bluuebunny/crossref_metadata_2025 huggingface dataset:
Diarrhea, Malabsorption, and Small-Bowel Disorders
Authors: Sweetser Seth R.
Published: August 2016

Diarrhea is a symptom or a sign, not a disease. As a symptom, it can manifest as 1 or more of the following: a decrease in consistency, an increase in fluidity, or an increase in number or volume of stools. A stool frequency of 3 or more times daily is considered abnormal; however, most people consider increased fluidity of stool as the essential characteristic of diarrhea. As a sign, diarrhea is an increase in stool weight or volume of more than 200 g or 200 mL per 24 hours for a person eating a Western diet. Although stool weight is often used in the objective definition, diarrhea should not be strictly defined by stool weight because the amount of dietary fiber influences the water content of the stool.
Hepatic Disorders
Authors: Sanchez William , Poterucha John J.
Published: August 2016

The evaluation of patients who have abnormal liver test results includes many clinical factors: the patient’s symptoms, age, risk factors for liver disease, personal or family history of liver disease, medications, and physical examination findings. A standard algorithm can aid in evaluating abnormal liver test results in an efficient, cost-effective manner.
Medical Ethics
Authors: Swetz Keith M. , Hook C. Christopher
Published: August 2016

Medicine is first and foremost a relationship—a coming together of a patient, who is ill or has specific needs, and a physician, whose goal is to help the patient. The physician-patient relationship is a fiduciary relationship; physicians have knowledge, skills, and privileges that patients do not have. In turn, patients trust that physicians act in their patients’ best interests. Medical ethics consists of a set of principles and systematic methods that guide physicians on how they ought to act in their relationships with patients and others and how to resolve moral problems that arise in the care of patients.
Palliative Care
Authors: Strand Jacob J. , Swetz Keith M.
Published: August 2016

Acute otitis externa, also known as swimmer’s ear, is an infection of the external auditory canal. A moist environment, eczematous dermatitis, repeated insertion of foreign bodies (eg, cotton swabs), and psoriasis can predispose to otitis externa. Most patients present with otalgia and otorrhea.
Preoperative Evaluation
Authors: Sundsted Karna K. , Mauck Karen F.
Published: August 2016

Cancer-related pain affects up to 60% of patients receiving cancer-directed therapies and between 70% and 90% of those patients with advanced-stage cancers. However, pain is a common symptom in many patients with serious illnesses other than cancer. Patients with chronic obstructive pulmonary disease, heart failure, end-stage renal disease requiring hemodialysis, and a variety of neurodegenerative disorders experience pain from their conditions. Pain in these conditions is often underrecognized and undertreated, which can lead to functional impairment and suboptimal quality of life.
Women’s Health
Authors: Sandhu Nicole P. , Shuster Lynne T. , Wang Amy T.
Published: August 2016

Quality improvement, broadly interpreted, refers to any formal approach taken to understand and better the performance of a system. Quality improvement, conversationally, more often is taken to mean those methodologies or tools appropriated from industry and applied to health care. The genesis of the quality movement in health care is often traced to 2 landmark Institute of Medicine reports. “To Err is Human” cast a magnifying glass on safety gaps in care delivery, implicating preventable medical errors in the death of nearly 100,000 hospitalized patients annually.
Benign Hematologic Disorders
Authors: Gangat Naseema
Published: August 2016

The menstrual cycle is composed of the follicular (proliferative), periovulatory, and luteal (secretory) phases. At periovulation, the mature follicle triggers a surge in luteinizing hormone level, causing ovum release and stimulating the residual ovarian follicle to transform into a corpus luteum. Circulating estrogen and progestin levels increase. A thickened, enriched endometrium develops owing to progestin secretion from the corpus luteum. Without fertilization, the corpus luteum atrophies, estrogen and progestin levels decline, follicle-stimulating hormone release is stimulated, and the endometrium sloughs.
Malignant Hematologic Disorders
Authors: Thompson Carrie A.
Published: August 2016

The 2 essential functions of the coagulation system (maintaining hemostasis and preventing and limiting thrombosis) are served by the procoagulant and anticoagulant components. Vascular injury results in activation of the phases of hemostasis, including vasospasm, platelet plug formation (platelet activation, adhesion, and aggregation), and fibrin clot formation (by activation of coagulation factors in the procoagulant system). The anticoagulant system controls excessive clot formation, while the fibrinolytic system breaks down and remodels blood clots.
Infective Endocarditis and Health Care–Associated Infections
Authors: Sohail M. Rizwan , Tosh Pritish K.
Published: August 2016

Infections in the immunocompromised person may occur in the clinical setting of neutropenia, B-cell and T-cell deficiencies, immunoglobulin deficiencies, complement deficiencies, and leukocyte dysfunction. Some patients have multiple defects due to both the underlying disease and its treatment. Patients with neutropenia are at higher risk for infections with Pseudomonas species, gram-positive cocci, Enterobacteriaceae, and Candida and Aspergillus species.
Cerebrovascular Diseases
Authors: Klaas James P. , Brown Robert D.
Published: August 2016

Acute and chronic interstitial inflammation can result in injury to renal tubules, leading to tubular dysfunction and, chronically, tubular atrophy. Causes of chronic tubulointerstitial damage include autoimmune and hereditary causes, analgesic nephropathy, uric acid, lithium, heavy metals, mercury, lead, and oxalate. Autosomal dominant polycystic kidney disease is the most common hereditary renal disease. It occurs in both males and females and is characterized by multiple bilateral renal cysts and cysts in other organs (eg, liver, spleen, and pancreas).
Neoplastic Diseases
Authors: Porter Alyx B.
Published: August 2016

Movement disorders are common in adult clinical practice. An important first step in evaluation and management of these disorders is identification of a potentially reversible cause, most commonly medication effect. All patients younger than 50 years presenting with any type of movement disorder should be evaluated for Wilson disease.
Genitourinary Cancer
Authors: Costello Brian A.
Published: August 2016

Colorectal cancer is diagnosed in approximately 137,000 Americans annually and causes 50,000 deaths each year. It is the third most common cause of cancer death in North America and Europe. The incidence of colorectal cancer has decreased since the early 2000s, after it peaked in the late 1990s. The decrease in colon cancer incidence and mortality is attributed to improved screening methods, consisting mainly of endoscopic surveillance. Screening colonoscopies should be initiated by age 50 years for persons with average risk.
Mood and Anxiety Disorders
Authors: Palmer Brian A.
Published: August 2016

The most common causes of hypercalcemia are malignancies and primary hyperparathyroidism. Patients with primary hyperparathyroidism have increased serum parathyroid hormone (PTH) values, but PTH is usually suppressed in cancer-associated hypercalcemia. Cancer-related hypercalcemia is often mediated by a PTH-related protein (PTHrP), which is secreted by the tumor and can be measured with current assays. In general, however, measuring PTHrP levels is of academic interest only and should not be done on a routine basis.
Critical Care Medicine
Authors: Kennedy Cassie C.
Published: August 2016

Alcohol and other substance use disorders are a major concern in all age groups and across all ethnic, socioeconomic, and racial groups. Despite high lifetime prevalence (up to 20%), less than 10% of persons with substance use disorders are involved in treatment (either self-help groups or professional care). Several pharmacologic agents are available to help diminish the craving for alcohol and other drugs or to deter relapse. Although several medications, including disulfiram, acamprosate, and naltrexone, may help prevent relapse, they are adjunctive and not a substitute for comprehensive psychosocial treatment.
Pulmonary Evaluation
Authors: Iyer Vivek N.
Published: August 2016

Obstructive lung diseases include chronic obstructive pulmonary disease (COPD) (eg, chronic bronchitis and emphysema), asthma, bronchiectasis, cystic fibrosis, obliterative bronchiolitis, and diffuse panbronchiolitis (eg, bullous lung disease, α‎1-antitrypsin deficiency, and airway stenosis). The 2 most prevalent obstructive lung diseases are COPD and asthma.
Sleep-Related Breathing Disorders
Authors: Junna Mithri R.
Published: August 2016

Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure of at least 25 mm Hg at rest, as measured during right heart catheterization (RHC). The many causes of PH are classified into 5 groups. The clinical presentation of patients with PH is nonspecific: progressive dyspnea, chest pain, lower extremity edema, and fatigue. Typically, a diagnosis of PH is suggested by an increased right ventricular systolic pressure on transthoracic Doppler echocardiography and is confirmed with RHC.
Connective Tissue Diseases
Authors: Ernste Floranne C.
Published: August 2016

Obstructive sleep apnea is defined as periodic cessation of airflow (duration ≥10 seconds) during sleep with complete obstruction of the upper airway and continued respiratory effort. Typically, the episode is terminated by a temporary arousal from sleep and return of normal upper airway patency. Hypopnea is defined as partial obstruction of the upper airway during sleep (duration ≥10 seconds), usually with a resultant desaturation of at least 4%. Hypopnea is also typically terminated by a temporary arousal. Such periodic episodes of apnea and hypopnea usually result in fragmented sleep and periodic desaturations.
Anatomy of the abdomen
Authors: Mahadevan Vishy
Published: August 2016

The trunk of the human body comprises the thorax, abdomen, and pelvis. Of the three, the abdomen is the largest. While the abdominal cavity is separated from the thoracic cavity by the diaphragm, there is no physical partition between the abdominal and pelvic cavities. The abdominal cavity is bounded anteriorly and laterally by the relatively pliant anterior abdominal wall, and posteriorly, by the more rigid posterior abdominal wall. The abdominal cavity is lined by a serous membrane, the peritoneum. The peritoneum is reflected over the abdominal viscera. The part of the peritoneum which lines the abdominal walls is termed the parietal peritoneum while the part which covers the viscera is termed the visceral peritoneum. The parietal and visceral parts of the peritoneum are of course continuous with each other. The retroperitoneum refers to the area that lies behind the peritoneal cavity and in front of the posterior abdominal wall. The abdominal viscera may be classified broadly into (a) those that are derived embryologically from the gut tube, and (b) those that are derived from the genitourinary ridge.
Anatomy of the limbs and spine
Authors: Mahadevan Vishy
Published: August 2016

While the upper and lower limbs differ strikingly from each other in size and shape, there are, nevertheless, many functional similarities between the two in addition to shared features of structural design. Thus each limb may be pictured as a multijointed lever, with a freely mobile, ball-and-socket synovial joint at its proximal end whereby the limb articulates with the axial skeleton by means of a girdle. Each limb (upper and lower) is made up of three segments: arm, forearm, and hand in the upper limb, and thigh, leg, and foot in the lower limb. Each limb contains what one may term ‘junctional areas’ (or zones). In the upper limb, these are the axilla, cubital fossa, and carpal tunnel while in the lower limb, they are the femoral triangle, gluteal region, popliteal fossa, and tarsal tunnel. The vertebral column or spine (known colloquially as the backbone) forms the central axis of the body’s skeleton.
Urinary
Authors: Bradford Aidan
Published: August 2016

This chapter begins with a description of the overall functions of the kidney, the general principles of filtration, absorption, secretion, and urine formation, and the structural characteristics associated with these processes such as the afferent and efferent arterioles, the glomerulus, Bowman’s capsule, proximal tubule, loop of Henle, thick ascending limb, macula densa, distal tubule, collecting duct, peritubular capillaries, and vasa recta. The mechanisms involved in the control of renal blood flow through autoregulation are explained (i.e. the myogenic mechanism and tubuloglomerular feedback involving the macula densa). The mechanisms involved in the generation of a concentrated medullary interstitium are detailed such as the countercurrent multiplier and the countercurrent exchanger of the vasa recta. Glomerular filtration rate and the Starling forces involved in filtration at the renal corpuscle are defined along with the concept of clearance and its measurement using creatinine. The role of the kidneys in extracellular fluid homeostasis is explained in relation to sodium, potassium, water, and acid–base balance. The roles of renin, angiotensin, aldosterone, antidiuretic hormone, and atrial natriuretic peptide are outlined and some of the causes of hyponatraemia, hypernatraemia, hypokalaemia, hyperkalaemia, overhydration, and underhydration are given. The mechanism of bicarbonate absorption by the renal tubular cell is detailed along with the mechanism of formation of titratable acid and ammonium in the urine and the effects of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis on this process are explained. The chapter concludes with a brief characterization of the pathophysiology of acute and chronic renal failure.
Surgical pathology
Authors: Lowe David
Published: August 2016

Pathology is the study of disease; its causes and mechanisms. This chapter first covers chromosomal abnormalities, tissue response to injury, and cellular growth and repair. It then considers metabolic and endocrine disorders, vascular disorders and the body’s response to injury.
Healthcare-associated infection
Authors: Sykes Allison
Published: August 2016

Healthcare-associated infections (HCAIs) can develop either as a direct result of healthcare interventions such as medical or surgical treatment, or from being in contact with a healthcare setting. These infections have a significant impact on patient morbidity and mortality in addition to being an immense drain on the financial resources of health services. Surgical site infections account for approximately 14% of all HCAIs. However, many of these can be prevented through consistent implementation of evidence-based practices. The first step is a comprehensive preoperative assessment of risk factors which must then be followed by adherence to preventative strategies. These include preoperative MRSA screening and decolonization, appropriate hair removal, adherence to standard precautions, maintenance of asepsis, maintenance of normothermia, glucose control, use of protective dressings, administration of prophylactic antimicrobials, and implementation of appropriate isolation precautions.
Asepsis
Authors: Hall Louise
Published: August 2016

Theatre personnel must adhere to the basic principles of aseptic technique to prevent contamination of the operative site. Staff must achieve and maintain a sterile field during surgery, protecting the site from the adjacent non-sterile, physical environment. All personnel should understand the decontamination life cycle and the differences between sterile and non-sterile items. Patients undergoing surgical procedures must be cared for in a safe, clean environment which reduces the risk of contamination and protects from harm. It is essential that the design and fabric of the operating theatre facilitates good infection prevention and control practice and where possible, surfaces should be smooth, non-porous, and water-resistant. All parts of the environment must be accessible for cleaning, disinfection, and maintenance. The design of the ventilation system is crucial in maintaining optimal air quality, appropriate number of air changes, and environmental temperature.
Plain film radiology for surgeons
Authors: Spratt Jonathan D.
Published: August 2016

X-rays were put to diagnostic use only a year after their discovery, before realization of the dangers of ionizing radiation. Today, the Ionising Radiation (Medical Exposure) Regulations define the legal standards and aims of the justification process for analysis of the risk/benefit ratio to radiation exposure. The plain abdominal film has an ever narrowing application in the acute general surgical admissions unit; the most useful role is in the diagnosis of bowel obstruction, extraluminal gas, and renal tract calculi under protocoled use but there remains a significant role in neonates and infants due to a lower lifetime cancer induction risk compared with computed tomography. There is no role for skull series in the investigation of head-injured patients and there is a decreasing reliance on plain films in major spinal and body trauma. A continuing central role of plain film examination remains in the diagnosis of bone trauma and tumours and in following up urinary tract calculi and stent placement.
Abdominal wall and hernias
Authors: Sedman Peter
Published: August 2016

Hernia repairs comprise a significant proportion of the general surgeon’s workload in both elective and emergency practice and present a variety of challenges in their treatment. The treatment of herniae is evolving, with continuing improvements in technique. The decision on which herniae should be treated surgically depends on their natural history, particularly their risk of strangulation. Herniae in different locations lend themselves to differing techniques for repair. A thorough understanding of the relevant anatomy is essential for both the diagnosis and the treatment of herniae. For many herniae there is a choice of using open or laparoscopic techniques. The different types of mesh available for hernia repair are discussed in this chapter, with their advantages and limitations.
Colorectal
Authors: Kimble Adam , Hosie Kenneth B.
Published: August 2016

Colorectal surgery as a specialty deals with malignant and benign diseases of the lower gastrointestinal (GI) tract including the small bowel, appendix, colon, rectum, and anus. Acute disease of the lower GI tract contributes substantially to the work of the emergency general surgeon, and so it is important for the non-colorectal specialist to be aware of the principles of assessment, resuscitation, and management of lower GI pathology to ensure optimum patient care. Colorectal cancer (CRC) is the third most common cancer in the United Kingdom and its presentation is determined by the anatomical site of the tumour. Guidelines help identify patients presenting to primary care as either high or low risk of CRC, warranting either urgent referral and investigation in secondary care, or expectant management. Many common and benign perianal and rectal conditions also present with changes in bowel habit, rectal bleeding, and intestinal obstruction, and merit specialist treatment once malignancy has been excluded.
Clinical assessment and management of benign breast diseases
Authors: Goyal Amit , Reed Malcolm W. R.
Published: August 2016

The vast majority of the lesions that occur in the breast are benign. Although only 5% to 10% of new patients seen in the breast clinic will be diagnosed with breast cancer, it is essential that all are seen promptly and thoroughly assessed and those without breast cancer are reassured and managed appropriately to relieve symptoms and anxiety. The initial consultation should include clinical assessment, breast imaging, and biopsy as appropriate. This process is known as triple assessment and is the cornerstone of the diagnostic process. The term ‘benign breast diseases’ encompasses a heterogeneous group of lesions that may present a wide range of symptoms or may be detected as incidental microscopic findings. The incidence of benign breast lesions begins to rise during the second decade of life and peaks in the fourth and fifth decades, as opposed to malignant diseases, for which the incidence continues to increase after menopause. This chapter reviews triple assessment, common benign breast diseases, and their management.
Breast cancer treatment
Authors: Goyal Amit , Reed Malcolm W. R.
Published: August 2016

Breast cancer is the commonest form of malignancy in females affecting over 40 000 women annually in the United Kingdom. Survival has increased significantly in the past 20 years due to the combination of earlier diagnosis and improvements in treatment with the vast majority of patients receiving combined therapy with surgery, radiotherapy, and systemic therapy including chemotherapy and endocrine therapy. Many countries utilize mammographic screening on a population basis and this results in earlier stage diagnosis and improved survival along with the risk of overdiagnosis and over-treatment. Management of breast cancer is via a multidisciplinary team including surgeons, oncologists, radiologists, and pathologists along with clinical nurse specialists. New approaches to surgery including oncoplastic techniques aim to provide an optimal cosmetic and oncological outcome and this may be combined with the use of primary chemotherapy or endocrine therapy in an increasing proportion of patients.
Non-surgical treatment of breast cancer
Authors: Alzouebi Mymoona , Hatton Matthew Q. F.
Published: August 2016

Breast cancer has been the most common cancer in the United Kingdom since 1997 and is the commonest malignant disease in women with an annual incidence of nearly 50 000 new cases in the United Kingdom. One woman in nine will develop breast cancer during her lifetime and it is the leading cause of death from malignant disease in Western women. Surgery is key in the management of the primary tumour in early breast cancer. The main aim is to ensure adequate control of locoregional disease. However, with increased understanding that patients with breast cancer die not from uncontrolled local disease but from blood-borne metastases, there is now much greater emphasis on additional pre- and postoperative therapies to reduce risk of recurrence and improve long-term survival. These treatments include chemotherapy, radiotherapy, hormones, and molecular-targeted therapies. This chapter discusses different treatment modalities for breast cancer and their indications.
Transient ischaemic attack and stroke
Authors: Naylor A. Ross
Published: August 2016

Stroke is the third commonest cause of death and is the main cause of permanent neurological disability in the United Kingdom. About 20% of all strokes are haemorrhagic. Of ischaemic strokes, 80% affect the carotid territory and about half of these follow thromboembolism from the internal carotid artery. Key points for managing recently symptomatic patients include rapid referral, rapid investigation with non-invasive imaging, rapid implementation of medical therapy, and performing a carotid intervention (where indicated) as soon as possible after onset of symptoms. This move towards a more urgent approach to treating transient ischaemic attack (TIA) patients (i.e. on a par with myocardial infarction) follows awareness that the 7-day risk of stroke after a TIA is 10% (i.e. much higher than was previously thought). Evidence suggests that the ABCD2 scoring system can be used to fast-track high-risk patients to TIA clinics. For now, carotid endarterectomy remains the intervention of choice in the hyperacute period after onset of symptoms (< 14 days), as carotid stenting is associated with a significantly higher stroke risk during this time. The management of asymptomatic patients remains controversial, primarily because there is growing evidence that the risk of stroke on medical therapy has been decreasing over the last decade. In the United Kingdom, the National Institute for Health and Care Excellence recommends that stenting should not be offered to asymptomatic patients outside the ongoing randomized trials.
Cardiac surgery
Authors: Leslie Hamilton J. R.
Published: August 2016

Cardiac surgery for acquired heart disease encompasses surgery of the heart, pericardium, and great vessels. It has been in a state of constant change since it emerged as a specialty in the 1960s. Developments in both our understanding of the physiology of cardiopulmonary bypass and the technology of the circuit have led to rapid expansion in what is possible. Valve replacements have led to valve repairs and venous bypass grafts led on to the use of arteries as conduits. Transplantation of both heart and lungs has become standard practice, limited only by number of donors. Recent technological advances have made implantable ventricular assist devices a reality for patients with heart failure and the first generation of a fully implantable artificial heart is now in clinical trials.
Pulmonary surgery
Authors: Stamenkovic Sasha
Published: August 2016

Thoracic surgeons manage patients with many conditions other than lung cancer, and the spectrum of operations is from tracheal resection for post-tracheostomy stenosis to chest wall reconstruction for cosmetic reasons. There is an increasing use of minimally invasive techniques. Success relies on careful attention to every detail of the patient’s journey, commencing with history taking and going through to postoperative care. In this chapter, each of these stages is addressed individually with discussion on the rationale of treatments, the types of operations performed, preoperative imaging and work-up, surgical anatomy, operative techniques and pitfalls, and postoperative management and complications. Video-assisted thoracoscopic techniques can aid the surgeon and also help to minimize postoperative pain. The importance of systematic lymph node dissection in cancer cases is discussed.
Stones and infections
Authors: Hughes Benjamin , Burgess Neil
Published: August 2016

The lifetime risk of developing a urinary tract stone is 10–20% with a peak incidence occurring between the ages of 30 and 50 years. The recurrence rate is 50% and the incidence is increasing. Renal colic is one of the most common emergency urological presentations and is excruciatingly painful. This chapter covers the epidemiology and mechanisms of stone formation and treatment options. It also provides a practical guide to managing renal colic and obstruction. Urinary tract infection (UTI) affects females more than males except at the extremes of age when the incidence is similar. The lifetime risk of a UTI for a female is approximately 30% and so UTI represents a significant proportion of emergency and outpatient urological referrals. This chapter provides the relevant definitions associated with urological infections, describes the microbial aetiology, and covers diagnosis and management of general and specific urinary tract infections.
Genitourinary malignancies
Authors: Noon Aidan , Catto James
Published: August 2016

Genitourinary cancers include some of the most common (prostate adenocarcinoma is the most common male cancer) and expensive (urothelial carcinoma is one of the most expensive human cancers to manage) human malignancies. Changes in healthcare practice, such as screening for prostate cancer and the use of abdominal imaging for the identification of incidental renal cancer, have increased the detection of these cancers and produced a migration to low-stage disease at diagnosis. Refinements in treatment, such as systemic chemotherapy for testis cancer, have improved the prognosis for many genitourinary cancers, with the exception being bladder cancer. Surgery plays a key role in the treatment of most genitourinary cancers and is often performed using traditional or robot assisted laparoscopy (and increasingly through single incision surgery (LESS)). Molecular biological research has led to targeted molecular therapies for patients with metastatic renal cell carcinoma and urinary biomarkers for bladder cancer.
Benign prostatic hyperplasia and obstructive uropathy
Authors: Garthwaite Mary
Published: August 2016

Benign prostatic hyperplasia (BPH) is a chronic, complex disease that is often progressive. The term BPH refers to the actual histological changes of stromal-glandular hyperplasia seen within the prostate. The condition becomes clinically significant when this overgrowth of benign tissue is associated with bothersome lower urinary tract symptoms (LUTS). Based on an overall European prevalence of LUTS of 30%, approximately four million men aged >40 years will have LUTS in the UK. Although the causes of LUTS are multifactorial a significant proportion will be secondary to BPH. With the prevalence of LUTS and BPH increasing with age, the need for medical treatment will continue to increase. Progression of the disease can result in complications such as obstructive uropathy (acute or chronic urinary retention), urinary tract infection, and bladder stone formation. The need for BPH-related surgery is also classed as a complication of BPH progression. Risk factors for progression include age and prostate volume. Serum prostate-specific antigen (PSA) is correlated to prostate volume and can therefore be used to help determine the risk of progression. The aims of treatment are to alleviate LUTS and to prevent complications. Medical therapy is the now the most commonly used treatment modality for BPH. Rapid symptomatic relief can be gained from the use of alpha-blockers, whereas 5-alpha-reductase inhibitors have the added benefit of reducing the risk of developing urinary retention and the need for BPH-related surgery. Combination therapy, with both an alpha-blocker and a 5-alpha-reductase inhibitor, has been shown to provide greater and more durable benefits than monotherapy alone. Surgery is indicated if maximal medical therapy is insufficient to alleviate symptoms and improve quality of life, or if complications arise despite medical management. The initial management of obstructive uropathy involves catheterization, either urethral or suprapubic, to swiftly alleviate the obstruction, ensure the patient is comfortable and allow the resolution of any secondary renal impairment. Catheterization is usually temporary until surgery can be performed as definitive management, but may be required in the long-term if the patient is unfit for surgery or there is detrusor failure secondary to the chronic retention of urine.
Benign scrotal and penile conditions
Authors: Eardley Ian
Published: August 2016

Benign disorders of the penis and scrotum are common. Congenital problems include hypospadias and testicular maldescent. The most common penile problem is phimosis, or tight foreskin. It is important to avoid overtreatment of a non-retractile foreskin in children, but if there is true phimosis with scarring, then circumcision is usually required. Penile conditions that affect sexual function include penile curvature, erectile dysfunction and priapism. The most common cause of acute testicular pain in children is testicular torsion. Scrotal swellings are a common reason for men to present to surgeons. The most common causes of painless swellings are hydrocoele and epididymal cyst. Careful assessment of a scrotal swelling is important since testicular tumours can also present in this way. Ultrasound scanning is a useful adjunct in the assessment of scrotal swelling.
Joint and bone infections
Authors: Mahaluxmivala Jehangir , Makki Daoud
Published: August 2016

Septic arthritis is the infection of native or prosthetic joints. In native joints, bacterial infection is commonly caused by Staphylococcus aureus through haematogenous spread. Prompt recognition is essential to prevent destruction of articular cartilage. Diagnosis is confirmed by microbiological studies on joint aspirate but preliminary results can be negative. Treatment consists of surgical washout followed by antibiotics. Prosthetic joint infections are managed by washout with retention of prosthesis or two-stage revision depending on the time since initial surgery. Acute osteomyelitis is infection of bone caused often by haematogenous spread but can result from contamination of deep wounds, ulcers or previous surgery (internal fixation of fractures). Symptoms might be nonspecific and therefore a thorough history helps reach the diagnosis. MRI and bone scan identify the affected bony segment but diagnosis is confirmed through histological studies from biopsies. Treatment consists of intravenous antibiotics but surgical drainage might be required when antibiotherapy fails.
Benign and malignant skin lesions
Authors: Kang Mandeep , Ward David
Published: August 2016

Early determination between the diagnosis of benign and malignant skin lesions allows for appropriate management regimes to achieve the best long-term prognosis. A presumptive diagnosis can be made by considering the patient’s risk factors, history of the lesion, and its location and appearance. The definitive diagnosis is made by histological examination of biopsy specimens. The three common types of malignant skin lesions are: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. BCC comprises 60% of primary skin neoplasms. It is slow-growing and rarely metastasizes, and carries the best long-term prognosis. SCC comprises 20% of malignant skin lesions and metastatic disease is more common. MM comprises 1% of malignant skin neoplasms but accounts for over 60% of skin cancer deaths. It metastasizes to remote sites early with a poor prognosis in latter stages. Benign skin lesions generally do not require definitive treatment. Treatment for primary skin malignancies includes surgical excision with adjuvant therapy if required.
Upper airway obstruction
Authors: Swami Himanshu , Hawthorne Maurice
Published: August 2016

Common causes of sudden onset upper airway obstruction include allergy, trauma, infection, inhaled foreign body; slow onset obstruction is usually due to tumours. Speedy assessment of the severity and level of the obstruction is a key skill. Poiseulle’s equation indicates that small changes in diameter of the airway have dramatic effects on the flow of air through the upper airway. This as lead to the aphorism—‘if you are thinking about a tracheostomy you probably should be doing one right now.’ It is important to recognize prodromal symptoms in airway-threatening infections (e.g. pain and swallowing problems) before the airway is compromised and stridor starts. Valuable time can be bought in the acute situation with administration of oxygen, (or heliox), steroids while preparations are made to secure the airway. It should be remembered that since Hib vaccination, acute epiglottitis leading to death is now nearly always a disease of adults.
Acute neurosurgical emergencies
Authors: Wilson Mark , Sabin Ian
Published: August 2016

Neurosurgical emergencies often progress rapidly hence emergency management is essential to minimize further neurological damage. The brain can be injured in many ways, the most common being through direct traumatic brain injury. In the Western world, the most common mechanisms of these injuries are road traffic collisions, falls from height, and assaults. Ischaemic injury through embolic stroke or haemorrhagic injury from ruptured vascular malformations (e.g. cerebral aneurysms) are also common causes of neurosurgical emergencies. Acute hydrocephalus and infection problems (e.g. abscesses) are other conditions where prompt intervention is required. Similarly, acute spinal injuries can be traumatic, compressive, and infective.
Cancer screening
Authors: Sutton Paul , Dunne Declan , Hargreaves Anita , Poston Graeme J.
Published: August 2016

Cancer screening is now offered in most countries with an established health service for cervical, breast, and colorectal cancer. The premise on which cancer screening is employed is that early detection is commensurate with better survival. Subjecting an otherwise healthy population to investigation can however be associated with both physical and psychological harm. Clinicians must have an understanding of cancer screening, and the evidence upon which it is based. The World Health Organization published clear guidance in 1968 as to the acceptability of screening tests. At the heart of this is the ability of the test to detect at an earlier stage a disease that is treatable and would confer survival benefit, while remaining acceptable to the population being screened.
General principles of radiation oncology
Authors: Lee Chris D. , Den Dulk Marcel , Myint Arthur Sun
Published: August 2016

The aim of radiotherapy is to deliver optimal dose of radiation to either cure or control the cancer within the tolerance of normal surrounding tissues. The treatment is based on the principle that cancer cells are less likely to recover from the radiation damage compared to normal cells. The response to radiation depends on the radio sensitivity of cancer type treated. There are different types of radiation delivery methods; broadly external or internal (brachytherapy). There are early (acute) and delayed (late) side effects from radiation and the potential benefits of treatment need to be balanced carefully against the possible side effects. All new cases with cancer should be discussed at the local multidisciplinary team meeting to assess the need for radiation to improve surgical outcomes
Principles of safe surgery
Authors: Mishra Amitabh , McCulloch Peter
Published: August 2016

Surgery by its nature involves inflicting injury upon the patient, and thus carries the risk of unintentional injury to both patient and staff. Over 10% of hospital admissions1 experience an adverse event and of these approximately 7% result in permanent disability and 14% in death2. Half of hospital adverse events affect surgical patients and half are thought preventable. In a complex environment maintaining safety requires a culture of vigilance, mutual support and co-operation, well-designed standardized working practices that are adhered to in a disciplined fashion, and well-functioning technology and a high degree of technical knowledge. All surgeons must be aware of the specific hazards of the operating theatre and how to mitigate or avoid them. The emphasis of surgical training has shifted from developing surgeons who are technically competent to include other skills of leadership, teamwork, situational awareness and communication.
Surgical wounds
Authors: Crinnion James N.
Published: August 2016

The primary aim of most surgical incisions is to allow adequate unobstructed access to the operative site. Following completion of the procedure the incision must heal securely with an acceptable scar. The uncomplicated healing of surgical incisions is critically dependent on the adherence to sound technical principles. Poor surgical technique will predispose to wound breakdown, infection and ultimately excessive scarring. Surgical incisions that are made precisely and closed carefully usually heal without problems, unless there is a problem with the underlying pathology or procedure, such as an anastomotic leak. This chapter will describe the basic knowledge and surgical techniques that enable the surgeon to produce neat wounds that heal well.
Simulation and assessment
Authors: Sirimanna Pramudith , Lee Grace , Arora Sonal , Aggarwal Rajesh
Published: August 2016

An increased emphasis on patient safety and outcomes, coupled with the negative effect of work-hours restrictions, has contributed to the need for a paradigm shift in surgical training. Simulation has emerged as an adjunct to traditional training by providing a safe environment in which errors can be made and learned from. Modes of simulation include synthetic, virtual reality, animal tissue, and human models. The translational benefits on technical skills acquisition are well established, particularly for minimal access techniques such as laparoscopy. Simulation training has been demonstrated to be beneficial for training key non-technical skills that are critical for the development of expertise. To quantify performance gains from simulation training, validated assessment methods assess dexterity, procedural performance, and non-technical skills. Despite the documented benefits, the uptake of simulation into formal surgical training programs is lacking. Further studies regarding the cost effectiveness and effect on patient outcomes are required. Simulation also needs to be properly integrated into the curriculum at the appropriate stages of training.
Physical examination of the vasculature and joints
Authors: Woodley Caroline , Reed Malcolm W. R.
Published: August 2016

Consent is the permission obtained by a clinician from a patient to carry out a procedure on them. The need to obtain consent is rested on the fundamental ethical premise that any adult human has autonomy, the right of self-determination, and therefore the right to decide whether or not they allow another to invade their being. In order to make the decision of whether to give or refuse consent a patient must understand the treatment for which consent is being requested and the possible consequences of refusing treatment. In other words, they must be capable of making the decision and must be free to make the decision without coercion. The concept and requirements of consent are defined by common law, case law, and statutes that may vary between legal jurisdictions. A surgeon’s ethical responsibilities with respect to consent may extend beyond those required by law and those recommended by national bodies.
Preoperative assessment
Authors: Berthoud Mireille
Published: August 2016

There are three primary goals of preoperative assessment. The first is to assess perioperative risk. This requires a detailed knowledge of the patient’s underlying fitness, the level of their functional reserve, and the risks of the surgical and anaesthetic procedure that is planned. The second is to minimize perioperative risk by developing an appropriate care plan, which may include medical or social optimization. The third is to educate the patient about the choices he or she has before, during and after their procedure, both to relieve anxiety and to enable the patient to give informed consent. To achieve this pre-assessment needs to be timely, allowing for the possibility of medical optimization prior to surgery.
Enhanced recovery after surgery
Authors: Lobo Dileep N. , Ljungqvist Olle
Published: August 2016

A patient, once accepted for surgery, takes a complex journey through various departments and seeing a range of medical professionals. As a result, continuity of care may not be optimal when the care package is considered as a whole. The concept of Enhanced Recovery after Surgery (ERAS) addresses this lack of continuity by proposing that combining a series of treatments would substantially improve outcomes. The original ideas have been refined and the concept of ERAS is gaining acceptance. ERAS protocols have been published in thoracic, urological, gynaecological, and orthopaedic surgery, which have led to substantially faster recovery times and major reductions in postoperative complications and hospital stay. This chapter covers the broad perioperative principles that underpin ERAS as related to abdominal surgery, although the principles hold for other situations.
Principles of transfusion and haemostasis
Authors: Garner Jeff , Fletcher Andrew , Groves Jeremy
Published: August 2016

Adequate haemostasis and an understanding of coagulation is a prerequisite of safe surgery. Numerous medical and pharmacological interventions render the surgical patient more likely to bleed and the surgeon must be aware of these. Transfusion of blood or blood products can facilitate surgical procedures and prove lifesaving but the practitioner must be aware of the pros and cons of their use. There must be fastidious attention to detail throughout the transfusion process to prevent transfusion incidents, clerical mistakes remaining a common source of transfusion related harm. Adjuncts to transfusion, such as cell salvage, are available and their role must be understood. Massive transfusion presents its own challenges and has its own side effect profile and the role of near patient testing utilizing thromboelastography will be considered.
Venous thromboembolism: deep vein thrombosis and pulmonary embolism
Authors: Maclean Rhona M. , Makris Michael
Published: August 2016

Thrombosis is the formation of a clot within a blood vessel, thus preventing the flow of blood. There are distinct differences in the pathophysiology, prevention, and treatment of thrombosis occurring in arteries and veins. Arterial thrombosis takes place in a high pressure system where platelets are of primary importance and antiplatelet drugs are central to its prevention and treatment. Venous thrombosis, which occurs in a low-pressure system and primarily involves the coagulation cascade, is prevented by and treated with anticoagulants. While platelets and coagulation factors are closely interlinked, these differences can help to explain the presentation and treatment of thrombosis.
Skin loss
Authors: Al-Hadithy Nada
Published: August 2016

Trauma injuries vary in type and severity, but most commonly involve burns, lacerations, fractures, and crush injuries. Plastic surgeons have always been involved in the treatment of trauma, and in the UK plastic surgery grew out of the surgical treatment of facial injuries during the world wars. A collaborative, multidisciplinary approach is recognized as being crucial to success in this area. The advancement of reconstructive plastic surgery techniques has revolutionized the treatment of trauma. The ability to repair and reconstruct soft tissue defects has led to vastly improved patient outcomes, particularly in cases involving open fractures of the lower limb. This chapter gives an overview of approaches to managing wounds and skin loss in the trauma patient.
Burns: classification and principles of management
Authors: Al-Hadithy Nada
Published: August 2016

The consequences of a large surface area burn are far reaching with physiological, psychological, physical, social, and economic sequelae. Most burns are thermal with the largest proportion being scalds, particularly in the paediatric population. Thermal burns also include contact, flame, and flash injuries. Chemical and electrical injuries can cause deeply destructive damage to underlying muscle and bone with life threatening systemic effects under a deceptively small area of involved skin. Assessment, referral and management of burns requires a systematic approach with attention to the changing clinical presentation of the patient and understanding of the underlying pathophysiology. A multidisciplinary team is essential in providing the best clinical care. This chapter gives an overview of the patient journey from presentation to final outcome with insights into burns prognostication.
Trauma in conflict zones
Authors: Singleton James , Clasper Jon
Published: August 2016

This chapter describes the specific trauma prevalent in conflict zones – in broad terms these can be considered as ballistic and/or blast injuries. Gunshot injuries are covered, both in terms of the well-known ability to cause penetrating trauma and the emerging phenomenon of behind armour blunt trauma (BABT). Blast injuries are also discussed, including the different mechanisms capable of causing blast injury (i.e. the blast wave, fragments, the blast wind, and other mechanisms) and their effects on each body system. Finally, an overview of the clinical management of conflict casualties is provided from a surgical perspective. This covers general patterns of injury, emergent management of the combat casualty as well as specific treatment for ballistic and blast wounds sustained in a conflict environment.