Podcasts about pmid

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

Send a textIn this episode of Journal Club, Ben and Daphna review a non-inferiority trial from the European Journal of Pediatrics exploring surfactant administration thresholds in preterm neonates. The study, conducted in India, compares a 30% versus 40% FiO2 threshold for babies 26-32 weeks gestational age. The hosts break down the counterintuitive findings regarding respiratory support duration in younger subgroups and discuss the broader implications of using rigid FiO2 heuristics versus individualized patient assessment. They also debate how resource availability influences clinical protocols and the potential benefits of "LISA" (Less Invasive Surfactant Administration) for avoiding intubation.----Higher (40%) versus lower (30%) FiO2 threshold for surfactant administration in preterm neonates between 26 and 32 weeks of gestational age: a non-inferiority randomized controlled trial. Haq MI, Datta V, Bandyopadhyay T, Nangia S, Anand P, Murukesan VM.Eur J Pediatr. 2025 Nov 25;184(12):793. doi: 10.1007/s00431-025-06628-1.PMID: 41288797 Clinical Trial.Support the showAs always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below. Enjoy!

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

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

Unlike most of our episodes, this episode isn't filled with practical tips that we want you to implement in your training. Instead, we're taking you into the science and practice of elite runner training. You'll learn about how they structure their training volume and intensity, the crucial training components they don't skip, and more!Thank you to our sponsors:✨ Amazfit: User-friendly simple running watches with advanced features, at an affordable price point. Use link http://bit.ly/4nai73H for 10% off your purchase.✨Wahoo KICKR RUN: A treadmill that feels like running outdoors. Shop here: http://bit.ly/4nai73H and read the full review: https://runtothefinish.com/wahoo-kickr-run-treadmill/✨Probio: NSF-certified, clinically dosed, all-in-one supplement. Use this link for 40% off your order and an additional 10% and free shipping on a subscription.✨Join us on Patreon.com/treadlightlyrunning or subscribe on Apple Podcasts for special subscriber-only content!In this episode, you'll learn:✅ How elite runners find financial support for their training✅ Why elite runners train in groups✅ The crucial training component that elites include (and recreational runners often skip)✅ How many miles/hours per week do elite runners train?✅ Elite runner training intensity and sample workoutsReferences

Fetal Microcephaly has an incidence of 2 to 12 in10,000 births in the USA and can be diagnosed prenatally via ultrasound (in second or early third trimester) or postnatally via measurement of head circumference (HC).  Antepartum, this is a unique diagnosis since we are mainly used to using PERCENTAGES for biometrics and for fetal weight, butmicrocephaly is not diagnosed by HC percentage- but by Standard Deviation (SD). Microcephaly has been linked to developmental delay, seizures, as well as feeding, vision and hearing problems.  Prognosis depends on the severityof the microcephaly and whether it is associated with other anomalies. What SD is diagnostic of microcephaly? What are the potential etiologies? What genetic syndromes are most associated with true microcephaly? Is fetal cranial MRIrecommended? Listen in for details. 1.     Sukenik-Halevy R, Golbary Kinory E, Laron KenetT, Brabbing-Goldstein D, Gilboa Y, Basel-Salmon L, Perlman S. Prenatalgender-customized head circumference nomograms result in reclassification ofmicrocephaly and macrocephaly. AJOG Glob Rep. 2023 Jan 29;3(1):100171. doi:10.1016/j.xagr.2023.100171. PMID: 36864987; PMCID: PMC9972400.2.     SOGC CO (2019) No. 380-Investigation andManagement of Prenatally Identified Microcephaly3.     Fetal Medicine Foundation: Microcephaly; https://fetalmedicine.org/education/fetal-abnormalities/brain/microcephaly

🧭 REBEL Rundown 📌 Key Points 💨 HFNC met criteria for non-inferiority to BPAP for preventing intubation or death within 7 days in four of the five ARF subgroups.🧪 Bayesian dynamic borrowing increased power across subgroups but created variable certainty, especially in smaller groups such as COPD.🫁 The immunocompromised hypoxemia subgroup did not meet non-inferiority, leading to early trial stopping for futility.️ Rescue BPAP use, subgroup-specific exclusion criteria, and non-standardized BPAP delivery are important contextual factors that influence how subgroup results should be interpreted. Click here for Direct Download of the Podcast. 📝 Introduction Bilevel Positive Airway Pressure (BPAP) has long been a foundational modality in the management of acute respiratory failure (ARF), particularly in COPD exacerbations and cardiogenic pulmonary edema, where it can rapidly reduce work of breathing and improve gas exchange. It remains a core tool in our respiratory support arsenal.High-flow nasal cannula (HFNC), however, has expanded what we can offer patients by delivering many of the same physiologic benefits through a far more comfortable interface. With high flows, modest PEEP, and effective dead-space washout, HFNC can improve oxygenation and decrease work of breathing while preserving the ability to talk, cough, eat, and interact with staff and family. This combination of physiologic support and tolerability makes HFNC especially attractive in patients where comfort, anxiety, or cardiovascular stability are key considerations, and in settings where prolonged noninvasive support may be needed. Rather than competing with BPAP, HFNC broadens our options in ARF and allows us to better match the modality to the patient and their underlying disease process.The RENOVATE trial set out to answer a high-impact question across five distinct etiologic groups: Is HFNC non-inferior to BPAP (NIV) for preventing intubation or death in acute respiratory failure? 🧾 Paper Azoulay É, et al. High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA. 2025 PMID: 39657981 🔙Previously Covered On REBEL: HFNC: Part 1 – How It WorksHFNC: Part 2 – Adult and Pediatric IndicationsFLORALI and AVOID TrialFLORALI-2: NIV vs HFNC as Pre-Oxygenation Prior to IntubationThe Pre-AeRATE Trial – HFNC vs NC for RSI ️ What They Did CLINICAL QUESTION Is HFNC non-inferior to BPAP for rate of endotracheal intubation or death at 7 days in patients with acute respiratory failure due to a variety of causes? STUDY DESIGN Multicenter, randomized non-inferiority trial33 Brazilian hospitalsNov 2019 – Nov 2023Adaptive Bayesian hierarchical modeling with dynamic borrowingOpen label, outcome adjudicators blindedPatients were classified into 5 subgroups SUBGROUPS 1. Non-immunocompromised hypoxemiaSpO₂ < 90% on room air orPaO₂ < 60 mm Hg on room air plusIncreased respiratory effort (accessory muscle use, paradoxical breathing, thoracoabdominal asynchrony) orRespiratory rate > 25 breaths/min2. Immunocompromised hypoxemiaDefined as:Use of immunosuppressive drugs for >3 monthsOR high-dose steroids >0.5 mg/kg/dayOR solid organ transplantOR solid tumors or hematologic malignancies (past 5 years)OR HIV with AIDS / primary immunodeficiency3. COPD exacerbation with acidosisHigh clinical suspicion of COPD as primary diagnosisRR >25 with accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchronyABG: pH 454. Acute cardiogenic pulmonary edema (ACPE)Sudden onset dyspnea and rales± S3 heart soundNo evidence of aspiration, infection, or pulmonary fibrosisCXR consistent with pulmonary edema5. Hypoxemic COVID-19 (added June 2023)Added due to deviations between expected and observed outcome proportionsAny patient across the other 4 groups with PCR-confirmed SARS-CoV-2 infection in any of the above groups POPULATION Inclusion Criteria:≥18 yrs with ARF* in one of 5 pre-defined subgroups excluding COPD was defined by the following:Hypoxemia with SpO₂

Contributors: Travis Barlock MD, Ian Gillman PA, Jacob Altholz MD, Jeffrey Olson MS4 In this episode, EM attending Travis Barlock and medical student Jeffrey Olson listen in to the two remaining cases presented from EMM's recent event, Tox Talk 2025.  Talk 1- Methemoglobinemia- Ian Gillman Cyanosis + chocolate-colored blood + normal PaO₂ + pulse ox stuck at ~85% = Methemoglobinemia → Treat with methylene blue The medications that can cause it can be remembered with… Watch out with methylene blue as it can cause serotonin syndrome While treating with methylene blue the pulse ox can drop dramatically but this is not a real drop in oxygenation but rather an effect of how the methylene blue affects the sensor BADNAPS: causes of methemoglobinemia Benzocaine Aniline Dyes Dapsone Nitrites/Nitrates (Found in meds, preservatives, and well water) Antimalarials Pyridium Sulfonamides Talk 2- Intratecal TXA and Hierarchy of Controls for Error Avoidance - Jacob Altholz Hierarchy of Controls in terms of error prevention includes all of the layers of protection which can be categorized as elimination, substitution, engineering controls, administration controls, and PPE References Centers for Disease Control and Prevention. (2022, April 28). Hierarchy of controls. National Institute for Occupational Safety and Health. https://www.cdc.gov/niosh/learning/safetyculturehc/module-3/2.html Pushparajah Mak RS, Liebelt EL. Methylene Blue: An Antidote for Methemoglobinemia and Beyond. Pediatr Emerg Care. 2021 Sep 1;37(9):474-477. doi: 10.1097/PEC.0000000000002526. PMID: 34463662. Produced by Jeffrey Olson, MS4 Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

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

Stress fractures are common injuries in athletes and military recruits, that's' understandable- based on the physical forces placed on the long bones. A stress fracture can be defined as a partial or complete fracture of the bone that is a result from repeated application of stress lower than that required to fracture the bone in a single loading situation. In pregnancy, the body is subjected to various physiological changes that make women more vulnerable. In this pregnancy, we will highlight a REAL patient case which our team cared for on the inpatient service where a simple cough at 34 weeks leads to a painful spontaneous rib fracture! Is there any data published on this? Are serum tests for bone turn-over required as part of this workup? Listen in for clinical pearls!1. 1962: Long A.E.: “Stress fracture of the ribs associated with pregnancy”. Surg. Clin. North Am., 1962, 42, 909.2. 2000: Baitner AC, Bernstein AD, Jazrawi AJ, Della Valle CJ, Jazrawi LM. Spontaneous rib fracture during pregnancy. A case report and review of the literature. Bull Hosp Jt Dis. 2000;59(3):163-5. PMID: 11126720. https://pubmed.ncbi.nlm.nih.gov/11126720/3. 2015: Rib stress fractures in pregnancy: a case report and review of literature. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/file:///C:/Users/hchapa/Downloads/1575956493464-5157163%20(1).pdf4. Zhang Y, Li R, Zhang J, Zhou W, Yu F. Changes in Serum Concentrations of Bone Turnover Markers in Healthy Pregnant Women. International Journal of Clinical Practice. 2023.

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

Hitting the wall is dreaded amongst all marathoners – but it doesn't have to be an inevitable experience. This episode delves into the research and statistics of hitting the wall in the marathon. Then, we provide you with a clear, practical guide of how to train, pace, and fuel so you can avoid hitting the wall.✨Join us on Patreon.com/treadlightlyrunning or subscribe on Apple Podcasts starting in December, when we'll be releasing special subscriber-only content!In this episode, you'll learn:✅ What does hitting the wall feel like?✅ What role does glycogen play in hitting the wall (or avoiding it)?✅ Pacing strategies to avoid hitting the wall✅ Why carb loading matters✅ How training can be protective against hitting the wall✅ Does dehydration cause you to hit the wall?✅ What to do if you hit the wallIf you enjoyed this episode, you may also like:

Is the 25-40g of protein per meal max a thing of the past? In a very recent article that released this month, "The Anabolic Response to Protein Ingestion During Recovery from Exercise Has No Upper Limit in Magnitude and Duration in Vivo in Humans" (PMID: 38118410), we see that a 100g protein intake has a "greater and prolonged anabolic response" than the traditional and previously thought of upper limit of 25g. What does this mean for clients? Listen in as I explain more about the study and its application. Topics discussed:- Protein and Upper Limit to Muscle Gain- Muscle Protein Synthesis- Study Details- Application of The Study- Gut Health Considerations- Reminders---------- ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠My Live Program for Coaches: The Functional Nutrition and Metabolism Specialization ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠www.metabolismschool.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠---------- [Free] Metabolism School 101: The Video Series⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠http://www.metabolismschool.com/metabolism-101⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠----------Subscribe to My Youtube Channel: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://youtube.com/@sammillerscience?si=s1jcR6Im4GDHbw_1⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠----------⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Grab a Copy of My New Book - Metabolism Made Simple⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠---------- Stay Connected: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Instagram: @sammillerscience⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Youtube: SamMillerScience⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Facebook: The Nutrition Coaching Collaborative Community⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠TikTok: @sammillerscience⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠----------“This Podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast and the show notes or the reliance on the information provided is to be done at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment and is for educational purposes only. Always consult your physician before beginning any exercise program and users should not disregard, or delay in obtaining, medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions. By accessing this Podcast, the listener acknowledges that the entire contents and design of this Podcast, are the property of Oracle Athletic Science LLC, or used by Oracle Athletic Science LLC with permission, and are protected under U.S. and international copyright and trademark laws. Except as otherwise provided herein, users of this Podcast may save and use information contained in the Podcast only for personal or other non-commercial, educational purposes. No other use, including, without limitation, reproduction, retransmission or editing, of this Podcast may be made without the prior written permission of Oracle Athletic Science LLC, which may be requested by contacting the Oracle Athletic Science LLC by email at ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠operations⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠@sammillerscience.com⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠. By accessing this Podcast, the listener acknowledges that Oracle Athletic Science LLC makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information featured in this Podcast."

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

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

In this episode of the Epigenetics Podcast, we talked with Peggy Farnham from the Keck School of Medicine at USC about her work on establishing the ChIP Method in mammalian cells. In this episode, we dive into the relationship between transcription factors, chromatin dynamics, and gene expression with Professor Peggy Farnham from the Keck School of Medicine at USC. Professor Farnham shares her profound insights into how her groundbreaking research has reshaped our understanding of gene regulation and its implications in cancer. We explore how she has been a pioneer in mapping the genome-wide landscape of regulatory proteins, illuminating the molecular logic behind transcriptional control and its disruption in cancer biology. The interview starts with her instrumental role in adapting chromatin immunoprecipitation (ChIP) technology from yeast to human cells. Professor Farnham reflects on the technical challenges she faced during this transition, such as the quest for visibility of signals in mammalian systems. Her ability to innovate and troubleshoot challenges led to significant advancements in techniques that allow for the rapid identification of transcription factor binding sites, fundamentally changing the landscape of epigenetic research. As the discussion progresses, we learn about Professor Farnham's active involvement in the ENCODE project, where she contributed to high-resolution mapping of transcription factors and regulatory elements in human cells. She articulates her appreciation for collaborative efforts in science, highlighting how working within a consortium harnesses the collective expertise of diverse research groups. This collaboration not only bolstered the credibility of the data produced but also propelled the field forward in understanding the complexity of gene regulation. Through her participation in various projects, such as the Psyc-ENCODE consortium and the Roadmap Epigenome Mapping Consortium, Professor Farnham shares insights into her investigation of epigenetic variations, particularly in relation to complex disorders like schizophrenia. Her findings underscore the nuances of enhancer variability among individuals and the implications for understanding disease mechanisms, thereby advancing our knowledge of genetic regulation and its contributions to diverse biological outcomes. Moreover, the episode highlights Professor Farnham's reflective understanding of emerging technologies in the field. She discusses the evolution of methods that allow researchers to investigate gene regulation at single-cell resolution, recognizing the significant implications these innovations have for our comprehension of cellular differentiation and the transcriptional landscape. References Weinmann AS, Bartley SM, Zhang T, Zhang MQ, Farnham PJ. Use of chromatin immunoprecipitation to clone novel E2F target promoters. Molecular and Cellular Biology. 2001 Oct;21(20):6820-6832. DOI: 10.1128/mcb.21.20.6820-6832.2001. PMID: 11564866; PMCID: PMC99859. Wells J, Farnham PJ. Characterizing transcription factor binding sites using formaldehyde crosslinking and immunoprecipitation. Methods (San Diego, Calif.). 2002 Jan;26(1):48-56. DOI: 10.1016/s1046-2023(02)00007-5. PMID: 12054904. Rhie SK, Schreiner S, Witt H, et al. Using 3D epigenomic maps of primary olfactory neuronal cells from living individuals to understand gene regulation. Science Advances. 2018 Dec;4(12):eaav8550. DOI: 10.1126/sciadv.aav8550. PMID: 30555922; PMCID: PMC6292713. Tak YG, Hung Y, Yao L, et al. Effects on the transcriptome upon deletion of a distal element cannot be predicted by the size of the H3K27Ac peak in human cells. Nucleic Acids Research. 2016 May;44(9):4123-4133. DOI: 10.1093/nar/gkv1530. PMID: 26743005; PMCID: PMC4872074. Related Episodes The Effect of lncRNAs on Chromatin and Gene Regulation (John Rinn) CpG Islands, DNA Methylation, and Disease (Sir Adrian Bird) The Future of Protein–DNA Mapping (Mitch Guttman) MLL Proteins in Mixed-Lineage Leukemia (Yali Dou) Contact Epigenetics Podcast on Mastodon Epigenetics Podcast on Bluesky Dr. Stefan Dillinger on LinkedIn Active Motif on LinkedIn Active Motif on Bluesky Email: podcast@activemotif.com

Psychogenic nonepileptic seizures (PNES) are common, often misunderstood, and increasingly encountered in pediatric emergency care. These events closely resemble epileptic seizures but arise from abnormal brain network functioning rather than epileptiform activity. In this episode of PEM Currents, we review the epidemiology, pathophysiology, and clinical features of PNES in children and adolescents, with a practical focus on Emergency Department recognition, diagnostic strategy, and management. Particular emphasis is placed on seizure semiology, avoiding iatrogenic harm, communicating the diagnosis compassionately, and understanding how early identification and referral to cognitive behavioral therapy can dramatically improve long-term outcomes. Learning Objectives Identify key epidemiologic trends, risk factors, and semiological features that help differentiate psychogenic nonepileptic seizures from epileptic seizures in pediatric patients presenting to the Emergency Department. Apply an evidence-based Emergency Department approach to the evaluation and initial management of suspected PNES, including strategies to avoid unnecessary escalation of care and medication exposure. Demonstrate effective, patient- and family-centered communication techniques for explaining the diagnosis of PNES and facilitating timely referral to appropriate outpatient therapy. References Sawchuk T, Buchhalter J, Senft B. Psychogenic Nonepileptic Seizures in Children-Prospective Validation of a Clinical Care Pathway & Risk Factors for Treatment Outcome. Epilepsy & Behavior. 2020;105:106971. (PMID: 32126506) Fredwall M, Terry D, Enciso L, et al. Outcomes of Children and Adolescents 1 Year After Being Seen in a Multidisciplinary Psychogenic Nonepileptic Seizures Clinic. Epilepsia. 2021;62(10):2528-2538. (PMID: 34339046) Sawchuk T, Buchhalter J. Psychogenic Nonepileptic Seizures in Children - Psychological Presentation, Treatment, and Short-Term Outcomes. Epilepsy & Behavior. 2015;52(Pt A):49-56. (PMID: 26409129) Labudda K, Frauenheim M, Miller I, et al. Outcome of CBT-based Multimodal Psychotherapy in Patients With Psychogenic Nonepileptic Seizures: A Prospective Naturalistic Study. Epilepsy & Behavior. 2020;106:107029. (PMID: 32213454) Transcript This transcript was generated using Descript automated transcription software and has been reviewed and edited for accuracy by the episode's author. Edits were limited to correcting names, titles, medical terminology, and transcription errors. The content reflects the original spoken audio and was not substantively altered. Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I'm your host, Brad Sobolewski, and today we are talking about psychogenic non-epileptic seizures, or PNES. Now, this is a diagnosis that often creates a lot of uncertainty in the Emergency Department. These episodes can be very scary for families and caregivers and schools. And if we mishandle the diagnosis, it can lead to unnecessary testing, medication exposure, ICU admissions, and long-term harm. This episode's gonna focus on how to recognize PNES in pediatric patients, how we make the diagnosis, what the evidence says about management and outcomes, and how what we do and what we say in the Emergency Department directly affects patients, families, and prognosis. Psychogenic non-epileptic seizures are paroxysmal events that resemble epileptic seizures but occur without epileptiform EEG activity. They're now best understood as a subtype of functional neurological symptom disorder, specifically functional or dissociative seizures. Historically, these events were commonly referred to as pseudo-seizures, and that term still comes up frequently in the ED, in documentation, and sometimes from families themselves. The problem is that pseudo implies false, fake, or voluntary, and that implication is incorrect and harmful. These episodes are real, involuntary, and distressing, even though they're not epileptic. Preferred terminology includes psychogenic non-epileptic seizures, or PNES, functional seizures, or dissociative seizures. And PNES is not a diagnosis of exclusion, and it does not require identification of psychological trauma or psychiatric disease. The diagnosis is based on positive clinical features, ideally supported by video-EEG, and management begins with clear, compassionate communication. The overall incidence of PNES shows a clear increase over time, particularly from the late 1990s through the mid-2010s. This probably reflects improved recognition and access to diagnostic services, though a true increase in occurrence can't be excluded. Comorbidity with epilepsy is really common and clinically important. Fourteen to forty-six percent of pediatric patients with PNES also have epilepsy, which frequently complicates diagnosis and contributes to diagnostic delay. Teenagers account for the highest proportion of patients with PNES, especially 15- to 19-year-olds. Surprisingly, kids under six are about one fourth of all cases, so it's not just teenagers. We often make the diagnosis of PNES in epilepsy monitoring units. So among children undergoing video-EEG, about 15 to 19 percent may ultimately be diagnosed with PNES. And paroxysmal non-epileptic events in tertiary epilepsy monitoring units account for about 15 percent of all monitored patients. Okay, but what is PNES? Well, it's best understood as a disorder of abnormal brain network functioning. It's not structural disease. The core mechanisms at play include altered attention and expectation, impaired integration of motor control and awareness, and dissociation during events. So the patients are not necessarily aware that this is happening. Psychological and psychosocial features are common but not required for diagnosis and may be less prevalent in pediatric populations as compared with adults. So PNES is a brain-based disorder. It's not conscious behavior, it's not malingering, and it's not under voluntary control. Children and adolescents with PNES have much higher rates of psychiatric comorbidities and psychosocial stressors compared to both healthy controls and children with epilepsy alone. Psychiatric disorders are present in about 40 percent of pediatric PNES patients, both before and after the diagnosis. Anxiety is seen in 58 percent, depression in 31 percent, and ADHD in 35 percent. Compared to kids with epilepsy, the risk of psychiatric disorders in PNES is nearly double. Compared to healthy controls, it is up to eight times higher. And there's a distinct somatopsychiatric profile that strongly predicts diagnosis of PNES. This includes multiple medical complaints, psychiatric symptoms, high anxiety sensitivity, and solitary emotional coping. This profile, if you've got all four of them, carries an odds ratio of 15 for PNES. Comorbid epilepsy occurs in 14 to 23 percent of pediatric PNES cases, and it's associated with intellectual disability and prolonged diagnostic delay. And finally, across all demographic strata, anxiety is the most consistent predictor of PNES. Making the diagnosis is really hard. It really depends on a careful history and detailed analysis of the events. There's no single feature that helps us make the diagnosis. So some of the features of the spells or events that have high specificity for PNES include long duration, so typically greater than three minutes, fluctuating or asynchronous limb movements, pelvic thrusting or side-to-side head movements, ictal eye closure, often with resisted eyelid opening, ictal crying or vocalization, recall of ictal events, and rare association with injury. Younger children often present with unresponsiveness. Adolescents more commonly demonstrate prominent motor symptoms. In pediatric cohorts, we most frequently see rhythmic motor activity in about 27 percent, and complex motor movements and dialeptic events in approximately 18 percent each. Features that argue against PNES include sustained cyanosis with hypoxia, true lateral tongue biting, stereotyped events that are identical each time, clear postictal confusion or lethargy, and obviously epileptic EEG changes during the events themselves. Now there are some additional historical and contextual clues that can help us make the diagnosis as well. If the events occur in the presence of others, if they occur during stressful situations, if there are psychosocial stressors or trauma history, a lack of response to antiepileptic drugs, or the absence of postictal confusion, this may suggest PNES. Lower socioeconomic status, Medicaid insurance, homelessness, and substance use are also associated with PNES risk. While some of these features increase suspicion, again, video-EEG remains the diagnostic gold standard. We do not have video-EEG in the ED. But during monitoring, typical events are ideally captured and epileptiform activity is not seen on the EEG recording. Video-EEG is not feasible for every single diagnosis. You can make a probable PNES diagnosis with a very accurate clinical history, a vivid description of the signs and appearance of the events, and reassuring interictal EEG findings. Normal labs and normal imaging do not make the diagnosis. Psychiatric comorbidities are not required. The diagnosis, again, rests on positive clinical features. If the patient can't be placed on video-EEG in a monitoring unit, and if they have an EEG in between events and it's normal, that can be supportive as well. So what if you have a patient with PNES in the Emergency Department? Step one, stabilize airway, breathing, circulation. Take care of the patient in front of you and keep them safe. Use seizure pads and precautions and keep them from falling off the bed or accidentally injuring themselves. A family member or another team member can help with this. Avoid reflexively escalating. If you are witnessing a PNES event in front of you, and if they're protecting their airway, oxygenating, and hemodynamically stable, avoid repeated benzodiazepines. Avoid intubating them unless clearly indicated, and avoid reflexively loading them with antiseizure medications such as levetiracetam or valproic acid. Take a focused history. You've gotta find out if they have a prior epilepsy diagnosis. Have they had EEGs before? What triggered today's event? Do they have a psychiatric history? Does the patient have school stressors or family conflict? And then is there any recent illness or injury? Only order labs and imaging when clinically indicated. EEG is not widely available in the Emergency Department. We definitely shouldn't say things like, “this isn't a real seizure,” or use outdated terms like pseudo-seizure. Don't say it's all psychological, and please do not imply that the patient is faking. If you see a patient and you think it's PNES, you're smart, you're probably right, but don't promise diagnostic certainty at first presentation. Remember, a sizable proportion of these patients actually do have epilepsy, and referring them to neurology and getting definitive testing can really help clarify the diagnosis. Communication errors, especially early on, worsen outcomes. One of the most difficult things is actually explaining what's going on to families and caregivers. So here's a suggestion. You could say something like: “What your child is experiencing looks like a seizure, but it's not caused by abnormal electrical activity in the brain. Instead, it's what we call a functional seizure, where the brain temporarily loses control of movement and awareness. These episodes are real and involuntary. The good news is that this condition is treatable, especially when we address it early.” The core treatment of PNES is CBT-based psychotherapy, or cognitive behavioral therapy. That's the standard of care. Typical treatment involves 12 to 14 sessions focused on identifying triggers, modifying maladaptive cognitions, and building coping strategies. Almost two thirds of patients achieve full remission with treatment. About a quarter achieve partial remission. Combined improvement rates reach up to 90 percent at 12 months. Additional issues that neurologists, psychologists, and psychiatrists often face include safe tapering of antiseizure medications when epilepsy has been excluded, treatment of comorbid anxiety or depression, coordinating care between neurology and mental health professionals, and providing education for schools on event management. Schools often witness these events and call prehospital professionals who want to keep patients safe. Benzodiazepines are sometimes given, exposing patients to additional risk. This requires health system-level and outpatient collaboration. Overall, early diagnosis and treatment of PNES is critical. Connection to counseling within one month of diagnosis is the strongest predictor of remission. PNES duration longer than 12 months before treatment significantly reduces the likelihood of remission. Video-EEG confirmation alone does not predict positive outcomes. Not every patient needs admission to a video-EEG unit. Quality of communication and speed of treatment, especially CBT-based therapy, matter the most. Overall, the prognosis for most patients with PNES is actually quite favorable. There are sustained reductions in events along with improvements in mental health comorbidities. Quality of life and psychosocial functioning improve, and patients use healthcare services less frequently. So here are some take-home points about psychogenic non-epileptic seizures, or PNES. Pseudo-seizure and similar terms are outdated and misleading. Do not use them. PNES are real, involuntary, brain-based events. Diagnosis relies on positive clinical features, what the events look like and when they happen, not normal lab tests or CT scans. Early recognition and diagnosis, and rapid referral to cognitive behavioral therapy, change patients' lives. If you suspect PNES, get neurology and mental health professionals involved as soon as possible. Alright, that's all I've got for this episode. I hope you found it educational. Having seen these events many times over the years, I recognize how scary they can be for families, schools, and our prehospital colleagues. It's up to us to think in advance about how we're going to talk to patients and families and develop strategies to help children who are suffering from PNES events. If you've got feedback about this episode, send it my way. Likewise, like, rate, and review, as my teenagers would say, and share this episode with a colleague if you think it would be beneficial. For PEM Currents: The Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

In this week's nugget, we explore some of the knowns and  unknowns when it comes to eating farmed animals who may carry bacteria known to cause disease in humans. The spotlight is on  helicobacter pylori, campylobacter jejuni, and e.coli. You might think twice about what you store in the freezer or throw on a barbeque. The Ingest podcast:https://www.pcsg.org.uk/podcast/h-pylori/Almagro-Martínez, C., Alenda-Botella, A. & Botella-Juan, L. Systematic review on the zoonotic potential of Helicobacter pylori. Discov Public Health 22, 432 (2025). https://doi.org/10.1186/s12982-025-00834-wQuaglia NC, Dambrosio A. Helicobacter pylori: A foodborne pathogen? World J Gastroenterol. 2018 Aug 21;24(31):3472-3487. doi: 10.3748/wjg.v24.i31.3472. PMID: 30131654; PMCID: PMC6102504.Aziz M, Park DE, Quinlivan V, Dimopoulos EA, Wang Y, Sung EH, Roberts ALS, Nyaboe A, Davis MF, Casey JA, Caballero JD, Nachman KE, Takhar HS, Aanensen DM, Parkhill J, Tartof SY, Liu CM, Price LB, .2025.Zoonotic Escherichia coli and urinary tract infections in Southern California. mBio16:e01428-25.https://doi.org/10.1128/mbio.01428-25https://www.food.gov.uk/news-alerts/news/report-into-the-sources-of-human-campylobacter-infection-published-0Harmful impacts of microplastic pollution on poultry and biodegradation techniques using microorganisms for consumer health protection: A reviewhttps://www.sciencedirect.com/science/article/pii/S0032579124010344?via%3Dihub

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

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

There are more running shoe brands and models than ever - and all the jargon can feel confusing. In this episode, we help you navigate what features of a running shoe actually matter - and what's just good marketing. You'll learn about supershoes vs supertrainers, why heel to toe drop matters, what the different foams do, and more.Thank you to our sponsors:✨ Amazfit: User-friendly simple running watches with advanced features, at an affordable price point. Use link http://bit.ly/4nai73H for 10% off your purchase.✨Title Nine: Comfortable sports bras that actually fit, from a women-owned company. Use code RUNTOTHEFINISH for free shipping at https://runtothefinish.com/title-nine/✨Join us on Patreon.com/treadlightlyrunning or subscribe on Apple Podcasts for special subscriber-only content!In this episode, you'll learn:✅ The difference between carbon and nylon plated shoes✅ Why you shouldn't train in supershoes all the time✅ How to safely introduce carbon plated shoes✅ The pros and cons of high stack height shoes✅ The most important features to consider when buying new running shoes✅ Understanding PEBA, TPU, and EVA foams✅ Do you need a running shoe rotation?If you enjoyed this episode, you may also like:

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

In resuscitative trauma surgery every second counts. Can time and lives be saved by moving interventions closer to the point of injury? In this episode, we discuss a recent journal article on prehospital resuscitative thoracotomy as a treatment for traumatic cardiac arrest. Opening the chest on the street, who should do it, why should we do it, and for whom?• Hosts:  Mr Prashanth Ramaraj. General Surgery trainee, Edinburgh rotation. @LonTraumaSchool Dr Roisin Kelly. Major Trauma Junior Clinical Fellow, Royal London Hospital.  Mr Max Marsden. Resuscitative Major Trauma Fellow, Royal London Hospital. @maxmarsden83 Mr Christopher Aylwin. Consultant Trauma & Vascular Surgeon, Royal London Hospital and Co-Programme Director MSc Trauma Sciences at Queen Mary University of London. @cjaylwin Mr Zane Perkins. Consultant Trauma & UGI Surgeon, Royal London Hospital and Prehospital Surgeon at London's Air Ambulance. @ZBPerkins  • Learning objectives: A)    To be aware of the steps of a resuscitative thoracotomy (RT)B)     To understand the rational for prehospital (PH) trauma interventions.C)     To understand the timelines required to optimise success in PH RT.D)    To be familiar with the training governance for clinicians undertaking PH RT.E)     To recognise that PH RT is predominantly an intervention for cardiac tamponade.F)     To understand the contexts in which PH RT might be successful as a standardised intervention.• References: Perkins ZB, Greenhalgh R, Ter Avest E, Aziz S, Whitehouse A, Read S, Foster L, Chege F, Henry C, Carden R, Kocierz L, Davies G, Hurst T, Lendrum R, Thomas SH, Lockey DJ, Christian MD. Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest. JAMA Surg. 2025 Feb 26;160(4):432–40. doi: 10.1001/jamasurg.2024.7245. PMID: 40009367; PMCID: PMC11866073. https://pubmed.ncbi.nlm.nih.gov/40009367/ ter Avest, E., Kocierz, L., Alvarez, C. et al. Improving decision-making for prehospital Resuscitative Thoracotomy in traumatic cardiac arrest: a data-driven approach. Crit Care 29, 485 (2025). https://doi.org/10.1186/s13054-025-05705-z. https://pubmed.ncbi.nlm.nih.gov/41233917/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listenBehind the Knife Premium:General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-reviewTrauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlasDominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkshipDominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotationVascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-reviewColorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-audio-reviewSurgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-audio-reviewCardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-reviewDownload our App:Apple App Store: https://apps.apple.com/us/app/behind-the-knife/id1672420049Android/Google Play: https://play.google.com/store/apps/details?id=com.btk.app&hl=en_US

Los artículos que se tratan en el episodio de hoy están listados aquí: The neonatal SOFA score in very preterm neonates with early-onset sepsis. Tagerman M, Sahni R, Polin R. Pediatr Res. 2025 Oct 9. doi: 10.1038/s41390-025-04068-z. Online ahead of print.PMID: 41068313Systemic Postnatal Corticosteroids, Bronchopulmonary Dysplasia, and Survival Free of Cerebral Palsy. Doyle LW, Mainzer R, Cheong JLY. JAMA Pediatr. 2025 Jan 1;179(1):65-72.doi: 10.1001/jamapediatrics.2024.4575.PMID: 39556404 Bienvenidos a La Incubadora: una conversación sobre neonatología y medicina basada en evidencia. Nuestros episodios ofrecen la dosis ideal (en mg/kg) de los más recientes avances para el neonato y para las increíbles personas que forman parte de la medicina neonatal.Soy tu host, Maria Flores Cordova, MD.Este podcast está presentado por los médicos neonatólogos Dani de Luis Rosell, Elena Itriago, Carolina Michel y Juliana Castellanos.No dudes en enviarnos preguntas, comentarios o sugerencias a nuestro correo electrónico: nicupodcast@gmail.comSíguenos en nuestras redes:Twitter: @incubadorapodInstagram: @laincubadorapodcastCreado originalmente por Ben Courchia MD y Daphna Yasova Barbeau MD http://www.the-incubator.org  Bienvenidos a La Incubadora: una conversación sobre neonatología y medicina basada en evidencia. Nuestros episodios ofrecen la dosis ideal (en mg/kg) de los más recientes avances para el neonato y para las increíbles personas que forman parte de la medicina neonatal. Soy tu host, Maria Flores Cordova, MD. Este podcast está presentado por los médicos neonatólogos Dani de Luis Rosell, Elena Itriago, Carolina Michel y Juliana Castellanos. No dudes en enviarnos preguntas, comentarios o sugerencias a nuestro correo electrónico: nicupodcast@gmail.comSíguenos en nuestras redes:Twitter: @incubadorapodInstagram: @laincubadorapodcast Creado originalmente por Ben Courchia MD y Daphna Yasova Barbeau MD http://www.the-incubator.org

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

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

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

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

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

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

Picture this: a patient with early-stage breast cancer is sitting in front of you in the clinic. You are about to offer your expert management plan. The age-old question arises—should you really perform a sentinel lymph node biopsy, or could omission actually help this patient more? Today, we're tackling one of the hottest debates in modern breast cancer care.Should we rethink sentinel lymph node biopsy for select patients, and can skipping it actually improve quality of life without sacrificing cancer control? The stakes couldn't be higher—balancing accurate cancer staging and minimizing harm is the name of the game. Together, we're breaking down the latest evidence from the SOUND and INSEMA trials. What do these landmark studies mean for your patients, your practice, and the future of axillary management? Ready for a journal review that might just change your next consult? Hosts:- Rashmi Kumar, MD, PhDResident, University of Michigan General Surgery Residency ProgramTwitter/X: @RashmiJKumar- Melissa Pilewskie, MDAttending Breast Surgical Oncologist, Co-Director of the Weiser Family Center for Breast Cancer, Michigan Medicine Twitter/X: @MPilewskie- Stephanie Downs-Canner, MDAttending Breast Surgical Oncologist & Physician-Scientist, Memorial Sloan Kettering Cancer Center, Program Director of the Breast Surgical Oncology Fellowship Training Program Twitter/X: @SDownsCannerLearning Objectives:- Understand when and for whom it is safe and beneficial to omit sentinel lymph node biopsy (SLNB) in early-stage breast cancer patients.- Identify the risks associated with foregoing SLNB, including loss of nodal staging, and analyze how this impacts treatment selection and prognosis.- Review key findings from the SOUND and INSEMA trials and their influence on axillary management.- Discuss implications for adjuvant therapy, genomic profiling, and multidisciplinary clinical practice.- Recognize which patient populations should still receive SLNB, and the importance of individualized, multidisciplinary decision-making.References:- Gentilini OD, Botteri E, Sangalli C, et al. Sentinel Lymph Node Biopsy vs No Axillary Surgery in Patients With Small Breast Cancer and Negative Results on Ultrasonography of Axillary Lymph Nodes: The SOUND Randomized Clinical Trial. JAMA Oncol. 2023;9(11):1557–1564. doi:10.1001/jamaoncol.2023.3759 https://pubmed.ncbi.nlm.nih.gov/37733364/- Reimer T, Stachs A, Veselinovic K, et al. Axillary surgery in breast cancer – primary results of the INSEMA trial. N Eng J Med. 2024. doi:10.1056/NEJMoa2412063.https://pubmed.ncbi.nlm.nih.gov/39665649/- Sparano JA, Gray RJ, Makower DF, Albain KS, Saphner TJ, Badve SS, Wagner LI, Kaklamani VG, Keane MM, Gomez HL, Reddy PS, Goggins TF, Mayer IA, Toppmeyer DL, Brufsky AM, Goetz MP, Berenberg JL, Mahalcioiu C, Desbiens C, Hayes DF, Dees EC, Geyer CE Jr, Olson JA Jr, Wood WC, Lively T, Paik S, Ellis MJ, Abrams J, Sledge GW Jr. Clinical Outcomes in Early Breast Cancer With a High 21-Gene Recurrence Score of 26 to 100 Assigned to Adjuvant Chemotherapy Plus Endocrine Therapy: A Secondary Analysis of the TAILORx Randomized Clinical Trial. JAMA Oncol. 2020 Mar 1;6(3):367-374. doi: 10.1001/jamaoncol.2019.4794. PMID: 31566680; PMCID: PMC6777230. https://pubmed.ncbi.nlm.nih.gov/31566680/- Slamon DJ, Fasching PA, Hurvitz S, Chia S, Crown J, Martín M, Barrios CH, Bardia A, Im SA, Yardley DA, Untch M, Huang CS, Stroyakovskiy D, Xu B, Moroose RL, Loi S, Visco F, Bee-Munteanu V, Afenjar K, Fresco R, Taran T, Chakravartty A, Zarate JP, Lteif A, Hortobagyi GN. Rationale and trial design of NATALEE: a Phase III trial of adjuvant ribociclib + endocrine therapy versus endocrine therapy alone in patients with HR+/HER2- early breast cancer. Ther Adv Med Oncol. 2023 May 29;15:17588359231178125. doi: 10.1177/17588359231178125. Erratum in: Ther Adv Med Oncol. 2023 Sep 29;15:17588359231201818. doi: 10.1177/17588359231201818. PMID: 37275963; PMCID: PMC10233570. https://pubmed.ncbi.nlm.nih.gov/37275963/Sponsor Disclosure: Visit goremedical.com/btkpod to learn more about GORE® SYNECOR Biomaterial, including supporting references and disclaimers for the presented content. Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available. Rx only Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listenBehind the Knife Premium:General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-reviewTrauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlasDominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkshipDominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotationVascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-reviewColorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-audio-reviewSurgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-audio-reviewCardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-reviewDownload our App:Apple App Store: https://apps.apple.com/us/app/behind-the-knife/id1672420049Android/Google Play: https://play.google.com/store/apps/details?id=com.btk.app&hl=en_US

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

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

Around the start of 2026, a study sparked viral headlines claiming that cheese could reduce dementia risk. But... nutrition science almost never works like this. One study can't "prove" a food is protective or harmful, and viral health claims often miss the most important details of research: how the data was gathered, what was actually measured, what variables were controlled for, and what it means in real life. In this episode, we unpack what the 'viral cheese study' (PMID: 41406402) actually found, what it DOESN'T mean, and why critical thinking around nutrition headlines matters more than ever. We discuss: • Why viral food headlines are so persuasive (and so often misleading) • What the cheese study REALLY reported • The difference between correlation and causation in nutrition research • Why long-term dietary recall data can be unreliable • How bias (including our personal food preferences) shapes interpretation of research • What "show me the data" really means in a world of clickbait science • How to interpret food and brain health studies without falling into extremes We also speak to Emily Sonestedt, research group leader and associate professor at Lund University, and one of the authors of the viral study. "Your Brain On..." is hosted by neurologists, scientists, and public health advocates Drs. Ayesha and Dean Sherzai. SUPPORTED BY: the 2026 NEURO World Retreat. A 5-day journey through science, nature, and community, on the California coastline: https://www.neuroworldretreat.com/  'Your Brain On... Cheese' • SEASON 6 • EPISODE 6 ——— LINKS The study, 'High- and Low-Fat Dairy Consumption and Long-Term Risk of Dementia: Evidence From a 25-Year Prospective Cohort Study': https://pubmed.ncbi.nlm.nih.gov/41406402/  ——— FOLLOW US Join NEURO World: https://neuro.world/ Instagram: https://www.instagram.com/thebraindocs YouTube: https://www.youtube.com/thebraindocs More info and episodes: TheBrainDocs.com/Podcast

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

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

In this Complex Care Journal Club podcast episode, Drs. Reshma Amin and Christopher Baker discuss a clinical practice guideline from the American Thoracic Society on the care of infants and children with tracheostomies. They describe the role of interprofessional and family-centered decision-making, safety- and ethics-driven recommendations, and next steps for implementation across diverse healthcare settings. SPEAKERS Reshma Amin, MD, MSc Staff Respirologist, Director of Sleep Medicine and Long-term Ventilation The Hospital for Sick Children Senior Associate Scientist, SickKids Research Institute Professor, The University of Toronto Christopher D. Baker, MD Director, Ventilation Care Program, Children's Hospital Colorado Professor of Pediatrics - Pulmonary Medicine University of Colorado School of Medicine HOST Kilby Mann, MD Associate ‌Professor Pediatric Rehabilitation Medicine Children's Hospital Colorado DATE Initial publication date: January 13, 2026. JOURNAL CLUB ARTICLE Amin R, Agarwal A, Chiang J, Collaco JM, Cristea AI, Propst EJ, Sobotka SA, Balakrishnan K, Benscoter D, Brenner MJ, Castro-Codesal ML, Cuevas Guaman M, Daines CL, Dawson JA, Edwards JD, Graham RJ, Henningfeld JK, Hoekstra NE, Jackson AJ, Johnson RF, Kam K, Kun SS, Napolitano N, Pacheco A, Panitch HB, Prager JD, Shi JY, Soma M, St-Laurent A, Syed F, Watters KF, Zielinski D, Ho ATN, Velagapudi RK, Zeba F, Knight SL, Iyer N, Baker CD. Care of Infants and Children with Tracheostomies: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2025 Nov;211(11):2001-2020. doi: 10.1164/rccm.202508-2055ST. PMID: 41123183; PMCID: PMC12618984. OTHER ARTICLES REFERENCED Sherman JM, Davis S, Albamonte-Petrick S, Chatburn RL, Fitton C, Green C, Johnston J, Lyrene RK, Myer C 3rd, Othersen HB, Wood R, Zach M, Zander J, Zinman R. Care of the child with a chronic tracheostomy. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 2000 Jan;161(1):297-308. doi: 10.1164/ajrccm.161.1.ats1-00. PMID: 10619835. ‌ Sterni LM, Collaco JM, Baker CD, Carroll JL, Sharma GD, Brozek JL, Finder JD, Ackerman VL, Arens R, Boroughs DS, Carter J, Daigle KL, Dougherty J, Gozal D, Kevill K, Kravitz RM, Kriseman T, MacLusky I, Rivera-Spoljaric K, Tori AJ, Ferkol T, Halbower AC; ATS Pediatric Chronic Home Ventilation Workgroup. An Official American Thoracic Society Clinical Practice Guideline: Pediatric Chronic Home Invasive Ventilation. Am J Respir Crit Care Med. 2016 Apr 15;193(8):e16-35. doi: 10.1164/rccm.201602-0276ST. PMID: 27082538; PMCID: PMC5439679. ‌ TRANSCRIPT https://cdn.bfldr.com/D6LGWP8S/as/wkhzg7pznk5cgb23sk9xg7w7/Amin_and_Baker_Final_transcript_1-9-26_kh_ra_Baker Clinicians across healthcare professions, advocates, researchers, and patients/families are all encouraged to engage and provide feedback! You can recommend an article for discussion using this form: https://forms.gle/Bdxb86Sw5qq1uFhW6. Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children's Hospital. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open-access. For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu CITATION Amin R, Baker CD, Mann K. Balancing Safety, Practicality, and Equity in Pediatric Tracheostomy Guidelines. 1/2026. OPENPediatrics. Online Podcast. https://soundcloud.com/openpediatrics/balancing-safety-practicality-and-equity-in-pediatric-tracheostomy-guidelines.

Helllllo Geoffs! This week your fave gruesome twosome are back to discuss the wild story of Karolina Olssen, including a side-quest into the world of tooth worms! We're also talking about New Orleans ‘Casket Girls,' so you're in for a treat! We've got an obituary with a twist, one for a gal with a familiar name and so much more, including, duh, some dumb.ass.criminalllllls! Watch us on YouTube: Youtube.com/@obitchuarypodcast Buy our book: prh.com/obitchuary Come see us live on tour: obitchuarypodcast.com Join our Patreon: Patreon.com/cultliter Follow us on Twitch: https://www.twitch.tv/otwitchuary Follow along online: @obitchuarypod on Twitter & Instagram @obitchuarypodcast on TikTok Check out Spencer's other podcast Cult Liter wherever you're listening! Sources:https://www.fox13news.com/news/florida-man-sets-own-home-fire-after-shooting-toward-neighbors-house-tampa-police-sayGerabek WE. The tooth-worm: historical aspects of a popular medical belief. Clin Oral Investig. 1999 Mar;3(1):1-6. doi: 10.1007/s007840050070. PMID: 10522185.https://en.wikipedia.org/wiki/Karolina_Olssonhttps://www.sindecusemuseum.org/tooth-wormshttps://en.wikipedia.org/wiki/Karolina_Olssonhttps://abc7news.com/post/exclusive-funeral-director-gives-san-jose-man-alexander-pinons-brain-parents-requested-clothing/18277944/https://www.neworleans.com/things-to-do/history/the-casket-girls-of-new-orleans/https://en.wikipedia.org/wiki/Casquette_girlhttps://www.verylocal.com/ursuline-convent-casket-girls/20209/https://www.neworleans.com/things-to-do/history/the-casket-girls-of-new-orleans/https://en.wikipedia.org/wiki/Casquette_girlhttps://www.newspapers.com/search/results/?keyword=casket+girls+https://www.newspapers.com/image/822672357/?match=1&terms=casket%20girls%20https://www.newspapers.com/image/435976310/?article=40c78fc4-853d-4dd3-a414-15313498c6f2&terms=%22new%20years%20eve%22https://www.newspapers.com/image/87342546/?match=1&terms=%22home%20wrecker%20dies%22https://www.cbsnews.com/news/naked-man-arrested-at-planet-fitness-said-he-thought-it-was-a-judgement-free-zone-police-say/ Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

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

🧭 REBEL Rundown 📌 Key Points 💀 Mortality: No statistically significant difference in 28-day mortality between ketamine vs etomidate for intubation in critically ill patients, though there was a ~1% absolute difference favoring ketamine. 📉🫀⚠️ Hemodynamics: Ketamine induction was associated with more cardiovascular collapse, mainly driven by new/increased vasopressor use (dose escalation or addition of a vasoactive agent). 💉⬆️ Click here for Direct Download of the Podcast. 📝 Introduction Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence intubation (RSI) has raged for years with no clear winner. Etomidate has been touted in the past for its rapid onset and minimal intrinsic effects on hemodynamics. However, the drug is well known as a transient adrenal suppressant though the impact of this suppression isn’t clear. Ketamine has risen in recent years as an alternative, due to its perceived hemodynamic stability, analgesic properties and absence of adrenal suppression. Additionally, recent data points towards improved mortality when ketamine was selected over etomidate (Kotani 2023). High quality randomized controlled trials are needed to further elucidate which agent should be selected in critically ill patients. 🧾 Paper Casey JD et al. Ketamine or etomidate for tracheal intubation of critically ill adults. NEJM 2025. PMID: 41369227 🔙Previously Covered On REBEL REBEL EM: The EvK Trial: Ketamine vs Etomidate for Rapid Sequence IntubationREBEL EM: From Debate to Data: Emerging Insights into RSI Induction with Ketamine vs Etomidate ️ What They Did CLINICAL QUESTION In critically ill adults undergoing tracheal intubation, does the use of ketamine instead of etomidate result in improved 28 day mortality? STUDY DESIGN Multicenter, randomized, open-label trial in both emergency departments and ICUs. POPULATION Inclusion Criteria:Critically ill patients > 18 years of age undergoing tracheal intubation with the use of an induction agentExclusion Criteria:Known pregnancyPrisonersPrimary diagnosis of traumaNeed for immediate intubation precluding randomizationClinicians determined that the use of ketamine or etomidate was either necessary or contraindicated INTERVENTION & COMPARATOR Intervention (HFNC Group):Ketamine administered based on a provided nomogram: full dose (2.0 mg/kg), intermediate dose (1.5 mg/kg) or reduced dose (1.0 mg/kg)Comparator (BPAP Group):Etomidate administered based on a provided nomogram: full dose (0.3 mg/kg), intermediate dose (0.25 mg/kg) or reduced dose (0.2 mg/kg) OUTCOMES Primary: In-hospital death from any cause by day 28.Secondary:Cardiovascular collapse during intubation defined as SBP < 65 mm Hg, receipt of new or increased dose of vasopressors or cardiac arrest.Exploratory Procedural:Lowest systolic blood pressureLowest systolic blood pressure below 80 mmHgHighest systolic blood pressure above 180 mmHgLowest oxygen saturationLowest oxygen saturation below 80%Successful first attempt intubationTime from induction to intubationExploratory Clinical:Number of ventilator free daysVasopressor-free daysICU free days Safety: Systolic blood pressure at 24 hours after enrollmentOngoing receipt of vasopressors at 24 hours 📈 Results: 2365 patients were randomizedKetamine: 1176Etomidate: 1189> 99% of patients received the drug they were randomized to receiveNMBA: 69% of patients in both groups received rocuronium~ 95% of patients had video laryngoscopy for the primary intubation attempt 💥 Critical Results 💪 Strengths Multicenter ED + ICU cohort of critically ill patients → improves external validityStrong randomization → balanced baseline characteristicsRight population for the question → appropriately focused on a sick cohort where induction choice matters mostHigh protocol adherence → most patients received the agent they were randomized toExcellent follow-up → minimal loss to follow-up / outcome capture ⚠️ Limitations No blinding → potential performance/resuscitation biasTrauma excluded → limits applicability to peri-intubation trauma careCase-mix skewed toward septic shock → may reduce generalizability to other shock etiologiesPower assumptions → designed to detect a 5% mortality difference (possibly overly ambitious)Equipoise-only enrollment → excluded patients with clear indication/contraindication → selection bias + reduced real-world applicabilityComposite secondary outcome with non-equivalent endpoints (e.g., cardiac arrest vs vasopressor titration)Ketamine dosing by actual body weight (vs ideal) → may have increased dose/exposure in some patients 🗣️ Discussion The increase in cardiovascular collapse seen with ketamine was driven by the “new or increased vasopressor use” piece of the composite outcome not by the more clinically relevant severe hypotension (SBP < 65 mm Hg) or cardiac arrest.The increase in CV collapse is a secondary outcome and hypothesis generating onlyCare beyond induction agent isn’t clearly delineated and may have varied between groupsReasons why there was more CV collapse in the ketamine group:Patients in the etomidate group were more likely to be on pressors or have pressor increases prior to induction agent administrationKetamine has analgesic properties which may affect hemodynamics (etomidate does not have analgesic effects)The standard ketamine dose of 2 mg/kg is higher than the induction dose used by most (1-1.5 mg/kg)Ketamine dosing was based on actual body weight though ideal body weight dosing is more accepted. This may have resulted in unnecessarily large ketamine doses that may have had a greater effect on hemodynamics.This is a study of patients with clinical equipoisePatients who the clinician determined would clearly benefit from one agent or the other or in whom one agent or the other was contraindicated were excluded from the study.This may add a selection bias to the results.Clinicians were not blinded to the induction agent administeredThe absence of blinding can introduce bias.For instance, knowledge of the agent the patient was randomized to may result in different resuscitative treatment prior to intubation.An induction agent nomorgram was provided to allow clinicians to choose their induction dose depending on patient stability.A 5% difference in mortality may be overly ambitious. As Josh Farkas points out in his post on this article, PCI for STEMI only has a 3% absolute difference in mortality versus standard care.The 1% absolute difference in mortality while not statistically significant would be clinically significant if it was real. The study would have to be much larger to show a statistically significant 1% difference.About 2% of patients in each group received additional medications during induction (propofol, benzodiazepines, opiates). It is unclear why these agents were selected in specific cases and how they may have affected the outcomes in question. 📘 Author's Conclusion “Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate.“ 💬 Our Conclusion In this well done RCT, induction with ketamine did not result in a lower 28-day mortality when compared to induction with etomidate in critically ill adults. The secondary outcome of an increase in cardiovascular collapse is interesting and should be studied more in the future. 🚨 Clinical Bottom Line This data should not drive clinicians to abandon the use of ketamine in RSI. To the contrary, the study leaves open the possibility of a clinically meaningful difference in mortality favoring ketamine that may be borne out in a larger study. However, etomidate can be considered as a first-line option for RSI and may be the superior drug in patients at high-risk for cardiovascular decompensation. Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), Frank Lodeserto, MD and Anand Swaminathan, MD (X: @EMSwami) 📚 References Kotani Y et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: a meta-analysis of randomized trials J Crit Care 2023;77:154317. PMID: 37127020 👤Associate Author Anand Swaminathan MD, MPH All Things REBEL EM Meet The Team 🔎 Your Deep-Dive Starts Here The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence ... Resuscitation Read More REBEL Cast Ep120: Etomidate vs Ketamine for RSI in the ED? Background: Standard rapid sequence intubation (RSI) in the emergency department involves administration of ... Procedures and Skills Read More The post The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation appeared first on REBEL EM - Emergency Medicine Blog.

Send us a textIn this Journal Club episode, Ben and Daphna review a salient study from JAMA Network Open examining outcomes of infants born at 21 weeks' gestation at the University of Iowa. They walk through resuscitation practices, early physiologic challenges, survival trends, and short-term developmental outcomes, while placing the data in the broader context of shifting limits of viability. The discussion highlights both cautious optimism and the many unanswered questions that remain as neonatology continues to push the boundaries of what is possible.----Outcomes of Infants Born at 21 Weeks' Gestational Age. Hyland RM, Mat HD, Boly TJ, Thomas BJ, Stanford AH, Harmon HM, Bermick JR, Davila RC, Colaizy TT, Dagle JM, Klein JM, Greiner AL, Bell EF, McNamara PJ; University of Iowa Neonatology Program.JAMA Netw Open. 2025 Dec 1;8(12):e2548211. doi:10.1001/jamanetworkopen.2025.48211.PMID: 41385227 Free PMC article.Support the showAs always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below. Enjoy!

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

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

Hey guys! Happy 2026! I know Dry January is super popular, so I wanted to take today's episode to dive into alcohol and fat loss. We're diving into how and why it affects fat loss, and specifically how it's harder as we age. Research published on PubMed shows that women tend to reach higher blood alcohol levels than men drinking the same amount, partly because they generally have less body water and a smaller volume for alcohol to distribute into (PMID 10890798, PMID 11329488). Research also shows that as we age, total body water and lean body mass decline, so the same amount of alcohol results in higher blood alcohol concentrations in older adults (PMID 837653, PMID 18090653).Join the Shred (starts Jan 12th)Apply for coaching CURED Serenity gummies (code Emma saves 20% through jan)HAPI supplements The EmPowered Community free Facebook group Follow Emma on InstagramFollow Emma on Facebook

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

In mid-December 2025, the FDA approved an at home devicethat aims to treat depression by sending electric current into a part of the brain (the prefrontal cortex) known to regulate mood. This has been available in the UK since 2019 but it is new to the US. The manufacturer has stated that over 55,000 patients have used the device across Europe, the UK, Switzerland, and Hong Kong. How does this work? Is there data to support this new therapy? In this episode, we will summarize three consecutive years of data (2023, 2024,2025) to answer that question. Listen in for details. 1.     Sci Amer: https://www.scientificamerican.com/article/u-s-approves-first-device-to-treat-depression-with-brain-stimulation-at-home/2.     August 12, 2023: Burkhardt, Gerrit et al.Transcranial direct current stimulation as an additional treatment to selectiveserotonin reuptake inhibitors in adults with major depressive disorder inGermany (DepressionDC): a triple-blind, randomised, sham-controlled,multicentre trial The Lancet, Volume 402, Issue 10401, 545 – 5543.     October 21, 2024: Woodham, R.D., Selvaraj, S.,Lajmi, N. et al. Home-based transcranial direct current stimulation treatmentfor major depressive disorder: a fully remote phase 2 randomizedsham-controlled trial. Nat Med 31, 87–95 (2025). https://doi.org/10.1038/s41591-024-4.     December 15, 2025: Moshfeghinia R, Bordbar S,Roointanpour Y, Arab Bafrani M, Shalbafan M. Efficacy and safety of home-basedtranscranial direct current stimulation (tDCS) on patients with depressivedisorders: a systematic review and meta-analysis of randomized clinical trials.Sci Rep. 2025 Dec 15;15(1):43850. doi: 10.1038/s41598-025-28648-5. PMID:41398008; PMCID: PMC12705823.

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

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

Will running in the “grey zone” cause you to flounder - or appropriately dosed amounts let your fitness flourish? This remastered episode, originally from January 2024, provides a nuanced discussion on how moderate intensity running can be beneficial in the correct doses - but why you don't want to train every day in this zone.✨Join us on Patreon.com/treadlightlyrunning or subscribe on Apple Podcasts starting in December, when we'll be releasing special subscriber-only content!In this episode, you'll learn:✅ What is the grey zone in running?✅ The benefits and detriments of running in the grey zone✅ How to use the talk test✅ When to use zone 3 training✅ Should you do all of your long runs at marathon pace?✅ What is polarized training (hard days hard, easy days easy)✅ Marathon pace/zone 3 workouts✅ Zone 2 vs zone running when you are a beginner runnerIf you enjoyed this episode, you may also like

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