Podcast appearances and mentions of arch intern med

This week we talk about all things bone health on the podcast.  From what foods to eat to improve bone health and reduce the risk of hip fractures, to the calcium 'thieves' hidden in our diets, to exercise and much much more.  Dr. Rajiv Bajekal (MS, FRCS Orth., MCh Orth., IBLM) is a Consultant Spinal Surgeon based in London with over 35 years of expertise in Orthopaedics and Spinal Surgery. Specialising in the lumbar spine, he has a deep focus on managing conditions such as sciatica, low back pain, spinal stenosis, osteoporotic fractures, and infections. Dr. Bajekal prioritizes holistic and often non-surgical solutions for patients in severe pain, combining his surgical knowledge with his expertise as a Board-Certified Lifestyle Medicine Practitioner. A strong advocate for lifestyle medicine, Dr. Bajekal has personally experienced the transformative benefits of a whole-food, plant-based diet and incorporates these principles into his practice.  Dr. Bajekal has contributed to the UK's first plant-based nutrition course at Winchester University, where he developed a module on bone health and osteoporosis. He also co-authored a chapter on bone health in the academic book Plant-Based Nutrition in Clinical Practice. Passionate about education, he is known for making complex spinal topics accessible and engaging. For more information, visit www.rajivbajekal.com and follow him on Instagram @drrajivbajekal Relevant studies:1. Tong, T.Y.N., Appleby, P.N., Armstrong, M.E.G. et al. Vegetarian and vegan diets and risks of total and site-specific fractures: results from the prospective EPIC-Oxford study. BMC Med 18, 353 (2020). https://doi.org/10.1186/s12916-020-01815-3 2.     Gómez-Cabello A, Ara I, González-Agüero A, Casajús JA, Vicente-Rodríguez G. Effects of training on bone mass in older adults: a systematic review. Sports Med. 2012;1;42(4):301-25. 3.  Messina M. Soy and Health Update: Evaluation of the Clinical and Epidemiologic Literature. Nutrients. 2016;8(12):754. Published 2016 Nov 24. doi:10.3390/nu8120754 4.  Sahni S, Mangano KM, McLean RR, Hannan MT, Kiel DP. Dietary Approaches for Bone Health: Lessons from the Framingham Osteoporosis Study. Curr Osteoporos Rep. 2015;13(4):245-255. doi:10.1007/s11914-015-0272-1 5.  Qiu, Rui & Cao, Wen-ting & Tian, Hui-yuan & He, Juan & Chen, Gengdong & Chen, Yu Ming. (2017). Greater Intake of Fruit and Vegetables Is Associated with Greater Bone Mineral Density and Lower Osteoporosis Risk in Middle-Aged and Elderly Adults. PLOS ONE. 12. e0168906. 10.1371/journal.pone.0168906.6.  Wallace TC. Dried Plums, Prunes and Bone Health: A Comprehensive Review. Nutrients. 2017 Apr 19;9(4):401. doi: 10.3390/nu9040401. PMID: 28422064; PMCID: PMC5409740.7.  Sahni S, Mangano KM, McLean RR, Hannan MT, Kiel DP. Dietary Approaches for Bone Health: Lessons from the Framingham Osteoporosis Study. Curr Osteoporos Rep. 2015 Aug;13(4):245-55. doi: 10.1007/s11914-015-0272-1. PMID: 26045228; PMCID: PMC4928581.8.  Laird E, Ward M, McSorley E, Strain JJ, Wallace J. Vitamin D and bone health: potential mechanisms. Nutrients. 2010 Jul;2(7):693-724. doi: 10.3390/nu2070693. Epub 2010 Jul 5. PMID: 22254049; PMCID: PMC3257679.9.  Bolland M J, Avenell A, Baron J A, Grey A, MacLennan G S, Gamble G D et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis BMJ 2010; 341 :c3691 doi:10.1136/bmj.c369110.  Bolland MJ, Grey A, Avenell A, Gamble GD, Reid IR. Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women's Health Initiative limited access dataset and meta-analysis. BMJ. 2011 Apr 19;342:d2040. doi: 10.1136/bmj.d2040. PMID: 21505219; PMCID: PMC3079822.11.  Li K, Kaaks R, Linseisen J, et alAssociations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg)Heart 2012;98:920-92512.  Price CT, Langford JR, Liporace FA. Essential Nutrients for Bone Health and a Review of their Availability in the Average North American Diet. Open Orthop J. 2012;6:143-149. doi:10.2174/187432500120601014313.  Bawa S. The significance of soy protein and soy bioactive compounds in the prophylaxis and treatment of osteoporosis. J Osteoporos. 2010 Mar 8;2010:891058. doi: 10.4061/2010/891058. PMID: 20981338; PMCID: PMC295724114.  Zhang X, Shu X, Li H, et al. Prospective Cohort Study of Soy Food Consumption and Risk of Bone Fracture Among Postmenopausal Women. Arch Intern Med. 2005;165(16):1890–1895. doi:10.1001/archinte.165.16.189015.  Tucker KL, Morita K, Qiao N, Hannan MT, Cupples LA, Kiel DP. Colas, but not other carbonated beverages, are associated with low bone mineral density in older women: The Framingham Osteoporosis Study. Am J Clin Nutr. 2006 Oct;84(4):936-42. doi: 10.1093/ajcn/84.4.936. PMID: 17023723. 16.  Chen L, Liu R, Zhao Y, Shi Z. High Consumption of Soft Drinks Is Associated with an Increased Risk of Fracture: A 7-Year Follow-Up Study. Nutrients. 2020;12(2):530. Published 2020 Feb 19. doi:10.3390/nu1202053017.  Cheraghi Z, Doosti-Irani A, Almasi-Hashiani A, Baigi V, Mansournia N, Etminan M, Mansournia MA. The effect of alcohol on osteoporosis: A systematic review and meta-analysis. Drug Alcohol Depend. 2019 Apr 1;197:197-202. doi:10.1016/j.drugalcdep.2019.01.025. Epub 2019 Feb 27. PMID: 30844616.18.  Chang HC, Hsieh CF, Lin YC, Tantoh DM, Ko PC, Kung YY, Wang MC, Hsu SY, Liaw YC, Liaw YP. Does coffee drinking have beneficial effects on bone health of Taiwanese adults? A longitudinal study. BMC Public Health. 2018 Nov 20;18(1):1273. doi: 10.1186/s12889-018-6168-0. PMID: 30453911; PMCID: PMC6245613.19.  Benedetti, Maria Grazia & Furlini, Giulia & Zati, Alessandro & Letizia Mauro, Giulia. (2018). The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients. BioMed Research International. 2018. 1-10. 10.1155/2018/4840531.

Un nouvel épisode du Pharmascope est disponible et on s'attaque cette fois au trouble d'usage d'alcool. Dans cette première partie, Nicolas, Isabelle et une nouvelle invitée discutent du dépistage et de l'évaluation de cette maladie sous diagnostiquée, en plus de réviser la prise en charge du sevrage alcoolique. Les objectifs pour cet épisode sont: Procéder au dépistage du trouble d'usage d'alcool Diagnostiquer un trouble d'usage d'alcool Discuter des bénéfices et des désavantages associés aux principaux traitements pharmacologiques du sevrage alcoolique Ressources pertinentes en lien avec l'épisode Lignes directrices canadiennes récentes en trouble d'usage d'alcoolWood E, Bright J, Hsu K, et coll. Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder. CMAJ. 2023 Oct 16;195(40):E1364-E1379. Repères canadiens sur l'alcool et la santé : rapport final. Centre canadien sur les dépendances et l'usage de substances. 2023 Guide canadien sur les risques associés à l'usage d'alcoolCoalition canadienne pour la santé mentale des personnes pagées. Lignes directrices sur le trouble lié à l'utilisation de l'alcool chez les personnes âgées. 2023. Guide de l'INESSS sur la prise en charge du trouble d'utilisation d'alcoolINESSS. Sevrage d'alcool et prévention des rechutes. 2021. US Preventive Services Task Force; Curry SJ, Krist AH, Owens DK, et coll. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Nov 13;320(18):1899-1909. Mitchell AJ, Bird V, Rizzo M, et coll. Accuracy of one or two simple questions to identify alcohol-use disorder in primary care: a meta-analysis. Br J Gen Pract. 2014 Jul;64(624):e408-18. Bush K, Kivlahan DR, McDonell MB, et coll. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998 Sep 14;158(16):1789-95. Maldonado JR, Sher Y, Das S, et coll. Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome. Alcohol Alcohol. 2015 Sep;50(5):509-18. Kaner EF, Beyer FR, Muirhead C, et coll. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018 Feb 24;2(2):CD004148. Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD005063. Daeppen JB, Gache P, Landry U, et coll. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002 May 27;162(10):1117-21. Elholm B, Larsen K, Hornnes N, Zierau F, Becker U. Alcohol withdrawal syndrome: symptom-triggered versus fixed-schedule treatment in an outpatient setting. Alcohol Alcohol. 2011 May-Jun;46(3):318-23. Minozzi S, Amato L, Vecchi S, Davoli M. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD005064. Airagnes G, Valter R, Ducoutumany G, Vansteene C, Trabut JB, Gorwood P, Dubertret C, Matta J, Charles-Nelson A, Limosin F. Magnesium in the treatment of alcohol withdrawal syndrome: a multicenter randomized controlled trial. Alcohol Alcohol. 2023 May 9;58(3):329-335.

Did you know that one simple change in your kitchen could transform your health? In today's episode, Miles Hassell, MD, explores the extensive health benefits of extra virgin olive oil (EVOO). Drawing on three lines of evidence, he makes a compelling case for making EVOO your primary kitchen fat. A few takeaways from Miles Hassell, MD: Studies have shown that EVOO supports gut health. A healthy gut can contribute to improved digestion, a stronger immune system, and even better mental health. Regular consumption of EVOO has been associated with a lower incidence of dementia. This connection underscores the importance of incorporating EVOO into your diet as part of a proactive approach to brain health. Research indicates that higher consumption of olive oil is linked to a lower incidence of certain cancers. The powerful antioxidant and anti-inflammatory properties of EVOO play a significant role in reducing cancer risk. One of the most well-documented benefits of EVOO is its ability to lower the risk of heart disease. Unlike other vegetable oils, EVOO has been consistently shown to promote cardiovascular health.   Miles Hassell, MD emphasizes that EVOO is not just a cooking ingredient but a therapeutic tool. Its unique composition of monounsaturated fats, antioxidants, and anti-inflammatory compounds makes it a powerhouse for health promotion.  While other vegetable oils lack the same level of evidence for health benefits, EVOO stands out for its protective effects. When compared to other oils, EVOO consistently comes out on top.  Making the switch to EVOO can be a simple yet powerful change to improve your overall health. So next time you're cooking, reach for the EVOO and enjoy both its flavor and its multitude of health benefits.   Join the cause! Support the podcast and be a champion of a future episode by donating here: https://greatmed.org/donate/ For more information and references head to: https://greatmed.org   Purchase Good Food Great Medicine    Twitter (X): https://x.com/greatmedorg Instagram: @mileshassellmd Facebook: https://www.facebook.com/people/GreatMedorg/61554645308577/ Substack: https://substack.com/@greatmed YouTube: https://www.youtube.com/@greatmedicine email: info@greatmed.org   References for Today's Episode: Markellos C, Ourailidou ME, Gavriatopoulou M, Halvatsiotis P, Sergentanis TN, Psaltopoulou T. Olive oil intake and cancer risk: A systematic review and meta-analysis. PLoS One. 2022 Jan 11;17(1):e0261649. doi: 10.1371/journal.pone.0261649. PMID: 35015763; PMCID: PMC8751986. Millman JF, Okamoto S, Teruya T, Uema T, Ikematsu S, Shimabukuro M, Masuzaki H. Extra-virgin olive oil and the gut-brain axis: influence on gut microbiota, mucosal immunity, and cardiometabolic and cognitive health. Nutr Rev. 2021 Nov 10;79(12):1362-1374. doi: 10.1093/nutrit/nuaa148. PMID: 33576418; PMCID: PMC8581649. Guasch-Ferré M, Hruby A, Salas-Salvadó J, Martínez-González MA, Sun Q, Willett WC, Hu FB. Olive oil consumption and risk of type 2 diabetes in US women. Am J Clin Nutr. 2015 Aug;102(2):479-86. doi: 10.3945/ajcn.115.112029. Epub 2015 Jul 8. PMID: 26156740; PMCID: PMC4515873 Valls-Pedret C, Lamuela-Raventós RM, Medina-Remón A, Quintana M, Corella D, Pintó X, Martínez-González MÁ, Estruch R, Ros E. Polyphenol-rich foods in the Mediterranean diet are associated with better cognitive function in elderly subjects at high cardiovascular risk. J Alzheimers Dis. 2012;29(4):773-82. doi: 10.3233/JAD-2012-111799. PMID: 22349682. Moreno-Luna R, Muñoz-Hernandez R, Miranda ML, Costa AF, Jimenez-Jimenez L, Vallejo-Vaz AJ, Muriana FJ, Villar J, Stiefel P. Olive oil polyphenols decrease blood pressure and improve endothelial function in young women with mild hypertension. Am J Hypertens. 2012 Dec;25(12):1299-304. doi: 10.1038/ajh.2012.128. Epub 2012 Aug 23. PMID: 22914255. Cougnard-Grégoire A, Merle BM, Korobelnik JF, Rougier MB, Delyfer MN, Le Goff M, Samieri C, Dartigues JF, Delcourt C. Olive Oil Consumption and Age-Related Macular Degeneration: The Alienor Study. PLoS One. 2016 Jul 28;11(7):e0160240. doi: 10.1371/journal.pone.0160240. PMID: 27467382; PMCID: PMC4965131. Kien CL, Bunn JY, Tompkins CL, Dumas JA, Crain KI, Ebenstein DB, Koves TR, Muoio DM. Substituting dietary monounsaturated fat for saturated fat is associated with increased daily physical activity and resting energy expenditure and with changes in mood. Am J Clin Nutr. 2013 Apr;97(4):689-97. doi: 10.3945/ajcn.112.051730. Epub 2013 Feb 27. Erratum in: Am J Clin Nutr. 2013 Aug;98(2):511. PMID: 23446891; PMCID: PMC3607650. Guasch-Ferré M, Liu G, Li Y, Sampson L, Manson JE, Salas-Salvadó J, Martínez-González MA, Stampfer MJ, Willett WC, Sun Q, Hu FB. Olive Oil Consumption and Cardiovascular Risk in U.S. Adults. J Am Coll Cardiol. 2020 Apr 21;75(15):1729-1739. doi: 10.1016/j.jacc.2020.02.036. Epub 2020 Mar 5. PMID: 32147453; PMCID: PMC7233327. Ferrara LA, Raimondi AS, d'Episcopo L, Guida L, Dello Russo A, Marotta T. Olive oil and reduced need for antihypertensive medications. Arch Intern Med. 2000 Mar 27;160(6):837-42. doi: 10.1001/archinte.160.6.837. PMID: 10737284. Priore P, Cavallo A, Gnoni A, Damiano F, Gnoni GV, Siculella L. Modulation of hepatic lipid metabolism by olive oil and its phenols in nonalcoholic fatty liver disease. IUBMB Life. 2015 Jan;67(1):9-17. doi: 10.1002/iub.1340. Epub 2015 Jan 28. PMID: 25631376. Gutiérrez-Repiso C, Soriguer F, Rojo-Martínez G, García-Fuentes E, Valdés S, Goday A, Calle-Pascual A, López-Alba A, Castell C, Menéndez E, Bordiú E, Delgado E, Ortega E, Pascual-Manich G, Urrutia I, Mora-Peces I, Vendrell J, Vázquez JA, Franch J, Girbés J, Castaño L, Serrano-Ríos M, Martínez-Larrad MT, Catalá M, Carmena R, Gomis R, Casamitjana R, Gaztambide S. Variable patterns of obesity and cardiometabolic phenotypes and their association with lifestyle factors in the Di@bet.es study. Nutr Metab Cardiovasc Dis. 2014 Sep;24(9):947-55. doi: 10.1016/j.numecd.2014.04.019. Epub 2014 Jun 9. PMID: 24984822. Ramsden CE, Zamora D, Leelarthaepin B, Majchrzak-Hong SF, Faurot KR, Suchindran CM, Ringel A, Davis JM, Hibbeln JR. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis. BMJ. 2013 Feb 4;346:e8707. doi: 10.1136/bmj.e8707. Erratum in: BMJ. 2013;346:f903. PMID: 23386268; PMCID: Juul F, Vaidean G, Lin Y, Deierlein AL, Parekh N. Ultra-Processed Foods and Incident Cardiovascular Disease in the Framingham Offspring Study. J Am Coll Cardiol. 2021 Mar 30;77(12):1520-1531. doi: 10.1016/j.jacc.2021.01.047. PMID: 33766258. Schnabel L, Kesse-Guyot E, Allès B, Touvier M, Srour B, Hercberg S, Buscail C, Julia C. Association Between Ultraprocessed Food Consumption and Risk of Mortality Among Middle-aged Adults in France. JAMA Intern Med. 2019 Apr 1;179(4):490-498. doi: 10.1001/jamainternmed.2018.7289. PMID: 30742202; PMCID: PMC6450295. ​​Lane MM, Gamage E, Du S, Ashtree DN, McGuinness AJ, Gauci S, Baker P, Lawrence M, Rebholz CM, Srour B, Touvier M, Jacka FN, O'Neil A, Segasby T, Marx W. Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses. BMJ. 2024 Feb 28;384:e077310. doi: 10.1136/bmj-2023-077310. PMID: 38418082; PMCID: PMC10899807. Alonso-Pedrero L, Ojeda-Rodríguez A, Martínez-González MA, Zalba G, Bes-Rastrollo M, Marti A. Ultra-processed food consumption and the risk of short telomeres in an elderly population of the Seguimiento Universidad de Navarra (SUN) Project. Am J Clin Nutr. 2020 Jun 1;111(6):1259-1266. doi: 10.1093/ajcn/nqaa075. PMID: 32330232. Taneri PE, Wehrli F, Roa-Díaz ZM, Itodo OA, Salvador D, Raeisi-Dehkordi H, Bally L, Minder B, Kiefte-de Jong JC, Laine JE, Bano A, Glisic M, Muka T. Association Between Ultra-Processed Food Intake and All-Cause Mortality: A Systematic Review and Meta-Analysis. Am J Epidemiol. 2022 Jun 27;191(7):1323-1335. doi: 10.1093/aje/kwac039. PMID: 35231930.    

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities. Episodes originally aired from 2016 to 2021.Originally released: November 14, 2019The FDA label for ACTEMRA® (tocilizumab)--the first medication approved for use in giant cell arteritis in 2017--is 40 pages long. Of the information provided in this document, which includes important dosing information, dose adjustments based on leukocyte count, clinical trial and epidemiologic data, there is a box of text on the first page of the insert. "WARNING: RISK OF SERIOUS INFECTIONS," it reads.What do you make of this warning? And with such a clear and broad-sweeping statement stamped on the medication, how do you mitigate the medico-legal risk of using this drug?This week on the program we launch into a two-part series focused on some of the events that follow major clinical trials. In part 1, we cover the three major classifications of FDA alerts for medical treatments using two examples from the neurologic pharmacopoeia. In part 2, we emphasize the importance of post-publication peer review. And both are equally instrumental in our medical decision-making.Produced by James E Siegler with the support of Michael Rubenstein (University of Pennsylvania) and Zachary Newcomer (University of Florida). Music courtesy of Coldnoise, Cuicuitte, Doctor Turtle, Jahzzar, and Peter Rudenko under a CC license. Sound effects by Mike Koenig and Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. None of what is discussed here should be misconstrued as medical advice, so don't just go prescribing drugs off-label! (Or willy nilly, as my grandmother might say) Be sure to follow us on Twitter (now X) @brainwavesaudio for the latest updates to the podcast.REFERENCESBallard C, Hanney ML, Theodoulou M, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol 2009;8(2):151-7. PMID 19138567Dorsey ER, Beck CA, Darwin K, et al. Natural history of Huntington disease. JAMA Neurol 2013;70(12):1520-30. PMID 24126537Hubers AA, van Duijn E, Roos RA, et al. Suicidal ideation in a European Huntington's disease population. J Affect Disord 2013;151(1):248-58. PMID 23876196Moore TJ, Singh S, Furberg CD. The FDA and new safety warnings. Arch Intern Med 2012;172(1):78-80. PMID 22232155Rose RV, Kass JS. Prescribing antipsychotic medications to patients with dementia: boxed warnings and mitigation of legal liability. Continuum (Minneap Minn) 2019;25(1):254-9. PMID 30707196Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294(15):1934-43. PMID 16234500Schultz JL, Killoran A, Nopoulos PC, Chabal CC, Moser DJ, Kamholz JA. Evaluating depression and suicidality in tetrabenazine users with Huntington disease. Neurology 2018;91(3):e202-7. PMID 29925548Shen V, Clarence-Smith K, Hunter C, Jankovic J. Safety and efficacy of tetrabenazine and use of concomitant medications during long-term, open-label treatment of chorea associated with Huntington's an

Contributor: Ricky Dhaliwal MD Educational Pearls: Primary adrenal insufficiency (most common risk factor for adrenal crises) An autoimmune condition commonly known as Addison's Disease Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids Mineralocorticoid deficiency leads to hyponatremia and hypovolemia Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules Water follows sodium and generates a hypovolemic state Glucocorticoid deficiency contributes further to hypotension and hyponatremia Decreased vascular responsiveness to angiotensin II Increased secretion of vasopressin (ADH) from the posterior pituitary An adrenal crisis is defined as a sudden worsening of adrenal insufficiency Presents with non-specific symptoms including nausea, vomiting, fatigue, confusion, and fevers Fevers may be the result of underlying infection Work-up in the ED includes labs looking for infection and adding cortisol + ACTH levels Emergent treatment is required 100 mg hydrocortisone bolus followed by 50 mg every 6 hours Immediate IV fluid repletion with 1L normal saline The most common cause of an adrenal crisis is an acute infection in patients with baseline adrenal insufficiency Often due to a gastrointestinal infection References 1. Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1 2. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. doi:10.1210/jc.2015-1710 3. Cronin CC, Callaghan N, Kearney PJ, Murnaghan DJ, Shanahan F. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. 1997;157(4):456-458. 4. Feldman RD, Gros R. Vascular effects of aldosterone: sorting out the receptors and the ligands. Clin Exp Pharmacol Physiol. 2013;40(12):916-921. doi:10.1111/1440-1681.12157 5. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884  Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit  

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: November 8, 2018 A patient comes into the emergency department. They've got a headache. You get some basic labs, a chest x-ray, and a CT scan. And then you get a drug screen. But does this information even help you? And could it hurt the patient? This week on the BrainWaves podcast, Dr. Emily Rosenthal shares her experience with Dr. Kelley Humbert on the ethics of toxicology "screening" and how she manages patients with a substance use disorder. Produced by Emily Rosenthal, Kelley Humbert, and Jim Siegler. Music by Montplaisir, Lee Rosevere, and Kevin McLeod. Sound effects by Mike Koenig, Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Bates GP, Dorsey R, Gusella JF, et al. Huntington disease. Nat Rev Dis Primers 2015;1:15005. PMID 27188817Eisen JS, Sivilotti ML, Boyd KU, Barton DG, Fortier CJ, Collier CP. Screening urine for drugs of abuse in the emergency department: do test results affect physicians' patient care decisions? CJEM 2004;6(2):104-11. PMID 17433159Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med 2010;363(24):2320-31. PMID 21142534Lager PS, Attema-de Jonge ME, Gorzeman MP, Kerkvliet LE, Franssen EJ. Clinical value of drugs of abuse point of care testing in an emergency department setting. Toxicol Rep 2017;5:12-17. PMID 29270362Silver B, Miller D, Jankowski M, et al. Urine toxicology screening in an urban stroke and TIA population. Neurology 2013;80(18):1702-9. PMID 23596074Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med 2010;170(13):1155-60. PMID 20625025Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol (Phila) 2009;47(4):286-91. PMID 19514875 We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

Kaue, Ingrid e Luísa conversam sobre os riscos da hipocalemia e como fazer reposição de potássio: classificação da hipocalemia, quais os riscos, reposição enteral, reposição venosa e quando usar diuréticos poupadores de potássio, tudo neste episódio. Referências: Ferreira JP, Butler J, Rossignol P, et al. Abnormalities of Potassium in Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(22):2836-2850. doi:10.1016/j.jacc.2020.04.021 Kim GH, Han JS. Therapeutic approach to hypokalemia. Nephron. 2002;92 Suppl 1:28-32. doi:10.1159/000065374 Cohn JN, Kowey PR, Whelton PK, Prisant LM. New guidelines for potassium replacement in clinical practice: a contemporary review by the National Council on Potassium in Clinical Practice. Arch Intern Med. 2000;160(16):2429-2436. doi:10.1001/archinte.160.16.2429 Kim MJ, Valerio C, Knobloch GK. Potassium Disorders: Hypokalemia and Hyperkalemia. Am Fam Physician. 2023;107(1):59-70. Asmar A, Mohandas R, Wingo CS. A physiologic-based approach to the treatment of a patient with hypokalemia. Am J Kidney Dis. 2012;60(3):492-497. doi:10.1053/j.ajkd.2012.01.031 Grobbee DE, Hoes AW. Non-potassium-sparing diuretics and risk of sudden cardiac death. J Hypertens. 1995;13(12 Pt 2):1539-1545. Ferreira JP, Butler J, Rossignol P, et al. Abnormalities of Potassium in Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(22):2836-2850. doi:10.1016/j.jacc.2020.04.021 Goyal A, Spertus JA, Gosch K, et al. Serum Potassium Levels and Mortality in Acute Myocardial Infarction. JAMA. 2012;307(2):157–164. doi:10.1001/jama.2011.1967 Macdonald JE, Struthers AD. What is the optimal serum potassium level in cardiovascular patients?. J Am Coll Cardiol. 2004;43(2):155-161. doi:10.1016/j.jacc.2003.06.021

An eponymous sign that helps in the diagnosis of glandular fever.     Check out the paper mentioned.   Otsuki T, Ishizuka K, Hirose M, Ie K. Hoagland sign in infectious mononucleosis. BMJ Case Rep. 2022 Nov 16;15(11):e252839. https://pubmed.ncbi.nlm.nih.gov/36384885/    Check out the obituary of Colonel Robert. J. Hoagland MD - https://courierpostonline.newspapers.com/article/the-charlotte-observer-robert-j-hoagland/82137229/   Check out the Patient.info page on glandular fever, written by Dr Colin Tidy - https://patient.info/ears-nose-throat-mouth/sore-throat-2/glandular-fever-infectious-mononucleosis    Check out the book review of Hoagland's book. Moser RH. Infectious Mononucleosis. Arch Intern Med. 1968;121(6):572. doi:10.1001/archinte.1968.03640060086018    www.rnzcuc.org.nz podcast@rnzcuc.org.nz https://www.facebook.com/rnzcuc https://twitter.com/rnzcuc   Music licensed from www.premiumbeat.com Full Grip by Score Squad   This podcast is intended to assist in ongoing medical education and peer discussion for qualified health professionals.  Please ensure you work within your scope of practice at all times.  For personal medical advice always consult your usual doctor 

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: September 21, 2017 Atrial fibrillation increases your risk of clotting. Anticoagulation increases your risk of bleeding. Surgery increases your risk of both. Dr. Mike Rubenstein speaks with Dr. Jim Siegler this week about how providers weigh the risks and benefits of anticoagulant bridging in the perioperative setting. Produced by Michael Rubenstein and James E Siegler. Music by Chris Zabriskie, Lee Rosevere, and Jason Shaw. Voiceover by Erika Mejia. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. REFERENCES Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med 2008;168(1):63-9. PMID 18195197Raval AN, Cigarroa JE, Chung MK, et al. Management of patients on non-vitamin K antagonist oral anticoagulants in the acute care and periprocedural setting: a scientific statement from the American Heart Association. Circulation 2017;135(10):e604-33. Erratum in: Circulation 2017;135(10 ):e647. Erratum in: Circulation 2017;135(24):e1144. PMID 28167634Rechenmacher SJ, Fang JC. Bridging anticoagulation: primum non nocere. J Am Coll Cardiol 2015;66(12):1392-403. PMID 26383727Schulman S, Carrier M, Lee AY, et al. Perioperative management of dabigatran: a prospective cohort study. Circulation 2015;132(3):167-73. PMID 25966905Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation 2015;131(5):488-94. PMID 25499873Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation 1991;84(2):527-39. PMID 1860198  We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date. 

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: May 14, 2020 Can you hear that too? You can't? Well, that doesn't mean I'm having auditory hallucinations. It could just be tinnitus, which describes the irritating sound of ringing, buzzing, clicking, or hissing that affects 10% to 20% of the world's population. But is this a ringing in the ears or a ringing in the brain? Produced by James E Siegler. Music courtesy of Andrew Sacco, Jon Watts, Kai Engel, Lovira, Patches, and Kevin McLeod. Unless otherwise mentioned in the podcast, no competing financial interests exist in the content of this episode. Sound effects by Mike Koenig and Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Arenberg IK, Countryman LF, Bernstein LH, Shambaugh GE Jr. Van Gogh had Menière's disease and not epilepsy. JAMA 1990;264(4):491-3. PMID 2094236 Crummer RW, Hassan GA. Diagnostic approach to tinnitus. Am Fam Physician 2004;69(1):120-6. PMID 14727828 Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope 1999;109(8):1202-11. PMID 10443820 Han BI, Lee HW, Kim TY, Lim JS, Shin KS. Tinnitus: characteristics, causes, mechanisms, and treatments. J Clin Neurol 2009;5(1):11-9. PMID 19513328 Langguth B, Kreuzer PM, Kleinjung T, De Ridder D. Tinnitus: causes and clinical management. Lancet Neurol 2013;12(9):920-30. PMID 23948178 Lockwood AH. Tinnitus. Neurol Clin 2005;23(3):893-900, viii. PMID 16026681 Lockwood AH, Salvi RJ, Burkard RF, Galantowicz PJ, Coad ML, Wack DS. Neuroanatomy of tinnitus. Scand Audiol Suppl 1999;51:47-52. PMID 10803913 Mattox DE, Hudgins P. Algorithm for evaluation of pulsatile tinnitus. Acta Otolaryngol 2008;128(4):427-31. PMID 18368578 Palomar García V, Abdulghani Martínez F, Bodet Agustí E, Andreu Mencía L, Palomar Asenjo V. Drug-induced otoxicity: current status. Acta Otolaryngol 2001;121(5):569-72. PMID 11583387 Sullivan M, Katon W, Russo J, Dobie R, Sakai C. A randomized trial of nortriptyline for severe chronic tinnitus. Effects on depression, disability, and tinnitus symptoms. Arch Intern Med 1993;153(19):2251-9. PMID 8215728  We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date. 

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: January 3, 2019 For young patients who have no reason to clot, it's good to know which diagnostic tests you should send, when you should send them, and how they can be erroneously interpreted. Dr. Kristy Yuan, a vascular neurologist from the University of Pennsylvania, summarizes her approach in this week's clinical case. Produced by James E Siegler and Kristy Yuan. Music by Chris Zabriskie, How the Night Came, Doctor Turtle, and Swelling. Sound effects by Mike Koenig and Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Cohn DM, Vansenne F, de Borgie CA, Middeldorp S. Thrombophilia testing for prevention of recurrent venous thromboembolism. Cochrane Database Syst Rev 2012;12(12):CD007069. PMID 23235639 Connors JM. Thrombophilia testing and venous thrombosis. N Engl J Med 2017;377(12):1177-87. PMID 28930509 Garcia D, Erkan D. Diagnosis and management of the antiphospholipid syndrome. N Engl J Med 2018;378(21):2010-21. PMID 29791828 Ho WK, Hankey GJ, Quinlan DJ, Eikelboom JW. Risk of recurrent venous thromboembolism in patients with common thrombophilia: a systematic review. Arch Intern Med 2006;166(7):729-36. PMID 16606808 Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report. Chest 2016;149(2):315-352. PMID 26867832 Mintzer DM, Billet SN, Chmielewski L. Drug-induced hematologic syndromes. Adv Hematol 2009;2009:495863. PMID 19960059  We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

De kwaliteit van je voeding blijkt nauw verbonden aan de kwaliteit van je slaap.   Mensen die niet zo lekker slapen hebben opvallend veel oxidatieve stress in hun lijf.   Wat is één van de grootste veroorzakers van oxidatieve stress in je lijf? Je raadt het al: het eten van dierlijke producten.   Kijk, een beetje oxidatie is normaal en voorkom je niet, maar als het opstapelt en niet onschadelijke wordt gemaakt ontstaat er stress.   Wat kan oxidatie oplossen? Precies: fruit en groen.   Alleen fruit en groen bevatten anti-oxidanten die oxidatie onschadelijk kunnen maken.   En ja hoor, uit experimenten bleek zowel uit objectieve als subjectieve metingen dat het eten van 2 stuks (kiwi) fruit, 1 uur voor het slapengaan, slechte slapers beter deed doen inslapen en 1 uur extra kwalitatieve slaap opleverde.   Haha, moet je nagaan als ongeveer je hele dieet uit fruit en groen bestaat ;-) Haha, en moet je nagaan wat er met je gebeurt als je eens een maand lang super super goed en diep slaapt?   Over dit en nog veel meer een podcast met Mirjam Reijnders   Wat doe je als je als kind onveilig bent gehecht? Last hebt van angst, depressie en daaropvolgend slaapproblemen ontwikkeld?   Mirjam Reijnders vertelt over hoe ze balans terugbracht in haar leven.   Equilibrium.   Hoe creëer je evenwicht en balans in jouw leven?   Daarover deze podcast.   Van wandelend hoofd naar voelen en samenwerken met het lijf. Veel luisterplezier!   Sta jij achter dit werk en wil dat het voortzet?   Supergaaf als je de podcast deelt met je vrienden, familie en op je socials.   Hoe meer abonnees, hoe meer likes en hoe meer financiële steun, hoe meer impact we kunnen maken. Win-win!   Via de knop doneren op de website www.jannekevandermeulen.nl/doneren kun je bijdragen.   Heb je dat al gedaan? Onwijs gaaf en een groot dankjewel!   Via: Spotify Apple podcast PodBean YouTube   Lees het boek De Eiwitleugen als je alles wil weten over een dieet rijk aan rauw fruit en planten.   Bestellen kan via: https://www.jannekevandermeulen.nl/product/de-eiwit-leugen/ Vrolijke groet en veel liefs, Janneke   De website van Mirjam is: https://equilibrium-training-coaching.nl/over-mirjam/     DE WIN-WIN METHODE | VOOR WINNAARS | ZONDER VERLIEZERS           BRONNEN: ​ Cohen et al,. Sleep Habits and Susceptibility to the Common Cold. Arch Intern Med. 2009 Jan 12;169(1):62-7.   ​Lin et al., Effect of kiwifruit consumption on sleep quality in adults with sleep problems. Asia Pac J Clin Nutr. 2011 20(2):169-174.          

Taking a minor break from ruffling the f*cking cages and feathers of what we call modern society these days and I wanted to talk about something a bit more conventional but important nevertheless and that is sleep. I have a multitude of studies for you to do your own research as I want to present this topic as clear cut as possible.   Time Stamps:   (0:28) Are You Enjoying the Podcast? (2:30) Going On a Journey With Sleep (6:40) Adverse Effects From Poor Sleep (16:30) Stress and the Blood-Brain Barrier (18:50) Naps ---------------------------- Resources: [i] Pilcher JJ, Walters AS. How sleep deprivation affects psychological variables related to college students' cognitive performance. J Am Coll Health. 1997 Nov;46(3):121-6. View Abstract [ii] Walker MP, et al. Practice with sleep makes perfect: sleep-dependent motor skill learning. Neuron. 2002 Jul 3;35(1):205-11. View Abstract [iii] Rosen IM, et al. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006 Jan;81(1):82-5. View Abstract [iv] Cohen S, et al. Sleep habits and susceptibility to the common cold. Arch Intern Med. 2009 Jan 12;169(1):62-7. View Full Paper [v] Patel SR, et al. Association between reduced sleep and weight gain in women. Am J Epidemiol. 2006 Nov 15;164(10):947-54. View Full Paper [vi] Donga E, et al. A single night of partial sleep deprivation induces insulin resistance in multiple metabolic pathways in healthy subjects. J Clin Endocrinol Metab. 2010 Jun;95(6):2963-8. View Abstract [vii] Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. 2000 Oct;57(10):649-55. View Full Paper [viii] Kim TW, Jeong JH, Hong SC. The impact of sleep and circadian disturbance on hormones and metabolism. Int J Endocrinol. 2015;2015:591729. View Full Paper [ix] Vgontzas AN, et al. IL-6 and its circadian secretion in humans. Neuroimmunomodulation. 2005;12(3):131-40. View Abstract [x] Meier-Ewert HK, et al. Absence of diurnal variation of C-reactive protein concentrations in healthy human subjects. Clin Chem. 2001 Mar;47(3):426-30. View Full Paper [xi] Meier-Ewert HK, et al. Effect of sleep loss on C-reactive protein, an inflammatory marker of cardiovascular risk. J Am Coll Cardiol. 2004 Feb 18;43(4):678-83. View Abstract [xii] van Leeuwen WM, et al. Sleep restriction increases the risk of developing cardiovascular diseases by augmenting proinflammatory responses through IL-17 and CRP. PLoS One. 2009;4(2):e4589. View Full Paper [xiii] Chennaoui M, et al. Effect of one night of sleep loss on changes in tumor necrosis factor alpha (TNF-α) levels in healthy men. Cytokine. 2011 Nov;56(2):318-24. View Abstract [xiv] Vgontzas AN, et al. Chronic insomnia is associated with a shift of interleukin-6 and tumor necrosis factor secretion from nighttime to daytime. Metabolism. 2002 Jul;51(7):887-92. View Abstract [xv] He J, et al. Sleep restriction impairs blood-brain barrier function. J Neurosci. 2014 Oct 29;34(44):14697-706. View Full Paper [xvi] Zlokovic BV. The blood-brain barrier in health and chronic neurodegenerative disorders. Neuron. 2008 Jan 24;57(2):178-201. View Abstract [xvii] Hurtado-Alvarado G, et al. Blood-Brain Barrier Disruption Induced by Chronic Sleep Loss: Low-Grade Inflammation May Be the Link. J Immunol Res. 2016;2016:4576012. View Full Paper [xviii] Esposito P, et al. Corticotropin-releasing hormone and brain mast cells regulate blood-brain-barrier permeability induced by acute stress. J Pharmacol Exp Ther. 2002 Dec;303(3):1061-6. View Full Paper [xix] Steiger A. Sleep and the hypothalamo-pituitary-adrenocortical system. Sleep Med Rev. 2002 Apr;6(2):125-38. View Abstract [xx] Vgontzas AN, et al. Daytime napping after a night of sleep loss decreases sleepiness, improves performance, and causes beneficial changes in cortisol and interleukin-6 secretion. Am J Physiol Endocrinol Metab. 2007 Jan;292(1):E253-61. View Full Paper ---------------------------- Follow Me on Instagram! @tayloredwellbeing ---------------------------- Click Here to Apply to Work with Me or visit taylorsappington.com/application

CUPOM: BLACKFRIDAYGUIA www.tadeclinicagem.com.br/guia - Conheça o Guia TdC com 7 dias grátis Um serviço de revisão e atualização continuados em clínica médica. A informação que você precisa, do jeito que você prefere. Junte-se aos mais de 800 assinantes. Assine o Guia, ganhe tempo e atualize-se sem esforço. Joanne, Kaue e Lucca conversam sobre armadilhas no tromboembolismo pulmonar (TEP): Quando pedir d-dímero e ajuste, em que momento iniciar a anticoagulação, como fazer a estratificação, quando trombolisar, qual anticoagulante iniciar, anticoagular ou não o TEP subsegmentar/assintomático e um pouco de TEP na gestante. Referências: 1. Kahn SR, de Wit K. Pulmonary Embolism. N Engl J Med. 2022 Jul 7;387(1):45-57. doi: 10.1056/NEJMcp2116489. PMID: 35793208. 2. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019; 54. 3. Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 163:701. 4. Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545. 5. Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation 2005; 112:e28. 6. Aujesky D, Obrosky DS, Stone RA, et al. A prediction rule to identify low-risk patients with pulmonary embolism. Arch Intern Med 2006; 166:169. 7. Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest 2013; 144:1539. 8. Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, Rutschmann OT, Sanchez O, Jaffrelot M, Trinh-Duc A, Le Gall C, Moustafa F, Principe A, Van Houten AA, Ten Wolde M, Douma RA, Hazelaar G, Erkens PM, Van Kralingen KW, Grootenboers MJ, Durian MF, Cheung YW, Meyer G, Bounameaux H, Huisman MV, Kamphuisen PW, Le Gal G. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014 Mar 19;311(11):1117-24. doi: 10.1001/jama.2014.2135. Erratum in: JAMA. 2014 Apr 23-30;311(16):1694. PMID: 24643601. 9. Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, Hutten BA, Jaff MR, Manja V, Schulman S, Thurston C, Vedantham S, Verhamme P, Witt DM, D Florez I, Izcovich A, Nieuwlaat R, Ross S, J Schünemann H, Wiercioch W, Zhang Y, Zhang Y. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020 Oct 13;4(19):4693-4738. doi: 10.1182/bloodadvances.2020001830. PMID: 33007077; PMCID: PMC7556153. 10. Duffett L, Castellucci LA, Forgie MA. Pulmonary embolism: update on management and controversies. BMJ. 2020 Aug 5;370:m2177. doi: 10.1136/bmj.m2177. PMID: 32759284. 11. van der Hulle T, Cheung WY, Kooij S, Beenen LFM, van Bemmel T, van Es J, Faber LM, Hazelaar GM, Heringhaus C, Hofstee H, Hovens MMC, Kaasjager KAH, van Klink RCJ, Kruip MJHA, Loeffen RF, Mairuhu ATA, Middeldorp S, Nijkeuter M, van der Pol LM, Schol-Gelok S, Ten Wolde M, Klok FA, Huisman MV; YEARS study group. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017 Jul 15;390(10091):289-297. doi: 10.1016/S0140-6736(17)30885-1. Epub 2017 May 23. Erratum in: Lancet. 2017 Jul 15;390(10091):230. PMID: 28549662.

During the ageing process, physical capabilities (e.g., muscular strength) and cognitive functions (e.g., memory) gradually decrease. Regarding cognitive functions, substantial functional (e.g., compensatory brain activity) and structural changes (e.g., shrinking of the hippocampus) in the brain cause this decline.From a glance:Dementia affects approximately 47 million individuals globally with projections of 130 million by the year 2050.Late-onset Alzheimer's disease is the most common form of dementia, accounting for approximately 75% of all cases and is characterized by a progressive decline in cognitive function, memory, and cerebral volume.The pathogenesis of Alzheimer's disease is poorly understood; however, aging, genetics, and an individual's diet and lifestyle over several decades appear to be key determinants.Excitingly, growing evidence points towards a relationship between cognition and measures of muscular strength and muscle mass. First part of this episode goes into the brain ageing process and the second half is about the effects of resistance training on brain function. Studies/ references mentioned:1. Wilke J, Giesche F, Klier K, Vogt L, Herrmann E, Banzer W. Acute effects ofresistance exercise on cognitive function in healthy adults: a systematic2. Stillman CM, Cohen J, Lehman ME, Erickson KI. Mediators of physical activityon neurocognitive function: a review at multiple levels of analysis. FrontHum Neurosci. 2016;10:6263. Liu-Ambrose T, Nagamatsu LS, Graf P, Beattie BL, Ashe MC, Handy TC. Resistance training and executive functions: a 12-month randomized controlled trial. Arch Intern Med. 2010;170:170–8You can follow me or contact me here ---Newsletter: https://bit.ly/3ewI5P0Instagram: louisanicola_Twitter : louisanicola_YouTube: Louisa NicolaThe information provided in this show is not medical advice, nor should it be taken or applied as a replacement for medical advice. The Neuro Experience podcast, its employees, guests and affiliates assume no liability for the application of the information discussed.

Description: An immersive viewing of The Broken Column by Frida Kahlo reflection on serious illness, chronic pain, medical gaze and resilience.  Artwork: The Broken Column: https://en.wikipedia.org/wiki/The_Broken_Column References: Herrera, Hayden. Frida Kahlo: The Paintings. Harper Perennial. 2002.Kahlo, Frida. The Diary of Frida Kahlo: an Intimate Self-Portrait. Abrams. 2005.Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med. 2012;172(19):1444–1453. Budrys V. Neurological deficits in the life and works of Frida Kahlo. Eur Neurol. 2006;55(1):4-10. 

Episode 100: Sexercise. Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD. Have you ever wondered if sex is a good workout? Drs. Civelli, Grewal and Arreaza discuss the topic based on evidence offered by science. The following episode is not recommended for young children or people who consider sex a sensitive topic. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's 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.___________________________Sexercise. Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD. A: If I say “bow chika wow wow” what's the first thing that comes to mind? The Chipmunks movie right?B: Yes, exactly, I can hear Alvin in his high-pitched voice, [higher tone] “bowchicka wow wow”. For those of you unfamiliar with this movie, don't feel too left out because even Alvin was hinting to exactly what you're thinking.A: Yep, we're going there today people.  Let's talk about sex.  Medically speaking of course. B: That's right because 1. If you're doing it, your risk for heart attacks and strokes are decreased after age 50 and 2. If you're not doing it, ask you're doctor, we should be discussing it and why not.A: Yes, that is the guideline-directed recommendation actually. We're recognizing more and more the importance of sexual activity in medicine and its impact on overall health, quality of life and even level of risk for mortality. However, given the sensitive nature of sexuality, few studies have been done to better correlate and define exactly what this means for our health specifically. Sex can be an embarrassing topic to discuss by patients, doctors and researchers which has been largely influenced by culture, religion and other societal norms.  Well, today let's break this proverbial glass. B: I agree, let's talk about sexuality activity and what research do we have.A: It has been said that Dr. Masters and Dr. Johnson were the earliest pioneers of this type of investigation. They published the first study of its kind in 1966, which examined the physiological responses of sexual activity. This was an 11-year observational study involving 382 females, ages 18 to 78, and 312 male volunteers, 21 to 89 years of age. The study identified a progressive increase in respiratory rates, up to 40 per minute, an increased heart rate 110 to 180 beats/min and an increase in systolic blood pressure by 30 to 80mmhg during sexual activity. In 1970, Hellerstein and Friedman identified the mean heart rate at the time of orgasm was 117.4 beats per minute with a range of 90 to 144. This was done in middle-age men, average age 47.5. Interestingly, the 24-hr ekg monitoring also identified a lower peak post coital heart rate, which was usually lower than the heart rates achieved with normal daily activities (around 120.1 beats per minute). In 1984, Bohlen et al. did a racier study with 10 couples using ECG, oxygen consumption (measured using a fast-responding polarographic O2 gas analyzer), heart rate and blood pressure monitoring before and during 4 types of sexual activity. This study obtained data during self-stimulation, partner stimulation, man-on-top and woman-on-top coitus.  The men were aged 25 to 43 years of age.  Results showed that self-stimulation increased the heart rate by 37 % from baseline to orgasm compared with a 51 % increase with man-on-top coitus. B: So already it was clear in 1966 to 1984 that physical exertion in the bedroom correlates to physiologic responses like increased heart rate, blood pressure, etc.  However, our question of the day is, does sexual activity count as exercise, and to that question we ask why or why not?A: When I think about exercise, I think about heart rate and blood pressure.  I think about indicators of energy expenditures and/or intensity. And specifically, while I'm working out…I'm talking about at the gym, and I'm running on the treadmill for example, my mental state is, how much longer until I can quit.  Duration and level of intensity while under this physical exertion feels most important. And according to the AHA, this has been heavily studied.  That's why 150 active intentional minutes of exercise are recommended per week to improve cardiovascular health. Does this translate to sexual activity? B: Well before we answer this, let's first mention the Bruce protocol. Have you ever heard of this? The Bruce protocol is a standard test of cardiovascular health, comprised of multiple stages of exertion on a treadmill, with three minutes spent per stage. Also at each stage, the incline and speed of the treadmill are elevated to increase cardiac work output, which is called METS. Stage 1 of the Bruce protocol is performed at 1.7 miles per hour and a 10% incline. Stage 2 is 2.5 mph and 12%, while Stage 3 goes to 3.4 mph and 14%. If you're a pilot for example, the FAA expects testing to achieve 85-100% of Maximum Predicted Heart Rate (220 minus your age) for a 9-minute duration.  With the Bruce protocol in mind, we circle back to our question of the day, does sex count as exercise?A: In 2007, Palmeri et al. reported that in 19 men and 13 women aged 40-75 years old, the intensity of sexual activity was comparable to stage II of the standard multistage Bruce protocol (moderate intensity) on a treadmill for men and stage I (low intensity) for women. In addition, maximal heart rate and blood pressure during sexual activity was approximately 75 % of that attained during maximum treadmill stress testing of the Bruce protocol. Collectively, based on these above studies, the physiological responses of sexual activity seem to be at a moderate intensity. B: Okay, so “you're saying there's a chance.” Right, one in a million Lloyd. Another movie reference, if you've seen the American classic Dumb and Dumber, you can appreciate it.  The point is, the level of intensity was identified by Palmeri's research but are we convinced sex may be used as exercise based on studies that were conducted more than a quarter of a century ago? As a studious, thriving resident physician, with a heavy background in research, I turned to Up to date for more data, and recommendations.  I had zero findings. Naturally I turned to Men's Health magazine to see what is out there to the general public:A: “You're in bed with your partner and you just finished a vigorous sex session. You're hot and sweaty, worked past that side cramp you got while thrusting, and are convinced you just burned as many calories as you would at the gym. You figure you can skip the treadmill today since your sex workout—a.k.a sex exercises, a.k.a sexercises—got you plenty of cardio.Well, we may have bad news: it depends on the type of sex you're having—specifically, how active you are during it, and how long you're having it—but unless you're really going at it for a couple of hours, odds are, it wasn't that great of a workout. To better quantify this, couples were evaluated while running on a treadmill for 30 minutes and compared to their sexercise. The results, which were published in the journal PLOS ONE, concluded that men burn 100 calories during the average sex session, while women burn about 69 calories. The researchers estimated that men burn roughly 4.2 calories per minute during sex, while women burn 3.1 calories. B: Men may be more physically active during sex which potentially explains why they burn more calories, study author Antony Karelis. But the main reason, Karelis told Time, is that “Men weigh more than women, and because of this, the energy expenditure will be higher in men for the same exercise performed.”It's also worth knowing that sex sessions in the study lasted an average of 25 minutes That's far longer than average. Times varied in the study, ranging from 10 to 57 minutes.  A: The longer the session, the more calories burned.  B: One study in the New England Journal of Medicine found that most sex sessions last six minutes. A: Here are some tips for burning more calories during sex:Make some moans and sighs to burn some extra calories.Change your position to make it more of a workout, especially women. If you're on top, move your hips like a belly dancer. It will feel good while giving you a workout.Experiment with a position where you squat on top of your partner and then bounce up and down. That's a great way to work out your thighs and rear.Try being on top rather than on the bottom, because research suggests that requires more energy.Kiss in unusual positions. Have the guy on his back. Do a push up on top of him. Come down to kiss him and then push back up.Take off your clothes in ways that burn calories. Draw it out and make it part of your foreplay. Or tease him as you get undressed. Do a seductive dance with a silk scarf, for example.Give a good massage to get your heart rate up. Ramp things up by going deeper. It's more sensual and works different muscles. Take turns so you can both get the calorie burn and its arousing impact. B: Harvard source:  During sexual intercourse, a man's heart rate rarely gets above 130 beats a minute, and his systolic blood pressure nearly always stays under 170. All in all, average sexual activity ranks as mild to moderate in terms of exercise intensity.  A: As for oxygen consumption, it comes in at about 3.5 METS (metabolic equivalents), which is about the same as taking a walk or playing ping pong. Sex burns about five calories a minute; that's four more calories used than watching TV. B: How do we decide if one is fit enough for sexual activity? For a 50-year-old man, the risk of having a heart attack in any given hour is about one in a million; sex doubles the risk, but it's still just two in a million. For men with heart disease, the risk is 10 times higher — but even for them, the chance of suffering a heart attack during sex is just 20 in a million. In short, if you are able to climb 3 flights of stairs, you are safe to proceed.  A: Circling back to exercise, keep in mind 4-5 calories burned per minute is still better than zero. Any time spent engaging in any level of physical activity is better than sitting on the couch.  B: Further, “Having sex for at least 10 minutes contributes to your cardiorespiratory health, increased serotonin levels (the happy hormone), and improved sleep,” Silberstang says. Studies have found that sex can relieve everything from anxiety and depression to high blood pressure.  A: When men orgasm, their bodies release serotonin, oxytocin, and prolactin, all hormones associated with better moods, relaxation, and lowered stress. Multiple studies have also found links between regular sex and a reduced risk for heart disease and prostate cancer, and a stronger immune system. One reason that sex isn't classified as a workout is due to its average duration: 3 to 13 minutes,” Silberstang explains. “So, naturally, one of the ways to make sex more of a cardio workout is to increase the time of the act.” C: The present study indicates that energy expenditure during sexual activity appears to be approximately 85 kcal or 3.6 kcal/min and seems to be performed at a moderate intensity in young healthy men and women. These results suggest that sexual activity may potentially be considered, at times, as a significant exercise. Moreover, both men and women reported that sexual activity was a highly enjoyable and more appreciated than the 30 min exercise session on the treadmill. Therefore, this study could have implications for the planning of intervention programs as part of a healthy lifestyle by health care professionals. B: We look forward to future studies that may further show the relationship between psychosocial/qualitative factors and energy expenditures which could explain how these variables could affect overall health and quality of life.____________________________Now we conclude episode 100, “Sexercise.” If you ever wondered if sexual intercourse was a good workout, today we learned that in general it is not an energy-demanding activity. The average man burns just 24 kilocalories during sex, but with some adjustments you can burn more calories, especially if the activity takes longer. If your patient is not having sex, they do not have to start having it just to exercise, remind everyone to be sexually responsible to prevent the spread of sexually transmitted infections and unintended pregnancies. Even without trying, every night you go to bed being a little wiser.Today we thank doctors Valerie Civelli, Namdeep Grewal, and Hector Arreaza. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week!_____________________References:Frappier, Julie; Isabelle Toupin, Joseph J. Levy, Mylene Aubertin-Leheudre, and Antony D. Karelis. Energy Expenditure during Sexual Activity in Young Healthy Couples, PLOS One, plos.org, Published: October 24, 2013, https://doi.org/10.1371/journal.pone.0079342. Casazza, Krista, Ph.D., R.D.; Kevin R. Fontaine, Ph.D.; Arne Astrup, M.D., Ph.D.; et al. Myths, Presumptions, and Facts about Obesity, N Engl J Med 2013; 368:446-454 DOI: 10.1056/NEJMsa1208051 Blaha, Michael Joseph, M.D., M.P.H. Is Sex Dangerous If You Have Heart Disease?. Health. Jons Hopkins Medicine, accessed June 20, 2022. https://www.hopkinsmedicine.org/health/wellness-and-prevention/is-sex-dangerous-if-you-have-heart-disease    Jackson G. Erectile dysfunction and cardiovascular disease. Arab J Urol. 2013;11(3):212-216. doi:10.1016/j.aju.2013.03.003. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442980/   DeBusk R, Drory Y, Goldstein I, Jackson G, Kaul S, Kimmel SE, Kostis JB, Kloner RA, Lakin M, Meston CM, Mittleman M, Muller JE, Padma-Nathan H, Rosen RC, Stein RA, Zusman R. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of The Princeton Consensus Panel. Am J Cardiol. 2000 Jul 15;86(2):175-81. doi: 10.1016/s0002-9149(00)00896-1. PMID: 10913479.Davey Smith G, Frankel S, Yarnell J (1997) Sex and death: are they related? Findings from the Caerphilly Cohort Study. BMJ 315: 1641-1644. doi:https://doi.org/10.1136/bmj.315.7123.1641. Ebrahim S, May M, Ben Shlomo Y, McCarron P, Frankel S et al. (2002) Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study. J Epidemiol Community Health 56: 99-102. doi:https://doi.org/10.1136/jech.56.2.99. Laumann EO, Glasser DB, Neves RC, Moreira ED Jr. (2009) A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res 21: 171-178. doi:https://doi.org/10.1038/ijir.2009.7. Lindau ST, Gavrilova N (2010) Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ 340: c810. doi:https://doi.org/10.1136/bmj.c810. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA et al. (2007) A study of sexuality and health among older adults in the United States. N Engl J Med 357: 762-774. doi:https://doi.org/10.1056/NEJMoa067423. McCall-Hosenfeld JS, Jaramillo SA, Legault C, Freund KM, Cochrane BB et al. (2008) Correlates of sexual satisfaction among sexually active postmenopausal women in the Women's Health Initiative-Observational Study. J Gen Intern Med 23: 2000-2009. doi:https://doi.org/10.1007/s11606-008-0820-9. Bartlett RG Jr. (1956) Physiologic responses during coitus. J Appl Physiol 9: 469-472. Bohlen JG, Held JP, Sanderson MO, Patterson RP (1984) Heart rate, rate-pressure product, and oxygen uptake during four sexual activities. Arch Intern Med 144: 1745-1748. doi:https://doi.org/10.1001/archinte.144.9.1745.  Hellerstein HK, Friedman EH (1970) Sexual activity and the postcoronary patient. Arch Intern Med 125: 987-999. doi:https://doi.org/10.1001/archinte.125.6.987.  Larson JL, McNaughton MW, Kennedy JW, Mansfield LW (1980) Heart rate and blood pressure responses to sexual activity and a stair-climbing test. Heart Lung 9: 1025-1030.  Masini V, Romei E, Fiorella AT (1980) Dynamic electrocardiogram in normal subjects during sexual activity. G Ital Cardiol 10: 1442-1448. Nemec ED, Mansfield L, Kennedy JW (1976) Heart rate and blood pressure responses during sexual activity in normal males. Am Heart J 92: 274-277. doi:https://doi.org/10.1016/S0002-8703(76)80106-8.  Palmeri ST, Kostis JB, Casazza L, Sleeper LA, Lu M et al. (2007) Heart rate and blood pressure response in adult men and women during exercise and sexual activity. Am J Cardiol 100: 1795-1801. doi:https://doi.org/10.1016/j.amjcard.2007.07.040. Casazza K, Fontaine KR, Astrup A, Birch LL, Brown AW et al. (2013) Myths, presumptions, and facts about obesity. N Engl J Med 368: 446-454. doi:https://doi.org/10.1056/NEJMsa1208051. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN et al. (2007) Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 39: 1423-1434. doi:https://doi.org/10.1249/mss.0b013e3180616b27.  Drenowatz C, Eisenmann JC (2011) Validation of the SenseWear Armband at high intensity exercise. Eur J Appl Physiol 111: 883-887. doi:https://doi.org/10.1007/s00421-010-1695-0.  Johannsen DL, Calabro MA, Stewart J, Franke W, Rood JC et al. (2010) Accuracy of armband monitors for measuring daily energy expenditure in healthy adults. Med Sci Sports Exerc 42: 2134-2140. doi:https://doi.org/10.1249/MSS.0b013e3181e0b3ff. Mackey DC, Manini TM, Schoeller DA, Koster A, Glynn NW et al. (2011) Validation of an armband to measure daily energy expenditure in older adults. J Gerontol A Biol Sci Med Sci 66: 1108-1113.  Mignault D, St-Onge M, Karelis AD, Allison DB, Rabasa-Lhoret R (2005) Evaluation of the Portable HealthWear Armband: a device to measure total daily energy expenditure in free-living type 2 diabetic individuals. Diabetes Care 28: 225-227. doi:https://doi.org/10.2337/diacare.28.1.225-a.  Ryan J, Gormley J (2013) An evaluation of energy expenditure estimation by three activity monitors. Eur J Sport Sci: 1-8. St-Onge M, Mignault D, Allison DB, Rabasa-Lhoret R (2007) Evaluation of a portable device to measure daily energy expenditure in free-living adults. Am J Clin Nutr 85: 742-749. Welk GJ, McClain JJ, Eisenmann JC, Wickel EE (2007) Field validation of the MTI Actigraph and BodyMedia armband monitor using the IDEEA monitor. Obesity (Silver Spring) 15: 918-928. doi:https://doi.org/10.1038/oby.2007.624. Wetten AA, Batterham M, Tan SY, Tapsell L (2013) Relative Validity of Three Accelerometer Models for Estimating Energy Expenditure During Light Activity. J Phys Act Health. Brazeau AS, Karelis AD, Mignault D, Lacroix MJ, Prud'homme D et al. (2011) Test-retest reliability of a portable monitor to assess energy expenditure. Appl Physiol Nutr Metab 36: 339-343. doi:https://doi.org/10.1139/h11-016. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN et al. (2007) Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation 116: 1081-1093. doi:https://doi.org/10.1161/CIRCULATIONAHA.107.185649. Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr. et al. (2011) 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc 43: 1575-1581. doi:https://doi.org/10.1249/MSS.0b013e31821ece12.  Steinke EE, Jaarsma T, Barnason SA, Byrne M, Doherty S et al. (2013) Sexual Counseling for Individuals With Cardiovascular Disease and Their Partners: A Consensus Document From the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP). Circulation. 

Episode 92: Paleo vs Keto vs Mediterranean. Sapna and Danish explain the main differences between three meal plans: Paleo, Keto, and Mediterranean. Intro about fad diets.Introduction: Fad diets.  By Hector Arreaza, MD.  It is estimated that 2/3 of Americans are overweight or have obesity (73% of men and 63% of women), but only 19% of people claim to “be on a diet”, and 77% of people are trying to “eat healthier”[1]. It seems like many of us are on the weight-loss wagon together, hoping for a cure for this disease.These days it is commonplace to hear about fad diets. Fad diets are short-lived eating patterns that make unrealistic claims about weight loss and improving health, with little to no effort on your part. “The Super-Duper diet will make you lose 100 pounds, eliminate your cellulite, erase stretch marks, remove your wrinkles, and give you extra energy to fly to the moon and back, buy the super-duper diet now!” We surely have a lot of products that make senseless promises, claim many victims, and leave people with empty pockets.   Today is May 6, 2022. Sapna and Danish will enlighten us again with more nutrition discussions. When you go around your grocery store, have you wondered what “keto-friendly” really means? We hope after today, you get a better idea about it. Today we are presenting a brief discussion to compare three common dietary approaches for weight loss: Keto, Paleo, and Mediterranean. I'm sure you have heard some things about these diets, but we want to add to your fund of knowledge. Whether they are fad diets or not, we'll let you decide. Enjoy it!  This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.___________________________Paleo vs Keto vs Mediterranean. Prepared by Sapna Patel, MS4, and Danish Khalid, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.Welcome back to our Nutrition series!D: In our previous episode, we talked about calorie balance and macronutrients. The basics of nutrition. So, if you haven't already listened to that, pause this, and go listen to that first. As we will only continue to build on that knowledge. Now, let's begin…S: Whether your goals are to lose fat or gain muscle. Nowadays, we've got so many ways to achieve our nutritional goals. It can be difficult and overwhelming to know which one is best for you. So today,  we will talk about some of the main “diets'' that are well known to all.Comment: People hate the word “Diet”, should we call them meal plans or Nutrition plans?S: The Paleo meal plan. The Ketogenic meal plan. The Mediterranean meal plan. And as we go through each of them, we will compare them and discuss which fit certain nutritional goals.Comment: These meal plans are very trendy right now, some people call them fad diets, but only time can tell if these diets really work long term or not.  D: Let's start with the Paleo meal plan. What is it? Also known as the Paleolithic diet, Caveman diet, or Stone-Age diet, this meal plan revisits the way humans ate almost 2.5 million years ago—The hunter-gatherer lifestyle. Overall, the meal plan is high in protein, moderate in fat (mainly unsaturated fats), low-moderate in carbohydrates (restricting high-glycemic carbohydrates), high in fiber, and low in sodium and refined sugars. It includes mainly lean meats, fish, fruits, vegetables, nuts, and seeds.Comment: It is low in carbs because carbs were so rare and uncommon in nature before agriculture was introduced to humanity. Animals (including humans) had to wait until the season when the fruit was ripe to enjoy something sweet.S: So, what are some of the benefits of the Paleo meal plan? Well, studies have shown that the paleo meal plan produces greater short-term benefits, including-          Greater weight loss-          Reduced waist circumference-          Decreased blood pressure-          Increased insulin sensitivity-          Improved cholesterolD: You must be wondering, what's the catch? Aside from the diminishing long-term effects. Although the meal plan focuses on many essential food groups, it also omits others such as whole grains, dairy, and legumes. This could lead to suboptimal intake of important nutrients. Additionally, the restrictive nature of the meal plan may also make it difficult for people to adhere to such a meal plan in the long run. With these confounding facts, there hasn't been a strong link that the paleo meal plan improves cardiovascular risk or metabolic disease.S: Basically, for those looking for a cleaner meal plan, the paleo meal plan is geared towards eliminating high-fat and processed foods that have little nutritional value and too many calories. Moving on to the Ketogenic Meal plan.D: What is the Ketogenic Meal plan? Basically, the ketogenic meal plan is a high fat, moderate protein, and low carb lifestyle. It's about creating ketones. For example, beta-hydroxybutyrate, acetoacetate, and acetone. Ketones are basically a fourth macronutrient. Although we don't find it in our day-to-day food, it's what our body creates.So why do we need ketones, and why does our body create them in the first place? Our body uses carbohydrates, more specifically glucose, as the major source of energy for its daily needs. So, imagine, when we are in periods of starvation and deprive ourselves of carbohydrates. The body would resort to breaking down protein to create glucose for our demanding body in a process called gluconeogenesis. That seems illogical, right? Why would our body break down muscle?  That is where ketones come in. While our body is trying to keep up with demands, our liver is working on creating another source of energy. A process called ketogenesis, where ketones are made through fat, more specifically medium-chain fatty acids, to fuel our body.S: So, what's so great about the Ketogenic Meal plan? Well, for starters, during ketogenesis due to low blood glucose feedback, the stimulus for insulin secretion becomes low, which sharply reduces the stimulus for fat and glucose storage. Additionally, people will initially experience rapid weight loss up to 10 lbs. in the first 2 weeks or less. Although the first few pounds may be water weight loss due to the diuretic effect of this meal plan, eventually you obtain fat loss.In this meal plan, lean body muscle is largely spared. So those who are overweight individuals with metabolic syndrome, insulin resistance, and type II diabetes mellitus, are more likely to see improvements in clinical markers for disease risk. Additionally, reducing weight, mainly truncal obesity, may help improve blood pressure, blood glucose regulation, triglyceride levels, and HDL cholesterol.D: That sounds awesome! What do I have to eat? Well, the dietary macronutrients are divided into approximately 55-60% fats, 30-35% protein, and 5-10% carbohydrates. Specifically, no more than 50 grams of carbohydrates.Comment: The difference between ketosis and ketoacidosis is a frequent question done by patients and medical providers. The main difference is that in ketosis your glucose level is normal or low and your pH is still physiologic, but in ketoacidosis, the pH is lower than 7.35 and glucose is above 250 mg/dL. So, when a person is in ketosis, you will not see the, for example, Kussmaul's breathing pattern, but in ketoacidosis, you will see that breathing pattern. If you want more info about the keto meal plan, you can listen to our episode 59, done by a great medical student Constance.  S: Finally, the Mediterranean meal plan.The hallmark of this meal plan is simple…minimally processed foods. The main characteristic of a Mediterranean meal plan includes a low-moderate protein intake (very low consumption of red meat, moderate consumption of fish and shellfish), moderate-high fat (rich in unsaturated fats, lower in saturated fats), and moderate to high carbohydrates (legumes, unrefined grains). A very different take from the previous two meal plans.D: What is the hype all about? Why year after year does the Mediterranean meal plan come out on top? Well, the reason why it's one of the better options is because of the style of eating. It encourages vegetables and good fats (limiting bad fats) and discriminates against added sugar. No preservation, no packaging, no processing. This style of eating plays a big role in preventing heat disease, and reducing risk factors such as obesity, diabetes, high cholesterol, or high blood pressure.S: In fact, numerous studies have shown that the Med meal plan promotes weight loss and prevents heart attacks and helps with type 2 diabetes by improving levels of hemoglobin A1c, blood sugar levels, and decreasing insulin resistance. No wonder why out of all these meal plans, it's the only one that meets the AHA dietary recommendations.D: In a meta-analysis of randomized trials including the large PREDIMED trial, a Mediterranean meal plan reduced the risk of stroke compared with a low-fat diet (HR 0.60, 95% CI 0.45 to 0.80) but did not reduce the incidence of cardiovascular or overall mortality. By contrast, in observational studies, a Mediterranean meal plan was associated with lower overall mortality and cardiovascular mortality.Following a Mediterranean meal plan may lead to a reduction in total cholesterol. For example, in a 2011 meta-analysis of six randomized trials comparing the Mediterranean approach with a low-fat diet in 2650 individuals with overweight or obesity, a Mediterranean meal plan led to a greater reduction in total cholesterol (-7.4 mg/dL, 95% CI -10.3 to -4.4) but a nonsignificant reduction in LDL cholesterol (-3.3 mg/dL, 95% CI -7.3 to +0.6 mg/dL [5]. A Mediterranean meal plan may also decrease LDL oxidation.S: Additionally, in observational studies, a Mediterranean meal plan was also associated with a decreased incidence of Parkinson disease, Alzheimer disease, and cancers, including colorectal, prostate, aerodigestive, oropharyngeal, and breast cancers. Comment: I am excited to try the Mediterranean meal plan when I visit Spain this coming summer. It will be my first time in Valencia. Keep in mind, with any meal plan, it will work differently for everyone. Just because it worked for an individual doesn't mean it'll work for you. And vice versa. Besides, everyone has different goals we want to achieve, like all of us here.What do you call someone who can't stick with a meal plan?  A deserter. ProteinFatCarbohydratePaleo Meal HighModerateLow-ModerateKetogenic Meal planModerateHighLowMediterranean Meal planModerateModerate-HighModerate-High Conclusion: Now we conclude our episode number 92 “Paleo vs Keto vs Mediterranean.” The take-home messages are: Paleo is a style of eating that encourages unprocessed foods, mainly lean meats, fruits and vegetables in their natural state; Keto consists of eating less than 50 carbs a day and encourages high-fat foods; and the Mediterranean plan promotes good quality fats from vegetable sources, moderate protein and low to moderate carbs. These meal plans have a main goal in common: help your patients lose weight, improve their overall health, and decrease mortality. Even without trying, every night you go to bed being a little wiser.This week we thank Hector Arreaza, Sapna Patel, Danish Khalid, and Shantal Urrutia. Audio edition: Suraj Amrutia. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Weight Loss Industry Analysis 2020, Cost & Trends, franchisehelp.com, https://www.franchisehelp.com/industry-reports/weight-loss-industry-analysis-2020-cost-trends/. Accessed on May 2, 2022. Masood W, Annamaraju P, Uppaluri KR. Ketogenic Diet. [Updated 2021 Nov 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.Taylor B, Rachel M, Adrien B, et al. The Paleo Diet For Health Professionals. In: University of California, Davis - Nutrition. 2018.Miguel A. Martínez-González, Alfredo Gea and Miguel Ruiz-Canela, originally published on 28 Feb 2019, https://doi.org/10.1161/CIRCRESAHA.118.313348. Circulation Research. 2019;124:779–798.Gerber, M., & Hoffman, R. (2015). The Mediterranean diet: Health, science and society. British Journal of Nutrition, 113(S2), S4-S10. doi:10.1017/S0007114514003912. Colditz, Graham A. “ Healthy Diet in Adults.” UpToDate, 11 Dec 2019, https://www.uptodate.com/contents/healthy-diet-in-adults.Fitó M, Guxens M, Corella D, Sáez G, Estruch R, de la Torre R, Francés F, Cabezas C, López-Sabater MDC, Marrugat J, García-Arellano A, Arós F, Ruiz-Gutierrez V, Ros E, Salas-Salvadó J, Fiol M, Solá R, Covas MI; PREDIMED Study Investigators. Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized controlled trial. Arch Intern Med. 2007 Jun 11;167(11):1195-1203. doi: 10.1001/archinte.167.11.1195. PMID: 17563030.

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

Listen to a 5-minute summary of a study investigating the effects of variation in sleep duration and quality on postprandial blood sugar responses after breakfast the following morning, published in Diabetologia. A quick overview of the key findings is presented. Publication: Tsereteli N, Vallat R, Fernandez-Tajes J, et al. Impact of insufficient sleep on dysregulated blood glucose control under standardised meal conditions. Diabetologia. 2021 Nov 30. doi: 10.1007/s00125-021-05608-y Epub ahead of print. Additional references: Zee PC, Turek FW (2006) Sleep and health: everywhere and in both directions. Arch Intern Med. 166(16):1686–1688. Lee SWH, Ng KY, Chin WK (2017) The impact of sleep amount and sleep quality on glycemic control in type 2 diabetes: a systematic review and meta-analysis. Sleep Med Rev 31:91–101. Kim D, Hoyos CM, Mokhlesi B, Pamidi S and Jun JC (2020) Editorial: Metabolic Health in Normal and Abnormal Sleep. Front. Endocrinol. 11:131. doi: 10.3389/fendo.2020.00131 Kothari V, Cardona Z, Chirakalwasan N, Anothaisintawee T, Reutrakul S (2021) Sleep interventions and glucose metabolism: systematic review and meta-analysis. Sleep Med 78:24–35. For more free education, visit the DKIP website, follow us on Twitter (@dkipractice) or connect on LinkedIn. Funding statement: This independent educational activity is supported by an educational grant from Novo Nordisk A/S. The educational content has been developed by Liberum IME in conjunction with an independent steering committee; Novo Nordisk A/S has had no influence on the content of this education.

In this episode, we turn our focus to the present to see how recent research could be used to shape the future of anesthesiology. In previous episodes, we reviewed how the pioneers of anesthesia were able to successfully use ether and chloroform without the full knowledge of those drugs that we have today. In that spirit, we explore whether there is untapped potential in our current scientific expertise that could help improve the delivery of modern-day anesthesia.This season of the podcast began with the retelling of the origin story of anesthesia use. We revisited the classic tale of Ether Day with the benefit of hindsight and almost two centuries of clinical advances. But the stories about William T.G. Morton, Simpson Young and John Snow are also just chapters in a much larger story of medical progress. It is our story, too. While this season of The Etherist is ending, the story of anesthesia continues, as does the push for clinical progress. In this episode, we try to answer the question: What will be the next chapter in the story of anesthesiology?This is the fourth and final episode of season 3 of “Anesthesiology News presents The Etherist.” Sponsored by Masimo and Medtronic.Suggested ReadingBrown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. _N Engl J Med_. 2010;363:2638-2650. İnce R, Adanir SS, Sevmez F. The inventor of electroencephalography (EEG): Hans Berger (1873–1941). Childs Nerv Syst. 2021;37:2723–2724. https://doi.org/10.1007/s00381-020-04564-z Gibbs FA, Gibbs LE, Lennox WG. Effects on the electroencephalogram of certain drugs which influence nervous activity. Arch Intern Med. 1937;60:154-166. Glorfeld J. Hans Berger has a real brainstorm: accident inspires a career and the invention of EEG. Cosmos. November 20, 2020. Accessed November 16, 2021. https://cosmosmagazine.com/health/hans-berger-has-a-real-brainstorm/ Mets B. Waking Up Safer? An Anesthesiologist's Record. SilverWood Books; 2018. Purdon PL, Sampson A, Pavone KJ. Clinical electroencephalography for anesthesiologists part I: background and basic signatures. Anesthesiology. 2015;123(4):937-960. doi:10.1097/ALN.0000000000000841 Science News. Electric currents picked up from head show brain action. Science News Letter. 1935;719(27):35. Accessed November 16. https://www.sciencenews.org/archive/electric-currents-picked-head-show-brain-action Sanders L. How Hans Berger's quest for telepathy spurred modern brain science: instead of finding long-range signals, he invented EEG. Science News. July 6, 2021. Accessed November 16, 2021. https://www.sciencenews.org/article/hans-berger-telepathy-neuroscience-brain-eegFollow Us:Our WebsiteApple PodcastsSpotifyGoogle PodcastFind Us on Social:TwitterFacebookLinkedInInstagram

O uso da Varfarina é extremamente comum na nossa prática clínica e precisamos saber como manejar sua intoxicação. Kaue e Rapha conversam sobre essa intoxicação em 3 situações - Paciente com sangramento grave, sangramento leve e o paciente com RNI (ou INR) alterado mas sem sangramento. Referências: Crowther MA, Ageno W, Garcia D, et al. Oral vitamin K versus placebo to correct excessive anticoagulation in patients receiving warfarin: a randomized trial. Ann Intern Med 2009; 150:293. Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:160S. Leissinger CA, Blatt PM, Hoots WK, Ewenstein B. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol 2008; 83:137. Gunther KE, Conway G, Leibach L, Crowther MA. Low-dose oral vitamin K is safe and effective for outpatient management of patients with an INR>10. Thromb Res 2004; 113:205. Farrow GS, Delate T, McNeil K, et al. Vitamin K versus warfarin interruption alone in patients without bleeding and an international normalized ratio > 10. J Thromb Haemost 2020; 18:1133. Refaai MA, Goldstein JN, Lee ML, et al. Increased risk of volume overload with plasma compared with four-factor prothrombin complex concentrate for urgent vitamin K antagonist reversal. Transfusion 2015; 55:2722. Goldstein JN, Refaai MA, Milling TJ Jr, et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet 2015; 385:2077. Hylek EM, Regan S, Go AS, et al. Clinical predictors of prolonged delay in return of the international normalized ratio to within the therapeutic range after excessive anticoagulation with warfarin. Ann Intern Med 2001; 135:393. Kuijer PM, Hutten BA, Prins MH, Büller HR. Prediction of the risk of bleeding during anticoagulant treatment for venous thromboembolism. Arch Intern Med 1999; 159:457.

Hoje, Rapha Rossi e Mateus Prata falam um pouco da utilidade de cada um dos escores prognósticos utilizados nos pacientes com Síndrome Coronariana Aguda (TIMI, GRACE e HEART), assim como suas principais diferenças. Referências: 1. Antman EM, Braunwald E, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16;284(7):835-42. 2. Granger CB, et al; Global Registry of Acute Coronary Events Investigators. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003 Oct 27;163(19):2345-53 3. Mahler SA, et al. Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Crit Pathw Cardiol. 2011 Sep;10(3):128-33.

Join Erin and Michelle as they take on the tough subject of low back pain. There are a lot of misconceptions about low back pain and quite frankly the US and world has over-medicalized it and spent a lot of money managing it. 80% of us will have low back pain at some point in our lives, so it's important to know where you can find the right support and have accurate information. This episode will help dispel common low back pain misconceptions and reduce common fears that often come with an episode of pain. Remember, pain is multifactorial and can be caused by many things - this is pain neuroscience 101. If you have an episode of low back pain, find your trusted PT and get on an individualized plan early. There is not a one size fits all for the treatment of low back pain. When we understand what persistent pain is, learn how to nudge and stay active we see positive change! References: - Acute low back pain. (2020, May 11). Retrieved April 14, 2021, from https://www.cdc.gov/acute-pain/low-back-pain/index.htm - Chou, R., Qaseem, A., Owens, D. K., Shekelle, P., & Guidelines, C. (2011). Clinical Guideline Diagnostic Imaging for Low Back Pain : Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine, 154(November 2010), 181–190. https://doi.org/10.7326/0003-4819-154-3-201102010-00008 - Freburger, J., et al. (2009). The Rising Prevalence of Chronic Low Back Pain. Arch Intern Med, 169(3): 251–258. doi:10.1001/archinternmed.2008.543 - Fritz, J. M., Childs, J. D., Wainner, R. S., & Flynn, T. W. (2012). Primary care referral of patients with low back pain to physical therapy: Impact on future health care utilization and costs. Spine, 37(25), 2114–2121. - Hartvigsen, Jan, Hancock, Mark J., Kongsted, Alice, Louw, Quinette, Ferreira, Manuela L,Genevay, Stéphane, Hoy, Damian, Karppinen, Jaro, Pransky, Glenn, Sieper, Joachim et al. (2018) What low back pain is and why we need to pay attention. The Lancet doi:10.1016/S0140-6736(18)30480-X Disclaimer: This podcast contains general information for community education purposes only, and does not take into account your specific comorbidities that your current healthcare provider may be managing. Please contact your care provider with questions regarding anything particular to you.

Un nouvel épisode du Pharmascope est maintenant disponible et ce n’est pas une mince affaire

Master your breast cancer screening spiel, cultivate your approach to the breast mass, and empower your patients with empathetic shared decision-making (which we know you’re all already fabulous at)!  On this fantastic episode, we are joined by Dr. Nancy Keating @NancyKeatingMD, policy wonk and primary care doc extraordinaire at Brigham and Women’s Hospital. This episode is rife with drama, as the ACS butts heads with the USPTF and the ACR, and you have to figure out  what’s right for the patient by talking with them--almost as exciting as that moment on Grey’s when Izzie cuts the...anyway, I won’t ruin a key plot point in the most excellent medical show of all time, all in a day’s work, here at The Curbsiders. Enjoy!    Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).    Show Notes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!   Credits Producer and Writer: Nora Taranto MD Show Notes: Nora Taranto MD, Isabel Valdez PA  Infographic: Nora Taranto MD Cover Art: Kate Grant, MD  Hosts: Stuart Brigham MD, FACP; Matthew Watto MD, FACP; Paul Williams MD, FACP, Nora Taranto MD    Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com Reviewer: Arielle Medford MD  Guest: Nancy Keating MD, MPH   Sponsors   Provider Solutions & Development Provider Solutions & Development is a community of experts dedicated to offering guidance and career coaching to physicians and clinicians throughout their entire career journey. With exclusive access to hundreds of opportunities across the nation, reach out today to begin the search for your perfect practice: www.psdrecruit.org/curbsiders.     VCU Health CE The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. Note: A free VCU Health CloudCME account is required in order to seek credit.     Time Stamps Sponsor - Provider Solutions & Development www.psdrecruit.org/curbsiders. Sponsor - VCU Health Continuing Education 00:30   Intro & Guest Bio 03:27   Guest one-liner 05:27   Best Advice for Women in Medicine 07:34   Picks of the Week Sponsor - Provider Solutions & Development www.psdrecruit.org/curbsiders. 10:00   Case 1: Brenda Cantwell and Breast Lump DDx 13:39   Clinical Breast Exam vs Self Breast Exam 17:26   Practical Tips for the Clinical Breast Exam 21:50   Imaging to Evaluate the Breast Lump 26:36   Demystifying BIRADS 28:36   Epidemiology Potpourri 33:02   Breast Pain without a Mass 34:30   Case 2: Mammie Gram and Breast Screening 46:03   Average Risk vs High Risk Screening 47:18   Breast Risk Prediction Tools 48:51   Breast Density 53:16   Imaging Modalities 61:28     Shared Decision Making in Screening   68:04    Case 3: Ms Britta Lumpworth and When to Stop Screening Mammograms 74:42    Take Home Points and Outro Sponsor - VCU Health Continuing Education     Links* Evicted: Poverty and Profit in the American City by Matthew Desmond Run The List podcast  ACOG Practice Bulletin 179, 2017 Elmore et al, Ten Year Risk of False Positive Screening Mammograms and Clinical Breast Examinations, N Engl J Med, 1998.  Thomas, et al, Randomized trial of breast self-exam in Shanghai: final results. JNCI, 2002. Semagliazov et al, Results of a prospective randomized investigation [Russia] to evaluate the significance of self-examination for the early detection of breast cancer, Vopr Onkol, 2003.  Fuller, M. S., Lee, C. I., & Elmore, J. G. Breast cancer screening: an evidence-based update. The Medical clinics of North America, 2015. Chan et al, False-negative rate of combined mammography and ultrasound for women with palpable breast masses. Breast Cancer Res Treat, 2015.  ACS Recommendations for the Early Detection of Breast Cancer, 2020. USPTF Breast Cancer Screening Recommendations, 2016.  Henderson et al, Breast Examination Techniques, 2020.  Kolb et al. Comparison of the performance of screening mammography, physical exam, and breast ultrasound and evaluation of factors that influence them: an analysis of 27.825 patient evaluations, Radiology, 2002.  Mammogram Interpretation, Chapter 2. Radiology Key.Com.  Flobbe et al, The Additional Diagnostic Value of Ultrasonography in the Diagnosis of Breast Cancer. Arch Intern Med, 2003.  ACS Understanding Mammogram Readings, 2019.  Bittner, Guide to mammography reports: BIRADS terminology, Am Fam Physician, 2010.  Seer cancer statistics review, 1975-2017. 2020.  Anders CK et al, Breast carcinomas arising at a young age: unique biology or a surrogate for aggressive intrinsic subtypes?. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2011  ACS How Common is Breast Cancer?  SEER Lifetime Risk (%) of Dying from Cancer by Site and Race/Ethnicity: Females, Total US, 2014-2016 Garcia et al, Cardiovascular disease in women: clinical perspectives, Circ res, 2017.  Cancer Statistics Center: Breast Statistics.  Independent UK Panel on Breast Cancer Screening, The Benefits and harms of breast cancer screening: an independent review, Lancet, 2012.  CDC Breast Cancer Screening Guidelines 2020  ACS Breast Cancer Screening Guidelines, 2015 USPTF Breast Cancer Screening Recommendations, 2016.  ACR Breast Cancer Screening Update, 2018.  Canadian Task Force Breast Cancer Screening Recommendations  UK-NHS Breast Cancer Screening Recommendations  Biller-Andorno et al. Perspective: Abolishing Mammography Screening Programs? A View from the Swiss Medical Board, N Eng J Med, 2014.  Nelson et al, Effectiveness of Breast Cancer Screening: Systematic Review and Meta-analysis to Update the 2009 US PTF Recommendation, Ann Intern Med, 2016.  Miller et al, Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial, BMJ, 2014.  Breast Cancer Risk Assessment Tool (NCI)   BCSC Breast Cancer Risk Assessment Tool  Health Decision/University of Wisconsin Decision Tool Harding Center for Risk Literacy Fact Box   Keating et al, Breast Cancer Screening in 2018: Time for Shared Decision Making, Jama Insights, 2018.  ePrognosis life expectancy calculator      *The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.   Goal Listeners will learn how to evaluate a breast lump in the primary care clinic, what the guidelines recommend for asymptomatic breast cancer screening, and how to engage a patient in shared-decision making given the data available on mammograms.    Learning objectives After listening to this episode listeners will…   Triage and evaluate the Breast Lump  Perform breast cancer risk assessment  Recall the Guideline Recommendations for Breast Cancer Screening and how they vary  Engage patients in conversation about breast cancer screening Perform Shared-Decision Making in deciding when to start mammogram screening and when to stop    Disclosures Dr. Keating reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.    Citation Taranto, N, Keating, NL, Williams PN, Brigham SK, Valdez I, Medford A, Watto MF. “#234 The Breast Lump, and Breast Cancer Screening”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list. Final publishing date: September 28, 2020.   Tags Breast Cancer, Mammogram, Breast Lump, Mass, Cancer Screening, USPTF, American Cancer Society, Screening Guidelines, Controversy, Tomosynthesis, Shared Decision Making , primary care, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student

Many patients over age 65 take daily medications that have anticholinergic properties. We know the addition of these drugs can affect quality of life and cognition.  In this episode, we talk with Dr. Kristin Meyer, an expert in geriatrics to  explore the latest data and discuss what Pharmacists can do to promote the appropriate use of anticholinergics. Additional Resources/References Beers Criteria: By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767 Anticholinergic Risk Scale: Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med. 2008;168(5):508–513. doi:10.1001/archinternmed.2007.106 Recent arge study associating anticholinergics with dementia: Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677 This episode is accredited for CPE.  For CE details and to claim credit click here: https://bit.ly/2UT97Ww  See omnystudio.com/listener for privacy information.

Many patients over age 65 take daily medications that have anticholinergic properties. We know the addition of these drugs can affect quality of life and cognition.  In this episode, we talk with Dr. Kristin Meyer, an expert in geriatrics to  explore the latest data and discuss what Pharmacists can do to promote the appropriate use of anticholinergics. Additional Resources/References Beers Criteria: By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767 Anticholinergic Risk Scale: Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med. 2008;168(5):508–513. doi:10.1001/archinternmed.2007.106 Recent arge study associating anticholinergics with dementia: Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677 This episode is accredited for CPE.  For CE details and to claim credit click here: https://bit.ly/2UT97Ww 

Many patients over age 65 take daily medications that have anticholinergic properties. We know the addition of these drugs can affect quality of life and cognition.  In this episode, we talk with Dr. Kristin Meyer, an expert in geriatrics to  explore the latest data and discuss what Pharmacists can do to promote the appropriate use of anticholinergics.Additional Resources/ReferencesBeers Criteria:By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767Anticholinergic Risk Scale:Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med. 2008;168(5):508–513. doi:10.1001/archinternmed.2007.106Recent arge study associating anticholinergics with dementia:Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677This episode is accredited for CPE.  For CE details and to claim credit click here: https://bit.ly/2UT97Ww See omnystudio.com/listener for privacy information.

Good lifestyle habits lead to better memory health Even small changes to improve your life, building good habits, can have effects that add up to a point of...  Better health, better cognitive function, and a better life. Your choices will bear fruit. Just like my mango tree. Who doesn’t love mangoes? The sweet smelling fruit is just so good. My family’s mango tree is an old tree, about 90 years old. The tree stopped bearing fruit a few years ago.  It’s been neglected. Fungal growth is spreading around. So we pruned. We planted. We attacked the fungal growth. We made changes here and there. Fortunately, it wasn’t too late to do something about it. Then things started to get better. No, much better! The tree started producing so many fruits that I’ve more mangoes than I‘ve chutney jars, Thai salads and gelato boxes. Yum! Your cognitive fitness is much like the mango tree.- But don’t leave it before it’s too late To be at your peak, to help prevent memory loss starts with the right nurturing, personalised to your situation The small changes in your lifestyle really do matter. Our daily habits add up to a bumper crop of memory health later in life. Habits are powerful. You probably don’t even realise you were doing them. That’s because they’ve been ingrained in your life, in your routine. Harness that power. Imagine being armed with habits that reduce your risks for memory loss. You become more confident. You go into battle ready armed to live life fiercely- on your own terms. Raar! What an image, right? But how do you go about creating and living with those good, daily habits? It’s hard to consistently make good choices that stick. There’s a way though. A way to learn how to successfully build new habits. Six principles that will lead to new, powerful habits. As long as you’re resolute. As long as you’re willing to keep at it. As long as you’re willing to keep grinding. You have your goal, your vision. And I know you can reach it. It is never too late to start. Do you really want to deprive your community of ALL that you can be? In today’s show, you will learn the 6 facets of how to build successful habits. Find out also what is the most often neglected element key to habit formation. Episode Highlights It’s Never Too Late For Change Setting The Right Goals For Developing Behaviour Repetition Leads To Successful Habit Formation 6 Principles For New Habit Success Quick Exercise For Finding Purpose The Biggest Takeaway about Key Lifestyle Factors For Better Health DOWNLOAD THE PDF TRANSCRIPTION   About Our Host David Norris is an occupational therapist who has been in this practice for 20 years. He has dealt with a lot of clients who seek help with their memory loss problems. David began asking himself about how these people can get ahead of these problems. It is then that he started teaching his clients how to improve their brain health to prevent memory loss. David Norris is also the director and founder of Occupational Therapy Brisbane.   Building New Habits It’s Never Too Late For Change My family's 90+ year old mango tree was able to bore fruits after years of not doing so. The tree had been neglected and was experiencing some fungal growth. Support and some tending helped it to thrive again. There is still the opportunity for your body to be primed to achieve as much as possible. Poor conditions increase the likelihood of memory loss happening again. It is never too late to start correcting your illness. Changing our diet can have a dramatic impact on your gut microbiome resulting in improved health and being.  Short exercises will release endorphins and give you improved endurance and focus. Meditation can easily be used to tackle stress. Setting The Right Goals For Developing Behaviour Goals are amazing. But set it too high and you set yourself up for failure. When you fall short of your goals, it’s easy to turn back to what you were doing before and give up. Not having goals though is like going on bushwalker track under dark conditions without a torch. The key is to narrow your vision and take each step at a time.  The step-by-step, methodological activity will help embed that new behaviour. Repetition Leads To Successful Habit Formation Old habits can sneak in and make you undermine your commitment to developing good behaviour like eating healthy. You feel guilt and shame. It erodes your sense of purpose, self, and strength to keep going. You want good behaviour to transform into good habits.  Committing to repetitive action will set you up for success. Habits can deal with anything. You do them even unconsciously. 6 Principles For New Habit Success Setting up supportive environments allows you to build things that trigger the new behaviour. Leverage context by keeping things simple. Do not overcomplicate things.  Eliminate friction or resistance by removing other choices or tasks. Put in place reward systems to support behaviour. Practice and repetition makes a habit stick. Having a sense of meaning to why you’re doing something is a powerful motivator. Quick Exercise For Finding Purpose Before starting, it’s important to be non-judgmental about yourself and be open. Think about what your family member will say about you at your funeral. Think about what your co-worker or community member will share about your impact in their lives. Think about what a stranger who has heard about you would say about you. This exercise will help you figure out what is the most important thing for you. What are the changes that need to be made for you to become that person they all talked about? You can still grow into the person you want to be at the end of your life.   Previously Recommended Resources Articles   The Science of Habit, October 2015. David Neal, Ph.D. Jelena Vujcic, MPH Orlando Hernandez, Ph.D. Wendy Wood, Ph.D. http://www.washplus.org/sites/default/files/resource_files/habits-neal2015.pdf  Exercise dose and quality of life: Results of a randomized controlled trial., Arch Intern Med. 169(3): 269–278. Corby K. Martin, Timothy S. Church, Angela M. Thompson, Conrad P. Earnest, Steven N. Blair (2009)  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2745102/ Effects of interval training on quality of life and cardiometabolic risk markers in older adults: a randomized controlled trial. Clin Interv Aging. 2019;14:1589–1599. Published 2019 Sep 4. doi:10.2147/CIA.S213133 Ballin M, Lundberg E, Sörlén N, Nordström P, Hult A, Nordström A. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732517/  Regular exercise and the trajectory of health-related quality of life among Taiwanese adults: a cohort study analysis 2006-2014. BMC Public Health. 2019;19(1):1352. Published 2019 Oct 23. doi:10.1186/s12889-019-7662-8 Chang HC, Liang J, Hsu HC, Lin SK, Chang TH, Liu SH. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806516/ Long-Term Impact of Caregiving and Metabolic Syndrome with Perceived Decline in Cognitive Function 8 Years Later: A Pilot Study Suggesting Important Avenues for Future Research. Open J Med Psychol. 2013;2(1):23–28. doi:10.4236/ojmp.2013.21005 Brummett BH, Austin SB, Welsh-Bohmer KA, Williams RB, Siegler IC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952276/#!po=65.0000  Gonzalez, C. (2006). The European Prospective Investigation into Cancer and Nutrition (EPIC). Public Health Nutrition, 9(1a), 124-126. doi:10.1079/PHN2005934 https://www.cambridge.org/core/journals/public-health-nutrition/article/european-prospective-investigation-into-cancer-and-nutrition-epic/F506B4D995930AD84F74289B5F16D132#  The Microbiome and Mental Health: Looking Back, Moving Forward with Lessons from Allergic Diseases. Clin Psychopharmacol Neurosci. 2016;14(2):131–147. doi:10.9758/cpn.2016.14.2.131 Logan AC, Jacka FN, Craig JM, Prescott SL. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857870/   Books Atomic Habits: The life-changing million copy bestseller by James Clear  Want to get 1% better everyday? Then this book may be just the next step for you. "A supremely practical and useful book, James Clear distils the most fundamental information about habit formation, so you can accomplish more by focusing on less." -Mark Manson   https://amzn.to/2twTRnB    Podcast Episodes Podcast Ep 005: Food, Mood, Microbiome and Your Memory with Dr Amy Loughman Podcast Ep 008: How Your Gut Health Affects Your Brain and Memory Health with Scott C Anderson   The Biggest Takeaway about Key Lifestyle Factors For Better Health Memory Health and making changes to help your body to achieve as much as it can is still possible. Remember the fruitless mango tree that bore again even when it was over 90+ years old. Quotable “Success takes time. Building these habits into your life takes time. These habits that make you into the gorgeous human being that you will be and are, will take time” - David Norris   What was your BIGGEST takeaway from this episode?      All the best  David  P.S. Did you get the free guide?  If not, here’s the link.    Disclaimer: Always seek the advice of your doctor or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

All guidelines advocate for lifestyle interventions in the management of diabetes, including exercise, healthy eating and weight normalisation. But how can we actually help patients achieve this? Join us this week for a discussion of practical tips to achieve a healthy lifestyle, with expert advice from Professor Naveed Sattar. References Davies MJ, et al. Diabetes Care. 2018; 41(12):2669-2701 Galaviz KI, et al. Diabetes Care. 2018; 41(7):1526-1534 Dutton GR, et al. Prog Cardiovasc Dis. 2015; 58(1):69-75 Lean M, et al. Lancet. 2018; 391(10120):541-551 Consentino F, et al. Eur Heart J. 2020; 41(2):255–323 Salas-Salvadó J, et al. Diabetes Care. 2011; 34(1):14-9 Huo R, et al. Eur J Clin Nutr. 2015; 69(11):1200-8 Sluik D, et al. Arch Intern Med. 2012; 172(17):1285-95 Hansen E, et al. J Strength Cond Res. 2012; 26(2):327-34 This independent educational activity is supported by an educational grant from Novo Nordisk A/S. The educational content has been developed by Liberum IME in conjunction with an independent steering committee; Novo Nordisk A/S has had no influence on the content of this education.

Welcome to the first episode of PERTCast, the official podcast of the PERT Consortium! Episode 1: Oren Friedman interviews Vic Tapson about risk stratification of the pulmonary embolism patient. Oren Friedman MD Associate Director, Cardiac Surgery ICU  Pulmonary Critical Care  Cedars-Sinai Medical Center Victor Tapson MDProfessor of MedicineDirector, Venous Thromboembolism and Pulmonary Vascular Disease Research ProgramAssociate Director, Pulmonary and Critical Care SectionCedars-Sinai Medical Center PE risk stratification Pearls: history and classifications. Patient’s appearance and vitals (initial and trend) are most important parts of risk stratification algorithm. Syncope can have a wide differential. Syncope in setting of PE can have significant consequences. Patient resting comfortably can be reassuring, but at the same time ask- what happens on exertion, to gauge the severity of symptoms (i.e. dizziness, near syncope etc.) Profound hypoxemia is under recognized in PE classification. European Society of Cardiology (ESC) integrates PESI, and sPESI score that is much more practical way of PE classification. ESC classification divide PE into Intermediate PE (Submassive PE) in to two categories- Intermediate high risk (positive sPESI score, RV dysfunction and biomarker positivity) or Intermediate low risk (Positive sPESI score, and RV dysfunction or biomarker positivity). PE classification is heterogeneous, patient’s hemodynamics can evolve, so will be their risk stratification score. Biomarkers in PE risk stratification: Troponin more sensitive than BNP. Be careful for false positives (elevated BNP in chronic heart failure) Lactic acid can provide prognostic information in setting of PE. CTA based risk stratification: Contrast reflux into IVC/Liver RV/LV ratio >0.9 Clot burden, 40% occlusion of pulmonary circulation can be associated with high PE related mortality.  Echo based risk stratification: Normal RV can’t generate systolic pressure in the excess of 50-60 mm Hg. Elevated PA systolic pressure >70-80 mm HG suggest chronic component of RV failure RV need to have good systolic function to generate high PA pressure TAPSE is not the holy grail of RV dysfunction, interpret with caution. Residual DVT Extensive DVT (above knee) with higher risk PE have worse outcomes. Patient activity (few days to weeks) should be restricted. IVC filter should not be considered in every case of PE with DVT.  Treatment Pearls: Every patient with acute PE should be promptly anticoagulated. Change in vital trends or persistently abnormal vital signs may help in consideration of advance reperfusion strategies in same PE category.  Take home message: Look at patient’s appearance + Vitals (HR, RR) and add other objective measures (sPESI, Biomarkers, imaging) + Residual clot burden in risk stratification. Activate the multidisciplinary PERT to leverage input from local experts. References: Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69, 3069a-3069k. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-9. Van der meer RW, Pattynama PM, Van strijen MJ, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology. 2005;235(3):798-803. Prandoni P, Lensing AW, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531. Becattini C, Cohen AT, Agnelli G, et al. Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT: Systematic Review and Meta-analysis. Chest. 2016;149(1):192-200. Grau E, Tenías JM, Soto MJ, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry. Crit Care Med. 2007;35(8):1937-41.

We investigate the claim that a subjective assessment is an accurate way to measure functional capacity. We also explore whether self-reported ability to climb two flights of stairs is the best subjective method to assess functional capacity and whether exercise tolerance greater than or equal to 4 metabolic equivalents predicts the risk of perioperative complications in any major non-cardiac surgery. Our guests today are Dr. Elisa Walsh and Dr. Laurie Shapiro of the Massachusetts General Hospital.  Full show notes available at depthofanesthesia.com.  Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Wijeysundera et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018; 391: p2631-2640. Fleisher et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130: e278-e333. Hlatky et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989 Sep 15;64(10):651-4. Wang et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med. 2004;350(7):655. Kistrop et al. N-terminal pro-brain natriuretic peptide, C-reactive protein, and urinary albumin levels as predictors of mortality and cardiovascular events in older adults. JAMA. 2005;293(13):1609. Struthers et al. The potential to improve primary prevention in the future by using BNP/N-BNP as an indicator of silent ‘pancardiac’ target organ damage. European Heart Journal, Volume 28, Issue 14, July 2007, Pages 1678–1682 Carliner et al. Routine preoperative exercise testing patients undergoing major noncardiac surgery. Am J Cardiol 1985;56;51-58. Sgura et al. Supine exercise capacity identifies patients at low risk for perioperative cardiovascular events and predicts long-term survival. Am J Medicin 2000; 108. Kistorp et al. N-terminal pro-brain natriuretic peptide, C-reactive protein, and urinary albumin levels as predictors of mortality and cardiovascular events in older adults. JAMA. 2005;293(13):1609. Reilly et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med. 1999 Oct 11;159(18):2185-92. Melon et al. Validated questionnaire vs physicians' judgment to estimate preoperative exercise capacity. JAMA Intern Med. 2014 Sep;174(9):1507-8. Weinstein et al. Comparison of Preoperative Assessment of Patient's Metabolic Equivalents (METs) Estimated from History versus Measured by Exercise Cardiac Stress Testing. Anesthesiol Res Pract. 2018; 2018: 5912726. Ryding et al. Prognostic Value of Brain Natriuretic Peptide in Noncardiac Surgery: A Meta-analysis. Anesthesiology. 8 2009, Vol.111, 311-319. Wright et al. Examining Risk: A Systematic Review of Perioperative Cardiac Risk Prediction Indices. Mayo Clin Proc. 2019. Wiklund RA, Stein HD, Rosenbaum SH. Activities of daily living and cardiovascular complications following elective, noncardiac surgery. Yale J Biol Med 2001; 74: 75–87 Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett Jr DR, Tudor-Locke C, Greer JL, Vezina J, Whitt-   Glover MC, Leon AS. 2011 Compendium of Physical Activities: a second update of codes and MET values. Medicine and Science in Sports and Exercise, 2011;43(8):1575-1581. --

Dr. Julie Freischlag is the dean of the Wake Forest University School of Medicine and the CEO of the Wake Forest University Baptist Medical Center. She did her general surgery training and vascular surgery fellowship at the University of California, Los Angeles where she later served as the Chief of the Section of Vascular Surgery. She went on to become the Chair of Surgery at Johns Hopkins University from 2003 - 2014. In 2013 she was elected as the first woman president of the Society for Vascular Surgery. She is the author of nearly 300 peer-reviewed journal articles and over 50 book chapters and has given over 250 invited lectures on a variety of topics in vascular surgery. Clinically, she has developed significant expertise in the management of thoracic outlet syndrome.  Throughout her career, she has demonstrated a notable dedication to teaching and mentoring the next generation of general and vascular surgeons. Thoracic Outlet Syndrome: A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome. Orlando MS et al. J Am Coll Surg. 2015. The Art of Caring in Thoracic Outlet Syndrome. Editorial. Freischlag JA. Diagnostics. 2018, 8, 35. Remaining or Residual First Ribs are the Cause of Recurrent Thoracic Outlet Syndrome. Likes K et al. Annals of Vascular Surgery. 2014; 28: 939-945.  Video: Transaxillary First Rib Resection - Dr. Freischlag’s approach Aortic Aneurysm - The OVER trial: The Aneurysm Detection and Management Study Screening Program: Validation Cohort and Final Results. Lederle FA et al. Arch Intern Med. 2000;160(10):1425–1430.  Open versus Endovascular Repair of Abdominal Aortic Aneurysm. Lederle FA et al. NEJM. May 30, 2019. Leadership and Diversity in Healthcare: Developing Diverse Leaders at Academic Health Centers. A Prerequisite to Quality Health Care? Shaikh U et al. Am J of Medical Quality. 2018. If you enjoy our content, please contribute to Support Audible Bleeding! Tell us about yourself through our Fall 2019 Listener Survey!

We’ve recently rolled out a new epistaxis treatment protocol here at MCHD. Join the podcast team as we discuss some nosebleed background information along with the classic and emerging treatment options. Did somebody say TXA?? Yep, we have TXA and this is a perfect opportunity introduce the MCHD epistaxis/TXA treatment protocol. It’s simple, cheap and minimally invasive. With rapidly accumulating evidence that we will improve patient centered outcomes using this treatment, this is an episode that you don’t want to miss. REFERENCES: 1. Klepfish A, Berrebi A, Schattner A. Intranasal tranexamic acid treatment for severe epistaxis in hereditary hemorrhagic telangi- ectasia. Arch Intern Med 2001; 161: 767. 2. Gaillard S, Dupuis-Girod S, Boutitie F, Rivi ere S, Morini ere S, Hatron PY, Manfredi G, Kaminsky P, Capitaine AL, Roy P, Gueyffier F, Plauchu H, for the ATERO Study Group. Tranexamic acid for epistaxis in hereditary hemorrhagic telangiectasia patients: a European cross-over controlled trial in a rare disease. J Thromb Haemost 2014; 12: 1494–502. 3. Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013;31:1389–92. 4. Birmingham AR, Mah ND, Ran R, et al. Topical tranexamic acid for the treatment of acute epistaxis in the emergency department. Am J Emerg Med. 2018;36:1242-1245. 5. Zahed R, Mousavi, Jazayeri MH,Nader iA,et al.Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized controlled trial. Acad Emerg Med. 2018;25:261-266. 6. Akkan, Sedat et al. Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial. Annals of Emergency Medicine, Volume 74, Issue 1, 72 - 78 7. Min, H. J., Kang, H., Choi, G. J., & Kim, K. S. (2017). Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis. Otolaryngology–Head and Neck Surgery, 157(6), 921–927. 8. Kikidis D, Tsioufis K, Papanikolaou V, Zerva K, Hantzakos A. Is epistaxis associated with arterial hypertension? A systemic review of the literature. Eur Arch Otorhinolaryngol. 2014; 271(2):237-243

Episode 282 brings you the COMPLETE guide on metformin! Every possible interaction, MoA, and question has been answered and summarized here on this episode! My goal for this is to truly summarize the full picture of metformin as too many people demonize it for reasons that literally are so insignificant, they should barely even be paid a notice. So with that in mind, get your notepads ready, this one is FULL of information! And yes, a few references for those of you that wish to read further!   REFERENCES 1. Lamanna C, Monami M, Marchionni N, Mannucci E. Effect of metformin on cardiovascular events and mortality: a meta-analysis of randomized clinical trials. Diabetes Obes Metab. 2011;13(3):221–228. [PubMed] 2. Franciosi M, Lucisano G, Lapice E, Strippoli GF, Pellegrini F, Nicolucci A. Metformin therapy and risk of cancer in patients with type 2 diabetes: systematic review. PLoS One. 2013;8(8):e71583. [PMC free article] [PubMed] 3. Cohen RD, Woods HF. Clinical and biochemical aspects of lactic acidosis. Philadelphia: Blackwell Scientific Publications; 1976. 4. Metformin hydrochoride. Boxed warning. [October 6, 2015]. Available at: https://dailymed​.nlm​.nih.gov/dailymed/fda/fdaDrugXsl​.cfm?setid​=b8004451-7b26-425b-b5ea-cbb1b08e30e3&type=display. 5. Inzucchi SE, Lipska KJ, Mayo H, Bailey CJ, McGuire DK. Metformin in patients with type 2 diabetes and kidney disease: a systematic review. JAMA. 2014;312(24):2668–2675. [PMC free article] [PubMed] 6. Gan SC, Barr J, Arieff AI, Pearl RG. Biguanide-associated lactic acidosis. Case report and review of the literature. Arch Intern Med. 1992;152(11):2333–2336. [PubMed] 7. Goergen SK, Rumbold G, Compton G, Harris C. Systematic review of current guidelines, and their evidence base, on risk of lactic acidosis after administration of contrast medium for patients receiving metformin. Radiology. 2010;254(1):261–269. [PubMed] 8. Kajbaf F, Arnouts P, de Broe M, Lalau JD. Metformin therapy and kidney disease: a review of guidelines and proposals for metformin withdrawal around the world. Pharmacoepidemiol Drug Saf. 2013;22(10):1027–1035.[PubMed] 9. Calabrese AT, Coley KC, DaPos SV, Swanson D, Rao RH. Evaluation of prescribing practices: risk of lactic acidosis with metformin therapy. Arch Intern Med. 2002;162(4):434–437. [PubMed] 10. Emslie-Smith AM, Boyle DI, Evans JM, Sullivan F, Morris AD. Contraindications to metformin therapy in patients with Type 2 diabetes--a population-based study of adherence to prescribing guidelines. Diabet Med. 2001;18(6):483–488. [PubMed] 11. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function. [June 16, 2016]. Available at: http://www​.fda.gov/Drugs​/DrugSafety/ucm493244.htm. 12. Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function—measured and estimated glomerular filtration rate. N Engl J Med. 2006;354(23):2473–2483. [PubMed] 13. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes, 2015: a patient-centred approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabtologia. 2015;58(3):429–442. [PubMed] 14. KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update. Am J Kidney Dis. 2012;60(5):850–886. [PubMed] 15. Flory JH, Hennessy S. Metformin use reduction in mild to moderate renal impairment: possible inappropriate curbing of use based on food and drug administration contraindications. JAMA Intern Med. 2015;175(3):458–459. [PubMed] 16. Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. 2010;(4) CD002967. [PubMed] 17. Organization for Economic Cooperation and Development. [October 20, 2015]. Available at: http://www​.oecd.org/about​/membersandpartners​/list-oecd-member-countries.htm. 18. Eurich DT, Weir DL, Majumdar SR, et al. Comparative safety and effectiveness of metformin in patients with diabetes mellitus and heart failure: systematic review of observational studies involving 34,000 patients. Circ Heart Fail. 2013;6(3):395–402. [PubMed] 19. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130(6):461–470. [PubMed] 20. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604–612. [PMC free article] [PubMed] 21. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. [PMC free article] [PubMed] 22. Agency for Healthcare Research and Quality. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and Quality; [October 6, 2015]. Available at: http://www​.effectivehealthcare​.ahrq.gov/index​.cfm/search-for-guides-reviews-and-reports​/?pageaction=displayproduct&productid=318. 23. Santaguida PL, Raina P, Ismaila P. The Development of the McHarm Quality Assessment Scale for adverse events. 2012 24. Viswanathan M, Ansari M, Berkman N. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); Mar 8, 2012. [October 6, 2015]. Assessing the Risk of Bias of Individual Studies in Systematic Reviews of Health Care Interventions. [Internet] 2008-. Available from: http://www​.ncbi.nlm.nih​.gov/books/NBK91433/ 25. Andersson C, Olesen JB, Hansen PR, et al. Metformin treatment is associated with a low risk of mortality in diabetic patients with heart failure: a retrospective nationwide cohort study. Diabetologia. 2010;53(12):2546–2553. [PubMed] 26. Eurich DT, Majumdar SR, McAlister FA, Tsuyuki RT, Johnson JA. Improved clinical outcomes associated with metformin in patients with diabetes and heart failure. Diabetes Care. 2005;28(10):2345–2351. [PubMed] 27. Weir DL, McAlister FA, Senthilselvan A, Minhas-Sandhu JK, Eurich DT. Sitagliptin use in patients with diabetes and heart failure: a population-based retrospective cohort study. JACC Heart Fail. 2014;2(6):573–582. [PubMed] 28. Wang Z. Converting odds ratio to relative risk in cohort studies with partial data information. Journal of Statistical Software. 2013;55(5):1–11. 29. Dechartres A, Altman DG, Trinquart L, Boutron I, Ravaud P. Association between analytic strategy and estimates of treatment outcomes in meta-analyses. JAMA. 2014;312(6):623–630. [PubMed] 30. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–188. [PubMed] 31. Knapp G, Hartung J. Improved tests for a random effects meta-regression with a single covariate. Stat Med. 2003;22(17):2693–2710. [PubMed] 32. Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–406. [PubMed] 33. Richy FF, Sabido-Espin M, Guedes S, Corvino FA, Gottwald-Hostalek U. Incidence of lactic acidosis in patients with type 2 diabetes with and without renal impairment treated with metformin: a retrospective cohort study. Diabetes Care. 2014;37(8):2291–2295. [PubMed] 34. Eppenga WL, Lalmohamed A, Geerts AF, et al. Risk of lactic acidosis or elevated lactate concentrations in metformin users with renal impairment: a population-based cohort study. Diabetes Care. 2014;37(8):2218–2224. [PubMed] 35. Romero SP, Andrey JL, Garcia-Egido A, et al. Metformin therapy and prognosis of patients with heart failure and new-onset diabetes mellitus. A propensity-matched study in the community. Int J Cardiol. 2013;166(2):404–412. [PubMed] 36. Ito H, Ohno Y, Yamauchi T, Kawabata Y, Ikegami H. Efficacy and safety of metformin for treatment of type 2 diabetes in elderly Japanese patients. Geriatr Gerontol Int. 2011;11(1):55–62. [PubMed] 37. Sterner G, Elmståhl S, Frid A, et al. Renal function in a large cohort of metformin treated patients with type 2 diabetes mellitus. British Journal of Diabetes and Vascular Disease. 2012;12(5):227–231. 38. Zhang X, Harmsen WS, Mettler TA, et al. Continuation of metformin use after a diagnosis of cirrhosis significantly improves survival of patients with diabetes. Hepatology. 2014;60(6):2008–2016. [PMC free article] [PubMed] 39. Becquemont L, Bauduceau B, Benattar-Zibi L, et al. Cardiovascular Drugs and Metformin Drug Dosage According to Renal Function in Non-Institutionalized Elderly Patients. Basic Clin Pharmacol Toxicol. 2015[PubMed] 40. Ekström N, Schiöler L, Svensson AM, et al. Effectiveness and safety of metformin in 51 675 patients with type 2 diabetes and different levels of renal function: A cohort study from the Swedish National Diabetes Register. BMJ Open. 2012;2:4. Article Number: e001076. [PMC free article] [PubMed] 41. Aguilar D, Chan W, Bozkurt B, Ramasubbu K, Deswal A. Metformin use and mortality in ambulatory patients with diabetes and heart failure. Circulation: Heart Failure. 2011;4(1):53–58. [PMC free article] [PubMed] 42. Masoudi FA, Inzucchi SE, Wang Y, Havranek EP, Foody JM, Krumholz HM. Thiazolidinediones, metformin, and outcomes in older patients with diabetes and heart failure: an observational study. Circulation. 2005;111(5):583–590. [PubMed] 43. Morgan CL, Mukherjee J, Jenkins-Jones S, Holden SE, Currie CJ. Association between first-line monotherapy with sulphonylurea versus metformin and risk of all-cause mortality and cardiovascular events: a retrospective, observational study. Diabetes Obes Metab. 2014;16(10):957–962. [PubMed] 44. Roussel R, Travert F, Pasquet B, et al. Metformin use and mortality among patients with diabetes and atherothrombosis. Arch Intern Med. 2010;170(21):1892–1899. [PubMed] 45. Evans JM, Doney AS, AlZadjali MA, et al. Effect of Metformin on mortality in patients with heart failure and type 2 diabetes mellitus. Am J Cardiol. 2010;106(7):1006–1010. [PubMed] 46. Inzucchi SE, Masoudi FA, Wang Y, et al. Insulin-sensitizing antihyperglycemic drugs and mortality after acute myocardial infarction: insights from the National Heart Care Project. Diabetes Care. 2005;28(7):1680–1689. [PubMed] 47. Shah DD, Fonarow GC, Horwich TB. Metformin therapy and outcomes in patients with advanced systolic heart failure and diabetes. J Card Fail. 2010;16(3):200–206. [PMC free article] [PubMed] 48. Tinetti ME, McAvay G, Trentalange M, Cohen AB, Allore HG. Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study. BMJ. 2015;351:h4984. [PMC free article] [PubMed] 49. Ampuero J, Ranchal I, Nunez D, et al. Metformin inhibits glutaminase activity and protects against hepatic encephalopathy. PloS One. 2012;7(11):e49279. [PMC free article] [PubMed] 50. Nkontchou G, Cosson E, Aout M, et al. Impact of metformin on the prognosis of cirrhosis induced by viral hepatitis C in diabetic patients. J Clin Endocrinol Metab. 2011;96(8):2601–2608. [PubMed] 51. Blonde L, Rosenstock J, Mooradian AD, Piper BA, Henry D. Glyburide/metformin combination product is safe and efficacious in patients with type 2 diabetes failing sulphonylurea therapy. Diabetes Obes Metab. 2002;4(6):368–375. [PubMed] 52. Cryer DR, Nicholas SP, Henry DH, Mills DJ, Stadel BV. Comparative outcomes study of metformin intervention versus conventional approach the COSMIC Approach Study. Diabetes Care. 2005;28(3):539–543. [PubMed] 53. Garber AJ, Larsen J, Schneider SH, Piper BA, Henry D. Simultaneous glyburide/metformin therapy is superior to component monotherapy as an initial pharmacological treatment for type 2 diabetes. Diabetes Obes Metab. 2002;4(3):201–208. [PubMed] 54. Gregorio F, Ambrosi F, Manfrini S, et al. Poorly controlled elderly Type 2 diabetic patients: the effects of increasing sulphonylurea dosages or adding metformin. Diabet Med. 1999;16(12):1016–1024. [PubMed] 55. Hanefeld M, Brunetti P, Schernthaner GH, Matthews DR, Charbonnel BH. One-year glycemic control with a sulfonylurea plus pioglitazone versus a sulfonylurea plus metformin in patients with type 2 diabetes. Diabetes Care. 2004;27(1):141–147. [PubMed] 56. Marre M, Howlett H, Lehert P, Allavoine T. Improved glycaemic control with metformin-glibenclamide combined tablet therapy (Glucovance) in Type 2 diabetic patients inadequately controlled on metformin. Diabet Med. 2002;19(8):673–680. [PubMed] 57. Schweizer A, Dejager S, Bosi E. Comparison of vildagliptin and metformin monotherapy in elderly patients with type 2 diabetes: a 24-week, double-blind, randomized trial. Diabetes Obes Metab. 2009;11(8):804–812.[PubMed] 58. Bannister CA, Holden SE, Jenkins-Jones S, et al. Can people with type 2 diabetes live longer than those without? A comparison of mortality in people initiated with metformin or sulphonylurea monotherapy and matched, non-diabetic controls. Diabetes Obes Metab. 2014;16(11):1165–1173. [PubMed] 59. Bodmer M, Meier C, Krahenbuhl S, Jick SS, Meier CR. Metformin, sulfonylureas, or other antidiabetes drugs and the risk of lactic acidosis or hypoglycemia: a nested case-control analysis. Diabetes Care. 2008;31(11):2086–2091. [PMC free article] [PubMed] 60. Huizinga MM, Roumie CL, Greevy RA, et al. Glycemic and weight changes after persistent use of incident oral diabetes therapy: a Veterans Administration retrospective cohort study. Pharmacoepidemiol Drug Saf. 2010;19(11):1108–1112. [PubMed] 61. Leung S, Mattman A, Snyder F, Kassam R, Meneilly G, Nexo E. Metformin induces reductions in plasma cobalamin and haptocorrin bound cobalamin levels in elderly diabetic patients. Clin Biochem. 2010;43(9):759–760. [PubMed] 62. Roumie CL, Hung AM, Greevy RA, et al. Comparative effectiveness of sulfonylurea and metformin monotherapy on cardiovascular events in type 2 diabetes mellitus: a cohort study. Ann Intern Med. 2012;157(9):601–610. [PMC free article] [PubMed] 63. Wang CP, Lorenzo C, Espinoza SE. Frailty Attenuates the Impact of Metformin on Reducing Mortality in Older Adults with Type 2 Diabetes. J Endocrinol Diabetes Obes. 2014;2(2) [PMC free article] [PubMed] 64. Tzoulaki I, Molokhia M, Curcin V, et al. Risk of cardiovascular disease and all cause mortality among patients with type 2 diabetes prescribed oral antidiabetes drugs: retrospective cohort study using UK general practice research database. BMJ. 2009;339:b4731. [PMC free article] [PubMed] 65. American Diabetes Association. Standards of Medical Care in Diabetes--2016. [June 30, 2016]. Available at: http://care​.diabetesjournals​.org/content/39/Supplement_1. 66. Bolen S, Tseng E, Hutfless S, et al. Diabetes Medications for Adults With Type 2 Diabetes: An Update.Rockville (MD): Agency for Healthcare Research and Quality (US); 2016. AHRQ Comparative Effectiveness Reviews. 67. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38(1):140–149. [PubMed] 68. Tuot DS, Lin F, Shlipak MG, et al. Potential impact of prescribing metformin according to eGFR rather than serum creatinine. Diabetes Care. 2015;38(11):2059–2067. [PMC free article] [PubMed] 69. Palmer SC, Mavridis D, Nicolucci A, et al. Comparison of Clinical Outcomes and Adverse Events Associated With Glucose-Lowering Drugs in Patients With Type 2 Diabetes: A Meta-analysis. Jama. 2016;316(3):313–324. [PubMed] 70. MacDonald MR, Eurich DT, Majumdar SR, et al. Treatment of type 2 diabetes and outcomes in patients with heart failure: a nested case-control study from the U.K. General Practice Research Database. Diabetes Care. 2010;33(6):1213–1218. [PMC free article] [PubMed] 71. U.S. Department of Veterans Affairs. Office of Research & Development. VA CSP Study No. 597: Diuretic Comparison Project. [August 29, 2016]. Available at: http://www​.research.va​.gov/programs/csp/597/ 72. Canadian Diabetes Association. Clinical Practice Guidelines: Pharmacotherapy for Type 2 Diabetes. [June 30, 2016]. Available at: http://guidelines​.diabetes​.ca/bloodglucoselowering​/pharmacologyt2-(1) 73. Gong L, Goswami S, Giacomini KM, Altman RB, Klein TE. Metformin pathways: pharmacokinetics and pharmacodynamics. Pharmacogenet Genomics. 2012;22(11):820–827. [PMC free article] [PubMed] 74. Weir MA, Gomes T, Mamdani M, et al. Impaired renal function modifies the risk of severe hypoglycaemia among users of insulin but not glyburide: a population-based nested case-control study. Nephrol Dial Transplant. 2011;26(6):1888–1894. 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The ketogenic diet has been prescribed medically as a regimen for children with refractory seizures. It has since gained popularity recently as a weight loss strategy. This diet is important to understand because of its effect on overall body physiology in order to best counsel patients, especially as patients may be bringing it up more frequently as a current "fad diet"! Resources: Nordmann AJ, Nordmann A, Briel M, et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166:285. Hall KD, Chen KY, Guo J, et al. Energy expenditure and body composition changes after an isocaloric ketogenic diet in overweight and obese men. Am J Clin Nutr 2016; 104:324. Fung TT, van Dam RM, Hankinson SE, et al. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann Intern Med 2010; 153:289. Martin‐McGill KJ, Jackson CF, Bresnahan R, Levy RG, Cooper PN. Ketogenic diets for drug‐resistant epilepsy. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD001903. DOI: 10.1002/14651858.CD001903.pub4. McKenzie A, Hallberg S, Creighton BC, Volk BM, Link T, Abner M, et al. A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes. JMIR Diabetes. 2017;2(1):e5 Hallberg SJ, McKenzie AL, Williams P, et al. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at One Year: An Open Label, Non-Randomized, Controlled Study. Diabetes Ther. 2018. DOI: 10.1007/s13300-018-0373-9 Sumithran, Priya, and Joseph Proietto. "Ketogenic diets for weight loss: a review of their principles, safety and efficacy." Obesity Research & Clinical Practice 2.1 (2008): 1-13.

Kontakt: ivajuntan@gmail.com    -Musik: Blind Love Dub by Jeris (c) copyright 2017 Licensed under a Creative Commons Attribution (3.0) license. http://dig.ccmixter.org/files/VJ_Memes/55416 Ft: Kara Square (mindmapthat) Dagens huvudartikel: Azoulay E, Chaize M, Kentish-Barnes N. Involvement of ICU families in decisions: fine-tuning the partnership. Ann Intensive Care. 2014;4:37. https://annalsofintensivecare.springeropen.com/track/pdf/10.1186/s13613-014-0037-5 Övriga nämnda artiklar: Schwab AP. Formal and effective autonomy in healthcare. J Med Ethics. 2006;32(10):575-9. White DB, Braddock CH, 3rd, Bereknyei S, Curtis JR. Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med. 2007;167(5):461-7. Thermaenius J, Schandl A, Sluys KP. Development and initial validation of the Swedish Family Satisfaction Intensive Care Questionnaire (SFS-ICQ). Intensive Crit Care Nurs. 2019;50:118-24.

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

In this episode, explore data from the major study proving uric acid crystals are present in the synovial fluid of patients with gout, as well as the tale of two rheumatologists who injected their own knees (while still working in the hospital) with uric acid to prove it is the trigger for inflammation in gout. The episode finishes with some ripping yarns about the history of the medications we use to treat this condition.   Intro :10 Controversy surrounding uric acid’s role in gout :45 “Game changing” paper published in 1961 2:07 The first description of pseudo gout 5:53 How do you prove uric acid triggered the inflammatory response? 6:37 One of my favorite studies 6:43 Faires and McCarty inject themselves with uric acid 7:49 Details of what they experienced 8:22 4 hours later … 8:52 Both patients receive treatment 9:12 Review of what we’ve discussed so far 10:06 Let’s try and answer the question posited in The History of Gout, Part 1 10:35 Colchicine – previously a medicinal plant 10:41 A look at the history of urate-lowering therapy 12:59 Probenecid was developed to reduce the excretion of penicillin 13:18 The history of allopurinol 14:32 Don’t give allopurinol to patients on azathioprine 17:21 The answer to the question posed in Part 1 17:49 Summary 18:12 We’d love to hear from you! Send your comments/questions to rheuminationspodcast@healio.com. References: Barnett R. Lancet. 2018;391:2595. Faires JS, Mccarty DJ. Lancet. 1962;280:682-685.   Kippen I, et al. Ann Rheum Dis. 1974;33:391-396. Marson P, Pasero G. Reumatismo. 2011;63:199-206. McCarty DJ, Hollander JL. Ann Intern Med. 1961;54:452-460. Nuki G, Simkin PA. Arthritis Res Ther. 2006;doi: 10.1186/ar1906. Rundles RW. Arch Intern Med. 1985;145:1492-1503. Shyambhavee, Behera BK. J Pharmacol Clin Toxicol. 2017;5:1098. Storey GD. Rheumatology. 2001;40:1189-1190. West JB. Am J Physiol Lung Cell Mol Physiol. 2014;doi:10.1152/ajplung.00223.2014.

Do you know the etymology of the word “gout,” or how a simple microscope aided in the identification of tophi? Join me as I explore the history of this inflammatory arthritis and highlight the important scientists who shaped the modern era of gout. Intro :10 What to expect in Part 2 :48 A question: Which urate-lowering therapy was made for an expressly different reason than to treat gout? 1:34 The first modern description of gout 1:54 Let’s go back to the Greeks 3:05 Why is it called “gout?” 3:06 An anecdote from medical school 4:13 Hippocrates’ words of wisdom on gout 4:58 First century AD: Gout is linked with excessive eating and drinking 6:01 Things get muddled 6:20 1683: The modern era of gout is described 6:42 “Gout Perspectives” published in The Lancet in 2018 7:06 Self-taught Dutch scientist, Antony van Leeuwenhoek, pioneers the microscope and identifies tophi 8:29 Swedish chemist Carl Wilhelm Scheele discovers uric acid 11:38 William Hyde Wollaston tests tophi and discovers it’s full of uric acid 12:57 Emperor of uric acid, Alfred Baring Garrod, associates elevated serum uric acid with gout 13:48 If anyone knows how the thread test works, please email me 14:58 He theorized that uric acid causes gout 15:37 A look back at what we know 16:09 What we don’t know: What’s in the joints of patients with acute gout? 16:22 Stay tuned for The History of Gout, Part 2 16:34 We’d love to hear from you! Send your comments/questions to rheuminationspodcast@healio.com. References: Barnett R. Lancet. 2018;391:2595. Faires JS, Mccarty DJ. Lancet. 1962;280:682-685.   Kippen I, et al. Ann Rheum Dis. 1974;33:391-396. Marson P, Pasero G. Reumatismo. 2011;63:199-206. Mccarty DJ, Hollander JL. Ann Intern Med. 1961;54:452-460. Nuki G, Simkin PA. Arthritis Res Ther. 2006;doi: 10.1186/ar1906. Rundles RW. Arch Intern Med. 1985;145:1492-1503. Shyambhavee, Behera BK. J Pharmacol Clin Toxicol. 2017;5:1098. Storey GD. Rheumatology. 2001;40:1189-1190. West JB. Am J Physiol Lung Cell Mol Physiol. 2014;doi:10.1152/ajplung.00223.2014.

Author:  Nick Tsipis, MD Educational Pearls:   Persistent fever or positive blood cultures should raise suspicion for endocarditis Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages   References: Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813. Murdoch DR, Corey GR, Hoen B et. al. International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603

Author: Dylan Luyten, MD Educational Pearls:   Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth? Oral repletion is faster, cheaper, and more effective than IV repletion. Give IV potassium when patients have K < 2.5 mmol/L or present with arrhythmias and/or characteristic EKG changes (flattened T waves). Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation.  Checking a level is unnecessary.   References Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department. Emerg Med Pract. 2016 Nov 22;18(Suppl Points & Pearls):S1-S2   Whang R, Flink EB, Dyckner T, et al. Magnesium depletion as a cause of refractory potassium repletion. Arch Intern Med 1985; 145:1686.

Author: Dave Rosenberg, M.D. Educational Pearls EKG changes that can be seen in DKA include ST elevation and peaked T-waves secondary to derangements in K levels. In DKA,  serum K is high, but total body K is low, which can cause said EKG abnormalities. Many things cause ST elevation besides MI, so think beyond STEMI. When someone in in DKA, think about the “Three I’s” for underlying cause: (not taking) insulin, ischemia, infection. References:  Nageswara Rao Chava. ECG in Diabetic Ketoacidosis. Arch Intern Med. 1984;144(12):2379–2380. doi:10.1001/archinte.1984.00350220101022

In this podcast, Vinay Nadkarni joins Adam Cheng to discuss clinical debriefing and the importance of quantitative data to inform the debriefing process.  Dr. Nadkarni reflects on the robust post-cardiac arrest debriefing program that has been established in his own institution, and discusses the key ingredients for improving patient outcomes. References 1. Edelson D, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med. 2008;168(10):1063-1069. 2. Wolfe H, Zebuhr C, Topjian A, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med. 2014;42(7):1688-1695. 3. Kessler D, Cheng A, Mullan P. Debriefing in the emergency department after clinical events: a practical guide. Ann Emerg Med. 2015;65(6):690-698.

Author: Mark Kozlowski M.D. Educational Pearls: Humans cannot “multitask” effectively - a more accurate term is “task interruption.” When doing more than one task at once, we are more likely to forget key details and perform both tasks more slowly overall. Do not interrupt people who are focusing on critical tasks - programming a pump or drawing up doses. Think about ways to reduce task interruption in your hospital for a better clinical practice. References: Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/archinternmed.2010.65

This is Scott Selinger and welcome to another edge-of-your-seat-amazing talking blogpost - ABC’s for ECP’s, the podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians.  Today I’d like to talk a little bit about this new world of patient satisfaction scores.I really like my new car.  I got it a few months ago and it’s been working great.  But then a few weeks ago I folded the back seat down and now it won’t come back up.  So like most men, I hit it a few times and then decided to take it to the dealership.  It was a pretty easy, seamless process of getting in and out but there were a few snags.  For instance, they told me I needed a new part and they’d call when they got it in - but that didn’t happen and when I called 2 weeks later I found out that the part I needed had been there for 10 days.  And then there was the little issue of the fact that when I got the car home, the seat was still broken.  I brought it back, saw a different service advisor, who apologized profusely, and they got it fixed the same day.  The kicker was, every time I was there, I was reminded before I left that “by the way you might be getting a survey …” at which point I cut them off and just gave them a thumbs up and said “all 5’s guys!” because I really wasn’t interested in hearing the spiel – the surveys they send out are based on top box scoring, so if they get anything except a 5 out of 5, they get dinged, even if they had nothing to do with the dissatisfying issue.This is getting to my main point about patient satisfaction surveys and its effect on us as physicians.  This is something I slowly started hearing more about towards the end of residency, but at the time the satisfaction scores at the resident clinic were abysmal and we felt sort of resigned to that because a lot of the dissatisfying factors were systems issues beyond our control.  That’s if you can imagine patients being dissatisfied by frequently seeing random doctors, long wait times, bedside manners that were still under construction, and frequently being told that they didn’t need antibiotics for their cold or opioid pain medications for their headache. But now that I’m out practicing, I’m realizing how huge an issue this is.  I’m still trying to figure out when someone needs steroids and when they need antibiotics or the best way to convince them they need to quit smoking or lose weight and honestly, sometimes this weighs on my mind especially when I have someone demanding something I know is unreasonable.  With all the money that is tied to patient satisfaction scores between Medicare reimbursements based on it as well as organizations and practitioners trying to maintain patient loyalty and the insurance money that comes along with it, it’s no wonder it frequently feels like our profession is starting to more resemble that of the service industry, but saddled with the complexities of human health.  To tie back to the car problem I had, a colleague of a colleague now routinely, in her follow up emails to her patients, has a little tagline at the bottom talking about what they should do if they get a survey!  Patient satisfaction scores are now commonly being tied to physician pay and advancement or retention at their current job, the theory being to incentivize us to make that extra effort to make sure our patients are satisfied by their medical care.And in theory this sounds great because why shouldn’t patients have an exceptional experience every time?  Why should they expect any different of us than they do of their mechanics (and I don’t mean to pick on mechanics - I’m just still a little miffed at mine).  Well, there may be a few reasons, just because our profession is a little different than many others in the service industry.A study[1] just published a few weeks ago in the Journal of Patient Preferences and Adherence (which I, like I’m assuming many of you, didn’t realize existed until today) surveyed about 4000 doctors in a state medical society about exactly this which came back with 155 responses.  Granted, that’s a small number, but there are some disturbing statistics from it.  First, 78% of respondents said that these patient satisfaction surveys affected their job satisfaction moderately to severely, with 28% of people saying they had thought about leaving the medical profession because of them.  Second, just over half of respondents said that they had inappropriately prescribed an antibiotic or narcotic or ordered an unnecessary lab test because of the patient satisfaction surveys.Finally, while there were 6 neutral or positive comments given on patient satisfaction rankings, there were 47 negative comments and I do appreciate the fact that they published them.  They are actually divided up into 5 themes including the two I just mentioned as well as:- that they’re a poor way to evaluate the quality of medical care,- that there’s too much weight on them and not enough administrative effort to improve medical outcomes- that they’re perceived as a conflict of interest        So that’s one side of the coin, and it is a very striking viewpoint from the healthcare providers, but that study of course needs to be taken with a grain of salt as it is a small number and certainly could select out for the most dissatisfied people to respond.        But what about from the patient side?  Is there validity to these viewpoints?  Well there was another larger study about two years ago[2] published in JAMA that looked at patient satisfaction surveys from 52,000 respondents over 7 years.  While high patient satisfaction was associated with less frequent ER visits, it was also associated with greater inpatient use, higher overall healthcare and prescription drug expenditures, and increased mortality.  There was commentary both ways when this article came out and to date as best I could see, there hasn’t been another large study published regarding this, but if you could tie it to the study looking at the physicians perspectives on these surveys, it’s not hard to believe this data might be real.        So what are we supposed to do with all this information?  There’s been so much change in what the role of a physician is supposed to be.  We’ve gone from a paternalistic approach more to one of shared decision making.  But is the heavy weight of patient satisfaction surveys unbalancing the power of shared decision making?  And aren’t we now being asked to be more paternalistic to society by reducing health care expenses, antibiotic and opioid prescriptions, and be more dogged about preventative cancer screenings and weight loss?        I think the missing part of the equation is time and communication and we definitely do need to be able to clearly communicate our thoughts with patients.  So far, I’ve seen great feedback from people when I’ve actually stopped and instead of auto-refilling medications I don’t think are appropriate or ordering easy labs I know aren’t indicated, I explain to them why doing so would give me that gnawing pit in my stomach that knows when I do something wrong.  We’re all so rushed these days, I think this gets lost and I’ve certainly been guilty of it on occasion, but this has to be a point where we hold the line.  This is why most of us went into medicine in the first place - to help people and to be educators, not to be vending machines.          I haven’t gotten a call for a survey for the car dealership yet.  I’m conflicted though and I actually feel differently now than when I started writing this.  If I give my honest opinion, which was my emotional urge and first reaction, it’s going to bring down someone’s score, it might get him disciplined or he might take a salary cut - it could contribute to his getting fired.  And the errors made were system errors too - probably nothing to do with the guy I dealt with.  Giving anything but 5’s would just seem spiteful.  I guess I’ll wait and see …I know I covered a lot of ground here and I’m hoping you have a few opinions to share (and at this point I feel like I know who all of “you” are as I haven’t seen too many downloads yet) so as always, we’d love to hear your feedback on this, so if you have any burning questions or comments,  you can post them on the blog at canocecp.blogspot.com, our podcast page on itunes, our facebook page or email them to canocecp@gmail.com.  And if you have time, be sure to head on over to our facebook page for the Northern California Chapter of the ACP Council of Early Career Physicians so you can find out more about the events going on in the chapter. [1] Patient Prefer Adherence. 2014 Apr 3;8:437-46. doi: 10.2147/PPA.S59077. eCollection 2014.Impact of patient satisfaction ratings on physicians and clinical care.Zgierska A1, Rabago D1, Miller MM2.[2] Arch Intern Med. 2012 Mar 12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13.The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality.Fenton JJ1, Jerant AF, Bertakis KD, Franks P.

Episode 7: Nutritional Deficiencies and Dietary Supplements Public Interest in Nutritional Supplementation 50% of the U.S. adult population uses dietary supplements 1990-1997 400% growth in dietary supplement sales for humans Currently growing at 15% per year $37 billion annually 85% of regular supplement users believe that dietary supplements are good for health 82% of Americans would try herbs for terminal illness { http://www.cfsan.fda.gov/~dms/fdsupp.html; Boothe DM. 2004 Vet Clin Small Anim 34:7-38 ; Blendon RJ. 2001 Arch Intern Med 161:805-810 }   Similar interest in supplement use for pets 30% of pet owners have used or have considered using dietary supplements 90% of veterinarians sell some type of herbs or nutraceuticals $20-50 million in annual sales {Boothe DM. 2004 Vet Clin Small Anim 34:7-38}   Important Questions Concerning Nutritional Supplements What are nutritional supplements? Terminology, Definitions, Contents Why do we need nutritional supplements? Evidence for nutritional deficiencies - When should we use nutritional supplements? How do we recognize/suspect the need? What nutritional supplements should we use? - What kind of nutritional supplement is best? How do we use nutritional supplements?   Conventional Thinking About Nutritional Supplementation “The proper role of a supplement is to correct a diagnosed nutrient deficiency” {Small Animal Clinical Nutrition 4th Ed p. 116} However, diagnosis is difficult with current tools and difficult to recognize based on conventional definitions of deficiency “ The most common form of veterinary supplements is a wide variety of vitamin and vitamin-mineral combinations that are used by 10% of animal owners” {Small Animal Clinical Nutrition 4th Ed p. 116} Predominantly consist of isolated, or synthetic, vitamins “Routine use of vitamin mineral supplements is not needed when a dog or cat eats typical commercial pet food” “…dogs and cats consuming commercial dry rations were ingesting from two to five times the daily allowance of vitamins” {Small Animal Clinical Nutrition 4th Ed p. 116} They are already receiving potentially excessive amounts of isolated, or synthetic vitamins The conventional approach to nutritional supplementation is to provide more of the same isolated and synthetic nutrients that are already present in high amounts in the pet foods, expecting a better outcome It has been claimed that insanity is continuing to do the same thing, expecting a different result   Confusion in Terminology: What Are Nutritional Supplements? Food: (according to section 201(f) of the Food, Drug, and Cosmetic Act) “a raw, cooked, or processed edible substance, ice, beverage, or ingredient used or intended for use or for sale in whole or in part for human consumption” “articles used for food or drink for man or other animals, chewing gum, and articles used for components of any such articles.” This includes “dietary supplements and dietary ingredients” { http://www.cfsan.fda.gov/~dms/fsbtac13.html http://www.cfsan.fda.gov/~dms/fc01-1.html1  http://www.cfsan.fda.gov/~ear/ims-a-30.html} Drugs:  “articles [food or non-food] intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals” “ articles (other than food) intended to affect the structure or any function of the body of man or other animals” { http://www.cfsan.fda.gov/~dms/fsbtac13.html   http://www.cfsan.fda.gov/~dms/fc01-1.html1 http://www.cfsan.fda.gov/~ear/ims-a-30.html}   “Medical Food” originally applied to humans For dietary management of a disease or health condition Under the direction of a physician Label must state that the product is to be used to manage a specific medical disorder or condition