bluuebunny/crossref_metadata_2025 huggingface dataset:
Finding Health Between Personal and Disease Processes
Authors: Sullivan Mark D.
Published: December 2016

Patient autonomy on a personal level is ultimately rooted in biological autonomy on a subpersonal level. Patient decisional autonomy concerns the conscious choices patients make concerning treatments and lifestyle, whereas biological autonomy concerns the ability of patients to shape their environment. To understand the roots of health in this biological autonomy, we must bridge the chasm characteristic of modern natural science between personal meaning and impersonal mechanism. We will find that “health” and “action” represent blind spots for medical and biological theory, respectively. Modern medicine strongly distinguishes the impersonal disease from the patient who has the disease. Four disciplines at the margin of biomedicine are reviewed that challenge this separation: psychosomatics, placebo, alternative medicine, and geriatrics. Attention to personal goals during diagnosis and treatment is one way to bridge the gap between impersonal disease and the patient as person. But, ultimately, the impersonal biomedical disease model needs to be challenged.
Patient-Centered Health Is Produced by Patients
Authors: Sullivan Mark D.
Published: December 2016

More fundamental than the patient’s capacity to perceive and value health is the capacity of the patient to produce health. Population and individual health do not originate from health care. Health care is not just inefficient at producing health; it can produce significant iatrogenic harm in clinical, social, and cultural ways. Patients may be overtreated. Non-patients may be overdiagnosed. Our culture is seduced into the belief that all death and disease can be controlled. Iatrogenesis transforms into expropriation as we become confused and forgetful about the sources of health itself. We have gradually strengthened our clinical safety net and weakened our social safety net. Yet, international studies suggest social spending improves population health more than clinical spending. The right to health is usually approximated as the right to health care. But this is inadequate and counterproductive. A better policy is a right to health capability.
Disease as a vague and thick cluster concept
Authors: Keil Geert , Stoecker Ralf
Published: December 2016

This chapter relates the problem of demarcating the pathological from the non-pathological in psychiatry to the general problem of defining ‘disease’ in the philosophy of medicine. Section 2 revisits three prominent debates in medical nosology: naturalism versus normativism, the three dimensions of illness, sickness, and disease, and the demarcation problem. Sections 3–5 reformulate the demarcation problem in terms of semantic vagueness. ‘Disease’ exhibits vagueness of degree by drawing no sharp line in a continuum and is combinatorially vague because there are several criteria for the term’s use that might fall apart. Combinatorial vagueness explains why the other two debates appear hopeless: Should we construe ‘disease’ in a naturalistic or in a normative way? Neither answer is satisfactory. How should we balance the three dimensions of pathology? We do not have to, because illness, sickness and disease (narrowly conceived) are non-competing criteria for the application of the cluster term ‘disease’.
The American experience with the categorical ban against executing the intellectually disabled: New frontiers and unresolved questions
Authors: Blume John H. , Johnson Sheri L. , Hritz Amelia C.
Published: December 2016

In 2002, in Atkins v Virginia, the US Supreme Court ruled that executing individuals with intellectual disability violated the Constitution’s Cruel and Unusual Punishment Clause. The Court, however, left it to the states to implement the new categorical exclusion. Post-Atkins, some states have adopted definitions of intellectual disability and procedures that make it virtually impossible for defendants to prevail. Setting aside the disparate treatment of those who clearly fall within the clinical definition of intellectual disability, questions remain about the fairness and morality of executing someone who falls just on the ‘wrong’ side of the diagnostic line, but in every relevant respect is equally disabled. Atkins represents a steps down the road toward humanitarian recognition that many persons with mental disabilities are not sufficiently morally culpable for the death penalty.
Typical and atypical mental disorders: Moral implications for academic–industry collaborations
Authors: Stein Dan J.
Published: December 2016

This chapter draws on cognitive–affective science findings about categorization in order to contrast more typical disorders with more atypical disorders. It focuses on a few atypical mental disorders (substance use disorders, pathological gambling) as key exemplars. Some moral implications for individual and public healthcare are considered, with a focus on the ethics of collaborations between clinicians and those involved in industry. Collaborations between academic institutions and industry partners raise the potential for conflicts of interest and other problems. The pharmaceutical industry is sometimes viewed as a ‘good’ industry that can go wrong, while the tobacco industry is viewed as a ‘bad’ industry that can do no right. The alcohol and gambling industries present a continuum of benefits and harms that needs to be acknowledged, and there are important opportunities for these industries to do more good for those suffering from or at risk for substance use and related conditions.
Transthoracic echocardiography/two-dimensional and M-mode echocardiography
Authors: Fernández Miguel Ángel García , de Diego José Juan Gómez
Published: December 2016

The echocardiogram is an extremely useful technique that gives all relevant information on morphology and function of the heart in a wide range of clinical situations. The very first step in echo is how to achieve the images needed for the cardiac evaluation. This chapter covers the basics of echo imaging acquisition including patient positioning and the pivotal concepts of echocardiographic window and view. The two-dimensional echo planes are carefully explained with a detailed description of the cardiac structures that can be studied in every view. The clinical scenarios where a specific imaging mode or orientation could be especially useful are also detailed. Finally M-mode imaging is covered, including detailed explanations of the habitual findings in normal studies.
Contrast echocardiography
Authors: Ahmed Asrar , Galiuto Leda , Monaghan Mark , Senior Roxy
Published: December 2016

Contrast echocardiography is an established and widely used technique employing gas-filled ultrasound contrast agents for diagnosis of cardiovascular disease, and contrast agents have become an integral part of a modern echocardiographic laboratory. Contrast echocardiography has been shown to improve diagnostic accuracy, reproducibility, and confidence across a range of indications with reduced downstream costs. Microbubble contrast agents now have a proven safety track record and it is imperative that through appropriate education and training, use of contrast is encouraged in day-to-day clinical and echocardiographic practice. This chapter discusses the basic principles of contrast echocardiography and reviews the utility of this technique in different clinical settings.
Stress echocardiography: diagnostic criteria and interpretation
Authors: Colonna Paolo , Alcantara Monica , Tanaka Katsu
Published: December 2016

This chapter discusses the diagnosis and interpretation of stress echocardiography, which needs a careful side-by-side analysis of each myocardial segment. The first step is the accurate analysis of regional wall motion at rest with particular attention on hypokinetic segments. In the second step, after a global evaluation of stress images, all segments should be carefully analysed for the presence of reduced wall thickening or delayed contraction compared to rest, preferably with a quad screen analysis. Particular attention has to be placed on assessment of wall thickening rather than wall motion or endocardial excursion as these may result from tethering of neighbouring segments or translational movement of the heart. The wall motion response to stress can be schematized based on the changes that occur during low stress and high stress, compared to rest baseline.
Digital echocardiography laboratory
Authors: Bjørnerheim Reidar , Derumeaux Genevieve , Gackowski Andrzej
Published: December 2016

Modern digital echo laboratories are based on echo scanners working in a network with file server(s) and work-station computers for offline analysis and reporting. They may be based on vendor-specific software, but are preferably based on vendor-independent software solutions, being able to handle data from all brands of scanners. To enable analysis of advanced echocardiographic techniques, plug-ins for vendor-specific solutions should be integrated in the otherwise vendor-independent software. To obtain full efficiency, the system should be integrated with the hospital information system for patient demographics and scheduling, and the approved report should automatically be returned to the electronic patient record without the need for scanning or other handling by manpower. To obtain this, a variety of standards have been developed, most of them for medical imaging in general. Scanners of all major brands deliver data compatible with those standards, even if compatibility problems may occur. When the optimal solution for the individual organization has been established, running the echo lab changes significantly. Digital images are stored on safe repositories without quality loss and are available for viewing outside the echo lab. Offline measurements, structured reporting, education, research, quality control, and financial analyses are available. The lab becomes more efficient and cost-effective.
Left ventricle: cardiac mechanics and left ventricular performance
Authors: Donal Erwan , Kou Seisyou , Senguptadd Partho
Published: December 2016

The complexity of left ventricular (LV) function(s) assessment in heart failure patients is related to the complexity of heart anatomy, but also to the complexity of electromechanical interaction, and to the load dependency of all the parameters that could be applied in clinical practice. Three perpendicular axes orienting the global geometry of the LV define the local cardiac coordinate system: radial, circumferential, and longitudinal. Speckle tracking is the technique of choice for quantifying myocardial deformation (regional and global). Longitudinal LV deformation, which is predominantly governed by the subendocardial region, is the most vulnerable component of LV mechanics and therefore most sensitive to the presence of myocardial disease.
Heart failure: preserved left ventricular ejection fraction
Authors: De Sutter Johan , Lipiec Piotr , Henri Christine
Published: December 2016

Nearly half of all patients with heart failure present with a preserved left ventricular ejection fraction (HFPEF). HFPEF is a pathophysiologically and clinically heterogeneous disease with an overall similar outcome to heart failure patients with a reduced ejection fraction. It is predominantly seen in elderly patients and comorbidities such as obesity, diabetes, hypertension, a sedentary lifestyle, and myocardial ischaemia play important roles in its development. In this chapter the conventional echocardiographic hallmarks of HFPEF including a preserved ejection fraction, left ventricular hypertrophy, left atrial dilatation, diastolic dysfunction, and pulmonary hypertension are presented. For the evaluation of left ventricular diastolic dysfunction, it is important to keep in mind that no single echocardiographic parameter is sufficiently accurate and reproducible to be used in isolation to make a diagnosis of diastolic dysfunction. The value of newer techniques including three-dimensional echocardiography and longitudinal strain assessment for the diagnosis and follow-up of HFPEF patients are promising but require further evaluation. As exercise-induced dyspnoea may be the first manifestation of HFPEF, the role of exercise echo (or diastolic stress testing) with evaluation of exercise-induced changes in left ventricular filling pressure and pulmonary artery systolic pressure is also presented. This chapter ends with a discussion on the echocardiographic parameters that can be used for risk stratification and follow-up of HFPEF patients.
Ischaemic heart disease: coronary artery anomalies
Authors: Picano Eugenio , Pinto Fausto , Michalski Blazej
Published: December 2016

Coronary anomalies occur in less than 1% of the general population and their clinical presentation can range anywhere from a benign incidental finding to the cause of sudden cardiac death. Since congenital coronary arteries anomalies are often considered as the first cause of cardiac death in young athletes in Europe, careful attention has to be paid in this specific subpopulation in case of suggestive symptoms. Although focused expert echocardiography is the first-line imaging tool, coronary computed tomography or radiation-free magnetic resonance imaging are recommended for more definitive definition of the coronary course in persons suspected of having coronary artery anomalies. Most coronary anomalies belong to the group of anomalous origin. Aneurysms are defined as dilations of a coronary vessel 1.5 times the normal adjacent coronary artery segment. Coronary artery fistulas are communications between one or more coronary arteries and a cardiac chamber (coronary-cameral), the pulmonary artery, or a venous structure (such as the sinus or superior vena cava).
Heart valve disease (aortic valve disease): anatomy and pathology of the aortic valve
Authors: Basso Cristina , Thiene Gaetano , Yen Ho Siew
Published: December 2016

The gross features of the aortic valve apparatus, consisting of three semilunar leaflets, three interleaflet triangles, three commissures, and the aortic wall, are discussed both in terms of normal and pathological anatomy. The concept of aortic annulus and the relationship of the aortic valve with the coronary arteries, the membranous septum, and conduction system and the mitral valve are addressed. When dealing with pathology, the chapter focuses on the main distinctive features of aortic valve stenosis and aortic valve incompetence. Regarding the former, the abnormalities reside in the cusps, either two or three in number, with cusp thickening, and calcification with or without commissural fusion (thus distinguishing senile and chronic rheumatic valve disease); in the latter, the gross changes can affect either the cusps (infective endocarditis with tissue perforation/laceration and rheumatic valve disease with tissue retraction) or the aortic wall (ascending aorta aneurysm either inflammatory or degenerative). The distinctive gross abnormalities in the various conditions are illustrated.
Heart valve disease (aortic valve disease): aortic stenosis
Authors: Baumgartner Helmut , Orwat Stefan , Sade Elif , Bermejo Javier
Published: December 2016

Echocardiography has become the gold standard for the assessment of patients with aortic stenosis (AS). It allows morphological assessment of the aortic valve and provides information on the aetiology of the disease. The quantification of AS includes primarily the measurement of transaortic jet velocities and gradients as well as the calculation of the valve area, thus combining flow-dependent and relatively flow-independent variables. Awareness of potential pitfalls is fundamental when assessing these variables. Haemodynamic consequences of AS on left ventricular (LV) size, wall thickness, and function as well as associated valve lesions and estimates of pulmonary artery pressure are required for the comprehensive evaluation of the disease. In the setting of classical low-flow–low-gradient AS with reduced LV systolic function, low-dose dobutamine echocardiography is of particular diagnostic and prognostic importance. The entity of severe low-flow–low-gradient AS in the presence of preserved LV function remains a particular diagnostic challenge. For accurate differentiation from pseudo-severe AS or misclassified moderate AS, an integrated approach including additional variables such as the extent of valve calcification by computed tomography may be required. In addition to the assessment of AS aetiology and quantification of its severity, echocardiography can provide predictors of outcome that may have a major impact on the decision for intervention.
Heart valve disease (aortic valve disease): aortic regurgitation
Authors: Tribouilloy Christophe , Lancellotti Patrizio , Peters Ferande , de Diego José Juan Gómez , Pierard Luc A.
Published: December 2016

Echocardiography is the cornerstone examination for the assessment of aortic regurgitation (AR): it provides reliable evaluation of the aortic valve and allows diagnosis and identification of the mechanism of regurgitation. The specific aetiology of the disease can be identified in the majority of cases. A combination of quantitative and quantitative Doppler and two-dimensional (2D) echocardiographic parameters allows the evaluation of the severity of AR and determination of the haemodynamic and left ventricular function repercussions. Echocardiography allows the detection of associated lesions of the aortic root or other valves. In symptomatic patients, echocardiography is essential to confirm the severity of AR. In asymptomatic patients with moderate or severe AR, echocardiography is essential for regular follow-up, by providing precise and reproducible measurements of LV dimensions and function, and for identifying patients who should be considered for elective surgical intervention. In most cases, transthoracic echocardiography (TTE) provides all of the necessary information and transoesophageal echocardiography in usually not required. Real-time three-dimensional (3D) TTE can be complementary to 2D echocardiography for the assessment of the mechanism and quantification of AR by increasing the level of confidence, especially when 2D echocardiographic data are inconclusive or discordant with clinical findings. Tissue Doppler imaging and especially the speckle tracking method are promising approaches to detect early LV dysfunction in patients with asymptomatic severe AR. Echocardiography is therefore the key examination for the assessment of AR and at the centre of the strategic discussion concerning the indications and timing of surgery.
Heart valve disease (mitral valve disease): anatomy and morphology of the mitral valve
Authors: La Canna Giovanni
Published: December 2016

The mitral valve is a complex anatomical structure that includes the valve tissue (leaflets), the left atrioventricular junction (annulus), and the valve suspension system (chordae tendineae, papillary muscles, and left ventricle). Its functional anatomy can be analysed using two- and three-dimensional transthoracic and transoesophageal echocardiography. Based on certain hallmarks (commissures, clefts), in vivo mitral valve tissue anatomy can be accurately categorized. In addition, three-dimensional reconstruction provides a quantitative model for comprehensive valve analysis. This chapter describes the anatomy and morphology of the mitral valve, including the subvalvular suspension system and functional anatomy and dynamics of the mitral annulus.
Heart valve disease (mitral valve disease): mitral regurgitation
Authors: Lancellotti Patrizio , Dulgheru Raluca , Vannan Mani , Yoshida Kiyoshi
Published: December 2016

Mitral regurgitation (MR) is increasingly prevalent in Europe. Echocardiography has a key role in the diagnosis and management of patients with MR. Each echocardiographic study in patients with MR should aim to characterize mitral valve morphology, identify the mechanism of valve dysfunction, quantify the severity of MR, and give hints regarding the aetiology of the disease affecting the valve. Assessment of MR severity should be based on a step-wise approach including two-dimensional-derived Doppler data and, when available, data derived from three-dimensional echocardiography. MR assessment by quantitative methods should be implemented in each patient when possible. It is imperative not only to quantify the MR severity, but also to assess its consequences on the left ventricle, left atrium, and pulmonary vascular bed and to put everything into the clinical context (presence of symptoms, individual risk assessment, etc.) before taking any decision to correct the valvular incompetence. A rigorous echocardiographic study and a correct interpretation in the individual clinical context are needed to decide if the patient should be operated on or followed up closely. Exercise stress echocardiography, when appropriate, should be part of the evaluation algorithm in patients with both primary and secondary MR, as it has proved to be useful in individual risk stratification.
Endocarditis
Authors: Habib Gilbert , Thuny Franck , Van Camp Guy , Matskeplishvili Simon
Published: December 2016

Echocardiography plays a key role in the assessment of infective endocarditis (IE). It is useful both for the diagnosis of endocarditis, the assessment of the severity of the disease, the prediction of short-term and long-term prognosis, the prediction of embolic risk, the management of the complications of endocarditis, and the follow-up of patients under specific antibiotic therapy. The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology and the ‘Recommendations for the practice of echocardiography in infective endocarditis’ of the European Association for Echocardiography have underlined the value and limitations of echocardiography in IE, and gave clear recommendations for the optimal use of both transthoracic and transoesophageal echocardiography in IE. New data in the field of echocardiography in IE includes more extensive use of three-dimensional transoesophageal echocardiography, inclusion of other imaging techniques, and new important publications in the field of the prediction of embolic risk by echocardiography.
Restrictive cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy
Authors: Elliott Perry , Haugaa Kristina H. , Caso Pio , Cikes Maja
Published: December 2016

Restrictive cardiomyopathy is a heart muscle disorder characterized by increased myocardial stiffness that results in an abnormally steep rise in intraventricular pressure with small increases in volume in the presence of normal or decreased diastolic left ventricular volumes and normal ventricular wall thickness. The disease may be caused by mutations in a number of genes or myocardial infiltration. Arrhythmogenic right ventricular cardiomyopathy is an inherited cardiac muscle disease associated with sudden cardiac death, ventricular arrhythmias, and cardiac failure. It is most frequently caused by mutations in desmosomal protein genes that lead to fibrofatty replacement of cardiomyocytes, right ventricular dilatation, and aneurysm formation.
Isolated ventricular non-compaction
Authors: Weidemann Frank , Habib Gilbert , Vazquez Clara
Published: December 2016

Isolated ventricular non-compaction (IVNC) in adults is a rare congenital cardiomyopathy characterized by the presence of prominent myocardial trabeculations in the apical segments of the left ventricle with deep inter-trabecular recesses in communication with the ventricular cavity. Until now there is no clear genetic or laboratory test for the diagnosis of IVNC and thus the diagnosis is defined by clinical and imaging criteria. During echocardiography a maximal end-systolic ratio between the non-compacted endocardial layer and the compacted layer of greater than 2 is consistent with IVNC. This chapter focuses on the definition of IVNC and typical imaging features seen by standard and by advanced echocardiography.
Familial cardiomyopathies
Authors: Rigo Fausto , Fernández-Golfín Covadonga , Pinamonti Bruno
Published: December 2016

The tricuspid valve is currently the subject of much interest from echocardiographers and surgeons. Functional tricuspid regurgitation is the most frequent aetiology of tricuspid valve pathology, is characterized by structurally normal leaflets, and is due to annular dilation and/or leaflet tethering. A primary cause of tricuspid regurgitation with/without stenosis can be identified only in a minority of cases. Echocardiography is the imaging modality of choice for assessing tricuspid valve diseases. It enables the cause to be identified, assesses the severity of valve dysfunction, monitors the right heart remodelling and haemodynamics, and helps decide the timing for surgery. The severity assessment requires the integration of multiple qualitative and quantitative parameters. The recent insights from three-dimensional echocardiography have greatly increased our understanding about the tricuspid valve and its peculiarities with respect to the mitral valve, showing promise to solve many of the current problems of conventional two-dimensional imaging. This chapter provides an overview of the current state-of-the-art assessment of tricuspid valve pathology by echocardiography, including the specific indications, strengths, and limitations of each method for diagnosis and therapeutic planning.
Cardiac masses and potential sources of emboli
Authors: Benyounes Nadia , Pepi Mauro , Esposito Roberta , Ginghina Carmen , Cohen Ariel
Published: December 2016

Cardiac masses are abnormal structures within or immediately adjacent to the heart. They have to be distinguished from variants of normal cardiac structures, postoperative changes, and ultrasound artefacts. These abnormal masses may be localized in the left or right heart cavities, with different clinical manifestations according to their localization. Among the abnormal cardiac masses (thrombus, vegetations, tumours), tumours are not discussed in this chapter. Echocardiography is the main but not the only imaging technique for the evaluation of cardiac masses, and is largely available. Hence, it is indicated in patients with a systemic embolic event, searching for a cardiac source embolism. When transthoracic echocardiography is negative, transoesophageal echocardiography is indicated, in cryptogenic ischaemic events (no cause found). Right heart masses are mainly responsible for pulmonary embolisms, but may be the cause of a systemic embolus, via the atrial septum. Right heart thrombi rarely form in situ, and are hence more often venous thrombi entrapped in the right heart on their way to the pulmonary arteries. Echocardiography is mandatory in the setting of pulmonary embolism.
Cardiac tumours
Authors: Andrade Maria João , Hanzevacki Jadranka Separovic , Ronderos Ricardo
Published: December 2016

Transthoracic and transoesophageal echocardiography represent the first-line diagnostic tools for imaging space-occupying lesions of the heart. Cardiac masses can be classified as tumours, thrombi, vegetations, iatrogenic material, or normal variants. Occasionally, extracardiac masses may compress the heart and create a mass effect. Cardiac masses may be suspected from the clinical presentation. This is the case in patients with an embolic event presumed to be of cardiac origin or in patients with infective endocarditis. Otherwise, a cardiac mass can be identified during the routine investigation of common, non-specific cardiac manifestations or as an incidental finding. In general, an integrated approach which correlates the patient’s clinical picture with the echocardiographic findings may reasonably predict the specific nature of encountered cardiac masses and, in the case of tumours, discriminate between primary versus secondary, and benign versus malignant. Furthermore, echocardiography alone or with complementary imaging modalities, can provide information to decide on the resectability of cardiac tumours and assist on planning the therapy and follow-up. Because several normal structures and variants may mimic pathological lesions, a thorough knowledge of potential sources of misinterpretation is crucial for a correct diagnosis. After surgical resection, histological investigation is mandatory to confirm the diagnosis.
Systemic diseases and other conditions: introduction
Authors: Hagendorff Andreas
Published: December 2016

Cardiac structures and their function as well as the vascular system can be affected by general systemic influences. Exceptional physiological conditions like competitive sports or pregnancy cause typical, but normally reversible alterations in the heart. Certain systemic diseases will cause cardiovascular alteration and damage, which can be life-threatening or can introduce the development of myocardial failure due to humoral, immunological, or inflammatory affections on the myocardium or the valves. In the following chapters in this section, the echocardiographic findings which can be documented due to the physiological compensatory effects in athlete’s heart as well as in pregnancy are described. Then, the typical echocardiographic characteristics in patients with systemic diseases are described with respect to the main cardiac target which is affected. The targets of the systemic diseases are the coronary arteries, the heart valves, the myocardium, the pericardium, as well as the right ventricle.
Diseases with a main influence on heart valves
Authors: Hagendorff Andreas , Chammas Elie , Essop Mohammed Rafique
Published: December 2016

The high spatial and temporal resolution, widespread availability, and non-invasive nature of echocardiography make it the imaging modality of choice for assessment of cardiac valvular disease. Echocardiography allows not only detailed evaluation of valve morphology, but also makes possible assessment of the haemodynamic consequences and impact on left and right ventricular size and function. Based on this data, a more informed decision may be made on the nature and timing of surgical or percutaneous intervention. A wide variety of diseases may afflict the cardiac valves. In some such as rheumatic heart disease and degenerative disease, abnormality of valve function is the most important manifestation. Many systemic diseases, however, may affect the cardiac valves and not infrequently, echocardiography may be the first clue to a systemic illness. The salient points of diseases affecting mainly the cardiac valves are discussed in this chapter.
Diseases with a main influence on right ventricular function
Authors: Voilliot Damien , Kasprzak Jaroslaw D. , Bossone Eduardo
Published: December 2016

As an important and independent predictive factor of morbidity and mortality, right ventricular (RV) function should be carefully assessed in patients with chronic obstructive lung disease, lung fibrosis, liver cirrhosis, or obesity. RV assessment requires a complete study of the ‘RV-pulmonary circulation unit’ with estimation of RV preload, RV intrinsic contractility, and RV afterload. Therefore, estimation of pulmonary arterial pressure, pulmonary vascular resistance, and left ventricular systolic and diastolic function should be included in this evaluation, in addition to conventional RV systolic function assessment. Three-dimensional echocardiography has emerged as an interesting tool in RV assessment and exercise echocardiography may be interesting in the risk stratification of patients.
Acute cardiac care
Authors: Price Susanna , Senior Roxy , Popescu Bogdan A.
Published: December 2016

Echocardiography is fundamental to the assessment and management of patients with acute cardiac disease, and differs from outpatient echocardiography in some key areas. Echocardiography provides important information throughout the whole patient pathway, having been shown to change interventions in 60–80% patients in the pre-hospital setting, improve diagnostic accuracy and efficiency in the emergency room, and reveal the aetiology of unexplained hypotension in 48% of medical intensive care patients. Echocardiography is now included in the universal definition of acute myocardial infarction, and in international guidelines regarding the management of cardiac arrest. In the critical care setting, echocardiography can be used to as a haemodynamic monitor, to determine abnormalities of cardiac physiology and coronary perfusion, as well as defining the underlying cardiac diagnosis. This chapter focuses on situations relevant to acute cardiac care, however, where discussed elsewhere in this textbook (acute coronary syndromes, pulmonary embolism, takotsubo, aortic disease, pericarditis, cardiomyopathies, heart failure, and valvular disease) they are not covered in detail here.
Coronary artery imaging
Authors: Hagendorff Andreas , Stankovic Ivan , Takeuchi Masaaki
Published: December 2016

Assessment of coronary artery disease using echocardiography is normally performed by the detection of regional wall motion abnormalities at rest or stress-induced myocardial hypoperfusion and ischaemia. Direct visualization of native coronary arteries by echocardiography is uncommon, but possible. In contrast, imaging of coronary artery flow by transthoracic color-coded Doppler echocardiography is increasingly popular, especially in combination with the administration of adenosine for the non-invasive assessment of coronary flow velocity reserve.
Competence and certification
Authors: Stefanidis Alexandros S. , Popescu Bogdan A.
Published: December 2016

Echocardiography has become a mainstay in the evaluation process of patients with known or suspected cardiovascular diseases. In recent years this ongoing trend has been accompanied by a number of challenging issues related to training, competence, certification, and credentialing. The clinical benefits of recognition of individuals and clinical settings are well recognized, and certification-accreditation is critical in all areas of cardiovascular imaging to ensure optimal performance and interpretation of quality studies for patient diagnosis and management. The certification-accreditation procedure of the European Association of Cardiovascular Imaging has been developed to test the adequacy of competence of individuals and clinical settings. In this chapter, the rationality and current methodology of these procedures are described.
Training for emergency echocardiography
Authors: Neskovic Aleksandar N.
Published: December 2016

Emergency echocardiography refers to the use of echocardiography in the assessment of patients with suspected cardiovascular disease requiring immediate diagnosis and treatment. The European Association of Cardiovascular Imaging (EACVI) has recently set standards for adequate education and training for the safe and efficient use of echocardiography in emergency cardiac care. The level of competence in echocardiography required for emergency cases is at least the same as for elective cases and competence requirements for emergency echocardiography are the same for cardiologists and non-cardiologists. The EACVI recognizes two levels of competence in emergency echocardiography: the independent operator level and the expert operator level. This chapter discusses general considerations as well as requirements and levels of competence regarding training for emergency echocardiography.
Laboratory accreditation
Authors: Nihoyannopoulos Petros , Gargani Luna
Published: December 2016

Accreditation and certification of echocardiography laboratories is a crucial step to standardize and homogenize the practice of echocardiography and therefore, ultimately, to protect patients from undergoing cardiovascular imaging examination performed by unqualified people and/or in an inappropriate environment. The European Association of Cardiovascular Imaging (EACVI) aims at setting up a European standard in laboratory practices and patient care. Following the success of the individual certification process, the EACVI launched Laboratory Accreditation in three different modules: transthoracic echocardiography, transoesophageal echocardiography, and stress echocardiography. For each module, two levels are available: the basic standard accreditation, aimed to fulfil mandatory requirements for an adequate clinical service, and the advanced standard accreditation, set to establish a smaller number of advanced laboratories with state-of-the-art equipment, providing extensive teaching and research and covering all modules. The accreditation process is designed to uniformly raise standards of practice and equipment, and to be used as an educational tool to improve the overall quality of the laboratories, both from a clinical and scientific perspective.
Models of paediatric palliative care
Authors: Hain Richard D.W. , Jassal Satbir Singh
Published: December 2016

The UK has a variety of resources for children with life-limiting conditions that are perhaps unrivalled in the world. This is both good and bad. It offers the potential for children and their families to have choices about the location of their care. On the other hand, a multiplicity of agencies brings with it the risk of miscommunication and internecine strife. This chapter summarizes ideal models of palliative care, defining the four categories of life-limiting conditions in childhood and the role of paediatric palliative medicine specialists.
Nausea and vomiting
Authors: Hain Richard D.W. , Jassal Satbir Singh
Published: December 2016

The management of nausea and vomiting requires an understanding of the probable mechanism and logical consideration of drug selection. But it also requires an approach that is individualized to the emotional and psychological needs of the child and family. This chapter examines the pathophysiology of vomiting, alongside guidelines for management and antiemetic therapy. Medications for use to control the symptoms of nausea and vomiting are covered, as well as guidance on exploring and managing the expectations of the patient and family.
Skin symptoms
Authors: Hain Richard D.W. , Jassal Satbir Singh
Published: December 2016

Skin symptoms are commonly seen in paediatric palliative medicine. This chapter covers important skin symptoms, including epidermolysis bullosa, pruritus, fungating tumours, and pressure sores. Detail is provided on managing these conditions, including information on appropriate dressings and pharmacological treatment.
Specific non-malignant diseases
Authors: Hain Richard D.W. , Jassal Satbir Singh
Published: December 2016

The number of life-limiting conditions in paediatrics is vast, and paediatric palliative medicine is generally based equally on both malignant and non-malignant conditions. There are several medical conditions that are common enough for it to be helpful to know about them in more detail. As all the conditions, by definition, have no cure, it is best to tackle each symptom with which the child presents individually, never forgetting that medical intervention is not the only modality open to us. Common conditions, such as Duchenne muscular dystrophy, mucopolysaccharidosis type 1, mucopolysaccharidosis type 3, Batten’s disease, spinal muscular atrophy, and trisomy 18, are covered in this chapter. Details of clinical features and prognosis are described for each.
Formulary
Authors: Hain Richard D.W. , Jassal Satbir Singh
Published: December 2016

This chapter is a formulary of drugs commonly used in paediatric palliative medicine. A summary of use and doses and routes is provided in each instance, with many sections also accompanied by notes to assist the practitioner when administrating and choosing treatments.
The primacy of relation
Authors: Stanghellini Giovanni
Published: December 2016

Perhaps the highest philosophical principle consists in holding oneself open to the dialogue. Building on Martin Buber’s philosophy, this chapter argues that there is no ‘I’ taken in itself. The ‘I’ of the ‘I–You’ combination is different from the ‘I’ of the ‘I–It’ combination. When a person says ‘I’ he refers to one or other of these. There is a radical difference between a person’s attitude to another person and her attitude to things. In the personal relation, an ‘I’ confronts a ‘You’. In the connexion with things, an ‘I’ connects with an ‘It’. These two attitudes constitute respectively the world of the ‘You’ and the world of ‘It’. The ‘You’ cannot be appropriated. So long as the ‘I’ remains in the relationship with the ‘You’ it cannot be reduced to an experienced object—an ‘It’.
The dialogue with alterity: narratives and the dialectic of identity
Authors: Stanghellini Giovanni
Published: December 2016

This chapter introduces the notion of ‘alterity’. The ‘You’ may take several forms in human life that are essential for personal identity and becoming. We may collectively call ‘alterity’ these forms of the ‘You’. Experiencing oneself as a person involves more than a sense of self-sameness. Our identity as a human person is a narrative identity that stems from the dialectics between what we are and the alterity that we encounter in our life. It introduces the concept of ‘narrative identity’ as one basic form of dialogue with alterity. Mental health is the equilibrate dialectic and proportion between sedimentation and innovation, that is, between the alterity that comes manifest through the encounter with one’s un-chosen, ‘involuntary’ disposition or with an event, and the capacity of the person to cope with, modulate, appropriate, and make sense of them.
Emotions: the person in between moods and affects
Authors: Stanghellini Giovanni
Published: December 2016

This chapter explains that emotions are another manifestation of alterity. The dialectics between person and alterity is paradigmatically manifest in my emotional experience. I cannot choose my emotions, yet they are an essential part of my own Self. Emotions are characterized by their connection to motivation and movement. Emotions are functional states, which motivate and may produce movements. Emotions are kinetic, dynamic forces that drive us in our ongoing interactions with the environment. This understanding of ‘emotion’ focuses on the embodied nature of emotions. Essential for the understanding of the dialectics between emotions and the person is the distinction between the two forms that emotional experience may take: affects and moods.
Emotions and the dialectic of narrative identity
Authors: Stanghellini Giovanni
Published: December 2016

This chapter argues that a significant part of a person’s self-experience and self-understanding is based on self-narratives—an ongoing process of establishing coherent formulations about who I am, who I was, and where I am going. Through self-narratives I seek to understand my actions and experiences as a semantically coherent pattern of chronologically ordered elements, and to grasp the way I relate myself to that understanding and to the world. The emotional experiences of moods and affects play a crucial role in the life and self-experience of the person. A given mood can develop itself into a character trait, that is, a permanent part of one’s sense of personal identity; this transformation occurs pre-reflectively and without a deliberate and thematic involvement of the person. Through narratives, moods can also be incorporated actively, reflectively, and thematically into a person’s identity. Moods are connected to self-understanding. My questioning about myself is often elicited by my mood before my identity becomes an explicit problem.
Alterity and the recoil of one’s actions
Authors: Stanghellini Giovanni
Published: December 2016

This chapter shows that alterity manifests itself in the course of my action. All action is a circle wherein our conscious purposes are projected in deeds whose consequences inevitably express something beyond what was intended; the deed recoils back upon the purpose, throwing it into question, exposing the disparity between its intended meaning and its actual outcome. All conscious intentions are unable to anticipate the full train of consequences, unable to force the world to become a simple mirror of our purposes. Whenever I act, via the externalization of my unwilled intentions, I experience a kind of alienation from myself. Recognition, in the case of the recoil of the unintended consequences of my actions, implies both self-knowledge—knowing myself as reflected in my actions—and responsibility—acknowledging that I avow all the consequences of my actions, although they are unintended, and I am ready to respond for them.
An anthropology of non-recognition
Authors: Stanghellini Giovanni
Published: December 2016

This chapter argues that in order to become (and remain) a ‘healthy’ person, I need the others to recognize me in my being-so, that is, in my otherness with respect to them, and at the same time I need their acknowledgement of the value of the otherness that I am. Also, I need to be able to recognize the otherness of the Other. What kind of reaction can generate in me my awareness of non-recognition, be it a kind of emotional dis-attunement, or misunderstanding; or, in general, what could be the outcome of my failed dialogue with the Other? The various shelters or defensive housings in which each of us seeks refuge with respect to our failure in dealing with the aporias of recognition include scepticism, cynicism, mysticism, agnosticism, and contemplation.
What is a symptom?
Authors: Stanghellini Giovanni
Published: December 2016

This chapter explains that the concept of symptom covers a vast array of indexicalities, focusing on the bio-medical concept of ‘symptom’. In biological medicine, a symptom is an index for diagnosis and the epiphenomenon of an underlying pathology. In the biomedical paradigm, symptoms have causes, rather than meanings. In general, causality goes from aetiology (e.g. a virus), to symptom(s) (breathing difficulties), to dysfunction (poor physical performance due to blood hypo-oxygenation, and thus reduced adaptation of the person to his or her environment). Another important assumption is that symptoms are considered accidental, i.e. non-essential to the living organism. Many of these assumptions—if we apply this paradigm to the field of psychic pathology— are at least controversial, or even counterfactual.
Symptom as cypher
Authors: Stanghellini Giovanni
Published: December 2016

This chapter argues that the symptom-as-aletheia concept can be better explained in the light of Jaspers’ concept of ‘cypher’. Cyphers show what without them would remain implicit for us. Symptoms are a special category of cyphers: through them alterity, that is, the hidden yet operative (and perplexing) dimension of our existence, is made manifest. Like symptoms, cyphers are the contingent opportunity of recognition, of a possible encounter between the person and the encompassing dimension of her existence. The cypher must keep on an inexhaustible signification with which no definite interpretation is commensurate. Symptoms in the phenomenological–hermeneutic paradigm are anomalies, but not abnormal phenomena in a strict sense. Rather, they are what awakens one’s care for oneself. The symptom reflects and reveals alterity in oneself—in it, alterity becomes conspicuous. From the vantage offered by the symptom one can see oneself from another, often radically different and new, perspective.
Depression and the idealization of common-sense desire
Authors: Stanghellini Giovanni
Published: December 2016

This chapter argues that the form of loving relationship characterizing a melancholic person is a special kind of idolatrous desire, namely the idealization of common-sense desire. Dostoevsky’s short novel A Gentle Creature shows that her way of loving her husband is not rooted in the love for the Other seen as an individual person. Love is a feeling whereby we feel displaced. Love hurts because of its power to be an event in our life that forces us to reconsider our habits and jeopardizes our narcissistic identity. Yet, the Gentle creature relies on her fixed idea—the common-sense prototype of the exemplary marriage. It is an idealization of common-sense desire. This is a vulnerable shelter as a defence from the missed encounter with the Other. Dostoevsky’s Gentle creature tries to solve the riddle of the Other by emptying the Other of his personal identity and reducing him to a stereotype.