Podcasts about pfts

My pelvic floor therapist's website says it best;  “there is a good chance that you have already been told that pelvic floor issues are “normal,” “part of getting older” or “just how your body is after childbirth.” We are here to tell you that there is help and hope. At Moses & Johnson (MOJO) Therapy Associates, we treat the issues that are talked about the least but often impact our daily lives the most.”  I have the wonderful and beautiful Ellen, a PFT and new mommy, on to talk all about pelvic floor, who is it for (aka everyone), what areas of life it can help you with such as fertility, pregnancy, post partum, sexual intercourse, PAIN, etc.  We dive into many things, like our own stories + how specifically it has helped us, all the muscles in your pelvic floor, Ellen talks about the benefits of dry needling, we talk about potty training, why it hurts to have sex and what we can do to fix that, ending period cramps, pros and cons of kegels, how PFT is more than helping with the physical stuff…mental health too.  Pelvic floor issues are common, not normal, and it's time we all know about it, it's time we give people in pain hope, it's time to change these certain hardships we face.  I truly cannot thank Ellen enough for coming on and sharing the important things about PFT.  We both believe it should be a requirement after delivery and Ellen shares a little about how MOJO's research could help make that a possibility. BIG DEAL.  I can't wait to have Ellen back and possibly some other PFTs to come on and share more about this.MOJO's website— https://www.mojoph.comInstgram— https://www.instagram.com/mojopelvichealth

Learning Objectives:-Review the history and flawed assumptions in the use of race and how race-specific PFT reference equations might lead to health disparities.-Understand the evidence behind the recommendation to use race-neutral reference equations.-Review the quantitative impact of switching from race-specific to race-neutral reference equations.-Assess the many remaining gaps in our understanding of how to use pulmonary function tests to improve health.Speakers:Nirav Bhakta, MD, Associate Professor of Medicine, Pulmonary and Critical Care at the University of California, San FranciscoDr. Bhakta is a national thought leader and Vice-chair of the American Thoracic Society Pulmonary Function Testing Committee. Dr. Bhakta co-chaired the ATS workshop on race and PFTs that led to the publication of the 2023 ATS Statement.Panelists:Thomas R. Vendegna, MD, Pulmonology and Critical Care, CMO French Hospital Medical Center (Facilitator)Jeff Sippel, MD, Critical Care Medicine, UC HealthRobert Wiebe, MD, CMO, CommonSpirit HealthSuchitra Pilli, MD, Interventional Pulmonology and Critical Care, Medical Director for Respiratory Therapy, CHI Health Omaha, Assistant Professor, Creighton UniversityGary Greensweig, DO, Chief Physician Executive, Physician Enterprise, CommonSpirit HealthAnkita Sagar, MD, System Vice President, Clinical Standards and Variation Reduction, Physician Enterprise, Associate Clinical Professor of Medicine at Creighton University School of Medicine

Listen to ASCO's JCO Oncology Practice essay, “Patient is Otherwise Healthy” by Dr. Scott Capozza, Board Certified Oncology Physical Therapist at Smilow Cancer Hospital Adult Cancer Survivorship Clinic at Yale Cancer Center. The essay is followed by an interview with Capozza and host Dr. Lidia Schapira. Capozza shares his personal experience with the long-term effects of cancer treatment. TRANSCRIPT ‘Patient Is Otherwise Healthy' by Scott J. Capozza, PT, MSPT  Let me start by saying: I know I am one of the fortunate ones. Being diagnosed with cancer at any age puts many in a tailspin. I was no different when I was diagnosed with stage II testicular cancer at age 22 years. I was still in graduate school, completing my physical therapy program; suddenly, I had to schedule an orchiectomy, retroperitoneal lymph node dissection, and two cycles of chemotherapy around lectures, laboratory work, and practical examinations. Fast forward 20 years and I have an unbelievably supportive wife who has seen me through so much of my long-term survivorship concerns.   Despite my fertility challenges, we are so very fortunate that my wife was able to conceive three healthy, happy, and strong kids (conceived only through the roller coaster that is fertility preservation and reproduction medicine, which so many adolescent and young adult survivors must deal with and is emotionally very challenging, but that is a discussion for another day). I have a great career as a board-certified physical therapist in oncology, where I can help enhance the physical well-being of patients throughout the cancer care continuum. The journey to this path as a survivor was not a straight line, though that also is a discussion for another day.  What I do not remember signing up for was all the late and long-term side effects of cancer treatment, or maybe I did sign for them in a sort of deal with the devil so that I could finish PT school on time and return to my precancer life of running and being with my friends. We sign on the dotted line to rid the cancer from our bodies, but just like the mortgage, student loans, and back taxes, we end up having to pay in the end. Unfortunately, paying off this debt comes with a high interest rate (a multitude of adverse effects) heaped on top of the principal balance.  And while it would be very easy to blame my hyperlipidemia on my cancer treatments,1 I am pretty sure there is a likely strong genetic component. My grandmother had high cholesterol for as long as I could remember. As your quintessential Italian grandmother, she was 105 pounds soaking wet and ate like a bird (while being insulted if I did not have a 4th helping of her lasagna) but had to take her blasted pills for high cholesterol for all her adult life. She died a month short of her 103rd birthday and was still sharp as a tack until the very end. I will gladly sign on the dotted line for that outcome. My immediate postcancer treatment years were great. I resumed running and ran several marathons, returned to a relatively normal social life, and started along my career. I met my wife, and she was enthusiastically willing to live her life with a cancer survivor. Marriage, house, kids, job…everything was going great. Until things started going downhill. About 10 years postchemotherapy, I noticed that my exercise tolerance was decreasing. It was harder and harder to keep up with friends on our long runs. I felt more fatigued overall. I went from running 10 miles to seven to five to now barely being able to complete two miles. My chest would feel tight as if a vise was clamping down on my ribs. Running up short hills in my neighborhood, which I had routinely done in the past, felt like I was ascending Mount Everest without supplemental oxygen or Sherpa support.  When I brought this up to my primary care physician, he looked perplexed. I am young(ish), no family history of heart disease, nonsmoker, healthy weight, and only enjoy a hard cider once a week. He performed an ECG in the office, just to double check to make sure I was not crazy.   When my heart rhythms started throwing out inverted T-waves, his eyes got larger. He said that I did not fit the description of someone who should be experiencing these symptoms.  “I had cancer, remember?” I remind him although he is very familiar with my medical history and we know each other well. “Oh. Yeah.” My doctor nods….  My doctor thankfully took my concerns seriously and directed me to a series of referrals to cardiac and pulmonary specialists. Through the Pandora's box which is patient access to electronic medical records, I was able to read his postvisit report. He very accurately described the results of the physical examination and our conversation. He did write in his report that he would be placing referrals to cardiology and pulmonology. It was a very thorough evaluation, and I could tell that he was truly listening to me and not dismissing my concerns. What caught my eye, though, was the opening line to his assessment: “Patient is an otherwise healthy 42-year-old male…” Otherwise healthy? I have high cholesterol; had to endure heartache and struggle to have a family because of treatment-induced fertility issues; I wear hearing aids because of cisplatin induced ototoxicity; and now, I have to go for a full cardiopulmonary work-up, all because, I had testicular cancer at age 22 years. To me it did not feel like that I was otherwise healthy. To further work up my symptoms, I was scheduled for cardiac testing. I have a new appreciation for what my own patients go through when they have to get magnetic resonance imaging (MRI) after I had a cardiac stress MRI. I had no idea just how tiny and claustrophobia-inducing an MRI machine is, so now I nod my head in agreement with my patients when they tell me how anxiety-producing it is to get an MRI. I had a treadmill stress test and echocardiogram, and these all came to the same conclusion: I have a thickened left ventricle in my heart, which throws off the ECGs but is just my normal anatomy. Phew.  When I went for my pulmonary function test (PFT), though, the results were different. The pulmonologist came in with that same perplexed look, as he is expecting to see someone other than an early 40s, healthy weight individual sitting there. Our conversation went something like this: Pulmonologist: Do you, or did you ever, smoke? Me: No. Pulmonologist: Do you have carpets, rugs, or animals at your house?  Me: No. Pulmonologist: Do you work in a factory or someplace where you're surrounded by potentially toxic chemicals? Me: No. Pulmonologist: Do you think you gave your best effort on the PFT? Me (slightly annoyed): Yes. Pulmonologist: I don't get it; you have the lungs of someone with chronic obstructive lung disease, but you don't fit into any of the risk factors. Me: I had bleomycin as part of my chemotherapy regiment for testicular cancer 20 years ago.  Pulmonologist: Oh. Yeah. Oh.  This is the crux of long-term survivorship: We look OK on the outside, but inside our body systems deteriorate faster than the noncancer population.2 For pediatric cancer and adolescents and young adult cancer survivors who could potentially have decades of life ahead of them, these late and long-term side effects are a perpetual consequence for surviving cancer. There is no light at the end of tunnel for us; the tunnel extends endlessly, and we grasp for any daylight we can to help us navigate the darkness moving forward. While there have been multiple studies addressing the long-term toxicity sequelae of cancer therapy, there is still inadequate understanding of optimal screening, risk reduction, and management and inadequate awareness of potential late effects among both medical professionals and survivors alike.3 Given the complexity of long-term toxicities for long-term survivors, a multidisciplinary team of health professionals can provide a comprehensive approach to patient care. For me, a key member of this team was the cardiac advanced practice nurse, who called me at 4:45 pm on a Friday afternoon to tell me that my cardiac evaluation was normal. Physical therapists do this by addressing fatigue, balance deficits, and functional decline through our multitude of rehabilitation tools. Cardiologists, pulmonologists, primary care physicians, dietitians, and mental health care workers can all meaningfully contribute to the well-being and long-term care of cancer survivors. The many health care providers in the lives of cancer survivors can also empower through education. However, the education pathway ends up being a two-way street, as so often it is the survivor who has to educate the nononcology provider about our internal physiological needs that belie our external appearance.  As for me, I am trying out new inhalers to help with my breathing. I take a low-dose statin every morning with breakfast. I am now plugged into annual cardiac follow-ups. I do not run anymore, though, as the psychological toll of not being what I once was has affected me more than the physical toll. I march on, trying to be the best husband, father, physical therapist, and cancer survivorship advocate that I can be.  While we may be living clinically with no evidence of disease, we live with the evidence of the history of our disease every day. Like petrified trees or fossilized shells, cancer treatments leave permanent physical and psychological reminders of our cancer experience. As greater attention is being focused on the optimized management of long-term toxicities in cancer survivorship, my sincere hope is that there will be effort to educate cancer and noncancer medical staff alike about the real physical and psychosocial adverse effects as well as advances in treatment that will both prevent development of long-term toxicity and yield better solutions for when they do occur. I hope better options will be available to all cancer survivors with all stages and all disease types in the not-so-distant future. I am OK, really, but I am not sure ‘otherwise healthy' really applies to me. Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira, Professor of Medicine at Stanford University. Today we're joined by Scott Capozza, Board Certified Oncology Physical Therapist at Smilow Cancer Hospital at the Yale Cancer Center. In this episode, we will be discussing his Art of Oncology article, “Patient is Otherwise Healthy.”   At the time of this recording, our guest has no disclosures.   Scott, welcome to our podcast and thank you for joining us. Scott Capozza: Thank you very much for having me. This is a great honor. Dr. Lidia Schapira: I look forward to chatting with you about this. First of all, what a great title. How did the title and the idea of sharing your experience with this audience, the readers of JCO OP and JCO publications, come to you? Tell us a little bit about the motivation and the inspiration. Scott Capozza: So the title actually came from my doctor's note, as I alluded to in the article, the Pandora's Box, so to speak, of patient access to medical records. I was reading his assessment of my regular wellness visit. And in that visit, I had discussed that I was having some breathing issues and some endurance issues with running, and I just didn't feel myself. And I knew that I hadn't had any significant cardio or pulmonary workups anytime recently. On top of that, we'd already discussed some of my other comorbidities, like my blood pressure, that sort of thing. So his intro line was “Patient is a 42-year-old otherwise healthy male.” Well, that's what caught my eye. I said, “Am I really otherwise healthy? I've got high cholesterol. I have this history of cancer. I am dealing with all kinds of late effects, and we're working those late effects up. And so am I truly otherwise healthy?” And I love my PCP, and he listens to me. And so I'm grateful for him and for him taking me seriously, because not everybody has that. Not every survivor has that person, that quarterback, so to speak.   So that was really what kind of drove me to write the article. It was just an idea that it was in my head. I did not write the article right away. I'm now 48. So this was actually even a couple of years ago. But I think I wrote it because I really was writing it more for the non oncology provider, for the PCPs, and for the pulmonologists and the cardiologists who don't work in the oncology space like you and I do, to be cognizant of these late effects. And just because somebody is a year out from treatment, five years out from treatment, or in my case, 20 years out from treatment, that these late effects are real and they can play havoc with our quality of life. Dr. Lidia Schapira: So let me talk a little bit about nomenclature and the semantics. You know this field very well, and you know that not every person with a history of cancer identifies as a survivor. But the term is really helpful for us. And in the original article that Fitzhugh Mullan wrote in New England Journal called the “Seasons of Survival,” he reflected as a physician with cancer that you go through different periods in your survivorship, journey or life. Can you tell us a little bit about that and what it's been for you? When did you feel that you were a cancer survivor? Do you use the term and what have those seasons or those stages felt like for you? Scott Capozza: That's a great question. And for my old patients, I have this conversation with them as well. For me specifically, yes, I do identify as a cancer survivor. I will say, though, that when I was going through my treatments, I did not identify with that word. I also think that because I was young, I was 22, 23 at the time of my diagnosis, and I did not want any association with cancer, that I really did not want that label attached to me. At that time, I was a physical therapy student and a runner. Full disclosure, I'm a Boston Red Sox fan. You can hold that against me if you want. So I didn't want this extra label, so I didn't want it anyway in the first place. I do, I remember having a conversation with my nurses, and they said, “Oh, you should go to this walk or whatever that was happening for cancer survivors.” And I said, “But I'm in the middle of chemo. I've still got my port. And I don't think I should go because I'm not done with treatment.” And so that's why I think it's great that we have, the American Cancer Society and NCI have come out with very clear definitions that say that a person is a cancer survivor from the mode of diagnosis, and I use that for my own patients as well, because they have that same question. They ask me, “Am I really a survivor? Am I really done?” That sort of thing. And I say, no, I go by those definitions now. And so I always frame it as, you have to survive the words “You have cancer.” So that's me with the relationship with the term survivor.   To your other point of the question, as far as the seasons of survivorship. Absolutely. And I think that we see this more prevalently with our younger population, with our pediatric survivors, and for me, as an adolescent, young adult survivor, an AYA. So I have gone through these seasons of survivorship. When I was diagnosed, I was young and I was single and I was finishing school. That's one thing. I was not dating anybody. So when I did just start to date somebody and move towards marriage and that sort of thing, and all of a sudden, now my fertility issues, because of my treatments, now that came to the forefront. So that became a new season, so to speak. How are we going to tackle that? And now as a father, that's a different season because I have three children, two boys, and it's on my mind that they have my genetic makeup. So are they at higher risk of developing testicular cancer because of me? So I'm in a different season now than I was when I was single and 25.  Dr. Lidia Schapira: And so you also talk about having cisplatin induced ototoxicity. And now this latest problem, which is the bleomycin induced lung problem. That is what sort of unraveled this new season of trying to put these pieces together. How have you thought about this and perhaps shared it with your wife and your family? This idea that the exposures you had to toxic drugs which cured you and gave you this fortunate possibility of being a long term survivor keep on giving, that they keep on manifesting themselves. And fortunately, you have, it seems, a very receptive primary care doctor who listens but may not be particularly able to guide you through all this and may not know. So he's sort of taking his cues from you. How do you negotiate all this? The idea that there may still be something that's going to happen to you as a result of these exposures? Scott Capozza: Being vigilant, I think, is really important. And I think open lines of communication with my providers, open lines of communication with my wife. And also, again, my children are at this point now where I can have those conversations with them. I don't think that I could have done that when they were younger, but now I think they can start to understand why daddy wears hearing aids now is because daddy had to get a certain medicine to help get him healthy, to help get rid of the cancer. So to frame it in that context, I think it makes it easier for them to understand why I have this cytotoxicity from cisplatin. And they even know now with my pulmonary issues that daddy can't necessarily run with them. That was always going to be a goal. I was going to be able to run with my children, and I can't do that. I am still able to bike. It does not stress my pulmonary system as much as running does. So we are able to cycle as a family, and so we are able to do that.  But as far as other late effects that might show up another five years or 10 years from now, those are things that I will continue to have those conversations with my PCP to say, do we need to continue to do cardiac screening every so often? Do we need to continue to do pulmonary screenings, blood work, that sort of thing? I also know that I am very fortunate that I work in the field, so I am surrounded by it, which sometimes is good and sometimes can be a little discerning, knowing what's out there also. So it is an interesting balance to be able to wear both of those hats at the same time. Dr. Lidia Schapira: I have a couple questions that arose to me reading your essay. Now, I am an oncologist, so I know you know about these late effects. One of your lines is, this is the crux of long term survivorship that is appearing healthy, being labeled as otherwise healthy, but really having these exposures that predispose you to getting other illnesses and diagnoses. Do you think it would help if your PCP and pulmonologist wrote that you had an exposure to bleomycin in requesting the PFTs? Instead of just saying 42-year-old with such a symptom, 42-year-old with an exposure to bleomycin and dyspnea. Do you think that writing that in your chart, instead of just saying ‘otherwise healthy', just putting cancer survivor, testicular cancer survivor, and adding the exposures every time they require a test, could that in any way have made your life easier as you reflect back on the last few years?  Scott Capozza: That's a really interesting question. I never thought of that before, and I think that could go one of two ways. A, it could be validating, but I could see the flip side of that where it's, you're constantly reminded of it. So I don't know that there's a perfect answer to that. I don't know what I would prefer, honestly. If we could hop back in time and change the documentation, then we make an addendum to the documentation. I don't know that I would really want that because obviously I know it. But do I want to continue to see that every time I open up my chart? I don't know. And I can see how it can be frustrating for my patients that when they get through my chart notifications or whatever it might be, that they're constantly reminded by it, and then that can lead to fear of occurrence, and that can lead to anxiety and depression. And all the things that you and I know, being providers in the oncology space, we know that these are all things also that our patients experience. So I don't know. I'll have to think about that a little more. Dr. Lidia Schapira: Maybe the next essay you send to us is about shared decision making, even, and how this is used, playing it forward a little bit in the cancer record, it's there and prominent. But in your primary care and other records, how important is that as a qualifier? All of these things are really interesting, and I wonder how you have used your personal experience in treating other patients and whether or not you disclose to your own patients that you are a cancer survivor.  Scott Capozza: I don't lead with it because it's not my story. It's their story. It's their experience. So I never lead with it. I do think that patients are savvy. They do want to know who's on their care team. So I tell this story often that I was working with a young woman with breast cancer. She was still in the middle of treatment. She was very understandably upset. And I was about to say something along those lines of, “I can appreciate what you're going through, because I went through this, too.” And she said, “I know who you are. I looked you up.” Dr. Lidia Schapira: Wow.  Scott Capozza: Yes. But she followed that up with saying, “And because I looked you up and because you're a survivor, that's why I want you working with me.” So again, it goes both ways. So in that instance, it did, it did work out. So, no, I never lead with it. I think patients a lot of times just figure it out on their own. If I'm working with a patient and we've been working together for a while, we might have that conversation, then it might come up. But again, it's about our patients. It's about making sure that they have the highest quality care. And so that's why they're at the center of everything that we do. So, no, I don't lead with it. Dr. Lidia Schapira: So as we wrap up, I have two questions. One is, did you share your essay with your primary care doctor? Scott Capozza: I have not yet. I have not actually seen him since it was published. My annual physical is coming up later in the summer. I was thinking that I would bring it to him to see what his reaction would be. Dr. Lidia Schapira: That sounds cool. Will you let me know what he says or she says? And the other question is, since you did decide to put your story in front of an audience of oncology professionals, what is your message to them? Scott Capozza: I think the message, again, is to listen to your patients. And again, you alluded to it a moment ago, the shared decision making, I think that's so critical. I think that's where we are now, and that's where we need to continue to move as a profession, not just in oncology, but I mean, across all health domains. And so I think that for oncology providers specifically, listen to our patients and to validate those concerns, to educate and then do something about it also, I think, is really critical. Dr. Lidia Schapira: And involving other members of the multidisciplinary team is key. I mean, we acknowledge we need that during treatment, but I think post-treatment, it's equally important to refer people to think about it, to think about referring for rehabilitation or prehabilitation in certain cases. To minimize the baggage that people carry into survivorship.  Scott, thank you. Thank you for writing. I wish you good health, and I thank you very much for sending us your story.   So until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all of ASCO podcast shows asco.org/podcast.    The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Like, share and subscribe so you never miss an episode and leave a rating or review.  Guest Bio:  Dr. Scott Capozza is a Board Certified Oncology Physical Therapist at Smilow Cancer Hospital at the Yale Cancer Center.

Date: 4/9/24Name of podcast: Dr. PatientEpisode title and number: 14 Slavery and Modern HealthcareEpisode summary: Many of the health inequities that we see in healthcare today stem from beliefs held in the time of slavery that have led to "myths" about black bodies and black health. Compounded by historical policy making related to socioeconomics, red lining, civil rights and more, people of color in the US are still facing inequity in healthcare today, from access to treatment to outcomes. Linda Villarosa is  an author on race and health in America, professor and journalist in residence at The City College of New York, contributing writer to the NY Times and a contributor to the 1619 project.Guest(s): Linda VillarosaKey Terms:11:12 – Drapetomania11:32 – Spirometer23:04 – Momnibus billReferences: 03:29 – Black women in the US have a higher death rate in pregnancy than white women with the same socioeconomic status03:39 – Big review article showing how black patients receive pain meds less often 03:45 – Study from University of Virginia 2016 medical students beliefs about black body myths04:04 – Race correction on PFTs (pulmonary function tests)05:51 – A black woman with a PhD is more likely to die in childbirth than a white woman with a high school degree07:51 – The history of Dr. J Marion Sims09:23 – Statue of Dr. J Marion Sims  taken down in NYC09:39 – Anarcha, Lucy, and Betsey (The Mothers of Gynecology) art installation in Montgomery, AL09:47 – Say Anarcha book10:20 – Dr. Cartwright12:32 – (Lack of) science behind the spirometer race correction15:07 – Weathering book21:23 – CA maternal death rates23:41 – Dr. Mary Bassett, NY Health Commissioner, requires anti-bias training26:03 – “Lightly Black and Green” movement at HBCUs

Welcome to this special medical review episode of Everyday Oral Surgery. Today, we are joined once again by the Oral and Maxillofacial Surgeon, Dr. Andrew Jenzer, DDS. Dr. Jenzer is here to walk us through all things related to pulmonary physiology and pathology, and the various methods of management and care. We begin with the basics of pulmonary problems that may arise in patients before moving on to a detailed discussion about the relationship between applied physiology, oxygen, and math. Then, we dive into the world of PFTs, explore common pulmonary disease states, and our guest details what every medical professional needs to know about pulmonary embolisms. Be sure to take notes for this one!Key Points From This Episode:For this special medicine review, we welcome Dr. Andrew Jenzer, DDS back to the show. The basics of pulmonary issues that may arise in patients. A detailed discussion on applied physiology, oxygen, and math. Recommendations for the amount of oxygen that should be delivered via nasal cannula.  Pulmonary function tests; the ins and outs of PFTs.  Exploring common pulmonary disease states, starting with asthma. Defining and treating bronchospasms and laryngospasms. Chronic obstructive pulmonary disease – what it is and how to handle it. What all medical professionals need to know about pulmonary embolisms. Links Mentioned in Today's Episode:Dr. Andrew Jenzer — https://surgery.duke.edu/profile/andrew-clark-jenzer Dr. Andrew Jenzer Email — andrew.jenzer@duke.edu KLS Martin — https://www.klsmartin.com/en/   KLS Martin 35% Discount Code — StuckiFavs Everyday Oral Surgery Website — https://www.everydayoralsurgery.com/ Everyday Oral Surgery on Instagram — https://www.instagram.com/everydayoralsurgery/ Everyday Oral Surgery on Facebook — https://www.facebook.com/EverydayOralSurgery/Dr. Grant Stucki Email — grantstucki@gmail.comDr. Grant Stucki Phone — 720-441-6059 

We are excited to bring you a fantastic episode today where we are joined by two guest experts to discuss the recent JAMA Surgery manuscript, “Clinical Implications of Removing Race-Corrected Pulmonary Function Tests for African American Patients Requiring Surgery for … Continue reading →

In this podcast, Dr. Nicole Roeder, a pulmonologist with Ridgeview Specialty Clinics, brings her knowledge and experience to discuss how to properly diagnose and manage asthma and chronic obstructive pulmonary disease (COPD) in patients exhibiting signs and symptoms of these chronic conditions. Enjoy the podcast. Objectives:Upon completion of this podcast, participants should be able to: Identify signs and symptoms of asthma and chronic obstructive pulmonary disease (COPD). Review methods for diagnosing asthma and COPD. Select treatment options for asthma and COPD. This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.  CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org. Click the link below, to complete the activity's evaluation. CME Evaluation (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker's outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. Thank-you for listening to the podcast. SHOW NOTES:   *See the attachment for additional information.  PODCAST OVERVIEW COPD - Major contributor - tobacco use - Environmental exposures - Types (chronic bronchitis, emphysema, mixed) - Symptoms and exam - Exacerbation red flag -  more frequent use of rescue inhaler use, more cough and wheeze - Tests (imaging - CXR, CT, pulmonary function testing, spirometry, BODE screening test, alpha antitrypsin) - Inpatient COPD management - Outpatient COPD management - Prevention (immunizations, vaccines, smoking cessation, daily maintenance medication/compliance) - Severe COPD considerations (lung transplant, endobronchial valves) - Pulmonary Rehab (9-week program, multidisciplinary team, baseline assessment, exercise/education sessions) - Pulmonary Function Testing (PFT) including spirometry, lung volume testing, lung diffusion capacity, and    methachoine challenge testing ASTHMA- Prevalence - Work-up (CXR, PFTs, CT chest, Allergy testing, referral to pulmonary) - Theophylline (bronchodialiator, antiinflammatory) - Differential Dx - consider other conditions if not improvment (CHF, PE, pneumothorax, etc.) - Peak flow testing - Action plans (Green, Yellow, Red) - Treatment - for mild, moderate and severe cases Thanks to Dr. Nicole Roeder for her expert knowledge and contribution to this podcast. Please check out the additional show notes for more information/resources.

Barstool Radio is back and hosted by Kevin Clancy, John Feitelberg, Tom Scibelli, and Pat McAuliffe. Get inside and stir up the Barstool drama every day. Timecodes: 0:00 - Taylor Swift and Travis Kelce are public 18:35 - Rico Bosco gives his thoughts on Taylor at the chiefs game 20:00 - Keegs vs KFC on Taylor Swift/Travis Kelce 37:11 - Gaz and Ben DiGiulio on Viceroy drama 51:00 - PFTs brother vs Dave 52:40 - Pizzafest recap 53:45 - Calls: Taylor Swift/milkshakes being all the boys 56:20 - Defending KFC vs Kelly 57:35 - Calls 1:18:30 - Surviving barstool has already begun 1:35:00 - Marty, Francis, Big Ev and Klemmer come on to prep their competition tomorrow Watch Kirk Minihane Live in Saco this Saturday at 8PM ET. https://barstool.tv/ppv Support our sponsors Stacker2 Energy Buy Stacker2Chew Energy Gummies and B12 Energy Shots at Dollar General, where you can find all your favorite Stacker 2 products, or go to Stacker2.com. HelloFresh Go to https://HelloFresh.com/50barstoolradio and use code 50barstoolradio for 50% off plus 15% off the next 2 months! Check out Barstool Sports for more: http://www.barstoolsports.com Follow Barstool Sports here: Facebook: https://facebook.com/barstoolsports Twitter: https://twitter.com/barstoolsports Instagram: http://instagram.com/barstoolsports #BarstoolRadio #BarstoolSports

Join us as we take a quick trip to the Emerald Isle on the countdown to Dublin. We visited FSM Bray to watch their PFT. We then caught up with Tom and Dena Hogan to discuss Ireland's PFT tour, what we can expect at HYROX Dublin and what their plans are for 23/24. To find a PFT event click here - https://pft.hyrox.com/global To buy BLDR click here - https://bldrinternational.com/en-gb (use code UKHXR at checkout).   Follow our guest on Instagram Dena - @denahogan1 Tom - @hogan.tom FSM Bray - @fsm.bray Find out more about us  by clicking Here Support us on Patreon Here or Buy us a beer if you like what we do  

Pyromusicals are all about the timing of the effects.  If these aren't right, the visual effects don't live in the same world as the music it shares the moment with.  Bo, AJ, and Jamie talk primary product category prefire times (cakes, shells, and single shots) and rap on best practices for getting to know your product PFTs.

Pulmonary hypertension (PH), being a serious complication of systemic sclerosis (SSc), develops late in the course of SSc and carries with it a poor prognosis. With the median survival of about 3 years, new evidence suggests that early diagnosis and treatment can significantly improve survival. Joining us this week is Christopher P Denton PhD FRCP, senior author of “Dynamic Prediction of Pulmonary Hypertension in Systemic Sclerosis Using Landmark Analysis,” published in Arthritis and Rheumatology. Dr. Denton's latest study explores “the prediction of short-term risk for PH using serial pulmonary function tests (PFTs)” 

This week: Blowing a .46 on the breathalyzer is kind of incredible, seeing as you should be unconscious. D saw a lot in his parents' bar. Tom drank a lot in the Marine Corps. Lots of stuff about the Marine Corps this week, actually. Physical fitness tests, running a lot, that kind of stuff. Tom discovered a new species of lizard in Afghanistan, or so he thought. And other stuff, too. Follow us on Instagram/Twitter/Tik Tok Subscribe, like, review, comment, follow, whatever you do on whatever app you get us on. If you haven't heard, videos on YouTube and Spotify. Most importantly, tell your friends about us!

Lung Cancer Histology and Staging*Workup for a nodule that is concerning: **Ensure there is a dedicated CT scan of the chest to evaluate **Try to obtain old imaging; the rate of change is important **Can get PET, but even if a lesion if not FDG-avid, but growing quickly we should consider biopsy anyway**Referral to pulmonary medicine, who can assist with biopsy and also regional lymph node evaluation (important – more below)**PFTs are often ordered because it provides information about lung function in anticipation of possible surgery for treatment Lung Cancer Histology: *Non-small cell lung cancer (NSCLC)**Umbrella term for a variety of cancers**Increased risk in smokers**More common types: ***Adenocarcinoma (~50% of all lung cancers)****Most common overall; cancer of the mucus producing cells****IHC: TTF-1, NapsinA, CK7 positive***Squamous Cell Carcinoma (22.7%)****More often seen in patients with a smoking history ****IHC: p63 positive and cytokeratin pearls***Remaining ~15% are the other types of lung cancer / mixed histologies**Small cell lung cancer (SCLC)***Neuroendocrine tumor with very different pathology***Much more aggressive than NSCLC***Oncologic emergency***IHC: Chromogranin and synaptophysin positive IHC pearls: TTF-1 usually means lung cancer (but can be negative in squamous cell lung cancer). This will be important in the future (we promise :])*Staging for NSCLC:**Nodal evaluation: lymph node evaluation is part of the workup for NSCLC**Single digit = central/mediastinal nodes (higher risk)**Double digit = peripheral/hilar/intrapulmonary lymph nodes (lower risk)**“R” vs. “L” is direction *Pearl: Why is this important? If there is nodal involvement, systemic therapy is going to be necessary *Putting it all together: **T: Tumor size: T1-4**N: Nodal involvement***N0: no nodal involvement ***N1: Nodes closest to the primary tumor (double digits)****Ipsilateral peribronchial, hilar, intrapulmonary ***N2: Further away (single digit)****Ipsilateral mediastinal and/or subcarinal LN***N3: Contralateral any node or supraclavicular LN **M: Metastasis – in lung cancer, patients with certain patterns of metastatic disease are still curable! ***M0: no mets***M1a: Contralateral lobe, pleural effusion or pericardial effusion à these are generally still curable!***M1b: single site of metastatic disease à these are generally still curable!***M1c: multiple sites of metastatic disease à these are generally not curable*Staging for SCLC: **Limited stage - meaning it can fit in “one radiation field”**Extensive stage - does not fit in “one radiation field”*Once lung cancer is diagnosed:**Go to NCCN to learn the flow of ongoing management**Complete staging (if not already done):***CT C/A/P (don't necessarily need if a PET scan is done)***PET Scan***MRI brain à in general this is needed, but there are some exception to this (see NCCN)**Referral to pulmonary for nodal evaluationReferences: NCCN.orghttps://doi-org.proxy.library.vanderbilt.edu/10.1016/j.semcancer.2017.11.019-Article about IHC markers for lung cancer Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

The boys chat through what a PFT (Personal Fitness Test) is and what they have learnt from doing many (painful) sessions. Max explains how mental arithmetic helps him through the workout and attempts to compare the PFT to an exam in spectacular failure.Music Credits:https://uppbeat.io/t/mood-maze/trendsetterLicense code: ZADHRBZF8YOZJDE4

Healthcare costs due to Chronic Obstructive Pulmonary Disease (COPD) is in excess of $32 billion due to high rates of re-hospitalizations and ED visits, complex and inefficient clinical pathways during transitions of care, and intensive resource burden on clinical and administrative staff. The average cost per COPD patient readmission in the U.S. typically falls between $9,000 and $12,000. Unlike other high cost chronic conditions like CHF and diabetes, it seems that many ACOs are not as purposeful in their targeting of COPD as part of their population health playbook. This is a massive unmet need with many COPD patients experiencing fragmented and inconsistent care that drives poor clinical outcomes and high economic burden. Consequently, COPD now represents the 3rd leading cause of death and the 5th most costly chronic disease in the US. What is it about this particular chronic condition that makes it so less prone for population health management with ACOs and other risk-bearing entities?  Why is this chronic disease so universally undiagnosed? How can we implement chronic care management programs that actually make an impact on patient lung health and clinical outcomes? For anyone that wants to know more about “Effective COPD Management to Achieve Value-Based Care Goals”, look no further than this week's episode with Dr. MeiLan Han. She is Professor and Chief of Pulmonary and Critical Care Medicine at the University of Michigan who is widely known for her expertise on Chronic Obstructive Pulmonary Disease. Dr. Han is a leading pulmonologist, researcher, lung health advocate, consultant, and national volunteer spokesperson for the American Lung Association. She is also the author of the new book, “Breathing Lessons: A Doctor's Guide to Lung Health.”   Episode Bookmarks: 01:30 Introduction to Dr. MeiLan Han (pulmonologist, COPD researcher, lung health advocate, author, and speaker) 05:30 Origins in rural, small town America that led to a career in pulmonary medicine and research 07:00 “Many people that have lung damage and don't know it. We don't do a good job of diagnosing lung disease in this country.” 07:30 Only half of the 25-30M Americans with COPD even have a diagnosis! 08:00 Undiagnosed lung disease led to server morbidity and increased mortality during COVID-19 pandemic 08:30 Research continues to be under-funded due to lack of awareness of lung health importance 09:20 11M Americans suffering from long-haul COVID 09:40 Societal threats to lung health (ex: air pollution, hazardous chemicals, plastic microparticles in lungs) 10:00 “The pandemic was a golden opportunity to raise awareness for lung health, but now people are starting not to listen.” 12:00 The impact of race and socioeconomic status on COVID death rates, and overall poor lung health in marginalized communities 13:30 COPD is more common in rural communities where there is less access to care 14:20 Virtual care is not a perfect solution in areas where there is a “digital divide” 16:00 Half of adult Americans have at least one chronic condition and more than two thirds of Medicare patients have two or more. 17:00 Ambulatory Care Sensitive Conditions as an opportunity for ACOs to achieve cost savings 18:30 The challenges of developing and implementing COPD Quality Improvement Measures 19:00 Difficulties in collecting data from spirometry and PFTs in the Electronic Medical Record 20:00 Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations and the difficulties of tracking symptoms and exacerbations 22:00 The lack of reporting requirements on COPD has limited progress of health systems and EHR companies 23:00 The relative ease of collecting Blood Pressure and A1c results and why capturing data related to COPD is so much more difficult 24:45 Diagnosis gaps of COPD in the early stages due to “therapeutic nihilism” 26:15 Lack of spirometry testing possibly due to the ...

Welcome to DipShips, the "Legitimate" Boating Podcast! Every week, Carl, Jordan, PM, and Metty talk all things boating, after giving a rundown of their weeks and telling a few stories. This week, the crew talks about ubering a firepit, the distinct lack of PFTs, Nightmare Floats, and Jordan's Long Con. | If you wanna support us, check us out on Patreon! https://www.patreon.com/m/DipShipsPod | Check out our podbean for more links: https://dipships.podbean.com/ | Have any questions for us, or topics to talk about? Send them to DipShipsPod @ yahoo . com! | Follow us on Twitter: https://twitter.com/DipShipsPod Carl: https://twitter.com/TheCalamityCarl Jordan: https://twitter.com/EXPayline PM: https://twitter.com/GFPPM Metty: https://twitter.com/MettaurMan 

Short episode of some recent acquisitions and classics. Note to listeners: I'm going to start removing some past episodes of PFTS in the coming weeks on Soundcloud and iTunes, so make sure to download anything you've missed before it's gone! Tracklist: Felipe Dulzaides, Lance Ferguson, Sapo, Stone Alliance, Blossom Dearie, Diasonics

Key points: -Ask about common triggers for asthma like smoke or allergens as well as medication adherence -Asthma is a clinical diagnosis but ancillary tests like PFTs may help -Symptom frequency and severity can help you classify the asthma as intermittent versus persistent -Learn about controller/maintenance therapy, including the new SMART therapy -Learn about steroid use for acute exacerbations as well as next line medications like magnesium, ipratropium, and epinephrine Supplemental information: NIH 2020 guideline updates: https://pediatrics.aappublications.org/content/147/6/e2021050286 Peds in review 2019: https://pedsinreview.aappublications.org/content/40/11/549 Asthma control test: https://www.greenhillspeds.com/wp-content/uploads/2015/12/Asthma-Control-Test-4-to-11-years.pdf GINA 2020 Pocket Guide: https://ginasthma.org/wp-content/uploads/2020/04/Main-pocket-guide_2020_04_03-final-wms.pdf NIH Guidelines 2007: https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma JAMA 2021 guideline update summary: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2780356

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Loie Farina (Northwestern University CardioNerds Ambassador), Dr. Josh Cheema, and Dr. Graham Peigh from Northwestern University for drinks along the shores of Lake Michigan at North Avenue Beach. They discuss a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presents with progressive symptoms of heart failure and is found to have a severe, non-ischemic cardiomyopathy. The etiology of her cardiomyopathy is not clear until her untimely death. She is ultimately diagnosed with cardiac AL amyloidosis with isolated vascular involvement a real occam's razor or hickam's dictum conundrum. We discuss the work-up and management of her condition including a detailed discussion of the differential diagnosis, the underlying features of systemic sclerosis with cardiac involvement as well as cardiac amyloidosis, the role of a shock team in managing cardiogenic shock, and how to identify those with advanced or stage D heart failure. Advanced heart failure expert Dr. Yasmin Raza (Northwestern University) provides the ECPR segment.  Episode introduction by CardioNerds Clinical Trialist Dr. Liane Arcinas. Claim free CME just for enjoying this episode!  Disclosures: NoneJump to: Pearls - Notes - References CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Summary - Occam's Razor or Hickam's Dictum? This is a case of a 52-year-old woman with limited cutaneous systemic sclerosis who presented with progressive dyspnea on exertion and weight loss over the course of 1 year. Her initial work-up was notable for abnormal PFTs and finding of interstitial pneumonia on high-resolution CT, an ECG with frequent PVCs and normal voltage, a transthoracic echocardiogram with a mildly reduced ejection fraction of 40%, and a right/left heart catheterization with normal coronary arteries, filling pressures, and cardiac output. Scleroderma-related cardiac involvement is suspected. She is placed on GDMT, but her condition worsens over the next several months, and repeat echocardiogram shows severely reduced biventricular function, reduced LV global longitudinal strain (GLS) with apical preservation of strain, severely reduced mitral annular tissue Doppler velocities, and a normal left ventricular wall thickness. Scleroderma-related cardiac involvement remains highest on the differential, but because of some findings on the echo that are concerning for cardiac amyloidosis, an endomyocardial biopsy was obtained. It showed vascular amyloid deposition without interstitial involvement. The diagnosis of cardiac amyloid was discussed but deemed unlikely due to lack of interstitial involvement. However, a serologic work-up soon revealed a monoclonal serum lambda light chain and a follow-up bone marrow biopsy showed 20% plasma cells. She was discharged with very near-term follow-up in oncology clinic with a presumptive diagnosis of AL amyloidosis, but she unfortunately returned in shock and suffered a cardiac arrest. She initially survived and underwent emergent veno-arterial extracorporeal membrane oxygenation (VA ECMO) cannulation with subsequent left ventricular assist device placement (LVAD). However, she passed away due to post-operative hemorrhage. Autopsy was consistent with a final diagnosis of cardiac AL amyloidosis with isolated vascular involvement.  Case Media - Occam's Razor or Hickam's Dictum? EKG CXR TTE Pathology CMR Episode Teaching -Occam's Razor or Hickam's Dictum? Pearls Scleroderma causes repeated focal ischemia-reperfusion injuries which result in patchy myocardial fibrosis. Cardiac involvement in scleroderma is frequent but often not clinically evident; when symptomatic, it is associated with a poor prognosis.

A little something different this week! I bought a Giogio Moroder record the past weekend in San Diego (with a classic sample) and figured I'd switch things up from the more usual PFTS flavor. Dig in! Tracklist: Giorgio Moroder, Bobby Caldwell, Kraftwerk, Keni Burke, Mtume, Orange Lake Drive, Sade

Dr. Walker, a Pulmonologist and Critical Care specialist at Brigham and Women's Hospital, explains how she diagnoses and manages COPD. They help breakdown a number of topics, including PFTs, severity classification, principles of outpatient and inpatient management, and how to talk about prognosis with your patients.

The crew  comes together buzzling like the bees in the summer to discuss hot topics that only patreon deserves! Harry Potter 20th year anniversary with J.K Rowling, how do we feel about Harry Potter as a whole, farting in jars for PFTs and last but not least hitting your kids. Don't you wish we could all just have a good conversation over a beer or 20? Look no further and grab a seat at the bar as Boogered Up invites you in on conversation about topics every week and crazy stories from past adventures. Where the beer is cold and takes are HOT! New episodes every Monday! Lets get crackin!

Jesse is my only child. He is 33 years old.  He was born May 1988. He was diagnosed at 7 months because of low weight and he had bronchitis.  They discovered the gene in 1989 and told us there would be a cure by the time he was a teenager. He had a feeding tube in middle school.  He had IV a few times in middle school and high school.  He had aspergillus and the mac virus in high school but his PFT's were still good. He went to college and didnt take care of himself (we were never very strict about his regime) and got sicker.  He was on IV's more ofter and his PFTs went down to around 55.Joan Galinken is a CF Mom who lives in New Jersey.  Her son Jesse is 33 years old, married and a new father. It's been a long road of ups and downs like the CF journey always is.  In the height of the pandemic Jesse got his new lungs. Joan talks about the fear of getting transplant in June of 2020, and about the transplant itself.  She would love to connect with other CF Mom's how have kids who received a lung transplant.  You can reach out to her at the email address below.For more information on The Bonnell Foundation find us at https://thebonnellfoundation.org/Vertex Pharma - the science of possibility.  https://www.vrtx.comSponsored by  https://www.fordfund.org/globalcaringmonth  To contact Joan Galinkin:  jgalinkiin@gmail.comThe original music in this podcast is performed by Kevin Allan, who happens to have Cystic Fibrosis.  You can find him on Facebook here: https://www.facebook.com/KevinAllanMusicThis podcast was produced by JAG in Detroit Podcasts. https://jagindetroit.com/

This episode we apply our knowledge of the sections of PFTs to specific respiratory pathophysiologic processes. 

In this episode, we discuss normal respiratory mechanics, indications for PFTs and their main components. Tune in later this week for Part 2 where we will discuss how to interpret them! 

Respiratory diseases remain a significant health issue for firefighters and emergency responders who face increased exposure to gases, chemicals and smoke in the line of duty. Each year, over 250 local firefighters from paid and volunteer departments raise funds and participate in our Fight For Air Climb, racing the steps in full gear to raise critical awareness for occupational exposure and increased risk for lung disease in first responders. Firefighters should go through periodic lung function tests, or pulmonary function tests (PFTs), to ensure they are healthy enough to do their job safely and help identify early warning signs of lung disease. First responders have higher rates of many cancer types, including bladder, brain, colon, leukemia, lymphoma, non-hodgkin lymphoma, lung, kidney, melanoma, multiple myeloma, prostate and testis. The longer you're on the job, the greater your risk. Here to talk more about this today is Dr. Mary Reid, Chief of Cancer Screening, Survivorship and Mentorship at Roswell Park Comprehensive Care Center. To learn ways to keep your lungs protected as a Firefighter or First Responder, visit our resource page here. To read more about Roswell Park Comprehensive Cancer Center's First Responder Lung Cancer Screening program, click here. You can also read a local article about How Firefighters can Reduce their Cancer Risk featuring Lackawanna Fire Department.

Part 1 of the series on asthma deals with the major etiologies of this condition, how they present, and how they are worked up. Listeners may want to check out the episode on PFTs if they haven't already - an understanding of basic PFT parameters will be assumed in this episode.

This is our fourth free lesson covering Spanish for COPD. In this lesson, the doctor explains the pulmonary function tests (PFTs) in Spanish. The post Pulmonary Function Tests in Spanish appeared first on Podcasts by Doc Molly.

Does obesity hypoventilation syndrome (OHS) give you respiratory distress? Are you baffled by bilevel? The wait is over! Learn all the ins and outs about OHS from Dr. Aneesa Das, @AneesaDas,  a sleep specialist and pulmonologist at The Ohio State University! You’ll learn tips and tricks regarding the diagnosis and management of OHS, the important role PCPs can play, and why on earth we’re discussing the didgeridoo! Free CME for this episode at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME! Credits Written and Produced by: Cyrus Askin, MD Infographic: Cyrus Askin, MD Cover Art: Kate Grant MBChb, MRCGP Hosts: Cyrus Askin, MD; Matthew Watto MD, FACP; Paul Williams MD, FACP; Stuart Brigham MD Reviewer: Leah Witt, MD Editor: Matthew Watto, MD (written materials); Clair Morgan of nodderly.com Guest: Aneesa Das, MD Sponsor: The American College of PhysiciansJoin the American College of Physicians today! Post-training physicians can take advantage of a special limited-time $100 dues discount. Visit acponline.org/acp100 and use the code CURBSIDERS. Membership discount is available only until May 31, 2021.  Sponsor: Birch by Helix birchliving.com/curb Birch is giving $200 dollars off ALL mattresses and 2 free eco-rest pillows at birchliving.com/curb   Sponsor: HRSA National Health Service Corps NHSC.HRSA.gov Applications will be accepted through May 6. Visit NHSC.HRSA.gov to learn about eligibility and the application process. CME Partner: VCU Health CEThe Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org.Show Segments Intro, disclaimer, guest bio Guest one-liner Picks of the Week Case from Kashlak Basic risk factors for OHS and red flags That pathophysiologic trifecta Physical Exam & History - OHS Surveys and specific testing Labs and other tests (PFTs, Echo, and more) OSA, OHS, and Central Sleep Apnea Treating OSA: CPAP vs Bilevel The importance of weight loss Keys for inpatient management Perioperative considerations Take-home points Outro

Pulmonary function tests are used all the time in the inpatient and outpatient setting. They can help nail a new diagnosis of COPD, or track pulmonary function in children with cystic fibrosis.  Newer tests can identify neuromuscular respiratory disease before symptoms present, and even help diagnose asthma in a toddler. In this episode, Andrew explains the common (and up-and-coming) PFTs, how they work, and how to interpret them. 

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2020.11.11.378638v1?rss=1 Authors: Ilangumaran Ponmalar, I., Ayappa, K. G., Basu, J. K. Abstract: Developing alternate strategies against pore forming toxin (PFT) mediated bacterial virulence factors require an understanding of the target cellular response to combat rising antimicrobial resistance. Membrane-bound protein complexes involving PFTs, released by virulent bacteria are known to form pores leading to host cell lysis. However, membrane disruption and related lipid mediated active repair processes during attack by PFTs remain largely unexplored. We report counter intuitive and non-monotonic variations in lipid diffusion, measured using confocal fluorescence correlation spectroscopy, due to interplay of lipid ejection and crowding by membrane bound oligomers of a prototypical cholesterol dependent cytolysin, Listeriolysin O (LLO). The observed protein concentration dependent dynamical cross-over is correlated with transitions of LLO oligomeric state populations from rings to arc-like pore complexes, predicted using a proposed two-state free area based diffusion model. At low PFT concentrations, a hitherto unexplored regime of increased lipid diffusivity is attributed to lipid ejection events due to a preponderance of ring-like pore states. At higher protein concentrations where membrane inserted arc-like pores dominate, lipid ejection is less eficient and the ensuing crowding results in a lowering of lipid diffusion. These variations in lipid dynamics are corroborated by macroscopic rheological response measurements of PFT bound vesicles. Our study correlates PFT oligomeric state transitions, membrane remodelling and mechanical property variations, providing unique insights into developing strategies to combat virulent bacterial pathogens responsible for several infectious diseases. Copy rights belong to original authors. Visit the link for more info

Our very first Cribsiders/Curbsiders crossover episode! Learn about cystic fibrosis care across the lifespan. We dive into the diagnosis of CF (don’t lick your patients!), management of pulmonary and extrapulmonary complications, and the future of CF. You’ll also get tips on CF in adolescents and young adults, as well as recognizing undiagnosed CF in older patients. Our guest, Dr. Whittney Warren, is a pulmonary critical care doctor and the medical director of the Adult Cystic Fibrosis clinic in an academic hospital in Texas. Show notes: https:/www.thecribsiders.com/.   Credits Writer, Producer, Infographic, CME Questions: Clara Mao  Cover Art: Christopher Chiu MD Hosts: Justin Berk MD, Christopher Chiu MD, and Matthew Watto MD Editor: Justin Berk MD; Clair Morgan of nodderly.com Guest: Whittney Warren DO    Time Stamps Intro / Disclaimer 0:00 Guest bio 2:25 Guest one-liner, picks of the week 3:15 Explaining CF to patients, life expectancy  7:00 Types of CF mutations and phenotypes 11:50 Presentation of CF in older patients 15:20 Screening and diagnosis 16:40 PFTs and airway clearance 25:20 Nutrition and the “CF diet” 29:10 CF exacerbations and antibiotic selection 32:25 Extrapulmonary manifestations 39:35 Transition of care for CF adolescents (alcohol, exercise, sex) 43:50 CFTR modulator therapy 51:35 Lung transplantation 54:45   Goal Listeners will develop a systematic approach towards long-term management and acute exacerbations of cystic fibrosis.   Learning objectives After listening to this episode listeners will…   Explain the pathophysiology underlying cystic fibrosis. Identify maintenance therapies that optimize pulmonary function and nutritional status in patients with cystic fibrosis. Choose evidence-based practices in the management of cystic fibrosis-associated pulmonary exacerbations. Recognize common extrapulmonary complications of cystic fibrosis in children and adults. Describe available disease-modifying agents in cystic fibrosis care.   Disclosures Dr. Warren reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.    Citation Warren W, Mao C, Watto MF, Chiu C, Berk J. “Cystic Fibrosis Licked-ty Split with Dr. Whittney Warren”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ Original Air Date: July 6, 2020.

This one is so good, we unlocked the vault and brought it back for a replay. In this Season 5 kick-off to 2020, Dos Marcos sit down with Jesse Cole, owner of the Savannah Bananas. He wears a yellow tuxedo. His players dance and go on dates during games. Parking penguins. Grandma beauty pageants. A breakdancing first base coach. It's all part of the Savannah Bananas "Fans First" experience. Jesse shares his family's amazing story and delivers a clear message: if businesses aren't different they won't exist. Get a notepad handy and listen to how Jesse and his wife Emily turned a floundering baseball team into a sold out spectacle. Discover lessons you can apply in your business. And find out how Fans First U is helping businesses deliver remarkable experiences. More highlights include: Listen carefully, respond creatively. Why the Savannah Bananas send fans a playlist to listen to on the way to the ballpark. If you were to charge admission, how would you change the experience? Looking at your customers as fans. We also talk about: Magic Castle Hotel's popsicle hotline. A message from dead Marilyn Monroe. Soapy Joe's Carwash karaoke. PFTs. Incentivizing stories instead of sales. And of course, Maverick! Nationwide Help Center Nationwide has launched a BACK TO BUSINESS HUB packed with useful information for independent retailers. For Dos Marcos listeners seeking expert advice as they navigate the changing environment, we have an email address for you to use: help@nationwidegroup.org. Thank you to our headline sponsor Nationwide Marketing Group. As a member of Nationwide Marketing group, you instantly have access to over 200+ ambitious, entrepreneurial-minded advocates who are dedicated to helping your business thrive. Nationwide serves more than 5,500 independent retail members with tools, resources, training, and technology to help their businesses grow. Also, thanks to our sponsor, PureCare. PureCare designs essential elements necessary to create a healthy sleep environment. PureCare manufactures the official mattress and pillow protectors of both the National Sleep Foundation and the Woman’s Choice Award. Watch the live video of most episodes at Facebook.com/MattressPodcast. Make sure and subscribe to our email for your direct dose of Dos Marcos.

Rob Gronkowski is a Tampa Bay Buc and Leroy Insider called it 2 weeks ago. We talk about the trade, Leroy's retirement and how Hank's feeling after all of this (3:08 - 20:50). Hot Seat/ Cool Throne including every team doing new jerseys (20:50 - 37:49). Trey Wingo joins the show to talk about hosting the draft Thursday night, the logistical nightmare of a remote draft, why Tua is slipping, his Bear escapades, and we give him some tips from classic movies for draft 1 liners (37:49 - 62:24). Segments include This League and our Mt Flushmore of dumbest fears + the debut of PFTs new song "We Interviewed Condoleeza"

In this Season 5 kick-off to 2020, Dos Marcos sit down with Jesse Cole, owner of the Savannah Bananas. He wears a yellow tuxedo. His players dance and go on dates during games. Parking penguins. Grandma beauty pageants. A breakdancing first base coach. It's all part of the Savannah Bananas "Fans First" experience. Jesse shares his family's amazing story and delivers a clear message: if businesses aren't different they won't exist. Get a notepad handy and listen to how Jesse and his wife Emily turned a floundering baseball team into a sold out spectacle. Discover lessons you can apply in your business. And find out how Fans First U is helping businesses deliver remarkable experiences. More highlights include: Listen carefully, respond creatively. Why the Savannah Bananas send fans a playlist to listen to on the way to the ballpark. If you were to charge admission, how would you change the experience? Looking at your customers as fans. We also talk about: Magic Castle Hotel's popsicle hotline. A message from dead Marilyn Monroe. Soapy Joe's Carwash karaoke. PFTs. Incentivizing stories instead of sales. And of course, Maverick! This is a Bonfire Certified episode you don't want to miss. Welcome to 2020! Thank you to our headline sponsor Nationwide Marketing Group. As a member of Nationwide Marketing group, you instantly have access to over 200+ ambitious, entrepreneurial-minded advocates who are dedicated to helping your business thrive. Nationwide serves more than 5,500 independent retail members with tools, resources, training, and technology to help their businesses grow. Also, thanks to our sponsor, PureCare. PureCare designs essential elements necessary to create a healthy sleep environment. PureCare manufactures the official mattress and pillow protectors of both the National Sleep Foundation and the Woman’s Choice Award. Watch the live video of most episodes at Facebook.com/DosMarcosPodcast. Make sure and subscribe to our email to get a direct dose of Dos Marcos.

In this Live Friday CME Series recap, Dr. Todd Holcomb, an Internist and hospitalist with Lakeview Clinic and Ridgeview Medical Center, presents an interesting Internal Medicine case that is sure to scratch some heads, and remind us of the need to go back to the beginning, if it's not making sense after several attempts. Dr. Holcomb is accompanied by cardiologist Dr. Joshua Buckler, with Minneapolis Heart Institute, Dr. Jonathan Larson, family physician at Lakeview Clinic, Dr. Carl Dean, nephrologist with Kidney Specialists of Minnesota, and Dr. David Gross, radiologist with Consulting Radiologists.  So put on your thinking caps, listen closely and ask yourself what you would do as Dr. Holcomb guides us through this interesting case. Enjoy the podcast! OBJECTIVES:    Upon completion of this podcast, participants should be able to: Identify secondary causes of hypertension. Identify when further testing is warranted. Discuss newer treatments available for cholesterol related conditions. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.   CLICK ON THE FOLLOWING LINK FOR YOUR CME CREDIT: CME Evaluation: "2019 Internal Medicine Case Conference" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.   FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: PART 1: Alright, let's break down the first portion of this case discussion. This is a 60 yo male with chest pain for over a year. Intermittent aching and burning in right anterior chest, worse with activity and lately has worsened overall with a stressful job and strong family hx of heart disease. General exam ins unremarkable. ECG normal. HDL is 60 and LDL slightly up at 137. PFTs and CXR are normal.  Stress echo is normal.  Cardiology referral results in a low Ca++ score but some plaque in the LAD. Dr. Buckler, the cardiologist, feels this is ischemic heart disease until proven otherwise. Therefore, a coronary angiogram is necessary. Imaging has its limitations, as do stress tests. When the history still doesn't point in another explicable direction, we must follow the logic and most likely etiology, which is till coronary artery disease and ACS. One of the problems with stress tests in general, is there are limitations inherent. It's hard to miss the big stuff, but the more minor findings can be missed. With a high pretest probability, he could have perhaps gone straight to angio. In this case, though, he was started on a statin and aspirin. Per Dr. Buckler, Imdur could also have been given. Two year later, he comes in with headaches in the same area of the head since his wife recently passed away. He takes Advil for this. BP has been elevated at home. Dr. Jonathan Larson, family physician, questions the type of headache, it's location and possible etiologies. Is the Advil causing rebound headaches or contributing to the headaches? The elevated home blood pressures also need further investigation. His kidney function is temporarily normal. NSAIDs are d/c'd and Lisinopril is started. A month later, the headaches have improved. BP improved, but not tremendously. In addition, his chest pain has gone away. A new antihypertensive, a combo HCTZ/Lisinopril regimen is started. Although Amlodipine would have been a reasonable choice. A year later, he returns with the same chest pain on exertion. Normal ECG. Normal renal function too. He now goes back to a CT angiogram showing multi-vessel disease. Per Dr. Buckler, one of the reasons he has worsened on a statin is that we may have limited understanding of his pathology, or potentially the CTA was not accurate the first time. Virtual FFT now can show the flow and how significant the lesion is, which is an advancement in this technology. Unfortunately, despite aggressive lipid therapy, sometimes people progress. A few days after the CTA, his Creatinine goes up a bit and GFR goes to 43. This is also after years of Lisinopril. Dr. Carl Dean comments on this alteration in renal function. He feels this is not entirely unexpected, but the data doesn't really reflect CIN (contrast induced nephropathy). Yet intuitively and experientially, we sometimes see this. The amount of contrast used is significantly more on a CTA than on an invasive angio. At this point, the ACE inhibitor is held and Amlodipine is started. Renal function now has improved. The angiogram demonstrates significant 3 vessel disease, with good downstream targets. The SYNTAX surgical risk score directs the cardiologist toward CABG instead of PCI. Post angio, he develops some lower extremity edema, and he is discontinues on Amlodipine, resumed on the HCTZ, Lisinopril. The creatinine is now 2.4. Did he receive enough fluids for the angiogram? Or was the few hundred cc's he obtained during the angio okay? Again, hindsight is 20/20, but the data doesn't support a causality for AKI due to CIN, nor is there a true preventable measure, including n-acetylcysteine or bicarbonate. Perhaps, in this case, CIN as a possibility in the past as discussed, that many would not argue with overhydrating. Ultimately it was felt the ACE and contrast contributed to his creatinine elevation. The ACE combo is now stopped and he is started on Hydralazine and Metoprolol. Creatinine improves, and he goes into CABG surgery. He is discharged and he continues on aspirin and Plavix for 3 months, and Carvedilol and Hydralazine. Atorvastatin is increased to 80 mg daily, a more aggressive dose. EF is normal on echo.  Do statins affect kidney function positively or negatively? According to Dr. Dean, there is no trial that supports either. His BP starts to increase, and Lisinopril is once again added, along with an increase of creatinine, and the ACE is again d/c'd. HCTZ was added. Then spironolactone for ongoing HTN. He's still running high though. Labetalol is replacing carvedilol now. And the pressure is still running high. What is happening here? What to do next? Do we try Lisinopril again? It is attempted, and he once again fails the creatinine test. It goes up again. PART 2: What we do now for this patient? It seems he can only improve on Lisinopril for blood pressure, but his creatinine continues to go up. According to Dr. Dean, in this patient, Lisinopril may not be a great option going forward, not only due to creatinine increase, but it will not help him in terms of mortality outcome. renal artery stenosis is a concern in this case. Dr. Tara McMichael interjects the question, could a loop diuretic have been tried? With a creatinine of 2.3, a loop diuretic could have been an option, since volume and sodium retention could be contributing to the hypertension. Isosorbide with hydralazine is also an option if more meds were to be added. Per Dr. Buckler, however, a four drug regimen that is poorly controlling blood pressure doesn't necessarily indicate adding a fifth drug. We need to know if there is a secondary cause of HTN. Sometimes, even in the setting of renal artery stenosis, patients still require significant anti-HTN drug regimens. Also, per Dr. Dean, the pretest probability in this type of patient for renal artery disease is high. And will an intervention be desirable if it is found? The ASTRAL trial demonstrated no improvement in outcomes. The CORAL trial was also done and considered to be a negative trial. One of the trial criticisms though was that it didn't include patients with severe enough disease. According to Dr. Dean, refractory hypertension should cause screening for this and an intervention should be done if it is seen.  Our patient has a renal u/s that shows bilateral RAS. Dr. David Gross, radiologist discussed the results of the MRA. The aorta, SMA and celiac trunk show atherosclerosis. The renal arteries are paired bilaterally. They have moderate to high grade narrowing of the arteries. Dr. Buckler asks the question of the safety of gadolinium in renal disease. In the setting of low GFR, in other words, less than 30, the risk for nephrogenic systemic fibrosis exists, although very rare. This is usually fatal, though. Basically, he has 4 out of 4 arteries occluded. Dr. Dean feels referral to a center of excellence for this unique issue is best for the patient. He undergoes transaortic endarterectomy, as his creatinine is rapidly going up. A significant plaque is resected from the aorta which was extending into the renal arteries. Post-procedure, he is placed on metoprolol, requiring nothing further. Rosuvastatin, Zetia and baby aspirin is started. Basically, unclogging the pipes resulted in a cure. And a while later, he's no longer on any antihypertensives. Blood pressures are great now. LDL now 57 on the new cholesterol meds. Zetia has limited data, but the PcsK9 inhibitor and his LDL is now 1. Dr. Buckler states there is a lot of unknowns about the LDL levels and whether there is a point of diminishing returns, but the science is not there yet. In this case, Dr. Buckler feels that stopping the Zetia and continuing the pcksk9 inhibitor makes sense. PART 3: Renovascular HTN is more commonly found in the setting of acute, severe, refractory, very high blood pressure. Work-up is needed when there is a strong possibility of secondary cause, and in the absence of another secondary cause, like pheochromocytoma or hyperaldosteronism. Also in an acute rise in BP, a young age, elevated Cr after starting an ace inhibitor, etc. Renal asymmetry on imaging and flash pulmonary edema are other clues. If Cr and BP are stable in the setting of stenosis, no intervention is indicated. Testing can potentially worsen function, as can the interventions performed to treat the disease. Who benefits most? People with short term hx of HTN, people who fail optimal medical therapy, not tolerating medical therapy and progressive renal failure. Ultrasound and CTA or MRA are the options for work-up. US is cheaper, but time consuming and operator dependent, with modest sensitivity/specificity. CTA is accurate for atherosclerosis. Highly sensitive and better if GFR below 30. MRA is highly sens/spec. Gadolinium complications can ensue in low GFR situations. Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9) will lower LDL up to 60%. 50% decease in stroke and MI risk. The PCSK9 enzyme binds to liver LDL receptors and thereby increases plasma LDL levels. so inhibiting this enzyme leads to a lower LDL level. These inhibitors also can decrease triglycerides, increase HDL somewhat and decrease the volume of atheroma. Low adverse effects are noted with the med as well. Regarding renovascular HTN, Dr. Dean also reminds us that someone who is significantly older with chronic renal ischemia in the setting of this disease, may not have improvement in renal function even after intervention. Therefore, some of these patients who suddenly reperfuse a chronically ischemic kidney may actually worsen. Renal artery stenosis is also not an absolute contraindication for ACE. Such as in low EF heart failure. If the creatinine markedly rises, it can be discontinued again. Fibromuscular dysplasia patients, unlike atherosclerosis patients, should all receive an intervention. This is more commonly found in younger patients. Dr. Buckler addresses the ease of use and cost of the PCSK9 inhibitors. It turns out the cost is high at this point, up to $14k/year. But coverage has shown promise in FH and refractory high LDL. As it was alluded to by Dr. Holcomb, the patient really doesn't exercise and has a very stressful job, as it turns out. His dies wasn't discussed. Was he managing his risk factors very well? What does that mean nowadays? We have potent medications and skillful intervention options for reacting to this sort of pathology nowadays, but where are we at with prevention? Hopefully a conversation for another day.

Hank lost to Big Cat and PFTs team when they were starting 3 players on the bye and Cooper Kupp had zero points. Embarrassin, we break down where everything went wrong, give our DFS diaries, go through questions from the audience + an interview with Big Cat and PFT  

In this episode, we did the second part of pulmonary physiology for this summer. We covered pulmonary function tests (PFTs/spirometry), obstructive lung disease (asthma, COPD), restrictive lung disease, and more. Enjoy! Welcome to Physiology by Physeo (an InsideTheBoards podcast)! This show brings together some of the best boards-relevant content for physiology and pathophysiology from three innovative platforms: Physeo, InsideTheBoards, and Med School Phys. Having gone through the grind of med school ourselves, we understand the fast-paced lifestyle you're living right now, so our aim is to help the listener learn while on-the-go. By listening to our show, you'll be one step closer to slaying the USMLE. Discounted Physeo Subscription for InsideTheBoards listeners Head over to Physeo's Website and sign up for a subscription. Use the code ITB25 to receive 25% off your subscription. Keep calm and watch Physeo. InsideTheBoards Study Smarter Series for the USMLE Step 1 and COMLEX Level 1 Check out the ITB Study Smarter Series Podcast channel. We're covering high yield practice questions to help you study on the go during your dedicated USMLE Step 1 prep time. Go to bit.ly/ITBpodcasts or just click here to check it out on iTunes.  ITB Audio Qbank and iOS Beta App The ITB iOS app is here. It includes all our podcasts (with exclusive and expanded content), early access to podcasts we'll be releasing in the future, some meditations designed specifically for medical students and intended for use during your dedicated USMLE prep time (gotta keep those stress levels down, right?), plus the beta version of our all audio qbank. There's a sample of high yield audio questions for each version, and of course you can purchase a subscription to help us finish the full scale, Android and iOS app, which will have tons more features. It's not perfect. But it is THE PERFECT companion for studying for the boards on the go. And we're adding content and improving it all the time. Search the App Store for "InsideTheBoards" or click here to download it now.  Android user? Until we release the cross-platform version of the app this summer, you can still subscribe to the podcast version of ITB's All-Audio Qbank by clicking here.  The #listenlearnlive Contest ("We'll Pay For Yours Boards" thanks to Physicianloans.com) We're giving away all kinds of prizes in exchange for your help promoting all of InsideTheBoards' podcasts.   You earn entries by completing certain actions like sharing or reviewing our podcasts. But you probably know that ITB is all about promoting the wellbeing of medical students. So we also want to push the hashtag #listenlearnlive. The "live" part of this represents our interest in not just your scores, but also your lives outside of medicine. Hence, you can also earn entries just for doing healthy things like exercising, walking your dog, spending time with your fam, or listening to music and then snapping a photo, tagging us, and using the hashtag #listenlearnlive in a social media post. It's actually three separate, month-long contests running now through July. The Top Three winners at the end of each month's contest will be placed into a drawing for the Grand Prize: your USMLE Step 1/Step 2 or COMLEX Level 1/Level 2 Registration Fee (thanks to the generosity of Physicianloans.com )That's a prize worth over $600. We're also giving away things like subscriptions to our All-Audio Qbank. Just go to bit.ly/paymyusmle to sign up.  Legal Stuff InsideTheBoards and Physeo are not affiliated with the NBME, USMLE, COMLEX, NBOME or any professional licensing body. InsideTheBoards fully adheres to the policies on irregular conduct outlined by the aforementioned credentialing bodies.  All information, content, and materials published by this podcast are for informational purposes only and are NOT intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified healthcare provider. Please consult your healthcare provider regarding personal medical decisions.

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

SMA News Today’s Director of Multichannel Content, Michael Morale, discusses how SMA and ALS are linked via a central hub molecule crucial to protein development. Also, Community Editor Kevin Schaefer reads from his latest column, in which he shares his experiences with pulmonary function tests (PFTs). Are you interested in understanding gene therapy? ExploreGeneTherapy.com has helpful information about gene therapy, including its history and how it is being investigated for the treatment of genetic diseases. Visit www.exploregenetherapy.com

Take a deep breath and tune in to this week’s episode full of COPD diagnosis and management pearls, with expert Dr. Denitza Blagev, a pulmonologist, intensivist, and Medical Director for Quality, Speciality Care at Intermountain Healthcare in Utah with a particular interest in physician wellness and issues related to women in medicine. We cover: history taking, interpreting PFTs, patient counseling, inhalers and medications, exacerbations, antibiotics, steroids, and who needs BIPAP...so basically everything you ever wanted to know about chronic obstructive pulmonary disease. Take our self assessment here. Sponsored by @nephmadness. Registration opens March 15th at AJKDblog.org Written and produced by: Leah Witt, MD, Cyrus Askin, MD. Edited by Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 NephMadness announcement 01:10 Disclaimer 01:45 Intro 03:50 Guest bio 05:03 One liner; What advice would you give our younger self?; Should I do a fellowship?; Book recommendations 10:30 Picks of the week 15:50 Case of COPD from Kashlak Memorial 16:55 Initial approach to a potential case of COPD 18:34 Misdiagnosis of COPD 20:10 Classic spirometry in COPD and GOLD 0 21:30 Diagnosis of emphysema 23:18 Diagnosis of chronic bronchitis 24:54 Counseling the patient with a new diagnosis of COPD 27:00 Spirometry 28:45 How to read PFTs 33:29 How to order PFTs and get what you want 36:00 Why does pre- and post-bronchodilator response matter? 38:45 Asthma COPD overlap syndrome 40:13 Staging of COPD, does it matter? 42:50 Prognosis in COPD 45:00 Therapies with mortality benefit 48:29 Therapies to improve symptoms and prevent exacerbations 52:00 Azithromycin as chronic therapy 53:00 Counseling patients on therapy 55:00 Short acting inhalers in COPD 56:20 Treatment of COPD exacerbations 59:18 Antibiotics, who needs them in exacerbation 61:52 Nebulized inhaled steroids 63:18 Duration of antibiotics and steroids during an exacerbation 66:30 Who needs BIPAP chronically? 69:22 Who needs BIPAP during an exacerbation? 71:33 How often should PFTs be repeated? 73:00 When should we suspect PE in COPD exacerbation? 74:25 Which labs should be check in the initial COPD workup? 76:46 Take home points Tags: copd, chronic, pulmonary, disease, asthma, emphysema, bronchitis, inhaler, nebulizer, steroids, embolism, exacerbation, bipap, cpap, antibiotics, azithromycin, doxycycline, mortality, oxygen, spirometry, dlco, fev1, fvc, pfts, #nephmadness, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student

Dr. Rafael Perez is a Professor of Medicine on faculty at the University of Louisville and is the Chief of Medicine at the Louisville VA Hospital. In this lecture, Dr. Perez discusses PFTs. His faculty profile can be found here: http://louisville.edu/medicine/departments/medicine/doctors/perez_r