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2
Caring by the hour: Women, work, and organizing at Duke Medical Center. Urbana: University of Illinois Press, 1988.
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I matti del Duce: Manicomi e repressione politica nell'Italia fascista. Roma: Donzelli editore, 2014.
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4
Physicians and Hospitals: The Great Partnership at the Crossroads (Duke Press Policy Studies). Duke University Press, 1985.
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Barber, Mary, Flavio Casoy, and Rachel Zinns. State Psychiatric Hospitals. Edited by Hunter L. McQuistion. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190610999.003.0016.
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State hospitals have represented an increasingly small piece of the public mental health system due to deinstitutionalization and ongoing hospital downsizing and closure. However, state hospitals continue to treat people with the most serious and complex mental illnesses. Freedom from the need to produce revenue and the luxury of time are two factors that leave state hospitals vulnerable to cuts but are also clinical assets. In this chapter, two cases illustrating histories common to patients treated in the state hospital are discussed—a patient with complex trauma and a patient with schizophrenia—exploring how state hospital systems can be designed to support individuals in their pursuit of recovery.
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Dodd, William. An account of the rise, progress, and present state of the Magdalen Hospital, for the reception of penitent prostitutes. Together with Dr. Dodd's ... Highness the Duke of York Fourth edition. Gale ECCO, Print Editions, 2010.
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7
Norko, Michael A., Craig G. Burns, and Charles Dike. Hospitalization. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199360574.003.0027.
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A significant number of people with serious mentally illness are found in correctional settings and must be provided with clinical care commensurate with their needs. Many of those needs may be met within the mental health care systems established in jails and prisons. When clinical conditions are more complex and require more intensive management, the availability of hospital level of care becomes important. The relationship for care for an incarcerated patient between acute psychiatric care in jails and prisons on the one hand and forensic or community hospitals on the other varies by jurisdiction. While the decision to pursue hospitalization for an acutely ill inmate is driven chiefly by clinical considerations, it is also influenced by security and safety concerns. These factors need to be considered on an individual basis, weighing the advantages and disadvantages of treatment in an outside hospital versus management in the prison or jail with available resources. Involuntary medication and involuntary hospital transfer implicate important legal rights, the protection of which requires due process established by federal and state laws and case precedents. Clinicians working in corrections and in hospital settings that admit inmates and detainees need to be aware of the relevant procedures required for these involuntary treatment modalities. In all jurisdictions, hospital level care is necessary for a subset of sentenced inmates and jail detainees and must therefore be made available when appropriate. This chapter discusses a variety of models linking psychiatric care across institutional boundaries.
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Lupton, Joshua. Hospital Acquired Pneumonia. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199976805.003.0023.
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Pneumonia consists of inflammation of the pulmonary parenchyma, typically resulting from a microbial infection. Hospital-acquired pneumonia (HAP) occurs in (typically elderly) patients in long-term care facilities, with regular IV therapy, with immunosuppression, or with a history of recent treatment at a hospital. It is associated with high mortality. The majority HAP patients present with some constellation of cough, fever, sputum production, and pleuritic chest pain. Patients with chronic obstructive pulmonary disease (COPD) and cystic fibrosis are at increased risk for pneumonia. The Infectious Disease Society of America requires infiltrates on chest x-ray or other imaging for the diagnosis of pneumonia. For hospitalized patients, empiric antimicrobial therapy for HAP should be given as soon as pneumonia is highly suspected. There is currently a vaccine available against Streptococcus pneumonia that all patients should be offered before discharge from the hospital. The elderly are already more susceptible to HAP due to decreased mobility and increased comorbidities.
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Morley, Peter Thomas. Pathophysiology and causes of cardiac arrest. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0061.
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Sudden cardiopulmonary arrest (CPA) is still the commonest cause of death globally. CPAs are usually categorized according to where they occur, with out-of-hospital arrests accounting for approximately 75% of CPA deaths and in-hospital the remaining 25%. The arrests are also sub-categorized according to the initial rhythm, with the best outcomes associated with shockable rhythms. Large registries have demonstrated a variable incidence of out-of-hospital CPAs in adults (50–150/100,000 person years), with a range of outcomes (3–16% survival to hospital discharge). The majority of CPAs in adults are due to cardiac causes, but teaching surrounding the management of cardiac arrests now includes an increased focus on the identification and correction of underlying causes, irrespective of the rhythm. While identifying an underlying cause is often challenging, this is probably one of reasons explaining the improved survival seen with in-hospital compared with the out-of-hospital CPA. The incidence of CPAs in children is highest in infants, and decreases with age. The majority of CPAs in children are due to respiratory causes. Cardiac causes in children and young adults include a variety of familial, genetic, and acquired conditions. The pathophysiology of cardiac arrests is also now better understood. A large number of biochemical pathways are activated as a result of the CPA. These result in the post-cardiac arrest syndrome, which affects many systems in the body, but in particular the brain, heart, and kidneys.
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Vincent, Laura, and Carl Waldmann. Rehabilitation from critical illness after hospital discharge. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0386.
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The majority of patients admitted to intensive care units survive to hospital discharge, but then face a long and challenging functional recovery, due to the physical and psychological sequelae of their critical illness. There is associated physical, emotional, and financial strain on families and care-givers, in addition to the ongoing impact on patients themselves. The optimization of post-ICU morbidity and ‘health-related quality of life’ have thus become key components of the critical care treatment pathway. Structured exercise rehabilitation programmes, tailored to the specific needs of individual patients can enhance the long-term recovery from critical illness, but the practical implementation of such programmes remains inconsistent and non-standardized. Validated screening and assessment tools are being developed to identify those patients who would benefit from post-ICU rehabilitation programmes, target the specific needs of individuals and monitor the response to treatment. Ongoing research aims to determine the features of a successful post-ICU rehabilitation programme, with respect to the location and supervision of the regime, and the actual content of the intervention. Rehabilitation commenced as soon as possible after hospital discharge is likely to be most effective, but further evidence is required to identify the timing of treatment that would achieve the optimal therapeutic impact. The National Institute of Clinical Excellence have issued a post-ICU rehabilitation guideline. As well as providing a framework for implementation of such a programme, this further endorses the understanding that exercise rehabilitation can no longer be considered an afterthought and should be fully incorporated into the critical care treatment pathway.
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Rubin, Donald, Xiaoqin Wang, Li Yin, and Elizabeth Zell. Bayesian causal inference: Approaches to estimating the effect of treating hospital type on cancer survival in Sweden using principal stratification. Edited by Anthony O'Hagan and Mike West. Oxford University Press, 2018. http://dx.doi.org/10.1093/oxfordhb/9780198703174.013.24.
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This article discusses the use of Bayesian causal inference, and more specifically the posterior predictive approach of Rubin’s causal model (RCM) and methods of principal stratification, in estimating the effects of ‘treating hospital type’ on cancer survival. Using the Karolinska Institute in Stockholm, Sweden, as a case study, the article investigates which type of hospital (large patient volume vs. small volume) is superior for treating certain serious conditions. The study examines which factors may reasonably be considered ignorable in the context of covariates available, as well as non-compliance complications due to transfers between hospital types for treatment. The article first provides an overview of the general Bayesian approach to causal inference, primarily with ignorable treatment assignment, before introducing the proposed approach and motivating it using simple method-of-moments summary statistics. Finally, the results of simulation using Markov chain Monte Carlo (MCMC) methods are presented.
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Bontemps, Arna. Health. University of Illinois Press, 2017. http://dx.doi.org/10.5406/illinois/9780252037696.003.0018.
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This chapter looks at the history of Provident Hospital, which had been started by Negro doctors in the late nineteenth century to address the poor health conditions among Negroes in Chicago, with particular emphasis on its role in addressing the high mortality rates due to tuberculosis on the South Side during the period. It begins with an overview of Provident Hospital, which opened in 1891 with thirteen beds and the first training school for Negro nurses in the United States, and considers some of its doctors, led by Dr. Daniel Williams. It then discusses Provident's alliance with the University of Chicago that established the hospital as a recognized educational center, along with its affiliation with the city's important social agencies through its Social Services Department. It also describes Provident's initiative to solve the problem of proper hospitalization of tuberculosis patients in Chicago through its Department of Medicine in collaboration with white physicians and social workers.
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Badiola, Ignacio, Tulsi Singh, Jiabin Liu, and Nabil Elkassabany. Acute Pain in the Opioid-Tolerant Patient. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190271787.003.0045.
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The number of people addicted to prescription and illicit opioids continues to increase, and many of these patients present to the hospital or pain center with acute pain issues. The matter is further complicated by the increasing number of patients with legitimately painful conditions treated with chronic opioid therapy. Typically, these patients are difficult to manage during any acute pain episode due to their opioid tolerance and opioid-induced hyperalgesia. This difficulty often leads to inadequate pain management, increased suffering, and delayed hospital discharge. Increased awareness is needed among pain management physicians and other clinicians who care for opioid-tolerant patients, yet there is a lack of evidence-based medicine regarding the optimal treatment of this population.
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Greaves, Claire D., and Mike J. Dunn. The nuclear medicine patient. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199655212.003.0018.
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Following the administration of a radiopharmaceutical, the patient is essentially a mobile source of radiation. The hazards from the patient are contamination from radioactive tissue/body fluids, and exposure to the radiation emitted from the patient. These hazards present a risk to the patient due to self-absorbed radiation, healthcare workers, other patients, members of the public, family members (including the foetus), colleagues at work, and carers. This chapter presents the methodology used for assessing the doses to patients and critical groups, and discusses its limitations. It considers the risks and protective measures for: the patient (both adults and paediatrics), the foetus and young children including reproduction, breastfeeding, and close contact, hospital and external workers who may come into contact with the patient or be at risk of contamination, and the general public (inside and outside the hospital environment). The risks are presented along with practical guidance to minimize the hazard.
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Lyster, Haifa. Antimicrobial stewardship in the immunocompromised patient. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198758792.003.0011.
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Immunocompromised patients are at a high risk of infection with resistant organisms due to their increased exposure to hospital environments, including the intensive care unit, their frequent need for invasive procedures, and increased antimicrobial use. To limit this growing trend, and due to the paucity of development of new antimicrobial agents with novel mechanisms of action, the judicious use of the agents currently available should be encouraged. A broad spectrum of possible infections combined with the diagnostic uncertainty, clinical condition, and the specialist teams’ perceptions make antimicrobial stewardship very difficult. However, evidence presented in this chapter illustrates how stewardship in the immunocompromised host may be achieved.
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Morris, Rhiain. Psychological management of coronary heart disease. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0123.
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Both anxiety and depression have been found to increase the risk of developing coronary heart disease (CHD) and lead to exacerbation of cardiac symptoms, with the latter subsequently impacting recovery/rehabilitation (e.g. leading to an increased number of readmissions to hospital, and an increased mortality risk following myocardial infarction (MI)). This may be due to pathophysiologic effects, such as vascular inflammation and autonomic dysfunction, and poor lifestyle/behavioural patterns, including non-attendance at cardiac rehabilitation classes; and/or poor treatment adherence. Psychosocial factors such as stress, hostility, social isolation, socio-economic status, and psychological defensiveness can also affect the course of cardiac illness.
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Cata, Juan P. Metastatic Spine Disease. Edited by David E. Traul and Irene P. Osborn. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190850036.003.0013.
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Metastatic spinal cord compression (MSCC) is a medical emergency that requires early diagnosis and treatment. Medical management or surgery can be indicated depending on different factors including duration of the symptoms, patient comorbidities, and hospital resources. Patients scheduled for decompressive laminectomy due to MSCC may present to the operating room with pain, high requirements of opioids, hematological disorders, impending bone fractures, nausea and vomiting, and electrolytes disorders. Multimodal intraoperative monitoring is needed to minimize spinal cord injury. The immediate postoperative care of these patients is directed to accelerate recovery by providing multimodal analgesia, encouraging early ambulation, and optimizing their nutritional status.
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Burns, Tom, and Mike Firn. Daily living skills. Edited by Tom Burns and Mike Firn. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198754237.003.0024.
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This chapter covers interventions with people who need encouragement with cooking or shopping due to motivational, cognitive, and information-processing difficulties associated with severe mental illness. Community outreach allows an in vivo approach to supporting these tasks that enable people to survive outside of hospital and which contribute to their quality of life. Functional assessment, activity analysis, and collaborative goal setting are discussed, together with ways of measuring progress. The evidence base for interventions such as social skills training is critiqued. A case study and summary care plan illustrate typical approaches with patients in the community.
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Chen, Q. Cece, and Shengping Zou. Postoperative Pain Management. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190457006.003.0016.
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Postoperative pain management is an important aspect of caring for a surgical patient as inadequate pain control can be associated with increased morbidity and mortality. Failure to effectively control postoperative pain is often due to poor communication and poorly coordinated care between the care teams, poor communication with the patient, insufficient education, unrealistic expectations, fear of complications from the pain regimen, inaccurate pain assessment, and limited effective pain treatment modalities. An effective pain management can therefore lead to improved patient comfort, satisfaction, earlier ambulation, faster recovery time, decreased hospital stay and cost of care, and reduced postoperative complications.
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Cist, Alexandra, and Philip Choi. Religion and Spirituality in the Intensive Care Unit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190272432.003.0011.
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The Intensive Care Unit is an area of the hospital that can elicit high levels of emotional and spiritual distress due to high mortality and prognostic uncertainty. Religion and spirituality are often manifest through prayer, rituals, and ceremonies, which can unite the patient and family with the care team. However, miracle language and other religious or spiritual topics that misalign with the expectations of the medical team can also lead to discord. The acute nature of ICU care poses challenges in creating a therapeutic alliance necessary to effectively address the religious and spiritual needs of patients and families. In this chapter, we provide a practical approach to provide high quality spiritual care in the ICU.
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Kisely, Steve. Assessing the effectiveness of compulsory community treatment. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198788065.003.0005.
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This chapter initially considers methodological issues that arise in assessing the effectiveness of compulsory community treatment. It then reviews the evidence from uncontrolled, controlled, and randomized studies of various types of intervention. Although uncontrolled studies suggest some reduction in health service use following compulsory community treatment, this is not generally confirmed in studies with matched or randomized controls. Although proponents of compulsory community treatment argue that it is less coercive than the alternatives of compulsory admission to hospital or arrest, research findings suggest that it remains an unproven way of reducing either procedure. Even where changes in outcome have been shown, such as decreased criminal victimization, it is not clear whether these are due to the legislative framework or to a greater intensity of contact.
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Borenstein, Jason, Ayanna Howard, and Alan R. Wagner. Pediatric Robotics and Ethics. Oxford University Press, 2017. http://dx.doi.org/10.1093/oso/9780190652951.003.0009.
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As robots leave the lab and are deployed in hospital or other healthcare settings, the community of users may become overreliant on and overtrust such technology. Thus, there is a pressing need to examine the tendency to overtrust and develop strategies to mitigate the risk to children, parents, and healthcare providers that could occur due to an overreliance on pediatric robotics. To overcome this challenge, we seek to consider the broad range of ethical issues related to the use of robots in pediatric healthcare. This chapter provides an overview of the current state of the art in pediatric robotics, describes relevant ethical issues, and examines the role that overtrust plays in these scenarios. We conclude with suggested strategies to mitigate the relevant risks and describe a framework for the future deployment of robots in the pediatric domain.
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Guthrie, Graeme. Narrowing the Gap. Oxford University Press, 2017. http://dx.doi.org/10.1093/acprof:oso/9780190641184.003.0004.
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Manager-shareholder conflict arises due to low levels of managerial ownership and the resulting wide separation of ownership and control. However, strong boards of directors can make even small ownership stakes more effective at motivating executives to work in shareholders’ best interests by granting stock options, repurchasing shares, and issuing debt. Ultimately they can approve a leveraged buyout, although a strong board is needed to overcome the conflicts of interest involved in management-led buyouts. This chapter uses events at HCA, the for-profit hospital chain that undertook the world’s largest leveraged buyout followed a few years later by the largest private equity IPO, to explain how boards can narrow the gap between ownership and control. It uses a novel representation of a firm’s capital structure to analyze the techniques for boosting ownership-generated incentives at relatively low cost to shareholders.
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Cooper, Jill, and Nina Kite. Occupational therapy in palliative care. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656097.003.0046.
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Occupational therapy in palliative care aims to help patients achieve their optimum independence in activities that are important to them. The specific functional difficulties may include extreme fatigue, anxiety and shortness of breath due to advanced disease including metastatic spinal cord compression, fractures, or peripheral neuropathies. Patients may have problems with cognition and perception, body image, life role, and spiritual issues as well as physical disabilities. This chapter describes the broad range of areas in which the occupational therapist works in palliative care together with the interprofessional team. They take a key role in organizing and facilitating safe discharge and care at home, with the aim of achieving best quality of life and avoiding re-admission to hospital wherever possible. The occupational therapist analyses and assesses specific problems and provides a treatment programme or solution to help the patient remain as independent as possible, using clinical reasoning and evidence-based practice.
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Jumean, Marwan F., and Mark S. Link. Post-cardiac arrest arrhythmias. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0065.
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Our understanding of arrhythmias following resuscitated cardiac arrest has evolved over the past two decades to entail complex pathophysiological processes including, in part, ischaemia and ischaemia-reperfusion injury. Electrical instability after the return of spontaneous circulation (ROSC) is common, ranging from atrial fibrillation to recurrent ventricular tachycardia and fibrillation. Electrical instability following out-of-hospital cardiac arrest is most commonly due to myocardial ischaemia and post-arrest myocardial dysfunction. However, electrolyte disturbances, elevated catecholamine levels, the frequent use of vasopressors and inotropes, and underlying structural heart disease or channelopathies also contribute in the acute setting. Limited data exists that specifically address the management of arrhythmias in the immediate post-arrest period. In addition to treating any potential reversible cause, the management in the haemodynamically-stable patient includes beta-blockers, class I (lignocaine and procainamide) and III anti-arrhythmic agents (amiodarone). Defibrillation is often needed for recurrent ventricular arrhythmias.
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Spoletini, Giulia, and Nicholas S. Hill. Non-invasive positive-pressure ventilation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0090.
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Non-invasive ventilation (NIV) has been increasingly used over the past decades to avoid endotracheal intubation (ETI) in critical care settings. In selected patients with acute respiratory failure, NIV improves the overall clinical status more rapidly than standard oxygen therapy, avoids ETI and its complications, reduces length of hospital stay, and improves survival. NIV is primarily indicated in respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema and associated with immunocompromised states. Weaker evidence supports its use in other forms of acute hypercapnic and hypoxaemic respiratory failure. Candidates for NIV should be carefully selected taking into consideration the risk factors for NIV failure. Patients on NIV who are unstable or have risk factors for NIV failure should be monitored in an intensive or intermediate care units by experienced personnel to avoid delay when intubation is needed. Stable NIV patients can be monitored on regular wards.
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Rao, Chethan P. Venkatasubba, and Jose Ignacio Suarez. Management of non-traumatic subarachnoid haemorrhage in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0239.
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Non-traumatic subarachnoid haemorrhage (ntSAH) is a complex disease affecting multiple systems and the hospital course of affected patients can be variable. ntSAH is associated with high morbidity and mortality, with the causes of early deaths being either rebleeding or hydrocephalus. The risk of rebleeding is reduced by immediate control of arterial blood pressure and early securing of ruptured aneurysms by either endovascular coiling or surgical clipping. Ongoing management focuses on prevention, detection, and management of delayed neurological deficits. Current recommendations include prophylactic use of nimodipine, maintenance of hypertension and euvolaemia or hypervolaemia, and endovascular treatment of vasospasm that fails to respond to medical therapy. Systemic complications following ntSAH include myocardial injury, acute lung injury, venous and pulmonary thromboembolism, fluid and electrolyte abnormalities, and severe sepsis. Each of these complications should be treated on its merits. Due to the complexity of management patients with ntSAH should be treated in a critical care environment by a collaborative team of neurosurgeons, neuroradiologists, neurologists and intensivists.
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Mythen, Monty, and Michael P. W. Grocott. Peri-operative optimization of the high risk surgical patient. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0361.
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Flow-based cardiovascular variables, such as cardiac output and oxygen delivery predict peri-operative outcome better than alternative, predominantly pressure-based measures. Targeting flow-based goals, using fluid boluses with or without additional blood or vasoactive agents in patients undergoing major surgery has been shown to improve outcome in some studies. However, the literature is limited due to a large number of small single-centre studies, and heterogeneity of interventions and outcomes evaluated. Early studies used pulmonary artery catheters to monitor blood flow, but newer studies have used less invasive techniques, such as oesophageal Doppler monitoring or pulse contour analysis. Meta-analysis of the current evidence base suggests that this approach is unlikely to cause harm and may not reduce mortality, but reduces complications and duration of hospital stay. Goal-directed therapy is considered an important element of enhanced recovery packages that have been shown to improve outcome after several types of major elective surgery.
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Morrison, Karen. Prevention of neurological disease. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0347.
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Neurological disease is very common. It is estimated that one-third of consultations with general practitioners involve neurological complaints, and neurological disorders are present in one-third of patients admitted to hospital. In considering how to reduce the incidence of neurological disease, one must take into account the feasibility of prevention, and the overall morbidity caused by the disease. In stroke, which is very common, interventions which reduce incidence by a small percentage have the potential to have a large impact on a population basis. A disorder such as migraine, while not life-limiting, accounts for significant morbidity and time off work (one study suggests that there are the equivalent of 112 million bedridden days per year due to migraine alone), so, again, interventions that reduce the frequency of episodes even by a small percentage can have great overall impact. This chapter discusses the major categories of neurological disease based on pathogenesis, and current and future approaches to prevention.
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Barclay, Philip, and Helen Scholefield. High dependency and intensive care. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0030.
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The development of maternal critical care is essential in reducing morbidity and mortality due to a substandard level of care. The level of critical care should depend upon the patient’s severity of illness, not their physical location. Escalation to level 3 (intensive) care is uncommon in pregnancy, with a median admission rate of 2.7 per 1000 births, mainly due to hypertensive disorders of pregnancy and haemorrhage. Maternal ‘near misses’ occur more frequently, with 6.5 per 1000 births meeting Mantel’s criteria, of which 85% is due to major obstetric haemorrhage. The admission rate to maternal high dependency units (level 2 care) varies from 1% to 5%. Acute physiological scoring systems have been found to be reliable when applied to parturients receiving level 3 care but overestimate mortality. Maternal early warning scores have been derived from simplified versions of these systems, with allowance made for physiological changes seen in pregnancy. There are many different maternity scoring systems in use throughout England and Wales. All share the same principle that parameters should be recorded regularly during the hospital stay, with deviations from normal quantified, recorded, and acted upon. A chain of response is then required to ensure that suitably qualified staff, possessing appropriate critical care competencies, attend in a timely fashion. Appropriate resources must be available with equipment readily to hand and suitably trained staff so that invasive monitoring can be used. Clear admission criteria are required for level 2 care within the delivery suite and escalation to level 3, with suitable arrangements for transfer.
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Fye, W. Bruce. Analyzing and Managing Abnormal Heart Rhythms. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199982356.003.0017.
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Cardiac arrhythmias (abnormal heart rhythms) can be life-threatening or simply annoying. Implantable pacemakers were introduced around 1960 to treat slow heart rates that might cause a patient to faint. Sudden cardiac death is usually due to ventricular fibrillation, a very fast chaotic heart rhythm that immobilizes the heart. External defibrillators were used in CCUs, but most patients who experience sudden death are not in hospitals. The introduction of automatic implantable cardiac defibrillators (ICDs) in the mid-1980s provided a safety net for patients at high risk for sudden death. These heart rhythm technologies were expensive, and concerns were raised about their costs and appropriate use. During the final quarter of the century, catheter-based diagnostic techniques were developed to evaluate patients with known or suspected arrhythmias. Cardiologists who focused on heart rhythm disorders were known as electrophysiologists. The emergence of clinical cardiac electrophysiology is an example of continuing subspecialization within cardiology.
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Grossman, Jonah, Tanzila Shams, and Cathy Sila. Neurological Complications of Infective Endocarditis. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199937837.003.0167.
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Infective endocarditis is the fourth leading cause of life-threatening infections, accounting for 40,000 annual U.S. hospital admissions. Due to decline in rheumatic heart disease, a shift in causative organisms from viridans streptococci to S. aureus, Group D Streptococcus, and multidrug-resistant species has been observed. The spectrum of neurological complications ranges widely from cerebrovascular pathologies-including septic embolization, mycotic aneurysms, and intracerebral hemorrhages-to seizures, meningitis, cerebritis, and abscess. Transthoracic echocardiogram remains the standard for initial investigation whereas CT scans, MRI with DWI sequence, and cerebral angiograms are useful for exploring neurological complications. Antibiotic regimens, tailored to culprit organisms, should be initiated early after obtaining blood cultures and continued for 4 to 6 weeks. Antithrombotic treatment may pose increased risk for intracerebral hemorrhage, even in the absence of mycotic aneurysms (MA). Unruptured MA must be treated according to risk of rupture and overall health of the patient. MAs either at risk or previously ruptured should be secured by neurosurgical or endovascular means. Early cardiac surgery is a viable option for prevention of septic embolization for high-risk cardiac diseases such as perivalvular abscess and infection with resistant organisms, but may increase mortality rates for those with decompensated heart failure.
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Wilson, A. P. R., and Preet Panesar. Antimicrobial drugs in critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0053.
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The pharmacokinetics of antimicrobials are altered in critically-ill patients, particularly in the presence of renal or hepatic failure. Maintaining a choice or diversity of antibiotics is important due to the emergence of resistance. Antibiotic use should also be kept to the minimum and local protocols need to be established. For community-acquired infection, co-amoxiclav or a parenteral cephalosporin can be used, while for hospital-acquired infection, piperacillin/tazobactam, ciprofloxacin, or ceftazidime are recommended. For suspected vascular catheter infection or methicillin-resistant Staphylococcus aureus (MRSA) infection, teicoplanin or vancomycin should be used, with meropenem or imipenem reserved for second line treatment. Prophylactic antibiotics should not be continued once a surgical patient has returned from the theatre. Patients with febrile neutropenia receive piptazobactam, meropenem, ceftazidime or ciprofloxacin and a glycopeptide. Antifungals, usually caspofungin or liposomal amphotericin, are used if fungal infection is suspected, especially after failed antibacterial treatment. Cephalosporin use has declined as they have been linked with emergence of MRSA and Clostridium difficile. However, this reflects overuse and they still have a place as part of a diverse choice of antibiotics. Vancomycin and teicoplanin use has increased greatly in order to treat MRSA and line infections, but resistance remains unusual. Carbapenem use has increased rapidly with the emergence of extended spectrum beta-lactamase producing Gram-negative bacteria.
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Choon, Francis Chin Kuok, and Phua Dong Haur. Management of radiation poisoning. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0331.
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In radiation poisoning, a distinction between exposure and contamination should be made. Decontamination by removing clothes, washing of skin, and removal of debris can remove up to 90% of external contaminated radiation. Treatment of acute life-threatening injuries takes priority over treatment of radiation poisoning. Triage of severely exposed patients can give an indication of dose and severity of the radiation dose absorbed. Survival is related to dose absorbed. Identification of the radiation source should be made by the radiation characteristics to determine the shielding necessary for protection of hospital staff and the antidote required. Early gastric lavage and specific antidotes for ingested radiation poisoning should be used with caution. Death is mainly due to infection and haemorrhage. Acute radiation syndrome (ARS) is a manifestation of haematopoietic, gastrointestinal, cardiovascular, central nervous system, and cutaneous syndromes. Those receiving whole body doses of 1–5 Gy may recover easily with appropriate medical management; those with doses of 6–10 Gy may survive with intensive management; and those with doses of >10 Gy seldom survive. Treatment of ARS is supportive with the use of antibiotics, colony-stimulating factors, blood products, and stem cell transplants. Protection of the staff is by reducing time exposed, increasing distance from source and proper shielding. Psychological counselling should be available to patient or staff if required.
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Hopkins, Ramona O., and James C. Jackson. Neurocognitive impairment after critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0382.
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More than 5 million individuals are admitted to intensive care units (ICUs) in North America annually. Due to improvements in treatment, increasing numbers of these individuals survive and go on to develop long-term neurocognitive impairment in a variety of cognitive domains. As evidence from over two dozen studies demonstrates, neurocognitive impairment occurs in up to two-thirds of individuals. While it may be particularly common in those with pre-existing vulnerabilities, even patients who are young with robust health prior to critical illness are at risk of post-ICU neurocognitive impairment. While neurocognitive impairment may improve over time and even dissipate in a subset of ICU survivors, neurocognitive impairment is often permanent and, in some cases may be progressive. As commonly occurs in the context of acquired brain injury, the neurocognitive impairment observed after critical illness is typically diffuse, although domains including memory, attention, and executive functioning are often particularly impaired. This impairment is sufficiently severe to negatively impact daily functioning. Although the risk factors and mechanisms undergirding neurocognitive impairment have yet to be fully elucidated, potential contributors include inflammation, hypoxia, and delirium. While one way to impact on the prevalence and incidence of cognitive impairment after critical illness is to attempt to modify key ‘in-hospital’ risk factors, another approach involves the use of post-ICU cognitive rehabilitation, which is increasingly being successfully employed with other impaired medical populations.
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Baldwin, Matthew, and Hannah Wunsch. Mortality after Critical Illness. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199653461.003.0003.
Full textAbstract:
Many critically ill patients now survive what were previously fatal illnesses, but long-term mortality after critical illness remains high. While study populations vary by country, age, intervention, or specific diagnosis, investigations demonstrate that the majority of additional deaths occur in the first 6 to 12 months after hospital discharge. Patients with diagnoses of cancer, respiratory failure, and neurological disorders leading to the need for intensive care have the highest long-term mortality, while those with trauma and cardiovascular diseases have much lower long-term mortality. Use of mechanical ventilation, older age, and a need for care in a facility after the acute hospitalization are associated with particularly high 1-year mortality among survivors of critical illnesses. Due to challenges of follow-up, less is known about causes of delayed mortality following critical illness. Longitudinal studies of survivors of pneumonia, stroke, and patients who require prolonged mechanical ventilation suggest that most debilitated survivors die from recurrent infections and sepsis. Potential biologic mechanisms for increased risk of death after a critical illness include sepsis-induced immunoparalysis, intensive care unit-acquired weakness, neuroendocrine changes, poor nutrition, and genetic variance. Studies are needed to fully understand how the severity of the acute critical illness interacts with comorbid disease, pre-illness disability, and pre-existing and acquired frailty to affect long-term mortality. Such studies will be fundamental to improve targeting of rehabilitative, therapeutic, and palliative interventions to improve both survival and quality of life after critical illness.
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Scott, Charles L., and Brian Falls. Mental illness management in corrections. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199360574.003.0002.
Full textAbstract:
An increasing number of individuals with mental illness are now treated in correctional environments instead of community settings. In the incarcerated population, prevalence estimates of serious mental illness (SMI) range from 9 to 20% compared to 6% in the community. More astonishingly, over three times more persons with serious mental illness in the United States are located in jails and prisons than in hospitals. It was not always like this. How did U.S. correctional systems become de facto mental health institutions for so many? Scholars point to a number of reasons for the increasing prevalence of mental illness among incarcerated individuals, including deinstitutionalization and limited community resources, prominent court decisions and legislative rulings, and the ‘revolving door’ phenomenon. There are many similarities between correctional and community mental health care services. Both systems typically provide appropriate medications, emergency care, hospitalization, medication management, and follow-up care. However, key differences often exist in correctional systems, including restricted formularies due to concerns of medication abuse or cost, alternative involuntary medication procedures, restricted access by visitors, and the inability of mental health providers to control the treatment environment. This chapter summarizes the historical context of correctional versus community mental health; factors resulting in the increasing management of people with mental illness in correctional settings; and similarities and differences between the provision of mental health care in correctional versus community settings.
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Roberts, Charlotte A. Leprosy. University Press of Florida, 2020. http://dx.doi.org/10.5744/florida/9781683401841.001.0001.
Full textAbstract:
Leprosy is an infection and neglected tropical disease that is steeped in myths, and, although it is described in history books, it can remain a challenge to manage today. Written in an accessible manner for professionals and the public alike, this book takes a global view of leprosy past and present. As a backdrop, it starts with exploring what we actually know about leprosy from medicine, how it is spread to humans, and its effects on the body. It then moves to consider its diagnosis and treatment in people, past and present. The focus switches next to the ways in which leprosy is diagnosed in skeletons (paleopathology), from just looking at the bones to analyzing the DNA of the bacteria preserved in the bones. By doing so, information on skeletons with evidence of leprosy across the globe is synthesized with the aim of considering the current state of global knowledge regarding the origin, evolution, and history of leprosy. In particular, the book explores how all the people diagnosed with leprosy in their skeletons in the past were buried, and the myth that everybody was ostracized and segregated into leprosy hospitals, due to stigma, is dismissed. It concludes with thoughts on a future for leprosy, the need to continue to dispel its myths and to seriously reconsider the use of the word “leper” when discussing leprosy today and in the past.
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Wang, Kevin K. W. Neurotrauma. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190279431.001.0001.
Full textAbstract:
This new book volume, simply titled Neurotrauma, aims to bring together the latest clinical practice and research in the field of two forms of trauma to the central nervous system: namely, traumatic brain injury (TBI) and spinal cord injury (SCI). Nationally, more 1.9 million Americans sustain a TBI annually. In parallel, there are an estimated 12,000 new cases of SCI in the United States annually. In addition, approximately 1.2 million people live with paralysis due to SCI. In recent years, dramatic advancements in the field have resulted in much improved outcomes for patients and higher standards of care. This volume brings together the latest research and clinical practice in the treatment of neurotrauma in a comprehensive but easy-to-follow format. Our target readership is intentionally broad. It includes clinicians who are involved in caring for TBI in the emergency room, hospital, or neurointensive care unit or during patient rehabilitation; clinical research professionals; research nurses; and nonclinical academic researchers, such as research professors, research scientists, medical students, graduate students, and nurse specialists, as well as biomedical industry R&D scientists and clinical associates. As editor of this volume, I want all readers to find a chapter or section on almost all aspects related to TBI or SCI. I also hope that they will encounter some areas they might be already familiar with. Yet, at the same time, I hope that they will also discover or rediscover other less familiar areas in neurotrauma that they have always wanted to learn more about. Last, I want to make this volume as layman-like and as easy to follow as possible so that it can also serve as a resource book for TBI or SCI patients or caregivers who want to better educate themselves about these conditions.
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Jha, Vivekanand. Acute kidney injury in the tropics. Edited by Norbert Lameire. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0241.
Full textAbstract:
The spectrum of acute kidney injury (AKI) encountered in the hospitals of the tropical zone countries is different from that seen in the non-tropical climate countries, most of which are high-income countries. The difference is explained in large part by the influence of environment on the epidemiology of human disease. The key features of geographic regions falling in the tropical zones are climatic, that is, high temperatures and absence of winter frost, and economic, that is, lower levels of income. The causes and presentation of tropical AKI reflect these prevailing cultural, socioeconomic, climatic, and eco-biological characteristics.Peculiarities of tropical climate support the propagation of several infectious organisms that can cause AKI and the disease-transmitting vectors. In contrast to the developed world, where AKI usually develops in already hospitalized patients with multiorgan problems and iatrogenic factors play a major role, tropical AKI is acquired in the community due to issues of public health importance such as safe water, sanitation, infection control, and good obstetric practices. Infections such as malaria, leptospirosis, typhus, HIV, and diarrhoeal diseases; envenomation by animals or insects; ingestion of toxic herbs or chemicals; intravascular haemolysis; poisoning; and obstetric complications form the bulk of AKI in the tropics. Poor access to modern medical facilities and practices such as seeking treatment from traditional faith-healers contribute to poor outcomes.AKI extracts macro- and microeconomic costs from the affected population and reduces productivity. Improvement in the outcomes of tropical AKI requires improvement in basic public health through effective interventions, and accessibility to effective medical care.
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Shaibani, Aziz. Pseudoneurologic Syndromes. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190661304.003.0022.
Full textAbstract:
The term functional has almost replaced psychogenic in the neuromuscular literature for two reasons. It implies a disturbance of function, not structural damage; therefore, it defies laboratory testing such as MRIS, electromyography (EMG), and nerve conduction study (NCS). It is convenient to draw a parallel to the patients between migraine and brain tumors, as both cause headache, but brain MRI is negative in the former without minimizing the suffering of the patient. It is a “software” and not a “hardware” problem. It avoids irritating the patient by misunderstanding the word psychogenic which to many means “madness.”The cause of this functional impairment may fall into one of the following categories:• Conversion reaction: conversion of psychological stress to physical symptoms. This may include paralysis, hemisensory or distal sensory loss, or conversion spasms. It affects younger age groups.• Somatization: chronic multiple physical and cognitive symptoms due to chronic stress. It affects older age groups.• Factions disorder: induced real physical symptoms due to the need to be cared for, such as injecting oneself with insulin to produce hypoglycemia.• Hypochondriasis: overconcern about body functions such as suspicion of ALS due to the presence of rare fasciclutations that are normal during stress and after ingestion of a large amount of coffee. Medical students in particular are targets for this disorder.The following points are to be made on this topic. FNMD should be diagnosed by neuromuscular specialists who are trained to recognize actual syndrome whether typical or atypical. Presentations that fall out of the recognition pattern of a neuromuscular specialist, after the investigations are negative, they should be considered as FNMDs. Sometimes serial examinations are useful to confirm this suspicion. Psychatrists or psychologists are to be consulted to formulate a plan to discover the underlying stress and to treat any associated psychiatric disorder or psychological aberration. Most patients think that they are stressed due to the illness and they fail to connect the neuromuscular manifestations and the underlying stress. They offer shop around due to lack of satisfaction, especially those with somatization disorders. Some patients learn how to imitate certain conditions well, and they can deceive health care professionals. EMG and NCS are invaluable in revealing FNMD. A normal needle EMG of a weak muscles mostly indicates a central etiology (organic or functional). Normal sensory responses of a severely numb limb mean that a lesion is preganglionic (like roots avulsion, CISP, etc.) or the cause is central (a doral column lesion or functional). Management of FNMD is difficult, and many patients end up being chronic cases that wander into clinics and hospitals seeking solutions and exhausting the health care system with unnecessary expenses.It is time for these disorders to be studied in detail and be classified and have criteria set for their diagnosis so that they will not remain diagnosed only by exclusion. This chapter will describe some examples of these disorders. A video clip can tell the story better than many pages of writing. Improvement of digital cameras and electronic media has improved the diagnosis of these conditions, and it is advisable that patients record some of their symptoms when they happen. It is not uncommon for some Neuromuscular disorders (NMDs), such as myasthenia gravis (MG), small fiber neuropathy, and CISP, to be diagnosed as functional due to the lack of solid physical findings during the time of the examination. Therefore, a neuromuscular evaluation is important before these disorders are labeled as such. Some patients have genuine NMDs, but the majority of their symptoms are related to what Joseph Marsden called “sickness behavior.” A patient with carpal tunnel syndrome (CTS) may unconsciously develop numbness of the entire side of the body because he thinks that he may have a stroke.