Podcast #332 – Door To Furosemide Time

Author: Nick Hatch, MD

Educational Pearls:

  • Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002).
  • A flaw in the study is that there were significant baseline differences between groups.

References:

Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794

Podcast # 331: Oral Rehydration Therapy (ORT)

Author: Nick Hatch, MD

Educational Pearls:

  • The sodium-glucose cotransporter in the gut is essential for rehydration.
  • Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
  • ORT has saved millions of lives globally.
  • Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

Podcast #330: Behcet Disease

Author: Nick Hatch, MD

Educational Pearls:

  • Behcet Disease is an autoimmune disease that can affect any organ system.
  • Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes.
  • Patients with Behcet disease with hypotension should have low threshold for giving steroids.

References:

Arlt W, Allolio B. Adrenal insufficiency. Lancet, 2003; 361:1881.

Sakane T, Takeno M, Suzuki N, Inaba G. Behçet’s disease. New England Journal of Medicine. 1999; 341:1284.

Podcast # 329: Hypokalemic Periodic Paralysis

Author: Dylan Luyten , MD

Educational Pearls:

  • Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.
  • Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.
  • Supplemental potassium can rapidly reverse symptoms.
  • Important to rule out thyrotoxicosis (get a TSH!).
  • Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.

 

References:

Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic

Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.

Podcast # 328: Sleep Deprivation

Author: Sam Killian, MD

Educational Pearls:

  • Insufficient sleep and disrupted circadian rhythms are a major health problem today
  • Millions of dollars, thousands of deaths, and millions of  injuries are related to sleep deprivation every year
  • 56 billion dollars – 24,000 deaths – 2.5 million disabiling injuries related to a sleep-type deprivation
  • Exxon valdez, challanger, chyrnobel linked to sleep deprivation- at least partially
  • Data has shown that in the Spring (when people lose an hour of sleep) there were 8% more traffic accidents on the Monday immediately after daylight savings. Conversely, in the Fall (when people gain an hour of sleep), there were 8% fewer traffic accidents on the Monday immediately after daylight savings.
  • Studies have also shown an increased risk of myocardial infarction in Spring immediately after daylight savings, and a decreased risk of myocardial infarction in the Fall immediately after daylight savings.

References:

Corren S. Traffic Accidents and Daylight Saving Time. New England Journal of Medicine. 1996;335(5):355-357. doi:10.1056/nejm199608013350517

Janszky I, Ljung R. Shifts to and from Daylight Saving Time and Incidence of Myocardial Infarction. New England Journal of Medicine. 2008;359(18):1966-1968. doi:10.1056/nejmc0807104.

Podcast # 327: No More Hemoccults

Author: Don Stader, MD

Educational Pearls:

  • The use of fecal occult blood tests is falling out of favor in emergency departments.
  • In the ED, small amounts of bleeding are often not clinically significant and can lead to harms and costs of over-testing.
  • They have relatively high false positive and false negative rates.
  • Fecal occult blood tests have strong evidence suggesting their efficacy in cancer screening.

References:

Cuthbert JA, Hashim IA. Diagnostic Fecal Occult Blood Testing in Hospitalized and Emergency Department Patients: Time for Change? Laboratory Medicine. 2018. doi:10.1093/labmed/lmy010.

Podcast # 326: Valley Fever

Author: Michael Hunt, MD

Educational Pearls:

  • Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias.
  • A thorough history is critical to the diagnosis. Disease is localized to  the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America.
  • Disease is caused by inhaling fungal spores which damage the lung. Rarely, the disease can disseminate and cause infections that require systemic anti fungal therapy.

 

References:

Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis–United States, 1998-2011. MMWR Morb Mortal Wkly Rep 2013; 62:217.

Saubolle MA, McKellar PP, Sussland D. (2007). Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. Journal of Clinical Microbiology. 45:26.

Taylor AB, Briney AK. (1949). Observations on primary coccidioidomycosis. Annals of Internal Medicine. 30:1224.

Podcast #325: Vaping and Pneumonia

Author: Sam Killian, MD

Educational Pearls:

  • Being exposed to E-cigarette vapor may increase risk of pneumonia.
  • Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes.

References:

Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epithelial cells. The European Respiratory Journal. 7;51(2).

Podcast #324: Superwarfarin

Author: Rachel Beham, PharmD

Educational Pearls:

  • Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy.
  • Brodifacoum is commonly known as “superwarfarin” and has a very long half life of 120+ days.
  • Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use.
  • Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months).

References:

Lipton R.A.; Klass E.M. (1984). “Human ingestion of a ‘superwarfarin’ rodenticide resulting in a prolonged anticoagulant effect”. JAMA. 252: 3004?3005.

La Rosa F; Clarke S; Lefkowitz J. B. (1997). “Brodifacoum intoxication with marijuana smoking”. Archives of Pathology & Laboratory Medicine. 121: 67?69

Podcast #323: Calcium Channel Toxicity

Author: Jared Scott, M.D.

Educational Pearls:

  • Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin.
  • Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance.
  • Resultant cardiac depression and hypotension.
  • Pancreatic beta cells also use calcium to release insulin, so calcium channel blockade can cause hyperglycemia.
  • Treatment for calcium channel toxicity include: fluid resuscitation, calcium gluconate, vasopressors, and high dose insulin.
  • Dosing for insulin therapy is usually 1-5 Units/kg/hr. Make sure to add dextrose!

 

References:

Boyer EW, Shannon M. (2001).Treatment of calcium-channel-blocker intoxication with insulin infusion. New England Journal of Medicine. 344:1721.

Proano L, Chiang WK, Wang RY. (1995).Calcium channel blocker overdose. American Journal of Emergency Medicine. 13:444.

St-Onge M, Dubé PA, Gosselin S, et al. (2014). Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology. 52:926.