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Contributor: Travis Barlock, MD Educational Pearls: Key clinical considerations when managing heart transplant patients due to their unique pathophysiology 1. Arrhythmias A transplanted heart is denervated, meaning it lacks autonomic nervous system innervation The lack of vagal tone results in an increased resting heart rate Adenosine can be used since it primarily slows conduction through the AV node  Atropine is ineffective in treating transplant bradyarrhythmia because its mechanism is to inhibit the vagus nerve - but the heart lacks vagal tone Allograft rejection can also cause tachycardia Consult transplant surgery - treatment is usually 500 mg methylprednisolone 2. Rejection Transplant patients are administered immunosuppressants Clinical presentation of acute rejection looks similar to heart failure with increased BNP, increased troponin, and pulmonary edema  Cardiac allograft vasculopathy is a form of chronic rejection Patients will not report chest pain due to denervated heart Symptoms are usually weakness and fatigue 3. High risk of infection due to immunosuppression Increased risk of infections which includes CMV, legionella, tuberculosis, etc Immunosuppressants have side effects such as acute kidney injury or pancytopenia 4. Radiographic Cardiomegaly A study found that radiographic cardiomegaly does not connote heart failure They hypothesized it is instead the result of a mismatch between the size of the transplanted heart and the space in the thoracic cavity  References Murphy JD, Mergo PJ, Taylor HM, Fields R, Mills RM Jr. Significance of radiographic cardiomegaly in orthotopic heart transplant recipients. AJR Am J Roentgenol. 1998 Aug;171(2):371-4. doi: 10.2214/ajr.171.2.9694454. PMID: 9694454. Park MH, Starling RC, Ratliff NB, McCarthy PM, Smedira NS, Pelegrin D, Young JB. Oral steroid pulse without taper for the treatment of asymptomatic moderate cardiac allograft rejection. J Heart Lung Transplant. 1999 Dec;18(12):1224-7. doi: 10.1016/s1053-2498(99)00098-4. PMID: 10612382. Pethig K, Heublein B, Wahlers T, Dannenberg O, Oppelt P, Haverich A. Mycophenolate mofetil for secondary prevention of cardiac allograft vasculopathy: influence on inflammation and progression of intimal hyperplasia. J Heart Lung Transplant. 2004 Jan;23(1):61-6. doi: 10.1016/s1053-2498(03)00097-4. PMID: 14734128. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Aaron Lessen, MD Educational Pearls: Point-of-care ultrasound (POCUS) is used to assess cardiac activity during cardiac arrest and can identify potential reversible causes such as pericardial tamponade Ultrasound could be beneficial in another way during cardiac arrest as well: pulse checks Manual palpation for detecting pulses is imperfect, with false positives and negatives Doppler ultrasound can be used as an adjunct or replacement to manual palpation for improved accuracy Options for Doppler ultrasound of carotid or femoral pulses during cardiac arrest: Visualize arterial pulsation Use color doppler Numerically quantify the flow and correlate this to a BP reading - slightly more complex Doppler ultrasound is much faster than manual palpation for pulse check Can provide information almost instantaneously without waiting the full 10 seconds for a manual pulse check The main priority during cardiac arrest resuscitation is to maintain quality compressions If pulses are unable to be obtained through Doppler within the 10-second window, resume compressions and try again during the next pulse check References Cohen AL, Li T, Becker LB, Owens C, Singh N, Gold A, Nelson MJ, Jafari D, Haddad G, Nello AV, Rolston DM; Northwell Health Biostatistics Unit. Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest. Resuscitation. 2022 Apr;173:156-165. doi: 10.1016/j.resuscitation.2022.01.030. Epub 2022 Feb 4. PMID: 35131404. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/

In this episode of From A to Arbitration, Cole and Mallory, stepping in for Corey, provide a detailed summary of the Nolan arbitration decision. They begin by clarifying that the effective dates for LMOU implementation is from May 27th to June 26th. They then proceed to summarize key changes across various articles, including non-discrimination (adding pregnancy), no layoff provisions (retained), salaries and wages (with increases of 1.3%, 1.4%, and 1.5% and a $1,000 one-time increase for Step P employees), COLAs (retroactive), back pay details, CCA pay adjustments, and modifications to carrier pay tables (eliminating certain steps in Table 2). A significant portion of the discussion focuses on Article 8, detailing changes to work schedules, the right to refuse overtime beyond twelve hours or sixty hours per week without disciplinary action, and the establishment of new overtime designation lists. They also cover the new employee retention and mentoring program (NERP), including provisions for training, initial assignments, and limitations on new employee work locations. The discussion emphasizes practical implementation strategies for members and emphasizes the need for shop stewards and branch presidents to ensure compliance with the new provisions. Cole and Mallory also explain crucial language changes and detail specific considerations for grievances and potential conflicts, emphasizing proactive measures for members to take advantage of new rights and avoid potential abuse of power by management. They also address various questions raised in advance and provide clarifications on important dates and details. A significant theme throughout the episode is the importance of education and proactive strategies for handling the new contract provisions, and the need for vigilance from union members to prevent potential abuses of power from management. https://fromatoarbitration.com/fatas-2023-2026-nalc-national-agreement-guide/ https://www.fromatoarbitration.com/

Contributor: Travis Barlock, MD Educational Pearls: What is Hoover's sign used to identify? This physical exam maneuver differentiates between organic vs. functional (previously known as psychogenic) leg weakness. Organic causes include disease processes such as stroke, MS, spinal cord compression, guillain-barre, ALS, and sciatica, among others In Functional Neurologic Disorder, the dysfunction is in brain signaling, and treatment relies on more of a psychiatric approach How is Hoover's Sign performed? Place your hand under the heel of the unaffected leg and ask the patient to attempt to lift the paralyzed leg. If the paralysis is due to an organic cause, then you should feel the unaffected leg push down. This is due to the crossed-extensor reflex mechanism, an unconscious motor control function mediated by the corticospinal tract. If you don't feel the opposite heel push down, that is a positive Hoover's Sign. How sensitive/specific is it? An unblinded cohort study in patients with suspected stroke found a sensitivity of 63% and a specificity of 100% Fun Fact There's also a pulmonary Hoover's sign, named after the same doctor, Charles Franklin Hoover, which refers to paradoxical inward movement of the lower ribs during inspiration due to diaphragmatic flattening in COPD. References McWhirter L, Stone J, Sandercock P, Whiteley W. Hoover's sign for the diagnosis of functional weakness: a prospective unblinded cohort study in patients with suspected stroke. J Psychosom Res. 2011 Dec;71(6):384-6. doi: 10.1016/j.jpsychores.2011.09.003. Epub 2011 Oct 6. PMID: 22118379. Stone J, Aybek S. Functional limb weakness and paralysis. Handb Clin Neurol. 2016;139:213-228. doi: 10.1016/B978-0-12-801772-2.00018-7. PMID: 27719840. Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Educational Pearls: Physiologic stimulation of ventilation occurs through changes in levels of: Arterial carbon dioxide (PaCO2) Arterial oxygen (PaO2) Hypercapnia is an elevated level of CO2 in the blood - this primarily drives ventilation Hypoxia is a decreased level of O2 in the body's tissues - the backup drive for ventilation Patients at risk of hypercapnia should maintain an O2 saturation between 88-92% Normal O2 saturation is 95-100% In patients who chronically retain CO2, their main drive for ventilation becomes hypoxia An audit was performed of SpO2 observations of all patients with a target range of 88–92% at a single hospital over a four-year period This found that excessive oxygen administration was more common than insufficient oxygen and is associated with an increased risk of harm Individuals at risk of hypercapnia include but are not limited to patients with COPD, hypoventilation syndrome, or altered mental status References Homayoun Kazemi, Douglas C. Johnson, Respiration, Editor(s): V.S. Ramachandran, Encyclopedia of the Human Brain, Academic Press, 2002, Pages 209-216, ISBN 9780122272103, https://doi.org/10.1016/B0-12-227210-2/00302-2. O'Driscoll BR, Bakerly ND. Are we giving too much oxygen to patients at risk of hypercapnia? Real world data from a large teaching hospital. Respir Med. 2025 Mar;238:107965. doi: 10.1016/j.rmed.2025.107965. Epub 2025 Jan 30. PMID: 39892771. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Unfiltered Chat – AI Review of the Conversation

Contributor: Aaron Lessen, MD Educational Pearls: Quick background info Cardiac arrest is when the heart stops pumping blood for any reason. This is different from a heart attack in which the heart is still working but the muscle itself is starting to die. One cause of cardiac arrest is when the electrical signals are very disrupted in the heart and start following chaotic patterns such as Ventricular tachycardia (VTach) and Ventricular fibrillation (VFib) One of the only ways to save a person whose heart is in VFib or VTach is to jolt the heart with electricity and terminate the dangerous arrhythmia. A recent study in the Netherlands looked at how important the time delay is from when cardiac arrest is first identified to when a defibrillation shock from an Automated External Defibrillator (AED) is actually given. Their main take-away: each minute defibrillation is delayed drops the survival rate by 6%! These findings reinforce the importance of rapid AED deployment and early defibrillation strategies in prehospital cardiac arrest response. References Stieglis, R., Verkaik, B. J., Tan, H. L., Koster, R. W., van Schuppen, H., & van der Werf, C. (2025). Association Between Delay to First Shock and Successful First-Shock Ventricular Fibrillation Termination in Patients With Witnessed Out-of-Hospital Cardiac Arrest. Circulation, 151(3), 235–244. https://doi.org/10.1161/CIRCULATIONAHA.124.069834 Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

TEXT: GALATIANS 6:11-16 | SUMMARIZED AND SIMPLIFIED INTRO ILLUSTRATION : I'll never forget sitting down with an older gentlemen from the church I grew up in named Don. He had taken me and another young preacher boy from our church out for dinner at McDonalds and he wanted to impart some counsel to us.…

Contributor: Aaron Lessen, MD Educational Pearls: Colchicine is most commonly used for the prevention and treatment of gout There is research investigating the anti-inflammatory and cardioprotective effects of colchicine  This drug has a narrow therapeutic index: a small margin between effective dose and toxic dose Colchicine overdoses can be unintentional or intentional and are associated with poor outcomes Phase 1: 10 - 24 hours after ingestion Patient looks well but may have mild symptoms mimicking gastroenteritis Phase 2: 24 hours - 7 days after ingestion Multiple organ dysfunction syndrome (MODS) Phase 3: recovery is usually within a few weeks of ingestion Treatment for colchicine overdose Treat early and aggressively Gastrointestinal decontamination with activated charcoal and orogastric lavage  Dialysis and ECMO for MODS treatment References Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010 Jun;48(5):407-14. doi: 10.3109/15563650.2010.495348. PMID: 20586571. Gasparyan AY, Ayvazyan L, Yessirkepov M, Kitas GD. Colchicine as an anti-inflammatory and cardioprotective agent. Expert Opin Drug Metab Toxicol. 2015;11(11):1781-94. doi: 10.1517/17425255.2015.1076391. Epub 2015 Aug 4. PMID: 26239119. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Travis Barlock, MD Educational Pearls: What is Portal Vein Thrombosis? The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels How does it present? Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever How is it diagnosed? Abdominal CT or MRI with contrast What causes it? Cirrhosis Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.) Oral Contraceptive Pills (OCPs) Cancer such as hepatocellular carcinoma How is it treated? Aggressive fluid resuscitation Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes Heparin, same dosing as a bolus for a DVT Endovascular treatment, such as a thrombectomy with IR Surgical evaluation if there has been tissue death in the mesentery References Hilscher, M. B., Wysokinski, W. E., Andrews, J. C., Simonetto, D. A., Law, R. J., & Kamath, P. S. (2024). Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies. Gastroenterology, 167(4), 664–672. https://doi.org/10.1053/j.gastro.2024.05.017 Intagliata, N. M., Caldwell, S. H., & Tripodi, A. (2019). Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology, 156(6), 1582–1599.e1. https://doi.org/10.1053/j.gastro.2019.01.265 Ju, C., Li, X., Gadani, S., Kapoor, B., & Partovi, S. (2022). Portal Vein Thrombosis: Diagnosis and Endovascular Management. Pfortaderthrombose: Diagnose und endovaskuläres Management. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 194(2), 169–180. https://doi.org/10.1055/a-1642-0990 Summarized by Jeffrey Olson MS3 | Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Meghan Hurley, MD Educational Pearls: Gastroenteritis clinical diagnoses: Diarrhea with or without vomiting and fever Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest Treatment for mild to moderate dehydration: oral or IV rehydration Begin orally to avoid unnecessary IV in a pediatric patient Administer ODT Ondansetron (Zofran) to prevent vomiting Meta-analysis showed that 2-8 mg orally, based on body weight, decreased vomiting quickly Wait 15-20 minutes for the medication to take effect Use streamlined method for oral rehydration: Fluids such as over-the-counter Pedialyte, Infalyte, Rehydrate, Resol, and Naturalyte may be used If patient weighs less than 10kg: administer 5mL of fluid per minute for 20 minutes If patient weighs 10kg or more: administer 10mL of fluid for 20 minutes If the patient can keep the fluid down, double the fluid volume and repeat If the patient once again keeps the fluid down, double the fluid volume and repeat If successful with each attempt, the patient may be discharged home Can prescribe ODT Zofran for 1-2 days at home If the patient vomits more than once during this oral rehydration process, intravenous rehydration must be initiated References Churgay CA, Aftab Z. Gastroenteritis in children: Part II. Prevention and management. Am Fam Physician. 2012 Jun 1;85(11):1066-70. PMID: 22962878. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Welcome to Episode 194 of the China EVs and More podcast! In this episode, hosts Tu Le and Lei Xing wrap up 2024 and share insights into the global EV and mobility sectors. Key topics discussed include:1.China's Dominance in the EV Market:•China's remarkable sales of nearly 13 million NEVs in 2024, representing a 50% domestic market share.•The continued decline of foreign automakers in China, including shrinking market shares for Mercedes, Volkswagen, and Porsche.2.Tesla's Market Strategies:•The Model Y's global success as the best-selling vehicle in 2024 and its dominant position in China.•The unveiling of Tesla's updated Model Y (Juniper) and the strategic focus on maintaining competitiveness in the Chinese market.3.CES 2025 Highlights:•A strong presence of Chinese companies, with brands like Zeekr, XPeng, and Li Auto showcasing cutting-edge technologies.•Innovations in LiDAR, smart cockpits, and EV design from companies such as NVIDIA and RoboSense.4.Policy and Market Trends:•The impact of US restrictions on Chinese automotive hardware and software.•China's government incentives to boost EV adoption, including expanded trade-in policies for older ICE vehicles.5.Emerging Players and Innovations:•Xiaomi's ambitions to scale EV production with its Su-7 model.•The rise of premium features like Dolby Atmos and Vision in vehicles like the Zeekr 009 MPV.Companies Mentioned•Tesla•BYD•NIO•XPeng•Zeekr•Li Auto•Volkswagen•Porsche•Mercedes-Benz•Xiaomi•RoboSense•NVIDIA•HuaweiJoin Tu and Lei each week for expert insights on the challenges and opportunities shaping the future of global mobility.

Contributor: Aaron Lessen, MD Educational Pearls: If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best? A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed pain and satisfaction with the procedure from both guardian and provider perspectives. Participants: 55 patients were enrolled; 30 completed the 3-month follow-up. Cosmetic Ratings (Median and IQR): Sutures: 70.5 (59.8–76.8) Dermabond: 85 (73–90) Steri-Strips: 67 (55–78) (P = 0.254, no statistically significant difference) Satisfaction and Pain: No significant differences in guardian or provider satisfaction Pain levels were comparable across all methods Even though there was no statistically significant difference in guardian-perceived cosmetic outcomes, the Dermabond did have the highest ratings at the end of the study. References Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 40(10), 700–704. https://doi.org/10.1097/PEC.0000000000003244 Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Chapter 1 What's The Greatest Salesman in the World by Og Mandino"The Greatest Salesman in the World" by Og Mandino is a self-help classic that combines storytelling with practical wisdom on achieving success. The book follows the journey of Hafid, a poor camel boy who aspires to become the greatest salesman in the world. Through a series of scrolls, each conveying timeless principles and philosophies, readers learn about perseverance, the power of positive thinking, and the importance of self-discipline and resilience. Mandino emphasizes the role of habits in achieving personal and professional goals, showcasing that success is within reach for anyone willing to embody these transformative concepts. The book encourages readers to adopt a mindset of abundance, take responsibility for their lives, and cultivate the habit of greatness.Chapter 2 The Greatest Salesman in the World by Og Mandino Summary"The Greatest Salesman in the World" by Og Mandino is a self-help book that presents principles for personal success through the story of a poor camel boy named Hafid who rises to become a wealthy and successful salesman. The book is structured around ten scrolls, each containing a lesson or principle that guides Hafid on his journey to success. Here's a summary of these scrolls and their key teachings:Scroll I: The Power of Thought This scroll emphasizes that thoughts are powerful and shape our lives. By controlling our thoughts, we can create a positive and successful mindset.Scroll II: Love Love is the greatest motivation for action. It encourages salespeople to treat others with kindness and respect, leading to stronger relationships and sales success.Scroll III: The Habit of Laughter Laughter brings joy and is a crucial component in relieving stress. This attitude of joy helps in overcoming obstacles in sales.Scroll IV: The Habit of Persistence Persistence and resilience are key to overcoming failures and challenges. This scroll teaches that successful people keep trying despite setbacks.Scroll V: The Power of Goal Setting Setting clear and specific goals is essential for achieving success. It's important to have a vision and focus on achieving it.Scroll VI: The Importance of Taking Action Success requires decisive action. This scroll encourages readers to act on their plans and not to procrastinate.Scroll VII: The Value of Being Prepared Preparation is crucial in any sales endeavor. Being ready can make the difference between success and failure.Scroll VIII: The Power of Self-Discipline Self-discipline is vital for maintaining focus and achieving one's goals. It helps to resist temptations that distract from one's purpose.Scroll IX: The Importance of Training Continuous learning and improvement are necessary for success. This scroll advocates for the importance of education and gaining experience.Scroll X: The Value of Gratitude Cultivating an attitude of gratitude yields happiness and attracts positivity, helping salespeople build better relationships with clients.Throughout the book, Og Mandino blends parables and motivational tips, encouraging readers to adopt these principles in their own lives, not just in sales but in any field of endeavor. Ultimately, it is about fostering a positive mindset, resilience, and dedication to achieving personal and professional goals.Chapter 3 The Greatest Salesman in the World AuthorOg Mandino was an American author best known for his self-help and motivational literature. He was born on December 12, 1923, in Framingham, Massachusetts, and led a difficult early life that included struggles with alcoholism and a medical condition that left him feeling despondent. He eventually found purpose in writing and became one of the most popular motivational writers of his time.The Greatest Salesman in the World was published in 1968. This book is structured as a fictional

Contributor: Aaron Lessen, MD Educational Pearls: Many patients present to the ED with elevated BP Many are referred from outpatient surgery centers or present after an elevated measurement at home Persistent questions on the best way to treat these patients The AHA published a scientific statement on the management of elevated BP in the acute care setting Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage Includes aortic dissection or subarachnoid hemorrhage  Require aggressive treatment Asymptomatic markedly elevated inpatient BP: SBP/DBP >180/110–120 mm Hg without evidence of new or worsening target-organ damage AND asymptomatic elevated inpatient BP: SBP/DBP ≥130/80 mm Hg without evidence of new or worsening target-organ damage No benefits to urgent treatment in the ED, but there are harms to treating patients in this manner These patients do not require IV medications  Provide reassurance and instructions on following up with their PCP to manage their BP in the outpatient setting Removed the term “hypertensive urgency” References Bress AP, Anderson TS, Flack JM, et al. The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension. 2024;81(8). doi:https://doi.org/10.1161/hyp.0000000000000238 Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3  Donate: https://emergencymedicalminute.org/donate/  

This week on The Beat, CTSNet Editor-in-Chief Joel Dunning reflects on the most popular content of 2024 at CTSNet. He discusses the top interview, the most popular guest editor series, and reveals the leading CTSNet contributor of the year. He also looks at the top clinical videos in cardiac, congenital, and thoracic surgery, as well as the most-read JANS articles and the editors' top picks.   Joel also reviews recent JANS articles on cutibacterium acnes infective endocarditis, long-term outcomes of antegrade thoracic stent grafting during repair of acute DeBakey I dissection, comparing right- versus left-first implantation in off-pump sequential double-lung transplantation, and the impact of patient-prosthesis mismatch on long-term outcomes after aortic valve replacement. Before closing, he highlights upcoming events in CT surgery.   JANS Items Mentioned  1.) Cutibacterium Acnes Infective Endocarditis—An Emerging Pathogen  2.) Long-Term Outcomes of Antegrade Thoracic Stent Grafting During Repair of Acute DeBakey I Dissection  3.) Comparing Right- Versus Left-First Implantation in Off-Pump Sequential Double-Lung Transplantation: An Observational Cohort Study  4.) Impact of Patient-Prosthesis Mismatch on Long-Term Outcomes After Aortic Valve Replacement  CTSNET Content Mentioned  1.) CTSNet Summarized—Most Popular Content of 2024  2.) CTSNet Summarized—Top Cardiac Procedure Videos of 2024  3.) CTSNet Summarized—Top Congenital and Thoracic Procedure Videos of 2024    4.) CTSNet Summarized—Top JANS Articles of 2024    5.) CABG With a Long LAD Endarterectomy  Other Items Mentioned  CTSNet Events Calendar  Disclaimer The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.

Contributor: Megan Hurley MD Educational Pearls: What is the mediastinum? The thoracic cavity is separated into different compartments by membranes The lungs exist in their own pleural cavities, and the mediastinum is everything in between The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves. What is a pneumomediastinum? Air in the mediastinum How can pneumomediastinum be categorized? Traumatic Ex. Stab wound to the trachea Ex. Boerhaave's Syndrome of the esophagus, possibly from an endoscopic procedure. This mechanism in particular is a higher risk of infection because not only air but food can accumulate in the mediastinum Ex. Intubation with a bougie These will likely need surgical repair Nontraumatic Ex. Forceful inhalation causing microperforations in the trachea. Possibly while inhaling something like drugs Ex. Bad asthma for similar reasons Ex. Gas forming bacteria What happens if you use positive pressure ventilation on a patient with a hole in their trachea? The positive pressure will force extra air into the mediastinum The air will move between the layers of subcutaneous tissue and can track up into the neck and face regions recognized as crepitus on exam This can also cause a tension pneumomediastinum in which the air pressure in the compartment constricts the heart, impeding its ability to fill during diastole These patients can undergo bronchoscopy because that procedure does not require positive pressure and will not worsen the condition. Endoscopies do require positive pressure so endoscopies are not an option How is a tension pneumomediastinum treated? By inserting a needle into the space from below the xiphoid process to allow the air to escape, similar to a pericardiocentesis As a temporizing measure, if the hole is high enough in the trachea, the intubation can be continued by deliberately pushing the endotracheal tube into the right main bronchus, creating a seal, and only ventilating the right lung while the patient heads to surgery. This is called right-mainstemming. References Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. J Intensive Care Soc. 2017 Feb;18(1):52-56. doi: 10.1177/1751143716662665. Epub 2016 Aug 3. PMID: 28979537; PMCID: PMC5606356. Grewal, J., & Gillaspie, E. A. (2024). Pneumomediastinum. Thoracic surgery clinics, 34(4), 309–319. https://doi.org/10.1016/j.thorsurg.2024.06.001 Underner, M., Perriot, J., & Peiffer, G. (2017). Pneumomédiastin et consommation de cocaïne [Pneumomediastinum and cocaine use]. Presse medicale (Paris, France : 1983), 46(3), 249–262. https://doi.org/10.1016/j.lpm.2017.01.002 Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

All audio files listed on this page were extracted from the Ramadan 2024 Daily Juz (Summarised Translation & Tafsir Series) available on Al Madrasatu Al Umariyyah Youtube channel. https://youtube.com/playlist?list=PL2dRQaGGWZOBYkqSWcfhzetBvPKOUFkf4&feature=shared Although best efforts were made to carefully separate or compile individual Surah from the lengthy original version, human error may still occur. Please refer back to the original videos for clarification.

Contributor: Travis Barlock MD Educational Pearls: What is the ST segment? The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave).  It should appear isoelectric (flat) in a normal ECG. What if the ST segment is elevated? This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural) This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis What if the ST segment is depressed? This is evidence that only the innermost part of the muscular wall of the heart is becoming ischemic This has a much broader differential and includes a partial occlusion of a coronary artery but also any other stress on the body that could cause a supply-and-demand mismatch between the oxygen the coronaries can deliver and the oxygen the heart needs This is called subendocardial ischemia What else should you look for in the ECG to identify subendocardial ischemia? The ST-depressions should be at least 1 mm The ST depressions should be present in leads I, II, V4-6 and a variable number of additional leads. There is often reciprocal ST elevation in aVR > 1 mm The most important thing to remember when you see subendocardial ischemia is…history Still, keep all cardiac causes on your differential, such as unstable angina, stable angina, Prinzmetal angina, etc. Also consider a wide array of non-cardiac causes such as severe anemia, severe hypertension, pulmonary embolism, COPD, severe pneumonia, sepsis, shock, thyrotoxicosis, stimulant use, DKA, or any other state that lead to reduced oxygen supply to the subendocardium and/or increased myocardial oxygen demand. References Birnbaum, Y., Wilson, J. M., Fiol, M., de Luna, A. B., Eskola, M., & Nikus, K. (2014). ECG diagnosis and classification of acute coronary syndromes. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 19(1), 4–14. https://doi.org/10.1111/anec.12130 Buttà, C., Zappia, L., Laterra, G., & Roberto, M. (2020). Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 25(3), e12726. https://doi.org/10.1111/anec.12726 Cadogan, E. B. a. M. (2024, October 8). Myocardial Ischaemia. Life in the Fast Lane • LITFL. Retrieved December 7, 2024, from https://litfl.com/myocardial-ischaemia-ecg-library/#:~:text=ST%20depression%20due%20to%20subendocardial,left%20main%20coronary%20artery%20occlusion. Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Alec Coston MD Educational Pearls: Causes of seizures in a fairly well-appearing child with diarrhea: Electrolyte abnormalities: hypocalcemia, hyponatremia Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures Hypoglycemia If the child has diarrhea and appears very sick, differential diagnosis may include: Hemolytic uremic syndrome (HUS): simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or enterohemorragic E. coli) One of the main causes of acute kidney injury in children Toxic ingestions such as salicylates, lead, or iron In this case, the child had a seizure but appeared well and was afebrile: Consult with neurology led to a diagnosis of benign convulsions with mild gastroenteritis (CwG) First identified in 1982 in Japan Viral gastroenteritis with diarrhea and convulsions but does not include fever, severe dehydration, or electrolyte abnormalities Uncommon illness caused by rotavirus and norovirus pathogens Criteria for discharge is similar to a febrile seizure - the patient had one seizure that lasted less than 15 minutes and he quickly returned to his baseline, so he was able to be safely discharged home This diagnosis does not predispose him to epilepsy later in life References Lee YS, Lee GH, Kwon YS. Update on benign convulsions with mild gastroenteritis. Clin Exp Pediatr. 2022 Oct;65(10):469-475. doi: 10.3345/cep.2021.00997. Epub 2021 Dec 27. PMID: 34961297; PMCID: PMC9561189. Mauritz M, Hirsch LJ, Camfield P, et al. Acute symptomatic seizures: an educational, evidence-based review. Epileptic Disorders. 2200;1(1). doi:https://doi.org/10.1684/epd.2021.1376 ‌Noris, Marina*; Remuzzi, Giuseppe*, †. Hemolytic Uremic Syndrome. Journal of the American Society of Nephrology 16(4):p 1035-1050, April 2005. | DOI: 10.1681/ASN.2004100861    Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Aaron Lessen MD Educational Pearls: Can opioids cause cardiac arrest? Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest. In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids. Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)? Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC) Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA But does naloxone improve neurologic outcomes? Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes What is the dose? 2-4 mg IN/IV depending on access. High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV References Orkin, A. M., & Dezfulian, C. (2024). Recognizing the fastest growing cause of out-of-hospital cardiac arrest. Resuscitation, 198, 110206. https://doi.org/10.1016/j.resuscitation.2024.110206 Quinn, E., & Du Pont, D. (2024). Naloxone administration in out-of-hospital cardiac arrest: What's next?. Resuscitation, 201, 110307. https://doi.org/10.1016/j.resuscitation.2024.110307 Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2010). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42–46. https://doi.org/10.1016/j.resuscitation.2009.09.016 Wampler D. A. (2024). Naloxone in Out-of-Hospital Cardiac Arrest-More Than Just Opioid Reversal. JAMA network open, 7(8), e2429131. https://doi.org/10.1001/jamanetworkopen.2024.29131 Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen MD Educational Pearls: A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue Prospective, observational study of acute stroke management Conducted at a large urban, comprehensive stroke center The study evaluated patients in multiple categories:  admitted to med/surg admitted to med/surg but held in the ED admitted to the ICU Admitted to ICU but held in the ED Examined the amount of time nurses and providers spent with each patient This was analyzed in conjunction with the knowledge of each providers' salaries and the overhead costs of the med/surg unit, ICU, and ED  Conclusions: Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost $1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large $2267 for ICU inpatient boarding vs $2165 for ICU care Holding in the ED negatively impacts patients since they receive less time from providers Holding also results in increased financial costs References Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O'Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012 Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

 I summarize my the latest version of the greatest and most important book I will ever write: The Unchained Man. This will change your life.

Contributor: Aaron Lessen MD Educational Pearls: Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma Majority are caused by automobile collisions or motorcycle accidents Due to sudden deceleration mechanism accidents Clinical manifestations Signs of hypovolemic shock including tachycardia and hypotension, though not always present Patients may have altered mental status Imaging Widened mediastinum on chest x-ray, though not highly sensitive CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used Four types of aortic injury (in order of ascending severity) I: Intimal tear or flap II: Intramural hematoma III: Pseudoaneurysm IV: Rupture Management Hemodynamically unstable: immediate OR for exploratory laparotomy and repair Hemodynamically stable: heart rate and blood pressure control with beta-blockers Minor injuries are treated with observation and hemodynamic control Severe injuries may receive surgical management Some patients benefit from delayed repair An endovascular aortic graft is a surgical option Mortality 80-85% of patients die before hospital arrival 50% of patients that make it to the hospital do not survive References Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma [published correction appears in J Trauma Acute Care Surg. 2015 Feb;78(2):447]. J Trauma Acute Care Surg. 2015;78(1):136-146. doi:10.1097/TA.0000000000000470 Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027 Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-341. doi:10.1016/j.jvs.2013.09.007 Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med. 2020;59(3):418-423. doi:10.1016/j.jemermed.2020.05.003 Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248(3):748-762. doi:10.1148/radiol.2483071416 Summarized by Jorge Chalit, OMS3 | Edited by Meg Joyce & Jorge Chalit Donate: https://emergencymedicalminute.org/donate/  

Contributor: Taylor Lynch, MD Educational Pearls: What is neutropenic fever? Specific type of fever that is seen in cancer patients and other patients with impaired immune systems These patients are highly susceptible to infection Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour. The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe. Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning What is the workup and treatment? Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray. Do not preform a rectal exam or obtain a rectal core temperature. This could cause bacteremia. Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin. Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room) References Peseski, A. M., McClean, M., Green, S. D., Beeler, C., & Konig, H. (2021). Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert review of anti-infective therapy, 19(3), 359–378. https://doi.org/10.1080/14787210.2020.1820863 Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269 Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3  

Episode 186: Unveiling AI's Realism: My Keynote Summarized by AvatarsIn this episode, Dr. Janel Anderson delves into the fascinating world of AI-generated content, showcasing a realistic, AI-generated discussion that interpreted her keynote, Take Charge of Your Future. Two incredibly realistic AI “people” capture the essence of her speech, from the importance of continuous learning to making workplace connections and pushing your growth edges. While overall the AI narrators do a great job of summarizing the content, Dr. Anderson clarifies minor inaccuracies in the AI's interpretation and assesses its performance. This episode highlights how technology can amplify human connection and innovation. Whether you're a tech enthusiast or curious about leadership and personal growth, you'll find insightful ideas to apply in your professional journey.Find show notes at https://janelanderson.com/186

Contributor: Aaron Lessen, MD Educational Pearls: Pediatric case study where the child's tongue was stuck in the opening of a hard plastic drink lid Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time There is a risk of ischemia with prolonged entrapment Initially tried 2% viscous lidocaine for analgesia and lubricant The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar! Sugar granules absorb water which decreases tissue edema This option avoids sedation and aggressive treatment References A Young Girl with Tongue Swelling Jarjour, Jane et al. Annals of Emergency Medicine, Volume 84, Issue 3, 317 - 318 Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Megan Hurley, MD Educational Pearls: Fevers Tylenol Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated Can limit the amount of amniotic fluid produced Can lead to growth restriction Can cause premature closure of the ductus arteriosus Cough Cough drops Humidifier Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss Congestion Flonase (Fluticasone nasal spray) Nasal rinses Humidifier 1st generation anti-histamines (Diphenhydramine, Doxylamine, etc.) However, these tend to have more side effects such as fatigue, drowsiness, and dizziness Concider switching to a 2nd generation (Cetirizine, Loratidine, etc.) during the day Disease specific treatments Flu (A and B) gets tamiflu (Oseltamivir) Covid gets paxlovid (Nirmatrelvir/ritonavir) Antibiotics for suspected pneumonia Additional recommendations Elevating the head of bed Nasal strips Stay well hydrated Tea Ice chips Echinacea Zinc Rest Avoid NSAIDs Pseudophedrine Afrin (Oxymetazoline) Combined meds in general References Antonucci, R., Zaffanello, M., Puxeddu, E., Porcella, A., Cuzzolin, L., Pilloni, M. D., & Fanos, V. (2012). Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn. Current drug metabolism, 13(4), 474–490. https://doi.org/10.2174/138920012800166607 Black, E., Khor, K. E., Kennedy, D., Chutatape, A., Sharma, S., Vancaillie, T., & Demirkol, A. (2019). Medication Use and Pain Management in Pregnancy: A Critical Review. Pain practice : the official journal of World Institute of Pain, 19(8), 875–899. https://doi.org/10.1111/papr.12814 D'Ambrosio, V., Vena, F., Scopelliti, A., D'Aniello, D., Savastano, G., Brunelli, R., & Giancotti, A. (2023). Use of non-steroidal anti-inflammatory drugs in pregnancy and oligohydramnios: a review. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 36(2), 2253956. https://doi.org/10.1080/14767058.2023.2253956 Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3  

JD Vance crushes the vice-presidential debate, over 218,000 people are on the voter rolls illegally in Arizona, and Iran attacks Israel.Click here to join the member-exclusive portion of my show: https://bit.ly/4biDlriEp.1586- - -DailyWire+:Join the Fight for 47 with 47% Off NEW Annual DailyWire+ Memberships using code FIGHT! https://dailywire.com/subscribeFrom the white guys who brought you “What is a Woman?” comes Matt Walsh's next question: “Am I Racist?” | IN THEATERS NOW! Get tickets: https://www.amiracist.comOrder your Mayflower Cigars here: https://bit.ly/3Qwwxx2 (Must be 21+ to purchase. Exclusions may apply)- - -Today's Sponsors:PureTalk - Get one year free of DW+ Insider: https://www.PureTalk.com/KnowlesFirst Liberty Institute - Go to https://supremecoup.com/knowles to learn how you can help stop the radical Left's takeover of the Supreme Court.- - -Socials:Follow on Twitter: https://bit.ly/3RwKpq6Follow on Instagram: https://bit.ly/3BqZLXAFollow on Facebook: https://bit.ly/3eEmwygSubscribe on YouTube: https://bit.ly/3L273Ek

On this week's incredibly on-time New Flesh podcast, Brett & Jesse speak some evil about the now-in-theaters (very) Americanized U.S. remake of SPEAK NO EVIL, the 2022 original is now on Shudder and made Brett's best horror movies of the year list that year. Before the main event, some horror news! Summarized at bottom. THE CROW early releases continue on Patreon. Bonus episodes upcoming as well! Get in on the action for $5 https://www.patreon.com/newfleshpodcast The Life of Chuck at TIFF, Creep Tapes update, Terrifier 3 popcorn bucket, The Crow available now at home, and more.

President Trump has his first debate with Kamala Harris and the two Democrat moderators, Eric Swalwell freaks out over cat memes, and Vanity Fair is furious that people are converting to Catholicism. Click here to join the member-exclusive portion of my show: https://bit.ly/4biDlri Ep.1571 - - - DailyWire+: Join the Fight for 47 with 47% Off NEW Annual DailyWire+ Memberships using code FIGHT! https://dailywire.com/subscribe From the white guys who brought you “What is a Woman?” comes Matt Walsh's next question: “Am I Racist?” | IN THEATERS THIS FRIDAY! Get tickets NOW: https://www.amiracist.com Order your Mayflower Cigars here: https://bit.ly/3Qwwxx2 (Must be 21+ to purchase. Exclusions may apply) - - -  Today's Sponsors: Good Ranchers - Exclusive offer for my listeners with promo code KNOWLES: https://www.goodranchers.com Stamps - Get a 4-week trial, free postage, and a digital scale at https://www.stamps.com/knowles. Thanks to Stamps.com for sponsoring the show! - - - Socials: Follow on Twitter: https://bit.ly/3RwKpq6 Follow on Instagram: https://bit.ly/3BqZLXA Follow on Facebook: https://bit.ly/3eEmwyg Subscribe on YouTube: https://bit.ly/3L273Ek

Contributor: Travis Barlock, MD Educational Pearls: SVT: supraventricular tachycardia Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine EKG criteria before adenosine administration in SVT Regular rhythm Monomorphic: ​​all QRS complexes are identical If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine  Adenosine can worsen polymorphic VTach and lead to VFib References Ganz, Leonard I., and Peter L. Friedman. “Supraventricular Tachycardia.” New England Journal of Medicine, vol. 332, no. 3, 19 Jan. 1995, pp. 162–173, https://doi.org/10.1056/nejm199501193320307. Smith JR, Goldberger JJ, Kadish AH. Adenosine induced polymorphic ventricular tachycardia in adults without structural heart disease. Pacing Clin Electrophysiol. 1997;20(3 Pt 1):743-745. doi:10.1111/j.1540-8159.1997.tb03897.x Viskin, Sami, et al. “Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy.” Circulation, vol. 144, no. 10, 7 Sept. 2021, pp. 823–839, https://doi.org/10.1161/circulationaha.121.055783. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3  

Contributor: Aaron Lessen, MD Educational Pearls: How does an automated blood pressure cuff work? Automated blood pressure cuffs work differently than taking a manual blood pressure. While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff. An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures. These oscillations are at a maximum when the pressure in the cuff matches the mean arterial pressure (MAP) and therefore the machines are most accurate at reporting the MAP. The machines then use the MAP and other information about the oscillations to estimate the systolic and diastolic pressures, which are less accurate. What should you do if you need more accurate systolic and diastolic blood pressures? Take a manual blood pressure. Get an arterial-line (a-line), which provides continuous data for the blood pressure at the end of a catheter. What happens if the cuff is too big or too small for the patient? If the cuff is too small it will overestimate the pressure. If the cuff is too large it will underestimate the pressure. What should you do if the cuff cycles a bunch of times before reporting a blood pressure? It probably isn't very accurate so consider another method. Bonus fact! The MAP is not directly in the middle of the systolic and diastolic pressures but is weighted towards the diastolic pressure. The MAP can be calculated by adding two-thirds of the diastolic pressure to one third of the systolic pressure. For example if the BP is 120/90 the MAP is 100 mmHg. References Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179–189. https://doi.org/10.1586/17434440.2016.1128821 Liu, J., Li, Y., Li, J., Zheng, D., & Liu, C. (2022). Sources of automatic office blood pressure measurement error: a systematic review. Physiological measurement, 43(9), 10.1088/1361-6579/ac890e. https://doi.org/10.1088/1361-6579/ac890e Vilaplana J. M. (2006). Blood pressure measurement. Journal of renal care, 32(4), 210–213. https://doi.org/10.1111/j.1755-6686.2006.tb00025.x Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3  

What happens in a person's life that causes a sinner to become a saint? Today, Sinclair Ferguson looks closely at a familiar Bible verse that gets to the heart of our spiritual transformation. Read the transcript: https://ligonier.org/podcasts/things-unseen-with-sinclair-ferguson/sanctification-summarized A donor-supported outreach of Ligonier Ministries. Donate: https://www.ligonier.org/donate/ Explore all of our podcasts: https://www.ligonier.org/podcasts

Democrats kick off the DNC by claiming America is on stolen land, Tim Walz ruined Thanksgiving, and a new study shows the Shroud of Turin is 2,000 years old. Click here to join the member-exclusive portion of my show: https://bit.ly/4biDlri Ep.1556 - - - DailyWire+: From the white guys who brought you “What is a Woman?” comes Matt Walsh's next question: “Am I Racist?” | Get tickets NOW: https://www.amiracist.com Get 35% off an Annual Membership NOW with code FIGHT: https://dailywire.com/subscribe Order your Mayflower Cigars here: https://bit.ly/3Qwwxx2 (Must be 21+ to purchase. Exclusions may apply) - - -  Today's Sponsors: Good Ranchers - Get the Michael Knowles box: https://www.goodranchers.com/dailywire. Use code KNOWLES for additional savings. PureTalk - Get one year free of DW+ Insider: http://www.PureTalk.com/Knowles  - - - Socials: Follow on Twitter: https://bit.ly/3RwKpq6 Follow on Instagram: https://bit.ly/3BqZLXA Follow on Facebook: https://bit.ly/3eEmwyg Subscribe on YouTube: https://bit.ly/3L273Ek

Contributor: Megan Hurley, MD Educational Pearls:  Heat cramps Occur due to electrolyte disturbances Most common electrolyte abnormalities are hyponatremia and hypokalemia Heat edema Caused by vasodilation with pooling of interstitial fluid in the extremities Heat rash (miliaria) Common in newborns and elderly Due to accumulation of sweat beneath eccrine ducts Heat syncope Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure Treatment is removal from the heat source and rehydration (IV fluids or Gatorade) Heat exhaustion Patients have elevated body temperature (greater than 38º C but less than 40º C) Symptoms include nausea, tachycardia, headache, sweating, and others Normal mental status or mild confusion that improves with cooling Treatment is removal from the heat source and hydration Classic heat stroke From prolonged exposure to heat Defined as a core body temperature > 40.5º C, though not required for diagnosis or treatment Presentation is similar to heat exhaustion with the addition of neurological deficits including ataxia Patients present “dry” Exertional heat stroke Prolonged exposure to heat during exercise Similar to classic heat stroke but the patients present “wet” due to antecedent treatment in ice baths or other field treatments Management of heat-related illnesses includes: Cooling Rehydration Evaluation of electrolytes Antipyretics are not helpful because heat-induced illnesses are not due to hypothalamic dysregulation References Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35:141. Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. Lancet 2021; 398:698. Epstein Y, Yanovich R. Heatstroke. N Engl J Med 2019; 380:2449. Gardner JW, JA K. Clinical diagnosis, management, and surveillance of exertional heat illness. In: Textbook of Military Medicine, Zajitchuk R (Ed), Army Medical Center Borden Institute, Washington, DC 2001. Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999; 15:251. Lipman GS, Gaudio FG, Eifling KP, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update. Wilderness Environ Med 2019; 30:S33. Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce, MS1  

Ephesians 5:29-33 Sometimes it is helpful to simplify. When we can distill a group or individual's purpose down to one simple statement, it becomes easier to see one's priorities. He can use the statement as a lens by which to view all of the lesser responsibilities. We find such a statement about marriage in today's passage! Don't miss it!

White House Press Secretary Karine Jean-Pierre can't name a single Kamala achievement, President Trump returns to X, and the American Society of Plastic Surgeons comes out against “gender-affirming care” for minors. Click here to join the member-exclusive portion of my show: https://bit.ly/4biDlri Ep.1551 - - - DailyWire+: From the white guys who brought you “What is a Woman?” comes Matt Walsh's next question: “Am I Racist?” | Get tickets this Thursday, Aug 15: https://www.amiracist.com Get tickets to Backstage LIVE at the Ryman, tomorrow, August 14! https://bit.ly/46igytS Check out my new candle collection, available now: https://bit.ly/3VrZ6Ot Order your Mayflower Cigars here: https://bit.ly/3Qwwxx2(Must be 21+ to purchase. Exclusions may apply) - - -  Today's Sponsors: Birch Gold - Text "KNOWLES" to 989898, or go to https://birchgold.com/Knowles, for your no-cost, no-obligation, FREE information kit. Zero Debt USA - Learn how to get out of debt today! Visit http://www.donewithdebt.com - - - Socials: Follow on Twitter: https://bit.ly/3RwKpq6 Follow on Instagram: https://bit.ly/3BqZLXA Follow on Facebook: https://bit.ly/3eEmwyg Subscribe on YouTube: https://bit.ly/3L273Ek

President Trump closes the RNC with perhaps the best speech of his political career, Democrat sources say Biden is likely to bow out, and the list of Secret Service failures continues to mount, all while Kimberly Cheatle keeps her job. Click here to join the member-exclusive portion of my show: https://bit.ly/4biDlri Ep.1534 - - - DailyWire+: Get 10% off your tickets to “Sound of Hope: The Story of Possum Trot” at http://angel.com/MICHAEL We are giving you a presidential discount. Get 47% off annual memberships now with code FIGHT: http://dailywire.com/subscribe Check out my new candle collection, available now: https://bit.ly/3VrZ6Ot Order your Mayflower Cigars here: https://bit.ly/3Qwwxx2(Must be 21+ to purchase. Exclusions may apply) - - -  Today's Sponsors: Kudos - Earn more credit card rewards, points, and cash back at https://joinkudos.com. Use code “KNOWLES” to get $20 back after your first eligible purchase! Ramp - Get $250 when you join Ramp. Go to http://www.ramp.com/KNOWLES Roman - For treatment that works fast and lasts long, grab the moment. Learn more at http://www.Ro.co/KNOWLES - - - Socials: Follow on Twitter: https://bit.ly/3RwKpq6 Follow on Instagram: https://bit.ly/3BqZLXA Follow on Facebook: https://bit.ly/3eEmwyg Subscribe on YouTube: https://bit.ly/3L273Ek

The first Presidential debate sends Democrats into a full-blown panic, Anthony Blinken says getting more gay is in our national security interests, and a UK mother is encouraged to abort her Down Syndrome baby at full term.  Click here to join the member-exclusive portion of my show: https://bit.ly/4biDlri Ep.1521 - - - DailyWire+: Check out my new candle collection, available now: https://bit.ly/3VrZ6Ot Get 10% off your tickets to Sound of Hope: The Story of Possum Trot at http://angel.com/MICHAEL  Get 30% off your DailyWire+ Membership today with code DEBATE: https://bit.ly/4akO7wC  Get your Yes or No game here: https://bit.ly/3X6tlKY - - -  Today's Sponsors: Birch Gold - Text "KNOWLES" to 989898, or go to https://birchgold.com/KNOWLES, for your no-cost, no-obligation, FREE information kit. Kudos - Earn more credit card rewards, points, and cash back at https://joinkudos.com. Use code “KNOWLES” to get $20 back after your first eligible purchase! Freedom Project Academy - Save 10% on tuition when you enroll at https://freedomforschool.com/ - - - Socials: Follow on Twitter: https://bit.ly/3RwKpq6 Follow on Instagram: https://bit.ly/3BqZLXA Follow on Facebook: https://bit.ly/3eEmwyg Subscribe on YouTube: https://bit.ly/3L273Ek