Latest Updates

Metabolic Response to Critical Illness - Part 2

Palmer Q. Bessey, MD
    • Use of growth hormone for manipulation of metabolic response and muscle characteristics. This in combination with early physical therapy/exercise aids in preservation.
    • Anti-cytokine antibodies for partial attenuation of metabolic response. These approaches have elucidated the complexity of mechanisms leading to the metabolic response of critically ill patients.
    • Relatively recent adoption of the important role of the gut in metabolic response. This includes production of mediators and functioning as a barrier to bacteria which dramatically affect severity of metabolic response.

Urogenital Fistulas and Female Urethral Diverticula

    •  For iatrogenic vesicovaginal fistula, delaying repair until healing has occurred is no longer mandatory, and outcomes for immediate repair are comparable to delayed repairs. 
    •  Concomitant stress incontinence surgery with autologous fascial pubovaginal sling at the same time as repair of complex urethral diverticula appears to be safe and effective.
    • MRI is a valuable tool for surgical planning and is recommended prior to urethral diverticulectomy.

Medications and Botulinum Toxin for Overactive Bladder

    • Emerging role of beta agonist therapy for treatment of OAB
    • The pharmacologic use of onabotulinumtoxinA (Botox®) upgraded to strongest rating of “standard" (strength of evidence grade B) by the amended 2014 AUA/SUFU guidelines.
    • Studies reporting trigonal injections of Botox may be associated with superior continence rates

Pneumonia and other Pulmonary Infections

Scott A. Fruhan, MD, MBA, Karen D. Serrano, MD
    • Pneumonia is caused by a variety of infectious agents, including bacteria, viruses, and fungi. The diagnosis of pneumonia is determined based on a combination of clinical features and radiographic studies.
    • Providers should identify patients at risk for health care–associated pneumonia or infection with resistant organisms. 
    • Tuberculosis has both active and latent forms, which are treated with different antibiotic regimens. Definitive diagnosis requires either acid-fast bacilli smear and culture or nucleic acid amplification testing of sputum.

Viral Upper Respiratory Infection

James Creswell Simpson, MD, Kristin H. Dwyer, MD, MPH
    • Adult epiglottitis has reported mortality between 7 and 20%. A high index of suspicion is recommended in patients who are stridorous, are drooling, or have odynophagia. Airway control is critical; the airway should be secured early and under controlled conditions, with personnel and equipment for surgical airway readily available. Orotracheal intubation or tracheostomy can both trigger a sudden loss of airway, and bag-mask ventilation may worsen airway obstruction. These patients require emergent otolaryngology consultation, and the emergency physician must be prepared to establish a definitive airway. Patients should never be left unmonitored and should be kept sitting up to maximize airway patency. 

Kidney Biopsy

Gearoid McMahon, MD, Adina Voiculescu, MD
    • Summarizes different indications
    • Helps select most appropriate technique of biopsy
    • Summarizes type and frequency of complications
    • Gives guidance for treatment of complications

Physiologic and Anatomic Changes during Pregnancy

    • A recent study using MRI demonstrated that left uterine displacement of at least 30° (not 15° as previously taught) is needed to relieve aortocaval compression.
    • Pharyngeal volume decreases while airway Mallampati class increases throughout labor, which may contribute to increased risk of difficult intubation throughout labor.
    • Thrombocytopenia commonly occurs in parturients, but the risk of spinal-epidural hematoma is exceedingly low.

Gastrointestinal Diseases in Pregnancy

Jennifer X Cai, MD, MPH, Punyanganie S. de Silva, MBBS, MPH, MRCP(UK)
    • Most inflammatory bowel disease medications, including biologics are safe during pregnancy.
    • Based on recent studies, proton pump inhibitors (PPI) are generally considered to be safe in pregnant women and are usually reserved as second line treatment for GERD complications or for women who did not respond to previous treatments.
    • Polyethylene glycol PEG as a low-risk drug and the preferred drug for chronic constipation in pregnancies.
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