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1
Press Council of India. Special Inquiry Committee to Examine the Increasing Incidents of Attacks/Assaults on Journalists, and the Pressures/Impediments in the Way of Free Functioning of the Press in the State of Bihar. Report of the Special Inquiry Committee of the Press Council of India appointed to Examine the Increasing Incidents of Attacks/Assaults on Journalists, and the Pressures/Impediments in the Way of Free Functioning of the Press in the State of Bihar. [New Delhi]: The Council, 1992.
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2
Young, Harold, and Anthony Marmarou. The estimated incidence of normal pressure hydrocephalus in assisted living and extended care facilities for the senior Virginia residents: Report of the Division of Neurological Surgery at the Medical College of Virginia of Virginia Commonwealth University to the Governor and the General Assembly of Virginia. Richmond, Va: Commonwealth of Virginia, 2005.
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3
Sharfstein, Joshua M. Crisis Management. Oxford University Press, 2018. http://dx.doi.org/10.1093/oso/9780190697211.003.0007.
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A useful management approach for responding to crises is the incident command system. Developed in the 1970s to coordinate efforts at the scenes of fires and other disasters, incident command is now the standard management structure recommended for a broad range of disasters by the Federal Emergency Management Agency. Key attributes of incident command include clear leadership, specified roles, and management by objective. Once an agency has developed the ability to activate an incident command or a modified version of incident command, it is worth using it regularly—including to better manage everyday public health challenges. Doing so builds the muscles of an organization in such areas as mobilizing resources, public communications, and decision-making under pressure.
4
Measuring Pressure Ulcer Incidence and Prevalence (Clinical Monographs). EMAP Healthcare, 2000.
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5
Fagard, Robert, Giuseppe Mancia, and Renata Cifkova. Blood pressure. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656653.003.0014.
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Prevention of hypertension can help prevent cardiovascular disease and renal complications. Obesity, a high sodium and low potassium intake, physical inactivity, and high alcohol consumption all contribute to the development of hypertension, and randomized controlled trials have shown that appropriate lifestyle modifications are able to reduce blood pressure and/or prevent the development of hypertension. The major complications of hypertension are stroke, coronary heart disease, heart failure, peripheral artery disease, and chronic kidney disease. Multiple randomized controlled trials and their meta-analyses have shown that treatment with antihypertensive drugs reduces the incidence of fatal and non-fatal cardiovascular events. In addition, meta-analyses have shown that there are no clinically relevant differences in the effects of the five major drug classes on outcome, so all of them are considered suitable for the initiation and maintenance of antihypertensive therapy. Nevertheless, the therapeutic approach in the elderly, women, and patients with diabetes, cerebrovascular, cardiac, or renal disease deserves special attention.
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Randerath, Winfried J., and Shahrokh Javaheri. Sleep and the heart. Edited by Sudhansu Chokroverty, Luigi Ferini-Strambi, and Christopher Kennard. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199682003.003.0040.
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Heart function and sleep are closely associated. While NREM sleep reduces cardiac workload, phasic REM sleep increases sympathetic activity and cardiac vulnerability. Heart failure (HF) patients suffer from disturbed sleep due to frequent awakenings, periodic limb movements, sleep apnea, and depression. Insomnia seems to be associated with incident HF, and, when comorbid, results in a vicious circle. There is much evidence of a relationship between breathing disturbances during sleep and heart diseases. At least 50% of HF patients suffer from obstructive (OSA) or central (CSA) sleep apnea, both associated with impaired prognosis. OSA is a risk factor for arterial hypertension, atrial fibrillation, and HF. Continuous positive airway pressure devices reduce adverse cardiac events and improve outcome in severe OSA in compliant subjects. Adaptive servoventilation (ASV) is superior to other therapeutic options for CSA. However, the use of ASV is contraindicated in severe HF with reduced, but not preserved, ejection fraction.
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Jenkins, Joy, Oscar Westlund, Ryan J. Thomas, and Edson C. Tandoc. Critical Incidents in Journalism. Taylor & Francis Group, 2020.
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8
Critical Incidents in Journalism. Taylor & Francis Group, 2020.
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9
Incidence and implications of atypical exercise blood pressure responses of cardiac rehabilitation patients. 1985.
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10
Incidence and implications of atypical exercise blood pressure responses of cardiac rehabilitation patients. 1986.
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11
Incidence and implications of atypical exercise blood pressure responses in adults without diagnosed coronary heart disease. 1986.
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12
Incidence and implications of atypical exercise blood pressure responses in adults without diagnosed coronary heart disease. 1985.
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13
Resistance in Digital China: The Southern Weekly Incident. Bloomsbury Publishing Plc, 2020.
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14
Chen, Sally Xiaojin. Resistance in Digital China: The Southern Weekly Incident. Bloomsbury Publishing Plc, 2021.
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15
Ghebrehewet, Samuel, Alex G. Stewart, David Baxter, Paul Shears, David Conrad, and Merav Kliner, eds. Health Protection. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198745471.001.0001.
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This book is an accessible and practical core text on the three domains of health protection: Communicable Disease Control, Emergency Preparedness Resilience and Response (EPRR), and protection of the public from environmental hazards (Environmental Public Health). The editors have attempted to develop an “all hazards approach” to dealing with health protection situations. Most health protection books confine themselves to one of the three domains, whereas this book presents a practical and all hazards approach, with some account of the overarching principles of health protection on which day-to-day practice rests. The target audience is health protection practitioners, students, doctors, nurses and other non-medical professionals who may encounter health protection issues in their daily practice. From a clear introduction to the essential principles of health protection work, the book guides readers through how to manage real health protection incidents using a combination of case studies and quick reference action checklists. Each case study provides a common health protection scenario which develops in stages, in the same way as a real-life case or incident. As the story unfolds, the reader will learn about the nature and significance of the specific threat to population health, the practical steps and issues involved in an effective public health response and the health protection principles underpinning that response. Other chapters outline the general principles of health protection, providing a deeper understanding of key tools and mechanisms, as well as insights into new and emerging health protection issues. A series of individual checklists dealing with a broad range of commonly-faced diseases, hazards and incidents complete the book. These give concise and practically-focused information that can be used even by non-specialists in time-pressured situations. In particular, the variety of chapters covered throughout the book, on Communicable Diseases, Emergency Preparedness Resilience and Response, and Environmental Public Health, offer a unique perspective borne out of practical experience, not easily accessible elsewhere.
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Talbert, Matthew, and Jessica Wolfendale. Introduction. Oxford University Press, 2018. http://dx.doi.org/10.1093/oso/9780190675875.003.0001.
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IN THE IRAQI TOWN of Haditha in 2005, US Marines killed 24 Iraqi civilians, including women and children. Charges against six Marines were dropped and a seventh was acquitted. How should we assess this and similar incidents? On the one hand, punishing the Marines might be unreasonable since they were subject to extreme situational pressures leading up to the massacre, including combat stress, exposure to constant attacks, and the loss of one of their own. On the other hand, perhaps they ...
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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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Jenkins, Joy, Oscar Westlund, Ryan J. Thomas, and Edson C. Tandoc Jr. Critical Incidents in Journalism: Pivotal Moments Reshaping Journalism Around the World. Taylor & Francis Group, 2020.
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19
Jenkins, Joy, Oscar Westlund, Ryan J. Thomas, and Edson C. Tandoc Jr. Critical Incidents in Journalism: Pivotal Moments Reshaping Journalism Around the World. Taylor & Francis Group, 2020.
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20
Jenkins, Joy, Oscar Westlund, Ryan J. Thomas, and Edson C. Tandoc Jr. Critical Incidents in Journalism: Pivotal Moments Reshaping Journalism Around the World. Taylor & Francis Group, 2020.
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21
Liu, Yang. Perioperative Management of Pheochromocytoma. 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/9780190678333.003.0044.
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Pheochromocytomas are rare neuroendocrine tumors that arise from catecholamine producing cells in the adrenal glands. In the pediatric population, catecholamine-secreting tumors typically present around ages 11 and 12 and occur in 0.8% to 1.7% of hypertensive children. Pheochromocytomas represent significant management challenges to the anesthesiologist, particularly when undiagnosed. Many different anesthetic techniques and various antihypertensive agents have been successfully used to attenuate the intraoperative variations in blood pressure. After resection, periodic follow-up is highly recommended for all patients with pheochromocytoma because of the high incidence of recurrence and malignancy. This chapter uses a case study of a 12-year-old boy who presents for a scheduled laparoscopic cortical sparing adrenalectomy for unilateral pheochromocytoma.
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The effects of Reynolds number, rotor incidence angle, and surface roughness on the heat transfer distribution in a large-scale turbine rotor passage. East Hartford, Conn: United Technologies Research Center, 1989.
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23
Ferreira, Isabel, and Jos WR Twisk. Physical activity, cardiorespiratory fitness, and cardiovascular health. Edited by Neil Armstrong and Willem van Mechelen. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198757672.003.0017.
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It is now recognized that cardiovascular disease (CVD) is partly a paediatric problem, i.e. the onset begins in childhood, although clinical symptoms may not become apparent until later in life. Therefore, from a primary prevention point of view, the extent to which physical activity or physical fitness in childhood may deter this process is of utmost importance. Although physical activity and CRF at a young age have not been directly linked to the incidence of CVD, evidence thus far supports cardiovascular health benefits of early higher physical activity and CRF levels on cardiometabolic risk factors like obesity, blood pressure, insulin resistance, and their maintenance throughout the course of life. By affecting these intermediary pathways, lifelong (high-intensity) physical activity may also deter the age-related decreases in CRF and related signs of premature arterial ageing.
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Meier, Petra M., and Thomas O. Erb. Craniosynostosis and Apert Syndrome. Edited by Kirk Lalwani, Ira Todd Cohen, Ellen Y. Choi, and Vidya T. Raman. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190685157.003.0021.
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Apert syndrome is a complex, progressive multisystem condition of the craniosynostosis spectrum originating from a fibroblast growth factor receptor disorder. Multidisciplinary treatment teams may include craniofacial surgery, neurosurgery, otolaryngology, ophthalmology, oro-maxillofacial surgery, and pediatric intensive care. Secondary to midface hypoplasia, children often present with a compromised airway and have a high incidence of sleep disorders. Anesthetic considerations include difficult airway assessment, the presence of obstructive sleep apnea syndrome, and increased intracranial pressure. Extensive remodeling procedures can be associated with massive hemorrhage (e.g., venous sinus bleeding) and venous air embolism. Transfusion-related complications include coagulopathy, metabolic derangements, and primarily noninfectious hazards such as transfusion-related acute lung injury and transfusion-related immunomodulation. Multimodal blood management should focus on a combination of appropriate surgical techniques and blood conservation, along with guidance from point-of-care testing (including coagulation).
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Twisk, Jos, and Isabel Ferreira. Physical activity, physical fitness, and cardiovascular health. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199232482.003.0025.
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The incidence of morbidity and mortality related to CVD is rather low in a paediatric population. Studies investigating the relationship between physical activity, physical fitness, and cardiovascular health in children and adolescents are therefore mostly limited to CVD risk factors as outcome measures. For this reason, this chapter will focus on the association of physical activity and physical fitness with CVD risk factors in children and adolescents. These risk factors can be divided into the so-called traditional CVD risk factors; that is, lipoproteins [total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides (TG)], blood pressure, body fatness, and diabetes, and ‘new’ CVD risk factors; that is, other lipoproteins [lipoprotein(a) (Lp(a)), apolipoprotein (apo)B, and apoA-1], coagulation and inflammation markers [fibrinogen, C-reactive protein (CRP)], homocysteine, and heart rate variability.
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Neligan, Patrick J., and John G. Laffey. Obstetric physiology and special considerations in ICU. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0365.
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Pregnant patients constitute less than 1% of intensive care unit admissions, and fewer than 1% of obstetric patients become critically ill. Critical illness may result from pregnancy-specific diseases, diseases that pregnancy predisposes to, or are co-incidental to pregnancy. The presence of a second patient—the foetus—may necessitate adjustments to therapeutic and supportive strategies. However, the foetus is generally robust despite maternal illness. The physiological changes of pregnancy are significant, but may delay the diagnosis of critical illness, requiring modifications to standard management approaches. These include increases in minute ventilation, resulting in a ‘low normal’ PaCO2, a reduction in mean arterial pressure, but increased heart rate, low serum creatinine, relative hypoglycaemia, relative leukocytosis, and reduced lower oesophageal sphincter tone. Pre-eclampsia is a disease of the uteroplacental unit that results in abnormal maternal physiology. Pregnant women are at risk for acute respiratory distress syndrome, due to gastropulmonary aspiration and increased risk of community-acquired pneumonia, sepsis, principally of the genito-urinary system, and thromboembolic disease.
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Neary, John, and Neil Turner. Nutcracker syndrome and phenomenon. Edited by Neil Turner. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0048.
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Nutcracker syndrome describes symptomatology associated with obstruction to the left renal vein caused by pressure from the overlying superior mesenteric artery. Modern imaging methods show that some degree of left renal vein obstruction may be a common incidental finding in asymptomatic patients so it is better described as ‘nutcracker phenomenon’, NCP. The association of NCP with symptoms and signs is often speculative. NCP may be seen at any age but most patients with symptoms attributed to it are teenagers or young adults. The strongest evidence is for association with episodic macroscopic haematuria. There is weak evidence that it may in some circumstances account for orthostatic (postural) proteinuria, microscopic haematuria, or pain syndromes. Apart from rare examples of extreme haemorrhage the syndrome has not been associated with life-threatening features other than through complications of treatment. Various interventions have been employed, recently most commonly endovascular or extravascular approaches to stenting the vein, but serious adverse consequences from stent migration and thrombosis have been described.
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May, Joshua. Defending Moral Judgment. Oxford University Press, 2018. http://dx.doi.org/10.1093/oso/9780198811572.003.0004.
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Wide-ranging debunking arguments aim to support moral skepticism based on empirical evidence (particularly of evolutionary pressures, framing effects, automatic emotional heuristics, and incidental emotions). But such arguments are subject to a debunker’s dilemma: they can identify an influence on moral belief that is either substantial or defective, but not both. When one identifies a genuinely defective influence on a large class of moral beliefs (e.g. framing effects), this influence is insubstantial, failing to render the beliefs unjustified. When one identifies a main basis for belief (e.g. automatic heuristics), the influence is not roundly defective. There is ultimately a trade-off for sweeping debunking arguments in ethics: identifying a substantial influence on moral belief implicates a process that is not genuinely defective. We thus lack empirical reason to believe that moral judgment is fundamentally flawed. Our dual process minds can yield justified moral beliefs despite automatically valuing more than an action’s consequences.
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Lunn-Rockliffe, Sophie. Early Christian Political Philosophy. Edited by George Klosko. Oxford University Press, 2011. http://dx.doi.org/10.1093/oxfordhb/9780199238804.003.0009.
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Early Christian political philosophy is not a unified, theoretical, and coherent system, but is embedded in a range of Christian works of apology, theology, and exegesis. Literate (and therefore elite) Christians from the apologists to Augustine were subject to a range of political and social pressures, and their political thinking was often contingent and incidental. What is the ultimate goal of political life for Christians? What is the good life for Christians? Between Constantine's reign and that of Theodosius at the close of the fourth century, emperors veered from the pious to the “heretical,” with a single pagan interruption. It was a common rhetorical conceit for Christians to redefine philosophy as Christianity, and one that became more urgent during Julian's reign. He attempted to wrest Greek philosophy and culture from the Christians for his revived paganism, dubbed “Hellenism,” and even barred Christians from teaching in his school edict of 362. This article focuses on early Christian political philosophy as well as ecclesiology, eschatology, and asceticism.
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Mushambi, Mary C., and Rajesh Pandey. Management of the difficult airway. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0026.
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Failed or difficult intubation is still a major cause of maternal morbidity and mortality. The management of the airway in the pregnant patient requires careful consideration of anatomical and physiological changes, training issues, and situational factors. Despite significant improvements in monitoring and airway equipment, and a reduction in anaesthetic-related maternal mortality, the incidence of failed intubation in the pregnant woman in many units has remained between 1/250 and 1/300. This may result from many factors such as the reduction of the number of caesarean deliveries performed under general anaesthesia which has resulted in limited opportunities to teach airway skills in obstetrics, the increased incidence of obesity, and the rise in maternal age and associated co-morbidities. Improved training and careful planning and performance of a general anaesthetic (i.e. reducing the risk of aspiration; optimum pre-oxygenation, patient positioning, and application of cricoid pressure; and availability of appropriate airway equipment) have the potential to reduce airway-related morbidity and mortality in the pregnant woman. Simple bedside tests such as Mallampati scoring, thyromental distance, neck movement, and ability to protrude the mandible may help to predict a potential difficult airway, particularly when used in combination. Management of a predicted difficult airway requires early referral to the anaesthetists, formulation of an airway management strategy, and involvement of the multidisciplinary team in decision-making. Fibreoptic equipment and skills should be readily available when required. Management of the unpredicted difficult airway should make maintenance of maternal and fetal oxygenation the primary goal. Decision-making during a failed intubation on whether to proceed or wake the patient should involve the obstetrician and ideally be planned in advance. The periods during extubation and recovery are high risk and require preparation and planning in advance.
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Banerjee, Amitava, and Kaleab Asrress. Screening for cardiovascular disease. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0351.
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Screening involves testing asymptomatic individuals who have risk factors, or individuals who are in the early stages of a disease, in order to decide whether further investigation, clinical intervention, or treatment is warranted. Therefore, screening is classically a primary prevention strategy which aims to capture disease early in its course, but it can also involve secondary prevention in individuals with established disease. In the words of Geoffrey Rose, screening is a ‘population’ strategy. Examples of screening programmes are blood pressure monitoring in primary care to screen for hypertension, and ultrasound examination to screen for abdominal aortic aneurysm. The effectiveness and feasibility of screening are influenced by several factors. First, the diagnostic accuracy of the screening test in question is crucial. For example, exercise ECG testing, although widely used, is not recommended in investigation of chest pain in current National Institute for Health and Care Excellence guidelines, due to its low sensitivity and specificity in the detection of coronary artery disease. Moreover, exercise ECG testing has even lower diagnostic accuracy in asymptomatic patients with coronary artery disease. Second, physical and financial resources influence the decision to screen. For example, the cost and the effectiveness of CT coronary angiography and other new imaging modalities to assess coronary vasculature must be weighed against the cost of existing investigations (e.g. coronary angiography) and the need for new equipment and staff training and recruitment. Finally, the safety of the investigation is an important factor, and patient preferences and physician preferences should be taken into consideration. However, while non-invasive screening examinations are preferable from the point of view of patients and clinicians, sometimes invasive screening tests may be required at a later stage in order to give a definitive diagnosis (e.g. pressure wire studies to measure fractional flow reserve in a coronary artery). The WHO’s principles of screening, first formulated in 1968, are still very relevant today. Decision analysis has led to ‘pathways’ which guide investigation and treatment within screening programmes. There is increasing recognition that there are shared risk factors and shared preventive and treatment strategies for vascular disease, regardless of arterial territory. The concept of ‘vascular medicine’ has gained credence, leading to opportunistic screening in other vascular territories if an individual presents with disease in one territory. For example, post-myocardial infarction patients have higher incidence of cerebrovascular and peripheral arterial disease, so carotid duplex scanning and measurement of the ankle–brachial pressure index may be valid screening approaches for arterial disease in other territories.
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Leys, Didier, Charlotte Cordonnier, and Valeria Caso. Stroke. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0067.
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Stroke is a major public health issue. Many are treatable in the acute stage, provided patients are admitted soon enough. The overall incidence of stroke in Western countries is approximately 2400 per year per million inhabitants, and 80% are due to cerebral ischaemia. The prevalence is approximately 12 000 per million inhabitants. Stroke is associated with increased long-term mortality, handicap, cognitive and behavioural impairments, recurrence, and an increased risk of other types of vascular events. It is of major interest to take the heterogeneity of stroke into account, because of differences in the acute management, secondary prevention, and outcomes, according to the subtype and cause of stroke. In all types of stroke, early epileptic seizures, delirium, increased intracranial pressure, and non-specific complications are frequent. In ischaemic strokes, specific complications, such as malignant infarcts, spontaneous haemorrhagic transformation, early recurrence, and a new ischaemic event in another vascular territory, are frequent. In haemorrhagic strokes, the major complication is the subsequent increased volume of bleeding. There is strong evidence that stroke patients should be treated in dedicated stroke units; each time 24 patients are treated in a stroke unit, instead of a conventional ward, one death and one dependence are prevented. This effect does not depend on age, severity, and the stroke subtype. For this reason, stroke unit care is the cornerstone of the treatment of stroke, aiming at the detection and management of life-threatening emergencies, stabilization of most physiological parameters, and prevention of early complications. In ischaemic strokes, besides this general management, specific therapies include intravenous recombinant tissue plasminogen activator, given as soon as possible and before 4.5 hours, otherwise aspirin 300 mg, immediately or after 24 hours in case of thrombolysis, and, in a few patients, decompressive surgery. In intracerebral haemorrhages, blood pressure lowering and haemostatic therapy, when needed, are the two targets, but surgery does not seem effective to reduce death and disability.
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Leys, Didier, Charlotte Cordonnier, and Valeria Caso. Stroke. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0067_update_001.
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Stroke is a major public health issue. Many are treatable in the acute stage, provided patients are admitted soon enough. The overall incidence of stroke in Western countries is approximately 2400 per year per million inhabitants, and 80% are due to cerebral ischaemia. The prevalence is approximately 12 000 per million inhabitants. Stroke is associated with increased long-term mortality, handicap, cognitive and behavioural impairments, recurrence, and an increased risk of other types of vascular events. It is of major interest to take the heterogeneity of stroke into account, because of differences in the acute management, secondary prevention, and outcomes, according to the subtype and cause of stroke. In all types of stroke, early epileptic seizures, delirium, increased intracranial pressure, and non-specific complications are frequent. In ischaemic strokes, specific complications, such as malignant infarcts, spontaneous haemorrhagic transformation, early recurrence, and a new ischaemic event in another vascular territory, are frequent. In haemorrhagic strokes, the major complication is the subsequent increased volume of bleeding. There is strong evidence that stroke patients should be treated in dedicated stroke units; each time 24 patients are treated in a stroke unit, instead of a conventional ward, one death and one dependence are prevented. This effect does not depend on age, severity, and the stroke subtype. For this reason, stroke unit care is the cornerstone of the treatment of stroke, aiming at the detection and management of life-threatening emergencies, stabilization of most physiological parameters, and prevention of early complications. In ischaemic strokes, besides this general management, specific therapies include intravenous recombinant tissue plasminogen activator, given as soon as possible and before 4.5 hours, otherwise aspirin 300 mg, immediately or after 24 hours in case of thrombolysis, and, in a few patients, decompressive surgery. In intracerebral haemorrhages, blood pressure lowering and haemostatic therapy, when needed, are the two targets, but surgery does not seem effective to reduce death and disability.
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Leys, Didier, Charlotte Cordonnier, and Valeria Caso. Stroke. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199687039.003.0067_update_002.
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Stroke is a major public health issue. Many are treatable in the acute stage, provided patients are admitted soon enough. The overall incidence of stroke in Western countries is approximately 2400 per year per million inhabitants, and 80% are due to cerebral ischaemia. The prevalence is approximately 12 000 per million inhabitants. Stroke is associated with increased long-term mortality, handicap, cognitive and behavioural impairments, recurrence, and an increased risk of other types of vascular events. It is of major interest to take the heterogeneity of stroke into account, because of differences in the acute management, secondary prevention, and outcomes, according to the subtype and cause of stroke. In all types of stroke, early epileptic seizures, delirium, increased intracranial pressure, and non-specific complications are frequent. In ischaemic strokes, specific complications, such as malignant infarcts, spontaneous haemorrhagic transformation, early recurrence, and a new ischaemic event in another vascular territory, are frequent. In haemorrhagic strokes, the major complication is the subsequent increased volume of bleeding. There is strong evidence that stroke patients should be treated in dedicated stroke units; each time 24 patients are treated in a stroke unit, instead of a conventional ward, one death and one dependence are prevented. This effect does not depend on age, severity, and the stroke subtype. For this reason, stroke unit care is the cornerstone of the treatment of stroke, aiming at the detection and management of life-threatening emergencies, stabilization of most physiological parameters, and prevention of early complications. In ischaemic strokes, besides this general management, specific therapies include intravenous recombinant tissue plasminogen activator, given as soon as possible and before 4.5 hours, mechanical thrombectomy in case of proximal occlusion (middle cerebral artery, intracranial internal carotid artery, basilar artery), on top of thrombolysis in the absence of contraindication or alone otherwise, aspirin 300 mg, immediately or after 24 hours in case of thrombolysis, and, in a few patients, decompressive surgery. In intracerebral haemorrhages, blood pressure lowering and haemostatic therapy, when needed, are the two targets, while surgery does not seem effective to reduce death and disability.
35
Goldsmith, David J. Cardiovascular disease and chronic kidney disease. Edited by David J. Goldsmith. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0098.
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Even after as full a statistical adjustment as can be made for traditional cardiovascular risk factors has been undertaken, impaired kidney function and raised concentrations of albumin in urine each increase the risk of cardiovascular disease (CVD) by two- to fourfold, the degree increasing with severity. If the patient is also suffering from diabetes (as either the cause of CKD or a complication of it), the risks of CVD increase two- to fourfold again. CKD patients should, therefore, be acknowledged as having perhaps the highest cardiovascular risk of any patient cohort. CVD is underdiagnosed and undertreated in these patients. In early CKD the manifestations of CVD are similar to those of other patients. In late CKD and particularly in patients on dialysis the epidemiology is different. Left ventricular hypertrophy is very common and sudden cardiac death is greatly increased in incidence. Heart failure is a common complication. Calcification of valves and vessels becomes increasingly common and bad CVD outcomes are associated with hyperphosphataemia and other manifestations. The mechanisms by which risks are increased are not fully understood. The evidence base for the effectiveness of established therapies for CVD is relatively light in patients with CKD, but there is evidence for benefit of lipid-lowering therapies and most nephrologists believe that blood pressure and volume control are important for good long-term outcomes. Evidence of impact on CVD of interventions to alter mineral bone disease is disappointingly weak.
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Paech, Michael J., and Patchareya Nivatpumin. Postdural puncture headache. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0027.
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Postdural puncture headache (PDPH) may follow either deliberate or unintentional (accidental) penetration of the interdigitating meninges, the dura and arachnoid mater. It is one of the most common and clinically important complications of regional anaesthesia and analgesia in the obstetric population. The headache develops as a consequence of cerebrospinal fluid loss, low intracranial pressure and cerebrovascular changes in the upright position and can prove debilitating. The diagnosis is clinical, making thorough assessment and regular review all the more important, to revise treatment plans, exclude rare serious pathology such as subdural haematoma, and avoid misdiagnosis. This chapter reviews the pathophysiology, incidence, risk factors (needle, technical and patient related), features, natural history, diagnosis, and management of PDPH. High level evidence supports prevention by using small gauge, non-cutting spinal needles, but other preventative strategies against either unintentional dural puncture or PDPH are poorly supported. The absent or poor efficacy of measures such as bed rest, hydration, cerebral vasoconstrictor therapy, epidural or intrathecal saline injection, intrathecal catheter placement or prophylactic epidural blood patch, is noted. Validation of better evidence supporting epidural morphine or intravenous cosyntropin is required. Symptomatic treatment of PDPH is also unreliable. Very limited evidence that requires substantiation supports a modest benefit from caffeine, gabapentinoids or intravenous hydrocortisone. The intervention of epidural blood patch is highly likely to relieve post-spinal PDPH, but only completely resolves epidural needle-induced PDPH in 30–50% of cases. Much detail about EBP remains undetermined, but delayed intervention and injection of approximately 20 mL of autologous blood appear appropriate.
37
T. Wave Phenomena. Courier Dover Publications, 2014.
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