Podcast appearances and mentions of arch dis child

Welcome to Episode 44 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 44 of “The 2 View” – The Pitt, Cardiac Arrest in Young People, and Influenza Associated Encephalopathy. Segment 1 – Fraud and Conspiracy and Schemes, Oh My! Florida Physician Assistant Pleads Guilty to a $7.3 Million Health Care Fraud Conspiracy. United States Attorney's Office: District of New Hampshire. United States Department of Justice. Justice.gov. December 3, 2024. https://www.justice.gov/usao-nh/pr/florida-physician-assistant-pleads-guilty-73-million-health-care-fraud-conspiracy Nurse Practitioner Sentenced To Five Years In Prison For $11.2 Million Disability Loan Fraud Scheme. United States Attorney's Office: Sothern District of New York. United States Department of Justice. Justice.gov. February 5, 2025. https://www.justice.gov/usao-sdny/pr/nurse-practitioner-sentenced-five-years-prison-112-million-disability-loan-fraud The Board of Certification for Emergency Nursing. BCEN. February 17, 2023. http://www.bcen.org Segment 2 – Prehospital Tourniquet Application Rittblat M, Gendler S, Tsur N, Radomislensky I, Ziv A, Bodas M. The cost of saving lives: Complications arising from prehospital tourniquet application. WILEY Online Library. Acad Emerg Med. December 16, 2024. https://onlinelibrary.wiley.com/doi/10.1111/acem.15070 The Center for Medical Education. 2 View: Emergency medicine PAs & NPs: 41 - RCVS and CVT, CPR Care Science, Prehospital Tourniquets, Blood Pressure. 2 View: Emergency Medicine PAs & NPs. January 22, 2025. https://2view.fireside.fm/41 Segment 3 – Cardiac Arrest in Young People Chia MYC, Lu QS, Rahman NH, et al. Characteristics and outcomes of young adults who suffered an out-of-hospital cardiac arrest (OHCA). NIH: National Library of Medicine – National Center for Biotechnology Information. PubMed. Resuscitation. February 2017. https://pubmed.ncbi.nlm.nih.gov/27923113/ Parekh S. Teen athlete saved after cardiac arrest speaks out: What to know about lifesaving role of CPR, AEDs in schools. GMA. ABC News. September 6, 2024. https://www.goodmorningamerica.com/wellness/story/teen-athlete-saved-after-cardiac-arrest-speaks-lifesaving-113460919 The Center for Medical Education. 2 View: Emergency medicine PAs & NPs: 42 - Pink Cocaine, Holiday Heart Syndrome, Pertussis, Research Updates, and More! 2 View: Emergency Medicine PAs & NPs. February 12, 2025. https://2view.fireside.fm/42 Tseng Z, Nakasuka K. Out-of-Hospital Cardiac Arrest in Apparently Healthy, Young Adults. JAMA Network. Jamanetwork.com. February 20, 2025. https://jamanetwork.com/journals/jama/article-abstract/2830678 Segment 4 – Influenza Associated Encephalopathy Fazal A, Reinhart K, Huang S, et al. Reports of Encephalopathy Among Children with Influenza-Associated Mortality - United States, 2010-11 Through 2024-25 Influenza Seasons. CDC: Morbidity and Mortality Weekly Report (MMWR) Morb Mortal Wkly Rep. February 27, 2025. https://www.cdc.gov/mmwr/volumes/74/wr/mm7406a3.htm Surtees R, DeSousa C. Influenza virus associated encephalopathy. NIH: National Library of Medicine – National Center for Biotechnology Information. PMC: PubMed Central. Arch Dis Child. June 2006. https://pmc.ncbi.nlm.nih.gov/articles/PMC2082798/ Segment 5 – The Pitt Max. The Pitt | official trailer | Max. Accessed March 27, 2025. https://www.youtube.com/watch?v=ufR_08V38sQ The Pitt. Max. Accessed March 27, 2025. https://www.max.com/shows/pitt-2024/e6e7bad9-d48d-4434-b334-7c651ffc4bdf Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Episode 180: Pediatric Hip PainFuture Dr. Pena-Brockett explains the differential diagnosis in a 14-year-old patient who has a new onset of left hip pain. Dr. Arreaza adds comments and explains toxic synovitis.  Written by Natalie Pena-Brockett, MSIV, California Health Sciences University. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Having a limping kid can be terrifying. Many questions may cross your mind: Is this a permanent damage? What is going on here? Where is the pain located? Do I need to send this child to the hospital? Today, hopefully, we can help you ease some of your fears. Case: This is a 14-year-old boy with no past medical history, no trauma, presents to the family medicine clinic with a complaint of left-sided hip pain. Mom notes that her son has been limping for the last week and complaining of pain in his left hip and knee when he walks. He has never experienced this pain before this week. He does not take any medications. Physical exam: He is afebrile and all of his vitals are within normal limits. On exam, you note that his BMI is at the 90th percentile (overweight), and has an antalgic gait where he is favoring the right side and has tenderness on his left groin. His left foot is turned outward while standing up straight. His left knee has negative findings on specialized tests, but he has restricted movement of the left hip. Discussion: This is a common topic that you will see on board exams or limping into your office. Although pediatric hip pain may seem like a benign musculoskeletal concern, taking the time to take a complete history and perform a thorough physical exam is critical to assess the severity of the patient's concern.Physical Exam for Pediatric Hip Pain.Observation: Every physical exam begins the moment you first see the patient. This allows you to gauge the patient's comfort level, the natural stature, length, and positioning of the patient's extremities, skin changes, gait, and ability to bear weight. Palpation: In medicine, our hands are one of our greatest tools for evaluating patients, especially those with musculoskeletal concerns. This is the time to palpate the area for any tenderness or gross deformities of the pelvis, hip, knee, or leg. Special Tests: In the world of MSK, we have all sorts of tests to evaluate the range of movement of our joints and tendons. When specifically evaluating the hip, the most common are the FABER(flexion, abduction, external rotation),test to assess the sacroiliac joint, Ober's Test to assess the iliotibial band, and Straight Leg Raise to assess for lumbar radiculopathy.Legg-Calve Perthes Disease-Legg-Calve Perthes disease is an idiopathic avascular necrosis of the femoral head. -It is most commonly observed in patients between the ages of 2-12 years and in a higher ratio of males to females 1. -It often manifests as an atraumatic limp with limited movement in abduction and internal rotation. -X-ray imaging may demonstrate a widening of the joint space and sclerosis of the femur, and MRI will confirm osteonecrosis of the femoral head. -Early diagnosis is key to minimizing the risk of developing osteoarthritis of the hip. -The goal of treatment is to maintain the shape of the femoral head and the range of motion of the hip. -The first-line treatment includes managing pain with NSAIDs, limiting weight-bearing activity, and physical therapy for range of motion.-If the disease progresses, bracing and casting can be used to retain the femoral head within the acetabulum to keep the shape and integrity of the femoral head. In more serious cases, a surgical osteotomy may be done to cut and realign the bones. Developmental Dysplasia of the Hip (DDH)-Developmental Dysplasia of the Hip (DDH) is a pediatric condition that results in unilateral or bilateral instability of the hip due to the abnormal development of the acetabulum or femur. -This is most commonly seen in newborns, especially those which develop in a breech position. -These patients often present with a shortened leg or asymmetric gluteal creases and a Trendelenburg gait when walking. -The Trendelenburg gait is an abnormal gait caused by weak hip abductor muscles. The person's trunk shifts over the affected hip during the stance phase of walking and away from it during the swing phase, making it look like the person is missing steps or limping. -On physical exam, hip joint laxity can be evaluated with the Ortolani and Barlow maneuvers to apply pressure to the proximal femur to assess dislocatability of the hip joints. These maneuvers would both be considered positive if a “clunk” is felt over the hip as this means that the hip is dislocated with pressure. Due to the patient's age usually being under 6 months old, ultrasound is the most common imaging modality to confirm the diagnosis, otherwise, an X-ray can be used. -The treatment in patients under 18 months old, a Pavlik Harness is often used to treat patients to maintain the placement of the hip within the acetabulum. -Patients between the ages of 18 months and 9 years old, are most often treated with open or closed reduction of the hip. -There is generally less success in reduction treatment of children older than 9 years old as they have likely developed femoral head deformities and are at greater risk of osteonecrosis. -Children with DDH should continue to be monitored with regular imaging to evaluate for complications. These patients should also be made aware that they are also at increased risk of requiring a hip replacement, especially if their treatment included a reduction. 2Slipped Capital Femoral Epiphysis (SCFE)-Slipped Capital Femoral Epiphysis (SCFE) is one of the most common pediatric hip pathologies in which the capital femoral epiphysis is anterolaterally displaced from the femoral neck. -Although slightly more common in males than females between the ages of 10 to 16, the greatest risk factor for an SCFE is childhood obesity 3. -Common symptoms include an insidious onset of unilateral hip pain and a change in gait due to the displacement of the hip from the acetabulum. In some instances of chronic SCFE, some patients will experience ipsilateral knee pain due to compensation. -A SCFE can be evaluated with an AP radiograph which will demonstrate a widened physis in the early stages or the classic “slipped ice cream cone sign” which is the posterior displacement of the femoral epiphysis. -Management of a SCFE includes limiting weight-bearing activities as well as screw fixation by an orthopedic surgeon to stabilize the hip.Patients should consider pinning the contralateral hip due to increased risk of developing a future SCFE. Early diagnosis is critical as untreated SCFE can lead to osteonecrosis.Osgood-Schlatter-Osgood-Schlatter is a repetitive-use pediatric condition as a result of traction to the growth plate of the tibial tubercle. -This pathology is most common in male children between the ages of 9 to 14 years old 4. -Active athletes or children with rapid growth spurts are at greater risk of developing Osgood-Schlatter than non-active children.-These children often present with an achy knee pain that can lead to a unilateral limping gait.  On physical exam, these patients often have a bony prominence over the tubercle that is tender to palpation with greater tenderness over the patellar tendon. -The knee will have full range of motion and stability, but will likely have a warmth and erythema over the knee.  Imaging of the knees can have nonspecific findings and diagnosis is made clinically. -For management, it is recommended that children continue their regular activities and rest with NSAIDs for pain management as needed 5. Physical therapy can be prescribed to prevent deconditioning as this can result in recurrence or additional injuries.Arreaza: It seems like the pain is more localized to the knee, but it can be referred to the hip. If you have tenderness on the tibial tubercle, you got the diagnosis. Juvenile Idiopathic Arthritis (JIA)-Juvenile Idiopathic Arthritis (JIA) is a systemic rheumatologic condition in children that often presents as a polyarticular pain. The onset of disease is often bimodal with peaks between 2 to 5 years old and 10 to 14 years old. 6-Patients will often complain of minor symmetric joint pain and stiffness until an infection causes an inflammatory reaction that exacerbates the joint pain or can increase joint involvement. Small joints are the most likely to be involved, but hips and knees can also be affected. -Lab evaluation will demonstrate inflammation with an elevated ESR, low hemoglobin, and a positive ANA. -Disease management starts with NSAIDS for pain control and can escalate to immunosuppressive measures for moderate disease7.Toxic Synovitis-Toxic synovitis, also known as transient synovitis, is the leading cause of acute hip pain and limping in children aged 2–12, more commonly affecting boys. -This self-limited inflammatory condition, often confused by its name as "toxic," has no relation to a toxic state. It typically arises after an upper respiratory or other viral infection (e.g., rubella or coxsackie virus).-Children with toxic synovitis may show mild to moderate hip pain, limp, and keep their hip in abduction and external rotation. Movement is usually possible within a limited range, and weight-bearing is often maintained.-Evaluation: A thorough history and physical exam are key, as laboratory tests like CBC, ESR, and CRP are often normal, mainly used to rule out other conditions like septic arthritis. X-rays typically show no abnormalities, although small changes may appear. Ultrasound can help detect joint effusion and rule out septic arthritis if no effusion is present.Arreaza: DDX: DDH, SCFE, Osgood Schlatter, and toxic synovitis.Osteopathic Manipulative Treatment in Pediatric Hip PathologiesSacroiliac Articulatory Technique- this is a technique in which you move the joint into an out of its barrier to reduce restriction and improve movementCounterstrain of Tender points (psoas, piriformis, hip adductors)- in this technique we shorten the muscle to decrease tension.  This allows the muscle to increase blood lymphatic flow to reduce nociceptive and proprioceptive activity of the muscleBalanced Ligamentous Tension of the Innominate- with this technique, we manipulate the joint in a way that moves the ligaments into neutral position so that there is balance in all planes of motion.  The goal is to again release tension within the muscles and the jointClinical Decision Making Now that we have covered the most common differential diagnoses for pediatric hip pain, let's revisit our patient presentation and identify the key characteristics to determine which diagnosis he most likely has.The patient is 14 years old.  This makes DDH and Legg-Calve Perthe less likely, and SCFE more likely.He has been complaining of symptoms for 1 week, which indicates that is not likely a chronic condition. This makes DDH and Osgood-Schlatter less likely.The patient has never experienced joint pain like this before.  This makes JIA, DDH, and Osgood-Schlatter less likely.The patient is overweight. This makes SCFE more likely.The unilateral hip tenderness and no knee pain.      This makes Osgood-Schlatter and JIA less likely.The patient has antalgic gait and limited internal rotation of the foot. This makes Legg-Calve Perthes and SCFE more likely. Now when we take the epidemiological factors, the history of the present illness, and the physical exam findings into account, this patient's presentation best aligns with a SCFE. We would order a bilateral AP and Frog-leg views of the hips. If either imaging shows a widened physis or the classic “ice cream cone sign”, this is when we would start the referral process for an orthopedic surgery consultation for internal fixation. As family medicine physicians, we would give instructions for strict non-weight bearing activities and analgesics or anti-inflammatories for pain management.Keep in mind some of the DDX: Calve Legg-Perthes disease, Developmental Dysplasia of the Hip (DDH), Juvenile Idiopathic Arthritis (JIA), Osgood Schlatter, toxic synovitis, and Slipped Capital Femoral Epiphysis (SCFE). Hopefully, the next time you have a pediatric patient present with a complaint of hip pain, you'll feel more comfortable evaluating and working up the case._________________________This week we thank Hector Arreaza and Natalie Pena-Brockett. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Osteonecrosis of the femoral head / Legg-Calvé-Perthes disease | Time of Care. Accessed October 27, 2024. https://www.timeofcare.com/osteonecrosis-of-the-femoral-head-legg-calve-perthes-disease/Scott EJ, Dolan LA, Weinstein SL. Closed Vs. Open Reduction/Salter Innominate Osteotomy for Developmental Hip Dislocation After Age 18 Months: Comparative Survival at 45-Year Follow-up. J Bone Joint Surg Am. 2020;102(15):1351-1357. doi:10.2106/JBJS.19.01278. https://europepmc.org/article/med/32769602Perry DC, Metcalfe D, Costa ML, Van Staa T. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child. 2017;102(12):1132-1136. doi:10.1136/archdischild-2016-312328. https://pubmed.ncbi.nlm.nih.gov/28663349/Haines M, Pirlo L, Bowles K-A, Williams CM. Describing Frequencies of Lower-Limb Apophyseal Injuries in Children and Adolescents: A Systematic Review. Clin J Sport Med. 2022;32(4):433-439. doi:10.1097/JSM.0000000000000925. https://pubmed.ncbi.nlm.nih.gov/34009802/Wall EJ. Osgood-Schlatter disease: practical treatment for a self-limiting condition. Phys Sportsmed. 1998;26(3):29-34. doi:10.3810/psm.1998.03.802. https://pubmed.ncbi.nlm.nih.gov/20086789/Oberle EJ, Harris JG, Verbsky JW. Polyarticular juvenile idiopathic arthritis - epidemiology and management approaches. Clin Epidemiol. 2014;6:379-393. doi:10.2147/CLEP.S53168. https://pubmed.ncbi.nlm.nih.gov/25368531/Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken). 2011;63(4):465-482. doi:10.1002/acr.20460. https://pubmed.ncbi.nlm.nih.gov/21452260/Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-393 Overview: Adolescents seeking hormonal treatment for gender incongruence has become more common. A recent systematic review looking at the benefits and side effects found in clinical studies updates our current understanding of this approach. Gain insights and confidence to make informed and compassionate care decisions. Episode resource links: Taylor J, Mitchell A, Hall R, Langton T, Fraser L, Hewitt CE. Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence: a systematic review. Arch Dis Child. 2024 Apr 9:archdischild-2023-326670. Coleman E, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-S259.  Gender Affirming Hormonal Care for the Primary Care Provider Thriving for Transgender Youth Update on Trans-Competent Primary Care Guest: Alan M. Ehrlich, MD, FAAFP Thoughts? Suggestions? Email us at FranklySpeaking@pri-med.com  Music Credit: Richard Onorato

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-393 Overview: Adolescents seeking hormonal treatment for gender incongruence has become more common. A recent systematic review looking at the benefits and side effects found in clinical studies updates our current understanding of this approach. Gain insights and confidence to make informed and compassionate care decisions. Episode resource links: Taylor J, Mitchell A, Hall R, Langton T, Fraser L, Hewitt CE. Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence: a systematic review. Arch Dis Child. 2024 Apr 9:archdischild-2023-326670. Coleman E, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-S259.  Gender Affirming Hormonal Care for the Primary Care Provider Thriving for Transgender Youth Update on Trans-Competent Primary Care Guest: Alan M. Ehrlich, MD, FAAFP Thoughts? Suggestions? Email us at FranklySpeaking@pri-med.com  Music Credit: Richard Onorato

In this Complex Care Journal Club podcast episode, Dr. Lorna Fraser discusses the results of a prospective cohort study comparing outcomes for children receiving home blends vs formula via gastrostomy tube. She describes the central role of patients and families in study design, opportunities for ensuring equitable access to blended diets, and next steps from this work. SPEAKER Lorna Fraser, PhD, MBChB, MRCPCH, MSc, MMedSci Professor of Palliative Care and Child Health, Cicely Saunders Institute and School of Life Sciences and Population Health King's College London HOST Kathleen Huth, MD, MMSc Pediatrician, Complex Care Service, Division of General Pediatrics Boston Children's Hospital Assistant Professor of Pediatrics Harvard Medical School DATES Initial Publication date: April 8, 2024 JOURNAL ARTICLES Journal Club Article Citations Fraser LK, Bedendo A, O'Neill M, Taylor J, Hackett J, Horridge KA, Cade J, Richardson G, Phung H, McCarter A, Hewitt CE. Safety, resource use and nutritional content of home-blended diets in children who are gastrostomy fed: Findings from 'YourTube' - a prospective cohort study. Arch Dis Child. 2023 Dec 21:archdischild-2023-326393. doi: 10.1136/archdischild-2023-326393. Fraser LK, Bedendo A, O'Neill M, Taylor J, Hackett J, Horridge K, Cade J, Richardson G, Phung H, Mccarter A, Hewitt C. 'YourTube' the role of different diets in gastrostomy-fed children: Baseline findings from a prospective cohort study. Dev Med Child Neurol. 2023 Nov 10. doi: 10.1111/dmcn.15799. OTHER REFERENCES Hron B, Fishman E, Lurie M, Clarke T, Chin Z, Hester L, Burch E, Rosen R. Health Outcomes and Quality of Life Indices of Children Receiving Blenderized Feeds via Enteral Tube. J Pediatr. 2019 Aug;211:139-145.e1. doi: 10.1016/j.jpeds.2019.04.023. Epub 2019 May 23. PMID: 31128885; PMCID: PMC6660979. Maddison J, Taylor J, O'Neill M, Cade J, Hewitt C, Horridge K, McCarter A, Fraser LK, Beresford B. Outcomes for gastrostomy-fed children and their parents: qualitative findings from the 'Your Tube' study. Dev Med Child Neurol. 2021 Sep;63(9):1099-1106. doi: 10.1111/dmcn.14868. Epub 2021 Apr 1. PMID: 33792913. University of York. YourTube: Home blended diets for children who are gastrostomy fed. Infographic. Accessed March 13, 2024. https://www.york.ac.uk/media/healthsciences/images/research/phs/mhrc/Yourtube%20-%200102%20Infographic%20print.pdf University of York. YourTube for parent/healthcare professional. YouTube. January 19, 2024. Accessed March 13, 2024. https://youtu.be/5POi2Cjp8og University of York. YourTube for young people. YouTube. January 19, 2024. Accessed March 13, 2024. https://youtu.be/NlVriI0O-oI TRANSCRIPT chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://op-docebo-images.s3.amazonaws.com/Transcripts/Building+the+Evidence+for+Blended+Diets_Fraser_040824.pdf Clinicians across healthcare professions, advocates, researchers, and patients/families are all encouraged to engage and provide feedback! You can recommend an article for discussion using this form: https://forms.gle/Bdxb86Sw5qq1uFhW6 Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children's Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open access-and thus at no expense to the user.For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu CITATION Fraser L, Huth K. Building the Evidence for Blended Diets: Benefits and Barriers to Access. 4/2024. OPENPediatrics. Online Podcast. https://on.soundcloud.com/pcQSrJTHvF4H4yiY6

Welcome to the 9th & SPECIAL EASTER EPISODE of the BSCOS Paediatric Orthopaedic Digest (POD)cast with our Adam Galloway @GallowayAdam -  Physiotherapist and lead of the @BSCOS_UK AHP Committee! Adam qualified in 2013, and has always had a firm interest in paediatric orthopaedics with an MSc in Clinical Research Methods. His name is well known in the UK, working with the team in Leeds @Kidsortho_leeds and as an NIHR funded PhD investigating the non-surgical treatment of Perthes' Disease @NONSTOPPhD !!! Listen in to the episode to learn more!   We scoured 35 journals & highlighted the most impactful studies that we feel can change practice or improve outcomes in Paediatric Orthopaedics.  Follow Updates on @BSCOS_UK    REFERENCES:   1.    Health-related Quality of Life in Idiopathic Toe Walkers: A Multicenter Prospective Cross-sectional Study. Morrow et al. J Pediatr Orthop. Apr 2024 PMID: 38273462   2.    The effect of Sildenafil, a phosphodiesterase-5 inhibitor, on tendon healing: an experimental study in rat model of achilles tendon injury. Kurt et al. Arch Orthop Trauma Surg. March 2024. PMID: 38148369   3.    Is percutaneous Achilles tendon lengthening safe and effective for older children with idiopathic toe walking? Kha et al. J POSNA. Feb 2024  DOI: https://doi.org/10.1016/j.jposna.2024.100021   4.    Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient-Reported Outcomes but Less Donor-Site Morbidity Compared With Gracilis Tendon Autograft. Runer et al. Arthroscopy. Feb 2024  PMID: 37479150   5.    Incidence of Skin Sensitivity Following Dermabond Application in Pediatric Orthopedic Surgery. Kortiz et al. J Pediatr Orthop. Feb 2024. PMID: 37820062   6.    Wait-and-scan: an alternative for curettage in atypical cartilaginous tumours of the long bones. Scholte et al. Bone Joint J. Jan 2024. PMID: 38160684   7.    The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial. Larsen et al. J Bone Joint Surg Am. Feb 2024. PMID: 37973031   8.    Rate and Risk Factors for Contralateral Slippage in Adolescents Treated for Slipped Capital Femoral Epiphysis: A Comprehensive Analysis of 3,528 Cases. Momtaz et al. J Bone Joint Surg Am. March 2024. PMID: 38271486   9.    MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum. Bachman et al. Am J Sports Med. March 2024. PMID: 38349668.   10. Trends in inequalities in childhood overweight and obesity prevalence: a repeat cross-sectional analysis of the Health Survey for England. Broadbent et al. Arch Dis Child. Feb 2024. PMID: 38262695   11. Reapplication of the Pavlik Harness for Treatment of Developmental Dysplasia of the Hip After Initial Pavlik Harness Failure. Tomaru et al. J Pediatr Orthop. Feb 2024. PMID: 37981894   12. Skin Antisepsis before Surgical Fixation of Extremity Fractures. he PREP-IT Investigators. N Engl J Med. Feb 2024. PMID: 38294973     Follow Hosts: @AnishPSangh @AlpsKothari @Pranai_B See those of you travelling at EPOSNA 2024 in Washington DC!!!

Welcome to our festive 2023 Episode 8 of the BSCOS Paediatric Orthopaedic Digest (POD)cast with our legendary guest Professor Deborah Eastwood @deboraheastwood from Great Ormond Street Hospital @GreatOrmondSt & Royal National Orthopaedic Hospital @RNOHnhs ! She is the biggest name in paediatric orthopaedics – as recent President of the British Orthopaedic Association @BritOrthopaedic - previous President of the European Paediatric Orthopaedic Society as well as a great researcher, clinician and teacher, having been awarded Trainer of the Year a number of times!!! She has a wealth of knowledge on policy and keen to help promote diversity in orthopaedics @orthodiversity as well as championing sustainability.    We scoured 35 journals & highlighted the most impactful studies that we feel can change practice or improve outcomes in Paediatric Orthopaedics.  Follow Updates on @BSCOS_UK    REFERENCES:   1.     Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage? Morris et al. Bone Joint J. Dec 2023 PMID: 38035597   2.     Test of stability as an aid to decide the need for osteotomy in association with open reduction in developmental dysplasia of the hip. Zadeh et al. J Bone Joint Surg Br. Jan 2000 PMID: 10697309.   3.     Soft Tissue Releases With Simultaneous Guided Growth Decrease Risk of Spastic Hip Displacement Recurrence. Hsu et al. J Pediatr Orthop. Oct 2023 PMID: 37493018   4.     Fatigue-related gait adaptations in children with cerebral palsy. Oudenhoven et al. Dev Med Child Neurol. Dec 2023. PMID: 37243486.   5.     Understanding caregiver experiences with disease-modifying therapies for spinal muscular atrophy: a qualitative study. Xiao L et al. Arch Dis Child. Nov 2023. PMID: 37419673.   6.     Kleidon TM et al. Midline Compared With Peripheral Intravenous Catheters for Therapy of 4 Days or Longer in Pediatric Patients: A Randomized Clinical Trial. JAMA Pediatr. Nov 2023. PMID: 37695594   7.     The Right Way to Teach Lefties - Exploring the Experiences of Left-Handed Trainees and Surgeons. Brooks et al. J Surg Educ. Nov 2023. PMID: 37563001.   8.     Changes Induced by Early Hand-Arm Bimanual Intensive Therapy Including Lower Extremities in Young Children With Unilateral Cerebral Palsy: A Randomized Clinical Trial. Araneda et al. JAMA Pediatr. Nov 2023. PMID: 37930692   9.     Analysis of Growth After Transphyseal Anterior Cruciate Ligament Reconstruction in Children. Bolzinger M et al. J Pediatr Orthop. Oct 2023. PMID: 37522467.   10.  Collagenase treatment decreases muscle stiffness in cerebral palsy: A preclinical ex vivo biomechanical analysis of hip adductor muscle fiber bundles. Howard JJ et al. Dev Med Child Neurol. Dec 2023. PMID: 37198748   11.  HipScreen mobile app for the measurement of hip migration percentage in children with cerebral palsy: Accuracy, reliability, and discriminatory ability. Kulkarni et al. Dev Med Child Neurol. Nov 2023. PMID: 37143284   12. AI = Appropriate Insight? ChatGPT Appropriately Answers Parents' Questions for Common Pediatric Orthopaedic Conditions. Zusman NL et al. J POSNA. Nov 2023. https://jposna.org/index.php/jposna/article/view/762/920     Follow Hosts: @AnishPSangh @AlpsKothari @Pranai_B Hope you all have a fantastic festive period and see you all in 2024!!! Sign up to BSCOS Annual Meeting in Leeds March 2024 at https://www.miceorganiser.com/bscos2024  

Should I take ADHD medication and supplements?This week, I'm discussing this all-important subject.After an ADHD diagnosis, one of the first things we think about is whether or not to try medication.This is a big topic. And each person is different. So, join me as we navigate ADHD medication in adulthood - the pros, cons and alternatives. I must clarify that I am a coach. I'm also somebody who takes ADHD medication. But I am not a doctor. I am not a psychiatrist, psychologist or nutritionist. None of the information in this podcast should be used to make any decisions about your treatment. Always consult with a qualified professional who deals specifically with the topic that you are facing right now.Here are the highlights: (3:47) The effects of ADHD medication(10:17) ADHD medication and supplements(16:47) Responsible use of medication(24:17) The pros and cons of ADHD medicationMedication - explainer articles:Main kinds of medication:https://www.understood.org/en/articles/how-adhd-medication-worksNon-stimulant medication:https://www.verywellmind.com/non-stimulant-adhd-medication-20884New triple reuptake inhibitor medication:https://www.drugtopics.com/view/novel-adhd-therapy-more-tolerable-less-effective-than-current-treatment-options#Safely using Omega 3:https://www.additudemag.com/adhd-and-fish-oil-supplements-whats-a-safe-dosage/#:~:text=Although%20one%20Japanese%20study%20gave,3%20intake%20to%20that%20level.Fish oil or medication study:https://www.kcl.ac.uk/omega-3-fish-oil-as-effective-for-attention-as-drugs-for-some-children-with-adhdExercise:https://lightbulbadhd.com/blog/adhd-and-exercise-xPF6jhttps://www.additudemag.com/the-adhd-exercise-solution/Mehren A, Reichert M, Coghill D, Müller HHO, Braun N, Philipsen A. Physical exercise in attention deficit hyperactivity disorder - evidence and implications for the treatment of borderline personality disorder. Borderline Personal Disord Emot Dysregul. 2020 Jan 6;7:1. doi: 10.1186/s40479-019-0115-2. PMID: 31921425; PMCID: PMC6945516.Sleep:https://lightbulbadhd.com/blog/adhd-and-sleep-problems-in-adultshttps://www.sleepfoundation.org/mental-health/adhd-and-sleepCommunity:Harpin, VA The effect of ADHD on the life of an individual, their family, and community from preschool to adult life, Arch Dis Child 2005;90(Suppl I):i2–i7. doi: 10.1136/adc.2004.059006

Nocturnal enuresis is a common problem for pediatric patients that can be quite distressing for children as well as their parents. In this episode join Madeline Snipes, a medical student at the Medical College of Georgia as she discusses nocturnal enuresis with Chief of Pediatric Urology at the Children's Hospital of Georgia, Dr. Bradley Morganstern, and Associate Professor of Pediatrics, Dr. Susan Goldberg, on an overview of nocturnal enuresis. Specifically, they will review:  • The definition of nocturnal enuresis and its basic epidemiology.   • The potential causes of nocturnal enuresis.   • The appropriate workup for a pediatric patient with nocturnal enuresis.   • When referral to a pediatric urologist is indicated.   • The various treatment options for a pediatric patient with nocturnal enuresis.   • And finally the potential sequelae that may result from untreated nocturnal enuresis.  Special thanks to Dr. Jordan Gitlin, pediatric urologist at NYU's Winthrop Hospital, and Dr. Shreeti Kapoor, general pediatrician and associate professor of pediatric medicine at the Medical College of Georgia at Augusta University.  FREE CME Credit (requires free sign-up):  Link coming soon! References: 1. Nevéus T, Fonseca E, Franco I, et al. Management and treatment of nocturnal enuresis—an updated standardization document from the International Children's Continence Society. Journal of Pediatric Urology. 2020;16(1):10-19. doi:10.1016/j.jpurol.2019.12.020  2. Järvelin MR, Vikeväinen-Tervonen L, Moilanen I, Huttunen NP. Enuresis in seven-year-old children. Acta paediatrica Scandinavica. 1988;77(1):148-153. doi:10.1111/j.1651-2227.1988.tb10614.  3. de Sena Oliveira AC, Athanasio B da S, Mrad FC de C, et al. Attention deficit and hyperactivity disorder and nocturnal enuresis co-occurrence in the pediatric population: a systematic review and meta-analysis. Pediatric Nephrology. 2021;36(11):3547-3559. doi:10.1007/s00467-021-05083-y  4. Forsythe WI, Redmond A. Enuresis and spontaneous cure rate. Study of 1129 enuretis. Arch Dis Child. 1974;49(4):259-263. doi:10.1136/adc.49.4.259  5. von Gontard A, Mauer-Mucke K, Plück J, Berner W, Lehmkuhl G. Clinical behavioral problems in day- and night-wetting children. Pediatr Nephrol. 1999;13(8):662-667. doi:10.1007/s004670050677  6. Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med. 2009;360(14):1429-1436. doi:10.1056/NEJMcp0808009  7. Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int. 2006;97(5):1069-1073. doi:10.1111/j.1464-410X.2006.06074.x  8. Sá CA, Martins de Souza SA, Villela MCBVA, et al. Psychological Intervention with Parents Improves Treatment Results and Reduces Punishment in Children with Enuresis: A Randomized Clinical Trial. J Urol. 2021;205(2):570-576. doi:10.1097/JU.0000000000001351  9. Jackson EC. Nocturnal enuresis: giving the child a "lift". J Pediatr. 2009;154(5):636-637. doi:10.1016/j.jpeds.2009.01.041  10. Plaire JC, Pope JC 4th, Kropp BP, et al. Management of ectopic ureters: experience with the upper tract approach. J Urol. 1997;158(3 Pt 2):1245-1247.  11. Alnatour IM, Alnashrati T. Nocturnal Enuresis. Middle East Journal of Family Medicine. 2022;20(7):127-131. doi:10.5742/MEWFM.2022.9525106  12. van Summeren JJGT, Holtman GA, van Ommeren SC, Kollen BJ, Dekker JH, Berger MY. Bladder Symptoms in Children With Functional Constipation: A Systematic Review. J Pediatr Gastroenterol Nutr. 2018;67(5):552-560. doi:10.1097/MPG.0000000000002138  13. Brownrigg N, Braga LH, Rickard M, et al. The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial. J Pediatr Urol. 2017;13(4):374.e1-374.e8. doi:10.1016/j.jpurol.2017.06.005 

Did you know that household Tylenol is one of the most common causes of both intentional and unintentional toxicity in the pediatric population? Dr. George Hsu, a Pediatric Emergency Physician, joins Dr. Rebecca Yang and Medical Students Morgan Franklin and Ifrah Waris to discuss the evaluation and management for acetaminophen overdose in a pediatric patient.  Specifically, they will:  Review the basic assessment skills and evaluation for a child presenting with a potential acetaminophen overdose Discuss the diagnostic options and monitoring of acetaminophen overdose Discuss how to use the Rumack-Matthew nomogram in the treatment of acetaminophen overdose Medications and treatments reviewed: N-acetylcysteine, activated charcoal, and gastric lavage Discuss the potential complications of acetaminophen overdose Special thanks to Dr. Rebecca Yang and Dr. Arden Conway for peer reviewing this episode. Special thanks to Dr. Rebecca Yang and Dr. Arden Conway for peer reviewing the discussion today.  FREE CME Credit (requires free sign-up): Link Coming Soon! References:  Agrawal S, Khazaeni B. Acetaminophen Toxicity. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441917/ Heard K. J. (2008). Acetylcysteine for acetaminophen poisoning. The New England journal of medicine, 359(3), 285–292. https://doi.org/10.1056/NEJMct0708278 Hinson JA. Mechanism of acetaminophen-induced liver toxicity. In: Kaplowitz N, DeLeve LD, eds. Drug-Induced Liver Disease. 3rd ed. London, England: Academic Press; 2013:305-330. Hon KL, Hui WF, Leung AKC. Antidotes for childhood toxidromes. Drugs in Context 2021; 10: 2020-11-4. DOI: 10.7573/dic.2020-11-4 Greene SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. Postgrad Med J. 2005 Apr;81(954):204-16. doi: 10.1136/pgmj.2004.024794. PMID: 15811881; PMCID: PMC1743253. Lee J, Fan NC, Yao TC, Hsia SH, Lee EP, Huang JL, Wu HP. Clinical spectrum of acute poisoning in children admitted to the pediatric emergency department. Pediatr Neonatol. 2019 Feb;60(1):59-67. doi: 10.1016/j.pedneo.2018.04.001. Epub 2018 Apr 19. PMID: 29748113. Manov I, Motanis H, Frumin I, Iancu TC. Hepatotoxicity of anti-inflammatory and analgesic drugs: ultrastructural aspects. Acta Pharmacol Sin. 2006 Mar;27(3):259-72. doi: 10.1111/j.1745-7254.2006.00278.x. PMID: 16490160. Myers WC, Otto TA, Harris E, Diaco D, Moreno A. Acetaminophen overdose as a suicidal gesture: a survey of adolescents' knowledge of its potential for toxicity. J Am Acad Child Adolesc Psychiatry. 1992 Jul;31(4):686-90. doi: 10.1097/00004583-199207000-00016. PMID: 1644732. Park, B. K., Dear, J. W., & Antoine, D. J. (2015). Paracetamol (acetaminophen) poisoning. BMJ clinical evidence, 2015, 2101. Riordan M, Rylance G, Berry K. Poisoning in children 2: painkillers. Arch Dis Child. 2002 Nov;87(5):397-9. doi: 10.1136/adc.87.5.397. PMID: 12390909; PMCID: PMC1763068. Silberman J, Galuska MA, Taylor A. Activated Charcoal. [Updated 2022 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482294/ Shekunov, J., Lewis, C. P., Vande Voort, J. L., Bostwick, J. M., & Romanowicz, M. (2021). Clinical Characteristics, Outcomes, Disposition, and Acute Care of Children and Adolescents Treated for Acetaminophen Toxicity. Psychiatric Services, appi-ps. Sheridan DC, Hendrickson RG, Lin AL, Fu R, Horowitz BZ. Adolescent Suicidal Ingestion: National Trends Over a Decade. J Adolesc Health. 2017 Feb;60(2):191-195. doi: 10.1016/j.jadohealth.2016.09.012. Epub 2016 Nov 23. PMID: 27889404. Silberman J, Galuska MA, Taylor A. Activated Charcoal. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482294/ Runde TJ, Nappe TM. Salicylates Toxicity. [Updated 2021 Jul 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499879/ Yarema M, Chopra P, Sivilotti MLA, Johnson D, Nettel-Aguirre A, Bailey B, Victorino C, Gosselin S, Purssell R, Thompson M, Spyker D, Rumack B. Anaphylactoid Reactions to Intravenous N-Acetylcysteine during Treatment for Acetaminophen Poisoning. J Med Toxicol. 2018 Jun;14(2):120-127. doi: 10.1007/s13181-018-0653-9. Epub 2018 Feb 8. Erratum in: J Med Toxicol. 2018 Mar 12;: PMID: 29423816; PMCID: PMC5962465.  

Welcome to the podcast with Dr. Brendan McCarthy! In this episode we go over, why are testosterone levels decreasing? and what can we do moving forward? This is part 1 of a 3 part series. Dr. Brendan McCarthy founded Protea Medical Center in 2002. While he's been the chief medical officer, Protea has grown and evolved into a dynamic medical center serving the Valley and Central Arizona. A nationally recognized as an expert in hormone replacement therapy, Dr McCarthy s the only instructor in the nation who teaches BioHRT on live patients. Physicians travel to Arizona to take his course and integrate it into their own practices. Besides hormone replacement therapy, Dr. McCarthy has spoken nationally and locally before physicians on topics such as weight loss, infertility, nutritional therapy and more. Thank you for tuning in and don't forget to hit that SUBSCRIBE button! Let us know in the COMMENTS if you have any questions or what you may want Dr. McCarthy to talk about next! Check out Dr. Brendan McCarthy's Book! https://www.amazon.com/Jump-Off-Mood-Swing-Hormones/dp/0999649604 --More Links-- Instagram: www.instagram.com/drbrendanmccarthy TikTok: www.tiktok.com/drbrendanmccarthy Clinic Website: www.protealife.com Cited Links: 7:00 & 8:32 • Elliott, Christopher S., et al. "Epidemiologic trends in penile anomalies and hypospadias in the state of California, 1985–2006." Journal of pediatric urology 7.3 (2011): 294-298. • Nelson CP, Park JM, Wan J, et al. The increasing incidence ofcongenital penile anomalies in the United States. J Urol 2005;174:1573e6 • Nassar N, Bower C, Barker A. Increasing prevalence of hypospadias in Western Australia, 1980e2000. Arch Dis Child 2007;92:580e4 • Aho M, Koivisto AM, Tammela TL, et al. Is the incidence of hypospadias increasing? analysis of Finnish hospital discharge data 1970e1994. Environ Health Perspect 2000;108:463e5 12:30 - Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone treatment on body composition and muscle strength in men over 65 years of age. J Clin Endocrinol Metab. 1999;84[8]:2647-2653 14:06 - Azad et al., 2003. Azad N, Pitale S, Barnes WE, Friedman N: Testosterone treatment enhances regional brain perfusion in hypogonadal men. J Clin Endocrinol Metab 2003; 88:3064-3068. 30:12 - Layton JB, Li D, Meier CR, et al. Testosterone lab testing and initiation in the United Kingdom and the United States, 2000 to 2011. J Clin Endocrinol Metab. 2014;99(3):835-842 - Layton JB, Kim Y, Alexander GC, Emery SL. Association Between Direct-toConsumer Advertising and Testosterone Testing and Initiation in the United States, 2009-2013. JAMA. 2017;317(11):1159–1166. doi:10.1001/jama.2016.21041   #lowtestosterone #testosterone #menshealth #erectiledysfunction #libido #testosteronebooster #testosteronereplacementtherapy #testosteronetherapy #hormonereplacementtherapy

Welcome to Episode 4 of the BSCOS Paediatric Orthopaedic Digest (POD)cast with guest Ms Claire Murnaghan (@cfmurn) from Royal Children's Hospital Glasgow. We scoured 35 journals & highlighted the most impactful studies that we feel can change practice or improve outcomes in Paediatric Orthopaedics. Follow Updates on @BSCOS_UK REFERENCES: 1. Cast revision is effective for critical three-point index values in paediatric forearm fractures: a prospective study. Subasi et al. J Pediatr Orthop B. Sept 2022. PMID 35132001 2. Concordance of SARS-CoV-2 Results in Self-collected Nasal Swabs vs Swabs Collected by Health Care Workers in Children and Adolescents. Waggoner et al. JAMA. PMID 36018570 3. Effectiveness of an intervention for reducing sitting time and improving health in office workers: three arm cluster randomised controlled trial. Edwarson et al. BMJ. Aug 2022. PMID 35977732 4. High recall bias in retrospective assessment of the pediatric International Knee Documentation Committee Questionnaire (Pedi-IKDC) in children with knee pathologies. Macchiarola et al., KSSTA. Oct 2022. PMID 35218375 5. Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group. Am J Sports Med. Sept 2022. PMID 35984091 6. Efficacy and Safety of "Sleeper Plate" in Temporary Hemiepiphysiodesis and the Observation of "Tethering". Gerges et al. J Pediatr Orthop. Aug 2022. PMID 35605208 7. Walking activity after multilevel orthopedic surgery in children with cerebral palsy. Church et al. Dev Med Child Neurol. Oct 2022. PMID 35338776 8. Closed reduction and percutaneous pinning versus open reduction and internal fixation for Jakob type 3 lateral condyle fractures in children. Liu et al. Int Orthop. Oct 2022. PMID 35723700 9. 8 out of 10 patients do well after surgery for tarsal coalitions: A systematic review on 1284 coalitions. Hollander et al. Foot Ankle Surg. Oct 2022. PMID 35397990 10. Trends in weight loss attempts among children in England. Ahmad et al. Arch Dis Child. July 2022. PMID 35851294 11. Clinically Detected Leg Length Discrepancy in Patients With Idiopathic Clubfoot Deformity: Prevalence and Outcomes. Addar & Bouchard. J Pediatr Orthop. Aug 2022. PMID 35543605 12. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Perry et al. Lancet. July 2022. PMID 35780790 Follow Hosts: @AnishPSangh @AlpsKothari @Pranai_B

By the end of this two-part series, listeners will be able to:Verbalize a more progressive definition of palliative care, and distinguish it from "end-of-life" care or hospice care.Define appropriate patient populations for referral to palliative care.Sensitively and clearly introduce palliative care referral with patients and families. Recognize the value of communication training, and verbalize a simple framework for difficult conversations. Define the challenges of learning/practicing difficult communication as a resident/fellow, and elaborate some strategies to help mitigate these challenges. About our guests: Stockton Beveridge, M.D., is an Assistant Professor in the Department of Pediatrics in the Division of Developmental / Behavioral Pediatrics, serving as the director of Pediatric Palliative Care. Dr. Beveridge's research interests have focused on the challenges faced by caregivers of children with medical complexity, particularly in the Latino population. He is additionally interested in the intersection of religion and medicine, particularly in medical crisis. He sits on the hospital's Ethics Committee and is also the medical director for Schwartz Rounds.Katie Maddox, M.D., is an Assistant Professor in the Department of Pediatrics in the Division of Developmental / Behavioral Pediatrics at UT Southwestern. She is a board-certified pediatric palliative care physician at Children's Health Dallas. Her clinical and research interests relate to caring for children with special healthcare needs and communication skills training in medical education. Dr. Maddox has received the Educational Innovation Award for developing communication skills training and the Pediatric Society of Greater Dallas White Hat Award.References:Center to Advance Palliative Care--https://www.capc.org/ Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. J Oncol Pract. 2017 Oct;13(10):e844-e850. doi: 10.1200/JOP.2016.018796. Epub 2017 Apr 26. PMID: 28445100.Gillis J. "We want everything done". Arch Dis Child. 2008 Mar;93(3):192-3. doi: 10.1136/adc.2007.120568. PMID: 18319382.How to support PedsCrit:Please rate and review on Spotify or Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.Support the show

By the end of this two-part series, listeners will be able to:Verbalize a more progressive definition of palliative care, and distinguish it from "end-of-life" care or hospice care.Define appropriate patient populations for referral to palliative care.Sensitively and clearly introduce palliative care referral with patients and families. Recognize the value of communication training, and verbalize a simple framework for difficult conversations. Define the challenges of learning/practicing difficult communication as a resident/fellow, and elaborate some strategies to help mitigate these challenges. About our guests: Stockton Beveridge, M.D., is an Assistant Professor in the Department of Pediatrics in the Division of Developmental / Behavioral Pediatrics, serving as the director of Pediatric Palliative Care. Dr. Beveridge's research interests have focused on the challenges faced by caregivers of children with medical complexity, particularly in the Latino population. He is additionally interested in the intersection of religion and medicine, particularly in medical crisis. He sits on the hospital's Ethics Committee and is also the medical director for Schwartz Rounds. Katie Maddox, M.D., is an Assistant Professor in the Department of Pediatrics in the Division of Developmental / Behavioral Pediatrics at UT Southwestern. She is a board-certified pediatric palliative care physician at Children's Health Dallas. Her clinical and research interests relate to caring for children with special healthcare needs and communication skills training in medical education. Dr. Maddox has received the Educational Innovation Award for developing communication skills training and the Pediatric Society of Greater Dallas White Hat Award.References: Center to Advance Palliative Care--https://www.capc.org/  Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. J Oncol Pract. 2017 Oct;13(10):e844-e850. doi: 10.1200/JOP.2016.018796. Epub 2017 Apr 26. PMID: 28445100.Gillis J. "We want everything done". Arch Dis Child. 2008 Mar;93(3):192-3. doi: 10.1136/adc.2007.120568. PMID: 18319382.How to support PedsCrit:Please rate and review on Spotify or Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.Support the show

True anaphylactic shock can be one of the most harrowing calls in all of EMS and emergency medicine. However, as is true with much of our core clinical content, dogma and myths persist. MCHD District Chief Spencer Hall joins the podcast crew to discuss anaphylaxis diagnostic criteria, treatment, and much more. REFERENCES 1. Anagnostou K, Turner PJ. Myths, facts, and controversies in the diagnosis and management of anaphylaxis. Arch Dis Child. 2019 Jan;104(1):83-90. 2. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000 Aug;30(8):1144-50. 3. Prince BT, Mikhail I, Stukus DR. Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy. 2018 Jun 20;11:143-151.

Dr. José Campos is back, this time helping us review some of the latest literature on the diagnosis and management of CPAM in children. In this podcast, we're reviewing a typical case with Dr. Todd Ponsky and incorporating literature from the last few years. Hosts: Rod Gerardo and Ellen Encisco Articles if you want to follow along; Kunisaki SM, Lal DR, Saito JM, Fallat ME, St Peter SD, Fox ZD, Heider A, Chan SS, Boyd KP, Burns RC, Deans KJ, Gadepalli SK, Hirschl RB, Kabre R, Landman MP, Leys CM, Mak GZ, Minneci PC, Wright TN, Helmrath MA; MIDWEST PEDIATRIC SURGERY CONSORTIUM. Pleuropulmonary Blastoma in Pediatric Lung Lesions. Pediatrics. 2021 Apr;147(4):e2020028357. doi: 10.1542/peds.2020-028357. Epub 2021 Mar 24. PMID: 33762310. https://pubmed.ncbi.nlm.nih.gov/33762310/ Jelin EB, O'Hare EM, Jancelewicz T, Nasr I, Boss E, Rhee DS. Optimal timing for elective resection of asymptomatic congenital pulmonary airway malformations. J Pediatr Surg. 2018 May;53(5):1001-1005. doi: 10.1016/j.jpedsurg.2018.02.032. Epub 2018 Feb 10. PMID: 29514740. https://pubmed.ncbi.nlm.nih.gov/29514740/ Elhattab A, Elsaied A, Wafa T, Jugie M, Delacourt C, Sarnacki S, Aly K, Khen-Dunlop N. Thoracoscopic surgery for congenital lung malformations: Does previous infection really matter? J Pediatr Surg. 2021 Nov;56(11):1982-1987. doi: 10.1016/j.jpedsurg.2021.01.036. Epub 2021 Jan 27. PMID: 33573805. https://pubmed.ncbi.nlm.nih.gov/33573805/ Downard CD, Calkins CM, Williams RF, Renaud EJ, Jancelewicz T, Grabowski J, Dasgupta R, McKee M, Baird R, Austin MT, Arnold MA, Goldin AB, Shelton J, Islam S. Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee. Pediatr Surg Int. 2017 Sep;33(9):939-953. doi: 10.1007/s00383-017-4098-z. Epub 2017 Jun 6. PMID: 28589256. https://pubmed.ncbi.nlm.nih.gov/28589256/ Cook J, Chitty LS, De Coppi P, Ashworth M, Wallis C. The natural history of prenatally diagnosed congenital cystic lung lesions: long-term follow-up of 119 cases. Arch Dis Child. 2017 Sep;102(9):798-803. doi: 10.1136/archdischild-2016-311233. Epub 2017 Jun 5. PMID: 28584070. https://pubmed.ncbi.nlm.nih.gov/28584070/

*The opinions are our own, and do not reflect the opinions of BSCOS, their working groups, committees or members.* Please follow BSCOS on twitter: @BSCOS_UK References Tolk JJ, Eastwood DM, Hashemi-Nejad A. Leg length discrepancy in patients with Perthes' disease: a note of caution for the arthroplasty surgeon. Bone Joint J. 2021 103-B(11): 1736-1741.PMID:34719271 Harris H, Bhutta MF, Rizan C. A survey of UK and Irish surgeons' attitudes, behaviours and barriers to change for environmental sustainability. Ann R Coll Surg Engl. 2021 Nov;103(10):725-729.PMID:34719956. Shi Y, Dykhoff HJ, Guevara LRH, Sangaralingham LR, Schroeder DR, Flick RP, Zaccariello MJ, Warner DO. Moderators of the association between attention-deficit/hyperactivity disorder and exposure to anaesthesia and surgery in children. Br J Anaesth. 2021 Nov;127(5):722-728. . Epub 2021 Sep 6.PMID:4503832. Woolford SJ, Sidell M, Li X, Else V, Young DR, Resnicow K, Koebnick C. Changes in Body Mass Index Among Children and Adolescents During the COVID-19 Pandemic. JAMA. 2021 Oct 12;326(14):1434-1436.PMID:34448817 Clever D, Thompson D, Gosselin M, Brouillet K, Guilak F, Luhmann SJ. Pilot Study Analysis of Serum Cytokines to Differentiate Pediatric Septic Arthritis and Transient Synovitis. J Pediatr Orthop. 2021 Nov-Dec 01;41(10):610-616.PMID:34483309. Baghdadi S, Nguyen JC, Arkader A. Nonossifying Fibroma of the Distal Tibia: Predictors of Fracture and Management Algorithm. J Pediatr Orthop. 2021 Sep 1;41(8):e671-e679.PMID:34138818. Birke O, George JS, Gibbons PJ, Little DG.The modified Dunn procedure can be performed safely in stable slipped capital femoral epiphysis but does not alter avascular necrosis rates in unstable cases: a large single-centre cohort study. J Child Orthop 2021 15(5): 479-87.PMID:34858535 Liyanarachi S, Hulleberg G, Foss OA. Is Gastrocnemius Tightness a Normal Finding in Children?: A Cross-Sectional Study of 204 Norwegian Schoolchildren. J Bone Joint Surg Am. 2021 Oct 20;103(20):1872-1879.PMID:34432740. Pennock AT, Heyworth BE, Bastrom T, Bae DS et al. Changes in superior displacement, angulation and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study. J Shoulder Elbow Surg 2021 Dec; 30(12): 2729-2737.PMID:34089880 Tahririan MA, Ramtin S, Taheri P. Functional and radiographic comparison of subtalar arthroereisis and lateral calcaneal lengthening in the surgical treatment of flexible flatfoot in children. Int Orthop 2021 Sep; 45(9): 2291-98.PMID:33796883 Mills H, Flowers MJ, Agrawal Y, Nicolaou N. Outcomes of distally un-threaded screw fixation of slipped capital femoral epiphysis at skeletal maturity: a matched cohort study. J Pediatr Orthop B 2021 Nov; 30(60: 540-548.PMID:32932415 Johnson MA, Gohel S, Mitchell SL, Lynn JJM, Baldwin KD. Entire-spine Magnetic Resonance Imaging findings and costs in children with presumed Adolescent Idiopathic Scoliosis. J Pediatr Orthop 2021 41(10): 585-590.PMID:34411047 Hancock GE, Baxter I, Balachander V, Flowers MJ, Evans OG. What can we learn from COVID-19 protocols with regard to management of nonoperative pediatric orthopaedic injuries? J Pediatr Orthop 2021 41(8): e600-e604.PMID:34138819 Cummins D, Kerr C, McConnell K, Perra O. Risk factors for intellectual disability in children with spastic cerebral palsy. Arch Dis Child 2021 106(10): 975-980.PMID:33727240 E17 Stay Another Day: https://www.youtube.com/watch?v=-wNhdjoF-6M BSCOS Podcast TEAM Host: Anish Sanghrajka, NNUH @AnishPSangh Co-Host: Alpesh Kothari, Oxford Producer: Pranai Buddhdev @Pranai_B

This episode is from my milk 101 mini course (first released on YouTube). In this episode, we cover: How to transition from breastmilk/formula to milk? What about "toddler milk"? Can milk cause constipation? Can milk cause increased mucus? In the previous episode, which is part 1 of the milk 101 mini course, we chatted about: Does my kid really need to drink milk? Which one is the best? Is oat milk a good choice? How to choose the best milk for my unique kid? What if my kid doesn't want to drink milk? How much milk should you give your kids? How much is too much? Articles/resources I mentioned

In this episode, it’s time for you decide what is best for your health. This episode is sponsored by WYSK Spark Radio, https://live365.com/station/Spark-Radio-a82219. To keep this podcast going please feel free to donate at https://paypal.me/yopistudio?locale.x=en_US If you would like to read more on this topic or any other previous topics, you can do so by checking out our blog at https://yopistudio.blogspot.com/ Feel free to see what we are up to by following us at:  https://twitter.com/Dauricee https://www.facebook.com/yopistudio/ https://www.facebook.com/LouisianaEntertainmentAssociation/ To listen to the podcast, watch creative videos and skits go to https://www.youtube.com/channel/UCvn6tns6wKUwz9xZw11_vAQ/videos Interested in projects Daurice has worked on in the movie industry you can check it out at www.IMDb.com under Daurice Cummings. For comments or questions, you can reach us at yopi@post.com To read more about today’s topic check out the references below. References: https://yopistudio.blogspot.com/2020/09/vaccines-sids.html https://www.sott.net/article/441188-WHO-admits-Gates-backed-vaccine-caused-recent-polio-outbreak-in-Africa https://foreignaffairsintelligencecouncil.wordpress.com/2020/09/14/un-forced-to-admit-gates-funded-vaccine-is-causing-polio-outbreak-in-africa/ https://www.msn.com/en-us/money/companies/coronavirus-update-global-death-toll-edges-toward-900000-as-astrazeneca-halts-vaccine-trial-after-patient-struck-by-illness/ar-BB18RCtk https://pubmed.ncbi.nlm.nih.gov/31841767/ pic.twitter.com/f8aVQ4EFGG  WHO. International Classification of Diseases, 9th Revision. Geneva, Switzerland: World Health Organization, 1979. WHO. International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Geneva, Switzerland: World Health Organization, 1992. CDC. Table 31. Number of infant deaths and infant mortality rates for 130 selected causes, by race: United States, 2006. Natl Vital Stat Rep 2009; 57: 110–112. ICD-6, issued in 1948, and ICD-7, issued in 1955, included "Prophylactic inoculation and vaccination" as a separate cause of death category with subcategories  (codes Y40-Y49) for death due to "vaccination against smallpox" (code Y40), "inoculation against whooping cough" (code Y42), "inoculation against other infectious disease" (code Y49), etc. The ICD-8, issued in 1965, deleted the subcategories for death due to inoculation against individual diseases while maintaining "Prophylactic inoculation and vaccination" (code Y42) as a separate cause of death category. When the ICD-9 was issued in 1979, authorities removed all cause of death classifications associated with vaccination. Health Resources and Services Administration. National Vaccine Injury Compensation Program. U.S. Department of Health and Human Services. (Data as of June 2, 2014).   The measles vaccine was administered at 9 months of age from 1963 to 1965. ACIP. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR (December 29, 1989) / 38(S-9): 1-18. Bergman AB, Beckwith JB, Ray CG, eds. Sudden Infant Death Syndrome. Proceedings of the Second International Conference on Causes of Sudden Death in Infants, Seattle and London: University of Washington Press, 1970:18. Bergman AB. The "Discovery" of Sudden Infant Death Syndrome. New York, NY, USA: Praeger Publishers, 1986: 209 (Appendix III). MacDorman MF and Rosenberg HM. Trends in infant mortality by cause of death and other characteristics, 1960-88 (vital and health statistics), Volume 20. Hyattsville,MD, USA: National Center for Health Statistics, U.S. Government Printing, 1993. Malloy MH and MacDorman M. Changes in the classification of sudden unexpected infant deaths: United States, 1992-2001. Pediatrics 2005; 115: 1247–1253. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol 1991; 11: 677–84.  Goldwater PN. Sudden infant death syndrome: a critical review of approaches to research. Arch Dis Child 2003; 88: 1095–100. Vaccine Injury Compensation. Hearing Before the Committee on Labor and Human Resources; 98th Congress, 2nd Session, (May 3, 1984): 63-67. Mitchell E, Krous HF, Donald T, and Byard RW. Changing trends in the diagnosis of sudden infant death. Am J Forensic Med Pathol 2000; 21: 311–314. Overpeck MD, Brenner RA, Cosgrove C, Trumble AC, Kochanek K, and MacDorman M. National under ascertainment of sudden unexpected infant deaths associated with deaths of unknown cause. Pediatrics 2002; 109: 274–283. Byard RW and Beal SM. Has changing diagnostic preference been responsible for the recent fall in incidence of sudden infant death syndrome in South Australia? J Pediatr Child Health 1995; 31: 197–199. Vennemann MM, Butterfass-Bahloul T, Jorch G, Brinkmann B, Findeisen M, Sauerland C, et al. Sudden infant death syndrome: no increased risk after immunisation. Vaccine 2007; 25: 336–340. Stratton K, Almario DA, Wizemann TM, and McCormick MC. Immunization safety review: vaccinations and sudden unexpected death in infancy. Washington DC, USA: National Academies Press, 2003. Essery SD, Raza MW, Zorgani A, MacKenzie DA, et al. The protective effect of immunisation against diphtheria, pertussis and tetanus (DPT) in relation to sudden infant death syndrome. FEMS Immunology and Microbiology 1999 August 1; 25(1-2): 183-92. Madsen T. Vaccination against whooping cough. JAMA 1933; 101: 187-88. Werne J and Garrow I. Fetal anaphylactic shock: occurrence in identical twins following second injection of diphtheria toxoid and pertussis antigen. JAMA 1946; 131: 730-35.        Kalokerinos A. Every Second Child Was Doomed to Death — Unless One Dedicated Doctor Could Open His Colleagues' Eyes and Minds. New Canaan, CT: Keats Publishing, Inc., 1974. Noble GR., et al. Acellular and whole-cell pertussis vaccines in Japan: report of a visit by U.S. scientists. JAMA 1987; 257: 1351-56. Cherry JD., et al. Report of the task force on pertussis and pertussis immunization. Pediatr (Jun 1988); 81(6): 933-84. Congressional Budget Office. Factors contributing to the infant mortality ranking of the United States. CBO Staff Memorandum (February 1992): Table 2, International Infant Mortality Rates by Ranking. Goldman GS and Miller NZ. Relative trends in hospitalizations and mortality among infants by the number of vaccine doses and age, based on the Vaccine Adverse Event Reporting System (VAERS), 1990–2010. Human and Experimental Toxicology 2012; 31(10): 1012-1021.  Torch WC.  DPT immunization: A potential cause of the sudden infant death syndrome (SIDS). Amer Acad of Neur, 34th Annual Meet, Apr 25-May 1, 1982. Neur 32(4): pt. 2. Baraff LJ, Ablon WJ, Weiss RC. Possible temporal association between diphtheria-tetanus toxoid-pertussis vaccination and sudden infant syndrome. Pediatric Infectious Disease Journal 1983; 2: 7-11. Walker AM., et al. Diphtheria-tetanus-pertussis immunization and sudden infant death syndrome. Am J Public Health (August 1987); 77(8): 945-51.    Scheibner V. and Karlsson LG. Evidence of the association between non-specific stress syndrome, DPT injections and cot death. Proceedings of the 2nd National Immunisation Conference in Canberra (May 27-29, 1991). Scheibner V. Vaccination: 100 Years of Orthodox Research Shows that Vaccines Represent a Medical Assault on the Immune System. Blackheath, NSW, Australia: Scheibner Publications, 1993: 59-70; 225-235; 262. Scheibner V. Dynamics of critical days as part of the dynamics of non-specific stress syndrome discovered during monitoring with Cotwatch breathing monitor. Journal of the Australasian College of Nutritional & Environmental Medicine (December 2004); 23(3): 1-5. Ottaviani G, Lavezze AM, and Matturri L. Sudden infant death syndrome (SIDS) shortly after hexavalent vaccination: another pathology in suspected SIDS? Virchows Archiv 2006; 448: 100–104. Zinka B, Rauch E, Buettner A, Rueff F and Penning R. Unexplained cases of sudden infant death shortly after hexavalent vaccination. Vaccine 2006; 24(31-32): 5779–5780.            Kuhnert R, Hecker H, Poethko-Muller C, Schlaud M, Vennemann M, Whitaker HJ, et al. A modified self-controlled case series method to examine association between multidose vaccinations and death. Stat Med 2011; 30(6): 666–677. Unsolicited correspondence received by the Thinktwice Global Vaccine Institute.   GlaxoSmithKline. Rotarix1 (Rotavirus Vaccine, Live, Oral) Oral Suspension. Product insert from the manufacturer (April 2008): 6. FDA. Center for biologics evaluation and research, vaccines and related biological products advisory committee meeting (February 20, 2008): 127–128. Buttram H and England C. Shaken Baby Syndrome or Vaccine-Induced Encephalitis: Are Parents Being Falsely Accused? Bloomington, Indiana: Author House, 2011. CDC. About the sudden unexpected infant death investigation (SUIDI) reporting form. Department of Health and Human Services (accessed May 13, 2013).    

Dr. Reda Bassali, professor of pediatrics and pediatric hospitalist at the Medical College of Georgia, joins Dr. Zac Hodges and Gavriella Mendel (M3) to discuss this very important topic in pediatric medicine. What exactly is bronchiolitis and why is this topic so important? How do you make the diagnosis and what other diagnoses should you consider? What treatments work, and more importantly, which treatments do not? What patients can go home and who needs to be admitted? All of this and more from the Department of Pediatrics and the Medical College of Georgia.  Check out our website for detailed show-notes: https://www.augusta.edu/mcg/pediatrics/residency/podcast.php Special thanks to Dr. Kathryn McLeod for providing peer review for this episode. Citation: Hodges, Z. (Host). Bassali, R. (Host).  Mendel, G. (Host). McLeod, K. (Contributor). (2020, Nov 15). Bronchiolitis. (S1:18) [Audio Podcast Episode]. MCG Pediatric Podcast. Medical College of Georgia Augusta. Questions, comments, or feedback? Please email us at mcgpediatricpodcast@augusta.edu  Links:  NoseFrida-- https://www.nosefrida.com  References/further reading: Silver AH, Nazif JM. Bronchiolitis. Pediatr Rev. 2019;40(11):568-576. doi:10.1542/pir.2018-0260   Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis [published correction appears in Pediatrics. 2015 Oct;136(4):782]. Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742  Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2017;389(10065):211-224. doi:10.1016/S0140-6736(16)30951-5   Cunningham S, Rodriguez A, Adams T, et al. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet. 2015;386(9998):1041-1048. doi:10.1016/S0140-6736(15)00163-4 Franklin D, Babl FE, Schlapbach LJ, Oakley E, Craig S, Neutze J, Furyk J, Fraser JF, Jones M, Whitty JA, Dalziel SR, Schibler A. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018 Mar 22;378(12):1121-1131. doi: 10.1056/NEJMoa1714855. PMID: 29562151. Lin J, Zhang Y, Xiong L, Liu S, Gong C, Dai J. High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis. Arch Dis Child. 2019 Jun;104(6):564-576. doi: 10.1136/archdischild-2018-315846. Epub 2019 Jan 17. PMID: 30655267.

In this episode, I point out the latest information on vaccinations, SIDS, Polio, COVID, and what is happening with the vaccines that the Gates Foundation is funding. This episode is sponsored by WYSK Spark Radio, https://live365.com/station/Spark-Radio-a82219. To keep this podcast going please feel free to donate at paypal.me/yopistudio If you would like to read more on this topic or any other previous topics, you can do so by checking out our blog at https://yopistudio.blogspot.com/ Feel free to see what we are up to by following us at:  https://twitter.com/Dauricee https://www.facebook.com/yopistudio/ https://www.facebook.com/LouisianaEntertainmentAssociation/ To listen to the podcast, watch creative videos and skits go to https://www.youtube.com/channel/UCvn6tns6wKUwz9xZw11_vAQ/videos Interested in projects Daurice has worked on in the movie industry you can check it out at www.IMDb.com under Daurice Cummings. For comments or questions, you can reach us at yopi@post.com To read more about today’s topic check out the references below. References https://yopistudio.blogspot.com/2020/09/vaccines-sids.html https://www.sott.net/article/441188-WHO-admits-Gates-backed-vaccine-caused-recent-polio-outbreak-in-Africa https://foreignaffairsintelligencecouncil.wordpress.com/2020/09/14/un-forced-to-admit-gates-funded-vaccine-is-causing-polio-outbreak-in-africa/ https://www.msn.com/en-us/money/companies/coronavirus-update-global-death-toll-edges-toward-900000-as-astrazeneca-halts-vaccine-trial-after-patient-struck-by-illness/ar-BB18RCtk https://pubmed.ncbi.nlm.nih.gov/31841767/ pic.twitter.com/f8aVQ4EFGG  WHO. International Classification of Diseases, 9th Revision. Geneva, Switzerland: World Health Organization, 1979. WHO. International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Geneva, Switzerland: World Health Organization, 1992. CDC. Table 31. Number of infant deaths and infant mortality rates for 130 selected causes, by race: United States, 2006. Natl Vital Stat Rep 2009; 57: 110–112. ICD-6, issued in 1948, and ICD-7, issued in 1955, included "Prophylactic inoculation and vaccination" as a separate cause of death category with subcategories  (codes Y40-Y49) for death due to "vaccination against smallpox" (code Y40), "inoculation against whooping cough" (code Y42), "inoculation against other infectious disease" (code Y49), etc. The ICD-8, issued in 1965, deleted the subcategories for death due to inoculation against individual diseases while maintaining "Prophylactic inoculation and vaccination" (code Y42) as a separate cause of death category. When the ICD-9 was issued in 1979, authorities removed all cause of death classifications associated with vaccination. Health Resources and Services Administration. National Vaccine Injury Compensation Program. U.S. Department of Health and Human Services. (Data as of June 2, 2014).   The measles vaccine was administered at 9 months of age from 1963 to 1965. ACIP. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR (December 29, 1989) / 38(S-9): 1-18. Bergman AB, Beckwith JB, Ray CG, eds. Sudden Infant Death Syndrome. Proceedings of the Second International Conference on Causes of Sudden Death in Infants, Seattle and London: University of Washington Press, 1970:18. Bergman AB. The "Discovery" of Sudden Infant Death Syndrome. New York, NY, USA: Praeger Publishers, 1986: 209 (Appendix III). MacDorman MF and Rosenberg HM. Trends in infant mortality by cause of death and other characteristics, 1960-88 (vital and health statistics), Volume 20. Hyattsville,MD, USA: National Center for Health Statistics, U.S. Government Printing, 1993. Malloy MH and MacDorman M. Changes in the classification of sudden unexpected infant deaths: United States, 1992-2001. Pediatrics 2005; 115: 1247–1253. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol 1991; 11: 677–84.  Goldwater PN. Sudden infant death syndrome: a critical review of approaches to research. Arch Dis Child 2003; 88: 1095–100. Vaccine Injury Compensation. Hearing Before the Committee on Labor and Human Resources; 98th Congress, 2nd Session, (May 3, 1984): 63-67. Mitchell E, Krous HF, Donald T, and Byard RW. Changing trends in the diagnosis of sudden infant death. Am J Forensic Med Pathol 2000; 21: 311–314. Overpeck MD, Brenner RA, Cosgrove C, Trumble AC, Kochanek K, and MacDorman M. National under ascertainment of sudden unexpected infant deaths associated with deaths of unknown cause. Pediatrics 2002; 109: 274–283. Byard RW and Beal SM. Has changing diagnostic preference been responsible for the recent fall in incidence of sudden infant death syndrome in South Australia? J Pediatr Child Health 1995; 31: 197–199. Vennemann MM, Butterfass-Bahloul T, Jorch G, Brinkmann B, Findeisen M, Sauerland C, et al. Sudden infant death syndrome: no increased risk after immunisation. Vaccine 2007; 25: 336–340. Stratton K, Almario DA, Wizemann TM, and McCormick MC. Immunization safety review: vaccinations and sudden unexpected death in infancy. Washington DC, USA: National Academies Press, 2003. Essery SD, Raza MW, Zorgani A, MacKenzie DA, et al. The protective effect of immunisation against diphtheria, pertussis and tetanus (DPT) in relation to sudden infant death syndrome. FEMS Immunology and Microbiology 1999 August 1; 25(1-2): 183-92. Madsen T. Vaccination against whooping cough. JAMA 1933; 101: 187-88. Werne J and Garrow I. Fetal anaphylactic shock: occurrence in identical twins following second injection of diphtheria toxoid and pertussis antigen. JAMA 1946; 131: 730-35.        Kalokerinos A. Every Second Child Was Doomed to Death — Unless One Dedicated Doctor Could Open His Colleagues' Eyes and Minds. New Canaan, CT: Keats Publishing, Inc., 1974. Noble GR., et al. Acellular and whole-cell pertussis vaccines in Japan: report of a visit by U.S. scientists. JAMA 1987; 257: 1351-56. Cherry JD., et al. Report of the task force on pertussis and pertussis immunization. Pediatr (Jun 1988); 81(6): 933-84. Congressional Budget Office. Factors contributing to the infant mortality ranking of the United States. CBO Staff Memorandum (February 1992): Table 2, International Infant Mortality Rates by Ranking. Goldman GS and Miller NZ. Relative trends in hospitalizations and mortality among infants by the number of vaccine doses and age, based on the Vaccine Adverse Event Reporting System (VAERS), 1990–2010. Human and Experimental Toxicology 2012; 31(10): 1012-1021.  Torch WC.  DPT immunization: A potential cause of the sudden infant death syndrome (SIDS). Amer Acad of Neur, 34th Annual Meet, Apr 25-May 1, 1982. Neur 32(4): pt. 2. Baraff LJ, Ablon WJ, Weiss RC. Possible temporal association between diphtheria-tetanus toxoid-pertussis vaccination and sudden infant syndrome. Pediatric Infectious Disease Journal 1983; 2: 7-11. Walker AM., et al. Diphtheria-tetanus-pertussis immunization and sudden infant death syndrome. Am J Public Health (August 1987); 77(8): 945-51.    Scheibner V. and Karlsson LG. Evidence of the association between non-specific stress syndrome, DPT injections and cot death. Proceedings of the 2nd National Immunisation Conference in Canberra (May 27-29, 1991). Scheibner V. Vaccination: 100 Years of Orthodox Research Shows that Vaccines Represent a Medical Assault on the Immune System. Blackheath, NSW, Australia: Scheibner Publications, 1993: 59-70; 225-235; 262. Scheibner V. Dynamics of critical days as part of the dynamics of non-specific stress syndrome discovered during monitoring with Cotwatch breathing monitor. Journal of the Australasian College of Nutritional & Environmental Medicine (December 2004); 23(3): 1-5. Ottaviani G, Lavezze AM, and Matturri L. Sudden infant death syndrome (SIDS) shortly after hexavalent vaccination: another pathology in suspected SIDS? Virchows Archiv 2006; 448: 100–104. Zinka B, Rauch E, Buettner A, Rueff F and Penning R. Unexplained cases of sudden infant death shortly after hexavalent vaccination. Vaccine 2006; 24(31-32): 5779–5780.            Kuhnert R, Hecker H, Poethko-Muller C, Schlaud M, Vennemann M, Whitaker HJ, et al. A modified self-controlled case series method to examine association between multidose vaccinations and death. Stat Med 2011; 30(6): 666–677. Unsolicited correspondence received by the Thinktwice Global Vaccine Institute.   GlaxoSmithKline. Rotarix1 (Rotavirus Vaccine, Live, Oral) Oral Suspension. Product insert from the manufacturer (April 2008): 6. FDA. Center for biologics evaluation and research, vaccines and related biological products advisory committee meeting (February 20, 2008): 127–128. Buttram H and England C. Shaken Baby Syndrome or Vaccine-Induced Encephalitis: Are Parents Being Falsely Accused? Bloomington, Indiana: Author House, 2011. CDC. About the sudden unexpected infant death investigation (SUIDI) reporting form. Department of Health and Human Services (accessed May 13, 2013).        

References:Adriana Sarah Nica, Adela Caramoci, Mirela Vasilescu, Anca Mirela Ionescu, Denis Paduraru, Virgil Mazilu.  Magnesium supplementation in top athletes - effects and recommendations. Medicina Sportiva (2015), vol. XI, no 1, 2482-2494 Journal of the Romanian Sports Medicine SocietyAikawa JW. Magnesium: its biological significance. Boca Raton, FL: CRC Press, 1981:21–38.Abbasi B, Kimiagar M, Sadeghnijat K, Shirazi MM, Hedayati M, Rashidkhani B. “The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trial.”  J Res Med Sci. 2012 Dec 17 (12): 1161-9.PubMed PMID: 23853635. Arnaud MJ: Update on the assessment of magnesium status. Br J Nutr 2008;99(suppl 3):S24–S36 Brilla LR, Haley TF. Effect of magnesium supplementation on strength training in humans. J Am Coll Nutr 1992;11:326​​​​​​​Chandrasekaran NC, Weir C, Alfraji S, Grice J, Roberts MS, Barnard RT. Effects of magnesium deficiency--more than skin deep. Exp Biol Med (Maywood). 2014 Oct;239(10):1280-91. doi: 10.1177/1535370214537745. Epub 2014 Jun 13.Ebel H, Gunther T. Magnesium metabolism: a review. J Clin Chem Biochem 1980;18:257–70.Emelyanov A, Fedoseev G, Barnes PJ: Re- duced intracellular magnesium concentra- tions in asthmatic patients. Eur Respir J 1999;13:38–40.Fawcett WJ, Haxby EJ, Male DA: Magnesium: physiology and pharmacology. Br J Anaesth 1999;83:302–320.Institute of Medicine, Food and Nutrition Board. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press, 1997.Guerrero-Romero F, Rodríguez-Morán M. Relationship between serum magnesium levels and C-reactive protein concentration, in non-diabetic, non-hypertensive obese subjects. Int J Obes Relat Metab Disord. 2002;26:469–74.Hosty´nek JJ, Hinz RS, Lorence CR, Price M, Guy RH. Metals and the skin. Crit Rev Toxicol 1993;23:171–235Jahnen-Dechent W, Ketteler M. Magnesium basics. Clin Kidney J 2012;5:i3–i14Kupetsky-Rincon EA1, Uitto J. Magnesium: novel applications in cardiovascular disease--a review of the literature. Ann Nutr Metb. 2012;61(2):102-10.Lansdown AB. Physiological and toxicological changes in the skin resulting from the action and interaction of metal ions. Crit Rev Toxicol1995;25:397–462.Mochizuki M, Akagi K, Inoue K, Shimamura K.[A single dose toxicity study of magnesium sulfate in rats and dogs]. J Toxicol Sci. 1998 May;23 Suppl 1:31-5Navarrete-Cortes A, Ble-Castillo JL, Guerrero-Romero F, Cordova-Uscanga R, Juárez-Rojop IE, Aguilar-Mariscal H, Tovilla-Zarate CA, Lopez-Guevara Mdel R. No effect of magnesium supplementation on metabolic control and insulin sensitivity in type 2 diabetic patients with normomagnesemia. Magnes Res. 2014 Apr-Jun;27(2):48-56. doi: 10.1684/mrh.2014.0361.Nedeltcheva AV, Kilkus JM, Imperial J, Schoeller DA, Peney PD. “Insufficient sleep undermines dietary efforts to reduce adiposity.”  ANN Intern Med. 2010 Oct 5:153(7):435-41. PubMed PMID: 20921542.Nowacki W, Daveau M, Malpuech-Bruge C. Inflammatory responsefollowing acute magnesium deficiency in the rat. Biochim Biophys Acta 2000;1501:91–8Nielsen FH, Johnson LK, Zeng H.  Magnesium supplementation improves indicators of low magnesium status and inflammatory stress in adults older than 51 years with poor quality sleep.  Magnes Res. 2010 Dec;23(4):158-68. doi: 10.1684/mrh.2010.0220. Epub 2011 Jan 4.Malon A, Brockmann C, Fijalkowska- Morawska J, Rob P, Maj-Zurawska M: Ionized magnesium in erythrocytes – the best magnesium parameter to observe hypo- or hypermagnesemia. Clin Chim Acta 2004; 349:67–73.Martin K, Jackson CF, Levy RG, Cooper PN. Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database Syst Rev. 2016 Feb 9;2:CD001903. doi: 10.1002/14651858.CD001903.pub3.Meolie AL, Rosen C, Kristo D, Kohrman M, Gooneratne N, Aguillard RN, Fayle R, Troell R, Townsend D, Claman D, Hoban T, Mahowald M. Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence; Clinical Practice Review Committee; American Academy of Sleep Medicine.J Clin Sleep Med. 2005 Apr 15;1(2):173-87.Rodríguez-Morán M, Guerrero-Romero F. Serum magnesium and C-reactive protein levels. Arch Dis Child. 2008;93:676–80University of Maryland Medical Center “Magnesium” access May 8. 2016 http://umm.edu/ health/medical/altmed/supplement/magnesiumShils ME. Magnesium. In: Shils ME, Olson JA, Shike M, eds. Modern nutrition in health and disease. 8th ed. Philadelphia: Lea & Febiger, 1993:164–84.Simsek E, Karabay M, Kocabay K: Assess- ment of magnesium status in newly diag- nosed diabetic children: measurement of erythrocyte magnesium level and magne- sium tolerance testing. Turk J Pediatr 2005; 47:132–137.Waring, RH  Report on Absorption of magnesium sulfate (Epsom salts) across the skin.  School of Biosciences, University of Birmingham. B15 2TT, U.K. r.h.waring@bham.ac.uk   URL http://www.epsomsaltcouncil.org/wpcontent/uploads/2015/10/report_on_absorption_of_magnesium_sulfate.pdfWinkelmann RK. The relationship of the structure of the epidermis to percutaneous absorption. Br J Dermatol 1969;81:11–22Witkowski M, Hubert J, Mazur A. Methods of assessment of magnesium status in humans: a systematic review. Magnes Res. 2011 Dec;24(4):163-80. doi: 10.1684/mrh.2011.0292.

If you are a parent, then you have been sleep deprived more often than you probably remember (or would like to admit). Heck, many parents I know operate in a cycle of sleep deprivation wherein half of the time they are sleeping decently and the other half is a solid 3-4 hours of interrupted and crappy sleep. Consider this the rule book on how to workout while sleep deprived. When my son was born and put me through the navy seal-style sleep deprivation training, I couldn't find anything helpful out there to guide me in not giving up my workout habit without injuring myself or making the exhaustion worse. Enjoy! And note, whether its the job, familial issues, or the kids that's ruining your sleep, this will not last forever. Hang in there!Citations:http://www.gallup.com/poll/166553/less-recommended-amount-sleep.aspx[ii] Jean-Louis G, Kripke DF, and Ancoli-Israel S. Sleep and quality of well-being. Sleep 23: 1115–1121, 2000.[iii] Slow-wave sleep: a recovery period after exercise CM Shapiro, R Bortz, D Mitchell, P Bartel, and P Jooste Science 11 December 1981: 214 (4526), 1253-1254. [DOI:10.1126/science.7302594][iv] S Taheri. The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity. Arch Dis Child 2006;91:11 881-884 doi:10.1136/adc.2005.093013[v] Ayalon RD1, Friedman F Jr. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstet Gynecol. 2008 Nov;199(5):576.e1-5. doi: 10.1016/j.ajog.2008.06.080. Epub 2008 Sep 25.[vi] 5. Lehmann M, Baumgartl P, Wiesenack C, Seidel A, Baumann H, et al. Training-overtraining: influence of a defined increase in training volume vs training intensity on performance, catecholamines and some metabolic parameters in experienced middle- and long-distance runners. European journal of applied physiology and occupational physiology. 1992;64:169–177. [PubMed][vii] Kellmann M. Preventing overtraining in athletes in high-intensity sports and stress/recovery monitoring. Scand J Med Sci Sports. 2010;20(Suppl 2):95–102.[viii] Snyder AC. Overtraining and glycogen depletion hypothesis. Med Sci Sports Exerc. 1998;30:1146–1150.[ix] Lehmann M, Dickhuth HH, Gendrisch G, Lazar W, Thum M, et al. Training-overtraining. A prospective, experimental study with experienced middle- and long-distance runners. Int J Sports Med. 1991;12:444–452[x] Swanson DR. Atrial fibrillation in athletes: implicit literature-based connections suggest that overtraining and subsequent inflammation may be a contributory mechanism. Med Hypotheses. 2006;66:1085–1092[xi] Eudi, A. Efficacy and safety of ingredients found in preworkout supplements. American Journal of Health-System Pharmacy April 1, 2013 vol. 70 no. 7 577-588.[xii] Spiegel K, Leproult R, and Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet 354: 1435–1439, 1999.[xiii] Sellwood KL, Brukner P, Williams D, Nicol A, Hinman R. Ice-water immersion and delayed-onset muscle soreness: a randomised controlled trial. Br J Sports Med. 2007;41:392–7.[xiv] http://www.lifetime-weightloss.com/blog/2015/7/14/why-exercise-isnt-enough.htmlBecome a supporter of this podcast: https://www.spreaker.com/podcast/faithful-fitness-by-better-daily--5150768/support.

If you are a parent, then you have been sleep deprived more often than you probably remember (or would like to admit). Heck, many parents I know operate in a cycle of sleep deprivation wherein half of the time they are sleeping decently and the other half is a solid 3-4 hours of interrupted and crappy sleep. Consider this the rule book on how to workout while sleep deprived. When my son was born and put me through the navy seal-style sleep deprivation training, I couldn't find anything helpful out there to guide me in not giving up my workout habit without injuring myself or making the exhaustion worse. Enjoy! And note, whether its the job, familial issues, or the kids that's ruining your sleep, this will not last forever. Hang in there!Citations:http://www.gallup.com/poll/166553/less-recommended-amount-sleep.aspx[ii] Jean-Louis G, Kripke DF, and Ancoli-Israel S. Sleep and quality of well-being. Sleep 23: 1115–1121, 2000.[iii] Slow-wave sleep: a recovery period after exercise CM Shapiro, R Bortz, D Mitchell, P Bartel, and P Jooste Science 11 December 1981: 214 (4526), 1253-1254. [DOI:10.1126/science.7302594][iv] S Taheri. The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity. Arch Dis Child 2006;91:11 881-884 doi:10.1136/adc.2005.093013[v] Ayalon RD1, Friedman F Jr. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstet Gynecol. 2008 Nov;199(5):576.e1-5. doi: 10.1016/j.ajog.2008.06.080. Epub 2008 Sep 25.[vi] 5. Lehmann M, Baumgartl P, Wiesenack C, Seidel A, Baumann H, et al. Training-overtraining: influence of a defined increase in training volume vs training intensity on performance, catecholamines and some metabolic parameters in experienced middle- and long-distance runners. European journal of applied physiology and occupational physiology. 1992;64:169–177. [PubMed][vii] Kellmann M. Preventing overtraining in athletes in high-intensity sports and stress/recovery monitoring. Scand J Med Sci Sports. 2010;20(Suppl 2):95–102.[viii] Snyder AC. Overtraining and glycogen depletion hypothesis. Med Sci Sports Exerc. 1998;30:1146–1150.[ix] Lehmann M, Dickhuth HH, Gendrisch G, Lazar W, Thum M, et al. Training-overtraining. A prospective, experimental study with experienced middle- and long-distance runners. Int J Sports Med. 1991;12:444–452[x] Swanson DR. Atrial fibrillation in athletes: implicit literature-based connections suggest that overtraining and subsequent inflammation may be a contributory mechanism. Med Hypotheses. 2006;66:1085–1092[xi] Eudi, A. Efficacy and safety of ingredients found in preworkout supplements. American Journal of Health-System Pharmacy April 1, 2013 vol. 70 no. 7 577-588.[xii] Spiegel K, Leproult R, and Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet 354: 1435–1439, 1999.[xiii] Sellwood KL, Brukner P, Williams D, Nicol A, Hinman R. Ice-water immersion and delayed-onset muscle soreness: a randomised controlled trial. Br J Sports Med. 2007;41:392–7.[xiv] http://www.lifetime-weightloss.com/blog/2015/7/14/why-exercise-isnt-enough.html

If you are a parent, then you have been sleep deprived more often than you probably remember (or would like to admit). Heck, many parents I know operate in a cycle of sleep deprivation wherein half of the time they are sleeping decently and the other half is a solid 3-4 hours of interrupted and crappy sleep. Consider this the rule book on how to workout while sleep deprived. When my son was born and put me through the navy seal-style sleep deprivation training, I couldn't find anything helpful out there to guide me in not giving up my workout habit without injuring myself or making the exhaustion worse. Enjoy! And note, whether its the job, familial issues, or the kids that's ruining your sleep, this will not last forever. Hang in there!Citations:http://www.gallup.com/poll/166553/less-recommended-amount-sleep.aspx[ii] Jean-Louis G, Kripke DF, and Ancoli-Israel S. Sleep and quality of well-being. Sleep 23: 1115–1121, 2000.[iii] Slow-wave sleep: a recovery period after exercise CM Shapiro, R Bortz, D Mitchell, P Bartel, and P Jooste Science 11 December 1981: 214 (4526), 1253-1254. [DOI:10.1126/science.7302594][iv] S Taheri. The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity. Arch Dis Child 2006;91:11 881-884 doi:10.1136/adc.2005.093013[v] Ayalon RD1, Friedman F Jr. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstet Gynecol. 2008 Nov;199(5):576.e1-5. doi: 10.1016/j.ajog.2008.06.080. Epub 2008 Sep 25.[vi] 5. Lehmann M, Baumgartl P, Wiesenack C, Seidel A, Baumann H, et al. Training-overtraining: influence of a defined increase in training volume vs training intensity on performance, catecholamines and some metabolic parameters in experienced middle- and long-distance runners. European journal of applied physiology and occupational physiology. 1992;64:169–177. [PubMed][vii] Kellmann M. Preventing overtraining in athletes in high-intensity sports and stress/recovery monitoring. Scand J Med Sci Sports. 2010;20(Suppl 2):95–102.[viii] Snyder AC. Overtraining and glycogen depletion hypothesis. Med Sci Sports Exerc. 1998;30:1146–1150.[ix] Lehmann M, Dickhuth HH, Gendrisch G, Lazar W, Thum M, et al. Training-overtraining. A prospective, experimental study with experienced middle- and long-distance runners. Int J Sports Med. 1991;12:444–452[x] Swanson DR. Atrial fibrillation in athletes: implicit literature-based connections suggest that overtraining and subsequent inflammation may be a contributory mechanism. Med Hypotheses. 2006;66:1085–1092[xi] Eudi, A. Efficacy and safety of ingredients found in preworkout supplements. American Journal of Health-System Pharmacy April 1, 2013 vol. 70 no. 7 577-588.[xii] Spiegel K, Leproult R, and Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet 354: 1435–1439, 1999.[xiii] Sellwood KL, Brukner P, Williams D, Nicol A, Hinman R. Ice-water immersion and delayed-onset muscle soreness: a randomised controlled trial. Br J Sports Med. 2007;41:392–7.[xiv] http://www.lifetime-weightloss.com/blog/2015/7/14/why-exercise-isnt-enough.html

Abdominal pain is common; so are strongly held myths and legends about what is concerning, and what is not.   One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain.  Morbidity and mortality varies by age and condition.   Abdominal Surgical Emergencies in Children: A Relative Timeline General Advice Neonate (birth to one month) Necrotizing Enterocolitis Pneumatosis Intestinalis. Essentials: Typically presents in 1st week of life (case reports to 6 months in chronically ill children) Extend suspicion longer in NICU graduates Up to 10% of all cases of necrotizing enterocolitis are in full-term children Pathophysiology is unknown, but likely a translocation of bacteria Diagnosis: Feeding intolerance, abdominal distention Abdominal XR: pneumatosis intestinalis Management: IV access, NG tube, broad-spectrum antibiotics, surgery consult, ICU admission Intestinal Malrotation with Volvulus Essentials: Corkscrew Sign in Malrotation with Volvulus Bilious vomiting (80-100%) in the 1st month; especially in the 1st week May look well initially, then rapidly present in shock Ladd’s bands: abnormally high tethering of cecum to abdominal wall; peristalsis, volvulus, ischemia Diagnosis: History of bilious emesis is sufficient to involve surgeons Upper GI series: corkscrew appearance US (if ordered) may show abnormal orientation of and/or flow to superior mesenteric artery and vein Management: Stat surgical consult IV access, resuscitation, NG tube to decompress (bowel wall perfusion at risk, distention worsens) Hirschprung Disease Essentials: Problem in migration of neural crest cells Aganglionic colon (80% rectosigmoid; 15-20% proximal to sigmoid; 5% total colonic aganglionosis) colon (known as short-segment disease) Poor to no peristalsis: constipation, perforation, and/or sepsis Diagnosis: May be diagnosed early as “failure to pass meconium in 1st 48 hours” In ED, presents as either bowel obstruction or enterocolitis Contrast enema Beware of the toxic megacolon (vomiting, distention, sepsis) Management: Resuscitation, antibiotics, NG tube decompression, surgical consultation; stable patients may need rectal biopsy for confirmation Staged surgery (abdominoperineal pull-through with diverting colostomy, subsequent anastomosis) versus one-stage repair. Infant and Toddler (1 month to 2 years) Pyloric Stenosis Essentials: Hypertrophy of pyloric sphincter; genetic, environmental, exposure factorsString Sign in Pyloric Stenosis. Diagnosis: Hungry, hungry, not-so-hippos; they want to eat all of the time, but cannot keep things down Poor weight gain (less than 20-30 g/day) US: “π–loric stenosis” (3.14); pylorus dimensions > 3 mm x 14 mm UGI: “string sign” Management: Trial of medical treatment with oral atropine via NGT (muscarinic effects decrease pyloric tone) Ramstedt pyloromyotomy (definitive) Intussusception Essentials: Majority (90%) ileocolic; no pathological lead point Small minority (4%) ileoileocolic due to lead point: Meckel’s diverticulum, polyp, Peyer’s patches, Henoch-Schönlein purpura (intestinal hematoma) Diagnosis: Target Sign (Donut Sign). Ultrasound sensitivity and specificity near 100% in experienced hands Abdominal XR may show non-specific signs; used mainly to screen for perforation before reduction Management: Hydrostatic enema: contrast (barium or water-soluble contrast with fluoroscopy) or saline (with ultrasound) Air-contrast enema: air or carbon dioxide (with either fluoroscopy or ultrasound); higher risk for perforation than hydrostatic (1% risk), but generally safer than perforation from contrast Consider involving surgical service early (precaution before reduction) Traditional disposition is admission; controversial: home discharge from ED Young Child and Older (2 years and up) Appendicitis Essentials: Appendicitis occurs in all ages, but rarer in infants. Infants do not have fecalith; rather they have some other anatomic or congenital condition.  More common in school-aged children (5-12 years) and adolescents Younger children present atypically, more likely to have perforated when diagnosed. Diagnosis: Non-specific signs and symptoms Often have abdominal pain first; vomiting comes later Location/orientation of appendix varies Appendicitis scores vary in their performance Respect fever and abdominal pain   Management: Traditional: surgical On the horizon: identification of low-risk children who may benefit from trial of antibiotics If perforated, interval appendectomy (IV antibiotics via PICC for 4-6 weeks, then surgery) Obstruction SBO. Incarcerated Inguinal Hernia. Essentials: Same pathophysiology and epidemiology as adults: “ABC” – adhesions, “bulges” (hernias), and cancer. Diagnosis: Obstruction is a sign of another condition. Look for cause of obstruction: surgical versus medical Abdominal XR in low pre-test probability CT abdomen/pelvis for moderate-to-high risk; confirmation and/or surgical planning Management: Treat underlying cause NG tube to low intermittent wall suction Admission, fluid management, serial examinations   Take these pearls home: Consider surgical pathology early in encounter Resuscitate while you investigate Have a low threshold for imaging and/or consultation, especially in preverbal children   Selected References Necrotizing Enterocolitis Neu J, Walker A. Necrotizing Enterocolitis. N Eng J Med. 2011; 364(3):255-264. Niño DF et al. Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nature. 2016; 13:590-600. Walsh MC et al. Necrotizing Enterocolitis: A Practitioner’s Perspective. Pediatr Rev. 1988; 9(7):219-226. Malrotation with Midgut Volvulus Applegate KE. Intestinal Malrotation in Children: A Problem-Solving Approach to the Upper Gastrointestinal Series. Radiographics. 2006; 26:1485-1500. Kapfer SA, Rappold JF. Intestinal Malrotation – Not Just the Pediatric Surgeon’s Problem. J Am Coll Surg. 2004; 199(4):628-635. Lee HC et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1):49-51. Martin V, Shaw-Smith C. Review of genetic factors in intestinal malrotation. Pediatr Surg Int. 2010; 26:769-781. Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood. Surgery. 2010; 149(3):386-391. Hirschprung Disease Amiel J, Sproat-Emison E, Garcia-Barcelo M, et al. Hirschsprung disease, associated syndromes and genetics: a review. J Med Genet 2008; 45:1. Arshad A, Powell C, Tighe MP. Hirschsprung's disease. BMJ 2012; 345:e5521. Aworanti OM, McDowell DT, Martin IM, Quinn F. Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease? Eur J Pediatr Surg 2016; 26:192. Clark DA. Times of first void and first stool in 500 newborns. Pediatrics 1977; 60:457. Dasgupta R, Langer JC. Evaluation and management of persistent problems after surgery for Hirschsprung disease in a child. J Pediatr Gastroenterol Nutr 2008; 46:13. De Lorijn F, Reitsma JB, Voskuijl WP, et al. Diagnosis of Hirschsprung's disease: a prospective, comparative accuracy study of common tests. J Pediatr 2005; 146:787. Doig CM. Hirschsprung's disease and mimicking conditions. Dig Dis 1994; 12:106. Khan AR, Vujanic GM, Huddart S. The constipated child: how likely is Hirschsprung's disease? Pediatr Surg Int 2003; 19:439. Singh SJ, Croaker GD, Manglick P, et al. Hirschsprung's disease: the Australian Paediatric Surveillance Unit's experience. Pediatr Surg Int 2003; 19:247. Suita S, Taguchi T, Ieiri S, Nakatsuji T. Hirschsprung's disease in Japan: analysis of 3852 patients based on a nationwide survey in 30 years. J Pediatr Surg 2005; 40:197. Sulkowski JP, Cooper JN, Congeni A, et al. Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants. J Pediatr Surg 2014; 49:1619. Pyloric Stenosis Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pedaitr Surg. 2007; 16:27-33. Dias SC et al. Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis. Insights Imaging. 2012; 3:247-250. Kawahara H et al. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the olive? J Pediatr Surg. 2005; 40:1848-1851. Mack HC. Adult Hypertrophic Pyloric Stenosis. Arch Inter Med. 1959; 104:78-83. Meissner PE et al. Conservative treatment of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate does not replace pyloromyotomy. Pediatr Surg Int. 2006; 22:1021-1024. Mercer AE, Phillips R. Can a conservative approach to the treatment of hypertrophic pyloric stenosis with atropine be considered a real alternative to pyloromyotomy? Arch Dis Child. 2013; 95(6): 474-477. Pandya S, Heiss K, Pyloric Stenosis in Pediatric Surgery.Surg Clin N Am. 2012; 92:527-39. Peters B et al. Advances in infantile hypertrophic pyloric stenosis. Expert Rev Gastroenterol Hepatol. 2014; 8(5):533-541. Intussusception Apelt N et al. Laparoscopic treatment of intussusception in children: A systematic review. J Pediatr Surg. 2013; 48:1789-1793. Applegate KE. Intussusception in Children: Imaging Choices. Semin Roentgenol. 2008; 15-21. Bartocci M et al. Intussusception in childhood: role of sonography on diagnosis and treatment. J Ultrasound. 2015; 18 Gilmore AW et al. Management of childhood intussusception after reductiion by enema. Am J Emerg Med. 2011; 29:1136-1140.:205-211. Chien M et al. Management of the child after enema-reduced intussusception: hospital or home? J Emerg Med. 2013; 44(1):53-57. Cochran AA et al. Intussusception in traditional pediatric, nontraditional pediatric, and adult patients. Am J Emerg Med. 2011; 523-527. Loukas M et al. Intussusception: An Anatomical Perspective With Review of the Literature. Clin Anatomy. 2011; 24: 552-561. Mendez D et al. The diagnostic accuracy of an abdominal radiograph with signs and symptoms of intussusception. Am J Emerg Med. 2012; 30:426-431. Whitehouse et al. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg. 2010; 45:1182-1186. Appendicitis Amin P, Chang D. Management of Complicated Appendicitis in the Pediatrc Population: When Surgery Doesn’t Cut it. Semin Intervent Radiol. 2012; 29:231-236 Blakely ML et al. Early vs Interval Appendectomy for Children With Perforated Appendicitis. Arch Surg. 2011; 146(6):660-665. Bundy DG et al. Does This Child Have Appendicitis? JAMA. 2007; 298(4):438-451. Cohen B et al. The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg. 2015 Jun;50(6):923-7 Herliczek TW et al. Utility of MRI After Inconclusive Ultrasound in Pediatric Patients with Suspected Appendicitis. AJT. 2013; 200:969-973. Janitz et al. Ultrasound Evaluation for Appendicitis. J Am Osteopath Coll Radiol. 2016; 5(1):5-12. Kanona H et al. Stump Appendicitis: A Review. Int J Surg. 2012; 10:4255-428. Kao LS et al. Antibiotics vs Appendectomy for Uncomplicated Acute Appendicitis. Evid Based Rev Surg. 2013;216(3):501-505. Petroianu A. Diagnosis of acute appendicitis. Int J Surg. 2012; 10:115-119. Mazeh H et al. Tip appendicitis: clinical implications and management. Amer J Surg. 2009; 197:211-215. Puig S et al. Imaging of Appendicitis in Children and Adolescents. Semin Roentgenol. 2008; 22-28. Schizas AMP, Williams AB. Management of complex appendicitis. Surgery. 2010; 28(11):544-548. Shogilev DJ et al. Diagnosing Appendicitis: Evidence-Based Review. West J Emerg Med. 2014; 15(4):859-871. Wray CJ et al. Acute Appendicitis: Controversies in Diagnosis and Management. Current Problems in Surgery. 2013; 50:54-86 Intestinal Obstruction Babl FE et al. Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial. Pediatrics. 2009 Jun;123(6):1548-55 Chinn WM, Zavala DC, Ambre J. Plasma levels of lidocaine following nebulized aerosol administration. Chest 1977;71(3):346-8. Cullen L et al. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med. 2004 Aug;44(2):131-7. Gangopadhyay AN, Wardhan H. Intestinal obstruction in children in India. Pediatr Surg Int. 1989; 4:84-87. Hajivassiliou CA. Intestinal Obstruction in Neonatal/Pediatric Surgery. Semin Pediatr Surg. 2003; 12(4):241-253. Hazra NK et al. Acute Intestinal Obstruction in children: Experience in a Tertiary Care Hospital. Am J Pub Health Res. 2015; 3(5):53-56. Kuo YW et al. Reducing the pain of nasogastric tube intubation with nebulized and atomized lidocaine: a systematic review and meta-analysis. J Pain Symptom Manage. 2010 Oct;40(4):613-20.  . Pediatric Surgery Irish MS et al. The Approach to Common Abdominal Diagnoses in Infants and Children. Pedaitr Clin N Am. 1998; 45(4):729-770. Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emerg Med Clin N Am. 2007; 25:1009-1040. McCullough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin N Am. 2003; 21:909-935. Pepper VK et al. Diagnosis and Management of Pediatric Appendicitis, Intussusception, and Meckel Diverticulum. Surg Clin N Am. 2012   This post and podcast are dedicated to Mr Ross Fisher for his passion and spirit of collaboration in all things #FOAMed.  Thank you, sir!

Myocardial infarction (MI) in children is uncommon, but underdiagnosed.  This is due to two main factors: the etiologies are varied; and the presenting symptoms are “atypical”. We need a mental metal detector!  Case examples Congenital Two main presentations of MI due to congenital lesions: novel and known.  The novel presentation is at risk for underdiagnosis, due to its uncommonness and vague, atypical symptoms.  There are usually some red flags with a careful H&P.  The known presentation is a child with a history of congenital heart disease, addressed by corrective or palliative surgery.  This child is at risk for expected complications, as well as overdiagnosis and iatrogenia.  Risk stratify, collaborate with specialists. The fussy, sweaty feeder: ALCAPA Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) is an example of what can go wrong during fetal development: any abnormality in the number, origin, course, or morphology of the coronary arteries can present as a neonate with sweating during feeds (steal syndrome), an infant in CHF, or an older child with failure to thrive or poor exercise tolerance. The stable child with chest pain: myocardial bridge Normal coronary arteries run along the epicardial surface of the heart, with projections into the myocardium.  If part of the artery’s course runs within the myocardium (i.e. the artery weaves into and/or out of the myocardium), then there is a myocardial bridge of the coronary artery.  With every systolic contraction, the artery is occluded.  Although a myocardial bridge may not cause symptoms (especially at distal portions), the area it supplies is at risk. With any minor trauma or exertion, demand may outpace supply, resulting in ischemia.  Diagnosis is made on coronary angiography. The unwell child post-cardiac surgery: Fontan problems The child with single ventricle physiology may have a Norwood procedure at birth (creation of a neoaorta, atrial septectomy, and Blalock-Taussig shunt), a Bidirectional Glenn procedure at 3-6 months (shunt removed, superior vena cava connected to pulmonary arteries), and a Fontan procedure at about 2-3 years of age (inferior vena cava blood flow is shunted into the pulmonary arteries). These children depend on their preload to run blood passively into the pulmonary circuit; afterload reduction is also important to compensate for a poor left ejection fraction, as well as to avoid the development of pulmonary hypertension.  They are typically on an anticoagulant (often aspirin), a diuretic (e.g. furosemide), and an afterload reduction agent (e.g. enalapril).  Any disturbance in volume status (hyper- or hypovolemia), anticoagulation, or afterload may cause myocardial strain or infarction.  Take the child s/p Fontan seriously and involve his specialists early with any concerns. Autoimmune The body’s inflammatory-mediated reaction to a real or perceived insult can cause short- and long-term cardiac sequelae.  Find out how well the underlying disease is controlled, and what complications the child has had in the past. The red, hot, crispy, flaky child: acute Kawasaki disease Kawasaki disease (KD) is an acute systemic vasculitis, diagnosed by the presence of fever for five or more days accompanied by four or more criteria:  bilateral conjunctival injection, mucositis, cervical lymphadenopathy, polymorphous rash, and palmar or sole desquamation.  The criteria may occur (and disappear) at any time during the illness. Infants are under double jeopardy with Kawasaki Disease.  They are more likely to have incomplete KD (i.e. not fulfill strict criteria) and if they have KD, they are more likely to suffer the dangerous consequences of aneurysm formation (chiefly coronary arteries, but also brain, kidney).  Have a low threshold for investigation. Treatment includes 2 g/kg/day IVIG and high-dose aspirin (30-50 mg/kg/day) acutely, then low-dose aspirin (5 mg/kg/day) for weeks to months.  Regular and long-term follow-up with Cardiology is required. The aftermath: sequelae of Kawasaki disease The family and child with a history of KD may have psychological trauma and continuous anxiety about the child’s risk of MI.  Approximately 4.7% of children who were promptly diagnosed and correctly treated will go on to have cardiac sequelae. Children who have no detected cardiac sequelae by 8 weeks, typically continue to be asymptomatic up to 20 years later.  Smaller aneurysms tend to regress over time, especially those < 6 mm. Thrombi may calcify, or the lumen may become stenotic due to myofibroblast proliferation.  Children with any coronary artery dilatation from KD should be followed indefinitely. Giant aneurysms (≥8 mm) connote the highest risk for MI.  Parents often are concerned about recurrence, and any subsequent fever can be distressing.  There is a low rate of recurrence for KD: approximately 2%.  Infants who have coronary aneurysms are at the highest risk for recurrence. The older child with vague chest complaints and hypercoagulability: Systemic Lupus Erythematosus and Anti-Phospholipid Syndrome Up to 15% of cases of SLE begin in childhood.  Adult criteria are used, with the caveat that the diagnosis of SLE in children can be challenging; many children only manifest a few of the criteria initially before going on to develop further systemic involvement. The Systemic Lupus International Collaborating Clinics (SLICC) revised the criteria in 2012.  The patient should have ≥4/17 clinical and/or immunologic criteria.  The clinical criteria are: acute cutaneous (malar); chronic cutaneous (discoid); oral; alopecia; synovitis; serositis; renal; neurologic; hemolytic anemia; leukopenia; or thrombocytopenia.  The immunologic criteria are: ANA; anti-dsDNA; anti-Sm; antiphospholipid; low complement; and/or Direct Coombs (in absence of hemolytic anemia).  At least one criterion should be clinical, and at least one should be immunologic.  Children with antiphospholipid syndrome (APS) may occur with or without SLE.  Patients are at risk for venous and arterial thrombi formation.  APS may also cause structural damage, such as valvular thickening and valvular nodes (Libman-Sacks endocarditis).  Mitral and aortic valves are at the highest risk. Although most children with chest pain will not have MI, those with comorbidities should be investigated carefully. Trauma Direct, blunt trauma to the chest can cause myocardial stunning, dysrhythmias, or an asymptomatic rise in Troponin I.  However, some children are at risk for disproportionate harm due to a previously unknown risk factor.  Clinically significant cardiac injury occurs in up to 20% of patients with non-penetrating thoracic trauma. The motor vehicle collision: blunt myocardial injury Direct trauma (steering wheel, airbag, seatbelt), especially in fast acceleration-deceleration injury, may cause compression of the heart between the sternum and the thoracic spine. Electrocardiography (ECG) should be performed on any patient with significant blunt chest injury.  A negative ECG is highly consistent with no significant blunt myocardial injury. Any patient with a new abnormality on ECG (dysrhythmia, heart block, or signs of ischemia) should be admitted for continuous ECG monitoring. Elevation in troponin is common, but not predicted.  A solitary elevated troponin without ECG abnormality is of unclear significance.  Author’s advice: obtain troponin testing if there is an abnormal ECG, more than fleeting suspicion of BCI, and/or the child will be admitted for monitoring. Hemodynamically labile children should be resuscitated and a stat transesophageal echocardiogram obtained. The high-velocity object: coronary artery dissection or thrombus Direct trauma (e.g. MVC, baseball, high-velocity soccer ball) may cause damage to the left anterior descending artery or left circumflex artery, at the highest risk due to their proximity to the chest wall.  Thrombosis and/or dissection may result, often presenting in a focal pattern of ischemia on the ECG. Echocardiography may reveal valvular damage related to the injury, as well as effusion and ejection fraction.  Since there is often a need to investigate the coronary anatomy, percutaneous coronary intervention (PCI) is recommended. The minor trauma with disproportionate complaint: myocardial bridge As mentioned in the congenital section (above), a known variation of a coronary artery’s course involves weaving in and out of the myocardium, creating a baseline risk for ischemia.  Even minor trauma in a child with a myocardial bridge may cause acute thrombus, or slow stenosis from resulting edema.  Unfortunately, the presence of myocardial bridging is often unknown at the time of injury.  Approximately 25% of the population may have myocardial bridging, based on autopsy studies. Take the child seriously who has disproportionate symptoms to what should be a minor injury. Hematologic Coagulopathic and thrombophilic states may predispose children to focal cardiac ischemia.  The best documented cormorbidity is sickle cell disease, although other pro-thrombotic conditions also put the child at risk. The child with sickle cell disease and chest pain: when it’s not acute chest syndrome Sickle cell disease (SCD) can affect any organ system, although the heart is traditionally considered a lower-risk target organ for direct sickling and ischemia.  The major cardiac morbidity in sickle cell is from strain, high-output failure and multiple, serial increases in myocardial demand, causing left ventricular hypertrophy and congestive heart failure. However, there is mounting evidence that acute myocardial ischemia in sickle cell disease may be underappreciated and/or attributed to other causes of chest pain. Other cardiac sequelae from SCD include pulmonary hypertension, left ventricular dysfunction, right ventricular dysfunction, and chronic iron overload. Evidence of myocardial ischemia/infarction in children with SCD has been demonstrated on single-photon emission computed tomography (SPECT) scan. The puffy faced child with chest pain: nephrotic syndrome hypercoagulability Children who suffer from nephrotic syndrome lose proteins that contribute to the coagulation cascade.  In addition, lipoprotein profiles are altered: there is a rise in the very low-density lipoproteins (LDL), contributing to accelerated atherosclerosis.  Typically nephrotic patients have normal levels of high-density lipoproteins (HDL), unless there is profuse proteinuria. Children with difficult-to-control nephrotic syndrome (typically steroid-resistant) may form accelerated plaques that rupture, causing focal MI, as early as school age. The previously well child now decompensated: undiagnosed thrombophilia Asymptomatic patent foramen ovale (PFO) is the cause of some cases of cryptogenic vascular disease, such as stroke and MI.  However, the presence of PFO alone does not connote higher risk.  When paired with an inherited or acquired thrombogenic condition, the venous thrombus may travel from the right-sided circulation to the left, causing distal ischemia.  Many of these cases are unknown until a complication arises. The chronically worried, now with a reason: hypercholesterolemia A family history of adult-onset hypercholesterolemia is not necessarily a risk factor for early complications in children, provided the child does not have the same acquired risk factors as adults (e.g. obesity, sedentary lifestyle, smoking, etc).  Parents may seek help in the ED for children with chest pain and no risk factors, but adult parents who have poor cholesterol profiles. The exception is the child with familial hypercholesterolemia, who is at risk for accelerated atherosclerosis and MI. Infectious Myocarditis has varied etiologies, including infectious, medications (chemotherapy agents), immunologic (rheumatologic, transplant rejection), toxins (arsenic, carbon monoxide, heavy metals such as iron or copper), or physical stress (electrical injury, heat illness, radiation). In children, the most common cause of myocarditis is infectious (viruses, protozoa, bacteria, fungal, parasites).  Of these, viral causes are the most common (adenovirus, enterovirus, echovirus, rubella, HHV6). The verbal child may complain of typical chest complaints, or may come in with flu-like illness and tachycardia or ill appearance out of proportion to presumed viral illness. The most common presenting features in children with myocarditis are: shortness of breath, vomiting, poor feeding, hepatomegaly, respiratory distress, and fever. The infant in shock after a ‘cold’: myocarditis Beware of the poor feeding, tachycardic, ill appearing infant who “has a cold” because everyone else around him has a ‘cold’.  That may very well be true, but any virus can be invasive with myocardial involvement.  Infants are only able to increase their cardiac output through increasing their heart rate; they cannot respond to increased demands through ionotropy.  Look for signs of acute heart failure, such as hepatomegaly, respiratory distress, and sacral edema. The child with tachycardia out of proportion to complaint: myocarditis The previously healthy child with “a bad flu” may simply be very symptomatic from influenza-like illness, or he may be developing myocarditis.  Look for chest pain and tachycardia out of proportion to presumed illness, and constant chest pain, not just associated with cough. The “pneumonia” with suspicious chest x-ray: myocarditis Acute heart failure may mimic viral pneumonia.  Look for disproportionate signs and symptoms. Toxins Younger children may get into others’ medications, be given dangerous home remedies, take drugs recreationally, have environmental exposures (heavy metals), suffer from a consequence of a comorbidity (iron or copper overload) or have adverse events from generally safe medications. The hyperactive boy with a hyperactive precordium: methylphenidate Attention deficit hyperactivity disorder (ADHD) is growing in rate of diagnosis and use of medications.  As the only medical diagnosis based on self-reported criteria, many children are given stimulants regardless of actual neurologic disorder; with a higher proportion of children exposed to stimulants, adverse effects are seen more commonly. Methylphenidate is related to amphetamine, and they both are dopaminergic drugs.  Their mechanisms of action are different, however.  Methylphenidate increases neuronal firing rate.  Methamphetamine reduces neuronal firing rate; cardiovascular sequelae such as MI and CHF are more common in chronic methamphetamine use. Although methylphenidate is typically well tolerated, risks include dysrhythmias such as ventricular tachycardia. The child with seizure disorder and chest pain: anti-epileptics Some anti-epileptic agents, such as carbamazepine, promote a poor lipid profile, leading to atherosclerosis and early MI.  Case reports include school-aged children on carbamazepine who have foamy cells in the coronary arteries, aorta, and vasa vasorum on autopsy.  It is unclear whether this is a strong association. The spice trader: synthetic cannabinoids Synthetic cannabinoids are notoriously difficult to regulate and study, as the manufacturers label them as “not for human consumption”.  Once reports surface of abuse of a certain compound, the formula is altered slightly and repackaged, often in a colorful or mysterious way that is attractive to teenagers. The misperceptions are: are a) synthetics are related to marijuana and therefore safe and b) marijuana is inherently “safe”. Both tend to steer unwitting teens to take these unknown entities.  Some suffer MI as a result. Exposure to tetrahydrocannabinol (THC) in high-potency marijuana has been linked to myocardial ischemia, ventricular tachycardia, and ventricular fibrillation.  Marijuana can increase the heart rate from 20-100%, depending on the amount ingested. K2 (“kush 2.0”) or Spice (Zohai, Genie, K3, Bliss, Nice, Black Mamba, fake weed, etc) is a mixture of plant leaves doused in synthetic chemicals, including cannabinoids and fertilizer (JWH-108), none of which are tested or safe for human consumption.  Synthetic cannabinoids have a higher affinity to cannabinoid receptors, conferring higher potency, and therefore worse adverse effects.  They are thought to be 100 to 800 times more potent as marijuana. Bath salts (Purple Wave, Zoom, Cloud Nine, etc) can be ingested, snorted, or injected.  They typically include some form of cathinone, such as mephedrone, similar to the substance found in the naturally occurring khat plant. Hallucinations, palpitations, tachycardia, MI, and dysrhythmias have been reported from their use as a recreational drug. Chest pain with marijuana, synthetic cannabinoid, or bath salt ingestion should be investigated and/or monitored. Riding that train: high on cocaine Cocaine is a well-known cause of acute MI in young people.  In addition to the direct stimulant causes acutely, such as hypertension, tachycardia, and impaired judgement (coingestions, risky behavior), chronic cocaine use has long-term sequelae.  Cocaine causes accelerated atherosclerosis.  That, in conjunction with arterial vasospasm and platelet activation, is a recipe for acute MI in the young. Cranky: methamphetamine Methamphetamine is a highly addictive stimulant that is relatively inexpensive and widely available.  Repeated use causes multiple psychiatric, personality, and neurologic changes.  Risky behavior, violence, and motor vehicle accidents are all linked to this drug.  Like cocaine, methamphetamine may cause fatal dysrhythmias, acute MI from demand ischemia, and long-term sequelae such as congestive heart failure. Summary Acute MI is a challenging presentation in children: Easily missed: uncommon and atypical Varied etiology Respect vague symptoms with a non-reassuring H&P Try to detect it: CATH IT! References Congenital AboulHosn JA et al. Fontan Operation and the Single Ventricle. Congenit Heart Dis. 2007; 2:2-11. Aliku TO et al. A case of anomalous origin of the left coronary artery presenting with acute myocardial infarction and cardiovascular collapse. African Health Sci. 2014; 14(1): 23-227. Andrews RE et al. Acute myocardial infarction as a cause of death in palliated hypoplastic left heart syndrome. Heart. 2004; 90:e17. Canale LS et al. Surgical treatment of anomalous coronary artery arising from the pulmonary artery. Interactive Cardiovascaulr and Thoracic Surgery. 2009; 8:67-69. Güvenç O et al. Correctable Cause of Dilated Cardiomyopathy in an Infant with Heart Failure: ALCAPA Syndrome. J Curr Pediatr. 2017; 15:47-50. Hastings RS et al. Embolic Myocardial Infarction in a Patient with a Fontan Circulation. World Journal for Pediatric Congenital Heart Surgery. 2014; 5(4)L631-634. Hoffman JIE et al. Electrocardiogram of Anomalous Left Coronary Artery From the Pulmonary Artery in Infants. Pediatr Cardiol. 2013; 34(3):489-491. Kei et al. Rare Case of Myocardial Infarction in a 19-Year-Old Caused by a Paradoxical Coronary Artery Embolism. Perm J.2015; 19(2):e107-e109. Liu Y, Miller BW. ALCAPA Presents in an Adult with Exercise Inlerance but Preserved Cardiac Function. Case Reports Cardiol. 2012; AID 471759. Möhlenkamp S et al. Update on Myocardial Bridging.Circulation. 2002;106:2616-2622. Murgan SJ et al. Acute myocardial infraction n the neonatal period. Cardiol Young. 2002; 12:411-413. Sieweke JT et al. Myocardial infarction in grown up patients with congenital heart disease: an emergening high-risk combination. International Journal of Cardiology. 2016; 203:138-140. Schwerzmann M et al. Anomalous Origin of the Left Coronary Artery From the Main Pulmonary Artery in Adults. Circulation. 2004; 110:e511-e513. Tomkewicz-Pajak L et al. Arterial stiffness in adult patients after Fontan procedure. Cardiovasculr Ultrasound. 2014; 12:15. Varghese MJ et al. The caveats in the diagnosis of anomalous origin of left coronary artery from pulmonary artery (ALCAPA). Images Paediatr Cardiol. 2010; 12(3): 3–8. Autoimmune Ayala et al. Acute Myocardial Infarction in a Child with Systemic Lupus Erythematosus and Antiphospholipid Syndrome. Turk J Rheumatol. 2009; 24:156-8. Nakano H et al. Clinical characteristics of myocardial infarction following Kawasaki disease: Report of 11 cases. J Pediatr. 1986; 108(2):198-203. Pongratz G et al. Myocardial infarction in an adult resulting from coronary aneurysms previously documented in childhood after an acute episode of Kawasaki’s disease. European Heart J. 1994. 15:1002-1004. Newburger JW et al.  Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. A Statement for Health Professionals From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004;110:2747-2771. Son MB et al. Kawaski Disease. Pediatr Rev. 2013; 34(4). Yuan S. Cardiac surgical procedures for the coronary sequelae of Kawasaki disease. Libyan J Med. 2012; 7:19796. Trauma Abdolrahim SA et al. Acute Myocardial Infarction Following Blunt Chest Trauma and Coronary Artery Dissection. J Clin Diagnost Res. 2016; 10(6):14-15. Galiuto L et al. Post-traumatic myocardial infarction with hemorrhage and microvascular damage in a child with myocardial bridge: is coronary anatomy actor or bystander. Signa Vitae. 2013; 8(2):61-63. Janella BL et al. Acute Myocardial Infarction related to Blunt Thoracic Trauma. Arq Bras Cardiol. 2006; 87:e168-e171. Liu X et al. Acute myocardial infarction in a child with myocardial bridge World J Emerg Med. 2011; 2(1):70-72. Long WA et al. Childhood Traumatic Infarction Causing Left Ventricular Aneurysm: Diagnosis by Two-Dimensional Echocardiography. JACC. 1985; 5(6):1478-83. Smith S. Right Bundle Branch Block after Blunt Trauma: A Tragic Case. [Blog Post] July 22, 2012. Retrievable at: http://hqmeded-ecg.blogspot.com/2012/07/right-bundle-branch-block-after-blunt.html. Hematologic Carano N et al. Acute Myocardial Infarction in a Child: Possible Pathogenic Role of Patent Foramen Ovale Associated with Heritable Thrombophilia. Pediatr. 2004; 114(2):255-258.      Chacko P et al. Myocardial Infarction in Sickle Cell Disease. J Cardiovascl Transl Res. 2013; 6(5):752-761. De Montalembert M et al. Myocardial ischaemia in children with sickle cell disease. Arch Dis Child. 2004; 89:359-362. Gladwin MT et al. Cardiovascular Abnormalities in Sickle Cell Disease. JACC. 2012; 59(13):1123-1133. Osula S et al. Acute myocardial infarction in young adults: causes and management. Postgrad Med J. 2002; 78:27-30. Silva JMP et al. Premature acute myocardial infarction in a child with nephrotic syndrome. Pediatr Nephrol. 2002; 17:169-172. Suryawanshi SP. Myocardial infarction in children: Two interesting cases. Ann Pediatr Cardiol. 2011 Jan-Jun; 4(1): 81–83. Infectious Cunningham R et al. Viral myocarditis Presenting with Seizure and Electrocardiographic Findings of Acute Myocardial Infarction in a 14-Month-Old Child. Ann Emerg Med. 2000; 35(6):618-622. De Vettten L et al. Neonatal Myocardial Infarction or Myocarditis? Pediatr Cardiol. 2011; 32:492-497. Durani Y et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med. 2009; 27:942-947. Erden I et al. Acute myocarditis mimicking acute myocardial infarction associated with pandemic 2009 (H1N1) influenza virus. Cardiol J. 2011; 552-555. Hover MH et al. Acute Myocarditis Simulating Myocardial Infarction in a Child. Pediatr. 1191; 87(2):250-252. Lachant D et al. Meningococcemia Presenting as a Myocardial Infarction. Case Reports in Critical Care. 2015; AID 953826. Laissy JP et al. Differentating Myocardial Infarction from Myocarditis. Radiology. 2005; 237(1):75-82. Miranda CH et al. Evaluation of Cardiac Involvement During Dengue Viral Infection. CID. 2013; 57:812-819. Rettig JS et al. Myocarditis in Children Requiring Critical Care Transport. In:  "Diagnosis and Treatment of Myocarditis", Milei J, Ambrosio G (Eds). DOI: 10.5772/56177. Toxins De Chadarévian JP et al. Epilepsy, Atherosclerosis, Myocardial Infarction, and Carbamazepine. J Child Neurol. 2003; 18(2):150-151. McIlroy G et al. Acute myocardial infarction, associated with the use of a synthetic adamantly-canabinoid: a case report. BMC Pharmacology and Toxicology. 2016; 17:2. Mir A et al. Myocardial Infarction Associated with Use of the Synthetic Cannabinoid K2. Pediatr. 2011; 128(6):1-6 Munk K et al. Cardiac Arrest following a Myocardial Infarction in a Child Treated with Methylphenidate. Case Reports Pediatr. 2015; AID 905097. Rezkalla SH et al. Cocaine-Induced Acte Mycardial Infarction. Clin Med Res. 2007; 5(3):172-176. Schelleman H et al. Methylphenidate and risk of serious cardiovascular events in adults. Am J Psychiatry. 2012 Feb;169(2):178-85. Sheridan J et al. Injury associated with methamphetamine use: a review of the literature. Harm Reduction Journal, 2006; 3(14):1-18. Stiefel G et al. Cardiovascular effects of methylphenidate, amphetamines and atomoxetine in the treatment of attention-deficit hyperactivity disorder. Drug Saf. 2010 Oct 1;33(10):821-42.   This post and podcast are dedicated to Edwin Leap, MD for his sanity and humanity in the practice of Emergency Medicine.  Thank you, Dr Leap for all that you do.

When should you commit to getting urine? When can you wait? When should you forgo testing altogether? When do I get urine? Symptoms – either typical dysuria, urgency, frequency in a verbal child, or non-descript abdominal pain or vomiting in a well appearing child. Fever – but first look for an obvious alternative source, especially viral signs or symptoms. No obvious source? Risk stratify before “just getting a urine”. In a low risk child, with obviously very vigilant parents, who is well appearing, you may choose not to test now, and ensure close follow up. Bag or cath? The short answer is: always cath, never bag. (Pros and cons in audio) What is the definition of a UTI? According to the current clinical practice guideline by the AAP, the standard definition of a urinary tract infection is the presence of BOTH pyuria AND at least 50 000 colonies per mL of a single uropathogen. Making the diagnosis in the ED: The presence of WBCs with a threshold of 5 or greater WBCs per HPF is required. What else goes into the urinalysis that may be helpful? Pearl: nitrites are poorly sensitive in children.  It takes 4 hours for nitrites to form, and most children this age do no hold their urine. Pearl: the enhanced urinalysis is the addition of a gram stain.  A positive gram stain has a LR+ of 87 in infants less than 60 days, according to a study by Dayan et al. in Pediatric Emergency Care. When can I just call it pyelonephritis? In an adult, we look for UTI plus evidence of focal upper tract involvement, like CVA tenderness to percussion or systemic signs like nausea, vomiting, or fever.  It is usually straightforward. It’s for this reason that the literature uses the term “febrile UTI” for children.  Fever is very sensitive, but not specific in children. The ill-appearing child has pyelonephritis.   The well-appearing child likely has a “febrile UTI”, without upper involvement.  However, undetected upper tract involvement may be made in retrospect via imaging, if done. How should I treat UTIs? For simple lower tract disease, treat for at least 7 days.  There is no evidence to support 7 versus 10 versus 14 days.  My advice: use 7-10 days as your range for simple febrile UTI in children. Pyelonephritis should be treated for a longer duration.  Treat pyelonephritis for 10-14 days. What should we give them? Sulfamethoxazole and trimethoprim (Bactrim) is falling out of favor, mostly because isolates in many communities are resistant.  There is an association of Stevens-Johnson Syndrome (SJS) with Bactrim use.  This may be confounded by its prior popularity; any antibiotic can cause SJS, but there are more case reports with Bactrim. Cephalexin (Keflex): 25 mg/kg dose, either BID or TID.  It is easy on the stomach, rarely interacts with other meds, has high efficacy against E. coli, and most importantly, cephalexin has good parenchymal penetration. Nitrofurantoin is often used in pregnant women, because the drug tends to concentrate locally in the urine.  However, blood and tissue concentrations are weak.  It may be ineffective if there is some sub-clinical upper tract involvement. Cefdinir is a 3rd generation cephalosporin available by mouth, given at 14 mg/kg in either one dose daily or divided BID, up to max of 600 mg.  This may be an option for an older child who has pyelonephritis, but is well enough to go home. Whom should we admit? The first thing to consider is age.  Any infant younger than 2 months should be admitted for a febrile UTI.  Their immune systems and physiologic reserve are just not sufficient to localize and fight off infections reliably. The truth is, for serious bacterial illness like pneumonia, UTI, or severe soft tissue infections, be careful with any infant less than 4-6 months of age. Of course, the unwell child – whatever his age – he should be admitted.  Think about poor feeding, irritability, dehydration – in that case, just go with your gut and call it pyelonephritis, and admit. What is the age cut-off for a urine culture? In adults, we think of urine culture only for high-risk populations, such as pregnant women, the immunocompromised, those with renal abnormalities, the neurologically impaired, or the critically ill, to name a few. In children, it’s a little simpler.  Do it for everyone. Who is everyone? Think of the urine rule of 10s: 10% of young febrile children will have a UTI 10% of UAs will show no evidence of pyuria Routine urine culture in all children with suspected or confirmed UTI up to about age 10 What do I do then with urine culture results? From a quality improvement and safety perspective, consider making this a regular assignment to a qualified clinician. Check once in 24-48 hours to find possible growth of a single uropathogen with at least 50 000 CFU/mL.  Look at the record to see that the child is one some antibiotic, or the reason why he may not.  Call the family if needed. A second check at 48-72 hours may be needed to verify speciation and sensitivities. The culture check, although tedious, is important to catch those small children who did not present with pyuria and who may need antibiotics, or to verify that the right agent is given. Ok, so your UA is negative…now what? The culture is cooking, but you are not convinced.  Below is the differential diagnosis for common causes of pyuria in children:   What kind of follow-up should the child get? The younger the child, the more we worry about missing a decompensation.  Encourage the parents to call the child's primary care clinician for a re-check in a few days, and to discuss whether or not further work-up such as imaging is indicated.  As always, strict return to ED precautions are helpful. Who needs imaging? A more accurate question is: what is an important anomaly to detect? Vesiculo-ureteral reflux – a loose ureteropelvic junction causes upstream reflux when the bladder constricts. Uretero-pelvic junction obstruction – in older children or young adults with hematuria, UTI, abdominal mass, or pain.  Infants born with UPJ obstruction have congenital hydronephrosis. Ureterocoele – a cystic mass in the bladder.  It is not malignant, but can cause ureteral dilation, and hydronephrosis.  Treatment is surgical. Ectopic ureter – either a duplication of the draining system, or an abnormal connection, such as the epidydimis or cervix. Posterior urethral valves – occur only in boys, and they are a bit of a misnomer.  The most common type of congenital bladder outlet obstruction, posterior urethral valves are just extra folds of membrane in the lumen of the prostatic urethra.  Usually ablation by cystoscopy does the trick. Urachal remnant – a leftover from fetal development, and an abnormal connection between the bladder and the umbilicus.  Look for an “always wet” belly button in an infant, or an umbilical mass with pain and fever in an older child. Imaging of choice as an outpatient? Renal and bladder ultrasound (RBUS) after the first UTI is recommended (although incompletely followed in practice). If the RBUS is positive, or with the second UTI, DMSA scan to evaluate possible renal scarring. So, with all of this testing – are we over doing it? Like anything, it’s a balance.  A few tips to avoid iatrogenia by way of a summary. If a child over 3 months of age is well, has no comorbidities, has a low grade fever "in the 38s" (38-38.9 °C) without a source, especially if less than 24 hours, you are very safe to do watchful waiting at home. More to the point, an otherwise well child with an obvious upper respiratory tract infection has a source of his fever. If your little patient has risk factors for UTI, or you are otherwise concerned, send the UA and send the culture.  You can opt out of the culture by middle school in the otherwise healthy child. And finally, deputize parents to carry the ball from here – the child needs ongoing primary care and his pediatrician may elect to do some screening.  Don’t promise or prime them for it – rather, encourage the conversation. BONUS: Suprapubic aspiration (details in podcast audio; video below) BONUS BONUS: Infant Clean Catch Technique Step One: feed the baby, wait twenty minutes.     Step Two: clean the genitals with soap and warm water and dry with gauze.  Have your sterile urine container open and at the ready.     Step Three: one person holds the baby under his armpits with his legs dangling.  The other person gently taps the bladder (100 taps/min), then massages the lower back for 30 seconds.     Step Four: Clean Catch! (can also repeat process)   References Bonsu BK, Shuler L, Sawicki L, Dorst P, Cohen DM. Susceptibility of recent bacterial isolates to cefdinir and selected antibiotics among children with urinary tract infections. Acad Emerg Med. 2006 Jan;13(1):76-81. Coulthard MG, Lambert HJ, Vernon SJ, Hunter EW, Keir MJ, Matthews JN. Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits. Arch Dis Child. 2014 Apr;99(4):342-7. Dayan PS et al.  Test characteristics of the urine Gram stain in infants