bluuebunny/crossref_metadata_2025 huggingface dataset:
Insomnia—Behavioral Treatments
Authors: Garland Sheila N. , Vargas Ivan , Grandner Michael A. , Perlis Michael L.
Published: February 2021

Insomnia is a disorder with significant psychiatric comorbidity. This chapter provides an overview of how to assess and treat insomnia in patients with comorbid psychiatric disorders using cognitive behavioral interventions. First, the authors review the theoretical framework for the behavioral and cognitive perspectives regarding the etiology of chronic insomnia. They then provide a step-by-step guide for the assessment of insomnia, including the use of validated measures and the necessary components of a semi-structured clinical interview needed to identify predisposing, precipitating, and perpetuating factors while at the same time paying attention to possible comorbidities and differential diagnostic possibilities that may better explain the patient’s difficulty. How to treat insomnia using cognitive behavioral therapy for insomnia (CBT-I) techniques of stimulus control therapy and sleep restriction therapy with formal cognitive restructuring in order to target arousal, dysfunctional behaviors and maladaptive thoughts, beliefs, and attitudes is explained. The authors discuss a number of contemporary issues with the delivery of CBT-I including the concurrent use of sleeping medications, the limitations and side effects of CBT-I, and alternative CBT-I delivery models. Further, the chapter examines the efficacy and effectiveness data for CBT-I in patients with psychiatric comorbidities. Lastly, the chapter presents a case example of CBT-I delivery in a patient with insomnia and comorbid major depressive disorder. The authors conclude with recommendations for future research.
Sleep-Related Movement Disorders
Authors: Gupta Ravi
Published: February 2021

Sleep-related movement disorders include disorders that manifest as simple and mostly stereotyped movements occurring at sleep–wake interface or during sleep. Restless legs syndrome (RLS), the most common sleep-related movement disorder. RLS is a treatable condition that psychiatrists must be familiar with due to its common comorbidity with a broad range of psychiatric disorders. In addition, commonly used psychotropic medications are known to induce or worsen RLS symptoms in predisposed individuals, and these symptoms may be mistaken for akathisia or sleep-initiation insomnia and lead to mismanagement. This chapter discusses, among other RLS-related topics, the diagnosis, epidemiology, predisposing factors, genetic factors, and the role of iron metabolism.
Bipolar and Related Disorders
Authors: Dinerman Jacob G. , Davis Brett J. , Janos Jessica A. , Walsh Samantha L. , Sylvia Louisa G.
Published: February 2021

Bipolar disorder is a debilitating mental health condition marked by episodes of mania or hypomania and depression. A person with bipolar disorder cycles between these mood episodes throughout his or her lifetime, leading to significant impairment in functioning and overall quality of life. Sleep disturbances pervade the course of bipolar disorder, occurring before, during, and after mood episodes. Sleep disturbances also negatively impact the treatment outcome for individuals with bipolar disorder. Thus, interventions aimed at improving sleep in this clinical population are needed. This chapter discusses sleep disturbances in the context of bipolar disorder as well as empirically validated strategies to improve sleep specifically for bipolar disorder.
Anxiety, Obsessive-Compulsive, and Related Disorders
Authors: Rohrs Bruce , Gangewere Benjamen , Kaplan Alicia , Chopra Amit
Published: February 2021

Despite its common comorbidity, sleep disturbance is often underrecognized and undertreated in individuals with anxiety disorders. Compared to mood disorders, sleep disturbance in this population is less well studied except for panic disorder and generalized anxiety disorder. Some evidence suggests a bidirectional link between anxiety disorders and sleep disturbance. Polysomnography findings point to some commonalities across anxiety disorders, including longer sleep onset latency, reduced total sleep time, and reduced sleep efficiency. The underlying biological mechanisms linking anxiety disorders and sleep disturbance are still unclear. However, there is limited evidence suggesting a connection between impaired executive functioning due to sleep problems and failure to inhibit anxiety related thoughts and feelings. Cortisol irregularities and disruption in the serotonergic system may also play a role. Evidence suggests that anxiety sensitivity is a transdiagnostic factor that contributes to both anxiety disorders and sleep disturbance. Further research is warranted to elucidate common biological and psychological factors underlying sleep disturbances and anxiety disorders. There is an imminent need to systematically assess the impact of sleep disturbance on symptom severity and treatment outcomes in anxiety, obsessive-compulsive, and related disorders. Limited evidence is available for medications and targeted psychotherapeutic interventions for management of sleep disturbance thus warranting the development of robust sleep interventions to achieve optimal clinical outcomes in this patient population.
Psychotropic Medications and Sleep
Authors: Jangro William C. , Neff Daniel A.
Published: February 2021

Psychiatric disorders, apart from impairing functioning during waking hours, also exert profound effects on sleep. The interventions used in treating these disorders can exert equally strong influences on sleep homeostasis. Pharmacologic agents that treat psychiatric disorders give rise to a broad range of effects on sleep, both beneficial and deleterious. This chapter reviews the available data on how sleep is affected by medications commonly used for the treatment of psychiatric disorders. While the focus will be on antidepressants, antiepileptic mood stabilizers, and antipsychotics, as these are the best studied medication classes in the psychiatric population, hypnotics and stimulants are also addressed. The authors focus, where available, on studies conducted in psychiatric populations.
Forensic Sleep Medicine
Authors: Weiss Kenneth J. , Watson Clarence , Pressman Mark R.
Published: February 2021

Patients with sleep disorders can exhibit behavior that includes violent acts. The behavior may occur during various sleep stages, ranges in complexity, and requires an analysis of consciousness. When the behavior harms another person and criminal charges follow, expert testimony will be required to explain the physiology of the disorder and impairments in consciousness that determine criminal culpability, that is, whether there was conscious intent behind the behavior. In this chapter, sleep-related conditions associated with violent behavior are discussed, along with guidelines for presenting scientific testimony in court. These disorders include rapid eye movement (REM) behavior disorder, somnambulism and other non-REM partial awakenings, and hypersomnolence. Feigned symptoms and malingering must be ruled out, and the clinical parameters for them are discussed. While the physiology of sleep disorders has widely been known, admissibility in court is not automatic. Standards for acceptable expert testimony are discussed.
A Roadmap Toward Convergence Mental Health
Authors: Smith Erin , Lavretsky Helen , Reynolds III Charles F , Berk Michael , Eyre Harris A.
Published: February 2021

The shift toward convergence mental health will be underpinned by developments in three main areas: (i) research, (ii) initial commercialization, and (iii) scaling up market penetration. Unique barriers exist within each area. Within the research stage, the main challenges are in the following areas: informational, leadership, structural and organizational, and education and workforce development. This chapter addresses each of these areas and provides recommendations for moving forward. Further, this chapter examines where the mental health sector currently is and where it is heading to understand the challenges and opportunity to advance convergence mental health from research to initial commercialization to scaling up market penetration to advance brain science discoveries and translate these findings from the lab to make them readily available and accessible.
Practical Aspects of Initiating and Maintaining a Multidisciplinary Program
Authors: Thaler Erica R. , Rodin Julianna
Published: February 2021

This chapter, written from the perspective of an otorhinolaryngologist/head and neck surgeon, discusses the practical aspects involved in creating a successful multidisciplinary program to provide upper airway stimulation therapy for patients with obstructive sleep apnea. Topics covered are critical professional elements, including proper education and training; the importance of multidisciplinary professional collaboration; how best to develop an integrated approach; and the optimal administrative approach. Economic considerations and cost-effectiveness information relevant to this therapy are also discussed. The goal is to guide the interested practitioner in building a robust program providing upper airway stimulation therapy that will be adaptable to future technological innovation in this burgeoning field.
Neuroimaging and fluid biomarkers of Alzheimer’s disease
Authors: Varma Vijay R , Chuang Yi-Fang , Thambisetty Madhav
Published: February 2021

Neuroimaging and fluid biomarkers have revolutionized the way we define Alzheimer’s disease (AD), identify at-risk individuals, diagnose those with symptoms, and may eventually enable us to treat patients in the earliest stages of the disease. We review advances in imaging the principal pathological hallmarks and functional perturbations in the AD brain and map progress in identifying cerebrospinal fluid and blood biomarkers of AD. Together, these modalities have provided invaluable insights into the evolution of AD decades before the onset of cognitive impairment. While they have been rapidly adopted into clinical settings, the evidence base for this remains contested. However, the clear value of neuroimaging and fluid biomarkers is in their relevance to clinical trials and the recruitment of individuals who perceive themselves to be at sufficiently high risk to warrant joining research studies testing experimental AD treatments. This marks a paradigm shift in our efforts to overcome one of the global public health challenges of our time.
Conducting research in low- and middle-income settings
Authors: Guerchet Maëlenn , Mayston Rosie , Prina A Matthew
Published: February 2021

A vast research gap in publishing between high-income (HIC) and low and middle-income countries (LMIC) exists. Given sociocultural, health systems, and geopolitical differences, results from studies carried out in high resource countries are clearly not generalizable to a truly global context. Collaborations and equal partnerships are contributing to strengthen partnerships between HIC and LMIC research, improve research capacity, and increase outputs from LMIC. This chapter aims to highlight challenges and opportunities in carrying out collaborative research in LMICs, based on the experience of UK-based researchers working with many partners across diverse settings. Cross-cultural work is not always easy and specific issues need to be addressed at different stages of the research regarding foundations for research, data collection, and impact and sustainability in order to make real impact in policy and practice. The rise of global health research is an opportunity to develop neuropsychiatric research in LMIC.
Early onset Alzheimer’s disease
Authors: Ellajosyula Ratnavalli
Published: February 2021

The term ‘early onset Alzheimer’s disease’ (EOAD) is used when symptoms of Alzheimer’s disease (AD) occur in patients younger than 65 years. EOAD is an uncommon condition and data on epidemiology is limited. Prevalence rates range from 15 to 200 and incidence rates 2.4–22.6 per 100,000 population. Prevalence rates increase with age similar to that for late onset AD. The prevalence of autosomal dominant EOAD is 5.2 per 100,000. Half of these patients have an underlying mutation in amyloid precursor protein, presenilin 1 or 2 genes. Apolipoprotein E genotype is a risk factor for EOAD and homozygotes have an earlier age of onset. Methodological issues and geographical location make comparisons across epidemiological studies difficult. Further cross-national and cross-cultural studies with standardized methodology are necessary to understand the role of risk and protective factors, as well as to estimate the burden of the disease.
Huntington’s disease
Authors: R Dutra Juliana , P Garcia Tanya , Marder Karen
Published: February 2021

Huntington’s disease (HD) is an autosomal dominant, neurodegenerative disorder caused by an unstable expansion in the cytosine adenine guanine (CAG) trinucleotide repeat in the huntingtin gene. The disease onsets gradually over many years and its symptoms include extrapyramidal movement disorder, cognitive impairment, and behavioural changes. Understanding the overall progression of HD is critical to designing clinical trials with possible disease modifying agents. Research in this area has exploded in the past two decades, as different multicentre studies have evaluated both clinical and biological measures in individuals at different stages of the disease (i.e. at-risk for the genetic mutation, pre-manifest, and manifest HD). In this chapter, we provide readers with a current understanding of HD progression. This includes an overview of the current standard for how HD is clinically evaluated, descriptive epidemiology of the disease, genetics of HD, and a review of potential disease modifiers.
Rare neurodegenerative parkinsonism (PSP, MSA, CBD)
Authors: Rowe James B , Coyle-Gilchrist Ian TS
Published: February 2021

Progressive supranuclear palsy (PSP), corticobasal syndrome (CBS), and multiple system atrophy (MSA) are three neurodegenerative disorders that lead to parkinsonism amidst a constellation of other distinctive clinical signs and symptoms. In their classical forms they are distinct, and associated with specific neuropathologies. However, non-classical presentations of these pathologies are increasingly recognized, and may even form the majority of presentations, especially for PSP. In addition, phenotypic mimicry, syndromic evolution during the course of illness, and high rates of misdiagnosis and under-diagnosis have all complicated the estimation of the prevalence and incidence of these disorders. Here we review the available data for the epidemiology of these disorders, which arises mainly from Europe, the USA, and Japan. We set these estimates in the context of the changing diagnostic criteria and contemporary knowledge of clinico-pathological correlations. Despite the challenges, and widely varying methods, there is a convergence of estimated prevalence and incidence over the last 20 years, at least for the classical presentations of these three disorders. New studies are required that take into account revised clinical diagnostic criteria, non-classical presentations, and misdiagnosis.
Stroke and TIA
Authors: Norrving Bo
Published: February 2021

Concurrent data on stroke epidemiology are important for preventive actions and healthcare planning. Reliable global statistics have only been available for less than a decade, and signal an urgent need for action to prevent stroke. Stroke is the second leading cause of death and disability worldwide. The bulk of stroke burden is borne by developing countries. Geographical differences between countries and regions persist and have even increased. There is still no country in the world where the burden of stroke, in terms of absolute number of people affected by or died from stroke, has declined over the last two decades. The overall burden of stroke in younger adults is increasing globally, and now represents almost half of the total burden from stroke. Risk factors for stroke are well known. Stroke is highly preventable, and treatable. With appropriate actions a substantial reduction in the burden of stroke should be possible.
The epidemiology of apathy in neurological disorders
Authors: Starkstein Sergio , Hayhow Bradleigh , Wibawa Pierre
Published: February 2021

Apathy is defined as an independent psychiatric syndrome characterized by deficits in goal-directed behaviour, goal-directed cognitions, and the emotional concomitants of goal-directed behaviour. Apathy is present in both neurodegenerative disorders such as dementia, and in acute neurological disorders such as stroke. This chapter will review the frequency and correlates of apathy in Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, and stroke. In all these disorders, diagnosis of apathy is complicated by the symptom overlap with depression and cognitive impairment. Nevertheless, structured diagnostic interviews, ratings scales, and standardized diagnostic criteria for apathy have been recently developed. Apathy is one of the most frequent behavioural complications of neurological disorders; it is associated with poor quality of life and increased caregiver burden. Treatment of apathy is limited to small case series, and its specific management in the different neurological condition remains unclear.
Behavioural and psychological symptoms of dementia
Authors: van der Linde Rianne , Dening Tom
Published: February 2021

The term: ‘behavioural and psychological symptoms of dementia’ (BPSD) refers to a mixed group of phenomena. BPSD are the non-cognitive features of dementia and include depression, anxiety, psychotic symptoms, apathy, irritability, aggression, and sleep and eating problems. They occur in around 80% of people with dementia at some stage, several of them becoming more frequent as dementia progresses. Some BPSD, notably apathy, are very persistent. BPSD often limit the person’s quality of life and can be stressful for carers. Causes of BPSD include biological, psychological, social, and environmental factors. This chapter explores how they are assessed and measured, and how they may usefully grouped together in symptom clusters. Usually four symptom groups are found: affective symptoms, psychosis, hyperactivity, and euphoria. However, these are not always consistent and in particular apathy does not consistently belong in one group. Approaches to management of BPSD are outlined.
Epidemiology of schizophrenia and related disorders
Authors: Jablensky Assen , Jongsma Hannah E , Kirkbride James B , Jones Peter B
Published: February 2021

Epidemiological approaches to understanding the frequency, distribution, and determinants of psychotic disorders, such as schizophrenia, have played a vital role in delineating the aetiology and course of these conditions for almost a century. Despite several milestones, reviewed in this chapter, many methodological and clinical aspects of these disorders continue to provide challenges to studying the epidemiology of psychotic disorders, including issues of case definition, case ascertainment, and study design. After summarizing these challenges, we review the current neuropsychiatric epidemiologic knowledge of the incidence, prevalence, and aetiology of psychotic disorders. Here, we also provide a contemporary overview of the role that genetic, neurodevelopmental, demographic and environmental risk factors, including inflammation, traumatic life events, substance abuse, urban living, and minority status have on risk, course, and outcome of psychotic disorder. We conclude with future directions required to elucidate the interplay of these factors in contributing to the global burden of psychotic disorders.
Myasthenia gravis
Authors: Heldal Anne Taraldsen , Gilhus Nils Erik
Published: February 2021

Myasthenia gravis (MG) is an autoimmune disorder caused by auto-antibodies targeting the neuromuscular junction, leading to muscle weakness and fatigability. A large number of MG epidemiological studies have been performed, with a trend towards an increase in MG prevalence over time. Annual MG incidence has also increased over time, explained by factors such as improved case-finding, with better neurological services and an ageing population. The mortality rate of MG has been markedly reduced. The excess mortality rate is now particularly the case during the first few years after diagnosis. The aetiology of acquired MG is unknown, including both genetic and environmental risk factors, except from paraneoplasia in cases with thymoma. Genome-wide association studies (GWAS) have become an important approach for identifying susceptibility genes for complex traits. Migration studies should provide new insights into genetic and environmental causative factors and should be a major issue for future epidemiological studies.
Sensory loss—vision
Authors: Foster Paul J , Khawaja Anthony , Balk Lisanne J , Muthy Zaynah , Petzold Axel
Published: February 2021

This chapter focuses on degenerative optic neuropathy. The retina and optic nerve share their embryological origin with the brain and are widely regarded as part of the central nervous system. Retinal microvasculature and neuronal components offer a unique ‘window’ on tissues that are closely allied to intracranial structures. Consequently, the eye is vulnerable to the same processes that cause neurodegenerative diseases. Axonal damage in the brain may affect the retinal nerve fibre layer (RNFL), the inner plexiform, and ganglion cell layers, halting at the level of the inner nuclear layer. On this basis, it seems that it is likely that patterns and trends in the inner retinal layers mirror those in the brain, and that these patterns may reflect wider risk of neurodegenerative changes. The dementias and Parkinson’s disease are associated with measurable changes in the retina and optic nerve. Two specific forms of degenerative optic neuropathy that deserve special consideration on the basis of their greater frequency are glaucoma and multiple sclerosis (MS) associated optic neuritis (MSON).
Sensory loss—hearing
Authors: Goman Adele M , Lin Frank R
Published: February 2021

Hearing loss is a major public health issue. Hearing loss increases with age and nearly two-thirds of adults over the age of 70 have hearing loss. Epidemiologic studies have demonstrated that hearing loss in older adults is strongly and independently associated with accelerated cognitive decline and incident dementia. Hypothesized mechanistic pathways underlying this observed association include the effects of poor hearing and distorted peripheral encoding of sound on cognitive load, brain structure/function, and reduced social engagement. Identifying interventions to reduce cognitive decline is a critical public health priority. Research thus far has suggested that interventions for hearing loss can provide benefits to cognitive functioning although further research is needed to determine whether hearing rehabilitative strategies could affect cognitive decline and the risk of dementia.
Global evidence generation
Authors: Ogunniyi Adesola
Published: February 2021

Disparities in the distribution of neurological and mental health disorders (NMHD) in different regions of the world can provide clues on the putative risk factors while providing basis for intervention strategies. This chapter utilizes the Global Burden of Diseases (GBD) data and the disability adjusted life years (DALY) calculations in the different World Health Organization (WHO) regions to adduce reasons for the peculiarities observed. The focus is on the most common NMHD, particularly those for which preventive strategies are likely to result in improved health outcomes for the majority of those affected. In this regard, stroke, epilepsy, and depressive disorders have been given special attention because of their high societal impact and the extensive studies from different regions. Dementia deserves special mention in view of its looming epidemic in low and middle income countries (LMICs), while its burden is lessening in high income countries (HICs) due to appropriate interventions and higher education.
Hybrid coronary revascularization
Authors: Kayatta Michael O. , Liberman Henry A. , Halkos Michael E.
Published: February 2021

Traditionally, the treatment of coronary artery disease has been divided among medical therapy, percutaneous coronary intervention, or coronary artery bypass grafting. However, with hybrid coronary revascularization (HCR), both percutaneous coronary intervention and coronary artery bypass grafting are utilized to treat different lesions in the same patient; the goal being to take advantage of the benefits of each procedure while minimizing their limitations. This chapter will discuss the advantages and disadvantages of hybrid coronary revascularization, patient selection, and the various techniques and strategies used in successful hybrid coronary revascularization programmes.
Cardiovascular assessment and care
Authors: Spiers Christine
Published: February 2021

Cardiovascular disease remains a major cause of death in the United Kingdom. The early recognition of cardiovascular deterioration in the acutely ill patient is an essential skill for practitioners in acute care. This chapter offers an overview of the cardiovascular system and normal physiological and compensatory mechanisms which support cardiovascular function. Cardiac assessment is explored in some detail including symptom review, cardiac monitoring, and chest pain assessment. The complex subject of arrhythmia interpretation and management is reviewed in some depth. The chapter concludes with a focus on the management of acute coronary syndromes, heart failure, and cardiogenic shock. All three conditions are potentially life-threatening and rapid assessment and treatment is essential to prevent mortality; evidence-based management of these conditions is considered in detail within this chapter.
Acute kidney injury
Authors: Osorio Cristina , Fotis Theofanis
Published: February 2021

Assessing and supporting kidney function is an integral aspect of acute care. AKI (acute kidney injury) may cause sudden, life-threatening biochemical disturbances and hence the early identification, escalation to treatment and management of AKI is an important focus in the management of acutely ill patients. This chapter reviews kidney anatomy and physiology followed by the nursing care involved in assessing and managing abnormal kidney function. The focus is on relevance and applicability to clinical practice and understanding of kidney function as protective measures and early detection of anomalies greatly reduces the risk of acute kidney injury. Common renal pathologies are explored and the role of renal replacement therapies is discussed.
The care of patients with gastrointestinal disease and nutritional support for the acutely ill patient
Authors: Martyn Katharine , Creed Fiona
Published: February 2021

Acutely ill patients are often admitted to hospital with gastrointestinal conditions, in particular pelvic and abdominal pain. It is therefore essential that nurse has an understanding of the factors that impact on gut function. This chapter will therefore provide an overview of the gastrointestinal (GI) system and explore the normal anatomy and physiology of the GI tract and the accessory organs (liver, gall bladder, and pancreas). It explores the role of the nurse in caring for patients with nausea and vomiting, diabetes mellitus, and the importance of nutritional assessment and management during episodes of acute illness.
Bronchiolitis
Authors: Fulton Crawford , Thorburn Kentigern
Published: February 2021

Bronchiolitis is one of the commonest reasons for paediatric critical care admission in infants. This chapter explores the epidemiology of bronchiolitis, risk factors for severe illness, and various management strategies. In particular, this chapter explores the assessment of a deteriorating child with bronchiolitis and escalation strategies, including high-flow nasal cannula oxygen and non-invasive respiratory support progressing to invasive mechanical ventilation. This chapter includes a review of the literature related to supportive therapies such as nebulized saline, bronchodilators, and saturation targets. Indications for intubation, various intensive care strategies, and their relative effectiveness are also discussed. The role of respiratory extracorporeal membrane oxygenation in bronchiolitis is also explored.
Paediatric acute respiratory distress syndrome
Authors: Eberhardt Christiane S. , Rimensberger Peter C.
Published: February 2021

Acute respiratory distress syndrome (ARDS) is an important condition associated with significant morbidity and mortality in both adults and children. Chapter 6 begins by explaining the definition of paediatric ARDS (PARDS), its severity stratification, risk factors for its development, and its pathophysiology. The evidence base for lung-protective ventilation strategies is covered, with recommended goals given permissive hypoxaemia and hypercapnia. Different modes of ventilation for ARDS are examined: non-invasive ventilation, conventional mechanical ventilation, high-frequency oscillatory ventilation, and neutrally-adjusted ventilator assist, and the relative merits of pressure and volume limitation for lung protection in adults and children. Adjuvant therapies for PARDS are explored: fluid restriction; neuromuscular blocking agents; prone positioning; steroids; inhaled nitric oxide; and surfactant therapy. The chapter concludes by addressing the challenges that remain in defining and managing ARDS, and suggests how patients should be followed up following discharge.
Difficult airway in the Paediatric Intensive Care Unit
Authors: O’Donohoe Elizabeth , Breen Thomas , Reynolds Fiona
Published: February 2021

Children with difficult airways can come to significant harm if not appropriately assessed and managed. Chapter 10 discusses the signs of airway compromise in children and indications for intubation in the Intensive Care Unit (ICU). The role of the paediatric airway in respiratory physiology is examined. Recognizing a difficult paediatric airway is vital in the ICU—common causes of upper airway obstruction are listed and techniques for assessing paediatric airways addressed. The choice of drugs for rapid sequence induction in the Paediatric ICU is explained, and algorithms for the management of the unanticipated difficult tracheal intubation and ‘cannot intubate, cannot ventilate’ illustrated. Finally, the chapter includes the fundamental concepts of team brief, checklists, and crisis resource management in the safe management of difficult airways in children.
Extracorporeal life support
Authors: Barbaro Ryan P. , Annich Gail , Kirsch Roxanne
Published: February 2021

Using the narrative about a child with severe respiratory infection and septic shock, this chapter illustrates important learning points around both veno-arterial and veno-venous extracorporeal life support (ECLS) in children. Several important considerations such as patient selection, anticoagulation, management of bleeding complications, and respiratory rehabilitation on ECLS are discussed. The chapter includes a brief discussion of other forms of mechanical circulatory support (e.g. ventricular assist device) and early mobilization while on ECLS. The chapter highlights difficulties with prognostication, ethical decision-making dilemmas in patients on longer-term ECLS support, and provides a useful framework for decision-making.
Biological aspects of human ageing
Authors: Gray Doug , Proctor Carole , Kirkwood Tom
Published: February 2021

At the molecular and cellular levels, human ageing is characterized by the accumulation of unrepaired random damage and an accompanying loss of function. A major source of damage is oxidative stress caused by the generation of reactive oxygen species as a by-product of respiration. DNA and proteins are both susceptible to damage, but whereas DNA damage repair systems exist, faulty proteins are generally removed by protein degradation systems. During ageing, these systems become less efficient and the subsequent accumulation of damaged protein promotes protein aggregation, a process which is especially problematic in the ageing brain. Other aspects of ageing include genetic and epigenetic changes, mitochondrial dysfunction, telomere shortening, and cellular senescence, all subject to stochasticity. The complexity of the biology of ageing has led to an increase in the use of systems biology approaches whereby the use of mathematical modelling and bioinformatic tools complement the more traditional experimental approaches.
Biomarkers for Alzheimer’s disease
Authors: Vergallo Andrea , Hampel Harald , Bun René S. , Lista Simone
Published: February 2021

Reflecting the neuropathological hallmarks of Alzheimer’s disease (AD), cerebrospinal fluid (CSF) concentrations of Aβ‎1-42, t-tau, and p-tau and positive amyloid positron emission tomography (PET) imaging are considered core biomarkers for AD. Unfortunately, their use for screening is limited by their invasive nature (CSF biomarkers) or high cost (PET imaging). Among the biologic specimens that may be scrutinized for identifying novel AD biomarkers, circulating blood is a convenient source for sampling. The dynamic range of high-throughput technological platforms, coupled with advances in bioinformatics, holds the promise that proteomics will be a significant contributor to the field of blood-based AD biomarkers. Here, the chapter summarizes the blood-based biomarker platforms applied to the investigation of AD and reviews recent achievements in plasma/serum proteomics related to AD. These findings set the stage for the implementation of systems biology in the context of the evolving precision medicine paradigm for AD.
Clinical biomarkers in the diagnosis of dementia
Authors: Barber Robert
Published: February 2021

Biomarkers support clinical practice in almost every area of medicine and are increasingly used in the assessment of brain diseases. Their role in the diagnosis of dementia is covered in this chapter. Structural neuroimaging should be considered in all patients with suspected dementia. Functional imaging offers additional insights into the biological activity of the brain, providing estimates of regional cerebral blood flow, glucose metabolism, dopamine neurotransmission, and amyloid burden. Certain dementias, notably Alzheimer’s disease, also have a characteristic profile of cerebrospinal fluid biomarkers. The diagnostic roles of these different biomarkers are explored to help guide their application in clinical practice.
Clinical cognitive assessment
Authors: O’Dowd Sean
Published: February 2021

Clinical cognitive assessment demands a multifaceted approach. The history is key and the examiner must ascertain from the patient and/or an informant the salient symptoms leading to the presentation, as this will have useful localization—and diagnostic—value. An exploration of the affected cognitive domains should be supplemented by an effort to establish the tempo of progression of the syndrome—the relevant background history, family history, and the psychosocial milieu. Cognition can be assessed in both a qualitative and a quantitative fashion; it is important to ensure that all domains are evaluated. Other neurological or psychiatric symptoms should be noted, and the cognitive examination should be supplemented by an appropriately focused neurological examination. A thorough clinical assessment, or ‘phenotyping’ exercise, will often strongly suggest a diagnosis prior to imaging or other tests or, at the very least, guide the appropriate investigation approach for an individual patient.
Neurostimulation therapies
Authors: O’Connor Daniel W. , Plakiotis Christos , Farnbach Peter
Published: February 2021

Electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS) all entail the delivery of electrical impulses to the brain with the aim of relieving mental disorders. ECT is an effective treatment of depression, mania and catatonia and, to a lesser extent, of schizophrenia. Its side effects, principally cognitive impairment, are mitigated through the use of individually tailored, unilateral delivery. TMS is more convenient but of lesser effectiveness. DBS, while reversible and thus safer than lesional surgery, is a major undertaking that is reserved at present for profoundly disabling depression, obsessive-compulsive disorder (OCD), and Tourette’s syndrome.
Pharmacological treatment of dementia
Authors: Jones Roy W
Published: February 2021

This chapter summarizes the available clinical evidence for pharmacological treatments for dementia with an emphasis on practical considerations and realistic expectations of currently available antidementia drugs. It covers the treatment of both cognitive and non-cognitive symptoms. The search for specific treatments for dementia has inevitably concentrated on Alzheimer’s disease (AD), partly because it is the commonest cause of dementia and partly because scientific progress has provided more potential therapeutic targets for AD than other dementias. AD is treated with AChEIs (donepezil, galantamine, or rivastigmine) and the goals of treatment should be explained at the commencement of treatment. For dementia with Lewy bodies (DLB) use AChEI, especially for hallucinations and other behavioural disturbance and consider memantine or increasing dose if BPSD symptoms persist. For vascular dementia (VaD) look for sources of emboli (e.g. carotid disease) and consider anticoagulation for atrial fibrillation, and low-dose aspirin. Ensure other relevant conditions (e.g. hypertension and diabetes) are being managed appropriately.
Late-onset schizophrenia
Authors: Lee Ellen E. , Hou Baichun , Vahia Ipsit V. , Jeste Dilip V.
Published: February 2021

Late-onset schizophrenia remains an understudied subtype of schizophrenia, despite growing recognition of its impact and distinction from early-onset schizophrenia. This chapter reviews the existing literature on late-onset schizophrenia including beginning with the nomenclature and epidemiology. Then we provide a review of key risk factors and correlates—including genetic risk, sex differences, comorbid sensory loss and physical illness, cognitive and psychiatric symptoms, sociodemographic factors, adverse life events, neuropathology, and inflammation. The chapter ends with clinical issues, including symptoms, differential diagnosis, treatments, and prognosis. Recent studies have examined the role of oestrogen treatments and a new therapy for tardive dyskinesia therapy as well as inflammatory mechanisms in schizophrenia.
Alcohol and substance misuse
Authors: Rao Tony , Jones Katy A.
Published: February 2021

Older people now represent a group at highest risk of rising substance misuse. This applies to alcohol as well as both illicit and prescription drugs. It is a trend that is likely to continue for decades to come, during which time we expect to see further increases in rates of illicit and prescription drug misuse. These problems are likely to pose a considerable burden on public health and clinical services, the problems being compounded by comorbid mental and physical disorders, polypharmacy and psychosocial problems such as retirement, loneliness, and bereavement. There is considerable scope for education and workforce development to improve screening and assessment, as well as exploring barriers to entering treatment, treatment options, and factors to promote recovery. Given the limited evidence base for treatment of substance misuse in older people, there is a pressing need for further research through both observational and analytical studies.
Sexuality in older age
Authors: Hinchliff Sharron , Fileborn Bianca
Published: February 2021

This chapter examines the research evidence to present key issues in the sexuality and ageing field. The chapter utilizes a sexual rights framework to contextualize sexuality and ageing for psychiatry and psychiatric practice. It discusses sexual activity in middle and later life and the sexual difficulties that older adults can experience. It explores sexual risk-taking in older cohorts and the current global trend of increased diagnoses of STIs in older adults. It also discusses the highly neglected areas of sexual violence, sexual consent, and partner communication in older adults. The chapter ends with a focus on the barriers to sexual communication between health professionals and older patients, and provides guidance and tips—specifically the ‘Three Ps’ approach: Privacy, Permission, and Practice—for clinicians to use to improve sexual communication with patients.
Gynaecology
Authors: Goumalatsou Charlotte
Published: February 2021

This chapter in the Oxford Handbook of Clinical Specialties describes the gynaecology specialty, including history and examination, sexual health and dysfunction, gynaecological anatomy, genital abnormalities, and female genital mutilation. It also explores menstruation, polycystic ovarian syndrome, menorrhagia, premenstrual syndrome, menopause, and HRT (hormone replacement therapy). It discusses pregnancy, including termination, miscarriage, and ectopic pregnancy. It investigates the vulva, vaginal discharge, PID (pelvic inflammatory disease), the uterus, pelvic pain, dyspareunia, fibroids (uterine leiomyomata), and endometriosis. It explores subfertility and ovarian hyperstimulation syndrome. It describes contraception and sterilization, as well as incontinence and prolapse. It investigates vulval lumps, ulcers, carcinoma, and cervical screening. It describes cancer, including vaginal, ovarian, and endometrial, as well as benign ovarian tumours and gynaecological surgery.
Orthopaedics
Authors: Clutton Juliet
Published: February 2021

This chapter in the Oxford Handbook of Clinical Specialties explores orthopaedics. It explains terminology and principles of examination, and reviews different areas of the body in turn: the neck and neck pathologies are described, as well as the shoulder, elbow, wrist, and hand. Back examination is discussed and causes of back pain are described alongside simple lower back pain and specific and sometimes sinister back pain. The hip is investigated, from history and examination to painful hips in children and developmental dysplasia. Knees and feet are explored, including club foot and knee history and examination, pain in the knee, and knees that swell. Bones are discussed, including osteomyelitis and benign and malignant bone tumours, congenital disorders of bone and cartilage, and osteochondroses. Joints are investigated, from joint replacement (arthroplasty) to aspiration, injections, and tendon rupture and injury. Soft tissue and sports injuries are also explored.
Emergency medicine
Authors: Graham Blair
Published: February 2021

This chapter in the Oxford Handbook of Clinical Specialties explores the specialty of emergency medicine. It describes the work of a doctor in the emergency department (ED), including an overview of emergency medicine and ED teams, triage, crowding, exit block, clinical decision-making, patient expectations, and patient assessment. It investigates common procedures in depth, including advanced life support and management of pain and sedation. It discusses commonly encountered problems such as shock, the unwell child, and major trauma from brain injury to thoracic, abdominal, and pelvic trauma, as well as major burns, environmental emergencies, emergency toxicology, sepsis, loss of consciousness, stroke, acute severe headache, chest pain, acute shortness of breath, abdominal pain, atraumatic back pain, extremity problems, common limb injuries, bites and stings, foreign body ingestion, and wound care.
Pre-hospital emergency medicine
Authors: Collingwood Terry
Published: February 2021

This chapter in the Oxford Handbook of Clinical Specialties explores the specialty of pre-hospital emergency medicine. It reviews pre-hospital emergency medicine in general, including activation of the emergency services and major trauma networks in the UK. It gives practical advice on assessment on arrival at the scene, hazards to consider, triage, and initial patient assessment before going into specifics including how to deal with shock, the entrapped patient, pre-hospital analgesia, splintage and manipulation, and injuries to the head, spine, and chest. It explores pre-hospital care of special interest groups and emergency anaesthesia, traumatic cardiac arrest, and how to approach a major incident. It investigates the importance of public health, and how to develop lasting resilience as a member of the pre-hospital emergency team.
Forced migration
Authors: Foxen Patricia
Published: February 2021

Forced migration has increased dramatically in the past few decades, and the causes of displacement have become increasingly complex. There is no doubt that wars and natural disasters propel forced migration. In addition, factors such as population pressures, international development projects and transnational extractive businesses, environmental degradation, flooding and drought resulting from climate change and extreme weather, intense economic inequality and marginalization, rampant criminal trafficking networks (of humans, drugs, and other resources), corruption, and ineffectual justice systems are also important in understanding forced migration. The interaction of these processes contributes to vast levels of human insecurity. Furthermore, the weakness of many nation-states in looking after their vulnerable populations can contribute to these push factors, leading to widespread migration. It is critical that both forced migration and the humanitarian apparatus designed to address it be understood in contemporary society within this broader confluence of factors, themselves embedded in processes of rapid globalization, neoliberal economic policies, and growing inequality.
Sociocultural phenomenology of world migrations
Authors: Alarcón Renato D.
Published: February 2021

World migrations, a strong component of the process of globalization, reflect a complex set of phenomena in need of detailed description and deep understanding. The role of sociocultural factors and variables in the different aspects of the migration process includes an analysis of factors or reasons for migrating followed by the decision-making process, the participants, the journey itself, and its vicissitudes. In addition to explanations offered about the structure and development of a variety of emotional experiences and their consequences (stigma and clinical entities included), the processes of acculturation, acculturative stress, and its sociocultural management are subjected to careful assessment. Empowering individuals in terms of civic capacity and personal efficacy, fostering of solidarity and strong social identities besides a shared commitment to collective well-being are important ingredients of this process. The elaboration of advanced legislation, public health measures, appropriate public education, and specific professional training are also indispensable measures.
Early assessment of mental health and options for documentation of torture in newly arrived asylum seekers
Authors: Sveaass Nora , Lie Birgit
Published: February 2021

This chapter describes experiences regarding early health assessment of persons seeking protection in a new society, and discusses these in relation to existing research. as well as to policies and recommendations from states, academia, and civil-society organizations. Early identification and documentation of torture and other human rights violations with regard to follow-up, protection needs, right to reparation, and access to justice are touched upon. There is a growing acknowledgement of the importance of early assessment of health and early identification of health-related problems in persons exposed to ongoing and serious stress. We will argue that this should also be understood in terms of international obligations to provide health care and other forms of redress to persons subjected to torture and ill treatment. States receiving refugees and asylum seekers must consider good health assessments and services to persons seeking protection, as part of their human rights obligations, as well as good and sound public health approach.