bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of verbal and written information on pain perception in patients undergoing fixed orthodontic treatment: a randomized controlled trial
Authors: Montebugnoli Francesca , Incerti Parenti Serena , D’Antò Vincenzo , Alessandri-Bonetti Giulio , Michelotti Ambra
Published: August 2019

Background

Pain can discourage patients from seeking orthodontic treatment or compromise their compliance during therapy.

Objectives

To determine the effects of verbal and written information on orthodontic pain after fixed appliance placement.

Trial design

Two-arm parallel design randomized controlled trial.

Methods

Healthy adolescents with permanent dentition enrolled for orthodontic treatment were assigned to the study or control group using computer-generated random lists and allocation concealment with sealed envelopes. Participants completed baseline questionnaires to assess anxiety (State-Trait Anxiety Inventory Trait Version, Form X-2) and somatosensory amplification (Somatosensory Amplification Scale). Brackets were placed in the maxillary arch, from first molar to first molar, and an Australian archwire 0.012 inch was used for alignment. General verbal information on orthodontic treatment was given to all patients by the same clinician. Participants included in the study group received also detailed verbal instructions on orthodontic pain together with a take-home information leaflet by another clinician. Outcome included assessments of pain intensity with a Numerical Rating Scale (NRS) on the day of appliance placement (Day 1, bedtime) and twice a day for the following 6 days (Day 2 to Day 7, morning, bedtime), and analgesic consumption. Participants, statistician, and clinicians who gave general verbal information on orthodontic treatment and instructions about how to score pain intensity were blinded to group assignment.

Results

Sixty patients were assigned to the study (n = 30, mean age: 15.4 ± 1.3 years) or control group (n = 30, mean age: 14.7 ± 3.2 years). At baseline, no significant between-group differences were present in terms of anxiety and somatosensory amplification. Orthodontic pain scores were significantly lower in the study group compared with the control one, at bedtime on Day 1 (P < 0.05) and in the morning of Day 2 (P < 0.01). No significant between-group differences were found in following measurements. Overall, analgesic consumption was significantly lower in study compared with the control (P < 0.01).

Conclusion

A combination of verbal and written information on orthodontic pain after placement of fixed appliances reduced patient’s self-reported pain in the early stages.

Registration

This study was not registered.
16-year follow-up of the Danish Acute Myocardial Infarction 2 (DANAMI-2) trial: primary percutaneous coronary intervention vs. fibrinolysis in ST-segment elevation myocardial infarction
Authors: Thrane Pernille G , Kristensen Steen D , Olesen Kevin K W , Mortensen Leif S , Bøtker Hans Erik , Thuesen Leif , Hansen Henrik S , Abildgaard Ulrik , Engstrøm Thomas , Andersen Henning R , Maeng Michael
Published: August 2019

Aims

The DANish Acute Myocardial Infarction 2 (DANAMI-2) trial found that interhospital transport to primary percutaneous coronary intervention (pPCI) was superior to fibrinolysis at the local hospital in patients with ST-segment elevation myocardial infarction (STEMI) at 30 days. The present study investigates the 16-year cardiovascular outcomes.

Methods and results

We randomized 1572 STEMI patients to pPCI or fibrinolysis at 24 referral hospitals and 5 invasive centres in Denmark. Patients randomized to pPCI at referral hospitals were immediately transported to the nearest invasive centre. The main endpoint of the current study was a composite of death or rehospitalization for myocardial infarction (MI). Outcome information beyond 3 years was obtained through Danish health registries. After 16 years, pPCI-treated patients had a sustained lower rate of composite endpoint compared to patients treated with fibrinolysis in the overall cohort [58.7% vs. 62.3%; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76–0.98], and among patients transported for pPCI (58.7% vs. 64.1%; HR 0.82, 95% CI 0.71–0.96). No difference in all-cause mortality was found, but cardiac mortality was reduced by an absolute of 4.4% in favour of pPCI (18.3% vs. 22.7%; HR 0.78, 95% CI 0.63–0.98). pPCI postponed a main event with 12.3 months in average compared to fibrinolysis (95% CI 5.0–19.5).

Conclusion

The benefit of pPCI over fibrinolysis was maintained at 16-year follow-up. pPCI reduced the composite endpoint of death or rehospitalization for MI, reduced cardiac mortality, and delayed average time to a main event by approximately 1 year.
Imipenem/relebactam activity compared to other antimicrobials against non-MBL-producing carbapenem-resistant Enterobacteriaceae from an academic medical center
Authors: Kulengowski Brandon , Burgess David S
Published: August 2019

Background

Carbapenem-resistant Enterobacteriaceae (CRE) cause significant mortality and are resistant to most antimicrobial agents. Imipenem/relebactam, a novel beta-lactam/beta-lactamase inhibitor combination, and 16 other antimicrobials were evaluated against non-metallo-beta-lactamase-producing carbapenem-resistant Enterobacteriaceae clinical isolates from a United States tertiary academic medical center.

Objectives

To evaluate imipenem/relebactam and other commonly utilised antimicrobial agents against carbapenem-resistant Enterobacteriaceae. Methods: Clinical isolates (n  = 96) resistant to ertapenem or meropenem by BD Phoenix (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) and negative for metallo-beta-lactamase-production by an EDTA (Sigma-Aldrich Corp., St. Louis, MO, USA)/phenylboronic acid (Sigma-Aldrich Corp., St. Louis, MO, USA) disk diffusion assay were identified and collected from January 2012 to January 2017. In vitro susceptibility by broth microdilution was performed according to CLSI guidelines using CLSI susceptibility breakpoints for 17 antimicrobials (Sigma-Aldrich Corp., St. Louis, MO, USA).

Results

CRE primarily produced Klebsiella pneumoniae carbapenemase (KPC) and consisted primarily of K. pneumoniae (55%) and Enterobacter spp. (25%), followed by Citrobacter spp. (10%), Escherichia coli (5%), and others (5%). CRE were most susceptible to imipenem/relebactam (100%), followed by amikacin (85%), tigecycline (82%), and polymyxin B/colistin (65%). The median reduction of imipenem minimum inhibitory concentrations (MICs) of non-MBL-producing CRE was 16-fold but ranged from 0.5 to >512-fold. The MIC50, MIC90 and MIC range of imipenem/relebactam was 0.5/4, 1/4 and 0.06/4–1/4 mg/L, respectively.

Conclusions

Imipenem/relebactam exhibits excellent activity against CRE that produce KPC.
Vedolizumab use in patients with inflammatory bowel diseases undergoing surgery: clinical trials and post-marketing experience
Authors: Shen Bo , Blake Aimee , Lasch Karen , Smyth Michael , Bhayat Fatima
Published: August 2019

Background

Patients with inflammatory bowel diseases frequently require surgery, but immunotherapies used in disease management may increase the risk of post-operative complications. We investigated frequencies of post-operative complications in patients who received vedolizumab—a gut-selective antibody approved for the treatment of moderately to severely active ulcerative colitis and Crohn’s disease—in clinical-trial and post-marketing settings.

Methods

This post hoc analysis of safety data from GEMINI 1, GEMINI 2, and long-term safety studies included patients who had had colectomy or bowel surgery/resection. Data from the post-marketing Vedolizumab Global Safety Database were also analysed (data cutoff point: 19 May 2016). Adverse events relating to post-operative complications were identified using Medical Dictionary for Regulatory Activities preferred terms.

Results

Of 58 total surgeries in patients included in GEMINI 1 and GEMINI 2, post-operative complications were reported for 3/51 vedolizumab-treated patients (5.9%) and 1/7 placebo-treated patients (14.3%). In the long-term safety study, 157/2,243 patients (7%) had colectomy or bowel surgery/resection; of these 157 patients who underwent surgery, 11 (7%) experienced a post-operative complication. Median time between last pre-operative vedolizumab dose and surgery was 23 days in GEMINI 1, 20 days in GEMINI 2, and 39‒40 days in the long-term safety study. In the post-marketing setting, based on data covering approximately 46,978 patient-years of vedolizumab exposure, post-operative complications were reported in 19 patients.

Conclusions

In clinical trials, complications of colectomy and bowel surgery/resection appeared infrequent, with minimal difference between vedolizumab and placebo. The frequency of post-operative complications in the post-marketing setting appears low.
Comprehensive N-glycosylation analysis of immunoglobulin G from dried blood spots
Authors: Simunovic Jelena , Vilaj Marija , Trbojevic-Akmacic Irena , Momcilovic Ana , Vuckovic Frano , Gudelj Ivan , Juric Julija , Nakic Natali , Lauc Gordan , Pezer Marija
Published: August 2019

Immunoglobulin G (IgG) glycans are emerging as a new putative biomarker for biological age and different diseases, requiring a robust workflow for IgG glycome analysis, ideally beginning with a simple and undemanding sampling procedure. Here, we report the first comprehensive study on total N-glycans of IgG isolated from dried blood spots (DBSs), which was performed in a high-throughput mode. We compared the IgG N-glycan profiles originating from DBS with those originating from plasma, compared different media for DBS collection, evaluated analytical variation and assessed IgG N-glycan profile stability for different storage conditions. In conclusion, we show that DBSs are a good and stable source material for a robust IgG N-glycan analysis by ultra-performance liquid chromatography, suitable for blood sampling in conditions where no trained personnel and necessary laboratory equipment are available.
Assessing causal links between metabolic traits, inflammation and schizophrenia: a univariable and multivariable, bidirectional Mendelian-randomization study
Authors: Lin Bochao D , Alkema Anne , Peters Triinu , Zinkstok Janneke , Libuda Lars , Hebebrand Johannes , Antel Jochen , Hinney Anke , Cahn Wiepke , Adan Roger , Luykx Jurjen J
Published: August 2019

Background

Blood immunoreactive biomarkers, such as C-reactive protein (CRP), and metabolic abnormalities have been associated with schizophrenia. Studies comprehensively and bidirectionally probing possible causal links between such blood constituents and liability to schizophrenia are lacking.

Methods

To disentangle putative causal links between CRP blood levels and schizophrenia in both directions, we conducted multiple univariable Mendelian-randomization (MR) analyses, ranging from fixed-effect to inverse variance-weighted (IVW), weighted-median, MR Egger and generalized summary-data-based Mendelian-randomization (GSMR) models. To prioritize metabolic risk factors for schizophrenia, a novel multivariable approach was applied: multivariable Mendelian-randomization–Bayesian model averaging (MR-BMA).

Results

All forward univariable MR analyses consistently showed that CRP has a protective effect on schizophrenia, whereas reverse MR analyses consistently suggested absent causal effects of schizophrenia liability on CRP blood levels. Using MR-BMA, as the top protective factors for schizophrenia we prioritized leucine and as the prime risk-factor triglycerides in medium very-low-density lipoprotein (VLDL). The five best-performing MR-BMA models provided one additional risk factor: triglycerides in large VLDL; and two additional protective factors: citrate and lactate.

Conclusions

Our results add to a growing body of literature hinting at metabolic changes—in particular of triglycerides—independently of medication status in schizophrenia. We also highlight the absent effects of genetic liability to schizophrenia on CRP levels.
Advances in spatiotemporal models for non-communicable disease surveillance
Authors: Blangiardo Marta , Boulieri Areti , Diggle Peter , Piel Frédéric B , Shaddick Gavin , Elliott Paul
Published: August 2019

Surveillance systems are commonly used to provide early warning detection or to assess an impact of an intervention/policy. Traditionally, the methodological and conceptual frameworks for surveillance have been designed for infectious diseases, but the rising burden of non-communicable diseases (NCDs) worldwide suggests a pressing need for surveillance strategies to detect unusual patterns in the data and to help unveil important risk factors in this setting. Surveillance methods need to be able to detect meaningful departures from expectation and exploit dependencies within such data to produce unbiased estimates of risk as well as future forecasts. This has led to the increasing development of a range of space-time methods specifically designed for NCD surveillance. We present an overview of recent advances in spatiotemporal disease surveillance for NCDs, using hierarchically specified models. This provides a coherent framework for modelling complex data structures, dealing with data sparsity, exploiting dependencies between data sources and propagating the inherent uncertainties present in both the data and the modelling process. We then focus on three commonly used models within the Bayesian Hierarchical Model (BHM) framework and, through a simulation study, we compare their performance. We also discuss some challenges faced by researchers when dealing with NCD surveillance, including how to account for false detection and the modifiable areal unit problem. Finally, we consider how to use and interpret the complex models, how model selection may vary depending on the intended user group and how best to communicate results to stakeholders and the general public.
Transketolase of Staphylococcus aureus in the Control of Master Regulators of Stress Response During Infection
Authors: Tan Xin , Ramond Elodie , Jamet Anne , Barnier Jean-Philippe , Decaux-Tramoni Baptiste , Dupuis Marion , Euphrasie Daniel , Tros Fabiola , Nemazanyy Ivan , Ziveri Jason , Nassif Xavier , Charbit Alain , Coureuil Mathieu
Published: August 2019

Staphylococcus aureus is a leading cause of both acute and chronic infections in humans. The importance of the pentose phosphate pathway (PPP) during S. aureus infection is currently largely unexplored. In the current study, we focused on one key PPP enzyme, transketolase (TKT). We showed that inactivation of the unique gene encoding TKT activity in S. aureus USA300 (∆tkt) led to drastic metabolomic changes. Using time-lapse video imaging and mice infection, we observed a major defect of the ∆tkt strain compared with wild-type strain in early intracellular proliferation and in the ability to colonize kidneys. Transcriptional activity of the 2 master regulators sigma B and RpiRc was drastically reduced in the ∆tkt mutant during host cells invasion. The concomitant increased RNAIII transcription suggests that TKT—or a functional PPP—strongly influences the ability of S. aureus to proliferate within host cells by modulating key transcriptional regulators.
Effect of Mycobacterium tuberculosis Enhancement of Macrophage P-Glycoprotein Expression and Activity on Intracellular Survival During Antituberculosis Drug Treatment
Authors: Wu Qian , Hossfeld Austin , Gerberick Abigail , Saljoughian Noushin , Tiwari Charu , Mehra Smriti , Ganesan Latha Prabha , Wozniak Daniel J , Rajaram Murugesan V S
Published: August 2019

Multidrug-resistant Mycobacterium tuberculosis is a serious public threat for tuberculosis control and prevention. We demonstrated that M. tuberculosis infection induces P-glycoprotein expression in macrophages, suppressing heat shock factor 1, which reduces the effectiveness of antituberculosis drugs within infected macrophages.
Performance of the Fecal Immunochemical Test in Patients With a Family History of Colorectal Cancer
Authors: Moosavi Sarvee , Gentile Laura , Gondara Lovedeep , Mcgahan Colleen , Enns Robert Alan , Telford Jennifer
Published: August 2019

Objective

To assess the performance of a fecal immunochemical test (FIT) among participants of a population-based colorectal cancer (CRC) screening program with one or more first-degree relatives (FDR) with CRC.

Methods

Asymptomatic 50 to 74 years olds with a FDR diagnosed with CRC, enrolled in a colon screening program completed FIT (two samples, cut-off 20 µg Hemoglobin/gram feces) and underwent colonoscopy. FIT-interval CRCs were identified from the British Columbia cancer registry. Logistic regression analysis was used to identify variables associated with the detection of CRC and high-risk polyps (nonmalignant findings that required a 3-year surveillance colonoscopy) in those patients undergoing FIT and colonoscopy.

Results

Of the 1387 participants with a FDR with CRC, 1244 completed FIT with a positivity rate of 10.8%, 52 declined FIT but underwent colonoscopy and 90 declined screening. Seven CRCs were identified: six in patients with a positive FIT, one in a patient who only had colonoscopy. No CRCs were found in patients with a negative FIT. The positive and negative predictive values of FIT in the detection of CRC were 4.8% and 100%, respectively. On multivariate logistic regression, positive FIT, and not type of family history, was the only variable associated with detection of CRC or high-risk polyps. At 2-year follow-up, there was no FIT interval cancer detected in the study cohort.

Conclusion

FIT is more strongly associated with high-risk findings on colonoscopy than type of family history. FIT may be an alternative screening strategy to colonoscopy in individuals with a single FDR with CRC.
Notes on the behavior and first records of three enigmatic anchialine shrimps (Decapoda: Caridea: Barbouriidae, Palaemonidae) in the Bahamas
Authors: Ditter Robert E , Snyder Alexis P , Schulman Stacie E , Bracken-Grissom Heather D
Published: August 2019

Barbouria cubensis von Martens, 1872, Parhippolyte sterreriHart & Manning, 1981 (Barbouriidae) and Macrobrachium lucifugumHolthuis, 1974 (Palaemonidae) are recorded for the first time from anchialine systems on Acklins Island, Bahamas. Seventy-two individuals of B. cubensis, 29 of P. sterreri, and nine of M. lucifugum were collected in July 2017 from five sites across the island. We also report on observations on behavior for all three species during collection and of B. cubensis monitored in a laboratory setting over a two-year period.
The Activation of the Crime of Aggression before the International Criminal Court: Some Overlooked Implications Arising for States Parties and Non-States Parties to the Rome Statute
Authors: de Souza Dias Talita
Published: August 2019

On 17 July 2018, in celebration of the 20th anniversary of the Rome Statute of the International Criminal Court (ICC, the Court), the jurisdiction of the Court was finally activated for the crime of aggression, following a decision made by the Assembly of States Parties (ASP) in December 2017. This resulted from a long and painstaking process which not only furthered the divide between states parties and non-parties but also generated controversy within the ASP itself. In an attempt to reach a minimum common denominator, the ASP decided to exclude from the ICC’s jurisdiction situations involving states parties that have not ratified the amendments in respect of that crime (‘the Kampala Amendments’). Moreover, since the adoption of the Amendments in 2010, it has been agreed that the ICC will not exercise its jurisdiction over the crime of aggression if committed by nationals or on the territory of non-states parties, except when there is a Security Council referral. This combination of jurisdictional hurdles has led many to believe that the crime of aggression will have a limited role to play before the ICC. Nonetheless, a closer look at the Activation Decision, the Kampala Amendments and certain key provisions of the ICC Statute reveals that the activation of the crime of aggression might have a series of overlooked implications for non-parties and parties alike, including those that have not ratified the amendments. In particular, this article will argue that, aside from Security Council referrals, there may still be instances where the Court can apply the crime of aggression to situations involving those states.
Long-Term Outcomes of Sentinel Lymph Node Biopsy for Ductal Carcinoma in Situ
Authors: Hung Peiyin , Wang Shi-Yi , Killelea Brigid K , Mougalian Sarah S , Evans Suzanne B , Sedghi Tannaz , Gross Cary P
Published: August 2019

The use of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is controversial. Using population-cohort data, we examined whether SLNB improves long-term outcomes among patients with DCIS who underwent breast-conserving surgery. We identified 12 776 women aged 67–94 years diagnosed during 2001–2013 with DCIS who underwent breast-conserving surgery from the US Surveillance, Epidemiology, and End Results-Medicare dataset, 1992 (15.6%) of whom underwent SLNB (median follow-up: 69 months). Tests of statistical significance are two-sided. Patients with and without SLNB did not differ statistically significantly regarding treated recurrence (3.9% vs 3.7%; P = .62), ipsilateral invasive occurrence (1.4% vs 1.7%, P = .33), or breast cancer mortality (1.0% vs 0.9%, P = .86). With Mahalanobis-matching and competing-risks survival analyses, SLNB was not statistically significantly associated with treated recurrence, ipsilateral invasive occurrence, or breast cancer mortality (P ≥ .27). Our findings do not support the routine performance of SLNB for older patients with DCIS amenable to breast conservation.
Old Concepts Making New History: Refugee Self-reliance, Livelihoods and the ‘Refugee Entrepreneur’
Authors: Skran Claudena , Easton-Calabria Evan
Published: August 2019

Although not new topics in the field of refugee studies, self-reliance, livelihoods and entrepreneurship have recently taken on a heightened emphasis. However, critical questions remain regarding how and by whom self-reliance is defined and measured, and the intended and unintended outcomes of historical and contemporary efforts to foster it. This introductory article highlights key points arising from the Special Issue and presents a short history of the evolution of the concept of self-reliance in the twentieth and twenty-first centuries, including its linkage to livelihoods. The article then discusses contemporary connections between self-reliance and entrepreneurship vis-à-vis the promotion of the ‘refugee entrepreneur’. It concludes with a brief overview of the articles and themes in the issue. Overall, the article argues for an expanded definition of refugee self-reliance that promotes social as well as economic components and moves beyond narrowly implemented programmes targeting individual and market-based solutions.
PINOID is required for lateral organ morphogenesis and ovule development in cucumber
Authors: Liu Xiaofeng , Hao Ning , Li Huiyuan , Ge Danfeng , Du Yalin , Liu Renyi , Wen Changlong , Li Yuhong , Zhang Xiaolan , Wu Tao
Published: August 2019

CsPID regulates the morphogenesis of leaf, tendril, and floral organs, as well as ovule genesis, by modulating the expression of genes related to auxin transport and ovule development, and by interacting with the polarity regulator CsREV.
Cell type-specific gene expression underpins remodelling of cell wall pectin in exocarp and cortex during apple fruit development
Authors: Collins Patrick P , O’donoghue Erin M , Rebstock Ria , Tiffin Heather R , Sutherland Paul W , Schröder Roswitha , McAtee Peter A , Prakash Roneel , Ireland Hilary S , Johnston Jason W , Atkinson Ross G , Schaffer Robert J , Hallett Ian C , Brummell David A
Published: August 2019

Young apple epidermal cells process cell wall pectic arabinan and galactan side chains different from other cell types, resulting in debranched linear arabinans and the absence of galactans.
Plum and Posner's Diagnosis and Treatment of Stupor and Coma
Authors: Posner Jerome B. , Saper Clifford B. , Schiff Nicholas D. , Claassen Jan
Published: August 2019

This text is an update of a classic work on diagnosing the cause of coma, with the addition of new sections on the treatment of comatose patients. The first chapter provides an up-to-date review on the brain mechanisms that maintain a conscious state in humans and how lesions that damage these mechanisms cause loss of consciousness or coma. The second chapter reviews the neurological examination of the comatose patient, which provides the basis for determining whether the patient is suffering from a structural brain injury causing the coma or from a metabolic disorder of consciousness. The third and fourth chapters review the pathophysiology of structural lesions causing coma and the specific disease states that result in coma. Chapter 5 is a comprehensive treatment of the many causes of metabolic coma. Chapter 6 review psychiatric causes of unresponsiveness and how to identify and treat them. Chapters 7 and 8 review the overall emergency treatment of comatose patients, followed by the treatment of specific causes of coma. Chapter 9 examines the long-term outcomes of coma, including the minimally conscious state and the persistent vegetative state, how they can be distinguished, and their implications for eventual useful recovery. Chapter 10 reviews the topic of brain death, the standards for examination of a patient that are required to make the determination of brain death, and the ethics of diagnosis and treatment of patients who, by definition, have no way to approve of or communicate about their wishes.
Initial Management of Patients with Stupor and Coma
Authors: Posner Jerome B. , Saper Clifford B. , Schiff Nicholas D. , Claassen Jan
Published: August 2019

This chapter provides a general approach to the emergency care of comatose patients. It presents a clinical regimen for the diagnosis and management of patients suffering from stupor or coma. Of all the acute problems in clinical medicine, as the chapter explains, none is more challenging than the prompt diagnosis and effective management of the patient in coma. This is largely because the causes of coma are so many and the physician possesses only a limited time in which to make the appropriate diagnostic and therapeutic judgments. The authors detail basic emergency procedures to evaluate and support the essential airway, breathing, and circulation, and then move through a methodical, step-by-step examination and evaluation of all body systems, focusing on eye and pupillary reactions, motor responses, reflexes, and muscle tone.
Gastrointestinal therapy techniques
Authors: Waldmann Carl , Rhodes Andrew , Soni Neil , Handy Jonathan
Published: August 2019

This chapter discusses gastrointestinal therapy techniques and includes discussion on insertion of a Sengstaken–Blakemore tube in critical care (discussing aspects of the procedure such as indication, equipment, preparation, insertion, post-insertion, pharmacological measures, complications, follow-up therapy) and upper gastrointestinal endoscopy (including presentation, causes, hospital management, clinical approach, resuscitation, initial investigations, endoscopy, endoscopic therapy, medical therapy, and follow-up).
Neurological disorders
Authors: Waldmann Carl , Rhodes Andrew , Soni Neil , Handy Jonathan
Published: August 2019

This chapter discusses neurological disorders and includes discussion on delirium, status epilepticus, meningitis and encephalitis, intracerebral haemorrhage, subarachnoid haemorrhage, ischaemic stroke, Guillain–Barré syndrome, myasthenia gravis, intensive care unit-acquired weakness, tetanus, botulism, rehabilitation and critical illness, and hyperthermias. The aim is to provide a summary of the extensive complex neuological pathologies that can present to an intensive care clinician. Where appropriate, descriptions are provided on clinical presentation, epidemiology, diagnosis (including investigations), and management. Of note, some of the conditions covered can arise on the ward or prehospital environments with subsequent requirement for intensive care, but they can also arise de novo on the intensive care unit itself, highlighting the need for intensive care clinicians to maintain a broad knowledge and understanding of their presentation and management.
Trauma and burns
Authors: Waldmann Carl , Rhodes Andrew , Soni Neil , Handy Jonathan
Published: August 2019

This chapter discusses trauma and burns and includes discussion on initial management of major trauma (ABCDE), head injury (both primary and secondary, but also clinical management, general intensive care unit care, and specific treatment of raised intracranial pressure), spinal trauma, chest trauma, pelvic trauma, the fluid management of burns and the general management of burns, and penetrating trauma. The concepts of permissive hypotension, ongoing resuscitation, and injury severity scores are discussed, together with the importance of the tertiary survey. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized. Burns treatment includes the effect of inhalational injury to the airway. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized.
Looking after critically ill children
Authors: Waldmann Carl , Rhodes Andrew , Soni Neil , Handy Jonathan
Published: August 2019

This chapter discusses paediatrics in critical care and includes discussion on both paediatric transfers for the adult intensivist and looking after a vulnerable child (safeguarding children for the adult practitioner). With the centralization of specialist services into a limited number of hospitals across the UK, an increasing number of children require an interhospital transfer. These include but are not limited to the transfer of the critically ill child. Between 2012 and 2014, 18 500 transfers of critically ill or injured children were undertaken across the UK, of which 2400 were undertaken by non-specialist teams. These patients are some of the sickest children. It is while in transit that these patients are most at risk and the transferring team is most exposed. To minimize risks it is important that the team holds the relevant skills to stabilize and transfer children. A systematic approach is vital. The patient’s condition should be optimized before transfer and any likely difficulties anticipated and a plan to tackle any complications swiftly and effectively is agreed prior to the transfer. In this chapter we offer our approach to the safe transfer of the critically ill child. The second part of this chapter offers an introduction into the safeguarding of vulnerable children. A 2009 survey conducted by the National Society for the Prevention of Cruelty to Children asking children to self-report abuse and neglect found that 18.6% of 11–17-year-olds said they had experienced some type of severe maltreatment. The high prevalence of child abuse makes it likely for the medical practitioner who is mostly caring for adult patients to encounter vulnerable children in clinical practice. This will often happen when participating in the resuscitation of a critically ill or injured child, when anaesthetizing a child, or when looking after a caregiver of such a child. The aim of this chapter is to provide these practitioners with the information that will help them to identify possible child abuse and make them aware of their responsibilities towards these children and their options for action.
Imaging Modalities
Authors: Rosado-de-Christenson Melissa L.
Published: August 2019

The chapter titled imaging modalities describes various methods of imaging the thorax. Imaging of patients presenting with thoracic complaints typically begins with chest radiography. Ambulatory patients should undergo posteroanterior (PA) and lateral chest radiographs. Anteroposterior (AP) chest radiography should be reserved for debilitated, critically ill and traumatized patients. Special chest radiographic projections such as decubitus chest radiography may be employed for specific indications. Chest CT is the imaging study of choice for evaluating most abnormalities found on radiography. Contrast-enhanced chest CT is optimal for evaluation of vascular abnormalities, the hila and some mediastinal lesions. CT angiography is routinely employed in patients with suspected pulmonary thromboembolism or acute aortic syndromes. High-resolution chest CT is reserved for the evaluation of diffuse infiltrative lung disease and often includes expiratory and prone imaging. FDG PET/CT is increasingly employed in the assessment of patients with malignancy for the purposes of initial staging and post therapy re-staging of affected patients. Ventilation/perfusion scintigraphy is used in the assessment of pulmonary thromboembolism. Additional thoracic imaging techniques include: Fluoroscopy for evaluation of the diaphragm, and ultrasound for evaluation of the thyroid and the pleural space.
Introduction to Portable Chest Radiography: Support Devices
Authors: Rosado-de-Christenson Melissa L.
Published: August 2019

The introduction to portable chest radiography outlines a systematic approach to the performance and interpretation of bedside or portable chest radiography. These studies are frequently obtained in critically ill, debilitated and traumatized patients and are performed as anteroposterior (AP) chest radiographs. In each case, the radiologist should identify and assess all visible medical devices for appropriate positioning and exclusion of post procedural or post placement complications. In fact, it is important to explain the nature of all radiopaque structures visible on the radiograph. The radiologist then assesses the lung volume, presence or absence of airspace or interstitial disease, the pulmonary vasculature, and the pleural spaces and chest wall. Comparison to prior studies is important for the identification of subtle changes and abnormalities. Critical findings such as malpositioned medical devices, new consolidations, interval atelectasis, pneumothorax and/or pneumoperitoneum need to be promptly communicated to the clinical staff. In some cases, patients with new abnormalities may require further assessment with more advanced imaging such as chest CT.
Cardiac Conduction Devices
Authors: Ternes Tyler H.
Published: August 2019

Cardiac conduction devices (CCDs) include pacemakers and implantable cardioverter defibrillators (ICDs) and are used for permanent management of cardiac conduction abnormalities. Most CCDs consist of a generator which houses the battery and computer. They gather electronic information and send electric pulses through their attached leads. Typically, the leads are placed via transvenous approach into the right atrial appendage, right ventricle, or coronary sinus, depending on the purpose. A single chamber pacer may be utilized to manage SA nodal disease, with a lead in the right ventricle. Dual-chamber pacers are often used for AV nodal disease, and have leads in the right atrium and right ventricle. Biventricular pacing may be used to improve synchronized right and left ventricular function, with the additional lead positioned in the coronary sinus to stimulate the left ventricle. The presence of a thick “shock coil” confirms the defibrillator capability of the device (ICD). Radiographic evaluation following CCD placement should ensure proper lead placement, and exclude pneumothorax, hemothorax, and/or hemopericardium. Subsequent imaging should exclude Twiddler’s syndrome (change in generator position) and lead fracture. Temporary pacing devices may also be used in emergent and postoperative settings, and typically consist of epicardial leads that can be easily removed.
Volume Loss
Authors: Walker Christopher M.
Published: August 2019

Atelectasis is one of the most frequently encountered imaging abnormalities on chest radiography and CT, with different implications when detected in hospitalized patients as compared to those encountered in the outpatient setting. Bedridden and postoperative patients often have a dependent type of atelectasis, whereas lobar atelectasis detected in an outpatient is often a harbinger of underlying malignancy (e.g. lung cancer). Medical malpractice cases are sometimes based on the missed diagnosis of lung cancer manifesting as atelectasis and misinterpreted by a radiologist. It is imperative that radiologists be familiar with the direct and indirect imaging signs of atelectasis, as well as the classic patterns of lobar atelectasis. Specific signs of lobar atelectasis will be described including the S sign of Golden and the luftsichel sign. A confident knowledge of lung anatomy, particularly with regard to hilar anatomy and the normal appearance of mediastinal contours and the interlobar fissures, will enable the radiologist to confidently diagnose atelectasis and narrow the differential diagnostic considerations.
Atelectasis: Opaque Hemithorax
Authors: Walker Christopher M.
Published: August 2019

Atelectasis resulting in an opaque hemithorax often indicates serious underlying disease including lung cancer or other tumors, with or without associated pleural effusion. Total lung atelectasis is usually caused by lung cancer obstructing a main bronchus, but can also result from mucus plugging, contralateral intubation of a main stem bronchus, bronchial stricture, or foreign body aspiration. A large amount of fluid and blood may be drawn into the collapsed lung with little or no loss of volume, resulting in a “drowned lung”. Chest radiographic findings of mediastinal shift toward or away from the opaque hemithorax, and associated findings pertaining to superior displacement of the ipsilateral hemidiaphragm and upper abdominal structures help establish volume loss as the etiology of the opaque hemithorax. Absence of these findings indicates preservation of volume in the ipsilateral hemithorax which may indicate the presence of a mass, an obstructing central lesion with associated drowned lung or a large pleural effusion with associated ipsilateral atelectasis. Pneumonectomy will result in an opaque hemithorax secondary to fluid filling of the pneumonectomy space. Unilateral pneumonia is a rare cause of opaque hemithorax.
Lower Lobe Atelectasis
Authors: Walker Christopher M.
Published: August 2019

Lower lobe atelectasis may be the initial imaging manifestation of lung cancer, and its detection on chest radiography and/or CT often allows the interpreting radiologist to be the first to suggest the diagnosis. Affected patients may be asymptomatic or present with vague complaints. Varying degrees of lower lobe atelectasis may occur due to other etiologies. Moderate and marked degrees of lobar atelectasis typically result in a triangular-shaped opacity with its apex oriented towards the hilum. Displaced interlobar fissures are a direct (primary) sign of atelectasis. A unique imaging feature of right lower lobe atelectasis is associated displacement of the minor fissure, in addition to the displaced major fissure that characteristically occurs in right or left lower lobe atelectasis.
Nontraumatic Thoracic Aorta
Authors: Raptis Constantine
Published: August 2019

Chest pain represents one of the most common reasons for emergency department visits. Imaging often plays a key role in the patient’s care. Diseases of the media (aortic dissection, intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU)) have been grouped under the term acute aortic syndrome. Other conditions may be seen in patients suspected of an acute aortic syndrome, including thoracic aortic aneurysm, aortic fistula, aortic thrombus and vasculitis. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.
Introduction to Pleural Disease
Authors: Walker Christopher M.
Published: August 2019

The chapter titled introduction to pleural disease discusses the imaging and clinical features of diseases of the pleura. The pleural space is a potential space located between the visceral and parietal pleural surfaces. Pleural effusion and pneumothorax are the most common manifestations of pleural disease and are caused by a wide variety of disease processes. Pleural thickening may be related to benign or malignant processes. Bilateral discontinuous nodular pleural thickening is characteristic of pleural plaques. Pleural thickening with calcification may also be seen in fibrothorax. Malignant pleural disease may manifest with pleural effusion, pleural nodules or masses, or a combination of the two. There are several CT features suggestive of malignant pleural thickening including circumferential pleural thickening, pleural nodules or masses, involvement of the mediastinal pleural surface, and pleural thickening measuring greater than 1 cm in thickness. Metastatic disease is the most common pleural neoplasm. Mesothelioma is uncommon but remains the most common primary pleural malignancy and is almost always seen in patients with previous asbestos exposure. Pleural abnormalities must be differentiated from pulmonary processes. Pleural masses may exhibit obtuse angles with the adjacent pleural surfaces, displace rather than engulf adjacent pulmonary vasculature, and may exhibit the incomplete border sign.
Opportunistic Fungal Infection
Authors: Betancourt Sonia L.
Published: August 2019

Opportunistic fungal infections are caused by fungi that are nonpathogenic in the immunocompetent host, many of which are part of the normal upper respiratory tract flora. These organisms may cause pulmonary infection in immunocompromised hosts. Immunocompromised patients and patients with febrile neutropenia with opportunistic fungal infections may have normal chest radiographs. Thus, chest CT should be performed for further evaluation. Imaging abnormalities in this patient population should raise suspicion for opportunistic infection. Neutropenia is the single most important risk factor for Aspergillosis. Aspergillus is the most common opportunistic infection in patients with hematologic malignancy and bone marrow transplantation. Aspergillus spp., Candida spp., and Cryptococcus spp. are the most common fungal infections in patients with solid organ transplantation. Pneumocystis jirovecii is the most common fungal infection in patients AIDS with CD4 count s<200 cells/mm3. Cryptococcal pneumonia is also common in this population. There has been a recent increase in uncommon fungal pathogens causing invasive pulmonary disease.
Lung Cancer: Staging
Authors: Benson Ryo E. C.
Published: August 2019

Lung cancer staging is a process used to assess the extent of spread of lung cancer, determine the most appropriate treatment and predict the patient’s prognosis. Clinical staging is performed prior to surgical resection, while surgical-pathologic staging is based on histologic analysis of the resected tumor and lymph nodes. Restaging is performed following treatment. Staging is based on the TNM classification system. T refers to the primary tumor, N to thoracic lymph node involvement and M to metastatic disease. Recent changes to T and M descriptors were made to better reflect actual survival. For the majority of non-small cell lung cancers, the presence or absence of mediastinal lymph node spread is the most important outcome predictor. Although no changes were made to the N descriptor, the actual intrathoracic lymph node stations were recently clarified. Although the majority of small cell lung cancers are metastatic at the time of presentation, the presence of limited versus extensive spread of disease determines treatment options. However, the overall prognosis and survival for affected patients is poor. TNM staging is now recommended for carcinoid tumors as well as small cell lung cancer.
Bronchiolitis
Authors: Little Brent P. , Henry Travis S.
Published: August 2019

In children, the term bronchiolitis refers to an acute respiratory illness caused by bronchiolar infection, typically by respiratory syncytial virus (RSV) or other viruses. In adults, the term refers to a primarily bronchiolar pattern of infection or inflammation caused by many pulmonary infections, systemic inflammatory conditions, inhaled irritants, certain systemic conditions, and accompanying several congenital diseases. Imaging may be helpful to assess the extent and severity of bronchiolitis and to establish a differential diagnosis based on the distribution of imaging findings, their respective morphologies, and any ancillary findings. Presence of cavities or architectural distortion with a bronchiolitis pattern, especially in the upper lungs, should prompt consideration of tuberculosis. Aspiration bronchiolitis is a common finding in patients with severe reflux or with impaired swallowing mechanisms. Early diagnosis of hypersensitivity pneumonitis can lead to prompt identification of the offending antigen. In cases with pure centrilobular nodules, smoking history is paramount – smokers get RB, non-smokers have a higher likelihood of hypersensitivity pneumonitis.
Eosinophilic Lung Diseases
Authors: Martínez-Jiménez Santiago
Published: August 2019

Eosinophilic lung disease (ELD) comprises a group of disorders that affect the lungs and manifest with blood and/or tissue eosinophilia. ELD may be secondary to a variety of conditions such as infection by parasites (e.g. ascariasis, strongyloidiasis, paragonimiasis, etc.), drug reaction, bronchopulmonary aspergillosis (ABPA) and malignancy. ELD may also be a primary process either limited to the lung (e.g. acute and chronic eosinophilic disease) or as part of a systemic disorder (e.g. allergic granulomatosis with polyangiitis or hypereosinophilic syndrome). On imaging ABPA is characterized by tubular branching opacities that may exhibit the finger-in-glove sign (i.e. inspissated mucus within dilated central bronchi). Strongyloidiasis often manifests with multifocal pulmonary opacities affecting all pulmonary lobes. AEP may simulate cardiogenic pulmonary edema on imaging. Chronic eosinophilic pneumonia (CEP) may have varied imaging manifestations, including the so-called “photographic negative of pulmonary edema”.
Ground-Glass Opacities
Authors: Bueno Juliana
Published: August 2019

Ground-glass opacity (GGO) is defined at thin-section CT as abnormally increased lung density in which vascular and bronchial margins remain visible. This contrasts with consolidation in which those margins are obscured. In the setting of diffuse lung disease, GGO may be related to airspace filling, interstitial thickening or both. Pathologic processes manifesting as diffuse GGO have widely varied symptoms according to the etiology. The assessment of diffuse GGO is primarily achieved with HRCT. Helpful features in establishing a differential diagnosis include: chronicity, distribution of opacities and ancillary findings. Differential diagnosis of acute GGO includes infection, alveolar hemorrhage and pulmonary edema. Chronic GGO may be seen in hypersensitivity pneumonitis, organizing pneumonia, acute or chronic eosinophilic pneumonia, pulmonary alveolar proteinosis and desquamative interstitial pneumonia (DIP). GGO is a nonspecific HRCT pattern that should always be interpreted in light of acuity of symptoms, specific clinical presentation and laboratory results.
Cystic Lung Disease
Authors: Bueno Juliana
Published: August 2019

A lung cyst is a round parenchymal lucency or low-attenuating area with a well-defined interface with adjacent normal lung and surrounded by an epithelial or fibrous wall that is often less than 2 mm in thickness. Diseases that manifest with lung cysts comprise a limited but well known group of entities. Classic diseases manifesting with diffuse lung cysts include pulmonary Langerhans cell histiocytosis (PLCH), lymphangioleiomyomatosis (LAM), lymphocytic interstitial pneumonia (LIP) and Birt-Hogg-Dubé syndrome. However, it is important to recognize other conditions that may mimic cystic lung disease, such as pneumatoceles, tracheobronchial papillomatosis, cavitary disease (e.g. tuberculosis, fungal infection), bronchiectasis, and emphysema. Differentiation between true cysts and cyst mimics may be difficult, and may rely on identification of ancillary findings.