Podcast # 479: Clots and Pregnancy

Author:  Nick Hatch, MD

Educational Pearls:

  • Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer
  • A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE
  • Using this protocol, only 1 DVT was missed. No PE’s were missed.
  • This protocol has growing evidence as an option in pregnant women in whom you must rule out a DVT/PE but more validating studies are likely necessary

References

van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertoletti L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865. PubMed PMID: 30893534.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

 

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Podcast # 478: Psychedelics and Depression

Author: Chris Holmes, MD

Educational Pearls:

  • Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes
  • Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience
  • This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial results

References

https://www.nationalgeographic.com/culture/2019/05/ancient-hallucinogens-oldest-ayahuasca-found-shaman-pouch/

Carhart-Harris RL et. al. Psilocybin with psychological support for treatment-resistant depression: six-month follow-up. Psychopharmacology (Berl). 2018 Feb;235(2):399-408. doi: 10.1007/s00213-017-4771-x. Epub 2017 Nov 8. PubMed PMID: 29119217; PubMed Central PMCID: PMC5813086.

Palhano-Fontes F et. al. Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: a randomized placebo-controlled trial. Psychol Med. 2019 Mar;49(4):655-663. doi: 10.1017/S0033291718001356. Epub 2018 Jun 15. PubMed PMID: 29903051; PubMed Central PMCID: PMC6378413.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 477: Postpolypectomy Electrocoagulation Syndrome

Author:  Nick Hatch, MD

Educational Pearls:

  • Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy
  • Occurs when cautery causes transmural thickening from a contact burn
  • Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc.
  • CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging
  • Treatment is often with antibiotics and supportive care – in severe cases, hospitalization may be required.

References

Benson BC, Myers JJ, Laczek JT. Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation. Case Rep Emerg Med. 2013;2013:687931. doi: 10.1155/2013/687931. Epub 2013 Jul 15. PubMed PMID: 23956889; PubMed Central PMCID: PMC3728495.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 476: Evidence for Patient Satisfaction

Author: Dylan Luyten, MD

Educational Pearls:

  • Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated
  • Having others in the room or with the patient while they wait also has a positive effect
  • Under-promising and over-delivering can result in better patient experience
  • Managing up others and services provided also is demonstrated to improve satisfaction
  • Perceived time with health care members (physicians, APPs, nurses, etc) also is supported to improve satisfaction
  • Sitting with patients increases the perception of time

 

References

Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Acad Emerg Med. 2000 Jun;7(6):695-709. Review. PubMed PMID: 10905652.

Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2017;5(2):101–106. doi:10.1177/2374373517731359

 

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 475: Orthostatic Vital Signs and Syncope

Author: Michael Hunt, MD

Educational Pearls:

  • A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope
  • Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs
  • There was no statistically significance between orthostatic vital signs and serious outcomes in 30 days

Editor’s note: study used a composite end-point of multiple serious outcomes

References

White JL, Hollander JE, Chang AM, Nishijima DK, Lin AL, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Nicks BA, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019 Mar 25;. doi: 10.1016/j.ajem.2019.03.036. [Epub ahead of print] PubMed PMID: 30928476.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD>

Podcast # 474: Obesity Hypoventilation Syndrome

Author: Peter Bakes, MD

Educational Pearls:

  • The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver
  • Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure
  • OHS criteria includes obesity, sleep disordered breathing, and alveolar hypoventilation (PaCO2 > 45 mmHg)
  • The causes of OHS are multifactorial, and include mechanical problems with breathing and hormonal changes

References

Balachandran JS, Masa JF, Mokhlesi B. Obesity Hypoventilation Syndrome Epidemiology and Diagnosis. Sleep Med Clin. 2014;9(3):341–347. doi:10.1016/j.jsmc.2014.05.007

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 473: Direct to Consumer Antibiotics

Author: Sam Killian, MD

Educational Pearls:

  • A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers
  • Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care providers, respectively
  • Nearly 4/10 antibiotic prescriptions from telemedicine visits were not indicated based on antibiotics guideline recommendations

References

Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-2491. Epub 2019 Apr 8. PubMed PMID: 30962253.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 472: SMART Crystalloids

Author: Gretchen Hinson, MD

Educational Pearls:

  • In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks
  • Compared to normal saline, a balanced crystalloid (either lactated Ringer’s or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions and Major Adverse Renal Events Trial)
  • Balanced crystalloids such as lactate Ringer’s may be preferable in more critically ill populations

References

Yau YW, Kuan WS. Choice of crystalloids in sepsis: a conundrum waiting to be solved. Ann Transl Med. 2016;4(6):121. doi:10.21037/atm.2016.02.09

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 471: Cyclic Vomiting

Author: Don Stader, MD

Educational Pearls:

  • Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two.
  • CHS is thought to be caused by activation of THC receptors in the gut
  • CVS is associated with migraines and therefore responds to similar medications
  • Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol)
  • Amitriptyline, as well as anti-epileptics can be used to prevent CVS
  • Opioids worsen CVS

References

Lapoint J, Meyer S, Yu CK, Koenig KL, Lev R, Thihalolipavan S, Staats K, Kahn CA.Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8. PubMed PMID: 29560069; PubMed Central PMCID: PMC5851514.

Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10. Epub 2010 Jan 28.

Hikita T, Kodama H, Kaneko S, Amakata K, Ogita K, Mochizuki D, Kaga F, Nakamoto N, Fujii Y, Kikuchi A. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia. 2011;31(4):504. Epub 2010 Dec 8.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 470: Zofran and Pregnancy

Author: Jared Scott, MD

Educational Pearls:

  • Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy
  • 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron
  • Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis)
  • When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient

Editor’s note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0)

References

Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD