Podcasts about am j med

Contributor: Travis Barlock MD Educational Pearls Frank's sign is a curious physical exam finding first described in the literature in 1973 Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases The pathophysiology is still not fully understood One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation References Elliott WJ, Karrison T. Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease: a prospective cohort study. Am J Med. 1991;91(3):247-254. doi:10.1016/0002-9343(91)90123-f Nazzal S, Hijazi B, Khalila L, Blum A. Diagonal Earlobe Crease (Frank's Sign): A Predictor of Cerebral Vascular Events. Am J Med. 2017;130(11):1324.e1-1324.e5. doi:10.1016/j.amjmed.2017.03.059 Stoyanov GS, Dzhenkov D, Petkova L, Sapundzhiev N, Georgiev S. The Histological Basis of Frank's Sign. Head Neck Pathol. 2021;15(2):402-407. doi:10.1007/s12105-020-01205-4 Summarized & Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

In part 2, we dig into the history of pulmonary hypertension. How did this strange diagnosis first get recognized, what does it have to do with cows with thick necks and urinary catheters in the heart? Intro 0:11 In this episode 0:17 Recap of part 1 0:26 How was pulmonary hypertension discovered? 2:38 1891 3:51 1901 5:07 1935 7:02 Hilar dance 12:58 Cardiac catheterization: 1929 15:03 When did cardiac catheterization become relevant? 20:10 1965: Aminorex 24:40 World Health Organization: 1975 26:37 1980s: toxic oil syndrome of Spain 28:20 Preview of part 3 33:15  Back to cardiac catheterization 34:08 Briskets disease 35:45 1947 37:56 Pulmonary physiology and prostaglandin therapies (in the next episode) 38:41 Schistosomiasis outbreaks in Egypt 1938 40:26 Chronic thromboembolism 45:03 Thanks for listening 48:16 We'd love to hear from you! Send your comments/questions to Dr. Brown at rheuminationspodcast@healio.com. Follow us on Twitter @HRheuminations @AdamJBrownMD @HealioRheum. References: Barst RJ. Ann Thorac Med. 2008;doi:10.4103/1817-1737.37832. Bodo R. J Physiol. 1928;doi:10.1113/jphysiol.1928.sp002447. Dresdale DT, et al. Am J Med. 1951;doi:10.1016/0002-9343(51)90020-4. Egypt. Stanford.edu. Published 2015. https://schisto.stanford.edu/pdf/Egypt.pdf. Hewes JL, et al. Pulm Circ. 2020;doi:10.1177/2045894019892801. Johnson S, et al. Am J Respir Crit Care Med. 2023;doi:10.1164/rccm.202302-0327SO. Newman JH. Am J Respir Crit Care Med. 2005;doi:10.1164/rccm.200505-684OE. Weir EK, et al. Circulation. 1996;doi:10.1161/01.cir.94.9.2216. Disclosures: Brown reports no relevant financial disclosures.

A new year and a new beginning. Special guest co-host Pedro Mendes joins Dr. Chris Labos to answer a viewer question about menopause. Become a supporter of our show today either on Patreon or through PayPal! Thank you! http://www.patreon.com/thebodyofevidence/ https://www.paypal.com/donate?hosted_button_id=9QZET78JZWCZE Email us your questions at thebodyofevidence@gmail.com. Assistant researcher: Aigul Zaripova, MD Editor: Robyn Flynn Theme music: “Fall of the Ocean Queen“ by Joseph Hackl Rod of Asclepius designed by Kamil J. Przybos Chris' book, Does Coffee Cause Cancer?: https://ecwpress.com/products/does-coffee-cause- cancer Obviously, I'm not your doctor (probably). This podcast is not medical advice for you; it is what we call information. References: Geographic variability of menopausal symptoms 1) Nappi RE et al. Global cross-sectional survey of women with vasomotor symptoms associated with menopause: prevalence and quality of life burden. Menopause. 2021 May 24;28(8):875-882. doi: 10.1097/GME.0000000000001793. 2) Nappi RE, et al. Prevalence and quality-of-life burden of vasomotor symptoms associated with menopause: A European cross-sectional survey. Maturitas. 2023 Jan;167:66-74. doi: 10.1016/j.maturitas.2022.09.006. What's the normal duration of symptoms 3) Avis NE, et al. Study of Women's Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015 Apr;175(4):531-9. doi: 10.1001/jamainternmed.2014.8063. The Women's Health Initiative (WHI) studies Rossouw JE et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33. doi: 10.1001/jama.288.3.321. Anderson GL et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004 Apr 14;291(14):1701-12. doi: 10.1001/jama.291.14.1701. Decline in HRT after WHI studies Sprague BL, Trentham-Dietz A, Cronin KA. A sustained decline in postmenopausal hormone use: results from the National Health and Nutrition Examination Survey, 1999-2010. Obstet Gynecol. 2012 Sep;120(3):595-603. doi: 10.1097/AOG.0b013e318265df42. Danish Osteoporosis Prevention Study Schierbeck LL metal. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ. 2012 Oct 9;345:e6409. doi: 10.1136/bmj.e6409. Kronos Early Estrogen Prevention Study (KEEPS) Harman SM, et al. Arterial imaging outcomes and cardiovascular risk factors in recently menopausal women: a randomized trial. Ann Intern Med. 2014 Aug 19;161(4):249-60. doi: 10.7326/M14-0353. Kronos Early Estrogen Prevention Study (KEEPS) Hodis HN et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. N Engl J Med. 2016 Mar 31;374(13):1221-31. doi: 10.1056/NEJMoa1505241. Stopping hormonal therapy Berman RS et al. Risk factors associated with women's compliance with estrogen replacement therapy. J Womens Health. 1997 Apr;6(2):219-26. doi: 10.1089/jwh.1997.6.219. Grady D, Sawaya GF. Discontinuation of postmenopausal hormone therapy. Am J Med. 2005 Dec 19;118 Suppl 12B:163-5. doi: 10.1016/j.amjmed.2005.09.051. Tapering vs. abrupt stop or hormonal therapy Haimov-Kochman R et al. Gradual discontinuation of hormone therapy does not prevent the reappearance of climacteric symptoms: a randomized prospective study. Menopause. 2006 May-Jun;13(3):370-6. doi: 10.1097/01.gme.0000186663.36211.c0. PMID: 16735933.

Pedro Magno e Kaue Malpighi falam sobre o passo a passo da prescrição de rivaroxabana e apixabana: quando indicar? o que orientar o paciente? qual dose tomar? Tudo nesse episódio! No Guia TdC comentamos sobre como reverter o sangramento associado aos DOACs. Você pode ler esse tópico gratuitamente, basta clicar no link abaixo e fazer o login: Manejo de Sangramento Maior em Pacientes em Uso de Anticoagulante Oral | Guia TdC (tadeclinicagem.com.br) Referência: Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603. doi:10.1093/eurheartj/ehz405 Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [published correction appears in Eur Heart J. 2021 Feb 1;42(5):507. doi: 10.1093/eurheartj/ehaa798] Siontis KC, Zhang X, Eckard A, et al. Outcomes Associated With Apixaban Use in Patients With End-Stage Kidney Disease and Atrial Fibrillation in the United States [published correction appears in Circulation. 2018 Oct 9;138(15):e425. doi: 10.1161/CIR.0000000000000620]. Circulation. 2018;138(15):1519-1529. doi:10.1161/CIRCULATIONAHA.118.035418 Holt A, Strange JE, Rasmussen PV, et al. Bleeding Risk Following Systemic Fluconazole or Topical Azoles in Patients with Atrial Fibrillation on Apixaban, Rivaroxaban, or Dabigatran. Am J Med. 2022;135(5):595-602.e5. doi:10.1016/j.amjmed.2021.11.008 Beyer-Westendorf J, Siegert G. Of men and meals. J Thromb Haemost. 2015;13(6):943-945. doi:10.1111/jth.12973

In an effort to protect us from getting killed by something we've ingested, our brain's vomit control center processes a lot of information from several different places … and sometimes is a little overly cautious.   LEARN MORE To learn more about this topic, start your googling with these keywords:  Emesis: The act of vomiting Vomiting: The oral eviction of gastrointestinal contents due to contractions in the gut and stomach. Nausea: A diffuse sensation of uneasiness and discomfort often felt as the need to vomit. Vomiting Center: An area in the brain's medulla oblongata that initiates and controls emesis. Chemoreceptor Trigger Zone: An area in the area postrema of the medulla oblongata that is sensitive to certain toxic chemicals in the blood.  Nucleus Tractus Solitarius: A region in the medulla oblongata that receives input from the cardiovascular, respiratory and GI systems.  Vagus Nerve: A cranial nerve that regulates internal organ functions, including vomiting.  Vestibular System: A Sensory system that provides our brain with information about motion, head position, and spatial positioning for balance. SUPPORT MINUTEEARTH If you like what we do, you can help us!: Become our patron:   Share this video with your friends and family Leave us a comment (we read them!)   CREDITS David Goldenberg | Script Writer, Narrator and Director Arcadi Garcia i Rius | Illustration, Video Editing and Animation  Nathaniel Schroeder | Music MinuteEarth is produced by Neptune Studios LLC      OUR STAFF Lizah van der Aart • Sarah Berman • Arcadi Garcia i Rius David Goldenberg • Melissa Hayes • Alex Reich  Henry Reich • Peter Reich • Ever Salazar Alexander Vidal • Leonardo Souza • Kate Yoshida   OUR LINKS Youtube | TikTok |   Twitter |   Instagram |   Facebook |   Website |   Apple Podcasts |    REFERENCES Singh P, Yoon SS, Kuo B. Nausea: a review of pathophysiology and therapeutics. Therap Adv Gastroenterol. 2016;9(1):98-112. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699282/ Hasler, W. (2013). Pathology of emesis: its autonomic basis. Handbook of Clinical Neurology, Vol. 117 (3rd series) Autonomic Nervous System. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/24095137/ Zhong W, Shahbaz O, Teskey G, Beever A, Kachour N, Venketaraman V, Darmani NA. Mechanisms of Nausea and Vomiting: Current Knowledge and Recent Advances in Intracellular Emetic Signaling Systems. Int J Mol Sci. 2021 May 28;22(11):5797. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/34071460/ Kowalski A, Rapps N, Enck P. Functional cortical imaging of nausea and vomiting: a possible approach. Auton Neurosci. 2006 Oct 30;129(1-2):28-35. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/16945593/ Hornby, PJ. Central neurocircuitry associated with emesis. Am J Med. 2001 Dec 3;111 Suppl 8A:106S-112S. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/11749934/ Kuo, Braden. (2022). Personal Communication. Director of the Center for Neurointestinal Health at Mass General. https://www.massgeneral.org/doctors/17189/brad-kuo

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021.  Originally released: December 27, 2018 As I'm sitting in a coffee shop in upstate New York this holiday season, procrastinating on the various papers that need writing, bills that need paying, and Christmas cards that need writing, I can't help but feel comforted by the warm relief of a cup of coffee. The rich aroma and jolting heat, which come with the promise of productivity. There's nothing like it. So before resigning to my post-holiday to-do list, I thought I would start the day off re-mastering a prior show we put out in 2017 on the neuroscience behind your morning mocha. Enjoy! Produced by James E Siegler. Music by Andy Cohen and Little Glass Men. Sound effects by Mike Koenig and Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. Be sure to follow us on Twitter @BrainWavesaudio for the latest updates to the podcast. REFERENCES Ferré S. An update on the mechanisms of the psychostimulant effects of caffeine. J Neurochem 2008;105(4):1067-79. PMID 18088379Martín ED, Buño W. Caffeine-mediated presynaptic long-term potentiation in hippocampal CA1 pyramidal neurons. J Neurophysiol 2003;89(6):3029-38. PMID 12783948Nawrot P, Jordan S, Eastwood J, Rotstein J, Hugenholtz A, Feeley M. Effects of caffeine on human health. Food Addit Contam 2003;20(1):1-30. PMID 12519715Park CA, Kang CK, Son YD, et al. The effects of caffeine ingestion on cortical areas: functional imaging study. Magn Reson Imaging 2014;32(4):366-71. PMID 24512799Pelchovitz DJ, Goldberger JJ. Caffeine and cardiac arrhythmias: a review of the evidence. Am J Med 2011;124(4):284-9. PMID 21435415Ribeiro JA, Sebastião AM. Caffeine and adenosine. J Alzheimers Dis 2010;20 Suppl 1:S3-15. PMID 20164566  We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

What is silica? How does it impact your risk of developing autoimmunity if you inhale it, inject it or even snort it up your nose? Listen and find out! ·       Intro 0:12 ·       In the previous episodes 0:28 ·       The Ajax incident of 1979 1:15 ·       Silica and its association with autoimmune disease 4:11 ·       The history of silica and the health risks 5:21 ·       Rheumatoid scleroderma, etc. 8:14 ·       Cardiff pneumoconiosis medical panel 9:49 ·       Databases 12:51 ·       Silica exposure and the development of serologies 15:02 ·       What would happen if you injected silica into the veins? 16:51 ·       Anca vasculitis 18:33 ·       Thanks for listening 23:23 Disclosures: Brown reports no relevant financial disclosures. We'd love to hear from you! Send your comments/questions to Dr. Brown at rheuminationspodcast@healio.com. Follow us on Twitter @HRheuminations @AdamJBrownMD @HealioRheum. References: Blanc PD, et al. Am J Med. 2015;doi:10.1016/j.amjmed.2015.05.001. Boudigaard SH, et al. Int J Epidemiol. 2021;doi:10.1093/ije/dyaa287. Conrad K, et al. Lupus. 1996;doi:10.1177/096120339600500112. Hoy RF, et al. Allergy. 2020;doi:10.111/all.14202. Klockars M, et al. Br Med J (Clin Res Ed). 1987;doi:10.1136/bmj.294.6578.997. Park CG, et al. Environ Health Perspect. 1999;doi:10.1289/ehp.99107s5793. Pollard KM. Front Immunol. 2016;doi:10.3389/fimmu.2016.00097.  

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: July 18, 2017 Although physicians use medications to treat headaches, the mind can become tolerant. In fact, many otherwise helpful medications may even aggravate a pre-existing headache syndrome. In this BrainWaves brief, we discuss the concept of medication-overuse headache and its treatment, which may be counterintuitive and is often challenging for patients. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision-making in routine clinical practice. Any cases discussed in this episode are fictional and do not contain any patient health-identifying information. The content in this episode was vetted and approved by Roderick Spears. REFERENCES Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol 2004;3(8):475-83. PMID 15261608Dodick DW. Clinical practice. Chronic daily headache. N Engl J Med 2006;354(2):158-65. Erratum in: N Engl J Med 2006;354(8):884. PMID 16407511Tomkins GE, Jackson JL, O'Malley PG, Balden E, Santoro JE. Treatment of chronic headache with antidepressants: a meta-analysis. Am J Med 2001;111(1):54-63. PMID 11448661 We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

The podcast crew dives deep into one of the early "STEMI equivalent" ECG patterns: ST elevation in aVR with diffuse ST depression. What does the evidence say about this pattern? Is there a FOAM lesson to be learned? How should we incorporate this ECG into our practice? REFERENCES 1. Harhash AA, Huang JJ, Reddy S, Natarajan B, Balakrishnan M, Shetty R, Hutchinson MD, Kern KB. aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion. Am J Med. 2019 May;132(5):622-630. 2. https://www.mchd-tx.org/wp-content/uploads/2023/10/ST-elevation-AVR-ECGs-DeIDd.pdf

Panel: Pramod Chandru and Shreyas Iyer.Case Summary: 61-year-old male presenting with 2 distinct episodes of shortness of breath, chest pain, and associated presyncope.   Asymptomatic by the time of arrival to the emergency department.   ECG and observations at triage were unremarkable.  No recent travel or recent major surgeries.  Initial troponin and serial troponin were 80ng/L.   D-dimer was ordered given static troponin and the nature of symptoms: 0.58.  Although this D-dimer was negative when age-adjusted, a V/Q scan was pursued as the patient was not felt to fit a ‘low risk' pre-test probability for PE (IV contrast shortage dictated V/Q over CTPA).  Bilateral segmental pulmonary PE identified on V/Q scan with mild right heart strain evident on subsequent CTPA and TTE.   Key Discussion Points: If a case does not follow the usual ‘pattern' of your initial diagnosis, consider alternate aetiologies.  There are many tools available for risk-stratifying PE including PERC, age-adjusted D-dimer, and the YEARS diagnostic pathway. However, the way in which to appropriately utilize these tools is nuanced.   A paper published in JAMA in December 2021 demonstrates some ways in which these tools can be used together (see first reference below).   The PESI score (even prior to definitive diagnosis) can be useful to risk stratify patients with possible PE and help determine their disposition.   Take-Home Points: Pre-test probability is incredibly important, particularly in entities such as PE where only highly invasive imaging modalities are diagnostic.  Having a structured approach to protect yourself from your own mistakes is extremely important (such as a hypothesis and hypothesis testing approach).  References & Background Reading:  Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2021 Dec 7;326(21):2141-2149. doi: 10.1001/jama.2021.20750.  Thiruganasambandamoorthy, V., Stiell, I.G., Sivilotti, M.L. et al. Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study. BMC Emerg Med 14, 8 (2014). https://doi.org/10.1186/1471-227X-14-8. Crane SD, Risk stratification of patients with syncope in an accident and emergency department Emergency Medicine Journal 2002;19:23-27. Almulhim KN. The Characteristics of Syncope-Related Emergency Department Visits: Resource Utilization and Admission Rate Patterns in Emergency Departments. Cureus. 2022 Feb 8;14(2):e22039. doi: 10.7759/cureus.22039. PMID: 35340474; PMCID: PMC8913182.  Iwuji K, Almekdash H, Nugent KM, Islam E, Hyde B, Kopel J, Opiegbe A, Appiah D. Age-Adjusted D-Dimer in the Prediction of Pulmonary Embolism: Systematic Review and Meta-analysis. J Prim Care Community Health. 2021 Jan-Dec;12:21501327211054996. doi: 10.1177/21501327211054996. PMID: 34814782; PMCID: PMC8640977.  Schouten HJ, Geersing GJ, Koek HL, et al. Diagnostic accuracy of conventional or age-adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. 2012. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK133492/. Franco-Moreno AI, Bustamante-Fermosel A, Ruiz-Giardin JM, Muñoz-Rivas N, Torres-Macho J, Brown-Lavalle D. Utility of probability scores for the diagnosis of pulmonary embolism in patients with SARS-CoV-2 infection: A systematic review. Rev Clin Esp (Barc). 2023 Jan;223(1):40-49. doi: 10.1016/j.rceng.2022.07.004. Epub 2022 Sep 22. PMID: 36241500; PMCID: PMC9492501.  Christ M, Geier F, Popp S, Singler K, Smolarsky A, Bertsch T, Müller C, Greve Y. Diagnostic and prognostic value of high-sensitivity cardiac troponin T in patients with syncope. Am J Med. 2015 Feb;128(2):161-170.e1. doi: 10.1016/j.amjmed.2014.09.021. Epub 2014 Oct 15. PMID: 25447619.  Lindner G, Pfortmueller CA, Funk GC, Leichtle AB, Fiedler GM, Exadaktylos AK. High-Sensitive Troponin Measurement in Emergency Department Patients Presenting with Syncope: A Retrospective Analysis. PLoS One. 2013 Jun 18;8(6):e66470. doi: 10.1371/journal.pone.0066470. PMID: 23823330; PMCID: PMC3688899.  Music/Sound Effects: ENGINE by Alex-Productions | https://onsound.eu/, Music promoted by https://www.free-stock-music.com, Creative Commons / Attribution 3.0 Unported License (CC BY 3.0), https://creativecommons.org/licenses/by/3.0/deed.en_US.  Feel It by MBB feat. JV Saxx | https://soundcloud.com/mbbofficial, https://www.instagram.com/JVSAXX/, Music promoted by https://www.free-stock-music.com, Creative Commons / Attribution-ShareAlike 3.0 Unported (CC BY-SA 3.0), https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. Lakeside by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com, Creative Commons / Attribution 3.0 Unported License (CC BY 3.0), https://creativecommons.org/licenses/by/3.0/deed.en_US.  Ocean Love by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons / Attribution 3.0 Unported License (CC BY 3.0), https://creativecommons.org/licenses/by/3.0/deed.en_US. Nostalgic Marshmallows by Arthur Vyncke | https://soundcloud.com/arthurvost, Music promoted by https://www.free-stock-music.com, Creative Commons / Attribution-ShareAlike 3.0 Unported (CC BY-SA 3.0), https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. Sound effects from https://www.free-stock-music.com. Promotional Video (Soundtrack):Pina Colada by Scandinavianz | https://soundcloud.com/scandinavianz,Music promoted by https://www.free-stock-music.com, Creative Commons / Attribution 3.0 Unported License (CC BY 3.0), https://creativecommons.org/licenses/by/3.0/deed.en_US.Disclaimer:Please be advised that the individual views and opinions expressed in this recording strive to improve clinical practice, are our own, and do not represent the views of any organization or affiliated body. Therapies discussed are general and should not be a substitute for an individualized assessment from a medical professional.Thank you for listening!Please send us an email to let us know what you thought.You can contact us at westmeadedjournalclub@gmail.com.You can also follow us on Facebook, Instagram, and Twitter!See you next time!~

Kāds muskuļiem sakars ar jaunību un spēju pretoties slimībām? Kādas bioķīmiski aktīvas (hormoniem līdzīgas) vielas izdala muskuļi darbojoties un kādus procesus organismā tās ietekmē? Kādēļ skrējēji skriešanu uzskata par labāko līdzekli pret saaukstēšanos un vīrusiem? Vai muskuļi patiesi izdala pretiekaisuma “zāles”? Vai zinājāt, ka, novecojot  mazinās muskuļu masa, un tās sarukums ir viens no galvenajiem iemesliem, kādēļ  kļūstam vairāk pakļauti dažādu nopietnu slimību, tai skaitā cukura diabēta, vēža un Alcheimera riskam? Kā un kāpēc regulāras fiziskas aktivitātes palīdz ierobežot šos riskus un nodzīvot mūžu veselam?Saruna ar Tomu Jāni Eglīti ORTO Klīnikas sporta ārstu rezidentu par jaunību, kuras atslēga paslēpta mūsu muskuļu darbībā.Saruna balstīta zinātniskos pētījumos:  1.https://pubmed.ncbi.nlm.nih.gov/23897689/ - Pedersen BK. Muscle as a secretory organ. Compr Physiol. 2013 Jul;3(3):1337-62. doi: 10.1002/cphy.c120033. PMID: 23897689.2.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803609/ Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. J Cachexia Sarcopenia Muscle. 2018 Feb;9(1):3-19. doi: 10.1002/jcsm.12238. Epub 2017 Nov 19. PMID: 29151281; PMCID: PMC5803609.3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8473039/ Plotkin DL, Roberts MD, Haun CT, Schoenfeld BJ. Muscle Fiber Type Transitions with Exercise Training: Shifting Perspectives. Sports (Basel). 2021 Sep 10;9(9):127. doi: 10.3390/sports9090127. PMID: 34564332; PMCID: PMC8473039.4.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035379/ Srikanthan P, Karlamangla AS. Muscle mass index as a predictor of longevity in older adults. Am J Med. 2014 Jun;127(6):547-53. doi: 10.1016/j.amjmed.2014.02.007. Epub 2014 Feb 18. PMID: 24561114; PMCID: PMC4035379.5.https://www.who.int/publications/i/item/9789240015128 WHO guidelines on physical activity and sedentary behaviour6.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7149380/ Exercise, Immunity, and Illness 

Listen in as Dr. Nally discussed the history of gout, why Hippocrates only thought it happened to royalty and how you can treat and prevent it with a ketogenic or carnivorous lifestyle. Show Note Sources: Kanbara A., Seyama I. Effect of urine pH on uric acid excretion by manipulating food materials. Nucleosides, Nucleotides Nucleic Acids. 2011;30(12):1066–1071. Towiwat P., Li Z.G. The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout. Int J Rheum Dis. 2015;18(5):495–501. Bedir A., Topbas M., Tanyeri F., Alvur M., Arik N. Leptin might be a regulator of serum uric acid concentrations in humans. Jpn Heart J. 2003;44(4):527–536. Garrod AB. The Nature and Treatment of Gout and Rheumatic Gout, 2nd ed, Walton and Maberly, London 1863. Dalbeth N, Phipps-Green A, Frampton C, et al. Relationship between serum urate concentration and clinically evident incident gout: an individual participant data analysis. Ann Rheum Dis 2018; 77:1048. Hall AP, Barry PE, Dawber TR, McNamara PM. Epidemiology of gout and hyperuricemia. A long-term population study. Am J Med 1967; 42:27. Campion EW, Glynn RJ, DeLabry LO. Asymptomatic hyperuricemia. Risks and consequences in the Normative Aging Study. Am J Med 1987; 82:421. Zalokar J, Lellouch J, Claude JR, Kuntz D. Epidemiology of serum uric acid and gout in Frenchmen. J Chronic Dis 1974; 27:59. BRILL JM, MCCARTY DJ. "STUDIES ON THE NATURE OF GOUTY TOPHI" BY MAX FREUDWEILER, 1899. (AN INFLAMMATORY RESPONSE TO INJECTED SODIUM URATE, 1899). AN ABRIDGED TRANSLATION, WITH COMMENTS. Ann Intern Med 1964; 60:486. McCarty DJ, Hollander JL. Identification of urate crystals in gouty synovial fluid. Ann Intern Med 1961; 54:452. Seegmiller JE, Howell RR, Malawista SE. The inflammatory reaction to sodium urate: its possible relationship to the genesis of acute gouty arthritis. JAMA 1962; 180:469. Hutton J, Fatima T, Major TJ, et al. Mediation analysis to understand genetic relationships between habitual coffee intake and gout. Arthritis Res Ther 2018; 20:135. Fanning N, Merriman TR, Dalbeth N, Stamp LK. An association of smoking with serum urate and gout: A health paradox. Semin Arthritis Rheum 2018; 47:825. Lin KC, Lin HY, Chou P. Community based epidemiological study on hyperuricemia and gout in Kin-Hu, Kinmen. J Rheumatol 2000; 27:1045. Zhang Y, Woods R, Chaisson CE, et al. Alcohol consumption as a trigger of recurrent gout attacks. Am J Med 2006; 119:800.e13. Hunter DJ, York M, Chaisson CE, et al. Recent diuretic use and the risk of recurrent gout attacks: the online case-crossover gout study. J Rheumatol 2006; 33:1341. Chhana A, Lee G, Dalbeth N. Factors influencing the crystallization of monosodium urate: a systematic literature review. BMC Musculoskelet Disord 2015; 16:296. Loeb JN. The influence of temperature on the solubility of monosodium urate. Arthritis Rheum 1972; 15:189. Horvath SM, Hollander JL. INTRA-ARTICULAR TEMPERATURE AS A MEASURE OF JOINT REACTION. J Clin Invest 1949; 28:469. Martinon F, Pétrilli V, Mayor A, et al. Gout-associated uric acid crystals activate the NALP3 inflammasome. Nature 2006; 440:237. Guerne PA, Terkeltaub R, Zuraw B, Lotz M. Inflammatory microcrystals stimulate interleukin-6 production and secretion by human monocytes and synoviocytes. Arthritis Rheum 1989; 32:1443. Terkeltaub R, Zachariae C, Santoro D, et al. Monocyte-derived neutrophil chemotactic factor/interleukin-8 is a potential mediator of crystal-induced inflammation. Arthritis Rheum 1991; 34:894. di Giovine FS, Malawista SE, Thornton E, Duff GW. Urate crystals stimulate production of tumor necrosis factor alpha from human blood monocytes and synovial cells. Cytokine mRNA and protein kinetics, and cellular distribution. J Clin Invest 1991; 87:1375. Guerne PA, Terkeltaub R, Zuraw B, Lotz M. Inflammatory microcrystals stimulate interleukin-6 production and secretion by human monocytes and synoviocytes. Arthritis Rheum 1989; 32:1443.

Recording of the Evidence Based Hair Podcast for the Oct 24, 2022 issue.    STUDIES REFERENCED Han JJ et al (starts at 5:28) Association of resilience and perceived stress in patients with alopecia areata: A cross-sectional study. J Am Acad Dermatol. 2022 Jul;87(1):151-153.   Gressler J et al (starts at 20:55 ). Re-pigmentation of scalp hair - A feature of early melanoma. Am J Med. 2022 Sep 25;S0002-9343(22)00711-2.   Lackey A et al (starts at 24:09) Repigmentation of gray hairs with lentigo maligna and response to topical imiquimod. JAAD Case Rep. 2019 Dec; 5(12): 1015–1017   Nguyen et al (starts at 27:18). Characterizing and assessing the reliability of TikTok's most viewed alopecia-related videos. J Eur Acad Dermatol Venereol. 2022 Aug 14.   Nagrani NS, Goldberg LJ (starts at 37:24). Sebaceous gland atrophy in seborrheic dermatitis of the scalp; a pilot study. J Cutan Pathol. 2022 Nov;49(11):988-992.   Headington JT, Gupta AK, Goldfarb MT, et al (starts at 41:26). A morphometric and histologic study of the scalp in psoriasis. Paradoxical sebaceous gland atrophy and decreased hair shaft diameters without alopecia. Arch Dermatol. 1989;125:639-642.   Klein EJ et al (starts at 46:38). Supplementation and hair growth: A retrospective chart review of patients with alopecia and laboratory abnormalities. JAAD Int. 2022 Aug 30;9:69-71.   Chang CJ et al (starts at 59:21). Use of Straighteners and Other Hair Products and Incident Uterine Cancer. J Natl Cancer Inst. 2022 Oct 17;djac165.

Die J-Kurve und warum Kalium kein Blutdrucksalz ist – Meersalz (Fleur de Sel) Mikropastik, z.B. Aquasale, de Camargue. https://www.ndr.de/ratgeber/verbraucher/Fleur-de-Sel-Plastik-in-Meersalz-nachgewiesen,salz378.html Manchmal mit Jod beigemischt Kalium-Chlorid Ist Salz schädlich? Frauen in Hongkong haben weltweit die höchste Lebenserwartung mit 87,3 Jahren, obwohl sie mehr als doppelt so viel wie z.B. laut USA-Richtlinien empfohlen konsumieren. Liu ZM, Ho SC, Tang N, Chan R, Chen YM, Woo J. Urinary sodium excretion and dietary sources of sodium intake in Chinese postmenopausal women with prehypertension. PLoS One 2014; 9: e104018. Altersstandardisierte geschätzte Natriumaufnahme und gesunde Lebenserwartung bei der Geburt in 182 Ländern Sterblichkeit: J-Kurve Zwei Achsen: nach oben Sterblichkeit Nach rechts: Natrium Aufnahme Keine Linie, mehr Salt schlechter, weniger besser Sondern J Mittlerer Bereich niedrig, Sowohl links, bei niedrigen, als rechts, bei hohen Konzentrationen, Sterblichkeit hoch Empfohlenen täglichen Aufnahmeschwellen. AHA = American Heart Association. 1.4 WHO = 2.0 ESC = Europäische Gesellschaft für Kardiologie. 2.3 Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 2013; 3: e003733. UN. Healthy life expectancy (HALE) at birth (years). July 31, 2014. http://data.un.org/Data.aspx?q=life+expectancy&d=WHO&f=MEASURE_ CODE%3aWHOSIS_000002 (accessed July 11, 2018). Die starre natriumarme Diät ist fade, eintönig, geschmacklos und unerträglich. Um daran festzuhalten, bedarf es der Askese eines Eremiten. Pickering G. The nature of essential hypertension. London: Churchill, 1961. 2016 Mente A, O'Donnell M, Rangarajan S, et al. Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies. Lancet 2016; 388: 465–75. Lancet wurde attackiert so schlechte Wissenschaft zu publizieren. Johnston I. Lancet attacked for publishing study claiming low-salt diet could kill you. Independent May 21, 2016: 12. Action on Salt Graham MacGregor http://www.actiononsalt.org.uk AHA diffamiert die Studie als schlicht falsch; Produkte mit mehr Salz empfohlen als sie selbst raten. American Heart Association. American Heart Association comment strongly refutes study findings on sodium consumption. May 21, 2016. http:// newsroom.heart.org/news/american-heart-assocation-strongly-refutesstudy- findings-on-sodium-consumption (accessed July 22, 2018). Messerli FH, Rimoldi SF, Bangalore S. Salt, tomato soup, and the hypocrisy of the American Heart Association. Am J Med 2017; 130: 392–93. 2018 Epidemiologische Kohortenstudie, 94.378 Erwachsene, 35-70 (mittleres Alter 50), 18 Länder für Median 8,1 Jahren. 58% Frauen, keine Herz-Kreislauf-Erkrankungen zum Zeitpunkt der Rekrutierung. Bestätigen, dass niedrige Natrium aufnahme MI und Schlaganfall leicht erhöhen. Eine höhere Natriumaufnahme assoziiert mit mehr Schlaganfällen (0,42 Ereignisse pro 1000 Jahre), weitgehend auf China beschränkt, 6 g / Tag. Provokant: Inverse Korrelation zwischen Natriumaufnahme und Herzinfarkt und Sterblichkeit, trotz der starke Patienten Wie Wir, der Podcast zur gleichnamigen ärztlich-initiierten Plattform für den Erfahrungs- und Wissensaustausch unter Patienten. Immer mit konkreten Tipps zur optimalen Behandlung oder noch besser Vorbeugung. Noch nicht bei PWW dabei? Dann werden Sie jetzt aktiv! Werden Sie Teil der Patienten Wie Wir-Community! Jetzt registrieren auf https://www.patientenwiewir.de. Sie sind schon bei PWW dabei? Dann Gruppe gründen, Fragen stellen, Fragen beantworten... … und empfehlen Sie diesen Podcast sowie PWW weiter. --- Send in a voice message: https://podcasters.spotify.com/pod/show/harald-hhw-schmidt/message

Pyrlcasts, brought to you by Pyrls.com! We take a closer look at interesting and relevant clinical topics related to pharmacotherapy. Want to learn more clinical pearls? Boost your clinical confidence? Visit and sign-up for an account at pyrls.com to get over 10 high-quality charts absolutely FREE! Episode References: Center for Behavioral Health Statistics and Quality. (2021). Results from the 2020 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/ COCAINE HYDROCHLORIDE NASAL solution. Lannett Company, Inc. Accessed via DailyMed. Updated August 27, 2020. Zimmerman JL. Cocaine intoxication. Crit Care Clin. 2012;28(4):517-526. doi:10.1016/j.ccc.2012.07.003 Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644 Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2013 Sep 10;62(11):1040-1]. J Am Coll Cardiol. 2013;61(23):e179-e347. doi:10.1016/j.jacc.2013.01.014 Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014 Dec 23;130(25):e433-4. Dosage error in article text]. Circulation. 2014;130(25):e344-e426. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation [published correction appears in Circulation. 2015 Apr 14;131(15):e408]. Circulation. 2011;124(22):2458-2473. doi:10.1161/CIR.0b013e318235eb4d Richards JR, Laurin EG. Cocaine. [Updated 2022 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430769/ Lo KB, Virk HUH, Lakhter V, et al. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med. 2019;132(4):505-509. doi:10.1016/j.amjmed.2018.11.041

References Dr Guerra's lecture notes J.of Neuroinflammation. 2016. volume 13, Article number: 264 Am J Med. 2020 Jun;133(6):713-722.e7. J Hepatol. 2014 Aug;61(2):396-407. --- Send in a voice message: https://anchor.fm/dr-daniel-j-guerra/message

Teaching More About Less: Preparing Clinicians for Practice. Lessing JN, Pierce RG, Dhaliwal G. Am J Med. Published Ahead of Print. doi:10.1016/j.amjmed.2022.01.060 The State of Spine Care in the United States: Opinion of a Recovering Interventional Spine Physiatrist. Farooque M. Spine. Published Ahead of Print. doi:10.1097/BRS.0000000000004343 Due to copyright laws, unless the article is open source we cannot legally post the PDF on the website for the world to download at will. Brought to you by CSMi – https://www.humacnorm.com/ptinquest Learn more about/Buy Erik's courses – The Science PT Support us on the Patreons! Music for PT Inquest: “The Science of Selling Yourself Short” by Less Than Jake Used by Permission Other Music by Kevin MacLeod – incompetech.com: MidRoll Promo – Mining by Moonlight

Recording of the Evidence Based Hair Podcast for the March 28, 2022 issue.       STUDIES HIGHLIGHTED   Trueb RM et al (starts at 3:27). Minoxidil-induced hypertrichosis in a breastfed infant. J Eur Acad Dermatol Venereol. 2022 Mar;36(3):e224-e225.   Gangal et al (starts at 7:08). Mask-associated acquired trichorrhexis nodosa of the beard. JAAD Case Rep. 2022 Mar;21:101-102.   Trueb RM et al. Prepubertal pattern hair loss (starts at  13:38) Clin Exp Dermatol. 2022 Jan;47(1):173-175.):24-30   Katayama S et al (starts at 17:00). Rapidly Progressive Hair Loss May Be the Only Sign of Syphilis. Am J Med 2022 Feb 22;S0002-9343(22)00130-9.   Kolla et al (starts at 32:34). Dermatologists' knowledge of dermoscopic features in hair and nail disorders. J Eur Acad Dermatol Venereol. 2022 Feb 11.   Rutnin S et al (starts at 37:32)). Variation of Hair Follicle Counts among Different Scalp Areas: A Quantitative Histopathological Study. Skin Appendage Disord. 2022 Jan;8(1):24-30.   Xie et al (starts at 42:27). Hair shaft miniaturization causes stem cell depletion through mechanosensory signals mediated by a Piezo1-calcium-TNF-α axis. Cell Stem Cell 2022 Jan 6;29):

Contributor: Chris Holmes, MD Educational Pearls: Many are taught that patients with cocaine chest pain should not receive beta-blockers due to unopposed alpha agonism, but is this true? 363 consecutive admissions for chest pain with positive cocaine on urine toxicology were reviewed in a retrospective cohort study 60 patients in this cohort received a beta-blocker and multivariate analysis demonstrated a reduction in myocardial infarction risk Another retrospective cohort study demonstrated no association of negative outcomes with beta-blocker administration in those with a recent positive result on cocaine urine toxicology Two more recent meta-analyses were performed finding no association between adverse clinical outcomes and beta-blocker administration for cocaine chest pain No prospective randomized-controlled trials have been performed to evaluate the use of beta-blockers for treatment of cocaine chest pain in the ED setting References Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use [published correction appears in Ann Emerg Med. 2008 Jul;52(1):90]. Ann Emerg Med. 2008;51(2):117-125. doi:10.1016/j.annemergmed.2007.04.015 Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879. doi:10.1001/archinternmed.2010.115 Pham D, Addison D, Kayani W, et al. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J. 2018;35(9):559-563. doi:10.1136/emermed-2017-207065 Lo KB, Virk HUH, Lakhter V, et al. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med. 2019;132(4):505-509. doi:10.1016/j.amjmed.2018.11.041 Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644 Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990;112(12):897-903. doi:10.7326/0003-4819-112-12-897 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

Un nouvel épisode du Pharmascope est disponible! Dans ce 90ème épisode et la deuxième et dernière partie de notre série concernant l'usage du fer, Nicolas, Sébastien et Isabelle décortiquent les subtilités de la posologie optimale de fer.  Les objectifs pour cet épisode sont les suivants: Comparer les avantages et les inconvénients des différentes posologies de fer possibles (prise intermittente, uniquotidienne, biquotidienne)Conseiller un patient lors de l'initiation d'un traitement de ferExpliquer dans quel contexte l'administration de fer intraveineux est indiqué Ressources pertinentes en lien avec l'épisode Lignes directricesSnook J et coll. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut. 2021;70:2030-51. British Columbia Ministry of Health. Iron Deficiency - Diagnosis and Management. BCGuidelines.ca. Avril 2019. Article de revuePasricha S-R et coll. Iron deficiency. Lancet. 2021;397:233-48. Articles portant sur la posologie du fer oralLee H et coll. Iron dosing frequency. Can Fam Physician. 2021;67:436. Rimon E et coll. Are we giving too much iron? Low-dose iron therapy is effective in octogenarians. Am J Med. 2005;118:1142-7. Fernandez-Gaxiola AC, De-Regil LM. Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women. Cochrane Database Syst Rev. 2019;1:CD009218. Düzen Oflas N et coll. Comparison of the effects of oral iron treatment every day and every other day in female patients with iron deficiency anaemia. Intern Med J. 2020;50:854-8. Kaundal R et coll. Randomized controlled trial of twice-daily versus alternate-day oral iron therapy in the treatment of iron-deficiency anemia. Ann Hematol. 2020;99:57-63. Utilisation du fer intraveineuxLitton E et coll. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ. 2013;347:f4822. Ponikowski P et coll. Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: a multicentre, double-blind, randomised, controlled trial. Lancet. 2020;396:1895-1904.

Welcome to Episode 10 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 10 of “The 2 View” – Skipping a Beat, Strep Throat, Hyperthyroidism and TSH, and More… Skipping a Beat: Zio Patch and Loop Recorders Barrett PM, Komatireddy R, Haaser S, et al. Comparison of 24-hour Holter monitoring with 14-day novel adhesive patch electrocardiographic monitoring. Am J Med. PubMed.gov. Published January 2014. Accessed October 6, 2021. https://pubmed.ncbi.nlm.nih.gov/24384108/ Burke J, Haigney MCP, Borne R, Krantz MJ. Smartwatch detection of ventricular tachycardia: Case series. HeartRhythm Case Rep. NCBI. Published October 2020. Accessed October 6, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573479/ Elsinger F, Smithuis R, Spijkerboer A. Cardiovascular devices on Chest X-Ray. Radiology Assistant. Radiologyassistant.nl. Published December 1, 2018. Accessed October 6, 2021. https://radiologyassistant.nl/cardiovascular/devices/cardiovascular-devices Elsinger F, Smithuis R, Spijkerboer A. Cardiovascular devices on Chest X-Ray. Radiology Assistant. Radiologyassistant.nl. Published December 1, 2018. Accessed October 6, 2021. https://radiologyassistant.nl/cardiovascular/devices/cardiovascular-devices#loop-recorders iRhythm Technologies, Inc. Why Zio. Irhythmtech.com. Accessed October 6, 2021. https://www.irhythmtech.com/patients/why-zio Loop Recorder Implantation. Johns Hopkins Medicine. Hopkinsmedicine.org. Accessed October 6, 2021. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/loop-recorder-implantation Yenikomshian M, Jarvis J, Patton C, et al. Cardiac arrhythmia detection outcomes among patients monitored with the Zio patch system: a systematic literature review. Curr Med Res Opin. Taylor & Francis Online. Published May 28, 2019. Accessed October 6, 2021. https://www.tandfonline.com/doi/full/10.1080/03007995.2019.1610370 Hyperthyroidism and TSH Collection Tubes and Description. Additive B, Color/Volume U. COLLECTION TUBES AND DESCRIPTION. NYU Langone Medical Center. Testmenu.com. Accessed October 6, 2021. https://www.testmenu.com/nyumc/TestDirectory/SiteFile?fileName=sidebar%5Ccollection%20tubes%20and%20descriptions.pdf Graves' disease. Mayo Clinic. Mayoclinic.org. Accessed October 6, 2021. https://www.mayoclinic.org/diseases-conditions/graves-disease/symptoms-causes/syc-20356240 Plasma Separation: Why Do You Need It? How Do You Achieve It? DCN Dx. Dcndx.com. Published July 17, 2019. Accessed October 6, 2021. https://dcndx.com/plasma-separation-why-you-need-it/ What are Normal Thyroid Hormone Levels? UCLA Health. Uclahealth.org. Accessed October 6, 2021. https://www.uclahealth.org/endocrine-center/normal-thyroid-hormone-levels Mike & Martha's Something Sweet Home - National APP week. Nationalappweek.com. Published July 9, 2021. Accessed October 6, 2021. http://www.nationalappweek.com Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Last month we asked you a trivia question regarding food and the manufacturing of war weaponry. It was another 2-part question and we asked: During what war were Americans urged to save this food fat so that it could be used to manufacture bombs? The answer was: World War II and bacon. Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. We hope to see you at the November Original EM Boot Camp LIVE in Las Vegas!

In this episode, host Dr Laurence Sperling and guests talk about how COVID affected patient-partnered dyslipidemia care, causing clinical teams to innovate. Relevant disclosures can be found with the episode show notes on Medscape.com (https://www.medscape.com/viewarticle/958311). The topics and discussions are planned, produced, and reviewed independently of our advertiser. This podcast is intended only for US healthcare professionals. Resources Patel P, Dhindsa D, Eapen DJ, et al. Optimizing the potential for telehealth in cardiovascular care (in the era of COVID-19): time will tell. Am J Med. 2021;134:945-951. doi:10.1016/j.amjmed.2021.03.007 American Medical Association. Telemedicine and team-based care: improve patient care and team engagement by using team-based care in telemedicine. https://edhub.ama-assn.org/steps-forward/module/2781279 Bhaskar S, Bradley S, Chattu VK, et al. Telemedicine as the new outpatient clinic gone digital: position paper from the Pandemic Health System REsilience PROGRAM (REPROGRAM) International Consortium (part 2). Front Public Health. 2020;8:410. doi:10.3389/fpubh.2020.00410 Arevian AC, Springgate B, Jones F, et al. The Community and Patient Partnered Research Network (CPPRN): application of patient-centered outcomes research to promote behavioral health equity. Ethn Dis. 2018;28(Suppl 2):295-302. doi: 10.18865/ed.28.S2.295. Stewart MP, Fink R, Kosirog E, Saseen JJ. Bridging health disparities: a national survey of ambulatory care pharmacists in underserved areas. Pharm Pract (Granada). 2021;19:2359. doi:10.18549/PharmPract.2021.2.2359 Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186]. Circulation. 2019;139(25):e1082-e1143. Golden RL. William Osler at 150: An Overview of a Life. JAMA. 1999;282:2252–2258. doi:10.1001/jama.282.23.2252

Kaue e Raíza discutem um caso de monoartrite aguda apresentado pelo Iago. Quais as causas mais importantes no pronto-socorro? Como iniciar a investigação? O que pedir no líquido sinovial? Referências: 1) Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488 2) Sack K. Monarthritis: differential diagnosis. Am J Med 1997; 102:30S. 3) Mohana-Borges AV, Chung CB, Resnick D. Monoarticular arthritis. Radiol Clin North Am 2004; 42:135. 4) Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA 1990; 264:1009. 5) McCutchan HJ, Fisher RC. Synovial leukocytosis in infectious arthritis. Clin Orthop Relat Res 1990; :226. 6) Siva C, Velazquez C, Mody A, Brasington R. Diagnosing acute monoarthritis in adults: a practical approach for the family physician. Am Fam Physician. 2003 Jul 1;68(1):83-90. PMID: 12887114. 7) Becker JA, Daily JP, Pohlgeers KM. Acute Monoarthritis: Diagnosis in Adults. Am Fam Physician. 2016 Nov 15;94(10):810-816. PMID: 27929277. 8) Jeong H, Kim AY, Yoon HJ, et al. Clinical courses and predictors of outcomes in patients with monoarthritis: a retrospective study of 171 cases. Int J Rheum Dis. 2014;17(5):502–510. 9) Ma L, Cranney A, Holroyd-Leduc JM. Acute monoarthritis: what is the cause of my patient's painful swollen joint? CMAJ. 2009;180(1):59–65. 10) Baker DG, Schumacher HR Jr. Acute monoarthritis. N Engl J Med. 1993;329(14):1013–1020. 11) Kienhorst LB, Janssens HJ, Fransen J, Janssen M; British Society for Rheumatology. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study. Rheumatology (Oxford). 2015;54(4):609–614. 12) Bardin T. Gonococcal arthritis. Best Pract Res Clin Rheumatol. 2003;17(2):201–208. 13) Davis, Benjamin T., and Mark S. Pasternack. "Case 19-2007: A 19-Year-Old College Student with Fever and Joint Pain." New England Journal of Medicine 356.25 (2007): 2631-2637.

Timestamps:00:00 Intro01:00 How does the cardiovascular laboratory support patient care?01:47 Can you tell us a bit about ceramides? What are they?04:14 When should ceramides be tested? 06:04 Can you modify someone’s ceramides such that the test can be repeated and monitored, or is it once in a lifetime because ceramides or more static?08:05 What is the controversary around ceramides? 09:52 Could you give our listeners an introduction to Lipoprotein(a)?11:45 Who should be tested for Lipoprotein(a)?13:59 How do we treat elevated Lipoprotein(a)? 17:20 How did your interests in laboratory medicine develop? How has this brought meaning for you in your career professionally? 19:23 Outro Resources:1.  Ceramides and Ceramide Scores: Clinical Applications for Cardiometabolic Risk Stratification. Hilvo M, Vasile VC, Donato LJ, Hurme R, Laaksonen R. Front Endocrinol (Lausanne). 2020 Sep 29;11:570628. doi: 10.3389/fendo.2020.570628. eCollection 2020. PMID: 33133018 Free PMC article. Review. 2.  Measuring the contribution of Lp(a) cholesterol towards LDL-C interpretation. Fatica EM, Meeusen JW, Vasile VC, Jaffe AS, Donato LJ. Clin Biochem. 2020 Dec;86:45-51. doi: 10.1016/j.clinbiochem.2020.09.007. Epub 2020 Sep 28. PMID: 32997972 3.  Ceramides improve atherosclerotic cardiovascular disease risk assessment beyond standard risk factors. Meeusen JW, Donato LJ, Kopecky SL, Vasile VC, Jaffe AS, Laaksonen R. Clin Chim Acta. 2020 Dec;511:138-142. doi: 10.1016/j.cca.2020.10.005. Epub 2020 Oct 12. PMID: 33058843 4.  Ceramide Scores Predict Cardiovascular Risk in the Community. Vasile VC, Meeusen JW, Medina Inojosa JR, Donato LJ, Scott CG, Hyun MS, Vinciguerra M, Rodeheffer RR, Lopez-Jimenez F, Jaffe AS. Arterioscler Thromb Vasc Biol. 2021 Apr;41(4):1558-1569. doi: 10.1161/ATVBAHA.120.315530. Epub 2021 Feb 18. PMID: 33596665 5.  High-Sensitivity Cardiac Troponin for the Diagnosis of Patients with Acute Coronary Syndromes. Vasile VC, Jaffe AS. Curr Cardiol Rep. 2017 Aug 24;19(10):92. doi: 10.1007/s11886-017-0904-4. PMID: 28840515 Review. 6.  Natriuretic Peptides and Analytical Barriers. Vasile VC, Jaffe AS. Clin Chem. 2017 Jan;63(1):50-58. doi: 10.1373/clinchem.2016.254714. Epub 2016 Oct 10. PMID: 28062611 Review. 7.  Diseased skeletal muscle: a noncardiac source of increased circulating concentrations of cardiac troponin T. Jaffe AS, Vasile VC, Milone M, Saenger AK, Olson KN, Apple FS. J Am Coll Cardiol. 2011 Oct 18;58(17):1819-24. doi: 10.1016/j.jacc.2011.08.026. Epub 2011 Sep 29. PMID: 21962825 8.  Elevated cardiac troponin T levels in critically ill patients with sepsis. Vasile VC, Chai HS, Abdeldayem D, Afessa B, Jaffe AS. Am J Med. 2013 Dec;126(12):1114-21. doi: 10.1016/j.amjmed.2013.06.029. Epub 2013 Sep 28. PMID: 24083646

The exciting conclusion to Chapter Two: Renal Circulation and Glomerular Filtration Rate - Determinants of GFR - First step in making urine is separation of an ultrafiltrate - Governed by starling forces - Balance of hydraulic and osmotic forces - GFR = LpS (P gc – P us - Osmotic Pressure Cap p) - Normal GFR 95 in women, 120 in men - Cap Hydrolic pressure remains constant - glom cap Oncotic progressively rises - Due to filtration of protein free fluid (protein concentration rises in the capillary) - Filtration gradient begins at 13 mmHg and falls to zero after filtration of 20% or RPF! - GFR is capped at 20% of RPF called filtration equilibrium - So GFR is dependent on RPF, unless you can change glomerular hydraulic pressure - Glomerular hydraulic pressure is controlled by balance of twin arteriole (afferent and efferent) - Constriction of afferent arteriole reduces RPF, GFR, and glom pressure - Dilation of afferent arteriole increases RPF, GFR, and glom pressure - Constriction of the efferent arteriole increases Glom pressure, increasing GFR - Besides glom hydrostatic pressure the other starlings forces are rarely relevant to changes in GFRLetty says: referred to this NEJM review article later JC thought she was referring to something else -see #2- and then Roger referred to this again)Normotensive Acute Renal Failure from Gary Abuelo in NEJM 2007. https://www.nejm.org/doi/10.1056/NEJMra064398 (note in this article, Dr. Abuelo acknowledges the newer terminology of the time, AKI rather than ARF but chooses not to embrace it). In figure 2, he highlights the classic examples of how autoregulation can be affected. In the table, additional examples are provided but all within the framework of alterations related to autoregulation and the interplay between the two resistance vessels.- Regulation of GFR - Autoregulation - The ability to keep glomerular pressure constant over wide range of systemic arterial pressure - When pressure < 70 autoregulation fails and GFR will fall with decreases in systemic pressure - When pressure falls below 40-50 GFR ceases - At least some of this autoregulation is mediated with Ang2. Giving ACEi markedly disrupts autoregulation - Nitric oxide, not important - TGF - Chloride in macula densa - Blocked by furosemide - Group affect of nephrons - Ang 2 sensitizes - Adenosine mediates - Function of TGF - 90% of filtrate is reabsobed in PT and LOH - 10% is reabsobed dismally - Need to control the amount of fluid delivered distally to prevent overwhelming the resorptive capacity of the distal nephron - Talks about acute renal success without naming it (but did reference it) - Mentions glucosuria blunts TGF. Hmmm... - Neurohormonal influences - Volume changes in ang2, sympathetic NS - Role of PGE - Interesting discussion of change of the nephrons perfumed with volume depletion, shifting of blood from outer coretex to inner medullary cortical gloms with their long loops - Dopamine and ANP both increased with volume up - Dopamine causes vasodilation of afferent and efferent arteriole - ANP causes afferent vasodilation and efferent vasodilation constriction, increasing GFR without affecting RPF - Glomerular hemodynamics and renal failure - Decreased glomerular mass results in hyperfiltration of remaining gloms - Mediated through afferent vasodilationJC talks about this classic study in critical care: High vs. Low blood pressure target in Septic Shock. https://www.nejm.org/doi/pdf/10.1056/NEJMoa1312173In this multi-center open label trial of 776 patients randomized to either a MAP of 65-70 or 80-85 with the primary endpoint of mortality. There was no difference in mortality at 28 days between the two groups (but a small difference in AKI in the patients who had chronic HTN- in the higher BP target, there was a decrease in need for RRT; there was also a higher incidence of afib in the high target group overall). - Results in compensation and stable GFR in short term, long term maladaptive - Reason for ACEi- Clinical Evaluation of Renal Circulation - Concept of clearance and measurement of GFR - GFR as an index of functioning renal mass - Had a patient today s/p nephrotomy, 72 years old, Cr0.9!Melanie referred to this article in Circulation which demonstrates that SGLT2 inhibitors do decrease single nephron GFR (in mice) and that this is related to a decrease in the afferent arteriole diameter and then they show that this is related to a local increase in adenosine. Kidokoro K, Cherney DZI et al. Evaluation of glomerular hemodynamic function by empagliflozin in diabetic mice using in vivo imaging Circulation 140 (4) 2019https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.037418 - Fall in GFR earlier and only sign of renal disease - Serial monitoring is used to assess severity and follow the course of disease - GFR is useful for dosing drugs - How to measure GFR - Consider fructose polysaccharide inulin (love the parenthetical, not insulin) - Inulin filtered = inulin excreted - Filtered inulin = plasma inulin concentration x GFR - Inulin excreted = urine concentration x urine volume - Use Alber a to get GFR = [Urine]insulin x urine volume / [plasma]inulin - GFR = inulin clearance - There is not an available assay for inulin - Creatinine clearance - Freely filtered - Not reanbsorbed - Not metabolized - Small amount excreted - CrCl exceeds GFR by 10-20%Roger says the SGLT2 inhibitor story is about the afferent arteriole and he thought it reminded him of the MDRD study and the concept that the lower protein intake would be protective and delay the progression of CKD. The concept was that low protein diets would decrease glomerular pressure by decreasing the intake of amino acids that lead to arteriolar vasodilation and increased GFR. Klaur S, Levey AS et al. The effects of Dietary Protein Restirciton and blood-pressure control on the progression of chronic renal disease. NEJM 1994 330:877-884. https://www.nejm.org/doi/full/10.1056/nejm199403313301301 - Compensated for by noncreatinine chromogens (acetone proteins, as Orbi acid, pyruvate) that over estimate Cr by 10-20% - Cr Cl = [Urine]cr x urine volume / [Plasma]cr - Two major limitations - Incomplete collections - 20-25 mg/kg in adult men - 15-20 mg/kg in adult womenThe term “Acute renal success” comes from Thurau K and Boylan JW. Acute renal success. The unexpected logic of oliguria in acute renal failure. Am J Med 1976 61(3): 3038-15. - Falls by 50% from age 50 to 90 to 10 mg/kg - Increased tubular secretion with decreased kidney function - GFR of 40-80 cr secretion may account for as much as 35% of creatinine excretion - In some cases CrCl can exceed GFR by a factor of 2 - Give cimetidine 1200 mg! - It is important to appreciate however that exact knowledge of GFR is not required. More important to know if GFR is changing - Why is radio labeling the solution DTPA and iothalamate? - Talks about the reality of progressive disease despite stable GFR and CrCl - On to plasma Cr and GFRIf you think placing dialysis lines is too easy, here is a wonderful review of micropuncture technique in the kidneys by Volker Vallon.Micropuncturing the Nephron. Pflugers Arch 2009 458(1): 189-201. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2954491/ - Creatinine excretion = creatinine production (and this is constant) - Creatinine excretion = [Cr] x GFR = constant - If GFR falls in half, creatinine excretion will fall in half, while creatinine production remains the same, so creatinine will rise and rise until [Cr] x GFR = creatinine production and then it will level off. - Changes in creatinine load - High protein diet can increase it - Vegetarian diet can decrease itJC brought up studies on fenoldopam, of which there are many. This is one such study in patients undergoing cardiac surgery. JAMA 2014 Bove T et al. Effect of fenoldopam on use of renal replacement therapy among patients with acute kidney injury after cardiac surgery: a randomized clinical trial https://pubmed.ncbi.nlm.nih.gov/25265449/ - Cooked meat can increase Cr by 1 mg/dL - Talks about need for steady state to assess GFR - Talks about the curvilinear relationship - Then he talks Cockcroft GaultThe one, the only: The Cockcroft Gault: Prediction of creatinine clearance from serum creatinine. Nephron 16: 31–41, 1976 https://pubmed.ncbi.nlm.nih.gov/1244564/ - Cirrhosis masks kidney insufficiency, low meat intake, low BUN production - Can someone explain what we are supposed to take from figure 2-12 - Stable Cr does not mean stable kidney diseaseRoger describes the study design for the seminal paper on the use of ACE inhibitors to slow the decline in renal function in diabetic kidney disease (then called diabetic nephropathy) and the decision to use the doubling of the serum creatinine as an endpoint. Lewis EJ The effect of Angiotensin-converting-enzyme inhibition on diabetic nephropathy NEJM 1993 https://www.nejm.org/doi/full/10.1056/NEJM199311113292004 - Ketoacidosis can raise the Cr 0.5 to 2.0mg/dL - On to BUN - Destination of amino acids produces ammonia - We detoxify ammonia by converting to urea - Increased with increased protein load - Increased catabolismMelanie mentioned an old study on ingestion of expired blood: Cohen TD. Induced azotemia in humans following massive protein and blood ingestion and the mechanism of azotemia in gastrointestinal hemorrhage. AM J Med Sci 1956 https://pubmed.ncbi.nlm.nih.gov/13302213/ - Tetracycline causes decreased anabolism - Trauma - Steroids - Urea excretion is variable and tied to hydration and FF - Renal plasma flow and PAH

This episode details how psoriatic arthritis and the spondyloarthropathies came to be recognized as a distinct clinical entity after decades of nerdy arguing. Intro :10 Shout out to Cleveland Clinic Biologic Therapies Summit :30 In this episode 1:29 A 30,000-foot view 2:34 When did PsA separate from rheumatoid arthritis? 3:34 Mary Stults Sherman 7:11 Verna Wright and Dr. John Moll put PsA on the map 9:09 Recognizing PsA as a disease 15:20 An anecdote about Wright 16:18 Putting the SpA puzzle pieces together 18:19 The severity of disease 19:08 Episode wrap-up 20:46 Disclosures: Brown reports no relevant financial disclosures. We’d love to hear from you! Send your comments/questions to Dr. Brown at rheuminationspodcast@healio.com. Follow us on Twitter @HRheuminations @AdamJBrownMD @HealioRheum References: Ankylosing Spondylitis, Churchill Livingstone, Edinburgh, London, Melbourne, New York, 1980. Espinoza LR, Helliwell P. Clinical Rheumatology. 2014;33:1335-1336. Gladman DD, et al. Q J Med. 1987;62:127-141. Kane D, et al. Rheumatology. 2003;42:1460-1468. Moll JMH. Reumatismo. 2007;59 Suppl 1:13-18. Moll JM, Wright V. Semin Arthritis Rheum. 1973;3:55-78. Seronegative polyarthritis, North-Holland Pub. Co., New York, Amsterdam, 1976. Wright V. Am J Med. 1959;27:454-462. Wright V. Ann Rheum Dis. 1956;15:348-356. Wright V. BMJ. 1994;309:1739-1740.

I will be discussing the case of a 66-year-old woman who ignored a Bull's eye rash, indicative of Lyme disease, and later developed acute renal failure. This case was described by Mishra and colleagues in the American Journal of Medicine .She presented with a tick bite followed by a rash. She ignored the tick bite and rash.A month later she developed acute renal failure. Her renal functions improved following hydration, antibiotics, and discontinuation of her losartan and nonsteroidal anti-inflammatory drugs,” the authors explain. Renal failure has been described in dogs but not in people. The renal failure could have been related to other factors. Ignoring a tick and rash for a month could not have helped.Mishra AK, Hashmath Z, Oneyssi I, Bose A. Disseminated Erythema Migrans. Am J Med. 2020 Feb 13. pii: S0002-9343(20)30114-5. For free access to case report. https://pubmed.ncbi.nlm.nih.gov/32061730/You can hear more about these cases through his blogs, social media, and YouTube. Sign up for our newsletter to keep up with these cases.How to Connect with Dr. Daniel Cameron:Check out his website: https://www.DanielCameronMD.com/Call his office: 914-666-4665Email him: DCameron@DanielCameronMD.com Send him a request: https://danielcameronmd.com/contact-daniel-cameron-md/Like him on Instagram: https://www.instagram.com/drdanielcameron/Join his Facebook group: https://www.facebook.com/danielcameronmd/Follow him on Twitter: https://twitter.com/DrDanielCameronSign up for his newsletter: https://www.DanielCameronMD.com/Subscribe and ring the bell: https://www.youtube.com/user/danielcameronmd/ Leave a review on iTunes or wherever else you get your podcasts.We, of course, hope you’ll join the conversation, connect with us and other readers, ask questions, and share your insights. Dr. Cameron is a Lyme disease expert and the author "Inside Lyme: An expert's guide to the science of Lyme disease." He has been treating adolescents and adults for more than 30 years.Please remember that the advice given is general and not intended as specific advice as to any particular patient. If you require specific advice, then please seek that advice from an experienced professional.

View the full show notes on Google Docs here: http://bit.ly/3cpvlJc 2020 BLS/ACLS Guideline Changes Merchant RM, Topjian AA, Panchal AR, et al. Part 1: Executive summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Published October 21, 2020. Accessed January 20, 2021. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000918 Highlights of the 2020 American Heart Association Guidelines for CPR and ECC. American Heart Association. Published 2020. Accessed January 20, 2021. https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts2020eccguidelinesenglish.pdf Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get with The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. Published April 9, 2020. Accessed January 20, 2021. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.120.047463 Topjian A, Aziz K, Kamath-Rayne BD, et al. Interim Guidance for Basic and Advanced Life Support in Children and Neonates with Suspected or Confirmed COVID-19. Pediatrics. Published 2020. Accessed January 20, 2021. https://pediatrics.aappublications.org/content/early/2020/04/13/peds.2020-1405 Hunt EA, Jeffers J, McNamara L, et al. Improved Cardiopulmonary Resuscitation Performance with CODE ACES2: A Resuscitation Quality Bundle. Journal of the American Heart Association. Published December 7, 2018. Accessed January 20, 2021. https://www.ahajournals.org/doi/10.1161/JAHA.118.009860 Procedural Pearl of the Month - Fish Hooks Roberts M, Roberts JR. The Proceduralist. https://www.theproceduralist.org/. Accessed January 20, 2021. The Procedural Pause by James R. Roberts, MD, & Martha Roberts, ACNP, PNP. Fishing Out the Fishhook. Emergency Medicine News. Published September 1, 2020. Accessed January 20, 2021. https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=108 Droperidol DeFranco, C, DO. Oldie but a Goodie: 10 Pearls of Droperidol. Acep.org. Published 2021. Accessed January 20, 2021. https://www.acep.org/how-we-serve/sections/pain-management/news/may-2020/oldie-but-a-goodie-10-pearls-of-droperidol/ Ho, J, FAAEM MD, Perkins J, FAAEM MD. Clinical Practice Statement: Safety of Droperidol Use in the Emergency Department. Aaem.org. Published September 7, 2013. Accessed January 20, 2021. https://www.aaem.org/UserFiles/file/Safety-of-Droperidol-Use-in-the-ED.pdf Cisewski, D MD. Droperidol Use in the Emergency Department – What's Old is New Again. Emdocs.net. Published August 1, 2019. Accessed January 20, 2021. http://www.emdocs.net/droperidol-use-in-the-emergency-department-whats-old-is-new-again/ Ken's Third View SGEM#315: Comfortably Numb with Topical Tetracaine for Corneal Abrasions. Thesgem.com. Published January 16, 2021. Accessed January 20, 2021. http://thesgem.com/2021/01/sgem315-comfortably-numb-with-topical-tetracaine-for-corneal-abrasions/ Shipman S, Painter K, Keuchel M, Bogie C. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Ann Emerg Med. Published October 27, 2020. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/33121832/ SGEM#316: What A Difference an A.P.P. Makes? Diagnostic Testing Differences Between A.P.P.S and Physicians. Thesgem.com. Published January 23, 2021. Accessed January 24, 2021. http://thesgem.com/2021/01/sgem316-what-a-difference-an-a-p-p-makes-diagnostic-testing-differences-between-a-p-p-s-and-physicians/ Pines JM, Zocchi MS, Ritsema TS, Bedolla J, Venkat A, US Acute Care Solutions Research Group. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. Acad Emerg Med. Published November 21, 2020. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/33107088/ Gonorrhea Questions Answered Scully BE, Fu KP, Neu HC. Pharmacokinetics of ceftriaxone after intravenous infusion and intramuscular injection. Am J Med. Published October 19, 1984. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/6093511/ Meyers BR, Srulevitch ES, Jacobson J, Hirschman SZ. Crossover study of the pharmacokinetics of ceftriaxone administered intravenously or intramuscularly to healthy volunteers. Antimicrob Agents Chemother. Published November 1983. Accessed January 20, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC185948/ Shatsky M. Evidence for the use of intramuscular injections in outpatient practice. Am Fam Physician. Published February 15, 2009. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/19235496/ Trivia Question: Send answers to 2viewcast@gmail.com Please note that for this month, if you get the trivia question correct, you will win 20% off any CCME course you want. That's right, ANY CCME course you want. You can buy it for yourself or give it to a friend - it's your 20% off. So, download and listen to the episode for the question! Please email us your guesses at 2viewcast@gmail.com, that's the number 2, view, cast @gmail.com and tell us who you want to give a shout-out to.

The completion of the Endocarditis for the Rheumatologist trilogy! This episode focuses on the glomerulonephritis of endocarditis as well as the immunologic abnormalities you can see on labs. Brought to you by GSK. Consider the long-term impact of disease activity flares and corticosteroid use on patients with active SLE. Learn more now at treatfortodayandtomorrow.com. Intro :11 In this episode :22 Recap of previous episodes :39 About episode three 1:00 How labs can give a clue to endocarditis being a culprit 1:23 The immune complex nature of infective endocarditis 6:30 How do you measure immune complex? 9:10 What are the effects of immune complex formation on the organ systems? 12:37 Brought to you by GSK. Considering a treatment change for patients with active SLE? Learn about a treatment option for your patients at treatfortodayandtomorrow.com. Cryoglobulins and rheumatoid factor in infective endocarditis 15:12 The kidneys and infective endocarditis 16:45 Glomerulonephritis and infective endocarditis 24:15 ANCA-positive vasculitis and infective endocarditis 29:09 A summary of infective endocarditis 32:21 Takeaways 33:28 A preview of next episode 33:48 Conclusion 34:12 Disclosure: Brown reports no relevant financial disclosures. We’d love to hear from you! Send your comments/questions to Dr. Brown at rheuminationspodcast@healio.com. Follow us on Twitter @HRheuminations @AdamJBrownMD @HealioRheum References: Bayer AS, et al. N Engl J Med. 1976;295:1500-1505. Boils CL, et al. Kidney Int. 2015;87:1241-1249. Forte WC, et al. Arq Bras Cardiol. 2001;76:43-52. Hurwitz D, et al. Clin Exp Immunol. 1975;19:131-141. Langlois V, et al. Medicine (Baltimore). 2016;95:e2564. Levy RL, Hong R. Am J Med. 1973;54:645-652. Ma T-T, et al. PLoS One. 2014;9: https://doi.org/10.1371/journal.pone.0097843. Messias-Reason IL, et al. Clin Exp Immunol. 2002;127:310-315. Petersdorf RG. N Engl J Med. 1976;295:1534-1535. Spain DM, King DW. Ann Intern Med. 1952;36:1086-1089. Williams Jr RC, Kunkel HG. J Clin Invest. 1962;41:666-675. Tire squealing sound effect by Mike Koenig.

This episode focuses on the clinical aspects of endocarditis you can catch in the exam room, emphasizing the joint and skin manifestations, along with some interesting historical insights on Osler nodes and Janeway lesions. Brought to you by GSK. Considering a treatment change for patients with active SLE? Learn about a treatment option for your patients at treatfortodayandtomorrow.com. Intro :11 In this episode :22 About episode two 2:28 Rheumatologic manifestations of infectious endocarditis 4:28 Musculoskeletal manifestations of infectious endocarditis in the back 5:55 The lack of patterns for infectious endocarditis causing joint pain 9:48 Myalgias and the connection with endocarditis 12:48 The skin and its connection with endocarditis 15:37 What are Janeway lesions 17:13 What are Osler nodes? 19:28 Brought to you by GSK. Consider the long-term impact of disease activity flares and corticosteroid use on patients with active SLE. Learn more now at treatfortodayandtomorrow.com. What causes these lesions? 21:24 Differentiating Osler’s nodes and Janeway lesions 25:20 What are splinter hemorrhages? 28:08 Petechiae and its association to infective endocarditis 31:43 What about leukocytic vasculitis? 33:17 Other puzzle pieces to look for 37:18 A preview of next episode 40:30 Conclusion 42:12 Disclosure: Brown reports no relevant financial disclosures. We’d love to hear from you! Send your comments/questions to Dr. Brown at rheuminationspodcast@healio.com. Follow us on Twitter @HRheuminations @AdamJBrownMD @HealioRheum References: Chahoud J, et al. Cardiol Rev. 2016;24:230-7. Farrior JB, Silverman ME. Chest. 1976;70:239-43. Godeau P, et al. Rev Med Interne. 1981;2:29-32. Gunson TH, Oliver GF. Australas J Dermatol. 2007;48:251-5. Heffner JE. West J Med. 1979;131:85-91. Loricera J, et al. Clin Exp Rheumatol. 2015;33:36-43. Koslow M, et al. Am J Med. 2014;S0002-9343(14)00188-0.    Murillo O, et al. Infection. 2018;46. Meyers OL, Commerford PJ. Ann of the Rheum Dis. 1977;36:517-519. Parikh SK, et al. J Am Acad Dermatol. 1996;35:767-8. Young J. et al. J R Coll Physicians Lond. 1988;22:240-3.

Mikki Williden, PhD is a Registered Nutritionist in Auckland, New Zealand specializing in sports and performance nutrition. I met Mikki at the Ancestral Health Symposium in Boulder, Colorado in 2016, and she has recently launched a new podcast called Mikkipedia as an exploration of all things health, well being, fitness, food and nutrition. She kindly invited me on as a guest, which of course is a role reversal for me. On this podcast, Mikki and I discuss my personal health journey and what motivated me to start NBT. We get into some detail, including what my life looked like before I knew anything about health and the specific steps that got me headed in the right direction. We talk about bike racing and business and how both have evolved for me, as well as the habits that I’ve built to maintain my current state of health and performance. Here’s the outline of this podcast with Mikki Williden: [00:00:19] Christopher Kelly on Robb Wolf’s Paleo Solution podcast. [00:01:50] Robb Wolf’s podcast, The Healthy Rebellion. [00:02:24] Chris's health journey. [00:03:18] Mikki’s interview with Greg Potter, on The Mikkipedia Podcast. [00:04:21] Book: The Paleo Diet for Athletes: The Ancient Nutritional Formula for Peak Athletic Performance, by Loren Cordain and Joe Friel. [00:05:38] Autoimmune Protocol (AIP) diet. [00:06:45] Chris Kelly on Ben Greenfield's podcast. [00:11:36] Relative Energy Deficiency in Sport (REDS); Podcast: How to Identify and Treat Relative Energy Deficiency in Sport (RED-S); with Nicky Keay. [00:14:51] Mickey Trescott’s books on AIP. [00:17:22] Framing interventions in terms of performance. [00:20:43] Diet changes over time. [00:20:59] Keto Summit; Jeremy and Louise Hendon. [00:21:59] Dom D’Agostino, PhD. [00:22:53] Problems with the Keto diet. [00:24:15] Podcasts featuring Katie compton and Jeremy Powers. [00:26:01] Racing and fueling. [00:28:25] Changing goals: from performance to healthspan. [00:30:51] Book: Tiny Habits: The Small Changes That Change Everything, by BJ Fogg, PhD. [00:31:04] B Strong blood flow restriction training; Podcast: Blood Flow Restriction Training for Improved Strength, Performance, and Healthspan, with Jim Stray-Gundersen, MD. [00:35:33] NBT over time - changes in approach. [00:37:44] Supervised machine learning; bloodsmart.ai. [00:40:09] Stephen Genuis, PhD; Multiple studies on toxicants excreted in sweat. [00:44:11] Identifying your values; Motivational interviewing, Acceptance and commitment therapy (ACT). [00:45:49] Services offered by NBT; book a free 15-minute starter session. [00:46:54] Podcast: How to Manage Stress, with Simon Marshall, PhD. [00:48:39] Intermountain Risk Score. Study: Horne BD, May HT, Muhlestein JB, Ronnow BS, Lappé DL, Renlund DG, et al. Exceptional mortality prediction by risk scores from common laboratory tests. Am J Med. 2009;122: 550–558. [00:48:57] PhenoAge; Podcast: How to Measure Your Biological Age, with Megan Hall. [00:52:32] Supplements: Thorne Multi-Vitamin Elite, Thorne Creatine. [00:54:56] A day in the life of Chris Kelly. [00:56:30] Podcast: Air Pollution Is a Cause of Endothelial Injury, Systemic Inflammation and Cardiovascular Disease, with Arden Pope, PhD. [00:59:49] California wildfires. [01:02:28] Cliff Harvey. [01:03:04] Influential podcast guests. [01:03:41] Podcasts with Malcolm Kendrick: Why Cholesterol Levels Have No Effect on Cardiovascular Disease (And Things to Think about Instead) and A Statin Nation: Damaging Millions in a Brave New Post-health World. [01:04:38] Podcasts with Stephanie Welch: Disruptive Anthropology: An Ancestral Health Perspective on Barefooting and Male Circumcision and The Need for Tribal Living in a Modern World. [01:04:48] Josh Turknett, MD, president of Physicians for Ancestral Health; Podcasts include The Migraine Miracle, How to Protect Your Brain from Decline, and How to Support Childhood Cognitive Development. [01:05:51] Book: The WEIRDest People in the World: How the West Became Psychologically Peculiar and Particularly Prosperous, by Joe Henrich. [01:06:44] My Migraine Miracle; Book: Migraine Miracle: A Sugar-Free, Gluten-Free Ancestral Diet to Reduce Inflammation and Relieve Your Headaches for Good; Video: Migraine as the Hypothalamic Distress Signal — Joshua Turknett, M.D. (AHS14). [01:08:44] How To Win At Angry Birds: The Ancestral Therapeutic Paradigm - AHS19. Podcast: How to Win at Angry Birds: The Ancestral Paradigm for a Therapeutic Revolution; 4-quadrant model.   [01:14:05] NBT’s retainer program.

Dernier épisode et certainement le plus controversé de notre série sur la goutte! Dans ce 62ème épisode du Pharmascope, Nicolas, Sébastien et Isabelle tentent de répondre à plusieurs questions croquantes: Quand initier un traitement prophylactique contre la goutte? Comment ajuster les doses? Suivre les niveaux d’acide urique, est-ce pertinent? Et la prophylaxie de la prophylaxie,c’est utile? Les objectifs pour cet épisode sont: Discuter du moment idéal pour débuter un traitement prophylactique de la goutteExpliquer les avantages et les inconvénients d’une approche d’ajustement de dose d’hypouricémiant selon l’atteinte de niveaux cibles d’acide uriqueExpliquer les bénéfices et les risques d’une prophylaxie anti-inflammatoire concomitante à l’initiation d’un traitement hypouricémiant Ressources pertinentes en lien avec l’épisode Lignes directrices portant sur la prise en charge de la goutteFitzGerald JD et coll. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Rheumatol. 2020;72:879-95. Richette P et coll. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout. Ann Rheum Dis. 2020;79:31-8. Qaseem A et coll. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:58-68. Articles de revue portant sur la prise en charge de la goutteDrug and Therapeutics Bulletin. Latest guidance on the management of gout. BMJ. 2018;362:k2893. Sidari A, Hill E. Diagnosis and Treatment of Gout and Pseudogout for Everyday Practice. Prim Care. 2018;45:213-36. Dugré N. L’hyperuricémie et la goutte. Québec Pharmacie. Juin/juillet 2015. 25p. Initiation d’un traitement hypouricémiant pendant une crise de goutteTaylor TH et coll. Initiation of allopurinol at first medical contact for acute attacks of gout: a randomized clinical trial. Am J Med. 2012;125:1126-34.e7. Hill EM et coll. Does starting allopurinol prolong acute treated gout? A randomized clinical trial. J Clin Rheumatol. 2015;21:120-5. Ajustement des doses d’hypouricémiants selon des niveaux ciblesStamp LK et coll. A randomised controlled trial of the efficacy and safety of allopurinol dose escalation to achieve target serum urate in people with gout. Ann Rheum Dis. 2017;76:1522-8. Stamp L et coll. Serum urate as surrogate endpoint for flares in people with gout: A systematic review and meta-regression analysis. Semin Arthritis Rheum. 2018;48:293-301. Prophylaxie anti-inflammatoire concomitante avec la colchicinePaulus HE et coll. Prophylactic colchicine therapy of intercritical gout. A placebo-controlled study of probenecid-treated patients. Arthritis Rheum. 1974;17:609-14. Borstad GC et coll. Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis. J Rheumatol. 2004;31:2429-32.

Our guest is Peter McCullough, MD, MPH, consultant cardiologist and Vice Chief of Medicine at Baylor University Medical Center in Dallas, Texas. He is an internationally recognized authority on the role of chronic kidney disease as a cardiovascular risk state with more than a thousand publications and more than five hundred citations in the National Library of Medicine. His works have appeared in the New England Journal of Medicine, Journal of the American Medical Association, Lancet and other top-tier journals worldwide. However, he is not with us to discuss the cardiorenal syndrome nor his many illustrious achievements in cardiology. Rather, he joins us to tell us about an article on the outpatient treatment of COVID-19 of which he is first author. The paper is titled and was published in the American Journal of Medicine online on August 6, 2020. GUEST: Peter McCullough, MD, MPH: https://twitter.com/McCulloughBHVH (Twitter) LINKS: McCullough P, et al. “Pathophysiological Basis and Rational for Early Outpatient Treatment of SARS-CoV-2 (COVID-19) Infection” (https://www.amjmed.com/article/S0002-9343(20)30673-2/fulltext (Open Access) in Am J. Med) WATCH ON YOUTUBE: https://youtu.be/2cWtMEZZ-FE (Watch the episode) on our YouTube channel SUPPORT THE SHOW: https://www.patreon.com/accadandkoka (Make a small donation) on our Patreon page on and join our discussion group or receive a free book. Support this podcast

In Part 2 of 2 of our "Mini Grand Rounds" series, we discuss the use of thrombolytics in the setting of cardiac arrest and wrap it up with our final recommendations.References:Lederer W, Lichtenberger C, Pechlaner C, et al. Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out‐of‐hospital cardiac arrest. Resuscitation 2001; 50(1): 71-76Abu-Laban RB, Christenson JM, Innes GD, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med 2002; 346: 1522-8Comess KA, DeRook FA, Russell ML, et al. The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity. Am J Med 2000; 109: 351-6Courtney DM, Kline JA. Prospective use of a clinical decision rule to identify pulmonary embolism as likely cause of outpatient cardiac arrest. Resuscitation 2005; 65: 57-64Neumar RW, Otto CWL MS, Kronik SI, et al. Part 8: Adult advanced cardiovascular   life support: 2010 American Heart Association guidelines for cardiopulmonary   resuscitation and emergency cardiovascular care. Circulation 2010; 122: S729-67

Episode 18: Cervical PolypsThe sun rises over the San Joaquin Valley, California, today is June 26, 2020.As our nation continues to battle the OPIOID epidemic (along with other epidemics), our good, old-fashioned aspirin at high doses (900 to 1300 mg) was found to be effective and safe to treat acute migraine headaches. Further research is needed to recommend aspirin as a prophylactic therapy, but it’s promising. Findings of this research were published in November 2019 by Dr Biglione and collaborators in The American Journal of Medicine (1,2). Aspirin keeps giving us surprises after more than 120 years on the market! Also, the Food and Drug Administration has approved the first over-the-counter ibuprofen and acetaminophen combination drug for the U.S. It’s called Advil Dual Action which contains 250 mg of ibuprofen and 500 mg of acetaminophen. It will be available later in 2020 (3).Talking about epidemics, have you heard that diabetes is a surgical disease? Some experts support the cure of diabetes with bariatric surgery, and yes, it may not be the first choice, but it is effective when used appropriately. However, according to a research presented during Endo Online 2020, Dr Yingying Luo, stated that having bariatric surgery BEFORE developing type 2 diabetes results in a greater weight loss, especially within the first 3 years after surgery. The probability of achieving BMI less than 30, and the chance of reaching excess weight loss of more than 50%, is higher in patients WITHOUT diabetes before surgery(4). Diabetes prevention is another good reason to send your patients to bariatric surgery in a timely manner when they meet criteria. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “A good head and good heart are always a formidable combination. But when you add to that a literate tongue or pen, then you have something very special.” ― Nelson MandelaI always thought that having a good brain and a good heart were enough to be wise, but Mr Mandela taught me that having a good tongue or pen makes than person even more special. Do you get it? Being wise and compassionate, and being able to communicate that information to others is very important. That’s why we have this exercise called Rio Bravo qWeek– to learn how to transfer information from our head and our hearts to our co-residents and patients. I hope we can become better communicators every day. Before I introduce our guest today, I want to take a minute to correct myself. In episode 15, I said “more higher”, I noticed my mistake, and I correct it now: It is not “more higher”, it’s just “higher”. Also, I hope you heard the beautiful quote we used at the end of our episode 17. I want to clarify that we do not have any political affiliation, but we have the same values and principles we shared with the good people of America, including politicians, artists, NGOs, religions, and other groups. I encouraged you to “examine what is said, not him who speaks” (Arab proverb), especially in this podcast. We have a very pleasant and clever resident who has some things to say today. Welcome, Dr Yodaisy Rodriguez.Question Number 1: Who are you?My name is Yodaisy Rodriguez Acosta. I graduated from medical school in Cuba. Before moving to the US, I worked in Honduras and in Venezuela as part of Medical collaboration programs. I love outdoor activities, gardening, crafting, movies, and dogs. My perfect day is having a picnic with my family.Question number 2: What did you learn this week? I learned about cervical polyps this week. Clinicians may encounter normal variants and benign neoplasms of the cervix on pelvic examination. It is important, as family medicine doctors, to become familiar with a normal cervix, so we can identify what looks ABNORMAL.Cervical polyp definition-A cervical polyp is a growth or tumor found in the cervical canal. It is a lobular or tear-shape growth, red or purple, it can also be very vascularized. After you see a couple of them you learn to recognize them. -They present more commonly in post-menarche and pre-menopausal women who have been pregnant. - It is included in the Cervical Noncystic lesions.-The etiology is unknown. Chronic inflammation of the cervical canal may be the cause. Hormonal factors may also play a role, since endometrial hyperplasia and cervical polyps coexist. -Differential diagnosis includes an endometrial polyp or prolapsed leiomyoma.-Malignancy in polyps is uncommon.What to do when you see a cervical polypPolyps should always be removed if they are symptomatic (eg, bleeding, excessive discharge), large (≥3 cm), or appear atypical. Polypectomy is usually a small procedure done in the office. Malignancy is rarely found in a cervical polyp, however, polyps that are removed should be submitted to the laboratory for histological study.Question number 3: Why is that knowledge important for you and your patients?Because cervical cancer is very common. Every year, nearly 13,000 cases of cervical cancer are diagnosed, with more than 4,000 deaths. Cervical cancer is typically asymptomatic. We should become familiar with the screening and management of cervical diseases. Having the right information will help us answer our patient’s concerns.  Question number 4: How did you get that knowledge?I learned because I had a patient with a cervical polyp. When you receive an abnormal pap result, you normally look up the next step by using the ASCCP app, but what do you do when the cervix looks abnormal during the physical exam? How do you perform a polyp removal? Thanks to my OBGYN attendings, and thanks to my gynecology rotations, I have improved my knowledge and abilities in managing abnormal cervix. I learned that if a patient has a grossly visible cervical lesion, biopsy should be performed. If biopsy cannot be performed at that visit, cervical cytology should be collected, and the patient should have a biopsy as soon as possible. Comment: We had a patient recently with an abnormal cervical exam. It was described as a “cavity” between 3 and 6 o’clock. The resident explained to me that “he has never seen any cervix like that”. Our patient had weight loss and abdominal pain, along with bilateral hydronephrosis. The cervical biopsy was done at the time of the placement of bilateral ureter stents in the OR. The biopsy resulted in squamous cell carcinoma of the cervix. So, I agree with you, grossly abnormal cervix should prompt us to perform a biopsy in a timely manner.Cervical cytology became the standard screening with the introduction of the Papanicolaou (Pap) smear in 1941. Now we start screening for cervical cancer at age 21 regardless of sexual activity. Cultural concerns should be addressed and respected when possible. A patient at age 21 may decline pelvic exam, you have to be culturally sensitive and discuss the matter with the patient and encourage pap smear with tact, but respect patient’s preferences.Question number 5: Where did that knowledge come from? 1) Up To Date. 2) Cervical Cancer: Evaluation and Management by Jennifer Wipperman and collaborators, published in the American Family Physician in 2018.3) FP notebook app 4) American Society for Colposcopy and Cervical Pathology (ASCCP) app ____________________________Speaking Medical: Pioikilothermiaby Edvard Davtyan, MS4Good afternoon, my name is Edvard Davtyan, I am a 4th year medical student. I will be presenting the word of the week, Poikilothermia. This may sound like a phrase used in the world of thermodynamics. However, this phrase is more commonly used in the realm of Biology and Medicine. The term poikilothermia means “cool extremity”. It is originated from the word poikilothermwhich is used to describe animals or organisms whose internal temperature varies considerably with the temperature of its surroundings. These animals are also referenced by the common vernacular “cold-blooded.” The term is derived from Greek poikilos,meaning “varied”, and thermos, meaning “heat.”In Medicine, the loss of thermoregulation in humans is referred to as poikilothermia. This is seen in states of sedation (esp. REM sleep), effects of hypnotic drugs and acute limb ischemia. Poikilothermia is 1 of the 6 P’s in clinical presentation of acute limb ischemia: Pain, Pallor, Paresthesia, Pulselessness, Poikilothermia, and Paralysis. Hope this has been interesting for you, remember, if your patient has poikilothermia, it doesn’t mean they are cold-blooded, it just means you should probably check their ankle-brachial index (ABI).____________________________Espanish Por Favor: Chorroby Dr Claudia Carranza(Recorded Previously on 6/10/2020)Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is chorro. Chorro means jet or stream; some patients use this word to describe their bowel movement. Patients can come to you with the complaint: “Doctor, tengo chorro”, which means “Doctor, I have the runs” or in other words, “I’m having diarrhea”. This is more common in the Spanish-speakers coming from Mexico. You can then continue the interview and ask about how often, for how many days and if it’s bloody or melanotic, etc. Chorro can also mean a ton or lots; so, a patient might say “Doctor, tengo un chorro de problemas” which means “Doctor, I have a ton of problems”. Now you know the Spanish word of the week, “CHORRO”.____________________________For your Sanity (Medical Joke of the Week): ***by Dr Steven Saito and Dr Lisa ManzanaresA cosmetic surgeon sign says: “If life gives you lemons, a simple surgery will give you melons”.____________________________Now we conclude our episode number 18 “Cervical Polyps”. Dr Rodriguez recommended us to get used to a normal cervix. If a cervix looks odd, do not hesitate to or perform a biopsy schedule patient for biopsy. If you see a cervical polyp, a polypectomy can be easily performed in the office. Remember to send that sample to pathology. Edvard explained that Poikilothermia refers to cold-blooded animals, but it also refers to a “cold limb” as a sign of acute limb ischemia. Chorro was explained by Dr Carranza as a “less elegant” way to say diarrhea in Spanish. This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Yodaisy Rodriguez, Claudia Carranza, Edvard Davtyan, Lisa Manzanares, and Steven Saito. Audio edition: Suraj Amrutia. See you soon! _____________________References:The American Journal of Managed Care, https://www.ajmc.com/newsroom/aspirin-effective-in-treating-acute-migraine-preventing-recurrent-migraine-review-finds.Biglione B, Gitin A, Gorelick PB, et al. Aspirin in the treatment and prevention of migraine headaches: possible additional clinical options for primary healthcare providers [published online November 8, 2019]. Am J Med. doi: 10.1016/j.amjmed.2019.10.023.“FDA approves combination ibuprofen-acetaminophen drug for U.S.”, ADA News, March 02, 2020, https://www.ada.org/en/publications/ada-news/2020-archive/march/fda-approves-combination-ibuprofen-acetaminophen-drug-for-us“Bariatric surgery may be less beneficial in diabetes”, Family Practice News, Vol 50, No. 4, April 2020, page 11. “Benign cervical lesions and congenital anomalies of the cervix” by Marc R Laufer, MD, UptoDate, Last updated on May 28, 2020. https://www.uptodate.com/contents/benign-cervical-lesions-and-congenital-anomalies-of-the-cervix?search=cervical%20polyp§ionRank=1&usage_type=default&anchor=H16&source=machineLearning&selectedTitle=1~28&display_rank=1#H16, accessed on June 22, 2020.“Cervical Cancer: Evaluation and Management” by Jennifer Wipperman, MD, MPH; Tara Neil, , MD; and Tracy Williams, MD, Am Fam Physician. 2018 Apr 1;97(7):449-454. https://www.aafp.org/afp/2018/0401/p449.html American Society for Colposcopy and Cervical Pathology (ASCCP), App.

This episode explores the history of cryoglobulinemic vasculitis, from the first person who froze a tube of blood and noticed something strange happened, to the discovery of hepatitis C. We also throw in how the lab test for cryoglobulins is performed and some of the data we have on therapy. Brought to you by GSK. Consider the long-term impact of disease activity, flares and corticosteroid use on patients with active SLE. Learn more now at treatfortodayandtomorrow.com Intro :20 In this episode :45 How is this test done? 1:30 What is the first description of cryoglobulins? 4:15 The first time “cryoglobulins” is used 10:26 Hepatitis C is discovered and linked to cryoglobulinemia 16:28 What do we know about the pathophysiology? 19:38 Why does HCV do this? 22:12 Brought to you by GSK. Considering a treatment change for patients with active SLE? Learn about a treatment option for your patients at treatfortodayandtomorrow.com. What’s in the blood as a result of immune complex? 24:52 What do we know about autoimmune diseases and the prevalence of cryoglobulins? 26:03 What about treatment? 28:25 Summary of this three-part series 36:16 Disclosure: Brown reports no relevant financial disclosures. We’d love to hear from you! Send your comments/questions to rheuminationspodcast@healio.com. Follow us on Twitter @HRheuminations @AdamJBrownMD @HealioRheum References: Brouet JC, et al. Am J Med. 1974;57:775-788. Cacoub P, et al. Clin Gastroenterol Hepatol. 2019;17:518-526. De Vita S, et al. Arthritis Rheum. 2012;64:843-853. Fuentes A, et al. Curr Rheumatol Rep. 2019;21:doi:10.1007/s11926-019-0859-0. Lerner AB, Watson CJ. Am J Med Sci. 1947;214:410-415. Lospalluto J, et al. Am J Med. 1962;32:142-147. Meltzer M, Franklin EC. Am J Med. 1966;40:828-836. Pascual M, et al. J Infect Dis. 1990;162:569-570. Ragab G, Hussein MA. J Adv Res. 2017;8:99-111. Tzioufas AG, et al. Arthritis Rheum. 1986;29:1098-1104. Wintrobe MM, Buell, MV. Bull. Johns Hopkins Hosp. 1933;52:156-165.

Patricia Westmoreland, MD, returns to the Psychcast to conduct a Masterclass on treating bulimia. Dr. Westmoreland, an attending psychiatrist at the Eating Recovery Center in Denver, previously discussed eating disorders. She is an adjunct assistant professor in the department of psychiatry at the University of Colorado at Denver, Aurora, and has a private forensic psychiatry practice in Denver. Takeaway points Anorexia nervosa and bulimia nervosa can have life-threatening medical complications. All medical complications can resolve with consistent nutrition and full weight restoration. Eating disorders must be treated and associated behaviors stopped to prevent complications from returning. Anorexia-related medical complications usually are attributable to weight loss and malnutrition. Bulimia-related medical complications can occur at any weight, and are related to the mode and frequency of purging. Complications include metabolic abnormalities, such as electrolyte and acid-base disturbances, volume depletion, and damage to the colon. Patients with bulimia have a lower mortality rate than do those with anorexia. However, the mortality of patients with bulimia is two times higher than that of age-matched healthy controls because of acid-base disturbances and severe electrolyte abnormalities. The weight of the patients with bulimia does not matter. Acid-based disturbances and severe electrolyte abnormalities can kill patients at any time without warning and at any weight. Summary About 90% of purging behaviors consists of self-induced vomiting and/or laxative abuse. Self-induced vomiting can cause local complications such as gastric reflux, which can lead to dysphagia and dyspepsia; hematemesis from Mallory-Weiss tears in the esophagus; nosebleeds and subconjunctival hemorrhages; and parotid gland enlargement, known as sialadenosis, which is a chronic, noninflammatory cause of swelling of the major salivary glands. Systemic complications of self-induced vomiting include metabolic derangements, such as hypokalemia, metabolic alkalosis, and volume depletion, which can lead to pseudo-Bartter syndrome from chronic aldosterone secretion as the body attempts to maintain blood pressure; the syndrome is characterized by hyperaldosteronism, metabolic alkalosis, hypokalemia, and normal blood pressure. Treatment of local complications: Gastric reflux can be treated with proton pump inhibitors, and the patient should be screened for Barrett’s esophagus with esophagogastroduodenoscopy. Dental complications such as erosion of the enamel should be addressed with fluoride-based mouthwashes and toothpastes, and gentle toothbrushing. Parotid gland enlargement is treated by sucking on sour candies, applying hot packs, and using anti-inflammatory medications. Treatment of systemic complications: Hypokalemia, which is diagnosed on a basic metabolic panel, needs immediate repletion orally or intravenously. Depending on the severity of the hypokalemia, the patient may need cardiac monitoring in the hospital or ICU to prevent mortality from a lethal arrhythmia. In pseudo-Bartter syndrome, the elevated aldosterone does not normalize until a few weeks after purging stops, so individuals can develop edema and the other electrolyte abnormalities. Treatment is spironolactone, 25-200 mg/day. Complications from laxative abuse occur primarily from stimulant laxatives, which stimulate the myenteric plexus, the nerves of the intestines, and increase intestinal secretions and motility. Cathartic colon syndrome occurs from continued use of stimulant laxatives, which damage the nerves of the colon by rendering it incapable of peristalsis without continued use of laxatives. Individuals who abuse laxatives more than three times per week for at least 1 year are at risk of cathartic colon syndrome and need to stop laxatives immediately. References Westmoreland P et al. Medical complications of anorexia nervosa and bulimia. Am J Med. 2016;129(1):30-7. Mehler PS, Walsh K. Electrolyte and acid-base abnormalities associated with purging behaviors. Int J Eat Disord. 2016 Mar;49(3):311-8. Gibson D et al. Medical complications of anorexia nervosa and bulimia nervosa. Psychiatr Clin North Am. 2019 Jun;42:263-74. Sato Y, Fukado S. Gastrointestinal symptoms and disorders in patients with eating disorders. Clin J Gastroenterol. 2015 Oct;8(5):255-63. *  *  * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com

Join the EMGuideWire team as they discuss Superior Vena Cava Syndrome! Shownotes: Definition: Any condition leading to obstruction of blood flow through the SVC Pathophysiology: Pathology in adjacent anatomy (lung, lymph node, thymus, mediastinum) or within the SVC itself obstructs venous return to the right atrium. As the SVC is compressed, venous collaterals form alternative pathways returning blood to the right atrium which can dilate over several weeks. As a result, upper body venous pressure increases, which in extreme cases lead to airway congestion and venous cerebrovascular congestion and edema. Hemomdynamic compromise is most often by direct compression of the heart, not from SVC obstruction. Risk factors: Indwelling device through the SVC (Central line, dialysis catheter, pacemaker) Lung cancer Lymphoma Thymoma Presentation: Signs – plethoric appearance, dilated neck and chest veins, swollen face/neck/chest Symptoms – congestive symptoms (head fullness, swelling), cardiopulmonary symptoms (chest pain, dyspnea, stridor, hoarseness), and neurologic symptoms (headache, confusion, obtundation, visual disturbances) Work-up: Is the patient unstalbe? Do they have severe SVC? If yes, secure airway, support breathing, support circulation Consult vascular/cardiothoracic surgery If patient is stable, then: Confirm diagnosis and evaluate for malignant obstruction CBC, CMP, PT/INR, CXR, CT chest w/contrast Does the patient have a malignant obstruction or thrombosis? Yes -> consult heme/onc and admit No -> observe in ED     References: García Mónaco R, Bertoni H, Pallota G, et al. Use of self-expanding vascular endoprostheses in superior vena cava syndrome. Eur J Cardiothorac Surg 2003; 24:208. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85:37. Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena caval obstruction. Is it a medical emergency? Am J Med 1981; 70:1169. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862.

In this second part of the Abnormal Liver Function Test podcast series, Dr. Tara McMichael continues her discussion and case presentation around abnormal liver function tests. Enjoy the second part of the "Abnormal Liver Function Test" podcast! Objectives:     Upon completion of this podcast, participants should be able to: Identify the appropriate next steps when discovering abnormal liver function tests. Identify how to diagnose cirrhosis, autoimmune hepatitis, and cholecystitis. Address appropriate 2nd and 3rd line testing for abnormal LFTs. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Abnormal Liver Function Tests (LFTs) - Part 2" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”    FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: PART-2:   CASE 2: 69 yo female with 2 days of low back pain. Also some dark urine for about a week. She has some fatigue as well. No jaundice or bowel changes. She's not much of a drinker, minimal wine. PMH incudes obesity, hyperlipidemia and a prediabetic state. She take vitamins, calcium and glucosamine. No drugs and no significant family history. She's had about a 10 lb unintential weight loss. Also some early satiety. Her BMI is 32, but otherwise her VS and entire exam is normal. Additionally, she's been taking aspirin for her back pain. Laboratory eval reveals AST of 767,  ALT 818, and ALP 173. These are all modestly to significantly elevated. The AST and ALT are over 4 times upper limit of normal. Basically she's not really ill appearing at this point. Differential diagnosis at this point includes acute viral hepatitis. We must consider testing for A, B, C as well as EBV and CMV. These are IgM and IgG studies typically. Billiary obstruction and cirrhosis seems less likely in this case. Also not likely ETOH related. NASH is a possibility. We should also review her meds as a potential cause. Was she actually taking aspirin, or is she just calling it aspirin. Let's not forget some of the less common diseases like autoimmune hepatitis, Wilson's hemochromatosis and other rare infections. Right-sided heart failure may be an option. Hepatitis serologies, EBV, CMV, Tylenol level, iron and copper levels, ESR as well as PT/INR would be appropriate. CRP was a bit elevated at 11. Gamma globulins are obtained and noted to be elevated. The rest of the labs were all normal as well. A liver ultrasound reveals no abnormalities. A GI consult was obtained and it was felt this is a case of autoimmune hepatitis. Typically this is a dx of exclusion, and now that we've excluded a lot, we will shift to various autoimmune tests. ANA. This may be positive, however there are more specific tests for this condition, such as anti-smooth muscle, antimitochondrial, and anti liver-kidney microsomal antibodies, and various other antibody tests. Gamma globulins are also often elevated in AIH What is this condition? We don't fully know. There are several types of autoimmune hepatitis, however type-1 is the most common. It is actually not an entirely uncommon disease with a prevalence in Europe of 11 to 25 per 100,000. In the U.S., there is no exact data. One could infer that it would be similar. Ultimately, the body is attacking the liver for unclear reasons. Concurrent autoimmune thyroiditis can accompany this. A known hx of inflammatory bowel dz can predispose to this condition. Typically AST and ALT are 10-20 times upper limits of normal, usually therefore much higher than cirrhosis. Imaging is usually normal, unless the disease has advanced by the time diagnosis is made. Remission is not uncommon, upwards of 50 to 60%. Corticosteroids and azathioprine are common medications given for this. These can be tapered, and LFTs are rechecked on a regular basis throughout the taper and discontinuation of the medications. Sometimes, stronger immunosuppressants are needed. GI at minimum but sometimes hepatology referral is warranted for this diagnosis. Liver biopsy is often done for this condition. And indeed was on this patient which showed findings consistent with autoimmune hepatitis. Often, a degree of fibrosis is seen in AH. Well people, that's a wrap. for autoimmune hepatitis. Stay tuned for the final case presentation in the next segment, coming up shortly with Dr. McMichael here on Ridgeview Podcast CME series. CASE 3: So, the final caser is an 80 yo male with fever and confusion. He's high functioning at baseline, lives alone at home. He called his daughter and she noted he wasn't "acting himself". Altered mental status can be caused by many things, as we know. The differential diagnosis includes infection, hypoxia, metabolic derangement, toxin related, dementia, CNS lesions and so many more! This guy has a hx of CLL and type 2 DM, as well as HTN and BPH. Not a big drinker, about 1 to 2 beverages per day. He has a fever of 100.8. VS are normal otherwise. He's uncomfortable and restless appearing. Alert and oriented to person. Sepsis now is a big concern. What's causing it? He still has a gallbladder, but we need to know some more about his exam reveals not much more, other than tenderness in the epigastric and LUQ areas of the abdomen. Preliminary labs include normal UA, EBC 35.8, but remember the cLL hx. BMP unremarkable but a little dry with BUN 32. ALP is 256. AST and ALT are just bumped over normal. Lipase and trop are normal. Total bili is normal. So probable not ascending cholangitis. CXR was normal. So prompted a CT abdomen to rule out abdominal pathology. This revealed cholelithiasis. Compared to ultrasound, CT is not as helpful in terms of ruling out biliary obstruction, although often we will see pericholecystic inflammation. For cases of acute cholecystitis (AC), CT scan findings include the following: gallstones within the gallbladder (GB), the cystic duct, or both; more than 3mm of focal or diffuse thickening of the GB wall in a non-contracted GB; indistinct liver-GB interface; fluid in the GB fossa in the absence of ascites, enlargement of the GB, with the transverse diameter measuring more than 5 cm; infiltration of the surrounding fat; increased bile attenuation, caused by biliary sludge; and GB mucosal sloughing. At the same time, ultrasound is the gold standard. So this was done, and antibiotics were ordered. There is a non-mobile gallstone in the gallbladder neck. The CBD also has a small distal stone. He was admitted, taken to surgery for lap cholecystectomy and cholangiogram which confirmed the distal CBD stone. He was taken for ERCP and stenting the next day. In cholestatic presentations, the ALP is usually higher than AST and ALT. Serum bilirubin is not as helpful in delineating hepatocellular vs cholestatic picture. The Tokyo guidelines? Not widely used at this point. They're used to grade who needs to go to surgery first. In general, it's recommended to follow the American Anesthesiology guidelines for physical status. There are several grading systems, but there is little banter about this when it comes down to the decision to go to surgery or not. According to a paper in 2017 in the American Journal of Surgery by Madni et al, "Most grading scales which have been developed are used to predict the risk of conversion to an open cholecystectomy. There is a paucity in the literature of scoring systems to predict other metrics such as hospital length of stay, iatrogenic injury, and total operative time." HIDA scan can be done if there is no obvious stone, and whether you think this is truly gallbladder dysfunction and the patient should go to surgery, according to the World Society of Emergency Surgery Guidelines. Now, if this were a woman child-bearing age, while there could be a gallbladder etiology, always be sure to check a pregnancy test. HELLP syndrome must be considered. Fitz Hugh Curtis syndrome should also be considered in sexually active women with abdominal pain and elevated LFTs. Remember, especially in patients with altered mental status to keep your net cast wide. Our elderly patients are notorious for unusual presentations of common disease. Just a fair warning. A special thanks to Dr. McMichael for joining us and sharing these cases today. Have a great month everyone and we'll see you soon. REFERENCES:1. D'Amico et al. J Hepatology, 2006, Natural History and Prognostic Indicators in Cirrhosis: A systematic review 2. Salpeter et al. Am J Med. 2012. Systematic Review of Noncancer Presentations with a median survival of  months or less. 3. Wond et al, Gastroenterology, 2015. Nonalcoholic Steatohepatitis is the second leading cause of liver disease in adults awaiting liver transplantation in the United States.

Mais um caso clínico! Dessa vez o Raphael Coelho apresenta o caso, sendo que os outros integrantes não sabem o diagnóstico final. O paciente do caso tem 87 anos e está em uma UTI de pós operatório. Recomendamos que você pare em cada bloco de informação, para montar o seu raciocínio e maximizar o aprendizado. Respondemos o desafio da semana passado e já deixamos um novo! Gostou do episódio? Quer sugerir alguma hipótese diagnóstica ou fazer uma correção? Entra em contato com a gente pelo Instagram @tadeclinicagem ou pelo e-mail tadeclinicagem@gmail.com. Se você curte o podcast, por favor nos avalie no aplicativo que você escutou. REFERÊNCIAS: Marcantonio ER. "Delirium in Hospitalized Older Adults", N Engl J Med 2017; 377:1456-1466, DOI: 10.1056/NEJMcp1605501 Inouye SK. "The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients". Am J Med 1994; 97:278. Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium?: value of bedside instruments. JAMA 2010; 304:779.

Karl Doghramji, MD, is professor of psychiatry with secondary appointments in neurology and medicine at Thomas Jefferson University in Philadelphia. He also directs the Sleep Disorders Center at Thomas Jefferson. Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Classification and consequences  Insomnia is defined by the DSM-5 as dissatisfaction with sleep quantity or quality, difficulty falling asleep or staying asleep, or both. The symptoms need to occur at least three times per week for more than 3 months and cause dysfunction or distress in the patient. 20%-30% of the population reports insomnia; within inpatient psychiatry populations, the rates rise to up to 80%. Insomnia is thought to be caused by central nervous system hyperarousal or hyperactivity of unclear etiology, and there is evidence of genetic vulnerability. Insomnia is associated with significant impairments, such as diminished ability to enjoy life and sleep during inappropriate times (i.e., while driving or in occupational settings). In addition, insomnia confers increased risk for chronic illnesses such as major depressive disorder, substance use disorder, as well as diabetes, hypertension, and dementia. Treating insomnia  It is best to first treat the comorbidities of insomnia, such as mood disorders and anxiety, and then target insomnia with both behavioral modifications and medications. When prescribing medications, choose a pharmacologic agent that targets the period of sleep difficulty. Evaluation of insomnia must examine the dimensions of sleep, including falling asleep (sleep initiation), compared with staying asleep (sleep maintenance). Behavioral techniques  Stimulus control therapy: If a person is unable to fall asleep within 20-30 minutes, either at initiation or in the middle of sleep cycle, he/she should get out of bed and do something outside of the room and return to bed only when feeling sleepy. Relaxation therapies, such as progressive muscle relaxation, can improve sleep if performed once a week for 12 weeks. Sleep hygiene improvements, such as addressing late caffeine consumption, room brightness, and daytime napping can mitigate insomnia. Pharmacologic interventions  Over-the-counter options include valerian root and histamine1 antagonists, such as diphenhydramine and melatonin. Melatonin is modestly effective at low doses, though the effects have not panned out in meta-analyses. At low doses, melatonin may increase total sleep time or improve sleep initiation by a few minutes. Watch out for adverse effects with long-term use of melatonin, such as disruption of other receptors, decreased fertility, and altered efficacy of chemotherapeutic agents. Prescription drugs approved by the Food and Drug Administration Benzodiazepines approved for insomnia include flurazepam (Dalmane), temazepam (Restoril), estazolam (Prosom), and triazolam (Halcion). However, those medications have long half-lives and tend to contribute to excessive daytime sedation. “Z-drugs” are the selective benzodiazepine receptor agonists. Zaleplon (Sonata) and zolpidem are useful for sleep initiation but might not help with sleep maintenance through the entire night. Eszopiclone (Lunesta) and zolpidem extended release (Ambien CR) can help with sleep initiation and sleep maintenance through the entire sleep period. Z-drugs, especially if mixed with alcohol, can contribute to parasomnias such as sleep walking and sleep driving. The FDA counsels that if patients develop parasomnias, they should not be rechallenged with those drugs. Nonscheduled medications include ramelteon (Rozerem), a melatonin receptor agonist that is effective for sleep initiation, and low-dose doxepin (Sinequan), which is effective for middle to late portions of the night. References Pavlova MK and Latreille V. Sleep disorders. Am J Med. 2019 Mar 132(3):292-9. Clark J. Slumber Camp. Conquer insomnia. For clinicians. Slumber Camp is an award-winning, 28-day, online course that teaches the principles of cognitive-behavioral therapy for insomnia. Cui R and Fiske A. Predictors of treatment attendance and adherence to treatment recommended among individuals receiving cognitive behavioral therapy for insomnia. Cogn Behav Ther. 2019 Mar 14:1-7. Christensen MA et al. Direct measurements of smartphone screen-time: Relationships with demographics and sleep. PLoS One. 2016 Nov 9;11(11):e0165331.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych

Episode 24:   David H. Henry, MD, host of Blood & Cancer, is on location at the 2019 annual meeting of the American Society of Clinical Oncology in this podcast. Dr. Henry speaks with one of his own residents, Ronak Mistry, DO, about recent research among “bloodless medicine” patients, iron deficiency, and the ASCO experience. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about what happens when patients do their own literature search for treatment options.   Show notes By Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia  “Bloodless medicine” patients demonstrated superior outcomes following cardiovascular surgery when their hemoglobin was optimized to a higher level. Iron deficiency is defined as transferrin saturation less than 20 with concurrent ferritin 100-300 or ferritin less than 100. Intravenous iron repletion is superior to oral iron repletion among patients with heart failure. Iron repletion in heart failure correlates with improved functional status. Iron deficiency anemia in heart failure goes underrecognized and undertreated.   Additional reading Iron supplementation, response in iron-deficiency anemia: Analysis of five trials. Am J Med. 2017 Aug;130(8):991.e1-991.e8. Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion. 2014 Oct;54(10 Pt 2):2668-77.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry, MD on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz            

Heute geht es innerhalb einer kleinen Serie zu Ernährung um das Thema Salz //   Wieder konfrontativ und massiver Streits in der Wissenschaft, wie bei Zucker & Cholesterin. Salz? Kochsalz (auch Streusalz im Winter) Natrium-Chlorid, meist allein auf Natrium bezogen Meersalz (Fleur de Sel) Mikropastik, z.B. Aquasale, de Camargue. https://www.ndr.de/ratgeber/verbraucher/Fleur-de-Sel-Plastik-in-Meersalz-nachgewiesen,salz378.html  Manchmal mit Jod beigemischt Kalium-Chlorid Ist Salz schädlich? Frauen in Hongkong haben weltweit die höchste Lebenserwartung mit 87,3 Jahren, obwohl sie mehr als doppelt so viel wie z.B. laut USA-Richtlinien empfohlen konsumieren. Liu ZM, Ho SC, Tang N, Chan R, Chen YM, Woo J. Urinary sodium excretion and dietary sources of sodium intake in Chinese postmenopausal women with prehypertension. PLoS One 2014; 9: e104018. Natrium: Bad science? //   Altersstandardisierte geschätzte Natriumaufnahme und gesunde Lebenserwartung bei der Geburt in 182 Ländern Sterblichkeit: J-Kurve Zwei Achsen: nach oben Sterbliuchkeit Nach rechts: Natrium Aufnahme Keine Linie, mehr Salt schlechter, weniger besser Sondern J Mittlerer Bereich niedrig, Sowohl links, bei niedrigen, als rechts, bei hohen Konzentrationen, Sterblichkeit hoch Empfohlenen täglichen Aufnahmeschwellen.  AHA = American Heart Association. 1.4 WHO = 2.0 ESC = Europäische Gesellschaft für Kardiologie. 2.3 Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 2013; 3: e003733. UN. Healthy life expectancy (HALE) at birth (years). July 31, 2014. http://data.un.org/Data.aspx?q=life+expectancy&d=WHO&f=MEASURE_ CODE%3aWHOSIS_000002 (accessed July 11, 2018). Die starre natriumarme Diät ist fade, eintönig, geschmacklos und unerträglich. Um daran festzuhalten, bedarf es der Askese eines Eremiten. Pickering G. The nature of essential hypertension. London: Churchill, 1961. 2016  130.000 Personen, 49 Länder :  Salzrestriktion nur in Patienten mit erhöhtem Blutdruck Reduktion von Herzerkrankungen, Schlaganfall und Tod;  bei alle anderen schädlich. Mente A, O’Donnell M, Rangarajan S, et al. Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies. Lancet 2016; 388: 465–75. Lancet wurde attackiert so schlechte Wissenschaft zu publizieren. Johnston I. Lancet attacked for publishing study claiming low-salt diet could kill you. Independent May 21, 2016: 12. Action on Salt Graham MacGregor  http://www.actiononsalt.org.uk AHA diffamiert die Studie als schlicht falsch;  Produkte mit mehr Salz empfohlen als sie selbst raten. American Heart Association. American Heart Association comment strongly refutes study findings on sodium consumption. May 21, 2016. http:// newsroom.heart.org/news/american-heart-assocation-strongly-refutesstudy- findings-on-sodium-consumption (accessed July 22, 2018). Messerli FH, Rimoldi SF, Bangalore S. Salt, tomato soup, and the hypocrisy of the American Heart Association. Am J Med 2017; 130: 392–93. 2018 Epidemiologische Kohortenstudie, 94.378 Erwachsene, 35-70 (mittleres Alter 50), 18 Länder für Median 8,1 Jahren. 58% Frauen,  keine Herz-Kreislauf-Erkrankungen zum Zeitpunkt der Rekrutierung. Bestätigen, dass niedrige Natrium aufnahme MI und Schlaganfall leicht erhöhen. Eine höhere Natriumaufnahme assoziiert mit mehr Schlaganfällen (0,42 Ereignisse pro 1000 Jahre), weitgehend auf China beschränkt, 6 g / Tag.  Provokant: Inverse Korrelation zwischen Natriumaufnahme und Herzinfarkt und Sterblichkeit, trotz der starken und direkter Assoziation mit Blutdruck (2,8 mm Hg / g). Mente A, O’Donnell M, Rangarajan S, et al. Urinary sodium excretion, blood pressure, cardiovascular disea...

"You hate on everything! What do you even do with your patients? Why so negative?" We've heard it all before, and so have the authors of this paper. This open source article explores and defends the position of being skeptic within the medical world. The Case for Being a Medical Conservative. Mandrola J, Cifu A, Prasad V, Foy A. Am J Med. 2019 Mar 6. pii: S0002-9343(19)30167-6. doi: 10.1016/j.amjmed.2019.02.005. [Epub ahead of print] Open Source! Due to copyright laws, unless the article is open source we cannot legally post the PDF on the website for the world to download at will. That said, if you are having difficulty obtaining an article, contact us. Produced by: Matt Hunter Music for PT Inquest: "The Science of Selling Yourself Short" by Less Than Jake Used by Permission

Take a listen to this medical mystery and learn about a not-so-rare condition — depending on where you live. Hear some interesting historical stories about the physicians who helped establish the diagnosis, as well as an interview with a renowned expert. Intro :11 A 57-year-old woman presents with multiple-week history of joint pain. She also complains of lesions on her forearms. :32 Initial lab results 1:30 She arrives at my office 1:50 Review of her vitals 1:57 Physical exam findings and patient history 2:05 What about the nodules on her skin? 3:20 Tests leading to diagnosis 4:40 What’s the diagnosis? 4:55 A personal anecdote 5:20 Symmetrical polyarticular inflammatory arthritis in the setting of erythema nodosum 6:18 What do we know about Löfgren Syndrome? 7:45 History of this diagnosis 8:35 What we know 100 years later 11:13 Focus on the inflammatory arthritis of Löfgren Syndrome 14:25 Are these different diseases? 18:07 Summary of what we’ve discussed so far 19:13 Unsung heroes who showed sarcoidosis is associated with inflammatory arthritis 20:40 Introduction of Dr. Daniel Culver 28:26 An update on sarcoidosis with Dr. Culver 29:17 Why should we care about staging on X-ray? 29:22 Are there any clues that it may be sarcoid based on histology and morphology of the granuloma itself? 30:56 How does bronchoalveolar lavage help? 32:58 How often do you see remissions in non-Löfgren’s sarcoidosis? 34:41 What are your thoughts on the serum biomarkers? 36:34 Can you comment with your thoughts on the link between the environment and the disease? 38:25 What about infectious triggers? 40:06 Do you think genetic studies will eventually be used for diagnosis or prognosis? 41:18 Where do you think we’ll be with the diagnosis and treatment of sarcoidosis in 10 years? 42:38 Thank you, Dr. Dan Culver 44:28 Episode recap 44:40 Follow us on Twitter @HRheuminations and leave us a review in iTunes 45:18 Daniel Culver, DO, is director of the Interstitial Lung Disease Program at Cleveland Clinic and director of The Sarcoidosis Center of Excellence at Cleveland Clinic. We’d love to hear from you! Send your comments/questions to rheuminationspodcast@healio.com. Follow us on Twitter @AdamJBrownMD @HealioRheum @HRheuminations References: Grunewald J, Eklund A. Am J Respir Crit Care Med. 2009;179:307-312. Le Bras E, et al. Arthritis Care Res (Hoboken). 2014;66:318-322. Lofgren S, Lundback H. Acta medica Scandinavica. 1952;142. Maña J, et al. Am J Med. 1999;107:240-245. Palmer DG, Schumacher HR. Ann Rheum Dis. 1984;43:778–782. Segura BT, et al. Medicina Clinica (Barc). 2014;143:166-9.

Obesity Paradox The idea that a high BMI appears to be protective and decreases death in people, but also is associated with increased risk of death.    ***More simply put - there is data out there that shows being overweight can be a good thing for some, yet a bad thing for others*** Acronyms HTN : hypertension Normal BMI (Nml) = 30 Evidence showing OW+ is bad for our health: Tons of it out there, I don't think I need to list too many. But here are some as it is still important to remember this. Arch Intern Med. 2002 Sep 9;162(16):1867-72. Overweight and obesity as determinants of cardiovascular risk: the Framingham experience.Wilson PW1, D'Agostino RB, Sullivan L, Parise H, Kannel WB. Looked at relationships between BMI and CVD risk factors, CVD endpoints prospectively from the Framingham HEart Study of ppl 35-75 who were followed for up to 44 years. CV endpoints the looked at: Angina, MI, Coronary hrt dz, or stroke. Conclusions: the overweight category is assoc with increased relative and population risk for HTN, and CVD. Ob risk of HTN was 42% OW risk of HTN was 27.8% Nml  risk of HTN 15.3%   NHANES III (1988-1994) to NHANES III (1999-2000) Showed increase prevalence of Metabolic Syndrome (MetSyn) and that weight was associated with increased risk of MetSyn: Nml 5% OW 22% Ob 60% http://care.diabetesjournals.org/content/34/1/216.long N Engl J Med. 2002 Aug 1;347(5):305-13.Obesity and the risk of heart failure.Kenchaiah S1, Evans JC, Levy D, Wilson PW, Benjamin EJ, Larson MG, Kannel WB, Vasan RS. 5881 participants in Framingham. Used Cox proportional-hazards model Found: For each 1 unit increase in BMI women’s risk of heart failure increased by 7%, 5% in men. Nurses’ Health Study https://www.ncbi.nlm.nih.gov/pubmed/7872581 114,281 female registered nurses aged 30 to 55 years who did not have diagnosed diabetes mellitus, coronary heart disease, stroke, or cancer in 1976. Over 11 states. Findings: BMI 35 was associated with 6X higher “relative risk” of T2DM Look AHEAD study and others Have shown that even a 5% weight loss can improve risk profiles for diabetes and cardiovascular health Lancet. 2014 Aug 30;384(9945):755-65. doi: 10.1016/S0140-6736(14)60892-8. Epub 2014 Aug 13.Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5·24 million UK adults.Bhaskaran K1, et. al. “Assuming causality, 41% of uterine and 10% or more of gallbladder, kidney, liver, and colon cancers could be attributable to excess weight. We estimated that a 1 kg/m(2) population-wide increase in BMI would result in 3790 additional annual UK patients developing one of the ten cancers positively associated with BMI.” ***granted i’m not sure any paper should have been published that uses the world “assume.” After all that just makes a “bleep” out of you and me. But as other studies do seem to show an assoc we’ll let it slide*** ************************************************** So there is a lot of data out there that shows associations between excess fat mass and MetSyn, HR, cancers, and 200+ diseases. From some evidence you would conclude that obesity does cause health problems. The Obesity Paradox: The strange thing is of the people getting diseases, the people who have the better prognosis are the ones overweight!!! And while all the above more talk about risk factors, we still do see patients of normal weight getting HTN, having coronary hrt disease, T2DM, getting the other 200+ diseases. Am J Med. 2007 Oct;120(10):863-70.Obesity paradox in patients with hypertension and coronary artery disease.Uretsky S1, et. al. 22,576 ppl with HTN and CAD Outcomes looked at:  first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke. Obese Class I(30-35) had a HR of 0.68 compared to Nml BMI patients. Lancet. 2006 Aug 19;368(9536):666-78. Association of bodyweight with total mortality and with cardiovascular events in coron...

Stephen Anderson has been an Acupuncturist and Chinese Medicine practitioner for nearly 20 years.  He’s had over 2500 patients and upwards of 40,000 consultations (that would be over 3/4 million acupuncture needles, but who’s counting). In 2016, Steve went through the Kresser Institute’s Practitioner Training Program for Functional and Evolutionary Medicine, completing the ADAPT Level 1 Framework.  Since then, his focus has shifted to working more with clients who are ready to make a deeper commitment to their health. Steve is on the podcast today talking about his transition into Functional Medicine and his practical application of our Blood Chemistry Calculator to guide treatment decisions and keep clients motivated.  Steve is currently running his busy clinic in Australia and is now introducing an easy way for Aussies to get lab work done locally and try the calculator for themselves. Here’s the outline of this interview with Stephen Anderson: [00:00:12] The Holistic Practitioner (THP) Podcast. [00:00:25] THP Podcast: Dr. Tommy Wood - Reframing Insulin Resistance. [00:02:07] Taichi. [00:03:30] Chinese Kung Fu Academy; Grandmaster Henry Sue. [00:03:58] Cheng Man-ch'ing. [00:04:29] Hypothalamic–pituitary–adrenal (HPA) axis. [00:07:48] Accelerated learning. [00:07:54] Book: How to Develop a Super Power Memory, by Harry Lorayne; Peg memory system. [00:08:09] Podcast: Learning to Learn with Jonathan Levi.  Course: Become a SuperLearner. [00:09:28] Acupuncture. [00:10:52] Polycystic ovary syndrome (PCOS). [00:12:30] Dr. Michael D. Fox at the Jacksonville Center for Reproductive Medicine. [00:17:13] Functional Medicine. [00:18:57] Simon Marshall, PhD. Podcasts: How to Create Behaviour Change and Why We Self-Sabotage (And What to Do Instead). [00:20:25] Kresser Institute for Functional and Evolutionary Medicine; ADAPT Practitioner Training Program. [00:23:16] Dr. Amy Nett. [00:24:11] Hierarchy of treatment. [00:25:52] THP Podcast: A Patient’s Perspective of Functional Medicine Treatment. [00:29:26] Blood Chemistry Calculator. [00:29:37] THP Podcast: Chris Kelly On Becoming An Effective Health Coach. [00:29:41] Dr. Bryan Walsh; Podcasts:  1, 2, 3, 4, 5, 6. [00:29:42] Megan Roberts; Podcast: Why Your Diet Isn’t Working: Under Eating and Overtraining.  Blog post: What We Eat and How We Train Part 1: Coach and Ketogenic Diet Researcher, Megan Roberts. [00:31:06] 7-Minute Analysis. [00:36:39] 5-year wellness score; Intermountain Risk Score. Study: Horne BD, May HT, Muhlestein JB, Ronnow BS, Lappé DL, Renlund DG, et al. Exceptional mortality prediction by risk scores from common laboratory tests. Am J Med. 2009;122: 550–558. [00:39:14] Thomas Dayspring, Peter Attia; LDL-P. [00:42:13] Familial Hypercholesterolemia. [00:44:17] Mediterranean diet, B-vitamins, Thorne Choleast-900 (Monacolin K), Ubiquinol, Glutathione. [00:46:35] Feedback via lab results as the incentive to change behaviour. [00:49:58] Coronary artery calcium scan; Podcasts: How Not to Die of Cardiovascular Disease, with Ivor Cummins; The True Root Causes of Cardiovascular Disease, with Jeff Gerber. [00:52:12] Podcast: Optimal Diet and Movement for Healthspan, Amplified Intelligence and More with Ken Ford. [00:53:14] stephenanderson.com.au/nbt.

Bryan Hayes and David Juurlink explain why several common meds we use in the ED can cause dangerous complications for older patients. See http://gempodcast.com/2016/03/30/dangerous-med-combos-in-older-adults/ to leave a comment. Look twice at the med list before you prescribe these! Two distinguished guests join me this month, David Juurlink (@DavidJuurlink) and Bryan Hayes (@PharmERToxyGuy) to discuss medication interactions. There are many medications that we commonly prescribe in the ED that can have potentially deadly side effects when combined with other meds that a patient is already on. It is important to always check the patient’s medication list prior to writing a new script. We present two examples of clinical cases in which commonly used medications could prove dangerous in combination with other medications: cellulitis, and a community-acquired pneumonia. We discuss potential side effects from medication interactions (with a little pathophysiology thrown in), and some alternative medications that may be safer. References: 1. Baillargeon J, Holmes HM, Lin YL, Raji MA, Sharma G, Kuo YF. Concurrent use of warfarin and antibiotics and the risk of bleeding in older adults. Am J Med. 2012;125(2):183-189. http://www.ncbi.nlm.nih.gov/pubmed/22269622 2. Ho JM, Juurlink DN. Considerations when prescribing trimethoprim-sulfamethoxazole. CMAJ. 2011;183(16):1851-1858. http://www.ncbi.nlm.nih.gov/pubmed/21989472 3. Fralick M, Macdonald EM, Gomes T, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: Population based study. BMJ. 2014;349:g6196. http://www.ncbi.nlm.nih.gov/pubmed/25359996 4. Juurlink DN, Mamdani M, Kopp A, Laupacis A, Redelmeier DA. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;289(13):1652-1658. http://www.ncbi.nlm.nih.gov/pubmed/12672733 5. Juurlink DN. The cardiovascular safety of azithromycin. CMAJ. 2014;186(15):1127-1128. http://www.ncbi.nlm.nih.gov/pubmed/25096666 6. Wright AJ, Gomes T, Mamdani MM, Horn JR, Juurlink DN. The risk of hypotension following co-prescription of macrolide antibiotics and calcium-channel blockers. CMAJ. 2011;183(3):303-307. http://www.ncbi.nlm.nih.gov/pubmed/21242274 Sound credits: This podcast uses sounds from freesound.org by Jobro and HerbertBoland