Latest Updates

Autism Spectrum Disorder and Cannabis

    • Autism spectrum disorder incidence has been increasing over the last few decades
    • Prenatal cannabis exposure has been implicated in some studies for detrimental effects; cannabis exposure may result in hypermethylation of genes required for neuronal development in the fetus
    • Conventional therapies for core and non-core symptoms are inadequate and often require polypharmacy
    • Cannabidiol has recently emerged as a promising candidate therapy for children and adolescents with autism spectrum disorder

Mechanical Ventilation: Respiratory Physiology and Conventional Ventilation

Lewis J Kaplan, MD, FACS, FCCM, FCCP, Adrian A. Maung, MD, FACS, FCCM
    • Berlin Modification of the definition of ARDS and PaO2/FIO2 ratio into mild (P/F < 300), moderate (P/F ratio < 200) and severe (P/F < 100)
    • The first ventilator, the iron lung, was developed in 1928 and extensively used in the 1940s during the polio epidemics. Nearly all current mechanical ventilators are positive-pressure ventilators; one negative-pressure ventilator is available but is primarily used for pulmonary toilet in patients with cystic fibrosis.
    • On a mechanical level, increases in PEEP move the zero-pressure point (ZPP) more proximally within the airway. Optimal PEEP is the PEEP that places the ZPP within a cartilaginous portion of the airway instead of a more distal, collapsible segment.

Systemic Vasculitis Syndromes

Brian F Mandell, MD, PhD, FACP, Alexandra Villa-Forte, MD, MPH
    • Therapy for cutaneous vasculitis is first directed at recognizing and eliminating any underlying precipitant. Infectious etiologies should be sought and treated. Potential offending drugs should be withdrawn. Association with myelodysplasia and myeloproliferative disease should be considered, especially if cytopenias or abnormal cell forms are evident on peripheral blood smear. 
    • Early reports of PAN and MPA did not adequately distinguish the two entities. It is now generally accepted that PAN is a rare disorder that is linked to arteritis of medium-sized muscular arteries; small vessels are unaffected, so purpura should not be present in patients with classic PAN.
    • The standard approach to the treatment of patients with potentially life-threatening systemic vasculitic syndromes has been to introduce therapy with a course of high-dose corticosteroids along with a second immunosuppressive agent to induce remission and then, depending on the disease, to gradually taper the corticoster­oids and continue immunosuppressive therapy with the safest effective immunosuppressant to maintain remission. The noncorticosteroid second agent may initially be cyclophosphamide, which is felt to be one of the most potent agents. 

Systemic Vasculitis Syndromes

Brian F Mandell, MD, PhD, FACP, Alexandra Villa-Forte, MD, MPH
    • Therapy for cutaneous vasculitis is first directed at recognizing and eliminating any underlying precipitant. Infectious etiologies should be sought and treated. Potential offending drugs should be withdrawn. Association with myelodysplasia and myeloproliferative disease should be considered, especially if cytopenias or abnormal cell forms are evident on peripheral blood smear. 
    • Early reports of PAN and MPA did not adequately distinguish the two entities. It is now generally accepted that PAN is a rare disorder that is linked to arteritis of medium-sized muscular arteries; small vessels are unaffected, so purpura should not be present in patients with classic PAN.
    • The standard approach to the treatment of patients with potentially life-threatening systemic vasculitic syndromes has been to introduce therapy with a course of high-dose corticosteroids along with a second immunosuppressive agent to induce remission and then, depending on the disease, to gradually taper the corticoster­oids and continue immunosuppressive therapy with the safest effective immunosuppressant to maintain remission. The noncorticosteroid second agent may initially be cyclophosphamide, which is felt to be one of the most potent agents. 

Lower Blepharoplasty

Branko Bojovic, MD, FACS, Martin Buta, MD, MBA
    • Modern eyelid surgery demands a tailored approach that recognizes anatomical, functional, and aesthetic characteristics that are particular to a patient’s age, gender, ethnicity, and medical history.
    • Fat conservation should guide any surgical treatment plan in order to achieve optimal revolumization of aged periorbital structures.
    • The transconjunctival approach to lower eyelid blepharoplasty can be augmented with fat transposition to recontour the lid-cheek junction and minimize or remove periorbital grooves and hollows.

Caustic and Toxic Ingestions

CDR Thomas Q Gallagher, DO, CDR Robert L Ricca, MD
    • Use of steroids in the medical and surgical management of caustic injuries
    • Button batteries as a source of caustic injury
    • Management of strictures secondary to caustic injury, including stent placement
    • Initial medical management of caustic injury
    • Surgical management of caustic injury

Important Infections Due To Molds

Jaime S Green, MD, Jo-Anne H. Young, MD, FACP
    • Diagnostic technology is evolving for mold infections, advancing to include β-d-glucan, nucleic acid, or antigen testing, although this may not be available at all centers.
    • There are three general classes of antifungal agents, and the specific class used for an individual infection differs depending on whether the need to treat is superficial or invasive infection and on the preference for an oral or an intravenous agent in a specific situation.
    • Therapeutic drug monitoring is becoming more common with advanced azole treatment courses.
    • The epidemiology of a mold species responsible for an individual infection may depend on previous exposure to and treatment with various antifungal agents.

Acute Liver Failure

Constantine J Karvellas, MD, SM, FRCPC, R. Todd Stravitz, MD, FACP, FACG, FAASLD
    • Improved intensive care management of patients with acute liver failure (ALF) has decreased the incidence of cerebral edema/intracranial hypertension
    • High-volume plasma exchange improves overall survival in patients with ALF
    • Improved understanding of the abnormalities of global hemostasis in patients with ALF
    • Improved sanitation and mass vaccination has decreased the incidence of ALF due to hepatotrophic viruses
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