Latest Updates

Delirium In The Emergency Department: Diagnosis, Evaluation, And Management

Maura Kennedy, MD, MPH
    • Confusion Assessment Method for delirium diagnosis: the first diagnostic tool to operationalize the DSM definition of delirium; currently the most widely used tool for delirium diagnosis; validated in numerous clinical settings and languages and adapted for use in the ICU.
    • Delirium Triage Screen (DTS): the only delirium tool developed for use in the emergency setting; consists of two questions assessing attention and level of arousal/consciousness using the Richmond Agitation Sedation Scale. The DTS can reliably exclude delirium in a matter of seconds; patients with a positive DTS screen should undergo a secondary screening with a test with greater specificity.
    • Delirium prevention decreases the morbidity, mortality, and health care costs for hospitalized patients. The Hospital Elder Life Program is a multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine was the first successful nonpharmacologic delirium prevention program and addressed reorientation, sleep protocols, mobility, and hearing and visual impairments. A recent meta-analysis demonstrated that multicomponent nonpharmacologic programs are effective in delirium prevention in medical and surgical inpatient settings.

Late Stage Prostate Cancer

Karthik Giridhar, MD, Manish Kohli, MD
    • Emphasis on landmark clinical trials in metastatic prostate cancer (especially since 2010)
    • Critical analysis and summary of PSA-based prostate cancer screening
    • Advances and integration of genomic sciences in early and advanced stages of prostate cancer

Minimally Invasive Approaches in Liver Surgery

Melissa E Hogg, MD, MS, FACS, Waseem Lutfi, BS
    • Evidence of improved outcomes following laparoscopic liver surgery
    • Robotic versus laparoscopic liver surgery outcomes
    • Retrospective studies with long-term follow-up are now being published, and early indications point to oncologic equivalence of minimally invasive approaches compared to open approaches for liver surgery.
    • No randomized clinical trials have yet been published comparing minimally invasive and open approaches for liver surgery.

Wound Management and the Utility of Adjunctive Technologies in Diabetic Limb Salvage

Tammer Elmarsafi, DPM, MBBCh, John S Steinberg, DPM, FACFAS
    • The use of combined hydrosurgical debridement and methylene blue indicator effectively reduces wound biofilm.
    • Negative-pressure wound therapy with instillation is an important innovation, which improves wound management outcomes.
    • Collagen-based allografts are helpful adjunctive therapies which can improve clinical outcomes in the complex host.
    • Mesenchymal stem cell–based allografts may provide nonsurgical patients with alternative options.
    • Split-thickness skin grafts and alternative methods for wound coverage should be part of the surgical plan.

The Natural History Of Chronic Liver Disease

Esperance A K Schaefer, MD, MPH
    • Further subclassification of “compensated” versus “decompensated” cirrhosis yields increased prognostic accuracy
    • The concept of acute-on-chronic liver failure has emerged as a distinct clinical state with particularly poor survival
    • Advances in techniques in liver transplantation have resulted in improved survival, but geographic disparities in organ availability and a universal shortage in organs result in a continued high mortality from end-stage liver disease

Constipation: Diagnosis and Investigation 

Charles H Knowles, MBBChir, PhD, FRCS
    • Publication of the Rome IV guidelines regarding classification of functional constipation and irritable bowel syndrome.
    • Publication of key studies questioning the diagnostic accuracy of anorectal manometry alone in the diagnosis of pelvic floor dyssynergia, with subsequent changes in Rome IV diagnostic criteria.
    • Increasing ability to directly measure, and thus recognize, the complexity of higher mammalian colonic contractile motor patterns with new understanding that in most patients, chronic constipation (CC) is more likely a problem of dysregulated (even perhaps increased) rather than decreased motor activity.
    • A general move away from silo investigation and management of CC that acknowledges the interface between gastroenterologist and colorectal surgeon, and colorectal surgeon and urogynecologist.

Pathophysiology of the Diabetic Foot

Paul J Kim, DPM, MS
    • There is now consensus that a multidisciplinary approach is needed for diabetic foot ulcer management.
    • The classic soft tissue reconstructive ladder is disrupted by technologies including negative pressure wound therapy and biological scaffolds.
    • An emphasis in correcting biomechanical abnormalities is being widely adopted.

Constipation: Medical and Surgical Treatment

Charles H Knowles, MBBChir, PhD, FRCS
    • Development and rigorous trialing of new drugs with specific effects on motility (prokinetics) and colonic secretory activity (secretogogues).
    • Key publication of US-wide retrospective cohort data identifying high surgical morbidity and increased health utilization after colectomy for constipation.
    • Recent ascendancy of laparoscopic ventral mesh rectopexy as the favored procedure for internal rectal prolapse (intussusception).
    • Decline of sacral nerve stimulation as a treatment for chronic constipation following two negative multicenter randomized trials.
    • Publication of UK-led high-quality systematic reviews of all main surgical approaches to treating chronic constipation with summary evidence statements and European consensus leading to graded practice recommendations.
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