bluuebunny/crossref_metadata_2025 huggingface dataset:
Control of radioactive substances
Authors: Reay Jill , Sutton David , J Martin Colin
Published: November 2017

The possession, use, transport, and disposal of radioactive materials are controlled through regulation to limit exposure of the public and workers. This chapter describes the methodologies employed. Regulation is enacted through a system of notification and licensing, based upon recommendations from the IAEA and ICRP. A competent authority is empowered to permit an organization to hold, use, or dispose of any radionuclide, provided certain conditions are met. These take the form of limits on the quantities of different radioactive materials held, and requirements for security and protection. They require an evaluation of the impact of waste disposal. Methodologies for estimating doses received by critical groups from release of radioactive material into the environment are explained. Minimization of the waste produced and regulation of its disposal are essential components in the overall strategy to protect the environment. Controls over the transport of radioactive materials and medical administrations to patients are considered.
Interventional radiology and cardiology
Authors: Martin Colin J , Sutton David G
Published: November 2017

Doses from interventional radiology and cardiology procedures have risen as techniques have developed and allowed more challenging procedures to be undertaken. The dose levels for individual procedures have increased with the complexity resulting in risks of tissue reactions such as erythema and epilation. The increase in numbers of procedures has resulted in risks of damage to the eyes of interventional staff. Factors affecting patient doses and optimization of patient protection are discussed. Methods of assessing doses to patients’ skin are described. The arrangements that should be in place to identify those patients at risk of tissue reactions through setting of dose trigger levels are explained, and the subsequent follow-up recommended is described. The potential protection that can be obtained through use of shielding devices by staff to reduce their dose is considered, and methods for monitoring staff doses reviewed.
The nuclear medicine patient
Authors: Greaves Claire D , Dunn Mike J
Published: November 2017

Following the administration of a radiopharmaceutical, the patient is essentially a mobile source of radiation. The hazards from the patient are contamination from radioactive tissue/body fluids, and exposure to the radiation emitted from the patient. These hazards present a risk to the patient due to self-absorbed radiation, healthcare workers, other patients, members of the public, family members (including the foetus), colleagues at work, and carers. This chapter presents the methodology used for assessing the doses to patients and critical groups, and discusses its limitations. It considers the risks and protective measures for: the patient (both adults and paediatrics), the foetus and young children including reproduction, breastfeeding, and close contact, hospital and external workers who may come into contact with the patient or be at risk of contamination, and the general public (inside and outside the hospital environment). The risks are presented along with practical guidance to minimize the hazard.
Magnetic resonance imaging
Authors: Condon Barrie , MacFarlane Jennifer
Published: November 2017

Magnetic resonance imaging employs strong electromagnetic fields that present a variety ofhazards. This chapter considers the interaction of the strong magnetic field with externalferromagnetic objects and those implanted in the body. The interaction of strong RF fieldscan induce currents in wires and cables which can, in certain circumstances, result in burns.By the same mechanism, excessive heating can be caused in passive implanted devicesand the operation of active implants can fail or be critically altered. The direct impact of theMR environment on the human body is described in terms of the effect of (i) the staticmagnetic field, (ii) movement through the static magnetic field, (iii) the heating effects of theRF field, and (iv) the acoustic noise. The risks involved in the use of cryogens are brieflydiscussed. Finally, practical safety procedures are recommended.
Pain
Authors: Hatfield Anthea
Published: November 2017

This chapter answers many questions, for example, ‘What is pain?’ and ‘Why pain is harmful?’. How we perceive pain and the physiology of pain are discussed. Plasticity and wind-up and the role of ketamine in preventing chronic pain are also included in this fascinating chapter.
Postoperative pain
Authors: Hatfield Anthea
Published: November 2017

This chapter begins with a list of pain principles. It goes on to describe misunderstandings about pain and guidelines are given for diagnosing non-surgical causes of pain, such as myocardial ischaemia. Gauging the severity of pain and using pain scales are explained as well as the use of an acute pain service. Different techniques are described for assessing pain in different groups including the elderly, neonates, and the mentally impaired. Pre-emptive analgesia and multimodal analgesia are discussed. Suggestions for looking after patients with nerve blocks and day surgery patients are offered.
Analgesics
Authors: Hatfield Anthea
Published: November 2017

Analgesics are drugs used to relieve pain. They are divided into groups: opioids, non-steroidals, and adjuvants. This chapter gives you detailed information on their pharmacology. Once you fully understand the chemistry of these drugs you can go on to understand their clinical properties, how they react differently in different groups of people, and their side effects.
Respiratory physiology
Authors: Hatfield Anthea
Published: November 2017

Breathing and normal respiration must be understood by recovery room staff. This chapter explains how patients breathe and what is happening when patterns of respiration alter. Terms that sound complicated, like functional residual capacity, are explained and the way in which breathing is driven from the brain and by chemoreceptors in the lungs is simply described.
Working with facts
Authors: Hatfield Anthea
Published: November 2017

This is basically an introduction to statistics. Even if you have never approached the subject before I hope you will not find it daunting. Once you understand statistics you can read articles where facts and figures appear with real understanding. Sit down quietly and take one section at a time. Once you have digested this chapter turn to the suggested reading at the end of the chapter.
Laboratory tests
Authors: Deveza Leticia A. , Ding Changhai , Jin Xingzhong , Wang Xia , Zhu Zhaohua , Hunter David J.
Published: November 2017

In clinical practice, laboratory tests play a major role in the investigation of underlying diseases predisposing to osteoarthritis (OA) (e.g. metabolic and genetic causes) and in the differential diagnosis of other joint disorders, particularly autoimmune and crystal-related arthropathies. In terms of diagnosis and management of OA, there is still no recommendation in guidelines for the use of laboratory tests. However, an increasing number of potential applications of laboratory tests in OA are emerging. In this regard, research investigating the role of vitamin D and other substances such as inflammatory markers, cytokines, and adipokines in the OA process is helping to reveal novel pathophysiologic mechanisms and, consequently, new possible therapeutic approaches. Furthermore, biochemical markers of cartilage, bone, and synovium metabolism is a growing field in OA and may also contribute to the diagnosis of early OA stages, assessment of prognosis, and management, once properly validated.
Introduction: the comprehensive approach
Authors: Doherty Michael , Bijlsma Johannes , Arden Nigel , Hunter David J. , Dalbeth Nicola
Published: November 2017

This introductory chapter to the section on management of osteoarthritis (OA) emphasizes the need for a full assessment of the patient, not just in terms of joint symptoms and examination findings but a full holistic assessment of the person, including the impact of OA on their life, their illness perceptions of OA, and the presence of comorbidities. An individualized package of care can then be developed. Patients should be fully informed about OA and fully involved in all management decisions. Apart from education, which is an ongoing not one-off process, other core treatments to be considered in every person with OA are exercise (both strengthening and aerobic) and strategies to reduce adverse mechanical factors, including weight loss if overweight or obese. Topical non-steroidal anti-inflammatory drugs are the safest analgesic drug to try first for peripheral joint OA. Other treatments can be selected as required from a wide range of drug and non-pharmacological options, to address the needs of the individual. The patient requires regular follow-up for reassessment and re-adjustment of management as required. Currently there are sparse data on predictors of response to treatment, limiting a stratified medicine approach. Caveats to the research evidence for OA and its transition to clinical practice are discussed, and one way of improving this (reporting overall treatment effect and the proportion attributable to placebo in clinical trials) is presented. Optimizing contextual effects, which are an integral part of any treatment and which may explain the majority of improvement that a patient experiences for their OA, is emphasized as a key aspect of care.
Patient information strategies for decision-making and management of osteoarthritis
Authors: Hawker Gillian , Lyddiatt Anne , Li Linda , Stacey Dawn , Jaglal Susan , Munce Sarah , Waugh Esther
Published: November 2017

Osteoarthritis (OA) is a chronic, disabling disease that warrants care that aligns with the principles of ‘chronic disease management’. Central to the success of chronic disease management is the ‘informed, activated patient’. Patient information strategies, including the use of patient decision aids, are essential to enabling patients with OA to self-manage their disease and engage in informed, shared decision-making. Such strategies are best delivered by a multidisciplinary team of healthcare providers and adapted to the characteristics, preferences, and values of the individual OA patient. Patients actively involved in their own disease management, that is, ‘self-management’, including shared goal-setting and decision-making about treatment interventions, are, on average, more adherent to treatment recommendations, have enhanced self-efficacy and, ultimately, experience better health outcomes.
Addressing adverse mechanical factors
Authors: Nguyen Christelle , Rannou François
Published: November 2017

Non-pharmacological approaches are widely and consistently recommended for the management of osteoarthritis (OA). This recommendation is based on biomechanical observations and emphasizes the therapeutic interest of biomechanical interventions able to modulate adverse mechanical factors affecting the symptomatic OA joint. Therapeutic approaches include braces, orthoses, insoles, joint protection, joint-preserving surgical procedures, walking sticks, and other aids. Overall, biomechanical interventions aim to modulate joint biomechanics, in order to improve joint mechanosensitivity, decrease mechanical joint loading, and eventually reduce pain. These interventions must be adjusted to the biomechanical specificities of each joint, and of the individual patient. This chapter uses an evidence-based approach, including the most recent European League Against Rheumatism, Osteoarthritis Research Society International, and American College of Rheumatology recommendations, to describe and to review non-pharmacological strategies available in daily clinical practice, designed to modulate mechanical joint loading, with a focus on the management of hand, hip, and knee OA. The interest of weight loss, specific and non-specific exercises, patient education, and self-care programmes is discussed elsewhere in this book.
Prospects for disease modification
Authors: Yu Shirley P. , Hunter David J.
Published: November 2017

The tremendous individual and societal burden underpin a strong rationale for the development of disease-modifying agents for osteoarthritis. Current approaches to managing the disease remain largely palliative and focused on alleviating symptoms, specifically pain and functional limitation. The chapter considers the multitude of tissues that potentially can be targeted in this heterogeneous disease of osteoarthritis and the agents that can modify these tissues. It first focuses on molecules targeting inflammatory pathways and then breaks that down by particular tissue targeted: specifically and in particular synovium, cartilage, and bone. There is widespread demonstration of the ability to modify osteoarthritis in preclinical models; however, this has not been translated to the human disease to the satisfaction of regulatory bodies at this point in time. There are a number of products currently in testing that demonstrate great promise although there remain considerable challenges to the demonstration of disease modification.
Guidelines
Authors: Zhang Weiya , Doherty Michael
Published: November 2017

A number of treatment guidelines have been developed to optimize the treatment of osteoarthritis, some of which were recently updated. Fifty-one non-pharmacological, pharmacological, and surgical treatments are addressed in these guidelines but only two (oral opioid and intra-articular steroid injection) reach the minimal clinically important difference above placebo. Recommendations for these treatments vary depending on joint sites, risk:benefit ratio, and population. Exercise, self-management, and weight reduction if obese are universally recommended. While topical non-steroidal anti-inflammatory drugs (NSAIDs) remain a safe first-line drug option, the safety of paracetamol, the universally recommended first-line oral analgesic is increasingly questioned. Other analgesics such as oral NSAIDs (including selective cyclooxygenase 2 inhibitors), opioids, and antidepressants should be used according to patient characteristics and comorbidities. Nutraceuticals and complementary medicines remain controversial. While lavage is not recommended, total joint replacement is still considered as an effective treatment for the later stage of the disease irrespective of lack of placebo (sham) controlled trials. Stratified care has been attempted for recommendation according to joint affected and comorbidities but there is no evidence to support whether this can improve treatment outcomes. Guideline development groups differ in their composition and methodology. While the overall quality of guidelines has been improved, their applicability remains poor. Of the various factors that may influence implementation, suboptimal publishing and the efficacy paradox need to be recognized as important barriers.
Epidemiology and risk factors for calcium pyrophosphate deposition
Authors: Abhishek Abhishek , Doherty Michael
Published: November 2017

Calcium pyrophosphate crystal deposition (CPPD) is rare in younger adults but becomes increasingly common over the age of 55 years, especially at the knee. Ageing and osteoarthritis (OA) are the main attributable risk factors. Hyperparathyroidism, hypomagnesaemia, haemochromatosis, and hypophosphatasia are other less common risk factors. Rare families with familial CPPD have been reported from many different parts of the world, and mainly present as young-onset polyarticular CPPD. Recent studies suggest that CPPD occurs as the result of a generalized constitutional predisposition and may also associate with low cortical bone mineral density. Previous meniscectomy, joint injury, and constitutional knee malalignment are local biomechanical risk factors specifically for knee chondrocalcinosis. Although associated with OA, current evidence suggests that CPPD does not associate with development or progression of OA.
Pathophysiology of calcium pyrophosphate deposition
Authors: Abhishek Abhishek , Doherty Michael
Published: November 2017

Calcium pyrophosphate (CPP) dihydrate crystals form extracellularly. Their formation requires sufficient extracellular inorganic pyrophosphate (ePPi), calcium, and pro-nucleating factors. As inorganic pyrophosphate (PPi) cannot cross cell membranes passively due to its large size, ePPi results either from hydrolysis of extracellular ATP by the enzyme ectonucleotide pyrophosphatase/phosphodiesterase 1 (also known as plasma cell membrane glycoprotein 1) or from the transcellular transport of PPi by ANKH. ePPi is hydrolyzed to phosphate (Pi) by tissue non-specific alkaline phosphatase. The level of extracellular PPi and Pi is tightly regulated by several interlinked feedback mechanisms and growth factors. The relative concentration of Pi and PPi determines whether CPP or hydroxyapatite crystal is formed, with low Pi/PPi ratio resulting in CPP crystal formation, while a high Pi/PPi ratio promotes basic calcium phosphate crystal formation. CPP crystals are deposited in the cartilage matrix (preferentially in the middle layer) or in areas of chondroid metaplasia. Hypertrophic chondrocytes and specific cartilage matrix changes (e.g. high levels of dermatan sulfate and S-100 protein) are related to CPP crystal deposition and growth. CPP crystals cause inflammation by engaging with the NALP3 inflammasome, and with other components of the innate immune system, and is marked with a prolonged neutrophilic inflitrate. The pathogenesis of resolution of CPP crystal-induced inflammation is not well understood.
Investigations of calcium pyrophosphate deposition
Authors: Abhishek Abhishek , Doherty Michael
Published: November 2017

Joint aspiration and microscopic examination of the aspirated synovial fluid remains the gold standard for the diagnosis of calcium pyrophosphate crystal deposition (CPPD). If synovial fluid aspiration is not feasible, plain radiography and/or ultrasound scanning may be used to detect chondrocalcinosis (CC) which predominantly occurs due to calcium pyrophosphate (CPP) crystals, and this can be used as a diagnostic surrogate for CPPD as suggested by the EULAR Task Force. Acute CPP crystal arthritis often associates with a brisk acute phase response (elevated C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR), plasma viscosity) and neutrophilia. A mildly raised CRP and/or ESR may be present in chronic CPP crystal inflammatory arthritis. On the contrary, asymptomatic CC, or CPPD with osteoarthritis does not cause raised acute phase reactants. As CPPD most commonly occurs due to increasing age and osteoarthritis, investigations to screen for underlying metabolic abnormalities should be carried out in those with early-onset CPPD (under 55 years), or in those with florid polyarticular CC. As hyperparathyroidism gets more common with ageing its presence should be specifically sought in all age groups. Tests for other predisposing metabolic conditions should only be carried out in the presence of specific clinical features. Genotyping for mutations, especially in the ANKH gene, may be warranted in those with a family history of premature CPPD and no evidence of inherited metabolic predisposition, but such testing is unavailable to most clinicians.
Glaucoma
Authors: Tatham Andrew , Khaw Peng Tee
Published: November 2017

This chapter explores glaucoma. It starts off with an outline of optic nerve head anatomy and then describes aqueous fluid dynamics and the pathogenesis of glaucoma. It then goes on to discuss the clinical skill areas of optic nerve head assessment in glaucoma, glaucoma imaging devices, tonometry and tachymetry, gonioscopy, and perimetry. The chapter also details ocular hypertension, primary open-angle glaucoma, primary angle closure, and secondary angle closure. In addition, it discusses normal tension glaucoma, steroid-induced glaucoma, traumatic glaucoma, inflammatory glaucomas, pseudoexfoliative glaucoma, pigmentary glaucoma, and neovascular glaucoma. It then covers aqueous misdirection, iridocorneal endothelial syndrome and iridocorneal dysgenesis, ocular hypotensive agents, laser therapy for glaucoma, and glaucoma surgery.
Interest and disinterest in the mid-twentieth century
Authors: Clark David
Published: November 2017

Offering free medical care to the entire population, the National Health Service (NHS) was a comprehensive system of universal entitlement based on collective provision of healthcare within a market economy. In its early years, it revealed that little attention was being paid to the needs of terminally ill and dying people. Nevertheless, some important information did begin to emerge on these matters, championed by charitable institutions outside the NHS. This chapter examines early reports on the plight of the terminally ill, the content of medical commentary on the subject, and the emerging flickers of research interest that became visible. It shows how over time, the discourse shifted from anecdote to a semblance of evidence—and created a bridgehead for future development in an emerging field of hospice and palliative care.
The importance of trials for global mental health
Authors: Thornicroft Graham , Patel Vikram
Published: November 2017

This chapter sets the scene for the book as a whole by defining key terms, giving a brief history of randomized controlled trails (RCTs) in mental health research, explaining why RCTs can produce strong forms of evidence, and by locating trials within the translational research continuum. The authors describe criteria with which to judge the quality of pragmatic RCTs. Finally the authors discuss how the results of trials can be used to inform policy, investment, and service delivery decisions in low and middle income countries.
Design issues in global mental health trials in low-resource settings
Authors: Weiss Helen
Published: November 2017

In this chapter we outline the key principles in design and analysis of trials for mental health. The chapter focuses on randomized controlled trials as these are the gold-standard trial design, which minimizes confounding due to other factors and enables us to draw conclusions about the effectiveness of the intervention. Other key principles of trial design discussed in the chapter include methods to develop a clearly stated, testable research hypothesis, definition of well-defined outcomes, appropriate choice of the control condition, masking of providers and participants where possible, realistic sample size estimates, and appropriate data monitoring and statistical analysis plans. The chapter also outlines alternatives to the parallel arm superiority trial design, such as equivalence and non-inferiority trials, cross-over, stepped wedge, fixed adaptive, and patient preference trial designs.
Suicide prevention trials
Authors: Vijayakumar Lakshmi , Pearson Melissa , Kumar Shuba
Published: November 2017

The majority of suicides occur in LAMIC. This chapter presents findings from two low-cost, feasible interventions aimed at reducing suicides. The Suicide Prevention Multisite Intervention Study (SUPRE-MISS) of WHO assessed the effectiveness of brief intervention and contact (BIC) as an intervention strategy in five countries. Another trial in South India examined the effectiveness of a central pesticide storage facility as a means of reducing pesticide suicides. Some challenges that such trials face are the large sample sizes required to detect a significant change, making them uneconomical and unfeasible. Dearth of reliable data on suicide and underreporting because of cultural norms and legal barriers compound the problem. Future research should incorporate effective surveillance for reliable data, address high-risk groups, and initiate large-scale intervention at the community level involving multiple collaborators. Multipronged strategies, addressing social inequities, and improving health services would be the way forward to reduce the burden of suicide.
Economic modelling for global mental health
Authors: McDaid David
Published: November 2017

This chapter sets out the case for making use of economic modelling techniques to help inform decisions on effective and cost-effective actions for global mental health. Models potentially can be used to augment information obtained from controlled trials, for instance to look at the potential cost-effectiveness of actions over time periods beyond trial duration, to help adapt evidence obtained in one context to likely scenarios in other settings where infrastructure, costs, and current treatment options may be very different, or to help identify priority areas for research. The strengths and limitations of different modelling approaches are discussed and examples of how they have been used to inform policy making highlighted. The chapter ends by setting out key steps that should be taken when both planning and presenting the findings from a modelling study.
Introduction
Authors: Elwood Mark
Published: November 2017

This chapter shows the plan of the book. Later chapters will cover the definition of causation, study designs that can demonstrate causation, how results are presented, the interpretation of studies stressing the non-causal explanations of observation bias, confounding, and chance variation. Then come positive aspects of causation, the Bradford-Hill principles, systematic reviews and meta-analyses, and an overall scheme for assessing studies and diagnosing causation. Further chapters present appraisals of six published studies: randomised trials, cohort studies, and case-control studies. An appendix presents statistical methods with examples.
The results obtained from studies of causation
Authors: Elwood Mark
Published: November 2017

This chapter shows the format and derivation of results from studies. Cohort and intervention studies yield relative risk and risk difference, also known as attributable risk, and number needed to treat (NNT). Count and person-time methods are shown. Additive and multiplicative models for two or more exposures are shown. Case-control studies give primarily odds ratio; the relationship between this and relative risk is explained. Different sampling schemes for case-control studies include methods were a case can also be a control. Surveys yield results similar to cohort studies.
Combining results from several studies: systematic reviews and meta-analyses
Authors: Elwood Mark
Published: November 2017

This chapter explains systematic reviews, the PRISMA format, and meta-analysis. It discusses publication bias, outcome reporting bias, funnel plots, the issue of false positive results in small studies, along with search strategies, electronic databases, PubMed, and the Cochrane collaboration. It discusses the assessment of quality, risks of bias, limitations of meta-analysis, heterogeneity testing, effect modification, and meta-regression methods. In part two, it explains statistical methods for meta-analyses are presented, including the Mantel-Haenszel and Peto methods for individual patient data, the inverse variance weighted method using final results, and random effects methods. Forest plots and tests of heterogeneity are explained.
Critical appraisal of a randomized clinical trial
Authors: Elwood Mark
Published: November 2017

This chapter presents a randomised trial carried out in primary care in the UK, assessing the use of an antibiotic, chloramphenicol, for acute eye infections (conjunctivitis) in children. This study shows the challenges of conducting a high quality randomised trial in primary care, including issues of the appropriate assessment of outcome. The critical assessment follows the scheme set out in chapter 10: describing the study, assessing the non-causal explanations of observation bias, confounding, and chance variation; assessing time relationships, strength, dose-response, consistency and specificity, and applying the results to the eligible, source, and target populations; and then comparing the results with evidence from other studies, considering consistency and specificity, biological mechanisms, and coherence with the distribution of exposures and outcomes. The chapter gives a summary and table of the critical assessment and its conclusions; and comments on the impact of the study and research carried out since.
Introduction to health measurement scales
Authors: Streiner David L. , Norman Geoffrey R. , Cairney John
Published: November 2017

This chapter provides a brief overview of the need for measurement in the health sciences. As interventions are increasingly aimed at improving subjective states, such as quality of life or pain, it becomes ever more important to be able to measure these accurately. This means that the items must be clear, unambiguous, and as free from biases as possible. Test constructors must also be aware of the different options for responding to the items. Finally, issues of reliability and validity need to be addressed. The chapter also has a ‘road map’ and flow chart, outlining the steps in scale construction, and indicating the chapters addressing the relevant topics.
Reliability
Authors: Streiner David L. , Norman Geoffrey R. , Cairney John
Published: November 2017

This chapter reviews the basic theory of reliability, and examines the relation between reliability and measurement error. It derives the standard form of reliability, the intraclass correlation or ICC, from repeated measures ANOVA. The chapter explores issues in the application of the reliability coefficient, including absolute versus relative reliability, the reliability of multiple observations, and the standard error of measurement. It examines several other measures of reliability—Cohen’s kappa, Pearson r, and the method of Altman and Bland—and derives the relation between them and the ICC. The chapter determines the variance of a reliability estimate. It also calculates sample size estimates for reliability studies, and methods to combine reliability estimates in systematic reviews.
Reporting test results
Authors: Streiner David L. , Norman Geoffrey R. , Cairney John
Published: November 2017

Journals are becoming increasingly more stringent in their requirements for what must be reported in articles about the psychometric properties of scales. This chapter reviews three of the most commonly used guidelines; the Standards for Educational and Psychological Testing, the STARD initiative (Standards for Reporting of Diagnostic Accuracy), and the Guidelines for Reporting Reliability and Agreement Studies (GRRAS). It abstracts portions of these guidelines that are most relevant for scales used in research settings. These cover the reporting of test development, reliability, and validity. The chapter also has a flow chart, adapted from STARD, that should be included when submitting a manuscript about scale development to a journal.
Recording of neural signals, neural activation, and signal processing
Authors: Stegeman Dick F. , Van Putten Michel J. A. M.
Published: November 2017

This chapter discusses recording of electrophysiological signals in the context of clinical neurophysiology. We first discuss the interpretation of signals and differences between signals in terms of their underlying (electro)physiology. As a most prominent aspect of applied electrophysiology, the biophysics of volume conduction in extracellular space is discussed. We also present some basics of advanced procedures to analyse neurophysiological data. Aspects of electrical stimulation are treated too, including recent developments in diagnostic and therapeutic constant current stimulation. We finally discuss the background of hazardous electric currents and the safety of bioelectric equipment. Aspects that are relevant in the digitization and post-processing of data are briefly reviewed.
Reflex studies
Authors: Valls-Solé Josep
Published: November 2017

Reflex studies are an important part of clinical neurophysiology assessment in health and disease. They are essential to get information on conduction in proximal segments of peripheral nerves, spinal and supraspinal integration of sensory inputs on the motor pathway, and excitability of motor structures. They do not require special equipment, except for a sweep-triggering hammer that is essential, for instance, to elicit monosynaptic reflexes, such as the jaw jerk. For consensual reflexes, it is also recommended to use two recording channels, which facilitate recognition of potential disturbances in the afferent or efferent path of the reflex. What follows is a review of some of the most relevant reflexes that can be studied for neurophysiology assessment in clinical practice.
Generalized peripheral neuropathies
Authors: Franssen Hessel
Published: November 2017

The chapter on generalized peripheral neuropathies describes how to perform and interpret electrophysiological studies aimed at diagnosing polyneuropathy. It first reviews methodological issues, such as stimulation and recording, and takes into account temperature. Next, the relevant pathophysiology of single myelinated axons, as found in animal experiments, is discussed and related to findings on nerve conduction studies performed in patients. This is followed by a discussion of criteria for axon loss and demyelination. Finally, typical findings in specific neuropathies are described and examples of typical findings are shown in the figures.
Neurophysiology in amyotrophic lateral sclerosis and other motor degenerations
Authors: de Carvalho Mamede , Swash Michael
Published: November 2017

Electromyography is critical for the diagnosis of motor neuron disease, as its findings exclude mimicking disorders, and confirm signs of widespread motor unit loss and reinnervation. In chronic conditions the slow disease course allows giant, stable motor unit potentials to appear. In contrast, in amyotrophic lateral sclerosis, the rapid degenerative process is characterized by signs of denervation and unstable motor unit potentials, where motor units become dysfunctional before having time to sustain very large reinnervated motor unit potentials. Fasciculation potentials are observed in both conditions. In amyotrophic lateral sclerosis fasciculation potentials are important supporting electrodiagnostic evidence, permitting earlier diagnosis. Many methods have been developed to quantify and monitor the lower motor neuron pool, but few have been used in clinical trials. Their role as tools to follow interventions or to interpret pathogenesis remains incompletely explored. Electromyography is a sensitive and reliable test in the diagnosis and assessment of motor neuron diseases.
Sleep disorders
Authors: Zaiwalla Zenobia , Killick Roo
Published: November 2017

As sleep medicine advances, there is increasing demand on services including neurophysiology to investigate sleep disorders. This chapter classifies the sleep disorders according to the main symptom presenting to the clinician, including excessive daytime sleepiness, insomnia, patients sleeping at the wrong times due to a circadian rhythm disorder, and movements or behaviours in sleep. The clinical presentation of common sleep disorders in each category are outlined, including obstructive sleep apnoea, narcolepsy, restless leg syndrome, periodic leg movements disorder, circadian rhythm disorders, and non-rapid eye movement and rapid eye movement parasomnias. The chapter discusses the overlap of symptoms in different sleep disorders, and the importance of selecting appropriate sleep studies, and recognizes the pitfalls, both clinical and in interpretation of sleep studies. The difficulties in diagnosing narcolepsy and differentiating from other causes of excessive daytime sleepiness, and when to investigate parasomnias is explained.
Intraoperative monitoring
Authors: Nuwer Marc R.
Published: November 2017

Intraoperative monitoring and testing is conducted to improve neurological outcomes from surgery that incurs risk of neurological injury. Many techniques are familiar from the outpatient neurodiagnostic laboratory, and can be applied with minor modifications to the operating room setting. Other techniques are specific to the operating room. Transcranial electrical motor evoked potentials cannot be applied to awake patients, but are commonly used under general anaesthesia. Monitoring teams understand the tactics for obtaining quality recordings and calling alarms when potentials change past preset limits. Surgeons and anaesthesiologists have a variety of tactics for responding to adverse neurodiagnostic changes beginning with easy actions. In experienced hands, intraoperative neurophysiological monitoring substantially reduces post-operative deficits. For example, in spinal cord monitoring the risk of paraplegia and paraparesis is reduced by 60%. Monitoring is carried out by a technologist in the operating room under the supervision of an experienced neurophysiologist. In straightforward cases, the neurophysiologist may remotely monitor from outside the operating room.
Re-thinking care in later life: the social and the clinical
Authors: Phillipson Chris
Published: November 2017

Key points

• Geriatric medicine developed strong links with social perspectives on ageing during its initial phase of development.

• Geriatric medicine and social gerontology developed along separate paths from the 1970s with the emergence of competing paradigms about the ageing process.

• Fiscal austerity, changes to the welfare state, and the increase of age-related conditions such as dementia create possibilities for collaboration between geriatric medicine and social gerontology.

• Areas for joint work between the disciplines include

o supporting the development of age-friendly communities

o rebuilding community services

o challenging health inequalities.
Service models
Authors: Martin Finbarr
Published: November 2017

Key points

• There is increasing concern about quality of care received by older people in our health services.

• Real progress over recent decades in overcoming ignorance and ageism is at risk if these services cannot become age-attuned.

• Today’s older people are older, more numerous, and present complex challenges of multimorbidity and frailty.

• Traditional divisions of staff and skills between primary and secondary care, and between clinical specialties, are an obstacle to meeting the challenge.

• Promising innovative new models of care are emerging and will need refinement through research and experience.

• Skills and attitudes needed to recognize and manage the geriatric syndromes must be mainstreamed through education, training, and dissemination of good practice.

• Specialists in old-age medicine and mental health cannot do it all, but must champion this transformation.
Incontinence, the sleeping geriatric giant: challenges and solutions
Authors: Wagg Adrian
Published: November 2017

Key points

• The prevalence of urinary incontinence increases in association with increasing age.

• Behavioural and lifestyle interventions, including exercise, are effective in older people.

• There is an increasing evidence base for pharmacological therapy of urgency incontinence in the elderly and frail elderly.

• Surgical management for older men and women is associated with benefit but should be performed with due regard to potential benefits and harms, remaining life expectancy, and the expectations of both patient and, where relevant, caregiver.

• Continence care should be based around provision by specialist nurse practitioners working within a multiprofessional, integrated service.
Substance misuse and older people: a question of values
Authors: Crome Ilana
Published: November 2017

Key points

• Substances are drugs that alter mental state and are potentially addictive.

• Substance abuse is not confined to the younger population; it is also prevalent in older people—alcohol and prescription drugs are the most commonly misused in this population.

• The possibility of substance misuse should not be dismissed because of the patient’s age.

• Recommended alcohol limits are likely to be lower than for younger adults.

• Risk factors differ for older people, e.g. bereavement, retirement, loneliness, boredom.

• Substance misuse is often accompanied by other mental and physical disorders.

• Older people can improve with treatment so should be comprehensively assessed and offered evidence-based treatment regimes that are adjusted to take their special needs into account.
Involving older people in the design and conduct of clinical trials
Authors: Wilde Kate , Jones Zena
Published: November 2017

Key points

• There are strong policy drivers in the UK to involve patients not only as participants in research, but also as members of the research team.

• Patient and public involvement (PPI) can have significant benefits to the patient as well as to the research project.

• Many research funders require PPI explicitly described and evaluated in research proposals.

• Researchers need increased awareness of PPI, guidance, and a framework of how best to implement PPI within their research strategies.

• There is a risk of ‘tokenistic’ involvement of service users.

• There is the potential for a power struggle between the PPI representative with personal experience and the lead researcher with academic knowledge of the condition studied.

• There is a need to formally evaluate the impact of PPI on the effectiveness of research to bring new treatments to patients.
Respiratory problems
Authors: Adam Sheila , Osborne Sue , Welch John
Published: November 2017

A requirement for respiratory support is the most frequent cause of critical care admission. Effective care requires an appreciation of the relevant anatomy and physiology, skills of physical assessment and use of monitoring, knowledge of a range of airway and breathing problems and the different challenges they present, and an understanding of the most appropriate means of airway management and respiratory support. This chapter details essential respiratory physiology and the advantages, disadvantages, and potential complications of different methods of monitoring and respiratory support, including holistic care of patients with artificial airways and various modes of mechanical ventilation, the use of nitric oxide, prone positioning and extra-corporeal devices, and management of the weaning patient.
Sepsis and multiple organ dysfunction
Authors: Adam Sheila , Osborne Sue , Welch John
Published: November 2017

Sepsis—a dysregulated systemic inflammatory response to infection—occurs at some point in most critical illnesses, and is the most common cause of multiple organ dysfunction syndrome (MODS). Patients with MODS always present great challenges to the critical care team and are often at high risk of death. This chapter discusses the latest thinking about the infective causes and complex evolution of sepsis, with details of how each of the main body systems can be affected (e.g. in the form of acute respiratory distress syndrome) and how different organ functions can be assessed and dysfunction recognized. The priorities, principles, and practicalities of holistic care and management of patients with sepsis and MODS, including adjunct therapies and blood purification, is also described.
Airway
Authors: Beed Martin , Sherman Richard , Mahajan Ravi
Published: November 2017

Airway obstruction

Complications at intubation

Airway/facial trauma

Airway/facial burns

Airway infections

Airway foreign bodies

Airway haemorrhage

Endotracheal tube complications

Tracheostomy complications

An obstructed airway is a medical emergency requiring immediate treatment. Where possible, patients at risk should be identified early so that airway obstruction can be prevented. Although upper airway obstruction may be gradual in onset it more commonly progresses very rapidly. Continuous assessment is required to identify signs of impending airway obstruction....
Circulation
Authors: Beed Martin , Sherman Richard , Mahajan Ravi
Published: November 2017

Cardiac arrest

Hypotension and shock

Anaphylaxis

Haemorrhagic shock

Septic shock

Cardiogenic shock

Acute coronary syndromes

Bradycardia

Tachycardia

Cardiac tamponade

Hypertensive crises

Critical care teams are often involved in the resuscitation of in-hospital cardiac arrests, and in the aftercare of successfully resuscitated patients.

Unexpected cardiac arrests in the ICU are relatively uncommon and they are often preceded by prolonged attempts to resuscitate or support failing organs. If CPR is required, follow BLS/ALS guidelines (...
Haematology and oncology
Authors: Beed Martin , Sherman Richard , Mahajan Ravi
Published: November 2017

Blood product transfusion and transfusion reactions

Clotting derangement

Disseminated intravascular coagulation

Neutropaenia

Severe haemolysis

Vasculitic crises

Tumour lysis syndrome

Superior vena cava obstruction

Cord compression

Blood product transfusion is common in critically ill patients. The risks and expense associated with transfusion require that practitioners use products appropriately and can manage complications....
Common emergency procedures
Authors: Beed Martin , Sherman Richard , Mahajan Ravi
Published: November 2017

Transfers and retrievals

Rapid sequence intubation

Laryngeal mask airway insertion

Needle cricothyroidotomy

Needle thoracocentesis

Intercostal chest drain insertion

Arterial line insertion

Central venous access

Intravenous cutdown

Intraosseous access

External pacing

Pericardiocentesis

Fibreoptic bronchoscopy

Intra-abdominal pressure measurement

Lumbar puncture

Sengstaken–Blakemore tube insertion

Prone positioning

• Intrahospital transfer (e.g. to ICU or to CT scan)....
Introduction
Authors: Powell Craig M. , Monteggia Lisa M.
Published: November 2017

The Autisms: Molecules to Model Systems is designed to introduce the genetic basis for multiple autisms and discuss the gene mutations within the context of their biological function. The text is directed to advanced undergraduate students, graduate students, postdoctoral fellows, psychology students and professionals, psychiatrists, neurologists, and neuroscience researchers alike. It is hoped that readers will be engaged in this emerging field and will be motivated to read further and to cultivate their own understanding and constructs for future research into this enigmatic group of disorders known as the autisms.
Paradigm 6: Improved Knowledge About Mental Illness Will Eradicate Stigma
Authors: Stuart Heather , Arboleda-Flórez Julio , Sartorius Norman
Published: November 2017

Chapter 7 discusses the differences between misconceptions that respond to information, and prejudices that are deep-seated and resistant to change. It is important to maintain a clear distinction between programs that are designed to reduce disability by improving mental health literacy and help-seeking, from those designed to decrease stigma and social rejection. There is a danger that increased understanding of the neurobiological basis for mental illnesses engenders stigma by sharpening divisions between what is considered “normal” and “abnormal” and by consolidating stereotypes of immutability, uncontrollability, and dangerousness.
Paradigm 7: Attitude Change Is the Yardstick of Success
Authors: Stuart Heather , Arboleda-Flórez Julio , Sartorius Norman
Published: November 2017

Chapter 8 discusses how attitude change as a consequence of anti-stigma programming is likely to yield disappointing results, both because the changes tend to be small and because attitude change is not a good predictor of behavioural change, which should be the main goal of anti-stigma programs. It also discusses how is unlikely that anti-stigma programs that solely target changes in attitudes will result in meaningful improvements in social inclusion and social equity for people who have a mental illness. It also covers how ocial structures are an important target for change, given that they have the ability to create inequities even in the absence of individual prejudices.