bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of COVID-19 on Families of Pediatric Solid Organ Transplant Recipients
Authors: Forner-Puntonet Mireia , Castell-Panisello Eudald , Quintero Jesús , Ariceta Gema , Gran Ferran , Iglesias-Serrano Ignacio , Gisbert-Gustemps Laura , Daigre Constanza , Ibañez-Jimenez Pol , Delgado Mercedes , Español-Martín Gemma , Parramon Gemma , Pont Teresa , Ramos-Quiroga Josep Antoni
Published: May 2021

Objective

The COVID-19 pandemic and lockdown measures have had a clear psychological impact on families, and specifically those with children with chronic illnesses have reported greater overloads and exhaustion. The objective of this study was to evaluate the exposure, impact and experience of the pandemic on families of pediatric solid organ transplant (SOT) recipients compared to families of healthy children and adolescents.

Methods

We recruited 96 families, 48 with a pediatric SOT recipient and 48 healthy controls, matched by child age and gender. A primary caregiver from each family responded to an online sociodemographic questionnaire and the COVID-19 Exposure and Family Impact Survey (CEFIS), which explores the exposure, impact and experience of the pandemic and lockdown on families.

Results

Exposure to the pandemic was greater in families of healthy children and adolescents. The impact was mostly negative in both groups: caregivers reported increased anxiety (76%) and mood disturbances (71.9%) and hindered quality of sleep (64.6%) and health habits (58.3%). On the positive side, family relationships improved. Qualitatively, the SOT group positively perceived isolation and established hygienic measures as protective and destigmatizing, although they reported fear of virus transmission to their child.

Conclusions

The psychological impact of the pandemic has been similar in both groups, although families of transplant recipients have protected themselves more, probably because they are used to prevention measures and they see contagion as a graver risk. Additionally, SOT recipients’ families presented some idiosyncratic elements, especially a decrease in their perception of stigma associated with the medical condition.
Simultaneous aortic and pulmonary valve replacement in a young patient after intracardiac repair for tetralogy of Fallot: mechanical or biological valve? A case report
Authors: Okubo Ryo , Kimura Fumiaki , Harada Hideyuki , Kobayashi Daita , Shirasaka Tomonori , Kamiya Hiroyuki
Published: May 2021

Pulmonary valve stenosis and regurgitation can occur in the distant stages after intracardiac repair of tetralogy of Fallot (TOF). Aortic regurgitation (AR) can also occur, although it is rare in postoperative patients. However, there are few reports of simultaneous replacement of the pulmonary and aortic valves in young patients after intracardiac repair of TOF, and there are no clear guidelines for selecting a valve prosthesis in such patients. We report a case of severe pulmonary valve stenosis and regurgitation with severe AR 38 years after the TOF operation, in which urgent double valve replacement and right ventricular outflow tract patching were performed with a mechanical valve in the aortic valve position and a bioprosthetic valve in the pulmonary valve position, with a successful outcome.
An extraordinary rare anastomotic band causing food bolus obstruction following uneventful minimally invasive esophagectomy: endoscopic treatment
Authors: Baili Efstratia , Davakis Spyridon , Syllaios Athanasios , Boura Maria , Meropouli Antonia , Charalabopoulos Alexandros
Published: May 2021

The most common long-term complication post esophagectomy implicating the esophagogastric anastomosis is stricture-induced stenosis leading to late postoperative dysphagia. Herein, we present a case of a male patient readmitted to our Upper Gastrointestinal Department due to a food bolus obstruction through an anastomotic epithelial band arisen from a prior esophagogastric anastomosis performed 5 months earlier. A band transection in between two hemostatic clips placed on both sides of the band, followed by a release and fragmentation of the foreign body into several pieces led to its final transoral removal endoscopically. The patient experienced a direct resolution of his dysphagia and discharged on the same day. At 6 months follow-up, he remains symptom-free. In conclusion, endoscopic state-of-the-art techniques when combined with standard hemostatic surgical principles in a minimally invasive manner are excellent tools for the management of post-esophagectomy syndromes.
Incarceration of transplanted kidney through incisional hernia
Authors: Nawabi Atta , Marlor Derek , Camarata Christopher , King Clay D , Nawabi Perwaiz
Published: May 2021

Transplanted allograft kidney herniation through an incisional hernia resulting in incarceration is a rare condition with only one other similar case reported in the literature. The primary imaging modalities used to diagnose kidney herniation are graft ultrasound, abdominal computed tomography and abdominal magnetic resonance imaging [Sugi et al. (Imaging of renal transplant complications throughout the life of the allograft: comprehensive multimodality review. Radiographics 2019;39:1327-1355)]. Treatment should be based on patient’s symptoms. This case report highlights the initial presentation of hematuria in a 57-year-old male that eventually led to the diagnosis of a right-sided incarcerated grafted kidney through an incisional hernia. Subsequently, the patient underwent transplant nephrectomy.
A Call to Thaw the Shoulder
Authors: Al-Rashid Mamun
Published: May 2021

The shoulder joint is an intrinsically unstable joint with a very wide range of multidirectional motions that allow positioning of the arm in a variety of functional planes. Complaints of gradual and spontaneous limitation of shoulder range of motion require prompt attention due to their functional consequences. Adhesive capsulitis is a common shoulder condition that can be painful and functionally disabling. Most cases are idiopathic, with a smaller number of individuals developing it secondary to previous trauma or surgery. Adhesive capsulitis is a clinical diagnosis of painful shoulder with global loss of passive and active range of motion and normal radiological findings. This chapter reviews the clinical signs, differential diagnoses, and treatment options for adhesive capsulitis.
A “Spooky” Shoulder Blade
Authors: Sharma Joyti , Melendez-Benabe John
Published: May 2021

Disorders affecting the scapula can lead to significant limitations in arm movement and pain. Scapular winging is a rare, painful, and debilitating condition that leads to limited functional abilities of the upper limb. This condition can be caused by multiple etiologies, most commonly lesions to the long thoracic nerve (serratus anterior weakness) and spinal accessory nerve (trapezius weakness). Other less common types may be caused by lesions affecting the dorsal scapular nerve. These neurological lesions produce characteristic and distinct types of scapular winging or dyskinesis. This chapter reviews the various types of scapular winging and discusses their evaluation, diagnosis, and management options.
A Construction Worker Sidelined by Elbow Pain
Authors: Subbarao Bruno
Published: May 2021

Lateral epicondylitis is an enthesopathy, a disorder involving the attachment of a tendon to a bone. It is a painful condition caused by chronic repetitive microtrauma and inflammation of and around the common extensor tendon attachment located at the lateral epicondyle of the humerus. Also known as “tennis elbow,” lateral epicondylitis is often due to repetitive motions and therefore can be managed conservatively by addressing any improper biomechanics that may have led to undue stress or tension on the tendons. Pain and inflammation can otherwise be managed in a similar manner as other inflammatory conditions—through a multimodal approach of therapies, bracing, pharmaceuticals, injections, and, if necessary, surgery. This chapter will provide the key components of the evaluation and stepwise management of this condition.
The Case of the Burning Pinky
Authors: Pham Quynh Giao
Published: May 2021

Pain and paresthesias affecting the fifth digit may be caused by lesions affecting the lower cervical spine roots, brachial plexus, or the ulnar nerve. Cubital tunnel syndrome is the most common compression neuropathy affecting the ulnar nerve. Cubital tunnel syndrome commonly presents with sensation abnormalities in the fourth and fifth digits with positive Tinel’s sign at the elbow. Cubital tunnel syndrome can arise from ulnar nerve compression at the ulnar groove or between two heads of the flexor carpi ulnaris muscle proximally. This chapter reviews the signs and symptoms of cubital tunnel syndrome and discusses its evaluation and diagnosis. It also discusses treatment considerations.
Ghostly White Hands That Come and Go
Authors: Cruz-Jimenez Maricarmen , Cuevas-Trisan Ramon
Published: May 2021

The evaluation of hand pallor and discoloration requires immediate attention to assess vascular compromise and ischemia. Raynaud’s is a rare condition that affects approximately 5% of the U.S. population. It is a vascular condition that may be idiopathic (primary) or a manifestation of a systemic disease (secondary). It affects arteries, particularly at their most distal segments of the fingers and to a lesser degree the toes. The vessels suffer severe vasospasm that leads to ischemia and pain. The diagnosis is made by triggering the vasospasm using tests such as the cold stimulation test. Raynaud’s can be very disabling and painful, leading to finger and toe amputations in severe cases. The condition has no cure, and treatment modalities include some pharmacological and interventional analgesic procedures, with overarching goals centered around patient education, their awareness on how to protect their hands from attacks, and lifestyle modifications. Secondary Raynaud’s is primarily managed by treating the underlying cause and avoiding triggers.
Physiological Changes During Pregnancy
Authors: Missouri Shairko , Miller Trevor , Mueller Taylor
Published: May 2021

Pregnancy is a normal maternal physiological state that is developed to accommodate and nurture the fetus and enable the mother during labor. Pregnancy engenders multiple systemic changes—whether it be hormonal, mechanical, or circulatory. The gravid uterus and the increase in progesterone and estrogen levels attributes to the multisystemic changes. The increase in peptide hormones alters connective tissue characteristics, leading to structural changes to the kidneys, ureters, rib cage, diaphragm, and abdominal compartments. Cardiac output, pulmonary blood flow, and circulating blood volume are all increased in response to rising metabolic demands. There are additional significant changes in many biochemical laboratory results in comparison to the nonpregnant women. Awareness of those changes will not only enable clinicians to navigate normal pregnancy but also to identify critical pathological values that assist in further management.
The Placenta
Authors: Gonzalez Sandra N. , Patel Easha , Riley Christa L.
Published: May 2021

The human placenta is the interface between the mother and the fetus, allowing for the transfer of nutrients and gases and the removal of waste products from the fetal metabolism, which are processes necessary for optimal fetal growth and development. Increasingly, many parturients receive various medications during pregnancy and many parturients require surgery during pregnancy and are therefore exposed to anesthesia. It is important to understand what medications administered to the mother reach the fetus and how those medications affect the fetus. Placental functions also include endocrine and metabolic functions that are involved in the regulation of both maternal metabolism as well as fetal growth and development. These functions evolve throughout the duration of the pregnancy, and as the placenta develops, its features adjust to provide the support needed for a successful outcome. The anatomy and physiology of the placenta change dynamically, resulting in a large surface area for transfer of substances and for increasing blood flow that supports the high metabolic demands of the growing fetus. Abnormalities in any of its functions can compromise the viability of the pregnancy or result in poor perinatal outcomes such as intrauterine growth retardation.
Coexisting Disease and the Parturient: Part Two
Authors: Aquino Benjamin F. , Heidari Afshin , Haghi Leila
Published: May 2021

Coexisting medical conditions in pregnancy significantly increase the risk of adverse outcomes for both the mother and fetus. Understanding and managing these conditions is essential to mitigating this risk. Because the issues mentioned herein tend to be less common, is it all the more imperative that they be recognized quickly, identified correctly, and treated appropriately when they do occur. These include autoimmune thrombocytopenic purpura (ATP), therapeutic anticoagulation with neuraxial anesthesia, multiple sclerosis, myasthenia gravis, HIV infection, systemic lupus erythematosus (SLE), and abuse of substances such as cocaine and marijuana. All of these can have considerable implications on peripartum physiology and the subsequent anesthesia management of pregnant patients with these conditions. The goal here is not for comprehensiveness, but rather to give the reader concise, pertinent details that can be referenced quickly to guide appropriate peripartum management of anesthesia.
Local Anesthetics
Authors: Eddins Michelle
Published: May 2021

Local anesthetics are used in obstetric practice to achieve analgesia and anesthesia via neuraxial procedures (spinal or epidural). Local anesthetics exhibit their effect by blocking voltage-gated sodium channels on neurons, thereby inhibiting the achievement of an action potential which is required for nerve impulse propagation. There are two major groups of local anesthetics—the aminoamides and the aminoesters. The most commonly used aminoamide local anesthetics in obstetric anesthesia are lidocaine, bupivacaine, and ropivacaine. The most commonly used aminoester local anesthetics in obstetric anesthesia are 2-chloroprocaine and tetracaine. Epinephrine can be added to local anesthetics to prolong their duration of action. The addition of sodium bicarbonate to local anesthetics hastens their onset of action. Local anesthetic systemic toxicity (LAST) can occur when large doses of local anesthetic are administered. Systemic toxicity from local anesthetics can be fatal and must be treated promptly with 20% lipid emulsion. Rarely, anaphylaxis can occur after the administration of local anesthetics. This occurs most commonly with the aminoesters.
Non-pharmacologic Labor Analgesia
Authors: Marotta Michael , Gutman David
Published: May 2021

Non-pharmacologic labor analgesia techniques have been shown to have questionable and variable efficacy but are noninvasive and overall appear to be safe. The individual experience of labor pain is multifactorial and has both physiologic and psychosocial components. Distinct approaches to labor analgesia target one or more of labor pain’s contributing factors. Pharmacologic approaches aim to relieve the pain of labor by blocking physiologic sources. Non-pharmacologic labor analgesia attempts to help women cope with or distract them from labor pain by targeting psychosocial and physiologic sources. The psychosocial contributions to labor pain are not well understood, and their presence and impact vary greatly between individuals. As such, they are difficult to define, difficult to study, and difficult to treat. This has led to a paucity of high-quality data on the subject, but non-pharmacologic techniques are likely an important and useful component of labor analgesia. Various approaches to non-pharmacologic treatment include, but are not limited to, biofeedback, continuous labor support, hypnosis, relaxation, acupuncture, water immersion, and sterile water injections. Generally speaking, these techniques have been shown to have questionable and variable efficacy but are non-invasive and overall appear to be safe.
Neuraxial Techniques and Medications for Cesarean Delivery
Authors: Baron Elvera L. , Katz Daniel
Published: May 2021

Neuraxial anesthesia is the preferred anesthetic technique for cesarean delivery. Several options are available for medications and for neuraxial anesthetic delivery. This chapter begins by reviewing the advantages of neuraxial anesthesia as compared to general anesthesia, contraindications of neuraxial placement, and potential complications with recommended management strategies. Additionally, it provides a detailed overview of each neuraxial technique for cesarean delivery: epidural, spinal, and combine spinal epidural anesthesia. Advantages, disadvantages, and common medications with suggested doses are summarized for each technique. Finally, an anatomically based approach with appropriate patient positioning is reviewed and strategies for supplementation of inadequate neuraxial blockade are discussed.
Airway Management
Authors: Sirianni Joel , Mester Robert
Published: May 2021

Airway management during pregnancy is covered in this chapter as maternal airway manipulation is high risk, requiring expert knowledge and experience in planning for the maternal airway, maternal physiology, aspiration prophylaxis, and the difficult airway. This chapter describes the many changes to the maternal gastrointestinal tract and respiratory system commonly seen in pregnancy, which elevate risks to the mother and fetus that are not typically seen in the nonparturient. It reviews the changes that lead to a higher risk of aspiration, hypoxemia, airway friability, and difficult intubation during induction of general anesthesia. It covers the keys to providing safe anesthesia to the parturient through mitigation of risks by focusing on prophylactic medications, aspiration treatment, airway preparation, planning for the difficult airway and emergence, and the postpartum airway.
Anesthesia for Fetal Surgery
Authors: Evans Beata , Quinn Kevin , Petersson Rajanya S. , Wills Timothy , Kromah Fatoumata
Published: May 2021

Over the past decade, advancements in prenatal ultrasound and availability of fetal MRI have allowed for early diagnosis of congenital anomalies, and anesthetic and surgical developments have facilitated successful management and interventions of fetal anomalies. Fetal anomalies such as twin to twin transfusion syndrome, neural tube defects, and malformations impacting the fetal airway, cardiac, thoracic, abdominal, and urological systems affect the smallest and most vulnerable patient population. Minimally invasive, open, and ex-utero intrapartum procedures are three types of interventions available for the treatment of correctable fetal anomalies. These fetal procedures halt further progression of congenital anomalies early in fetal development and decrease fetal/neonatal morbidity and mortality.1 Open fetal surgical procedures are indicated for neural tube defect and congenial diaphragmatic hernia repair. These open surgical procedures improve fetal conditions, and impact postdelivery disability and fetal/neonatal death.2 Conditions in which the fetus’ airway may be compromised by a head or neck mass increase the newborn’s risk for respiratory and cardiovascular failure. In such situations, an ex utero intrapartum therapy (EXIT) procedure may be performed. During the EXIT procedure, the fetus remains dependent on placental oxygenation provided by the maternal circulation. Anesthetic choice for fetal surgery depends on maternal comorbidity, airway evaluation, type of fetal surgery, and surgical needs.
Cytoskeleton
Authors: Benarroch Eduardo E.
Published: May 2021

The cytoskeleton consists primarily of microfilaments, microtubules, and intermediate filaments. Actin microfilaments have major role in growth, maintenance, and dynamic changes of growth cones and dendrites; stabilization of proteins at specific membrane locations; and vesicle dynamics during endocytosis and exocytosis. Microtubules provide the major tracks for intracellular transport and local cues for positioning of mitochondria and other organelles. The intermediate filaments in neurons are the neurofilaments that have a major role in regulating axonal caliber and mechanical stability. Glial fibrillary acid protein is a primary component of intermediate filaments in astrocytes. Nuclear lamins participate in regulation of the chromatin organization, trafficking of transcription factors across the nuclear envelope, and transduction of mechanical signals. Mutations affecting these cytoskeletal proteins produce a wide range of neurologic disorders, including neurodevelopmental disorders, peripheral neuropathies, myopathies, and leukodystrophy. All components of the cytoskeleton are involved in adult-onset neurodegenerative disorders.
Homeostasis and Adaptation
Authors: Benarroch Eduardo E.
Published: May 2021

Central control of homeostasis and adaptation to internal challenges or external challenges requires interactions among the hypothalamus, amygdala, and several areas of the cerebral cortex. These areas directly or indirectly provide input to brainstem autonomic areas. The hypothalamus is critical for basic vital functions, including energy metabolism, fluid and electrolyte balance, thermoregulation, wake–sleep cycle, responses to internal or environmental stressors, and reproduction. The amygdala provides automatic tagging of the valence (positive or negative) and intensity of innate or conditioned environmental stimuli and triggers automatic survival responses. The insula integrates multiple sensations to create a feeling of the body. The anterior cingulate provides subjective relevance to these feelings and initiates predictive visceromotor commands that are compared to interoceptive inputs reaching the insular cortex. Disorders of these circuits, for example, in the setting of seizures or limbic encephalitis, are potentially life-threatening.
Emotion and Social Cognition
Authors: Benarroch Eduardo E.
Published: May 2021

Emotion is a cognitive and behavioral state critical for survival. Processing of emotions includes a network that encompasses the amygdala and the orbitofrontal, insular, and cingulate cortices, and their connections with the other cortical areas, basal forebrain, ventral striatum, hypothalamus, and brainstem. These areas interact to assess the positive or negative valence of environmental stimuli and bodily feelings and initiate survival responses, promote arousal, attribute value for decision-making, and guide action selection and social behavior. Focal, degenerative, or psychiatric disorders affecting components of this emotion network manifest with profound disturbances in affect, decision-making, and social behavior.
Epidemiology and Radiologic Imaging of Vascular Disease
Authors: Arora Harendra , Kumar Priya Ajit , McLean Duncan
Published: May 2021

Vascular disease is one of the leading causes of morbidity and mortality in the United States and throughout the world. One of the key offending factors in the pathogenesis of vascular disease is atherosclerosis, which involves endothelial damage as a result of generalized inflammation of the vasculature. The clinical sequelae related to atherosclerosis are varied based on the extent and anatomic location involved. Typically, atherosclerotic disease exists in multiple sites, even if it clinically presents in one location. Aortic atherosclerosis results in aneurysms, dissections, penetrating ulcers, intramural hematomas, and occlusive disease. Carotid artery stenosis, which is caused predominantly by atherosclerosis, is associated with an increased risk of stroke. Peripheral arterial disease results in insufficient blood flow to the lower extremities, which manifests as intermittent claudication. The risk of limb loss from poor circulation is often overshadowed by the risk of mortality from coexistent coronary artery and cerebrovascular atherosclerosis.
Vascular Surgery of the Upper Extremity
Authors: Canonico Andrew , Jones Cameron , Lutzker Tatiana N. , Gage Parr K.
Published: May 2021

Upper extremity and hand ischemia may be caused by several factors, the most common of which is arterial occlusion/peripheral vascular disease. Compared to vascular surgery for the lower extremity, upper extremity intervention is quite rare, accounting for approximately 4% of all vascular bypass procedures. This may be due to the more robust collateral circulation in the upper extremity. This chapter examines the main conditions, treatments, anesthetic concerns, and management in the field of upper extremity vascular surgery, including revascularization for both acute and chronic upper limb ischemia and other common interventions, such as hemodialysis access for patients with end-stage renal disease.
Perioperative Management of Combined CABG and CEA Procedures
Authors: Nguyen Hieu , Lutzker Tatiana N. , Gage Parr K.
Published: May 2021

Combined coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) procedures can be done in individuals who have concomitant coronary and carotid artery disease. This chapter reviews briefly the history of revascularization procedures (endarterectomy, carotid artery stenting). It also discusses risk factors that increase mortality in individuals who undergo these procedures, as well as the selection criteria for identifying individuals who would be appropriate candidates for combined CABG/CEA procedures. The perioperative management, including preoperative optimization, intraoperative concerns, and postoperative complications of these patients, also are reviewed. Finally, a brief survey of the current literature is provided to examine the current recommendations on whether or not combined procedures should be done compared to staged procedures.
Vascular Surgery
Authors: Yoon Jeongae , Sankova Susan K.
Published: May 2021

Endovascular surgery has gone through remarkable advancement since its inception, and its capacity to perform complex vascular surgeries with a minimally invasive approach has gained popularity. This advancement has afforded surgery on patients who were deemed to be too high risk for open procedures and lowered the risk of complex procedures with extensive disease burden. This chapter discuss two of the most commonly performed endovascular procedures of the neck/chest/upper extremities: carotid artery stenting for carotid stenosis and thoracic endovascular aortic repair for thoracic aortic aneurysm or dissection. The continued advancement of endovascular devices and techniques is changing the landscape of the management of vascular disease.
Anesthesia for Amputation Surgery
Authors: Little Michael B.
Published: May 2021

This chapter examines the perioperative anesthetic concerns for patients undergoing amputation surgery of the upper or lower extremity. Most amputation surgeries, particularly of the lower extremity, are the result of peripheral artery disease (PAD). This chapter discusses multiple comorbid conditions associated with PAD, such as diabetes mellitus, hypertension, tobacco use, and sepsis and how they impact risk stratification and anesthetic management. It also discusses pertinent anatomical considerations, intraoperative management with general anesthesia, neuraxial anesthesia, and/or regional anesthesia. It also discusses short- and long-term postoperative outcomes, including major adverse cardiac events and chronic phantom limb pain as well as strategies to improve outcomes.
Lung Isolation Techniques
Authors: Johnson William , Nikolaidis Melissa , Saied Nahel
Published: May 2021

Lung isolation can be used during thoracic surgery to selectively ventilate a single lung for a discrete purpose. There are several indications for lung isolation, with the strength of each indication varying from absolutely indicated to preferable. Indications for lung isolation are reviewed in this chapter. Three main techniques for achieving lung isolation are also reviewed in detail. These include intentional mainstem with a single-lumen endotracheal tube, use of a double-lumen endobronchial tube and use of a bronchial blocker. The benefits and drawbacks of each technique are discussed. Finally, specific steps to troubleshoot hypoxia during one-lung ventilation are reviewed.
Anterior Mediastinal Masses
Authors: Sidoran Kevin , Tafeese Hanan , Perry Tiffany D. , Desvarieux Tricia
Published: May 2021

Anterior mediastinal masses can affect the airway, breathing, and circulation (ABC) and often entail a well-planned multidisciplinary team approach with regard to management. The anesthetic management of these cases depends on the individual’s risk and symptomology. Anesthesia can range from standard general to awake cannulation for extracorporeal membrane oxygenation depending on severity of presentation and extent of airway and cardiovascular compromise. It is crucial to avoid an “intubate, cannot ventilate” situation or cardiovascular collapse. Patients who present with the superior vena cava syndrome can be particularly challenging. The goal of this chapter is to describe a case-based approach to anterior mediastinal masses focused on the ABCs. By reviewing the etiology of mediastinal masses, examining the presentation of symptoms, exploring the pathophysiology and the risks to the ABCs, the authors emphasize the need for a multidisciplinary approach to care for these patients effectively.
Postoperative Management and Complications in Thoracic Surgery
Authors: Demos Daniel , McGough Edward
Published: May 2021

The goal of this chapter is to provide the necessary framework to manage thoracic surgery patients in the intensive care unit (ICU) during the initial postoperative visit. Thoracic surgery impairs postoperative respiratory function, which can lead to postoperative complications. Complications are commonly associated with specific risk factors such as age, results of preoperative pulmonary function tests, cardiovascular comorbidity, smoking status, and chronic obstructive pulmonary disease. The authors focus on immediate postoperative concerns, including ventilator management and weaning, as well as postoperative hemorrhage. After the patient arrives at the ICU and is immediately assessed, the focus pivots to analgesia and resuscitation with an emphasis on goal-directed fluid management. Last, a basic understanding of common postoperative complications, including diagnosis and management, is paramount to quality ICU care.
Pulmonary Pathophysiology in Anesthesia Practice
Authors: Haynes Gary R. , McClure Brian P.
Published: May 2021

This chapter compares normal and abnormal pulmonary function and discusses clinical considerations when evaluating patients for surgery and anesthesia. Basic pulmonary physiology and the effect that positive pressure ventilation has on lung function are reviewed. The action of anesthetic drugs on the control of ventilation, and the pathophysiologic effect of the common pathophysiologic conditions of pulmonary hypertension and pulmonary embolism are discussed.
Anesthetic Management Techniques (Regional Anesthesia)
Authors: Kabes Tyler , Przkora Rene , Mora Juan C.
Published: May 2021

This chapter provides an overview of the different blocks and procedures available to control the perioperative pain of patients undergoing thoracic surgical interventions. The authors describe each procedure, as well as its clinical indications, limitations, key anatomical structures, procedural techniques, and required equipment and medications. The procedures covered here include neuraxial procedures such as the thoracic epidural, in addition to blocks such as the paravertebral, intercostal, serratus anterior plane, erector spinae, transversus thoracis muscle plane, and Pecs I and II. Also included are images of skin landmarks, sonoanatomy, and a step-by-step procedure description. An overview of the regional techniques can be found in the chapter’s provided tables.
Visit 4
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

In Visit 4, the survivor and clinician focus on four goals. First, they conduct a review of the verbal rehearsal strategies taught in the last visit—which verbal rehearsal strategies were used, for what, when, and where, and modify as needed. Second, the clinician and survivor work together to review the cognitive restructuring skills of realistic probabilities and decatastrophizing, primarily reviewing how helpful these methods are in re-thinking memory problems or barriers, and which method appeared to aid coping. Next, the external strategies of keeping a schedule and memory routines are taught, including the rationale for keeping a day planner; simplifying the schedule; and assuring daily review of the schedule. Finally, memory routines are discussed and homework is assigned to apply a chosen compensatory strategies.
Visit 5
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

In this visit, the survivor and clinician will first review homework such as what strategies the survivor has used since the prior visit and how successful they have been. The clinician and survivor will also review external strategies of external cueing and distraction reduction (auditory and visual distractions) and the importance of limiting multitasking which adversely affects the learning of new information. They will also cover the topic of distraction reduction with respect to use of electronic devices and social media, especially passive scrolling through social media pages. The rationale for and concepts involved in activity scheduling and pacing are also discussed. The survivor is asked to apply the chosen compensatory strategy and practice it in daily life.
Memory and Attention Adaptation Training
Authors: Ferguson Robert , Gillock Karen
Published: May 2021

Memory and Attention Adaptation Training (MAAT) is a cognitive-behavioral therapy (CBT) designed to help cancer survivors self-manage and mitigate the late and long-term effects of cancer and cancer therapy on memory function. Cancer-related cognitive impairment (CRCI) is a set of mild to moderate memory and attention impairments that can have an adverse influence on quality of life. CRCI symptoms tend to present during active treatment, but for some individuals cognitive changes can persist for years. While the exact prevalence of CRCI is unknown, review of the literature estimates that nearly half of all survivors may experience some form of CRCI. Causes of CRCI are multiple and are the subject of continued research. Chemotherapy, genetic vulnerability, neurovascular damage, inflammation, and hormonal/endocrine disruption have all been identified as candidate mechanisms of persistent cognitive change. Given the multiple causal mechanisms, finding a biomedical treatment for CRCI remains elusive. MAAT was developed as a CBT to help cancer survivors make adaptive behavioral and cognitive changes to improve performance in the valued activities that CRCI hinders. MAAT consists of eight visits and has been designed for administration through telehealth technology, improving access to survivorship care that so many cancer survivors may lack after the time and expense of cancer treatment. Survivors are provided a workbook they can use to work with their clinician and to reinforce learning and adaptive coping. This clinician manual guides the clinician step by step on MAAT administration and provides background on the theoretical underpinnings of CRCI and MAAT.
Visit 1
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

During Visit 1, clinicians provide survivors with an introduction and overview of MAAT and review the eight-session training schedule. The education component covers cancer background, significance, and causes as well as helping survivors recognize that not all memory/attention failures are related to cancer or cancer treatment (reattribution). MAAT highlights the important rationale that while we can’t know all the causes of cancer-related memory problems, we do know that factors such as stress, fatigue, and the divided attention of busy, daily life also contribute to memory problems, and we can change environment and stress response and manage fatigue by using compensatory strategies aimed at minimizing the effects of memory failures. Self-awareness is introduced, and self-monitoring forms are explained and assigned for homework in order to identify the environmental, affective, and cognitive antecedents of memory failures in daily life. Survivors are instructed in progressive muscle relaxation, home practice and application in daily activity.
Visit 3
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

In this visit, survivors review their practice, their response to quick relaxation, and their overall ability to use relaxation skills in a practical way since the prior visit. They also review their use of self-instructional training, review homework, and discuss any other memory and attention problems they’ve noticed. Visit 3 involves reviewing verbal rehearsal strategies (verbal rehearsal, spaced rehearsal, chunking, and rhymes) and selecting one to focus on. The survivor learns how to identify and challenge thinking that leads to excessive stress or erodes emotional strength and resilience and to practice the new memory and attention strategy by applying in daily life. The clinician introduces and teaches cognitive restructuring techniques of probability estimation and decatastrophizing.
Visit 6
Authors: Ferguson Robert J. , Gillock Karen Lee
Published: May 2021

In Visit 6, survivors are introduced to their first combined internal and external strategies: active listening and verbal rehearsal for socializing. Active listening is a compensatory strategy used in MAAT to help reduce social avoidance due to cognitive difficulties. Active listening involves using basic interviewing methods, such as summarizing and clarifying what one heard, so that survivors can compensate for parts of conversation they may miss. It presents an opportunity to clarify and “verbally rehearse” the conversational point to register and encode that point. Verbal rehearsal also provides a strategy to help become re-engaged in previously avoided social activity. Three steps can be taken to aid with active listening skills: (1) review nonverbal behaviors and paralinguistic tone; (2) review summarization (when the listener repeats back a summary of what it is they believed they heard, thus rehearsing the message); and (3) review clarification to seek assurance that what was heard was the intended message. Further, fatigue management and sleep improvement are highlighted if relevant to the survivor, with the rationale of using simple behavior change to minimize the potential impact of sleep problems and fatigue on cognitive function.
Defining obesity
Authors: Sinha Sunil , Abubakar Hawa
Published: May 2021

Obesity is defined in different ways in different parts of the world, though an excess of adipose tissue may be the easiest acceptable definition of the problem. In most of the world, the body mass index, easily calculated using the two metrics of height and weight, is used as a surrogate marker of obesity. The limitations of the body mass index include that it does not account for fat mass or distribution and the ‘healthy’ obese are clubbed with the unhealthy. Also, due to its heterogeneity, a simple scale of obesity is inapplicable to the Caucasian population compared to the people of Mongoloid descent and many Eastern countries have used different cut-offs to label overweight and obese.
Genetics of obesity
Authors: Rose Chase D. , Pathmanathan Ajintha
Published: May 2021

Genetic studies of obese animals and humans have led to findings of multiple genes that confer risk of developing obesity. Individuals can be classified as having genetic obesity, strong or slight genetic predisposition, or genetic resistance to obesity. The current evidence based on familial studies suggests that 40–80% of the variation between individual body mass indices has a genetic basis. The genetic reference tool ‘human obesity gene map’ provides a global encyclopaedia for identified genes, mutations, and qualitative trait loci. Studies such as genome-wide association studies have pointed researchers towards new pathways of neurohumoral mechanisms, other regulators of energy balance, and the interplay with the obesogenic environment. Gene studies have also unmasked the presence and significance of human microbiomes (particularly gut microbiomes) in the pathogenicity of obesity. The likelihood or presence of clinical obesity can be predicted in an individual through the use of genetic susceptibility with 60% accuracy. When gut microbiomes are identified, the predictive accuracy increases to 90%.
Neuromuscular blocking agents in obesity
Authors: Pathmanathan Ajintha , Stewart Paul
Published: May 2021

Obese patients present unique challenges to the anaesthesiologist, requiring careful management of neuromuscular blockade to facilitate intubation, optimize surgical conditions, and ensure safe recovery of patients. Neuromuscular blockade is a key component of the balanced anaesthesia technique initially identified by Cecil Gray and colleagues and termed the Liverpool technique—a triad of unconsciousness, analgesia, and muscle relaxation. Furthermore, monitoring of blockade prior to reversal will allow the anaesthesiologist to select the appropriate reversal agent and correct dosage. Confirmation of recovery of the train-of-four ratio to greater than 0.9 prior to extubation will reduce the adverse effects associated with residual neuromuscular blockade that may be exacerbated in the obese patient. This chapter reviews neuromuscular blocking agents, monitoring of neuromuscular blockade, and reversal agents. This will optimize the management of neuromuscular blockade to improve safety and outcomes in the obese patients.
Patient selection and overview of selected procedures
Authors: Pontell Matthew E. , Galvez Alvaro , Renza-Stigone Elizabeth , Castellanos Andres
Published: May 2021

The surgical management of morbid obesity is a rapidly evolving practice, the indications for which continue to be the subject of discussion. Current indications for bariatric surgery include the following: patients with a body mass index (BMI) of at least 40 kg/m2 who are reasonable candidates for surgery, patients with a BMI of at least 35 kg/m2 with at least one severe comorbid condition associated with morbid obesity, and patients with a BMI between 30 and 34.9 kg/m2 with type 2 diabetes mellitus or metabolic syndrome. Patients who meet these indications and decide to proceed require a thorough, multidisciplinary preoperative assessment. In the current practice at the authors’ institution, preoperative planning can take anywhere between 3 and 6 months. All patients undergo a comprehensive medical evaluation during this time period and are evaluated by cardiology, pulmonology, psychiatry, and gastroenterology specialists who then dictate the appropriate workup required before proceeding with surgery. The field of weight loss surgery has evolved appreciably over the past years, and it continues to do so. The surgical procedures that served as the forefront of this field have been continuously modified to create those that are employed in current practice. Despite the numerous options available to the surgeon, there is still no evidence-based algorithm recommending one procedure over another, nor is there a proven, single best surgical option. The three most commonly practised procedures are the laparoscopic adjustable gastric band, the laparoscopic sleeve gastrectomy, and the laparoscopic Roux-en-Y gastric bypass. At the authors’ institution, the laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass are routinely offered to patients, both of which are relatively safe options for surgical weight loss.
Peripheral nerve blocks in the morbidly obese patient
Authors: Mahmoud Ammar , Aman Mansoor M. , Aman Fahad
Published: May 2021

Morbidly obese patients have an elevated risk from opioid- and sedative-induced respiratory compromise. Post-surgical pain control should include a multimodal approach with an emphasis on peripheral nerve blocks when indicated. The appropriate utilization of regional anaesthetic techniques provides superior analgesia when compared to oral medications alone and offers a favourable safety profile. This chapter aims to highlight the basics of ultrasound-guided regional anaesthesia, and the specifics of performing common upper and lower extremity peripheral nerve blocks in morbidly obese patients.
Salivary gland manifestations and management
Authors: Carter Emily
Published: May 2021

Salivary gland dysfunction is one of the main consequences of Sjögren’s syndrome (SS), primarily due to autoimmune destruction of the excretory tissue of the glands, resulting in inflammation and symptoms such as xerostomia and salivary gland enlargement. In this chapter, the anatomy, physiology, and the structure of the glands are outlined. The pathological process of SS in the major salivary glands and its complications are described. Patients with SS are more susceptible to ascending sialadenitis, pain, and swelling of the salivary glands, which can be managed with a variety of medical, minimally invasive, and surgical techniques. Other salivary gland conditions which may present in ways similar to SS are mentioned in this chapter, and discussed in more details in the section Overlap and mimics of SS.
The asymptotic tidal remnants of cold dark matter subhaloes
Authors: Errani Raphaël , Navarro Julio F
Published: May 2021

We use N-body simulations to study the evolution of cuspy cold dark matter (CDM) haloes in the gravitational potential of a massive host. Tidal mass-losses reshape CDM haloes, leaving behind bound remnants whose characteristic densities are set by the mean density of the host at the pericentre of their respective orbit. The evolution to the final bound remnant state is essentially complete after ∼5 orbits for nearly circular orbits, while reaching the same remnant requires, for the same pericentre, ∼25 and ∼40 orbits for eccentric orbits with 1:5 and 1:20 pericentre-to-apocentre ratios, respectively. The density profile of tidal remnants is fully specified by the fraction of mass lost, and approaches an exponentially truncated Navarro–Frenk–White profile in the case of heavy mass-loss. Resolving tidal remnants requires excellent numerical resolution; poorly resolved subhaloes have systematically lower characteristic densities and are more easily disrupted. Even simulations with excellent spatial and time resolution fail when the final remnant is resolved with fewer than 3000 particles. We derive a simple empirical model that describes the evolution of the mass and the density profile of the tidal remnant applicable to a wide range of orbital eccentricities and pericentric distances. Applied to the Milky Way, our results suggest that 108–$10^{10}\, \mathrm{M_{\odot }}$ haloes accreted $\sim 10\, \mathrm{Gyr}$ ago on 1:10 orbits with pericentric distance $\sim 10\, \mathrm{kpc}$ should have been stripped to 0.1–1 per cent of their original mass. This implies that estimates of the survival and structure of such haloes (the possible hosts of ultra-faint Milky Way satellites) based on direct cosmological simulations may be subject to substantial revision.