bluuebunny/crossref_metadata_2025 huggingface dataset:
Craniopharyngiomas
Authors: Raper Daniel M. S. , Jane John A.
Published: October 2018

Craniopharyngiomas (CPs) are rare tumors arising from the developmental Rathke’s pouch and present in a bimodal distribution peaking at 5 to 14 and 50 to 74 years. Symptoms at onset include visual loss, headache, and hypopituitarism. Most tumors contain solid and cystic components, and fluid within the cyst usually contains cholesterol crystals. Histopathology is classified into adamantinomatous (most common in children) and papillary (almost exclusively in adults) subtypes. Magnetic resonance imaging is the definitive diagnostic modality for sellar and suprasellar lesions. In addition to imaging, formal visual evaluation and detailed endocrinologic workup are a critical aspect of preoperative assessment. The role of radical surgical resection, versus decompression combined with radiotherapy, remains controversial. The most common complications of surgical and radiotherapeutic treatments include pituitary stalk and hormonal deficiencies, along with cerebrospinal fluid leak. As 5-year overall survival for patients with CP is in the range of 55% to 85%, CP remains a challenging condition to treat and requires a multidisciplinary approach.
Ependymomas
Authors: Klimo Paul , Shimony Nir
Published: October 2018

Pediatric posterior fossa tumors are usually ependymoma, pilocytic astrocytoma, or medulloblastoma. Ependymoma appears well-demarcated with heterogeneous enhancement on magnetic resonance imaging (MRI). Full neural axis MRI is indicated to assess for metastatic disease. Management is typically surgical resection of the tumor, with consideration for cerebrospinal fluid diversion if patients present with severe hydrocephalus. Extent of resection of the tumor is the most important factor in predicting recurrence and overall survival, and gross total resection is ideal. Infratentorial ependymomas have 2 molecular subtypes, which has implications for responsiveness to adjuvant therapy and prognosis. Infratentorial ependymomas are biologically different from supratentorial ependymomas. Postoperative radiation improves local control.
Spine Metastases
Authors: Barzilai Ori , Bilsky Mark H. , Laufer Ilya
Published: October 2018

A decision-making framework called NOMS (neurologic, oncologic, mechanical, and systemic) facilitates and guides therapeutic decisions for patients with spinal metastases. Patients should be evaluated for signs of myelopathy or cauda equina. The Epidural Spinal Cord Compression scale facilitates reporting of the degree of radiographic spinal cord compression. A determination of the expected histology-specific tumor response to conventionally fractionated external beam radiation and systemic therapy should be made. Radiation therapy effectively treats biologic pain and radiosensitive tumors such as multiple myeloma. Patients should undergo a careful evaluation of movement-associated pain as tumor-induced spinal instability is an independent indication for surgery. Determination of tumor-associated mechanical instability can be facilitated by the Spinal Instability Neoplastic Score. Herein, the authors present a case of spinal multiple myeloma managed using the NOMS framework and in consideration of current evidence and treatment paradigms.
Supratentorial Tumors
Authors: Traul David E. , Diehl Rachel
Published: October 2018

Surgical resection of supratentorial brain tumors presents a unique set of challenges to the anesthesiologist. While symptoms from these lesions vary in presentation, increased intracranial pressure (ICP) is frequently part of the constellation and an important piece of anesthetic management. Along with maintenance of ICP, the goals of induction, maintenance, and emergence from these resections are to maintain cerebral blood flow (CBF) and cerebral metabolic rate and optimize neuroprotection. There is no single technique that is agreed upon in literature to encompass these goals, however a combination of IV anesthetics with low-dose volatile agents (0.5 MAC) is common in practice. Management of ICP is the hallmark of these cases since increased ICP may lead to ischemia, poor surgical visualization, and catastrophic herniation.
Transsphenoidal/Pituitary Surgery
Authors: Abatzis Vaia T. , Nemergut Edward C.
Published: October 2018

Patients with tumors of the pituitary gland represent a heterogeneous yet commonly encountered neurosurgical population. Optimal anesthetic care requires an understanding of the complex pathophysiology secondary to each patient’s endocrine disease. Although patients presenting with Cushing’s disease and acromegaly have unique manifestations of endocrine dysfunction, all patients with tumors of the pituitary gland require meticulous preoperative evaluation and screening. There are many acceptable strategies for optimal intraoperative anesthetic management; however, the selection of anesthetic agents should be tailored to facilitate surgical exposure, preserve cerebral perfusion and oxygenation, and provide for rapid emergence and neurological assessment. Postoperatively, careful monitoring of fluid balance and serum sodium is essential to the early diagnosis of diabetes insipidus (DI). DI is most often transient but can require medical therapy. A thorough understanding of the preoperative assessment, intraoperative management, and potential complications are fundamental to successful perioperative patient care and avoidance of morbidity and mortality.
Interventional Neuroradiology
Authors: Osborn Irene P. , Huang Liang
Published: October 2018

Interventional neuroradiology is one of the rapidly evolving specialties in medicine that provides minimally invasive and percutaneous treatment of diseases of the brain and spine. The new paradigm for management of a cerebral aneurysm begins with a detailed study of the anatomy and architecture of the lesion. Following this, decisions are made and devices are employed to treat the lesion in the event of a rupture or to prevent a future rupture. The anesthetic implications are different from intracranial clipping and require a different set of priorities. The procedure is performed in the radiology suite with unique concerns such as patient access, lack of movement, and radiation exposure. This discussion will focus on the safe management of endovascular coiling procedures.
Extracranial-Intracranial Bypass
Authors: Saasouh Wael , Traul David E.
Published: October 2018

Extracranial-intracranial (EC-IC) bypass is a surgical procedure used to preserve or rescue cerebral circulation when the arterial supply is disrupted. There are several techniques of EC-IC bypass depending on the location of the anomaly and the vessels involved, the purpose being to provide a connection from a patent extracranial artery to an artery within the cranium, thus bypassing the anomalic or thrombosed portion. The mainstay of the anesthetic management of this procedure includes careful preoperative evaluation, meticulous intraoperative management, and close postoperative observation. Intracranial bleeding and hyperperfusion after the procedure are the two principal concerns, and proper management strategies should be in place for all cases.
Metastatic Spine Disease
Authors: Cata Juan P.
Published: October 2018

Metastatic spinal cord compression (MSCC) is a medical emergency that requires early diagnosis and treatment. Medical management or surgery can be indicated depending on different factors including duration of the symptoms, patient comorbidities, and hospital resources. Patients scheduled for decompressive laminectomy due to MSCC may present to the operating room with pain, high requirements of opioids, hematological disorders, impending bone fractures, nausea and vomiting, and electrolytes disorders. Multimodal intraoperative monitoring is needed to minimize spinal cord injury. The immediate postoperative care of these patients is directed to accelerate recovery by providing multimodal analgesia, encouraging early ambulation, and optimizing their nutritional status.
Myelomeningocele
Authors: Spaliaras Joanne
Published: October 2018

Spina bifida is a defect in which the vertebral arch of the spinal column is either incompletely formed or absent. Failure of closure of the neural tube during the third week of gestation leads to the constellation of defects observed in patients with meningomyelocele or open spina bifida. Myelomeningocele is the most common neural tube defect and the most severe birth defect compatible with long-term survival. It is associated with several characteristic central nervous system anomalies. Leak of cerebrospinal fluid (CSF) is commonly observed. The major indication for early operative repair (within 48 hours of delivery) is prevention of infection. Protection of the exposed neural tissue from trauma and drying is essential. An understanding of the pathophysiology and associated conditions of myelomeningocele helps guide anesthetic management of these patients.
The Patient for Epilepsy Surgery
Authors: Ibrahim Haitham , Osborn Irene P.
Published: October 2018

Epilepsy surgery as a treatment option is usually reserved for medically intractable epilepsy, when anticonvulsant medication has failed to achieve adequate seizure control and the seizure frequency impairs quality of life. Intraoperative brain mapping is often requested by the surgeon and necessitates special planning by the anesthesiologist to provide the best possible operating conditions. Awake craniotomy with the “asleep-awake-asleep” pattern can be considered as a technique in such procedures but requires cautious management for achieving maximum patient satisfaction. Certain patients are not appropriate candidates for craniotomy in the awake state, but general anesthesia can still be considered with specific considerations.
Traumatic Brain Injury and C-Spine Management
Authors: Wecksell Matthew , Fomberstein Kenneth
Published: October 2018

Traumatic brain injury encompasses two different types of pathology: that caused at the time of the initial physical insult, called primary injury, and then further, secondary injury caused by either host cellular responses such as oxidative injury and inflammation or by physiological insults such as ischemia, hypoxia, hypo- or hypercapnia, intracranial hypertension, and hypo- or hyperglycemia. While primary injury falls to the realm of public health (e.g., encouraging helmet use for sports, discouraging impaired driving, etc.), many secondary injuries are avoidable with proper medical management. As the stem case for this chapter, an older patient experiences a fall and is incoherent on presentation to the emergency room. This case concerns her initial management, stabilization, diagnosis, and airway management. With progression of her traumatic brain injury, the authors discuss intracranial pressure management, surgical management, and resuscitation as well as likely postoperative sequelae.
Cerebrospinal Fluid Shunts
Authors: Kim Jinu , Scoco Aleka
Published: October 2018

Placement and revision of ventricular shunts has saved more lives in Western society than any other neurosurgical procedure. Estimates of a total of 75,000 shunt procedures are done yearly in North America. The majority of these cerebrospinal fluid (CSF)-diverting shunts originate in the lateral ventricle, drain into the peritoneum and are described as ventriculoperitoneal (VP) shunts. Other less common CSF shunt variants include ventriculoatrial and ventriculopleural. VP shunts are the most common neurosurgical procedure performed in both adults and children. An understanding of CSF flow dynamics, intracranial pressure, and cerebral perfusion helps guide anesthetic management of these procedures.
Subarachnoid Hemorrhage
Authors: Kevin Luk K. H. , Sharma Deepak
Published: October 2018

Subarachnoid hemorrhage (SAH) is commonly caused by rupture of an intracranial aneurysm, arteriovenous malformation, or due to trauma. Prompt diagnosis and intervention are required to control intracranial pressure, maintain cerebral perfusion, and prevent rebleeding. Clinical grading of the bleed predicts morbidity and mortality, whereas imaging grading predicts risk of cerebral vasospasm. Hydrocephalus can occur as a result of SAH, which requires treatment with an external ventricular drain. Endovascular and open microsurgical procedures are available for securing the vascular abnormalities. Patients are typically monitored in a neurocritical care unit for up to 21 days post-bleed to monitor for the development of cerebral vasospasm/delayed cerebral ischemia (DCI). Mainstay of treatment for DCI includes induced hypertension, balloon angioplasty, and intraarterial vasodilator therapy. In addition, patient may experience significant derangement in their cardiac, pulmonary, and endocrine systems, requiring inotropic support, mechanical ventilation, or insulin infusion therapy.
Venous Air Embolism
Authors: Metzner Julia I. , Sharma Deepak
Published: October 2018

Venous air embolism (VAE) is typically the entrainment of air from the surgical field into the vascular system producing adverse systemic effects based on the severity of embolism. Historically, VAE has most often been associated with sitting position craniotomies. However, there is now a clear recognition of the potential risk of this complication during craniotomy in any position, albeit with lesser incidence and severity. VAE can also occur during cervical spine surgery in the sitting position, although less often. While in many circumstances VAE may be subclinical and even undetected, it has the potential to lead to significant cardiovascular compromise during surgery, with the risk of adverse outcomes. Hence, it is imperative for anesthesiologists to be aware of the causes of and risk factors for VAE, its clinical presentation, diagnostic options, and treatment strategies to effectively prevent and intervene early in this potentially fatal condition.
Postoperative Visual Loss in Spine Surgery
Authors: Traul David E.
Published: October 2018

Postoperative visual loss (POVL) is a rare but devastating condition associated with many types of nonocular surgery. In spine surgery, the most common causes of POVL are ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO), and cortical blindness. Although the association of POVL with spine surgery has long been recognized, the low incidence of this complication hinders the identification of patient and perioperative risk factors and limits our understanding of the causes of POVL. In adult spine surgery, POVL is most frequently attributed to ION whereas CRAO is more commonly seen in cardiac procedures. POVL due to cortical blindness has the highest incidence in pediatric spine surgery. While several risk factors for POVL have been identified in spine surgery, there are currently no standardized practice guidelines to eliminate the risk for POVL. Currently, there are no effective treatments for POVL, and recovery from ION and CRAO is limited.
General: Myasthenia Gravis
Authors: Frankel Shimon
Published: October 2018

In this chapter the essential aspects of myasthenia gravis and Eaton-Lambert syndrome are reviewed. The chapter is divided into preoperative, intraoperative, and postoperative sections with important subtopics related to the main topic in each section. Issues addressed with regard to preoperative evaluation include assessment of disease severity, medication for myasthenia gravis, and presence of Lambert-Eaton syndrome. Intraoperative issues discussed are the type of anesthesia used for such patients and dealing with varying degrees of muscle relaxation common to patients with these neuromuscular disorders. Postoperative concerns addressed include postoperative weakness and myasthenic crisis. Conditions that worsen these syndromes are also discussed and treatment modalities are reviewed.
General: Laryngeal Papillomatosis
Authors: Kakascik Aimee
Published: October 2018

In this chapter the essential aspects of anesthesia for laryngeal papillomatosis are reviewed. Specifically, the hazards of this type of surgery, including the risk of airway fire, are reviewed. The steps needed to treat airway fire are reviewed, as well as precautions to take in order to prevent it. The chapter is divided into preoperative, intraoperative, and postoperative sections with important subtopics related to the main topic in each section. Topics addressed under preoperative evaluation include related respiratory and cardiac concerns, and premedication. Intraoperative management addresses issues related to induction, including use of a reinforced endotracheal tube. Postoperative treatment of airway fire and postoperative carbon dioxide laser complications are also discussed.
Endocrine: Thyroidectomy
Authors: Gupta Ruchir
Published: October 2018

In this chapter the essential aspects of anesthesia for thyroid surgery are reviewed. An emphasis is placed on airway management of the thyroid patient as well as on drug therapy prior to anesthetizing thyroid patients. Myxedema coma and thyroid storm are reviewed in detail. The patient discussed is to undergo resection of a goiter. The chapter is divided into preoperative, intraoperative, and postoperative sections with important subtopics related to the main topic in each section. Preoperative topics discussed are patient hemodynamics, use of beta blockers, airway assessment, and antithyroid therapy, including iodine. Intraoperative issues covered include monitoring, awake fiber-optic intubation, and management of bleeding. Postoperative issues addressed include extubation and treatment of postoperative stridor.
Endocrine: Pheochromocytoma
Authors: Yuan Stanley , Cooley John
Published: October 2018

In this chapter the essential aspects of anesthesia for pheochromocytoma resection are discussed. Specifically, multisystemic syndromes associated with this disease, preoperative optimization, and intraoperative therapy are reviewed. Additionally, the use of specialized monitoring and drug therapy are considered. The chapter is divided into preoperative, intraoperative, and postoperative sections with important subtopics related to the main topic in each section. Issues addressed that are related to preoperative evaluation include medical clearance, diagnosis of pheochromocytoma, avoiding hypertensive crisis, and treating hypotension. Intraoperative topics concern monitoring and induction of the patient, and treating both hyper- and hypotension as either arises. Postoperative issues discussed include assessment and treatment of delirium and hypotension.
Trauma: Multisystem Injury
Authors: McCall Dion M. , Amin Molly , Gajewski Michal
Published: October 2018

In this chapter the essential aspects of anesthesia for multisystemic trauma injury are explored. The patient in the case requires open reduction internal fixation of a closed right humerus fracture sustained in a motor vehicle accident. Subtopics discussed include the Focused Assessment by Sonography in Trauma (FAST) survey, Glasgow Coma Scale, massive blood transfusion protocol, and shock. The chapter is divided into preoperative, intraoperative, and postoperative sections with important subtopics related to the main topic in each section. Topics related to preoperative evaluation include assessment using the FAST survey and Glasgow Coma Scale. Intraoperative topics include anesthetic management and dealing with shock and other complications. Postoperative management is also discussed.
Pediatrics: Patent Ductus Arteriosus
Authors: Wingard Peggy
Published: October 2018

In this chapter the essential aspects of anesthesia for patent ductus arteriosus (PDA) repair are discussed. The case presented is of a 30-week neonate requiring PDA repair. Subtopics include adjustments in management due to infant prematurity and prevention of necrotizing enterocolitis. The chapter is divided into preoperative, intraoperative, and postoperative sections with important subtopics related to the main topic in each section. Issues presented regarding preoperative evaluation include concerns related to the patient’s prematurity and risk for necrotizing enterocolitis. Intraoperative management addressed includes choice of monitors, inhalational agents used, potential complications, and postligation. Postoperative topics include use of antibiotics, when repair is the wrong procedure, and postoperative complications.
Clinical Scenario #3: Periprocedural Complications
Authors: Gupta Ruchir , Tran Minh Chau Joe
Published: October 2018

In this chapter the essential aspects of treatment options regarding a clinical scenario are discussed. The chapter begins with a mock scenario concerning a patient with periprocedural complications. The mock scenario is followed by a task statement that describes the specific action that the student must take. In this case, the task is to discuss a medication error with the patient. Included in this process is demonstrating to the patient the physician’s understanding of and concern for the situation of the patient, as well as a commitment to patient safety. An action plan is then presented in a stepwise manner with mock responses and a discussion of the responses. Grading points are also discussed and how to achieve maximum score is presented.
Consent and anaesthetic risk
Authors: Jenkins Kath
Published: October 2018

This chapter describes the importance of obtaining informed consent for anaesthesia. It covers some ethical points to guide this process. Informed consent requires good knowledge of the risks of anaesthetic practice and their likelihood. The chapter contains a detailed table of perioperative adverse outcomes, linked to real-life examples to aid clarity of communication to the patient. There are detailed suggestions of how to identify the higher-risk patient and estimate their risk of perioperative mortality and morbidity.
Cardiovascular disease
Authors: Telford Richard , Murphy Peter
Published: October 2018

This chapter describes the anaesthetic management of the patient with cardiovascular disease. The topics include ischaemic heart disease (including perioperative myocardial infarction and percutaneous coronary intervention), valvular heart disease (including prosthetic valves), congenital heart disease, cardiomyopathy, pericardial disease, and the patient with a transplanted heart. For each topic, preoperative investigation and optimization, treatment, and anaesthetic management are described.
Respiratory disease
Authors: Herbert Lara , McCormick Bruce
Published: October 2018

This chapter describes the anaesthetic management of the patient with respiratory disease. It describes the assessment of respiratory function and preoperative respiratory investigations, and ventilatory strategies to reduce pulmonary complications. Common respiratory conditions covered include respiratory tract infection, smoking, asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea, sarcoidosis, restrictive pulmonary disease, and the patient with a transplanted lung. For each topic, preoperative investigation and optimization, treatment, and anaesthetic management are described. Recommendations for the patient who may require post-operative respiratory support (e.g. non-invasive ventilation) are provided.
Bone, joint, and connective tissue disorders
Authors: Berry Colin
Published: October 2018

This chapter describes the anaesthetic management of the patient with those musculoskeletal disorders which are relevant to anaesthetic practice. Topics covered include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, systemic sclerosis, scoliosis, and achondroplasia. For each topic, preoperative investigation and optimization, treatment, and anaesthetic management are described.
Neurological and muscular disorders
Authors: Teasdale Andrew , Halsall Jane
Published: October 2018

This chapter describes the anaesthetic management of the patient with those neurological or muscular disorders which are relevant to anaesthetic practice, including malignant hyperthermia. Other topics covered include epilepsy, cerebrovascular disease, Parkinson’s disease, spinal cord lesions, myasthenia gravis, multiple sclerosis, Guillain-Barré syndrome, motor neuron disease, dystrophia myotonica, and the muscular dystrophies. For each topic, preoperative investigation and optimization, treatment, and anaesthetic management are described. For malignant hyperthermia, trigger-free anaesthetic techniques are described, as well as the management of an acute episode.
Orthopaedic surgery
Authors: Griffiths Richard , Leighton Ralph
Published: October 2018

This chapter discusses the anaesthetic management of orthopaedic surgery. It begins with general principles of the anaesthetic management of orthopaedic surgical patients, including the management of fat embolism syndrome, bone cement implantation syndrome, compartment syndrome, and the use of tourniquets. Surgical procedures covered include total hip joint replacement (including revision total hip joint replacement), femoral neck fracture surgery, total knee joint replacement, arthroscopy, cruciate ligament repair, ankle surgery, foot surgery, spinal surgery (including the cervical spine), shoulder surgery (including total shoulder joint replacement), elbow replacement surgery, hand surgery, and trauma, including fractures of limbs or spine.
Ear, nose, and throat surgery
Authors: Roberts Fred
Published: October 2018

This chapter discusses the anaesthetic management of ear, nose, and throat surgery (otolaryngological surgery). It begins with a discussion of relevant general principles (including the shared airway) and covers airway obstruction and sleep apnoea. Surgical procedures covered include grommet insertion, tonsillectomy, adenoidectomy, myringoplasty, stapedectomy, tympanoplasty, nasal cavity surgery, microlaryngoscopy, tracheostomy, laryngectomy, pharyngectomy (including glossectomy), radical neck dissection, and parotidectomy. It concludes with a series of vignettes of other ear, nose, and throat procedures.
The critically ill patient
Authors: Nolan Jerry
Published: October 2018

This chapter discusses the anaesthetic management of the critically ill patient suffering from trauma or life-threatening illness. It begins by describing the principles of immediate trauma care, and the primary and secondary surveys. It then goes into more detail about head injuries, chest injuries, abdominal injuries, pelvic fractures, spinal injuries, limb injuries, burns, multiple trauma, post-cardiac arrest resuscitation care, and septic shock. It concludes by describing the transfer of the critically ill patient to the operating theatre or to another unit.
Practical anaesthesia
Authors: Ross Nicki , Arumugakani Gururaj , Wood Philip , Thomas Rhys , Dawes Rob , Mercer Simon , Jagdish S. , Bodenham Andrew , Bunker Nicholas , Saddler John , Myles Paul
Published: October 2018

This chapter discusses a collection of practical topics of relevance to the anaesthetist. Topics covered include herbal medicines, blood exposure incidents, target-controlled infusions, death on the table, dealing with a complaint, anaphylaxis follow-up, latex allergy, long-term venous access, enhanced recovery and cardiac output monitoring, depth of anaesthesia monitoring, neuromuscular blockade and reversal, evidence-based anaesthesia, and the Cochrane Collaboration. There is a section on military anaesthesia which includes damage control resuscitation, medical emergency response team, the Triservice Anaesthesia Apparatus, and military uses of total intravenous anaesthesia.
Blood products and fluid therapy
Authors: Telford Richard
Published: October 2018

This chapter discusses the anaesthetic uses of blood products and other fluids. It begins with a discussion of blood products (red cells, platelets, fresh frozen plasma, and so on). It goes on to describe blood conservation techniques such as cell salvage. Massive transfusion is discussed with its protocol. The problems posed by Jehovah’s Witnesses who refuse blood products are explored. The chapter concludes with a discussion of fluid and electrolyte therapy.
Acute pain
Authors: Dashfield Adrian
Published: October 2018

This chapter discusses the management of acute pain. It begins with an introduction which describes the benefits of acute pain management and the measurement of pain. Analgesic drugs are then described, including paracetamol, non-steroidal anti-inflammatory drugs, and opioids (including their comparative efficacy). Patient-controlled analgesia, epidural analgesia, and continuous peripheral nerve blockade are described. Transcutaneous electrical nerve stimulation and acupuncture are discussed. The management of the patient with a substance misuse disorder is discussed. The chapter concludes with a discussion of non-opioid adjuvant analgesics.
Cultures and their roles: An overview
Authors: Bhugra Dinesh , Ventriglio Antonio , Bhui Kamaldeep S.
Published: October 2018

Cultures are an integral part of our being. We are born in cultures, which mould our behaviours, attitudes, and cognitions. Culture is a system of meanings and knowledge, belief systems, and morals as well as laws. Culture is acquired, and people change in response to culture and, in return, individuals change culture. Culture informs our world view and offers symbols with specific meanings, not only for individuals in that particular culture but also for others looking in. Culture needs to be differentiated from race and ethnicity. Furthermore, for migrants there are stages in the process of migration that affect their processes of acculturation, which can result in different types of adjustment in the new country, including assimilation, biculturalism, and deculturation. The response of the new country is also important in welcoming or rejecting migrants whatever their reason for migration. Cultural competence is a part of good clinical practice.
Therapeutic encounters
Authors: Bhugra Dinesh , Ventriglio Antonio , Bhui Kamaldeep S.
Published: October 2018

When individuals experience distress, they try to make sense of this and, in the first instance, may seek help from personal, folk, or social sectors. If these interventions do not work, they will contact the professional sector. It is likely that the healthcare system will direct their help-seeking behaviour. In addition, the explanatory models they have will direct them into help-seeking accordingly. Once therapeutic interaction has started, the explanatory models of the individuals, their families, carers, and those of the clinician will affect therapeutic engagement. Race, gender, social status, education, and economic status will all affect explanatory models and where individuals seek help. If different from that of the patient, the culture of the clinician will affect therapeutic alliance. Working with interpreters requires training if the primary language of the patient differs from that of the healthcare professional.
Mental state assessment: Basic principles
Authors: Bhugra Dinesh , Ventriglio Antonio , Bhui Kamaldeep S.
Published: October 2018

Mental state assessment or examination lies at the core of assessing patients and reaching a diagnosis that can be followed by appropriate and suitable management strategies. It is important that clinicians take enough time to carry out the assessment, which may require several sessions. This is especially true for patients whose cultures may differ from those of the clinician. It is important that assessments are not rushed and that gradual therapeutic alliance is developed so that patients and their carers have confidence in the clinician. Clinicians should take time to understand the cultural context of the individual and the significance of culture in the genesis, perpetuation, and prognosis of illness symptoms. Health professionals need to be aware of cultural idioms of distress and emotional and clinical needs. Even when both the clinician and the patient come from the same culture, a thorough and proper assessment is necessary.
Assessment tools and cultural formulation
Authors: Bhugra Dinesh , Ventriglio Antonio , Bhui Kamaldeep S.
Published: October 2018

Assessment tools can support clinical assessments but cannot replace them. They can be used for a number of purposes. They are standardized tools but may require some adjustments if they are being used in cultures other than those in which they were developed. If they have been translated into other languages, it is essential that translation be carried out with proper conceptual equivalence rather than simple literal translation. The experiences of migration and acculturation need to be assessed carefully. Furthermore, for the first time DSM-5 includes concepts of cultural formulation; the key features include cultural identity of individuals, cultural explanations of their illnesses, cultural factors related to their environment and levels of functioning, various cultural elements of relationship between the clinician and the individual, and overall cultural assessment. At the heart of cultural formulation lie the principles of cultural sensitivity.
Psychopharmacology and culture
Authors: Bhugra Dinesh , Ventriglio Antonio , Bhui Kamaldeep S.
Published: October 2018

Prescribing medicine is one of many therapeutic strategies that clinicians use in managing mental illness in patients. In different cultures, patients have varying expectations of types of medication. Some cultures prefer injections, whereas others like syrups. Patients from some cultures have faith in small tablets whereas others in big tablets. Colour of tablets also affects compliance. In addition, cultural factors like diet, smoking, and religious rituals also play a role in developing and maintaining therapeutic adherence. Individual pharmacodynamics and pharmacokinetic factors are likely to be strongly influenced by ethnic and racial factors. Environmental and personality factors can play an important role in efficacy of medication. There is no doubt that medication is an important part of the therapeutic interaction. Clinicians must give the right information about medication in terms that patients and their families can understand clearly, especially the meaning of the medication and its purpose and potential side effects.
Risk assessment and analysis of outcomes
Authors: Ludman Peter F.
Published: October 2018

To ensure that patients receive optimal care, and to find ways to improve, we have to measure the therapy delivered and patient outcomes. Increasingly this happens in a public forum. This chapter deals with this complex process and potential pitfalls. To assess care a wide range of information needs to be collected for each patient, and must be as complete and accurate as possible. Analysis needs to take into account different patient characteristics to tease out differences in outcome that might be due to healthcare delivery rather than patient comorbidity. The methods used to display these results are pivotal in interpretation and triggering early warning of potential problems, and are discussed. In this era of transparency and openness, the central role of patients is acknowledged—patient involvement is now central to modern medicine. The benefits and potential undesirable consequences of public reporting of outcomes are also explored in this chapter.
Primary percutaneous coronary intervention for ST-elevation myocardial infarction
Authors: Adam Zulfiquar , de Belder Mark A.
Published: October 2018

This chapter covers primary percutaneous coronary intervention (PPCI), with an investigation of the limitations of the competing thrombolysis procedure, optimal timing, and a discussion of the technical aspects associated with delivering PPCI. Comparing randomized trials that look at differential outcomes in both the short and long term, and covering the European Society of Cardiology guidelines for ST-elevation myocardial infarction treatment, the chapter provides an overview and analysis of the risks and benefits of PPCI.
Revascularization in patients with diabetes mellitus
Authors: Kassimis George , Banning Adrian
Published: October 2018

Coronary artery disease (CAD) is virtually ubiquitous in adults with diabetes mellitus (DM) and it confers a substantially worse prognosis than for non-diabetic patients. There are more than 150 million adults worldwide estimated to have DM, at least half of whom will die from cardiovascular causes. Maturity-onset or type 2 DM accounts for up to 95% of all cases of diabetes and its prevalence has increased by 40% in industrialized countries and almost tripled in developing countries. It has been estimated that the global prevalence of DM among adults will be 7.7% (439 million individuals) in 2025. In the USA, the costs related to DM have been estimated at $174 billion in 2007—$116 billion for direct and $58 billion for indirect medical costs such as disability and work loss—while they are expected to rise to $192 billion by 2020.
Out-of-hospital cardiac arrest: role of percutaneous coronary intervention
Authors: Radsel Peter , Noc Marko
Published: October 2018

Out-of-hospital cardiac arrest (OHCA) remains the leading cause of death in developed countries, with an annual incidence from 36 to 81 events per 100,000. Prehospital treatment includes immediate recognition, bystander cardiopulmonary resuscitation, defibrillation, and advanced cardiac life support known as a ‘chain of survival’. Owing to improvements in the ‘chain of survival’, the proportion of patients with re-establishment of spontaneous circulation on the field may nowadays exceed 50%. This leads to increased hospital admission observed in communities with mature prehospital emergency services. According to autopsy and immediate coronary angiography (CAG), significant coronary artery disease may be documented in more than 70% of patients. Moreover, in the presence of ST-elevation myocardial infarction (STEMI) in post-resuscitation electrocardiogram, acute thrombotic lesions may be found in up to 90%. However, the absence of STEMI does not exclude obstructive or thrombotic coronary stenosis, which may be present in 25–58% of patients. Because of these findings, interventional cardiologists are increasingly alerted for immediate CAG and percutaneous coronary intervention in OHCA patients.
Oral antiplatelet therapies in percutaneous coronary intervention
Authors: Khanna Vikram , Gershlick Tony , Curzen Nick
Published: October 2018

As our understanding of the pathophysiology of adverse cardiovascular events evolves, the central role of platelets has become increasingly recognized. Plaque rupture, platelet activation, aggregation, and thrombus formation occur as a result of complex interactions between platelets, vascular endothelium, inflammatory cells, and circulating proteins and red blood cells. These processes can lead to vascular occlusion, ischaemia, and infarction in the native circulation consequent on plaque erosion or disruption. Similarly, during percutaneous coronary intervention and stent implantation, coronary vessel trauma and inflammation, as well as delayed stent endothelialization with ongoing exposure of the platelet-atttrative metal stent struts, combine to make some patients susceptible to adverse thrombotic events, including the potentially fatal stent thrombosis. This chapter will review key components of the processes and determine how therapeutic strategies can attenuate potential adverse cardiovascular events.
The role of bivalirudin in percutaneous coronary intervention
Authors: Schüpke Stefanie , Massberg Steffen , Kastrati Adnan
Published: October 2018

Rapid progress has been made in interventional cardiology over the past years; many patients with coronary artery disease, even those with complex lesions, are nowadays being treated with percutaneous coronary intervention (PCI). As a result, a major focus of current cardiovascular research is on reducing negative periprocedural clinical events associated with PCI, particularly in high-risk patients. Among the most dangerous periprocedural events are thrombotic complications, leading to recurrent myocardial or cerebral ischaemia, often with fatal outcome. Anticoagulant and antiplatelet treatment, therefore, is an integral part of current PCI strategies. However, prevention of procedural thrombotic events with the use of anticoagulants occurs at the expense of severe bleeding complications. Hence, there has been a strong effort over the last few years to develop and validate novel anticoagulant regimens that provide protection against thrombotic complications, but have only minor effects on normal haemostasis. Parts of these efforts has also been the development of bivalirudin.
Optimal medical therapy in percutaneous coronary intervention patients: statins and angiotensin-converting enzyme inhibitors as disease-modifying agents
Authors: Corbett Simon J. , Curzen Nick
Published: October 2018

The majority of this textbook is concerned with the indications for, and applications of, the numerous techniques that interventional cardiologists have at their disposal to assess and treat significant coronary stenosis. However, it is well recognized that atherosclerosis is far from being a discrete pathological process, such that by the time people present with clinically apparent coronary artery disease (CAD), they will often have widespread atheroma throughout their coronary tree. Combined with the reproducible observation that the majority of acute coronary syndromes arise from lesions that were not previously flow-limiting, much research effort has been directed at identifying treatment strategies that will favourably modify all of the patient’s atherosclerotic burden, not just that which can be targeted by percutaneous or surgical revascularization. In this chapter, we focus on the rationale and evidence base supporting the use of statins and renin–angiotensin–aldosterone system inhibition in patients with CAD.
Contrast-induced acute kidney injury
Authors: McCullough Peter A.
Published: October 2018

Contrast-induced acute kidney injury, previously known as contrast-induced nephropathy, is an important complication in the catheterization laboratory. The definition of contrast-induced acute kidney injury should be harmonized with the Kidney Disease International Global Outcomes criteria which calls for >=0.3 mg/dl (26.5 micromol/L) rise in serum creatinine within 48 hours of contrast exposure. If there is a sustained reduction in estimated glomerular function from a baseline above 60 to a new baseline below 60 ml/min/1.73 m2 at 90 days after the procedure, then a definition of chronic kidney disease (Stage 3) would be met as a late outcome of this complication.
Stent thrombosis
Authors: Malik Nikesh , Banning Amerjeet , Gershlick Tony
Published: October 2018

Over the past three decades, new strategies have evolved to optimize coronary revascularization techniques. As such, both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have become standard treatments. Following the publication of trials showing a mortality benefit from CABG over PCI in only certain complex patient subsets, together with the clear central role of PCI in managing acute coronary syndromes, PCI has become the dominant mode of revascularization. The development of PCI has, however, been fraught with setbacks over the past 30 years. One critical issue in the early stages was the high restenosis rate, requiring a repeat procedure in up to one-third of patients. The development of bare metal stents and then drug-eluting stents (DES) dramatically reduced the incidence of restenosis now to less than 5%. While such improved clinical outcomes with DES have supported the widespread use of PCI, the issue of stent thrombosis remains a serious concern and hence the focus of continued research.
Coronary artery perforation
Authors: Gunning Mark , Khoo Chee Wah
Published: October 2018

There are few scenarios in the cardiac catheterization laboratory quite as dramatic as a coronary artery perforation. While some instances of this mishap are subtle, others are quite dramatic. Fortunately this occurrence is rare, but carries with it a significant risk of serious adverse events. The potential for harm may be reduced by the brisk identification of the problem within the catheter laboratory, together with early implementation of treatment. A clear understanding of the mechanism, implications, and management of this complication are essential tools for the capable interventional cardiologist.
Rotational atherectomy
Authors: de Belder Adam , Thomas Martyn , Barbato Emanuele
Published: October 2018

Since 1979, plain old balloon angioplasty (POBA) has provided relief of angina for many patients. Recurrent symptoms due to restenosis diminished with bare metal stent and, more recently, drug-eluting technology. A limitation to achieving good results with POBA and stenting is calcification within the artery, which can not only prevent passage of balloons and stents into a lesion but may also prevent adequate lumen expansion. Rotational atherectomy or rotablation can treat highly resistant calcified plaque within coronary arteries to allow adequate vessel expansion and ensure optimal stent deployment. The concept of using a high-speed diamond-tipped drill spinning at 150,000 rpm driven by compressed air to clear an artery that is 3 mm in diameter is challenging, yet this technique has been available for use in coronary arteries since 1989 when Bertrand (Lille, France) and Erbel (Essen, Germany) first used it in humans.
Carotid artery stenting
Authors: Malik Iqbal , Hamady Mohamed
Published: October 2018

Stroke can be debilitating or fatal, and is the third leading cause of death in the developed world. Correctable risk factors include the standard cardiovascular conditions of diabetes mellitus, hypertension, smoking, and hyperlipidaemia. Atrial fibrillation has to be sought and the need for anticoagulation to reduce embolic risk assessed. Stenosis of the internal carotid artery (ICA) is a major correctable cause of ischaemic stroke, the risk being related to higher degree of narrowing and the presence of recent symptoms. Coronary stenting or coronary artery bypass surgery can be used for immediate relief of anginal symptoms or to improve prognosis with haemodynamically significant stenoses. Carotid intervention is not usually done for haemodynamic or flow indications, but to reduce future emboli. Carotid endarterectomy (CEA) has become the preferred method of invasive treatment for patients with asymptomatic or symptomatic high-grade ICA stenosis. However, for significant (>50% angiographic) ICA stenosis, carotid artery stenting is a reasonable alternative to CEA. Its true place is as yet undecided, and awaits the conclusion of further randomized trials.
Left atrial appendage occlusion
Authors: Panikker Sandeep , Betts Tim , Leo Milena
Published: October 2018

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting 1.5–2% of the general population and more than 8% of those older than 80 years. Because of the progressive ageing of our population, an exponential increase in incidence is expected over the next few decades. Patients with AF have an increased mortality and morbidity, particularly owing to fatal or disabling stroke. The risk of embolic stroke is five times higher in the presence of AF, with an average annual rate around 5%, but there is a progressive increase with age and the presence of other risk factors, such as prior stroke or transient ischaemic attack, hypertension, diabetes mellitus, congestive heart failure, female sex, and vascular disease, as predicted by the CHADS2 and the CHA2DS2-VASc scores. Moreover, strokes associated with AF are more severe, with a 50% greater likelihood of becoming disabled or handicapped and more than 50% likelihood of death. Intracardiac thrombus formation due to the Virchow triad of events (endothelial or endocardial damage or dysfunction, abnormal blood stasis, and altered haemostasis, platelet function, and fibrinolysis) followed by distal embolization leads to thromboembolic events manifest as transient ischaemic attack, ischaemic stroke, and peripheral embolism in patients with AF.