{"title":"Medically unexplained symptoms","authors":"M. Sharpe","doi":"10.1093/med/9780198746690.003.0623","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0623","url":null,"abstract":"Physical symptoms are not always associated with disease. In secondary medical care as many as a third of patients present with symptoms unexplained by disease. Such ‘medically unexplained symptoms’ pose a challenge for clinical services that focus on identifying and treating disease. The principles of effective management are to: (a) avoid overinvestigation and giving speculative treatment for disease; (b) take a positive approach with the patient, accepting the reality of the symptoms while explaining clearly that they do not indicate disease; (c) identify and provide treatment for associated depression and anxiety disorders; (d) refer for psychiatric or psychological treatment when required. Complex cases with multiple persistent medically unexplained symptoms are at particular risk of iatrogenic harm and require active multidisciplinary management. Psychological treatments such as cognitive behaviour therapy may be effective.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"35 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116488412","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Gastrointestinal bleeding","authors":"V. Brown, T. Rockall","doi":"10.1093/med/9780198746690.003.0291","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0291","url":null,"abstract":"Gastrointestinal bleeding (GIB) is a common emergency, which can be subdivided into upper and lower, and acute or chronic, with acute upper GIB further subdivided into variceal (11%) and nonvariceal (89%) bleeding. Risk stratification in acute upper GIB can be performed using simple clinical and endoscopic criteria that can be used to estimate the risk of mortality, but there are no validated systems for use in acute lower GIB. The immediate management of the hypovolaemic patient is first directed towards resuscitation and then to identification of the site and cause of bleeding. Most patients will stop bleeding spontaneously and should then be investigated with either upper gastrointestinal endoscopy or colonoscopy as appropriate. Patients with acute ongoing upper GIB require urgent investigation by oesophagogastroduodenoscopy with a view to applying endoscopic haemostatic therapy, which is efficacious in up to 95% of patients. High-dose proton pump inhibitor treatment should be given following successful endoscopic therapy to patients with major ulcer bleeding. If these techniques fail to arrest bleeding, then either selective mesenteric angiography with embolization or surgery is indicated. Patients who are unstable with acute lower GIB require early oesophagogastroduodenoscopy (to exclude an upper gastrointestinal cause) and then an interventional radiological procedure to embolize the bleeding vessel(s); surgery is generally a last resort.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"288 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127554075","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Immunization","authors":"D. Goldblatt, M. Ramsay","doi":"10.1093/med/9780198746690.003.0074","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0074","url":null,"abstract":"Immunization is one of the most successful medical interventions ever developed: it prevents infectious diseases worldwide. The basis for its success is that the human immune system can respond to vaccines by producing pathogen-specific antibody and memory cells (both B and T cells) which protect the body should the pathogen be encountered. Most currently licensed vaccines contain live or killed bacterial or viral constituents, bacterial polysaccharides, or bacterial toxoids, while new types of vaccines are being developed that contain DNA. Most vaccines are delivered directly into skin or muscle via needles, or they are administered orally. New edible vaccines and vaccines delivered via the skin without the use of needles are being developed. The Expanded Programme on Immunization, set up by the World Health Organization to define which vaccines should be delivered in resource-poor countries, has done much to increase vaccination coverage among infants most at risk of infectious diseases.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126242968","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Paroxysmal nocturnal haemoglobinuria","authors":"Lucio Luzzatto","doi":"10.1093/med/9780198746690.003.0530","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0530","url":null,"abstract":"Paroxysmal nocturnal haemoglobinuria (PNH) is a unique disorder in which many of the patient’s red cells have an abnormal susceptibility to activated complement. This results from the presence of a clone that originates from a haematopoietic stem cell bearing an acquired somatic mutation in the X-linked gene PIGA, required for the biosynthesis of the glycosylphosphatidylinositol molecule which anchors many proteins to the cell membrane, including the complement regulators CD59 and CD55. The ‘classical’ presentation is with ‘passing blood instead of urine’ (haemoglobinuria). Sometimes the patient presents with the full triad of (1) haemolytic anaemia, (2) pancytopenia, and (3) thrombosis—most commonly of intra-abdominal veins. An element of bone marrow failure is always present; and sometimes the disease may be preceded by or may evolve to bone marrow aplasia indistinguishable from acquired aplastic anaemia. Definitive diagnosis is based on demonstrating the presence of a discrete population of ‘PNH red blood cells’ by flow cytometry using anti-CD59. In most cases, especially when the patient is transfusion dependent and/or has severe signs and symptoms, there is an indication for long-term treatment with the complement inhibitor eculizumab.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128121758","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Malignant disease in pregnancy","authors":"R. Crawford","doi":"10.1093/med/9780199204854.003.1417","DOIUrl":"https://doi.org/10.1093/med/9780199204854.003.1417","url":null,"abstract":"Cancer in pregnancy is rare, affecting less than 1 in 1,000 live births. It may be specific to pregnancy (gestational trophoblastic disease) or incidental to it, the less infrequent conditions being melanoma, lymphoma, and cervical malignancy. Tumours of the uterine cervix, ovary, breast, or thyroid can metastasize to the placenta, but not to the fetus. Gestational trophoblastic disease arises from fetal chorion and is a malignant transformation of the placenta. Melanoma and haematological tumours, which also can invade the placenta, may cross into the fetal circulation. Pregnancy may cause enlargement of a pituitary tumour and a previously silent tumour may present with symptoms in pregnancy. Rare cases of colonic and neurological cancers developing in pregnancy have also been reported.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"44 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128171236","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Organic psychoses","authors":"Curtis A. McKnight, Jason P. Caplan","doi":"10.1093/med/9780198746690.003.0629","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0629","url":null,"abstract":"A psychosis is a syndrome characterized by delusions and hallucinations. Organic psychoses refer to those psychoses attributed to identifiable brain diseases andare thereby distinguished from primary psychoses such as schizophrenia. Almost any condition that affects the brain can cause an organic psychosis. Delirium and dementia are the most common, although there are many other causes including other neurodegenerative diseases, autoimmune disorders, multiple sclerosis, endocrinopathies, metabolic disorders, and infections. Making the diagnosis of an organic psychosis requires a high index of suspicion and appropriate investigation. The treatment is usually that of the primary disease when that is possible, while the symptoms of psychosis can be managed using antipsychotic drugs.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"62 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115775407","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Older people in hospital","authors":"G. Ellis, A. MacLullich, R. Harwood","doi":"10.1093/med/9780198746690.003.0056","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0056","url":null,"abstract":"Older people usually present to hospital because of a crisis: a sudden change in health, function, or circumstances that causes worry, distress, or overwhelms independence or care provision. Crises may relate to the individual, the carer, care systems, or the environment. At the point of presentation it may not be clear which, or what combination, of these is responsible. It is necessary to identify all relevant factors for hospital care to be effective and efficient. Admission to hospital for an acute illness can have a major negative impact on an older person’s ongoing functional abilities, hence systems of care need to know when to expect and how to manage functional deterioration.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"41 19","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"113936849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Alzheimer’s disease and other dementias","authors":"J. Schott","doi":"10.1093/med/9780198746690.003.0574","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0574","url":null,"abstract":"Dementia is defined as a syndrome consisting of progressive impairment in memory and other cognitive deficits (aphasia, apraxia, agnosia, or disturbance in executive function) in the absence of another explanatory central nervous system disorder, depression, or delirium, sufficient to interfere with activities of daily living. In recent years there has been a move to consider and classify patients with less severe forms of cognitive impairment—so-called mild cognitive impairment—and non-memory presentations, with the latest DSM-V criteria identifying individuals with major or minor neurocognitive syndromes. Ongoing research using biomarkers suggest that there is a long presymptomatic phase for many causes of dementia.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"116 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131983760","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Malignant diseases of the urinary tract","authors":"T. Eisen, F. Hamdy, R. Huddart","doi":"10.1093/med/9780198746690.003.0508","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0508","url":null,"abstract":"Bladder cancer—the seventh commonest cancer in the United Kingdom and the fourth most common in men. Nonmuscle-invasive disease is usually treated by transurethral resection with postoperative intravesical chemotherapy with mitomycin or bacillus Calmette–Guérin. Local muscle-invasive disease in patients who are fit enough is usually treated with radical cystoprostatectomy and cisplatin-based chemotherapy. Metastatic disease is typically treated with cisplatin-based chemotherapy. Renal cell cancer—approximately 3% of the total cancer burden. For operable patients with no distant disease, the treatment of choice is nephron-sparing (if possible) or radical nephrectomy. Metastatic renal cancer can behave in a very variable manner. Palliative nephrectomy may be required for bleeding or pain. First-line systemic treatment is with antiangiogenic tyrosine kinase inhibitors targeting vascular endothelial growth factor receptor signalling. Prostate cancer—second most common cause of male cancer deaths in the Western world. Most cases are asymptomatic at presentation, being detected following measurement of serum prostate-specific antigen (PSA) or after digital rectal examination, although screening by measurement of PSA remains a contentious issue. Clinically localized prostate cancer is treated with active monitoring, radiotherapy, or minimally invasive surgery. Locally advanced disease is likely to progress and requires intervention, usually in the form of androgen deprivation therapy and radiotherapy. First-line treatment for metastatic prostate cancer is androgen deprivation therapy; second-line treatment may be with newer antiandrogens in combination with steroids and cytotoxics. Testicular cancer—affects predominantly young adult men in whom they are the most common malignant tumours. For most patients, initial management consists of an inguinal orchidectomy, with or without immediate adjuvant therapy. Standard treatment of metastatic germ cell tumours is with a combination of bleomycin, etoposide, and cisplatin.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130291654","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Listeriosis","authors":"H. Hof","doi":"10.1093/med/9780198746690.003.0142","DOIUrl":"https://doi.org/10.1093/med/9780198746690.003.0142","url":null,"abstract":"Listeriosis is caused by the Gram-positive bacillus Listeria monocytogenes, whose natural habitat is the soil. Consumption of soft cheeses, other dairy products, meat products, seafood, and vegetables is the principal route of infection. Patients at particular risk include those who are immunocompromised, very young, or very old. Pregnant women are also at risk, although they develop only mild disease, but the bacteria can be transmitted to the child either in utero or during birth, causing serious systemic disease. The disease varies from a mild, influenza-like illness to fatal septicaemia and meningoencephalitis. Purulent, localized infections of any organ are sometimes seen. Aside from supportive care, the usual treatment of choice is high-dose intravenous ampicillin, which must be administered for at least 2 weeks. The prognosis is poor, with mortality of up to 30%. Prevention depends upon those that are vulnerable avoiding high-risk foods. There is no vaccine.","PeriodicalId":347739,"journal":{"name":"Oxford Textbook of Medicine","volume":"112 ","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132948460","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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