bluuebunny/crossref_metadata_2025 huggingface dataset:
Immunology of Bipolar Disorder
Authors: Barbosa Izabela G. , Bauer Moises E. , Soares Jair C. , Teixeira Antônio L.
Published: January 2019

Bipolar disorder (BD) is a severe, chronic, and recurrent psychiatric illness. It has been associated with a high prevalence of medical and psychiatric comorbidities, cognitive impairment, and a progressive course of illness. Its neurobiology is not completely understood, but recent evidence has shown a wide range of immune changes. Here we review several data supporting the presence of immunological dysfunction in BD: (1) increased frequency of autoimmune diseases; (2) distinct immune cell profile; (3) altered release of cytokines by stimulated mononuclear cells; (4) elevated levels of circulating immune markers; (5) inflammatory changes in the central nervous system; (6) relationship with clinical comorbidities; and (7) the effect of current treatments on the immune system and the role of immunomodulatory agents.
Immune-Based Biomarkers and Therapies in Psychiatry
Authors: Singhal Gaurav , Baune Bernhard T.
Published: January 2019

Research has established the role of complex immune-inflammatory signalling pathways within the brain during psychiatric disorders and associated development of cognitive deficits, anxiety, depression, dementia, and loss of social and communication skills. Various immune changes such as changes in the expression of cytokines, chemokines, T and B cell subsets, and increases in the levels of pro-inflammatory eicosanoids in the brain have been reported. However, the intricacies associated with the molecular pathways and biophysiological measures for the investigation of mental illnesses have posed a multitude of questions to our scientific community when devising the treatment and management strategies for the brain to return to its healthy state. Although antidepressants, mood-stabilisers, and atypical antipsychotic medications have shown great potential to treat psychiatric disorders, adjunctive treatment with anti-inflammatory agents can augment the overall therapeutic efficacy of antipsychotic drugs by downregulating the immune-inflammatory signalling pathways.
Aortic valve repair
Authors: Boodhwani Munir , Khoury Gebrine El
Published: January 2019

Aortic valve replacement remains the gold standard for the treatment of severe aortic valve disease. Techniques for valve repair are emerging as a feasible alternative to valve replacement in selected patients. Advantages include potential reduction in the risks of prosthesis-related complications such as thromboembolism, endocarditis, anticoagulant-related hemorrhage, and reoperation due to structural valve deterioration. In this chapter, the key features of aortic valve and root anatomy, an approach to valve assessment and lesion classification, a demonstration of commonly used reparative techniques for aortic valve repair, and outcomes are reviewed. Furthermore, it also examines the outcomes of aortic valve repair in unselected cohorts, as well as distinct subsets of patients undergoing aortic valve preservation and repair.
Aortic valve: Conventional valve replacement and transcatheter valve implantation
Authors: Kempfert Jörg , Walther Thomas
Published: January 2019

The natural history of untreated severe aortic valve stenosis (AS), with an average survival of 3 years after the onset of angina or syncope and only 1½ years after onset of heart failure, strongly suggests early surgical therapy which represents the only curative option. Since the first pioneering work in the early 1960s, conventional aortic valve replacement (AVR) has become a routine procedure performed more than 200,000 times annually worldwide. The surgical technique of AVR has evolved to a highly standardized procedure resulting in excellent outcome and patient safety. Transcatheter techniques have emerged in the last decade allowing for valve implantation with avoidance of important complications of major surgery particularly in high-risk patients. However, potential drawbacks and procedure-related complications remain important. The techniques and technologies continue to emerge and improve. Conventional surgery, valve substitutes, and transcatheter technologies are discussed in this chapter.
Current status of heart transplantation
Authors: Ali Ayyaz , Kormos Robert L.
Published: January 2019

Cardiac transplantation has extended and improved the lives of patients suffering from severe heart failure over many decades. Despite advances in medical therapy, cardiac transplantation remains the definitive treatment for end-stage heart disease. Surgical techniques for organ procurement and implantation, development of appropriate methods for preserving the heart, and understanding the immunological challenges associated with transplantation were among the many areas which required focused investigation. In the current era, heart transplantation is associated with a low operative mortality and excellent long-term survival, however, the major obstacle of shortage of suitable donor organs remains. In the following chapter, recipient selection and management, donor organ procurement and preservation, and surgical techniques of heart transplantation are described in detail.
Neural Mechanisms of Anaesthetics
Authors: McKinstry-Wu Andrew , Kelz Max B.
Published: January 2019

For more than 170 years since their discovery, the mechanisms by which general anaesthetics act on the central nervous system (CNS) to produce their signature triad of reversible unconsciousness, amnesia, and immobility have remained incompletely understood. Recently, numerous studies have begun to illuminate mechanisms of anaesthetic hypnosis at molecular, neuronal, and neural-network levels. Despite these advances, an integrated understanding of anaesthetic hypnosis across organizational levels remains elusive. Nevertheless, multiple relevant anaesthetic molecular targets have been identified along with subcortical and cortical centres involved in entering and exiting the anaesthetic state. On the network scale, recent studies suggest cortical network properties that change at the moment of loss of consciousness are not merely indicative of that loss, but possibly the cause of it. Taken together, these actions on the CNS from receptor to network modulation offer a tantalizing if incomplete picture of how general anaesthetics act to produce reversible unconsciousness.
Introduction to Electroencephalography
Authors: Avidan Michael , Sleigh Jamie
Published: January 2019

This chapter presents an introduction to electroencephalography, a non-invasive electrophysiological monitoring method to record electrical activity of the brain. It discusses waveforms in the electroencephalogram (EEG), and EEG changes with general anaesthesia. It covers EEG neurobiology, effects of different drugs (e.g., opioids, NMDA blockers, GABAergic intravenous induction agents, hydrocarbon-based volatile anaesthetic drugs), EEG changes as a function of patients’ age, and the titration of anaesthesia. It also covers special concepts in anaesthetic monitoring, including power spectrum, spectral edge frequency, spectrogram, cross frequency coupling and coherence, proprietary pEEG indices, EEG measures of connectivity, and artefacts. Finally, it discusses future directions within the specialty.
Neuromuscular Junction
Authors: Stäuble Christiane G. , Lewald Heidrun , Blobner Manfred
Published: January 2019

This chapter outlines an introduction to the neuromuscular junction. It covers anatomy and physiology (including presynaptic physiology and pharmacology, postsynaptic physiology and pharmacology, and margin of safety of neurotransmission), paralytics, reversal agents, the mechanisms of action of muscle relaxants (and their structure-activity relationship, intrinsic activity at the neuromuscular junction, effects on acetylcholine receptors of the CNS/ANS, the carotid body, bronchial smooth muscle, and histamine release and anaphylaxis by relaxants), and the acetylcholinesterase enzyme. The chapter furthermore discusses pre-clinical pharmacology and pharmacological variables of neuromuscular block, pharmacokinetics (models and parameters, factors influencing pharmacokinetics of relaxants, and their elimination and metabolism), clinical pharmacology of succinylcholine and nondepolarizing neuromuscular blocking drugs, factors confounding the clinical pharmacology of relaxants, reversal agents (including the cholinesterase inhibitors Neostigmine and Pyridostigmine) as well as the selective relaxant binding agent sugammadex), and special considerations in neuroanaesthesia and neurocritical care.
Neurotoxicity of General Anaesthetics
Authors: Ellis Margaret K. Menzel , Brambrink Ansgar
Published: January 2019

This chapter covers the neurotoxicity of general anaesthetics. It discusses how a large body of preclinical evidence shows an association of anaesthetic exposure with neural cell injury and death in the developing brain. Several putative mechanisms have been demonstrated in vitro and in in vivo animal models. Furthermore, these exposures have been associated with impaired behavioural and cognitive development in young animals. Several retrospective human studies of neurocognitive and behavioural disorders following childhood exposure to anaesthesia suggest a similar association, and prospective studies in humans are currently ongoing. The implication of this information on anaesthetic practise remains to be seen.
Interventional Neuroradiology
Authors: Manning Nathan , Gelber Katherine M. , Crimmins Michael , Meyers Philip M. , Heyer Eric J.
Published: January 2019

Neuroradiology is a rapidly evolving field in the diagnosis and treatment of cerebrovascular diseases. This chapter reviews fundamental principles for providing care to patients undergoing interventional neuroradiology (INR) surgical procedures from the viewpoint of the patient, the neuro-interventionalist, the anaesthetist, and the neuro-intensivist. It provides a background of endovascular treatment of cerebral disorders and then focuses on the treatment of three disorders that are treated by endovascular therapy: cerebral aneurysms, carotid artery stenosis, and acute ischaemic stroke. It also covers intracranial pressure monitoring and treatment, motor deficit, management of blood pressure and ICP, and anaesthetic care for patients with acute ischaemic stroke.
Anaesthesia for Complex Spine Surgeries
Authors: Farag Ehab , Ebrahim Zeyd
Published: January 2019

This chapter discusses the pre-operative evaluation of the patient scheduled for complex spine surgery, and focuses on functional capacity, neurological assessment, and upper airway examination. In patients undergoing cervical spine surgery, awake fibreoptic intubation may be the safest technique for upper airway management, especially in patients with significant spinal cord compression or unstable cervical spine. Increased intra-ocular pressure during spine surgery in the prone position may compromise the ocular perfusion pressure. Maintaining proper ocular perfusion pressure is crucial to avoid postoperative vision loss or impairment. Avoiding muscle relaxants and high concentrations of inhalation anaesthetics are important for the anaesthetic management during intra-operative electrophysiological monitoring. Avoiding hypervolaemia is important to avoid endothelial glycocalyx damage.
Cerebrovascular Disease
Authors: Amlong Corey , Sanders Robert D.
Published: January 2019

Peri-operative stroke is a rare consequence of surgical intervention and anaesthesia that has profound effect on patient outcomes; incurring a cerebrovascular accident (CVA) in the setting of noncardiac, non-neurologic surgery is associated with an adjusted eightfold increase in mortality. Just as concerning as the high mortality is the degree of disability associated with a cerebrovascular event. Disability from stroke is broad in scope, ranging from mild deficits in cognition or mobility to complete dependence on others for activities of daily living. This chapter on cerebrovascular disease discusses peri-operative considerations (including timing of elective surgery, type of anaesthetic, blood pressure, anaemia, glycaemic control, and anticoagulation), and care of the patient with peri-operative CVA.
Shorter Oxford Textbook of Psychiatry
Authors: Harrison Paul , Cowen Philip , Burns Tom , Fazel Mina
Published: January 2019

This book provides an up-to-date, authoritative, and highly readable overview of psychiatry, suitable for all psychiatrists, as well as medical students, general practitioners, and other mental health professionals. Written by experienced clinicians, the new edition has been substantially rewritten and updated. The first three chapters cover the symptoms and signs of psychiatric disorders, psychiatric classification (including DSM-5), and how to conduct a psychiatric assessment. Chapters on ethics and the law (including the Mental Health Act), aetiology, and evidence-based approaches, set the scene for description of the major syndromes of adult psychiatry. In each chapter, description of the cardinal clinical features is accompanied by the latest evidence on epidemiology, aetiology, treatment, and outcome. Subsequent chapters cover child psychiatry, the psychiatry of old age, intellectual disability, forensic psychiatry, substance misuse, suicide, and self-harm, and psychiatry in medical settings. After a new chapter on global mental health, two chapters cover psychological and psychopharmacological treatments: their indications, efficacy, side effects, and mechanisms. The final chapter describes how psychiatric services are organized.
Aetiology
Authors: Harrison Paul , Cowen Philip , Burns Tom , Fazel Mina
Published: January 2019

‘Aetiology’ provides an account of current approaches to aetiological issues in psychiatry, both at the level of clinical syndromes and that of the individual patient. Uniquely in medicine, psychiatric aetiology requires an intuitive understanding of the patient in their personal and social context as well as knowledge derived from a wide range of relevant sciences. After discussion of the strengths and weaknesses of the main aetiological models, there follows an outline of the principal approaches of the key scientific disciplines relevant to the aetiology of psychiatric conditions, ranging from sociology and psychology to genetics and neuroscience. The chapter gives examples of important applications that have enriched knowledge of the aetiology of psychiatric conditions but highlights the fact that psychiatry is a clinical discipline where causation is inevitably complex, and that it is therefore necessary to use a broad approach to understanding the problems of individual patients.
Depression
Authors: Harrison Paul , Cowen Philip , Burns Tom , Fazel Mina
Published: January 2019

‘Depression’ provides an overview of the psychiatric approach to clinical depression. The chapter begins with an account of the clinical phenomenology of depression and how the various symptoms and signs are captured in modern classificatory and diagnostic schemes of mood disorder. Adequate aetiological formulations of depression require the use of many different scientific approaches, ranging from genetics and brain imaging to neuropsychology and sociology. The chapter covers relevant examples from the various fields and explains how an integrated conceptual scheme can provide a richer understanding of the origin of depressive conditions, as well as leading to improved treatment approaches. The efficacy of various forms of treatment for depression, ranging from psychotherapies and pharmacology to electroconvulsive therapy, is described. There follows advice on how effective evidence-based treatments are best integrated with good clinical management.
Child psychiatry
Authors: Harrison Paul , Cowen Philip , Burns Tom , Fazel Mina
Published: January 2019

‘Child psychiatry’ covers the developmental period and includes how to assess and treat emotional and behavioural difficulties from infancy to 18 years. This chapter outlines the epidemiology of the different psychiatric presentations during childhood, with reference to both ICD-10 and DSM-5 classification systems. Aetiology of child psychiatric disorders is covered in detail both as part of the general chapter information and as part of the section for each specific disorder within the chapter, including attention-deficit hyperactivity disorder, autism spectrum disorder, and anxiety and depressive disorders. The specific learning disorders are also covered in this chapter. How to assess children as well as their families and the broader social and school context are discussed, including the role of different psychological assessments. The emphasis of treatment is different for child populations, with greater utilization of psychological treatments, both for the individual child as well as their families and broader systems, including schools.
Global psychiatry
Authors: Harrison Paul , Cowen Philip , Burns Tom , Fazel Mina
Published: January 2019

‘Global psychiatry’ discusses the global mental health movement. Across the globe, and especially in low- and middle-income settings, there is a high prevalence of untreated psychiatric illness. In lower resourced settings there is often the need to address the added influence of poverty. The chapter discusses the question of how to scale up services and models, including using lay mental health workers and also integration of mental health care into primary health care settings to better meet the needs of those suffering from psychiatric illnesses across the globe. Four areas are discussed in more detail—the HIV/AIDS pandemic, perinatal mental illness, child and adolescent mental health, and humanitarian emergencies.
Health priorities in displacement
Authors: Fernandez Gustavo , Bouchet-Saulnier Françoise , Koscalova Alena , Jobanputra Kiran , Tijerino Ana Maria , Boulle Philippa , Mulloni Veronique , Ciglenecki Iza , Avril Nathalie , Aloudat Tammam , Rull Monica , Maury Pierre , Voiret Isabelle
Published: January 2019

This chapter provides updated and re-considered guidelines for the top ten priorities in providing care in situations of displacement. It outlines the two major causes of displacement—armed conflict and natural disaster—and the increasingly complex environments in which displacement is occurring, with increased urban crises, complex hostilities, and the lack of enforcement of humanitarian principles. This complexity has mandated a reconsideration of the previously established top priorities by the same Médecins Sans Frontières team who provided the original. This chapter provides a list and discussion of the updated top ten priorities in humanitarian health interventions, adapted based on years of operational experience and acknowledgement of the special circumstances of many of today’s humanitarian crises.
Anaemia
Authors: Salmon Margaret , Muldoon Lily , Ritzenberg Max
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management of the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Jaundice
Authors: Tubman Michelle
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management for the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Malnutrition
Authors: Chan Kevin , Turnbull Jennifer
Published: January 2019

This chapter outlines the reality in many humanitarian settings, where low resources and limitations in human resources, diagnostics, and infrastructure make the controlled diagnostic process more challenging, supporting a more symptomatic approach to diagnosis and management. This chapter outlines the key principles of syndromic case management, including essential components of clinical assessment, development of differential diagnoses, and flow charts for management for the most commonly encountered conditions and most important causative agents. The management principles contained in this chapter are adapted for humanitarian settings and provide opportunities for capacity building when highly trained local human resources may be scarce.
Global impact of antimicrobial resistance
Authors: Berry Catherine
Published: January 2019

This chapter describes the worrisome trend of resistance development in antibacterial agents with exponential increases in resistance to the most effective classes of antibiotics. Described by the World Health Organization as a major global health security threat, the annual deaths from drug-resistant infection are projected to increase from 700,000 to 10 million by 2050. This chapter outlines the impact of antimicrobial resistance in humanitarian settings and provides practical approaches which can be used by organizations and health providers.
Neurology
Authors: Berkowitz Aaron L.
Published: January 2019

With diagnostic tests such as neuroimaging, electroencephalography, electromyography, and cerebrospinal fluid analysis often unavailable, this chapter outlines how a logical approach to clinical diagnosis in neurology can significantly narrow the differential diagnosis between many of the leading causes of death and disability due to neurologic disease. With the pronounced sparsity of neurologists in low-income countries, patients in humanitarian settings with neurological conditions most often present to general providers or mental health practitioners. With this in mind, this chapter provides both a syndromic approach to neurological diagnosis for common clinical complaints, such as headache, vertigo, and weakness as well as systematic guidance for management of the most common neurological conditions, including stroke, epilepsy, and movement disorders.
Obstetrics
Authors: Black Benjamin Oren , O’Toole Susan Ann
Published: January 2019

This chapter provides the fundamental principles of care in obstetrics, taking into account important cultural considerations in humanitarian settings. The chapter lays out the general strategies to reduce maternal mortality and morbidity, and provides specific guidance for antenatal care, the medical management of the stages of labour, and postnatal care.
Ophthalmology
Authors: Mapham William
Published: January 2019

This chapter covers the essential background and clinical management of ophthalmology complaints as seen in humanitarian settings. It provides information on the importance of recognizing and treating ophthalmological conditions in the field due to their prevalence and the availability of treatment options to prevent lasting disability of blindness. It provides an approach to eye care for the non-specialist and guidance for the diagnosis and treatment of common eye conditions.
Major trauma
Authors: Nott David
Published: January 2019

This chapter provides essential management guidance for medical providers in low-resource environments when surgical services are not readily available. ‘Major trauma’ reviews management of a trauma patient, from initial assessment and medical management, to basic, yet lifesaving, surgical procedures.
Medical management of the surgical abdomen
Authors: Beveridge Massey , Baldan Marco
Published: January 2019

This chapter provides essential management guidance for medical providers in low-resource environments when surgical services are not readily available. ‘Medical management of the surgical abdomen’ provides practical advice for the non-surgeon on medical management options for an acute abdomen when definitive surgical care is not available.
Burns
Authors: Beveridge Massey
Published: January 2019

This chapter provides essential management guidance for burns for medical providers in low-resource environments when surgical services are not readily available. The chapter provides the clinical management principles for burns and guidance for averting subsequent disability.
Blood transfusion
Authors: Kosack Cara , Guegen Monique
Published: January 2019

This chapter outlines how clinical management decisions in humanitarian emergency situations can be greatly enhanced by a well-functioning blood transfusion service. The chapter covers blood transfusion, and details principles of establishing services in low-resource environments. It provides information on transfusion indications and options, as well as practical guidance on donor selection and screening, blood collection, and the transfusion process, including potential transfusion reactions.
Ultrasound
Authors: Lyon Matthew , Kuhn W. Ted
Published: January 2019

This chapter outlines how clinical management decisions in humanitarian emergency situations can be greatly enhanced by the utilization of point-of-care ultrasound. The chapter recognizes the advancing technology of point-of care ultrasound and its use in humanitarian missions, and provides guidance on the essential components of clinical ultrasound (image acquisition, image interpretation, and clinical integration).
Second-Messenger Modifiers (“Mood Stabilizers”)
Authors: Ghaemi S. Nassir
Published: January 2019

The drug class of second-messenger modifiers includes agents called “mood stabilizers.” It consists of lithium and some anticonvulsants: valproate, carbamazepine, and lamotrigine. The standard mood stabilizers each have strengths and weaknesses. Lithium is still the gold standard, most proven agent; no other drug has been clearly shown to be more effective than lithium. The clinical pharmacology of specific agents within each class, including their efficacy and side effects, is explored. Specific phenomena that are surveyed include chronic renal insufficiency, liver side effects, polycystic ovarian syndrome, teratogenicity, Stevens-Johnson syndrome, and drug interactions. Benefits for lithium include suicide prevention and possibly dementia prevention.
GABAergic Agonists (“Anxiolytics”)
Authors: Ghaemi S. Nassir
Published: January 2019

The drug class of GABAergic agonists includes the agents that are benzodiazepines and most hypnotic agents. Gamma amino-butyric acid (GABA) receptors are distributed throughout the neocortex, and have a general inhibitory effect on brain activity. All benzodiazepines have the same basic mechanism of activity. Their differences involved their pharmacokinetics; namely, their half-life and speed of onset. They also differ in potency of affect. Benzodiazepines are the classic group of medications that have primarily anti-anxiety effects. Mechanistically, they are GABAergic agonists. In this effect, they stimulate activity at the GABA-a receptor. The clinical pharmacology of specific agents within each class, including efficacy and side effects, is explored. Specific phenomena surveyed include withdrawal, tolerance, and addiction. The limited efficacy of hypnotic agents is scrutinized.
Addictions
Authors: Ghaemi S. Nassir
Published: January 2019

The diagnosis and treatment of addictions is examined in this chapter. Addictions are seen as either secondary (self-medication) or primary, with the former being more common in psychiatric settings than the latter. Addictions are seen as lower in the hierarchy of diagnosis than mood or psychotic states, and caused by the latter. The common report of purported comorbidity is seen as an overestimation, with substance abuse often being part of other conditions. Symptomatic treatment is seen to be questionable in benefit over risk for currently available agents. Alcoholics Anonymous 12-Step–style programs can be effective for primary addictions, but less so for secondary addictions.
Post-traumatic Stress
Authors: Ghaemi S. Nassir
Published: January 2019

The concept of trauma has been a central feature of psychiatry and psychology ever since a century ago, when a Viennese neurologist concluded that many of his young female patients with hysteria had experienced childhood sexual abuse. The concept of trauma soon was extended to adults, mainly soldiers. “Hysteria,” “shell shock,” “war neurosis”—it all became mutated in DSM-III’s radical revision of 1980 into “post-traumatic stress disorder” (PTSD). In this chapter, the diagnosis and treatment of post-traumatic stress are explored. DSM-based diagnoses are viewed as broad, and overly oriented toward comorbidity. Instead, PTSD-like symptoms occur as part of the typical stressors that trigger mood or psychotic states. True PTSD can occur with severe trauma, as in childhood sexual abuse or war trauma. Symptomatic treatment is seen to be questionable in benefit over risk, both for antipsychotics and for SRIs.
Historical Insights in Psychopharmacology
Authors: Ghaemi S. Nassir
Published: January 2019

The writings of two classic thinkers in psychiatry in the 19th and 20th centuries, Emil Kraepelin and Aubrey Lewis, are provided and examined for insights they provided into continuing problems in the diagnostic and treatment of psychiatric conditions today. Kraepelin was the famed great late 19th-century psychiatric leader from Germany who identified the basic distinction between schizophrenia (dementia praecox) and manic-depressive illness. He laid the foundations of much of psychiatric diagnosis that remains relevant today, and he was a committed defender of the biological approach to psychiatry, although he was conservative with the use of drugs, which were ineffective in his day. Lewis (1900–1975) was the most prominent figure in British psychiatry through most of the 20th century. He was the leader of the Institute of Psychiatry at the Maudsley Hospital for much of the middle of the 20th century. That institution in London was the most influential educational center for psychiatry in the nation. Through his leadership there, Lewis was extremely influential. He tended to be skeptical about the use of psychotropic medications, and emphasized social aspects of psychiatric illness.
Ten Fallacies and Ten Truths of Psychopharmacology—Explained
Authors: Ghaemi S. Nassir
Published: January 2019

Ten fallacies and ten truths in the practice of psychopharmacology are provided and explained. The fallacies are: More is better; What gets you well keeps you well; Treat to remission; Polypharmacy is good; Make one change at a time; 4–8 weeks is a sufficient trial of a drug; Dose low, go slow; Always taper a drug; Treat the most severe symptom; and Always incorporate the patient’s preference. The ten truths are: Your treatment is as good as your diagnosis; Treat diseases, not symptoms; All drugs are guilty until proven innocent; All drugs are toxic, dosing and indication make them therapeutic; Always have an exit strategy; Most current psychotropic drugs have some dramatic benefits but are not disease-modifying—the clearest exception is lithium; Older drugs are more effective than newer drugs; Newer drugs are more tolerable older drugs; Treatment “resistance” usually reflects either misdiagnosis or an invalid diagnosis; and Course, not symptoms, reveals the diagnosis These examples highlight common issues or debates in clinical psychopharmacology, and provide a perspective that promotes the Hippocratic, disease-oriented, clinically based approach of this text.
Gemini IFU, VLA, and HST observations of the OH Megamaser Galaxy IRAS17526 + 3253★
Authors: Sales Dinalva A , Robinson A , Riffel R A , Storchi-Bergmann T , Gallimore J F , Kharb P , Baum S , O’Dea C , Hekatelyne C , Ferrari F
Published: January 2019

We present a multiwavelength study of the OH megamaser galaxy IRAS17526 + 3253, based on new Gemini multi-object spectrograph integral field unit (GMOS/IFU) observations, Hubble Space Telescope F814W, and H α + [N ii] images, and archival 2MASS and 1.49 GHz VLA data. The Hubble Space Telescope(HST) images clearly reveal a mid-to-advanced stage major merger whose northwestern and southeastern nuclei have a projected separation of ∼8.5 kpc. Our HST/H α + [N ii] image shows regions of ongoing star formation across the envelope on ∼10 kpc scales, which are aligned with radio features, supporting the interpretation that the radio emission originates from star-forming regions. The measured H α luminosities imply that the unobscured star formation rate (SFR) is ∼10–30 M⊙ yr−1. The GMOS/IFU data reveal two structures in northwestern separated by 850 pc and by a discontinuity in the velocity field of ∼ 200 km s−1. We associate the blueshifted and redshifted components with, respectively, the distorted disc of northwestern and tidal debris, possibly a tail originating in southeastern. Star formation is the main ionization source in both components, which have SFRs of ∼2.6–7.9 M⊙ yr−1 and ∼1.5–4.5 M⊙ yr−1, respectively. Fainter line emission bordering these main components is consistent with shock ionization at a velocity ∼200 km s−1 and may be the result of an interaction between the tidal tail and the northwestern galaxy’s disc. IRAS17526 + 3253 is one of only a few systems known to host both luminous OH and H2O masers. The velocities of the OH and H2O maser lines suggest that they are associated with the northwestern and southeastern galaxies, respectively (Martin et al.; Wagner).
A short and sudden increase of the magnetic field strength and the accompanying spectral variability in the O9.7 V star HD 54879
Authors: Hubrig S , Küker M , Järvinen S P , Kholtygin A F , Schöller M , Ryspaeva E B , Sokoloff D D
Published: January 2019

Only 11 O-type stars have been confirmed to possess large-scale organized magnetic fields. The presence of a −600 G longitudinal magnetic field in the O9.7 V star HD 54879 with a lower limit of the dipole strength of ∼2 kG was discovered a few years ago in the framework of the ESO large program ‘B-fields in OB stars’. Our FORS 2 spectropolarimetric observations from 2017 October 4 to 2018 February 21 reveal the presence of short- and long-term spectral variability and a gradual magnetic field decrease from about −300 G down to about −90 G. Different scenarios are discussed in an attempt to interpret our observations. Our FORS 2 radial velocity measurements indicate that HD 54879 is a member of a long-period binary.
Clinical impact of subgrouping ANCA-associated vasculitis according to antibody specificity beyond the clinicopathological classification
Authors: Deshayes Samuel , Martin Silva Nicolas , Khoy Kathy , Yameogo Seydou , Mariotte Delphine , Lobbedez Thierry , Aouba Achille
Published: January 2019

Objectives

In ANCA-associated vasculitis (AAV), classifications have emerged to individualize homogeneous clinical and outcomes patterns, including the recently defined anti-MPO granulomatosis with polyangiitis (GPA) subgroup. This study aimed to retrospectively evaluate the impacts of re-classification based on clinicopathological criteria and/or ANCA specificity.

Methods

A retrospective monocentric study conducted at Caen University Hospital led to the identification of PR3 or MPO-ANCA AAV patients from January 2000 or September 2011, respectively, to June 2016. Eosinophilic GPA patients were excluded. AAVs were thereby also classified either as GPA or microscopic polyangiitis (MPA) according to the European Medicines Agency vasculitis algorithm.

Results

A total of 150 AAV patients were included (94 GPA, 56 MPA; 87 anti-PR3 and 63 anti-MPO patients). GPA patients exhibited a worse relapse-free survival but a better renal survival (P < 0.001 and P = 0.021, respectively) than MPA patients. Overall, relapse-free and renal survival rates were similar between anti-PR3 and anti-MPO patients (P = 0.35, 0.17 and 0.15, respectively). Similarly, the prognosis was identical between anti-MPO MPA patients and anti-PR3 MPA patients (P = 0.33, 0.19 and 0.65, respectively), and between anti-MPO GPA patients and anti-PR3 GPA patients (P = 0.06, 0.99 and 0.64, respectively). Moreover, anti-PR3 GPA and anti-MPO GPA patients exhibited no differences in clinical manifestations or BVAS score.

Conclusion

Clinicopathological classification appeared to be the strongest criterion for distinguishing among homogeneous prognoses of AAV. Individualizing the anti-MPO GPA subgroup does not appear to bring additional value to clinical practice, but multicentre studies are required to confirm this trend.
Utility of a Multilevel Modeling Approach to Investigate Differences in Isolation Frequency of Fusarium culmorum in Agricultural Soil Across the Inland Pacific Northwest
Authors: Robinson Andrew , Ryu Dojin , Lee Hyun Jung
Published: January 2019

The plant pathogen Fusarium culmorum represents an inoculum source capable of contaminating grains with deoxynivalenol in the Inland Northwest region of the United States. A multilevel modeling approach utilizing varying intercepts for different sampling quadrats, fields, and iterations in the dataset was performed to characterize differences in isolation frequency of F. culmorum collected during a 2-year soil survey. Differences in the isolation frequency of F. culmorum varied the most by sampled field followed by quadrat and iteration, respectively. Higher relative elevation within the sampling region of a field limited the amount of F. culmorum recovered. The effect of annual climate variables was investigated using combinations of single-variable and multivariable model equations with linear and polynomial terms. The same data analysis approach was applied to an external dataset of F. culmorum isolation frequencies in grains from fields across eastern Australia. These results represent a case study for investigating variability within datasets containing overdispersed fungal counts and incorporating climate summaries as predictor variables.
Quantitative Analysis of Heel Skin Microcirculation Using Laser Doppler Flowmetry and Tissue Spectrophotometry
Authors: Held Manuel , Bender Dominik , Krauß Sabrina , Wenger Andrea , Daigeler Adrien , Rothenberger Jens
Published: January 2019

OBJECTIVE:

To examine perfusion changes in the heel skin of individuals with and without diabetes mellitus to understand how skin is pathologically affected by diabetes mellitus.

METHODS:

This case-control study was conducted at an academic hospital in Tuebingen, Germany. A total of 30 subjects were enrolled in the study: 15 with known type 2 diabetes mellitus and 15 without. Each subject was asked to lie in a supine position on a hard lateral transfer mat for 10 minutes.

MAIN OUTCOME MEASURES:

Heel perfusion was quantitatively assessed directly after relief of pressure and after 3 and 6 minutes after relief of pressure using laser Doppler flowmetry and tissue spectrophotometry.

MAIN RESULTS:

Directly after relief of pressure, blood flow increased in the superficial skin layers (2 mm below the surface of the skin) in both groups. However, in deep skin layers (8 mm below the surface of the skin), blood flow increased in patients with diabetes mellitus and decreased in healthy patients. Oxygen saturation (SO2) was higher in healthy subjects directly after pressure relief.

CONCLUSIONS:

The increase in blood flow in superficial skin layers indicates reactive hyperemia after exposure in both groups. The prolonged hyperemia in deep skin layers in patients with diabetes indicates increased tissue vulnerability. Despite the increase in blood flow in deep skin layers, the SO2 and thus supply of tissue in patients with diabetes were reduced.
Diagnosis and Management of Cutaneous Psoriasis: A Review
Authors: Brandon Alisa , Mufti Asfandyar , Gary Sibbald R.
Published: January 2019

Psoriasis is a chronic inflammatory disease that is characterized by plaque, inverse, guttate, pustular, and erythrodermic variants. This review focuses on the epidemiology, diagnosis, and treatment of cutaneous psoriasis. Other related topics discussed include peristomal psoriasis, the Koebner phenomenon, and the relationship between biologic therapy and wound complications.

GENERAL PURPOSE:

To provide information about the diagnosis and management of cutaneous psoriasis.

TARGET AUDIENCE:

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES:

After completing this continuing education activity, the provider should be better able to:
Hospital-Based Addiction Medicine Healthcare Providers: High Demand, Short Supply
Authors: Braithwaite Vivian , Nolan Seonaid
Published: January 2019

Substance use disorders account for a significant burden of disease and place an enormous strain on the health care system in the United States and beyond. Despite death tolls climbing, a myriad of evidence-based medications exist to effectively treat many substance use disorders including nicotine, alcohol, and opioid use disorders. To date, hospitals have largely been overlooked as a setting ripe for the delivery of specialized addiction care. This occurs despite a high lifetime prevalence of a substance use disorder (50%) occurring among hospitalized individuals. A potential barrier to this is the lack of addiction medicine training that currently exists in undergraduate and graduate medical education. Consequently, a paucity of existing physicians report feeling competent to adequately screen for, diagnose or treat substance use disorders. Given the prevalence, cost and potentially lethal consequences of substance use disorders, a critical need exists to improve its identification and evidence-based management in hospital settings.
Role of the Hospital in the 21st Century Opioid Overdose Epidemic: The Addiction Medicine Consult Service
Authors: Priest Kelsey C. , McCarty Dennis
Published: January 2019

Objective:

The aim of the study was to explore and describe the structure and design elements of addiction medicine consult (AMC) services within selected US hospitals.

Methods:

As part of a larger mixed methods study, 10 qualitative semi-structured telephone interviews were completed with board-certified addiction medicine physicians affiliated with the Addiction Medicine Foundation's Addiction Medicine Fellowship Programs at 9 US hospitals. Interviews were transcribed, coded, and analyzed using a directed content analysis.

Results:

Interviews completed with established AMC services in 9 hospitals probed AMC structure and design commonalities and differences across 4 domains: (1) availability and coverage, (2) team composition, (3) scope and responsibility, and (4) financing. Only 1 service provided weekend consults and most services did not provide coverage in the emergency department. Interprofessional teams were common with a variety of discipline combinations. AMC service scope and responsibility, generally, included 3 types of activities: (1) education and culture change, (2) the delivery of psychosocial and medical services, and (3) hospital guidance document development. Finally, most AMC services existed within a fragile financial environment with idiosyncratic arrangements.

Conclusions:

As opioid use disorder (OUD)-related hospitalizations increase stakeholders look to innovative care delivery mechanisms to improve care and outcomes for persons with OUD. The implementation of an AMC service may be an organizational intervention for achieving these aims. Understanding the shared and different approaches to AMC service structure and design is an important first step for delivery systems interested in implementing or expanding these services.
Predictors for 30-Day and 90-Day Hospital Readmission Among Patients With Opioid Use Disorder
Authors: Moreno Jessica L. , Wakeman Sarah E. , Duprey Matthew S. , Roberts Russell J. , Jacobson Jared S. , Devlin John W.
Published: January 2019

Objectives:

To identify the incidence, characteristics, and predictors for 30 and 90-day readmission among acutely hospitalized patients with opioid use disorder (OUD).

Methods:

This retrospective, cohort study evaluated consecutive adults with OUD admitted to an academic medical center over a 5-year period (10/1/11 to 9/30/16). Multivariable logistic regression was used to determine independent predictors for 30 and 90-day readmissions based on pertinent admission, hospital, and discharge variables collected via chart review and found to be different (with a P < 0.10) on univariate analysis.

Results:

Among the 470 adults (mean age 43.1 ± 12.8 years, past heroin use 77.9%; admission opioid agonist therapy use [buprenorphine 22.6%; methadone 27.0%]; medical [vs surgical] admission 75.3%, floor [vs ICU] admission 93.0%, in-hospital mortality 0.9%), 85 (18.2%) and 151 (32.1%) were readmitted within 30 and 90 days, respectively. Among the 90-day readmitted patients, median time to first readmission was 26 days. Buprenorphine use (vs no use) at index hospital admission was independently associated with reduced 30-day (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.24–0.93) and 90-day (OR 0.57, 95% CI 0.34–0.96) readmission; prior heroin (vs prescription opioid) use was associated with reduced 90-day readmission (OR 0.59, 95% CI 0.37–0.94) and length of hospital stay was associated with both greater 30-day (OR 1.02, 95% CI 1.01–1.05) and 90-day (OR 1.04, 95% CI 1.01–1.06) readmission rates.

Conclusions:

Among patients with OUD taking buprenorphine at the time of hospital admission, 30-day and 90-day hospital readmission was reduced by 53% and 43%, respectively.
A Dosimetry Study of Portable X-ray Fluorescence in Vivo Metal Measurements
Authors: Specht Aaron J. , Zhang Xinxin , Goodman Benjamin D. , Maher Ed , Weisskopf Marc G. , Nie Linda H.
Published: January 2019

Portable x-ray fluorescence devices have grown in popularity for possible metal exposure assessment using in vivo measurements of bone and toenail. These measurements are accompanied by a small radiation dose, which is typically assessed by radiation safety committees to be minimal. However, an understanding of precise dose under different instrument conditions is still needed. This study set out to do a thorough investigation of the exact dose measurements using optically stimulated dosimeters, thermoluminescent dosimeters, and simulation with a Monte Carlo N-Particle transport code to assess the skin and total-body effective dose typical of portable x-ray fluorescence devices. We showed normal linear relationships between measurement time, x-ray tube current, and radiation dose with the device, and we showed a second order polynomial relationship with increasing voltage and radiation dose. Dose was quantified using thermoluminescent dosimeters, optically stimulated dosimeters, and simulations, which gave similar dose estimations. Skin dose for a standard 50-kV, 40-μA measurement for bone and toenail in vivo was 48.5 and 28.7 mSv, respectively, according to simulation results. Total-body effective dose was shown as 3.4 and 2.0 μSv for in vivo bone and toenail measurements, respectively, for adults using the portable x-ray fluorescence device.