Latest Updates

Bipolar Disorder: An Update on Diagnosis, Etiology, and Treatment

Thurston M. Bauer, MD, Marsal Sanches, MD, PhD, Jair C. Soares, MD, Antonio L Teixeira, MD, PhD
    • In the DSM-5, the diagnosis of mania or hypomania requires the presence of increase in energy or goal-directed activities compared with the habitual in the subject along with mood elevation. This change will contribute to increasing diagnostic reliability.
    • In the DSM-5, the term mixed feature is a course specifier and can be applied to depressive, manic, and hypomanic episodes. Seasonal patterns can now be used for all types of mood episodes. These changes will lead to alterations in study designs and data analysis and potentially advance mental health research.
    • There is increasing evidence of the thinning of cortical gray matter in the brains of patients with bipolar disorder when compared with healthy controls. The greatest deficits were found in parts of the brain that control inhibition and emotion, such as the frontal and temporal regions. This finding clarifies aspects of the mechanisms underlying the developments and maintenance of bipolar symptoms.
    • Neuroimaging studies showed that lithium treatment was associated with reduced thinning of gray matter, which suggests a protective effect of this medication on the brain.
    • Combining pharmacotherapy and psychotherapy can reduce the rate of recurrence mood episodes and medication adherence in bipolar patients. Electroconvulsive therapy is highly effective and can be beneficial in treatment-resistant patients.

Medical Futility

Jacob A Blythe, MA, MD, Stephanie Harman, MD
    • Medical futility has developed as an ethical construct to approach patient/family requests for clinical interventions that are not medically effective in achieving their intended goal and creates recourse for clinicians to address these requests.
    • Several states now have legislation that govern medical futility that offers protections for both clinicians and patients and families.
    • A process-based approach incorporating the concept of “potentially inappropriate” care has now been established in society guidelines promoting a shared decision-making approach and aligning the goals of clinicians and patients and families.

Microsurgical Reconstruction of the Upper Extremity

Nikolas H Kazmers, MD, MSE, L. Scott Levin, MD, FACS, Zvi Steinberger, MD, Stephanie Thibaudeau, MD
    • Recent literature highlighting considerations for surgical timing of microsurgical reconstruction is reviewed and summarized.
    • Recent literature highlighting risk factors for failure of free flaps is reviewed and summarized.
    • Newer concepts, including perforator freestyle flaps, have been introduced.

Diagnosis, Etiology, and Treatment of Premenstrual Dysphoric Disorder

Marlene P. Freeman, MD, Edwin Raffi, MD, MPH
    • Diagnosing PMDD only formally achieved after ruling out other underlying mood or anxiety disorder, and if the symptoms persist for two consecutive months, in a cyclic fashion.
    • Differential Diagnosis for PMDD include any mood or anxiety disorder, or PTSD. Providers should rule out PME of one of these disorders first.
    • The etiology of PMDD is likely multifactorial and includes the interplay between genetics, neurosteroids, neurotransmitters, brains structure and function, and the pathophysiology that connects these factors.
    • Of the pharmacologic approaches, serotonergic reuptake inhibitors and oral contraceptives should initially be considered for treatment of PMDD.

Erectile Dysfunction: Evaluation, Including Diagnostic Studies

Sevann Helo, MD, Kevin T McVary, MD, Nicholas Tadros, MD MCR
    • Risk assessment in patients with cardiovascular disease
    • Penile Doppler ultrasonography
    • Cavernosometry and cavernosography

Immunosuppression

Steven Gabardi, PharmD, BCPS, FAST, FCCP, Miae Kim, MS, PharmD, BCPS
    • Full review of all available literature on transplant immunosuppression use in renal transplantation
    • Recommendations for strategies to manage common adverse reactions from transplant immunosuppressants
    • Evaluation of specific medications that are used for the management of antibody-mediated rejection

Head and Neck Melanoma: An Overview

Samuel Kim, MD, Deepak Narayan, MD
    • A recently discovered gain-of-function mutation in the RAC1 gene in melanomas may provide a potential target for pharmacologic treatment.
    • Adoptive cell therapy has been refined and advanced to become an effective form of personalized cancer therapy, but the search continues to generalize its use.
    • Expanding our knowledge of and targeting the tumor microenvironment, which provides several means of tumor protection, may unlock the full potential of immunotherapy.

Inhalation Injury

Erica I Hodgman, MD, Madhu Subramanian, MD, Steven E Wolf, MD
    • CT of the chest has taken a greater role in determining injury severity in inhalation injury.
    • Airway control and ventilator management remain the mainstays of treatment in those with severe injury.
    • Volumetric diffusive respiration is a mode specifically developed for inhalation injury that has been shown to decrease use of other rescue modes of ventilation.
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