Podcasts about chest ct

We review Acute Respiratory Distress Syndrome Hosts: Sadakat Chowdhury, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/ARDS.mp3 Download Leave a Comment Tags: Critical Care, Pulmonary Show Notes Definition of ARDS: Non-cardiogenic pulmonary edema characterized by acute respiratory failure. Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio 5 cm H2O. Severity based on oxygenation (Berlin criteria): Mild: PaO2/FiO2 200-300 mmHg Moderate: PaO2/FiO2 100-200 mmHg Severe: PaO2/FiO2

In this episode, Pamela J. McShane, MD, describes the 3 pillars for nontuberculous mycobacterial (NTM) lung disease diagnosis:Clinical symptomsRadiographic evidenceMicrobiologic dataWe will also hear from a patient who details his diagnostic journey and will hear Dr. McShane discuss an illustrative clinical case.Presenter: Pamela J. McShane, MD Professor of Medicine Division of Pulmonary and Critical Care Medicine The University of Texas Health Science Center at Tyler Tyler, Texas Link to program page: https://bit.ly/3QzJo2BLink to downloadable slides: https://bit.ly/3Qh8T7G

Dr. Lauren Kim discusses chest CT findings seen in marijuana smokers with Dr. Luke Murtha and Dr. Giselle Revah. Chest CT Findings in Marijuana Smokers. Murtha et al. Radiology 2023; 307(1):e212611.

Dr. Lauren Kim discusses clinical implications of sex differences in airways at chest CT from the COPDGene cohort with Dr. Surya Bhatt.   Sex Differences in Airways at Chest CT: Results from the COPDGene Cohort. Bhatt et al. Radiology 2022; 305:699–708.

Full article: https://www.ajronline.org/doi/abs/10.2214/AJR.22.28515  In this podcast, Shambo Guha Roy, MD discusses an article in which the authors studied the effect of different reconstruction kernels and slice thickness on chest CT image quality performed on photon-counting detector CT used in ultra-high-definition mode.

Full article: https://www.ajronline.org/doi/full/10.2214/AJR.22.27895  AI algorithm application to contrast-enhanced chest CT, in comparison with clinical reports, resulted in high negative predictive value and moderate positive predictive value with high number of false positives in incidental pulmonary embolism detection, which raises the question: help or hindrance? Rachana Borkar MBBS, DMRD, DNB discusses potential benefits include second reads, worklist triage in high volume settings, and expedited treatment of incidentally detected pulmonary embolisms.

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital and we are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode an 18 -year old with sore throat, and unilateral L-sided neck pain for ~2 weeks. Here's the case presented by Rahul: An 18-year-old female presents to the ED with cough, fever, fatigue, sore throat, and unilateral L-sided neck pain for ~2 weeks. The patient also has been having non-specific chest pain, weight loss, and decreased appetite for ~ 1 month. Patient has no recent travel h/o, no h/o of vaping or illicit drug use, and there were no sick contacts at home. Vitals revealed an HR 105, BP 116/66, Temp 38.3, and respiratory rate 35, She was 65 Kg and SPO2 on 2L NC was 100%. Physical exam was negative except (L) neck tender to palpation. There was no goiter, lymphadenopathy or hepatosplenomegaly. An initial chest x-ray was significant for possible multi-lobar pneumonia versus metastases. A Chest CT revealed multifocal septic emboli in the lungs. Echo did not show any gross vegetation. She has no rash or any trauma to the neck or difficulty swallowing, no oral ulcers, joint pain, or diarrhea. She had no recent dental work or drinking of unpasteurized milk or eating raw fish or meat. She was admitted to the PICU as she had hypotension requiring fluid boluses, and lab works significant for hyponatremia, rhabdomyolysis, worsening AKI, elevated ferritin, and elevated D-dimer. Her serum uric acid was 9.9, LDH = 230 (normal) ,ESR 78 (normal = 20 or less). Her serum lactate and serum troponin and BNP were all normal. Pertinently, US neck revealed an occlusive thrombus in the (L) IJ vein (done so as to avoid contrast in face of AKI), and blood cultures sent. To summarize key elements from this case, this 18-year-old female presents with fever +cough+sore throat Fatigue + Weight loss (L) neck pain Hypotension with abnormal labs including a concerning WBC with (L) shift, anemia, AKI, elevated uric acid, and ESR Chest CT with possible pulmonary emboli US showing occlusion. All of which brings up a concern for possible malignancy or pulmonary emboli from a septic focus in the neck and a possible diagnosis of Lemierre syndrome This episode will be organized… Definition Diagnosis (physical, laboratory) Management Rahul: What is the definition of Lemierre's syndrome? Lemierre's syndrome, also known as post-anginal septicemia or necrobacillosis, is characterized by bacteremia, internal jugular vein thrombophlebitis, and metastatic septic emboli secondary to acute pharyngeal infections. All of which are seen in our above case presentation. Previously called as the forgotten disease as its incidence was decreasing due to the increasing use of antibiotics especially penicillin for URI. However, recently there is an increase in Lemierre's disease cases with decreased use of antibiotics due to antibiotic stewardship. The recent increase in Lemierre disease due to decreased antibiotic use has not been proven and remain controversial. Rahul what are some of the causative organisms of Lemierre syndrome? The most common causative agent of Lemierre's syndrome is Fusobacterium necrophorum, followed by Fusobacterium nucleatum and anaerobic bacteria such as streptococci, staphylococci, and Klebsiella pneumoniae. Rahul: Can you tell our listeners about the pathophysiology of Lemierre's syndrome? Lemierre syndrome can occur in health adults (more common in males in the age group of 14-24 years). Risk factors include immunocompromised patients, organisms, and environmental conditions. Lipopolysaccharides in F. necrophorum have endotoxic...

Full article: https://www.ajronline.org/doi/abs/10.2214/AJR.22.27664  Gregory Lee, MD and Jean Jeudy, MD discuss the accuracy of visual scoring of coronary artery calcium on chest CT, regardless of contrast. By more accurately reporting these scores, large groups of patients may greater benefit from preventative treatment of coronary disease.

Lesions of the chest wall- these can be hard to figure out, especially when incidental.  Dr. Frederick summarizes a new paper that simplifies narrowing the diagnosis and providing management recommendations.  Also in this podcast, Dr. Gibbs provides an update on imaging of Covid, in the acute phase and in patients who have recovered from the disease. Diagnostic and Imaging Approaches to Chest Wall Lesions. Mansour et al.  RadioGraphics 2022; 42. Chest CT in COVID-19: What the Radiologist Needs to Know. Kwee and Kwee. RadioGraphics 2020; 40:1848–1865.

Episode 47: Hearing Carotid Lung.  Dr Civelli explains the updates on screening for lung cancer, hearing loss and carotid artery stenosis; Kafiya explains the use of bupropion and naltrexone in methamphetamine abuse, question of the month pneumonia.Introduction: Methamphetamine useBy Kafiya Arte, MS4, and Ariana Lundquist, MD.Today is April 12, 2021.Bakersfield, California, has a methamphetamine (meth) epidemic currently ravaging this area. We as health care workers believe we can spot somebody addicted to meth from a mile away by their characteristic “older-than-stated-age” appearance and obvious “meth mouth”. However, the actual scope of the epidemic is much larger. It’s not just people who are experiencing homelessness that are addicted to, and dying from, meth.  I saw while volunteering at a needle exchange at Weill Park, people getting out of nice-looking cars wearing clean, pressed clothes with sharps containers full of used needles ready to exchange. One man even had a teacup poodle in tow. It’s clear that meth can affect anybody.  Between May 10 and June 10, 2014, 31.8% of randomly selected patients in the ED of Kern Medical admitted to having used methamphetamine at least once in their life. It’s not just the individual who addicted to meth who is affected. 36.1% of children removed from their home by child protective services in Kern County during the month of May 2014 were cases that involved methamphetamine[1]. Meth accounted for nearly 75% of all drugs seized by the Bakersfield Police Department[2]. Statewide, meth kills more Californians than any single opioid alone[3]. Amphetamine overdose deaths have increased 212% from 777 in 2012 to 2,427 in 2018 in California. In 2020, Kern County had more than double the rate of deaths related to overdose of psychostimulants, of which meth was the dominant drug, compared to the state of California (20.48/100k residents versus 8.21/100k residents, respectively)[3]. This devastating problem, unfortunately, does not have a currently FDA-approved drug to treat it. A promising study called Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. Bupropion decreases the dysphoria of meth withdrawal that drives continued use; while naltrexone decreases cravings, therefore preventing relapse, as it does with alcohol use disorder.  A total of 403 participants with nearly daily meth use were included in the two-stage randomized, double blind trial conducted at 8 different sites from May 23, 2017 to July 25, 2019. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo.  The results of the study showed a 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. A response was defined as at least three meth negative urine samples out of four samples obtained at the end of each of the two stages.  The trial concluded that although the response rate among participants that received naltrexone and bupropion was low, it was higher than that among participants who received placebo. Although the ADAPT-2 trial did not provide any recommendations that can be adapted to clinical practice, it serves as a starting point for further research of the additive or synergistic effects of bupropion and naltrexone in the treatment of meth use disorder.  Hopefully, it will also serve as a catalyst for more pioneering research regarding the legitimization of meth use disorder as a treatable disease with major medical, psychiatric, socioeconomic and legal consequences. Clinicians should stay up to date with research regarding meth use disorder such as ADAPT-2, as it is our duty to understand the health crises that affect our patients on a daily basis, and the tools we can use to treat them.This is Rio Bravo qWeek, 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. ________________________________Question of the MonthWritten by Hector Arreaza, MD, read by Jennifer Thoene, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!     Hearing Carotid LungBy Valerie Civelli, MD, and Ariana Lundquist, MDScreening for hearing loss in older adultsHearing loss definition: To answer this, let’s first talk Hertz and Decibels. Many studies and guidelines define mild hearing loss as the inability to hear frequencies associated with speech processing under 25 dB and moderate hearing loss as the inability to hear those frequencies under 40 dB[5].  The most important range for speech processing is typically 500 to 4000 Hz. To check hearing, we often use pure-tone audiometry, which is the most standard quantitative measurement; however, this is not a perfect test. There is often discordance between objectively measured deficits and subjective perceptions of hearing problems. In one study, 1 in 5 persons who reported hearing loss had a normal hearing test result, while 6% of those with severe hearing loss detected on audiometry did not report feeling that they had hearing loss.[6]  I wonder if their significant other would agree with the 6% who self-reported no hearing loss but failed the hearing test?  That would be a great study! Risk factors for hearing loss: The #1 risk factor for hearing loss is increasing age. Hearing loss increases with age after 50 attributable to normal degeneration of hair cells in the ear.  This leads to the most common cause of hearing loss in older adults: Presbycusis.  Presbycusis is your diagnosis for patients with gradual, worsening of perceived high-frequency tones. Insufficient evidence for screening: If the patient reports hearing loss, you should order a hearing test. However, on March 23, 2021, for asymptomatic adults 50 years or older, the US Preventive Services Task Force (USPSTF) published a statement that re-confirmed the 2012 recommendations. That is, current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults without symptoms. This statement aligns with the AAFP and is referenced in their practice guidelines. This recommendation applies to asymptomatic older adults (age >50 years) who have not noticed any issues with their hearing. It excludes adults with conductive hearing loss, congenital hearing loss, sudden hearing loss, or hearing loss caused by recent noise exposure, or those reporting signs and symptoms of hearing loss.Screening for Carotid Artery StenosisDo not screen: For the general adult population without symptoms of carotid artery stenosis, do not screen. This is a Grade D recommendation for all adults without a history of stroke or neurologic signs or symptoms of a transient ischemic attack. This is a re-endorsement statement made in Feb of this year, 2021, recommitting to 2014 statements.  The evidence continues to show that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. The USPSTF has made other recommendations related to stroke prevention and cardiovascular health. These include: Screening for high blood pressure in adultsScreening for abdominal aortic aneurysmInterventions for tobacco smoking cessation in adults, including pregnant personsInterventions to promote a healthy diet and physical activity for the prevention of cardiovascular disease:In adults with cardiovascular risk factorsIn adults without known cardiovascular risk factorsAspirin use to prevent cardiovascular disease and colorectal cancerStatin use for the primary prevention of cardiovascular disease in adultsLung Cancer Screening Grade B recommendation: On March 9, 2021, there are updated Grade B recommendations by the USPSTF.  For patients 50-80 years old, with a 20 pack-year history of smoking and still smoke or quit within 15 years, annual screening with low dose CT is now recommended.Stop screening when a person has not smoked for 15 year, or has a condition that substantially limits life expectancy or limits their ability to undergo curative lung surgeryThe USPSTF modified guidelines so we are screening earlier and with lower pack years.  It used to be recommended to do low dose Chest CT at age 55-80, but it’s now at 50-80.  Also, pack-years was 30 but it’s now at 20 pack-years that we should screen for lung cancer.  So, screen sooner at 50, and at lower threshold of 20. Screen for lung cancer in male and female patients.Conclusion: Now we conclude our episode number 47 “Hearing Carotid Lung”. Dr Civelli gave us an update on USPSTF screening in asymptomatic adults. For hearing loss, there is insufficient evidence to give a recommendation. For carotid artery stenosis, there is a grade D, meaning do not screen. And for lung cancer screening, it is a grade B recommendations, meaning screen your patients. Don’t forget to order a low dose CT of chest in patients of ANY sex, OLDER than 50 years, WITH a 20 pack/year smoking history, and currently smoking or quit less than 15 years ago. That’s a mouthful, but once you start following the guideline, it gets easier to recall.Remember, even without trying, every night you go to bed being a little wiser. Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Jennifer Thoene, Valerie Civelli, Kafiya Arte, Arianna Lundquist, Jacqueline Uy, and voluntarily unidentified medical assistants. Audio edition: Suraj Amrutia. See you next week! _____________________References:The Impact of Methamphetamine in Kern County: 2014, Update September 2014, Kern County Mental Health Department, https://transforminglocalcommunities.com/wp-content/uploads/2018/05/tlc-the-impact-of-meth-in-kern-county-2014-update.pdf Klein, Kerry, To Bakersfield Cops, Concern For Opioids Grows - But Meth Is Still King. Valley Public Radio News, NPR for Central California. May 1, 2019, https://www.kvpr.org/post/bakersfield-cops-concern-opioids-grows-meth-still-king#stream/0 California Opioid Overdose Surveillance Dashboard, California Department of Public Heallh, https://skylab.cdph.ca.gov/ODdash/, accessed on March 27, 2021. Klein, Kerry, Meth Is Making A Comeback In California – And It’s Hitting The San Joaquin Valley Hard. Valley Public Radio News, NPR for Central California. June 28, 2019, https://www.kvpr.org/post/meth-making-comeback-california-and-it-s-hitting-san-joaquin-valley-hard#stream/0 Feltner C, Wallace IF, Kistler CE, et al. Screening for Hearing Loss in Older Adults: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Mar. (Evidence Synthesis, No. 200.) Chapter 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK569275/   US Preventive Services Task Force. Screening for Hearing Loss in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(12):1196–1201. doi:10.1001/jama.2021.2566. https://jamanetwork.com/journals/jama/fullarticle/2777723.    Screening for Hearing Loss in Older Adults, March 23, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening#fullrecommendationstart Screening for Asymptomatic Carotid Artery Stenosis, February 02, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening. Lung Cancer: Screening, March 09, 2021, US Preventive Services Task Force, https://uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening.    

Full article: https://www.ajronline.org/doi/abs/10.2214/AJR.20.24758  Kerem Ozturk, MD discusses why awareness of early chest CT findings is required for early detection and accurate diagnosis of immune checkpoint inhibitor therapy-related adverse events such as pneumonitis, new consolidation, worsening thoracic tumor burden, pleural/pericardial effusion, and pulmonary emboli in the emergency department.

Podcast Contents 0:00-1:15–Introduction by Jeffrey S. Klein, MD, Editor of RadioGraphics. 1:16-05:10–Nonepithelial Tumors of the Larynx: Single-Institution 13-Year Review with Radiologic-Pathologic Correlation. Ong et al, RadioGraphics 2020; 40:2011–2028.   05:11-09:29–One Algorithm May Not Fit All: How Selection Bias Affects Machine Learning Performance. Yu and Eng, RadioGraphics 2020; 40:1932–1937.  09:30-14:03– Abdominal Imaging Manifestations of Recreational Drug Use. Mansour et al, RadioGraphics 2020; 40:1895–1915.  14:31-18:21–Assessing Immunotherapy with Functional and Molecular Imaging and Radiomics. García-Figueiras et al, RadioGraphics 2020; 40:1987–2010. 18:22- 22:29–Chest CT in COVID-19: What the Radiologist Needs to Know. Kwee and Kwee, RadioGraphics 2020; 40:1848–1865.  22:30-24:23–Pulmonary COVID-19: Multimodality Imaging Examples. Ko et al, RadioGraphics 2020; 40:1893–1894. 24:24-24:52 Outro RSNA2020 Virtual Meeting https://www.rsna.org/annual-meeting

Jeffrey Guccione, MD highlights the keys points of a new AJR article, which retrospectively compares the imaging features on CT of coronavirus pneumonia and influenza. The importance of this research is put into the broader context of the evolving COVID-19 pandemic, including the possibility for concurrent outbreaks of SARS-CoV-2 and influenza. The strengths and weaknesses are outlined along with some future avenues for investigation. Article: https://www.ajronline.org/doi/full/10.2214/AJR.20.23304

On today's episode we discuss: — Climate: A cross-sectional study surveying 128 researchers, clinicians, and academic personnel showed that 63.3% found social media to be the most important source of information while 67.2% found it to be misinformation. A majority of the respondents supported mandatory peer review and organization of a trustworthy COVID-19 database to combat potentially deadly misinformation. A systematic review and meta-analysis evaluating 14 qualifying studies claims to have found that COVID-19 patients with a BMI exceeding 25 kg/m^2 had worse prognosis in all age groups, especially the elderly population, suggesting that this population should be "given special attention to reduce morbidity and mortality associated with COVID-19 infection" to limit their moderate-to-high complication risk. A survey study conducted in London, England by Imperial College London found among 167 St. Mary's Hospital healthcare workers, 44% attested to self-quarantining during the past 4 months due to symptoms consistent with COVID-19 and 54% of symptomatic workers tested RT-PCR positive. Since previous infection and positive antibody tests do not necessarily indicate immunity, this study suggests a possible massive shortage of healthcare workers during the anticipated second wave of COVID-19 in November 2020 and calls for the creation of safety guidelines in order to prevent such a shortage. — Transmission and Prevention: A retrospective study of presumed COVID-19 negative patients (n=103) conducted at four inpatient rehabilitation facilities (IRF) in New Jersey, USA found 6.8% of asymptomatic participants (n=7) tested positive for SARS-CoV-2 on admission (71% [n=5] of this group developed symptoms in 2-5 days), and overall 11.6% (n=12) tested positive within 14 days of admission. Authors suggest SARS-CoV-2 testing on admission to post-acute care settings is worthwhile for appropriate infection control regardless of symptom presence. — Management: A systematic review of 46 case series and case studies with radiologic findings from 923 symptomatic and asymptomatic pediatric patients diagnosed with COVID-19 by RT-PCR found that: 1. Chest CT was the most common imagining modality used 2. Chest CT was able to detect radiological evidence of COVID-19 in 19% of asymptomatic patients. 3. The most common abnormality seen on scans was ground-glass opacities (39%), and 4. The most common location of lesions was the lower lobe of the right lung (40%). These findings emphasize the need for further investigation of chest CT as a screening tool for COVID-19 in children and for study of other imaging alternatives like lung ultrasound to minimize exposure to radiation. A case report conducted at the Department of Internal Medicine at Michigan State University highlights the case of a 29-year-old male who died from COVID-19 acute respiratory distress syndrome (CARDS) and ventilator-induced lung injury (VILI), displaying both phenotypes of CARDS, the milder type L form and the more severe type H form (which resembles full-blown ARDS). The patient's cause of death was a tension pneumothorax from VILI associated with type H CARDS. This case suggests the need for a better understanding of CARDS and transition to type H in order to prevent patients' entry to the VILI vortex and potential death from COVID-19. --- Support this podcast: https://anchor.fm/covid19lst/support

This week's case covers Chest CT anatomy, aortic aneurysms and dissections. Go to https://www.dviacademy.com/offers/cVoy4VAN/checkout for the corresponding video and PDF notes.Book and video packages for anatomy and biochemistry available at https://www.dviacademy.com/

David A. Bluemke, MD, PhD, Editor of Radiology discusses four research articles from the May 2020 issue of Radiology. ARTICLES DISCUSSED – Biological Effects of Low-Dose Chest CT on Chromosomal DNA. Sakane et al. Radiology 2020; 295:439–445. [FULL TEXT] Pediatric Chest Radiographic and CT Findings of Electronic Cigarette or Vaping Product Use–associated Lung Injury (EVALI). Artunduaga et al. Radiology 2020; 295:430–438. [FULL TEXT] Growth and Clinical Impact of 6-mm or Larger Subsolid Nodules after 5 Years of Stability at Chest CT. Lee et al. Radiology 2020; 295:448–455. [FULL TEXT] Long-term Evolution of Hepatocellular Adenomas at MRI Follow-up. Vernuccio et al. Radiology 2020; 295:361–372.  [FULL TEXT]

Välkommen till aprilavsnittet av AKUTBOKEN podcast. Här är ämnena och artiklarna i detta avsnitt: Dödsfall av covid-19 i Italien Onder et al. (2020) Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA doi: 10.1001/jama.2020.4683. PMID: 32203977 DT thorax för diagnostisk av covid-19 Ai et al. (2020) Correlation of Chest CT […]

On this episode of the Donut of Destiny, Alastair and Praveen discuss COVID in the context of cardiac CT. Topics covered include:what are the typical and atypical CT appearances of COVID that may be incidentally identified on cardiac CTwhat precautions should be taken when scanning COVID patientswhat are some new roles of cardiac CT in the post-COVID eraTune in and enjoy! References:Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 CasesRadiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNAUse of cardiac computed tomography amidst the COVID-19 pandemicEpisode transcript

Welcome to Finance and Fury – Focus on what you can control Australia has been cancelled – IMO - The largest overreaction in history – the world of medical martial law Working from home, no public gatherings, not even meant to shake hands - Panic is the disease – The panic is creating the real world effects – shortages, people potentially losing jobs, share market crashing – The fear of the virus is having the real world events – cancelling ANZAC day Can't change anything about the virus and there are so many stories going around – bioweapon, most deadly disease ever, 5G creating this – who knows what to believe – doesn’t matter – all of these stories serve the same function – of creating fear by putting this outside of your control What is another name for a story? A Novel – In this case – the Novel Coronavirus – Definition of novel – noun: an invented prose narrative that is usually long and complex and deals especially with human experience through a usually connected sequence of events Coronavirus - any of a family of single-stranded RNA viruses that have a lipid envelope studded with club-shaped projections, infect birds and many mammals including humans. Coronaviruses can cause a variety of illnesses in animals, but in people coronaviruses cause one-third of common colds and sometimes respiratory infections in premature infants. Irony here – the stories of the virus are the thing having the real world effects All have the same effect – first is fear – The fear has gone viral – like a viral video or meme spreading in the internet age – I haven’t met anyone with the virus – the news reports on public figures with it – but anyone out there know somebody personally with it? Or who has died of it? There are over 7bn people worldwide – so there will always be someone to report on But we have accepted mass quarantine and the cancelling of events – in fear of us getting it – that is the real danger – what legislation can be done to us in response – shutting down of events Second effect is like a magic trick – everyone looking at your left hand in fear while you pick pocket them with the right The Story - Doesn’t matter if it is a bio-weapon, released by the US government in China, or released by the Chinese Government, or is 5G - all those novels make you focus on the enemy of the disease – not the personal freedoms and loss that is occurring In the end – the effects of this are coming from the lockdowns, cancellation of events, markets crashing and businesses responding out of fear of the future – all to an invisible killer – that has created the response for massive disruptions in life - 197 confirmed cases of coronavirus (COVID-19), including 3 deaths The last one was over a week ago – 82yo man in Aged Care facility, others 95yo woman 2 weeks ago in same Aged Care facility – other was a 78yo man weeks ago The real killer – fear, despair, depression – Suicide remains the leading cause of death for Australians aged between 15 and 44 - fears of losing a job or the depression form that is a bigger killer Based around annual figures – 192 Australians would have committed suicide over the past 2 weeks – tragically – I know one of these people But these effects are creating additional fear Seen a lot of people expressing worry and fear - They’re afraid we’re about to all get sick and die, lose their jobs, the share market is going to continue to crash – The Stories and media reporting is manipulating people to be in a constant state of fear - When we are scared, we don’t think clearly or act effectively – fight, flight or freeze – most people freeze – so fear over things outside of your control is not a useful emotion. It’s not practical – nor are these solutions – lets the magician trick you out of your wallet Being practical is better - You need to shake the worry off and get control of your thoughts and actions First, the bad news. There’s not a darn thing you personally can do to prevent the things above from occurring. We are little fish in a big sea full of predators who are the ones that can actually cause change on those levels. Now the good news. What we can change are our immediate environments and responses to events. If you are expending a great deal of energy and emotion, focus it on the things that you can change. These are the things that will have the biggest effect on whether you live or die – and whether you can take advantage of bad situations Event + Response = Outcome – Share markets – Event = market crashing – response is to either sell, hold or buy – Outcome = Retaining funds or buying when markets are down = regain long term returns Selling = outcome of guaranteeing losses So far – this episode has been a bit of a bummer - I see so many people utterly panicking over things beyond their control. We, the ordinary, everyday people, cannot prevent what governments want to do - but we can make our opinions known but sometimes a public outcry works against you - Actions to take in your own lives – Your power ends at the knowledge of these events – and information is not knowledge When the wheels of the government are already in motion, there isn’t a whole lot we as individuals can do to stop them - We are screaming into the void when we rant about it – they can cancel sporting events We can be outraged all we want – personally only have the power to point out these things to try and help calm as much as I can. I cannot fix the responses - matter how much I want to do so - I’m not a powerful politician We’re probably being lied to anyway and see through the vested interest of those presenting the information Ask yourself - Do you really deep down think we get the whole story on any of these events? We’re probably never going to know – but the “reality” we’re given depends on the agenda of the news network that shows the footage – at lot out of context – all to try and prove that their narrative is as bad as they say We simply cannot rely on the news to accurately inform us. The mainstream media is the modern-day Ministry of Propaganda – lookup operation mockingbird, the Smith-Mundt Modernization Act of 2012 or read trust me I’m lying if you want to learn more about this – Through the media, you can get a general idea of what’s going on – but everyone’s got a bias. Everyone’s got an agenda. Example of this following the numbers in cases – China Feb 12th – China reported 44k – next day went to 59k – so modelling shows exponential growth – and was reported on as such – but wasn’t due to new people getting the illness – but the methodology changing on testing – China started diagnosing patients by ground glass in lungs from CT scans Testing can’t be trusted in a lot of regions - Many coronavirus patients have 'ground glass' in their lung scans. ... CT scans are considered less thorough than lab tests Reading some studies - Of 1014 patients, 59% (601/1014) had positive RT-PCR results, and 88% (888/1014) had positive chest CT scans. In patients with negative RT-PCR results, 75% (308/413) had positive chest CT findings. Consultant – Paras Lakhani – radiologist at Thomas Jefferson university – all it represents is fluid in the lung spaces – notes that it isn’t helpful – all types of infection – bacterial, viral, or sometimes non-infections cases like someone who vapes appears with these patterns Also - CDC did admit to – testing has false positives for other types of coronaviruses – SARS, MERS or the common cold And the little guys lie us got dragged along for a brutal ride on a tidal wave of manufactured panic – by experts working off these numbers in modelling – you can see news, but know that you’re only getting a biased fraction of the real story Last thing that you can do is see through the magic tricks to distract - Everyone has a vested interest – World bank and Central banks - World bank with their pandemic bonds (cover on Friday) and Central banks are allowed to expand mandates to take further control over the economy Media – Reporting is their moneymaker Experts – get funding from this or are making paid appearances Work out your sphere of influence – as this is what you can control Then there are the circles that really count the most: Relationships - your close friends, your family members, your immediate neighbourhoods. Finances – your investments, cash balances/emergency funds When you think about where you personally can make the most changes that will have the greatest effect on your survival, where does your power lie? It’s within what you can control - things we can actually do something about so completely freaking out over the news is not productive at all. The lesson about focusing our energy on the things we can control is the most important thing My ability to respond is limited to sharing practical tips and advising – wish I could do more but that’s the reality. And you’ve got to live in reality. Your power lies what you can control – and that is being prepared and having emergency planning in place – This is the Good News - you do have power – Can prepare your finances for these types of events and have good social circles/community in place to become better prepared Preparing finances – Few things here – but the biggest is making sure you have a few months of cash buffers Investments – if they go down – control your actions and don’t sell – if you have surplus cash – better to invest Cash reserves – if you have months of funds to survive being fired or losing business income out of government responses to Corona – less likely to panic and be able to avoid sensationalisms Insurances – if you get sick and can’t work – make sure covered But these are all things that should be done anyway – regardless of media creating panic – if you have control and know you will survive – no need to fall into the fear trap Building a network - You build your community by being a decent human being, by helping when you can, and by looking out for one another – even family members - by building our inner circles, those small intimate circles, we become stronger. Treat others with respect. Seek out those with the same values who are also helpful and respectful. Those are the folks you want around you Bottom of Form. Looking after your health – be physically fit, eat well, and don’t let these events stress you out is this foolproof? Or course not. But nothing is – at least there is a plan in place Try to focus on what you can control, not on what you can’t Summary - the current events can be incredibly overwhelming. When you find yourself getting overwhelmed, take a look at your circles. Are you getting overwhelmed by the big circles you can do nothing about? Be prepared ahead of time - Be aware – your situational awareness is your best defence If you’re letting the news cycles drive you into a panic, then it’s time to take a step back. Turn off the television, phone or computer or wherever you get your news. Focus on what you can do – and there’s a lot you can do – but panicking over things you can shouldn’t be one Thank you for listening to today's episode. If you want to get in contact you can do so here: http://financeandfury.com.au/contact/ Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases https://pubs.rsna.org/doi/10.1148/radiol.2020200642

The Wicked Crown:Coronavirus The sun rises over the San Joaquin Valley, California,today is March 6, 2020. This week, the United States Preventive Services Task Force (USPSTF) updated its recommendation for hepatitis C screening to include all asymptomatic adults, with no evidence of liver disease, aged 18 to 79 years. A one-time screening for most adults is enough, more frequent screenings is recommended in patients with continued risk for Hepatitis C infection. There is limited evidence to recommend a screening frequency(1) at this time.Also, COVID-19 is spreading but not as fast as corona-phobia. The Coronavirus is still a hot topic in the media with over 100,000 confirmed cases and 3,500 deaths worldwide. There are over 250 infected patients and 14 deaths reported in United States(2). We’ll have time to talk about Coronavirus later on in this episode.We are all very ignorant what happens is that not all ignore the same things. Albert Einstein._____________________Hello! Our quote for today is very proper because we are going to try to fight ignorance about a hot, current topic. Welcome again to Rio Bravo qWeek, I am Dr Arreaza, a faculty in Rio Bravo residency program. I am happy to inform that Our pilot episode was a success, we received feedback, and we hope to keep improving. Thanks to all who have supported this project, including Rene Mendizabal and Sheila Toro, two podcasters who gave me technical support, and Suraj Amrutia, however, he may edit this later to delete his name.Our Episode number 2 is called “The Wicked Crown”, do you want to be the king or the queen who receives this crown? Listen until the end to find out if you want it, you may be surprised! Today our guest is Dr Terrance McGill, one of our PGY2s, who accepted the challenge to talk about Coronavirus, you are very brave, Terrance, thank for being here. How are you?So, this podcast is based in 5 questions. We are going to jump right in.QUESTION NUMBER 1: Who are you? I am Terrance McGill, 2nd year resident born and raised in Bakersfield, California where our residency program is located. QUESTION NUMBER 2: What did you learn this week?This week, I learned about Coronavirus.What is it?Coronaviruses are pleomorphic, single-stranded RNA virus measuring 100-160nm in diameter. The name derives from “crown-like” appearance due to club-shaped projections surrounding the viral envelope. In general, human coronaviruses are difficult to cultivate in vitro, and some strains only grow in human tracheal organ cultures [1].The current coronavirus disease outbreak is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This virus is thought to have an animal origin. The primary source of infection became human-to-human transmission in early January 2020.EpidemiologyThe coronavirus disease outbreak (COVID-19) began in Wuhan, China, in December 2019, and has since spread to 103 countries and territories, including the United States. As of March 9, 2020, there were 80,000+ reported cases in mainland China, and more than 20,000 cases in locations outside mainland China. 423 cases have been confirmed in the US, and 19 deaths have been reported in the CDC, as of the last update on March 9, 2020, with at least 13 people dead at Life Care Center nursing home in suburban Seattle, according to the King County Health Department.Public health measures may not be able to fully contain the spread of COVID-19 because of its characteristics, however they will be effective in delaying the onset of widespread community transmission, reduce peak incidence and its impact on public services, thus decreasing the overall attack rate. Also minimizing the size of the outbreak can reduce global deaths by providing health systems the opportunity to scale up and respond. Vaccines are currently in development and the containment of the coronavirus will provide more time for vaccines to become manufactured.This is what I call “seeing the glass half full”. The mortality rate is estimated to be 3.4% by the World Health Organization.Presentation:Coronavirus has an incubation period that lasts 2 to 7 days. Usually begins as a systemic illness marked by onset of fever accompanied with malaise, headache, myalgias and followed and one – two days by nonproductive cough, dyspnea. In severe cases, respiratory function may worsen during second week of illness and progress to frank ARDS accompanied by multi-organ dysfunction. Risk factors for severe disease include age greater than 50 years and comorbidities such as cardiovascular disease, diabetes, and hepatitis.The presentation of coronavirus is similar to influenza, and all persons age six months and older should receive annual influenza vaccination. Vaccination will help to prevent influenza and in turn possibly prevent unnecessary evaluation for COVID-19.Uncommon symptoms include runny nose, sore throat, productive cough, and GI symptoms. Labs: leukopenia (25%), leukocytosis (30%), lymphopenia (63%), and elevated ALT and AST (37%). Thrombocytopenia (36%). Most patients have normal serum levels of procalcitonin on admission. Chest CT images have shown bilateral involvement in most patients. Multiple areas of consolidation and ground glass opacities are typical findings reported to date.When to test?Positive symptoms and close contact with confirmed infected patients or travel within 14 days to China, Iran, Italy, Japan, South Korea. This list may change over time. Contact your local public health department if a person under investigation is identified. Start isolation protocol. Samples from nasopharynx, oropharynx and possibly sputum will be needed, also notify immediately the CDC’s Emergency Operations Center (EOC) at 770-488-7100.  TreatmentThere is currently no antiviral therapy available for the coronavirus so prevention and containment is key. The best ways to stay safe are to wash your hands with soap and water, or alternatively use alcohol-based hand sanitizers with at least 62% alcohol. Avoid touching your face as this is an easy way to prevent contact with mucosal membranes. Stay up-to-date on this information by visiting CDC and WHO websites. Hand washing cannot be overstated. Wash your hands for 20 seconds (sign happy birthday twice or you can get creative with your favorite song), use cold or warm water (work about the same), liquid soap is preferred (if no soap, use only water), wash all surfaces of hands, common missed places are the back of hands, the lower palm and around fingernails. Hand washing is not only a chemical disinfection, but also a mechanical removal of germs. Don’t forget to dry your hands(3)  What about mask use?Wear a mask if you are sick or if you are taking care of an infected patient. QUESTION NUMBER 3: Why is that knowledge important for you and your patients? Coronavirus is a current cause of nationwide fear and is a persistent headline in the news. Is important for us as providers to be able to educate our patients on the signs and symptoms of the coronavirus and to identity which patients may be affected by the coronavirus.  QUESTION NUMBER 4: How did you get that knowledge?Interest in this topic came from the various news headlines and news leaders regarding updating guidelines on preventing the spread of coronavirus.QUESTION NUMBER 5: Where did that knowledge come from? Harrison’s Principles of Internal medicine, CDC, WHO, AAPF.Harrison’s is a classic! CDC and WHO are reliable sources of information. Terrance, now give us a summaryCOVID-19 is a novel acute viral illness that affects the respiratory system, it is transmitted person-to-person, with a mortality rate of 3.4%; being elderly or chronically ill places patients at higher risk of mortality. The preventive measures proven to be effective so far are hand washing and isolation of infected patients. Reasons to be worried? Limited surge capacity of our health system, partial availability of testing (improving), limited supply of protective equipment which may put healthcare workers at risk (avoid “panic shopping”), vulnerable population at risk, no cure and no vaccine(4). Reasons to be optimistic? Disease is mild in most people, children seem particularly protected from severe disease, and there has been extraordinary global cooperation from doctors, scientists and public health officials(4).We can end this podcast on that positive note. Thanks for the information, Terrance. So, “corona” is the Latin word for crown or halo. The coronavirus is a crown you don’t want to get, but if you get it and survive it, you should consider yourself a king or queen who got crowned with the wicked crown. ____________________________Speaking Medicalby Lisa ManzanaresThe medical word of the day is Dermatophagoides farinae. (Farin-EYE) This name doesn’t sound very common, but it actually refers to a very common organism, the American House Dust Mite.  Why do we care?  Dermatophagoides farinae is a common household allergen known to cause asthma, allergic rhinitis, and atopic dermatitis.  The feces of the mites are responsible for the majority of the reactions from Dermatophagoides farinae. Yuck.  Even worse, their meal of choice is dead human skins cells that have been shed. So, next time one of your patients complains that their allergies are flaring and they don’t know why, think: Dermatophagoides farinae.___________________________Espanish Por Favorby Roberto Velazquez (Dr RAVA)Today's word of the day is cuadril, which actually means the buttocks. People may use this word to refer to the pelvic girdle, and it refers to the area of the lower back, pelvis, hips, and buttocks. The scenario when someone will use may sound like this: “Doctor, ayer me caí y me duele mucho el cuadril”. This means: “Doctor, I fell yesterday and my pelvic area hurts… or somewhere in there”.  This points to a nonspecific location, since the area that is hurting can be anywhere in the lower back, the sacroiliac joint, the buttocks, hips, or anywhere else in the pelvis. It’s a broad term, huh?  Now you know the Spanish word of the day, cuadril, all you need to do now is to assess your patient’s cuadril.___________________________For your Sanityby Terrance McGillThis week we bring you a riddle. Pay attention.A father and son were in a car accident where the father was killed. The son was brought by ambulance to the hospital in critical condition. The little boy was on the verge of death. He needed emergency surgery. The best trauma surgeon in town was called to the operating room. The surgeon came to the OR, looked at the little boy and said “I can't operate on him. He is my son.”Who is the doctor? If you thought the surgeon was the mother of the boy. You are correct! If you already knew the answer to this riddle, maybe you will enjoy the twist that when this was told to a female surgeon, she also looked momentarily blank before being horrified by her reaction(4). Yes, we have very competent trauma surgeons who are women.March 8, 2020, was International Women’s Day. For all those great women who listen to us, Happy International Women’s Day!_________________________References:USPSTF, Hepatitis C Virus Infection in Adolescents and Adults: Screening,  Release Date: March 2020,  https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/hepatitis-c-screening1 , accessed on March 6, 2020.World-O-Metters, https://www.worldometers.info/coronavirus/, accessed on March 6, 2020.Brenda Goodman, MA, The Power of Hand-Washing to Prevent Coronavirus, March 06, 2020, https://www.medscape.com/viewarticle/926373?src=soc_fb_200310_mscpedt_news_mdscp_handwash&faf=1, accessed March 9, 2020.Infectious Disease Doctor: What Does (And Doesn't) Scare Me About The Coronavirus, https://www.wbur.org/commonhealth/2020/03/02/infectious-disease-doctor-coronavirus , accessed on March 9, 2020.Sandra Ondraschek-Norris, https://www.theguardian.com/women-in-leadership/2013/aug/15/guilty-of-unconscious-bias-job-rolesHarrison’s Principles of Internal medicine- 19th edition. Deniis L. Kasper, et. AlWorld Health Organization. Coronavirus disease 2019 (COVID-19) situation report–34. Geneva, Switzerland: World Health Organization; 2020.Jernigan DB. Update: Public Health Response to the Coronavirus Disease 2019 Outbreak — United States, February 24, 2020. MMWR Morb Mortal Wkly Rep 2020;69:216–219.Can we contain the COVID-19 outbreak with the same measures as for SARS?The Lancet Infectious Annelies Wilder-Smith,Calvin J Chiew,Vernon J Lee.5 March 2020Nursing Home Hit by Coronavirus Says 70 Workers Are Sick. New York Times. Mike Baker. March 8, 2020

Neste episódio do Geto Highlights, o Dr. Pablo Rydz entrevista o Dr. Rodrigo Caruso Chate, médico radiologista do Hospital Israelita Albert Einstein e do Incor, que fala sobre o papel do radiologista no diagnóstico do novo coronavírus. Referências: Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases https://pubs.rsna.org/doi/10.1148/radiol.2020200642 Emerging Coronavirus 2019-nCoV Pneumonia https://pubs.rsna.org/doi/10.1148/radiol.2020200274 Corona Cases https://coronacases.raioss.com/forum/corona-forum-1 Confira a agenda do Grupo de Estudos de Tórax (Geto) em https://www.spr.org.br/evento/28/grupo-de-estudos-do-torax-da-spr-geto/programacao e participe presencialmente ou à distância https://www.spr.org.br/educacao-digital/40/transmissoes-via-web/programacao

David A. Bluemke, MD, PhD, Editor of Radiology gives an update on Coronavirus (COVID-19).   Link to Articles: Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases Essentials for Radiologists on COVID-19: An Update—Radiology Scientific Expert Panel

The TWiP'ers solve the case of the Sudanese Boy With Fever, and reveal antibodies against that slow invasion of red blood cells potentiate other malaria-blocking antibodies. Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin Subscribe (free): iTunes, Google Podcasts, RSS, email Links for this episode Antibodies that slow malaria invasion (Cell) Hero: Sir Leonard Rogers (pdf) Letters read on TWiP 175 Become a patron of TWiP. Case Study for TWiP 175 70 yo man born in India, came to US 1985. Has not gone back for 2-3 years. Admitted with acute onset of fever, cough, not eating well. Was fine until a week ago, had lost consciousness, fever 102F. Negative cultures for urine and blood. Some kidney stones, type II diabetes, elevated cholesterol, no surgeries. No family medical issues. Started on vancomycin on zosyn. Works in post office, lives with house in private home. No toxic habits. Has history of hiking trip 1-2 months prior, in Rhode Island, in June. No pets, animals. Exam unimpressive. Labs: crit 25, hemoglobin 9. Platelets 39. Bilirubin 5.3. Liver enzymes slightly elevated. Chest CT clear, blood smear: anisocytosis, microcytosis, polychromasia, 4.3% reticulocytes. Daniel orders one test, 90 minutes later starts treatment. HIV negative.   Send your case diagnosis, questions and comments to twip@microbe.tv Music by Ronald Jenkees

Dr. Jed Gorden speaks with Dr. Jack West, reviewing the obstacles limiting broader adoption of lung cancer screening in practice and how novel approaches are needed to reach areas outside of tertiary care hospitals.

This podcast presents an interesting internal medicine case of a patient who initially presented to themselves to the clinic with a chief complaint of a cough, and the chain of events that occurred with this particular case.  Joining Dr. John Peitersen, (Internal Medicine) in the case discussion today include: Dr. Barrett Larson, (Pulmonary Medicine), Dr. James Currie (Lakeview Clinic-Infectious Disease), Dr. Matthew Herold (Emergency Medicine), Dr. David Gross (Radiology), Dr. Susan Bowers (Pathology), Dr. Kevin White (Hospitalist), along with various other providers and Allied Health staff.  Enjoy the podcast. Objectives: Upon completion of this CME event, program participants should be able to: Perform a differential diagnosis on cases presented. Identify limitations of certain tests. Discuss the interpretation of lab results on the cases presented. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit:  CME Evaluation: 2019 Internal Medicine Case Conference (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.” FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.   Show Notes:      This is the case of a 44 year old woman who initially presents for a cough for about a week. She is obese and has OSA. She is on flonase. She had a low grade fever. Exam doesn’t reveal much besides a serous OM and some mild anterior cervical lymphadenopathy. Conservative care was advised, as well as follow-up in the next couple weeks if not improving. Dr. Peiterson now will tell us the chain of events in this peculiar case. Joining Dr. John Peitersen in the discussion today are: Dr. Barrett Larson from Ridgeview pulmonary medicine, Dr. James Currie, Lakeview Clinic infectious disease, Dr. Matthew Herold, Ridgeview emergency medicine, Dr. David Gross, Radiologist with Consulting Radiologists, Ltd, Dr. Susan Bowers, Pathology, Dr. Kevin White, Ridgeview hospitalist, and various others from the provider and allied health audience.      The initial small segment of this discussion had recording difficulty, so our conversation picks up immediately after the initial presentation of the patient.   CHAPTER 1 REVIEW:      So... let’s recap up to this point. So far we have heard input from Dr. Peiterson, Dr. Larson the pulmonologist, Dr. Gross the radiologist and Dr. Bowers the pathologist. So, initially she was seen for what sounds like a viral URI, and was told to f/u if not improving. Well, we all see this kind of case every day, right? She was then treated by phone with Azithromycin; seen by different providers; Reports “crackling in the lungs’, malaise and subjective fever. She has a Son who had strep 9-days ago. Ears look better today. Cryptic tonsils. VSS. Negative strep test. This was felt to be Viral bronchitis.  CXR offered, patient declined due to $.      Five months later, the patient sees a sleep doctor. Continued cough noted. Pulmonary function tests are likely now indicated. Is there mild asthma? PFTs are able to give us a lot of information. Is the FEV1-FVC ratio acceptable.  Yes, it’s above 80 -  in her case. Chance of asthma markedly low. However the diffusion capacity is low at 83. For some reason, she is not absorbing O2. Nothing really going on with her expiratory loop, or any other major issues with this test. Is the patient’s obesity contributing to her poor lung perfusion? Interestingly, her weight has decreased by 15 lbs since her last visit.       Pulmonary physician recommended a CXR, a 4 week post nasal drip protocol. Additionally is a metacholine challenge needed here? Often a pre- and post-neb peak flow will first be done first. Then the metacholine challenge is done if the clinical picture fits. Is it time to rule-in or out asthma and spare someone years of MDI use. Diffusion capacity should be normal in asthma.       Dr. Peitersen reflects on an often asked board question. When to get a chest xray for the complaint of persistent cough. Barring other obvious reasons such as new chest pain, high fever/shaking chills or focal exam findings, The American College of Chest Physicians recommends that if a cough is present for greater than 8 weeks, a CXR is indicated. This patient’s CXR reveals interstitial changes that bring up a broad list of possibilities on the differential. These include CHF, infection, autoimmune disease.      Chest CT non-contrast was now ordered and shows reticulonodular areas and some regions of consolidation that are almost mass like. Other patchy areas noted throughout. No endobronchial findings. Lymphadenopathy is also noted in various areas of the intra- and extra-thoracic regions. CT with contrast is important to see vascular issues, but also to see small hilar lymph nodes. Sometimes contrast can falsely increase the density of a nodule leading you to call it a granuloma. Hi Resolution chest CT is an older term, but current modern CT scans accomplish this . This involves 1 mm cuts vs. 3 mm cuts. Essentially thinner cuts to see nodules better.      The patient is now seeing a new pulmonologist and has normal vital signs, unremarkable lung exam, which is not totally unusual despite a very abnormal looking xray or CT. A PET CT scan is advised and will show hypermetabolic lesions. Essentially it will help find other areas of concerning activity that would be less risky to biopsy. Radiologist generally avoid biopsy of central lesions that are near important organs and structures. Insurance declines the PET CT, but a node was biopsied in the thigh. Dr. Bowers comments that this biopsy could be a low grade lymphoma, although at this point it would need further assessment, but this is a send-out, looking for B and T cell rearrangement. A hematopathologist would also be good to consult with in this case. For now, this is benign specimen.       Another lymph node specimen was obtained, now axillary. This one shows really no other concerning findings. Tiny granulomas are noted. A variety of staining procedures were performed and all were negative. For Dr. Bowers, Toxoplasmosis may need to be considered.   CHAPTER 2:      Toxoplasmosis seems unlikely because this patient is apparently not immunocompromised. The differential dx does include various other infectious etiologies, such as bartonella, brucellosis and Q-fever. Melioidosis as well. Therefore, a travel history such as to SE Asia should be obtained. So, what now? There are about 20 possible infectious etiologies for this presentation...we need to do more tests. But, the patient was lost to follup for some time.       Now it is 16-months later, and she returns to urgent care with cough, fever, increased respiratory rate, O2 sats are marginal and an abnormal lung exam. Mild leukocytosis noted, and anemia which is new. Dr. White interjects with the following questions: 1. Has she ever been treated with a steroid? 2. Did anyone perform laryngoscopy? In the setting of normal chest imaging, these things should be considered. But of course, since her last CT scan was abnormal, a pulmonary etiology is of highest concern. And indeed a repeat CXR shows worsening overall interstitial change along with increase in the density of the azygoesophageal fissure which was noted on previous CT. The UC provider feels this looks like pneumonia. She was treated for pneumonia and a potpourri of other remedies were tried. Unfortunately, she did not follow-up with her medical doctor. She did see her naturopathologist who resumed drops for bartonella and Lyme disease. As Dr. Currie said, though, Lyme Disease does not present with granulomatous lymph lesions.       She now presents to the Emergency department 18 months after the UC visit. She is SOB, coughing, and states she has “chronic lyme disease”. She is 85% on RA. She has SIRS. Leukocytosis, and a respiratory alkalosis is noted. Her CXR shows Left upper lobe infiltrate that is quite dense. This must be followed to ensure resolution. Lactate and influenza were normal. The commentary from Dr. Herold in the audience was that this patient is not quite meeting sepsis criteria, but quite ill all the same. The decision to initiate broad spectrum antibiotics was made. Further history demonstrates that she was diagnosed with Lyme disease at age 10 and has struggled with health issues ever since. The patient had ongoing frustrations about cost of care and so she continued to see her naturopathologist.       Regarding another good exchange between Dr. Gross and Dr. Herold, involved the discussion of using CT to differentiate this very abnormal CXR for infiltrate vs. empyema. Ultrasound can also be employed for thoracentesis if indeed it is empyema.       Dr. Currie also makes the point that "chronic lyme disease" is not a known condition, so that when patients present with this issue or concern, other underlying disease states must be considered.      While CAP is the leading dx, other considerations in the differential still exist. Dr. Curry also states that azithromycin/Ceftriaxone is a reasonable inpatient treatment regimen going forward. She is feeling better on hospital day 2, but her blood cx come back positive in all 4-bottles. Strep pneumonia is the culprit, and is the current, but certainly not chronic reason for her symptoms. TTE was recommended to rule out endocarditis, especially given her chronic issues. Echo showed high right sided pressures, and a CT PE study was done showing no PE. Dr. Gross discusses the CT reading and notes bilateral signifcant hilar and subcarinal lymphadenopathy. Dense alveolar consolidation around the bronchi and layering left sided pleural effusion. Also noted is a large spleen and some prominent retroperitoneal nodes. Hospital day 3 she has left sided chest pain and had an unchanged repeat chest CT.       Dr. Bowers, the pathologist, discussed the blood cell differential and comments that she is anemic and that is the primary issue. All other counts are normal. Mild rouleaux (stacking of cells) is noted on the morphology and prompts you to think about increased proteins, such as monoclonal and fibrinogen. On hospital day 3, the patient was to go home on levaquin. She is supposed to f/u with pulmonary, but then develops another fever and requires O2 once again. Fever after 40-hours of antibiotics is not entirely unexpected in this patient, especially due to her past history and the likelihood of some underlying etiology that has yet to be discovered.   CHAPTER 3:      Okay, so her immunoglobulins are low. What does that mean? Well, this looks like Chronic Variable Immunodefincy disorder. Does she need IVIG? Yes, it is worth a try per the immunologist. Especially since she is having fevers, rigors and need for increased oxygen. Repeat CXR shows some mild improvement in infiltrate, but a bit more of a CHF pattern, perhaps. ID is involved now and they feel that CVID made sense as a diagnosis. Her symptoms improved and no further IVIG is given. In terms of follow-up, the patient has done quite well. No further hospitalizations to date. There were some barriers in her care involving cost and insurance issues. A repeat CT in 2018 was reviewed by Dr. Gross and she still has some reticulonodular infiltrates. No further dense consolidation in the lung. Lymphadenopathy has improved in general. And the spleen is still enlarged. The patient apparently then was referred to another facility and had another node biopsy after she had yet another scan that showed once again some worsenening. IVIG is helpful for these patients and unfortunately is also very expensive. Many of these patients succomb to cancers of various types, as opposed to infection as they once did many years ago.       According to UpToDate, Common variable immunodeficiency is the most common form of severe antibody deficiency in adults and kids. It is somewhat complex, but in general is due to severe antibody deficiency due to impaired B cell differentiation with defective immunoglobulin production. Recurrent infections, chronic lung disease, GI disease and increased susceptibility to lymphoma are common. Besides having very low IgG, IgA and IgM levels, there is also a poor or absent response to vaccinations.      Feel free to comb through the literature on this one, and while it is not ultra common, it is not unreasonable to consider this in your patients who just can’t seem to avoid getting sick on a regular basis, or who happen to have significantly waned immunity to pathogens they were once immunized for.   Thanks to Dr. Peiterson for bringing this baffling diagnosis to our attention, and to everyone else involved in presenting this case.

Dr. Jed Gorden speaks with Dr. Jack West, reviewing the obstacles limiting broader adoption of lung cancer screening in practice and how novel approaches are needed to reach areas outside of tertiary care hospitals.

February and March Quick Summary February and March Podcast Articles   Ondansetron in pediatric n/v/d, Chest CT for elderly rib fractures, Management of Infectious Diarrhea, Antibiotics for elderly UTI, BVM during intubation, Blunt Thoracolumbar trauma evaluation, Gender and NSTEMI treatment, Predictors of Antibiotic Failure in Nonpurulent SSTI, Safety of PERC + YEARS in Patients with Low Probability of PE, POCUS for RD in the ED, Oral vs IV Antibiotics for Bone & Joint Infection, Impact of Scribes in the ED, EtO2 Monitoring to Assess Preox in ED RSI, Burnout in EM Residents, Predicting SBI in Febrile Infants < 60 days old.

Vincent and Daniel solve the case of the Man in the City with Groin Rash, catch up on the long backlog of email, and present a new case, possibly the most complex one yet on the show. Hosts: Vincent Racaniello and Daniel Griffin Become a patron of TWiP. Links for this episode: Bloodless malaria diagnostic (BBC) Image credit Letters read on TWiP 154 Case Study for TWiP 154 Daniel's colleague will solve this case, in two weeks. 79 year old man history of chronic lymphocytic leukemia that became B cell lymphoma, had chemotherapy a few weeks before coming. Was discharged with scrip for prednisone, but pharmacy made error gave him enough to take every day for over two weeks. Patient has fevers up to 100 degrees at home, headache, develops dry nonproductive cough. Brought to ER by family, there reports has lost weight. No nausea, no vomiting, no abdominal pain or diarrhea. Admitted to hospital. Has fever, chest x-ray suggests pneumonia, started on ab. Fever and symptoms continue, stop steroids. Chest CT shows multifocal ground glass opacifications and nodules. Increase ab to broader spectrum, ID is consulted. Positive test for latent TB. History hypertension, coronary artery disease, enlarged prostate. Gets bactrim, antifungal, antiviral. Born in DR, living in US since 70s. Visits occasionally had been a few months before. Lives with wife, no pets, no smoking, no toxic habits. Heart rate in 90s, looking fatigued, coughing, scattered crackles in lung, old systolic murmur, no rashes, confused, but family says he is always like that. TB test is negative. Negative for strongyloides. WBC count has increased, 30% eosinophils (over 7000). Stool ONP ordered but becomes constipated. CAT scan of belly shows thickening of colon. Send your case diagnosis, questions and comments to twip@microbe.tv Music by Ronald Jenkees

Author: Chris Holmes, M.D. Educational Pearls The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT. Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mechanism of injury that includes rapid deceleration was also associated. If a patient has none of the above findings, then there is only a small chance that there will be an abnormal chest CT. References: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

When to Perform Preoperative Chest CT for RCC Staging - Jesse Ory, Kyle Lehmann and Jeff Himmelman Song credits 1. Don't fear the reaper: blue oyster cult 2. No diggity: blackstreet

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin The TWiPanosomes solve the case of the Young Man from Anchorage, and discuss how cestode parasites increase the resistance of brine shrimp to arsenic toxicity. Links for this episode: Trichinella life cycle (pdf) When parasites are good for health (PLoS Path) The Origin of AIDS by Jacques Pepin Letters read on TWiP 105  Case study for TWiP 105 This week's case involves a 32 yo male with several concerns. Spent 6 weeks doing religious missionary work in Kenya, performed baptisms in Lake Victoria.Waist deep in water, no shoes. Took malaria drugs, ate lots of interesting foods: cichlids, ugali, corn based food, flavored with greens; stew with some sort of meat, beef and goat. Five weeks after return developed rash with fever, shortness of breath. Three of four friends who were with him in Kenya reported similar symptoms. The fourth who did not get sick did not go in water, nor did he eat very much. No medical/surgical history, no drugs. Had some sexual activity while there. Elevated white count, 70% eosinophils. Chest CT shows nodules in lungs. Doc told him, allergy, you will be fine. The water he went into is near a village, there are rodents nearby, and a runoff. Send your diagnosis to twip@microbe.tv Send your questions and comments to twip@microbe.tv