The medical podcast for your cortex and funny bone. Dr Mel Herbert, Dr Jess Mason and the FOOLYBOO team bring you a Medicine, Science, History and Humor Podcast that won't hurt a bit.
The medical podcast for your cortex and funny bone. Dr Mel Herbert, Dr Jess Mason and the FOOLYBOO team bring you a Medicine, Science, History and Humor Podcast that won't hurt a bit.
A short, focused discussion of emergency medicine topics with perspectives from emergency physicians as well as other specialties. Here's the problem: When I listen to a 45 minute lecture that goes through about 15 different studies and has 50 slides, I come out feeling like a genius. An hour later, I have forgotten 95% of it. Here's the solution: ercast. We cover a single issue and try to tease out all the relevant elements without overstuffing your frontal cortex. It's for physicians and anyone interested in a bare bones look at emergency care.
Rank #1: ZDoggMD.
Zubin Damania (ZDoggMD) is an internist and founder of Turntable Health, an innovative healthcare startup that was part of an urban revitalization movement in Las Vegas. During a decade-long hospitalist career at Stanford, he experienced our dysfunctional health care system firsthand leading to burnout and depression. He created videos under the pseudonym ZDoggMD as an outlet to find his voice. This launched a grassroots movement — half a billion youtube views and a passionate tribe dedicated to improving health care for everyone. ERcast 2.0 Launches May 1 Click hereto learn more Or hereto sign up and skip the details In this interview we cover a wide range of topics including Underwear How ZDogg went from hospitalist to rapper to Medicine 3.0evanaglist Meditation The Mind Illuminated The roots of anxiety Mental preparation before giving a talk ZDogg's response to criticism, antipathy, and negative feedback from the anti-vaccine movement Nurse practitioners A Smattering of Performance Improvement, Stress Management, and Wellness Episodes Finding the Joyin Your Job Performance Coach Jason Brooks Making Order Out of Chaos How to Not Freak Out When Consultants Give Bad Advice Beating Stress and the Hot Offload Mastering the Storm Full Video Interview Below https://www.youtube.com/watch?v=bujZmXEtuHA My Favorite Zdogg Song https://www.youtube.com/watch?v=NAlnRHicgWs
Rank #2: How to Use the Pulse Ox Like a Boss.
From Essentials of Emergency Medicine NYC 2017, Reuben Strayer explains how the pulse ox might be the most useful bit of tech in the ED. Pearls: The pulse ox waveform is an excellent indicator of mechanical heart rate and peripheral perfusion. For patients breathing room air, pulse oximetry can be used to monitor for hypoventilation. Nail polish has minimal impact on the accuracy of pulse oximetry. If you are unable to get a good pulse ox waveform by adjusting or repositioning the probe, be concerned that the patient is poorly perfused. “The respiratory rate is the most vital of the vital signs.” Experienced doctors look at a patient who seems well, but understands that they’re not truly well, because they subconsciously notice tachypnea. Subconsciously is the only way to notice tachypnea, because respiratory rate is often not measured accurately. Since we don’t always have access to reliable respiratory rate, Strayer’s go-to vital sign is the oxygen saturation. “Reusable pulse oximeter probes are gross.” One study found that even when these probes are cleaned by standard procedure, ⅔ had bacteria cultured from them. Strayer recommends using single use probes in your department. Wilkins MC. Residual bacterial contamination on reusable pulse oximetrysensors. Respir Care. 1993 Nov;38(11):1155-60. PubMed PMID: 10145923. Data is conflicting about the effect of nail polish on pulse oximetry readings, but overall it is felt that the impact is minimal. Earlier data suggested that nail polish decreased sat readings by 2-10%, but more recent studies found minimal effect. If it seems that the waveform is affected by nail polish, you can remedy the situation by turning the probe 90 degrees, so it goes sideways through the finger. Yamamoto LG, et al. Nail polish does not significantly affect pulse oximetry measurements in mildly hypoxic subjects. Respir Care. 2008 Nov;53(11):1470-4. PubMed PMID: 18957149. As long as a patient is breathing room air, pulse ox can monitor ventilation and function as a hypoventilation alarm. Significantly hypercapnic patients saturate less than 95% when they’re breathing room air. So if you need to monitor a patient for hypoventilation, such as due to intoxication or procedural sedation, the pulse ox will do a great job of telling you if the patient is still breathing. If you need to give supplemental oxygen, then use capnography to monitor respirations. The pulse oximeter does so much more than provide oxygen saturation. It provides the photoplethysmogram (PPG) which is a waveform that tells you the “mechanical” heart rate. While telemetry gives the electrical heart rate, what really matters to your organs is the mechanical rate. This can be especially helpful during transvenous or transcutaneous pacing. When you have reliable tracing, the pulse ox heart rate is more reliable than the telemetry heart rate. The pulse ox can measure the peripheral perfusion index which is a more sensitive and earlier indicator of hypoperfusion than blood pressure. This is a numerical value which indicates the strength of the pulsations read by the pulse oximeter. It is based on the amplitude of the pulse ox waveform and expressed as a number between 1 (low) and 10 (high). The perfusion index dips before the stroke volume drops and long before the heart rate rises. Many monitors will report the perfusion index in tiny print after the word PERF. Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med.2002 Jun;30(6):1210-3. PubMed PMID: 12072670. van Genderen ME, et al. Peripheral perfusion index as an early predictor for central hypovolemia in awake healthy volunteers. Anesth Analg. 2013 Feb;116(2):351-6. PubMed PMID: 23302972. What if you don’t have a reliable pulse ox tracing? Most of the time this is because the probe is poorly positioned, the patient is moving too much, or there’s a lot of ambient light. If you’ve corrected for these problems and you still don’t have a good tracing, you should be concerned that the patient is poorly perfused. One study of 20,000 anesthesia cases showed that pulse ox failure was directly related to worsening physical status. Moller JT, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993 Mar;78(3):436-44. PubMed PMID: 8457044. How does the pulse ox measure oxygen saturation and what is the best way to position the oximeter probe on the finger? One side of the pulse ox puts emits visible (red) light and infrared light. On the other side is the detector. The percent oxygen saturation is calculated based on the different way in which oxyhemoglobin absorbs visible and infrared light compared with deoxyhemoglobin. The pulse ox measures carboxyhemoglobin as if it were oxyhemoglobin, giving a falsely elevated pulse ox reading for a victim of carbon monoxide poisoning. The best spot for a peripheral pulse ox is a place with a lot of capillaries and arterioles, like the fingertips, earlobes, nose, or forehead. Functionally, it doesn’t seem to matter whether the emitter is on the dorsum, volar aspect, or even side of the finger. For convenience sake, most find it ergonomically superior to have the cord and emitter on the dorsum of the finger. Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg.2007 Dec;105(6 Suppl):S10-7. Review. PubMed PMID: 18048891 Vegfors M, Lennmarken C. Carboxyhaemoglobinaemia and pulse oximetry. Br JAnaesth. 1991 May;66(5):625-6. PubMed PMID: 2031826 DeMeulenaere, Susan. "Pulse oximetry: uses and limitations." The Journal for Nurse Practitioners 3.5 (2007): 312-317. Link. Chan ED, et al. Pulse oximetry: understanding its basic principles facilitates appreciation of its limitations. Respir Med. 2013 Jun;107(6):789-99. PMID: 23490227
A podcast about how doctors think. Presented by Figure 1, the knowledge-sharing app for healthcare. Learn more at Figure1.com/ddx
Rank #1: Young, fit and female? Higher chance of misdiagnosis. .
Welcome to DDx, an original podcast by Figure 1 about how doctors think. On episode 1, host and emergency doctor Raj Bhardwaj presents a real medical case as told by the doctor who diagnosed it. A young woman is almost misdiagnosed - perhaps fatally - when she presents at an E.R. with nausea, vomiting and myalgia.
Rank #2: Extreme reactions to marijuana..
Chronic vomiting, a flushed complexion, and acute agitation: can cannabis be the cause? A growing consensus among doctors suggests cannabinoid hyperemesis syndrome is real and on the rise.
Meet 'em, greet 'em, treat 'em and street 'em
Rank #1: SGEM#209: Cephalexin – You Are My Only One for Uncomplicated Cellulitis.
[display_podcast]Date: February 27th, 2018Reference: Moran et al. Effect of Cephalexin plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis – A Randomized Clinical Trial. JAMA May 2017.Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant (PA) working primarily in rural Missouri in community hospitals. He also hosts a great…
Rank #2: SGEM#219: Shout, Shout, PERC Rule Them Out.
[display_podcast]Date: May 16, 2018Reference: Freund et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA February 2018.Guest Skeptic: Dr. Jeffrey Kline (@klinelab) is the Vice Chair of Research in Emergency Medicine and a professor of physiology, Indiana University…
We believe in the educational merits of Free Open Access Medical education (FOAM), which includes podcasts, blogs, articles on PubMed Central, conferences streamed for free and more. As a result, we would like to encourage others to move beyond quoting podcasts and into the realm of tying “cutting edge” FOAM to the core content. We’ll provide some review and references for listeners to go read. Why, indeed, should we FOAM it alone when FOAM can inspire us to go, read, think, and be excellent?
Rank #1: Episode 15 - Atrial Fibrillation/Flutter.
This week we review a post by Brent Reed on Academic Life in EM, covering pharmacologic management of atrial fibrillation. Then, we delve into core content Emergency Medicine cardiology using Rosenalli (Rosen's Emergency Medicine and Tintinalli's Emergency Medicine: A Comprehensive Review Guide). We cover atrial fibrillation, atrial flutter, and, everyone's favorite, multifocal atrial tachycardia. Key Texts: Tintinalli (7e): Ch ; Rosen's (8e) Ch As always, visit foamcast.org for show notes and the generously donated Rosh Review questions.
Rank #2: Episode 18 - Geriatrics.
This week we review Dr.Ken Milne's podcast, the Skeptics Guide to Emergency Medicine new feature - Hot off the Press. It's all about geriatric falls, y'all. Then, we delve into core content pearls on the geriatrics using Rosenalli (Rosen's Emergency Medicine and Tintinalli's Emergency Medicine: A Comprehensive Review Guide). We review polypharmacy, abdominal pain, and other key pearls. As always, visit foamcast.org for show notes and the generously donated Rosh Review questions. Thanks y'all! -Jeremy Faust and Lauren Westafer
Core EM Emergency Medicine Podcast
Rank #1: Episode 17.0 – Asthma and COPD.
Pearls from our weekly conference discussing severe asthma and COPD exacerbations. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_17_0_Final.m4a Download 4 Comments Tags: Asthma, BPAP, COPD, NIPPV, Respiratory Show Notes Shownotes EMCrit: Delayed Sequence Intubation REBEL EM: The Crashing Asthmatic EM:RAP: The Rule of 2s Abdo WF, Heunks LM. Oxygen-induced hypercapnia in COPD: myths and facts. Critical Care 16(5):323. PMID: 23106947 Read More
Rank #2: Episode 23.0 – SBO.
This week we review small bowel obstruction presentation, diagnosis and management. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_19_0_Final_Cut.m4a Download Leave a Comment Tags: Large Bowel Obstruction, SBO Show Notes 5 Minute Sono: Small Bowel Obstruction EM Lyceum: GI Imaging FOAMCast: Episode 23 – SBO and Mesenteric Ischemia Read More
The Hippo Education Podcast is the place for the best free audio CME on earth. Hippo RAPs (Reviews and Perspectives) bring you the latest news, updated clinical practice information and important stuff you need to know for your specialty. Our RAP roster is Emergency Medicine, Primary Care, Pediatrics, Urgent Care and growing. The Hippo faculty are always on duty to make sure you have the info you need from a source you can trust.
Rank #1: Primary Care RAP - Hypogonadism.
Primary Care RAP presents a segment on Hypogonadism Featuring Margaret Wierman, MD and Andrew Buelt, DO
Rank #2: Urgent Care RAP - Smoking Cessation Update.
Mike and Rob dive back in to give you some new finds on Smoking Cessation from the March 2016 Edition of Urgent Care RAP.
The Best Science (BS) Medicine Podcast is a weekly presentation where practitioners can get evidence-based drug therapy content that is practical, entertaining and promotes healthy scepticism. In essence, we are the Medication Mythbusters. We present information that is useful and relevant to physicians, pharmacists, nurses, physician assistants and other health professionals, and that can easily be incorporated into day-to-day practice. The podcast is presented by Dr. James McCormack, Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia and Dr Michael Allan, Associate Professor in the Department of Family Practice at the University of Alberta. For more about us and to get the show notes for each episode, visit our website at www.bsmedicine.com or www.medicationmythbusters.com
Rank #1: Episode 432: All the evidence for all the medications for a failing heart – PART III.
In episode 432, James and Mike finish their review of the evidence around medications for systolic heart failure. In this episode our goal was to try to make sense of the process by adding as much art as possible to the evidence and also use a modicum of common sense. Let us know if we achieved our goal.Show notes
Rank #2: Episode 439: Taking a hard look at the evidence: PDE5 inhibitors in erectile dysfunction.
In episode 439, Mike and James invite Adrienne to take us through the impressively large amount of evidence for the PDE5 inhibitors for erectile dysfunction. We find that the NNTs are 2-3 for the not clearly defined endpoint of successful intercourse. There is a 20% absolute increase in adverse effects but almost no one stops using these medications because of these effects. Go figure.
EM Basic- your boot camp guide to emergency medicine. Made for medical students and emergency medicine interns to review common chief complaints in emergency medicine from the ground up
Rank #1: Abdominal pain.
Abdominal pain is one of the most common complaints in the ED. In this podcast we will review how to get a good history, how to do a solid abdominal exam, and a systematic method for figuring out how to effectively use imaging with to make a diagnosis or, at the very least, rule out "the badness".
Rank #2: Seizures.
We encounter seizure disorders frequently in the ED. In this episode, we'll review all the important points about seizures including the confusing and difficult topic of pseudosezures. We'll also go in depth on the ED treatment of seizures and status epilepticus.
With help from leading experts, dark web entrepreneurs, and a homegrown house band, Toxicologists Howard Greller (@heshiegreshie) and Dan Rusyniak (@drusyniak) take you on an entertaining and educational journey into the field of Medical Toxicology.Special thanks to our announcer, Josh Shelov (@shelovj), Witness Protection Products™, and our house band, Meconium Aspirate.Comments, questions, suggestions, future topics, recipes? @dantastictox.Stay Healthy, True Believers!
Rank #1: Hell Hath No (Fire &) Fury Like a Poisoner Scorned.
Join Dan (@drusyniak) & Howard (@heshiegreshie) as they take a dive into the world of political poisoning with Dr. Chris Holstege (@ChrisHolstege) and learn why the cure for that acne may be more chips (or not). Thanks as always to @shelovj and @prettysimpleduo. Comments & suggestions - @dantastictox
Rank #2: Release the Kratom.
Join Dan (@drusyniak) &Howard (@heshiegreshie) as they speak with Dr. Ed Boyer about therapies for opioid use disorder, including kratom, ibogaine, and loperamide. Great stuff, deep science and a dispelling of some myths while recognizing some less than savvy science out there. . . Looking forward to part 2, where we find that the dulcet tones of Dan and Howard are the right frequency to treat your blues. Delicious Links Many of the therapeutics both prescribed and otherwise in the Pharmacological Treatment of Opioid Use Disorder. Mitragynia speciosa korth - self-treatment of opioid withdrawal using kratom. Not only adults are affected by these agents. Neonatal abstinence syndrome due to maternal kratom use. Where can you get these products and agents? Look at the impact of internet pharmacy regulation on opioid analgesics availability. But be careful where you buy. Suspected adulteration of commercial kratom products with 7-hydroxymitragynine. Get intracellular with mu-opioid receptor desensitization by beta-arrestin-2 determines morphine tolerance but not dependence. Some more information as described in beta-arrestin 2 knockout mice. How strong do you like your tea? Quantification of Morphine, Codeine, and Thebaine in Home‐Brewed Poppy Seed Tea by LC‐MS/MS. While out guest certainly doesn’t believe in the magic of ibogaine, there are many out there that still do. Here’s one example of what to look out for . . . in a patient with prolonged multiple cardiac arrhythmias after ingestion of internet purchased ibogaine. Some interesting stuff on addiction research and the use of ibogaine, a “vast, uncontrolled experiment.” Keep your eyes peeled for more cases of tianeptine misuse as reported in poison control center experience with tianeptine: an unregulated pharmaceutical product with potential for abuse. And if you haven’t already read it (and why not?) here is a great post about the toxicity of loperamide used for opioid use disorder - The Worst of Both Worlds. Special Thanks Thank you for your continued support. As always, we are looking for feedback - comments, questions, suggestions, recipes, etc. Let us know. Reach us at @toxandhound. We want to hear from you! Thank you to our house band Pretty Simple Duo (@prettysimpleduo), our announcer Josh Shelov (@shelovj), and Reverend Matt Winston of Witness Protection Products. Kraken image by Bryan Alexander. Music "Pamgaea" by Kevin MacLeod. License: CC BY Interested in #FOAMtox? Like this podcast? Take a gander at The Tox and The Hound. It’s like a podcast, but for your eyes. Listen on iTunes or Spotify! Earholes happy? Rate and review! Show the love!
Intended for the medical professional who enjoys learning for the sake of it. Dr. Porat is a practicing Colorado Hospitalist and Board Certified in Internal Medicine.
Rank #1: Pneumonia - Part 1.
Does the patient really have pneumonia? Differential diagnosis and mimics are considered in this common clinical problem. Dive deeper into how microbes and the immune system interact in lower respiratory infections.
Rank #2: Pulmonary Embolism - part 1.
The topics covered are D-Dimer testing, false positive over-diagnosis of PE on CT scanning, the ADJUST-PE study, and clinical signs and symptoms of a pulmonary embolism.
You make tough calls when caring for acutely ill and injured children. Join us for strategy and support -- through clinical cases, research and reviews, and best-practice guidance in our ever-changing acute care landscape. Please visit our site at http://PEMplaybook.org/ for show notes and to get involved with the show -- see you there!
Rank #1: Vomiting in the Young Child: Nothing or Nightmare.
In the young child, vomiting is the great imitator:Gastrointestinal, Neurologic, Metabolic, Respiratory, Renal, Infectious, Endocrine, Toxin-related, even Behavioral.To help us organize, below is a review of can't-miss diagnoses by age.The Neonate: Malrotation with VolvulusIn children with malrotation, 50% present within the first month of life, with the majority occurring in the first week after birth. 90% of children with malrotation with volvulus will present by one year of age. This is a pre-verbal child’s disease – which makes it even more of a challenge to recognize quickly. The sequence of events usually is fussiness, irritability, and forceful vomiting. The vomit quickly turns bilious. Green vomit is a surgical emergency. Babies may also present unwell, with bloating and abdominal tenderness to palpation. Be aware that later stages of malrotation may present as shock – they present in hypovolemic shock due to third-spacing from necrotic bowel and/or septic shock from translocation or perforation. In the undifferentiated sick neonate, always consider a surgical emergency such as malrotation with volvulus. In the stable patient, get an upper GI contrast study. Rapid-fire word association for other vomiting emergencies in a neonate: Fever, irritability and vomiting? Think meningitis, UTI, or sepsis. Premature, unwell, and vomiting? Think necrotizing enterocolitis. Remember, 10% of cases of NEC can be full-term. Look for pneumatosis intestinalis. Systemically ill, afebrile, and vomiting for no other reason? Think inborn error of metabolism. Screen with a glucose, ammonia, lactate, and urine ketones. Others include congenital intestinal atresia or webs, meconium ileus, or severe GERDThe Infant: Non-Accidental TraumaAll that vomits is not necessarily from the gut. Abusive head injury is the most common cause of death from child abuse. Infants especially present with non-specific complaints like fussiness or vomiting. Up to 30% of infants with abusive head injury may be misdiagnosed on initial presentation. Louwers et al. in Child Abuse and Neglect developed and validated a six-question screening tool for use the in ED. The power of this tool was that it was validated for any chief complaint – it is not an injury evaluation checklist – it is a screen for potential abuse in the undifferentiated child: Is the history consistent? Was seeking medical help unnecessarily delayed? Does the onset of injury fit with the developmental level of the child? Is the behavior of the child and his interaction with his care-givers appropriate? Do the findings of the head-to-toe examination match the history? Are there any other red flags or signals that make you doubt the safety of the child or other family members? On multivariable analysis, if at least one of the questions was positive, there was an OR of 189 for abuse (CI 97 – 300). In other words, if any of those six questions are problematic, get your child protective team involved. Other important diagnoses in the infant: intussusception and pyloric stenosis (rapid review in audio).The Toddler: Diabetic Ketoacidosis (DKA)The important diagnosis not to miss in the vomiting toddler or early school age child is the initial presentation of diabetic ketoacidosis. Children under 5 (especially those under 2) and those from lower socioeconomic groups have a higher risk of DKA as their initial presentation of diabetes. This is true for any child that isn’t quite acting right – check a finger stick blood sugar as a screen. The International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria for DKA: Hyperglycemia, with a blood glucose of >200 mg/dL (11 mmol/L) AND Evidence of metabolic acidosis, with a venous pH of less than 7.3 or a bicarbonate level of < 15 mEq/L AND Ketosis, found either in the urine or if directly checked in the blood. If you have access to checking a serum beta-hydroxybutryrate – the unsung ketone – it can help in diagnosis in unclear cases. Cerebral Edema Criteria: Minor criteria: headache, vomiting, irritability or lethargy; hypertension in the face of hypovolemia. Major criteria: change in mental status, including agitation or delirium; incontinence (especially if inappropriate for the child’s age); sluggish pupils and cranial nerve palsies; relative bradycardia (Cushing’s triad). Cerebral Edema Action Items: Immediately give mannitol, 1 g/kg over 15-20 minutes. May repeat it in 2 hours if needed. Hypertonic saline (3% NaCl) is second-line therapy. Put the head of the bed up 30 degrees. Alert your colleagues and counsel your parents. Make sure everyone knows what to watch out for. As you can see, vomiting in the young child can be really anything! Keep your differential broad, and think by age and by system. Differential Diagnosis of Vomiting in Children The general approach to the child with chiefly vomiting starts with the decision: sick or not sick. If ill appearing, establish rapid IV access, or if needed IO. Rapid blood sugar and if available a point of care pH and electrolytes. Be the detective in your history and doggedly go after any red flags as you go methodically by organ system. Do a careful physical exam. The general assessment is always helpful – is the child irritable, listless, agitated? What is his work of breathing? Effortless tachypnea may be a sign of acidosis or sepsis. Is the abdomen soft or is it tender or distended. Always look in the diaper area – is there a hernia, is there a high-riding, tender, discolored scrotum without cremasteric reflex? Ovarian torsion has been reported in infants as young as 7 months. Any skin signs? Look for petechiae, urticaria, purpura. In other words, use your best judgement, have the dangerous differentials in the back of your mind, and pull the trigger when red flags mount up. Otherwise, a good history and a good exam will get you where you need to be.Take home points for the young child with vomiting: Neonates are allowed to regurgitate (effortless reflux of stomach contents -- the happy spitter-upper). They are not allowed to vomit (forceful, unpleasant contraction of abdominal muscles). Consider surgical causes of forceful vomiting, especially if the child does not look anything other than well. Bilious is bad – green vomit is always a surgical emergency – do not pass go – get the surgeons involved early Not all vomiting is GI related – if it is not obviously benign, think methodically by organ system and adjust your targeted history and physical to pick up any leads. Match the tempo of your treatment to the tempo of the disease.ReferencesApplegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics. 2006; 26(5):1485-500. Glaser NS, Wootton-Gorges SL, Buonocore MH et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006 Apr;7(2):75-80. Louwers ECFM, Korfage IJ, Affourtit MJ et al. Accuracy of a screening instrument to identify potential child abuse in emergency departments. Child Abuse & Neglect. 2014; (38): 1275–1281. Lee HC, Pickard SS, Sridhar S et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1): e49–e51. Marcin JP, Glaser N, Barnett P et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002; 141(6):793-7. Parashette KR, Croffie J. Intestinal Malrotation in Children: A Problem-solving Approach to the Upper Gastrointestinal. Pediatrics in Review. 2013; (34)7: 307-321. Wolfsdorf JI, Allgrove J, Craig ME et al. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014 Sep;15 Suppl 20:154-79. This post and podcast are dedicated to Damian Roland, BMedSci (Hons), MB BS, MRCPCH, for his fervor in the care of children and his dedication to quality medical education. Nausea and Vomiting | Non-Accidental Trauma | DKA Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP
Rank #2: Bronchiolitis.
"By the pricking of my thumbs, Something wheezing this way comes." -- Witches in Macbeth, with apologies to William Shakespeare "Bronchiolitis is like a pneumonia you can’t treat. We support, while the patient heals." -- Coach, still apologetic to the Bard The Who The U.S. definition is for children less than two years of age, while the European committee includes infants less than one year of age. This is important: toddlerhood brings with it other conditions that mimic bronchiolitis – the first-time wheeze in a toddler may be his reactive airway response to a viral illness and not necessarily bronchiolitis. The What The classic clinical presentation of bronchiolitis starts just like any other upper respiratory tract infection: with nasal discharge and cough, for the first 1-2 days. Only about 1/3 of infants will have a low-grade fever, usually less than 39°C. We may see the child in the ED at this point and not appreciate any respiratory distress – this is why precautionary advice is so important in general. Then, lower respiratory symptoms come: increased work of breathing, persistent cough, tachypnea, retractions, belly breathing, grunting, and nasal flaring. Once lower respiratory symptoms are present, like increased work of breathing, they typically peak at day 3. This may help to make decisions or counsel parents depending on when the child presents and how symptomatic he is. You’ll hear fine crackles and wheeze. A typical finding in bronchiolitis is a minute-to-minute variation in clinical findings – one moment the child could look like he’s drowning in his secretions, and the next minute almost recovered. This has to do with the dynamic nature of the secretion, plugging, obstruction, coughing, dislodgement, and re-plugging. The Why Respiratory syncytial virus is the culprit in up to 90% of cases of bronchiolitis. The reason RSV is so nasty is the immune response to the virus: it binds to epithelial cells, replicates, and the submucosa becomes edematous and hypersecretes mucus. RSV causes the host epithelia and lymphocytes to go into a frenzy – viral fusion proteins turn the membranes into a sticky goop – cells fuse into other cells, and you have a pile-on of multinucleated dysfunction. This mucosal chaos causes epithelial necrosis, destruction of cilia, mucus plugs, bronchiolar obstruction, air trapping, and lobar collapse. High-Risk Groups Watch out especially for young infants, so those less than 3 months of age. Apnea may be the presenting symptom of RSV. Premature infants, especially those less than 32 weeks’ gestation are at high risk for deterioration. The critical time is 48 weeks post-conceptional age. Other populations at high-risk for deterioration: congenital heart disease, pulmonary disease, neuromuscular disorders, metabolic disorders. Guiding Principles In the full term child, greater than one month, and otherwise healthy (no cardiac, pulmonary, neuromuscular, or metabolic disease), we can look to three simple criteria for home discharge. If the otherwise healthy child one month and older is: Euvolemic Not hypoxic Well appearing He can likely go home. The How Below is a list of modalities, treatments, and the evidence and/or recommendations for or against: Chest Radiograph Usually not necessary, unless the diagnosis is uncertain, or if the child is critically ill. Factors that are predictive of a definite infiltrate are: significant hypoxia (< 92%), grunting, focal crackles, or high fever (> 39°C). Ultrasound Not ready for prime time. Two small studies, one by Caiulo et al in the European J or Pediatrics and one by Basile et al. in the BMC Pediatrics that show some preliminary data, but not enough to change practice yet. Viral Testing Qualitative PCR gives you a yes or no question – one that you’ve already answered. It is not recommended for routine use. PCR may be positive post-infection for several weeks later (details in audio). Quantitative PCR measures viral load; an increased quantitative viral load is associated with increased length of stay, use of respiratory support, need for intensive care, and recurrent wheezing. However, also not recommended for routine use. There is one instance in which viral testing in bronchiolitis can be helpful – in babies less than a month of life, the presence of RSV virus is associated with apnea. Blood or Urine Testing Routine testing of blood or urine is not recommended for children with bronchiolitis. Levine et al in Pediatrics found an extremely low risk of serious bacterial illness in young febrile infants with RSV. The main thing is not to give in to anchoring bias here. If an infant of 3 months of age or older has a clear source for his low-grade fever – and that is his bronchiolitis – then you have a source, and very rarely do you need to go looking any further. He’s showing you the viral waterfall from his nose, and his increased work of breathing. It’s not going to be in his urine. Bronchodilators! Should we use bronchodilators in bronchiolitis? It seems lately that this is a loaded question – with strong feelings on either side amongst colleagues. The short answer is that the American Academy of Pediatrics, the UK’s National Institute for Health and Care Excellence, as well as the Canadian Pediatric Society currently recommend against them. However, in continental Europe and Australia, the language is softened to “not routinely recommended”. Pros and Cons in Audio; the 2006 AAP Guidelines and the 2014 AAP Guidelines use same data to come to divergent recommendations. Steroids There is no role for steroids in the treatment of bronchiolitis, even in those with a family or personal history of atopy. Nebulized Hypertonic Saline May show some benefit in admitted patients, after repeated treatments; no data to support its use in ED patients (no immediate effect). Nebulized Epinephrine One randomized controlled double blinded study in eight centers in Norway published in the NEJM showed no benefit to nebulized epinephrine over nebulized saline. Again, probably asking too much of one single intervention. The Cochrane review found 19 studies that included a total of 2256 children with acute bronchiolitis treated with nebulized epinephrine. There were no differences in length of hospital stay between the placebo and treatment groups, and so they concluded that for inpatients, nebulized epinephrine is not worth the hassle. However – and this may just be an artifact of meta-analysis – there may be some benefit to outpatients. One study of combined high-dose steroid and epinephrine therapy was not statistically significant when other factors were controlled, but Cochrane concluded that nebulized epinephrine itself may be helpful for outpatients. It won’t affect the overall disease time course, but it may make them feel better enough to go home from the ED and continue observation there. High-Flow Nasal Cannula Oxygen High-flow oxygen via nasal cannula requires specialized equipment and delivers humidified oxygen at 1-2 L/g/min. In addition to oxygenation, high flow nasal cannula also likely offers some low-grade positive end-expiratory pressure, which may help with alveolar recruitment. The evidence for its use is based on observational studies, which have found improved respiratory parameters and reduced rates of intubation. Nasal CPAP also has some promising properties in the right clinical setting. Antibiotics Not recommended. When bronchiolitis is from a clear viral source, the risk of accompanying bacteremia is less than 1%. A meta-analysis of randomized clinical trials found that antibiotics in bronchiolitis did not improve duration of symptoms, length of hospital stay, need for oxygen therapy, or hospital admission. Summary: The Good, the Bad, and the Ugly The Good Nasal suction and hydration are your best allies. You may elect to give a bronchodilator as a trial once and reexamine, if you’re a bronchodilating believer. The Bad Steroids, antibiotics, and a blind obeying of the guidelines. Weigh the risks and benefits of every intervention, including hospitalization – it’s not always a benign thing. The Ugly Take a moment to assess the child and make a clinical diagnosis of bronchiolitis, after you’ve excluded cardiac disease, anatomic anomalies, and foreign body aspiration. Wheezing without upper respiratory symptoms is not viral, and it is not bronchiolitis. When all else fails, remember: in the otherwise healthy, term infant greater than a month of age, if he is well appearing, euvolemic, and not hypoxic, he will often do well with good precautionary advice and supportive care at home. Every thing else: be skeptical, be thorough, and above all, be careful. References Alansari K, Toaimah FH, Khalafalla H, El Tatawy LA, Davidson BL, Ahmed W. Caffeine for the Treatment of Apnea in Bronchiolitis: A Randomized Trial. J Pediatr. 2016 May 14. pii: S0022-3476(16)30170-6. [Epub ahead of print] American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93. Beggs S, Wong ZH, Kaul S, Ogden KJ, Walters JA. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev. 2014 Jan 20;(1):CD009609. Bergroth E, Aakula M, Korppi M, Remes S, Kivistö JE, Piedra PA, Camargo CA Jr, Jartti T. Post-bronchiolitis Use of Asthma Medication: A Prospective 1-year Follow-up Study. Pediatr Infect Dis J. 2016 Apr;35(4):363-8. Cunningham S, Rodriguez A, Adams T, Boyd KA, Butcher I, Enderby B, MacLean M, McCormick J, Paton JY, Wee F, Thomas H, Riding K, Turner SW, Williams C, McIntosh E, Lewis SC; Bronchiolitis of Infancy Discharge Study (BIDS) group. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet. 2015 Sep 12;386(9998):1041-8. Flett KB, Breslin K, Braun PA, Hambidge SJ. Outpatient course and complications associated with home oxygen therapy for mild bronchiolitis. Pediatrics. 2014 May;133(5):769-75. Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2016 Aug 20. [Epub ahead of print] Halstead S, Roosevelt G, Deakyne S, Bajaj L. Discharged on supplemental oxygen from an emergency department in patients with bronchiolitis. Pediatrics. 2012 Mar;129(3):e605-10. Johnson LW, Robles J, Hudgins A, Osburn S, Martin D, Thompson A. Management of bronchiolitis in the emergency department: impact of evidence-based guidelines? Pediatrics. 2013 Mar;131 Suppl 1:S103-9. Lashkeri T, Howell JM, Place R. Capnometry as a predictor of admission in bronchiolitis. Pediatr Emerg Care. 2012 Sep;28(9):895-7. Lehners N, Tabatabai J, Prifert C, Wedde M, Puthenparambil J, Weissbrich B, Biere B, Schweiger B, Egerer G, Schnitzler P. Long-Term Shedding of Influenza Virus, Parainfluenza Virus, Respiratory Syncytial Virus and Nosocomial Epidemiology in Patients with Hematological Disorders. PLoS One. 2016 Feb 11;11(2):e0148258. Liet JM, Ducruet T, Gupta V, Cambonie G. Heliox inhalation therapy for bronchiolitis in infants. Cochrane Database Syst Rev. 2015 Sep 18;(9):CD006915. Mammas IN, Spandidos DA. Paediatric Virology in the Hippocratic Corpus. Exp Ther Med. 2016 Aug;12(2):541-549. Mansbach JM, Clark S, Teach SJ, Gern JE, Piedra PA, Sullivan AF, Espinola JA, Camargo CA Jr. Children Hospitalized with Rhinovirus Bronchiolitis Have Asthma-Like Characteristics. J Pediatr. 2016 May;172:202-204.e1. Meissner HC. Viral Bronchiolitis in Children. N Engl J Med. 2016 Jan 7;374(1):62-72. Munywoki PK, Koech DC, Agoti CN, Kibirige N, Kipkoech J, Cane PA, Medley GF, Nokes DJ. Influence of age, severity of infection, and co-infection on the duration of respiratory syncytial virus (RSV) shedding. Epidemiol Infect. 2015 Mar;143(4):804-12. Oakley E, Borland M, Neutze J, Acworth J, Krieser D, Dalziel S, Davidson A, Donath S, Jachno K, South M, Theophilos T, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial. Lancet Respir Med. 2013 Apr;1(2):113-20. Epub 2012 Dec 21. Oakley E et al. Nasogastric Hydration in Infants with Bronchiolitis Less Than 2 Months of Age. J Pediatr. 2016. [Article in Press] Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis. JAMA Pediatr. 2016 Jun 1;170(6):602-8. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502. Roqué i Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2016 Feb 1;2:CD004873. Skjerven HO et al. Racemic adrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013 Jun 13;368(24):2286-93. This post and podcast are dedicated to Linda Girgis MD, FAAFP, for her authenticity, innovation, and clear and honest voice on the the frontlines. Thank you, Dr Linda. Bronchiolitis Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP
This podcast account features all of the audio clips from the Academic Life in Emergency Medicine (ALiEM) educational blog site. http://www.ALiEM.com
Rank #1: ACEP EQUAL: ACEP Non-STEMI Clinical Policy (Dr. Tomaszewski and Dr. Ross).
Drs. Christian Tomaszewski and Michael Ross reviews the 2018 ACEP Clinical Policy on Critical Issues in the Evaluation and Management of Emergency Department Patients with Suspected Non–ST-Elevation Acute Coronary Syndromes (NSTEMI). Read the entire policy here: https://www.acep.org/patient-care/clinical-policies/nonst-elevation-acute-coronary-syndromes/Dr. Tomaszewski was the lead for writing this clinical policy and is a Professor of Emergency Medicine at UC San Diego. Mr. Ross is a Professor of Emergency Medicine at Emory. He is the Medical Director of Observation Medicine for the Department of Emergency Medicine and the Chest Pain Center Director for Emory university.Hosted by Dr. Jason Woods
Rank #2: ACEP-EQUAL: Antibiotics Review.
This is a bonus episode from our discussion of antibiotic stewardship in sepsis. Dr. Jessica Whittle, ACEP liaison to the IDSA, gives a rapid-fire review of antibiotic use by body system and common pitfalls of antibiotic choice. Host Jason Woods, MD guides the discussion.
Join cohosts Kendall Britt, MD and Amy Rogers, MD for a 15 minute check-up on current issues in medicine and health policy. The doctors examine current medical concerns in light of the best available medical evidence and the policy issues of the day with a focus on their impact on the doctor patient relationship.
Rank #1: Episode 3: Affordable Care Act.
Since March 2010, health care in the U.S. has been subject to the Affordable Care Act, also known as Obamacare. There is a significant amount of confusion about what exactly this law does or does not do. In this episode, we talk about the key provisions of the law and how it affects the delivery of healthcare in the U.S. We cover: the effect of the law on insurance subsidies the pre-exisiting conditions clause the mandatory coverage provision pharmaceutical pricing and other key requirements of the law. In this episode we refer to the following information: Insurance companies requesting rate reviews under Obamacare
Rank #2: Episode 70: Our Thoughts on Trumpcare, Part 1.
UPDATE: Since the episode aired (like the very next day) the Congressional Budget Office came out with their assessment of the American Healthcare Act. It was not positive. Stay tuned to the second part of this episode coming out on Monday, March 20, where we will discuss what they had to say. _________________ Over the past week, we've finally gotten to take a look at the elusive Republican healthcare plan, the proposed replacement for Obamacare. In this episode we talk about the faults opponent found with Obamacare, and how the proposed plan, which we call Trumpcare, attempts to address those issues. This is the first installment of a two-part episode on Trumpcare, so be sure to listen this week and next week to get our full analysis. Resources: Health Affairs Blog on AHCA Kaiser's side-by-side comparison of Obamacare and AHCA Obamacare Essential Healht Benefits Be sure and subscribe in iTunes or Stitcher if you haven’t already. And you know we’d appreciate it so much if you would tell your friends about 2 Docs Talk! Listen on iTunes Listen on Stitcher Now Available on Google Play Music!
Bedside Rounds is a storytelling podcast about medical history and medicine’s intersections with society and culture. Host Adam Rodman seeks to tell a few of these weird, wonderful, and intensely human stories that have made modern medicine.
Rank #1: 3 - Dark Winter.
In episode 3 of Bedside Rounds, I talk about the human triumph of small pox vaccination, and discuss the government exercise called Dark Winter which simulated a bioterrorism attack on the United States.
Rank #2: 45 - The French Disease at 500.
In 1495, a mysterious and deadly plague struck the city of Naples. Over the next 500 years, the medical attempts to understand and treat this new disease -- syphilis -- would mold and shape medicine in surprising ways. In this episode, Tony Breu and I will perform an historical and physiological biography of syphilis, covering the development of germ theory, epic poetry, mercury saunas, intentionally infecting patients with malaria, magic bullets, and lots and lots of experiments on poor rabbits. This presentation was performed live at the American College of Physicians’ national meeting in Philadelphia on April 11, 2019. Sources (WARNING -- LONG LIST): Swain, K. ‘Extraordinarily arduous and fraught with danger’: syphilis, Salvarsan, and general paresis of the insane. Lancet Psychiatry 5, (2018). Kępa, M. et al. Analysis of mercury levels in historical bone material from syphilitic subjects – pilot studies (short report). Kępa Małgorzata 69, 367-377(11) (2012). Forrai, J. Syphilis - Recognition, Description and Diagnosis. (2011). doi:10.5772/24205 Parascandola, J. From mercury to miracle drugs: syphilis therapy over the centuries. Pharm Hist 51, 14–23 (2009). Eisler, C. Who Is Dürer’s ‘Syphilitic Man’? Perspect Biol Med 52, 48–60 (2009). Rothschild, B. M. History of Syphilis. Clin Infect Dis 40, 1454–1463 (2005). Schwartz, R. S. Paul Ehrlich’s Magic Bullets. New Engl J Medicine 350, 1079–1080 (2004). Fee, E. The wages of sin. Lancet 354, SIV61 (1999). O’Shea, J. ‘Two Minutes with Venus, Two Years with Mercury’-Mercury as an Antisyphilitic Chemotherapeutic Agent. J Roy Soc Med 83, 392–395 (1989). Mahoney, J., Arnold, R., Sterner, B. L., Harris, A. & Zwally, M. Penicillin Treatment of Early Syphilis: II. Jama 251, 2005–2010 (1984). Waugh, M. Role played by Italy in the history of syphilis. Sex Transm Infect 58, 92–95 (1982). Thorburn, A. Fritz Richard Schaudinn, 1871-1906: protozoologist of syphilis. Sex Transm Infect 47, 459–461 (1971). CROSBY, A. W. The Early History of Syphilis: A Reappraisal. Am Anthropol 71, 218–227 (1969). Clark, E. G. & Danbolt, N. The Oslo study of the natural history of untreated syphilis An epidemiologic investigation based on a restudy of the Boeck-Bruusgaard material a review and appraisal. J Chron Dis 2, 311–344 (1955). MUNGER, R. S. Guaiacum, the Holy Wood from the New World. J Hist Med All Sci IV, 196–229 (1949). Thomas, E. & r, W. Rapid Treatment of Early Syphilis with Multiple Injections of Mapharsen. J Nerv Ment Dis 99, 88 (1944). WIEDER, L., FOERSTER, O. & FOERSTER, H. MAPHARSEN IN THE TREATMENT OF SYPHILIS: FURTHER EXPERIENCES. Arch Dermatol Syph 35, 402–413 (1937). THON, L. SHOULD THE INTERNIST KNOW SYPHILIS? J Amer Med Assoc 97, 994–996 (1931). Sarton, G. The Earliest Printed Literature on Syphilis, being Ten Tractates from the Years 1495-1498. Karl Sudhoff , Charles Singer , Henry E. Sigerist. Isis 8, 351–354 (1926). COLE, H., GERICKE, A. & SOLLMANN, T. THE TREATMENT OF SYPHILIS BY MERCURY INHALATIONS: HISTORY, METHOD AND RESULTS. Arch Dermatol Syph 5, 18–33 (1922). Mason, U. Observation: Use and Abuse of Salvarsan. J Natl Med Assoc 3, 340–3 (1911). Fleming, A. & Colebrook, L. ON THE USE OF SALVARSAN IN THE TREATMENT OF SYPHILIS. Lancet 177, 1631–1634 (1911). Evans, A. The Treatment of Syphilis by Salvarsan (Dioxy-diamido-arseno-benzol). Brit Med J 1, 617 (1911). Boeck, W. History, Theory and Practice of Syphilisation. New Engl J Medicine 73, 20–25 (1865). Veale, H. Remarks on Syphilis and Its Treatment. Edinb Medical J 10, 10–26 (1864). LaFond RE and Lukehart SA, Biological Basis for Syphilis. Clinical Microbiology Reviews 2006. Secher L et al, Treponema pallidum in peripheral nerve tissue of syphilitic chancres. Acta dermato-venereologica 1982. Hollander DH, Turner TB, The role of temperature in experimental treponemal infection. American journal of syphilis, gonorrhea, and venereal diseases, 1954 Eagle H, et al. The effect of hyperpyrexia on the therapeutic efficacy of penicillin in experimental syphilis. American journal of syphilis, gonorrhea, and venereal diseases, 1947. Kampmeier RH, Syphilis therapy: an historical perspective. Journal of the American Venereal Disease Association 1976. Pachner AR, Spirochetal Diseases of the CNS. Neurologic clinics, 1986. Sell S et al, Experimental syphilitic orchitis in rabbits: ultrastructural appearance of Treponema pallidum during phagocytosis and dissolution by macrophages in vivo. Laboratory investigation; a journal of technical methods and pathology, 1982. Taylor SH, Diuretics in cardiovascular therapy. Perusing the past, practising in the present, preparing for the future. Zeitschrift für Kardiologie, 1985. Ovchinnikov NM, [Treponema pallidum in peripheral nerves of rabbit syphiloma]. Vestnik dermatologii i venerologii, 1975. Cheek DB, Wu F, The Effect of Calomel on Plasma Epinephrine in the Rat and the Relationship to Mechanisms in Pink Disease, Archives of Disease in Childhood, 1959 Vogl A, The discovery of the organic mercurial diuretics, American Heart Journal, 1950 Schwemlein GX et al, Penicillin and fever therapy in early syphilis, Journal of the American Medical Association, 1948. Stringham JS, On the Diuretic Effects of Mercury in a Case of Syphilis. The Medical and physical journal, 1807 Evanson RL et al, Effect of mercurial diuretics on tubular sodium and potassium transport in the dog. The American journal of physiology, 1972 Sell S and Salman J, Demonstration of Treponema pallidum in Axons of Cutaneous Nerves in Experimental Chancres of Rabbits, Sexually Transmitted Diseases, 1992 Penn CW, Avoidance of Host Defences by Treponema pallidum in Situ and on Extraction from Infected Rabbit Testes, Microbiology 1981. Beutler B and Munford RS, Tumor Necrosis Factor and the Jarisch–Herxheimer Reaction, The New England Journal of Medicine 1996. Radolf JD et al, Treponema pallidum: doing a remarkable job with what it's got. Trends in Microbiology, 1999 Tight RR, Perkins RL, Treponema pallidum infection in subcutaneous polyethylene chambers in rabbits. Infection and immunity, 1976 Salazar JC et al, Treponema pallidum Elicits Innate and Adaptive Cellular Immune Responses in Skin and Blood during Secondary Syphilis: A Flow-Cytometric Analysis. The Journal of Infectious Diseases, 2007 Azevedo BF et al, Toxic Effects of Mercury on the Cardiovascular and Central Nervous Systems. Journal of Biomedicine and Biotechnology 2012, Clarkson TW and Magos L, The Toxicology of Mercury and Its Chemical Compounds, Critical Reviews in Toxicology 2008. Fitzgerald TJ, The Th1/Th2-like switch in syphilitic infection: is it detrimental? Infection and immunity, 1992 Batterman RC et al, THE SUBCUTANEOUS ADMINISTRATION OF MERCAPTOMERIN (THIOMERIN®): Effective Mercurial Diuretic for the Treatment of Congestive Heart Failure. Journal of the American Medical Association, 1949 Batterman RC, The status of mercurial diuretics for the treatment of congestive heart failure. American Heart Journal, 1951 Bleich HL et al, The Role of Regional Body Temperature in the Pathogenesis of Disease, The New England Journal of Medicine, 1981 Vander Veer JB et al, The Prolonged Use of an Oral Mercurial Diuretic in Ambulatory Patients with Congestive Heart Failure. Circulation 1950 Cox DL et al, The outer membrane, not a coat of host proteins, limits antigenicity of virulent Treponema pallidum. Infection and immunity, 1992. Fildes P, The Mechanism of the Anti-bacterial Action of Mercury. Br J Exp Pathol, 1940 Clarkson TW, THE MECHANISM OF ACTION OF MERCURIAL DIURETICS IN RATS; THE METABOLISM OF 203Hg‐LABELLED CHLORMERODRIN. British Journal of Pharmacology and Chemotherapy, 1965 Engelkens HJ et al, The localisation of treponemes and characterisation of the inflammatory infiltrate in skin biopsies from patients with primary or secondary syphilis, or early infectious yaws. Genitourinary Medicine, 1993 Belum GR et al, The Jarisch–Herxheimer reaction: Revisited. Travel Medicine and Infectious Disease, 2013 Arando M et al, The Jarisch–Herxheimer reaction in syphilis: could molecular typing help to understand it better? Journal of the European Academy of Dermatology and Venereology, 2018. Butler T, The Jarisch–Herxheimer Reaction After Antibiotic Treatment of Spirochetal Infections: A Review of Recent Cases and Our Understanding of Pathogenesis. The American Journal of Tropical Medicine and Hygiene, 2016 Carlson JA et al, The Immunopathobiology of Syphilis: The Manifestations and Course of Syphilis Are Determined by the Level of Delayed-Type Hypersensitivity. The American Journal of Dermatopathology 2011. Aronson IK and Soltani K, The enigma of the pathogenesis of the Jarisch-Herxheimer reaction. The British Journal of Venereal Diseases, 1976 Sellato TJ et al, The Cutaneous Response in Humans to Treponema pallidum Lipoprotein Analogues Involves Cellular Elements of Both Innate and Adaptive Immunity, The Journal of Immunology 2001 Spiller HA, Rethinking mercury: the role of selenium in the pathophysiology of mercury toxicity. Clinical Toxicology 2017 Sell S et al, Reinfection of chancre-immune rabbits with Treponema pallidum. I. Light and immunofluorescence studies. The American journal of pathology 1985. Grant SS and Hung DT, Persistent bacterial infections, antibiotic tolerance, and the oxidative stress response, Virulence 2013 Lant AF, Modern diuretics and the kidney. Journal of Clinical Pathology, 1981 Kamath SU et al, Mercury-based traditional herbo-metallic preparations: a toxicological perspective, Archives of Toxicology 2012. Yeter et al, Mercury Promotes Catecholamines Which Potentiate Mercurial Autoimmunity and Vasodilation: Implications for Inositol 1,4,5-Triphosphate 3-Kinase C Susceptibility in Kawasaki Syndrome. Korean Circulation Journal 2013 Wöβmann W et al, Mercury intoxication presenting with hypertension and tachycardia. Archives of Disease in Childhood, 1999 Giacani L et al, Identification of the Treponema pallidum subsp. pallidum TP0092 (RpoE) Regulon and Its Implications for Pathogen Persistence in the Host and Syphilis Pathogenesis. Journal of Bacteriology 2013. Edwards AM, From tooth to hoof: treponemes in tissue‐destructive diseases. Journal of Applied Microbiology, 2003 Wolgemuth CW, Flagellar motility of the pathogenic spirochetes. Seminars in Cell & Developmental Biology 2015. Solomon HC and Kopp I, Fever Therapy. The New England Journal of Medicine 1937. Rice KM et al, Environmental Mercury and Its Toxic Effects. Journal of Preventive Medicine and Public Health 2014. Drusin LM, Electron microscopy of Treponema pallidum occurring in a human primary lesion. Journal of bacteriology 1969. McNeely MC et al, Cutaneous secondary syphilis: Preliminary immunohistopathologic support for a role for immune complexes in lesion pathogenesis. Journal of the American Academy of Dermatology 1986. Borenstein LA et al, Contribution of rabbit leukocyte defensins to the host response in experimental syphilis. Infection and immunity 1991. Cabot RC et al, Case 51-1976 — Bicentennial CPC — Syphilis, Diarrhea and Death in the 1820's. The New England Journal of Medicine 1976. Hobman JL and Crossman LC, Bacterial antimicrobial metal ion resistance. Journal of Medical Microbiology 2015 Gelpi A and Tucker JD, After Venus, mercury: syphilis treatment in the UK before Salvarsan. Sexually Transmitted Infections 2015. MacHaffie et al, A study of the effectiveness of mercurial diuretics in treatment of cardiac decompensation. The American Journal of Cardiology 1958 Aberer W et al, Ammoniated mercury ointment: outdated but still in use. Contact Dermatitis 1990 Farhi D, Dupin N, Origins of syphilis and management in the immunocompetent patient: Facts and controversies. Clinics in Dermatology (2010) 28, 533–538 Frith J, “Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins,” Journal of Military and Veterans’ Health, 20(4), retrieved online at: http://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/ Howes OD et al, “Julius Wagner-Jauregg, 1857-1940,” American Journal of Psychiatry, April 2009 Volume 166 Number 4, Volume 166, Issue 4, April, 2009, pp. 409-409. Karamanou M et al, “Julius Wagner-Jauregg (1857-1940): Introducing fever therapy in the treatment of neurosyphilis.” Psychiatriki. 2013 Jul-Sep;24(3):208-12. Simpson WM, “Artificial fever therapy of syphilis,” JAMA. 1935;105(26):2132-2140. Tsay CJ, “Julius Wagner-Jauregg and the Legacy of Malarial Therapy for the Treatment of General Paresis of the Insane,” Yale J Biol Med. 2013;86(2): 245–254 Wagner-Jauregg J, “The history of malaria treatment of general paralysis.” Am J Psychiatry. 1946;02: 577-582 Shafer JK et al, Untreated syphilis in the male Negro: A prospective study of the effect on life expectancy. Public Health Rep. 1954 Jul; 69(7): 684–690. Abara WE et al, Syphilis Trends among Men Who Have Sex with Men in the United States and Western Europe: A Systematic Review of Trend Studies Published between 2004 and 2015. PLoS One. 2016; 11(7): e0159309. Nutton V, The Reception of Fracastoro's Theory of Contagion: The Seed That Fell among Thorns? Osiris, Vol. 6, Renaissance Medical Learning: Evolution of a Tradition (1990) Tsaraklis A, Preventing syphilis in the 16th century: the distinguished Italian anatomist Gabriele Falloppio (1523-1562) and the invention of the condom. 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Emergency Medicine Cases – Where the Experts Keep You in the Know. For complete episodes please visit emergencymedicinecases.com
Rank #1: Episode 71 ACLS Guidelines 2015 – Cardiac Arrest Controversies Part 1.
A lot has changed over the years when it comes to managing the adult in cardiac arrest. As a result, survival rates after cardiac arrest have risen steadily over the last decade. With the release of the 2015 American Heart Association ACLS Guidelines 2015 online on Oct 16th, while there aren’t a lot a big changes, there are many small but important changes we need to be aware of, and there still remains a lot of controversy. In light of knowing how to provide optimal cardio-cerebral resuscitation and improving patient outcomes, in this episode we’ll ask two Canadian co-authors of The Guidelines, Dr. Laurie Morrison and Dr. Steve Lin some of the most practice-changing and controversial questions. The post Episode 71 ACLS Guidelines 2015 – Cardiac Arrest Controversies Part 1 appeared first on Emergency Medicine Cases.
Rank #2: Episode 4: Acute Congestive Heart Failure.
Dr. Eric Letovsky and Dr. Brian Steinhart describe a practical way to approach patients with undifferentiated SOB and acute congestive heart failure, the utility of various symptoms and signs in the diagnosis of CHF, as well as the controversies surrounding the best use of BNP and Troponin in the ED. A discussion of the use of ultrasound for patients with SOB as well as the indications for formal Echo are reviewed. In the second part of the episode they discuss the management of acute congestive heart failure based on a practical EM model, as well as the difficulties surrounding disposition of patients with CHF. The post Episode 4: Acute Congestive Heart Failure appeared first on Emergency Medicine Cases.