bluuebunny/crossref_metadata_2025 huggingface dataset:
Mental health in Brazilian homeless
Authors: de Miranda e Silva Etienne , Martins da Silva Anderson Sousa , Castaldelli-Maia João Mauricio
Published: January 2022

The studies presented in this chapter reveal the general scenario of mental health and substance use disorders in homeless people in Brazil. As a general rule, both in Brazil and worldwide, mental health and substance use disorders are more prevalent in this subpopulation compared to the general population. The majority of the Brazilian studies are concentrated in the South and Southeast regions. No study was found in the North region. Regarding gender, there was a higher prevalence of men in the studies. Among the mental health disorders, psychotic and affective disorders were the most prevalent in this subpopulation. Regarding substance use, cannabis and alcohol were those most used in the adult population, followed by cocaine (crack). Brazilian homeless individuals under 18 years old report a high prevalence of inhalant use. Disorder due to the use of inhalants in homeless people is more associated with children and adolescents, while crack is more associated with the adult population. There are few studies on tobacco smoking and injectable drugs, although the few available show significant rates. The authors believe that approaching mental health and substance use disorders in this subpopulation could contribute to a more organized and centred life, helping individuals in making use of all the possible resources available (e.g. housing, healthcare, social networks, financial incentives). Brazilian psychosocial care centres (Centros de Atenção Psicossocial (CAPS)) have been playing an essential role in this outcome. CAPS are freely available for all the individuals living in Brazil, legally or not. The studies conducted in Brazilian underline the need for more effective early interventions aimed at preventing long-term deleterious, almost unchangeable outcomes in this vulnerable population.
Indian perspectives on homelessness and mental health
Authors: Tripathi Adarsh , Das Anamika , Kar Sujita Kumar
Published: January 2022

Home is a place of belongingness and homeless mentally ill people form a highly vulnerable group. The vicious cycle of poverty, ill health, and homelessness in India makes the context even more pertinent. Various definitions exist for homelessness in India but none can describe the population fully. Epidemiological studies from India give some estimates of the prevalence of psychiatric disorders in this group. Psychotic disorder is the most common diagnosis followed by mood disorders, substance use disorders, and intellectual disability. Administrative factors such as lack of rehabilitative services and scarcity of mental health resources; illness factors such as untreated mental disorder, impaired ability to self-care, and high comorbidities; and social factors such as high stigma, poverty, low literacy, rapid urbanization, lack of employment, and other housing barriers are the major reasons in India contributing to homelessness in the mentally ill population. There remains a duality in this population that homelessness and mental illness act as risk factors for each other. Women form a higher risk group with regard to being homeless and mentally ill. The major support in India for this population comes from non-governmental organizations (NGOs) and NGOs such as the Richmond Fellowship Society, Shraddha Foundation, The Banyan, Aashray Adhikar Abhiyan, Ashadeep, and Hope Kolkata Foundation remain as pioneers in psychosocial rehabilitation. India also has programmes and policies to support this population. The Mental Healthcare Act (2017) lays down various provisions for the homeless mentally ill. There is a need for government–NGO collaboration and more facilities for psychosocial rehabilitation to help this vulnerable population in need.
Tobacco smoking and homelessness
Authors: Davanso Lucas C. , Castaldelli-Maia João Mauricio
Published: January 2022

The prevalence of smoking among the homeless is high. It is three or four times higher than in the general population. A combination of factors makes smoking among the population experiencing homelessness particularly dangerous with a higher possibility of health complications. Habits like tobacco scavenging and the high amount of money they have to spend, when considering the cost of cigarettes in a context of an extremely low income, to maintain the addiction and avoid the craving symptoms resulting from nicotine abstinence places this particular group in a vulnerable situation. This review chapter seeks a better understanding of what is known about tobacco use in its various forms within the homeless population. It summarizes the medical literature surrounding the topic and tries to understand if there are prevention or treatment strategies to approach smoking in this population.
Care of the patient with inherited cardiac conditions and congenital heart diseases
Authors: Ingles Jodie , Bueser Tootie , McKeown Pascal , Moons Philip , Fitzsimons Donna
Published: January 2022

The inherited basis of certain cardiac conditions is a rapidly expanding area of knowledge development and future innovations in care pathways are anticipated. Understanding the genetic basis of disease can have significant benefit. Inherited cardiac conditions encompasses cardiomyopathies, arrhythmic syndromes, aortopathies, and others and are defined by their clinical and genetic heterogeneity. Sudden cardiac death is a tragic outcome of some inherited cardiac conditions and therefore effective screening and primary prevention is vitally important. There is also a risk of poor psychological outcomes and changes to family and social function. Congenital heart disease is a collection of gross structural abnormalities of the heart or intrathoracic great vessels that have actual or potential functional significance. Congenital heart disease comprises a wide spectrum of simple, moderate, and complex severity lesions. The population of patients with congenital heart disease is growing, which results in an increased demand for nursing care. While treatment options have improved in many cases, the impact of inherited cardiac conditions and congenital heart diseases is multifaceted and lifelong. Caring for patients with these conditions requires a holistic and ongoing assessment, a distinct patient- and family-centred approach, and shared decision-making from all professionals in the interdisciplinary team.
Addressing the current challenges for the delivery of holistic care
Authors: Thompson David R. , Kyriakou Martha , Uchmanowicz Izabella , Keenan Jan , Khatib Rani , Hill Loreena , Neubeck Lis , Lambrinou Ekaterini , Barrowcliff Abigail
Published: January 2022

Contemporary challenges for holistic care include frailty and ageing, multimorbidity, polypharmacy, caregiver involvement, palliative and supportive care, cultural and socioeconomic issues, and gender inequalities. Frailty is a growing health problem among older people, especially women, and linked with an increased risk in mortality, disability, and cognitive decline. Patients with cardiovascular disease (CVD) often present with other comorbidities such as diabetes, obesity, cancer, depression, arthritis, frailty, and cognitive impairment, which require a tailored ‘person-centred’ holistic approach using skilled clinical judgement and good communication and should draw upon a range of resources, including informal carers, friends, and family, who often provide considerable support to people with multimorbidity. Polypharmacy, the concurrent use of multiple medications by a person, is a growing issue, especially among older people with multimorbidity. Problematic polypharmacy occurs where the benefits of one or more of these medicines are not realized, patients experience inappropriate or avoidable adverse drug reactions, or patients are non-adherent. Regular medicines review, evaluation of adherence, and appropriate deprescribing are essential. Many patients with advanced CVD and serious symptoms require palliative care which should be integrated with usual cardiovascular care from diagnosis. Cultural and socioeconomic issues are increasingly being recognized as important determinants of the cause and outcome of CVD and should be considered in any intervention, such as health behaviour change, when holistically assessing a patient with CVD. Females with CVD should be provided with equal access to care, a prompt diagnosis, and treatments based on the guidelines and recommendations at the same rate and intensity as their male counterparts.
Lipid Disorders
Authors: Lüscher Thomas F. , Mach François
Published: January 2022

Lipids, in particular, LDL cholesterol, lipoprotein(a), and triglycerides, have a very close and steep relationship to major cardiovascular events, such as myocardial infarction, stroke, and death. Elevated lipid levels are due to genetics and/or nutritional factors. Familial hypocholesterolaemia is due to LDL-receptor or PCSK9 mutations which lead to massively elevated LDL-cholesterol and in turn premature myocardial infarction and death. Lipids can be lowered with dietary measures and medication, such as statins, Niemann-Pick C1-like protein 1 inhibitors (Ezetimibe), PCSK9 inhibitors, and, to a lesser degree and primarily triglycerides, by omega 3 fatty acids. Lipid-lowering is recommended in individuals at high risk and patients after major cardiovascular events. Target levels of LDL-cholesterol to be achieved by lipid lowering drugs depend on the individual risk of the patient and vary from <1.0 mmol/l up to 3.0 mmol/l.
Smoking and Cessation
Authors: Sudano Isabella , Lüscher Thomas F.
Published: January 2022

Tobacco use is not only associated with a high incidence of cancer and vascular disease, such as myocardial infarction, peripheral arterial disease, stroke, and dementia, and impotence among others, but also may cause respiratory diseases such as chronic obstructive pulmonary disease, infections, osteoporosis, gum disease, impaired taste, smell, and sight. Thus, smoking cessation is highly recommended by all guidelines and primarily rests on advice given to patients, (1) ASK; (2) ADVISE; (3) ASSESS; (4) ASSIST, and (5) ARRANGE. In addition, there are pharmacological agents that help in smoking cessation, such as nicotine replacement therapy, partial nicotine receptor agonists, and central acting compounds inhibiting dopamine and adrenaline re-uptake.
Angina Pectoris
Authors: Guttmann Oliver P. , Gämperli Oliver , Baumbach Andreas
Published: January 2022

Angina pectoris is characterized by retrosternal thoracic pain, typically radiating to the left arm and triggered by physical or emotional stress or cold. It is classified according to the Canadian Cardiovascular Society into class I, II, III, or IV depending on symptom severity. Diagnosis is made clinically, with an exercise tolerance test reproducing symptoms, as well as non-invasive functional imaging, coronary CT angiography, or coronary angiography. Treatment options are anti-anginal drugs (e.g. nitrates, calcium antagonists, beta blockers, nicorandil), but angina in the context of coronary artery disease of class II or IV or persistent symptoms in spite of anti-anginal drugs is managed with percutaneous coronary intervention (PCI) and stenting or bypass surgery, respectively. Indeed, in stable anginas, anti-anginal drugs are the first choice, and if not successful, or in the presence of large ischaemic burden, PCI or bypass surgery is indicated. PCI improves symptoms of angina pectoris, but does not improve outcomes in stable coronary artery disease. Patients with left main coronary artery disease should be revascularized by either PCI or bypass surgery.
Carotid Artery Disease
Authors: Roffi Marco , Binder Ronald
Published: January 2022

The vast majority of carotid artery lesions are of atherosclerotic origin. Other conditions such post-radiation vasculopathy, spontaneous or traumatic carotid artery dissection, Takayashu disease, fibromuscular dysplasia or Ehlers Danlos syndrome may affect the carotid artery but account for the minority of cases.
Atherosclerosis of the extracranial carotid artery is common and is typically located at the origin of the internal carotid artery. It is estimated that 10-20% of ischemic strokes are related to carotid artery disease. The main mechanism of stroke related to carotid disease is embolic; rarely, it can be hymodynamic in case of critical carotid stenosis or occlusion in the presence of insufficient collateral circulation.
Peripheral Arterial Disease
Authors: Cheshire Nick , Amann-Vesti Beatrice
Published: January 2022

Peripheral arterial disease is defined as an alteration in the function or structure of any of the non-coronary arterial beds and therefore involves (1) lower extremity arterial disease (LEAD), (2) aortic disease, (3) vascular disease of the intestinal arteries, (4) extracranial cerebrovascular disease, and (5) diseases of the circulation of the upper limbs. The most common underlying causes are atherosclerosis, fibromuscular dysplasia, dissection, or spasm, e.g. Raynaud’s disease. Depending on the vascular bed involved, peripheral arterial disease may cause claudication of the limbs, visceral pain, and transient ischaemic attacks or stroke, among others. Diagnosis involves clinical examination, auscultation, determination of blood pressure at the ankle and palm, as well as duplex sonography and eventually angiography. The treatment of choice is, in most cases, peripheral transluminal angioplasty with balloons and/or stents and in some patients, bypass surgery. For secondary prevention, cardiovascular factor management and antiplatelet therapy as recommended.
Indications for Pacemakers
Authors: Haldar Shouvik
Published: January 2022

Heart rates outside the normal range are referred to as either bradycardia (i.e. <60 bpm) or tachycardia (i.e. >100 bpm). Bradycardia can cause symptoms such as dizziness and syncope, in general at much lower heart rates than <60 bpm. In patients with bradycardia and symptoms, pacemakers may be considered. Severe bradycardia is usually caused by intrinsic problems in the electrical conduction system, i.e. the sinoatrial node, atrioventricular junction, or His-Purkinje system. Pacemakers are comprised of a pulse generator and one or more leads that connect the generator to the heart, i.e. the atrium and/or ventricle. Therefore, pacing can be achieved with single chamber and dual chamber pacing. Pacemakers are characterized by the chamber where they pace, the chamber where they sense and the response to sensing and rate adaptive features.
Indications for Implantable Cardioverter Defibrillators
Authors: John Camm A.
Published: January 2022

The implantable cardioverter defibrillator (ICD) can recognize potentially lethal ventricular arrhythmias such as ventricular tachycardias (VT) and ventricular fibrillation (VF). Furthermore, such devices can terminate arrhythmias such as VT by overdrive pacing (i.e. anti-tachycardia pacing or ATP) or by applying an electric shock. ICDs may be used in primary prevention, i.e. implantation due to a high or very high risk of sudden death without a previous event or in secondary prevention, i.e. after an episode of a life-threatening arrhythmia, syncope, or survived sudden death (if a reversible cause can be excluded). More recently for selected patients subcutaneous defibrillators have become available that can only defibrillate, but have no ATP capacity. These devices are particularly useful for young patients with cardiomyopathies.
Chronic Heart Failure
Authors: Cleland John G.F. , Lüscher Thomas F.
Published: January 2022

One in five people will develop heart failure. It mainly affects older people and is usually due to the cumulative effects of many common cardiovascular problems, such as hypertension, ischaemic heart disease, atrial fibrillation, and valve disease. Renal retention of water leads to congestion that causes symptoms (e.g. breathlessness) and signs (e.g. peripheral oedema) that can be controlled to a variable extent with diuretics. The prognosis is poor unless the underlying cause of heart failure can be corrected, or congestion can be controlled. For some causes of heart failure, effective treatments exist. Diseased heart valves may be repaired or replaced surgically or percutaneously. A combination of RAAS inhibitors, beta blockers, CRT, ICD, ARNI (angiotensin receptor neprilysin inhibitor), and SGLT2 inhibitors reduce the mortality rate of heart failure with an LVEF <40% (HFrEF) by greater than 60%. However, for other common types of heart failure (e.g. those with an LVEF >50%) effective treatments are mainly lacking.
Arrhythmogenic Right Ventricular Cardiomyopathy
Authors: Saguner Ardan M. , Calkins Hugh
Published: January 2022

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is commonly an autosomal-dominant inherited cardiomyopathy characterized by fibrofatty infiltration of the right ventricle and sometimes, also, the left ventricular myocardium. The clinical presentation involves palpitations, syncope, chest pain, heart failure, and sudden cardiac death. The ECG is characterized by negative T-waves predominantly involving V1-V3 as well as less commonly epsilon waves in these leads. The diagnosis is confirmed by cardiac imaging using cardiac magnetic resonance and/or echocardiography. It is recommended that ARVC patients should not perform competitive sports. An indication for an ICD should be considered in patients with a high risk of it.
Endocarditis
Authors: Prendergast Bernard , Lüscher Thomas F.
Published: January 2022

Endocarditis is an inflammation of the heart valve leaflets, most commonly caused by bacteria, and frequently leads to valvular dysfunction, (usually regurgitation). The condition is diagnosed clinically, supported by imaging (i.e. echocardiography, CT and positron emission tomography), inflammatory markers and blood cultures, and has a high risk of embolic complications (particularly affecting the brain). Treatment involves intravenous antibiotics for 2–6 weeks and cardiac surgery if there is significant valve damage, risk of embolism or abscess formation. Antibiotic prophylaxis is recommended for patients at high risk of endocarditis (in particular, those with previous endocarditis, mechanical or biological prosthetic valves, previous valve repair, or congenital heart disease) undergoing invasive dental procedures.
Preoperative Screening Prior to Non-Cardiac Surgery
Authors: Schmied Christian , Lüscher Thomas F. , Kristensen Steen Dalby
Published: January 2022

Non-cardiac operations may have a considerable risk of cardiac complications, including myocardial infarction and heart failure or sudden death. This risk depends on the type of surgery and the patient involved, in particular, his or her physical performance during exercise testing, his or her clinical risk factors and/or cardiac diseases. In these patients, risk/benefit considerations have to be made and pre-treatment before surgery is recommended to reduce the perioperative risk.
Neurolytic agents
Authors: Chaudhari Mahesh
Published: January 2022

This chapter covers neuroablation, chemical neurolysis, and common neurolytic agents for managing malignant pain. Neurolytic procedures of peripheral nerves/plexus and visceral blocks are listed, and the selection of a neurolytic agent is explained.
Pelvic pain
Authors: Bhaskar Arun
Published: January 2022

Pelvic pain in patients with malignancy can be debilitating and has a significant impact on survival and quality of life. This chapter uses a particular case study to illustrate the complex nature of problems for patients with pelvic malignancy. The chapter covers initial care in both the community and a specialist pain clinic, palliative care, and sacral pain, and finishes with the key learning points.
Mesothelioma and chest wall pain
Authors: Sharma Manohar , Gupta Sanjeeva , Vas Lakshmi
Published: January 2022

Approximately 1800 new cases of mesothelioma are diagnosed each year in England. This chapter addresses the impact on daily living, pain control options, treatments and management options through the use of a case study. Opioid switching, intrathecal neurolysis, percutaneous cervical cordotomy and other pain control options are covered, and the chapter ends with key learning points.
Evolution of pain in a cancer survivor
Authors: Marley Kate , Sharma Manohar
Published: January 2022

The number of cancer survivors in increasing because the incidence of cancer is rising, and there is also improved survival with earlier diagnosis and treatment. Selection of advanced pain management techniques in cancer patients can often be complex due to the dynamic nature of pain, frailty of the patient and a short prognosis. This chapter uses a case study to address how cancer pain can evolve as well as management options and concludes with a list of key learning points.
Cervical cordotomy technique
Authors: Viswanathan Ashwin , Sharma Manohar
Published: January 2022

There is a growing interest in percutaneous cervical cordotomy (PCC) as an effective pain relief procedure in the UK and abroad because of an expected increase in mesothelioma cases and its role in otherwise difficult to control cancer pain in small number of cases. This chapter covers the efficacy and complications of cervical cordotomy, as well as details of the technique, equipment, patient position, and needle insertion, and concludes with some key learning points.
Interventions for head and neck cancer pain
Authors: Vas Lakshmi
Published: January 2022

Head and neck cancers (HNC) are the sixth most common cancer and include oral, pharynx, larynx, nasal cavity and sinus malignancies. Pain may be caused by the cancer invading nerve, muscle and bone, tumour pressure or mucositis. This chapter discusses the role of interventional procedures that target TGN, GPN, stellate ganglion, sphenopalatine ganglion and myofascial pain sources.
Neurosurgical techniques for cancer pain
Authors: Eldridge Paul , Bhargava Deepti
Published: January 2022

The neurosurgical principles of treating pain apply in cancer pain as much as they do in any other situation and treating the cause is of necessity at the site of the tumour itself. This chapter covers examples of neuromodulation such as spinal cord stimulation, deep brain stimulation, and TENS among others, as well as various neuroablation techniques. The chapter ends with some key learning points.
Pain in cancer survivors
Authors: Brown Matthew
Published: January 2022

The growth in the population of cancer survivors is complicated in that many have unique pathological, social, and psychological sequalae of their disease and its treatment. This chapter covers some of the different causes of pain in cancer survivors including treatment-related causes of pain such as persistent post-surgical pain (PPSP). This chapter also addresses the management of pain in cancer survivors and then ends with some key learning points.
Control of complex pain at the end of life in a hospice or community setting
Authors: Choi Eugene , Krishnasamy Priya , Gidwani Umesh K.
Published: January 2022

Uncontrolled pain causes unnecessary suffering, decreased ability to cope with illness, interference with daily activities, extended or repeated hospital admissions, disruption of other anticancer therapies and poor satisfaction for patients, families, carers, and health care providers. This chapter discusses the ethical concerns for pain management in the community hospice setting, pain management in patients with substance use disorder, and complementary and alternative therapies for pain, before concluding with a list of key learning points.
Hormones and Receptors
Authors: Funder John W.
Published: January 2022

Hormones are one of the two overarching command and control systems in the body, the other being the central and peripheral nervous system. They complement one another in various ways: hormones are like radio, widely transmitted, requiring a specific receiver (aka receptor); the nervous system is like a landline telephone network. There are obvious differences, in that the nervous system is partially under conscious control. There are less obvious differences, in that endocrine receptors are high affinity, allowing signalling via low levels of circulating hormones; receptors for neurotransmitters are low affinity, rapidly on and off, allowing millisecond responses. After considerations of binding per se, and further distinction between the two control systems, a case study on the complexity surrounding one particular endocrine receptor is presented. The ancillary mechanisms in epithelial tissues conferring aldosterone selectivity on mineralocorticoid receptors, their evolution from a primordial corticoid receptor, and mechanisms of receptor antagonism detailed.
Genetic Aspects of Endocrine Disease
Authors: Cole Trevor
Published: January 2022

In 1953, when Watson and Crick published their paper on the double helical structure of DNA, it would have been difficult to foresee the future impact this would have on clinical care, and unlikely anyone would have predicted the relatively slow progress over the subsequent 33 years compared to rapidity of change in the last decade. The current speed and low cost of molecular genetic analysis means that genomic testing now has the potential to provide diagnostic answers, individualized care (often described as personalized or precision treatment) and clear guidance for members of the extended family, in a timely manner for many patients with acute disease episodes or complex rare disorders. The challenge now to health provision across the globe is to interpret and manage appropriately the huge amount of data generated, and develop a workforce and service structures which can deliver this technology in an efficient, effective, and equitable manner. Understanding how genes may act directly on one or multiple glands, often with the ability to result in hyperfunction and hypofunction in a mutation dependent manner or alternatively modify the action of multiple genes in a complex pathway has had a major impact on our understanding in endocrinology and will be illustrated in the following chapters. This review will provide some historical background and identify how the field of genomics will continue to impact of clinical practice in Endocrinology and Diabetes, as well as addressing some of the challenges and barriers that need to be overcome.
Histopathology of Pituitary Tumours
Authors: Syro Luis V. , Rotondo Fabio , Kovacs Kalman
Published: January 2022

Pituitary adenomas are frequently occurring, benign neoplasms that can be distinguished based on their clinical presentation, hormone secretion, growth potential, and morphology. This chapter describes the pituitary gland and its wide spectrum of tumours based on their morphologic characteristics including histologic, immunohistochemical, transcription factor profiles, ultrastructural features along with their molecular and genetic characteristics that emanate from pituitary gland dysfunction. It summarizes both the clinically functioning as well as non-functioning adenomas. The histopathologic descriptions in this chapter can be utilized as a diagnostic tool to establish diagnosis and classification of the various pituitary tumour types currently defined by the World Health Organization (WHO).
Imaging of the Pituitary
Authors: Bonneville Jean-François , Nagi Sonia , Potorac Iulia
Published: January 2022

Magnetic resonance imaging (MRI) is currently considered as a major keystone of the diagnosis of diseases of the hypothalamic-hypophyseal region. The relatively small size of the pituitary gland, its deep location at the skull base, and the numerous physiological variants impede the precise assessment of the anatomical structure of the pituitary gland. Advanced MRI technology, particularly 3T MR, is able to depict tiny lesions such as corticotropic picoadenomas with greater reliability, but also helps in the differential diagnosis of larger tumours, their extension, and their relationship with the surrounding structures. This chapter describes and illustrates the role of MRI in the diagnosis of the main different lesions of the sellar region, which are likely to interest endocrinologists such as pituitary adenomas, Rathke cleft cysts, hypophysitis, and a few neoplastic and non-neoplastic entities.
Surgery of Pituitary Tumours
Authors: Penn David L. , Repetti Caroline S. , Laws Edward R.
Published: January 2022

There exist many different types of tumours that originate from the pituitary gland and the surrounding structures of the sella turcica. The most common of these tumours include pituitary adenomas and craniopharyngiomas. Pituitary tumours can cause symptoms secondary to mass effect or clinical syndromes, such as in Cushing’s disease and acromegaly, from excess hormone production. Surgical resection of pituitary tumours is generally the first-line treatment. There are two groups of surgical approaches, transcranial and endonasal, with the endoscopic transsphenoidal route rapidly becoming the standard. Surgical resection is highly successful for relief of symptoms caused by mass effect. Resection of functioning adenomas can be more challenging, but remission rates of these syndromes after surgery are high. Although the complications from these operations can be serious, they occur infrequently. The most prevalent complication associated with transsphenoidal surgery is postoperative cerebrospinal fluid leak; however, advances in surgical technique have significantly reduced its incidence. Significant and continued surgical experience improves outcomes and decreases complication.
Pituitary Incidentalomas
Authors: Karavitaki Niki , Teng Chai Shu , Ahmed Shahzada
Published: January 2022

A pituitary incidentaloma is defined strictly as a totally asymptomatic tumour, clinically and biochemically silent, discovered incidentally in a patient who is asymptomatic or, less strictly, a pituitary mass discovered in the course of evaluation for an unrelated problem. The prevalence of pituitary incidentalomas found by computed tomography (CT) ranges from 3.7% to 20% and of those found by MRI is around 10%. Although the differential diagnosis is wide, the most common aetiology is pituitary adenoma. The diagnostic evaluation includes assessment for hormonal hypersecretion and for pressure effects by the lesion (mainly hypopituitarism and visual disturbance). Overall, the published data suggest that lesions smaller than 1 cm follow benign course. In contrast, masses bigger than 1 cm are associated with higher risk of enlargement often leading to pressure effects and requiring neurosurgical intervention. If surgery is not indicated, regular follow-up mainly with imaging is recommended. A safe and cost-effective protocol for this remains to be elucidated.
Clinical Assessment of the Thyroid Patient
Authors: Pedersen Inge Bülow , Andersen Stig
Published: January 2022

Goitre and thyroid abnormalities are common in populations with both low and high iodine intake. A clinical investigation of the thyroid, including inspection, palpation, and auscultation of the thyroid gland, remains first-line evaluation for goitre and thyroid nodules. Clinical symptoms and signs of hyper- and hypothyroidism are many and may overlap considerably with complains and abnormalities commonly seen in other diseases and in apparently healthy people. The first-line test for thyroid dysfunction is measurement of thyroid-stimulation hormone (TSH) in serum. The diagnosis and evaluation of nosological type of thyroid disorder should be substantiated by further biochemical tests and imaging procedures. Interpretation of laboratory tests of thyroid function highly depend on information on medication and clinical conditions including pregnancy.
Thyroid Imaging: Non-Isotopic Techniques
Authors: Hegedüs Laszlo , Bennedbæk Finn N.
Published: January 2022

Clinical examination and evaluation of thyroid function remain fundamental in the evaluation of thyroid disorders, but observer variation leads to a considerable heterogeneity in the evaluation of patients with suspected thyroid disease. Thus, it is not surprising that imaging of the thyroid is often performed. Although it most often cannot distinguish between benign and malignant lesions, and its clinical value is thought to be limited, a recent survey confirms the value of ultrasonography (US) in euthyroid patients with a solitary thyroid nodule. The thyroid gland can be evaluated by several non-isotopic imaging techniques. The most commonly used are US, CT, and MRI. Each method has advantages and limitations, and there is no absolute clinical indication for performing any of these imaging procedures in most patients.
Thyrotoxic Periodic Paralysis
Authors: Kung Annie W.C. , Cheung C.L.
Published: January 2022

Thyrotoxic periodic paralysis (TPP) is a condition featuring attacks of muscle weakness in the presence of hyperthyroidism. Hypokalaemia is the hallmark of TPP. The condition may be life-threatening if there is weakness of respiratory muscles or cardiac arrhythmias. If hyperthyroidism is uncontrolled, TPP is recurrent in nature. The condition has been linked with genetic mutations or variants in certain ion channels that code for sodium and potassium across cell membranes. The main ones are the KCNJ family and L-type calcium channel alpha 1 subunit. The abnormality in these ion channels leads to shifts of potassium across cell membrane in hyperthyroid state.
Pathogenesis of Non-Toxic Goitre
Authors: Führer Dagmar , Jäschke Holger
Published: January 2022

In clinical terms goitre is a thyroid enlargement above the gender- and age specific reference range and may present with euthyroid, hyperthyroid, or hypothyroid function. On morphological grounds, goitre may be diffuse or nodular. Histologically, thyroid nodules are distinguished by morphological criteria according to the World Health Organization (WHO) classification. On functional grounds, nodules are classified as either ‘cold’, ‘normal’, or ‘hot’ depending whether they show decreased, normal, or increased uptake of radioactive nuclides such as technetium on scintiscan. In contrast to solitary nodular thyroid disease, which has a more uniform clinical, pathological, and molecular picture, multinodular goitre (MNG) usually comprises a mixed group of nodular entities. The aetiology of non-toxic goitre includes extrinsic factors like dietary iodine and intrinsic factors like age, gender, or genetic disposition. This chapter discusses the interplay of the aforementioned aspects in the pathogenesis of benign non-toxic goitre.
Management of Non-Toxic Multinodular Goitre
Authors: Graf Hans , Paz-Filho Gilberto
Published: January 2022

Multinodular goitre (MNG) is a common thyroid disorder associated with more than one thyroid nodule. The clinical presentation varies from a completely asymptomatic goitre to a life-threatening disease with upper airway compression. Patients should have a careful clinical evaluation, thyroid function tests, ultrasonography, cross-sectional imaging, and fine-needle aspiration. The best therapeutic approach will depend on the size and location of the goitre, the presence of compressive symptoms and the clinical status. The recommended treatments include clinical observation, surgery, and administration of radioactive iodine (131I). Suppressive treatment with levothyroxine is discouraged due to its low efficacy compared with surgery or 131I and adverse effects. Total thyroidectomy is effective, but surgical complications may occur. The use of radioiodine after the elevation of thyroid-stimulating hormone (TSH) levels, either via the exogenous administration of recombinant human TSH or through the induction of transient primary subclinical hypothyroidism by antithyroid drugs, are relative novel alternative treatments.
Rickets and Osteomalacia (Acquired and Heritable Forms)
Authors: Whyte Michael P.
Published: January 2022

Rickets and osteomalacia refer to the consequences of generalized impairment of skeletal mineralization during growth and adult life, respectively. Among the complications can be deformity, fracture, weakness, and pain. The many acquired or heritable causes typically involve low circulating levels of inorganic phosphate (Pi), often with hypocalcaemia and secondary hyperparathyroidism. Commonly, the pathogenesis features deficiency of vitamin D leading to malabsorption of dietary calcium (Ca). Especially rare forms involve aberrant bioactivation or action of vitamin D, elevated circulating levels of a phosphatonin (typically fibroblast growth factor 23) that cause renal Pi wasting and hypophosphatemia, or alkaline phosphatase deficiency. All types have some medical treatment, but success depends on correcting the aetiology or effectively addressing the pathogenesis, often requiring supplementation with vitamin D or an analogue together with Ca or Pi. Although general guidelines for therapy may be available, skilled personalized treatment and follow-up are key to safe and successful outcomes.
Management of Primary Aldosteronism
Authors: Drake William M. , Brown Morris J.
Published: January 2022

Major advances have been made since Jerome Conn first described the meticulous assessment and surgical treatment of a patient with severe primary aldosteronism (PA) more than 60 years ago. Diagnostic criteria, although still imperfect, have been refined; high definition cross-sectional imaging is widely available; adrenal vein sampling (AVS) is practised to a high standard in selected centres; low-morbidity laparoscopic adrenalectomy (replacing open surgery involving rib resection) is now routine; preliminary data are emerging about the utility of radiofrequency ablation of adrenal nodules as an alternative to surgery; and the range of medical therapies, available or in development, is expanding. Despite this, based on current prevalence estimates, it remains the case that under 1% of patients with PA are fully evaluated and treated. Given the evidence that PA is associated with substantial excess cardiometabolic morbidity over and above that conferred by elevated blood pressure alone, this underprovision of clinical care represents a major public health issue. This chapter will describe the current approach to the management of PA (from its initial suspicion, diagnosis, differential diagnosis, treatment, and evaluation of the success of treatment) and highlight areas of particular uncertainty and controversy.
Cushing's Syndrome
Authors: Newell-Price John
Published: January 2022

Harvey Cushing described the first case of Cushing’s syndrome with a severe phenotype in 1912. Since that time, investigation and management of Cushing’s syndrome has remained a significant clinical challenge and patients suspected of this diagnosis warrant referral to major centres. Endogenous Cushing’s syndrome is due the chronic, excessive, and inappropriate secretion of cortisol. When presentation is florid, diagnosis is usually straightforward, but in modern practice Cushing’s syndrome is frequently and increasingly considered in mild cases in the absence of the classical signs in the context of osteoporosis, diabetes, and hypertension, as well as in the context of gynaecological and psychiatric clinics. Achieving a diagnosis can be difficult. Appropriate management of Cushing’s syndrome is dependent on correctly identifying the cause of excess cortisol. Separating ACTH-independent causes (adrenal tumours) from ACTH-dependent causes (pituitary or ectopic secretion of ACTH) is usually simple. However, many ectopic sources are occult and the identification of the source of ACTH secretion may require meticulous and repeated investigations. In most circumstances the mainstay of therapy remains surgery to either an ACTH-secreting tumour or directly to the adrenal glands, but additional treatment with cortisol-lowering or opposing drugs and tumour-directed therapy is often needed.
Management of Adrenal Insufficiency
Authors: Arlt Wiebke
Published: January 2022

In 1855, Thomas Addison identified a clinical syndrome characterized by wasting and hyperpigmentation as the result of adrenal gland destruction. This landmark observation paved the way for progress in understanding and treating adrenal insufficiency, with the introduction of adrenal extracts for treatment of Addison’s disease by the groups of Hartman and Pfiffner in 1929. However, long-term survival of patients with adrenal insufficiency only became possible after the seminal work of Edward Kendall, Philip Hench, and Tadeus Reichstein on the characterization and therapeutic use of cortisone. In 1946, Lewis Sarrett, a Merck scientist, achieved a partial synthesis of cortisone, which marked the beginning of industrial-scale production of cortisone. In 1948, in a fundamental clinical experiment at the Mayo Clinic, the first patient with Addison’s received intravenous injections of Kendall’s Compound E, cortisone, resulting in ‘notable improvement of his condition’. This was followed by ground-breaking trials on the use of cortisone in rheumatoid arthritis. In November 1950, cortisone was made available to all physicians in the United States, which culminated in the award of the 1950 Nobel Prize in Medicine to Kendall, Hench, and Reichstein. This progress reached other countries and widespread availability of cortisone in the United Kingdom was achieved by joint efforts of Glaxo and the Medical Research Council. Though almost 150 years have passed since Addison’s landmark observations and 60 years since the introduction of life-saving cortisone, there are still advances and challensges in the management of adrenal insufficiency, summarized in this chapter.
Overview and Pathophysiology of Neuroendocrine Neoplasms
Authors: Srirajaskanthan Rajaventhan , Rindi Guido
Published: January 2022

Neuroendocrine neoplasms are increasing in incidence and prevalence. Recent epidemiological data suggests an overall incidence of 7 per 100 000 population in USA. Symptoms can be diverse with a number of tumours causing distinct clinical syndromes, most commonly carcinoid syndrome. Investigations to aid diagnosis include biochemical, cross-sectional, and functional imaging. Histology remains the gold standard for diagnosis. Treatment options are dependent in part of the site of the primary tumour. Surgery remains the only chance of cure and should be offered to all patients when appropriate. There are a number of systemic palliative treatment therapies and a number of local regional therapies that can be employed for liver metastases. For patients with carcinoid syndrome or functional tumours somatostatin analogues can be very effective a reducing hormone secretion. Median overall survival has been improving over the last 30 years to 9.3 years.
Gastrinoma
Authors: Toumpanakis Christos , Caplin Martyn E.
Published: January 2022

Gastrinomas are functional neuroendocrine tumours, characterized by autonomous release of gastrin by the tumour cells, which results in symptoms not only due to the tumour growth per se, but also due to gastric acid hypersecretion. Gastrinomas can either be sporadic or can be associated with multiple endocrine neoplasia type 1 (MEN-1) syndrome in 25% of cases. The duodenum (especially the first and the second part) is the most common location for both sporadic and MEN-1 associated gastrinomas. Most of the symptoms in patients with gastrinomas include peptic ulcers resistant to treatment, erosive oesophagitis, and chronic diarrhoea. Fasting serum gastrin levels of >10-fold the upper normal limit in the presence of gastric p H<2 or basal acid output (BAO)>15 mmol/h confirm the clinical suspicion, of a gastrinoma. Precise localization of primary tumour as well as metastatic deposits can be achieved through the new molecular imaging studies (68Ga-DOTA PET) in combination with good quality cross-sectional imaging studies and endoscopic ultrasound. Once the diagnosis is established, it is important to control gastric acid hypersecretion and prevent its complications, by using high-doses proton pump inhibitors. The aim of surgery in patients with sporadic gastrinomas is curative resection, in order to decrease the risk of development of distant metastases, as well as to completely control the hormonal symptoms. The benefit of surgery in gastrinomas associated with MEN-1 syndrome is controversial. All patients with advanced and inoperable disease should have systemic antitumour treatment (somatostatin analogues, molecular targeted agents, chemotherapy, peptide receptor radionuclide therapy) in order to prolong the survival rates.
Insulinoma and Hypoglycaemia
Authors: Mak Ingrid Y.F. , Grossman Ashley B.
Published: January 2022

Hypoglycaemia is a clinical syndrome with diverse aetiologies. While the list of possible causes is extremely long, excluding patients with diabetes then the most frequent cause in patients who are otherwise well is an insulinoma. Insulinomas are the most common functioning pancreatic islet cell tumour and may be part of the multiple endocrine neoplasia type 1 syndrome. Patients present with episodic symptoms of neuroglycopaenia and catecholamine responses, and diagnosis is confirmed by evidence of endogenous hyperinsulinaemic hypoglycaemia with tumour localization by CT, MRI, endoscopic ultrasound, functional imaging, and/or intra-arterial calcium stimulation with venous sampling. Most tumours are benign and solitary, making surgical cure and long-term remission possible with complete resection. Diazoxide, everolimus, and somatostatin analogues are the major medical options for hormonal control in metastatic disease, while peptide receptor radionuclide therapy, chemotherapy, and liver-debulking procedures are reserved for the more aggressive tumours. Important differential diagnoses of hypoglycaemia without apparent causes include medications, non-insulinoma pancreatogenous hypoglycaemic syndrome, autoimmune hypoglycaemia, and non-islet cell tumour hypoglycaemia.
Somatostatinoma
Authors: Wass John A.H.
Published: January 2022

Somatostatinomas are rare neuroendocrine tumours they may be sporadic or familial. About half are pancreatic somatostatinomas which are often large and associated with features of somatostatin excess. Slightly less than half are duodenal tumours which are much more amenable to surgical resection. The main features of pancreatic somatostatinoma are hyperglycaemia, cholelithiasis, diarrhoea, abdominal pain, and weight loss. These rumours are best localized with 68ga-dotatate. The treatment is optimally with surgery and if not possible by surgical debulking. Somatostatin analogues relieve symptoms and may inhibit growth. Overall survival is 75.2% at 5 years. Without metastases there is a high survival rate.
Management of Thyroid Disorders After Pregnancy
Authors: Amino Nobuyuki , Arata Naoko
Published: January 2022

Subclinical autoimmune thyroiditis exacerbates after delivery through immune rebound mechanism and may result in five types of thyroid dysfunction. Overall, the prevalence is around 5% in most countries. Typically, an exacerbation induces destructive thyrotoxicosis followed by transient hypothyroidism, defined as postpartum thyroiditis. Late development of permanent hypothyroidism is found frequently and patients should have thyroid function testing once every 1 to 2 years. Destructive thyrotoxicosis in postpartum thyroiditis should carefully be differentiated from postpartum Graves’ disease. Onset time of postpartum thyroiditis is 1–6 months after parturition but Graves’ disease typically develops at 3–12 months postpartum. Anti-TSH receptor antibodies are raised and thyroid blood flow is increased in Graves’ disease but not in postpartum thyroiditis. Postpartum Graves’ disease should be treated with antithyroid drugs.