bluuebunny/crossref_metadata_2025 huggingface dataset:
Endocrinology and metabolism
Authors: Provan Drew
Published: February 2018

This chapter contains guidance for the generalist, general physician, and trainee endocrinologist on how to approach a wide range of endocrine and metabolic conditions by means of structured flow charts or tables. Electrolyte disturbances (low and high sodium, potassium, calcium states), as well as common clinical presentations that often have an endocrine cause (hypertension, polydipsia/polyuria, obesity, delayed/precocious puberty, short stature, galactorrhoea, gynaecomastia, amenorrhoea, hirsutism, impotence, and infertility), are covered. Guidance is also given on the further investigation of states of endocrine excess and deficiency, including hypopituitarism, acromegaly, hyper-/hypoadrenalism, and hyper-/hypothyroidism. Investigation and classification of common and rare causes of diabetes and hyperlipidaemia are included, as well monitoring of glucose control and the investigation of hyperglycaemic emergencies. Protocols are provided for the common endocrine dynamic tests. All sections contain references to up-to-date published guidance. Although information is provided on paediatric conditions, more detailed texts will be required for specialist paediatric diagnoses.
Immunology and allergy
Authors: Provan Drew
Published: February 2018

This chapter covers the role of the immunology laboratory in the diagnosis of immunological and allergic disorders, including testing for autoimmune diseases, allergic diseases, lymphocyte and neutrophil phenotype and function, and immunochemical analysis of serum proteins for the diagnosis of immune deficiency and myeloma. Information is provided on the tests, with ranges and explanation of the interpretation of abnormal results. Critical results requiring immediate action are highlighted.
Cardiology
Authors: Provan Drew
Published: February 2018

This chapter describes and discusses commonly used investigations in the assessment of patients with cardiovascular disease. It reviews electrocardiography (ECG), including ECG monitoring, and exercise testing. It describes cardiac imaging techniques, including echocardiography, cardiac magnetic resonance imaging (MRI), and nuclear cardiology (myocardial perfusion imaging and radionuclide ventriculography). It also includes information on cardiac catheterization (including pulmonary artery catheterization) and a section on tilt table testing.
Gastroenterology
Authors: Provan Drew
Published: February 2018

This chapter summarizes key investigations to diagnose symptoms and signs in the gastrointestinal lumen, liver, and pancreas, looking at the risk and benefits of each procedure, as well as indications, special considerations, and safety concerns prior to booking. These investigations diagnose abnormal appearances, measure disordered motility, determine the presence of infection, study absorption within the intestinal lumen, and measure disordered physiology. Less invasive tests such as faecal occult blood samples are used to screen subjects to determine those at higher risk of pathology who would require more invasive investigation. Judicious use of blood tests provides a similar role in triaging before more complex tests and highlights those patients at greater risk. Finally, for practical diagnostic procedures, including ascitic tap which junior doctors are likely to complete on the wards, there are practical guides to safely completing the procedure.
Respiratory medicine
Authors: Provan Drew
Published: February 2018

Respiratory medicine is the study of lung function. This chapter outlines the investigations in current use, including blood gas analysis, sleepiness scans, bronchoscopy, flow–volume loops, peak flow charts, needle biopsy of the pleura, spirometry, lung volume analysis, and sweat test.
Poisoning and overdose
Authors: Provan Drew
Published: February 2018

This chapter covers the most appropriate investigations of common poisons encountered in clinical practice.
Rheumatology
Authors: Provan Drew
Published: February 2018

This chapter examines the role of investigations in diagnosis, assessing disease activity, and monitoring treatment in rheumatic disease. It reviews the relevance of haematology and biochemistry tests in clinical context, including differential diagnosis of anaemia and cytopenia which may reflect the disease process, co-morbidity, or adverse drug effects. Bone biochemistry and markers are also described. Autoantibodies are important in diagnosis and prognosis in rheumatology. Interpretation of rheumatoid factor, anti-cyclic citrullinated peptide (CCP) antibodies, antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), extractable nuclear antigens (ENA), antiphospholipid antibodies, and also HLA-B27 is discussed. Arthrocentesis is a technique specific to rheumatology, and neurophysiology is useful in distinguishing neurological versus inflammatory muscle disease, in addition to nerve entrapment syndromes and neuropathies. The chapter also introduces the use of diagnostic imaging and early identification of inflammatory arthritis, including X-ray, ultrasound, magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT), nuclear medicine bone scintigraphy, and dual-energy X-ray absorptiometry (DXA).
Gastrointestinal system
Authors: Rogler Gerhard
Published: February 2018

Rheumatic diseases and diseases of the gastrointestinal (GI) tract are connected in two ways. The extraintestinal manifestations of inflammatory GI diseases such as inflammatory bowel disease affect joints in up to one-third of patients. On the other hand, several rheumatic diseases such as vasculitis or systemic lupus erythematosus (SLE) induce a wide spectrum of gastrointestinal manifestations. The GI tract constitutes a huge area in contact with the environment. It is exposed to billions of food antigens, commensal bacteria, and potential pathogens. Some of those antigens are thought to play a role in the pathogenesis of rheumatic diseases. The intestinal barrier function and the gut immune system are tightly regulated, as on one hand tolerance for food antigens and the resident commensal flora needs to be maintained, and on the other hand pathogens need to be rapidly and effectively eliminated. Non-infectious, chronic inflammatory diseases of the small and large intestine with rheumatic manifestations have been well known for decades. Among the susceptibility genes for Crohn’s disease and ulcerative colitis are some that also cause susceptibility to rheumatoid arthritis or SLE, indicating a shared susceptibility and overlapping pathological mechanisms. Subsequently, similar therapeutic principles have successfully been applied in autoimmune GI and rheumatological diseases such as steroids, immunosuppressants, and anti-TNF (tumour necrosis factor) antibodies.
Epigenetics
Authors: Gay Steffen , Neidhart Michel
Published: February 2018

In higher eukaryotic organisms epigenetic modifications are crucial for proper chromatin folding and thereby proper regulation of gene expression. Epigenetics include DNA methylation, histone modifications, and microRNAs. First described in tumors, the involvement of aberrant epigenetic modifications has been reported also in other diseases, i.e. metabolic, psychiatric, inflammatory, and autoimmune. Deregulation of epigenetic mechanisms occurred in patients with rheumatoid arthritis, systemic lupus erythematosus, and scleroderma. Many questions remain: e.g. what is the cause of these epigenetic changes and how can we interfere in the pathological process? Here we discuss whether supplementation with methyl donors could represent a novel therapeutic concept for such diseases.
Joints and Connective tissue—structure and function
Authors: Pap Thomas , Korb-Pap Adelheid , Hartmann Christine , Bertrand Jessica
Published: February 2018

Synovial joints are complex functional elements of the vertebrate body that provide the organism with motion capabilities and, thus, with the ability for locomotion and for direct physical interaction with its environment. They are composed of different connective tissues structures that are derived from the same developmental structures in the embryo, but have distinct cellular and biochemical properties. Articular cartilage and synovial membrane are key components of synovial joints and show a number of peculiarities that makes them different from other tissues in our body. An in-depth knowledge of these structural and functional peculiarities is not only important for understanding key features of articular function, but also provides explanations for important characteristics of both degenerative and inflammatory joint diseases. This chapter reviews the structure, biochemical composition, and function of articular cartilage and synovium, and points to important links between physiology and pathological conditions, particularly arthritis. Special emphasis is put on the interaction of resident cells with both the extracellular matrix and other neighbouring or invading cells.
Signalling pathway inhibitors
Authors: Fleischmann Roy
Published: February 2018

Oral, small-molecule signalling pathway inhibitors, including ones that inhibit the JAK and other pathways, are currently in development for the treatment of rheumatoid arthritis (RA). Many of the pro-inflammatory cytokines implicated in the pathogenesis of RA utilize cell signalling that involves the JAK-STAT pathways and therefore inhibition of JAK-STAT signalling, by targeting multiple RA-associated cytokine pathways, has the potential to simultaneously reduce inflammation, cellular activation, and proliferation of key immune cells. Spleen tyrosine kinase (SyK) is a cytoplasmic tyrosine kinase that is an important mediator of immunoreceptor signalling in mast cells, macrophages, neutrophils, and B cells. Interruption of SyK signalling should interrupt production of tumour necrosis factor (TNF) and metalloproteinase and therefore affect RA disease activity. Tofacitinib, approved in many countries for the treatment of RA, is an orally administered small-molecule inhibitor that targets the intracellular Janus kinase 3 and 1 (JAK1/3) molecules to a greater extent than JAK2; there are other JAK inhibitors in development which are purported to be more specific for JAK3 (Vertex 509), specific for JAK1/2 (baricitinib) or more specific for JAK1 (Galapagos and INCYTE) where clinical data has been reported. Tofacitinib has been investigated in multiple clinical trials which have investigated its efficacy (clinical, functional, and radiographic) and safety in patients who have failed disease-modifying anti-inflammatory drugs (DMARDs) as monotherapy or in combination with DMARDs, compared to an inhibitor of tumour necrosis factor alpha (TNFα‎‎) and in patients who have failed TNFα‎‎ inhibitors. Vertex 509 has been investigated as monotherapy or in combination with MTX in DMARD failures while baricitinib, GLPG0634 (Galapagos), and INCB039110 (Incyte) have been investigated in phase 1 and 2 clinical trials in combination with MTX. Each of these medications has demonstrated efficacy; their safety profile has been shown to be generally similar although with some differences from each other and some differences from most of the currently approved biological agents. Fostamatinib disodium is an orally available inhibitor of SyK which was investigated in multiple phase 3 clinical trials in RA but was found to be generally ineffective with significant safety signals. This chapter discusses what is currently known and understood about the efficacy and safety of these oral, small-molecule DMARDs.
Stem cell therapies
Authors: Tyndall Alan , van Laar Jacob M.
Published: February 2018

Since the start of the international project in 1997, over 2000 patients have received a haematopoietic stem cell transplant (HSCT), mostly autologous, as treatment for a severe autoimmune disease, with overall 85% 5-year survival and 43% progression-free survival. Around 30% of patients in all disease subgroups had a complete response, often durable despite full immune reconstitution. In many cases, e.g. systemic sclerosis, morphological improvement such as reduction of skin collagen and normalization of microvasculature was documented, beyond any predicted known effects of intense immunosuppression alone. It is hoped that the results of the three running large prospective randomized controlled trials will allow modification of the protocols to reduce the high transplant-related mortality which relates to regimen intensity, age of patient, and comorbidity. Multipotent mesenchymal stromal cells (MSC) have been recently tested in various autoimmune diseases, exploiting their immune modulating properties and apparent low acute toxicity. MSC display immune privilege in that the patient requires no immunosuppression prior to allogeneic MSC infusion. Despite encouraging many small phase I/II studies, only 2 prospective controlled trials which achieved their primary endpoints have been published.
Injection therapy
Authors: Platt Philip , Atchia Ismael
Published: February 2018

Joint and soft tissue injections with glucocorticoids and other agents remain a critical aspect of the management of musculoskeletal conditions. Injection therapy has previously consisted mainly of glucocorticoid and local anaesthetic, but other agents such as hyaluronic acid, radioactive agents, plasma-rich products, and biologics have also been introduced in the practice of musculoskeletal clinicians.
Overall glucocorticoid injection remains the most widely performed procedure, and is an effective treatment for an inflamed joint or soft tissue. This procedure has been widely used for at least five decades. Hydrocortisone was the initial steroid used but longer-acting steroid agents are now favoured for large joints. There is evidence of efficacy not only for inflammatory arthritis conditions, but also for osteoarthritis. There are certain contraindications for injection therapy. Hyaluronic acid (viscosupplementation) injection has become part of the management of osteoarthritis. More recently other agents such as disease-modifying anti-rheumatic drugs (DMARDs) and biologics have been injected with varying degree of success.
The ability to deliver an injection accurately depends on appropriate knowledge of the anatomy and, as for any procedures, the experience and skill of the clinician. The approach to different joints and soft tissue structures is described in this chapter.
Principles of spine surgery
Authors: Fairbank Jeremy , Batista Nuno
Published: February 2018

Spine surgery addresses pain, loss of function and deformity of the spine. Earlier conceptions of chronic pain have changed, but there is still a limited role for surgery to manage painful spinal pathology. Loss of function is caused by tumours, fractures and infections, all of which can be helped by surgery. Deformity is called scoliosis and/or kyphosis, and be corrected by surgery. Spinal deformity is increasingly recognized in adults as an important cause of disability, especially when there is loss of sagittal balance. Advances in anaesthesia and implant technology have allowed the spine surgeon greater opportunities to help seriously disabled patients in ways not possible 20 years ago. Fractures occur following trauma, but are also associated with impaired bone strength, particularly through osteoporosis.
Perioperative management of immunosuppression
Authors: Carmona Loreto , Galindo Maria
Published: February 2018

Many rheumatologists are concerned about the complications of maintaining immunosuppression at the time of elective surgery. Complications may be increased risk of infection, or a slow healing of the surgical wound. On the other hand, stopping medication may place the patient at undesirable levels of disease activity. Many rheumatologists actually act on art, stopping the drug perioperatively depending on blood count, drug type and dose, previous postoperative complications, type of surgery, and other factors. The timing of stopping treatment preoperatively and restarting after surgery also significantly differ among rheumatologists. All in all, there is a great variability in clinical practice related to the perioperative use of immunosuppressants.
This chapter reviews the evidence on methotrexate, glucocorticoids, and biological therapies related to the perioperative period, and it proposes some recommendations on the management of immunosuppressant drugs in rheumatic diseases. Factors that may be related to complications will also be reviewed.
Viral arthritis
Authors: Naides Stanley J.
Published: February 2018

Viral infection may cause sudden onset polyarthralgia or polyarthritis. Recognizing viral syndromes during the acute phase of illness is critical as markers of acute infection may fade during convalescence. While joint symptoms and signs in many cases are self limited, in others joint involvement may persist for months to years. Acute and chronic findings may resemble classic idiopathic diseases such as rheumatoid arthritis or systemic lupus erythematosus. Some viral infections may manifest with rash, vasculitis, or organ involvement. Understanding of epidemiology, geography, clinical presentation, virus behaviour and host response assists diagnosis and selection of appropriate management. Understanding virus-host interactions may offer insights into mechanisms of pathogenesis in idiopathic rheumatic diseases.
Mycobacterial diseases
Authors: Abdulkader Rita , Watts Richard A.
Published: February 2018

The main diseases caused by mycobacterial infection are tuberculosis (TB) and leprosy. Despite a fall in the prevalence of these diseases over the last decade, they are still significant causes of morbidity and mortality worldwide. Atypical mycobacterial infections are encountered less frequently. Immigration patterns, the frequency of human immunodeficiency infection, and the increased numbers of patients on immunosuppressive treatments render mycobacterial infections relevant not only to physicians in the developing world where they traditionally occurred but also in the developed world. Skeletal TB occurs in 1–3% of cases of TB infection, and is more frequently encountered in the immunocompromised. A high index of suspicion is required, diagnosis relies on a combination of clinical features and radiological, histological, and microbiological tests. Multidrug regimens are required for treatment with surgery in selected cases.
Leprosy is caused by M. leprae infection. The disease is still a leading cause of disability worldwide. Diagnosis is usually clinical. The course of the disease is indolent but may be interrupted by acute inflammatory reactions, which contribute to nerve damage and disability. Treatment aims at eliminating the mycobacteria using multidrug regimens, and management of complications including leprosy reactions and long-term nerve damage.
Atypical mycobacterial infections affecting bone and joints are uncommon; they usually follow direct inoculation of the pathogen. Haematogenous dissemination is encountered in immunocompromised patients. These microorganisms are not usually susceptible to the same drug regimens used in the treatment of tuberculosis.
Juvenile idiopathic arthritis
Authors: Baildam Eileen
Published: February 2018

Juvenile idiopathic arthritis (JIA) is defined as arthritis lasting for 6 weeks or more presenting in childhood at any age up to 17 years. Arthritis is diagnosed clinically by the presence of joint pain, stiffness, and swelling with inflammation limiting the range of individual joint movement. There are subtypes that tend to follow distinct courses and with phenotypes that vary widely from a serious systemic inflammatory disorder of systemic JIA to single-joint monoarthritis. The differential diagnosis of JIA is wide and the best chance of long-term remission is where treatment is started as early as possible. However, there is often delay in diagnosis in childhood and there is no single reliable diagnostic test so pattern recognition is fundamental. There are associated disorders such as silent uveitis that must be screened for and managed as part of essential multidisciplinary care. Systemic JIA is complicated by potentially life-threatening macrophage activation syndrome that is often underdiagnosed but where the diagnosis is based on easy clinical tests and where awareness is vital. This chapter covers descriptions of the classification criteria for chronic arthritis in children, clinical presentations and likely course for the various subtypes.
Systemic lupus erythematosus—management
Authors: Dey Ida Dzifa , Isenberg David
Published: February 2018

Systemic lupus erythematosus (SLE) is an autoimmune rheumatic disease with varied presentation and a disease course characterized by remission and flares. Over the last 50 years the prognosis of SLE has improved considerably. The introductions of corticosteroids and later of cytotoxic drugs, dialysis, and renal transplantation were the major contributors to this improvement.
Nevertheless, the treatment and general management of lupus continues to present a challenge. While lupus may, for some patients, represent a relatively mild set of problems, many others require large doses of immunosuppressive drugs, which carry long-term concerns about side effects.
New immunotherapeutic drugs, with actions more closely targeted to the immune cells and molecules involved in the pathogenesis of SLE, are being introduced and the future looks promising. The role of early atherosclerosis and cardiovascular disease as a cause of death in patients with SLE is increasingly recognized and will present further challenges in the future.
Juvenile-onset systemic lupus erythematosus
Authors: Watson Louise , Beresford Michael W.
Published: February 2018

Paediatric or juvenile-onset systemic lupus erythematosus (JSLE) is a rare autoimmune condition, differing from the adult form in terms of severity, organ manifestations, and a less striking female predominance. The diagnosis relies on the adult-derived American College of Rheumatology SLE classification criteria. Genetic, autoantibody, and host immune responses, characteristic of this disease, result in a clinically heterogeneous phenotype. A proportion of paediatric SLE patients will have evidence of a genetic deficiency known to be associated with SLE, such as C1q deficiency, and screening for these is required. A challenging diagnosis to make in the younger age group, the management of JSLE compared to adult-onset SLE requires special consideration towards the significant long-term consequences of the disease and treatment toxicity, combined with an onset during a fundamental time with regards to growth and development. A comprehensive, multidisciplinary team approach to the management of JSLE is essential. With a more severe phenotype and limited comorbidities, patients with JSLE represent an invaluable opportunity for investigating the pathogenesis. To date, clinical trials informing interventions in JSLE are very limited and treatment choices rely on the outcome of adult trials. Patient and family involvement in research to improve outcomes and understanding is essential. New treatments, including biological therapies, are becoming available for clinical use and new treatment combinations have been used to induce and maintain clinical remission.
Large-vessel vasculitis
Authors: Pipitone Nicolò , Versari Annibale , Salvarani Carlo
Published: February 2018

Large-vessel vasculitis includes giant cell arteritis (GCA) and Takayasu’s arteritis (TAK). GCA affects patients aged over 50, mainly of white European ethnicity. GCA occurs together with polymyalgia rheumatica (PMR) more frequently than expected by chance. In both conditions, females are affected two to three times more often than males. GCA mainly involves large- and medium-sized arteries, particularly the branches of the proximal aorta including the temporal arteries. Vasculitic involvement results in the typical manifestations of GCA including temporal headache, jaw claudication, and visual loss. A systemic inflammatory response and a marked response to glucocorticoids is characteristic of GCA. GCA usually remits within 6 months to 2 years from disease onset. However, some patients have a chronic-relapsing course and may require longstanding treatment. Mortality is not increased, but there is significant morbidity mainly related to chronic glucocorticoid use and cranial ischaemic events, especially visual loss. The diagnosis of GCA rests on the characteristic clinical features and raised inflammatory markers, but temporal artery biopsy remains the gold standard to support the clinical suspicion. Imaging techniques are also used to demonstrate large-vessel involvement in GCA. Glucocorticoids are the mainstay of treatment for GCA, but other therapeutic approaches have been proposed and novel ones are being developed.
TAK mainly involves the aorta and its main branches. Women are particularly affected with a female:male ratio of 9:1. In most patients, age of onset is between 20 and 30 years. Early manifestations of TAK are non-specific and include constitutional and musculoskeletal symptoms. Later on, vascular complications become manifest. Most patients develop vessel stenoses, particularly in the branches of the aortic artery, leading to manifestations of vascular hypoperfusion. Aneurysms occur in a minority of cases. There are no specific laboratory tests to diagnose TAK, although most patients have raised inflammatory markers, therefore, imaging techniques are required to secure the diagnosis. Glucocorticoids are the mainstay of treatment of TAK. However, many patients have an insufficient response to glucocorticoids alone, or relapse when they are tapered or discontinued. Immunosuppressive agents and, in refractory cases, biological drugs can often attain disease control and prevent vascular complications. Revascularization procedures are required in patients with severe established stenoses or occlusions.
Hypermobility syndromes
Authors: Hakim Alan J. , Grahame Rodney
Published: February 2018

Hypermobility-related syndromes constitute a family of heritable disorders of connective tissue (HDCT) that derive from abnormalities affecting genes that encode for the connective tissue matrix proteins such as collagen, fibrillin, and tenascin. They range from such commonplace though poorly recognized conditions such as the joint hypermobility syndrome (JHS) to the better-known, if rarer, eponymous syndromes such as the Marfan syndrome (MFS) and the different types of the Ehlers-Danlos syndrome (EDS). The more common presentations are with skin pathology (bruising, scaring), joint or spinal and/or muscle pain and instability with vulnerability to injury and chronic widespread pain, cardiac valve pathologies, and in MFS and vascular EDS, arterial dilatation with the risk of dissection and rupture. JHS (widely considered synonymous with the EDS hypermobility type) is further complicated by cardiovascular autonomic dysfunction such as orthostatic intolerance, palpitations, and syncope, and the recently described and commonly encountered pan-gastrointestinal dysmotility. The latter can manifest as gastro-oesophageal reflux, gastroparesis, slow-transit constipation, or rectal evacuatory dysfunction with rectal intussusception. In addition, HDCT are associated with bladder and uterine problems as a consequence of pelvic floor weakness.
Such multisystemic conditions need to be managed by a multidisciplinary team able to draw on medical, surgical, physical, and psychological interventions by appropriately experienced specialists and therapists.
This chapter introduces the reader to the epidemiology, genetics, classification, and clinical presentation of JHS, EDS, and MFS. It also describes the key investigations required to support a diagnosis and assess complications of an HDCT, as well as the multidisciplinary approach to management.
The heart team in acute cardiac care
Authors: Kappetein Arie Pieter , Antonides Christiaan , Windecker Stephan
Published: February 2018

The complexity of acute cardiac care today makes it necessary that patients are looked after by more than one health care professional. Complex tasks require complex systems. Teamwork is essential for minimizing adverse events caused by miscommunication and misunderstanding about roles and responsibilities, and it can have an immediate and positive impact on the patient. The increasing complexity and specialization of care of the cardiac patient in the acute setting, combined with an ever increasing number of therapeutic options, make it necessary to coordinate teams of doctors for each specialty area. Multidisciplinary decision making optimizes care and is mandatory in light of evolving options and improvement of quality of care and will lead to more efficiency.
Neurological assessment of the acute cardiac care patient
Authors: De Deyne Cathy , Eertmans Ward , Dens Jo
Published: February 2018

Many techniques are currently available for cerebral physiological monitoring in the intensive cardiac care unit environment. The ultimate goal of cerebral monitoring applied during the acute care of any patient with/or at risk of a neurological insult is the early detection of regional or global hypoxic/ischaemic cerebral insults. In the most ideal situation, cerebral monitoring should enable the detection of any deterioration before irreversible brain damage occurs or should at least enable the preservation of current brain function (such as in comatose patients after cardiac arrest). Most of the information that affects bedside care of patients with acute neurologic disturbances is now derived from clinical examination and from knowledge of the pathophysiological changes in cerebral perfusion, cerebral oxygenation, and cerebral function. Online monitoring of these changes can be realized by many non-invasive techniques, without neglecting clinical examination and basic physiological variables—with possible impact on optimal cerebral perfusion/oxygenation—such as invasive arterial blood pressure monitoring or arterial blood gas analysis.
Blood gas analysis
Authors: Paul Richard , Grant Paul
Published: February 2018

Acid-base homeostasis is vital for the maintenance of normal tissue and organ function, as both acidosis and alkalosis can have harmful and potentially life-threatening effects. Arterial blood gas analysis, combined with routine clinical history and examination, can provide useful information for the management of the critically ill cardiac patient. Most acid-base derangements are reversed by treatment of the underlying disease process, rather than simple correction of the abnormal pH, and prognosis is determined by the nature of the underlying disease, rather than the extent of pH value deviation. Within this chapter, a six-step approach is presented for prompt and accurate acid-base interpretation. Water and electrolyte disorders are common in the intensive cardiac care unit, particularly in patients with cardiac failure. Prompt recognition and treatment is required to prevent cardiovascular and neurological compromise. Therapeutic strategies range from simple electrolyte substitution and fluid management to extracorporeal filtration of excess fluid and electrolytes. These are discussed within this chapter.
Biomarkers of coagulation and thrombosis
Authors: Hvas Anne-Mette , Grove Erik L , Kristensen Steen Dalby
Published: February 2018

Coagulation is evaluated by conventional coagulation analyses, often supplemented by point-of-care tests. Recently, a number of point-of-care tests for evaluation of platelet function and the efficacy of antiplatelet therapy has been investigated. Thrombophilia contributes to the risk of thrombosis, and a battery of complex assays is required to identify all thrombophilias. Disseminated intravascular coagulation is characterized by microthrombosis and clinical bleeding. A scoring system for overt disseminated intravascular coagulation provides a five-step diagnostic algorithm. The cornerstone of the management of disseminated intravascular coagulation is treatment of the underlying triggering condition. Heparin-induced thrombocytopenia is an adverse immunological effect of heparin therapy. Besides thrombocytopenia, the major clinical consequence of heparin-induced thrombocytopenia is an increased risk of thrombosis. The diagnosis is based on clinical symptoms and detection of platelet-activating heparin-induced thrombocytopenia antibodies. When heparin-induced thrombocytopenia is strongly suspected, it is recommended to stop heparin treatment, investigate for heparin-induced thrombocytopenia antibodies, and initiate non-heparin anticoagulant treatment.
Mechanical complications of myocardial infarction
Authors: López-Sendón José , López de Sá Esteban
Published: February 2018

Mechanical complications after an acute infarction involve different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies occurring in <1% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment (Ibanez et al, 2017). Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.
Acute heart failure
Authors: Farmakis Dimitrios , Parissis John , Papingiotis George , Filippatos Gerasimos
Published: February 2018

Acute heart failure is defined as the rapid development or change of symptoms and signs of heart failure that requires urgent medical attention and usually hospitalization. Acute heart failure is the first reason for hospital admission in individuals aged 65 or more and accounts for nearly 70% of the total health care expenditure for heart failure. It is characterized by an adverse prognosis, with an in-hospital mortality rate of 4–7%, a 2–3-month post-discharge mortality of 7–11%, and a 2–3-month readmission rate of 25–30%. The majority of patients have a previous history of heart failure and present with normal or increased blood pressure, while about half of them have preserved left ventricular ejection fraction. A high prevalence of cardiovascular or non-cardiovascular comordid conditions is further observed, including coronary artery disease, arterial hypertension, atrial fibrillation, diabetes mellitus, renal dysfunction, chronic lung disease, and anaemia.
Perioperative cardiac care of the high-risk non-cardiac patient
Authors: Balik Martin
Published: February 2018

Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
The galaxy clustering crisis in abundance matching
Authors: Campbell Duncan , van den Bosch Frank C , Padmanabhan Nikhil , Mao Yao-Yuan , Zentner Andrew R , Lange Johannes U , Jiang Fangzhou , Villarreal Antonia Sierra
Published: February 2018

Galaxy clustering on small scales is significantly underpredicted by sub-halo abundance matching (SHAM) models that populate (sub-)haloes with galaxies based on peak halo mass, Mpeak. SHAM models based on the peak maximum circular velocity, Vpeak, have had much better success. The primary reason for Mpeak-based models fail is the relatively low abundance of satellite galaxies produced in these models compared to those based on Vpeak. Despite success in predicting clustering, a simple Vpeak-based SHAM model results in predictions for galaxy growth that are at odds with observations. We evaluate three possible remedies that could ‘save’ mass-based SHAM: (1) SHAM models require a significant population of ‘orphan’ galaxies as a result of artificial disruption/merging of sub-haloes in modern high-resolution dark matter simulations; (2) satellites must grow significantly after their accretion; and (3) stellar mass is significantly affected by halo assembly history. No solution is entirely satisfactory. However, regardless of the particulars, we show that popular SHAM models based on Mpeak cannot be complete physical models as presented. Either Vpeak truly is a better predictor of stellar mass at z ∼ 0 and it remains to be seen how the correlation between stellar mass and Vpeak comes about, or SHAM models are missing vital component(s) that significantly affect galaxy clustering.
Using advanced technologies to quantify beef cattle behavior1
Authors: Richeson John T , Lawrence Ty E , White Brad J
Published: February 2018

For decades, we have relied upon visual observation of animal behavior to define clinical disease, assist in breeding selection, and predict growth performance. Limitations of visual monitoring of cattle behavior include training of personnel, subjectivity, and brevity. In addition, extensive time and labor is required to visually monitor behavior in large numbers of animals, and the prey instinct of cattle to disguise abnormal behaviors in the presence of a human evaluator is problematic. More recently, cattle behavior has been quantified objectively and continuously using advanced technologies to assess animal welfare, indicate lameness or disease, and detect estrus in both production and research settings. The current review will summarize three methodologies for quantification of cattle behavior with focus on U.S. beef production systems; 1) three-axis accelerometers that quantify physical behavior, 2) systems that document feeding and watering behavior via radio frequency, and 3) triangulation or global positioning systems to determine location and movement of cattle within a pen or pasture. Furthermore, advances in Wi-Fi and radio frequency technology have allowed many of these systems to operate remotely and in real-time and efforts are underway to develop commercial applications that may allow early detection of respiratory or other cattle diseases in the production environment. Current challenges with commercial application of technology for early disease detection include establishment of an appropriate algorithm to ensure maximum sensitivity and specificity, reliable and repeatable data collection in harsh environments, cost:benefit, and integration with traditional methodology for clinical diagnosis. Advanced technologies have also allowed cattle researchers to determine temporal variance in behavior or variability between experimental treatments. However, these data sets are typically very large and challenges exist regarding statistical analysis and reporting.
An unusual cause of an isolated scapula fracture
Authors: Donovan Megan , Attia Magdy W.
Published: February 2018

This article reviews an isolated scapula fracture in a teenage athlete. Although rarely reported in professional athletes, scapula fracture should be included in the differential diagnosis of shoulder injuries. Proper imaging is key to effective diagnosis and management.
What are the cardiovascular effects of the newer classes of drugs for type 2 diabetes?
Authors: Covino Jean , Hoffman Jennifer
Published: February 2018

New classes of drugs to treat type 2 diabetes are continually being developed and marketed. The FDA has issued guidance to the pharmaceutical industry that newer hypoglycemic agents should not be associated with unacceptable increases in cardiovascular risk. To date, five trials have assessed specific cardiovascular endpoints for these newer agents. Empagliflozin and liraglutide have been found to improve cardiovascular outcomes.
Saving the Safety Net
Authors: Kennedy Maureen Shawn
Published: February 2018

Will Medicaid ‘reform’ render it useless?
AMA Resolution Opposes Independent Practice by APRNs
Authors: Sofer Dalia
Published: February 2018

An old debate heats up again.
Seniors Need Hip Fracture Surgery Within 24 Hours
Authors: Potera Carol
Published: February 2018

Early surgery found to reduce life-threatening complications.
Addressing the ICU Patient's Information Needs
Authors: Zolot Joan
Published: February 2018

Nurse researchers create an educational pathway.
CMS Delays Fines for Nursing Home Infractions
Authors: Mechcatie Elizabeth
Published: February 2018

Moratorium elicits concern among nursing home advocates.
FDA Warns Against Unregulated Products
Authors: Aschenbrenner Diane S.
Published: February 2018

Some drugs that aren't approved by the Food and Drug Administration (FDA) may still be legally sold in the United States. These include drugs compounded by licensed physicians, pharmacists, and pharmacies. However, drugs manufactured in other countries that do not come from reputable sources cannot be legally sold here, although these drugs can sometimes be purchased online.

The FDA reports on adverse events from two unregulated products: a compounded subcutaneous drug (glutamine, arginine, and carnitine) and an overseas product, Balguti Kesaria Ayurvedic Medicine, which is adulterated and potentially lethal.

The agency's BeSafeRX web page contains resources to help patients determine if an online pharmacy is reputable.
Risk of Heart-Related Death From Gout Medication
Authors: Aschenbrenner Diane S.
Published: February 2018

Preliminary results from a clinical safety trial of the gout medication febuxostat (Uloric) indicate that, when compared with allopurinol, the standard gout treatment, febuxostat increases the risk of heart-related deaths.

The Food and Drug Administration will provide additional information after the final trial results are submitted and analyzed.
Expanding RN Scope of Practice to Include Lumbar Puncture
Authors: Ernst Jennifer , Aliory Christine D. , Yows Catherine R.
Published: February 2018

The competing demands of caring for high-acuity patients, reducing health care costs, and improving access to specialty care are complex challenges facing all health care providers. One approach—empowering nurses to expand their scope of practice—has been successfully employed for two decades by the nurse and physician leadership of a neurology department in an urban academic medical center. This article discusses the department's implementation of a quality improvement initiative to enhance access to neurology services in an ambulatory clinic by extending nursing practice to include lumbar puncture. Outcomes data from 2005 to 2016 demonstrate that through the department's comprehensive instructional program, RNs have competently and safely acquired new skills that have led to an expansion of their traditional roles, improved patient access to specialty care, and reduced costs.
Interprofessional Collaborative Practice Model Improves Staff Communication, Patient Care
Authors: Rosenberg Karen
Published: February 2018

According to this study:

Experienced clinicians reported that working within a nurse-led interprofessional collaborative practice model increased their knowledge and led to changes in behavior and practice.
Clinical Updates in Women’s Health Care Summary: Arthritis
Authors: Pattanaik Debendra
Published: February 2018

Arthritis is a commonly encountered problem in daily clinical practice, and with an aging population it will be as prevalent as any other chronic illness, such as diabetes mellitus, hypertension, and hypercholesterolemia. Obstetrician–gynecologists often encounter patients with arthritic symptoms in their practices. They may find it challenging to identify the underlying cause of arthritis and provide recommendations, as well as provide obstetric care to patients with known arthritis. The monograph will discuss common forms of arthritis, diagnostic testing and appropriate management, and referral of patients who need specialized care. Commonly encountered forms of inflammatory arthritis are discussed in this monograph with special emphasis on diagnosis and management. Management of arthritis in the context of pregnancy and lactation also is discussed.
Interosseus Wiring of Distal Radius Fractures With Volar Comminution
Authors: Githens Thomas , Murphree Jacob , Daneshfar Cy , MacKay Brendan
Published: February 2018

Interosseous wiring is a technique that has been used for decades to help achieve interfragmentary compression and subsequent osteosynthesis in a number of fracture patterns. Comminuted distal radius fractures with larger volar fragments present challenges for reconstruction and reestablishment of length, rotation, and alignment of the metadiaphyseal region. In many instances, the use of bridge plating in these fracture patterns is difficult as the fragments are prone to displacement. Utilizing interosseous wiring in distal radius fractures with larger volar fragments provides an extraordinarily useful technique, allowing for anatomic reduction and restoration of the articular block. This stabilizing aid provides an ideal reduction for proper placement of a volar locked plate. This study describes the technique of interosseous wiring in a 75-year-old female patient with distal radius and ulnar fractures with subsequent volar locked plate placement. This technique provides an efficient and cost-effective tool to improve anatomic reduction, interfragmentary compression, and proper plate placement in distal radius fractures of this morphology.
Metformin for lung cancer prevention and improved survival: a novel approach
Authors: Roos Juliana F. , Qudsi Mariam , Samara Arwa , Rahim Madina M. , Al-Bayedh Samar A. , Ahmed Hafez
Published: February 2018

Diabetes mellitus has been associated with increased risk for the development of many types of cancer. Metformin, an oral medication and first-line treatment for type 2 diabetes mellitus, has been suggested to reduce cancer risk and mortality in various types of cancer. This study focuses on assessing metformin association with lung cancer as reported in the literature. Recent studies and reviews investigating metformin effects on lung cancer incidence and patient survival are critically and systematically discussed.