• Fundamental Clinical Skills
    • Internal Medicine
      • IM Cardiovascular Medicine
        • 1

          Chronic Stable Angina

          By Benjamin J Scirica, MD, MPH; J. Antonio T. Gutierrez, MD
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          Chronic Stable Angina

          • BENJAMIN J SCIRICA, MD, MPHSenior Investigator, TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Associate Professor of Medicine, Harvard Medical School, Boston, MA
          • J. ANTONIO T. GUTIERREZ, MDCardiovascular Medicine Fellow, Brigham and Women's Hospital, Boston, MA

          By definition, chronic stable angina is angina that has been stable with regard to frequency and severity for at least 2 months. Chronic stable angina is the initial manifestation of coronary heart disease in approximately 50% of patients. Typically, this type of angina occurs in the setting of atherosclerotic coronary arterial narrowing, although other causes are possible. This review covers the epidemiology, pathophysiology, initial evaluation, differential diagnosis, management, and treatment of patients with chronic stable angina. Figures show noninvasive testing and the probability of coronary artery disease; diagnosis of patients with suspected ischemic heart disease; probability of severe coronary artery disease; coronary outcomes for high- versus low-intensity statin therapy; optimal medical therapy (OMT) versus OMT and percutaneous coronary intervention for chronic angina; OMT versus percutaneous coronary intervention for stable coronary heart disease; and coronary artery bypass grafting versus percutaneous coronary intervention for diabetes and coronary artery disease. Tables list the grading of angina pectoris by the Canadian Cardiovascular Society classification system, the differential diagnosis of chest pain, conditions promoting myocardial oxygen supply and demand mismatch, the features of typical angina, the classification of chest pain, a comparison of the pretest likelihood of coronary heart disease (CHD) in low-risk and high-risk symptomatic patients, the posttest probability of significant CHD based on pretest probabilities of CHD and normal or abnormal results of noninvasive studies, survival according to risk groups based on Duke treadmill scores, high- and moderate-intensity statin therapy, revascularization to improve survival compared with medical therapy, revascularization to improve symptoms with significant anatomic (≥ 50% left main or ≥ 70% nonleft main coronary artery disease) or physiologic (fractional flow reserve ≤ 0.80) coronary artery stenoses, and questions recommended by an expert panel for patients with chronic stable angina at follow-up visits.

          This review contains 7 highly rendered figures, 13 tables, and 109 references.

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        • 2

          Hypertension

          By Marc P Bonaca, MD, MPH
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          Hypertension

          • MARC P BONACA, MD, MPHVascular Section, Cardiovascular Division, Brigham and Women’s Hospital, Assistant Professor, Harvard Medical School, Boston, MA

          Hypertension is a common chronic disorder with an increasing prevalence in the context of an aging population. Patients with hypertension are at risk for adverse cardiovascular, renal, and neurologic outcomes. Treatment of hypertension reduces this associated risk; therefore, early diagnosis and systematic management are critical in reducing morbidity and mortality. Although hypertension is multifactorial, a large component is related to lifestyle, including excess sodium intake, lack of physical activity, and obesity. Lifestyle intervention and education, therefore, are critical to both prevention and treatment of hypertension. Patients diagnosed with hypertension should be evaluated for their overall risk, with specific therapies and treatment targets guided by their characteristics and comorbidities. Several professional and guideline societies have published recommendations with regard to the diagnosis and treatment of hypertension, which have many similarities but also several areas of discussion and ongoing debate. Recent evolutions in the field include the expanded indications for home-based and ambulatory blood pressure monitoring and outcomes trials, which add important data regarding optimal treatment targets. These evolutions are likely to be addressed in ongoing guideline updates.

          Key words: ambulatory blood pressure monitoring, antihypertensive therapy, blood pressure, blood pressure targets, cardiovascular risk, high blood pressure, home blood pressure monitoring, hypertension, screening, secondary hypertension

          This review contains 9 figures, 13 tables, and 59 references.

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        • 3

          Approach to the Cardiovascular Patient

          By Catherine M. Otto, MD; David M Shavelle, MD
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          Approach to the Cardiovascular Patient

          • CATHERINE M. OTTO, MDJ. Ward Kennedy-Hamilton Endowed Chair in Cardiology, Professor of Medicine, Departmentof Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, WA
          • DAVID M SHAVELLE, MDAssociate Clinical Professor of Medicine, Keck School of Medicine at USC, Director, Interventional Cardiology Fellowship, Director, Cardiac Catheterization Laboratories, USC Medical Center, Los Angeles County, Los Angeles, CA

          The complete evaluation of the cardiovascular patient begins with a thorough history and a detailed physical examination. These two initial steps will often lead to the correct diagnosis and assist in excluding life-threatening conditions. The history and physical examination findings should be assessed in the overall clinical status of the patient, including the patient's specific complaints, lifestyle, comorbidities, and treatment expectations. This chapter discusses the cardiovascular conditions that frequently require evaluation: chest pain, dyspnea, palpitations, syncope, claudication, and cardiac murmurs; and reviews the background, history and physical examination, and diagnostic tests available for each. Diagnostic algorithms are provided, and the appropriate use of invasive and noninvasive cardiac testing for each condition is discussed.

          This review contains 8 highly rendered figures, 12 tables, and 52 references.

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        • 4

          St-segment Elevation Myocardial Infarction

          By Grant William Reed, MD; Christopher Paul Cannon, MD
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          St-segment Elevation Myocardial Infarction

          • GRANT WILLIAM REED, MDFellow, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
          • CHRISTOPHER PAUL CANNON, MD Cardiovascular Division, Brigham and Women’s Hospital, Professor of Medicine, Harvard Medical School, Executive Director of Cardiometabolic Trials, Harvard Clinical Research Institute, Boston, MA

          Patients with acute coronary syndrome fall into two groups: those with unstable angina or non—ST segment elevation (formerly non—Q wave) myocardial infarction (NSTEMI) and those with acute ST segment elevation (formerly Q wave) myocardial infarction (STEMI). STEMI is the focus of this chapter. The epidemiology, pathophysiology, diagnosis, differential diagnosis, and complications of STEMI are elaborated. Reperfusion therapy (including time to reperfusion; diagnostic coronary angiography; primary, facilitated, rescue, and late percutaneous coronary intervention [PCI]; thrombolytic therapy and choice of thrombolytic agent; early invasive strategy; coronary artery bypass grafting; and therapeutic hypothermia), medical therapy (including aspirin, P2Y12 inhibitors, glycoprotein IIb/IIIa inhibitors, anticoagulants, nitrates, beta blockers, inhibition of the renin-angiotensin-aldosterone system, oxygen, analgesia, lipid-lowering therapy, prophylactic antiarrhythmics, and magnesium), risk stratification, secondary prevention, and post-STEMI care are also covered. Tables delineate classifications of MI as defined by proximal cause of myocardial ischemia, Killip classification of acute MI and mortality rates, differential diagnosis of ST segment elevation, contraindications for administering thrombolytic agents, and major recommendations for antithrombotic therapy in patients with STEMI treated with primary PCI and thrombolysis. Algorithms indicate a diagnostic approach to acute coronary syndromes and corresponding pathology and reperfusion strategies. Electrocardiogram changes in STEMI and corresponding territory of myocardium are depicted. A variety of graphs are included.

          This review contains 11 highly rendered figures, 7 tables, and 151 references.

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        • 5

          Venous Thromboembolism

          By Daniel J. Corrigan, MD; Christopher Kabrhel, MD, MPH
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          Venous Thromboembolism

          • DANIEL J. CORRIGAN, MDResident, Harvard Affiliated Emergency Medicine Residency Program, Brigham and Women’s Hospital and Massachusetts General Hospital, Resident, Department of Emergency Medicine, Harvard Medical School, Boston, MA
          • CHRISTOPHER KABRHEL, MD, MPHDirector, Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Associate Professor of Emergency Medicine, Department of Emergency Medicine, Harvard Medical School, Boston, MA

          Venous thromboembolism (VTE) encompasses both deep vein thrombosis (the development of clots in the large veins of the extremities, with the deposition of clotting factors, platelets, and red blood cells) and pulmonary embolism (which occurs when a portion of a clot dislodges, travels through the right heart, and embeds in the pulmonary vasculature). Risk factors for VTE include recent surgery, extremity trauma, age, obesity, smoking, cancer, antiphospholipid antibody syndrome, and inherited risk factors, such as factor V Leiden. This review details the epidemiology and risk factors, pathophysiology, stabilization and assessment, supportive care and empirical therapy, diagnosis, treatment, and outcomes of patients with venous thromboembolism. Figures show the pathophysiology of right heart failure in acute pulmonary embolism; a venous sonogram showing a large acute deep vein thrombosis in a dilated, noncompressible right common femoral vein in cross section; and a computed tomographic pulmonary angiography demonstrating intraluminal filling defects caused by pulmonary embolism in the lobar artery of the left lower lobe and the main artery of the right lung in a patient with chest deformity. Tables list risk factors for VTE, the Wells score, the revised Geneva score for PE, and pulmonary embolism rule-out criteria.

          This review contains 3 highly rendered figures, 11 tables, and 49 references.

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        • 6

          Diseases of the Aorta

          By Anna M Booher, MD; Kim A Eagle, MD
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          Diseases of the Aorta

          • ANNA M BOOHER, MDClinical Assistant Professor, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
          • KIM A EAGLE, MDAlbion Walter Hewlett Professor of Internal Medicine, Chief of Clinical Cardiology, Clinical Director, Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI

          This review covers the major presentations affecting the aorta: aortic aneurysms (abdominal aortic aneurysms and thoracic aortic aneurysms), acute aortic syndromes (including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer), other nonacute aortic processes, and traumatic disease of the aorta. The section on abdominal aortic aneurysms covers screening, clinical presentation, diagnostic evaluation, management to reduce the risk of aneurysm rupture, open surgical treatment and endovascular aortic repair, and the role of medical therapy. The section on thoracic aortic aneurysms also covers pathophysiology, etiology, and inherited and inflammatory conditions. Aortic dissections affect either the ascending aorta (type A) or the descending aorta (type B) and may be classified as acute or chronic. The discussion of aortic dissection describes the clinical presentation, diagnostic steps and decisions, and treatment for both type A and type B dissections. The figures include two algorithms: a potential management strategy for patients with thoracic aortic aneurysm and a logical procedure for the evaluation and treatment of a suspected aortic dissection. Figures also include illustrations, computed tomographic images, and echocardiograms of various aortic presentations. Tables list normal aortic dimensions by computed tomographic angiography and echocardiography, etiology and associated factors in diseases of the aorta, revised Ghent criteria for the diagnosis of Marfan syndrome, size criteria for elective surgical intervention in thoracic aortic aneurysm, and independent predictors of in-hospital death. Also included is a follow-up imaging timeline for acute aortic syndromes.

          This review contains 9 figures, 6 tables, and 132 references.

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        • 7

          Cardiovascular Biomarkers

          By Parul U Gandhi, MD; James L Januzzi Jr, MD
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          Cardiovascular Biomarkers

          • PARUL U GANDHI, MDClinical and Research Fellow, Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, MA
          • JAMES L JANUZZI JR, MDRoman W. DeSanctis Endowed Clinical Scholar, Department of Medicine, Cardiology Division, Massachusetts General Hospital, Hutter Family Professor of Medicine, Harvard Medical School, Boston, MA

          The value of circulating biomarkers to care for patients with cardiovascular disease has grown significantly over the last few decades. The majority of clinical data focus on the use of natriuretic peptides (NPs) for the diagnosis, prognosis, and management of patients with heart failure (HF) and troponin measurements in patients with suspected or proven acute coronary syndrome (ACS). Part of the reason for the slow adoption of biomarkers beyond these two classes has been limitation in the optimal modes of application of new assays. Future studies are needed to clarify the use of biomarkers, with the ultimate goal of simplifying the diagnosis, prognosis, and patient care of complex cardiovascular conditions. This chapter reviews the use of established biomarkers for HF, ACS, and atrial fibrillation (AF). Tables include a summary of emerging and established cardiovascular biomarkers, characteristics of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide, cutoff points for NP measurement, differential diagnosis of elevated NP concentrations, biomarkers in HF with preserved ejection fraction, summary of NP management trials, third universal definition of myocardial infarction, and guidelines for recommendations of biomarkers in HF. Figures depict the various causes of NP release, the complex mechanism of troponin release in patients with HF, the ischemic and nonischemic etiologies of troponin release, timing of biomarker release during myocardial infarction, and the biomarkers involved in the pathogenesis of AF. Algorithms demonstrate evaluating outpatients with dyspnea in the clinic using NPs in their workup and the use of troponin to assist with determining an appropriate management strategy for a patient with ACS.

          This review contains 7 highly rendered figures, 8 tables, and 202 references.

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        • 8

          Diagnosis and Treatment of States of Shock

          By Ahmed Reda Taha, MD, FRCP, FCCP, FCCM
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          Diagnosis and Treatment of States of Shock

          • AHMED REDA TAHA, MD, FRCP, FCCP, FCCMCritical Care Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

          Shock remains a diagnosis of significant mortality and morbidity. The current definition defines shock as an acute clinical syndrome that results from inadequate tissue perfusion, which is significantly different from the previous definition of hypotension. Clinical manifestation varies broadly, and is based on the underlying etiology, degree of organ perfusion, and previous organ dysfunction. This review covers the classification, pathogenesis and organ response, evaluation, and management of shock. Figures show the balance between oxygen delivery and oxygen consumption, perfused capillary density, the Krogh Cylinder Model demonstrating the Anoxic-Hypercapnic Lethal Corner, the relation between systolic blood pressure, mean arterial pressure, and diastolic arterial pressure, glycolysis, and the approach to the patient with shock. Tables list clinical and metabolic markers of perfusion alteration to the organs, hemodynamic parameters in different types of shock, normal hemodynamic parameters, problems associated with the use of pulmonary artery catheter, clinical presentation of hypovolemic shock according to severity, causes of cardiogenic shock and cardiogenic pulmonary edema, and receptor activity of different vaspressors and clinical indication.

          This review contains 6 figures, 7 tables, and 55 references.

          Key Words: Shock; Hypovolemic shock; Cardiogenic shock; Neurogenic shock; Vasogenic shock; Septic shock; Obstructive shock

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        • 9

          Cardiac Catheterization and Intervention

          By Dharam J. Kumbhani, MD, SM, MRCP, FACC; Deepak L Bhatt, MD, MPH, FACP
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          Cardiac Catheterization and Intervention

          • DHARAM J. KUMBHANI, MD, SM, MRCP, FACCAssistant Professor of Medicine, Division of Cardiology, University of Texas Southwestern Medical School, Dallas, TX
          • DEEPAK L BHATT, MD, MPH, FACPExecutive Director of Interventional Cardiovascular Programs, Brigham and Womens Hospital Heart & Vascular Center, Professor of Medicine, Harvard Medical School, Boston, MA

          Cardiac catheterization involves the insertion of a catheter (hollow polymer-coated tubing) into a blood vessel of the heart or into one of its chambers. Cardiac catheterization procedures are one of the most commonly performed cardiac procedures today. This review outlines the basics of angiography and coronary anatomy, the technical details of cardiac catheterizations, preferred access sites, and hemodynamic measurements. The basic steps in coronary intervention are listed. Common indications and contraindications for cardiac catheterization and intervention are described, as are appropriate use criteria for diagnostic catheterization and coronary intervention, fractional flow reserve (FFR) and intravascular ultrasonography, and complications of cardiac catheterization and percutaneous coronary intervention. Future directions in the field are discussed. Tables describe normal hemodynamic measurements, derived measurements during right heart catheterization, coronary artery disease prognostic index for medically managed patients, American College of Cardiology (ACC)/American Heart Association (AHA) guidelines regarding indications for coronary angiography, ACC/AHA appropriate use criteria for diagnostic catheterization, common indications for FFR, and risk of cardiac catheterization and coronary angiography. Figures include an overview of coronary anatomy, angiograms of the coronary arteries, images of a normal cardiac cycle and hemodynamic waveforms, the design of a stent, FFR evaluation, basic intravascular ultrasonography measurements, and coronary imaging with an optical coherence tomography system.

          This review contains 7 highly rendered figures, 8 tables, and 62 references.

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        • 10

          Unstable Angina and Other Acute Coronary Syndromes

          By R Scott Wright, MD, FACC, FESC, FAHA; Joseph G Murphy, MD, FACC, FESC
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          Unstable Angina and Other Acute Coronary Syndromes

          • R SCOTT WRIGHT, MD, FACC, FESC, FAHAProfessor of Medicine, Consultant in Cardiology and the Coronary Care Unit, Mayo Clinic, Rochester, MN
          • JOSEPH G MURPHY, MD, FACC, FESCProfessor of Medicine, Consultant in Cardiology and the Coronary Care Unit, Chair, Section of Scientific Publications, Mayo Clinic, Rochester, MN

          Patients with coronary artery disease (CAD) present clinically when their disease enters an unstable phase known as an acute coronary syndrome (ACS), in which the cap of a previously stable atheromatous coronary plaque ruptures or erodes, which in turn activates a thrombotic cascade that may lead to coronary artery occlusion, myocardial infarction (MI), cardiogenic shock, and patient death. There are nearly 2 million episodes of ACS in the United States annually; it is the most common reason for hospitalization with CAD and is the leading cause of death in the developed world.

          This review contains 2 figures, 16 tables, and 70 references.

          Key Words: coronary artery disease, myocardial infarction, cardiogenic shock

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      • IM Allergy & Immunology
        • 1

          Allergic Response

          By Joud Hajjar, MD; Lawrence B Schwartz, MD, PhD
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          Allergic Response

          • JOUD HAJJAR, MDAllergy and Immunology Fellow, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
          • LAWRENCE B SCHWARTZ, MD, PHDCharles & Evelyn Thomas Professor of Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA

          This chapter begins with a definition of allergic response and a discussion of the epidemiology of atopic disorders, as well as the development of IgE-mediated hypersensitivity. Subjects covered in a section on humoral and cellular mechanisms of allergic sensitization include antigen-presenting cells and sensitization, T cells, and IgE and IgE receptors. A discussion of mast cells and basophils includes information on mediators, biomarkers, eosinophils, and eosinophil mediators. Therapy of atopic disorders is also discussed. Figures depict inflammatory mechanisms in allergic inflammation, microscopy of a mast cell before and after the introduction of antigen, and mediators released by activated human mast cells. Tables outline selected cytokines and chemokines involved in IgE-mediated allergic inflammation, serum tryptase levels, examples of patterns of serum total tryptase elevations and interpretations, and a summary of therapeutic interventions for allergic diseases.
          This chapter contains 3 highly rendered figures, 4 tables, 84 references, 1 teaching slide set, and 5 MCQs.

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        • 2

          Urticaria and Angioedema

          By Justin R Chen, MD; David A. Khan, MD
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          Urticaria and Angioedema

          • JUSTIN R CHEN, MDFellow Physician, Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
          • DAVID A. KHAN, MDProfessor of Internal Medicine and Pediatrics, Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX

          Urticaria and angioedema are common diseases with diverse origins that constitute a substantial component of medical practice. Urticaria, or hives, refers to one or more areas of intensely pruritic papules or plaques with swelling of the superficial dermis (wheal) surrounded by local erythema (flare). Angioedema refers to deep dermal subcutaneous swelling that may manifest as swelling of the mucosa of the face, tongue, pharynx, larynx, or intestines that can be alarming and, in some cases, life threatening. These conditions are heterogeneous in their presentation and chronicity. Although allergies are responsible for some cases, autoimmunity and dysregulation of the bradykinin system often play a significant role, leading to challenging diagnostic and therapeutic dilemmas. This review discusses the epidemiology, natural history, pathophysiology, diagnosis, and treatment of acute and chronic urticaria and angioedema. Emphasis is placed on physical triggers, the role of proper laboratory testing, and alternative agents for refractory cases. Emerging therapies for hereditary and acquired angioedema syndromes are also covered. Tables list the causes of acute and chronic urticaria, an escalating treatment approach for difficult cases, and a comparison of available parenteral therapies specific to bradykinin-mediated angioedema. Figures illustrate the mechanisms of urticaria, photographs of typical presentations, and an evidence-based diagnostic algorithm for clinicians. 

          This review contains 9 highly rendered figures, 5 tables, and 100 references.

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        • 3

          Anaphylaxis

          By Cem Akin, MD, PhD
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          Anaphylaxis

          • CEM AKIN, MD, PHDAssociate Physician, Harvard Medical School, Brigham and Women’s Hospital, Department of Rheumatology, Immunology, and Allergy, Boston, MA

          Anaphylaxis, a serious allergic reaction, is rapid in onset and marked by flushing, urticaria, angioedema, pruritus, bronchospasm, and abdominal cramping with nausea, vomiting, and diarrhea. It is not uncommon; approximate lifetime prevalence of anaphylaxis was estimated to be 0.5 to 2% or possibly higher due to the common academic belief that the incidence of anaphylactic reactions is underreported. Rarely, anaphylaxis may cause death, most commonly from drugs, foods, and insect stings. This review covers the epidemiology, etiology, pathogenesis, diagnosis, clinical manifestations, treatment, and prognosis. Figures show inflammatory pathways in allergic inflammation and mast cell degranulation and pathways of activation. Tables list the diagnostic criteria, selected mast cell activators of possible clinical relevance, signs and symptoms that may be encountered according to tissue site, and common considerations in the differential diagnosis.

          This review contains ­2 highly rendered figures, 4 tables, and 73 references.

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        • 4

          Food Allergies

          By Edmond A. Hooker, MD, DrPH; Charles Kircher, MD
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          Food Allergies

          • EDMOND A. HOOKER, MD, DRPHAssistant Professor, Residency Research Director, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
          • CHARLES KIRCHER, MD Clinical Instructor, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH

          Food allergies are responsible for a considerable number of emergency department visits. Food allergy can be divided into classic (i.e., IgE-mediated) reactions to specific allergens after exposure via skin or mucosal membrane and non–IgE-mediated food allergies, which include T cell–mediated immunity, enteropathies to specific proteins, and mixed disorders (e.g., eosinophilic esophagitis). Food-induced anaphylaxis can be life threatening and requires immediate treatment with epinephrine, even if the causative agent has not been identified. This review describes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with food allergies. Figures show IgE-mediated allergic reactions to food and other allergens, classification of adverse reactions to foods, commercially available epinephrine autoinjectors, a sample anaphylaxis action plan, and a map showing school access to epinephrine in the United States as of September 4, 2014. Tables list potential food allergies with estimated self-reported prevalence, National Institute of Allergy and Infectious Disease clinical criteria of anaphylaxis, non–IgE-mediated food intolerance disorders, Rome III diagnostic criteria for irritable bowel syndrome, food allergy mimickers, and potential criteria for prolonged observation.

          This review contains 5 highly rendered figures, 6 tables, and 54 references.

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        • 5

          Drug Allergies

          By Edmond A. Hooker, MD, DrPH; Natalie P. Kreitzer, MD
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          Drug Allergies

          • EDMOND A. HOOKER, MD, DRPHAssistant Professor, Residency Research Director, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
          • NATALIE P. KREITZER, MDNeurocritical Care Fellow in Training, Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH

          Adverse drug reactions (ADRs) are very common, causing approximately 2% of emergency department visits. It is estimated that approximately one-half of these ADRs are preventable. Although most ADRs and allergic reactions are minor, some may be severe, and the emergency physician's first priority should be the identification of anaphylactic or life-threatening reactions. This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of ADRs and drug allergies. Figures show the Gell and Coombs system, the four basic immunologic mechanisms for drug reactions, drugs as haptens and prohaptens, chemical structure of different β-lactam antibiotics, and management of the patient with possible drug allergy. Tables list the types of adverse drug reactions, drugs frequently implicated in allergic reactions in the emergency department, classification of allergic reactions, pretreatment protocol for radiocontrast allergy, and important parts of a history and physical examination of a patient with a suspected or confirmed drug hypersensitivity reaction.

          This review contains 5 highly rendered figures, 5 tables, and 115 references.

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      • IM Dermatology
        • 1

          Malignant Cutaneous Tumors

          By Allan C Halpern, MD; Patricia L. Myskowski, MD
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          Malignant Cutaneous Tumors

          • ALLAN C HALPERN, MDChief, Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY
          • PATRICIA L. MYSKOWSKI, MDAttending Physician, Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY

          This chapter reviews the most common malignant cutaneous tumors. The section on malignant tumors of the epidermis discusses nonmelanoma skin cancer (i.e., basal cell carcinoma and squamous cell carcinoma) and malignant melanoma. The section on malignant tumors of the dermis covers metastatic tumors, primary tumors (Merkel cell carcinoma, Paget disease, extramammary Paget disease, angiosarcoma, and dermatofibrosarcoma protuberans), and Kaposi sarcoma (i.e., classic Kaposi sarcoma, African Kaposi sarcoma, organ-transplant Kaposi sarcoma, and HIV-associated Kaposi sarcoma). The final section covers cutaneous lymphomas. The coverage of each disease includes a discussion of epidemiology, etiology, diagnosis, differential diagnosis, treatment, and prognosis. Tables provide the adjusted estimated relative risks of melanoma by nevus type and number, the American Joint Committee on Cancer (AJCC) TNM classification and staging system, the estimated probability of 10-year survival in patients with primary cutaneous melanoma, and an overview of overview of therapy for cutaneous T cell lymphoma. Figures illustrate the presentation of many malignant cutaneous tumors.

          This review contains 10 highly rendered figures, 5 tables, and 105 references.

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        • 2

          Cutaneous Adverse Drug Reactions

          By Neil H. Shear, MD, FRCPC; Sandra Knowles, BScPhm; Lori Shapiro, MD, FRCPC
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          Cutaneous Adverse Drug Reactions

          • NEIL H. SHEAR, MD, FRCPCProfessor and Chief of Dermatology, Department of Medicine, Divisions of Dermatology and Clinical Pharmacology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, CA
          • SANDRA KNOWLES, BSCPHMAssistant Professor (Status Only), Department of Pharmacy, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, CA
          • LORI SHAPIRO, MD, FRCPCAssistant Professor of Medicine, Department of Medicine, Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, CA

          An adverse drug reaction is defined as any noxious, unintended, and undesired effect of a drug that occurs at doses used in humans for prophylaxis, diagnosis, or therapy. A cutaneous eruption is one of the most common manifestations of an adverse drug reaction. This chapter reviews the epidemiology, etiology, diagnosis, clinical manifestations, and differential diagnosis of adverse drug reactions, as well as laboratory tests for them. Also discussed are the types of cutaneous eruption: exanthematous eruption, urticarial eruption, blistering eruption, pustular eruption, and others. The simple and complex forms of each type of eruption are reviewed. The chapter includes 4 tables and 12 figures. Tables present the warning signs of a serious drug eruption, clinical features of hypersensitivity syndrome reaction and serum sickness-like reaction, characteristics of Stevens-Johnson Syndrome and toxic epidermal necrolysis, and clinical pearls to identify anticoagulant-induced skin necrosis. Figures illustrate hypersensitivity syndrome reaction, a fixed drug eruption from tetracycline, pseudoporphyria from naproxen, linear immunoglobulin A disease induced by vancomycin, pemphigus foliaceus from taking enalapril, pemphigus vulgaris from taking penicillamine, toxic epidermal necrolysis after starting phenytoin therapy, acneiform drug eruption due to gefitinib, acute generalized exanthematous pustulosis from cloxacillin, coumarin-induced skin necrosis, a lichenoid drug eruption associated with ramipril, and leukocytoclastic vasculitis from hydrochlorothiazide. This chapter contains 106 references.

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        • 3

          Benign Cutaneous Tumors

          By Elizabeth A Abel, MD
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          Benign Cutaneous Tumors

          • ELIZABETH A ABEL, MDAdjunct Clinical Professor of Dermatology, Stanford University School of Medicine, Stanford, CA, Private Practice, California Skin Institute, Mountain View, CA

          Tumors of the cutaneous surface may arise from the epidermis, dermis, or subcutaneous tissue or from any of the specialized cell types in the skin or its appendages. Broad categories include tumors derived from epithelial, melanocytic, or connective tissue structures. Within each location or cell type, lesions are classified as benign, malignant, or, in certain cases, premalignant. Benign epithelial tumors include tumors of the surface epidermis that form keratin, tumors of the epidermal appendages, and cysts of the skin. Melanocytic (pigment-forming) lesions are very common. One of the most frequently encountered forms is the nevus cell nevus. Tumors that are derived from connective tissue include fibromas, histiocytomas, lipomas, leiomyomas, and hemangiomas. This chapter provides an overview of each type of tumor, including sections on epithelial tumors, tumors of the epidermal appendages, familial tumor syndromes, melanocytic tumors, neural tumors, connective tissue tumors, vascular birthmarks, acquired vascular disorders, Kimura disease, lipoma, leiomyoma, and lymphangioma circumscriptum. The sections discuss various forms and their diagnosis, differential diagnosis, and treatment. Figures accompany the descriptions.

          This chapter contains 83 references, 26 highly rendered figures, and 5 MCQs.

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        • 4

          Approach to the Diagnosis of Skin Disease

          By Robert T Brodell, MD; Stephen E Helms, MD; Lindsey B Dolohanty, MD
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          Approach to the Diagnosis of Skin Disease

          • ROBERT T BRODELL, MDProfessor and Chair, Department of Dermatology and Professor of Pathology, University of Mississippi Medical School, Jackson, MI, Instructor in Dermatology, University of Rochester School of Medicine and Dentistry, Rochester, NY
          • STEPHEN E HELMS, MDAssociate Professor of Internal Medicine, Dermatology Section, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio, Assistant Clinical Professor of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio, Professor of Dermatology, University of Mississippi Medical School, Jackson, MI
          • LINDSEY B DOLOHANTY, MDAssistant Professor, Department of Dermatology, University of Rochester School of Medicine, Rochester, NY

          The diagnosis of skin disease is not something that changes radically year to year. In fact, for hundreds of years physicians have been assessing the skin to diagnose and treat skin diseases and  to “view” internal diseases. The latest edition of this review provides several updates that enhance our approach to the diagnosis of skin disease with active links to updated digital references and atlases. These will be valuable to students, residents, and physicians interested in improving their dermatologic diagnostic skills. A new algorithm highlights our suggested approach to cutaneous diagnoses. It is our hope that readers will begin to “think like dermatologists” as they digest the contents of this review. 

          Key words: Macule, papule, vesicle, bulla, plaque, excoriation, scale, ulceration, diagnosis, errors

          This review contains 13 figures, 5 tables, 17 references, and 7 additional readings.

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        • 5

          Fungal, Bacterial, and Viral Infections of the Skin

          By Jan V. Hirschmann, MD
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          Fungal, Bacterial, and Viral Infections of the Skin

          • JAN V. HIRSCHMANN, MDProfessor of Medicine, University of Washington School of Medicine, Staff Physician, Puget Sound VA Medical Center, Seattle, WA

          The skin can become infected by viruses, fungi, and bacteria, including some that ordinarily are harmless colonizing organisms. The most common fungal infections are caused by dermatophytes, which can involve the hair, nails, and skin. Potassium hydroxide (KOH) preparations of specimens from affected areas typically demonstrate hyphae, and either topical or systemic antifungal therapy usually cures or controls the process. The most common bacterial pathogens are Staphylococcus aureus and group A streptococci, which, alone or together, can cause a wide variety of disorders, including impetigo, ecthyma, and cellulitis. Topical antibiotics may suffice for impetigo, but ecthyma and cellulitis require systemic treatment. S. aureus, including methicillin-resistant strains, can also cause furuncles, carbuncles, and cutaneous abscesses. For these infections, incision and drainage without antibiotics are usually curative. Warts are the most common cutaneous viral infection, and eradication can be difficult, especially where the skin is thick, such as the palms and soles, or the patient is immunocompromised. Most therapies consist of trying to destroy the viruses by mechanical, chemical, or immune mechanisms. This review covers dermatophyte infections, yeast infections, bacterial infections, and viral infections of the skin. Figures show the classic annular lesion of tinea corporis, a typical kerion presenting as a zoophilic Microsporum canis infection of the scalp (tinea capitis), tinea corporis, tinea barbae, tinea pedis between and under the toes and on the plantar surface, inflammatory tinea pedis, tinea unguium, tinea manuum, angular cheilitis, prominent satellite lesions of discrete vesicles associated with candidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema and edema on the cheeks, eyelids, and nose, furuncle, carbuncle, nasal folliculitis, pitted keratolysis, trichomycosis axillaris, necrotizing fasciitis, Fournier gangrene, folliculitis, plantar wart, condyloma acuminatum, and benign lesions of bowenoid papulosis. Tables list dermatophyte species, terminology of dermatophyte infections, topical agents for dermatophyte infections, treatment options for impetigo (adult doses), and treatment options for erythrasma.

          This review contains 29 figures, 5 tables, and 33 references.

          Keywords: Staphylococcus aureus, methicillin-resistant strains, furuncles, carbuncles, cutaneous abscesses, dermatophytes, zoophilic Microsporum canis, andidiasis, facial candidiasis, Candida paronychia, tinea versicolor, nonbullous impetigo, bullous impetigo, ecthyma, leg cellulitis, erythema

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        • 6

          Acne Vulgaris and Rosacea

          By James Q Del Rosso, DO
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          Acne Vulgaris and Rosacea

          • JAMES Q DEL ROSSO, DOAdjunct Clinical Professor (Dermatology), Touro University College of Osteopathic Medicine, Henderson, NV

          Acne vulgaris is the most common disorder seen in general dermatology practice, accounting for approximately 10% of visits each year. Both sexes and all ethnicities are affected, usually in the late preteenage or early teenage years. Both inflammatory and comedonal lesions of acne vulgaris characteristically involve the face, but truncal involvement is also relatively common. Multiple clinical presentations may be observed, with severity often progressing over time during adolescence. Severe forms of acne vulgaris can be especially disfiguring and debilitating, and are more likely to lead to permanent scarring. Therapeutic options are chosen primarily on the basis of clinical severity, with adjustments in treatment made on the basis of response or disease progression. Rosacea begins in adulthood, usually in the third decade of life or later. The disorder predominantly affects the central face in fair-skinned people, mostly those of northern European ancestry, although individuals of any race may be affected. Rosacea may present as one or more of a variety of clinical phenotypes (subtypes); it is a chronic disorder characterized by periods of exacerbation and remission. Fortunately, rosacea is not associated with scarring, although a subset of patients may develop localized proliferations of sebaceous and fibrous tissue called a phyma. Like acne vulgaris, rosacea may also adversely impact quality of life. Figures in this chapter illustrate acne vulgaris and inflammatory papules. Tables detail laboratory evaluation for women with acne vulgaris and hyperandrogenism, surgical/physical modality options for specific acne lesions and acne scars, major topical therapies for acne vulgaris, and commonly prescribed systemic therapies for acne. This chapter contains 50 references.

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        • 7

          Psoriasis

          By Elizabeth A Abel, MD; Mark Lebwohl, MD
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          Psoriasis

          • ELIZABETH A ABEL, MDAdjunct Clinical Professor of Dermatology, Stanford University School of Medicine, Stanford, CA, Private Practice, California Skin Institute, Mountain View, CA
          • MARK LEBWOHL, MDSol and Clara Kest Professor and Chairman, Department of Dermatology, Mount Sinai School of Medicine, New York City, NY

          Psoriasis is an immune-mediated inflammatory cutaneous disorder characterized by chronic, scaling, erythematous patches and plaques of skin. It can begin at any age and can vary in severity. Psoriasis can manifest itself in several different forms, including pustular and erythrodermic forms. In addition to involving the skin, psoriasis frequently involves the nails, and some patients may experience inflammation of the joints (psoriatic arthritis). Because of its highly visible nature, psoriasis can compromise both the personal and the working lives of its victims. Breakthroughs in the treatment of psoriasis have led to a better understanding of its pathogenesis.

          This review contains 12 figures, 8 tables, and 79 references.

          Keywords: Psoriases, Pustulosis of Palms and Soles, Pustulosis Palmaris et Plantaris, Palmoplantaris Pustulosis, Pustular Psoriasis of Palms and Soles

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      • IM Endocrinology & Metabolism
        • 1

          Adrenal Insufficiency

          By D. Lynn Loriaux, MD, PhD, MACP
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          Adrenal Insufficiency

          • D. LYNN LORIAUX, MD, PHD, MACPProfessor of Medicine and Chief, Division of Endocrinology and Metabolism, Oregon Health and Science University, Portland, OR

          Adrenal insufficiency (Addison disease) can be categorized as primary or secondary; the former results from adrenal cortex destruction, whereas the latter is caused by disruption of pituitary secretion of adrenocorticotropic hormone. The clinical pictures are the same, and their signs can be differentiated only by the presence of hyperpigmentation and vitiligo in autoimmune disease. Diagnosing both chronic and acute syndromes requires laboratory confirmation; however, the only available diagnostic test for adrenal insufficiency is cosyntropin stimulation. Relative adrenal insufficiency is a hypothetical situation stemming from misinterpretation of this test, and there is no pathophysiologic evidence of its existence. The most common form of congenital adrenal hyperplasia is the 21-hydroxylase deficiency syndrome.

          This module contains 1 highly rendered figure, 2 tables, 4 references, and 5 MCQs.

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        • 2

          Adrenal Hypertension

          By Naomi D.L. Fisher, MD; Gail K Adler, MD, PhD
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          Adrenal Hypertension

          • NAOMI D.L. FISHER, MDDivision of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA
          • GAIL K ADLER, MD, PHDDivision of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA

          The secondary causes of hypertension are associated with the excess of the principal hormones produced by the adrenal glands: cortisol, epinephrine, and aldosterone. Excess aldosterone production is recognized as primary hyperaldosteronism, or primary aldosteronism (PA). Individuals with PA are at increased risk for a variety of disorders, including atrial fibrillation, coronary artery disease, myocardial infarction, and stroke. Pheochromocytoma is a very rare tumor (accounting for fewer than one in 10,000 hypertension cases) and is marked by high secretions of catecholamines, mostly epinephrine as well as norepinephrine. Cushing disease and Cushing syndrome are addressed in a separate review.

          This review contains 5 highly rendered figures, 4 tables, and 39 references.

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        • 3

          Type 1 Diabetes Mellitus

          By Joseph I. Wolfsdorf, MB, BCh; Katharine Garvey, MD, MPH
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          Type 1 Diabetes Mellitus

          • JOSEPH I. WOLFSDORF, MB, BCHProfessor of Pediatrics, Harvard Medical School, Boston, MA
          • KATHARINE GARVEY, MD, MPHInstructor of Pediatrics, Harvard Medical School, Boston, MA

          Type 1 diabetes mellitus is a heterogeneous metabolic disease characterized by destruction of the pancreatic beta cells resulting in an absolute deficiency of insulin secretion with subsequent hyperglycemia. This review details the definition and classification, epidemiology, pathophysiology, pathogenesis, prevention, diagnosis, and management of type 1 diabetes mellitus. Figures show the opposing actions of insulin and glucagon, particularly within the liver, on substrate flow and plasma levels; plasma glucose, insulin and C-peptide levels; the structure of human proinsulin; the cellular actions of insulin; measurement of insulin levels after the administration of glucose; the pathways that lead from insulin deficiency to the major clinical manifestations of type 1 diabetes mellitus; the pathogenesis of type 1 autoimmune diabetes mellitus; the relationship between hemoglobin A1C and calculated average glucose level; basal-bolus and insulin pump regimens; and management of diabetic ketoacidosis. Tables list the etiologic classification of diabetes mellitus, criteria for the diagnosis of diabetes, American Diabetes Association standards for glycemic control in diabetes mellitus, insulin preparations, potential advantages of continuous subcutaneous insulin infusion compared with multiple daily injections, cardiovascular risk factor screening and treatment, and typical admission laboratory findings and monitoring in diabetic ketoacidosis.

          This review contains 10 highly rendered figures, 7 tables, and 66 references.

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      • IM Ethics & Professionalism
        • IM Gastroenterology
          • 1

            Constipation

            By Charles H Knowles, MBBChir, PhD, FRCS
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            Constipation

            • CHARLES H KNOWLES, MBBCHIR, PHD, FRCS

            This review presents an overview of the management of constipation. The review addresses the diagnosis of primary and secondary forms and then discusses in greater detail the investigative workup and modern management of chronic constipation (primary). The review addresses what simple and more advanced investigations are relevant for determining pathophysiology and gives an overview of treatment options, including pharmacologic, behavioral, and surgical approaches for thus defined subgroups of patients (evacuation disorder, slow transit constipation).

            This review contains 3 figures, 6 tables, and 89 references.

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          • 2

            Irritable Bowel Syndrome With Diarrhea

            By Judy Nee, MD; Jacqueline L. Wolf, MD
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            Irritable Bowel Syndrome With Diarrhea

            • JUDY NEE, MDInstructor in Medicine, Harvard Medical School, BIDMC, Beth Israel Deaconess Medical Center, Boston, MA
            • JACQUELINE L. WOLF, MDAssociate Professor of Medicine, Harvard Medical School, BIDMC, Beth Israel Deaconess Medical Center, Boston, MA

            Irritable bowel syndrome (IBS) is a complex, functional gastrointestinal condition characterized by abdominal pain and alteration in bowel habits without an organic cause. One of the subcategories of this disorder is IBS with diarrhea (IBS-D). Clinically, patients who present with more than 3 months of abdominal pain or discomfort associated with an increase in stool frequency and/or loose stool form are defined as having IBS-D. This review addresses IBS-D, detailing the epidemiology, etiology and genetics, pathophysiology and pathogenesis, diagnosis, clinical manifestations and physical examination findings, differential diagnosis, treatment, emerging therapies, complications, and prognosis. Figures show potential mechanisms and pathophysiology of IBS, IBS-D suspected by clinical assessment and Rome III criteria, pharmacologic and nonpharmacologic treatment options, potential mechanisms of action of probiotics, and potential treatment modalities. Tables list the Rome criteria for IBS, alarm signs and symptoms suggestive of alternative diagnoses, IBS criteria, differential diagnosis of IBS-D, dietary advice options for IBS-D, and alternative and emerging therapies in IBS-D.

            This review contains 5 highly rendered figures, 6 tables, and 99 references. 

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          • 3

            Esophageal Disorders

            By Michael F. Vaezi, MD, PhD, MSc (EPI)
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            Esophageal Disorders

            • MICHAEL F. VAEZI, MD, PHD, MSC (EPI)Professor of Medicine, Clinical Director of Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN

            Typically, symptoms that may indicate the presence of an esophageal disorder include heartburn, dysphagia, odynophagia, and regurgitation. Endoscopy is the technique of choice to evaluate the mucosa of the esophagus and to detect structural abnormalities, whereas esophageal manometry is the standard test to diagnose motor disorders of the esophageal body and the lower esophageal sphincter. This review examines normal esophageal anatomy and physiology, the diagnosis of esophageal disorders, disease states causing dysphagia, and gastroesophageal reflux disease. Figures show the cross-sectional anatomy of the esophagus; an algorithm for the evaluation of dysphagia; the anatomy of the gastroesophageal junction; esophagograms of patients with achalasia, late-stage achalasia, and diffuse esophageal spasm; endoscopic views of esophageal strictures; a proximal esophageal web on barium swallow in a patient with Plummer-Vinson syndrome; an endoscopic view of the esophagus of a 25-year-old man with a 3-year history of severe dysphagia; photographs of midesophageal traction diverticulum, multiple epiphrenic diverticula, long-segment Barrett esophagus, and severe Candida esophagitis; and a treatment algorithm for extraesophageal manifestations of gastroesophageal reflux disease. Tables list the high-resolution manometry classification of esophageal motility disorders, causes of esophageal strictures, classic endoscopic findings in patients with eosinophilic esophagitis, the Los Angeles classification of erosive esophagitis, categories of dysplasia, surveillance of Barrett metaplasia, medications implicated in pill-induced esophagitis, and classification of caustic esophageal injury.

            This review contains 13 highly rendered figures, 8 tables, and 111 references.

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          • 4

            Gastrointestinal Motility and Functional Disorders

            By Adil E Bharucha, MBBS, MD
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            Gastrointestinal Motility and Functional Disorders

            • ADIL E BHARUCHA, MBBS, MDProfessor of Medicine, Director, Motility Interest Group, Mayo Clinic, Rochester, MN

            Gastrointestinal (GI) motility disorders represent diseases characterized by abnormal, predominantly impaired, sometimes exaggerated, movement of contents through the GI tract due to neuromuscular dysfunctions in the absence of mucosal disease and mechanical causes of impaired passage. By contrast, functional GI disorders represent illnesses, defined only by GI symptoms, which occur in the absence of mucosal or structural abnormality or of known biochemical or metabolic disorders. The first section of this chapter discusses the enteric and extrinsic neural regulation of GI sensorimotor functions and normal GI motility in humans. Disorders such as gastroparesis (including diabetic gastroparesis, idiopathic gastroparesis, and postsurgical gastroparesis), dumping syndrome, intestinal pseudo-obstruction, small intestinal bacterial overgrowth, megacolon (including Hirschsprung disease, toxic megacolon, and colonic pseudo-obstruction), chronic constipation (including defecatory disorders, normal transit constipation, and slow transit constipation), functional dyspepsia, functional diarrhea and irritable bowel syndrome, and fecal incontinence are then discussed in depth. Tables present a comparison of GI motility and functional disorders, the causes of gastroparesis, the etiology of intestinal pseudo-obstruction and fecal incontinence, common medical conditions and medications associated with constipation, and the symptom severity scale in fecal incontinence. Illustrations, graphs, magnetic resonance images, and algorithms are provided.
            This chapter contains 10 highly rendered figures, 6 tables, 92 references, and 5 MCQs.

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          • 5

            Lower Gastrointestinal Bleeding

            By Jennifer Nayor, MD; John R. Saltzman, MD
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            Lower Gastrointestinal Bleeding

            • JENNIFER NAYOR, MDClinical Research Fellow, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA
            • JOHN R. SALTZMAN, MDDirector of Endoscopy, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, Associate Professor of Medicine, Harvard Medical School, Boston, MA

            Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system.

            This review contains 8 highly rendered figures, 5 tables, and 100 references.

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          • 6

            Peptic Ulcer Diseases

            By Edward A Lew, MD, MPH
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            Peptic Ulcer Diseases

            • EDWARD A LEW, MD, MPHStaff Gastroenterologist, VA Boston Healthcare System, Brigham and Women’s Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MA

            Peptic ulcers are defects or breaks in the inner lining of the gastrointestinal (GI) tract. Although the pathogenesis is multifactorial they tend to arise when there is an imbalance between protective and aggressive factors, such as when GI mucosal defense mechanisms are impaired in the presence of gastric acid and pepsin. Peptic ulcers extend through the mucosa and the muscularis mucosae, a thin layer of smooth muscle separating the mucosa from the deeper submucosa, muscularis propria, and serosa. Peptic ulcer disease affects up to 10% of men and 4% of women in Western countries at some time in their lives. This chapter discusses the pathogenesis of peptic ulcer disease and the etiologic contribution of Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs, and gastrinoma or other hypersecretory states. Also addressed are rare and unusual causes for ulcers and GI bleeding. A section on the diagnosis of peptic ulcers discusses clinical manifestations, physical examination findings, laboratory and imaging studies, and surgical diagnosis. Differential diagnosis is also reviewed. Tests to establish the etiology of peptic ulcer disease include endoscopy, quantitative serologic tests, the urea breath test, and the fecal antigen test. Discussed separately are treatments for uncomplicated duodenal ulcers, uncomplicated gastric ulcers, intractable duodenal or gastric ulcers, complicated peptic ulcers (bleeding ulcers, acute stress ulcers, perforated ulcers, obstructing ulcers, fistulizing ulcers, and Cameron ulcers), H. pylori ulcers, and gastric cancer. Figures illustrate the etiopathogenesis of peptic ulcers, prevalence of H. pylori infection in duodenal and gastric ulcer patients compared with normal controls, the approach to a patient with new and undiagnosed ulcerlike symptoms refractory to antisecretory therapy, an upper GI series showing an uncomplicated duodenal ulcer, a chest x-ray showing pneumoperitoneum from a perforated duodenal ulcer, gastric biopsy samples showing H. pylori organisms, and the approach to treatment and follow-up in patients with either complicated or uncomplicated duodenal or gastric ulcer. Tables list differential diagnoses of peptic ulcer disease, commonly used regimens to eradicate H. pylori, additional antimicrobial agents with activity against H. pylori, and FDA-approved antisecretory drugs for active peptic ulcer disease. This chapter contains 76 references.

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          • 7

            Diverticulosis, Diverticulitis, and Appendicitis

            By William V. Harford, MD, FACP
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            Diverticulosis, Diverticulitis, and Appendicitis

            • WILLIAM V. HARFORD, MD, FACPProfessor, Internal Medicine, University of Texas Southwestern Medical Center, Director, GI Endoscopy, VA Medical Center, Dallas, TX

            Colonic diverticula are herniations of colonic mucosa and submucosa through the muscularis propria. They occur where perforating arteries traverse the circular muscle layer, in parallel rows between the mesenteric and antimesenteric taenia. Colonic diverticular disease may present as diverticulosis, diverticulitis, or diverticular bleeding. Of patients with known diverticulosis, only 10% to 20% will develop diverticulitis. Diverticulitis varies in presentation and severity. This chapter discusses the diagnosis, differential diagnosis, and management of diverticulitis and its complications. Appendicitis is generally caused by obstruction of the lumen of the appendix, followed by infection. In the United States, the lifetime risk of appendicitis is about 9% for males and 7% for females. This chapter also discusses the diagnosis of appendicitis (including typical and atypical presentations and appendicitis as it presents in special groups of patients) and its management. Figures illustrate imaging study findings in diverticulitis and appendicitis. Tables describe the modified Hinchey classification of acute diverticulitis, the differential diagnosis of acute diverticulosis, and the differential diagnosis of appendicitis. This chapter contains 92 references.

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          • Constipation
            • Peptic Ulcer Disease
            • IM Geriatric Medicine
              • 1

                Approach to the Geriatric Patient

                By Tia Kostas, MD; Mark Simone, MD; James L Rudolph, MD, SM
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                Approach to the Geriatric Patient

                • TIA KOSTAS, MDAssistant Professor of Medicine, Section of Geriatrics & Palliative Medicine, Department of Medicine, University of Chicago, Chicago, IL
                • MARK SIMONE, MDInstructor of Medicine, Harvard Medical School, Associate Program Director-Primary Care, Mount auburn Hospital Internal Medicine Residency, Director, Quality Improvement, Division of Geriatric Medicine, Department of Medicine, Mount Auburn Hospital, Cambridge, MA
                • JAMES L RUDOLPH, MD, SMAssociate Professor of Medicine, Harvard Medical School, Chief (Interim) Geriatrics and Palliative Care, Director, Boston, GRECC, VA Boston Healthcare System, Jamaica Plain, MA, Acting Clinical Chief, Associate Epidemiologist, Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA

                As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in theDiagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults.

                This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

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              • 2

                Assessment of the Geriatric Patient

                By Michelle Martinchek, MD
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                Assessment of the Geriatric Patient

                • MICHELLE MARTINCHEK, MD

                Geriatric syndromes are complex conditions that are common in older adults and often have multiple contributing factors. These syndromes do not fit into discrete disease or organ system categories like other conditions. As the population of older adults continues to grow, it is important that providers are equipped to assess older adults for these geriatric syndromes. These syndromes are associated with functional disability and other poor outcomes. Examples of these syndromes include cognitive impairment, delirium, falls, frailty, weight loss, and pressure ulcers. Understanding the epidemiology, pathogenesis, and predisposing factors may help providers identify patients at risk for these syndromes. Furthermore, a thorough assessment is key in the evaluation of these syndromes.

                This review contains 48 references, 4 figures, and 8 tables.

                Key Words: cognition, dementia, delirium, fall, frailty, gait, geriatric, malnutrition, pressure ulcer, weight loss

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            • IM Hematology
              • 1

                Acute Leukemia

                By Richard A. Larson, MD; Roland B Walter, MD, PhD, MS
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                Acute Leukemia

                • RICHARD A. LARSON, MDProfessor of Medicine, Pritzker School of Medicine, University of Chicago. Chicago, IL
                • ROLAND B WALTER, MD, PHD, MSAssistant Member, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, Associate Professor of Medicine, Division of Hematology/Department of Medicine, University of Washington, Seattle, WA

                The acute leukemias are malignant clonal disorders characterized by aberrant differentiation and proliferation of transformed hematopoietic progenitor cells. These cells accumulate within the bone marrow and lead to suppression of the production of normal blood cells, with resulting symptoms from varying degrees of anemia, neutropenia, and thrombocytopenia or from infiltration into tissues. They are currently classified by their presumed cell of origin, although the field is moving rapidly to genetic subclassification. This review covers epidemiology; etiology; classification of leukemia by morphology, immunophenotyping, and cytogenetic/molecular abnormalities; cytogenetics of acute leukemia; general principles of therapy; acute myeloid leukemia; acute lymphoblastic leukemia; and future possibilities. The figure shows the incidence of acute leukemias in the United States. Tables list World Health Organization (WHO) classification of acute myeloid leukemia and related neoplasms, expression of cell surface and cytoplasmic markers for the diagnosis of acute myeloid leukemia and mixed-phenotype acute leukemia, WHO classification of acute lymphoblastic leukemia, WHO classification of acute leukemias of ambiguous lineage, WHO classification of myelodysplastic syndromes, European LeukemiaNet cytogenetic and molecular genetic subsets in acute myeloid leukemia with prognostic importance, cytogenetic and molecular subtypes of acute lymphoblastic leukemia, terminology used in leukemia treatment, and treatment outcome for adults with acute leukemia.

                This review contains 1 highly rendered figure, 9 tables, and 117 references.

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              • 2

                Lymphomas

                By Kieron Dunleavy, MD; Wyndham H Wilson, MD, PhD
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                Lymphomas

                • KIERON DUNLEAVY, MDAttending Physician/Investigator, Lymphoma Therapeutics Section, Metabolism Branch, National Cancer Institute, Bethesoa, Maryland
                • WYNDHAM H WILSON, MD, PHDSenior Investigator, Chief, Lymphoma Therapeutics Section, Metabolism Branch, National Cancer Institute, Bethesoa, Maryland

                Lymphoma is the fifth most common type of cancer in the United States, with 74,490 new cases estimated in 2009. Approximately 15% of patients with lymphoma have Hodgkin lymphoma; the remainder have one of the non-Hodgkin lymphomas. The incidence of non-Hodgkin lymphoma has increased steadily over recent decades. This chapter reviews the epidemiology, classification, clinical features, pathology, diagnostic evaluation, staging and prognosis, and treatment of Hodgkin and non-Hodgkin lymphoma. Other topics discussed include the acute and chronic effects of therapy for Hodgkin disease, as well as the subtypes of non-Hodgkin lymphomas, including indolent B cell lymphoma, follicular lymphoma, small lymphocytic lymphoma, mantle cell lymphoma, marginal-zone lymphoma, diffuse large B cell lymphoma (DLBCL), primary central nervous system lymphoma (PCNSL), Burkitt lymphoma, and HIV-related non-Hodgkin lymphoma. Figures illustrate the cellular appearance of Hodgkin lymphoma subtypes and DLBCL, diagnosis of DLBCL subtypes by gene expression, computed tomography and plain chest film in primary mediastinal cell lymphoma, MRI of the brain in PCNSL, and gene expression and gene expression predictors of survival among patients with DLBCL treated with rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine [Oncovin], and prednisone (R-CHOP). Tables describe the Ann Arbor classification and the Cotswold modification for staging of lymphoma; the International Prognostic Score for advanced Hodgkin lymphoma; the World Health Organization classification of hematopoietic neoplasms; chromosomal translocations in non-Hodgkin lymphoma; the Eastern Cooperative Oncology Group performance scale; the International Prognostic Index for aggressive non-Hodgkin lymphoma; and the Follicular Lymphoma International Prognostic Index. This chapter has 185 references.

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            • IM Hepatology
              • 1

                Evaluating the Patient With Liver Disease

                By Andrew J Muir, MD, MHS
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                Evaluating the Patient With Liver Disease

                • ANDREW J MUIR, MD, MHSClinical Director of Hepatology, Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC

                 Until the advanced stages of cirrhosis, the identification of liver disease can be challenging for clinicians. In the earlier stages of the condition, most forms of chronic liver disease are asymptomatic or associated with vague and rather nonspecific complaints, such as fatigue. Even in the setting of cirrhosis, liver enzymes may be normal or mildly elevated. Patients with liver disease are currently recognized through a variety of routes, including screening programs, routine laboratory testing, and imaging performed for other complaints.

                This review contains 5 figures, 10 tables and 64 references

                Key Words: Primary biliary cirrhosis, Variceal hemorrhage, hepatocellular carcinoma, Hepatitis A, B and C, Discriminant function, Liver biopsy, Alcoholic liver disease, Autoimmune hepatitis, Hemochromatosis, Nonalcoholic fatty liver disease, Wilson disease

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              • 2

                Cirrhosis and Complications of Portal Hypertension

                By Andres Cardenas, MD; Isabel Graupera, MD; Elsa Sola, MD; Pere Ginès, MD, PhD
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                Cirrhosis and Complications of Portal Hypertension

                • ANDRES CARDENAS, MDGI Unit, Hospital Clínic and University of Barcelona, Institut d’Investigacions Biomèdiques August Pi-Sunyer, Ciber de Enfermedades Hepaticas y Digestivas, Instituto Reina Sofía de Investigación Nefrológica, Barcelona, Spain
                • ISABEL GRAUPERA, MDLiver Unit, Hospital Clínic and University of Barcelona, Institut d’Investigacions Biomèdiques August Pi-Sunyer, Ciber de Enfermedades Hepaticas y Digestivas, Instituto Reina Sofía de Investigación Nefrológica, Barcelona, Spain
                • ELSA SOLA, MDLiver Unit, Hospital Clínic and University of Barcelona, Institut d’Investigacions Biomèdiques August Pi-Sunyer, Ciber de Enfermedades Hepaticas y Digestivas, Instituto Reina Sofía de Investigación Nefrológica, Barcelona, Spain
                • PERE GINÈS, MD, PHDChairman, Liver Unit, Hospital Clínic, Professor of Medicine, University of Barcelona, Institut d’Investigacions Biomèdiques August Pi-Sunyer, Ciber de Enfermedades Hepaticas y Digestivas, Instituto Reina Sofía de Investigación Nefrológica, Barcelona, Spain

                Cirrhosis is the most advanced stage of all the different types of chronic liver diseases. It is defined as a diffuse disorganization of normal hepatic structure by extensive fibrosis associated with regenerative nodules. Hepatic fibrosis is potentially reversible if the causative agent is removed. However, advanced cirrhosis leads to major alterations in the hepatic vascular bed and is usually irreversible. Cirrhosis is a progressive and severe clinical condition associated with considerable morbidity and high mortality. It leads to a wide spectrum of characteristic clinical manifestations, mainly attributable to hepatic insufficiency and portal hypertension. Major complications of portal hypertension include ascites, gastrointestinal (GI) variceal bleeding, hepatic encephalopathy (HE), renal failure, and bacterial infections. In recent years, major advances in the understanding of the natural history and pathophysiology of cirrhosis and the treatment of its complications have led to improved management, quality of life, and life expectancy of patients with this disease. Cirrhosis is also a risk factor for developing hepatocellular carcinoma (HCC). Decompensated cirrhosis carries a poor short-term prognosis; thus, orthotopic liver transplantation (OLT) should always be considered in suitable candidates. This chapter describes the epidemiology, etiology and genetic factors, pathogenesis, diagnosis, general management, and treatment of cirrhosis. Complications of cirrhosis are discussed, including ascites, spontaneous bacterial peritonitis, dilutional hyponatremia, hepatorenal syndrome, variceal bleeding, hepatopulmonary syndrome and postpulmonary hypertension, HE, and HCC. Indications and contraindications for liver transplantation are described. Figures show liver biopsy results and ultrasound images in cirrhosis from hepatitis C, a patient with tense ascites, transjugular intrahepatic portosystemic shunting (TIPS), large esophageal varices with red spots, and HCC. Tables outline the main causes of cirrhosis and the diagnostic methods for identifying them, the Child-Pugh score, diagnostic criteria for hepatorenal syndrome, grades of HE, and indications for liver transplantation.
                This chapter contains 6 highly rendered figures, 8 tables, 73 references.

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            • IM Infectious Diseases
              • 1

                Urinary Tract Infections

                By Sigal Yawetz, MD
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                Urinary Tract Infections

                • SIGAL YAWETZ, MDAssociate Physician, Brigham and Women’s Hospital, Boston, MA; Assistant Professor of Medicine, Harvard Medical School, Boston, MA

                Urinary tract infection (UTI) is the most common bacterial infection, affecting women far more than men. Aerobic gram-negative bacteria are the most common uropathogens causing UTI, with Escherichia coli remaining the most predominant organism in complicated infections. UTI can result in a variety of infections and inflammations, from asymptomatic bacteriuria to typical symptomatic cystitis to acute pyelonephritis, as well as bacterial prostatitis in men.

                In general, antimicrobial therapy is warranted for any symptomatic infection of the urinary tract. However, new consensus treatment guidelines for uncomplicated UTI in women, set by the Infectious Diseases Society of America and the European Society for Microbiology of Infection Diseases in 2010, account for the increasing antimicrobial resistance of pathogens and focus on first-line empirical treatment regimens. To reduce the use of antibiotics, treatment and prevention of recurrent UTI may involve several strategies on varying levels of effectiveness; some of the more well-tested options include probiotics, antiseptics, and topical estrogen. Antimicrobial approaches should be reserved for women in whom these options prove to be ineffective.

                This review contains 7 highly rendered figures, 7 tables, and 120 references.

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              • 2

                Acute Pneumonia

                By John I Hogan, MD; Benjamin Davis, MD
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                Acute Pneumonia

                • JOHN I HOGAN, MD
                • BENJAMIN DAVIS, MD

                Acute pneumonia continues to represent a major source of morbidity, mortality, and healthcare expenditure in the U.S. It is imperative that clinicians at all levels of training have a firm understanding of this potentially deadly infection and its numerous complications. The current state of our diagnostic capabilities often dictates that clinicians will need to make important therapeutic decisions in patients presenting with acute pneumonia before identifying a culprit pathogen. Only after understanding the pathogenesis of pneumonia under different clinical circumstances can one devise rational empiric therapeutic regimens. In this practical review we offer a succinct description of the epidemiology and pathogenesis of acute pneumonia. We then proceed to discuss the evaluation and management of patients presenting with acute pneumonia with emphasis on the most valuable clinical trials and major guidelines that we use to inform our clinical decisions. Despite significant advances in the field of infectious disease over the past century, clinicians continue to recognize pneumonia, the infection of the pulmonary parenchyma, as a major source of morbidity and mortality. In this article we attempt to provide the general practitioner with a practical review of acute pneumonia and its complications. Prioritizing the needs of the general practitioner, we most thoroughly address community acquired pneumonia (CAP). Though we do not intend for this review to be completely comprehensive, in this article we also briefly discuss healthcare associated pneumonia (HCAP), hospital associated pneumonia (HAP), and ventilator associated pneumonia (VAP). Focusing much of our attention on the most important clinical trials and guidelines underpinning the diagnosis and management of this common problem, we hope that this publication will serve as a useful review to aid in clinical decision making.

                This review contains 45 references, 1 figure and 5 tables.

                Key Words: Pneumonia, viral pneumonia, bacterial pneumonia, community-acquired pneumonia, ventilator-associated pneumonia, VAP, healthcare-associated pneumonia, hospital-acquired pneumonia


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              • 3

                Vaccines and Vaccination

                By Lindsey Obradovich, PharmD, MSc; Nicholas C Issa, MD
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                Vaccines and Vaccination

                • LINDSEY OBRADOVICH, PHARMD, MSCSenior Research Pharmacist, Investigational Drug Service, Brigham and Women’s Hospital, Boston, MA
                • NICHOLAS C ISSA, MDAssistant Professor of Medicine, Harvard Medical School, Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA

                The advent of vaccination began a new era in the world and in medicine. From the eradication of smallpox and near-eradication of polio to the significant reduction in many childhood diseases, vaccination has saved countless lives. Progress continues today in the form of safer and more effective vaccines, along with new vaccines against old and emerging pathogens that threaten worldwide pandemics. Several vaccines have been approved recently by the Food and Drug Administration, including a more immunogenic pneumococcal vaccine, new meningococcal serotype B vaccines, a 9-valent HPV vaccine, and the first adjuvanted influenza vaccine. Additional advancement with improved vaccines against herpes zoster and novel vaccines against emerging pathogens (Ebola and Zika viruses) is on the horizon. In this review, we discuss the immune mechanisms by which vaccines induce protection, the different types of vaccines, and the most recent recommendations by the Advisory Committee on Immunization Practices for vaccination schedules in adults. Key information for the general practitioner is presented in a concise and easy-to-read format, summarized in tables whenever possible. Vaccination in special populations, such as pregnant women, immunocompromised patients, international travelers, and health care workers, is also included in this review. A list of guidelines is also included.

                Key words: immunocompromised host, postexposure prophylaxis, travel, vaccination, vaccine

                This review contains 7 highly rendered figures, 12 tables, and 57 references.

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              • 4

                Specific Antibiotic Agents

                By Alyssa R. Letourneau, MD, MPH; Michael S. Calderwood, MD, MPH
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                Specific Antibiotic Agents

                • ALYSSA R. LETOURNEAU, MD, MPHDepartment of Medicine , Harvard Medical School, Assistant Director, Antimicrobial Stewardship Program, Massachusetts General Hospital, Boston, MA
                • MICHAEL S. CALDERWOOD, MD, MPHAssistant Professor, Department of Medicine, Harvard Medical School, Assistant Hospital Epidemiologist/Associate Director, Antimicrobial Stewardship, Brigham and Women’s Hospital, Boston, MA

                The simultaneous use of multiple antibiotics in a shotgun fashion should be avoided because of the problems of drug toxicity and hypersensitivity reactions, microbial superinfections, and antagonisms between certain agents. Most bacterial infections can be treated satisfactorily with a single antibiotic agent. There are a limited number of situations, however, in which the simultaneous administration of different antibiotics is warranted. This review covers specific antimicrobial agents, including β-lactam antibiotics, aminoglycosides, polymyxins, tetracyclines, macrolides, clindamycin, nitroimidazoles, chloramphenicol, vancomycin, lipoglycopeptides, oxazolidinones, daptomycin, streptogramins, sulfonamides and trimethoprim, fluoroquinolones, nitrofurantoin, fosfomycin, rifamycins, and fidaxomicin, and provides empirical therapy recommendations. Figures show an overview of penicillin antibiotics, an overview of β-lactam/β-lactamase inhibitor combinations, and a positive D-zone test for inducible clindamycin resistance. Tables list antibacterial guidelines for initial inpatient empirical therapy and empirical sepsis guidelines.

                This review contains 3 highly rendered figures, 2 tables, and 48 references.

                Keywords: β-Lactam Antibiotics ,penicillins,Cephalosporins, Carbapenems , monobactams, Gentamicin, Tobramycin, Polymyxins, Tetracyclines, Clarithromycin, Clindamycin

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              • 5

                Urinary Tract Infections

                By Sigal Yawetz, MD
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                Urinary Tract Infections

                • SIGAL YAWETZ, MDAssociate Physician, Brigham and Women’s Hospital, Boston, MA; Assistant Professor of Medicine, Harvard Medical School, Boston, MA

                Urinary tract infection (UTI) is the most common bacterial infection, affecting women far more than men. Aerobic gram-negative bacteria are the most common uropathogens causing UTI, with Escherichia coli remaining the most predominant organism in complicated infections. UTI can result in a variety of infections and inflammations, from asymptomatic bacteriuria to typical symptomatic cystitis to acute pyelonephritis, as well as bacterial prostatitis in men.

                In general, antimicrobial therapy is warranted for any symptomatic infection of the urinary tract. However, new consensus treatment guidelines for uncomplicated UTI in women, set by the Infectious Diseases Society of America and the European Society for Microbiology of Infection Diseases in 2010, account for the increasing antimicrobial resistance of pathogens and focus on first-line empirical treatment regimens. To reduce the use of antibiotics, treatment and prevention of recurrent UTI may involve several strategies on varying levels of effectiveness; some of the more well-tested options include probiotics, antiseptics, and topical estrogen. Antimicrobial approaches should be reserved for women in whom these options prove to be ineffective.

                This review contains 7 highly rendered figures, 7 tables, and 120 references.

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              • 6

                HIV and AIDS

                By Daniel R. Kuritzkes, MD, FACP
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                HIV and AIDS

                • DANIEL R. KURITZKES, MD, FACP

                In the quarter-century since the first report of AIDS in the United States, HIV infection has spread throughout the population, disproportionately affecting black women, Hispanic women, and men who have sex with men. The prognosis for persons infected with HIV has improved dramatically with the introduction and evolution of highly active antiretroviral therapy (HAART). The underlying principle of HAART is that a combination of potent antiretrovirals, each of which requires different mutations in the HIV genome for resistance to develop, can suppress replication sufficiently to prevent mutation and the emergence of resistance. The prospect that currently available antiretroviral therapy (ART) regimens may suppress HIV replication indefinitely provides the hope that infected patients will have life expectancies similar to those of age-matched uninfected individuals. For these patients, HIV care has shifted from an emphasis on treatment and prevention of the complications of HIV disease itself to a focus on suppression of HIV replication and management of short- and long-term complications of HIV, ART toxicities, and aging. This chapter describes the epidemiology, pathophysiology and pathogenesis, prevention, diagnosis, and management of acute and chronic HIV infection and AIDS, with figures and tables illustrating each chapter section.


                This review contains 9 highly rendered figures, 22 tables, and 248 references.

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            • IM Interdisciplinary Medicine
              • 1

                Physicians' Role in Curbing the Worst Drug Crisis in America: Prescription Opioid Abuse

                By Sairam Atluri, MD, FIPP; Gururau Sudarshan, MD, FRCA
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                Physicians' Role in Curbing the Worst Drug Crisis in America: Prescription Opioid Abuse

                • SAIRAM ATLURI, MD, FIPPDirector, Tristate Pain Management Institute, Cincinnati, OH
                • GURURAU SUDARSHAN, MD, FRCADirector, Cincinnati Pain Physicians, Cincinnati, OH

                Opioids have an important role in the management of acute, cancer, and chronic pain. However, their indiscriminate use in chronic pain has led, in part, to the epidemic of prescription drug abuse, resulting in a dramatic increase in morbidity and mortality in America. Most of this abuse originates from legitimate prescriptions by physicians. Prescribing opioids to chronic pain patients while restricting them to those who abuse them is very challenging, and physicians seek appropriate and unbiased prescribing guidelines. Our review, based on analysis of the available literature, focuses on striking a balance between overprescribing and underprescribing. The core concept of this strategy relies in using screening tools to identify patients who are at high risk for opioid abuse along with diligent monitoring using prescription monitoring programs and urine drug screens, while also limiting opioid doses. Hopefully, using these principles, physicians can more confidently prescribe opioids to those who would benefit from these powerful drugs and at the same time keep opioids away from those who could potentially be harmed.

                Key Words: abuse, addiction, chronic pain, dose limitation, misuse, monitoring, opioids, overdose, screening

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              • 2

                Diet and Exercise in the Treatment of Obesity

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                Diet and Exercise in the Treatment of Obesity

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              • 3

                Diet

                By Elizabeth G Nabel, MD, FACP
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                Diet

                • ELIZABETH G NABEL, MD, FACPPresident, Brigham and Women’s Hospital, Professor of Medicine, Harvard Medical School, Boston, MA

                An unhealthy diet is a major risk factor for chronic diseases such as cardiovascular diseases, cancer, diabetes, and conditions related to obesity. In the 20th century, the average American diet shifted from one based on fresh, minimally processed vegetable foods to one based on animal products and highly refined, processed foods, leading to an increased consumption of calories, fat, cholesterol, refined sugar, animal protein, sodium, and alcohol and far less fiber and starch than was healthful. As a result, more than one third of US adults are obese, with an estimated medical cost of $147 billion. Physicians have an important role in educating patients about healthful nutrition and in providing dietary guidelines. This module discusses the role of energy in weight loss; the structure of fat and cholesterol, their effects on blood lipid levels and cardiovascular risk, and related dietary recommendations; carbohydrates; dietary fiber; proteins; vitamin and mineral consumption; water and food consumption; and the relationship between diet and health. Tables review the principles of a healthy diet; recommended daily intake of fat and other nutrients; types of dietary fiber and representative food sources; types of vitamins; essential minerals and trace elements; and dietary guidelines for healthy people. Figures include a graph showing the percentage of adults who are healthy weight, overweight, and obese and the structure of fat and cholesterol.

                This review contains 2 highly rendered figures, 6 tables, and 37 references.

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              • 4

                Exercise

                By Elizabeth G Nabel, MD, FACP
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                Exercise

                • ELIZABETH G NABEL, MD, FACPPresident, Brigham and Women’s Hospital, Professor of Medicine, Harvard Medical School, Boston, MA

                Numerous observational studies have demonstrated an inverse relationship between physical activity and risk of many chronic illnesses. The protective effect of exercise is strongest against coronary artery disease, hypertension, stroke, type 2 diabetes mellitus, obesity, anxiety, depression, osteoporosis, and cancers of the colon and breast. Despite these proven benefits, only 25% of adults in the United States exercise at recommended levels. Globally, physical inactivity is the fourth leading risk factor for death, followed by overweight and obesity. This module describes exercise physiology, including cardiovascular response to dynamic exercise, pulmonary response, musculoskeletal response, metabolic effects, effects on blood lipid levels, hematologic effects, effects on vascular inflammation, effects on body fluids, and psychological effects. Exercise and the elderly and the relationship between exercise and longevity are reviewed. Prescribing exercise and complications of exercise are also discussed. Tables describe the categories of patients screened for possible coronary artery disease, exercise time required to consume 2,000 kcal, and exercise advice for patients. Figures include a graph showing the number of adults who met the federal physical activity guidelines criteria, the top 10 global risk factors for death in 2004, the process of providing energy for the muscle, and trends in physician prescriptions for exercise.

                This module contains 4 highly rendered figures, 3 tables, 35 references, and 5 MCQs.

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              • 5

                Medical Evaluation of the Surgical Patient

                By Marie Gerhard-Herman, MD; Jonathan Gates, MD
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                Medical Evaluation of the Surgical Patient

                • MARIE GERHARD-HERMAN, MDDepartment of Medicine, Cardiovascular Division, Brigham and Womens Hospital, Boston, MA
                • JONATHAN GATES, MDDirector of the Burn and Trauma Unit, Department of Surgery, Brigham and Womens Hospital, Boston, MA

                Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium.

                This review contains 3 highly rendered figures, 12 tables, and 68 references.

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              • 6

                Psychoactive Medications

                By Mark J Neavyn, MD; Kavita M Babu, MD
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                Psychoactive Medications

                • MARK J NEAVYN, MDDirector of Medical Toxicology, Department of Emergency Medicine, Hartford Hospital, Hartford, CT
                • KAVITA M BABU, MDFellowship Director, Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA

                Psychoactive medications are defined as medications that affect the central nervous system neurotransmitter pathways with the intention to modulate mood or consciousness. This broad category of medications includes sedative-hypnotic agents such as benzodiazepines and barbiturates, antidepressants, neuroleptics, and mood stabilizers. The principal source of exposure for these medications is through prescription drug use and misuse. This review discusses the principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcomes related to sedative-hypnotics, antidepressants, neuroleptics, and lithium. Tables include common benzodiazepine and barbiturate compounds, dosing instructions for multidose activated charcoal, flumazenil dosing recommendations, commonly available tricyclic and atypical (noncyclic) antidepressants, dosing recommendations for sodium bicarbonate in serum alkalinization, benzodiazepine dosing recommendations in serotonin syndrome, dosing recommendations for cyproheptadine, signs and symptoms that differentiate  neuroleptic malignant syndrome from serotonin syndrome, and indications for renal replacement therapy based on lithium concentration and clinical setting. Figures show action potentials in the His-Purkinje syndrome, an electrocardiogram tracing demonstrating a terminal R wave, and a QT interval nomogram.

                This review contains 2 highly rendered figures, 9 tables, and 101 references.

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            • IM Nephrology
              • 1

                Chronic Kidney Failure and Dialysis

                By Raghu V Durvasula, MD; Jonathan Himmelfarb, MD
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                Chronic Kidney Failure and Dialysis

                • RAGHU V DURVASULA, MDAssistant Professor of Medicine, Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Seattle, WA
                • JONATHAN HIMMELFARB, MDDepartment of Medicine, Division of Nephrology, University of Washington School of Medicine, Seattle, WA

                Chronic kidney disease (CKD) is a clinical syndrome arising from progressive kidney injury, formerly known as chronic renal failure, chronic renal disease, and chronic renal insufficiency. It is classified into five stages based primarily on glomerular filtration rate (GFR). This article discusses the epidemiology of CKD and end-stage renal disease (ESRD), as well as etiology and genetics, pathophysiology, and pathogenesis. The section on diagnosis looks at clinical manifestations and physical findings, laboratory (and other) tests, imaging studies, and biopsy. A short section on differential diagnosis is followed by a discussion of treatment, including hemodialysis and peritoneal dialysis. Long-term complications of patients on dialysis include cardiovascular disease, renal osteodystrophy, dialysis-related amyloidosis, and acquired cystic disease (renal cell carcinoma). The final section addresses prognosis and socioeconomic burden. Figures include the classification system for CKD, prevalence of CKD in the United States, rising prevalence, risk of, and leading causes of ESRD in the United States, plus the changing prevalence of ESRD over time, clinical manifestations of uremia, and an overview of hemodialysis circuit. Tables look at the burden of CKD relative to other chronic disorders, the specific hereditary causes of kidney disease, and situations when serum creatinine does not accurately predict GFR. Other tables list equations for estimating GFR, the causes of CKD without shrunken kidneys, and clinical features distinguishing chronic kidney disease from acute kidney injury. ESRD and indications for initiation of dialysis are presented, as well as typical composition of dialysate and reasons for failure of peritoneal dialysis. This chapter contains 71 references.

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              • 2

                Nephrolithiasis

                By José Luiz Nishiura, MD, PhD; Ita Pfeferman Heilberg, MD, PhD
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                Nephrolithiasis

                • JOSÉ LUIZ NISHIURA, MD, PHDAssociate Researcher, Nephrology Division, Federal University of São Paulo, São Paulo, Brazil.
                • ITA PFEFERMAN HEILBERG, MD, PHDAssociate Professor, Nephrology Division, Federal University of São Paulo, São Paulo, Brazil.

                Nephrolithiasis is a highly prevalent condition, but its incidence varies depending on race, gender, and geographic location. Approximately half of patients form at least one recurrent stone within 10 years of the first episode. Renal stones are usually composed of calcium salts (calcium oxalate monohydrate or dihydrate, calcium phosphate), uric acid, or, less frequently, cystine and struvite (magnesium, ammonium, and phosphate). Calcium oxalate stones, the most commonly encountered ones, may result from urinary calcium oxalate precipitation on the Randall plaque, which is a hydroxyapatite deposit in the interstitium of the kidney medulla. Uric acid nephrolithiasis, which is common among patients with metabolic syndrome or diabetes mellitus, is caused by an excessively acidic urinary pH as a renal manifestation of insulin resistance. The medical evaluation of the kidney stone patient must be focused on identifying anatomic abnormalities of the urinary tract, associated systemic diseases, use of lithogenic drugs or supplements, and, mostly, urinary risk factors such as low urine volume, hypercalciuria, hyperuricosuria, hypocitraturia, hyperoxaluria, and abnormalities in urine pH that can be affected by dietary habits, environmental factors, and genetic traits. Metabolic evaluation requires a urinalysis, stone analysis (if available), serum chemistry, and urinary parameters, preferably obtained by two nonconsecutive 24-hour urine collections under a random diet. Targeted medication and dietary advice are effective to reduce the risk of recurrence. Clinical, radiologic, and laboratory follow-ups are needed to prevent stone growth and new stone formation, to assess treatment adherence or effectiveness to dietary recommendations, and to allow adjustment of pharmacologic treatment.

                This review contains 5 highly rendered figure, 3 tables, and 105 references.

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              • 3

                Acute Kidney Injury - Part I

                By Paul W Sanders, MD, FACP; Anupam Agarwal, MD, FASN
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                Acute Kidney Injury - Part I

                • PAUL W SANDERS, MD, FACPProfessor and Director, Nephrology Research and Training Center, University of Alabama at Birmingham, Chief, Renal Section, Birmingham Veterans Affairs Medical Center, Birmingham, AL
                • ANUPAM AGARWAL, MD, FASNProfessor and Director, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL

                Acute renal failure (ARF) has been defined as a syndrome in which an abrupt decrease in renal function produces retention of nitrogenous waste products. Translating this abstract description into a clinically useful, accurate, and widely accepted definition has been challenging, in large part because of the focus on serum creatinine concentration, which is easily obtained but has the inherent limitation of poor detection of rapid or subtle, but clinically important, changes in the glomerular filtration rate (GFR). In recent years, therefore, the term acute kidney injury (AKI) has replaced ARF because AKI denotes the entire clinical spectrum from mild increases in serum creatinine to overt renal failure. AKI is defined by the Risk-Injury-Failure-Loss-ESRD (RIFLE) criteria, based on serum creatinine concentration and urine flow rate. The Acute Kidney Injury Network (AKIN) subsequently modified the definition further and divided AKI into three stages. This chapter includes discussions of the etiology and diagnosis of AKI in hospitalized patients and community-acquired AKI. The specific causes, management, and complications of AKI are also discussed. Figures illustrate the pathophysiologic classification of AKI and the effect of hyperkalemia on cardiac conduction—electrocardiogram (ECG) changes. A worksheet for following patients with AKI is provided. 

                This review contains 3 figures, 20 tables, and 46 references.

                Keywords:Acute kidney injury, dialysis, contrast, rhabdomyolysis, nephropathy, urinalysis, multiple myeloma, ethylene glycol, sepsis, hepatorenal syndrome

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              • 4

                Acute Kidney Injury - Part II: Special Situations

                By Paul W Sanders, MD, FACP; Anupam Agarwal, MD, FASN
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                Acute Kidney Injury - Part II: Special Situations

                • PAUL W SANDERS, MD, FACPProfessor and Director, Nephrology Research and Training Center, University of Alabama at Birmingham, Chief, Renal Section, Birmingham Veterans Affairs Medical Center, Birmingham, AL
                • ANUPAM AGARWAL, MD, FASNProfessor and Director, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL

                Acute renal failure (ARF) has been defined as a syndrome in which an abrupt decrease in renal function produces retention of nitrogenous waste products. Translating this abstract description into a clinically useful, accurate, and widely accepted definition has been challenging, in large part because of the focus on serum creatinine concentration, which is easily obtained but has the inherent limitation of poor detection of rapid or subtle, but clinically important, changes in the glomerular filtration rate (GFR). In recent years, therefore, the term acute kidney injury (AKI) has replaced ARF because AKI denotes the entire clinical spectrum from mild increases in serum creatinine to overt renal failure. AKI is defined by the Risk-Injury-Failure-Loss-ESRD (RIFLE) criteria, based on serum creatinine concentration and urine flow rate. The Acute Kidney Injury Network (AKIN) subsequently modified the definition further and divided AKI into three stages. This part of the AKI review specifically discusses special situations: rhabdomyolysis, aristolochic acid nephropathy, acute urate nephropathy, acute phosphate nephropathy, AKI in multiple myeloma, ehytlene glycol poisoning, contrast-induced nephropathy, AKI in sepsis, hepatorenal syndrome, and AKI in pregnancy.

                This review contains 10 tables, and 47 references.

                Keywords:Acute kidney injury, dialysis, contrast, rhabdomyolysis, nephropathy, urinalysis, multiple myeloma, ethylene glycol, sepsis, hepatorenal syndrome

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            • IM Neurology
              • 1

                Dizziness

                By Kevin A. Kerber, MD, MS; Robert W. Baloh, MD
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                Dizziness

                • KEVIN A. KERBER, MD, MSAssistant Professor, Department of Neurology, University of Michigan, Ann Arbor, MI
                • ROBERT W. BALOH, MDProfessor, Departments of Neurology and Surgery (Head and Neck), UCLA Medical Center, Reed Neurological Research Center, Los Angeles, CA

                Dizziness is the quintessential symptom presentation in all of clinical medicine. It is a common reason that patients present to a physician. This chapter provides background information about the vestibular system, then reviews key aspects of history-taking and examination of the patient, then discusses specific disorders and common presentation types. Throughout the chapter the focus is on neurologic and vestibular disorders. Normal vestibular anatomy and physiology are discussed, followed by recommendations for history-taking and the physical examination. Specific disorders that cause dizziness are explored, along with common causes of non-specific dizziness. Common presentations are discussed, including acute severe dizziness, recurrent attacks, and recurrent positional vertigo. Finally, the chapter looks at laboratory investigations in diagnosis and management. Figures include population prevalence of dizziness symptoms, the anatomy of inner structures, primary afferent vestibular nerve activity, the head thrust test, the Dix-Hallpike maneuver, the supine positional test, the canalith repositioning procedure, and the barbecue roll maneuver. Tables list physiologic properties and clinical features of the components of the peripheral vestibular system, information to be acquired from history of the present illness, common symptoms patients report as dizziness, examination components, distinguishing among common peripheral and central vertigo syndromes, common causes of nonspecific dizziness, types of dizziness presentations, relevant imaging abnormalities on neuroimaging studies, vestibular testing components, and medical therapy for symptomatic dizziness.

                This review contains 8 highly rendered figures, 11 tables, and 69 references.

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              • 2

                Stroke and Other Cerebrovascular Diseases

                By Scott E. Kasner, MD, MSCE, FAHA, FAAN; Christina A Wilson, MD, PhD
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                Stroke and Other Cerebrovascular Diseases

                • SCOTT E. KASNER, MD, MSCE, FAHA, FAANProfessor, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Director, Comprehensive Stroke Center, University of Pennsylvania Health System, Philadelphia, PA
                • CHRISTINA A WILSON, MD, PHDAssistant Professor, Department of Neurology, University of Florida, Gainesville, FL

                Stroke is a leading cause of neurologic morbidity and mortality, and rapid treatment is key for a good outcome. This review addresses the epidemiology, common presenting symptoms, causes, and treatment of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Current recommendations for the emergent evaluation and treatment of an acute ischemic stroke are highlighted, including recently updated indications and contraindications for intravenous recombinant tissue plasminogen activator administration and recent guidelines for the expanded role of endovascular mechanical embolectomy for stroke due to acute large vessel occlusion. An algorithm of diagnostic evaluations to assist with identification of the cause of ischemic stroke is offered. Evidence-based primary and secondary stroke prevention is discussed, including the ideal choice of antithrombotic based on identified stroke mechanism and optimal risk factor management. Best practice supportive measures for the post-stroke patient are highlighted, including recent guidelines for the management of elevated intracranial pressure. Management of uncommon causes of ischemic stroke is also addressed. 

                Key Words: Intracerebral hemorrhage, ischemic stroke, recombinant tissue plasminogen activator, subarachnoid hemorrhage

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              • 3

                Clinical Aspects of Alzheimer Disease

                By David Knopman, MD
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                Clinical Aspects of Alzheimer Disease

                • DAVID KNOPMAN, MDProfessor of Neurology, Department of Neurology, Mayo Clinic, Rochester, MN

                The clinical diagnosis of Alzheimer disease (AD) has been well established, but there is a widespread misunderstanding about the relationship between dementia (a syndrome) and AD (a cause of dementia). AD is the most common etiology that causes dementia in mid- and late life. The prototypical clinical presentation is that of a gradually worsening problem with learning new information, that is, a short-term memory deficit, accompanied by cognitive impairment in other domains, including language, spatial cognition, and executive functioning, as well as changes in personality and behavior. A key element of the diagnosis of dementia is that daily functioning is impaired. The concept of mild cognitive impairment (MCI) as the earliest symptomatic presentation of a dementing illness is now widely accepted. MCI due to AD typically presents with isolated problems with learning and memory without substantial loss of ability to function in daily life.  Less common variants of AD are now recognized and include a disorder in which spatial and visual cognitive dysfunction occurs or in which word-finding problems predominate at the onset of symptoms. Although AD as a cause of dementia is the most common among etiologies, AD often co-occurs with other neurodegenerative diseases and with cerebrovascular disease. The presence of multietiology dementia in which AD is a contributor is particularly common in the eighth decade of life and beyond. 

                Key words: Alzheimer disease, cognitive impairment, dementia, mild cognitive impairment

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              • 4

                Epilepsy and Related Disorders

                By Barbara Dworetzky, MD; Jong Woo Lee, MD, PhD
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                Epilepsy and Related Disorders

                • BARBARA DWORETZKY, MDAssociate Professor of Neurology, Harvard Medical School, Chief, Division of Epilepsy, EEG, and Sleep Neurology, Director, The Edward B. Bromfield Epilepsy Program, Brigham and Women’s Hospital, Boston, MA
                • JONG WOO LEE, MD, PHDAssistant Professor of Neurology, Harvard Medical School, Director, ICU EEG Monitoring, The Edward B. Bromfield Epilepsy Program, Brigham and Women’s Hospital, Boston, MA

                Epilepsy is a chronic disorder of the brain characterized by recurrent unprovoked seizures. A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event. A reversible or avoidable seizure precipitant, such as alcohol, argues against underlying epilepsy and therefore against treatment with medication. This chapter discusses the epidemiology, etiology, and classification of epilepsy and provides detailed descriptions of neonatal syndromes, syndromes of infancy and early childhood, and syndromes of late childhood and adolescence. The pathophysiology, diagnosis, and differential diagnosis are described, as are syncope, migraine, and psychogenic nonepileptic seizures. Two case histories are provided, as are sections on treatment (polytherapy, brand-name versus generic drugs, surgery, stimulation therapy, dietary treatments), complications of epilepsy and related disorders, prognosis, and quality measures. Special topics discussed are women?s issues and the elderly. Figures illustrate a left midtemporal epileptic discharge, wave activity during drowsiness, cortical dysplasias, convulsive syncope, rhythmic theta activity, right hippocamal sclerosis, and right temporal hypometabolism. Tables describe international classifications of epileptic seizures and of epilepsies, epilepsy syndromes and related seizure disorders, differential diagnosis of seizure, differentiating epileptic versus nonepileptic seizures, antiepileptic drugs, status epilepticus protocol for treatment, when to consider referral to a specialist, and quality measures in epilepsy. 

                This review contains 7 figures, 10 tables, and 33 references.

                Key Words: Seizures, focal (partial)seizure, generalized seizures, Myoclonic seizures, Atonic seizures, Concurrent electromyographyTonic-clonic (grand mal) seizures

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              • 5

                Headache

                By Benjamin W Friedman, MD, MS
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                Headache

                • BENJAMIN W FRIEDMAN, MD, MSProfessor of Emergency Medicine, Department of Emergency Medicine,Albert Einstein College of Medicine, Montefi ore Medical Center, Bronx, NY

                Headaches are one of the most common complaints of patients seen by emergency physicians. They can be classified as primary headaches, which have no identifiable underlying cause, and secondary headaches, which are classified according to their cause. The majority of headaches are benign in origin, and most patients with headache can be treated successfully in the emergency department and discharged home; however, some have potentially life-threatening causes, and consideration of a broad differential diagnosis for all patients is essential. This review covers the primary headache disorders, pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes. The figure shows areas of the brain sensitive to pain. Tables review differential diagnosis of headache, International Headache Society primary headache criteria, clinical characteristics of secondary headaches, high-risk clinical characteristics among patients with a headache peaking in intensity within 1 hour, drugs associated with headache, and parenteral treatment of acute migraine.

                This review contains 1 figure, 9 tables, and 58 references.


                Key words: migraine, calcitonin gene related peptide, greater occipital nerve block, venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, Ottawa, subarachnoid, cluster headache, trigeminal autonomic cephalalgias, post-traumatic headache

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              • 6

                Blunt Cerebrovascular Injuries

                By Clay Cothren Burlew, MD, FACS
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                Blunt Cerebrovascular Injuries

                • CLAY COTHREN BURLEW, MD, FACSProgram Director, Trauma and Acute Care Surgery Fellowship, Department of Surgery, Denver Health Medical Center, Associate Professor of Surgery, University of Colorado, Denver, CO

                Blunt cerebrovascular injuries (BCVIs) are increasingly recognized in trauma patients, with 1 to 3% of all blunt trauma patients being diagnosed with a carotid artery injury or a vertebral artery injury. Specific injury patterns are associated with BCVI and serve as the trigger for injury screening in asymptomatic patients. Multislice (> 64-slice) computed tomographic angiography is the routine imaging test performed to identify BCVI. Once an injury is identified, antithrombotic treatment almost universally prevents BCVI-related stroke. Endovascular therapy for BCVI is reserved for those patients who are markedly symptomatic or have an enlarging pseudoaneurysm on repeat imaging.

                Key Words: blunt cerebrovascular injuries, blunt trauma, carotid artery injury, stroke, vertebral artery injury

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              • 7

                Parkinsonism and Related Disorders

                By Elizabeth J. Slow, MD, PhD; Anthony E. Lang, MD
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                Parkinsonism and Related Disorders

                • ELIZABETH J. SLOW, MD, PHDAssistant Professor, Morton and Gloria Shulman Movement Disorders Clinic and The Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, University of Toronto, Toronto, ON
                • ANTHONY E. LANG, MDProfessor, Morton and Gloria Shulman Movement Disorders Clinic and The Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, University of Toronto, Toronto, ON

                Parkinsonism describes the core clinical criteria of tremor, bradykinesia, rigidity, and postural instability. There is a large differential diagnosis, but the most common cause of parkinsonism is due to Parkinson disease. This review details the epidemiology, etiology/genetics, pathogenesis, diagnosis and differential diagnosis, management, and prognosis of Parkinson disease, dementia with Lewy bodies, progressive supranuclear palsy, corticobasal degeneration, vascular parkinsonism, normal pressure hydrocephalus, and drug-induced parkinsonism. 

                This review contains 8 figures, 32 tables, and 73 references.

                Keywords: Parkinson disease, parkinsonism, levodopa, cogwheel ridigity, multiple system atrophy, dementia, substantia nigra, palsy, neurodegenerative disease, hydrocephalus, Lewy body, Lewy neurite

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            • IM Oncology
              • 1

                Colorectal Cancer

                By Cathy Eng, MD, FACP
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                Colorectal Cancer

                • CATHY ENG, MD, FACPAssociate Professor, Associate Director of the Colorectal Center, The University of Texas M.D. Anderson Cancer Center, Houston, TX

                Colorectal cancer is the third most common cancer and the second leading cause of cancer death in the United States. Although environmental factors, including diet and lifestyle, clearly play a role in the etiology of colorectal cancer, as many as 25% of patients with colorectal cancer have a family history of the disease, which suggests the involvement of a genetic factor. Inherited colon cancers can be divided into two main types: the well-studied but rare familial adenomatous polyposis (FAP) syndrome, and the increasingly well-characterized, more common hereditary nonpolyposis colorectal cancer (HNPCC, a.k.a. Lynch Syndrome). The prevention, screening, diagnosis, and treatment of cancers of the colon and rectum are covered in this chapter. Figures illustrate various forms of adenomatous polyps, the tumor, node, metastasis (TNM) staging system for colorectal cancer, and the five-year survival rate in patients with colorectal carcinoma. Tables describe risk factors; possible chemopreventive agents; evidence supporting the effectiveness of screening tests; features and usage issues with different fecal occult blood tests; recommendations for early detection, screening, and surveillance for patients at different levels of risk; colorectal cancer staging systems; indicators of poor prognosis; and chemotherapeutic and biologic agents in the treatment of colorectal cancer. This chapter contains 197 references.

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              • 2

                Cancer Epidemiology and Prevention

                By Alfred I. Neugut, MD, PhD, FACP; David P Wu, MD
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                Cancer Epidemiology and Prevention

                • ALFRED I. NEUGUT, MD, PHD, FACPMyron Studner Professor of Cancer Research, Professor of Medicine and Public Health, Columbia University Medical Center, New York, NY
                • DAVID P WU, MDPostdoctoral Clinical Fellow in Hematology Oncology, Columbia University Medical Center, New York, NY

                Recently surpassing heart disease, cancer is now the leading cause of death (one in four) in the United States. Worldwide, cancer control is becoming increasingly important as life expectancy improves because of lower infant mortality and fewer deaths from infectious diseases. Morbidity and mortality from many forms of cancer can be controlled through primary or secondary prevention. Primary prevention can be defined as risk modification to lower cancer occurrence. Secondary prevention refers to the use of screening tests to detect cancers at early stages. Environmental carcinogens, inherited factors that predispose to cancer, and screening and early detection are covered in major sections. Also included are discussions of infectious agents, occupational carcinogens, iatrogenic causes, carcinogens affecting the reproductive system, and miscellaneous environmental causes. Tables outline established causes of human cancer, common hereditary cancers and syndromes attributable to germline mutations in predisposing genes, and the American Cancer Society’s recommendations for early detection of cancer. This chapter contains 138 references.

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              • 3

                Tumor Immunology

                By Rachel L Maus, PhD; Haidong Dong, MD, PhD; Svetomir N Markovic, MD, PhD
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                Tumor Immunology

                • RACHEL L MAUS, PHDResearch Fellow, Department of Immunology, Mayo Clinic, Rochester, MN
                • HAIDONG DONG, MD, PHDConsultant, Associate Professor of Immunology, Departments of Urology and Immunology, Mayo Clinic, Rochester, MN
                • SVETOMIR N MARKOVIC, MD, PHDConsultant, Professor of Medicine and Oncology, Departments of Oncology, Immunology and Hematology, Mayo Clinic, Rochester, MN

                The immune system has effectively evolved to protect the host against foreign invaders, including bacterial, viral, and parasitic infiltrates. Less clear has been the interaction and the protective effects the immune system mounts against its own infiltrates: cancer cells. Here we consider the dynamic interactions between cancer and the associated host immune response by highlighting the key players involved in engaging an effective antitumor immune response and the mechanisms responsible for enabling the evolution of cancer cells to escape immunosurveillance. By developing an appreciation for the dual function of the immune system in the setting of cancer biology, we also consider the clever strategies that have been employed to uncover tumor targets, including tumor-associated antigens and the mechanisms for enhancing or reengaging the immune system to mount an effective antitumor immune response. Finally, we incorporate these key findings into the context of immunotherapy, a rapidly evolving field aimed at combating tumor escape by enabling the host immune system to regain its tumor-eradicating functions.

                This review contains 5 figures, 9 tables and 60 references

                Key words: adoptive T cell therapy, checkpoint inhibitors, cytokine therapy, immunotherapy, neutralizing antibodies, tumor immunity, tumor microenvironment, vaccines 

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              • 4

                Breast Cancer

                By Nancy E Davidson, MD
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                Breast Cancer

                • NANCY E DAVIDSON, MDDirector, University of Pittsburgh Cancer Institute and UPMC Cancer Center, Hillman Professor of Oncology, University of Pittsburgh, Pittsburgh, PA

                Invasive breast cancer, the most common nonskin cancer in women in the United States, will be diagnosed in 235,000 women in this country in 2013 and is expected to result in approximately 40,000 deaths. Incidence and mortality reached a plateau and appear to be dropping in both the United States and parts of western Europe. This decline has been attributed to several factors, such as early detection through the use of screening mammography and appropriate use of systemic adjuvant therapy, as well as decreased use of hormone replacement therapy. However, the global burden of breast cancer remains great, and global breast cancer incidence increased from 641,000 in 1980 to 1,643,000 in 2010, an annual rate of increase of 3.1%. This chapter examines the etiology, epidemiology, prevention, screening, staging, and prognosis of breast cancer. The diagnoses and treatments of the four stages of breast cancer are also included. Figures include algorithms used for the systemic treatment of stage IV breast cancer and hormone therapy for women with stage IV breast cancer. Tables describe selected outcomes from the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 and P-2 chemoprevention trials, tamoxifen chemoprevention trials for breast cancer, the TNM staging system and stage groupings for breast cancer, some commonly used adjuvant chemotherapy regimens, an algorithm for suggested treatment for patients with operable breast cancer from the 2011 St. Gallen consensus conference, guidelines for surveillance of asymptomatic early breast cancer survivors from the American Society of Clinical Oncology, and newer agents for metastatic breast cancer commercially available in the United States.

                This review contains 2 highly rendered figures, 8 tables, and 108 references.

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            • IM Palliative Medicine
              • 1

                Practicing Evidence-based Medicine

                By Michael Barnett, MD; Niteesh Choudhry, MD, PhD
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                Practicing Evidence-based Medicine

                • MICHAEL BARNETT, MDFellow in General Internal Medicine, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
                • NITEESH CHOUDHRY, MD, PHDAssociate Professor, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

                Today, a plethora of resources for evidence-based medicine (EBM) are available via alert services, compendia, and more. In theory, a clinician researching a topic or looking for information regarding a clinical decision should easily find the literature or synopses needed. However, the real challenge lies in recognizing which resources (out of hundreds or possibly thousands) present the best and most reliable evidence. As well, evidence from research is only part of the decision calculus, and the clinician, not the evidence, makes the final decisions. Medical decision analysis attempts to formalize the process and reduce it to algebra, but it is difficult or impossible to represent all the components of a decision mathematically and validly let alone do so in “real time” for individual patients. This review discusses these challenges and more, including how to ask answerable questions, understand the hierarchy for evidence-based information resources, critically appraise evidence, and apply research results to patient care. Figures show the total number of new articles in Medline from 1965 to 2012, a “4S” hierarchy of preappraised medicine, percentage of physician and medical student respondents with a correct or incorrect answer to a question about calculating the positive predictive value of a hypothetical screening test, a nomogram for Bayes’s rule, an example of nomogram use for pulmonary embolism, and a model for evidence-informed clinical decisions. Tables list selected barriers to the implementation of EBM; Patient, Intervention, Comparison, and Outcome (PICO) framework for formulating clinical questions; guides for assessing medical texts for evidence-based features; clinically useful measures of disease frequency and statistical significance and precision; definitions of clinically useful measures of diagnostic test performance and interpretation; definitions of clinically useful measures of treatment effects from clinical trials; summary of results and derived calculations from the North American Symptomatic Carotid Endarterectomy Trial (NASCET); and selected number needed to treat values for common therapies.

                This review contains 6 highly rendered figures, 9 tables, and 28 references.

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            • IM Psychiatry
              • 1

                Overview of Anxiety Disorders

                By Jon E Grant, JD, MD, MPH
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                Overview of Anxiety Disorders

                • JON E GRANT, JD, MD, MPH

                Anxiety disorders are the most common psychiatric disorders among adults in the United States. Although anxiety disorders generally result in significant psychosocial impairment, most adults do not seek treatment until many years after the onset of the anxiety disorder. The treatment literature for anxiety disorder has grown tremendously since the 1980s, and both psychotherapy and medications may prove beneficial for people with anxiety disorders. This review presents a general overview of the anxiety disorders.

                This review contains 7 tables, and 33 references.

                Key words: agoraphobia, anxiety disorder, generalized anxiety disorder, panic disorder, separation anxiety disorder, social anxiety disorder, specific phobia, treatment of anxiety

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              • 2

                Depressive Disorders: Update on Diagnosis, Etiology, and Treatment

                By Jair C. Soares, MD; Isabelle E. Bauer, PhD; Antonio L Teixeira, MD, PhD; Marsal Sanches, MD, PhD
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                Depressive Disorders: Update on Diagnosis, Etiology, and Treatment

                • JAIR C. SOARES, MDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
                • ISABELLE E. BAUER, PHDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
                • ANTONIO L TEIXEIRA, MD, PHDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
                • MARSAL SANCHES, MD, PHDDepartment of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX

                This review discusses the changes in the diagnostic criteria for depressive disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and recent findings exploring the etiology of and treatment strategies for these disorders. Depressive disorders are typically characterized by depression in the absence of a lifetime history of mania or hypomania. New developments in the DSM-5 include the recognition of new types of depressive disorders, such as disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, and the addition of catatonic features as a specifier for persistent depressive disorder. These diagnostic changes have important implications for the prognosis and treatment of this condition. A thorough understanding of both the clinical phenotype and the biosignature of these conditions is essential to provide individualized, long-term, effective treatments to affected individuals. 

                This review contains 1 table and 52 references

                Key words: brain volumes, depressive disorders, DSM-5, hormones, inflammation, neuropeptides, somatic therapy, stress

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              • 3

                Personality Disorders

                By Yosefa A. Ehrlich, BS; Amir Garakani, MD; Stephanie R Pavlos, MA; Larry Siever, MD
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                Personality Disorders

                • YOSEFA A. EHRLICH, BSDoctoral Student in Clinical Psychology, City University of New York Graduate Center, New York, NY
                • AMIR GARAKANI, MDAssistant Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
                • STEPHANIE R PAVLOS, MADoctoral Student in Clinical Psychology, St. Johns University, Queens, NY
                • LARRY SIEVER, MDProfessor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY

                Personality can be defined as an organizational system of self that shapes the manner in which a person interacts with his or her environment. Personality traits develop in adolescence or early adulthood and are thought to be shaped by early childhood experiences and enduring throughout a lifetime. Personality traits that prevent an individual from being able to function in society or that cause significant distress are diagnosed as personality disorders. A thorough history is needed to rule out other psychiatric and medical disorders. This chapter reviews the diagnostic criteria, differential diagnosis, comorbidity, prevalence, etiology (including genetics and neurobiology), prognosis, and treatment of paranoid, schizoid, schizotypal, borderline, antisocial, narcissistic, histrionic, avoidant, obsessive-compulsive, and dependent personality disorders. A discussion of the relevance of personality disorders to primary care practices and approaches to managing such patients is also included. Tables describe the diagnostic criteria of each personality disorder. Figures illustrate the prevalence of personality disorders in the general and psychiatric populations; schizotypal personality disorder in the community, general population, and clinical population; childhood trauma in individuals with personality disorder; and comorbid disorders in individuals with borderline personality disorder. A model of brain processing in borderline personality disorder is also featured.

                This chapter contains 5 highly rendered figures, 10 tables, 230 references, and 5 MCQs.

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              • 4

                Overview of Schizophrenia and Other Psychotic Disorders

                By James A. Wilcox, MD, PhD; Donald W. Black, MD
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                Overview of Schizophrenia and Other Psychotic Disorders

                • JAMES A. WILCOX, MD, PHD
                • DONALD W. BLACK, MD

                Psychotic disorders are among the most disabling conditions and constitute a major public health problem. Described throughout recorded time, they affect as many as 5% of the population and cause a disproportionate amount of suffering and loss to society. In the chapter on schizophrenia spectrum and other psychotic disorders, the DSM-5 lists delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, and schizoaffective disorder, as well as categories for substance- or medically induced psychotic disorders. The term psychosis indicates that the individual has a severe inability to interpret the surrounding environment in a realistic way. Symptoms include hallucinations, delusions, and bizarre behavior. Psychotic disorders are associated with premature death, mostly attributable to suicide. The pathophysiology and etiology of psychotic disorders are only now beginning to be understood, and treatment for these conditions remains suboptimal. Researchers are currently refining the cause of these symptoms and developing more effective treatments.  

                This review contains 2 tables, and 33 references.

                Key words: brief psychotic disorder, delusions, hallucinations, psychosis, schizoaffective disorder, schizophrenia, schizophreniform disorder 

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              • 5

                Sleep Disorders

                By Sudhansu Chokroverty, MD, FRCP, FACP
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                Sleep Disorders

                • SUDHANSU CHOKROVERTY, MD, FRCP, FACPProfessor and Director of Sleep Research, Medical Director of Devry Technology Training Program, Co-Chair Emeritus of Neurology, Department of Neurology, JFK Neuroscience Institute, Edison, NJ, Professor of Neuroscience, Seton Hall University, South Orange, NJ, Clinical Professor of Neurology, Robert Wood Johnson Medical School, New Brunswick, NJ

                Recent research has generated an enormous fund of knowledge about the neurobiology of sleep and wakefulness. Sleeping and waking brain circuits can now be studied by sophisticated neuroimaging techniques that map different areas of the brain during different sleep states and stages. Although the exact biologic functions of sleep are not known, sleep is essential, and sleep deprivation leads to impaired attention and decreased performance. Sleep is also believed to have restorative, conservative, adaptive, thermoregulatory, and consolidative functions. This review discusses the physiology of sleep, including its two independent states, rapid eye movement (REM) and non–rapid eye movement (NREM) sleep, as well as functional neuroanatomy, physiologic changes during sleep, and circadian rhythms. The classification and diagnosis of sleep disorders are discussed generally. The diagnosis and treatment of the following disorders are described: obstructive sleep apnea syndrome, narcolepsy-cataplexy sydrome, idiopathic hypersomnia, restless legs syndrome (RLS) and periodic limb movements in sleep, circadian rhythm sleep disorders, insomnias, nocturnal frontal lobe epilepsy, and parasomnias. Sleep-related movement disorders and the relationship between sleep and psychiatric disorders are also discussed. Tables describe behavioral and physiologic characteristics of states of awareness, the international classification of sleep disorders, common sleep complaints, comorbid insomnia disorders, causes of excessive daytime somnolence, laboratory tests to assess sleep disorders, essential diagnostic criteria for RLS and Willis-Ekbom disease, and drug therapy for insomnia. Figures include polysomnographic recording showing wakefulness in an adult; stage 1, 2, and 3 NREM sleep in an adult; REM sleep in an adult; a patient with sleep apnea syndrome; a patient with Cheyne-Stokes breathing; a patient with RLS; and a patient with dream-enacting behavior; schematic sagittal section of the brainstem of the cat; schematic diagram of the McCarley-Hobson model of REM sleep mechanism; the Lu-Saper “flip-flop” model; the Luppi model to explain REM sleep mechanism; and a wrist actigraph from a man with bipolar disorder.

                This review contains 14 highly rendered figures, 8 tables, 115 references, and 5 MCQs.

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              • 6

                Overview of Posttraumatic Stress Disorder

                By Dana Downs, MA, MSW; Carol North, MD, MPE
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                Overview of Posttraumatic Stress Disorder

                • DANA DOWNS, MA, MSWClinical Research Manager (Retired), Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX
                • CAROL NORTH, MD, MPEMedical Director, The Altshuler Center for Education & Research at Metrocare Services, The Nancy and Ray L. Hunt Chair in Crisis Psychiatry and Professor of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX

                Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may follow exposure to trauma. The experience of trauma has potential personal implications. Some individuals develop PTSD after trauma; others may be more resilient, experiencing distress but not succumbing to psychopathology; and yet others may emerge from the experience with new strength and direction.

                This review contains 1 figure, 5 tables, and 46 references

                Keyword: Posttraumatic stress disorder, transcranial magnetic stimulation (TMS), deep brain stimulation, vagal nerve stimulation, transcranial direct current stimulation, Diagnostic and Statistical Manual of Mental Disorders, hypothalamic-pituitary-adrenal (HPA) axis

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              • 7

                Overview of Substance Use Disorders

                By Alexander W Thompson, MD, MBA, MPH; Timothy Ando, MD; Emily Morse, DO
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                Overview of Substance Use Disorders

                • ALEXANDER W THOMPSON, MD, MBA, MPHClinical associate professor, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA.
                • TIMOTHY ANDO, MDPsychiatry Resident, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA
                • EMILY MORSE, DOChief Resident in Psychiatry, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA

                Substance use disorders are a major source of morbidity and mortality, contributing to a significant proportion of deaths in the United States and worldwide each year. A substantial rise in deaths related to drug overdoses in recent decades has drawn increasing public attention to this issue. However, the majority of individuals struggling with substance use disorders remain untreated. The financial costs and health burden are substantial. This review provides a broad overview of substance-related and addictive disorders. The evolution of the classification system is described, and the diagnostic criteria for the various substance use disorders are reviewed. Epidemiology and etiologic considerations, including neurobiological pathways, genetics, environmental influences, and dimensional risk factors, are examined. Finally, individual substances and their related disorders are reviewed, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, stimulants, tobacco, and other or unknown substances. Intoxication and withdrawal syndromes are described where applicable, and clinical management concepts are discussed. 

                This review contains 6 figures, 5 tables, and 71 references.

                Key words: abuse, addiction, alcohol, caffeine, cannabis, dependence, diagnosis, DSM-5, epidemiology, hallucinogen, hypnotic, inhalant, intoxication, methamphetamine, nicotine, opioid, sedative, stimulant, substance use disorders, tobacco, tolerance, withdrawal

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              • 8

                The Psychiatric Interview and Mental Status Examination

                By Donald W. Black, MD
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                The Psychiatric Interview and Mental Status Examination

                • DONALD W. BLACK, MD

                The interview and mental status examination are integral to the comprehensive patient assessment and typically follow a standard approach that most medical students and residents learn. The psychiatrist should adjust his or her interview style and information-gathering approach to suit the patient and the situation. For example, inpatients are typically more symptomatic than outpatients, may be in the hospital on an involuntary basis, and may be too ill to participate in even the briefest interview. Note taking is an essential task but should not interfere with patient rapport. The interview should be organized in a systematic fashion that, although covering all essential elements, is relatively stereotyped so that it allows the psychiatrist to commit the format to memory that, once learned, can be varied. The psychiatrist should start by documenting the patient’s identifying characteristics (age, gender, marital status) and then proceed to the chief complaint, history of the present illness, past medical history, family and social history, use of drugs and alcohol, medications, and previous treatments. A formal mental status includes assessment of the patient’s appearance, attitude, and behavior; orientation and sensorium; mood and affect; psychomotor activity; thought process, speech, and thought content; memory and cognition (including attention and abstraction); and judgment and insight. With the data collected, the psychiatrist will construct an accurate history of the symptoms that will serve as the basis for developing a differential diagnosis, followed by the development of a comprehensive treatment plan.

                This review contains 1 figure, 3 tables, and 12 references.

                Key words: assessment, differential diagnosis, interviewing, mental status examination, treatment plan

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              • 9

                Bipolar Disorders and Their Clinical Management, Part I: Epidemiology, Etiology, Genetics, and Neurobiology

                By Vladimir Maletic, MD; Bernadette DeMuri-Maletic, MD
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                Bipolar Disorders and Their Clinical Management, Part I: Epidemiology, Etiology, Genetics, and Neurobiology

                • VLADIMIR MALETIC, MD
                • BERNADETTE DEMURI-MALETIC, MDClinical Assistant Professor of Psychiatry and Mental Health Sciences, Medical College of Wisconsin, Milwaukee, WI

                The concept of bipolar disorders has undergone a substantial evolution over the course of the past two decades. Emerging scientific research no longer supports the notion of bipolar disorder as a discrete neurobiologic entity. Most likely, there are a number of different biotypes with similar phenotypical manifestations. Advancements in genetic research suggest that bipolar disorders have a polygenetic pattern of inheritance, sharing common genetic underpinnings with a number of other psychiatric disorders, including schizophrenia, autistic spectrum disorder, and major depressive disorder. Contemporary etiological theories are discussed in some detail, inclusive of the role of immune disturbances, oxidative stress, and changes in neuroplasticity and neurotransmission, which underpin functional and structural brain changes associated with bipolar disorders. Contemporary epidemiologic research and understanding of disease evolution are discussed from the perspective of its clinical relevance. Our review provides a succinct summary of relevant literature.

                This review contains 4 figures, 2 tables, and 80 references.

                Key Words: bipolar disorders, endocrine disturbances, epidemiology, genetics, glia, immunity, neurobiology, neuroplasticity, neurotransmitters

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              • 10

                Bipolar Disorders and Their Clinical Management, Part II: Diagnosis, Differential Diagnosis, and Treatment

                By Bernadette DeMuri-Maletic, MD; Vladimir Maletic, MD, MS
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                Bipolar Disorders and Their Clinical Management, Part II: Diagnosis, Differential Diagnosis, and Treatment

                • BERNADETTE DEMURI-MALETIC, MDClinical Assistant Professor of Psychiatry and Mental Health Sciences, Medical College of Wisconsin, Milwaukee, WI
                • VLADIMIR MALETIC, MD, MSClinical Professor of Psychiatry and Behavioral Sciences, University of South Carolina School of Medicine, Greenville, SC

                Bipolar disorder is a biologically and phenotypically diverse disorder and its diagnosis and treatment provides a significant challenge to even the most seasoned clinician. We provide an update on the diagnosis and differential diagnosis of bipolar disorder, reflecting recent changes in DSM-5. Our review provides a succinct summary of the treatment literature, encompassing pharmacologic and psychosocial interventions for bipolar depression, mania/hypomania, mixed states, and prevention of disease recurrence. We provide a brief critical review of emerging treatment modalities, including those used in treatment resistance. Challenges involved in maintaining adherence are further discussed. Additionally, we review common treatment adverse effects and provide recommendations for proper side effect monitoring. There is evidence of significant functional impairment in patients with bipolar disorder and we conclude with a discussion of the impact of impairment on prognosis and quality of life.

                This review contains 4 figures, 7 tables, and 45 references.

                Key Words: bipolar disorders, differential diagnosis, maintenance pharmacotherapy, prognosis, psychosocial interventions, treatment, quality of life

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              • 11

                Mistreatment of Elders

                By Emily I Gorman, MD; Judith Linden, MD
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                Mistreatment of Elders

                • EMILY I GORMAN, MDDepartment of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA
                • JUDITH LINDEN, MDAssociate Professor and Vice Chair for Education, Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA

                Elder mistreatment affects a considerable proportion of individuals older than 60 to 65 years of age and may include intentional abuse (physical, sexual, emotional, or financial) and neglect. As the proportion of the population that is older than 65 years of age increases, elder mistreatment will become an increasingly common issue. Only a minority of cases of elder abuse are reported; thus, an interview with the patient should be conducted in private if elder mistreatment is suspected. Patient risk factors for elder mistreatment include cognitive or behavioral impairment, poor physical health, and poor social supports. This review examines the approach to the patient, as well as definitive treatment, disposition, and outcomes for victims of elder abuse. The figure shows an algorithm for elder abuse assessment and intervention. Tables list types of elder abuse, factors predisposing to elder mistreatment, indicators of abuse, and the Elder Abuse Suspicion Index.

                This review contains 1 highly rendered figure, 4 tables, and 42 references.

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            • IM Pulmonary & Critical Care Medicine
              • 1

                Approach to the Patient With Shock

                By David C Mackenzie, MD, CM
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                Approach to the Patient With Shock

                • DAVID C MACKENZIE, MD, CMDirector of Emergency Ultrasound, Maine Medicine Medical Center, Portland ME, Assistant Professor of Emergency Medicine, Tufts University School of Medicine, Boston, MA

                There are four main categories of shock: hypovolemic, distributive, cardiogenic, and obstructive. Although the main end point (i.e., inadequate delivery of oxygenated blood to the body’s tissues and organs) of each of these categories of shock is the same, the pathophysiologic mechanisms differ. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with shock. Figures show the Frank-Starling relationship illustrating changes in distributive and cardiogenic shock, the FAST examination, lung ultrasonography in pulmonary edema, pericardial effusion, apical four-chamber view of the heart with right ventricular enlargement, and a parasternal short-axis view of the heart. Tables list representative historical information associated with specific categories of shock; point-of-care ultrasound applications for the evaluation of shock; criteria for severe sepsis and septic shock; vasopressor dosages, mechanisms of action, clinical effects, and indications; anaphylaxis diagnostic criteria; and causes of cardiogenic shock.

                This review contains 6 highly rendered figures, 6 tables, and 32 references.

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              • 2

                Asthma

                By Haitham Nsour, MBBS; Anne E. Dixon, MA, BMBCH
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                Asthma

                • HAITHAM NSOUR, MBBSAssistant Professor, Department of Medicine, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT
                • ANNE E. DIXON, MA, BMBCHProfessor, Department of Medicine, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT

                Asthma is one of the most common diseases in developed nations. A pathognomonic feature of asthma is episodic aggravations of the disease; these exacerbations can be life-threatening and contribute to a significant proportion of the public health burden of asthma. In the emergency department, successful management of asthma exacerbations requires early recognition and intervention before they become severe and potentially fatal. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for asthma. Figures show the management of asthma exacerbations in the emergency department and hospital, pooled odds ratio comparing inhaled corticosteroids and oral corticosteroids with oral corticosteroids alone following emergency department discharge, and an asthma discharge plan at the emergency department. Tables list current asthma prevalence among selected demographic groups in the United States, risk factors for fatal asthma exacerbations, differential diagnosis of asthma exacerbations, and dosages of drugs for asthma exacerbations.

                This review contains 2 highly rendered figures, 8 tables, and 127 references.

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              • 3

                Approach to the Patient With Cough

                By Christopher H. Fanta, MD
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                Approach to the Patient With Cough

                • CHRISTOPHER H. FANTA, MDDirector, Partners Asthma Center; Member, Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women’s Hospital; and Professor of Medicine, Harvard Medical School, Boston, MA

                The cough reflex is critically important in the clearance of abnormal airway secretions and protection of the lower respiratory tract from aspirated foreign matter. A weak or ineffective cough can lead to respiratory compromise from even a relatively minor bronchial infection. Persistent cough is often one of a constellation of symptoms indicative of respiratory disease—a potential clue in the differential diagnosis of the patient’s illness. Given the widespread distribution of sensory nerve endings of the cough reflex throughout the upper and lower respiratory tract, it is not surprising that myriad respiratory diseases, involving lung parenchyma and airways, can manifest with cough. Sometimes cough is the sole or predominant symptom in a patient who is otherwise well. Evaluating and treating the patient with persistent cough who has few, if any, other respiratory symptoms is a common challenge for the practicing physician. This review covers the normal cough mechanism, impaired cough, pathologic cough, cough suppressant therapy, and new developments. Figures show a flow-volume loop during cough, a posteroanterior chest x-ray in a patient presenting with chronic cough, flow-volume curves and spirograms documenting expiratory airflow obstruction, and the approach to the patient with chronic cough. The table lists selected examples of extrapulmonary physical findings of potential importance in the assessment of cough.

                This review contains 4 highly rendered figures, 1 table, and 94 references.

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              • 4

                Pulmonary Hypertension, Cor Pulmonale, and Other Pulmonary Vascular Conditions

                By Matthew Moll, MD; Mayank Sardana, MBBS; Harrison W. Farber, MD, FAHA, FCCP
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                Pulmonary Hypertension, Cor Pulmonale, and Other Pulmonary Vascular Conditions

                • MATTHEW MOLL, MDResident, Department of Internal Medicine, Boston Medical Center, Boston, MA
                • MAYANK SARDANA, MBBSFellow, Division of Cardiology, University of Massachusetts Medical School, Worcester, MA
                • HARRISON W. FARBER, MD, FAHA, FCCPProfessor of Medicine, Pulmonary Center, Boston University School of ­Medicine, Boston, MA

                This review covers the diseases that affect the pulmonary vasculature directly. These conditions include pulmonary hypertension; pulmonary arterial hypertension; chronic thromboembolic pulmonary hypertension; pulmonary hypertension attributed to left heart disease, lung disease and/or hypoxemia, and other disorders; cor pulmonale; pulmonary atriovenous malformations; and pulmonary aneurysms. Figures show changes in the pulmonary vasculature in pulmonary hypertension, pathways involved in the development of pulmonary hypertension, general guidelines for the evaluation of suspected pulmonary hypertension, enlarged proximal pulmonary arteries with pruning of distal pulmonary vasculature (typical of advanced pulmonary arterial hypertension), the remodeling of the heart and continuous-wave Doppler study results observed with chronic pulmonary hypertension, ventilation and perfusion scans of  the lungs with results typical of chronic thromboembolic pulmonary hypertension, and a general approach to the treatment of patients with pulmonary arterial hypertension. Tables list the revised nomenclature and classification of pulmonary hypertension, the World Health Organization classification of functional capacity in patients with pulmonary hypertension, advanced vascular medications for pulmonary artery hypertension, and perioperative management of pulmonary arterial hypertension.

                This review contains 8 highly rendered figures, 4 tables, and 118 references.

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            • IM Rheumatology
              • 1

                Osteoarthritis

                By Christopher Wise, MD, FACP
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                Osteoarthritis

                • CHRISTOPHER WISE, MD, FACPRobert Irby Professor of Medicine, Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Medical College of Virginia, Richmond, VA

                Osteoarthritis is a common form of arthritis characterized by degeneration of articular cartilage and pathologic changes in surrounding bone and periarticular tissue. The disease process results in pain and dysfunction of affected joints and is a major cause of disability in the general population. Prognosis is variable; greater muscle strength, mental health, self-efficacy, social support, and aerobic exercise are associated with better outcomes. This review outlines the classification of osteoarthritis (primary and secondary) and its epidemiology and etiologic factors, including risk factors, normal articular cartilage, and pathologic changes. Diagnosis is reviewed in terms of general considerations and specific joint involvement and related complications. The differential diagnosis is discussed. Management of osteoarthritis includes nonpharmacologic measures, pharmacologic therapy, surgery, and disease-modifying or chondroprotective therapy. Tables describe causes of secondary osteoarthritis, risk factors for osteoarthritis, and treatment of osteoarthritis. Figures demonstrate the microscopic appearance of normal and osteoarthritic articular cartilage, the diagnostic process for osteoarthritis, the hands of a patient with typical primary osteoarthritis, destructive changes in the interphalangeal joints, knee radiographs, and an osteoarthritic hip joint.

                This review contains 6 highly rendered figures, 3 tables, and 113 references.

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              • 2

                Rheumatoid Arthritis: Treatment

                By Gary S. Firestein, MD; Anna-Karin H. Ekwall, MD, PhD
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                Rheumatoid Arthritis: Treatment

                • GARY S. FIRESTEIN, MDProfessor of Medicine, Dean and Associate Vice Chancellor of Translational Medicine, UC San Diego School of Medicine, La Jolla, California
                • ANNA-KARIN H. EKWALL, MD, PHDSpecialist in Rheumatology, University of California San Diego School of Medicine, La Jolla, CA, Researcher/Postdoc, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden

                The main goal of treatment of rheumatoid arthritis (RA) has evolved from modest improvement to low disease activity and will soon be complete remission. To reach this goal, the rheumatologist and patient should define the goal and treatment strategy together. Disease activity should be measured regularly using validated composite measures such as disease activity score, simple disease activity index, and clinical disease activity index. Management involves efforts to relieve pain and discomfort, preserve strength and joint function, and prevent structural deformities. Surgical intervention is important for replacing destroyed joints and for restoring function and preventing further damage. This review discusses the role of drug therapy, including nonsteroidal antiinflammatory drugs, methotrexate, antimalarial drugs, sulfasalazine, leflunomide, tofacitinib, biologic drugs, T cell– and B cell–targeted therapy, glucocorticoids, and other immunosuppressive agents. Nonmedical therapy, surgery, and prognosis are also detailed. Tables include the American College of Rheumatology definition of improvement of RA and comparisons of various antirheumatic treatments using small-molecule and biologic drugs. Figures include an algorithm for pharmacologic management of RA and a graph showing mean disease activity scores.

                This review contains 2 highly rendered figures, 3 tables, and 54 references.

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              • 3

                Scleroderma and Related Disorders

                By Kristine Phillips, MD, PhD
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                Scleroderma and Related Disorders

                • KRISTINE PHILLIPS, MD, PHDScleroderma Program, Division of Rheumatology, University of Michigan, Ann Arbor, MI

                Scleroderma spectrum diseases are a heterogeneous group of disorders that are distinguished by abnormalities of the connective tissue in the skin and, in some cases, other organs. Each disorder may be characterized by the extent of cutaneous and internal involvement, as well as histopathologic features of skin biopsy. Scleroderma spectrum diseases include systemic scleroderma, localized scleroderma, and eosinophilic fasciitis. This chapter reviews the classification, epidemiology, etiology, pathophysiology and pathogenesis, diagnosis, differential diagnosis, treatment, outcome measures, management, and clinical course of scleroderma as well as the definition and classification, etiology/genetics, differential diagnosis, and treatment of localized scleroderma. Also discussed are the definition and classification, epidemiology, etiology/genetics/pathogenesis, diagnosis, differential diagnosis, and treatment of eosinophilic fasciitis. Tables review the classification of—and antinuclear antibodies in—scleroderma as well as the key assessments and interventions in scleroderma management. Figures illustrate the disease's presentation and clinical manifestations, including several images of scleroderma of the hands; face, palmar, and buccal telangiectasias in a patient with scleroderma; a radiograph demonstrating calcinosis of the elbow; Raynaud’s phenomenon; high-resolution computed tomographic images of diffuse cutaneous scleroderma, scleroderma and severe pulmonary hypertension, and limited cutaneous scleroderma; plus an esophagram demonstrating hypomotility.

                This review contains 11 highly rendered figures, 3 tables, and 72 references.

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              • 4

                Systemic Lupus Erythematosus

                By Kyriakos A. Kirou, MD; Michael D. Lockshin , MD
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                Systemic Lupus Erythematosus

                • KYRIAKOS A. KIROU, MDAssistant Professor of Clinical Medicine, Weill Medical College of Cornell University, Co-director, Mary Kirkland Center for Lupus Care, Hospital for Special Surgery
                • MICHAEL D. LOCKSHIN , MDProfessor of Medicine and Obstetrics-Gynecology, Weill Medical College of Cornell University, Director, Barbara Volcker Center, Hospital for Special Surgery

                Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune illness characterized by autoantibodies directed at nuclear antigens that cause clinical and laboratory abnormalities, such as rash, arthritis, leukopenia and thrombocytopenia, alopecia, fever, nephritis, and neurologic disease. Most or all of the symptoms of acute lupus are attributable to immunologic attack on the affected organs. Many complications of long-term disease are attributable to both the disease and its treatment. Intense sun exposure, drug reactions, and infections are circumstances that induce flare; the aim of treatment is to induce remission. This chapter is divided into sections dealing with SLE’s definitions; epidemiology; pathogenesis; disease classification, diagnosis, and differential diagnosis; and treatment.

                This review contains 10 figures, 11 tables, and 97 references.

                Key Words: Systemic lupus erythematosus, Dermatomyositis, Sjögren syndrome, rheumatoid arthritis, systemic sclerosis, Discoid lupus erythematosus, truncal psoriasiform, annular polycyclic rash

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              • 5

                Back Pain and Common Musculoskeletal Problems

                By Christopher M. Wise, MD; Huzaefah Syed, MD
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                Back Pain and Common Musculoskeletal Problems

                • CHRISTOPHER M. WISE, MDW. Robert Irby Professor of Medicine, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Virginia Commonwealth University Health System, Richmond, VA
                • HUZAEFAH SYED, MDAssistant Professor of Medicine, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Virginia Commonwealth University Health System, Richmond, VA

                Knowledge of the common nonarticular regional rheumatic disorders is important because of their high prevalence in primary care practice, the dependence on clinical findings for diagnosis, and the high cost that can result from unnecessary laboratory evaluations. The ability to recognize important patterns of pain and associated physical signs is essential to making a correct diagnosis; in most cases, radiographic and laboratory studies are not needed. This review covers the common causes of pain in the neck, back, shoulder, chest wall, elbow, hand and wrist, hip girdle, knee and lower leg, and ankle and foot.

                This review contains 5 figures, 11 tables, and 96 references.

                Key words Acute back pain, Chronic back pain, Lumbar stenosis, Shoulder pain, Chest wall pain, Elbow pain, Hand and wrist pain, Carpal Tunnel Syndrome, Hip girdle pain, Knee and lower leg pain, Ankle and foot pain

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            • IM Nutrition
              • 1

                Overview of Enteral Nutrition

                By Rebecca Lynch, MS, RD, LDN, CNSC; Erin Sisk, MS, RD, LDN, CNSC
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                Overview of Enteral Nutrition

                • REBECCA LYNCH, MS, RD, LDN, CNSC
                • ERIN SISK, MS, RD, LDN, CNSC

                Enteral nutrition (EN) is recognized as a medical nutrition therapy for patients with a functional gastrointestinal tract who are unable to maintain their weight and health by oral intake alone either due to a highly catabolic medical condition or a functional limitation. EN support provides calories and protein to help improve or maintain adequate weight, lean body mass, and overall nutritional status. EN also provides nonnutritive benefits such as maintaining intestinal integrity, supporting the immune system, and preventing infection. EN support can be tailored to a patient’s nutrient needs, and there are various formulas that vary in composition of macronutrients, concentration, and electrolytes for specific disease processes or conditions that may help with tolerance and absorption. EN support complications include issues with access, diarrhea, constipation, electrolyte abnormalities, hyperglycemia, and dehydration/overhydration. Generally, EN is well tolerated. While a patient is on this type of nutrition support, it is important to closely monitor tolerance, weight, laboratory values if indicated, and overall clinical progress, with adjustment to the regimen as needed.

                This review contains 1 figure, 4 tables, and 48 references.

                Key words: enteral access, enteral formula, enteral nutrition support, gastric residuals, gastrointestinal tract, immunonutrition, malnutrition, medical nutrition therapy, tube feed formula, tube feed tolerance, tube feeding, volume-based feeding

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              • 2

                Diet and Nutrition in the Treatment of Prediabetes and Diabetes

                By Priscilla Escalona Villasmil, MD; Richard D Siegel, MD
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                Diet and Nutrition in the Treatment of Prediabetes and Diabetes

                • PRISCILLA ESCALONA VILLASMIL, MD
                • RICHARD D SIEGEL, MD

                The incidence of type 2 diabetes has been increasing dramatically throughout the world, closely linked to Westernized dietary patterns, physical inactivity, and rising rates of obesity, and has become a challenging health problem. Lifestyle changes are effective measures to prevent diabetes, and diet is one of the most important components of diabetes treatment. There is now strong evidence from epidemiologic studies and randomized controlled trials (RCTs) that type 2 diabetes can be prevented or at least delayed in those at high risk for progressing to diabetes by a combination of diet and physical activity resulting in weight loss. Medical nutrition therapy (MNT) is the process by which the nutrition prescription is customized for patients with diabetes. RCTs have demonstrated a positive effect of MNT in diabetes management. Studies documenting the effectiveness of MNT for type 1 and 2 diabetes report improvements in hemoglobin A1C and in other outcomes. A nutrition prescription should be individualized for each patient based on individual preferences, cultural background, and social and financial context. Lifestyle interventions should be considered monotherapy in prediabetes and the initial treatment of type 2 diabetes. Evidence from prospective cohort studies and RCTs has shown the importance of eating patterns in the prevention and management of diabetes. With the worldwide increase in obesity, it will be important to get further evidence of how lifestyle interventions affect clinical outcomes such as microvascular and macrovascular disease.

                This review contains 6 figures, 6 tables and 90 references

                Key words:  Diabetes mellitus, nutrition, prevention, obesity, lifestyle, glucose, diet, physical activity

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              • 3

                Nutritional Management of Celiac Disease

                By Ciarán P Kelly, MD; Satya Kurada, MD; Mariana Urquiaga, MD
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                Nutritional Management of Celiac Disease

                • CIARÁN P KELLY, MDProfessor of Medicine, Medical Director of The Celiac Center, Director of Gastroenterology Fellowship Training Program, Harvard Medical School, Boston, MA
                • SATYA KURADA, MD
                • MARIANA URQUIAGA, MD

                Celiac disease (CD) is an autoimmune disorder characterized by an immune response to gluten peptides in wheat, barley, and rye. The diagnosis of celiac disease is confirmed by three important characteristics: consistent symptoms, positive celiac-specific serology, and small intestinal biopsy findings of inflammation, crypt hyperplasia, and villous atrophy. CD may present with overt gastrointestinal symptoms, including diarrhea (or constipation), weight loss, and abdominal bloating and discomfort, or covertly with micronutrient deficiencies such as iron deficiency with anemia. A gluten-free diet (GFD) remains the mainstay of treatment. The aim of this review is to highlight the pathogenesis of CD, concepts and challenges associated with a GFD, and nutritional management of CD applicable in clinical practice to internists, gastroenterologists, and dietitians. Patients should be referred to an expert celiac dietitian for education on adherence to a GFD to address gluten contamination in the diet, the psychosocial implications of following a GFD, and macro- and micronutrient disequilibria arising from celiac disease and the GFD. Several novel therapeutics are on the horizon in various stages of development, including glutenases, antigliadin antibodies, tight junction regulators, modulation of the immune response to gliadin, and efforts to engineer less toxic gluten-containing foodstuffs.

                This review contains 3 figures, 5 tables, and 61 references.

                Key words: celiac disease, genetic engineering, food engineering, gluten, glutenases, gluten-free diet, oats, IgY, nutrition, tight junction regulators, wheat

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            • IM Women Health
              • 1

                Primary and Preventive Care of Women

                By Janet B. Henrich, MD
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                Primary and Preventive Care of Women

                • JANET B. HENRICH, MDAssociate Professor of Medicine and Obstetrics and Gynecology, Yale University, New Haven, CT

                Women’s health can be defined as diseases or conditions that are unique to women or that involve gender differences that are particularly important to women. This definition acknowledges the increasing scientific evidence supporting a focus on sex and gender and expands the concept of women’s health beyond the traditional focus on reproductive organs and their function. Over time, the definition has come to include an appreciation of wellness and prevention, the interdisciplinary and holistic nature of women’s health, the diversity of women and their health needs over the life span, and the central role of women as patients and as active participants in their health care. This broader interdisciplinary perspective has important implications for clinicians providing care to women. In addition to understanding basic female physiology and reproductive biology, clinicians need to appreciate the complex interaction between the environment and the biology and psychosocial development of women. When dealing with conditions that are not specific to women, clinicians need to be aware of those aspects of disease that are different in women or have important gender implications. The ability to apply this information requires that clinicians adopt attitudes and behavior that are culturally and gender sensitive. Figures visualize female life expectancy, age-adjusted death rates, female breast cancer incidence and death rates, trends in female cigarette smoking, and the U.S. Preventive Services Task Force guidelines for preventive primary care in women. 


                This chapter contains 5 highly rendered figures, 52 references, 5 MCQs, and 1 teaching slide set.

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              • 2

                Urinary Incontinence and Overactive Bladder Syndrome

                By Kristie A. Greene, MD; Lennox Hoyte, MD, MSEECS
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                Urinary Incontinence and Overactive Bladder Syndrome

                • KRISTIE A. GREENE, MDFellow, Female Pelvic Medicine and Reconstructive Surgery, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL
                • LENNOX HOYTE, MD, MSEECSAssociate Professor and Director, Female Pelvic Medicine and Reconstructive Surgery, University of South Florida College of Medicine, Director, Urogynecology, and TGH-Pelvic Floor Disorders Group, Tampa General Hospital, Tampa, FL

                Urinary incontinence falls into two broad categories: stress incontinence and urge incontinence. Stress urinary incontinence occurs when urethral closure pressure cannot increase sufficiently to compensate for a sudden increase in intra-abdominal pressure, as from a cough or Valsalva maneuver. Urge urinary incontinence occurs when an unintended bladder contraction creates an insuppressible urge to void, leading to urinary leakage. When women have signs and/or symptoms of both stress and urge incontinence, it is referred to as mixed urinary incontinence. Overactive bladder syndrome is defined by the Standardization Subcommittee of the International Continence Society (ICS) as urinary urgency, with or without urge incontinence and usually with frequency and nocturia. Nocturia, which is often associated with urinary frequency, is defined as a need to urinate that awakens the person during the night. This chapter discusses the epidemiology and physiology of urinary incontinence and overactive bladder syndrome in women, as well as diagnosis and treatment. Tables list foods and beverages that may cause urinary frequency and urgency; features of urge incontinence, stress incontinence, and mixed incontinence; American Urologic Association (AUA) guidelines regarding level of evidence and indications for adult urodynamics; and currently available antimuscarinic drugs and their dosages, selectivity, efficacy, and side effects. Figures depict the journal of someone with mixed incontinence, a typical urodynamics suite, a urodynamic study of someone with detrusor overactivity, incontinence pessaries, and transobturator and retropubic slings.

                This review contains 5 figures, 5 tables, and 44 references.

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          • General Surgery
            • 1

              Abdominal Pain and Abdominal Mass

              By Blake D. Babcock, MD; Mohammad F. Shaikh, MD; Alexander E. Poor, MD; Wilbur B. Bowne, MD
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              Abdominal Pain and Abdominal Mass

              • BLAKE D. BABCOCK, MDSurgical Resident, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
              • MOHAMMAD F. SHAIKH, MDSurgical Resident, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
              • ALEXANDER E. POOR, MDAssociate Director of Research, Department of Surgery, Vincera Institute, Philadelphia, PA
              • WILBUR B. BOWNE, MDAssociate Professor of Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA

              Acute abdominal pain and abdominal mass are intimately connected; therefore, the diagnostic process for evaluating abdominal pain and abdominal masses is largely the same and has been preserved since ancient times. The primary goals in the management of patients with abdominal pain and/or abdominal mass are to establish a differential diagnosis by obtaining a clinical history, to refine the differential diagnosis with a physical examination and appropriate studies, and to determine the role of operative intervention in the treatment or refinement of the working diagnosis. This review describes the process of diagnosing abdominal pain, including taking a clinical history and performing a physical examination. Investigative studies, including laboratory tests, imaging, and pathology are reviewed. Management, including surgical treatment, is discussed. Tables describe intraperitoneal and extraperitoneal causes of acute abdominal pain, frequency of specific diagnoses in patients with acute abdominal pain, and common abdominal signs and findings noted on physical examination. Figures show abdominal pain in specific locations, a data sheet, the differential diagnosis of an abdominal mass by quadrant or region, characteristic patterns of abdominal pain, acute appendicitis with associated appendicolith, bilateral adrenal masses, adrenocortical carcinoma, retroperitoneal leiomyosarcoma, pancreatic mass, a sagittal ultrasonogram of the pancreas, ultrasonograms of the liver, a dark and well circumscribed abdominal mass, gastroesophageal junction adenocarcinoma, and percutaneous biopsy of a large abdominal mass. An algorithm outlines the assessment of acute abdominal pain and abdominal mass.

              This review contains 14 figures, 5 tables, and 143 references.

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            • 2

              Initial Management of Life-threatening Trauma

              By Jay Doucet, MD, FACS, FRCSC, RDMS; Emily Cantrell, MD
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              Initial Management of Life-threatening Trauma

              • JAY DOUCET, MD, FACS, FRCSC, RDMSProfessor of Surgery, Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, UC San Diego Health System, San Diego, CA
              • EMILY CANTRELL, MDAssistant Professor of Surgery, Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA

              Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care.

              This review contains 12 figures, 8 tables and 63 references

              Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey

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            • 3

              Fundamentals of Endovascular Surgery

              By C Louis Garrard III, MD
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              Fundamentals of Endovascular Surgery

              • C LOUIS GARRARD III, MDAssistant Professor of Surgery, Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN.

              The technology and innovations in endovascular surgery are advancing at a dramatically rapid pace. In this review, the fundamentals of endovascular procedures that are necessary to take advantage of this advancing technology are outlined and explained. Preoperative patient assessment, appropriate access site selection, and vascular access technique are explained. The selection and use of appropriate guide wires, catheters, and sheaths are also reviewed and outlined. The basic techniques for angioplasty and stenting are described as well. Finally, appropriate closure techniques and postprocedure care are described. As with any operation or procedure, mastering the fundamentals is necessary to proceed to advanced intervention.

              This review contains 10 figures, 1 table, 1 video, and 13 references.

              Key words: access troubleshooting, arterial access, endovascular instruments, endovascular preparation, endovascular techniques

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            • 4

              Preoperative Evaluation of the Vascular Patient

              By Issam Koleilat, MD; Christopher G. Carsten, MD
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              Preoperative Evaluation of the Vascular Patient

              • ISSAM KOLEILAT, MDVascular Surgery Fellow, Greenville Health Systems, Greenville, SC
              • CHRISTOPHER G. CARSTEN, MDChief, Division of Vascular Surgery, Greenville Health Systems, Greenville, SC

              Almost as critical as an operation itself is the preparation of the patient. Although this often includes psychosocial concerns such as expectations of recovery, inpatient stay, and other patient-centered issues, the discussion prior to surgery should not be limited to these factors. A medical assessment of the patient’s fitness and physiologic preparedness for the planned procedure must be performed by the surgeon and the resultant findings and plan reviewed with the patient. Although vascular disease affects multiple organ systems requiring a thorough general preoperative patient assessment, the focus of preoperative risk reduction strategies center on cardiac outcomes. Therefore, this review focuses on cardiac-related interventions with added coverage of preoperative strategies regarding diabetes, pulmonary and renal risk assessment, and infection reduction. Lastly, the perioperative management of anticoagulation/antiplatelet medications and cerebrovascular disease are discussed Techniques and treatments to optimize patients for surgery are integrated into the respective sections, allowing for a primer to guide this critical phase in a patient’s journey through surgery. Tables outline the Revised Cardiac Risk Index, assessment of functional capacity from patient self-reported activities, optimal delay in elective surgery after percutaneous coronary revascularization according to the 2014 American College of Cardiology/American Heart Association clinical practice guidelines, Respiratory Failure Risk Index, Szilagyi classification of vascular surgical site infection, and recommendations regarding perioperative management of anticoagulants and antiplatelet agents. A suggested algorithm for preoperative cardiac workup and the Cockcroff-Gault equation are provided.

              This review contains 2 figures, 6 tables, and 115 references.

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            • 5

              Surgical Treatment of Obesity and the Metabolic Syndrome

              By Iman Ghaderi, MD, MSc; Nisha Dhanabalsamy, MD; Carlos A Galvani, MD
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              Surgical Treatment of Obesity and the Metabolic Syndrome

              • IMAN GHADERI, MD, MSCAssistant Professor of Surgery, Section of Minimally Invasive & Robotic Surgery, Division of General Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
              • NISHA DHANABALSAMY, MDPostdoctoral Research Fellow, Section of Minimally Invasive & Robotic Surgery, Division of General Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
              • CARLOS A GALVANI, MDAssociate Professor of Surgery and Section Chief, Section of Minimally Invasive & Robotic Surgery, Division of General Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.

              Obesity and obesity-related comorbid conditions have been steadily increasing in the United States over the past few decades. Despite the availability of several anti-obesity measures such as diet, exercise, pharmacotherapy and behavioral modifications, bariatric surgery is the only effective modality that can provide a sustainable long-term weight loss and improve obesity-associated comorbidities. In this chapter, we discuss perioperative assessment and work-up of morbidly obese patients, minimally invasive approaches to various bariatric surgery procedures including laparoscopic adjustable gastric band, sleeve gastrectomy, gastric bypass and biliopancreatic diversion with duodenal switch, and their short and long term outcomes. We also address revisional bariatric surgery and use of robotic platform and other new procedures and their role in metabolic and bariatric surgery.

              Keywords: Obesity, comorbidities, metabolic surgery, bariatric surgery, gastric bypass, adjustable gastric band, sleeve gastrectomy, Biliopancreatic Diversion with Duodenal Switch, revisional surgery

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            • 6

              Breast Cancer

              By Stephen B Edge, MD, FACS, FASCO; Lindi VanderWalde, MD, FACS; Alyssa D. Throckmorton, MD, FACS
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              Breast Cancer

              • STEPHEN B EDGE, MD, FACS, FASCOProfessor of Oncology, VP Healthcare Outcomes and Policy, Roswell Park Cancer Institute, Buffalo, NY
              • LINDI VANDERWALDE, MD, FACSBreast Surgical Oncologist, Baptist Cancer Center, Baptist Memorial Health Care Corporation, Memphis, TN
              • ALYSSA D. THROCKMORTON, MD, FACSBreast Surgical Oncologist, Baptist Cancer Center, Baptist Memorial Health Care Corporation, Memphis, TN; Clinical Assistant Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN

              Breast cancer is the most common malignancy in women in the Western world. Its prevalence and public health impact are increasing in developing countries, and breast cancer leads to the death of hundreds of thousands of women worldwide annually. In the United States, surgeons are involved in the treatment of most women with breast cancer and surgical care must be coordinated with other components of comprehensive breast cancer treatment. This review covers breast evaluation and management of findings suspicious for cancer, management of clinical or screening-detected findings, management of breast cancer, noninvasive cancer (carcinoma in situ), invasive breast cancer, special circumstances, and follow-up after breast cancer treatment. Figures show ultrasound images of representative breast lesions demonstrating key characteristics, structure of breast, impact of basement membrane invasion: invasive cancer, histologic subtypes of ductal carcinoma in situ, specimen mammogram of breast cancer-localizing wire, breast cancer wide excision specimen painted with six colors of ink to orient the specimen for pathologic analysis of surgical margins, microscopic appearance of invasive ductal and invasive lobular cancer, overall survival from the NSABP B-06 study, and anatomy of the axilla. Tables list components of the breast history, BI-RADS classification, American Joint Committee on Cancer (AJCC) TNM staging system: T, N, and M categories, AJCC TNM staging system: anatomic stage/prognostic groups, Nottingham Grading System for invasive breast cancer, and relative indications for mastectomy.

              This review contains 9 highly rendered figures, 6 tables, and 216 references

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            • 7

              Lymphatic Mapping and Sentinel Node Biopsy

              By David W. Ollila, MD, FACS; Karyn B. Stitzenberg, MD, MPH; Kristalyn Gallagher, DO, FACS
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              Lymphatic Mapping and Sentinel Node Biopsy

              • DAVID W. OLLILA, MD, FACSAssociate Professor of Surgery, University of North Carolina, Chapel Hill, NC
              • KARYN B. STITZENBERG, MD, MPHAssociate Professor of Surgery, University of North Carolina, Chapel Hill, NC
              • KRISTALYN GALLAGHER, DO, FACSAssistant Professor of Surgery, University of North Carolina, Chapel Hill, Chapel Hill, NC

              With an estimated 232,670 new cases in the United States in 2014, breast cancer is among the most common malignancies treated by US surgeons. Meanwhile, the incidence of melanoma is rising faster than for all other solid malignancies, with an estimated 76,100 new cases of invasive melanoma in the United States in 2014. Over the past 20 years, significant strides have been made in the management of these two diseases from the standpoint of both surgical and adjuvant therapy. For both diseases, the presence or absence of lymph node metastases is highly predictive of patient outcome and is the most important prognostic factor for disease recurrence and cancer-related mortality. This review covers lymphatic mapping and sentinel node biopsy for melanoma, special circumstances associated with sentinel node biopsy in melanoma, lymphatic mapping and sentinel node biopsy in breast cancer, and radiation exposure guidelines and policies. The figures show lymphatic mapping and sentinel lymph node biopsy for melanoma, lymphatic mapping and sentinel node biopsy for breast cancer, and touch-imprint cytology from lymphatic mapping and sentinel node biopsy for breast cancer.

              This review contains 3 highly rendered figures and 89 references.

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            • 8

              Postoperative Management of the Hospitalized Patient

              By Edward Kelly, MD, FACS
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              Postoperative Management of the Hospitalized Patient

              • EDWARD KELLY, MD, FACS

              Effective surgical treatments are available for a wide variety of diseases in the modern era; at the same time, surgical interventions have become increasingly complex and specialized. The contemporary surgeon must coordinate evaluation and management of patients with multiple medical diagnoses and shepherd these patients through an increasingly elaborate process of medical and surgical care. To provide effective care, the organ systems–oriented approach is key. This approach, demonstrated in the following review, guides the practitioner through each organ system in order and can be used to generate a differential diagnosis for each system and a comprehensive problem list for each patient. The comprehensive problem list and surgical care plan have found new interest as extended recovery after surgery (ERAS) pathways.

              This review contains 107 references and 5 tables.

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            • 9

              Postoperative Pain Management

              By Abhishek Parmar, MD, MS
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              Postoperative Pain Management

              • ABHISHEK PARMAR, MD, MSAssistant Professor, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL

              The aim of this review is to provide practical clinical information on modern pain management options to guide the clinician on evidence-based practices, optimizing the treatment of pain and avoiding practices that may lead to potential abuse. Postoperative pain management is an essential component of any surgeon’s practice and has clear implications for surgical outcomes, patient satisfaction, and population health. Understanding options within a multimodal approach to pain management in the acute setting is a key determinant to improving outcomes for our patients. This review discusses multimodal analgesic options, including a variety of pain medications (opiates, antiinflammatory medications, and patient-controlled analgesia) and techniques (epidural catheter placement, regional nerve blocks) to be used in tandem. Lastly, best possible practices to avoid opiate abuse are discussed.

              This review contains 4 figures, 5 tables, 1 video and 96 references.

              Key words: antiinflammatories, epidural, narcotics, patient-controlled analgesia, postoperative pain, regional nerve block

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            • 10

              Gastroesophageal Reflux Disease and Hiatal Hernia

              By James A Rydlewicz, MD; Matthew R. Pittman, MD; Kyle A. Perry, MD
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              Gastroesophageal Reflux Disease and Hiatal Hernia

              • JAMES A RYDLEWICZ, MDClinical Instructor of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
              • MATTHEW R. PITTMAN, MDClinical Instructor of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
              • KYLE A. PERRY, MDAssistant Professor of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH

              Gastroesophageal reflux disease (GERD) is common, affecting approximately 18 to 27% of adult Americans, and can have a considerable impact on quality of life. Hiatal hernias are present in 80% of patients with symptomatic GERD. This review covers the basic pathophysiology, evaluation, and treatment algorithms for patients with GERD and hiatal hernia. Figures show normal gastroesophageal junction anatomy, treatment algorithm for patients with symptomatic GERD, schematic and endoscopic images of long segment Barrett esophagus, a normal barium esophagogram, esophageal intraluminal pressures assessed by esophageal manometry, test results from a 48-hour wireless pH study, laparoscopic Nissen fundoplication, laparoscopic gastroesophageal junction reinforcement, classification of paraesophageal hernia, and endoscopic view of Cameron ulcers at the level of the diaphragm in the setting of a type III paraesophageal hernia. Tables list risk factors for GERD and a standardized approach to Nissen fundoplication.

              This review contains 10 figures, 2 tables, and 58 references.

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            • 11

              Management of Uncomplicated Gallstones and Benign Gallbladder Disease

              By Rebecca C Britt, MD, FACS; Jessica R Burgess, MD
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              Management of Uncomplicated Gallstones and Benign Gallbladder Disease

              • REBECCA C BRITT, MD, FACSAssociate Professor, Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
              • JESSICA R BURGESS, MDAssistant Professor, Department of Surgery, Eastern Virginia Medical School, Norfolk VA

              Gallbladder disease is one of the most common problems that the general surgeon will encounter. This comprehensive review discusses the management of uncomplicated gallstone disease, functional gallbladder disease, and gallbladder polyps. It provides indications for cholecystectomy in the asymptomatic patient. There is a thorough review of the diagnosis and management of symptomatic cholelithiasis, including special situations such as pregnancy and cirrhosis, and the latest evidence regarding routine versus selective cholangiography during cholecystectomy. This review also discusses the latest updates to the criteria for diagnosing functional gallbladder disease and sphincter of Oddi dysfunction. 

              This review contains 6 figures, 6 tables, and 99 references.

              Key words: asymptomatic gallstones, biliary dyskinesia, cholangiography, gallbladder polyps, laparoscopic cholecystectomy, sphincter of Oddi dysfunction, symptomatic cholelithiasis

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            • 12

              Management of Acute Wounds

              By Lee D. Faucher, MD, FACS; Angela L. Gibson, MD, PhD
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              Management of Acute Wounds

              • LEE D. FAUCHER, MD, FACSAssociate Professor of Surgery University of Wisconsin School of Medicine & Public Health, Madison WI.
              • ANGELA L. GIBSON, MD, PHDAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

              Acute wounds are the result of local trauma and may be associated with severe life-threatening injuries. All patients with acute wounds should be assessed for comorbidities such as malnutrition, diabetes, peripheral vascular disease, neuropathy, obesity, immune deficiency, autoimmune disorders, connective tissue diseases, coagulopathy, hepatic dysfunction, malignancy, smoking practices, medication use that could interfere with healing, and allergies. The authors address the key considerations in management of the acute wound, including anesthesia, location of wound repair (e.g., operating room or emergency department), hemostasis, irrigation, débridement, closure materials, timing and methods of closure, adjunctive treatment (e.g., tetanus and rabies prophylaxis, antibiotics, and nutritional supplementation), appropriate closure methods for specific wound types, dressings, postoperative wound care, and potential disturbances of wound healing. The introduction briefly reviews the physiology of wound healing and the conclusion addresses new technologies in acute wound care.

              This review contains 11 figures, 16 tables, and 101 references.

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          • Emergency Medicine
            • 1

              Focused Assessment With Sonography for Trauma

              By David Barounis, MD ; Elise Hart, MD
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              Focused Assessment With Sonography for Trauma

              • DAVID BAROUNIS, MD Attending Physician, Departments of Emergency Medicine and Critical Care Medicine, Advocate Christ Medical Center, Oak Lawn, IL
              • ELISE HART, MDPostgraduate Year 3, Emergency Medicine Residency Program, Advocate Christ Medical Center, Oak Lawn, IL

              The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients.

              Key words: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

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            • 2

              Drugs of Abuse

              By Matthew D Zuckerman , MD; Kavita Babu, MD, FACEP, FACMT
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              Drugs of Abuse

              • MATTHEW D ZUCKERMAN , MDAssistant Professor, Department of Emergency Medicine, Medical Toxicology, University of Colorado Anschutz Medical Campus, Aurora, CO
              • KAVITA BABU, MD, FACEP, FACMTFellowship Director, Division of Medical Toxicology, Associate Professor, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA

              The term “drugs of abuse” lacks a formal medical definition. Historically, discussions of drugs of abuse focused on “street drugs”; however, the adverse effects of the nonmedical use of prescription medications, such as opiates, benzodiazepines, and therapeutic amphetamines, are increasingly seen. The purpose of this review is to aid the clinician in identifying and treating a broad representation of drugs of abuse, which may include those illicitly produced in laboratories (e.g., methamphetamine), diverted pharmaceuticals (oxycodone), and herbal products (marijuana). This review covers stimulants, hallucinogens, cannabinoids, and sedative-hypnotics. Figures show substances ranked according to weighted harm score on a normalized scale from 0 being no harm to 100 being extreme harm to self and others, a treatment algorithm for sympathomimetic toxicity, a treatment algorithm for sedative-hypnotic overdose, and a treatment algorithm for opioid overdose. Tables list commonly abused sympathomimetic agents, modern novel drugs of abuse, commonly abused sedative-hypnotic agents, commonly abused opiates, and pitfalls of the drug screen.

              This review contains 4 highly rendered figures, 5 tables, and 89 references

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            • 3

              Trauma to the Abdomen and Pelvis

              By Zahir Basrai, MD; Timothy Jang, MD; Manuel Celedon , MD
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              Trauma to the Abdomen and Pelvis

              • ZAHIR BASRAI, MDAttending Physician, Department of Emergency Medicine, Veterans Affairs Medical Center, West Los Angeles, Clinical Instructor, David Geffen School of Medicine at UCLA
              • TIMOTHY JANG, MDAttending Physician, Department of Emergency Medicine, Veterans Affairs Medical Center, West Los Angeles, Clinical Instructor, David Geffen School of Medicine at UCLA
              • MANUEL CELEDON , MD

              Abdominal trauma accounts for approximately 12% of all trauma. The evaluation of abdominal trauma is difficult as the patient may have concomitant distracting injuries or alteration of mental status. As a result, a systematic approach to abdominal trauma is needed to ensure that life threatening injuries are not missed. The evaluation and management of abdominal trauma is directed by the Western and Eastern Trauma Association guidelines.Trauma to the abdomen is divided into two main categories, penetrating and blunt. The initial steps in management of both types are determined by the hemodynamic stability of the patient. Unstable patients with either pattern of injury are emergently taken to the operating room (OR) for exploration. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is being used at select trauma centers in unstable patients with abdominal trauma that are unresponsive to standard trauma resuscitation. For hemodynamically stable patient with penetrating trauma, recent data on selective non-operative management has shown promising outcomes. Patients with tenuous hemodynamics and blunt abdominal trauma are resuscitated with blood transfusions while being worked up by a Focused Assessment with Sonography for Trauma (FAST) exam or deep peritoneal lavage (DPL). If the patient stabilizes further work up with labs and imaging is performed. Patients that remain tenuous should be taken to the OR. Hemodynamically stable patients with blunt trauma and evidence of peritonitis on exam can be evaluated with labs and imaging to assess for organ injury. Non- tender patients can be evaluated with labs and serial abdominal exams. The American Association for the Surgery of Trauma (AAST) organ injury scales are used to guide the definitive management of patients with intraabdominal injury. The Young-Burgess Classification System can be used to characterize pelvic fractures and to guide stabilization and definitive management. Tables demonstrate the AAST Injury Scales for the different abdominal organs. Images demonstrate the FAST exam and CT findings for different abdominal organs.

              This review contains 14 figures, 6 tables and 48 references

              Key Words: Abdominal Trauma, Penetrating Trauma, Blunt Trauma, FAST exam, Liver Trauma, Splenic Trauma, Intestinal Trauma, Pancreatic Trauma, Diaphragmatic Trauma, Aortic Trauma, Pelvic Fracture, Deep peritoneal lavage, DPL, Focused Assessment with Sonography for Trauma, REBOA, Resuscitative Endovascular Balloon Occlusion of the Aorta

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            • 4

              Extremity Trauma: Nonaxial Skeleton Fractures, Sprains, Dislocations

              By David A. Meguerdichian, MD, FACEP; John Eicken, MD
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              Extremity Trauma: Nonaxial Skeleton Fractures, Sprains, Dislocations

              • DAVID A. MEGUERDICHIAN, MD, FACEPAssistant Medical Director for Emergency Medicine/GME, STRATUS Center for Medical Simulation, Attending Physician, Department of Emergency Medicine, Brigham and Women’s Hospital, Instructor of Emergency Medicine, Harvard Medical School, Boston, MA
              • JOHN EICKEN, MDDepartment of Emergency Medicine, Brigham and Women’s Hospital, Instructor, Harvard Medical School, Boston, MA

              Orthopedic extremity injuries may require emergent orthopedic consultation, but are typically managed by the acute care provider. Initial management for all fractures should focus on providing immediate analgesia and ensuring adequate blood flow distal to the fracture. This review summarizes the assessment and stabilization, diagnosis, treatment and disposition, and outcomes for fractures, dislocations, and sprains. Figures include illustrations of fracture types, carpal bones and their articlulation in the wrist, bones of the hand, the anatomy of the hip demonstrating the areas where hip fractures occur, the Weber classification, the Bohler angle, and fractures of the proximal fifth metatarsal; a bedside sonogram of a fracture of the distal radius; and 10 radiographs showing various fractures and dislocations. Tables list the Gustilo classification of open fractures; common terms used to accurately describe fractures; components of the Ottawa Knee Rules and the Ottawa Ankle/Foot Rules; Schatzker classification system of tibial plateau fractures; common fractures of the hand and foot, respectively, with their associated treatment, splint, and recommended follow-up; normal anatomic alignments that should be assessed on radiographic evaluation of a possible Lisfranc injury; common splints and the associated fractures they are used to treat; AC joint injuries graded according to the severity of injury to the joint structures; and the four stages of worsening lunate instablity.

              This review contains 18 highly rendered figures, 11 tables, and 98 references.

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            • 5

              Venomous Bites and Stings

              By J Patrick Walker, MD, FACS
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              Venomous Bites and Stings

              • J PATRICK WALKER, MD, FACSChief of Surgery, ETMC, Crockett, TX, Houston County Surgical Associates, Crockett, TX

              Approximately 8000 persons are bitten by venomous snakes in the US each year.  Mortality is low (4 to 6/yr), but morbidity can be significant, treatment costly. Overuse of surgery and antivenom is common. Simply cutting the wound with attempted aspiration is not indicated. Fasciotomy should only be used for patients with elevated compartment pressures. CroFab is a highly effective (but expensive) treatment useful for serious envenomation. Antivenom should be used in patients with life-threatening symptoms (hypotension, clinical coagulopathy) or rapid advancement of local signs, and to reduce compartment pressures to avoid fasciotomy. The most significant morbidity from insect envenomation is secondary to anaphylaxis. A bite from the black widow spider can induce abdominal cramping and pain that can mimics an acute abdomen. Brown recluse envenomation can produce tissue necrosis and long-term complications. Most events are seen rarely by the average physician; this review can be a useful guide in management. 

              Key words: antivenom, copperhead bite, CroFab, insect bite, rattlesnake bite, snakebite, water moccasin bite

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            • 6

              Bowel Obstruction

              By Andrew S. Liteplo, MD, FACEP
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              Bowel Obstruction

              • ANDREW S. LITEPLO, MD, FACEP Massachusetts General Hospital, Dept of Emergency Medicine. Chief, Division of Emergency Ultrasound, Massachusetts General Hospital Associate Professor, Harvard Medical School, Boston, MA

              Small bowel obstruction can be a surgical emergency, and may be the ultimate diagnosis in 2 to 15% of patients presenting to the emergency department with abdominal pain. Bowel obstruction can be either mechanical (caused by extrinsic compression, twisting of the bowel, or intrinsic obstruction) or functional (caused by an impaired ability of the bowel to propel contents distally). The most common cause of small bowel obstruction in the developed world is postoperative adhesions.This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and outcomes for patients with bowel obstruction.Figures show sonograms of small bowel obstruction, pneumatosis, and an abdominal wall hernia; and a computed tomographic scan of small bowel obstruction. Videos show ultrasonography of fluid-filled, dilated loops of bowel with decreased peristalsis; pendulous peristalsis; a ventral hernia with protruding bowel; normal peristalsis; and absent peristalsis in ileus. Tables list the differential diagnosis for smallbowel obstruction, and a summary of performance of imaging modalities in diagnosing small bowel obstruction.

              This review contains 4 highly rendered figures, 5 videos, 2 tables, and 26 references.

              Keywords: Bowel obstruction; Small bowel obstruction; Bowel peristalsis; Small intestinal peristalsis; Obstipation; Postoperative adhesions; Pendulous peristalsis; Decreased peristalsis

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            • 7

              Upper Airway Disorders

              By Lawrence Proano, MD, DTMH ; Seth Gemme, MD; Robert Partridge, MD, MPH, DTMH
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              Upper Airway Disorders

              • LAWRENCE PROANO, MD, DTMH Clinical Professor of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI
              • SETH GEMME, MDRhode Island Hospital; Chief Resident, The Alpert Medical School of Brown University, Providence, RI
              • ROBERT PARTRIDGE, MD, MPH, DTMH Adjunct Associate Professor of Emergency Medicine, he Alpert Medical School of Brown University, Providence, RI

              Upper airway disorders are frequently encountered in the primary care setting and present in both adults and children.  This review covers earache, sinusitis, sore throat, peritonsillar abscess, sialolithiasis and sialadenitis, parotitis, epiglottitis, epistaxis, foreign body in the ear, nose, or throat, and Ludwig angina. Figures show right-sided peritonsillar abscess demonstrating swelling and distortion of the anterior and posterior tonsillar pillars and uvular deviation, peritonsillar abscess demonstrated by an ultrasound image of a hypoechoic fluid collection, ultrasound imaging of sagittal view of the tonsillar pillars, lateral radiograph of the neck demonstrating a swollen epiglottis and widened vallecula, photographs of brawny swelling of the submandibular region of the neck in Ludwig angina, and a patient with peritonsillar abscess with extension to the base of the tongue. Tables list criteria for diagnosing acute sinusitis, and clinical presentations that best identify patients with acute bacterial versus viral rhinosinusitis.

              This review contains 7 highly rendered figures, 2 tables, and 62 references.

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            • 8

              Aortic Aneurysm

              By Christine E Lee, MD, MPH; Leily Naraghi, MD; Beatrice Hoffmann, MD, PhD, RDMS
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              Aortic Aneurysm

              • CHRISTINE E LEE, MD, MPHClinical Instructor, Harvard Medical School, Ultrasound Faculty, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
              • LEILY NARAGHI, MDEmergency Medicine Physician and Emergency Ultrasound Fellow, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, United States
              • BEATRICE HOFFMANN, MD, PHD, RDMSAssociate Professor Harvard Medical School, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.

              Aortic diseases are relatively rare but are associated with high morbidity and mortality. Emergency physicians (EPs) should consider aortic disease in all patients with pain in the torso, particularly those with other diverse or seemingly unconnected complaints. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with abdominal aortic aneurysms (AAAs), thoracic aortic aneurysms (TAAs), and aortic dissection. Figures show a transverse image of an AAAs with a transmural hematoma, a three-dimensional computed tomographic angiogram (CTA) rendering of a thoracic aneurysm associated with a bicuspid aortic valve in the typical ascending aortic location, a chest x-ray film demonstrating prominent and blurred aortic knob due to TAA, acute aortic dissection subtypes, an electrocardiogram and transesophageal echocardiography of a patient with acute ascending aortic dissection, magnetic resonance images of a patient with dissection of the proximal descending aorta, CT representations of a type A dissection involving a dilated ascending aorta and a type B dissection involving the descending thoracic aorta, and a decision algorithm for evaluation and treatment of a suspected aortic dissection. Tables list normal aortic dimensions by CTA and echocardiography, average annual rate of expansion and rupture of AAA based on current diameter, and the etiology of TAA.

              Key words: AAA, aorta, aortic dissection, ascending aortic dissection, descending aortic dissection, intimal tear, intramural hematoma, thoracic aortic aneurysm

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            • 9

              Diarrheal Illness

              By Jeremy S Faust, MD, MS, MA
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              Diarrheal Illness

              • JEREMY S FAUST, MD, MS, MABrigham & Women’s Hospital/Brigham Faulkner Hospital Department of Emergency Medicine, Clinical Instructor, Harvard Medical School, Boston, MA

              Diarrhea, qualitatively defined as an increase in stool frequency and liquid content, is a frequent complaint in patients presenting to emergency departments. Although most cases are uncomplicated viral infections, the most frequent causes of dangerous underlying entities are often not viral. In uncomplicated cases, laboratory testing for metabolic derangements is not required unless there are signs of moderate to severe dehydration or the patient has particular risks, such as chronic kidney disease. Secondary infections associated with antibiotic use (C difficile–associated diarrhea), other significant nosocomial exposures, recent international travel history, the presence of a nonintact immune system (HIV/AIDS, cancer/chemotherapy), and exposure to high-risk environments (including zoonotic exposures, outbreak-prone environments such as day care facilities) increase the likelihood of a bacterial or other infectious cause requiring either microbiologic testing or empirical antimicrobial treatments. Diarrhea is often present as a feature of clinically significant noninfectious conditions, including complications of inflammatory bowel diseases (Crohn disease and ulcerative colitis), overdoses, and withdrawal syndromes. In such cases, after hemodynamic stability has been ensured, advanced workup and treatment are guided by the underlying condition and antecedent risks, not the presence of diarrhea per se. Oral rehydration is the first step in management for mild dehydration caused by uncomplicated diarrhea. Intravenous fluids may be necessary in moderate to severe dehydration and in cases of electrolyte derangement requiring resuscitation where fluid choice and rate are paramount, as well as in patients who cannot tolerate oral intake. In cases of suspected bacteria-caused diarrhea, antibiotics, most often fluoroquinolones, reduce both the severity and duration of illness. In patients safe for home management, antidiarrheal agents such as loperamide may be used in uncomplicated and resolving cases. Probiotics appear safe in most cases and impart a small but clinically detectable decrease in the duration and severity of illness. Although there have been fears of bacterial outbreaks following natural disasters, improvements in local and global health efforts have led to decreases in cholera outbreaks, and typical viral causes of diarrhea are generally the most common causes.

               This review contains 4 figures, 5 tables and 32 references

              Key words: Clostridium difficile, diarrhea, infectious diseases, inflammatory bowel diseases, medication side effects, overdose syndromes, sepsis, traveler’s diarrhea, zoonotic infections 

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            • 10

              Cardiac Arrest and Resuscitation

              By Shamai A. Grossman, MD, MS; Patrick Hughes, MD; Oren Mechanic, MD, MPH
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              Cardiac Arrest and Resuscitation

              • SHAMAI A. GROSSMAN, MD, MSAssociate Professor of Emergency Medicine, Harvard Medical School, Vice Chair for Health Care Quality, Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA
              • PATRICK HUGHES, MDHarvard Affiliated Emergency Medicine Residency Program, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Resident
              • OREN MECHANIC, MD, MPHHarvard Medical School, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Attending Physician

              The ultimate goal of cardiac resuscitation is full neurologic recovery; however, the probability of achieving this goal deteriorates rapidly with each minute of cardiac arrest. The most essential steps are rapid recognition of cardiac arrest, early high-quality chest compressions with minimal interruptions, and early defibrillation. Additional key components include effective leadership and followership, appropriate airway management, and effectual investigation for possible reversible causes of the arrest. This review discusses the role of and evidence for using pharmacologic agents. Additional discussion evaluates the use of ultrasonography and end-tidal CO2 in cardiac arrest resuscitation. Lastly, this review discusses cardiac arrest in special circumstances, such as patients who are pregnant, have left ventricular assist devices, or are subjects of trauma.

              This review contains 6 figures, 3 tables and 101 references

              Key words: advanced cardiovascular life support, antidysrhythmics, asystole, cardiac arrest, basic life support, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, pulseless electrical activity, resuscitation, ventricular fibrillation, ventricular tachycardia

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            • 11

              Genitourinary Trauma

              By Daniel Lakoff, MD; Adam D. Hill, MD
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              Genitourinary Trauma

              • DANIEL LAKOFF, MDAssistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai & Elmhurst Hospital Center, New York, NY
              • ADAM D. HILL, MDAssistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai & Elmhurst Hospital Center, New York, NY

              Injury to the urogenital tract from blunt or penetrating trauma comprises 10% of injuries sustained from trauma with renal injuries comprising the majority of those cases at 1-5 % of all trauma, followed by bladder injuries. Worldwide variations in trauma mechanisms exist, with blunt trauma causing the majority of renal trauma in the United States. Careful attention to the mechanism, anatomic location, and specific physical and radiologic findings can aid in the diagnosis and appropriate management to optimize patient outcomes. Unless trauma is overtly obvious on a physical examination, imaging is required for diagnosis and staging purposes. Owing to the complexity of the urogenital tract, there is a great deal of variation in management, ranging from a conservative approach in most renal injuries to the need for operative intervention with intraperitoneal bladder rupture. This review discusses common practice and provides more recent up-to-date guidelines pertaining to the clinical history, examination findings, and imaging modalities, along with the diagnosis and management of injuries to the genitourinary system.

              Keywords: Genitourinary Trauma, Renal Trauma, Ureter Trauma, Bladder Trauma, Urethral Trauma, External Genitalia Trauma

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            • 12

              Delirium in the Emergency Department: Diagnosis, Evaluation, and Management

              By Maura Kennedy, MD, MPH
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              Delirium in the Emergency Department: Diagnosis, Evaluation, and Management

              • MAURA KENNEDY, MD, MPHDivision Chief, Geriatric Emergency Medicine, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Emergency Medicine, Harvard Medical School, Boston, MA

              Delirium, an acute confusional state characterized by disturbances in attention, cognition, and arousal, is present in 7 to 10% of older emergency department (ED) patients, underdiagnosed in the ED setting, and associated with increased short-term mortality. Delirium is typically precipitated by a physiologic stressor, such as an acute medical illness, a new medication, or a change in environment. The keys to the care and management of delirious patients are timely diagnosis of delirium and identification and treatment of the precipitating cause. The medical evaluation should include a formal delirium assessment that includes tests of attention and targeted diagnostic tests to identify the underlying etiology, such as infection, metabolic derangement, neurologic emergencies, new medications, and/or toxidromes. Pharmacologic treatment of delirium should be limited to patients who are severely agitated and at risk for substantial harm to self and/or others and patients with delirium secondary to alcohol withdrawal. Typical and atypical psychotics at low doses are first line for use in severely agitated patients. Benzodiazepines may worsen delirium and should be reserved for treatment of patients with delirium secondary to alcohol withdrawal or if sedation is required for critical imaging and/or procedures. ED physicians should also be conscious of and strive to minimize iatrogenic precipitants of delirium.

              This review contains 2 figures, 10 tables and 53 references

              Key words: aged, agitation, arousal attention, confusion, delirium, delirium/diagnosis, delirium/etiology, delirium/therapy, dementia complications, geriatrics, risk factors

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            • 13

              Acute Respiratory Failure and ­mechanical Ventilation

              By Lawrence A. DeLuca, Jr, EdD, MD
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              Acute Respiratory Failure and ­mechanical Ventilation

              • LAWRENCE A. DELUCA, JR, EDD, MDAssociate Professor of Emergency Medicine, University of Arizona/Banner University Medical Center, Department of Emergency Medicine, Tucson AZ

              Patients with acute respiratory failure present to the emergency department (ED) on a regular basis, and emergency physicians (EPs) are expected to be skilled in endotracheal intubation. Historically, although a significant portion of emergency medicine residency training focuses on airway management, extended management of the ventilated patient has received relatively short shrift. Recent data indicate that not only is endotracheal intubation one of the most commonly performed ED procedures, but also that in the initial hours of care, it is also often the EP rather than the intensivist who provides the bulk of critical care to the patient. It is therefore critical that EPs are skilled in ongoing management of the ventilated patient in the early hours as inappropriate management of the ventilator or sedation/analgesia can have a significant impact on complications such as ventilator-induced lung injury, ventilator-associated pneumonia (VAP), ventilator weaning, and delirium. This review outlines basic strategies for the physiologic management of respiratory failure patients to reduce periintubation complications and discuss ventilation strategies, appropriate use of analgesia/sedation, and prevention of secondary complications such as VAP and delirium. Basic troubleshooting of common ventilator problems is also reviewed. Although it is not expected that the EP will replace the intensivist, the goal of this review is to optimize patient management early in the ED stay, to facilitate the transition between the ED and the intensive care unit, and to reduce preventable complications by optimizing the care of ventilated patients in the ED.

              This review contains 9 figures, 4 tables and 46 references

              Key words: acute respiratory distress syndrome, analgesia, chronic obstructive pulmonary disease, delirium, hypercapnia, hyperventilation, hypoxia, patient-ventilator dyssynchrony, pulmonary edema, respiratory failure, sedation, ventilator-associated pneumonia

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            • 14

              Urologic Infections

              By Tatyana Vayngortin, MD; Nisa S Atigapramoj, MD
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              Urologic Infections

              • TATYANA VAYNGORTIN, MDPediatric Emergency Medicine Fellow, Department of Emergency Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, CA
              • NISA S ATIGAPRAMOJ, MDAssistant Clinical Professor of Pediatrics and Emergency Medicine, Department of Emergency Medicine, UCSF Benioff Children’s Hospital, San Francisco, CA

              Urinary tract infections (UTIs) affect people of all ages. Although the incidence of invasive bacterial diseases continues to decline, the prevalence of UTIs in febrile pediatric patients continues to remain a focus for serious bacterial infection in this population. In older age groups, symptoms become more obvious and present more classically. Clinical practice guidelines have been developed because morbidity can be dependent upon the rapid identification of a UTI with prompt initiation of appropriate antimicrobials. This review provides a summary for the evaluation of UTIs with discussion of diagnosis and management. 

              This review contains 6 figures, 5 tables and 47 references

              Key words: antibiotics, cystitis, pyelonephritis, urinary tract infection, uropathogens

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            • 15

              Pacemaker Therapy

              By Shamai A. Grossman, MD, MS; Ryan M Kring, MD
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              Pacemaker Therapy

              • SHAMAI A. GROSSMAN, MD, MSAssociate Professor of Emergency Medicine, Harvard Medical School, Vice Chair for Health Care Quality, Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA
              • RYAN M KRING, MDChief Resident in Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Beth Israel Deaconess Medical Center, Boston, MA

              The number of permanent pacemakers implanted per year increased by 55.6% between 1993 and 2009, and is continuing to rise. Accordingly, the number of patients treated in the emergency department who have permanent pacemakers is increasing, and it is important for physicians in the emergency department to be familiar with the operation and potential complications of these devices. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with pacemakers presenting to the emergency department. Figures show examples of dual chamber pulse generators from four major pacemaker manufacturers, VVI pacing with a lower rate limit of 60 beats per minute,  DDD pacing with a lower rate limit of 60 beats per minute and an upper rate limit of 120 beats per minute, a 12-lead electrocardiogram with bifascicular block, a proprietary algorithm (Managed Ventricular Pacing, Medtronic Inc.) aimed at reducing ventricular pacing, and an example of a pacemaker pocket infection. Tables list North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group generic five-position code for antibradycardia pacing, and Levels of Evidence and Society Guideline Recommendations for Selected Pacing Indications.

              This review contains 6 highly rendered figures, 2 tables, and 28 references.

              Key Words: Single-chamber pacing (VVI), Dual-chamber pacing (DDD), Cardiac resynchronization therapy, Sinus node dysfunction, Chronotropic incompetence, Complete Heart Block, Bifasicular Block, Mode Switching, Electromagnetic interference

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          • OBGYN
            • 1

              Contraception

              By Eva Luo, MD, MBA; Siripanth Nippita, MD, MS
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              Contraception

              • EVA LUO, MD, MBABeth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
              • SIRIPANTH NIPPITA, MD, MSBeth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

              Most individuals will wish to avoid pregnancy for some part of their reproductive years. A variety of hormonal and nonhormonal contraceptive methods are available, which have different characteristics related to systemic effects, bleeding patterns, and effort required on the user’s part. The goal of contraceptive counseling is to identify a method that is safe and compatible with the individual’s preferences. Clinicians may often be able to help patients initiate contraception on the day of the initial office visit. They should remain available and supportive to patients who wish to switch methods and provide comprehensive counseling for all available contraceptive methods as well as emergency contraception options.

              This review contains 8 figures, 6 tables and 47 references.

              Key words: birth control, contraception, emergency contraception, Essure, hysteroscopy, interval, laparoscopy, microinserts, postpartum, salpingectomy, sterilization

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            • 2

              The Puerperium

              By Sarah Kleinman, CNM; Hope A Ricciotti, MD
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              The Puerperium

              • SARAH KLEINMAN, CNMAtrius Health, Boston, MA
              • HOPE A RICCIOTTI, MDChair, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

              The puerperium starts after the birth of a baby and continues until 6 to 8 weeks postpartum. Several recent interventions in management have been shown to improve outcomes. Delayed cord clamping, the practice of waiting for a period of time after a baby is born before clamping and cutting the umbilical cord, can increase hemoglobin levels, improve iron stores, and increase birth weight in newborns. Rooming in, the practice of mothers and newborns staying together, improves infant sleep and breast-feeding without affecting maternal sleep. Immediately after birth, significant physiologic and anatomic changes occur. Thromboembolic events are more common in the postpartum state than during pregnancy, but the majority of women do not require specific thromboprophylaxis but should be encouraged to walk after birth. Women who have not been previously immunized for influenza; tetanus, diphtheria, pertussis (Tdap); and rubella should be offered these immunizations. Women with uncomplicated pregnancies may engage in exercise within days after delivery. Pelvic floor physical therapy performed during pregnancy and postpartum may assist in maintaining or regaining muscle tone of the pelvic floor and may prevent or treat urinary incontinence. Perinatal depression affects one in seven women. Baby blues, which include mood swings, anxiety, tearfulness, and insomnia, should resolve by 2 weeks after delivery. Patients should be screened for depression using a standardized, validated tool and appropriate treatment initiated. All women should undergo a comprehensive postpartum visit within 6 weeks of delivery.

              This review contains 2 figures, 1 table and 32 references

              Key words: delayed cord clamping, hemodynamic changes, perinatal depression, postpartum, puerperium, rooming in, skin-to-skin contact

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            • 3

              Abnormal Menstrual Bleeding

              By Chu Hsiao, BS, MD-PhD; Leanne Dumeny, MS, BS, MD-PhD; Candice P. Holliday, MD, JD; Lisa Spiryda, MD-PhD
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              Abnormal Menstrual Bleeding

              • CHU HSIAO, BS, MD-PHDTrainee, Department of Anthropology, University of Florida College of Medicine, Gainesville, FL
              • LEANNE DUMENY, MS, BS, MD-PHDTrainee, Department of Pharmacotherapy and Translational Research, University of Florida College of Medicine, Gainesville, FL
              • CANDICE P. HOLLIDAY, MD, JDResident, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, AL
              • LISA SPIRYDA, MD-PHDProfessor and Chair, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, AL

              Abnormal uterine bleeding (AUB) is a common presentation that can occur in all age groups. AUB is an umbrella term for any uterine bleeding that occurs outside a woman’s normal pattern in volume, regularity, and/or timing. AUB is described by using frequency, regularity, duration, and volume or by using PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy and premalignant conditions; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified). Workup for AUB comprises a history (with a detailed menstrual history), physical examination (including a pelvic and bimanual examination), lab tests, and imaging (primarily transvaginal ultrasonography). For treatment, medical therapies should be considered before surgical therapies, especially when fertility is desired. The decisions for treatment are based on etiology, fertility concerns, contraindications, or patient preference. Of the medical therapies, there are hormonal and nonhormonal therapies. The most common treatments for AUB are levonorgestrel intrauterine device, tranexamic acid, oral contraceptives, and nonsteroidal anti-inflammatory drugs. The most common surgical treatments are myomectomy, endometrial ablation, uterine artery embolization, and hysterectomy.

              This review contains 7 figures, 10 tables and 45 references

              Key words: abnormal uterine bleeding, adenomyosis, contraceptives, endometrial, fibroids, hysterectomy, menorrhagia

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            • 4

              Menopause

              By Susan D. Reed, MD, MPH; Eliza L. Sutton, MD, FACP
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              Menopause

              • SUSAN D. REED, MD, MPHProfessor, Department of Obstetrics and Gynecology, Department of Epidemiology, Director, Women’s Reproductive Health Research Program, University of Washington School of Medicine, Chief of Service, Obstetrics and Gynecology, Harborview Medical Center, Seattle, WA
              • ELIZA L. SUTTON, MD, FACPAssociate Professor, Division of General Internal Medicine, Department of Medicine, Medical Director, Women’s Health Care Center, University of Washington Medical Center, Seattle, WA

              The female reproductive system matures in a continuous, natural process from menarche to menopause as the finite numbers of oocytes produced during fetal development are gradually lost to ovulation and senescence. Menopause is defined as the permanent cessation of menses; by convention, the diagnosis of menopause is not made until the individual has had 12 months of amenorrhea. Menopause is thus characterized by the menstrual changes that reflect oocyte depletion and subsequent changes in ovarian hormone production. However, hormonal changes, rather than the cessation of menstruation itself, cause the manifestations that occur around the time of menopause. Therefore, a woman who has undergone a hysterectomy but who retains her ovaries can experience normal menopausal symptoms as oocyte depletion leads to changes in estrogen levels, even though cessation of menstruation occurred with surgery. This review covers definitions, natural menopause, menopausal transition and postmenopausal symptom management, and premature ovarian insufficiency. Figures show stages of reproductive aging, serum concentrations of hormones during menopausal transition and postmenopause, hormonal changes associated with reproductive aging, symptoms of menopausal transition and menopause, treatment algorithm(s), and Women’s Health Initiative findings: risks and benefits of estrogen alone and estrogen plus progestin by age group: 50 to 59, 60 to 69, and 70 to 79 years. Tables list target tissues, physical manifestations, and menopausal symptoms; selective estrogen receptor modulators used in postmenopausal women;differential diagnosis and evaluation of common menopausal symptoms; estrogen doses; progestogen dosing for endometrial protection; nonhormonal pharmaceutical hot flash therapies; and pharmacologic therapy for genitourinary atrophy.

              This review contains 6 highly rendered figures, 7 tables, and 119 references.

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            • 5

              Prenatal Screening and Diagnosis

              By Barbara O’Brien, MD; Emily Willner, MD
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              Prenatal Screening and Diagnosis

              • BARBARA O’BRIEN, MDAssociate Professor of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School; Director, Maternal Fetal Medicine Fellowship, Beth Israel Deaconess Medical Center, Boston, MA
              • EMILY WILLNER, MDClinical Fellow of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School; Chief Resident, Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, MA

              Prenatal genetic testing offers patients and providers the opportunity to screen for aneuploidy, genetic syndromes, and congenital malformations during pregnancy. Screening options include taking a clinical history, evaluation of maternal serum markers or noninvasive cell-free DNA, and ultrasound evaluation during the first and second trimesters. Invasive diagnostic testing such as amniocentesis or chorionic villus sampling allows for further investigation of positive screening results and a directed test to identify aneuploidy as well as specific gene mutations and gain, loss, or rearrangement of genetic information. Laboratory methods for testing fetal samples differ by types of genetic abnormalities that can be detected and turnaround time for results; these methods include karyotype, fluorescence in situ hybridization, and microarray.

              This review contains 5 figures, 5 tables and 43 references

              Key words: amniocentesis, aneuploidy, cell-free DNA, chorionic villus sampling, karyotype, microarray, prenatal genetic screening, ultrasonography

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            • 6

              Nausea and Vomiting of Pregnancy

              By Elizabeth Roberts, MD; Brett C Young, MD
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              Nausea and Vomiting of Pregnancy

              • ELIZABETH ROBERTS, MDDepartment of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
              • BRETT C YOUNG, MDDepartment of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA

              In pregnancy, the majority of women experience at least some nausea and vomiting. For many women, these symptoms are mild and self-limiting and resolve by the second trimester. A minority of women experience severe symptoms of hyperemesis gravidarum with persistent vomiting, weight loss, and electrolyte derangements. The diagnosis of hyperemesis gravidarum is based on clinical history and exclusion of other etiologies of nausea and vomiting. First-line pharmacologic treatment is with pyridoxine and doxylamine. Other medical treatments include metoclopramide, phenothiazines, antacids, and ondansetron. In refractory cases, corticosteroids and enteral or parenteral nutrition may be considered.

              This review contains 3 figures, 2 tables and 83 references

              Key words: enteral feeding, hyperemesis gravidarum, maternal outcomes, nausea and vomiting of pregnancy, neonatal outcomes, nonpharmacologic antiemetics, pharmacologic antiemetics

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            • 7

              Vaginitis

              By Monica Mendiola, MD, OB GYN Residency Director; Rachel A Blake, MD, OB GYN Resident
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              Vaginitis

              • MONICA MENDIOLA, MD, OB GYN RESIDENCY DIRECTORDepartment of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School Affiliate, Boston, MA
              • RACHEL A BLAKE, MD, OB GYN RESIDENTDepartment of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School Affiliate, Boston, MA

              Vulvovaginal complaints are a common indication for women to seek gynecologic care. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis, which account for 22 to 50%, 17 to 39%, and 4 to 35% of vaginitis, respectively. This review describes the presentation, diagnosis, and prevention strategies for the most important causes of vulvovaginitis, including characteristic findings on office microscopy and newer available diagnostic testing. It outlines treatment modalities for uncomplicated infections in healthy women, as well as nuances of treatment for recurrent and persistent infections, pregnant women, and HIV-positive women. It also explores the diagnosis and management of non-infectious vaginitis as well special consideration for vaginitis in children and adolescents.

              This review contains 4 figures, 8 tables, and 55 references.

              Key words: vaginitis, vulvovaginitis, bacterial vaginosis, candidiasis, trichomoniasis, vaginitis treatment

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            • 8

              Female Pelvic Pain: Assessment

              By Mario Castellanos, MD; Louise P King, MD
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              Female Pelvic Pain: Assessment

              • MARIO CASTELLANOS, MDGynecologic Surgeon, Division of Surgery and Pelvic Pain, St Joseph’s Hospital and Medical Center, Phoenix, AZ, United States; Associate Professor, Obstetrics and Gynecology, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ 85013, United States; Clinical Assistant Professor, Obstetrics and Gynecology; University of Arizona College of Medicine - Phoenix, Phoenix, AZ 85004, United States,
              • LOUISE P KING, MDSurgeon, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Assistant Professor of Obstetrics, Gynecology and Reproductive Medicine, Director of Reproductive Bioethics, Harvard Medical School, Boston, MA, United States

              Chronic pelvic pain (CPP) in women is responsible for greater than 10% of referrals to gynecologists. A majority of them will remain undiagnosed or inadequately treated. Over time, CPP may lead to a syndrome that results in disability, loss of employment, and discord within relationships. This review discusses how to achieve a comprehensive assessment of CPP from a variety of causes.

              This review contains 12 figures, 2 tables and 57 references

              Key Words: dysmenorrhea, dyspareunia, endometriosis, interstitial cystitis, irritable bowel syndrome, pelvic floor dysfunction, pelvic pain, pudendal neuralgia, somatic pain, visceral pain

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            • 9

              Cervical Cancer Screening

              By Huma Farid, MD
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              Cervical Cancer Screening

              • HUMA FARID, MDClinical Instructor, Department of Obstetrics/Gynecology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA

              Since the Papanicolaou (Pap) smear became implemented as a screening tool for cervical cancer, the mortality from cervical cancer has sharply declined in the United States. The discovery of the human papillomavirus (HPV) as the causative agent in the progression from dysplasia of the cervix to cervical cancer has changed the types of screening offered to women and the management of abnormal Pap smears. The management of abnormal Pap smears has changed depending on the age of the woman, with women under the age of 24 years being managed more conservatively given the low rates of cervical cancer in this age group and the high rates of regression of HPV and cytologic abnormalities. Colposcopy remains the first line in evaluation of an abnormal Pap smear, with excisional treatment reserved for high-grade dysplasias with a high risk of progression to cervical cancer. Treatment for cervical dysplasia is highly effective, but even after treatment, there is an increased risk of recurrence or progression to cervical cancer for up to 20 years, and these women should be followed closely.

              This review contains 18 figures, 3 tables and 53 references

              Key words: cervical cancer screening, high-grade cervical dysplasia, human papillomavirus, low-grade cervical dysplasia, management of abnormal Pap smears, Pap smear, recurrence of cervical dysplasia, treatment of dysplasia

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            • 10

              Normal Menstrual Cycle

              By Rebecca Pierson, MD; Kelly Pagidas, MD
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              Normal Menstrual Cycle

              • REBECCA PIERSON, MDAssistant Professor, Department of Obstetrics, Gynecology and Women’s Health, University of Louisville School of Medicine, Louisville, KY
              • KELLY PAGIDAS, MDProfessor, Division Director and Program Director, Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Women’s Health, University of Louisville School of Medicine, Louisville, KY

              A normal menstrual cycle is the end result of a sequence of purposeful and coordinated events that occur from intact hypothalamic-pituitary-ovarian and uterine axes. The menstrual cycle is under hormonal control in the reproductively active female and is functionally divided into two phases: the proliferative or follicular phase and the secretory or luteal phase. This tight hormonal control is orchestrated by a series of negative and positive endocrine feedback loops that alter the frequency of the pulsatile secretion of gonadotropin-releasing hormone (GnRH), the pituitary response to GnRH, and the relative secretion of luteinizing hormone and follicle-stimulating hormone from the pituitary gonadotrope with subsequent direct effects on the ovary to produce a series of sex steroids and peptides that aid in the generation of a single mature oocyte and the preparation of a receptive endometrium for implantation to ensue. Any derailment along this programmed pathway can lead to an abnormal menstrual cycle with subsequent impact on the ability to conceive and maintain a pregnancy.

              This review contains 7 figures and 26 references

              Key words: follicle-stimulating hormone, follicular phase, gonadotropin-releasing hormone, luteal phase, luteinizing hormone, menstrual cycle, ovulation, progesterone, proliferative phase, secretory phase

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            • 11

              Preconception Care

              By Laura Bookman, MD; Tariro Mupombwa, MD
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              Preconception Care

              • LAURA BOOKMAN, MDStaff Physician, Department of Obstetrics and GynecologyBeth Israel Deaconess Medical Center, Assistant Professor of Obstetrics, Gynecology and Reproductive BiologyHarvard Medical School, Boston, MA
              • TARIRO MUPOMBWA, MDChief OBGYN Resident, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Clinical Fellow, Harvard Medical School, Boston, MA

              The goal of preconception care is to optimize the health and knowledge of every woman prior to pregnancy. Inquiring about plans for pregnancy can occur at any patient encounter, not just at a scheduled preconception care visit, because many women do not present for care until they are already pregnant. Identifying medical, social, environmental, and psychological risks prior to pregnancy can lead to interventions that may enhance the health of both mother and baby. Relevant preconception issues discussed in this review include medications; medical, surgical, mental health, and social history, including substance use and intimate partner violence; immunization recommendations; nutrition; genetic screening; and infectious disease.


              This review contains 2 figures, 3 tables and 51 references

              Key words: depression, diabetes, exercise, hypertension, immunizations, intimate partner violence, nutrition, preconception care, reproductive life plan, thyroid disease

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            • 12

              Pain Relief in Labor

              By Nathan Liu, MD; Philip E Hess, MD
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              Pain Relief in Labor

              • NATHAN LIU, MDClinical Fellow, Harvard Medical School, Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
              • PHILIP E HESS, MDAssociate Professor, Harvard Medical School, Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA

              Labor pain is a complex entity composed of physical, emotional, and psychological factors. The physical treatment of pain is most effectively managed with pharmacologic therapies. Pharmacologic treatments are distinguished by being administered in the neuraxis (spinal or epidural) or systemically. All pharmacologic therapies have side effects associated with the medications being used. Nonpharmacologic methods have undergone refinement in the last century. These methods focus on the emotional and psychological factors surrounding labor. Both psychological methods, exemplified by the practice of Lamaze, and physical methods, such as continuous labor support, can be effective in producing a satisfying labor experience.

              This review contains 2 figures, 5 tables and 42 references

              Key words: combined spinal epidural, doula, epidural analgesia, labor pain, neuraxial analgesia, nitrous oxide, opioid therapy, parturient, psychoprophylaxis

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            • 13

              Polycystic Ovary Syndrome

              By Snigdha Alur-Gupta, MD; Anuja Dokras, MD, PhD
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              Polycystic Ovary Syndrome

              • SNIGDHA ALUR-GUPTA, MDDivision of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
              • ANUJA DOKRAS, MD, PHDDivision of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA

              Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine disorder in women of reproductive age. In this review, the pathophysiology and current diagnostic criteria for PCOS are reviewed. Treatment options for symptoms commonly associated with PCOS such as hirsutism, acne, and menstrual irregularity are reviewed. Combined hormonal contraceptives are the first line of therapy in women not attempting pregnancy. The metabolic complications commonly associated with PCOS are impaired glucose tolerance and dyslipidemia. A summary of the current guidelines on screening and prevention of these complications is presented. In addition, PCOS is associated with an increased risk of depressive symptoms and anxiety disorders for which patients should be monitored.

              This review contains 5 tables and 57 references. 

              Keywords: Polycystic ovary syndrome, PCOS 

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            • 14

              Infertility

              By Eric D. Levens, MD; Alan H. DeCherney, MD; Katherine A Green, MD
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              Infertility

              • ERIC D. LEVENS, MDShady Grove Fertility Reproductive Science Center, Rockville, MD
              • ALAN H. DECHERNEY, MDChief, Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
              • KATHERINE A GREEN, MDClinical Fellow, Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

              Infertility affects 12 to 18% of couples in the United States and may be due to female factors, male factors, or both. A systematic evaluation of the common causes of infertility can identify conditions that may be treated by the obstetrician-gynecologist to help the couple achieve their family-building goals or those that require referral to a subspecialist. This review discusses current recommendations regarding the workup and treatment of the common causes of infertility, including tubal and pelvic factors, ovulatory disorders, and male factors. Advances in assisted reproductive technology are also discussed, including the use of genetic screening in in vitro fertilization and fertility preservation options for individuals facing gonadotoxic therapy.

              This review contains 6 figures, 6 tables, and 50 references.

              Key words: anovulation, assisted reproductive technology, clomiphene citrate, infertility, letrozole, oocyte cryopreservation, ovulation induction, semen analysis, tubal factor, uterine factor

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            • 15

              Fecal Incontinence: Nonsurgical Management

              By Madeleine Blank, MD; Lilian Chen, MD
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              Fecal Incontinence: Nonsurgical Management

              • MADELEINE BLANK, MDDivision of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
              • LILIAN CHEN, MDAssistant Professor of Surgery, Division of Colorectal Surgery, Department of General Surgery, Tufts Medical Center, Boston, MA

              Fecal incontinence is the uncontrolled passage of feces or flatus. It is a debilitating and often unrecognized condition whose prevalence is increasing with our aging population and often carries significant stigmata associated with decreased quality of life. It is also one of the leading causes of nursing home admissions in the United States. The etiology of fecal incontinence is multifactorial, with many risk factors contributing to this disease process. Treatment may be challenging and needs to be individualized. In this review, we discuss the initial evaluation of the patient presenting with fecal incontinence, adjunctive testing modalities, and nonoperative management.

              This review contains 6 figures, 2 tables and 50 references

              Key words: accidental bowel leakage, biofeedback, bowel incontinence, fecal incontinence, pelvic floor physical therapy, pelvic floor retraining

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            • 16

              Reproductive Health in LGBTQ Populations

              By Marybeth Meservey, RN, MS, WHNP-BC; Yvonne Gomez-Carrion, MD, FACOG
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              Reproductive Health in LGBTQ Populations

              • MARYBETH MESERVEY, RN, MS, WHNP-BCWomen’s Health Nurse Practitioner, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
              • YVONNE GOMEZ-CARRION, MD, FACOGAssistant Professor of Obstetrics and Gynecology, Harvard Medical School, Supervisor of OB-Gyn, Resident Surgical Service, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA

              The healthcare community and lay public have become more aware of transgender (TG) people in the past decade as celebrities have publicly transitioned and activists have pushed back against restrictive laws. Movies, television, nonfiction books, and novels increasingly represent the experience of people who are TG. News organizations and entertainment outlets have given attention to the lives, needs, and challenges of TG and gender-nonconforming individuals. Nonetheless, TG individuals are often fearful when seeking healthcare. Experiences of shame, judgment, and rejection with providers lead to anxiety in future encounters. The number of clinical providers who feel prepared to offer care for TG individuals is limited. Many TG individuals have been denied basic primary and preventive healthcare as a result of their TG status. Understanding the concepts of TG and gender nonconformance expands the skill set of the healthcare professional for providing culturally competent care to all patients and their family members.

              This review contains 26 figures, and 59 references.

              Key Words: cis-sexual, gender binary, gender confirmation surgery, gender dysphoria, gender nonconforming, intersex, LGBTQ, queer, transgender, WPATH

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          • Pediatrics
            • 1

              Pediatric Rashes

              By Summer Stears-Ellis, MD
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              Pediatric Rashes

              • SUMMER STEARS-ELLIS, MDClinical Instructor, Emergency Ultrasound Fellow, Department of Emergency Medicine, The University of Arizona, Tucson, AZ

              Pediatric rashes are a common chief complaint in the emergency department (ED) and a source of anxiety for both parents and providers. Many of these rashes will not require intervention aside from symptomatic relief and parental reassurance. However, there is a subset of rashes that are the result of underlying life-threatening conditions that will warrant immediate intervention and treatment to prevent further deterioration and possible death. This review focuses on outlining the pathology of seven potentially deadly pediatric rashes that ED physicians are likely to encounter, how they present, and how to treat and manage them according to the most recent available guidelines. Figures show primary lesions, pattern of lesions, and distribution of rash associated with bacterial meningitis, toxic shock syndrome (TSS), Rocky Mountain spotted fever, Stevens-Johnson syndrome/toxic epidermal necrolysis, erythema multiforme minor and major, necrotizing fasciitis, and Henoch-Schönlein purpura. Tables list bacterial meningitis antibiotic treatment, Centers for Disease Control and Prevention clinical and laboratory criteria for TSS, TSS antibiotic treatment regimens, scoring systems for toxic epidermal necrolysis and necrotizing fasciitis, and the latest guidelines as of June 2017.

              This review contains 9 figures, 6 tables, and 50 references.

              Key words: Pediatric rash, toxic shock syndrome, skin rash, rash distribution, Rocky Mountain spotted fever, Stevens-Johnson syndrome, toxic epidermal necrolysis,  necrotizing fasciitis, Henoch-Schönlein purpura

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            • 2

              Pediatric Fever

              By Clifford C. Ellingson, MD; Dale P. Woolridge, MD, PhD
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              Pediatric Fever

              • CLIFFORD C. ELLINGSON, MDDepartment of Pediatric and Emergency Medicine, University of Arizona and Banner University Medical Center, Tucson, AZ
              • DALE P. WOOLRIDGE, MD, PHDProfessor, Department of Pediatric and Emergency Medicine, University of Arizona, Tucson, AZ

              Fever is one of the most common chief complaints among pediatric emergency departments. The evaluation and approach to a pediatric fever can be challenging. Although most cases of fever are viral in origin, the potential for a deadly bacterial infection would make even the most seasoned practitioner attentive. This review discusses the initial assessment of the pediatric patient and both necessary and recommended workups for pediatric fevers among various age groups. Common infections of bacterial and viral causes for fever are discussed and treatment recommendations offered. 

              Key words: Pediatric fever, otitis media, pneumonia, urinary tract infection, neonatal sepsis, bacteremia, meningitis, serious bacterial infection, viral illness.

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            • 3

              Pediatric Minor Head Injury and Concussion

              By Chad Scarboro, MD; Simone Lawson, MD
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              Pediatric Minor Head Injury and Concussion

              • CHAD SCARBORO, MDAssistant Professor, Department of Emergency Medicine/Pediatric Emergency Medicine, Carolinas Medical Center, Charlotte, NC
              • SIMONE LAWSON, MDPediatric Emergency Medicine Fellow, Department of Emergency Medicine/Pediatric Emergency Medicine, Carolinas Medical Center, Charlotte, NC

              Head injury is one of the most common reasons children present to the emergency department (ED) and the leading cause of pediatric death and disability. Head injuries can range from having no neurologic deficits to death. Management in the ED centers on determining if there is a serious brain injury and preventing secondary brain injury. In most cases of mild traumatic brain injury, serious injuries can be ruled out based on the history of the injury, associated symptoms, and clinical assessment. Concussion is a common presentation of head injury and encompasses a wide range of symptoms. Computed tomography should be used judiciously, and extensive research has led to algorithms to aid in this decision. Prior to discharge from the ED, parents will often have questions about when their child may resume normal activity. This is a decision that most often will involve the patient’s primary care provider or a concussion specialist as the ED provider is unable to follow progression or resolution of symptoms. However, the ED provider should be able to provide anticipatory guidance.

              Key words: computed tomography, concussion, head injury, mild traumatic brain injury, traumatic brain injury

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            • 4

              Comprehensive Overview of Pediatric Airway Management

              By Dale Woolridge, MD ; Lisa Goldberg , MD; Garrett S. Pacheco, MD
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              Comprehensive Overview of Pediatric Airway Management

              • DALE WOOLRIDGE, MD Banner University Medical Center – Tucson, Program Director, Emergency Medicine and Pediatrics Combined Residency Program
              • LISA GOLDBERG , MDResident Physician, Department of Emergency Medicine, University of Arizona at South Campus, Tucson, AZ
              • GARRETT S. PACHECO, MDAssistant Professor, Departments of Emergency Medicine and Pediatrics, University of Arizona, Tucson, AZ

              Pediatric endotracheal intubation is a procedure that can be stress provoking to the emergency physician. Although the need for this core skill is rare, when confronted with this situation, the emergency physician must have knowledge of the anatomic, physiologic, and pathologic components unique to the pediatric airway to optimize success. Furthermore, the emergency physician should be well versed in the various equipment and adjuncts as well as techniques developed to effectively manage the pediatric airway. This review covers the pathophysiology and practice of endotracheal intubation. Figures show a gum elastic bougie; the Mallampati classification; appropriate oropharyngeal, laryngeal, and tracheal axes; advancing the laryngoscope to lift the epiglottis; endotracheal tube position in neonates; and synchronized intermittent mandatory ventilation pressure-regulated volume control mechanical ventilation. Tables list endotracheal tube sizes, neonatal endotracheal tube sizes, pediatric laryngeal mask airway sizes, commonly used induction agents, and endotracheal tube insertion depth guidelines.

              This review contains 6 highly rendered figures, 5 tables, and 74 references.

              Key words: emergent tracheal intubation; endotracheal tube; laryngoscopy; pediatric airway; pediatric airway management; pediatric endotracheal intubation; pediatric laryngeal mask; video laryngoscopy

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            • 5

              Pediatric Upper Airway Obstruction

              By Michael W. Chan, MD; Suzanne M. Schmidt, MD
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              Pediatric Upper Airway Obstruction

              • MICHAEL W. CHAN, MDFellow, Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
              • SUZANNE M. SCHMIDT, MD Attending Physician, Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Assistant Professor, Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL

              Upper airway obstruction is a common reason that children present for emergency care, and causes range from simple and benign etiologies to life-threatening conditions requiring emergent intervention. Both congenital and acquired conditions can result in airway obstruction at various levels, and due to the high risk of acute decompensation associated with some of these conditions, rapid diagnosis and treatment are essential. This review covers assessment and stabilization, diagnosis, and treatment of foreign-body aspiration, croup, bacterial tracheitis, epiglottitis, peritonsillar abscess, and retropharyngeal abscess. Figures show a diagram of the pediatric airway, an anteroposterior radiograph of the neck demonstrating the characteristic “steeple sign” in croup, an algorithm for the treatment of croup, lateral radiographs demonstrating a thickened epiglottis, consistent with a diagnosis of epiglottitis,  and a widening of the prevertebral soft tissues of the neck, consistent with a diagnosis of retropharyngeal abscess. Tables list causes of upper airway obstruction by anatomic location, symptoms of upper airway obstruction by anatomic location, severity of croup, and microbiology of deep neck abscesses.

              This review contains 5 figures, 10 tables, and 32 references

              Key words: Upper airway obstruction; Pediatric upper airway obstruction, Foreign-body aspiration, Croup, Bacterial tracheitis, Epiglottitis, Peritonsillar abscess, Retropharyngeal abscess, Stridor

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            • 6

              Child Abuse and Nonaccidental Trauma

              By S Terez Malka, MD
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              Child Abuse and Nonaccidental Trauma

              • S TEREZ MALKA, MDAssistant Professor, Department of Emergency Medicine, Department of Pediatric Emergency Medicine, Massachusetts General Hospital, Boston, MA.

              Child abuse accounts for over 1% of visits to pediatric emergency departments (EDs), and injuries related to abuse have higher morbidity and mortality than accidental injuries. Recognizing child abuse and neglect in the ED is challenging but critical to prevent recurrent episodes of abuse and long-term physical and emotional sequelae. This review defines child abuse and neglect and explores historical and physical examination findings, assessment and diagnosis, treatment, disposition, and outcomes for victims of child abuse. Figures show x-rays demonstrating common fracture patterns associated with abusive injury and an algorithm for evaluation of nonaccidental trauma in the ED. Tables list key historical elements in the evaluation for abuse or neglect, bruising characteristics suggestive of abuse, fractures that are specific for abuse, and recommended laboratory evaluation for suspected abuse. 

              This review contains 4 figures, 4 tables, and 37 references.

              Key words: child abuse, child neglect, nonaccidental trauma, sexual abuse

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            • 7

              Pediatric Infectious Diarrhea and Dehydration

              By John W. Martel, MD, PhD; Scott McCorvey, MD, MS
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              Pediatric Infectious Diarrhea and Dehydration

              • JOHN W. MARTEL, MD, PHDAssistant Professor, Department of Emergency Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME
              • SCOTT MCCORVEY, MD, MSResident, Department of Emergency Medicine, Maine Medical Center, Portland, ME

              Diarrhea is a common emergency department (ED) complaint, leading to more than 1.5 million outpatient visits and 200,000 hospital admissions in the United States alone. Although concomitant dehydration also exists in some cases, there are no standard clinical criteria to aid in identifying those children who merit intravenous resuscitation. Current pediatric volume repletion guidelines are based primarily on the estimated degree of volume depletion per the World Health Organization, Centers for Disease Control and Prevention, and American Academy of Pediatrics criteria. These practice guidelines stratify patients into mild (3 to 5% volume depletion), moderate (5 to 10% volume depletion), and severe (> 10% volume depletion). The vast majority of pediatric patients presenting with nausea, vomiting, and/or diarrhea suffer from virus-mediated enterocolitis and require no testing or intravenous fluid resuscitation due to the self-limiting nature of these syndromes; rotavirus and Norwalk virus are two of the most common causes of infectious diarrhea in both developing and developed countries. Although bacterial pathogens rarely cause infectious colitis, children who present with more severe symptoms, including fever, bloody stool, and significant abdominal discomfort, warrant additional diagnostic evaluation. Obtaining a careful history, including exposures to livestock, well water, travel, and antibiotic use, as well as recent intake of undercooked meat, is key to identifying patients who may be at higher risk for bacteria-mediated illnesses. Tables identify common diarrheal pathogens, diarrheal subtypes, and clinical abnormalities associated with volume depletion and more severe syndromes, such as hemolytic-uremic syndrome.

              This review contains 5 highly rendered figures, 7 tables, and 77 references.

              Key words: Clostridium difficile, dehydration, diarrhea, gastroenteritis, hemolytic-uremic syndrome, pediatrics

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            • 8

              Pediatric Abdominal Emergencies

              By Jeffrey Bullard-Berent, MD, FAAP, FACEP; Aaron Kornblith, MD
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              Pediatric Abdominal Emergencies

              • JEFFREY BULLARD-BERENT, MD, FAAP, FACEPVice Chair, Emergency Medicine, Medical Director, Child Ready Virtual Pediatric Emergency Department, Professor of Emergency Medicine and Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
              • AARON KORNBLITH, MDAssistant Professor, Emergency Medicine and Pediatrics, Benioff Children’s Hospital, San Francisco, University of California, San Francisco, San Francisco, CA

              Pediatric abdominal emergencies represent a diverse group of conditions affecting children of all ages and are a common cause of emergency department visits. The challenge for emergency physicians is discerning which child presenting with the common complaints of abdominal pain, nausea, vomiting, and diarrhea has an abdominal emergency. The emergency physician must use a thorough history, developmentally appropriate examination skills, and integration of his or her knowledge base to arrive at the correct diagnosis. This review evaluates the most common pediatric abdominal emergencies organized by chronicity from birth to adolescents: midgut volvulus, infantile hypertrophic pyloric stenosis, incarcerated inguinal hernia, ileocecal intussusception, Meckel diverticulum, and appendicitis. Readers will understand common presentations as well as the evaluation and treatment options for each diagnosis.  

              This review contains 7 figures, 6 tables and 61 references

              Key words: abdominal pain, appendicitis, hernia, hypertrophic pyloric stenosis, intussusception, Meckel diverticulum, midgut volvulus

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            • 9

              Pediatric Seizures and Status Epilepticus

              By Lindsey Retterath, MD ; Dale Woolridge, MD
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              Pediatric Seizures and Status Epilepticus

              • LINDSEY RETTERATH, MD Banner University Medical Center – Tucson, Resident Physician, Department of Emergency Medicine and Department of Pediatrics
              • DALE WOOLRIDGE, MD Banner University Medical Center – Tucson, Program Director, Emergency Medicine and Pediatrics Combined Residency Program

              Seizures represent a common neurologic complaint among pediatric patients in the emergency department (ED). They can be classified as generalized or focal. In terms of etiology, seizures are most basically broken down into “acute symptomatic” seizures, which are due to another primary medical cause, and unprovoked seizures which occur as a primary pathology. Febrile seizures are the most common types of seizures in children, which themselves can be simple or complex. The most concerning seizures are those which associate with meningismus, encephalitis, metabolic derangements, intracranial mass, and, of course those which progress to status epilepticus. Significantly, it is appropriate and even critical to assume status epilepticus and intervene accordingly whenever a child arrives to the ED seizing for an unspecified period of time. This review covers the initial evaluation, resuscitation, management, work-up, and disposition of pediatric patients who present to the emergency room with seizures. Figures in this chapter illustrate stepwise and algorithmic approaches to initial management, expanded differential, systematic diagnostic approach, and disposition for pediatric patients presenting with seizures and status epilepticus. Tables list important physical exam components for evaluating children with seizures, classifications of seizures, common seizure look-alikes in children, features of febrile seizures, etiologies of pediatric seizures.

              Key Words: Pediatric seizures, febrile seizures, pediatric neurologic emergencies, pediatric emergency medicine, status epilepticus 

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            • 10

              Pediatric Orthopedic Emergencies

              By Priya Gopwani, MD; Joy Koopmans, MD
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              Pediatric Orthopedic Emergencies

              • PRIYA GOPWANI, MDAttending Physician, Assistant Professor of Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
              • JOY KOOPMANS, MDAttending Physician, Department of Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago at Central DuPage Hospital, Health Systems Clinician, Northwestern University Feinberg School of Medicine, Winfield, IL

              Proper care of orthopedic injuries and emergencies in children and adolescents requires knowledge of the altered bone and ligament characteristics, varying stages of skeletal development, and potential for congenital or developmental abnormalities. Pediatric fractures affecting the growth plate require unique management to maintain optimal growth. Whereas some specific fractures in these skeletally immature patients require urgent surgical repair, other fractures remodel extremely well and can be managed with a simple splint. Particular dislocations are common in this population and may have concomitant fractures. There are several overuse injuries seen primarily in children, and treatment aims to keep the patient active while allowing the injury to heal. Potentially devastating osteoarticular infections occur in the pediatric population and must be differentiated from more benign causes of joint pain, such as transient synovitis or congenital abnormalities. Children are also at risk for abnormalities such as slipped capital femoral epiphysis or Legg-Calvé-Perthes disease, which are rarely diagnosed in the adult population. It is imperative for a clinician to be aware of these and other nuances to optimally care for orthopedic injuries and emergencies in the pediatric population.

              Key words: bone, musculoskeletal, orthopedic, skeletal

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          • Intensive Care Unit
            • 1

              Sepsis

              By Michael R. Filbin, MD
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              Sepsis

              • MICHAEL R. FILBIN, MDAssistant Professor, Harvard Medical School, Department of emergency Medicine, Massachusetts General Hospital, Boston, MA

              Sepsis accounts for approximately one in three hospital deaths and is associated with very high health care costs due to prolonged lengths of stay in the intensive care unit and hospital. Sepsis is essentially an immunologic response to infection that is propagated systemically, leading to diffuse cellular and microcirculatory dysfunction, vasodilation, vital organ hypoperfusion, and eventual failure. This review covers the pathophysiology, stabilization/assessment, diagnosis, treatment, and disposition and outcomes of sepsis. Figures show the inflammatory and thrombotic response to infection, the action of nitric oxide on vascular smooth muscle cells, accelerated glycolysis and increased lactate production as a result of the catecholamine surge seen in septic shock, sepsis mortality associated with number of organ failures identified in the emergency department (ED), and protocolized therapy for septic shock. Tables list definitions of sepsis syndromes; frequently cited scoring systems for mortality prediction in ED patients with sepsis; Sequential Organ Failure Assessment (SOFA) score; current recommendations regarding treatment bundles at 3 and 6 hours of resuscitation; antibiotic recommendations based on suspected source; and vasopressors used in septic shock with recommended dosing, mechanism of action, and indications.

              This review contains 5 highly rendered figures, 6 tables, and 42 references.

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            • 2

              Chronic Obstructive Pulmonary Disease

              By Andrew J Schissler, MD; George Washko, MD; Carolyn E. Come, MD, MPH
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              Chronic Obstructive Pulmonary Disease

              • ANDREW J SCHISSLER, MDClinical and Research Fellow, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
              • GEORGE WASHKO, MDAssociate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
              • CAROLYN E. COME, MD, MPHInstructor in Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

              Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and death worldwide. This edition reviews the epidemiology and etiologies of COPD, including the gender effects, racial differences, and more recently identified genetic factors associated with this condition. It details the many pathogenetic mechanisms thought to be associated with this disease state, such as increased airway inflammation and turnover of extracellular matrix. There is a detailed discussion about diagnosis, classification, and the therapeutic options available for both stable disease and acute exacerbations. The recent evidence supporting various treatments, such as vaccinations, inhaled bronchodilators, inhaled corticosteroids, oral corticosteroids, antibiotics, supplemental oxygen, pulmonary rehabilitation, and surgery, is reviewed in depth. There is further evaluation of experimental approaches, such as bronchoscopic lung reduction procedures and the use of extracorporeal carbon dioxide removal for hypercapnic respiratory failure. The many complications associated with COPD are described, acknowledging that evidence continues to suggest that COPD has a significant systemic component associated with increased rates of psychiatric illness, cardiovascular disease, osteoporosis, and skeletal muscle dysfunction along with lung cancer. Overall this text serves as an excellent evidence-based guide to better understand, diagnose, and manage COPD and its array of associated complications.

              Key words: chronic obstructive pulmonary disease (COPD), COPD complications, COPD diagnosis, COPD management, COPD pathophysiology, Global Initiative for Chronic Obstructive Lung Disease (GOLD)

              This review contains 6 highly rendered figures, 4 tables, and 239 references.

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            • 3

              Glycemic Control in the Intensive Care Unit

              By Eden A. Nohra, MD; Grant V. Bochicchio, MD, MPH, FACS
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              Glycemic Control in the Intensive Care Unit

              • EDEN A. NOHRA, MDResearch Coordinator, Acute and Critical Care Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
              • GRANT V. BOCHICCHIO, MD, MPH, FACSEdison Professor of Surgery, Chief of Acute and Critical Care Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO

              The human body is programmed to maintain constant homeostasis of all body systems through a complex neuroendocrine and autonomic network. Through a variety of exaggerated autonomic and cytokine responses, illness and injury alter this homeostasis. Mechanisms that are impaired include glucose cellular transport and peripheral and hepatic insulin uptake. Over the past several decades, numerous reports have described the deleterious effects of glucose variability and hyperglycemia. In a randomized prospective study of critically ill patients, Van den Berghe first reported that intensive glucose control (≤ 110 mg/dL) significantly decreased morbidity and mortality. This study was a catalyst for a multitude of subsequent reports evaluating the effects of glycemic control in other patient populations. This review focuses on the pathophysiology of hyperglycemia in critical illness, and then summarizes the recent literature on glucose control. Tables outline the mortality benefit of intensive insulin therapy in surgical and medical intensive care unit patients in relation to duration of application, and functions of the first four glucose transporters. An illustration depicts insulin binding to the insulin receptors on the cell membrane surface.

              This review contains 1 figure, 2 tables, and 103 references.

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            • 4

              Inotropes and Vasopressors for Shock

              By Amour B U Patel, MBBS, BSc; Gareth L Ackland, PhD, FRCA, FFICM
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              Inotropes and Vasopressors for Shock

              • AMOUR B U PATEL, MBBS, BSCAnaesthetist, Department of Anaesthesia, University College London Hospital, University College London Hospitals NHS Trust, London, UK
              • GARETH L ACKLAND, PHD, FRCA, FFICMConsultant Anaesthetist, William Harvey Research Institute, QMUL Queen Mary, University of London, Department of Anaesthesia, Royal London Hospital, BartsHealth NHS Trust, London, UK

              Inotropes and vasopressors play a key role in the management of shock. The goal of therapy is to restore end-organ perfusion by augmenting cardiac output and vascular tone. Despite their frequent use, randomized controlled trials have failed to identify optimal inotropes and/or vasopressors for shock. The pathophysiology underlying various types of shock and the prognostic importance of various biomarkers are required to refine the use of these agents. In the absence of such evidence, the aims of treatment are exemplified by the PROCESS/ARISE/PROMISE trials in septic shock. Shock is a medical emergency requiring experienced, vigilant practitioners who use fluids in combination with inotropes/vasopressors at the lowest dose to maintain end-organ perfusion without causing adverse effects. The increasing recognition that prolonged treatment with fluid and/or vasoactive drugs promotes deleterious, off-target effects highlights the need to focus on systemic physiology rather than pursuing isolated hemodynamic targets.

              Key words: biomarkers, clinical vigilance, fluid resuscitation, inotropes/vasopressors, systemic physiology

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            • 5

              Assessment of Acute Respiratory Failure

              By Nathan R. Manley, MD/MPH; Martin A Croce, MD, FACS
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              Assessment of Acute Respiratory Failure

              • NATHAN R. MANLEY, MD/MPHResident, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
              • MARTIN A CROCE, MD, FACSProfessor, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN

              Acute respiratory failure (ARF) is fundamentally a dysfunction of gas exchange and can be due to either inadequate carbon dioxide elimination causing hypercapnia or poor oxygen exchange and delivery causing hypoxemia. A variety of etiologies exist that cause ARF in the surgical patient, including previous lung disease, such as chronic obstructive pulmonary disease or asthma, neurologic compromise of respiratory drive, nutritional and metabolic derangements that can alter respiratory metabolism and mechanics, direct lung injury, and infection. The type of surgery and the time since surgery are other key factors that influence medical decision making and that will influence priorities in the assessment and management of ARF. This review explores the full spectrum of ARF in the surgical patient, focusing particularly on its assessment and initial management. Figures illustrate algorithms in the approach to the surgical patient with ARF and show example radiographic images of acute respiratory distress syndrome (ARDS), a common complication. Tables summarize indications for emergent intubation, key etiologies of ARF, and the evolving definitions of acute lung injury and ARDS.

              Key words: acute respiratory distress syndrome, acute respiratory failure, hypercapnia, hypoxemia, mechanical ventilation 

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            • 6

              Respiratory Viral Infections

              By Michael G. Ison, MD, MSc
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              Respiratory Viral Infections

              • MICHAEL G. ISON, MD, MSCAssociate Professor, Divisions of Infectious Diseases & Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL

              The respiratory tract can be infected by a diverse group of viruses that produce syndromes ranging in severity from mild colds to fulminant pneumonias. Respiratory viral infections are a leading cause of morbidity, hospitalization, and mortality throughout the world; influenza and pneumonia were the most prevalent infectious causes of death during the 20th century in the United States. Respiratory viral infections are also a common cause of acute illness and physician visits in the United States. This chapter discusses the etiology, pathophysiology, and approach to the diagnosis of respiratory viral infections, as well as common syndromes, including common colds, pharyngitis and laryngitis, acute bronchitis, influenza syndrome, croup, bronchiolitis, reactive airway disease exacerbation, and pneumonia. The chapter also describes infections caused by specific agents, such as adenoviruses; human and zoonotic coronaviruses, including the MERS-CoV, which has emerged as a newly recognized pathogen causing severe respiratory viral infections; human metapneumovirus (hMPV); influenza virus; parainfluenza viruses; respiratory syncytial virus (RSV); and rhinovirus. The discussion of these infections includes classification and pathogenesis, epidemiology and transmission, diagnosis, complications, treatment, and prevention. Most notably, the emergence of the 2009 pandemic influenza A/H1N1 virus has enhanced our understanding of the pathogenesis and management of influenza. The chapter notes several novel antivirals, including DAS181, CMX001 (brincidofovir), and ALN-RSV01, that hold promise as future therapies against common respiratory viruses.

              Tables describe epidemiologic features of principal human respiratory viruses, laboratory methods for diagnosis of respiratory viral infections, and agents used to prevent and treat influenza. A sidebar lists Internet resources for respiratory viral infections. The chapter is also enhanced by a graph, numerous depictions of the viruses discussed, and a chest radiograph of a patient infected with influenza.

              This review contains 10 highly rendered figures, 3 tables, and 109 references.

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            • 7

              Approach to the Patient With Acute Respiratory Failure

              By Eddy Fan, MD; Alice Vendramin, MD
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              Approach to the Patient With Acute Respiratory Failure

              • EDDY FAN, MDAssistant Professor, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
              • ALICE VENDRAMIN, MDFellow, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

              Acute respiratory failure (ARF) is a common reason for admission to the intensive care unit (ICU), and is associated with significant morbidity and mortality. Failure of one or more components of the respiratory system can lead to hypoxemia, hypercabia, or both. Initial evaluation of patients with ARF should include physical examination, chest imaging, and arterial blood gases (ABG) sampling. As ARF is often a life-threatening emergency, a patient’s oxygenation and ventilation will need to be supported at the same time that diagnostic and therapeutic interventions are planned. The priorities for early treatment are essentially those of basic life support: airway and breathing. The first step is to assess a patient’s airway and ascertain that it is patent. This is followed by efforts to support both oxygenation and ventilation. This can include non-invasive or invasive mechanical ventilatory support. As with all interventions, there are risks inherent in the use of mechanical ventilation, which may be minimized by the use of lung protective ventilation (i.e., with low tidal volumes and airway pressures). Finally, due to the potential complications associated with mechanical ventilation, it is important to regularly assess whether a patient continues to require the assistance of the ventilator, and to liberate patients from mechanical ventilation at the earliest opportunity when clinically safe and feasible to do so. Figures depict pressure-time curve. Tables list the clinical causes of hypoxemic respiratory failure, oxygen delivery devices, indications for noninvasive positive pressure support, common causes of abnormal respiratory mechanics, and common causes of acute respiratory distress syndrome (ARDS).

              This review contains 2 highly rendered figures, 5 tables, and 86 references.

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            • 8

              Hypertensive Crises

              By Akinyi Ragwar, MD; Jeffrey Siegelman, MD, FACEP
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              Hypertensive Crises

              • AKINYI RAGWAR, MDResident Physician, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
              • JEFFREY SIEGELMAN, MD, FACEPAssistant Professor, Assistant Residency Director, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA

              Hypertension is the most common chronic medical condition, affecting more than 1 billion people worldwide. When acute hypertension causes end-organ damage, this is termed a hypertensive emergency. Hypertension can result in a variety of life-threatening clinical scenarios, including aortic dissection, intracerebral hemorrhage, renal dysfunction, pulmonary edema, acute coronary syndrome, and eclampsia. These require aggressive management, whereas asymptomatic hypertension can be managed on an outpatient basis. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition of patients with hypertensive crises, including a discussion of the various pharmacologic agents available to the emergency physician. Figures show the types of hypertensive emergency, clinical manifestations, and pharmacologic treatment. 

              Key words: acute coronary syndrome, aortic dissection, asymptomatic hypertension, eclampsia, hypertension, hypertensive crisis, hypertensive encephalopathy, stroke

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            • 9

              Heart Failure

              By Sachin P Shah, MD; Mandeep R. Mehra, MD
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              Heart Failure

              • SACHIN P SHAH, MDCenter for Advanced Heart Disease, Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, Director, Cardiovascular Intensive Care Unit, Lahey Hospital and Medical Center, Burlington, MA
              • MANDEEP R. MEHRA, MDMedical Director, Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA

              Heart failure is a syndrome related to abnormal cardiac performance with a consequence of impaired cardiac output at rest or with exertion and/or congestion, which usually leads to symptoms of fatigue, dyspnea, and edema. The syndrome is characterized by various phenotypes related to a vast array of etiologies with diverse management targets. The current broad categorization of heart failure separates patients based on ejection fraction. Further description of the phenotype beyond ejection fraction is imperative to correctly identify the etiology of heart failure and, ultimately, to choose medical, device, and surgical therapies appropriately. This review covers the epidemiology of heart failure, defining the phenotype and etiology of heart failure, recognition and management of acute decompensated heart failure, management of chronic heart failure with a reduced ejection fraction, implantable cardioverter-defibrillators in heart failure with a reduced ejection fraction, management of heart failure with a preserved ejection fraction, and advanced heart failure. Figures show the evolution of therapy in chronic heart failure from the symptom-directed model, the complex pathophysiology and principal aberrations underlying heart failure with preserved ejection fraction, and concepts underlying surgical therapy in advanced heart failure using Laplace’s law. Tables list various etiologies of heart failure; sensitivity and specificity of clinical, biomarker, and radiographic data in the diagnosis of acute decompensated heart failure; drugs and devices with a demonstrated survival benefit in heart failure with a reduced ejection fraction; neurohormonal antagonist dosing in heart failure with a reduced ejection fraction; randomized, placebo-controlled trials in heart failure with a preserved ejection fraction; categorization of heart failure according to American Heart Association/American College of Cardiology heart failure stage, New York Heart Association functional class, and Interagency Registry for Mechanically Assisted Circulatory Support level; and poor prognostic indicators in heart failure.

              This review contains 3 highly rendered figures, 7 tables, and 113 references.

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            • 10

              Seizure

              By Robert Silbergleit, MD
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              Seizure

              • ROBERT SILBERGLEIT, MDProfessor, Neurological Emergencies Research, Department of Emergency Medicine, Ann Arbor, MI

              A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event in both children and adults. Epilepsy, a chronic disorder of the brain characterized by recurrent unprovoked seizures, is far less common. Patients who present to the emergency department with seizures vary considerably in underlying etiology, symptoms, and prognosis. Optimal care of the seizure patient in the emergency department requires differentiating those who need little intervention from those requiring intensive resuscitation. This review presents the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of seizure. Figures show the progression of selected neuronal pathophysiologic mechanisms involved over time during and after status epilepticus, tongue bite from seizure, a general emergency department management strategy for patients with seizure presentations, an electroencephalogram of a patient who experienced convulsive syncope after placement of an intravenous line, and staged treatment of status epilepticus. Tables list key elements of the initial emergency department management of status epilepticus, third-line medications for treatment of seizures, and the Status Epilepticus Severity Score (STESS).

              Key words: acute seizure, convulsion, epilepsy, seizure, status epilepticus

              This review contains 5 highly rendered figures, 3 tables, and 54 references.

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            • 11

              Acid-base Disorders

              By Aaron Skolnik, MD, FAAEM; Jessica Monas, MD, FAAEM, FACEP
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              Acid-base Disorders

              • AARON SKOLNIK, MD, FAAEMMedical Toxicologist, Banner – University Medical Center Phoenix, Assistant Medical Director, Banner Poison & Drug Information Center, Clinical Assistant Professor, Department of Emergency Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ
              • JESSICA MONAS, MD, FAAEM, FACEPEmergency Physician, Banner – University Medical Center Phoenix, Clinical Assistant, Professor, Dept. of Emergency Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ

              Under physiologic conditions, the acid-base balance of the body is maintained via changes in ventilation that eliminate carbon dioxide, buffering of acid loads, and renal excretion of hydrogen ions. Failure to maintain the pH of the blood between 7.35 and 7.45 can result in life-threatening conditions. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of acid-base disorders. Figures show the relationship between hydrogen ions and blood pH, proximal tubular bicarbonate reabsorption, the secretion of hydrogen ions, renal ammonia production, ammonium diffusion, metabolic alkalosis, electrocardiographic changes in hypokalemia and hyperkalemia, pseudoinfarction caused by hyperkalemia, and an algorithmic approach to suspected acid-base disorders. Tables list causes of high–anion gap metabolic acidosis, metabolic acidosis with a normal anion gap, type 1 renal tubular acidosis, type 4 renal tubular acidosis and aldosterone resistance, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis; treatment of hyperkalemia; and a stepwise approach for the evaluation of suspected acid-base disorders.

              This review contains 9 highly rendered figures, 9 tables, 64 references, and a list of pertinent Web sites.

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            • 12

              Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

              By Richard M Pino, MD, PhD, FCCM; Molly Paras, MD; Erica S Shenoy, MD, PhD
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              Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

              • RICHARD M PINO, MD, PHD, FCCMAssociate Professor and Division Chief of Critical Care in the Department of Anesthesia, Critical Care and Pain Medicine
              • MOLLY PARAS, MDDivision of Infectious Diseases, Department of Medicine
              • ERICA S SHENOY, MD, PHDAssistant Professor of Medicine at Harvard Medical School, and the Associate Chief of the Infection Control Unit

              The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. 

              Key words: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

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            • 13

              Disclosure of Error in the Intensive Care Unit

              By Leslie Hale, MD; Katrina Kirksey Harper, MD; Anna Bovill Shapiro, MD
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              Disclosure of Error in the Intensive Care Unit

              • LESLIE HALE, MDClinical Instructor in the Department of Anesthesiology, Weill Cornell Medical College, New York, NY.
              • KATRINA KIRKSEY HARPER, MDAssistant Clinical professor, emergency medicine and critical care medicine, in the Departments of Emergency Medicine and Pulmonary Critical Care Medicine, NYU Langone and NYU Lutheran Medical Centers, Brooklyn, NY.
              • ANNA BOVILL SHAPIRO, MDAnesthesiologist and Intensivist at Guam Regional Medical City, Guam.

              Each year, as many as 98,000 hospital deaths in the United States can be attributed to medical error. Considering that at least half of all medical errors go unreported, the impact they have on mortality, morbidity, prolonged hospital stay, rising hospital costs, and the doctor-patient relationship cannot be overemphasized. At the heart of the dilemma are patients and their family members, who rely on clinicians to provide optimal medical care, devoid of mistakes and error, and want an apology if an error has taken place. In this review, we discuss the moral obligation of hospitals to disclose medical error, no matter what the impact. Whereas in the past, a paternalistic approach to medicine viewed this acknowledgment as weakness, there is now a consensus to advocate for full disclosure, apology, and discussions that facilitate early disclosure of error using teams representing administration, patient care liaisons, and treatment providers. Many institutions now recognize that medical errors are commonly the result of a breakdown of checks and balances, and an increasing number are implementing protocols that target system errors to prevent similar future occurrences. We examine institutions across the United Statesthat take a proactive approach by assembling “communication and resolution” programs to address the concerns of patients and their families through the process of disclosure. We also explore barriers to disclosure, which are attributed to lack of training, fear of litigation, and the “shame and blame culture.” We discuss the benefit, to both patient and provider, of disclosure of accountability as we move toward a culture of strengthening systems and improving patient care and patient-provider relationships.

              Key words: apology, culture, disclosure, error, resolution

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          • Ethics & Professionalism
            • 1

              Management of Psychosocial Issues in Terminal Illness

              By Jane DeLima Thomas, MD; Eva Reitschuler-Cross, MD; Susan D Block, MD
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              Management of Psychosocial Issues in Terminal Illness

              • JANE DELIMA THOMAS, MDAttending Physician, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Instructor in Medicine, Harvard Medical School, Boston, MA
              • EVA REITSCHULER-CROSS, MDClinical Assistant Professor of Medicine, University of Pittsburgh, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA
              • SUSAN D BLOCK, MDChair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital Co-Director, HMS Center for Palliative Care, Professor of Psychiatry and Medicine, Harvard Medical School, Boston, MA

              Patients facing serious or life-threatening illness experience challenges to their psychological, social, and spiritual lives as well as to their physical function and comfort. Physicians may be accustomed to focusing on the biomedical aspects of illness, but they have a critical role in assessing the patient's psychosocial issues to identify sources of distress and help implement a plan for mitigating them. An appropriate psychosocial assessment requires a methodical and rigorous approach and includes assessment of any psychosocial issue affected by or affecting a patient's experience of illness. This chapter outlines a structured approach to addressing psychosocial issues by discussing (1) the doctor-patient relationship; (2) coping with illness; (3) family dynamics and caregiving; (4) ethnic and cultural issues; (5) religious, spiritual, and existential issues; (6) mental health issues, including adjustment disorder, depression, anxiety, personality disorders, aberrant drug behaviors, and major mental health issues; and (7) grief and bereavement. Tables outline psychosocial assessment questions, factors predisposing patients with serious illness to depression, risk factors for suicide in patients with terminal illness, and classes of antidepressants, anxiolytics, and sedatives. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire is provided, as well as a list of Web sites with further resources about psychosocial issues in serious illness.

              This review contains 1 highly rendered figure, 6 tables, and 216 references.

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            • 2

              Brain Death and Organ Donation

              By Thomas I. Cochrane, MD, MBA
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              Brain Death and Organ Donation

              • THOMAS I. COCHRANE, MD, MBAAssociate Neurologist, Division of Neuromuscular Disease, Department of Neurology, Brigham and Women’s Hospital, Assistant Professor of Neurology, Harvard Medical School, Boston, MA

              Brain death is the state of irreversible loss of the clinical functions of the brain. A patient must meet strict criteria to be declared brain dead. They must have suffered a known and demonstrably irreversible brain injury and must not have a condition that could render neurologic testing unreliable. If the patient meets these criteria, a formal brain death examination can be performed. The three findings in brain death are coma or unresponsiveness, absence of brainstem reflexes, and apnea. Brain death is closely tied to organ donation, because brain-dead patients represent approximately 90% of deceased donors and thus a large majority of donated organs. This review details a definition and overview of brain death, determination of brain death, and controversy over brain death, as well as the types of organ donation (living donation versus deceased donation), donation after brain death, and donation after cardiac death. A figure presents a comparison of organ donation after brain death and after cardiac death, and a table lists the American Academy of Neurology Criteria for Determination of Brain Death.

              This review contains 1 highly rendered figure, 3 table, and 20 references.

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            • 3

              Advance Care Planning

              By Lauren Jodi Van Scoy, MD; Michael Green, MD, MS; Benjamin Levi, MD, PhD
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              Advance Care Planning

              • LAUREN JODI VAN SCOY, MDAssistant Professor, Departments of Medicine and Humanities, Penn State College of Medicine, Hershey, PA
              • MICHAEL GREEN, MD, MSProfessor, Departments of Humanities and Medicine, Penn State College of Medicine, Hershey, PA
              • BENJAMIN LEVI, MD, PHDProfessor, Departments of Humanities and Pediatrics, Penn State College of Medicine, Hershey, PA

              Advance care planning (ACP) is defined by the Institute of Medicine as an iterative process that involves discussing end-of-life issues, clarifying relevant values and goals of care, and embodying preferences through written documents and medical orders. ACP is predicated on the principle of respect for autonomy, which recognizes an individual’s right to accept or decline medical therapies. With the development of medical technologies that can sustain life (including mere physiologic existence), effective ACP has become a critical yet underused process for patients, their families, and clinicians. This review discusses the emergence of ACP, promises and pitfalls of advance directives, and promising approaches, including ACP interventions and research, as well as a focus on public engagement and future directions. Figures show a timeline of important advances in ACP since 1990, key features of the comprehensive ACP process, the three core aspects or pillars for implementation of ACP, stages of change for ACP behaviors, and two commercially available end-of-life games. Tables list theoretical pros and cons of advance directives, ACP resources, examples of recent research studies on ACP interventions, types and examples of ACP resources, and public engagement campaigns.

              This review contains 5 highly rendered figures, 5 tables, and 100 references.

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            • 4

              Clinical Trial Design and Statistics

              By Julie Ann Sosa, MA, MD, FACS; Samantha M. Thomas, MS; April K.S. Salama, MD
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              Clinical Trial Design and Statistics

              • JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT
              • SAMANTHA M. THOMAS, MSBiostatistician, Department of Biostatistics & Bioinformatics, Duke Cancer Institute, Durham, NC
              • APRIL K.S. SALAMA, MDAssistant Professor of Medicine, Division of Medical Oncology, Duke University School of Medicine, Durham, NC

              A clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention.  Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.

              This review contains 2 highly rendered figures, 2 tables, and 38 references

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            • 5

              Withdrawing Life Support and Medical Futility

              By David Oxman, MD
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              Withdrawing Life Support and Medical Futility

              • DAVID OXMAN, MD

              Life support technologies have the potential to save many lives. However, in some cases – particularly when disease is advanced or incurable – the use of these interventions may simply prolong the dying process while causing significant pain and suffering. The ethical basis for withdraw of life support has been clearly elucidated in medical ethics and the law, but given the emotions surrounding these issues, it is not surprising that controversy still exists.  This review discusses withdrawal of life support and withdrawal of artificial nutrition. Additionally, this review explores medical futility, including the historical background, futility and the law, focus on process: hospital futility policies and ethics committees, and current practice and the future of medical futility. Illustrative case reports are presented. The table lists some examples of responding to requests for non-beneficial care from patients or surrogates.

              This review contains 1 figure, 3 tables, and 27 references.

              Key Words: Withdrawal of life support; Withdrawal of care; Medical futility  

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            • 6

              Preparing for the Ethical Practice of Precision Medicine

              By Megan A Allyse, PhD; Richard R Sharp, PhD
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              Preparing for the Ethical Practice of Precision Medicine

              • MEGAN A ALLYSE, PHD
              • RICHARD R SHARP, PHD

              The role of genetics in medicine is changing quickly. New discoveries are rapidly bridging the chasm from bench to bedside, and in addition to medical advances, thousands of people are exploring their genetic traits and ancestry through direct-to-consumer companies. Staying abreast of these changes and their potential implications for patient care can be difficult. To help, we suggest several high-level points of reference regarding the current state of genomic medicine, with a focus on the ethical and social issues raised by these technologies. This review covers the rise of genomic medicine, information overload, direct access to genetic information, genetic discrimination, and informed consent. Tables list the American College of Medical Genetics and Genomics recommendations for reporting of incidental findings in clinical exome and genome sequencing, an excerpt from the Genetic Information Nondiscrimination Act, and genetics education resources for physicians.

              This review contains 3 tables, and 44 references.

              Key words: Genomic medicine, genetic medicine, medical genetics, genetic testing, direct-to-consumer genetics, genetic discrimination

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            • 7

              Ethical and Social Issues in Medicine

              By Roberta Springer Loewy, PhD (PHIL, ETHICS); Erich H. Loewy, MD, FACP (deceased); Faith T. Fitzgerald, MD, MACP
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              Ethical and Social Issues in Medicine

              • ROBERTA SPRINGER LOEWY, PHD (PHIL, ETHICS)Professor and Bioethics Education Consultant, VCF, University of California, Davis, Sacramento, CA
              • ERICH H. LOEWY, MD, FACP (DECEASED)Professor and Founding Chair of the Bioethics Program (Emeritus), University of California, Davis, Sacramento, CA
              • FAITH T. FITZGERALD, MD, MACPProfessor of Internal Medicine, University of California, Davis, Sacramento, CA

              So rapidly has the field of health care ethics continued to grow that, when recently “googled,” the term produced 28.2 million hits. The challenge is to address the ethical and social issues in medicine in this very limited article space. It remains an impossible task to present more than a superficial discussion of these complex issues and the complicated cases in which they are to be found. Like good medicine, good ethics cannot be practiced by algorithm. The authors have opted to provide an operational guide to help clinicians sort through the ethical and social quandaries they must face on a daily basis. To that end, the authors have chosen to divide this chapter into the following sections:
              1. A brief description of the biopsychosocial nature of ethics and how it differs from personal morality
              2. A method for identifying and dealing with ethical issues
              3. A discussion of the role of bioethicists and ethics committees
              4. The professional fiduciary role of clinicians
              5. Listings of some of the common key bioethical and legal terms (online access only)
              6. A very brief discussion of the terms cited in the above listings (online access only)

              This reviews contains 4 tables, 8 references, 1 appendix, and 20 additional readings.

              Keywords: Ethical, social, right, wrong, good, bad, obligation, moral authority, critically reflective, and multiperspectival activity, Curiosity, Honesty, Patience, Open-mindedness

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        • Elective Specialty Areas
          • Nephrology
            • 1

              Nephrolithiasis

              By José Luiz Nishiura, MD, PhD; Ita Pfeferman Heilberg, MD, PhD
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              Nephrolithiasis

              • JOSÉ LUIZ NISHIURA, MD, PHDAssociate Researcher, Nephrology Division, Federal University of São Paulo, São Paulo, Brazil.
              • ITA PFEFERMAN HEILBERG, MD, PHDAssociate Professor, Nephrology Division, Federal University of São Paulo, São Paulo, Brazil.

              Nephrolithiasis is a highly prevalent condition, but its incidence varies depending on race, gender, and geographic location. Approximately half of patients form at least one recurrent stone within 10 years of the first episode. Renal stones are usually composed of calcium salts (calcium oxalate monohydrate or dihydrate, calcium phosphate), uric acid, or, less frequently, cystine and struvite (magnesium, ammonium, and phosphate). Calcium oxalate stones, the most commonly encountered ones, may result from urinary calcium oxalate precipitation on the Randall plaque, which is a hydroxyapatite deposit in the interstitium of the kidney medulla. Uric acid nephrolithiasis, which is common among patients with metabolic syndrome or diabetes mellitus, is caused by an excessively acidic urinary pH as a renal manifestation of insulin resistance. The medical evaluation of the kidney stone patient must be focused on identifying anatomic abnormalities of the urinary tract, associated systemic diseases, use of lithogenic drugs or supplements, and, mostly, urinary risk factors such as low urine volume, hypercalciuria, hyperuricosuria, hypocitraturia, hyperoxaluria, and abnormalities in urine pH that can be affected by dietary habits, environmental factors, and genetic traits. Metabolic evaluation requires a urinalysis, stone analysis (if available), serum chemistry, and urinary parameters, preferably obtained by two nonconsecutive 24-hour urine collections under a random diet. Targeted medication and dietary advice are effective to reduce the risk of recurrence. Clinical, radiologic, and laboratory follow-ups are needed to prevent stone growth and new stone formation, to assess treatment adherence or effectiveness to dietary recommendations, and to allow adjustment of pharmacologic treatment.

              This review contains 5 highly rendered figure, 3 tables, and 105 references.

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            • 2

              Medical Management of Transplant Patients

              By Nidyanandh Vadivel, MB, BCh; Nelson B Goes, MD
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              Medical Management of Transplant Patients

              • NIDYANANDH VADIVEL, MB, BCHNephrologist, Division of Nephrology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
              • NELSON B GOES, MDRenal Transplant Program, Swedish Medical Center, Seattle WA

              Kidney transplant is the best form of renal replacement therapy for most end-stage kidney disease patients due to improved quality of life and superior patient survival compared to chronic maintenance dialysis. Long-term outcome of kidney allograft recipients depends on the longevity of the allograft and optimal management of their comorbidities such as cardiovascular disease risk factors. According to organ procurement and transplant data in the United States, 14.5% of the deceased donor kidney wait list comprised patients who failed their first allograft and were awaiting second kidney transplant. Optimal immunosuppression management is key to both short- and long-term outcomes of allograft transplant by preventing rejection while avoiding or minimizing risk of over immunosuppression such as with infections and neoplasia. Cardiovascular disease is the leading cause of mortality after kidney transplant. It accounts for approximately 50% of deaths in the post transplant period and 30% of deaths among patients with preserved renal allograft function. Hence, it is crucial to optimally manage cardiovascular risk factors such as hypertension and diabetes post transplant. In this chapter, we review medical management of kidney transplant recipients, including commonly used induction therapies, maintenance immunosuppressive agents, and posttransplant medical complications such as posttransplant diabetes mellitus, hypertension, cardiovascular disease, bone disease, and BK viral infection.

              This review contains 1 table and 47 references

              Key Words: kidney transplantation, immunosuppression, rejection, post transplant diabetes mellitus (PTDM), BK viral infection,  calcineurin inhibitors,

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            • 3

              Approach to the Patient With Glomerular Disease

              By Richard J. Glassock, MD, MACP; Fernando C. Fervenza, MD, PhD; An S De Vriese, MD, PhD
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              Approach to the Patient With Glomerular Disease

              • RICHARD J. GLASSOCK, MD, MACPEmeritus Professor, Department Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA
              • FERNANDO C. FERVENZA, MD, PHDDivision of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
              • AN S DE VRIESE, MD, PHDDivision of Nephrology AZ Sint-Jan Brugge-Oostende AV Brugge, Belgium

              Glomerular diseases of the kidneys are associated with a limited array of clinical syndromes, including asymptomatic hematuria and/or proteinuria, acute nephritis, nephrotic syndrome, rapidly progressive glomerulonephritis, and chronic glomerulonephritis. The specific diseases that underlie these syndromes are numerous and heterogeneous. Broadly, they may be divided into primary and secondary disorders depending on whether the kidneys are the sole organs affected or whether other organ systems are also involved in the disease processes. A systematic approach involving a careful history, physical examination, assessment of renal function, and urinalysis (composition and microscopy) and protein excretion, combined with biochemical and serologic testing, can provide important clues to diagnosis and prognosis. Renal biopsy is often required for a complete and accurate diagnosis as well as a prognosis and therapeutic decision making.

              This review contains 4 figures, 6 tables and 92 references

              Key words: glomerular filtration rate, glomerulonephritis, hematuria, nephrotic syndrome, proteinuria, renal biopsy, serum complement

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            • 4

              Nutritional Support in Acute Kidney Injury

              By Alice Sabatino , RD, MSc; Giuseppe Regolisti , MD; Filippo Fani , MD; Enrico Fiaccadori, MD, PhD
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              Nutritional Support in Acute Kidney Injury

              • ALICE SABATINO , RD, MSCParma University Medical School, Parma, Italy
              • GIUSEPPE REGOLISTI , MD Parma University Medical School, Parma, Italy
              • FILIPPO FANI , MD Parma University Medical School, Parma, Italy
              • ENRICO FIACCADORI, MD, PHD Parma University Medical School, Parma, Italy

              Protein-energy wasting (PEW) is particularly common in patients with acute kidney injury (AKI). It is correlated, at least in part, with specific factors of the reduction of renal function and is associated with significant increase in mortality and morbidity. In this clinical condition, the optimal nutritional support remains an open question due to its qualitative composition in terms of macro- and micronutrients. In fact, data on critically ill patients have confirmed that nutritional support targeting the real protein and energy needs is associated with improvement of clinical outcome. However, data available in AKI patients are still scarce. AKI is characterized by increased risk of both under- and overfeeding because of the coexistence of many factors that can influence the evaluation of nutrient needs, such as a rapid change in body weight due to alterations in fluid balance, loss of nutrients during renal replacement therapy (RRT), and the presence of hidden calories in the RRT (ie, calories derived from anticoagulants and/or from solutions used in the different dialysis methods). As AKI comprises a highly heterogeneous group of patients, with oscillatory nutrient needs during patients’ clinical course, nutritional requirements should be frequently reassessed, individualized, and carefully integrated with RRT. Nutrient needs in patients with AKI can be difficult to estimate and should be directly measured, especially in the intensive care unit setting.

              This review contains 4 figures, 3 tables and 104 references

              Keywords: Malnutrition In ICU Patients,  Acute Kidney Injury, Nutritional Support, Indirect Calorimetry, Resting Energy Expenditure, Lipid Oxidation Rate, Glucose Oxidation Rate, Micronutrients

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            • 5

              Kidney Neoplasia

              By Andre P Fay, MD; Pablo M Barrios; Fábio A B Schutz, MD; Carlos H Barrios, MD
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              Kidney Neoplasia

              • ANDRE P FAY, MDDepartment of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA
              • PABLO M BARRIOSPUCRS School of Medicine, Porto Alegre, Brazil
              • FÁBIO A B SCHUTZ, MDLatin American Cooperative Oncology Group, Porto Alegre, Brazil; Centro Oncológico Antônio Ermínio de Moraes, São Paulo, Brazil
              • CARLOS H BARRIOS, MDPUCRS School of Medicine, Latin American Cooperative Oncology Group, Porto Alegre, Brazil

              The incidence of kidney cancer is rising. Due to the widespread use of abdominal imaging for unrelated indications, small renal masses have been increasingly detected incidentally. A better understanding of the biology underlying the different tumor types arising from the kidney cortex has opened new avenues to define diagnosis, prognosis, and treatment strategies. Complete surgical resection remains the standard approach to treat renal neoplasms, and no systemic treatments have proven to be effective after a curative intent surgery. Approximately 30 to 40% of patients with kidney cancer will experience recurrence after a definitive treatment and will ultimately succumb to their disease. Drugs targeting the vascular endothelial growth factor and mammalian target of rapamycin pathways have significantly changed the outcome of patients with metastatic renal cell carcinoma (mRCC). Recently, the new era of immunotherapy has brought a new breath to the treatment of mRCC and will integrate into the landscape of treatment, improving clinical outcome.

              This review contains 3 figures, 7 tables and 129 references

              Key words: benign kidney tumors, cystic renal mass, kidney cancer, kidney neoplasms, metastatic renal cell carcinoma, renal cell carcinoma, small renal masses

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            • 6

              Conservative Management of Acute Kidney Injury

              By Rolando Claure-Del Granado, MD, FASN; Etienne Macedo, MD, PhD; Ravindra L. Mehta, MD, FASN
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              Conservative Management of Acute Kidney Injury

              • ROLANDO CLAURE-DEL GRANADO, MD, FASNHead, Division of Nephrology, Hospital Obrero #2 - Caja Nacional de Salud, Professor of Medicine, School of Medicine, Universidad Mayor de San Simon, Cochabamba, Bolivia
              • ETIENNE MACEDO, MD, PHDAssistant Adjunct Professor, Nephrology Division, Department of Medicine, University of California San Diego, USA
              • RAVINDRA L. MEHTA, MD, FASNProfessor of Clinical Medicine, Director, CREST and MAS in Clinical Research Programs, University of California San Diego, USA

              Acute kidney injury (AKI) is one of the most common complications occurring among intensive care unit (ICU) patients and is independently associated with a higher risk of mortality. In critically ill patients, AKI presentation is heterogeneous, varying from asymptomatic elevations in serum creatinine to the need for dialysis in the context of multiorgan failure. Within this range of clinical presentation, the kidney is often overlooked because improving and maintaining cardiac performance are the focus. In addition, aggressive fluid resuscitation may impose significant demands on the kidney wherein the normal excretory capacity may be overwhelmed. ICU patients often have underlying comorbidities, including chronic kidney disease and heart failure, which further limit the range of renal capacity. Drug and nutritional administration contribute to the demand for fluid removal to maintain fluid balance. The dissimilarities of the critical care environment and the extra demand kidney capacity highlight the need for different strategies for management and treatment of AKI in the critically ill patients. We focus this review on the general and nondialytic therapy of AKI.

              This reference contains 5 figures, 3 tables and 90 references

              Key words: Acute kidney injury, fluid resuscitation, loop diuretics, vasoactive agents, fluid overload, hiperkalemia, and metabolic acidosis.

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            • 7

              Metabolic Alkalosis

              By Fouad T Chebib, MD
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              Metabolic Alkalosis

              • FOUAD T CHEBIB, MD

              Metabolic alkalosis is a common clinical problem encountered by the nephrologist. An understanding of the pathogenesis of this electrolyte disorder, which includes a generative and a maintenance phase, is essential to elucidating the etiology and deciding on the appropriate treatment. Metabolic alkalosis is characterized by an increase in pH, a decrease in [H+], and an increase in [HCO3]. The generative phase of metabolic alkalosis involves either loss of acid (e.g., gastrointestinal losses), gain of bicarbonate (e.g., antacids), or cellular shift (e.g., hypokalemia). The maintenance phase involves impairment of the renal handling of bicarbonate (decreased glomerular filtration, increased bicarbonate tubular reabsorption). We discuss the different etiologies, such as chloride depletion (e.g., vomiting), potassium depletion (e.g., primary hyperaldosteronism), and hypercalcemic states (e.g., milk-alkali syndrome). This review also discusses the symptoms, diagnosis, and prognosis of metabolic alkalosis. A diagnostic algorithm based on volume status and urine electrolytes will help differentiate the different etiologies. Treatment options are summarized based on chloride-sensitive or chloride-resistant metabolic alkalosis.

              This review contains 5 figures, 3 tables and 12 references

              Key words: chloride resistance, chloride sensitivity, generative phase, maintenance phase, metabolic alkalosis, syndromes with metabolic alkalosis

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            • 8

              Kidney Transplantation: an Overview--recipient Evaluation and Immunosuppression

              By Jamil Azzi, MD; Belinda T. Lee, MD; Anil Chandraker, MD
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              Kidney Transplantation: an Overview--recipient Evaluation and Immunosuppression

              • JAMIL AZZI, MDInstructor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
              • BELINDA T. LEE, MDCharles Bernard Carpenter Transplant Fellow, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
              • ANIL CHANDRAKER, MDMedical Director of Kidney and Pancreas Transplantation, Associate Professor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA

              Half a century after the first successful kidney transplantation, we still stand at the crossroads of immunology and transplantation, where science meets art in the management of complex end-stage renal disease (ESRD) patients. Successful transplantation requires not only a lifetime’s commitment from patients but also a multidisciplinary approach, bringing together surgeons, transplant nephrologists, primary care physicians, scientists, and nurses to provide coordinated care. Although transplantation is the treatment of choice for the vast majority of ESRD patients, many patients remain on dialysis due to a relative imbalance between demand for and supply of suitable organs. This chapter provides a comprehensive overview of recipient evaluation and immunosuppression. Risk factors that prohibit transplantation are discussed, as are human leukocyte antigen/ABO compatibility, transplant immunobiology, induction therapy, maintenance therapy, transplantation for special populations, and future directions in the field. Tables outline Amsterdam Living Donation Forum guidelines, ABO blood group compatibilities, and pretransplant immunologic testing. Visual aids include graphs, charts, cell illustrations, and an evaluative algorithm.

              This chapter contains 10 figures, 3 tables, 101 references, and 5 Board-styled MCQs.

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            • 9

              Management of Chronic Kidney Disease and Its Complications

              By Joshua S. Hundert, MD; Ajay K Singh, MBBS, FRCP (UK), MBA
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              Management of Chronic Kidney Disease and Its Complications

              • JOSHUA S. HUNDERT, MDClinical Fellow, Department of Medicine, Division of Nephrology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
              • AJAY K SINGH, MBBS, FRCP (UK), MBAAssociate Professor of Medicine, Associate Dean for Global Education and Continuing Education, Harvard Medical School, Director, Continuing Medical Education, Department of Medicine and Renal Division, Brigham and Women’s Hospital, Boston, MA

              Management of early renal failure helps in the reduction or prevention of end-stage renal disease. The monitoring of renal function is discussed, and the chapter includes a table that shows commonly used methods for monitoring. Risk factors for chronic renal failure include stroke and cardiac disease. Risk factors for renal disease progression are diabetes mellitus, hypertension, proteinuria, smoking, protein intake, and hyperlipidemia. Complications of chronic renal failure that are addressed include sodium and water imbalance, potassium imbalance, acidosis, calcium and phosphorus imbalance, and anemia. There is also a section that discusses the case for early referral to a nephrologist. Tables present the equations used to estimate the glomerular filtration rate (GFR); stages of chronic kidney disease and the appropriate steps in their management; risk factors for chronic kidney disease in which the testing of proteinuria and estimation of GFR are indicated; appropriate diet for patients who have chronic kidney disease; and guidelines for diagnosing and treating anemia resulting from chronic kidney disease. An algorithm outlines the steps in management of calcium and phosphate in patients with kidney disease.

              This review contains 3 figures, 10 tables and 50 references

              Key Words End-stage renal disease, chronic kidney disease, glomerular filtration rate, Modification of Diet in Renal Disease, Proteinuric renal disease, Hyperuricemia

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          • Radiology
            • 1

              Focused Assessment With Sonography for Trauma

              By David Barounis, MD ; Elise Hart, MD
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              Focused Assessment With Sonography for Trauma

              • DAVID BAROUNIS, MD Attending Physician, Departments of Emergency Medicine and Critical Care Medicine, Advocate Christ Medical Center, Oak Lawn, IL
              • ELISE HART, MDPostgraduate Year 3, Emergency Medicine Residency Program, Advocate Christ Medical Center, Oak Lawn, IL

              The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients.

              Key words: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

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            • 2

              Neuroimaging for the Clinician

              By Joshua P Klein, MD, PhD
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              Neuroimaging for the Clinician

              • JOSHUA P KLEIN, MD, PHDChief, Division of Hospital Neurology, Department of Neurology, Brigham and Women’s Hospital, and Assistant Professor of Neurology, Harvard Medical School, Boston, MA

              Modern neuroimaging has revolutionized the practice of neurology by allowing visualization and monitoring of evolving pathophysiologic processes. High-resolution magnetic resonance imaging (MRI) can now resolve structural abnormalities on a near-cellular level. Advances in functional imaging can assess the in vivo metabolic, vascular, and functional states of neuronal and glial populations in real time. Given the high density of data obtained from neuroimaging studies, it is essential for the clinician to take an active role in understanding the nature and significance of imaging abnormalities. This chapter reviews computed tomography and MRI techniques (including angiography and advanced sequences), specialized protocols for investigating specific diagnoses, risks associated with imaging, disease-specific imaging findings with general strategies for interpretation, and incidental findings and artifacts. Figures include computed tomography, T1- and T2-weighted signal intensity, diffusion-weighted magnetic resonance imaging, magnetic resonance spectroscopy, imaging in epilepsy and dementia, extra-axial versus intra-axial lesions, typical lesions of multiple sclerosis, spinal imaging, spinal pathology, vascular pathology, intracranial hemorrhage, and common imaging artifacts. Tables list Hounsfield units, patterns of enhancement from imaging, advanced techniques in imaging, magnetic resonance imaging sequences, and the evolution of cerebral infarction and intraparenchymal hemorrhage on magnetic resonance imaging.

              This review contains 12 figures, 6 tables, and 213 references.

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            • 3

              Trauma Imaging

              By Joel A. Gross, MD; Martin L. Gunn, MBChB, FRANZCR; Kathleen R. Fink, MD
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              Trauma Imaging

              • JOEL A. GROSS, MDAssociate Professor, Director, Emergency Radiology, Department of Radiology, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA
              • MARTIN L. GUNN, MBCHB, FRANZCRAssociate Professor, Department of Radiology, University of Washington, Seattle, WA
              • KATHLEEN R. FINK, MDAssistant Professor, Department of Radiology, University of Washington, Seattle, WA

              Due to increased use of computed tomography (CT) and ultrasonography, technological advances in equipment design, and increased availability of imaging equipment in the emergency department, imaging studies have revolutionized the assessment of the trauma patient in the past three decades. This review examines commonly used imaging modalities in trauma evaluation, initial and additional imaging, brief introduction to CT, and an overview of CT image processing and reviewing a CT scan. Head imaging, spine imaging, chest imaging, and abdominal and pelvic imaging are presented, along with injury grading, solid-organ injury appearances and specific abdominal solid-organ injuries, urinary system injury, penetrating trauma, unexplained intraperitoneal fluid, vascular injury and musculoskeletal injury. Figures show lateral view of the cervical spine; volume rendering of the pelvis; CT windows; CT imaging of acute intracranial bleeding, herniation in acute subdural hemorrhage, post-traumatic pseudoaneurysm of descending thoracic aorta, subscapular hematoma of the liver, liver laceration, pseudoaneurysm of the liver, shattered kidney and the nonperfused right kidney attributable to a traumatic renal artery injury, tigroid spleen, a focus of gas and stranding adjacent to the lateral wall of the ascending colon, extravasated urinary contrast (white material) surrounding the proximal right indicating ureteral laceration or transection, intraperitoneal bladder rupture, and contrast extravasation in the liver; magnetic resonance imaging versus CT of shear injuries; and magnetic resonance imaging in the setting of cervical spine trauma. Tables list New Orleans Criteria, Canadian CT Head Rule, CT in Head Injury Patients (CHIP) Prediction Rule, Marshall CT Classification, Rotterdam Classification, Biffl Carotid Artery Injury Grading Scale, and Modified Denver Criteria for Blunt Cerebrovascular Injury (BCVI) Screening.

              This review contains 18 highly rendered figures, 7 tables, and 105 references.

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            • 4

              Imaging of Malignant and Benign Tumors of the Pancreas

              By Ersan Altun, MD; Richard C Semelka, MD
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              Imaging of Malignant and Benign Tumors of the Pancreas

              • ERSAN ALTUN, MDAssistant Professor of Radiology, Department of Radiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
              • RICHARD C SEMELKA, MDProfessor of Radiology, Director of MRI, Director of Quality and Safety, Department of Radiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC

              Pancreatic cross-sectional imaging has been widely used to diagnose and stage pancreatic neoplasms. The most commonly used techniques include multidetector CT, MRI, and endoscopic ultrasonography. Hybrid imaging including positron emission tomography combined with CT has a limited role. Dedicated imaging applications of these modalities for the evaluation of pancreatic neoplasms and their accuracies for different neoplasms are summarized in this review. Critical and differential imaging findings of the most common neoplasms of the pancreas, including adenocarcinoma, neuroendocrine tumors, cystic neoplasms, lymphoma, and metastases, emphasizing the most accurate imaging techniques are also discussed. Additionally, the most common mimics of the pancreatic neoplasms and their imaging findings are reviewed.

              This review contains 32 references, 13 figures, and 5 tables.

              Key words: adenocarcinoma, CT, EUS, intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, MRI, neuroendocrine tumors, PET-CT, serous cystadenoma

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            • 5

              Critical Care Ultrasonography

              By S Patrick Bender, MD; Thomas R Pace, MD; Joshua Farkas, MD
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              Critical Care Ultrasonography

              • S PATRICK BENDER, MD
              • THOMAS R PACE, MD
              • JOSHUA FARKAS, MD

              The use of bedside ultrasonography in the intensive care unit continues to expand due to its broad utility, including diagnosis of various conditions, evaluation of hemodynamics, and improvement in the speed and safety of certain bedside procedures. In this review, the reader will gain a better understanding of the physical properties of ultrasound waves and potential artifacts. The five standard views to perform a basic echocardiographic evaluation are described. This examination provides an adequate assessment of the left ventricle, helping to differentiate acute coronary syndrome, stress cardiomyopathy, and regional or global left ventricular dysfunction. Right ventricular function can be assessed qualitatively or, if desired, quantitatively via measurement of tricuspid annular plane excursion. Echocardiography also allows for assessment of volume status, detection of cardiac tamponade, and signs of hemodynamically significant pulmonary embolism. We also describe bedside ultrasound use for pulmonary assessment and for guidance of thoracentesis. Lung ultrasonography is very sensitive for the detection of pneumothoraces and pleural effusions. The lung parenchyma may also be evaluated by identifying various artifacts such as A-lines and B-lines to delineate underlying pulmonary pathology. Understanding these artifacts allows an experienced practitioner to detect various pathologies such as pneumonia, cardiogenic pulmonary edema, atelectasis, and other conditions. Finally, we discuss abdominal ultrasonography, including the performance of a focused assessment with sonography in trauma examination, performance of a paracentesis, and diagnosis of a pneumoperitoneum.

              This review contains 11 figures, 1 table, and 53 references.

              Key words: bedside ultrasonography, echocardiography, focused assessment with sonography in trauma (FAST), focused cardiac ultrasonography (FoCUS), point-of-care ultrasonography

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            • 6

              Endoscopic Ultrasonography

              By Marvin Ryou, MD; Nitkin Kumar, MD
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              Endoscopic Ultrasonography

              • MARVIN RYOU, MDAssociate Staff Physician, Brigham and Women’s Hospital, Boston, MA
              • NITKIN KUMAR, MDDirector, Bariatric Endoscopy Institute, Addison, IL

              Endoscopic ultrasonography (EUS) is a versatile tool that can be used to perform a variety of diagnostic and therapeutic procedures in the upper or lower gastrointestinal tract. The proximity of the echoendoscope to the pancreas, liver, and other thoracic and abdominal organs allows detailed examination or minimally invasive intervention that would not be feasible by surgical or percutaneous approaches. EUS is available with radial or linear scanning arrays and is capable of guiding fine-needle aspiration to acquire tissue for cytologic analysis. This review covers the role of EUS in chronic pancreatitis; pancreatic cysts; submucosal tumors; suspected choledocholithiasis; fecal incontinence; staging of malignancy in esophageal, pancreatic, gastric, and rectal cancer; celiac plexus block/neurolysis; fiducial placement; pseudocyst drainage and cystogastrostomy/cystoduodenostomy; endoscopic necrosectomy; and biliary drainage. Figures show peripancreatic cysts, gastrointestinal stromal tumor, common bile duct stone, esophageal adenocarcinoma, pancreatic head mass causing biliary obstruction and invading portal confluence, fine-needle aspiration of a pancreatic head mass, rectal adenocarcinoma, abdominal aorta with celiac artery and superior mesenteric artery, celiac plexus neurolysis, necrosectomy, and EUS-guided choledochoduodenostomy for failed endoscopic retrograde cholangiopancreatography. Tables list the Rosemont criteria for chronic pancreatitis and pancreatic cystic lesions.

              Key words: bile duct stone, biliary drainage, echoendoscope, endoscopic ultrasonography, fine-needle aspiration, pancreatic cyst

              This review contains 12 highly rendered figures, 2 tables, and 62 references.

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            • 7

              Imaging for Nephrolithiasis

              By Daniel A Wollin, MD; Joanne Dale, MD; Ruiyang Jiang, MD; Stephanie Sexton, MD; Glenn M Preminger, MD
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              Imaging for Nephrolithiasis

              • DANIEL A WOLLIN, MD
              • JOANNE DALE, MD
              • RUIYANG JIANG, MD
              • STEPHANIE SEXTON, MD
              • GLENN M PREMINGER, MD

              Nephrolithiasis is a common condition that affects a large number of Americans. An imaging diagnosis is required for adequate treatment and follow-up, and a large variety of imaging modalities exist for this purpose. In this review, we discuss the advantages, disadvantages, and specific uses for a wide array of imaging methods, including plain radiography, ultrasonography, CT, and others. In addition, special attention is paid to specific clinical situations for individual tests, such as when dealing with children, pregnant women, and patients in an intraoperative setting. Approximate costs and radiation doses of each modality are discussed as well. At the conclusion of this review, the reader should understand the utility of each imaging technique, along with the optimal situation for use and reasoning for these decisions.

              This review contains 5 highly rendered figures, 2 tables, and 85 references


              Key words: CT, diagnosis, digital tomosynthesis, fluoroscopy, follow-up, imaging, intravenous pyelography, MRI, nephrolithiasis, radiation dose, radiography, ultrasonography


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          • Anesthesiology
            • 1

              Acute Kidney Injury in Critically Ill Patients

              By Monica G Valero, MD; Zara Cooper, MD, MSc, FACS
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              Acute Kidney Injury in Critically Ill Patients

              • MONICA G VALERO, MD
              • ZARA COOPER, MD, MSC, FACS

              Acute kidney injury is a common disease that affects critically ill patients and increases morbidity and mortality. Even though there have been extensive efforts to prevent this disease, the incidence has steadily increased over the last decade. This could be attributed to better recognition or to overestimation of the disease based on the most recent consensus criteria. Complications of acute kidney injury have a significant effect on quality of life, morbidity, and mortality. Despite advances in the field, this disease continues to be a challenge, and decreasing the mortality associated with it remains difficult. Plenty of literature has been published about the appropriate definition, diagnosis, and treatment of the disease. One of the topics of ongoing discussion deals with the lack of consensus about the exact timing for initiation of renal replacement therapy (RRT). Even though RRT adds more complexity to the treatment, recent publications suggest that early versus late initiation of RRT is related to reduced mortality in critically ill patients. Further high-level studies of this intervention are warranted to standardize treatment.

              This review contains 5 figures, 7 tables, and 77 references.              

              Key words:Acute Kidney Injury Network (AKIN), acute kidney injury, chronic kidney disease, Kidney Disease: Improving Global Outcomes (KDIGO), renal biomarkers, replacement therapy, Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE)

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            • 2

              Preoperative Testing and Planning for Safer Surgery

              By Valerie Ng, MD, PhD; Alden H. Harken, MD, FACS; Sarah Markham, MD; Jill Antoine, MD
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              Preoperative Testing and Planning for Safer Surgery

              • VALERIE NG, MD, PHDProfessor Emeritus, Department of Laboratory Medicine, University of California, San Francisco-East Bay; and Chair Laboratory Medicine and Pathology, Alameda County Medical Center, Oakland, CA
              • ALDEN H. HARKEN, MD, FACSProfessor and Chair, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA
              • SARAH MARKHAM, MDSurgical Resident, University of California, San Francisco-East Bay Surgical Residency Program, Department of Surgery, Alameda County Medical Center, Oakland, CA
              • JILL ANTOINE, MDMedical Director, Anesthesiology, Pre-Operative Clinic, Department of Anesthesia, Highland Hospital, Alameda Health Systems, Oakland, CA

              Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997).

              This review contains 4 highly rendered figures, 3 tables, and 111 references

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            • 3

              Noninvasive and Invasive Ventilatory Support I

              By Pauline K. Park, MD, FACS, FCCM; Nicole L Werner, MD, MS; Carl Haas, MLS,2 RRT-ACCS
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              Noninvasive and Invasive Ventilatory Support I

              • PAULINE K. PARK, MD, FACS, FCCMAssociate Professor, Dept. of Surgery, University of Michigan
              • NICOLE L WERNER, MD, MSFellow, Surgical Critical Care, University of Michigan Health System, Ann Arbor, MI
              • CARL HAAS, MLS,2 RRT-ACCSEducation and Research Coordinator, Adult Respiratory Care, University of Michigan Health System, Ann Arbor, MI

              Invasive and noninvasive ventilation are important tools in the clinician’s armamentarium for managing acute respiratory failure. Although these modalities do not treat the underlying disease, they can provide the necessary oxygenation and ventilatory support until the causal pathology resolves. Care must be taken, as even appropriate application can cause harm. Knowledge of pulmonary mechanics, appreciation of the basic machine settings, and an understanding of how common and advanced modes function allow the clinician to optimally tailor support to the patient while limiting iatrogenic injury. This first chapter reviews pulmonary mechanics, machine settings, and current options for noninvasive and invasive support of respiratory failure.

              This review contains 7 figures, 3 tables and 44 references

              Key Words: hypoxemia, hypercapnia, mechanical ventilation, noninvasive ventilation, respiratory failure

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            • 4

              Noninvasive and Invasive Ventilatory Support II

              By Pauline K. Park, MD, FACS, FCCM; Nicole L Werner, MD, MS; Carl Haas, MLS,2 RRT-ACCS
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              Noninvasive and Invasive Ventilatory Support II

              • PAULINE K. PARK, MD, FACS, FCCMAssociate Professor, Dept. of Surgery, University of Michigan
              • NICOLE L WERNER, MD, MSFellow, Surgical Critical Care, University of Michigan Health System, Ann Arbor, MI
              • CARL HAAS, MLS,2 RRT-ACCSEducation and Research Coordinator, Adult Respiratory Care, University of Michigan Health System, Ann Arbor, MI

              Invasive and noninvasive ventilation are important tools in the clinician’s armamentarium for managing acute respiratory failure. Although these modalities do not treat the underlying disease, they can provide the necessary oxygenation and ventilatory support until the causal pathology resolves. Care must be taken as even appropriate application can cause harm. Knowledge of pulmonary mechanics, appreciation of the basic machine settings, and an understanding of how common and advanced modes function allows the clinician to optimally tailor support to the patient while limiting iatrogenic injury. This second chapter reviews indications for mechanical ventilation, routine management, troubleshooting, and liberation from mechanical ventilation

              This review contains 6 figures, 7 tables and 60 references

              Keywords: Mechanical ventilation, lung protective ventilation, sedation, ventilator-induced lung injury, liberation from mechanical ventilation

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            • 5

              Ventilator Weaning

              By Brian Brajcich, MD; Ann Hwalek, DO; Joseph Posluszny, MD
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              Ventilator Weaning

              • BRIAN BRAJCICH, MDGeneral Surgery Resident, Northwestern University
              • ANN HWALEK, DOGeneral Surgery Resident, Loyola University, Stritch School of Medicine,
              • JOSEPH POSLUSZNY, MDAssistant Professor of Surgery, Northwestern University

              Ventilator weaning/liberation is a complex process that requires focus on a patient’s respiratory mechanics, strength, awareness, airway patency, and secretions while also keeping in mind a patient’s overall clinical status and critical illness. The recommendations in the chapter are based on evidence-based medicine when available. When no clear data can definitively guide patient management, clinical guidelines and accepted practices are described.  Our hope is that the reader finds this chapter as a reliable and safe way to approach ventilator liberation.

              This review contains 4 figures, 6 tables and 77 references

              Key Words: ABCDE bundle, diaphragm dysfunction, negative inspiratory force, reintubation, RSBI, sedation, spontaneous breathing trial, tracheostomy, ventilator liberation, ventilator weaning

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            • 6

              Transfusion Therapy

              By Ronald Chang, MD; John B. Holcomb, MD
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              Transfusion Therapy

              • RONALD CHANG, MD
              • JOHN B. HOLCOMB, MD

              Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking.

              Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

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            • 7

              Extracorporeal Membrane Oxygenation

              By Julian Villar, MD, MPH; Stephen Ruoss, MD; Richard HA , MD; Joe Hsu, MD, MPH
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              Extracorporeal Membrane Oxygenation

              • JULIAN VILLAR, MD, MPHClinical Fellow, Critical Care Medicine, Department of Medicine, Stanford University Medical School
              • STEPHEN RUOSS, MDProfessor, Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University Medical School
              • RICHARD HA , MDAssociate Physician, Cardiothoracic Surgery Surgical Directory of Mechanical Circulatory Support, Department of Cardiothoracic Surgery, The Permanente Medical Group,
              • JOE HSU, MD, MPHAssistant Professor, Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University Medical School

              Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, is the practice of using circulatory assist devices and a gas exchange system to maintain sufficient tissue oxygen delivery, supplementing pulmonary and/or cardiac function in patients whose native physiology is too severely altered to be successfully supported solely by conventional life support techniques (eg, mechanical ventilation and inotropic and vasopressor drugs). ECMO should be considered in patients who are at a high risk of death due to a potentially reversible etiology of cardiopulmonary collapse. Indications for ECMO can be broadly divided into profound respiratory failure and/or cardiogenic shock. The indications include acute respiratory distress syndrome, heart failure, postoperative cardiogenic shock, and as an adjunct to cardiopulmonary resuscitation in patients with cardiac arrest. ECMO is currently experiencing a renaissance, and familiarity with its concepts is important for all critical care practitioners.

              This review contains 8 figures, 8 tables and 34 references

              Key Words: complications, equipment, indications, management basics, outcomes

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            • 8

              Cardiac Support Devices

              By Charles C. Hill, MD; Lindsay Raleigh, MD
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              Cardiac Support Devices

              • CHARLES C. HILL, MD
              • LINDSAY RALEIGH, MD

              Mechanical circulatory support (MCS) involves the use of intra-aortic balloon pump (IABP), short-term percutaneous ventricular assist devices, long-term surgically implanted continuous-flow ventricular assist devices (cf-LVADs), and extracorporeal membrane oxygenation (ECMO) for the treatment of acute and chronic heart failure and cardiogenic shock. IABP is increasingly recognized as an important adjunct in the postoperative treatment arsenal for those patients with severely reduced left ventricular systolic function. Short-term percutaneous options for the treatment of acute right and left heart failure include both the Impella and Tandem Heart, whereas the Centrimag is often used in the surgical setting for acute cardiogenic shock and heart failure. Long-term surgical MCS options include the total artificial heart and the cf-LVADs HeartWare and Heartmate II. ECMO is frequently used for the treatment of acute cardiogenic shock and may be placed peripherally via a percutaneous approach or with central cannulation. ECMO is also increasingly used in the setting of acute cardiac life support, known as extracorporeal life support.

              Key words: cardiac critical care, extracorporeal membrane oxygenation, long-term ventricular assist device, mechanical circulatory support, short-term ventricular assist device 

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            • 9

              Modes of Ventilation

              By Michael J Harrison, MBBS, MD, FRCA, FANZCA
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              Modes of Ventilation

              • MICHAEL J HARRISON, MBBS, MD, FRCA, FANZCAHonorary Clinical Associate Professor, University of Auckland, New Zealand

              Lung ventilation is required to maintain oxygenation and eliminate carbon dioxide. The basic parameters of ventilation—tidal volume, respiratory rate, airway resistance, and lung and thoracic compliance—all combine to affect the airway pressure. These parameters, in turn, can affect cardiac output and hemodynamic stability through their effect on intrathoracic pressure and on venous return to the heart. Since the 1950s, many machines have been designed to allow the physician to optimize ventilation. These designs have revolved around three physical variables: volume, pressure, and time. Volume is required to overcome the anatomic respiratory dead space and allows gas exchange in the alveoli. Pressure is required to inflate the elastic system comprising the lungs and thorax, but must also be limited to prevent tissue damage. Time not only determines the respiratory rate but also the rate of flow of gas in and out of the lungs.

              Many permutations of these basic parameters in anesthesia machines are available today. Knowledge of the common forms of ventilation and their advantages and disadvantages will guide the anesthesiologist in choosing from among these various complex systems.

              This review contains 5 figures, 3 tables, and 27 references.

              Key words: CPAP, HFOV, IMV, IPPV, jet ventilation, PEEP, pressure cycled, pulmonary ventilation, SIMV, spontaneous, volume cycled

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            • 10

              Airway Procedures

              By Ju-Mei Ng, MD
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              Airway Procedures

              • JU-MEI NG, MDAssistant Professor of Anesthesia, Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Boston

              There has been a marked increase in the number and complexity of airway procedures performed both in the operating room and procedural areas. The anesthesiologist is challenged with establishing a patent shared airway and maintaining adequate gas exchange in patients with compromised airways and/or respiratory function. This review presents a general approach to the patient presenting for an airway procedure and highlights the commonly occurring complications. Airway fire, bleeding, and airway disruption or obstruction may occur. Some of the newer interventional bronchoscopic procedures are introduced, with emphasis on anesthetic implications. A more detailed discussion surrounds the anesthetic management of central airway obstruction and airway stenting.

              This review contains 8 figures, 5 tables, 30 references. 

              Key Words: anesthesia for flexible bronchoscopy, anesthesia for rigid bronchoscopy, airway stenting, bronchoscopy, central airway obstruction, interventional pulmonology, total intravenous anesthesia, ventilation

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          • Dermatology
            • 1

              Cutaneous Adverse Drug Reactions

              By Neil H. Shear, MD, FRCPC; Sandra Knowles, BScPhm; Lori Shapiro, MD, FRCPC
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              Cutaneous Adverse Drug Reactions

              • NEIL H. SHEAR, MD, FRCPCProfessor and Chief of Dermatology, Department of Medicine, Divisions of Dermatology and Clinical Pharmacology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, CA
              • SANDRA KNOWLES, BSCPHMAssistant Professor (Status Only), Department of Pharmacy, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, CA
              • LORI SHAPIRO, MD, FRCPCAssistant Professor of Medicine, Department of Medicine, Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, CA

              An adverse drug reaction is defined as any noxious, unintended, and undesired effect of a drug that occurs at doses used in humans for prophylaxis, diagnosis, or therapy. A cutaneous eruption is one of the most common manifestations of an adverse drug reaction. This chapter reviews the epidemiology, etiology, diagnosis, clinical manifestations, and differential diagnosis of adverse drug reactions, as well as laboratory tests for them. Also discussed are the types of cutaneous eruption: exanthematous eruption, urticarial eruption, blistering eruption, pustular eruption, and others. The simple and complex forms of each type of eruption are reviewed. The chapter includes 4 tables and 12 figures. Tables present the warning signs of a serious drug eruption, clinical features of hypersensitivity syndrome reaction and serum sickness-like reaction, characteristics of Stevens-Johnson Syndrome and toxic epidermal necrolysis, and clinical pearls to identify anticoagulant-induced skin necrosis. Figures illustrate hypersensitivity syndrome reaction, a fixed drug eruption from tetracycline, pseudoporphyria from naproxen, linear immunoglobulin A disease induced by vancomycin, pemphigus foliaceus from taking enalapril, pemphigus vulgaris from taking penicillamine, toxic epidermal necrolysis after starting phenytoin therapy, acneiform drug eruption due to gefitinib, acute generalized exanthematous pustulosis from cloxacillin, coumarin-induced skin necrosis, a lichenoid drug eruption associated with ramipril, and leukocytoclastic vasculitis from hydrochlorothiazide. This chapter contains 106 references.

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            • 2

              Benign Cutaneous Tumors

              By Elizabeth A Abel, MD
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              Benign Cutaneous Tumors

              • ELIZABETH A ABEL, MDAdjunct Clinical Professor of Dermatology, Stanford University School of Medicine, Stanford, CA, Private Practice, California Skin Institute, Mountain View, CA

              Tumors of the cutaneous surface may arise from the epidermis, dermis, or subcutaneous tissue or from any of the specialized cell types in the skin or its appendages. Broad categories include tumors derived from epithelial, melanocytic, or connective tissue structures. Within each location or cell type, lesions are classified as benign, malignant, or, in certain cases, premalignant. Benign epithelial tumors include tumors of the surface epidermis that form keratin, tumors of the epidermal appendages, and cysts of the skin. Melanocytic (pigment-forming) lesions are very common. One of the most frequently encountered forms is the nevus cell nevus. Tumors that are derived from connective tissue include fibromas, histiocytomas, lipomas, leiomyomas, and hemangiomas. This chapter provides an overview of each type of tumor, including sections on epithelial tumors, tumors of the epidermal appendages, familial tumor syndromes, melanocytic tumors, neural tumors, connective tissue tumors, vascular birthmarks, acquired vascular disorders, Kimura disease, lipoma, leiomyoma, and lymphangioma circumscriptum. The sections discuss various forms and their diagnosis, differential diagnosis, and treatment. Figures accompany the descriptions.

              This chapter contains 83 references, 26 highly rendered figures, and 5 MCQs.

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            • 3

              Malignant Cutaneous Tumors

              By Allan C Halpern, MD; Patricia L. Myskowski, MD
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              Malignant Cutaneous Tumors

              • ALLAN C HALPERN, MDChief, Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY
              • PATRICIA L. MYSKOWSKI, MDAttending Physician, Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY

              This chapter reviews the most common malignant cutaneous tumors. The section on malignant tumors of the epidermis discusses nonmelanoma skin cancer (i.e., basal cell carcinoma and squamous cell carcinoma) and malignant melanoma. The section on malignant tumors of the dermis covers metastatic tumors, primary tumors (Merkel cell carcinoma, Paget disease, extramammary Paget disease, angiosarcoma, and dermatofibrosarcoma protuberans), and Kaposi sarcoma (i.e., classic Kaposi sarcoma, African Kaposi sarcoma, organ-transplant Kaposi sarcoma, and HIV-associated Kaposi sarcoma). The final section covers cutaneous lymphomas. The coverage of each disease includes a discussion of epidemiology, etiology, diagnosis, differential diagnosis, treatment, and prognosis. Tables provide the adjusted estimated relative risks of melanoma by nevus type and number, the American Joint Committee on Cancer (AJCC) TNM classification and staging system, the estimated probability of 10-year survival in patients with primary cutaneous melanoma, and an overview of overview of therapy for cutaneous T cell lymphoma. Figures illustrate the presentation of many malignant cutaneous tumors.

              This review contains 10 highly rendered figures, 5 tables, and 105 references.

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            • 4

              Eczematous Disorders, Atopic Dermatitis, and Ichthyoses

              By Seth R Stevens, MD
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              Eczematous Disorders, Atopic Dermatitis, and Ichthyoses

              • SETH R STEVENS, MDPartner Physician, Southern California Permanente Medical Group, Woodland Hills, CA, and Assistant Clinical Professor, Case Medical School, Cleveland, OH

              This review describes eczematous dermatitis, or eczema, a skin disease that is characterized by erythematous vesicular, weeping, and crusting patches; atopic dermatitis, a common chronic inflammatory dermatosis that generally begins in infancy; and the ichthyoses, a group of diseases of cornification that are characterized by excessive scaling. The purpose of this review is to examine the major variants, epidemiology, etiology, diagnosis, differential diagnosis, and treatment of these dermatologic diseases. Figures depict chronic eczematous dermatitis, allergic contact dermatitis to poison ivy, seborrheic dermatitis, nummular eczema, acute eczematous patches, lichenified patches that appear after chronic rubbing of eczematous patches, erythroderma (total body erythema), and marked scaling (acquired ichthyosis). Tables list the diagnostic criteria for atopic dermatitis and the differential diagnosis of atopic dermatitis.

              This review contains 9 highly rendered figures, 2 tables, and 88 references.

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            • 5

              Infestations

              By Dirk Elston, MD
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              Infestations

              • DIRK ELSTON, MDDirector, Ackerman Academy of Dermatopathology, New York, NY

              This review looks at parasitic diseases of the skin. Scabies, caused by the human itch mite (Sarcoptes scabiei), and pediculosis, caused by the bloodsucking louse, are the most prevalent parasitic diseases in temperate regions. For treatment of scabies, ivermectin is suitable for mass drug administration during severe outbreaks, although patients with heavy scabies infestation may exhibit Mazzotti reactions during treatment with oral ivermectin. Another promising scabicide is Tinospora cordifolia lotion. The increase in global travel has also meant a worldwide increase in parasitic disorders endemic to tropical regions; these disorders include cutaneous larva migrans, pyodermas, arthropod-reactive dermatitis, myiasis, tungiasis, urticaria, and cutaneous and mucocutaneous leishmaniasis. Finally, patients with delusional parasitosis will express the belief that parasitical organisms are infesting their skin. Pimozide, an antipsychotic, has been successfully used to treat delusional parasitosis.

              This module contains 16 highly rendered figures, 2 tables, 15 references, and 5 MCQs.

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          • Urology
            • 1

              Urologic Infections

              By Tatyana Vayngortin, MD; Nisa S Atigapramoj, MD
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              Urologic Infections

              • TATYANA VAYNGORTIN, MDPediatric Emergency Medicine Fellow, Department of Emergency Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, CA
              • NISA S ATIGAPRAMOJ, MDAssistant Clinical Professor of Pediatrics and Emergency Medicine, Department of Emergency Medicine, UCSF Benioff Children’s Hospital, San Francisco, CA

              Urinary tract infections (UTIs) affect people of all ages. Although the incidence of invasive bacterial diseases continues to decline, the prevalence of UTIs in febrile pediatric patients continues to remain a focus for serious bacterial infection in this population. In older age groups, symptoms become more obvious and present more classically. Clinical practice guidelines have been developed because morbidity can be dependent upon the rapid identification of a UTI with prompt initiation of appropriate antimicrobials. This review provides a summary for the evaluation of UTIs with discussion of diagnosis and management. 

              This review contains 6 figures, 5 tables and 47 references

              Key words: antibiotics, cystitis, pyelonephritis, urinary tract infection, uropathogens

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            • 2

              Management of Small Renal Masses

              By Keith A Lawson , MD, MSc; Antonio Finelli , MD, MSc, FRCSC
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              Management of Small Renal Masses

              • KEITH A LAWSON , MD, MSCDivision of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON
              • ANTONIO FINELLI , MD, MSC, FRCSCDivision of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON

              The rise in incidentally discovered enhancing solid renal tumors has spurred the development of new approaches to managing this unique clinical entity known as the small renal mass (SRM). These approaches are grounded on a better understanding of the natural history of SRM, with the goal to reduce the morbidity associated with their management and avoid overtreatment. In this chapter, we review the body of evidence pertaining to the classification and clinical management of SRMs with respect to diagnosis, treatment, and follow-up. In addition, we discuss the controversies and active areas of development for this rapidly evolving field that strides towards a precision medicine paradigm. 

              This review contains 6 figures, 6 tables and 63 references

              Keywords: Small renal mass, renal cell carcinoma, radical nephrectomy, renal tumor biopsy, active surveillance, natural history, oncocytoma, robotic surgery, partial nephrectomy

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            • 3

              Introduction to Ureteroceles: Presentation, Diagnosis, and Initial Management

              By Joseph W McQuaid, MD, MPH; David A Diamond, MD
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              Introduction to Ureteroceles: Presentation, Diagnosis, and Initial Management

              • JOSEPH W MCQUAID, MD, MPHPediatric Urology Fellow, Boston Children’s Hospital Clinical Fellow in Surgery, Harvard Medical School, Boston, MA
              • DAVID A DIAMOND, MDUrologist-in-Chief, Associate Clinical Ethicist, & Senior Associate in Urology, Boston Children’s Hospital Professor of Surgery (Urology), Harvard Medical School Alan B. Retik Chair & Professor of Surgery, Harvard Medical School, Boston, MA

              The diagnosis and treatment of ureteroceles continue to evolve. Not only are the majority of patients diagnosed prenatally, but a significant proportion of cases can be dealt with in a minimally invasive, endoscopic fashion. Although a single treatment strategy for all ureteroceles is an unrealistic expectation, more valuable to the practicing urologist is an understanding of the variable anatomy and presentation of this entity and an appreciation for the breadth of treatment options at his or her disposal. This, the first of our two reviews on ureteroceles, provides the necessary background.

              This review contains 10 figures, 6 tables and 35 references

              Key words: bladder trigone, cecoureterocele, ectopic ureterocele, extravesical ureterocele, intravesical ureterocele, lower tract approach, obstructed ureterocele, reflux, transurethral incision, transurethral puncture, upper tract approach, ureterocele, ureterocele algorithm

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            • 4

              Conservative Management of Male Stress Urinary Incontinence

              By Tammy Ho, MD; H Henry Lai, MD
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              Conservative Management of Male Stress Urinary Incontinence

              • TAMMY HO, MD
              • H HENRY LAI, MD

              Stress urinary incontinence is a demoralizing complication of common urologic procedures such as radical prostatectomy. Basic evaluation of postprostatectomy incontinence should include a careful history and physical examination with a focus on assessing the degree of incontinence and amount of bother and to rule out detrusor dysfunction. Evaluation can be supplemented by a voiding diary, pad test, urodynamics, and cystoscopy as indicated. Management options include behavioral modification, pelvic floor physical therapy, external drainage devices, and occlusive penile clamps. Randomized controlled trials have shown that pelvic floor physical therapy improves continence or enhances recovery of continence in the postoperative period but only when initiated before or immediately after catheter removal. Men who have intrinsic sphincter deficiency can be evaluated for injection of urethral bulking agents, including collagen, carbon-coated zirconium oxide beads, calcium hydroxylapatite particles, and heat-vulcanized polydimethylsiloxane. Injectable bulking agents have the advantage of being minimally invasive and are generally considered safe. However, multiple reinjections are often required due to deteriorating efficacy over time and thus should be considered only in patients with mild stress incontinence or in patients who are poor surgical candidates for slings or the artificial urinary sphincter.

              This review contains 3 figures and 54 references

              Key words: conservative management, injectable urethral bulking agents, pelvic floor physical therapy, postprostatectomy urinary incontinence, stress urinary incontinence

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            • 5

              Erectile Dysfunction: Evaluation, Including Diagnostic Studies (doppler Ultrasound, Cavernosography/cavenosometry)

              By Sevann Helo, MD; Nicholas Tadros, MD MCR; Kevin T McVary, MD
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              Erectile Dysfunction: Evaluation, Including Diagnostic Studies (doppler Ultrasound, Cavernosography/cavenosometry)

              • SEVANN HELO, MD
              • NICHOLAS TADROS, MD MCR
              • KEVIN T MCVARY, MD

              Erectile dysfunction (ED) is a common condition in the aging population that can be broadly classified as organic, psychogenic, or mixed. A thorough evaluation of a patient with ED begins with acknowledging that it is intimately related to a host of medical, neurologic, and psychological conditions. Providers should be confident in their ability to obtain a relevant history, perform a targeted physical exam, and, when indicated, select appropriate diagnostic testing. Patients should also be evaluated for associated urologic conditions, including male hypogonadism and lower urinary tract symptoms, the treatment of which may improve ED symptoms. It is also important that clinicians be aware that ED may be a “sentinel event” for undiagnosed cardiovascular disease as the implications of intervention can potentially be lifesaving.

              This review contains 7 figures, 10 tables and 138 references

              Key words: cardiovascular disease, Doppler ultrasonography, erectile dysfunction, hypogonadism, lower urinary tract symptoms, male impotence, metabolic syndrome, penile tumescence, Peyronie disease, premature ejaculation, sexual desire, testosterone

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            • 6

              Pediatric Renal Trauma

              By Douglas A Husmann, MD
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              Pediatric Renal Trauma

              • DOUGLAS A HUSMANN, MDAnson L Clark Professor of Urology, Mayo Clinic, Rochester MN

              This review addresses the new staging criteria applied to classify renal trauma accurately. We discuss the unique differences in the etiology and management of renal trauma between adults and children. The commentary defines the differences in managing low-, medium-, and high-velocity traumatic injuries compared with blunt renal trauma, and the criteria and methods used to screen for these injuries in children are provided. Absolute and relative indications for surgical exploration of traumatic renal injuries are examined. Management of the complications of acute and delayed renal hemorrhage, asymptomatic and symptomatic urinomas, chronic pain, and hypertension is discussed. Recommendations for physical activity following the traumatic loss of a kidney are reviewed.

              This review contains 10 figures, 7 tables and 49 references

              Key words: false aneurysm, hematuria, kidney, nonpenetrating wounds, penetrating wounds, renal hypertension, renal trauma, therapeutic embolization, traumatic shock, urinoma

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            • 7

              Role of Radiotherapy in Localized Prostate Cancer

              By Joelle Helou, MD, MSc; Andrew Loblaw, MD, MSc, FRCPC
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              Role of Radiotherapy in Localized Prostate Cancer

              • JOELLE HELOU, MD, MSCRadiation Oncologist, Radiation Medicine Program, Princess Margaret Cancer Centre; Department of Radiation Oncology, University of Toronto, Toronto, ON
              • ANDREW LOBLAW, MD, MSC, FRCPCRadiation Oncologist and Clinician Scientist, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre; Departments of Radiation Oncology and Health Policy, Measurement and Evaluation, University of Toronto, Toronto, ON

              Radiation is a standard treatment approach in the treatment of prostate cancer, in either a definitive or postoperative setting. There is mounting evidence of improved cancer outcomes with higher doses of radiation in all risk categories, including low-risk prostate cancer patients. Technical advances with the emergence of inverse planning intensity-modulated techniques combined with image guidance have allowed for dose escalation using external-beam radiation therapy (EBRT). However, despite more accurate treatment delivery, dose-escalated radiation has consistently translated into increased toxicity. Stereotactic body radiotherapy and brachytherapy offer great means of dose escalation to the prostate without increasing the dose to the surrounding organs. Radiation options for low-risk patients include hypofractionated EBRT and brachytherapy monotherapy. Intermediate-risk patients can be divided into favorable and unfavorable groups. For favorable-risk disease, monotherapeutic approaches could be considered, whereas for unfavorable intermediate-risk and high-risk disease, a combination of therapies must be considered. In the postoperative setting, adjuvant radiation improves biochemical outcomes in patients with adverse pathologic features (pT3 and/or positive margins).

              This review contains 2 figures, 5 tables, 1 video and 135 refereces

              Key words: prostate cancer, radiation therapy, brachytherapy, stereotactic ablative body radiation, hypofractionation, hormonal therapy

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            • 8

              Stress Urinary Incontinence Assessment and Conservative Treatments

              By Sidhartha Kalra, MD; Benjamin M Brucker, MD
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              Stress Urinary Incontinence Assessment and Conservative Treatments

              • SIDHARTHA KALRA, MD
              • BENJAMIN M BRUCKER, MD

              Stress urinary incontinence (SUI) is a prevailing condition affecting women’s physical, psychological, and social well-being. SUI is the most common type of urinary incontinence, with an estimated prevalence of 8 to 33%. Despite increased awareness, it is still commonly underreported. Identifying the problem and developing an individualized assessment and treatment plan are essential for achieving the best outcome and quality of life for these women. Numerous tools exist that may aid clinicians in making an appropriate diagnosis and then selecting the optimal treatment, including behavioral, medical, and surgical approaches. Although a plethora of treatment options exist for SUI, conservative management is considered an effective first-line option for most patients. The purpose of this review is to discuss the current understanding of SUI in women and to outline the evaluations and conservative management options with the best available scientific evidence.

              This review contains 3 highly rendered figures, 2 tables, and 57 references

              Key words: Stress Urinary Incontinence, Conservative management, Pelvic Floor Exercises, Pessary, Vaginal inserts, medical treatment

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            • 9

              Pathophysiology and Treatment of Infection Stones

              By Patrick T Gomella, MD, MPH; Patrick W Mufarrij, MD
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              Pathophysiology and Treatment of Infection Stones

              • PATRICK T GOMELLA, MD, MPH
              • PATRICK W MUFARRIJ, MD

              Infection stones are a well-known clinical entity that can cause significant long-term morbidity and even mortality if not treated appropriately. Infection stones are primarily composed of magnesium ammonium phosphate and calcium carbonate apatite. These stones form in alkaline urine containing ammonium. This environment is generated by infection with urease-producing organisms. Definitive treatment is aimed at removal of all stone. Percutaneous nephrolithotomy is typically the procedure of choice. Medical therapy can be used as an adjunct to surgery or as primary treatment in patients who are not surgical candidates.

              This review contains 8 highly rendered figures, 4 tables, and 72 references

              Key words: Infection stone; struvite; percutaneous nephrolithotomy; urease; dissolution therapy; magnesium ammonium phosphate; calcium carbonate apatite

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            • 10

              Nephrolithiasis in Pregnancy

              By Eric P Raffin, MD; Vernon M Pais Jr, MD
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              Nephrolithiasis in Pregnancy

              • ERIC P RAFFIN, MD
              • VERNON M PAIS JR, MD

              Nephrolithiasis is a common condition that practicing urologists will encounter and manage. The pregnant patient presents unique challenges when it comes to the diagnosis and treatment of stones. Altered anatomy and physiology, considerations of the fetus, and various imaging and procedural contraindications make navigating the care of pregnant patients with nephrolithiasis more complex than that of the general population. This review presents an algorithmic approach to the diagnosis and management of nephrolithiasis in the pregnant patient. Certain areas that are highlighted include diagnostic imaging modalities and the pros and cons of each with regard to the pregnant patient. Also discussed in detail are various treatment options, including medical management and available surgical interventions. As renal colic is the most common reason for nonobstetric hospitalization in pregnant women, it is important that they are managed with a multidisciplinary approach.

              This review contains 2 highly rendered figures, 4 tables, and 26 references

              Key words: low-dose CT, medical expulsive therapy, nephrolithiasis, obstructive hydronephrosis, percutaneous nephrostomy, physiologic hydronephrosis, pregnancy, renal colic, resistive index, ureteral stent, ureteroscopy

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            • 11

              Medical Management of Neurogenic Bladder

              By Anne P Cameron, MD, FRCSC, FPMRS; John T Stoffel, MD, FPMRS
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              Medical Management of Neurogenic Bladder

              • ANNE P CAMERON, MD, FRCSC, FPMRS
              • JOHN T STOFFEL, MD, FPMRS

              In the management of neurogenic bladder (NGB), the goals are first and foremost to protect the upper tract from damage. The second treatment goal is to maintain urinary continence, but all the while maintaining the patient’s quality of life. These goals are achieved by treating most patients with NGB in a targeted fashion based on urodynamic findings. Medical therapy optimization and appropriate bladder drainage are the cornerstones of NGB management. Detrusor overactivity, poor bladder compliance, and incontinence related to these are best initially managed with antimuscarinic agents,; however, there is an increasing role for the new beta3 agonists. In the event these therapies fail, botulinum toxin is often the next choice; however,  is an expensive treatment, and some patients may be treated with combination drug therapy. Nocturnal polyuria is also extremely common in this group of patients and is quite bothersome. After other risk factors have been excluded, medical treatment with desmopressin may be a suitable alternative.

              This review contains 3 highly rendered figures, 2 tables, and 85 references


              Key words: adrenergic alpha blockers, antimuscarinics, botulinum toxin, desmopressin, imipramine, mirabegron, multiple sclerosis, neurogenic bladder, spinal cord injury

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          • Otolaryngology
            • Ophthalmology
              • 1

                Eye and Orbit

                By Steven Patrick Davis, MD
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                Eye and Orbit

                • STEVEN PATRICK DAVIS, MDAssistant Professor, Clerkship Director, Department of Emergency Medicine, The George Washington University School of Medicine & Health Sciences, Washington, DC

                Pathologic conditions involving the eye and orbit can range from benign lesions to conditions resulting in vision loss and, potentially, death. These conditions may be difficult for the clinician to identify, as many manifest similarly on gross examination. This review presents the assessment and stabilization, diagnosis, treatment and disposition, and outcomes for 15 conditions affecting the eye and orbit. Figures include photographs of a chalazion, dacrocystitis and postoperative cellulitis, preseptal cellulitis, orbital cellulitis, epidemic keratoconjunctivitis, hyperacute conjunctivitis caused by Neisseria gonorrhoeae, corneal abrasions, varicella-zoster virus keratitis, dendritic herpes simplex virus keratitis, corneal ulcers, chemical keratitis, acute angle closure glaucoma, posterior vitreous detachment, and acute and superior retinal detachment. Tables list ocular pain and visual disturbance in ocular disease, common predisposing conditions in preseptal and orbital cellulitis, common ocular chemical exposures, common pharmacologic therapies in acute angle closure glaucoma, and common predisposing conditions in scleritis, episcleritis, and uveitis. Videos show visualization of detaching retinas by bedside ultrasound imaging.

                This review contains 23 highly rendered figures, 5 tables, 2 videos, and 88 references.

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