bluuebunny/crossref_metadata_2025 huggingface dataset:
Principles in Reconstruction after Resection of Extremity and Truncal Sarcomas
Authors: Nelson Jonas A. , Matros Evan
Published: January 2021

Reconstruction of sarcoma defects of the trunk or extremity requires detailed understanding of a variety of techniques for wound closure. Advances in reconstruction and oncologic treatment have led to higher rates of limb salvage in patients who would have previously undergone amputation. Such defects often require consideration of the reconstructive ladder, moving from the most simplistic closure to free flaps. As previous surgeries or radiation therapy can create a challenging wound environment with scar and fibrosed tissues, at times the more complex up-front option will be a better long-term solution for a patient following sarcoma resection. A multidisciplinary approach to the initial management, resection, and reconstruction is certainly warranted to attain the best overall outcome for the patient from the oncologic and aesthetic standpoint. This review provides an overview of the reconstructive techniques employed in addressing defects of the trunk and extremities following sarcoma resection.
This review contains 20 Figures and 30 References. 
Key words: abdominal wall reconstruction, chest wall reconstruction, free flap, lower extremity reconstruction, pedicled flap, propeller flap, reconstructive elevator, reconstructive ladder, upper extremity reconstruction
Adjuvant Radiation for Tissue Extremity and Truncal Sarcomas
Authors: Wasif Nabil , Qu Melody
Published: January 2021

In this review, we cover the clinical use of radiation therapy in the treatment of soft tissue extremity and truncal sarcomas. After a brief overview of the seminal trials establishing the efficacy of radiation therapy as a component of limb-preserving therapy, we cover current indications for use and discuss when radiation therapy can be withheld without compromising oncologic outcomes. Controversies in treatment sequencing with surgery are fleshed out with pros and cons for both pre- and postoperative treatment. Finally, different modalities of radiation therapy are discussed and common toxicities are covered.

This review contains 3 figures, 1 table and 41 references
Key words: brachytherapy, limb preservation, neoadjuvant therapy, radiation therapy, soft tissue sarcoma
On Being A Physician
Authors: Nabel Elizabeth G
Published: January 2021

The role of a physician as healer has grown more complex, and emphasis will increasingly be on patient and family-centric care. Physicians must provide compassionate, appropriate, and effective patient care by demonstrating competence in the attributes that are essential to successful medical practice. Beyond simply gaining medical knowledge, modern physicians embrace lifelong learning and need effective interpersonal and communication skills. Medical professionalism encompasses multiple attributes, and physicians are increasingly becoming part of a larger health care team. To ensure that physicians are trained in an environment that fosters innovation and alleviates administrative burdens, the Accreditation Council for Graduate Medical Education has recently revamped the standards of accreditation for today’s more than 130 specialties and subspecialties.
This review contains six references.
General Approach to the Poisoned Patient
Authors: Gordon Emily , Bird Steven B
Published: January 2021

Poisoning and ingestions constitute an increasing amount of morbidity and mortality nationwide. According to the American Association of Poison Control Centers (AAPCC), 2.2 million exposures were reported in 2013, and ingestions are currently the leading cause of injury-related death in the United States. Exposures include intentional overdose or suicide attempts, accidental overdose in drug abusers or children, and work-related injuries or acts of terrorism. According to the AAPCC, 50% of exposures are in children less than 5 years old and 80% of exposures are unintentional. When it comes to the unstable undifferentiated and possibly poisoned patient, one must take a stepwise approach similar to that for any critically ill patient, This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of poisoning. Figures show The Full Outline of Unresponsiveness (FOUR) scale, a patient with methemoglobinemia, a hand with scaling due to mercury poisoning, an electrocardiogram with examples of QT prolongation and QRS widening, and an electrocardiogram of bidirectional ventricular tachycardia, pathognomonic of digitalis glycoside poisoning. Tables list a stepwise approach to a potentially poisoned patient, a general approach to the poisoned patient,  heart rate, toxidromes, anticholinergic toxidrome, cholinergic toxidrome, Glasgow Coma Scale, toxins and associated odors, electrocardiogram findings, causes of anion-gap metabolic acidosis, and antidotes. 

This review contains 5 highly rendered figures, 13 tables, and 23 references

Key words: Poison ingestion, Accidental poisoning, Toxidrome, Accidental overdose
Gallstones and Biliary Tract Emergencies
Authors: Lobon Luis F. , Billington Michael
Published: January 2021

Patients with diseases of the biliary tract (which includes the hepatic bili canaliculi, hepatic bile ducts, common bile duct, and gallbladder) typically present with symptoms that include abdominal pain, nausea, vomiting, and jaundice. This review covers the pathophysiology, assessment and stabilization, diagnosis and treatment, and disposition and outcomes for common biliary tract emergencies (cholelithiasis, acute cholecystitis, choledocholithiasis, and ascending cholangitis). 
This review contains 5 figures, 11 tables, and 34 references.
Keywords: Cholelithiasis, gallbladder disease, acute cholecystitis, gallstones, choledocholithiasis, ascending cholangitis
Integrating Principles and Practice of Palliative Medicine in Emergency Care
Authors: O’Malley Patricia J.
Published: January 2021

Trajectories of serious illness and dying have changed in the last century; people now live longer, often with prolonged debility in advanced stages of illness. With more options for aggressive interventions at the end of life, patients and families face increasingly complex medical decisions. Many of these patients will present repeatedly to the emergency department (ED) before their death, and emerging evidence suggests that integrating palliative care into the treatment of advanced illness, including in the emergency setting, can improve outcomes. This review covers changing trajectories of illness and death, palliative care as a medical specialty, emerging models of integration, essential palliative care competencies for the ED clinician, and managing the actively dying patient in the ED. Figures show palliative care through the trajectory of serious illness, theoretical trajectories of disease, life expectancies for women and men, and patient-centered communication. Tables list philosophy of palliative care, domains of suffering addressed by palliative care, palliative performance scale, NURSE mnemonic for accepting and responding to emotion, palliative care communication competencies in the intensive care unit: effect on clinical outcomes and family satisfaction, and SPIKES mnemonic for breaking bad news.
 
This review contains 4 highly rendered figures, 6 tables, and 113 references
Unstable Angina and Non-ST Segment Elevation Acute Coronary Syndrome
Authors: Blomkalns Andra L.
Published: January 2021

Unstable angina and non-ST-segment acute coronary syndrome represent a frequent and serious presentation to the emergency department.  While most patients present with chest discomfort, atypical presentations warrant that clinicians maintain a high index of suspicion. This review summarizes the present nomenclature, definitions, and pathophysiology for this high morbidity disease process. The rapid acquisition of an electrocardiogram and serial cardiac troponins are mainstays of diagnosis.  Also outlined is an approach for initial assessment, high-risk ECG findings, risk stratification, biomarker strategies, and subsequent stabilization.  Once diagnosed, treatment options for these patients aim to halt continued ischemia and resultant necrosis. These therapies may include agents such as supplemental oxygen, nitrates, anti-platelet agents, beta blockers, anti-coagulation, anti-thrombin and statin therapies in appropriate settings. Caution should be exercised when dosing high-risk patients for bleeding such as those who are elderly or who weigh less than 60kg. Emergent angiography is reserved for patients who develop hemodynamic instability, cardiogenic shock, pulmonary edema, persistent angina refractory to medical therapy, and sustained arrhythmia.
This review contains 2 figures, 12 tables, and 64 references.
Keywords: acute coronary syndrome, unstable angina, myocardial infarction, troponin, electrocardiogram
Panic Attacks and Anxiety Disorders
Authors: Wittmann Curtis
Published: January 2021

This review discusses the acute diagnosis and management of panic and anxiety disorders. Anxiety disorders are among the most common psychiatric disorders in the country and are a relatively common cause of presentation to the emergency department. Most anxiety disorders can be conceptualized as fear- or phobia-based disorders, including panic disorder, specific phobia, social phobia, acute stress disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. Each of these disorders is discussed, including prevalence and common clinical presentations. The initial evaluation of patients with a suspected or diagnosed anxiety disorder will be based on their current symptoms. Some patients may be highly agitated and may require deescalation or sedation to perform a reasonable history and physical examination. To achieve this, providers should ensure their own safety first, with attention to the physical layout of the emergency department, ensuring that they are closer to the room exit than the patient (so that they cannot be trapped). The presence of police or security may be necessary to provide optimal care and an appropriate evaluation. Typical treatment of acute exacerbations of anxiety disorders includes medical management, most often benzodiazepines, which can provide immediate relief. Psychiatric consultation may be necessary in certain cases. For most patients, outpatient management rather than inpatient admission will lead to the most effective management of their anxiety.
 
Key words: anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, stress disorder
This review contains 1 highly rendered figure, 17 tables, and 29 references.
Acute Care: Pain Management
Authors: Ranniger Claudia
Published: January 2021

Pain is a chief complaint in more than 50% of emergency department (ED) visits. Injury accounts for approximately one-third of presentations associated with pain; other common diagnoses include neck and back pain, minor infections, abdominal pain, and headache. In the ED, pain is underdiagnosed and undertreated, and existing pain management practices in the ED are inconsistent.  Inadequate pain management is common, and pain remains unchanged or worsens during the ED visit for more than 40% of patients.  Patient satisfaction improves when expectations for pain control are met. This review covers the pathophysiology of pain and the practice of pain management. Figures show the approach to pain management in the ED, an example of a numerical and visual analog scale pain rating scale, field block of the pinna, ultrasound probe and hand position for ultrasound-guided regional anesthesia, regional anesthesia of the face, innervation of the hand and fingers, regional anesthesia of the median, radial and ulnar nerves, innervation of the foot, ultrasound-guided regional anesthesia of the posterior tibialis nerve, regional anesthesia of the sural nerve, and method of regional anesthesia of the dorsal foot. 
This review contains 13 figures, 16 tables, and 72 references.
Key words: Acute pain, Pain management, Oligoanalgesia, Pain assessment, Inadequate pain management, Acute pain management, Pain management in the emergency department, Pain in the ED, Pain presentation
Frostbite and Hypothermia
Authors: Schneider Jeffrey I.
Published: January 2021

Frostbite and hypothermia are becoming increasingly common as the popularity of extreme and outdoor sports rises and the homeless population increases. Advanced age is also associated with an increased risk of frostbite and hypothermia; thus, their incidence will likely continue to increase as the population ages. Frostbite occurs when there is sufficient heat loss to produce ice crystals within either superficial or deep flesh. Hypothermia is defined as an involuntary drop in body temperature to below 35°C, but a useful functional definition is a decrease in temperature that results in an inability of the body to maintain its natural functions. This review details the assessment and stabilization, diagnosis, and treatment and disposition for frostbite and hypothermia. Figures show factors that may predispose individuals to developing frostbite, long-term consequences of severe frostbite, and an approach for pleural cavity lavage. Tables list factors that increase the risk of frostbite, degrees of frostbite, three phases of frostbite, and staging of hypothermia.
This review contains 3 highly rendered figures, 4 tables, and 71 references.
Dysbarism
Authors: Lehnhardt Kris
Published: January 2021

Dysbarism is defined as any medical condition that arises as a result of changes in ambient pressure. This review describes dysbarism with a focus on the undersea environment. Conditions discussed in this review include middle and inner ear barotrauma, pulmonary barotrauma, immersion pulmonary edema, decompression illness, and gas toxicities. For each, assessment and stabilization, treatment and disposition, and outcomes are presented. Figures show the AQUARIUS habitat for saturation diving; the anatomy of the external, middle, and inner ear; the Teed classification; the paranasal sinuses; and an example of a recompression chamber. Tables list the types of diving, gas laws relevant to diving, units of underwater pressure, compositions of typical breathing gas mixtures, decompression illness risk factors, symptoms of decompression illness (in order of frequency), signs and symptoms of decompression illness based on body system, maximum recommended depth to reduce the risk of central nervous system oxygen toxicity for various breathing gas mixtures, and progression of nitrogen narcosis symptoms with increasing depth.
This review contains 5 highly rendered figures, 9 tables, and 120 references.
Gynecologic Emergencies in the Nonpregnant Patient
Authors: Huancahuari Nadia , Genthon Alissa
Published: January 2021

Nonpregnant patients with gynecologic emergencies often present with pelvic pain that may or may not be unilateral. Many gynecologic emergencies are associated with high morbidity and, occasionally, mortality if left untreated. This review examines the assessment and stabilization, diagnosis, and treatment and disposition of patients with various gynecologic emergencies, including ovarian torsion, cervicitis, pelvic inflammatory disease, uterine fibroids, endometriosis, dysfunctional uterine bleeding, Bartholin cysts, and vulvovaginitis. Figures show an algorithm of gynecologic emergencies, a longitudinal sonogram and a computed tomography (CT) scan showing ovarian torsion, a CT scan and sonogram of  a tubo-ovarian abscess, and illustrations of a Bartholin cyst and a Word catheter. Tables list assessment, stabilization, and management guidelines for the subtopics in this review.

This review contains 7 figures, 15 tables, and 68 references.
Keywords: Ovarian torsion, cervicitis, uterine fibroids, endometriosis, Bartholin’s cyst, vulvovaginitis, sexually transmitted infection, bleeding.
Central Nervous System Infections
Authors: Johnson Nicholas J. , Gaieski David F.
Published: January 2021

Infections of the central nervous system (CNS) are among the most devastating diseases that present to the emergency department (ED). Because of the great potential for morbidity, as well as the importance of prompt treatment, emergency physicians must remain vigilant of these diseases, which are also fraught with diagnostic challenges. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of CNS infections. Figures show causes of viral meningitis, an algorithm for the initial evaluation and management of patients with a suspected CNS infection, clinical manifestations of community-acquired meningitis in patients 16 years of age and older, assessment of nuchal rigidity, Kernig sign, and Brudzinski sign for meningeal irritation, proper positioning of the patient for lumbar puncture, and a sagittal view of the lumbar puncture needle as it is advanced into the subarachnoid space. Tables list CNS pathogens based on predisposing and associated conditions, cerebrospinal fluid diagnostic studies for meningitis, adult patients who should receive computed tomography prior to lumbar puncture, classic cerebrospinal fluid characteristics in meningitis, empirical therapy for bacterial meningitis based on predisposing and associated conditions, recommended doses for antibiotics commonly used in the treatment of bacterial meningitis, and antimicrobial therapy for selected CNS infections.
 
This review contains 8 highly rendered figures, 7 tables, and 94 references
Complications Following Bariatric Surgery
Authors: Harris David A , Sheu Eric G.
Published: January 2021

Bariatric surgery has proven to be the most effective and durable treatment for obesity and obesity-related diseases. As such, the number of bariatric procedures performed has dramatically increased over the past several decades. Although multiple bariatric procedures have been performed, the sleeve gastrectomy, Roux-en-Y[H1]  gastric bypass, and gastric band have been by far the most common operations in the United States in the last decade. Given the prevalence of bariatric surgery and increased push to short-track postoperative hospital stays, emergency department (ED) visits are common in this patient cohort. This review covers the pathophysiology, diagnosis, and treatment of complications that ED providers are likely to see in patients after bariatric surgery. Although many complications are shared between all bariatric procedures, there are unique surgery-specific complications. To address the needs of these patients, providers must understand the surgery that their patients have had and how the postoperative timing and nature of their complaints inform the likely etiology of their presentation.
This review contains 6 figures, 4 tables, and 83 references.
Key words: anastomotic leak, bariatric surgery, cholelithiasis, complications, dehydration, dumping syndrome, gastric banding, gastrogastric fistula, internal hernia, malnutrition, mesenteric vein thrombosis, Roux-en-Y gastric bypass, sleeve gastrectomy, stricture, ulcer, vitamin deficiency
Hernias in the Emergency Department
Authors: Westergaard Mary C. , Berhanu Daniel , Barclay-Buchanan Ciara J.
Published: January 2021

Hernia is defined as an abnormal protrusion of an organ or tissue through a pathologic defect in its surrounding wall. Overall, hernia is common and is generally believed to be a benign condition associated with some morbidity, although it is not thought to be associated with significant mortality. Between 2001 and 2010, 2.3 million inpatient abdominal hernia repairs were performed in the United States, of which 567,000 were performed emergently. In some cases, a hernia can be a deadly condition. In 2002, hernia was listed as the cause of death for 1,595 US citizens. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of hernia. Figures show anatomic locations of the various abdominal wall, groin, lumbar, and pelvic floor hernias; a direct inguinal hernia; an indirect inguinal hernia; point-of-care sonograms showing a ventral wall hernia and an abdominal wall hernia; and the differential diagnosis of an abdominal mass based on anatomic location. Tables list risk factors for the development of inguinal hernia, sex-based differences in inguinal hernia development, risk factors for the development of incisional hernia, factors to consider when assessing the patient for a hernia, and factors associated with the highest rates of incarceration in patients with groin hernia.
Key words: emergent hernia, hernia incarceration, incisional hernia, inguinal hernia, strangulated hernia
This review contains 6 highly rendered figures, 5 tables, and 66 references.
Eosinophilic Esophagitis
Authors: Chan Walter W , Jagadeesan Vikrant S
Published: January 2021

Eosinophilic esophagitis (EoE) is a chronic disorder characterized by eosinophil-predominant inflammation of the esophagus and clinical symptoms of esophageal dysfunction. It is believed to be immune/antigen-mediated, and its diagnosis requires recognition of specific clinical features with appropriate histologic findings on esophageal mucosal biopsies. Over the last 10 years, there has been an increase in the prevalence of EoE worldwide. A recent analysis estimated a prevalence of 56.7 per 100,000 persons, with males more often affected than females. This review covers the epidemiology, pathophysiology and pathogenesis, diagnosis, differential diagnosis, treatment, complications, and prognosis of EoE.
This review contains 3 figures, 2 tables, and 46 references.
Key words: dysphagia, eosinophilic esophagitis, eotaxin-3, esophageal dysfunction, esophageal eosinophilia, food impaction, inflammation of the esophagus
Irritable Bowel Syndrome with Diarrhea
Authors: Nee Judy , Wolf Jacqueline L.
Published: January 2021

Irritable bowel syndrome (IBS) is a complex, functional gastrointestinal condition characterized by abdominal pain and alteration in bowel habits without an organic cause. One of the subcategories of this disorder is IBS with diarrhea (IBS-D). Clinically, patients who present with more than 3 months of abdominal pain or discomfort associated with an increase in stool frequency and/or loose stool form are defined as having IBS-D. This review addresses IBS-D, detailing the epidemiology, etiology and genetics, pathophysiology and pathogenesis, diagnosis, clinical manifestations and physical examination findings, differential diagnosis, treatment, emerging therapies, complications, and prognosis. Figures show potential mechanisms and pathophysiology of IBS, IBS-D suspected by clinical assessment and Rome III criteria, pharmacologic and nonpharmacologic treatment options, potential mechanisms of action of probiotics, and potential treatment modalities. Tables list the Rome criteria for IBS, alarm signs and symptoms suggestive of alternative diagnoses, IBS criteria, differential diagnosis of IBS-D, dietary advice options for IBS-D, and alternative and emerging therapies in IBS-D.
This review contains 5 figures, 6 tables and 42 references
KEYWORDS: IBS-D, eluxadoline, rifaximin, probiotics, bloating, antidepressants, bile acid malabsorption, microscopic colitis, celiac
Eosinophilic Gastroenteritis
Authors: Burakoff Robert , Winter Rachel
Published: January 2021

Eosinophilic gastroenteritis (EG) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal (GI) tract. This review addresses the epidemiology, etiology and genetics, pathophysiology and pathogenesis, diagnosis, differential diagnosis, treatment, complications, and prognosis of EG. A figure shows the histologic appearance of stomach and duodenal mucosa in patients with EG. Tables list symptoms of EG and differential diagnosis.
This review contains 1 highly rendered figure, 2 tables, and 27 references.
Gallstone Disease
Authors: Apstein Michael D.
Published: January 2021

Gallstone disease (cholelithiasis), very common in the United States, afflicts around 15% of the adult population and accounts for approximately 1.8 million ambulatory visits per year. Elective laparoscopic cholecystectomy for the removal of gallstones is currently the most commonly performed abdominal operation in the United States, with around 750,000 operations per year. Although the majority of patients with asymptomatic gallstones will never develop symptoms, approximately 25% of these initially asymptomatic patients will develop biliary pain and 3% will develop complications over a 10-year follow-up period. This review discusses the pertinent pathophysiology and treatment of gallstones and their complications. It is imperative for the primary care physician, gastroenterologist, and surgeon to rapidly identify those patients at risk for complications of gallstone disease and offer the best evidence-based therapies available. It is also important for the physician to understand when and if to offer treatment for those patients with asymptomatic gallstone disease. Figures show the mixed micelle, the anatomy of gallstones, radial endoscopic sonogram of a gallstone in common bile duct (CBD), an algorithm depicting the risk of CBD stone in patients with known cholelithiasis, and endoscopic retrograde cholangiography images of a large gallstone within CBD and stone fragments in duodenum following lithotripsy and extraction. Tables list risk factors for gallstone formation, common medications associated with gallstone formation, and uncommon complications of gallstone disease.
This review contains 5 highly rendered figures, 3 tables, and 53 references.
Liver Transplantation for the Gastroenterologist
Authors: Catana Andreea M. , Curry Michael P.
Published: January 2021

The first liver transplantation (LT) was performed in 1963, and currently more than 65,000 people in the United States are living with a transplanted liver. In 2012, the number of adults who registered on the LT waiting list decreased for the first time since 2002; 10,143 candidates were added compared with 10,359 in 2011. LT offers long-term survival for complications of end-stage liver disease and prolongs life in properly selected patients, but problems such as donor deficit, geographic disparities, and long waiting lists remain. This overview of LT for the gastroenterologist details the indications for LT and patient selection, evaluation, liver organ allocation, prioritization for transplantation, transplantation benefit by the Model for End-Stage Liver Disease (MELD), MELD limitations, sources of liver graft, strategies employed to decrease the donor deficit, complications, and outcomes. Figures include indications for LT in Europe and the United States, Organ Procurement and Transplantation Network regions in the United States, the number of transplants and size of active waiting lists, mortality by MELD, regional disparity, patient survival rates with and without hepatitis C virus, and unadjusted patient and graft survival. Tables list LT milestones, indications for LT, contraindications for LT, minimal listing criteria for LT, criteria for LT in acute liver failure, LT evaluation process, adult recipient listing status 1A, and early posttransplantation complications.
This review contains 7 highly rendered figures, 8 tables, and 46 references.
Liver Disease in Pregnancy
Authors: Chang Matthew S , Rutherford Anna E.
Published: January 2021

Liver disease in pregnancy can be unique to pregnancy or coincidental to pregnancy, or pregnancy can occur in women with chronic liver disease, cirrhosis, or portal hypertension. The gestational age of the pregnancy can help determine the diagnosis. Liver disease occurring during pregnancy has the potential to be life threatening to mother and fetus, and any elevation in liver tests should be investigated. Disorders unique to pregnancy include hyperemesis gravidarum; intrahepatic cholestasis of pregnancy; preeclampsia/eclampsia; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; and acute fatty liver of pregnancy. Liver diseases coincidental to pregnancy include acute viral hepatitis, gallstones/biliary disease, and thrombosis such as Budd-Chiari syndrome/hepatic vein thrombosis. Pregnant women may have chronic liver disease or cirrhosis from all of the same etiologies as nonpregnant women, most commonly chronic viral hepatitis. Treatment options may differ during pregnancy because of the potential risks to the fetus. Women who have cirrhosis or portal hypertension or who are post liver transplantation should be managed in conjunction with a hepatologist.
 This review contains 4 figures, 6 tables and 40 references
Key words: acute liver failure, delivery, trimester
Cystic Fibrosis in Childhood and Adolescence
Authors: Sabharwal Sabina
Published: January 2021

Although cystic fibrosis (CF) has historically been considered a pulmonary disease, with the increasing life expectancy of these patients, gastrointestinal manifestations are becoming more important. Moreover, nutritional status is closely linked to pulmonary function and, thus, overall mortality. This review discusses gastrointestinal (including nutritional, pancreatic, and hepatobiliary) manifestations of CF and their management. It also discusses studies that have been critical to our understanding of these manifestations of CF.
This review contains 1 figure, 1 table, and 36 references.
Key words: body mass index, constipation, cystic fibrosis transmembrane regulator, distal intestinal obstruction syndrome, pancreatic insufficiency
Kidney Disease in Pregnancy
Authors: Vellanki Kavitha , Hou Susan
Published: January 2021

Pregnancy-induced changes in renal hemodynamics play an important role in favorable maternal and fetal outcomes. Renal plasma flow and glomerular filtration rate (GFR) increase by approximately 50% in normal pregnancy, leading to a decrease in both blood urea nitrogen and serum creatinine when compared with prepregnancy levels. Hence, serum creatinine–based formulas are not accurate in calculating estimated GFR in pregnant patients. The most compelling risk for pregnant women with moderate to severe chronic kidney disease is the risk of rapid progression of underlying kidney disease; the mechanisms for such decline are yet to be elucidated. The rule of kidney disease not progressing when serum creatinine is less than 1.4 mg/dL does not apply to women with lupus nephritis. New-onset lupus is an indication for kidney biopsy during pregnancy because diffuse proliferative lupus nephritis requires prompt treatment and first-line treatments are teratogenic. Infertility is common in women on dialysis and is usually reversed after successful kidney transplantation. Pregnancy outcomes have improved over the years with increasing intensity of hemodialysis in end-stage kidney disease patients. Pregnancy post–kidney transplantation should be planned and teratogenic medications discontinued before conception.
Key words: glomerular filtration rate, proliferative lupus nephritis, serum creatinine, pregnancy post–kidney transplantation, end-stage kidney disease, infertility, kidney biopsy
Epidemiology of Acute Kidney Injury
Authors: Torres Costa e Silva Verônica , Antunes Caires Renato , Costalonga Elerson Carlos , Burdmann Emmanuel A.
Published: January 2021

The worldwide incidence of acute kidney injury (AKI) is increasing. Recent surveys demonstrated that AKI occurs in 21% of hospital admissions. In low-income countries, AKI has a bimodal presentation. In large urban centers, the pattern of AKI is very similar to that found in high and upper middle-income countries, with a predominance of hospital-acquired AKI, occurring mostly in older, critically ill, multiorgan failure patients with comorbidities. At the same time, in regional hospitals in small urban communities and rural areas, AKI is usually a community-acquired disease (related to diarrheal and infectious diseases, animal venom, and septic abortion). Although AKI mortality seems to be decreasing, it remains extremely high, varying from 23.9 to 60% in recent series. The most important risk factors for short-term mortality (in hospital or < 90 days) in AKI are the primary diagnosis (sepsis) and the severity of the acute illness, expressed by the presence of nonrenal organ dysfunction. New biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, cystatin C, and interleukin-18 measurements, have been able to identify patients with AKI who are at risk for a less favorable prognosis, such as the likelihood of the need for renal replacement therapy, nonrecovery of kidney function, and higher mortality. Several studies have demonstrated an association between hospital-associated AKI and postdischarge mortality in a variety of contexts, and the most important risk factors for this late lethality are older age, preexisting comorbid disease (chronic kidney disease [CKD], cardiovascular disease, or malignancy), and incomplete organ recovery with ongoing residual disease. AKI is associated with de novo end-stage renal disease (ESRD) (CKD, progression of preexisting CKD) and the occurrence of ESRD in the long term. Herein, it is suggested that high-risk patients recovering from an AKI episode, such as those with baseline CKD, diabetes mellitus, or heart failure and those dialyzed for AKI, should likely be followed by a nephrologist.
Acute Graft Dysfunction
Authors: Adebiyi Oluwafisayo , Wiseman Alexander C. , Cooper James E.
Published: January 2021

Acute renal allograft dysfunction represents a spectrum of abnormalities that may be seen from the time of transplant surgery to eventual organ failure. Although renal allografts are often plagued by similar conditions as seen in native kidneys, they are also at risk for unique abnormalities specific to the transplant setting, such as delayed graft function (DGF), acute and chronic graft rejection, post-transplantation infections, and perinephric fluid collections.
This review contains 5 figures, 10 tables, and 94 references.
Keywords: Acute renal allograft dysfunction, delayed graft function, acute graft rejection, chronic graft rejection, perinephric fluid collections, post-transplantation infections
Metabolic Disorders: Inborn Errors of Amino Acid, Ammonia, Organic Acid, and Fatty Acid Metabolism
Authors: Chopra Sameer S , Berry Gerard T
Published: January 2021

The small molecule diseases include inborn errors of carbohydrate, ammonia, amino acid, organic acid, and fatty acid metabolism. They are central among the biochemical genetic disorders that may present with life-threatening illnesses during infancy and childhood. Many of these disorders are now detected through routine newborn screening. Internists should be familiar with small molecule metabolic disorders as early diagnosis and therapy may enable many patients to survive into adulthood. Additionally, because some patients may not manifest symptoms until late adolescence or adulthood, recognition of the possibility of an inborn error of metabolism in a patient with unusual signs or symptoms may lead to referral to a metabolic specialist and timely diagnosis and treatment. This module reviews the diagnosis, treatment, and natural history of disorders of amino acid, ammonia, organic acid, and fatty acid metabolism. Figures show the methionine-homocysteine-cysteine pathway and branched-chain amino acid metabolism.
This module contains 2 highly rendered figures, 18 references, 53 recommended readings, and 5 MCQs.
Primary Sjogren Syndrome: Clinical Features and Management
Authors: Giattino Stephanie L , St. Clair E William
Published: January 2021

Primary Sjögren syndrome (SS) is a chronic inflammatory disease affecting the lacrimal and salivary glands, resulting in dry eyes and dry mouth. It may also lead to systemic manifestations, including fatigue, arthritis, lung involvement, kidney disease, neuropathy, and vasculitis, and predisposes to B cell lymphoma. The diagnosis of primary SS is based on a composite of clinical, serologic, and pathologic features, namely, objective evidence of dry eyes and dry mouth and either a positive test for anti-SSA (Ro) antibodies or a positive labial salivary gland biopsy. Primary SS may be confused with other conditions affecting the lacrimal and salivary glands, such as chronic hepatitis C virus infection, sarcoidosis, and a new entity, IgG4-related disease. The management of patients with primary SS is largely symptomatic and consists of tear supplementation, regular dental hygiene, and liberal use of moisturizers. Cyclosporine 0.05% ophthalmic emulsion and lifitegrast 5% ophthalmic solution are approved agents for the treatment of dry eyes. Two oral secretagogues, pilocarpine and cevimeline, have been shown in trials to significantly reduce the symptoms of dry eyes and dry mouth. Although hydroxychloroquine may reduce fatigue and joint pain, the results of a randomized controlled trial failed to confirm its efficacy in this clinical setting. More serious organ system involvement may be managed with corticosteroids and other immunomodulatory drugs. Although no disease-modifying drugs are currently approved for the treatment of primary SS, a robust pipeline of promising therapies for this disease is currently in development.
This review contains 3 figures, 5 tables, and 69 references.
Key words: anti-Ro/SSA antibodies, B cell lymphoma, classification criteria, EULAR Sjögren’s syndrome Patient Reported Index (ESSPRI), EULAR Sjögren’s Syndrome Disease Activity Index (ESSDAI), hydroxychloroquine,  keratoconjunctivitis sicca, rituximab, Sjögren syndrome
Fever in Returning Travelers
Authors: Wilson Mary E , Chen Lin H
Published: January 2021

Fevers in individuals with recent tropical travel require rapid assessment because many of the potential causes are treatable and/or have important public health implications. History and clinical findings are essential to identify the likely causes of the fever and, thus, recognize those that require urgent intervention.This review outlines obtaining the travel history, incubation periods, undifferentiated fever, and evaluation based on syndromes. Figures show the most common diagnoses and range of incubation periods; the top specific diagnoses in febrile returned travelers by geographic region; countries/areas at risk for dengue transmission; images of Aedes aegypti and Aedes albopictus, vectors of dengue virus and chikungunya virus; countries and territories where chikungunya cases have been reported (as of March 10, 2015), excluding where imported cases only are documented; cases of Ebola virus disease in Africa, 1976–2015, by species and size; and an algorithm for approach to workup. Tables list Web sites and resources for travel medicine; the epidemiology of fever in travelers; key areas of exposure queries in returned travelers; obtaining exposure history in febrile returned travelers; estimated protective effect of previous vaccination; common posttravel infections, by incubation period; guiding principles for care of febrile patients returning from tropical travel; common clinical findings and associated infections; key cannot-miss diagnoses with fever; malaria antigens; fever syndromes, diagnoses, and diagnostic tests to be considered; and major hemorrhagic fevers and their distribution based on world regions.
This review contains 7 highly rendered figures, 12 tables, and 151 references.
Infections in Cancer Patients
Authors: Hammond Sarah P. , Satyanarayana Gowri
Published: January 2021

Infection is a common complication in cancer patients who receive cytotoxic chemotherapy and other targeted therapies. A clear understanding of the underlying host risk factors, the immunologic effects of specific cancer therapies, and the anatomic location of the tumor and its impact on surrounding structures helps predict the types of infection to which the host is most vulnerable. This review covers fever in the setting of neutropenia, infection risk with biological and targeted cancer therapy, and infections in patients with solid tumors. Figures show risk for fever and neutropenia, and empirical antibiotic algorithm for initial management of febrile neutropenia in patients at high risk for complications, radiographic findings associated with invasive fungal disease, a schematic of hepatitis B virus infection and reactivation after anti-CD20 therapy, and management of nonpurulent cellulitis in cancer patients. Tables list the Multinational Association of Supportive Care in Cancer (MASCC) risk index score, the Clinical Index of Stable Febrile Neutropenia (CISNE) scoring system, common bacterial pathogens that cause infection in neutropenic patients, assessment of specific signs and symptoms during febrile neutropenia, empirical antibiotic management of febrile neutropenia, criteria for addition of vancomycin to empirical antibiotic regimen for febrile neutropenia, and biological and targeted agents commonly used to treat hematologic malignancy and associated infections.
 
This review contains 5 highly rendered figures, 7 tables, and 107 references
Important Infections Due To Molds
Authors: Ando Timothy
Published: January 2021

Mold-based fungal infections have become increasingly important over several decades, paradoxically because advances in medical practice have allowed patients with chronic medical conditions to live longer and have lives that are more productive. Allergic bronchopulmonary aspergillosis can affect those individuals with an atopic predisposition. Use of direct antimold antifungal agents can decrease the number of steroid treatment courses and monoclonal antibody therapy used in these patients. Pulmonary invasive aspergillosis remains the most important opportunistic mold infection among immunocompromised patients. Surrogate markers of diagnosis can include β-d-glucan or Aspergillus galactomannan antigen testing, although the specificity of both tests is not robust. There are three general classes of antifungal agents in use, with less nephrotoxic options. With safer therapeutic options, empirical treatment occurs with tremendous frequency among otherwise immunosuppressed individuals. Thus, clinicians will need to maintain a high suspicion for mold infections that can be resistant to a previously used antifungal therapy. Attention to liver function testing during long-term use of these advanced-generation azole antifungal agents, and at times therapeutic drug monitoring with blood levels, will be needed. The echinocandin class of antifungal agents does not have hepatic or renal toxicity in general, but these agents need to be administered via an intravenous route. With routine use of agents that have activity against aspergillosis, fusariosis, mucormycosis, or other mold infections become evident for a minority of at-risk patients.

This review contains 5 figures, 3 tables and 90 references
Key words: allergic bronchopulmonary aspergillosis, dematiaceous fungi, Exserohilum, fusariosis, invasive aspergillosis, mucormycosis, Scedosporium
The Colon, Appendix, Rectum, and Anus
Authors: Chu Daniel I. , Romine Margaret M
Published: January 2021

The colon, appendix, rectum, and anus have unique anatomic features, both structural and functional, that contribute to normal and pathologic states. Structural features discussed in this review include the layers of the intestinal wall, vascular anatomy, lymphatic drainage, and innervation. Functional features highlighted include the role(s) each organ plays in immunity, nutrient absorption, electrolyte secretion, water absorption, continence, and elimination of waste. A clear understanding of these structural and functional details is the foundation on which surgical techniques and treatment strategies are based when addressing surgical pathology.
This review contains 7 highly rendered figures, 3 tables, and 58 references.
Key words: anus, appendix, colon, colorectal pathology, colorectal surgery, rectum
Cognitive Disorders Other than Alzheimer Disease
Authors: Gale Seth A , Daffner Kirk R.
Published: January 2021

Higher cognitive functions, such as abstract reasoning, complex decision making, and language, are the mental faculties that separate our species from other animals. When these faculties become impaired as a result of neurologic disease, striking and devastating behavioral changes result. Many neurologic diseases are associated with impaired cognition and behavior, and their etiologies are as varied as their clinical presentations. In this review, the focus is on dementia with Lewy bodies (DLB), the frontotemporal dementias (FTDs), and vascular cognitive impairment (VCI). The review covers the epidemiology and diagnosis of  DBB, FTDs, and VCIs, as well as the etiology and genetics. Figures show neuroimaging in DLB, management of DLB, FTLD clinical syndromes, FTLD clinicopathologic correlations: approximate distribution of pathotypes for behavioral-variant FTD and primary progressive aphasia (PPA) variants, PPA-semantic subtype, PPA-logopenic subtype, post-stroke VCI, and subcortical ischemic vascular disease subtype of VCI. Tables list diagnostic criteria for DLB; FTD genetics: gene/protein relationship, clinical syndrome, salient gestures; VCI: clinical and pathologic features of the main subtypes; summary guidance based on VCI prevention studies; and summary guidance based on VCI treatment studies.
This review contains 8 highly rendered figures, 5 tables, and 254 references.
Chorea: Classification, Differential Diagnosis, and Treatment
Authors: Battista James P , Walker Ruth H
Published: January 2021

Chorea is a common hyperkinetic movement disorder that can have a large differential diagnosis. Causes can include genetic and sporadic etiologies, including metabolic abnormalities, autoimmune, structural, paraneoplastic, psychogenic, and iatrogenic causes. The workup can be challenging due to this large number of possible causes, and can include basic metabolic and specialized blood analysis such as genetic testing, in addition to imaging studies and cerebrospinal fluid analysis. Treatment of symptoms outside the realm of reversible causes can be challenging, and is a major focus of current research. This review covers sporadic causes, genetic causes, and management. Figures show a flowchart for evaluation of patients with chorea, a computed tomography scan of a Huntington disease patient showing caudate head atrophy, brain computed tomography scan showing calcification, and acanthocytosis. Videos show mild and moderate Huntington disease, Huntington disease-like 2,  and chorea-acanthocytosis. Tables list metabolic abnormalities that can manifest as chorea, paraneoplastic and nonparaneoplastic syndromes associated with chorea, and reported successful therapies for chorea.
This review contains 4 highly rendered figures, 4 videos, 3 tables, and 108 references.
Surgical Treatment Of Obesity
Authors: Pernar Luise , Robinson Malcolm K.
Published: January 2021

Obesity is associated with numerous comorbidities and shortens life expectancy. Currently, over one third of adults in the United States are obese, making management of obesity a significant public health concern. Given the modest benefits of behavior change alone, weight loss surgery has become a popular tool in the treatment of obesity. Numerous studies have documented the benefits of weight loss surgery in promoting weight loss and resolution of comorbidities. The hormonal and physiologic changes that are induced by some weight loss procedures are not yet fully elucidated, but it is thought that changes in hunger sensation and metabolism drive the observed effects.

This review contains 4 figures, 2 videos, 3 tables and 60 references
Key words: bypass, obesity, sleeve gastrectomy, surgery, weight loss