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Family Medicine & Pharmacy Podcast

Updated 7 days ago

Health & Fitness
Medicine
Science
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priority topics for family medicine and community pharmacy

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priority topics for family medicine and community pharmacy

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By Rsuave427 - Mar 13 2017
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Love the overview of patho and treatments.

iTunes Ratings

6 Ratings
Average Ratings
6
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Love it. Want more.

By Rsuave427 - Mar 13 2017
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Love the overview of patho and treatments.

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Family Medicine & Pharmacy Podcast

Updated 7 days ago

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priority topics for family medicine and community pharmacy

Rank #1: Pediatric Fever

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The bulk of this episode is based on the UK NICE guideline: Feverish illness in children under 5, published in 2013. http://guidance.nice.org.uk/CG160

The guideline covers:

The Traffic Light System in assessing risk for serious infection

This assessment tool takes into consideration color/appearance, activity, respiratory, circulation and hydration, and “other” parameters. For each parameter, their associated signs and symptoms are assigned a color code: “green” (low risk), “amber” (intermediate risk) and “red” (high risk). The table can be found here.

Age-appropriate investigations for pediatric fever

Once the risk for serious infection is determined, the following investigation should be performed:

Age CBC diff BC CRP UA/UC LP CXR Stool culture <1mo yes yes yes yes yes if indicated if indicated 1-3mo yes yes yes yes if unwell, or WBC >15 or <5M/mL if indicated if indicated >=3mo, RED yes yes yes yes yes yes if indicated >=3mo, AMBER yes yes yes yes if <1yr if fever >39 and WBC >20 if indicated >=3mo, GREEN no no no yes no no if indicated

And at the same time, empiric parenteral antibiotic coverage for meningitis (3rd generation cephalosporin plus ampicillin/amoxicillin) should be started if LP is indicated.

The post Pediatric Fever appeared first on Family Pharm Podcast.

Mar 06 2014

26mins

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Rank #2: ADHD 1: CADDRA Guideline

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*This episode was recorded in January 2014.

This is the topic that started it all. As Tina planned to study ADHD for school, we discussed how this would be useful information for other pharmacy students and medical trainees as well.

We looked to the comprehensive CADDRA guideline for the assessment, differential diagnoses, and treatment strategies for ADHD.

CADDRA Guideline:

ADHD Checklist on CADDRA ADHD Assessment Toolkit, page 8.20

The post ADHD 1: CADDRA Guideline appeared first on Family Pharm Podcast.

Mar 31 2014

16mins

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Rank #3: A Fib 5: Antithrombotics

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Antiplatelets:

  • ASA
  • Clopidogrel

Anticoagulants:

  • Warfarin
  • Apixaban
  • Dabigatran
  • Rivaroxaban

Clotting Cascade:

Clotting Factor Song, by Emily Anne Nagler:

Twelve, eleven, nine, it’s clotting factor time
8 and 9 to 10a 5, that’s how we stay alive

Don’t forget to say: the tissue factor way
7 to 7a helps 10 go to 10a

Then 2 to thrombin, and 1 to fibrin
And that’s how it ends

The post A Fib 5: Antithrombotics appeared first on Family Pharm Podcast.

Mar 03 2014

33mins

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Rank #4: Gastroenteritis in Children

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Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis: 

UK NICE Guideline: Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84

CPS Guideline: Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy

History:

  • onset of diarrhea and/or vomiting (gastro is sudden in onset)
  • duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days)
  • sick contact
  • pathogen exposure
  • travel history

History suggestive of increased risk of dehydration:

  • young age (esp <6mo)
  • low birth weight infants
  • >5 diarrhea in 24h
  • >2 vomiting in 24h
  • no oral intake
  • signs of malnutrition

Think about differential diagnosis if:

  • fever >38 in children younger than 3 months
  • fever >39 in children older than 3 months (fever workup required)
  • shortness of breath or tachypnoea
  • altered conscious state
  • neck stiffness
  • bulging fontanelle in infants
  • non-blanching rash
  • blood and/or mucus in stool
  • bilious (green) vomit
  • severe or localised abdominal pain
  • abdominal distension or rebound tenderness.

SSx of dehydration and shock

Table 1 in NICE

Increasing severity of dehydration

No clinically detectable dehydration

Clinical dehydration

Clinical shock

Symptoms (remote and face-to-face assessments)

Appears well

Red flag Appears to be unwell or deteriorating

Alert and responsive

Red flag Altered responsiveness (for example, irritable, lethargic)

Decreased level of consciousness

Normal urine output

Decreased urine output

Skin colour unchanged

Skin colour unchanged

Pale or mottled skin

Warm extremities

Warm extremities

Cold extremities

Signs (face-to-face assessments)

Eyes not sunken

Red flag Sunken eyes

Moist mucous membranes (except after a drink)

Dry mucous membranes (except for ‘mouth breather’)

Normal heart rate

Red flag Tachycardia

Tachycardia

Normal breathing pattern

Red flag Tachypnoea

Tachypnoea

Normal peripheral pulses

Normal peripheral pulses

Weak peripheral pulses

Normal capillary refill time

Normal capillary refill time

Prolonged capillary refill time

Normal skin turgor

Red flag Reduced skin turgor

Normal blood pressure

Normal blood pressure

Hypotension (decompensated shock)

Table 2 in CPS

TABLE 2

Clinical assessment of degree of dehydration *

Mild (under 5%)

Moderate (5-10%)

Severe (over 10%)

Slightly decreased urine output

Slightly increased thirst

Slightly dry mucous membrane

Slightly elevated heart rate

Decreased urine output

Moderately increased thirst

Dry mucous membrane

Elevated heart rate

Decreased skin turgor

Sunken eyes

Sunken anterior fontanelle

Markedly decreased or absent urine output

Greatly increased thirst

Very dry mucous membrane

Greatly elevated heart rate

Decreased skin turgor

Very sunken eyes

Very sunken anterior fontanelles

Lethargy

Cold extremities

Hypotension

Coma

*Some of these signs may not be present

SSx of hypernatremic dehydration:

  • jittery
  • increased muscle tone
  • hyperreflexia
  • convulsions
  • drowsiness or coma

Labs:

  • No routine blood work
  • Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia
  • Blood gas if shock suspected

Stool culture if:

  • blood and/or mucus in stool
  • immunocompromized
  • septicemia suspected
  • travel history
  • diarrhea not improved by day 7
  • uncertainty about diagnosis of gastroenteritis

Blood culture if antibiotic started

Watch for HUS in E. coli O157:H7

Treatment:

Figure 1 in CPS

No dehydration

  • continue breastfeeding and other milk feeds
  • encourage fluid intake
  • discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see 1.2.1.2)
  • offer ORS solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2).

Dehydration

ORT

  • Contraindications
    • IVF indicated (shock, deterioration, persistent vomiting despite NG tube)
    • paralytic ileus
    • monosaccharide malabsorption
  • use low-osmolarity ORS solution (240–250 mOsm/l)[5] (eg Pedialyte, Gastrolyte in Canada) for oral rehydration therapy
  • give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
  • give the ORS solution frequently and in small amounts
  • consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs (see table 1)
  • plain water discouraged by CPS
  • consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently
  • monitor the response to oral rehydration therapy by regular clinical assessment

IVF

  • indications:
    • Shock
    • a child with red flag symptoms or signs (see table 1) shows clinical evidence of deterioration despite oral rehydration therapy
    • a child persistently vomits the ORS solution, given orally or via a nasogastric tube.
  • Initial bolus
    • 20mL/kg of NS, then another one if still shocked
    • If no response to 2 boluses, consider other causes of shock. Consult PICU.
  • IVF therapy
    • Use NS or D5NS
    • If shocked: add 100mL/kg for fluid deficit to maintenance
    • If no shocked: add 50mL/kg for fluid deficit to maintenance
    • Early oral rehydration recommended. Switch to ORT as early as tolerated.
  • IVF in Hypernatremic dehydration
    • Urgent consult to specialist
    • Use NS or D5NS still
    • replace slowly over 48 hours, aiming at reducing serum sodium at a rate of less than 0.5mmol/L per hour

Maintenance after rehydration

  • Encourage breastfeeding, milk, and fluids
  • Consider giving 5mL/kg of ORS after each large watery stool
  • If dehydration recurs, restart ORT

Antibiotic indications:

  • suspected or confirmed septicaemia
  • extra-intestinal spread of bacterial infection
  • younger than 6 months with salmonella gastroenteritis
  • patient malnourished or immunocompromised with salmonella gastroenteritis
  • Clostridium difficile-associated pseudomembranous enterocolitis
  • giardiasis
  • dysenteric shigellosis
  • dysenteric amoebiasis
  • cholera

Do not use antidiarrhoeal medications.

Home care

Red flags for dehydration (seek medical attention):

  • appearing to get more unwell
  • changing responsiveness (for example, irritability, lethargy)
  • decreased urine output
  • pale or mottled skin
  • cold extremities

Also seek medical attention if length of illness beyond the usual course:

  • diarrhoea: 5–7 days and in most children it stops within 2 weeks
  • vomiting: 1 or 2 days and in most children it stops within 3 days

If not dehydrated:

  • to continue usual feeds, including breast or other milk feeds
  • to encourage the child to drink plenty of fluids
  • to discourage the drinking of fruit juices and carbonated drinks
  • plain water also discouraged by CPS
  • to offer ORS solution as supplemental fluid

with clinical dehydration:

  • that rehydration is usually possible with ORS solution
  • premixed ORS preferred due to risk of error (CPS)
  • to give 50 ml/kg of ORS solution for rehydration plus maintenance volume over a 4-hour period
  • to give this amount of ORS solution in small amounts, frequently
  • to seek advice if the child refuses to drink the ORS solution or vomits persistently
  • to continue breastfeeding as well as giving the ORS solution
  • not to give other oral fluids unless advised
  • not to give solid foods.

after rehydration:

  • drink plenty of their usual fluids, including milk feeds if these were stopped
  • avoid fruit juices and carbonated drinks until the diarrhoea has stopped
  • reintroduce the child’s usual diet
  • give 5 ml/kg ORS solution after each large watery stool if you consider that the child is at increased risk of dehydration

Disease prevention

  • washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis
  • hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
  • towels used by infected children should not be shared
  • children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
  • children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
  • children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

The post Gastroenteritis in Children appeared first on Family Pharm Podcast.

Mar 22 2014

19mins

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Rank #5: Pediatric UTI

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AAP Guideline on Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

UK NICE guideline: Urinary tract infection in children

Summary:

  • For children with fever, UTI should be suspected.
  • For children at a very low risk for UTI, or greater than 3 years of age, a bag urine for urinalysis is an appropriate first step. If the urinalysis is suspicious for UTI, such as being positive for leukocyte esterase or nitrite, or if the children is not at a very low risk for UTI, then a catheterized urine sample should be obtained for urine culture prior to starting empiric antibiotics.
  • If the culture comes back negative, then antibiotics treatment covering UTI can be stopped.
  • Febrile UTI is presumed to be pyelonephritis, and should be investigated with Bladder and Renal Ultrasound. If the ultrasound shows structural abnormalities, or if the child has recurrent febrile UTIs, a VCUG should be considered, especially in younger children.

The post Pediatric UTI appeared first on Family Pharm Podcast.

Mar 16 2014

12mins

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Rank #6: A Fib 4: Rhythm Control Medications

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Tina discusses the following rhythm control medications for atrial fibrillation:

Class 3 antiarrhythmics: blocks potassium channels and prolongs action potential duration

  • Amiodarone
  • Dronedarone
  • Sotalol

Class 1 antiarrhythmics: blocks sodium channels, which results in a slowed atrial conduction, lengthens atrial refractoriness, and suppresses automaticity

  • propafenone
  • flecainide

Indiana University’s P450 Drug Interaction Table: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/

References:

The post A Fib 4: Rhythm Control Medications appeared first on Family Pharm Podcast.

Feb 24 2014

19mins

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Rank #7: A Fib 2: CCS 2012 Treatment Guidelines

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The CHADS2 and HAS-BLED predictive index are useful in assessing a patient’s thromboembolic risk and in predicting which antithrombotic therapy is most suitable; and that is either aspirin, clopidogrel, or anticoagulants. The 3 new anticoagulants may be simpler to use and may have less intracranial hemorrhage side effect than warfarin, there has been longer clinical experience with warfarin and an antidote is present if needed.

As for rate control and rhythm control, there is no significant difference in controlling survival and mortality between the two. Therapy is chosen based on patient’s symptoms and preference. Rate control medications include BB, non-dihydropyridine CCB, and digoxin. And rhythm control includes dronedarone, flecainide, sotalol, and amiodarone. We will go over details of these medications in the next episode.

Catheter ablation is mainly for symptom control. It may be first line for highly selected patients,  is often considered 2nd line after multiple drug therapy, or for patients who failed on multiple antiarrhythmic therapy and maintenance of sinus rhythm is still desired.

  • Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control

http://www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext

  • The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure

http://www.onlinecjc.ca/article/S0828-282X%2812%2901379-7/abstract

  • Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Catheter Ablation for Atrial Fibrillation/Atrial Flutter

http://www.onlinecjc.ca/article/S0828-282X(10)00012-7/fulltext

The post A Fib 2: CCS 2012 Treatment Guidelines appeared first on Family Pharm Podcast.

Feb 15 2014

15mins

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Rank #8: A Fib 3: Rate Control Medications

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Tina discusses the following rate control medications for atrial fibrillation:

Beta blockers

  • Bisoprolol
  • Metoprolol
  • Atenolol

Calcium channel blockers (non-dihydropyridines)

  • verapamil
  • diltiazem

Digoxin

References:

The post A Fib 3: Rate Control Medications appeared first on Family Pharm Podcast.

Feb 22 2014

21mins

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Rank #9: A Fib 1: Etiology and Diagnosis

Feb 09 2014

17mins

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Rank #10: CHF 2: medications

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Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well:

  • Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone
  • Loop diuretic: furosemide
  • Digoxin
  • Vasodilators: hydralazine and isosorbite dinitrate

For a quick summary of the CCS 2013 recommendations:

ACE inhibitors:

  • all asymptomatic patients with an EF < 35%
  • all symptomatic HF patients and EF < 40%

ARB:

  • if intolerant to ACEI
  • add to ACEI if intolerant or contraindicated for BB
  • add to ACEI and BB if NYHA class II-IV HF and EF ≤ 40% deemed at increased risk of HF events

BB:

  • all HF patients with an EF ≤ 40%
  • initiated at a low dose and titrated to the target dose or maximal tolerated dose

MRA:

  • patients > 55 years with mild to moderate HF during standard HF treatments with EF ≤ 30% (or ≤ 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or
  • with elevated BNP or NT-proBNP levels
  • after an MI with EF ≤ 30% and HF or
  • EF ≤ 30% alone in the presence of diabetes
  • EF < 30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments

Diuretics:

  • for congestive symptoms
  • When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms
  • persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium

Digoxin:

  • patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy
  • patients with chronic atrial fibrillation (AF) and poor control of ventricular rate

Isosorbide dinitrate and hydralazine:

  • black Canadians with HF-REF
  • non-black HF patients unable to tolerate an ACE inhibitor or ARB

Drug information from:

The post CHF 2: medications appeared first on Family Pharm Podcast.

Jan 11 2014

21mins

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