Latest Updates

Chronic Kidney Failure and Dialysis

Raghu V Durvasula, MD, Jonathan Himmelfarb, MD
    • Studies in populations of European ancestry have identified a role for variants of the uromodulin (UMOD) gene in modulating the risk of developing CKD. Encoding Tamm-Horsfall protein, which is synthesized by tubular epithelial cells of the thick ascending limb, certain allelic variants of UMOD appear to confer a protective effect of developing CKD, with a reduced odds ratio of 0.76.
    • An alternative approach is to measure the urine protein-to-creatinine spot ratio, which detects all forms of protein present in the urine and eliminates potential imprecisions attributable to urinary concentration. A spot ratio greater than 0.2 is suggestive of underlying kidney injury.
    • The gold standard for hemodialysis access remains the AV fistula, which is surgically created by connecting an artery directly to a vein, typically in the arm. AV fistulas remain superior to other forms of dialysis access and are associated with higher achieved clearance, longer patency rates, fewer infectious complications, and overall greater patient sense of well-being.

Chronic Kidney Failure and Dialysis

Raghu V Durvasula, MD, Jonathan Himmelfarb, MD
    • Studies in populations of European ancestry have identified a role for variants of the uromodulin (UMOD) gene in modulating the risk of developing CKD. Encoding Tamm-Horsfall protein, which is synthesized by tubular epithelial cells of the thick ascending limb, certain allelic variants of UMOD appear to confer a protective effect of developing CKD, with a reduced odds ratio of 0.76.
    • An alternative approach is to measure the urine protein-to-creatinine spot ratio, which detects all forms of protein present in the urine and eliminates potential imprecisions attributable to urinary concentration. A spot ratio greater than 0.2 is suggestive of underlying kidney injury.
    • The gold standard for hemodialysis access remains the AV fistula, which is surgically created by connecting an artery directly to a vein, typically in the arm. AV fistulas remain superior to other forms of dialysis access and are associated with higher achieved clearance, longer patency rates, fewer infectious complications, and overall greater patient sense of well-being.

Diagnosis of Diabetic Foot

Anil Hingorani, MD, FACS
    • Development of guidelines for diagnosis and treatment of diabetic foot to help codify worldwide data across various specialties involved with diabetic foot 
    • Magnetic resonance angiography (MRA) and spiral CT angiography (CTA) have been proposed as alternatives to invasive angiography in the evaluation of vascular occlusive disease
    • Currently, it is clear that resistant organisms, particularly methicillin-resistant Staphylococcus aureus (MRSA), are playing a growing role in the development of skin and soft tissue infections. Traditionally arising in patients who had previously been hospitalized and those who had previously received antibiotic therapy, MRSA-associated infections are now frequently encountered in outpatient settings

Diagnosis of Diabetic Foot

Anil Hingorani, MD, FACS
    • Development of guidelines for diagnosis and treatment of diabetic foot to help codify worldwide data across various specialties involved with diabetic foot 
    • Magnetic resonance angiography (MRA) and spiral CT angiography (CTA) have been proposed as alternatives to invasive angiography in the evaluation of vascular occlusive disease
    • Currently, it is clear that resistant organisms, particularly methicillin-resistant Staphylococcus aureus (MRSA), are playing a growing role in the development of skin and soft tissue infections. Traditionally arising in patients who had previously been hospitalized and those who had previously received antibiotic therapy, MRSA-associated infections are now frequently encountered in outpatient settings

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. 
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