bluuebunny/crossref_metadata_2025 huggingface dataset:
Alcohol septal ablation for obstructive hypertrophic cardiomyopathy
Authors: Knight Charles , Mohiddin Saidi , O’Mahony Constantinos
Published: October 2018

Hypertrophic cardiomyopathy (HCM) is a genetic disease occurring in up to 1 in 500 of the general population. HCM is often undiagnosed or misdiagnosed, and asymptomatic cases are often unrecognized. Asymmetric left ventricular hypertrophy (LVH) most often develops during the period of rapid body growth of adolescence, but it may be present in childhood or even before birth. Progressive LVH after age 20 is uncommon, but initial diagnosis even in old age is not. The hypertrophy predominantly involves the left ventricle, and is often more marked than in any other cardiac disease. Hypertrophy may involve the right ventricle, and an atrial myopathy may be progressive (left atrial enlargement and increased risks of atrial fibrillation). Right ventricle and left atrium involvement may be secondary to the left ventricular disease and/or a primary consequence of the basic molecular defect. The LVH represents hypertrophy and hyperplasia of several cell types, including cardiac myocytes, fibroblasts, and smooth muscle cells, along with excessive collagen and matrix deposition, and abnormalities of the microvasculature. The normal parallel arrangement of myocytes is often disturbed (fibre disarray).
Robotic percutaneous coronary intervention
Authors: Weisz Giora
Published: October 2018

Percutaneous coronary intervention (PCI) has seen steady technological progress over the past four decades. Despite improved patient safety and efficacy, modern interventionalists continue to face significant occupational hazards, including radiation exposure, cataracts, and orthopaedic injuries. Robotic remote navigation systems have been developed to address the risks and procedural challenges associated with conventional PCI. The development of novel robotic remote control navigation systems represents the dawn of a new era of interventional cardiology.
Mental health and emotional well-being
Authors: Barr Owen , Gates Bob
Published: October 2018

This chapter has a strong emphasis on promoting mental health and emotional well-being. It also recognizes that people with intellectual disabilities may develop mental health problems similar to, but perhaps more frequently than, people who do not have intellectual disabilities. This chapter considers what emotional well-being is, factors contributing to mental health, and the importance of assertiveness. It then explores how to support people with intellectual disabilities to access general primary, secondary, and tertiary mental health services, before giving specific consideration to anxiety, psychotic and organic disorders, dementia, psychopathology, autistic spectrum disorders, self-harm, substance misuse, and the challenges to emotional well-being that may arise from the experience of bereavement.
Planning with people and their families
Authors: Barr Owen , Gates Bob
Published: October 2018

This chapter builds on the information within Chapter 4 and gives more in-depth consideration to the practicalities of accurate nursing assessments and writing outcome-focused care plans. It provides detailed information on important considerations when planning nursing interventions with people with intellectual disabilities and their carer/carers, including the role of advocacy, life planning, client health records, consent process, making best interests decisions, vulnerability, and safeguarding children and adults. It adds to this practical information by providing information on the necessary wider considerations for effective nursing and collaborative interdisciplinary and inter-agency working across the UK and the Republic of Ireland, including care pathways, health action planning, health facilitation, case management, and direct care payments.
Accessing general health services
Authors: Barr Owen , Gates Bob
Published: October 2018

The knowledge of practical-focused and applied information within this chapter builds on the underpinning information in Chapter 5 relating to physical health and well-being. This provides essential information to nurses for people with intellectual disabilities, so that they can support people access general healthcare services. It explores the remit of general primary, secondary, and palliative care services and the roles of people who work within these services. It provides clear information on the role of all members of the primary care team and the key professionals with whom people with intellectual disabilities will often be in contact, including dentists, podiatrists, audiologists, dieticians, physiotherapists, occupational therapists, community mental health nurses, and practice nurses. It also gives clear practical information about how to support people with intellectual disabilities to access services in general hospital, children departments, emergency departments, dental departments, mental health, and maternity and palliative care.
People with intellectual disabilities and forensic nursing
Authors: Barr Owen , Gates Bob
Published: October 2018

In the UK, it has been suggested that as many as 7% of prisoners have an intelligence quotient (IQ) of less than 70, and a further 25% have an IQ of 70 to 79. The ‘Transforming Care’ programme of work (England) has highlighted that a number of people with intellectual disabilities are within inpatient beds in a range of settings who might be better placed elsewhere. Nurses for people with intellectual disabilities have a key role when working in forensic services, along with their colleagues who work either directly in prisons or as ‘in-reach practitioners’. Nurses can provide focused risk assessment management strategies in order to inform person-centred care and treatment approaches. They will need to understand the complexities of the forensic population of people with intellectual disabilities, the rights, and aspects of mental health legislation, along with the enormous number of agencies involved. This chapter supports this complex arena of practice with a detailed examination of the issues that nurses for people with intellectual disabilities will need to know.
The law
Authors: Barr Owen , Gates Bob
Published: October 2018

All citizens are required to act within the law and simultaneously are protected by the law. However, as a potentially vulnerable group, people with intellectual disabilities are sometimes identified specifically in law for their protection. More general legislation is sometimes highly relevant to people with intellectual disabilities and can impinge on the practice of the nurse for people with intellectual disabilities. This chapter presents a thorough overview of a range of primary legislation relevant for students and nurses for people with intellectual disabilities. Where appropriate, relevant legislation is outlined for each of the jurisdictions of the UK and the Republic of Ireland. Where a student finds an omission for the jurisdiction in which they are working, they will find helpful resources and may also find it useful to append their own notes to the sections within the chapter; the layout of the book has been designed for students to make relevant notes on.
National occupational standards and professional requirements
Authors: Barr Owen , Gates Bob
Published: October 2018

Nurses for people with intellectual disabilities are autonomous and accountable practitioners, and in order to behave in a professional manner, they need to be aware of, and remain up-to-date with, the requirements of, and resources from, the professional bodies that regulate their practice. This chapter provides an overview of the role of the professional regulators of nursing in the UK and the Republic of Ireland and the continuing importance of this to registered nurses. It also explores the need for nurses to engage in continuing professional development and outlines opportunities for career development in areas, including specialist and advanced nursing practice, management, education, and research.
Emergencies
Authors: Barr Owen , Gates Bob
Published: October 2018

Nurses for people with intellectual disabilities are often required to make autonomous professional decisions and respond to people with intellectual disabilities in emergency or challenging situations. This chapter explores how the likelihood of an emergency situation may be assessed and, if possible, avoided through proactive nursing decisions. It also provides practical advice and lists additional resources that will be of use when responding to emergency situations, including the management of a person in a seizure, self-harm, self-injury, missing person, risk of suicide, allergies, adverse reactions to medication, medication errors, and needlestick/sharps injuries. The chapter concludes with consideration of, and practical advice on, concerns about unsafe standards of care or complaints and the importance of accurate recording and reporting.
Introduction
Authors: Campbell Colin , Craissati Jackie
Published: October 2018

The UK government’s Offender Personality Disorder (OPD) strategy has provided a unique opportunity to revise the way in which health and criminal justice agencies collaborate in order to develop creative psychologically informed approaches to managing a complex group of individuals. This introduction to ‘Managing Personality Disordered Offenders: A Pathways Approach’ outlines the development and implementation of the strategy from the perspective of a consortium of mental health trusts—the London Pathways Partnership (LPP). It outlines the commissioning constraints in this particular geographical setting and details both the theoretical underpinnings and operational models used to implement the OPD pathway in community and secure settings. The chapter concludes with a review of the first four years of these services and a reappraisal of the strategic model.
Intervening in secure settings
Authors: Campbell Colin , Attwell Pamela
Published: October 2018

The chapter begins by reviewing the existing evidence base for services for personality disordered offenders within secure settings, outlining approaches used both in the UK and internationally. The chapter goes on to describe the implementation of the Offender Personality Disorder (OPD) strategy in secure services, setting out the commissioning context and the focus on social environments, including Psychologically Informed Planned Environments (PIPEs) and Enabling Environments. It reviews the approach chosen by the London Pathways Partnership in terms of service model (residential, day programme, and outreach) and the intensity of the interventions used. The delivery of the services is then described in detail, including the development phase; referrals and assessment; intervention; and pathway progression. The chapter reviews the progress of the services over the first four years, including what worked and what didn’t, and concludes with an outline of evaluations of the services and proposals for future developments.
The Offender Personality Disorder pathway: Modelling collaborative commissioning in the NHS and criminal justice system
Authors: Burns Mick , Campbell Colin , Craissati Jackie
Published: October 2018

The complex process by which the current Offender Personality Disorder pathway came into existence and the importance of joint operations, both co-commissioning and co-delivery, are explored in this chapter. The importance of providing system leadership and the difficulty inherent in holding together a complex network of service provision in two parallel systems while maintaining effective service delivery is explored. A brief overview of the evolution of commissioning in both health and justice settings is given, as well as a description of ‘co-commissioning’ and the tensions and benefits evident in this unique approach. The importance of collaboration and working towards identified outcomes from a set of agreed strategic principles is emphasized, along with the importance of relationships and the impact the approach has on workforce and environments across the pathway.
Addiction (Oxford Psychiatry Library)
Authors: Nutt David J. , Nestor Liam J.
Published: October 2018

Part of the Oxford Psychiatry Library series, this resource is a clear and comprehensive overview of the brain science underpinning addiction that helps explain the current and future therapeutics for the range of addictions, using full colour images to enhance understanding. It focuses on the nature of addiction as a brain disorder that includes a range of different behavioural traits such as impulsivity and reward dependence, and discusses the critical role of kinetic and pharmacological factors. The also explains how the primary pharmacological targets of drugs of abuse are now understood, the relation to the variable nature of addiction to different substances, and how this may lead to new approaches to treatment.
The dopamine system and addiction
Authors: Nutt David J. , Nestor Liam J.
Published: October 2018

Substances of addiction work by triggering transient, exaggerated increases in dopamine in brain areas that process rewards. These surges in dopamine resemble, and can greatly surpass, physiological increases triggered by natural rewards (e.g. food). Research also suggests that dopamine functioning in the brain may predispose some individuals to initiating substance abuse—particularly the use of stimulants, which induce further deficits within the dopamine system. The development of substance addiction is associated with dysregulated dopaminergic transmission, which results in a hyposensitivity to non-drug rewards and, importantly, impairments in cognition that are involved in controlling impulsivity and drug urges.
Nicotine addiction
Authors: Nutt David J. , Nestor Liam J.
Published: October 2018

Cigarette smoking presents with considerable health risks and induces high costs on healthcare resources. People continue to smoke cigarettes in the face of adversity because they contain nicotine, which is highly addictive. Nicotine is a stimulant that exerts its effects within the brain by acting at nicotinic acetylcholine receptors (nAChRs). nAChRs are located in areas of the brain involved in reward processing, motivation, and cognitive control, which results in disruptions to behaviour when nicotine addiction has developed. Disturbances to the brain and behaviour are particularly evident during early nicotine abstinence when people are in withdrawal. Importantly, treatments (e.g. varenicline, bupropion) that attenuate disturbances to reward and cognition in the brain during withdrawal in early nicotine abstinence are conferred with the efficacy to promote smoking cessation and protect against relapse.
Conclusion and overview
Authors: Nutt David J. , Nestor Liam J.
Published: October 2018

Substance addiction is a chronic relapsing disorder. It is the manifestation of the long-term pharmacological actions of substances on the receptor mechanisms of the brain’s neural circuitry. There are different neurotransmitter systems (e.g. dopamine, GABA, opioids) and even appetite hormones, acting within this neural circuitry in addiction, but their collective roles in the disorder remain equivocal. Importantly, disturbances to these systems may also pre-date addiction, which leads people to initiate substance abuse (e.g. stress, reward sensitivity). People may also be at an increased risk of initiating substance abuse due to age (e.g. adolescence), where there is an imbalance in the maturation of neural circuits. The pharmacokinetics of addictive drugs also plays a significant role in their abuse potential. Addiction is a recurrent disorder that is difficult to cure. Treatments that possess efficacy in aiding people to remain abstinent and stabilize their lives are the best courses of treatment for addiction disorders.
Introduction
Authors: Howes Oliver
Published: October 2018

Schizophrenia and related disorders are common, affecting about 1 in 100 people, and typically begin in late adolescence and early adulthood, when people are in the prime of their lives. They are also major causes of disease burden globally and are amongst the top causes of disability in working-age adults in the world. Carers are significantly affected by the burden of these disorders, which are a leading cause of healthcare costs. Schizophrenia and related disorders are also major causes of premature mortality due to suicide and elevated rates of comorbid conditions, particularly cardiometabolic disorders. It is clear that the stakes are high, and this book aims to help the clinician give their patients the best odds of getting better.
The neurobiology of antipsychotic treatment response and resistance
Authors: Kaar Stephen J. , Potkin Steven , Howes Oliver
Published: October 2018

Dopamine D2/3 receptor occupancy by antipsychotic drugs is central to clinical response and many of their side effects. Yet the locus of dopaminergic alterations in the majority of patients with schizophrenia is not the D2/3 receptor but, instead, presynaptic, comprising elevated striatal dopamine synthesis and release capacity. However, whilst this explains why dopamine D2/3 receptor blockade is effective in many patients, a proportion of patients does not respond. In some this is because of inadequate antipsychotic blockade of dopamine receptors, but there are others who do not respond to antipsychotic treatment despite substantial dopamine D2/3 receptor blockade. The neurobiology of treatment resistance does not seem to involve the presynaptic dopamine dysfunction typically seen in patients, suggesting that it needs different treatments. Disruptions to the glutamatergic system, and to dopamine D1 and D2/3 receptors and serotonin 2A receptors have all been proposed as potential mechanisms underlying treatment resistance and as targets for novel treatments.
Managing common adverse effects of clozapine
Authors: Rohde Christopher , Nielsen Jimmi
Published: October 2018

Adverse effects during clozapine treatment are common, and can be divided into very common (>10%: constipation, weight gain, metabolic side effects, sedation, and sialorrhea), common (1–10%: seizures and enuresis), and cardiac (sinus tachycardia, electrocardiogram abnormalities, and orthostatic hypotension) adverse effects. Most adverse effects are benign, but often reduce the quality of life for the patient, leading to reduced adherence and thereby psychotic relapse. As a consequence, treatment of these adverse effects is important and should not be neglected. In this chapter, we present specific treatment strategies for each adverse effect. In addition, we also emphasize that, by applying simple general managing strategies, such as reducing the clozapine dose, re-arranging the dose, or augmentation with another antipsychotic drug, many of these adverse effects can be avoided or reduced, which should reduce the need for specific rescue medications.
Pharmacological management of treatment-resistant schizophrenia: alternatives to clozapine
Authors: Barnes Thomas R. E.
Published: October 2018

Other than for clozapine, there are no pharmacological interventions with robust evidence of a positive benefit–risk balance for the treatment-resistant schizophrenia. For patients with treatment-resistant schizophrenia, there is usually little to be gained, in comparison to switching the antipsychotic to clozapine, from alternatives such as a further switch to a non-clozapine antipsychotic medication, the prescription of high-dose or combined antipsychotic medications, or the augmentation of continuing antipsychotic medication with other medications, such as antidepressants, mood stabilizers, or benzodiazepines. However, where these are tried, each initiation of high-dose or combined antipsychotic medication or an augmentation strategy should be treated as an individual trial and appropriately monitored and reviewed, with discontinuation in case of inefficacy or benefit that is outweighed by safety or tolerability concerns.
Illustrative case studies
Authors: Agid Ofer , Barnes Thomas R. E. , Byrne Majella , Chintoh Araba , Correll Christoph U. , Gee Siobhan , Howes Oliver , Jolley Suzanne , Kane John , Lally John , Lee Jimmy , MacCabe James H. , Marder Stephen , McCutcheon Robert , Nielsen Jimmi , Peters Emmanuelle , Remington Gary , Rohde Christopher , Takeuchi Hiroyoshi , Taylor David , Yang Yvonne
Published: October 2018

This chapter presents case histories illustrating key aspects of the treatment of schizophrenia based on the authors’ clinical experience of patients that they have treated over the years, although identifying details have been changed. The art of clinical practice includes interpreting and applying evidence to help individual patients who often do not fit into the categories used in clinical trials. The cases show the application of evidence, and also its limitations, in real-world settings. This emphasizes the need for the evidence discussed throughout this book to be considered in the individual context of each patient. You will see variation in the approaches taken by the expert clinicians discussing their cases, reflecting how they interpret and apply evidence in a given clinical context. Each case is followed by a series of learning points and links to other chapters in the book where the issue is considered further.
The Spiritual Event of Serious Illness
Authors: Balboni Michael J. , Balboni Tracy A.
Published: October 2018

This chapter explores patients’ personal accounts of spirituality and illness within four Boston hospitals, finding that the majority of patients consider spirituality and religion important to their illness experience. It highlights several interlocking themes that explain how religion and spirituality operate within a person’s personal experience. One key theme, spiritual transformation, highlights a shift that takes place for many patients within illness. Almost all patients, as they stare at the reality of their own mortality, find that our cultural camouflage of death disappears, and this serves as a catalyst for patients to directly consider and weigh spiritual issues. The Boston patient sample offers a “thick” account of patient experience within a metro area that is far less religious than many other places in the United States. Patient data confirm the claim that, for nearly all, illness emerges as a spiritual event of great importance.
The Secular–Sacred Divide in Medicine
Authors: Balboni Michael J. , Balboni Tracy A.
Published: October 2018

This chapter argues, in addition to the plausibility structures described in Chapter 6, that modern consciousness comprises a series of related bifurcations of life and that medicine is a social institution that is informed by understandings of human nature, human knowledge, and social structures that fall on the opposite side of the wall from religion. Modern Western societies advance this dualism to such an extent that there appears to be no unity or interconnection between “opposite” spheres, divided between immanence and transcendence. This consciousness leads to social structures that divide human nature (body vs. soul), human knowledge (science vs. special revelation), and social structures based on a privatization of religion, the secularization of time and space, and a strict separation between the state and church.
A Spirituality of Immanence
Authors: Balboni Michael J. , Balboni Tracy A.
Published: October 2018

This chapter argues that by secular medicine’s repudiation of religious partners, it ironically establishes itself as a religious-like phenomenon. Medicine is dangerously close to aligning itself with a spirituality of immanence centered on bodily cure and comfort as chief affection or ultimate concern. This realignment away from Western religions and toward a spirituality of immanence monopolizes the structures of medicine, marginalizing the Abrahamic religious traditions, and animating a rival spiritual power. Contemporary medicine is not freed from spirituality or religion. Medicine in its contemporary secular institutions and professions is both intrinsically spiritual in its ultimate concerns and loves and infused with a veiled, quasi-religious structure embedded in its systems. Clinicians are deeply socialized into immanence, leading them to unconsciously avoid or neglect their patients’ spiritual needs.
Why Medicine Should Resist Immanence
Authors: Balboni Michael J. , Balboni Tracy A.
Published: October 2018

This chapter outlines four reasons why medicine should resist a spirituality of immanence as its chief love. First, this spirituality is incongruent with the beliefs of most American patients and their experience of serious illness. Second, a spirituality of immanence fails the test of religious pluralism, an essential characteristic of medicine in the twenty-first century. Third, this spirituality enables and encourages impersonal social forces, including bureaucracy, market forces, and the technological imperative, to affect how medicine is conceived, practiced, and experienced. Finally, immanence is creating a professional socialization with negative clinician outcomes, such as burnout. The argument especially focuses on the impact of immanence in creating conditions for impersonal medicine and its subsequent impact on clinician socialization. Apart from partnership with traditional religions, medicine is helpless to resist impersonal forces overtaking the patient–clinician relationship.
Suicide and Nonsuicidal Self-Injury
Authors: Soloff Paul , Schmahl Christian
Published: October 2018

This chapter reviews current data on the prevalence of suicidal behavior and non-suicidal self-injury (NSSI) in patients with PDs; the characteristics of attempters versus completers; and the epidemiology of NSSI in borderline personality disorder (BPD). In addition, it presents explanatory models for suicide and NSSI. Also, there are comprehensive discussions of the neurobiological mechanisms involved in both suicidality and NSSI focusing on the structural and functional neuroimaging of emotion dysregulation, impulsivity, executive cognitive deficits, affective interference and cognitive function, and the Endogenous Opioid System. The chapter concludes with a detailed description of pain processing as it interacts with NSSI.
The Neurobiological Basis of Borderline Personality Disorder
Authors: Friedel Robert O. , Schmahl Christian , Distel Marijn
Published: October 2018

This chapter provides an overview of the biological underpinnings of borderline personality disorder (BPD). The total body of evidence indicates that BPD has a strong neurobiological basis. The material in this chapter is presented in five sections: one describing the structure of genetic and environmental risk factors for BPD and four describing our current knowledge about the anatomy and pathophysiology of symptom in each of the four domains of the disorder, that is, affective dysregulation, impulsive aggression, disturbances of perception and cognition, and interpersonal impairments. The chapter concludes with a discussion of the clinical, research, and educational implications of this information.
The Neurobiological Basis of Avoidant Personality Disorder
Authors: Wilberg Theresa , Silk Kenneth
Published: October 2018

This chapter reports neurobiological findings relevant to avoidant personality disorder (AvPD) and focuses on several areas and dimensions assumed to be of special interest with respect to it. Because there are many different psychiatric disorders, cognitive styles, and interpersonal patterns that can overlap with AvPD, the chapter is selective in what areas are considered. The chapter begins with a discussion of biological findings that pertain to the diagnosis of AvPD, summarizing developments in genetics, neurotransmitters, and neuroimaging. It then turns to areas of temperament, emotional dysfunction, attachment, and stress regulation. Because these areas are applicable across all personality disorders, the chapter emphasizes how they apply more specifically to AvPD.
Neurobiological Underpinnings of Psychosocial Treatment in Personality Disorders
Authors: Goodman Marianne , Chen Jennifer , Hazlett Erin A.
Published: October 2018

This chapter focuses on the psychotherapies with the largest empirical basis and most relevant to personality dysfunction and include behavioral therapy, cognitive-behavioral therapy, interpersonal psychotherapy, psychodynamic psychotherapy, and psychoanalytic psychotherapy.
Gynaecological cancers
Authors: Cassidy Jim , Bissett Donald , Spence OBE Roy A. J. , Payne Miranda , Morris-Stiff Gareth , Bhattacharyya Madhumita
Published: October 2018

Genitourinary cancers examines the malignancies arising in the kidney, ureter, bladder, prostate, testis, and penis. Renal cancer has high propensity for systemic spread, largely mediated by overexpression of vascular endothelial growth factor (VEGF). Treatments include surgery, immunotherapy, and targeted therapy. Wilms tumour, a childhood malignancy of the kidney, warrants specialist paediatric oncology management to provide expertise in its unique pathology, staging, and treatment, often with surgery and chemotherapy. Cancer of the bladder and ureters, another tobacco related cancer, may present as either superficial or invasive disease. The former is managed by transurethral resection and intravesical therapy. The latter may require radical surgery, preoperative chemotherapy, or radiotherapy. Prostate cancer, the commonest male cancer, is an androgen dependent malignancy. It has attracted controversy with regards to PSA screening, and potential over treatment with radical prostatectomy. Division into low, intermediate, and high risk disease according to tumour grade, stage, and PSA helps in deciding best treatment, antiandrogen therapy for metastatic disease, radiotherapy and adjuvant hormone therapy for locally advanced disease, either surgery or radiotherapy for early intermediate risk disease, and active monitoring for low risk cases. Testicular cancer divides according to pathology into seminoma, nonseminomatous germ cell tumours (NSGCT), and mixed tumours, the latter two frequently producing tumour markers, alpha-fetoprotein (AFP) and/or human chorionic gonadotrophin (HCG). Stage I disease is managed by inguinal orchidectomy and surveillance or adjuvant chemotherapy. More advanced disease is managed by chemotherapy, with high probability of cure in the majority. Penile cancer, often HPV related, can be excised when it presents early, but delay in presentation may lead to regional and systemic spread with poor prognosis.
Skin cancers
Authors: Cassidy Jim , Bissett Donald , Spence OBE Roy A. J. , Payne Miranda , Morris-Stiff Gareth , Bhattacharyya Madhumita
Published: October 2018

Tumours of the central nervous system examines the epidemiology, aetiology, genetics and pathology of these heterogeneous tumours. Clinical presentation reflects the site of origin and rate of growth. Investigation usually comprises imaging (MRI superior to CT for most), and biopsy; requirement for additional staging depends on pathology. The treatment of low-grade gliomas may be delayed if small with few symptoms, otherwise surgery and/or radiotherapy. High grade gliomas may be managed with surgery, radiotherapy, and temozolomide chemotherapy in fit patients. Unfit patients should be offered supportive care only. Brief summaries are provided for management of ependymoma, pineal tumours, meningioma, germ-cell CNS tumours, pituitary tumours, CNS lymphoma, acoustic neuroma, medulloblastoma, and spinal cord tumours. Radiotherapy for primary CNS tumours is described along with its side effects, and chemotherapy for these diseases is reviewed. Brain metastases far outnumber primary brain tumours, with generally poor prognosis, but this relates both to the pathology and patient performance status. Appropriate treatment may include surgery, radiotherapy, and/or chemotherapy.
Quality and readability of online information about type 2 diabetes and nutrition
Authors: Bernard Stephanie , Cooke Tiffany , Cole Tascha , Hachani Laura , Bernard Johnathan
Published: October 2018

Objective:

The internet has become a vital resource through which patients learn about medical conditions. The aim of this study was to assess the quality and readability of online information about nutrition and diabetes management.

Methods:

An internet search was conducted using three search terms of varying sophistication (how to eat with diabetes, diabetes diet, and medical nutrition therapy for diabetes) and the three most popular search engines (Yahoo, Bing, and Google). Forty-two websites were prospectively analyzed for quality of information and assessed for readability using the Flesch-Kincaid score.

Results:

The 42 websites reviewed demonstrated wide variability in quality, regardless of the search term entered. The reading level required to understand the materials varied based on sophistication of the search term and ranged from the 6th- to the 11th-grade level.

Conclusions:

The quality of online information on nutrition education for patients with diabetes was extremely variable and readability often was higher than the average American reading level (8th grade). An awareness of quality and readability of the materials found on the internet can strengthen the patient-provider relationship.
The Russian feldsher
Authors: Ramer Samuel C.
Published: October 2018

The feldsher is a physician assistant (PA) prototype. Developed in Russia during the 19th century to serve as healthcare personnel at a time of physician scarcity, feldshers provided medical services throughout the Russian Empire and later Soviet Union. Their medical role from the mid-19th century until the Bolshevik revolution in 1917 was crucial, particularly in rural and underserved regions. During wartime, many served in the military as medics. During the late 20th century, feldshers' numbers waned compared with physicians and nurses. In the 21st century, they remain a presence in the Russian medical system but their future is in transition as their numbers decline. However, earlier this year, Russian President Vladimir Putin urged the Russian State Duma to create more feldsher-midwife stations in rural areas. This indicates that the Russian government, at the highest levels, see the need for more feldshers to serve, essentially, as PAs in remote areas.
One in Seven Babies Exposed to Zika Virus In Utero Has Birth Defects
Authors: Potera Carol
Published: October 2018

Nurses play an important role in monitoring the health of these infants.
Opioid Use by Pregnant Women Jumps Fourfold
Authors: Potera Carol
Published: October 2018

Rate of naloxone given for overdoses also increases by 75%.
Hormonal Therapy Before Surgery for Uterine Fibroids
Authors: Atkinson Debbi
Published: October 2018

Editor's note: This is a summary of a nursing care–related systematic review from the Cochrane Library. For more information, see http://nursingcare.cochrane.org.
Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships: Results of a National Longitudinal Study
Authors: Foster Lauren M. , Cuddy Monica M. , Swanson David B. , Holtzman Kathleen Z. , Hammoud Maya M. , Wallach Paul M.
Published: October 2018

Purpose

An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined.

Method

An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences.

Results

The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining.

Conclusions

Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.
Do One Then See One: Sequencing Discovery Learning and Direct Instruction for Simulation-Based Technical Skills Training
Authors: Kulasegaram Kulamakan , Axelrod Daniel , Ringsted Charlotte , Brydges Ryan
Published: October 2018

Purpose

When teaching technical skills, educators often include a mix of learner self-regulation and direct instruction. Appropriate sequencing of these activities—such as allowing learners a period of discovery learning prior to direct instruction—has been shown in other domains to improve transfer of learning. This study compared the efficacy of learners trying a novel simulated suturing task before formal instruction (Do then See) versus the more typical sequence of formal instruction, followed by practice (See then Do) on skill acquisition, retention, and transfer.

Method

In 2015, first-year medical students (N = 36) were randomized into two groups to learn horizontal mattress suturing. The See then Do group had access to instructors before independent practice, whereas the Do then See group explored the task independently before accessing instructors. Participants were assessed at the transition between interventions, and as training ended. Skill retention, and transfer to a novel variation of the suturing task, were assessed after one week. Performance was scored on a five-point global rating scale by a blinded rater.

Results

The groups did not differ significantly on immediate posttest or retention test (F[1,30] = 0.96, P < 0.33). The Do then See group (N = 16) outperformed the See then Do group (N = 16) on the transfer test; 2.99 versus 2.52 (F[1,28] = 10.14, P < 0.004, η2 = 0.27).

Conclusions

Sequencing discovery learning before direct instruction appeared to improve transfer performance in simulation-based skills training. Implications for future research and curricular design are discussed.
Striving While Accepting: Exploring the Relationship Between Identity and Implicit Bias Recognition and Management
Authors: Sukhera Javeed , Wodzinski Michael , Teunissen Pim W. , Lingard Lorelei , Watling Chris
Published: October 2018

Purpose

Implicit biases worsen outcomes for underserved and marginalized populations. Once health professionals are made aware of their implicit biases, a process ensues where they must reconcile this information with their personal and professional identities. The authors sought to explore how identity influences the process of implicit bias recognition and management.

Method

Using constructivist grounded theory, the authors recruited 11 faculty and 10 resident participants working at an academic health science center in Canada. Interviews took place from June to October 2017. Participants took an online version of the mental illness implicit association test (IAT) which provides users with their degree of implicit dangerousness bias toward individuals with either physical or mental illness. Once they completed the IAT, participants were invited to draw a rich picture and interviewed about their picture and experience of taking their IAT. Data were analyzed using constant comparative procedures to develop focused codes and work toward the development of a deeper understanding of relationships among themes.

Results

Once implicit biases were brought into conscious awareness, participants acknowledged vulnerabilities which provoked tension between their personal and professional identities. Participants suggested that they reconcile these tensions through a process described as striving for the ideal while accepting the actual. Relationships were central to the process; however, residents and faculty viewed the role of relationships differently.

Conclusions

Striving for self-improvement while accepting individual shortcomings may provide a model for addressing implicit bias among health professionals, and relational dynamics appear to influence the process of recognizing and managing biases.
Whiplash Patients’ Responses on the Impact of Events Scale-R
Authors: Bunzli Samantha , Maujean Annick , Andersen Tonny E. , Sterling Michele
Published: October 2018

Objectives:

Posttraumatic stress disorder (PTSD) symptoms are common among people with whiplash following a motor vehicle crash. The Impact of Events Scale-Revised (IES-R) screens for PTSD symptoms with psychologist referral recommended for above-threshold scores. Recent data indicate that PTSD symptoms post-whiplash may relate more to pain and disability than the crash itself. This study explored the interpretation of IES-R items by people with whiplash to establish whether responses relate to the crash or to whiplash pain and disability.

Methods:

Adults with whiplash scoring >24 on the IES-R were eligible. The 3-step test-interview technique was used and responses analyzed using content analysis. A coding framework was developed, comprising 5 categories: “congruent”—responses related to the crash; “incongruent”—responses did not relate to the crash; “ambiguous”—responses were both congruent and incongruent; “confusion”—participants misunderstood the item content; “not applicable”—irrelevancy of items to participants’ circumstances.

Results:

The 15 participants (mean IES-R=37/88) were inclined to respond congruently to specific PTSD items and incongruently to nonspecific PTSD items. Participants were more inclined to rate nonspecific PTSD items in terms of pain and disability, for example, >60% responded incongruently to item 2: “I had trouble staying asleep”; item 4: “I felt irritable and angry”; item 15: “I had trouble falling asleep”; and item 18: “I had trouble concentrating.”

Discussion:

Incongruent responses on nonspecific PTSD items may inadvertently inflate levels of PTSD symptoms measured with the IES-R for some whiplash patients, raising implications for the assessment and treatment of the psychological sequelae of whiplash.
Clinical Updates in Women’s Health Care Summary: Perioperative Pain Management
Authors: Lian Xun , Adsumelli Rishimani , Griffin Todd R. , Gan Tong J.
Published: October 2018

The opioid epidemic in the United States has become a public health crisis, which continues to worsen. The purpose of this monograph is to help obstetrician–gynecologists develop a perioperative framework with which to identify patients at risk of dependence and addiction and to describe a multimodal approach to postoperative pain management using the pathways of enhanced recovery after surgery. Preoperative counseling and optimization of comorbid medical conditions, comprehensive patient education, and optimal postoperative management also will be reviewed.
Volatile Organic Compounds in Patients With Acute Kidney Injury and Changes During Dialysis*
Authors: Hüppe Tobias , Klasen Robert , Maurer Felix , Meiser Andreas , Groesdonk Heinrich-Volker , Sessler Daniel I. , Fink Tobias , Kreuer Sascha
Published: October 2018

Objectives:

To characterize volatile organic compounds in breath exhaled by ventilated care patients with acute kidney injury and changes over time during dialysis.

Design:

Prospective observational feasibility study.

Setting:

Critically ill patients on an ICU in a University Hospital, Germany.

Patients:

Twenty sedated, intubated, and mechanically ventilated patients with acute kidney injury and indication for dialysis.

Interventions:

Patients exhalome was evaluated from at least 30 minutes before to 7 hours after beginning of continuous venovenous hemodialysis.

Measurements and Main Results:

Expired air samples were aspirated from the breathing circuit at 20-minute intervals and analyzed using multicapillary column ion-mobility spectrometry. Volatile organic compound intensities were compared with a ventilated control group with normal renal function. A total of 60 different signals were detected by multicapillary column ion-mobility spectrometry, of which 44 could be identified. Thirty-four volatiles decreased during hemodialysis, whereas 26 remained unaffected. Forty-five signals showed significant higher intensities in patients with acute kidney injury compared with control patients with normal renal function. Among these, 30 decreased significantly during hemodialysis. Volatile cyclohexanol (23 mV; 25–75th, 19–38), 3-hydroxy-2-butanone (16 mV, 9–26), 3-methylbutanal (20 mV; 14–26), and dimer of isoprene (26 mV; 18–32) showed significant higher intensities in acute kidney impairment compared with control group (12 mV; 10–16 and 8 mV; 7–14 and not detectable and 4 mV; 0–6; p < 0.05) and a significant decline after 7 hours of continuous venovenous hemodialysis (16 mV; 13–21 and 7 mV; 6–13 and 9 mV; 8–13 and 14 mV; 10–19).

Conclusions:

Exhaled concentrations of 45 volatile organic compounds were greater in critically ill patients with acute kidney injury than in patients with normal renal function. Concentrations of two-thirds progressively decreased during dialysis. Exhalome analysis may help quantify the severity of acute kidney injury and to gauge the efficacy of dialysis.
Cardiovascular Effects of Drugs Used to Treat Attention-Deficit/Hyperactivity Disorder
Authors: Fay Thomas B. , Alpert Martin A.
Published: October 2018

Attention-deficit/hyperactivity disorder (ADHD) is a clinical syndrome characterized by persistent inattention, impulsivity, and hyperactivity. It is most commonly encountered in children and adolescents but may persist into adulthood. A variety of psychostimulant and nonpsychostimulant medications have proven to be successful in reducing inattention, impulsivity, and hyperactivity in those with ADHD. Psychostimulants used to treat ADHD include methylphenidate and related drugs and various amphetamine preparations. Non-psychostimulant medications used to treat ADHD include atomoxetine and two alpha-2 adrenergic agonists: guanfacine extended-release and clonidine extended-release. The psychostimulants and atomoxetine have been shown, on average, to increase heart rate by 3–10 beats/min, systolic blood pressure by 3–8 mm Hg, and diastolic blood pressure by 2–14 mm Hg. These drugs may also delay ventricular repolarization. The alpha-2 adrenergic agonists may reduce heart rate and blood pressure. For these reasons, there is concern about the safety of psychostimulant and nonpsychostimulant medications in patients with ADHD. In part 1 of this review, we discuss the epidemiology and natural history of ADHD, describe the pharmacology of drugs used to treat ADHD, and discuss in detail studies assessing the effects of ADHD drugs on blood pressure, heart or pulse rate, and electrocardiographic indices of ventricular repolarization.