Latest Updates

Clinical Aspects of Alzheimer Disease

    • Amyloid positron emission tomography is available for aiding in the diagnosis of Alzheimer disease as an etiology of dementia, but its role in routine clinical practice has not been established.
    • Genotyping of dementia patients for diagnostic purposes is not currently recommended at this time. Persons who carry at least one copy of the e4 allele of the APOE gene are at slightly greater risk for developing dementia due to AD. 
    • The mental status examination is a cornerstone of the diagnosis of AD dementia. The Montreal Cognitive Assessment (MoCA) represents the most recent attempt to craft a bedside examination that is more sensitive and specific for milder symptomatic disease than the older Mini-Mental State examination.

Process Improvement in Surgery

    • A number of reports supporting the efficacy of process improvement are available. Jimmerson and colleagues, describing results across a broad range of clinical areas at a university-based quarternary medical center, published both general and specific instances of improvement in efficiency and quality. OR processes such as OR turnaround and surgical throughput are fertile areas for such work.
    • A core innovation in the origin of “scientific management” was the focus on the details of industrial processes by Frederick W. Taylor. Taylor’s work comes down to us today in the process flow diagram (in TPS Lean terminology, the process flow diagram is referred to as a “value stream map”), which is a schematic representation of the steps in any process, frequently annotated with time intervals and comments. 

Cervical Radiculopathy

Robert B Bolash, MD, Pavan Tankha, DO
    • Physical exam maneuvers have demonstrated high specificity and low sensitivity for cervical radiculopathy
    • CT myelography may offer better sensitivity for foraminal and bony abnormalities as compared to MRI
    • Cervical epidural steroid injections may result in the resolution of symptoms in 40-75% of patients
    • Failure to respond to conservative and interventional approaches in three months warrants a surgical consult

Neuro-Ophthalmology

    • Additional imaging and electrophysiologic studies prove helpful. Optical coherence tomo­graphy (OCT) provides high-resolution cross-sectional images of the retina that aid in distinguishing retinal pathology from optic neuropathy.
    • When uncertainty prevails regarding the differentiation of anomalous optic disk elevation from papilledema, additional diagnostic tests can be helpful. Fluorescein angiography will demonstrate dye leakage at the optic nerve head in papilledema.
    • MRI is essential to establish the cause of most visual field deficits. Although careful visual fields may suggest a specific localization, in many cases, imaging serves to establish whether the responsible lesion is vascular, neoplastic, or inflammatory.

Neurology of Rheumatic Diseases

    • Patients with lupus are more vulnerable than their peers to ischemic or hemorrhagic stroke. Among 1,249 lupus patients who were followed for up to 8 years, there were 36 strokes or TIAs, usually associated with active lupus.
    • About 10% of patients with lupus have a seizure sometime during the course of their illness. The seizures are varied: single or recurrent, partial or generalized. The seizures are more likely in patients with anti-Smith or antiphospholipid antibodies and less likely in patients receiving chronic hydroxychloroquine therapy and can be associated with other cerebral abnormalities, such as focal brain lesions, strokes, or psychosis.
    • Lumbar imaging is not indicated for initial management of most cases of low back or lumbar radiculopathy. Red flags that tag patients as more likely to need imaging are trauma, fever or other indication of infection, known malignancy that tends to metastasize to bone or epidural space, immunosuppression, significant leg weakness, or sphincter dysfunction. Lumbar MRI and CT, sometimes comple­mented by CT myelography, are the best modalities for delineating mechanisms of root compression, which can vary, including disk herniation, lateral recess stenosis, or foraminal stenosis.

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

Sushanth Reddy, MD, FACS, Laura Stafman, MD
    • Advance directives such as a living will, a do not resuscitate order, and a designation of a power of attorney for health care are legally binding mechanisms to preserve patient autonomy when patients have lost decision-making capacity. Although these directives are frequently used to make decisions regarding life-supporting therapy, surgeons may also need to refer to these documents or to patients’ surrogates for surgical decision making to treat patients in accordance with their autonomous wishes. There is some information to suggest that surgeons value the utility of an advance directive as it can serve as a guide to patients’ preferences in the postoperative setting when life-supporting therapy has become ineffective or patient survival is unlikely. 
    • The Physician Orders for Life-Sustaining Treatment (POLST) program was designed in Oregon in the 1990s to address the lack of advance directives in frail patients and those with chronic diseases. Although POLST is different from advance directives, both aim to address end-of-life care.
    • When patients do not have decision-making capacity, physicians are obliged to find someone who can make decisions for the patient. If the patient has previously designated a durable POAHC agent, this agent is the first person health care providers should turn to for decision making.

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

Sushanth Reddy, MD, FACS, Laura Stafman, MD
    • Advance directives such as a living will, a do not resuscitate order, and a designation of a power of attorney for health care are legally binding mechanisms to preserve patient autonomy when patients have lost decision-making capacity. Although these directives are frequently used to make decisions regarding life-supporting therapy, surgeons may also need to refer to these documents or to patients’ surrogates for surgical decision making to treat patients in accordance with their autonomous wishes. There is some information to suggest that surgeons value the utility of an advance directive as it can serve as a guide to patients’ preferences in the postoperative setting when life-supporting therapy has become ineffective or patient survival is unlikely. 
    • The Physician Orders for Life-Sustaining Treatment (POLST) program was designed in Oregon in the 1990s to address the lack of advance directives in frail patients and those with chronic diseases. Although POLST is different from advance directives, both aim to address end-of-life care.
    • When patients do not have decision-making capacity, physicians are obliged to find someone who can make decisions for the patient. If the patient has previously designated a durable POAHC agent, this agent is the first person health care providers should turn to for decision making.

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

Sushanth Reddy, MD, FACS, Laura Stafman, MD
    • Advance directives such as a living will, a do not resuscitate order, and a designation of a power of attorney for health care are legally binding mechanisms to preserve patient autonomy when patients have lost decision-making capacity. Although these directives are frequently used to make decisions regarding life-supporting therapy, surgeons may also need to refer to these documents or to patients’ surrogates for surgical decision making to treat patients in accordance with their autonomous wishes. There is some information to suggest that surgeons value the utility of an advance directive as it can serve as a guide to patients’ preferences in the postoperative setting when life-supporting therapy has become ineffective or patient survival is unlikely. 
    • The Physician Orders for Life-Sustaining Treatment (POLST) program was designed in Oregon in the 1990s to address the lack of advance directives in frail patients and those with chronic diseases. Although POLST is different from advance directives, both aim to address end-of-life care.
    • When patients do not have decision-making capacity, physicians are obliged to find someone who can make decisions for the patient. If the patient has previously designated a durable POAHC agent, this agent is the first person health care providers should turn to for decision making.
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