What's New | Decker

Patients with borderline resectable pancreatic adenocarcinoma who are able to undergo successful resection may have survival comparable to patients with resectable disease.
For patients with locally advanced pancreatic adenocarcinoma, neoadjuvant FOLFIRINOX may allow up to 61% of patients to undergo successful resection.
For patients with resectable pancreatic adenocarcinoma and a positive intraoperative frozen section, additional resection to achieve a negative neck margin after a positive frozen section may not be associated with improved overall survival.

The 2003 Rotterdam criteria are more broadly inclusive than the NIH criteria, allowing improved sensitivity for PCOS diagnosis. Diagnosis by the Rotterdam criteria requires the presence of two of the following three conditions: (1) hyperandrogenism, (2) oligo-ovulation, and (3) a classic PCOM described as evidence of any one or both of the following in either ovary: (1) presence of 12 or more follicles measuring 2 to 9 mm in diameter [see Figure 1] and/or (2) an increased ovarian volume (> 10 mL) in the absence of a dominant follicle or corpus luteum in either ovary.
The goals of evaluation are to (1) determine the source of hyperandrogenism (i.e., adrenal or ovarian), (2) assess the severity of androgen excess, (3) rule out an adrenal or ovarian tumor, and (4) screen for metabolic accompaniments of PCOS, including insulin resistance and the MetS.
Spironolactone, an aldosterone antagonist, has demonstrated efficacy against acne and hirsutism associated with PCOS. The antiandrogenic effects of spironolactone are attributed to (1) reduced adrenal androgen production, (2) competitive blockade on androgen receptors in target tissue, and (3) some degree of suppression of 5a-reductase, the enzyme responsible for conversion of testosterone to a more potent androgen dihydrotestosterone.

The 2003 Rotterdam criteria are more broadly inclusive than the NIH criteria, allowing improved sensitivity for PCOS diagnosis. Diagnosis by the Rotterdam criteria requires the presence of two of the following three conditions: (1) hyperandrogenism, (2) oligo-ovulation, and (3) a classic PCOM described as evidence of any one or both of the following in either ovary: (1) presence of 12 or more follicles measuring 2 to 9 mm in diameter [see Figure 1] and/or (2) an increased ovarian volume (> 10 mL) in the absence of a dominant follicle or corpus luteum in either ovary.
The goals of evaluation are to (1) determine the source of hyperandrogenism (i.e., adrenal or ovarian), (2) assess the severity of androgen excess, (3) rule out an adrenal or ovarian tumor, and (4) screen for metabolic accompaniments of PCOS, including insulin resistance and the MetS.
Spironolactone, an aldosterone antagonist, has demonstrated efficacy against acne and hirsutism associated with PCOS. The antiandrogenic effects of spironolactone are attributed to (1) reduced adrenal androgen production, (2) competitive blockade on androgen receptors in target tissue, and (3) some degree of suppression of 5a-reductase, the enzyme responsible for conversion of testosterone to a more potent androgen dihydrotestosterone.

Hydrochlorothiazide is not beneficial in treating ICU-acquired hypernatremia
Hypernatremia after hypertonic saline irrigation is rare, but might cause severe complications
Hypercalcemia induces targeted autophagic degradation of aquaporin-2 at the onset of nephrogenic diabetes insipidus
Hypernatremia identified as new predictor of worse clinical outcomes after percutaneous endoscopic gastrostomy placement

Jennifer A Johnson, MD, Daniel R Kuritzkes, MD, FACP

Treatment as prevention reduces the risk of HIV transmission by at least 96%.
Preexposure prophylaxis, either as oral or injectable formulations , may reduce the risk of HIV acquisition by more than 90% when taken with good adherence.
Postexposure prophylaxis reduces the risk of HIV acquisition by at least 80%.
Combination antiretroviral therapy reduces the risk of mother-to-child transmission of HIV to less than 1%.
Risk reduction counseling and barrier protection remain important components of the HIV prevention toolkit.

Updating consensus guideline recommendations up to January 2016
Adding a duplex scan image showing a deep vein thrombosis (DVT) in the diagnosis section
Adding a computed tomographic (CT) scan showing a pulmonary embolism (PE)
Showing the various types of approved inferior vena cava filters
Adding five separate flow-chart figures depicting a stepwise management algorithm for the evaluation and treatment of DVT and PE
Adding a section on catheter-associated upper extremity thrombosis
Adding a section on extended prophylaxis, the use of non–vitamin K antagonists, updates on stockings
Writing five new multiple-choice questions based on the review

Molecular tests for gene point mutations, insertions, deletions, fusions and expression alterations are available that can be used to help risk stratify intermediate risk differentiated thyroid cancers into either surgical management or observation .
Stage IV anaplastic thyroid cancer requires aggressive approach for complete resection and prompt transition to adjuvant definitive-intention therapy to attain long-term survival.
Radiofrequency ablation (RFA) is being studied in clinical trials as alternative to high risk surgical patients and selected benign thyroid nodules.
To avoid neck scar, consider robotic thyroidectomy with approaches including trans axillary (most common), bilateral axilla-breast, retro auricular, and transoral (requires CO2 gas insufflation, not a “clean” procedure) approaches for patients with indeterminate, likely benign lesions if BMI <35.
Transoral endoscopic thyroidectomy can be considered for patients with a thyroid mass without evidence of lymph node metastases as retrospective review of 422 patients did not demonstrate significant difference in complications compared to open thyroidectomy group.

There is a shift to change the definition of massive transfusion to focus on units per time as opposed to total units administered.
While laparotomy is still considered the gold standard treatment for gunshot wounds to the abdomen, selective NOM of penetrating abdominal wounds is possible. NOM can only be performed in centers that have the staffing and resources to perform serial examinations and the ability to take the patient to the OR at any time should they decompensate.
Resuscitation of the trauma patient, like much of critical care, is a sophisticated art of balancing the needs of competing organ systems in a patient with multiple injuries. Resuscitation of the trauma patient focuses on prevention of the lethal triad of trauma and secondary injury. The term refers to a triad of acidosis, coagulopathy, and hypothermia resulting from injury and blood loss.

General Surgery