bluuebunny/crossref_metadata_2025 huggingface dataset:
Drug-Induced Movement Disorders
Authors: Mehta Shyamal H. , Morgan John C. , Sethi Kapil D.
Published: February 2014

Movement disorders as a consequence of prescribed medications and drugs of abuse are commonly encountered in the clinical setting. In this chapter we discuss the different types of movement disorders caused by dopamine-receptor blocking agents, other medications, and drugs of abuse.
Chest medicine
Authors: Longmore Murray , Wilkinson Ian B. , Baldwin Andrew , Wallin Elizabeth
Published: February 2014

Signs:

Examining the respiratory system –

Investigations:

Bedside tests in chest medicine

Further investigations in chest medicine

Pulmonary conditions:

Pneumonia

Specific pneumonias

Complications of pneumonia

Bronchiectasis

Cystic fibrosis (cf)

Fungi and the lung

Lung tumours

Asthma

Management of chronic asthma

Chronic obstructive pulmonary disease (...
Endocrinology
Authors: Longmore Murray , Wilkinson Ian B. , Baldwin Andrew , Wallin Elizabeth
Published: February 2014

The essence of endocrinology

Diabetes mellitus (dm):

Classification and diagnosis

Treating diabetes mellitus

Helping people with established diabetes

Diabetic neuropathy and diabetic foot care

Hypoglycaemia

Thyroid and parathyroid disease:

Thyroid function tests (tfts)

Thyrotoxicosis

Thyroid eye disease

Hypothyroidism (myxoedema)

Parathyroid hormone and hyperparathyroidism...
Eponymous syndromes
Authors: Longmore Murray , Wilkinson Ian B. , Baldwin Andrew , Wallin Elizabeth
Published: February 2014

ABC

We thank Dr Simon Eyre, our Specialist Reader, and Kushalinii Ragubathy, our Junior Reader, for their contribution to this chapter.

Altered perception in size and shape of body parts or objects ± an impaired sense of passing time—as experienced by Alice...
Reference intervals, etc.
Authors: Longmore Murray , Wilkinson Ian B. , Baldwin Andrew , Wallin Elizabeth
Published: February 2014

The Gaussian (‘Normal’) distribution

Drug therapeutic ranges in plasma

Gentamicin

Some important drug interactions

Haematology reference intervals

Biochemistry reference intervals

Once upon a time, in a famous hospital named R— in the middle of England, there lived a crusty old surgeon and a brilliant young house officer. The surgeon issued infallible and peremptory edicts such as “All my patients with a haemoglobin less than 100 must be transfused.” Everyone did as the surgeon said (this was a long time ago) except for the wily house officer who understood statistics, sampling error, and the play of chance. One day she was rung up by the haematologist who asked her “Why have you requested 3 blood counts on Mrs Wells today? One is enough. You are wasting our resources!” “Not so,” said the house officer. “The first Hb was 98, the second was 97 and the third was 101g/L. I knew if I was persistent, I stood a good chance of preventing an unnecessary transfusion. She is a patient of Mr X.” The two conspirators smiled at each other down the telephone, and no more was said. Of course the right way of dealing with this problem is through clinical governance and dialogue with the surgeon. But the point remains: numbers are elastic, despite, on occasion, being given to 3 decimal places. Don’t believe in them as absolute entities, and don’t believe that the normal range is anything other than arbitrary; think before you act: think statistically. ...
Practical procedures
Authors: Longmore Murray , Wilkinson Ian B. , Baldwin Andrew , Wallin Elizabeth
Published: February 2014

Placing nasogastric tubes

Placing iv cannulae (drips)

Cut down on to a vein

Catheterizing bladders

Draining ascites

Diagnostic aspiration of a pleural effusion

Abdominal paracentesis

Inserting a chest drain

Relieving a tension pneumothorax

Aspiration of a pneumothorax

Lumbar puncture (lp)

Cardioversion/defibrillation

Arterial blood gas sampling...
Primary care presentation
Authors: Wise Elspeth
Published: February 2014

For many patients their first presentation to a medical professional with a musculoskeletal complaint is in a primary care setting. They may have as little as 10 minutes to explain their problem, be examined, and have a management plan determined. Quite commonly the musculoskeletal problem may present as an aside—by the way doctor, while I'm here'. All of this presents a challenge to the assessing primary care physician, who may have had little specific training for what makes up a large part of their workload. What training they have had may be inappropriate for their day-to-day job, as it is often secondary care led. The conditions that are classically seen in a secondary care setting and that are emphasized in the medical school curriculum are rarely seen in primary care. Patients also may not necessarily present with the classical symptoms described in textbooks; often it is over time, and with repeated contact, that the diagnosis may become more obvious. This chapter looks at the prevalence data for primary care and discusses the routine workload of a primary care physician.
Neuroendocrine system
Authors: Straub Rainer H.
Published: February 2014

Endocrine abnormalities are very common in patients with chronic autoimmune rheumatic diseases (CARDs) due to the systemic involvement of the central nervous system and endocrine glands. In recent years, the response of the endocrine (and also neuronal) system to peripheral inflammation has been linked to overall energy regulation of the diseased body and bioenergetics of immune cells. In CARDs, hormonal and neuronal pathways are outstandingly important in partitioning energy-rich fuels from muscle, brain, and fat tissue to the activated immune system. Neuroendocrine regulation of fuel allocation has been positively selected as an adaptive programme for transient serious, albeit non-life-threatening, inflammatory episodes. In CARDs, mistakenly, the adaptive programmes are used again but for a much longer time leading to systemic disease sequelae with endocrine (and also neuronal) abnormalities. The major endocrine alterations are depicted in the following list: mild activation of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, inadequate secretion of ACTH and cortisol relative to inflammation, loss of androgens, inhibition of the hypothalamic-pituitary-gonadal axis and fertility problems, high serum levels of oestrogens relative to androgens, fat deposits adjacent to inflamed tissue, increase of serum prolactin, and hyperinsulinaemia (and the metabolic syndrome). Neuroendocrine abnormalities are demonstrated using this framework that can explain many CARD-related endocrine disturbances. This chapter gives an overview on pathophysiology of neuroendocrine alterations in the context of energy regulation.
Outcomes
Authors: Scott David L.
Published: February 2014

Outcomes evaluate the impact of disease. In rheumatology they span measures of disease activity, end-organ damage, and quality of life. Some outcomes are categorical, such as the presence or absence of remission. Other outcomes involve extended numeric scales such as joint counts, radiographic scores, and quality of life measures. Outcomes can be measured in the short term—weeks and months—or over years and decades. Short-term outcomes, though readily related to treatment, may have less relevance for patients. Clinical trials focus on short-term outcomes whereas observational studies explore longer-term outcomes. The matrix of rheumatic disease outcomes is exemplified by rheumatoid arthritis. Its outcomes span disease activity assessments like joint counts, damage assessed by erosive scores, quality of life evaluated by disease-specific measures like the Health Assessment Questionnaire (HAQ) or generic measures like the Short Form 36 (SF-36), overall assessments like remission, and end result such as joint replacement or death. Outcome measures are used to capture the impact of treating rheumatic diseases, and are influenced by both disease severity and the effectiveness of treatment. However, they are also influenced by a range of confounding factors. Demographic factors like age, gender, and ethnicity can all have crucial impacts. Deprivation is important, as poverty invariably worsens outcomes. Finally, comorbidities affect outcomes and patients with multiple comorbid conditions usually have worse quality of life with poorer outcomes for all diseases. These multiple confounding factors mean comparing outcomes across units without adjustment will invariably show major differences.
Genetics of rheumatoid arthritis
Authors: Eyre Steve , Worthington Jane
Published: February 2014

A range of epidemiological studies have clearly established that susceptibility to rheumatoid arthritis (RA) is determined by both genetic and environmental factors. Studies over the last five decades have used a variety of approaches to identify the genetic variants associated with disease. HLA DRB1 was the first RA susceptibility locus to be discovered and has the largest effect size. We describe current understanding of the complexities of HLA association for RA.
Linkage and small-scale association studies prior to 2007 provided convincing evidence for only one more RA susceptibility locus, PTPN22. Major breakthroughs in high-throughput genotyping and systematic discovery and mapping of hundreds of thousands of single nucleotide polymorphisms (SNPs) led to large-scale genome-wide association studies used for the first time for RA in 2007. This approach has had a dramatic impact on our knowledge of the susceptibility loci for RA, such that over 60 risk variants have now been robustly identified. We present an overview of these studies and the loci that have been identified. We consider how this knowledge is contributing to a greater understanding of the aetiology and pathology of the disease and in turn how this can influence management of patients presenting with an inflammatory arthritis. We consider some of the unanswered questions and the approaches that will need to be taken to address them.
Pathogenesis of juvenile idiopathic arthritis
Authors: Bending David , Nistala Kiran , Wedderburn Lucy R.
Published: February 2014

Although the term juvenile idiopathic arthritis (JIA) encompasses a heterogeneous group of diseases, they all share a common pathological hallmark: inflammation of the synovium. Highly activated T cells, monocytes, and neutrophils are attracted to the joint and secrete mediators that not only perpetuate inflammation but also may attenuate immune regulation. In the oligoarticular and polyarticular forms of JIA, which are thought to be autoimmune conditions, dysregulated adaptive immunity is a likely factor in disease pathogenesis; the nature of the interactions between T effector (Teff) cells and T regulatory cells (Treg) is probably a key factor in controlling disease progression. Factors that affect the frequency and function of Tregs and/or the sensitivity of Teffs to mechanisms of immune suppression will therefore impact on the disease course. In the systemic form of JIA, however, dysregulation of innate immune pathways appears more central to disease pathogenesis resulting in augmented levels of interleukins IL-1β‎, IL-6, and IL-18. In the end, a final, common pathological pathway in JIA is the activation of monocytes and neutrophils, which are the principal mediators of joint inflammation and damage. This is supported by the fact that the therapies that have targeted innate cytokine pathways have shown greater success in the treatment of JIA.
Haematology
Authors: Kesteven Patrick
Published: February 2014

This chapter describes the common haematological abnormalities seen in rheumatic conditions with special reference to laboratory findings and diagnostic traps. The chapter is organized into sections dealing with red cell abnormalities (and the distinction between anaemia of chronic disease and iron deficiency); white cell abnormalities (neutrophilia and neutropenia); platelets (thrombocytosis, idiopathic thrombocytopenic purpura and thrombotic thrombocytopenic purpura); and finally coagulation abnormalities (lupus anticoagulant).
Biochemical investigation of rheumatic diseases
Authors: Lopez Berenice , Twomey Patrick J.
Published: February 2014

It is important for rheumatologists to have an understanding of biochemical tests including an awareness of their limitations. The biological variability of an analyte both within and between individuals, the limitations of the measurement technology, the sensitivity of laboratory internal quality control and external quality assurance procedures, as well as interlaboratory variations in practices including sample collection procedures, may all impact on the interpretation of a result. Biochemical tests are often requested to monitor organ-specific dysfunction arising as an adverse consequence of pharmacotherapy or as a component of a systemic rheumatic disease, although dysfunction may also reflect infection or coincidental pathology. Patients with rheumatic diseases are at high risk of renal and hepatic disease. Serum creatinine and its derivative estimated glomerular filtration rate (eGFR) are the most readily available surrogate markers of GFR and are used to assess renal impairment and monitor its course. However, the use of creatinine alone lacks sensitivity and a substantial loss of function must occur before creatinine levels are increased. Additional biochemical screening for kidney damage can be performed by assessment of glomerular integrity, including proteinuria or albuminuria and haematuria. A wide spectrum of rheumatic diseases can affect the liver with various degrees of involvement and hepatic pathology. These often present with cholestatic or hepatitic biochemical profiles. The medical management of rheumatic diseases also involves medications that are hepatotoxic, and routine monitoring of liver function is recommended. This approach is not problem-free and may be improved by quantitative determinations of non-invasive markers of liver fibrosis in the future. Together with imaging techniques, biochemical tests play an important role in the assessment and differential diagnosis of metabolic bone disease.
Cardiopulmonary investigations
Authors: Schreiber Benjamin E. , Keir Gregory J. , Coghlan J. Gerry
Published: February 2014

Cardiopulmonary investigations are growing in number and complexity, but are crucial in management of patients with multisystem disease. Patients with rheumatological conditions are frequently at increased risk of a wide range of cardiac and pulmonary complications. Cardiac complications include accelerated atherosclerosis, valvular dysfunction, and pericardial, myocardial and endocardial involvement. Pulmonary complications include airways disease, interstitial lung disease, pulmonary embolism, and pulmonary hypertension.
We aim to present some practical frameworks for selecting the appropriate initial tests in different clinical situations. This chapter is in three sections. In the first section, we review the recommended investigations for common clinical symptoms: shortness of breath, cough, chest pain, and syncope. In the second section, we review the importance of cardiopulmonary investigations in specific rheumatological conditions. In the third section we review the unique characteristics of the cardiopulmonary tests, stressing their particular strengths and weaknesses and associated complications.
Analgesics
Authors: Foo Joanne , Saleem Benazir , Conaghan Philip G.
Published: February 2014

Pain is one of the commonest presenting symptoms of musculoskeletal disorders and may be one the hardest to treat successfully. The available analgesic options provide different modes of action and their ranks continue to expand with new agents, some with multiple target action. This chapter reviews currently available analgesics (paracetamol and opioids) used for managing musculoskeletal pain and the agents used for neuropathic pain, including their mechanism of action, pharmacokinetics and side effects. The role of neuroleptic agents is reviewed, and a brief outline of some newer therapies for the treatment of pain such as tapentadol, and a potential therapy, anti-nerve growth factor monoclonal antibodies.
Signalling pathway inhibitors
Authors: Fleischmann Roy
Published: February 2014

Oral, small-molecule signalling pathway inhibitors, including ones that inhibit the JAK and SyK pathways, are currently in development for the treatment of rheumatoid arthritis (RA). Tofacitinib 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 while baricitinib (formerly INCB028050) predominantly inhibits JAK1/2. Many of the proinflammatory 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. Fostamatinib disodium is an orally available inhibitor of spleen tyrosine kinase (SyK), which 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 may interrupt production of tumour necrosis factor (TNF) and metalloproteinase and therefore affect RA disease activity. Tofacitinib has been investigated in multiple phase 2 and phase 3 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. The efficacy of fostamatinib and baricitinib has been investigated in phase 2 trials; both are in large phase 3 clinical programmes. Each of these medications has demonstrated efficacy; their safety profile has been shown to be different from each other and from currently approved biological agents. This chapter discusses what is currently known and understood about their efficacy and safety.
Perioperative management of immunosuppression
Authors: Carmona Loreto , Galindo Maria
Published: February 2014

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.
Vaccination in immunocompromised children
Authors: Heijstek Marloes , Abinun Mario , Wulffraat Nico
Published: February 2014

Can immunocompromised children be safely and effectively vaccinated? This chapter discusses the recommendations from the European League Against Rheumatism (EULAR) for the immunization of immunocompromised patients. Patients with rheumatic or autoinflammatory diseases treated with high-dose glucocorticoids, high-dose disease-modifying anti-rheumatic drugs (DMARDs), or biologicals are considered immunocompromised. Safe and effective vaccination is crucial in these patients, given their increased risk of infection.
Safe vaccination implies that vaccination has no effect on disease activity and has only mild adverse effects. Effective vaccination denotes that patients are protected against infections after immunization. Particularly in severely immunosuppressed patients, concerns arise on the safety of (live-attenuated) vaccines and on the detrimental effect of immunosuppressive treatment on the immunogenicity of vaccines.
Overall, vaccinations do not increase disease activity and do not cause severe adverse events. Although non-live vaccines are safe, it is recommended to withhold live-attenuated vaccines in patients on high-dose immunosuppressive drugs and biologicals. However, booster vaccinations can be considered when essential.
Generally, immunogenicity of vaccines is good with some exceptions: responses are reduced in patients on high-dose glucocorticoids and rituximab; methotrexate reduces responses to (pneumococcal) polysaccharide vaccines; and anti-tumour necrosis factor alpha (TNFα‎) may lower vaccine-induced antibody concentrations. Offering vaccination before immunosuppressive drugs and/or measuring antibodies after immunization is recommended.
Mycobacterial diseases
Authors: Abdulkader Rita , Watts Richard A.
Published: February 2014

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.
Fungal arthritis
Authors: Kemper Carol A. , Deresinski Stanley C.
Published: February 2014

Fungal infections of the musculoskeletal system are uncommon and diagnosis is often delayed. Infection is more common in the immunocompromised patient. The most important infections are due to candida species, Histoplasmosis capsulatum, Blastomycosis dermatiditis, and Coccidioides immitis. Amphotericin B remains the initial therapeutic agent of choice for many serious fungal infections, especially for those who are severely immunosuppressed, have life-threatening or central nervous system disease, or who have failed azole therapy.
Pathogenesis of rheumatoid arthritis
Authors: Thomas Ranjeny , Cope Andrew P.
Published: February 2014

In depth molecular and cellular analysis of synovial tissue and fluid from patients with rheumatoid arthritis has provided important insights into understanding disease pathogenesis. Advances in the 1980s and 1990s included modern cloning strategies, sensitive and specific assays for inflammatory mediators, production of high-affinity neutralizing monoclonal antibodies, advances in flow cytometry, and gene targeting and transgenic strategies in rodents. In the 21st century, technological platforms offer unparalleled opportunities for systematic and unbiased interrogation of the disease process at a whole-genome level. Here we describe the key molecular and cellular characteristics of the inflamed synovium and how infiltrating cells get there. With this background, we outline current concepts of the different phases of disease, how the first phase of genetic susceptibility evolves into autoimmunity, triggered by the exposome, prior to the onset of clinically apparent inflammatory disease. We then describe the pathways that actively contribute to this early inflammatory phase and document the key effector cells and molecules of the innate and adaptive immune systems that orchestrate and maintain chronic synovial inflammatory responses. We summarize how this inflammatory milieu translates to cartilage destruction and bone resorption in synovial joints, and conclude by reviewing those factors in inflamed synovium that promote immune homeostasis.
Large-vessel vasculitis
Authors: Pipitone Nicolò , Versari Annibale , Salvarani Carlo
Published: February 2014

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 long-standing 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.
Gout
Authors: Dalbeth Nicola
Published: February 2014

Gout is a common and treatable disorder of purine metabolism. Gout typically presents as recurrent self-limiting episodes of severe inflammatory arthritis affecting the foot. In the presence of persistent hyperuricaemia, tophi, chronic synovitis, and joint damage may develop. Diagnosis of gout is confirmed by identification of monosodium urate (MSU) crystals using polarizing light microscopy. Hyperuricaemia is the central biochemical cause of gout. Genetic variants in certain renal tubular urate transporters including SLC2A9 and ABCG2, and dietary factors including intake of high-purine meats and seafood, beer, and fructose, contribute to development of hyperuricaemia and gout. Gout treatment includes: (1) management of the acute attack using non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or low-dose colchicine; (2) prophylaxis against gout attacks when commencing urate-lowering therapy (ULT), with NSAIDs or colchicine; and (3) long-term ULT to achieve a target serum urate of less than 0.36 mmol/litre. Interleukin (IL)-1β‎ is a central mediator of acute gouty inflammation and anti-IL-1β‎ therapies show promise for treatment of acute attacks and prophylaxis. The mainstay of ULT remains allopurinol. However, old ULT agents such as probenecid and benzbromarone and newer agents such as febuxostat and pegloticase are also effective, and should be considered in patients in whom allopurinol is ineffective or poorly tolerated. Management of gout should be considered in the context of medical conditions that frequently coexist with gout, including type 2 diabetes, hypertension, dyslipidaemia, and chronic kidney disease. Patient education is essential to ensure that acute gout attacks are promptly and safely managed, and long-term ULT is maintained.
Disorders of bone mineralization—osteomalacia
Authors: Jadon Deepak R. , Ahmed Tehseen , Bhalla Ashok K.
Published: February 2014

Disorders of bone mineralization cause rickets in children and osteomalacia in adults. Both remain common in developing countries. Incidence in Western countries had declined since the fortification of foodstuffs, but appears to be increasing again. Calcium and inorganic phosphate are the key precursors for bone mineralization and growth. The commonest aetiology of osteomalacia is vitamin D deficiency, primarily due to low dietary intake and inadequate sun exposure. In the last decade gene mutations have been identified that are responsible for inherited rickets and osteomalacia, particularly those that result in phosphate deficiency, hypophosphatasia, and vitamin D receptor or metabolizing enzyme mutations. Additionally, the pathogenesis of tumour-induced osteomalacia is becoming better understood. Osteomalacia may present as bone pain and tenderness, muscle pain and weakness, and skeletal deformity or fracture. Key investigations include biochemical assessment and plain radiographs. Radioisotope bone scans and bone biopsy may be considered in selected cases. Differential diagnoses include osteoporosis, seronegative arthritides, and localized soft tissue disorders. Treatment, guided by the underlying aetiology, aims to reduce symptoms, fracture risk, bone deformity and sequelae. Vitamin D deficient patients require vitamin D and calcium replacement.
Panniculitides
Authors: Sunderkötter Cord , Requena Luis
Published: February 2014

Panniculitis is an inflammation that originates
primarily in the subcutaneous fatty tissue (panniculus adiposus). It is associated with
rheumatological diseases and with adverse events to rheumatological therapies (e.g.
poststeroid panniculitis, erythema nodosum, infective panniculitis). The panniculitides are
classified histopathologically into mostly septal panniculitis and mostly lobular
panniculitis, according to the major or denser localization of the infiltrate, and also into
those with or without vasculitis. Additional criteria involve the composition of the
inflammatory infiltrate, the cause, and an underlying or associated disease. The clinical
hallmarks of panniculitis are subcutaneous nodules or plaques, often located on the lower
limb. A deep excisional biopsy is often required for a more precise diagnosis, given the
often sparse and monotonous clinical symptoms. Erythema nodosum is the most common form and
a typical example of septal panniculitis. It occurs in response to many different provoking
factors, the most common trigger in children being a 'strep throat', in adults sarcoidosis.
Clinically, it presents with a sudden symmetrical appearance of painful, tender, warm,
erythematous nodes or plaques, usually on the shins, which resemble bruises. Classical and
cutaneous polyarteriitis nodosa present a mostly septal panniculitis associated with
vasculitis. Here subcutaneous, partially ulcerating nodules are surrounded by livedo
racemosa. The mostly lobular panniculitides not associated with vasculitis include lupus
panniculitis (lupus erythematosus profundus, typically with ensuing lipoatrophy and
predilection for the upper part of the body), panniculitis in dermatomyositis (often
calcifiying), cold panniculitis, pancreatic panniculitis, panniculitis due toα‎-antitrypsin
deficiency, poststeroid panniculitis (in children after rapid withdrawal of
corticosteroids), calciphylaxis (with and without renal failure), and factitious
panniculitis (after mechanical, physical, or chemical injuries to the subcutaneous tissue,
often self-inflicted). Nodular vasculitis (formerly erythema induratum Bazin) is a lobular
panniculitis with vasculitis involving mostly the small blood vessels of the fat lobule. It
appears to present a (hyper)reactive response to certain infections (tuberculosis,
streptococci, candida) or to cold exposure or chronic venous insufficiency in susceptible
females. In conclusion, the panniculitides are a heterogenous group of diseases requiring a
systematic work-up and knowledge of certain histological or clinical criteria.
Sarcoidosis
Authors: Müller-Quernheim Joachim , Zissel Gernot , Prasse Antje
Published: February 2014

Sarcoidosis is a systemic disease characterized by non-necrotizing granulomata and manifestations in almost any organ. Diagnosis relies on the exclusion of other granulomatous disorders and a compatible pattern of symptoms and clinical findings. Inflammatory lesions and granulomata may undergo spontaneous resolution or persist in chronic disease with eventual fibrosis and permanent organ damage. Immunological disease mechanisms are linked to severe derangements of the cytokine network. In systemic resolution or under prednisolone therapy of symptomatic disease proinflammatory cytokines are downregulated and histological lesions may completely vanish. Corticosteroid-resistant disease, however, requires treatment with an immunosuppressive regimen consisting of prednisolone and an immunosuppressive agent or anti-tumour necrosis factor (TNF) monoclonal antibodies.
Psychiatric assessment of older people
Authors: Thomas Alan
Published: February 2014

The venue for assessment varies but given the choice there are substantial advantages in the first assessment being conducted at home. The aims of the assessment are to do more than achieve a diagnosis, though this is crucial; the aim should also be to produce a holistic assessment of all needs leading to the involvement a range of appropriate professionals in health and social care services to address these needs and carry out their own specialist assessments. Information from informants will supplement that of the patient and enable completion of all the important domains in the psychiatric history. The mental state examination will include a special emphasis on cognitive assessment and a brief physical looking for neurological signs is important.
Psychological treatments
Authors: Wilkinson Philip
Published: February 2014

This introduction to psychological treatments reviews the range and applications of talking therapies with older people. Reminiscence therapy is described and reference is made to the therapies addressed in later chapters. The potential benefits of psychological therapy are discussed with guidance on applying findings from clinical trials to individual patients. The wider benefits of an understanding of psychological approaches are outlined; these include use of psychological formulations and augmenting the effects of psychotropic medication. The status of psychological treatment services for older people is reviewed and barriers to access are considered.
Interpersonal psychotherapy
Authors: Wilkinson Philip
Published: February 2014

Interpersonal psychotherapy (IPT) is a structured psychological treatment developed for the management of depressive disorder that has been further refined and evaluated in the treatment of older adults. IPT is based on attachment, communication and social theories and focuses on the interpersonal origins and effects of depression. In this chapter, the delivery of IPT is described and illustrated with a case example. The four possible foci in IPT (complicated bereavement, role transition, interpersonal disputes, and interpersonal deficits) are explained. The evidence base for the efficacy of IPT in late-life depression is reviewed, including the Maintenance Therapies in Late Life Depression trials. Newer applications, including care management interventions and the treatment of anxiety, are described.
Memory assessment services
Authors: Banerjee Sube
Published: February 2014

Memory clinics were first developed in the 1970s and 1980s to help facilitate research. More recently they have evolved into Memory Services increasingly focussing on delivering early diagnosis and intervention for people with dementia and their carers. Compared with traditional community mental health services their focus is no early diagnosis in itself rather than the management of complex problems in dementia. The increasing awareness of dementia, and the extent of the health and social care challenge presented by dementia, has led to the development many more memory services and this development has been encouraged by different governments around the world. There is good evidence for the clinical and cost effectiveness of early diagnosis and intervention of dementia and memory services aim to achieve this. This chapter considers who memory services are for and what they should aim to achieve. It reviews the evidence base and discusses “what good looks like” for memory services and considers the need to understand the specific problem that such services are designed to address. A good memory service makes the diagnosis well, explains the diagnosis well and provides the immediate care, support and treatment that is needed by the person with dementia and their carers. Knowledge is power for people with dementia their carers.
Social care
Authors: Moriarty Jo
Published: February 2014

Social care is the broad term for the support provided to people living at home and in care homes. Major changes have taken place to this sector in the past few years and this chapter describes the key policy developments that have impacted upon what support is provided to older people with mental health problems and how it is funded. The policy of personalisation is intended to increase choice and control but as yet it is unclear whether this will lead to improved outcomes in terms of quality of life or independence. Some longstanding issues such as the high prevalence of people with unidentified mental health problems in long term care continue to provide challenges for organisations providing social care support.
Mild Cognitive Impairment and predementia syndromes
Authors: O’Brien John T. , Grayson Louise
Published: February 2014

Mild cognitive impairment is a term used to describe a condition or conditions where subjects have recognisable degrees of objective cognitive impairment which fall short of current standardised definitions for either a dementia syndrome in general, or for particular disorders such as Alzheimer’s disease, dementia with Lewy bodies or frontotemporal dementia. This chapter summarises some of the key issues surrounding the historical development of pre-dementia syndromes, considers the conceptual issues related to the use of the term mild cognitive impairment as a diagnosis, summarises what is known regarding epidemiology, clinical features, pathophysiology, prognosis, therapeutics and outlines current clinical practice in the area. The chapter concludes with a review of recent research developments and looks at the new diagnostic criteria, in particular the potential use of biomarkers to allow diagnosis of Alzheimer’s disease (AD) at an early, or mild cognitive impairment, stage.
The experience of depression
Authors: Boast Judith
Published: February 2014

This is a personal account of an episode of depression at the age of 71. The author discusses the symptoms of low mood, loss of confidence and sleep disturbance. She discusses how the condition affected her life, and how she struggled to cope with everyday activities. Antidepressant treatment was of some benefit for a limited period but side effects were troublesome. The situation improved slowly and altogether the episode lasted around two years.
Suicide and attempted suicide in older people
Authors: Chiu Helen , Tsoh Joshua
Published: February 2014

Attempted and completed suicide among older adults are global public health challenges of escalating significance. This chapter presents epidemiological data on such behaviours, and addresses the risk factors in the domains of mental health, personality, physical health and functioning, social factors (e.g. life events and social support) and neurobiological mechanisms, as derived from retrospective (mainly psychological autopsy [PA] studies) and prospective case-control studies. Suicide prevention initiatives in the elderly have taken a great stride forward in the past decade based on better understanding of the risk and protective factors. Given the complex, multi-determined nature of suicidal behaviours, further improvements will require sustained collaborations across clinicians, researchers, health administrators and politicians in different nations. Furthermore, older males are generally at higher risk of suicide than females; they tend to use more lethal means in their suicide acts, are more susceptible to the effects of bereavement and widowhood, and respond less favourably to comprehensive suicide prevention programs. Further research on the gender differences of suicidal behaviours is urgently needed, to understand the different underlying psychopathological mechanisms, and to adequately address the healthcare needs of older men, the largest group of completed suicides across the world.
The effect of ageing on personality
Authors: Woods Bob , Windle Gill
Published: February 2014

Ageing and personality interact. Whilst experiences that may be associated with age, including changes in roles and social networks, losses and health challenges, may require adaptation of aspects of personality, personality across the life-span fundamentally influences how ageing is experienced. There are indications that extraversion, conscientiousness and openness show reduced levels in later life, but people’s rank order on personality traits remains stable. Development continues into later life, but builds on earlier experiences and ways of coping. Personality resources such as self-esteem, perceived control, self-efficacy and resilience shape the person’s response to adversity in later life, enabling older people to maintain high levels of well-being, despite the challenges. Dementia, the ultimate challenge, is accompanied by personality change, with raised neuroticism and lowered conscientiousness both predicting its onset and accompanying its course. Pre-morbid personality does also appear to have some influence on behavioural problems experienced.
Mental capacity and decision-making
Authors: Hughes Julian C. , Heginbotham Christopher
Published: February 2014

In this chapter we start by defining terms and approaches to the assessment of mental or decision-making capacity. We outline basic principles – from the Mental Capacity Act 2005 (MCA), which covers England and Wales, as well as from Scottish legislation –where the principles are relevant to other jurisdictions. More conceptual issues, for instance to do with values and best interests, soon emerge, especially in connection with life-sustaining decisions. We discuss advance directives and lasting powers of attorneyand various tests of capacity, along with safeguards in connection with research. We then provide some conceptual analysis of the notions of ‘capacity’ and ‘competence’. We hope to have demonstrated that capacity and decision-making are complex matters because they reflect deeper issues to do with our standing as situated human beings in the world.
Testamentary capacity
Authors: Jacoby Robin
Published: February 2014

In most Anglophone jurisdictions the mental capacity to make a Will is governed by the Banks v Goodfellow judgment of 1870. This requires a testator to know what a Will is, the extent of his estate, and who might expect to benefit from his bounty. No mental disorder may affect the disposition of his estate. Older people, especially those with dementia and delirium, are liable to change their Wills under the influence or abuse of others, which leads to acrimonious family disputes. Old age psychiatrists are increasingly called upon to assess the capacity of people about to make Wills, as well as retrospective assessments of the capacity of deceased persons whose Wills are challenged in the courts.
Vestibular and Auditory Systems
Authors: Fisch Adam
Published: February 2014

Chapter 14 discusses vestibular and auditory systems, including the ear, the vestibular system, central auditory pathways, and auditory physiology.
Sleep and Wakefulness
Authors: Fisch Adam
Published: February 2014

Chapter 25 discusses sleep and wakefulness and their neurocircuitry, as well as suprachiasmatic circuitry and the flip-flop switch.
Emergency Neurology
Authors: Levin Morris
Published: February 2014

Emergency Neurology is designed as a resource for clinicians at all levels of training in all fields of medicine who treat patients with urgent and emergent neurological syndromes. It uses a novel approach focusing on the ‘clinical impasse’ that so often occurs in complex cases, and emphasizes the creative intellectual process clinicians relish. Authored by Morris Levin, along with colleagues from the Dartmouth-Hitchcock Medical Center, this resource presents 32 common urgent/emergent cases divided in to four distinct sections: (1) Diagnostic Questions (ADULT), (2) Treatment Considerations (ADULT), (3) Ethical, Neuropsychiatric and Legal issues, and 4) Pediatric issues. The chapters are short and to the point, bearing in mind the increasing work demands on physicians, with key questions addressed much as a consultant would do over the phone or in the hallway, and a list of key clinical points appears at the end of each case discussion, followed by a list of suggested articles or chapters for those interested in doing further reading on the subject.
Words and Idioms
Authors: Wulff Stefanie
Published: February 2014

This chapter presents a constructionist analysis of words and idioms. It provides a summary of early constructionist research that argued in favor of viewing idioms not as anomalies, and addresses the problem of how the degree of semantic and syntactic irregularity of different constructions can be measured quantitatively. The chapter proposes a quantitative measure that numerically expresses this degree of semantic similarity and which can be considered a numerical measure of compositionality.
Collostructional Analysis
Authors: Stefanowitsch Anatol
Published: February 2014

This chapter discusses the concept of collostructional analysis, a family of quantitative corpus-linguistic methods that allow researchers to express the strength of the relationship between word constructions and the grammatical structures they occur in. It provides several case studies and shows how varying collostructional measures can enlighten constructionist analyses of lexical and grammatical constructions. The chapter explains that although adoption of collostructional analysis is a comparatively recent development in Construction Grammar, it has already been applied to a fairly wide range of constructions in the context of research questions ranging from systemic description over language variation and change to language acquisition and processing. It also addresses important methodological issues of collostructional analysis such as the use of inferential statistics, the cognitive mechanisms assumed, as well as the choice of statistical tests.