Podcasts about am j surg

Is private equity's growing influence in continuing medical education changing the quality of learning in the health professions? As a CME professional, you need to navigate an increasingly complex funding landscape where commercial support has dropped, and private equity firms are rapidly acquiring education providers. Understanding these shifts is crucial for developing sustainable, high-quality educational programs and navigating your way as a CME professional. In this episode, we'll explore: How CME funding has evolved from primarily university-based to a complex mix of commercial support, registration fees, and private investment Why private equity firms are acquiring CME providers and what this means for content development Key strategies for maintaining educational quality and professional relationships in an environment of frequent mergers and acquisitions Listen now to gain insights into the $4.23 billion CME industry's funding transformation and position yourself for success in this rapidly changing landscape. Timestamps 00:00 Introduction: The Art of Hustling Pool and CME 00:54 AI Bootcamp for Medical Writers 01:32 The Complex Financial Side of CME 02:06 Evolution of CME Funding 02:42 Pharmaceutical Influence and Regulations 05:47 The Impact of Compliance and Regulatory Codes 07:06 Current CME Funding Landscape 08:21 Private Equity in CME 10:48 Challenges and Questions for CME Professionals 12:08 Conclusion: Ensuring Educational Quality Resources Ratnasekera A, Impact of private equity on graduate medical education: A slippery slope. Am J Surg. https://doi.org/10.1016/j.amjsurg.2024.116160 ACCME's Standards for Integrity and Independence in Continuing Education (2020) ACCME Data Report. Thriving Through Growth and Innovation—2023. ACCME. Toolkit for the Standards for Integrity and Independence in Accredited Continuing Education

Guest: Dr. Christian de Virgilio is the Chair of the Department of Surgery at Harbor-UCLA Medical Center. He is also Co-Chair of the College of Applied Anatomy and a Professor of Surgery at UCLA's David Geffen School of Medicine. He completed his undergraduate degree in Biology at Loyola Marymount University and earned his medical degree from UCLA. He then completed his residency in General Surgery at UCLA-Harbor Medical Center followed by a fellowship in Vascular Surgery at the Mayo Clinic.   Resources:  Rutherford Chapters (10th ed.): 174, 175, 177, 178 Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/ The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext  KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/    Outline: Steal Syndrome Definition & Etiology Steal syndrome is an important complication of AV access creation, since access creation diverts arterial blood flow from the hand. Steal can be caused by multiple factors—arterial occlusive disease proximal or distal to the AV anastomosis, high flow through the fistula at the expense of distal arterial perfusion, and failure of the distal arterial networks to adapt to this decreased blood flow.  Incidence and Risk Factors The frequency of steal syndrome is 1.6-9%1,2, depending on the vessels and conduit choice Steal syndrome is more common with brachial and axillary artery-based accesses and nonautogenous conduits. Other risk factors for steal syndrome are peripheral vascular disease, coronary artery disease, diabetes, advanced age, female sex, larger outflow conduit, multiple prior permanent access procedures, and prior episodes of steal.3,4  Long-standing insulin-dependent diabetes causes both medial calcinosis and peripheral neuropathy, which limits arteries' ability to vasodilate and adjust to decreased blood flow. Patient Presentation, Symptoms, Grading Steal syndrome is diagnosed clinically.  Symptoms after AVG creation occurs within the first few days, since flow in prosthetic grafts tend to reach a maximum value very early after creation. Native AVFs take time to mature and flow will slowly increase overtime, leading to more insidious onset of symptoms that can take months or years. The patient should have a unilateral complaint in the extremity with the AV access. Symptoms of steal syndrome, in order of increasing severity, include nail changes, occasional tingling, extremity coolness, numbness in fingertips and hands, muscle weakness, rest pain, sensory and motor deficits, fingertip ulcerations, and tissue loss.  There could be a weakened radial pulse or weak Doppler signal on the affected side, and these will become stronger after compression of the AV outflow. Symptoms are graded on a scale specified by Society of Vascular Surgery (SVS) reporting standards:5  Workup Duplex ultrasound can be used to analyze flow volumes. A high flow volume (in autogenous accesses greater than 800 mL/min, in nonautogenous accesses greater than 1200 mL/min) signifies an outflow issue. The vein or graft is acting as a pressure sink and stealing blood from the distal artery. A low flow volume signifies an inflow issue, meaning that there is a proximal arterial lesion preventing blood from reaching the distal artery. Upper extremity angiogram can identify proximal arterial lesions. Prevention Create the AV access as distal as possible, in order to preserve arterial inflow to the hand and reduce the anastomosis size and outflow diameter.  SVS guidelines recommend a 4-6mm arteriotomy diameter to balance the need for sufficient access flow with the risk of steal. If a graft is necessary, tapered prosthetic grafts are sometimes used in patients with steal risk factors, using the smaller end of the graft placed at the arterial anastomosis, although this has not yet been proven to reduce the incidence of steal.  Indications for Treatment Intervention is recommended in lifestyle-limiting cases of Grade II and all Grade III steal cases. If left untreated, the natural history of steal syndrome can result in chronic limb ischemia, causing gangrene with loss of digits or limbs. Treatment Options Conservative management relies on observation and monitoring, as mild cases of steal syndrome may resolve spontaneously. Inflow stenosis can be treated with endovascular intervention (angioplasty with or without stent) Ligation is the simplest surgical treatment, and it results in loss of the AV access. This is preferred in patients with repetitive failed salvage attempts, venous hypertension, and poor prognoses. Flow limiting procedures can address high volumes through the AV access. Banding can be performed with surgical cutdown and placement of polypropylene sutures or a Dacron patch around the vein or graft. The Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) technique employs a percutaneous endoluminal balloon inflated at the AVF to ensure consistency in diameter while banding Plication is when a side-biting running stitch is used to narrow lumen of the vein near the anastomosis. A downside of flow-limiting procedures is that it is often difficult to determine how much to narrow the AV access, as these procedures carry a risk of outflow thrombosis. There are also surgical treatments focused on reroute arterial inflow. The distal revascularization and interval ligation (DRIL) procedure involves creation of a new bypass connecting arterial segments proximal and distal to the AV anastomosis, with ligation of the native artery between the AV anastomosis and the distal anastomosis of the bypass. Reversed saphenous vein with a diameter greater than 3mm is the preferred conduit. Arm vein or prosthetic grafts can be used if needed, but prosthetic material carries higher risk of thrombosis. The new arterial bypass creates a low resistance pathway that increases flow to distal arterial beds, and interval arterial ligation eliminates retrograde flow through the distal artery.  The major risk of this procedure is bypass thrombosis, which results in loss of native arterial flow and hand ischemia. Other drawbacks of DRIL include procedural difficulty with smaller arterial anastomoses, sacrifice of saphenous or arm veins, and decreased fistula flow. Another possible revision surgery is revision using distal inflow (RUDI). This procedure involves ligation of the fistula at the anastomosis and use of a conduit to connect the outflow vein to a distal artery. The selected distal artery can be the proximal radial or ulnar artery, depending on the preoperative duplex. The more dominant vessel should be spared, allowing for distal arterial beds to have uninterrupted antegrade perfusion. The nondominant vessel is used as distal inflow for the AV access. RUDI increases access length and decreases access diameter, resulting in increased resistance and lower flow volume through the fistula. Unlike DRIL, RUDI preserves native arterial flow.  Thrombosis of the conduit would put the fistula at risk, rather than the native artery.  The last surgical revision procedure for steal is proximalization of arterial inflow (PAI). In this procedure, the vein is ligated distal to the original anastomosis site and flow is re-established through the fistula with a PTFE interposition graft anastomosed end-to-side with the more proximal axillary artery and end-to-end with the distal vein. Similar to RUDI, PAI increases the length and decreases the diameter of the outflow conduit. Since the axillary artery has a larger diameter than the brachial artery, there is a less significant pressure drop across the arterial anastomosis site and less steal. PAI allows for preservation of native artery's continuity and does not require vein harvest.  Difficulties with PAI arise when deciding the length of the interposition graft to balance AV flow with distal arterial flow. 2. Ischemic Monomelic Neuropathy Definition Ischemic monomelic neuropathy (IMN) is a rare but serious form of steal that involves nerve ischemia. Severe sensorimotor dysfunction is experienced immediately after AV access creation. Etiology IMN affects blood flow to the nerves, but not the skin or muscles because peripheral nerve fibers are more vulnerable to ischemia. Incidence and Risk Factors IMN is very rare; it has an estimated incidence of 0.1-0.5% of AV access creations.6 IMN has only been reported in brachial artery-based accesses, since the brachial artery is the sole arterial inflow for distal arteries feeding all forearm nerves. IMN is associated with diabetes, peripheral vascular disease, and preexisting peripheral neuropathy that is associated with either of the conditions. Patient Presentation Symptoms usually present rapidly, within minutes to hours after AV access creation. The most common presenting symptom is severe, constant, and deep burning pain of the distal forearm and hand. Patients also report impairment of all sensation, weakness, and hand paralysis. Diagnosis of IMN can be delayed due to misattribution of symptoms to anesthetic blockade, postoperative pain, preexisting neuropathy, a heavily bandaged arm precluding neurologic examination. Treatment Treatment is immediate ligation of the AV access. Delay in treatment will quickly result in permanent sensorimotor loss.   3. Perigraft Seroma Definition A perigraft seroma is a sterile fluid collection surrounding a vascular prosthesis and is enclosed within a pseudomembrane. Etiology and Incidence Possible etiologies include: transudative movement of fluid through the graft material, serous fluid collection from traumatized connective tissues (especially the from higher adipose tissue content in the upper arm), inhibition of fibroblast growth with associated failure of the tissue to incorporate the graft, graft “wetting” or kinking during initial operation, increased flow rates, decreased hematocrit causing oncotic pressure difference, or allergy to graft material. Seromas most commonly form at anastomosis sites in the early postoperative period. Overall seroma incidence rates after AV graft placement range from 1.7–4% and are more common in grafts placed in the upper arm (compared to the forearm) and Dacron grafts (compared to PTFE grafts).7-9 Patient Presentation and Workup Physical exam can show a subcutaneous raised palpable fluid mass Seromas can be seen with ultrasound, but it is difficult to differentiate between the types of fluid around the graft (seroma vs. hematoma vs. abscess) Indications for Treatment Seromas can lead to wound dehiscence, pressure necrosis and erosion through skin, and loss of available puncture area for hemodialysis Persistent seromas can also serve as a nidus for infection. The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines10 recommend a tailored approach to seroma management, with more aggressive surgical interventions being necessary for persistent, infected-appearing, or late-developing seromas.   Treatment The majority of early postoperative seromas are self-limited and tend to resolve on their own Persistent seromas have been treated using a variety of  methods-- incision and evacuation of seroma, complete excision and replacement of the entire graft, and primary bypass of the involved graft segment only. Graft replacement with new material and rerouting through a different tissue plane has a higher reported cure rate and lower rate of infection than aspiration alone.9     4. Infection Incidence and Etiology The reported incidence of infection ranges 4-20% in AVG, which is significantly higher than the rate of infection of 0.56-5% in AVF.11  Infection can occur at the time of access creation (earliest presentation), after cannulation for dialysis (later infection), or secondary to another infectious source. Infection can also further complicate a pre-existing access site issue such as infection of a hematoma, thrombosed pseudoaneurysm, or seroma. Skin flora from frequent dialysis cannulations result in common pathogens being Staphylococcus, Pseudomonas, or polymicrobial species. Staphylococcus and Pseudomonas are highly virulent and likely to cause anastomotic disruption. Patient Presentation and Workup Physical exam will reveal warmth, pain, swelling, erythema, induration, drainage, or pus. Occasionally, patients have nonspecific manifestations of fever or leukocytosis. Ultrasound can be used to screen for and determine the extent of graft involvement by the infection.   Treatments In AV fistulas: Localized infection can usually be managed with broad spectrum antibiotics.  If there are bleeding concerns or infection is seen near the anastomosis site, the fistula should be ligated and re-created in a clean field. In AV grafts: If infection is localized, partial graft excision is acceptable. Total graft excision is recommended if the infection is present throughout the entire graft, involves the anastomoses, occludes the access, or contains particularly virulent organisms Total graft excision may also be indicated if a patient develops recurrent bacteremia with no other infectious source identified. For graft excision, the venous end of the graft is removed and the vein is oversewn or ligated. If the arterial anastomosis is intact, a small cuff of the graft can be left behind and oversewn. If the arterial anastomosis is involved, the arterial wall must be debrided and ligation, reconstruction with autogenous patch angioplasty, or arterial bypass can be pursued. References   1. Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and Characteristics of Patients with Hand Ischemia after a Hemodialysis Access Procedure. J Surg Res. 1998;74(1):8-10. doi:10.1006/jsre.1997.5206 2. Ballard JL, Bunt TJ, Malone JM. Major complications of angioaccess surgery. Am J Surg. 1992;164(3):229-232. doi:10.1016/S0002-9610(05)81076-1 3. Valentine RJ, Bouch CW, Scott DJ, et al. Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg. 2002;36(2):351-356. doi:10.1067/mva.2002.125848 4. Malik J, Tuka V, Kasalova Z, et al. Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies. J Vasc Access. 2008;9(3):155-166. doi:10.1177/112972980800900301 5. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002;35(3):603-610. doi:10.1067/mva.2002.122025 6. Thermann F, Kornhuber M. Ischemic Monomelic Neuropathy: A Rare but Important Complication after Hemodialysis Access Placement - a Review. J Vasc Access. 2011;12(2):113-119. doi:10.5301/JVA.2011.6365 7. Dauria DM, Dyk P, Garvin P. Incidence and Management of Seroma after Arteriovenous Graft Placement. J Am Coll Surg. 2006;203(4):506-511. doi:10.1016/j.jamcollsurg.2006.06.002 8. Gargiulo NJ, Veith FJ, Scher LA, Lipsitz EC, Suggs WD, Benros RM. Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas. J Vasc Surg. 2008;48(1):216-217. doi:10.1016/j.jvs.2008.01.046 9. Blumenberg RM, Gelfand ML, Dale WA. Perigraft seromas complicating arterial grafts. Surgery. 1985;97(2):194-204. 10. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. doi:10.1053/j.ajkd.2019.12.001 11. Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg. 2008;48(5):S55-S80. doi:10.1016/j.jvs.2008.08.067

In this episode, podcast hosts Dr. Josh Roshal, Dr. Darian Hoagland, and Dr. Maya Hunt discuss the ins and outs of professional development time (PDT) and professional identity formation (PIF) during surgical training. Joined by insights from fellow CoSEF members, the team dives into key topics such as mentorship, timing, and making the most of this critical phase in residency. From rapid-fire tips to personal reflections, this episode offers a wealth of advice for trainees considering their PDT and PIF.. Episode Hosts: –Dr. Josh Roshal, University of Texas Medical Branch, @Joshua_Roshal, jaroshal@utmb.edu –Dr. Darian Hoagland, Beth Israel Deaconess Medical Center, @DHoaglandMD, dlhoagla@bidmc.harvard.edu –Dr. Maya Hunt, Indiana University, @dr_mayathehunt, mayahunt@iu.edu –CoSEF: @surgedfellows, cosef.org Guests:  -Dr. Ariana Naaseh, Washington University in St. Louis, @ariananaaseh, a.naaseh@wustl.edu -Dr. Colleen McDermott, University of Utah, @ColleenMcDMD, Colleen.McDermott@hsc.utah.edu -Dr. Shahnur Ahmed, Indiana University, shahme@iu.edu -Dr. Xinyi “Cathy” Luo, Tulane University, @DoctorSoySauce, xluo@tulane.edu -Dr. Ananya Anand, Stanford University, @AnanyaAnandMD, aa24@stanford.edu References: Smith SM, Chugh PV, Song C, Kim K, Whang E, Kristo G. Perspectives of Surgical Research Residents on Improving Their Reentry Into Clinical Training. J Surg Educ. 2024 Nov;81(11):1491-1497. doi: 10.1016/j.jsurg.2024.07.005. Epub 2024 Aug 31. PMID: 39217679. https://pubmed.ncbi.nlm.nih.gov/39217679/ Kochis MA, Cron DC, Coe TM, Secor JD, Guyer RA, Brownlee SA, Carney K, Mullen JT, Lillemoe KD, Liao EC, Boland GM. Implementation and Evaluation of an Academic Development Rotation for Surgery Residents. J Surg Educ. 2024 Nov;81(11):1748-1755. doi: 10.1016/j.jsurg.2024.08.015. Epub 2024 Sep 23. PMID: 39317122. https://pubmed.ncbi.nlm.nih.gov/39317122/ Gkiousias V. Scalpel Please! A Scoping Review Dissecting the Factors and Influences on Professional Identity Development of Trainees Within Surgical Programs. Cureus. 2021;13(12):e20105. doi:10.7759/cureus.20105 https://pubmed.ncbi.nlm.nih.gov/35003955/ Rivard SJ, Vitous CA, De Roo AC, et al. “The captain of the ship.” A qualitative investigation of surgeon identity formation. Am J Surg. 2022;224(1 Pt B):284-291. doi:10.1016/j.amjsurg.2022.01.010 https://pubmed.ncbi.nlm.nih.gov/35168761/ Irby DM, Cooke M, O'Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med J Assoc Am Med Coll. 2010;85(2):220-227. doi:10.1097/ACM.0b013e3181c88449 https://pubmed.ncbi.nlm.nih.gov/20107346/ Veazey Brooks J, Bosk CL. Remaking surgical socialization: work hour restrictions, rites of passage, and occupational identity. Soc Sci Med 1982. 2012;75(9):1625-1632.doi:10.1016/j.socscimed.2012.07.007 https://pubmed.ncbi.nlm.nih.gov/22863331/ Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med J Assoc Am Med Coll.2015;90(6):718-725.doi:10.1097/ACM.0000000000000700 https://pubmed.ncbi.nlm.nih.gov/25785682/ Huffman EM, Anderson TN, Choi JN, Smith BK. Why the Lab? What is Really Motivating General Surgery Residents to Take Time for Dedicated Research. J SurgEduc.2020;77(6):e39-e46.doi:10.1016/j.jsurg.2020.07.034 https://pubmed.ncbi.nlm.nih.gov/32768383/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Contributor: Jorge Chalit-Hernandez, OMS3 Typically presents with biliary colic Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours Often associated with fatty meals but not always Must rule out other causes of pain Peptic ulcer disease - typically presents with epigastric pain Pancreatitis - pain that radiates to the back or family history of pancreatitis Laboratory workup  LFTs including ALT, AST, and alkaline phosphatase are within the reference range Lipase and amylase within the reference range Imaging workup RUQ ultrasound is unremarkable Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal  Opiates may give false-positive results Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi Some patients may benefit from surgical intervention i.e. cholecystectomy Classic biliary-type pain (best predictor of response to cholecystectomy) Pain for > 3 months duration Positive HIDA scan References Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003 Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798 Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690 Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3 Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Travis Barlock MD Educational Pearls: Assessment of head and neck vascular injury due to blunt trauma Symptomatic patients require screening head and neck CT angiography EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma: Unexplained neurological deficits Arterial nosebleed GCS < 6 Petrous bone fracture Cervical spine fracture Any size fracture through the transverse foramen LeFort fractures type II or type III EAST guidelines include a grading scale for vascular injury: Grade I: Luminal irregularity or dissection with 25% luminal narrowing, intraluminal thrombus, or raised intimal flap Grade III: Pseudoaneurysm Grade IV: Occlusion Grade V: Transection with free extravasation References Bensch FV, Varjonen EA, Pyhältö TT, Koskinen SK. Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke. Emerg Radiol. 2019;26(4):365-372. doi:10.1007/s10140-019-01677-0 Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. doi:10.1016/s0002-9610(99)00245-7 Kim DY, Biffl W, Bokhari F, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;88(6):875-887. doi:10.1097/TA.0000000000002668 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Raphael e Marcela convidam novamente Nathalie Santana para falar sobre tratamento do hipertiroidismo em 4 clinicagens: como escolher o melhor tratamento? como controlar os sintomas? como prescrever drogas antitireoidianas? como monitorar o paciente? Use o cupom TDC2024 para assinar o HITT do Medcof e ganhe um cupom de 6 meses gratuitos do Guia TdC! https://hiit.grupomedcof.com.br Referências: 1. Azizi, F et al. “Effect of long-term continuous methimazole treatment of hyperthyroidism: comparison with radioiodine.” European journal of endocrinology vol. 152,5 (2005): 695-701. doi:10.1530/eje.1.01904 2. Villagelin, Danilo et al. “Outcomes in Relapsed Graves' Disease Patients Following Radioiodine or Prolonged Low Dose of Methimazole Treatment.” Thyroid : official journal of the American Thyroid Association vol. 25,12 (2015): 1282-90. doi:10.1089/thy.2015.0195 3. Kahaly, George J et al. “2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism.” European thyroid journal vol. 7,4 (2018): 167-186. doi:10.1159/000490384 4. Villagelin, Danilo et al. “A 2023 International Survey of Clinical Practice Patterns in the Management of Graves' Disease: A Decade of Change.” The Journal of clinical endocrinology and metabolism, dgae222. 5 Apr. 2024, doi:10.1210/clinem/dgae222 5. Ross, Douglas S et al. “2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis.” Thyroid : official journal of the American Thyroid Association vol. 26,10 (2016): 1343-1421. doi:10.1089/thy.2016.0229 6. Shalaby M, Hadedeya D, Toraih EA, et al. Predictive factors of radioiodine therapy failure in Graves' Disease: A meta-analysis. Am J Surg. 2022;223(2):287-296. doi:10.1016/j.amjsurg.2021.03.068 7. Carella, C et al. “Serum thyrotropin receptor antibodies concentrations in patients with Graves' disease before, at the end of methimazole treatment, and after drug withdrawal: evidence that the activity of thyrotropin receptor antibody and/or thyroid response modify during the observation period.” Thyroid : official journal of the American Thyroid Association vol. 16,3 (2006): 295-302. doi:10.1089/thy.2006.16.295 8. Struja T, Kaeslin M, Boesiger F, et al. External validation of the GREAT score to predict relapse risk in Graves' disease: results from a multicenter, retrospective study with 741 patients. Eur J Endocrinol. 2017;176(4):413-419. doi:10.1530/EJE-16-0986 9. Park SY, Kim BH, Kim M, et al. The longer the antithyroid drug is used, the lower the relapse rate in Graves' disease: a retrospective multicenter cohort study in Korea. Endocrine. 2021;74(1):120-127. doi:10.1007/s12020-021-02725-x 10. Azizi F, Amouzegar A, Tohidi M, et al. Increased Remission Rates After Long-Term Methimazole Therapy in Patients with Graves' Disease: Results of a Randomized Clinical Trial. Thyroid. 2019;29(9):1192-1200. doi:10.1089/thy.2019.0180 11. Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet. 2024;403(10428):768-780. doi:10.1016/S0140-6736(23)02016-0 12. Lee SY, Pearce EN. Hyperthyroidism: A Review. JAMA. 2023;330(15):1472-1483. doi:10.1001/jama.2023.19052 13. https://www.tadeclinicagem.com.br/guia/146/tempestade-tireotoxica/

Happy New Year! Thank you for being a part of our journey this year. We are looking forward to sharing more medical misadventures with you in 2024.  Today Sara and Ashley discuss the deadliest fire in Boston's history and how its aftermath influenced the way hospitals treat burn victims and respond to mass casualties. If you are enjoying Don't Look Under the Med, please help us out and leave a five-star review! And make sure you follow the podcast on your favorite platform so you never miss an episode. Books: Pletcher, L. (2017). Massachusetts Disasters: True Stories of Tragedy and Survival. Globe Pequot. Articles: Bench Press- How the Cocoanut Grove Fire Changed Burn Care at Mass General and Beyond, by Andrew Glyman Academic Articles: Saffle JR. The 1942 fire at Boston's Cocoanut Grove nightclub. Am J Surg. 1993 Dec;166(6):581-91. doi: 10.1016/s0002-9610(05)80661-0. PMID: 8273835. Podcast Art By: Irit Mogilevsky --- Support this podcast: https://podcasters.spotify.com/pod/show/dontlookunderthemed/support

  I wanted to try something new today with the podcast. As I've become older and more seasoned, I've had a growing interest in history and the history of things, particularly in medicine. I was never a big history fan in high school. I tolerated it. Don't get me wrong, I had some great teachers of history in high school. But I was much more of a science and math nerd. For a while I've wanted to do an episode about Osgood Schlatter apophysitis, which is such a common problem in pediatrics. I did some digging into some of the historical articles about Osgood Schlatter and thought I'd take an episode to take about some of the interesting things I found and ways it was managed a century ago. Let's get some plutonium and the Delorean and take a trip back a century ago and talk some Osgood Schlatter.  Connect with The Host! Subscribe to This Podcast Now!        The ultimate success for every podcaster – is FEEDBACK! Be sure to take just a few minutes to tell the hosts of this podcast what YOU think over at Apple Podcasts! It takes only a few minutes but helps the hosts of this program pave the way to future greatness! Not an Apple Podcasts user? No problem! Be sure to check out any of the other many growing podcast directories online to find this and many other podcasts via The Podcaster Matrix!     Housekeeping -- Get the whole story about Dr. Mark and his launch into this program, by listing to his "101" episode that'll get you educated, caught up and in tune with the Doctor that's in the podcast house! Listen Now! -- Interested in being a Guest on The Pediatric Sports Medicine Podcast? Connect with Mark today!   Links from this Episode: -- Dr. Mark Halstead: On the Web -- On Twitter -- Taft Robert B. Osgood Schlatter's Disease. Radiology. May 1, 1929. https://pubs.rsna.org/doi/abs/10.1148/12.5.414 -- UHRY E. OSGOOD-SCHLATTER DISEASE. Arch Surg. 1944;48(5):406–414. https://jamanetwork.com/journals/jamasurgery/article-abstract/546672 -- KRIDELBAUGH WW, WYMAN AC. Osgood-Schlatter's disease. Am J Surg. 1948 Apr;75(4):553-61. doi: 10.1016/0002-9610(48)90366-3. PMID: 18912091. https://pubmed.ncbi.nlm.nih.gov/18912091/     Calls to the Audience Inside this Episode: -- Be sure to interact with the host, send detailed feedback via our customized form and connect via ALL of our social media platforms! Do that over here now! -- Interested in being a guest inside The Pediatric Sports Medicine Podcast with Dr. Mark? Tell us now! -- Ready to share your business, organization or efforts message with Dr. Mark's focused audience? Let's have a chat! -- Do you have feedback you'd like to share with Dr. Mark from this episode? Share YOUR perspective!   Be an Advertiser/Sponsor for This Program!     Tell Us What You Think: Feedback is the cornerstone and engine of all great podcast. Be sure to chime in with your thoughts, perspective sand more.  Share your insight and experiences with Dr. Mark by clicking here!   The Host of this Program: Mark Halstead:  Dr. Mark Halstead received his medical degree from the University of Wisconsin Medical School. He stayed at the University of Wisconsin for his pediatric residency, followed by a year as the chief resident. Following residency, he completed a pediatric and adult sports medicine fellowship at Vanderbilt University. He has been an elected member to the American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness and the Board of Directors of the American Medical Society for Sports Medicine (AMSSM). He has served as a team physician or medical consultant to numerous high schools, Vanderbilt University, Belmont University, Washington University, St. Louis Cardinals, St. Louis Blues, St. Louis Athletica, and St.

Hernias are some of the most common problems treated by general surgeons. The field of abdominal wall surgery has rapidly evolved as a result of innovation and the development of new techniques. In this podcast, Drs. Charlotte Horne and Jenny Shao join Vahagn Nikolian to discuss their decision to pursue careers as abdominal wall specialists, the role that hernia surgeons play in modern day surgical programs, and the pathway to becoming a hernia surgeon.  ·       Dr. Charlotte Horne is an Assistant Professor of Surgery at Pennsylvania State University. ·       Dr. Jenny Shao is an Assistant Professor of Surgery at the University of Michigan. ·       Dr. Vahagn Nikolian is an Assistant Professor of Surgery at Oregon Health & Science University. Recommended Reading: Shulkin JM, Mellia JA, Patel V, Naga HI, Morris MP, Christopher A, Heniford BT, Fischer JP. Characterizing hernia centers in the United States: what defines a hernia center? Hernia. 2022 Feb;26(1):251-257. doi: 10.1007/s10029-021-02411-x. Epub 2021 Apr 19. PMID: 33871743. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012 Nov;204(5):709-16. doi: 10.1016/j.amjsurg.2012.02.008. Epub 2012 May 16. PMID: 22607741. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other Hernia episodes here: https://behindtheknife.org/podcast-category/hernia/

Advancing Women in Urology: Sponsorship and It's Role in Career Advancement in Medicine Host: Jay D. Raman, MD, FACS Guest: Peggy Pearle, MD and Simone Thavaseelan, MD Outline: Segment #1 Defining Sponsorship Segment #2 Role in Career Advancement/Importance Segment #3 Identifying the Issue Segment #4 Key Characteristics of healthy/effective Sponsorship Segment #5 Opportunities for Action ACKNOWLEDGEMENT This educational series was made possible by support from Urovant Resources: Jain, S. Why Sponsorship in Medicine Matters. Wolters Kluwer Health, https://www.wolterskluwer.com/en/expert-insights/why-sponsorship-in-medicine-matters (2020). Ayyala, M.S., et al. Mentorship Is Not Enough: Exploring Sponsorship and Its Role in Career Advancement in Academic Medicine. Acad Med. 94, 94-100 (2019). Lewiss R.E., et al. Is Academic Medicine Making Mid-Career Women Physicians Invisible? J Womens Health (Larchmt). 29,187-192 (2020). Tesch, B.J., Wood, H.M., Helwig, A.L., Nattinger, A.B. Promotion of women physicians in academic medicine. Glass ceiling or sticky floor? JAMA. 273,1022-5 (1995). Silva, C. Study: Women Get Fewer Game Changing Leadership Roles. Harvard Business Review, https://hbr.org/2012/11/study-women-get-fewer-game-changing Hewlett, S.A., Peraino, K., Sherbin, L., Sumberg, K. The Sponsor Effect: Breaking Through the Last Glass Ceiling. Boston, Mass Harvard Business Review (2011). Richter, K.P., et al. Women Physicians and Promotion in Academic Medicine. N Engl J Med. 383, 2148-2157 (2020). Foust-Cummings H. Sponsoring Women to Success. Catalyst, http://www.catalyst.org/system/files/sponsoring_women_to_success.pdf. (2011) Velez, D., et al. Rising Tides: Challenges and Opportunities for Women in the Urologic Workforce. Urology. 150, 47-53 (2021). Harris, C. How to find the person who can help you get ahead at work. TEDWomen, https://www.youtube.com/watch?v=gpE_W50OTUc.(2018). Penaloza NG,, et al. Someone Like Me: An Examination of the Importance of Race-Concordant Mentorship in Urology. Urology. 22. (2022) Butler, P.D. When excellence is still not enough. Am J Surg. 220, 543-544 (2020)

In this episode from the Endocrine Surgery team at BTK we discuss how Dr. Yeh built the section of endocrine surgery at UCLA. From Sydney, Australia to Santa Monica, he discusses the risks and challenges involved in becoming a leader in academic endocrine surgery. In this podcast we answer the question “why endocrine surgery,” and mention tips for success at all level of training from medical students to early faculty. Finally, we take a moment to honor and remember Dr. Orlo Clark.               Dr. Michael Yeh is a Professor of Surgery at UCLA and serves as Section Chief of the UCLA Endocrine Surgery program which he established.  Dr. Masha Livhits is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department  Dr. James Wu is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department  Dr. Na Eun Kim is an Endocrine Surgery Fellow at UCLA in her first year of fellowship Dr. Rivfka Shenoy is a PGY-6 General Surgery Resident at UCLA who has completed two years of research  Dr. Max Schumm is a PGY-6 General Surgery Resident at UCLA who has completed two years of research. He is a future endocrine surgeon.  Important Papers  Krishnamurthy VD, Gutnick J, Slotcavage R, Jin J, Berber E, Siperstein A, Shin JJ. Endocrine surgery fellowship graduates past, present, and future: 8 years of early job market experiences and what program directors and trainees can expect. Surgery. 2017 Jan;161(1):289-296. doi: 10.1016/j.surg.2016.06.069. Epub 2016 Nov 17. PMID: 27866719. Krishnamurthy VD, Jin J, Siperstein A, Shin JJ. Mapping endocrine surgery: Workforce analysis from the last six decades. Surgery. 2016 Jan;159(1):102-10. doi: 10.1016/j.surg.2015.08.024. Epub 2015 Oct 9. PMID: 26456130. Kulaylat AN, Kenning EM, Chesnut CH 3rd, James BC, Schubart JR, Saunders BD. The profile of successful applicants for endocrine surgery fellowships: results of a national survey. Am J Surg. 2014 Oct;208(4):685-9. doi: 10.1016/j.amjsurg.2014.03.013. Epub 2014 Jun 21. PMID: 25048570; PMCID: PMC4639920. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other Endocrine Surgery episodes here: https://behindtheknife.org/podcast-category/endocrine/

Join Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross as they tackle Cancer Emergencies.   Case 1 - Learning Points: These are complex patients and multidisciplinary care should be provided with input from oncology.  A step-up approach should be used, starting with medical management prior to considering surgery in appropriate patients. Highly selected patients may benefit from surgery, namely those with a high performance status, a prognosis of months if the bowel obstruction was resolved, minimal carcinomatosis, and a single transition point. Diversion, bypass, or resection are all options, but a patient's capacity to heal related to recent systemic therapy needs to be taken into account.  Consent for surgery should focus on goals of care, quality of life, and achievable outcomes, and highlight the inherent risk in patients with advanced disease and a limited lifespan.  Case 2 - Learning Points: Colorectal malignancy is an exceedingly common cause of general surgical emergency and requires a thoughtful, systematic approach The role of stenting as a bridge to surgery in obstructing distal colon malignancy is somewhat controversial but can help to avoid permanent stomas; however there is some potential risk of perforation and possibly disease recurrence Treatment decisions should take place in the context of an informed discussion with the patient and consideration of both quantity and quality of life whenever possible Consistent involvement of a multidisciplinary team, including radiology, enterostomal therapy, and surgical oncology can be extremely useful in guiding complex decisions References: Shariff F, Bogach J, Guidolin K, Nadler A. Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review. Ann Surg Oncol. 2021 Oct 18. doi: 10.1245/s10434-021-10922-1. Epub ahead of print. Ripamonti C, Gerdes H and Easson A. Management of malignant bowel obstruction. Eur J Cancer 2008 May;44(8):1105-15 Chen, T, Huang, Y. & Wang, G. Outcome of colon cancer initially presenting as colon perforation and obstruction. World J Surg Onc 15, 164 (2017).  Olmsted C, Johnson A, Kaboli P, et al. Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration. JAMA Surg. 2014;149(11):1169–75. Dunn GP, Martensen R, Weissman D.  Surgical palliative care: a resident's guide. Essex: American College of Surgeons; 2009. Biondo S, Martí-Ragué J, Kreisler E, et al. A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer. Am J Surg. 2005;189:377–83. National Comprehensive Cancer Network. https://www.nccn.org/. Accessed October 15, 2021. Shariat-Madar B, Jayakrishnan TT, Gamblin TC, Turaga KK. Surgical management of bowel obstruction in patients with peritoneal carcinomatosis. J Surg Oncol. 2014 Nov;110(6):666-9. doi: 10.1002/jso.23707.  Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Dr. Brian Cameron is a pediatric surgeon at McMaster University in Hamilton, Ontario. He has dedicated himself both to pediatric surgery and to global surgery, and has worked around the world in resource-limited settings. This was a particularly memorable episode for us because Dr. Cameron retires this year! This episode was a chance for us to ask him about his career, his life story, and of course, global surgery. Congratulations again to Dr. Cameron on his well-earned retirement! Links: 1. Establishing disability weights for congenital pediatric surgical conditions: a multi-modal approach. Poenaru D, Pemberton J, Frankfurter C, Cameron BH, Stolk E. Popul Health Metr. 2017 Mar 4;15(1):8. doi: 10.1186/s12963-017-0125-5. PMID: 28259148 Free PMC article. 2. Procedural skills training for Canadian medical students participating in international electives. Margolick J, Kanters D, Cameron BH. Can Med Educ J. 2015 Apr 20;6(1):e23-33. eCollection 2015. PMID: 26451227 Free PMC article. 3. Surgical training in Guyana: the next generation. Cameron BH, Martin C, Rambaran M. Can J Surg. 2015 Feb;58(1):7-9. doi: 10.1503/cjs.010414. PMID: 25621909 Free PMC article. 4. Evaluating the long-term impact of the Trauma Team Training course in Guyana: an explanatory mixed-methods approach. Pemberton J, Rambaran M, Cameron BH. Am J Surg. 2013 Feb;205(2):119-24. doi: 10.1016/j.amjsurg.2012.08.004. Epub 2012 Dec 13. PMID: 23246285 5. International surgery: the development of postgraduate surgical training in Guyana. Cameron BH, Rambaran M, Sharma DP, Taylor RH. Can J Surg. 2010 Feb;53(1):11-6. PMID: 20100407 Free PMC article. 6. Teaching in Fiji: practising medicine, coping with coups. Cameron BH. CMAJ. 1989 Apr 1;140(7):833-5. PMID: 2924235 Free PMC article. No abstract available. 7. Lancet commission on global surgery: https://www.thelancet.com/commissions/global-surgery 8. Bethune Roundtable: https://www.cnis.ca/what-we-do/public-engagement-in-canada/bethune-round-table/ 9. Morad Hameed Trauma system app: https://www.em-consulte.com/article/859211/the-electronic-trauma-health-record-design-and-usa 10. Masters of Global Surgical Care at UBC: https://www.grad.ubc.ca/prospective-students/graduate-degree-programs/master-global-surgical-care Bio ( from https://www.ccghr.ca/q-brian-cameron/): Dr. Brian Cameron is a Professor of Pediatric Surgery at McMaster University and a pediatric surgeon at McMaster Children Hospital. He is the director of both the McMaster International Surgery Desk and MacGlObAS. His research interests include global surgical research and education.

Listen as chiropractor and founder of the Cox Technic, Dr. James Cox explains what Cox Technic is and why it is so effective for treating back pain. James M. Cox, DC, DACBR, FICC, Hon.D.Litt., FACO(H) Dr. Cox is the developer of Cox® Technic Flexion Distraction Manipulation and the proud participant in the on-going federal research projects involving the Keiser University, National University of Health Sciences, Palmer College of Chiropractic Research Center, Loyola Stritch School of Medicine, University of Illinois, University of Iowa, Auburn University, etc. He is a member of the postgraduate faculty of the National University of Health Sciences and has been privileged to speak throughout the world. Resources: About Dr. Cox curriculum vitae  More about Cox Technic Find a Back Doctor The Cox 8 Table by Haven Medical References: Chesterton P, Evans W, Wright M, Lolli L, Richardson M, Atkinson G. Influence of Lumbar Mobilizations During the Nordic Hamstring Exercise on Hamstring Measures of Knee Flexor Strength, Failure Point, and Muscle Activity: A Randomized Crossover Trial. J Manipulative Physiol Ther. 2020 Nov 25:S0161-4754(20)30201-3. doi: 10.1016/j.jmpt.2020.09.005. Epub ahead of print. PMID: 33248746. INFLUENCE OF LUMBAR MOBILIZATIONS DURING THE NORDIC HAMSTRING EXERCISE ON HAMSTRING MEASURES OF KNEE FLEXOR STRENGTH, FAILURE POINT, AND MUSCLE ACTIVITY: A RANDOMIZED CROSSOVER TRIAL. AFTER SPINAL MOBILIZATION, IMMEDIATE CHANGES IN BILATERAL HAMSTRING FORCE PRODUCTION AND PEAK TORQUE OCCURRED DURING THE NHE. THE EFFECT ON THE NHE FAILURE POINT WAS UNCLEAR. ELECTROMYOGRAPHIC ACTIVITY INCREASED ON THE IPSILATERAL SIDE. Meet the Nordic hamstring exercise, also known as the Nordic hamstring curl—your potential new favorite go-to that can help keep you healthy while boosting your performance.  me 19 Lead researcher Nicol van Dyk, Ph.D., of Aspetar Orthopaedic and Sports Medicine Hospital in Qatar, told Runner's World the move is simple: Begin in a kneeling position with both ankles secured—tucking your feet under a bar, for example, or having a running buddy hold them down—and then progressively lean forward as slowly as possible while keeping your back straight. When you can't resist anymore, just fall forward, catching yourself with your hands against the floor. Check out the video below for how to do it properly.   Ekşi MŞ, Özcan-Ekşi EE, Özmen BB, Turgut VU, Huet SE, Dinç T, Kara M, Özgen S, Özek MM, Pamir MN. Lumbar intervertebral disc degeneration, end-plates and paraspinal muscle changes in children and adolescents with low-back pain. J Pediatr Orthop B. 2020 Nov 27. doi: 10.1097/BPB.0000000000000833. Epub ahead of print. PMID: 33252539. FATTY INFILTRATION IN THE PARASPINAL MUSCLES AND IVDD WERE CLOSELY ASSOCIATED WITH MODIC CHANGES IN CHILDREN AND ADOLESCENTS WITH LBP. LUMBAR IVDD IN CHILDREN AND ADOLESCENTS COULD BE THE RESULT OF A MECHANICAL PATHOLOGY   Karartı C, Özüdoğru A, Basat HÇ, Özsoy İ, Özsoy G, Kodak Mİ, Sezgin H, Uçar İ. Determination of Biodex Balance System Cutoff Scores in Older People With Nonspecific Back Pain: A Cross-sectional Study. J Manipulative Physiol Ther. 2020 Nov 25:S0161-4754(20)30153-6. doi: 10.1016/j.jmpt.2020.07.006. Epub ahead of print. PMID: 33248744. DETERMINATION OF BIODEX BALANCE SYSTEM CUTOFF SCORES IN OLDER PEOPLE WITH NONSPECIFIC BACK PAIN: A CROSS-SECTIONAL STUDY BBS CUTOFF SCORES ARE SENSITIVE AND SPECIFIC IN DISTINGUISHING BETWEEN POOR AND GOOD POSTURAL PERFORMANCE IN OLDER PEOPLE WITH NSLBP.   TRACTION EFFECTS: TRACTION AND DISTRACTION STUDIES ON WHICH OUR WORK IS BASED. Luigi Albano, DC introduced the first paper on which I built the remaining studies. This gives us foundational understanding as to the benefits of placing a spine into distraction prior to producing ranges of motion – IT FIRST REDUCES STENOTIC EFFECTS THAT COULD CAUSE GREATER NERVE AND DRG COMPRESSION AND CHEMICAL INFLAMMATORY IRRITATION. - JMC   Gaowgzeh RAM, Chevidikunnan MF, BinMulayh EA, Khan F. Effect of spinal decompression therapy and core stabilization exercises in management of lumbar disc prolapse: A single blind randomized controlled trial. J Back Musculoskelet Rehabil. 2020;33(2):225-231. doi: 10.3233/BMR-171099. PMID: 31282394. A COMBINATION OF SPINAL DECOMPRESSION THERAPY WITH CORE STABILIZATION EXERCISE HAS PROVEN TO BE MORE SIGNIFICANT WHEN COMPARED WITH CSE ALONE TO REDUCE PAIN AND DISABILITY IN SUBJECTS WITH CHRONIC LDP.   Demirel A, Yorubulut M, Ergun N. Regression of lumbar disc herniation by physiotherapy. Does non-surgical spinal decompression therapy make a difference? Double-blind randomized controlled trial. J Back Musculoskelet Rehabil. 2017 Sep 22;30(5):1015-1022. doi: 10.3233/BMR-169581. PMID: 28505956. THIS STUDY SHOWED THAT PATIENTS WITH LHNP RECEIVED PHYSIOTHERAPY HAD IMPROVEMENT BASED ON CLINICAL AND RADIOLOGIC EVIDENCE. NON-INVASIVE SPINAL DECOMPRESSION THERAPY (NSDT) CAN BE USED AS ASSISTIVE AGENT FOR OTHER PHYSIOTHERAPY METHODS IN TREATMENT OF LUMBAR DISC HERNIATION.   Karimi N, Akbarov P, Rahnama L. Effects of segmental traction therapy on lumbar disc herniation in patients with acute low back pain measured by magnetic resonance imaging: A single arm clinical trial. J Back Musculoskelet Rehabil. 2017;30(2):247-253. doi: 10.3233/BMR-160741. PMID: 27636836. SEGMENTAL TRACTION THERAPY MIGHT PLAY AN IMPORTANT ROLE IN THE TREATMENT OF ACUTE LBP STIMULATED BY LDH.   Kamanli A1, Karaca-Acet G, Kaya A, Koc M, Yildirim H Conventional physical therapy with lumbar traction; clinical evaluation and magnetic resonance imaging for lumbar disc herniation. Journal of Back and Musculoskeletal Rehabilitation, vol. 30, no. 2, pp. 247-253, 2017 CONVENTIONAL PHYSICAL THERAPIES WITH LUMBAR TRACTION WERE EFFECTIVE IN THE TREATMENT OF PATIENT WITH SUBACUTE LDH. THESE RESULTS SUGGEST THAT CLINICAL IMPROVEMENT IS NOT CORRELATED WITH THE FINDING OF MRI. PATIENTS WITH LDH SHOULD BE MONITORED CLINICALLY   Choi J, Lee S, Hwangbo G. Influences of spinal decompression therapy and general traction therapy on the pain, disability, and straight leg raising of patients with intervertebral disc herniation. J Phys Ther Sci. 2015 Feb;27(2):481-3. doi: 10.1589/jpts.27.481. Epub 2015 Feb 17. PMID: 25729196; PMCID: PMC4339166. SPINAL DECOMPRESSION THERAPY AND GENERAL TRACTION THERAPY ARE EFFECTIVE AT IMPROVING THE PAIN, DISABILITY, AND SLR OF PATIENTS WITH INTERVERTEBRAL DISC HERNIATION. THUS, SELECTIVE TREATMENT MAY BE REQUIRED   JUDOVICH BD. Herniated cervical disc; a new form of traction therapy. Am J Surg. 1952 Dec;84(6):646-56. doi: 10.1016/0002-9610(52)90127-x. PMID: 12986095. CLINICAL STUDIES INDICATE THAT IN THE AVERAGE INTRACTABLE CASE THE CERVICAL SPINE SHOULD BE STRETCHED BY FORCE RANGING FROM 25 TO 45 POUNDS. ALMOST HALF THE PATIENTS IN A SERIES OF SIXTY CASES EXPERIENCED PARTIAL OR COMPLETE MOMENTARY RELIEF WHEN THIS FORCE WAS APPLIED. ROENTGEN STUDIES REVEAL THAT IN THE AVERAGE PATIENT THE INTERVERTEBRAL SPACES OF THE CERVICAL SPINE BEGIN TO SHOW MEASURABLE WIDENING WITH TRACTION FORCE RANGING FROM 25 TO 50 POUNDS. THE NECESSARY FORCE TO RELIEVE PAIN CANNOT BE TOLERATED BY THE AVERAGE PATIENT WHEN IT IS ADMINISTERED AS A CONSTANT PULL. IF ADMINISTERED INTERMITTENTLY, ADEQUATE AND MUCH GREATER TRACTION LOAD CAN BE TOLERATED WITHOUT THE DISCOMFORT WHICH WOULD NORMALLY ACCOMPANY SUCH FORCE. A NEW METHOD OF MOTORIZED INTERMITTENT TRACTION IS PRESENTED. THE CLINICAL RESULTS OF INTERMITTENT TRACTION, BECAUSE OF ADEQUATE FORCE, HAVE BEEN EXCELLENT AS COMPARED TO CONVENTIONAL TRACTION METHODS.   Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. Eur Spine J. 2000 Jun;9(3):202-7. doi: 10.1007/s005869900113. PMID: 10905437; PMCID: PMC3611397. BECAUSE OSTEOPATHIC MANIPULATION PRODUCED A 12-MONTH OUTCOME THAT WAS EQUIVALENT TO CHEMONUCLEOLYSIS, IT CAN BE CONSIDERED AS AN OPTION FOR THE TREATMENT OF SYMPTOMATIC LUMBAR DISC HERNIATION, AT LEAST IN THE ABSENCE OF CLEAR INDICATIONS FOR SURGERY. Further study into the value of manipulation at a more acute stage is warranted.   Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low-back pain. Can Fam Physician. 1985 Mar;31:535-40. PMID: 21274223; PMCID: PMC2327983. RESULTS OF SPINAL MANIPULATION IN 283 PATIENTS WITH LOW BACK PAIN ARE PRESENTED. THE PHYSICIAN WHO MAKES USE OF THIS RESOURCE WILL PROVIDE RELIEF FOR MANY PATIENTS.   Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):197-210. doi: 10.1016/j.jmpt.2003.12.023. PMID: 15129202. THE APPARENT SAFETY OF SPINAL MANIPULATION, ESPECIALLY WHEN COMPARED WITH OTHER “MEDICALLY ACCEPTED” TREATMENTS FOR LDH, SHOULD STIMULATE ITS USE IN THE CONSERVATIVE TREATMENT PLAN OF LDH.   Kane MD, Karl RD, Swain JH. Effects of Gravity-Facilitated Traction on lntervertebral Dimensions of the Lumbar Spine*. J Orthop Sports Phys Ther. 1985;6(5):281-8. doi: 10.2519/jospt.1985.6.5.281. PMID: 18802302. MEAN POSTERIOR SEPARATION WAS SIGNIFICANT AT ALL LEVELS EXCEPT L1-L2 AND L5-S1. MEAN INTERVERTEBRAL FORAMINAL SEPARATION WAS SIGNIFICANT AT ALL LEVELS BUT L5-S1. IF INCREASES IN INTERVERTEBRAL DIMENSIONS PLAY A ROLE IN THE RELIEF OF LOW BACK SYNDROME, THEN GRAVITY-FACILITATED TRACTION MAY BE AN EFFECTIVE MODALITY IN THE TREATMENT OF THIS CONDITION.   Unlu Z, Tasci S, Tarhan S, Pabuscu Y, Islak S. Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniation measured by clinical evaluation and magnetic resonance imaging. J Manipulative Physiol Ther. 2008 Mar;31(3):191-8. doi: 10.1016/j.jmpt.2008.02.001. PMID: 18394495. TRACTION, ULTRASOUND, AND LOW POWER LASER THERAPIES WERE ALL EFFECTIVE IN THE TREATMENT OF THIS GROUP OF PATIENTS WITH ACUTE LDH. THESE RESULTS SUGGEST THAT CONSERVATIVE MEASURES SUCH AS TRACTION, LASER, AND ULTRASOUND TREATMENTS MIGHT HAVE AN IMPORTANT ROLE IN THE TREATMENT OF ACUTE LDH   Chung TS, Yang HE, Ahn SJ, Park JH. Herniated Lumbar Disks: Real-time MR Imaging Evaluation during Continuous Traction. Radiology. 2015 Jun;275(3):755-62. doi: 10.1148/radiol.14141400. Epub 2015 Jan 22. Erratum in: Radiology. 2015 Jun;275(3):934-5. PMID: 25611735. HERNIATED LUMBAR DISKS: REAL-TIME MR IMAGING EVALUATION DURING CONTINUOUS TRACTION CONTINUOUS TRACTION ON HERNIATED LUMBAR DISKS AND SURROUNDING STRUCTURES RESULTED IN CHANGE IN DISK SHAPE, DISK REDUCTION WITH OPENING IN THE INTERVERTEBRAL DISK, REDUCTION OF HERNIATED DISK VOLUME, SEPARATION OF THE DISK AND ADJOINING NERVE ROOT, AND WIDENING OF THE FACET JOINT.   Isner-Horobeti ME, Dufour SP, Schaeffer M, Sauleau E, Vautravers P, Lecocq J, Dupeyron A. High-Force Versus Low-Force Lumbar Traction in Acute Lumbar Sciatica Due to Disc Herniation: A Preliminary Randomized Trial. J Manipulative Physiol Ther. 2016 Nov-Dec;39(9):645-654. doi: 10.1016/j.jmpt.2016.09.006. Epub 2016 Nov 9. PMID: 27838140. HIGH-FORCE VERSUS LOW-FORCE LUMBAR TRACTION IN ACUTE LUMBAR SCIATICA DUE TO DISC HERNIATION: A PRELIMINARY RANDOMIZED TRIAL PATIENTS WITH ACUTE LUMBAR SCIATICA SECONDARY TO DISC HERNIATION WHO RECEIVED 2 WEEKS OF LUMBAR TRACTION REPORTED REDUCED RADICULAR PAIN AND FUNCTIONAL IMPAIRMENT AND IMPROVED WELL-BEING REGARDLESS OF THE TRACTION FORCE GROUP TO WHICH THEY WERE ASSIGNED. THE EFFECTS OF THE TRACTION TREATMENT WERE INDEPENDENT OF THE INITIAL LEVEL OF MEDICATION AND APPEARED TO BE MAINTAINED AT THE 2-WEEK FOLLOW-UP. DURING THE 2-WEEK FOLLOW-UP AT DAY 28, ONLY THE LT10 GROUP IMPROVED (P < .05) IN VAS (–52%) AND EIFEL SCORES (–46%).   Onel D, Tuzlaci M, Sari H, Demir K. Computed tomographic investigation of the effect of traction on lumbar disc herniations. Spine (Phila Pa 1976). 1989 Jan;14(1):82-90. doi: 10.1097/00007632-198901000-00017. PMID: 2913674. COMPUTED TOMOGRAPHIC INVESTIGATION OF THE EFFECT OF TRACTION ON LUMBAR DISC HERNIATIONS. CHANGES OCCURRING UNDER THE EFFECT OF A TRACTION LOAD OF 45 KG HAVE BEEN EVALUATED IN 30 PATIENTS WITH LUMBAR DISC HERNIATION WITH CT INVESTIGATION. THE HERNIATED NUCLEAR MATERIAL (HNM) HAS RETRACTED IN 11 (78.5%) OF MEDIAN, SIX (66.6%) OF POSTEROLATERAL, AND FOUR (57.1%) OF LATERAL HERNIATIONS.   Clarke J, van Tulder M, Blomberg S, de Vet H, van der Heijden G, Bronfort G. Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration. Spine (Phila Pa 1976). 2006 Jun 15;31(14):1591-9. doi: 10.1097/01.brs.0000222043.09835.72. PMID: 16778694. INTERMITTENT OR CONTINUOUS TRACTION AS A SINGLE TREATMENT FOR LBP CANNOT BE RECOMMENDED FOR MIXED GROUPS OF PATIENTS WITH LBP WITH AND WITHOUT SCIATICA. NEITHER CAN TRACTION BE RECOMMENDED FOR PATIENTS WITH SCIATICA BECAUSE OF INCONSISTENT RESULTS AND METHODOLOGICAL PROBLEMS IN MOST OF THE STUDIES INVOLVED. HOWEVER, BECAUSE HIGH-QUALITY STUDIES WITHIN THE FIELD ARE SCARCE, BECAUSE MANY ARE UNDERPOWERED, AND BECAUSE TRACTION OFTEN IS SUPPLIED IN COMBINATION WITH OTHER TREATMENT MODALITIES, THE LITERATURE ALLOWS NO FIRM NEGATIVE CONCLUSION THAT TRACTION, IN A GENERALIZED SENSE, IS NOT AN EFFECTIVE TREATMENT FOR PATIENTS WITH LBP   Beattie PF, Nelson RM, Michener LA, Cammarata J, Donley J. Outcomes after a prone lumbar traction protocol for patients with activity-limiting low back pain: a prospective case series study. Arch Phys Med Rehabil. 2008 Feb;89(2):269-74. doi: 10.1016/j.apmr.2007.06.778. PMID: 18226650. TRACTION APPLIED IN THE PRONE POSITION USING THE VAX-D FOR 8 WEEKS WAS ASSOCIATED WITH IMPROVEMENTS IN PAIN INTENSITY AND RMDQ SCORES AT DISCHARGE, AND AT 30 AND 180 DAYS AFTER DISCHARGE IN A SAMPLE OF PATIENTS WITH ACTIVITY-LIMITING LBP. CAUSAL RELATIONSHIPS BETWEEN THESE OUTCOMES AND THE INTERVENTION SHOULD NOT BE MADE UNTIL FURTHER STUDY IS PERFORMED USING RANDOMIZED COMPARISON GROUPS.   REAL-TIME MR IMAGING WHILE PERFORMING TRACTION IS POSSIBLE. Mitchell UH, Beattie PF, Bowden J, Larson R, Wang H. Age-related differences in the response of the L5-S1 intervertebral disc to spinal traction. Musculoskelet Sci Pract. 2017 Oct;31:1-8. doi: 10.1016/j.msksp.2017.06.004. Epub 2017 Jun 9. PMID: 28624722. TO DETERMINE DIFFERENCES IN THE APPARENT DIFFUSION COEFFICIENT (ADC) OBTAINED WITH LUMBAR DIFFUSION-WEIGHTED IMAGING (DWI) OF THE L5-S1 IVD BEFORE, AND DURING, THE APPLICATION OF LUMBAR TRACTION STATIC TRACTION WAS ASSOCIATED WITH AN INCREASE IN DIFFUSION OF WATER WITHIN THE L5-S1 IVDS OF MIDDLE-AGE INDIVIDUALS, BUT NOT IN YOUNG ADULTS, SUGGESTING AGE-RELATED DIFFERENCES IN THE DIFFUSION RESPONSE. FURTHER STUDY IS NEEDED TO ASSESS THE RELATIONSHIP BETWEEN THESE FINDINGS AND THE SYMPTOMS OF BACK PAIN. HIGHLIGHTS: STATIC TRACTION IS ASSOCIATED WITH AN INCREASE IN ADC IN OLDER DISCS, NOT YOUNGER. INVERSE RELATIONSHIP BETWEEN BASELINE ADC AND PERCENT INCREASE WITH TRACTION. FINDINGS SUGGEST PRESENCE OF AGE-RELATED CHANGES IN THE RATE OF DIFFUSION RESPONSE.   SAAL, JEFFREY A., MD; SAAL, JOEL S., MD Nonoperative Treatment of Herniated Lumbar Intervertebral Disc with Radiculopathy: An Outcome Study, Spine: April 1989 - Volume 14 - Issue 4 - p 431-437 64 PATIENTS WITH LUMBAR HERNIATED NUCLEUS PULPOSUS WITHOUT SIGNIFICANT STENOSIS WERE TREATED NON SURGICALLY. 90% GOOD OR EXCELLENT OUTCOME WITH A 92% RETURN TO WORK RATE. FOR THE SUBGROUPS WITH EXTRUDED DISCS AND SECOND OPINIONS, 87% AND 83% HAD GOOD OR EXCELLENT OUTCOMES, RESPECTIVELY, ALL (100%) OF WHOM RETURNED TO WORK. SICK LEAVE TIME FOR THESE SUBGROUPS WAS 2.9 MONTHS (+/- 1.4 MONTHS) AND 3.4 MONTHS (+/- 1.7 MONTHS), RESPECTIVELY. THESE RESULTS COMPARED FAVORABLY WITH PREVIOUSLY PUBLISHED SURGICAL STUDIES. FOUR OF SIX PATIENTS WHO REQUIRED SURGERY WERE FOUND TO HAVE STENOSIS AT OPERATION.   Sari H, Akarirmak U, Karacan I, Akman H. Computed tomographic evaluation of lumbar spinal structures during traction. Physiother Theory Pract. 2005 Jan-Mar;21(1):3-11. PMID: 16385939. DURING TRACTION OF INDIVIDUALS WITH ACUTE LDH THERE WAS A REDUCTION OF THE SIZE OF THE HERNIATION, INCREASED SPACE WITHIN THE SPINAL CANAL, WIDENING OF THE NEURAL FORAMINA, AND DECREASED THICKNESS OF THE PSOAS MUSCLE.   Park WM, Kim K, Kim YH. Biomechanical analysis of two-step traction therapy in the lumbar spine. Man Ther. 2014 Dec;19(6):527-33. doi: 10.1016/j.math.2014.05.004. Epub 2014 May 22. PMID: 24913413. A COMBINATION OF GLOBAL AXIAL TRACTION AND LOCAL DECOMPRESSION WOULD BE HELPFUL FOR REDUCING TENSILE STRESS ON THE FIBERS OF THE ANNULUS FIBROSUS AND LIGAMENTS, AND INTRADISCAL PRESSURE IN TRACTION THERAPY. THIS STUDY COULD BE USED TO DEVELOP A SAFER AND MORE EFFECTIVE TYPE OF TRACTION THERAPY   Chow DHK, Yuen EMK, Xiao L, Leung MCP. Mechanical effects of traction on lumbar intervertebral discs: A magnetic resonance imaging study. Musculoskelet Sci Pract. 2017 Jun;29:78-83. doi: 10.1016/j.msksp.2017.03.007. Epub 2017 Mar 20. PMID: 28347933. HORIZONTAL TRACTION WAS EVIDENTLY EFFECTIVE IN INCREASING THE DISC HEIGHT OF LOWER LUMBAR LEVELS, PARTICULARLY IN THE POSTERIOR REGIONS OF THE DISCS. FURTHER EVIDENCE OF THE EFFECTS OF TRACTION OF DIFFERENT MODES, MAGNITUDES, AND DURATIONS ON THE CHANGE IN DISC HEIGHT IS REQUIRED FOR PROPER CONTROL OF TRACTION APPLIED TO SPECIFIC DISC LEVELS. HIGHLIGHTS: MECHANICAL EFFECTS OF TRACTION ON LUMBAR DISCS WAS EVALUATED USING MRI. HORIZONTAL TRACTION USING 42% OF BODY WEIGHT WAS ASSOCIATED WITH AN INCREASED DISC HEIGHT OF LOWER LUMBAR DISCS. HORIZONTAL TRACTION ALSO RESULTED IN REDUCED LORDOSIS AND CHANGE IN TILT ANGLE. THE EFFECTS WERE MORE PROMINENT AT THE POSTERIOR DISCAL REGIONS.   Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789. a  systematic  review  of  randomized, controlled  trials  and  systematic  reviews  published  through  April 2015  on  noninvasive  pharmacologic  and  nonpharmacologic treatments  for  low  back  pain.  Updated  searches  were  performed through  November  2016. Recommendation  1: Given  that  most  patients  with  acute  or subacute  low  back  pain  improve  over  time  regardless  of  treat-ment,  clinicians  and  patients  should  select  nonpharmacologic treatment  with  superficial  heat  (moderate-quality  evidence),  massage,  acupuncture,  or  spinal  manipulation  (low-quality  evidence). If  pharmacologic  treatment  is  desired,  clinicians  and  patients should  select  nonsteroidal  anti-inflammatory  drugs  or  skeletal muscle  relaxants  (moderate-quality  evidence).  (Grade:  strong recommendation) Recommendation  2: For  patients  with  chronic  low  back  pain, clinicians  and  patients  should  initially  select  nonpharmacologic treatment  with  exercise,  multidisciplinary  rehabilitation,  acupuncture,  mindfulness-based  stress  reduction  (moderate-quality  evidence),  tai  chi,  yoga,  motor  control  exercise,  progressive relaxation,  electromyography  biofeedback,  low-level  laser therapy,  operant  therapy,  cognitive  behavioral  therapy,  or  spinal manipulation  (low-quality  evidence).  (Grade:  strong recommendation) Recommendation  3: In  patients  with  chronic  low  back  pain  who have  had  an  inadequate  response  to  nonpharmacologic  therapy, clinicians  and  patients  should  consider  pharmacologic  treatment with  nonsteroidal  anti-inflammatory  drugs  as  first-line  therapy,  or tramadol  or  duloxetine  as  second-line  therapy.  Clinicians  should only  consider  opioids  as  an  option  in  patients  who  have  failed  the aforementioned  treatments  and  only  if  the  potential  benefits  out-weigh  the  risks  for  individual  patients  and  after  a  discussion  of known  risks  and  realistic  benefits  with  patients.  (Grade:  weak  recommendation,  moderate-quality  evidence) Low  back  pain  is  one  of  the  most  common  reasons for  physician  visits  in  the  United  States.  Most  Americans  have  experienced  low  back  pain,  and  approximately  one  quarter  of  U.S.  adults  reported  having  low back  pain  lasting  at  least  1  day  in  the  past  3  months  (1).Low  back  pain  is  associated  with  high  costs,  including those  related  to  health  care  and  indirect  costs  from missed  work  or  reduced  productivity  (2).  The  total  costs attributable  to  low  back  pain  in  the  United  States  were estimated  at  $100  billion  in  2006,  two  thirds  of  which were  indirect  costs  of  lost  wages  and  productivity  (3).Low  back  pain  is  frequently  classified  and  treated on  the  basis  of  symptom  duration,  potential  cause, presence  or  absence  of  radicular  symptoms,  and  corresponding  anatomical  or  radiographic  abnormalities. Acute  back  pain  is  defined  as  lasting  less  than  4  week   Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt ED. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):493-505. doi: 10.7326/M16-2459. Epub 2017 Feb 14. PMID: 28192793. Background: A  2007  American  College  of  Physicians  guideline addressed  nonpharmacologic  treatment  options  for  low  back pain. The  current  evidence  on  non-pharmacologic  therapies  for  acute  or  chronic  nonradicular  or  ra-dicular  low  back  pain from  MEDLINE  (January  2008  through  February 2016),  Cochrane  Central  Register  of  Controlled  Trials,  CochraneDatabase  of  Systematic  Reviews,  and  reference  lists. Evidence  continues  to  support  the  effectiveness  of  exercise,  psychological  therapies,  multidisciplinary  rehabilitation,  spinal  manipulation,  massage,  and  acupuncture  for  chronic  low  back  pain. Funding  Source:Agency  for  Healthcare  Research  and Quality.  (PROSPERO:  CRD42014014735)Ann  Intern  Med.2017;166:xxx-xxx.  doi:10.7326/M16-2459Annals.org the  American  College  of  Physicians  (ACP)and  American  Pain  Society  (APS)  recommended  spinal manipulation  as  a  treatment  option  for  acute  low  back pain  and  several  nonpharmacologic  therapies  for  sub-acute  or  chronic  low  back  pain.    Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, Andersen MØ, Fournier G, Højgaard B, Jensen MB, Jensen LD, Karbo T, Kirkeskov L, Melbye M, Morsel-Carlsen L, Nordsteen J, Palsson TS, Rasti Z, Silbye PF, Steiness MZ, Tarp S, Vaagholt M. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018 Jan;27(1):60-75. doi: 10.1007/s00586-017-5099-2. Epub 2017 Apr 20. PMID: 28429142. Purpose: To summarise recommendations about 20 non-surgical interventions for recent onset ( If treatment is needed, the guidelines suggest using patient education, different types of supervised exercise, and manual therapy. The guidelines recommend against acupuncture, routine use of imaging, targeted treatment, extraforaminal glucocorticoid injection, paracetamol, NSAIDs, and opioids.   Krekoukias G1, Gelalis ID1,2, Xenakis T1, Gioftsos G3, Dimitriadis Z4, Sakellari V3. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017 May;25(2):66-73. doi: 10.1080/10669817.2016.1184435. Epub 2016 Jun 23. MANUAL THERAPY SPINAL MOBILIZATION IS PREFERABLE TO CONVENTIONAL PHYSIOTHERAPY IN ORDER TO REDUCE THE PAIN INTENSITY AND DISABILITY IN SUBJECTS WITH CHRONIC LBP AND ASSOCIATED DISK DEGENERATION. THE FINDINGS OF THIS STUDY MAY LEAD TO THE ESTABLISHMENT OF SPINAL MOBILIZATION AS ONE OF THE MOST PREFERABLE APPROACHES FOR THE MANAGEMENT OF LBP DUE TO DISK DEGENERATION.   REFERENCES FOR 25% RELIEF PAPER BY WIRTH ET AL Wirth B1, Riner F1, Peterson C1, Humphreys BK1, Farshad M2, Becker S3, Schweinhardt P1. An observational study on trajectories and outcomes of chronic low back pain patients referred from a spine surgery division for chiropractic treatment. Chiropr Man Therap. 2019 Feb 5;27:6. doi: 10.1186/s12998-018-0225-8. eCollection 2019. Refs on minimal clinical improvement determination: Farrar JT, Young JP, Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–158. doi: 10.1016/S0304-3959(01)00349-9. [PubMed] [CrossRef] Kovacs FM, Abraira V, Royuela A, Corcoll J, Alegre L, Cano A, et al. Minimal clinically important change for pain intensity and disability in patients with nonspecific low back pain. Spine (Phila Pa 1976) 2007;32:2915–2920. doi: 10.1097/BRS.0b013e31815b75ae. [PubMed] [CrossRef] Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004;8:283–291. doi: 10.1016/j.ejpain.2003.09.004. [PubMed] [CrossRef] Robinson-Papp J, George MC, Dorfman D, Simpson DM. Barriers to chronic pain measurement: a qualitative study of patient perspectives.Pain Med. 2015;16:1256–1264. doi: 10.1111/pme.12717. [PMC free article] [PubMed] [CrossRef] Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976) 2008;33:90–94. doi: 10.1097/BRS.0b013e31815e3a10. [PubMed] [CrossRef]   Chung TS1, Yang HE, Ahn SJ, Park JH. Herniated Lumbar Disks: Real-time MR Imaging Evaluation during Continuous Traction. Radiology 2015 Jan 22:141400. CONTINUOUS TRACTION ON HERNIATED LUMBAR DISKS AND SURROUNDING STRUCTURES RESULTED IN CHANGE IN DISK SHAPE, DISK REDUCTION WITH OPENING IN THE INTERVERTEBRAL DISK, REDUCTION OF HERNIATED DISK VOLUME, SEPARATION OF THE DISK AND ADJOINING NERVE ROOT, AND WIDENING OF THE FACET JOINT.    Wong A, Parent E, Dhillon S, Prasad N, Kawchuk G: Do Participants With Low Back Pain Who Respond to Spinal Manipulative Therapy Differ Biomechanically From Nonresponders, Untreated Controls or Asymptomatic Controls? Spine: 01 September 2015 - Volume 40 - Issue 17 - p 1329–1337  doi: 10.1097/BRS.0000000000000981 PARTICIPANTS WITH LBP AND ASYMPTOMATIC CONTROLS ATTENDED 3 SESSIONS FOR 7 DAYS. ON SESSIONS 1 AND 2, PARTICIPANTS WITH LBP RECEIVED SMT (+LBP/+SMT, N = 32) WHEREAS ASYMPTOMATIC CONTROLS DID NOT (−LBP/−SMT, N = 57). IN THESE SESSIONS, SPINAL STIFFNESS AND MULTIFIDUS THICKNESS RATIOS WERE OBTAINED BEFORE AND AFTER SMT AND ON DAY 7. RESULTS. AFTER THE FIRST SMT, SMT RESPONDERS DISPLAYED STATISTICALLY SIGNIFICANT DECREASES IN SPINAL STIFFNESS AND INCREASES IN MULTIFIDUS THICKNESS RATIO SUSTAINED FOR MORE THAN 7 DAYS; THESE FINDINGS WERE NOT OBSERVED IN OTHER GROUPS. SIMILARLY, ONLY SMT RESPONDERS DISPLAYED SIGNIFICANT POST-SMT IMPROVEMENT IN APPARENT DIFFUSION COEFFICIENTS.     Wong AYL1,2, Parent EC3, Dhillon SS4, Prasad N5, Samartzis D6, Kawchuk GN3. Differential patient responses to spinal manipulative therapy and their relation to spinal degeneration and post-treatment changes in disc diffusion. Eur  Spine J. 2019 Jan 2. doi: 10.1007/s00586-018-5851-2. NON-SPECIFIC LOW BACK PAIN PATIENTS WHO RESPOND WITH >30% RELIEF SHOW HIGHER APPARENT DIFFUSION COEFFICIENT DISC DIFFUSION OF WATER THAN NON POSITIVE RESPONDERS. MRI WAS PERFORMED BEFORE AND AFTER SMT ON DAY 1 OF CARE. OSWESTRY DISABILITY TEST WAS ALSO USED.     Beattie PF, Butts R, Donley JW, Liuzzo DM. The Within-Session Change in Low Back Pain Intensity Following Spinal Manipulative Therapy is Related to Differences in Diffusion of Water in the Intervertebral Discs of the Upper Lumbar Spine and L5-S1. Orthop Sports Phys Ther. 2013 Nov 21. Doctoral Program in Physical Therapy, Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC. STUDY TO DETERMINE DIFFERENCES IN THE CHANGES IN DIFFUSION OF WATER WITHIN THE LUMBAR INTERVERTEBRAL DISCS BETWEEN THOSE SUBJECTS WITH LOW BACK PAIN (LBP) WHO DID, AND DID NOT, REPORT A WITHIN-SESSION REDUCTION IN PAIN INTENSITY FOLLOWING A SINGLE TREATMENT OF SPINAL MANIPULATIVE THERAPY (SMT) WAS DONE. CHANGES IN THE DIFFUSION OF WATER WITHIN THE LUMBAR INTERVERTEBRAL DISCS AT THE L1-2, L2-3, AND L5-1 LEVELS APPEAR TO BE RELATED TO DIFFERENCES IN WITHIN-SESSION PAIN REPORTS FOLLOWING A SINGLE TREATMENT OF SPINAL MANIPULATIVE THERAPY. PARTICIPANTS UNDERWENT T2- AND DIFFUSION-WEIGHTED LUMBAR MAGNETIC RESONANCE IMAGING SCANS IMMEDIATELY BEFORE, AND AFTER, RECEIVING A SINGLE TREATMENT OF SMTJ     Kuo, Ya-Wen PhD; Hsu, Yu-Chun MS; Chuang, I-Ting MS; Chao, Pen-Hsiu Grace PhD; Wang, Jaw-Lin PhD Spinal Traction Promotes Molecular Transportation in a Simulated Degenerative Intervertebral Disc Model. Spine: April 20th, 2014 - Volume 39 - Issue 9 - p E550 Traction biomechanics studied in the porcine model biomechanical benefits include disc height recovery, foramen enlargement, and intradiscal pressure reduction. 48 thoracic discs were dissected from 8 porcine spines and then divided into 3 groups: intact, degraded without traction, and degraded with traction. From Day 4 to Day 6, half of the degraded discs received a 30 min traction treatment per day (traction force: 20 kg, loading: unloading = 30 sec: 10 sec). Traction treatment is effective in enhancing nutrition supply and promoting disc cell proliferation of the degraded discs.  

ReferencesBartoszewska M, Kamboj M, Patel DR (2010) Vitamin D, muscle function, and exercise performance. Pediatr Clin North Am 57:849-861. doi:10.1016/j.pcl.2010.03.008 Brazier M, Grados F, Kamel S et al (2005) Clinical and laboratory safety of one year's use of a combination calcium + vitamin D tablet in ambulatory elderly women with vitamin D insufficiency: results of a multicenter, randomized, double-blind, placebo-controlled study. Clin Ther 27:1885-1893. doi:10.1016/j.clinthera.2005.12.010 Hoang MT, Defina LF, Willis BL, Leonard DS, Weiner MF, Brown ES. (2011) Association between low serum 25-hydroxyvitamin D and depression in a large sample of healthy adults: the Cooper Center longitudinal study. Mayo Clin Proc. 2011 Nov;86(11):1050-5.Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL (2011) Vitamin D supplementation during pregnancy: double-blind, randomized clinical trial of safety and effectiveness. J Bone Miner Res 26:2341-2357. doi:10.1002/jbmr.463; 10.1002/jbmr.463 Jones G (2008) Pharmacokinetics of vitamin D toxicity. Am J Clin Nutr 88:582S-586S Karaplis AC, Chouha F, Djandji M, Sampalis JS, Hanley DA (2011) Vitamin D status and response to daily 400 IU vitamin D3 and weekly alendronate 70 mg in men and women with osteoporosis. Ann Pharmacother 45:561-568. doi:10.1345/aph.1P439 Kimball SM, Ursell MR, O'Connor P, Vieth R (2007) Safety of vitamin D3 in adults with multiple sclerosis. Am J Clin Nutr 86:645-651 Koutkia P, Chen TC, Holick MF (2001) Vitamin D intoxication associated with an over-the-counter supplement. N Engl J Med 345:66-67. doi:10.1056/NEJM200107053450114 Lips P, Binkley N, Pfeifer M et al (2010) Once-weekly dose of 8400 IU vitamin D(3) compared with placebo: effects on neuromuscular function and tolerability in older adults with vitamin D insufficiency. Am J Clin Nutr 91:985-991. doi:10.3945/ajcn.2009.28113 Maalouf J, Nabulsi M, Vieth R et al (2008) Short- and long-term safety of weekly high-dose vitamin D3 supplementation in school children. J Clin Endocrinol Metab 93:2693-2701. doi:10.1210/jc.2007-2530 Matthews LR, Ahmed Y, Wilson KL, Griggs DD, Danner OK (2012) Worsening severity of vitamin D deficiency is associated with increased length of stay, surgical intensive care unit cost, and mortality rate in surgical intensive care unit patients. Am J Surg . doi:10.1016/j.amjsurg.2011.07.021 Roth DE (2011) Vitamin D supplementation during pregnancy: safety considerations in the design and interpretation of clinical trials. J Perinatol 31:449-459. doi:10.1038/jp.2010.203; 10.1038/jp.2010.203 Vieth R (1999) Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr 69:842-856 Vieth R (1999) Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr 69:842-856 Wang Y, DeLuca HF (2011) Is the vitamin d receptor found in muscle? Endocrinology 152:354-363. doi:10.1210/en.2010-1109 Wielders JP, Muskiet FA, van de Wiel A (2010) Shedding new light on vitamin D--reassessment of an essential prohormone. Ned Tijdschr Geneeskd 154:A1810 

Does smoking cause lung cancer? How could you ever know? The second in a three-part series on causality, I’m joined by Dr. Shoshana Herzig to discuss how Austin Bradford Hill and Richard Doll set out to try and answer this question -- and along the way revolutionized the way we think about what causes disease. In this episode, we’ll talk about the first double-blinded randomized controlled trial, the long shadow of tuberculosis, and why epidemiology is beautiful. Plus, a brand new #AdamAnswers about chest compressions! Please support Bedside Rounds by filling out the listener demographic survey: https://survey.libsyn.com/bedsiderounds Sources: Bost TC. Cardiac arrest during anaesthesia and surgical operations. Am J Surg 1952;83: 135-4 Council, T. Tobacco Smoking and Lung Cancer. Brit Med J 1, 1523 (1957). Crofton J, The MRC randomized trial of streptomycin and its legacy: a view from the clinical front line. J R Soc Med. 2006 Oct; 99(10): 531–534. Daniels M and Bradford Hill A, Chemotherapy of Pulmonary Tuberculosis in Young Adults, Br Med J. 1952 May 31; 1(4769): 1162–1168. Dangers of Cigarette-smoking. Brit Med J 1, 1518 (1957). Doll, R. & Hill, B. A. Lung Cancer and Other Causes of Death in Relation to Smoking. Brit Med J 2, 1071 (1956). Doll, R. & Hill, B. A. Smoking and Carcinoma of the Lung. Brit Med J 2, 739 (1950). Hill, A. The Environment and Disease: Association or Causation? J Roy Soc Med 58, 295–300 (1965). HOFFMAN, F. L. CANCER AND SMOKING HABITS. Ann Surg 93, 50–67 (1931). Hurt R, Modern cardiopulmonary resuscitation—not so new after all. J R Soc Med. 2005 Jul; 98(7): 327–331. Keating C, Smoking Kills: The Revolutionary Life of Richard Doll. 2009. Keith A, Three Hunterian Lectures ON THE MECHANISM UNDERLYING THE VARIOUS METHODS OF ARTIFICIAL RESPIRATION PRACTISED SINCE THE FOUNDATION OF THE ROYAL HUMANE SOCIETY IN 1774. (1909). The Lancet, 173(4464), 825–828. Kouwenhoven WB et al, Closed-chest cardiac massage, JAMA, JAMA. 1960;173(10):1064-1067. Morabia, A. Quality, originality, and significance of the 1939 “Tobacco consumption and lung carcinoma” article by Mueller, including translation of a section of the paper. Prev Med 55, 171–177 (2012). Ochsner, A. & bakey. Primary pulmonary malignancy: treatment by total pneumonectomy; analysis of 79 collected cases and presentation of 7 personal cases. Ochsner J 1, 109–25 (1999). Ochsner, A. My first recognition of the relationship of smoking and lung cancer. Prev Med 2, 611–614 (1973). Parascandola, M. Two approaches to etiology: the debate over smoking and lung cancer in the 1950s. Endeavour 28, 81–86 (2004). Phillips, C. V. & Goodman, K. J. The missed lessons of Sir Austin Bradford Hill. Epidemiologic Perspectives Innovations 1, 1–5 (2004). Proctor, R. Angel H Roffo: the forgotten father of experimental tobacco carcinogenesis. B World Health Organ 84, 494–495 (2006). Wynder, E. RE: “WHEN GENIUS ERRS: R. A. FISHER AND THE LUNG CANCER CONTROVERSY”. Am J Epidemiol 134, 1467–9 (1991).

In this Careercast, Dr. Salina Wydo interviews Dr. Paula Ferrada on exploring the gender and diversity gap in trauma surgery.  Dr. Ferrada shares her personal experiences, as well as insights and practical advice on improving inclusivity in our community, and encourages individual surgeons to succeed by “[doing] what you want not to spite them, but in spite of them.” For more information on the topic, please visit the joint AWS/EAST Careercast #45 on the Importance of Mentoring  Other additional reading:Abelson JS, Chartrand G, Moo T, et al. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016;212:566-572.Valsangkar N, Fecher AM, Rozycki G, et al. Understanding the barriers to hiring and promoting women in surgical subspecialties. JACS. 2016;223(2):387-398.Cochran A, Hauschild T, Elder W, et al. Perceived gender-based barriers to careers in academic surgery. Am J Surg. 2013;206:263-268.Sexton KW, Hocking KM, Wise et al. Women in academic surgery: the pipeline is busted. Journal of Surgical Education. 2012;69(1):84-90.Yu PT, Parsa PV, Hassanien O, et al. Minorities struggle to advance in academic medicine: a 12-y review of diversity at the highest levels of America’s teaching institutions. Journal of Surgical Research. 2013;182:212-218 Abelson JS, Symer MM, Yeo HL, et al. Surgical time out: our counts are still short on racial diversity in academic surgery. Am J Surgery. 2018;215:542-548. ACGME Residents and Fellows by Sex and Specialty, 2015

It's definitely summer in the northern hemisphere! Here's #4 of the summer re-run series. We hope you enjoy it!   What is the most effective way to prepare senior medical students for the transition to residency?  Do the new intensive 'Surgical Boot Camps' for junior residency work? This study attempted to fill some of the gaps in the understanding of the effects of such courses on learning and performance in residency. Authors:  Wunder JA, Brandt CP, Lipman JM. Publication details: A surgical residency preparatory course for senior medical students leads to earlier independence in ACGME competencies. Am J Surg. 2017 Nov 8. [Epub ahead of print]  View the abstract here Follow our co-hosts on Twitter!  Jason R. Frank: @drjfrank  Jonathan Sherbino: @sherbino  Linda Snell: @LindaSMedEd  Want to learn more about KeyLIME? Click here!

What is the most effective way to prepare senior medical students for the transition to residency?  Do the new intensive 'Surgical Boot Camps' for junior residency work? This study attempted to fill some of the gaps in the understanding of the effects of such courses on learning and performance in residency. Authors:  Wunder JA, Brandt CP, Lipman JM. Publication details: A surgical residency preparatory course for senior medical students leads to earlier independence in ACGME competencies. Am J Surg. 2017 Nov 8. [Epub ahead of print]  View the abstract here Follow our co-hosts on Twitter!  Jason R. Frank: @drjfrank  Jonathan Sherbino: @sherbino  Linda Snell: @LindaSMedEd  Want to learn more about KeyLIME? Click here!

Show Notes for Podcast Five of Sex & Why Host: Jeannette Wolfe Topic: Stress Response This Podcast focuses on the basics of the acute human stress response. Please see Dr Morgenstern's excellent write up: Performance Under Pressure Review: https://first10em.com/2017/03/13/performance-under-pressure/ Components of stress response Trigger Speed of activation Magnitude of response Time to return to baseline Things that affect cortisol response time of day health genetics personality early pre-natal/childhood stressors- epigenetics can change DNA expression current stressors smoking if female- where you are in cycle or use of OCP interaction with testosterone Sensation of psychological stress is not always associated with physiological stress (i.e. cortisol stress response) Conversely in psychological studies in which subjects get exogenous steroids (i.e take a hydrocortisone pill) although there are often associated behavioral changes from the steroids participants rarely feel anxious. Somewhat ironic that women report more psychological stress but that men die on average 7 years earlier Things that reliably trigger physiological stress:  Demands >>> Resources Unpredictability Uncontrollability Novelty Learning on stress is U shaped curve A little stress helps things stick more As stress increases harder to draw  Some suggested sex differences: In general women have higher baseline HR than men (despite this, women are believed to have a higher parasympathetic baseline tone) Triggers: Men may be more vulnerable to stressors that trigger dominancy/hierarchy Women may be more vulnerable to stressors that trigger social isolation Free Cortisol is the active form and men appear to have higher free cortisol levels Women may be more sensitive to acth- similar cortisol level with less trigger. Men more likely to respond to threat of hierarchy, women social exclusion Stress resiliency: Time to respond, magnitude of response time until return to baseline To what, how quickly, how much, how long.  Studies discussed in podcast Alexander, G. M., Wilcox, T., & Woods, R. (2009). Sex differences in infants' visual interest in toys. Archives of Sexual Behavior, 38(3), 427–33. https://doi.org/10.1007/s10508-008-9430-1 Ali, Amir; Subhi, Yousif; Ringsted, Charlotte; Konge, Lars. Gender differences in the acquisition of surgical skills : a systematic review. /I: Surgical endoscopy, Vol. 29, Nr. 11, 11.2015, s. 3065-3073. Deane, R., Chummun, H., & Prashad, D. (2002). Differences in urinary stress hormones in male and female nurses at different ages. Journal of Advanced Nursing, 37 , 304–310. Shane MD, Pettitt BJ, Morgenthal CB, Smith CD (2008) Should surgical novices trade their retractors for joysticks? Videogame experience decreases the time needed to acquire surgical skills. Surg Endosc 22:1294–1297 Theorell Tores, On Basic Physiological Stress Mechanisms in Men and Women: Gender Observations on Catecholamines, Cortisol and Blood Pressure Monitored in Daily Life. Psychosocial Stress and Cardiovascular Disease in Women, DOI 10.1007/978-3-319-09241-6_7  Published 2015 pp 89-105 Turecki, G., & Meaney, M. J. (2016). Effects of the Social Environment and Stress on Glucocorticoid Receptor Gene Methylation: A Systematic Review. Biological Psychiatry, 79(2), 87–96. https://doi.org/10.1016/j.biopsych.2014.11.022  Yael, Sofer, et al. "GENDER D. S. F. C. H. L. I. M. . E. P. (2016). (2015). Original Article GENDER DETERMINES SERUM FREE CORTISOL: HIGHER LEVELS IN MEN EP161370.OR. Endocrine Practice. https://doi.org/10.4158/EP161370.OR  White MT, Welch K (2012) Does gender predict performance of novices undergoing fundamentals of laparoscopic surgery (FLS) training? Am J Surg 203:397–400  

Children the world over are fascinated with what can possibly “fit” in their orifices.  Diagnosis is often delayed.  Anxiety abounds before and during evaluation and management.     Most common objects:1,2 Food Coins Toys Insects Balls, marbles Balloons Magnets Crayon Hair accessories, bows Beads Pebbles Erasers Pen/marker caps Button batteries Plastic bags, packaging Non-pharmacologic techniques Set the scene and control the environment.  Limit the number of people in the room, the noise level, and minimize “cross-talk”.  The focus should be on engaging, calming, and distracting the child. Quiet room; calm parent; “burrito wrap”; guided imagery; have a willing parent restrain the child in his or her lap – an assistant can further restrain the head. Procedural Sedation Most foreign bodies in the ear, nose, and throat in children can be managed with non-pharmacologic techniques, topical aids, gentle patient protective restraint, and a quick hand.  Consider sedation in children with special health care needs who may not be able to cooperate and technically delicate extractions.  Ketamine is an excellent agent, as airway reflexes are maintained.3  Remember to plan, think ahead: where could the foreign body may be displaced if something goes wrong?  You may have taken away his protective gag reflex with sedation.  Position the child accordingly to prevent precipitous foreign body aspiration or occlusion. L’OREILLE – DAS OHR – вухо – THE EAR – LA OREJA – 耳 – L'ORECCHIO Essential anatomy: The external auditory canal. Foreign bodies may become lodged in the narrowing at the bony cartilaginous junction.4  The lateral 1/3 of the canal is flexible, while the medial 2/3 is fixed in the temporal bone – here is where many foreign bodies are lodged and/or where the clinician may find evidence of trauma.  Pearls: Ask yourself: is it graspable or non-graspable?5 Graspable: 64% success rate, 14% complication rate Non-graspable: 45% success rate, 70% complication rate5 If there is an insect in the external auditory canal, kill it first. They will fight for their lives if you try to dismember or take them out.  “In the heat of battle, the patient can become terrorized by the noise and pain and the instrument that you are using is likely to damage the ear canal.”5,6  Use lidocaine jelly (preferred), viscous lidocaine (2%), lidocaine solution (2 or 4%), isopropyl alcohol, or mineral oil. Vegetable matter? Don’t irrigate it – the organic material will swell against the fixed structure, and cause more pain, make it much harder to extract, and may increase the risk of infection. Pifalls: Failure to inspect after removal – is there something else in there? Failure to assess for abrasions, trauma, infection – if any break in skin, give prophylactic antibiotic ear drops Law of diminishing returns: probability of successful removal of ear foreign bodies declines dramatically after the first attempt   LE NEZ – DIE NASE – ніс – THE NOSE – LA NARIZ – 鼻 – IL NASO Essential anatomy: Nasopharyngeal and tracheal anatomy. Highlighted areas indicate points at which nasal foreign bodies may become lodged.4 Pearls: Consider using topical analgesics and vasoconstrictors to reduce pain and swelling – and improve tolerance of/cooperation with the procedure. Use 0.5% oxymetolazone (Afrin) spray and a few drops of 2 or 4%   Pros: as above.  Cons: possible posterior displacement of the foreign body.7 Be ready for the precipitous development of an airway foreign body Pitfalls: Beware of unilateral nasal discharge in a child – strongly consider retained foreign body.8 Do not push a foreign body down the back of a patient's throat, where it may be aspirated into the trachea. Be sure to inspect the palate for “vacuum effect”: small or flexible objects may be found on the roof of the mouth, just waiting to be aspirated.   LA GORGE – DER HALS – горло – THE THROAT – LA GARGANTA – 喉 – LA GOLA Before we go further – Remember that a foreign body in the mouth or throat can precipitously become a foreign body in the airway.  Foreign body inhalation is the most common cause of accidental death in children less than one year of age.9,10 Go to BLS maneuvers if the child decompensates. Infants under 1 year of age – back blows: head-down, 5 back-blows (between scapulae), 5 chest-thrusts (sternum).  Reassess, repeat as needed. Children 1 year and up, conscious – Heimlich maneuver: stand behind patient with arms positioned under the patient’s axilla and encircling the chest. The thumb side of one fist should be placed on the abdomen below the xiphoid process. The other hand should be placed over the fist, and 5 upward-inward thrusts should be performed. This maneuver should be repeated if the airway remains obstructed.  Alternatively, if patient is supine, open the airway, and if the object is readily visible, remove it.  Abdominal thrusts: place the heel of one hand below the xiphoid, interlace fingers, and use sharp, forceful thrusts to dislodge.  Be ready to perform CPR. Children 1 year and up, unconscious – CPR: start CPR with chest compressions (do not perform a pulse check). After 30 chest compressions, open the airway. If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects further into the pharynx and may damage the oropharynx.  Attempt to give 2 breaths and continue with cycles of chest compressions and ventilations until the object is expelled. Chest films are limited: 80% of airway foreign bodies are radiolucent.11  Look for unilateral hyperinflation on expiratory films: air trapping.  Essential anatomy: Most esophageal foreign bodies in children occur at the level of the thoracic inlet / cricopharyngeus muscle (upper esophageal sphincter).  Other anatomically narrow sites include the level of the aortic arch and the lower esophageal sphincter. Coin en face – in the esophagus – lodged at the thoracic inlet.12  The pliable esophagus accommodates the flat coin against the flat aspect of the vertebra.11 Beware the “double-ring” sign: this is a button battery13 This is an emergency: the electrolyte-rich mucosa conducts a focal current from the narrow negative terminal of the battery, rapidly causing burn, necrosis, and possibly perforation.  Emergent removal is required. Button batteries that have passed into the stomach do not require emergent intervention – they can be followed closely. Not a button battery, not a sharp object, not a long object? If there is no obstruction, consider revaluation the next day – may wait up to 24 hours for passage.14  Sharieff et al.15 found that coins found in the mid to distal esophagus within 24 hours all passed successfully. What conditions prompt urgent removal? Size Infants: objects smaller than 2 cm wide and 3 cm long will likely pass the pylorus and ileocecal valve10 Children and adults: objects smaller than 2 cm wide and 5 cm long will likely pass the pylorus and ileocecal valve9 Character Sharp objects have a high rate of perforation (35%)1 Pearls: History is essential. Believe the parents and assume there is an aspirated/ingested foreign body until proven otherwise. History of choking, has persistent symptoms and/or abnormal xray? Broncoscopy! Cohen et al.16 found that of 142 patients evaluated at a single site university hospital, 61 had a foreign body. Of the 61 patients, 42 had abnormal physical exams and radiographs and 17 had either abnormal physical exams or radiographs, and 2 had normal physical exams and radiographs, but both had a history of persistent cough.  Bottom line: history of choking PLUS abnormal exam, abnormal films, or persistent symptoms, evaluate with bronchoscopy. For patients with some residual suspicion of an aspirated foreign body (mild initial or improving symptoms; possibly abnormal chest x-ray; low but finite risk), consider chest CT with virtual bronchoscopy as a rule-out strategy.17,18 Outpatients who have passed a small and non-concerning object into the stomach or beyond: serial exams and observing stools – polyethylene glycol 3350 (MiraLAX) may be given for delayed passage19 Pifalls: A single household magnet will likely pass through the GI tract, with the aforementioned dimensional caveats. Two or more magnets, however, run the risk of attraction and trans-bowel wall pressure necrosis. Not all magnets are created equal. Neodymium magnet toys (“buckyballs”) were recalled in 2014 (but are still out there!) due to their highly attractive nature.  These magnets must be removed to avoid bowel wall ischemia. 19–21 Patients should avoid wearing belt buckles or metallic buttons in case of single magnet ingestion while waiting for the single magnet to pass DES OUTILS DU MÉTIER – DIE HANDWERKSZEUG – Знаряддя праці – TOOLS OF THE TRADE – LAS HERRAMIENTAS DEL OFICIO – GLI ATTREZZI DEL MESTIERE –  仕事のツール It’s best to keep your armamentarium as large as you can.   Curette A small foreign body in the lateral 1/3 of the auditory canal may be amenable to a simple curettage.  Hair beads (if the central hole is accessible) may be manipulated out with the angled tip of a rigid curette.  Steady the operating hand by placing your hypothenar eminence on the child’s zygoma or temporal scalp, to avoid jutting the instrument into the ear canal with sudden movement.  There is a large selection of disposable simple and lighted curettes on the market. Right-angle Hook Various eponymous hooks are available for this purpose; one in popular use is the Day hook, which may be passed behind the foreign body.22  An inexpensive and convenient alternative to the commercially available right-hooks is a home-made version: make your own by straightening out a paperclip and bending it to a right angle23 at 2-3 mm from the end (be sure not to use the type that have a friable shiny metallic finish, as the residue may be left behind in the ear canal).  If it is completely lodged, use of a right-angle hook will likely only cause trauma to the canal. Alligator forceps Alligator forceps are best for grasping soft objects like cotton or paper.  Smooth, round or oval objects are not amenable to extraction with alligator forceps.  When using them, be sure to get a firm, central grip on the object, to avoid tearing it into smaller, less manageable pieces.  Pro tip: Look before you grip! Be careful to visualize the area you are gripping, to avoid pulling on (and subsequently avulsing) soft tissue in the ear canal. Cyanoacrylate (Dermabond®, SurgiSeal®) Apply cyanoacrylate to either side of a long wooden cotton swab (the lecturer prefers the cotton tip side, for improved grip/molding around object).  Immediately apply the treated side to the object in the ear canal in a restrained patient.  Steady the hypothenar eminence on the child’s face to avoid dislodgement of the cotton swab with sudden movement.  Apply the treated swab to the foreign body for 30-60 seconds, to allow bonding.  Slowly pull out the foreign body.  Re-visualize the ear canal for other retained foreign bodies and abrasion or ear canal trauma. Did the cyanoacrylate drip?  Did the swab stick to the ear canal? No problem – use 3% hydrogen peroxide or acetone.24  Pour in a sufficient amount, allow to work for 10 minutes.  Both agents help to dissolve ear wax, the compound, or both.  Repeat if needed to debond the cyanoacrylate from the ear canal.24,25 Irrigation Irrigation is the default for non-organic foreign bodies that are not amenable to other extraction techniques.  Sometimes the object is encased in cerumen, and the only “instrument” that will fit behind the foreign body is the slowly growing trickle of water that builds enough pressure to expulse it.  Do not use if there is any organic material involved: the object will swell, causing much more pain, difficulty in extraction, and possibly setting up conditions for infection. Position the child either prone or supine, gently restrain (as above).  Let gravity work for you: don’t irrigate in decubitus position with the affected ear up.  It may be more accessible to you, but you may never get the foreign body out. To use a butterfly needle: use a small gage (22 or 24 g) butterfly set up, cut off the needle, connect the tubing to a 30 mL syringe filled with warm or room-temperature water. Insert the free end of the tubing gently, and “secure” the tubing with your pinched fingers while irrigating (think of holding an ETT in place just after intubation and before taping/securing the tube).  Gently and slowly increase the pressure you exert as you irrigate. To use an IV or angiocatheter: use a moderate size (18 or 20 g) IV, remove the needle and attach the plastic catheter to a 20 mL syringe, and irrigate as above. Acetone Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal24,26,27  Use in cases where there is no suspicion of perforation of the tympanic membrane. Docusate Sodium (Colace®) Cerumen is composed of sebaceous ad ceruminous secretions and desquamated skin.  Genetic, environmental, and anatomical factors combine to trap a foreign body in the external canal.  Use of a ceruminolytic such as docusate sodium may help to loosen and liberate the foreign body.28  Caveat medicus: Adding docusate sodium will make the object more slippery – this may or may not be an issue given the nature of the foreign body. In the case where loosening the ear wax may aid extraction (and will not cause a slippery mess), consider filling the ear canal will docusate sodium (Colace), having the child lie with the affected side up, waiting 15 minutes, and proceeding.  This is especially helpful when planning for irrigation. Magnets Rare earth magnets (a misnomer, as their components are actually abundant) such as neodymium can be useful in retrieving metallic foreign bodies (e.g. button batteries in the nose or ears).29,30  Magnetic “pick-up tools” – used by mechanics, engineers, and do-it-yourselfers – are inexpensive and readily available in various sizes, shapes, and styles such as a telescoping extender.  Look for a small tip diameter (to fit in the ear canal as well as the nose) and a strong “hold” (at least a 3-lb hold). Alternatively, you may purchase a strong neodymium bar magnet (30- to 50-lb hold) to attach to an instrument such as an alligator forceps, pick-up forceps, or small hemostat (a pacemaker magnet may also work).  The magnetic bar, placed in your palm at the base of the instrument, will conduct the charge (depending on the instrument) and allow you to retrieve many metallic objects.31  Although stainless steel is often said to be “non-magnetic”, it depends on the alloy used, and some may actually respond to the strong rare earth magnet.  Most stainless steel has a minimum of 10.5% chromium, which gives the steel its 'stainless' properties (essentially corrosion resistance).  A basic stainless steel has a “ferritic” structure and is magnetic.  Higher-end stainless steel such as in kitchen cutlery have an “austenitic” structure, with more chromium added, and so less magnetic quality.  (Ironically, the more “economical” instruments in the typical ED suture kit have less chromium, and so are more magnetic – use these with your neodymium bar magnet to conduct the magnetic charge and extract the metallic foreign body.) Bottom line: if it’s metal, it’s worth a try to use a magnet.  Even if the metal is very weakly magnetic, the strong neodymium magnet may still be able to exert a pull on it and aid in extraction. Snare Technique A relatively new method, described by Fundakowski et al.32 consists of using a small length of 24-gauge (or similar) wire (available inexpensively online, and kept in your personal “toolkit”; see Appendix B below) to make a loop that is secured by a hemostat (the 24-gauge wire is easily cut into strips with standard trauma scissors).  After treatment with oxymetolazone (0.05%) and lidocaine (1 or 2%) topically, the loop is passed behind the foreign body (in the case report, a button battery).  Pull the loop toward you until you feel that it is sitting up against the button battery.  Now, turn the hemostat 90° to improve your purchase on the foreign body.  Pull gently out.  This technique is especially useful when the foreign body has created marked edema, either creating a vacuum effect or making it difficult for other instruments to pass. Balloon Catheters (Katz extractor®, Fogarty embolectomy catheter) Small-caliber devices (5, 6, or 8 F) originally designed for use with intravascular or bladder catheterization may be used to extract foreign bodies from the ear or nose.7,33  A catheter designed specifically for foreign body use is the Katz extractor.  Inspect the ear or nose for potential trauma and to anticipate bleeding after manipulation (especially the nose).  Deflate the catheter and apply surgical lubricant or 2% lidocaine jelly. Insert the deflated catheter and gently pass the device past the foreign body.  Inflate the balloon and slowly pull the balloon and foreign body out.  Re-inspect after extraction. NB, from the manufacturer of the Katz extractor, InHealth: “the Katz Extractor oto-rhino foreign body remover is intended principally for extraction of impacted foreign bodies in the nasal passages. This device may also be used in the external ear canal, based upon clinical judgment.” Mother’s kiss The mother’s kiss was first described in 1965 by Vladimir Ctibor, a general practitioner from New Jersey.34 “The mother, or other trusted adult, places her mouth over the child’s open mouth, forming a firm seal as if about to perform mouth-to-mouth resuscitation. While occluding the unaffected nostril with a finger, the adult then blows until feeling resistance caused by closure of the child’s glottis, at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth. This puff of air passes through the nasopharynx, out through the non-occluded nostril and, if successful, results in the expulsion of the foreign body. The procedure is fully explained to the adult before starting, and the child is told that the parent will give him or her a “big kiss” so that minimal distress is caused to the child. The procedure can be repeated a number of times if not initially successful.”34 Positive Pressure Ventilation with Bag Valve Mask This technique is an approximation of the above mother’s kiss technique – useful for unwilling parents or unsuccessful tries.10,25  The author prefers to position the child sitting up.  A self-inflating bag-mask device is fitted with a very small mask: use an abnormally small mask (otherwise inappropriately small for usual resuscitative bag-mask ventilation) to fit over the mouth only.  Choose an infant mask that will cover the child’s mouth only.  Occlude the opposite nostril with your finger while you form a tight seal with the mask around the mouth. Deliver short, abrupt bursts of ventilation through the mouth – be sure to maintain good seals with the mask and with your finger to the child’s nostril – until the foreign body is expulsed through the affected nostril. Beamsley Blaster (Continuous Positive Pressure) Technique For the very uncooperative child with a nasal foreign body amenable to positive pressure ventilation who fails the mother’s kiss and bag-mask technique, a continuous positive pressure method may be used. Connect one end of suction tubing to the male adaptor (“Christmas tree”) of an air or oxygen source.  Connect the other end of the suction tubing to a male-to-male adaptor (commonly used for chest tube connections or connecting / extending suction tubes).  Insert the end of the device into the child’s unaffected nostril.  The air flow will deliver positive pressure ventilation continuously. With this technique there is a theoretical risk of barotrauma to the lungs or tympanic membranes.  However, there is only one case reported in the literature of periorbital subcutaneous emphysema. To minimize this risk, some authors recommend limiting to a maximum of four attempts using any positive pressure method.10 Nasal speculum Optimize your visualization with a nasal speculum.  The nostrils, luckily, will accommodate a fair amount of distention without damage.  Hold the speculum vertically to avoid pressure on and damage to the vessel-and-nerve-rich nasal septum.  Hold the handle of the speculum in the palm of your hand comfortably and while placing your index finger on the patient’s ala.  This will help to control the speculum and your angle of sight. Your other hand is then free to use a hook or other tool for extraction. Lighting is especially important when using the nasal speculum: a focused procedure light or head lamp is very helpful.  The author keeps a common camping LED headlamp in his bag for easy access. Suction tips / catheters Various commercial and non-commercial suction devices are on the market for removal of foreign bodies.  All connect to wall suction, and vary by style, caliber of suction, and tip end interface.  A commonly available suction catheter is the Frazier suction tip (right), a single-use device used in the operating room. A modification to suction can be made with the Schuknecht foreign body remover (left; not to be confused with the suction catheter of the same name): a plastic cone-shaped tip placed on the end of the suction catheter to increase vacuum surface area and seal.  Laryngoscope and Magill Forceps If a child aspirates and occludes his airway, return to BLS maneuvers (as above).  If the child becomes obtunded, use direct laryngoscopy to visualize the foreign body and remove with the Magill forceps.  Hold the laryngoscope in your left hand as per usual.  Hold the Magill forceps in your right hand – palm side down – to grasp and remove the foreign body.  Take-home Points  Beware the “vacuum palate”: a flat (especially clear plastic) foreign body hiding on the palate Take seriously the complaint of foreign body without obvious evidence on initial inspection – believe that something is in there until proven otherwise Control the environment, address analgesia and anxiolysis, have a back-up plan Motto Like a difficult airway: plan through the steps MERCI – DANKE – Дякую – THANK YOU – GRACIAS –  ありがとう— GRAZIE Appendix A: Prevention At the end of the visit, after some rapport has been established, counsel the caregivers about age-appropriate foods and “child-proofing” the home.  This is a teachable moment – and only you can have this golden opportunity! Age-appropriate foods 0-6 months: breastmilk or formula 6-9 months: introduce solid puree-consistency foods 9-12 months: small minced solids that require no chewing (well cooked, soft, chopped foods) Although molars (required for chewing) erupt around 18 months, toddlers need to develop coordination, awareness to eat hard foods that require considerable chewing. Not until 4 years of age (anything that requires chewing to swallow):             Hot dogs             Nuts and seeds             Chunks of meat or cheese             Whole grapes             Hard or sticky candy             Popcorn             Chunks of peanut butter             Chunks of raw vegetables             Chewing gum Child-proofing the home Refer parents to the helpful multi-lingual site from the American Academy of Pediatrics: http://www.healthychildren.org/English/safety-prevention/at-home/Pages/Childproofing-Your-Home.aspx An abbreviated list: use age-appropriate toys and “test” them out before giving them to your child to verify that there are no small, missing, or loose parts.  Secure medications, lock up cabinets (especially with chemicals), do not store chemicals in food containers, secure the toilet bowl, and unplug appliances. Parents should understand that “watching” their child alone cannot prevent foreign body aspiration: a recent review found that in 84.2% of cases, incidents resulting in an airway foreign body occurred in the presence of an adult.35 Best overall tip: get down on all fours and inspect your living area from the child’s perspective.  It is amazing what you will find when you are least expecting it. Appendix B: The Playbook's ENT Foreign Body Toolkit Although your institution should supply you with what you need to deal with routine problems, we all struggle with having just what we need when we need it.  High-volume disposable items such as cyanoacrylate (Dermabond), curettes, supplies for irrigation, alligator forceps, and the like certainly should be supplied by the institution.  However, some things come in very handy as our back-up tools. NB: we should be cognizant of the fact that tools that must be sterilized or autoclaved are not good candidates for our personal re-usable toolkits. These items can all be found inexpensively – shop around online, or in home improvement stores: Head lamp, LED camping style: $5-15 Neodymium magnet “pick-up tool”: $5-15 Neodymium bar magnet: $6-20 Wire, 24-gauge, spool of 25 yards (for snare technique): $6 Day hook: $15-20 References Chapin MM, Rochette LM, Annest JL, Haileyesus T, Conner KA, Smith GA. Nonfatal Choking on Food Among Children 14 Years or Younger in the United States, 2001–2009. Pediatrics. 2013;132(2):275-281. doi:10.1542/peds.2013-0260. Committee on Injury V. Policy Statement—Prevention of Choking Among Children. Pediatrics. 2010:peds.2009-2862. doi:10.1542/peds.2009-2862. Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies. Am J Emerg Med. 2004;22(4):310-314. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-1189. DiMuzio J, Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol. 2002;23(4):473-475. Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: an in vitro comparative study. Ann Emerg Med. 1993;22(12):1795-1798. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24(11):785-792; quiz 790-792. doi:10.1097/PEC.0b013e31818c2cb9. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med. 1997;15(1):54-56. Tahir N, Ramsden WH, Stringer MD. Tracheobronchial anatomy and the distribution of inhaled foreign bodies in children. Eur J Pediatr. 2009;168(3):289-295. doi:10.1007/s00431-008-0751-9. Rempe B, Iskyan K, Aloi M. An Evidence-Based Review of Pediatric Retained Foreign Bodies. Pediatr Emerg Med Pract. 6(12). Digoy GP. Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin North Am. 2008;41(3):485-496, vii - viii. doi:10.1016/j.otc.2008.01.013. Loren Yamamoto, Inaba A, DiMauro R. Radiologic Cases in Pediatric Emergency Medicine; University of Hawaii. Radiol Cases Emerg Med. http://www.hawaii.edu/medicine/pediatrics/pemxray/zindex.html. Accessed February 20, 2015. Painter K. Energizer makes button battery packages safer for kids. USA Today. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010. Sharieff GQ, Brousseau TJ, Bradshaw JA, Shad JA. Acute esophageal coin ingestions: is immediate removal necessary? Pediatr Radiol. 2003;33(12):859-863. doi:10.1007/s00247-003-1032-4. Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected Foreign Body Inhalation in Children: What Are the Indications for Bronchoscopy? J Pediatr. 2009;155(2):276-280. doi:10.1016/j.jpeds.2009.02.040. Haliloglu M, Ciftci AO, Oto A, et al. CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration. Eur J Radiol. 2003;48(2):188-192. doi:10.1016/S0720-048X(02)00295-4. Jung SY, Pae SY, Chung SM, Kim HS. Three-dimensional CT with virtual bronchoscopy: a useful modality for bronchial foreign bodies in pediatric patients. Eur Arch Otorhinolaryngol. 2011;269(1):223-228. doi:10.1007/s00405-011-1567-1. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55(3):239-242. doi:10.1097/MPG.0b013e3182687be0. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care. 2013;29(11):1170-1174. doi:10.1097/PEC.0b013e3182a9e7aa. Brown JC, Otjen JP, Drugas GT. Pediatric magnet ingestions: the dark side of the force. Am J Surg. 2014;207(5):754-759; discussion 759. doi:10.1016/j.amjsurg.2013.12.028. Menner AL. Pocket Guide to the Ear: A Concise Clinical Text on the Ear and Its Disorders. Thieme; 2011. Colina D, Dudek S, Lin M. Tricks of the Trade: ENT Dilemmas - How Do I Get That Out of There? ACEP News. http://www.acep.org/Clinical---Practice-Management/Tricks-of-the-Trade--ENT-Dilemmas---How-Do-I-Get-That-Out-of-There-/?__taxonomyid=118010. Published July 2009. Accessed February 5, 2015. Abadir WF, Nakhla V, Chong P. Removal of superglue from the external ear using acetone: case report and literature review. J Laryngol Otol. 1995;109(12):1219-1221. Kadish H. Ear and Nose Foreign Bodies “It is all about the tools.” Clin Pediatr (Phila). 2005;44(8):665-670. doi:10.1177/000992280504400803. Chisholm EJ, Barber-Craig H, Farrell R. Chewing gum removal from the ear using acetone. J Laryngol Otol. 2003;117(4):325. doi:10.1258/00222150360600995. White SJ, Broner S. The use of acetone to dissolve a Styrofoam impaction of the ear. Ann Emerg Med. 1994;23(3):580-582. Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med. 2000;36(3):228-232. doi:10.1067/mem.2000.109166. Bledsoe RD. Magnetically adherent nasal foreign bodies: a novel method of removal and case series. Am J Emerg Med. 2008;26(7):839.e1-e839.e2. doi:10.1016/j.ajem.2008.01.036. Dolderer JH, Kelly JL, Morrison WA, Penington AJ. FOREIGN-BODY RETRIEVAL USING A RARE EARTH MAGNET: Plast Reconstr Surg. 2004;113(6):1869-1870. doi:10.1097/01.PRS.0000119869.01081.1C. Yeh B, Roberson JR. Nasal magnetic foreign body: a sticky topic. J Emerg Med. 2012;43(2):319-321. doi:10.1016/j.jemermed.2010.02.013. Fundakowski CE, Moon S, Torres L. The snare technique: a novel atraumatic method for the removal of difficult nasal foreign bodies. J Emerg Med. 2013;44(1):104-106. doi:10.1016/j.jemermed.2012.07.070. Chan TC, Ufberg J, Harrigan RA, Vilke GM. Nasal foreign body removal. J Emerg Med. 2004;26(4):441-445. doi:10.1016/j.jemermed.2003.12.024. Cook S, Burton M, Glasziou P. Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. Can Med Assoc J. 2012;184(17):E904-E912. doi:10.1503/cmaj.111864. Gregori D, Morra B, Snidero S, et al. Foreign bodies in the upper airways: the experience of two Italian hospitals. J Prev Med Hyg. 2007;48(1):24-26. This post and podcast are dedicated to Linda Dykes, MBBS(Hons) for her can-do attitude and collaborative spirit.  Thank you for sharing your knowledge, experience, and heart with the world.

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad. On arrival, he was in compensated shock, with tachycardia. He decompensates and needs blood. How do we manage his hemodynamics and when do we perform massive transfusion? Pediatric Massive Transfusion 40 mL/kg of blood products given at any time within the first 24 hours. Adolescents and Adult Massive Transfusion 6-8 units of packed red blood cells (PRBCs) Adults have about 5 L of circulating blood. Not including plasma, one could replace all circulating erythrocytes with about 10 units of PRBCS The best ratio of PRBCs:Plasma:Platelets is unknown, but consensus is 1:1:1. 1 unit of PRBCS is typically 300 mL of volume. The typical initial transfusion of PRBCs in children is 10 mL/kg. Massive transfusion in children is defined as 40 mL/kg of any blood product. Once you start to give a child with major trauma the second 10 mL/kg dose of PRBCs – start thinking about other blood components, and ask yourself whether you should initiate your massive transfusion protocol. The goal is to have the products ready to use in the case of the dynamic trauma patient. The Thromboelastogram (TEG) Direct measures the four components of clot formation. When there is endolethial damage and bleeding, the sequence that your body takes to address it is as follows:  Platelets migrate and form a plug Clotting factors aggregate and reinforce the platelets Fibrin arrives an acts like glue Other cells migrate and support the clot. R time – reaction time – the initial line in the tracing that shows time to beginning of clot formation. Treated with platelets K factor – kinetics of the clot –how much the clot allows the pin to move, or the amplitude. Treated with cryoprecipitate Alpha angle – the slope between the R and K measurements – reflects how quickly the fibrin glue is working. Treated with cryoprecipitate Ma – maximum amplitude – reflects the overall strength of the clot. Treated with platelets LY30 – the clot lysis at 30 min – is the decrease in strength of the clot’s amplitude at 30 min. Treated with an antifibrinolytics (tranexamic acid) Shape Recognition Red wine glass: a normal tracing with a normal reaction time and a normal amplitude. That patient just needs support and monitoring. Champagne glass: a coagulopathic TEG tracing – thinned out, with less amplitude. This patient needs specific blood products. Puffer fish or blob: a hyperfibrinolytic tracing. That patient will needs clot-stablizer. TEG – like the FAST – can be repeated as the clinical picture changes. The Trauma Death Spiral Lethal triad of hypothermia, acidosis, and coagulopathy. Keep the patient perfused and warm. Each unit of PRBCs contains 3 g citrate, which binds ionized calcium, causing hypotension. In massive transfusion, give 20 mg/kg of calcium chloride, up to 2 g, over 15 minutes. Calcium chloride is preferred, as it is ionically readily available – just use a larger-bore IV and watch for infiltration. Calcium gluconate could be used, but it requires metabolism into a bioavailable source of calcium. Prothrombin complex concentrate (PCC) Prothrombin complex concentrate (PCC) is derived from pooled human plasma and contains 25-30 times the concentration of clotting factors as FFP. Four-factor PCCs contain factors II, VII, IX and X, while 3-factor PCCs contain little or no factor VII. The typical dose of PCC is 20-50 units/kg In the severely hemorrhaging patient – you don’t have time to wait for the other blood products to thaw – PCC is a powder that is reconstituted instantly at the bedside. Tranexamic acid (TXA) Tranexamic acid (TXA), is an anti-fibrinolytic agent that functions by stopping the activation of plasminogen to plasmin, and the degradation of fibrin. The Clinical Randomisation of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) investigators revealed a significant decrease in death secondary to bleeding when TXA was administered early following trauma. Based on the adult literature, one guideline is to give 15 mg/kg loading dose of TXA with a max 1 g over 10 minutes followed by 2 mg/kg/h for at least 8 h or until bleeding stops. Resuscitative Pearls Our goal here is damage control. Apply pressure whenever possible. Otherwise, resuscitate, identify the bleeding source, and slow or stop the bleeding with blood products or surgery. How Children are Different in Trauma In adults, we speak of “permissive hypotension” (also called “balanced resuscitation” or “damage control resuscitation”). The idea is that if we bring the adult patient’s blood pressure up to normal, we may be promoting clot rupture. To avoid this, we target a MAP of 65 and look for clinical signs of sufficient perfusion. Adults tolerate hypotension relatively well, and is sufficient until we send them to the OR or interventional radiology suite. In children, this is simply not the case. Hypotension in children is a sign of pre-arrest. Remember, they compensate with an increased systemic vascular resistance and tachycardia to maintain blood pressure. We should not allow children to become hypotensive – severe tachycardia alone should prompt us to resuscitate. In other words, permissive hypotension is not permissible for children. FAST is not sensitive enough to rule-out abdominal trauma. Fox et al in Academic Emergency Medicine found a sensitivity of 52%; with a 95% confidence interval [CI] = 31% to 73%. Often children even with high-grade splenic and liver lacerations can be managed non-operatively. If they are supported adequately, they are observed in the ICU and can avoid surgery in many cases. Unfortunately, a negative FAST cannot help with detecting or grading the laceration for non-operative management. In other words, feel free to use ultrasound – especially for things that we in the ED will react to and intervene on – but CT may help to manage the traumatized child non-operatively. General Guideline for Imaging in Pediatric Trauma CT Head and Neck, non-contrast: in concerning mechanisms of injury, patients that are difficult to assess (especially those under 3 months), those with a GCS of 13 or lower. CT Chest, IV contrast: for suspicion of vascular injury that needs exploration, especially in penetrating trauma. Otherwise, chest xray will tell you everything you need to know in children – especially in blunt trauma. Hemo or pneumothoraces are readily picked up by US or CXR. Rib fractures on CXR predict pulmonary contusions. If you are concerned about great vessel injury, then CT Chest may be helpful; otherwise consider omitting it. CT Abdomen and Pelvis, IV contrast: helpful in grading splenic and liver lacerations with goal to manage non-operatively. Abdominal tenderness to palpation, significant bruising, or a seat belt sign are concerning and would generally warrant a CT. Also, consider in liver function test abnormalities, or hematuria. Extremity injuries: in general can be evaluated with physical exam and plain films. However, some injuries in high-risk anatomically complex areas such as the hand and wrist, tibial plateau, and midfoot may be missed by plain films, and CT may be helpful here. Remember: you can help to mitigate post-traumatic stress and risk for adult healthcare aversion. Summary Massive transfusion in children is at 40 mL/kg of total blood products. Think about it if you are giving your second transfusion to the traumatized child. Do everything you can to support perfusion and avoid the death spiral of hypothermia, coagulopathy, and acidosis. Keep the child perfused with blood as needed, correct coagulopathy, avoid too much crystalloid, and make sure to use the least high-tech of all of these interventions – keep him dry and covered with warm blankets. Do a careful physical exam, and use CT selectively with an end-point in mind – the default is not the pan-scan – evaluate possible injuries depending on your suspicions from history, physical, and lab tests. Become familiar with the relatively new modalities in trauma such as TXA, cryoprecipitate and the emerging technology of thromboelestogram – red wine is good for you, champagne is weak, and a puffer fish is trouble. Selected References Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010 Nov;19(4):286-91. doi: 10.1053/j.sempedsurg.2010.07.002. Fox JC, Boysen M, Gharahbaghian L, Cusick S, Ahmed SS, Anderson CL, Lekawa M, Langdorf MI. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82. Harvey V, Perrone J, Kim P. Does the use of tranexamic acid improve trauma mortality? Ann Emerg Med. 2014 Apr;63(4):460-2. Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7. Nosanov L, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013 Nov;206(5):655-60. Ryan ML, Van Haren RM, Thorson CM, Andrews DM, Perez EA, Neville HL, Sola JE, Proctor KG. Trauma induced hypercoagulablity in pediatric patients. J Pediatr Surg. 2014 Aug;49(8):1295-9. Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83. This post and podcast are dedicated to Larry Mellick, MS, MD, FAAP, FACEP. Thank you for your dedication to medical education, and sharing your warm bedside manner, extensive knowledge and talents, and your patient interactions with the world. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP