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1
Sourati, Ainaz, Ahmad Ameri, and Mona Malekzadeh. Acute Side Effects of Radiation Therapy. Cham: Springer International Publishing, 2017. http://dx.doi.org/10.1007/978-3-319-55950-6.
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Hinkelbein, Wolfgang, Gregor Bruggmoser, Hermann Frommhold, and Michael Wannenmacher, eds. Acute and Long-Term Side-Effects of Radiotherapy. Berlin, Heidelberg: Springer Berlin Heidelberg, 1993. http://dx.doi.org/10.1007/978-3-642-84892-6.
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Bruneau, William. A User's Guide to Sida acuta, Sida cordifolia, and Sida rhombifolia : : How to Grow, Harvest, and Make Medicinals from the World's Best Herbal ... Superior Fiber, Grow Them with Your Tomatoes. CreateSpace Independent Publishing Platform, 2018.
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4
Wagg, Adrian, and Shashi Gadgil. Acute pain in the elderly. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199234721.003.0011.
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Physiological changes that occur with age affect the pharmacokinetics and pharmacodynamics of drugs used in acute pain management. Elderly patients are often reluctant to complain of pain and seek treatment and may sometimes be unable to express pain due to impaired cognition or language. Evidence suggests the elderly as a group that receive inadequate analgesia and are often in pain. Health care professionals are often reluctant to administer sufficient analgesia due to fear of encouraging addiction or inducing side effects. The approach to pain management in this group should follow the World Health Organization (WHO) analgesic ladder with close monitoring for potential side effects and with escalation of treatment till sufficient analgesia is achieved. Choice of drugs and the route of administration should be tailored to the individual patient and should consider the nature of their pain and any disability or co-morbidity that will affect their response to the chosen agent. Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with extreme caution, monitoring for potential gastrointestinal (GI) and renal side effects and long-term use should be avoided if possible. Opioids are effective analgesics and should not be denied to the elderly but their use should be monitored carefully and side effects such as nausea and constipation anticipated and treated.
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Cassidy, Jim, Donald Bissett, Roy A. J. Spence OBE, Miranda Payne, and Gareth Morris-Stiff. Overview of acute oncology. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199689842.003.0031.
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Describes the common causes of spinal cord compression, the symptoms and speed of onset. Outlines immediate diagnostic and therapy options. Emphasis on the need for early diagnosis and therapy to ensure optimal outcomes in longer term.Describes the most common and dreaded of cytotoxic chemotherapy side-effects which is pancytopaenia caused by killing of bone marrow cells. Life threatening when accompanied by infection – neutropaenic sepsis. Outlines symptoms, investigations and immediate therapy guidelines.
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Sourati, Ainaz, Ahmad Ameri, and Mona Malekzadeh. Acute Side Effects of Radiation Therapy: A Guide to Management. Springer, 2018.
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7
Sourati, Ainaz, Ahmad Ameri, and Mona Malekzadeh. Acute Side Effects of Radiation Therapy: A Guide to Management. Springer, 2017.
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8
Walker, Suellen M. Evidence and outcomes in acute pain management. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199234721.003.0005.
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Inadequate control of post-operative pain can be associated with acute morbidity and have adverse effects on recovery and emotional well-being. The aims of acute pain medicine are reducing pain intensity, control of side effects, hastening rehabilitation, and improving acute and long-term outcomes. League tables compare the efficacy of analgesics, based on the number-needed-to-treat (NNT) to achieve 50% pain reduction. Systematic reviews of different interventions for acute pain are conducted and regularly updated in the Cochrane Library. The second edition of Acute Pain Management: Scientific Evidence by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine provides a useful summary of the current evidence.
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1948-, Hinkelbein W., ed. Acute and long-term side-effects of radiotherapy: Biological basis and clinical relevance. Berlin: Springer-Verlag, 1993.
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10
Wannenmacher, Michael, Wolfgang Hinkelbein, Gregor Bruggmoser, and Hermann Frommhold. Acute and Long-Term Side-Effects of Radiotherapy: Biological Basis and Clinical Relevance. Springer, 2011.
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11
Hinkelbein, W., G. Bruggmoser, and H. Frommhold. Acute and Long-Term Side-Effects of Radiotherapy: Biological Basis and Clinical Relevance (Recent Results in Cancer Research). Springer-Verlag, 1993.
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12
Keshav, Satish, and Alexandra Kent. Psychiatry in gastrointestinal medicine. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0206.
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This chapter discusses psychiatric conditions with gastrointestinal (GI) consequences (including eating disorders, depression, and side effects of psychiatric medications), and GI diseases with psychiatric symptoms (including hepatic encephalopathy, coeliac disease, Wilson’s disease, acute intermittent porphyria, functional GI disease, and inflammatory bowel disease).
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Wijdicks, Eelco F. M., and Sarah L. Clark. Antihypertensives and Antiarrhythmics. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190684747.003.0013.
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Acute brain injury can precipitate a hypertensive response, which for the most part is the result of stress-induced, increased sympathetic activity. Acute stroke with hypertension may not be a response but more often a prior, untreated hypertension or a patient with no access to medication. This hypertensive response may wane quickly, and aggressive treatment of these temporary surges in blood pressure could have unwanted consequences. Important characteristics of most antihypertensive drugs used in the neurosciences intensive care unit are cost, having a rapid onset with a short duration of action, and having a low incidence of adverse side effects. Many of the antiarrhythmic drugs also have antihypertensive effects, so these drug classes are best combined in one chapter. This chapter discusses blood pressure targets, the most appropriate antihypertensive medications to use for acute management, and clinically relevant cardiac arrhythmias and their treatment.
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Feng, Alexander J., George C. Chang Chien, and Alan D. Kaye. NMDA Receptor Antagonists, Gabapentinoids, Alpha-2 Agonists, and Dexamethasone. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190457006.003.0002.
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Surgical pain is a major obstacle in the recovery of patients. Effective pain management is of upmost importance to optimize a patient’s recovery, decrease medical complications, and increase patient satisfaction. Traditional pain management with opioids and nonsteroidal anti-inflammatory drugs have significant side effect profiles leading to medical complications or insufficient pain management from reluctance of use. Adjuvant analgesic can provide improved pain management with significantly less side effect profile. In addition, the clinician can, with synergistic effects of adjuvant medications, lower the total dosages used, thus lessening the likelihood of the side effects that occur when medications are used alone at a higher dosage. This chapter presents several adjuvant analgesics—NMDA receptor antagonists, gabapentinoids, alpha-2 agonists, and dexamethasone—and evidence for their use. Ultimately, through the use of traditional pain management options along with adjuvant analgesics, the effectiveness of acute pain management can be increased while adverse outcomes are reduced and functional recovery and quality of life improved.
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Candido, Kenneth D., and Teresa M. Kusper. Long-Acting Perioperative Opioids. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190457006.003.0009.
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Opioid medications are extensively utilized in the management of acute and chronic pain in the outpatient and inpatient clinical settings, as well as being used worldwide during both routine and complex surgeries. They have a long-standing, proven history of providing pain control during the perioperative period and have become an indispensable element of postsurgical analgesia. This chapter describes perioperative application of opioid medications, with a special focus on the long-acting opioids, morphine and hydromorphone. Most common side effects engendered using these agents and the remedies available for the treatment of those side effects are briefly discussed. Finally, the chapter provides a concise summery of various factors influencing the effectiveness of opioid analgesics, as well as analgesic considerations for special patient populations.
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Verheugt, Freek W. A. Fibrinolytic therapy. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0038.
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Fibrinolytic agents are able to reopen blood vessels that are occluded by a fresh thrombus. Urokinase, streptokinase, and streptokinase derivatives were the first effective agents. Recombinant plasminogen activators became available and they are specific for thrombus-bound fibrin. Significant bleeding is the major side effect of fibrinolysis, a major hurdle for its use. The current era of mechanical reperfusion has made fibrinolytic therapy a niche treatment for acute arterial thrombosis such as ST elevation myocardial infarction and stroke. Only for pulmonary embolism with haemodynamic consequences and mechanical heart valve thrombosis may lytic therapy have a place in selected patients.
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Hickey, Thomas, and Jessica Feinleib. Pain Management in the Patient with Substance Use Disorder. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190457006.003.0015.
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Managing pain in the patient with substance use disorder can be challenging. This chapter describes those challenges and provides strategies to address them. Specifically it discusses the prevalence and specific considerations for commonly abused substances, the need for aggressive communication among perioperative clinicians, and a strategy to decrease acute postoperative pain and associated complications using opioid-sparing, multimodal analgesia. It includes a discussion of the concept of equianalgesic opioid doses and management of opioid-related side effects including respiratory depression, with regard to buprenorphine, naltrexone, and methadone. Specific consideration is given to the surgical patient treated with buprenorphine, and a defined clinical plan is outlined.
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Wijdicks, Eelco F. M., and Sarah L. Clark. Pain Management. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190684747.003.0004.
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Adequate pain control has a high priority. In any acute neurologic pain syndrome it must be assumed that pain management is possible, effective, and simple; unfortunately, most patients in pain have been poorly managed. The pharmacopeia of pain management is growing and changing and several trends have been noted. Pain is underreported in the intensive care unit and should be treated when indicated. Acetaminophen is often the first agent used in pain management. Next are weak narcotic analgesics which could have less severe side effects than stronger opioid analgesics. This chapter discusses types of pain in the neurosciences intensive care unit and specific pharmacologic approaches.
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Schlabach, Elizabeth Schroeder. Kitchenettes. University of Illinois Press, 2017. http://dx.doi.org/10.5406/illinois/9780252037825.003.0005.
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This chapter continues the investigation of the two authors with a comparison of Wright's 1941 photographic essay 12 Million Black Voices and his final literary publication, The Outsider, set in Chicago and Harlem, to Brooks' 1945 collection of poetry, A Street in Bronzeville, and her only novel, Maud Martha (1953). The chapter argues that migration to the city and its unkept promise of freedom left African Americans on Chicago's South Side suspended between two planes of existence. The harshest points of this suspension were the one-bedroom kitchenette apartments that began to burst as more migrants poured into Bronzeville. Through their work, Brooks and Wright illustrates an acute consciousness of the symbiotic relationship between the streets of Bronzeville and opportunities for cultural production.
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Lubelczyk, Rebecca. Detoxification or supervised withdrawal. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199360574.003.0017.
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Drugs or alcohol are used at the time of the offense by over half of all detainees, necessitating screening for both intoxication and risk of withdrawal from substances at intake. Intoxication and withdrawal can mimic signs and symptoms of an acute mental disorder or exacerbate an underlying chronic disease. One of the most difficult challenges a clinician may face is differentiating whether the presentation is due to a combination of intoxication/withdrawal and mental illness versus mental illness alone. Using substances while on psychiatric medications can alter the pharmacology, change the effectiveness, and exacerbate the side effects of medications, potentially causing lack of response, nonadherence, or dangerous physical effects. Substance use also puts the patient at risk for trauma and exposure to infections from risky behaviors while intoxicated. The clinician faces an imposing challenge in any attempt to accurately assess underlying psychopathology in the midst of acute detoxification. It is a generally accepted practice to reassess the patient’s psychotropic treatment needs once their detoxification is complete, but individual cases may require acute intervention based on the severity of the patient’s mental illness. This chapter attempts to educate the correctional clinician on the common presentations of intoxication and withdrawal syndromes of various substances. The similarities and distinctions of such syndromes with mental illnesses are discussed. Standardized medical management approaches to safeguard patient safety during supervised withdrawal are also presented. Following such a process allows the clinician to subsequently assess the patient’s true mental health and substance abuse treatment needs.
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Lubelczyk, Rebecca. Detoxification or supervised withdrawal. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199360574.003.0017_update_001.
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Drugs or alcohol are used at the time of the offense by over half of all detainees, necessitating screening for both intoxication and risk of withdrawal from substances at intake. Intoxication and withdrawal can mimic signs and symptoms of an acute mental disorder or exacerbate an underlying chronic disease. One of the most difficult challenges a clinician may face is differentiating whether the presentation is due to a combination of intoxication/withdrawal and mental illness versus mental illness alone. Using substances while on psychiatric medications can alter the pharmacology, change the effectiveness, and exacerbate the side effects of medications, potentially causing lack of response, nonadherence, or dangerous physical effects. Substance use also puts the patient at risk for trauma and exposure to infections from risky behaviors while intoxicated. The clinician faces an imposing challenge in any attempt to accurately assess underlying psychopathology in the midst of acute detoxification. It is a generally accepted practice to reassess the patient’s psychotropic treatment needs once their detoxification is complete, but individual cases may require acute intervention based on the severity of the patient’s mental illness. This chapter attempts to educate the correctional clinician on the common presentations of intoxication and withdrawal syndromes of various substances. The similarities and distinctions of such syndromes with mental illnesses are discussed. Standardized medical management approaches to safeguard patient safety during supervised withdrawal are also presented. Following such a process allows the clinician to subsequently assess the patient’s true mental health and substance abuse treatment needs.
22
Constantinides, Avghi, and Shahla J. Modir. Homeopathic Approach to Addiction. Edited by Shahla J. Modir and George E. Muñoz. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190275334.003.0014.
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This chapter describes the homeopathic approach to the treatment of addiction, exploring both how homeopathy works and how it is helpful in the treatment of various addictions. It reviews the history of homeopathy, the homeopathic paradigm of disease, and the principles of remedy choice from a homeopathic perspective. It discusses the laws of homeopathy, including the law of similar vital force, treatment of the whole person, and the principle of minimum dose. The chapter provides case examples for alcohol, stimulants, and opiate addictions that utilize case study and observational data suggesting the value of homeopathic remedies. It reviews the administration of a homeopathic remedy including potency, frequency, contraindications, and side effects. It discusses the differences between acute and chronic homeopathy including the contrasting relationship between Western and homeopathic medicine.
23
Mebazaa, Alexandre, and Mervyn Singer. Therapeutic strategy in cardiac failure. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0152.
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The fundamental therapeutic principles of heart failure management are for acute heart failure with mainly signs of pulmonary congestion, normal or high blood pressure, and no signs of low cardiac output to reduce pulmonary congestion without affecting blood pressure. Management principles of cardiogenic shock management comprise improvement of forward flow with restoration/maintenance of adequate organ perfusion. Appropriate management requires sound appreciation of the underlying pathophysiology, awareness of the actions and potential side-effects of each therapeutic intervention, and a level of monitoring and investigation sophisticated enough to assess disease severity, and the effectiveness (or otherwise) of any treatment being given. Where possible, consideration of previous comorbidity factors and chronic symptomatology should guide how aggressive intervention should be. However, these must be based on documented fact, rather than hearsay or supposition. The patient should always be given the benefit of the doubt.
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Cheng, Jerry, and David Madigan. Bayesian approaches to aspects of the Vioxx trials: Non-ignorable dropout and sequential meta-analysis. Edited by Anthony O'Hagan and Mike West. Oxford University Press, 2018. http://dx.doi.org/10.1093/oxfordhb/9780198703174.013.3.
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This article discusses Bayesian approaches to aspects of the Vioxx trials study, with a focus on non-ignorable dropout and sequential meta-analysis. It first provides a background on Vioxx, a COX-2 selective, non-steroidal anti-inflammatory drug (NSAID) approved by the FDA in May 1999 for the relief of the signs and symptoms of osteoarthritis, the management of acute pain in adults, and for the treatment of menstrual symptoms. However, Vioxx was found to cause an array of cardiovascular side-effects such as myocardial infarction, stroke, and unstable angina. As a result, Vioxx was withdrawn from the market. The article describes an approach to sequential meta-analysis in the context of Vioxx before considering dropouts in the key APPROVe study. It also presents a Bayesian approach to handling dropout and showcases the utility of Bayesian analysis in addressing multiple, challenging statistical issues and questions arising from clinical trials.
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Sampson, Brett G., and Andrew D. Bersten. Therapeutic approach to bronchospasm and asthma. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0111.
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The optimal management of bronchospasm and acute asthma is reliant upon confirmation of the diagnosis of asthma, detection of life-threatening complications, recognition of β2 agonist toxicity, and exclusion of important asthma mimics (such as vocal cord dysfunction and left ventricular failure). β2 agonists, anticholinergics, and corticosteroids are the mainstay of treatment. β2 agonists should be preferentially administered by metered dose inhaler via a spacer, and corticosteroids by the oral route, reserving nebulized (and intravenous) salbutamol, as well as intravenous hydrocortisone, for situations when these routes are not possible. A single intravenous dose of magnesium may be of benefit in severe asthma, but repeat dosing is likely to cause serious side effects. Parenteral administration of adrenaline may prevent the need for intubation in the patient in extremis. Aminophylline has an unfavourable side effect profile and has not been shown to offer additional benefit in adults. However, it does have a role in paediatric asthma. Unproven medical therapies with potential benefit include ketamine, heliox, inhalational anaesthetics, and leukotriene antagonists. The need for ventilatory support is usually preceded by worsening dynamic hyperinflation, exhaustion, hypoxia, reduced conscious state, or a combination of these. While non-invasive ventilation may have a temporizing role to allow time for response to medical therapy, there is insufficient evidence for its use, and should not delay invasive ventilation. If invasive ventilation is indicated, a strategy of hypoventilation and permissive hypercapnoea, minimizes barotrauma and dynamic hyperinflation. Extracorporeal support may have a role as a rescue therapy.
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Madl, Ulrike. Pathophysiology of glucose control. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0258.
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Hyperglycaemia is a frequent phenomenon in critically-ill patients, associated with increased morbidity and mortality. Hyperglycaemia results in cellular glucose overload and toxic adverse effects of glycolysis and oxidative phosphorylation, especially in tissues with insulin-independent glucose uptake, and acute hyperglycaemia can exert a variety of negative effects. It is the main side effect of intensive insulin therapy. Both severe and moderate hypoglycaemia are independent risk factors of mortality in critically-ill patients. Prolonged hypoglycaemia induces neuronal damage, but may also have adverse cardiovascular effects. Several risk factors predispose critically-ill patients to hypoglycaemic events. Rapid glucose fluctuations may induce oxidative stress and lead to vascular damage. Glucose complexity is a marker of endogenous glucose regulation. Association between hyperglycaemia and outcome is weaker in diabetic critically-ill patients than in non-diabetic patients. Pre-admission glucose control in diabetic critically-ill patients plays a role in the response to glucose control and mortality.
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Kulkarni, Kunal, James Harrison, Mohamed Baguneid, and Bernard Prendergast, eds. Transplantation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198729426.003.0030.
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Organ transplantation is now a well-established therapy for patients with end-stage organ failure. Over the last 20 years, the results of transplantation have improved incrementally for many reasons, including better recipient selection, improved anaesthetic and surgical techniques, the introduction of more effective antiviral agents, and better post-transplant immunosuppressive management. The problem of early graft loss from acute rejection is now uncommon, and the main challenges today are chronic allograft rejection and the side effects of non-specific suppression of the immune response. Randomized clinical trials continue to inform and further improve clinical practice. Because transplantation today is largely successful, the traditional endpoints of 1-year patient and graft survival are no longer sufficient, and more sophisticated endpoints are needed that reflect graft function and quality of life after transplantation. This chapter brings together studies which recognize this need for clinical trials which improve practice and focus on more broadly defined endpoints.
28
Rahman, Anisur. Conventional treatments in systemic lupus erythematosus. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198739180.003.0006.
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A new diagnosis of SLE can be frightening for patients, and the importance of education and reassurance must be remembered—clinical nurse specialists can play a key role in this. Equally, lifestyle advice regarding sun-protection and smoking cessation should not be neglected. Many patients have a mild disease characterized by ongoing symptoms such as rash, hair loss, and joint or chest pain. Symptomatic treatment, topical corticosteroids, antimalarials, and non-steroidal anti-inflammatory drugs are generally sufficient to manage these cases, but acute symptomatic flares may require short-term oral or intramuscular corticosteroids. Lupus nephritis should be managed with a combination of corticosteroids and immunosuppressants. Oral mycophenolate, or the low-dose Euro-Lupus intravenous cyclophosphamide regimen, are used to induce remission. Low-dose corticosteroid plus azathioprine or mycophenolate is used to maintain remission. Corticosteroids are highly effective but have diverse side effects and should be used in the lowest dose compatible with maintaining control of disease activity.
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Boudreau, J. Donald, Eric J. Cassell, and Abraham Fuks. Phases III and IV—Doctoring. Oxford University Press, 2018. http://dx.doi.org/10.1093/oso/9780199370818.003.0017.
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Phases III and IV of the Physicianship Curriculum focus on clinical knowledge, skills, judgment, and discernment—in short, on “doctoring.” Phase III learning activities occur mainly in clinics, day hospitals, and other outpatient settings; phase IV is in hospitals or other contexts for care of persons with acute illnesses. Students serve as members of health care teams and attending teachers ensure that, whenever possible, instruction involves actual patients encountered by the students. This is designed to provide role models of bedside (and patient-side) behaviors and avoid the depersonalization of paper- (or computer-) based reviews of clinical “cases.” Phase III has four 12-week modules addressing 12 clinical disciplines. Phase IV includes four 6-week modules in mandatory rotations and additional time for electives. Direct patient contact is emphasized, supplemented by case-based teaching, journal clubs, and sessions on imaging and other diagnostic tools. An important goal is to foster critical appraisal.
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Goldberg, Pablo H., Prerna Martin, Carolina Biernacki, and Moira A. Rynn. Treatments for Pediatric Bipolar Disorder. Oxford University Press, 2015. http://dx.doi.org/10.1093/med:psych/9780199342211.003.0009.
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The past two decades have seen significant advances in the development of evidence-based treatments for pediatric bipolar disorder. Practice guidelines recommend pharmacotherapy with mood stabilizers or second-generation antipsychotics (SGAs) as the first-line treatment. Lithium, risperidone, aripiprazole, quetiapine, and olanzapine are approved by the U.S. Food & Drug Administration for treating bipolar disorder in children and adolescents. The pharmacological literature suggests that SGAs are faster and more effective than mood stabilizers in treating acute manic or mixed episodes, but they have significant side effects and require careful monitoring. While mild to moderate bipolar disorder can be treated with monotherapy, combination pharmacotherapy with an SGA and a mood stabilizer is recommended for youth with severe bipolar disorder. A growing body of literature also suggests the efficacy of psychosocial interventions, with family psychoeducation and skills building as adjunct treatments to pharmacotherapy. More type 1 studies of pharmacotherapy and psychosocial treatments are needed.
31
Richette, Pascal. Principles of gout management. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0044.
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The general goals of gout therapy are to manage acute flares and to prevent recurrences and prevent or reverse the complications of urate deposition by lowering urate levels. The choice of drug should be made on the basis of the patient’s co-morbidities, other medications, and side effect profile. Treatment of flares can be achieved with non-steroidal anti-inflammatory drugs, colchicine, or corticosteroids (systemic or intra-articular). Interleukin-1 blockers could become an alternative in patients contraindicated for traditional anti-inflammatory agents. Lowering of urate levels below monosodium urate (MSU) saturation point with both a non-pharmacological and pharmacological approach allows to dissolve MSU crystals and to cure gout. Serum urate (SUA) levels should be maintained below 6 mg/dL (360 μmol/L) or below 5 mg/dL (300 μmol/L) in patients with severe gout to facilitate faster dissolution of crystals. Urate-lowering therapy (ULT) should be initiated close to the first diagnosis of gout. Allopurinol and febuxostat are the most widely used xanthine oxidase inhibitors to lower SUA levels. If the SUA target cannot be reached by these agents, uricosurics are indicated, either alone or in combination with a xanthine oxidase inhibitor. In patients with severe tophaceous gout in whom the SUA target cannot be reached with any other available drug, pegloticase is indicated. Since ULT initiation may trigger acute attacks of gout, prophylaxis with an anti-inflammatory agent is recommended, mostly with low-dose colchicine. Of note, patient education, appropriate lifestyle advice, and treatment of comorbidities are also important parts of the management of patients with gout.
32
Leaver, Susannah, and Timothy Evans. Hypoxaemia in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0085.
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Hypoxaemia is a reduction in the partial pressure of oxygen in the blood below 8 kPa/60 mmHg. Hypoxaemia results from one, or several, or a combination of causes. Calculating the alveolar–arterial gradient can help to delineate the cause. Acute respiratory failure manifests in a number of ways, the most sensitive indicator being an increased respiratory rate. Diagnosis is dependent on a comprehensive history, examination in combination with appropriate blood tests, and imaging. Hypoxaemia is the final common pathway of a number of conditions and the exact cause may not be immediately apparent. Despite this, the same management principles apply. A trial of non-invasive ventilation can be used to support patients during respiratory failure who do not require immediate endotracheal intubation. However, it is recommended that this is instituted for a preset trial period (e.g. 1–2 hours) in an HDU/ICU setting where facilities for definitive airway management are available. Invasive ventilation aims to facilitate treatment of the underlying condition whilst minimizing side effects through lung protective ventilatory strategies.
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Smith, Jad. At the Wrong End of Time, 1976–95. University of Illinois Press, 2017. http://dx.doi.org/10.5406/illinois/9780252037337.003.0004.
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This chapter details events in the life of John Brunner from 1976 to 1995. At the height of his career, Brunner retreated from the science fiction (SF) world partly because of his health. Not long after finishing The Shockwave Rider, he began to have excruciating headaches due to acute hypertension. He started taking a drug known in the UK as Aldomet, from which he suffered serious side effects, including the loss of his creativity. Brunner also experienced a mid-career crisis. On the one hand, he felt ambivalent about the direction of the field, especially as the market swung back toward space opera, and Hollywood followed suit. On the other hand, with many of his original ambitions as a SF author now realized, he felt uncertain about his own goals. It was not until 1981 that Brunner began working on his next major SF project, The Crucible of Time (1983). On August 25, 1995, a month shy of his sixty-first birthday, Brunner died of a massive stroke at the Intersection WorldCon in Glasgow.
34
Hopkins, Philip M. Adverse drug reactions in anaesthesia. Edited by Michel M. R. F. Struys. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0022.
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Adverse drug reactions are implicated in more than 40% of anaesthesia-related deaths. Undoubtedly, many more patients experience morbidity from adverse drug reactions. Widely cited definitions of adverse drug reactions encompass common side-effects but this chapter focuses on those that are unexpected reactions to drugs administered by anaesthetists and that occur at normal drug doses. The chapter includes a comprehensive account of malignant hyperthermia, which remains a major contributor to anaesthesia related to deaths. Malignant hyperthermia is a pharmacogenetic condition triggered by potent inhalational anaesthetics and possibly also suxamethonium. The genetic basis, pathophysiology, clinical presentations, and management of malignant hyperthermia are discussed. The chapter covers two other pharmacogenetic conditions: the acute porphyrias and butyrylcholinesterase (plasma cholinesterase) deficiency. Drug-induced anaphylaxis is another cause of perioperative morbidity and mortality. Recent data indicate that anaphylaxis during anaesthesia may be much more common than previously thought. The other type of adverse drug reaction covered in the chapter is serotonin syndrome. Perioperative serotonin syndrome is most likely to occur when patients who are already taking serotonergic drugs, such as selective serotonin reuptake inhibitor antidepressants or ‘triptan’ antimigraine treatments, are given a second drug with serotonergic properties, such as tramadol.
35
Myburgh, John, and Naomi E. Hammond. Choice of resuscitation fluid. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0069.
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Fluid resuscitation is a ubiquitous intervention in critically-ill patients. There is wide variation in practice and emerging evidence that the choice of resuscitation fluid may affect outcome in selected patient populations. It is likely that beneficial or adverse effects relate not only to the physicochemical properties of the fluid but also to the volume (dose) and rate of administration. Interstitial oedema is a common side-effect associated with all fluids and its development is associated with organ dysfunction. Crystalloids should be first-choice resuscitation fluids for almost all patients, with evidence that balanced salt solutions confer any benefit over saline being limited to observational data. Consideration of serum sodium (or osmolality), pH, renal function and coagulation status may affect selection of a specific crystalloid solution. On the balance of evidence, colloids do not confer any clinical advantage over crystalloids and they should be used with caution, if at all. Albumin is contraindicated for the resuscitation of patients with severe traumatic brain injury. Hydroxyethyl starch is associated with increased risk of death and acute kidney injury in critically-ill patients, particularly those with severe sepsis and septic shock. Current evidence does not support the use of other semi-synthetic colloids for resuscitation.
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Beydon, Laurent, and Flavie Duc. Inhalational anaesthetic agents in critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0046.
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Inhalational anaesthetic agents have limited applications in the intensive care unit (ICU), as their delivery requires specific equipment, which are not routinely available. Sevoflurane and isoflurane are the two agents eligible for this purpose. They both show good clinical tolerance and versatility, but may raise cerebral blood flow above 1 minimum alveolar concentration. This property makes them unsuitable for sedation in patients suffering from acute brain injury. Sevoflurane is known to be partly metabolized via the cytochrome pathway in inorganic fluoride. This latter accumulates in a dose- and time-dependent manner, especially in a closed circuit with soda lime. However, no clinical renal injury has been proven, despite several studies reporting on sevoflurane in ICUs. A fresh gas flow above 2 L/min is required to limit inorganic fluoride build-up. Halogenates have been proven to allow efficient sedation in ICU patients for up to several days. They may be considered as therapeutic agents especially in refractory status asthmaticus. Insufficient data exist to recommend halogenates to treat status epilepticus. Nitrous oxide, in 50% oxygen, may serve to allow sedation/analgesia for short and moderately procedures. Xenon, an inert gas that discloses anaesthetic properties with extremely fast onset and recovery, and also has no haemodynamic side effects remains confined to the operating theatre. It requires specific anaesthetic machines and is, at present, too expensive to represent a routine inhalational anaesthetic agent.
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Stevens, Philip, and Paul Dark. Ileus and obstruction in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0182.
Full textAbstract:
Obstruction is the commonest cause of acute intestinal failure in critical care. Management is dependent upon whether it is adynamic or mechanical in origin. Paralytic ileus is managed conservatively by correction of electrolyte disturbances, nutritional support, and minimization of enterostatic drug use. Pharmacological agents aimed at reducing sympathetic stimuli may be useful, although widespread application is limited due to anti-muscarinic side effects. Peripherally acting μ-opioid receptor antagonists, may have a role, although data in critical illness are lacking. Prokinetic agents have not been shown to reduce ileus in clinical trials. Colonoscopic decompression may be required when conservative management fails. Rarely, surgical decompression becomes necessary if ileus arises in the context of abdominal compartment syndrome. Mechanical obstruction is more likely to require surgery, although adhesional obstruction, responsible for 80% of small bowel obstruction, may settle within 7 days of conservative management. Large bowel obstruction is more commonly due to tumours, diverticular stricture, or volvulus, and more likely to require endoscopic or surgical intervention. The hallmark of obstruction is colic, characterized by an inability to settle, in contrast to the peritonitic patient who lies completely still. Peritonitis in the presence of obstruction indicates possible perforation or necrosis for which urgent operative intervention is required. Clinical features may be absent in sedated patients hence the index of suspicion should remain high in any critically-ill patient intolerant of enteral feeding.
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Keh, Didier. Steroids in critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0054.
Full textAbstract:
The benefit of prolonged application of moderate-dose corticosteroids in systemic inflammatory diseases remains controversial. In critical illness, the endogenous cortisol effect may become insufficient due to adrenal dysfunction and corticosteroid resistance to counterbalance an exaggerated and protracted inflammatory response, which has been termed ‘critical illness-related corticosteroid insufficiency’ (CIRCI). There is evidence that moderate-dose hydrocortisone (200–300 mg/day) significantly fastens shock reversal in patients with septic shock, but may improve survival probably only in patients with high risk of death. Thus, therapy should be considered only in refractory shock with poor response to fluid administration and vasopressor therapy. The indication should be based on clinical judgement and not on cortisol measurement. The application prolonged of moderate-dose methylprednisolone (1 mg/kg/day) was found to be most effective in early acute respiratory distress syndrome, and associated with improved lung function, reduction of mechanical ventilation, and faster discharge from the ICU, but a survival benefit was found only in pooled data, including cohort studies. A continuous infusion and weaning of corticosteroids may be preferable to bolus applications and abrupt withdrawal to avoid side effects such as rebound of inflammation and shock, glucose variability, or respiratory failure. There is currently no evidence that prolonged application of moderate-dose corticosteroids increase the risk of secondary infections or muscle weakness, but infection surveillance should be implemented and combination with muscle relaxants be avoided.
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Williams, John, and Francis Bonnet. Analgesics in anaesthetic practice. Edited by Michel M. R. F. Struys. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0018.
Full textAbstract:
Each year, approximately 230 million major surgical procedures are undertaken worldwide, with over three-quarters of the patients complaining of pain postoperatively and 10% complaining of severe pain. Pain is not, however, just an unpleasant sensory consequence of surgery, but can also have significant physiological implications impacting negatively on well-being and postoperative outcome. Postoperative pain may also result in changes within the central nervous system, leading to the development of chronic pain states lasting in excess of 3–6 months. Adequate analgesia has proven to be effective when employed in the perioperative period at combating many of these adverse effects. An understanding of the basic physiological and pharmacological mechanisms responsible for producing, transmitting, and sustaining pain has allowed for a variety of effective analgesic agents to be fashioned and used clinically to treat pain. Morphine, the archetypal opioid analgesic, is the most familiar of these agents with a long history of use and evidence of effectiveness; morphine possesses a number-needed-to-treat (NNT) to reduce pain by 50% of around 3 when given in doses of between 10 and 15 mg. Non-steroidal agents and paracetamol are similarly effective in the immediate postoperative period with NNTs of between 2 and 4. More recently, a number of analgesic adjuncts such as gabapentin, pregabalin, ketamine, clonidine, and nefopam have found favour for the treatment of acute postoperative pain. None of these agents, however, are without side-effects, ensuring that the search for effective analgesic agents continues to be a vibrant area of research with new analgesic agents continuing to be developed.
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Ho, Kwok M. Kidney and acid–base physiology in anaesthetic practice. Edited by Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0005.
Full textAbstract:
Anatomically the kidney consists of the cortex, medulla, and renal pelvis. The kidneys have approximately 2 million nephrons and receive 20% of the resting cardiac output making the kidneys the richest blood flow per gram of tissue in the body. A high blood and plasma flow to the kidneys is essential for the generation of a large amount of glomerular filtrate, up to 125 ml min−1, to regulate the fluid and electrolyte balance of the body. The kidneys also have many other important physiological functions, including excretion of metabolic wastes or toxins, regulation of blood volume and pressure, and also production and metabolism of many hormones. Although plasma creatinine concentration has been frequently used to estimate glomerular filtration rate by the Modification of Diet in Renal Disease (MDRD) equation in stable chronic kidney diseases, the MDRD equation has limitations and does not reflect glomerular filtration rate accurately in healthy individuals or patients with acute kidney injury. An optimal acid–base environment is essential for many body functions, including haemoglobin–oxygen dissociation, transcellular shift of electrolytes, membrane excitability, function of many enzymes, and energy production. Based on the concepts of electrochemical neutrality, law of conservation of mass, and law of mass action, according to Stewart’s approach, hydrogen ion concentration is determined by three independent variables: (1) carbon dioxide tension, (2) total concentrations of weak acids such as albumin and phosphate, and (3) strong ion difference, also known as SID. It is important to understand that the main advantage of Stewart over the bicarbonate-centred approach is in the interpretation of metabolic acidosis.