bluuebunny/crossref_metadata_2025 huggingface dataset:
Survival after introduction of adjuvant treatment in stage III melanoma: a nationwide registry-based study
Authors: Helgadottir Hildur , Ny Lars , Ullenhag Gustav J , Falkenius Johan , Mikiver Rasmus , Olofsson Bagge Roger , Isaksson Karolin
Published: May 2023

Background

Adjuvant treatments with PD-1 and BRAF+MEK inhibitors statistically significantly prolong recurrence-free survival in stage III cutaneous melanoma. Yet, the effect on overall survival is still unclear. Based on recurrence-free survival outcomes, these treatments have been approved and widely implemented. The treatments have considerable side effects and costs, and overall survival effect remains a highly anticipated outcome.

Methods

Clinical and histopathological parameters were obtained from the Swedish Melanoma Registry for patients diagnosed with stage III melanoma between 2016 and 2020. The patients were divided depending on if they were diagnosed before or from July 2018, based on the timepoint when adjuvant treatment was introduced in Sweden. Patients were followed up until the end of 2021. In this cohort study, melanoma-specific and overall survival were calculated using the Kaplan-Meier method and Cox-regression analyses.

Results

There were 1371 patients diagnosed with stage III primary melanoma in Sweden in 2016-2020. The 2-year overall survival rates, comparing the 634 patients in the precohort and the 737 in the postcohort, were 84.3% (95% confidence interval [CI] = 81.4% to 87.3%) and 86.1% (95% CI = 83.4% to 89.0%), respectively, with an adjusted hazard ratio of 0.91 (95% CI = 0.70 to 1.19, P = .51). Further, no statistically significant overall or melanoma-specific survival differences were seen when comparing the precohort and the postcohort in different subgroups for age, sex, or tumor characteristics.

Conclusions

In this nationwide population-based and registry-based study, no survival benefit was detected in patients diagnosed before or after the implementation of adjuvant treatment in stage III melanoma. These findings encourage a careful assessment of the current recommendations on adjuvant treatment.
Shaoyao Gancao Decoction protects against dextran sulfate sodium-induced ulcerative colitis by down-regulating ferroptosis
Authors: Hu Shian , Luo Yue , Yang Xuebing , Zhou Zhe , Zhou Feng , Zhong Lulu , Tan Yang , Pei Gang , Tan Yang
Published: May 2023

Objectives

Shaoyao Gancao Decoction (SGD) is a well-known Chinese herbal prescription used to treat ulcerative colitis (UC). This study was designed to evaluate the effect of SGD in dextran sulfate sodium-induced UC and to reveal the potential mechanism.

Methods

A UC mouse model was established by the administration of dextran sulfate sodium. The mice were given SGD extract intragastrically for 7 days. Histological pathology, inflammatory factors, and ferroptosis regulators were determined in vivo. In addition, ferroptotic Caco-2 cells were prepared to investigate the underlying mechanism of the effects of SGD.

Key findings

The results showed that SGD reduced the disease activity index, the level of inflammatory factors, and histological damage in mice with UC. Moreover, SGD down-regulated the level of ferroptosis in cells in colon tissue, as evidenced by a reduced iron overload, decreased glutathione depletion, and a lower level of malondialdehyde production, compared with the model group. Correspondingly, similar effects of SGD on ferroptosis were observed in Erastin-treated Caco-2 cells. The results of our in vitro reactive oxygen species assays and the changes in mitochondrial structure observed by scanning electron microscopy also supported these results.

Conclusion

Taken together, these findings suggest that SGD protected against UC by down-regulating ferroptosis in colonic tissue.
Poorly differentiated sarcoma of the maxillary sinus: a histopathology dilemma of a rare tumor
Authors: Šimunjak Tena , Šimunjak Boris , Jurlina Martin , Zrno Matea
Published: May 2023

Sarcomas are a rare heterogeneous group of neoplasms of mesenchymal origin. In the redistribution of all head and neck malignancies, sarcomas are represented by only 1%. Herein, we report a case of a 66-year-old patient with right maxillary sinus sarcoma that spread through the ostiomeatal complex, infiltrated the septum, all ethmoid cells, frontal sinus, involved the entire right nasal cavity and penetrated to the nasopharynx. Patient was treated with neoadjuvant chemotherapy, surgery and adjuvant radiotherapy. The histopathology indicated poorly differentiated sarcoma with elements of Ewing’s sarcoma, but also with elements consistent with osteosarcoma. Molecular pathological analysis excluded Ewing's sarcoma. Samples were also sent for review to the other Pathology Clinics. They suggested poorly differentiated high-grade pleomorphic sarcoma with elements of osteosarcoma. The accurate diagnosis of the head and neck sarcoma type can be a histopathology dilemma posing a great challenge in the choice of therapeutic approach, and thus the treatment outcome.
A large dedifferentiated retroperitoneal liposarcoma extended to the testis: a rare case report
Authors: Habonimana Patrice , Niyonkuru Evrard , Nisabwe Simon , Mazti Asmae , Moataz Amine , Dakir Mohamed , Debbagh Adil , Aboutaieb Rachid
Published: May 2023

Liposarcomas are neoplasms of mesodermal origin representing less than 1% of all malignant tumors and 1 to 2% of urogenital lesions. Primary retroperitoneal liposarcomas extending into the inguinal canal are rare. We present the case of a large retroperitoneal liposarcoma invading the left testicle and its spermatic cord. It was diagnosed by imaging as a large mass that compresses surrounding abdominal structures and communicating with the inguinal canal. A surgical intervention consisting of en bloc resection of the tumor and the left testicle with its cord was performed by 2 routes, intercostal and inguinal. Histology showed a dedifferentiated liposarcoma, which is a rare entity with a high rate of malignancy and a poor prognosis. The treatment of choice is wide surgical resection with clear margins; chemotherapy and radiotherapy are less sensitive. The patient did not manifest any particular complaints during the first six months after surgery.
Rheumatoid nodule presenting as an indeterminate soft tissue mass in the sole of the foot
Authors: Patel Ravi , Nand Raghav , Sunderamoorthy Dakshinamurthy
Published: May 2023

A 64-year-old lady with a background of rheumatoid arthritis presented to the foot and ankle clinic with lump underneath the sole of her foot causing significant discomfort. Examination revealed she had a swelling of the first and the second metatarsophalangeal joints. Magnetic resonance imaging revealed abnormal soft tissue thickening between the second and the third metatarsal and a single large encapsulating indeterminate soft tissue mass with a peripheral inflammatory rim. The appearance was suggestive of a malignant sarcoma rather than a rheumatoid nodule or rheumatoid tenosynovitis. The patient was referred to the regional sarcoma unit where the scans were reviewed, and a sarcoma was ruled out. The patient then underwent excision of the indeterminate soft tissue mass. Histology revealed granulomatous infiltration suggestive of a rheumatoid nodule. This has not been described previously in the literature.
Hot on the Trail: Pilgrimage and Crime in Early Modern Spain
Authors: Scott Amanda L
Published: May 2023

Though pilgrims were purportedly sacred travelers, their actual identities and motivations for travel were far from certain. Connotations with criminality and fraud also ran deep. Beginning with a strange case in which an epileptic French priest traveling to Santiago de Compostela was arrested and investigated as an alleged spy, this article considers the ambiguities surrounding pilgrim identity and the difficulty communities had in determining intention and motivation. Drawing upon secular and church records from Navarre, Aragon, and Gipuzkoa, this article examines the methods courts employed to reveal or impose identities, including using complex forensic techniques such as building a blind criminal lineup, associative triangulation of place and person, and relying upon medical and linguistic evaluation. In many cases, these processes of evidence gathering and particularly the idea that suspects could be definitively identified runs contrary to our understanding of the lack of sophistication of early modern criminal procedure and epistemology.
Managing Waste: The Provisioning of Public Latrines and the Disposal of Night Soil in Southern Gold Coast (Ghana), c. 1878–1950
Authors: Amoako-Gyampah Akwasi Kwarteng
Published: May 2023

Although Gold Coast Africans in the pre-colonial period believed that supernatural forces were the final causes of diseases, they were also clearly aware of the health implications of indiscriminate defecation and other environmental pollutants. Two types of latrines existed in the Gold Coast to displace excrement beyond the healthful space of the community. One existed inside the house, which European writers referred to as privy huts. The second type was communal latrines located on the outskirts of the town boundary. Irrespective of the true conditions, European adventurers and later colonial officials viewed the Gold Coast through the prism of the racial politics of the “civilizing mission.” They conceived toileting techniques and practices as well as the management of excrement among Africans as “primitive,” unhygienic, and therefore, anathema to “civilization.” This article examines the provision of latrines and the management and disposal of human excrement in the southern Gold Coast during the colonial period. It demonstrates that despite European claims to superior toileting techniques, latrines provided by the colonial administration before the twentieth century were mostly ad hoc, inadequate, very basic, and inefficient. Similarly, colonial technologies for disposing excrement proved inefficient. Thus, the management of human waste in the Gold Coast posed technocratic barriers to public health and highlighted the limits of colonial measures and technologies.
Clinical Pharmacology of Atovaquone and Proguanil Hydrochloride
Authors: Beerahee Misba
Published: May 2023

Background: Atovaquone and proguanil hydrochloride is a new antimalarial combination that is used for treatment and prophylaxis of malaria.

Methods: The clinical pharmacology of atovaquone and proguanil was reviewed.

Results: Atovaquone is a highly lipophilic compound with low aqueous solubility, the absorption of which is limited by the rate and extent of dissolution. Dietary fat increases the rate and extent of atovaquone absorption, increasing AUC two- to threefold and C fivefold over fasting. Proguanil is rapidly and extensively absorbed regardless of food intake. Atovaquone is highly protein bound (> 99%) but does not displace other highly protein bound drugs in vitro, indicating significant drug interactions arising from displacement are unlikely. Atovaquone is predominantly eliminated unchanged in feces, with negligible excretion in urine. Proguanil is partially metabolized and partially excreted unchanged in urine. Its principal metabolite, cycloguanil, is also excreted in urine. Metabolism of proguanil is mediated in the liver by the cytochrome P450 3A and 2C subfamilies.The elimination half-life of atovaquone is 2 to 3 days in adults and 1 to 2 days in children.The elimination half-lives of proguanil and cycloguanil are 12 to 15 hours in adults and children. Dosage adjustments based on body weight categories in children (Vi dose for 11-20 kg, h dose for >20-30 kg, 3/4 dose for >30-40 kg, and full dose for >40 kg) achieve plasma concentrations that are safe and effective during prophylaxis and treatment of malaria. No dose adjustments for race, proguanil metabolizer status, gender, or elderly patients are needed, or for patients with mild to moderately impaired renal or hepatic function.

Conclusion: The clinical pharmacology of atovaquone and proguanil provides a rationale for the dosing regimens recommended for treatment and prophylaxis of malaria.
Atovaquone and Proguanil Hydrochloride: A Review of Nonclinical Studies
Authors: Pudney Mary , Gutteridge Win , Zeman Anton , Dickins Maurice , Woolley Joseph L.
Published: May 2023

Background: Safe and effective antimalarial drugs are needed for treatment and prophylaxis of malaria. The combination of atovaquone and proguanil hydrochloride is a new antimalarial drug combination that has recently become available in many countries.

Methods: Data were reviewed from nonclinical studies evaluating the microbiology, secondary pharmacology, pharmacokinetics, and toxicology of atovaquone and proguanil hydrochloride.

Results: Atovaquone is highly active against asexual erythrocytic stages of Plasmodium falciparum in vitro (IC60 0.7-6 nM) and in animal models. Proguanil per se has only weak antimalarial activity in vitro (IC50 2.4-19 p.M), and its effectiveness depends on the active metabolite cycloguanil (IC60 0.5-2.5 nM). The combination of atovaquone and proguanil is synergistic in vitro. Both drugs also have activity against gametocytes and pre-erythrocytic (hepatic) stages of malaria parasites. Atovaquone is a ubiquinone antagonist that inhibits mitochondrial electron transport and collapses mitochondrial membrane potential. The proguanil metabolite cycloguanil is a dihydrofolate reductase inhibitor, but the mode of action of proguanil is unknown. In screening evaluations of secondary pharmacology, neither atovaquone nor proguanil had activity that adversely affected gastrointestinal, cardiovascular, or central or autonomic nervous system functions at clinically relevant concentrations. After oral administration, atovaquone exposure is extensive in rats but limited in dogs, while proguanil and cycloguanil exposure is extensive in dogs but limited in rats. In both species, toxicity was related to proguanil exposure, the principal manifestations being salivation, emesis, and loss of body weight. Neither atovaquone nor proguanil was teratogenic or mutagenic. An increased incidence of hepatic adenomas and adenocarcinomas was seen in mice, but not rats, after lifetime exposure to atovaquone, and appears to be related to species-specific differences in hepatic enzymatic activity. No additional toxicity was evident in animals treated with the combination of atovaquone and proguanil hydrochloride compared to those treated with either drug alone.

Conclusion: Nonclinical studies of atovaquone and proguanil hydrochloride supported the clinical development of this combination for treatment and prophylaxis of malaria.
Elevated methemoglobin levels in patients treated with high-dose hydroxocobalamin
Authors: Dyrud Martinus , Niu Jianli , Kohler Lisa
Published: May 2023

Objective

The aim of this study was to assess the impact of hydroxocobalamin (OHCbl) infusion on arterial blood gas and oximetry values in patients with vasoplegic syndrome.

Methods

Blood samples collected from 95 patients receiving OHCbl infusion were assayed using the ABL90 FLEX Plus blood gas analyzer for the concentration of methemoglobin (MetHb), total hemoglobin (tHb), carboxyhemoglobin (COHb), arterial oxygen saturation (SaO2), arterial oxygen partial pressure (PaO2), and arterial carbon dioxide partial pressure (PaCO2). Interference of OHCbl on these variables was evaluated using the measured difference between the preinfusion and postinfusion samples.

Results

Blood MetHb (%) measured after the infusion of OHCbl (5g) were significantly higher than the baseline levels, with a median of 4.8 (IQR, 3.0−6.5) versus 1.0 (IQR, 1.0−1.2) (P < .001). Blood COHb (%) increased from a median of 1.3 (IQR, 1.0−1.8) to 1.7 (IQR, 1.3−2.2) (P < .001) following the OHCbl infusion. No differences were seen in median levels of tHb, PaO2, PaCO2, and SaO2 between pre- and post-OHCbl treatment.

Conclusion

The presence of OHCbl in blood clearly interfered with the oximetry measurements of the hemoglobin component fractions by falsely increasing the levels of MetHb and COHb. Blood levels of MetHb and COHb cannot be reliably determined by the co-oximetry when OHCbl is known or suspected.
The Unbearable Silence of Responsibility
Authors: Lemma Alessandra
Published: May 2023

The responsible therapist is defined as the one who makes a unique ‘psychoanalytic promise’ to the patient: I will allow you to ‘use’ me, within the boundaries of the analytic setting, to serve your best interests in developing a mind of your own. It is suggested that this promise can only be kept if the therapist maintains a horizontal relationship with the patient, that is a structurally similar relationship of equals, and ensures that it does not become a malignant vertical relationship where the therapist abuses the asymmetrical power that is inherent to their role within the analytic relationship. The chapter focuses on the inherent asymmetry in the analytic relationship and its ethical implications. It suggests that the therapist inevitably impacts the analytic process through their needs, desires, anxieties, and defences and engages with the uses and abuses of the concept of countertransference. It proposes that the development of the analytic attitude needs to be articulated in relation to what is termed the ethical chóros. This denotes a principled internal space that regulates practice through supporting self-questioning in relation to our work and the obligations therapists have towards their patients.
Bioethical Principles
Authors: Lemma Alessandra
Published: May 2023

This chapter introduces the dominant model used in bioethics today: the Four Principles approach as described by Beauchamp and Childress. It provides a succinct overview of the four principles of bioethics, namely respect for autonomy (the obligation to respect the decision-making capacities of autonomous persons); non-maleficence (the obligation to avoid causing harm); beneficence (the obligation to provide benefits and to balance benefits against risks); and justice (the obligation of fairness). It also discusses the challenge of balancing competing duties and ethical demands. Although this bioethical model does not typically feature in psychoanalytic writings, it is suggested that it offers a foundational moral analytical framework and a common moral language that is well suited to analytic practice, with some additional specifications, which will be elaborated in Chapter 3.
A Psychoanalytic Principled Approach
Authors: Lemma Alessandra
Published: May 2023

Chapter 3 builds on the Four Principles model and re-interprets it for specific use by psychoanalytic clinicians, adding and introducing a fifth principle—veracity. Framed by a discussion of the telos of psychoanalytic therapy, the chapter discusses the ethical importance of addressing ‘what is psychoanalysis for?’ because this bears on the question of consent to treatment. It is suggested that the specificity of the psychoanalytic method, namely that the work is mediated by the relationship that develops between therapist and patient, means that the person of the therapist is central to its integrity and outcome. Recognizing this is fundamental to ethical practice because from this fact derive the therapist’s ethical obligations towards the patient. Ethical principles are in the service of protecting the conditions under which psychoanalytic work can be carried out for the benefit of the patient and without obstructing the process and/or harming the patient.
Motility disorders of the oesophagus
Authors: Müller Michaela , Niebisch Stefan , Gockel Ines
Published: May 2023

Oesophageal motility disorders comprise a group of disorders characterized by malfunction of the swallowing act due to damage to neuromuscular structures responsible for the coordination of oesophageal function. The leading symptom is dysphagia for solids and/or liquids and it is frequently associated with additional symptoms, including regurgitation, chest pain, heartburn, and weight loss. Manometry represents the gold standard for the diagnosis of motility disorders of the oesophagus which has been defined in the Chicago Classification by the introduction of high-resolution impedance manometry and will be presented in this chapter with special emphasis on motility disorders which are of particular relevance to gastroenterologists and surgeons.
Upper gastrointestinal perforation
Authors: Hendricks Alexander , Ellrichmann Mark , Schafmayer Clemens
Published: May 2023

Perforations of the upper gastrointestinal tract are rare events but if present, are serious conditions. Timely diagnosis and therapeutic initiation are crucial for a beneficial patient outcome. In general, endoscopic and surgical approaches are suitable methods. Endoscopically, there are multiple methodologies available dependent on the extent of the laceration and ongoingly, more innovative techniques are being introduced. Smaller and acute lesions without significant amounts of contamination can be sufficiently treated with clipping devices. Larger defects can be treated by either endoscopic stenting or the more innovative approach of endoscopic vacuum therapy. The surgical approach is usually the option of last resort. Morbidity and mortality rates postoperatively are high, hence the indication for a surgical revision of upper gastrointestinal perforations must be strict and well weighted. In sum, to guarantee the most optimal outcome for the patient, it is crucial to pursue an interdisciplinary approach involving specialists from endoscopy, intensive care medicine, and surgery.
Oesophageal cancer
Authors: Stüben Björn-Ole , Karstens Karl-Frederick , Nentwich Michael , Izbicki Jakob R. , Reeh Matthias
Published: May 2023

Oesophageal surgery remains a challenge for the surgeon despite rapid medical advances in the recent past. The procedures are particularly difficult because of the thoraco-abdominal localization of the oesophagus and its vicinity to vital organs. Although oesophageal operations are usually only carried out in high-volume centres which provide around-the-clock interdisciplinary care, they are still accompanied by a high number of complications. This chapter summarizes the history of oesophageal surgery and provides an overview of the conventional surgical approaches used for oesophageal resections, including transhiatal blunt oesophageal dissection and gastric pull-up, subtotal en bloc oesophagectomy—abdominothoracic approach, abdominothoracic en bloc oesophagectomy with high intrathoracic anastomosis, and limited resection of the gastro-oesophageal junction with isoperistaltic jejunal interposition.
Gastric cancer
Authors: Arigami Takaaki , Natsugoe Shoji
Published: May 2023

Although the occurrence of gastric cancer has gradually decreased in East Asia, it is still the fifth most common malignancy and the second leading cause of cancer-related death worldwide. The International Agency for Research on Cancer has proposed that Helicobacter pylori, rubber production, tobacco smoking, as well as X-ray and gamma radiation are risk factors for gastric cancer. Further analysis of carcinogenesis will support the early detection of gastric cancer. Since the majority of patients with gastric cancer have no signs or symptoms of the disease, it is clinically difficult to detect these patients without screening. Moreover, representative diagnostic tools that have been used to detect early gastric cancer include upper gastrointestinal barium X-ray radiography, oesophagogastroduodenoscopy, endoscopic ultrasonography, computed tomography, and fluorodeoxyglucose positron emission tomography. In particular, magnifying narrow-band imaging (M-NBI) has been a promising approach for an accurate assessment. The recent development of M-NBI is critical for the strategic utilization of treatments such as endoscopic submucosal dissection. In 2016, the Union for International Cancer Control published the eighth edition of the TNM Classification of Malignant Tumours which defined a new stage grouping for gastric cancer. It contributes to the clinical management of tumour diagnosis and treatment for patients with gastric cancer.
Credentialing, Certification, and Scope of Practice Issues for the Palliative APRN
Authors: Lappen Kerstin Lea , McGraw Matthew , Meyer Kate
Published: May 2023

Advanced practice registered nurses (APRNs) must understand the requirements and complexity of credentialing, certification, and licensing in order to practice safely, legally, and to the fullest extent of their scope. Standardization of APRN practice is lacking from state to state, and, to that end, the Consensus Model for APRN Regulation, Licensure, Accreditation, Certification, and Education (LACE) provides guidance for states to develop uniformity in the regulation of APRN roles. By allowing the APRN to practice to the fullest scope in accordance with their education and clinical preparation, there will be increased mobility to practice and improved access to healthcare. Specialty certification is a valuable endeavor to demonstrate the clinician’s expertise and commitment to quality care and to the profession.
The Palliative APRN in Nursing Education
Authors: Cormack Carrie L. , Lindell Kathleen O.
Published: May 2023

The advanced practice registered nurse (APRN) in palliative education has an important role in shaping the future generation of APRNs and specialty practice APRNs who care for individuals with serious illness and their families. These APRN educators must use their expertise and leadership to develop curriculum and facilitate education in primary and specialty palliative skills and clinical practice. Palliative APRN educators have an opportunity to address the growing workforce shortage in palliative care and answer the call for increased professional palliative care education. This chapter outlines the processes for APRN faculty and schools of nursing to prioritize palliative care and implement this necessary content into their curriculums to ensure that every nursing graduate is prepared at time of graduation to provide high-quality care to individuals with serious illness and their families. It also addresses the standards, framework, resources, and essential content for graduate faculty to development and implement a specialty palliative care program.
The Palliative APRN in the Emergency Department
Authors: Loschiavo Sarah , Starkweather Angela
Published: May 2023

The emergency department often serves as a port of entry to palliative care services for patients with complex symptoms and/or care coordination, individuals with chronic disease(s), and people at the end of life. This chapter outlines the role of the palliative advanced practice registered nurse (APRN) in the emergency department and highlights strategies for the successful integration of palliative care in the emergency department setting and common barriers to its implementation. Various models that may be used are described along with approaches to operationalize the provision of palliative care to patients in the emergency department. Methods to identify patients at greatest need for palliative care and guide the evaluation of palliative care services are discussed. Guidance for death notification by telephone or using other technologies is offered.
Care of Veterans with Palliative Care Needs
Authors: Foy Alice C. , Rice Robert David , Melocoton Joseph Albert
Published: May 2023

The Department of Veterans Affairs, through the Veterans Health Administration, is deeply committed to the service of veterans with serious illness and promotes palliative and end-of-life care as a priority. The unique demographics and experiences of veterans and their families can make end-of-life care complicated, thus requiring specialized skills and resources. As advanced practice registered nurses (APRN) working with interprofessional teams, palliative APRNs are well-positioned to direct access and implement quality palliative and hospice service delivery in a continuum of practice settings. There are subpopulations of veterans who need special attention as well as common diagnoses to assess and manage. To mitigate suffering for the veteran and to provide the best care and honor end-of-life preferences, training, education, and resources are available for the palliative APRN working with this population. These resources assist the APRN in meeting the unique biopsychosocial challenges of veterans and their families, including trauma-informed care, moral injury, suicide prevention, posttraumatic stress disorder (PTSD) management, substance use, homelessness, caregiver support, or existential distress.
Anorexia and Cachexia
Authors: Smeltz Robert , Shabin Renata
Published: May 2023

This chapter defines anorexia and cachexia and discusses their relationship as a syndrome. As symptoms, anorexia and cachexia are often seen in most advanced stages of disease. The assessment of anorexia and cachexia is fundamental to establishing an effective treatment plan. For the advanced practice registered nurse (APRN), setting goals and providing patient and family with education on the limits of reversing anorexia and cachexia in advanced disease is critical. A multimodal holistic approach involving pharmacologic and nonpharmacologic measures delivered by an interdisciplinary care team is essential to addressing cachexia and anorexia syndrome.
Bowel Symptoms
Authors: Chow Kimberly , Koranteng Lauren
Published: May 2023

This chapter discusses three common bowel symptoms that are highly prevalent and distressful for palliative care patients: constipation, diarrhea, and obstruction. These symptoms rarely occur in isolation of other clinical manifestations of disease and can affect a person’s quality of life and eligibility for treatment and even may be life-threatening. The advanced practice registered nurse must approach care with a global understanding of the patient’s individual needs, their primary illness, disease-related complications, and past and current treatments. Assessment and management is always provided with respect for the patient’s culture, privacy, and goals of care.
Depression and Suicide
Authors: Chovan John
Published: May 2023

Depressive symptoms are an expected response to psychosocial stress. Diagnosis of and living with a life-threatening, chronic illness cause psychosocial stress that can lead to depressive symptoms. Not all constellations of depressive symptoms, however, are of such severity or duration to constitute a depressive disorder. Irrespective of a diagnosis, depressive symptoms can impact negatively on the patient’s functioning and quality of life and that of their families. Depressive symptoms and depression are discussed across the illness trajectory, including biopsychosocial models of depression, advanced practice registered nurse (APRN) self-assessment, patient and family assessment techniques and tools, and evidence-based guidelines. Patient- and family-centered treatment approaches include pharmacological interventions and nonpharmacological techniques such as psychotherapy, complementary and alternative therapies, and wellness approaches. Because self-harm is associated with depression, patients must be assessed for suicide at every encounter, thus techniques for assessing and intervening are described.
Palliative Emergencies
Authors: Syrett Ann Quinn , Buckley Marcia J. , Carlson Beth
Published: May 2023

This chapter highlights four emergencies that occur in palliative care: hemorrhage, spinal cord compression, seizures, and superior vena cava syndrome. Palliative advance practice registered nurses (APRNs) should understand their etiology, pathophysiology, workup, and management so they can rapidly and expertly respond to these emergencies. Palliative APRNs possess a unique skill set that combines holistic care of patients with the ability to manage acute, often potentially devastating symptoms that often affect patients’ goals and wishes. Goals of care can be static, and the disease state needs to be considered when making treatment and management decisions for these palliative emergencies.
Evaluating and Managing the Agitated Patient
Authors: Hong Victor , Baumhauer Jennifer , Leung Stephen
Published: May 2023

This chapter describes all aspects of the evaluation and management of the agitated patient, one of the most common, and challenging, presentations encountered in psychiatric emergency care. Agitated behaviors range from restlessness to overt physical aggression and can escalate rapidly, placing both the patient and staff at risk of harm. Although early recognition and intervention are crucial for success, the wide variety of underlying etiologies of agitation present barriers to optimal care. This chapter will review how tailoring of treatment interventions has developed to more precisely and effectively target the behaviors while always keeping the safety of the patient and staff at the forefront of one’s mind. It will also review the rise of verbal de-escalation as a first line intervention for agitation management, as well as describing principles of pharmacologic management should verbal de-escalation be inadequate. Special population such as those with personality disorders, substance intoxication or withdrawal, and psychosis or mania, will be explored as each may have particularly effective interventions as well pitfalls to avoid. Finally, as a measure of last resort, guidelines around seclusion and/or restraint will be provided.
Emergency Psychiatry Evaluation and Treatment of Mood Disorders
Authors: Maloy Katherine
Published: May 2023

Mood disorders are highly prevalent and a common cause of presentations to the emergency department. Depression is highly comorbid with substance use disorders and can worsen the course of medical illness. It is also a risk factor for suicide. In addition, depression can be a frequent cause of overuse of emergency services because urgent psychiatric care can be difficult to access outside of a hospital setting. Patients with mania frequently present to the emergency department when their behavior has become so disruptive in the community that the patients are a danger to themselves or others. These patients can be difficult to manage in the emergency setting, particularly when dedicated psychiatric space is not available. The neurologic phenomenon of catatonia can feature in both bipolar illness and depression and is not solely seen in psychotic illness. Emergency clinicians should be familiar with catatonic features and act quickly to treat life-threatening complications such as malignant catatonia. The COVID-19 pandemic has worsened existing disparities in access to care and increased prevalence of mood disorders while straining health care services, particularly emergency departments. As clinicians in the emergency setting, recognizing and treating mood disorders can have a positive impact on patients.
Geriatrics
Authors: Cho Daniel , Takeshita Junji , Huynh Victor , Gomes Ishmael , Hishinuma Earl
Published: May 2023

Psychiatric emergencies in the geriatric population are expected to increase in the next decade and pose a unique challenge for clinicians in the emergency department or emergency consult setting. This cohort generally presents with numerous medical comorbidities and polypharmacy, and clinicians must be aware of age-related changes in physiology and pharmacokinetics. Geriatric psychiatric emergencies may also be precipitated by psychosocial factors such as retirement, grief, or elder abuse. Evaluation should initially focus on safety and typically requires utilization of collateral sources of history. Underlying medical etiologies of delirium should be ruled out, in addition to dementia screening and evaluation of depression or decompensated psychiatric illness. Medications should be used judiciously if indicated, and particular attention should be given to drug interactions and risk of toxicity. The COVID-19 pandemic has complicated the evaluation and management of psychiatric emergencies because there must now be clear procedures for screening, isolating, and treating COVID-19-positive patients. Age remains one of the most robust risk factors for both morbidity and mortality due to COVID-19. The growing use of telepsychiatry has improved access to emergency psychiatric services, geriatric patients included, but can be challenging.
On Measurement and Semantics
Authors: West Colin
Published: May 2023

In everyday language, well-being means different things to different people. The lack of precision resulting from this colloquial language contributes to confusion in discussions of well-being in medicine. To effectively measure and then respond to promote well-being, metrics are required that align with established conceptual frameworks for well-being. This chapter reviews concepts related to measurement instrument validity, the complexity of domains relevant and contributing to well-being, and selected instruments with the most robust evidence base for their use. It will also provide an overview of optimal survey design approaches to inform high-quality measurement. Finally, this chapter specifically discusses key elements of clear messaging around well-being issues in medicine.
What’s at Stake?
Authors: Philibert Ingrid , Konopasek Lyuba
Published: May 2023

This chapter aggregates information on the consequences of burnout in physicians across the continuum of education and practice, including estimates on the impact of burnout on the US health care system. Consequences include increased sick days (absenteeism), lower professional effectiveness in the workplace (presenteeism), reduced participation in team-based models of care, lower quality of care, and higher rates of errors. Physician burnout affects individual physician experience, well-being, and professional fulfillment. Burnout has important consequences for patient experience, quality of patient care, and the work experience of the interprofessional team. Burnout in attending physicians and residents may contribute to burnout and cynicism in medical students. Finally, due to effects on workforce turnover, burnout has great costs to both the health care system and society.
Individually Focused Well-Being Interventions
Authors: Hussain Farah N. , Yaden Mary Elizabeth , Tomescu Oana
Published: May 2023

While a system-level approach is necessary to achieve a significant positive impact on the well-being of medical students and graduate medical education (GME) trainees, individuals share a concurrent responsibility to commit to intentional and strategic self-care that promotes their own well-being. The goals of this chapter are to emphasize the importance of a shared responsibility framework using organizational and individual strategies to promote well-being, introduce an expanded framework for strategic self-care, review the data for many individual-focused strategies that can be utilized by learners when practicing strategic self-care, and provide guidance for the creative integration of individual-focused practices and wellness strategies into programmatic structures and longitudinal curricula. When training programs and schools support well-being by both improving system-level drivers of burnout and facilitating opportunities for strategic self-care, medical students and GME trainees feel valued and encouraged to better care for themselves and the populations they serve.
The Impact of Operation Bushmaster on Medical Student Decision-making in a High-Stress, Operational Environment
Authors: Cole Rebekah , Garrigan Audra G , Peters Sidney A , Conley Sean P , Rudinsky Sherri L , Tilley Laura , Vojta Leslie , Schwartz James , Weston Christopher , Goolsby Craig
Published: May 2023

Introduction

Operation Bushmaster is a high-fidelity military medical field practicum for fourth-year medical students at the Uniformed Services University. During Operation Bushmaster, students treat live-actor and mannequin-based simulated patients in wartime scenarios throughout the five-day practicum. This study explored the impact of participating in Operation Bushmaster on students’ decision-making in a high-stress, operational environment, a crucial aspect of their future role as military medical officers.

Materials and Methods

A panel of emergency medicine physician experts used a modified Delphi technique to develop a rubric to evaluate the participants’ decision-making abilities under stress. The participants’ decision-making was assessed before and after participating in either Operation Bushmaster (control group) or completing asynchronous coursework (experimental group). A paired-samples t-test was conducted to detect any differences between the means of the participants’ pre- and posttest scores. This study was approved by the Institutional Review Board at Uniformed Services University #21-13079.

Results

A significant difference was detected in the pre- and posttest scores of students who attended Operation Bushmaster (P < .001), while there was no significant difference in the pre- and posttest scores of students who completed online, asynchronous coursework (P = .554).

Conclusion

Participating in Operation Bushmaster significantly improved the control group participants’ medical decision-making under stress. The results of this study confirm the effectiveness of high-fidelity simulation-based education for teaching decision-making skills to military medical students.
Radiative association of P+(3P) and O(3P) for the PO+ formation
Authors: Qin Zhi , Hu Peigen , Li Jing , Liu Linhua
Published: May 2023

Phosphorus (P) is essential for the development of life since it is a fundamental element in many important biological molecules. Due to its biogenic importance, many astrochemists have begun to investigate the possibility of the phosphorus-bearing species formed in interstellar environments. Radiative association (RA) is a possible way for the formation of the phosphorus monoxide ion (PO+) in interstellar and related environments. Laboratory measurements are almost impossible to carry out, so theoretical calculations are essential for investigating such formation mechanism of PO+. The quantum mechanical method is used to obtain its cross sections and rate coefficients. Thirty contributing processes for the computation of the total rate coefficient are considered, including 22 transition dipole processes and eight permanent dipole processes. The total rate coefficient varies little over the entire temperature range of 1–10 000 K and its magnitude is of the order of (4–8) × 10−17 cm3 s−1. The 2 1Σ+ → X 1Σ+ transition process dominates the formation of PO+ by RA over the entire temperature range considered here. The C 1Π → X 1Σ+ and 2 3Σ+ → a 3Σ+ are also relatively important, but their rate coefficients are about an order of magnitude smaller than that of the 2 1Σ+ → X 1Σ+ channel. The obtained cross sections and rate coefficient can be used to model the P astrochemistry in the interstellar medium.
Redshift evolution of the dark matter haloes shapes
Authors: Cataldi P , Pedrosa S E , Tissera P B , Artale M C , Padilla N D , Dominguez-Tenreiro R , Bignone L , Gonzalez R , Pellizza L J
Published: May 2023

In this work, we aim at investigating the morphology evolution of Milky Way mass-like dark matter haloes selected from the cielo and IllustrisTNG projects. The connection between halo shapes and their environment has been studied in previous works at z = 0 but their connection remains yet to be fully understood. We focus on the evolution across cosmic time of the halo shapes and the relation with the infalling material, using hydrodynamical simulations. Our findings show that haloes tend to be more triaxial at earlier times as a consequence of stronger accretion in the direction of the filaments. As the haloes evolve towards a dominant isotropic accretion mode and relaxation, their shape at 20 per cent of the virial radius becomes more spherical. In agreement with previous results, baryons have an important effect within the inner regions of the haloes, driving them from triaxial to rounder shapes. We also find a correlation between the strength of the quadrupole infalling mode and the degree of ellipticity of the haloes: as the filament strength decreases steadily with redshift, the haloes became more spherical and less elliptical.
Long-term relationships between the abundance of pest molluscs and weather in agricultural fields in South Australia
Authors: Baker Geoff H
Published: May 2023

Invasive snails, Cernuella virgata, Theba pisana and Cochlicella acuta, infest grain crops prior to harvest in early summer in southern Australia. They breed in autumn–early winter and peak in abundance in spring following the recruitment of young snails. Long-term studies (20 years) were established on three farms in South Australia (two practicing pasture–cereal rotations and one continuous cropping) to better understand the role of prevailing weather in driving the population dynamics of the three snail species and to develop predictive models that might assist farmers and off-farm grain handlers to anticipate future peaks in snail abundance and tailor their management practices accordingly. The three species are asynchronous in their population dynamics; they peak in numbers in different years. The abundance of C. virgata in late spring (preharvest) was most closely associated with, and could be broadly predicted by, the previous autumn to spring rainfall, but no significant associations were found between the rainfall and the abundance of C. acuta and T. pisana. Local air temperatures had little apparent association with the abundance of all three species. Broader scale weather, exemplified by the El Niño Southern Oscillation Index, was only occasionally, and weakly, related to the spring abundance of C. virgata.
Formal Excess in the Opening Movement of Fanny Hensel’s String Quartet in E♭ Major (1834)
Authors: Kim Catrina S
Published: May 2023

This article analyzes the Adagio opening movement of Fanny Hensel’s sole string quartet by reading the ways in which it dialogues with several genres: the increasingly independent early nineteenth-century slow introduction; the slow first movement; eighteenth- and early nineteenth-century sonata form; and the fantasia. I build this generic context by considering the historical development of the slow introduction and drawing attention to such overlapping identities in two cello sonata movements by Ludwig van Beethoven and in Hensel’s Sonata o Fantasia in G minor for Piano and Cello (1829).
A homozygous mutation in the human selenocysteine tRNA gene impairs UGA recoding activity and selenoproteome regulation by selenium
Authors: Vindry Caroline , Guillin Olivia , Wolff Philippe , Marie Paul , Mortreux Franck , Mangeot Philippe E , Ohlmann Théophile , Chavatte Laurent
Published: May 2023

The selenocysteine (Sec) tRNA (tRNA[Ser]Sec) governs Sec insertion into selenoproteins by the recoding of a UGA codon, typically used as a stop codon. A homozygous point mutation (C65G) in the human tRNA[Ser]Sec acceptor arm has been reported by two independent groups and was associated with symptoms such as thyroid dysfunction and low blood selenium levels; however, the extent of altered selenoprotein synthesis resulting from this mutation has yet to be comprehensively investigated. In this study, we used CRISPR/Cas9 technology to engineer homozygous and heterozygous mutant human cells, which we then compared with the parental cell lines. This C65G mutation affected many aspects of tRNA[Ser]Sec integrity and activity. Firstly, the expression level of tRNA[Ser]Sec was significantly reduced due to an altered recruitment of RNA polymerase III at the promoter. Secondly, selenoprotein expression was strongly altered, but, more surprisingly, it was no longer sensitive to selenium supplementation. Mass spectrometry analyses revealed a tRNA isoform with unmodified wobble nucleotide U34 in mutant cells that correlated with reduced UGA recoding activities. Overall, this study demonstrates the pleiotropic effect of a single C65G mutation on both tRNA phenotype and selenoproteome expression.