Podcasts about sempa

Ayer les mostré un video, que repetiré ahorita, en el que se muestra como una turba intercepta un vehículo del Servicio Nacional de Protección Ambiental, baja al oficial que lo conduce y se apropia del camión. La persona que describe la situación identifica al dueño del camión como Pichón y al jefe de la turba como Maceta. Les dije que desde San Cristóbal me habían dicho que tratara el tema con cuidado porque el poder de este grupo trasciende y que han dado palizas y quemado equipos de personas que no obedecen sus reglas. Por SEntido común pregunté si nadie va a investigar a la camioneta blanca de doble cabina que interceptó el camión, como no hay manera que se investigue las extracciones nocturnas de la cuenca baja del río Nizao en la zona que va desde el puente de Lucas Díaz hasta la desembocadura. Anoche recibí la foto de la persona que in situ estaba dirigiendo la operación identificado como Huáscar. Ese señor dio una prueba de fuerza por encima de un oficial del ejército dominicano y estaba en la esquina dirigiendo al tigueraje como un Jimmy Hoffa cualquiera. Aunque no le conozco tenía noticias del señor Wacar como líder de las extracciones en Mucha Agua de donde fue desplazado y donde se había apropiado de los agregados. Como fue sacado de Mucha agua el señor Huascar se ha trasladado a rio Nizao y no hay manera de que el director del SEMPA se entere. Yo prefiero no creer lo que se dice por Nizao de que el poder Huáscar está respaldado por el propio general que dirige el organismo de protección ambiental, pero por lo menos que haga un allante. Ese allante sería darse cuenta de que los depredadores trabajan de seis de la tarde a cinco de la mañana. Que han hecho zanjas para que solo puedan pasar sus vehículos pesados y que impiden a agricultores llegar  a sus conucos. El director del SEMPA nos puede allantar un poquito e identificar los lugares alquilados para guardar equipos como palas mecanicas y buldozer que no son tan pequeños.  En definitiva yo no le pido al director del SEMPA que sea honesto o que cuide el medio ambiente creo que hay que pedirle que guarde las formas.

https://westminster-institute.org/events/how-to-think-strategically-about-russia-and-china/ Francis P. Sempa is the author of Geopolitics: From the Cold War to the 21st Century; America's Global Role: Essays and Reviews on National Security, Geopolitics, and War; and Somewhere in France, Somewhere in Germany: A Combat Soldier's Journey through the Second World War. He is a contributor to Population Decline and the Remaking of Great Power Politics and The Conduct of American Foreign Policy Debated. He has also written introductions to four books on U.S. foreign policy. His articles and book reviews on historical and foreign policy topics have appeared in Orbis, the University Bookman, Joint Force Quarterly, The Diplomat, American Diplomacy, the Asian Review of Books, Strategic Review, National Review, Presidential Studies Quarterly, Human Rights Review, the Claremont Review of Books, the Washington Times, the South China Morning Post, the International Social Science Review, Caixin Online, Real Clear History, and The American Spectator. He is an Assistant United States Attorney for the Middle District of Pennsylvania, adjunct professor of political science at Wilkes University, and a former contributing editor to American Diplomacy.

V úvodu představuje Paul Brandwagt Richarda a jeho službu. Poselství Richarda z Ugandy spočívá v apelu na každého, kdo se narodil znovu, aby povstal a kázal evangelium.

What if conservatives did the ranking for #CSPAN's top presidents? Listen to @RealClearHistry's Francis P. Sempa's ranking & read his op/ed: https://tinyurl.com/643fkk6h

In this episode I share with you my TOP TIPS for bedside ultrasound (Technically it's 15 tips, but who's counting?) I originally gave this during the virtual SEMPA conference this year (2021). Check it out! Don't forget to check out Courses.coreultrasound.com for all your CME educational needs! If you're interested in an online ultrasound fellowship, check out www.ultrasoundleadershipacademy.com!

In this ultrasound podcast, I will be discussing a few of my favorite cases. This was initially recorded for the SEMPA virtual conference last week, and I'm stoked to share it with you all here. Check it out and let me know what you think! Don't forget to check out Courses.coreultrasound.com for all your CME educational needs! If you're interested in an online ultrasound fellowship, check out www.ultrasoundleadershipacademy.com!

Vous avez développé un produit innovant ou juste une idée audacieuse mais vous manquez d'un cadre pour avancer ? Rejoignez les Trophées Europe 1 et rencontrez des coachs, des investisseurs ou des responsables d'incubateurs qui vous donneront toutes les clés pour réussir. Envoyez-nous votre candidature à E1-lafrancebouge@europe1.fr et vous serez peut-être bientôt sur notre antenne !

In celebration of International Women's Day we've got an extra special episode with a few of the amazing women working at Liberty Music PR. In this episode they discuss their experiences as women in the music industry as well as highlighting ways that men and women alike can help to support, celebrate and champion women both in the workplace and societally. They also discuss current topics and issues surrounding women's rights, and discuss ways that people can move forward and become more progressive, breaking the norm and ending taboos surrounding women and what they do. If you've been affected by anything discussed in this episode, or even just want a chat, feel free to reach out to us at bee@libertymusicpr.com Looking for some ways to support women? - Here are some virtual events you can attend: AHRI's International Women's Day Virtual Event: Explore how creating a truth-telling workplace culture – where everyone is safe to speak up and speak out – can help eliminate sexual harassment. [Free] : https://www.ahri.com.au/international-womens-day/ She-EO's Virtual 2021 Summit: Hear from cutting-edge thinkers, innovators, and women working on the ‘World's To-Do List' on what's next for the economy, education, food security, housing and more. [Free] : https://sheeo.world/sheeo-summit-2021/ Women in Tech's Tech(Know) Day: This online conference will showcase women in tech (cis, trans, non-binary) and their craft, as well as career, personal development, business and strategy insight. [Free] : https://www.techknowday.com/ You can also check out our International Women's Day pieces on our blog: https://www.libertymusicpr.com/blog/ Follow our socials: Instagram : https://www.instagram.com/libertymusicpr/?hl=en Facebook : https://www.facebook.com/libertymusicpr YouTube : https://www.youtube.com/channel/UCQx69bvV15mML8xsdtK-ZKg LinkedIn : https://www.linkedin.com/company/liberty-music-pr

Discussion à deux sur l'état de la situation pour nos dojos avec la crise du COVID-19. On aborde l'évolution du podcast depuis nos débuts, les bons bons et mauvais côtés des réseaux sociaux et du gaming. On vous dévoile également ce qui s'en viens sur PATREON.

Words of wisdom consist of bits of advice extracted from different teachings of His Holiness the Dalai lama. This series covers how to train our ourselves from anger, family life, religion, daily practice, emotions, and understanding once own mind.

Rencontre avec Sempaï Annie Picard, Directrice et Chargée de projet au siège social de la fédération Karaté Sunfuki. On parle de son parcours dans les arts martiaux, marqué par des ennuis de santé.

YourHostRob is joined by Publicist & LinkUpTv Editor, Wardah Sempa to share her thought on public relationships, industry politics and dating on the down low. Follow @wardahsempa @yourhostrob

Rencontre avec Sempaï Jacob Roch, un jeune karatéka de 18 ans originaire de Boisbriands, médaillé de bronze au Irish Open 2020

Rencontre virtuelle avec Sempaï Nathalie Boutin, championne 2020 du Irish Open et pharmacienne propriétaire

Rencontre virtuelle avec Sempaï René Forget, ex-policier, Humoriste et propriétaire des Centres de Karaté Sunfuki de Rosemont et Bois-des-Filion

On discutent de tout et de rien: cinéma, lecture, jeux vidéos, covid-19, politique internationale, éducation. L'enregistrement s'est fait par téléconférence... bonne écoute!

Salut à toi ami(e) internaute. Nous sommes le samedi 21 décembre au moment de cette news et il y 18 ans, je déposais le nom de domaine tmdjc.com. D'abord seul, puis rejoint par Rico, puis Sempaï, Aod, Puce et bien d'autres... Pendant 18 ans j'ai expérimenté l'écrit, l'animation, la vidéo, la musique et bien évidement... le podcast ! Pour fêter ça dignement, je te propose un Informel spécial 18 ans. Pendant une petite heure, je vais te retracer l'histoire du site avec quelques surprises et inédits, puis je vais te laisser la parole pour que tu puisses nous partager ce que tu veux. Je t'invite à venir me rejoindre au coin du feu et à lancer le podcast... Durée : 1:43:40 | Publié le : 21/12/19 | Réalisation : Tmdjc Générique de fin : "Générique (ça ne dure pas)" de l'album "en quelques notes" de Tmdjc Pour les messages d'anniversaire, vous pouvez entendre dans l'ordre d'apparition : l'équipe de Level MAX!!, Yetcha, Bruno et Natacha Rocca, Creepers, Mikadotwix, Neithan, Rock, Ender, David Rampillon, Donax (Crevette), Zéphirin, Anfalmyr, Aod, l'équipe de Beside Games, La 187Team, Mea, Albafika, Legacy, Flashou, Mehdi Deez, Fozzie, Pr0sk_, WellcooK, Izeniel, L'équipe de 3ème Espace, InkS et Fqpeh.

Salut à toi ami(e) internaute. Nous sommes le samedi 21 décembre au moment de cette news et il y 18 ans, je déposais le nom de domaine tmdjc.com. D'abord seul, puis rejoint par Rico, puis Sempaï, Aod, Puce et bien d'autres... Pendant 18 ans j'ai expérimenté l'écrit, l'animation, la vidéo, la musique et bien évidement... le podcast ! Pour fêter ça dignement, je te propose un Informel spécial 18 ans. Pendant une petite heure, je vais te retracer l'histoire du site avec quelques surprises et inédits, puis je vais te laisser la parole pour que tu puisses nous partager ce que tu veux. Je t'invite à venir me rejoindre au coin du feu et à lancer le podcast... Durée : 1:43:40 | Publié le : 21/12/19 | Réalisation : Tmdjc Générique de fin : "Générique (ça ne dure pas)" de l'album "en quelques notes" de Tmdjc Pour les messages d'anniversaire, vous pouvez entendre dans l'ordre d'apparition : l'équipe de Level MAX!!, Yetcha, Bruno et Natacha Rocca, Creepers, Mikadotwix, Neithan, Rock, Ender, David Rampillon, Donax (Crevette), Zéphirin, Anfalmyr, Aod, l'équipe de Beside Games, La 187Team, Mea, Albafika, Legacy, Flashou, Mehdi Deez, Fozie, Pr0sk_, WellcooK, Izeniel, L'équipe de 3ème Espace, InkS et Fqpeh.

Salut à toi ami(e) internaute. Nous sommes le samedi 21 décembre au moment de cette news et il y 18 ans, je déposais le nom de domaine tmdjc.com. D'abord seul, puis rejoint par Rico, puis Sempaï, Aod, Puce et bien d'autres... Pendant 18 ans j'ai expérimenté l'écrit, l'animation, la vidéo, la musique et bien évidement... le podcast ! Pour fêter ça dignement, je te propose un Informel spécial 18 ans. Pendant une petite heure, je vais te retracer l'histoire du site avec quelques surprises et inédits, puis je vais te laisser la parole pour que tu puisses nous partager ce que tu veux. Je t'invite à venir me rejoindre au coin du feu et à lancer le podcast... Durée : 1:43:40 | Publié le : 21/12/19 | Réalisation : Tmdjc Générique de fin : "Générique (ça ne dure pas)" de l'album "en quelques notes" de Tmdjc Pour les messages d'anniversaire, vous pouvez entendre dans l'ordre d'apparition : l'équipe de Level MAX!!, Yetcha, Bruno et Natacha Rocca, Creepers, Mikadotwix, Neithan, Rock, Ender, David Rampillon, Donax (Crevette), Zéphirin, Anfalmyr, Aod, l'équipe de Beside Games, La 187Team, Mea, Albafika, Legacy, Flashou, Mehdi Deez, Fozie, Pr0sk_, Wellcook, Izeniel, L'équipe de 3ème Espace, InkS et Fqpeh.

The host for Yen Sempa on Onua FM, Bright Kwasi Asempa one-on-one interviewed The Secretary, Northern Timber Association, Mr. Daniel A. Agyemang and a member of the association, Isaac K. Narh on the issue today. The interviewees pleaded with the government for it support in fighting against the unnecessary felling of rosewood in the forest.

Drivers unions at the Ho Bus Terminal in the Volta Region are preparing a demonstration come Thursday 13th June 2019 against the District MTTD and a section of the GPRTU over some alleged injustices. Throwing more light on the issue is a Liaison Officer for the transport unions, Efo Koku on Onua FM’s Yen Sempa hosted by Bright Kwasi Asempa.

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections. Try to create a rapport that is comfortable and open for your patient to provide as much detail as they can. Nachi: And as with any infectious work up, tachycardia, hypotension, and fever should all raise the concern for possible sepsis. In your sepsis source differential, definitely consider PID in addition to the usual sources. As a mini plug for a prior issue, PID was actually covered in the December 2016 issue of Emergency Medicine Practice, in detail. Jeff: Getting back to the physical exam: though some question the utility of the pelvic exam as our diagnostics get better, the literature suggests the pelvic definitely still has a big role both in diagnosing and differentiating STDs and other pathology. Don’t skip this step when indicated. Nachi: Now that we have a broad overview, let’s talk about specific STDs, covering diagnosis, testing, and treatment. Jeff: If following along in the article, appendices 1, 2 and 3, list detailed physical exam findings for the STDs were going to discuss, while table 3 lists treatment options. A great resource to use while following along or as a reference during a clinical shift! Nachi: First up, let’s talk chlamydia, the most common bacterial cause of STDs, with 1.7 million reported infections in 2017. Most are asymptomatic, which increases spread, especially in young women. Jeff: Chlamydia trachomatis has a 2-3 day life cycle in which elementary bodies enter endocervical and urethral cells and replicate, eventually causing host cell wall rupture and further spread. Nachi: Though patients with chlamydia are often asymptomatic, cervicitis in women and urethritis in men are the most common presenting symptoms. Vaginal discharge is the most common exam finding followed by cervical ectropion, endocervical mucus, and easily induced bleeding. Other presenting symptoms include urinary frequency, dysuria, PID, or even Fitz-Hugh-Curtis syndrome, which is a PID induced perihepatitis. In men, epididymitis, prostatitis, and proctitis are all possible presenting symptoms also. Jeff: And of note, chlamydia can also cause both conjunctivitis and pharyngitis. Nachi: This article has a ton of helpful images. Check out figures 1 and 2 for some classic findings with chlamydial infections. Jeff: When testing for chlamydia, nucleic acid amplification is the test of choice as it has the highest sensitivity, 92% when tested from a first-catch urine sample vs. 97% from a vaginal sample. While these numbers are similar, and you’re gut may be to forego the pelvic exam, consider the pelvic exam to aid in the diagnosis of PID and to evaluate for cervicovaginal lesions or other concomitant stds. Nachi: Similarly, in men, the test of choice is also a nucleic acid amplification test, with a first catch urine preferred over a urethral swab. Jeff: And lastly, nucleic acid amplification is also the test of choice from rectal and oropharyngeal samples, though you need to check with your lab first as nucleic acid amplification is not technically cleared by the FDA for this indication. Nachi: Treatment for chlamydia is simple, 1g of azithromycin, or doxycycline 100 mg BID x 7 days. Fluoroquinolones are a second line treatment modality. Jeff: In pregnant women, chlamydia can lead to ectopic pregnancy, premature rupture of membranes, and premature delivery. The single 1g azithromycin dose is also safe and effective with amox 500 mg TID x 7 days as a second line. Pregnant women undergoing treatment should have a documented test-of cure 3-4 weeks after treatment. Nachi: Next up, we have gonorrhoeae, the gram-negative diplococci. Gonorrhea is the second most commonly reported STD, affecting 0.8% of women and 0.6% of men, with over 500,000 reported cases in 2017. Jeff: Gonorrhea attaches to epithelial cells, altering the surface structures leading to penetration, proliferation and eventual systemic dissemination. Nachi: Though some may be asymptomatic, women often present with cervicitis, vaginal pruritis, mucopurulent discharge, and a friable cervical mucosa, along with dysuria, frequency, pelvic pain and abnormal vaginal bleeding. Jeff: Men often present with epididymitis, urethritis, along with dysuria and mucopurulent discharge. Proctitis, pharyngitis, and conjunctivitis are all possible complications. Nachi: In it’s disseminated form, gonorrhea can lead to purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: In both men and women the test of choice for gonorrhea again is NAAT, with endocervical samples being preferred to urine samples due to higher sensitivity. In men, urethral and first catch urine samples have a sensitivity and specificity of greater than 97%. Nachi: And as with chlamydial samples, the FDA has not approved gonorrhea NAAT for rectal and oropharyngeal samples, but most labs are able to process these samples. Jeff: Yeah, definitely check before you go swabbing samples that cannot be run. Lastly, in regards to testing, though it won’t likely change your management in the moment, the CDC does recommend a gonococcal culture in cases of confirmed or suspected treatment failure Nachi: It’s also worth noting that although NAAT can be used in children, but culture is additionally preferred in all settings due to legal ramifications of sexual abuse. Jeff: It pains me just to think about how awful that is. Ugh. Moving on to treatment: when treating gonorrhea, the current recommendation is to treat both with cefitriaxone and azithro. 250 mg IM is the preferred dose, up from just 125 mg IM which was preferred dose two decades ago along with 1g of azithro. Nachi: And if ceftriaxone IM cannot be administered easily, 400 mg PO cefixime is the second line treatment of choice. If there is a documented cephalosporin allergy, PO gemifloxacin or gentamycin may be used. And for those with an azithomycin intolerance, a 7 day course of doxycycline may be substituted instead. Jeff: In pregnant women, gonococcal infections are associated with chorioamnionitis, premature rupture of membranes, preterm birth, low birth weight, and spontaneous abortions. Pregnant woman therefore should be treated with both ceftriaxone and azithro in the same manner as their non pregnant counterparts. Nachi: There is also one quick controversy to discuss here. Jeff: oh yeah, go on… Nachi: The CDC currently recommends the IM dose of ceftriaxone, not IV. And this is because of the depot effect. However, it’s unclear if this effect is in fact true, as IM and IV ceftriaxone levels measured in blood 24 hours later are similar. So if the patient has an IV already, should we just give the ceftriaxone IV instead of IM? Jeff: I think it is probably okay, but I’ll wait for a bit more research. For now, I would continue to stick with the CDC recommendation of IM as the correct route. Nachi: And with the continuing rise of STD’s and the public health and economic burden we are describing here, I think the IM route, which is known to be effective, should still be used -- until the CDC changes their recommendations. Next up we have the great imitator/masquerader, syphilis, caused by the spirochete Treponema pallidum. LIke the other STDs we’ve discussed so far, cases of syphilis are also on the rise with over 30k cases in 2017, a 10% increase from 2016. Jeff: Syphilis is spread via direct contact between open lesions and microscopic abrasions in the mucous membranes of vagina, anus, or oropharynx. The organism then disseminates via the lymphatics and blood stream. Nachi: Infection with syphilis comes in three stages. Primary syphilis is characterized by a single, painless lesion, or chancre, which occurs about 3 weeks after inoculation. 6-8 weeks later, secondary syphilis develops. This often presents with a rash, typically on the palms and soles of the feet, or with condyloma lata, or lymphadenopathy. Jeff: Tertiary syphilis doesn’t appear until about 20 years post infection and it includes gummatous lesions and cardiac involvement including aortic disease. Nachi: Patients at any stage may go long periods without any symptoms, which is known as latent syphilis. In addition, at any stage a patient may develop neurosyphilis, which can present with strokes, altered mental status, cranial nerve dysfunction, and tabes dorsalis. Jeff: In early syphilis, dark-field examination is the definitive method of detection, though this is impractical in the ED setting. There are, instead, 2 different algorithms to follow. The CDC traditional algorithm recommends a nontreponemal test like rapid plasma reagin or RPR or the venereal disease research lab test also called VDRL, followed by confirmational treponemal test (fluoresent treponemal antibody absorption or FTA-ABS or T pallidum passive agglutination also called TP-PA). More recently there has been a shift to the reverse sequence, with screening with a treponemal assay followed by a confirmatory nontreponemal assay. Nachi: The reason for the change is that there is an increased availability of rapid treponemal assays. And where available, the reverse sequence offers increased throughput and the ability to detect early primary syphilis better. The CDC, however, still recommends the traditional testing pathway -- that is nontreponemal tests first like RPR or VDRL, followed by treponemal tests like FTA-ABS or TP-PA. The article also notes that emergency clinicians should rely on clinical manifestations in addition to serologic testing, when determining whether to treat for syphilis. Jeff: For neurosyphilis, the CSF-VDRL test is highly specific but poorly sensitive. In cases of a negative CSF-VDRL but still with high clinical suspicion, consider a CSF FTA-ABS test, which has lower sensitivity, but is also highly specific and may catch the diagnosis. Nachi: Treatment for primary, secondary, and early latent syphilis is with 2.4 million units of Penicillin G IM. For ocular and neurosyphilis, treatment is with 18-24 million units of pen G IV every 4 hours or continuously for 10-14 days. In patients who have a penicillin allergy, skin testing and desensitization should be attempted rather than azithromycin due to concerns for resistance. Jeff: For pregnant women, PCN is the only proven therapy. Interestingly, there is some evidence to suggest that a second IM dose may be beneficial in treating primary and secondary syphilis in pregnancy though data are limited. Nachi: We also have to mention the Jarisch-Herxheimer reaction before moving on. This is a syndrome of fevers, chills, headache, myalgias, tachycardia, flushing and hypotension following high dose PCN treatment due to a massive release of endotoxins when the bacteria die. This typically occurs in the first 12 hours but can occur up to 24 hours after treatment. Treatment is supportive. Concern of this reaction should never delay PCN treatment!! Jeff: The next condition to discuss is Bacterial vaginosis, or BV, which, interestingly, is not always an STD. It is therefore critically important to choose your words wisely when speaking with a patient who has BV. Nachi: That is an important point that is worth repeating. BV is not always an STD. So what is BV? BV occurs when there is a decrease or absence of lactobacilli that help maintain the acidic pH of the vagina leading to an overgrowth of Gardnerella, bacteroides, ureaplasma and mycoplasma. BV does not occur in those who have never had intercourse and it may increase the risk of other STDs and HIV. Jeff: 50% of women with BV are asymptomatic, while the others will have a thin, grayish-white, homogeneous vaginal discharge with a fishy smell, along with pruritis. Nachi: To diagnose BV, most use the amsel criteria, which requires 3 of following 4: 1) a thin, milky, homogeneous vaginal discharge, 2) the release of a fishy odor before or after the addition of potassium hydroxide, 3) a vaginal pH > 4.5, and 4) the presence of clue cells in the vaginal fluid. These criteria are 90% sensitive and 77% specific, with clue cells being the most reliable predictor. Jeff: And for those of us without immediately available microscopy, you can make the diagnosis based on characteristic vaginal discharge alone. Treat with metronidazole, 500 mg BID for 7 days, metronidazole gel, or an intravaginal applicator for 5 days, with the intravagainal applicator being better tolerated than the oral equivalent Nachi: BV in pregnancy increases risk of preterm birth, chorioamnionitis, postpartum endometriitis and postcesarean wound infections. Pregnant patients are treated the same as nonpregnant or with 400 mg of clindamycin BID x 7 days. Jeff: Always nice when there is really only one treatment regimen across the board. And that will be a general theme for treatment options in pregnancy with a few exceptions. Nachi: Next up we have Granuloma inguinale, or donovanosis, which is caused by Klebsiella granulomatis. Jeff: Granuloma inguinale is endemic to India, the Caribbean, central australia, and southern africa. It is rarely diagnosed in the US. Nachi: Granuloma inguinale presents with highly vascular, ulcerative lesions on the genitals or perineum. They are typically painless and bleed easily. If disseminated, Granuloma inguinale can lead to intra-abdominal organ and bone lesions and elephantiasis-like swelling of the external genitalia. Jeff: Granuloma inguinale can can be diagnosed by microscopy from the surface debris of purulent ulcers. Nachi: Once you have the diagnosis, the CDC recommends treatment with azithromycin for at least 3 weeks and until all lesions have resolved. Jeff: Next we have lymphogramuloma venereum or LGV. Nachi: LGV is a C. Trachomatis infection of the lymphatics and lymph nodes. This is predominantly a disease of the tropics and subtropical areas of the world. Jeff: On exam, in the primary stage, you would expect a small, painless papule, pustule, nodule or ulcer on the coronal sulcus of the penis or on the posterior forchette, vulva, or cervix of women. The primary stage eventually progresses to the secondary stage, which is characterized by unilateral lymphadenopathy with fluctuant, painful lymph nodes known as buboes. Nachi: Check out figure 11 for a great classic image of the “groove sign” which is involvement of both the inguinal and femoral lymph nodes, and is seen in 15-20% of cases. And actually even more common than the groove sign is a presentation with proctitis. Jeff: Testing for LGV should be based on high clinical suspicion, and NAAT should be performed on a sample from the primary ulcer base or from aspirate from a bubo. Nachi: Treatment for LGV is with doxycycline 100 mg BID x 21 days. Jeff: So, to summarize, for LGV, remember painful lymphadenopathy, especially in those with proctitis. Treat with doxy. Nachi: Next we have Mycoplasma genitalium, which causes nongonococcal urethritis in men and mucopurulent cervicitis and PID in women. Jeff: Unfortunately, there is no diagnostic test for M. genitalium, and it should be considered clinically, especially in the setting of recurrent urethritis. Nachi: Treat with azithro, but not 1g x 1. Instead, M. Genitalium should be treated with a course of azithro, with 500 mg on day 1 followed by 250 mg daily for 4 days. Moxifloxacin is an alternative. Jeff: Simple enough. Moving on to everybody’s favorite, genital herpes. Nachi: umm, I’m not sure sure anybody would call herpes their favorite. Why would you even say that? Jeff: i don’t know, seemed natural at the time… Regardless, primary genital herpes is caused by either HSV1 or HSV2. Though only an estimate, and likely an underestimate at that, it is estimated that at least 1 in 6 people in the US between 14 and 49 have genital herpes. Nachi: That’s much higher than I would have thought. Jeff: Patients usually contract oral herpes from HSV-1 due to nonsexual contact with saliva and genital herpes due to sexual contact with an infected person. Nachi: Keep in mind, however, that HSV1 can and will also cause genital infections if spread via oral sex. Jeff: Localized symptoms include pain, itching, dysuria, and lymphadenopathy and systemic symptoms include fever, headache, and malaise. In women, look for herpetic vesicles on the external genitalia along with tender ulcers in areas of rupture, see figure 12 for a characteristic image. Nachi: Though symptoms tend to be more severe in woman, men may present with vesicles on the glans penis, penile shaft, scrotum, perianal area, and rectum or even with dysuria and penile discharge. Jeff: HSV1 and 2 infections also have the ability to recur, though recurrences tend to become less frequent and severe over time. Nachi: It’s noteworthy that there is also a direct correlation between stress levels and the severity of an HSV outbreak. Jeff: Herpes can be diagnosed by viral culture of an unroofed vesicle or by NAAT. PCR based assays can also differentiate between HSV1 and HSV2 Nachi: While there is no cure, antivirals may help prevent and shorten outbreaks. Ideally you should begin treatment within 72 hours of lesion appearance. Treat with acyclovir, valacyclovir, or famciclovir. In addition, don't forget about adjuncts like analgesia, sitz bathes, and urinary catheter placement for severe dysuria. Jeff: HSV can also be vertically transmitted from mother to child so in pregnancy, treat with acyclovir 400 mg 3x/day for 7 days or valacyclovir Nachi: And because transmission is so easy, babies born to mothers with active lesions should be delivered by cesarean section. Jeff: Let’s move on to human papillomavirus, or HPV. There are over 100 types of HPV with 40 being transmitted through skin to skin contact, typically via vaginal and anal intercourse. Nachi: Most infections are asymptomatic and clear within 2 years. Jeff: Right, but one of the main reasons this is such a big deal is that HPV types 16 and 18 are oncogenic strains and can lead to cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers. Amazingly, HPV is responsible for more than 95% of the cervical cancers in women. Nachi: Hence the importance of the new vaccine series that most young adults and children are now opting for. Vaccination should occur in women through age 26 or men through age 21 if not previously vaccinated. Jeff: Critically important to take advantage of a vaccine that can prevent cancer! Nachi: And though not as important in terms of health consequences, just be aware that HPV 6 and 11 may lead to anogenital warts, known as condyloma acuminata. Jeff: In terms of exam findings, as you just mentioned, most infections are asymptomatic and self-limited. If symptoms do develop, HPV typically causes those cauliflower like or white plaque like growths lesions on the external genitalia, perineum, and perianal skin. Nachi: For testing, there is a limited role in the ED. Diagnosis should be made by visual inspection, followed eventually by a biopsy. Jeff: And just like the biopsy, which is unlikely to be done in the emergency department, most treatment is also not ED based. Treatment options include cryotherapy, immune-based therapy, and surgical excision, which has both the highest success rates and lowest recurrence. Nachi: Next up, we have trichomoniasis. Jeff:Trichomoniasis is a single-celled, flagellated, anaerobic protozoa, that directly damages the epithelium, causing microulcerations in the vagina, urethra, and paraurethral glands. Nachi: With an estimated 3.7 million infected people in the US, this is something you’re also bound to see. Jeff: Risk factors include recent or current incarceration, IV drug use, and co-infection with BV. Nachi: Note the common theme here - co infection. It’s very common for patients to have more than one STD, so make sure not to anchor when you think you’ve nailed the diagnosis. Jeff: On exam the majority of both women and men are asymptomatic. In women, you may find a purulent, frothy vaginal discharge, vaginal odor, vulvovaginal irritation, itching, dyspareunia, and dysuria Nachi: And don’t forget about the classic colpitis macularis, or the strawberry cervix. Though this is frequently taught and stressed, it’s actually only seen in 2-5% of infected women. Jeff: But to be fair, a strawberry cervix and frothy vagianl discharge together have a specificity of 99% for trich, which is really not bad. Nachi: While many EDs sadly aren’t blessed with a wet mount, the wet mount has the advantage of being simple, convenient, and generally low cost. Jeff: While all of that is true regarding the wet mount, it’s no longer first line, again with NAAT being preferred, as it’s highly sensitive, approaching 100%. Nachi: And for those of us who don’t have access to NAAT, there are also antigen-detecting tests which don’t perform quite as well, but they are much more sensitive than the traditional wet mount. Jeff: Treatment for trichomoniasis is with oral metronidazole, 2g in a single oral dose a or 500 mg twice a day for 7 days. Alternatively, the more expensive tinidazole, 2g for 1 dose, is actually superior according to the most recent evidence. Nachi: For pregnant patients, trichomoniasis is unfortunately associated with premature delivery and premature rupture of membranes, with no improvement following treatment. Still, patients should be tested and treated, preferentially with metronidazole, to relieve symptoms and prevent partner spread. Jeff: We have two more special populations to discuss in this month’s issue - those in correctional facilities and sexual partner treatment. If you are lucky enough to be involved in treating those in correctional facilities, keep in mind that rates of gonorrhea, chlamydia, syphilis, and trichomoniasis are higher in persons in both juvenile and adult detention facilities than the general public. Nachi: In general for patients in correctional facilities, maintain a lower threshold for just about everything. This is just an at-risk population. Jeff: Let’s move on to sexual partners, and expedited partner therapy or EPT. Nachi: Once you’ve diagnosed a patient with an STD, you can also provide a prescription or medication to the patient to give to their partner or partners. Jeff: This practice is critically important to stop partners from unknowingly spreading the STD further which is a real problem. Unless prohibited by law, emergency clinicians should routinely offer EPT to patients with chlamydia, gonorrhea, or trichomoniasis. To see your states’ current status, the CDC maintains a list of the status in all 50 states. Nachi: In terms of specific partner therapies, for chlamydia, EPT can be accomplished with a single 1g dose of azithromycin or doxycyclin 100 mg bid for 7 days. Consider concurrent treatment for gonococcal infection also. Jeff: For Gonorrhea, EPT includes a single oral dose of 400 mg of cefixime and a 1g oral dose of azithromycin. Nachi: For EPT for syphilis, unfortunately the partner has to present to the ED for a single IM injection of penicillin G. While this does place a burden on the partner, it opens up an opportunity for additional serologic testing and possibly treatment of his or her partners as well. Jeff: Routine EPT for those with BV is not recommend as the data shows that partner treatment does not affect rates of relapse or recurrence. Nachi: For genital herpes, you should counsel patients and their partners that they should abstain from sexual activities when there are lesions or prodromal symptoms. Make sure to refer partners for evaluation as well. Jeff: Since there isn’t much data on HPV partner notification, for now, encourage patients to be open with their partners so they may seek treatment as well. Nachi: And lastly, for Trichomoniasis, EPT includes 2 g of metronidazole or 500 mg BID for 7 days or that single 2g dose of tinidazole. Jeff: In general, it is always better to have the partner present to a physician for diagnosis and treatment, but EPT is an option when that seems unlikely or impossible. Nachi: Also, when possible be sure to inquire about drug allergies and provide some guidelines on ER presentation for allergic reactions. Jeff: So that wraps up EPT. Let’s discuss disposition. Though most will end up going home, a few may require IV medications, such as those with severe HSV, disseminated gonococcus, and neurosyphilis. Nachi: Admission should also be strongly considered in those who are pregnant or with concern for complications. Those with severe nausea, vomiting, high fever, the inability to tolerate oral antibiotics, and those failing oral antibiotics should also be considered for admission. Jeff: But if your patient doesn’t meet those criteria, as most will not, and they are headed home, stress the importance of follow up. Especially for those with gonorrhea and chlamydia, for whom a test of cure after completion of their medication is recommended. This is even more important for pregnant women. Nachi: Chlamydia, gonorrhea, HIV, and syphilis are among the many infectious diseases that require mandatory reporting. Definitely familiarize yourself with your states’ reporting laws, as most of these patients will be headed home and you’ll want to make sure you don’t miss your chance to prevent further spread. Jeff: Perfect, so that’s it for this month’s issue. Let’s close out with some high yield points and clinical pearls. Nachi: STDs are under recognized by patients and healthcare professionals. They can often present with minimal or no symptoms and are passed unknowingly to partners. Jeff: STD’s can have devastating effects during pregnancy on the fetus. Treat these patients aggressively in the ER. Nachi: The rising rate of STD’s continues to be an economic burden on the U.S. healthcare system. Jeff: Patients can present with multiple STD’s concurrently. Avoid premature diagnostic closure and consider multiple simultaneous processes. Nachi: Urinary tract infections and STD’s can present similarly. Be sure to do a pelvic exam to avoid misdiagnosis. For the exam, always have a chaperone present. Jeff: Acute unilateral epididymitis is most commonly a result of chlamydia in men under the age of 35. Nachi: Chlamydia is the most common bacterial STD. The diagnostic test of choice is nucleic acid amplification testing (NAAT). Treat with azithromycin or doxycycline. Jeff: Gonorrhea is the second most common STD. The diagnostic test of choice here is again NAAT. Treat with ceftriaxone and azithromycin. Nachi: Gonorrhea can lead to disseminated infection such as purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: Syphilis has a wide variety of presentations over three stages. For concern of early syphilis, send RPR or VDRL for nontreponemal testing as well as an FTA-ABS or TP-PA for treponemal testing. Nachi: Tertiary syphilis can present with gummatous lesions or aortic disease many years after the primary syphilis infection. Jeff: At any stage of syphilis, the central nervous system can become infected, leading to neurosyphilis. Nachi: Bacterial vaginosis presents with a white, frothy, malodorous vaginal discharge. Treat with metronidazole. Jeff: Genital herpes is caused by HSV-1 or HSV-2. Diagnosis can often be made clinically. If sending a sample for testing, be aware that viral shedding is intermittent, so you may have a falsely negative result. Antivirals can help prevent or shorten outbreaks and decrease transmission. Nachi: Lymphogranuloma Venereum presents with small, painless papules, nodules, or ulcers. Groove sign is present in only 15%-20% of cases. Jeff: Consider Fitz-Hugh-Curtis syndrome in your differential for a sexually active patient with right upper quadrant pain. Nachi: Offer expedited partner therapy to all patients with STD’s to prevent further spread Jeff: So that wraps up Episode 27 - STDs in the ED! Incredibly high yield topic with lots of pearls. Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: I’ll repeat that, since saving money is important. APPs, use the promotion code APP4 at checkout to receive 50% off on your subscription. Speaking of PAs - for those of you attending the SEMPA conference in just a few weeks, make sure to check out the EB Medicine Booth, #302 for lots of good stuff. For those of you not attending the conference, just be jealous that your colleagues are hanging out in New Orleans. Nachi: And the address for this month’s credit is ebmedicine.net/E0419, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 3. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr- 03):1-137. (Expert guidelines/systematic review) 5. Torrone E, Papp J, Weinstock H. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years- -United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838. (Expert guideline/systematic review) 98. Schillinger JA, Gorwitz R, Rietmeijer C, et al. The expedited partner therapy continuum: a conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 Suppl 1):S63-S75. (Systematic review; 42 articles) 103. Centers for Disease Control and Prevention. 2018 National Notifiable Conditions (Historical). National Notifiable Diseases Surveillance System (NNDSS). Accessed March 10, 2019. (CDC website) 105. Carter MW, Wu H, Cohen S, et al. Linkage and referral to HIV and other medical and social services: a focused literature review for sexually transmitted disease prevention and control programs. Sex Transm Dis. 2016;43(2 Suppl 1):S76-S82. (Systematic review; 33 studies)

Join John Bielinski for live CME in 2019 www.Emergency-Medicine-Institute.com Demystifying Emergency Medicine Conference April 1-4, 2019 Marriott Key West Beachside Master labs/CXR and EKGs Urgent Care Medicine Conference July 8-11, 2019 The Lakefront Anchorage  All aspects of urgent care medicine Critical Access Emergency Medicine Conference Oct 8-11, 2019 Yellowstone For critical access providers who are solo providers

Back in April 2017 we went to SEMPA 360 and we have been saving some pearls just for a reminder of what SEMPA can offer when it comes to a conference.  The long wait is over and to help support our SEMPA friends we have an interview of some quick pearls from expert Robert Dachs.

Dr. Nick Governatori, an Assistant Residency Director at Thomas Jefferson University Hospital and former Director of Education on the EMRA Board talks about Advanced Practice Providers (APP) with Lynn Scherer, currently the Associate Director of APP Services and EMPA Residency Program Director with the Albert Einstein Medical Center and the Past President of SEMPA, and Dr. Matt Rudy, former EMRA President, and current Assistant Professor at Augusta University's Medical College of Georgia.

Brian Lin is back for the second part of our conversation with him from the 2017 SEMPA 360 conference, but this time we are talking about two subjects with a lot of dogma: the Golden Period for wound closure and dog bite closure.  This brief review is designed to remind you of some of the key components in order to better care for your patients.

Major Jonathan Monti, PA-C is our first SEMPA 360 posting from the recent 2017 conference.  We were able to talk to a variety of people at the conference thanks to the staff there and we truly appreciate their help.  For the first time ever, SEMPA had what they call the "EMPA of the Year" award and this went to the very deserving Major Monti.  We had the exclusive chance to interview him immediately after the award and his thoughts are included here.

We just came back from SEMPA 360 and it was a blast!  But today, we have a two part interview with Rob Orman.  The first half, today's discussion, is all about patient satisfaction.  Next week, we will further our "grab bag" discussion with some other interesting questions that others wanted to hear from Rob about, but all I can say is you do not want to miss the pearls from the interview so make sure to listen to both!