bluuebunny/crossref_metadata_2025 huggingface dataset:
GLIOMA-02 HISTOPATHOLOGIC AND MOLECULAR PROFILE OF GLIOMAS: A 9-YEAR RETROSPECTIVE STUDY OF CASES DIAGNOSED IN LAGOS NIGERIA
Authors: Odukoya Lateef , Kollmeyer Thomas , Eckel-Passow Jeanette , Ida Cristiane , Lachance Daniel , Fonkem Ekokobe , Badmos Kabir , Bankole Olufemi , Kitange Gaspar , Daramola Adetola , Anunobi Charles , Jenkins Robert
Published: October 2023

BACKGROUND

The diagnosis and management of patients with brain tumors currently uses WHO defined morphologic and molecular features. However, neuro-oncology practice in low resource settings relies solely on histomorphology. This study aims to reclassify glioma cases diagnosed in the Department of Anatomic and Molecular Pathology Lagos University Teaching Hospital using the WHO 2021 classification.

METHODS

Fifty-six cases of glioma diagnosed between 2013 to 2021 were evaluated. Morphologic diagnosis was reassessed. Five-micron sections were obtained for immunohistochemistry (IHC), and genetic testing (DNA and RNA) after manual macrodissection for tumor enrichment used 10-µm sections. IHC for IDH1-R132H, ATRX, BRAF-V600E, p53, Ki67 and H3-K27M and Oncoscan chromosomal microarray analysis were performed. NGS mutation/fusion analysis and EPIC methylation array profiling are in progress.

RESULTS

Of the 56 cases evaluated, median age was 22 years (range, 1-60); 71% were male. The initial morphologic diagnoses included 21 pilocytic astrocytoma, 11 glioblastoma, 9 ependymoma, 7 diffuse astrocytoma, 3 anaplastic astrocytoma, 2 high-grade gliomas, 1 oligodendroglioma, 1 diffuse midline glioma, and 1 pleomorphic xanthoastrocytoma (PXA). Histomorphologic re-evaluation revealed discordant diagnosis in 29% (16/56) of cases. Of the 56 cases, 73% (41/56) had usable DNA yield and 38% (21/56) had DNA yield of ≥750ng. Chromosomal microarray analysis was completed for 50% (28/56) cases. The revised WHO 2021 diagnosis was: 5 glioblastoma IDH-wildtype, 5 pilocytic astrocytoma, 4 glioma NEC, 3 posterior fossa ependymoma, group B, 3 PXA, 3 astrocytoma IDH-mutant, 2 pediatric low-grade gliomas, 2 supratentorial ependymoma, ZFTA fusion-positive, 1 posterior fossa ependymoma, group A. In 71% (20/28) of cases with molecular testing, diagnosis was revised using WHO 2021 criteria.

CONCLUSION

Most cases had usable DNA. Overall, histologic re-evaluation and molecular based on the WHO 2021 criteria refined the diagnosis in 48% (27/56) of cases.
GLIOMA-05 A NOVEL CONCEPT FOR TREATMENT OF GLIOBLASTOMA: VAGUS NERVE ELECTRICAL STIMULATION FOR SUPPRESSION OF CYTOKINE (IL-6) SIGNALING
Authors: Brem Steven
Published: October 2023

Glioblastoma is an aggressive, incurable cancer. Innovative approaches are urgently needed. There is resurgent interest in harnessing the power of the immune system (O’Rourke DM, 2017; Liau LM, 2023). Glioblastoma is a key target for cytokine reprogramming of the tumor microenvironment involving macrophages, monocytes, lymphocytes, and myeloid-derived cells. Furthermore, as with other cancers, the incidence and poor prognosis is linked to the age of the patient, and chronic, low-grade inflammation, or “inflammaging” (Franceschi, 2014). There is strong clinical, genomic (Coppola, 2014), preclinical data linking the progression of glioblastoma to the cytokine, IL-6. Yi Fan and colleagues (Wang, 2018; Yang, 2021) showed that blockade of IL-6 increases survival in mouse models of glioblastoma, an effect enhanced with the use of immune checkpoint blockade (ICB). These results were validated and extended by others (Tsukamoto, 2018; Lamano,2019). Taken together, we translated the findings to a prospective, multicenter clinical trial (NRG BRAIN-010, NCT04729959; PI, Stephen Bagley) for recurrent glioblastoma, combining stereotactic radiosurgery, IL-6R blockade (tocilizumab) and ICB (atezolizumab). To date, the regimen is well-tolerated with an acceptable safety profile. Vagus nerve stimulation is FDA-approved for control of medically refractory epilepsy. It is currently being evaluated in a multicenter, pivotal trial to treat advanced rheumatoid arthritis (RESET-RA, NCT04539964). Electrical stimulation of the vagus nerve activates the inflammatory reflex (Kelly, 2022), with a reduction of inflammatory cytokines, including IL-6 (Koopman, 2016). Electrical stimulation of the vagus nerve uses the ‘inflammatory reflex’ and exploits the cholinergic effect on T-cells (Levine, 2020). Taken together, we now propose a clinical trial to assess the safety and efficacy of vagal nerve stimulation for patients with glioblastoma and are in discussion with industry (SetPoint Medical) to design a prospective, clinical trial for treatment of glioblastoma.
MENINGIOMA-03 FUNCTIONAL OUTCOME AFTER SURGERY FOR INTRACRANIAL MENINGIOMA AT THE KENYATTA NATIONAL HOSPITAL
Authors: Kagasi Travor , Magoha Michael , Wekesa Vincent
Published: October 2023

BACKGROUND

Intracranial meningiomas represent 34.4% to 41.4% of all brain tumors at the Kenyatta National Hospital. Surgical outcomes have been asessed priviously by Simpson grade achieved at surgery, recurrence rates, rates of complication, overall and progression free survival amongst other surgical outcomes. The functional outcome that assess the performance of these patients in activities of daily life is a less studied outcome.

BROAD OBJECTIVE

This was a retrospective observational cross-sectional study to determine the functional outcome after surgery for intracranial meningioma among adult patients operated at the Kenyatta National Hospital

MATERIALS AND METHOD

Exposure data was collected on age, sex, extent of resection (Simpson grade) of intracranial Meningioma, and WHO grade of meningioma. Outcome data was the Functional Independent Measure.

RESULTS

42 participants were enrolled, with an average age of 46.8 years and a male-to-female ratio of 1:4.25. Mean presentation was within 13.6 months with headaches 97.7% and seizures 41.9%. Average size of meningioma was 138.4 cm3, and perilesional edema was observed in 90.6% of cases. Surgical resection achieved a Simpson grade II in 52.4% of cases and Simpson grade I in 38.1% of cases. Histologic grade was commonly WHO grade 1 (95.2%), specifically the Meningothelial variant (61.9%). Functional status improved with a mean total gain of 161.9% in the Functional Independent Measure (FIM), a motor sub score gains of 174%, and a cognitive sub score gain of 149.6%. There was no statistically relevant association between the functional outcome and extent of surgical resection.

CONCLUSION

There was statistically significant improvement in the functional outcome after surgery for intracranial meningioma measured using the Functional Independence Measure. The Simpson grade achieved at surgery did not influence the functional outcome.
METASTASES-03 PREVALENCE AND CLINICAL SIGNIFICANCE OF UNSUSPECTED INTRACRANIAL FINDINGS IN PATIENTS UNDERGOING ONCOLOGICAL WHOLE BODY18
F- FLUORODEOXYGLUCOSE (FDG) PET CT IMAGING.
Authors: Nyamieri Diana Kerubo , Waa Sheila , Nguku Samuel
Published: October 2023

BACKGROUND

Most oncological 18F –fluoro-2-deoxyglucose (18F-FDG PET) are acquired from the base of the skull to the upper thighs, as lesions that take up FDG are usually within this field of view. Routine inclusion of brain within the field of view of all oncological 18FDG PET/CT studies leads to increase of both time of acquisition and radiation dose (albeit marginal) delivered by the CT component of the study, therefore it can be debated if inclusion brain in oncological 18FDG PET-CT has any additional value.

OBJECTIVE

To identify the prevalence of clinically unsuspected intracranial findings in patients undergoing routine oncological 18 FDG PET CT examinations in Aga Khan University Hospital (AKUHN)with the inclusion of the brain in the field of view.

METHODS

Patients who underwent oncological limited whole-body 18 FDG PET/CT scan between February 2019 to December 2021 were retrospectively reviewed. The patient’s age, sex, type of malignancy, disease stage, presence of clinically unsuspected intracranial finding, and clinical information was reviewed. Clinical impact of the identified intracranial findings was also recorded.

RESULTS

A total of 3523 oncological whole body FDG PET were included in the study. Clinically unsuspected intracranial findings were identified in 132 cases (3.7%) out of which 62 (1.7%) were clinically significant. The most common intracranial finding was metastasis. 22 cases underwent a follow up MRI brain and the sensitivity and specificity were 94.7% and 66.7% respectively. Change in management was seen in 25/32(78%) cases.

CONCLUSION AND RECOMMENDATION

Inclusion of brain in the field of view of oncological FDG PET CT can lead to early detection of unsuspected intracranial metastasis resulting in management change especially for malignancies that have a propensity to metastasize to the brain such as in breast and lung cancers.
PAEDIATRIC-15 MANAGEMENT OF PEDIATRIC CENTRAL NERVOUS SYSTEM TUMORS BY A NEURO-ONCOLOGY MULTIDISCIPLINARY TEAM : OUR EXPERIENCE
Authors: Drogba Landry , Djonde Grace , Broalet Esperance , Gbazi Marc , Diaby Raissa , Oka Dominique Ndri
Published: October 2023

The outcome of pediatric central nervous system tumors has improved over the past decades due to advances in diagnostic testing, treatment and increased understanding of the disease biology. Nevertheless, the probability of survival of this tumors remains much lower in low-to middle-income countries. The gaps that prevent optimal clinical management of brain tumors are multifactorial and mostly related to underdiagnosis; a lack of specialized and dedicated radiologic, histopathologic, neurosurgical, radiotherapeutic, and oncology services, and a deficiency of coordinated multidisciplinary care in many centers. The aim of this report was to evaluate the impact of multidisciplinary team meetings on the clinical management of pediatric central nervous system tumors in Abidjan (Côte d'Ivoire). We retrospectively reviewed the clinical data of pediatric patients (aged <15 years) with central nervous system tumors diagnosed and treated in the Neurosurgery Department and National Center of Radiotherapy between 2019 (the year a neuro-oncological multidisciplinary staff was established) and 2023. Data on patient demographics, clinical notes, imaging studies, tumor characteristics and multidisciplinary team decision were collected from the multidisciplinary team database. During the multidisciplinary team meetings era, 40 pediatric central nervous system tumors were diagnosed and treated. The median age at diagnosis was 8.5 years. The mostly histological types were high grade and low grade gliomas. Decision-making was largely consistent with available guidelines. Therapeutic were surgery, external beam radiation treatment with concurrent and adjuvant chemotherapy. Benefits of neuro-oncology multidisciplinary team include coordination, direction for complicated cases, education, and a forum for communication, and clinical trials.
PATIENT ADVOCACY-01 WHY IS NEURO- ONCOLOGY MISSING FROM CIVIL SOCIETY CANCER ADVOCACY AGENDA?
Authors: Makumi David , Okumu Roselyne , Muya Rose
Published: October 2023

BACKGROUND

Cancer civil society and patient groups across Africa play a major role in pressuring governments to develop, fund, and implement national cancer control plans and to keep their commitments to international declarations. Additionally, community cancer awareness is mainly driven by lay cancer advocates and cancer survivors. The cancer policy and legislation landscape in Kenya has largely been shaped by the civil society through consistent advocacy

OBJECTIVE

Explore barriers and enablers to meaningful engagement of cancer civil society advocates in advancing neuro-oncology in Africa.

METHODOLOGY

This is a desk review of current developments and literature in advocacy for neuro-oncology with insights and perspectives of practicing oncology nurses and civil society cancer advocates in Kenya.

FINDINGS

Cancer advocacy in Kenya has traditionally focused on creating awareness on the more common cancers, breast, cervical prostate and Gastro-intestinal cancers. Over the last 10 years’ attention has gradually shifted to access and cost of care. Cancers of the central nervous system such as gliomas, neuroblastomas and meningiomas, though not uncommon do not feature prominently in advocacy discourses. This is due the fact that they are perceived as ‘rare’, complex, difficult to explain and with poor outcomes.

DISCUSSION AND IMPLICATIONS

There is a growing appreciation of the need to develop a framework through which civil society can contribute to the development of quality neuro oncology services. Cancer civil society organizations, neurosurgeons, neurologists, oncologists, academicians, and other healthcare professionals must work together to overcome structural barriers so that neuro oncology is not left behind in the national cancer plans. Stakeholders will need to establish guidelines with well defined mechanism for engaging, involving and acknowledging the contribution of cancer advocates in advancing neuro-oncology. This will require a cultural shift from neuro-oncology professionals to accommodate the input of lay civil society advocates.
PITUITARY TUMORS-01 HYPERPROLACTINEMIA AS A CLINICAL MARKER OF INVASIVE PROLACTINOMAS
Authors: Gankpe Gbetoho Fortune , Benzagmout Mohammed
Published: October 2023

BACKGROUND

Prolactinomas can acquire an invasion feature and challenge the management. Many features of invasive pituitary adenomas have been investigated in the literature, from radiological, histopathological to molecular perspectives. Here, we have decided to focus on serum prolactin level and evaluate its behavior in invasive prolactinoma patients.

METHODS

It is a retrospective and consecutive view of 75 prolactinomas patients registered at the Hassan II University Hospital of Fez in Morocco. Patients were categorized into two groups: invasive and noninvasive prolactinoma. A non-parametric predicted ROC curve was performed to investigate the sensitivity and specificity of serum PRL level according to the invasiveness.

RESULTS

A total of 31 patients (41.3%) represented the invasive group and the mean age was 35.6 years old compared to the group of noninvasive (34,1 years old). Males are more likely to be affected by invasive tumor than women (<0,00001). Serum PRL level was higher (2048.6 ± 1882.4) in invasive prolactinoma (p=0.001) and almost all invasive tumors had a PRL level greater than 1000 ng/ml. The predicted ROC curve of the distribution of the serum PRL levels showed an area under curve (AUC) of 89.8% and the calculated value of the threshold to fit a good sensitivity of 80% and false positive rate of 11.6% was estimated to 900 ng/ml.

CONCLUSION

Based on clinical manifestations, hyperprolactinemia and MRI scan, the prolactinoma patients – especially men – presenting a larger tumor size and serum PRL level higher than 900ng/ml, should be considered as an invasive prolactinoma patient. As a matter of fact, with those patients an appropriate treatment should begin as soon as possible.
PITUITARY TUMORS-02 EVOLUTION OF PITUITARY SURGERIES TO THE TRANS-SPHENOIDAL APPROACH IN A NIGERIAN TEACHING HOSPITAL: LEANING ON LOCAL TRANSFER OF SKILLS
Authors: Balogun Simon , Omon Henry , Anele Christopher , Ajekwu Temitope , Ejembi Gabriel , Ojo Omotayo , Komolafe Edward
Published: October 2023

BACKGROUND

Globally pituitary surgeries have evolved from transcranial surgeries (TCS) to transsphenoidal (TSS) as the standard of care. This is due to the many benefits of TSS over TCS. However, this evolution has been comparably slow in some parts of Africa. Before 2019, all sellar surgeries in our hospital, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife were done via TCS. To improve the quality of care to our patients, we started the TSS. The evolution into TSS involved local skill transfer.

METHOD

We collaborated with a neurosurgeon from another teaching hospital in Nigeria with expertise in TSS who visited three times. All patients had microscopic TSS. The equipment was sourced for by local neurosurgeons with backup brought by the visiting neurosurgeon. The brain scans were sent ahead, and the visiting surgeon arrived the day before surgery. We compared our experience of TCS over the last 10yrs with our recent TSS experience.

RESULTS

Sixty-nine sellar tumours were surgically operated over 10yrs. 7 of the recent cases had TSS, one was which was done entirely by the local team. There were 2 cases of mortality from the TCS while no mortality from the TSS. The complication rates for the TCS were diabetes insipidus (DI) (22%), Tumour bed hematoma requiring evacuation (10%), SSI (7%) and post-operative seizures (6%). Of the 7 TSS, one had DI, and another had CSF leak and tension pneumocephalus requiring evacuation. 78% of the TCS had intraoperative blood transfusion. None of the TSS had blood. Average post-operative hospital stay was 3 for the TCS and was 9 for the TCS.

CONCLUSION

Our experience with the TCS approach and evolution to the TSS showed the TSS to be better. While overseas training for skill enhancement is desirable, the transfer of local skills can enhance neurosurgery practice in developing countries.
Assessment of ecological variables I
Authors: Jelliffe Derrick B , Jelliffe E F Patrice , Zerfas Alfred , Neumann Charlotte G
Published: October 2023

Human malnutrition is always an ecological problem. It is the end-result of multiple overlapping and interacting factors in the community’s eco logy—that is its physical, biological, social, and cultural environments, including economic constraints and political priorities. The amount of various foods and nutrients available to persons of different age-groups will depend, among other things, upon such environmental conditions as climate, type of soil, agricultural practices, methods of food storage, transport, and marketing. It will also be related to a range of political and cultural factors, including the general economic level, governmental policy concerning an equitable distribution of resources (money, productive land) among the population, the educational level, and population changes, such as occur in urbanization and with an influx of refugees. Cultural influences including local cooking practices, meal patterns, and food classifications, and especially the distribution or restriction of more nutritious foods for vulnerable age-groups will be highly relevant.
Stimulating action
Authors: Jelliffe Derrick B , Jelliffe E F Patrice , Zerfas Alfred , Neumann Charlotte G
Published: October 2023

It is sometimes assumed that the presentation of the carefully reasoned results of well-planned nutritional assessment activities will automatically result in action. This is not the case (Jelliffe and Jelliffe 1987).
Examination of the limbs and trunk
Authors: Bannister Sir Roger
Published: October 2023

Examination of the limbs and trunk involves observation of posture; muscle tone, tested by investigating the resistance of muscles to passive movement; the presence or absence of involuntary movements and of muscular wasting and fasciculation; voluntary power in the various muscle groups motor coordination; the reflexes; and sensation. Neurological disorders also sometimes cause trophic symptoms.
The Effects Of Maternal Cigarette Smoking On Placental Structure And Function In Mid- To Late Gestation
Authors: Burton Graham J
Published: October 2023

Although the harmful effects of maternal cigarette smoking on the developing fetus have been extensively researched, surprisingly little attention has been paid to the placenta. The studies that have been performed generally fall into three categories: 1. Those describing the weight and macroscopic appearances of the organ at the time of delivery. 2. Those describing changes in its histological structure. 3. Those describing alterations in the organ's enzymatic and synthetic activities. The findings in each of these three areas will be considered in turn, before discussing possible causative mechanisms.
Parental smoking and respiratory problems in childhood
Authors: Evans Julie-Ann , Golding Jean
Published: October 2023

There have been many studies on the possible respiratory effects of exposure to tobacco smoke during childhood. Studies with reasonably large numbers are listed in Table 10.1. There is a lack of consistency in ages, condition, type of population, and statistical methods used. Nevertheless, the vast majority of studies do find some effects of smoking. These are summarized briefly below. Nine studies have looked at parental smoking and chronic cough in the child. Three of these found no association (Liard et al. 1982; Schenker et al. 1983; Clifford et al. 1989), one found an association with both parents smoking (Bland et al. 1978), one found an association that was due more to maternal than paternal smoking (Charlton 1984) and two found an association with the number of smokers in the household, which disappeared after controlling for adult phlegm production (Colley 1974a; Lebowitz and Burrows 1976). Two further studies showed an association with parental smoking when the coughs occurred together with colds (Weiss et al. 1980; Ekwo et al. 1983).
Prenatal Smoking Interventions: Programmes With Important Potential
Authors: Floyd R Louise , Hogue Carol , Marks James , Kendrick Juliette , Zahniser Christine , Gunter Eileen , Stevens Judy
Published: October 2023

Improving pregnancy outcome by providing high-quality prenatal care has been, and continues to be, a major public health priority in the United States. By providing: 'a foundation for improving the health of the pregnant woman, infant, and family,' the prenatal care system: 'is a cornerstone of health care delivery in our society' (US Public Health Service 1989). Prenatal care is the mechanism through which effective screening for risk factors, counselling to reduce risks, and treatment for health conditions is delivered. Guidelines for content of prenatal care, recently developed by a US Public Health Service expert panel (1989), call for systematic preconception and prenatal counselling to encourage smoking cessation before, during, and after pregnancy. The panel found that: 'among behaviours capable of having adverse effects on pregnancy, smoking has been best studied' (US Public Health Service 1989). The panel judged that scientific evidence is good for an association between maternal smoking and poor pregnancy outcome, for the efficacy of smoking cessation to improve pregnancy outcome, and for the efficacy of health promotion activities that help women stop smoking.
Psoriatic arthropathy
Authors: Silman Alan J , Hochberg Marc C
Published: October 2023

Epidemiologically, the concept of psoriatic arthritis is a complex one. Initially described several years ago as the association of arthritis in a patient with psoriasis (Alibert 1922), the concept has been considerably refined as understanding of different clinical and pathological entities of arthritis has increased. The dilemma seems superficially simple: if all the cases observed can be explained by the chance co-occurrence of two relatively common disorders, psoriasis and a specific type of arthritis such as rheumatoid arthritis, then the syndrome is not appropriate for consideration in an epidemiological sense. Alternatively, if either there is a distinct clinical or pathological type of arthritis restricted to psoriasis, or the presence of psoriasis increases the susceptibility to certain specific types of arthritis, then it is relevant to consider this disorder as a separate entity and investigate its epidemiology. There is also a middle ground and that is the possibility that the presence of psoriasis modifies the clinical and other features of any concurrent arthritis although the latter’s occurrence is no different from that observed in the nonpsoriatic population.
Pharmaco-epidemiology
Authors: Silman Alan J , Hochberg Marc C
Published: October 2023

Pharmaco-Epidemiology and the Rheumatic Diseases

Pharmaco-epidemiology is the application of epidemiological methods to the effects of drugs in human populations. Thus the descriptive epidemiology of patterns of drugs use both within and between populations, including trends over time, fall within this remit and as such are comparable to descriptive data on any environmental exposure within a population. The investigation of the role of drugs in improving prognosis is the remit of the intervention study, more conventionally known as the clinical trial. The conduct of clinical trials should adhere to sound epidemiological principles but their results are more relevant to publications of therapeutics and will not be considered further here. The most widely accepted application of pharmaco-epidemiology is in the ascertainment of toxicity of drugs, where they are investigated as risk factors in a similar fashion to other environmental agents. Thus the frequency of specific toxic reactions together with their possible predictors are appropriate targets for investigation.
Thoracic, Cardiac And Vascular Surgery
Authors: Paul D
Published: October 2023

This chapter deals, in large part, with anaesthesia for the surgical treatment of smoking related diseases. The patients tend to be middle-aged or older and have mixed pathologies including chronic obstructive airways disease, ischaemic heart disease and peripheral vascular disease. Many vascular patients also have diabetes.
Head And Neck Surgery
Authors: McNeil M
Published: October 2023

All forms of surgery involving the patients head and neck result in some special requirements, regardless of which specific surgical specialty is performing. Plastic surgeons, ENT surgeons, maxillofacial surgeons or general surgeons can all produce specific problems for the anaesthetist by virtue of the fact that they are operating in and around the airway.
Maxillofacial Surgery
Authors: McNeil M
Published: October 2023

Maxillofacial surgery is surgery to the bones and the skull. The indications for the surgery can vary from trauma, to congenital malformations to cosmetic surgery. The trauma patients can often present problems because of the effects of the tissue damage on their airway. Furthermore, there is some¬ times an underlying head injury which, of course, must be treated as the number one priority. Many of these injuries are associated with alcohol abuse, road traffic accidents and assault. The anaesthetist must carefully assess the airway with particular attention to any limitation in mouth opening, which can commonly result from fractures to the facial bones. Awake fibreoptic intubation may be the safest technique of intubating these patients.
Eye Surgery
Authors: Runcie C J
Published: October 2023

Eye surgery can be performed under either local or general anaesthesia. Traditionally, local anaesthesia has been given by the surgeons, but anaesthetists are increasingly involved.
Biological aspects of psychiatry
Authors: Lader Malcolm , Herrington Reginald
Published: October 2023

Each of the main biological hypotheses of the mechanisms of psychiatric disorders—affective illness, schizophrenia, and anxiety—relies to a substantial extent on data accruing from therapeutic trials. However, it must be borne in mind constantly that the modes of action of most psychotropic drugs are still poorly understood. Consequently, elaborating hypotheses on the pathophysiology of disorder based on mechanisms of drug action is little more than attempting to explain one unknown in terms of another. Nevertheless, establishing such hypotheses has proved heuristic, at least in stimulating studies incorporating careful clinical observations. Developments in the symptomatology of chronic schizophrenia and in the nosology of the anxiety disorders owe much to observations made in the course of therapeutic studies. This chapter’s emphasis on biological processes in psychiatric disorders should not lead to the impression that other influences, for example social or psychological, are unimportant. Rather it is the interaction between these various factors that would best repay careful analysis (Kidman 1985).
Drugs of abuse
Authors: Lader Malcolm , Herrington Reginald
Published: October 2023

The general topic of substance misuse and abuse is in itself a large specialty with many aspects impinging on day-to-day medical practice. Also, psychological, sociological, economic and political considerations are important in this area. Indeed, illicit drug distribution and sales constitutes one of the biggest ‘industries’ in the USA and is fast assuming similar proportions in many other countries in Europe and elsewhere.
Cardiac arrest associated with special circumstances
Authors: Skinner David V , Vincent Richard
Published: October 2023

A number of conditions other than major cardiac arrhythmias present with life-threatening disorders of circulatory or respiratory function. They can often be suspected from the patient‘s immediate history or surroundings, but occasionally the underlying pathology is obscure. Airway protection, ventilation, and circulatory support, as previously described, remain central to their treatment; but particular aspects of diagnosis and management are worth noting.
Management of common arrhythmias associated with cardiac arrest
Authors: Skinner David V , Vincent Richard
Published: October 2023

This chapter will encompass the recognition and treatment of arrhythmias that cause either circulatory arrest or a profound fall in cardiac output. The correct interpretation of an arrhythmia requires a ‘noisefree‘ ECG, a lead configuration that gives a clear P wave as well as a distinct QRS (leads II and V1 are best), and a familiarity with the patterns and mechanisms of common rhythm disorders. These ideals may be difficult to achieve during cardiopulmonary arrest.
Biochemistry and pharmacology of cardiac arrest
Authors: Skinner David V , Vincent Richard
Published: October 2023

The biochemical derangements associated with cardiac arrest are determined partly by the clinical setting in which the arrest occurred, and partly by the effects of circulatory standstill whatever the cause. For example, cardiac arrest following a period of profound hypoxia may be accompanied by a metabolic acidosis, whereas when ventilation has been suppressed (stroke, drugs) or obstructed (choking, trauma, drowning), the picture will be complicated by a prior respiratory acidosis with a raised Pco2
Children in the Accident and Emergency department
Authors: Morton Rosemary J , Phillips Barbara M
Published: October 2023

Between 20 and 30 per cent of attenders at District General Hospital Accident and Emergency (A & E) departments are children under 16 years old. In England and Wales there are more than two million child attenders at A & E departments annually. There is a disproportionately high number of attenders under five years of age.

It is sometimes considered that because children are small they require a smaller provision of space in hospital buildings than do adults. In fact the opposite is true. Children attending A & E departments are usually accompanied by at least one adult, and often siblings, prams, or pushchairs.
Respiratory and ENT problems
Authors: Morton Rosemary J , Phillips Barbara M
Published: October 2023

1 The severity of acute respiratory disease is best assessed by observation of the child’s work of breathing and his state of alertness.

2 The child with respiratory disease who is drowsy or agitated is probably hypoxic. Pulse oximetry is a useful tool to assess hypoxia.

3 Respiratory disease is more likely to be severe in infants under the age of one year

4 Inspiratory stridor is always a serious symptom.
The origins and physiology of menstruation
Authors: Campbell Steven , Cameron lain T
Published: October 2023

Menstruation is the physiological process during which healthy adult tissue lining the uterus disintegrates and is expelled from the body. A new surface is formed by rapid healing or regeneration although, intriguingly, scarring does not occur. Menstruation is therefore an unusual event, possibly without parallel in adult mammalian physiology.
Menstrual dysfunction secondary to medical disease
Authors: Higham Jenny
Published: October 2023

Menstruation, being the end result of a complex endocrine pathway, is susceptible to a wide variety of influences. Disruption of menstruation can be provoked by both systemic and local disease. This chapter concerns the precipitation of the common problem of excessive menstrual bleeding by ill-health. It should be remembered that only a very small proportion of menorrhagia cases can be attributed correctly to systemic disease. For these few, however, the correct diagnosis may result in successful curative therapy, rather than disappointing palliative medication or unnecessary surgery.
Hysteroscopic endometrial ablation
Authors: Goldrath Milton
Published: October 2023

Menorrhagia represents a widespread clinical problem, and is the leading cause of elective hysterectomy in women with a normal uterus (D’Esopo 1962; Cole and Berlin 1977; Dyck et al. 1977). Various methods are used to treat this condition, including dilatation and curettage (D&C), hormone therapy, ergot derivatives, anti-fibrinolytic agents, and non-steroidal anti-inflammatory drugs (Nilsson and Rybo 1971). While oral contraceptives appear to be the most effective approach to medical treatment, their usefulness is limited by side-effects and contraindications to therapy. Until recently, women who did not respond to pharmacologic intervention were limited to one of two options: hysterectomy or continued cycles of heavy menstrual bleeding.
lntermenstrual and post-coital bleeding
Authors: Landgren Britt-Marie , Schoultz Bo von
Published: October 2023

Disruption of the cyclical pattern of menstrual bleeding may occur at any age and for a variety of reasons. An understanding of the physiological life cycle variations is essential to determine whether a pattern of bleeding episodes should be regarded as normal or abnormal. Normal men-struation occurs in response to the decline in progesterone following the regression of the corpus luteum. Any alteration in the cyclical exposure of the endometrium first, to unopposed oestrogen during the follicular phase and, after ovulation, to oestrogen and progesterone, is likely to result in disturbances in the menstrual pattern. Intermenstrual bleeding may last only a few hours or persist for several days. Bleeding perceived as abnormal or unusual evokes fear and anxiety and is a common reason for gynaecological consultation.
Care in labour
Authors: Mander Rosemary
Published: October 2023

The term ‘normal’ is difficult to define (Downe 1996). For clarity, therefore, this chapter covers care of the woman with an uncomplicated labour and birth where medical/high-tech intervention is not required. The environment for labour and birth is discussed first, followed by support in labour and the control of pain. These three factors are fundamental and closely interrelated in the care of women in labour. Routines in care are then examined, the evidence base and its quality are described, and the extent to which that evidence informs present practice.
Differentiation of the common dementias
Authors: Feldman Howard H , O’Brien John T
Published: October 2023

With the greying of society, diseases causing dementia are now recognized as being one of the most important challenges facing western medicine in the 21st century. The term ‘dementia’ describes a syndrome of acquired loss of cognitive function, behavioural changes, and loss of social function. There is no implied aetiology for dementia and most broadly it represents a neuro-behavioural syndrome that occurs in a large number of diseases. Most dementias occur on the basis of primary degenerative disorders of the central nervous system, though some occur with multisystem inflammatory diseases, infectious diseases, or metabolic/endocrine disorders. Surgically treatable dementias account for a very small percentage of all cases. The potential reversibility of dementia has been emphasized, though longitudinal studies from dementia clinics have demonstrated that in practice this is seen in only 3 to 8 per cent of cases (Clarfield 1988). In patients with dementia associated features such as depression, toxicity related to medications and metabolic disorders are the most frequently modifiable/ reversible problems (Clarfield 1988). The course of dementia is quite variable, though most typically a progressive declining disorder is seen. However, with careful workup and management of treatable components of dementia patients may live with an optimal level of function through their illnesses. The broadest goal for each dementia clinic, community based team, and individual practitioner should be to diagnose and manage each individual to their best level of cognition, behaviour, and function.
Carer support
Authors: Gilliard J , Rabins P V
Published: October 2023

Introduction It is estimated that dementia affects approximately one in ten of the population over the age of 65, one in five of those over the age of 80, and a smaller proportion of younger people (Alzheimer’s Disease Society, 1995). This means that there are about 640000 people with dementia in the United Kingdom and approximately 3900000 in the United States. Most of these are cared for by a family member, so that when we consider the numbers of people who are affected by dementia we should probably at least double the above figures.
Non-pharmacological approaches to treatment
Authors: Woods Bob , Bird Mike
Published: October 2023

In the context of the dementias, a group of diseases with no known cure and none at present foreseeable, it is crucial to define the concept of ‘treatment’. The conceptual basis adopted for this chapter is an assertion made by Woods and Britton in 1985: We need to break away from our pre-occupation with treatment in the sense of cure and recovery, and be aware of the different types of goals that are feasible, and the value of some of the more limited goals in improving the patient’s quality oflife (Woods and Britton, 1985, p. 217).
Abbreviations
Authors: Wilson G R , Nee P A , Watson J S , Harrison R K
Published: October 2023

PIPJ PMH IVFR local anaesthetic LA metacarpal MC metacarpophalangeal joint middle phalanx MPJ non-accidental injury MP open reduction and internal fixation NAI proximal interphalangeal joint ORIF past medical history.
Nail bed injuries
Authors: Wilson G R , Nee P A , Watson J S , Harrison R K
Published: October 2023

Significant nail deformity may require later corrective surgery. This may be avoided by the correct primary treatment! A surgical approach is preferred.
Frostbite
Authors: Wilson G R , Nee P A , Watson J S , Harrison R K
Published: October 2023

Prevent stiffness by allowing mobility within the dressings from day 1. Very early debridement is not warranted as a surprising amount of healing can take place at the fingertips. Lesions of the fingertips similar to burn wounds, with a similar classification by depth (see p. 66).
Fall on outstretched hand (FOOSH)
Authors: Wilson G R , Nee P A , Watson J S , Harrison R K
Published: October 2023

Common injury in elderly women and young men. Pain in the wrist after a fall. Exact mechanism of injury often not recalled. Look for swelling and deformity.
Bennett’s fracture
Authors: Wilson G R , Nee P A , Watson J S , Harrison R K
Published: October 2023

A fracture of the articular surface of the base of the thumb metacarpal. The small fragment remains in place. The rest of the metacarpal is subluxed owing to the pull of the EPB tendon (Fig. 31.l(a)).
Long-term complications of dialysis: an introductory chapter
Authors: Harris Susan , Brown Edwina A
Published: October 2023

Charing Cross hospital (CXH) was one of the first centers in the UK to begin a maintenance hemodialysis program. Encouraged by the work of Scribner and his colleagues in the USA, Professor de Wardener sent a team of doctors and nurses to Seattle in 1964 to learn the technique. It was decided to start with just one patient. This patient was carefully selected to have the best chance of a successful outcome, such that the result of the treatment would be most likely to encourage other centers to take an interest in chronic dialysis. In 1964, watched by all 15 members of the renal team, this patient began his first treatment on a schedule of long-term hemodialysis (this patient survived for 27 years). Teething problems were expected, difficulties with fluid and electrolyte balance were anticipated and tackled as they arose. But the expectation was that this would be a complete renal replacement therapy, and that once patients were established on hemodialysis they would return to work and live a full and happy life. For, apart from the problems of vascular access which were fully recognized and described as ‘the Achilles heel’ of long-term dialysis (de Wardener, 1966) the other long-term complications such as amyloidosis and cardiovascular disease could not have been foreseen.
Clones, Clones, Clones
Authors: Greaves Mel
Published: October 2023

If there is one respect in which cancer is special as an illness, it is that all the cancer cells in one patient are, in almost every case, derived from a single cell. They are a clone. Not necessarily all identical because the capacity of the progeny of the founder or mother cell to diversify genetically is another critical feature of cancer cells, as we shall see - but a clone nonetheless. A clone of up to or more than 1012 (a million, million) cells that may have dispersed throughout the body. A clone that if removed from the confines of the body could, given suitable conditions, expand to fill any large and well-known building. But clones - multiple copies of the same thing, abound in nature.
How Cancer Cells Play the Winning Game
Authors: Greaves Mel
Published: October 2023

To generate a fully-fledged or dominant cancer clone, a cell has to subvert multiple rules of engagement and negotiate major evolutionary bottlenecks. For most types of cancer, this is only possible by the accumulation of a set of mutations in genes exercising different, but complementary or interlocking, functions. Because of the statistical rarity of DNA damage creating one of these mutations and because accrual of a set of mutations is only possible by sequential addition, the process can only operate in single cells, or clonally and over an extended period of time. This makes the whole process probabilistic and pervaded by chance (Fig. 8.1).
Other Ways of Getting Bugged
Authors: Greaves Mel
Published: October 2023

You might suppose that cancers caused by common viruses must be very unusual. Not so. Around 15 per cent of the total cancer burden world wide can be linked to persistent infection with common viruses or other microbial invaders that are transmitted person to person. These cancers are all more common in less developed countries and it is likely that they have been around for a very long time. The links include liver cancer (or hepatocarcinoma) with hepatitis B and C (HBV and HCV); both nasopharyngeal cancer (which is very common in South East Asia) and African Burkitt’s lymphoma with Epstein Barr virus (EBV); Kaposi’s sarcoma with a new human herpes virus (HHV8); and finally, a form of adult leukaemia (common in southern Japan and the Caribbean basin) that is associated with an RNA virus or retrovirus called HTLV-1. These cancers are all of special interest because of the opportunity they provide for prophylactic vaccination.
Epilogue: Cancer In The Twenty-First Century
Authors: Greaves Mel
Published: October 2023

The evolutionary and historical picture I have tried to paint might encourage a fatalistic trait of resigned inevitability. I hope not, because that’s not how I and, I believe, most cancer researchers (admittedly inveterate optimists) now see the problem. Cancer is in one sense an inevitability, at a certain level. The height of that level for different cancers is however a social variable. Understanding how cancer clones operate tactically is one half of the battle won. We can tackle the clone more cleverly or we can confront the social ratchet that escalates risk; or we can try to do both. It surely has to be both, but there are choices and priorities to be made. There still will not be a ‘magic bullet’, however sophisticated, for cancer in general. Political leaders and advisers should now recognize that the problem isn’t equivalent to the task of building the first atomic bomb and getting a man on the moon.
Preoperative investigations
Authors: Hwang Dr Nian Chih , Sinclair Dr Michael
Published: October 2023

The baseline ECG may show areas of new or old myocardial infarctions, abnormal rhythms, conduction defects, or evidence of ventricular hypertrophy, atrial dilatation, and electrolyte abnormalities. The exercise ECG was developed to identify the patient with coronary artery disease who presented with atypical chest pain or with a normal resting ECG and symptoms suggestive of coronary artery disease. It helps the cardiologist to identify patients at risk for myocardial infarction and to decide who should have coronary angiography. Exercise testing includes using the treadmill or bicycle in the cardiac catheterization or radionuclear laboratories. All exercise stress test protocols progressively increase myocardial work. The most familiar protocol, the Bruce protocol, consists of 3-min stages where the grade of inclination and the speed of the treadmill increase gradually. The heart rate and blood pressure are continuously measured, and the exercise is terminated when symptoms and signs of myocardial ischaemia, dysrhythmias, and left ventricular dysfunction occur. Development of hypotension during the stress test indicates a significant stenotic lesion of the left main stem (left main coronary artery). However, exercise-induced ischaemic changes in the awake patient, even though they may occur at a reproducible rate-pressure product, may not be applicable to the stress of coronary artery bypass graft surgery and anaesthesia. Stress during surgery could provoke similar dysrhythmias, and a history of them occurring during exercise testing can provide valuable information for the anaesthetist.
Preoperative visit and preparation
Authors: Hwang Dr Nian Chih , Sinclair Dr Michael
Published: October 2023

Review the medication that the patient has been prescribed; as the types of drugs used will give an indication of the patient’s symptoms. For example, nitrates, -blockers, calcium-channel blockers, potassium-channel activators, aspirin, and/ or cholesterol lowering agents are taken to relieve angina, intravenous infusions of heparin and/ or nitroglycerin are taken to relieve unstable angina, digoxin, diuretics, and vasodilators (such as ACE inhibitors) are to relieve congestive cardiac failure (from poor ventricular function or incompetent valve), and digoxin and warfarin are taken when atrial fibrillation is present. Any complications with previous general anaesthetics should be ascertained. The usual examination of the airway and of potential venous and arterial access should be carried out. Ascending thoracic aortic aneurysm is associated with Marfan’s syndrome, and the possibility of difficult laryngoscopy should be anticipated in the presence of a high arched palate. A clinical impression of the cardiac status of the patient can be obtained by taking note of the conditions discussed below.
Guidelines for implantation of an automatic internal cardioverter–defibrillator
Authors: Hwang Dr Nian Chih , Sinclair Dr Michael
Published: October 2023

Recurrent sustained ventricular tachycardia (episodes of at least 10 con secutive ventricular ectopic beats) is a known sequela of ischaemic heart disease and acute myocardial infarction. An automatic internal cardioverter-defibrillator can be implanted subcutaneously in the chest to treat recurrent ventricular dysrhythmias when the side-effects of chronic drug therapy are undesirable (amiodarone) or when medical therapy fails.