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

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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

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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

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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

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Podcast # 469: Go PO

Author: Dave Rosenberg, MD

Educational Pearls:

  • Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration
  • However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these
  • Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not

References

Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476

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

Podcast # 468: Typhlitis

Educational Pearls:

  • Typhlitis refers to the presence of enterocolitis in the setting of neutropenia – also known as neutropenic enterocolitis
  • Commonly a result of chemotherapy for hematologic malignancies.
  • The infection is usually polymicrobial/fungal and can lead to septic shock
  • Usually presents with fever, abdominal pain, with associated GI complaints
  • Workup includes CBC for the ANC (usually <500), and a CT abdomen (look for bowel thickening)
  • Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents
  • Mortality can be as high as 50%

References

Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645.

Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285.

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

Podcast # 467: Cauda Equina Syndrome

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord
  • Trauma, infection, hematoma, disc rupture/herniation can cause this – basically anything that can cause pressure and fill space
  • Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation
  • Post-void residual that is abnormally high may be an indicator
  • MRI is diagnostic modality of choice
  • Emergent surgical decompression is treatment

References

Jalloh I, Minhas P. Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J. 2007 Jan;24(1):33-4. doi: 10.1136/emj.2006.038182. PubMed PMID: 17183040; PubMed Central PMCID: PMC2658150.

Podcast # 466: Subacute Sclerosing Panencephalitis

Author: Nicholas Hatch, MD

Educational Pearls:

  • Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days
  • A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection
  • SSPE is a central nervous system disease that has no cure and is nearly universally fatal
  • Educating patients on the importance of vaccination should include discussion of these long term consequences

References

Pallivathucal LB, Noymer A. Subacute sclerosing panencephalitis mortality, United States, 1979-2016: Vaccine-induced declines in SSPE deaths. Vaccine. 2018 Aug 23;36(35):5222-5225. doi: 10.1016/j.vaccine.2018.07.030. Epub 2018 Jul 26. PubMed PMID: 30057285.

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

Podcast # 465: As easy and 1, 2, 10 – Capillary Refill and Sepsis

Author: Ryan Circh, MD

Educational Pearls:

  • The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation
  • Capillary refill time was standardized (this is not straightforward):
    • A glass microscope slide was pressed on the ventral side of the right index finger
    • Pressure was increased until the skin was blanched
    • This pressure was sustained for another 10 seconds
    • After pressure was removed, the time to return to normal skin color was timed
    • Greater than three seconds was considered abnormal.
  • No difference between the two groups for mortality at 28-days

Editor’s note: lactates have become so ingrained in our practice it will be tough to change habits but this is an excellent quiver for those of us that hate the over reliance on this lab value alone, despite some of the limitations of the study.

References

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi:10.1001/jama.2019.0071

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

Podcast # 464: Narcan’t?

Author: Aaron Lessen, MD

Educational Pearls:

  • A problem of take-home-naloxone is the administration of it by an able-bodied bystander
  • Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone
  • Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present
  • Half of those in the presence of others had a bystander that was not impaired
  • Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients

References

Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007.

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