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1
Van den Bosch, Filip. Extra-articular, extra-skin disease. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198737582.003.0014.
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Psoriatic disease is a multisystem disorder that affects skin and nails. Besides arthritis and spondylitis, involvement of other organ systems occurs in a significant proportion of patients. Within these extra-articular, extra-skin manifestations, eye and gut disease occupy an important place since they are linked in a bi-directional way: eye inflammation and bowel disease occur more frequently in patients with psoriasis and psoriatic arthritis, but there is also an increased prevalence of psoriasis in patients with uveitis or inflammatory bowel disease. In this chapter, we will focus primarily on spondyloarthritis concept-related extra-articular, extra-skin manifestations, such as uveitis, Crohn’s disease, and ulcerative colitis: prevalence, clinical presentation, and therapeutic consequences are discussed.
2
Tasse, Jordan C., and Bulent Arslan. Management of Acute Iliocaval Thrombosis. Edited by S. Lowell Kahn, Bulent Arslan, and Abdulrahman Masrani. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199986071.003.0035.
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Acute deep vein thrombosis (DVT) occurs in approximately 300,000 people per year in the United States. Iliocaval thrombosis is most commonly related to the progression of lower extremity DVT. Inferior vena cava (IVC) thrombosis occurs in approximately 4–15% of patients with acute DVT. Vena cava thrombosis is frequently associated with neoplastic disease. Foreign body placement such as an IVC filter or a venous catheter is a frequently reported cause of iliocaval thrombosis. External compression due to right common iliac artery mass effect (May–Thurner syndrome), tumor, lymphadenopathy, or aortic aneurysm are also commonly seen. This chapter discusses the interventional measures to manage acute iliocaval thrombosis.
3
Merino, Esperanza, and Eliseo Pascual. Brucellar arthritis. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199642489.003.0104.
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Joint infection is the most common local complication of brucellosis and is a frequent cause of infectious arthritis in endemic areas. Brucellosis is prevalent in countries of the Mediterranean basin, the Near East, South America, and possibly sub-Saharan Africa. Brucella melitensis and B. abortus are the most common species. Arthralgia occurs in 70% of patients with brucellosis, Large peripheral joints are a common site of localized infection. The sacroiliac joint is frequently involved (30–75%) in recent series. First-line treatment is with doxycycline combined with either streptomycin or gentamycin.
4
Karlberg, Helena. Craniosynostosis Repair. Edited by Erin S. Williams, Olutoyin A. Olutoye, Catherine P. Seipel, and Titilopemi A. O. Aina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190678333.003.0023.
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Craniosynostosis is the fusion of one or more cranial sutures; such fusion occurs due to multiple factors and typically occurs in utero. Depending on the sutures involved, the infant can have significant abnormalities in skull shape. The structural abnormality is corrected surgically, frequently after a series of operations starting from infancy and occurring even late in childhood, depending on the sutures that are fused. During these surgeries, an infant can lose substantial volumes of blood, increasing the risk of hypovolemia and venous air embolism. It is imperative for the pediatric anesthesiologist to employ various modalities to minimize blood loss and also recognize clinical signs indicating the need for transfusion.
5
Thomas, Daniel Rh. Other bacterial diseasesPasteurellosis. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780198570028.003.0021.
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Pasteurellosis is a zoonosis that occurs worldwide, caused by bacteria of the genus Pasteurella, and other related organisms. Pasteurellosis reported in humans is most frequently caused by the species Pasteurella multocida. In humans, cutaneous infection is most common, but more severe outcomes have been reported, particularly in those with underlying chronic disease. Infection in animals is usually subclinical, but may give rise to a range of clinical symptoms, depending on the host species. Disease in animals usually occurs as a consequence of stress such as overcrowding, chilling, transportation, or as a result of a concurrent infection. In animals, pasteurellosis is known as: shipping fever or pneumonia, transport or transit fever, stockyard pneumonia, bovine pneumonic pasteurellosis, haemorrhagic septicaemia, or avian, bird or fowl cholera. The pasteurella bacterium is commonly present in the mouth and gastrointestinal tract of a wide range of mammals. Transmission to humans occurs after bites, scratches, or licks from infected animals, most frequently from dogs or cats, although infection has been associated with other animals including: cows, pigs, hamsters and rabbits. However, not all patients report a history of direct animal contact. Infection may be prevented through the avoidance of animal bites and the prompt hygienic care of wounds. Health professionals should be aware of the risk of pasterurellosis in immunocompromised patients exposed to companion animals.
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West, Tyler R., and Kelly J. Baldwin. Spinal and Intracranial Epidural Abscess, and Subdural Empyema. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199937837.003.0151.
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A spinal epidural abscess is an infection that resides in the epidural space of the spinal canal, and most commonly occurs from hematogenous seeding or direct extension from adjacent structures. Normal skin flora such as Staphylococcus and Streptococcus spp are the most common organisms to cause an epidural abscess, typically when host immunity is compromised or due to barrier disruption. The clinical presentation is heterogeneous, but often will progress over time to spinal cord compression. Intracranial epidural abscess and subdural empyema occur within the skull and are frequently spread via direct extension of infections from contiguous structures or as complications from neurosurgical procedures. Prompt diagnosis and treatment is essential for improving morbidity and mortality.
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Emlet, Lillian L., and James M. Dargin. Airway Equipment (DRAFT). Edited by Raghavan Murugan and Joseph M. Darby. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190612474.003.0029.
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Patients frequently require airway management during rapid response team (RRT) activations. Airway management during RRT activations frequently occurs in locations that are not well equipped or prepared to perform airway procedures. Therefore, it is important that RRTs arrive with the proper equipment and medications to safely secure the airway whenever necessary. An “airway bag” that is stocked by a hospital’s central supply department and carried by RRTs ensures the availability of functioning equipment and helps to standardize the process of airway management during RRT activation. In this chapter, we will review recommendations for equipment required in emergency airway management, including portable routine and difficult airway equipment and medications.
8
Smedley, Julia, Finlay Dick, and Steven Sadhra. Gastrointestinal and urinary tract disorders. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199651627.003.0010.
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Hepatic angiosarcoma 264Hepatic cirrhosis 266Acute hepatotoxicity 268Gastrointestinal cancers 270Renal failure 272Bladder cancer 274This otherwise very rare hepatic cancer occurs among workers exposed to VCM and, less frequently, pesticide-exposed agricultural workers. Reactor (autoclave) cleaners may be highly exposed to VCM, a genotoxic carcinogen. When this association was first recognized, VCM production workers showed 400× expected incidence of hepatic angiosarcoma. However, owing to improved exposure control, the disease is now very rare in developed countries....
9
Gann, Kyle. The Human Faith Theme and the Whole-Tone Hypothesis. University of Illinois Press, 2018. http://dx.doi.org/10.5406/illinois/9780252040856.003.0003.
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The Concord Sonata is a cyclic work based on a theme that occurs in all four movements, known as the “Human Faith” theme. The appearances of this theme in various keys suggest an overarching harmonic structure based on the whole-tone scale, giving way frequently to an opposition between the keys of A and E-flat. A whole-tone scale plus one other note serves as an importance source-chord for the entire sonata.
10
van Prooijen, Jan-Willem. Origins of the Moral Punishment Instinct. Oxford University Press, 2018. http://dx.doi.org/10.1093/oso/9780190609979.003.0004.
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Third-party punishment occurs among insect species, cleaner fish, and non-human primates. This suggests that organisms do not need a sophisticated sense of morality to be punitive. Why, then, did humans evolve a moral punishment instinct? The main proposition of this chapter is that people evolved a sense of morality as a consequence of their punishment instincts. In ancestral groups of hunter-gatherers, punishment had genetic consequences, as it frequently meant death, exclusion, or unattractively low social standing. Punishment therefore has put social selection pressures on our ancestors to evolve intrinsic motivations to pursue the interests of the group. Furthermore, whereas punishment is frequently portrayed as costly, the chapter illuminates that punishers also reap important benefits: punishment can be a form of costly signaling, emphasizing punishers’ power, making them attractive mates.
11
Khanna, Puja. Treatment of acute gout. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0045.
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Acute gout is a common inflammatory arthritis in the adult population. Epidemiological evidence suggests that the prevalence of gout is steadily on the rise due to longevity, coexisting comorbidities, and iatrogenic causes contributing to hyperuricaemia. Acute gout usually presents as a self-limiting flare of synovitis that occurs due to deposition of monosodium urate crystals. The frequency of flares generally increases over time in patients who continue to have hyperuricaemia and their risk factors for acute gout attacks have not been adequately addressed. Effective treatment of acute gouty arthritis is primary focused on pain which is the primary symptom but must target both the pain and underlying inflammation. Acute gout is frequently treated with non-steroidal anti-inflammatory agents, colchicine, and corticosteroids. This chapter reviews the available therapies for management of acute gout and ones that have shown promising results.
12
Yager, Joel, Philip S. Mehler, Eileen D. Yager, and Alison R. Yager. Integrated Care for Binge Eating and Other Eating Disorders. Edited by Robert E. Feinstein, Joseph V. Connelly, and Marilyn S. Feinstein. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190276201.003.0015.
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Binge eating disorder, bulimia nervosa, and anorexia nervosa, particularly milder cases, often go unrecognized and untreated in primary care practice settings. Eating disorders are frequently associated with shame, and masked by other prominent physical and psychiatric conditions that demand attention. Among adults, binge eating disorder, the most prevalent of the eating disorders, occurs with increasing frequency, in tandem with higher rates and degrees of obesity, across all age ranges, and in both genders. Bulimia nervosa and anorexia nervosa are more common in females, and although they are most often seen in pediatric and adolescent medicine practices cases, they are also seen in adult practice populations. This chapter describes pathways by which primary care practices can implement integrated and collaborative care treatment programs, likely to benefit large numbers of patients, and effectively coordinate with specialist levels of care, as necessary.
13
Iung, Bernard. Epidemiology and physiopathology. Edited by Gilbert Habib. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0389.
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The incidence of infective endocarditis (IE) is estimated at between 15 and 60 cases per million inhabitants per year from population-based studies in industrialized countries. The presentation of IE has changed since patients are getting older and Staphylococcus is now becoming the microorganism most frequently responsible, which is partly attributable to healthcare-associated infections. The incidence of IE is higher in patients with heart valve prosthesis, previous endocarditis, and complex congenital heart disease. In developing countries, IE occurs in younger patients with a majority of rheumatic valve disease and is most frequently due to streptococci. IE is the consequence of bacteraemia on a diseased native valve or foreign material, leading to vegetation or tissue destruction, or both of these. The main consequences of these lesions are heart failure due to valvular regurgitation, embolic events due to vegetation migration, and perivalvular abscesses.
14
Abhishek, Abhishek, and Michael Doherty. Clinical features of calcium pyrophosphate crystal deposition. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0050.
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Calcium pyrophosphate deposition (CPPD) occurs in the elderly, and is commonly asymptomatic. However, it can cause acute calcium pyrophosphate (CPP) crystal arthritis, chronic CPP crystal inflammatory arthritis, and is frequently present in joints with osteoarthritis (OA). Acute CPP crystal arthritis presents with rapid onset of acute synovitis, which frequently affects the knees, wrists, shoulders, and elbows. It can mimic sepsis in the elderly, and may require hospital admission. Patients with CPPD plus OA may have more inflammatory signs and symptoms (e.g. joint swelling, stiffness) than those with OA alone. Additionally, patients with CPPD plus OA may also have intermittent attacks of acute CPP crystal arthritis. Some patients with CPPD may have more chronic inflammatory joint involvement and are classified as chronic CPP crystal inflammatory arthritis. This chapter describes the clinical features and differential diagnosis of common clinical manifestations of CPPD and outlines some of its rarer manifestations.
15
Sklar, Marisa, Joanna C. Moullin, and Gregory A. Aarons. Study Design, Data Collection, and Analysis in Implementation Science. Edited by David A. Chambers, Wynne E. Norton, and Cynthia A. Vinson. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190647421.003.0006.
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This chapter provides an introduction to study design, data collection, and analysis in implementation science. Although the randomized controlled trial is frequently employed in implementation science, a number of alternatives are relied on for addressing the unique challenges present. Alternatives include the cluster randomized control trial, roll-out designs such as the stepped wedge, cumulative trial, and effectiveness–implementation hybrid designs. Data collection and data analytic techniques must also address the unique challenges present in implementation science. Often, implementation occurs over time, often, across complex, multilevel contexts. Implementation scientists frequently utilize mixed, qualitative, and quantitative methodologies for collecting, analyzing, and interpreting data. Data represent the outer context of service systems and the inner context of organizations such that the data are often nested and hierarchical in nature. This chapter highlights the previously mentioned topics, particularly as they relate to currently funded implementation studies focused on the cancer control continuum.
16
Riedl, Rachel. Political Parties, Regimes, and Social Cleavages. Edited by Orfeo Fioretos, Tulia G. Falleti, and Adam Sheingate. Oxford University Press, 2016. http://dx.doi.org/10.1093/oxfordhb/9780199662814.013.13.
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Historical institutionalism is central to the study of political parties because party creation, competition, and adaptation are fundamentally processes structured over time. In these processes, time and sequence frequently are necessary components of causal arguments in understanding contemporary political outcomes. An historical approach to party politics highlights how, in particular moments, agency and contingency can generate long-term legacies, whereas in other moments party systems are resilient to elite attempts to re-order competition. Historical institutionalist arguments identify the mechanisms that sustain particular outcomes over time, and demonstrate when change occurs, according to which constraints, opportunities, and antecedent conditions.
17
Abdulkader, Rita, and Richard A. Watts. Mycobacterial diseases. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199642489.003.0103.
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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.
18
Whitney, Laura, and Tihana Bicanic. Antifungal stewardship. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198758792.003.0016.
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Although the principles of antifungal stewardship are similar to those of antibiotic stewardship, there are a number of key differences, as outlined in this chapter. Antifungal prescribing occupies a specialist niche: it occurs much less frequently than antibacterial prescribing due to the smaller, but increasing, population at risk of fungal infection. Antifungal stewardship is thus less established compared with programmes directed at antibacterials, with a narrower and more complex evidence base. This chapter provides examples of successful stewardship programmes in different settings, allowing readers to understand the challenges of antifungal stewardship and how to address these and enabling them to build a successful stewardship programme at their own institution.
19
Keegan, James, and Charles D. Deakin. Pathophysiology and management of anaphylaxis in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0314.
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Anaphylaxis is a severe life-threatening systemic hypersensitivity reaction, which occurs in approximately 10–20 per 100,000 population per annum, and accounts for 0.3% of adult critical care admissions. Anaphylaxis most commonly results from an exaggerated immune reaction to foreign antigens, prompting release of vasoactive substances from mast cells. A broad range of agents including foods, insect stings, latex, and drugs can trigger anaphylaxis. Common food allergens include nuts, shellfish, milk, and eggs. The most frequently implicated drugs include neuromuscular blocking agents (NMBAs) and antibiotics. The clinical features of anaphylaxis are variable and may occur together or in isolation. Epinephrine is the primary treatment for anaphylaxis, administered via the intramuscular route. Measurement of mast cell tryptase is essential for the diagnosis of anaphylaxis. Samples should be taken immediately, at 1–2 hours, and at 24 hours after the onset of symptoms. Investigations should be directed at identification of the trigger agent, and patients should be provided with information to enable them to avoid probable triggers and recognize future episodes.
20
Wise, Matt, and Paul Frost. ICU treatment of acute kidney injury. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0151.
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Traditionally, the etiology of acute kidney injury (AKI) is considered in terms of prerenal, renal, and obstructive causes. However, this categorization is less useful in the ICU, where the etiology of AKI is usually multifactorial and often occurs in the context of multi-organ failure. Hypotension, nephrotoxic drugs, and severe sepsis or septic shock are the most important identifiable factors. Less frequently encountered causes include pancreatitis, abdominal compartment syndrome, and rhabdomyolysis. Primary intrinsic renal disease such as glomerulonephritis is extremely uncommon. A previous history of cirrhosis, cardiac failure, or haematological malignancy, and age >65 years, are important risk factors. This chapter covers symptoms, complications, diagnosis, investigations, prognosis, and treatment of renal failure in the ITU.
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Kingeter, Adam J., and Bantayehu Sileshi. Aortic Disruption. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0006.
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This chapter covers the mechanism, classification, presenting signs, and basic principles of management for aortic dissection. Aortic disruption occurs when a tear develops in the aortic intima with passage of blood into the new space between the intima and media. A hypothetical patient presenting with signs of dissection is presented first, followed by sections covering classification systems of dissection, risk factors for dissection, and basic principles of management. Acute stabilization, diagnostic imaging, definitive management, and long-term follow up of patient management are discussed. In addition the dissection location and its implication on principles of management and outcome are covered. The chapter concludes with some discussion questions covering frequently encountered aspects of management touched on in the chapter.
22
Krel, Regina, and Paul G. Mathew. Headache. Edited by Angela O’Neal. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190609917.003.0003.
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Migraine is a common disorder that affects women of menstruating age, and it is frequently the chief complaint of women presenting in the neurology clinic. The prevalence of menstrually related migraine can range from 20–60%, while pure menstrual migraine occurs in less than 10% of women. In addition to utilizing non–gender-specific abortive and preventative strategies, understanding migraine and its relationship to hormones, particularly estrogen, can have clinical implications for optimal treatment. This chapter seeks to provide insight into diagnosing menstrually related migraine, the role of decreased estrogen just prior to menstrual cycle onset and migraine, as well as the therapeutic options that are available to treat and possibly prevent menstrual migraine attacks.
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Waters, Janet. Weakness in the Hand of a Woman During Pregnancy. Edited by Angela O’Neal. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190609917.003.0023.
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Carpal tunnel syndrome is the most common neuropathy experienced by pregnant women. It has an incidence of 3.4% in the general population in the United States. It occurs more frequently in pregnant women than in the general population, with an incidence of 17%. It is the most common mononeuropathy in pregnant women. This chapter covers the symptoms and signs that allow a clinician to make the diagnosis of carpal tunnel syndrome. Neuroanatomy and physiological changes that predispose pregnant women to this disorder are described. Management and prognosis of carpal tunnel syndrome in pregnancy are discussed: conservative management with wrist splints worn at night is effective in over 80% of patients. Local steroid injections can provide relief in patients with severe symptoms.
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Finfer, Simon, and Oliver Flower. Assessment and immediate management of spinal cord injury. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0344.
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Spinal cord injury is a potentially devastating injury, which may occur in isolation, but more commonly occurs in the setting of multiple injuries. Motor vehicle accidents and falls are the most common causes. Depending on the level of the injury and its completeness, patients may be left with paraplegia or tetraplegia. The injury may be immediately obvious based on history and clinical examination, but may have to be actively excluded in multiply-injured patients. Thoracolumbar spine fractures are almost always evident on plain X-rays, whereas computed tomography (CT) or magnetic resonance imaging (MRI) is frequently required to exclude cervical spine injuries. Immediate management should be directed at the detection and treatment of life-threatening injuries. Patients should be transferred to a facility specializing in the management of spinal cord injury as soon as feasible. Acute management of the spinal injury itself is largely supportive and aimed at avoiding preventable secondary injury. Respiratory complications are common, and high thoracic or cervical injuries may lead to neurogenic shock. Early identification of the injury and appropriate management results in improved outcome, reducing disability and costs of long-term management.
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Klyce, Daniel W., and James C. Jackson. Affective and mood disorders after critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0383.
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Survivors of critical illness frequently have significant and persistent mental health problems, which may develop or worsen following intensive care unit (ICU) admission. Chief among these problems is depression, which occurs in approximately a third of all individuals after critical illness and is associated with a wide array of untoward outcomes. Depression is manifest in a diversity of ways and risk factors may contribute to significant depressive symptoms after critical. Questions persist about whether treatment of depression after critical illness is most effective using conventional approaches or whether the depressive symptoms observed in ICU survivors may be clinically distinct and may optimally respond to carefully tailored innovative approaches. One promising strategy for managing the mental health needs of patients after critical illness involves ICU recovery clinics, which target the unique constellation of cognitive, psychiatric, and functional challenges common to survivors of critical illness.
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Fink, John K. Upper Motor Neuron Disorders. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199937837.003.0031.
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Symptomatic disturbance of corticospinal and corticobulbar tracts (collectively, the upper motor neuron UMN) occurs in innumerable acquired central nervous system disorders including the consequences of trauma, hypoxia-ischemia, inflammation (e.g. multiple sclerosis), toxins (e.g. thiocyanate1 and specific organophosphorus compound toxicity2) and deficiencies (e.g. hypocupremia3 and vitamin B12 deficiency). Variable degrees of UMN disturbance frequently accompany degenerative disorders in which disturbance of another neurologic system results in the primary clinical. Neuropathologic studies have shown prominent axon degeneration involving corticospinal tracts (HSP and PLS) and corticobulbar tracts (PLS); and mildly affecting dorsal columns (HSP and PLS to some degree). Myelin loss is considered secondary to axon degeneration. Loss of cortical motor neurons is observed in PLS. Anterior horn cells are typically spared in both HSP and PLS. Presently, treatment for HSP and PLS is symptomatic and includes physical therapy and spasticity reducing medications.
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Gibson, K. Michael, Cornelis Jakobs, and Philip L. Pearl. Succinic Semialdehyde Dehydrogenase Deficiency. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199972135.003.0029.
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Succinic semialdehyde dehydrogenase (SSADH) deficiency presents with intellectual disability, disproportionate deficit in expressive language, hypotonia, ataxia, and seizures.1,2 (1 Pearl et al 2011; 2 Vogel et al 2012). A diagnosis of autism spectrum disorder frequently occurs, correlated with neuropsychiatric morbidity (ADHD, OCD, PDD). 1,3 The biochemical hallmark, γ-hydroxybutyric acid (GHB), is elevated in physiological fluids, as is γ-aminobutyrate (GABA) in cerebrospinal fluid (CSF).4,5 Both species are neuroactive. Clinical manifestations are universally present in early childhood, although diagnosis delayed to adulthood has been reported.6 Acute decompensation or complications relate primarily to seizures, intercurrent illnesses sometimes associated with respiratory dysfunction in the setting of hypotonia, or adverse medication responses. Diagnostic confirmation requires urine organic acid analysis (increased GHB) with confirmation via enzyme assay (white cells) and/or molecular characterization of the aldehyde dehydrogenase 5a1 (ALDH5A1) gene.
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Abnet, Christian C., Olof Nyrén, and Hans-Olov Adami. Esophageal Cancer. Oxford University Press, 2018. http://dx.doi.org/10.1093/oso/9780190676827.003.0009.
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Esophageal cancer shows distinct geographic distributions, changing incidence rates, and primary risk factors when examined separately as squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma remains the dominant histologic type in many low- and middle-income countries and occurs frequently, while adenocarcinoma is classified as rare but predominates in Western countries. Tobacco and alcohol are the dominant risk factors for squamous cell carcinoma in Western countries, but not in high-incidence Asian populations, where hot beverages and specific nutritional deficiencies may be important. For adenocarcinoma, tobacco use is causal while alcoholic beverages are not. Rather, obesity and gastroesophageal reflux disease are the other dominant identified risk factors. Genetic predisposing factors and somatic mutations are also cell type specific. The differences in esophageal cancer incidence within and between countries, by sex and race, and in known risk factors suggest major strides in understanding the etiology of esophageal cancer is within reach.
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Ritchie, James, Darren Green, Constantina Chrysochou, and Philip A. Kalra. Renal artery stenosis. Edited by Neil Turner. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0213.
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Renovascular disease refers to a narrowing of a main or branch renal artery. Consequences include loss of functional renal tissue and renovascular hypertension, with other manifestations depending on the underlying cause. Worldwide the most common cause is atherosclerotic narrowing, with other causal pathologies including fibromuscular disease (FMD) and inflammatory conditions. FMD occurs much more frequently in women than in men, and is associated with smoking but genetic predisposing factors are also suspected. In South East Asia, Takayasu arteritis is an important cause.Takayasu disease often presents in a non-specific syndromic manner with fatigue and malaise. FMD often presents with early-onset hypertension. Atherosclerotic renal artery stenosis is often clinically silent with suspicion raised due to the existence of other cardiovascular pathology with the more dramatic presentations of acute decompensated heart failure or acute kidney injury less common. Clinical criteria can identify patients at risk.
30
Hanschel, Dirk. Enforcement of Federal Law against the German Länder. Oxford University Press, 2017. http://dx.doi.org/10.1093/acprof:oso/9780198746560.003.0016.
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This chapter examines the various legal and political means of federal law enforcement by Germany’s Federal Government and by the Federal Constitutional Court. This is understood as a form of resolution of vertical power conflicts within federations. While by its nature the main focus of this chapter lies on the legal means of federal law enforcement within the context of the notion of executive federalism, it also devotes some attention to the political dimension. Since German federalism is strongly based on consensus and cooperation, this dimension is very important in practice. Where antagonism between the Federation and the Länder occurs (whether expressed in political or legal terms), it is frequently either motivated by party politics or triggered by matters where specific subnational interests are at stake. Apart from negotiation, adjudication by the Constitutional Court is one of the key instruments to deal with that.
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Gordon, Caroline, and S. Sam Lim. Epidemiology of systemic lupus erythematosus. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198739180.003.0003.
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This chapter looks at the epidemiology of lupus—this disease is more common than is generally recognized and occurs most frequently in women. There is a significantly higher risk of developing lupus in people of African, Hispanic, and Asian (especially Chinese) descent, with increased incidence and prevalence in some other ethnic minority races. They appear to develop a more severe phenotype, often with renal involvement and at an earlier age than white people of North European descent. Although deaths due to lupus are now less common in North American and European countries, deaths due to renal lupus remain a significant problem in the ethnic minorities. Management should target reducing factors that increase the risk of lupus disease activity, damage, and mortality. Raising awareness of lupus, leading to early diagnosis and institution of appropriate therapy to reduce disease activity, will reduce chronic damage and the associated risk of subsequent premature death.
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Shahane, Shantanu. Osteoarthritis of the elbow joint. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199550647.003.005.005.
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♦ Symptomatic, primary osteoarthritis of the elbow usually occurs in young men involved in heavy manual labour.♦ Common causes of secondary osteoarthritis of the elbow are trauma, infection, bleeding disorders and neuropathic conditions.♦ Clinically, the commonest presenting symptom is loss of motion. Patients can also complain of pain, locking and ulnar nerve symptoms.♦ Plain X-rays are usually sufficient for diagnosis. They show reduction in joint space and osteophytes at the tip of olecranon and coronoid processes. Loose bodies are also frequently seen.♦ Symptoms in early stages of arthritis are controlled by nonoperative means. Steroids are rarely used in clinical practice.♦ In advanced cases, numerous operative treatments including arthroscopic and open procedures are available.♦ Total Elbow replacement (TER) for primary degenerative arthritis of the elbow is only to be considered as the last option and when stringent pre and post-operative requirements are followed.
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Duffield, Jeremy S. Disordered scarring and failure of repair. Edited by David J. Goldsmith. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0140.
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Scarring is the name given to fibrous tissue accumulation in the skin, which, when it forms elsewhere, is known as fibrosis, but the terms are frequently used interchangeably. The scientific study of fibrosis or scarring was established and developed in skin wounding, as a part of the normal repair response, long before it was appreciated that pathological fibrosis or scarring occurs as a consequence of sustained or iterative injury to internal organs. Increasing experimental evidence indicates that the process of skin wounding with scarring is very similar to the process of organ injury with fibrosis detected in vital organs including the kidney. Kidney fibrosis develops in glomeruli, where it is known as glomerulosclerosis (literally hardening of glomeruli due to fibrotic tissue), or in the interstitial virtual space between tubules and peritubular capillaries, known as interstitial fibrosis. Increasingly fibrosis of the kidney and the cells that make fibrous tissue are seen as targets for therapeutic intervention in chronic diseases of the kidney.
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Peris, Tara S., and John Piacentini. Helping Families Manage Childhood OCD. Oxford University Press, 2016. http://dx.doi.org/10.1093/med:psych/9780199357604.001.0001.
Full textAbstract:
Childhood obsessive compulsive disorder (OCD) is a complex condition that is often accompanied by high levels of family stress and strain. Families of youth with OCD face a unique set of difficulties in that they often are intimately involved in their children’s symptoms. This pattern of responding to OCD, frequently referred to as accommodation, comes in many forms, and for most families, it occurs daily. Research suggests that accommodation is accompanied by increased levels of family distress, anxiety, and conflict, which, when high enough, can undermine successful OCD treatment. Although evidence-based treatments exist for childhood OCD, few protocols offer strategies for treating these more complex family presentations. This program offers an empirically supported approach for managing childhood OCD complicated by poor family functioning. It identifies specific family features that may contribute to treatment nonresponse in childhood OCD, and provides clinicians with an innovative set of strategies for addressing them. By focusing on emotion-regulation strategies and family-problem-solving exercises, families learn to troubleshoot difficult OCD episodes in an effective and supportive manner.
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Krzych, Scott. Beyond Bias. Oxford University Press, 2021. http://dx.doi.org/10.1093/oso/9780197551219.001.0001.
Full textAbstract:
“Bias” is a term that circulates frequently in the contemporary landscape of political media, a term intended to diagnose a failure when media outlets fail to maintain journalistic objectivity. Beyond Bias interrogates what would seem, at first glance, to be examples of utterly biased political media—contemporary conservative documentary films. However, rather than dismiss such cases of political representation as exemplars of ideological nonsense, reactionary propaganda, and so on, Beyond Bias locates in conservative media a mode of discourse central to contemporary democratic debate in the United States. Specifically, this book identifies conservative media as a mode of hysterical discourse. As the book makes clear, hysterical political discourse occurs when debate is simulated as a means to avoid a more substantive exchange. Drawing from psychoanalytic theories of hysteria and aesthetic politics, and likewise by placing conservative documentaries in the context of many concerns central to Documentary Studies (participation, observation, representation, the archive, etc.), Beyond Bias views conservative documentary, and conservative media and politics more generally, not as the biased excesses of the contemporary political landscape but rather as texts central to understanding the implicit, though sometimes affectively traumatic, antagonisms inevitable in democracy and constitutive of democratic debate.
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Noris, Marina, and Tim Goodship. The patient with haemolytic uraemic syndrome/thrombotic thrombocytopenic purpura. Edited by Giuseppe Remuzzi. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0174.
Full textAbstract:
The patient who presents with microangiopathic haemolytic anaemia, thrombocytopenia, and evidence of acute kidney injury presents a diagnostic and management challenge. Haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are two of the conditions that frequently present with this triad. They are characterized by low platelet count with normal or near-normal coagulation tests, anaemia, and signs of intravascular red cell fragmentation on blood films, and high LDH levels.HUS associated with shiga-like toxins produced usually by E.coli (typically O157 strains) may occur in outbreaks or sporadically, with geographical variations in incidence. It is predominantly a disease of young children in which painful blood diarrhoea in a minority of infected patients is succeeded by microangiopathy and acute kidney injury. Management is supportive and recovery is usual, although permanent renal damage may lead to later deterioration. Older patients may be affected and tend to have worse outcomes. Neuraminidase-producing Streptococcus pneumoniae infections (usually pneumonia) very rarely cause a similar HUS.Atypical HUS occurs sporadically and is increasingly associated with defects in the regulation of the complement pathway, either genetic or autoimmune-caused. It may respond to plasma exchange for fresh frozen plasma. Recurrences are common, including after transplantation.TTP is associated with more neurological disease and less renal involvement, but HUS and TTP overlap substantially in their manifestations. The underlying problem is in von Willebrand factor (vWF) cleavage. The plasma metalloprotease ADAMTS13 is responsible for cleaving vWF multimers, a process that is important to prevent thrombosis in the microvasculature. Autoantibodies or rarely genetic deficiency may impair this process. Plasma exchange may remove antibodies and replenish the protease.
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Doris, John M., and Shaun Nichols. Broad-Minded: Sociality and the Cognitive Science of Morality. Edited by Eric Margolis, Richard Samuels, and Stephen P. Stich. Oxford University Press, 2012. http://dx.doi.org/10.1093/oxfordhb/9780195309799.013.0018.
Full textAbstract:
The article gives an overview on the concept of individualism in cognitive science. Individualism maintains that optimal human reasoning is substantially asocial, and therefore implies that sociality does not facilitate, and may impede, reasoning. The cognitive science of morality very frequently proceeds with individualist assumptions. The individualist may allow that normal development requires sociality, but deny that optimal reasoning in mature individuals requires it. The optimal cognitive functioning is both developed and sustained through sociality. The optimal exercise of rationality is a socially embedded process. It means that sociality is not just a precondition of rationality, but that even among those with normal cognitive functioning, the optimal exercise of rationality typically occurs as part of a social process. The sociality has a significant role in substantial cognitive achievement, such as scientific and technological discovery. A large body of research indicates that motivation plays a crucial role in reasoning. The optimal human reasoning is substantially asocial, and sociality is necessary for the development of optimal reasoning. The sociality is necessary for the sustenance of optimal reasoning, and for the transmission of information. One important feature of group interactions is that they are likely to induce emotional responses. Many familiar emotions such as anger, guilt, and sympathy are characteristically triggered by cues in social interaction.
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Kuypers, Dirk R. J., and Morie A. Gertz. Light-chain deposition disease. Edited by Giuseppe Remuzzi. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199592548.003.0154_update_001.
Full textAbstract:
Light-chain deposition disease (LCDD) is characterized by extracellular tissue deposition of non-amyloid monoclonal immunoglobulin light chains (predominantly kappa light chains) in various organs including kidneys, heart, and liver. It is a rare cause of renal insufficiency. In two-thirds of cases it is associated with multiple myeloma, while in the remainder their monoclonal B cell proliferation does not meet the criteria for that diagnosis.Renal involvement occurs almost invariably and dominates the clinical course of the disease: greater than 90% of patients with LCDD have renal functional impairment; acute or rapidly progressive kidney failure usually develops over a period of months. Nephrotic-range proteinuria is present in 40–50% of patients while approximately 20% of patients develop nephrotic syndrome. Arterial hypertension and microscopic haematuria can be present. Extrarenal symptoms are related to affected organs with cardiomyopathy, cachexia, haemorrhages, infections, and MM progression as main causes of death.The diagnosis of LCDD is often delayed and whilst bone marrow examination will often identify associated MM, renal biopsy frequently provides the final diagnostic proof. Abnormal light chains can be detected and quantified by serum or urine protein electrophoresis and immunofixation. Quantification of urine and serum free kappa/lambda light chains has proven a useful screening tool and might also plays a role in therapeutic monitoring.Treatment consists of chemotherapy directed against the monoclonal immunoglobulin-producing plasma cells.
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Price, Elizabeth J., and Anwar R. Tappuni, eds. Oxford Textbook of Sjögren's Syndrome. Oxford University Press, 2021. http://dx.doi.org/10.1093/med/9780198806684.001.0001.
Full textAbstract:
The Oxford Textbook of Sjögren’s Syndrome is an authoritative textbook, rich with valuable illustrations and figures, providing a practical guide to diagnosing and managing all aspects of this condition. Sjögren’s syndrome is a chronic, immune-mediated condition typically presenting in women in their fifth or sixth decade. With increased awareness and improvement in diagnostic tests, younger women and occasionally men are now being diagnosed with this condition. Frequently, Sjögren’s syndrome occurs in association with other autoimmune diseases, usually rheumatoid arthritis, systemic lupus erythematosus, or scleroderma. The hallmark of this condition is dryness of the eyes and mouth, but many patients have systemic effects that can be debilitating, including fatigue, peripheral neuropathy, and lung damage. It has potentially serious long-term complications, including a higher risk of developing lymphoma and foetal congenital heart block. Diagnosis of the condition can be challenging as the presenting symptoms are variable. Management of the condition can be complex as the course of the disease is unpredictable and the available therapy is mainly symptomatic, with no known cure as yet. Experts in the condition from around the world have contributed to this book to provide the most up-to-date information on pathophysiology, classification criteria, diagnostic tests, systemic manifestations of the disease, and emerging therapeutic options. The publication of this book coincides with a period of increased interest in Sjögren’s within the scientific, medical, and pharmacological worlds.
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Chapman, Rachel, and Stefano Sabato. Massive Transfusion in a Child. Edited by Erin S. Williams, Olutoyin A. Olutoye, Catherine P. Seipel, and Titilopemi A. O. Aina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190678333.003.0020.
Full textAbstract:
Massive transfusion in a child is likely to occur in cases of trauma or during surgeries that are at risk for severe blood loss such as liver transplantation and craniofacial procedures. It may also occur when least expected, if inadvertent injury to a vascular structure occurs during surgery. Ability to enlist assistance with administration of the various blood products required and also with checking frequent laboratory results will facilitate the process. Knowledge of the different factors that rapidly become depleted as well as lab values that need to be closely monitored is necessary to avoid further complications during massive blood transfusion.
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Pipitone, Nicolò, Annibale Versari, and Carlo Salvarani. Large-vessel vasculitis. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199642489.003.0133.
Full textAbstract:
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.
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Pipitone, Nicolò, Annibale Versari, and Carlo Salvarani. Large-vessel vasculitis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199642489.003.0133_update_003.
Full textAbstract:
Large-vessel vasculitis includes giant cell arteritis (GCA) and Takayasu’s arteritis (TAK). GCA affects patients aged over 50, mainly of white European ethnicity. GCA occurs together with polymyalgia rheumatica (PMR) more frequently than expected by chance. In both conditions, females are affected two to three times more often than males. GCA mainly involves large- and medium-sized arteries, particularly the branches of the proximal aorta including the temporal arteries. Vasculitic involvement results in the typical manifestations of GCA including temporal headache, jaw claudication, and visual loss. A systemic inflammatory response and a marked response to glucocorticoids is characteristic of GCA. GCA usually remits within 6 months to 2 years from disease onset. However, some patients have a chronic-relapsing course and may require longstanding treatment. Mortality is not increased, but there is significant morbidity mainly related to chronic glucocorticoid use and cranial ischaemic events, especially visual loss. The diagnosis of GCA rests on the characteristic clinical features and raised inflammatory markers, but temporal artery biopsy remains the gold standard to support the clinical suspicion. Imaging techniques are also used to demonstrate large-vessel involvement in GCA. Glucocorticoids are the mainstay of treatment for GCA, but other therapeutic approaches have been proposed and novel ones are being developed. TAK mainly involves the aorta and its main branches. Women are particularly affected with a female:male ratio of 9:1. In most patients, age of onset is between 20 and 30 years. Early manifestations of TAK are non-specific and include constitutional and musculoskeletal symptoms. Later on, vascular complications become manifest. Most patients develop vessel stenoses, particularly in the branches of the aortic artery, leading to manifestations of vascular hypoperfusion. Aneurysms occur in a minority of cases. There are no specific laboratory tests to diagnose TAK, although most patients have raised inflammatory markers, therefore, imaging techniques are required to secure the diagnosis. Glucocorticoids are the mainstay of treatment of TAK. However, many patients have an insufficient response to glucocorticoids alone, or relapse when they are tapered or discontinued. Immunosuppressive agents and, in refractory cases, biological drugs can often attain disease control and prevent vascular complications. Revascularization procedures are required in patients with severe established stenoses or occlusions.
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Gotman, Jean, and Nathan E. Crone. High-Frequency EEG Activity. Edited by Donald L. Schomer and Fernando H. Lopes da Silva. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190228484.003.0033.
Full textAbstract:
Activities with frequencies between 60 and 80 Hz and approximately 500 Hz are labeled here as high-frequency activities. They were largely ignored until the beginning of the millennium, but their importance is now well recognized. They can be divided into activities occurring in the healthy brain in relation to sensory, motor, and cognitive or memory activity and activities occurring in the epileptic brain in the form of brief events (high-frequency oscillations), which appear to be an important marker of the brain regions that are able to generate seizures of focal origin. In humans, most of the work related to these activities has been done in intracerebral electrodes, where they are relatively frequent and easy to identify. They have been recorded in scalp electroencephalograms in some circumstances, however. This chapter reviews the recording methods, the circumstances in which they occur, their mechanism of generation, and their clinical significance.
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Sever, Mehmet Şükrü, and Raymond Vanholder. Acute kidney injury in polytrauma and rhabdomyolysis. Edited by Norbert Lameire. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199592548.003.0252_update_001.
Full textAbstract:
The term ‘polytrauma’ refers to blunt (or crush) trauma that involves multiple body regions or cavities, and compromises physiology to potentially cause dysfunction of uninjured organs. Polytrauma frequently affects muscles resulting in rhabdomyolysis. In daily life, it mostly occurs after motor vehicle accidents, influencing a limited number of patients; after mass disasters, however, thousands of polytrauma victims may present at once with only surgical features or with additional medical complications (crush syndrome). Among the medical complications, acute kidney injury (AKI) deserves special mention, since it is frequent and has a substantial impact on the ultimate outcome.Several factors play a role in the pathogenesis of polytrauma (or crush)-induced AKI: (1) hypoperfusion of the kidneys, (2) myoglobin-induced direct nephrotoxicity, and intratubular obstruction, and also (3) several other mechanisms (i.e. iron and free radical-induced damage, disseminated intravascular coagulation, and ischaemia reperfusion injury). Crush-related AKI is prerenal at the beginning; however, acute tubular necrosis may develop eventually. In patients with crush syndrome, apart from findings of trauma, clinical features may include (but are not limited to) hypotension, oliguria, brownish discoloration of urine, and other symptoms and findings, such as sepsis, acute respiratory distress syndrome, disseminated intravascular coagulation, bleeding, cardiac failure, arrhythmias, electrolyte disturbances, and also psychological trauma.In the biochemical evaluation, life-threatening hyperkalaemia, retention of uraemic toxins, high anion gap metabolic acidosis, elevated serum levels of myoglobin, and muscle enzymes are noted; creatine phosphokinase is very useful for diagnosing rhabdomyolysis.Early fluid administration is vital to prevent crush-related AKI; the rate of initial fluid volume should be 1000 mL/hour. Overall, 3–6 L are administered within a 6-hour period considering environmental, demographic and clinical features, and urinary response to fluids. In disaster circumstances, the preferred fluid formulation is isotonic saline because of its ready availability. Alkaline (bicarbonate-added) hypotonic saline may be more useful, especially in isolated cases not related to disaster, as it may prevent intratubular myoglobin, and uric acid plugs, metabolic acidosis, and also life-threatening hyperkalaemia.In the case of established acute tubular necrosis, dialysis support is life-saving. Although all types of dialysis techniques may be used, intermittent haemodialysis is the preferred modality because of medical and logistic advantages. Close follow-up and appropriate treatment improve mortality rates, which may be as low as 15–20% even in disaster circumstances. Polytrauma victims after mass disasters deserve special mention, because crush syndrome is the second most frequent cause of death after trauma. Chaos, overwhelming number of patients, and logistical drawbacks often result in delayed, and sometimes incorrect treatment. Medical and logistical disaster preparedness is useful to improve the ultimate outcome of disaster victims.
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Lambert, Heather. Urinary tract infection in infancy and childhood. Edited by Neil Sheerin. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199592548.003.0180_update_001.
Full textAbstract:
Urinary tract infection (UTI) in childhood is a common problem, which is frequently dismissed as trivial because most children with UTI have a good outcome. However, UTI is an important cause of acute illness in children and causes a considerable burden of ill health on children and families. In addition, UTI may be a marker of an underlying urinary tract abnormality. UTI in a few may cause significant long-term morbidity, renal scarring, hypertension, and renal impairment that may not present until adult life. Predicting which children will go on to have long-term sequelae remains a challenge.The risk of renal scarring is greatest in infants, the very group in whom diagnosis is often overlooked or delayed because clinical features are non-specific. Delay in treatment is associated with an increased risk of scarring in susceptible children. Thus accurate and rapid diagnosis of UTI is essential and requires a very high index of suspicion particularly in the youngest.The role of vesicoureteric reflux in acquired scarring is not fully understood though there is clearly an association, possibly because it is a risk factor for acute pyelonephritis. Scarring when it occurs is in the areas affected by acute pyelonephritis. Higher grades of reflux are associated with a worse outcome.Management and investigation of children with UTI consumes considerable healthcare resources. Limited understanding of the natural history and basic pathophysiology, variations in strategy with time and setting, and lack of evidence on long-term outcomes have resulted in considerable uncertainty. Some propose a minimal approach doing little investigation unless there is clear evidence for it; others favour an approach of continuation of current practice based on clinical experience until further evidence evolves. Some of the themes behind these controversies are explored.
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Scadding, John. Neuropathic pain. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780198569381.003.0386.
Full textAbstract:
Pain signalled by a normal sensory system, nociceptive pain, serves a vital protective function. The peripheral and central nervous somatosensory systems permit rapid localization and identification of the nature of painful stimuli, prior to appropriate action to minimize or avoid potentially tissue damaging events. A reduction or absence of pain resulting from neurological disease emphasizes the importance of this normal protective function of pain. For example, tissue destruction occurs frequently in peripheral nerve diseases which cause severe sensory loss such as leprosy, and in central disorders such as syringomyelia. Neuropathic pain results from damage to somatosensory pathways and serves no protective function. This chapter provides an overview of neuropathic pain, considering its context, clinical features, pathophysiology, and treatment.In the peripheral nervous system, neuropathic pain is caused by conditions affecting small nerve fibres, and in the central nervous system by lesions of the spinothalamic tract and thalamus, and rarely by subcortical and cortical lesions. The clinical feature common to virtually all conditions leading to the development of neuropathic pain is the perception of pain in an area of sensory impairment, an apparently paradoxical situation. The exception is trigeminal neuralgia.Neuropathic pain is heterogeneous clinically, aetiologically, and pathophysiologically. Within a given diagnostic category, whether defined clinically or aetiologically, there are wide variations in reports of pain by patients. This heterogeneity poses one of the greatest challenges in understanding the mechanisms of neuropathic pain. Knowledge of the pathophysiology is an obvious pre-requisite to the development of effective treatments. The goal of a pathophysiologically based understanding of the symptoms and signs of neuropathic pain is, of course, just such a rational and specific approach to treatment. While this is not yet achievable, clinical-pathophysiological correlations have led to some recent advances in treatment.
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Izzedine, Hassan, and Victor Gueutin. Drug-induced acute tubulointerstitial nephritis. Edited by Adrian Covic. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0084.
Full textAbstract:
Drug-induced acute tubulointerstitial nephritis (ATIN) is the most common aetiology of ATIN and a potentially correctable cause of acute kidney injury (AKI). An interval of 7–10 days typically exists between drug exposure and development of AKI, but this interval can be considerably shorter following re-challenge or markedly longer with certain drugs. It occurs in an idiosyncratic and non-dose-dependent manner. Antibiotics, NSAIDs, and proton pump inhibitors are the most frequently involved agents, but the list of drugs that can induce ATIN is continuously increasing. The mechanism of renal injury is postulated to involve cell-mediated immunity, supported by the observation that T cells are the predominant cell type comprising the interstitial infiltrate. A humoral response underlies rare cases of ATIN, in which a portion of a drug molecule (i.e. methicillin) may act as a hapten, bind to the tubular basement membrane (TBM), and elicit anti-TBM antibodies. The classic symptoms of fever, rash, and arthralgia may be absent in up to two-thirds of patients. Diagnostic studies, such as urine eosinophils and renal gallium-67 scanning provide only suggestive evidence. Renal biopsy remains the gold standard for diagnosis, but it may not be required in mild cases or when clinical improvement is rapid after removal of an offending medication. Pathologic findings include interstitial inflammation, oedema, and tubulitis. The time until removal of such agents and the severity of renal biopsy findings provide the best prognostic value for the return to baseline renal function. Poor prognostic indicators are the long duration of AKI (> 3 weeks), a patient’s advanced age, and the high degree of interstitial fibrosis. Early recognition and appropriate therapy are essential to the management of drug-induced ATIN, because patients can ultimately develop chronic kidney disease. The mainstay of therapy is timely discontinuation of the causative agent, whereas controversy persists about the role of steroids.
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Osman, Nadir I., and Christopher R. Chapple. Urinary fistula. Edited by Christopher R. Chapple. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199659579.003.0041.
Full textAbstract:
Genitourinary fistulae (GuF) are one of the oldest described causes of incontinence. They are associated with significant social and psychological debilitation. In developed countries, they most commonly occur after iatrogenic injury to the urinary tract during gynaecological surgery for benign conditions, whereas in developing countries the most common cause remains prolonged obstetric labour. The most frequent type of GuF occurs between the bladder and vagina. GuF require careful evaluation to confirm the diagnosis and assess the number, location, and anatomy of defects, as well as any associated injuries before operative management is undertaken. The surgical approach to each fistula is individualized and relies upon the use of healthy vascularized tissue to repair defects, preferably with interposition of a tissue flap to augment repairs.
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Raza, Karim, Caroline Cardy, and Elizabeth Justice. Rheumatoid arthritis. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0267.
Full textAbstract:
Rheumatoid arthritis is a chronic systemic inflammatory disorder. It is characterized by inflammation of the synovium with consequent cartilage and bone destruction. Extra-articular manifestations frequently occur.
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Balboni, Michael J., and Tracy A. Balboni. The Frequency of Spiritual Care at the End of Life. Edited by Michael J. Balboni and Tracy A. Balboni. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199325764.003.0004.
Full textAbstract:
Data suggest that clinicians infrequently provide spiritual care within life-threatening illness, at least within the perspective of patients’ accounts. Boston patients indicate that 13% of patient–nurse relationships and 6% of patient–physician relationships at any point in their clinical relationship entailed a spiritual care encounter. Nurses and physicians perceive spiritual care to be a more frequent occurrence. The gap in perception that exists may partially be due to underlying religious demographic differences between patients, nurses, and physicians. While most patients experience illness as a spiritual event, and there are notable medical outcomes and growing national guidelines calling for clinician spiritual care, by most accounts, including nurses and physicians, spiritual care seldom occurs. Questions arise regarding why physicians neglect or avoid providing spiritual care in serious illness.