield
Authors: Ralls Frank M. , Grigg-Damberger Madeleine
Published: August 2019

This chapter discusses the relationship between a commonly misdiagnosed parasomnia and various precipitating factors. Expertise in differentiating a benign parasomnia from significant medical disorders in adults and children is important, as is the ability to correctly identify and modify predisposing and precipitating factors. The case presented in this chapter illustrates how making a premature decision based on a small piece of information delayed an important diagnosis and increased the risk of further morbidity. The peak prevalence of sleep terrors is 18 months of age, but they may be seen at any age during childhood. When recurrent sleep terrors recur or develop in adults, evaluation for other primary sleep disorders, including sleep apnea, restless legs, shift work, and sleep deprivation, is warranted, and polysomnography is usually indicated. Identifying and correcting precipitating factors may minimize the recurrence of sleep terrors. Treatment of sleep apnea may greatly reduce the frequency of night terrors and other parasomnias.
My Father Went Down the Rabbit Hole
Authors: Ralls Frank M. , Glassheim Elyssa , Grigg-Damberger Madeleine
Published: August 2019

After treatment, this elderly gentleman with apparent depression rapidly became cognitively impaired and began hallucinating, eventually ending up in the psychiatric ward. This case provides insight into the complexities that may arise in the clinical evaluation and pharmacologic management of often-evolving cognitive, behavioral, and sleep-related changes in elderly individuals. This case additionally emphasizes the importance of sleep in emotional and mental stability, as well as the importance of physicians being well versed in the adverse effects of prescribed and over-the-counter medications. Mirtazapine can induce restless legs syndrome and periodic limb movements in sleep, conditions that can fragment sleep and interfere with cognition. Use of pramipexole has been shown to cause compulsive and impulsive behaviors in patients with restless legs syndrome, Parkinson disease, and multiple system atrophy. Donepezil can cause hallucinations in patients, which can be difficult to distinguish from hallucinations caused by dementia or Charles Bonnet syndrome; in these cases, establishing a timeline is integral in discovering the etiology.
Sooner Than Later If Not Right After Stroke
Authors: Dadisman Amy K. , Andrews Noah D. , Mehra Reena , Katzan Irene L.
Published: August 2019

The case involves a patient with interrelated sleep symptoms related to central hypersomnia, restless legs syndrome, and sleep disordered breathing (SDB) occurring after stroke. The prevalence of SDB after stroke has been noted to be very high, up to 70%, and consists of a higher contribution of central sleep apnea compared to the general population. Recurrent stroke is associated with a higher prevalence of SDB compared to first-time stroke. Contributions to SDB as related to stroke do not appear to have consistencies in terms of location and size of stroke. Untreated SDB can also contribute to stroke risk, with mechanisms involving increased systemic inflammation, prothrombotic biochemical markers, and dysfunction of cerebral autoregulation. Although there are post-hoc subgroup data in a randomized controlled trial suggesting reduction in stroke outcomes when SDB is treated with positive airway pressure, overall there are few studies that have rigorously examined the impact of treatment. Hypersomnia can be treated with modafinil and restless legs syndrome may become manifest due to sleep fragmentation.
Cardiovascular System in the Critically Ill Patient
Authors: Ripoll Sanz Juan G. , Jiramethee Norlalak , Diaz-Gomez Jose L.
Published: August 2019

This chapter provides an overview of fundamental pathophysiologic concepts for the diagnosis and management of cardiovascular disorders in critically ill patients. Three major topics are presented: 1) the importance of vascular–cardiac pump coupling as an integrated system, 2) practical considerations of ventricular dysfunction, and 3) systemic vessels as a crucial factor for cardiac output control and fluid responsiveness.
Acute Respiratory Distress Syndrome
Authors: Patch Richard K. , Findlay James Y.
Published: August 2019

Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by acute hypoxemic respiratory failure. Patients with ARDS have pulmonary damage from an acute, usually severe, diffuse inflammatory lung injury that leads to increased vascular permeability and loss of aerated tissue. Mortality from ARDS is estimated to range from 26% to 58%, and in-hospital mortality is high (46.1%) for those with severe ARDS. Survivors have extensive morbidity, including neurocognitive dysfunction, physical disabilities, and psychiatric illnesses such as depression, anxiety, and posttraumatic stress disorder. Lung function may be compromised for as long as 5 years.
Pulmonary Malignancy
Authors: Zaied Ali A. , Johnson Margaret M.
Published: August 2019

Although the number of new lung cancer cases has decreased, most are diagnosed at an advanced stage owing to the asymptomatic nature of the disease. Furthermore, patients may need intensive care admission for paraneoplastic syndromes such as hypercalcemia, Lambert-Eaton myasthenic syndrome (LEMS), syndrome of inappropriate secretion of antidiuretic hormone (SIADH), Cushing syndrome, and superior vena cava syndrome (SVCS). Pulmonary infections must be considered in the differential diagnosis of chemotherapy-related lung toxicity.
Anaphylaxis and Anaphylactic Shock
Authors: Motosue Megan S. , Volcheck Gerald W.
Published: August 2019

Anaphylaxis is a serious allergic reaction that is rapid in onset and potentially fatal. Prompt recognition of the symptoms and institution of treatment are important in management. The lifetime prevalence of anaphylaxis is estimated to be 0.05% to 2% and appears to be increasing. Allergic reactions vary in severity, with the most severe culminating in anaphylactic shock. Common triggers include food, venom, and drugs. Triggers for events vary by age. Among children and young people, food is a common trigger; among middle-aged and older people, medications and venoms are common triggers. Neuromuscular blocking agents, antibiotics, and latex are the most common causes of anesthesia-associated anaphylaxis. This chapter briefly discusses the background, diagnosis, and management of anaphylaxis.
Acute Coronary Syndrome
Authors: Ketha Siva S. , Moreno Juan Carlos Leoni
Published: August 2019

Acute coronary syndrome (ACS) encompasses all clinical manifestations caused by active myocardial ischemia and includes 3 entities: unstable angina (UA), acute non–ST-segment elevation myocardial infarction (NSTEMI), and acute ST-segment elevation myocardial infarction (STEMI). Atherosclerotic plaque rupture is the most consistent pathophysiologic event in ACS. After plaque rupture, cardiac myocytes die as a consequence of continued occlusion, thereby causing acute myocardial infarction (MI). Prompt recognition of ACS is crucial because the greatest therapeutic effect is achieved if treatment is performed soon after presentation.
Panhypopituitarism
Authors: Donegan Diane , Bancos Irina
Published: August 2019

Hypopituitarism is defined as a deficiency in 1 or more pituitary hormones. The pituitary gland is composed of the anterior pituitary, which originates from an invagination of the oral ectoderm and forms the Rathke pouch, and the posterior pituitary, which is derived from the neural ectoderm of the diencephalon. The anterior pituitary is composed of 5 types of hormone-producing cells: Somatotrophs produce growth hormone; gonadotrophs, follicle-stimulating hormone and luteinizing hormone; thyrotrophs, thyrotropin; 4 lactotrophs, prolactin; and corticotrophs, corticotropin. Identification of hypopituitarism is important because of its association with premature death due to respiratory and cardiovascular complications.
Thyroid Disorders in the Intensive Care Unit
Authors: Moss John E.
Published: August 2019

Thyroid disorders are relatively uncommon among patients in the intensive care unit (ICU) but may lead to serious morbidity and death. A working knowledge of these disorders is essential to their recognition and treatment, and an intensivist should be able to recognize and treat the 3 most common thyroid disorders in the ICU: myxedema coma, thyroid storm, and euthyroid sick syndrome.
Acute Liver Failure
Authors: Findlay James Y. , Wijdicks Eelco F. M.
Published: August 2019

Acute liver failure (ALF) is an uncommon condition in which an acute insult results in a rapid deterioration of liver function, encephalopathy, and coagulopathy in the absence of prior underlying liver disease. It is differentiated from rapid deterioration in the setting of underlying liver disease (acute on chronic liver failure) and from the gradual deterioration in liver function that can occur in chronic liver failure.
Acid-Base Disorders
Authors: Demirci Onur
Published: August 2019

In the human body, many essential cellular processes, such as transmembrane transport and metabolic pathways, are extremely pH sensitive. Normally, systemic acid-base equilibrium is tightly controlled with an arterial pH between 7.35 and 7.45. However, because of acid production, the intracellular pH is usually slightly lower, at 7.0 to 7.2, a value closer to a neutral pH of 6.8 at 37°C. In practice, though, intracellular pH is neither measured nor directly treated. Because of the ease of measuring the pH of the blood with an arterial blood gas test, we, as clinicians, treat disturbances of acid-base hemeostasis of this extracellular compartment.
Disorders of Water and Electrolyte Balance
Authors: Zaw Yuzana , Keddis Mira T.
Published: August 2019

This chapter describes the physiology of water balance; disorders of hyponatremia and hypernatremia and the approach to their evaluation, diagnosis, and treatment; and disorders of electrolyte imbalance, including those of potassium, calcium, phosphorus, and magnesium.
Rheumatologic and Autoimmune Emergencies
Authors: Krause Megan L. , Moder Kevin G.
Published: August 2019

Rheumatologic emergencies are overall very rare. However, when they do occur, they must be recognized quickly to prevent severe morbidity and mortality. Examples are acute arthritis, catastrophic antiphospholipid antibody syndrome, giant cell arteritis, and transverse myelitis.
Cardiac Pacing in the Intensive Care Unit
Authors: Schleifer J. William , Mookadam Farouk , Ramakrishna Harish
Published: August 2019

Patients with pacemakers and implantable cardioverter-defibrillators are commonly encountered in the intensive care unit. Knowledge of device function and indications for device implantation and extraction are required for safe perioperative and critical care management.
Clinical Management of Heart Transplant Recipients
Authors: Sadiqi Arzoo , Jahanyar Jama
Published: August 2019

The challenges of managing heart transplant recipients postoperatively relate to right ventricular failure, immunosuppression, and the unique physiology of the donor heart. Clinical management of heart transplant recipients requires a multidisciplinary team approach with a coordinated effort between intensivists, cardiac surgeons, heart transplant cardiologists, and infectious disease specialists.
Clinical Management of Kidney Transplant Recipients
Authors: Onigkeit James A.
Published: August 2019

Kidney transplant is common. More than 19,000 kidney transplants were performed in the United States in 2017. About two-thirds were deceased donor transplants, and about one-third were living donor transplants. The clinical management of a kidney transplant recipient begins in the operating room. Posttransplant complications can be divided into 2 categories: surgical and medical.
Small Intestinal Transplant
Authors: Sen Ayan
Published: August 2019

Intestinal transplant (ITx) is becoming a valid option for patients with intestinal failure who are receiving long-term parenteral nutrition and have associated complications. Since then the number of intestinal transplants performed in the United States has increased dramatically (from 5 in 1990 to 146 in 2016). Furthermore, 1-year graft and patient survival rates are similar to those for solid abdominal organ transplants (up to 80%). Short gut syndrome and functional bowel problems are the most common clinical conditions leading to intestinal failure and subsequent eligibility for ITx.
Serotonin Syndrome
Authors: Gobeske Kevin T. , Wijdicks Eelco F. M.
Published: August 2019

Serotonin syndrome affects the central nervous system, the autonomic nervous system, and the neuromuscular system and can have acute and potentially life-threatening manifestations. By definition, serotonin syndrome is associated with changes in serotonin exposure and thus might be described more accurately as serotonergic excess or serotonin toxicity. The central nervous system effects of serotonin involve regulation of attention, arousal, mood, learning, appetite, and temperature.
Aneurysmal Subarachnoid Hemorrhage
Authors: Lanzino Giuseppe , Pira Biagia La
Published: August 2019

The term subarachnoid hemorrhage (SAH) refers to extravasation of blood into the subarachnoid space. The term spontaneous is used to distinguish causes other than traumatic. The characteristic SAH pattern of most aneurysmal causes is SAH blood around the basal cisterns or around the circle of Willis. This chapter focuses on aneurysmal SAH (aSAH) related to rupture of an intracranial aneurysm. A medical and neurosurgical emergency, aSAH is associated with a 1-month mortality as high as 40%, and survivors have considerable morbidity and persisting neurologic deficits. Early recognition and management of aSAH are critical to optimizing outcomes.
Intracranial Arteriovenous Malformations
Authors: Flemming Kelly D. , Link Michael J.
Published: August 2019

Intracranial arteriovenous malformations (AVMs) are a type of intracranial vascular malformation that consists of an abnormal connection of arteries and veins without intervening capillary beds. AVMs may come to medical attention because of seizure, intracranial hemorrhage, or incidental radiographic findings in a patient undergoing brain imaging for a different indication. This chapter focuses on the epidemiology, natural history, diagnosis, and management of intracranial AVMs.
Traumatic Epidural and Subdural Hematomas
Authors: Maloney Patrick R. , Clarke Michelle J.
Published: August 2019

Traumatic brain injury is a broad topic and encompasses a spectrum of pathophysiologic disorders that result in increased intracranial pressure (ICP), cerebral edema, bleeding, mass effect, cerebral herniation, and death. Traumatic epidural hematoma (EDH) and subdural hematoma (SDH) are the focus of this chapter. EDH and SDH are intracranial blood collections that have mass effect within the intracranial vault (Figure 88.1) for which operative and nonoperative management criteria are established.
Encephalitis
Authors: Aksamit Allen J.
Published: August 2019

Encephalitis is an inflammatory process affecting the parenchyma of the brain, most commonly diffusely, and therefore leading to a clouding of consciousness early in its course. At a gross pathologic level, encephalitis is generally nonpurulent and is distinguished from cerebritis, which tends to be overtly purulent on gross inspection. Encephalitis is the preferred term for viral or autoimmune inflammation of the brain.
Brain and Spine Tumors
Authors: Sattur Mithun , Welz Matthew E. , Bendok Bernard R.
Published: August 2019

Despite advances in imaging methods, neurosurgical techniques, adjuvant radiation, radiosurgery, and chemotherapy, neurocritical care of the patient with neuraxial tumors is an important component of care. Treatment of these tumors may include management of refractory (often focal) seizures and treatment of mass effect and shift from associated edema. This chapter outlines the important pathophysiologic concepts behind the clinical presentation, neurosurgical management, and perioperative intensive care of patients who have these tumors.
Central Line Placement
Authors: Will Nicholas D. , Beam W. Brian
Published: August 2019

Central venous catheter placement is one of the most commonly performed procedures in the intensive care unit. Common indications for central venous catheter placement include the need for vasoactive or caustic medication infusions, vascular access in patients with poor peripheral veins, long-term access for intravenous medications, infusion of parenteral nutrition, hemodynamic monitoring, transvenous cardiac pacing, and access for hemodialysis or plasmapheresis. There are no absolute contraindications to central venous catheter placement because it is a potentially lifesaving intervention, but careful planning and site selection are warranted in some cases, such as a patient with a known coagulopathy.
Lumbar Drain
Authors: Van Gompel Jamie J.
Published: August 2019

Lumbar drainage has a major role in neurosurgical and neurocritical care procedures. Lumbar drain insertion is a simple and, when done well, low-risk procedure. A lumbar drain is often necessary in the management of perioperative cerebrospinal fluid (CSF) leaks, the most common use, but it may be beneficial for patients with subarachnoid hemorrhage and communicating hydrocephalus and for patients undergoing surgery involving the aorta with possible damage to the spinal cord. CSF removal optimizes spinal cord blood flow. This chapter describes lumbar drain insertion and some of the associated perils and pitfalls.
Essentials of Multimodal Brain Monitoring
Authors: Fugate Jennifer E.
Published: August 2019

Intensive care unit (ICU) clinicians spend a substantial amount of time monitoring patients and their organ systems. Staples of systemic monitoring include continuous electrocardiography, pulse oximetry, serum laboratory values of liver and kidney function, urinary output, and ventilator parameters. Monitoring methods for the brain have lagged somewhat in technologic advances. Neuroimaging is essential to supplementing the clinical examination, and the technology has become increasingly sophisticated.
Common Neurosurgical Procedures
Authors: Hines Kevin , Tjoumakaris Stavropoula , Jabbour Pascal M. , Rosenwasser Robert H. , Gooch M. Reid
Published: August 2019

Medical management of the neurosurgical patient can be complicated. These patients may suffer from a difficult neurosurgical pathology while still living with challenging comorbidities. As a result, this population often requires cooperation between multiple teams including neurosurgeons, neurologists, neurointensivists, and hospitalists. In this chapter, the authors review common neurosurgical procedures that the neurohospitalist encounters, including ventriculoperitoneal shunting, craniotomy and craniectomy, cervical spine decompression with or without fusion, lumbar spine decompression and/or fusion, and cerebral angiograms. The authors aim to highlight the methodology, indications, and issues of perioperative medical management. Understanding these procedures is vital to minimizing adverse events and providing the best possible care for neurosurgical patients.
Blood Glucose Management in the Neurosurgical Patient
Authors: Furlong Kevin , Villuri Satya
Published: August 2019

It is well established that both hyperglycemia and hypoglycemia are important markers for poor outcomes and increased inpatient mortality in both critically ill and general floor patients. Similar, hyperglycemia and hypoglycemia are associated with adverse outcomes in neurosurgical patients. However, the presence of central nervous system injury and its treatment result in significant differences in various aspects of blood glucose management in these patients compared to the general patient population. The purpose of this chapter is to give a brief overview of blood glucose management before, during, and after neurosurgery. Particular emphasis is placed on blood glucose goals in the different inpatient settings, management of blood glucose levels in patients taking glucocorticoids, and the role of nutrition in blood glucose management.
Rehabilitation Medicine in the Neurosurgical Patient
Authors: Harrop Catriona M. , Gustafson Kristin , Maddula Swathi , Bresnehan James , Koehler Philip
Published: August 2019

The rehabilitation of the patient with neurologic injury encompasses a vital role in the recovery process for the patient. As hospitalists, it is essential that we understand the post-acute care needs of the neurologically injured patient, so that we can better prevent and treat sequela of neurologic injury. The chapter is split into two parts, addressing separately patients with brain injury and patients with spinal cord injury. Among the issues discussed are sleep disturbance disorders; musculoskeletal disorders; cardiovascular, respiratory, and GI disorders; urological disorders; nutrition; endocrine disorders; skin-related problems such as pressure injury, and bone-related disorders such as heterotopic ossification (HO).
Introduction
Authors: Klugman Craig M. , Lamb Erin Gentry
Published: August 2019

This introduction offers a definition of the growing field of health humanities. Emerging from medical humanities, whose primary focus has been on the physician and patient relationship, health humanities is a larger enterprise; it studies health, which is broader than just medicine, within its sociocultural context, which reflects the historical biases of cultures. Practitioners come to health humanities with diverse disciplinary training, and thus research methods vary broadly within the field. What unites these methods, and the field, is a focus on applied research driven by shared values, particularly a commitment to social justice. Health humanities is a transdisciplinary field, wherein much research aims to engage external stakeholders in the research itself, and to translate the results of that research back to those stakeholders in beneficial ways. The chapters of this volume represent only some of the diverse methods of research within health humanities, but will allow the reader to sample and practice several different modes of health humanities inquiry.
Pain Catastrophizing and Anxiety
Authors: Darnall Beth
Published: August 2019

The optimization of perioperative patients involves targeting the modifiable individual factors that influence pain, function, and surgical outcomes. However, many untapped opportunities exist, particularly in the psychological realm. Indeed, psychological factors—including pain anxiety and pain catastrophizing—are among the most influential perioperative factors yet rarely are targeted in the perioperative timeframe. To date, research has largely focused on the characterization of behavioral risk factors that associate with or predict poor surgical outcomes, whereas fewer perioperative studies and programs have focused on perioperative interventions. As such, interventions that effectively address the highest-yield targets may meaningfully improve perioperative care and favorably alter the long-term trajectory of health after surgery. This chapter aims to elucidate key research to date for pain anxiety and pain catastrophizing and underscore their importance as therapeutic targets in the perioperative timeline; it also reviews data on their malleability and responsivity to intervention, and highlights promising relevant clinical programs.
Preoperative Nutritional Management
Authors: McAnally Heath B.
Published: August 2019

Malnutrition in the developed world generally comprises both excess of calories with poor macronutrient (carbohydrate—protein—fat) proportioning, and deficit of multiple micronutrients (vitamins, minerals, and phytonutrients). These excesses, deficits, and imbalances all confer health risks, and many are associated with the development of systemic inflammation and chronic pain. In the perioperative context, malnutrition is also associated with suboptimal surgical outcomes; from a nutrient deficiency standpoint, compromised wound healing and increased incidence of infections are seen. From a caloric excess standpoint, obesity confers markedly increased perioperative morbidity and mortality. Most of the evidence-based literature supports the use of so-called immunonutrition preoperatively in populations at risk. As with all of the lifestyle modification issues discussed in this book, enhancement of patients’ intrinsic motivation and thoughtful identification and replacement of maladaptive habits with better alternatives are of the essence.
Organization of services
Authors: Sivan Manoj , Phillips Margaret , Baguley Ian , Nott Melissa
Published: August 2019

This chapter discusses the organization of rehabilitation services. It starts with the principles of comprehensive delivery and organization of services, and then outlines the merits and drawbacks of different systems. Regional services can offer a range of specialist outpatient resources that are not available on the local level. Local services should deliver all standard post-acute inpatient rehabilitation, and there may be an advantage to create a dedicated united working from a physical base. Early supported discharge services can bridge the gap between inpatient and community services, with outpatient and community services providing longer term rehabilitation. Finally, community-based rehabilitation in developing countries is discussed.
History and examination
Authors: Sivan Manoj , Phillips Margaret , Baguley Ian , Nott Melissa
Published: August 2019

This chapter describes the principles of taking a history, an essential part of a comprehensive assessment of an individual by a rehabilitation physician, including presenting complaints; assessment of body function, activities, and participation; past medical and functional history; review of symptoms; personal and environmental history; and the individual’s perception of their condition. The approach taken in eliciting a history in rehabilitation settings is unique in that there is equal emphasis on understanding the impact of any illness on body function, activities, and participation in the context of that particular individual in the unique environment they live in. Describing examination of the neurological system and musculoskeletal system, the chapter provides details of how to design a rehabilitation plan, and methods for successful implementation.
Rehabilitation assessment and evaluation
Authors: Sivan Manoj , Phillips Margaret , Baguley Ian , Nott Melissa
Published: August 2019

This chapter describes assessment procedures in rehabilitation medicine. Covering initial, ongoing, and outcome assessment, it also describes different types of assessment measures (including descriptive, discriminative, predictive, evaluative assessments) and their specific suitability in different circumstances. Critical appraisal of different assessment tools are covered as well as assessment within the International Classification of Functioning and Health (ICF) framework, which provides a framework that describes a person’s health status as the interaction between three domains: body functions and structures, limitations in activity execution or performance, and restriction of participation. Rasch Analysis as applied to outcome measures in rehabilitation medicine is then explained. Acknowledging that rehabilitation is a complex intervention including a multidisciplinary team, sensible approaches to goal setting, and attainment are discussed.
Sexual function
Authors: Sivan Manoj , Phillips Margaret , Baguley Ian , Nott Melissa
Published: August 2019

This chapter starts by defining different aspects of sexuality and sexual health, and exploring the biopsychosocial model of sexual function. Male and female physiologies are illustrated, and the psychology of sexuality is described in the context of rehabilitation post disability. The PLISSIT model for managing and exploring sexual problems is described, with examples of how to manage conversations with patients. Both male and female fertility and sexual function are described, including methods of overcoming erectile dysfunction and problems with ejaculation. Hyper- and hyposexuality and the promotion of a good quality of life in sexual rehabilitation are discussed.
Technical aids and assistive technology
Authors: Sivan Manoj , Phillips Margaret , Baguley Ian , Nott Melissa
Published: August 2019

The purpose of this chapter is to explain key terminology and considerations in the provision of assistive technology. Assistive solutions are individualized, tailored combinations of assistive devices and services and have the potential to enable people to engage in their chosen life roles. Generic principles and selection processes are explored to support decision-making and provide a foundation for assistive technology practice. Developments in everyday technologies are also highlighted to illustrate their increased potential to be used by a wider range of people. Within this chapter, examples of digital assistive technology are provided to illustrate key features and considerations in the assistive technology process. Assistive technology principles, however, can be applied to both low- and high-tech assistive products.
Muscle disorders
Authors: Sivan Manoj , Phillips Margaret , Baguley Ian , Nott Melissa
Published: August 2019

There are a wide variety of inherited muscle conditions that result in disability and thus a need for rehabilitation. This chapter covers some of the commoner muscle conditions seen by the rehabilitation physician, such as acquired myopathies, systemic disease, Duchenne muscular dystrophy, alongside their more frequent impairments. As with many of the conditions described in this handbook, the general principles of rehabilitation apply and more detailed information given in other chapters remains relevant for specific activity limitations and participation restrictions.
Cognitive Dysfunction as a Symptom Dimension Across Major Psychiatric Disorders
Authors: Pan Zihang , McIntyre Roger S.
Published: August 2019

Cognitive dysfunction is a symptom domain across multiple psychiatric disorders. Cognitive deficits in individuals with major depressive disorder (MDD) and bipolar disorder (BD) are significant contributors to global occupational and functional disability. The subdomains of learning and memory, executive function, processing speed, and attention and concentration are significantly impaired in individuals with MDD and BD. Treatment outcomes of cognitive symptoms with first-line agents have been suboptimal. Neuroinflammatory pathways are hypothesized to play key roles in the pathoaetiology of cognitive symptoms in MDD and BD. There is compelling evidence to suggest that elevation of systemic proinflammatory cytokines is involved in neurotoxicity, apoptosis, and aberrant neurocircuit function. These substrates offer opportunities to identify relevant biomarkers, refine treatment targets, and manage cognitive deficits across major psychiatric illnesses. This chapter provides an overview of cognitive symptoms across MDD and BD and discusses potential neurobiological substrates contributing to cognitive dysfunction.
Understanding of Self and Others: Neurobiological Underpinnings of Social Cognition
Authors: Goer Franziska K. , Elliott Rebecca
Published: August 2019

This chapter examines the processes underlying interpersonal interactions in both healthy control individuals (HC) and those with major depressive disorder (MDD). The chapter focuses on four key types of social cognition that give rise to the intricate and dynamic nature of human social functioning, including self-referential processing, other-processing (‘theory of mind’), moral emotion, and social decision-making. It reviews studies investigating the neural substrates of social cognition in HC and MDD, most commonly using functional magnetic resonance imaging. Key brain areas identified include prefrontal cortex (PFC; including, most prevalently, the orbitolateral, medial–lateral, and dorsolateral PFC), temporal–parietal regions (in relation to theory of mind), and subgenual anterior cingulate cortex (in relation to both specific moral emotions, such as guilt, and moral content more generally).
Can Non-Pharmacological Antidepressant Treatments Influence the Processing of Affective Information?
Authors: Kaltenboeck Alexander , Harmer Catherine
Published: August 2019

Depressive disorders are commonly associated with abnormalities in affective cognition. When processing information with emotional content, the depressed brain typically exhibits mood-congruent negative biases; that is, an abnormal preference for negative relative to positive information. In turn, recent psychopharmacological research has revealed that antidepressant drug treatments have the ability to push affective information processing more towards a preferential processing of positive information. These observations have led to the postulation of a cognitive neuropsychological model of antidepressant treatment action. This model suggests that negative biases play an important causal (rather than just epiphenomenal) role in the development of depressed mood and efficacious antidepressant interventions exert their clinical effects by acutely counterbalancing these cognitive abnormalities. In this chapter, we extend the focus to non-pharmacological treatments for depression and ask whether they too can influence affective cognition, and, if so, what these effects look like. We highlight recent studies investigating how cognitive behavioural therapy, electroconvulsive therapy, transcranial direct current stimulation, and environmental therapeutics impact on affective information processing in patients with depression. We show that, for each of these treatments, at least some evidence exists that suggests an influence on affective cognition and that in some cases the observed effects are directly in line with the cognitive neuropsychological model. However, as will become clear, the currently available evidence is rather sparse and, in many regards, incomplete. We therefore conclude that—similar to antidepressant drugs—non-pharmacological treatments can also influence affective information processing in patients with depression. However, whether these changes can counterbalance negative biases, and whether they are causally involved in the clinical effects of the different treatments, remains to be elucidated by future research.
Temporomandibular joint surgery
Authors: Breeze Johno , Parmer Sat , McLeod Niall
Published: August 2019

This chapter contains eight clinical vivas on the subject of temporomandibular joint surgery. This will provide candidates sitting the vivas component of the Oral and Maxillofacial Surgery FRCS examination with practical knowledge in the assessment of temporomandibular joint conditions such as ankylosis, recurrent dislocation, as well as treatment such as joint replacement, arthroscopy, and arthrocentesis. It will also provide insight for clinicians in allied specialties, such as otolaryngology and plastic surgery, in how to engage in a debate with a senior clinician in the contemporary management of such complex cases.
Aesthetics
Authors: Breeze Johno , Parmer Sat , McLeod Niall
Published: August 2019

This chapter contains eight clinical vivas on the subject of aesthetic facial surgery. This will provide candidates sitting the vivas component of the Oral and Maxillofacial Surgery FRCS examination with practical knowledge in the assessment of aesthetic conditions such as a dorsal nasal hump of prominent ears. It will also focus on types of treatment such as fillers, lasers, or a brow lift. It will also provide insight for clinicians in allied specialties, such as otolaryngology and plastic surgery, in how to engage in a debate with a senior clinician in the contemporary management of such complex cases.