Podcasts about ddavp

In this week's episode we'll learn about the role of autologous transplant for relapsed myeloma. In an updated analysis of the GMMG ReLApsE trial, salvage autologous transplant offered no survival benefit compared to control chemotherapy. These findings may have clinical implications in an era of alternative, and highly effective, treatment options. After that: Response to DDAVP, or desmopressin, in bleeding disorders. This study is the first large scale meta-analysis to assess the response rate to DDAVP in bleeding disorders. Authors provide new insights into determinants of response, which vary according to the disease type. Finally, turning to diffuse large B cell lymphoma. Germinal center B cells depend on the activity of DOT1 and EZH2 to maintain their pro-proliferative identity. New research shows that combined treatment with DOT1L and EZH2 inhibitors has synergistic activity in vitro.Featured Articles:Salvage autologous transplant in relapsed multiple myeloma: long-term follow-up of the phase 3 GMMG ReLApsE trialDDAVP response and its determinants in bleeding disorders: a systematic review and meta-analysisTargeting DOT1L and EZH2 synergizes in breaking the germinal center identity of diffuse large B-cell lymphoma

My traditional set review. Which is also a star-studded panel discussion. But instead of looking at individual cards, we look at the decks. How do we see decks in the upcoming format, what cards are we hopeful and what synergies excited about. My guests are: Jason Ye, a Pro Tour star and one of the brains behind the Slogurk decks. But we all know that in reality, Jason only wants is to develop quirky draft build-arounds. And you are in for a treat here! https://x.com/JasonILTG Adam (aka Ddavp) - don't get fooled by his joviality, there is a sharp and competitive mind behind the cordial exterior. And jokes that would make many-a-dad blush. https://twitter.com/adam_ddavp Springbok7 - a second time guest and already an integral part of the team. The level-headed member of the skeleton crew, internally tutting at our shenanigans. You can find them streaming on Twitch: https://www.twitch.tv/springbok7 Mike, AKA Tresio, this editions newcomer, but entering with a bang. Just showing how becoming a patron and putting some effort can connect you with the creator. Tresio started by asking me question for Magic Numbers episodes and now advanced to co-hosting the show. And pulled their weight fearlessly with some excellent takes! Follow them on https://x.com/tresio Join the ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Discord⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠, sign up for ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Patreon⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠, and use this ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Linktree⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ for everything else! ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ This podcast is sponsored by ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠mtgazone.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ - get your reading fix from the best and brightest Magic writers in the business. You can get the BulkBox at ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://www.bulkbox.co.uk/store/⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ if you are in the UK. Remember to use SIERKO10 code for a 10% discount! If you are outside of UK, you can find your local distributor on the BulkBox website. Watch this episode and see the slides: ⁠⁠https://youtu.be/MsFMWW3nVfo⁠⁠ Theme song: You Do You, Mana Junkie by essesq (c) copyright 2020 Licensed under a Creative Commons Attribution (3.0) license. ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠http://dig.ccmixter.org/files/essesq/61332⁠⁠⁠⁠⁠

Me, JasonILTG, Tajoordan and DDAVP look at the upcoming set and try to figure out how would we want a deck in each color pair to look like. To do so we first explore the format synergies and the cards we like and later assemble them in simple limited deck with some reasonable limitations (1-2 rares, 6-8 uncommons and rest just commons). Check this out if you are prepping for the prerelease and want to exercise your brain before the format hits Arena. My esteemed guests are all accomplished limited players: JasonILTG - https://twitter.com/jasoniltg Check out their site with some great articles: experimentalsynthesizer.blog/articles Adam AKA DDAVP - https://twitter.com/adam_ddavp And Tajoordan: They all stream so check their links in their Twitter bios. Slides for this episode are available for everyone at https://www.patreon.com/posts/slides-for-106-97522251 so you can look through our builds in your own time, or even modify them Join the ⁠⁠⁠⁠Discord⁠⁠⁠⁠, sign up for ⁠⁠⁠⁠Patreon⁠⁠⁠⁠, and use this ⁠⁠⁠⁠Linktree⁠⁠⁠⁠ for everything else! ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ This podcast is sponsored by ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠mtgazone.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ - get your reading fix from the best and brightest Magic writers in the business. Theme song: You Do You, Mana Junkie by essesq (c) copyright 2020 Licensed under a Creative Commons Attribution (3.0) license. ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠http://dig.ccmixter.org/files/essesq/61332

Dr. Nayantara Coelho-Prabhu, Mayo Clinic gastroenterologist specializing in the care of patients with gastrointestinal bleeding and endoscopy, talks through many aspects of acute GI bleeding. She helps to clarify the prioritization of medications, when to incorporate imaging, broadens our differentials for upper and lower GI bleeding, gives mindblowing advice on stool guiac testing and SO much more in this over-stuffed (or should we say constipated) chapter of Always on EM. There is also a special cameo from Dr. Luke Wood going over how to insert a Minnesota tube (esophageal balloon tamponade device)!   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   RECOMMENDATION: Dieulafoy lesion video from New England Journal of Medicine: https://youtu.be/tzJQDen1nug?si=zOmywZ1VN3VvA004    REFERENCES: Drescher MJ, Stapleton S, Britstone Z, Fried J, Smally AJ. A call for reconsideration of the use of fecal occult blood testing in emergency medicine. Journal of Emerg Med. 2020. 58(1)54-58 Mathews BK, Ratcliffe T, Sehgal R, Abraham JM, Monash B. Fecal Occult Blood testing in hospitalized patients with upper gastrointestinal bleeding. Journal of Hospital Medicine. 2017. 12(7)567-569 Harewood GC, McConnell JP, Harrington JJ, Mahoney DW, Ahlquist DA. Detection of occult upper gastrointestinal bleeding: performance in fecal occult blood tests. Mayo Clin Proc. 2002 Jan;77(1):23-28 Blatchford O, et al. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet 2000. Oct 14;356(9238):1318-21 Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J. Acute upper gastrointestinal haemorrhage in west of scotland: case ascertainment study. BMJ 1997. Aug 30;315(7107):510-4 Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med. 2007 Sep;25(7):774-9 Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917 Roberts I, Shakur-STill H, Afolabi A, et al. Effects of High-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020. 395(10241):1927-1936 Aziz M, Haghbin H, Gangwani MK, Weissman S, Patel AR, Randhawa MK, Samikanu LB, Alyousif ZA, Lee-Smith W, Kamal F, Nawras A, Howden CW. Erythromycin improves the quality of esophagogastroduodenoscopy in upper gastrointestinal bleeding: a network meta-analysis. Dig Dis Sci 2023. Apr;68(4):1435-1446 Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol 2022;00:1-17 Vigano GL, Mannucci PM, Lattuada A, Harris A, Remuzzi G. Subcutaneous desmopressin (DDAVP) shortens the bleeding time in uremia. Am J Hematol 1989. May;31(1):32-5 Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FL, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010. Sep 8;2010(9):CD002907 Gao Y, Qian B, Zhang X, Liu H, Han T. Prophylactic antibiotics on patients with cirrhosis and upper gastrointestinal bleeding: A meta-analysis. PLoS One 2022. Dec 22;17(12):e0279496 Steffen R, Knapp J, Hanggi M, Iten M. Use of the REBOA catheter for uncontrollable upper gastrointestinal bleeding with hemorrhagic shock. Anaesthesiologie 2023. May;72(5):332-337 Sato M, Kuriyama A. Countering hemorrhagic shock due to duodenal variceal rupture with resuscitative endovascular balloon occlusion of the aorta. Am J Emerg Med 2023. Feb;64:204.e1-204.e3

We resume our hematological consultation series with an overview of von Willebrand disease, the most common inherited bleeding disorder. In this episode, we talk about the initial steps we should take to evaluate suspected von Willebrand disease (vWD) and how to differentiate the various subtypes. We will focus on vWD type 1 and 3! Be sure to tune in next week as we discuss vWD type 2 and management.Content: - Taking a bleeding history - What is von Willebrand factor? - What tests should we order for diagnosis? - What are the different types of vWD?- What is the DDAVP challenge? ** Want to review the show notes for this episode and others? Check out our website: https://www.thefellowoncall.com/our-episodesLove what you hear? Tell a friend and leave a review on our podcast streaming platforms!Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Emergency Medicine Clinical Pearls and EMPoweRx Conference  Special Guest: Megan Rech, PharmD, MS, BCCCP, FCCM, FCCP   https://empowerx-conference.com https://rutgers.cloud-cme.com/course/courseoverview?P=0&EID=17157&formid=2931 https://empharmnet.org/ 03:35 – EMPoweRx Conference 12:28 – TXA in Epistaxis 21:40 – DDAVP in Antiplatelet-Associated ICH 34:47 – Awareness with Paralysis Reference List: https://pharmacytodose.files.wordpress.com/2023/03/em-pearls-references.pdf PharmacyToDose.Com  @PharmacyToDose  PharmacyToDose@Gmail.com Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Alexis "AC" Gomez, a second year fellow at the combined MGH, Brigham and Women's, and Boston Children's nephrology program, discusses her approach to hyponatremia with host Dr. Joyce Zhou. She shares the pathophysiology behind her diagnostic framework for hyponatremia and her systematic approach, and discusses pearls such as how to use ddAVP clamps in treating this disorder. Run the List podcast on AccessMedicine: https://accessmedicine.mhmedical.com/multimedia.aspx#1460

Does your head spin when you look at a von Willebrand panel? In this episode, Dr. Angela Weyand teaches us about the most typical presentations of VWD, how to interpret those pesky antigen and activity levels, and how DDAVP works for bleeds.

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Here's the case: A 6-year-old child with a known h/o craniopharyngioma who has been endocrinologically intact with exception of needing thyroid replacement was admitted to the PICU prior to craniotomy to proceed with further tumor resection as well as the removal of a secondary cyst impacting his brainstem. The patient is receiving Keppra for seizures and per mother, he has recently been significantly more sleepy at school. On POD Op day 5: the PICU the bedside nurse notices increased urine output (6cc/kg/hr to as high as 10cc/kg/hr). Initially, there was an increase in Na to 157mEq/L within 48-72 hours the serum Na dropped to 128mEq/L To summarize key elements from this case, this patient has: Increase UOP Rapidly increasing Na initially followed by a drop All of which brings up a concern for Na abnormality post craniotomy In today's episode, we will be breaking down all things Sodium & the Brain. We will discuss diagnostic & management frameworks related to three pathologies: Central Diabetes Insipidus Syndrome of inappropriate Anti-Diuretic Hormone or SIADH Cerebral Salt Wasting These diagnoses can certainly be seen individually inpatients or as a spectrum of diseases — as we go through each of these diagnoses, pay particular attention to patient characteristics and lab abnormalities. Namely, serum sodium, serum osm, and urine osm. To build the fundamentals, lets first start with classic nephrology saying: Serum Na represents Hydration This takes us into a brief review of normal physiology — talking about three important hormones: ADH Aldosterone Atrial Natriuretic Peptide (ANP) Let's go through a quick multiple-choice question. A patient is recently started on DDAVP for pan-hypopituitarism. The medication acts similarly to a hormone that is physiologically synthesized in which of the following from which are in the body? A. Paraventricular Nucleus of the Hypothalamus B. Supraoptic Nucleus of the Hypothalamus C. Anterior Pituitary D. Vascular Endothelium The correct answer here is B the Supraoptic Nucleus of the Hypothalamus. Remember that ADH is synthesized in the hypothalamus and released from the posterior pituitary. What are the physiologic actions of ADH? ADH Increases H2O permeability by directing the insertion of aquaporin 2 (AQP2) H2O channels in the luminal membrane of the principal cells. Thus, as we will see with Central Diabetes insipidus, in the absence of ADH, the principal cells are virtually impermeable to water. Let's talk about our next hormone, aldosterone. What are the important physiologic considerations? Aldosterone is secreted from the adrenal cortex as a byproduct of the RAAS. Aldosterone increases Na+ reabsorption by the renal distal tubule, thereby increasing extracellular fluid (ECF) volume, blood volume, and arterial pressure. It also helps in secreting K and H. This physiology is applied directly at the bedside when we have patients in the ICU who have a contraction alkalosis secondary to diuretics. The increase in aldosterone as these patients lose free water from their Lasix administration results in hypokalemia and metabolic alkalosis. Alright, what about the third hormone, ANP? Atrial natriuretic peptide (ANP) is released from the atria in response to an increase in blood volume and atrial pressure. ANP causes relaxation of vascular smooth muscle, dilation of arterioles, and decreased TPR. causes increased excretion of Na+ and water by the kidney, which reduces blood volume and attempts to bring arterial pressure down to normal. As ANP causes natriuresis, diuresis, and inhibition of renin, you can consider this hormone as having a complementary & opposite effect to ADH and aldosterone. Alright, now that we...

Dr. Joel Topf joins us on Rounds to discuss and review key concepts in the recognition and management of acute kidney injury (AKI) in the SICU. AKI is a common and morbid complication among hospitalized patients. Further, trauma and surgical patients, in particular, are at an increased risk for AKI due to the myriad of pre-, intra-, and postrenal insults that commonly occur at the time of injury, during resuscitation, surgery,, as well as from iatrogenic insults including IV contrast, NSAIDs, antibiotics (aminoglycosides and the infamous Pip/Tazo/Vanco ice cream sandwich). From the use of a DDAVP clamp in patients with severe hyponatremia to the use of balanced solutions in critically ill patients, kidney_boy breaks it down for us as only a true salt whisperer can!

Take your salt game to the next-next level. We brushed off this fan favorite episode and rebooted #48 hyponatremia deconstructed with our Chief of Nephrology, Dr. Joel Topf aka @kidney_boy aka The Salt Whisperer for your CME earning pleasure. Learn the correct steps to diagnose and manage this common and dangerous condition. Topics covered include: true versus false hyponatremia, SIADH, tea and toast hyponatremia, beer potomania, safe rates of sodium correction, IV fluid choice, vaptans and more. 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 Original episode written and produced by: Matthew Watto MD, FACP  Show Notes and CME questions by: Deb Gorth ScM Cover Art and Infographic by: Edison Jyang Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP    Editor: Molly Heublein (written materials); Matthew Watto MD (audio)  Guest: Joel Topf MD Sponsors   POCUS Fellowship at University of Pennsylvania A novel, collaborative, POCUS fellowship training is available at the University of Pennsylvania for IM and FM graduates!  In 2016 they leveraged the robust EM ultrasound fellowship training infrastructure with UPenn’s progressive Department of Medicine to create the 1st multi-specialty clinical ultrasound fellowship.  Their graduating fellows have made them proud by accepting leadership positions, and if you want to be on the cutting edge, you should join their team.   Interview season is in full swing and they’re actively accepting applications.  Please go to pennultrasound.org or contact nathaniel.reisinger@pennmedicine.upenn for information.  You can apply for fellowship using the eusfellowships.com portal.   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 00:00 Intro 03:30 Guest interview 07:15 Pick of the week w/Dr. Topf 16:20 Clinical case of hyponatremia 17:48 False hyponatremia normal osmolality 19:34 False hyponatremia high osmolality 20:36 Understanding why osmolality matters 23:28 Workup false hyponatremia 24:45 Recap of discussion so far 25:40 ADH dependent vs independent hyponatremia 27:00 Psychogenic polydipsia 289:15 Renal failure and hyponatremia 30:03 Tea and toast, and Beer Drinker’s potomania 35:22 ADH dependent hyponatremia 38:15 Volume versus osmolality 40:00 Volume status exam 45:14 Additional testing with urine lytes and uric acid 47:30 Treatment for SIADH  52:42 Discussion of the vaptans 58:21 Additional testing in SIADH 62:50 When to admit patient for hyponatremia 63:59 Clinical case of hyponatremia complications 68:56 Fluids and rate of correction 73:36 DDAVP clamp 76:30 Moderate hyponatremia 78:35 Diuretic dosing DOES matter! 81:59 Loop diuretics for SIADH 84:25 Take home points 87:25 Outro Links* Dr. Joel Topf’s Textbook Dr. Joel Topf’s Blog Dungeons and Dragons Tartine (cookbook) by Elizabeth M. Prueitt I Hate You, Don’t Leave Me by Hall Strauss Intentional Parenting by Sissy Goff Mindset by Carol Dweck Nintendo Switch 8.0 Bit Techno- The Curbsiders Theme Song by Stuart Kent Brigham Ure-Na  European Society of Endocrinology Clinical Practice Guidelines.  Don’t miss Dr. Topf on twitter aka @kidney_boy.   *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 recall the pathophysiology of hyponatremia and develop a systematized approach to identifying the type and cause of hyponatremia, as well as how to safely manage hyponatremia.    Learning objectives After listening to this episode listeners will…   Differentiate true and false hyponatremia Recall the pathophysiology of true and false hyponatremia  Interpret blood and urine tests to identify the cause of hyponatremia Recall the limitations of the volume status exam List ADH dependent causes of hyponatremia List ADH independent causes of hyponatremia  Explain the pathophysiology of beer drinker’s potomania and “tea and toast” hyponatremia Use uric acid to differentiate SIADH from other causes of hyponatremia Basic therapy for SIADH Recall safe rates of correction for hyponatremia   Disclosures Dr. Topf has received honoraria from AstraZeneca and Cara Therapeutics. He is joint venture partner in Davita Dialysis centers receiving dividends. The Curbsiders report no relevant financial disclosures.    Citation Topf J, Gorth DJ, Williams PN, Brigham SK, Heublein M, Jyang E, Watto MF. “REBOOT #48 Hyponatremia Deconstructed”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list Original air date: July 17, 2017; Updated September 7, 2020.

Contributor: Charleen Melton, PharmD Educational Pearls: Desmopressin (DDAVP) is an analogue of anti-diuretic hormone (ADH) that has been used for the treatment of intracranial hemorrhage. It works by increasing the release of Von Willebrand factor, helping to stabilize clots.  The use of DDAVP for intracranial hemorrhage in patients on antiplatelet agents (mainly Aspirin and Plavix) was recently reviewed In this retrospective review, they found an 88% decreased likelihood of hemorrhage expansion, in those who received DDAVP, compared to those who did not. Furthermore, they found no significant increase in adverse effects like hyponatremia or thrombosis  However, no difference in mortality or neurological status was found DDAVP for intracranial hemorrhage in the setting of antiplatelet agents may be safe and reduce the expansion of intracranial bleeds but not change important patient outcomes References Feldman EA et al. Retrospective assessment of desmopressin effectiveness and safety in patients with antiplatelet-associated intracranial hemorrhage. Crit Care Med 2019 Sep 24; [e-pub] Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Show notes at pharmacyjoe.com/episode444. In this episode, I ll discuss an article about desmopressin effectiveness and safety in patients with antiplatelet-associated intracranial hemorrhage. The post 444: Desmopressin (DDAVP) in patients with antiplatelet-associated intracranial hemorrhage appeared first on Pharmacy Joe.

Solve hypernatremia with tips and tactics from Dr. Joel Topf, MD (@kidney_boy), our Kashlak Chief of Nephrology. We review the diagnostic workup for hypernatremia, polydipsia and polyuria, review the pathophysiology of diabetes insipidus, and how to differentiate between nephrogenic and central DI. Plus, we walk through how to treat hypernatremia in the acute setting and Dr. Topf shares clinical pearls on why hypernatremia is the opposite of hyponatremia… It’s easy! Full show notes at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written by Hannah R. Abrams and Joel Topf MD Producer: Hannah R. Abrams Cover Art and infographic by: Hannah R. Abrams Hosts: Hannah R. Abrams; Stuart Brigham MD; Matthew Watto MD, FACP Editors: Matthew Watto MD, FACP; Emi Okamoto MD  Guest: Joel Topf MD Check out Dr. Topf’s podcast! The NephJC podcast, Freely Filtered, discusses the latest NephJC topic every two weeks. Subscribe here or on iTunes.  Time Stamps 00:00 Intro, disclaimer, guest bio 03:25 Joel’s one liner and plug for his new podcast 05:34 Hannah shares a really weird analogy 07:10 Picks of the week*: In Shock (book) by Rana Awdish; HBO’s From the Earth to the Moon; Once Upon a Time in Hollywood (film); Glass(film) directed by M. Night Shyamalan (Stuart’s anti-pick)POCUS! Sign up for a course today from the ACP, AIUM or TRUST.  13:18 Why hypernatremia is easy 14:49 The case of Paula Uric - new onset hypernatremia with hypercalcemia 16:12 Hypernatremia risk factors; ADH, osmolality and the kidney  21:20 Loop of Henle and the sodium, potassium and 2 chloride channel 22:05 How hypercalcemia mimics nephrogenic diabetes insipidus 29:30 Hypercalcemia workup 33:10 Differentiating central from nephrogenic diabetes insipidus 37:35 DDAVP, desmopressin and treatment of nocturia 38:50 The case of Manny Uric - altered mental status and hypernatremia Na = 162; Why do patients in the ICU develop hypernatremia? 42:29 Calculate the fluid deficit; total body water 48:05 Estimate insensible losses (electrolyte free water clearance) 54:48 What if your hypernatremic patient is also hypovolemic? 57:30 Does fluid restriction work in heart failure? 58:35 Hypernatremia - Is there such a thing as too fast in adults?  63:44 Thiazides versus acetazolamide for nephrogenic DI 68:34 Take home points 71:20 Outro Links* In Shock (book) by Rana Awdish HBO’s From the Earth to the Moon Once Upon a Time in Hollywood (film) Glass (film) directed by M. Night Shyamalan (though consider avoiding, per Stuart) POCUS! Sign up for a course today from the ACP, AIUM or TRUST *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 my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra. Disclosures Dr Topf lists the following disclosures on his website: “I have an ownership stake in a few Davita run dialysis clinics and a vascular access center. Takeda Oncology made a donation to MM4MM the program that is taking me to Mount Everest in 2018”. The Curbsiders report no relevant financial disclosures. Citation Topf J, Abrams HR, Brigham SK, Okamoto E, Watto MF. “170 Hypernatremia is Easy with Joel Topf MD”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list. September 2, 2019.

Dr. McCann received a B.A. in Music from Brown University and a Master’s in Library Science from University at Albany. She went on to receive her Doctor of Medicine degree (MD) and simultaneously earned a Master’s in Public Health (MPH) in Tropical Medicine (TM) at Tulane University in New Orleans. She completed both an Internal Medicine residency at Banner Samaritan Medical Center and a Pediatrics residency at Phoenix Children’s Hospital in Phoenix, AZ. Dr. McCann practiced medicine at the Arizona Center for Integrative Medicine where she worked and trained with renowned Andrew Weil, M.D., as one of 35 distinguished fellows in residence throughout the world. Dr. McCann also became certified in medical acupuncture through the American Academy of Medical Acupuncture, studied environmental medicine and chelation with Dr. Walter Crinnion and biotoxins with Dr. Ritchie Shoemaker. Dr. McCann is on staff at Hoag Memorial Hospital in Newport Beach, California and has been in private practice in Costa Mesa since 2008. She founded Partners in Health at the Spring Center in August 2009. Do you specialize in mold primarily, or biotoxin illnesses in general? She specializes in functional and integrative medicine. It turns out that a lot of people who come in have at the root of their issues biotoxin illness and env’t toxicity. And along those lines: what is your take on why mold and Lyme seem to occur together so often?  She thinks that Lyme and chronic infections are ubiquitous. Ticks are spreading and there is more global warming, so we’re seeing an increase in the level of burden and incidence of infection. Many people are walking around asymptomatic at some level. It takes an inflammatory response, like being in a moldy building that will exacerbate the situation. You can also see it the other way. People might be living in a moldy env’t but tolerating it ok. But then if they get bit by a tick, then suddenly they have Lyme and can’t tolerate their environment anymore. On top of that, our world is so toxic with env’t chemical burden, so heavy metals, solvents etc also contribute to our inability to manage our body burden. She sees these things interplaying quite a bit. Can you describe for our audience what some of the symptoms might be that would tip you off to consider a biotoxin illness as the root of their issues? Generally it’s a laundry list of symptoms and it will cover many different systems. The more weird, wacky symptoms people tend to have that aren’t easily explained, the more she thinks of this. Some of the big ones: chronic fatigue especially. This is the most common symptom. They can look like they might have other illnesses too. Could look like an osteoarthritis or fibro case, but they’ll have other symptoms too: GERD, bloating, IBS, etc. Neurological symptoms, memory, word finding problems, issues concentrating, light and sound sensitivity, blurry vision. Often neurological symptoms: tremors, tingling, numbness. Respiratory symptoms. Asthma as an adult. It’s good to think of mold and biotoxin exposure with that. When she’s thinking about mold, patients can also get dysautonomia issues, temperature regulation, balance issues, etc, Static shocks, skin sensitivity, rashes. In her own case, she had fatigue and worsening food sensitivities. She went from being gluten and dairy free to suddenly reacting to everything. The list got really long, because she was living in a moldy house. What is your take on why mold toxicity is suddenly such a huge problem? Why now? It is getting worse. Some of it is because we’re using a lot of antifungals in agriculture, plant stores, etc. Those are self-selecting for more toxic molds in an indoor environment that weren’t there before. Also, in CA at least, construction is very poorly done. If the house is up in 6 mo, and we build with wood and paper which are fuel for the mold. It’s a combo of the way we’re building and poor construction. We just can’t handle the total load too. If someone is looking to buy a house, or build a new one, are there any red flags to look for in terms of building materials or construction that make a house more susceptible to mold, even if there isn’t any already present? When looking for a house, if it’s current construction, part of it depends on the market and part on the level of sensitivity. Patients need to become advocates for themselves and have a sense of their level of sensitivity. If they’re feeling relatively healthy, they might be better able to walk into a building and smell mold. If you smell a musty smell, there’s mold there. Check out the place using nose and eyes, and look for areas where there might be water damage. Usually it will be hidden, though: in the walls, water leaking behind the walls or a sprinkler system hitting the walls. Those are things that need to be considered. If they want to make sure, there are a variety of tests we can talk about to do pre-emptively. In a hot market, it’s tricky. No seller is going to wait for you to get a mold test back. When looking at new construction, she watches places go up fast: frames aren’t covered, and if it rains, it rains. If it hasn’t totally dried out, then you seal that in. In many instances, you’re better with concrete, bc that won’t become moldy, and plaster instead of sheet rock (older forms of building). Then also take into consideration what your materials should be, if concerned about env’t chemicals. Most of the chemicals we’re exposed to are in our homes. We want to avoid formaldehyde in particle boards, and the chemicals in the foam that they use in building, too. What exactly is an ERMI vs a HERTSMI test? If someone is looking to test their house or workplace for mold, why is it so important to get these rather than a non-specific mold test? What are the kinds of tests they DON’T want to get, that won’t give them the right information? This is hotly debated: Dr Shoemaker maintains that ERMI is the best, and that’s what we should use. We could use HERTSMI too — some indoor professionals will argue that the air trap test is better. We have to ask what the question is that we’re asking, and from that standpoint, pick the best test. If you smell mold in the bathroom and you think there’s a water leak in the bathroom, you want to test in a way that will access that information. So collect the dust with ERMI or HERTSMI under the sink. Or even open the wall socket and swab in there. If the question is “is the house moldy in general,” that requires a different way of looking at the problem. You might want to do a whole house screening, and you might still want to test in the areas where you’re more likely to have a problem (where the water pipes are). She’s sometimes recommended collecting the dust off the HVAC system as a way of testing the whole house. In terms of ERMI and HERTSMI: the former is DNA PCR looking at 36 different molds. Some are mycotoxin producing and some are not. You get a composite score. The higher the score, the more concerning the situation: the more mycotoxin producing molds. HERTSMI is just looking at 5 mycotoxin-producing molds and they grade the spore count to give you a HERTSMI score. They don’t always correlate, so you have to use the information and understand the info you’re trying to answer when interpreting it. If they think the house is moldy, and it has a musty smell, and it may be in a particular part of the house, do you need a mold inspector? They will analyze the entire house, in all the places that there might be water damage. They can hopefully help the patient identify where they want to do additional testing. Usually a combination of tests can be most helpful. She was in an incredibly moldy house and had an inspector come in to get a baseline outside and a sample in the kitchen where they knew there was a problem. Then they did wall samples in all the places in the house where it appeared there was water damage. With those pieces of information, they could compare the outside ambient air to the inside house air to what was actually in the wall cavity and make a good determination overall. If someone is looking to hire a remediation company for mold, what are some of the most important questions to ask to make sure they do it right? She’s been more reliant upon her inspectors to refer her to a remediation company. You want to make sure that whoever is doing the inspection doesn’t have a vested interest in finding more mold than there necessarily is. The inspectors write the treatment plan for the house. The more thorough the inspection, the more thorough the remediation should be. Understand that the remediators are there to remove the moldy parts of the house. They aren’t necessarily going to identify plumbing leaks contributing to the problem and solve it. They probably won’t rebuild and reconstruct whatever has been removed. You would need a contractor to do that. She learned the hard way: she had to become her own general contractor. She needed to find a remediator and find the people who would identify the leaks and fix them. They weren’t the same people. In terms of other questions: find out how they will protect the rest of the house. They should put up negative pressure barriers so that any of the work and materials that get removed won’t be spread throughout the house. You need to ask how they’re going to use air filtration systems and what they’ll do to prevent it from coming back. Some remove the damaged material, paint or do fogging. Sometimes the inspectors will recommend a level of cleaning. What binders do you prefer for biotoxin elimination (cholestyramine, colestipol, activated charcoal, Zeolyte, bentonite clay)? She tends to gravitate toward activated charcoal and clay. Those are generally well tolerated. It depends on the person’s tolerance. Some people prefer one over the other. She doesn’t love cholestyramine or colestipol; she’ll use them if necessary. The former is a powder and it smells foul. If you’re prescribing from a conventional pharmacy, it contains aspartame. Some of that may be financial too: they can’t afford the compounded, clean cholestyramine. Colestipol and Welchol are 25% as effective at binding some of the biotoxins. One of her mentors teaches that the cholestyramine is better at binding ochratoxins and less at some of the other toxins. There may be a possibility of the urine mycotoxin testing to see which is most appropriate. She sometimes will use chlorella and adjusts the dose by tolerance: 1 cap once a day of one of them and titrate to bowel tolerance. Sometimes she’ll do muscle testing. She doesn’t do Zeolyte. The other supplements: phosphatidylcholine is invaluable in helping patients recover from biotoxin illness and chronic infections. Not necessarily the liposomal version. Mycotoxins are tiny and they can pass in between cells. This is a building block of every cell of the body, and it is well tolerated by most people. No toxic effects. The only caveat is that in sensitive people, if you give it to them too fast, they might have a detox reaction, so she starts slowly and then works up. With bentonite: just puts it in water and people drink it. Sometimes they might encapsulate the powder. Do you ever test for mycotoxins directly, or do you just stick with indirect markers like TGFb1, complement c3a and c4a? She doesn’t test everyone for mycotoxins bc the tests are expensive: $300-700 or so. She does one of them through a test that accepts Medicare. It may depend on the person too, how sick they are and how high a priority it is. Personally she doesn’t find that it is essential to have that test. In terms of the blood testing that Shoemaker has taught us: the TGFb1 requires special handling. It has to be sent to Cambridge Biomedical. Has to be spun down twice and sent on dry ice to Cambridge. Then they started sending it to Viracor instead. The reference range changed and the numbers changed a little bit. She has done thousands of TGFb1 on people over the years. Most of the time, people would have it between 4-5000. But the levels didn’t always correlate with the severity of illness. There are some cases where it will be high and some where it will be low. Not just mold drives TGFb1 so it’s harder to interpret. She will still occasionally order it as a screening. But taking a good history of the medical complaints and a house history. The same thing with c4a: it has to be sent on dry ice, has to go to National Jewish. Quest did it for awhile and they stopped. She’s had patients with c4as who are deathly ill around 3000. Others feel totally fine with 20K. It’s more about the history. Do you have any great testing recommendations for solvents? She hasn’t found a good test for this. Genova has a test; so does Great Plains and US Biotek. If the primary treatment is going to be some form of detox: sauna, binders, alkalinization, coffee enemas, colonics, etc, then we don’t necessarily have to know exactly what the toxin is. They’ll feel better just with the detox protocol. Why does mold exposure so often lead to MARCoNS? What is the causal connection there? She doesn’t have the answer to this. Some colleagues find that it’s really important. Some don’t test for it and don’t think it’s relevant at all. She’s decided that it’s not a requirement of the Shoemaker protocol. But if there’s chronic rhinorrhea, chronic sinusitis, some kind of URI issue — even if she doesn’t suspect mold, she might check. When might you send a patient for a NeuroQuant MRI? Dr Mary Ackerley has done more on this than she has. She’s looking at all the money that these patients have to lay out and whether that will change what she does. Is it necessary A young man came to see her asking for a NeuroQuant, and he had substantial atrophy based on the reports: and he now is terrified of this. But what she’s doing isn’t any different than it would have been without the NeuroQuant, and now he’s scared about that. Some of the benefits: she does order them sometimes, and there are a few additional reports on the NeuroQuant that Dr Ackerley is teaching the community about (the morphology report and the flare lesion report and the triage report) — she’s still learning about some of these additional reports as to how useful they might be in managing patients. Do you ever use VIP nasal sprays? What are the concerns associated with this? She uses this very little. For the most part, she focuses on doing detox. By the time they get to the VIP in the Shoemaker protocol, they don’t need it. She hasn’t used it much. She was given it personally and didn’t notice a thing. Shoemaker is very clear that you have to be out of the moldy building, give the first dose in the office, and check labs immediately afterwards. Her sense from her colleagues is that generally it’s well tolerated and it may be very beneficial in some patients. Sometimes they may have to take tiny doses and take a long time to ramp up. We have a lot of other tools in our tool kit. If her patients are doing sauna, colonics and coffee enemas, IVPC and the binders, they generally don’t need VIP. What does an MMP-9 elevation tell you, and is there anything you specifically do about this in terms of treatment, or is it the same protocol you’d use regardless? Same question for VEGF and ADH. She has found them less and less valuable over time. Since we’re still in the learning phases of how to manage biotoxin illness — maybe start with urine mycotoxin testing as a baseline and some of these tests. If the VIP is less than 23, at LabCorp only (can’t send it to Quest), then we can follow that. If, doing all the other things we know to do, it doesn’t come up, then perhaps consider VIP. Hers went up without taking it. The MSH — she used to use it a lot more. She would test it and some people would be non-detectable. A normal range is supposed to be >35, but most people are in the 20s or less. It’s not supposed to change. The MMP-9 means a lot of other things. It’s not just about biotoxins: it could be high in COPD and a variety of other states. She hasn’t found it useful. ADH: she’s tested that and if it’s low, she gave one person DDAVP to try to help their urinary frequency and they didn’t tolerate it. Ask the question, what will you do with the information? What’s the deal with the low amylose diet? Why is this helpful, and who is it helpful for? Low amylose: amylose is grains. Want to avoid those, but on this diet, corn is ok. But corn is the most moldy food source out there. This isn’t useful if people are going to eat a lot of moldy corn. She has a slide in her lecture about the contamination of the corn in the horse feed in Texas in the 70s. They developed liquefaction of the brain. The owners realized this was from the feed. The horses recovered — but that same corn continued to be used in the human food sources. Lots of hispanics ate a lot of corn in that area and the rates of neural tube defects skyrocketed. The usual rates of spina bifida are 4/10K and the rates were 3 and 4 times that in that area. So the diet: her recommendation is a modified ketogenic diet, removing the grains for people in a moldy environment. We have to stop eating moldy food. Shoemaker didn’t think this was important, and she does. You mention ISEAI: The International Society of Environmentally Acquired Illness. Can you tell us what that is?  She’s on the board. Several of the early adaptors with Dr Shoemaker had a philosophical split and they went on to create this. These folks were interested in learning and teaching about mold exposures and environmentally acquired illness, including env’t chemicals and toxicants in this rubric, working together to be more inclusive of the practitioners and more expansive in their ways of getting people to wellness. There is no right way to treat these folks. We have to use all the tools in our tool kit. We need to identify food sensitivities, heal leaky gut, etc. They are in the process of formulating their inaugural event in the Phx area in May 2019. They anticipate an amazing panel of speakers. She thinks this is a place where practitioners and lay people alike can learn about how to get themselves well. There are different levels of membership too. It will be a fabulous conference and a great resource. They intend to create a certification program so people can have a good foundation of how to treat biotoxin illness and will be pooling resources so that this is as scientific as possible. For more info, see https://iseai.org/   Contact Dr McCann: https://www.thespringcenter.com/   A few extra resources: to deal with the trauma of mold illness, check out Annie Hopper’s work, Wired for Healing.   For vagus nerve dysfunction, check out the work of Steven Porgus on the Poly-Vagal Theory,  or Stanley Rosenberg: Accessing the Healing Power of the Vagus Nerve.

Show notes at pharmacyjoe.com/episode307. The post 307: How desmopressin (DDAVP) can be used for intracranial hemorrhage appeared first on Pharmacy Joe.

In this episode, we discuss the management of and treatments for nocturnal enuresis, nighttime bedwetting. Joining us is pediatric urology nurse practitioner, Marguerite Korber, NP, who runs many of the enuresis clinics at Children's Colorado. In this episode: At age 5, the primary care physician should make a formal diagnosis of nighttime wetting and give the family a proactive, therapeutic treatment plan. It's recommended that families come to a urology specialist or enuresis clinic around age 7 The reasons for bedwetting may differ according to whether patient has primary or secondary nocturnal enuresis. Before making a referral to urology, primary care physicians can perform an initial workup, evaluating: If the child is ready to become potty-trained and, therefore, dry at night Functional bladder capacity to see if nocturnal enuresis has anything to do with diabetes or UTI concerns If their bladder is releasing earlier than it should and/or doesn't have the appropriate, expected capacity Despite the parents' frustration, until the child is affected by their nighttime bedwetting, initiating them to be responsible for some of their behavioral modifications during the day will be difficult. The important aspects to focus on in a physical exam are the abdominal exam, lumbar spine evaluation, neurologic evaluation and urethral opening evaluation. Constipation plays a large role in nocturnal enuresis. The abdominal exam will tell you whether or not constipation is a contributing factor, specifically in that descending colon. "If you can palpate stool, then you know that it's probably sitting in the rectum as well." The urethral opening tends to be more of an issue for boys specifically. Bedwetting enuresis management options include behavioral therapy, fluid shifting and addressing constipation. How to effectively implement the use of alarm therapy as a bedtime wetting management option – and what parents need to know up front. What criteria allows for using Desmopressin, a DDAVP, as the right option when pursuing pharmacologic therapy Options for managing chronic nocturnal enuresis: By changing any dysfunctional voiding components to their day time habits, patients will be better prepared for the natural progression of the night time to occur. Providers need to provide alternative treatments for patients when cost is a barrier to care, such as with a bed alarm. Pull-ups can be a cost effective solution to involuntary nighttime bed wetting. Oftentimes with nocturnal enuresis, it's necessary to treat the whole family, helping parents to manage their frustration.

Step up your salt game. We deconstruct hyponatremia with expert tips from our Chief of Nephrology, Dr. Joel Topf aka @kidney_boy aka The Salt Whisperer. Topics include: true versus false hyponatremia, SIADH, tea and toast/beer potomania, safe rates of sodium correction, fluid restriction, salt tablets, IV fluid choice, DDAVP clamps, and more. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case: 85yo F with anxiety, asthma, HTN (on a CCB), hypothyroidism with TSH of 3 on therapy. Sodium was 128 from previous values 134-137 mg/dL. She is more fatigued than usual. Time Stamps 00:00 Intro 03:00 Guest interview 06:45 Pick of the week w/Dr. Topf 15:50 Clinical case of hyponatremia 17:18 False hyponatremia normal osmolality 19:04 False hyponatremia high osmolality 20:06 Understanding why osmolality matters 22:58 Workup false hyponatremia 24:15 Recap of discussion so far 25:10 ADH dependent vs independent hyponatremia 26:30 Psychogenic polydipsia 28:45 Renal failure and hyponatremia 29:33 Tea and toast, and Beer Drinker’s potomania 34:42 ADH dependent hyponatremia 37:45 Volume versus osmolality 39:30 Volume status exam 44:44 Additional testing with urine lytes and uric acid 47:00 Treatment for SIADH 52:12 Discussion of the vaptans 57:51 Additional testing in SIADH 62:20 When to admit patient for hyponatremia 63:29 Clinical case of hyponatremia complications 68:26 Fluids and rate of correction 73:06 DDAVP clamp 76:00 Moderate hyponatremia 78:05 Diuretic dosing DOES matter! 81:29 Loop diuretics for SIADH 83:55 Take home points 86:55 Outro Tags: hyponatremia, salt, sodium, SIADH, ADH, vasopressin, fluids, electrolytes, kidney, nephrology, osmolality, urine, concentration, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student

What to actually do (besides nothing) for severe hyponatremia

Neurocritical Care Society and Society for Critical Care Medicine recommendations for reversal of antithrombotic agents in patients with intracranial hemorrhage Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage : A Statement for Healthcare Professionals from the Neurocritical Care Society... - PubMed - NCBI http://www.ncbi.nlm.nih.gov/pubmed/26714677 Antithrombotic: Timing, Antidote, Factor Replacement, antifibrinolytics Vitamin K antagonists (warfarin) If INR > 1.3 then Vitamin K 10 mg IV, plus 3 or 4 factor PCC IV (dosing based on weight, INR and PCC type) OR FFP 10–15 ml/kg IV if PCC not available Direct factor Xa inhibitors: activated charcoal (50 g) within 2 h of ingestion, activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Direct thrombin inhibitors (dabigatran): Activated charcoal (50 g) within 2 h of ingestion, AND Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Idarucizumab 5 g IV (in two 2.5 g/50 mL vials) consider hemodialysis or idarucizumab redosing for refractory bleeding after initial administration if 1) dabigatran was taken with 3-5 half lives and NO evidence of renal insufficiency or 2) dabigatran was taken beyond 3-5 half lives WITH renal insufficiency For other DTIs: Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Unfractionated heparin: Protamine 1 mg IV for every 100 units of heparin administered in the previous 2–3 h (up to 50 mg in a single dose) LMWH Enoxaparin: Dosed within 8 h: Protamine 1 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Dosed within 8–12 h: Protamine 0.5 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Minimal utility in reversal >12 h from dosing Dalteparin, Nadroparin and Tinzaparin: Dosed within 3–5 half-lives of LMWH: Protamine 1 mg IV per 100 anti-Xa units of LMWH (up to 50 mg in a single dose) OR rFVIIa 90 mcg/kg IV if protamine is contraindicated Danaparoid: rFVIIa 90 mcg/kg IV Pentasaccharides: Activated PCC (FEIBA) 20 units/kg IV or rFVIIa 90 mcg/kg IV Thrombolytic agents (plasminogen activators): Cryoprecipitate 10 units IV OR antifibrinolytics (tranexamic acid 10–15 mg/kg IV over 20 min or e-aminocaproic acid 4–5 g IV) if cryoprecipitate is contraindicated Antiplatelet agents: DDAVP 0.4 mcg/kg x 1, if neurosurgical intervention, transfuse one apheresis unit

In this EM Cases episode Dr. Melanie Baimel and Dr. Ed Etchells discuss a simple and practical step-wise approach to the emergency management of hyponatremia: 1. Assess and treat neurologic emergencies related to hyponatremia with hypertonic saline 2. Defend the intravascular volume 3. Prevent further exacerbation of hyponatremia 4. Prevent rapid overcorrection 5. Ascertain a cause Dr. Etchells and Dr. Baimel answer questions such as: What are the indications for giving DDAVP in the emergency management of hyponatremia? What is a simple and practical approach to determining the cause of hyponatremia in the ED? How fast should we aim to correct hyponatremia? What is the best fluid for resuscitating the patient in shock who has a low serum sodium? Why is the management of the marathon runner with hyponatremia counter-intuitive? What strategies can we employ to minimize the risk of Osmotic Demyelination Syndrome (OSD) and cerebral edema in the emergency management of hyponatremia? and many more... The post Episode 60: Emergency Management of Hyponatremia appeared first on Emergency Medicine Cases.

In this EM Cases episode Dr. Melanie Baimel and Dr. Ed Etchells discuss a simple and practical step-wise approach to the emergency management of hyponatremia: 1. Assess and treat neurologic emergencies related to hyponatremia with hypertonic saline 2. Defend the intravascular volume 3. Prevent further exacerbation of hyponatremia 4. Prevent rapid overcorrection 5. Ascertain a cause Dr. Etchells and Dr. Baimel answer questions such as: What are the indications for giving DDAVP in the emergency management of hyponatremia? What is a simple and practical approach to determining the cause of hyponatremia in the ED? How fast should we aim to correct hyponatremia? What is the best fluid for resuscitating the patient in shock who has a low serum sodium? Why is the management of the marathon runner with hyponatremia counter-intuitive? What strategies can we employ to minimize the risk of Osmotic Demyelination Syndrome (OSD) and cerebral edema in the emergency management of hyponatremia? and many more... The post Episode 60: Emergency Management of Hyponatremia appeared first on Emergency Medicine Cases.

Rapid over-correction of Hyponatremia can have devastating consequences: for one, osmotic demyelination syndrome (ODS) can result in destruction of the pons and a locked-in state. We don't see ODS very much as it's onset is delayed and usually sets in after the patient is admitted to hospital (or worse, sent home). Nonetheless, we need to know how to manage Hyponatremia in the ED so that we prevent ODS from ever happening. In this Best Case Ever, Dr. Melanie Baimel describes the case of a young woman who came in to the ED after drinking alcohol and taking Ecstasy, wanted to leave AMA after her Hyponatremia had inadvertently been corrected too rapidly, and the conundrum that ensues. In the upcoming episode, Dr. Baimel and the first ever Internal Medicine specialist on EM Cases, Dr. Ed Etchels, discuss a rational step-wise approach to managing Hyponatremia, tailored for the EM practitioner; when you might consider giving DDAVP in the ED, the best way to correct Hyponatremia, how to manage the patient who's Hyponatremia has been corrected too quickly, and an easy approach to the differential diagnosis. Get a sneak peak at the algorithm that will be explained and reviewed in the upcoming episode...... [wpfilebase tag=file id=577 tpl=emc-play /] [wpfilebase tag=file id=578 tpl=emc-mp3 /] The post Best Case Ever 33: Over-correction of Hyponatremia appeared first on Emergency Medicine Cases.

Rapid over-correction of Hyponatremia can have devastating consequences: for one, osmotic demyelination syndrome (ODS) can result in destruction of the pons and a locked-in state. We don't see ODS very much as it's onset is delayed and usually sets in after the patient is admitted to hospital (or worse, sent home). Nonetheless, we need to know how to manage Hyponatremia in the ED so that we prevent ODS from ever happening. In this Best Case Ever, Dr. Melanie Baimel describes the case of a young woman who came in to the ED after drinking alcohol and taking Ecstasy, wanted to leave AMA after her Hyponatremia had inadvertently been corrected too rapidly, and the conundrum that ensues. In the upcoming episode, Dr. Baimel and the first ever Internal Medicine specialist on EM Cases, Dr. Ed Etchels, discuss a rational step-wise approach to managing Hyponatremia, tailored for the EM practitioner; when you might consider giving DDAVP in the ED, the best way to correct Hyponatremia, how to manage the patient who's Hyponatremia has been corrected too quickly, and an easy approach to the differential diagnosis. Get a sneak peak at the algorithm that will be explained and reviewed in the upcoming episode...... [wpfilebase tag=file id=577 tpl=emc-play /] [wpfilebase tag=file id=578 tpl=emc-mp3 /] The post Best Case Ever 33: Over-correction of Hyponatremia appeared first on Emergency Medicine Cases.

In this VetGirl podcast, Dr. Marie Holowaychuk, DACVECC discusses the use of desmopressin (DDAVP) for the treatment of aspirin-induced coagulopathy! So, if you're about to take a dog to surgery, and just found out he's been on chronic aspirin therapy, consider listening to this podcast... it'll help with the oozing!

In this VetGirl podcast, Dr. Marie Holowaychuk, DACVECC discusses the use of desmopressin (DDAVP) for the treatment of aspirin-induced coagulopathy! So, if you're about to take a dog to surgery, and just found out he's been on chronic aspirin therapy, consider listening to this podcast... it'll help with the oozing!

Click to Subscribe to All Ben's Fitness & Get A Free Surprise Gift from Ben. Click here for the full written transcript of this podcast episode In this January 20 free audio episode: vitamin D, good carbohydrates, using weight vest and ankle weights for calorie burning, skiing for triathlon training, too much urination during exercise, exercise and hashimotos disease, and how to stay fit when you're partying. Remember, if you have any trouble listening, downloading, or transferring to your mp3 player just e-mail ben@bengreenfieldfitness.com.And don't forget to leave the podcast a ranking in iTunes - it only takes 2 minutes of your time and helps grow our healthy community! Just click here to go to our iTunes page and leave feedback. ---------------------------------------- Anonymous asks: Hi there Ben, i have a question on what is considered the safest least  injury free running form?  heel to toe   or  midfoot to forefoot? Also  any thought on Newton Running shoes? i run in a new pair of Asics  pronation support shoe..i roll inward ..ive had trouble with hip and  knee when .physical thearpy said hip is rotated and gluteus medius is  weak. He also suggested midfoot to forefoot running is better on the  body and he wears Newtons.  i looked up proper running form and seems  more people run midfoot to forefoot as well. Any thoughts or advice on this. Thanks. Anonymous asks: Hi there Ben have a question about the pros and cons to white rice?  I  eat quinoa rice on occasion and had a couple bobybuilding friends tell  me to eat white rice and chicken pre-workout to help increase energy  levels. im a triathlete and very clean eater and am anti-white rice. i  am struggling with getting enough good carbohydrates in. i rarely eat pastas or  rice or potatoes. usually two days out to a race is the only time i eat  them. struggling with energy levels and recovering and my friends  suggested it was due to no substatial carbs. i eat quinoa oats in the  a.m on a swim and bike day and weight days/ run days i go with egg  whites in the a.m. Any helpful advice?  THanks Listener Sal asks: Hey Ben, I have a question regarding weight vests and ankle weights.  I am   a student, and I spend much of my time in the library or in class sitting   down.  However, I do walk quite a bit to and from class, going up lots of   stairs throughout the day as well.  I was wondering how beneficial it would   be to throw on some ankle weights or even a weight vest underneath my   clothes.  Since it is winter, and i am usually wearing pants or a   sweatshirt anyways, I doubt anyone would notice.  Would this extra weight   cause any substantial calorie burn throughout the day?  Would it build leg   and general body strength? Also, what are the downsides to having this   stress on the body for such a long period of time.  I am not expecting much  from this idea, but thought that positive effects might be worth it since   it would take up no additional time in my day.  I would appreciate any   suggestions or comments on this topic.  Thanks, Sal Listener Lance asks: How can alpine skiing fit into "off season" base building? I am an avid skier who lives 4 hrs away from the hill, but still manage 30+ days a year from school vacations and weekends. In the past, I just skied until the snow ran out, then went mountain biking until it snowed again. This year I want to participate in a long triathlon season, so endurance training is the priority. Unfortunately, skiing is an anaerobic sport, and in the past it kept me unfit on the bike. I am unsure about how to balance the sports. There are two points of conflict: Weekends: Usually the only available time either to ski or do long rides or runs. Spring: There is often quite an overlap between spring skiing and training that needs to be done for spring races. How can I fit together my disparate interests so I can enjoy the ski season, but still have reasonable fitness for spring Xterra races? Listener Diane asks: Ben,  I don't know if you have ever come across anything like this  but I am getting desperate.  My docs are stumped.  For the last few years during stressful exercise(mostly races) of any length I start urinating every 10-15 min copious amts. I am very competitive and successful (won my age group in Kona this year), and this is negatively impacting my times as you can imagine.  If it starts during a triathlon usually doesn't start until the bike portion.  If a marathon usually after first hour.  It is rare for it to happen during training unless out very hard for long time.  I don't feel bad just very wet.  My primary doctor thought maybe diabetes insipidus and gave me DDAVP to take before race.  This worked maybe twice. He sent me to urology who didn't feel they could help.  I take electrolytes and have tried different ones and it doesn't change anything.  During a recent Ironman event in Nov at mile 20 on the bike I started every 15 min and then on the run hit the portapotty every mile. This is an example of how it usually goes. If you have any suggestions I would be very appreciative.  I have not found anyone else with this problem. Listener Chuck asks:  I have a trip to Las Vegas planned for April 16-19th.  I plan to have a good time, not kill myself, but probably drink a fair bit each night.  Of course, I'll try to get in as many good workouts as I can, but how will this affect me for the half Ironman on May 8th? And what can I do maintain as best as possible on the trip? Listener Carmen asks: What do you know about exercise and Hashimotos thyroid disease and how it affects adreanal health? Limitations? Listener Brad asks:  I just got turned on to your podcasts on my new phone through Google Listen. Your advise and podcasts are awesome and now I look forward to the advice you give each week on your podcast regarding triathlons. Last year I got in a few Ironman 70.3 at 42 years of age under my belt in just my second year of doing triathlons with a best of 5:14 in Kansas with a fractured foot. Had way to much energy when I finished both of them. I wish I would have known about you before committing my current coach here locally. He is one of the best here in Dallas area with 20+ yrs experience so I know I am in good hands. Maybe in the future it work out. I heard your latest podcast about the UA mouthpiece and I should be getting mine within a week. My dentist was able to pass it off as a sleep aid for grinding my teeth at night so after insurance I only paid $62 of the $495 price tag. I will let you know how it works for me as I increase my workouts. Still doing off season work and light workouts. Again, please keep informed on your findings with the mouthpiece. Listener Dave asks: I have been following your podcasts on the benefits of goat milk.  I have an acquaintance that has a friend that raises goats.  The milk is raw, unpasteurized straight from the goat.  He has offered to let me have some.  Would you have any concerns about this milk and implementing it into a diet? Listener Todd asks: Ben, I've been reading alot about Vit. D3 sources, and that the tablet form (small white disc, that comprises 90% of the Vit. D3 out there) is not very well absorbed by the body. Because D3 is oil soluble, we should be taking it in oil form (i.e. a gelcap).  It was even suggested that this form is better that the sublingual spray.  Any thoughts on this? ---------------------------------------- For  the next 2 weeks, the podcasts from Ben Greenfield Fitness will primarily focus on "Listener Q&A's", due to Ben's undertaking of a huge triathlon-focused side project that is going to bring you an instant and affordable way to get customized triathlon training advice! For more information on that project, and to stay in the loop on what's going on with that project (called the Rock Star Triathlete Academy) simply go to http://www.rockstartriathlete.com.