Latest Updates

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.

Psychiatric Diseases in Pregnancy

    • In March 2019, the U.S. Food and Drug Administration approved Zulresso (Brexanolone) injection for intravenous (IV) use for the treatment of postpartum depression (PPD) in adult women. This is the first drug approved by the FDA specifically for treatment of PPD and is currently available only under a restricted distribution program due to concerns about serious risks including excessive sedation or sudden loss of consciousness during administration. Specific restrictions and requirements are planned to be detailed on the medication’s associated black box warning label. 
    • All women should be screened multiple times during pregnancy and in the postpartum period for depression, regardless of their risk factors or medical history. Many tools such as the Edinburgh Postnatal Depression Scale form are available to assist in screening.
    • When considering intrapartum pain management in women with opioid use disorder, it is important to avoid drugs with an opioid antagonist component, such as nalbuphine, as this can precipitate withdrawal symptoms. Use of other medications such as NSAIDs can reduce the amount of opioids required.
    • The effect of marijuana use in pregnancy is unclear, as studies are confounded due to co-existing mental health disorders, socioeconomic status, parental education, and cigarette smoking. Despite these limitations, several studies have demonstrated an association with preterm labor, low birth weight, NICU admission, and stillbirth. As with any drug of abuse, abstinence during pregnancy should be encouraged.

Thyroiditis, Goiter, Thyroid Nodules, and Thyroid Cancer

Paul W. Ladenson, MD
    • 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum
    • 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis.

Thyroiditis, Goiter, Thyroid Nodules, and Thyroid Cancer

Paul W. Ladenson, MD
    • 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum
    • 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis.
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