Latest Updates

Seronegative Spondyloarthritis: Diagnosis And Management

Walter P Maksymowych, MB, ChB, FRCP (UK), FRCPC, FACP
    • The combined use of T1-weighted MRI with a water-sensitive MRI sequence significantly enhances early detection of spondyloarthritis, identifies patients responsive to therapeutic intervention with tumor necrosis factor inhibitors (TNFIs), and constitutes a key prognostic factor for structural progression.
    • Treatment of patients with TNFI early in the disease course when radiographic sacroiliitis is not yet evident is highly effective, especially in patients with an elevated C-reactive protein and/or features of inflammation on MRI.
    • Treatment targeting interleukin-17 is an effective new treatment option for patients with spondyloarthritis, especially in the setting of concomitant psoriasis.  
    • Imaging recommendations that allow for precision in diagnosis.

Cardiovascular System: Heart Diseases

    • MRI safe devices and leads: older implanted devices were considered an absolute contraindication for MRI, depriving patients of the benefits of this important diagnostic imaging modality. Although many of the fears of device malfunction during MRI have been shown to be unfounded, newer devices and leads have been manufactured to ensure safety within the MRI scanner.
    • Leadless pacemakers: a recent innovation is the implantation of miniaturised pacemakers directly into the myocardium, avoiding the need for pacemaker leads.
    • Recent studies suggest improved outcomes by novel cardiac resynchronization therapy pacing modes (LV only modes).
    • Device innovation for MAZE procedures: technologic advances allow reduction of invasiveness of MAZE procedures, such as robotic-assisted procedures, or translate advances in energy delivery developed in transcatheter ablations to the surgical world (cryoMAZE).

Anesthesia for Urologic Surgery

Dan B Ellis, MD, Anton Wintner, MD
    • Transurethral resection of the prostate (TURP) is a common technique to treat benign prostatic hypertrophy. However, it may be associated with significant fluid absorption and result in TUR syndrome. Previously a source of significant morbidity following TURP, TUR is characterized by altered mental status, hypertension, nausea, vomiting, and cerebral edema. Fortunately, a change in surgical technique and a change in the irrigant used in the procedure can minimize its occurrence.
    • Extracorporeal shockwave lithotripsy (ESWL) and cystoscopy or ureteroscopy with laser lithotripsy are effective ways to treat obstructing ureteral stones. ESWL and cystoscopy or ureteroscopy have replaced previous techniques that required patients to be submerged in water.
    • Percutaneous ultrasonic lithotripsy is an effective yet more invasive approach to complex kidney stones that cannot be addressed using ESWL or cystoscopy or ureteroscopy. Although percutaneous ultrasonic lithotripsy can be highly effective, it is significantly more invasive as it requires a flank incision.

Recurrent Urinary Tract Infections

    • In simple recurrent UTIs, urologic investigation beyond urine cultures may not be warranted.
    • High risk patients warranting imaging or cystoscopy include hematuria, obstructive symptoms, structural abnormalities and immunocompromised.
    • Behavioral changes, cranberry, probiotics, oral estrogens don’t reduce uti’s, vaginal estrogen does in postmenopausal women.
    • Three strategies for antibiotic prevention: (1) low-dose daily  (2) postcoital (3) patient-initiated treatment.
    • 6-12 months of any prophylaxis (and vaginal estrogen >65 yo) reduces UTIs.  UTIs return when antibiotics stop.

Pharmacologic Differences in Children

Raymond Park, MD, Lauren Kelly Ugarte, MA, MD
    • There is increasing focus on the impact of anesthetic medication effects on the developing brain with a goal to improve patient safety.
    • Dexmedetomidine is one particular medication found to confer protection to the developing brain in the anesthesia setting and will likely have increasing clinical applications for the pediatric anesthesiologist.
    • Technology and innovative engineering have led to the development and application of tools to improve pediatric patient compliance with anesthesia-related procedures such as needleless medication delivery systems to aid in painless IV placement and the use of small electronics as distraction for mask induction.

The Post-Anesthesia Care Unit

Evan R Bohnenblust, MD
    • When proper monitoring and dosage is used, the incidence of residual neuromuscular blockade is greatly reduced when sugammadex is administered as a reversal agent. (Brueckmann B, Sasaki N, Grobara P, et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth 2015;115:743–51).
    • In patients who have undergone neuraxial anesthesia for lower extremity joint surgery, fast-track discharge from PACU (discharge prior to return of motor function) may significantly reduce total PACU time and is not associated with increased length of stay or 30-day readmission. (Aasvang EK, Jørgensen CC, Laursen MB. Safety aspects of postanesthesia care unit discharge without motor function assessment after spinal anesthesia: a randomized, multicenter, semiblinded, noninferiority, controlled trial. Anesthesiology 2017;126:1043–52).
    • Important risk factors for early PACU delirium may include age, male gender, longer preoperative fasting, higher ASA score, the use of benzodiazepines, opioids, and volatile anesthetics, and transfusion of red blood cells or fresh frozen plasma (Hernandez BA, Lindroth H, Rowley P, et al. Post-anaesthesia care unit delirium: incidence, risk factors and associated adverse outcomes. Br J Anaesth 2017;119:288–90).
    • In patients undergoing major intra-abdominal surgery, the Surgical Apgar Score may provide an objective scoring system to predict the need for postoperative ICU admission (Sobol JB, Gershengorn HB, Wunsch H, et al. The surgical Apgar score is strongly associated with intensive care unit admission after high-risk intraabdominal surgery. Anesth Analg 2013;117:438–46).

Carotid Endarterectomy

Louisa Palmer, MD, Amanda Widing, MD,1 PGY-3 Resident
    • Increased focus on patient selection with respect to 3- to 5-year predicted survival
    • Improvement in medical management including preoperative optimization and updated decision support for preoperative cardiac testing
    • Improvement in outcomes after carotid artery stenting makes it a reasonable alternative to carotid endarterectomy
    • Increased prevalence of ultrasound-guided techniques for deep and superficial cervical plexus block
    • Investigation of use of transcranial Doppler for detection of carotid thrombosis and early hyperperfusion syndrome

Nonpulmonary Thoracic Procedures

Jaida C Fitzgerald, MD
    • Compared to open surgery, minimally invasive surgical approaches for esophagectomy have been associated with less blood loss as well as shorter length of stay at intensive care unit and the hospital.
    • Implementation of thoracic epidural analgesia for post esophagectomy pain control has been shown to result in earlier mobilization, decreased incidence of pulmonary complications, and decreased incidence of anastomotic leaks.
    • There is a decreased incidence of respiratory complications with the intraoperative use of lung protective strategies during esophagectomy.
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