bluuebunny/crossref_metadata_2025 huggingface dataset:
Coronary anomalies
Authors: Basso Cristina , Perèz-Pomares José Maria , Thiene Gaetano , Houyel Lucile
Published: August 2018

Coronary artery anomalies occur either in isolation or in the context of congenital heart defects (CHD). Isolated coronary artery anomalies include anomalies of connection to the pulmonary artery or to the aorta, anomalies of the intrinsic coronary arterial anatomy including anomalous orifices, and anomalies of myocardial/coronary arterial interaction including myocardial bridges and fistulae. Such defects are of major significance in clinical cardiology and cardiac surgery because of their association with myocardial ischaemia and sudden death. Coronary anomalies associated with CHD can result from three types of developmental perturbation: (1) anomalous epicardial course (in congenitally corrected transposition of the great arteries and L-looped ventricles), (2) anomalous communication with a high-pressure ventricular cavity (pulmonary atresia with intact ventricular septum and hypoplastic left heart syndrome), or (3) anomalous connection to the aorta. Outflow tract defects represents 30–40% of CHD, and their main characteristic is great artery defects influencing coronary arterial anatomy.
Myocardial non-compaction
Authors: Sheppard Mary N.
Published: August 2018

Isolated left ventricular non-compaction is a controversial entity which has only been reported in the past 30 years. It is becoming more frequently diagnosed due to the use of echocardiography and MRI. It can present in fetal life, infancy, childhood, and adult life. Clinically, the patient can present with cardiac arrhythmias, cardiac failure, systemic emboli due to thrombosis within the ventricles, and sudden death. It can be a genetic entity associated with mutations in many genes associated with hypertrophic cardiomyopathy, dilated cardiomyopathy, and arrhythmogenic cardiomyopathy. It is a rare entity found at autopsy and is more common in children than adults. In the past the prognosis has been considered worse in children then in adults. Treatment is usually empirical, dealing with the cardiac failure, arrhythmias, and thromboemboli.
Developmental aspects of cardiac arrhythmias
Authors: Postma Alex V. , Sedmera David , Vostarek Frantisek , Christoffels Vincent M. , Bezzina Connie R.
Published: August 2018

The rhythmic and synchronized contraction of atria and ventricles is essential for efficient pumping of blood throughout the body. This process relies on the proper generation and conduction of the cardiac electrical impulse. Electrophysiological properties differ in various regions of the heart, revealing intrinsic heterogeneities rooted, at least in part, in regional differences in expression of ion channel and gap junction subunit genes. A causal relation between transcription factors and such regionalized gene expression has been established. Abnormal cardiac electrical function and arrhythmias in the postnatal heart may stem from a developmental changes in gene regulation. Genome-wide association studies have provided strong evidence that common genetic variation at developmental gene loci modulates electrocardiographic indices of conduction and repolarization and susceptibility to arrhythmia. Functional aspects are illustrated by description of selected prenatally occurring arrhythmias and their possible mechanisms. We also discuss recent findings and provide background insight into these complex mechanisms.
Advanced therapies to treat cardiovascular diseases: controversies and perspectives
Authors: Giacca Mauro , Ibáñez Borja
Published: August 2018

There is a pressing need to develop novel therapies for myocardial infarction and heart failure, two conditions that affect over 20% of the world population. Despite important advances in achieving revascularization of the ischaemic myocardium and the usefulness of devices in assisting failing hearts, therapy for these conditions remains poor. The final extent of myocardial tissue loss after infarction is a major determinant of post-infarction mortality due to heart failure. In this chapter we review the current strategies aimed at counteracting injury due to acute myocardial ischaemia–reperfusion and the experimental approaches to achieve cardiac and vascular regeneration once damage has occurred. We critically discuss the possibility of inducing tissue restoration by gene transfer or exogenous cell implantation, and report on the exciting possibility of stimulating the endogenous capacity of cardiac regeneration using growth factors and small regulatory RNAs.
The zebrafish as a model for cardiac development and regeneration
Authors: Chaudhry Bill , de la Pompa José Luis , Mercader Nadia
Published: August 2018

The zebrafish has become an established laboratory model for developmental studies and is increasingly used to model aspects of human development and disease. However, reviewers and grant funding bodies continue to speculate on the utility of this Himalayan minnow. In this chapter we explain the similarities and differences between the heart from this distantly related vertebrate and the mammalian heart, in order to reveal the common fundamental processes and to prevent misleading extrapolations. We provide an overview of zebrafish including their husbandry, development, peculiarities of their genome, and technological advances, which make them a highly tractable laboratory model for heart development and disease. We discuss the controversies around morphants and mutants, and relate the development and structures of the zebrafish heart to mammalian counterparts. Finally, we give an overview of regeneration in the zebrafish heart and speculate on the role of the model organism in next-generation sequencing technologies.
Cells to repair the infarcted myocardium
Authors: Salvatori Daniela , Devalla Harsha D. , Passier Robert
Published: August 2018

The adult mammalian heart has poor regenerative capacity. Loss of functional cardiomyocytes following myocardial infarction leads to the replacement of functional muscle by scar tissue. This has a detrimental effect on cardiac function and may lead to heart failure. Potential regeneration of severe cardiac damage would require replacement of dead and damaged cardiomyocytes by transplantation, recruitment of endogenous progenitor cells, or induction of cardiomyocyte proliferation. For more than a decade, clinical trials to ameliorate the injured heart have been under way. However, after evaluation of the outcome of these trials it is evident that the beneficial effects of these cell-based transplantations are only marginal, and beneficial effects, if any, are not caused by regeneration of cardiomyocytes. In recent years, alternative approaches and various cell sources have been studied and suggested for cardiac repair. Recent advances in these cell-based therapies or strategies to activate endogenous cardiac repair are discussed.
The role of non-coding RNA/microRNAs in cardiac disease
Authors: Reckman Yolan J. , Pinto Yigal M.
Published: August 2018

In the past two decades, our knowledge about non-coding DNA has increased tremendously. While non-coding DNA was initially discarded as ‘junk DNA’, we are now aware of the important and often crucial roles of RNA transcripts that do not translate into protein. Non-coding RNAs (ncRNAs) play important functions in normal cellular homeostasis and also in many diseases across all organ systems. Among the different ncRNAs, microRNAs (miRNAs) and long non-coding RNAs (lncRNAs) have been studied the most. In this chapter we discuss the role of miRNAs and lncRNAs in cardiac disease. We present examples of miRNAs with fundamental roles in cardiac development (miR-1), hypertrophy (myomiRs, miR-199, miR-1/133), fibrosis (miR-29, miR-21), myocardial infarction (miR-15, miR17~92), and arrhythmias/conduction (miR-1). We provide examples of lncRNAs related to cardiac hypertrophy (MHRT, CHRF), myocardial infarction (ANRIL, MIAT), and arrhythmias (KCNQ1OT1). We also discuss miRNAs and lncRNAs as potential therapeutic targets or biomarkers in cardiac disease.
Epigenetics and post-transcriptional regulation of cardiovascular development
Authors: Yang Jin , Han Pei , Li Wei , Chang Ching-Pin
Published: August 2018

Cardiac organogenesis requires the control of gene expression at distinct developmental windows in order to organize morphogenetic steps in the correct sequence for heart development. This is facilitated by concerted regulation at three levels: chromatin, transcription, and post-transcriptional modifications. Epigenetic regulation at the chromatin level changes the chromatin scaffold of DNA to regulate accessibility of the DNA sequence to transcription factors for genetic activation or repression. At the genome, long non-coding RNAs work with epigenetic factors to alter the chromatin scaffold or form DNA-RNA complexes at specific genomic loci to control the transcription of genetic information. After RNA transcription, the expression of genetic information can be further modified by microRNAs. Each layer of gene regulation requires the participation of many factors, with their combinatorial interactions providing variations of genetic expression at distinct pathophysiological phases of the heart. The major functions of chromatin remodellers and non-coding RNAs are discussed.
Complex network interactions: cardiovascular systems biology
Authors: Grunert Marcel , Perrot Andreas , Rickert-Sperling Silke
Published: August 2018

A large quantity of molecular information on heart development, function, and disease has been generated over recent decades. However, most recent studies have been dominated by reductionistic approaches, and thus many aspects remain unclear, particularly regarding the primary causes of complex cardiovascular diseases such as congenital heart malformations. With the advent of high-throughput technologies, systems-based approaches have developed rapidly in biology and medicine. In the biology of cardiovascular systems complex data within or across different molecular levels of biological systems or pathways can be integrated and combined to identify the causes underlying cardiac diseases, which might not be possible otherwise. This is in agreement with data suggesting that biological molecules in individual regulatory layers, such as transcripts, proteins, and metabolites, act within networksrather than independently of each other. Thus systems biology provides a promising approach to fully addressing the complexities of congenital heart disease.
Childhood cardiomyopathy
Authors: Kaski Juan , Norrish Gabrielle
Published: August 2018

Cardiomyopathy in childhood is a rare and heterogeneous disease. The true prevalence is unknown; however, epidemiological studies from the United States, Australia, and Finland have reported an annual incidence of between 0.65 and 12.4 per 100,000. The most common type of cardiomyopathy in childhood is dilated cardiomyopathy followed by hypertrophic cardiomyopathy, while restrictive cardiomyopathy and other forms are much rarer (58.6% vs 25.5% vs 2.5% respectively). Although children may present at any age, the majority present under 1 year of age (63.4%).
Introduction to Intra-Operative and Surgical Radiography
Authors: Hughes Jim
Published: August 2018

This book is designed to be both a quick guide and a reference text for radiographers and other staff who perform imaging during surgical procedures. Over 40 of the most common procedures are covered in detail, from initial setup to sending final images, with sections on patient positioning, C-arm approach, anatomy, surgical hardware, and alternative techniques. These include cases related to orthopaedics, urology, paediatrics, neurology, and other branches of medicine. Each chapter covers both surgical and imaging techniques, to give the radiographer a better idea of what is required in terms of imaging and technique, along with comprehensive positioning graphics and accompanying high-quality radiograph images. The techniques and methods demonstrated are fully explained, and will allow staff to confidently perform imaging for procedures not covered in the text. Also included are sections on the practical skills required for working in theatres (such as team work and safe practice), infection control, radiation protection, exposures, and image quality, as well as discussions about the function, systems, and usage of intraoperative imaging equipment. This includes both image intensifier (II) systems and the newer flat-panel detector systems. Image artefacts and the effects of under- and overexposure are also covered, with examples of radiograph images and details on how to remedy them. Each chapter is separated by specialty and body region for quick reference and ease of navigation, while key points and imaging considerations are highlighted in each procedure for emphasis.
C-arm systems
Authors: Hughes Jim
Published: August 2018

This chapter covers the design and functions of mobile C-arm X-ray systems used in intra-operative imaging (also known as ‘image intensifiers’, or IIs), including the movements and adjustments used for positioning and systems of X-ray production and image generation. C-arm and mobile C-arm imaging technology was born of the necessity to perform real-time X-ray imaging during surgical procedures. These systems perform real-time motion or cine imaging series as well as still images. The larger units, which are fixed, are generally used in dedicated imaging suites, whereas the smaller units, being mobile, can be moved to wherever a procedure requiring imaging takes place.
Image receptors
Authors: Hughes Jim
Published: August 2018

The receptor head is the system that converts the X-ray beam into a visible image and allows it to be displayed. Modern systems accomplish this by using either an image intensifier (II) or a flat-panel detector (FPD). Both allow real-time fluoroscopy, as well as last-image hold, image storage and retrieval, and other features to assist in procedures or reduce radiation dose. This chapter covers the design and functions of image receptor heads used on C-arm systems that produce images from the incident X-ray beam. This includes the process of intensification and amplification of the image within an II system, as well as the function and the use of newer FPD systems.
Exposures and image quality
Authors: Hughes Jim
Published: August 2018

In C-arm systems, the X-ray beam output is determined by both the signal returned from the automatic exposure device (AED) in the receptor and the exposure table set up for the exam type. The settings for the exposure (as well as aspects of the image receptor and display) will affect the qualities or resolutions of the resulting image. This chapter covers the factors and qualities of images produced by an X-ray C-arm system, and the effect that varying exposure factors has on the resulting image quality and resolutions. This includes spatial, temporal, and contrast resolutions, as well as the effects of under- and overexposure, and distortion or artefacts on the produced images.
Radiation protection
Authors: Hughes Jim
Published: August 2018

The basics of radiation protection in theatre for the patient follow principles similar to those used in plain-film imaging. These include ensuring positive identification of the patient, justification of radiation exposure, avoiding irradiation of pregnant patients wherever possible, minimization and optimization of exposures performed (ALARP principle), protection of all staff involved, and recording and monitoring of all exposures performed. This chapter covers the aspects of protection from radiation for the patient, surgical team, and the radiographer when performing imaging during surgical interventions. Topics covered include the use of beam collimation, minimizing exposure to the patient and team, radiation scatter, and the use and requirements of radiation shielding such as lead aprons and barriers.
Working in theatre
Authors: Hughes Jim
Published: August 2018

This chapter covers the typical layout and requirements of an operating theatre or surgery room, including the requirements for infection control and sterile fields/sterile techniques and effective working with the surgical team. Radiation protection and the management of a radiation-controlled area is also covered. Theatre practice can be an intimidating and unfamiliar place for newly qualified staff, especially when working without assistance for the first time. It is important to try and gain as much familiarity with the theatre environment before working as the lone radiographer in the department. However, there are some basic guidelines that, if followed, should help avoid most potential issues.
Orthopaedics
Authors: Hughes Jim
Published: August 2018

This chapter covers the basic approaches and techniques used in orthopaedic surgery, including the insertion and positioning of hardware and fixators, closed and open techniques (including manipulation under anaesthetic), and the typical imaging requirements for these. The discussion includes elective and trauma cases, as well as emergency procedures that may be performed out of regular working hours. They generally involve either repair to the skeleton and joints after injury (e.g. resiting a dislocated joint or aligning and supporting a fractured long bone) or alterations (such as fusion or replacement of a damaged joint or lengthening of a bone with a growth defect).
Shoulder and humerus
Authors: Hughes Jim
Published: August 2018

Surgical intervention is sometimes required to ensure correct reduction and functionality of the limb. Due to the location of the shoulder and humerus next to the torso and the relative infrequency of such procedures, they can represent a challenge for the radiographer. This chapter covers a selection of orthopaedic procedures involving the shoulder and proximal humerus, covering clavicle plating, tuberosity fracture fixation with screws, plating of the proximal humerus and shoulder, plating of the humeral shaft, and antegrade and retrograde intramedullary nailing of the humerus. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Distal humerus and elbow
Authors: Hughes Jim
Published: August 2018

The elbow is a complex region to perform surgery on. This chapter covers a selection of orthopaedic procedures involving the distal humerus and the elbow, covering plating of the distal humerus, tension band wiring of the olecranon, and plating of the olecranon. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images. The elbow and distal humerus can often be injured through trauma. To maintain functionality of the limb, it is essential they heal correctly. The regions must also undergo opposing forces from the muscles that move the arm, and these can separate fractures causing delay or failure to heal.
Forearm and wrist
Authors: Hughes Jim
Published: August 2018

This chapter covers a selection of orthopaedic procedures involving the forearm and wrist, covering plating of the radius and ulna, and plating and/or K-wiring of the wrist. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment with accompanying radiographs demonstrating the resulting images. The wrist is one of the most commonly injured regions of the body, as it is used with the hands to protect the body and head when falling. The forearm is more often injured in direct trauma, but any injuries to it may also affect the articulations at the wrist or elbow.
Pelvis
Authors: Hughes Jim
Published: August 2018

The pelvis is a complex area of anatomy, and fractures to it may be stable or unstable, depending on the location and nature of the injury. Lower-energy trauma may result in avulsion fractures and stable injuries that can be treated conservatively. High-energy trauma to the pelvis can result in unstable combinations of primary and contrecoup fractures. Such injuries are medical emergencies and will require surgical fixation. This chapter provides an overview of orthopaedic surgical procedures of the pelvis. The discussion includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Hip and femur
Authors: Hughes Jim
Published: August 2018

Fractures of the hip are associated with various complications. Patients with hip fractures are often bed-bound and require intensive nursing and care. The rate of hip fractures is likely to continue to rise globally, and early intervention is currently seen as the optimal course for patients with such injuries. This chapter covers a selection of orthopaedic procedures involving the hip and femur, covering cannulated hip screws, dynamic hip screws, antegrade and retrograde femoral intra-medullary nailing, and plating of the midshaft of the femur. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Distal femur and knee
Authors: Hughes Jim
Published: August 2018

The knee is one of the main load-bearing joints of the body, and injuries to it can involve damage to the joint or articular surfaces, or fractures to the long bones in case of high-energy trauma. The position of the contralateral leg can cause difficulty in positioning for imaging, but good positioning and technique should allow demonstration of the region for intervention. This chapter covers a selection of orthopaedic procedures involving the distal femur and knee, covering distal femoral plating and LISS plates, tension band wiring of the patella, and cerclage wiring of the patella. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Tibia and ankle
Authors: Hughes Jim
Published: August 2018

The ankle and distal tibia can often be damaged through inversion injuries, or from twisting trauma at the foot. Fractures to the tibial plateau will reduce the functioning of the limb and articulation of the knee. It is often the lateral side of the plateau that is damaged, the fixation of which will be covered in this chapter, reviewing a selection of orthopaedic procedures involving the tibia and ankle, covering tibial plateau screws; tibial plating; tibial intramedullary nailing; and fixation of the medial, lateral, and posterior malleolus of the ankle. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Neurological procedures
Authors: Hughes Jim
Published: August 2018

Procedures for the correction or repair of damage to the nervous system can be daunting, and, in some centres, imaging for such cases may be performed only by more specialist radiographers. Here, a calm and methodical approach, combined with good communication with the surgical team, is the best technique to adopt. This chapter covers a selection of neurological procedures for remediation of injury to the spine, covering anterior plating of the cervical spine and pedicle screws and the fixation of the thoracic and lumbar spine. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Paediatrics
Authors: Hughes Jim
Published: August 2018

As children’s bones are still growing, different techniques are employed for the reduction and fixation of fractures in children than those used in adults. For all paediatric procedures, radiation protection is of paramount significance. This is best achieved by using dose reduction settings on the image intensifier, good collimation to avoid excessive irradiation, and judicious use of Pb shielding on or around the patient. This chapter covers a selection of orthopaedic procedures for paediatric patients, covering manipulation under anaesthesia, K-wiring, and elastic nailing or flexi-nailing for long bone injuries. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Urology
Authors: Hughes Jim
Published: August 2018

Most urology procedures requiring imaging involve removing or bypassing any occlusions to the flow of urine from the kidneys. For demonstrating the urinary tract under X-ray, an iodine-based contrast is used. The radiation dose may be higher in urological procedures than in orthopaedic cases due to the thickness of the patient’s abdomen as compared to the extremities, and the need for longer screening times to demonstrate the flow of the contrast agent. This chapter covers a selection of urology procedures for the removal of ureteric blockages and insertion of stents, covering retrograde pyelograms and antegrade pyelograms (including percutaneous access with lithotripsy). Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Hepatobiliary
Authors: Hughes Jim
Published: August 2018

Surgical treatment of pathologies of the gall bladder or biliary tree may involve the removal of stones and occlusions from biliary ducts, opening up of the ducts where they have become narrowed, or removal of the gall bladder itself if required. These procedures are often performed under a minimally invasive approach to reduce the risks of infection and scarring, and as such can require imaging guidance. This chapter covers a selection of hepatobiliary procedures that require the demonstration of the biliary vessels and gall bladder, including laparoscopic cholangiogram and endoscopic retrograde cholangiopancreatogram. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Pain clinic procedures
Authors: Hughes Jim
Published: August 2018

Targeted injections of pharmacological agents around the spine, known as ‘injection therapy’, are among the most commonly offered treatments for medium–long-term back pain. These procedures are typically performed on an outpatient basis, with less requirements for anaesthesia and sterile fields than the more invasive surgical procedures. They may be performed as diagnostic tests, or to give either short- or long-term relief from pain symptoms associated with the spine. This chapter covers a selection of pain clinic procedures, covering facet joint injections, nerve root injections, and epidural/sacral injections under imaging control. Each procedure includes images that demonstrate the position of the C-arm, patient, and surgical equipment, with accompanying radiographs demonstrating the resulting images.
Diagnostic reasoning
Authors: Sprigings David
Published: August 2018

Diagnostic reasoning is the mental process by which physicians turn information about the patient into the name of a disease. To do this, physicians must gather and evaluate evidence relevant to the clinical problem, and then choose a diagnosis or make a decision about management. As in detective work, with which diagnostic reasoning has many similarities, physicians have to reason from observed effects to their possible causes. This chapter explores the thinking behind diagnostic reasoning, drawing on insights from cognitive psychology, philosophy, and the design of computer programs. If physicians have a deeper understanding of the reasoning that underpins making a diagnosis, they may be more astute diagnosticians, and better able to teach the skill to novices. And, however physicians arrive at a diagnosis, they need to be able to articulate their reasoning to the patient and their colleagues.
Dealing with uncertainty
Authors: Sprigings David
Published: August 2018

Uncertainty is a frequent and often uncomfortable element in the physician’s professional life. Its many overlapping sources range from biological variation in patients and diseases, to the inherent unpredictability of the future. This chapter focuses on dealing with uncertainty in diagnosis, prognosis, and management. How can good judgements be made and wise decisions taken when the information on which they are based is incomplete?
Taking the history
Authors: Sprigings David
Published: August 2018

The aim of doctors is to understand the patient and the disease. Taking the history is key to both of these objectives. Only through talking to patients can doctors can get to know them as people, and their personal experience of illness, and the history remains the richest source of information about their diseases. Most diagnoses are suggested by the history, with examination and investigation providing supporting and confirmatory evidence. By the same token, if doctors reach the end of the history without some idea as to the cause of the patient’s problem, they need to go back and retake it, because their chances of arriving at the correct diagnosis without this map to guide them are slim. History taking is a conversation with a purpose, not a cross-examination; as well as using questions, doctors often need to use other conversational devices to help the flow of information. This chapter looks at some aspects of history taking that are of particular relevance to diagnosis in internal medicine.
The physical examination
Authors: Sprigings David
Published: August 2018

Notwithstanding the advances of the past 40 years in imaging—which is, in effect, an extension of the examination—physical signs remain central to the physician’s assessment of patients, especially those with acute illness. Failure to detect these signs contributes to misdiagnosis. To be effective clinicians, physicians must have a competent examination technique, and also need a clear understanding of what the signs can and can’t reveal in a given clinical situation.
The psychological examination
Authors: Price Jonathan
Published: August 2018

The psychological examination (also known as the mental state examination) has broad aims, which include assessing the likelihood of common and important psychiatric diagnoses such as dementia, delirium, depression, and anxiety. This chapter provides a detailed guide to conducting a mental state examination and the interpretation of the findings.
Confidentiality
Authors: Rathmell Anna
Published: August 2018

Patients’ trust in confidentiality is the key to their feeling comfortable with their doctors and being honest about the nature of their medical complaints. Confidentiality is therefore essential for the provision of good healthcare. However, the doctor’s obligation to respect medical confidentiality is not, as is sometimes believed, absolute and there are circumstances where breaching confidentiality may be morally the best course of action and legally required.
Consent
Authors: Rathmell Anna
Published: August 2018

In contemporary medicine, the traditional paternalistic model of healthcare has largely been replaced with a model which focuses on patient autonomy and the right of patients to have as much control as possible over decisions relating to their medical care. In English law, this has led to the concept of informed consent and the right of patients to withdraw their consent at any time, even if they have previously given consent or signed a consent form.
Palpitation
Authors: Davey Patrick
Published: August 2018

Palpitation is a symptom defined as unpleasant awareness of the heartbeat and is typically described by patients as a disagreeable sensation of pulsation or movement in the chest or adjacent areas. Palpitations can be due to cardiac arrhythmias or a broad range of other disorders. This chapter addresses the differential diagnosis of palpitations as well as the main causes, the specific clues indicating the presence and nature of an arrhythmia, diagnostic tests, therapies available, prognosis, and dealing with uncertainty.
Acute chest pain
Authors: Timperley Jonathan , Hothi Sandeep
Published: August 2018

This chapter discusses acute chest pain, including definitions, differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom.
Chronic chest pain
Authors: Timperley Jonathan , Hothi Sandeep
Published: August 2018

This chapter discusses chronic chest pain, such as stable angina, unstable angina, or acute coronary syndromes, and musculoskeletal pain. It includes definitions, differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom.
Hypotension
Authors: Timperley Jonathan , Hothi Sandeep
Published: August 2018

Hypotension is defined as a systolic arterial blood pressure of less than 90 mm Hg, or a diastolic arterial pressure of less than 60 mm Hg, and may lead to shock, with clinical evidence of inadequate blood supply to critical organs. It can be due to hypovolaemia, cardiac pump failure, or vasodilatation. This chapter describes the clinical approach to patient with hypotension.
Acute breathlessness
Authors: Timperley Jonathan , Hothi Sandeep
Published: August 2018

Acute breathlessness or dyspnoea is the new onset of an unpleasant awareness of breathing, at rest or at a level of exercise, which did not previously cause symptoms. It is often associated with other symptoms—including wheeze, cough, chest pain, and palpitation—which, together with the patient’s comorbidities, help shape the differential diagnosis. Five disorders—decompensated heart failure, exacerbations of asthma or chronic obstructive pulmonary disease, pneumonia, and pulmonary embolism—account for 80% of diagnoses. In older patients, acute breathlessness often results from multiple interrelated pathologies (e.g. pneumonia on a background of COPD, triggering acute atrial fibrillation). This chapter describes the clinical approach to the patient presenting with acute breathlessness.
Chronic breathlessness
Authors: Sprigings David , Jeffrey Andrew , Barber Phil , Clayton Nigel
Published: August 2018

Chronic breathlessness (dyspnoea) can be defined as an unpleasant awareness of breathing at a level of exercise which would not cause symptoms in a healthy person of the same age (or which did not previously cause symptoms), persisting for more than 1 month. Breathlessness may be accompanied by other symptoms such as chest tightness, cough, or wheeze, which together with the patient’s comorbidities and risk factors for specific diseases help shape the differential diagnosis.
Peripheral oedema
Authors: Timperley Jonathan , Hothi Sandeep
Published: August 2018

Peripheral oedema is a palpable swelling caused by increased interstitial fluid in soft tissues, and can be due to local or systemic disease. Fluid distribution between capillaries and the interstitium is governed by Starling forces. The lymphatic system returns excess fluid and protein from the extracellular, interstitial space to the bloodstream. Thus, interstitial oedema may arise from factors that increase capillary pressure or permeability, factors that reduce plasma colloid osmotic pressure, factors that impede lymphatic drainage, or a combination of these causes. This topic addresses the diagnosis of peripheral oedema.
Murmur
Authors: Timperley Jonathan , Hothi Sandeep
Published: August 2018

Murmurs arise from turbulent flow in the heart or great vessels. This may occur because of a structural abnormality of the heart, or increased flow across normal cardiac structures (e.g. innocent flow murmur in pregnancy; the tricuspid flow murmur which may be heard in atrial septal defects with a large left-to-right shunt). Turbulence occurs when laminar blood flow is disrupted. Murmurs are classified by their timing in relation to the cardiac cycle as systolic, diastolic, or continuous. Systolic murmurs are heard in up to 50% of adults. More than 90% of young adults and around 50% of older adults with a systolic murmur have a structurally normal heart on echocardiography (i.e. an innocent murmur). Diastolic or continuous murmurs always indicate structural disease. Anaemia, pregnancy, and thyrotoxicosis may result in a high-output state with a functional (flow) murmur. This chapter describes the clinical approach to the patient with a murmur.
Cough
Authors: Smith Jacky
Published: August 2018

A cough is an explosive forced expiratory manoeuvre, usually against a closed glottis, and gives rise to a characteristic sound. Acute cough is defined as a cough of less than 3 weeks duration, and chronic cough as one of more than 8 weeks duration. Acute cough is the commonest presenting symptom in primary care: by far the most frequent cause is a viral respiratory tract infection. The main effect of coughing is on quality of life and this is particularly prominent in patients with chronic cough, as these frequently develop physical complications such as chest pain, retching and vomiting, hoarseness, incontinence, sleep disturbance, and syncope. In addition, psychological distress and social embarrassment are often features. This chapter covers the approach to diagnosis for acute and chronic cough as well as diagnostic tests, therapies, prognosis, and dealing with uncertainty.
Wheeze
Authors: Jeffrey Andrew A.
Published: August 2018

A wheeze is a high-pitched musical sound which reflects airflow obstruction. It may be monophonic or polyphonic, and may be heard during inspiration, expiration, or both phases of respiration. Stridor is the term used to describe wheeze which is louder over the neck than the chest, and may be audible without a stethoscope. Wheezing is typically associated with breathlessness, and may present as an acute or chronic problem. It is most often due to asthma or chronic obstructive pulmonary disease. In stable patients, a detailed history should be taken, with particular attention to the speed of onset of wheeze; trigger factors; and history of atopy. The clinical features, measurement of peak expiratory flow, and spirometry will usually differentiate between possible diagnoses. This chapter describes the approach to the diagnosis of patients with wheeze.
Haemoptysis
Authors: Panchal Rakesh
Published: August 2018

Haemoptysis is the expectoration of blood or blood-stained sputum resulting from haemorrhage into the respiratory tract. Massive haemoptysis (5% of cases) is usually defined as >600 ml in 24 hours. Haemoptysis is a common and non-specific symptom. It can vary from blood-streaked sputum to massive, life-threatening haemorrhage. Haemoptysis may originate from the bronchial arteries (90%), pulmonary arteries (5%), or non-bronchial collaterals. Haemoptysis causing haemodynamic instability and/or respiratory compromise is a medical emergency. Unexplained haemoptysis may herald a serious underlying lung condition and therefore requires a thorough diagnostic workup. The majority of patients can be safely investigated and managed as outpatients. Urgent workup or inpatient management will be determined by the rate and severity of bleeding, and knowledge of either the source of bleeding and/or the underlying condition. This chapter covers the approach to diagnosis, diagnostic tests, therapies, prognosis, and dealing with uncertainty.
Pleural effusion
Authors: Grundy Seamus
Published: August 2018

Pleural effusion is a common clinical problem which can present both to primary and secondary care. The process by which fluid accumulates can be divided into transudative or exudative. Transudative effusions occur in the presence of normal pleura and are caused by increased oncotic or hydrostatic pressures. Exudative effusions are associated with abnormal pleura and are caused either by increased pleural fluid production due to local inflammation or infiltration or by decreased fluid removal which is caused by obstruction of the lymphatic drainage system. Patients may be entirely asymptomatic or they may present with breathlessness, particularly if the effusion is large. Other symptoms include a cough and systemic symptoms such as weight loss, anorexia, and fever. Chest pain is suggestive of inflammation/infiltration of the parietal pleura and points towards malignancy or empyema. This chapter describes the assessment and diagnosis of the patient with pleural effusion.
Chylothorax
Authors: Crawshaw Anjali
Published: August 2018

Chylothorax is an accumulation of lymphatic fluid in the pleural space due to obstruction or injury of the thoracic duct.
Difficulty swallowing
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Dysphagia is a difficulty in the process of swallowing. Dysphagia is an alarm symptom, and therefore requires referral to secondary care for investigations. There are multiple causes, divided into oesophageal, neurological, surgical, and extrinsic obstruction. This chapter covers the approach to diagnosis, key diagnostic tests, therapies, prognosis, and dealing with uncertainty.
Acute abdominal pain
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Acute abdominal pain is pain which is below the chest and above the pelvic brim and which has been present for ≤4 weeks. However, typically, patients present within hours of the onset of pain. The differential diagnosis does not differ much in primary and secondary care, although patients in hospital are probably more likely to be prone to iatrogenic illnesses such as pancreatitis, intestinal ischaemia, and Clostridium difficile-associated colitis. This chapter covers the approach to diagnosis, key diagnostic tests, therapies, prognosis, and dealing with uncertainty.
Chronic abdominal pain
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Separating chronic and acute abdominal pain is often difficult, and an arbitrary time limit of 4 weeks is often used. However, many chronic conditions (e.g. chronic pancreatitis) can cause relapsing symptoms, which may be acute during each episode. Pain receptors in the abdomen respond to chemical and mechanical stimuli. Stretch is the commonest mechanical stimulus to the viscera, although distension, torsion, and contraction are also sensed. Chemical receptors are stimulated by inflammation and infection, and this stimulation leads to the production of various substances, including serotonin, bradykinin, substance P, prostaglandins, and histamine. There are inter-individual differences in pain perception, with some people (e.g. patients with irritable bowel syndrome) being more sensitive to painful stimuli. Chronic abdominal pain occurs in 9%–15% of all children, and is present on questioning in 75% of adolescents and 50% of adults who are otherwise healthy. It is often a non-specific symptom that alone has a poor sensitivity for organic disease. Usually, it is the associated symptoms, and/or abnormal blood tests, that direct the doctor to a diagnosis. This chapter covers the approach to the diagnosis of chronic abdominal pain, key diagnostic tests, therapies, prognosis, and dealing with uncertainty.
Dyspepsia
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Dyspepsia is a term encompassing several symptoms of the upper gastrointestinal (GI) tract, including acid reflux, heartburn, nausea, vomiting, and abdominal pain or discomfort. Up to 40% of the population suffer with dyspepsia; 5%–10% will consult their GP, and 1% will undergo endoscopic assessment. Over-the-counter medications cost patients £100 million annually, and prescribed drugs cost the NHS over £463 million annually. There is a steady rise in incidence with increasing age. Helicobacter pylori is present in 40% of the UK population, with many individuals acquiring the infection in childhood and remaining asymptomatic. It has been associated with peptic ulcer disease and distal gastric cancer. This chapter covers the approach to diagnosis, key diagnostic tests, therapies, and prognosis as well as dealing with uncertainty when it comes to the initial diagnosis.
Constipation
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Patients and doctors often define constipation differently. The normal frequency of defaecation is once every 3 days to three times per day, and constipation may be defined as abnormally infrequent defaecation. A change in the normal pattern and frequency for the particular patient is pertinent. There are numerous causes of constipation, and most can be encountered in both primary and secondary care. In patients with chronic constipation without an evident cause, irritable bowel syndrome (IBS) is the cause in 59%, pelvic floor dysfunction in 25%, slow transit in 13%, and a combination of pelvic floor dysfunction and slow transit in 3%. Constipation affects twice as many women as men, with a higher prevalence in pregnant women. Prevalence is also greater in the elderly, affecting ~20% in the community.
Acute diarrhoea
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Acute diarrhoea is the abrupt onset of a change in bowel habit, with the passage of an unusually high volume of stool (greater than the normal of 200 ml per day), and/or increased bowel frequency of bowel opening (greater than the normal of up to three times per day). Infectious diarrhoea is the commonest cause of acute diarrhoea worldwide, responsible for 3 million deaths per year in children under 5 years in the developing world, mainly due to dehydration. In England, 20% of adults suffer an intestinal infection each year, most causing a benign, self-limiting illness.
Chronic diarrhoea
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Four to five per cent of the Western population suffers from chronic diarrhoea (defined as the passage of >3 stools per day, for >4 weeks), with irritable bowel syndrome (IBS) being the commonest cause in 20–40-year-old patients. It is the commonest reason for referral to secondary care gastroenterology clinics. The list of possible causes of chronic diarrhoea is long but, in the absence of rectal bleeding, loss of weight, or abnormal blood tests, it is unlikely to be due to a serious illness. Laboratory investigations should include serum glucose, electrolytes, renal and liver tests, full blood count, thyroid tests, a coeliac antibody test, C-reactive protein (CRP) measurement to check for systemic inflammation, faecal fat and elastase estimation to check pancreatic exocrine function, faecal microscopy, and culture, although this is insensitive for giardiasis. In young patients with typical features of IBS, these laboratory investigations can be abbreviated to include only glucose, electrolytes, the coeliac antibody test, CRP measurement, and thyroid tests. Endoscopic examination of the large and small intestines is generally only required where there is a suspicion of coeliac disease, chronic giardiasis, microscopic colitis, inflammatory bowel disease, or colorectal cancer. A therapeutic trial of metronidazole for giardiasis is justified where this seems a likely diagnosis.
Rectal bleeding
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Rectal bleeding is a common symptom, affecting all age groups, with the highest incidence in the sixth and seventh decades and associated with a higher mortality and morbidity with increasing age. Epidemiological studies have shown rectal bleeding to occur in nearly 1% of hospital admissions. Bleeding stops spontaneously in 80% of cases, although rebleeding occurs in 25%. Common causes are haemorrhoids, diverticular disease, and colorectal cancer or polyps.
Jaundice
Authors: Keshav Satish , Kent Alexandra
Published: August 2018

Jaundice, also known as icterus, is the yellowish discolouration seen in skin, mucous membranes, and sclerae when the plasma bilirubin concentration is >40 μ‎mol/l. Jaundice may arise from increased production of bilirubin, for instance, in haemolysis; from reduced conjugation in the liver, as in Gilbert’s syndrome; or from reduced excretion via bile, as in intra-hepatic cholestasis. Jaundice also occurs when the flow of bile is obstructed, for instance, by gallstones or pancreatic cancer (extra-hepatic cholestasis). The clinical approach to the jaundiced patient is described in this topic.