bluuebunny/crossref_metadata_2025 huggingface dataset:
Laboratory Tests in Rheumatic Disorders
Authors: Schur Peter H.
Published: July 2014

Chapter 28 discusses acute-phase response, which is a major pathophysiological phenomenon that accompanies inflammation. The acute-phase response accompanies both acute and chronic inflammatory states. It can occur in association with a wide variety of disorders, including infection, trauma, infarction, inflammatory arthritides, and various neoplasms. Acute-phase proteins are defined as those proteins whose plasma concentrations change by at least 25% during inflammatory states. These changes largely reflect their production by hepatocytes.
Venous Thromboembolic Diseases
Authors: Piazza Gregory , Goldhaber Samuel Z.
Published: July 2014

This chapter reviews the pathophysiology of VTE, including its risk factors and long-term consequences. Diagnostic algorithms that integrate clinical findings, laboratory testing, and imaging are described. The role of risk stratification for identification of high-risk PE patients is highlighted. Options for the management of VTE are reviewed. Finally, practical recommendations for the prevention of VTE are provided.
Sleep Apnea
Authors: Kirsch Douglas B. , Epstein Lawrence J.
Published: July 2014

More has been learned about sleep in the last 60 years than in the preceding 6000 years, to paraphrase one sleep researcher, and sleep apnea is an area in which knowledge growth has been particularly exponential. In the last several decades, sleep specialists have learned how to study sleep, subdividing it into stages based on the sleep-related changes in the electroencephalogram (EEG), eye movements, and muscle tone. Additional measurements of airflow, respiratory effort, limb muscle movements, electrocardiogram (EKG), and oxygen saturation allow a full characterization of the changes and problems that occur during sleep. The process of studying physiological parameters during sleep, called polysomnography, has allowed sleep specialists to better understand the nocturnal rhythms of sleep and identify disruptors, one of the most common being obstructive sleep apnea (OSA). This chapter covers the epidemiology, pathophysiology, evaluation, and treatment of this common chronic disorder and its significant long-term effects on patient's well-being and health.
Sepsis Syndrome
Authors: Englert Joshua A. , Baron Rebecca Marlene
Published: July 2014

Sepsis is a clinical syndrome characterized by systemic inflammation leading to tissue injury that arises as a complication of an infection. According to current paradigms, sepsis arises as a result of the infection of a normally sterile body compartment. Infection leads to activation of the innate immune system to produce a systemic inflammatory response. This response is a necessary component of the body's defense against infection under normal conditions, but it is the lack of regulation of this response that is central to the pathogenesis of sepsis. As discussed in more detail below, this dysregulated inflammatory state can lead to tissue injury and dysfunction in organs not involved in the original infectious insult. Although sepsis remains a condition with exceedingly high morbidity and mortality, recent early management and treatment strategies have demonstrated exciting improvements in overall outcomes.
Hemodynamic Monitoring in the ICU
Authors: Kritek Patricia A.
Published: July 2014

Hemodynamic monitoring is a central part of the care of many patients in the intensive care unit (ICU). The most invasive form of hemodynamic monitoring is a pulmonary artery catheter (PA catheter), often referred to as a Swan-Ganz catheter after its coinventors Jeremy Swan and William Ganz. More commonly, a patient's central venous pressure and arterial pressure will be monitored via a central venous catheter and an arterial line, respectively. There are limited data that use of hemodynamic monitoring impacts mortality of critical patients. In fact, the use of PA catheters has been a subject of great debate for nearly four decades. That being said, many intensivists believe the data from these devices contribute to better management of patients in the ICU and can have a role in diagnosing certain life-threatening conditions. The majority of this chapter focuses on the use of pulmonary artery catheters including their potential roles in the ICU, the placement of these devices, the measurements they provide, and the subsequent interpretation of these data.
Arterial Blood Gases
Authors: Richards Jeremy B. , Roberts David H.
Published: July 2014

An arterial blood gas (ABG) provides clinically useful information about an individual's acid–base status, the partial pressure of arterial carbon dioxide, the partial pressure of arterial oxygen, and the arterial oxygen saturation. Hypoxia, dyspnea, or suspected acid–base disturbance are clear indications to check an ABG. Altered mental status, critical illness, and acute respiratory distress syndrome (ARDS) are specific clinical syndromes or presentations that warrant checking an ABG.

An ABG is helpful in evaluating pulmonary pathophysiology as the presence and severity of hypoxia and/or hypercapnia can be quantified. Because an ABG can rapidly provide information about oxygenation, ventilation, and acid–base status, ABGs are particularly useful and common in the critical care setting.
Pulmonary and Critical Care Medicine Summary
Authors: Kritek Patricia A.
Published: July 2014

Chapter 45 discusses pituitary disorders, including lesions, adenomas, gonadotropin and tsa-adenomas, genetic syndromes, ACTH deficiency, TSH deficiency, LH and FSH deficiencies, and prolactin deficiency.
Thyroid Disease
Authors: Kim Matthew
Published: July 2014

This chapter reviews the evaluation and etiologies of amenorrhea with a special emphasis on hypothalamic amenorrhea (HA) and polycystic ovary syndrome (PCOS).
Reproductive and Androgenic Disorders
Authors: Yialamas Maria A.
Published: July 2014

The adrenal gland consists of the cortex and medulla. The adrenal cortex secretes three classes of steroid hormones: glucocorticoids, mineralocorticoids, and androgens. The outer zona glomerulosa secretes the mineralocorticoid aldosterone, which performs a key role in the maintenance of blood pressure, vascular volume, and potassium homeostasis. The central zona fasciculata produces cortisol, which is crucial in the stress response and controls intermediary metabolism and immune functions. The inner layer, the zona reticularis, produces androgens, which serve as precursors of testosterone and androstenedione; they play a role in the development of secondary sexual characteristics in females.
Diabetes Mellitus: Control and Complications
Authors: Wexler Deborah J. , Nathan David M.
Published: July 2014

Metabolic syndrome (MetS), also referred to as the insulin resistance syndrome or syndrome X, refers to a constellation of metabolic abnormalities that tend to cluster together and lead to a substantial increase in risk of atherosclerotic cardiovascular disease (CVD). Although manifestations of MetS have been recognized since the 1920s, it was first described as a syndrome by Gerald Reaven in 1988. The most commonly used definition of MetS in the United States is the one proposed by the National Cholesterol Education Program's Adult Treatment Panel III (NCEP ATPIII). The definition was first published in 2001 and then updated in 2004 (see table 52.1); however, there are other definitions as well (see table 52.2). Most definitions include insulin resistance (IR) or abdominal obesity as the essential criterion. The NCEP definition does not require the presence of IR or obesity as an essential criterion. However, most individuals diagnosed with MetS according to the NCEP definition are both obese and insulin resistant.
Endocrine Summary
Authors: McMahon Graham T.
Published: July 2014

Acute renal failure, now referred to as acute kidney injury (AKI), complicates 5–10% of general hospital admissions and is associated with increased morbidity and mortality and prolonged hospitalizations. The definition of AKI varies, but it is usually defined as an increase in serum creatinine concentration of 25–50% above the baseline, a decline in estimated glomerular filtration rate (eGFR) of 25–50%, or the need for renal replacement therapy. It is now recognized that changes in GFR are delayed manifestations of renal injury, and the development of urinary biomarkers may help to identify AKI earlier in the course of injury. The major causes of AKI in hospitalized patients include prerenal causes (~40%), postrenal causes (~5–10%), and intrinsic diseases affecting blood vessels, glomeruli, or tubules. Of the intrinsic causes, tubular disorders (acute tubular necrosis and acute interstitial nephritis) are the most common etiologies, accounting for 40–50% of all causes of AKI. Acute glomerulonephritis and vascular disorders are rare etiologies of AKI in hospitalized patients (〈5%).
Electrolyte Disorders
Authors: Mount David B.
Published: July 2014

The regulation of acid–base balance in the body underlies the importance of pH in a variety of cellular and subcellular biological functions; for example, regulation of protein synthesis and intermediate carbohydrate metabolism are pH-sensitive processes. Clinically, this is apparent by the failure to grow normally in an acidemic environment and explains an increase in anaerobic glycolysis in alkalemia, due to an increase in a rate-limiting step of glycolysis phosphofructokinase-l. pH is important in numerous transport functions across membranes, such as increasing acid extrusion from cells when cellular pH drops. In general, cellular pH is lower than extracellular pH related to the electronegativity within cellular structures. The delivery of oxygen to tissues such as the brain and skeletal muscle is very much dependent on extracellular pH via the shift in the oxyhemoglobin dissociation curve.
Acid–Base Disturbances
Authors: Seifter Julian L.
Published: July 2014

According to projections from the United States Renal Data Service (USRDS), 〉600,000 individuals in the United States will have end-stage renal disease (ESRD) by 2010. The leading cause of ESRD in the United State is diabetes, followed by hypertension. As the care of diabetic patients has improved, particularly in the area of cardiovascular disease, they are living through their cardiovascular complications long enough to develop ESRD. As a consequence, since the inception of the Medicare ESRD program. the dialysis population has gradually become older with increasing numbers of comorbid conditions. Renal replacement therapy in the form of hemodialysis or peritoneal dialysis may serve as a bridge to the best form of renal replacement, renal transplantation. The demand for suitable kidneys for transplantation far exceeds the supply, leaving many patients on dialysis for extended periods of time.
Diarrhea and Malabsorption
Authors: Perencevich Molly L. , Burakoff Robert S.
Published: July 2014

The objective definition of diarrhea is stool weight 〉200 g per day. The more common subjective definition is frequency of defecation that is greater than or equal to three stools per day combined with less-than-normal form and consistency. Diarrhea is also defined by duration. Acute diarrhea is defined as 〈2 weeks in duration, persistent diarrhea between 2 and 4 weeks, and chronic diarrhea more than 4 weeks in duration. In the United States most cases of acute diarrhea are due to infections and are self-limited. Noninfectious etiologies are more common in chronic diarrhea. The evaluation and general management of acute and chronic diarrhea are discussed in this chapter.
Inflammatory Bowel Disease
Authors: Friedman Sonia
Published: July 2014

Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal tract that can affect any site from the mouth to the anus. The two major types of IBD are Crohn's disease (CD) and ulcerative colitis (UC).
Pancreatic Disease
Authors: Brown Alphonso , Freedman Steven D.
Published: July 2014

Acute pancreatitis may be defined as the development of acute inflammation of the pancreas initially localized to the pancreatic parenchyma and interstitium. It is a fairly common condition with an annual incidence of the United States of 80 cases per 100,000 individuals. Within the United States, the annual cost of hospital facilities for the treatment of pancreatic diseases is approximately $3.6–6 billion a year. There is also an annual cost to society of $250 million per year in lost worker productivity associated with hospitalization.
Gastroenterology Board Review Questions
Authors: Mutinga Muthoka L. , Burakoff Robert S.
Published: July 2014

This chapter provides 21 Gastroenterology Board Review Questions.
Hepatology Summary
Authors: Greenberger Norton J.
Published: July 2014

This chapter provides review topics in Gastroenterology and Hepatology.
Adult Congenital Heart Disease
Authors: Kim Yuli Y. , Landzberg Michael J. , Valente Anne Marie
Published: July 2014

Historically, individuals with complex congenital heart disease rarely lived past childhood. Due to tremendous advances in diagnosis and treatment, now 85–90% of children born with congenital heart disease will survive into adulthood. Estimates suggest that over 1 million adults with congenital heart disease currently live in the United States. The number of adults with congenital heart disease (ACHD) is growing by approximately 5% each year. The majority of these patients do not appear to be followed by ACHD specialists. Therefore, it is essential that all physicians familiarize themselves with the unique clinical presentations of these patients, including the anatomy, physiology, and natural history in order to facilitate proper management and referral.
EKG Refresher
Authors: Nohria Anju
Published: July 2014

Despite the emergence of many tools to evaluate cardiac structure and function, the EKG remains an important, if not the most important, test. Th e EKG is crucial for interpretation of cardiac rhythm, conduction system abnormalities, and for the detection of myocardial ischemia. The EKG is also important in the workup of valvular heart disease, cardiomyopathy, pericarditis, and hypertensive disease. Last, the EKG detects electrolyte and metabolic abnormalities that may affect the heart, including disorders of potassium, calcium, and magnesium, and can be used to monitor drug treatment (specifically antiarrhythmic therapy).
Dementia
Authors: Budson Andrew E. , Stark Aleksandra C.
Published: July 2014

Dementia is a decline of cognitive function that eventually impairs the ability to carry out everyday activities. Dementia affects approximately 4–5 million people in the United States to varying degrees. Only approximately 1 in 100 individuals 〈65 years are thought to be affected by dementia, but this proportion reaches as many as one in three individuals age 〉85 years. There are a number common causes of cognitive impairment that are reviewed in this chapter (see table 91.1).
Neurology Board Review Questions
Authors: Henderson Galen V.
Published: July 2014

This chapter provides 20 Neurology Board Review Questions.
Neurology Summary
Authors: Cho Tracey A. , DeCroos Emily Choi , Berry James D. , Singhal Aneesh B.
Published: July 2014

This chapter provides a summary of topics in Neurology.
Women’s Health Board Review Questions
Authors: Saxena Aditi R. , Solomon Caren
Published: July 2014

This chapter provides 18 Gynecology Board Review Questions.
Dermatology for the Internist
Authors: Schalock Peter C. , Sober Arthur J.
Published: July 2014

The most common type of therapy in dermatology is the use of topical medicaments placed directly on affected skin. The main base used for most medicaments is white petrolatum. Ointments, creams, and lotions, whether compounded as a prescription or as an over-the-counter product, are petrolatum based. An ointment has no water added and thus does not need a preservative. A cream simply is petrolatum with added water to make it more cosmetically elegant and more easily rubbed into the skin. A lotion is a cream with even more water. All products with water added require a preservative to prevent bacterial and/or fungal overgrowth plus a masking fragrance. Many of these added chemicals can provoke allergic contact dermatitis (discussed further below). Ointments are the most protective for the skin and the most hydrating although the least accepted by patients due to their greasy nature. Creams are most often used. Other bases include gels, solutions, and foams.
Occupational Medicine
Authors: Tishler Lori Wiviott
Published: July 2014

Occupational injuries are among the leading causes of morbidity and mortality in the United States, and occupational medicine physicians play a role in preventing, recognizing, diagnosing, and treating these illnesses. Yet, many illnesses that can be occupationally related are indistinguishable from other sorts of chronic illness. This chapter provides an overview of occupational medicine with a focus on the occupational history, disability, and worker's compensation.
Approach to the Internal Medicine Board Examination
Authors: Mushlin Stuart B.
Published: July 2014

This chapter is different from the others. Its intent is to concentrate your mind on the American Board of Internal Medicine (ABIM) examination, its purpose, and its likely test scenarios. The ABIM moved to a written rather than oral test in the 1960s. The testing has been extensively validated and is unlikely to change much in its character. Essentially, the ABIM wants to determine if you have the core knowledge in all the disciplines to be an effective and efficient physician. It further wants to discriminate between you and the other test takers so that you can see how you compare with others taking the examination. Many candidates, in their increasing anxiety over the subject matter, lose sight of these major objectives. To pass the examination it is not necessary to regurgitate in photographic detail one of the standard textbooks of medicine or the latest Medical Knowledge Self-Assessment Program (MKSAP) review; however, you should feel that you know the core body of knowledge in all the major medical specialties.
Board Practice 2
Authors: Britton Kathryn , Miller Amy Leigh
Published: July 2014

This chapter contains 25 questions in a Board Practice Test.
General and endocrine examination
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Approaching the physical examination

First impressions

Set-up

General examination

Colour

Temperature

Hydration

Oedema

Nutritional status

Lymph nodes

Hands and upper limbs

Recognizable syndromes

Vitamin and trace element deficiencies

The elderly patient

The endocrine system

Symptoms in endocrinology

The rest of the history

General endocrine examination

Examining the thyroid

Examining the patient with diabetes

Important presentations
Skin, hair, and nails
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Introduction

History

The dermatological history

Hair and nail symptoms

Examination

Examining the skin

Pictorial glossary of terms

Examining a lump

Widespread skin eruptions

Examining an ulcer

The elderly patient

Presenting patterns
The locomotor system
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Introduction

History

Important locomotor symptoms

The rest of the history

Outline locomotor history

Examination

Outline locomotor examination

The GALS screen

Hand

Elbow

Shoulder

Spine

Hip

Knee

Ankle and foot

Important presentations

The elderly patient
The ear, nose, and throat
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Introduction

History

Symptoms of ear disorders

Symptoms of nasal disorders

Symptoms of throat disorders

Examination

Examining the ear

Examining the nose

Examining the nasal sinuses

Examining the mouth and throat

Important presentations
The breast
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Introduction

History

Important symptoms

Examination

Inspection of the breast

Palpation of the breast

Examining beyond the breast

Breast cancer

Other important presentations
The psychiatric assessment
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Approach to the psychiatric assessment

The history (part 1)

The history (part 2)

Risk assessment

Mental state examination

Important presentations

Medical conditions with psychiatric symptoms and signs
Other investigations
Authors: Thomas James , Monaghan Tanya
Published: July 2014

Computed tomography (CT)

Magnetic resonance imaging (MRI)

Barium swallow and meal

Barium follow-through

Barium enema

Endoscopic retrograde cholangiopancreatography (ERCP)

Ultrasound

Oesophagogastroduodenoscopy (OGD)

Colonoscopy

Capsule endoscopy

Exercise tolerance test (ETT)

Echocardiography

Coronary angiography and angioplasty

Bronchoscopy
Critical Illness and Long-Term Outcomes Worldwide
Authors: Adhikari Neill KJ
Published: July 2014

Interest in the global burden of critical illness and its sequelae are growing, but comprehensive data to describe the burden of acute and post-acute illness and the resources available to provide care are lacking. Challenges to obtaining population-based global estimates of critical illness include the syndrome-based definitions of critical illness, incorrect equating of ‘critical illness’ with ‘admission to an intensive care unit’, lack of reliable case ascertainment in administrative data, and short prodrome and high mortality of critical illness, limiting the number of prevalent cases. Estimates of the burden of post-critical illness morbidity are even less reliable, owing to the limited number of observational studies, inaccurate coding in administrative data, and the unclear attributable risk of these morbidities to critical illness. Modelling techniques will be required to estimate the burden of critical illness and disparities in access to critical care using existing data sources. Demands for critical care and post-discharge care for survivors are likely to increase because of urbanization, an ageing demographic, and ongoing wars, disasters, and pandemics, while the ability to assume the cost of increased critical care may be limited due to economic factors. Major public health questions remain unanswered regarding the worldwide burden of critical illness and its sequelae, variation in resources available for treatment, and strategies that are broadly effective and feasible to prevent and treat critical illness and its consequences.
The Overlap of Palliative Care and Critical Illness
Authors: Hope Aluko A , Nelson Judith E
Published: July 2014

Palliative care focuses on control of symptom distress, communication about care goals, alignment of treatment with patients’ values and preferences, transitional planning, and support for both patient and family. Palliative care is a fundamental concept which is relevant throughout the trajectory of critical illness, even in those patients pursuing aggressive treatments to prolong life. This chapter discusses ways in which effective integration of the core elements of palliative care during acute treatment of critical illness may help ICU survivors and their families to prepare for challenges to come. It also addresses approaches for providing palliative care after ICU discharge. Finally, this chapter reviews the respective roles of palliative care specialists and other clinicians in optimizing quality of life for those burdened by the consequences of critical illness.
Caring for the ICU Survivor: The Family Caregiver Burden
Authors: Christopher T Erb , Siegel Mark D
Published: July 2014

Almost fifty million people in the United States provide informal, non-professional supportive care to chronically ill and disabled family members. Survivors of critical illness often depend upon such care for their well-being and recovery. ICU survivors may need help with physical, psychological, and cognitive deficits, often involving many hours of care per day. Families play essential caregiving roles, supporting survivors’ diverse and profound needs, often with minimal outside help. Caregiving can be personally fulfilling, but many families suffer financially, physically, and emotionally as a result of caring for loved ones after critical illness. While some institutional programmes provide direct support to ICU survivors, little infrastructure exists to support the activity of informal family caregivers. Measures are needed to identify caregivers at risk and to develop and provide effective treatments both within and beyond the ICU. Research has begun to elucidate some of the ways in which providers of critical care can identify those at risk of long-term psychological or emotional hardship and suggests strategies to prevent some of the overwhelming sequelae of critical illness among families. More work is needed to provide a deeper and more nuanced understanding of risk factors and preventive strategies for caregiver burden following critical illness. This chapter reviews the burdens of caregiving and suggests ways to help ICU survivors’ families manage the daunting challenge of helping their loved ones recover from life-threatening illness.
Chronic Multiple Organ Dysfunction
Authors: Fischer Kevin M , Carson Shannon S
Published: July 2014

This chapter reviews the clinical syndrome of chronic multiple organ dysfunction (MOD) following acute critical illness. Chronic MOD, also referred to as chronic critical illness, occurs in patients who have survived the acute phase of their illness or injury but remain dependent on life support for weeks or months. This condition presents unique physiologic and metabolic abnormalities distinct from those encountered in the acute illness. These include neuroendocrine and immune dysregulation, ICU-acquired weakness, persistent respiratory failure, and brain dysfunction. The symptom burden for these patients is high, and long-term survival is limited for elderly patients and those for whom MOD persists for weeks. Comprehensive and systematic programmes will need to be designed and implemented involving bundled best-practice interventions in order to reduce the incidence and treat the consequences of chronic MOD.
The Long-Term Outcomes of Acute Kidney Injury
Authors: Wald Ron , Harel Ziv
Published: July 2014

Recent research has provided important insights on the long-term outcomes of patients who develop acute kidney injury (AKI) in the setting of critical illness. Large epidemiologic studies have demonstrated compelling associations between episodes of AKI and progressive kidney disease and death, respectively, although such studies do not establish causality due to the potential for confounding. Whether AKI is intrinsically toxic or a mere by-product of serious comorbidities (e.g. prior chronic kidney disease, heart failure, diabetes), there is no doubt that AKI survivors are a high-risk group who would likely benefit from close post-discharge follow-up. Recent studies have shown that a minority of patients with AKI receive specialized nephrology follow-up after discharge, suggesting an opportunity for quality improvement. Emerging research is evaluating factors that predict chronic kidney disease, end-stage renal disease, and death among AKI survivors. This work will, it is hoped, suggest new targets for prevention and treatment, with the goal of enhancing the likelihood of recovery following AKI.
Consequences of Endotracheal Intubation and Tracheostomy
Authors: Schönhofer Bernd , Kluge Stefan
Published: July 2014

Endotracheal intubation and tracheostomy are associated with a broad spectrum of complications, which are similar and overlapping, and range from injury to airway structures to nosocomial lower respiratory infections. Anatomical damage to the airway occurs as both early and late complications and is generally the consequence of procedural factors: emergency endotracheal intubation, abnormal anatomy, unsatisfactory patient positioning, inexperienced operator skill, and the use of an inadequate technique. Upper airway endoscopy and bronchoscopy, using the flexible and rigid approaches, are useful for the diagnosis and treatment of the complications of endotracheal intubation and tracheostomy.
Depressive Mood States Following Critical Illness
Authors: Bienvenu O Joseph
Published: July 2014

Patients with critical illnesses treated in intensive care units face severe physical and psychic stresses, and survivors often have financial and other burdens. The prevalence of depressive mood states in survivors varies by measure and follow-up time, but the median prevalence across >30 studies was 28% (mostly measured within a year of critical illness). Severe depressive states (e.g. major depressive episodes) are less common than minor depressive states. Risk factors include female sex, lesser educational attainment, unemployment, and medical and psychiatric comorbidity. Potential critical illness/intensive care-related risk factors include severity of organ failure, high-dose benzodiazepine administration, longer ICU stays, stressful ICU experiences, and early post-intensive care distress. Depressive symptoms in survivors are associated with impaired physical function, other psychiatric morbidity, cognitive and work difficulties, and lower health-related quality of life. Research is needed to evaluate the preventive or therapeutic role of psychological interventions during intensive care and psychological recovery programmes.
Introduction: Neuromuscular and Musculoskeletal Disorders Following Critical Illness
Authors: Naeem Ali
Published: July 2014

Chapter 23 provides an outline to neuromuscular and musculoskeletal disorders following critical illness. It describes post-intensive care syndrome in relation to its potential physical effects on a patient’s %uality of life. The connections between mechanical ventilation and ICU ac%uired weaknesses (ICUAW) are explored, as are the wide range of possible physical deficits in ICU patients.
Bone and Joint Disease Following Critical Illness
Authors: Barry Amelia , Trudel Guy
Published: July 2014

Bone and joint processes take second stage to life-threatening organ failure in the setting of critical illness. However, bone and joint disorders can cause significant impairment in survivors of critical illness. Return to pre-admission function is often limited by acquired complications such as joint contractures, heterotopic ossification, and altered bone metabolism. Critical care physicians should maintain a high index of suspicion for joint contractures, as they are often asymptomatic but the source of enduring disability once the critical illness had receded. Research is needed to document the effectiveness of alternate positioning, stretching, and bracing which are the current standard practice for prevention of contractures. Heterotopic ossification should be considered in the context of a swollen, warm, painful musculoskeletal site. Early detection with triple phase bone scan and, in some cases, prophylaxis with non-steroidal anti-inflammatory medication or radiation may be warranted. Bone hyperresorption in ICU patients can be caused by immobility, heightened inflammatory status, medication, hormonal changes, and vitamin D deficiency. Laboratory biomarkers can guide treatment, which is important to prevent long-term osteoporosis and stress fractures. Systematic physical examination and early patient mobilization may represent important steps to detect and prevent joint contractures and heterotopic ossification.
Genetic Determinants of Sepsis Outcomes
Authors: Yende Sachin , Angus Derek C
Published: July 2014

Bone and joint processes take second stage to life-threatening organ failure in the setting of critical illness. However, bone and joint disorders can cause significant impairment in survivors of critical illness. Return to pre-admission function is often limited by acquired complications such as joint contractures, heterotopic ossification, and altered bone metabolism. Critical care physicians should maintain a high index of suspicion for joint contractures, as they are often asymptomatic but the source of enduring disability once the critical illness had receded. Research is needed to document the effectiveness of alternate positioning, stretching, and bracing which are the current standard practice for prevention of contractures. Heterotopic ossification should be considered in the context of a swollen, warm, painful musculoskeletal site. Early detection with triple phase bone scan and, in some cases, prophylaxis with non-steroidal anti-inflammatory medication or radiation may be warranted. Bone hyperresorption in ICU patients can be caused by immobility, heightened inflammatory status, medication, hormonal changes, and vitamin D deficiency. Laboratory biomarkers can guide treatment, which is important to prevent long-term osteoporosis and stress fractures. Systematic physical examination and early patient mobilization may represent important steps to detect and prevent joint contractures and heterotopic ossification.
Critical Illness Neuropathy, Myopathy, and Sodium Channelopathy
Authors: Rich Mark M
Published: July 2014

Skeletal muscle weakness is a common problem that complicates recovery from critical illness. The primary causes of weakness include neuropathic disorders, myopathic disorders, and mixed disorders. Recent studies have demonstrated that reduced excitability of the nerve and muscle cell membranes might contribute to weakness during the acute stages of the polyneuropathy and myopathy encountered in critically ill patients. In both tissues, an acquired sodium channelopathy can lead to increased inactivation of channels, leading to inexcitability an paralysis. Experimental sepsis models have demonstrated a similar reduction in excitability in myocardial cells as well as in motor neurons within the spinal cord. The presence of a channelopathy in multiple tissues raises the possibility that reduced excitability of neurons within the CNS might contribute to septic encephalopathy. If this is the case, a single therapy to improve excitability might treat failure of a number of electrically active tissues.
The Impact of Critical Illness on Skeletal Muscle Structure
Authors: Hough Catherine L
Published: July 2014

Patients with critical illness are at risk of profound weakness and skeletal muscle loss, and recovery is marked by prolonged physical functional impairment in many survivors. Muscle and nerve abnormalities found in critically ill patients include loss of muscle mass, muscle membrane inexcitability, polyneuropathy, mitochondrial dysfunction with bioenergetic failure, as well as changes in skeletal muscle structure. The most common histological abnormalities are atrophy of both type I and II fibres and thick filament loss; muscle necrosis is less common. While recent studies have illuminated the pathogenesis of critical illness myopathy, additional high-quality translational research is needed to identify targets for therapeutic intervention.
Malnutrition in Critical Illness: Implications, Causes, and Therapeutic Approaches
Authors: Heyland Daren K , Mourtzakis Marina
Published: July 2014

Malnutrition is generally defined as an inadequate intake of nutrients or calories for appropriate physiological functioning. Undernourishment specifically refers to hypocaloric intake as well as reduced macro- and micronutrient intakes relative to the calculated recommendation for a patient. This chapter discusses the undernourishment of the critically ill patient and its attendant physiological and clinical consequences. Achieving 80–90% of prescribed protein and calories is both achievable and is associated with the beneficial physiological and clinical outcomes in a significant proportion of patients. Strategies to maximize these benefits as well as minimizing the risk of enteral nutrition are essential. These should include early initiation of enteral nutrition (within 24–48 hours), adoption of second-generation feeding protocols, use of motility agents, small bowel feeding tubes, and elevation of the head of the bed. Given the encouraging results of early mobilization, it could be hypothesized that combining early mobilization and nutrition interventions would limit muscle mass loss and maintain muscle integrity and function in critically ill patients.
Introduction: Therapeutic and Rehabilitation Strategies in the ICU
Authors: Nicholas Hart
Published: July 2014

Chapter 37 provides an introduction to therapeutic and rehabilitation strategies in the ICU, particularly related to sedation and weaning from drugs. It covers how these are intended to reduce muscle wasting and preserve neuromuscular integrity, although more research and trials are needed.
Rethinking Sedation in the ICU
Authors: Galvin Sinead , Burry Lisa , Mehta Sangeeta
Published: July 2014

Analgesic and sedative medications are commonly given to manage pain, anxiety, and delirium in critically ill patients; such agents are also used to facilitate painful procedures and to promote greater tolerance of mechanical ventilation. The manner in which we administer, titrate, and monitor analgesia and sedation in the ICU can have an impact on both short- and long-term patient outcomes. The benefit of sedation strategies that limit drug exposure and promote greater wakefulness and patient interaction has been demonstrated in several randomized trials. The overall objective of sedation in the ICU has changed, such that a calm, comfortable, awake, and interactive patient is the goal. This can be achieved using an individualized, restrictive, goal-directed, and protocolized approach to analgo-sedation. This chapter discusses specific medications for analgo-sedation, administration, and monitoring strategies, and how these strategies relate to delirium in the ICU.
Effects of Insulin and Glycaemic Management on Neuromuscular Function
Authors: Hermans Greet
Published: July 2014

Observational studies have indicated an association between stress-induced hyperglycaemia and neuromuscular complications in critically ill patients. This observation is further supported by electrophysiological findings from two randomized controlled trials which suggested that titrating insulin therapy to achieve a normal blood glucose has a beneficial effect on neuromuscular function, associated with a reduced need for prolonged mechanical ventilation. The underlying pathophysiological mechanisms explaining these clinical observations are not well understood. There is no clear evidence that insulin has anabolic effects on muscle nor that it provides mitochondrial protection. It is possible that the effect of insulin therapy reflects a protective action on peripheral nerves; however, this hypothesis awaits confirmation. Overall, the potential benefits on neuromuscular function must be considered in light of large-scale randomized trials which demonstrate equivalent or worse outcome in critically ill patients managed with intensive insulin therapy.
Assessment of Peripheral and Respiratory Muscle Strength in ICU
Authors: Rafferty Gerrard , Moxham John
Published: July 2014

Skeletal muscle weakness affecting the respiratory and peripheral muscles is common in critically ill patients and can lead to difficulties in weaning, prolonged ICU admission, and significant morbidity in survivors. A number of techniques can be used to assess muscle strength. In the peripheral muscles, volitional techniques employing scoring systems or portable hand dynamometers are relatively simple and quick to use, requiring little or no specialist equipment. Such techniques can, however, only be applied to conscious and cooperative patients, preventing assessment of muscle weakness in many ICU patients. The volitional requirement also limits the ability to distinguish poor motivation and impaired cognition from true loss of muscle function. Non-volitional techniques involving motor nerve stimulation provide measures of muscle force production in non-cooperative patients but require specialist equipment. Normative data for comparative purposes are limited. Also, it is not clear which peripheral muscle best reflects generalized muscle weakness. Measurements of maximal inspiratory and expiratory pressures are widely used to assess respiratory muscle strength in ICU patients and are applicable to patients who can make some respiratory effort. As with all tests requiring patient cooperation, reliability is limited. Phrenic nerve stimulation allows direct, non-volitional assessment of diaphragm and phrenic nerve function, and normative values for comparative purposes are available. Magnetic phrenic nerve stimulation is well tolerated, can be performed in the presence of vascular catheters, and is used to document respiratory muscle weakness and track progression in critically ill patients.
Clinical Pathways for the Continuum of Rehabilitation
Authors: Hoffman Karen , Thomas Amanda , Brett Stephen
Published: July 2014

People who experience major illness or injury commonly are admitted to an intensive care unit, yet it is important to recognize that the intensive care unit is merely one part of a journey from the onset of illness or injury to recovery and subsequent rebuilding of life. This journey is characterized by a number of changes in the level of medical and nursing support, location, team, and often focus of care. These ‘way points’ on this journey to recovery represent opportunities for system failure and loss of key pieces of information. The patient-centred focus on treatment and recovery can be compromised by organizational deficits. What is recognized in many clinical fields is the requirement to assemble a continuum of care which anticipates these way points and minimizes the chances of information loss. These organized processes are termed clinical pathways and can be applied to patients recovering from serious illness or injury characterized by a stay in an intensive care unit. This chapter outlines the rationale and background of this concept and how it might be applied in practice for the benefit of recovering intensive care patients.
Leptospirosis and its complications
Authors: Easom Nicholas , Arnold Amber , Moore David
Published: July 2014

Leptospirosis infection commonly passes unnoticed, as shown by high seroprevalence rates in endemic areas. However, severe disease may rarely occur as exemplified in the case presented here. Complications including pulmonary haemorrhage, jaundice, renal impairment, myocarditis, and uveitis are all possibilities. The differential diagnosis of a returning traveller with pulmonary symptoms and fever are discussed along with the diagnosis, including serology, and management of severe leptospirosis including antibiotic choice.
HIV and prevention of mother-to-child transmission
Authors: Hegazi Aseel , Hay Phillip
Published: July 2014

Mother-to-child transmission (MTCT) of HIV in the UK is now a rare event due to routine screening for HIV in pregnancy, the commencement of antiretroviral therapy, viral load testing, and consideration of the need for caesarean section. However, seroconversion in late pregnancy may occur, as in the case presented. Diagnosis and management of seroconversion in late pregnancy are discussed with particular regard to interventions that have been shown to reduce MTCT. Ways of reducing the viral load rapidly, for example with the use of newer agents like the integrase inhibitor raltegravir, are also discussed.
HIV: opportunistic infections and immune reconstitution
Authors: Dwyer Ellen , Arnold Amber , Macallan Derek
Published: July 2014

A late-stage diagnosis of HIV continues to present considerable management issues due to multiple concomitant pathologies and the immune reconstitution syndrome (IRIS). This chapter presents a case where a patient is diagnosed with late-stage HIV complicated by Mycobacterium avium intracellare (MAI) infection and histoplasmosis. A discussion focusing on unmasking IRIS follows.
Candida infection in the intensive care unit
Authors: Moore Luke , Schelenz Silke
Published: July 2014

This chapter illustrates a classic case of candidaemia occurring in the intensive care setting. The combination of abdominal surgery, central venous line, TPN and broad-spectrum antibiotics are all classic risk factors for the development of Candida bloodstream infection, and dissemination of the yeast to other sites is not unusual. Involvement of the eye is one of the most common infection-related complications, followed by endocarditis and bone or joint infection. However, cerebral abscesses are a rare event in adults. The diagnosis and management of Candida infection (in this case the germ tube negative C. glabrata) is discussed with particular regard to screening for carriage, and testing for susceptibility to and choice of antifungal agents such as fluconazole and echinafungin.
Tropical liver abscess: diagnosis and management
Authors: Eder Marcus , Arnold Amber , Moore Elinor
Published: July 2014

There is a broad differential for a patient returning from the tropics with an infection. Physicians must focus on the timing (i.e. the possible incubation period of the disease), the person (i.e. risk factors for acquiring disease), and the place (i.e. exact geography of travel) to make a realistic differential diagnosis. In this chapter a case of amoebic liver abscess (ALA) in a returning traveller is presented. Diagnosis of ALA and differentiating between amoebic and pyogenic liver abscess is included. The management of amoebic liver abscesses is discussed including the role of antimicrobial therapy, as well as the assessment of fever in a returning traveller.
Severe falciparum malaria: treatment options in the UK
Authors: Eder Marcus , Arnold Amber , Moore Elinor
Published: July 2014

Malaria is the first consideration in any unwell patient who has been in a malaria-endemic area within the last year. A case of severe falciparum malaria is presented here with particular focus on issues related to the treatment and recognition of this condition in the UK. In the UK, poor outcomes come from a delay in the diagnosis; therefore the most important step in improving outcomes is to remember and test for this common tropical disease. Although malaria blood films are the gold standard in diagnosis and give additional information than just the diagnosis, rapid diagnostic tests (RDTs) are extremely useful, particularly in laboratories unfamiliar with looking at a malaria film. It is important to make an assessment of the severity of infection to identify those with a risk of a poor outcome. A discussion focusing on the choice of antimalarial agent for severe malaria infection, including a comparison of artesunate and quinine, follows the case.
Imported Plasmodium vivax
Authors: Wise Emily , Doherty Tom
Published: July 2014

Infection with Plasmodium vivax has traditionally be viewed as ‘benign’. However, severe and complicated infection has increasingly been recognized. Plasmodium vivax has the potential to relapse if the hypnozoite phase is not treated appropriately. A case of travel-related acute and relapsed infection is presented here and the management and diagnosis discussed.
Typhoid fever: antibiotic treatment choices
Authors: Feasey Nicholas , Parry Chris
Published: July 2014

Typhoid fever is caused by Salmonella enterica serovar typhi (S. typhi) and is a common cause of fever in a returning traveller. Treatment options have become more complicated with increasing antibiotic resistance including the emergence of isolates with decreased ciprofloxacin susceptibility. Treatment options include the third-generation cephalosporins and azithromycin. The risk of relapse is considered. A case of typhoid fever in a UK resident is presented and the pathophysiology, diagnosis, and management with particular emphasis on antibiotic choices are discussed.