bluuebunny/crossref_metadata_2025 huggingface dataset:
Cost Savings Associated with Palliative Care (DRAFT)
Authors: Hannon Breffni
Published: April 2018

Although the clinical benefits associated with hospital-based palliative care (PC) consultation teams are well established, few studies address the potential economic impact of these services. This study aimed to examine the effect of hospital-based PC teams on hospital costs for patients who died in the hospital, as well as for those discharged alive. Eight diverse hospital settings with established PC teams were chosen, and administrative data relating to direct costs (including laboratory, diagnostic imaging, pharmacy, and intensive care unit [ICU] costs) were analyzed. Propensity scoring was used to match PC patients with usual care (UC) patients. Of 2,630 PC patients who were discharged alive, net savings of $2,642 per admission were calculated, compared with 18,427 UC patients. For the 2,278 PC patients who died in the hospital, savings of $4,908 per admission were seen, when compared with 2,124 UC patients, confirming the additional economic benefits associated with hospital-based PC teams.
Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients (DRAFT)
Authors: Lawlor Peter
Published: April 2018

This chapter, reports on a prospectively matched controlled trial in which Inouye et al. examined the comparative effectiveness of a targeted multicomponent strategy for reducing the risk of delirium with that of usual standard care. The six targeted baseline risk factors in delirium-free patients admitted to a medical service in a teaching hospital were cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Using standardized interventions for each of these when present, 42/426 (9.9%) of those in the intervention group had a first-incident episode of delirium compared to 64/426 (15%) in the usual care group, representing a statistically significant reduction of approximately 33% in first-incident episodes of delirium. The number of patient-days with delirium (105 vs. 161) and delirium episodes (62 vs. 90) were significantly lower in the intervention group. Primary prevention of delirium was effective.
Effects of Morphine on Dyspnea (DRAFT)
Authors: Kamal Arif H. , Webb Jason A.
Published: April 2018

This chapter reports on an open, uncontrolled study to assess the effects of subcutaneous morphine on dyspnea in patients with terminal cancer. Twenty patients with dyspnea from restrictive respiratory failure received a subcutaneous dose of morphine relative to their opioid tolerance: 5mg for opioid naïve (5 patients) and 2.5 times regular dose for opioid tolerant (15 patients). Dyspnea and pain scores were measured every 15 minutes for 150 minutes. Dyspnea scores, but not respiratory rate, respiratory effort, nor arterial saturation of oxygen were affected. Ninety-five percent of patients reported improved dyspnea after morphine. This chapter describes the basics of the study and briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Palliative Oxygen Versus Room Air for Refractory Dyspnea (DRAFT)
Authors: Webb Jason A. , Kamal Arif H.
Published: April 2018

Palliative oxygen therapy is used for treating dyspnea in patients with cancer and advanced cardiopulmonary diseases, however, small trials have suggested that circulating air may be just as effective. This international, multicenter, randomized controlled trial compared oxygen versus room air delivered by a nasal cannula for relief of dyspnea for patients with any life-limiting illness. Patients were adults >18 years of age, with PaO2 > 7.3kPa, on optimized therapies for their illness, and an expected survival of >1 month. The study demonstrated no clinically significant symptomatic benefit of palliative oxygen versus room air delivered via nasal cannula for seven days in patients with life-limiting illnesses and refractory dyspnea.
Reduction of Cancer-Related Fatigue with Dexamethasone (DRAFT)
Authors: Patel Chirag A.
Published: April 2018

“Reduction of Cancer-Related Fatigue with Dexamethasone: A Double-Blind, Randomized, Placebo-Controlled Trial in Patients with Advanced Cancer” reviews the study of the same name and outlines a clinical scenario in which the study may be applied. It begins by describing the study’s background, including location and participants. It then describes the study design and outcomes measured. The chapter reviews key study results, criticisms and limitations identified within the study, and other related literature on cancer-related fatigue (CRF). It then discusses the implications of the findings on the management of CRF in advanced cancer patients. The chapter concludes with a patient scenario that describes the use of dexamethasone in an outpatient palliative care clinic to reduce CRF.
Parenteral Nutrition in Cancer Patients Undergoing Chemotherapy (DRAFT)
Authors: Loaiciga Francisco , Dev Rony
Published: April 2018

The meta-analysis by McGeer investigates the benefits of parenteral nutritional support for patients with cancer undergoing chemotherapy. The study concluded that total parenteral nutrition (TPN) has a detrimental effect (decreased survival and poorer tumor response), with an increased infection risk but no significant effect on hematologic or gastrointestinal toxicity. The authors report a net harm with the use of TPN in patients undergoing chemotherapy and recommend that such interventions should be discouraged. This chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Octreotide for Malignant Bowel Obstruction (DRAFT)
Authors: Dalal Shalini
Published: April 2018

This chapter describes a prospective study published in 2002 evaluating the role of octreotide in the symptomatic management of advanced cancer patients with bowel obstruction that cannot be treated surgically. The chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case. Topics covered include octreotide, bowel obstruction, vomiting, and abdominal distention.
Prevalence of Mood Disorders in Patients with Cancer (DRAFT)
Authors: Nguyen Linh
Published: April 2018

The prevalence of mood disorders in patients with cancer is uncertain in oncological, hematological, and palliative care settings because most studies have relied on depression symptom-screen methods rather than diagnostic instruments. Mitchell et al aimed to quantify the prevalence of mood disorders in studies where mood disorders were diagnosed by interview. Twenty-four palliative studies (n = 4,007) and 70 oncological and hematological studies (n = 10,071) were included in this meta-analysis of interview-based studies. The prevalence of depression was 24.6% and 20.7%, depression or adjustment disorder 24.7 and 31.6%, and all types of mood disorders 29% and 38%, respectively. There were no correlates of depression including age, gender, or palliative versus nonpalliative settings. Interview-defined mood disorders is less common in patients with cancer than reported previously (30%–40% prevalence) without a difference between palliative and nonpalliative care settings. Clinicians should remain attentive for all mood complications, not just depression.
Prognostic Disclosure to Patients with Advanced Cancer (DRAFT)
Authors: Hui David
Published: April 2018

This chapter discusses a classic study on prognostic disclosure. This prospective survey found that a large proportion of physicians were reluctant to have a frank prognostic discussion with their patients. Physicians in the study were more likely to withhold prognostic information, or to provide an overly optimistic prognosis, when the prognosis was particularly poor. It also illustrates the differences between foreseeing and foretelling and how both processes may contribute to communication of an inflated survival estimate. The chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
A Communication Intervention in the Intensive Care Unit (DRAFT)
Authors: Olson Lori , Sinclair Christian T.
Published: April 2018

Caregiver outcomes of anxiety, depression, and posttaumatic stress disorder are modifiable based on care received while a patient is in the intensive care unit (ICU) setting. When compared to usual ICU care (which did include family meetings), the intervention added a structured end-of-life conference according to VALUE-based guidelines and a 15-page bereavement informational booklet. Patients in the intervention arm also had longer conferences, more time with family speaking, and more life-sustaining treatments withdrawn. The chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Clinical Signs of Impending Death in Cancer Patients (DRAFT)
Authors: Mori Masanori
Published: April 2018

In this prospective, longitudinal, cohort study, the authors systematically characterized the frequency, onset, and diagnostic performance of 62 clinical signs for impending death in 357 advanced cancer patients admitted to two acute palliative care units. “Early signs” (e.g., Palliative Performance Scale <20%, Richmond Agitation Sedation Scale ≤–2) had a high frequency over the last 3 days but low positive predictive ratios (LRs) for impending death within 3 days. In contract, “late signs” (e.g., death rattle, respiration with mandibular movement, peripheral cyanosis) had a low frequency but high specificity and high positive LR. In addition, seven neurological signs (e.g., decreased response to verbal stimuli, drooping of nasolabial fold, grunting of vocal cords) and upper gastrointestinal bleeding had high positive LRs for impending death within 3 days. Upon further validation, these signs may assist clinicians in formulating the diagnosis of impending death and patients and families in preparing ahead.
Factors Considered Important at the End of Life (DRAFT)
Authors: Parikh Ravi B. , Odejide Oreofe O.
Published: April 2018

The chapter describes the national survey study by Steinhauser and colleagues, which assessed perspectives of seriously ill patients, family members, physicians, and other care providers (i.e., nurses, social workers, and chaplains) regarding the importance of several factors at the end of life. Survey respondents were asked to rate and rank the importance of attributes of quality at the end of life. This chapter highlights attributes that met consensus among all groups of respondents, those that were important to patients but not physicians, and attributes that had broad variation across all groups. It also includes items that were ranked the most important and least important by all groups. This chapter emphasizes areas of agreement as well as areas of diversity in the definition of a “good death” and discusses implications of these findings in providing end-of-life care.
Family Perspectives on End-of-Life Care at the Last Place of Care (DRAFT)
Authors: Finlay Esmé , FitzGerald Erin
Published: April 2018

Assessing quality of end-of-life (EOL) care is a challenging but essential task in hospice and palliative medicine. Patients die in diverse settings, and patients and families experience EOL care differently. Using a mortality follow-back methodology, this study assessed family/informants of patients who died in the United States in 2000. Informants were asked about EOL care outcomes, including whether patients received physical and emotional support, were treated with respect, received well-coordinated care, participated in shared decision-making with medical teams, and whether family received adequate information and support. The results showed that families of patients who died with hospice services were better supported and perceived that the decedents had fewer unmet needs, were more likely to be treated with respect, and received highly rated care. Patients and families who received hospice support in a home environment had better EOL care experiences than those who died in other settings.
Liverpool Care Pathway for Hospitalized Cancer Patients (DRAFT)
Authors: Paiva Carlos Eduardo , dos Santos André Filipe Junqueira
Published: April 2018

The Liverpool Care Pathway (LCP) for patients who are dying was developed in the UK with the aim of transferring the best practice of hospices to hospitals. In this chapter, an important cluster randomized trial is dissected. Sixteen Italian general medicine hospital wards were randomly assigned to implement the Italian LCP (LCP-I) program or standard health care practice. The results of this trial did not show a significant difference in the overall quality of end-of-life care between the wards in which the LCP-I program was implemented and the control wards (primary aim). Of the nine secondary outcomes investigated, only two showed significant improvements. At the end of the chapter, the authors present a real situation where one hospital CEO, after identifying end-of-life care as a weakness of his institution, evaluates the possibility to implement the LCP or to build a new physical structure dedicated to palliative care.
What Patients and Families Want to Know About Hospice (DRAFT)
Authors: Mackey Regina , Tanco Kimberson
Published: April 2018

Hospice services are widely used in the care of dying patients. With hospice, patients and their families gain access to various benefits and services. However, the decision to enroll into hospice can be difficult for patients with advanced illness and also the family caregivers. This study explores the hospice decision-making process and how the enrollment decision is shared between patients and their families. This study also explores the knowledge of hospice at the time of initial information visit and the patients’ and families’ priorities for information. The chapter also briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
The Impact of Hospice on Mortality of Widowed Spouses (DRAFT)
Authors: Tanco Kimberson , Mackey Regina
Published: April 2018

Caring for a sick spouse can have adverse health consequences and may increase mortality for the surviving spouse. This can be associated to a caregiver and widow/er effect, which may be related to the loss of beneficial social support and impact of stress from the advanced illness and death of the spouse. This study explores if the nature of end-of-life care that the decedent spouse received might be associated with the mortality risk of the surviving spouse. This is preceded by the hypothesis that “good deaths” may result in less stress on the families. At the same time, it is presumed that hospice care facilitates “good deaths” by optimizing symptom management, enables home deaths, and may enhance patient and family satisfaction.
Influence of Survival Probability on Preference for CPR (DRAFT)
Authors: Sinclair Christian T. , Jordan Allison E.
Published: April 2018

Informed discussions about cardiopulmonary resuscitation (CPR) help patients who are elderly correct misunderstandings about the success rate of CPR if the clinician shares likely estimates of survival after CPR. A wide range of preferences exists, and without discussion there is a significant risk that care will be delivered that is not consistent with the patient’s wishes. Clinicians should engage patients and document these discussions to help provide care that is patient-centered and efficient. The chapter describes the basics of this study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
The Hospital and Clinic Improvement Handbook
Authors: Ronen Boaz , Pliskin Joseph S. , Pass Shimeon , Berwick Donald M.
Published: April 2018

The Hospital and Clinic Improvement Handbook is about doing more using existing resources. For example, achieving more throughput in the operating rooms, reducing waiting times at the emergency department, and improving clinical quality. This is done using the well-established Lean techniques together with the breakthrough philosophies and techniques of the theory of constraints (TOC). These methods and their underlying tools are put together with techniques and methodologies implemented by the authors in dozens of healthcare organizations. The tools include the complete kit concept, the Pareto methodology, the focusing table, and the focusing matrix. The book introduces simple tools that can be implemented quite easily in any hospital or clinic. It also focuses on the implementation process using tools like the 3–1–1 model that directs managers where to focus their limited time resources to best improve the performance of their organizations. Finally, the book introduces effective yet simple performance measures and prescribes the process of ongoing improvement.
The Pareto Rule, the Pareto Based Methodology, the Focusing Table, and the Focusing Matrix (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

This chapter introduces one of the most powerful tools in management—the Pareto methodology and its derivatives. This upgrade of the Pareto (80/20) rule enables managers to use different policies for different entities. For the “vital few” cases, managers should use policies that are different from those used for the “trivial many” cases. The Pareto analysis classifies sources of the phenomenon into classes A, B, and C. Then, a differential policy is applied to members of each class. Finally, resources are allocated based on the first two steps. This chapter also presents the focusing table and the focusing matrix, which are among the simplest, nicest, and easiest to implement tools that allow focusing and enable good communication and empowerment within the organization.
The Efficiencies Syndrome (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

The efficiencies syndrome is a phenomenon that causes people or equipment to work more than necessary. This syndrome is fueled by managerial and cultural factors. The desire to show that the resource is busy is a result of either taking a local perspective or using inappropriate measures. This leads to enhancing this syndrome. Using the utilization of operating rooms as a measure of performance amplifies this syndrome and is counterproductive because it promotes increased utilization as a percentage. The correct measure should be throughput, and it should be measured directly. Because this is a more difficult metric to ascertain, resolving the efficiencies syndrome often requires a major change in performance measures as well as a change in organizational thinking.
The Effects of Variability and Uncertainty (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Uncertainty and variability are among the biggest enemies of healthcare systems. Variability that is not properly managed may turn noncritical resources into bottlenecks, leading to increased response times, decreased throughput, and deteriorating quality. The chapter presents tools and techniques to protect against variability (managing buffers, creating protective capacity, etc.) and to reduce variability (response times reduction, creating a group technology structure, working in small batches, etc.). The chapter also presents Litvak’s approach to managing variability.
Creating Value for Healthcare Organizations (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Creating value for healthcare organizations is the primary goal for their managers, both in for-profit and nonprofit organizations. In this chapter, we present the value-focused management methodology, a practical approach for increasing the value of a healthcare organization. The methodology is a multistep approach, including determining the goal, determining the performance measures, identifying the value drivers, deciding how to improve the value drivers, and implementation and control. The value-focused management methodology enables managers to examine systematically where they should devote their time and energy and in which areas the contribution will be marginally small.
Hepatobiliary surgery (DRAFT)
Authors: Prasad Raj K. , Wijetunga Imeshi
Published: April 2018

This chapter discusses common elective and emergency presentations to hepatobiliary surgery. Gallstone disease, being the commonest hepatobiliary condition encountered by general surgical trainees, is discussed in detail. A separate section on acute ascending cholangitis is included with a brief description of the steps involved in laparoscopic cholecystectomy. Acute pancreatitis is discussed in Pancreatic Surgery Chapter 3. An overview of the assessment and management of post-cholecystectomy complications, such as bile duct injury and vascular injuries, is provided with illustrations. Management of common malignant conditions of the liver, such as colorectal liver metastasis, hepatocellular carcinoma, and cholangiocarcinoma, is included with detailed discussion of pre-operative imaging. Liver resection surgery and liver transplant surgery, as well as non-surgical management, are discussed. Details of post-operative management of hepatobiliary patients are aimed at the junior surgical trainee working in a tertiary hepatobiliary unit to aid day-to-day management of post-operative patients on the wards, as well as subsequent follow-up.
Breast surgery (DRAFT)
Authors: Morgan Jenna , Wyld Lynda
Published: April 2018

Breast disease is a common surgical problem. It constitutes symptomatic disease, including breast lumps, nipple discharge, and breast abscesses, as well as asymptomatic disease detected on the NHS Breast Screening Programme (BSP) and patients identified at high risk of familial cancers. It is a busy subspecialty. Referrals for symptomatic breast disease primarily arise from primary care, where they constitute approximately 3% of general practice consultations. In addition, the NHS BSP screened over 2,000,000 women in 2014, of which 4.3% were referred for assessment. The cases in this chapter cover presentations that will be commonly encountered within the breast surgery unit, including the assessment of a breast lump and the surgical management of underlying benign and malignant pathology. It also covers the assessment and management of nipple discharge, as well as lactational and non-lactational breast abscess.
Endocrine surgery (DRAFT)
Authors: Morgan Jenna , Balasubramanian Saba
Published: April 2018

This chapter presents common cases that are clinically relevant to endocrine surgery. These include common surgical presentations often encountered at outpatient clinic, such as thyroid nodules/goitres and hypercalcaemia due to primary hyperparathyroidism, as well as important emergency surgical complications.Although most endocrine surgical conditions are managed by few surgeons with a special interest in these diseases, knowledge of the initial management and immediate treatment of complications is essential for all surgical trainees, particularly as some of these are life-threatening. These cases have been written to incorporate relevant pathophysiology, clinical information, diagnosis, and surgical management of thyroid, parathyroid, and adrenal disease.
Models, risks, and protections (DRAFT)
Authors: Casey Patricia
Published: April 2018

Several explanatory models have been proposed for AD. The stress model is the current model and the one on which the ICD-11 criteria will be based. Others include a crisis model, a biological model, and a transactional-cognitive model. The research on the risk and protective factors is sparse and some studies are poorly designed owing to inadequate confounder control. The presence of a stressor is essential, and it can be a common event such as relationship breakdown or more traumatic stressors that have come to be associated with PTSD. Personality disorder does not appear to be a specific risk factor but certain personality dimensions have been identified as increasing vulnerability. Maladaptive coping strategies, poor social supports, and childhood trauma have also been identified. Resilience is a protective factor. Thus, the variables that increase or decrease risk are similar to those identified for other common psychiatric disorders, but better-designed studies are required in the future.
The biological basis of adjustment disorders (DRAFT)
Authors: Doherty Anne
Published: April 2018

The biological basis of adjustment disorders examines the evidence for the biological factors associated with this common diagnosis. Although adjustment disorder is usually characterized as a disorder of psychological adjustment to life stressors, and while it shares overlapping psychopathology with both normal stress response and with major depression, there is evidence that the diagnosis may have pathophysiological characteristics that distinguish it from both. This chapter explores the evidence supporting underlying theories derived from diverse fields including genetics, neuroimaging, and neuroendocrine and neurotransmitter functioning, and considers how the pharmacological management of adjustment disorder is linked to said theories. It discusses the gaps in our knowledge and considers the causes for the relative lack of interest in this diagnosis compared with other diagnoses.
Treatment of adjustment disorders (DRAFT)
Authors: Casey Patricia
Published: April 2018

There are few randomized controlled studies of the treatment of AD. This is due to the transience of the symptoms, the difficulty obtaining a homogeneous population owing to the absence of diagnostic criteria, and the variable nature of the stressor, among others. Clinical guidelines specify that brief psychological interventions are preferred, and these incorporate elements from the many approaches now available on the assumption that their mechanism of action will also be effective in AD. Few have been tested specifically in AD. Low-intensity therapies specific to AD are being developed, such as biblio-therapy and online self-help. Pharmacological interventions have not been tested in quality trials, but despite this, antidepressants continue to be frequently prescribed. A few trials of anxiolytics have found some benefit for all the agents examined, but none used placebo. EMDR was found to be beneficial in a small pilot study and is worthy of further study.
Adjustment disorder in disorders of intellectual development (DRAFT)
Authors: Bradley Elspeth , Hollins Sheila , Korossy Marika , Levitas Andrew
Published: April 2018

People with disorders of intellectual development (DID) have a diversity of abilities and consequent support needs. Adjustment difficulties give rise to mental distress and behavioural concerns when expectations are more than can be managed in the absence of needed supports. People with DID also experience a disturbing range of negative life events, trauma, and adversity, all of which can trigger adjustment disorder. Unless such stressors are identified, the individual with DID may be diagnosed with more serious psychiatric disorder, and the opportunity to remove the stressor and offer psychological treatment that both minimizes the emotional impact of the stressor and enhances coping (best practice) is lost. Chronic adjustment disorder, other serious psychiatric disorders, and challenging behaviours may develop and be perceived as treatment resistant (as long as the stressor remains). These diagnostic and treatment issues, in the context of the lives of people with DID, are explored in this chapter.
Overview of Ethical Approaches (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

While there exists significant disagreement among bioethicists as to the appropriate course of action in specific cases, there is actually general agreement about how to approach ethical dilemmas. This involves classifying the nature of the dilemma, reviewing existing information, acquiring additional information, analyzing the issue from multiple viewpoints, and formulating a response in light of potential criticisms. Potential analytic viewpoints include principlism, consequentialism, virtue ethics, casuistry, narrative ethics, and the ethics of care. When a clear resolution is not possible, ideally the situation can be temporized or clearly unacceptable options—including rationing at the bedside—eliminated, in the hopes of further resolution eventually occurring.
The “Right to Die” (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Formerly referred to as “passive euthanasia,” forgoing life-sustaining medical treatment came to be accepted in the 1970s based on a patient’s right to privacy. In order to achieve this societal shift, the practice was clearly distinguished from active euthanasia, which was universally rejected. Over the ensuing decades, other permutations of “the right to die”—including receiving intensive pain medication at the end of life and palliative sedation—were considered and accepted to varying degrees. Modern advocates of euthanasia now argue that it is not, in fact, so different from forgoing life-sustaining medical treatment, which endangers the critical consensus that lies at the heart of the patient rights movement. Voluntarily stopping eating and drinking is also discussed, as well as the ethical equivalence of withdrawing and withholding life-sustaining treatment.
Forgoing Life-Sustaining Medical Treatment (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Forgoing life sustaining medical treatment takes on additional complexities depending on the mode of therapy forgone, which often varies in clinical practice. Compassionate extubation of the paralyzed or alert patient requires more in-depth ethical analysis. Some cardiologists are reluctant to deactivate pacemakers, requiring thoughtful comparison of these devices with implantable defibrillators, which do not prompt such debate. Dialysis is a burdensome intervention that may not prolong life and when instituted should be considered a time-limited trial. Enteral and parenteral nutrition create distinct issues in terms of emotional connotation, burden, and benefit.
Ethics of Child and Adolescent Palliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Over the course of childhood a patient’s decision-making capacity evolves. While eighteen is the age of majority in most states, younger patients may well have the ability to process information and make informed decisions. At the same time, the “dual process theory” of maturation reveals that emotional considerations may outweigh cognitive ones. Physicians must understand how to respond to parental requests for nondisclosure of diagnosis and prognosis, as well as differences of opinion between the patient and parents as to appropriate treatment options. Even when a child agrees with her parents regarding a treatment plan, this may reflect undue influence rather than voluntariness. And even when a treatment has a favorable benefit/burden ratio, an adolescent’s refusal may present such a logistical barrier that a modified treatment plan may need to be implemented.
Neuropalliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Neuropalliative care encompasses disorders of consciousness, cognitive impairment, trauma, and other conditions. Each prompts specific ethical considerations, such as the often shifting values (and even personalities) of patients with dementia, forcing one to determine whether previously expressed wishes are determinative. Patients with amyotrophic lateral sclerosis maintain cognition long after motor failure, and the predicable trajectory makes possible specific advance care planning. Patients who have suffered acute spinal cord injury may initially demand withdrawal of life sustaining medical treatment, yet studies have shown a significant proportion eventually achieve a quality of life acceptable to them. And patients who have suffered a stroke often recover significant function, thus making early limitation of treatment a potential “self-fulfilling prophecy.”
Death and Organ Donation (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

The concept of death by neurological criteria (i.e., brain death) was formulated in 1968 to describe a state of complete and irreversible loss of brain function. While there remain philosophical debates about the validity of the concept, it is enshrined in state law—with a few notable limitations—and impacts both the role of continued somatic support as well as making possible the donation of vital organs. In light of the shortage of organs available for transplantation, greater attention has recently been paid to death by circulatory criteria procurement protocols. One significant source of disagreement is the duration of pulselessness required to declare death and whether circulation needs to be irreversibly ceased or only permanently so.
Research in Palliative Care (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

There exists a dearth of empirical research in palliative care, both due to limited funding and also methodological hurdles. Some have questioned the appropriateness of doing research with palliative care patients, based on the vulnerability caused by the nature of their illness. But despite this added vulnerability, such patients may well be able to offer informed consent, and without quality research the field will not grow in its ability to provide optimal care to patients. Researchers also need to identify reliable and valid metrics for quality care, which can be challenging given the subjective nature of many measures (such as symptoms) and the treatment preferences that can vary from individual to individual.
Final Thoughts (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

It is not enough to know how to respond to ethical dilemmas in palliative care. Sufficient resources are required to implement the nuanced approach to ethical dilemmas presented in this textbook. In the developed world, there exists a profound shortage of palliative care clinicians, as well as regulatory barriers which may impede the provision of optimal palliative care. The situation is far more serious in the developing world, where access to symptomatic medications may be severely restricted due to lack of economic resources or bureaucratic barriers. Even when a qualified team is available and necessary tools are at hand, the emotional challenges inherent in caring for seriously ill patients may negatively impact team dynamics. This is particularly true in situations where members of the team believe they know what the “right” thing to do is, but external forces prevent them from doing it, thus causing moral distress.
Model-independent curvature determination with 21 cm intensity mapping experiments
Authors: Witzemann Amadeus , Bull Philip , Clarkson Chris , Santos Mario G , Spinelli Marta , Weltman Amanda
Published: April 2018

Measurements of the spatial curvature of the Universe have improved significantly in recent years, but still tend to require strong assumptions to be made about the equation of state of dark energy (DE) in order to reach sub-percent precision. When these assumptions are relaxed, strong degeneracies arise that make it hard to disentangle DE and curvature, degrading the constraints. We show that forthcoming 21 cm intensity mapping experiments such as Hydrogen Intensity and Real-time Analysis eXperiment (HIRAX) are ideally designed to carry out model-independent curvature measurements, as they can measure the clustering signal at high redshift with sufficient precision to break many of the degeneracies. We consider two different model-independent methods, based on ‘avoiding’ the DE-dominated regime and non-parametric modelling of the DE equation of state, respectively. Our forecasts show that HIRAX will be able to improve upon current model-independent constraints by around an order of magnitude, reaching percent-level accuracy even when an arbitrary DE equation of state is assumed. In the same model-independent analysis, the sample variance limit for a similar survey is another order of magnitude better.
Repair of Temporal Bone Defects via the Middle Cranial Fossa Approach: Treatment of 2 Pathologies With 1 Operation
Authors: Eddelman Daniel B , Munich Stephan , Kochanski Ryan B , Eggerstedt Michael , Kazan Robert P , Moftakhar Roham , Munoz Lorenzo , Byrne Rich W , Wiet R Mark
Published: April 2018

BACKGROUND

Temporal bone dehiscence (TBD) often results in leakage of cerebrospinal fluid (CSF) and/or encephalocele. TBD can also occur over the superior semicircular canal, causing debilitating vertigo. Both can be repaired surgically, but traditional treatment is focused only on one pathology, not both.

OBJECTIVE

To report our experience in the treatment of TBD via the middle cranial fossa (MCF) approach.

METHODS

A retrospective review was conducted for all patients who underwent MCF approach for surgical repair of any temporal fossa dehiscence.

RESULTS

A total of 34 patients underwent a total of 37 surgeries. Obesity was prevalent; 21 patients (61.8%) were obese (BMI [body mass index] > 30 kg/m2), and 7 (20.6%) were overweight (BMI 25-30 kg/m2). The most common presenting symptom was hearing disturbance (70.3%), followed by otorrhea (51.4%). Empty sella was noted on computed tomography or magnetic resonance imaging in 15 patients (45.5%). Eight of the 34 patients (23.5%) were found to have superior semicircular canal dehiscence (SCD). Hearing improved with surgical intervention in 25 of 26 patients with hearing loss as a presenting symptom (96%). CSF resolved in 18 of 19 cases (95%). Seventy-three percent of patients reported at least minimal improvement in vertigo.

CONCLUSION

TBD may present with symptoms of CSF leak/encephalocele, but may also present with superior SCD. We recommend consistent review of the temporal bone imaging to check for superior SCD, and repair of the SCD first to prevent complications involving the labyrinth and cochlea. MCF approach using a multilayer repair without a lumbar drain is highly effective with minimal risk of complications.
CE: Original Research: Exploring Clinicians’ Perceptions About Sustaining an Evidence-Based Fall Prevention Program
Authors: Porter Rebecca B. , Cullen Laura , Farrington Michele , Matthews Grace , Tucker Sharon
Published: April 2018

Purpose: This study aimed to address the knowledge gap between implementing and sustaining evidence-based fall prevention practices for hospitalized patients by exploring perspectives of the interprofessional health care team.

Design: A qualitative design was used to capture insights from clinicians across disciplines in a large midwestern academic medical center.

Methods: Four homogenous semistructured focus groups and three individual interviews involving a total of 20 clinicians were conducted between October 2013 and March 2014. Audio-recorded data were transcribed and analyzed using inductive qualitative analysis.

Findings: Two primary themes emerged from participants regarding the sustainability of an evidence-based fall prevention program: communication patterns within the interprofessional health care team and influences of hospital organizational practices and elements. Several subthemes also emerged. Participants gave nursing staff primary responsibility for fall risk assessment and prevention.

Conclusions: Individual professional perceptions and practices, as well as organizational characteristics, affect the sustainability of evidence-based fall prevention practices. While all team members recognized patient falls as a significant quality and safety issue, most believed that direct care nurses hold primary responsibility for leading fall prevention efforts. The data support the importance of effective interprofessional team communication and organizational practices in sustaining an evidence-based fall prevention program across inpatient units. Furthermore, the data call into question the wisdom in labeling quality indicators as “nursing sensitive”; the evidence indicates that a team approach is best.
Implications of vitamin D toxicity & deficiency
Authors: Waterbury Susan
Published: April 2018

Vitamin D deficiency is an increasing problem affecting all ages. Patients should be assessed for risk factors as part of preventive health maintenance. Vitamin D toxicity is a rare occurrence caused by oversupplementation and errors in food fortification. The connection between vitamin D deficiency and osteoporosis, is well established. However, a cause and effect relationship has yet to be established between vitamin D deficiency and many chronic illnesses. An evidence-based approach is treating patients for an underlying vitamin D deficiency in hopes of improving many chronic illnesses.
Herbal supplements
Authors: Pruitt Rosanne , Lemanski Ashley , Carroll Adam
Published: April 2018

Herbal supplements are used extensively worldwide without much awareness regarding their safety and efficacy. Extensive research to determine the safety, utility, and level of research support for commonly used herbs has culminated in an easily accessible summary chart for NP providers.
Creating a Culture of Wellness in Residency
Authors: Edmondson Emma K. , Kumar Anupam A. , Smith Stephanie M.
Published: April 2018

Despite increased awareness and recognition of the prevalence of physician burnout and the associated risks of depression and suicide, there is a paucity of actionable guidelines for residency programs to mitigate these risks for their residents. In this Invited Commentary, the authors acknowledge that, although there are inherent barriers to resident wellness, there are numerous modifiable barriers that present opportunities for programs to enable culture change and improve resident well-being. The authors frame the discussion with a personal narrative written by a resident in their internal medicine program who experienced burnout, depression, and suicidality during his intern year. They aim to inspire residency programs and hospital leadership to identify and intervene upon the modifiable barriers to wellness for residents in their programs in order to shape meaningful cultural change.
MRI in spondyloarthritis: when and how?
Authors: Kröber Georg , Weber Ulrich
Published: April 2018

Purpose of review

To summarize recent advances and challenges of using MRI toward early recognition of axial spondyloarthritis (SpA).

Recent findings

Low-grade bone marrow edema (BME) on sacroiliac joint (SIJ) MRI is nonspecific and may be misleading in recognition of axial SpA. Structural features on SIJ MRI along with BME may not only facilitate recognition of early disease, but also enhance specificity. Structural lesions on MRI and low-dose computed tomography are highly concordant, adding to criterion validity of SIJ MRI. There is accumulating evidence that SIJ MRI due to superior reliability of structural lesions may supplant the traditional imaging approach by pelvic radiographs in healthcare settings in which MRI is readily available. Pilot initiatives exploring the bone remodeling cascade in SIJs showed early reparative response upon biological treatment. Methodological challenges regarding evaluation and data processing of imaging examinations need to be addressed to enhance reproducibility and specificity of imaging in SpA.

Evaluation of SIJ MRI is contextual incorporating structural lesions and BME. MRI is but one element in pattern recognition toward diagnosis. An unmet need is dissemination of advances in imaging in SpA to the broad community of rheumatologists and radiologists.
The Effect of Hip Positioning on the Projected Femoral Neck–Shaft Angle: A Modeling Study
Authors: Bhashyam Abhiram R. , Rodriguez Edward K. , Appleton Paul , Wixted John J.
Published: April 2018

Objectives:

To determine and test mathematical models of the relationship between hip flexion–extension, femoral rotation, and NSA. We hypothesized that hip flexion–extension and femoral rotation would result in NSA measurement error.

Methods:

Two mathematical models were developed to predict NSA in varying degrees of hip flexion–extension and femoral rotation. The predictions of the equations were tested in vitro using a model that varied hip flexion–extension while keeping rotation constant, and vice versa. The NSA was measured from an anterior–posterior radiograph obtained with a C-arm. Attributable measurement error based on hip positioning was calculated from the models.

Results:

The predictions of the model correlated well with the experimental data (correlation coefficient = 0.82–0.90). A wide range of patient positioning was found to result in <5–10 degrees error in the measurement of NSA. Hip flexion–extension and femoral rotation had a synergistic effect in measurement error of the NSA. Measurement error was minimized when hip flexion–extension was within 10 degrees of neutral.

Conclusions:

This study demonstrates that hip flexion–extension and femoral rotation significantly affect the measurement of the NSA. To avoid inadvertently fixing the proximal femur in varus or valgus, the hip should be positioned within 10 degrees of neutral flexion–extension with respect to the C-arm to minimize positional measurement error.
Long-term Posttraumatic Survival of Spinal Fracture Patients in Northern Finland
Authors: Niemi-Nikkola Ville , Saijets Nelli , Ylipoussu Henriikka , Kinnunen Pietari , Pesälä Juha , Mäkelä Pirkka , Alen Markku , Kallinen Mauri , Vainionpää Aki
Published: April 2018

Study Design.

A retrospective epidemiological study.

Objective.

To reveal the long-term survival and causes of death after traumatic spinal fracture (TSF) and to determine the possible factors predicting death.

Summary of Background Data.

Increased mortality following osteoporotic spinal fracture has been represented in several studies. Earlier studies concerning mortality after TSF have focused on specific types of fractures, or else only the mortality of the acute phases has been documented. In-hospital mortality has varied between 0.1% and 4.1%.

Methods.

The study sample of 947 patients including all patients with TSF admitted to Oulu University Hospital, Finland, between January 1, 2007 and December 31, 2011. TSFs were identified using International Classification of Diseases 10th revision or Nordic Classification of Surgical Procedures codes and all patient records were manually reviewed. Times and causes of death, obtained from Statistics Finland's Archive of Death Certificates, were available until the end 2016 and 2015, respectively.

Results.

At the end of the follow-up 227 (24.0%) had died. Mortality was 6.8% after the first year and 19.1% after 5 years. Mortality was increased in all age groups compared with the general population, 1-year standardized mortality ratios ranging from 3.1 in over 65-year-olds to 19.8 in under 30-year-olds. In age groups of 50 to 64 years and over 65 years, the most important risk factors for death were males with hazard ratios of 3.0 and 1.6, respectively, and low fall as trauma mechanism with hazard ratios of 9.4 and 10.2, respectively.

Conclusion.

Traumatic spinal fractures are associated with increased mortality compared with the general population, high mortality focusing especially on older people and men. The increase seems to be comparable to the increase following hip fracture. Patients who sustain spinal fracture due to falling need special attention in care, due to the observation that low fall as trauma mechanism increased the risk of death significantly.

Level of Evidence: 3