bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving cancer services: the approach taken in England
Authors: Richards Mike
Published: November 2017

Chapter 7 focuses on the approach taken to cancer control in one country. England was amongst the first jurisdictions to attempt to develop and implement a comprehensive national cancer programme. Many of the individual actions described here are similar to those being taken in other parts of the United Kingdom and in other countries including Denmark, France, and Canada. However, although the actions required are often similar, the delivery mechanisms may well need to be different, depending on the organization of health services within a particular jurisdiction.
Community supports for people affected by cancer
Authors: Jefford Michael
Published: November 2017

Chapter 11 considers the supportive care needs of people affected by cancer – not just those who are told that they have a cancer diagnosis, but also their family members and friends, who are also often profoundly affected. The critical role of health care professionals in meeting the needs of all people affected by cancer is underscored. The many and varied sources of additional support provided outside the clinical setting are then described. The review focuses upon the needs of adults with cancer, though many of the issues and examples are also applicable to children, adolescents, and young adults with cancer. A critical issue is how to best integrate clinical programmes with the variety of supports outside the clinical setting.
From cancer care to cancer control: organization of population-based cancer control systems
Authors: Sutcliffe Simon
Published: November 2017

Chapter 15 discusses the need for a strategy directed to the elements of the cancer process, from primary prevention to end-of-life care, and that the strategy be directed to the entire population. A comprehensive, population-based strategy is based upon certain foundational premises.
Organizational structures for cancer control
Authors: Caron Lorraine
Published: November 2017

Chapter 17 discusses how comprehensive cancer control initiatives guided by well-known frameworks are being established through concerted stakeholders’ collaborations that include government, non-governmental organizations, as well as public/patient representatives.
Evaluating the outcomes of cancer control
Authors: Micheli Andrea , Baili Paolo , Ciampichini Roberta , Verdecchia Arduino
Published: November 2017

Chapter 18 covers the main characteristics and indicators necessary to implement a well-functioning cancer information system, and the up to date situation for the main cancer outcome indicators in various world geographical areas, and discusses them in relation to the implementation of the cancer control process.
Priority setting methods and cancer control
Authors: Peacock Stuart , Hedden Lindsay , Mitton Craig
Published: November 2017

Chapter 19 introduces some fundamental principles of priority setting, critiques the main priority setting approaches in the health sector, and describes some case studies which illustrate how alternative approaches have been employed, beginning with a brief description of the burden and cost of cancer, the introduction of two fundamental principles of priority setting, a critique of the main approaches to priority setting and presenting a readily adaptable way forward for this type of planning activity, and concludes with a discussion of the need to balance economics and ethics when addressing the challenge of setting priorities in cancer control.
Ethics and the idea of cancer control
Authors: Schwartz Lisa
Published: November 2017

Chapter 20 examines how proposed cancer control programmes can include ethical procedures and explore the value in their so doing and at the kinds of decisions that need to be made and at the ethical values and principles that can be applied to the decision-making processes.
Cancer control in developing countries
Authors: Magrath Ian
Published: November 2017

Chapter 22 discusses cancer control in developing countries and how methods need to be found to correct, or unlearn, messages that pervade these societies, and how solutions are most likely to be found through close collaboration between local health professionals and a variety of external organizations, institutions, and individuals that can offer specialized knowledge and training in appropriate skills.
Examination of the obstetric patient
Authors: Arulkumaran Sabaratnam , Farquharson David I. M. , Monga Ash , Papageorghiou Aris T. , Regan Lesley
Published: November 2017

Abstracts and keywords to be supplied.
Early history of muscular dystrophy
Authors: Emery Alan E. H. , Emery Marcia L. H.
Published: November 2017

Chapter 2 discusses how Duchenne muscular dystrophy was observed and perhaps even recorded in earlier times.
Edward Meryon’s contribution to muscular dystrophy
Authors: Emery Alan E. H. , Emery Marcia L. H.
Published: November 2017

Chapter 3 explores the first systematic study of the condition by Edward Meryon in the early 1850s. He lived during a very interesting period in English history, namely from 1807 to 1880, a time when much was changing in society and in the practice of medicine.
Recognition of other types of muscular dystrophy
Authors: Emery Alan E. H. , Emery Marcia L. H.
Published: November 2017

Chapter 9 attempts to resolve problems of heterogeneity are described as the situation appeared when this resource was first published in 1995.
Current trends and the future
Authors: Emery Alan E. H. , Emery Marcia L. H.
Published: November 2017

Chapter 13 briefly summarizes some of the current areas of research and future possibilities with regard to the muscular dystrophies as a group of related conditions.
Jaspers’ ‘Critique of Psychoanalysis’: between past and future
Authors: Monti Mario Rossi
Published: November 2017

Karl Jaspers publishes his Critique for psychoanalysis in 1950. This contribution represents the culmination of a journey originated many years before with the publication of General Psychopathology in 1913. In order to better understand the culmination of Jaspers’ journey the Author will take the following points into consideration: the stages that marked the history of Jaspers’ critical thought; the historical context; the tone of his criticism and, finally, its content. The final part of this essay attempts to show how some of Jaspers’ critical observations on psychoanalysis should not be considered as a thing of the past, because they were and still are a fundamental topic of discussion and debate within the Freudian psychoanalytic movement (International Psychoanalytical Association).
Jaspers, phenomenology, and the ‘ontological difference’
Authors: Sass Louis A.
Published: November 2017

This paper considers Karl Jaspers’ general position regarding human experience and the study thereof—as expressed in “The Phenomenological Approach in Psychopathology” (1912) and General Psychopathology (first published 1913). After describing Jaspers’ rejection of epistemological objectivism and physicalism, I consider later developments in hermeneutic phenomenology that are absent from his discussion. These include criticism of the “prejudice against prejudices” and also of what Heidegger termed the “forgetting of the ontological difference” (namely, neglect of general qualities of the experiential world and its presencing, in favour of focusing on entity-like phenomena that occur ‘within’ the horizons of this awareness). Jaspers presents phenomenology as a form of pure description, devoid of explanatory relevance, that offers “unprejudiced direct grasp of [experiential] events as they really are.” From a contemporary, hermeneutic standpoint, Jaspers’ vision seems overly modest regarding what phenomenology can offer to psychopathology, yet overly confident about the precision and certitude of the accounts it might provide.
Karl Jaspers the pathographer
Authors: Bormuth Matthias
Published: November 2017

Karl Jaspers belongs with his Strindberg and van Gogh: An attempt of a pathographic analysis in comparative relation to Swedenborg and Hölderlin (1922) to the classic representatives of the genre. He developed this way of thinking psychiatrically and philosophically even more clearly in the extensive case history incorporated into his
1936 monograph Nietzsche: An Introduction to the Understanding of His Philosophical Activity. Jaspers addressed the issue of pathography a third time in 1947 when he formulated a clinical casuistry of the prophet Ezekiel for a Festschrift dedicated to Kurt Schneider. The article at hand explores the three pathographical studies conducted by Jaspers in the context of a history of ideas. It will focus initially on three exemplary representatives of modern pathography. Then Jaspers’ approach will be introduced, starting with methodological considerations followed by three sections devoted to detailed analyses of his pathographical studies. Lastly, Jaspers’ philosophical premises will be explored in greater detail.
Karl Jaspers’ hierarchical principle and current psychiatric classification
Authors: Sass Henning , Volpe Umberto
Published: November 2017

The chapter aimed to provide a brief account of the clinical method of Karl Jaspers, along with a thorough presentation of his “hierarchical principle”, of his approach to systematic classification in psychiatry and of the aftermath of hierarchical classification concepts in the clinical psychiatric settings. A detailed historical perspective of how the Jaspers theories have influenced the subsequent classification systems and a comparison with operationalized diagnostic approaches are also presented, unveiling the most common shortcomings of the current diagnostic classifications in psychiatry. Furthermore, the role of the “inner perspective” and of the phenomenological description of subjective experiences in the clinical field is discussed, also in connection with the implications for research in psychiatry and the various intellectual frameworks for this scientific discipline.
Kidney and body fluids
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

The physiology of body fluid compartments is revised in association with clinical assessment of fluid balance and the management of fluid-related abnormalities. Electrolyte and acid-base disorders; causes, consequences and management are summarized. Acute kidney injury in the context of perioperative medicine is discussed; including definitions, risks, causes, recognition, prevention and preventative measures. Renal replacement therapy strategies are explained.
Gastrointestinal tract and liver
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

Anaesthetists are commonly involved in resuscitation and operative intervention in patients with chronic or acute gastrointestinal disorders or liver disease. The physiological consequences of bowel obstruction and anaesthetic considerations for laparotomy are described. Assessment and resuscitation in massive gastrointestinal haemorrhage is discussed; intervention and specialized management of variceal bleeds is also covered. The recognition, management and complications of acute, severe pancreatitis as well as multi-system effects of abdominal compartment syndrome are included. These are both commonly associated with critical illness and need for urgent intervention.
Endocrinology, metabolism, and body temperature
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter summarizes endocrine physiology that is of particular relevance to anaesthesia. Disorders of the adrenal cortex and medulla, pituitary and thyroid are described with perioperative management considerations highlighted. Current guidelines in perioperative steroid replacement are included. Diabetes is a particularly common problem encountered in clinical practice. Diabetic complications, pre-assessment and perioperative management aims are included. The surgical stress response is summarized with details of the neuroendocrine changes and their modification with anaesthetic technique. Consequences of perioperative hypothermia and use of therapeutic hypothermia are detailed.
Nervous and musculoskeletal systems
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter outlines the basic science related to the nervous and musculoskeletal systems which particularly apply to the conduct of anaesthesia. Consciousness, sleep and anaesthetic depth are discussed with the measurement of anaesthetic depth using bispectral index and evoked potentials. Factors which influence cerebral blood flow and intracerebral pressure are detailed, allowing understanding of neuroanaesthesia techniques. Pharmacological and anaesthetic management of seizures is also described. Diseases affecting the autonomic nervous system, testing for these disorders and the implication for anaesthesia are included. Physiological consequences of spinal cord injury with patterns of injury are described. Neuromuscular blocking agents, monitoring of blockade and implications for patients with neuromuscular disease is also explained.
Physics and clinical measurement
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter includes general concepts of interpreting laboratory results such as specificity, sensitivity and predictive values. In the measurement of blood coagulation, the cell-based mechanism for blood clotting is explained and the role of point-of-care viscoelastic testing using thromboelastography is described. Effects of ionizing radiation, safe levels, and radiation protection are also included.
Day surgery
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter describes the organizational factors necessary for the provision of a day surgery service; ideal layout of units, staffing levels and patient pathways. Guidelines for provision of day surgery regarding patient selection, recovery and nurse-led discharge are included from the AAGBI and BADS. Day surgery advances mean that patients having regional and central neuraxial blockade, as well as diabetic patients requiring insulin, can now successfully be managed on a day case basis.
Anaesthesia for general surgery (including transplantation)
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter focuses on aspects of anaesthesia for complex, major surgery such as hepatic resection and oesophagectomy. The theories and practice of enhanced recovery after surgery and perioperative optimisation with goal directed therapy are included here. The systemic impact of malignancy and its treatment modalities are also discussed.
The practical and ethical aspects of organ transplantation are discussed. Anaesthesia for renal and hepatic transplant is described, as well as considerations for anaesthetising the transplant recipient for non-transplant surgery. Recognition of transurethral resection syndrome in urological surgery is potentially life-saving; causes, management and avoidance are discussed. The NICE criteria for performing bariatric surgery, types of surgery, and conduct of anaesthesia for this challenging patient group is also covered.
Anaesthesia in the non-theatre environment
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

Anaesthetists regularly provide anaesthesia or sedation in remote sites such as radiology or endoscopy. This is associated with a number of extra considerations which are explained in this chapter. Some sites or procedures may pose more specific hazards and these are described in more detail in the sections on anaesthesia for MRI and ECT. Standards for providing safe sedation are also included.
Anaesthesia for orthopaedic surgery
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

The risks, benefits, and evidence for use of regional anaesthesia techniques are discussed generally and for specific procedures such as joint arthroplasty. Other perioperative considerations for primary and revision arthroplasty are described. The particular challenges of the patients presenting with fractured neck of femur, physiological changes of older age and goals for perioperative management are highlighted. Surgical procedures for scoliosis are performed in specialist centres and are discussed. Associated medical comorbidity, anaesthetic considerations and neurological monitoring for spinal cord function are described.
Neuroanaesthesia and neurocritical care
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter describes the general conduct of anaesthesia for neurosurgery with particular reference to techniques for reducing intracranial pressure, safe positioning, and recognition and management of air embolus. Management for specific common procedures such as shunt surgery, haematomas, traumatic brain injury and pituitary surgery is described. Neurosurgical conditions such as cerebral aneurysms and arteriovenous malformations may be managed in neuroradiology and the special considerations for the provision of anaesthesia for these cases are detailed. The principles of management of traumatic brain injury in critical care which aim to reduce secondary brain injury are explained.
Transfer medicine
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter on transfer medicine includes transfer indications, decisions, general considerations and complications as well as legal aspects of patient transfer. Considerations for specific patient groups are described for neurosurgical, trauma, spinal injury, burns and obstetric patients. Complications and management are detailed in an ABCDE format. Transfer equipment including ventilators with modes of ventilation are also considered.
Obstetric anaesthesia
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter covers the knowledge required for higher training in obstetric anaesthesia. Physiological changes of pregnancy, along with their relevance to anaesthetic management are highlighted. Common maternal comorbidity and the impact on antenatal course, delivery and anaesthesia are summarized. Modern labour analgesia techniques are compared. Anaesthetic management of common obstetric emergencies e.g. fetal distress, preeclampsia, massive haemorrhage, abnormal placentation, amniotic fluid embolus and uterine inversion are described. Finally, the recent Confidential Enquiry into Maternal Death is summarized along with the role of early warning scores to improve future care.
Pain medicine
Authors: Prout Jeremy , Jones Tanya , Martin Daniel
Published: November 2017

This chapter summarizes the assessment and management of acute and chronic pain for FRCA. Pain pathways and physiological consequences of pain are considered along with sites of action and the pharmacology of common analgesics. Assessment of pain for different patient groups and settings is explained. Pain management strategies, pharmacological, non-interventional and interventional techniques are described, including multidisciplinary management of chronic pain. Specific management of some common chronic pain conditions, such as trigeminal neuralgia, are discussed in more detail.
Principles and control methods
Authors: Goldstone Karen E
Published: November 2017

Justification, optimization, and limitation are the three underlying principles of good radiation protection. This chapter considers how these principles apply in a variety of exposure situations. Risk-based application of the principles results in control methods comprising control over areas, control over people, and control over radiation sources. These are implemented through judgements based on the use of dose limits, dose constraints, and application of the ALARA principle. Potential dose levels and possible control measures appropriate to each situation are reviewed and evaluated in risk assessments prior to work being undertaken.
Diagnostic radiology—Facility
Authors: Sutton David G , Martin Colin J
Published: November 2017

The exposure to radiation of staff and members of the public is restricted by seeking suitable compromises between the three basic elements of time, distance, and shielding. This chapter deals with the design of X-ray facilities to ensure that the distance and shielding elements are used appropriately. Criteria in the form of dose constraints for staff and the public based on the ALARP principle are used together with occupancies of adjacent areas to determine acceptable dose levels. Methods for calculating doses from workloads in terms of patient dose data are described. The results are then combined with the dose criteria to derive transmission requirements for protective barriers. Specific requirements for secondary scattered radiation and primary beams in radiography are considered. The methodology is described together with practical examples of room design for different X-ray techniques and elements of personnel radiation protection are discussed.
Radiotherapy: external beam radiotherapy
Authors: Peet Deborah J , Horton Patrick , Martin Colin J , Sutton David G
Published: November 2017

Design principles for radiotherapy facilities using X-ray, γ‎-ray, and electron beams are described, especially the requirements for primary and secondary shielding and maze and door entrances. These features are illustrated with reference to the shielded rooms (bunkers) required for linear accelerators, and example calculations are included for shielding and maze design to achieve required dose constraints. The impact of new clinical practices with intensity modulated radiation fields and flattening filter-free operation is also considered. Engineering controls and features for safe operation are described, and good practice in bunker construction and the provision of services to avoid weaknesses in the shielding is outlined. The principle shielding requirements for TomoTherapyTM, CyberKnifeTM, Gamma KnifeTM units, and kilovoltage X-ray units are also described. Finally, personnel monitoring, commissioning surveys, and environmental monitoring in radiation protection management in radiotherapy are discussed. Data for calculating shielding thickness and X-ray scatter for maze design are provided.
Non-coherent optical radiation sources
Authors: Taylor David K
Published: November 2017

Optical radiation is ubiquitous, and intense artificial sources find many applications in clinical practice, including zone illumination, diagnosis, and therapy. Its effects on humans are strongly wavelength-dependent, its hazards sometimes overlooked due to familiarity or masking by other wavelengths. This chapter examines non-laser sources of ultraviolet, visible, and infrared radiations, the risks likely to be encountered in clinical settings, the calculations needed to assess commonly encountered optical radiation sources, and the measures that can be taken to minimize the hazards to workers and patients, in compliance with the requirements of the Artificial Optical Radiation directive.
Electromagnetic fields
Authors: Hand Jeffrey W
Published: November 2017

Basic characteristics of electromagnetic fields in the microwave, radiofrequency, and extremely low frequency ranges and their interactions with biological tissues are introduced, and parameters such as polarization and specific absorption rate used for safety assessment are highlighted. Techniques and instrumentation for measuring these parameters are discussed. The concepts of dosimetry are introduced and examples of electromagnetic field safety guidelines and standards are outlined. The chapter closes with a discussion of some topics directly relevant to safety of clinical procedures, such as hyperthermia, and diathermy, as well as electromagnetic interference with equipment and implanted devices caused by the presence of mobile communications and radiofrequency identification systems.
Monitoring and equipment
Authors: Hatfield Anthea
Published: November 2017

Routine monitoring is an essential part of recovery room procedure. Respiration, a vital concern while awakening after anaesthesia, is given specific attention with reference to modern capnography. This chapter also describes additional monitoring in detail: pulse oximetry, blood pressure, central venous pressure, and arterial blood gases are clearly described. A comprehensive description of electrocardiography guides the student through this complicated subject. The monitoring of temperature and warming blankets, with suggestions for purchasing equipment, are included.
Mothers and babies
Authors: Hatfield Anthea
Published: November 2017

This chapter looks at pregnant mothers and the physiology of pregnancy. It describes how to look after these patients after operations they experience during their pregnancy as well as after Caesarean section. Instructions are given for the special care of newborn infants. Problems of postpartum haemorrhage, eclampsia, air and amniotic embolism, and aspiration pneumonia are discussed.
The elderly patient
Authors: Hatfield Anthea
Published: November 2017

Elderly patients have special problems and these are extensively described in this chapter. The changes in their physiology and metabolism are correlated with their drug requirements and comorbidities.
The respiratory system
Authors: Hatfield Anthea
Published: November 2017

This chapter discusses hypoxia and respiratory obstruction and the management of hypoventilation. Stridor and laryngospasm, laryngeal and vocal cord damage are described and ways of preventing these from occurring and treating them if they do occur are discussed. Aspiration and its complications and treatment are fully covered.
Cardiovascular disease
Authors: Hatfield Anthea
Published: November 2017

Cardiovascular disease is common and patients coming to recovery room with any of these common problems will need special care. The essential signs and symptoms of hypertension, cardiac failure, ischaemic heart disease, and valvular heart disease are outlined. The actions and side-effects of the drugs that these patients take to control their symptoms are described. Recognizing and treating hypotension and myocardial ischaemia are very important and relevant, and they are fully discussed in this chapter.
Cardiopulmonary resuscitation
Authors: Hatfield Anthea
Published: November 2017

This chapter will teach you about basic and advanced life support, how to use and care for the defibrillator, and give you information about the drugs to use in emergencies. Read and learn this information thoroughly. Be ready to save a life if a cardiac arrest occurs.
Chronic disorders
Authors: Hatfield Anthea
Published: November 2017

Diseases not covered elsewhere are found in this chapter. The subjects are AIDS, alcoholism, drug addiction, epilepsy, liver disease, multiple myeloma, musculoskeletal disease, myasthenia gravis, muscular dystrophy, Paget’s disease, Parkinson’s disease, psychiatric disease, phaeochromocytoma, porphyria, sickle cell disease, smoking, stroke, hypothyroidism, and many others.
Introduction: what is osteoarthritis?
Authors: Doherty Michael , Bijlsma Johannes , Arden Nigel , Hunter David J. , Dalbeth Nicola
Published: November 2017

This brief introductory chapter summarizes some of the key clinical and structural features of osteoarthritis (OA) and highlights some general observations and concepts concerning the nature of OA. General observations include the preservation of OA throughout human evolution; the occurrence of OA in many other animals; the dynamic, metabolically active nature of OA pathophysiology; the fact that most OA never associates with symptoms or functional impairment; and the good outcome in many cases of symptomatic OA. Such observations support the concept of OA as the inherent repair process of synovial joints, which can be triggered by a range of diverse insults and in which all the joint tissues are involved. Aetiologically, OA is a common complex disorder with recognized genetic, constitutional, and environmental risk factors, and these may combine in multiple ways to cause marked variation in phenotypic presentation and in some instances ‘joint failure’ with associated symptoms and disability. Within the spectrum of OA are some discrete subsets, the best defined being nodal generalized OA. However, in many people OA does not fit neatly into one type and its phenotypic characteristics may change as it evolves. Two striking associations of OA are with ageing and with crystal deposition, especially calcium crystals but also urate crystals, and there are a number of possible mechanisms to explain these.
Synovium and capsule
Authors: Lafeber Floris P. J. G. , Besselink Nick J. , Mastbergen Simon C.
Published: November 2017

Synovium is an integrated tissue of the diarthrodial joints that interacts with all the other joint tissues and specifically is important in nourishment and lubrication of the articular cartilage, removal of waste products, and immunological surveillance. Chronic as well as recurrent low-grade synovial inflammation definitely contributes to progression and symptoms of certain patients with osteoarthritis. Low-grade inflammation may even be causative in the disease. The challenge is that osteoarthritis is a heterogeneous disorder with inflammation not only of the synovial tissue but with its mediators also present in cartilage and bone. Therefore, despite the presence of inflammatory mediators, in some cases synovitis may be seen as a bystander and not as a driving force in pathogenesis. Future research must be directed toward defining the risk-to-benefit ratio for (systemic) anti-inflammatory therapy, especially when targeting mediators of low-grade inflammation.
Epidemiology
Authors: Arden Nigel , Nevitt Michael C.
Published: November 2017

Despite the impact of osteoarthritis (OA) on patients and the health service, OA remains an elusive condition to define and treat. Traditionally, OA has been diagnosed using radiographs and more recently magnetic resonance imaging; however, the last 20 years of research have changed our thinking about the disease and its treatment. We know today that OA takes up to 10–15 years to develop, has a range of risk factors, and that there is a considerable discordance between symptoms and structural signs, such that new classifications and definitions are moving away from structural criteria to combined structure and pain definitions. This chapter reviews the definition and classification of OA and its prevalence, incidence, and natural history.
Genetics
Authors: Valdes Ana M.
Published: November 2017

Epidemiological studies have demonstrated that osteoarthritis (OA) is a complex trait with numerous environmental and genetic risk factors. A great deal of effort has been spent elucidating these risk factors and progress has been made. It is clear however that the causes behind OA development and progression continue to remain largely elusive. Identification of those genes that, in conjunction with environmental factors, predispose to OA severity will lead to a better understanding of the mechanisms underlying disease development and thus promote improved health strategies for prevention. An understanding of the molecular signalling pathways involved in the initiation and progression of the disease will improve clinical diagnosis and help identify improved, tailored treatment regimens. This chapter focuses on these issues, exploring the heritability of OA, known genetic risk factors, and specific traits and outcomes studied in the genetics of OA.
Neurobiology of pain in osteoarthritis
Authors: Mease Philip
Published: November 2017

Significant advances in our understanding of the neurobiology of pain in osteoarthritis (OA) have occurred in the last decade and are herein summarized. Pain is the predominant symptom of OA and occurs at multiple levels from non-cartilage peripheral tissues to spinal cord, and brain and back. At each level, nerve function is regulated by complex ionic channels, neuropeptide expression, and cytokine and chemokine activity. Previously considered a non-inflammatory condition, it is now recognized that cell proliferation and inflammatory cytokine production occurs in OA synovium, contributing to peripheral sensitization. Genetic profile influences nociceptive neuropeptide expression and thus, pain perception. Both peripheral and central sensitizing factors, including increased neuropeptide and microglial activity, lead to pain augmentation and persistence. Pain processing in brain centres such as the somatosensory cortex and insula are influenced by affective areas such as the amygdala. Descending receptor pathways through the midbrain to the dorsal horn, such as norepinephrine, serotonin, opioid, and cannabinoid, normally provide pain inhibitory function but this function may be diminished in chronic pain states such as OA, leading to allodynia and hyperalgesia. Functional neuroimaging has contributed to our understanding of the complex interplay of peripheral and central mechanisms. Recent evidence that grey matter volume decrease in chronic pain states may be reversible (e.g. after pain relief post OA hip arthroplasty) illuminates the potential for central neuroplasticity. Greater understanding of the neurobiology of OA pain provides evidence for therapeutic approaches that address peripheral and/or central pain mechanisms and provides a guide for future targeted pain therapeutics.
Exercise for the person with osteoarthritis
Authors: Bennell Kim L. , Van Ginckel Ans , Dobson Fiona , Hinman Rana S.
Published: November 2017

Because of its beneficial effects on pain and physical dysfunction commonly reported by afflicted individuals, all clinical guidelines of osteoarthritis (OA) advocate exercise therapy as a vital component of conservative management strategies. Although the optimal exercise modalities in terms of dosage, exercise type, or delivery mode are not yet known, clinical benefits can be achieved with a wide range of exercise types. While treatment effect sizes may be considered small to moderate, they are similar to those of common analgesic drugs or oral non-steroidal anti-inflammatories but seem to elicit fewer side effects. To achieve optimal treatment outcomes, programme parameters should be individualized to the patient’s clinical characteristics and preferences. Where validated instruments could assist the clinician in monitoring the progress of an exercise intervention programme, adherence to exercise in the longer term is a prerequisite to maintain symptom relief over time. Whereas the current body of evidence mainly comprises clinical trials in people with knee OA, future studies should continue to address efficacy and safety of exercise therapy in individuals suffering from hand or hip OA and should further determine its ability to postpone the need for costly arthroplasty surgery.
Weight loss
Authors: Henriksen Marius , Christensen Robin , Heitmann Berit L. , Bliddal Henning
Published: November 2017

Obesity is widely acknowledged as a risk factor for both the incidence and progression of osteoarthritis. Loss of at least 10% of body weight is recognized as a cornerstone in the management of obese patients with osteoarthritis, and can lead to significant improvement in symptoms, pain relief, physical function, and health-related quality of life. However, questions still remain surrounding optimal management and whether structural disease progression can be arrested. Given the significant health, social, and economic burden of osteoarthritis, especially in obese patients, it is imperative to advance our knowledge of osteoarthritis and obesity, and apply this to improve care and outcomes. This chapter overviews what is known about osteoarthritis, obesity, and weight loss and discusses current key challenges in management and maintenance of weight loss for overweight and obese individuals with osteoarthritis.
Miscellaneous physical therapies
Authors: Holden Melanie A. , Thomas Martin J. , Dziedzic Krysia S.
Published: November 2017

Miscellaneous physical therapies, such as assistive devices, thermotherapy, manual therapy, and electrotherapy are commonly used to treat patients with osteoarthritis (OA) in addition to written information and exercise. However, the evidence underpinning specific miscellaneous physical therapies is often limited, with small study sizes, heterogeneous populations, and differing study designs making it difficult to draw firm conclusions about their effectiveness. One or more miscellaneous physical therapies feature within 15 current clinical guidelines for OA. The specific types of physical therapies addressed are variable, as are their recommendations. There is most agreement for miscellaneous physical therapies in hand OA, with multiple guidelines addressing and consistently recommending joint protection, splinting, and thermotherapy in addition to core treatment. However these recommendations are predominantly based on a small number of randomized controlled trials (RCTs). Use of walking aids and footwear is commonly addressed and recommended for patients with hip and knee OA, although recommendations are predominantly based on expert opinion. Other physical therapies recommended for hip and knee OA range from orthoses to less conventional leech therapy. When a recommendation for a miscellaneous physical therapy is not made, it is commonly due to limited clinical evidence, rather than evidence of harm. Due to limited evidence and lack of consensus between clinical guidelines, for some therapies, use of specific miscellaneous physical therapies in clinical practice should be based upon the best available evidence, a holistic, individualized clinical assessment and shared decision-making with the patient. Further large-scale, high-quality RCTs would be useful to inform future guideline recommendations and clinical practice.
Topical pharmacological treatments
Authors: Abhishek Abhishek , Jones Adrian , Doherty Michael
Published: November 2017

Topical pharmacological agents such as non-steroidal anti-inflammatory drugs (NSAIDs) and capsaicin are widely recommended as first-line analgesics in the treatment of osteoarthritis (OA) of the knee, hand, and potentially other peripheral joints in view of their safety and efficacy. Although initial studies were short in duration (2–4 weeks), recent randomized controlled trials have confirmed the efficacy of topical NSAIDs over longer (12-week) study periods. Systematic reviews demonstrate that their efficacy can be equivalent to oral NSAIDs for OA pain, but they have a significantly better systemic toxicity profile than the corresponding oral formulations. Topical capsaicin is less well studied than topical NSAIDs but has been demonstrated to be effective in several placebo-controlled clinical trials. Local warming and an uncomfortable burning sensation is a common problem with initial applications, but this subsides with continued treatment and can be minimized by using a low-strength preparation (e.g. 0.025%) initially. Several other topical treatments such as drug-free transfersome gel and local lignocaine patches have been shown to be effective in controlling pain due to OA. However, they have been studied in relatively few studies and currently are not recommended for general use.
Supplements for the treatment of osteoarthritis
Authors: Sawitzke Allen D. , Clegg Daniel O.
Published: November 2017

Foodstuffs have long been thought to affect health beyond just their supply of calories. Some have been used as a ‘dietary supplement’ to health and thereby aid patients with osteoarthritis. The evidence demonstrating the effectiveness of using dietary supplements to improve pain or protect the structure of the joint is not complete, but some preliminary conclusions are possible. This chapter is an inclusive review of the current published evidence for selected commonly recommended dietary supplements for the treatment of osteoarthritis. Among the dietary supplements, the most credible evidence continues to be for glucosamine, chondroitin sulphate, and their combination with additional evidence suggesting potential benefit for avocado soybean unsaponifiables, ginger, rose hip powder, and strontium. For most agents, systematic reviews are the best evidence thus far as large well-designed trials are uncommon. Some dietary supplements, especially combined glucosamine and chondroitin sulphate, may be helpful to reducing the pain of patients with osteoarthritis. Others may slow joint space narrowing of osteoarthritis particularly strontium and the combination of glucosamine and chondroitin sulphate although further evidence will be required to inform best practice.
Intra-articular injection therapy
Authors: Arden Nigel , O’Neill Terence
Published: November 2017

Intra-articular injection therapy is widely used in the management of osteoarthritis (OA). It has advantages over oral therapy in that it can provide targeted therapy to individual joint sites and at higher dose than could be achieved through oral administration and with fewer adverse effects. Intra-articular steroid therapy, the most widely used intra-articular therapy, is safe and effective in the short term particularly at the knee; though more studies are needed to better characterize the longer-term benefit. The role of intra-articular hyaluronic acid in clinical management of OA is less clear though it may have a role in selected patients in whom other therapies are contraindicated. Currently there are no factors which have been identified as being predictors of response to therapy with intra-articular therapy. Many other intra-articular agents have been used in the management of OA, however, because of the limited evidence base relating to efficacy and safety they cannot currently be recommended for use in routine clinical practice.
Arthroplasty and its complications
Authors: Price Andrew , Monk Paul , Beard David
Published: November 2017

Hip and knee replacement surgery is one of the most commonly performed orthopaedic procedures in the world. Within the United States, approximately 1 000 000 arthroplasty surgeries are performed a year and within the United Kingdom, around 200 000 hip and knee replacements are performed annually. There is considerable evidence to show the clinical and cost-effectiveness of these interventions. Many patients will get very effective relief of the pain and immobility resulting in a general improvement in their quality of life. However, there can be complications from the surgery and approximately 10–15% of patients may not do well after joint replacement. This chapter outlines the key points of arthroplasty practice including indications for surgery, the type of surgery performed, and review of the benefits and risks of the procedure.
Delivery (organization and outcome)
Authors: Brand Caroline A. , Ackerman Ilana N.
Published: November 2017

This chapter considers the organization and delivery of care for osteoarthritis (OA) within the broader context of chronic condition management, and with a specific focus on the current OA literature. It describes factors that have influenced healthcare reforms for people with chronic conditions such as OA, and the development and characteristics of chronic condition models of care. The chapter also examines existing models of care for OA, which are commonly multidisciplinary in nature and situated within primary care, community care, or secondary/tertiary care settings. It summarizes current evidence for the effectiveness and cost-effectiveness of OA models of care, acknowledging that limited data are available regarding access and efficiency outcomes. Barriers to the successful development, implementation, and sustainability of OA models of care are discussed, as well as enablers that could facilitate the success of models of care. The chapter also presents points to consider when planning the implementation and evaluation of models of care, such as the development of a program logic, use of theoretical models or frameworks, and careful selection of appropriate research designs (including mixed-methods approaches). Finally, it considers future challenges for OA models of care, particularly the rise of multi-morbidity among patient populations that will necessitate integrated chronic condition management rather than stand-alone OA services. Future models of care may require the design of specific OA modules that can be integrated with generic chronic condition models that address risk behaviour modification and optimize self-management and mental health outcomes.
Principles of gout management
Authors: Richette Pascal
Published: November 2017

The general goals of gout therapy are to manage acute flares and to prevent recurrences and prevent or reverse the complications of urate deposition by lowering urate levels. The choice of drug should be made on the basis of the patient’s co-morbidities, other medications, and side effect profile. Treatment of flares can be achieved with non-steroidal anti-inflammatory drugs, colchicine, or corticosteroids (systemic or intra-articular). Interleukin-1 blockers could become an alternative in patients contraindicated for traditional anti-inflammatory agents. Lowering of urate levels below monosodium urate (MSU) saturation point with both a non-pharmacological and pharmacological approach allows to dissolve MSU crystals and to cure gout. Serum urate (SUA) levels should be maintained below 6 mg/dL (360 μ‎mol/L) or below 5 mg/dL (300 μ‎mol/L) in patients with severe gout to facilitate faster dissolution of crystals. Urate-lowering therapy (ULT) should be initiated close to the first diagnosis of gout. Allopurinol and febuxostat are the most widely used xanthine oxidase inhibitors to lower SUA levels. If the SUA target cannot be reached by these agents, uricosurics are indicated, either alone or in combination with a xanthine oxidase inhibitor. In patients with severe tophaceous gout in whom the SUA target cannot be reached with any other available drug, pegloticase is indicated. Since ULT initiation may trigger acute attacks of gout, prophylaxis with an anti-inflammatory agent is recommended, mostly with low-dose colchicine. Of note, patient education, appropriate lifestyle advice, and treatment of comorbidities are also important parts of the management of patients with gout.
Treatment of calcium pyrophosphate deposition
Authors: Abhishek Abhishek , Doherty Michael
Published: November 2017

The treatment of calcium pyrophosphate crystal deposition (CPPD) is mainly symptomatic. Acute calcium pyrophosphate (CPP) crystal synovitis should be treated with rest, local application of ice packs, joint aspiration, and/or intra-articular corticosteroid injection (once joint sepsis has been excluded). Oral colchicine or prednisolone may be used if joint aspiration and/or injection are not feasible. Anti-inflammatory agents (with proton pump inhibitors) may be used but in general these should be avoided as most patients with acute CPP crystal arthritis are elderly, and at a high risk of gastrointestinal and renal complication of non-steroidal anti-inflammatory drug (NSAIDs). Principles of management of CPPD with osteoarthritis (OA) are identical to those for isolated OA. However, patients may have more inflammatory signs and symptoms and periodic joint aspiration and corticosteroid injection may be required more often than in isolated OA. Oral NSAIDs (with gastro-protection), colchicine, low-dose corticosteroids, hydroxychloroquine, and radiosynovectomy have been suggested as options for the treatment of chronic CPP crystal arthritis. There is growing interest in use of anti-interleukin-1 agents for acute or chronic CPP crystal arthritis but the efficacy of these agents has not been formally studied, and their use should be considered on an individual basis.