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Drug Research and Development for Adults Across the Older Age Span: Proceedings of a Workshop

Drug Research and Development for Adults Across the Older Age Span: Proceedings of a Workshop-/-The National Academies Collection: Reports funded by National Institutes of Health 2021; ():

There is a void in evidence-based information for making informed decisions on how to optimize care for older adults, particularly those 80 years and over. Because older adults are vastly underrepresented in clinical trials, there is a dearth of information about the appropriate use of drugs in this population. Yet older adults have higher rates of comorbidities and simultaneous use of multiple medications than the general population, and are the majority users of many medications. Additionally, age-related physiological and pathological changes, particularly for adults 80 years of age and older, can lead to significant differences in the pharmacokinetics (PK)2 and pharmacodynamics (PD)3 of a given drug compared to the general population. On August 5 and 6, 2020, the National Academies of Sciences, Engineering, and Medicine hosted a workshop titled Drug Research and Development for Adults Across the Older Age Span. The workshop was designed to examine the challenges and opportunities in drug research and development for older adult populations, explore barriers that impede safety and efficacy studies in these populations, and share lessons learned for better understanding clinical pharmacology for populations over age 65. This publication summarizes the presentation and discussion of the workshop.

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 33492915

Mental Health, Substance Use, and Wellbeing in Higher Education: Supporting the Whole Student

Mental Health, Substance Use, and Wellbeing in Higher Education: Supporting the Whole Student-/-The National Academies Collection: Reports funded by National Institutes of Health 2021; ():

Student wellbeing is foundational to academic success. One recent survey of postsecondary educators found that nearly 80 percent believed emotional wellbeing is a "very" or "extremely" important factor in student success. Studies have found the dropout rates for students with a diagnosed mental health problem range from 43 percent to as high as 86 percent. While dealing with stress is a normal part of life, for some students, stress can adversely affect their physical, emotional, and psychological health, particularly given that adolescence and early adulthood are when most mental illnesses are first manifested. In addition to students who may develop mental health challenges during their time in postsecondary education, many students arrive on campus with a mental health problem or having experienced significant trauma in their lives, which can also negatively affect physical, emotional, and psychological wellbeing. The nation's institutions of higher education are seeing increasing levels of mental illness, substance use and other forms of emotional distress among their students. Some of the problematic trends have been ongoing for decades. Some have been exacerbated by the COVID-19 pandemic and resulting economic consequences. Some are the result of long-festering systemic racism in almost every sphere of American life that are becoming more widely acknowledged throughout society and must, at last, be addressed. Mental Health, Substance Use, and Wellbeing in Higher Education lays out a variety of possible strategies and approaches to meet increasing demand for mental health and substance use services, based on the available evidence on the nature of the issues and what works in various situations. The recommendations of this report will support the delivery of mental health and wellness services by the nation's institutions of higher education.

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 33460324

Immune Reconstitution Inflammatory Syndrome

StatPearls-/- 2021; ():

Human immunodeficiency virus (HIV) targets the immune system by depleting CD4+ T lymphocytes and predisposing patients to an increased risk of opportunistic infections. The use of the highly active antiretroviral therapy (HAART) leads to the restoration of CD4+ T lymphocytes and the normalization of an immune response against pathogens.[1][2] This improvement in immunity has resulted in significant improvement in the quality of life and health care outcomes in HIV patients.[3] Although the introduction of HAART has been a landmark in preventing HIV-related deaths, there are still issues with HAART therapy. Since its inception, there have been several reported side effects of HAART and its possible interactions with other medications. Side effects can range from mild-severe allergic reactions, idiosyncratic reactions, hematological disorders to altered drug metabolism.[4][5] Additionally, using HAART therapy, the serum levels of certain medications can increase due to drug interaction causing significant side effects.[6] Another potential complication that may arise with HAART therapy is immune reconstitution inflammatory syndrome (IRIS). IRIS is a poorly understood disease, and its exact mechanism is not yet fully known. It is a state of dysregulated, hyper-inflammatory response against opportunistic infections that usually occurs in the first six months of treatment of HIV/AIDS patients.[7][8][9] IRIS is a potential complication of highly active antiretroviral therapy (HAART) and was first reported in the 1990s. It can lead to poor adherence and compliance with HAART in HIV/AIDS patients.[10][11][12] It can also increase the risk of drug resistance with HAART, worsen HIV progression to AIDS, and decrease the quality of life in HIV infected population. Overall, the IRIS has been associated with significant morbidity and mortality in HIV/ AIDS patients. This article provides a comprehensive review of the risk factors, pathophysiology, associated microorganisms, clinical presentations, and treatment of IRIS in HIV patients following the initiation of HAART.

*33620872*
 33620872

Venous Leg Ulcer

StatPearls-/- 2021; ():

Venous leg ulcers (VLUs) are late indicators of chronic venous insufficiency (CVI) and venous hypertension.[1][2][3][4] In normal conditions, calf muscle contraction and intraluminal valves promote prograde flow while preventing blood reflux.[5] However, when retrograde flow, obstruction, or both exist, the resultant chronic venous hypertension is responsible for the dermatologic and vascular complications that culminate in the formation of a VLUs.[6] VLUs are a costly medical problem with a high toll on worldwide healthcare systems.[7][8][9] In the United States, the Medicare and commercial insurance annual cost for VLU patients ascends to $18,986 and $13,653, respectively.[10] Together, these represent an annual burden of $14.9 billion for the United States payers, a considerable increase from a previous $1 billion estimate.[11] The situation may worsen as the aging, obese, and sedentary population increases globally, with an expected incidence rise for CVI and VLUs.[12] This problem demands a swift, coordinated, interdisciplinary call to action from all stakeholders.

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 33620871

Nivolumab

StatPearls-/- 2021; ():

Nivolumab is a medication used in the management and treatment of metastatic melanoma and several other tumors. It is a monoclonal antibody that targets the anti-PD1 receptor, an immune checkpoint. This activity outlines the indications, mechanism of action, and administration for nivolumab to manage advanced cancers. This activity will also highlight the dosing, monitoring, and adverse event profile, factor of paramount importance for the multidisciplinary healthcare team in treating patients with metastatic melanoma and related conditions.

*33620870*
 33620870

CT Patient Safety And Care

StatPearls-/- 2021; ():

Computed tomography (or CT) refers to a computerized x-ray imaging procedure in which narrow beams of rotating x-ray radiation are directed at a patient and then transcribed by a computer into cross-sectional "slices" of the specific area imaged. The increasing use of diagnostic computed tomography (CT) images has presented a unique challenge in understanding this procedure's risks to the general patient population. There are few direct risks associated with CT scanning. These range from contrast-induced allergic reactions, contrast-induced nephropathy, and long term risk of cancer development due to radiation exposure. Additional considerations include the patient's pregnancy status and radiation effect on the developing fetus. In addition to these considerations, there is radiation attributable risk to pediatric patients in comparison to adults.

*33620869*
 33620869

Gastric Lymphoma

StatPearls-/- 2021; ():

Gastric lymphoma accounts for only 3% of gastric cancers but is the most common location for extranodal Non-Hodgkin Lymphomas. These indolent cancers are often composed of mucosa-associated lymphoid tissue (MALT) with heterogeneous B-cells located in the stomach or diffuse large B-cells (more often high grade). More than 90% of Gastric MALT Lymphomas are associated with Helicobacter pylori infections. For this reason, treatment of H. pylori remains a key factor in treating gastric lymphomas.[1][2][3][4]

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 33620868

Vulva Cancer

StatPearls-/- 2021; ():

According to the Surveillance, Epidemiology, and End Results (SEER) Program, vulvar cancer represents 0.3% of all new cancer cases annually at a rate of 2.6 per 100,000 women per year in the United States. Diagnosis is usually made in the sixth through eighth decades of life and is commonly identified at an early stage of the disease. Squamous cell carcinoma (SCC) accounts for most vulvar cancers, while basal cell carcinoma (BCC), extramammary Paget disease, and vulvar melanoma comprise the less common subtypes. Surgery remains the mainstay of vulvar cancer treatment, with medical and radiation oncology playing an increasingly important role in preventing recurrence and improving outcomes.[1][2]

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 33620867

Osteopathic Manipulative Treatment: 5 Diaphragm Procedure

StatPearls-/- 2021; ():

Assessment and treatment of the five diaphragms fit into the respiratory-circulatory model of osteopathic medicine (OM). Body diaphragms are conventionally considered to be those anatomical structures that occupy a horizontal space. In reality, considering the three-dimensionality of the human body, it is preferable to consider them as areas in close anatomical continuity, able to influence each other: tentorium cerebelli, tongue, thoracic outlet, diaphragm, and pelvic floor. This activity reviews the anatomical connections of these body areas, how they are evaluated, and how they should be manually treated, with a view to possible clinical pictures. The osteopath's goal is to create space between the different anatomical structures (it is not possible to reshape the same structures manually), as space encloses the possibility of movement. To paraphrase Leonardo da Vinci; space is life.

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 33620866

CT Scan

StatPearls-/- 2021; ():

A computed tomography (CT) scan, commonly referred to as a CT, is a radiological imaging study. The machine was developed by physicist Allan MacLeod Cormack and electrical engineer Godfrey Hounsfield.[1][2][3] Their development awarded them the Nobel prize in Physiology or Medicine in 1979.[4] The first scanners were installed in 1974. Since then, technological advances and math have allowed single images to be computed into two-dimensional informative images. The CT scan is essentially an X-ray study, where a series of rays are rotated around a specified body part, and computer-generated cross-sectional images are produced. The advantage of these tomographic images compared to conventional X-rays is that they contain detailed information of a specified area in cross-section, eliminating the superimposition of images, which provides a tremendous advantage over plain films. CT scans provide excellent clinicopathological correlation for a suspected illness.[5][6] The use of CT scans augments the physician's ability to diagnose a patient's illness accurately. Low-dose CT scans are proving useful in preventative medicine and cancer screening. The study was initially called a CAT scan representing computer axial tomography, where the table moved after each axial image was obtained.[7][8][9] In a spiral or helical scan, the table moves continuously as the x-ray source and detectors rotate. This reduces the duration of the study significantly to provide quick results in emergent situations. It rapidly substituted cerebral angiography for detecting head trauma injuries and brain masses in a fast and extremely reliable way.[10][11][12] A radiologic technician acquires CT scans, which are interpreted and reported by a trained radiologist.

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 33620865

Myocardial Protection

StatPearls-/- 2021; ():

Surgeons became aware that they would never correct or cure heart conditions unless they could stop the blood circulation through the heart, open it, and operate in a bloodless field under direct vision. Two concepts were utilized to develop the first two open-heart surgery techniques, namely 'inflow obstruction' by John Lewis & Mansur Taufic in 1953 and the 'controlled cross circulation' technique by Walton Lillehei in 1954.[1] The latter approach was very successful and addressed pathologies previously considered impossible to surgically correct, such as VSD, AVSD, tetralogy of Fallot, and pulmonary stenosis. However, unforeseen limitations were discovered. Such limitations include difficulty operating on the beating heart, air embolism risk when the left side of the heart is exposed, and obscuring collateral flow from the coronary sinus and pulmonary veins. It was evident that the only way to achieve this was by arresting the heart. This was the genesis of the open-heart surgery era; the following is a detailed review of myocardial protection history, principles, and techniques.[2]

*33620864*
 33620864

Paramyxovirus

StatPearls-/- 2021; ():

Paramyxoviruses are enveloped, single-stranded negative-sense RNA viruses that replicate in the cytoplasm. Diseases caused by these viruses continue to produce high mortality and morbidity across the world.[1] With the development and use of vaccinations and medications, the incidence of serious illness due to paramyxoviruses has tremendously decreased. Yet despite the availability, given the freedom and choice of receiving pre and/or post-exposure treatment, the cases have increased even in developed countries. Cultivating effective vaccines is still in progress for some of the paramyxoviridae species.[2] The family Paramyxoviridae contains two subfamilies that are relevant to humans: Pneumovirinae and Paramyxovirinae. The subfamily Pneumovirinae gives rise to the genus Pneumovirus (respiratory syncytial virus). The subfamily Paramyxovirinae gives rise to the genus Morbillivirus (measles virus/ rubeola), to the genus Respirovirus (para-influenza viruses 1 and 3), and to the genus Rubulavirus (mumps virus and para-influenza viruses 2 and 4).[3] Measles and rubella are targeted for elimination in five different World Health Organization (WHO) regions by 2020.

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 33620863

COVID (SARS-COV-2) Vaccine

StatPearls-/- 2021; ():

COVID-19 vaccines (tozinameran (BNT162b2) and mRNA-1273 SARS-CoV-2) received FDA emergency use authorized (EUA) to prevent COVID-19 caused by the SARS-CoV-2 virus. This activity reviews the indications, administration, and contraindications for COVID-19 vaccines: tozinameran (BNT162b2) and mRNA-1273 SARS-CoV-2. This activity will also highlight the mechanism of action, adverse event profile, and other key elements of the COVID-19 vaccines in the clinical setting for the interprofessional team members when vaccinating individuals to prevent COVID-19 and its related conditions sequelae.

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 33620862

Breast Ptosis

StatPearls-/- 2021; ():

Breast ptosis is commonly associated with aging, macromastia, weight loss, pregnancy, and hormonal changes, although it can present in patients of all ages and breast sizes. The natural history of breast ptosis begins with the skin envelope stretch, ductal structures, and supporting ligaments. The breast parenchymal volume enlarges, rendering the supporting structures ineffective and causing skin redundancy. Ptosis also occurs when parenchymal volume decreases and skin redundancy ensues. The ptosis grading is based on the degree of inferior breast displacement, and various corrective techniques can be chosen according to the different types of ptosis.[1]

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 33620861

Von Economo Encephalitis

StatPearls-/- 2021; ():

Constantin Alexander von Economo, a psychiatrist and neurologist, reported in 1917 about encephalitis lethargica in front of the Vienna Psychiatric Society.[1] Sporadic cases of this brain and brainstem encephalitis were reported in 1916 and 1917, and similar cases were reported around the world between 1919 and 1920.[2] His primary description of the illness that raged in an epidemic in Europe and North America between 1916 and 1927 was named von Economo encephalitis.[3][4] A few weeks before, Jean-Rene Cruchet presented his observations to the Paris Medical Society after treating military patients with neuropsychiatric disorders showing unusual neurological signs. Encephalitis lethargica or von Economo encephalitis is also known as sleeping sickness. Originally it was classified into three clinical forms: somnolent-ophthalmoplegic, hyperkinetic, and amyostatic-akinetic. Currently, postencephalitic parkinsonism has a very close relationship with encephalitis lethargica, also called von Economo encephalitis.[3][5] Von Economo was nominated for the 1926, 1930, and 1932 Nobel Prize in Physiology or Medicine. Encephalitis lethargica came to light after the book "Awakening" written by an English neurologist, Oliver Sacks. A movie based on the book was released in 1990.[6]

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 33620860

Infant Head Lag

StatPearls-/- 2021; ():

Infants generally have a large head compared to the rest of their habitus, and the cervical group of paraspinal muscles is relatively weak at birth. Hence the reason for the notable head lag, especially during the first few weeks of life. During this stage, caregivers routinely support the infant's head until neck control is achieved. The gross motor skill development in infants typically follows a cephalocaudal sequence, and the gain of postural control heralds it. Postural control is an infant's ability to stabilize the center of their body mass/trunk with a dynamic or static base. This innate maturational process of the neck and trunk muscles is expected to evolve rapidly during the infancy stage. When an infant is pulled by the hand from a lying to sitting position, the expected response is to activate the head righting reflex and maintain the head position in line with his/her shoulders. Conversely, infant head lag is observed when the head seems to flop around or lags posteriorly behind the trunk during the pull-to-sit maneuver. Several articles have maintained that head lag should be absent by age 3 to 4 months when infants typically experience an increased ability to control their neck muscles.[1] Once neck control is attained, infants participate actively in a normal pick-up routine by stiffening their neck muscles while tensing up their trunk to decrease the lag between the chin and chest.[2] Persistent head lag beyond age 4 months has been associated with poor neurodevelopmental outcomes.[3] There is a higher incidence of head lag amongst preterm neonates and infants with cerebral palsy, and it is a likely predictor of developmental outcome. It may, however, not be accurate in predicting neurobehavioral effects when used as an isolated metric. A possible explanation could be that assessing one isolated response is not enough to predict neurodevelopmental outcomes accurately. Many studies have suggested that a combination of neonatal responses, like reflex responses, postural reactions, and tone, may hold the potential to predict alteration in brain development correctly.[4][5] Studies have also shown that head lag combined with other early childhood developmental alterations may be intricately linked with a higher risk of autism in specific populations. Head lag was more commonly observed in siblings of children with autism spectrum disorder (ASD) than low-risk infants.[3] Similarly, developmental problems relating to postural instability and axial hypotonicity have been described in infants with ASD.[6][7]

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 33620859

Siderosis Bulbi

StatPearls-/- 2021; ():

Siderosis bulbi refers to the pigmentary, degenerative process of the eye following chronic retention of an iron-containing intra-ocular foreign body (IOFB). It can also occur due to iron derived from the blood.[1] First described by Bunge in 1890, siderosis bulbi has an affinity for ocular structures of epithelial origin such as the cornea, iris, lens, trabecular meshwork, and retina. Iron deposition at these sites leads to the altered morphology of the tissues.[2] A comprehensive clinical evaluation is thus vital to timely detect the development of ocular siderosis and effectively manage these patients without delay.

*33620858*
 33620858

Polypoidal Choroidal Vasculopathy

StatPearls-/- 2021; ():

Polypoidal choroidal vasculopathy (PCV) is an exudative maculopathy characterized by multiple recurrent serosanguineous retinal pigment epithelial detachments (PED). It is similar to neovascular age-related macular degeneration in morphological characteristics. It was first described by Yannuzzi et al. at an annual meeting of the American Academy of Ophthalmology in 1982 and termed as idiopathic polypoidal choroidal vasculopathy (IPCV). in 1984, Kleiner et al. described a similar presentation in middle-aged black women and named it posterior uveal bleeding syndrome (PUBS).[1] Later, Yannuzzi et al. described PCV in detail and established its existence across both genders, various age groups, and races.[2]

*33620857*
 33620857

Intraocular Hemorrhage

StatPearls-/- 2021; ():

Intraocular hemorrhage means bleeding inside the eye. Bleeding can occur from any of the structures of the eye where there is a presence of vasculature. It can bleed inside the anterior chamber, vitreous cavity, retina, choroid, suprachoroidal space, or optic disc. It could occur either because of trauma or in association with systemic illness, or very rarely, it could occur spontaneously. Intraocular hemorrhage can be subdivided depending on the location of the bleed: Hyphema Bleeding from the iris, ciliary body, trabecular meshwork, and associated vasculature into the anterior chamber (bordered by cornea anteriorly, iridocorneal angles laterally, and lens posteriorly) is known as hyphema.[1] Microhyphema- a very minimal amount of blood in the anterior chamber, which is detectable only on microscopic examination. Vitreous Hemorrhage Bleeding in and around the anterior chamber of the eye is known as vitreous hemorrhage. It can be further subclassified as: Intragel hemorrhage: Extravasation of blood into space lined anteriorly by an anterior hyaloid membrane, laterally by non-pigmented ciliary epithelium, and posteriorly by the posterior hyaloid membrane is known as intragel hemorrhage. Properties of intragel hemorrhage: Settle inferiorly, Clots easily, As the RBC degenerates, the color of the vitreous hemorrhage changes from bright red to yellow. Preretinal hemorrhage can be subdivided into 2 categories: Subhyaloid hemorrhage is located between the internal limiting membrane and posterior subhyaloid membrane. Boat-shaped configuration: If the posterior hyaloid is intact, subhyaloid hemorrhage is immobile. If the posterior hyaloid is detached, subhyaloid hemorrhage shifts with the eye movement. It is most commonly seen in patients with proliferative diabetic retinopathy. Sub-ILM hemorrhage is bleeding between the internal limiting membrane and the nerve fiber layer of the retina is known as sub-ILM hemorrhage. It is immobile. It also has a boat-shaped configuration, with the upper border being horizontal. Sub ILM hemorrhage is most commonly seen with Valsalva retinopathy, Terson syndrome, and Retinal microaneurysm. If there is hemorrhage inside the Berger space, Cloquet canal, or canal of petit, it is also known as vitreous hemorrhage.[2]. Suprachoroidal hemorrhage occurs due to the rupture of long or short ciliary arteries into the suprachoroidal space between the choroid and sclera. It usually occurs intraoperatively and postoperatively, after trauma, and very rarely spontaneously. It can be subclassified as: Intraoperative - also known as expulsive suprachoroidal hemorrhage. Postoperative - also known as delayed suprachoroidal hemorrhage. Retinal hemorrhages are important markers signifying local or systemic vascular abnormality, which needs to be thoroughly investigated. Retina hemorrhages can occur at the following locations: Flame-shaped hemorrhages are located in the nerve fiber layer. Dot and blot hemorrhages are located in the Outer plexiform layer - Inner nuclear layer (OPL-INL)complex. Subhyaloid hemorrhages are located between the internal limiting membrane and the posterior hyaloid membrane. It is boat-shaped in the configuration. Sub-RPE hemorrhage is located between the retinal pigment epithelium and Bruch membrane. Subretinal hemorrhage- It is located between the RPE(retinal pigment epithelium) and the photoreceptor layer. Disc hemorrhage (also known as Drance hemorrhage): Linear hemorrhages which are perpendicular to the optic disc. The most common location is at the superotemporal or inferotemporal margin. Submacular hemorrhage needs a special mention as it is directly responsible for the quality of vision.

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 33620856

Utah Controlled Substance Prescribing

StatPearls-/- 2021; ():

Chronic pain and opioid use and abuse is a significant problem in the United States.[1] Over one-quarter of United States citizens suffer from chronic pain.[2] It is among the most common complaints seen in an outpatient clinic and the emergency department. The failure to manage chronic pain and the possible complication of opioid dependence related to treatment can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence.[3] Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined.[4] How a patient's chronic pain gets managed can have profound and long-lasting effects on a patient's quality of life. The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months.[5] There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy is in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical.[6] Unfortunately, studies have revealed an inherent lack of education regarding pain management in most medical schools and training programs. The Association of American Medical Colleges recognized the problem and has encouraged schools to commit to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum. Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, under prescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. The American Society of Addiction Medicine describes addiction as a treatable chronic disease that involves environmental pressures, genetics, an individual's life experiences, and interactions among brain circuits. Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, they identify five characteristics of addiction: 1. Craving for drug or positive reward. 2. Dysfunctional emotional response. 3. Failure to recognize significant problems affecting behavior and relationships. 4. Inability to consistently abstain. 5. Impairment in control of behavior. Unfortunately, most health providers' understanding regarding addiction is often confusing, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for effectively dealing with the challenges of addiction. In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion contributed to the under-treatment of pain. Over time, the manual has eliminated these terms and now uses "substance use disorder," ranging from mild to severe. Unfortunately, there are numerous challenges in pain management, such as both underprescribing and overprescribing opioids. The concerns are particularly prominent in patients with chronic pain. They have resulted in patients suffering from inadequately treated pain while at the same time developing concomitant opioid abuse, addiction, diversion, and overdose. As a result, providers are often negatively influenced and fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. To make the challenges even worse, chronic pain patients often develop opioid tolerance, significant psychological, behavioral, and emotional problems, including anxiety and depression related to under or overprescribing opioids. Clinicians that prescribe opioids face challenges that involve medical negligence in either failure to provide adequate pain control or risk of licensure or even criminal charges if it is perceived they are involved in drug diversion or misuse. All providers that prescribe opioids need additional education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with over and under prescribing opioids. Provider Opioid Knowledge Deficit There are substantial knowledge gaps around appropriate and inappropriate opioid prescribing, including deficits in understanding current research, legislation, and appropriate prescribing practices. Providers often have knowledge deficits that include: Understanding of addiction. At-risk opioid addiction populations. Prescription vs. non-prescription opioid addiction. The belief that addiction and dependence on opioids is synonymous. The belief that opioid addiction is a psychologic problem instead related to a chronic painful disease. With a long history of misunderstanding, poor society, provider education, and inconsistent laws, the prescription of opioids has resulted in significant societal challenges that will only resolve with significant education and training.

*33620855*
 33620855

Endometriosis

StatPearls-/- 2021; ():

Endometriosis is a chronic gynecologic disease characterized by the development and presence of histological elements like endometrial glands and stroma in anatomical positions and organs outside of the uterine cavity. The main clinical manifestations of the disease are chronic pelvic pain and impaired fertility. The localization of endometriosis lesions can vary, with the most commonly involved focus of the disease the ovaries followed by the posterior broad ligament, the anterior cul-de-sac, the posterior cul-de-sac, and the uterosacral ligament.[1] Endometriotic nodules also affect the intestinal tract and the urinary system like the ureter, the bladder, and the urethra. Nevertheless, endometriosis is not limited to the pelvis but can damage extra pelvic structures like the pleura, the pericardium, or the central nervous system.[2] The main theories utilized to explain the pathogenesis of endometriosis are Sampson's theory, the coelomic metaplastic theory, the stem cell theory, the Mullerian remnant theory, and the vascular and lymphatic metastasis theory.

*33620854*
 33620854

Cameron Lesions

StatPearls-/- 2021; ():

Gastrointestinal bleed is the most common diagnosis among GI-related hospital admissions. Of all the GI hemorrhages, nearly 50% are due to upper GI bleeding. The most common causes of upper GI bleed include peptic ulcer disease, gastroesophageal varices, esophagitis, angioectasia, and vascular lesions. The etiology is unknown in about 8% of the cases.[1] Cameron lesion is a rare cause of occult upper GI bleed. Cameron lesions are linear gastric ulcers or erosions on the mucosal folds at the diaphragmatic impression in patients with a large hiatal hernia. Cameron lesions were first described in 1986 by Cameron and Higgins. The lesions were seen in people who had the chest X-ray showing one-third or more of the stomach above the diaphragm. Of the total cases, 50% were found to be anemic.[2][3]

*33620853*
 33620853

Therapeutic Communication

StatPearls-/- 2021; ():

Therapeutic communication as a concept emerged early in medicine and has since shown significant benefits borne out in research. Two of the earliest reported cases of therapeutic communication, which primarily involved the idea of the therapeutic relationship and the benefits of such a relationship, were documented during the moral treatment era of asylums.[1] Both of the patients were admitted in 1791 and 1800, and both responded to moral treatment, despite having severe symptomatology. In the late 1800s, Florence Nightingale had previously commented on the importance of the "communication that develops between the nurse and the patient" in the late 1800s.[2][3] She was quoted as saying, "Always sit within the patient's view, so that when you speak to him, he has not painfully to turn his head round to look at you. Everybody involuntarily looks at the person when speaking. So, also by continuing to stand, you make him continuously raise his eyes to see you...." In the 1950s, Harry Stack Sullivan and Jurgen Ruesch, prominent figures in interpersonal theory and communication, respectively, both published the importance of communication in providing therapeutic benefit, specifically in mental illness.[4][5] Other significant contributors to the concept of therapeutic communication and related topics include Carl Rogers, Hildegard Peplau, and Tudor.[6][7] Of note, Hildegard Peplau published her original paper in 1952 and later published subsequent reviews and revisions in 1991 and 1997, which provided a foundation for the concept of therapeutic communication.[6] This theory, named "Theory of Interpersonal Relations," was founded on integrating knowledge of Sullivan's interpersonal theory, as well as psychoanalysis, psychotherapy, and nurse therapy.[8] Peplau's theory described multiple "phases" of the interaction and considered the relationship as a primary mediator for the healing process. The importance of the relationship to healing is accepted in common factors of psychotherapy research as a factor with empirical support.[9] Other theorists include Travelbee, Rogers, and King, who have all contributed to the field of therapeutic communication.[10] "Therapeutic communication" ultimately emerged as a term in PubMed-indexed literature as early back as 1964 to 1965, in the setting of psychotherapy, psychiatry, sociology, medicine, rehabilitation, and nursing literature.[11][12][13][14] Since then, the concept of therapeutic communication has expanded to apply to many other fields, particularly in healthcare. Other terms in the literature that overlap with therapeutic communication include patient-centered communication and therapeutic relationships.

*33620852*
 33620852

Videostroboscopy

StatPearls-/- 2021; ():

Video endoscopy with stroboscopy (also known as videostroboscopy or stroboscopy for short) is the most commonly used method to visualize vocal fold vibration and is an essential tool for voice assessment.[1][2] It is used to evaluate the pliability of the vocal fold mucosae and is an indication of the health and function of the mucosal tissue and deeper layers. The term stroboscopy comes from the Greek words for "whirling" and "to look at." This phenomenon was described in the early 1800s from a rotating wheel with slits viewing images on a separate rotating wheel, which provided the visual perception of motion.[3] This technology was applied to the observation of vocal fold vibration and was first described by Oertel in 1895.[4] During voice production, the vocal folds vibrate at high speeds, unable to be perceived by the naked eye. Stroboscopy is used to "slow down" the vibration for assessment. It uses a flexible or rigid endoscope combined with a microphone and a flashing light (strobe). The microphone is placed next to the larynx and estimates the fundamental frequency of the voice. The strobe frequency is then synchronized to be slightly less than the fundamental frequency of the voice, thus capturing successive phases of the glottic cycle.[3] The image sequences are played in advancing order to produce a "slow-motion" video clip of the vocal folds during phonation.[4][5][6] Similar to a flipbook where a series of images produces a perception of motion. This sampling across successive glottic cycles represents an estimate of the underlying vibratory function. The mechanism of laryngeal stroboscopy historically had been mistakenly attributed to talbot's law and the pertinence of vision when, in fact, it is due to the visual perception phenomena of the perception of flicker-free images and perception of apparent motion when no real motion exists.[3] The mechanism of stroboscopy lends itself to a low-cost alternative to other technologies such as high-speed video (HSV), which requires a more specialized camera and large volume data storage. There are some drawbacks due to the sampling technique to stroboscopy. As only periodic vocal fold movements from successive glottic cycles are captured, aperiodicity or fluctuating vocal fold movements are unable to be tracked. Specific examples include diplophonia, a condition of producing two separate pitches that will disrupt the stroboscopy microphone in estimating the fundamental frequency and cause irregular flashing and an inconsistent set of images.[7] It may also not accurately represent the movements of a single glottal cycle if there is irregularity from cycle to cycle.[8]

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 33620851

Biventricular Devices

StatPearls-/- 2021; ():

Heart failure is one of the major causes of morbidity and mortality worldwide, and it is associated with poor life expectancy, poor quality of life, and a higher economic burden on the healthcare system.[1] Heart failure can result from several causes, but left ventricular systolic dysfunction is the major cause of heart failure. Over the past three decades, advances in the medical management of patients with heart failure with reduced ejection fraction have improved the survival of the patients, but the morbidity and mortality related to heart failure remained elevated.[2] With an increase in the age of the population and advances in the treatment of ischemic heart diseases, the number of patients with heart failure continues to grow, which has introduced significant challenges to managing cardiac arrhythmia and advanced heart failure.[3] In patients with heart failure with reduced ejection fraction, electromechanical dyssynchrony from intraventricular conduction delays leads to hemodynamic inefficiencies, which consequently worsen functional mitral regurgitation and left ventricular remodeling, eventually leading to poor outcomes.[4][5] In the early 1990s, it was identified that electromechanical dyssynchrony plays a prominent role in heart failure, and pacing devices that stimulate several places in the heart at once could be utilized to offset this dyssynchrony and conduction delay.[6] In the late 1990s, Auricchio and Kass first described the efficacy of multisite pacing in humans, which led to cardiac resynchronization therapy (CRT), the first use of artificial electrical stimulation for heart failure.[7] Since then, cardiac resynchronization therapy (CRT) has been an important treatment modality for heart failure patients with reduced ejection fraction.[8] In this review, we will discuss the use of implantable pacing devices in heart failure with a primary focus on biventricular pacing (cardiac resynchronization), and we will discuss the pathophysiology, indications, complications, and clinical significance.

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 33620850

Safe And Effective Administration Of Vaccines And Epinephrine Autoinjection

StatPearls-/- 2021; ():

Vaccine administration is an essential tool for facilitating health and wellness in the general population. Vaccinations are administered to infants, children, teenagers, adults, and the elderly, and it is crucial for health care professionals to understand how to administer vaccines and educate patients about immunizations. Discussions on vaccine administration can be divided into three separate areas: patient history and consent, the immunization itself, and typical issues following vaccinations, including anaphylaxis. The purpose of this article is to help medical professionals safely and competently administer immunizations, as well as be comfortable with administering an epinephrine auto-injection in the case of anaphylaxis following inoculation.

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 33620849

Amniotic Membrane Graft

StatPearls-/- 2021; ():

The human amniotic membrane grafting is used as an adjunctive procedure across surgical specialties and in translational medicine to cultivate stem cells. It is easily available, and techniques of preparation and storage are relatively inexpensive. Experts use amniotic membrane graft (AMG) in multiple specialties, including ophthalmologists, dentists, urologists, burn specialists, ear, nose, and throat surgeons, gynecologists, and researchers in stem cell technology.[1][2][3]

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 33620848

Balanitis Xerotica Obliterans

StatPearls-/- 2021; ():

Balanitis xerotica obliterans, also known as lichen sclerosus, are white inflammatory patches that can affect both males and females. In males, the affected areas usually involve the foreskin and penile glans, termed specifically balanitis xerotica obliterans. Urethral stricture disease and meatal stenosis are common sequelae of this condition.[1][2]

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 33620847

Neonatal Hyperglycemia

StatPearls-/- 2021; ():

Neonatal hyperglycemia is usually defined as serum glucose greater than 150 mg/dl (8.3 mmol/L) or whole blood glucose greater than 125 mg/dl (6.9 mmol/L) irrespective of gestational or postmenstrual age. Usually, the safe target for a neonate's blood glucose level is 70 to 150 mg/dl.[1] The cut off for safe target is based on the renal glucose threshold of preterm neonates.

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 33620846

Lenvatinib

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Lenvatinib is FDA approved for the treatment of radioactive iodine-refractory differentiated thyroid cancer (DTC), unresectable or advanced hepatocellular carcinoma (HCC), and advanced renal cell carcinoma (RCC). It is a multiple receptor tyrosine kinase inhibitor that demonstrates potent antiangiogenic properties. This activity will highlight the mechanism of action, adverse event profile, and other key factors pertinent to members of the interprofessional team in the management of patients with radioactive iodine-refractory differentiated thyroid cancer (DTC), unresectable or advanced hepatocellular carcinoma (HCC), and advanced renal cell carcinoma (RCC).

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 33620845

Human Growth and Development

StatPearls-/- 2021; ():

In the context of childhood development, growth is defined as an irreversible constant increase in size, and development is defined as growth in psychomotor capacity. Both processes are highly dependent on genetic, nutritional, and environmental factors. Evaluation of growth and development is a crucial element in the physical examination of a patient. A piece of good working knowledge and the skills to evaluate growth and development are necessary for any patient's diagnostic workup. The early recognition of growth or developmental failure helps for effective intervention in managing a patient's problem. Stages in Human Growth and Development 1. Fetal stage: Fetal health issues can have detrimental effects on postnatal growth. One-third of neonates with intrauterine growth retardation might have curtailed postnatal growth.[1] Good perinatal care is an essential factor in promoting fetal health and indirectly postnatal growth. 2. Postnatal stage: The process of postnatal growth and development happens together but at different rates. The growth occurs by discontinuous saltatory spurts with a stagnant background.[2] There are five significant phases in human growth and development, 1. Infancy (neonate and up to one year age). 2. Toddler ( one to five years of age). 3. Childhood (three to eleven years old) - early childhood is from three to eight years old, and middle childhood is from nine to eleven years old. 4. Adolescence or teenage (from 12 to 18 years old). 5. Adulthood. Factors Affecting Growth and Development The growth and development are positively influenced by factors, like parental health and genetic composition, even before conception.[3]: 1. Genetic factors play a primary role in growth and development. The genetic factors influencing height is substantial in the adolescence phase.[4] A large longitudinal cohort study of 7755 Dutch twin pairs has suggested that the additive genetic factors predominantly explained the phenotypic correlations across the ages for height and body mass index.[5] 2. Fetal health has a highly influential role in achieving growth and development. Any stimulus or insult during fetal development causes developmental adaptations that produce permanent changes in the latter part of life. 3. After birth, the environmental factors may exert either a beneficial or detrimental effect on growth.[6]. 4. Socioeconomic factors: Children of higher socio-economical classes are taller than the children of the same age and sex in the lower socioeconomic groups. Urbanization has positively influenced growth. The secular trend is observed in growth where the kids grow taller and mature more rapidly than the previous generation. This secular trend is observed significantly in developed countries like North America. The family characteristics: Higher family education levels have a positive impact on growth. The inadequate emotional support and inadequate developmental stimulus, including language training, might cause growth and development deterioration. The human-made environment influences human growth and development significantly. Certain ongoing studies have proven the relationship of pollutants in sexual maturation, obesity, and thyroid function.[7] The excess lead exposure antenatally significantly associates with low birth weight. Noise pollution due to transportation sources also has an association with reduced prenatal growth. Nutrition 1. Malnutrition plays a detrimental role in the process of growth and development. 2. Deficiencies of trace minerals can affect growth and development.[8] Iron deficiency usually affects psychomotor development and does not affect growth. Zinc deficiency might cause growth retardation and developmental delay. Selenium, iodine, manganese, and copper also play a significant role. 3. Growth faltering or rapid weight gain in early childhood influences health in the later part of life. The diet in early childhood has a strong association with the likelihood of obesity later in life. 'Early Protein Hypothesis' shows that lowering the protein supply during infancy helps achieve normal growth and reduce obesity in early childhood.[9] This concept of the early protein hypothesis helps in improving the food products for children. 5. Genetic and environmental factors influence the growth and development in a perplexing interrelated pathway. Genetic and environmental risk factors are not mutually exclusive. Plasticity is the potential of a specific genotype to bring out diversified phenotypes in response to diverse environmental factors.[10] The developmental plasticity can happen from the embryonic stage to adolescence and can be passed onto the next generation. 6. Role of experience during early childhood: Exposure to adverse experiences in early childhood might hinder development. Profound neglect during early childhood can impair development. Children adopted before six months of age have similar development when compared to their non-adoptive siblings. If children adopted after six months have a high risk of cognition deficits, behavioral issues, autism, and hyperactivity.[11] Early intervention for children with adverse experiences is the pillar in healthy development.

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Breast Ductal Carcinoma in Situ

StatPearls-/- 2021; ():

Ductal carcinoma in situ (DCIS), also referred to as intraductal carcinoma, is a non-invasive breast cancer characterized by a proliferation of abnormal epithelial cells confined within the basement membrane. Disruption of the basement membrane layer would change the diagnosis from DCIS to invasive breast cancer. DCIS is considered to be a precursor for invasive breast cancer.[1] Specifically, the World Health Organization defines the term DCIS as "a neoplastic proliferation of epithelial cells confined to the mammary ductal-lobular system and characterized by subtle to marked cytologic atypia and an inherent but not necessarily obligate tendency to progression to invasive breast cancer."[2] Although grouped, DCIS is, in reality, a heterogeneous group of lesions that varies in the clinical presentation, genetics, biomarkers, morphologic features, as well as the clinical potential to progress to invasive breast cancer. Rates of diagnosis have been increasing with the use of screening mammography that detects pre-clinical microcalcifications. However, the diagnosis of DCIS does require a tissue biopsy. The treatment for DCIS is multidisciplinary and may include surgery, hormone therapy, and radiation therapy.

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 33620843

New Onset Refractory Status Epilepticus

StatPearls-/- 2021; ():

The International League Against Epilepsy (ILAE) defines status epilepticus (SE) as continuous clinical and/or electrographic seizure activity, or recurrent seizure activity without recovery to baseline, lasting for >/= 5 mins.[1] If the seizure activity continues despite treatment with adequate doses of an initial benzodiazepine and an acceptable second-line intravenous (IV) antiepileptic medication, the patient is considered to have progressed into refractory status epilepticus (RSE).[2] Super refractory status epilepticus (SRSE) is defined as RSE that continues or recurs despite the use of IV anesthetic agents for >/= 24 hours, including those cases that recur upon withdrawal or cessation of anesthetic agents.[3] RSE is seen in approximately 9% to 43% of all SE cases, with a reported in-hospital mortality of 15% to 33%.[4][5] It has been observed that approximately 4% to 12% of patients with SE eventually progress to SRSE, with in-hospital mortality reported to be as high as 40% to 54%.[6][7][8] The term new-onset refractory status epilepticus (NORSE) was first used by Wilder-Smith et al. in 2005 to describe cases of SRSE with no associated past medical history of epilepsy and with no identifiable cause despite initial evaluation.[9] In 2018 an international group of experts proposed a consensus definition of NORSE and related conditions to allow a more standardized terminology to improve patient management and clinical research. NORSE is defined as a "clinical presentation characterized by new onset of refractory status epilepticus, in a patient without active epilepsy or other preexisting relevant neurological disorder (acute strokes, brain masses, drug overdoses, etc.), and without a clear acute or active structural, toxic or metabolic cause." A closely related condition, febrile infection-related epilepsy syndrome (FIRES), has been defined as a subset of NORSE, associated with a prior febrile infection, with fever starting between 2 weeks to 24 hours before the onset of RSE.[10] In contrast, patients with NORSE may or may not be associated with fever before the start of RSE.

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 33620842

Serum Osmolality

StatPearls-/- 2021; ():

Osmolality indicates the concentration of all the particles dissolved in body fluid. It is routinely measured in clinical laboratories for the differential diagnosis of disorders related to the hydrolytic balance regulation, renal function, and small-molecule poisonings.[1] Serum and urine osmolality tests are usually measured together to be compared and reach the diagnosis of any disease that influences osmolality. Serum osmolality is affected by the concentration of blood chemicals like chloride, sodium (Na), proteins, bicarbonate, and glucose. The blood urea nitrogen (BUN) measurement is important for calculating the serum osmolality. Specific therapies and toxins that affect an individual's fluid balance should also be evaluated with serum osmolality. The 1975 Dorwart and Chalmers formula, serum osmolality = 1.86(Na) + (glucose/18) + (BUN/2.8) + 9 had been often used to calculate the plasma osmolality.[2] In 1976, Smithline and Gardner, proposed to use serum osmolality = 2(Na) + glucose/18 + BUN/1.8 as a simpler formula.[3] In 1987, Worthley et al. concluded that the best formula was the simple Smithline-Gardner formula, where the plasma concentrations are measured in mmol/l.[4] Many other formulas have been developed and used over the years, but the simple Smithline-Gardner formula remains the most useful.[5][6] Some authors argue that the formula 1.86(Na+K)+1.15(Glu/18)+(Urea/6)+14 is the most precise of them.[7] The normal serum osmolality should range from 275 to 295 mOsm/kg.[2][8] Water normally flows from the compartment of low osmolality to the compartment of high osmolality; this only occurs if the membrane between the two compartments is permeable to water. When water moves between plasma and intracellular compartments, the movement direction depends on both compartments' osmolalities. For example, if a cell is in a relatively hyperosmolar solution, fluid will move out of the cell towards the highly concentrated compartment to reach homeostasis. As a result, the cell will shrink.

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 33620841

EMS Long Spine Board Immobilization

StatPearls-/- 2021; ():

Blunt traumatic injuries are the leading cause of spinal cord injuries in the United States, with an annual incidence of approximately 54 cases per million population and about 3% of all blunt trauma admissions to the hospital.[1] Although spinal cord injuries represent only a small percentage of blunt trauma injuries, they are among the largest contributors to morbidity and mortality.[2][3] As a result, in 1971, the American Academy of Orthopedic Surgeons proposed using a cervical collar and a long spine board for spinal motion restriction for patients with suspected spinal injuries, which was based entirely on the mechanism of injury. At the time, this was based on consensus rather than evidence.[4] In the decades since spinal motion restriction, using a cervical collar and long spine board has become the standard in prehospital care. It can be found in several guidelines, including the Advanced Trauma Life Support (ATLS) and Prehospital Trauma Life Support (PHTLS) guidelines. Despite their widespread use, the efficacy of these practices has been called into question. In one international study comparing those who underwent spinal motion restriction to those who did not, the study found that those who did not receive routine care with spinal motion restriction had fewer neurologic injuries with disability. However, it should be noted that these patients were not matched for the severity of the injury.[5] Using healthy young volunteers, another study looked at lateral spine motion on a long spine board compared to a stretcher mattress and found that the long spine board allowed the greater lateral motion.[6] In 2019, a retrospective, observational, multi-agency prehospital study examined whether or not there was a change in spinal cord injuries after implementing an EMS protocol that limited spinal precautions to only those with significant risk factors or abnormal exam findings and found that there was no difference in the incidence of spinal cord injuries.[7] There are currently no high-level randomized control trials to either support or refute the use of spinal motion restriction. It is unlikely there will be a patient to volunteer for a study that could result in permanent paralysis violates current ethical guidelines. As a result of these and other studies, newer guidelines recommend limiting the use of long spine board spinal motion restriction to those with a concerning mechanism of injury or concerning signs or symptoms as described later in this article and limiting the duration that a patient spends immobilized.

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 33620840

Anatomy, Head and Neck, Suboccipital Muscles

StatPearls-/- 2021; ():

The suboccipital muscles are a group of four muscles that are located inferior to the occipital bone. These four muscles include the rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis superior, and obliquus capitis inferior. The muscles serve as postural support and allow extension and rotation movements of the neck. The muscles are innervated by the suboccipital nerve, which is formed by the dorsal ramus of C1. Three of the four muscles form the suboccipital triangle, a common anatomic landmark that localizes the vertebral artery and suboccipital nerve. This landmark is of particular importance to surgeons who operate in the posterior cervical region to avoid life-threatening bleeding. The vertebral artery travels a torturous course behind the suboccipital muscles while giving off branches that supply the suboccipital muscles. Clinically, the suboccipital muscles have importance regarding their close relationship to the vertebral artery and surgical access to the posterior cranial fossa. Various cranial pathologies can be accessed by a suboccipital surgical approach that requires knowledge of the posterior cervical region. The group of four muscles has been implicated in the pathogenesis of cervicogenic headaches due to their connections with the dura mater.

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 33620839

Renal Mass

StatPearls-/- 2021; ():

Renal mass is an abnormal growth in the kidney. The majority of renal masses are benign; however, a significant number of them require further intervention. The retroperitoneum's anatomy, signs, symptoms, or physical examination are insufficient for detecting renal masses. Imaging modalities such as CT, MRI, or ultrasound are used to diagnose such masses. Renal masses are classified into either solid or cystic. This review will focus on the solid tumor with minimal discussion on the cystic type. One of the main concerns for a solid renal mass is carcinoma. There were about 74,000 new cases in 2019; of these, it is expected that 15,000 patients will die from cancer. The five-year survival rate increases with early diagnosis. The survival rate for stage 1 and 2 renal cell carcinoma (RCC) is above 90% versus below 15% for certain types of stage 3 or metastatic disease.[1] Therefore, it is essential to diagnose and evaluate new renal masses in a timely manner to improve our patients' quality of life and prognosis. Arguably, the most critical indication of malignancy is the size of a tumor. Renal mass is commonly divided into two size categories; less than 4cm and more than 4cm. Because of the advancement of imaging tests such as CT, MRI, and ultrasound, more masses are detected incidentally during other workups. A cross-sectional study performed in 2011 showed that renal masses are found incidentally in 14% of patients who underwent CT colonography.[2] Since renal mass is a diverse subject with many nuances in both treatment and management, this review will explore renal mass, emphasizing small renal masses because of clinical practice relevance. We will examine the etiologies, diagnosis, and management of renal mass.

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 33620838

Ovarian Cancer

StatPearls-/- 2021; ():

Ovarian cancer is the leading cause of death in women diagnosed with gynecological cancers. It is also the fifth most frequent cause of death in women, in general.[1] Most of the cases are diagnosed at an advanced stage, which leads to poor outcomes of this disease. The existing screening tests have a low predictive value contributing further to this misery. Detailed gynecological evaluation along with transvaginal ultrasound and laboratory marker like cancer antigen-125 (CA-125) assay are the key early detection strategies which have shown no significant beneficial effect in the morbidity or mortality of this cancer.[2] The standard line of care treatment includes surgery and platinum-based chemotherapy; however, anti-angiogenic bevacizumab and Poly(ADP-ribose) polymerase (PARP) inhibitors have gained momentum in the management of this gynecological malignancy in the past decade.[3] A high rate of recurrence following the initial treatment has been observed. Most of these relapsed cases are less curable and known to have an increased incidence of treatment failures. Hence, effective prevention and detection strategies and new treatment modalities based on a better understanding of molecular characterization of this cancer are the need of the hour. This article reviews the epidemiology, risk factors of ovarian cancer and also highlights the evaluation and multidisciplinary approach in the management of this condition, along with a discussion of a few of the recent ongoing trials.

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 33620837

Enterococcus Infections

StatPearls-/- 2021; ():

Enterococci are Gram-positive facultative anaerobic cocci in short and medium chains, first discovered in 1899 in the human gastrointestinal tract. They were recognized as a separate genus from streptococci by DNA hybridization and 16S rRNA sequencing in 1984.[1] They are the first of the ESKAPE organisms (Enterococci spp., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp.) highlighted by the WHO as rising causes of nosocomial and antibiotic-resistant infections in the last few decades threatening public health.[2] Vancomycin-resistant enterococci (VRE) were first reported in 1933 in animals owing to the use of Avoparcin, which was a vancomycin analog used as an animal food additive. However, they were reported for the first time in humans in England in 1988, several years later.[3][4]

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 33620836

Atezolizumab

StatPearls-/- 2021; ():

Atezolizumab is a humanized IgG1 monoclonal anti-programmed death-ligand 1 (PD-L1) antibody that has been approved by the U.S Food Drug Administration (FDA) for various neoplastic conditions either as a single agent or in combination with other chemotherapeutic agents. Atezolizumab is a drug that is used in the management and treatment of various neoplastic conditions. It is in the monoclonal antibody class of medications. This activity covers the indications, contraindications, adverse events, and other therapeutic factors clinicians need to know to drive patient outcomes effectively.

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 33620835

Pericapsular Nerve Group Block

StatPearls-/- 2021; ():

Hip and knee surgery is a common orthopedic surgery among the elderly. In 2010 the prevalence of total hip replacement at fifty years of age was 0.58% and increased to 5.26% at eighty years in the United States (US).[1] A recent US study projected that compared to 2010, annual use of primary knee and hip total joint arthroplasty would increase by 210% (655K to 1375K) and 174% (293K to 512K) in 2020, respectively.[2] In 2015 the prevalence of total hip arthroplasty was estimated as more than 2.5 million individuals in the entire United States population.[3] Osteoporosis and osteoarthritis contribute significantly to the surgical indication. There is a wide diversity in the patient population requiring hip surgery; children with congenital hip dysplasia, young athletic adults who undergo hip arthroscopy, and frail elderly patients with multiple medical problems who experience traumatic accidents following mechanical falls. 7 to 28% of operated patients develop chronic pain after a hip surgery.[4] Regional anesthesia offers significant benefits in both pain control and recovery in patients undergoing total hip arthroplasties (THA). There is a wide range of regional anesthetic techniques. The most used in this anatomical area and the most supported by published literature are lumbar plexus block, femoral nerve block, and fascia iliaca block. Other techniques, such as selective obturator nerve infiltration and lateral femoral cutaneous nerve blocks, represent alternatives. New approaches have been described, such as quadratus lumborum block and local infiltration analgesia. However, these techniques require rigorous prospective studies.[5][6] A recent anatomical study on hip innervation has made it possible to identify the relevant landmarks targeted on the hip joint branches from the femoral nerve and the accessory obturator nerve. A new regional anesthesia technique is thus discovered called pericapsular nerve group block (PENG), which targets the anterior capsule of the hip by blocking these nerves.[7] The PENG block, first described by L Giron-Arango et al., is a novel regional analgesia technique to reduce pain after total hip arthroplasties (THA) while sparing motor function. This technique involves the deposition of the local anesthetic in the fascial plane between the psoas muscle and the superior pubic ramus. This is an interfascial plane block aiming to block articular branches supplied by femoral, obturator, and accessory obturator nerves, and is a promising regional anesthetic technique as an alternative to other regional nerve blocks such as femoral nerve block or an iliac fascia nerve block.[8][7][8]

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 33620834

Tennessee Controlled Substance Prescribing For Acute and Chronic Pain

StatPearls-/- 2021; ():

Opioid use and abuse for acute and chronic pain are a significant problem in the United States and Tennesee.[1][2][3] The rate of overdose-related to the use of illicit opioids has drastically increased in the United States, and the hardest hit is Tennesee. According to CDC, approximately 2,000 die each year. Over one-quarter of United States citizens suffer from chronic pain.[4] It is among the most common complaints seen in an outpatient clinic and the emergency department. The failure to manage acute and chronic pain appropriately and the possible complication of opioid dependence related to treatment can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence.[5] Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined.[6] How a patient's chronic pain gets managed can have profound and long-lasting effects on a patient's quality of life. The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months.[7] There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy is in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical.[8] Unfortunately, studies have revealed an inherent lack of education regarding pain management in most medical schools and training programs. The Association of American Medical Colleges recognized the problem and has encouraged schools to commit to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum. Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, under prescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. The American Society of Addiction Medicine describes addiction as a treatable chronic disease that involves environmental pressures, genetics, an individual's life experiences, and interactions among brain circuits. Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, they identify five characteristics of addiction: 1. Craving for drug or positive reward. 2. Dysfunctional emotional response. 3. Failure to recognize significant problems affecting behavior and relationships. 4. Inability to consistently abstain. 5. Impairment in control of behavior. Unfortunately, most health providers' understanding regarding addiction is often confusing, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for effectively dealing with the challenges of addiction. In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion contributed to the under-treatment of pain. Over time, the manual has eliminated these terms and now uses "substance use disorder," ranging from mild to severe. Unfortunately, there are numerous challenges in pain management, such as both underprescribing and overprescribing opioids. The concerns are particularly prominent in patients with chronic pain and have resulted in patients suffering from inadequately treated pain while at the same time there has been a development of concomitant opioid abuse, addiction, diversion, and overdose. As a result, providers are often negatively influenced and fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. To make the challenges even worse, chronic pain patients often develop opioid tolerance, significant psychological, behavioral, and emotional problems, including anxiety and depression related to under or overprescribing opioids. Clinicians that prescribe opioids face challenges that involve medical negligence in either failure to provide adequate pain control or risk of licensure or even criminal charges if it is perceived they are involved in drug diversion or misuse. All providers that prescribe opioids need additional education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with over and under prescribing opioids. Provider Opioid Knowledge Deficit There are substantial knowledge gaps around appropriate and inappropriate opioid prescribing, including deficits in understanding current research, legislation, and appropriate prescribing practices. Providers often have knowledge deficits that include: Understanding of addiction. At-risk opioid addiction populations. Prescription vs. non-prescription opioid addiction. The belief that addiction and dependence on opioids is synonymous. The belief that opioid addiction is a psychological problem instead related to a chronic painful disease. With a long history of misunderstanding, poor society, provider education, and inconsistent laws, the prescription of opioids has resulted in significant societal challenges that will only resolve with significant education and training. Definitions[9][10][11]: Abuse - Maladaptive pattern of opioid use for a purpose other than pain relief. Addiction - Compulsive pursuit of a chemical substance to find relief or reward. Dependence - Use of a drug that causes a withdrawal syndrome with cessation or reduction in the amount administered. Diversion - Transfering a controlled substance from an authorized person's use to an unauthorized person's use for distribution or possession. Misuse - Use of a medication in a manner different than how it was prescribed. Pseudo-addiction - Aberrant drug-seeking behavior similar to opioid use disorder driven by a need for relief of pain, resolves with pain control. Tolerance - Adaption to the effect of a drug.

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Kidney Transplantation

StatPearls-/- 2021; ():

Kidney transplantation is often the preferred treatment for those with end-stage renal disease.[1] The discipline of kidney transplantation has grown tremendously over the past 50 years. Patients with end-stage renal disease have better long-term survival if they are placed on the waiting list and eventually undergo kidney transplantation than those who stay on dialysis.[2] Furthermore, those who undergo transplantation often experience a better quality of life and a projected survival benefit of 10 years over those who remain on dialysis.[2] Since kidney transplantation was first successfully performed by Dr. Joseph Murray in 1954, there have been major developments in transplantation and immunology, allowing for a wider selection of acceptable donors and recipients.

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 33620832

Nephrogenic Systemic Fibrosis

StatPearls-/- 2021; ():

Nephrogenic systemic fibrosis (NSF) is a progressive multiorgan fibrosing condition mainly caused by patients' exposure to gadolinium-based contrast agents (GBCAs) used for magnetic resonance imaging (MRI).[1] This condition is primarily characterized by thickening of the skin and subcutaneous tissue in addition to systemic manifestations. The clinical features may involve any fibrous tissue in the body, including the internal organs such as the liver, heart, muscles, and lungs.[2][3][4] NSF is a clinically highly variable condition. Some patients may have only mild skin affection, other patients may have limited movement, and rarely, the disease may be lethal.[2] The condition was first described in 2000; however, several years later, a group of nephrologists explained the pathophysiology and the important role of GBCAs to induce this condition.[1][5][6] It occurs in patients with acute or severe chronic renal failure with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73 m^2.[7][8] The condition was initially called nephrogenic fibrosing dermopathy due to the cutaneous manifestations.[5][6][9][10][11] The term gadolinium-induced fibrosis or gadolinium-induced NSF has also been used.[1][12][13] Patients with severe renal insufficiency are at high risk of developing this condition if GBCAs are used in MRI. The incidence rate was dramatically reduced in the last years due to strict adherence of the health care providers with the regulatory guidelines that advise the radiologists to avoid using high-risk GBCAs in severe renal failure.

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 33620831

Scaphocephaly

StatPearls-/- 2021; ():

Scaphocephaly is the term used to describe the narrow and long abnormal skull shape in sagittal craniosynostosis due to the premature fusion of the sagittal suture forming an osseous ridge.[1] The head shape is described as a "boat-shaped" head, which is called dolichocephaly. It is the most common type of craniosynostosis. It is essential to make an early diagnosis since a delay may lead to abnormal growth of the cranial vault and affect brain growth and development.

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 33620830

Nail Biopsy

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The nail biopsy is an essential procedure utilized by dermatologists to establish the diagnosis of a variety of skin and nail pathologies. The nail biopsy encompasses several biopsy techniques that include but are not limited to the nail plate, nail bed, nail fold, and nail matrix.[1][2] The favored underlying diagnosis often determines the site of the biopsy and the techniques employed. The nail matrix is very delicate and carries its own biopsy risks and side effects. Even so, the majority of nail biopsies carry minimal to no risk of permanent nail dystrophy.[3]

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 33620829

Sacral Neuromodulation

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Sacral neuromodulation (SNM) is a safe, efficacious and minimally invasive advanced therapy indicated to treat urinary incontinence, urinary retention, urgency, frequency, and fecal incontinence in the United States for patients refractory to behavioral and pharmacologic therapy. In Canada and Europe, it is also indicated for chronic constipation.[1] Sacral neuromodulation therapy was developed in 1982 by Tanagho and Schmidt, gaining FDA approval in 1997.[2][3] To date, there have been approximately 300,000 patients treated with sacral neuromodulation implants worldwide.[4] Reviews suggest that between 16% to 29% of the population, with a few estimating up to 75%, experience some level of overactive bladder, including symptoms of urinary incontinence, urgency, or frequency.[5][6] Additionally, an estimated 25% to 40% of patients experiencing overactive bladder fail to achieve satisfactory results after first and second-line therapy (behavioral modifications and pharmacotherapy, respectively).[7] These patients have refractory overactive bladder and may be eligible for SNM therapy. SNM has been proven to produce good clinical results in otherwise intractable cases. One study conducted by Siegel et al. evaluated the therapeutic success rate in 340 patients using SNM at 36 months. The success rate for overactive bladder was 83% for patients who underwent SNM implantation (95% CI). Additionally, 80% of patients reported improvement in all urinary symptoms.[8][9] The mechanism of action of sacral neuromodulation is not completely understood. However, the therapy seems to modulate spinal cord reflexes and brain involvement via afferent signaling rather than direct motor stimulation of the detrusor or urethral sphincter.[10] The most widely accepted theory suggests that SNM blocks or otherwise interfere with the afferent input to the sacral spinal co, inhibiting detrusor overactivity resulting in clinical relief of urinary frequency and urgency.[11]

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 33620828

Rhinoplasty Tip-shaping Surgery

StatPearls-/- 2021; ():

Tip-shaping or refinement is a common request during a consultation for cosmetic nasal surgery. However, surgery of the nasal tip has a unique set of functional and aesthetic challenges that must be understood by the rhinoplasty surgeon to ensure a successful outcome. Unfortunately, poor nasal tip cosmesis or function is a frequent factor leading dissatisfied patients to seek secondary or revision rhinoplasty surgeries. Understanding the anatomic relationships of the nasal tip allows the surgeon to competently perform the surgical maneuvers required to create desired aesthetic changes while preserving function.

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 33620827

Nuclear Medicine Test

StatPearls-/- 2021; ():

Nuclear medicine is conducted by administering small doses of radioactive material to a patient and then using a device, gamma cameras, to detect the location of the material. There are a variety of radiotracers that can be given to a patient either through injection, inhalation, or ingestion. The most commonly used radiotracers include indium-111, technetium-99m, gallium-67, and fluorodeoxyglucose. All of these materials emit gamma radiation, which is picked up by an imaging device to determine a specific function of the patient's body.[1][2] Depending on which radiotracer is used, the radioactive material will be eliminated from the patient's body by either the lungs, urine, or stool within hours to days.[3] The process of administering radiotracers into the patient, instead of from an external source, is referred to as endoradiology. Nuclear medicine differs from other imaging studies because it can show the anatomic structures of the body and the function of organs. It can even show processes down to the molecular and cellular level, such as blood flow, cellular metabolism, expression of cell receptors, and more.[1][2][4]

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 33620826

Gallium Scan

StatPearls-/- 2021; ():

A gallium scan is a study that uses intravenously injectable isotopes of gallium to produce nuclear medicine images. Gallium was one of the first radioisotopes used for diagnostic nuclear medicine. Gallium, discovered in 1875 by Paul-Emile Lecoq de Boisbaudran, was first considered for diagnostic and therapeutic medical use in the 1940s by the research of H. C. Dudley and his co-workers. Gallium scans were initially used for localizing tumors and abscesses. Commercially available radiopharmaceuticals gallium-67 (67Ga) and gallium-68 (68Ga) are widely used. Although gallium-72 proved less useful for medical use, gallium-67, produced by proton bombarded zinc, and particularly gallium-68, produced by generator accelerating of germanium-68 (68Ge), emerged as solid contenders after measurement instrumentation became more advanced. Initially, gallium-67 was unexpectedly found to highlight Hodgkin's lymphoma, although it was intended for osseous cancer. It was later realized that the isotope could be used for a broader range of malignancies and inflammatory processes.[1] Historically, gallium-67 scans were used to diagnose many diseases, including bone infections, cancers (especially lymphomas), fevers of unknown origin, non-specific inflammation, and intra-abdominal abscesses. It was also used to evaluate inflammatory disease of the lungs like sarcoidosis, interstitial pneumonitis, pulmonary tuberculosis, and pulmonary fibrosis.[2] Gallium-67 is used with single-photon emission computed tomography (SPECT), while gallium-68 is used with positron emission tomography (PET). Gallium is trivalent metal and treated similarly to ferric iron in the body. Gallium-67 is relatively insoluble at normal pH and requires substances like citrate ions to form a complex to dissolve once in the body. Roughly 75% of the administered dose remains in the body after 48-72 hours and distributes evenly in soft tissues, liver, and bone. Around 90% of 67Ga is bound to transferrin in the blood plasma. Subsequently, it dissociates at low pH (exudate, or tumor site) and binds to lactoferrin due to vascular flow increased in the area. White blood cells may bind and transport 67Ga as well. Siderophores produced by bacteria have a good affinity for 67Ga and can form a complex to be taken up by the bacteria. It is also thought that bacteria have direct uptake of 67Ga via facilitated diffusion and nonspecific binding sites.[3] Gallium-68 (68Ga) is a positron-emitting isotope with a half-life of 68 minutes. It can be generated from germanium-68 or zinc-68. It can be used for the inherent properties in the radiometal itself or the chelated agent's chemical properties (most commonly a somatostatin analog). It is often attached to a specific chelating agent to be used as a tracer (e.g., DOTA-octreotate, also known as DOTATATE). The agent keeps gallium stably bound and free to distribute while binding to a specific receptor molecule. DOTATATE, DOTATOC, and DOTANOC are also referred to as GaTate, GaToc, and GaNoc, respectively. Bifunctional chelating is used to bind the metal (68Ga3+ ion) to a complex. The complex should have a high affinity with gallium for in vivo stability, while the targeting biomolecule (ex. drug, peptide, or antibody) in the complex is free to bind to a specific site and concentrate there. Essentially, gallium is paired with a compound that binds to a target tissue site. The complex is injected intravenously and is imaged with a PET detector at specific times depending on the desired target site uptake, but usually after one hour. In the case of GaTate, affinity is highest to the somatostatin receptor (SSTR) subtype 2. This leads to intense uptake in the spleen, adrenal glands, kidneys (not due to SSTR), and pituitary, with moderate intensity in the liver (not due to SSTR), thyroid, and saliva glands. There is also uptake in other areas such as the pancreas, bone, brain, and lymph nodes.[4] GaToc has a high affinity to SSTR subtype 5, and GaNoc has a high affinity to SSTR subtypes 3 and 5. A homogenous uptake is physiologic, while intense heterogeneous, irregular focal uptake is worrying. The PET scan is usually done with a whole-body computed tomographic (CT) scan for detailed anatomical mapping, referred to as a PET/CT scan. The renewed interest in gallium is due to its widespread availability as it is generator-produced and has a short half-life. Using gallium, on-site labeling, and radiopharmaceutical use can be done without a cyclotron nearby or delivering the product. The radiolabel paired has varying sensitivity and specificity inherent to the tissue or receptor properties.[5] DOTATATE has recently been given orphan drug status, and that also has renewed some of the interest in gallium-68. Gallium-67 is a gamma-emitting isotope with a half-life of 3.26 days that was used for imaging many pathologies, although now, fluorine-18 (18F) fluoro-deoxyglucose (FDG) (18F-FDG) has mostly replaced it. Both isotopes require a high-energy cyclotron for production and for doses to be individually purchased; therefore, they are not always available. 18F-FDG, a nonspecific metabolic indicator using glucose metabolism, has mostly replaced gallium-67, but recently there have been new developments in gallium's utility, now as a gallium-68 labeled radiotracers. This evolution includes a shorter half-life, on-site generation, somatostatin receptor, prostate (68Ga-PSMA-11 PET/MR) tracers, and other cancer diagnoses, including boney and soft tissue metastasis.[6][7] Gallium-67 (67Ga) is still used for imaging inflammation and granulomatous reactions. It produces low resolution and image quality and has a high radiation burden to patients due to its longer half-life. Imaging takes place at least two days after injection due to this long half-life. Gallium-67 is commonly bonded with citrate or nitrate (both dissociate in the blood when injected, leaving the gallium ion, 67Ga3+). Although WBC SPECT imaging has mostly replaced gallium-67 for infection imaging, there are still specific circumstances for it to be used. Examples include to rule out false negatives on spinal infections, immunocompromised patients, and chronic infections.[8] Gallium-68 is typically created by a 68Ge/68Ga generator. This process has an advantage over 18F-FDG, as 68Ga does not require a nearby cyclotron, and the parent isotope 68Ge has a half-life of 271 days. 68Ge is usually made from proton bombardment of 69Ga.[9] 68Ge decays through electron capture. 68Ga mostly decays through positron emission (yields 89%) with a mean MeV of 0.89 and maximum energy of 1.9MeV.[10] That is higher energy than 18F (with positron yield 96.7%), which is 0.25 MeV and max 0.63MeV. Since lower positron emission yields and higher endpoint energy emission leads to lower resolution in PET scans, this causes Gallium to have a theoretically lower resolution on imaging. Gallium has lower sensitivity and inferior spatial resolution than 18F, but gallium has a high clinical image contrast when labeled, making lesion detection easier.[10] Moreover, both radionuclides produce high-quality imaging as long as a 3mm detection scanner is used.[11] Imaging can occur in approximately one hour due to the short half-life. The 68Ga3+ cation allows it to join various molecules using oxygen, nitrogen, and sulfur as atom donors. Due to increased gallium-68 demands, it can also be created by a medical cyclotron.[12] Originally 68Ga was paired with ligands such as EDTA (ethylenediaminetetraacetic acid) derivatives, and years later, developed pairing with DTPA (diethylenetriaminepentaacetic acid) or DOTA (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid)-based derivatives. This allowed 68Ga-DOTA-octreotate to become an alternative to Indium-111-DTPA-octreoscan.[13] 68Ga can be paired with many molecules, including citrate, which gives it the same site affinities as 67Ga, but lower half-life. There are currently trials pairing 68Ga with antimicrobials such as ciprofloxacin and DOTA-depsidomycin.[8]

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Tapia Syndrome

StatPearls-/- 2021; ():

Tapia syndrome was first described by Spanish otorhinolaryngologist Antonio Garcia Tapia in 1904 as a lesion outside the central nervous system causing neurological signs and symptoms.[1] Nowadays, it is recognized as a rare complication of airway manipulation, with less than 100 cases described in the literature. The syndrome is characterized by unilateral paralysis of the tongue and vocal cord, manifesting as dysphonia, tongue deviation, and swallowing difficulty.[2] Although there is an increased propensity with specific procedures, Tapia syndrome can technically occur with any surgery requiring general anesthesia and orotracheal intubation.[3]

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Sonography Vascular And Lymphatic Assessment, Protocols, And Interpretation

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Ultrasonography is the use of sound waves to generate medical diagnostic images. The portability, cost-effectiveness, and non-invasive nature of ultrasound have contributed to its widespread use over recent decades.[1] Vascular ultrasound is a generalized term that includes venous duplex and Doppler sonographic assessment of myriad arterial and venous pathology, most commonly including peripheral arterial disease, arterial aneurysms, vascular malformations, venous thrombosis, and venous insufficiency. Sonography can also provide information about the lymphatic system via the depiction of lymph node size and morphology.[2] Herein, the broad general principles of arterial, venous, and lymph node sonography are discussed, with application to some of the more commonly encountered pathologies.

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Pilot Medical Certification

StatPearls-/- 2021; ():

A Federal Aviation Administration (FAA) flight physical is a physical examination for "fitness of flight" performed by an FAA trained, designated, and certified Aviation Medical Examiner (AME). These physicians are trained with an emphasis on examining and evaluating the medical entities that can cause sudden incapacitation in flight and/or cause an interruption in the smooth flow of or threat to the safety of our nation's airspace. FAA flight physicals fall into three different classes, intuitively designated FIRST, SECOND and THIRD class, which are commonly printed/typed in all capital letters. The requirements and valid timeframe of the medical examination are dependent on the class of medical licensure, the airman's age, and Special Issuances (SI) or special circumstances. AME's address common pitfalls, treatments that may be considered aeromedically significant.[1][2][3] These examinations are not only performed on pilots but also on Air Traffic Controllers (ATCs), Aviation Safety Inspectors (ASI), who may or may not also be pilots. Holding an FAA medical certification is a federal standard for a certain degree of overall health. Occasionally, individuals are not involved in aviation, and all are examined and given medical certificates as a representation of health. Examples of such persons are workers on offshore oil rigs, racecar drivers, and occasionally executives in organizations that cannot afford turnover in that position. Student pilots cannot fly solo without an instructor or another pilot until they have passed their medical exam. The Aviation Medical Examiner Any physician interested in becoming an AME is best suited by having an interest in aviation and an understanding of the concept of a forensic examination, as well as a love of learning and interest in all entities of medicine and capable of performing a comprehensive, thorough medical examination regardless of the Specialty of Origin (SOO). There is no residency training that is not acceptable to become an aviation medical examiner and board certification in the physician's primary specialty, and an unrestricted medical license in at least one state is required. However, regardless of SOO, the AME must be thoroughly competent in the ENT, ophthalmologic, neurologic, musculoskeletal, cardiovascular/cardiopulmonary, and psychiatric examination. The AME must also be computer literate, fluent in English, able to adapt to changing regulations/guidelines, and tolerant of a degree of bureaucracy. Fellowships in Aerospace Medicine are available, but there are few programs with a small allotment of positions few graduates and is not a requirement for AME certification.[4] The vast majority of AME's practice medicine full-time and do flight physicals in-between regular patients. There are very few AME's who do nothing more than FAA medicals as their primary job as a doctor, but many AME's semi-retire from their SOO and restrict their practice to flight physicals as they scale back towards total retirement. The AME must understand that they are not there to diagnose or treat the airman, and while the AME is a doctor, they are not the treating doctor but often speak with the treating physician regarding potential changes in a treatment regimen that make the difference between issuance of the medical vs. denial/deferral. AME often is but is not required to be a pilot themself. The AME reports to and is assisted by one of 9 Regional Flight Surgeons, who are then responsible to the Federal Air Surgeon (FAS) in Washington DC (the Guide). The FAS is assisted by Deputy Federal Air Surgeon(s), and there is an additional International "Regional" flight surgeon (RFS). Any AME can contact any RFS or FAS for assistance, which often helpful after 5 p.m. in the AME's respective time zone. The AME Training and Progression AME's are initially trained by the Federal Aviation Administration during a seven-day timeframe in Oklahoma City, OK. Advanced practitioners such as physician assistants and nurse practitioners are not currently eligible to be AME's. This training is a comprehensive and universal review of every specialty and subspecialty from the standpoint of how they pertain to general aviation and maintenance of health rather than focus on direct treatment. This initial training involves the most comprehensive review of all medical topics, in addition to decompression, the decompression chamber, Time of Useful Consciousness (TOC), evacuation and rescue operations, common patterns of injury, and accident analysis, to name a few. A static ground-based aircraft is used for simulated emergencies and fake "Hollywood Smoke," as well the option of another fuselage suspended over a swimming pool used in training Airline Attendants in Slide use and emergency evacuation into an aquatic environment. The training is also heavily focused on federal rules and regulations both appropriate to aviation as well as policy and procedure of being a designee of the Federal Government. Following initial training and certification, the physician is designated a Junior AME and able to perform SECOND and THIRD-class medicals for the next three years. During this timeframe, their examination decisions and documentation are evaluated, and the FAA visits them for inspection of office and equipment. Following this three-year timeframe, if the error margin is acceptable, the physician can petition to become a Senior AME and is then able to examine airman for and issue first class medicals. At this point, the physician can register to be able to perform physical examinations for ATC's. AME's are currently required to undergo online training every two years and in-person training for three days every four years. This training covers various topics and tends to be heavily focused on neurology and cardiopulmonary, but most major medical topics and guideline updates are covered. The chart of an examined airman may be reviewed periodically; If an AME is contacted, usually by email, identified errors, and positive and negative feedback may be given. This training continues throughout the career of the AME. After three years as a senior aviation medical examiner, the AME can request training to be designated for the Human Intervention and Motivational Study (HIMS) program and be designated as an Independent Medical Sponsor (IMS) to assist with certification of an airman who has had difficulty with substance abuse, mental health issues, or needs special issuance surrounding antidepressant therapy.[5] The HIMS AME often works closely with a HIMS psychiatrist or a general psychiatrist familiar with aviation requirements following a specific template. Additionally, they work with a neuropsychologist designated by the FAA and certified to do the appropriate neuropsychological testing specific to aviation. The AME is also responsible for monitoring the airman, often with a portable breathalyzer, office-based encounters commonly requiring 14 urine drug screens in a 12-month timeframe, and periodic reports to the FAA before and after special issuance is issued. The AME is then responsible and held accountable for reporting deviations and concerns to the FAA. MedExpress The FAA maintains a site known as MedExpress. The candidate-pilot is usually introduced and instructed by their flight instructor to set-up an initial account that follows the pilot throughout their lifetime. The candidate/pilot will log in before every new or their first exam and update their current medical history and/or demographics. They then save their update, and a unique code for that exam is generated and valid for 90 days. They bring this code to the exam, and the AME logs in, enters the code from the airman, and their chart populates. The AME then reviews the history, confirms ID and demographics then enter the exam portion of the encounter. The AME then submits the completed exam to the FAA electronically as either issued, denied, or deferred for further review. If issued, the AME is then able to print the medical certificate, sign it as the AME and have the airman sign it. The airman then leaves with the certificate in hand. Specifics of the Aviation Medical Exam All exams start with basic demographics, height, weight, BMI calculation, vitals, general medical exam of heart, lung, abdomen, and what one would consider a basic internal medicine annual exam.[6] Scars, tattoos, and any distinguishing body markings are required to be noted on all patients. Near and distant vision and optic fundi examination are completed. An external anal exam for hemorrhoids is performed, but the digital rectal exam is not required. Females do not require a pelvic exam. Urine dipstick is performed for protein and glucose only and no drug screen. BMI and OSA (obstructive sleep apnea) risk is assessed on all airmen. For some SECOND class and all FIRST class medicals, intermediate vision and conjugate gaze testing are required. Hearing requirements for all three classes are simply a "conversational speech test" with the AME's back turned to the candidate, but ATC requires audiometry at 500, 1000, 2000, 3000, and 4000 Hz. Military flight physicals do not apply to the civilian world. All medical requirements are publicly accessible in "the Guide," which can be found in PDF from any browser. This guide is periodically updated, and when the examiner logs onto their account to do a flight physical, all updates are mandatory acknowledgments before being able to progress to the main website to issue or document an exam. The Outcome of the Exam The result of the exam is either denial, deferral, or issuance. Cases of issuance may have restrictions such as the requirement for vision correction, not valid above a certain altitude, not valid for night flight, or invalid for a period less than what the medical would usually be valid for. The AME may issue the medical, and the pilot gets a letter from the FAA either requesting additional information or, if the AME made an error, a notice of withdrawal of the medical. It should be noted that the medical certification does not mean the student can fly solo (that would be a decision made by the instructor/flight school); it is simply one mandatory requirement before being allowed to fly alone.

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Vitamin A Deficiency

StatPearls-/- 2021; ():

Vitamin A is a fat-soluble vitamin essential in cell development, metabolism, immune competency, vision, and reproductive functions.[1][2] Vitamin A deficiency (VAD) is a highly prevalent health concern associated with substantial morbidity and mortality, mostly affecting young children in impoverished regions throughout the world. Insufficient intake of absorption leads to deficiency and compromise of essential physiologic processes. Natural sources of vitamin A include dark leafy greens, orange-colored vegetables, milk products, liver, and fish.[3] It is absorbed in the duodenum after hydrolyzation by pancreatic and intestinal enzymes and emulsified with dietary fats and bile acids.[4] The majority is then stored in the hepatic stellate cells.[5] Significant amounts are also stored in adipose tissue and the pancreas.[6] The recommended dietary allowance (RDA) of vitamin A by the Institute of Medicine in healthy adults is 700 micrograms/day for women and 900 micrograms/day for men.[7][8] For children, pregnant women, and lactating women, the RDA is 300 to 900, 770, and 1300 micrograms/day respectively. The minimum requirement to prevent symptomatic VAD in children 1 to 5 years of age is about 200 micrograms/day. Serum retinol levels are a good marker of vitamin A nutritional status. Deficiency is defined as a retinol concentration of fewer than 20 micrograms/dL.[8] Vitamin A deficiency-associated ocular symptoms have been shown to develop at concentrations less than 10 micrograms/dL.[8] Dietary vitamin A is ingested as either carotenoid from fruits and vegetables or retinoid from animal products. Carotenoids are a provitamin A, most commonly beta-carotene, and retinoids are active forms of vitamin A, such as retinol and retinyl esters. Retinoids have been shown to have 75% to 100% absorption, whereas carotenoid absorption varies greatly depending on the food matrix and type of carotenoid.[9][10] A 12 to 1 ratio of beta-carotene to retinol absorption in a diet of mixed fruits and vegetables is the estimated conversion used by the Centers for Disease Control and Prevention.[7] Many populations in developing countries rarely ingest meat, dairy, or carotenoid-rich vegetables leading to difficulty obtaining sufficient quantities of vitamin A.

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Primary Cutaneous Follicle Center Lymphoma

StatPearls-/- 2021; ():

Several B-cell and T-cell lymphomas can affect the skin, most of which are T-cell lymphomas. Among primary cutaneous B-cell lymphomas, primary cutaneous follicle center lymphoma (PCFCL) is the most common. Primary cutaneous lymphomas are classified based on the involvement of the skin without evidence of systemic or nodal disease at the time of diagnosis. B-cell lymphomas, which make up 25% of cutaneous lymphomas, have a distinct clinical course and prognosis compared to histologically comparable systemic lymphomas.[1] PCFCL is a low-grade B-cell lymphoma made up of follicle center cells. It typically occurs on the head or trunk and has an excellent prognosis.[2][1][3]

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 33620820

Tropical Sprue

StatPearls-/- 2021; ():

Tropical sprue is a malabsorption syndrome characterized by acute or chronic diarrhea. It is seen in the people of the tropical region in the absence of any specific cause of malabsorption.[1] It is thought to be infectious in etiology with a contribution of environmental factors. It affects the small intestine and is characterized by malabsorption and multiple nutritional deficiencies, especially vitamin B12 and folic acid.[2][3] The disease was first described by William Hillary in 1759 in a population with chronic diarrhea from Barbados.[4] The term "sprue" was added later by Patrick Manson in 1880 to describe persistent diarrhea seen in the Asian countries.

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Olfactory Training

StatPearls-/- 2021; ():

About 20 percent of people in the general population have an impairment of their sense of smell.[1][2][3] Impaired olfaction leads to diminished quality of life. It can be dangerous as the individual affected may miss environmental hazards such as the smell of natural gas or smoke from the fire.[4] Also, diminished olfaction may a warning sign for common neurodegenerative disorders, such as Alzheimer's dementia and idiopathic Parkinson disease.[5][6] The most common causes of olfactory decline are olfactory decline secondary to sinonasal disease, post-infectious olfactory dysfunction, and post-traumatic olfactory dysfunction.[7][8] If there is a clear structural pathology in the nose or brain, treatment may be oriented toward the underlying lesion, such as functional endoscopic nasal surgery for chronic rhinosinusitis with polyps and neurosurgical interventions for a brain tumor.[3][8][9] In patients with damage to the olfactory epithelium and olfactory pathways due to inflammation, toxins, trauma, viral infection, or unknown causes, olfactory decline therapy may be difficult.[3][8][9] Medications such as corticosteroids for chronic rhinosinusitis and other inflammatory conditions causing olfactory decline may be considered.[3][8] Other options may include sodium citrate, zinc, and vitamins, but their efficacy is not approved.[3][8] A non-surgical and non-pharmacological approach to improve olfactory functioning is olfactory training, where patients expose themselves twice daily to different odors over several months.[3][8] Several studies have reported on the efficacy of olfactory training.[10][11][12][13] However, these studies' findings were challenged for several reasons, such as the absence of an appropriate control group or the lack of placebo-controlled double-blinded protocols in these studies.[3][13] Moreover, some patients with olfactory dysfunction recover spontaneously. For instance, up to 20% of patients with post-traumatic olfactory dysfunction and up to 60% of patients with post-infectious olfactory dysfunction improve over the years spontaneously.[14][15] Additionally, patients of younger age, patients with a relatively well-preserved olfactory functioning, and patients with female gender and non-smokers have a good chance of a spontaneous improvement of olfactory functioning.[14] In any patient who uses tobacco, tobacco use should be discouraged as it is associated with diminished olfactory functioning and may support any attempt to improve olfactory functioning.[2] Olfactory training is comparatively simple, and, so far, serious side effects have not been reported. Although its precise mechanism of action and efficacy are incompletely understood, olfactory training is increasingly applied in routine care for patients with olfactory dysfunction due to different etiologies.[3][8][13]

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Substernal Thyroidectomy

StatPearls-/- 2021; ():

Substernal (or retrosternal) thyroidectomy is the surgical treatment of retrosternal goiters. Retrosternal (or intrathoracic, or substernal, or mediastinal) goiters are defined by deSouza and Smith as thyroid goiters, more than 50% of which are located below the thoracic inlet and into the mediastinum.[1] Several other definitions have emerged over the years, and thus, there is no clear consensus on the incidence of mediastinal goiters. Different studies report incidence rates from 0,2% to 45% of all goiters.[2] The majority of substernal thyroid masses are composed of benign multinodular nontoxic goiters. However, the substernal extension of the gland may be a carcinoma. Many substernal masses remain asymptomatic for many years and can oftentimes be discovered incidentally on imaging. Patients can also have neck compression symptoms due to the mass pressing against the trachea, great vessels, or esophagus. The substernal mass often extends into the anterosuperior mediastinum with a usually unilateral extension further into the chest. On occasion, the mass can extend into the posterior mediastinum. It is generally agreed that thyroxine suppression and radioiodine use are not acceptable as interventions and that surgery is the gold standard in retrosternal goiter management.[3] Surgery comprises of two different approaches; one is transcervical one, in which a cervicotomy is performed, and the other is extracervical.[4] Several different surgical techniques have been described, which will be discussed further in this article. However, no clear consensus exists on the indications for substernal thyroid goiter excision.

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Liver Cystic Disease

StatPearls-/- 2021; ():

Hepatic cysts (HCs) have been a common reason for consultation by gastroenterologists and hepatologists. HCs are defined as small abnormal fluid-filled lesions that develop within the liver tissue and usually arise from within hepatocytes, biliary cell epithelium, mesenchymal tissue, or metastases from extrahepatic organs. They may contain fluid or solid components. Liver cysts are mostly detected incidentally on imaging studies and tend to have a benign course. Small fractions are symptomatic and seldom associated with a significant life-threatening condition. HCs were discovered surgically before the use of diagnostic imaging. Simple cysts are the most common type. The prevalence of HCs is as high as 15-18% in the United States and 5 to 10% worldwide.[1] Most of the cases can be managed expectantly and do not require interventions. However, in a few cases, the cysts will be large enough to cause symptoms and require medical or surgical interventions. The differential diagnosis for liver cystic diseases is broad and includes infectious, inflammatory, neoplastic, congenital, and traumatic etiologies. In this review, we discuss the epidemiology, pathophysiology, diagnosis, manifestation, and treatment modalities for different common primary hepatic cystic lesions rather than focusing on diagnosing and managing metastatic lesions, Infectious cysts, and Hepatocellular carcinoma.[2]

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 33620816

Dysbetalipoproteinemia

StatPearls-/- 2021; ():

Familial dysbetalipoproteinemia, or type III hyperlipoproteinemia or remnant removal disorder, is defined as lipid disorder with a mutation or mutations in the apolipoprotein E gene (APOE), hyperlipidemia, hypertriglyceridemia, atherosclerosis with increased risk of peripheral vascular disease, and coronary artery disease. It can be autosomal recessive or dominant (rare) associated with E2/E2 genotype.

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 33620815

Primary Lung Tuberculosis

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Discovered in 1882 by Robert Koch, tuberculosis (TB), one of the oldest known infections, is a major global health problem and one of the top ten causes of death worldwide. It is a disease of humans, as it does not affect animals naturally.[1][2] Tuberculosis is the leading cause of death from an infectious agent worldwide, causing even more deaths in HIV/AIDS patients. A third of the world's population is said to have contracted the bacteria responsible for tuberculosis, Mycobacterium tuberculosis, with estimates of ten million new infections globally each year.[3][4] The global disease burden of tuberculosis is estimated to be around 24%, with remarkable socioeconomic implications.[5] The major pathology in tuberculosis is necrotizing granulomatous inflammation, with the lungs being the primary organs of involvement of the disease in up to 87% of the cases. Having that said, almost any bodily organ could be a site for the disease.[6][7] It commonly affects people living in crowded conditions such as institutionalized patients, immigrants from countries with a high prevalence of tuberculosis, immunocompromised such as HIV patients, and health care workers.[8][9] The worldwide incidence has been steadily decreasing, but it is still a common problem in regions such as Sub-Saharan Africa. It is still a major medical cause of mortality as the global death toll reaches up to 1.5 million deaths a year.[10] Lung function impairment is the major sequel of pulmonary tuberculosis.[11] In this topic, we will review pulmonary tuberculosis covering the main aspects of the disease.

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Drug Distribution

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Pharmacokinetics is the study of a drug moiety or a compound as it moves through the body after its administration. It involves the processes of drug absorption, bioavailability, clearance, and distribution.[1] Although these processes are theoretically separate, from a practical standpoint in-vivo, they are all inter-connected. After the drug is absorbed from the site of administration, it is distributed to extracellular fluids.[2] High reserves of plasma protein-bound drugs can cause prolonged effects by creating a sustained release mechanism.[3]

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Obeticholic Acid

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Obeticholic acid is a medication used in the management and treatment of primary biliary cholangitis. This activity describes the indications, action, and contraindications for obeticholic acid as a valuable agent in managing primary biliary cholangitis. This activity will highlight the mechanism of action, adverse event profile, and other key factors of obeticholic acid use pertinent for interprofessional team members in managing patients with primary biliary cholangitis.

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Gustatory Testing

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Gustation, better known as taste, is an important special sensation that affects diet and human pleasure. Loss of taste or altered taste can occur in many disorders of the peripheral or central nervous system, and gustatory testing allows us to better diagnose and manage these conditions. There is a complex interplay of gustatory, olfactory, somatosensory, and emotional stimuli in taste perception. This poses a difficult task for the clinician wishing to test gustation, and as such, a multidisciplinary approach must be adopted. A further issue is the lack of suitable objective tests. To date, there are no clinically useful objective tests of gustation.[1] and the majority of tests rely on subjective measures of taste. This is unreliable in certain pathologies such as dementia and other neurodegenerative disease. There is also a lack of standardization for taste testing and no universally accepted method.[2] This is not the case for olfactory function, where the University of Pennsylvania Smell Identification Test (UPSIT) and the Sniffin Sticks are regarded as robust and widely used tools for odor testing.[3][4] Additionally, many patients report on loss of taste while they actually have an impairment of the sense of smell. Therefore gustatory testing is important clinically.[5] Here we review the various methods of gustatory testing and their relevance in clinical practice. Gustatory Pathway The sensation of taste is complex, and although the gustatory pathway has been anatomically defined, the perception of flavor is not simply a product of this pathway alone. Chemicals known as tastants are detected by cells from taste buds, which lie within papillae. Fungiform papillae are the most numerous and are found in high concentration on the tongue's anterior two-thirds.[6] Circumvallate papillae are located within the sulcus terminalis in the posterior third, and foliate papillae are located laterally. There are, however, taste buds throughout the entire oral cavity, the posterior wall of the pharynx, and the epiglottis. These signals are carried via cranial nerves VII, IX, and X to the gustatory area in the midbrain (the nucleus of the solitary tract) and thereafter to the thalamus in the central tegmental tract. The thalamus relays this information to the cortex, specifically the anterior insula frontal operculum. There is some crossing of fibers in the central tegmental tract and subsequent synapse in the ventral posteromedial nucleus of the thalamus.[6] A key principle in taste detection is that there are five basic tastes: sweet, salty, sour, bitter, and umami (more recently, it has been suggested that fat may also be a further basic taste).[7][8][7] Each sensory cell is capable of detecting multiple tastes due to the presence of receptors to either glucose (sweet), sodium chloride (salty), Hions (sour), glutamate (umami), or bitter substances such as quinine or caffeine. Taste cells contain a variety of different receptors, allowing for different intensities of stimulation.[9] Signal combinations from the five different basic qualities and varying levels of intensity create a vast palette of flavors. This process is modulated by sensory input from cranial nerves I and V. Olfaction is an important part of taste, as demonstrated in wine tasting: opening the velum without swallowing allows volatile tastants to reach the olfactory epithelium, thus contributing to the perception of flavor.[10] It is also well documented that the loss of olfactory function limits taste.[11] Texture also informs how we perceive flavor; trigeminal pathways detect somatosensory information such as viscosity and hardness. Chemesthesis describes the sensations of stinging, heat, cooling, or tingling and is carried by fibers from cranial nerves V, IX, and X.[12] There is some debate over which pathway is most important clinically. However, the majority of gustatory studies examine the anterior two-thirds of the tongue, supplied by the chorda tympani branch of the facial nerve (VII).[13] Studies have also suggested that somatosensory trigeminal fibers anastomose with facial taste fibers peripherally, acting in concordance.[14][15] This further blurs the lines of the gustatory pathway. We must also consider the emotional component of flavor perception. There is wide individual variability, driven by past experience, likes, and dislikes, allowing for cortical modulation of how taste is perceived.[16] In one study, subjects described an altered taste of bland water after reading about events of moral transgression.[17] Let us not forget the metaphorical connection between taste and emotion, as evidenced in everyday vernacular: "Home sweet home," or being "dealt a bitter blow." Gustatory Dysfunction Gustatory disorders are classified clinically as either quantitative or qualitative.[18] The former comprises ageusia (a complete loss of taste), hypogeusia (diminished taste), or hypergeusia (a heightened sense of taste). Dysgeusia is a qualitative disorder where patients experience a distorted taste. This is further classified according to its relation to eating. If occurring while eating, it is described as a parageusia, but if permanently present or experienced in the absence of oral stimulation, we call it phantogeusia. A dysgeusia diagnosis is made following descriptions in the patient's own words and cannot be reliably tested. However, quantitative gustatory disorders can be measured.

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Laryngeal Botulinum Toxin Injection

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Botulinum toxin is an endotoxin produced from Clostridium botulinum, an anaerobic, gram-positive bacteria.[1] Injection of botulinum toxin into a muscle temporarily denervates the targeted muscle. It also reduces secretory function when injected into a gland. Although botulinum toxin has traditionally been utilized in facial cosmetics/aesthetics to address rhytids, it is also a useful tool in addressing laryngeal pathology. Before introducing botulinum toxin, laryngeal dystonia was historically treated with psychotherapy and speech therapy, both of which were significantly limited in their effectiveness for this disorder.[2] The use of botulinum toxin has been described in the management of both adductor and abductor laryngeal dystonia/spasmodic dysphonia (SD), vocal tremor, vocal process granuloma, and cricopharyngeal muscle dysfunction. By selectively denervating targeted laryngeal musculature, the surgeon can strategically address these pathologies. The vast majority (65%) of SD patients are female, with an average age of onset of 45 years. The prevalence of SD is 1 per 100,000.[3] In adductor spasmodic dysphonia (ADSD), the thyroarytenoid (TA) muscle is targeted for chemodenervation. Botulinum toxin chemodenervation, initiated in the 1980s by Blitzer and colleagues, is now considered the gold standard for the treatment of ADSD.[2]

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Regional Anesthesia For Breast Reconstruction

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Breast cancer is the most common cancer in women around the world. It is presented as the second cause of cancer deaths after lung cancer. The incidence of this aggressive disease with around 17,000,000 new cases each year becomes worrying and alarming.[1] The risk of dying from breast cancer increases by 5% for every one-year reduction in age at diagnosis, indicating the presence of more aggressive phenotypes than breast cancers occurring later in life.[2] According to US breast cancer statistics, 42,170 women in the US are expected to die of breast cancer in 2020. Cancer mortality is not related to the primary tumor but often to recurrence or general metastasis.[3][4] Surgery remains the main modality for the management of resectable breast cancer because it plays an important role in controlling locally advanced or metastatic disease. After a mastectomy, reconstruction should be offered to all breast cancer patients. These are the recommendations of the National Institute for Health and Clinical Excellence (NICE), but the type of reconstruction to be used is currently at the discretion of the surgeon and patient. About 10% to 20% of patients experience acute postoperative pain, which may progress to chronicity known as postmastectomy pain syndrome.[5] The improvement of anesthesia factors has positive significance for promoting the rehabilitation of patients. Effective pain management is a crucial component in enhanced recovery after surgery; thus, proper follow-up with a pain physician could prove beneficial to those presenting with postmastectomy pain syndrome. Several recent studies have shown a decrease in postoperative pain when regional anesthesia techniques are combined with general anesthesia during breast reconstruction surgery.[6][7][8] These studies suggest that locoregional anesthesia is involved in controlling acute postoperative pain, reducing opioid consumption, leading to early revalidation, and reduced patient length of stay. In this article, we will describe the main techniques of locoregional anesthesia involved in breast reconstruction surgery. These are paravertebral block, intercostal nerve block, erector spinae plane block (EPSB), pectoralis nerve block (Pecs), and serratus anterior plane blocks.

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Prosthetic Valve Endocarditis

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Prosthetic valve endocarditis (PVE) is a microbial infection of the endovascular that occurs on parts of a prosthetic valve or on the reconstructed native valve of the heart.[1] PVE accounts for 20% of infective endocarditis. It is the most severe form of infective endocarditis and is associated with high morbidity and mortality.[2] Based on the time of the disease acquirement, this disease is classified into two types, early and late PVE. The early PVE is acquired within one year of the surgery, while the late PVE is acquired after one year. The clinical importance of this classification is the distinct microbiological profiles between the former and the latter.

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Mitral Valve Minimally Invasive Surgical Treatment

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Medical advances have helped the US population live longer with more comorbidities than previously possible. As the aging population expands, the incidence of degenerative heart disease and valvular disease has increased.[1] Mitral valve disease is one of the most common valvular anomalies and often concomitant with aortic valve disease. Due to the center of the heart and association with other comorbidities that increase frailty, many patients are at high surgical risk and necessitate alternative therapeutic options.[1] Up to 50% of patients with moderate to severe mitral regurgitation (MR) are not considered surgical candidates.[2] Medical management in mitral regurgitation has poor outcomes with a 1-year mortality rate of 20%, a 5-year mortality rate of 50%, and a high hospitalization rate due to heart failure.[2] The advent of minimally invasive mitral valve repair in recent years provides a necessary therapeutic option for patients with symptomatic mitral valve disease. Additionally, studies of minimally invasive mitral valve repair have been shown to preserve cardiac structure and function when implemented early. Minimally invasive surgical mitral valve repair has become routine for the treatment of MR.[3] Enhancements of minimally invasive surgical techniques improved surgical trauma and postoperative recovery, resulting in increased acceptance of these techniques.[3] Different minimally invasive techniques include robotic repair, minimally invasive mitral valve surgery using a right mini-thoracotomy, percutaneous edge-to-edge mitral valve repair, and transcatheter mitral valve replacement. Many patients with symptomatic MR have a poor prognosis due to older age and comorbidities. Minimally invasive surgical approaches to mitral valve repair have provided important treatment options in these higher-risk surgical patients. The emergence of transcatheter mitral valve repair and replacement options further pushes the boundary of possibilities. Hence, patients who are not surgical candidates can live longer than previously possible.[4]

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Aortoenterofistula

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Aortoenteric fistula is a rare cause of massive upper gastrointestinal bleeding with a high degree of mortality. Fistulization can occur either primarily or secondarily, with secondary causes being more common. Primary causes arise via the native aorta, while secondary causes result from previous surgical interventions on the aorta when, most commonly, a synthetic graft material erodes into the adjacent enteric system. Presentation is variable but most commonly includes an upper GI bleed coupled with the knowledge of a prior aortic operation or the presence of an aortic aneurysm. Patients can decompensate quickly, and treatment is anchored in rapid diagnosis and early repair, either open or endovascular. The endovascular repair offers a less physiologically demanding repair that may serve as a bridging therapy to definitive surgical management. Complications following a repair are common, and mortality remains high for patients who develop aortoenteric fistulas.

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Testicular Teratoma

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Testicular teratoma is a germ cell-derived neoplasia composed of different somatic tissues and can be derived from one or more germinal layers (endoderm, mesoderm, and ectoderm). According to the WHO classification, germ cell tumors of the testis are divided into two main groups:[1]: Germ cell neoplasms comprise germ cell neoplasia in situ (GCNIS), seminoma, and non-seminoma (NSGCT). The latter encompasses teratoma (postpubertal type), embryonal carcinoma, choriocarcinoma, yolk sac tumors (YSTs). non-GCNIS tumors include spermatocytic tumors, YST prepubertal type, teratoma (prepubertal type). The vast majority of adult testicular teratomas are malignant germ cell tumors. Teratoma accounts for about 3 to 7% of NSGCT and about 50% of mixed GCTs. As stated in the WHO classification (2016), two types of testicular teratomas exist: Prepubertal teratoma is considered an indolent tumor and is not associated with germ cell neoplasia in situ; the testis shows normal spermatogenesis and has no metastatic potential. This histotype is not specific to children and can be found in adult patients. This group includes dermoid or epidermoid cysts. Postpubertal teratoma is GCNIS-derived and has metastatic potential (metastasizes in 22% to 37% of cases). A rare encounter is a teratoma with somatic-type transformation, defined as "teratoma that develops a distinct secondary component that resembles a somatic-type malignant neoplasm," which has specific prognosis and treatment and needs to be distinguished from postpubertal teratomas. The outcomes for patients with localized disease are good, and they are candidates for surgical therapy. Patients with metastatic disease have a poorer outcome that depends on several clinical and pathological factors and are treated in a multimodal approach involving different medical professionals. Metastatic tumors do not respond well to chemotherapy, and the goal is to achieve a complete surgical resection.

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Delivery, Face And Brow Presentation

StatPearls-/- 2021; ():

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference. Face presentation - an abnormal form of cephalic presentation where the presenting part is mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations.[1][2][3] In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries.[3] Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios.[2][4][5] These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse. Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed.[6] The ultrasound imaging can show a reduced angle between the occiput and the spine or, the chin is separated from the chest. However, ultrasound does not provide much predicting value in the outcome of the labor.[7]

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Kentucky KASPER and Controlled Substance Prescribing

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Opioid use and abuse for acute and chronic pain is a significant problem in the United States as well as Kentucky.[1][2][3] The rate of overdose-related to the use of illicit opioids has drastically increased in the United States and in Kentucky. Over one-quarter of United States citizens suffer from chronic pain.[4] It is among the most common complaints seen in an outpatient clinic and in the emergency department. The failure to manage acute and chronic pain appropriately, as well as the possible complication of opioid dependence related to treatment, can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence.[5] Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined.[6] How a patient's chronic pain gets managed can have profound and long-lasting effects on a patient's quality of life. The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months.[7] There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy is in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical.[8] Unfortunately, studies have revealed an inherent lack of education regarding pain management in most medical schools and training programs. The Association of American Medical Colleges recognized the problem and has encouraged schools to commit to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum. Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, under prescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. The American Society of Addiction Medicine describes addiction as a treatable chronic disease that involves environmental pressures, genetics, an individual's life experiences, and interactions among brain circuits. Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, they identify five characteristics of addiction: 1. Craving for drug or positive reward. 2. Dysfunctional emotional response. 3. Failure to recognize significant problems affecting behavior and relationships. 4. Inability to consistently abstain. 5. Impairment in control of behavior. Unfortunately, most health providers' understanding regarding addiction is often confusing, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for effectively dealing with the challenges of addiction. In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion contributed to the under-treatment of pain. Over time, the manual has eliminated these terms and now uses "substance use disorder," ranging from mild to severe. Unfortunately, there are numerous challenges in pain management, such as both underprescribing and overprescribing opioids. The concerns are particularly prominent in patients with chronic pain and have resulted in patients suffering from inadequately treated pain while at the same time there has been a development of concomitant opioid abuse, addiction, diversion, and overdose. As a result, providers are often negatively influenced and fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. To make the challenges even worse, chronic pain patients often develop opioid tolerance, significant psychological, behavioral, and emotional problems, including anxiety and depression related to under or overprescribing opioids. Clinicians that prescribe opioids face challenges that involve medical negligence in either failure to provide adequate pain control or risk of licensure or even criminal charges if it is perceived they are involved in drug diversion or misuse. All providers that prescribe opioids need additional education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with over and under prescribing opioids. Provider Opioid Knowledge Deficit There are substantial knowledge gaps around appropriate and inappropriate opioid prescribing, including deficits in understanding current research, legislation, and appropriate prescribing practices. Providers often have knowledge deficits that include: Understanding of addiction. At-risk opioid addiction populations. Prescription vs. non-prescription opioid addiction. The belief that addiction and dependence on opioids is synonymous. The belief that opioid addiction is a psychologic problem instead related to a chronic painful disease. With a long history of misunderstanding, poor society, provider education, and inconsistent laws, the prescription of opioids has resulted in significant societal challenges that will only resolve with significant education and training. Definitions [9][10][11]: Abuse - Maladaptive pattern of opioid use for a purpose other than pain relief. Addiction - Compulsive pursuit of a chemical substance to find relief or reward. Dependence - Use of a drug that causes a withdrawal syndrome with cessation or reduction in the amount administered. Diversion - Transfering a controlled substance from an authorized person's use to an unauthorized person's use for distribution or possession. Misuse - Use of a medication in a manner different than how it was prescribed. Pseudo-addiction - Aberrant drug-seeking behavior similar to opioid use disorder driven by a need for relief of pain, resolves with pain control. Tolerance - Adaption to the effect of a drug.

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Doppler Liver Assessment, Protocols, And Interpretation Of Results

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Doppler ultrasound is a non-invasive procedure; hepatic Doppler could enrich abdominal ultrasound examination. The benefits are significant; first, if the examiner uses liver Doppler will be able to know the abnormal vascular structures even if the lesion is not apparent (iso-echoic). Second, it will give clinicians and sonographers tremendous experience to catch the hemodynamic abnormalities easily.

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Parahiatal Hernia

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Parahiatal hernia (PHH) is a rare type of diaphragmatic hernia (DH), which is an abnormal protrusion of the viscera through an abnormal diaphragmatic defect between the left part of the right crus and the left crus. The diaphragm is a vital muscle for breathing, derived from the septum transversum (anterior portion), pleuroperitoneal folds (posterolateral part), and dorsal mesentery (posteromedial part). This anatomical barrier between the two cavities has normal openings for various structures to pass through. The hiatal opening at the 10th thoracic vertebral level allows the esophagus to pass through its right crus to form a gastroesophageal junction (GOJ). A PHH defect would occur to its left side. Due to the proximity, PHH always gets confused with a hiatus hernia.[1] (see Image 1) Hiatus Hernia The majority of diaphragmatic hernias are hiatal defect. The most prevalent of them are the sliding type, due to cephalad migration of GOJ (Type I), less frequent variant is paraesophageal in nature due to rolling of the stomach may be without any migration of GOJ (Type II) or with the migration of GOJ (Type III) and in the worst case, it is associated with herniation of other abdominal viscera along with stomach (Type IV).[2] The distinctive feature of the hiatal hernia is an abnormal protrusion of the viscera through a normal opening (Oesophageal hiatus) in contrast to PHH. In general, the stomach is the only herniated content, but other contents can be found, including transverse colon, omentum, small bowel, and the spleen.

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Understanding and Application of CDC Immunization Guidelines

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Immunization is the most effective and safe public health intervention in reducing the incidence, prevalence, morbidity, and mortality of various infectious diseases.[1][2][3] Vaccination is the most cost-effective preventive service. Despite the advancement in vaccine coverage, more than 40,000 adults and 300 children die every year in the USA from vaccine-preventable diseases.[4]

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Segmental Lung Resection

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Lung cancer is the second most common cancer in men and women in the United States and the leading cause of cancer death. One of the primary treatment approaches for lung cancer is removing all or part of the diseased lung. The earliest lung surgery approaches were limited by the complexity of operating on the lungs without general anesthesia as we know it today. This often resulted in the resection of more healthy tissue than may be necessary. The initial approach involved the removal of an entire lung, the pneumonectomy. As the morbidity and mortality of pneumonectomies became clear, the research ended in less radical procedures.[1] In 1962 Shimkin showed that lobectomy, or removing a single lobe of the lung, was equal to pneumonectomy in survival and carried lower morbidity.[2] This led to the current paradigm wherein lobectomy is the gold standard for lung cancer resection. The North American Lung Cancer Study Group (LCSG) released a prospective randomized study in 1995 that demonstrated increased recurrence and worse outcomes with sublobar resection than lobectomy in lung cancer.[3] Due to this result, segmentectomy is currently limited to patients that cannot undergo lobectomy. Multiple studies have been conducted to compare lobectomy and segmentectomy, incorporating thoracic surgery advancement since the LCSG study. Jensik first described resection of the anatomic lung segment in 1973.[4] There is ongoing interest in sublobar resection for lung cancer, although currently, indications remain limited.

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Prostate Imaging

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The prostate is a "walnut-shaped' gland, a part of the male reproductive system which produces and secrets thin alkaline fluid in the ejaculate. It contains glandular and stromal elements that are subject to enlargement and developing adenocarcinoma in an elderly patient. Infection is common in relatively younger patients. Imaging plays a vital role in the diagnosis of different prostatic pathology, including early detection of carcinoma. Imaging also helps obtain tissue samples, drain abscess and post-procedure collections, and stage and follow malignancy.

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Hypopharyngeal Cancer

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Hypopharyngeal cancer describes tumors arising between the oropharynx and the esophageal inlet, more precisely defined as between the level of the hyoid bone and the lower end of the cricoid cartilage, respectively. This group of cancers is further subdivided based on the anatomical locations within this area, namely post cricoid (the pharyngoesophageal junction), the piriform sinus, and the posterior pharyngeal wall. Hypopharyngeal cancers do not include carcinoma of the larynx as these are anatomically, pathologically, and therapeutically distinct.[1] Squamous cell carcinoma arising from the mucosal layer is the most common histology identified in 95% of the cases, while adenocarcinoma, sarcoma, and non-epidermoid carcinoma account for the remaining cases.[2] Tumors of the hypopharynx are characterized by local invasion and lymphatic spread, with 70% of patients presenting with lymph node involvement at the time of diagnosis.[1][3] Symptomatic burden from hypopharyngeal cancer is determined by the size and location of the primary tumor. Pain, bleeding, and dysphagia are the most common presenting complaints, with concomitant malnutrition a poor prognostic factor. Advanced tumors may invade the larynx giving features of airway compromise and aspiration. Surgical management requiring a combination of partial or total pharyngectomy and laryngectomy dependent on site and stage at presentation can lead to significant functional morbidity.[4] Hypopharyngeal cancer has an annual incidence of approximately 3,000 cases per year in the United States, accounting for around 7% of upper aerodigestive tract cancers. The prognosis is often worse due to the advanced stage commonly seen at presentation while considerably rarer than laryngeal cancer. The rate of nodal involvement and metastasis is high at diagnosis, with 50% to 70% of patients presenting with N1 disease or worse. Prognosis in hypopharyngeal cancer is dictated by stage with early disease (T1-T2) having a 60% 5-year survival compared with less than 25% in larger tumors (T3-T4) or those with multiple nodal spread.[5][6]

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Electrophysiologic Study Indications And Evaluation

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Electrophysiology (EP) study is an invasive percutaneous cardiac procedure used for the investigation and treatment of certain arrhythmias. The aims of conducting an EP study are to access the function of each component of the conduction system, identify the mechanism and precise focus for arrhythmia, risk stratification and determine the need for treatment or therapy, including ablation of the aberrant circuit. This article presents an overview including anatomy and physiology, indications in common cardiac pathologies, and clinical significance of EP studies.

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Septoplasty

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Nasal septoplasty is one of the most commonly performed procedures within ENT and plastic surgery. Indication for functional (as opposed to purely aesthetic) surgery is usually septal deviation resulting in significant and symptomatic nasal airway obstruction. Many surgical techniques exist and can be performed according to surgeon preference and expertise; these include endonasal, endoscopic and open procedures. Septoplasty can also be performed alongside or in addition to rhinoplasty, turbinoplasty, or as part of functional endoscopic sinus surgery for access. Operative recovery is usually a few weeks, and serious complications are rare. Appropriate patients must be listed for surgery to maximize patient outcomes.

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Eating Disorders

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Eating disorders are defined as the disruption in the eating behavior with excessive concern about body weight that impairs physical health or psychosocial functioning. Eating disorders can present as severe psychiatric illnesses associated with high rates of morbidity and mortality.[1] The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has changed the terminology "Eating disorders" to "Feeding and Eating Disorders." DSM-5 mentions eight categories in feeding and eating disorders. 1. Anorexia nervosa. 2. Bulimia nervosa 3. Binge eating disorder. 4. Avoidant or restrictive food intake disorder. 5. Pica 6. Rumination 7. Other specified feeding and eating disorders: 8. Purging disorder Night eating syndrome Atypical anorexia nervosa. Subthreshold bulimia nervosa and binge eating disorder. Orthorexia. 9. Unspecified feeding and eating disorders.

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Nuclear Medicine SPECT Scan Cardiovascular Assessment, Protocols, And Interpretation

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Myocardial perfusion single-photon emission computed tomography (MPS) is an important, cost-effective, and widely used non-invasive imaging modality. With the advancement in imaging techniques and for early detection of coronary artery disease, it is estimated that 9.1 million tests are performed annually in the United States.[1] Myocardial perfusion scan plays a crucial role in diagnosing ischemic coronary artery disease, predicting prognosis, assessing myocardial viability and effectiveness of medical therapy.[2] The sensitivity of this test is improving continuously due to better technologies, new software, and radiotracers.[3] During a myocardial perfusion scan, a gamma camera detects radiotracer which is injected intravenously to measure the distribution of coronary blood flow in the myocardium. By rotating the gamma camera at the regular angular interval in a 180-degree arc, multiple planar projections are collected. Myocardial uptake of tracer for scan dependent on two things.First transportation of radiotracer to the cell surface which is flow-mediated. Second, it requires the intact cell membrane to extract radiotracer. The extraction of radiotracer is directly dependent on blood flow. The same phenomena which cause a reduction in oxygen delivery and ischemic ECG changes on a treadmill can be assessed by perfusion defect on MPS. However, reduced uptake of tracer to specific region help to diagnose culprit artery responsible for patient symptoms. The difference in radiotracer uptake both at rest and stress, help to differentiate fixed and reversible defect.[4]

*33620793*
 33620793

Bayley Scales Of Infant and Toddler Development

StatPearls-/- 2021; ():

Bayley Scales of Infant and Toddler Development is an extensive formal developmental assessment tool for diagnosing developmental delays in early childhood. BSID is the commonly used abbreviation for Bayley Scales of Infant and Toddler Development. BSID scores are from a norm-referenced assessment of early childhood development. Nancy Bayley published the first BSID in 1969. The current BSID in use is BSID 4, published in 2019. BSID 4 is time-saving, has greater clinical sensitivity and accuracy when compared to BSD 3. It takes about 30 to 70 minutes to complete the test.

*33620792*
 33620792

Neonatal Therapeutic Hypothermia

StatPearls-/- 2021; ():

Hypoxic-ischemic encephalopathy among neonates is a significant cause of infant mortality and neurodevelopmental deficits.[1] It is a significant health issue throughout the world. According to recent data, the estimated incidence of neonatal hypoxic-ischemic encephalopathy is 1.5 per 1000 live births in developed countries.[2] With severe encephalopathy, mortality is more than sixty percent, and many of the survivors are disabled. A systematic review concluded that therapeutic hypothermia is beneficial in neonates with HIE.[3] As per current guidelines, it is mandatory to offer therapeutic hypothermia to all term neonates with evolving moderate or severe hypoxic-ischemic encephalopathy.

*33620791*
 33620791

Radiology Patient Safety and Communication

StatPearls-/- 2021; ():

Near the end of War and Peace, Tolstoy wrote (in Russian) that his protagonist Pierre Bezukhov fell ill and that, "despite the fact that the doctors treated him," Bezukhov recovered. These words, written before the advent of X-rays, illustrate a premise that still holds true for modern medical imaging: that investigations and treatments offered to benefit patients nevertheless expose patients to risks. Preventable adverse outcomes occur in part because medical imaging can be performed without strict regard to appropriate-use algorithms and because it subjects patients to risks that healthcare professionals/providers (HCPs) do not fully understand.

*33620790*
 33620790

Conventional Hearing Aid Indications And Selection

StatPearls-/- 2021; ():

This article will discuss the indications and selection of conventional hearing aids. Conventional hearing aids are non-invasive (not requiring surgery) and are placed behind the pinna, in the canal, or are body-worn. Invasive hearing aids, including bone-anchored hearing aids and cochlear implants, are excluded from coverage in this chapter. Hearing aids, by definition, are sound-amplifying devices that increase the user's ability to detect noise.[1] The components of a non-invasive hearing aid vary widely but broadly consist of a microphone, amplifier, receiver, and battery. The microphone converts external acoustic energy into electrical energy, which is amplified by the amplifier. The receiver detects this and converts it back into acoustic energy, projecting sound into the ear canal. The amplification is driven by the battery, which can be made from zinc-air batteries, mercury, alkaline or rechargeable batteries. A non-invasive hearing aid aims to increase the sound levels delivered to and hence detected by the hair cells in the cochlea.

*33620789*
 33620789

Anatomy, Abdomen and Pelvis, Inferior Hypogastric Plexus

StatPearls-/- 2021; ():

The inferior hypogastric plexus is also known as the pelvic ganglion. Classic anatomical studies have provided few details of the inferior hypogastric plexus morphology or the location and nature of the associated nerves. The fusion of the pelvic splanchnic nerves, sacral splanchnic nerves, and superior hypogastric plexus along with visceral afferent fibers forms the inferior hypogastric plexus. There have also been studies showing the contribution of spinal nerves S2-S5 to the inferior hypogastric plexus.[1] Dissection of the inferior hypogastric plexus is difficult due to its location, the multiplicity of its sympathetic and parasympathetic roots, and the complex distribution of its terminal branches. The density of surrounding connective tissue also precludes the pelvic-perineal anatomy; therefore, it is difficult to determine the exact relationship between the nerves and pelvic connective tissue. The inferior hypogastric plexus lends its clinical relevance to various urogenital pain syndromes, including endometriosis, prostatitis, and chronic pain of the sacral region, postherpetic neuralgia, and rectal pain, among others.[2] Therefore, any surgical procedure in this anatomical region must be met with due diligence, with respect to the underlying plexus that may be inadvertently damaged, thus causing a slew of related symptoms of the urogenital tract as well compromise of the pelvic autonomic innervation.[3][4]

*33620788*
 33620788

Sonography Physical Principles And Instrumentation

StatPearls-/- 2021; ():

The development of sonography or medical ultrasound was built on the understanding and research of sound, which can be dated as far back as the 6th century. Specifically, sonography can be tied to as far back as the 1700s, an Italian physicist, Lazaro Spallanzani, who was researching the navigation of bats.[1] In the early 20th century, more applicable uses of ultrasound were studied by French physicist Paul Langevin who eventually laid the groundwork for SONOR (Sound Navigation and Ranging) as he was commissioned to investigate the sunken Titanic.

*33620787*
 33620787

Brachycephaly

StatPearls-/- 2021; ():

The term "brachycephaly" is derived from the Greek words "brakhu" (short) and "cephalos" (head), meaning "short head." Brachycephaly is an infant skull deformity characterized by a lower than normal ratio of the skull's length to its width.[1] Infants with this form of skull deformity have a flattening of the cranium's occipital aspect; consequently, there is an apparent shortening of the skull in the anteroposterior dimension (length).[2] Brachycephaly may be positional (non-synostotic) or synostotic. The incidence of infant positional skull deformities has been on the rise since 1992. This appears to be related to the introduction of the measure of infant supine sleep positioning by the American Association of Pediatrics as a means to prevent sudden infant death syndrome (SIDS).[3][4] However, brachycephaly in infants can also occur due to the phenomenon of craniosynostosis. The skull in infants has the dual function of providing protection for the brain and allowing for its volumetric growth and development. The cranial vault or calvaria in infants comprises several bones separated by fibrous joints or cranial sutures. There are two frontal bones separated by a metopic suture and two parietal bones separated from each other by a sagittal suture. The two parietal bones are separated from the two frontal bones by a coronal suture (anterior fontanelle; the future Bregma). Paired squamosal sutures separate paired temporal bones on either side of the calvaria from the two parietal bones, and a lambdoid suture (posterior fontanelle; future lambda) separates a single occipital bone from the two parietal bones. Craniosynostosis refers to the premature mineralization and fusion of one or more of these fibrous joints, which occur between the bones of the calvaria before the completion of brain growth and development in infants.

*33620786*
 33620786

Intratympanic Steroid Injection

StatPearls-/- 2021; ():

Steroid treatment is routinely given for patients with inner ear disorders, such as unremitting Meniere's disease or idiopathic sudden sensorineural hearing loss (ISSNHL). However, for some patients, systemic steroids may be unsuccessful or contraindicated; therefore, intratympanic steroid (ITS) administration may be a suitable alternative for rapid symptom control.[1][2] ITS is increasingly used as a treatment for inner ear disease. It is generally well-tolerated, has been shown to result in superior perilymph concentration of steroids without the risk of systemic side effects, and so can be used as an alternative or in addition to systemic steroid use.[3] Idiopathic sudden sensorineural hearing loss (ISSNHL), considered an otological emergency, is defined as deafness of cochlear or retrocochlear origin within 72 hours, affecting at least 3 consecutive frequencies by 30 dB or greater with no identifiable cause. Global incidence has been estimated to be 5 to 20 per 100,000 persons per year.[4][5] In the UK, the National Institute for Health and Care Excellence (NICE) recommend steroids as first-line treatment for ISSNHL. This can comprise oral steroids, intratympanic steroid injections (ITSI), or a combination of both. Guidelines from the American Academy of Otolaryngology-Head and Neck in 2019 advise that clinicians offer patients intratympanic steroid salvage therapy where there is incomplete recovery from sudden sensorineural hearing loss (SSHL) 2 to 6 weeks after onset of symptoms.[6] Meniere's disease causes unstable or fluctuating sensorineural hearing levels and vestibular function due to the inner ear mechanisms' failure. The International Consensus (ICON) on treating Meniere disease recommends ITS as second-line therapy when medical treatment has failed.[7]

*33620785*
 33620785

Personalised cancer medicine: Future crafting in the genomic era

Personalised cancer medicine: Future crafting in the genomic era-/-Wellcome Trust-Funded Monographs and Book Chapters 2021; ():

What does it mean to personalise cancer medicine? Drawing on an ethnographic study with cancer patients, carers and practitioners in the UK, this book traces their efforts to access and interpret novel genomic tests, information and treatments as they craft personal and collective futures. Exploring multiple experiences of new diagnostic tests, research programmes and trials, advocacy and experimental therapies, the authors chart the different kinds of care and work involved in efforts to personalise cancer medicine, as well as the ways in which benefits and opportunities are unevenly realised and distributed. Comparing these experiences with policy and professional accounts of the 'big' future of personalised healthcare, the authors show how hope and care are multi-faceted, contingent and, at times, frustrated in the everyday complexities of living and working with cancer.

*33555770*
 33555770

Developing an evidence-based online method of linking behaviour change techniques and theoretical mechanisms of action: a multiple methods study

Developing an evidence-based online method of linking behaviour change techniques and theoretical mechanisms of action: a multiple methods study-/-Health Services and Delivery Research 2021; ():

BACKGROUND: Many global health challenges may be targeted by changing people's behaviour. Behaviours including cigarette smoking, physical inactivity and alcohol misuse, as well as certain dietary behaviours, contribute to deaths and disability by increasing the risk of cancers, cardiovascular diseases and diabetes. Interventions have been designed to change these health behaviours with a view to reducing these health risks. However, the effectiveness of these interventions has been quite variable and further information is needed to enhance their success. More information is needed about the specific processes that underlie the effectiveness of intervention strategies. AIM: Researchers have developed a taxonomy of 93 behaviour change techniques (i.e. the active components of an intervention that bring about behavioural change), but little is known regarding their potential mechanisms of action (i.e. the processes through which a behaviour change technique affects behaviour). We therefore aimed to examine links between behaviour change techniques and mechanisms of action. METHOD: First, we conducted a literature synthesis study of 277 behaviour change intervention studies, from which we extracted information on links, described by authors, between behaviour change techniques and mechanisms of action, and identified an average of 10 links per intervention report. Second, behaviour change experts (n = 105) were engaged in a three-round consensus study in which they discussed and rated their confidence in the presence/absence of 'links' and 'non-links' between commonly used behaviour change techniques (n = 61) and a set of mechanisms of action (n = 26). Ninety links and 460 'non-links' reached the pre-set threshold of 80% agreement. To enhance the validity of these results, a third study was conducted that triangulated the findings of the first two studies. Discrepancies and uncertainties between the studies were included in a reconciliation consensus study with a new group of experts (n = 25). The final results identified 92 definite behaviour change technique-mechanism of action links and 465 definite non-links. In a fourth study, we examined whether or not groups of behaviour change techniques used together frequently across interventions revealed shared theoretical underpinnings. We found that experts agreed on the underlying theory for three groups of behaviour change techniques. RESULTS: Our results are potentially useful to policy-makers and practitioners in selecting behaviour change techniques to include in behaviour change interventions. However, our data do not demonstrate that the behaviour change techniques are effective in targeting the mechanism of action; rather, the links identified may be the 'best bets' for interventions that are effective in changing mechanisms of action, and the non-links are unlikely to be effective. Researchers examining effectiveness of interventions in either primary studies or evidence syntheses may consider these links for further investigation. CONCLUSION: To make our results usable by researchers, practitioners and policy-makers, they are available in an online interactive tool, which enables discussion and collaboration (https://theoryandtechniquetool.humanbehaviourchange.org/); accessed 1 March 2020. This work, building on previous work to develop the behaviour change technique taxonomy, is part of an ongoing programme of work: the Human Behaviour Change Project (www.humanbehaviourchange.org/; accessed 1 March 2020). FUNDING: This project was funded by the Medical Research Council via its Methodology Panel: 'Developing methodology for designing and evaluating theory-based complex interventions: an ontology for linking behaviour change techniques to theory' (reference MR/L011115/1).

*33523611*
 33523611

Interventions for Tobacco Cessation in Adults, Including Pregnant Women: An Evidence Update for the U.S. Preventive Services Task Force

Interventions for Tobacco Cessation in Adults, Including Pregnant Women: An Evidence Update for the U.S. Preventive Services Task Force-/-U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews 2021; ():

OBJECTIVE: We undertook this systematic review to support the U.S. Preventive Services Task Force in updating its 2015 recommendation on tobacco cessation interventions for adults, including pregnant women. Our review addressed the effectiveness and safety of pharmacotherapy, behavioral interventions, and electronic cigarettes for tobacco cessation. DATA SOURCES: We conducted an overview of reviews for evidence related to pharmacotherapy and behavioral interventions among the general adult population and for behavioral interventions among pregnant women. We searched the following databases and organizations' websites to identify existing reviews through April 2019: PubMed, PsycInfo, the Database of Abstracts of Reviews of Effects, the Cochrane Database of Systematic Reviews, the Centre for Reviews and Dissemination Health Technology Assessment, the Agency of Healthcare Research and Quality, the Canadian Agency for Drugs and Technologies in Health, Center for Disease Control and Prevention's Guide to Community Preventive Services, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine), the National Health Service Health Technology Assessment Programme, and the Surgeon General. We conducted a search for primary evidence related to the effectiveness and safety of electronic cigarettes (through May 2020) and pharmacotherapy among pregnant women (through May 2020) and did not rely on existing systematic reviews for this evidence. We conducted ongoing surveillance for relevant literature through September 25, 2020. STUDY SELECTION: For the overview of reviews, we included reviews with or without meta-analysis that were published in the English language that systematically reported the effects of tobacco cessation interventions on health, cessation, or adverse outcomes. We excluded nonsystematic meta-analyses and narrative reviews. For primary evidence related to the effectiveness and safety of electronic cigarettes among adults and pharmacotherapy among pregnant women, we included randomized controlled trials and large observational studies that reported health or cessation outcomes at 6 months or more followup or adverse events at any time point. For all evidence, we conducted critical appraisal of all provisionally included reviews and excluded reviews rated as having "critically low" credibility according to AMSTAR-2 criteria and individual studies rated as "poor" quality according to study design-specific risk-of-bias criteria. Data were abstracted by one reviewer and confirmed by another. DATA ANALYSIS: We grouped reviews based on population and intervention and identified one or more reviews within each population and intervention subgroup that represented the most current and applicable evidence to serve as the basis for the main findings ("primary" reviews) and discussed complementary and discordant findings from other included reviews as necessary. We did not reanalyze any of the individual study evidence but presented pooled analyses and existing point estimates from included reviews. We narratively synthesized the primary evidence for electronic cigarettes among adults and pregnant women and medications for smoking cessation among pregnant women and where appropriate, conducted random-effects meta-analyses to pool study results. RESULTS: We included 67 systematic reviews, 33 of which served as the basis for the primary findings. While this review was broadly scoped to include abstinence of all tobacco products, the primary outcome in all cases was abstinence from combustible cigarette smoking. Among adults, combined pharmacotherapy and behavioral interventions significantly increased smoking abstinence by 83 percent versus usual care or minimal support control groups not using medication (risk ratio [RR] 1.83 [95% confidence interval [CI], 1.68 to 1.98]). Furthermore, all seven FDA-approved medications for smoking cessation were found to be effective in increasing smoking quit rates compared with placebo or nondrug arms at 6 or more months followup. The pooled RR for abstinence for nicotine replacement therapy (NRT, all forms) was 1.55 (95% CI, 1.49 to 1.61), for bupropion, 1.64 (95% CI, 1.52 to 1.77), and for varenicline, 2.24 (95% CI, 2.06 to 2.43). Combined NRT versus a single form of NRT showed a statistically significantly greater cessation effect (RR 1.25 [95% CI, 1.15 to 1.36]). Pooled analysis of trials directly comparing NRT and bupropion did not suggest a difference between the two types of pharmacotherapy; however, varenicline has been shown to be superior to both NRT and bupropion in achieving abstinence at 6 months or greater, although there are fewer trials testing these differences. Although less evidence is available, certain medications such as nortriptyline and cytisine used for tobacco cessation have shown potential benefits. None of the drugs were associated with serious adverse events, including major cardiovascular adverse events or serious neuropsychiatric events. Compared with various controls, behavioral interventions such as in-person advice and support from clinicians including physician advice, nurse advice, individual counseling with a cessation specialist, group behavioral interventions, telephone counseling, mobile phone-based interventions, interactive and tailored internet-based interventions, and the use of incentives had modest but significantly increased relative smoking cessation at 6 or more months (15% to 88% range in relative effects). For example, the pooled RR of physician advice versus no advice was 1.76 (95% CI, 1.58 to 1.96) for smoking cessation at 6 or more months' followup. There was a lack of clear benefit of motivational interviewing, decision aids, print-based, nontailored self-help materials, real-time video counseling, biofeedback (feedback on smoking exposure, smoking-related disease, or smoking-related harms), exercise, acupuncture, hypnotherapy, and system change interventions compared with controls; however, there was substantially less evidence related to each of these interventions. While some reviews found evidence of potential effect modification by specific intervention, population, or study design characteristics, there was no one factor that consistently predicted greater treatment effects, and nearly every subgroup analysis was found to be statistically significant. Few reviews on behavioral interventions captured information on potential harms, and none suggested serious adverse events that arose. We identified five trials that addressed the effectiveness and harms of the use of electronic cigarettes among adults. No trials testing the effects of electronic cigarettes for smoking cessation among pregnant women were identified. Results were mixed on smoking cessation effectiveness at 6 to 12 months among smokers intending to quit when compared with placebo devices or NRT. Four additional trials also reported on potential short-term harms of electronic cigarette use for cessation; none suggested relatively higher rates of serious adverse events. Among pregnant women, smoking cessation during late pregnancy was greater among women receiving any type of behavioral intervention, with evidence most clear for counseling versus controls (RR 1.31 [95% CI, 1.16 to 1.47]). Behavioral interventions were also associated with an increase in mean birthweight of babies as well as a decreased risk of low birth weight. We identified one new trial of NRT among pregnant women, but no new trials testing the effects of bupropion or varenicline in this population. For NRT, rates of validated cessation among women allocated to NRT (5.4% to 28.2%) compared with placebo (5.0% to 25.4%) were not statistically different (pooled RR 1.11 [95% CI, 0.79 to 1.56]). Benefits of NRT on infant health outcomes were seen in a few trials, but that evidence was limited. There was no clear evidence of harms from behavioral interventions or associated with NRT use during pregnancy, but harms also could not be ruled out given sparse reporting, low statistical power for evaluating rare harms, and limitations of observational study comparisons. LIMITATIONS: The comprehensiveness of our overview of reviews is limited by the recency and quality of the source reviews; with exceptions, we did not describe or cite individual trials because of the large volume of trials represented in the reviews. Furthermore, there are a limited number of trials testing the benefits and harms of electronic cigarettes among adults as well as the use of medications to assist pregnant women stop smoking. Such sparsity in research hampers our ability to make any robust conclusions about their effectiveness and potential harms. CONCLUSIONS: There is strong evidence that a range or pharmacological and behavioral interventions, both individually and in combination, are effective in increasing smoking cessation in adults. Moreover, behavioral interventions can help pregnant women stop smoking. Data on the effectiveness and safety of electronic cigarettes for smoking cessation among adults are limited as are data on the use of tobacco cessation pharmacotherapies among pregnant women. Future research should focus on direct comparisons between different combinations and classes of drugs, adaptations of interventions for diverse populations, and the efficacy and safety of electronic cigarettes.

*33523610*
 33523610

A school-based social-marketing intervention to promote sexual health in English secondary schools: the Positive Choices pilot cluster RCT

A school-based social-marketing intervention to promote sexual health in English secondary schools: the Positive Choices pilot cluster RCT-/-Public Health Research 2021; ():

BACKGROUND: The UK still has the highest rate of teenage births in western Europe. Teenagers are also the age group most likely to experience unplanned pregnancy, with around half of conceptions in those aged < 18 years ending in abortion. After controlling for prior disadvantage, teenage parenthood is associated with adverse medical and social outcomes for mothers and children, and increases health inequalities. This study evaluates Positive Choices (a new intervention for secondary schools in England) and study methods to assess the value of a Phase III trial. OBJECTIVES: To optimise and feasibility-test Positive Choices and then conduct a pilot trial in the south of England assessing whether or not progression to Phase III would be justified in terms of prespecified criteria. DESIGN: Intervention optimisation and feasibility testing; pilot randomised controlled trial. SETTING: The south of England: optimisation and feasibility-testing in one secondary school; pilot cluster trial in six other secondary schools (four intervention, two control) varying by local deprivation and educational attainment. PARTICIPANTS: School students in year 8 at baseline, and school staff. INTERVENTIONS: Schools were randomised (1 : 2) to control or intervention. The intervention comprised staff training, needs survey, school health promotion council, year 9 curriculum, student-led social marketing, parent information and review of school/local sexual health services. MAIN OUTCOME MEASURES: The prespecified criteria for progression to Phase III concerned intervention fidelity of delivery and acceptability; successful randomisation and school retention; survey response rates; and feasible linkage to routine administrative data on pregnancies. The primary health outcome of births was assessed using routine data on births and abortions, and various self-reported secondary sexual health outcomes. DATA SOURCES: The data sources were routine data on births and abortions, baseline and follow-up student surveys, interviews, audio-recordings, observations and logbooks. RESULTS: The intervention was optimised and feasible in the first secondary school, meeting the fidelity targets other than those for curriculum delivery and criteria for progress to the pilot trial. In the pilot trial, randomisation and school retention were successful. Student response rates in the intervention group and control group were 868 (89.4%) and 298 (84.2%), respectively, at baseline, and 863 (89.0%) and 296 (82.0%), respectively, at follow-up. The target of achieving >/= 70% fidelity of implementation of essential elements in three schools was achieved. Coverage of relationships and sex education topics was much higher in intervention schools than in control schools. The intervention was acceptable to 80% of students. Interviews with staff indicated strong acceptability. Data linkage was feasible, but there were no exact matches for births or abortions in our cohort. Measures performed well. Poor test-retest reliability on some sexual behaviour measures reflected that this was a cohort of developing adolescents. Qualitative research confirmed the appropriateness of the intervention and theory of change, but suggested some refinements. LIMITATIONS: The optimisation school underwent repeated changes in leadership, which undermined its participation. Moderator analyses were not conducted as these would be very underpowered. CONCLUSION: Our findings suggest that this intervention has met prespecified criteria for progression to a Phase III trial. FUTURE WORK: Declining prevalence of teenage pregnancy suggests that the primary outcome in a full trial could be replaced by a more comprehensive measure of sexual health. Any future Phase III trial should have a longer lead-in from randomisation to intervention commencement. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12524938. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 1. See the NIHR Journals Library website for further project information.

*33497158*
 33497158

Eplerenone versus placebo for chronic central serous chorioretinopathy: the VICI RCT

Eplerenone versus placebo for chronic central serous chorioretinopathy: the VICI RCT-/-Efficacy and Mechanism Evaluation 2021; ():

BACKGROUND: In chronic central serous chorioretinopathy, fluid accumulates in the subretinal space and causes permanent vision loss in approximately 30% of patients. There is no definitive treatment. Previous research suggests that the mineralocorticoid receptor antagonist eplerenone is effective but it is not licensed for chronic central serous chorioretinopathy. OBJECTIVES: The objective was to evaluate whether or not eplerenone was safe and superior to placebo for treating chronic central serous chorioretinopathy. We also aimed to set up a biobank of DNA, serum and plasma samples from treatment-naive participants for future research. DESIGN: The trial was a parallel, randomised (1 : 1 ratio), multicentre, double-masked, placebo-controlled superiority trial comparing eplerenone plus usual care with placebo plus usual care. Participants were randomly allocated to eplerenone or placebo using a secure online system that returned a unique number corresponding to a bottle of the investigational medicinal product. Participants, clinical care teams, pharmacists, outcome assessors and the trial management group were masked. SETTING: The trial took place in 22 NHS hospitals in the UK. PARTICIPANTS: Eligible participants were patients aged 18-60 years with treatment-naive chronic central serous chorioretinopathy of at least 4 months' duration, a best corrected visual acuity score of 54-85 letters and no other conditions affecting visual acuity or contraindications to taking eplerenone or placebo. INTERVENTIONS: The intervention was oral eplerenone (25 mg/day for 1 week, increased to 50 mg/day for up to 12 months). Placebo was a lactose-filled capsule that appeared identical to the overencapsulated eplerenone tablets. To maintain blinding, participants in the placebo group followed the same dose escalation schedule as the eplerenone group. Usual care was included in both groups and was administered at the discretion of clinicians. MAIN OUTCOME MEASURES: The primary outcome was best corrected visual acuity score at 12 months. Secondary outcomes were low-luminance visual acuity, central subfield retinal thickness, change in subretinal fluid thickness, systemic and ocular adverse events, macular atrophy of the retinal pigment epithelium, subfoveal choroidal thickness, choroidal permeability, resolution of subretinal fluid, time to recurrence of subretinal fluid, fundus fluorescein angiography phenotype, incidence of chronic central serous chorioretinopathy in the fellow eye, and patient-reported visual function. RESULTS: Between 11 January 2017 and 22 February 2018, 57 participants were randomised to eplerenone and 57 to placebo; 57 and 54 participants, respectively, were included in the analysis of the primary outcome. The modelled mean best corrected visual acuity score at 12 months in the eplerenone and placebo groups was 80.4 letters (standard deviation 4.6 letters) and 79.5 letters (standard deviation 4.5 letters), with an estimated difference between groups of 1.73 letters (95% confidence interval -1.12 to 4.57 letters; p = 0.24). Hyperkalaemia occurred in eight participants in each group (14%). No serious adverse events occurred in the eplerenone group; three unrelated serious adverse events occurred in the placebo group. LIMITATIONS: Limitations included the inability to prevent co-treatments and discontinuation of the investigational medicinal product in the event of resolution or hyperkalaemia. CONCLUSIONS: Eplerenone was safe but not superior to placebo in improving best corrected visual acuity in people with chronic central serous chorioretinopathy during 12 months of follow-up. In future work, ophthalmologists should investigate alternative treatments for this condition, which remains complicated to treat. TRIAL REGISTRATION: Current Controlled Trials ISRCTN92746680. FUNDING: This project was funded by the Efficacy and Mechanism Evaluation (EME) Programme, a MRC and National Institute for Health Research (NIHR) partnership. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 2. See the NIHR Journals Library website for further project information.

*33471454*
 33471454

Enhanced neoplasia detection in chronic ulcerative colitis: the ENDCaP-C diagnostic accuracy study

Enhanced neoplasia detection in chronic ulcerative colitis: the ENDCaP-C diagnostic accuracy study-/-Efficacy and Mechanism Evaluation 2021; ():

BACKGROUND: Chronic ulcerative colitis is a large bowel inflammatory condition associated with increased colorectal cancer risk over time, resulting in 1000 colectomies per year in the UK. Despite intensive colonoscopic surveillance, 50% of cases progress to invasive cancer before detection. Detecting early (precancer) molecular changes by analysing biopsies from routine colonoscopy should increase neoplasia detection. OBJECTIVES: To establish a deoxyribonucleic acid (DNA) marker panel associated with early neoplastic changes in ulcerative colitis patients. To develop the DNA methylation test for high-throughput analysis within the NHS. To prospectively evaluate the test within the existing colonoscopy surveillance programme. DESIGN: Module 1 analysed 569 stored biopsies from neoplastic and non-neoplastic sites/patients using pyrosequencing for 11 genes that were previously reported to have altered promoter methylation associated with colitis-associated neoplasia. Classifiers were constructed to predict neoplasia based on gene combinations. Module 2 translated analysis to a NHS laboratory, assessing next-generation sequencing to increase speed and reduce cost. Module 3 applied the molecular classifiers within a prospective diagnostic accuracy study, in the existing ulcerative colitis surveillance programme. Comparisons were made between baseline and reference colonoscopies undertaken in a stratified patient sample 6-12 months later. SETTING: Thirty-one UK hospitals. PARTICIPANTS: Patients with chronic ulcerative colitis, either for at least 10 years and extensive disease, or with primary sclerosing cholangitis. INTERVENTIONS: An optimised DNA methylation classifier tested on routine mucosal biopsies taken during colonoscopy. MAIN OUTCOME: Identifying ulcerative colitis patients with neoplasia. RESULTS: Module 1 selected five genes with specificity for neoplasia. The optimism-adjusted area under the receiver operating characteristic curve for neoplasia was 0.83 (95% confidence interval 0.79 to 0.88). Precancerous neoplasia showed a higher area under the receiver operating characteristic curve of 0.88 (95% confidence interval 0.84 to 0.92). Background mucosa had poorer discrimination (optimism-adjusted area under the receiver operating characteristic curve was 0.68, 95% confidence interval 0.62 to 0.73). Module 2 was unable to develop a robust next-generation sequencing assay because of the low amplification rates across all genes. In module 3, 818 patients underwent a baseline colonoscopy. The methylation assay (testing non-neoplastic mucosa) was compared with pathology assessments for neoplasia and showed a diagnostic odds ratio of 2.37 (95% confidence interval 1.46 to 3.82; p = 0.0002). The probability of dysplasia increased from 11.1% before testing to 17.7% after testing (95% confidence interval 13.0% to 23.2%), with a positive methylation result suggesting added value in neoplasia detection. To determine added value above colonoscopy alone, a second (reference) colonoscopy was performed in 193 patients without neoplasia. Although the test showed an increased number of patients with neoplasia associated with primary methylation changes, this failed to reach statistical significance (diagnostic odds ratio 3.93; 95% confidence interval 0.82 to 24.75; p = 0.09). LIMITATIONS: Since the inception of ENDCaP-C, technology has advanced to allow whole-genome or methylome testing to be performed. CONCLUSIONS: Methylation testing for chronic ulcerative colitis patients cannot be recommended based on this study. However, following up this cohort will reveal further neoplastic changes, indicating whether or not this test may be identifying a population at risk of future neoplasia and informing future surveillance programmes. TRIAL REGISTRATION: Current Controlled Trials ISRCTN81826545. FUNDING: This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership, and will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

*33439599*
 33439599

Florida Controlled Substance Prescribing

StatPearls-/- 2021; ():

Chronic pain and opioid use and abuse is a significant problem in the United States and in Florida.[1] Over one-quarter of United States citizens suffer from chronic pain.[2] It is among the most common complaints seen in an outpatient clinic and the emergency department. The failure to manage chronic pain, as well as the possible complication of opioid dependence related to treatment, can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence.[3] Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined.[4] How a patient's chronic pain gets managed can have profound and long-lasting effects on a patient's quality of life. The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months.[5] There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy is in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical.[6] Unfortunately, studies have revealed an inherent lack of education regarding pain management in most professional schools and training programs. Many schools have committed to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum. Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, under prescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. The American Society of Addiction Medicine describes addiction as a treatable chronic disease that involves environmental pressures, genetics, an individual's life experiences, and interactions among brain circuits. Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, they identify five characteristics of addiction: 1. Craving for drug or positive reward. 2. Dysfunctional emotional response. 3. Failure to recognize significant problems affecting behavior and relationships. 4. Inability to consistently abstain. 5. Impairment in control of behavior. Unfortunately, for most health providers, understanding of addiction is often confusing, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for effectively dealing with the challenges of addiction. In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion contributed to the under-treatment of pain. Over time, the manual has eliminated these terms and now uses "substance use disorder," ranging from mild to severe. Unfortunately, there are numerous challenges in pain management, such as both underprescribing and overprescribing opioids. The concerns are particularly prominent in patients with chronic pain and have resulted in patients suffering from inadequately treated pain while at the same time there has been a development of concomitant opioid abuse, addiction, diversion, and overdose. As a result, providers are often negatively influenced and fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. To make the challenges even worse, chronic pain patients often develop opioid tolerance, significant psychological, behavioral, and emotional problems, including anxiety and depression related to under or overprescribing opioids. Clinicians who prescribe opioids face challenges that involve medical negligence in either failure to provide adequate pain control or risk of licensure or even criminal charges if it is perceived they are involved in drug diversion or misuse. All providers that prescribe opioids need additional education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with over and under prescribing opioids. Prescribers of Controlled Substances In Florida: Physicians (DOs/MDs). Physician Assistants. Podiatrists. Dentists. Optometrists. Advanced Practice Registered Nurses. Veterinarians. Provider Opioid Knowledge Deficit There are substantial knowledge gaps around appropriate and inappropriate opioid prescribing, including deficits in understanding current research, legislation, and appropriate prescribing practices. Providers often have knowledge deficits that include: Understanding of addiction. At-risk opioid addiction populations. Prescription vs. non-prescription opioid addiction. The belief that addiction and dependence on opioids is synonymous. The belief that opioid addiction is a psychologic problem instead related to a chronic painful disease. With a long history of misunderstanding, poor society, provider education, and inconsistent laws, the prescription of opioids has resulted in significant societal challenges that will only resolve with significant education and training. Misuse of Controlled Substances Unfortunately, the misuse of controlled substances resulting in morbidity and mortality is rampant.[7] According to the National Survey on Drug Use and Health,2016, performed by the U.S. Department of Health and Human Services, over 10 million people misuse prescription pain medications, and over 2 million misuse sedatives, stimulants, and tranquilizers each year. The same study found that the most common reason for misuse is for the treatment of physical pain. The Center for Disease Control estimates more than 40,000 people die each year die from an opioid overdose. Controlled Substances There are three common classes of controlled substances commonly misused: opioids, depressants, and stimulants. Opioids Opioids are prescribed for pain control by binding to mu-opioid receptors in the central nervous system reducing pain signals to the brain as well as receptors in the GI tract and respiratory system, and are used to treat pain, diarrhea, and cough.[8] Common Opioids Codeine - One of the most commonly taken opioid medications. It is at the center of the opioid addiction problem in the United States and thus is highly regulated. Its main indication is for pain and cough. FDA-Approved Indication Pain Codeine plays a role in the treatment of mild to moderate pain. Its use is recognized in chronic pain due to ongoing cancer and palliative care. However, the use of codeine to treat other types of chronic pain remains controversial. Chronic pain, defined by the International Association for the Study of Pain, is pain persisting beyond the standard tissue healing time, which is three months.[1] The most prevalent causes of non-cancer chronic pain include back pain, fibromyalgia, osteoarthritis, and headache. Non-FDA Approved Indications Cough Codeine is useful in the treatment of various etiologies producing chronic cough. Also, 46% of patients with chronic cough do not have a distinct etiology despite a proper diagnostic evaluation. Codeine produces a decrease in cough frequency and severity in these patients. However, there is limited literature demonstrating the efficacy of codeine in chronic cough. The dose can vary from 15 mg to 120 mg a day. It is, however, indicated in the management of prolonged cough (in specific populations like lung cancer) usually as 30 mg every 4 to 6 hours as needed. Restless Leg Syndrome Codeine is effective in treating restless leg syndrome when given at night time, especially for those whose symptoms are not relieved by other medications. Persistent Diarrhea (Palliative) Codeine and loperamide are equally effective, and the choice between them has its basis in the assessment of the physician evaluating the small but undoubted addictive potential of codeine versus the higher cost of loperamide, and an individual difference in patient's vulnerability to adverse effects. Fentanyl - Transdermal patch and IV, commonly abused and used in mixture with other drugs. Fentanyl is a synthetic opioid that is 80-100 times stronger than morphine and is often added to heroin to increase its potency. It can cause severe respiratory depression and death, particularly mixed when mixed with other drugs or alcohol. It has a high addiction potential.[9] Hydrocodone - Hydrocodone is a schedule II semi-synthetic opioid medication used to treat pain. Immediate-release (IR) hydrocodone is available as a combination product (combined with acetaminophen, ibuprofen, etc.) and is FDA approved for the management of pain severe enough to require an opioid analgesic and for which alternative (non-opioid) treatments are inadequate. Single-entity hydrocodone is only available in extended-release (ER) formulations. It is FDA approved to treat persistent pain severe enough to require 24-hour, long-term opioid treatment, and for which alternative treatments are inadequate. Hydrocodone is also an antitussive and indicated for cough in adults.[10] Morphine Sulfate - FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides significant relief to patients afflicted with pain. Clinical situations that benefit significantly by medicating with morphine include managing palliative/end-of-life care, active cancer treatment, and vaso-occlusive pain during sickle cell crisis. Morphine is widely used off-label for almost any condition that causes pain. In the emergency department, morphine is given for musculoskeletal pain, abdominal pain, chest pain, arthritis, and even headaches when patients fail to respond to first and second-line agents. Morphine is rarely used for procedural sedation. However, clinicians will sometimes combine a low dose of morphine with a low dose of benzodiazepine-like lorazepam for small procedures.[11] Oxycodone - An opioid agonist prescription medication. The oxycodone immediate-release formulation is FDA-approved for the management of acute or chronic moderate to severe pain for which other treatments do not suffice, and for which the use of opioid medication is appropriate. The extended-release formulation is FDA-approved for the management of pain severe enough to require continuous (24 hours per day), long-term opioid treatment, and for which there are no alternative options to treat the pain. The oxycodone to morphine dose equivalent ratio is approximately 1 to 1.5 for immediate-release and 1 to 2 for extended-release formulations.[12] Tramadol - Tramadol is an FDA approved medication for pain relief. It has specific indications for moderate to severe pain. It is considered a class IV drug by the FDA. Due to possible abuse and addiction potential, limitations to its use should be for pain that is refractive to other pain medication, such as non-opioid pain medication. There are two forms of tramadol: extended-release and immediate release. The immediate-release is not for use as an "as needed" medication; instead, it is for pain of less than a week duration. For pain lasting more than a week, extended-release is the therapeutic choice - the indication for extended-release is for pain control under 24-hour management or an extended period. Off-label, the drug is useful for premature ejaculation and restless leg syndrome refractory to other medications. For the off-label use of tramadol for premature ejaculation, both sporadic and daily use is effective for the treatment of the condition. Patients indicate a preference for "as needed" therapy for premature ejaculation due to the lack of side effects compared to the daily use of tramadol.[13] Addiction, Dependence, and Tolerance While each of these terms is similar, providers should be aware of the differences. Addiction - the constant need for a drug despite harmful consequences. Pseudoaddiction - constant fear of being in pain, hypervigilance; usually, there is a resolution with pain resolution. Dependence - physical adaptation to a medication where it is necessary for normal function and withdrawal occurs with lack of the medication. Tolerance - lack of expected response to a medication increasing dose to achieve the same pain relief resulting from CNS adaptation to the medication over time.

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Scalp Vein Catheterization

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Peripheral intravenous (IV) catheterization is an essential procedure performed by a variety of interprofessional healthcare team members. IV access can allow for the sampling of blood for laboratory analysis. Also, IV catheterization allows for fluid and medication administration directly to the patient's circulatory system. Traditionally, IV catheterization is performed in the extremities (arms and hands being more common than legs or feet). This chapter will discuss obtaining peripheral IV access through scalp veins, a less often used but viable alternative to traditional extremity sites. Scalp IVs are an efficient and safe option. Knowing the unique considerations for obtaining IV access in the scalp is essential to successful utilization.[1]

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Intestinal Stoma

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The word stoma or ostomy is derived from the Latin word ostium, which means opening or mouth. An intestinal stoma is one of the most common surgical procedures. The exteriorization of either the small bowel (ileostomy) or large bowel (colostomy) through the anterior abdominal wall is performed. The first recorded intestinal stoma was created by the German surgeon Baum in 1879 to divert an obstructing colon carcinoma.[1] At present, the intestinal stoma is considered one of the most usual life-saving emergency procedures done worldwide.[2] It may be performed to manage wide ranges of benign and malignant gastrointestinal conditions on an emergency or elective basis. In the United States, more than 130.000 intestinal stomas are created per year to address diseases such as colorectal cancer, inflammatory bowel diseases, radiation injury, colonic diverticulitis, and fecal incontinence.[3][4] Intestinal stomas can be temporary or permanent.[5] Although intestinal stomas are considered to be life-saving surgical procedures, they are associated with various complications.

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Radiation Exposure Of Medical Imaging

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It is a general consensus that ionizing radiation is oncogenic in nature. Much of this agreement is based upon observation of increased incidence of carcinoma in a population surviving a nuclear attack or in uranium miners exposed to radiation at the workplace. The amount of radiation used by imaging modalities is negligible as compared to the abovementioned exposures. For instance, in the United States, people are exposed to average annual background radiation levels of about 3 mSv; exposure from a chest X-ray is about 0.1 mSv, and exposure from a whole-body computerized tomography (CT) scan is about 10 mSv, and that's one of the reasons why physicians usually miscalculate the potential risks associated with the radiation exposure while performing procedures using radiologic imaging.[1][2] This article will attempt to explain how to quantify radiation, the biological effect of radiation, risks to health care workers as a result of radiation exposure, and certain recommendations and tips for various medical professionals. Radiation is defined as a moving form of energy. It can be classified into two categories, i.e., ionizing and non-ionizing type. Ionizing radiations can be further classified into electromagnetic radiation (matter less) and particulate radiation. Electromagnetic radiations are energy packets (photons) traveling in the form of a wave. Basic examples of electromagnetic radiation are x-rays and gamma rays. Particulate radiation consists of a beam of particles that can be either charged or neutral. Electromagnetic radiations have high energy and can easily penetrate body tissues. Ionizing radiation is mainly used for diagnostic purposes.

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Echolalia

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The word echolalia is derived from the Greek roots "echo" and "lalia," where "echo" means "to repeat," and "lalia" means "speech." It is also termed echophrasia. Echolalia is the unsolicited repetition of utterances made by others. It is one of the most common echo phenomena and is a non-voluntary, automatic, and effortless pervasive behavior. Echolalia is a normal finding during language development in toddlers.[1]

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Ginger Root

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Ginger root is a plant-based, whole food spice used in the personal or professional treatment of various conditions, ranging from gastrointestinal upsets to cancer. It originates from the root of the Zingiber officinale plant. This activity reviews the history, nutritional property, powerful health benefits, mechanism of action, potential side effects, and the role of ginger root as a valuable agent in lifestyle medicine.

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Von Willebrand Factor

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Replacement therapy with Von Willebrand factor (vWF) can be used in the management and treatment of Von Willebrand disease (vWD) especially in patients who are refractory to treatment with Desmopressin. It is available as plasma-derived concentrates and more recently in a recombinant form. This activity reviews the indications, actions, and contraindications for the use of vWF as a therapeutic agent in the management of vWD. This activity will highlight the mechanism of action, adverse event profile, and other key factors like dosing, monitoring, and relevant interactions pertinent for members of the interprofessional team involved in the care of patients with vWD.

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Xeroderma

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Xeroderma refers to "dry skin" and is a common condition which results in skin roughness, tightness, flaking, and scaling.[1] It can cause pruritus, leading to excoriations and an increased risk of skin infections. xeroderma is multifactorial in etiology and may occur in response to changes in the environment, underlying diseases, medications, or advanced age.[2] Cleansing the skin with lukewarm water and applying a thick moisturizer immediately after bathing may repair the epidermal skin barrier function and restore hydration.[3]

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Ethylenediaminetetraacetic Acid (EDTA)

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Ethylenediaminetetraacetic acid (EDTA) is a medication used in the management and treatment of heavy metal toxicity. It is in the chelating class of drugs. This activity outlines and reviews the indications, action, and contraindications for EDTA as a valuable agent in managing lead toxicity. This activity will highlight the mechanism of action, side effect profile, and other key factors such as dosing, pharmacokinetics, and monitoring pertinent for members of the healthcare team in the use of EDTA.

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Magnetic Resonance Imaging Patient Positioning

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Proper patient positioning is essential for accurate diagnosis with all imaging modalities. In magnetic resonance imaging, patient positioning is vital to obtain good quality and, ultimately, an appropriate diagnosis. However, there are numerous approaches for patient positioning concerning anatomical reference and/or pathology. It is essential to be aware of 'coils,' which are accessories within the MRI with variable sizes and properties designed to transmit and receive signals from the regions of interest.

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Dysphonia

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Dysphonia is the impairment of voice production as diagnosed by a clinician, often used interchangeably with the complaint of hoarseness, which is a symptom of altered voice quality. While many patients experience dysphonia as a natural part of the aging process, it can be a symptom of a serious underlying condition. Clinicians need to recognize that when patients present with dysphonia for longer than four weeks and/or when it is associated with risk factors or other concerning signs and symptoms, further evaluation is warranted.[1][2][3]

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Normochromic Normocytic Anemia

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Anemia is a condition marked by a decrease in the number of red blood cell (RBC) mass in the blood. The main function of RBCs, or erythrocytes, is to carry oxygen from the lungs to the body tissues and carbon dioxide as a waste product from the body tissues to the lungs back. This process is facilitated by hemoglobin (Hb). A decrease in the number of RBCs transporting oxygen and carbon dioxide in anemia decreases the body's capacity for proper gas exchange. The impairment may result from blood loss, an increase in the destruction, or reduced production of RBCs. Traditionally, the decrease is quantified by the ratio of packed RBCs to blood volume, called hematocrit and hemoglobin concentration.[1][2] Anemia can be classified according to mean corpuscular volume (MCV), a measure of the average volume of RBCs in a specimen. Low MCV indicates microcytic, normal MCV indicates normocytic, and high MCV indicates macrocytic.[3] Anemia is generally defined as hemoglobin of less than 13.0 g/dL in men and less than 12.0 g/dL in premenopausal women[4] Normocytic normochromic anemia differs from other forms of anemia because the average size and hemoglobin content of the RBCs are typically within normal limits. RBCs typically appear similar to normal cells under microscopic examination, though in some cases, there may be variations in size and shape that equalize one another, resulting in average values within the normal range. Normocytic normochromic anemia most commonly occurs as a result of miscellaneous chronic infections and systemic diseases. Most normocytic anemias appear to be the outcome of the impaired production of RBCs.[5]

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Neonatal HIV

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Over 95% of HIV-infected pediatric cases are a result of vertical transmission. The pathophysiology of the human immunodeficiency virus (HIV) disease state in the pediatric population is similar to adults. However, differences occur in the clinical presentation, mode of infection, and therapeutic options. The pediatric and neonatal populations have a weaker immune system than adults, therefore, if infected with HIV, they are at a greater risk of opportunistic infections. As such, the delay of treatment may result in a rapid progression of the disease. One of the greatest advancements in medicine has been the prevention of mother-to-child transmission (PMTCT) of Human Immunodeficiency Virus Type 1 (HIV). The rate of transmission of HIV to neonates has been reduced to less than 1% with the implementation of appropriate strategies and careful planning. The increase in comprehensive serologic screening and the treatment of HIV-infected pregnant females have resulted in the reduction of vertical transmission. There are evidence-based prevention modalities that can be utilized at different stages of pregnancy and postpartum to improve outcomes. Antiretroviral therapies (ART) can be prescribed during gestation, antepartum during vaginal or elective cesarean delivery, postnatally to the neonate, and/or when breastfeeding.[1][2]

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Nummular Dermatitis

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Nummular dermatitis is a pruritic eczematous dermatosis characterized by multiple coin-shaped lesions. It may occur as a feature of atopic dermatitis, asteatotic eczema, or stasis dermatitis. The prognosis of this condition is excellent. Most cases can be treated successfully with conservative measures and topical corticosteroids, and a majority of patients will eventually achieve remission. Nummular dermatitis may also be referred to as nummular eczema, discoid eczema, and microbial eczema.

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Suicidal Ideation

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Suicidal ideations (SI), often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide. There is no universally accepted consistent definition of SI, which leads to ongoing challenges for clinicians, researchers, and educators.[1] [2] For example, in research studies, SI is frequently given different operational definitions. [3]This interferes with the ability to compare findings across studies and is frequently mentioned as a limitation in meta-analyses associated with suicidality. [4] Some SI definitions include suicide planning deliberations while others consider planning to be a discrete stage. Beyond the lack of clear nomenclature, there are other concerns. A systematic review of the numerousi nterprofessional clinical guidelines for suicide yielded no consensus on a clinical gold-standard for assessing and managing SI or people at risk of suicide. [1] Although scales to measure depression, SI and risk for suicide exist, none produce a score that is sufficiently reliable or clinically useful in predicting the very small subgroup of suicide ideators whose death by suicide is imminent. [5](The American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults, 3rd ed. 2016, p. 19). It is evident that suicidal ideations present in a "waxing and waning manner", [6] so the magnitude and characteristics of SI fluctuate dramatically.[7] It is critically important for healthcare professionals to recognize that SI is a heterogeneous phenomenon. It varies in intensity, duration, and character. As there is no "typical" suicide victim, there are no "typical" suicidal thoughts and ideations. Unfortunately, healthcare records often document SI in a binary yes/no fashion, although it encompasses everything from fleeting wishes of falling asleep and never awakening to intensely disturbing preoccupations with self-annihilation fueled by delusions. Therefore, thoroughly assessing and monitoring the pattern, intensity, nature, and impact of SI on the individual, and documenting this accordingly is important for all healthcare professionals. It is also important to reassess SI frequently due to its fluctuating pattern. The magnitude of SI fluctuations was studied using an ecological momentary assessment method. Individuals who attempted suicide in the past year plus a sample of suicidal in-patients recorded the intensity of their suicidal thoughts from hour to hour for four weeks. Analysis of these data showed dramatic fluctuations in the intensity of SI by all participants. All participants had SI which varied in its intensity, either upwards or downwards, by one standard deviation on most days. Many had one standard deviation fluctuations several hours apart within the same day.[7] This knowledge is important for all healthcare professionals to consider and highlights the need to monitor fluctuations and not dismiss the possibility of sudden increases in suicidal urges, even when the current level is mild and the individual currently has control over them. Additionally, SI is considered a better predictor of lifetime risk for suicide than imminent risk, so assessments should include describing the characteristics and impact of prior SI as well as current. [8]] The Center for Behavioral Health Statistics Quality publishes the results of the American nationwide household survey, the National Survey of Drug Use and Health (NSDUH). Piscopo's 2017 publication summarized the results from the 2009-2014 surveys which show that 6% of 18-25-year-olds respond affirmatively to the survey question, "At any time in the past 12 months, did you seriously think about trying to kill yourself?" In contrast, the lowest rate of SI was 1.6% in those aged 65 years and above. There is no clear association between endorsing SI and attempting suicide. For every 31 Americans with SI, only one individual will attempt suicide. The rates of suicide deaths also vary by gender, age, race, and other demographic variables. Further evidence of the weak association between reported SI and fatal suicides is apparent when comparing the NSDUH results to CDC mortality records. Despite the low prevalence of SI in white males over age 75 years, they have the highest rate of fatality by suicide (approx. 40 per 100,000). Meanwhile, females over 75 years have much lower rates (4 per 100,000). The suicide ideators in the 18-25-year-old group had significantly fewer suicide deaths (approx. 17.5 per 100,000 for males and 4 per 100,000 for females). Most people have control over SI and do not attempt suicide, even when endorsing SI. Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults (2016, p. 19) points out that SI is a symptom of another primary psychiatric diagnosis and suggests that 90% of people who end their lives by suicide meet the diagnostic criteria for one or more psychiatric diagnoses. However, data clearly show that numerous medical illnesses are associated with increased odds of suicide and that suicidal death extends through all demographic groups and includes virtually all psychiatric and medical diagnoses. The CDC's mortality records for 2017 reveal over 50% of deaths by suicide were by people with no known psychiatric illness. Some criticisms have been made that suicidality should be regarded as a distinct psychiatric diagnosis, with its symptoms and unpinning pathological processes. [2] [1] Although this is beyond the scope of this paper, this contention is becoming more widespread. [6] After reviewing all of the existing clinical guidelines, Bernert et al concluded there is an urgent need for "easily-accessible best practice guidelines, adaptable to diverse fields of medicine and clinical specialties, that may be the first point of contact for risk detection, intervention, and prevention."[1] Although this paper aims to focus primarily on suicidal ideation, it is important to provide context. Therefore, while the intention is not to broaden the focus to suicide, it is impossible to address the significance of SI without also discussing suicidal behaviors and outcomes to some extent. It is estimated by the Center for Disease Control and Prevention (CDC) that in 2017 there were approximately 10 million people in the USA who experienced suicidal thoughts. Fortunately, the majority of ideators in the USA and globally will never attempt suicide and fewer will use lethal means that result in death. Of the 10 million Americans with SI, it is estimated there were 1.4 million suicide attempts in 2017, but healthcare was only sought by approximately one-third of those who attempted. The degree of suicidal intent and the lethality of means used during attempts vary tremendously. One-half of the 47,000 suicides that occurred in America during 2017 were caused by firearms. (CDC). Globally, the World Health Organization (WHO) collects mortality data, including the prevalence and means of suicides, for all member nations. Beginning in 2013, after declaring that the rising suicide rates constituted a "global public health crisis", they advocated for evidence-based strategies to prevent suicides globally. In developing nations, where the ingestion of pesticides was the leading cause of fatal attempts, suicide prevention efforts promoted using less toxic pesticides. Evidence exists that reductions in suicides can be achieved by reducing access to lethal means, but this requires a comprehensive systemic approach that includes collaboration between policy-makers, healthcare professionals and interventions to reduce modifiable risk factors. [1] Primary Care Professionals concerning SI A recent meta-analysis of 44 studies of healthcare services used by suicide victims showed a chief reliance on primary care professionals in all countries. Only 31% of suicide decedents received inpatient or outpatient mental health services in the year before their death; 57% of the decedents had contact with mental health services at some point during their lifetime. [9] Primary care professionals are more apt to have an established relationship with patients and have a more complete understanding of their health history. Furthermore, due to having a pre-established relationship, when patients experience worsening SI or stressors that may precipitate suicidal behaviors, they are more likely to seek help from primary care professionals. Studies show that 80-90% of suicide decedents increased their contact with primary care professionals in the year and months before their suicide; 44% of those who died by suicide had contact with primary care in their last month of life. [9] [10] Although the impetus for increased contacts is undoubtedly variable, it does indicate opportunities exist for healthcare professionals to identify any new risk factors for suicide and offer treatment options to address modifiable factors. During their final visit with primary care professionals, 90% of suicide victims in a UK study disclosed their SI to primary care providers. [11] These same providers were interviewed about their experience losing a patient in their practice to suicide (n=39). In each case, the primary care physician had referred their patient for psychiatric services, so the physician's communication with both their patient and the psychiatric service professionals (physicians and community psychiatric nurses) could be examined in the study. Twenty percent of the physicians who heard their patients endorsing suicidal thoughts stated they were concerned about their patient's safety during their final appointment. [11] The researchers noted that many of the primary care providers were uncertain about how to interpret the meaning of SI when expressed by their patients. This was particularly evident when the patient had a history of voicing SI. Examples of statements from the primary care physicians include; "Although we put her down as a moderate suicide risk, none of us thought she'd ever do it because she talked about it so much". (p. 263). "He'd done this on numerous occasions. Taken overdoses, not as a suicidal attempt but in an attention-seeking, in a [state of] mental distress, help me, [a] cry for help ... there was never a disorder" [11] The limited understanding of how to assess and treat people with SI was apparent in some of the interviews in this UK study, although there was substantial variability between physicians. However, similar gaps in knowledge are also evident in other studies involving primary care professionals. An observational study of primary care providers in the Netherlands showed SI was assessed in only 44% of clinically depressed patients and 66% of new-onset depression patients. [12] The frequent lack of suicide risk prevention policies in primary care practices is also apparent and even when they do exist, there may be uncertainty regarding what they entail. [13] Julie Goldstein Grumet, director of US Health and Behavioral Health Initiatives for the Suicide Prevention Resource Center and the director of the Zero Suicide Institute published preliminary research data in the Jan. 2019 Journal of Health Care Compliance. Less than one-third of healthcare providers (n=15,000) who completed an optional self-test for the Zero Suicide initiative in the USA reported feeling knowledgeable about suicide risk warning signs. Similarly, only 1 in 3 knew their organization's procedures for patients at increased risk or felt confident in their ability to respond to a suicidal patient. Although standardized tools, instruments, and rubrics do not provide a clear indication of imminent suicidal risk, the American Psychiatric Association Clinical Guidelines for Evaluating Suicidality suggests these tools can be useful as prompts when interviewing to ensure thoroughness in the questions asked during the risk assessment. Grumet et al reported that only 35.5% of the providers stated they use any of these available tools when screening or assessing. Furthermore, only one-third of the healthcare professionals responsible for delivering treatment (n = 4,101) indicated they "strongly agreed" when self-rating their level of confidence or comfort in treating patients with elevated suicide risk. Although additional training is recommended by many to improve the competence of healthcare professionals, the outcomes from an interprofessional course which included how to assess SI produced modest results. Students were taught the importance of SI assessments during an online module and then required to practice completing suicide risk assessments on standardized patients. However, later in the semester, only 55% of the students (65.5% of medical; 54.5% of nursing; 46.4% of pharmacy) completed an SI assessment on the depressed standardized patient during their final objective clinical standardized exam (OSCE). [14] This emphasizes the importance of reinforcing learning in academic settings and monitoring competence and compliance in healthcare organizations. There were additional findings in the study of UK primary care physicians that are pertinent to consider. Multiple barriers with psychiatric services were described by the primary care physicians. The primary care providers commented that they often felt frustrated when they were left to manage suicidal patients alone or when the system created obstacles and referral mazes which made it difficult for them to advocate for what they believed was in their patient's best interests:[11] Examples of statements from the interviews include; "Because the patient did not attend his last psychiatric appointment, the psychiatrist discharged him and sent a letter to us stating this. I disagreed [because the patient needed the psychiatrist's expertise]" p. 264. "Sometimes we feel like we have to manipulate the system [to expedite referrals] just to get a patient assessed ... we, therefore, refer to hospital [emergency department] as patients will get seen and assessed on the day and they do follow-up as their referrals go to the CMHT (Community Mental Health)" p. 265.[11] Almost all of the physicians (90%) said they knew their deceased patient "well", but this knowledge may have been under-utilized during the subsequent psychiatric treatment planning. One of the physicians was frustrated about being excluded from providing input into the psychiatric treatment plan - a plan he disagreed with and which he suggested may have contributed to the suicide. [11] The issues and conclusions identified in this UK study are consistent with other studies. A review of literature focusing on improving primary practice professionals ability to detect and treat SI and prevent suicide produced four major recommendations: i) educating practitioners on risks for suicidal thoughts and behaviors ii) providing patient screening to identify suicide risk and/or mood disturbances iii) using evidence-based interventions, including collaborative, multi-disciplinary teams, to manage depression iv) assessing for the presence of suicide risk factors and managing suicide risk when symptoms arise. [15] These recommendations are similar to the reaction of the American accreditation agency, the Joint Commission (JC) to address frequent suicides following contact with ED, PCP and MH services. The Joint Commission's Sentinel Event database received 1,089 reports of suicides from 2010 to 2014 among patients receiving care in an accredited hospital or within 72 hours of hospital discharge or release from an emergency department. Shortcomings in the patient's psychiatric assessment were the most frequently cited root-cause. As of July 1, 2019, the JC requires the use of validated screening tools to assess any patient whose primary reason for seeking treatment or evaluation is for a behavioral health problem. However, universal screening was not mandated, although many organizations may elect to do this. The JC, working with other suicide reduction organizations, has numerous resources on its website to assist members to meet this accreditation requirement. Their stated rationale for new requirement included rising suicide rates, increased empirical knowledge and available risk assessment tools, and the non-compliance of over 21% of accredited behavioral health organizations and 5% of hospitals to meet JC's National Patient Safety Goal (NPSG) 15.01.01 "Element of Performance 1 - Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide" (Joint Commission, NPSG 15.01.01) [16] The JC advised that all accredited organizations should do the following: 1.) Review each patient's personal and family medical history for suicide risk factors. 2.) Screen all patients for suicide ideation using a brief, standardized, evidence-based screening tool. 3.) Review screening questionnaires before the patient leaves the appointment or is discharged. 4.) Take action based on the assessment results to inform the level of interventions needed. (The Joint Commission, 2016, p. 3) [17] Active and Passive Suicidal Ideation "Active" suicidal ideation denotes experiencing current, specific, suicidal thoughts. Active SI is present when there is a conscious desire to inflict self-harming behaviors and the individual has any level of desire, above zero, for death to occur as a consequence. The probable lethality of their actions, based on the means used for the suicide attempt, is not the focus. Rather, the individual's expectation that their attempt could produce a fatal outcome is the key consideration. [18] Example of an Active SI assessment item: Miller et al (1991) Modified Suicidal Ideation Scale "Over the past day or two when you have thought about suicide did you want to kill yourself? How often? A little? Quite often? A lot? Do you want to kill yourself now?" "Passive" SI refers to a general wish to die but when there is no plan of inflicting lethal self-harm to kill oneself. Passive SI includes indifference to an accidental demise which would occur if steps are not taken to maintain one's own life. Passive SI receives less attention from clinicians and researchers than active SI. Although most research studies do not distinguish between active and passive SI, few studies focus on passive ideations. One author pointed out the underlying assumption of healthcare professionals is that the desire for death is not typically thought of as a harbinger of more severe suicidal outcomes. [19] Examples of Passive SI assessment items: Beck et al (1979) Scale for Suicidal Ideation (SSI) was the first to measure "passive suicidal desire": 0 = Would take measures to save [one's own] life. 1 = Would leave life/death to chance. 2 = Would avoid steps to necessary to save or maintain life [20]. European Depression Scale item, "In the past month, have you ever wished you were dead?"[21] Miller et al (1991) Modified Suicidal Ideation Scale "Would you deliberately ignore taking care of your health? Do you feel like trying to die by eating too much (too little), drinking too much (too little), or by not taking needed medications?" Passive SI, Death Wishes, and the Older Adult Population Assessing SI is an essential component of suicide risk assessment for individuals extending beyond those with known psychiatric conditions, especially in the older adult populations around the world. Individuals who endorse SI have a higher lifetime risk of future suicide than individuals who have never experienced any SI, although the prediction value is only weak. The value of SI in predicting imminent suicide risk has not been shown but does factor into the overall assessment of protective versus risk factors in short-term, imminent suicide risk. A common misconception is that passive SI has less clinical importance. Large population-based studies (n>85,000) that compared the odds ratio to predict suicide attempts based on reported passive SI or reported active SI show there is no significant difference. Including questions to assess both active and passive SI was recommended as the best clinical practice to predict risk.[19] Compared to younger populations, older adults are more apt to endorse passive SI and less inclined to express active SI or seek mental health care. Also, the majority die on their initial attempt. [22] White males over 85 years have the highest rates, largely due to the use of lethal means like firearms. A systematic review revealed that older adults who died by suicide have very different personality profiles than younger suicide victims. Overall, older suicide victims had less evidence of maladaptive personalities and the majority did not meet the threshold for psychiatric diagnosis. The only significant association was with a relatively small number of older suicide victims who had obsessive-compulsive and avoidant personality disorders. The researchers suggested these personality traits may have made later-life changes and transitions more difficult. They also noted that older suicide victims were more heterogeneous in both their risk factors and experiences compared to early-life suicide victims. [23] Overall, there is a paucity of research addressing the nature of SI in older populations, although passive SI is understood to be more associated with older adults. However, when searching the literature using analogous terms like "death ideation", "death wish" "self-chosen death" and "wish to hasten death" (WTHD), it becomes more clear that this terminology has been ascribed to older adults' ideations. Healthcare professionals should bear in mind the social constructs and norms that influence the way suicidality is addressed and indirectly minimized by the use of these terms to describe SI in this age group. Without drifting too far into this literature, several examples of recent studies may help illuminate this relatively well-researched area of study. Death wishes: A death wish was expressed in 9.5% of a large sample (n= >35,000) of New Zealanders aged 65 and older who were being evaluated for home care services. Depression, poor self-reported health and loneliness were each independent, predictive variables of death wish. [24] Self-chosen death: Interviews with Dutch older adults (n=25) who were 70 years or older, (mean age of 82), who wanted to die because they considered their lives complete and no longer worth living. All of these ideators had age-related debilitation, but none had a terminal disease. They considered their death wish to be reasonable and wanted to have the same ability as those with terminal illnesses to chose death based on the Dutch euthanasia laws. [25]. Wish to hasten death: A systematic review of 16 studies examining WTHD in patients with advanced illnesses showed that feeling like a burden contributed and may have triggered the WTHD. [26]. A study of incarcerated prisoners aged 50 years and older (n=124) found past alcohol dependence and a self-rating one's health as poor/fair were equally associated with both passive (10%) and active (11%) SI. Compared to inmates who denied any SI, both groups of ideators had significantly higher incidences of previous suicide attempts and/or major depressive episodes. [27] A European study of retired middle-aged and older adults (n >35,000) examined the association between health status and passive suicidal ideations. They found increased odds of passive suicidal ideation when the participant had been diagnosed with a heart attack, diabetes/high blood sugar, chronic lung disease, arthritis, ulcer, and hip/femoral fractures. [28] Other studies show elevated odds ratios for suicide with hepatic disease [29], CVA [30] physical disability [31]). These findings suggest a need for all healthcare professionals to be aware that the lack of adherence to the medication or dietary regime may warrant further exploration concerning possible SI. Research findings from a community sample of older adults (n=1,226) who participated in the PROSPECT study (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) showed that SI was present in 29% of participants with major depression; 11% with minor depression; and 7% without depression. The findings from this study underscore the need to assess SI in older patients, including those who do not have signs and symptoms of depression. [32] A systematic review of self-harm in older adults concluded that more research needs to be done to better understand the characteristics of this population's unique characteristics and needs. Suicide attempts in this age group are usually fatal in their first attempt due to the lethality of their means, existing fragility and lack of desire or opportunity for rescue. Because older adults typically have frequent contact with PCPs, opportunities to detect SI and provide appropriate interventions. [33] Suicide Risk Assessment and Suicide Risk Formulation The suicide risk assessment (SRA) focuses on identifying the risk factors and protective factors for any given individual. This is followed by the suicide risk formulation (SRF) which assigns a level of imminent suicide risk. The subsequent triage and treatment plans are based on the SRF. One of the concerns discussed in the literature is the emphasis on the patient's communication of suicide ideation. [34] The American Psychiatric Association (2016) Practice Guidelines for the Psychiatric Evaluation of Adults states "When the clinician is communicating with the patient, it is important to remember that simply asking about suicidal ideas or other elements of the assessment will not ensure that accurate or complete information is received." (p. 21). Not all ideators are apt to share their SI. Over a dozen research studies have shown that 75% of patients who die by suicide denied SI the final time they were asked by a healthcare professional. Typically, their death by suicide occurred within the month of their last visit. [8] Berman completed chart reviews of 157 patients throughout the USA who died by suicide within 30 days of being evaluated by a healthcare professional. All victims were either receiving in-patient or out-patient mental health care; or were evaluated in an emergency department, or by their primary care professional. The Joint Commission requires healthcare professionals in these practice settings to assess SI for anybody at risk of suicide. However, despite being asked, the majority (66%) denied SI. Within two days, 50% of these individuals who had denied SI ended their lives by suicide. [8]] Berman noted that the denial of SI provides a basis for patient discharge if the individual was admitted due to SI. While this may be an incentive for a patient to deny SI, particularly if they want to be discharged, caution should be exercised. Berman states that too frequently clinicians assume that SI must exist for suicide to occur when in fact SI is only a risk factor for suicide. Additionally, SI is a weak predictor of increased lifetime risk, it does not predict imminent risk -- but, then again, nothing does. Ribet et al examined the root causes that may have contributed to 141 Veteran suicides within a week of their hospital discharge. Flaws in communication were frequently cited. It was also noted that almost half of the suicides occurred following an unplanned discharge. [35] The Joint Commission released multiple sentinel event warnings over the past decade based on reports of patient deaths in hospital or shortly after discharge from mental health units or release from emergency departments. They stated, "there is no typical suicide victim" and cautioned against assuming only certain individuals are at risk based upon their diagnosis or treatment setting. [17] Emergency Department Suicidal Ideation Assessments Beginning July 1, 2019, healthcare professionals are required by the Joint Commission's NPSG 15.01.01 to use a validated tool to assess suicidal risk for all patients whose primary reasons for seeking healthcare is the treatment or evaluation of a behavioral health condition. [17] The ability to accurately triage patients is both contingent on the reliability of the instruments and also the clinician's clinical judgments. Much remains to be learned about the risk factors for imminent, short-term and long-term suicidal behavior and the best way to identify risk. A recent prospective study in Canada compared the risk of suicide attempt within 6 months for individuals who presented in ED with SI, but whose presentations differed as evident in their responses to screening questions (n= 5,655). During ED triage screening, some individuals primarily endorsed SI characterized by an "ambivalence about living" while others expressed active SI. Within 6 months, 3% of the initially screened sample presented again in the ED with a suicide attempt. Individuals who initially identified with "ambivalence about living" had more than double the risk of suicide attempts (odds ratio [OR] = 2.57, 95% CI = 1.64-4.02, P < .001). Those with active suicidal ideation had more than triple the risk of an attempt within 6 months compared to non-SI individuals (OR = 3.75, 95% CI = 2.61-5.34, P < .001) Both active suicidal ideation and ambivalence about living are concerning presentations associated with risk of attempt within 6 months. Clinicians should be mindful that differentiating between active suicidal ideation and ambivalence about living are presentations that warrant follow-up due to the increased 6-month risk of attempts.[36][37] Data show that 10% of people who ended their lives by suicide visited an emergency department within two months of inflicting fatal self-harm. [38] People who have psychiatric histories, substance use disorders or depression were most apt to be assessed for SI but this negates the significance of many other known socioeconomic factors. Chart reviews of suicide victims who ended their lives within hours to days of being assessed by a healthcare professional showed the pitfalls of relying on too much on patients' admissions of SI. Berman's review of the victims' charts showed strikingly similar profiles between the patients who admitted to SI or denied the presence of SI. There were no significant differences in their diagnoses, current presentations or current circumstances. Almost all suicide decedents' charts had documentation showing current anxiety/agitation and sleep problems, current interpersonal problems or job/financial strain, current comorbid diagnoses, current social isolation/withdrawal, plus a history of SI/prior attempts plus many had a family history of a mental disorder. Healthcare professionals should bear in mind that relying on verbalized or reported SI as a gateway to assessing suicide risk may be inadequate, especially when SI is denied. [8] A 2013 study indicated that 0.6% of emergency department (ED) visits were due to suicidal thoughts, but when screening for SI was done, incidental, occult suicidal ideation was found in over 11% of patients who arrived due to medical complaints. Although SI was identified in medical patients and communicated, no follow-up regarding their SI occurred while on the medical unit. [39] The Joint Commission does not require universal screening of all patients, but some suicide risk reduction programs, professional organizations and healthcare systems are advocating and implementing policies for universal screening in ED. A recent study of ED nurses and physicians in ED showed that most felt confident completing SI screenings, but only 7% of physicians (residents and attendings) and 37% of nurses reported they did so all of the time or most of the time. [40] Focus group interviews with ED nurses produced skepticism that the risk for suicide can be more reliably assessed with a brief screening tool question, such as 'Do you have thoughts or plans to harm yourself?' compared to a clinician's judgment. The participants described their efforts to improve suicide screening during ED triage required an ongoing iterative process of assessing for SI which included probing, eliciting, evaluating and reacting to identify occult SI. [41] Children ages 10-12 years who presented at the ED were screened with the Ask Suicide-Screening Questions (ASQ) and Suicidal Ideation Questionnaire. Positive screen results were present in 54% of patients whose chief complaint was psychiatric, but screening also showed positive results for 7% who presented to the ED with chief medical complaints. The overall rate of SI for these pre-teens was 29% with 17% reporting engaging in prior suicidal behaviors. Although this sample was small, these findings highlight the potential value of screening children as young as 10 years for SI, including those who present with medical concerns. [42] These findings suggest that a substantial number of individuals who present in ED may have occult SI. The interprofessional ED team should bear in mind that some individuals may express suicidal thoughts differently, or deny SI when presented in the form of a screening tool, and feel more comfortable disclosing it when approached privately in a supportive, direct manner. The literature suggests that all healthcare providers in ED will benefit from additional training to increase their knowledge, skills, and confidence. [43] A large meta-analysis (71 studies N= 4,669,303 individuals) included inpatient and non-inpatient adult populations to examine whether expressing SI was associated with subsequent suicides. Only limited sensitivity of SI for suicide was found (41% at 95% Confidence Interval (CI) 35-48) which means approximately 60% of suicide victims did not report experiencing SI. These authors examined whether there was a difference between using a structured instrument to assess SI versus relying on the healthcare professional's clinical judgment. Using structured instruments to assess SI was associated with a non-significantly lower pooled odds ratio (2.38, 95% CI 1.14-4.99) than when SI was clinically defined (OR = 3.72, 95% CI 2.96-4.67), but a great deal of heterogeneity in the studies. An important finding was that having a suicide plan, which was reported in only four studies, did significantly increased eight-fold (OR = 8.51, 95% CI 5.51-13.06). Two studies used an expressed wish to die as their operational definition of SI (OR = 3.01, 95% CI 1.49-6.06). 65 studies did not specify the individual's level of intent or planning when describing SI. There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, OR = 3.41, 95% CI 2.59-4.49, 95% prediction interval 0.42-28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P 84.000 representing 12 samples from 23 countries) showed that people who reported having at least one lifetime psychotic experience had double the odds of experiencing SI in the future (5 articles; n = 56,191; OR 2.39, 95% CI,1.62-3.51); triple the odds of a future suicide attempt (8 articles; n = 66,967; OR = 3.15 95% CI, 2.23-4.45), and four times the odds of future suicide death (1 article; n = 15,049; OR= 4.39 95% CI, 1.63-11.78]. The authors concluded these elevated risks exceeded what could be explained by co-occurring psychopathology. suggesting healthcare professionals should be alert to the risk of SI in anybody with a history of psychotic experience.[47] These findings emphasize the need for healthcare professionals to recognize the importance of psychosis as a risk factor for SI and suicidal behaviors.

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Edoxaban

StatPearls-/- 2021; ():

Edoxaban is a medication used in the management and treatment of pulmonary embolism (PE), deep venous thrombosis (DVT), and non-valvular atrial fibrillation (NVAF). It is in the direct-acting oral anticoagulant class of drugs. This activity outlines the indications, action, and contraindications for edoxaban as a valuable agent in treating and managing thromboembolic events. This activity will highlight the mechanism of action, adverse event profile, and other key factors pertinent to the healthcare team members in the care of patients with pulmonary embolism, deep venous thrombosis, and non-valvular atrial fibrillation.

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Postpartum Care Of The New Mother

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The postpartum period begins soon after the baby's delivery and usually lasts six to eight weeks and ends when the mother's body has nearly returned to its pre-pregnant state.[1] The weeks following birth lay the foundation of long-term health and well-being for both the woman and her infant. Therefore, it is critical to establish a reliable postpartum (afterbirth) period that should be tailored into on-going, continuous, comprehensive care. Most maternal and infant deaths occur in the first month after birth. Hence effective postpartum care is mandatory to improve both short-term and long-term health consequences of mother and newborn.[2]

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Trigonocephaly

StatPearls-/- 2021; ():

Trigonocephaly is the premature closure of the metopic suture forming a triangular forehead, with an obvious or subtle osseous ridge. The word metopic comes from the Greek word "metopon," which translates to the forehead.[1] The premature fusion of the metopic suture, a type of craniosynostosis, produces a narrow forehead, causing the position of the eyes to be closer than usual (hypotelorism) with associated bitemporal narrowing and biparietal widening.[2] It should be distinguished from the benign metopic ridge where hypotelorism and the bitemporal narrowing are absent and have no other clinical features. 3D computed tomographic (CT) scans can be used to distinguish them.[3][4]

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Patient Restraint and Seclusion

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Working in the medical field does not come without its hazards. Unfortunately, even in the pursuit to provide aid to those in need, those same patients can become agitated and violent. The Occupational Safety and Health Administration (OSHA) stated that 75% of annual assaults in the workplace occur in the healthcare and social service fields. As reported in the National Crime Victimization Survey, healthcare workers face a 20% higher chance of being victimized in the workplace when compared to other workers. Because patient violence can occur in any clinical setting, it is imperative for providers to be prepared in order to minimize the risk of injury to the patient and caretakers. This document will discuss guidelines for harm reduction in the healthcare setting with a focus on patient restraint and seclusion.

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Granulosa Theca Cell Cancer

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Granulosa theca cell cancers include ovarian tumors, which consist of granulosa cells, theca cells, and fibroblasts in variable combinations. Granulosa cells in the sex cords produce sex steroids and several peptides needed for folliculogenesis and ovulation. They also give rise to granulosa theca cell tumors (GCT), which form about 5 percent of ovarian neoplasms and are the commonest sex cord-stromal tumors of the ovary (70 percent). There are two distinct types of GCT -adult and juvenile forms- based on characteristic clinicopathologic features. The adult type is the commonest variety and manifests in peri- or post-menopausal women, while the juvenile type constitutes only 5 percent of cases and occurs in prepubertal girls and young women. Theca cells are present in the ovarian stroma and play an essential role in fertility by producing the androgen substrate required for ovarian estrogen biosynthesis. Thecomas are uncommon and comprise less than 7 percent of sex cord-stromal tumors. They are usually benign and have an excellent prognosis. Malignant thecoma is rare and most often contains an element of granulosa cells, too, and hence the article focuses on GCTs unless otherwise specified. Finally, GCTs are distinct from epithelial ovarian cancers in that they are detected in the early stage, often in young females, and usually manifest with abdominal distension, pain, or rarely with features of hyperestrogenism/virilization. The extra ovarian spread is to the omentum and peritoneum and occasionally to the lungs, liver, or brain via hematogenous spread. Lymph node metastases are uncommon. These tumors are treated by surgery alone and have a good prognosis. However, they tend to have an indolent progression that is prone to late recurrence that is seen in as many as up to 25 percent despite having curative surgery.[1][2]

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PENG Regional Block

StatPearls-/- 2021; ():

The pericapsular nerve group Block (PENG) is a regional anesthetic technique that was described in 2018, developed primarily in total hip arthroplasties (THA) for postoperative analgesia with motor sparing benefits. The block is thought to provide more complete analgesia to the hip by depositing local anesthetic within the myofascial plane of the psoas muscle and superior pubic ramus.[1] Furthermore, the blocking and understanding of the terminal nerves that innervate the hip joint have also been described in patients with chronic hip pain. The indications for THA often include degenerative hip disease and traumatic hip fractures. These indications for surgery are relatively common in the elderly population and are associated with significant morbidity and mortality.[2] Operative intervention, such as THA, has also been associated with significant pain.[3] Historically, the most commonly performed peripheral nerve blocks include lumbar plexus block, a femoral nerve block, or a fascia iliaca compartment block to manage post-operative analgesia.[4] With the understanding that additional articular branches (i.e., from the sciatic nerve), these blocks will provide incomplete analgesia to the hip and may also predispose the patient to fall due to weakness of the quadriceps muscles.[5] Therefore the ideal block technique should provide complete analgesia of the hip joint and without muscle weakness.

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Occupational Therapy Assessment

StatPearls-/- 2021; ():

Occupational therapy has sometimes been mixed with physical therapy, but in its essence, occupational therapy is an assessment and intervention to help people through the therapeutic use of everyday activities. It starts with an assessment, and then an intervention is planned to allow those to maintain, recover, or even develop activities or occupations of individuals.

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Methocarbamol

StatPearls-/- 2021; ():

Methocarbamol is a medication used in the management and treatment of acute musculoskeletal pain. It is in the skeletal muscle relaxant class of medications. This activity reviews the indications, mechanism of action, and contraindications for methocarbamol as an option for use in the multimodal treatment of acute musculoskeletal pain. This activity will also underscore key factors to consider when prescribing: adverse event profile, evidence of efficacy, pharmacodynamic and pharmacokinetic considerations, and recommendations for monitoring in the management of patients with musculoskeletal pain and related conditions.

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Oral Mucosa Cancer

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Oral mucosal cancer is cancer that arises from the lining (mucosa) of the oral cavity. The oral cavity is compromised of the mucosa lining of the lips and cheeks, the teeth, gingiva (gums), anterior two-thirds of the tongue, the floor of the mouth, hard palate, and the retromolar trigone posterior to the wisdom teeth. It has a close anatomical relationship with the oropharynx, the boundary of which is the border between the hard and soft palate, the border between the anterior 2/3rds and posterior 1/3rd of the tongue, and the anterior pillars of the tonsils. The main risk factors are smoking and alcohol consumption. The mainstay of treatment is surgery, often with adjuvant radiotherapy.

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Breast Reconstruction Perforator Flaps

StatPearls-/- 2021; ():

Among women, breast cancer is the most commonly diagnosed cancer after non-melanoma skin cancer. It is presented as the second cause of cancer deaths after lung cancer. In 2020, 42,170 women in the United States are expected to die from breast cancer (U.S . Breast cancer statistics) Despite advanced breast conservation techniques due to advances in immunotherapy and hormone therapy for local control of disease, not all patients are good candidates for these techniques. Many patients require a mastectomy, both for the treatment of breast cancer and prophylactically for those with cancer genes. Plastic surgery offers two reconstruction methods; implant reconstruction and autologous reconstruction. Factors influencing these methods include the size and shape of the breast that is being rebuilt, the woman's age and health, her history of past surgeries, surgical risk factors (for example, smoking history and obesity), the availability of autologous tissue, and the location of the tumor in the breast.[1] Two types of autologous reconstruction techniques can be described: vascularized pedicled skin/muscle flaps (latissimus dorsi flap, TRAM flap) or free flaps (deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric artery (SIEA) flap, Gluteal artery perforator (GAP) flaps, and profunda artery perforator flap). Introduced by Holmstrom and Robbins, the deep inferior epigastric perforator flap (DIEP) is an aesthetic and better-accepted technique for autologous microsurgical breast reconstruction after mastectomy for breast cancer.[2][3] For breast reconstruction without sacrificing the rectus abdominis muscle, The first clinical use of skin and fatty tissue was reported by Koshima and Soeda and was then practiced by Allen and Treece and has become the benchmark for breast reconstruction but requires significant microsurgical experience to harvest.[4][5][6] The popularity has arisen because the use of the perforators and blood vessels only eliminates much of the significant morbidity to the abdominal wall and rectus musculature associated with the traditional transverse rectus abdominis myocutaneous (TRAM) flap. Breast reconstruction with DIEP flap ensures satisfactory long-term results in most patients because, in these procedures, the consistency of the reconstructed breast is almost identical to that of the natural breast in terms of softness and aesthetics and especially with the evolution of genetics, autologous breast reconstruction is becoming increasingly important especially in light of the increased rates of prophylactic mastectomies with BRCA mutations.

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X-ray Radiographic Patient Positioning

StatPearls-/- 2021; ():

Imaging of the body is often complicated by the fact that anatomic structures overlap each other. Diagnostic accuracy of radiographs generally refers to how well an exam can predict the presence (or absence) of a disease or condition. The technologist plays a pivotal role in improving diagnostic accuracy by providing diagnostic images.[1] This requires a technologist to be aware of the various positions and techniques required to isolate and provide a clearer view of a body part being imaged. In addition to better viewing an anatomic part, different projections also help anatomize an abnormality or localize a foreign body.[2][3]

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New York State Infection Control

StatPearls-/- 2021; ():

Infection control refers to the policy and procedures implemented to control and minimize the dissemination of infections in hospitals and other healthcare settings, with the main purpose of reducing infection rates. Infection control as a formal entity was established in the early 1950s in the United States. By the late 1950s and 1960s, a small number of hospitals began to recognize healthcare-associated infections (HAIs) and implemented some of these infection control concepts. The primary purpose of infection control programs was to focus on the surveillance for HAIs and in-cooperate the basic understandings of epidemiology to elucidate risk factors for HAIs.[1] However, most of the infection control programs were organized and managed by large academic centers rather than public health agencies, which lead to sporadic efficiency and suboptimal outcomes. It was not until the late 19th and early 20th century when the new era in infection control was started through three pivotal events. These events included the Institute of Medicine's 1999 report on errors in health care, the 2002 Chicago Tribune representation on HAIs, and the 2004/2006 publications of the significant reductions in bloodstream infection rate through the standardization of central venous catheter insertion process.[2][3][4] This new era in healthcare epidemiology is characterized by consumer demands for more transparency and accountability, increasing scrutiny and regulation, and expectations for rapid reductions in HAIs rates.[5] The role of infection control is to prevent and reduce the risk of hospital-acquired infections. This can be achieved by implementing infection control programs in the forms of surveillance, isolation, outbreak management, environmental hygiene, employee health, education, and infection prevention policies and management.[6]

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Tympanoplasty

StatPearls-/- 2021; ():

Chronic suppurative otitis media (CSOM), characterized by repeated or prolonged episodes of acute otitis media lasting for more than 12 weeks, can cause damage to the tympanic membrane (TM), resulting in a non-healing perforation.[1] Worldwide, CSOM is the most common childhood infectious disease.[2] Risk factors include upper respiratory tract infection, malnutrition, and poor hygiene. The symptoms of CSOM are otorrhoea that leaks into the external ear canal through the TM perforation and hearing loss. The hearing loss is typically a mild conductive loss (10 to 20dB); however, in some cases, ossicular chain erosion can occur, causing a more profound audiologic alteration (50 to 70dB).[3] Tympanic membrane perforations may present in either the pars tensa or pars flaccida (though the former is most common); the perforation can be further described as marginal or central depending on the position relative to the annulus, as well as wet or dry (persistent otorrhoea or no active otorrhoea respectively).[4][5] A subtype of CSOM is CSOM with cholesteatoma. Cholesteatomas are most commonly an acquired disease process occurring within the middle ear. They consist of a sac of squamous epithelium, usually in the attic, which can extend beyond the TM, eroding bone and thereby causing ossicular chain destruction. [6] Signs and symptoms of cholesteatoma are similar to CSOM and include foul-smelling otorrhoea, hearing loss, TM perforation, and attic retraction. Please see the StatPearls article entitled "cholesteatoma." Tympanoplasty is the surgical procedure performed to repair a perforated TM, with or without reconstruction of the ossicles (ossiculoplasty), with the aim of preventing reinfection and restoring hearing ability.[2] CSOM is the most common indication; large invasive cholesteatomas may require a mastoidectomy as well as reconstruction of the TM.[4][7] The history of tympanoplasty began in the 1950s when Wullstein and Zollner popularized the technique of using overlay graft to reconstruct the perforated TM and restore the sound conduction apparatus of the middle ear.[8] Since then, surgical approaches to tympanoplasty have been modified, as described herein. Wullstein Classification: Tympanoplasty can be classified into five types, according to the Wullstein classification.[9]: Type I: repair of the TM alone; no abnormality of the middle ear. Type I tympanoplasty is synonymous with myringoplasty. Type II: repair of the TM and middle ear; the malleus is eroded. Tympanoplasty involves grafting the TM to the incus. Type III: repair of the TM onto the stapes head; the malleus and incus have a defect. Type IV: the TM is grafted to the stapes footplate, which is movable. Type V: repair involves the stapes footplate, which is fixed.

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Swallowing Study

StatPearls-/- 2021; ():

In 2010, over 16 million people in the US required treatment for dysphagia, either in the community or inpatient setting. It is estimated that nearly 50% of hospitalized patients have a swallowing disorder, exposing them to the risk of aspiration pneumonia, increased re-hospitalization, and increased mortality. By identifying at-risk patients early on, appropriate management can commence helping reduce the risk of aspiration. Aspiration pneumonia leads to an increased length of hospital stay from complications that can be avoided. A holistic approach to nutritional needs can improve the patient's overall quality of life, in addition to their psychological health. In elderly patients, difficulties with swallowing can cause anxiety around a meal, and panic associated with this activity of daily living can result in the individual socially isolating themselves. A videofluoroscopic swallow study is considered the gold standard diagnostic tool for detecting dysphagia. It can assess dysphagia that may not be picked up by clinical examination or patient reporting.[1][2]

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Olfactory Testing

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Many patients are not aware of their olfactory deficits.[1] Therefore, olfactory testing is important. Additionally, common causes of olfactory decline create distinct patterns of olfactory deficits that are revealed through multicomponent olfactory tests.[2][3] Moreover, olfactory deficits may be a warning-sign for neurodegenerative disorders or infections such as coronavirus disease 2019 (COVID-19).[4] Thus, olfactory testing may uncover important clues of potentially dangerous conditions.

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Sensorineural Hearing Loss

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Hearing loss is a common complaint for which referrals are frequently made to secondary care for an otolaryngologist's attention. There are two types of hearing loss; conductive and sensorineural hearing loss.[1] Sensorineural hearing loss (SNHL) is the most common type and accounts for the majority of all hearing loss. Patients with new-onset hearing loss should be investigated and undergo full audiometric evaluation by a multidisciplinary team, including an otolaryngologist, audiologist, radiologist, and speech/language therapist.

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Ileal Conduit

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Urinary diversion involves the re-routing of urinary drainage to the outside of the body - either as a temporary or permanent solution. Commonly, a permanent urinary diversion is created after surgery to treat a bladder or pelvic malignancy, but it can be performed for other functional and anatomical abnormalities of the urinary tract. They can be classified as percutaneous, continent, or incontinent. We are focusing on incontinent diversion in this chapter, of which there are two types - cutaneous ureterostomy and intestinal or ileal conduit. Ureterostomy is rarely used and usually only as a last resort in salvage procedures. Ileal conduits are the most common form of incontinent urinary diversion, other options providing continent urinary diversion do exist, and these are more widely practiced in America, whereas in Europe, ileal conduits are preferred. Ileal conduits are the gold standard urinary diversion technique against which all others are measured today.[1][2] It is a passive conduit for urine to drain into an appliance. It was first described in the 19th century and developed further in the 1950s by Bricker.[3] It is thought to have originally been developed by French surgeons during World War II, but the technique did not come to prominence until 1950, when an effective adhesive appliance for ileostomy was introduced. As time has passed, and both oncological and surgical techniques have evolved, selecting the right patients for an ileal conduit has become more refined along with the surgical approach.

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Tympanostomy Tube

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In the United States, tympanostomy tube (TT) insertion is the most common ambulatory surgery performed on children under 15, with nearly 667,000 cases performed in 2006.[1] Almost 7% of all children will have a least one set of TT by 3 years of age.[2] The most commons reason that TT insertions are performed includes otitis media resulting in persistent middle ear fluid with hearing loss, recurrent acute otitis media, and persistent middle ear infections despite antibiotic therapy. Otitis media is the second most common illness diagnosed in children and is more common in children younger than seven due to their undeveloped immune system and poor Eustachian tube function.[3]

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Appropriate Magnetic Resonance Imaging Ordering

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Magnetic resonance imaging (MRI) is a diagnostic technique useful for noninvasive visualization of organs and soft tissue structures.[1] The ability to evaluate for structural integrity lends MRI for imaging the neural axis and large joints of the musculoskeletal system where it was used most heavily during its infancy. Since that time, MR's scope and application have broadened significantly and now encompasses abdominopelvic and cardiac imaging. Clinicians frequently order MRI to characterize soft tissue and osseous lesions or masses. In some cases, the varying MRI sequences can determine the composition of these abnormalities. For example, MRI elastography can diagnose and surveil hepatic fibrosis sparing the patient from an invasive and repetitive biopsy. MR angiography, using both contrast-enhanced and non-contrast techniques, can diagnose vascular occlusive disease and stenosis. Faster scan times and gating techniques minimizing cardiac and respiratory motion make MRI a useful non-invasive tool for cardiac evaluations of structure, function, and myocardial perfusion.[2][3] A major advantage of MRI is the ability to produce high-quality images with superior soft-tissue contrast without using ionizing radiation. The magnet generates images based on the specific and unique magnetic properties of the tissues driven by the spin properties of hydrogen molecules.[4] This makes MRI especially useful to evaluate "high radiation risk" patients like pregnant women and children. MRI is also valuable for patients with chronic conditions requiring routine imaging surveillance, such as multiple sclerosis and inflammatory bowel diseases.[5] MRI does not exist without hazard - the magnetic field can be dangerous and strict parameters are in place to ensure patient safety. Pre- imaging screening protocols are in place to assess the patient's risk factors ranging from occupational exposures to surgically implanted devices determined to be incompatible with the magnetic field. Though many of the newer generation implanted devices are MR compatible, it is crucial to consult with both the radiologist and MR technologists. The magnetic field can alter implanted devices and result in loss of function, positioning, and temperature changes. Additionally, while some prosthetic devices- like heart valves, stents, and artificial joints- are MR safe, they may cause signal artifacts that limit the diagnostic quality of the exam.[6] While in no way all-inclusive, this article provides information for clinicians to consider when ordering MR imaging.

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Plummer Disease

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Plummer disease, also known as toxic multi-nodular goiter, is a hormonally active multi-nodular goiter with hyperthyroidism. Plummer disease was first described by Henry Plummer, an American Physician in 1913. It consists of more than one autonomous thyroid nodules, or one or more autonomous nodules together with one or more nonautonomous solid, cystic, or mixed (solid and cystic) nodules or numerous small autonomous areas associated with a spectrum of hyperthyroidism ranging from subclinical hyperthyroidism to severe thyrotoxicosis. Autonomous nodules appear as hyperactive (hot or warm) and nonautonomous nodules as hypoactive (cold) or normoactive on nuclear medicine thyroid scintigraphy.

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Oral Melanoacanthoma

StatPearls-/- 2021; ():

Oral melanoacanthoma is a rare, benign macular brown-black lesion, which is usually asymptomatic, and distinguished by the sudden appearance and rapid growth. It is found to be secondary to tissue trauma and is self-limiting in nature. In the literature, up to 75% of reported cases are labeled as reactive.[1] Histologically it presents with acanthosis of the superficial epithelium and proliferation of dendritic melanocytes.[2] The most common location of oral melanoacanthomas is the buccal mucosa, but they can also be seen in labial mucosa, palate, gingiva, alveolar mucosa, and oropharynx.[1] There are two recognized phenotypes, the multifocal and the singular, the most common of which is the latter.

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Mo99 - Tc99m Generator

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Radionuclide production is a crucial component in nuclear imaging and therapeutic modalities. More than 90% of its production is used for diagnostic purposes. The majority of the radionuclides are produced in a nuclear reactor and a cyclotron. However, it is impractical to set up an imaging laboratory near a nuclear reactor or a cyclotron; therefore, a generator serves as a convenient system for on-site production and extraction of commonly used radionuclides such as 99m-Tc (6 hours) from its parent nuclide molybdenum 99 (66 hours). Other less widely used generator systems include 132-Te (3.2 days)/132-I (2.3 hours), 68-Ge (271 days)/ 68-Ga (68 minutes).

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Percutaneous Transluminal Angioplasty and Balloon Catheters

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Worldwide, atherosclerosis is the most common cause of morbidity and mortality manifesting as cardiovascular disease, carotid artery disease, peripheral vascular disease, and renal artery stenosis.[1] Angioplasty is a minimally invasive endovascular procedure to widen these stenosed arteries. Angioplasty procedures are mainly directed against atherosclerotic plaque to mold and remodel the plaque and subsequently (derived from the Greek terms aging- vessel and plasso-mold). Recent advances in interventional radiology have made it possible to potentially treat almost all anatomic lesions with endovascular means, since its inception in 1964, when Dr.Charles Dotter percutaneously dilated localized stenosis of the subsartorial artery in an 82-year-old female with a guidewire and coaxial Teflon catheter, the tools, and techniques of angioplasty have greatly evolved from simple angioplasty with balloon dilation to stent placement and atherectomy procedures.[2][3][4] Some of the types of stents used are: 1. Coronary angioplasty: Bare metal stent. Drug-eluting stent. Early generation drug-eluting stents: Sirolimus-eluting stent and Paclitaxel-eluting stent. Durable polymer drug-eluting stents: Everolimus-eluting stent, Zotarolimus eluting stent, Ridaforolimus-eluting stent. Bioabsorbable polymer drug-eluting stents. Thin-strut bioabsorbable polymer DES. Ultra-thin strut DES: Orsiro stent. Polymer free DES. Others: Combo stent - sirolimus elution from biodegradable polymer matrix which is abluminal in shape with a CD34 antibody layer. The choice of stent depends on local availability and interventional cardiologist's expertise - Everolimus-eluting stents, Zotarolimus-eluting stent, ridaforolimus-eluting stents, and the biodegradable stent are usually the first choice. A bare-metal stent is preferred in cases where the patient is actively bleeding, or the duration of dual antiplatelet therapy cannot be >30 days e.g., non-cardiac surgery within 4-6 weeks of PCI. 2. Carotid angioplasty: Self Expanding Stents. Cobalto alloy braided mesh stent. Nitinol open-cell stents (cylindrical or tapered). Nitinol closed-cell stents. Hybrid nitinol stent. New Hybrid Carotid Stent. There is no clear guideline on which stent is ideal; there is a trend towards a tailored approach where the choice of stent and procedure is made based on individual carotid anatomy, plaque complexity, anatomopathological variables, and local availability and technical expertise.[5] 3. Peripheral arteries: Balloon-expandable stents. Self-expandable stents. Covered stents. Drug-eluting stents. Drug coated balloon stent. Dual therapy stents. Bioabsorbable vascular scaffold. Bioengineered stent[6]. The choice of an appropriate stent depends on the access site, lesion location, stent availability, plaque complexity, and vascular anatomy evaluation, and expertise of the operator.[7] Angioplasty is sometimes combined with atherectomy procedures to remove the plaque using specialized devices. Types of atherectomy procedures are Mechanical: Directional, Rotational, or Orbital devices or Laser evaporative methods that require the use of costly disposable devices. Evidence regarding their efficacy is lacking, and their use is still under investigation in specific niche indications.

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Pennsylvania Child Abuse Recognition and Reporting

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Unfortunately, child abuse and maltreatment is an international, national, and Pennsylvania problem. The World Health Organization (WHO) defines child abuse and child maltreatment as "all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power."[1] There is significant morbidity and mortality associated with child abuse due to a child's inability to protect themselves. Healthcare providers frequently miss a large amount of child abuse cases. For the diagnosis of child abuse to be made, a high index of suspicion is needed.[2][3][4] Pennsylvania has created a legal structure and educational approach to assure health providers are able to identify abuse and neglect and know how to engage state agencies in the protection and care of the child. Child Abuse/Neglect In The State Of Pennsylvania Child abuse and neglect is a significant problem throughout the United States as well as Pennsylvania. Over 3 million children per year are abused or neglected in the U.S., and over 40,000 are the subjects of reports in Pennsylvania. It has been estimated that 1 in 1000 children in Pennsylvania is abused or neglected. The State of Pennsylvania has taken a proactive role by instituting the Pennsylvania Child Protective Services Law (CPS-L) as well as Act 15, Act 115, and General Protective Services Law (GPS-L) with the goal to reduce child abuse, neglect, and trafficking by improving procedures, reporting, and investigation. These laws are provided in detail below. Child Protective Services Versus General Protective Services: The Pennsylvania Child Welfare System is state-supervised and county-administered. Child Protective Services (CPS) and General Protective Services (GPS) are two main functions/services of the county children and youth agencies. When a call/referral is made to ChildLine, the trained professionals categorize it a CPS or GPS. Cases identified as CPS, require an investigation because the alleged act or failure to act has been identified as one of the 10 categories of abuse per the Child Protective Services Law (CPSL). Cases identified as GPS require an assessment for services and supports. In these cases, the act or failure to act is detrimental to a child but do not fall under the 10 categories of child abuse per the CPSL. GPS - Services to prevent the potential for harm to a child who meets one of the following conditions: Is without parental care or control, subsistence, education as required by law, or other care or control necessary for his/her physical, mental or emotional health or morals. Has been placed for care or adoption in violation of the law. Has been abandoned by his/her parents, guardian, or other custodian. Is without a parent, guardian, or legal custodian. Is habitually and without justification truant from school while subject to compulsory school attendance. GPS - Services to prevent the potential for harm to a child who meets one of the following conditions: Has committed a specific act or habitual disobedience of the reasonable and lawful commands of his parents, guardian or legal custodian. Is under 10 years of age and has committed a delinquent act. Has been formerly adjudicated dependent and is under jurisdiction of the court. Has been referred un the Juvenile Act and who commits and act that is defined ungovernable. Examples of CPS Cases: Causing bodily injury to a child through any recent act or failure to act. Fabricating, feigning, or intentionally exaggerating or inducing medical symptoms or disease which results in potentially harmful medical evaluation or treatment to the child through any recent act. Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a serious of such acts or failures to act. Causing sexual abuse or exploitation of a child through any act or failure to act. Creating a reasonable likelihood of bodily injury t o a child through act recent act or failure to act. Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act. Causing serious neglect of a child. Engaging in the following recent per se acts. Causing the death of the child through any act or failure to act. Engaging a child in a severe form of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000. Examples of GPS Cases -Services to prevent the potential for harm to a child who meets one of the following conditions: Is without proper parental care or control, subsistence, education as required by law, or other care or control necessary for his physical, mental, or emotional health, or morals. Has been placed for care or adoption in violation of law. Has been abandoned by his parents, guardian or other custodian. Is without a parent, guardian or legal custodian. Is habitually and without justification truant from school while subject to compulsory school attendance. Has committed a specific act of habitual disobedience of the reasonable and lawful commands of his parent, guardian or other custodian and who is ungovernable and found to be in need of care, treatment or supervision. Is under 10 years of age and has committed a delinquent act. Has been formerly adjudicated dependent under section 6341 of the Juvenile Act (relating to adjudication), and is under the jurisdiction of the court, subject to its conditions or placements and who commits an act which is defined as ungovernable in subparagraph (vi). Has been referred under section 6323 of the Juvenile Act (relating to informal adjustment), and who commits an act which is defined as ungovernable in subparagraph (vi). Case Scenario #1 A 4-year-old child is admitted to the hospital for a third episode of hypoglycemia and lethargy. Prior workup has been unable to determine an organic cause. The child is observed in the hospital for 3-days and no underlying pathologic process is discovered. The mother stays with the child, is extremely protective, and engaged in making sure "all stones are overturned" in an attempt to find the cause of the child's condition. The child is set for discharge in the morning and at 4 a.m., making rounds, the nurse finds the mother wide awake standing at the bedside. During her examination, the child has a seizure. A bedside rapid blood sugar tests reveal a dangerously low level. Glucagon is administered and the child recovers quickly. The nurse is suspicious of Munchausen syndrome by proxy. What should the nurse do? This is an example of potentially inducing medical symptoms with a potentially harmful result. This is a CPS case. The nurse is a mandated reporter who is required to immediately make a report of suspected child abuse as per the Child Protective Services Law via a call to the ChildLine at 1-800-932-0313 (24 hours a day, seven days a week) or electronic mandated reporter system at www.compass.state.pa.us/cwis. Given the gravity of the situation, in this hospital setting, clinicians and social work should also be contacted. Case Scenario #2 A 16-year-old child presents to the emergency department due to acting out at school. Shortly after arrival, the child asks for a sandwich. The school was unable to reach the biological mother, the biological father is deceased, and the child indicates his mother is on a "honeymoon" on a boat somewhere in the Cayman Islands. He has no other family. The mother left him with $50 ten days ago and told him to eat at the local fast-food restaurant and told him not to spend more than $5 a day. He says he is out of money and starving. There is no food in the house. Which of the following would be an appropriate response of the emergency department health providers? This is an example of a child that is without proper parental care. This is a GPS case. The child should be kept in the hospital and provided with food. ChildLine should be contacted and until GPS has evaluated the patient and arranged a safe environment, the child should not be discharged. Definitions: Child: An individual under 18 years of age. Perpetrator: A person who has committed child abuse as defined in the CPSL. The term includes only the following: A parent of the child. A spouse or former spouse of the child's parent. A paramour or former paramour of the child's parent. A person 14 years of age or older and responsible for the child's welfare or having direct contact with children as an employee of a child-care services, a school or through a program, activity or service. An individual 14 year so age or older who resides in the same home as the child. An individual 18 years of age or older who does not reside in the same home as the child but is related within the third degree of consanguinity or affinity by birth or adoption to the child. An individual 18 years of age or older who engage a child in severe forms of trafficking in persons or sex trafficking, as defined in section 103 of the Victims Protection Act of 2000. (Many agencies provide some additional information and description of the consanguinity or affinity mean here). (Some agencies provide a little more information regarding human trafficking or state that it will be discussed in detail later). Remember: The perpetrator does not need to be named to report suspected child abuse NOR does a relationship have to be determined! Person responsible for the child's welfare: a person who provides permanent or temporary care, supervision, mental health diagnosis or treatment, training or control of a child in lieu of parental care, supervision, and control. Direct contact: The care, supervision, guidance or control of children OR routine interaction with children. School Employees As Perpetrators: The Child Protective Services Law allows for school employees to be considered perpetrators under the definition provided for "person responsible for the child's welfare" or person "having direct contact with children" School employee-An individual who is employed by a school or who provides a program, activity, or service sponsored by a school. The term does not apply to administrative or other support personnel unless the administrative or other support personnel have direct contact with the children. 3 Components: A child. An act or Failure to Act. A perpetrator: Act: Something that is done to harm or cause potential harm to a child. Failure to Act: Something that is NOT done to prevent harm or potential harm to a child. Recent act or failure to act: An act or failure to act committed within two years of the date of the report to the Department or county agency. Categories of Abuse The definition of child abuse, via the Child Protective Services Law, starts with "shall mean intentionally, knowingly, or recklessly" Intentionally: Done with the direct purpose of causing the type of harm that resulted. Knowingly: Understanding that the harm is "practically certain to result" Recklessly: Conscious disregard for foreseeable risk. The term "child abuse" shall mean intentionally, knowingly, or recklessly doing any of the following: Causing bodily injury to a child through any recent act or failure to act. Fabricating, feigning or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act (This is also known as Munchausen By Proxy). Causing or substantially contributing to serious mental injury through any act or failure to act. Causing sexual abuse or exploitation of a child through any act of failure to act. Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act. Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act. Causing serious physical neglect of a child. Engaging in any of the following recent acts: Kicking, biting, throwing, burning, stabbing or cutting a child in a manner that endangers the child. Unreasonably restraining or confining a child, based on consideration of the method, location or the duration of the restraint or confinement. Forcefully shaking a child under one year of age. Forcefully slapping or otherwise striking a child under one year of age. Interfering with the breathing of a child. Causing a child to be present in a location while a violation of 18 Pa. C.S. section sign7508.2 (relating to operation of methamphetamine laboratory) is occurring, providing that the violation is being investigated by law enforcement. Leaving a child unsupervised with an individual, other than the child's parent, who the actor knows or reasonable should have known: Is required to register as a Tier II or Tier III sexual offender under 42 Pa. C.S. Ch. 97 Subch. H (relating to registration of sexual offenders), where the victim of the sexual offense was under 18 years of age when the crime was committed. Has been determined to be a sexually violent predator under 42 Pa. C.S. section sign9799.24 (relating to assessments) or any of its predecessors. Has been determined to be a sexually violent delinquent child as defined in 42 Pa. C.S. section sign9799.12 (relating to definitions). Please note the items in number 8 are also known as "Per Se Acts" Causing the death of the child through any act or failure to act. Engaging a child in a severe form of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000: Category number 10 was just recently added as of the passing of Act 115 of 2016. Bodily Injury: Impairment of physical condition of substantial pain: The law considers two parameters: impairment and pain: Impairment - If, due to the injury, the child's ability to function is reduced in any way; either temporarily or permanently. Pain - If the child experiences what a reasonable person believes to be substantial pain. Serious Mental Injury: A psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment that: Renders a child chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic or in reasonable fear that the child's life or safety is threatened or; Seriously interferes with a child's ability to accomplish age-appropriate developmental and social tasks. Serious Physical Neglect: Any of the following when committed by a perpetrator that endangers a child's life or health, threatens a child's well-being, causes bodily injury or impairs a child's health, development or functioning: A repeated, prolonged or egregious failure to supervise a child in a manner that is appropriate considering the child's developmental age and abilities. The failure to provide a child with adequate essentials of life, including food, shelter or medical care. Sexual Abuse and Exploitation: Any of the following: The employment, use, persuasion, inducement, enticement or coercion of a child to engage in or assist other individual to engage in sexually explicit conduct, which includes but is not limited to: Looking at sexual or other intimate parts of a child or another individual for the purpose of arousing or gratifying sexual desire in any individual. Participating in sexually explicit conversation either in person, by telephone, by computer or by computer-aided device for the purpose of sexual stimulation or gratification of any individual. Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual: The employment, use, persuasion, inducement, enticement or coercion of a child to engage in or assist other individual to engage in sexually explicit conduct, which includes but is not limited to: Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting or filming: This paragraph doe NOT include consensual activities between a child who is 14 years of age or older and another person 14 years of age or older and whose age is within four years of the child's age. Any of the following offenses committed against a child: Rape as defined in 18 Pa. C.S. section sign3121 (relating to rape). Statutory sexual assault ad defined in 18 Pa.C.S. section sign3122.1 (relating to statutory sexual assault). Involuntary deviate sexual intercourse as defined in 18 Pa. C.S. section sign3123 (relating to involuntary deviate sexual intercourse). Sexual assault as defined in 18 Pa. C.S. section sign3124.1 (relating to sexual assault). Institutional sexual assault as defined in 18 Pa. C.S. section sign3124.2 (relating to institutional sexual assault). Aggravated indecent assault as defined in 18 Pa. C.S. section sign 3125 (relating to aggravated indecent assault. Case Scenario #3 A 13-year-old female is brought to her pediatrician because of a recent decline in her grades. In the course of a private interview, she admits she has "problems with boys at school", and "bad dreams about boys always staring at her". The child privately admits she regularly gets up in the middle of the night and sleeps with the biological mother on her side of the bed, with her step-father next to her mother. The child indicates the step-father has commented that she is a "looker", has "big headlights", and she needs to "fend off the boys at school". The pediatrician attended high school with the step-father and is aware he is not the "brightest bulb" but seems to genuinely care about the child. The child indicates the step-father wears pajamas, has never touched her, and always knocks before entering the bathroom or her room. She says she is very anxious about attending school and is afraid to speak with her mother about her school problems. She says her step-father has always been "very good" to her mother and always kind and considerate to her as well. She does not want to get him into any trouble but feels his comments about her appearance are adding to her anxiety. What should the pediatrician do in this situation? This probably does not rise to the level of child abuse but it could potentially result in serious mental injury if untreated. The pediatrician should carefully document her evaluation and any decisions she makes. Assuming the mother is open to having the child receive mental health counseling concerning boys, end the child sleeping in the parent's bed, and stopping inappropriate comments from the step-father, this may not rise to the level of a report. However, if the pediatrician was concerned, it is safer to report. In this case, most likely ChildLine would refer the situation to GPS which would assist the family and patient in getting appropriate counseling. Human Trafficking: Federal: Human trafficking is a form of child abuse and violation of Federal and State law, that tends to encompass all of the other categories of abuse. This training section on human trafficking consists of sex and labor trafficking as it pertains to children. In the battle against human trafficking, the federal government created legislation known as "The Trafficking Victims and Protection Act of 2000" In 2014, the federal government enhanced legislation through the creation and passing of the "Preventing Sex Trafficking and Strengthening families Act of 2014. In 2015, the federal government also created and passed the "Justice for Victims of Trafficking Act of 2015. Human Trafficking: State Pennsylvania in turn enacted human trafficking legislation to amend titles 23 (Domestic Relations), 42 (Judiciary and Judicial Procedure), and 18 (Crimes and Offenses). These acts are now known as: Act 94 of 2015. Act 105 of 2015. Act 115 of 2016. Forms of Trafficking Sex Trafficking Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such acts has not attained 18 years of age; or The recruitment, harboring, transporting, provision, or obtaining of a person for labor of services, through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage (paying off debt through work); debt bondage (debt slavery, bonded labor or services for a debt or other obligation); or slavery Labor Trafficking Labor trafficking is obtained by use of threat or serious harm, physical restraint, or abuse of legal process Examples: Being forced to work for little or no pay (frequently in factories or farms). Domestic Servitude - providing services within a household from 10-16 hours per day (frequently in the form of child care, cooking, cleaning, yard work, gardening, etc.)

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Post-Traumatic Hand Stiffness

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The human hand is made up of skin, soft tissues, bones, tendons, ligaments, and muscles, which work together to enable the fine motor function required to carry out daily tasks such as writing, dressing, and washing, as well as highly skilled tasks such as operating machinery and playing musical instruments. It is this highly precise function that means even minor injuries to the hand can risk causing significant handicap to the individual. Following trauma to the hand, developing stiffness is a common finding and can have a significant effect on a patient's ability to work and overall quality of life. Evaluating and treating the stiff hand requires an understanding of the anatomy of the hand as well as the mechanism of the injury. These together with an understanding of the different modalities and timings of treatment can lead to successful management of the stiff hand. This article reviews the etiology, diagnosis, and treatment of post-traumatic hand stiffness.

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Trochlear Nerve Palsy

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The fourth cranial nerve, also known as the trochlear nerve, arises from the midbrain at the level of the inferior colliculus (ventral to the Sylvian aqueduct). This nerve supplies only a single muscle - the superior oblique (SO) muscle. It is the only cranial nerve that emerges from the dorsal aspect of the brainstem and decussates to supply the muscle of the contralateral side. The nerve has a very long course, making it more vulnerable to injury. Palsy of the trochlear nerve is a common presentation in ophthalmology clinics.[1]

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Lung Transplantation

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Lung transplantation is a well-established life-saving treatment to improve the quality of life of patients with end-stage respiratory failure not responding to other medical or surgical interventions.[1] The 36th adult lung and heart-lung transplant report summarize data from 69,200 adult lung transplants that have been performed through June 30, 2018, and reported to the International Thoracic Organ Transplant Registry.[2] The US Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR) reported survival rates of 85% at 1 year, 68% at 3 years, and 55% at 5 years.[3] Because lung transplantation is evolving both in the application and in success, it is worthwhile to be acquainted with the procedure. The first lung transplant procedure was performed by Dr. James Hardy and colleagues at the University of Mississippi in 1963. The recipient had chronic obstructive pulmonary disease (COPD) but was a suboptimal candidate for several reasons, including the presence of advanced lung cancer and renal insufficiency.[4] While the first successful combined heart and lung transplant was performed in 1981. Since then the field of lung transplantation has advanced in the selection of candidates, operative techniques, critical care management, immunosuppression, and long-term follow-up.

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Oral Mucositis

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Oral mucositis is a severely debilitating condition. It can occur due to radiation therapy (RT) to the head and neck, chemotherapeutic agents, high-dose chemotherapy agents, hematopoeitic stem cell transplantation (HSCT). It presents as erythema, edema, and ulcerations within the oral mucosa and pain with subsequent restriction in oral intake. In severe cases, this may even lead to the need for parenteral nutrition. In addition, the lesions weaken the skin barrier resulting in local or systemic infection.[1] It is a debilitating condition for patients due to pain and subsequent decreased oral intake resulting in worsened quality of life.[2] In severe cases, the subsequent cycle of chemotherapy may need to be given in a reduced dose or be delayed.

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Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae

StatPearls-/- 2021; ():

Since the founding of osteopathy by Andrew Taylor Still, M.D., D.O. in 1874, a fundamental principle of osteopathic medicine has been the treatment of somatic dysfunction by using osteopathic manipulative treatment (OMT).[1] Somatic dysfunction is an impaired function of integral components of the somatic system (the body framework). It can include the musculoskeletal, nervous, vascular, and lymphatic systems and combinations of these systems in affected areas of dysfunction.[1][2] High-velocity low amplitude (HVLA) OMT is one type of technique utilized by various practitioners that can be used to restore health to the somatic system. Specifically, HVLA therapy is a technique used in manual medicine that employs a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint. The force engages a restrictive barrier to elicit a release of the restriction. HVLA treatment is frequently associated with an audible and palpable "release" in the form of a "pop" accepted to represent cavitation of a spinal intervertebral joint and its subsequent release. The cervical (neck) region is an area between the cranium and the thorax consisting of vascular, musculoskeletal, and neural pathways. It is a common area of injury and somatic dysfunction, resulting in pain and loss of mobility. Understanding the diagnostic approach and the treatment of cervical spinal somatic dysfunction is a cornerstone of manual medicine. Dysfunction may occur at one or many anatomical locations: the atlantooccipital joint, the atlantoaxial joint, the paraspinal musculature, or any of the cervical vertebral joints. Collectively, manual (osteopathic) treatment may include various myofascial release techniques, muscle energy techniques, strain-counter strain techniques, and high-velocity low amplitude (HVLA) techniques. HVLA is used to relieve movement restrictions by applying a quick, therapeutic force of rapid duration that travels a short distance within the range of motion of a joint. HVLA therapy aims to restore a more "normal" range of motion within a joint and alleviate pain. Neck dysfunction is associated with significant health costs and disability, typically due to work-related injuries and improper ergonomic practices.[3] Symptoms involved in cervical musculoskeletal joint dysfunction include neck pain, stiffness, loss of neck mobility, arm pain, tingling in the upper extremities, weakness, dizziness, and headache. High-velocity low amplitude (HVLA) osteopathic manipulative treatment (OMT) of the cervical spine is a passive, direct therapy that provides a high-velocity, low amplitude manually applied force to treat motion loss in a somatic dysfunction.[4] Passive treatment implies that the patient stays inactive throughout this therapy and does not attempt to assist the physician in executing cervical HVLA treatment. This therapy provides direct engagement into the restrictive barrier of the cervical spine. The treatment goal is to forcefully stretch a contracted musculoskeletal system, producing an aggressive response of afferent nerve impulses from the muscle spindles to the central nervous system. The central nervous system will then send a reflex of inhibitory responses to the muscle spindle, relaxing the muscle.[5][3] HVLA therapy of the cervical spine should be performed only by practitioners who have been educated with this technique and have demonstrated practical and cognitive skills. Like any other procedure, education, along with pre-procedural screening for contraindications and a detailed review of the risks and benefits, is imperative before HVLA treatment. Informed consent to medical treatment is fundamental in both ethics and law. Patients have the right to receive advice and ask questions about HVLA treatments so that they can make well-founded decisions.[6]

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Breast Self Examination

StatPearls-/- 2021; ():

Breast cancer is the most prevalent malignancy among female populations and is responsible for the second-highest number of cancer-related deaths in American women.[1] The need for early detection has manifest several screening initiatives intent on curtailing morbidity and mortality associated with the disease. Breast Self-Examination was initially proposed as an intuitive, inexpensive, non-invasive, and universally accessible means of promptly identifying early-stage breast neoplasms. Unfortunately, this potential screening tool's positive aspects cannot be considered without the evidence contradictory to its value. Any evaluation of breast self-examination must include that current medical literature does not support the efficacy of the practice and that general implementation is discouraged by most medical societies and academies. International groups have suggested that breast self-examination programs may benefit specific populations in low-resource countries; however, this idea also remains under consideration. Despite studies refuting the utility of breast self-examination, proponents and breast cancer awareness organizations continue to encourage the controversial practice and seek to educate the public on proper implementation.[2][3]

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Hypovolemia

StatPearls-/- 2021; ():

Hypovolemia refers to a state of low extracellular fluid volume, generally secondary to combined sodium and water loss. All living organisms must maintain an adequate fluid balance to preserve homeostasis. Water constitutes the most abundant fluid in the body, at around 50% to 60% of the body weight. Total body water is further divided into the intracellular fluid (ICF), which comprises 55% to 75%, and the extracellular fluid (ECF), which comprises around 25-45%. The ECF is further divided into the intravascular and extravascular (interstitial) spaces. ECF is the more readily measured component as it can be estimated by arterial blood pressure.

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Histology, Natural Killer Cells

StatPearls-/- 2021; ():

Natural killer or NK cells belong to the granular lymphocyte of the innate immune arm. In particular, natural killer cells are designed to exert cytotoxicity against virus-infected cells and immunosurveillance of cancer cells. Various immunoreceptors on the NK cell surface are configured to sense any alteration of self cells caused by malignant transformation or viral infection, which are potentially nonspecific. In contrast, lymphocytes of the adaptive immune arm, B and T lymphocytes express one specific recognition receptor. NK cell receptors are grouped as inhibitory and activating receptors that are polymorphic and germline-encoded. Inhibitory receptors override activating receptors when encountering normal cells. However, surface molecular changes by a viral infection or tumor formation stimulate the activating receptors. Upon activation, natural killer cell release granzyme, perforin, effector molecules of the TNF family, and Fas-ligand to induce apoptosis of the target cell. Besides, NK cells synthesize and release other cytokines and chemokines such as Il-10, gamma-interferon, GM-CSF to recruit other immune effector cells to the activated site. NK cells also exhibit antibody-dependent cell cytotoxicity when antibodies tag the target antigen or cell. Nowadays, interventions targetting the inhibiting-activating state of NK cells has been using in clinical therapies.[1]

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New York State Child Abuse, Maltreatment, and Neglect

StatPearls-/- 2021; ():

The World Health Organization (WHO) defines child abuse and child maltreatment as "all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power."[1] There are four main types of abuse: Neglect (physical or emotional). Physical abuse. Psychological or emotional abuse. Sexual abuse. There are significant morbidity and mortality associated with child abuse due to a child's inability to protect themselves. For the diagnosis of child abuse to be made, healthcare providers need to maintain a high index of suspicion.[2][3][4] The New York State government has established a legal obligation of mandated reporters to intervene if there is evidence or suspicion of abuse, maltreatment, or neglect of a child less than 18 years of age. New York Legal Definitions for Abuse, Maltreatment, and Neglect (New York State Family Court Act) The purpose of the New York State law is to establish procedures to protect children from injury or mistreatment and safeguard their physical, mental, and emotional well-being. It provides due process for determining when the state, through its family court, may intervene against the wishes of a parent on behalf of a child so that the child's needs are appropriately met. The following is a summary of key definitions: "Respondent": any parent or other person legally responsible for a child's care who is alleged to have abused or neglected the child. "Child": any person or persons < 18 years of age. "Abused child": a child whose parent or another person legally responsible for his care: (i) inflicts or allows to be inflicted upon such child physical injury other than by accidental means which causes or creates a substantial risk of death, serious or protracted disfigurement, protracted impairment of physical or emotional health, or protracted loss or impairment of the function of any bodily organ; or (ii) creates or allows to be created a substantial risk of physical injury to such child by other than accidental means which would be likely to cause death or serious or protracted disfigurement, protracted impairment of physical or emotional health, or protracted loss or impairment of the function of any bodily organ; or (iii) (A) commits, or allows to be committed an offense against such child defined in article one hundred thirty of the penal law; (B) allows, permits, or encourages such child to engage in any act described in sections 230.25, 230.30, 230.32, and 230.34-a of the penal law; (C) commits any of the acts described in sections 255.25, 255.26, and 255.27 of the penal law; (D) allows such child to engage in acts or conduct described in article two hundred sixty-three of the penal law; or (E) permits or encourages such child to engage in any act or commits or allows to be committed against such child any offense that would render such child either a victim of sex trafficking or a victim of severe forms of trafficking in persons pursuant to 22 U.S.C. 7102 as enacted by public law 106-386 or any successor federal statute; (F) provided, however, that (1) the corroboration requirements contained in the penal law and (2) the age requirement for the application of article two hundred sixty-three of such law shall not apply to proceedings under this article. "Neglected child" or "maltreated child": a child: (i) whose physical, mental, or emotional condition has been impaired or is in imminent danger of becoming impaired as a result of the failure of his parent or other person legally responsible for his care to exercise a minimum degree of care (A) in supplying the child with adequate food, clothing, shelter or education in accordance with the provisions of part one of article sixty-five of the education law, or medical, dental, optometrical or surgical care, though financially able to do so or offered financial or other reasonable means to do so, or, in the case of an alleged failure of the respondent to provide education to the child, notwithstanding the efforts of the school district or local educational agency and child protective agency to ameliorate such alleged failure prior to the filing of the petition; or (B) in providing the child with proper supervision or guardianship, by unreasonably inflicting or allowing to be inflicted harm, or a substantial risk thereof, including the infliction of excessive corporal punishment; or by misusing a drug or drugs; or by misusing alcoholic beverages to the extent that he loses self-control of his actions; or by any other acts of a similarly serious nature requiring the aid of the court; provided, however, that where the respondent is voluntarily and regularly participating in a rehabilitative program, evidence that the respondent has repeatedly misused a drug or drugs or alcoholic beverages to the extent that he loses self-control of his actions shall not establish that the child is a neglected child in the absence of evidence establishing that the child's physical, the mental or emotional condition has been impaired or is in imminent danger of becoming impaired as set forth in paragraph (i) of this subdivision; or (ii) who has been abandoned, in accordance with the definition and other criteria set forth in subdivision five of section three hundred eighty-four-b of the social services law, by his parents or other person legally responsible for his care. The terms "maltreatment" and "neglect" are often used interchangeably but have different definitions. "Maltreatment" includes acts of omission and commission, whereas "neglect" only includes acts of omission. Maltreatment includes neglect, but neglect does not include maltreatment.[1]: "Person legally responsible": the child's custodian, guardian, or any other person responsible for the child's care at the relevant time. Custodian may include any person continually or at regular intervals found in the same household as the child when the conduct of such person causes or contributes to the abuse or neglect of the child. "Impairment of emotional health/condition": a state of substantially diminished psychological or intellectual functioning in relation to, but not limited to, such factors as failure to thrive, control of aggressive or self-destructive impulses, ability to think and reason, or acting out or misbehavior, including incorrigibility, ungovernability or habitual truancy, provided, however, that such impairment must be clearly attributable to the unwillingness or inability of the respondent to exercise a minimum degree of care toward the child. "Child protective agency": the child protective service of the appropriate local department of social services or such other agencies with whom the local department has arranged for the provision of child protective services under the local plan for child protective services or an Indian tribe that has entered into an agreement with the state department of social services pursuant to section thirty-nine of the social services law to provide child protective services. "Parent": a person who is recognized under the laws of the state of New York to be the child's legal parent. "Relative": any person who is related to the child by blood, marriage, or adoption and who is not a parent, putative parent, or relative of a putative parent of the child. "Suitable person": any person who plays or has played a significant positive role in the child's life or the life of the child's family. Types of Abuse and Neglect: Physical neglect. Physical abuse. Emotional neglect. Emotional abuse. Sexual abuse. Physical Neglect Physical neglect is the most common form of abuse. It is the failure to provide a child with adequate food, shelter, clothing, education, hygiene, medical care, protection from hazards in the environment, basic needs, or supervision needed for normal growth and development.[5] Physical Abuse Physical abuse of a child includes any non-accidental physical injury of a child inflicted by a parent or a caretaker resulting in or risking serious disfigurement, impairment of physical or emotional health, and loss of bodily function or death. Physical abuse includes beating, burning, biting, shaking, and excessive corporal punishment.[5] Emotional Neglect Emotional neglect is the failure of a parent or caregiver to supply a child with the love and support necessary for healthy emotional development. Examples include failure to provide warmth, attention, supervision, affection, praise, or encouragement to a child. Emotional Abuse Emotional abuse is commonly defined as the non-physical maltreatment of a child that can seriously interfere with his or her positive emotional development. Patterns of abusive behavior can include constant rejection, terrorizing, exposing a child to corruption, violence or criminal behavior, irrational behavior, and verbal abuse (excessive yelling, belittling, and teasing). Emotional abuse has the potential to cause serious cognitive, affective, or other behavioral health problems. Sexual Abuse [6] Sexual abuse is the involvement of dependent, developmentally immature children in sexual activities that they do not fully comprehend, to which they are unable to give consent, or that violate the social taboos of family roles. Sexual abuse and maltreatment include situations in which the parent, caregiver, or another person legally responsible for a child under 18 years of age, commits or allows to be committed any one of the following activities: Touching a child's mouth, genitals, buttocks, breasts or other intimate parts for the purpose of gratifying sexual desire; or forcing or encouraging the child to touch the caregiver, or other person legally responsible, in this way for the purpose of gratifying sexual desire. Engaging or attempting to engage the child in sexual intercourse or sodomy. Forcing or encouraging a child to engage in sexual activity with other children or adults. Exposing a child to sexual activity or exhibitionism for the purpose of sexual stimulation or gratification of another. Permitting a child to engage in sexual activity that is not developmentally appropriate and when such activity results in the child suffering from emotional impairment. Using a child in a sexual performance such as a photograph, play, motion picture, or dance regardless of whether the material itself is obscene. In addition, it is a crime to give indecent material to a child. Sexual abuse and maltreatment include such criminal offenses as rape, sodomy, other non-consensual sexual conduct, and prostitution. Social Service Laws Related to Care of Children in Residential Care Abused A person with a handicapping condition who is 18 years or older who is in residential care in one of the following facilities may be defined as an abused child: NYS School for the Blind (Batavia). NYS School for the Deaf (Rome). A private residential school which has been designed for special education. A special act school district or a state-supported school for the deaf or blind with a residential component. Neglected In New York State, a neglected child in residential care (including facilities operated by the Department of Social Services [DSS], Division for Youth [DFY], Office of Mental Health [OMH], Office for People with Developmental Disabilities [OPWDD], or the State Education Department [NYSED]) means a child whose custodian impairs, or places in danger of impairment, the child's physical, mental or emotional condition: By intentionally administering to the child, any prescription drug not ordered. Failing to adhere to standards for the provision of food, clothing, shelter, education, medical, dental, optometric, or surgical care, or the use of isolation or restraint. Failing to adhere to standards for the supervision of children by inflicting or allowing to be inflicted physical harm or risk of harm. Failing to conform to applicable state regulations for appropriate custodial conduct. Maltreated The Social Services Act includes a maltreated child 18 years of age or older, who is neglected and resides in one of the special residential care institutions previously listed. Abandoned Infant Protection Act First enacted in July 2000 and later amended in August 2010, the "New York State Abandoned Infant Protection Act" allows a person to abandon their infant in a safe manner. This law designates specific locations as "safe-havens" for parents to relinquish their unharmed newborns, ensuring that unwanted infants are surrendered to persons who can guarantee the child's safety and well-being. It also protects parents who feel that they have no other alternative to protect their child from harm. While the law protects those that relinquish unharmed infants, the abandonment of newborn infants in unsafe places is an example of extreme neglect with criminal penalties. Charges of abandonment may be incurred unless the following criteria are met: Infant < 30 days old. Intent that the infant be safe from physical injury and receive appropriate care. Infant left with an appropriate person or suitable location such as a hospital, police station, or fire department and notifies an appropriate person of the infant's location. Intent to abandon the infant by relinquishing responsibility for and rights wholly. Any mandated reporter who learns of abandonment must fulfill mandated responsibilities even if unsure of the name of the person abandoning the child.

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Paraneoplastic Encephalomyelitis

StatPearls-/- 2021; ():

Paraneoplastic encephalomyelitis (PEM) is a subtype of paraneoplastic neurological syndromes (PNS), a group of neurological manifestations associated with antibodies against intracellular and extracellular neuronal proteins that are invariably cancer-related, involving focal or multifocal inflammation of the brain or spinal cord or both.[1][2] The definite diagnosis of paraneoplastic neurological syndromes, per the 2004 definition, encompasses: 1. A classical syndrome (includes encephalomyelitis, limbic encephalitis, subacute cerebellar degeneration, and opsoclonus-myoclonus) and cancer develops within 5 years of diagnosis of the neurological disorder. 2. A non-classical neurological syndrome is one that resolves or significantly improves after cancer treatment, without immunotherapy. 3. A non-classical neurological syndrome with paraneoplastic antibodies and cancer develops within 5 years of the diagnosis of the neurological disorder.[3][4]. Paraneoplastic encephalomyelitis typically involves B-cell activation, with the production of autoantibodies that identify immune marker disease subtypes. Originally thought to be totally separable from primary autoimmune disease, paraneoplastic antibody markers are now thought to be of three types: - Autoantibodies targeting intracellular epitopes thought to cross-react between cancer and central nervous system proteins, glycoproteins, and complex carbohydrates. Associated diseases can include limbic encephalitis, encephalomyelitis, subacute cerebellar degeneration, opsoclonus myoclonus, optic neuritis, and rapidly progressive sensory polyneuropathy. These antibodies are not pathogenic in the classical sense. Patients do not usually respond to standard immunomodulatory therapies when these are the sole immune targets identified in the paraneoplastic process. Their function is just now being elucidated as providing targets for cytotoxic T cell infiltration into tumor and non-neoplastic cells with cross-reactive intracellular epitopes, the latter producing bystander destruction and paraneoplastic syndromes (for review, see).[5] Understanding the mechanism of such intracellular antibody targeting against intracellular tumor antigens may eventually provide an effective cancer therapeutics method.[6] - Autoantibodies targeting intracellular epitopes at synaptic sites, producing potentially treatable conditions. Diseases like progressive encephalomyelitis with rigidity and myoclonus (PERM), stiff person syndrome, and cerebellar ataxia have been linked to such antibodies, and passive transfer of such intracellular epitope targeted antibodies from patients to naive animal models can reproduce symptoms of the disease.[7] - Autoantibodies targeting extracellular epitopes that directly cause neurologic dysfunction. These autoantibodies were originally identified in non-paraneoplastic autoimmune disease, can be suppressed by antibody depleting or blocking therapies, and are often recognized as the first cancer evidence. Diseases produced by such antibodies include paraneoplastic myasthenia gravis, Lambert Eaton myasthenic syndrome, limbic encephalitis, encephalomyelitis, anti-myelin oligodendrocyte glycoprotein antibody-associated disease, and neuromyelitis optica spectrum disorder, among others. Recognizing the evolving concepts surrounding paraneoplastic and non-paraneoplastic autoimmune CNS disease has helped identify and treat these disorders.[8] There is overlap between traditional paraneoplastic disorders and extracellular epitope associated autoimmune encephalitides, a group of syndromes associated with autoantibodies against extracellular neuronal cell surface proteins, synaptic proteins, ion channels, or receptors, usually most common in the non-paraneoplastic disease.[9][10] This is especially important in the era of cancer chemotherapy with checkpoint inhibitors. The incidence of immunological toxicity is much higher with these therapies than in traditional cancer chemotherapy, producing immune-related adverse events that may present as paraneoplastic neurologic syndromes.[11][12] Recognizing which antibody targets are important in secondary immune disease production and which paraneoplastic antibodies are not amenable to immunomodulatory therapy is important for treatment decisions.[5]

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NP Safe Prescribing Of Controlled Substances While Avoiding Drug Diversion

StatPearls-/- 2021; ():

Chronic pain and opioid use and abuse is a significant problem in the United States.[1] Over one-quarter of United States citizens suffer from chronic pain.[2] It is among the most common complaints seen in an outpatient clinic and in the emergency department. The failure to manage chronic pain, as well as the possible complication of opioid dependence related to treatment, can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence.[3] Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined.[4] How a patient's chronic pain gets managed can have profound and long-lasting effects on a patient's quality of life. The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months.[5] There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy is in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical.[6] Unfortunately, studies have revealed an inherent lack of education regarding pain management in most professional schools and training programs. Many schools have committed to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum. Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, under prescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. The American Society of Addiction Medicine describes addiction as a treatable chronic disease that involves environmental pressures, genetics, an individual's life experiences, and interactions among brain circuits. Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, they identify five characteristics of addiction: 1. Craving for drug or positive reward. 2. Dysfunctional emotional response. 3. Failure to recognize significant problems affecting behavior and relationships. 4. Inability to consistently abstain. 5. Impairment in control of behavior. Unfortunately, for most health providers, understanding of addiction is often confusing, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for effectively dealing with the challenges of addiction. In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion contributed to the under-treatment of pain. Over time, the manual has eliminated these terms and now uses "substance use disorder," ranging from mild to severe. Unfortunately, there are numerous challenges in pain management, such as both underprescribing and overprescribing opioids. The concerns are particularly prominent in patients with chronic pain and have resulted in patients suffering from inadequately treated pain while at the same time there has been a development of concomitant opioid abuse, addiction, diversion, and overdose. As a result, providers are often negatively influenced and fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. To make the challenges even worse, chronic pain patients often develop opioid tolerance, significant psychological, behavioral, and emotional problems, including anxiety and depression related to under or overprescribing opioids. Clinicians that prescribe opioids face challenges that involve medical negligence in either failure to provide adequate pain control or risk of licensure or even criminal charges if it is perceived they are involved in drug diversion or misuse. All providers that prescribe opioids need additional education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with over and under prescribing opioids. Provider Opioid Knowledge Deficit There are substantial knowledge gaps around appropriate and inappropriate opioid prescribing, including deficits in understanding current research, legislation, and appropriate prescribing practices. Providers often have knowledge deficits that include: Understanding of addiction. At-risk opioid addiction populations. Prescription vs. non-prescription opioid addiction. The belief that addiction and dependence on opioids is synonymous. The belief that opioid addiction is a psychologic problem instead related to a chronic painful disease. With a long history of misunderstanding, poor society, provider education, and inconsistent laws, the prescription of opioids has resulted in significant societal challenges that will only resolve with significant education and training. Misuse of Controlled Substances Unfortunately, the misuse of controlled substances resulting in morbidity and mortality is rampant. [7] According to the National Survey on Drug Use and Health, 2016, performed by the U.S. Department of Health and Human Services over 10 million people misuse prescription pain medications, and over 2 million misuse sedatives, stimulants, and tranquilizers each year. The same study found that the most common reason for misuse is for the treatment of physical pain. The Center for Disease Control estimates more than 40,000 people die each year die from an opioid overdose. Controlled Substances There are three common classes of controlled substances that are commonly misused: opioids, depressants, and stimulants. Opioids Opioids are prescribed for pain control by binding to mu-opioid receptors in the central nervous system reducing pain signals to the brain as well as receptors in the GI tract and respiratory system and are used to treat pain, diarrhea, and cough. [8] Common Opioids Codeine - One of the most commonly taken opioid medications. It is at the center of the opioid addiction problem in the United States and thus is highly regulated. Its main indication is for pain and cough. FDA-Approved Indication Pain Codeine plays a role in the treatment of mild to moderate pain. Its use is recognized in chronic pain due to ongoing cancer and palliative care. However, the use of codeine to treat other types of chronic pain remains controversial. Chronic pain, defined by the International Association for the Study of Pain, is pain persisting beyond the standard tissue healing time, which is three months.[1] The most prevalent causes of non-cancer chronic pain include back pain, fibromyalgia, osteoarthritis, and headache. Non-FDA Approved Indications Cough Codeine is useful in the treatment of various etiologies producing chronic cough. Also, 46% of patients with chronic cough do not have a distinct etiology despite a proper diagnostic evaluation. Codeine produces a decrease in cough frequency and severity in these patients. However, there is limited literature demonstrating the efficacy of codeine in chronic cough. The dose can vary from 15 mg to 120 mg a day. It is, however, indicated in the management of prolonged cough (in specific populations like lung cancer) usually as 30 mg every 4 to 6 hours as needed. Restless Leg Syndrome Codeine is effective in the treatment of restless leg syndrome when given at night time, especially for those whose symptoms are not relieved by other medications. Persistent Diarrhea (Palliative) Codeine and loperamide are equally effective, and the choice between them has its basis in the assessment of the physician evaluating the small but undoubted addictive potential of codeine versus the higher cost of loperamide, and an individual difference in patient's vulnerability to adverse effects. Fentanyl - Transdermal patch and IV, commonly abused and used in mixture with other drugs. Fentanyl is a synthetic opioid that is 80-100 times stronger than morphine and is often added to heroin to increase its potency. It can cause severe respiratory depression and death, particularly mixed when mixed with other drugs or alcohol. It has high addiction potential. [9] Hydrocodone - Hydrocodone is a schedule II semi-synthetic opioid medication used to treat pain. Immediate-release (IR) hydrocodone is available as a combination product (combined with acetaminophen, ibuprofen, etc.) and is FDA approved for the management of pain severe enough to require an opioid analgesic and for which alternative (non-opioid) treatments are inadequate. Single-entity hydrocodone is only available in extended-release (ER) formulations. It is FDA approved to treat persistent pain severe enough to require 24-hour, long-term opioid treatment, and for which alternative treatments are inadequate. Hydrocodone is also an antitussive and indicated for cough in adults. [10] Morphine Sulfate - FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides significant relief to patients afflicted with pain. Clinical situations that benefit significantly by medicating with morphine include management of palliative/end-of-life care, active cancer treatment, and vaso-occlusive pain during sickle cell crisis. Morphine is widely used off-label for almost any condition that causes pain. In the emergency department, morphine is given for musculoskeletal pain, abdominal pain, chest pain, arthritis, and even headaches when patients fail to respond to first and second-line agents. Morphine is rarely used for procedural sedation. However, for small procedures, clinicians will sometimes combine a low dose of morphine with a low dose of benzodiazepine-like lorazepam. [11] Oxycodone - An opioid agonist prescription medication. The oxycodone immediate-release formulation is FDA-approved for the management of acute or chronic moderate to severe pain for which other treatments do not suffice, and for which the use of opioid medication is appropriate. The extended-release formulation is FDA-approved for the management of pain severe enough to require continuous (24 hours per day), long-term opioid treatment, and for which there are no alternative options to treat the pain. The oxycodone to morphine dose equivalent ratio is approximately 1 to 1.5 for immediate-release and 1 to 2 for extended-release formulations. [12] Tramadol - Tramadol is an FDA approved medication for pain relief. It has specific indications for moderate to severe pain. It is considered a class IV drug by the FDA. Due to possible abuse and addiction potential, limitations to its use should be for pain that is refractive to other pain medication, such as non-opioid pain medication. There are two forms of tramadol: extended-release and immediate release. The immediate-release is not for use as an "as needed" medication; instead, it is for pain of less than a week duration. For pain lasting more than a week, extended-release is the therapeutic choice - the indication for extended-release is for pain control under 24-hour management or an extended period. Off-label, the drug is useful for premature ejaculation and restless leg syndrome refractory to other medications. For the off-label use of tramadol for premature ejaculation, both sporadic and daily use is effective for the treatment of the condition. Patients indicate a preference for "as needed" therapy for premature ejaculation due to the lack of side effects compared to the daily use of tramadol. Addiction, Dependence, and Tolerance While each of these terms is similar, providers should be aware of the differences. Addiction - the constant need for a drug despite harmful consequences. Pseudoaddiction - constant fear of being in pain, hypervigilance; usually there is a resolution with pain resolution. Dependence - physical adaptation to a medication where it is necessary for normal function and withdrawal occurs with lack of the medication. Tolerance - lack of expected response to a medication resulting in an increase in dose to achieve the same pain relief as a result of CNS adaptation to the medication over time.

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Laryngeal And Tracheal Stents

StatPearls-/- 2021; ():

Laryngeal and tracheal stenosis is a very complex problem and a major cause of acute airway compromise.[1] The common causes of tracheal stenosis are acquired from trauma, prolonged intubation, or tracheostomy. On the other hand, laryngeal stenosis is commonly due to congenital abnormality or acquired from caustic injury and granulomatous disease.[2] There is no standard management for laryngotracheal stenosis; the commonly used treatments are endoscopic dilatation, laryngeal microsurgery or laser-assisted excision, and endoscopic stent placement.[3] Laryngeal and tracheal stents are solid or hollow materials used to prevent the lumen collapse or stabilize a surgical reconstruction of the larynx or trachea. The stents can be made of absorbable or non-absorbable materials of various sizes and shapes.[4] Here we are reviewing the causes of laryngotracheal pathologies and endoscopic stenting in managing them and its complications.

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Understanding Delaware Prescribing and Distribution Of Controlled Substances

StatPearls-/- 2021; ():

Chronic pain and opioid use and abuse are significant problems in the United States.[1] Over one-quarter of United States citizens suffer from chronic pain.[2] It is among the most common complaints seen in an outpatient clinic and in the emergency department. Failure to manage chronic pain, as well as the possible complication of opioid dependence related to treatment, can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence.[3] Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined.[4] How a patient's chronic pain is managed can have profound and long-lasting effects on a patient's quality of life. The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months.[5] There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy should be in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical.[6] Unfortunately, studies have revealed an inherent lack of education regarding pain management in most medical schools and training programs. The Association of American Medical Colleges recognized the problem and has encouraged schools to commit to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum. Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, underprescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. The American Society of Addiction Medicine defines addiction as "a primary, chronic disease of brain reward, motivation, memory, and related circuitry."[7] Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, there are five characteristics of addiction: 1. Craving for drug or positive reward. 2. Dysfunctional emotional response. 3. Failure to recognize significant problems affecting behavior and relationships. 4. Inability to consistently abstain. 5. Impairment in control of behavior. Unfortunately, many health providers' understanding regarding addiction is confused, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for how to effectively deal with the challenges of addiction. In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion that contributed to the undertreatment of pain. Over time, the manual has eliminated these terms and now defines an inclusive "substance use disorder" ranging from mild to severe. Pain management presents numerous challenges, including avoidance of both under and overprescribing opioids. This is particularly relevant when treating patients with chronic pain. Many patients suffer from inadequately treated pain while at the same time there are issues of opioid abuse, addiction, diversion, and overdose. As a result of concerns related to overprescribing, providers often fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. Determining appropriate opioid therapy for chronic pain patients is even more difficult because these patients often develop opioid tolerance as well as significant psychological, behavioral, and emotional problems. These can include anxiety and depression related to under or overprescribing opioids. Clinicians that prescribe opioids are at risk for allegations of medical negligence for failure to provide adequate pain control, while also risking loss of licensure or even criminal charges if they are perceived to be involved in drug diversion or misuse. All providers that prescribe opioids need education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with under and overprescribing opioids. Provider Opioid Knowledge Deficits Opioid prescribing providers may have knowledge gaps in multiple areas, including current research, legislation, and appropriate prescribing practices. Specific opportunities for education include: Definition of addiction. Knowledge of at-risk populations. Distinction between prescription and non-prescription opioid addiction. Clarification of the difference between addiction and dependence. Dispelling the myth that opioid addiction is a psychologic problem rather than related to chronic, painful disease. The practice of opioid prescription has long been surrounded by misinformation, education deficits, and inconsistent laws, resulting in societal challenges that must be addressed with education and training.

*33232097*
 33232097

Malignant Tumors of the Palate

StatPearls-/- 2021; ():

Malignancies of the hard and soft palate have a wide variety of characteristics. The hard palate, a subsite of the oral cavity, comprises the palatine bone's horizontal plate and the palatine process of the maxillary bone. Its boundaries include the alveolar ridge anteriorly, the soft palate posteriorly, the nasal cavity superiorly, and the oral cavity inferiorly. The hard palate is rich in minor salivary glands with close interaction between its mucosa and the underlying periosteum. This unique composition creates a different array of malignancies compared with other oral subsites.[1][2][3] The soft palate, on the other hand, is a subsite of the oropharynx. It is bordered by the hard palate anteriorly, palatoglossal and palatopharyngeal muscles laterally, and the uvula posteriorly. The most common malignant tumor histologies of the hard and soft palate include squamous cell carcinoma (SCC), mucoepidermoid carcinoma (MEC), adenoid cystic carcinoma (AdCC), polymorphous low-grade adenocarcinoma (PLGA), low-grade papillary adenocarcinoma (LGPA), acinic cell carcinoma (ACC), mucosal melanoma (MM), Kaposi sarcoma (KS), and non-Hodgkin lymphoma (NHL).[1]

*33232096*
 33232096

Colposcopy

StatPearls-/- 2021; ():

Colposcopy is a procedure in which a lighted, magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. Hans Hinselmen of Germany first described colposcopy in 1925 as a screening tool for cervical cancer. It is a diagnostic procedure performed to evaluate women with an abnormal Papinocalau (Pap) test, women with visual inspection with acetic acid (VIA), women positive for high-risk human papillomavirus (HPV) DNA, or with a suspicious appearing cervix even if the PAP test is normal. It is also performed as a post-treatment follow-up of intraepithelial and invasive carcinoma. Colposcopy is practiced by a number of different clinicians, including advanced practice clinicians, family medicine physicians, gynecologists, gynecological oncologists, and some internists. There is poor standardization of this process as well as training received or continued development based on daily, monthly, or more infrequently practiced procedures. It is well known that colposcopy has significant variability and poor reliability between colposcopists. The ASCCP (American Society for Colposcopy and Cervical Pathology) published colposcopy standards in 2017 to address these and other concerns.[1] The standardization of terminology was established to simplify and ensure a comprehensive colposcopic exam was performed at every encounter.

*33232095*
 33232095

Beyond PubMed : called unfree



Freezing Fertility: Oocyte Cryopreservation and the Gender Politics of Aging

Freezing Fertility: Oocyte Cryopreservation and the Gender Politics of Aging-/-Wellcome Trust-Funded Monographs and Book Chapters 2020; ():

Welcomed as liberation and dismissed as exploitation, egg freezing (oocyte cryopreservation) has rapidly become one of the most widely-discussed and influential new reproductive technologies of this century. In Freezing Fertility, Lucy van de Wiel takes us inside the world of fertility preservation-with its egg freezing parties, contested age limits, proactive anticipations and equity investments-and shows how the popularization of egg freezing has profound consequences for the way in which female fertility and reproductive aging are understood, commercialized and politicized. Beyond an individual reproductive choice for people who may want to have children later in life, Freezing Fertility explores how the rise of egg freezing also reveals broader cultural, political and economic negotiations about reproductive politics, gender inequities, age normativities and the financialization of healthcare. Van de Wiel investigates these issues by analyzing a wide range of sources-varying from sparkly online platforms to heart-breaking court cases and intimate autobiographical accounts-that are emblematic of each stage of the egg freezing procedure. By following the egg's journey, Freezing Fertility examines how contemporary egg freezing practices both reflect broader social, regulatory and economic power asymmetries and repoliticize fertility and aging in ways that affect the public at large. In doing so, the book explores how the possibility of egg freezing shifts our relation to the beginning and end of life.

*33661591*
 33661591

The Surgeon General's Call to Action to Improve Maternal Health

The Surgeon General's Call to Action to Improve Maternal Health-/-Publications and Reports of the Surgeon General 2020; ():

Optimizing maternal health is an important public health goal for the United States and is crucial to the well-being of future generations. The urgency of this goal is even more apparent during challenging times, such as the current pandemic which has highlighted striking health disparities in our nation. Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. However, efforts to improve maternal health must extend beyond this time period and begin with promoting mental and physical health in young girls and adolescents, and continue throughout the reproductive years. This life-course approach to improving maternal health is highlighted in this Call to Action. This approach is also used in Healthy Women, Healthy Pregnancies, Healthy Futures: The U.S. Department of Health and Human Services' (HHS) Action Plan to Improve Maternal Health in America. While the HHS Action Plan summarizes the Department's work to ensure the U.S. is one of the safest countries in the world to give birth, achieving this vision for all women, regardless of race, ethnicity, social and economic status, will require involvement from both public and private sectors. This Call to Action is intended to engage and equip individuals, organizations, and communities with actions to improve women's health prior to, during, and following pregnancy.

*33661589*
 33661589

Some Industrial Chemical Intermediates and Solvents

Some Industrial Chemical Intermediates and Solvents-/-IARC Monographs on the Identification of Carcinogenic Hazards to Humans 2020; ():

This volume of the IARC Monographs provides evaluations of the carcinogenicity of five High Production Volume chemicals: glycidyl methacrylate, 1-butyl glycidyl ether, 1-bromo-3-chloropropane, 4-chlorobenzotrifluoride, and allyl chloride. Glycidyl methacrylate is mainly used in the production of epoxy polymers and vinyl and acrylic resins. The polymers are subsequently used in dental sealants, composites and adhesives, bone composite materials, powder coatings, hydrogel lenses, and food contact material. 1-Butyl glycidyl ether is a reactive intermediate and viscosity-reducing solvent used in the manufacture of epoxy resins, and is also used as a surface modifier in the dyeing of cotton and wool. 1-Bromo-3-chloropropane is an intermediate in the manufacture of a wide range of pharmaceuticals, some pesticides, and other chemicals. 4-Chlorobenzotrifluoride is widely used as a solvent and diluent for inks, paints, toners, and coatings and in dispersive applications in the automotive industry. It is also a major component in industrial and consumer formulations such as cleaners, degreasers, stain removers, and sealants. Allyl chloride is almost exclusively used in the production of epichlorohydrin, a basic building block for epoxy resins and the synthesis of glycerol, although it is also an intermediate in the synthesis of various pesticides, pharmaceuticals, adhesives, and personal-care products. Exposure to all these agents may occur in various occupational settings as well as in the general population. An IARC Monographs Working Group reviewed epidemiological evidence, animal bioassays, and mechanistic evidence to reach conclusions as to the carcinogenic hazard to humans of exposure to these agents.

*33661588*
 33661588

Behavioral Health Barometer: United States, Volume 5: Indicators as measured through the 2017 National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services

Behavioral Health Barometer: United States, Volume 5: Indicators as measured through the 2017 National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services-/-Behavioral Health, United States 2019; ():

The Behavioral Health Barometer: United States, Volume 5: Indicators as measured through the 2017 National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services, is one of a series of national, regional, and state reports that provide a snapshot of behavioral health in the United States. The reports present a set of substance use and mental health indicators as measured through the National Survey on Drug Use and Health (NSDUH) and the National Survey of Substance Abuse Treatment Services (N-SSATS), sponsored by SAMHSA.

*33661590*
 33661590

Oral Cavity, Oropharyngeal, Hypopharyngeal, and Laryngeal Cancer Prevention (PDQ(R)): Health Professional Version

PDQ Cancer Information Summaries-/- 2002; ():

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about oral cavity, oropharyngeal, nasopharyngeal, hypopharyngeal, and laryngeal cancer prevention. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions. This summary is reviewed regularly and updated as necessary by the PDQ Screening and Prevention Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

*26389416*
 26389416

Oropharyngeal Cancer Treatment (Adult) (PDQ(R)): Health Professional Version

PDQ Cancer Information Summaries-/- 2002; ():

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of adult oropharyngeal cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

*26389168*
 26389168

Oropharyngeal Cancer Treatment (Adult) (PDQ(R)): Health Professional Version

PDQ Cancer Information Summaries-/- 2002; ():

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of adult oropharyngeal cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

*26389168*
 26389168

Childhood Mesothelioma Treatment (PDQ(R)): Patient Version

PDQ Cancer Information Summaries-/- 2002; ():

This PDQ cancer information summary has current information about the treatment of childhood mesothelioma. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care. Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change. The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Pediatric Treatment Editorial Board.

*31593394*
 31593394

Melanoma Treatment (PDQ(R)): Health Professional Version

PDQ Cancer Information Summaries-/- 2002; ():

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of melanoma. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decision. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

*26389469*
 26389469

Gastric Cancer Treatment (PDQ(R)): Health Professional Version

PDQ Cancer Information Summaries-/- 2002; ():

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of gastric cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

*26389209*
 26389209

Childhood Breast Cancer Treatment (PDQ(R)): Patient Version

PDQ Cancer Information Summaries-/- 2002; ():

This PDQ cancer information summary has current information about the treatment of childhood breast cancer. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care. Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change. The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Pediatric Treatment Editorial Board.

*31593393*
 31593393

RUNX1 Familial Platelet Disorder with Associated Myeloid Malignancies

GeneReviews((R))-/- 1993; ():

CLINICAL CHARACTERISTICS: RUNX1 familial platelet disorder with associated myeloid malignancies (RUNX1-FPDMM) is characterized by prolonged bleeding and/or easy bruising and an increased risk of developing a hematologic malignancy. RUNX1-FPDMM is characterized by thrombocytopenia with normal platelet size; bleeding is often greater than expected due to qualitative platelet dysfunction. Myeloid malignancies are the most common, including acute myelogenous leukemia (and myelodysplastic syndrome. T- and B-cell acute lymphoblastic leukemias and lymphomas have also been reported, as well as skin manifestations (e.g., eczema, psoriasis). DIAGNOSIS/TESTING: The diagnosis of RUNX1-FPDMM is established in a proband with suggestive findings and a heterozygous germline pathogenic variant in RUNX1 identified by molecular genetic testing. MANAGEMENT: Treatment of manifestations: Use of clotting promotors (e.g., desmopressin, epsilon aminocaproic acid, tranexamic acid) in instances of surgeries, injuries, or dental treatments; platelet transfusions may be used for severe bleeding or procedures with a high bleeding risk. Allogenic stem cell transplantation may be considered in individuals with early signs of malignancy and hematopoietic stem cell transplant may be used to treat myelodysplasia; however, recommendations regarding the indications and timing of stem cell transplant can vary. Emollients and topical steroids as needed for eczema; consider providing a medical letter for the school explaining easy bruising; consider use of a medical alert bracelet. Surveillance: Clinical examination for signs/symptoms of neoplasm (e.g., constitutional symptoms such as fatigue, unexplained fever, unexplained weight loss, shortness of breath) every six to 12 months. Complete blood count with differential every three to four months; bone marrow examination if constitutional symptoms and/or abnormalities on complete blood count are identified; skin exam as needed. Agents/circumstances to avoid: Medications that affect platelet function (e.g., NSAIDs and antiplatelet agents), activities with a high risk of trauma (e.g., high-risk contact sports), unnecessary radiation, and smoking. Evaluation of relatives at risk: It is appropriate to clarify the genetic status of apparently asymptomatic at-risk relatives of an affected individual in order to identify as early as possible those who would benefit from surveillance for malignancy and more targeted medical management. GENETIC COUNSELING: RUNX1-FPDMM is inherited in an autosomal dominant manner. Most individuals diagnosed with RUNX1-FPDMM inherited the causative pathogenic variant from a parent who may or may not have recognized manifestations of the disorder. If a parent of the proband is affected and/or is known to have the pathogenic variant identified in the proband, the risk to sibs of inheriting the pathogenic variant is 50%. If the RUNX1 pathogenic variant identified in the proband is not detected in parental DNA, the recurrence risk to sibs is slightly greater than that of the general population because of the possibility either of a false negative result in a parent (due to preferential loss of the chromosome with the RUNX1 pathogenic variant), or of parental germline mosaicism. Once the RUNX1 pathogenic variant has been identified in an affected family member, prenatal testing for a pregnancy at increased risk and preimplantation genetic testing are possible.

*33661592*
 33661592

Seattle nurses prove 'unity is power'.

1199 News 1983; 18 (9): 18-9

*10263171*
 10263171

What the National Hospital Union means to its members.

1199 News 1983; 18 (9): 12-5

*10263170*
 10263170

Chinatown Health Clinic.

1199 News 1983; 18 (10): 29-31

*10262725*
 10262725

600 RNs gain higher rates in Lenox Hill pact.

1199 News 1983; 18 (3): 30

*10259008*
 10259008

Michigan community joins striking nurses on patient care issues.

1199 News 1983; 18 (3): 12-3

*10259007*
 10259007

Reagan's new attack on health care for the poor.

1199 News 1983; 18 (7): 4

*10310229*
 10310229

Organizing state hospital workers in West Virginia.

1199 News 1983; 18 (1): 7-11

*10259944*
 10259944

N.Y. hospitals say 'no' to nuclear war plan.

1199 News 1983; 18 (1): 6

*10259943*
 10259943

The emotional cost of Reaganomics.

1199 News 1983; 18 (1): 19

*10259942*
 10259942

Social workers under fire.

1199 News 1983; 18 (2): 15-7

*10259945*
 10259945

The National Hospital Union in 1983. Ten years of struggle, ten years of progress.

1199 News 1983; 18 (8): 15-20

*10262226*
 10262226

3,200 Massachusetts professionals choose 1199.

1199 News 1983; 18 (4): 3-7

*10259947*
 10259947

National union seeks health coverage for unemployed.

1199 News 1983; 18 (4): 11

*10259946*
 10259946

Cancer and hospital workers.

1199 News 1982; 17 (9): 7-9

*10259941*
 10259941

1199 to Reagan: 'don't gut hospital standards'.

1199 News 1982; 17 (9): 19

*10259940*
 10259940

9,000 New York home care workers win first contract.

1199 News 1982; 17 (9): 10-1

*10259939*
 10259939

St. Barnabas nurses win it.

1199 News 1982; 17 (10): 9-10

*10259938*
 10259938

New nursing trends threaten LPNs' future.

1199 News 1982; 17 (10): 24-5

*10259937*
 10259937

While health services are slashed . . . now hospitals can use Medicare funds for union-busting.

1199 News 1982; 17 (5): 9

*10298512*
 10298512

Hospitals warned against Social Security pull-out.

1199 News 1982; 17 (5): 6-7

*10255122*
 10255122

Leon Davis: his passion for justice built a union.

1199 News 1982; 17 (3): 3-13

*10315953*
 10315953

New York contract: united membership plus strong new leadership equals victory.

1199 News 1982; 17 (8): 3-11

*10256500*
 10256500

Health care in crisis.

1199 News 1982; 17 (8): 23-6

*10256499*
 10256499

A first in day care for 1199ers' kids.

1199 News 1982; 17 (8): 15

*10256498*
 10256498

A hospital director recalls 22 years with 1199. Interview by Nancy Stiefel.

1199 News 1981; 16 (9): 23

*10252183*
 10252183

Connecticut Health Care Associates joins 1199.

1199 News 1981; 16 (10): 16-7

*10253003*
 10253003

These Southern hospital workers have left the plantation forever.

1199 News 1981; 16 (5): 8-9

*10251311*
 10251311

Long struggle brings 1199 contract for nurses in New Mexico.

1199 News 1981; 16 (3): 4-5

*10250584*
 10250584

The saints come marching in: victories at St. Clare's in New York are latest in series of 1199 wins at Catholic hospitals.

1199 News 1981; 16 (3): 3

*10250583*
 10250583

Physicians assistants: new 1199ers medical pioneers.

1199 News 1981; 16 (6): 24-5

*10314533*
 10314533

The service employees: a sister union that's a lot like us.

1199 News 1981; 16 (6): 7-10

*10251313*
 10251313

RWDSU and SEIU agree to merge.

1199 News 1981; 16 (6): 12-3

*10251312*
 10251312

Connecticut: big gains for 2,000 nursing home 1199ers.

1199 News 1981; 16 (1): 23-5

*10249600*
 10249600

King's Daughters' contract sets pace for Kentucky hospitals.

1199 News 1981; 16 (1): 13

*10249599*
 10249599

Government shouldn't reimburse union-busters.

1199 News 1981; 16 (2): 6

*10298107*
 10298107

Contract gains for 12,500 members.

1199 News 1981; 16 (8): 3-7

*10252182*
 10252182

2,000 Michigan LPNs affiliate with 1199.

1199 News 1981; 16 (8): 15-7

*10252181*
 10252181

Why nurses leave nursing.

1199 News 1981; 16 (4): 24-5

*10250585*
 10250585

Victory at St. Barnabas.

1199 News 1980; 15 (9): 3-5

*10247898*
 10247898

We're making more money than we used to, but we're living worse.

1199 News 1980; 15 (5): 6-7

*10247895*
 10247895

New York's League negotiations begin.

1199 News 1980; 15 (5): 3-5

*10247894*
 10247894

Hospital election win caps 12-year campaign.

1199 News 1980; 15 (3): 6

*10246674*
 10246674

Georgetown University Hospital goes 1199E.

1199 News 1980; 15 (3): 4-5

*10246673*
 10246673

Power for RNs through 1199.

1199 News 1980; 15 (3): 16-7

*10246672*
 10246672

New Hampshire RNs go 1199.

1199 News 1980; 15 (6): 15-7

*10246675*
 10246675

Why Syosset Hospital is sick.

1199 News 1980; 15 (7): 24-5

*10247496*
 10247496

A new voice in the hospital.

1199 News 1980; 15 (7): 16-8

*10247495*
 10247495

Patient care: the health care employee's responsibility.

1199 News 1980; 15 (1): 25-9

*10246126*
 10246126

Life in the hospitals in a new musical revue: Take Care.

1199 News 1980; 15 (2): 5-7

*10246127*
 10246127

Equal pay for women workers.

1199 News 1980; 15 (8): 8-9

*10247897*
 10247897

New minimum wage rates for League 1199ers.

1199 News 1980; 15 (8): 6-7

*10247896*
 10247896

A mother and her child: grievance wins leave so 1199er can be at ailing son's bedside.

1199 News 1979; 14 (10): 32

*10246669*
 10246669

1199s scholarship program.

1199 News 1979; 14 (10): 31

*10246668*
 10246668

Brooklyn Jewish: how the fight for a community's health was won.

1199 News 1979; 14 (11): 3-5

*10246670*
 10246670

New York 1199ers tell Mayor Koch: hands off voluntary hospitals.

1199 News 1979; 14 (6): 4-5

*10246671*
 10246671

Women in health care: today's goal is strength through unity.

1199 News 1979; 14 (7): 15-7

*10245788*
 10245788

A good beginning: 20 years in the hospitals.

1199 News 1979; 14 (12): 2-48

*10297812*
 10297812

Vollkorn fur die Fuhrer: zur geschichte der Vollkornbrotpolitik im "Dritten Reich".

1999 Z Sozial 20 21 Jhd 2001; 16 (1): 91-128

*20017268*
 20017268

Auf der spur von Medizinverbrechen: Keith Mant (1919-2000) und sein debut als forensischer pathologe.

1999 Z Sozial 20 21 Jhd 2001; 16 (1): 129-39

*20017267*
 20017267

Wie erarbeitet man sich einen naturlichen Korper? Korpernormalisierung in der Deutschen Nacktkulturbewegung um 1900.

1999 Z Sozial 20 21 Jhd 1999; 14 (2): 86-109

*22590769*
 22590769

Wehrmacht und Prostitution: zur Reglementierung der Geschlechterbeziehungen durch die Deutsche Militarverwaltung im besetzten Frankreich 1940-1944.

1999 Z Sozial 20 21 Jhd 1999; 14 (2): 35-55

*22590767*
 22590767

Eine Sowjetische Liste der Personenverluste im Zweiten Weltkrieg von 1946.

1999 Z Sozial 20 21 Jhd 1999; 14 (1): 126-33

*22590766*
 22590766

Diskurse und Erfahrungen: ein Ruckblick auf die Korpergeschichte der neunziger Jahre.

1999 Z Sozial 20 21 Jhd 1999; 14 (2): 142-60

*22590763*
 22590763

Arbeitsmarktpolitik, Migration und Rechtliche Stigmatisierung von fremden: von Weimar nach Bonn.

1999 Z Sozial 20 21 Jhd 1999; 14 (1): 92-125

*22590762*
 22590762

The child and the daemon: Mozart and deep play.

19th Century Music 2001; 25 (2-3): 91-107

*20217971*
 20217971

Ben Pimlott Memorial Lecture 2018The Women's Suffrage Movement in the Balfour Family.

20 Century Br Hist 2019; 30 (3): 299-320

Given on the centenary of women's suffrage, this lecture explores the tensions and conflicts the claim for the vote raised among elite women already enmeshed in parliamentary and political circles. Drawing on the unbuttoned and sometimes angry correspondence among A.J. Balfour's suffragist sisters-in-law Lady Frances Balfour and Lady Betty Balfour, Frances' collaborator (and suffragist leader) Millicent Fawcett, Lady Betty's militant suffragette sister Lady Constance Lytton, and their old friend (and wife of the anti-suffragist Prime Minister) Margot Asquith, it explores the appeal but also the costs of this democratic claim for such "incorporated" women - and explains why some nevertheless supported it.

*31330031*
 31330031

TCBH Duncan Tanner Essay Prize Winner 2018 Financing the Information Age: London TeleCity, the Legacy of IT-82, and the Selling of British Telecom.

20 Century Br Hist 2019; 30 (3): 424-446

This article is a history of the privatization of British Telecom. BT's privatization occupies a central position in histories of Thatcherism as a pivotal moment in Thatcherism's ideological focus on popular capitalism. These histories, however, overlook the important intersection of financial institutions and information technology policy in shaping BT's privatization. Financial institutions in the City of London formed a lobbying group, the City Telecommunications Committee, that pressured for BT's privatization and secured preferential treatment for the City from BT, ending a decades-long policy of uniform telecommunications services across Britain. Margaret Thatcher's government positioned BT's privatization as central to the success of two of Britain's information industries, electronics manufacturing and the City of London. Her government also cast BT's privatization as essential to an 'information revolution' that, through personal, networked computing, would further personal freedom and free markets. BT's privatization thus performed two important and related functions. First, it oriented Britain's telecommunications network to the City of London's needs, and secondly, it enacted an 'information revolution' that was portrayed as essential to the success of the City of London and British electronics. I label this fusion of City finance, neoliberal politics, and British telecommunications the 'London ideology', and this ideology shaped the broadly-held assumption that privatizing telecommunications was essential to reaching the 'information age'.

*31157870*
 31157870

'You Can't Dismiss that as Being Less Happy, You See it is Different'. Sexual Counselling in 1950s England.

20 Century Br Hist 2019; 30 (3): 375-398

This article uses the audio recordings of sexual counselling sessions carried out by Dr Joan Malleson, a birth control activist and committed family planning doctor in the early 1950s, which are held at the Wellcome Library in London as a case study to explore the ways Malleson and the patients mobilised emotions for respectively managing sexual problems and expressing what they understood as constituting a 'good sexuality' in postwar Britain. The article contains two interrelated arguments. First, it argues that Malleson used a psychological framework to inform her clinical work. She resorted to an emotion-based therapy that linked sexual difficulties with unconscious, repressed feelings rooted in past events. In so doing, Malleson actively helped to produce a new form of sexual subjectivity where individuals were encouraged to express their feelings and emotions, breaking with the traditional culture of emotional control and restraint that characterized British society up until the fifties. Second, I argue that not only Malleson but also her patients relied on emotions. The performance of mainly negative emotions reveals what they perceived as the 'normal' and sexual 'ideal'. Sexual therapy sessions reflected the seemingly changing nature of the self towards a more emotionally aware and open one that adopted both the language of emotions and that of popular psychology to articulate his or her sexual difficulties.

*30986822*
 30986822

Deindustrialization, the Linwood Car Plant and Scotland's Political Divergence from England in the 1960s and 1970s.

20 Century Br Hist 2019; 30 (3): 399-423

Scotland's political divergence from England is a key theme in late twentieth century British history. Typically seen in terms of the post-1979 Thatcher effect, this in fact developed over a longer timeframe, rooted in industrial changes revealed by analysis of the Linwood car plant in Renfrewshire. Conservatism and Unionism was an eminent political force in Scotland in the 1940s and 1950s. But in all general elections from 1959 onwards the vote share of Conservative and Unionist candidates was lower in Scotland than in England. From the late 1960s onwards there were also ambitions for constitutional change. This article breaks new conceptual and empirical ground by relating these important markers of political divergence to popular understanding among Scottish workers of deindustrialization. A Thompsonian moral economy framework is deployed. Expectations were elevated by industrial restructuring from the 1950s, with workers exchanging jobs in the staples for a better future in assembly goods. Labour governments earned a reputation in Scotland as better managers of this process than Conservative governments. The 1979 general election showed that Labourism was growing in popularity in Scotland just as its appeal faded in England. At Linwood moral economy expectations were compromised, chiefly by intermittent redundancy and recurrent threat of closure, which was averted in 1975 by Labour government intervention. When the plant was shut in 1981 criticisms of UK political-constitutional structures and Conservativism were intensified.

*30897624*
 30897624

"The British Soldier is no Bolshevik": The British Army, Discipline, and the Demobilization Strikes of 1919.

20 Century Br Hist 2019; 30 (3): 321-346

This article considers the breakdown in discipline in the British Army which occurred in Britain and on the Western Front during the process of demobilization at the end of the First World War. Many soldiers, retained in the army immediately after the Armistice, went on strike, and some formed elected committees, demanding their swifter return to civilian life. Their perception was that the existing demobilization system was unjust, and men were soon organized by those more politically conscious members of the armed forces who had enlisted for the duration of the war. At one stage in January 1919, over 50,000 soldiers were out on strike, a fact that was of great concern to the British civilian and military authorities who miscalculated the risk posed by soldiers. Spurred on by many elements of the press, especially the Daily Mail and Daily Herald, who both fanned and dampened the flames of discontent, soldiers' discipline broke down, demonstrating that the patriotism which had for so long kept them in line could only extend so far. Though senior members of the government, principally Winston Churchill, and the military, especially Douglas Haig and Henry Wilson, were genuinely concerned that Bolshevism had 'infected' the army, or, at the very least, the army had been unionized, their fears were not realized. The article examines the government's strategy regarding demobilization, its efforts to assess the risk of politicization and manage the press, and its responses to these waves of strikes, arguing that, essentially, these soldiers were civilians first and simply wanted to return home, though, in the post-war political climate, government fears were very real.

*30544173*
 30544173

'Co-operation and Communism cannot work side by side': Organized Consumers and the Early Cold War in Britain.

20 Century Br Hist 2019; 30 (3): 347-374

This article contributes to a better understanding of labour anti-communism in Britain through an exploration of the evolution of ideas and attitudes within the co-operative movement during the early Cold War. It demonstrates that the period witnessed an increasingly rigid separation of co-operation from communism and argues that this separation made it harder for activists within the co-operative movement to imagine a total or utopian alternative to capitalism. Drawing particularly on a close reading of the co-operative press as well as other sources, the study is divided into three main parts. The first section discusses sympathy among co-operators for the achievements of the Soviet Union, which increased during the war against fascism. The article then moves on to consider the continuing dialogue between British co-operators and their counterparts in European communist states and how international tensions shaped co-operators' views. The final major section explores the hardening of attitude towards communism after Marshall Aid was declared in June 1947, and underlines the role played by figures such as A. V. Alexander and Jack Bailey who worked with the Information Research Department at the Foreign Office to spread anti-communism within the movement. The conclusion reflects, more speculatively, on what implications this shift may have had for the medium and long-term decline of co-operation and the hegemony of capitalist consumerism post-war.

*29618059*
 29618059

Environmental History and New Directions in Modern British Historiography.

20 Century Br Hist 2019; 30 (3): 447-456

*29474706*
 29474706

A 'Radical Project': Youth Culture, Leisure, and Politics in 1980s Sheffield.

20 Century Br Hist 2019; ():

The Leadmill, a cooperative arts centre and nightclub in Sheffield, opened in 1980. The venue sought to provide an accessible leisure space for the economically and socially marginalized, and received funding for this from Sheffield City Council. Focusing on the cultural policies of the new urban left Labour Council in Sheffield during the 1980s, this article explores the relationship between Sheffield City Council and the Leadmill. It builds on recent scholarship on the 1980s that has sought to look beyond Thatcherism as an explanation for the decade, and sheds light on the everyday experiences of living through this period. This article argues for the reinvigoration of local history, and demonstrates that an exploration of a site of community leisure unveils cooperation and engagement between groups with disparate and contradicting aims. It tells a different story of the 1980s, one that recognizes how Thatcherism allowed and in some cases enabled the creation of spaces within which its critics could thrive. It shows how a range of political dialogues were present in shaping the policies of local government, and how the longer tradition of state and market interaction was shaped by the specific social, economic, and political contexts of the decade. Above all, it challenges presentations of the 1980s that favour the hegemonic power of Thatcherism and the decade as one of the triumph of individualism.

*30859230*
 30859230

Socialist Television Drama, Newspaper Critics and the Battle of Ideas During the Crisis of Britain's Post-War Settlement.

20 Century Br Hist 2019; ():

Due to the difficult methodological issues it presents, political historians are wary of using television - the most important mass medium of the later twentieth century - as a means of exploring vernacular political thinking. Attempting to show how television audiences were encouraged to think politically, the article outlines a method generated through an engagement with the work of disciplines beyond history, to help political historians more systematically assess the medium's popular impact. The article takes as its case study Britain during the 1970s, one of the most ideologically contested periods in the country's history. It analyses how television critics employed by the Daily Mirror and Daily Express encouraged their millions of readers to respond to the dramas of socialist playwrights Jim Allen and Trevor Griffiths, thereby giving historians an insight into the shape of those conversations spawned by their work, such private dialogues being the place where the full political meaning of television was ultimately created.

*30859211*
 30859211

Labour Activism and the Political Self in Inter-War Working-Class Women's Politics.

20 Century Br Hist 2019; 30 (1): 29-52

This article explores working-class women's experiences of political activism in the Labour Party in the 1930s. The article focuses upon the relationships formed with leaders, the bonds with fellow women, and the emotional fulfilment politics could bring, rather than considering the policies and campaigns which drew women into the party. It suggests how working-class women performed a political self which was shaped by but distinctive from a domestic self. Official political party materials from across Britain are drawn upon to uncover how working-class women in the years after equal franchise was won carved out a political space and the meanings of activism. Party members' private and public portrayals of women's activism are considered. Although the focus is upon working-class women's political experiences, the conclusions drawn here have implications for how the creation of a political self can be considered in studies of other political parties and voluntary organizations.

*30541119*
 30541119

Splinters: Cross-Dressing Ex-Servicemen on the Interwar Stage.

20 Century Br Hist 2019; 30 (1): 1-28

This article will examine how a series of theatrical shows which starred casts of cross-dressing ex-servicemen achieved critical and commercial popularity in interwar Britain despite increased cultural anxieties about the links between gender variance and transgressive acts, behaviours, and categories of identity. Prior to this study, historians have researched wartime concert parties where servicemen cross-dressed for each other's entertainment, but scant attention has been given to the popular phenomenon of ex-servicemen who performed cross-dressing revues for the general public. Staging revues on the home front exposed cross-dressing ex-servicemen to new forms of spectatorship: the theatregoing public, arts criticism in the press, and state censorship. This article will analyse these dynamics for the first time through an investigation of the First World War troupe Les Rouges et Noirs, who popularized the subgenre of veterans' cross-dressing revues with their debut production Splinters (1918). Critics commended the company's contribution to the war effort while also lauding the troupe for their entertainment value and 'bewitching' feminine mimicry. Some observers, like the Lord Chamberlain, found Les Rouges' cross-dressing troubling, but these views were in the minority and did not seriously hinder the performers' success. When carried out temporarily in a performative setting by artists who presented a skilful and beguiling representation of femininity, and whose status as ex-servicemen helped to dispel suspicions of immorality, cross-dressing could be a source of great pleasure, even as it constituted a source of cultural anxiety in other contexts.

*30380103*
 30380103

King Caz: Cazenove, Thatcherism, and the 1980s financial revolution.

20 Century Br Hist 2019; 30 (1): 108-131

This article shows how elite stockbrokers Cazenove and Co. responded to the 'Big Bang' deregulation of the financial sector in 1986, using social networks and inherited practices to navigate an ostensibly technical and modernizing revolution. The Thatcher administration's reform of the London Stock Exchange was an economic enterprise intended to end restrictive practices and open the City to competition. A more open meritocratic financial sector marked the 'death of gentlemanly capitalism' and coalesced with a political agenda for entrepreneurialism and popular capitalism. Yet this case study shows how Cazenove's culture drove its strategy, that privilege and hierarchy were sustained by influential cross-sector networks, and that there was resistance to change, even though technological change and new financial instruments were embraced as part of a strategy which mixed innovation with tradition. Essentially, elite networks persisted in the 1980s deregulated economy, as established relationships were used to optimum effect and became more important after Big Bang. A more mutually supportive relationship between finance and industry than has hitherto been imagined is also demonstrated. By showing how a modernizing revolution was navigated using social networks and traditions, this article restores the role of culture to financial history. It also contributes to a body of work in twentieth-century British history which challenges the perception that neoliberal ideas were consistently applied under Thatcherism and complicates the notion of a coherent Thatcherite project.

*30107594*
 30107594

Stateless Persons, Eligible Citizens and Protected Places: The British Nationality Act in Vanuatu.

20 Century Br Hist 2019; 30 (1): 53-80

The British Nationality Act (BNA) of 1948 was designed to provide a form of supranational citizenship to accommodate the separate nationality provisions that were beginning to proliferate as a result of constitutional change within the late empire, decolonization and the formation of the Commonwealth. Under the provisions of the BNA, members of the Commonwealth would continue to be unified by transnational forms of citizenship, at least in principle. The Act aimed to cover every political arrangement conceivable in the late empire and early Commonwealth and contributed to the transformation of Great Britain into a multicultural society, by providing the legal vehicle for immigration into the UK in the second half of the twentieth century. However, the BNA had its limits. It could not be applied to territories characterized by constitutional exceptionalism and jurisdictional hybridity. In the Condominium of the New Hebrides, jointly governed by France and Great Britain from 1906 to 1980, the majority of the indigenous population were unable to benefit from the BNA, despite efforts to extend its coverage in all eligible territories. As part of the condominium agreement, the indigenous population were ineligible for any form of citizenship-British, French or New Hebridean-and remained stateless until independence as the Republic of Vanuatu in 1980. This article examines the relationship between indigenous statelessness and the BNA, exploring the implementation, interpretation and extent of the BNA in a territory characterized by constitutional hybridity, compromise and ambiguity. It argues that despite its emphasis on universal commonwealth citizenship, the BNA could not accommodate the diverse political, legal and constitutional diversity that characterized the Dominions, Crown Colonies, protectorates, protected states and condominia that had proliferated under imperial rule and whose legacies continued to inform the possibilities for decolonization and the politics of post-colonial citizenship making.

*30085310*
 30085310

Pension Funds and the Politics of Ownership in Britain, c. 1970-86.

20 Century Br Hist 2019; 30 (1): 81-107

The growth of occupational pensions in the post-war era transformed the pattern of capital ownership in Britain, as workers' collective retirement savings purchased a substantial share of the national economy. This article examines the response of the Labour and Conservative parties to this significant material change, and considers how it shaped their respective politics of ownership at the end of the post-war settlement. It demonstrates that Labour and the trade union movement recognized occupational pension funds as a new form of social ownership but had to reconcile their desire to give pension scheme-members direct control over their investments with a broader belief that the funds needed be used for a state-coordinated revitalization of the industrial economy. Meanwhile, the Conservative Party's initial enthusiasm for occupational pensions, which it championed for helping to create a 'property-owning democracy', was challenged by a radical neoliberal critique in the early 1980s that sought to dismantle pension funds and to individualize investment. The findings in the article assert the need for historians to situate the politics of the tumultuous 1970s and 1980s in the context of the substantial economic and social changes that had taken place during the post-war decades. These changes often created opportunities to formulate new policies and political agendas, but they also served to highlight deeper tensions within the ideologies of the main political parties.

*29688553*
 29688553

'Action Not Words': The Conservative Party, Public Opinion and 'Scientific' Politics, c.1945-70.

20 Century Br Hist 2019; ():

From the late 1950s, Conservative research and policy thinkers underwent a conscious intellectual adjustment, which had profound implications for how the party conceived the relationship between politicians and the public during Edward Heath's period as Conservative leader after 1965. In response to contemporaneous debates regarding 'modernization', and as a result of their engagement with the emergent social sciences, a new generation of Conservatives tended to repudiate the party's traditional preference for idealist and organicist philosophical assumptions in favour of a rationalistic approach to political administration. Their preoccupation with economic management was concomitant of their loss of faith in the formative role of rhetorical and moral appeals in shaping public opinion. This article, by focusing on debates within the party's research and political apparatus-the Conservative Research Department, the Conservative Political Centre and Swinton College-will contend that, far from being the last gasp of a post-war consensual Conservatism, Heath's period as leader marked a relatively unique period in the party's history, in which the conception of the nature of political leadership held by those at the top of the party differed from the conception held by both their predecessors and successors.

*31236567*
 31236567

The Trial of Convoy PQ17 and the Royal Navy in Post-War British Cultural Memory.

20 Century Br Hist 2019; ():

This article explores the 1970 case of Broome v. Cassell & Co. in which an elderly wartime naval officer was awarded unprecedented damages for defamation in David Irving's account of the sinking of wartime Allied convoy PQ17 in 1942. The article examines the discourses and images deployed in this landmark British libel action, as a means of analysing how cultural memories of convoy PQ17 and the wartime Royal Navy were shaped and transmitted in post-war Britain. It is argued here that the trial offers a prism through which to explore wider anxieties that the generation who fought the Second World War held during the late 1960s. It maps how contemporary generational tensions, fears of national decline, and concerns about distorted cultural representations of war in Britain were embedded into the trial. This libel case thus became invested with considerable cultural significance among an ageing community of wartime survivors who were intent upon safeguarding wider memories of 'their' war.

*31230077*
 31230077

Feminism and the Politics of Prostitution in King's Cross in the 1980s.

20 Century Br Hist 2019; 30 (2): 231-263

In the 1980s, prostitution resurfaced as the object of feminist politics as second-wave activists grappled with Thatcherism, prostitute rights, tenant activism, anti-violence movements, and changes in the street sex trade and in policing. These conflicting imperatives converged on King's Cross, London. Events in King's Cross highlight some general trends, especially shifts in policing and in the geographic dispersal of the street sex trade. King's Cross also possessed singular features. It was the epicentre of street prostitution in London and the destination for hundreds of northern women migrating to the metropolis to sell sex. Intensified policing of the street trade provoked a heated neighbourhood dispute between council tenants and a media-savvy prostitute rights group. The year 1982 also marked a new configuration in local politics: the control of Camden Council by Labour Left and the formation of the Camden Women's Committee. In this challenging environment, newly elected municipal feminists in Camden set out to devise a feminist practice around prostitution. They found themselves embroiled in local disputes over public space, gender justice, policing, municipal progressivism, and resident action.

*31032861*
 31032861

Erratum.

20 Century Br Hist 2019; 30 (2): 297

*30933269*
 30933269

Toffee Men, Travelling Drapers and Black-Market Perfumers-South Asian Networks of Petty Trade in Early Twentieth Century Britain.

20 Century Br Hist 2019; 30 (2): 145-173

Selling small wares, novelties, and affordable luxuries manufactured from artificial silk, the South Asian door-to-door pedlar or 'travelling draper', and his compatriot the 'Indian toffee man', were once fairly commonplace figures in British working-class life and the object of fond childhood recollections for many. Unfortunately, they have now largely drifted from popular memory, having left little trace in the historical record. However, this article's reconstruction of their lives offers a new perspective on the pivotal role inter-racial social networks played in pioneering South Asian immigration, settlement, and trade in Britain. New research into this pre-Partition, pre-Windrush immigration, particularly in and around the English industrial city of Sheffield, provides a more detailed and more nuanced understanding of their quotidian experience, their relationship to British society, and their reception by the working-class neighbourhoods within which they lived and plied their trade. The article emphasizes the men's enduring sense of agency and economic autonomy, despite the attempts of various departments of state to prevent them from exercising their right, as British subjects, to live and work in Britain.

*30879062*
 30879062

'Secret Lists and Sanctions': The Blacklisting of the John Lewis Partnership and the Politics of Pay in 1970s Britain.

20 Century Br Hist 2019; 30 (2): 205-230

In 1977, the John Lewis Partnership (JLP) was blacklisted for breaching the Labour government's pay controls under the Social Contract. As the Callaghan administration struggled to establish economic credibility, extending its reach into the private sector emerged as a political priority. JLP became a test case of government resolve months before the Ford strike of autumn 1978 that ushered in the Winter of Discontent. This article uses JLP records to create a more nuanced picture of the tensions, contestations, and vacillations of pay policy in the late 1970s. By doing so, gaps between policy conception and implementation emerge and intersect; both the business and the government faced constraints in implementing policy, despite powerful beliefs about the integrity of their actions. The article is not primarily a case study, however, and aims to contribute to broader debates. The constitutional significance, rather than the commercial impact, of government sanctions became a keynote of critique of JLP's blacklisting, suggesting that contemporaries recognized this was a confrontation of the political moment between the state and the private sector. By looking from a business's perspective, we also gain insight into how organizations approached, negotiated with, and responded to the government. Recovering the JLP blacklisting episode further shows how business archives offer great promise as resources for political history.

*30753661*
 30753661

A 'Mixture of Britannia and Boadicea': Dorothy Crisp's Conservatism and the Limits of Right-Wing Women's Political Activism, 1927-48.

20 Century Br Hist 2019; 30 (2): 174-204

Dorothy Crisp is known for being the militant Chairman of the British Housewives League (BHL) after the Second World War, but historians have failed to recognize that her views and actions were the culmination of over twenty years of right-wing journalism and political activism through which she tried to influence the Conservative Party. This article re-evaluates Crisp's Conservatism and her political career. It asks why such a powerful pro-Conservative female activist failed to secure a place within Conservative politics during the 1930s and the 1940s. In doing so, it shows that Crisp was not willing to conform to traditional gender roles inside the Party or the broader Conservative movement and that she was a vocal advocate for gender equality. It was the combination of her attitude towards women's issues and her older brand of imperialist, ultra-patriotic, anti-statist Conservatism that was unusual for a right-wing woman in this period. Crisp's views on women's issues did not fit the domesticity agenda of the BHL or that of the 'Tory women's tradition', which could not provide her with an opportunity to achieve her career goals. The article also explores how the Party handled challenges from independent right-wing activists, especially women, in a period when 'one-nation' Conservatism was dominant. It engages with recent debates about 'Conservative feminism' and argues that Crisp was also an important figure because she kept alive the model of the independent radical female Conservative, which would become the hallmark of Margaret Thatcher's politics a generation later.

*30452733*
 30452733

The 'Rainbow Alliance' or the Focus Group? Sexuality and Race in the Labour Party's Electoral Strategy, 1985-7.

20 Century Br Hist 2019; ():

In the 1980s, Labour struggled to respond to a hostile political context during a protracted period of opposition. Diverse figures claimed that the Left was suffering from a structural decline in a supposed 'traditional working class' voting base: contentions which only became more influential after the 1983 electoral catastrophe. Competing solutions were proffered-including building a 'rainbow alliance' informed by equalities politics, or appealing to a southern 'new working class'. The latter interpretation gained greater influence on Neil Kinnock's leadership. To fully understand why one triumphed over the other in the evolving strategy of the Labour Party, we should in part trace discourses, including contemporary 'loony Left' scandals. However, we must also recognize the importance of 'epistemological practice', which was crucial in shaping how political actors acquired knowledge and forged interpretations of the electorate. Focusing on the evolution of the epistemological practice of Kinnock's leadership team-in particular, their increasing reliance on qualitative opinion research techniques like focus groups to supplement quantitative attitudinal polling-helps explain why they became convinced that recent controversies involving race and sexuality were having acutely negative consequences for Labour nationally. This furnishes us with a deeper understanding of the relationship between grassroots and national Left-wing politics in the 1980s. It also illuminates Labour's cautious approach to equalities politics into the 1990s.

*31280311*
 31280311

'Race', Black Majority Churches, and the Rise of Ecumenical Multiculturalism in the 1970s.

20 Century Br Hist 2019; ():

At the beginning of the 1970s, relations between the historic British churches and the new black-led churches were usually non-existent or marked by prejudices or ambivalences. This article examines the emergence, development, and significance of a cross-cultural ecumenical dialogue sponsored by the British Council of Churches. It places this in a context of both growing white liberal interest in the 'multi-racial' society and the increasing public assertiveness of collective black Christian consciousness. In doing so, it contributes to our understandings of religious change in the twentieth century: both in terms of perceptions of 'secularization' and the complex relationship between Christianity and race relations in the decades after Windrush.

*31270540*
 31270540

Counterculture, Local Authorities and British Christianity at the Windsor and Watchfield Free Festivals (1972-5).

20 Century Br Hist 2019; ():

Four free pop festivals, held in Windsor and Watchfield in 1972-75, attracted significant public attention. This article discusses the aims and ideals of the festivalgoers, the confused reactions of the authorities, the ambivalence of the Anglican Church and the hostility of some conservative groups. We argue that the free festivals mark an important stage in the constitution of the counterculture and that they created a model which later pop festivals (in particular Glastonbury) attempt to emulate. We show that themes relating to a revival of the pilgrimage experience became important markers of this new type of event, shifting the emphasis from political protest to a memorialized and performative activism.

*30657967*
 30657967

First Aid and Voluntarism in England, 1945-85.

20 Century Br Hist 2019; ():

First aid was the focus of growing voluntary activity in the post-war decades. Despite the advent of the National Health Service in 1948, increased numbers of people volunteered to learn, teach, and administer first aid as concern about health and safety infiltrated new activities and arenas. In this article we use the example of the Voluntary Aid Societies (VAS, focusing in particular on St John Ambulance) to highlight continuities and change in the relationship between state and voluntary sector in health and welfare provision during the four decades after 1945. Though the state assumed vastly expanded health and welfare responsibilities after the war, the continuing vitality of the VAS suggests cultural continuities that the post-war welfare state did not eradicate. The article therefore builds on the insights of historians who argue that volunteering remained a vital component of British society across the later twentieth century, and that the state and voluntary sector were not mutually exclusive.

*30715547*
 30715547

The Limits of Power: Wind Energy, Orkney, and the Post-war British State.

20 Century Br Hist 2019; ():

This article identifies the environmental components of the limits of industrial nationalization between 1945 and 1956, and with it the spatial dimensions of state power, through a case study of wind power experiments on the Orkney islands. Technocratic and socialist principles drove efforts to supply electricity to all corners of the nation, but material and environmental factors limited success, especially in remote regions. The article considers the materiality of islandness and its effects on the application of national-scale energy policy and emergence of 'alternative' energy solutions, in light of James C. Scott's theory of high modernism as an ideology which emanated from centres of power to rural peripheries. It argues that an environmental lens produces new thinking on the spatial constructions of state in post-war Britain that recognizes the influence of geographical edges as materially and imaginatively capable of disrupting a narrative of one-way power emanating from the centre. Wind joins other natural forces able to exert agency in narratives of technological development and modernism, which augment our understanding of energy, nature, and nation.

*31377787*
 31377787

The Ben Pimlott Memorial Lecture 2017: The Geopolitical Is Personal: India, Britain, and American Foreign Correspondents in the 1930s and 1940s.

20 Century Br Hist 2018; 29 (3): 388-410

This lecture explores the shared terrain between the new international history and the history of emotions. In the summer and fall of 1942, American foreign correspondents played a key role in sparking a furore over British rule in India. Drawing on their own first-hand reporting from India, they depicted the British Empire as retrograde and abusive, a dangerous, destabilizing force and a threat to the post-war peace. Diagnosing what it called 'a new landslide of anti-British feeling', the British Ministry of Information spearheaded the formation of high-level, interdepartmental, secret committee charged with the task of figuring out how to reconcile Americans to the British Empire. What they found was that the job itself was impossible: a significant proportion of Americans 'whose views, they concluded, were driven in large measure by emotion' would not under any circumstances soften their opinions about the British Empire.

*29939371*
 29939371

TCBH Duncan Tanner Essay Prize Winner 2017: The 'Progress of a Slogan': Youth, Culture, and the Shaping of Everyday Political Languages in Late 1940s Britain.

20 Century Br Hist 2018; 29 (3): 435-458

In 1948, worried that young people would take full employment and the welfare state for granted, the Labour Party trialled a new slogan: 'Ask your Dad'. This slogan encouraged the young to learn about the hardships which their parents had experienced in the inter-war years, largely under Conservative governments. Using archived interviews and letters sent to the press, this article provides the first study of the popular reception of this slogan. Most people had not heard of this slogan, and most of those who had heard of the phrase showed no knowledge that it was associated with politics, turning instead to popular culture. Those who understood the slogan were not the passive conduits of their party's message; often, they reworked political ideas to fit their own memories. Because repeating slogans was associated with a lack of political independence, not listening to party politics could conceal an intense interest in creating political change-an attitude which was, apparently, pronounced amongst the young. This article uses these responses to suggest how political language was as much produced by ordinary people's memories and daily discussion, as it was something drawn from professional campaigners.

*29672746*
 29672746

The 'Conchie Corps': Conflict, Compromise and Conscientious Objection in the British Army, 1940-1945.

20 Century Br Hist 2018; 29 (3): 411-434

*29584901*
 29584901

'The Lights of the Electric Octopus Have Been Switched Off': Visual and Political Culture in Edwardian London.

20 Century Br Hist 2018; 29 (3): 331-356

This article reconstructs the visual culture of politics in Edwardian London through a study of the 1907 London County Council election. It moves beyond the memorable account given in Graham Wallas's Human Nature in Politics to examine the actors, especially associations and newspapers, that participated in the election. Drawing upon newspapers, election addresses, cartoon, leaflets, and posters, the article argues that Edwardian London was a prime site in the application of new media for political communication. It shows, however, that new modes of communication could co-exist with, and intensify, established forms of public politics. It reveals a highly knowing visual culture of politics through which issues of authenticity and identity were contested, and recasts understanding of a controversial and critical election.

*29244188*
 29244188

Commercial Heritage as Democratic Action: Historicizing the 'Save the Market' Campaigns in Bradford and Chesterfield, 1969-76.

20 Century Br Hist 2018; 29 (3): 459-484

This article argues that the traditional retail market-a ubiquitous commercial feature of British towns and cities-produced a particular strand of heritage politics in late 1960s and early 1970s Britain. In recovering the activists involved in two campaigns to 'save the market' from redevelopment-one unsuccessful campaign in Bradford and one successful campaign in Chesterfield-I make the case for thinking through local urban heritage movements in comparative terms, focusing on how place-based citizenship collided with a nascent, national 'anti-development' mood in the early 1970s. The campaigns in Bradford and Chesterfield defended the transhistorical 'publicness' of the retail market-its spatial centrality, its collective ownership, and its relief of town or city rates-as a critique of contemporary, undemocratic privatization of communal space. Combining the archives of civic amenity, community action, and heritage societies with subjective attitudes towards preservation and redevelopment found in local 'letters to the editor' pages, this article reads the market as one physical nexus where local 'politics' and 'publics' collided and permutated in early 1970s provincial Britain. This focus on the lived heritage of socio-economic place has bearing on public history, the history of urban social movements, and architecture and planning historiography.

*29237077*
 29237077

Seance Sitters, Ghost Hunters, Spiritualists, and Theosophists: Esoteric Belief and Practice in the British Parliamentary Labour Party, c1929-51.

20 Century Br Hist 2018; 29 (3): 357-387

This article explores esoteric identities and cultures in the British Parliamentary Labour Party c1929-51. The historiography of the Labour Party has tended to overemphasize the one-dimensional nature of ideological affiliation and identity amongst Labour Members of Parliament in this period along the lines of a rather simplistic left/right dichotomy. Moreover, some historians have suggested that after 1918 particular socialist traditions and currents had become marginalized or dissolved once the party had developed a clearly defined constitution and the experience of political power. The argument presented here is that a range of esoteric identities remained a feature of labour culture through to the general election of 1951 and beyond. Three currents highlight the complexity and fluidity of specific strands of labour/socialist identity; in particular, spiritualism, theosophy and belief in the supernormal and the fantastic. Spiritualism and esotericism attracted a range of Labour MPs and shaped their reaction to contemporary political problems and the purpose and direction of working-class politics. An examination of such individuals and beliefs raises some new questions and challenges existing assumptions relating to labour identities in mid-twentieth century Britain. Socialist spiritualists, ghost hunters, and theosophists viewed political identity, mobilization and practice as an activity that drew as much on the personal, the spiritual and 'other-worldly' as it did on the economic, social and material basis of society.

*29077961*
 29077961

Corrigendum.

20 Century Br Hist 2018; ():

*30295896*
 30295896

Family Politics: Campaigning for Child Benefits in the 1980s.

20 Century Br Hist 2018; ():

Child benefit was seen by some to encourage the sort of welfare dependency that the moralistic individualism of Thatcherism opposed. Yet, surprisingly, the benefit survived the Thatcher years. Its survival reveals the conundrum the Conservative party have had regarding benefits for the family and family policy more broadly. Neo-liberals were supportive of the family as a vehicle for reinforcing Conservative values. Yet, the late 1970s and 1980s were periods of social change where the traditional family of the Conservative imagination was breaking down and consequently 'family policy' became a key political theme. By emphasizing the utility of child benefit as being fair to families, rather than its role in poverty alleviation, the Child Poverty Action Group (CPAG) was able to draw on this increased concern. As a result, their campaigns to save child benefit profited from increased support from across Conservatism. In tracing the development of CPAG's campaign, this article will demonstrate the cautiousness of Conservatives, even in the neo-liberal era, to changing some aspects of social policy. It will also highlight the challenge changing family patterns posed to the male breadwinner model that had long been embedded within the welfare policy prescriptions of both main parties.

*30418661*
 30418661

On Tour with the Prince: Monarchy, Imperial Politics and Publicity in the Prince of Wales's Dominion Tours 1919-20.

20 Century Br Hist 2018; 29 (1): 25-57

The stage managers of ritual and the media transformed the British monarchy in the late-nineteenth and early-twentieth century, consolidating its image as splendid and popular and also as more accessible and quasi-democratic. Historians have emphasized that these processes of modernization largely began in Britain. This article locates the origins of democratized royal ritual in the white dominions, especially after 1918. Canada, Australia and New Zealand were political and cultural laboratories where royal advisors and British and dominion politicians launched experiments in the practice of progressive empire and innovatory styles of informal ceremonial, which had a long-term impact on imperial and later Commonwealth relations. Focusing on the Prince of Wales's early dominion tours, the article argues that though royal diplomacy followed earlier itineraries in efforts to consolidate the racialized British world, it also threw up new and unintended consequences. These registered the rapidly changing international order after the collapse of the European monarchies, together with the demands of the prince's own modernist personality. Faced with republican and socialist opposition in Australia and Canada, the touring prince was drawn into competing forms of nationalism, as dominion politicians and journalists embraced him as representing domestic aspirations for self-government and cultural recognition. It is argued that modern royalty personified by the Prince of Wales problematizes the history of twentieth-century public reputations defined by the culture of celebrity. The British monarchy was forced to confront both the constitutional claims of empire and the politics of dominion nationalism, as well as the pressures of international publicity.

*29481684*
 29481684

International Institutions and Domestic Reform: Equal Pay and British Membership in the European Economic Community.

20 Century Br Hist 2018; 29 (1): 104-128

Despite having been overlooked in the standard histories of the UK and the European Community, gender politics and gender policies played a significant role in Britain's applications for membership in the EEC in the 1960s. Joining the European Community required that Britain comply with Article 119 on equal pay for equal work. A combination of domestic feminist and labour movement activism, the commitment of unions and parties, and the internationalization of formal commitments to women's rights constituted internal and external pressures for the passage of an Equal Pay Act in 1970. The article argues that the formal legislative commitment to gender pay equality, changing public attitudes towards women's employment, and European membership impacted further domestic social policy reform and slowly began to shift government attitudes towards gender equality.

*29481683*
 29481683

Reflections on 'British Studies in a Broken World', July 2017.

20 Century Br Hist 2018; 29 (1): 156-160

*29481682*
 29481682

Liberal Party Politics, the South African War, and the Rhetoric of Imperial Governance.

20 Century Br Hist 2018; 29 (1): 1-24

This article examines the imperial rhetoric of the Liberal Party during the South African War of 1899-1902, charting its use and development across five key controversies spanning the course of the conflict. Moving beyond traditional interpretations of the Liberal split as the product of competing visions of Empire and approaches to imperialism, this article argues for the need to recognize also the continuities within the imperial rhetoric of fin-de-siecle British Liberalism. Building on recent studies of political languages, it identifies how Liberal speakers from across the party operated within a rhetorical framework that emphasized three ideals of imperial governance: good government, self-government, and pluralism. In doing so, this article seeks to advance our understanding of the South African War as an episode in British party politics, demonstrating the complexity and nuance of the Liberal Party's response to the conflict. Furthermore, by undertaking an in-depth exploration of the rhetoric of imperial governance, this article highlights the Liberal response to the South African War as a case study for the reinvention and reiteration of both party and imperial languages in early twentieth-century Britain, with the potential to offer new insights into the political and imperial cultures of the period.

*29481681*
 29481681

Landlordism, Rent Regulation and the Labour Party in mid-twentieth century Britain, 1950-64.

20 Century Br Hist 2018; 29 (1): 79-103

This article examines the politics of private renting in 1950s and early 1960s Britain, through the radical approach taken by Labour Party towards private landlords. Through setting the radical aims of Labour in a mid-twentieth-century context of decrepit housing, rising rents and sluggish public housing programmes, Labour's rationale in arguing for the 'abolition' of the private landlord is more transparent. This article takes a chronological approach, investigating what actions Labour actors took, at local and national level, and what effect this had on the wider housing market. Part one takes a long view of Labour attitudes to the private rented sector. Part two explores the policy of 'municipalization'-the attempt to place rented homes under local authority control. Part three discusses the post-1962 policy shift to state-sponsored 'improvement' of private rented housing, prior to Labour's victory at the 1964 general election. Three key arguments are made: that Labour's radicalism hastened the collapse of the post-war private rented sector; that rental market weaknesses indicated the confused place of renting in the 'tenurial pattern'; and that the proposed 'abolition' of private landlords had a direct effect on slum clearance and the composition of British cities. The conclusion suggests that Labour's pursuit of the private landlord can shed light on the vast urban transformations of the post-war period. It invites greater attention to be paid to the effects that political ideas had on the composition of the twentieth-century British housing market.

*29481680*
 29481680

'A Tactical Manoeuvre to Apply Pressure': Race and the Role of Public Inquiries in the 1980 Bristol 'Riot'.

20 Century Br Hist 2018; 29 (1): 129-155

When violence erupted on the streets of England in 1981, it undoubtedly shocked the country in its scope and severity. However, such disorder had been foreshadowed when the St Pauls area of Bristol saw anti-police disturbances on 2 April 1980. This article focusses on the responses to this, from the local community and organizations as well as local and national government, which in the historiography has often been relegated to passing mentions prior to detailed discussion of the 1981 events. Utilizing recently released and understudied local records, it argues that appeals for a public inquiry from sections of the local community demonstrates the value awarded to them by this politically marginalized group, and the failings of other democratic forms of registering complaints. Public inquiries have long been a key component of the British constitutional system, allowing a unique public interaction with authorities-but it would take increased violence in Brixton the following year before establishment figures were sufficiently alarmed to grant one. This article argues that obtaining this government-endorsed response and an increased participation in the public discourse should be viewed as an aspect within a broader black civil rights movement, challenging claims that minorities played an underrepresented role in motivating advances. However, there was a clear division of attitudes towards public inquiries, demonstrating the moderate tactics utilized by local organizations and older generations, as opposed to more militant groups and the black youth who took to the streets.

*29481679*
 29481679

Working-Class Ideas and Experiences of Sexuality in Twentieth-Century Britain: Regionalism as a Category of Analysis.

20 Century Br Hist 2018; 29 (1): 58-78

This article will explore region as a category of analysis for understanding gender, sexual cultures, and the expression of same-sex desire. In unpicking the notion of regional difference in both its tangible and intangible forms, it outlines the corresponding impact on how sexual cultures developed and were experienced in twentieth-century Britain. By recognizing that the area in which an individual lived could have as much impact on their sense of self and their sexual experiences as issues of race, gender, and class, a new and fruitful avenue of interpretation is opened up for the history of sexuality and twentieth-century British history more broadly. Such a methodology has the potential to add a new dimension to all histories of non-state-sanctioned sexual experience such as illegitimacy, premarital sex, extramarital affairs, and prostitution. In using regional case studies and interrogating ideas of sexual taboo, this article offers a unique interpretation of sexual experience that destabilizes current London-centric narratives and offers a more democratic and nuanced history of sex.

*29481678*
 29481678

Community Business in Scotland: An Alternative Vision of 'Enterprise Culture', 1979-97.

20 Century Br Hist 2018; ():

The force and coherency with which Margaret Thatcher and her inner circle outlined their vision for 'enterprise culture', like so many aspects of Thatcherism, have masked the complexity of its origins and the histories of alternative responses. This article provides a history of an alternative vision for enterprise culture by examining the community business movement in Scotland, the largest experiment of its kind in the UK in the 1980s and a forerunner of social enterprise. Working across Scotland, but with a hub of activity in the Strathclyde region, practitioners worked with local people to find ways to develop their neighbourhood economy while improving their environment, creating jobs, and developing services needed in their area. This article outlines the origins of the movement, the shared values of its founding members, and how their training in community development informed the community business model. It analyses how practitioners put their ideas into practice and the reasons behind the fragmentation of the movement in the 1990s. It argues that although at face value the concept of community business may appear to chime with the dominant political rhetoric of Thatcher's 'enterprise culture', the history of the movement provides a signpost to an alternative, if unrealised, vision for Scotland's recovery from social and economic depression. Where previous historical research has focused on the political consequences of Thatcher's policies in Scotland, this research connects this discussion to the transformation of Scotland's civic society in the wake of deindustrialization.

*29893937*
 29893937

Exhibition Review Punk's 40th Anniversary-An Itchy Sort of Heritage.

20 Century Br Hist 2018; 29 (2): 309-317

*29800337*
 29800337

'Free and Equal Partners in Your Commonwealth': The Atlantic Charter and Anticolonial Delegations to London, 1941-3.

20 Century Br Hist 2018; 29 (2): 259-283

This article examines the efforts of two anticolonial politicians from the British Empire who used official visits to London and the rhetoric of the Atlantic Charter (14 August 1941) to advance their political careers and self-government for their territories: Burma's U Saw in 1941, and Nigeria's Nnamdi Azikiwe in 1943. Rather than a repetition of the 'Wilsonian moment', these campaigns show how anticolonial forces long active across the Empire took advantage of the opening offered by the Atlantic Charter to make claims on the British government in its wartime weakness. Both U Saw and Azikiwe had been involved in anticolonial politics long before the Charter, but its appearance provided an opportunity to advance their position vis-a-vis political competitors as well as to win concessions from the imperial state. Although the two leaders had different immediate objectives, they both used the prestige of official visits to London and the ambiguous universality of the Charter's language in pursuit of their aims. Their ability to do so attests to the power of anticolonial movements by the early 1940s, and points to alternative paths which the Empire might have followed.

*29800336*
 29800336

'Cinderella of the Education System': Margaret Thatcher's Plan for Nursery Expansion in 1970s Britain.

20 Century Br Hist 2018; 29 (2): 284-308

The Department of Education and Science, led by then Secretary of State Margaret Thatcher, published a White Paper in December 1972 calling for a dramatic expansion of public nursery education, so that it might be available within a decade to all families with 3- and 4-year-old children who chose to utilize it. While this failed policy is seldom remembered today, and Thatcher's efforts to promote the care and education of young children are not considered part of her considerable legacy, the White Paper's policy propositions challenge understandings about the formation and consistency of both Britain's child care policy and 'Thatcherism'. During this period, Thatcher believed that extending the frontiers of the state was appropriate to promote child welfare during the crucial first years of life. She conceived of nursery education as serving a developmental and educational purpose for all children, quite separate from welfare provisions for poor families or work supports for women. It is this crucial, albeit arbitrary, distinction which explains how nursery education was envisaged as an exception to her advocacy of cutting welfare spending.

*29800335*
 29800335

Housing the Citizen-Consumer in Post-war Britain: The Parker Morris Report, Affluence and the Even Briefer Life of Social Democracy.

20 Century Br Hist 2018; 29 (2): 225-258

This article examines debates about the design and provision of post-war housing within the papers and report of the Parker Morris committee. It does so to show how the models of citizens' rights and expectations which underpinned post-war welfare provision were transformed by mass affluence and the dynamic sphere of commercial consumption. Parker Morris's deliberations demonstrate that, as early as the 1950s, the citizen-subject was reimagined as a consuming individual, with requirements based on their expressive needs and consuming desires, and that this had far-reaching consequences for social democratic systems of universal welfare provision. The introduction of consumerist imperatives into publicly defined models of citizens' needs enhanced the political and cultural authority of the commercial domain, prompted a heightened role for commercial experts and market logics within public governance, and served to devalue socialized forms of provision in favour of consumer choice in the private market. The article thus engages with the growing scholarship on the politics of mass consumerism by showing how the material and emotional comforts of post-war affluence came to be constructed as critical to social democratic citizenship and selfhood. Situating this uneasy entanglement of social democratic rights with consumer satisfaction as part of a wider trajectory of political change, the piece suggests that Parker Morris marks an early but significant moment in the transition from post-war welfarism and social democracy to the consumer- and market-oriented forms of governance which came to dominate British politics and society in the latter part of the twentieth century.

*29800334*
 29800334

Dad 'never said much' but... Young Men and Great War Veterans in Day-to-Day-Life in Interwar Britain.

20 Century Br Hist 2018; 29 (2): 199-224

This article explores whether, how, and what young men in interwar Britain heard about the Great War from its veterans. Oral histories are used to enable the first detailed examination of the hitherto largely unexplored topic of the intergenerational transmission of representations of the Great War in interwar Britain. It shows that although many veterans were reticent about their war experiences, young men heard about Great War experiences from veterans more frequently than has previously been acknowledged. What they heard was heterogeneous, like representations in popular culture, but tended to emphasize positive and rewarding elements of wartime service rather than disillusion. While veterans' narratives could be fleeting and ephemeral, this examination of their character shows they should be considered an important component of the wider body of representations of the Great War in interwar popular culture through which young men might 'know' about the Great War. As well as examining what young men heard, consideration is given to alternative ways that young men learned about familial service, and to what triggered veterans' narratives and why some remained silent. Reasons for the trope of the silent veteran are suggested, and its strength in contemporary popular memory is illustrated in discussion of the 'discomposure' it could cause some interviewees.

*29267984*
 29267984

British Widows of the South African War and the Origins of War Widows' Pensions.

20 Century Br Hist 2018; 29 (2): 169-198

The South African War of 1899-1902 cost the lives of 22,000 British and colonial soldiers and created almost 5,000 British war widows. It was in this context that the first state pensions for the widows of rank and file soldiers were introduced in 1901. Triggered by unexpectedly high casualty rates and widespread dissatisfaction with charitable provision, the introduction of state pensions also reflected changing public attitudes towards soldiers and their dependants in the context of an imperial war. Dismissed in the historiography as insignificant because of its low rates and restrictive eligibility clauses, the 1901 scheme in fact delivered pensions to the majority of war widows and made the Edwardian state their most important source of financial support. This article, after discussing the social and political context in which widows' pensions were developed, analyses the economics of the scheme and how key eligibility rules were formulated, before investigating significant changes in the scheme to 1920, the point at which Boer War widows were finally granted full maintenance. Strongly influenced by the practices of Victorian armed forces charities and by contemporary ideologies of gender and class, the South African War pension regulations created precedents which would continue to shape pensions for military widows to the end of the twentieth century.

*29036498*
 29036498

Harold Wilson's 'Lavender List' Scandal and the Shifting Moral Economy of Honour.

20 Century Br Hist 2018; ():

Harold Wilson's resignation honours list of 1976 was almost universally condemned by politicians, civil servants, and the press because it contained a number of high honours to individuals who were seen as scandalously lacking in merit. Unknown officials leaked details to the press and used multiple internal mechanisms, including the Political Honours Scrutiny Committee, to try to block the list, but Wilson pushed it through. This article examines the controversy around the list in terms of how the various parties involved used ideas about scandal, honour, and merit to discredit Wilson, his secretary Marcia Falkender and the honours nominees. It shows that the scandal was shaped by three double standards: one of the main grounds for the disqualification of certain appointees was that they had not donated to Labour; in spite of their traditional prioritization of secrecy around honours, the civil service failed to uphold this tradition when it suited them not to; and critics of the list attacked Falkender's influence over the list even as they defended their own traditional place in determining who was selected for honours. The scandal also shows how the British establishment and British society was struggling to deal with broader questions about the value of exactly the kinds of service that Wilson honoured in the list, namely, capitalist entrepreneurship, popular culture, and contributions from traditional outsiders. While the list was universally condemned in 1976, these forms of service were to become more valued in honours lists from the 1990s.

*30590856*
 30590856

Multiple Deprivation, the Inner City, and the Fracturing of the Welfare State: Glasgow, c. 1968-78.

20 Century Br Hist 2018; 29 (4): 605-624

From 1968, the central government established a series of area-based initiatives that operated on the basis of 'positive discrimination' towards the social needs of local residents. Over the course of the next 10 years, this area-based positive discrimination became an increasingly important part of social policy in Britain. This article uses Glasgow as a case study to show, first, how both the local and the central government attempted to define the problem of 'multiple deprivation' in the 1970s. Second, it shows how social studies were used to locate multiply deprived communities within urban areas, thereby feeding into the identification of the 'inner city' as a policy problem. Finally, this article shows how evidence of the concentration of multiple deprivation and the adoption of area-based strategies contributed to the fracturing of the welfare state, eroding the universalist principles upon which post-war social policy had been based.

*29982817*
 29982817

Aspiration, Agency, and the Production of New Selves in a Scottish New Town, c.1947-c.2016.

20 Century Br Hist 2018; 29 (4): 576-604

Narratives of deindustrialization, urban decline and failing public housing and the negative outcomes associated with these processes dominate accounts of post-war Scotland, bolstering the interpretation of Scottish exceptionalism in a British context. Within these accounts working people appear as victims of powerful and long-term external forces suffering sustained and ongoing deleterious vulnerabilities in terms of employment, health, and housing. This article challenges this picture by focusing on the first Scottish new town which made space for working people's aspiration and new models of the self manifested in new lifestyles and social relations. Drawing on archival data and oral history interviews, we identify how elective relocation fostered and enabled new forms of identity predicated upon new housing, new social relations, and lifestyle opportunities focused on the family and home and elective social networks no longer determined by traditional class and gender expectations. These findings permit an intervention in the historical debates on post-war housing and social change which go beyond the materialistic experience to deeper and affective dimensions of the new town self.

*29860425*
 29860425

'Irish & Roman Catholic Which Upsets All the People Here': Michael McDonnell and British Colonial Justice in Mandatory Palestine, 1927-1936.

20 Century Br Hist 2018; 29 (4): 497-521

In 1927 Michael McDonnell, a diasporic Irish Catholic, was appointed Mandatory Palestine's Chief Justice, being directed to institute firm British-style legal-judicial foundations for future self-governance. This entailed common, equal status for Arab and Jewish Palestinians, implicitly de-privileging the Jewish National Home. McDonnell was resisted in this by the British Mandate's Anglo-Jewish, pro-Zionist Attorney General, Norman Bentwich. McDonnell prevailed but only at the cost of being characterized lastingly as a pro-Arab, Catholic anti-Semite. McDonnell's continuing defence of a supreme, independent judiciary antagonized the Palestine Executive of High Commissioner Arthur Wauchope, who tried to co-opt rather than subordinate Zionist interests. Consequent frictions culminated in 1936 with McDonnell adjudicating against supra-legal British repression of Palestine's great Arab rebellion. For this he was dismissed and ostracized, subsequently publishing critiques of British policy in fringe right-wing organs. Yet McDonnell professed explicitly non-racist views, reflecting a liberal-minded, constitutional Irish nationalist equation of Palestine with Ireland, seeing comparable settler-colonial abuses and native distress as remediable only by transcendentally impartial justice. Britain reneging on these principles led McDonnell, like those Irish imperial servants noted in India, to identify with colonial subjects against colonialism. His case is one of empire as a system of domination being challenged from within, although his removal foreshadowed emerging imperial counter-insurgency's tendency not only to repress subject populations but deny civil-progressive alternatives for managing post-colonial transition.

*29069506*
 29069506

Reconsidering 'Set the People Free': Neoliberalism and Freedom Rhetoric in Churchill's Conservative Party.

20 Century Br Hist 2018; 29 (4): 522-546

It is often assumed that 'Hayekian' or 'neoliberal' influences lay behind Conservative attacks on socialism in 1945 and subsequent calls to 'set the people free' in 1950 and 1951. This assumption has had consequences for our understanding of late-1940s Conservatism and for wider interpretations of post-war politics. Heeding recent calls to reconnect the inter-war and post-war parties and to pay closer attention to how opponents and contexts generate arguments, this article revisits senior Conservatives' rhetoric between 1945 and 1951 to break the link between neoliberal influence and freedom rhetoric. First, it argues that the rhetoric of 1945 was derived from a distinctly Conservative lineage of interwar argument and reflected strategies developed before the publication of F. A. Hayek's 'The Road to Serfdom'. Second, it demonstrates that senior Conservatives' emancipatory rhetoric in opposition after 1945 was neither a simple continuation of these themes nor primarily a response to the public's growing antipathy towards rationing and controls. Rather, such rhetoric was a complex response to Britain's immediate economic difficulties and the political challenges presented by austerity. Finally, the article sheds new light on the strategy that governed the party's campaigns in 1950 and 1951. Churchill and others' calls to 'set the people free' stemmed from a belief that the rhetorical opportunity lay in reconciling liberty with security. In that sense, the leadership had moved beyond begrudging compromises with the 'Attleean settlement' and was instead attempting to define a new identity within the parameters of the welfare state.

*29036716*
 29036716

Justifying British Advertising in War and Austerity, 1939-51.

20 Century Br Hist 2017; 28 (3): 390-413

Drawing together institutional papers, the trade- and national-press, and Mass-Observation documents, this article examines the changing ways that the Advertising Association justified commercial advertising from 1939 to 1951. It argues that the ability to repeatedly re-conceptualize the social and economic purposes of advertising was central to the industry's survival and revival during the years of war and austerity. This matters because the survival and revival of commercial advertising helps to explain the composition of the post-war mixed economy and the emergence of a consumer culture that became the 'golden age' of capitalism. While commercial advertising's role in supporting periods of affluence is well documented, much less is known about its relationship with war and austerity. This omission is problematic. Advertising was only able to shape the 1950s and 1960s economy because its corporate structures remained intact during the 1940s, as the industry withstood the challenges of wartime and the difficulties presented under Attlee's government. Recognizing the deliberate attempts of advertising people to promote a role for commercial advertising invites us to reconsider the inevitability of post-war affluence, while offering fresh insight into the debate around consumer education, freedom of choice, and the centrality of advertising and communication in democratic society: issues central to the society Britain was, and hoped to become.

*28922820*
 28922820

Archive Review: The Black Cultural Archives, Brixton.

20 Century Br Hist 2017; 28 (3): 465-473

*28922819*
 28922819

'If I Ever Have to Go to Prison, I Hope it's a Russian Prison': British Labour, Social Democracy and Soviet Communism, 1919-25.

20 Century Br Hist 2017; 28 (3): 344-366

Through the inter-war period, the USSR became an example of 'socialism in action' that the British labour movement could both look towards and define itself against. British visitors both criticized and acclaimed aspects of the new Soviet state between 1919 and 1925, but a consistently exceptional finding was the Soviet prison. Analysing the visits and reports of British guests to Soviet prisons, the aims of this article are threefold. Using new material from the Russian archives, it demonstrates the development of an intense admiration for, and often a desire to replicate, the Soviet penal system on the part of Labour members, future Communists, and even Liberals who visited Soviet Russia. It also critically examines why, despite such admiration, the effect of Soviet penal ideas failed to significantly influence Labour Party policy in this area. Finally, placing these views within a broader framework of the British labour movement's internal tussles over the competing notions of social democracy and communism, it is argued that a failure to affect policy should not proscribe reappraisals of these notions or the Soviet-Labour Party relationship, both of which were more complex than is currently permitted in the established historiography.

*28922818*
 28922818

Children, Class, and the Search for Security: Writing the Future in 1930s Britain.

20 Century Br Hist 2017; 28 (3): 367-389

This article is based on 269 essays written in 1937 by Middlesbrough schoolboys aged 12-16 years on the topic 'When I leave school', which were collected by the social research organization Mass Observation. The essays provide a counterpoint to social scientific surveys of ordinary people and allow us to work with the boys' own understandings of the world they inhabited. They offer an alternative lens on a period which, at least in relation to the industrial areas of Britain, is often characterized by poverty and unemployment. This representation is largely absent from the children's essays: instead, an overwhelming sense of possibility characterizes their writing, from their wildest fantasies to their most concrete plans. Most dreamt of lives that would be long, fulfilling, domesticated, and happy. This is not to say that they were oblivious to the world around them; indeed an emphasis on security and planning suggested an implicit awareness of material context. Nonetheless these boys expressed a marked determination that their lives would be better than those of their parents. As such, they embodied the educational and occupational aspirations that are more often seen as characteristic of post-war Britain. Their essays illustrate emergent and widely held expectations of social mobility and dreams of cradle-to-grave security in the years before the Second World War, articulated-as they were being lived-by a generation which would go on to elect the 1945 Labour government.

*28922817*
 28922817

'People Love Player's': Cigarette Advertising and the Teenage Consumer in Post-war Britain.

20 Century Br Hist 2017; 28 (3): 414-439

This article explores the background, creation and reception of a prominent cigarette advertising campaign from the early 1960s. The advertisements featured young couples falling in love as they shared Player's Medium cigarettes together. As such, the advertisements reflected the central place of the teenager within post-war British consumer culture. The campaign was built upon the insights of market research, particularly that carried out by Mark Abrams and his research organization Research Services Limited. Historians have played down the significance of Abrams's work, but it is argued here that the studies and reports Abrams produced rendered the teenage consumer knowable in a powerful way. Advertisers and manufacturers now had detailed knowledge about young people's consumption habits and their motivations. Such research helped the British tobacco industry formulate a controversial marketing strategy-the need to 'recruit' young people to the smoking habit-and the People Love Player's campaign was created with this in mind. The representations of love and gender included in the advertisements gave the campaign an emotional pull which was designed to resonate with young people. The advertisements were widely criticized and this drove the British tobacco industry to remove from its advertising appeals which might influence the young, such as love.

*28922816*
 28922816

Duncan Tanner Essay Prize 2016: Historical Pageants, Citizenship, and the Performance of Women's History before Second-Wave Feminism.

20 Century Br Hist 2017; 28 (3): 319-343

This article argues that the early twentieth-century craze for historical pageants provided an opportunity for women's groups to bring a nascent, accessible form of women's history into the lives of local communities across Britain. Mainstream historical pageants were organized across the country, depicting selected episodes from the past usually relating to the local area. However, more than 200 inter-war pageants staged by women's organizations, church groups, and a number of university colleges have not yet been studied. In these pageants, women imaginatively portrayed professional, religious, political, noble, and 'ordinary' women from across history. Prior to second-wave feminism, when scholars advanced the study of women within the academy, thousands of people had been invested in re-enacting women's history since the inter-war years. Emphasizing the bravery and public duties of women in the past, historical pageants provided a non-controversial format through which women's groups could effectively project their beliefs about the role they felt women should play as newly enfranchised citizens. These popular performances capture the dispersed, yet committed, dedication to encouraging women's social citizenship in the inter-war years, and a more pluralistic understanding of women's engagement with 'feminist' ideas in everyday life across Britain.

*28922815*
 28922815

The Consul and the Beatnik: The Establishment, Youth Culture and the Beginnings of the Hippy Trail (1966-8).

20 Century Br Hist 2017; 28 (3): 440-464

This paper analyses the attitudes expressed by consular and embassy officials to a new type of traveller they encountered in the mid-1960s. Their observations are contextualised within wider debates concerning 'youth' in the late 1950s and 1960s. Officials distinguished sharply between 'overlanders' (who could be tolerated or accommodated) and 'beatniks' whose behaviour was characterized as illegal and/or unacceptable. Smoking cannabis was identified as a key marker of beatnik behaviour. Officials' observations are contrasted with four accounts by new travellers from the period. The paper concludes with a proposal for an 'anti-nominian' approach to the study of youth cultures: researchers should be more sensitive to the constructed nature of the labels used to identify the various strands of youth identity.

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 28922814

Restoring Victory: Naval Heritage, Identity, and Memory in Interwar Britain.

20 Century Br Hist 2017; 28 (1): 57-82

In the decade following 1918, HMS Victory was restored as a memorial to the nation, empire, the Navy, and all the sailors who had lost their lives in the Great War. This piece of Britain's naval heritage became a focal point for Great War memory and a resource for narrating the Navy's place in post-war Britain. This article analyses the restoration campaign, focusing on its appeal work and the materials it produced, discourses surrounding the restoration and the use of Victory's oak to recover this ship's importance at the intersection between Britain and its Navy in the aftermath of the Great War, and the function that the Navy played in the construction of post-war memory and identity.

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 28922799

Kidnapping and a 'Confirmed Sodomite': An Intimate Enemy on the Northwest Frontier of India, 1915-1925.

20 Century Br Hist 2017; 28 (1): 29-56

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 28922797

Space, Emotions and the Everyday: The Affective Ecology of 1980s London.

20 Century Br Hist 2017; 28 (1): 110-142

This article explores the relationship between emotions, space and politics in 1980s London, using the Greater London Council, childcare, and racial harassment as particular foci. It brings together political history, the history of emotions, and geography to offer a new way of thinking about political culture, as well as contributing to the history of the 1980s. It is based upon archival sources.

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 28922796

A Lady 'in Proper Proportions'? Feminism, Lytton Strachey, and Florence Nightingale's Reputation, 1918-39.

20 Century Br Hist 2017; 28 (1): 1-28

Lytton Strachey's Eminent Victorians has long been regarded as a watershed in attitudes to Victorian culture, widely seen as having instigated a revolutionary backlash against the values and heroes of the Victorian era in England. Its impact, however, on the reputations of his four subjects-Thomas Arnold, General Gordon, Cardinal Manning and Florence Nightingale-has been subjected to surprisingly little scholarly attention. Drawing on the work of gender historians, this article reassesses Strachey's effect on the reputation of Nightingale, using biographies and contemporary reviews of Eminent Victorians. It argues that, far from 'debunking' the famous nurse as is generally assumed, Strachey in many ways enhanced her reputation and rendered her a plausible icon for English feminists of the 1920s and 1930s.

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 28922795

The Threshold of the State: Civil Defence, the Blackout and the Home in Second World War Britain.

20 Century Br Hist 2017; 28 (2): 186-208

This article reconsiders the way that the British state extended its control of the home during the Second World War, using the implementation of air raid precautions and the blackout as a lens through which to view the state's developing attitudes to domestic space. Presented here is not the familiar story of pitch-dark, dangerous streets or altered cityscapes of fear and destruction; instead, by examining personal testimony the article inverts traditional treatments of the blackout to look at the interior of dwellings, demonstrating how the realities of total warfare impinged upon the psychological elements that constituted the home. What emerges not only expands historical understandings of the wartime experience of civilians, it also shows civil defence measures as highly visible points on an often antagonistic trajectory of state interactions with citizens concerning the privacy and security of the dwelling in the modern city. The requirements of civil defence, I argue, were not merely the product of exceptional wartime circumstances, but symptomatic of long-standing attempts to open up dwellings to state scrutiny. These attempts had both a significant pre-war lineage and, crucially, implications beyond the end of the war in private homes and on social housing estates.

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 28922829

Telling Stories about Post-war Britain: Popular Individualism and the 'Crisis' of the 1970s.

20 Century Br Hist 2017; 28 (2): 268-304

This article argues that, by the 1970s, people in Britain were increasingly insistent about defining and claiming their individual rights, identities and perspectives. Using individual narratives and testimonies, we show that many were expressing desires for greater personal autonomy and self-determination. We suggest that this was an important trend across the post-war decades, and of particular importance to understanding the 1970s. This popular individualism was not the result of Thatcher; if anything, it was a cause of Thatcherism. But this individualism had multiple political and cultural valences; desires for greater individual self-determination, and anger with the 'establishment' for withholding it, did not lead inexorably to Thatcherism. There were, in fact, some sources for, and potential outlets for, popular individualism on the left-outlets that explicitly challenged class, gender and racial inequalities. With this, we suggest the possibility of a new meta-narrative of post-war Britain, cutting across the political narrative that organizes post-war British history into three periods: social democracy, 'crisis' and the triumph of 'neoliberalism'. The 1970s was a key moment in the spread of a popular, aspirational form of individualism in post-war Britain, and this development is critical to our understanding of the history of the post-war years.

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 28922828

Erratum.

20 Century Br Hist 2017; 28 (2): 318

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 28922827

The Burnley Dog War: The Politics of Dog-Walking and the Battle over Public Parks in Post-Industrial Britain.

20 Century Br Hist 2017; 28 (2): 239-267

This article investigates controversies surrounding dog walking and dog fouling in 1970s and early 1980s Britain, focusing on the microhistory of a series of events in a Lancashire mill town that became known as the 'Burnley Dog War.' A ban on dog walkers from Burnley's main public parks triggered a highly publicised seven-year struggle over access. On one level, the park ban served as a rallying cry for dog lovers across Britain, widening the dividing line between dog owners and dog haters. On another level, it constituted a struggle between antagonists over questions of belonging and exclusion in a town devastated by large-scale deindustrialisation. The dog war stimulated combatants to interrogate the nature and quality of their townscape and their sense of civic identity, the analysis of which allows scrutiny of the impact of deindustrialisation upon their sense of self and place. During the conflict, various aspects of the town's economic history, civic traditions, and landscapes, were alternately disavowed, recovered, rearticulated and contested in relation to its post-industrial present. As it will be shown, the Burnley dispute over dog walking and dog fouling serves as a lens for exploring post-industrial fractiousness along class lines.

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 28922826

Catholic Understandings of Female Sexuality in 1960s Britain.

20 Century Br Hist 2017; 28 (2): 209-238

Recent interpretations of religious change in modern Britain have stressed the importance of a sudden and abrupt 'sexual revolution' during the 1960s. The role the Churches played in bringing about their own demise remains a point of debate, particularly in the case of the Catholic Church. This article attempts to move beyond existing historical disputes over a 'religious crisis' and whether it was rooted in 'internal' causes (problems within the Church) or 'external', secular developments. It explores the way sexual knowledge was discussed and disseminated by Catholic authorities during this decade of perceived cultural transition, drawing on the previously unpublished papers of the Papal Commission for Birth Control 1963-5 and the training manuals of the Catholic Marriage Advisory Council (CMAC). These sources offer a unique insight into the often problematic task of reconciling Catholic thought with the discourses of 'sexual liberation'. While the central hierarchy's continued opposition to women's contraceptive autonomy has understandably dominated historical attention, the material presented here suggests that Catholic understandings of female sexuality were not universally at odds with the intellectual infrastructure of a 'sexual revolution'. On the question of female sexual pleasure, progressive Catholic authorities in both the Papal Commission and the CMAC made fervent efforts to engage with contemporary scientific modes of understanding. Perversely, this approach served to neglect certain aspects of corporeal and emotional experience, thereby limiting the case for meaningful doctrinal change.

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 28922825

In Quest of the Antique: The Bazaar, Exchange and Mart and the Democratization of Collecting, 1926-42.

20 Century Br Hist 2017; 28 (2): 159-185

The popularization of antique collecting is typically located in the second half of the twentieth century, with the rise of 'retrochic' and the emergence of new markets and online trading websites for anonymously exchanging second-hand goods. Close study of the printed literature connected with the inter-war second-hand trade, however, challenges conventional chronologies in the history of consumer culture, and can provide a new perspective on the role of collecting in British social and cultural life. This article examines the period, after the late 1920s, during which The Bazaar, Exchange and Mart reinvented itself as a forum for antique and decorative art enthusiasts. It argues that, in speaking to and publishing contributions from so-called 'small collectors', this 'Popular Weekly for Collectors and Connoisseurs' helped shape a modern and democratic culture of art appreciation in which ordinary people were actively invited to participate. The private correspondence archive of a Buckinghamshire subscriber who used the Exchange and Mart to sell his collection of 'Egyptian, Greek, and Roman Antiquities' to readers across the country during the 1930s reveals an intimate portrait of the desires, fantasies, and pleasures associated with the popular experience of collecting in pre-war Britain.

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 28922824

Tutankhamen, Egyptomania, and Temporal Enchantment in Interwar Britain.

20 Century Br Hist 2017; 28 (4): 516-542

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The Complex Holiday Calendar of 1902: Responses to the Coronation of Edward VII and the Growth of Edwardian Event Fatigue.

20 Century Br Hist 2017; 28 (4): 489-515

The coronation of Edward VII and events to mark the end of the South African War led to a series of public ceremonies and events in the United Kingdom that had a profound effect on attitudes linked to national occasions and public holidays. This article explores the circumstances surrounding the numerous local and national holidays of 1902. It considers the decision-making process linked to the declaration of a coronation double-bank holiday, which demonstrated the inadequacy of contemporary legislation. The public response to the postponement of the coronation, due to the king's contraction of appendicitis, led to a period of 'event fatigue' in response to further ceremonial events. This showcased how much the British people guarded their right to holiday time and how the coronation had become more synonymous with celebration than with royal ceremony. It also showcased the degree to which the British people had been politicized and were ready to defend what they saw as their rights, in rejection of deference and traditional authority.

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 29186628

Rethinking Folk Culture in Twentieth-Century Britain.

20 Century Br Hist 2017; 28 (4): 543-569

Research on folk culture in twentieth-century Britain has focused on elite and transgressive political episodes, but these were not its mainstream manifestations. This article re-evaluates the place of folk culture in twentieth-century Britain in the context of museums. It argues that in the modern heritage landscape folk culture was in an active dialogue with the modern democracy. This story begins with the vexed, and ultimately failed, campaign for a national English folk museum and is traced through the concurrent successes of local, regional, and Celtic 'first wave' folk museums across Britain from the 1920s to the 1960s. The educational activities of these museums are explored as emblematic of a 'conservative modernity', which gave opportunities to women but also restricted their capacity to do intellectual work. By the 1970s, a 'second wave' folk museology is identified, revealing how forms of folk culture successfully accommodated the rapid social change of the later twentieth century, particularly in deindustrializing regions. From this new, museums' perspective, folk culture appears far less marginal to twentieth-century British society. In museums folk culture interacted with mainstream concerns about education, regionalism, and commercialization.

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