Podcasts about EPUB

Well, even though low dose aspirin has been recommended for the reduction of preeclampsia risk for many years, 2 controversies persist: 1. who should get it, and 2. the dose we should use. While the current US recommendation still focuses on 81 mg low dose aspirin, initiated after 12 weeks of gestation (based on risk factors), there's increased movement and growing data supporting both universal adoption and the higher dose of 162 mg. In this episode, we will briefly summarize brand new data out of UT Southwestern which was just published at the SMFM Annual Pregnancy meeting in Las Vegas. Listen in for details.1. https://www.smfm.org/news/new-studyroutine-aspirin-therapypreventsseverepreeclampsiainat-risk-populations2. ACOG CO 7433. The Effect of Aspirin on the Risk of Preeclampsia Based on the Fetal Medicine Foundation First Trimester Risk.4. Bujold E, Rolnik DL, Poon L, Syngelaki A, Wright D, Nicolaides KH. The effect of aspirin on the risk of preeclampsia based on the Fetal Medicine Foundation first-trimester risk. Am J Obstet Gynecol. 2025 Oct 31:S0002-9378(25)00808-7. doi: 10.1016/j.ajog.2025.10.032. Epub ahead of print. PMID: 41177290.

The hook of hamate fracture is often a delayed diagnosis.  There are certain mechanism of injuries, usually sporting related, that should make us be more aware of this injury.   The pull test may also help you consider this diagnosis.   Wright TW, Moser MW, Sahajpal DT. Hook of hamate pull test. J Hand Surg Am. 2010 Nov;35(11):1887-9. doi: 10.1016/j.jhsa.2010.08.024. Epub 2010 Oct 20. PMID: 20961698.    Check out the OrthoBullets Page on Hoof of Hamate Fractures by Dr Sharareh and Dr Vitale   www.rnzcuc.org.nz podcast@rnzcuc.org.nz https://www.facebook.com/rnzcuc https://twitter.com/rnzcuc   Music licensed from www.premiumbeat.com Full Grip by Score Squad   This podcast is intended to assist in ongoing medical education and peer discussion for qualified health professionals.  Please ensure you work within your scope of practice at all times.  For personal medical advice, always consult your usual doctor

Send a textIn this episode of Journal Club, Ben and Daphna review a prospective cohort study from the Journal of Perinatology that examines the care of neonates following in-utero growth restriction. The hosts unpack the critical distinction between Fetal Growth Restriction (FGR) and Small for Gestational Age (SGA), highlighting how the "decay of information" in the NICU can lead clinicians to overlook early risk factors as babies grow. They discuss the study's alarming findings regarding the six-fold increased risk of Necrotizing Enterocolitis (NEC) in SGA infants and the importance of maintaining a comprehensive medical history throughout a patient's stay.----Care of neonates following in-utero growth restriction: A prospective cohort study exploring neonatal morbidity. Alda MG, Wood AG, MacDonald T, Charlton JK.J Perinatol. 2025 Sep;45(9):1219-1225. doi: 10.1038/s41372-025-02397-9. Epub 2025 Aug 21.PMID: 40841433 Free PMC article.Support the showAs always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below. Enjoy!

In this new book from my Bringers of the Light series we meet twins Pinky & Meggy. The girls with a little fairy blood inside live in the etheric town of Oakwood on the West Coast of the USA. Pinky & Meggy both think they know what love is. Until two love interests enter their life. Harry Winterbottom and Count Mashar both magical men on their own rights. Harry a hot wizard with a big Instagram following and an even bigger sex drive and Dark Matters agent Count Mashar with a sordid past and a closed heart. Will Pinky & Meggy find the love of their lives with these two paramours? Only time and a little magic will tell. ⭐️

There has been a shift in cervical cancer screening from primary cytology based to HPV based. Even HPV screening has had its evolution from physician collected samples to patient self-collection, either in a clinical setting or at home with an approved collection system. In May 2025, the FDA cleared the first at-home self-collection kit for HPV screening, specifically the Teal Wand by Teal Health. Now, we are seeing the advent of POSSIBLY another avenue for cervical HPV testing- although it is a bit awkward: the use of menstrual blood as an HPV screening test. In this episode we will review a new cross-sectional, population-based study from China which compared testing menstrual blood for human papillomavirus during cervical cancer screening to clinician-collected cervical samples for human papillomavirus (HPV). This concept, and these results, are not new at all! And there are important limitations to consider at this time. Listen in for details.1. Testing menstrual blood for human papillomavirus during cervical cancer screening in China: cross sectional population based study. BMJ 2026; 392 doi: https://doi.org/10.1136/bmj-2025-084831 (Published 04 February 2026)BMJ 2026;392:e084831https://www.bmj.com/content/392/bmj-2025-0848312. Naseri S, Young S, Cruz G, Blumenthal PD. Screening for High-Risk Human Papillomavirus Using Passive, Self-Collected Menstrual Blood. Obstet Gynecol. 2022 Sep 1;140(3):470-476. doi: 10.1097/AOG.0000000000004904. Epub 2022 Aug 3. PMID: 35926207; PMCID: PMC9377370.3. Fokom Domgue J, Chandra M, Oladoyin O, Desai M, Yu R, Shete S. Women's Preferences for Home-Based Self-Sampling or Clinic-Based Testing for Cervical Cancer Screening. JAMA Netw Open. 2026;9(2):e2558841. doi:10.1001/jamanetworkopen.2025.58841

In this research review, we are highlighting what Greg Nuckols has put together around the impact of sleep (or lack of it) on strength. The two studies below look at how sleep impacts strength and the findings weren't quite as big as you might have thought. We discuss what this means, how it applies and how you still want to focus on sleep to make sure it is a priority but also that you can still get work done if you fall short on any given night.1. Craven J, McCartney D, Desbrow B, Sabapathy S, Bellinger P, Roberts L, Irwin C. Effects of Acute Sleep Loss on Physical Performance: A Systematic and Meta-Analytical Review. Sports Med. 2022 Jun 16. doi: 10.1007/s40279-022-01706-y. Epub ahead of print. PMID: 35708888.2. Knowles OE, Drinkwater EJ, Urwin CS, Lamon S, Aisbett B. Inadequate sleep and muscle strength: Implications for resistance training. J Sci Med Sport. 2018 Sep;21(9):959-968. doi: 10.1016/j.jsams.2018.01.012. Epub 2018 Feb 2. PMID: 29422383. #complicatedsimple #progressive #openminded #PBE #EBP #noagenda #performance #training #nutrition #health #wellness #athlete #athletictraining #science #chiropractic #rehab #prevention #clinicallypressed #phd

In this episode, we simplify things. We break blood sugar control down into five simple strategies that actually make a difference — without extremes. We share:• Why meal timing matters as much as food quality• How to balance carbohydrates without cutting them out• The difference between glycemic index and glycemic load, and why it matters• Why eating enough is essential for blood sugar control in PCOS• How movement, sleep, nervous system and social factors shape blood sugar every day If you're tired of conflicting advice and feel like you're “doing everything right” but not seeing results, this episode is for you. These are the same foundations we teach inside our 12-week PCOS Recovery Program where we help you turn these principles into real-life habits with education, tools, and bi-weekly coaching support. Our next cohort starts February 18th! Enjoyed the episode? We'd love to hear it! Leave a rating, review and share with a loved one. ReferencesAli M, Reutrakul S, Petersen G, Knutson KL. Associations between Timing and Duration of Eating and Glucose Metabolism: A Nationally Representative Study in the U.S. Nutrients. 2023 Feb 1;15(3):729. doi: 10.3390/nu15030729. PMID: 36771435; PMCID: PMC9919634. Darraj A. The Link Between Sleeping and Type 2 Diabetes: A Systematic Review. Cureus. 2023 Nov 3;15(11):e48228. doi: 10.7759/cureus.48228. PMID: 38050514; PMCID: PMC10693913. Gómez-Ruiz RP, Cabello-Hernández AI, Gómez-Pérez FJ, Gómez-Sámano MÁ. Meal frequency strategies for the management of type 2 diabetes subjects: A systematic review. PLoS One. 2024 Feb 29;19(2):e0298531. doi: 10.1371/journal.pone.0298531. PMID: 38421977; PMCID: PMC10903815. Leung GKW, Huggins CE, Bonham MP. Effect of meal timing on postprandial glucose responses to a low glycemic index meal: A crossover trial in healthy volunteers. Clin Nutr. 2019 Feb;38(1):465-471. doi: 10.1016/j.clnu.2017.11.010. Epub 2017 Nov 22. PMID: 29248250. Tsereteli N, Vallat R, Fernandez-Tajes J, Delahanty LM, Ordovas JM, Drew DA, Valdes AM, Segata N, Chan AT, Wolf J, Berry SE, Walker MP, Spector TD, Franks PW. Impact of insufficient sleep on dysregulated blood glucose control under standardised meal conditions. Diabetologia. 2022 Feb;65(2):356-365. doi: 10.1007/s00125-021-05608-y. Epub 2021 Nov 30. PMID: 34845532; PMCID: PMC8741723.

Contributor: Alec Coston, MD Educational Pearls: Disclaimer: this has nothing to do with the ER but is too cool to not talk about. Condition: Carbamoyl phosphate synthetase 1 (CPS1) deficiency Rare inborn error of metabolism Inability to properly break down ammonia Leads to severe hyperammonemia and hepatic encephalopathy Natural history: Without treatment, typically fatal within the first few weeks of life Even with current standard treatments, life expectancy is often limited to ~5–6 years Breakthrough treatment: A team of researchers at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania developed the CRISPR-based targeted gene therapy for this patient. First-of-its-kind precision approach tailored to the patient's specific mutation Key components of the therapy: Whole-genome sequencing to identify the exact CPS1 mutation Creation of a custom base-editing enzyme designed to correct that specific mutation Design of a guide RNA to direct the base editor to the precise genomic location Delivery method: Lipid nanoparticles used to deliver the gene-editing machinery Nanoparticles can be targeted to specific tissues Why the liver works well: CPS1 is primarily expressed in hepatocytes The liver is relatively easy to target with lipid nanoparticles Hepatocytes divide frequently, allowing edited genes to be passed on as cells replicate Long-term impact: Once edited, cells continue producing functional CPS1 enzyme Potential for durable, possibly lifelong correction from a single treatment References https://www.nih.gov/news-events/news-releases/infant-rare-incurable-disease-first-successfully-receive-personalized-gene-therapy-treatment Choi Y, Oh A, Lee Y, Kim GH, Choi JH, Yoo HW, Lee BH. Unfavorable clinical outcomes in patients with carbamoyl phosphate synthetase 1 deficiency. Clin Chim Acta. 2022 Feb 1;526:55-61. doi: 10.1016/j.cca.2021.11.029. Epub 2021 Dec 29. PMID: 34973183. Bharti N, Modi U, Bhatia D, Solanki R. Engineering delivery platforms for CRISPR-Cas and their applications in healthcare, agriculture and beyond. Nanoscale Adv. 2026 Jan 5. doi: 10.1039/d5na00535c. Epub ahead of print. PMID: 41640466; PMCID: PMC12865601. Summarized and edited by Jeffrey Olson MS4 Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

En este episodio exploramos la novela Sin decir adiós de Harlan Coben y Reese Whiterspoon una historia cargada de suspenso, secretos familiares y giros inesperados. Hablamos sobre los personajes principales, sus motivaciones y cómo la narrativa mantiene al lector al filo del asiento. Especialmente la protagonista quien tiene que realizar un trabajo especial en otro pais, con un personaje enigmatico. Reese Witherspoon debuta como autora, aportando su voz única a la historia y guiándote a través de los acontecimientos que se desarrollan en la novela. Por otro lado, esta la colaboración de Harlan Coben, un escritor de renombre conocido por sus exitosas adaptaciones de novelas, que te mantiene enganchado hasta el final con su estilo de escritura.  Te dejamos el enlace para mas informacion de esta novela,  Sin Decir AdiósSi gustas escucharnos en nuestro contenido de Patreon no dudes en acompañarnos por esos rumbos lectores.Recuerda que si gustas apoyarnos en nuestras lecturas y reseñas, lo puedes realizar mediante: ☕️ Paypal o a través de nuestras redes sociales o correo electrónico.También te agradeceríamos

Well podcast family, we are back with another installment of our “You ask, We answer” edition. We've got 2 fascinating and real-world clinical conundrums in this episode, both suggested by two separate podcast family members. The first has to do with RH IG maternal administration. Here's the question: If a patient receives routine, prophylactic RH IG at 28 weeks but then has maternal trauma say 1 or 2 weeks after, does she still require an additional dose of RH IG? That's a good question because it's not as intuitive as you would think. We will explain in this episode and there is a bit of a contradiction in the guidance. The second question has to do with finding an asymptomatic uterine rupture at cesarean section. Is there such a thing as a “partial” (silent) uterine rupture? There's recent data from 2025 about this. Listen in for details.1. ACOG PB 181; 2017. 2. Baek S, Froese V, Morgenstern B. Risk Profiles and Outcomes of Uterine Rupture: A Retrospective and Comparative Single-Center Study of Complete and Partial Ruptures. J Clin Med. 2025 Jul 15;14(14):4987. doi: 10.3390/jcm14144987. PMID: 40725680; PMCID: PMC12295210.3. Vandenberghe G, Bloemenkamp K, Berlage S, Colmorn L, Deneux-Tharaux C, Gissler M, Knight M, Langhoff-Roos J, Lindqvist PG, Oberaigner W, Van Roosmalen J, Zwart J, Roelens K; INOSS (the International Network of Obstetric Survey Systems). The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study. BJOG. 2019 Feb;126(3):370-381. doi: 10.1111/1471-0528.15271. Epub 2018 Jun 12. PMID: 29727918.

In this episode of "PICU Doc on Call," Drs. Pradip Kamat and Rahul Damania dive into a pediatric ICU case involving a 4-year-old girl who presents with severe anemia and bleeding, ultimately diagnosed with von Willebrand disease (VWD). They chat about the causes and different types of VWD, walk through the key clinical features, and break down how to diagnose and manage this condition. Drs. Kamat and Damania highlight the important roles of desmopressin and factor concentrates in treatment. Throughout the episode, they stress the need to recognize VWD in kids who have mucosal bleeding and offer practical tips for intensivists on lab evaluation and treatment strategies for this common inherited bleeding disorder.Show Nighlights: Clinical case discussion of a 4-year-old girl with severe anemia and bleeding symptomsDiagnosis of von Willebrand disease (VWD) and its significance in pediatric critical careEtiology and pathogenesis of von Willebrand diseaseClassification of von Willebrand disease into types (Type 1, Type 2 with subtypes, Type 3)Clinical manifestations and symptoms associated with VWDDiagnostic approach for identifying von Willebrand disease, including laboratory testsManagement strategies for VWD, including desmopressin and von Willebrand factor concentratesRole of adjunctive therapies such as antifibrinolytics and hormonal treatmentsImportance of multidisciplinary collaboration in managing complex bleeding disordersOverview of the pathophysiology of von Willebrand factor and its role in hemostasisReferences:Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.Reference 1: Leebeek FW, Eikenboom JC. Von Willebrand's Disease. N Engl J Med. 2016 Nov 24;375(21):2067-2080.Reference 2: Ng C, Motto DG, Di Paola J. Diagnostic approach to von Willebrand disease. Blood. 2015 Mar 26;125(13):2029-37.Platton S, Baker P, Bowyer A, et al. Guideline for laboratory diagnosis and monitoring of von Willebrand disease: A joint guideline from the United Kingdom Haemophilia Centre Doctors' Organisation and the British Society for Hematology. Br J Haematol 2024 May;204(5):1714-1731.Mohinani A, Patel S, Tan V, Kartika T, Olson S, DeLoughery TG, Shatzel J. Desmopressin as a hemostatic and blood-sparing agent in bleeding disorders. Eur J Haematol. 2023 May;110(5):470-479. doi: 10.1111/ejh.13930. Epub 2023 Feb 12. PMID: 36656570; PMCID: PMC10073345.

Nurses are the backbone of patient care, but their role in antibiotic and diagnostic stewardship is still underrecognized. In this episode of The SHEA Podcast, host Dr. Marisa Holubar is joined by Dr. Eileen Carter and Dr. David Ha to explore why nurses are essential to stewardship success. Together, they discuss the evidence behind nursing engagement, persistent barriers to involvement, and real-world examples where nurse-led initiatives have reduced antibiotic use, infections, and waste. From IV-to-PO transitions to penicillin allergy assessment and diagnostic stewardship, this conversation offers practical strategies for engaging nurses, leveraging shared governance, and building stronger, more effective stewardship programs across care settings. References: Thurman Johnson C, Ridge LJ, Hessels AJ. Nurse Engagement in Antibiotic Stewardship Programs: A Scoping Review of the Literature. J Healthc Qual. 2023 Mar-Apr 01;45(2):69-82. doi: 10.1097/JHQ.0000000000000372. Epub 2022 Dec 12. PMID: 36729679; PMCID: PMC9991980. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019 Jan 15;321(2):188-199. doi: 10.1001/jama.2018.19283. PMID: 30644987. Carter EJ, Schramm C, Baron K, Zolla MM, Zavez K, Banach DB. Perceived usefulness of a mnemonic to improve nurses' evaluation of reported penicillin allergies. Antimicrob Steward Healthc Epidemiol. 2023 Jul 11;3(1):e124. doi: 10.1017/ash.2023.177. PMID: 37502243; PMCID: PMC10369439. Carter EJ, Zavez K, Schramm C, Zolla MM, Baron K, Banach DB. Multifaceted implementation strategy to improve the evaluation of penicillin allergies in perioperative patients: a pre-post feasibility implementation study. Infect Control Hosp Epidemiol. 2024 Oct 30;45(12):1-7. doi: 10.1017/ice.2024.119. Epub ahead of print. PMID: 39473231; PMCID: PMC11663472. Resources: ANCC Magnet Recognition Program: https://www.nursingworld.org/organizational-programs/magnet/ Breakpoints, The SIDP Podcast: https://breakpoints-sidp.org/18-waking-the-sleeping-giant-engaging-nurses-in-antimicrobial-stewardship/

Ausflug in die translationale Forschung im Bereich des Mikrobioms bei akuter Pankreatitis. Gibt es Unterschiede im buccalen oder rektalen Mikrobiom zwischen schweren und milden Verläufen? Sind Folgeerkrankungen mit unterschiedlichem Mikrobiom assoziiert? Viele spannende Antworten auf diese Fragen liefern die ausnahmsweise zwei besprochenen Studien. Außerdem besprechen wir mögliche klinische Anwendungen, weiterführende Fragen und klären ein paar Does und Don´ts zur Diagnostik und Behandlung der akuten Pankreatitis.Gast: Prof. Dr. Dr. Albrecht NeeßeModeration: Sophie HeislerBesprochene Publikationen:Ammer-Herrmenau C, Antweiler KL, Asendorf T, Beyer G, Buchholz SM, Cameron S, Capurso G, Damm M, Dang L, Frost F, Gomes A, Hamm J, Henker R, Hoffmeister A, Meinhardt C, Nawacki L, Nunes V, Panyko A, Pardo C, Phillip V, Pukitis A, Rasch S, Riekstina D, Rinja E, Ruiz-Rebollo ML, Sirtl S, Weingarten M, Sandru V, Woitalla J, Ellenrieder V, Neesse A. Gut microbiota predicts severity and reveals novel metabolic signatures in acute pancreatitis. Gut. 2024 Feb 23;73(3):485-495. doi: 10.1136/gutjnl-2023-330987. PMID: 38129103; PMCID: PMC10894816.Ammer-Herrmenau C, Meier R, Antweiler KL, Asendorf T, Cameron S, Capurso G, Damm M, Dang L, Frost F, Hamm J, Hoffmeister A, Kocheva Y, Meinhardt C, Nawacki L, Nunes V, Panyko A, Ruiz-Rebollo ML, Flórez-Pardo C, Phillip V, Pukitis A, Vaselane D, Rinja E, Sandru V, Schaefer A, Scholz R, Seelig J, Sirtl S, Ellenrieder V, Neesse A. Gut microbiota predict development of postdischarge diabetes mellitus in acute pancreatitis. Gut. 2025 Nov 26:gutjnl-2025-336715. doi: 10.1136/gutjnl-2025-336715. Epub ahead of print. PMID: 41298102.

How are hospitals using AI and HPC to assist them in helping save lives? This week, Technology Now is joined by Keith Perry, Senior Vice President and Chief Information Officer at St. Jude Children's Research Hospital to explore how St Jude uses the latest technologies to help treat and prevent illness and catastrophic disease, giving patients and families more time, and more hope, when it comes to diagnosis.This is Technology Now, a weekly show from Hewlett Packard Enterprise. Every week, hosts Michael Bird and Sam Jarrell look at a story that's been making headlines, take a look at the technology behind it, and explain why it matters to organizations.About Keith:https://www.linkedin.com/in/keith-perry-8562347/Sources:Hernigou P. Ambroise Paré III: Paré's contributions to surgical instruments and surgical instruments at the time of Ambroise Paré. Int Orthop. 2013 May;37(5):975-80. doi: 10.1007/s00264-013-1872-y. Epub 2013 Apr 12. PMID: 23580029; PMCID: PMC3631503.https://www.surgicalholdings.co.uk/history-of-surgical-instruments.htmlSmith-Bindman R, Kwan ML, Marlow EC, et al. Trends in Use of Medical Imaging in US Health Care Systems and in Ontario, Canada, 2000-2016. JAMA. 2019;322(9):843–856. doi:10.1001/jama.2019.11456https://caferoentgen.com/2023/10/07/a-tale-of-two-hands-the-story-behind-the-two-famous-radiographs-captured-by-wilhelm-roentgen/https://www.orau.org/health-physics-museum/collection/shoe-fitting-fluoroscope/index.html

This week, Marianna sits down with Chris Bositis and Cara McAnaney from the National Clinician Consultation Center (NCCC) to talk all about lower-barrier substance use and HIV prevention and treatment. Tune in to learn how direct-to-inject ties into that and why it matters for you as an HIV care provider. -- Resources: Waters RC, Hoog J, Bell C, Toland P, Valley J, Hurtado L, Kallsen MA, Johnson T, Gerard A, Fockele CE, Klein JW. Injectable-Only Overlapping Buprenorphine Starting Protocol in a Low-Threshold Setting. JAMA Netw Open. 2025 Aug 1;8(8):e2527016. doi: 10.1001/jamanetworkopen.2025.27016. PMID: 40815514; PMCID: PMC12357186.Rosenwohl-Mack S, Suen LW, Logan AA, Peterson D, Snyder HR. Outpatient Initiation of 7-Day Injectable Buprenorphine: A Direct-to-Inject Case Series. Subst Use Addctn J. 2025 Oct;46(4):1064-1069. doi: 10.1177/29767342251330412. Epub 2025 Apr 4. PMID: 40183345; PMCID: PMC12353995.D'Onofrio G, Herring AA, Perrone J, Hawk K, Samuels EA, Cowan E, Anderson E, McCormack R, Huntley K, Owens P, Martel S, Schactman M, Lofwall MR, Walsh SL, Dziura J, Fiellin DA. Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal. JAMA Netw Open. 2024 Jul 1;7(7):e2420702. doi: 10.1001/jamanetworkopen.2024.20702. PMID: 38976265; PMCID: PMC11231806. Help us track the number of listeners our episode gets by filling out this brief form! (https://www.e2NECA.org/?r=AQX7941)--Want to chat? Email us at podcast@necaaetc.org with comments or ideas for new episodes. --Check out our free online courses: www.necaaetc.org/rise-courses--Download our HIV mobile apps:Google Play Store: https://play.google.com/store/apps/developer?id=John+Faragon&hl=en_US&gl=USApple App Store: https://apps.apple.com/us/developer/virologyed-consultants-llc/id1216837691

This episode of EM Pulse dives into one of the most stressful scenarios in the ED: the febrile infant in the first month of life. Traditionally, a fever in this age group has meant an automatic “full septic workup,” including the dreaded lumbar puncture (LP). But times are changing. We sit down with experts Dr. Nate Kuppermann and Dr. Brett Burstein to discuss a landmark JAMA study that suggests we might finally be able to safely skip the LP in many of our tiniest patients. The Study: A Game Changer for Neonates Our discussion centers on a massive international pooled study evaluating the PECARN Febrile Infant Rule specifically in infants aged 0–28 days. While previous guidelines were conservative due to a lack of data for this specific age bracket, this study provides the evidence we've been waiting for. The Cohort: A large pool of infants across multiple countries. The Findings: The PECARN rule demonstrated an exceptionally high negative predictive value for invasive bacterial infections. The Big Win: The rule missed zero cases of bacterial meningitis. Defining the Danger: SBI vs. IBI The experts break down why we are shifting our terminology and our clinical focus. Serious Bacterial Infection (SBI)  Historically, this was a “catch-all” term including Urinary Tract Infections (UTIs), bacteremia, and meningitis. However, UTIs are generally more common, easily identified via urinalysis, and typically less life-threatening than the other two. Invasive Bacterial Infection (IBI)  This term refers specifically to bacteremia and bacterial meningitis. These are the “high-stakes” infections the PECARN rule is designed to rule out. Dr. Kuppermann notes that we should ideally view bacteremia and meningitis as distinct entities, as the clinical implications of a missed meningitis case are far more severe. The HSV Elephant in the Room One of the primary reasons clinicians hesitate to skip an LP in a neonate is the fear of missing Herpes Simplex Virus (HSV) infection. Low Baseline Risk: While the overall risk of HSV in a febrile infant is low, the risk of “isolated” HSV (meningitis without other signs or symptoms) is even rarer. Screening Tools: Most infants with HSV appear clinically ill. Clinicians can also use ALT (liver function) testing as a secondary screen – transaminase elevation is a common marker for systemic HSV. Clinical Judgment: If the baby is well-appearing, has no maternal history of HSV, no vesicles, and no seizures, the risk of missing HSV by skipping the LP is exceptionally low. Practical Application: Shared Decision-Making This isn’t just about the numbers—it’s about the parents. “Families don’t mind their babies being admitted… They do not want the lumbar puncture. It is the single most anxiety-provoking aspect of care.” — Dr. Brett Burstein The PECARN “Low-Risk” Criteria:  (Remember, this rule applies only to infants who are not ill-appearing.) Urinalysis: Negative Absolute Neutrophil Count (ANC): ≤ 4,000/mm³ Procalcitonin (PCT): ≤ 0.5 ng/mL The Bottom Line: If an infant is well-appearing and meets these criteria, physicians can have a nuanced conversation with parents about the risks and benefits of forgoing the LP, while still admitting the child for observation (often without empiric antibiotics) while cultures brew. Key Takeaways The “Well-Appearing” Filter: If an infant looks ill, the rule does not apply. These patients require a full workup, including an LP, regardless of lab results. Meticulous Physical Exam: Assess for a strong suck, normal muscle tone, brisk capillary refill, and any rashes or vesicles. History is Key: Always ask about maternal GBS/HSV status, pregnancy or birth complications, prematurity, sick contacts, and any changes in feeding, stooling or activity. Procalcitonin: PCT is the superior inflammatory marker for this rule. If your facility only offers traditional markers like CRP, the PECARN negative predictive value cannot be strictly applied. In the words of Dr. Kuppermann: “If you don’t have it, for God’s sakes, just get it! ALT to Screen for HSV: While not part of the official PECARN rule, our experts suggest that significantly elevated liver enzymes should raise suspicion for systemic HSV. Observe, Don’t Discharge: Being “low risk” does not mean the infant goes home. All infants ≤ 28 days still require admission for 24-hour observation and blood/urine cultures. We want to hear from you! Does this change how you approach febrile neonates in the ED? How do you handle shared decision-making with parents? Connect with us on social media @empulsepodcast or on our website ucdavisem.com. Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis Guests: Dr. Nate Kuppermann, Executive Vice President and Chief Academic Officer; Director, Children’s National Research Institute; Department Chair, Pediatrics, George Washington University School of Medicine and Health Sciences Dr. Brett Burstein, Clinician-Scientist and Pediatric Emergency Medicine Physician at Montreal Children’s Hospital, McGill University Resources: Burstein B, Waterfield T, Umana E, Xie J, Kuppermann N. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. 2026 Feb 3;335(5):425-433. doi: 10.1001/jama.2025.21454. PMID: 41359314; PMCID: PMC12687207“Hot” Off the Press: Infant Fever Rule “Hot” Off the Press: Infant Fever Rule Do I really need to LP a febrile infant with a UTI? PECARN Infant Fever Update: 61-90 Days Kuppermann N, Dayan PS, Levine DA, Vitale M, Tzimenatos L, Tunik MG, Saunders M, Ruddy RM, Roosevelt G, Rogers AJ, Powell EC, Nigrovic LE, Muenzer J, Linakis JG, Grisanti K, Jaffe DM, Hoyle JD Jr, Greenberg R, Gattu R, Cruz AT, Crain EF, Cohen DM, Brayer A, Borgialli D, Bonsu B, Browne L, Blumberg S, Bennett JE, Atabaki SM, Anders J, Alpern ER, Miller B, Casper TC, Dean JM, Ramilo O, Mahajan P; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019 Apr 1;173(4):342-351. doi: 10.1001/jamapediatrics.2018.5501. PMID: 30776077; PMCID: PMC6450281. Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O’Leary ST, Okechukwu K, Woods CR Jr; SUBCOMMITTEE ON FEBRILE INFANTS. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021 Aug;148(2):e2021052228. doi: 10.1542/peds.2021-052228. Epub 2021 Jul 19. Erratum in: Pediatrics. 2021 Nov;148(5):e2021054063. doi: 10.1542/peds.2021-054063. PMID: 34281996. ****Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.  

In this new book from my Bringers of the Light series we meet twins Pinky & Meggy. The girls with a little fairy blood inside live in the etheric town of Oakwood on the West Coast of the USA. Pinky & Meggy both think they know what love is. Until two love interests enter their life. Harry Winterbottom and Count Mashar both magical men on their own rights. Harry a hot wizard with a big Instagram following and an even bigger sex drive and Dark Matters agent Count Mashar with a sordid past and a closed heart. Will Pinky & Meggy find the love of their lives with these two paramours? Only time and a little magic will tell. ⭐️

Eustress – Distress in der Chirurgie: Wo endet guter Stress? Wo beginnt Überforderung? In dieser Folge sprechen wir darüber, wie sich Stress unterscheiden lässt, welche individuellen und strukturellen Faktoren dabei eine Rolle spielen und warum die Grenze zwischen Motivation und Überforderung oft fließend ist. Wir beleuchten typische Stressoren im chirurgischen Alltag, persönliche Warnsignale sowie Strategien, um nachhaltig leistungsfähig zu bleiben. Ein ehrlicher Blick auf Verantwortung und Resilienz in der Chirurgie – und darauf, wie ein gesunder Umgang mit Stress gelingen kann.Literatur:Association Between Surgeon Stress and Major Surgical ComplicationsAwtry J., Skinner S., Polazzi S., et al. . JAMA Surg. 2025;160(3):332–340. doi:10.1001/jamasurg.2024.6072Wider psychische Belastungen – resilientes Arbeiten in der Chirurgie [Against the mental stress-Resilient work in surgery]Thielmann B., Meyer F., Böckelmann I. Chirurgie (Heidelb). 2024 Feb; 95(2):135-147. German. doi: 10.1007/s00104-023-01977-9. Epub 2023 Nov 21. PMID: 37987763; PMCID: PMC10834595.Von Tabus zu Taten: Unsere psychische GesundheitDr. Victoria WittLokale und regionale Anlaufstellen für mentale GesundheitViele Unterstützungsangebote sind bewusst niedrigschwellig und vertraulich gehalten.Hausärztinnen und HausärzteErste Anlaufstelle, auch zur Koordination weiterer Hilfen. Wichtig: Bei akuter Eigen- oder Fremdgefährdung steht die Gefahrenabwehr im Vordergrund, gegebenenfalls unter Einbeziehung von Polizei oder Rettungsdienst.Betriebsärztlicher Dienst Fachärztinnen und Fachärzte für Psychiatrie und Psychotherapie sowie psychologische Psychotherapeutinnen und Psychotherapeuten SuchtberatungsstellenAmbulant, anonym, kostenfrei/kostengünstig Balintgruppen und ärztliche SupervisionGeschützter Raum zur Reflexion emotional belastender Fälle, zum Beispiel nach Komplikationen, bei Schuldgefühlen oder moralischem Stress Sozialpsychiatrischer DienstBeratung, Krisenhilfe und Unterstützung bei psychosozialen Belastungen(auch Angehörigenberatung möglich) Psychosozialen Notfallversorgung (PSNV)Regionale PSNV-Netzwerke bieten oft niedrigschwellige Vermittlung von Hilfen für Notfallhelfer (z.B. kurzfristige Termine bei Psychoherapeut*innen aus dem Netzwerk) Überregionale und internationale Angebote für mentale Gesundheit Telefon SeelsorgeTelefon 0800 111 0 111Kostenfrei, anonym, rund um die Uhr erreichbar Info-Telefon DepressionTelefon 0800 3344533Beratung, Information und Orientierung Deutsche Stiftung DepressionshilfeInformationen, Selbsttests und weiterführende Hilfsangebotehttps://www.deutsche-depressionshilfe.de International Doctors in Alcoholics AnonymousSelbsthilfeangebot speziell für Ärztinnen und Ärztehttps://www.idaa.org Institut für ÄrztegesundheitInformationen, Ressourcen, Prävention und Anlaufstellehttp://www.aerztegesundheit.de Royal College of Surgeons of EnglandImpulse und Ressourcen zur mentalen Gesundheit für Chirurginnen und Chirurgenhttps://www.rcseng.ac.uk/careers-in-surgery/wellbeing/ Initiative Neue Qualität der Arbeit / psyGAPsychische Gesundheit am ArbeitsplatzTools, Schulungen und Präventionsangebotewww.psyga.info Unterstützungsangebote speziell für Fachkräfte im Gesundheitswesen PSU-Helpline – Psychosoziale UnterstützungTägliche anonyme und kostenfreie Beratung von 9 bis 21 UhrBeratung durch geschulte Kolleginnen und Kollegen (Peers)Für Ärztinnen und Ärzte, Pflege, Rettungsdienst und weitere GesundheitsberufeGesprächsangebot bei emotionalen Belastungen und akuten KrisenOnline-Selbsttest zur Einschätzung der eigenen psychischen Belastungwww.psu-helpline.de Blaupause GesundheitInitiative zur Förderung psychischer Gesundheit im gesamten GesundheitswesenAufklärungsarbeit, Austauschformate und lokale PräventionsprojekteFokus auf Entstigmatisierung und niedrigschwellige Hilfe bereits im Studium und BerufsstartNetzwerkbasierter Ansatz mit wissenschaftlicher Begleitungwww.blaupause-gesundheit.de

Contributor: Alec Coston, MD Educational Pearls: BiPAP is often effective in severe asthma, but many patients struggle with mask tolerance due to intense air hunger–driven anxiety, often compounded by hypoxia. Benzodiazepines are commonly used for anxiety, but they can depress respiratory drive, making clinical improvement difficult to interpret (a lower RR may reflect sedation rather than true physiologic improvement). Low-dose fentanyl is a useful alternative when patients cannot tolerate BiPAP despite coaching. Opioids blunt the perception of dyspnea and are well established for treating air hunger. When carefully titrated, fentanyl provides anxiolysis without significant respiratory suppression. It is rapidly titratable (e.g., 25 mcg IV every 5 minutes). Evidence primarily comes from palliative and oncology literature, but growing clinical experience supports its use in severe asthma to improve BiPAP tolerance. Failure of fentanyl should prompt escalation to ketamine, often signaling impending need for intubation. References Pang GS, Qu LM, Tan YY, Yee AC. Intravenous Fentanyl for Dyspnea at the End of Life: Lessons for Future Research in Dyspnea. Am J Hosp Palliat Care. 2016 Apr;33(3):222-7. doi: 10.1177/1049909114559769. Epub 2014 Nov 25. PMID: 25425740. Summarized and edited by Meg Joyce, MS2 Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

En este episodio contamos con una recomendación de un libro polémico, una novela que puede ser del gusto de algunos lectores o simplemente una decepción.Alice Gould llega a un sanatorio mental. Ella afirma que está ahí por un motivo muy específico (y estratégico), pero el entorno —doctores, expedientes, reglas internas y miradas— pone en duda su relato. A partir de ahí, la novela juega a dos bandas: investigación y supervivencia emocional dentro de un lugar donde cada palabra puede ser prueba… o síntoma.Consigue el libro digital por aquíSi gustas escucharnos en nuestro contenido de Patreon no dudes en acompañarnos por esos rumbos lectores.Recuerda que si gustas apoyarnos en nuestras lecturas y reseñas, lo puedes realizar mediante: ☕️ Paypal o a través de nuestras redes sociales o correo electrónico.También te agradeceríamos

Drs. Ted Morton and Christine Lockowitz join Dr. Ryan Moenster to discuss all things amoxicillin, particularly in our pediatric patients. Our guests answer common questions, such as, what formulations should be used for certain infectious conditions and/or organisms and how to dose amoxicillin to maximize PK/PD optimization without inducing potential adverse events. It is a must-listen for all! This episode also qualifies for 1 hour of BCIDP credit! How to Obtain BCIDP Recertification Credit for this Episode: Visit sidp.org/BCIDP for more information. References: Bradley JS, Garonzik SM, Forrest A, Bhavnani SM. Pharmacokinetics, pharmacodynamics, and Monte Carlo simulation: selecting the best antimicrobial dose to treat an infection. Pediatr Infect Dis J. 2010 Nov;29(11):1043-6. doi: 10.1097/INF.0b013e3181f42a53. PMID: 20975453. Craig WA. Pharmacokinetic/pharmacodynamic parameters: rationale for antibacterial dosing of mice and men. Clin Infect Dis. 1998 Jan;26(1):1-10; quiz 11-2. doi: 10.1086/516284. PMID: 9455502. Hakenbeck R, Grebe T, Zähner D, Stock JB. beta-lactam resistance in Streptococcus pneumoniae: penicillin-binding proteins and non-penicillin-binding proteins. Mol Microbiol. 1999 Aug;33(4):673-8. doi: 10.1046/j.1365-2958.1999.01521.x. PMID: 10447877. Bax R. Development of a twice daily dosing regimen of amoxicillin/clavulanate. Int J Antimicrob Agents. 2007 Dec;30 Suppl 2:S118-21. doi: 10.1016/j.ijantimicag.2007.09.002. Epub 2007 Nov 5. PMID: 17983732. Bielicki JA, Stöhr W, Barratt S, Dunn D, Naufal N, Roland D, Sturgeon K, Finn A, Rodriguez-Ruiz JP, Malhotra-Kumar S, Powell C, Faust SN, Alcock AE, Hall D, Robinson G, Hawcutt DB, Lyttle MD, Gibb DM, Sharland M; PERUKI, GAPRUKI, and the CAP-IT Trial Group. Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial. JAMA. 2021 Nov 2;326(17):1713-1724. doi: 10.1001/jama.2021.17843. Erratum in: JAMA. 2021 Dec 7;326(21):2208. doi: 10.1001/jama.2021.20219. PMID: 34726708; PMCID: PMC8564579.

We have covered the subject of whether to include the decidual (innermost) layer when closing the uterine incision during cesarean section (CS) on at least 2 episodes. The most recent was in September 2025, when we focused on a published (September 2025) systematic review and meta-analysis from the Green Journal. Back then, we compared those new findings to our prior episode from 2023 on the same matter. Well, we are back at it again with the same subject as there is a new EXPERT REVIEW from the AJOG on hysterotomy closure technique which just came out January 2026. What did these authors conclude? There are also some controversial suggestions made by the authors. Listen in for details. 1. Antoine C, Meyer JA, Silverstein J, Buldo-Licciardi J, Lyu C, Timor-Tritsch IE. Endometrium-Free Closure Technique During Cesarean Delivery for Reducing the Risk of Niche Formation and Placenta Accreta Spectrum Disorders. Obstet Gynecol. 2025 Jun 1;145(6):674-682. doi: 10.1097/AOG.0000000000005813. Epub 2025 Jan 9. PMID: 39787602. 2. Gialdini, Celina et al.Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. eClinicalMedicine- Lancet (June 2024), Volume 72, 102632 3. Dahlke, Joshua D. MD; Mendez-Figueroa, Hector MD; Maggio, Lindsay MD, MPH; Sperling, Jeffrey D. MD, MS; Chauhan, Suneet P. MD, Hon DSc; Rouse, Dwight J. MD. The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees. Obstetrics & Gynecology 136(5):p 972-980, November 2020. | DOI: 10.1097/AOG.0000000000004120 4. Antoine C, Timor-Tritsch IE, Bujold E, Young BK, Reece EA. Endometrium-free closure technique for hysterotomy incision at cesarean delivery. Am J Obstet Gynecol. 2026 Jan;233(6S):S103-S114. doi: 10.1016/j.ajog.2025.07.009. PMID: 41485813.

On this week’s episode, we’re continuing our Guidelines Series exploring the 2022 ESC/ERS Guidelines for the diagnosis and treatment of Pulmonary Hypertension. If you missed our first episode in the series, give it a listen to hear about the most recent recommendations regarding Pulmonary Hypertension definitions, screening, and diagnostics. Today, we’re talking about the next steps after diagnosis. Specifically, we’ll be discussing risk stratification, establishing treatment goals, and metrics for re-evaluation. We’ll additionally introduce the mainstays of pharmacologic therapy for Pulmonary Hypertension. Meet Our Co-Hosts Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a pulmonary and critical care medicine fellow. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs, and bedside medical education. Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered. Key Learning Points 1) Episode Roadmap How to set treatment goals, assess symptom burden, and risk-stratify patients with suspected/confirmed pulmonary arterial hypertension (PAH). What tools to use to re-evaluate patients on treatment Intro to major PAH medication classes and how they map to pathways. 2) Case-based diagnostic reasoning Patient: 37-year-old woman with exertional dyspnea, mild edema, abnormal echo, telangiectasias + epistaxis → raises suspicion for HHT (hereditary hemorrhagic telangiectasia) and/or early connective tissue disease. Key reasoning move: start broad (Groups 2–5) and narrow using history/exam/testing. In a young patient without obvious left heart or lung disease, think more about Group 1 PAH (idiopathic/heritable/associated). HHT teaching point: HHT can cause PH in more than one way: More common: high-output PH from AVMs (often hepatic/pulmonary) Rare (1–2% mentioned): true PAH phenotype (vascular remodeling; associated with ALK1 in some patients), behaving like Group 1 PAH. 3) Functional class assessment WHO Functional Class: Class I: no symptoms with ordinary activity, only with exertion Class II: symptoms with ordinary activity Class III: symptoms with less-than-ordinary activity (can't do usual chores/shopping without dyspnea) Class IV: symptoms at rest Practical bedside tip they give: Ask if the patient can walk at their own pace or keep up with a similar-age peer/partner. If not, think Class II (or worse). 4) Risk stratification at diagnosis: why, how, and which tools Big principle: treatment choices are driven by risk, and the goal is to move patients to low-risk quickly. ESC/ERS approach at diagnosis (as described): Use a 3-strata model predicting 1-year mortality: Low: 20% ESC/ERS risk assessment variables (10 domains discussed): Clinical progression, signs of right heart failure, syncope WHO FC Biomarkers (NT-proBNP) Exercise capacity (6MWD) Hemodynamics Imaging (echo; sometimes cardiac MRI) CPET (peak VO₂; VE/VCO₂ slope) They note: even if you don't have everything, the calculator can still be useful with ≥3 variables. REVEAL 2.0: Builds on similar core variables but adds further patient context (demographics, renal function, BP, DLCO, etc.) Case result: both tools put her in intermediate risk (ESC/ERS ~1.6; REVEAL 2.0 score 8), underscoring that mild symptoms can still equal meaningful mortality risk. 5) Treatment goals and follow-up philosophy What they explicitly prioritize: Help patients feel better, live longer, and stay out of the hospital Use risk tools to communicate prognosis and to track improvement Reassess frequently (they mention ~every 3 months early on) until low risk is achieved “Time-to-low-risk” is an important treatment goal Also emphasized: The diagnosis is psychologically heavy; patients need clear counseling, reassurance about the plan, and connection to support groups. 6) Medication classes for the treatment of PAH Nitric oxide–cGMP pathway PDE5 inhibitors: sildenafil, tadalafil Soluble guanylate cyclase stimulator: riociguat Important safety point: don't combine PDE5 inhibitors with riociguat (risk of significant hypotension/hemodynamic effects) Endothelin receptor antagonists (ERAs) “-sentan” drugs: bosentan (less used due to side effects/interactions), ambrisentan, macitentan Teratogenicity emphasized Hepatotoxicity that requires LFT monitoring Can cause fluid retention and peripheral edema Prostacyclin pathway Prostacyclin analogs/agonists: Epoprostenol (potent; short half-life; IV administration) Treprostinil (IV/SubQ/oral/inhaled options) Selexipag (oral prostacyclin receptor agonist) 7) Sotatercept (post-guidelines) They note sotatercept wasn't in 2022 ESC/ERS but is now “a game changer” in practice: Mechanism: ligand trap affecting TGF-β signaling / remodeling biology Positioned as potentially more disease-modifying than pure vasodilators Still evolving: where to place it earlier vs later in regimens is an active question in the field 8) How risk category maps to initial treatment intensity General approach they outline: High risk at diagnosis: parenteral prostacyclin (IV/SubQ) strongly favored, often aggressive early Intermediate risk: at least dual oral therapy (typically PDE5i + ERA); escalate if not achieving low risk Low risk: at least one oral agent; many still use dual oral depending on etiology/trajectory For the case: intermediate-risk → start dual oral therapy (they mention tadalafil + ambrisentan as a typical choice), reassess in ~3 months; add a third agent (e.g., selexipag/prostacyclin pathway) if not low risk.  References and Further Reading Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S; ESC/ERS Scientific Document Group. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022 Oct 11;43(38):3618-3731. doi: 10.1093/eurheartj/ehac237. Erratum in: Eur Heart J. 2023 Apr 17;44(15):1312. doi: 10.1093/eurheartj/ehad005. PMID: 36017548. Condon DF, Nickel NP, Anderson R, Mirza S, de Jesus Perez VA. The 6th World Symposium on Pulmonary Hypertension: what’s old is new. F1000Res. 2019 Jun 19;8:F1000 Faculty Rev-888. doi: 10.12688/f1000research.18811.1. PMID: 31249672; PMCID: PMC6584967. Maron BA. Revised Definition of Pulmonary Hypertension and Approach to Management: A Clinical Primer. J Am Heart Assoc. 2023 Apr 18;12(8):e029024. doi: 10.1161/JAHA.122.029024. Epub 2023 Apr 7. PMID: 37026538; PMCID: PMC10227272. Hoeper MM, Badesch DB, Ghofrani HA, Gibbs JSR, Gomberg-Maitland M, McLaughlin VV, Preston IR, Souza R, Waxman AB, Grünig E, Kopeć G, Meyer G, Olsson KM, Rosenkranz S, Xu Y, Miller B, Fowler M, Butler J, Koglin J, de Oliveira Pena J, Humbert M; STELLAR Trial Investigators. Phase 3 Trial of Sotatercept for Treatment of Pulmonary Arterial Hypertension. N Engl J Med. 2023 Apr 20;388(16):1478-1490. doi: 10.1056/NEJMoa2213558. Epub 2023 Mar 6. PMID: 36877098. Ruopp NF, Cockrill BA. Diagnosis and Treatment of Pulmonary Arterial Hypertension: A Review. JAMA. 2022 Apr 12;327(14):1379-1391. doi: 10.1001/jama.2022.4402. Erratum in: JAMA. 2022 Sep 6;328(9):892. doi: 10.1001/jama.2022.13696. PMID: 35412560.

As OB healthcare providers, we have several pieces of guidance regarding determination of amniotic fluid volume antepartum. The SMFM has Consult Series #46 (2018), which describes the management of polyhydramnios. We'll touch on that in this episode. However, while we have clear understanding of the increased risks of oligohydramnios, where an MVP is preferred for diagnosis over AFI, we have less information about polyhydramnios. But a new study published in BJOG (January 2026) provides more insights on this. While MVP is preferred for oligo diagnosis, can the same be said for polyhydramnios? Is there an increased risk in perinatal morbidity with polyhydramnios, and is that better detected by MVP or AFI? This new study findings left the authors unsatisfied although it CONFIRMED what we have covered in past episodes. Listen in for details.1. Dashe, Jodi S. et al. SMFM Consult Series #46: Evaluation and management of polyhydramnios. American Journal of Obstetrics & Gynecology, Volume 219, Issue 4, B2 - B8 (2018)2. ACOG PB 229: Antepartum Fetal Surveillance (2021)3. Petrecca A, Chauhan SP, Tersigni C, Ghi T, Berghella V. Amniotic Fluid Index Versus Maximum Vertical Pocket Versus Both for Polyhydramnios. BJOG. 2026 Jan 7. doi: 10.1111/1471-0528.70139. Epub ahead of print. PMID: 41502220.

En este episodio, nos propusimos la tarea de realizar una lectura en conjunto, Any le recomendó este libro a Mix y se decidió comentarlo en un futuro cercano. Nos agrada hacer este tipo de ejercicio para poder hacer un mejor episodio y dar nuestras propias opiniones.Este libro aborda un tema delicado y presenta una investigación exhaustiva para encontrar a una niña desaparecida en un pequeño pueblo.  Erik, un personaje del libro, adquiere una librería cercana al pueblo, huyendo de su pasado intenta socializar con personas del lugar.  Además, un grupo de vecinos guardan secretos que poco a poco se irán descubriendo.

This Physician World Shared Practice Forum Podcast explores two multicenter studies on extubation outcomes in neonates and children following congenital cardiac surgery. These studies incorporate integration of machine learning and risk analytics for extubation decision-making, and examine extubation readiness and extubation failure outcomes. LEARNING OBJECTIVES - Understand the key factors influencing extubation outcomes following congenital cardiac surgery - Examine the use of machine learning and risk analytics in neonatal and pediatric extubation decisions - Discuss how machine learning can improve clinical decision-making and patient safety AUTHORS Daniel Hames, MD, MPH Assistant Professor of Pediatrics, Cardiac Care Unit Director of Quality and Safety University of Nebraska Medical Center Children's Nebraska Jeffrey Burns, MD, MPH Emeritus Chief Division of Critical Care Medicine Department of Anesthesiology, Critical Care and Pain Medicine Boston Children's Hospital Professor of Anesthesia Harvard Medical School DATE Initial publication date: January 27, 2026. ARTICLES REFERENCED - Hames DL, Abbas Q, Asfari A, Borasino S, Diddle JW, Gazit AZ, Lipsitz S, Marshall A, Reise K, Guerineau LR, Wolovits JS, Salvin JW. Extubation Failure in Neonates Following Congenital Cardiac Surgery: Multicenter Retrospective Cohort, 2017-2020. Pediatr Crit Care Med. 2025 May 1;26(5):e590-e599. doi: 10.1097/PCC.0000000000003703. Epub 2025 Feb 10. PMID: 39927824. - Hames DL, Abbas Q, Asfari A, et al. Clinical and Risk Analytics Associations With Extubation Failure in Children Following Congenital Cardiac Surgery: A Multicenter Retrospective Cohort Study, 2017-2020. Pediatr Crit Care Med. 2025;26(9):e1105-e1114. doi:10.1097/PCC.0000000000003793. TRANSCRIPT https://cdn.bfldr.com/D6LGWP8S/as/w7qqc97g6m9g5n5vrq5vkx6x/202601_WSP_Hames_Transcript. Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children's Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open-access thus at no expense to the user. For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu CITATION Hames DL, Burns JP. Integrating Risk Analytics in Post-Cardiac Surgery Extubation Readiness. 01/2026. OPENPediatrics. Online Podcast.

In this episode of Science of Slink, Dr. Rosy Boa shares vital lessons she wishes she had learned earlier in her 14-year pole dancing journey. Covering exercise science fundamentals, recognizing when a space isn't right for you, and the perils of diet culture and disordered eating, Dr. Boa offers practical advice and reflections aimed at helping fellow pole dancers avoid common pitfalls. Additionally, she emphasizes the importance of a healthy relationship with food and the benefits of understanding exercise science principles. Dr. Boa encourages listeners to contribute their own lessons and insights while promoting her online pole studio for further learning and community support.Are you a pole nerd interested in trying out online pole classes with Slink Through Strength? We'd love to have you! Use the code “podcast” for 10% off the Intro Pack and try out all of our unique online pole classes: https://app.acuityscheduling.com/catalog/25a67bd1/?productId=1828315&clearCart=true Citation for perfectionism & orthorexia: Oberle CD, Samaghabadi RO, Hughes EM. Orthorexia nervosa: Assessment and correlates with gender, BMI, and personality. Appetite. 2017 Jan 1;108:303-310. doi: 10.1016/j.appet.2016.10.021. Epub 2016 Oct 15. PMID: 27756637.Timestamps00:00 Welcome to Science of Slink00:57 My Pole Dancing Journey Begins02:06 Discovering Exercise Science05:29 Finding the Right Space for You08:57 Understanding Diet Culture and Disordered Eating13:31 Final Thoughts and Advice

Ursodiol (ursodeoxycholic acid) is a prescription bile acid medication used to dissolve cholesterol gallstones, prevent gallstones during rapid weight loss, and treat liver diseases like primary biliary cholangitis (PBC) by reducing toxic bile acids and cholesterol production. It works by changing bile composition, making it less saturated with cholesterol, and is available as oral medication. Of course, it is also the foundational medication for treatment of diagnosed Intrahepatic Cholestasis of Pregnancy (ICP). Does this medication reduce adverse perinatal outcomes? In this episode, we will review a new study from the Green Journal, which will be out in February 2026, examining the recurrence risk for ICP using data from NY. In a patient with prior history of ICP, is there any guidance on monitoring of serum bile acids in the subsequent pregnancy before symptoms develop? We will explain. PLUS we will review the data on whether Ursodiol may hold promise in recurrence prevention or in reduction of adverse outcomes once the condition is diagnosed. Listen in for details. 1. 2019: Chappell LC, Bell JL, Smith A, Linsell L, Juszczak E, Dixon PH, Chambers J, Hunter R, Dorling J, Williamson C, Thornton JG; PITCHES study group. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet. 2019 Sep 7;394(10201):849-860. doi: 10.1016/S0140-6736(19)31270-X. Epub 2019 Aug 1. PMID: 31378395; PMCID: PMC6739598. https://pubmed.ncbi.nlm.nih.gov/31378395/2. February 08, 2025: Rahim, Mussarat N et al. Pregnancy and the liver. The Lancet. 2021; Volume 405, Issue 10477, 498 – 513 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02351-1/fulltext3. SMFM CS 53; 20214. Rosenberg, Henri M. MD; Sarker, Minhazur R. MD; Ramos, Gladys A. MD; Bianco, Angela MD; Ferrara, Lauren MD; DeBolt, Chelsea A. MD. Intrahepatic Cholestasis of Pregnancy Recurrence in a Subsequent Pregnancy. Obstetrics & Gynecology 147(2):p 239-241, February 2026. | DOI: 10.1097/AOG.0000000000006033 https://journals.lww.com/greenjournal/fulltext/2026/02000/intrahepatic_cholestasis_of_pregnancy_recurrence.13.aspx5. Ovadia C, Sajous J, Seed PT et al. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis. Lancet Gastroenterol Hepatol. 2021 Jul;6(7):547-558. doi: 10.1016/S2468-1253(21)00074-1. Epub 2021 Apr 27. PMID: 33915090; PMCID: PMC8192305.6. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. European Association for the Study of the Liver; 2023

🧭 REBEL Rundown 📌 Key Points 🎯Partnership Focus: New collaboration with Arena Labs aimed at enhancing healthcare worker wellness.🏃🏽‍️‍➡️Personalized Coaching: Tools and coaching programs designed for stress management and performance improvement.📊Data-Driven Insights: Utilizing wearable sensor data to tackle burnout effectively.🌄Broad Impact: Offers a unique opportunity to contribute to large-scale healthcare improvements. Click here for Direct Download of the Podcast. 📝 Introduction Welcome back to REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine. In this episode, hosted by Drs. Mark Ramzy and Marco Propersi, we’re excited to introduce a collaboration with Arena Labs. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies.  Cognitive Question What would it look like in emergency medicine and critical care to be set up with the same tools as elite teams and professional athletes when it comes to measuring performance and recovery? How would our patients benefit? 💭 Why This is Important Burnout among healthcare workers is a growing concern, especially in such high-pressure environments as emergency and intensive care units. The collaboration with Arena Labs brings forth a vital focus on using data and coaching to build resilience among medical professionals. 🌟Be Brilliant at the Basics Ask yourself — “What is it on your time off that gives you a deep sense of fulfillment?”On your time off are you doing things that fill your bucket and add to your recovery? What is Allostasis and Allostatic Load Allostasis: Our body’s ability to adapt over time to stress. It’s relevant to the phase you are in during this particular season in your life. Ex. You are a first year medical student freaking out about your very first exam. Over time as you do more exams, they are still stressful, but by now you have developed modified study habits to succeed and get used to the frequent examsIn the context of emergency medicine, you may be nervous or stressed about your first shift at a new hospital but overtime you learn the staff, the location of equipment, the acuity of that particular site, the patient population so over time you get used to the stress of a shift at that new hospitalAllostatic Load: The wear and tear on the body from chronic stress due to maladaptation or poor recovery methods.This refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity.Ex. You are an emergency medicine physician at a very busy, high acuity center and have never prioritized taking care of yourself on/during a shift. As a result, external factors add to not being able to fully recover when you get home or are off shift (ie. Admin work, teaching obligations, family/friends) and so you never fully recover before you have to go back on shift to the same stressors you just exposed yourself to. So the cycle continuesFigure 1: Long term effects of Chronic Stress (Source: Andrew Hogue from NeuroFit) 🏥How This Applies to the Emergency Department or ICU? Healthcare workers in emergency departments (ED) and intensive care units (ICU) are often under enormous stress due to the nature of their work. Arena Labs’ program offers tailored solutions, helping ED and ICU staff manage their unique challenges through effective recovery techniques and performance tools. This approach caters specifically to the demanding schedules and the unpredictability inherent in these environments. 👀 Where to Learn More Intrigued by the possibilities this partnership offers? You can explore more by visiting Arena Labs’ website here. Also, check out the comprehensive coaching program available, designed specifically for healthcare providers looking to enhance their well-being and performance. 🚨 Clinical Bottom Line In an era where burnout is pervasive, our collaboration with Arena Labs offers a beacon of hope for healthcare workers. By leveraging cutting-edge data insights and practical coaching, this partnership aims to redefine healthcare wellness, fostering a sustainable, resilient workforce that’s equipped to navigate the pressures of modern medicine. Join us in this journey towards enhanced well-being and workforce empowerment, ensuring that those who care for us are also cared for. 📚References Guidi J, et al.Allostatic Load and Its Impact on Health: A Systematic Review. Psychother Psychosom. 2021; Epub 2020 Aug 14. PMID: 32799204Frueh BC, et al.“Operator syndrome”: A unique constellation of medical and behavioral health-care needs of military special operation forces. Int J Psychiatry Med. Epub 2020 Feb 13. PMID: 32052666 Meet the Authors Mark Ramzy, DO Co-Editor-in-Chief Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ Marco Propersi Co-Editor-in-Chief Chair of Emergency Medicine at Vassar Brothers Medical Center, Poughkeepsie, NY Brain Ferguson Founder and CEO Arena Labs The post REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams appeared first on REBEL EM - Emergency Medicine Blog.

Contributor: Aaron Lessen, MD Educational Pearls BRASH Syndrome: Bradycardia Renal Failure AV Nodal Blockade Shock Hyperkalemia  Clinical Features: Profound bradycardia and shock in patients on AV nodal blockers: Commonly, Beta Blockers or Calcium Channel Blockers Etiology:  Caused by an inciting kidney injury: Common triggers include precipitating illness, dehydration, or medications  Results in hyperkalemia The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock. Treatment:  IV Fluids, unless volume overloaded Epinephrine for bradycardia Lasix for volume overload, only if the patient is still making urine Low threshold to dialyze for hyperkalemia Focus on treating early and more aggressively.  References: Farkas JD, Long B, Koyfman A, Menson K. BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia. J Emerg Med. 2020 Aug;59(2):216-223. doi: 10.1016/j.jemermed.2020.05.001. Epub 2020 Jun 18. PMID: 32565167.   Summarized by Ashley Lyons OMS3 Editting by Ashley Lyons OMS3 and Jeffrey Olson MS4   Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-468 Overview: We first discussed aspirin use for primary prevention of cardiovascular disease in 2022 when the USPSTF recommended against it. In this follow-up episode, we review new trial data reinforcing that guidance and help you translate the evidence into safer prevention strategies. Build confidence in supporting patients with evidence-based approaches to reduce cardiovascular risk. Episode resource links: Aspirin, cardiovascular events, and major bleeding in older adults: extended follow-up of the ASPREE trial. Eur Heart J. 2025 Aug 12:ehaf514. doi: 10.1093/eurheartj/ehaf514. Epub ahead of print. PMID: 40796244. Guest: Robert A. Baldor MD, FAAFP   Music Credit: Matthew Bugos Thoughts? Suggestions? Email us at FranklySpeaking@pri-med.com The views expressed in this podcast are those of Dr. Domino and his guests and do not necessarily reflect the views of Pri-Med.

En este episodio hablamos de Mi adorada esposa, un thriller que desde las primeras páginas deja claro que aquí nada es normal, aunque todo intente parecerlo. Conocemos a una pareja “perfecta”: matrimonio estable, hijos, rutina… y un pacto tan oscuro como inquietante que se convierte en el verdadero motor de la historia.Any revela su oscuro secreto, mientras Mix comparte sus actividades nocturnas. 

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-468 Overview: We first discussed aspirin use for primary prevention of cardiovascular disease in 2022 when the USPSTF recommended against it. In this follow-up episode, we review new trial data reinforcing that guidance and help you translate the evidence into safer prevention strategies. Build confidence in supporting patients with evidence-based approaches to reduce cardiovascular risk. Episode resource links: Aspirin, cardiovascular events, and major bleeding in older adults: extended follow-up of the ASPREE trial. Eur Heart J. 2025 Aug 12:ehaf514. doi: 10.1093/eurheartj/ehaf514. Epub ahead of print. PMID: 40796244. Guest: Robert A. Baldor MD, FAAFP   Music Credit: Matthew Bugos Thoughts? Suggestions? Email us at FranklySpeaking@pri-med.com The views expressed in this podcast are those of Dr. Domino and his guests and do not necessarily reflect the views of Pri-Med.

This week we're traveling back to first-century Jerusalem with The Book of Clarence! Join us as we learn about Mary Magdalene, Barabbas, Biblical sick burns, and more! Sources: Martínez-Cruz, B., Mendizabal, I., Harmant, C. et al. Origins, admixture and founder lineages in European Roma. Eur J Hum Genet 24, 937–943 (2016). https://doi.org/10.1038/ejhg.2015.201 Gresham D, Morar B, Underhill PA, Passarino G, Lin AA, Wise C, Angelicheva D, Calafell F, Oefner PJ, Shen P, Tournev I, de Pablo R, Kuĉinskas V, Perez-Lezaun A, Marushiakova E, Popov V, Kalaydjieva L. Origins and divergence of the Roma (gypsies). Am J Hum Genet. 2001 Dec;69(6):1314-31. doi: 10.1086/324681. Epub 2001 Nov 9. PMID: 11704928; PMCID: PMC1235543. James Carroll, "Who Was Mary Magdalene?" Smithsonian Magazine https://www.smithsonianmag.com/history/who-was-mary-magdalene-119565482/   Cornelis Bennema, "Mary Magdalene: Recognizing the Shepherd's Voice," Encountering Jesus (2014). https://www.jstor.org/stable/j.ctt9m0t70.27  Meggan Watterson, Mary Magdalene Revealed: The First Apostle, Her Feminist Gospel & the Christianity We Haven't Tried Yet (audiobook).  Y'all Translation Bible, https://www.bible.com/bible/4108/JHN.20.YALL  NIV Study Bible Rotten Tomatoes: https://www.rottentomatoes.com/m/the_book_of_clarence_2024  Robert Daniels, https://www.rogerebert.com/reviews/the-book-of-clarence-film-review-2024  Alissa Wilkinson, https://www.nytimes.com/2024/01/11/movies/the-book-of-clarence-review.html  https://www.hollywoodreporter.com/movies/movie-reviews/the-book-of-clarence-review-lakeith-stanfield-1235780399/ 

Discover how Scribe by Pneuma Solutions transforms inaccessible PDFs into fully accessible formats in seconds. Learn step‑by‑step how to convert scanned manuals into audio, Braille, Daisy, Word, EPUB, and more. Michael Babcock demonstrates the power of Scribe from Pneuma Solutions, showing exactly how to turn an inaccessible 25‑page PDF into multiple accessible formats. Watch as he uploads a scanned user manual for the Tribit Stormbox Blast 2 speaker and instantly creates a version readable by screen readers. The demo highlights key features including browser-based reading, audio and Daisy book creation, automatic image descriptions, and support for multiple languages. You'll also see how to transfer your new accessible file to an NLS digital talking book player for easy offline listening. Relevant LinksPneuma Solutions Scribe: https://scribeit.ioPneuma Solutions: https://pneumasolutions.com Find Double Tap online: YouTube, Double Tap Website---Follow on:YouTube: https://www.doubletaponair.com/youtubeX (formerly Twitter): https://www.doubletaponair.com/xInstagram: https://www.doubletaponair.com/instagramTikTok: https://www.doubletaponair.com/tiktokThreads: https://www.doubletaponair.com/threadsFacebook: https://www.doubletaponair.com/facebookLinkedIn: https://www.doubletaponair.com/linkedin Subscribe to the Podcast:Apple: https://www.doubletaponair.com/appleSpotify: https://www.doubletaponair.com/spotifyRSS: https://www.doubletaponair.com/podcastiHeadRadio: https://www.doubletaponair.com/iheart About Double TapHosted by the insightful duo, Steven Scott and Shaun Preece, Double Tap is a treasure trove of information for anyone who's blind or partially sighted and has a passion for tech. Steven and Shaun not only demystify tech, but they also regularly feature interviews and welcome guests from the community, fostering an interactive and engaging environment. Tune in every day of the week, and you'll discover how technology can seamlessly integrate into your life, enhancing daily tasks and experiences, even if your sight is limited. "Double Tap" is a registered trademark of Double Tap Productions Inc. Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

Send us a textIn this episode of Journal Club, Ben and Daphna review a retrospective cohort study from the Journal of Perinatology examining the association between NICU capacity strain and neonatal outcomes. We discuss how high census and acuity on admission day correlate with increased mortality and morbidity when adjusted for hospital and patient factors. Join us as we explore why being "slammed with admissions" is more than just a badge of honor—it's a critical safety metric for our patients.----The association of NICU capacity strain with neonatal mortality and morbidity. Salazar EG, Passarella M, Formanowski B, Rogowski J, Edwards EM, Halpern SD, Phibbs C, Lorch SA.J Perinatol. 2025 Dec;45(12):1801-1808. doi: 10.1038/s41372-025-02449-0. Epub 2025 Oct 20.PMID: 41116036 Free PMC article.Support the showAs always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below. Enjoy!

Deep Dive in DDH is a three-part limited series where experts in the field of DDH have been invited to discuss the controversies in the management of hip dysplasia. Episode 1 was published in August and discussed management of DDH in infants under 6 months of age. In Episode 2, we are joined by Eduardo Novais at Nemour Children's Health in Jacksonville and Salil Upasani of Rady Children's Hospital and discuss the controversies in the management of developmental hip dislocations in the operating room including the process to decide between closed and open reduction, the use of concomitant osteotomies, adjunctive imaging, and casting protocols. Hosted by Will Morris (Scottish Rite for Children). Music by A. A. Aalto. Referenced Publications: Novais EN, Hill MK, Carry PM, Heyn PC. Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis. Clin Orthop Relat Res. 2016 May;474(5):1166-77. doi: 10.1007/s11999-015-4590-5. PMID: 26472583; PMCID: PMC4814411. Schmaranzer F, Justo P, Kallini JR, Ferrer MG, Miller P, Bixby SD, Novais EN. Hip Morphology on Post-Reduction MRI Predicts Residual Dysplasia 10 Years After Open or Closed Reduction. J Bone Joint Surg Am. 2024 Jan 17;106(2):110-119. doi: 10.2106/JBJS.23.00333. Epub 2023 Nov 22. PMID: 37992184; PMCID: PMC12205695. Morris WZ, Chilakapati S, Hinds SA, Herring JA, Kim HKW. The Clinical Significance of Infolded Limbus on Postreduction Arthrogram in Developmental Dysplasia of the Hip. J Pediatr Orthop. 2022 Apr 1;42(4):e309-e314. doi: 10.1097/BPO.0000000000002070. PMID: 35132011. Morris WZ, Hinds S, Worrall H, Jo CH, Kim HKW. Secondary Surgery and Residual Dysplasia Following Late Closed or Open Reduction of Developmental Dysplasia of the Hip. J Bone Joint Surg Am. 2021 Feb 3;103(3):235-242. doi: 10.2106/JBJS.20.00562. PMID: 33252590. Gans I, Sankar WN. The medial dye pool revisited: correlation between arthrography and MRI In closed reductions for DDH. J Pediatr Orthop. 2014 Dec;34(8):787-90. doi: 10.1097/BPO.0000000000000187. PMID: 24787303. Novais EN, Hollnagel KF, Bixby SD, Ferrer MG, Williams DN, Kim YJ, Schmaranzer F. Predictive value of post-reduction gadolinium-enhanced magnetic resonance imaging in detecting avascular necrosis after closed and open reduction for developmental dysplasia: A minimum 5-year follow-up study. J Child Orthop. 2025 Jul 6;19(4):329-338. doi: 10.1177/18632521251350524. PMID: 40630930; PMCID: PMC12230044. Paez C, Badrinath R, Holt J, Bomar JD, Mubarak SJ, Upasani VV, Wenger DR. Ligamentum Teres Transfer During Medial Open Reduction in Patients with Developmental Dysplasia of the Hip. Iowa Orthop J. 2021;41(1):47-53. PMID: 34552403; PMCID: PMC8259203.

It's a controversial topic: the impact of uterine incision (hysterectomy) on the neonate delivery interval (also called the U-D interval). Does it matter? Just to be clear, we're talking about time from uterine entry to fetal extraction, not skin incision to fetal extraction. Past publications have produced conflicting results, often limited by small sample sizes, heterogeneous indications for delivery, and reliance on surrogate markers (like apgar scores) rather than clinical morbidity. But a new study published in the Gray journal at the end of 2025 (December 30, 2025) gives some new insights. In this episode, we will review this retrospective study and play the “Devil's advocate” as we summarize the rebuttal data. As the reports are conflicting, we will end the podcast with a real-world interpretation and application of this data. Listen in for details. 1. Bart, Yossi et al. Uterine Incision-to-Delivery Interval and Neonatal Outcomes among Non-urgent, Term, Cesarean Deliveries. American Journal of Obstetrics & Gynecology, Volume 0, Issue 0. https://www.ajog.org/article/S0002-9378(25)00980-9/fulltext?rss=yes2. Maayan-Metzger A, Schushan-Eisen I, Todris L, Etchin A, Kuint J. The effect of time intervals on neonatal outcome in elective cesarean delivery at term under regional anesthesia. Int J Gynaecol Obstet. 2010 Dec;111(3):224-8. doi: 10.1016/j.ijgo.2010.07.022. Epub 2010 Sep 19. PMID: 20855070. https://pubmed.ncbi.nlm.nih.gov/20855070/3. Spain JE, Tuuli M, Stout MJ, Roehl KA, Odibo AO, Macones GA, Cahill AG. Time from uterine incision to delivery and hypoxic neonatal outcomes. Am J Perinatol. 2015 Apr;32(5):497-502. doi: 10.1055/s-0034-1396696. Epub 2014 Dec 24. PMID: 25539409.4. Bader AM, Datta S, Arthur GR, Benvenuti E, Courtney M, Hauch M. Maternal and fetal catecholamines and uterine incision-to-delivery interval during elective cesarean. Obstet Gynecol. 1990 Apr;75(4):600-3. PMID: 2107478.5. Tekin, E., Inal, H.A. & Isenlik, B.S. A Comparison of the Effect of Time from Uterine Incision to Delivery on Neonatal Outcomes in Women with One Previous and Repeat (Two or More) Cesarean Sections. SN Compr. Clin. Med. 5, 80 (2023). https://doi.org/10.1007/s42399-023-01427-x

Luke Hedrick, Dave Furfaro, and recurrent RFJC guest Robert Wharton are joined again today by Nicole Ng to discuss the FIBRONEER-IPF trial investigating Nerandomilast in patients with IPF. This trial was published in NEJM in 2025 and looked at Neradomilast vs placebo for treating patients with IPF, on or off background anti-fibrotic therapy. This agents is now FDA approved for pulmonary fibrosis, and understanding the trial results is essential for any pulmonary physician treating patients with IPF or progressive pulmonary fibrosis. Article and Reference Today’s episode discusses the FIBRONEER-IPF trial published in NEJM in 2025. Richeldi L, Azuma A, Cottin V, Kreuter M, Maher TM, Martinez FJ, Oldham JM, Valenzuela C, Clerisme-Beaty E, Gordat M, Wachtlin D, Liu Y, Schlecker C, Stowasser S, Zoz DF, Wijsenbeek MS; FIBRONEER-IPF Trial Investigators. Nerandomilast in Patients with Idiopathic Pulmonary Fibrosis. N Engl J Med. 2025 Jun 12;392(22):2193-2202. doi: 10.1056/NEJMoa2414108. Epub 2025 May 18. PMID: 40387033. https://www.nejm.org/doi/abs/10.1056/NEJMoa2414108 Meet Our Guests Luke Hedrick is an Associate Editor at Pulm PEEPs and runs the Rapid Fire Journal Club Series. He is a senior PCCM fellow at Emory, and will be starting as a pulmonary attending at Duke University next year. Robert Wharton is a recurring guest on Pulm PEEPs as a part of our Rapid Fire Journal Club Series. He completed his internal medicine residency at Mt. Sinai in New York City, and is currently a pulmonary and critical care fellow at Johns Hopkins. Dr. Nicole Ng is an Assistant Profess of Medicine at Mount Sinai Hospital, and is the Associate Director of the Interstitial Lung Disease Program for the Mount Sinai National Jewish Health Respiratory Institute. Infographic Key Learning Points Why this trial mattered IPF therapies remain limited: nintedanib and pirfenidone slow (but do not stop) decline and often cause GI side effects. Nerandomilast is a newer agent (a preferential PDE4B inhibitor) with antifibrotic + immunomodulatory effects. Phase 2 data (NEJM 2022) looked very promising (suggesting near-“halt” of FVC decline), so this phase 3 trial was a big test of that signal. Trial design essentials Industry-sponsored, randomized, double-blind, placebo-controlled, large multinational study (332 sites, 36 countries). Population: IPF diagnosed via guideline-aligned criteria with central imaging review and multidisciplinary diagnostic confirmation. Intervention: nerandomilast 18 mg BID, 9 mg BID, or placebo; stratified by background antifibrotic use. Primary endpoint: change in FVC at 52 weeks, analyzed with a mixed model for repeated measures. Key secondary endpoint: time to first acute exacerbation, respiratory hospitalization, or death (composite). Who was enrolled Typical IPF trial demographics: ~80% male, mean age ~70, many former smokers. Many were already on background therapy (~45% nintedanib, ~30–33% pirfenidone). Notable exclusions included significant liver disease, advanced CKD, recent major cardiovascular events, and psychiatric risk (suicidality/severe depression), reflecting class concerns seen with other PDE4 inhibitors. Efficacy: what the primary endpoint showed Nerandomilast produced a statistically significant but modest reduction in annual FVC decline vs placebo (roughly 60–70 mL difference). Importantly, it did not halt FVC decline the way the phase 2 data suggested; patients still progressed. Important nuance: interaction with pirfenidone Patients on pirfenidone had ~50% lower nerandomilast trough levels. Clinically: 9 mg BID looked ineffective with pirfenidone, so 18 mg BID is needed if used together. In those not on background therapy or on nintedanib, 9 mg and 18 mg looked similar—suggesting the apparent “dose-response” might be partly driven by the pirfenidone drug interaction Secondary and patient-centered outcomes were neutral No demonstrated benefit in the composite outcome (exacerbation/resp hospitalization/death) or its components. Quality of life measures were neutral and declined in all groups, emphasizing that slowing FVC alone may not translate into felt improvement without a disease-reversing therapy. The discussants noted this may reflect limited power/duration for these outcomes and mentioned signals from other datasets/pooling that might suggest mortality benefit—but in this specific trial, the key secondary endpoint was not positive. Safety and tolerability Diarrhea was the main adverse event: Higher overall with the 18 mg dose, and highest when combined with nintedanib (up to ~62%). Mostly mild/manageable; discontinuation due to diarrhea was relatively uncommon (but higher in those on nintedanib). Reassuringly, there was no signal for increased depression/suicidality/vasculitis despite psychiatric exclusions and theoretical class risk. How to interpret “modest FVC benefit” clinically The group framed nerandomilast as another tool that adds incremental slowing of progression. They emphasized that comparing absolute FVC differences across trials (ASCEND/INPULSIS vs this trial) is tricky because populations and “natural history” in placebo arms have changed over time (earlier diagnosis, improved supportive care, etc.). They highlighted channeling bias: patients already on antifibrotics may be sicker (longer disease duration, lower PFTs, more oxygen), complicating subgroup comparisons. Practical takeaways for real-world use All three antifibrotics are “fair game”; choice should be shared decision-making based on goals, tolerability, dosing preferences, and logistics. Reasons they favored nerandomilast in practice: No routine lab monitoring (major convenience advantage vs traditional antifibrotics). Generally better GI tolerability than nintedanib. BID dosing (vs pirfenidone TID). Approach to combination therapy: They generally favor add-on rather than immediate combination to reduce confusion about side effects—while acknowledging it may slow reaching “maximal therapy.” Dosing guidance emphasized: Start 18 mg BID for IPF, especially if combined with pirfenidone (since dose reduction may make it ineffective). 9 mg BID may be considered if dose reduction is needed and the patient is not on pirfenidone (e.g., monotherapy or with nintedanib).

In this Bringers of the Light Healing Portal session we bring in a healing touchstone portal. This session is for all beings who get attached to someone too quickly. Immediately pledging your love and yourself intimately and otherwise without fully vetting out the other being first.This healing portal session will install a memory touchstone in your aura that will remind you to slow your roll when you meet someone that is a potential romantic interest. It will ping you to “not go all in too quickly”. Thus saving you from future hurt feelings or mistakes or something else.THANKS FOR Being here

Hoy reseñamos Su peor pesadilla de Andrea Mara (título original: All Her Fault) y hablamos de por qué esta historia funciona tan bien como “thriller de ansiedad”: un error mínimo, una visita normal… y de pronto estás metido en el peor escenario posible para cualquier madre/padre.La premisa: Marissa llega a recoger a su hijo Milo de su “primer playdate”, toca la puerta… y la persona que abre no la conoce, no tiene al niño y jura que ahí no vive nadie con ese nombre. A partir de ahí, la historia se convierte en una espiral de dudas, acusaciones, secretos de barrio y paranoia social.Si ya leíste Su peor pesadilla o viste All Her Fault, cuéntanos: ¿qué versión te tuvo más tenso y por qué? Y si te gustó el episodio, compártelo con esa persona que ama los thrillers que te dejan diciendo: “NO puede ser…”.Leer el libro en digitalVer la serie en PeacockSi gustas escucharnos en nuestro contenido de Patreon no dudes en acompañarnos por esos rumbos lectores.Recuerda que si gustas apoyarnos en nuestras lecturas y reseñas, lo puedes realizar mediante: ☕️ Paypal o a través de nuestras redes sociales o correo electrónico.También te agradeceríamos

Uterine rupture or dehiscence associated with TOLAC results in the most significant increase in the likelihood of additional maternal and neonatal morbidity. It should be noted that the terms “uterine rupture” and “uterine dehiscence” are not consistently distinguished from each other in the literature and often are used interchangeably. Furthermore, the reported incidence of uterine rupture varies in part because some studies have grouped true, catastrophic uterine rupture together with asymptomatic scar dehiscence. In January 2026, a new meta-analysis examines the relationship between oxytocin use with TOLAC and uterine rupture. In this episode, we will summarize the key findings in that study and review the data on the use of internal monitors during TOLAC. Do internal monitors (FSE, IUPC) offer a safer TOLAC compared with external monitors? Listen in for details.1. Nicolì, Pierpaolo et al.Oxytocin dosing during trial of labor after cesarean to minimize the risk of uterine rupture: a systematic review and meta-analysisAmerican Journal of Obstetrics & Gynecology MFM, Volume 8, Issue 1, 1018462. Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology 130(5):p e217-e233, November 2017. | DOI: 10.1097/AOG.00000000000023983. ACOG Clinical Practice Guideline No. 10:Intrapartum Fetal Heart Rate Monitoring: Interpretation and Management. Obstetrics & Gynecology 146(4):p 583-599, October 2025. | DOI: 10.1097/AOG.00000000000060494. Bruno AM, Allshouse AA, Metz TD. Maximum Oxytocin Dose and Uterine Rupture During Trial of Labor After Cesarean. Obstet Gynecol. 2025 Dec 1;146(6):843-850. doi: 10.1097/AOG.0000000000006106. Epub 2025 Oct 30. PMID: 41325062.

This week’s Pulm PEEPs Pearls episode is a focused discussion between Furf and Monty about non-pharmacologic techniques for airway clearance in the non-Cystic Fibrosis bronchiectasis population. This is a focused, high-yield discussion of the key points about airway clearance, including practical tips and a discussion of the evidence. This episode was prepared in conjunction with George Doumat MD. Goerge is an internal medicine resident at UT Southwestern and joined us for a Pulm PEEPs – BMJ Thorax journal club episode. He is now acting as a Pulm PEEPs Editor for the Pulm PEEPs Pearls series. Key Learning Points 1) Why airway clearance matters in non-CF bronchiectasis Non-CF bronchiectasis is defined by irreversible bronchial dilation with impaired mucociliary clearance, leading to mucus retention. Retained sputum drives the classic vicious cycle: mucus → infection → neutrophilic inflammation → airway damage → worse clearance. Airway clearance techniques (ACTs) are meant to interrupt this cycle, primarily by improving mucus mobilization and symptom control. 2) What ACTs are trying to achieve clinically Main benefits are: More effective sputum clearance Reduced cough/dyspnea burden Improved activity tolerance and quality of life Effects on spirometry are usually small. Exacerbation reduction is possible, but evidence is mixed—some longer-term data suggest benefit for specific techniques. 3) The main ACT “families” and when to use them Breathing-based techniques (device-free, flexible) ACBT (Active Cycle of Breathing Technique): breath control → deep breaths with holds → huffing. Pros: portable, adaptable, good first-line option. Key requirement: teaching/coaching to get technique right. Autogenic drainage: controlled breathing at different lung volumes to move mucus from peripheral → central airways. Pros: no device, can work well once learned. Cons: more technically demanding, needs training and practice. PEP / Oscillatory PEP (stents airways + “vibrates” mucus loose) PEP: back-pressure helps prevent small airway collapse during exhalation; often paired with huff/cough. Oscillatory PEP (Flutter/Acapella/Aerobika): adds oscillation that many patients find easy and satisfying to use. Good fit for: people who benefit from airway stenting, want something portable, and prefer a device. Mechanical/manual techniques (help when patient can't self-clear well) HFCWO (“the vest”): external chest wall oscillation; helpful for high sputum volumes, dexterity limits, or difficulty coordinating breathing maneuvers. Postural drainage/percussion/vibration: caregiver/therapist-assisted options; still useful but consider: GERD/reflux risk with certain positions Hemoptysis risk with vigorous techniques 4) How to choose the “right” technique (the practical framework) There is no one-size-fits-all. Match the tool to the patient: Sputum burden (volume/viscosity) Strength, coordination, cognition, dexterity Comorbidities (GERD, hemoptysis history, severe obstruction/airway collapse) Lifestyle + portability (what they'll actually do) Cost/access and availability of respiratory therapy/physio support A key mindset from the script: this is not a lifetime contract—reassess and adjust over time with shared decision-making. 5) Evidence takeaways (what improves, what doesn't) ACTs reliably improve sputum expectoration and often symptoms/QoL. QoL/cough scores (e.g., SGRQ, LCQ) tend to improve modestly, particularly with oscillatory PEP and some vest studies. Lung function: typically minimal change; occasional short-term FEV₁ benefit is reported in some vest trials. Exacerbations: mixed overall; the script highlights a longer-term RCT of ELTGOL showing fewer exacerbations at 12 months vs placebo exercises. Safety: generally excellent; main cautions are hemoptysis and reflux (depending on technique/positioning). 6) Special population pearls Hemoptysis / fragile airways: start with gentle breathing-based ACTs (ACBT, controlled huffing); avoid overly vigorous oscillatory/manual methods if concerned. Severe obstruction or early airway collapse: PEP/oscillatory PEP can help by keeping small airways open on exhalation. Mobility/coordination barriers: consider HFCWO vest or simple oscillatory PEP devices to enable daily adherence. During exacerbations: keep it simple—1–2 reliable techniques, prioritize daily consistency, and re-check technique. 7) The “real” bottom line Start with simple, self-manageable options (often ACBT ± PEP). The “best” ACT is the one the patient will do consistently. Reassess technique and fit over time; education and demonstration are part of the therapy. References and Further Reading  Lee AL et al., “Airway clearance techniques for bronchiectasis,” Cochrane Database Syst Rev. 2015; PMC7175838. PMID: 26591003. Athanazio RA et al., “Airway Clearance Techniques in Bronchiectasis,” Front Med (Lausanne). 2020; PMC7674976. PMID: 33251032. Iacono R et al., “Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis,” Eur Rev Med Pharmacol Sci. 2015; PMID: 26078380. Polverino E et al., “European Respiratory Society statement on airway clearance techniques in bronchiectasis,” Eur Respir J. 2023; PMID: 37142337. Doumat G, Aksamit TR, Kanj AN. Bronchiectasis: A clinical review of inflammation. Respir Med. 2025 Aug;244:108179. doi: 10.1016/j.rmed.2025.108179. Epub 2025 May 25. PMID: 40425105.

Send us a textDescription: An immersive reading of With Child by Genevieve Taggard with reflection on pregnancy, maternal mortality, pace, and isolation. Website:https://anauscultation.wordpress.comWork:With Childby Genevieve Taggard Now I am slow and placid, fond of sun,Like a sleek beast, or a worn one:No slim and languid girl—not gladWith the windy trip I once had,But velvet-footed, musing of my own,Torpid, mellow, stupid as a stone.You cleft me with your beauty's pulse, and nowYour pulse has taken body. Care not howThe old grace goes, how heavy I am grown,Big with this loneliness, how you alonePonder our love. Touch my feet and feelHow earth tingles, teeming at my heel!Earth's urge, not mine,—my little death, not hers;And the pure beauty yearns and stirs.It does not heed our ecstacies, it turnsWith secrets of its own, its own concerns,Toward a windy world of its own, toward starkAnd solitary places. In the dark,Defiant even now, it tugs and moansTo be untangled from these mother's bones.References:Goldenberg RL, McClure EM. Maternal mortality. Am J Obstet Gynecol. 2011 Oct;205(4):293-5. doi: 10.1016/j.ajog.2011.07.045. Epub 2011 Aug 4. PMID: 22083050; PMCID: PMC3893928.https://www.who.int/news-room/fact-sheets/detail/maternal-mortality Hoyert DL. Maternal mortality rates in the United States, 2023. NCHS Health E-Stats. 2025. DOI: https://dx.doi.org/10.15620/cdc/174577.Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians; Denberg TD, Barry MJ, Boyd C, Chow RD, Fitterman N, Harris RP, Humphrey LL, Vijan S. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789.Moyer CA, Rounds J, Hannum JW. A meta-analysis of massage therapy research. Psychol Bull. 2004 Jan;130(1):3-18. doi: 10.1037/0033-2909.130.1.3. PMID: 14717648.

Currently, as of today's date, neither the ACOG nor SMFM currently support routine early induction of labor for suspected fetal macrosomia, instead recommending individualized counseling and reserving elective cesarean for extreme estimated fetal weights. However, a 2025 multicenter, open-label, randomized controlled trial was published in the Lancet comparing induction of labor versus standard care in pregnant women with fetuses suspected to be large for gestational age. The study used a parallel-group design with 1:1 randomization, enrolling women from 106 NHS hospitals across England, Scotland, and Wales. The per-protocol analysis demonstrated a significant reduction (40%) in shoulder dystocia with induction of labor at 38- 38 weeks and 4 days. Is this in conflict with the ACOG current guidance? In this episode, we will review the “Big Baby study” from the Lancet and provide 3 main limitations of this very large study, review the importance of PP vs ITT results, and explain why more data is still needed. Listen in for details. 1. ACOG PB 178; 2017 (reaffirmed 2024)2. Gardosi J, Ewington LJ, Booth K, Bick D, Bouliotis G, Butler E, Deshpande S, Ellson H, Fisher J, Gornall A, Lall R, Mistry H, Naghdi S, Petrou S, Slowther AM, Wood S, Underwood M, Quenby S. Induction of labour versus standard care to prevent shoulder dystocia in fetuses suspected to be large for gestational age in the UK (the Big Baby trial): a multicentre, open-label, randomised controlled trial. Lancet. 2025 May 17;405(10491):1743-1756. doi: 10.1016/S0140-6736(25)00162-X. Epub 2025 May 1. PMID: 40319899.3. Blaauwgeers, Anne N et al. Rethinking induction of labour for LGA fetuses: the Big Baby trial. The Lancet, Volume 406, Issue 10512, 1562

Episode 210: Heat Stroke BasicsWritten by Jacob Dunn, MS4, American University of the Caribbean. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. Definition:Heat stroke represents the most severe form of heat-related illness, characterized by a core body temperature exceeding 40°C (104°F) accompanied by central nervous system (CNS) dysfunction. Arreaza: Key element is the body temperature and altered mental status. Jacob: This life-threatening condition arises from the body's failure to dissipate heat effectively, often in the context of excessive environmental heat load or strenuous physical activity. Arreaza: You mentioned, it is a spectrum. What is the difference between heat exhaustion and heat stroke? Jacob: Unlike milder heat illnesses such as heat exhaustion, heat stroke involves multisystem organ dysfunction driven by direct thermal injury, systemic inflammation, and cytokine release. You can think of it as the body's thermostat breaking under extreme stress — leading to rapid, cascading failures if not addressed immediately. Arreaza: Tell us what you found out about the pathophysiology of heat stroke?Jacob: Pathophysiology: Under normal conditions, the body keeps its core temperature tightly controlled through sweating, vasodilation of skin blood vessels, and behavioral responses like seeking shade or drinking water. But in extreme heat or prolonged exertion, those mechanisms get overwhelmed.Once core temperature rises above about 40°C (104°F), the hypothalamus—the brain's thermostat—can't keep up. The body shifts from controlled thermoregulation to uncontrolled, passive heating. Heat stroke isn't just someone getting too hot—it's a full-blown failure of the body's heat-regulating system. Arreaza: So, it's interesting. the cell functions get affected at this point, several dangerous processes start happening at the same time.Jacob: Yes: Cellular Heat InjuryHigh temperatures disrupt proteins, enzymes, and cell membranes. Mitochondria start to fail, ATP production drops, and cells become leaky. This leads to direct tissue injury in vital organs like the brain, liver, kidneys, and heart.Arreaza: Yikes. Cytokines play a big role in the pathophysiology of heat stroke too. Jacob: Systemic Inflammatory ResponseHeat damages the gut barrier, allowing endotoxins to enter the bloodstream. This triggers a massive cytokine release—similar to sepsis. The result is widespread inflammation, endothelial injury, and microvascular collapse.Arreaza: What other systems are affected?Coagulation AbnormalitiesEndothelial damage activates the clotting cascade. Patients may develop a DIC-like picture: microthrombi forming in some areas while clotting factors get consumed in others. This contributes to organ dysfunction and bleeding.Circulatory CollapseAs the body shunts blood to the skin for cooling, perfusion to vital organs drops. Combine that with dehydration from sweating and fluid loss, and you get hypotension, decreased cardiac output, and worsening ischemia.Arreaza: And one of the key features is neurologic dysfunction.Jacob: Neurologic DysfunctionThe brain is extremely sensitive to heat. Encephalopathy, confusion, seizures, and coma occur because neurons malfunction at high temperatures. This is why altered mental status is the hallmark of true heat stroke.Arreaza: Cell injury, inflammation, coagulopathy, circulatory collapse and neurologic dysfunction. Jacob: Ultimately, heat stroke is a multisystem catastrophic event—a combination of thermal injury, inflammatory storm, coagulopathy, and circulatory collapse. Without rapid cooling and aggressive supportive care, these processes spiral into irreversible organ failure.Background and Types:Arreaza: Heat stroke is part of a spectrum of heat-related disorders—it is a true medical emergency. Mortality rate reaches 30%, even with optimal treatment. This mortality correlates directly with the duration of core hyperthermia. I'm reminded of the first time I heard about heat stroke in a baby who was left inside a car in the summer 2005. Jacob: There are two primary types: -nonexertional (classic) heat stroke, which develops insidiously over days and predominantly affects vulnerable populations like children, the elderly, and those with chronic illnesses during heat waves; -exertional heat stroke, which strikes rapidly in young, otherwise healthy individuals, often during intense exercise in hot, humid conditions. Arreaza: In our community, farm workers are especially at risk of heat stroke, but any person living in the Central Valley is basically at risk.Jacob: Risk factors amplify vulnerability across both types, including dehydration, cardiovascular disease, medications that impair sweating (e.g., anticholinergics), and acclimatization deficits. Notably, anhidrosis (lack of sweating) is common but not required for diagnosis. Hot, dry skin can signal the shift from heat exhaustion to stroke. Arreaza: What other conditions look like heat stroke?Differential Diagnosis:Jacob: Presenting with altered mental status and hyperthermia, heat stroke demands a broad differential to avoid missing mimics. -Environmental: heat exhaustion, syncope, or cramps. -Infectious etiologies like sepsis or meningitis must be ruled out. -Endocrine emergencies such as thyroid storm, pheochromocytoma, or diabetic ketoacidosis (DKA) can overlap. -Neurologic insults include cerebrovascular accident (CVA), hypothalamic lesions (bleeding or infarct), or status epilepticus. -Toxicologic culprits are plentiful—sympathomimetic or anticholinergic toxidromes, salicylate poisoning, serotonin syndrome, malignant hyperthermia, neuroleptic malignant syndrome (NMS), or even alcohol/benzodiazepine withdrawal. When it comes to differentials, it is always best to cast a wide net and think about what we could be missing if this is not heat stroke. Arreaza: Let's say we have a patient with hyperthermia and we have to assess him in the ER. What should we do to diagnose it?Jacob: Workup:Diagnosis is primarily clinical, hinging on documented hyperthermia (>40°C) plus CNS changes (e.g., confusion, delirium, seizures, coma) in a hot environment. Arreaza: No single lab confirms it, but targeted testing allows us to detect complications and rule out alternative diagnosis. Jacob: -Start with ECG to assess for dysrhythmias or ischemic changes (sinus tachycardia is classic; ST depressions or T-wave inversions may hint at myocardial strain). -Labs include complete blood count (CBC), comprehensive metabolic panel (electrolytes, renal function, liver enzymes), glucose, arterial blood gas, lactate (elevated in shock), coagulation studies (for disseminated intravascular coagulation, or DIC), creatine kinase (CK) and myoglobin (for rhabdomyolysis), and urinalysis. Toxicology screen if history suggests. Arreaza: I can imagine doing all this while trying to cool down the patient. What about imaging?-Imaging: chest X-ray for pulmonary issues, non-contrast head CT if neurologic concerns suggest edema or bleed (consider lumbar puncture if infection suspected). It is important to note that continuous core temperature monitoring—via rectal, esophageal, or bladder probe—is essential, not just peripheral skin checks. Arreaza: TreatmentManagement:Time is tissue here—initiate cooling en route, if possible, as delays skyrocket morbidity. ABCs first: secure airway (intubate if needed, favoring rocuronium over succinylcholine to avoid hyperkalemia risk), support breathing, and stabilize circulation. -Remove the patient from the heat source, strip clothing, and launch aggressive cooling to target 38-39°C (102-102°F) before halting to prevent rebound hypothermia. -For exertional cases, ice-water immersion reigns supreme—it's the fastest method, with immersion in cold water resulting in near-100% survival if started within 30 minutes. -Nonexertional benefits from evaporative cooling: mist with tepid water (15-25°C) plus fans for convective airflow. -Adjuncts include ice packs to neck, axillae, and groin; -room-temperature IV fluids (avoid cold initially to prevent shivering); -refractory cases, invasive options like peritoneal lavage, endovascular cooling catheters, or even ECMO. -Fluid resuscitation with lactated Ringer's or normal saline (250-500 mL boluses) protects kidneys and counters rhabdomyolysis—aim for urine output of 2-3 mL/kg/hour. Arreaza: What about medications?Jacob: Benzodiazepines (e.g., lorazepam) control agitation, seizures, or shivering; propofol or fentanyl if intubated. Avoid antipyretics like acetaminophen. For intubation, etomidate or ketamine as induction agents. Hypotension often resolves with cooling and fluids; if not, use dopamine or dobutamine over norepinephrine to avoid vasoconstriction. Jacob: What IV fluid is recommended/best for patients with heat stroke?Both lactated Ringer's solution and normal saline are recommended as initial IV fluids for rehydration, but balanced crystalloids such as LR are increasingly favored due to their lower risk of hyperchloremic metabolic acidosis and AKI. However, direct evidence comparing the two specifically in the setting of heat stroke is limited. Arreaza: Are cold IV fluids better/preferred over room temperature fluids?Cold IV fluids are recommended as an adjunctive therapy to help lower core temperature in heat stroke, but they should not delay or replace primary cooling methods such as cold-water immersion. Cold IV fluids can decrease core temperature more rapidly than room temperature fluids. For example, 30mL/kg bolus of chilled isotonic fluids at 4 degrees Celsius over 30 minutes can decrease core temperature by about 1 degree Celsius, compared to 0.5 degree Celsius with room temperature fluids. Arreaza: Getting cold IV sounds uncomfortable but necessary for those patients. Our favorite topic.Screening and Prevention:-Heat stroke prevention focuses on public health and individual awareness rather than routine testing. -High-risk groups—elderly, children, athletes, laborers, or those on impairing meds—should acclimatize gradually (7-14 days), hydrate preemptively (electrolyte solutions over plain water), and monitor temperature in exertional settings. -Communities during heat waves need cooling centers and alerts. -For clinicians, educate patients with CVD or obesity about early signs like dizziness or nausea. -No formal "screening" exists, but vigilance in EDs during summer surges saves lives. -Arreaza: I think awareness is a key element in prevention, so education of the public through traditional media like TV, and even social media can contribute to the prevention of this catastrophic condition.Jacob: Ya so heat stroke is something that should be on every physician's radar in the central valley especially in the summer time given the hot temperatures. Rapid recognition is key. Arreaza: Thanks, Jacob for this topic, and until next time, this is Dr. Arreaza, signing off.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! References:Gaudio FG, Grissom CK. Cooling Methods in Heat Stroke. J Emerg Med. 2016 Apr;50(4):607-16. doi: 10.1016/j.jemermed.2015.09.014. Epub 2015 Oct 31. PMID: 26525947. https://pubmed.ncbi.nlm.nih.gov/26525947/.Platt, M. A., & LoVecchio, F. (n.d.). Nonexertional classic heat stroke in adults. In UpToDate. Retrieved September 7, 2025, from https://www.uptodate.com/contents/nonexertional-classic-heat-stroke-in-adults. (Key addition: Emphasizes insidious onset in at-risk populations and the role of urban heat islands in exacerbating classic cases.) Heat Stroke. WikEM. Retrieved December 3, 2025, from https://wikem.org/wiki/Heat_stroke. (Key additions: Details on cooling rates for immersion therapy, confirmation that anhidrosis is not diagnostic, and fluid titration to urine output for rhabdomyolysis prevention.)Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

While endometriosis is highly associated with Chronic Pelvic Pian (CPP), some women may suffer from a different primary or coexistent secondary etiology: pelvic vascular congestion, called vascular origin (VO)- CPP. Although controversial as an entity, there have been diagnostic algorithms published (via pelvic ultrasound. MRI, or venography) for this condition. Approximately 10-40% of chronic pelvic pain cases may be attributed to pelvic vascular congestion (now termed pelvic venous disorder), though estimates vary considerably depending on the population studied and diagnostic criteria used. In premenopausal women specifically, the prevalence appears higher. One study found that 8% of all premenopausal women had documented chronic pelvic pain of unclear etiology along with dilated ovarian and pelvic veins on cross-sectional imaging. Therapies for this have been limited. Flavonoids are abundant in a colorful diet of fruits, vegetables, tea, and wine, with common sources including citrus fruits (flavanones), berries, apples, grapes (flavan-3-ols/anthocyanins), onions, kale, broccoli (flavonols), and tea, cocoa, red wine (flavan-3-ols), plus soybeans (isoflavones), all providing antioxidants and potential health benefits like better heart and brain health. On Dec. 23, 2025, in the journal Phlebology, researchers published a systematic review on the potential benefits of specific flavonoid mixtures which may provide relief to VO-CPP. Listen in for insights and details.1. Gloviczki ML, Demetres MR, Salazar G, Khilnani NM. Venoactive drugs for venous origin chronic pelvic pain in women: A systematic review. Phlebology. 2025 Dec 23:2683555251411027. doi: 10.1177/02683555251411027. Epub ahead of print. PMID: 41432346.2. Knuttinen MG, Machan L, Khilnani NM, Louie M, Caridi TM, Gupta R, Winokur RS. Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review. AJR Am J Roentgenol. 2023 Nov;221(5):565-574. doi: 10.2214/AJR.22.28796. Epub 2023 Apr 5. PMID: 37095667.

In 2002, the National Institute of Child Health and Human Development (NICHD) proposed the 3-Tier fetal heart rate (FHR) classification system that was subsequently adopted by many organizations, categorizing tracings into three groups: Category I (normal), Category II (indeterminate), and Category III (abnormal). Recently, our podcast team received an interesting question form one of our podcast family members: “If there is a change in the fetal heart rate tracing intrapartum, but it is still in the normal range (like 120 going to 150)- and variability is normal, is that an abnormality? And what is meant by a ‘ZigZag' FHT pattern (different than marked variability)?”. That is a fantastically complex question…and we will explain the answer in this episode.1. Zullo F, Di Mascio D, Raghuraman N, Wagner S, Brunelli R, Giancotti A, Mendez-Figueroa H, Cahill AG, Gupta M, Berghella V, Blackwell SC, Chauhan SP. Three-tiered fetal heart rate interpretation system and adverse neonatal and maternal outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol. 2023 Oct;229(4):377-387. doi: 10.1016/j.ajog.2023.04.008. Epub 2023 Apr 11. PMID: 37044237.2. Ghi T, Di Pasquo E, Dall'Asta A, et al. Intrapartum Fetal Heart Rate Between 150 and 160 BPM at or After 40 Weeks and Labor Outcome.Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(3):548-554. doi:10.1111/aogs.14024.3. The 3 Tier System: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ncc-efm.org/filz/NICHD_Reference_from_CCPR.pdf4. Jia YJ, Ghi T, Pereira S, Gracia Perez-Bonfils A, Chandraharan E. Pathophysiological Interpretation of Fetal Heart Rate Tracings in Clinical Practice. American Journal of Obstetrics and Gynecology. 2023;228(6):622-644. doi:10.1016/j.ajog.2022.05.0235. Ghi T, Di Pasquo E, Dall'Asta A, et al. Intrapartum Fetal Heart Rate Between 150 and 160 BPM at or After 40 Weeks and Labor Outcome. Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(3):548-554. doi:10.1111/aogs.14024.6. Yang M, Stout MJ, López JD, Colvin R, Macones GA, Cahill AG. Association of Fetal Heart Rate Baseline Change and Neonatal Outcomes. Am J Perinatol. 2017 Jul;34(9):879-886. doi: 10.1055/s-0037-1600911. Epub 2017 Mar 16. PMID: 28301895.

Endocrine Surgery emergencies are rare. However, they can be clinically significant and understanding how to navigate them as a surgeon in timely fashion is critical. Hosts:  Dr. Rebecca Sippel is an endowed professor of surgery and Division Chief of Endocrine Surgery at University of Wisconsin (UW) - Madison, and she is the most recent past president of the American Association of Endocrine Surgeons (AAES).  She is an internationally recognized leader in the field of endocrine surgery with over 250 publications. She was the principal investigator for a hallmark randomized controlled trial which studied the need for prophylactic central neck dissections in thyroid cancer.   Dr. Amanda Doubleday is a fellowship trained endocrine surgeon in private practice with an affiliation to UW Health. Her primary practice is with Waukesha Surgical Specialists in Waukesha WI. Her clinical interests are in robotic adrenalectomy, benign and malignant thyroid cancer and hyperparathyroidism. Dr. Simon Holoubek is a fellowship trained endocrine surgeon affiliated with UW Health. His primary practice is with UW Health with privileges at UW Madison and UW Northern Illinois. His clinical interests are aggressive variants of thyroid cancer, parathyroid autofluorescence, and nerve monitoring.  Learning Objectives: 1) Learn about thyroid storm in hyperthyroidism and treatment options. 2) Understand how to treat hypercalcemic crisis due to uncontrolled primary hyperparathyroidism. 3) Describe the modified surgical techniques required for thyroidectomy in patients with Graves' disease to prevent recurrent laryngeal nerve traction injury. 4) Identify clinical and intraoperative indicators of parathyroid carcinoma and explain the necessity of en bloc resection to prevent parathyromatosis. References: 1 Palit TK, Miller CC 3rd, Miltenburg DM. The efficacy of thyroidectomy for Graves' disease: A meta-analysis. J Surg Res. 2000 May 15;90(2):161-5. doi: 10.1006/jsre.2000.5875. PMID: 10792958. https://pubmed.ncbi.nlm.nih.gov/10792958/ 2 Yoshimura Noh J, Inoue K, Suzuki N, Yoshihara A, Fukushita M, Matsumoto M, Imai H, Hiruma S, Ichikawa M, Koshibu M, Sankoda A, Hirose R, Watanabe N, Sugino K, Ito K. Dose-dependent incidence of agranulocytosis in patients treated with methimazole and propylthiouracil. Endocr J. 2024 Jul 12;71(7):695-703. doi: 10.1507/endocrj.EJ24-0135. Epub 2024 May 3. PMID: 38710619. https://pubmed.ncbi.nlm.nih.gov/38710619/ 3 Christopher L, Mellman M, Buicko JL. Management of Hypercalcemic Crisis due to Primary Hyperparathyroidism During Pregnancy. Am Surg. 2023 Aug;89(8):3638-3640. doi: 10.1177/00031348231162704. Epub 2023 Apr 27. PMID: 37102502. https://pubmed.ncbi.nlm.nih.gov/37102502/ Sponsor Disclaimer: Visit goremedical.com/btkpod to learn more about GORE® SYNECOR Biomaterial, including supporting references and disclaimers for the presented content. Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available. Rx only Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen Behind the Knife Premium: General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-review Trauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlas Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-review Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-audio-review Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-audio-review Cardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-review Download our App: Apple App Store: https://apps.apple.com/us/app/behind-the-knife/id1672420049 Android/Google Play: https://play.google.com/store/apps/details?id=com.btk.app&hl=en_US