Latest Updates

Urothelial Carcinoma: Epidemiology, Pathogenesis, and Diagnosis

Ryan Hutchinson, MD, Yair Lotan, MD
    • Restrictions and bans on environmental, industrial and herbal medicine-related carcinogenic agents have largely eliminated these agents as drivers for urothelial cancers in industrialized countries; tobacco smoking remains the primary driver of bladder tumors in these countries.
    • The diagnosis and management of urothelial carcinomas are rapidly evolving with urine- and blood-based biomarkers in development to diagnose and monitor patients with bladder tumors.
    • Multimodality therapies including minimally invasive tumor resection and topical chemotherapy allow a majority of patients with bladder cancer to receive organ-sparing approaches.

Facial Transplantation

Mario A Aycart, MD, Bohdan Pomahac, MD
    • The Department of Health and Human Services redefined facial allografts as organs, rather than tissues.
    • There has been at least one reported case of chronic rejection in facial transplant recipients.
    • Successful transplantation and management of antibody-mediated acute rejection in a highly sensitized patient.

Determining Protein Requirements In The Acutely Ill Patient

L John Hoffer, MD, PhD
    • Explains the physiologic basis of protein requirements, how they are determined in normal health, and the ways acute and critical illness increase them
    • Explains and reconciles a current controversy over the amount of protein to provide to acutely ill patients
    • Explains the clinical information and physiologic reasoning necessary to choose the appropriate amount of protein to provide to an acutely ill patient

Urologic Infections

Nisa S Atigapramoj, MD, Tatyana Vayngortin, MD
    • UTI evaluation and management varies by age; rapid diagnosis and treatment prevents complications; infants may present solely with fever
    • Most common uropathogen is Escherichia coli (85%). Other pathogens include gram-negative bacteria and more rarely gram-positive bacteria
    • Antibiotic treatment should be based on local antibiograms plus individual patient risk factors and history
    • Indications for inpatient admission include: age under 2 months, sepsis, vomiting/inability to tolerate oral antibiotics, infection with a multidrug-resistant organism, immunocompromised state, a complicated social situation, or risk of no follow up
    • Risk factors for UTI in infants include age <12 months, uncircumcised males, temperature >39°C. Risk factors in adults include pregnancy, sexual activity, immunosuppression, urologic abnormalities or obstruction, long-term urinary catheter, neurogenic bladder, urinary incontinence

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.

Alterations In Macronutrient ­Metabolism In Starvation And Disease

L John Hoffer, MD, PhD
    • An explanation of the physiology of starvation and its progression to the disease called protein-energy malnutrition, with consideration of the modifying effects of metabolic adaptation and systemic inflammation and the roles they play in the clinical setting
    • Current definitions and explanations of important but frequently misunderstood terms related to starvation and its modifiers and consequences
    • A succinct explanation of the physiology of total fasting and its clinical correlates  
    • An explanation of the interactions among starvation, sarcopenia, frailty, involuntary weight loss, systemic inflammation, cachexia, and disuse muscle atrophy. Inadequate appreciation of these interactions can result in failure to diagnose and treat starvation-induced diseases.

Anxiolytics

Gurjit Bains, PharmD Candidate, Shadi Doroudgar, PharMD, BCPS, CGP, BCPP
    • γ-aminobutyric acid, serotonin, and norepinephrine are neurotransmitters implicated in anxiety disorders.
    • Benzodiazepines are useful for short-term treatment of anxiety disorders.
    • First-line medication treatment options typically consist of antidepressants; however, the time to full therapeutic effect is delayed.
    • Alternative pharmacologic treatment options such as buspirone are also available for the treatment of anxiety.
    • Non–FDA-approved treatments are also utilized, and other treatments options are gaining recognition for benefit in anxiety disorders as well.

Behavior Modification In The Treatment Of Obesity

Paul Davidson, PhD
    • Weight loss interventions are most successful when they involve an integrated approach including behavioral, dietary, and exercise components. The more often a patient is seen, the better the results.
    • In primary care practice, the 5As model of intervention, including the Assess, Advise, Agree, Assist, and Arrange steps, has been empirically validated and recommended as effective in treating overweight and obesity.
    • Both the comprehensiveness of behavioral skills and the quantity of treatment sessions are linked to improved outcomes.
    • Individualized plans and participation in small-group treatment have been shown to lead to greater success with weight loss.
    • Patients who demonstrate greater internal motivation, self-efficacy, and ability to regulate their eating tend to be more successful with weight loss and exercise within the first year.
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