bluuebunny/crossref_metadata_2025 huggingface dataset:
76 PREDICTIVE MODEL FOR MOBILITY DECLINE: INDIVIDUAL TRIAL MISTAKE THRESHOLDS IN SUSTAINED ATTENTION TO RESPONSE TASK (SART)
Authors: Rizzo R , Knight S , Newman L , Davis J , Duggan E , Kenny R A , Romero-Ortuno R
Published: February 2023

Background

The Sustained Attention to Response Task (SART) is a standard computer-based cognitive test designed to measure the sustained attention, fundamental for completing tasks that require supervision over time (Robertson et al., 1997). However, commonly used average features may result in loss of information and data misinterpretation, leading to inability to detect clinically expected associations (O’Halloran et al., 2014).

Methods

Here, we present a new method to visualise the full information obtained from the SART test, ordering by age, and categorising in groups based on mobility status in a large population-based study of ageing in Ireland. A new threshold, derived from the visualisation and based on the individual trial number of mistakes, was employed to individuate poorer SART performances, and to predict mobility and cognitive decline after 4 years in binary logistic regression models.

Results

Raw SART data were available for 4,864 participants aged 50 years and over at baseline. The new variable bad performances, expressing the number of SART trials with at least 4 mistakes, was the most significant predictor of mobility decline, defined as the transition from Timed Up-and-Go (TUG) < 12 to TUG ≥12 seconds (Odds Ratio (OR) = 1.29; 95% Confidence Interval (CI) 1.14–1.46; p < 0.001), and the only significant predictor of new falls (OR = 1.11; 95% CI 1.03–1.21; p = 0.011) compared to traditional SART variables in models adjusted for multiple covariates. No SART-related variables resulted significant predictors of cognitive decline, defined as a decrease of at least 2 points in the Mini-Mental State Examination (MMSE) score.

Conclusion

This multimodal visualisation and the new threshold approach could help clinicians to easily develop relevant hypotheses, and better identify subjects at higher risk of future mobility decline.
99 ASSESSMENT AND MANAGEMENT OF PAIN IN OLDER ADULTS WITH ACUTE FRACTURE ADMITTED UNDER AN ORTHOPAEDIC SERVICE
Authors: Killeen E , Doyle K , O'Toole R , Doran T , Collins D , Brewer L
Published: February 2023

Background

Older adults with acute fractures often have suboptimal pain control, in particular those with cognitive impairment. Effective pain management improves rehabilitation engagement and earlier discharge from acute care. Our study aimed to evaluate pain management of older adults with acute fracture admitted under an orthopaedic service in a tertiary hospital.

Methods

Prospective review of patients over 65 years with an acute fracture admitted under an orthopaedic service. Review of chart, medication prescription and pain status. Data included type of fracture, comorbidities, cognitive status and analgesia prescribed. Data analysed using Excel.

Results

40 inpatients included. Median age 82 years (range 65-93 years), 70% female. 53% had cognitive impairment, ranging from mild to severe dementia. 75% had >5 regular medications pre-admission. 80% had >5 comorbidities.

Two-thirds (73%) had an acute hip fracture. Most (80%) inpatients had a surgical intervention, the remaining were managed conservatively.

Analgesia prescriptions included paracetamol for almost all patients (95%), non-steroidal anti-inflammatory drugs for 3 (8%) and regular opioids in only 3 (8%).

43% of patients reported pain at time of data collection. 13% had analgesia changed in the 24 hours beforehand. Pain adversely affected function in 205 and mobility in 28%.

2 patients were unable to verbalise pain however no pain scales or visual assessments were used.

Documentation of pain assessment was best by nurses (100%) followed by doctors (60%) and allied health professionals (40%).

Conclusion

Older adults with acute fracture are often multimorbid with cognitive impairment. This patient population are often untreated for pain with suboptimal pain assessment and analgesia review or prescriptions. Consequently we developed a pain policy for use on our orthopaedic service as a guide for effective pain assessment and management for older adults with acute fracture.
MonoNet: enhancing interpretability in neural networks via monotonic features
Authors: Nguyen An-Phi , Moreno Dana Lea , Le-Bel Nicolas , Rodríguez Martínez María
Published: February 2023

Motivation

Being able to interpret and explain the predictions made by a machine learning model is of fundamental importance. Unfortunately, a trade-off between accuracy and interpretability is often observed. As a result, the interest in developing more transparent yet powerful models has grown considerably over the past few years. Interpretable models are especially needed in high-stake scenarios, such as computational biology and medical informatics, where erroneous or biased models’ predictions can have deleterious consequences for a patient. Furthermore, understanding the inner workings of a model can help increase the trust in the model.

Results

We introduce a novel structurally constrained neural network, MonoNet, which is more transparent, while still retaining the same learning capabilities of traditional neural models. MonoNet contains monotonically connected layers that ensure monotonic relationships between (high-level) features and outputs. We show how, by leveraging the monotonic constraint in conjunction with other post hoc strategies, we can interpret our model. To demonstrate our model’s capabilities, we train MonoNet to classify cellular populations in a single-cell proteomic dataset. We also demonstrate MonoNet’s performance in other benchmark datasets in different domains, including non-biological applications (in the Supplementary Material). Our experiments show how our model can achieve good performance, while providing at the same time useful biological insights about the most important biomarkers. We finally carry out an information-theoretical analysis to show how the monotonic constraint actively contributes to the learning process of the model.

Availability and implementation

Code and sample data are available at https://github.com/phineasng/mononet.

Supplementary information

Supplementary data are available at Bioinformatics Advances online.
Assessing the causal effects of a stochastic intervention in time series data: are heat alerts effective in preventing deaths and hospitalizations?
Authors: Wu Xiao , Weinberger Kate R , Wellenius Gregory A , Dominici Francesca , Braun Danielle
Published: February 2023

The methodological development of this article is motivated by the need to address the following scientific question: does the issuance of heat alerts prevent adverse health effects? Our goal is to address this question within a causal inference framework in the context of time series data. A key challenge is that causal inference methods require the overlap assumption to hold: each unit (i.e., a day) must have a positive probability of receiving the treatment (i.e., issuing a heat alert on that day). In our motivating example, the overlap assumption is often violated: the probability of issuing a heat alert on a cooler day is near zero. To overcome this challenge, we propose a stochastic intervention for time series data which is implemented via an incremental time-varying propensity score (ItvPS). The ItvPS intervention is executed by multiplying the probability of issuing a heat alert on day $t$—conditional on past information up to day $t$—by an odds ratio $\delta_t$. First, we introduce a new class of causal estimands, which relies on the ItvPS intervention. We provide theoretical results to show that these causal estimands can be identified and estimated under a weaker version of the overlap assumption. Second, we propose nonparametric estimators based on the ItvPS and derive an upper bound for the variances of these estimators. Third, we extend this framework to multisite time series using a spatial meta-analysis approach. Fourth, we show that the proposed estimators perform well in terms of bias and root mean squared error via simulations. Finally, we apply our proposed approach to estimate the causal effects of increasing the probability of issuing heat alerts on each warm-season day in reducing deaths and hospitalizations among Medicare enrollees in 2837 US counties.
Cryptococcal Meningitis and Clinical Outcomes in Persons With Human Immunodeficiency Virus: A Global View
Authors: Person Anna K , Crabtree-Ramirez Brenda , Kim Ahra , Veloso Valdiléa , Maruri Fernanda , Wandeler Gilles , Fox Matthew , Moore Richard , John Gill M , Imran Darma , Van Nguyen Kinh , Nalitya Elizabeth , Muyindike Winnie , Shepherd Bryan E , McGowan Catherine C
Published: February 2023

Background

Cryptococcal meningitis (CM) is a major cause of morbidity and mortality in persons with human immunodeficiency virus (HIV; PWH). Little is known about CM outcomes and availability of diagnostic and treatment modalities globally.

Methods

In this retrospective cohort study, we investigated CM incidence and all-cause mortality in PWH in the International Epidemiology Databases to Evaluate AIDS cohort from 1996 to 2017. We estimated incidence using quasi-Poisson models adjusted for sex, age, calendar year, CD4 cell count (CD4), and antiretroviral therapy (ART) status. Mortality after CM diagnosis was examined using multivariable Cox models. A site survey from 2017 assessed availability of CM diagnostic and treatment modalities.

Results

Among 518 852 PWH, there were 3857 cases of CM with an estimated incidence of 1.54 per 1000 person-years. Mortality over a median of 2.6 years of post-CM diagnosis follow-up was 31.6%, with 29% lost to follow-up. In total, 2478 (64%) were diagnosed with CM after ART start with a median of 253 days from ART start to CM diagnosis. Older age (hazard [HR], 1.31 for 50 vs 35 years), lower CD4 (HR, 1.15 for 200 vs 350 cells/mm3), and earlier year of CM diagnosis (HR, 0.51 for 2015 vs 2000) were associated with higher mortality. Of 89 sites, 34% reported access to amphotericin B; 12% had access to flucytosine.

Conclusions

Mortality after CM diagnosis was high. A substantial portion of CM cases occurred after ART start, though incidence and mortality may be higher than reported due to ascertainment bias. Many sites lacked access to recommended CM treatment.
Whole genomes of deep-sea sponge-associated bacteria exhibit high novel natural product potential
Authors: Hesketh-Best Poppy J , January Grant G , Koch Matthew J , Warburton Philip J , Howell Kerry L , Upton Mathew
Published: February 2023

Global antimicrobial resistance is a health crisis that can change the face of modern medicine. Exploring diverse natural habitats for bacterially-derived novel antimicrobial compounds has historically been a successful strategy. The deep-sea presents an exciting opportunity for the cultivation of taxonomically novel organisms and exploring potentially chemically novel spaces. In this study, the draft genomes of 12 bacteria previously isolated from the deep-sea sponges Phenomena carpenteri and Hertwigia sp. are investigated for the diversity of specialized secondary metabolites. In addition, early data support the production of antibacterial inhibitory substances produced from a number of these strains, including activity against clinically relevant pathogens Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus. Draft whole-genomes are presented of 12 deep-sea isolates, which include four potentially novel strains: Psychrobacter sp. PP-21, Streptomyces sp. DK15, Dietzia sp. PP-33, and Micrococcus sp. M4NT. Across the 12 draft genomes, 138 biosynthetic gene clusters were detected, of which over half displayed less than 50% similarity to known BGCs, suggesting that these genomes present an exciting opportunity to elucidate novel secondary metabolites. Exploring bacterial isolates belonging to the phylum Actinomycetota, Pseudomonadota, and Bacillota from understudied deep-sea sponges provided opportunities to search for new chemical diversity of interest to those working in antibiotic discovery.
Malondialdehyde treatment reduced immunoreactivity of amandin and delayed its digestion
Authors: Luo Xin , Ai Mingyan , Wu Yongyan , Wang Qia , Song Hongbo , Huang Qun , Lu Jiankang
Published: February 2023

Objectives

The secondary products of lipid oxidation are one of the main factors inducing protein oxidation. The effects of oxidation treatment with malondialdehyde (MDA) on the immunoreactivity of amandin and its digestion were studied.

Materials and Methods

The rabbit IgG binding ability of amandin was analyzed by western blotting, and the changes in amandin oxidation and immunoreactivity during digestion of amandin with different degrees of oxidation were investigated in combination with an almond allergen enzyme-linked immunosorbent assay kit. Alteration of linear epitopes of amandin by oxidation was investigated by liquid chromatography–tandem mass spectrometry (LC-MS/MS).

Results

The results showed that the immunoreactivity of amandin was significantly reduced after 1 mmol/L MDA and 100 mmol/L MDA treatment. However, the 1 mmol/L MDA treatment was owing to cleavage of linear epitope peptide in amandin and oxidation of the active amino acid. The 100 mmol/L MDA treatment was due to aggregation of amandin and significant decrease in its solubility. Oxidation also reduced digestibility of amandin and significantly affected immunoreactivity during digestion. LC-MS/MS also identified four oxidation-prone methionine sites (aa 264–274, 298–308, 220–240, and 275–297) in gamma conglutinin 1.

Conclusions

MDA treatment reduced the immunoreactivity of amandin. MDA treatment also led to protein aggregation, which slowed down the digestion of amandin and altered the immunoreactivity of amandin during digestion.
Taming the exception? Lessons from the routinization of states of emergency in France
Authors: Hennette Vauchez Stéphanie
Published: February 2023

This article examines a particular version of contemporary threats to the rule of law: the routinization of emergency powers. Although the global response to the pandemic since 2020 has certainly epitomized the sudden infatuation with states of emergency (SOEs), they have a longer history of becoming a new model of government that has come to saturate our contemporary political horizon, as every crisis (terrorism, pandemic, climate) seems to call for its own SOE. This article analyzes the unprecedented permanence of SOEs in contemporary paradigms of government. It first situates the contemporary practice of SOEs in the longer historical and theoretical frame of states of exception. It then reads the twentieth-century rise of the rule-of-law paradigm that is largely undergirded by an ambition to tame the exception as a challenge to this state of exception framework. Hence its failure to provide a relevant lens for analyzing contemporary SOEs. Through an in-depth study of recent French experiences of an SOE, this article shows that rather than derogate to or suspend the legal order, contemporary SOEs are intensely juridical and claim to be fully compatible with the rule of law. In that, they set a dangerous trap: as they borrow the forms and language of the rule of law, contemporary SOEs threaten to subvert the model’s meaning and sense from the inside.
Bridging the Digital Gap: Teaching Cyber Strategy and Policy through a Crisis Simulation
Authors: Winger Gregory , Ellis Stephanie , Glover Daniel
Published: February 2023

This article details an attempt to bridge the gulf between information technology (IT) and social science approaches to cybersecurity using a simulation. Digital affairs are increasingly central to public policy, and yet the subject's incorporation within political science education has been hamstrung by an underlying disciplinary divide and lack of familiarity. Despite their differences, both IT and political science have strong traditions of utilizing active learning methods and simulation to achieve learning outcomes. Drawing on this shared pedagogy, we created an interdisciplinary simulation that leverages elements of digital forensics to provide students with a unique, active learning experience of responding to a national cybersecurity crisis. The simulation was fielded during an intermediate level class on cyber conflict and generated an overwhelmingly positive response. Students credited the exercise with helping them better understand the unique characteristics of cyberspace as a geopolitical domain and appreciated how the lack of an IT background was not a barrier to addressing cyber policy issues.
Electromagnetic compatibility analysis and interference shielding method for AcoustoElectric Logging Tool 2.0
Authors: Chen Hongzhi , Lu Junqiang , Ju Xiaodong , Men Baiyong , Qiao Wenxiao
Published: February 2023

Acoustoelectric logging is an important reservoir permeability evaluation method in the field of oil and gas exploration. Its complex composition, weak acoustoelectric signals, vulnerability to electromagnetic interference and other characteristics require high electromagnetic compatibility. In this study, after systematically analysing the interference characteristics of the detector, the electromagnetic protection measures are found to be largely inadequate. A complete shielding of the transmitting acoustic system was proposed. The shielding effectiveness was calculated and tested. In the test, the shielding suppression was ineffective, and the interference was enhanced by 60 dB instead. The explanation of conducted interference was given, and the conducted interference simulation prediction model was established. The simulation result explains the experimental result well. According to the suppression measurements provided by the model, the conducted interference was effectively suppressed, making the shielding effect of the transmitting acoustic system meet the design requirements.
Incidence of human papillomavirus–related cancers among males and females aged 15-34 years in the United States
Authors: Guo Fangjian , Adekanmbi Victor , Hsu Christine D , Berenson Abbey B
Published: February 2023

Postmarket surveillance of the incidence of human papillomavirus (HPV)–related cancers is essential to monitor the effectiveness of HPV vaccines. We directly compared HPV-related cancer incidences during the pre- and postvaccine era to assess the effects of HPV vaccination among vaccine-eligible age groups in the United States using data from the US Cancer Statistics database. The 5-year average annual incidence rates for HPV-related cancers decreased in 2015-2019 compared with 2002-2006 among females aged 15-24 years and 25-34 years. Overall, a decrease in young males was not observed, whereas males aged 25-34 years experienced a slight decline in oropharyngeal squamous cell carcinoma between 2005-2009 and 2015-2019. Incidence rates for HPV-related cancers statistically significantly decreased in the vaccine era compared with the prevaccine era among females aged 15-34 years, suggesting the potential early effects of the introduction of HPV vaccination in the United States.
Self-Injury
Authors: Lewis Stephen P. , Hasking Penelope A.
Published: February 2023

Nonsuicidal self-injury (self-injury), the purposeful damaging of one’s own body tissue (e.g., cutting) without suicidal intent is a common and serious mental health concern across the globe. Unfortunately, it is also one that is frequently misunderstood and often stigmatized. Therefore, this book begins by introducing readers to self-injury to provide critical foundational knowledge on the topic. This involves addressing key questions, including what self-injury is; who self-injures; what contributes to self-injury; why people self-injure; and what risks are associated with self-injury engagement. In this way, the current chapter offers the needed foundation to adopt the person-centered framework that is emphasized and woven throughout the book.
Self-Injury and Stigma
Authors: Lewis Stephen P. , Hasking Penelope A.
Published: February 2023

For many years, self-injury has been marred in significant stigma. Understandably, this has rendered many people with lived experience reluctant to reach out to other individuals. Notwithstanding the widespread nature of this stigma, until recently only a paucity of efforts has focused on this area. As such, the present chapter first offers an overview of stigma and what is known about the stigmatization of self-injury. Next, it presents a new framework derived from the stigma literature with which to conceptualize the stigma associated with self-injury. As this is a relatively new advancement in the field, we also touch on key implications of this model (e.g., future research initiatives, paths to combat stigma) and why the person-centered approach articulated in the previous chapter is so important.
Use of Appropriate Language to Discuss Self-Injury
Authors: Lewis Stephen P. , Hasking Penelope A.
Published: February 2023

Language is a powerful form of communication that gives meaning and context to phenomena, and can shape people’s perceptions and judgments about people, events, and behaviors. This chapter highlights the importance of choosing appropriate language when discussing self-injury and/or people who engage in the behavior. It makes note of how stigmatizing language can foment internalized stigma, which may in turn impede help-seeking and recovery efforts. It then draws on recent work in the field to emphasize the importance of person-centered language that ensures a nonstigmatizing framing of the issue and highlight the importance of avoiding labels and reductionist terms to describe people who self-injure.
Why has AMBIT come about?
Authors: Talbot Laura , Fuggle Peter
Published: February 2023

This introductory chapter explains the structure and rationale of the book. The Adaptive Mentalization-Based Integrative Treatment (AMBIT) model has been developed to support professionals and networks working to help individuals with multiple needs; the model has undergone significant development in recent years, partly in response to the experiences of implementation and adaptation by different professions in different contexts described in this book. Some of the main issues that shape the AMBIT model are outlined: that many clients have multiple needs, that multiple needs attract multiple helpers, collaboration is hard to achieve, and the vital importance but fragility of the helping process. Attention is drawn to the importance of attachment theory to the model, and the importance of the worker’s state of mind in the helping process. Key features of a non-mentalizing helping system are described: lack of trust, a lack of making sense of behaviour, loss of narrative continuity, not holding the balance between perspectives when designing help, and problems with planning.
Epistemic trust and mistrust in helping systems
Authors: Fonagy Peter , Campbell Chloe
Published: February 2023

Recent developments in the theoretical underpinning of the AMBIT model are described in this chapter. Mentalizing theory is explained, including the concepts of the non-mentalizing modes: pretend mode, teleological mode, and psychic equivalence. Mentalizing is then applied to wider social systems and the importance of a mentalizing system around an individual in sustaining that individual’s capacity to mentalize is explained. The capacity to work cooperatively and collaboratively is understood in terms of the capacity for joint attention and the emergence of co-mentalizing, or the ‘we-mode’. It is through the experience of the we-mode that epistemic trust is generated, which is essential for social communication and learning. The implications of operating in a non-mentalizing system for professionals working in a helping context are described.
Working out what is going on
Authors: Talbot Laura
Published: February 2023

AMBIT Integrative Measure (AIM) cards are used in AMBIT practice to help a client and a worker develop a relationship that is both trusting and purposeful. The AIM cards are a pack of 40 cards, approximately the size of a typical set of playing cards. Each card represents an area of a person’s life and functioning, and the cards cover seven domain categories: daily life, socioeconomic factors, family relationships, social relationships, mental state, response to situation, and measure of complexity. The AIM cards can be used for a variety of purposes, including building a picture of a client’s strengths and needs (i.e. as an assessment tool), building a shared understanding of how a client’s difficulties have developed and connect with each other (i.e. as a formulation tool), supporting goal-setting, and as a way of measuring outcomes via the use of the rating scale. This chapter describes how the AIM cards can be used in various ways to support the client and worker to develop a shared sense of purpose.
Getting started with AMBIT
Authors: Dangerfield Mark
Published: February 2023

This chapter uses the implementation of AMBIT with an outreach community team for adolescents in Barcelona to describe the application of AMBIT principles in a new setting. The application of key AMBIT principles drawn from the AMBIT quadrant—Working with your Client, Working with your Team, Working with your Network, and Learning at Work—are described in reference to a case study involving one adolescent and the wider context in which implementation was taking place. The chapter describes the need to understand the impact of adverse relational experiences on adolescent mental health, and the implications of such experiences on a young person’s capacity for epistemic trust.
Enhancing multiprofessional cooperation in a child and youth social service institution
Authors: Huter Beate , Hollenstein Michael
Published: February 2023

This chapter describes the implementation of AMBIT in a combined residential, educational, and outreach service for children and adolescents in Austria. Particular aspects of AMBIT practice are explained as salient to the needs of the service, in particular, providing a mentalizing environment for professionals at risk of emotional burnout and dealing with increasing case complexity within the service. The four quadrants of the AMBIT wheel—Working with your Client, Working with your Team, Working with your Network, and Learning at Work—are covered, drawing on examples from clinical practice. The evaluation process for the service is described, explaining how evaluation was implemented and the key findings of the evaluation.
Creating and supporting a Team around the Worker
Authors: Talbot Laura
Published: February 2023

The Team around the Worker is one of the central, unique concepts in the AMBIT approach. This chapter uses a case example from the Adolescent Multi-Agency Support Service in London, a service that was set up and designed around the principle of the Team around the Worker—in this case, the social worker working with a family in which the removal of a child into care is being considered. The chapter describes how effective multiagency helping systems require a close level of attention to detail about the process of beginning helping relationships, attention to the beliefs and attitudes of both clients and workers, and recognition of the vulnerabilities that clients and workers may experience in this process.
Working with networks
Authors: Vilmar Janne Walløe , Jensen Stefan Lock
Published: February 2023

This chapter describes the implementation of the AMBIT approach within the healthcare system in Denmark. Using a case study involving complex needs and high risk in which network dis-integration was a real danger, the chapter explains how the application and adaptation of AMBIT principles was used in order to support the keyworker. An integration between the AMBIT approach and milieu therapy is discussed, via an emphasis shared by both models on the importance of mentalizing systems. The NET-Aim-Questionnaire was developed by this team to improve the functioning of network meetings and combat network dis-integration.
Chronic Low Back and Leg Pain
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of a 48-year-old woman who was operated from L4–L5 left discal herniation and spinal stenosis. Despite surgery, she continues to suffer from chronic low back and neuropathic leg pain. Lumbar magnetic resonance imaging does not show any new pathological image of discal herniation. She has received acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and epidural corticosteroid infiltrations without any efficacy; does not tolerate weak opioids; and is afraid of moving. Physical reconditioning and psychological advice are recommended. Opioids should not be proposed as first line, and conventional analgesics and NSAIDs are generally ineffective; lumbar epidural steroid injections are controversial. For chronic neuropathic (radicular) pain, recommendations should follow general guidelines for peripheral neuropathic pain.
Groin Pain After Hernia Repair
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of a 32-year-old man who suffers from persisting neuropathic groin pain after surgery for left inguinal hernia (open surgery). Examination of the painful area discloses mild sensory deficit, allodynia to brush as well as red skin and swelling. Because he did not want to receive oral medications, he was treated by topical agents. Postsurgical pain is commonly neuropathic, with common causes being hernia repair but also thoracotomy, mastectomy, knee/hip replacement, cholecystectomy, and varicose vein stripping. Management is similar to that of other peripheral neuropathic pains, but topical treatments should be preferred if the area of pain is small.
Pain and Paresthesia of the Hand
Authors: Trouvin Anne-Priscille
Published: February 2023

This chapter presents the case of a 42-year-old woman with rheumatoid arthritis (RA) who describes tingling, pins and needles and sometimes burning pain at the right wrist and palmar area of the thumb and index, extending to the forearm. Clinical examination shows no sensorimotor deficit, and percussion of the median nerve at the wrist induces paresthesia. Carpal tunnel syndrome is frequent in RA and mainly a clinical diagnosis. Complementary explorations are not always mandatory. Nerve conduction studies may provide objective confirmation of decreased sensory and motor conduction of the median nerve at the wrist. Imaging particularly using ultrasound can help when there is strong suspicion of a local cause of compression. Nonsurgical treatment includes rest, splinting, and local corticosteroid injections. In refractory cases or when there is motor involvement, surgical decompression is indicated.
Pain After Surgery for Hand Fracture
Authors: Sendel Manon , Gierthmühlen Janne , Baron Ralf
Published: February 2023

This chapter discusses the case of a patient who presents with persistent pain after a radial fracture and additionally experiences swelling, changes of skin color, and impaired range of motion. When differential diagnoses are excluded, a diagnosis of neuropathic pain or complex regional pain syndrome (CRPS) is possible. CRPS is diagnosed clinically according to the Budapest criteria, which include symptoms reported by the patient as well as signs that can be objectified in the clinical exam. Sometimes, additional methods, such as quantitative sensory testing and three-phase bone scintigraphy (3PBS), can be helpful. Because of the lack of sufficient data, CRPS therapy is mostly based on guidelines for neuropathic pain. It should always be interdisciplinary and multimodal.
Cold-Evoked Symptoms After Chemotherapy
Authors: Ventzel Lise , Finnerup Nanna Brix
Published: February 2023

This chapter presents the case of a man who has cold dysesthesia due to oxaliplatin-induced peripheral neuropathy. Chemotherapy-induced peripheral neuropathy is a daily challenge in cancer patients. Oxaliplatin can cause an acute neuropathy characterized by cold dysesthesia, a chronic neuropathy characterized by a “glove-and-stocking-like” distribution of symptoms (paresthesia, dysesthesia, and pain), and sensory loss. There are no established preventive treatments. In patients with oxaliplatin-induced neuropathy, treatment mainly consists of symptomatic antineuropathic drugs akin to other painful neuropathies, and it should not start with opioids. Patients with chemotherapy-induced neuropathy reporting paresthesia such as numbness or tingling but not pain should not be treated with analgesics.
My Body Is Boiling
Authors: Attal Nadine , Bouhassira Didier , Truini Andrea
Published: February 2023

This chapter presents the case of a woman who initially developed pain involving the lower limbs, compatible with sensory neuropathy (specifically small fiber neuropathy), and now reports pain “all over the body,” associated with multiple other symptoms, fulfilling criteria for fibromyalgia. Fibromyalgia may classically develop in the context of rheumatological diseases, such as chronic arthritis or spondylosis, but also in relation with stress, sleep disorders, past traumatic events, or any focal painful injury. Fibromyalgia may also be associated with painful (small fiber) neuropathy, but it is unclear whether the neuropathy is a trigger or may cause the pain and associated symptoms in fibromyalgia syndrome. Therapeutic management should be based on the clinical phenotype and include mainly therapeutic education, physical reconditioning, and cognitive–behavior therapy.
Burning Mouth
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of an elderly woman who suffers from chronic bilateral pain in the tongue described as burning. Pain is moderately improved by chewing gum but is worse in the evening or after talking. Examination of the tongue is normal, and there is no apparent sensory deficit. Biological testing is normal. This case is compatible with primary burning mouth syndrome (BMS). Although BMS is not considered as neuropathic, it has many similarities with neuropathic pains in terms of symptoms and mechanisms. Guidelines for neuropathic pain may apply to BMS with emphasis on pregabalin, gabapentin, and duloxetine. Secondary causes include mainly candidosis. Treatment is difficult, with weak evidence for efficacy of topical clonazepam.
Neuropathic Pain in a Child
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of an 11-year-old girl with hip osteosarcoma invading the lumbar plexus who suffers from extreme neuropathic pain with tactile allodynia, which is not relieved by strong opioids. This case illustrates that neuropathic pain in children is often related to cancer. Osteosarcoma is the leading type of cancer in children. It may be responsible for neuropathic pain because of plexus lesion, or it may induce nociceptive pain due to bone lesion. Other causes of neuropathic pain in children and adolescents include complex regional pain syndrome, cancer, Guillain–Barré syndrome, spinal cord injury, nerve trauma, and genetic conditions. Treatment of neuropathic pain in children is mainly based on gabapentin.
Topical Therapy
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of an elderly woman with intercostal postherpetic neuralgia with a well circumscribed and limited area of pain for whom topical agents are probably the best choice. These include U.S. Food and Drug Administration-approved daily use of 5% lidocaine plasters and capsaicin high-concentration patches every 3 months in specialized settings. Subcutaneous botulinum toxin A (off-label) may also be proposed by specialist use if pain is refractory. Topical agents are expected to have less efficacy if the pain is present in an area of total sensory loss. This case report illustrates that it is possible to combine several topical agents due to their distinct mechanisms and their different modalities of applications.
Physical Therapy
Authors: Attal Nadine , Tosti Grégory , Bouhassira Didier
Published: February 2023

This chapter presents the case of a woman with severe complex regional pain syndrome CRPS for whom physiotherapy should be implemented as part of multimodal management. It may be beneficial for motor deficit or neglect, major sensory deafferentation, physical deconditioning, and fear of pain and movement. Because physical exercises may be initially very painful, strong analgesics may be proposed before each exercise to facilitate rehabilitation. Physiotherapy includes a large variety of interventions, particularly manual therapy, therapeutic exercises including physical reconditioning, electrotherapy (e.g., transcutaneous electrical nerve stimulation), and sensorimotor rehabilitation strategies including mirror therapy and graded motor imagery. Virtual reality is increasingly investigated for the treatment of acute pain, but there are limited data regarding its efficacy on neuropathic pain.
Psychotherapies: How, When, and Why
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of a woman with postsurgical neuropathic pain who is suffering considerably because of multiple life events, social isolation, and anxiety. Psychological therapy plays a major role in the management of chronic neuropathic pain. It aims to decrease dysfunctional coping strategies, thoughts about pain, and catastrophizing, which are common consequences of chronic pain, and improve anxiety and mood. Cognitive–behavioral therapy has been the most studied. Psychotherapies may be recommended as stand-alone or add on to other treatments. Best candidates should be motivated and educated subjects, with maladaptive thoughts about their neuropathic pain and/or mood or anxiety disorders.
Complementary Investigations
Authors: Truini Andrea , Galosi Eleonora
Published: February 2023

This chapter presents the case of a woman with burning pain of the lower legs and lightheadedness when standing up from a sitting position who had normal neurological examination and electromyography. Hence, she was told that pain was “in her head,” but a psychiatrist stated that she did not suffer from a psychiatric condition. She was ultimately diagnosed with small fiber neuropathy based on complementary investigations, including laser evoked potentials and skin punch biopsy. This case illustrates the importance of an in-depth assessment of patients with chronic pain and shows the place of complementary investigations. The fact that pain was limited to the lower limbs and described as neuropathic should orient toward a neurological lesion.
When Do I Refer for Invasive Therapies?
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of a man who suffers from severe neuropathic pain due to cauda equina syndrome refractory to well-conducted treatments without psychiatric comorbidity. For this patient, invasive therapy may be considered. These techniques should only be considered after multidisciplinary evaluation including psychological assessment. Best candidates are patients with regional neuropathic pain. The choice of treatment depends on the clinical context, the origin of pain, and the area of pain. By far the most documented invasive therapy for neuropathic noncancer pain is spinal cord stimulation. Other invasive techniques include peripheral nerve stimulation or pulsed radiofrequency (minimally invasive), deep brain/epidural motor cortex stimulation, intrathecal therapy, and ablation surgery techniques in select conditions.
Invasive Brain Stimulation and Intrathecal Therapy
Authors: Attal Nadine , Bouhassira Didier
Published: February 2023

This chapter presents the case of a patient with traumatic spinal cord injury responsible for at-level allodynia and below-level spontaneous pain who is totally refractory to first-, second-, and third-line treatments, including noninvasive brain neurostimulation. He is a good candidate for invasive treatments, after multidisciplinary assessment. Because spinal cord stimulation is difficult due to his spinal cord lesion, invasive therapeutic options include intrathecal analgesic therapy or central invasive neurostimulation. Drugs officially labeled by the U.S. Food and Drug Administration for intrathecal administration include morphine, ziconotide, and baclofen. Trialing and small initial dosages are recommended. Motor cortex stimulation involves the placement of electrodes along the surface of the brain in the precentral gyrus, corresponding to the motor cortex area. The level of evidence regarding the efficacy of deep brain stimulation remains inconclusive in neuropathic pain.
Green Vomit . . . Ewwww!!!
Authors: Ro Esther , Jadcherla Yamini , Reynolds Maegan S.
Published: February 2023

The triad of bilious emesis, abdominal pain, and distention in a neonate is suggestive of intestinal obstruction typically from malrotation or midgut volvulus (MGV). Neonates may not always present with all of these findings, and neonates with more subtle findings may rapidly deteriorate and require prompt intervention. Initial resuscitation includes gastric decompression via nasogastric tube and intravenous fluids. Radiographic findings for MGV are nonspecific and can vary from normal to diffuse bowel dilatation. The clinician should not be reassured by normal radiographic imaging in this clinical setting. Fluoroscopic upper gastrointestinal (UGI) series is typically the first-line imaging exam to diagnose or exclude MGV. Ultrasound (US) can demonstrate reversed SMA/SMV relationship, which can indicate malrotation and prompt further evaluation with UGI. Volvulus can be diagnosed on UGI, as well as US. Definitive management includes surgical repair with detorsion of the bowel and a Ladd’s procedure.
My Baby Won’t Poop!
Authors: Jadcherla Yamini , Shet Narendra , Reynolds Maegan S.
Published: February 2023

Constipation is a very common emergency room complaint and is often multifactorial. Clinicians should have a high index of suspicion for Hirschsprung’s disease in infants who fail to pass meconium within the first 24 hours after delivery or who have a history of infrequent explosive bowel movements and poor weight gain. Examination can reveal abdominal distention, tight anal sphincter, and empty rectum with expulsion of gas and stool (positive “squirt sign”). Abdominal radiographs and contrast enemas can help to diagnose a distal obstruction or transition zone but may also be normal. Rectal biopsy is the gold standard for diagnosis. It is important to be mindful of complications of Hirschsprung’s disease, such as colonic perforation and enterocolitis, as these can occur years after surgical repair and have high rates of mortality.
Drooling, Drooling, Drooling All the Way Home
Authors: Lampl Brooke , Orajiaka Nkeiruka , Eby Meika
Published: February 2023

Foreign body (FB) ingestion is a common complaint in patients 6 months to 5 years old. Acute foreign body ingestions can present in many ways, from completely asymptomatic to drooling, difficulty swallowing, choking, respiratory distress, vomiting, and food refusal. Chronic foreign bodies may present with fever, hematemesis, hematochezia, chronic cough, or weight loss. There may be a patient reported history or caregiver-witnessed ingestion; for others, you may need to rely on symptoms and clinical suspicion. The most commonly ingested objects in children are coins, toys, jewelry, and batteries. Button batteries, magnets, and sharp objects require special attention as they are associated with increased morbidity.
Burn, Baby, Burn
Authors: Gotowka Cory , Coblentz Ailish , Stoner Michael
Published: February 2023

Button battery ingestions (BBIs) are the second most frequently ingested foreign bodies, second to coins. Unfortunately, the incidence of BBI continues to rise, with the majority occurring in children younger than 6 years of age. In addition to the increase in incidence, the rate of significant complications and death resulting from BBI has increased nearly sevenfold with the majority of serious outcomes and fatalities occurring in children between 1 and 3 years of age. Button batteries have characteristic radiographic appearances that can facilitate an early diagnosis. Honey may be used as a temporary measure, if it is suspected that the ingestion was less than 12 hours prior (10 mL of oral honey, or 10 mL of oral sucralfate (if the patient is younger than 1 year)). Endoscopy, by a subspecialist, is indicated as soon as possible for removal of the battery.
To Wheeze or Not to Wheeze
Authors: Vachon Linda , Rose Emily
Published: February 2023

Bronchiolitis is a common clinical syndrome of viral etiology in children <2 years of age. Many different viruses cause the presentation of initial upper respiratory symptoms (runny nose) with progression to lower respiratory tract involvement with increased work of breathing and diffuse wheezing and rales present on auscultation. Bronchiolitis is a clinical diagnosis and neither imaging nor laboratory testing is routinely indicated. Atypical presentations may warrant further investigation with a chest radiograph, but the information obtained on imaging rarely changes management in most children with bronchiolitis. Typical findings of viral infection on a chest x-ray are diffuse and include hyperinflation, peribronchial cuffing, and/or segmental or subsegmental atelectasis.
Weebly, Wobbly
Authors: Eby Meika , Orajiaka Nkeiruka , May Lauren
Published: February 2023

The evaluation of a pediatric patient with leg pain and/or limping can be challenging in many cases, including younger nonverbal or preverbal children who are unable to characterize or localize the pain, and those with referred pain from sites other than the actual area of pathology. This chapter discusses common causes of hip pathology in pediatric patients presenting with vague upper leg pain without any other systemic symptoms (e.g., fever). It describes the various presentations and differential diagnoses and highlights the importance of initial imaging choice and pertinent radiographic findings. Early diagnosis is critical as delay can lead to significant morbidity.
Extreme Extremity
Authors: Nimjareansuk Waroot S. , Kim Jane S.
Published: February 2023

Pediatric extremity fractures are common musculoskeletal injuries presenting to the Emergency Department. Increased bone elasticity, comparably stronger ligaments, and the presence of physeal growth plates lead to unique fracture patterns in children. Unique fractures in pediatrics include torus fractures, greenstick fractures, Salter-Harris fractures, and triplane fractures. Salter-Harris fractures are common and involve the physis or cartilaginous growth plate, located at the junction of the metaphysis and epiphysis. Physeal injuries tend to occur in active children with a peak age of 11–12 years and are classified into 5 subtypes, depending on the site of involvement. Triplane fractures are complex traumatic Salter-Harris type IV fractures involving the metaphysis, physis, and epiphysis of the distal tibia. Each diagnosis carries its own distinct radiographic findings, as well as short- and long-term follow-up. Timely diagnosis and appropriate treatment of pediatric extremity fractures are important to avoid long-term complications such as angular deformity, growth disturbances, and joint incongruity.
FOOSHING through the Snow . . .
Authors: Fernandez David , Setty Bindu N. , Barata Isabel A.
Published: February 2023

Supracondylar fractures are one of the most common pediatric fractures. They occur in children between the ages of 5 and 7 years after a fall on an outstretched hand with the elbow in extension (FOOSH). However, a small percentage occur from landing directly onto a flexed elbow. The hallmark feature is elbow pain and refusal to move the elbow. Proper and thorough physical exam is needed to evaluate for neurovascular injury. Ultimately, the diagnosis is made by an adequately obtained anteroposterior (AP) and lateral radiograph of the elbow. Management varies depending on the degree of displacement (Gartland classification).