bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes Associated With Trial of Labor After Cesarean Delivery
Authors: Erfani Hadi , Shamshirsaz Alireza A.
Published: February 2021

This article provides a summary of a prominent study in obstetrics. What are the risks of adverse maternal and neonatal outcomes associated with trial of labor after cesarean delivery? With this question, the article presents the basics of the study, including funding, location, patient population, study design, endpoints, results, and criticism and limitations. It then briefly reviews other relevant studies in the field and information and the main recommendations of the most recent practice bulletin provided by the American College of Obstetricians and Gynecologists and concludes with a relevant clinical scenario.
Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries
Authors: Janssen Matthew K. , Ralston Steven J.
Published: February 2021

The article provides a review of a landmark study characterizing the risk of repeat cesarean deliveries. This multicenter prospective cohort study of over 30,000 cesarean deliveries demonstrates that risks of cesarean delivery increase sequentially, even in the absence of placenta accreta. The most dramatic increase is noted in the high rates of accreta with placenta previa and multiple cesarean deliveries, greater than 40% with 3 of more cesarean deliveries. This review highlights the key findings, methodology, and impact of this landmark study. It discusses other studies that continue to verify these results as well as contextualize them in the management of placenta accreta with developing centers of excellence. Finally, the article provides a sample clinical case scenario that applies the findings of this study.
Antepartum Assessment of Fetal Well-Being
Authors: Hirshberg Jonathan S. , Raghuraman Nandini
Published: February 2021

This article provides a concise summary of a landmark paper from the field of Maternal-Fetal Medicine on antenatal fetal testing. The authors describe a novel approach to identify fetuses that are at risk of perinatal mortality. Combining ultrasonographic features and fetal heart rate monitoring, a biophysical profile (BPP) score was assigned to each fetus and the rates of perinatal mortality for each range of BPP score were determined. The article reviews the research question, funding sources, study design and outcomes. It places these findings in contemporary context and reviews relevant literature. The authors provide a clinical case to highlight the study’s applicable findings.
Transvaginal Ultrasound for Endometrial Assessment of Postmenopausal Bleeding
Authors: Garrett Alison A. , Taylor Sarah E.
Published: February 2021

This article provides a summary of a landmark study in gynecology. Can transvaginal ultrasonographic measurement of endometrial thickness be used to exclude endometrial abnormalities in women with postmenopausal bleeding? This article describes the basics of the study, including funding, study location, who was studied, the number of patients, study design, study intervention, endpoints, results, and criticism and limitations. This article also briefly reviews other relevant studies and information, discusses implications of the results, and concludes with a relevant clinical case.
A Midurethral Sling to Reduce Incontinence After Vaginal Repair
Authors: Maheshwari Deepali , Solomon Ellen
Published: February 2021

The OPUS (Outcomes Following Vaginal Prolapse Repair and Midurethral Sling) trial examined the effect of a prophylactic midurethral sling at the time of vaginal prolapse surgery in women without stress urinary incontinence. Women undergoing surgery for pelvic organ prolapse are at risk for developing postoperative stress urinary incontinence even if they do not complain of it preoperatively. This was a randomized controlled trial with intervention patients in the prophylactic midurethral sling group and control patients in the sham group. The authors identified a lower rate of de novo urinary incontinence at 3 and 12 months in women who received a prophylactic midurethral sling at the time of vaginal prolapse surgery. However, they also found higher rates of adverse events. This study provides valuable information for patient counseling and surgical decision-making with respect to concurrent prolapse and incontinence surgeries.
Robotic-Assisted Versus Laparoscopic Hysterectomy Among Women With Benign Gynecologic Disease
Authors: Arora Chetna , Advincula Arnold P.
Published: February 2021

This study aimed to compare outcomes between robotically assisted hysterectomy and laparoscopic hysterectomy for benign gynecologic conditions. The cohort study studied 264758 women who had a hysterectomy for benign indications from 2007 to 2010. Results showed that rates of complication for both types of hysterectomy were similar, and that patients who had a robot-assisted hysterectomy were less likely to have a length of stay greater than 2 days or require transfusion. The rate of discharge to a nursing facility were similar. Cost was over $2189 greater per robot-assisted laparoscopic surgery, In all, robot-assisted laparoscopic hysterectomy and laparoscopic hysterectomy had similar outcomes, but robot-assisted laparoscopic hysterectomies incur much greater cost.
Endometrial Ablation Versus Hysterectomy
Authors: Helou Christine , Yunker Mandy
Published: February 2021

This article reviews study methodology, results, limitations, and utility of the Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB). Criticisms and limitations of the study are proposed. Relevant information from other studies or guidelines are reviewed. The key findings from this study are then applied to a clinical case scenario. The results of this study, particularly those related to reoperation, were in line with other studies. While follow-up of enrolled patients was lengthy, the study was limited by slow recruitment leading to small sample sizes. Generalizability of this study is limited by the lack of randomized with regards to surgical technique and hysterectomy route, as well as use of resectoscopic ablation techniques. Both endometrial ablation and hysterectomy were found to be effective treatments for premenopausal women with DUB. Hysterectomy was more effective at treating bleeding symptoms but was associated with more adverse events and higher rates of infection. A small but significant proportion of women initially treated with ablation subsequently underwent reoperation with either repeat ablation or hysterectomy. The information from this study when used in context with similar studies is useful in guiding patient counseling for treatment of premenopausal DUB; however, treatment plans should ultimately be individualized based on patient-specific factors to maximize the likelihood of success with initial treatment.
Predictors of Success of Methotrexate Treatment for Tubal Ectopic Pregnancies
Authors: Fowler Mary Louise , Hendessi Paul , Noel Nyia
Published: February 2021

This study reviewed the use of a single dose of intramuscular methotrexate as therapy in women with an ectopic pregnancy. Therapy failure was more likely in women with higher hCG level and presence of cardiac activity at time of treatment. Age, parity, size of pregnancy, and the presence of intraperitoneal fluid were not found to correlate with treatment failures.
Convergence and the Changing Nature of Innovation
Authors: Arnold Amanda , Bowman Katherine
Published: February 2021

Convergence has the potential to shape cultures of innovation in health and medicine by providing a framework integrating perspectives from multiple disciplines and sectors to tackle challenges such as understanding and addressing mental health disorders and improving well-being. This chapter discusses examples of efforts to establish cultures that support convergence and lessons learned from multiple sectors. The chapter highlights changing perspectives from institutions engaged in convergent research, including universities, industry, philanthropic foundations, and government agencies. Facilitating progress toward solutions that could not otherwise be obtained serves as a critical motivation for pursuing convergence, even when approaches that rely on convergence challenge conventional institutional incentives and structures. Indeed, barriers to establishing and supporting convergence arise where existing organizational practices and structures misalign with the changing nature of innovation. Nevertheless, examples from across the innovation ecosystem, from American research universities to the biotechnology industry, reveal some of the strategies such organizations are using to actively create and foster cultures that support convergence. Federal agencies are also beginning to investigate funding incentives to support convergent work through their grant-making programs. The chapter concludes with an array of actions others have used to help foster convergence institutionally. These lessons learned may have relevance for those interested in establishing convergence in the realm of mental health.
Establishing Transdisciplinarity Within a University
Authors: McWhinnie Louise J. I.
Published: February 2021

The emergence of a growing debate surrounding transdisciplinary collaboration is a reaction to the increasing speed of change that confronts our society and the complexity of the dynamic and networked problems we face. The University of Technology Sydney instituted its first transdisciplinary program in 2014, resulting in the formation of a faculty 3 years later. This chapter provides an example of the integration of transdisciplinarity within a university’s mission and its early educational development and delivery. Highlighting the lack of precedent for such a radical change and the inherent challenges that educational institutions themselves may present to a successful implementation and integration, the author provides a case study to enable others to learn from this early adoption. The intent is to inform and aid the further development of industry and institutional transdisciplinary collaboration. In examining this real-world experiment, there are lessons to be learned. These will aid recognition of the potential of this new educational paradigm to enable a new generation to engage with complex problems in new ways in a rapidly changing world.
The OECD Approach to Responsible Innovation
Authors: Winickoff David E. , Garden Hermann
Published: February 2021

Ultimately, technology will be useless unless it can be diffused and built into society in ways that are socially robust—trustworthy, debated, accessible, and acceptable. Thirty-six member countries of the Organisation for Economic Co-operation and Development have recently enacted the Council Recommendation on Responsible Innovation in Neurotechnology, adopted on December 11, 2019. The Recommendation is the first international instrument in its field. Committed to the idea that we must not just innovate more but innovate well, the Recommendation embodies a “responsible innovation” approach that could serve as a model for technology governance both in neurotechnology and beyond. The Recommendation aims to help public and private actors address the ethical, legal and social challenges of neurotechnology while encouraging innovation. At least five overarching elements help set out a novel approach to neurotechnology governance: (i) mission orientation, (ii) inclusivity of the innovation process (iii) anticipatory governance, (iv) societal deliberation, and (v) the role of the private sector.
Precision Mental Health
Authors: Hack Laura M. , Williams Leanne M
Published: February 2021

Precision psychiatry is an emerging integrative approach that unifies the scientific foundation of the discipline and recent technological advances, directing them at narrowing the gap between discovery and clinical translation. Although depression in particular exerts a staggering toll, an understanding of which disease processes underlie the heterogeneity of depression as it is experienced by each person is lacking. While many effective treatments are available for depression, finding the right treatment for the right patient at the right time remains largely a matter of trial-and-error. Furthermore, the DSM provides a system for clinicians and researchers to communicate reliably about observed diagnostic signs and symptoms, yet a taxonomy does not exist for diagnosis and for guiding treatment choices that is based in an understanding of underlying pathophysiology. Thus, there is an urgent clinical need for an innovative approach. Functional imaging of large-scale neural circuits is one approach to developing a mechanistic taxonomy. Retrospective studies show that understanding disruptions to brain circuits markedly improves our ability to determine which patients are likely to benefit from which interventions. In this chapter, the authors present a model for precision psychiatry and why it is urgently needed at this time. Their primary focus is on the organ of dysfunction in psychiatry—the brain. They complement this approach with consideration of two blood-based markers, including inflammatory markers and pharmacogenetics. They review emerging findings that form the foundations of precise classification and initial results for precise treatment planning using these tools. They conclude by highlighting necessary steps to accelerate precision psychiatry from vision to reality.
Emerging Role for Technology in Positive Psychiatry Interventions
Authors: Treichler Emily B. H. , Lee Ellen E. , Jeste Dilip V
Published: February 2021

Increasing well-being, happiness, resilience, wisdom, and related positive psychiatry outcomes is possible via behavioral and psychological interventions. Convergence of psychiatry with computer science, engineering, and related disciplines will allow for the impact of these interventions to be personalized, maintained, and augmented in a number of ways. To illustrate such potential impacts, the authors use an example of a recent trial of a novel intervention to improve resilience within senior housing communities. Specialized technologies have the potential to improve fidelity and dissemination of positive psychiatry interventions. With the shortage of specialized mental health clinicians and the growing need for mental health services, technology can be used to extend the in-clinic services and provide greater support in the free-living environment. Development of such technologies to improve well-being will require mental health specialists to work directly with computer scientists, engineers, and people with mental illnesses. These collaborations will require infrastructure and support from research and academic organizations that partner with industry and community-based agencies and organizations.
A Social, Behavioral, and Implementation Science Perspective on Convergence Mental Health
Authors: Albert Steven M. , Ricci Edmund
Published: February 2021

Convergence is best approached through a systems science lens because it includes multiple levels of influence and organization and a host of mutually reinforcing elements. Each of these factors requires behavioral and social science research to ensure that convergence is appropriately anchored in the experience of patients and their communities. For example, the continuous assessment of mental state made possible through real-time mobile app recording of voice, movement, and biosignatures will be much less effective if people reject it because of privacy concerns or if this monitoring is not adequately linked to choices for self-care. Patients may need in-person contact with a therapist to choose an appropriate app and in-person boosters to support effective use. Use of the app and its effectiveness accordingly depend on social-behavioral factors. Likewise, the social and behavioral sciences are central for shortening the time between development and translation of mental health treatments and programs. Including the social and behavioral sciences in mental health convergence science suggests the need for broad-scale efforts that link mental health to population science to systems thinking. This effort places mental health within the broader framework of population health and to implementation science for reducing the time from development of a new treatment to its widespread use. The approach has implications for data collection and analysis in that it entails much larger datasets and need for greater computational power.
Convergence Mental Health Across the Life Span
Authors: Forbes Malcolm , Rego Thomas , Lavretsky Helen , Reynolds III Charles
Published: February 2021

The burden of geriatric mental disorders is significant and expected to rise in the 21st century. Existing therapies for geriatric mental disorders have modest efficacy and improved prevention, diagnosis, and treatment options are urgently needed. The field of precision psychiatry focuses on an individual’s unique attributes to help improve risk assessment, diagnosis, treatment, and prevention of psychiatric disorders. Within this state-of-the-art review, the authors provide a review of the field of precision psychiatry for geriatric mental disorders. They consider topics such as wearables, pharmacogenetics, smartphone apps, and chatbots to alleviate depression in late life and virtual reality, robotics, and brain stimulation for cognitive enhancement among elderly with dementia.
Innovation Diplomacy in the Clinical Neurosciences
Authors: Ternes Kylie , Dawson Walter , Eyre Harris A.
Published: February 2021

Clinical neuroscience diplomacy aims to influence the global policy environment for clinical neuroscience disorders (i.e., dementia, depression, and other mind/brain disorders) and bridges the disciplines of global brain health, global mental health, international affairs, management, law, and economics. Determinants of clinical neuroscience disorders include educational attainment, diet, access to health care, physical activity, social support, and environmental exposures, as well as chronic brain disorders and treatment. Global challenges associated with these determinants include large-scale conflicts and consequent mass migration, chemical contaminants, air quality, socioeconomic status, climate change, and global population aging. Given the rapidly advancing technological innovations impacting clinical neuroscience disorders, it is paramount to optimize the benefits and mitigate the drawbacks of such technologies.
Toward Multi-Omic–Informed Psychotropic Prescribing
Authors: Maruf Abdullah Al , Bousman Chad
Published: February 2021

Matching individuals to tolerable and efficacious pharmacotherapies in mental health has proven challenging. As such, efforts to personalize psychotropic prescribing in mental health has received considerable attention over the past decade. This attention has been fueled by technological advances in genomics, specifically, pharmacogenomics, and, more recently, epigenomics, transcriptomics, proteomics, and metabolomics that have facilitated the identification of clinically useful biological markers to guide medication selection and dosing. The convergence of these omic technologies is arguably the future of personalized psychotropic prescribing. This chapter provides an overview of the current genomic, epigenomic, transcriptomic, proteomic, and metabolomic knowledgebase as it relates to psychotropic drug response in an effort to identify promising linkages between and facilitate convergence across these approaches to guide safe and effective pharmacotherapy relevant to psychiatry.
Biobehavioral Sensing for Objective Evaluation of OCD Patients
Authors: Liu Gary , Hunt Patrick J , Pai Amruta , Schneider Sophie C , Sabharwal Ashutosh , Moukaddam Nidal J. , Goodman Wayne K. , Storch Eric A
Published: February 2021

Obsessive-compulsive disorder (OCD) is a debilitating mental disorder characterized by obsessive thoughts that trigger compulsive actions. While OCD is associated with significant disability, there are currently no objective markers for screening, diagnosis, or tracking of treatment progression in OCD patients. This is especially troublesome given reliance on subjective measurements and patient-reported outcomes. Here, to advance existing assessment approaches, the authors propose the utilization of engineering tools to objectively track the physiological, kinetic, behavioral, and affective state of individuals with OCD to aid in their clinical management. The utilization of these tools to aid in human measurements is termed biobehavioral sensing. Although the data are preliminary, the authors believe that these blueprints may be implemented in the near future to aid in the screening, diagnosis, and management of OCD. Furthermore, these ideas may also be expanded to assist in the care of patients with other mental health disorders.
Key Considerations for Developing Digital Health Accelerators
Authors: Lethlean Grace
Published: February 2021

The digital health sector is expanding rapidly and has large potential to generate both positive health and economic outcomes. Accelerator programs are one mechanism to support emerging digital health companies to become sustainable impactful businesses. This chapter explores accelerators, how and if they work, and considerations specific to developing an accelerator program for digital health. It then outlines key considerations for digital health accelerator program design and concludes with a globally unique case study. This discussion covers accelerator design from inception through to company and mentor selection, as well as exploring the impact of accelerator programs and mechanisms for operational sustainability.
Screening for Convergent Practitioners in Health Research and Innovation
Authors: MacRae Ian , Furnham Adrian
Published: February 2021

Convergence practice is an exciting and promising area of personnel and team development. One useful area of research and practice in improving the performance and outcomes of convergence teams is in understand what traits and characteristics make someone successful in a convergence role. Individual practitioners, scientists, entrepreneurs, specialists, and technicians who perform well in one environment or in a specific role do not always perform equally well in different roles or working environments. Defining the key characteristics, traits, behaviors, and requirements for convergence practice helps to identify, select, and manage convergence practitioners and teams far more effectively. The authors objective for this chapter is to draw on previous literature on convergence practitioners, transdisciplinary practice, and team science to review the key traits of high potential convergence practitioners. In so doing, they bridge the gap between the psychological research of high potential to create a practical model of convergence work in practice.
Consumer Participation in Personalized Psychiatry
Authors: Chaudhary Neha P. , Eyre Harris A.
Published: February 2021

Personalized psychiatry represents a paradigm shift that is long overdue. It is characterized by shifting screening, diagnosis, treatment, and prevention practices away from a “one size fits all” approach to one tailored to patients’ unique clinical, social, digital, and biological (e.g., genetic and epigenetic) profiles to enhance outcomes. This shift from traditional approaches to more tailored, personalized practices not only opens up an opportunity for, but also emphasizes the need for consumer participation in the design of these practices. This participation could be through research, policy, ethics discussions, clinical care, or novel solution development. This chapter outlines the rationale for consumer participation in personalized psychiatry and provides insights and examples of ways in which to enhance this participation. The outcome is novel solution development that appropriately focuses on end-user needs by incorporating consumer contributions to both product design as well as testing. Validation of new technologies prior to their implementation can be difficult through current research practices; however, consumers can help expand research practices by identifying the highest-priority questions to answer, advocating for necessary resources and influencing the design of models for joint clinical decision-making. As both research subjects and the ultimate beneficiaries or users of new technologies, consumers also have a critical perspective on ethical issues unique to personalized psychiatry—one that absolutely needs to be considered as this field continues to grow. The authors conclude that there is no substitute for the consumer voice.
Collaborative Research and Investment to Secure “Healthy Brains for All”
Authors: Staglin Garen K.
Published: February 2021

One Mind, Rutherford, California, is a lived-experience-led mental health nonprofit focused on helping people with brain illness and injury to recover so that they can succeed in their lives (www.onemind.org). The guiding principles of One Mind include an emphasis on people with “lived experience” participation, strategy collaboration across sectors and institutions, open science, and recognizing mental health as disorders of the brain and not as character flaws. One Mind takes the approaches of funding via philanthropy, government, and industry, convening diverse groups of experts and advocating. One Mind has strategically provided seed funding for research resulting in follow-on grants from National Institutes of Health, US Department of Defense, and other foundations of over $450 million over the last 20 years. This chapter explores One Mind’s work in support research and investment.
Unconventional Approaches to Investing in Mental Health Technology
Authors: Sobowale Kunmi
Published: February 2021

The increasing burden of mental illness and substance use disorders and associated gaps in treatment have spurred interest in mental health technologies. These technologies have the potential to improve treatment and access to care. However, funding to support these technologies has been minimal to date. A shift is needed from long-standing underfunding to commensurate financing of mental health research and treatment. This chapter explores novel financial instruments to increase funding. Taxes, social impact bonds, and blended finance are discussed. Although these financial instruments are not widely used in mental health, existing examples highlight the opportunity to create sufficient and sustainable funding for mental health technologies.
Convergence Mental Health
Authors: Randall James A , Altimus Cara M.
Published: February 2021

Precision health arose from a need to treat not just a person’s symptoms retroactively, but a holistic person proactively. Its tenants involve incorporating one’s genome, social, and medical characteristics, in addition to environmental and day-to-day factors in effort to not just treat people, but to keep them healthy. Many of the procedures and technologies in place to foster precision health in the physical medical space may also be extrapolated onto the mental health sphere as well, otherwise known as convergence mental health. This chapter outlines the principles and practices of precision health, including its current state of the science; how private, public, and government institutions may collaborate to foster better preventative mental healthcare; and the barriers and solutions to the universal adoption of precision health/technological integration into mental health-based practices. The four major identified barriers are (i) insufficient scientific evidence; (ii) insufficient data sharing between relevant health partners; (iii) lack of field-wide coordination; and (iv) difficulties with access, including: insurance, providers, and availability of practice.
Trans-Sectoral Neuroscience Innovation for the 21st Century
Authors: McCullough Michael , Roberts Laura , Saville Diana , Nguyen Calvin , Shao Bo , Enriquez Juan , Hoffman Reid
Published: February 2021

Humanity is on the verge of a radically productive era in brain science, yet far too many important and impactful ideas will never leave the lab due to the profit-driven infrastructure supporting translation. BrainMind is a platform and private community connecting people developing high-impact innovations in brain science with capital and entrepreneurial resources at scale. The BrainMind ecosystem is driving the coordination of expertise, capital, and infrastructure to bring critical life-saving ideas out of the lab and into real-world. clinical and commercial use. The BrainMind community includes members from research, medicine, entrepreneurship, investing, philanthropy, and policy, with the community growing to include more interdisciplinary voices including experts in statistics, clinical psychiatry, ethics, computer science, philosophy of mind, and economics, to name a few.
Psychopharmacology in Cancer Care
Authors: Roth Andrew , Nelson Chris
Published: February 2021

Clinicians who care for adult cancer patients have many tools to manage symptoms of depression, anxiety, cognitive changes, insomnia, and fatigue. Non-prescribing clinicians, such as psychologists, nurses, social workers, and occupational and physical therapists, provide frontline psychosocial interventions and physical support for cancer patients. Psychotropic treatments are sometimes required to resolve complex syndromes that mingle both medical and psychiatric features. Psychiatric medications are most frequently prescribed to cancer patients by oncologists, general medical practitioners, general psychiatrists, and psychiatric advanced practice providers such as nurse practitioners and physician assistants, as few oncology practices have dedicated psycho-oncologists. Non-prescribing practitioners who care for people with cancer are often the first to identify a psychiatric syndrome that requires a referral for psychopharmacologic intervention. They can also play an important role in educating patients about how psychopharmacologic agents can augment their cancer care. After psychotropic medications are started, non-prescribers can observe for improvement and detect problematic side effects if they arise, thus improving adherence with medication regimens. Practitioners who read this book will benefit from the highlighted clinical pearls to follow, and the potholes to avoid, regarding the tricky diagnostics and pharmacologic treatment of psychiatric syndromes. All clinicians will learn communication strategies that bridge distances of professional specialty and geography so that treatment by multiple providers may be more seamless, which it is hoped will enrich outcomes, both medical and emotional.
Mechanical Properties, Anatomy, and Control of the Upper Airway
Authors: Dewald Denise , Strohl Kingman P.
Published: February 2021

The physiology of the upper airway is fundamental to current and trending therapy for obstructive sleep apnea and neurostimulation in particular. Proper functioning of the upper airway will promote sleep health by supporting the requisite airflow without snoring or significant flow limitation. Dysfunction produces snoring, obstructive hypopneas, and the metabolic sequelae of sleep disordered breathing. How a particular section of the upper airway (e.g., velopharynx, oropharynx, or hypopharynx) remains open while it is suspended from the skull base, maxilla, and mandible is the result of anatomy and neuromuscular control. The genioglossus muscle, originally designed for bringing food into the mouth and swallowing, along with multiple other muscles, participates in the maintenance of patency of the muscular pharynx during wakefulness and sleep. If the genioglossus were the only muscle important for airway stability, then hypoglossal nerve stimulation would likely be universally rather than selectively effective; instead, its effectiveness is predicted by velopharyngeal functions, which in terms of sleep health are poorly described. Literature clearly indicates a fundamental role for muscles other than the genioglossus in maintaining airway diameter, shape, and wall stiffness. Models that incorporate a more complete neuromechanical coupling of these components are necessary to understand a stable airway during sleep and helpful for decisions in management of obstructive sleep apnea.
Clinical Protocol in the Multidisciplinary Setting
Authors: Waxman Jonathan , Shenouda Kerolos , Lin Ho-sheng , Badr Safwan
Published: February 2021

This chapter describes a presurgical protocol for patients with moderate to severe obstructive sleep apnea (OSA) who plan to undergo treatment with upper airway stimulation (UAStim). Patients must receive an initial evaluation including a medical and sleep history and physical examination focused on characteristics suggestive of upper airway narrowing. Criteria related to UAStim therapy and possible exclusion from implantation may be considered at this point. Some patients may be referred to a sleep specialist, but all must undergo in-laboratory or at-home polysomnography to diagnose OSA. Following an OSA diagnosis, treatment with continuous or auto-titrating positive airway pressure should be initiated. Unfortunately, CPAP adherence is low, and while there are several nonsurgical alternatives, many patients who are unable or unwilling to use CPAP will seek surgical treatment. Patients who are referred to otolaryngology for evaluation for UAStim therapy should undergo a medical and sleep history and physical examination including flexible fiberoptic laryngoscopy to evaluate upper airway anatomy. Patients must next undergo drug-induced sleep endoscopy (DISE), during which the upper airway is directly visualized in the operating room with fiberoptic endoscopy under sedation. The most common classification system to describe the location and pattern of upper airway collapse observed during DISE is the Velum, Oropharyngeal walls, Tonsils, Epiglottis (VOTE) system. Patients older than 22 years of age, with an apnea–hypopnea index between 15 and 64 (with central/mixed apneas <25% of the total), a body mass index <32 m/kg2, and without palatal complete concentric collapse may be offered UAStim treatment.
Efficacy and Safety
Authors: Ramprasad Vaibhav H. , Soose Ryan J.
Published: February 2021

Electrical stimulation of the hypoglossal nerve through implantable neuromodulation systems (UAS) has been demonstrated to be both safe and effective in the management of obstructive sleep apnea (OSA) in a subset of patients meeting specific clinical criteria. After decades of animal and human basic science research confirmed the feasibility and safety of UAS, multiple prospective studies, including the phase III multicenter Stimulation Therapy for Apnea Reduction (STAR) trial, demonstrated the efficacy of UAS in improving both polysomnographic (apnea–hypopnea index, oxygen desaturation index) and patient-reported (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, Snoring Visual Analog Scale) outcome measures. Even with the widespread dissemination into routine clinical practice and commercial availability of the therapy across the United States and Europe, these studies also consistently report very low procedure-related or therapy-related serious adverse event rates. Recent comparison studies with upper airway reconstructive surgical procedures suggest that UAS provides treatment that is at least as effective but with reduced postoperative pain and risk, and with preservation of the upper airway anatomy.
Is Compassion Innate? Spiritual and Eastern Perspectives
Authors: Wong Agnes M.F.
Published: February 2021

In this chapter, the author begins with an overview of compassion from different spiritual perspectives and develops an appreciation that although each tradition expresses it differently, compassion can be summed up aptly by the Golden Rule: “Do unto others as you would have them do unto you.” The author shows that the principle of compassion lies at the heart of all religious, ethical, and spiritual traditions, calling us always to treat all others as we wish to be treated ourselves. The chapter then dives deeper into the Eastern perspectives on compassion, with special attention given to the Buddhist view because many contemporary secular compassion training programs borrow the mind-training tools that originate from Buddhism. The author reviews the four immeasurables—loving-kindness, compassion, sympathetic joy, and equanimity—that are commonly practised together in the Buddhist tradition. Last, the author reviews the three different types of compassion—referential, insight-based, and nonreferential—in the Buddhist context.
Coronary artery spasm
Authors: Shimokawa Hiroaki , Takahashi Jun
Published: February 2021

Coronary artery spasm is a condition in which an epicardial coronary artery or coronary bypass graft exhibits abnormal transient constriction with the possible or subsequent development of myocardial ischaemia. Porcine models have demonstrated the important role of atherosclerotic/inflammatory changes of the coronary artery and established that hypercontraction of vascular smooth muscle cells plays a central role in the genesis of spasm and is, in part, dependent on activation of Rho-kinase, a molecular switch for vascular smooth muscle cell contraction. Fasudil, which is used for the treatment of cerebral vasospasm in Japan, is metabolized to hydroxyfasudil and functions as a selective Rho-kinase inhibitor. Recent studies demonstrated that inflammatory changes in the adventitia of the coronary artery play an important role for Rho-kinase activation of vascular smooth muscle cells. Prevention and treatment of coronary spasm is important in preventing acute coronary syndromes and sudden cardiac death.
Anomalous coronary arteries
Authors: Ong Chin Siang , Binder Ronald K. , Jacobs Marshall L. , Cameron Duke E.
Published: February 2021

Coronary artery anomalies have been recognized since antiquity and were described in various anatomical treatises by Renaissance scholars. In the mid-1970s, the clinical significance of anomalies of coronary artery origin and course with respect to sudden death was appreciated, and the first successful surgical unroofing procedure was performed. This chapter describes the embryology and normal anatomy of the coronary arteries and types of coronary artery anomalies and their classification. In particular, it discusses the anomalous aortic origin of a coronary artery (AAOCA), diagnosis of AAOCA, and indications for, types, and outcomes of surgical repair for AAOCA.
Fractional flow reserve
Authors: Ciccarelli Giovanni , Barbato Emanuele , Bruyne Bernard De
Published: February 2021

Fractional flow reserve is an index of the physiological significance of a coronary stenosis, defined as the ratio of maximal myocardial blood flow in the presence of the stenosis to the theoretically normal maximal myocardial blood flow (i.e. in the absence of the stenosis). This flow ratio can be calculated from the ratio of distal coronary pressure to central aortic pressure during maximal hyperaemia. More practically, fractional flow reserve indicates to what extent the epicardial segment can be responsible for myocardial ischaemia and, accordingly, fractional flow reserve quantifies the expected perfusion benefit from revascularization by percutaneous coronary intervention. Very limited evidence exists on the role on fractional flow reserve for bypass grafts.
Optical coherence tomography
Authors: Galougahi Keyvan Karimi , Roleder Tomasz , Maehara Akiko , Ali Ziad A.
Published: February 2021

Optical coherence tomography enables fast, high-resolution visualization of vascular tissue that is often not feasible by other imaging modalities. This chapter provides an overview of diagnostic applications of optical coherence tomography in coronary pathologies and the unique insights that optical coherence tomography can provide in percutaneous and surgical cardiovascular procedures.
Heart Team management in coronary revascularization
Authors: Head Stuart J. , Mack Michael J. , Holmes David R. , Taggart David P.
Published: February 2021

Multidisciplinary team decisions in medicine are thought to improve decision-making and to raise the level of care in situations where there may be multiple treatment options for a particular patient or patient group. A particularly prominent example of this is in oncology, where patients with cancer treated by a multidisciplinary team had significantly improved care and clinical outcomes as well as geographically more consistent therapy and treatment recommendations. Multidisciplinary Heart Teams for the treatment of cardiovascular diseases have received emphasis over recent years with increasingly overlapping treatment options for patients with coronary artery disease or valvular heart disease.
Optimal medical therapy for coronary artery disease
Authors: Holmes David R. , Fuster Valentin
Published: February 2021

Cardiovascular disease remains the leading cause of death in the United States and the developed world and is becoming increasingly more prevalent globally. Indeed, in less developed nations, cardiovascular disease is now a relatively greater burden than in more developed economies. It is currently the number one cause of death worldwide, as a result of two phenomena, namely increased life expectancy due to successful treatment/prevention of infectious disease as well as increased exposure to known risk factors such as tobacco use, obesity, and a sedentary lifestyle. Cardiovascular disease is typically the result of atherosclerosis which can present as coronary heart disease, cerebrovascular disease, peripheral arterial disease, or aortic atherosclerosis. Given the generalized disease process, many individuals develop and present with more than one clinical manifestation. This has important implications for screening, for example, in patients presenting with clinically evident peripheral arterial disease, consideration should be given for screening to detect the presence of asymptomatic coronary artery disease.
Anaesthetic management of on- and off-pump coronary artery bypass grafting
Authors: Baron Elvera L. , Weiner Menachem M. , Reich David L.
Published: February 2021

The anaesthetic considerations for the patient presenting for coronary artery bypass graft surgery are continuously evolving. Anaesthesiologists need to be familiar with advances in pharmacological risk reduction, new surgical techniques, and new monitoring modalities in patients undergoing coronary artery bypass graft surgery. Furthermore, many of the reportable quality metrics may be influenced by anaesthetic technique. This chapter reviews monitoring modalities for coronary artery bypass graft surgery, induction and maintenance of general anaesthesia, important considerations involved in initiation and weaning from cardiopulmonary bypass, as well as implications of quality metrics for coronary artery bypass graft surgery.
The selection of conduits for coronary artery bypass surgery
Authors: Gaudino Mario , Misfeld Martin , John R. , Brereton L.
Published: February 2021

Coronary artery bypass grafting is the most common adult cardiac surgery operation performed in the United States and probably worldwide. Complete revascularization and excellent patency of the implanted grafts are the primary aims of coronary artery bypass grafting; individualized selection of conduits appropriate for the specific coronary anatomy and clinical characteristics of each patient is key to achieving this goal.
Personal perspectives on the early development of internal thoracic artery grafting and the role of bilateral internal thoracic artery grafting
Authors: Green George E. , Lytle Bruce W.
Published: February 2021

This chapter presents personal perspectives on the early development of internal thoracic artery grafting and the role of bilateral internal thoracic artery grafting by George E. Green and Bruce W. Lytle, respectively.
Bilateral internal thoracic arteries
Authors: Taggart David P.
Published: February 2021

In an attempt to obtain more robust scientific evidence as to whether bilateral internal thoracic artery grafting offers a survival benefit over single internal thoracic artery grafting, the Arterial Revascularisation Trial (ART) enrolled 3102 patients between June 2014 and December 2017 in 28 centres in seven countries. The primary outcome was all-cause mortality at 10 years and the secondary outcome a composite of death, myocardial infarction, and stroke. This chapter describes the implications of the 10-year outcomes of ART.
Cannulation strategies of the aorta for coronary surgery
Authors: Raza Sajjad , Shorbaji Khaled , Deo Salil V. , Sabik Joseph F.
Published: February 2021

Coronary artery bypass grafting is one of the most commonly performed surgeries in the United States and worldwide. It can be performed with or without the use of cardiopulmonary bypass (referred to as on-pump or off-pump coronary artery bypass grafting, respectively). For most patients undergoing coronary artery bypass grafting, the on-pump approach remains the default option. This chapter describes the technique of aortic cannulation in patients undergoing on-pump coronary artery bypass grafting.
Redo coronary artery bypass grafting
Authors: Bakaeen Faisal G. , Svensson Lars G.
Published: February 2021

Patients who undergo redo coronary artery bypass grafting (CABG) are older, have more comorbidities, and a greater atherosclerotic burden than those who undergo primary CABG. In addition, redo CABG is technically more demanding than primary CABG. Sternal re-entry may be challenging because of the proximity of cardiovascular structures, including previous bypass grafts that could be at risk for injury. Furthermore, dissecting out the heart to institute cardiopulmonary bypass and exposing the coronary targets may be complicated by scar tissue and suboptimal dissection planes, with additional risk of injury to patent conduits or inadvertent manipulation of diseased conduits that can result in thromboembolic complications and ischaemia. Effective myocardial protection is especially important in redo CABG, and anatomical limitations must be overcome in patients with severe diffuse native disease or areas supplied by occluded grafts. Patent left internal thoracic arteries in redo CABG patients introduce an extra level of complexity in intraoperative management.
Coronary artery bypass grafting in octogenarians
Authors: Tam Derrick Y. , Karkhanis Reena , Fremes Stephen E.
Published: February 2021

The prevalence of coronary artery disease in the elderly is high and has been shown to be greater than 80% in patients over the age of 80 years. Coronary artery bypass grafting remains the treatment of choice in selected patients with advanced coronary disease in the absence of surgical contraindications. While much of the data presented in this chapter is not from the current decade, there are some recent studies that have examined trends and outcomes in the contemporary era.
Coronary artery bypass grafting and mitral valve surgery
Authors: Kilic Arman , Michler Robert E. , Acker Michael A.
Published: February 2021

With an ageing population and expected increases in the prevalence of heart failure, there will likely be more patients presenting with ischaemic mitral regurgitation (IMR). Multiple studies have shown that surgery can be performed safely in this patient population. Randomized trials have now addressed whether mitral valve repair should be performed concomitantly with coronary artery bypass grafting in the setting of moderate IMR, and whether mitral valve repair or replacement is superior in the setting of severe IMR. Novel percutaneous technologies to address the mitral valve are also in evolution. This chapter provides an overview of IMR including surgical indications, operative techniques, a review of randomized trial data, and percutaneous approaches for mitral valve disease.