Ridgeview Podcast: CME Series: Recent Episodes
Ridgeview
A quality, portable, on-demand continuing medical education, brought to you by Ridgeview's Continuing Education program.
DISCLOSURE ANNOUNCEMENT: The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
In this final podcast of the Ridgeview CME Podcast Series [sigh], Dr. Dennis Mohling, an obstetrician/gynecologist with Western OB/GYN, a Division of Ridgeview Clinics, along with one of his patients, Abie Rosckes discuss a special case around a improbable postpartum event and the decisions that were made.
*Disclosure note: None of the speakers or planners for this education activity have relevant financial relationships to disclose with any inelgible company - who's primary business is producing marketing, selling, re-selling, or distributin healthcare products used by or on patients.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Explain the presentation of late postpartum hemorrhage (PPH).
- Distinguish the need for rapid evaluation and treatment of late postpartum hemorrhage (PPH).
- Summarize the team members and resources needed (and available) to ensure rapid delivery of treatment in a patient experiencing postpartum hemorrhage.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.
Thank-you for listening to the podcast.
Thanks to Dr. Dennis Mohling and Abbie Roskes for their expert knowlege and contribution to this podcast.
Also a special thanks to Jason Hicks and Fred DeMeuse for their contribution to all the Ridgeview CME Podcasts the past 6 seasons, as they made the educational podcasts fun and entertaining.
In this podcast, Dr. Chris Solie, an emergency physician, along with Jason Hicks, Fred DeMeuse, Greta Sowels (physician assistants), working for Emergency Medicine Physicians and Consultants (EMPAC) who review journals and papers around emergency medicine.
*Disclosure note: None of the speakers or planners for this education activity have relevant financial relationships to disclose with any inelgible company - who's primary business is producing marketing, selling, re-selling, or distributin healthcare products used by or on patients.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Identify emergency medicine journal articles that may be potentially practice changing.
- Differentiate between using a HEAR score versus a HEART score when assessing patients coming into the ED with chest pain.
- Restate whether vaccination during pregnancy could reduce the burden of respiratory syncytial virus (RSV) - associated lower respiratory tract illness in newborns and infants.
- Discuss the rate of wound infection from suturing with sterile gloves, dressings, drapes, etc. versus non-sterile gloves, dressings in emergency department.
- Discuss the risk-benefit of using tranexamic acid (TXA) in the treatment of gastrointestional bleeds.
- Identify interventions designed to reduce fatigue among emergency department physicians.
- Determine whether a direct oral penicillin challenge is noninferior to the standard of care of penicillin skin testing followed by an oral challenge in patients with a low-risk pencillin allergy.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.
RESOURCES
Article 1: O’Rielly, C.M., Andruchow, J.E., McRae, A.D. et al. External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing. Can J Emerg Med 24, 68–74 (2022). https://doi.org/10.1007/s43678-021-00159-y
Article 2: Kampmann B, Madhi SA, Munjal I, et al. Bivalent Prefusion F Vaccine in Pregnancy to Prevent RSV Illness in Infants. N Engl J Med. 2023;388(16):1451-1464. doi:10.1056/NEJMoa2216480
Article 3: Zwaans JJM, Raven W, Rosendaal AV, et al. Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial. Emerg Med J. 2022;39(9):650-654. doi:10.1136/emermed-2021-211540
Article 4: HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5
Article 5: Fowler LA, Hirsh EL, Klinefelter Z, Sulzbach M, Britt TW. Objective assessment of sleep and fatigue risk in emergency medicine physicians. Acad Emerg Med. 2023;30(3):166-171. doi:10.1111/acem.14606
Article 6: Copaescu AM, Vogrin S, James F, et al. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA Intern Med. 2023;183(9):944-952. doi:10.1001/jamainternmed.2023.2986
Thank-you for listening to the podcast.
Thanks to Dr. Chris Solie, Jason Hicks, Fred DeMeuse and Greta Sowels for their expert knowledge and contribution to this podcast.
In this podcast, Dr. Purvi Gada, a hematologist and oncologist, along with Alicia Wojchik, a nurse practitioner, both with Minnesota Oncology, come together to discuss immunotherapy in regards to cancer treatment.
*Disclosure note: Alicia Wojchik, C-NP, speaker for this educational event, has disclosed that she is a consultant for Merk. All relevant financial relationships for this individual has been mitigated.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Describe how the immune system functions (works), and how it impacts immunotherapy.
- Define the difference between immunotherapy and chemotherapy.
- Describe how immunotherapy drugs work.
- Identify and manage side effects of immunotherapy.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.
Thank-you for listening to the podcast.
Thanks to Dr. Purvi Gada and Alicia Wojchik for their expert knowledge and contribution to this podcast.
In this podcast, Dr. Brian Driver, an emergency medicine physician with Hennepin Healthcare, brings his research expertise to this podcast and will help to decipher the complexities of research articles, what makes a good study, and how we can better interpret the literature.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Define what is meant by "evidence-based medicine".
- Explain what makes a good research study.
- Correctly interpret findings in research articles.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.
Thank-you for listening to the podcast.
Thanks to Dr. Brian Driver for his expert knowledge and contribution to this podcast.
In this podcast, Dr. Nick Schneeman, a geriatrican and the Chief Medical Officer for LifeSpark, brings his passion and expertise to discuss the state of care in geriatrics, along with how current delivery in care and payment models effect the geriatric population.
Disclosure note: Dr. Nick Schneeman , speaker for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Describe what is meant by "value-based care".
- Describe current barriers to delivering high value care to a senior population.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
PODCAST OVERVIEW- Geriatric care delivery and quality has not evolved significiantly. - Pockets of excellence exist in academic centers. - Social support systems is integral, but lacking in many parts of the country. - Fee for service (FFS) system is not a sustainable model per Dr. Schneeman for complex senior patients. - Training and exposure to the 'business platforms' in medicine is lacking with providers - FFS = paying for a specific service, procedure, treatment, etc.
Value Based Care (VBC)- Value based care = outcomes/cost - Clinical outcomes - Experience outcomes of patient/family and caregiving team - How is VBC measured? - Medical loss ratio (cost containment) - How does VBC work? - Organization contracts with payor - VBC organization takes on risk - Money savings opportunity - Half of seniors in USA are already in a VBC model - Medicare (CMS) - ACO (group of doctors, health care organization, etc.) - Medicare advantage (CMS product that insurance companies contract with federal government) - Cost Product (Medicare advantage product) - Introduced in MN with assumption that this state will do such a good job with cost containment, but this wasn't how it worked out. - For-profits don't participate in Medicare advantage products which keep the non-profits more accountable, although there are also disadvantages with for-profit programs. - How does the care delivery work in VBC organizations (Nick's viewpoint)? - Step 1: Journey from simple problems into complexity - Step 2: What is the current reality and quality of life? (When people hear you restating their story, trust goes up immensily.) - Step 3: What are you hoping for? (patient, family, etc.) - Step 4: Acute care planning - Step 5: Chronic care planning - Outcomes: POLST (physician orders for life-sustaining treatment) form that is comprehensive; Chronic care plans that are clear and purposeful and match goals of care - Well done POLST forms require intential discussion with patient and advocates who have decision making capacity and understanding of the patient's reality and values
Palliative Care- How it's integrated and its controversy - All practitioners should be able to make palliative decisions with and for their patients who they know intimately - Palliative care as a specialty exists largely due to a FFS model - Often this is a clinican the patient has never met before and is a one time consult - Private equity had created palliative care 'cold call' business models in recent years
Value Based Care (VBC) - continued- How does a practitioner go about doing this? - Make sure the organization you join actually values the primacy of primary care - Clinicians need TIME with their complex patients and to be paid for this time - FFS can work well for simple problems - Who does this well? Small pockets, mostly senior care (i.e. clinic-based, homebased healthcare etc.) - Nurse, APP, physician - are assigned to each patient and continue to follow their care, avoid overprescribing, inappropriate abx - Private equity and Big insurance is getting into the game, but their approaches tend to be siloed and perhaps less humanistic - Recruiting quality providers to this care delivery model is imperative - Improved patient outcomes and costs exisst (i.e. geriatric assessment before cancer care) - Value Based Care really has to be an "all in" experience for a clinic or organization for it to work
Training- Training typically happens in house, as opposed to a training program or course - Subspecialists will still be very much part of the care team, although decision making about proceeding with advanced therapies will be oriented around the VBC medical home team - Pharmacy is a valuable team member as well, especially if part of the "goals of care" as opposed to merely looking up medications - Challenge: SNFs and long term care facilities often have significant staff turnover, care quality issues, and these can lead to unnecessary care, ED visits and hospitalizations
Evidence Based Moment (EBM) ResourcesMagill MK. Time to Do the Right Thing: End Fee-for-Service for Primary Care. Ann Fam Med. 2016 Sep;14(5):400-1. doi: 10.1370/afm.1977. PMID: 27621155; PMCID: PMC5394371. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394371/pdf/0140400.pdf
Basu S, Phillips RS, Song Z, Landon BE, Bitton A. Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model. Ann Fam Med. 2016 Sep;14(5):404-14. doi: 10.1370/afm.1960. PMID: 27621156; PMCID: PMC5394379. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.annfammed.org/content/annalsfm/14/5/404.full.pdf
Thanks to Dr. Nick Schneeman for his expert knowledge and contribution to this podcast.
In this podcast, Dr. Nedaa Skeik, a vascular surgeon with Minneapolis Heart Institute, brings his knowledge and experience in regards to vascular insufficiency, and the importance of a timely diagnosis and management options.
*Disclosure note: Dr. Nedaa Skeik, speaker for this educational event, has disclosed that he received honorarium from Medtronic. All relevant financial relationships for Dr. Skeik have been mitigated.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Summarize the pathophysiology of different venous disorders.
- Recognize and confidently diagnose venous insufficiency.
- Identify the risks and benefits of different interventions for venous conditions.
- Differentiate medical management (conservative and interventional) for venous insufficiency.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
PODCAST OVERVIEW
Wide Range of Venous Disorders and Presentations - Morphologic (spider, reticular, varicose), skin discoloration, ulceration - Functional (venous reflux +/- loss of pumping mechanism - Anatomic (thrombosis, congenital anomalies) - Presentation (asymptomatic vs symptomatic)Anatomy PathophysiologyEpidemiology - Chronic vein abnormalities- Prevalence (venous insufficiency) - Varicose veins & prevalence- Presence of symptoms Risk factors - Family component- Other Clinical features - Correlation - severity of venous reflux, age- Asymptomatic - General symptoms - Vein appearance - Severity Disease Severity - Classification Scales - CEAP calssification scale- Venous Clinial Severity Score Disease Progression - Correlation- pregression of disease not well understoodDiagnosis - History - Symptoms - Exam findings - including venous ultrasound - Differential diagnoses (edema, skin manifestations, vein engorgement) - Pre-management considerations (severity, superficial and/or deep, proximal/distal, multiple or single, comorbidities) ManagementAsymptomatic - visual sclerotherapy- surface laser therapy - complications Symptomatic- compression therapy - exercise - leg elevation - skin care Conserative Therapy- leg elevation - exercise - compression stockings Pharmacologic Therapy and Skin Care- vasoactive drugs - rheologic agents - skin care Interventional Options - Preintervention measures (venous anatomy, preop medications, anesthesia) - Sclerotherapy (visual, US guided)- Vein closure procedures (thermal - RFA/EVLA, chemical, MOCA, PEM, EHIT) - Surgical (phlebectomy, ligation, stripping) Post Intervention Care - pain management - ambulation - leg elevation - compression - return to normal activity/work - post procedural US - follow up appointment
Thanks to Dr. Nedaa Skeik for his expert knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Gabi Hester, a pediatric hospitalist and Quality Improvement (QI) medical director for Children's Hospitals of Minnesota and St. Luke's Hospital in Duluth. Dr. Hester brings her knowledge and experience in everything related to croup and bronchiolitis (specifically pertaining to in-patients and to frontline healthcare providers).
*Dr. Gabi Hester, speaker for this educational event, has disclosed that she is a consultant who provides content recommendations to AvoMed. All relevant financial relationships for Dr. Hester have been mitigated.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- State at least 2 challenges in the recognition of and treatment of acute respiratory illnesses in children.
- Describe potential interventions for bronchiolitis that have not been shown to provide significant benefit to most patients.
- Recognize common "mimickers" of croup.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
PODCAST OVERVIEW
CROUP (layngotracheitis)Overview - 400,000 approx. ER visits/year in U.S. - Costly, approx. $53 million/year - Scary disease due to airway obstruction - Para-influenza most common - Classically, kids are admitted after 2 racemic epinephrine nebulizers - Dr. Hester studied croup and hospitalization (see resources below) - Kids admitted, and no further treatment or intervention (observed) Presentation and treatment - Rhinorrhea, low grade fever, barky cough (seal bark)- Inspiratory stridor, usually worse when agitated - Rarely insp and exp stridor (if progressed disease state) - Dexamethason 0.6 mg/kg (max dose of 12-16 mg) - Nebulized racemic epinephrine (RA) - bridge for steroid to kick in - reserved for stridulous patient - Think about croup mimics - not responding to racemic epinephrine - older kids (i.e. 7 yr old), think about other diagnoses - Epiglottitis - cough is less barky - respiratory distress and tripoding - thumb print sign - Bacterial tracheitis - can be complication of viral croup - can quickly decompensate - Foreign body, airway anomalies, etc. TREATMENT: - cool outdoor air can be soothing, no good studies to support - humidified air - imaging can be done (steeple sign on AP neck) but not routinely required - Worried about foreign body? Epiglottitis? - not responding to racemic epi - CXR if hypoxia. Not typical of croup to be hypoxia.Research (links below) - Most kids don't need further treatment after ED course. -
In this podcast, Dr. Robert Steffen, a cardiac surgeon with Minneapolis Heart Institute. Dr. Steffen brings his knowledge and experience regarding the prevalence of aortic valve disease, advancements in technology, as well as treatment modalities for patients who suffer with this problematic disorder.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- State the prevalence of aortic valve disease.
- Identify when patients with aortic valve disease need intervention.
- Describe the different therapeutic options for patients with aortic valve disease and when to use them.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
In this podcast, Dr. Michael Maddaus, a retired thoracic surgeon, but currently a physician coach with a special interest in helping surgeons. Dr. Maddaus brings his knowledge and experience around burnout, wellness, resiliency and other healthcare provider challenges.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Define reslience and identify how it applies to adversities encountered in medicine.
- Identify behaviors that promote resilience, including managing expectations, setting realistic goals and finding gratitude.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
PODCAST NOTES & REFERENCES
- Resilience Bank Account scientific paper: https://www.annalsthoracicsurgery.org/article/S0003-4975(19)31352-9/fulltext
- Podcast by Dr. Maddaus: https://www.sts.org/topics/resilient-surgeon
- Authors and Sites Referenced
- Love + Work by Marcus Buckingham
- www.principlesyou.com (Ray Dalio)
- www.jocko.com (Jocko Willink)
- Dark Horse by Todd Rose
- The End of Average by Todd Rose
- Waking Up and www.wakingup.com by Sam Harris
- www.michaelmaddaus.com
Thanks goes out to Dr. Michael Maddaus for his expert knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Matt Weber, a podiatrist with Ridgeview Specialty Clinics, brings his knowledge and experience around the causes of ankle instability, how common it is, and the different approaches for therapy and management.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Recognize ankle ligament instability from a patient's clinical history and exam.
- Diagnose ankle problems (pathology) assiciated with ankle instability, including acute injury vs. chronic conditions.
- Choose appropriate treatment protocols for an ankle instability condition.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
PODCAST OVERVIEW
Ankle Sprains - 25% go on to further sprains. - Graded 1-3 - Anatomy - Ottawa ankle rules - Physical therapy - Acute vs chronic
Ankle Surgery - Brostrom Gold (pants over vest) - Attenuated Gracilis Repair - Following surgery - 3-4 weeks immobilized, then boot for 2-3 weeks, then physical therapy. - 4 months post injury - back to activity
Thanks to Dr. Matt Weber for his expert knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Nicole Roeder, a pulmonologist with Ridgeview Specialty Clinics, brings her knowledge and experience to discuss how to properly diagnose and manage asthma and chronic obstructive pulmonary disease (COPD) in patients exhibiting signs and symptoms of these chronic conditions.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Identify signs and symptoms of asthma and chronic obstructive pulmonary disease (COPD).
- Review methods for diagnosing asthma and COPD.
- Select treatment options for asthma and COPD.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
PODCAST OVERVIEW
COPD - Major contributor - tobacco use - Environmental exposures - Types (chronic bronchitis, emphysema, mixed) - Symptoms and exam - Exacerbation red flag - more frequent use of rescue inhaler use, more cough and wheeze - Tests (imaging - CXR, CT, pulmonary function testing, spirometry, BODE screening test, alpha antitrypsin) - Inpatient COPD management - Outpatient COPD management - Prevention (immunizations, vaccines, smoking cessation, daily maintenance medication/compliance) - Severe COPD considerations (lung transplant, endobronchial valves) - Pulmonary Rehab (9-week program, multidisciplinary team, baseline assessment, exercise/education sessions) - Pulmonary Function Testing (PFT) including spirometry, lung volume testing, lung diffusion capacity, and methachoine challenge testing
ASTHMA- Prevalence - Work-up (CXR, PFTs, CT chest, Allergy testing, referral to pulmonary) - Theophylline (bronchodialiator, antiinflammatory) - Differential Dx - consider other conditions if not improvment (CHF, PE, pneumothorax, etc.) - Peak flow testing - Action plans (Green, Yellow, Red) - Treatment - for mild, moderate and severe cases
Thanks to Dr. Nicole Roeder for her expert knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Bill Roberts - a family medicine physician and Professor Emeritus with the University of Minnesota. Dr. Roberts brings his vast expertise of sports medicine to discuss a potpourri of sports medicine topics.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Summarize the evolution of changes to sports medicine.
- Identify common sports related injuries and treatment modalities.
- Describe how supplements, substances and proformance enhancing drugs (PEDs) impact athletes and the environment of sports medicine.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
Pre-participation Evaluation (sports qualifying exam) - Better screening questions and techniques - Mental health screening incorporation - Sudden Cardiac Death dilemma
"Weekend Warrior" - Activity level and training for things (marathons, etc.) - when to check in with your provider. - More CAD in older marathoners who started training later in life - CAD, not long distance running, associated with Sudden Cardiac Arrest (SCA/SCD).
Youth Athletes - Young children (pre-teen) should experience a wide variety of motor activities. - Life sports - throwing sports, running, biking, skiing
"The Runner" - Start slow, build slow. - Overuse injuries
Environmental - Heat and cold injuries
"We've got an athlete down!" - SCA - sudden cardiac arrest - heat stroke - hypthermia - concussion/head injury - stroke or ICH (intracranial hemorrhage) - electrolytes (hyponatremia due to overhydration)
Supplements, Substances and Performance Enhancement for Athletes - legal vs "illegal" - supplement use - "Eat well, sleep well, study well...." - peer and social pressure
Pearls of Wisdom - pearls from Dr. Roberts
Thanks to Dr. Bill Roberts for his expert knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Steve Smith - an emergency medicine physician with Hennepin Healthcare and full faculty Professor of Family Medicine at the University of Minnesota, discusses OMI (occlusion myocardial infarction) and NOMI (non-occlusion myocardial infarction) matrix, along with the importance of proper ECG interpretation and how this impacts the management of acute coronary syndrome. Dr. Smith also talks about STEMI and NSTEMI and the use (or the replacement) of these terms.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Express that acute coronary occlusion must be diagnosed and treated emergently.
- Recognize that ST elevation on the EKG is a very poor way of diagnosing occlusion myocardial infarction (OMI).
- Recognize that the entire QRST wave on the EKG is important for the diagnosis of occlusion mycardial infarction (OMI).
- Identify when other modalities (other than the EKG) may be needed to make a diagnosis of acute coroanary occlusion (OMI).
- Recognize that deep convolutional neural networks are the future of EKG diagnosis of acute coronary occlusion.
This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for additional information.
Links:Steve Smith ECG Blog
OMI Manifesto
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Kelly Lemieux - a pediatrician with Wazata Children's Clinic brings some insight into pediatric ADHD, specifically around the history, symptoms and treatment options.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Define the differential diagnosis for children presenting with academic difficulties.
- Utilize the DSM-5 criteria when diagnosing ADHD in children.
- Identify common co-morbidities for children with ADHD.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
ADHD History - 1902 - British pediatrician definition of ADHD- Evolution - 1990s - increase in diagnosis - 2013 - Change in age range for diagnosis
Diagnosis - Symptoms - Comorbidities - Concerns for learning disabilities - Diagnostic tools
Prevalence - CDC estimates 6 million children (ages 3 to 17) with ADHD (approx. 9.8%)
Assessment - Three key symptoms (inattention, hyperactivity, impulsivity) - How ADHD is explained to parents- Standarized tools (including listening to parents) - Neuropsychological testing & Vanderbilts
Nonpharmocologic strategics At school - ADHD coach - Therapy - Bounce ball chairs - special study halls - other resources
At home - Daily schedules - reducing disctractions (minimize) - noise cancelling - exercise
Pharmacologic interventions - Risk benefits - Prescribing age - 2 broad categories of medications (stimulants v. non-stimulants)- other medications - limitations
Thanks to Dr. Kelly Lemieux for her knowledge and contribution to this podcast. Please check out the additional show notes for more information/resources.
In this podcast, Dr. Daniel Marek - an orthopedic hand surgeon with Twin Cities Orthopedics, brings pearls and wisdom of how to better manage various injuries of upper extremity fractures in adults.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Summarize various types of upper extremity injuries that can occur in adults.
- Describe how to diagnose and treat common hand injures that present to an urgent or emergency healthcare setting.
- Evaluate when a referal is needed to an orthopedist and/or orthopedic surgeon.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
The Hand- Alignment - Fractures - Splinting
The WristScaphoid - The most commonly missed fracture - How to diagnose injury - Treatment = 6 to 10 weeks of treatment
Lunate - Rare fracture - Slow healing injury (6 to 10 weeks) - Requires splint and cast - Scapholunate ligament ter - 10 weeks of cast and surgery bookended - Lunate/Perilunate dislocation - needs immediate reduction and surgery - Triquetral Fracture - treatment with removable splint
Distal Radius and Ulna- Fall onto outstretched hand - most common - Colles' Fracture - ncbi.nlm.nih.gov/books/NBK553071/ - Smith's Fracture - ncbi.nlm.nih.gov/books/NBK547714/ - Barton's Fracture - ncbi.nlm.nih.gov/books/NBK499906/ - Ulnar styloid fracture - Median nerve symptoms - Volar displaced fractures very hard to maintain reduction - will likely need surgery. - What needs to be reduced? 3 radiographic angles (length, radial inclination, tilt) - Closed fracture complications - Splinting issues
The Forearm- Monteggia - Galeazzi - Radial head fracture (very common) - Radial neck fracture - Proximal ulna (olecranon)
The Humerus- Mid humerus - Proximal humerus - Distal humerus
Describing Fracture to Orthopedist- Looking at correct film/correct patient - Open or closed fracture - Location of fracture - Involvment of articular surface? - Simple or comminuted fracture and what direction? (transverse, oblique, spiral, avulsed) - Displaced? if so which direction - Angulation - Rotation - Impaction
Future horizon for Upper Extremity and Hand Surgery - Awake surgery - Hand transplant
Thanks to Dr. Daniel Marek for his knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Natalie Stoltman - a primary care physician with Lakeview Clinic, brings pearls and highlights around the topics of: behavior weight loss interventions in older adults, falls risk and increasing medications, chronic pain management in older adults, and current concepts of diabetes management in the post-acute and long-term care setting.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Summarize the latest standards in regards to care in geriatric medicine.
- Identify and review interventions targeting geriatric obesity.
- Identify falls risk enhancing drugs and ways for deprescribing.
- Summarize the updates provided related to chronic pain management in geriatrics.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
Major Themes: deprescribing medications, poly pharmacy, individualization of care and a tailored approach, and the need for a multidisciplinary team.
Beyond Behavior Weight Loss Intervention in Older Adults- Impact and Impairments - How to begin: "diet takes on new connotation in the elderly" - Weight loss interventions/behavior modifiations - Weight loss interventions - medications - Weight loss surgeries (Roux-n-y/Sleeve gastrectomy) - Multidisciplinary team
Getting Rid of "FRIDS" or Fall Risk Increasing Drugs- More than 30% of older adults fall - Deprescribing
Managing Chronic Pain in Older Adults- Classification of pain (nociceptive /neuropathic /nociplastic) - Pain evaluation - Nonpharmocologic interventions - Pharmacological
Current Concepts of Diabetes Management in the Post-Acute and Long-term Care Setting- Patient goals and change in goals - Goals of care - Life expectancy
Thanks to Dr. Natalie Stoltman for her knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Jon Cole - an emergency medicine physician with Hennepin Healthcare and medical director with Minnesota Poison Control Center and Samantha Lee, PharmD - managing director with Minnesota Poison Control Center discuss the poison control system - past and present; along with a disscusion around toxicology - the big, the bad, and the ugly.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Describe the purpose of the Minnesota Poison Control Center, and how it works.
- Name the most common call types coming into MN Poison Control Center.
- Summarize the management of toxicological exposures for APAP, bupropion and calcium channel blockers.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
HISTORY of MN POISON CONTROL CENTER
TOXICOLOGYCalcium Channel Blockers - Diltiazem, Verapamil, Amlodipine - Causes bad distributive shock - Pulmonary edema is an issue - Norepinephrine infusion is recommended in setting of shock with high dose insulin simultaneously - "Red, white and blue" therapy for refractory Ca++ blocker overdose - Activated charcoal - not for all patients, give if patient not at risk of aspiration for potentially lethal ingestions
Bupropion - Chemical structure similar to amphetamine and bath salts - Sympathomimetic effects (tachycardia, agitation, seizures, ultimately cardiogenic shock) - Treatment with benzodiazepines - usually high dose - may need intubation - Norepinephrine for cardiogenic shock - ECMO may be needed
Sodium Nitrite - Salt used to cure meats - Internet suicide phenomenon - Effect: Life threatening methemoglobinemia (chocolate colored blood, pallor, low O2 sats) - Very rapid onset of symptoms - Methylene Blue use
N-acetylcysteine (NAC) for acetaminophen poisoning - Transitioning from 3 bag Prescott regimen to a 2 bag regimen - Rumack-Matthew nomogram is the same
Article Resources:Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila). 2022 Nov;60(11):1205-1213. doi: 10.1080/15563650.2022.2131565. Epub 2022 Oct 25. PMID: 36282196.
Cole JB, Olives TD, Ulici A, Litell JM, Bangh SA, Arens AM, Puskarich MA, Prekker ME. Extracorporeal Membrane Oxygenation for Poisonings Reported to U.S. Poison Centers from 2000 to 2018: An Analysis of the National Poison Data System. Crit Care Med. 2020 Aug;48(8):1111-1119. doi: 10.1097/CCM.0000000000004401. PMID: 32697480.
Coralic Z, Kapur J, Olson KR, Chamberlain JM, Overbeek D, Silbergleit R. Treatment of Toxin-Related Status Epilepticus With Levetiracetam, Fosphenytoin, or Valproate in Patients Enrolled in the Established Status Epilepticus Treatment Trial. Ann Emerg Med. 2022 Sep;80(3):194-202. doi: 10.1016/j.annemergmed.2022.04.020. Epub 2022 Jun 17. PMID: 35718575.
Kline JA, Tomaszewski CA, Schroeder JD, Raymond RM. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. J Pharmacol Exp Ther. 1993 Nov;267(2):744-50. PMID: 8246150.
Thanks to Dr. Jon Cole and Samantha Lee, PharmD for their knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this podcast, Dr. Michelle Haroldson, a hospitalist and a sleep medicine physician with Ridgeview's Sleep Clinic, talkes about sleep and why it is important, specific sleep conditions and various treatments.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Summarize the importance of sleep for physical health and wellness
- Identify barriers to (impacts upon) sleep
- Identify treatment options for sleep disorders.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
How do we break the cycle of burnout? Approximately 50% of burnout is present with clinicians prior to COVID.
Why sleep is important- 1/3 of an individual's life is spent sleeping. - Sleep is when the body resets, restores, and heals - Higher mortality rates may occur with those who sleep less than 6 hrs a night. - Optimal sleep window is 6.5 to 8.5 hours a night.
Stages of Sleep- 4 stages (Light sleep, slow wave, dream sleep) - Sleep architecture -Shift work
REM sleep- what happens during this sleep stage
Sleep conditions/disorders - Narcolepsy - Sleep walking - Dream enactment - Sleep apnea - Sleep talking - Snoring - Kleine-Levin
Why see a sleep specialist- People are paying attention to their sleep- Sleep study
Impacts upon sleep - Society's values on sleep - Blue wave light - Lack of sleep associated with major accidents
How to improve sleep - Decide sleep is a priority - Appropriate bedtime - Decreasing exposure to blue wavelength light - Remove light from sleeping environment - Sleep temperature - White noise - Sleep zone
Medications that affect sleep (for better or worse) - Mental health or psychiatric meds - Vistaril, Benadryl - Beta blockers- Melatonin - antidepressants
Thanks to Dr. Michelle Haroldson for her knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
In this special podcast, discussions occur around the impact of physician burnout. Dr. Michelle LeClaire, a critical care physician with Minnesota VA Medical Center, discusses her first hand account of provider burnout, how burnout is measured, how we can affect change with physician champions and wellness programs, moral distress, residue, injury and gender discrepancies in medicine, and discussions occur around the culture, healthcare organizations, patient complexity, and how a pandemic can affect and lead to burnout.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Identify hallmarks of burnout and implications of burnout in clinicians.
- Define moral distress and moral injury.
- Describe gender discrepancies in medicine and burnout rates among gender.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
How do we break the cycle of burnout? Approximately 50% of burnout is present with clinicians prior to COVID.
Mini Z Asks 10 questions: 1. Overall "I am satisfied with my current job." 2. "I feel a great deal of stress because of my job." 3. "Using your own definition of 'burnout', please circle one of the following answers below: a) I enjoy my work. I have no symptoms of burnout. b) I am under stress and don't always have as much energy as I did, but I don't feel burned out. c) I am definately burning out and have one or more symptoms of burnout (e.g. emotional exhaustion). d) the symtpms of burnout that I am experiencing won't go away. I think about work frustrations a lot. e) I feel completly burned out. I am at the point where I may need to seek help. 4. My control of my workload is? 5. Sufficiency of time for documentation is: 6. Which number best describes the atmosphere in your primary work area? 7. My professional values are well aligned with those of my department leaders. 8. The degree to which my care team works efficiently together is: 9. The amount of time I spend on the electronic health record at home is: 10. My proficiency with the electronic health record is:
- Predisposed providers get burned out if you can predict it - you can prevent it.
Predictor factors include the three C's : Control, Chaos, Culture 1.) work control 2) chaos 3) culture which include time pressure and work control 4) controlling our schedule 5) chaos in the workplace 6) teamwork
Maslach burnout inventory/emotional exhaustion. These include reduced personal accomplishment, depersonalization and lack of compassion.
The control model of a job is the teeter-totter that demands control/support. You need to prevent burnout by offsetting the demands with control and support. - Burnout leas to more intent of leaving the job that is three times the odds of leaving. In addition, there are poor patient outcomes. Patient disenrollment, destabilzation of groups on the indiviual side - there is a high rat of alcoholism, suicide, broken relationships and substance abuse.
Items that help with burnout include physician champions, wellness programs and measuring burnout.
Culture is massive. Organizations job is to provide a benue for healthcare providers to treat and help patients.
External and internal factors of the "mini z" include teamwork, work control, sufficient time for documentation, stress, job satisfaction
Gender discrepancies Women have a 60% burnout over their male counterparts. Gender expectations for listening, a phenomenon of attracting more complicated patients, faster work pace, less values alignment with leadership.
Moral distress Situation troubling providers where they know the right thing to do and they cannot. Compromises and patient care due to staffing. Resources and administrative support not in place. This also secondary to social determinants, healthcare disparities, abusive families and patients, not being able to alleviate suffering.
Unresolved moral distress becomes moral injury. Moral injury is a more pervasive issue which leads to cognitive dissidents, depersonalization, bad ethical decision making.
Moral residue leads to unresolved moral distress.
EDM or ethical decision making is dealing with moral injury. Generally secondary to self-reflective providers, empowerment, having a practice - culture - open to multi-disciplinary and reflection, teamwork, mutual respect within the multi-disciplinary team, active involvement of the bedside nurses with end-of-life care, providers active in decision-making, practicing culture of ethical awareness.
Article:Trends in Clinician Burnout With Associated Mitigating and Aggravating Factors During the COVID-19 Pandemic
Thanks to Dr. Michelle LeClaire for her knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
This podcast, Dr. Lucas Dingman and Dr. Cady Welch, emergency medicine physicians with EMPAC and Rigeview, discuss six articles on various topics related to emergency medicine, as part of this first ED journal review.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Identify emergency medicine journal articles that may be potentially practice-changing
- Describe how to rule out a pulmonary embolism (PE) in the emergency department using the YEARS criteria and age adjusted d-dimer.
- Differentiate when antibiotics for treating diverticulitis is warranted.
- Describe the benefits of using a small percutaneous catheter chest tube for treating a traumatic hemothorax.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
Study #1: Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study) A Multicentre, Randomised, Open-label, Noninferiority Trial
- DINAMO study & diverticulitis - Multicenter, randomized, open label, non-inferiority trial (Nov.2016 - Jan.2020) - 480 randomized participants and put into two groups - Results: admission to hospitals, ED revisits, no complications, no major significant findings - Nonantibiotic outpatient treatment of mild acute diverticulitis is safe and effective and is not inferior to current standard treatment.
Study #2: Anterior–Lateral Versus Anterior–Posterior Electrode Position for Cardioverting Atrial Fibrillation
- EPIC Atrial Fibrilation ( EPIC AF) - Two positions for pad placement for cardioverting patients - Multicenter, randomized, open label trial - 467 randomized patients, scheduled for elective cardioversion - Results: 50% successful conversion to normal sinus rhythm after one biphasic shock, many patients needed multiple shocks to cardioconvert (4-5 shocks). - AHA Guidelines: pad placement for AF and VF, treatment recommendations - Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome.
Study #3: The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial
- Poiseuille's law and chest tubes - and involves components of rate of flow, radius of the tube, change in pressure and viscosity. - 120 participants - 8 years and older, traumatic hemothorax or pneumothorax, hemodynamically stable patient only - Treatment arm: 14 Fr cook catheter used (seldinger techique, anterior axillary or midaxillary line) - Control arm: 28-32 Fr. chest tube placed (standard way - 4th-5th intercostal, midaxillary line) - Results: Failure rate of the tube, repeat hemothorax requiring intervention, drainage outputs at different designated times, total chest tube days, insertion complications, ventilator days, ICU length of days, hospital length of stay - Patients had better experience with percutaneous catheter - Hemlich valve - Study discussed looks specifically at hemothoraces which require drainage of blood and chest tubes connected to traditional pleuro vac chamber - Small caliber 14 Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.
Study #4: Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial - ScienceDirect
- Single center, placebo controlled, blinded, randomized trial - Sample: 120 healthy adults, median age 40 years old presenting to ED with chief complaint of nausea/vomiting - Change in nausea score at 30 min. (drop in mm on VAS) - Mean nausea baseline = 50 - Limitations: fairly young healthy participants, difficult to blind (can smell difference) - Among ED patients with acute nausea and not requiring immediate IV access, aromatherapy with or without ondansetron provides greater nausea relief than oral ondansetron alone.
Study #5: Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial
- YEARS criteria with age adjusted vs only age adjusted - Cluster, randomized, crossover, non-inferiority trial to determine if YEARS plus age-adjusted could be used to rule out PE, age 18 or older, not pregnant - Sample size: 1414 patients within 18 EDs, PERC positive - Outcome: PE diagnosed in 100 patients, no missed PEs with patients with YEARS score of "0", - Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a concential diagnostic strategy, did not result in an inferior rate of thromboembolic events.
Study #6: Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial
- Randomized, single masked study (providers were masked), controlled clinical trial, non-inferiority study design, single center study - Participants: children - aged 8 weeks to 3 years, moderately dehydrated (dehydration score greater than 3, but less than 7) - Outcomes: Successful rehydration at 4 hours, hospitalization rate, time to initiation of treatment, repeat ED visits within 72 hrs -Results: no difference between the groups with succesful rehydration at 4 hours - Limitations: small sample size - Oral rehydration therapy (ORT) is as good as intravenous fluid therapy (IVF) in rehydration of moderately dehydration children due to gastroenteritis. In addition, the study found that less time was required to intiate ORT when compared with IVF in the ED. Patients treated with ORT had fewerer hospitalizations. Results of the study suggested that ORT be the initial treatment of choice for moderately dehydrated children less than three years old with gastroeneritis.
Thanks to Dr. Lucas Dingman and Dr. Cady Welch for their knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.
This podcast, Dr. Peter Eckman, a cardiologist and heart failure specialist, with Minneapolis Heart Institute, discusses heart failure and why it is an extensive medical issue.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Recognize heart failure as a problematic clinical disease and its morbidity and mortality that leads to comprehensive medical management.
- Identify and describe optimal contemporary medical therapy for heart failure.
- Describe novel options for heart failure.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
Heart Failure (HF)- Can occur without congestion or fluid retention - Characterized by fatigue, fluid retention, SOB, PND, orthopnea - We should consider the same urgency for heart failure as patients with CAD and CA.
Heart Failure Preserved/Reduced Ejection Fraction (HFpEF/HFrEF)- HFpEF is a Preserved Ejcetion Fraction over about 50% - HFpEF - congestive phenotype more of a fluid retention - an exercise intolerant phenotupe where the patient becomes intolerant of exercise induced dyspnea. - Pulm HTN phenotype - Increased pressure in the heart that gets transmitted to the lungs - HRrEF is Reduced EF is usually below 40%
Medications- 4 classes of medications (MRAs, BB, SGLT2, ARNIs) - Treatment with mineralocorticoid receptor antagonists (MRAs) has been demonstrated to improve clinical outcomes in patients with HFrEF with mild to severe symptoms and also in patients with left ventricular dysfunciton after myocardial infarction. - SGLT2 inhibitors reduced the risk of cardiovascular death and hospitalizations for heart failure in a broad range of patients with heart failure, supporting their role as a foundational therapy for heart failure, irrespective of ejection fraction or care setting. - ARNI (angiotensin receptor/neprilysin inhibitor) medication is a newer treatment for heart failure. The combination of sacubitril and valsartan has helped people live longer and have a better quality of life. - Comprehensive EF therapy involves BB, ARNI, MRAs, angiotensin receptor/neprilysin inhibitors. Spironolactone, SGLT2 inhibitors.
Treatment- Traditional therapy usually involves a BB and ACE inhibitor. - Currently we should be looking at comprehensive therapy when it comes to HF treatment. - STOP USING LISINOPRIL.- SGLT2 inhibitors contraindicated ketoacidosis, amputation UTI, weight loss - (SGLT2 inhibitors) DAPA-HF trial showed that dapagliflozin was superior to placebo at preventing cardiovascular deaths and heart failure events among patients with heart failure. (Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1911303#article_citing_articles ) - Catheterization - a vast majority of HF patients will need a right heart catheterization. - Cardiac pulmonary pressure monitoring Cardio MEMS - same day outpatient surgery which helps with medication adjustments and hospitalization in half. Works regardless of EF. - CardioVere laser spectroscopy which uses different wavelengths to detect light characteristics to determine the level of edema/fluid present wihin someone's tissues. Currently in development. - Casana is a toilet seat with certain sensors that detect and monitor impedance that check levels between different tissues, monitors HR and weight. - Cardiac contractility modulation causing electrical stumulation during a particular contraction of the myocyets it will augment potential (like a pacemeaker). -CORCHINCH - HF trial catheter based device that cinches up the heart, thereby making it smaller. It works more efficiently. (Source: Clinical Evaluation of the AccuCinch® Ventricular Restoration System in Patients Who Present With Symptomatic Heart Failure With Reduced Ejection Fraction (HFrEF): The CORCINCH-HF Study)
Novel Treatments- Atrial shunting procedure is investigational trials. Potentially impactful in exercise capacity and pressures but stay tuned as the verdict is not out. HfPEF exercise induced intolerance may be the best candidate. - SVC trial feasibility trial more durable effects of cardiac output. Stay tuned. - LVAD for advanced therapies. Sometimes a bridge for candidacy as well as recovery. - Biventricular pacing has shown promise.
*Heart failure is a problematic clinical disease entity with significant morbidity and mortality often leading to comprehensive medical management. It is often beneficial to enlist the help of our heart failure colleagues for these complicated patients.
Thanks to Dr. Peter Eckman - MHI heart failure specialist for his knowledge and contribution to this podcast.
Please check out the additonal show notes for additional information/resources.
This podcast, Elizabeth Hopfenspirger, DNP, a psychiatric and family practice nurse practitioner with Lakeview Clinic, discusses various mental health topics, primarily in the adult patient, but also touches on some pediatric issues. Today's discussion will focus on the following areas of mental health - depression, anxiety, mixed disorders, ADHD and psychosis.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Describe different implemention stratgies in how to better establish a therapeutic relationship with the patient.
- Recognize how many psychotropics medications are on a "spectrum".
- Realize that treatement choice depends on several variables - including presenting symptoms and underlying organic issues.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES: *See the attachment for additional information.
The state of mental health care in the US is not ideal- Lack of resources - Lack of practitioners - social, physical, economic and environmental challenges
CASE REVIEW #1- 18 year old female with predominantly anxiety - Respectful curiosity: listening and asking questions without judgement - Medication for generalilzed anxiety disorder- High intensity aerobic exercise can improve anxiety symptoms. - Trauma? ADHD/Learning difficulties? Sleep? Appette and restriction of food/eating disorders? Substance use/abuse? - SSRI: bupropion>fluoxetine?Sertaline?escitalopram>fluvoxamine>paxil (most activating to least activating) - For pure anxiety - Elizabeth prefers escitalopram, citalopram and sertaline - Trauma and trauma therapy: Trauma can be anything (death of a loved one, MVC, etc.) - Trauma therapy (EMDR: eye movement desensitization reprocessing) - IFS (internal family systems - recognizing and connecting with your own history and younger self) - ART (acceleraed resolution therapy) - Substance use: What is the substance doing for the patient? Why are they using? Helps to direct therapy and arrive at diagnosis. - ADHD (attention deficit hyperactivity disorder) - sometimes missed or ignored - PCPs have discomfort treating at times - trial of stimulant may be beneficial - Suicide ideation and other adverse effects while first starting certain meds is real, but rare- Article resources: Walkup, et.al (https://pubmed.ncbi.nlm.nih.gov/18974308/) Wetherell, et.al (https://pubmed.ncbi.nlm.nih.gov/23680817/) Critz-Christoph, et.al (https://pubmed.ncbi.nlm.nih.gov/21840164/) Trauma therapy : https://www.emdria.org/
CASE REVIEW #2- 32 year old male with depression - Labs? Physical activity? Testosterone concerns? - Lifestyle and sexual function - Post-retirement? (identity and purpose has changed/gone) - Consider bupropion if no seizures or other contraindications. Consult with neurologist if significant history - Sexual dysfunction an issue? Vortioxetine can be an option wich may help enhance libido - Physical activity (natural endorphins) and exposure to nature are improtant - Screen time? Smart phone and other screen time has dopaminergic effects; too much 'negative' screen time can be detrimental (If AHDH is poorly treated, screen addiction may increase.)
CASE REVIEW #3- 65 year old male with mixed depression and anxiety, off meds for many months - Find as many of patient's historical records as possible - Meeting a patient "where they are at". How motivates is the patient to get better? - Are they coasting (teenagers)? Are they taking an active role in getting better? - may need to wait to push/empower patient until after giving medication and psychotherapy some time - where is the patient in their willingness to change and get better? - Meds in this ager group (and many others) to avoid: TCAs and MAOIs - IF DM, HTN, CAD and other co-morbidities, fluoxetine is less likely to have interactions and adverse effects- Article resources: Prochasa and DiClemente - Stages of Change https://www.ncbi.nlm.nih.gov/books/NBK556005/)
Psychosis- Caplyta (stimulating) if more depressed with psychotic features - Zyprexa (sedating) if more manic/psychotic
Genetic testing for optimization of medications is an option - Serves as a 'guide' for medication choice - SLC6A4 gene, for instance, is responsible for serotonin reuptake into the presynaptic neuron
What to do while waiting for SSRI and SNRI to "work"?- Hydroxyzine, benzodiazepine - Sleep medication: - Doxylamine, Trazadone or Remeron (older patients) - Sleep medication: lunesta, sonata
Polypharmacy- Is polypharmacy present and patients feeling poorly with persistent symptoms? May need thoughtful/ careful deprescribing.
Nontraditional/novel treatment options- Nontraditional/novel options for treatment resistant depression, PTSD treatment, chronic pain, etc. - Ketamine - Psilocybe
Psychiatry & Primary Care- Incorporating psychiatry into our own primary care practices is anxiety provoking but inevitable in this day and age of healthcare - We can learn new things and leverage our existing resources to better help our patients - Time with our patients is a barrier - Ask the patient: what is the most pressing issue for you today? What is the most distressing thing for the patient? Then consider Maslow's Hierarchy of Needs and build up from there.- Article resources: Maslow Hierarcy of Needs (https://www.simplypsychology.org/maslow.html)
Please check out the additonal show notes for additional information/resources.
This podcast, Dr. Abby Elliott returns and the debut of Dr. Natalie Stoltman, both primary care physicians with Lakeview Clinic. They are both here for the third episode of Ridgeview Podcast CME Series: Journal Review. This is the episode where our speakers talk through new, practice changing and/or just interesting journal articles. In this episode we have six articles addressing subjects related to primary care, including antibiotic presecribing, weight loss modalities, intermittent fasting, non-alcoholic fatty liver disease, LDL levels in relation to coronary plaque, and proton pump inhibitors. The articles referenced in this podcast are linked in the attached show notes.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Identify when antibotics are warranted for pediatric infections.
- Compare the differences in weight change between individuals who participated in a commercial weight management program to those who participated in a "do-it-yourself (DIY)" approach.
- Explain intermittent fasting and its correlation to health outcomes.
- Define nonalcoholic fatty liver disease and explain the different treatment modalities.
- Explain the correlation between LDL levels and calcium scores/CTA and cardiac outcomes.
- Describe the best practice approach to proton-pump inhibitors (PPI) de-prescribing in ambulatory patients.
- Name significant/relevant findings of the journal articles being reviewed and discussed.
CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
Click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for article discussion summaries.
Journal Article 1: "Association of Inappropriate Outpatient Pediatric Antibiotic Prescriptions with Adverse DRug Events and Health Care Expenditures"
CITATION: Butler AM, Brown DS, Durkin MJ, et al. Association of Inappropriate Outpatient Pediatric Antibiotic Prescriptions With Adverse Drug Events and Health Care Expenditures [published correction appears in JAMA Netw Open. 2022 Jun 1;5(6):e2221479]. JAMA Netw Open. 2022;5(5):e2214153. Published 2022 May 2. doi:10.1001/jamanetworkopen.2022.14153. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792723
Journal Article 2: "Efficacy of a Commercial Weight Management Program Compared With a Do-It-Yourself Approach: A Randomized Clinical Trial"
CITATION: Tate DF, Lutes LD, Bryant M, et al. Efficacy of a Commercial Weight Management Program Compared With a Do-It-Yourself Approach: A Randomized Clinical Trial [published correction appears in JAMA Netw Open. 2022 Sep 1;5(9):e2235316]. JAMA Netw Open. 2022;5(8):e2226561. Published 2022 Aug 1. doi:10.1001/jamanetworkopen.2022.26561 Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2795182
Journal Article 3: "Intermittent Fasting and Obesity-Related Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials"
CITATION: Patikorn C, Roubal K, Veettil SK, et al. Intermittent Fasting and Obesity-Related Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials. JAMA Netw Open. 2021;4(12):e2139558. Published 2021 Dec 1. doi:10.1001/jamanetworkopen.2021.39558. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787246
Journal Article 4: "Clinical Care Pathway for the Risk Stratification and Management of Patiemts with Nonalcholic Fatty Liver Disease"
CITATION: Kanwal F, Shubrook JH, Adams LA, et al. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2021;161(5):1657-1669. doi:10.1053/j.gastro.2021.07.049. Available: https://www.gastrojournal.org/article/S0016-5085(21)03384-9/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F
Journal Article 5: "Association of Coronary Plaque With Low-Density Lipoprotein Cholesterol Levels and Rates of Cardiovascular Disease Events Among Symptomatic Adults"
CITATION: Mortensen MB, Caínzos-Achirica M, Steffensen FH, et al. Association of Coronary Plaque With Low-Density Lipoprotein Cholesterol Levels and Rates of Cardiovascular Disease Events Among Symptomatic Adults. JAMA Netw Open. 2022;5(2):e2148139. Published 2022 Feb 1. doi:10.1001/jamanetworkopen.2021.48139. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788975
Journal Article 6: "AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review"
CITATION: Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022;162(4):1334-1342. doi:10.1053/j.gastro.2021.12.247. Available: https://www.gastrojournal.org/article/S0016-5085(21)04083-X/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F
Please check out the additonal show notes for additional information/resources.
For this podcast, we don't just have one but two guests. Returning to the show is Dr. Tara McMichael, an Internal Medicine Physician with Lakeview Clinic and Internist for Ridgeview, and Stacy Jepsen, a clinical nurse specialist with Ridgeview. During this podcast, Dr. McMichael and Stacy will be discussing Post Intensive Care Syndrome, also known as PICS. They will both bring unique perspectives from the initial critical illness and care in the ICU to the patient's outpatient visits and long term prognosis.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Define post intensive care syndrome (PICS) and post intensive care syndrome-family (PICS-F).
- Identify risk factors for devcelopment of PICS and PICS-F.
- Summarize prevention and treatment strategies for PICS and PICS-F
- Interpret the prevalence of PICS within the community.
- Utilize available resources to support patients/families with PICS symptoms.
- Describe how patients and their families can be supported who are struggling with PICS.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
See the attachment for additional information.CLINICAL NURSE EDUCATOR*- Advance practice RN who operates as an expert clinician, educator, researcher or consultant.
- Masters or doctorate degree
- Role had been around the US for over 60 years.
POST INTENSIVE CARE SYNDROME (PICS)- New or worsening cognitive, psychological, physical limitation, post survival of critical illness and stay in ICU.
- Post intensive care syndrome - family (PICS): family memvers who have mental limiations from the experience of having a loved on eiwth a critical illness.
- First defined by Society of Critical Crea Medicine in 2010.
- Remains difficult to diagnose for coding and reimbursement. ICD-10 code does not exsist.
RISK FACTORS
- critical illness with stay in ICU
- Delirium
- Sedataion during hostpital stay
- Diagnosis of sepsis, ARDS, etc.
DIAGNOSIS
- Cognitive: short term memory loss, slow cognition, mental disorganization
- Physical: changes in balance and gait
- Psychological: anxiety, depression, insomnia, PTSD
TESTING
- no specific tests available for PICS
- MoCa
- Mini mental status
- PHQ9 (in setting of depression)
- GAD7 (in setting of anxiety)
- two or more symptoms in any category - cognitive, physical and psychological 4-6 weeks post hspitalization.
PREVALENCE
- Of 5.8 ICU admissions, 4.8 million survive
- Of the 4.8 million survivors, 50-80% will beet diagnostic criteria
- COVID has brought PICS to forefront.
PREVENTION- Prevention tips (multidisciplinary rounds, ABCDEF bundle, checklists for goals, support groups)
- ABCDEF Bundle
A - Assess, precent and manage pain
B - Sedation reduction and vent weaning
C - Choice of analgesic and sedation
D - delirium prevention, recognition and treatment
E - Early mobility
F - Family
BARRIERS
- Communication, not true barrier, but requires effort
PICS RESOURCES & TREATMENT
- PICS clinics (pros & cons)
- For primary care physician (it exists, dont; have to solve it one go; there are online resources available)
- Addition PICS resources (listed in show notes).
Thanks for listening.Please check out the additonal show notes for additional resources.
In this podcast, Dr. Jeff Twidwell, a urologist (retired) and Dr. Jim Lehmann, an internist (retired) join the podcast to discuss various aspects of prostate cancer from a unique personal and professional viewpoint.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Describe prostate specific antigen and what levels are considered normal.
- Identify when to include PSA testing and to what specific patient populations.
- Determine when a referral to a urologist is needed for further patient evaluation.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
See the attachment for additional information.Diagnosis - Call to action - "I will not miss a case of cancer of the prostate." (Dr. Jim Lehmann)
- Main risk factors: age, black/hispanic ethicity, genetics
- Evidence based moment (see show note attachment for link to referenced article)
Screening- PSA (prostate specific antigen) - level greater than 4.0 ng/ml is "abnormal"
- Age adjustment
- PSA levels reduced with 5-alpha reductase inhibitor
- PSA increases 0.75 ng/ml per year
- Stop screening when life expectancy is less than 10 years
- Shared decision making
Next Steps in Diagnosis- Biopsy (template and MRI)
- MRI
- 4K score blood test
- Ultrasound
- Gleason score and grade
- Decipher testing
- PSMA-PET scan
Prostate Cancer Care Team
- Urologists
- Primary Care
- Radiation oncology
- Oncology
Treatment*- Observation
- Surgery (open, DaVinci, Laparoscopy)
- Radiation
- Hormonal (androgen deprivation)
- Cryosurgery
- Brachytherapy (prostate radioactive seeds)
- Chemotherapy
- Immunotherapy (advanced prostate cancer)
- Proton therapy (up and coming)
Thanks for listening.Please check out the additonal show notes for additional resources.
In the second podcast of season 5, Dr. Nima Adimi, a pain and spine specialist at Ridgeview discusses many areas around pain management, including how we evaluate, manage and treat pain and spine patients, the multidisciplinary teamwork involved, current guidelines, new and contemporary management strategies, and what is in the pipeline for the future of pain medicine.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Describe the types of tools available for people suffering with chronic pain.
- Identify ways to get patients access for pain management.
- Differentiate the diverse and broad nature of treatments available to those suffering from chronic pain.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
See the attachment for additional information.In-take process:*About 80% of patients referred to Ridgeview's pain center are LBP patients. The first conversation is the usual Goals of Care which are highly important in setting the expectations for the patient, including what type of testing or imaging the patient has received, what treatment modalities have they tried.
Neuropathic pain is caused by damage or injury to the nerves that transfer information between the brain and spinal cord from the skin, muscules and other parts of the body. The pain is usually described as a burning sensation and affected areas often sensitive to the touch.
Nociplastic pain (a type of pain caused by damage to body tissue. A pain that feels sharp, aching or throbbing) or a type of pain which is mechanically different from the normal nociceptive pain caused by inflammation and tissue damage or the neuropathic pain which results from nerve injury. It may occur in combination with the other types of pain or in isolation. Its location may be generalized or multifocal and it can be more intense than would be expected from associated physical causes. Its causes are not fully understood, but is thought to be a dysfunction of the central nervous system whose processing of pain signals may have become distorted or sensitised. This type of pain typically arises in some chronic pain conditions, with the archetypal condition being fibromyalgia.
Opiod Induced HyperalgesiaWhich is a common diagnosis for Dr. Adimi. During this podcast, listeners learn the limitations for further interventions due to hyperalgesia. These interventions will often require opioid titration prior to implementing therapy.
Multimodal Treatment Options:Include non-addictive strategies, such as physical therapy, chropractic, fucntional/personal trainer, behavioral health. Discussions continue regarding medications such as gabapentinoids and their side effects, NSAIDs, muscle relaxers, medical cannabis, low dose naltrexone, etc.
Interventional StrategiesLeast invasive strategies are discussed, including: trigger point injectsions, epidural, radiofrequency ablation medial branch blocks, facet joint injections, occipital and trigeminal nerve blocks, spinal cord stimulators, peripheral nerve stimulators.
During this section of the podcast, Dr. Adimi discusses how spinal cord stimulators are impacting pain with new and exciting modalities, intrathecal pain pumps and their limitations an dhow the use of narcotics, anesthetics and snal poison (ziconotide) are implemented. Dr. Adimi notes that SCS are not effective for mechanical back pain/arthritis patients.
Vertiuflex for spinal stenosis patients is discussed, along with the "mild" procedure and minimally invasive lumbar decompression.
In wrapping up the podcast, Dr. Adimi discusses the future of pain and the new arena or space the pain specialist will be occupying. New research on SCS for Prakinson, movement disorders, dystonia as well as how it impacts select patient populations like Peripheral Diabetic Neuropathy Study.
Thanks for listening.Please check out the additonal show notes for additional resources.
In the first podcast of season 5, Dr. Glenn Paetow, the medical director of the Interdisciplinary Simulation and Education Center at Hennepin Healthcare answers many questions around simulation, education and training needs in healthcare. Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Describe the utility and effectiveness of healthcare simulation in medical education, quality improvement, and clinical operations.
- Summarize the tools and techniques within healthcare simulation.
- Review and use best practices in simulation debriefing.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
See the attachment for additional show information.History: Simulation* - Began as early as 1800s
- 1930s: aviation industry started using simulation
- 1960s: mannequins used for medical CPR and rescue breaths.
- 1980s: anesthesia started using simulation and pioneers for simulation with focus on
crises resource management and team training.
Benfits of Simulation: - Most helpful in advanced stages of learning
- Good for training teams to help reduce errors
- Increases positive outcomes
- Can be used for multiple madalities
- Finding latent risk threats
- Evidence based moment: "Benefits of Simulation" (article review)
Starting a Simulation Program: - Objective dependent
- Location
- Equipment (task trainers, mannequins, etc.)
- Simulation Specialist
- Educator
- Courses for educators and technology specialists
The Sim: Creating a Physicoligcally Safe Space: - Psychology safe space
- Pre-briefing
- Neurobiology of learning
- Deliberate practice
- Cognitive load / Yerkes Dodson Curve
Sim Structure: - 1 hour simulation session
- 5 minute pre-brief
- 10 to 20 minute simulation
- 30 to 40 minutes debrief (1 to 2 ration sim to debrief)
- Pitfalls
The Debrief: - many debriefing frameworks available
- Debriefing with Good Judgement - Reactions Phase
- Understanding Phase
- Conclusion/wrap-up
Thanks for listening.
In this podcast, Dr. Joseph Karam, a vascular surgeon with Minneapolis Heart Institute leads the discussion on everything related to vascular disease from head to toe. Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Define vascular disease.
- Identify vascular disease and differentiate the treatment modalities available.
- Describe clinical entities related to vascular disease such as peripheral artery disease (PAD), aortic aneurysms, carotid artery disease (CAD), and venous disease.
- Recognize when a referral to a vascular specialist is warranted.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
See the attachment for additional show information.Vascular Medicine* - Evolving profession & essential to any healthcare
system
Risk Factors - Prevention
- Reducing risk factors
- Social determinants
Carotid Disease - Asymptomatic CAD
- Work up (ultrasound, CTA)
- Treatment options
Thoracic/Abdominal Aortic Disease
- Thoracic aortic aneurysm (Type A, Type B)
- Abdominal aneurysm
- Infra renal aneurysms
- Aortic dissections
- Post-op complications (TVAR, abdominal aortic
aneurysm)
Peripheral Vascular Disease
- Studies of natural history
- Critical limb ischemia
- Acute limb ischemia
- Treatment
Thanks for listening.
In this podcast, Susan Gaines, is a Certified Life Coach who specializes in helping physicians deal with burnout, life purpose and reigniting passion. In this podcast, Susan talks about burnout, why it happens, what it looks like, and tools to fight it.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Recognize professional burnout in themselves and their colleagues.
- Explain the human and financial costs: personal, team, and system-wide.
- Identify at least 3 exercises that would calm onself in the midst of stress.
- Give examples for ways to build resilience longer term.
- State how to de-stigmatize asking for help, and demanding balance.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for additional show information. This podcast focuses predominately on physicians, but understand that many listeners of this podcast work in various healthcare roles. It is recognized that burnout, especially for the last several years affects each of the various specialties across the organization. Many of the concepts discussed in this podcast, though specifically for physicians, are applicable across various healthcare disciplines.
*For the articles referenced in the podcast, please see the attached Show Notes for links.
Article 1: "Death by 1000 Cuts": Medscape National Physician Burnout & Suicide Report 2021- 12,00 physicians surveyed across 29 specialties
- Results:
- 42% reported burnout
- 79% stated burnout started prior to the pandemic
- Causes: too many bureaucratic tasks, too many hours at work, lack of respect from all groups
- burn out had moderate to severe impact on their life
- approx. 300 physicians commit sucide each year.
Article 2: Estimating the Attributable Cost of Physician Burnout in the United States- $4.6 billion on national scale in physician turnober and reduced clinical hours
- At an organizational level - burnout costs $7600 per employed physician each year, due to turnover and reduced clinical hours
Thanks for listening.
In this podcast, Dr. Riddell Scott, a dermatologist with Ridgeview Medical Center and Clinics, leads the discussion about skin cancer. Dr. Scott discusses changes to our DNA, what dermatology office visits look like, types of skin cancer and treatments available, as well as prevention efforts.
Enjoy the podcast.
Objectives:Upon completion of this podcast, participants should be able to:
- Explain the 3 main types of skin cancer and how they differ from each type.
- State how most skin cancers are treated.
- Identify how sun exposure contributes to the onset of skin cancer.
- Describe 3 activities that help to reduce skin cancer incidence.
- Counsel patients about skin cancer prevention efforts.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for additional show information. What happens to our DNA- Ultraviolet light hits skin and energy is transferred
- Melanocytes & Melanin
- Skin cancer risk factors
Office visits- Family history
- Dermatology: pattern recognition
- Dermatoscope
- Patient education
- Repeat exams & recommendations
- ABCDE (asymmatry, border irregularity, color variation, diameter, evolution)
Types of skin cancer: Squamous , Basal Cell Carcinoma, Melanoma- Cell physiology
- Metastatic rate
- Presentation
- Primary vs secondary sources
- Diagnosis
- Stages (0,1,2)
- Treatment (biopsy, MOHS, surgery, radiation, medication)
Skin Cancer Prevention:- 3 Big Things:
- Wear a wide brimmed hat
- Wear sun protective clothing
- Wear sun screen daily
- Sunscreen recommendations
For more information* - see attached "Show Notes".**
Thanks for listening.
In this podcast, Edith Nagel Eisinger continues entertaining us with the seventh chapter of her memoirs in Waconia, MN. Edith Nagel Eisinger, was the wife of Dr. Harold Nagel and nurse in the hospital she talks about in her memoirs. In 1936, the Nagel's founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center.
Enjoy the next chapter of Edith Nagel Eisinger's story.
In this podcast, Dr. Andraya Huldeen, an obstetrician and gynecologist with Western OB/GYN, a division on Ridgeview Clinics will discuss several obstetrical myths; including medication safety profiles for pregnant women, epidurals, COVID vaccinations and induction of labor. Also joining in this podcast is Dr. Nate Beerling, an anesthesologist with Ridgeview, who will add to the discussion of epidurals. Enjoy the podcast! Objectives: Upon completion of this podcast, participants should be able to:
- Assess timing for induction of labor.
- Recognize there is lack of evidence of COVID vaccines causing infertility.
- Describe the different medication classes in pregnancy and how to balce risk/benefit in prescribing some medications.
- Summarize the role epidurals play in labor.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for additional show information. Medications in Pregnancy:- Current, but not standard system
- Risks vs outweighing benefits
- Old system: ABCD & X
- A: studied extensively, no risk
- B: used extensively & very few problems
- C: "waste baskeet garbage world"
- D: can cause increase risk of birth defects but benefit outweighs the risk
- X: Never use, serious side effects or defects
MYTH: All medications cause birth defects if taken during pregnancy- Cold medicines
- NSAIDs
- Acetaminophen
- Narcotics
- Ondansetron
MYTH: Cervical exam has to be less than 4 to get epidural
MYTH: Epidurals slow down labor and cause c-sections- History of epidurals
- Epidural at what stage of labor
- Epidural placement
- Combined Spinal Epidural
- Intrathecal: Spinal block
- Contraindications for epidurals/spinal blocks
- Complications:
- Epidural hematomoa
- Postural puncture headache
MYTH: COVID vaccinations are not safe for pregnant women
MYTH: COVID vaccine cause infertility- Concerns & live attenuated vaccines
- Pertussis vaccination
- COVID vaccination & infection & pregnancy outcomes
- IVF & Fertility Outcomes
MYTH: Induction of labor causes more c-sections- Previously: induction at 41 weeks unless medical reason to be induced earlier
- With higher primary C-section & repeat C-sections - morbidity & mortaility
- Prevent 1st C-section
- 39th week is lowest risk week to deliver
- "Arrival Trial"
- Induction of labor
- Bishop scale
- No specific order for starting induction - provider dependent
For links and resources* - see attached "Show Notes".**
Thanks for listening.
In this podcast,Dr. Greg Giese, an internal medicine physician with Ridgeview talks about diabetic ketoacidosis (DKA). More specifically Dr. Giese will discuss the pathophysiology, initial assessment findings and diagnosis of DKA, along with addressing the differences between diabetic ketoacidosis (DKA) and hypersmolar hyperglycemic state (HHS), and treatment options for DKA patients.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Define diabetic ketoacidosis.
- State the differences between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
- Summarize how to diagnose and treat diabetic ketoacidosis.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for additional show information. DKA: Deficit of insulin- Typical scenario
- Insulin deficienty + counterregulatory hormones
- Catabolic state
- Gluconeogensis
- Glycogenolysis
- Elevated blood sugar causes concomitant osmotic
diuresis
DKA: 3 Parts- Ketones (ketonemia)
- Hyperglycemia (lack of insulin)
- Acidosis (Anion gap Metabolic Acidosis)
Presentation- Critically ill individual on set in 24-48 hours
- Kussmaul respirations
- Other causes (infections, UTI, pneumonia, skin
infections, MI, drugs,)
- Altered mental status
- HHS: Hyperosmolar hyperglycemic state
Work-up- Basics
CBC with differential; metabolic panel, serum ketones, blood gas, urine analysis, plasma osmolality
- Evaluation:
Elevated WBC; elevated anion gap; electrolyte abnormalities; Chest x-ray
Results- Potassium (hold insulin if K was 3.4 or below)
- Hyponatremia
- Bicarb
- Anion gap
- Normal to elevated calcium
- BUN greater than creatinine ration
- Elevated creatinine
- Elevated WBC due to catecholamines and stress response
- Hgb/platelets
- Urine
Treatment- Fluids
- Potassium
- Insulin
Transition to baseline- Discontinue insulin when anion gap metabolic acidosis closed and able to take oral nutrition
- Bridge, start subcutaneous long acting insulin, stop insulin drip 1-2 hours later.
Thanks for listening.
In this podcast, Dr. Kim Thielen, a nephrologist/kidney specialist with Minnesota Kidney Specialists joins us today to continue part 2 of our discussion on acute kidney injury, as we wade further "into the weeds"
discuss intrinsic renal disease. This episode will break down hallmark urinary findings and
further subdivide intrinsic concerns into bland, nephrotic and nephritic, various causes, and
treatment.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- State the 3 types of urinary analysis findings related to instrinic acute kidney injury.
- Describe etiology of presentation of each type of intrinsic acute kidney injury.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for additional show information. Intrinsic Kidney Injuries: Urinary analysis findings- Bland Urine: no protein
- Nephrotic: protein
- Nephritic: protein and blood
Hallmark Urinary Findings: Casts
- Tamm Horsfall Protein : Mucoprotein made by tubular epithelial cells that precipitate out and congeal
to form casts on whatever is in the cells at the time. (i.e. RBCs, WBCs, tubular debris)
Bland Urine States- Crystalline Induced Renal Injury: obstruction and infllamatory response
- Uric Acid Neuropathy (Most common)
- Cancers, lymphomas, etc.
- Drugs: acyclovir, methotrexate, protease inhibitors, etc.
- Toxins: Ethylene glycol
- Bland Urine Disease states: results from injury to tubules, instertim or pre glomerular blodd vessels, not
the filters of the kidney
- Interstital Nephritis
- Hallmark: pyuria and WBC casts
- Biopsy: inflammatory infiltrate
- Causes: viral, PPIs, Adenover, mizalamin, etc., Checkpoint inhibitors
- Acute Tubular Necrosis
- Hallmark: tubular epithelial cell cast
- Granular: (course or fine) diagnostic of ATN
- Biopsy: denuded dilated tubular cells
- Causes: #1: Ischemia; toxins, drugs, contrast dye; pigment injury. myoglobin
- What about contrast dye?
- Categorized under ATN
- Per Dr. Thielen, plays a role, but injury is not solely dependent on dye alone.
- Hepatorenal Syndrome: ischemic injury to the kidney due to unopposed vasocontstriction
- Ace inhibitors cause unopposed efferent vasoconstriction + nonsteroidals cause
unposed afferent vasoconstriction = no glomerular perfusion pressure
- Multiple Myeloma
- Hallmark: Light chain cast nephropathy or myeloma kidney
- Light chains precipitate out causing obstruction, inflammatory response and causes
tubular damage
- Presentation: older possibly with anemia, bone pain and elevated creatinine with a bland urine.
- Protein to creatinine ratio: + for protein (non albumin)
- Dipstick: (which measures for albumin and not light chains) will be negative for protein aka
bland urine
- Hypertensive Nephrosclerosis
- Small vessel vascular disease
- Blood vessels prematurely atherosclerosis causing glomerular drop out and scarring of the
interstim
- Scleroderma
- Limited cutaneous systemic sclerosis
- Diffuse cutaneous systemic sclerosis: 60-80% have renal injury from disease state itself
- FANA positive
- Concern for Scleroderma Renal Crisis = medical emergency
- AKI, moderate to severe HTN and bland urine
- Uncontrolled accumulation of collage, thickens vascular walls, narrowing and renal
ischemia
- Occurs in 10-15% of those with Diffuse Cutaneous Systemic sclerosis and happens early
in disease
- Left untreated: renal failure in 1-2 months and death in 1 year
- Treatment: ACE Inhibitor
Nephrotic Urine States
- Urine protein: albumin excretion greater than 3.5g in 24 hours
- Nephrotic Syndrome:
- Present with 3 things (nephrotic range protein, hypoalbuminemia, peripheral edema)
- Hyperlipidemia: due to increased hepatic lipogenesis
- Increased risk of renal disease and arthroscleratic
- Venous thrombotic disease:
- Loose proteins other than albumin and develop a hypercoagulale state
- Renal and peripheral venous thrombosis
- Lipiduria (forms fatty casts, looks like a latese cross under microscope)
-Pathophysiology or nephrotic syndrome
- Glomerular capillary wall
- 3 layers that work as a glomerular filtration and responsible in the filtration between blood and
urine
- Fenestrated Capillary Enothelial cells (fenestrations allow plasma through to the basement
membrane)
- Glomerular Basement Membrane (maintains glomerular filtration barrier; negatively charged,
repels albumin)
- Epithelium: Podocytes (Have highly specialized foot processes that connect and form slit
diaphragms; Slit diaphragm important for the efficient flow of small solute and water)
- Anything that messes with any of these layers: nephrotic proteinuria
- Nephrotic Disease States:
- Biopsy: anyone with nephrotic proteinuria (besides diabetics)
1) Light microscopy: high overview
2) Immunofluorescens: looks for nephritic component and identif immunce complexes
3) Electron microscopy: (EM) helps look at the ultrastructure and better identify immune deposits
- Diabetic nephropathy
- Leading cause of kidney disease in U.S. and western society
- Responsible for 30-40% of all ESRD causes
- Hyperglycemia: produces inflammatory responses, oxidative stress, and injures the podocytes and
deposits that charge and affect the ability of the kidney to filter.
- Amyoidosis
- Organize into betapleted sheets and produce spikes of the capillary uniion and poke through the
GF membrane
- Easily identified by apple green birefringence on congo red
- Terminal illness
- Present with HTN, cardiac effects and elevated creatine
- Nephrotic Disease states based of histologic appearance
- Diagnosed by histologic appearance but does not determine the etiology
- Minimal Change Disease
- Fairly common
- Minimal change under light microscope
- EM: podocytes are abnormal, fused, no unique cell-cell junction
- Primary: Immune generated circulating facture; alters the cytoskeleton of the podocytes
- Secondary
- Nonsteriodal - most common cause of secondary minimal change disease
- Gama interferon
- Hodgkin's lymphoma
- Allergy: 30% of minimal change have associate allergy (mechanism unknown)
- Presentation
- Sudden onset (days to weeks)
- Marked edema and hypoablbuminemia
- 60% have normal blood pressure, 82% have normal creatinine
- Focal Segmental Glomerulosclerosis (FSGS) - primary and secondary
- Most common cause idopathic nephrotic syndrome in adults
- Primary glomerulonephritis in the US that causes ESRD
- Widespread podocyte injury
- Primary: circulating factor that messes with regulation of foot process and adhesion to the
glomerular basement membrane (afffect all podocytes)
- Present with nephrotic syndrome and rapid progression
- HTN and elevated creatinine
- Secondary: the visceral epithelial cells don't replicate
- Nephron loss or obesity or direct foot process injury
- Cannot replicate (podocytes), leads to decreased to podo denisty at specific areas (focal injury)
- 2/3 of all cases FSGS
- Present: with slowly increasing proteinuria and kidney impairment over time
- Causes: interferon, bisphosphonates, talc, anabolic steroids
- Genetics: gene mutations that encode for the slit diaphragms of the podocytes (affect all podocytes)
- Present in Childhood: full blown nephrotic and progress rapidly to ESRD
Membranous Nephropathy
- Most common cause of nephrotic syndrome in caucasion adults
- 80% present with nephrotic but develops more slowly to ESRD
- Primary: Major antigen identified
- antibody to trans-membrane receptor that is highly expressed on the glomerular podocyte
- Secondary: Cancers (lung, breast, GI), Lupus, Thyroiditis, Hep B, Syphilis, Nonsteroidals, Monoclonal
Antibodies
Nephritic Syndrome
- Hematuria and proteinuria
- Hematuria: blood from kidney or outside the kidney
- Outside the kidney: look the same
- Inside the kidney: dysmorphic red cells
- Present:
- Renal impairment for days to weeks
- Edmatous, HTN and look critically ill
- Vasculitis, sinusitis, oral ulcers
- Pulmonary renal syndrome: short of breath or hemoptysis
- Skin changes: bruising , bleeding, purpura
- Myalgias and arthritis
- Urine:
- Hallmark: red blood cell casts (polymorphic red cells)
- dipstick + for blood
- elevated proteinuria
- Biopsy: nephritic and + urine
Nephritic Disease States (based on immunofluorescence staining)
- Pauci Immune Disease
- Ankle vasculitis, common
- A paucity (little amount) of immune complexes
- See black on imaging
- Lab work: check on ANCA and peripheral eosinophils
- Anti-GBM Disease
- Renal limited, or classic pulmonary renal: Good Pasture's
- linear staining of the glomerular basement with anti IGG (looks like a ribbon on a package)
- Treat with cytotoxic agents
- Immune Complex
- Starry sky pattern
- Glomerulus looks dotted with stars
- Stars = immune complex definition
- Diseases: Lupus (FANA), Post Infectious GN, Membranous Proliferative GN
- IGA Nephropathy
- Most common cause of glomerulonephritis in the world
- Presentation:
- Peak incidence is the 2nd and 3rd decades of life
- 40-50% gross hematuria with upper respiratory and GI illness
- Risk Factors for Progression:
- younger age or hypertension at time of presentation
- > 1g proteinuria
- Elevated creatinine at time of presentation
Thanks for listening.
In this podcast, we are joined by Dr. Kim Thielen, a nephrologist/kidney specialist with Minnesota Kidney Specialists. This episode is part one of a two part series dealing with acute kidney injuries. During this episode Dr. Thielen will discuss pre and post acute kidney injury etiologies. Included with the podcast is additional shownotes that Dr. Thielen references throughout the podcast. Also check out the next podcast/episode on intrinsic kidney injuries. Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Describe how to work up a patient who presents with kidney injury.
- State the 3 types of kidney injury etiologies.
- Identify various causes of kidney injury.
- Choose treatment options for the specific types of kidney injury.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for additional show information. Acute Kidney Injury- Abrupt decrease in kidney function
- Suspected with oliguria, elevated creatinine, proteinuria, and hematuria
Oliguria
- Less than 500mls of urine in 24 hour period.
PreRenal- Anything that decreases circulating volume or disruption of blood flow to the kidney, causing ischemic kidney
- Causes:
- Total body salt and water depletion
- Dehydration
- Hemorrhage
- Decompensated right or left ventricular failure
- Renal arterial stenosis or renal vasospasm
Signs and Symptoms
- Orthostatic, hypotensive, tachycardiac
- Most sensitive indicator of ischemic kidney: Urinary sodium concentration
Urinary Sodium Concentration- Distinguishes between prerenal and instrinsic causes
- Urine sodium less than 20 in oliguria is indicator of ischemic kidney
Fractional Excretion of Sodium- Fractional excretion of less than 1% is indicative of ischemic kidney or a prerenal state
- Fractional excretion of 2% is indicative of tubulules not working or ATN
Fractional Excretion of Urea
- For patients on diuretics
- Urea not affected by water concentrating effect of kidney
- Prerenal state: fractional excretion of urea less than 35
- Intrinsic: fractional excretion of urea greater than 35
Classic Presentation of Prerenal
- BUN to Creatinine Ratio greater than 20.1 signifies dehydration
- Variables: GI bleed can increase BUN
- Elevated bicarb
Post Renal Etiologies
- Anything that interfers with the drainage of the urine from the renal pelvis out to the urethra.
- Causes:
- Intraluminal obstruction: stones or tumors
- Dysfunctional bladder: spinal injury, diabetes
- Dysfunction with bladder drainage
- Extrinsic compression on ureter
- Ruptured AAA: edema
- Retroperitoneal fibrosis
- Prostate
- Urethral strictures
Post Renal Presentation
- Can present with pain or not
- Decreased urine output or outflow
- Hypertensive
- Volume overload
Treatment
- Foley distal obstructions of urethra
- Imaging: ultrasound
- Horizontal view:
- Normal: (bright white) collecting system is collapsed due to normal drainage of pelvis
- Post renal obstruction
- Dilated (dark pools) collecting system
- Chronic obstruction
- Functional dilatation
- Further testing: functional lasix radiograph
- Kidney transplant: functional dilated picture
- Changed physiology of the ureter, and can get flow both ways and thus chronic dilation
Thanks for listening.
In this podcast, Dr. Lioudmila Sitnikova, a urologist with Minnesota Urology, discusses micturition, pathology of incontinence including stress, urge and neurological, as well as various treatments available.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Describe the normal function of the bladder.
- List the different types of incontienence.
- Describe how female urinary incontinence is diagnosed.
- Identify treatment options for each type of urinary incontinence.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the atachment for the full chapter summaries. Phases of Micturition- Storage
- Evacuation
Risk Factors
- BMI, smoking, caffiene, spicy food, heavy lifting, child-bearing, diabetes, pelvic surgeries.
Hormone Replacement Therapy (HRT)- Oral estrogen/progesterone vs placebo
Prevalence
- 1 out of 4 women over age 80 suffer incontinence.
Types & identification- Stress incontinence
- Urge incontinence
- Overflow incontinece
- Bladder outlet obstruction
Evaluation for incontinence- Questionnaires
- Voiding diaries
- Assess quality of life
- Physical assessment and pelvic exam
Treatment
- Stress incontinence: physical therapy, surgical, bulking agents, Burch procedure
- Urge incontinence: biofeedback, antimuscarinics and Beta 3 agonists, Botox, nerve stimulator
- Hypotonic bladder (non-obstructive urinary retention): nerve stimulator
*For links to reference materials please see the full show notes.
In this podcast,three great physicians come to gether to discuss colon cancer. Dr. Sabina Khan, a gastroenterologist with Rigeview, Dr. Dawn Stapleton , a general surgeon with Lakeview Clinic, and Dr. Purvi Gada, an oncologist and hemotologist with Minnesota Oncology; together they cover history, screening, staging and treatment for colon and colorectal cancer.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Summarize colonoscopy screening guidelines.
- Recognize symptoms of colon cancer in order to make a cancer diagnosis.
- Describe surgical and adjuvant therapies available for colon cancer diagnoses.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for the full chapter summaries.
Statistics
- Colon cancer is the 3rd leading cause of cancer death in the U.S.
- USPSTF recommendation states approximately 10.5% of new colorectal cancer occurs in individuals younger than 50 years old.
- Incidence of colorectal cancer has increased by almost 15% from the early 2000s to 2016.
- Recommended age to start colon screening is now at 45 years, down from 50 years old.
Screening Recommendations:
- screening tests and intervals are fecal immunochemical testing or high-sensitivity guaiac-based fecal occult blood testing every 2 years
- Colonoscopy every 10 years
- Flexible sigmoidoscopy every 10 years - plus fecal ummunochemical testing every 2 years.
Systematic Review: Post-Colonoscopy Complications & Review of Enhanced Recovery Programs in Colon Surgeries
- Complications post-colonoscopy
- ERAS: Enhanced Recovery After Surgery
- Fast track surgery protocols - shortened hosptial length of stay
- Adjuvant therapies
- Targeted therapies
- Treatment side effects
*For links to reference materials please see the full show notes.
In this podcast, Dr. Ron Tarrel, a Stroke Neurologist with Allina Health, discusses everything stroke. Dr. Tarrel walks through recognition, evaluation, and management of stroke. He also discusses current guidelines, as well as the future of stroke medicine. Enjoy the podcast! Objectives: Upon completion of this podcast, participants should be able to:
- Identify and describe warning signs of stroke and its initial presentation.
- Assess when initial urgent/emergent evaluation, imaging, coordination of care and decision making needs to occur in regards to stroke.
- Discuss treatment options and indications in regards to stroke care.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
ADDENDUM TO SHOW NOTES:Please note the Dr. Tarrel refers to TPA as a blood thinner at one point throughout the podcast. He would like the listerner to know that this medication (TPA) is a clot dissolving medication and not a blood thinner. Dr. Tarrel does not wish to confuse the listner on the nomenclature of TPA vs blood thinners (i.e. anticoagulants).
SHOW NOTES:FAST
The American Heart Association (AHA) put forth an initative for the lay person to recognize signs and symptoms of stroke and that was the FAST assessment which is (Facial asymmetry or weakness, Arm weakness, Speech difficulties, and Time), but now it has moved to the BE-FAST screening test. the BE portion of the FAST exam is assessment of Balance and Eyes to determine if there are posterior circulation findings.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.116.015169
HINTS Exam
The HINTS exam is a bit more specific and sensitve, looking for posterior circulation strokes in the correct patient population. Briefly, HINTS is a Head Impulse test direction-changing Nystagmus in eccentric gaze, or skew deviation.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.109.551234
Common Deficits
The majority of strokes are going to occur in the anterior circulation which would be the carotid distribution, then into MCA (M1, M2, M3, M4, M5). Most of the deficits are going to be unilateral weakness, sensory or cognitive symptoms - example: aphasia/ neglect (cortical symptoms). Whereas, posterior circulation (vertebrobasilar) may have more devastating qualities. Symptoms for posterior stroke can include dizziness, nausea and vomiting, nystagmus, coordination, ataxia. However, see the article linked below where posterior cirulation vs anterior crculation infarcts can sometimes be difficult to determine on a clinical exam alone. Therefore, neuroimaging is recommended to accurately determine stroke distribution.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.112.652420
This study indicates that the symptoms/signs considered typical of posterior circulation infarcts occur far less often than was expected. Inaccurate localization would occur commonly if clinicians relied on the clinical neurological deficits alone to differentiate posterior circulation infarcts from anterior circulation infarcts. Neuroimaging is vital to ensure acurate localization of cerebral infarction.
Hemorrhagic vs Ischemic Stroke
Which one is it? According to Dr. Tarrel, intracranial hemorrhage appears to exhibit more headache symptoms, such as this is the "worst headache of my life" , whereas ischemic stroke appears to be more painless, usually. Blood pressure and loss of consciousness can closely mimic hemorrhagic vs ischemic.
Telestroke Guidelines
Telestroke guidelines are generally insitution specific. Refer to the linked article below, on the current guidelines in telestroke medicine.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802246/pdf/tmj.2017.0006.pdf
BP / 1st Line Agent
For hemorrhagic strokes, the neurosurgeons and neurologist like the systolic blood pressure to be in the 140-160 range. BP is usually controlled with Nicardipine as a 1st line agent.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.117.020058
Last Known Well (LKW)
Last Known Well (LKW) is extremely important especially since we know that we are working against the closk for the use of lytic therapy (currently 4.5 hour window).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630074/pdf/nihms699406.pdf
https://www.ahajournals.org/doi/epub/10.1161/CIRCULATIONAHA.116.023336
Imaging
Imaging modalities for stroke workup can often include an initial non-contrast CT of the head to rule out ICH, but hen what happens? Generally, it is recommended to work in concert with the stroke neurologist to then determine the next line of imaging studies. If it is determined the patient looks to have a high NIHSS and concerns for LVOT (Large Vessel Occulusion) a CTA of the head and neck can be considered. Perfusion studies and advanced MR imaging should be discussed with consulting neurologists. Clinicians should also remember to follow their specific institutional guidelines for imaging studies if the stroke neurologist is unavailable or there is a delay in consultation.
LKW along with CTA and CT perfusion of the head in ischemic stroke patients can sometimes give us a picture of the infarct core with surrounding penumbra (ratio). If circumstances are faborable, it may allow the pursuit of a thrombectomy. The current guidelines are for thrombectomy within 6 hours, but consideration upwards of 24 and beyond in the right patient population. Please see the DAWN and DIFFUSE 3 trials.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.119.027974
ThrombectomyGenerally the neurointerventionalist does not pursue thrombectomy beyond the MCA (M2 region), sometimes depending on anatomy.
ASPECT Score
The ASPECT Score (Alberta Stroke Program Early CT Score) determines the volume of subcortical and cortical infarct involvement via perfusion study. Generally the score provided is 1-10. Anything less than a 6 portends a poor outcome. More early changes seen on CT suggest poorer outcomes from stroke. Patients with scores >8 have a better chance for an independent outcome.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.117.016745
IV TPA
IV TPA with thrombectomy is safe.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.109.568451
TNK appears to have the same efficacy as TPA. Single dose IV push over 5 minute infusion. Easier and faster delivery of TNK.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.119.025080
Institutions may have different absolute and relative contraindications to TPA. Practice should be guided by institutional protocol and consultation with neurology.
https://www.ahajournals.org/doi/epub/10.1161/STR.0000000000000086
Secondary Prevention
Secondary prevention of stroke with the aid of DAPT (Dual Antiplatelet Therapy) - usually Plavix and Aspirin. Patients with cerebra ischemia are at high risk for early recurrent stroke, and use of DAPT for secondary prevention is reflected in current guidelines. Good BP and lipid management is paramount for 2nd stroke prevention.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.119.028400
Scoring Systems
HAS-BLED score for major bleeding risk.
CHA2DS2-VASc Score for artrial fibrillation stroke risk.
Anti-thrombotic Therapy & Elderly Patients
Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/484991
Fall risk and anticoagulatoin for atrial fibrillation in the elderly: A delicate balance.
https://www.ccjm.org/content/ccjom/84/1/35.full.pdf
In this podcast, Dr. Laura Mohling, a pediatrician with Lakeview Clinic, talks about pathogens that infect children, childhood immunizations, current guidelines regarding vaccine scheduling, and vaccine hesitancy. Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Name at least 3 pathogens mentioned in the podcast children/adolescents were/are susceptible to.
- Distinguish between the two different meningococcal vaccines available.
- Summarize Human Papilloma Virus (HPV) recommendations for adolescents.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for the full chapter summaries.
Vaccines
- Biggest impact on public health
- Vaccine safety continues to improve.
- No causation of autism from MMR or other vaccines. (Andrew Wakefield debunking, Thimerosal-free).
- ACIP Schedule for Childhood Immunization
Meningococcus
- Causation - Neisseria meningitidis
- Incidence declining
- Case fatality approximately 15%, with 10-20% survivor have serious sequelae.
- Serogroups
- Serogroup B and C - most frequent cause of disease in U.S.
- Meningitis type B accounts for about 1/3 of cases in adolescents.
- Serogroup A is rare in U.S.
- Meningococcal Vaccine
- Meningococcal B vaccines (Trumenba and Bexsero) developed in 2014.
- Vaccine short duration of protection (1-2 years) based on antibody response
- Trumenba (2 doses 6 mos apart) \ Bexero (2 doses at least 1 mo apart)
- MenACWY vaccine in 2005 primary dose at age 11, booster at age 16.
HPV
- HPV vaccine is the cancer prevention vaccine!
- Statistics
- Vaccine - Gardasil 9
- ACIP recommendation of vaccine at age 11 or 12
- dosing schedule of HPV vaccine
COVID-19 (SARS-CoV2)
- Approved vaccine for age 12 and above. (Pfizer-BioNTech)
- RNA vaccines
- Antigentic target - how the vaccine works
- Co-administering with other vaccines
- ACIP, UpToDate, FDA statements regarding vaccine in adolescents
*For links to reference materials please see the full show notes.
In this podcast, Emily Clegg, senior director of risk mitigation response with Constellation, presents information around medical malpractice. Join us as Emily discusses definitions, the steps that occur in medical malpractice lawsuits, and tips in managing what could be only a stressful ordeal.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Define basic malpractice terms.
- Summarize the steps taken in a medical malpractice lawsuit, and what to expect if a lawsuit occurs.
- Identify ways in which a health care provider can protect their emotional health through the malpractice process.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for the full chapter summaries.
Basics of medical malpractice
- Lives in civil court
- 4 elements of medical malpractice
- Statute of limitations
Claims
- Where claims arise
- Contributing factors
- Initial steps in a claim
- Discovery - uncovering facts
- What depositions are like
- Small amount end up going to trial
Trial
- What trials are like
- Advice about speaking - honesty
Insurance/Damages
- Damages vs policy limitations
Communication
- Staying engaged
- Early communication beneficial
In this podcast, the Edith Nagel Eisinger's memoirs continues, with the sixth chapter. Edith Nagel Eisinger, was the wife of Dr. Harold Nagel and nurse in the hospital she talks about in her memoirs. In 1936, the Nagel's founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center. Enjoy the next chapter of Edith Nagel Eisinger's story.
In this podcast, Dr. Jim Kolbeck, interventional and structural cardiologist with Minneapolis Heart Institute at United Hospital, discusses ECMO (extracorporeal membrane oxygenation) and the various aspects of this procedure.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Explain the history and purpose for extra corporeal membrane oxygenation (ECMO).
- Assess when ECMO CPR (ECPR) is warranted.
- Identify and define inclusion criteria for ECMO and contraindications to ECMO.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for the full chapter summaries.
Chapter 1: Definitions
- History of ECMO
- Extracorporeal membrane oxygenation (ECMO):
- V-A Veno-Arterial
- V-V Veno-Venous
- Who gets ECMO
- V-A: Shock states
- V-V
- ECPR: V-A
- Out-of-hospital cardiac arrests
- ARREST Trial
- Refractory Cardiac Arrest
- Criteria
Chapter 2: Cannulation
- V-A ECMO
- Bifemoral
- V-V ECMO
- Bifemoral or Femoral/Jugular
- Dual Lumen: Jugular vein
- Anticoagulation
- V-V to V-A
- Discussions of care
Chapter 3:
- Cannulate and Ship Model
- Who's Involved
- The Machine: Cardiohelp (portable ECMO machine)
- Physiology of ECMO
- Monitoring the Results
Chapter 4:
- Who Gets ECMO
- Contraindications
- The Future / Next steps
In this podcast, Dr. Haylee Veazey, an emergency medicine physician, internist, and medical director of the Adult Gender and Sexual Health Clinic with Hennepin Health Care (HCMC), provides insight into the world of gender medicine.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Review and choose appropriate and non-offensive terminology in regards to gender affirming healthcare.
- Explain issues surrounding gender affirming care.
- Assess pertinent medical concerns for patients on gender affirming treatments.
- Identify ways to improve the experiences of transgender patients in the healthcare setting in order to reduce those delaying health care.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for the full chapter summaries.
Chapter 1: Definitions
- Getting on board with definitions
- Terminology and definitions:
- Assigned sex - Gender expression
- Gender - Gender dysphoria
- Cis-gender/Transgender
- Risk factors
Chapter 2: Medical Gender Affirming Care
- Informed consent
- HRT masculinization: Testosterone
- Hormone changes
- Risks
- HRT Feminization: Estrogen, etc.
- Hormone changes
- Risks
- Contraindications
- Testosterone blocking agents
- Monitoring
- Resources and Guidelines
Chapter 3: Surgical Gender Affirming Healthcare
- Top surgery or Chest surgery
- Masculinizing
- Feminizing
- Bottom surgery
- Feminizing (vaginoplasty, orchiectomy)
- Masculinizing (metoidioplasty, phalloplasty vaginectomy, hysterectomy,
oophorectomy, or salpingectomy)
Chapter 4: The Trans Broken Arm Syndrome - Care of the LGBTQ Population
- Don't necessarily have to ask about all surgeries a patient has (or has not) had, especially if that assessment not indicated for the presentation.
- Important items for primary care (screenings, safe spaces)
- Being comfortable with non-gendered language
For links and resources* - see attached "Show Notes".**
Heart disease in women is under recognized under treated, and under researched compared to men; although it is the number one killer of women in the world.
In this podcast, Dr. Retu Saxena, a cardiologist with Minneapolis Heart Institute, discusses the epidemiology, symptoms and pathology of heart disease as it relates to women and cardio-obstetrics.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Summarize the historical nature of heart disease in women.
- Recognize the cardiovascular risks in women.
- Identify signs/symptoms of heart disease in women.
- Review prevention efforts for heart disease in women.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
SHOW NOTES:
*See the attachment for the full chapter summaries.
Chapter 1:
- History of cardiovascular disease in women
- Symptoms
- Risk factors
Chapter 2:
- Cardio-Obstetrics (CV-Ob)
- Cardiomyopathies in pregnancy
Chapter 3:
- Treatment/Therapies and concerns
- Hypertension
- ICD guidelines, ASCVD risk scores, AHA guidelines, recommendations
* For journal articles cited, and web links - see attached "Show Notes".
As part of an annual review of medical literature, this podcast will dissect several medical journal articles, discuss some of their finer points, and how it can relate to medical practice today.
In this podcast Dr. Valerie Johnson, an emergency medicine physician with EMPAC, and Dr. Abby Elliott, a family medicine physician with Lakeview Clinic, cover a variety of topic areas from five journal articles. If you like to skip to the conclusion part of the article, this podcast is for you.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Define non-consensus TIA.
- Identify long-term risks of non-consensus TIA.
- Recognize the mechanism of action of GLP-1 agonists.
- Summarize key principles of sepsis recognition, early screening/detection, early management, and titration of care.
- Name significant/relevant findings of the journal articles being reviewed and discussed.
- Select a credible/relevant journal article.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
*See the attachment for article discussion summaries.
Journal Article 1: "Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined"
CITATION: Lundgren, J., Janus, C., Jensen, S., Juhl, C., Olsen, L., Christensen, R., Svane, M., Bandholm, T.,Bojsen-Møller, K., Blond, M., Jensen, J., Stallknecht, B., Holst, J., Madsbad, S. and Torekov, S., 2021. Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined. New England Journal of Medicine, 384(18), pp.1719-1730. Available: https://www.nejm.org/doi/full/10.1056/nejmoa2028198
Journal Article 2: "Diagnosis of Non-Consensus Transient Ischaemic Attack with Focal, Negative, and Non-Progressive Symptoms: Population-Based Validation By Investigation and Prognosis"
CITATION: Tuna, M. and Rothwell, P., 2021. Diagnosis of non-consensus transient ischaemic attacks with focal, negative, and non-progressive symptoms: population-based validation by investigation and prognosis. The Lancet, 397(10277), pp.902-912. Available: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31961-9/fulltext
Journal Article 3: "Cardiovascular Outcomes and Mortality Associated with Discontinuing Statins in Older Patients Receiving Polypharmacy"
CITATION: Rea, F., Biffi, A., Ronco, R., Franchi, M., Cammarota, S., Citarella, A., Conti, V., Filippelli, A., Sellitto, C.and Corrao, G., 2021. Cardiovascular Outcomes and Mortality Associated With Discontinuing Statins in Older Patients Receiving Polypharmacy. JAMA Network Open, 4(6), p.e2113186. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780952
Journal Article 4: "Early Care of Adults with Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report"
CITATION: Yealy, D., Mohr, N., Shapiro, N., Venkatesh, A., Jones, A. and Self, W., 2021. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Annals of Emergency Medicine, 78(1),pp.1-19. Available: https://www.annemergmed.com/article/S0196-0644(21)00117-7/fulltext
Journal Article 5: "Associations of Suicidality Trends with Cannabis Use as Function of Sex/Depression Status"
CITATION: Han, B., Compton, W., Einstein, E. and Volkow, N., 2021. Associations of Suicidality Trends With Cannabis Use as a Function of Sex and Depression Status. JAMA Network Open, 4(6), p.e2113025. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781215
The memoirs of Edith Nagel Eisinger continues. This podcast contains the fifth chapter of the personal memoirs of Edith Nagel Eisinger, wife of Dr. Harold Nagel. In 1936, the Nagel's founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center. Enjoy the next chapter of Edith Nagel Eisinger's story.
The memoirs of Edith Nagel Eisinger continues. This podcast contains the fourth chapter of the personal memoirs of Edith Nagel Eisinger, wife of Dr. Harold Nagel. In 1936, the Nagel's founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center.
Enjoy the next chapter of Edith Nagel Eisinger's story.
This podcast is a reading of the third chapter from the personal memoirs of Edith Nagel Eisinger, wife of Dr. Harold Nagel. In 1936, they founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center.
Enjoy the next chapter of Edith Nagel Eisinger's story.
Western and Eastern medicine both offer unique perspectives fundamental to healthcare today. In this podcast, Nikki Vanecek a traditional Chinese medicine practitioner with EastWest Acupuncture, discusses different modalities of Eastern medicine, and how both Eastern and Western medicine can benefit patients.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Describe acupuncture and the different Chinese medicine treatments.
- Identify when to refer patients for acupuncture and Chinese medicine treatment.
- Determine what is best treated with acupuncture or other Chinese medicine treatment modalities.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thank-you for listening to the podcast.
In this podcast, Dr. Chris Mast, Vice President of Clinical Informatics with EPIC, discusses how electronic health medical records (EHRs) are essential to today's modern day medical world, about implementing and using an EHR for improving patient care, and what the EHR future holds for healthcare.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Recognize the benefits that an integrated electronic health record system will bring to patients and healthcare providers.
- Identify steps that healthcare providers can take to maximize their efficiency and smoothly transition to new electronic systems from existing systems.
- List common roadblocks that prevent healthcare providers from taking full advantage of their electronic tools/resources.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1:
The importance of medical records has grown in the last 100 years, starting with the first paper medical records developed in the 1920s. Even back then, standardization was important, the American College of Surgeons established an association to achieve just that. In 1965, Medicaid and Medicare were developed and pushed the development of health information systems. The 1970s brought computerized physician ordering systems. The first information system was also rolled out in the University of Vermont Medical Center's gynecology unit. In the 1980s, growth in the computer world led to new possibilities in healthcare. Personal computers became more affordable. Dragons systems developed voice recognition software and by the late 1980s, Windows software was developed. From 1990 to the late 2000s there was the boom of the World Wide Web, ICD-30 coding, and legislation for the increase of electronic health records (the HiTech Act). Between 2008 and 2015 electronic health record adoption doubled.
EPIC is a privately owned company, which Dr. Mast states has allowed the company to focus on the long term, making sure that the software is a joy to use, and provide value to healthcare providers.
CHAPTER 2:
EPIC is an integrated comprehensive electronic health record system that offers many different functions to promote better patient and health care interactions. The features of EPIC provide a one-platform system, thereby eliminating the multiple database platforms used in the past or are still being used today.
One of the big benefits of EPIC is the ability to share pertinent patient information across organizations that both work with EPIC. However, with increasing interoperability (much like cell phones bounce off other network cell towers), communication between different EHR systems increase. This interoperability will only increase as standardization of data, like how a specific diagnosis - like heart failure is coded, improves. Dr. Mast states, "playing the percentages, you will be able to connect, if not now, in the near future".
The interoperability of EPIC assists in promoting care everywhere as well as the newer share everywhere features which is a limited one-time access to care everywhere for the non-EPIC health system evaluating a patient.
CHAPTER 3:
Connect customers, organizations that use EPIC software in partnership with another organization, benefit from a move-in ready EHR where they can start using the system immediately. The example used, is like moving into a furnished apartment, without having to find, build or organize everything. It's already there, ready to use.
EPIC is not a tiered system. There is not a platinum or gold level status. However, not every organization needs every module available on the EPIC platform. What kind of support will an EPIC customer receive? In the Connect scenario, there are essentially two groups of assistance. The connect partner, with their knowledge and support as well as the support team from EPIC.
There is also personalization of EPIC systems to create the features and information important to the workflow of an individual clinician.
CHAPTER 4:
EPIC is more than just a documentation software. Within the system, there are algorithms and models that allow the computer to analyze data and predict, say, patients that are trending towards sepsis. This information can be used to direct resources earlier, intervene earlier, and improve outcomes. Another example of AI modeling would be a patient discharged with congestive heart failure, and submitting daily weights. Modeling can trend that data and predict those that might fail outpatient treatment, provide opportunities for early interventions, and again, improve outcomes.
That is the present. The future of AI in electronic health records is endless. Ambient speech recognition is currently being trialed, providing documentation, transcription and even the possibility of cueing up orders. It is the fundamental theorem of informatics at work: clinician plus computer is greater than clinician alone.
Thank-you for listening.
In this podcast, Dr. Scott Sharkey, senior consulting cardiologist with Minneapolis Heart Institute, provides a discussion on cardiomyopathy and more specifically Takotsubo syndrome.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Describe how Takotsubo cardiomyopathy was discovered.
- Differentiate the diagnostic criteria for Takotsubo cardiomyopathy from other cardiology related conditions.
- Identify treatment options for Takotsubo cardiomyopathy.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1:
Cardiomyopathy. According to Dr. Sharkey, it is a general term for cardiac muscle disease, often times of unknown cause. Usually it refers to a dilated, poorly, contracting heart. Though it's also been called stress cardiomyopathy, Takotsubo does not behave like most cardiomyopathies. It's a microcirculatory disease, causing a stunned myocardium similar to an acute myocardial infarction, but with non-obstructive epicardial coronary arteries.
Dr. Sharkey and his colleagues first noticed this phenomenon in patients with myocardial infarction that showed deep T wave inversions on EKG, and initial ECHOs with ejection fractions of 25-30%. Weeks later, these injuries would resolve, findings they attributed to a stunned myocardium.
This phenomenon was then seen in a patient with a TBI, who again had a deep T wave inversion, and a large left ventricular regional wall motion abnormality with normal coronary arteries. The regional wall motion abnormality, again, resolved. These findings were noted in 20 similar cases that were then published in 1998. Though to note, this same syndrome was also present in the Japanese literature at this time.
Later, it was noted patients were developing these symptoms not just from severe illness or trauma, but also from deeply emotional situations. This led to a write-up in Circulation in 2005, which received the 'Paper of the Year' award.
From the early days to now, Dr. Sharkey went from seeing three to four patients per year with Takotsubo, to present day, one to two patients per week. The Minneapolis Heart Institute Foundation has done, and continues to do robust research on Takotsubo, noting that there is a subset of vulnerable patients that actually have recurrences of Takotsubo., They have also been able to study specific triggers for Takotsubo, like drug use, pheochromocytoma and critical illness in general.
CHAPTER 2:
Triggers for Takotsubo. As mentioned before, drug use, pheochromocytoma or critical illness are causes, but really any physical illness as well as any emotional stress are triggers for this syndrome. Death of a spouse is a good example of an emotional trigger, though as exemplified in the discussion, it can be any emotional situation. Teasing out the patient's history and the specific precipitation event is an art form.
The autonomic nervous system is implicated here. Catecholamine levels are very elevated in these patients, as opposed to lower levels seen in acute MI patients. Pheochromocytoma and accidental overdose of epinephrine will cause this as well.
The pathophysiology of the event is still being researched. It's postulated that this is all caused by vasospasms of the circulation or direct myocardial injury due to the catecholamine excess. It's presumed that effects occur on micro-circulatory level, and any disruption in blood flow is brief, less than 15-20 minutes, enough to raise serum troponins and cause wall motion abnormality.
The involvement is circumferential, so the ECG findings are more diffuse. EKG changes include ST segment elevation in about 40% of patients. Otherwise T wave inversion is often seen, but is a later development. ST depression is not generally seen in Takotsubo, and would instead indicate a coronary artery occlusion.
Echo findings show a classic, distinctive finding: poor contractility or akineses from the mid-heart to the apex, while the base of the heart is hypercontractile. Also called apical ballooning, the apex can be seen ballooning outward on echocardiograms. This is what is reminiscent of a Japanese clay pot, octopus trap, aka Takotsubo. And yes, the name is most certainly credited to the Japanese.
CHAPTER 3:
When a patient presents with an acute cardiac event that looks like Takotsubo, the patients still must undergo coronary angiogram to exclude a coronary occlusion. Cardiac echo and cardiac MRI are used to help diagnose this disease.
Beta blockers and ACE inhibitors are used early on in treatment, but Dr. Sharkey suspects that patients would probably recover without them. The reality is, most of these patients get better. The myocardium, in the setting to Takotsubo, should recover. A process that usually takes one to two weeks. Anti-platelets do not play a role here, but anticoagulants are often given until the myocardium has recovered to prevent a small risk of left ventricular thrombus.
Left ventricular outflow tract obstruction is a complicating factor in Takotsubo. Many of these patients are middle aged to older women, and have basal septal hypertrophy. This exacerbates, the outflow obstruction, which causes hypotension and shock in Takotsubo, 15-20% of the time. The left ventricular outflow obstruction should resolve with the resolution of Takotsubo.
As mentioned, Takotsubo can have a recurrent phenomenon, and remarkably, these patients all recover their heart function. Curiously, the precipitating cause for these patients tends to be emotional.
Though used in the initial treatment, beta blockers are not prescribed long-term for Takotsubo patients. In fact, Dr. Sharkey found that 30% of patients with a Takotsubo event were already on beta blockers, and 80% of those who have had recurrent Takotsubo were already on beta blockers and ACE inhibitors.
CHAPTER 4:
Patient presentation: Patients can present with chest discomfort and/or shortness of breath, much like an acute MI patient. They can also present with an acute concern of another nature. Dr. Sharkey gave the example of a patient presenting with a pasteurella multocida infection causing an airway obstruction. The patient's ongoing hypotension led to further work up and diagnosis of Takotsubo.
Takotsubo patients can also be discovered during inpatient stays when incidental ECG wave form changes, troponin elevation, tachycardia, and/or hypotension are noted. About 10% of Takotsubo patient's develop cardiogenic shock. Most survive their ICU stay, even if advanced treatment, like intra-aortic balloon pumps or ECMO are required.
For the critically ill, where beta blocker use is contraindicated in the light hypotension, Dr. Sharkey preferred choice of vasopressin followed by phenylephrine. Fortunately, patients recover from Takotsubo. However, malignant arrhythmias and cardiac arrest can happen. Patients are counseled to present to emergency care if their symptoms ever return.
Thank-you for listening.
In this podcast, Ashley Leland and Alex Ross, clinic pharmacists with Ridgeview, provide a discussion on medication therapy management, through a case study perspective.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Describe medication therapy management (MTM) and clinic pharmacists roles and responsibilities.
- Identify patients who may be candidates for a referral to a clinic pharmacist for medication therapy management (MTM) pharmacy services.
- Recognize the types of drug therapy problems (drug/ medication related) which a clinic pharmacist could help resolve.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1:
Medication Therapy Management can also be called CMM or Comprehensive Medical Management. For the sake of this episode, it will be referred to as MTM throughout.
MTM is a pharmacy service for targeted disease states like - asthma, COPD, diabetes, and/or congestive heart failure, and also for patients with polypharmacy. Really, any patient with concerns about their medications, can utilize this service.
The goal is to identify drug therapy problems: side effects, medication compliance, drug interactions, and overall management of symptoms, to improve outcomes, for example, reducing hospital readmissions.
CHAPTER 2:
In chapter 2, a patient was seen with a complex medical history, including heart failure, diabetes, new a-fib, and a recent hypokalemic event. MTM services identified several drug therapy problems, including drug interactions between the patient's diltiazem and atorvastatin, and between turmeric and Eliquis. Also identified was the need for diabetic management, and that the patient's over-the-counter potassium supplements were not sufficient in maintaining normal levels. In follow-up, the patient was doing well, had started taking farxiga, stopped the turmeric, and switched from diltiazem to metoprolol.
In this chapter, Ashley and Alex briefly discuss natural medications and the use of the Natural Medicines Database to evaluate over-the-counter supplements and herbals. It's noted that some patients want to take a more wholesome approach to their medications, they recommend doing the research for good manufacturing practices or USP verified supplements and herbals. A great resource is your local MTM pharmacist.
Another important service MTM pharmacists is helping patients navigate the financial decisions regarding medication cost. Whether suggesting alternatives or navigating the patient to assistance programs for specific mediations.
CHAPTER 3:
In chapter 3, a patient who recently changed countries, had several drug therapy problems like adjusting medications to what is available here in the US, adjusting dosages of his current medications, gaining access to a glucose monitor, and updating vaccines. It's a good example of the range of things a MTM pharmacy visit can manage.
Common drug interactions were touched on briefly. Highlighting the importance of knowing not just what over-the-counter medications a patient is taking, but the quantity as well. Also important, knowing the supplements and herbals being taken and how they might interact with any prescribed medications.
It's noted that the structure of an MTM visit, that hour long conversation just about medication management, helps break down barriers, and hone in on the issues that patients can have with their medications. It also brings up areas for opportunity elsewhere, where that medication discussion is happening in much shorter time periods.
CHAPTER 4:
The last patient case touches on an important demographic for MTM pharmacists, mental health regimens. This patient presented with a new tremor and agitation. Her drug therapy problems included duplicate therapy, suspected serotonergic complications, stimulating compounds, and an emotional attachment to her medications.
The results of her MTM visit included stopping her amitriptyline and her focus supplement. Tapering off her duplicate therapy escitalopram, and then returning for follow-up.
The follow-up time frame for patients depends on the complexity of drug therapy problems identified. Ashley found that setting the follow-up appointment during the current appointment, increases the follow through for patients.
MTM Pharmacy is located at 7-9 Ridgeview primary and specialty clinics. They can be directly consulted by the patient's primary care provider or patient's can reach out to any of the clinics they are located in. Patients that would specifically benefit from these services include those with polypharmacy, those who are not doing well with their current medication regimen, and those with chronic disease states.
Other areas where MTM pharmacy is involved, but not mentioned in depth here include - immunizations, opioid prescribing and stewardship, anticoagulation, and non-surgical weight loss programs.
Thank-you for listening.
In this podcast, Dr. Dennis Mohling, a board certified OB-GYN physician with Western OB-GYN, provides an insight into obstetric emergencies and how to deal with them if and when they occur.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Define each of the three stages of labor.
- Recognize life threatening obstetrical emergencies, and implement immediate, non-surgical treatment.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1: Retained Placenta
The first stage of labor involves regular contractions affecting cervical changes up to complete cervical dilation. The next stage is the pushing and delivery of the baby, and the third stage follows delivery, ending in delivery of the placenta.
The placenta is "retained" if it is still in the uterus after 30 minutes. The uterus cannot contract at this point and with approximately 500mls of blood going across the placenta-uterine interface retained placenta increases the risk for hemorrhage. Incidence is around 3%.
A long list of risk factors for retained placenta include: preterm delivery, history of retained placenta, placental abnormalities, velamentous cord, and uterine abnormalities - like bicornuate uterus or septate uterus. Prior C-sections are also a risk factor, as well as intrauterine growth restrictions, and severe preeclampsia.
After the 30-minute mark, preparation for manual extraction needs to begin. It's the "call for help" action step that will be a recurring theme in the discussion today. This includes the very important step of calling anesthesia. Manual extraction is a painful process, and great analgesia and sedation is a necessity.
Manual extraction: using the umbilical cord as a pathway to the uterus with the dominant hand and supporting the uterine fundus with the other. Use fingers to create a dissection plan and gradually peel away the placenta from the uterus, removing it in its entirety. Post-removal the uterus will contract, but IV Pitocin, IM methergine, and TXA can be given as well. Pitocin dosing: 20 units in a liter of LR, run wide open.
Average placental delivery can range from right away to 60 minutes post-delivery of the baby; but retained placenta can have a delayed presentation. This can cause prolonged bleeding requiring extraction days, to weeks postpartum.
There are three stages of abnormal placental attachment. Placenta accreta: the stria layer between the placenta and uterus is absent. Placenta increta: the placenta is invading the muscle wall of the uterus. Placenta percreta: the placenta has grown through the uterus and into other organs. With uterine wall involvement, this will result in a c-section and likely a hysterectomy.
CHAPTER 2: Uterine Inversion
Uterine inversion is yet another scary presentation and can result in severe hemorrhage, shock and death. The uterus can be mildly inverted and protruding or fully inverted outside of the pelvis.
Post-delivery, and in active management of the third stage, gentle cord contraction is the goal. Uterine inversion is thought to be the result of excessive cord traction, but the data on this is mixed. Incidence is 1 in 35,000, rare but still real. Larger babies, long labors and sometimes fast short fast labors, severe preeclampsia, retained placenta and other uterine abnormalities are risk factors, through these are only present in 50% of uterine inversion cases.
Treatment is non-surgical. The uterus needs to be returned as soon as it's discovered. Insert that, "call for help" step. Anesthesia, more personnel, including nurses and lab techs are part of that "help" response.
In order to return the uterus back inside the pelvis, pitocin should be stopped and uterine relaxant agents, like inhalation agents or nitroglycerin may be needed. The uterus is then pushed back through the vagina and cervix to its normal position. Once back in place, the placenta needs to stay intact. Uterine relaxant agents are turned off, and uterine tonic agents and TXA are started. Manual extraction of the placenta follows. As the uterus is never meant to be outside the body, antibiotics are started as well.
CHAPTER 3: Cord Prolapse
In delivery, the head of the baby should act as a barrier. If the umbilical cord slips in front, it will become compressed as the baby delivers, causing fetal asphyxia. Incidence is 2 in 1000.
Risk factors include: polyhydramnios, prematurity, breach, transverse lie, twin gestation, and after rupturing of membranes or other intrapartum procedures like cervical ripening with balloon catheter.
Presentation is generally obvious with visualization or palpation of a pulsatile mass in the vagina or out on the bed. The fetal monitor, with normal being 120-160 bpm, will show a slowing heart rate, with variable decelerations.
C-section is the eventual fix, but in preparation for that intervention, the compression on the cord must be reduced. This is accomplished by lifting or pushing the baby's head more cephalad for as long as it takes, until a C-section can be performed. The cord should not be cut, instead if it is outside the vagina, it should be covered in warm moist towels.
CHAPTER 4: Shoulder Dystocia
Shoulder dystocia is scary and way more common. It's the failure of the anterior shoulder to deliver after the head, and is instead stuck behind the pubic bone. Baby is at risk for brachial plexus injury as well as brain injury from asphyxia.
Unfortunately, this is not a predictable dilemma. Sometimes having bigger babies does increase risk of this, but that is not always the case. Advanced maternal age, maternal age, maternal obesity and diabetes can result in bigger babies. History of shoulder dystocia in the past is also a risk factor.
In the event of shoulder dystocia, a "turtle sign" may be noticed, where the baby's head comes out, then retreats between contractions.
Dr. Mohling's Steps for Shoulder Dystocia:
Step 1: Preparation. Position the mother appropriately right at the edge of the bed, give gentle traction, have a stool ready for suprapubic pressure.
Step 2: Do not make it worse, by pulling harder.
Step 3: McRoberts maneuver (hyperflexion of maternal legs) combined with suprapubic pressure, and of course "call for help".
Usually the dystocia is relieved in less than a minute. If this doesn't work, a generous episiotomy is done to give room to maneuver. Next step is delivery of the posterior arm, by reaching in and finding the hand. If not found, press the antecubital fossa to flex the arm. Risk of humerus fracture with delivery of the posterior arm is 1 in 5.
Other Manuevers:
Ritgen Maneuver: Adduction of the posterior shoulders by placing the fingers behind the scapula and adducting the anterior or posterior shoulder to reduce the AP diameter.
Woodscrew: Corkscrew the baby out, which sounds easier than it is.
Clavicle Fracture: Pulling the bone away from the baby so as not to cause lung injury. Difficult to do with the size of the bone and slippery conditions during delivery.
As last resort, the zavanelli maneuver, or attempting to return the baby back up the birth canal to the uterus for emergent c-section, may be performed.
Thank-you for listening.
In this podcast, Dr. Nicholas Deeter a Ridgeview family medicine physician, discusses how lifestyle intervention can be utilized for treatment of most chronic diseases, and how lifestyle medicine can influence one's health and nutrition.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Identify how lifestyle impacts chronic disease.
- Describe how the role of diet and exercise can be used as a form of disease treatment and prevention.
- Develop strategies to change and improve patient lifestyles.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1:
Heart disease, cancer, unintentional accidents, stroke and diabetes are all in the top ten leading causes of death. All of these are impacted by lifestyle. Here are the numbers: 3 out of 5 Americans have chronic disease. Half of Americans have some form of cardiovascular disruption, 38% will be diagnosed with cancer in their lifetime, and nearly 3 in 4 Americans are overweight or obese.
Lifestyle modifications alone, can prevent 80% of heart disease, stroke and type 2 diabetes and 40% of cancers. Dr. Deeter referenced the EPIC study, with 20,000 participants, outlining four lifestyle modifications: refrained from smoking, moderate to no alcohol, regular physical activity, and consistently eating 5 or more servings of fruits and vegetables daily. Participants that did these four things, lived 14 years longer than those who did not.
Preventable disease comes down to diet. for instance, much like smoking causes lung cancer, eating processed meats is directly linked to colon cancer. Education for our patients includes eating less processed or high sodium foods and working towards a plant based diet with an increase in fiber. "Plant based on a budget", "21-day Vegan kickstart", and nutritionfacts.org are all resources that patients can be pointed to.
CHAPTER 2:
Plant based diets can improve vascular health, reduce cardiovascular risks and lead to better daily performance. Briefly, proinflammatory markers were discussed in relation to meat, and how animal foods lead to Trimethylamine N-Oxide (TMAO) and advanced glycation end products. Moral of the story: less meat is better.
Changing diet can be challenging, and within the current industry, food is engineered like a drug for the brain. Dr. Deeter suggests counseling patient on taking small steps in the transition to healthier eating. For those that still want to eat meat, try cutting back one day a week, controlling the portion size, and source local and organic meat when possible. Eating by stoplight colors: green is go, yellow sparingly, and avoiding red foods, is another tactic in moving towards healthier eating. Dr. Deeter points again to a couple of resources that patients can use, including an app called Dr. Gregor's Daily Dozen which has a checklist of daily foods, with the goal for an individual to gain as many check marks per day as possible.
Talking about barriers, each person, patient, individual will have their own barriers. There is a psychological component to these things. Dr. Deeter suggested the book, "Never Binge Again", that he personally found helpful in understanding the reason behind personal eating habits.
CHAPTER 3:
Moving on from diet to some of the other aspects of lifestyle medicine; alcohol, exercise and sleep are addressed. There is no known safe level of alcohol, and drinking any alcohol at all increases the risk of breast cancer. Current recommendations for alcohol consumption is 1 drink for females, 2 drinks for males, per day, and under limit to under four drinks in a sitting.
Smoking cessation needs to address three areas: The dopamine addiction, the nicotine addiction and the habit or physical addiction. One of the first steps is to crate mindfulness: Why are you smoking? Dr. Deeter states that some individuals are able to cut back, just by introducing awareness to when and why they smoke.
Exercise recommendations include 75 minutes a week of high intensity training or 150 minutes per week or moderate intensity training. The addition of weight training helps with bone density and as Dr. Deeter says, "Muscle is expensive tissue", and uses up more glucose. Even starting with 15 minutes will start to show benefits for the individual.
Good sleep hygiene, a basic component to a healthy lifestyle, can help avoid things like Alzheimer's disease. The suggested level of sleep is 7-9 hours a night. Waking up tired probably means it's not enough. Many have undiagnosed sleep apnea that can contribute the decreased sleep. More tips are talked about in chapter four, but are mentioned here as well: lower the temperature in the room, and limit or stop screen time at least one hour before bedtime.
CHAPTER 4:
In closing, Dr. Deeter gave us some tips and tricks for lifestyle modification. Small steps is the key, "don't let perfect get in the way of better". Practice good sleep hygiene including avoiding electronics an hour before bedtime, and turning down the thermostat so that the room is cooler. Exercise tips: park farther away, take the stairs, and get steps in where possible. A 10kg weight loss can lower blood pressure by 5-10 points.
Whole and plant based were discussed extensively in this podcast, but another thing to consider is looking at caloric density. Other tricks for mealtime include drinking water before a meal, or having a bowl of soup or side salad prior to meals to help with hunger satiety.
Lastly, goal setting is important. Goals need to be specific, measurable, and attainable. Finding accountability, whether it is within immediate family units or help groups is an important aspect to help an individual reach their goals.
Thank-you for listening.
In this podcast, Dr. Cole Pueringer, a toxicology fellow with the Minnesota Poison Control System (Hennepin Healthcare), discusses various over-the-counter medications and their toxicological potential.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- List at least 3 potentially dangerous over-the-counter (OTC) medications.
- Discuss the basic clinical presentation and management of the following over-the-counter (OTC) medications: acetaminophen, diphenhydramine loperamide, ibuprofen, and dextromethorphan.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
Antihistamines:
Like so many other over-the-counter medications, the dose of antihistamines makes the poison. Sedation is the most common side effect in antihistamine overdose. Some, like diphenhydramine, are more toxic and have profound anticholinergic effects. Sinus tachycardia is one of the first presentations, but remember the phrases: Tachy as a tie, dry as a bone, mad as a hatter, red as a beet, hot as a hare and blind as a bat.
Excitatory toxidromes can be confusing, but urinary retention, impaired bowel motility and the absence of diaphoresis will differentiate anticholinergic toxicity from the other excitatory toxidromes. the higher the dose, the more side effects seen, leading to seizures and cardiac toxicity.
Physostigmine is an antidote for anticholinergic toxicity. Delirium is the main indication for physostigmine, but it can also be given to prevent intubation and at times to get a more accurate history from the patient. Physostigmine lowers the seizure threshold, so benzodiazepines are usually given prior administration. Most likely they have already been given to treat undifferentiated delirium and excitation. Of note, physostigmine is not the cure all for the toxidrome because it has a very short half life.
In the setting of seizures in overdose, very few anticonvulsants are safe. Benzodiazepines are some of the safer GABAergic agents. GABA is our main CNS inhibitory neurotransmitter, it essentially "tones down the nerves". Propofol and some other GABAergic agents can also help with tachycardia and hyperthermia. In these settings, benzodiazepines are given in very high doses.
Diphenhydramine causes sodium channel blockade, subsequently decreasing action potential. lowering calcium in the cells, and causing life threatening myocardial depression. Calcium is given in this circumstance, but the mainstay of treatment is sodium bicarbonate. It works by increasing overall sodium availability and the pH. The more acidotic the patient, the more of the drug becomes unbound and available. At higher pH levels, the sodium channel blockade weakens, and more of the drug becomes protein bound.
What about other antihistamines? While overdose of other antihistamines will be uncomfortable, the life threatening seizures and cardiac toxicity is unique to diphenhydramine.
Acetaminophen:
Acetaminophen is the highest nationally in morbidity and mortality of all drug overdoses. Most often taken on it's own, it's also mixed into many over-the-counter remedies. In the first 24-hours post-ingestion, the symptoms can be minimal. It's metabolized in the liver, and a small portion is metabolized by CIP 2E1, resulting in the toxic metabolite NAPQI. Normally, glutathione will detoxify NAPQI, but in acetaminophen overdose, glutathione stores are depleted and the excess NAPQI creates havoc in the liver.
In a reliable historian with an acute ingestion, the Rumack-Matthew nomogram is employed, and will help guide antidote therapy. Serum acetaminophen levels will not be helpful until 4 hours post-ingestion, unless something that slows GI transit time and absorption has been taken as well.
N-acetylcysteine or "NAC", is the antidote for Tylenol. If given within eight hours of ingestion it can prevent any liver toxicity. It can also be started any time a serious ingestion is suspected. Keep in mind, delayed-release Tylenol, certain populations, and conditions can obscure the diagnosis and in those settings the Rumack-Matthew nomogram can no longer be used.
Chronic alcoholics who have just stopped drinking and malnourished patients are at higher risk of toxicity. Subacute and chronic ingestion is also very common. Essential lab tests include serum acetaminophen levels, ALT and AST, and INR. One would expect any or all of these to be elevated in significant toxicity. If they are, NAC is given intravenously for nearly 24 hours.
NAC won't reverse hepatotoxicity that has already occurred, but will prevent more from happening.
Dextromethorphan:
Dextromethorphan, referred to sometimes as "robotripping" or "robo-frying". Taken in excess causes an individual to become disassociated. It is an NMDA antagonist, like ketamine, LSD and PCP. Expect to see the same clinical signs of serotonin excess, as well as dystonia. Patients can alternate dramatically between vacant blank stares, to incredibly violent outbursts. Patient and staff safety is a crucial element in treating this toxidrome. Rotatory nystagmus, a distinctive rapid "clock ticking" of the eyes is diagnostic of this type of ingestion.
Loperamide:
When Loperamide, an over-the-counter antidiarrheal, is used in abuse it can lead to death. It acts similar to opioids, slowing down the GI tract but without the central effects, because it is actively expelled from the CNS. In large doses, however, it delivers an opioid-like high.
Loperamide can cause respiratory depression, but also persistent arrhythmias. The lethal effects are due to loperamide's potassium channel blocker properties causing profound QT prolongation, sinusoidal waves and can lead to cardiac arrest. Potassium channel blockade is difficult to treat. ACLS drugs, electrolyte normalization like magnesium infusions, and even Narcan can be given, but more than likely these incredibly sick patients will need ECMO.
Ibuprofen:
Ibuprofen is, overall, a safe drug. Large quantities of the drug have to be taken for toxic effects. If taking over 200mg/kg if Ibuprofen, a patient is likely to have some GI symptoms and possibly an acute kidney injury. treatment would include possible admission for antiemetics and IV fluids.
Ibuprofen is metabolized as a propionic acid anion. If ore than 400mg/kg are taken, it will result in an anion gap metabolic acidosis.
At over 600mg/kg, a whole constellation of symptoms results: seizures, hypotension, and cardiac shock. These patients are severely ill and may require ECMO for an extended period of time. At this dosage, a 100kg patient would need to take 300 pills. Which leads to the question, "How did they fit that many pills in their stomach?"
Activated Charcoal:
Finally, a note on activated charcoal. It works great for almost everything, except alcohol ingestion and metals, by binding drugs in the GI tract. Drug absorption is decreased by 60% if given within an hour. It should be avoided if the airway is compromised or if the patient is a risk for seizure. In an intubated patient with recent ingestion, it's given via nasogastric tube.
Thank-you for listening.
In this podcast Dr. Demetri Yannopoulos, a interventional cardiologist with M Health Fairview and Interventional Cardiology Researcher Director with the University of Minnesota-Twin Cities, discusses ECPR (ECMO Cardiopulmonary Resuscitation), the recent Arrest Trial and the Mobile ECMO program.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Define the importance of time and quality of CPR on outcomes from out-of-hospital cardiac arrest (OHCA).
- Explain the role of ECPR and ECMO teams in the management of out-of-hospital cardiac arrest (OHCA) refractory cardiac arrest.
- Review the current state of the art management of cardiac arrest and the reorganization of EMS/hospital response to out-of-hospital cardiac arrest (OHCA).
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview *podcasts as well as any and all accompanying files, images, videos and documents is/are for Continuing Education (CE) and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview and Ridgeview Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.*
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on this presentation. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Demetri Yannopoulos, MD has received honoraria from Helmsley Charitable Trust and the National Institute of Health (NIH) within the past 24 months, as a grant for research studies. Upon an independent review of his presentation, confirms he is following ACCME guidelines, and there is no commercial tie to the named agencies and no impact on his podcast presentation.
Ridgeview's Continuing Education Committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
Chapter 1:
CPR was introduced in the 1960s. At the time, research at John Hopkins was being conducted on pigs in ventricular fibrillation and ventricular tachycardia who required defibrillation. It was noted that when pushing defibrillation paddles against the chest wall, the arterial pressure of the subjects increased. It was concluded that with compression, pulsatile flow was generated. This was essentially the first iteration of closed chest CPR. Over the next 50 years or so, clinicians have been looking for better ways to improve survival outcomes. Key factors include early identification, early CPR, along with obtaining resources and assistance to improve ventilation, perfusion, and defibrillation. Poor predictors of survival for cardiac arrest include CPR for greater than 30 minutes and individuals with coronary artery blockage. With the integration of ECMO, it was found that by bypassing the heart and lungs and essentially taking on their functions, outcomes improved.
Dr. Yannopoulos reiterates that CPR for greater than 30 minutes results in poor outcomes, thereby creating a goal to both normalize pressures during this time while also fixing the offending cause, such as a coronary artery occlusion. Around 2015, in the Minnesota metro area, visionary EMS directors implemented an alternative option: If a patient fails three shocks, with ongoing CPR, the patient was transferred to a tertiary care facility with ECMO cannulation capabilities. Once on ECMO, these patients were transferred to the University of MN where they underwent PCI to evaluate for reversible causes such as occluded coronary vessels, PE, etc. Outcomes of this therapy showed 30-40% patient survival, which is a game changing result, thus the need for a randomized control trial, the ARREST Trial.
Chapter 2:
The ARREST Trial studied a group of patients with out-of-hospital cardiac arrest (OHCA) in ventricular fibrillation, refractory to defibrillation and initial ACLS treatment. This was a randomized control trial where one group was randomized to an ECMO intervention arm, versus a standard ACLS therapy arm. It was a phase 2, single center, open-label, adaptive, safety and efficacy randomized clinical trial. Specific subject criteria included adults aged 18-75 with OHCA, refractory ventricular fibrillation, with no return of spontaneous circulation (ROSC) after three shocks, with an automated cardiopulmonary resuscitation device or LUCAS device and estimated transfer time shorter than 30 minutes. The primary outcome of the trial was survival to hospital discharge. Secondary outcomes included safety, survival and functional assessment at hospital discharge, at 3 months and 6 months after discharge. Results of the ACLS arm showed a 7% survivability, and zero at both three and six months, while the ECMO arm fared better with a 43% survivability.
After enrolling 30 patients, the study was terminated at the first pre-planned interim analysis by the National Heart, Lung and Blood Institute after a unanimous recommendation from the Data Safety Monitoring Board, because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group compared to the standard ACLS group. No unanticipated serious adverse events were observed. Conclusion: early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation, significantly improved survival to hospital discharge compared with standard ACLS treatment.
Chapter 3:
The Minnesota Mobile Resuscitation Consortium or MMRC, which was the first program to serve an entire metropolitan area in order to rapidly deliver extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation to patients with refractory ventricular fibrillation/ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA).
This was an observational cohort study that analyzed consecutive patients prospectively enrolled in the MMRC's ECMO-facilitated resuscitation program. Entry criteria were identical to the ARREST Trial, adults 18-75 with an out-of-hospital cardiac arrest in VF or CT with no return of spontaneous circulation post 3 shocks, use of a LUCAS or automated cardiopulmonary resuscitation device, and an estimated transfer time of less 30 minutes. The primary endpoint was functionally favorable survival to hospital discharge with Cerebral Performance Category (CPC) 1 or 2. CPC 1 results in good cerebral performance: conscious, alert, able to work, that might have some mild neuro or psych deficits. CPC 2 results in moderate cerebral disability; conscious, sufficient cerebral function for independent activities of daily living (ADLS). Secondary endpoints included 3-month functionally favorable survival.
Between the period of December 1, 2019 and April 1, 2020, 63 consecutive patients were transported, and of these 58 were treated by the mobile ECMO service. Post EMCO treatment 25 of the 58 or 43% were both discharged from the hospital and alive at 3 months with CPC 1 or 2.
This first, community-wide ECMO-facilitated resuscitation program in the US demonstrated 100% successful cannulation, 43% functionally favorable survival rates at hospital discharge and 3 months.
Chapter 4:
As the research continues, reaching 25-30% positive outcomes would be adequate to start a viable program. Dr. Yannopoulos speculates that with overall system improvement and refined protocols, that number can be as high as 70-80%, which is an incredible number. The future of ECPR will require a combined effort of the healthcare systems, policy makers, administrators, and communities. With a successful program in the urban and suburban areas, future research can hopefully expand access to more rural populations. Dr. Yannopoulos emphasizes that this is not a hospitalized based program, it relies on the EMS system, and those providers, especially medics, are key to the success of the program.
At the time of this interview, the mobile ECMO program was on hold due to COVID, but currently the mobile ECMO program has a pending restart date of March 1st.
Thanks for listening.
In this podcast Dr. Chris Solie, an ER physician with EMPAC, and Dr. Abby Elliott, with Lakeview Clinic, cover a variety of topic areas from six journal articles. If you like to skip to the conclusion part of the article, this podcast is for you.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Differentiate if chest pulmonary CTs are necessary when patients present with suspected venous thromboembolism (VTE).
- Name at least 2 benefits of nighttime antihypertensive dosing for patients.
- Assess when cardioversion would be deemed necessary for individuals experiencing A-fib.
- Identify the risks of short-term steroid use.
- Identify the relevance of lumbar MRI and its findings.
- Summarize the findings that IV contrast causing acute kidney injury is a myth.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
Journal Article 1: "Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability"
PEs and DVTs can be elusive. There are rising numbers of chest pulmonary CTAs being done with lower yields. These can result in increased cost and health risks. In this study, the adjusted d-dimer was looked at to see if the number of CTs being ordered can be reduced.
The Wells criteria was used to place patients into low, moderate or high clinical pretest probability for venous thromboembolism of VTE. In the podcast, "clinical pretest probability" is referred to as risk. Of the entire 2000 patients enrolled, the diagnosis of VTEW was only made in 7%. Participants that qualified as low risk numbered 1742 and 1200 of these had d-dimer less than 1000. No VTWE was found in these patients for the next 90 days. For those with a d-dimer between 500 and 999, none had a VTE at 90 days.
In moderate-risk groups with d-dimer less than 500, none had VTE at 90 days. Combining low-risk patients with a d-dimer less than 1000, non of these patients had evidence of VTE at 90 days. Even in the 467 patients with a d-dimer greater than 1000, only 87 had a VTE.
Moderate- or high-risk patients are not applicable for this study. According to the article, if the d-dimer is greater than 1000, and the patient is low-risk, there was a 20% incidence of VTE. While it is an impressive study, it is one peice of data and should not replace clinical gestalt and decision making when truly concerned about the presence of VTE.
Journal Article 2: "Bedtime Hypertension Treatment Improves Cardiovascular Risk Reduction: The Hygia Chronotherapy Trial"
HTN is difficult to manage in many patients. This was a large study out of Spain of approximately twenty thousand patients. Patients were selected to take their medication either in the AM or nighttime and 48-hour blood pressure monitoring was performed. Patients were followed for 6 years. Night time dosed patients had significantly lower cardiovascular event rates than the daytime group, as well as better blood pressure management. There is little evidence to not advise nighttime antihypertensive dosing for patients, unless there would be compliance concerns. Medications that would not be tolerated, or specific medications, like diuretics, that can disrupt sleep. This was an impressive study that demonstrates a rather simple maneuver to effect a remarkable change in cardiovascular risk. Bear in mind, diet and lifestyle may also contribute to the results, but those were not assessed in this study.
Journal Article 3: "Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation"
A-Fib is a common presentation in primary care practice and in Emergency Departments. In this study of early cardioversion strategy vs delayed, 437 patients, aged 18 and above, were reviewed. Necessary criteria included A-fib bit less than 36-hours and hemodynamic stability. The conclusion was that neither strategy delayed or early cardioversion was an inferior approach.
A large number of patients in this study spontaneously converted to normal sinus rhythm without demonstrating higher rates of stroke. However, this study was not powered to assess risk of long-term stroke, and this remains unknown. Though based on other studies referenced today, it's known that a patient cardioverted after 12-hours of A-fib has an increased risk of stroke.
Psychologically, being in A-fib can be disturbing for the individual, and remaining in A-fib is not always desirable from the patient perspective. There are also potential logistical and cost considerations with delayed approach including numerous repeat clinics and ER visits for a small number of patients.
Journal Article 4: "Short-term Use of Oral Corticosteroids and Related Harms Among Adults in the United States: Population-based Cohort Study"
An impressive review of three hundred thousand patients was performed. Corticosteroids were given for mostly musculoskeletal, respiratory and allergic issues. Sepsis, VTE and fracture were monitored for over a 90-day time period and statistically significant higher rates of all of these were noted.
Bear in mind, this was a study without true placebo, and patients essentially compared their experience on steroids to their experience not on steroids. It should probably be followed up with a prospective trial to help further validate these concerning findings.
Still, this study only looked at 3 different complications and the numbers here are pretty striking, with 205 of adults receiving steroids. There are a number of studies which have shown no evidence of benefit in the use of steroids for a variety of indications, including conditions, such as urticaria and even anaphylaxis.
Journal Article 5: "No Association Between MRI Changes In The Lumbar Sone and Intensity of Pain, Quality of Life, Depressive and Anxiety Symptoms in Patients With Low Back Pain"
In this study, out of Poland, patients were referred for a lumbar spine MRI by neurologists, surgeons or other specialists, but not by primary care. These MRIs were graded in the study based on criteria derived from the reading radiologists. The endpoint of the study was to compare the severity of MRI findings with the patient's self-assessment and scoring of pain, quality of life, etc. The study ultimately showed there was no correlation.
However, age and BMI, and total MRI scores did correlate. Physically active patients had better scores. Learning new ways of coping with pain and helping our patients with this reality can equal a more efficient use of time and money. Per this study, medications or a reassuring MRI, does not correlate to resolution of pain. Of course, MRIs are often indicated in the setting of significant neurologic findings and emergencies, but outside of those settings, some patients may not be convinced that an MRI is not necessary. Using articles like this one can assist to better counsel patients and reduce unnecessary MRIs.
Journal Article 6: "Contrast Associated Acute Kidney Injury Is A Myth: Yes"
IV contract is often blamed for acute kidney injury, or AKI. It turns out, like many time honored beliefs in medicine, this is not likely the case. While attempting to research and write a paper on this subject, the investigators quickly discovered that ample data already exists that shows CIN or contrast induced nephropathy, appears to be more a myth than truth.
One senior author of this paper demonstrated in a pool of thousands of patients in two other separate studies that there's no association between contrast and AKI. Another investigator who is a cardiologist demonstrated actually less incidence of AKI in a cohort of patients. So, while personal clinical experience and Gestalt should not be ignored, we also must maintain a desire to debunk dogma that is unfounded time and again in the scientific literature. With regard to AKI from IV contrast, maybe there will be a prospective randomized trial looking at this, but there seems to be a preponderance of evidence already to suggest it may not be necessary.
Thanks for listening.
Sources/Links:
Kearon C, de Wit K, Parpia S, et al. Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med. 2019;381(22):2125-2134. doi:10.1056/NEJMoa1909159 Available: https://www.nejm.org/doi/10.1056/NEJMoa1909159?url_ver=Z39.88-2003𝔯_id=ori:rid:crossref.org𝔯_dat=cr_pub%20%200pubmed
Hermida RC, Crespo JJ, Domínguez-Sardiña M, et al. Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. Eur Heart J. 2020;41(48):4565-4576. doi:10.1093/eurheartj/ehz754 Available: https://academic.oup.com/eurheartj/article/41/48/4565/5602478
Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, et al. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med. 2019;380(16):1499-1508. doi:10.1056/NEJMoa1900353 Available: https://www.nejm.org/doi/full/10.1056/NEJMoa1900353
Airaksinen, K. E., Grönberg, T., Nuotio, I., Nikkinen, M., Ylitalo, A., Biancari, F., & Hartikainen, J. E. (2013). Thromboembolic Complications After Cardioversion of Acute Atrial Fibrillation. Journal of the American College of Cardiology, 62 (13), 1187-1192. doi:10.1016/j.jacc.2013.04.089
Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415. Published 2017 Apr 12. doi:10.1136/bmj.j1415 Available: https://www.bmj.com/content/357/bmj.j1415
Yao, T., Huang, Y., Chang, S., Tsai, S., Wu, A. C., & Tsai, H. (2020). Association Between Oral Corticosteroid Bursts and Severe Adverse Events. Annals of Internal Medicine, 173 (5), 325-330. doi:10.7326/m20-0432
Babińska, A., Wawrzynek, W., Czech, E., Skupiński, J., Szczygieł, J., & Łabuz-Roszak, B. (2018). No association between MRI changes in the lumbar spine and intensity of pain, quality of life, depressive and anxiety symptoms in patients with low back pain. Neurologia I Neurochirurgia Polska . doi:10.5603/pjnns.a2018.0006 Available: file:///C:/Users/E55983/Downloads/No_association_between_MRI_changes_in_the_lumbar_s.pdf
Ehrmann, S., Aronson, D., & Hinson, J. S. (2018). Contrast-associated acute kidney injury is a myth: Yes. Intensive Care Medicine, 44 (1), 104-106. doi:10.1007/s00134-017-4950-6 Available: file:///C:/Users/E55983/Downloads/Ehrmann2018_Article_Contrast-associatedAcuteKidney.pdf
Davenport, M. S., Perazella, M. A., Yee, J., Dillman, J. R., Fine, D., Mcdonald, R. J., Weinreb, J. C. (2020). Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation. Radiology, 294 (3), 660-668. doi:10.1148/radiol.2019192094
In this podcast Dr. Todd Elftmann, a general surgeon with Lakeview Clinic and Ridgeview, discusses abdominal surgeries through a case review format.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Recognize the potential for appendicitis and/or cholecystitis.
- Initiate the appropriate work-up for appendicitis and/or cholecystitis.
- Create the appropriate referral for appendicitis and cholecystitis.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CASE 1:
The four "Elftmann criteria" include fever, elevated white blood cell count, history of pain or anorexia, and a positive physical exam. Two or more of these findings means a probable appendectomy. Peritoneal irritation is not a subtle finding and even the most stoic patients will grimace with palpation of the abdomen. Localized pain versus diffuse pain in all four quadrants can help determine if there is a rupture.
Additional work up includes, as always, a good history, plus lab work an x[ray of the abdomen in this case, and finally, a CT scan with oral contrast. The CT is the gold standard and has decreased the number of negative appendectomies to 1-2%. Ultrasound can be used, and is often for pediatric patients, but has limitations. CT scans are more sensitive and specific for appendicitis.
A white blood cell count is included in the lab work-up, but a patient with appendicitis may present with a normal white count. Conservative treatment is possible, but per the literature does have a failure rate, with anywhere from 25-50% of patients still requiring an appendectomy.
A perforated appendix does not guarantee an immediate OR visit. Depending on the patient and the surgeon's comfort level, treatment may include a delayed appendectomy with antibiotics, plus or minus a percutaneous drain if an abscess is present.
IV piperacillin tazobactam would be given as an inpatient, and oral Augmentin as an outpatient along with very close follow-up. For patients with a penicillin allergy, a fluoroquinolone plus metronidazole is appropriate. Surgery could occur approximately 8-12 weeks later after clinical and laboratory improvement.
Stump appendicitis occurs when a patient presents with a classic presentation of an appendicitis, post a previous appendectomy. It happens most commonly with patients who had an appendicolith and the entire base was not removed in the original surgery.
CASE 2:
Abdominal pain for patients that are pregnant can be complicated. Initial assessment includes a fetal exam, and assuring the viability of the fetus. Further consideration would include using ultrasound instead of CT for reduced radiation exposure.
In this case, a woman presented with right upper quadrant tenderness, fever, and hyperbilirubinemia indicative of cholecystitis. If she had jaundice, this would be Charcot's triad and would indicate cholangitis. Early surgical consultation, especially for a pregnant patient is important. Failed conservative treatment for these patients can have adverse outcomes.
For other work-up modalities, MRCP is an option, but if the patient is already going to the operating room, a cholangiogram can be performed in the OR with GI on standby for an ERCP, thereby eliminating the need for an extra test. MRCP is for patients that are not good operative candidates, and are too acute or sick to tolerate a procedure. A HIDA scan can evaluate whether the cystic duct is open and is good for non-toxic appearing patients where ultrasound is unremarkable or with fever of unknown origin.
The ongoing treatment of cholecystitis whether surgical or nonsurgical depends on the patient and the severity of their illness. It turns out, antibiotic choice for cholecystitis is similar to that of appendicitis with perforation. Antibiotics can range from cefazolin to zosyn or even meropenem. For severely penicillin allergic patients, a fluoroquinolone plus metronidazole can be used. For patients that are higher acuity, whether due to calculous or acalculous cholecystitis, and are not good surgical candidates, a percutaneous drain may be indicated.
Post-cholecystectomy, 85-90% of patients will not notice a change, 10% will report a looser bowel pattern, and 1% of patients will experience severe diarrhea. These patients can be treated with a bile binding medication like cholestyramine.
A key point today, the gallbladder is a surgical disease and Dr. Elftmann recommends early surgical consultation.
Thanks for listening.
Sources/Links:
Evidence for an Antibiotics-First Strategy for Uncomplicated Appendicitis in Adults: A Systematic Review and Gap Analysis. Journal of the American College of Surgeons. DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.01.009
Use of White Blood Cell Count and Polymorphonuclear Leukocyte Differential to Improve the Predictive Value of Ultrasound for Suspected Appendicitis in Children. Journal of the American College of Surgeons. DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.01.039
The Scientific Forum presentation, Operative vs Nonoperative Management of Appendicitis: A Long-Term Cost-Effectiveness Analysis, was held October 22 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast, and audio information is available online at facs.org/clincon2018.
The Panel Session, The Call Bladder: Dealing with the Acute Gallbladder, was held Monday, October 28 at the American College of Surgeons Clinical Congress 2019 in San Francisco (program, webcast and audio information).
Gallstone size and the risk of gallbladder cancer https://pubmed.ncbi.nlm.hin.gov/6632129
This podcast is Part 2 of the Clinical COVID-19 Review podcast. In this podcast, Dr. John Litell, an intensivist with Abbott Northwestern Hospital, and Dr. Haylee Veazey, an emergency medicine physician with Hennepin Healthcare, discuss clinical management for COVID-19 patients through a case review format.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Discuss and implement fundamental critical care support for COVID-19 patients.
- Recite best practices for screening and managing COVID patients in the hospital setting.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thanks for listening.
This podcast is the first of two podcasts that discusses the novel COVID-19 virus. Dr. Louis Mansky, a professor and the Director for the Institute of Molecular Virology at the University of Minnesota - Twin Cities, and Dr. Haylee Veazey, an emergency medicine physician with Hennepin Healthcare, provide an interesting discussion on the virus, testing and the COVID-19 vaccine.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Describe the pathophysiology of the COVID -19 virus.
- Recognize tests available for the COVID-19 virus, the methodology and efficacy of each.
- Describe the methodology in the development of COVID vaccines.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Thanks for listening.
This podcast presents, Dr. Michael Edwards, a rheumatologist with Ridgeview Specialty Clinics, who provides a discussion some unique arthritis cases.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Identify various causes of monoarthritis.
- Review the evaluation and management of monoarthritis.
- Recognize that lower back pain may be inflammatory in nature, and how to further evaluate and manage the inflammation/pain.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CASE 1 - Psoriatic Arthritis:
For our first case, our 77 year old male ended up with psoriatic arthritis. Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerns like chronic infections, skin lesions, or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging, starting with x-rays.
Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerrns like chronic infections, skin lesions or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging - starting with x-rays.
To tap or not to tap? That is the question for joint complaints. Arthrocentesis through an area of cellulitis or inflamed soft tissue is generally contraindicated. However, if a tap is feasible, the three C's: culture, WBC count, and crystals should be send. A cell count greater than 10,000 would be indicative of an inflammatory effusion. In the acute setting, the pros and cons should be weighted as to whether or not to inject steroids. If you suspect infection, though, do NOT inject corticosteroids.
Long-term treatment of psoriatic arthritis is individualized to the patient. Some patients manage with methotrexate, while others might need a biologic. Cost is a barrier in prescribing biologics, requiring referrals, and prior insurance authorization. Biologics target a specific part of the immune system. Contraindications would be patients who are already immunosuppressed, have TB, hepatitis or multiple sclerosis, or are in late stages of CHF. Other contraindications include breast, lung or melanoma cancer with a high risk of recurrence. When running a fever or prior to surgery, biologic doses should be delayed or paused.
CASE 2 - Ankylosing Spondylitis:
In case number 2, a young man with a long history of back pain ended up with ankylosing spondylitis. Again, the history becomes important in the diagnosis, keying us to be suspicious of this patient's chronic pain. For this case, though lab work was normal, an AP x-ray of the pelvis showed narrow and sclerotic sacroiliac joints with erosion.
Like psoriatic arthritis, this diagnosis falls under the category of seronegative spondylarthropathy. When tested, the patient will not have antibodies or positive rheumatoid factor. It is a reactive condition: sacroiliitis causes inflammatory changes and therefore pain. Inflammatory bowel conditions like Crohns and Ulcerative colitis fall into this same family of reactive conditions.
First line treatment for ankylosing spondylitis is NSAIDS taken on a scheduled basis to protect the joints. Long term management includes physical therapy and back education. Biologics can be used for pain refractory to NSAIDS.
This pain can go undiagnosed for years, and cause irreparable fusion of the spine, otherwise known as a bamboo sign as seen on x-ray. Again, a thorough history is key to catching and diagnosing these patients early, and preventing long-term complications.
CASE 3 - Gout:
Out last patient is a woman with a swollen knee, normal wbc, and elevated sed rate. Due to her history, and RA flare up would be considered in the differential, but unlikely due to a monoarthritic presentation. Following a similar work up as the first two cases, labs and imaging are obtained and the knee is tapped. The three C's mentioned earlier: culture, WBC count and crystals are sent and the results are positive for needle-like crystals which are negative birefringent when examined with polarizing microscopy. The patient has gout.
Treatment includes NSAIDS like Naprosyn or indomethacin. In an acute setting, oral steroids can be prescribed. Dosing for gouty monoarthritis is 20-30mg for 3-5 days. For patients already on baseline steroids, include a steroid taper back to baseline.
Additional work up could include uric acid levels. While not diagnostic, a uric acid greater than 9 may help identify patients at risk for future episodes. If the patient has 2 or more gout attacks a year. Allopurinol can be prescribed.
CONCLUSION:
To sum up all our cases today; a thorough history and exam are critical, keep the differential broad, and management is weighing the pros and cons of NSAIDS, steroids and whether or not to tap that joint. Septic arthritis can not be overlooked. Early recognition and diagnosis is key.
Thanks for listening.
This podcast presents, Dr. Michael Osterholm, an epidemiologist and Director of CIDRAP (Center Infectious Disease Research and Policies) with the University of Minnesota, who provides an update on the COVID-19 pandemic.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Describe the trends of where the U.S. began, where the U.S. is currently, and where the U.S. is going based on evidence of the virus outbreak.
- Differentiate how the COVID-19 pandemic affects the rural and suburban areas vs. high-populated urban areas.
- Identify challenges to mitigate strategies in combatting COVID-19.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
Enjoy the podcast.
This podcast presents, Dr. Elliot Francke, an infectious disease specialist with Midwest Infectious Disease Consultants, who provides an update on clostridioides difficile (C.Diff).
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Identify factors of clostridioides difficile (C.diff).
- Describe the management of clostridioides difficile (C.diff) in a hospital setting.
- Explain the clinician's role in clostridioides difficile (C.diff) prevention.
- Differentiate the status of clostridioides difficile (C.diff) at Ridgeview.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1:
ORIGIN STORY:
In 1983, a pseudomembranous colitis was identified. In 1935, the organism was isolated. In 1978, Clostridium Difficile was identified as an organism that produces toxins causing diarrhea. In the last year, the genius has been renamed and the organism is now known as Clostridioides Difficile.
The organism produces two toxins A and B. A is an immunogenic toxin that causes an influx of immune cells and some cell necrosis. Toxin S can be eliminated with a monoclonal antibody but does not stop the disease. Toxin B is of greater concern and causes cell death and pseudomembrane buildup in the large bowel lining. Bezlotoxumab is discussed again later, but is a commercial antibody that does not eliminate the disease but decreases the severity of it.
PREVALENCE:
Prevalence in the adult population is around 3-5%. For those over 60, prevalence is 50%. There are a large percentage of individuals who are colonized but not producing the toxin, otherwise known as non-toxigenic C. DIff.
C. Diff organisms are difficult to combat for several reasons. The organism is a gram positive rod, that does not have the attachment points for some standard antibiotics. It also has that ability to efflux antibiotics out of the cell. When attacked, it can produce spores that are impenetrable by both the immune system and many antibiotics, and can live for long periods of time on surfaces waiting for the right opportunity. Creepy microbes. Growth in the bowel can be inhibited by 14-16 natural flora identified in two Canadian studies.
RISK FACTORS:
Those at greater risk for C. Diff infections are over the age 65, in long-term hospitals or institutions, immunosuppressed, or chronic PPIs, or have had recent use of certain systemic antibiotics. The correlation to antibiotics was discovered in 1978, and originally linked to clindamycin. Currently use of 3rd or 4th generation cephalosporins and quinolones are risk factors; though that does not mean another antibiotic may also be the cause of infection.
CHAPTER 2:
PROBIOTICS:
Post-antibiotic treatment, the normal flora of the bowel reconstitute in 204 weeks. This occurs through food and bacteria introduced orally and also via the appendix which serves as a reservoir for bacterial flora. Probiotics are not necessary for every patient, but have proven benefits. Here are some numbers regarding probiotic success in reducing the disease; Lactobacillus, 60-65%, Bifidobacterium 80% and Kefir 65% reduction in C. Diff relapses. Dr. Francke recommends Keefer to his patients because it contains 11 of the 14-16 organisms identified to be beneficial in the aforementioned Canadian studies. Dr. Francke noted a decrease in relapse rates from 50-60% to 5-10%, through notes that this is an anecdotal observation.
TESTING:
Positive risk factors, combined with patient complaints of severe watery diarrhea, with or without blood, fever and an elevated white count, raises high suspicion for C. Diff. When suspected a PCR test should be ordered, rather than a stool culture or multiplex test. These would be used when another disease process is suspected. The C. Diff PCR looks for the DNA coding for the production of the toxins, both A and B, but again B is more concerning.
Two instances where PCR testing would not be required is the patient has already tested positive for C. Diff. or the patient has less than 3 stools a day - meaning they are not experiencing significant pathology of the disease.
Not every case of diarrhea is C. Diff, and differential diagnosis would include obtaining imaging - such as CT or X-ray. Colonic distention with edema on the wall of the colon could be seen in a case of C. Diff. If a patient were symptomatic, but the C. Diff PCR was negative, it is not recommended to treat them for C. Diff, as the toxin test has a 98% predictive value.
CHAPTER 3:
TREATMENT:
First line treatment for an initial infection is 125mg of oral vancomycin, 4 times a day for a 10-14 day course. After the first relapse, repeat oral vancomycin, but with longer taper over several weeks. A probiotic can be added at this stage. If a second relapse occurs, consider adding rifaximin or fidaxomicin, and for the severely ill, Bezlotoxumab can be given, which helps decrease the relapse rates. Metronidazole is no longer used as first line treatment due to a high relapse rate.
EFFECTIVENESS:
Oral vancomycin is 72-75% effective for treatment of an initial infection. After the first relapse, vancomycin treatment is again 72-75% effective. After the 2nd relapse, effectiveness is 50-65%. Use of fidaxomicin at any stage is 80-85% effective. Adding rifaximin to oral vancomycin increases effectiveness by 10-15%.
FMT: Fecal Microbiota Transplant
Fecal microbiota transplant is a treatment option for C. Diff. Fecal matter is collected from donors carefully screened for infectious disease. Administration to the patient is achieved in one of three ways: One time administration via nasogastric tube or enema or administered via 6-8 oral capsules over several days. Research has shown pre-treatment with Bezlotoxumab increases the effectiveness of FMT by 65-85%. Literature has also shown that a vancomycin taper can increase the success rate of FMT.
PREVENTION:
Community colonization of C. Diff has increased by 3-5%, but nosocomial infections have decreased. Prevention includes: handwashing with soap, isolation of infected patients, terminals cleans after discharge, and use of UVC light machines.
Antibiotic stewardship is also important and it takes a combined effort to ensure the most efficient and appropriate antimicrobial agents are being used.
For those being treated as outpatients it is most likely that other family members and even pets are already colonized. To prevent reinfection or spread, outpatient education includes, washing linens, wiping down commonly used surfaces with bleach, and hand washing.
Thanks for listening.
This podcast presents, Dr. Ron Tarrel, a Neurologist with Noran Neurological Clinic, who talks about brain injuries, specifically concussions, including symptoms and when follow-up is needed.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Identify and discuss the types of concussive injury.
- Explain the basic pathology of brain injury.
- Diagnose concussion based on history and examination findings.
- Determine appropriate evaluation and treatment recommendations and safe return to sport/daily living activities, etc.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1: Mechanisms, Pathophysiology, and Testing.
When we define concussion or brain injury, it's not only about the physical damage, but interruption of the physiologic process of the brain.
Unfortunately, there is not a nice, neat set of symptoms and the phrase traumatic brain injury seems to be a catchall phrase. Different mechanisms will affect our brains differently, but not uniformly. Whiplash can cause myofascial tissue damage in the cervical spine, affecting proprioception and balance. There are blunt trauma mechanisms causing fractures and or penetrating injuries to the brain. In addition to high energy explosions, causing thermal injury as well as particulate projectile injuries; and there are shearing injuries.
Briefly the different types of mechanisms/forces that lead to injury were discussed, including a deeper dive into ballistic, penetrating blunt force, blast/explosive wave, energy/thermal and shear injuries. Additionally, Dr. Tarrel discusses items that occur on the cellular level, however per TBI outline provides a more comprehensive list of metabolic dysregulation - such as: CPP, metabolic dysfunction, inflammation, apoptosis, axonal injury.
There is a variety of cognitive tests mentioned in this podcast, including the Slums exam, the mini mental status, sac, and the Skat 5 tests. Many are used in the field for assessment and represent a quick look at a singular moment in time. These tests help diagnose injury, but have limitations in terms of prognosis. The same can be said for impact testing for kids. These tests can provide a good baseline prior to an injury which helps in future diagnosis, but does not predict risk for injury.
Is there utility for lab workup in this patient population? Currently, the community is investigating Tau proteins, which are a brain derived neurotrophic factor. These trophic proteins have to do with inflammation and breakdown of normal homeostatic tissue. It has not been determined what is actually happening when a Tau protein is released. This continues to be an ongoing area of research.
CHAPTER 2: Symptoms...so let's say we have this patient...
Symptoms we are looking to investigate would be penetrating injury, skull fracture, loss of neurologic function, weakness, etc. Does the patient exhibit ataxia or disequilibrium? Are symptoms progressing? What is the level of awareness or consciousness? Signs of increased ICP or focal deficits. This patient would require an initial head CT and possibly an MRI.
When is discharge appropriate for these patients? Sometimes patients aren't able to give you specific information to look for the problem. Their complaints are generalized, and vague. You have to pay attention to these symptoms, but you might have to wait for the dust to settle and patient remains asymptomatic continue to observe for signs and symptoms.
Patients that have a loss of awareness or even vague changes should have a follow-up visit. Upon return if they are symptom free and have a negative neuro exam, further imaging would not be necessary. However, if there are symptoms, even some that seem vague like an imbalance, or "just not feeling right". Then further work up would be beneficial. A key takeaway here is that vague symptoms can challenge clinicians, but it's important to take these patients at face value.
Does follow up have to be with a neurologist? There are many neurologists that do not treat concussions. Head injuries have been a mainstay of the neurosurgery field, but also orthopedists are often sideline physicians that can specialize in concussions and would be appropriate for follow up.
CHAPTER 3: Societal Pressure and Treatments.
There's a certain pressure to clear concussions early and allow individuals to resume their regular activities. However, concussion protocols call for a gradual return to activity post event. Returning too fast and trying to force the brain to work only promotes "misfires" in the brain.
Treatment starts with reduced activities; low light stimulus, decreased physical activity, and limited, if any, screen time. Then, slowly, activities can be reintroduced, one at a time like steps on a ladder. If the patient tolerates the dark room, turn on the tv and watch nonsense. If that goes well, eat dinner with family, walk around the block. Slowly add in activities. If symptoms return, the patient takes a step back down the ladder, returning to the previous activity they were able to tolerate. The length of this process all depends on the individual, their symptoms, and their personal rate of recovery.
Other important aspects of recovery include a normal sleep wake cycle and adequate pain control. In a normal sleep wake cycle with adequate sleep, CSF is turned over twice as fast as nonopioid treatment. Opioids are good pain relievers, but also serve as a mood and energy suppressants. They are good medications when used appropriately. Non-opioid medications include, Tylenol, aspirin, if bleeding risk is low, and gabapentin. Gabapentin has been found to be a good baseline medication for TBI patients.
There is a mental health component to traumatic brain injuries. Those with underlying depression are more likely to develop severe symptoms post a TBI event.
Additional TBI Information
Traumatic Brain Injury: Brain Dysfunction resulting from some external force
Prevalence/Incidence:
- Incidence rates of 1/6 to 3.8 million in sports in the US annually.
Causes:--As you might imagine, there is a lot of physics and chemistry behind our understanding of concussion and the forces that lead to head injury.
- BALLISTIC: Ballistic injury generally refers to projectiles and their flight. Factors that influence the severity of ballistic injury include force speed and the direction of impact.
- PENTRATING INJURY: Penetrating injury is just that. An injury that pierces and enters the skull directly causing direct tissue destruction along with the penetrating forces.
- BLUNT FORCE INJURY: Blunt force injury is also direct physical force to the skull/head but without penetration
Impact of any kind not only triggers direct forces on the brain tissue itself, but there are complex cellular and molecular processes that lead to further dysfunction, neuronal dysfunction and cell death. There are multiple factors that contribute to this severity of injury that go beyond the initial impact.
The generally accepted formula for concussion is that it takes 90-100G's; the force of a object accelerating with gravity to cause brain/axonal injury. That can be equated to hitting a wall at approximately 20 miles/per hour. However, that does not determine the severity of injury of which multiple other factors play into.
- Is "whiplash" a common culprit in concussion?
Yes, to the idea that whiplash can cause concussive like symptoms. 100's and 100's of patients who suffered mechanical whiplash injuries who developed other changes including cognitive changes that would not necessarily relate to simple cervical spinal or spinal muscular injury. That is where the notion of shearing injury comes in and I will come back to that in a moment but I can also tell you that it works both ways. Patients with myofascial injury often develop a sense of dizziness or imbalance or vertigo. You can often tell the difference between true vestibular dysfunction, vertigo, and the feeling of dysequilibrium (some people use words like rafting or floating, etc.) or the sense of uncontrollable movement within their environment. There is a myofascial syndrome in which the normal resting length of muscles is affected related directly to, for instance, the neck injury. We have proprioceptive information from our spinal column to our brain which, based on normal resting length of muscle and muscle tension, provides information to our brain telling us when we are safe and stable within our environment. With soft tissue injury, specifically myofascial injury, injury to the muscle tissue and the fascial tissues which surround muscles individually and in groups, the resting length of muscle and fascial tension can change related to microscopic tearing or shearing of muscle fibers, inflammation and the body's own protective response which is for muscles to splint or spasm, or tighten up around an area of injury. This then leads to different proprioceptive information registered by the brain and one can get the feeling that he/she are off balance, floating, rafting, whatever because the normal resting length of our muscles in various positions has been altered in response to the injury and based on that, your brain believes your neck is in a position that is not. And the individual feels "off" in whatever way.
That same kind of shearing injury that we discussed affecting the spinal column, muscular and myofascial tissues also affects the brain and specifically the white matter or nerve tracts of the brain. Neurons have 2 specific components to them in regards to the delivery of information. First there are the dendrites which are nerve tracts that bring electrical signals to the nerve cell body and then long tails known as axons that take information away from the cell body, all in the white matter of our brain, not the thinking controlling cortical gray matter. These axons and dendrites live in a sort of ground substance in the brain and when forces are exerted on the brain tissue itself, just like the muscles and connective tissues around the spine, you can have a shearing injury that causes stretch and tearing to those tissues. This will necessarily affect normal transmission of electrical information from our cortex down to the spinal cord and information coming in from the body to the brain. So in other words, our thoughts and our commands coming out of our brain as well as how we register information coming into our brain is distorted because there is literally derailing of the information traveling in either direction. Obviously, how our brain interprets our world around us, our position in it, and how our brain organizes thoughts and responses to information can all be affected. This is believed the level of injury that causes some of the more subtle yet more confusing and difficult-to-treat symptoms that occur with a complex head injury.
- DESTRUCTIVE WAVEFORCE
Blast/Explosive wave, energy/thermal,
There are different mechanisms of blast injury created by the release of energy that can involve a wave of energy or heat and sometimes objects. One type of explosive device releases a "blast wave" causing the sudden release of expanding force emitting a pressurized energy impulse traveling out in all directions from the explosive center. These types of bombs affect air and fluid filled tissues especially, causing these tissues to burse (like a balloon filling up too fast). Thermal blasts will dramatically overheat objects in its wake (living and not). Finally, bombs can contain particles (e.g. shrapnel or nails, etc.) that can cause penetrating injury throughout a large circumferential area.
PHYSIOLOGY
- Cellular and molecular changes
- Vascular autoregulation
- CPP
- Metabolic dysfunction
- Inflammation
- Apoptosis
- Axonal injury
The pathophysiologic changes introduced by traumatic forces into a living organ, specifically the brain, then cause secondary changes in the autoregulatory mechanisms in the brain that support maintenance of blood flow, intracranial pressure, perfusion pressure, oxygenation and energy availability and utilization. Brain injury triggers a cascade of cellular processes and disruption of that homeostasis, which leads to neural dysfunction and death and are the secondary forms of injury after trauma.
Our brains thrive on a very exacting and delicate balance of energy and information going in and energy and information going out And if you introduce anything that alters that balance, it will lead to further brain dysfunction.
SYMPTOMS
- Thought/memory/concentration/reasoning
- Psychological changes
- Perceptual disturbance
- Alteration of sleep/wake cycles
- Headache
- Proprioception
- Sensory disturbances
- Nausea/vomiting
- Environmental sensitivities
PHYSICAL EXAM/DIAGNOSTIC TESTING
- Diagnostic Imaging
- CT or MRI initial image modality of choice
- Laboratory Testing
- Theoretical biomarkers but nothing that has been borne out.
- Cognitive Testing
- Standardized evaluation tools such as the SAC, SCAT5, Westmead, ImPACT for concussion may have limited validity, especially if there is no baseline test.
Thorough Neurologic Examination
Although generally there are no hard findings.
TREATMENT/MANAGEMENT
- Activity Restrictions
- Medications
- Functional Retraining
- Conditioning/Endurance
PROGNOSIS
- Return to ADL's
- Return to work
- Return to sport
- This is a BIG one. According to a paper in Pediatrics 2015 by Thomas et al, there was no added benefit in strict rest after concussion. This was a small study. Are there other papers or ongoing research to support prolonged rest?
- In the McCrory P. et al. Consensus statement on concussion in sport—the 5th
international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017; 51 : 838-847 advocates for a 6 step progressive re-introduction with 24 hours in between
RISKS OF RECURRENCE
- Recurrent injuries = cumulative and more permanent
TREATMENT
- Pain management, sleep, psych, light exercise, etc.
SEQUELA
- Parkinsonism
- Dementia
- Seizure
- CTE
PREVENTION
- STATE HIGH SCHOOL SPORT ASSOCIATIONS
- NCAA
- NFL/CFL
- FIFA
- ABA/WBA
- UFC
REFERENCES
1) Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children
JAMA Pediatr. 2018 November 01
2)Blast-Related Traumatic Brain Injury: Current Concepts and Research Considerations
Daniel W Bryden, Jessica I Tilghman, and Sidney R Hinds, II
3) A Review of the Molecular Mechanisms of Traumatic Brain Injury
Asma Akbar Ladak, Syed Ather Enam, Muhammad Talal Ibrahim
4) Management of acute moderate and severe traumatic brain injury
UpToDate
5) Concussion Diagnosis and Management Best Practices
NCAA Sport Science Institute
6) NFLPA Concussion Game Day Checklist Return-To-Participation Protocol
7) Traumatic Brain Injury Information Page
National Institute of Health
8) Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines
Archives of Physical Medicine and Rehabilitation
9) Prevalence and Epidemiology of Combat Blast Injuries from the Military Cohort 2001 - 2014
NCBI Bookshelf
10) Pathophysiology of Traumatic Brain Injury
Physiopedia
Thanks for listening.
This podcast presents, Dr. Nate Beerling, a Ridgeview Medical Center anesthesiologist, who discusses two rare but life threatening events - malignant hyperthermia (MH) and local anesthetic systemic toxicity (LAST). Dr. Beerling will discuss how they occur and how to treat these conditions.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Recognize risk factors related to local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH)
- Differentiate signs and symptoms of local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH).
- Determine initial treatment for local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH).
- Distinguish the differences in resuscitation between Advanced Cardiac Life Support (ACLS) protocols for local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1:
Malignant hyperthermia first appeared in letters written between anesthesiologists who noticed patients having "ether convulsions" in surgery.
It was formally discovered in the 1960s by Dr. Michael Denborough, in Australia. One of his patients' required surgery for a tibia fracture, and the patient was terrified about having surgery because 10 of his family members had died during surgery. This patient did actually have a malignant hyperthermia event, but survived.
Pathophysiology is of course complex, but remember 2 things: calcium release and ryanodine receptors.
First, let's trace the normal pathway for muscle reaction. Signal generates from the brain, travels down the nerve pathway till it synapses with a motor neuron. here acetylcholine is released and triggers a voltage. That voltage is sodium channels opening and causing depolarization and generating action potential, aka, the electrical signal. This signal travels down the muscle cell to the T-tubules where a dihydropyridine receptor is mechanically linked to an organelle called the sarcoplasmic reticulum where calcium lives. When that voltage travels down and sets off the dihydropyridine receptor, that then opens the ryanodine receptor, calcium is released into the cell which sets off the muscle contraction cycle.
Calcium binds to troponin, attracts it to the myosin. The myosin then contracts and shortens, causing an overall muscle contraction. ATP, the energy unit of the cell, has already been broken apart to cause the contraction. In order for the muscle cell to relax, a new ATP must attach to the myosin. That process will repeat as long as calcium is around.
In malignant hyperthermia, there is a double hit phenomenon. The patient has mutated ryanodine receptors and exposure to an induction agent (which we'll talk about later). The agent binds to the mutated ryanodine receptor and doesn't allow it to close. Calcium continues to leak which sets off this cycle of muscle contraction, release, contraction.
As new ATP is required to relax the muscle, ATP is quickly depleted. When ATP is gone, there is muscle contraction without ATP to release it. That's what causes the rigidity in malignant hyperthermia. The cell will now try to make energy in any way possible and reverts to anaerobic metabolism, with lactic acid production.
The clinical effects are hypoxia, increase in CO2 or hypercapnia, and lactic acidosis.
Let's use an example. Let's say there is a patient who is going to undergo a laparoscopic appendectomy. The induction agents that would be used include propofol, a neuromuscular blocking agent, fentanyl, versed, and lidocaine. In addition, the patient will receive an inhalation agent like cevoflorine, desflurane or isolflurane via a ventilator. It's these agents as well as the neuromuscular blocking agent, succinylcholine, that can cause a malignant hyperthermia event.
In a situation where malignant hyperthermia would develop, the obvious sign would be a rise in end tidal CO2. Though in this case example, which is laparoscopic, CO2 is used to insufflate the abdomen, and thus is part of your differential diagnosis. Look for rise in end tidal CO2 that does not respond to ventilation, arrhythmias, and hyperthermia. Rigidity in a patient is a pathognomonic sign of malignant hyperthermia.
What are the clinical manifestations?
A rise in end tidal CO2 and tachycardia. Hypoxia if they're using up all their oxygen. Hypertension in the presence of a huge catecholamine dump as a compensatory mechanism, and arrhythmias due to hyperkalemia. To drag it back to pathophysiology, all the energy or ATP has been used up in the cells, and they can't support normal metabolic processes. The cell dies, and potassium which mainly lives in the cell, gets released in the bloodstream causing hyperkalemia.
We mentioned the differential diagnosis earlier when talking about surgical insufflation of CO2, but other rule outs would be a rise in CO2 due to hypoventilation or hypermetabolic processes, like neuroleptic malignant syndrome or serotonin syndrome. Arrhythmias could be the result of a primary cardiac event.
When intubating the emergent patient with unknown past medical history, can succinylcholine be used? In general, succinylcholine is a "nice, safe drug". However, there is another neuromuscular blocking agent, Rocuronium, which has a reversal agent, sugammadex, that would work faster than succinylcholine would wear off, and also is not a malignant hyperthermia triggering agent. Always consider whether or not any neuromuscular blocking agent is actually appropriate for that particular patient and situation.
CHAPTER 2:
The first step when treating malignant hyperthermia, is to recognize it, then treat the life-threats. Treat the hyperkalemia, ventilate with 100% oxygen to replace what's being used up and most importantly - dantrolene.
In this case, dantrolene is the life-saving drug, the gold standard that has significantly decreased the mortality of malignant hyperthermia events. Discovered in the 1970s, it works by attaching to the ryanodine receptor and disengages the triggering agent from the ryanodine receptor and allows it to function normally again. Bolus dose for dantrolene is 2.5 mg/kg bolus that can be repeated. This is a change, as it used to be recommended that a bolus dose plus a drip be administered, but a new formulation has made reconstituting the drug easier. Thus, the recommendation is a bolus, with repeated boluses, if required.
The malignant hyperthermia kit should include: dantrolene (obviously), but also ACLS drugs. For treatment of hyperkalemia - insulin/dextrose and albuterol. Bicarbonate, which treats low pH, hyperkalemia, and helps alkalize the kidneys in light of muscle breakdown. Calcium is extremely important for myocardial stabilization.
Cooling in the OR could involve lavage of an open cavity, but also cold IV saline, and or ice packs to the axillary and groin areas. Once the body temperature has dropped below 38o C, cooling should be terminated to avoid hypothermia.
Ongoing care would include transfer to a tertiary care facility, where the patient can undergo continued monitoring. Dantrolene can be given intermittently every 4-6 hours for 24-hours, because malignant hyperthermia recrudescence can occur. Watch for kidney failure due to rhabdomyolysis, DIC, and if recrudescence occurs, hyperkalemia.
Malignant hyperthermia is an inherited autosomal dominant trait. When assessing for risk, a thorough history and physical is required to look for individual problems, as well as looking for a lethal family history from anesthesia. If there is a family history, it's best to avoid triggering agents.
If a patient has a malignant hyperthermia event, they don't need any further testing, they are confirmed. However, they may want genetic testing. There are 30 mutations of both the ryanodine and dihydropyridine receptors that have been linked to malignant hyperthermia. Those results can be used to help identify family members with the same mutations. Unlike the caffeine/halothane test, genetic testing doesn't require a muscle biopsy. The caffeine/halothane test is another way to confirm patients with malignant hyperthermia. It's done by applying caffeine and halothane to a fresh muscle biopsy. If a certain amount of contraction is achieved, it is diagnosed for malignant hyperthermia. However, to complete the test, the patient must be physically present at the institution performing it, and there are only 5 such institutions in North America. It would be best to refer these patients to a specialized institution before a scheduled surgery.
MHAUS.org is a great resource for information on malignant hyperthermia. There is also a hotline that can bel called during an event. It's staffed 24/7 by anesthesiologists that are highly trained in malignant hyperthermia. It's important to remember that these events are rare, and it's important to have all the resources and help possible during an event.
CHAPTER 3:
LAST is local anesthetic systemic toxicity. Much like MH, it is a life threatening reaction that is almost completely preventable when care is take while injecting local anesthetics. It is also managed differently than a normal cardiac arrest.
There are 2 types of symptoms of LAST, cardiac and neurological. Most of the time it is felt that the neurologic symptoms precede the cardiac ones.
These anesthetic agents work by blocking the sodium channels, and thereby block the depolarization of the nerves, both cerebral and cardiac. These agents are not always specific to sodium channels and can block other channels.
What predisposes cardiac effects depends on the agent, bupivacaine is most likely to cause cardiac issues; followed by ropivacaine, then lidocaine. This is related to the properties of the individual agents. The more lipophilic the agent, the more potent it is. Each anesthetic has a ratio of where it's most likely to be toxic at. Lidocaine is more likely to be toxic in the brain, than the heart. Bupivacaine is more likely to affect the heart at the same time it affects the brain. So, for example, if lidocaine were injected, there would be neurologic symptoms, but bupivacaine, if injected, because it's ration is lower, would have both cardiac and neurologic effects.
Safety of local anesthetics administered IV is due to dosage. For example, before almost every surgical case, a 1 to 1.5mg/kg bolus is given IV because it helps some of the sympathetic response i.e. the cardiac response to laryngoscopy and intubation, bronchospasms etc. Lidocaine is an antiarrhythmic, as well and probably one of the safest legal anesthetics to give IV. It's used as IV infusion for enhanced recovery after surgery for colorectal surgeries, and it's also used for renal colic in the emergency room setting. Giving IV lidocaine within that range of 1 to 1.15 mg/kg has been shown to be safe with almost zero chance of LAST. LAST can also occur when high doses are given and absorbed into the bloodstream.
It can get confusing looking at different percentages of drugs, and mixes. Lidocaine with epinephrine tends to depot the drug. The max dose of local anesthetic are based on the mass of the dose, the mg/kg, not the volume of the dose. For example, a fascia iliaca block is a volume block. You want to get a large volume of the medication to get a good coverage. A large volume of a dilute anesthetic is safe if it remains within the normal dose ranges.
Max doses for local anesthetics are:
- Lidocaine: 4mg/kg
- Lidocaine with Epi: 7mg.kg
- Bupivacaine: 3mg/kg
- Ropivacaine: 3mg/kg
For quick dosing, if using 25% bupivacaine, the max dose is the patient's weight in mls. For example, a patient that is 70kg, their max dose would be 70mls of 25% bupivacaine. If using 50% bupivacaine, the max dose is half their weight. For the same 70kg patient, the dose would be 35 mls. This same quick dosing can be used for ropivacaine.
Predisposition of patients for LAST include extremes of age, low muscle mass, the very end stages of liver or renal disease along with low-protein binding states.
Areas where LAST has a higher prevalence, is due to the vascularity of the tissue being injected, and how quickly it can be absorbed. This list of highest absorption to lowest is as follows: IV, tracheal, intercostal, paravertebral, epidural, abdominal wall, tap blocks and brachial plexus blocks, sciate, femoral, and then subcutaneous.
CHAPTER 4:
LAST presentation can be variable, but the classic presentation of LAST is first neurologic symptoms: excitatory, circumoral numbness, ringing in the ears, agitation, and just "not feeling right". This then can lead to delirium, sedation, coma and/or seizures. Then cardiac toxicity can develop. This can also be quite variable resulting in tachycardia to bradycardia, widening of the QRS, elongation of the QT, and/or flat out Vtach/Vfib.
In the event of LAST, treatment depends on the variable presentation. Mild symptoms require 1:1 monitoring of Spo2, cardiac rhythms and blood pressures to make sure it doesn't advance. If severe signs develop, in particular seizures, treatment must be aggressive and intralipid infusion should be started. Intralipid or lipid emulsion therapy is the first line drug in LAST; and works by affecting the agent through lipophilicity. It helps shift the diffusion gradient, and pull the anesthetic agents like bupivacaine off the sodium channels in the cardiac myocytes, and shuttle them away from the heart to the skeletal muscle and to the liver. A secondary mechanism is that it helps limit ischemia reperfusion syndrome and acts as a fluid bolus. It generally works fast - within minutes.
In a LAST event, ACLS doses are different. EPI doses should remain under a 100mcgs or a 1mcg/kg. EPI is arrhythmogenic and standard ACLS doses contribute to local anesthetic induces arrhythmias. Sodium channel blockers like lidocaine or procainamide should not be used. Other aspects of the ACLS protocol: CPR, defibrillation, and airway management remain unchanged. It is recommended that in this event that transfer to a facility that has ECMO should be considered.
Lipid emulsion dosing for adults over 70kg, is 200mls for the first bolus, with repeat doses of 100mls every few minutes. If under 70kg, the dosing returns to the old formulation of 1.5ml/kg bolus, and then an infusion of 0.25ml/kg/min. If rebolusing, increase the rate or the drip. Max dose is 12ml/kg. If reaching the max dose, consider that this event may not be LAST.
Is ultrasound or nerve stimulator better at reducing the risk of LAST when injecting anesthetic? It depends on who you ask. Ultrasound is like "turning the lights on". It allows you to see the spread of the anesthetic being injected.
Thanks for listening.
This podcast presents, Dr. Patrick Carolan, a pediatric emergency medicine physician with Minneapolis Children's Hospital and Clinics of Minnesota, who discusses the evaluation of fever in the neonate and young infant.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Recognize the implications of fever in the young infant.
- Discuss the differential diagnosis of fever and critical illness in the young infant.
- Implement new concepts in risk stratification for evaluating fever in young infants.
CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
DISCLOSURE ANNOUNCEMENT
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.
It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1:
Today we are talking about fever in the pediatric population, specifically those in the under 3-months of age. Dr. Pat Carolan of Children's Hospitals of Minnesota will help us demystify fever in this age group.
Going back to the mid-70s, there was a search for criteria to find high-risk vs low-risk pediatric fevers. In the original study out of Boston, it was identified that 10% of the patients under age 2, with WBC greater than 15, and a temperature greater than 38.9C, had severe bacteremia. This was the first set of criteria focused on identifying high-risk infants. With the intro of HIb vaccine in the the late 80s-early 90s, and the pneumococcal vaccine in the mid-90s, there is a much lower prevalence of these infections. The few cases that occur now are due to those who have not received or are non-responders to the vaccine. The shift in study of pediatrics has now been to better differentiate high-risk vs low-risk febrile infants.
What is considered a fever? The traditional definition of fever is a temperature over 100.4F. Pediatric fevers can be broken down into 3 groups. Those in 0-28 days are high-risk and regardless of a positive RSV or influenza test, get a full work up - including blood, urine, csf, cultures, antibiotics, and admission. What if they are 0-28 days and they have otitis media or RSV? The clinical exam of otitis media in this aged population would be difficult, and even if the clinician had confidence in a focal finding, those at this age group are still at significant risk and would get a full work up. RSV would be unusual in a 2-week old and even if positive , that would be an usual finding, and again these neonates would still get a full work up. The rates of bacteremia in studies have shown that a full work up is warranted. Infants at 3-months are lower-risk, and in general, can usually be managed as outpatients with lab work. Risk for infants in the 2nd month of life is harder to determine and they are the target of risk stratification tools discussed later in this podcast. These are the "tweeners". Initially, assessment of these infants include that across the room pediatric triage triangle. How are they reacting to stimulus? What does their skin color look like? What is their body tone? Have the parents noted whether the infant is engaged in feeding? Are they tachycardiac? Infants can present with fever, but some infants that are septic, can present afebrile or hypothermic. Remember, it is important not to overlook a potential differential diagnosis, including congenital ductal lesions or metabolic abnormalities.
CHAPTER 2:
Risk stratification tools vary, but utilize biomarkers such as procalcitonin and CRP as key features of the pathways. Each tool mentioned today, PECARN, Stepwise and Rochester, all have high sensitivity and high-negative predictive values. Choosing the appropriate tool depends on the patient population, ability to run specific biomarker tests, and comfort level in the subsequent interpretation. For example, the availability of a facility to run a procalcitonin would determine whether a particular stratification tool could be used. The most recent study, conducted by PECARN or the Pediatric Emergency Care Applied Research Network, is a large, multicenter study that uses procalcitonin, absolute neutrophil count and urine analysis as the base of its pathway. The PECARN is structured as a decision tree, formatted in a way, to quote Dr. Carolan that "helps decision making in the trenches."
Differentiating between the terms "serious" vs "invasive" infections.
Serious infections include, but are not limited to bacterial, bone and joint infections, and UTIs. Invasive includes pneumococcal meningitis and HIB. In the simplest terms, invasive infections are of greater concern, and is "the stuff we want to treat immediately". Bacterial organisms of concern include: group B strep and gram negative organisms for neonates, pneumococcus and more rarely, HIV at 1-month and older. E.Coli, especially as a uro pathogen and Listeria, though rarer, makes the list of concern as well. An important viral organism of concern is Herpes Simplex Virus, which depending on the facility, is an add on order when running CSF. HSV has 3 main types, the most devistating a CNS infection, which presents with fever and seizures - whether focal or generalized. Pleocytosis, or WBC greater than 16 in CSF, is abnormal in those less than 28-days of age. WBC greater than 10 is abnormal for 2-3 months of age. An absence of pleocytosis does not exclude a central nervous infection by HSV.
CHAPTER 3:
At 2-months of age, infants that meet low-risk criteria, can be treated as an outpatient - if next day follow-up can be assured. Conservative treatment for those with a UTI that have an abnormal urine and positive biomarker, would get blood cultures, LP and antibiotics. The odds ratio is low, but gram negative CNS infections can be devastating and require extended treatment of antibiotics. The stratification tools, PECARN, Stepwise, and Rochester, help guide practice for these 2-month old infants or "tweeners", but it can still be difficult to decide whether or not to do an LP. There is still a place for practitioner gestalt, and if something feels not quite right, an LP is appropriate.
Some infants are brought to the ER with reports of a fever, but upon presentation are afebrile. If a rectal temp performed at home, then it is regarded as a true fever, and the age appropriate work up should be started. Empiric treatment for infants include: Ampicillin and Cefotaxime. Cefotaxime is the go to for 3rd generation cephalosporin, instead of Rocephin, which can cause a rise in bilirubin in young infants. For those under 3-weeks, Acyclovir coverage is added till HSV is ruled out. Vancomycin would be used for those beyond 2-weeks of life with pneumococcus or staph infection with sepsis. Tamiflu is started for infants with positive influenza greater than 2-weeks and under 2-years of age, per CDC recommendations. For those infants who are not vaccinated, the plan of care does not change for those under 3-months or greater that are vaccinated. Intuitively, it would be suggested that they are at higher risk, but there is little data bout this specific group.
Thanks for listening.
In this podcast, Matt Bigos, MD, FACOG an obstetrician/gynecologist with OB-GYN West, presented at Ridgeview Medical Center's Live Friday CME Series on March 13, 2020. At the event, Dr. Bigos talked about hypertension in the OB patient.
Enjoy the podcast!
OBJECTIVES: Upon completion of this podcast, participants should be able to:
- Identify signs and symptoms of gestational hypertension and pre-eclampsia.
- Identify signs and symptoms of acute onset severe hypertension.
- Express when to promptly initiate treatment.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
Note: CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
PART 1: Hypertension in pregnancy is one of the worldwide leading causes of mortality, affecting 2-8% globally. That's 76,000 maternal and 500,000 infant deaths per year in the world.
RISK FACTORS:
- Nulliparity
- Multiple gestation
- Size of placenta/multiple placentas
- Hx of preeclamsia
- HTN hx
- Gestational diabetes
- Thrombophilia
- Lupus
- Obesity before pregnancy
- Antiphospholipid aby syndrome
- Older pregnancy
- Kidney dz
- IVF
- OSA
Exact mechanisms is unknown, but probably due to the placenta itself. Many theories exist, and there is a familial component.
Physiology changes with pre-eclampsia. With pregnancy in general, blood volume increases by 50%. Most of which is serum. In preeclampsia, oncotic pressure in the blood vessels decreases, and fluid leaking occurs, hence edema. Kidneys also lose protein which aids in losing intravascular volume. Be cautious with IV hydration in preeclampsia. Intense vasospasm also occurs. Thrombocytopenia occurs due to overuse of platelets. Hemolysis occurs as well. Look for elevations of LDH and bilirubin. Schistocytes can be seen if you can find a microscope. Periportal necrosis leads to elevated AST>ALT. Coagulation factors won't produce as well either. In the kidney, protein leaks through porous glomeruli. Urine output will decrease due to intrarenal vasospam. Uric acid levels can help differentiate chronic vs new HTN in pregnancy. Less amniotic fluid and smaller fetus size occurs. Placental abruption may happen, in addition.
PART 2: Gestational HTN is a BP of 140/90 (either or both) or greater. These must be noted on two separate occasions at least four hours apart. Diagnosed after 20 weeks of gestation in a woman with previously normal BP.
Preeclampsia is the same criteria, along with proteinuria. 24-hour urine collection for protein is the historic best way to check. Protein: Creatinine ration is the easiest to do, though. 2+ protein on the urine dipstick may also suffice.
Preeclampsia with severe features: BP 160/110 or both (= or >) on 2 occasions, 4 hrs apart. Or if you move to treating the BP, this would signify "severe" feature. Other features include: Mild HTN with platelets
In this podcast, Dr. Nicholas Schneeman, a family medicine physician specializing in geriatrics, and chief medical officer for LifeSprk, presented at Ridgeview Medical Center's Live Friday CME Series - Annual Dr. Lehmann Lecture Series, on February 14, 2020. At this annual event, Dr. Schneeman talked about value based care for the elderly, as well as moving away from the confusing, unfruitful and sometimes dangerous fee for service model we are currently practicing.
Enjoy the podcast!
OBJECTIVES: Upon completion of this podcast, participants should be able to:
- Describe current demographic trends in U.S. Medicare populations.
- Identify financial drivers under Medicare in clinics, hospitals, and skilled nursing facilities.
- Recognize patient profiles at risk for low value care.
- Describe past and current attempts to solve for low value care.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
Note: CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
INTRODUCTION: Dr. Nick Schneeman is a family medicine physician who specializes in geriatric medicine, and has a keen interest and expertise in value based care for the elderly, as well as moving away from the confusing, unfruitful and sometimes dangerous fee for service model we are currently practicing in. Dr. Schneeman is currently the chief medical officer of LIfesprk, and had over 30 years of clinical experience caring for this very special patient population. He joined us on February 14, 2020, for the annual Dr. Jim Lehmann lecture covering a variety of geriatric topics. Dr. Lehmann served his patients for many decades. Joining him and others in the audience today was the Spanus Family who helped fund this endeavor. Do sit back and enjoy the program. It is sure to make you think about how you fit into this complicated dilemma, but more importantly, how you can be part of the solution.
PART 1: The way in which to fix the geriatrics dilemma is to understand the quality and cost factors on a very deep level. We will have 1 billion elderly patients in the world in the next several years. In the 1930s, only 3 to 5 % of the population was seniors, now we are at 20+%. To further complicate this statistic, senior citizens age 85 and older have a significant cognitive impairment rate of 50%.
In the U.S., Medicare is the single payer system for our senior citizens. There are segments inside of Medicare where the costs are exorbitant, including the last 2-years of life where they go up 6-to-7 times what they were up to that point. Put another way, half of an individual's Medicare budget is spent in the last 6 months of life. Much of these costs unfortunately are very wasteful. Medicare is not sustainable in its current form; and it is going to continue to threaten our national economy.
PART 2: Edith is 86 years old and lives in her own home by herself. She has a doctor who she loves. Mild ailments have ensued and she no longer drives. Her son and daughter check in periodically and neighbors lend a hand at times.
Dr. John Goodparent and his partner Dr. Rachel Cakeandeatit are partner physicians who take care of Edith. They are a different kind of physician than the physicians of old, though, mostly working for large health systems with maximally loaded schedules. In addition, they are working either in the clinic or hospital, and no longer both.
Lately, Edith's daughter, Connie, has concerns and has been calling Dr. Goodparent. So, he sees her in the clinic and determines she has had some chronic cerebral ischemic changes, so refers her to a neurologist who performs a battery of tests with no resolution. Sinemet is tried for what is felt to be some Parkinson's issues. Connie comes to the house and finds her in a bit of disarray. She takes her to see Dr. Cakeandeatit who determines she's depressed, so givers her a sample of an SSRI. Her UA is dirty although no symptoms of UTI, but antibiotics are started nonetheless. Connie takes time with her at home. Edith improves a bit. Up until now, her care has been paid for my Medicare financial driver domain clinic. Physician incentives are pretty bad in this model. No value in the extra phone calls, etc., and you can't crank this kind of patient through the clinic in a 10-minute appointment slot. Not to mention having to juggle and address all the calls from Connie and other concerned parties.
Connie leaves town for a bit, and about a week later, Edith's son visits and sees her in a disheveled state. Now she's brought to the ER and meets Dr. Saverlife. Weakness and low grade fever are noted. Parkinson's history is acknowledged, with Lexapro and Sinemet on board, as well as a bunch of other new medications in the past several weeks to months. Final ER diagnosis is recurrent UTI and mild CHF. So a little more diuretic and now a fluoroquinolone are added.
Well, a short while later when a neighbor finds that she now has stacked newspapers on her front porch and Edith is found to be stool-stained and stuck between the wall and her toilet. 10-days in the hospital ensue, with a new diagnosis of C diff colitis. She is in A-fib with RVR. Multiple consultations happen. Abd CT and colonoscopy are performed due to a Hgb drop. SNF is recommended but the patient and family refuse. So its back to home again; her medications are tweaked to now include a PPR and Seroquel.
This current care is driven by domain hospital, and the hospital is paid a value-driven lump sum of money called a DRG. Administratively, we are pushed to get patients through the hospital and turn beds over. As providers, we are incentivized by part B, which is volume driven. See more patients and get paid more. Quality is not as rewarded.
Edith now falls down at home, has a hip fracture. Ativan is given, and more Seroquel due to increased delirium. IV fluids are given throughout her care. She's discharged now to a SNF. The 10-day old H and P is noted and her d/c orders, but there is no d/c summary yet from this hospitalization. Due to the hyperregulated state of SNFs, a lot of documentation must take place, orders, Q/A parameters, etc. The nurse calls the on-call doctor who has no prior knowledge of this patient. This care is paid under Medicare nursing home domain, which is a split system. The SNF gets a daily rate based on how much therapy the patient needs. Just recently this has transitioned to payment based on the patient's diagnoses. While we should be incentivized to help manage the patient under this system, we ae still driven by fee for service and volume on Medicare part B, meaning uncompensated calls and no resource management incentives either.
Edith doesn't really participate in rehab, demonstrates increased confusion and another urine is checked off the foley. Because it looks infected, she is restarted on Levaquin and an increase in Seroquel is also ordered. Big surprise here she continues to deteriorate, leading her down any number of etiology pathways for her further decompensated state. Edith is now back in the ED. And has entered the revolving door of rescue, rehab and relapse. Unfortunately, quality of care in this paradigm is suspect as best. It becomes a bit of a crap shoot, and there's little respect for consideration of patient autonomy. We've all experienced this, right? How do you have a meaningful "goals of care" conversation with patients and family when they're figuratively "stuck in the mud" of dilapidated care. There's obviously significant difficulty in obtaining informed consent. Drug cascading is highly prevalent. And as Dr. Schneeman eloquently illustrates for us, this is a complex issue made more complex by polypharmacy, limited time with our patients who are elderly with multiple comorbidities and multiple silos of care weighing in to crate a low quality, hyper expensive healthcare delivery model.
PART 3: How has the healthcare industry responded? We've done a lot of work-arounds. Care coordination being one big "fix"! This notion started in the 1990s. CMS has funded a number of trials looking at the topic of Care Coordination. Many different strategies exist, but nothing has worked. In 2011, there was an initiative from private industry to fi healthcare for example.
Dr. Jeff Brenner attempted to find a way in which we can use date to coordinate care for the 3-to-5% of hyper expensive patients within the Camden Coalition. But unfortunately this endeavor yielded no results. They couldn't fix things, per a recent follow-up article in the NEJM. There was a further attempt to tease out what could be of value in the 15 studies looking at care coordination. 1. Comprehensive d/c planning; 2. Timely communication of information; 3. medication reconciliation; 4. patient caregiver education with teachback; 5. open communication b/w providers; 6. prompt f/u visits with a provider.
As Dr. Schneeman points out, medication reconciliation does not really improve risk benefit discussion and the truth is many of the drugs our senior patients take are in fact problematic and dangerous most of the time as well. It does not teach us how to unwind the drug list. Big pharma has had a heavy hand in how these drugs have been used over the years, including off label use. The intermittent confusion our senior patients have is not due to asymptomatic bacteriuria. C-diff colitis in a fail old person is potentially life-threatening, not to mention the other adverse effects brought on by antibiotics given for this reason. Patient education with teach back doesn't really teach us anything. Open communication about cancer screening with limited life expectancy does not validate the notion of open communication. Prompt follow-up does not address the fact that blood pressure medications are not getting deescalated, nor the fact that the marginally functioning demented patients will still have an unavoidable and predictable decline regardless of what we do. Finally, per Dr. Schneeman, comprehensive discharge planning does not address the lack of science to help guide us in treating our patients with the comorbidity of progressive dementia. These very patients are in fact excluded from the trials that originally brought these drugs to market!
So what's going on here? Well, we're part of the problem as clinicians, for one. Secondly, we're living in a country where being multimorbid and elderly is not a good thing when it comes to quality of health care.
On a positive note, we have an opportunity to be part of the cure. In other words, we have the opportunity to begin thinking and acting on the real cost of the care we're providing, as though we are paying for every penny of it. The selling-off of primary care clinics has been an issue for physicians and has taken them out of the discussion of the bottom line. There is poor accountability for cost and quality, due to lack of peer review within our silos let alone across silos. Compensation is not equated to value, and unfortunately there are still some unscrupulous techniques from industry to try and inform our practice. We're also taught in a way that doesn't fit with the Edith's of the world nowadays. The "chief complaint" from Edith is a syndrome and not a single complaint. We can all relate to this.
Medicare Advantage is a platform that allows physicians to get paid based on quality of care. Dual eligible programs are also out there. As well as new payment options on the horizon, such as the Independence at Home demonstration project. Basically compensation for providing complex, in-home care.
Medication delivery devices, sensors and other tech that is out there to help us provide more care is proliferating. New brick an mortars are also popping up and are attaching Medicare Advantage to the underserved elderly communities. And then of course, there are more and more Dr. Schneemann's out there who want to provide complex, in-home care.
So what can we do? 1. Accept that we participate in low value care; 2. Subspecialty care needs to be just that, and no longer the primary care providers for these elderly patients. Ultimately the core solution is team base, flat hierarchy and a cultural shift to one of accountability across silos, thus creating a safety net for our patients.
The physicians are the ones who need to take this bull by the horn, and not rely on guidelines solely. We are in the trenches and must be negotiating the trajectory of care. Getting involved in a value based care and compensation model is imperative. It can be a double-edged sword though. We need to provide the appropriate care when it's warranted, but also not withhold care to save or make more money. The onus falls on us to e the experts and to rebuild the current construct. Let's stop merely ordering a bunch of stuff and begin to have those conversations with patients and families to understand and clarify goals and realistic outcomes before committing to multiple diagnostic tests and polypharmacy. This is made difficult in patients with cognative impairment, but it can be done!
PART 4: Well, it's a happy ending after all. Edith survives her last hospitalization. And as it turns out there is a geriatric specialist working for a geriatric center of excellence, who takes over her care. She is able to access her care and chart 24/7. Medications are deescalated, and the fog is lifting. Edith is now participating in therapy. While a moderate fall risk exists, she is more independent and now using a walker, and she gets Meals-On-Wheels. Edith is now teed up to move into an assisted living facility. In addition, she has advanced care planning with a team trained to do this. A POLST form is completed and while Edith and her family can consider 911/ER visits, she is DNR/DNI with a tilt toward hospice care in the setting of a major health complication or event. Home based care is the new focus and guess what...people working for Edith actually love their jobs.
Geriatric centers of excellence can be virtual; and they are made up of compassionate people providing personalize care that is also profitable. That's a lot of "P's".
Questions from the audience were addressed by Dr. Schneeman as follows: How do we help patient and families make those decisions and changes in care plans. Well, its never easy to make that kind of decision during an emergency. But it is made easier by having a long-term patient relationship in this desirable model, something that spans over months to years, where the home based care team is at the forefront of the patient's care experience. They will help patients and families make realistic decisions and will obviate the option of "let's give it one more try!", suggested by the well meaning son who's visiting from California and hasn't been home in a couple years.
In regards to "how do we fix this?", the new payment and reimbursement programs can and will. Essentially making geriatric care a subspecialty level compensation model. New practitioners and nurses are hungry for vocation and meaning in their work. Bottom line though is that fee for service for this demographic is not sustainable.
Are there local geriatric centers of excellence presently? Not yet, but the pendulum is swinging. Recruiting and employing physicians, nurses, APPs, and others who want longitudinal relationships with patients, and who have the personality and passion for this vocation will help to create such centers. It will be both exciting and game changing.
Thanks so much to Dr. Schneeman for his time and expertise on this topic, and to all who care for this special population of patients in our community.
In this podcast, Dr. Kimberlee Thielen, an internal medicine physician and nephrologist with Kidney Specialists of Minnesota, discusses hyponatremia, more specifically a water balance issue.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Define how sodium effects the body.
- Identify signs and symptoms of hyponatremia.
- Explain the 4 goals for hospitalized patients with hyponatremia.
- Select proper treatment modalities for individuals with identified hyponatremia.
CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1: When we are talking about hyponatremia we are not talking about Na+ problems but rather a water balance issue.
The normal amount of Na+ in the plasma water is usually 136-142 meq/L.
The body's Na+ balance is important for volume regulation which is controlled by renin angiotensin/Aldosterone system. This is different than the body's water balance which is maintained by antidiuretic hormone (ADH).
Normal physiology of water balance requires ADH which involves the hypothalamus-post pituitary and the kidneys.
To understand hyponatremia you need to first understand the physiology of water balance and where ADH is produced. ADH is produced in post pituitary and released by 2 physiologic stimulators: (1) elevated serum osmolality, (2) decrease circulating volume.
The majority of serum osms are made up of sodium. When your Na+ is high there are osmoreceptors in your hypothalamus that sense increased extracellular serum Na+ which synthesizes ADH which is released once again from the post-pituitary.
The posterior pituitary can also synthesize ADH 2nd low volume status regardless of serum osmolality.
Parasympathetic response from left atrium, aortic arch & carotids sense the low volume status or volume contraction with decrease arterial blood flow thereby stimulating a vagus nerve response which leads to the posterior pituitary releasing ADH.
ADH once released acts at the renal collecting tubule via cyclic AMP which inserts water channels called aquaporins in the collecting tubules flowing via the medullary interstitial osmotic gradient. Next water moves from the intratubular space to the medullary interstitial space thereby concentrating the osmolality. So the further you travel through the kidney more water is removed from intratubular space to medullary interstitium concentrating the urine.
A normal healthy person can concentrate their urine upwards of 1200 milli osms and dilute it to around 60 milli osms, which narrows as we age, likely to nephron drop.
We all tend to lose some GFR as we age.
Nephron Drop Out attrition of nephron units that scar up generally due to athrescleortic disease.
ADH- insert aquaporins into collecting tubules - based on osmolality of urine and interstitial water will flow down the osmotic gradient through the aquaporins. Collecting tubules as they go deeper into the kidney the medullary interstitial osmotic gradient increases. The water that is reclaimed is through a complex peritubular capillary network returning to the venous system.
CHAPTER 2: Hyponatremia in most patients is going to be hypo-osmolar hyponatremia.
When talking about hyponatremia we are generally talking about a serum Na+ less than 135 mew which once again is a water balance issue.
Most cases of hyperosmolar hyponatremia are clinical relevant and usually caused by hyperglycemia, prostate or uterine surgery, glycine, sorbitol, mannitol, IVIG. You get an increased osmolar state in the blood which pulls water from intracellular space leads to hyponatremia.
Pseudohyponatremia are iso-osmolar and generally a laboratory artifact. Can have your lab run serum Na+ via direct ion selective electrode measurement to obtain true Na+ level.
What is hypo-osmolar hyponatremia? Causes are divided into 3 categories: (1) water intoxication, (2) SIADH, (3) volume stimulated ADH.
You can differentiate by 2 urine tests: Test #1- Urine Osmolality which we would expect to be low or max dilute. Test #2 is Urine Sodium.
Water Intox - The urine Osms are maximally dilute.
SIADH and Volume stimulate ADH urine osms not max dilute. Urine sodium is low in volume stimulated ADH and generally >40 meq per/L in SIADH. Which is due to the kidney seeing itself as euvolemic. So this will cause the release of sodium into the urine.
In volume stimulated ADH the kidney perceives itself ischemic or underperfused. So the urine Na+
In this podcast, Dr. Richard Scott, Deputy Division Director for Carver County Public Health and Health and Human Services, discusses public health issues being experienced in the current (2020) COVID-19 outbreak.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Summarize what public health is doing to "flatten the epidemiological curve".
- Identify containment and community mitigation strategies.
- Identify strategies in how to ramp up pandemic management.
- Express the importance of communication during a pandemic.
CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
In this podcast, Dr. Matt Herold and Dr. David Larson, emergency medicine physicians (EMPAC) with Ridgeview Medical Center, discuss how Ridgeview Medical Center is operating, and the current hurdles being faced with the COVID-19 virus.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Summarize the preparations underway at Ridgeview in managing patients who have COVID-19 infection.
- Identify the barriers Ridgeview experiences during COVID-19 pandemic response.
CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
CHAPTER 1: We activated the hospital's emergency operations center, which typically happens with any disaster situation.
The emergency operations center oversees that the hospital and organization are prepared; in addition to collaborating with other health systems, including Minnesota Hospital Association, MDH, and CDC.
Dr. Larson notes that education is the key to remaining prepared and successful. He also emphasizes that vigilance is important for monitoring our resources.
Lack of staff appears to be an important resource and the biggest area of concern if COVID numbers continue to climb.
As an organization the temporary elimination of elective surgeries, endoscopy and other procedures may free up clinicians to help out in other areas, if the need arise.
Mechanisms are in place to identify healthcare providers who have been exposed by COVID patient and the necessary steps that must be undertaken to ensure compliance as well as the steps required to return to work.
Dr. Herold believes that some of the more important questions are how to use technology as aid in the care of infected patients and likely more important how do we eliminate or limit exposure.
In the current state of emergency declaration it does appear some of the EMTALA requirements have loosened. I would encourage those listeners at different locations to contact their organization for updated guidelines. I would also like to stress again that we are not EMATLA experts.
CHAPTER 2: Organizations are starting to cohort patients even going so far as to have dedicated receiving facilities for hospitalized COVID positive patients. Additional consideration may be a respiratory wind of the hospital dedicated to infected patients.
Not sure modeling is helpful and sometimes difficult to follow and interpret.
As Dr. Herold states that unfortunately this is the most sustained dynamic issue that has a potential to affect everything from PPE, to staffing, to resources as well as who knows best in real time and how they impact operations.
Communication and education is integral; most organizations have a centralized repository where real time information and "sources of truth" can be disseminated.
Team Huddles prior to shift are important for updates as well as clarifying objectives for the shift.
Continue to merge silos.
The state has limited us to testing hospitalized patients, NH or group home patients, along with ill healthcare workers.
CONCLUSION: Thanks for listening.
In this podcast, Dr. James Currie, an Infectious Disease Specialist and Internist with Lakeview Clinic, discusses the current COVID-19 pandemic, it's origins, where we are at of March 20, 2020 (the date of the podcast recording), and how we will continue to daily activities during the pandemic.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Explain the COVID-19 virus type and its clinical syndrome.
- Discuss the special challenges in identifying and preventing further spread of a viral pandemic.
- Differentiate current treatment modalities, methods of prevention, and potential future treatment options.
CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
INTRODUCTION: Hello everyone, and thanks for turning into this special Ridgeview Podcast CME Series. COVID-19 continues to emerge onto the scene here in the state of Minnesota, and the U.S. in general. We have Dr. Jim Currie today, who is a blue grass musician, but his day job is an infectious disease specialist and internist with Lakeview Clinic, and here today to discuss the pandemic, it's origins, where we are at as of March 20, 2020 (the date of the podcast recording); and how we will weather the storm. Dr. Currie has special interests and experience in all manner of infectious illness, and a special interest in chronic viral conditions, HIV and more. As we will learn, it is a time to prepare, and not to panic. Let's keep the faith in our system and continue to advocate for more and better preventative strategies, and other needs that we on the frontlines will have, as well as what our patients will need to stay ahead of this pandemic.
Welcome, and enjoy the podcast with Dr. Currie.
CHAPTER 1: Coronavirus includes many different viruses. They look "crown-like" under an electron microscope, which is where "corona" comes from. Most of them cause symptoms consistent with the common cold. In the last 10 years, some have caused serious illness, such as SARS-Cov-1. This current virus, SARS-CoV-2, or COVID-19, tends to cause more serious illness as well.
It is thought that this virus originated within a bat, but as Dr. Currie states, viruses are everywhere, including different species of animals, the water, and the soil among other places. There is evidence that viruses may have existed on earth when there were only single celled organisms present. In the traditional sense, viruses would probably not be considered life forms.
Present iteration of this virus started in Wuhan, China, and for reasons unclear, has spread easily to humans from an original host, and amongst humans with relative ease. The predecessor viruses, such as MERS, and H1N1 are also very aggressive, but did not spread as easily as this new coronavirus, known as COVID-19. Viruses are dependent on living cells; they insert their DNA (or RNA) into living cells and more viruses are made within these living cells. And in this virus's case, the spread happens via respiratory secretions.
We do not have enough data on this virus in terms of ease of transmission, but it's safe to say it is somewhere in the spectrum of influenza and chickenpox, for instance. We fortunately have a lot of information about this virus, but we still have much to learn.
Presently, there is an L and S type of COVID-19. And it is certainly possible that this virus has mutated already, and that there were always two subtypes. And further mutations can happen, but we do not yet know how quickly this virus mutates. Mutation can yield more virulent and less virulent virus types, which is important to remember. This is an RNA virus and it theorized that some of the reverse transcriptase inhibitors may be useful in treating this, but this hasn't played out yet. From a political and governmental standpoint, HIV research and treatment was a lesson we can learn from with this virus. In other words, funds and energy must be diverted to research, prevention and treatment for this and future similar viruses.
CHAPTER 2: So what about PPE (personal protective equipment) and reuse of masks, in particular the N95. Well, whenever possible, the mask should be disposed of between patients. However, there are actual guidelines for N95s that stem back to the H1N1 outbreak, as there were shortages then as well. So recommendations for reuse were derived from that. If the mask is not soiled or damaged, and the mask has been handled well, in other words, gloves to apply the mask and not touching the inside of the mask. A surgical mask over the N95 when treating COVID-19 patients. After seeing the patient the N95, should be placed in a breathable receptacle, such as a paper bag. If gong (immediately) from one COVID patient to another, the mask doesn't need to be removed.
Why are the elderly so much more severely affected? Well, age may have a lot to do with it. This particular virus has a significant effect at the level of the ACE2 receptor. Is this upregulated by nonsteroidals? Possibly, but there is no firm data or recommendation right now to take or not take these medications. But the ace2 is found in large quantities in the pulmonary vasculature, so it is theorized that much of the severity in pulmonary symptoms is due to what's happening here.
Incubation of this virus is about 4 days, and initial symptoms include non to mild URI symptoms and fever. Progression to serious illness occurs 7 to 9 days after you initially become symptomatic. But there is of course a spectrum in severity that seems to align with the spectrum of age of the patients whoa re infected. And to date, we don't know fully what's so special about this virus that would explain such drastic differences in severity and outcome. But it's suffice to say that people who are multimorbid with chronic lung disease, diabetes, and/or advanced age seem to be more predisposed to severe illness.
Coinfection of influenza with COVID-19 is not well known right now, but in more severe illness with influenza, there is easier facilitation of co-infection because of the presence of influenza. Each patient scenario and clinical syndrome will be different and perhaps broader testing can be done as those test kits become available. Is the test for COVID-19 accurate? What is the sensitivity and specificity. The OP swabs are known to have a lower return rate than the NP swabs. We don't know the exact sensitivity and specificity of these tests yet, because we have not done enough of them, but they are assumed to have high specificity and moderately good sensitivity.
What are we supposed to do when we are tested therefore and our test is negative? 2 weeks of quarantining to go on even after a negative test. It's plausible that when symptoms are vastly improved or gone, that one could go out and continue to social distance. With a positive test, or symptoms and concern for exposure, the minimum of 2-weeks of self-quarantining is the current recommendation. What is not known exactly though yet, is how much longer we should be quarantining patients beyond that, and how will we know when we are officially no longer shedding virus. PCR testing availability is not yet ramped up in the U.S. on the date of this recording, but we also have not employed serology testing for this in order to tell who has been exposed and who is actively still likely contagious. Common sense prevails still, and adherence to social distancing in all cases, and of course home isolation and quarantine if you have symptoms, tests pending, and exposures to know COVID. And until we massively screen the population to know who has it and who had it, such as in the case of serologies, we won't have a firm handle on the scale of this particular outbreak.
CHAPTER 3: Again, once symptoms have kicked in, we expect to see congestion, fever, cough, essentially URI symptoms. But the pneumonia and severe, even ARDS end of the spectrum is also seen. And the CXR findings may include patchy, interstitial, ground glass appearance, classically scattered in the periphery of the lungs. However, other findings can be seen as well, yet lobar consolidation is still most consistent with CAP bacterial pneumonia, CT has been noted to better detect the subtle pneumonia changes in the lungs, but it's use on a broader scale at this time is not recommended, at least here in the U.S. Remember, CT has a lot more rotation, and even if we pick up abnormalities, many of those patients test negative for COVID-19.
So, we have these hospitalized patients now, and what are we to do in our hospitals? We definitely will be isolating or cohorting our respiratory patients into one particular area of the ED and hospital in general. This will be a fluid process of course.
Identifying who potentially has the disease, for instance in Korea (South) and Singapore, in addition to isolation techniques, very aggressive case finding techniques including PCR testing but also merely checking temperatures, thus helping to enforce isolation and staying out of the public settings. IN Korea and Singapore, for instance, there was much better compliance with the above prescribed preventative measures. Indeed there are regional differences with this outbreak, and are likely due to adherence, resources and cultural differences throughout the world.
Pregnancy and COVID-19 at present has a lot of unknowns. We do not know of vertical transmission at this time, and we do worry about the potential for more severe illness given a mildly immunocompromised state, however thus far, based on the Wuhan experience, there is no data to suggest that pregnant patients will have amore severe course of the illness.
Most hospitalized patients in China, Italy, and elsewhere are inpatients for 7 to 10 days. Although it's not likely that treatment with oxygen at home or a SNF (skilled nursing facility) will not likely be implemented; because the progression of respiratory symptoms and shortness of breath to respiratory failure can apparently happen quickly, and these patients need to be in a medically supervised setting. PCR retesting to determine when someone is not infectious can not be done, as the test will remain positive. If ongoing fevers, of course one should not return to work, school, or otherwise. The jury is till out as to when one can go back onto society after symptoms resolve. In general, there's just not enough data yet to guide us in this. In general, at least a week after symptom and fever resolution may be appropriate, per Dr. Currie, but in Wuhan, for instance, these patients continue to be in quarantine, to the best knowledge for several weeks or more after resolution. Again, we just don't know yet.
CHAPTER 4: Treatment:
Well, this is a pretty easy chapter to summarize. We basically have no specific treatment for this virus yet. COVID-19 trials are under way with chloroquine, and we will need to contact those trial centers to see if it is proving to be effective. Remdesivir could perhaps be used in a compassionate plea use of this and other drugs can be done, along with a lot of paperwork before, during and after treatment. Again, we will see if this is an option, but right now e have do data to go off of, especially in an off-label use. A recent trial was published with lopinavir-ritonavir, which is remarkable in such a .short period of time. It was from China and was unfortunately not shown to be helpful. Preventative measures, outside of maintaining good overall health, have not been shown to be helpful. Vitamin D may theoretically be helpful, but again, no data yet. Steroids have no use in the treatment of COVID-19. No data et either exists in terms of taking patients off of the ACE inhibitors or ARBs. Right now, we are left with conservative measures, fever control, hydration, oxygen and more advanced inpatient support for severe infection, up to and including ventilator and ECMO use. This is a moving target. Panic is not the order of the day, and staying the course with our PPEs, social distancing and other prevention measures such as exceptionally good personal hygiene will hopefully do much to keep ourselves, our loved ones and out patients safe.
CONCLUSION: Thanks again to Dr. Currie for his time and expertise. We wish all of you the best. Be sure to say updated through your particular health system's source of all that is current and changing with this disease as things progress. For Ridgeview listeners, that is on the RidgeNet site, which is always accessible. IN the meantime, to all of our Ridgeview family, and to all of you out there in the world dealing with this pandemic, take good care of yourselves, your loved ones, and indeed, your patients.
Be sure to listen after the end of the podcast to a little ditty by Rich Larson on how we can take the fight to COVID-19. It's "Wash Your Hands". Thanks for the levity and sharing of your talents, Rich!
Stay safe out there friends, and we'll see you next time on Ridgeview Podcast CME Series.
In this podcast, Dr. Rachel Bies, a Pediatrician with Wayzata Children's Clinic, presented at Ridgeview Medical Center's Live Friday CME Series on January 24, 2020. At this event, Dr. Bies talked about the strategies of medical cannabis and CBD in the pediatric population.
Enjoy the podcast!
OBJECTIVES: Upon completion of this podcast, participants should be able to:
- Describe a brief history of medical cannabis.
- Identify potential uses of CBD oil and medical cannabis in the pediatric population.
- Recognize qualifying conditions for the MN Medical Cannabis Program among the pediatric population.
- Confidently discuss CBD or medical cannabis treatment with patients and families.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
Note: CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
In this podcast, Dr. Elliot Francke, an infectious disease physician with Midwest Infectious Disease Consultants (Minneapolis, MN) and head of the Antimicrobial Stewardship Committee at Ridgeview Medical Center. Dr. Francke discusses antimicrobials and how the notion of antimicrobial stewardship came about. Dr. Francke also discusses where we are today with antimicrobials and the trends for the future.
Enjoy the podcast!
Objectives: Upon completion of this podcast, participants should be able to:
- Identify the principles of antimicrobial stewardship and guidelines recommended by IDSA, SHEA, and JCAHO.
- Summarize how stewards help reduce inappropriate antibiotic use, reduce C. difficile rates, and reduce antimicrobial resistance.
CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
(If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)
The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”
FACULTY DISCLOSURE ANNOUNCEMENT
It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.
Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.
SHOW NOTES:
INTRODUCTION: Dr. Francke joins us today to discuss antimicrobials and how the notion of stewardship came about, as well as where we are with this today, and the trends for the future. Infectious disease topics are rapidly evolving, and while this recording happened a few months ago, there are inevitably going to be many updates, so exercise due diligence and read the literature to stay current. Let's jump into antibiotic stewardship with Dr. Elliot Francke.
CHAPTER 1: Good stuff have been discussed so far in this first of three chapters with Dr. Francke! Recapping up to this point...Earlier studies looked at the need for improved use and restriction of antimicrobials back in 1966 in Canada. Understandably, with the suggestion that an ID specialist sign-off on every antibiotic order was cumbersome and not well received Nearly 30 years later, however, two physicians, one name Gerding and another name McKowan were looking at the rise of C difficile, and it was discovered that this proliferation was linked to antibiotic use and misuse. Hence, he coined the term "stewardship". It was borne out of inspiration from a church sermon. Stewardship us not dictatorial, but rather suggestive and guideline oriented, which implores practitioners to "do the right thing" and find the narrowest spectrum agent that has low toxicity and cost optimization. Ultimately this was adopted by CMS and JCAHO as a requirement. The guidelines are published by IDSA and SHEA.
At the end of the 1990s, we were beginning to see resistance to multiple classes of antibiotics. Therefore, if we can limit or restrict to certain antibiotics, the theory is that we can reduce this emerging resistance. However, the literature doesn't actually support this as of yet. The literature does support the reduction of C. diff infection in the setting of limited antibiotic use, however.
The stewardship guidelines aim to educate people to make the best choices. It involves gathering information including resistance patterns, C. diff rates, use indications and cost of antimicrobials. These are reported to the institution, JCAHO and similar organizations. The aim is to be able to compare apples to apples with other facilities in the nation.
Administrative support for stewardship is equally as important as the medical staff's participation. These would include infection control, microbiology personnel, physicians, APPs and nursing staff. Currently, larger health systems are required to have antimicrobial stewardship programs, although in the future, smaller systems, hospitals and clinics will also require this. Collecting data can seem honors, however, these data (i.e. overall antibiotic use, costs, C. diff rates, formulary, resistance rates, etc.) can increasingly be collected from programs within or adapted to existing EMR systems more automatically.
Stay tuned for Part 2 with Dr. Francke, as we take a deeper dive into this issue of stewardship, how it's effectively implemented and enforced.
CHAPTER 2: Time to pause and regroup. Let's summarize Chapter 2 of our antimicrobial discussion with Dr. Francke. EMR currently is a data gathering device, and not used as a decision maker and analyzer as yet, therefore, the members of stewardship committees are and will remain necessary for the foreseeable future. In terms of actual "policing" of prescribing practices, the stewardship committee is not charged with this task. Hospital and institutional P and T committees as well as administration, but also JCAHO, DNV and similar organizations are the elements that actually can and do enforce best practices. Patient education and participation is paramount as well. Employees and staff should also be recruited and "signed-off" as aware and attuned to these best practices. As far as future possible education modalities for patients, we would like to provide a web link within an institution's guest site for patients to explore what they are taking or have received in the hospital.
The head of stewardship programs tend to be infectious disease specialists, however, this tends to be costly. PharmD's now are an increasing popular option for this role. There can sometimes be conflicts of interest with ID physicians being used for this role of chart review, but also and implications of the need for physician "consultation" as well. This program was implemented at ANW and has been a success thus far.
So what happens in a chart review? The ID specialist of PharmD is actually reading the chart, looking for appropriate empiric, therapeutic and prophylactic antimicrobial use. The PharmD follows published guideline recommendations, for instance Sanford and IDSA guidelines are used at our institution, as well as from individual society guidelines. There tends to be upwards of 96% compliance with these guidelines at our institution, actually. And this happened in a short period of time.
The next steps for stewardship are to tie into outpatient centers. But also the need to spotlight the overuse of antimicrobials in agriculture and having broader support in the medical industry, but also governmental agencies and various lobbying organizations. In order to accomplish this, though, education needs to happen and data must be presented in order for big food and big Pharma to adopt better practices in antimicrobial use.
Cost of antibiotics is not quite to the level of chemotherapy or biologics that are out there. We can combat cost by deescalating our antibiotics to the one that is cheapest and most effective after the initial doses of empiric antibiotics are given.
Chapter 3 will discuss more details on stewardship and how this may all play out in the outpatient setting, as well as what looms on the horizon with this topic and infectious disease in general.
CHAPTER 3: Summarizing chapter 3 with Dr. Francke, patients often ask for antibiotics by name. So how do we challenge this reality? First, ask the patient why the want a particular antibiotic. Plainly, we have to tell our patients that we're trying to reduce resistance; and actually show patients online or with educational materials which antibiotic is appropriate and why. Or, why an antibiotic is not actually indicated.
Outpatient antimicrobial stewardship will be an interesting challenge. We will need to rely on guidelines and antibiograms are updated on a yearly basis. Outpatient stewardship will need champions and drivers for this effort to have beneficial effect, and as Dr. Francke states - it will be mandatory in the coming years.
Duration of antibiotic treatment is now being looked at more and more. Will length of treatment affect potential resistance, C. diff rates, etc? Many of the durations of treatment are arbitrary and are borne out of the initial Pharma trials when drugs are at their inception and emerging. At this point, duration of treatment presumptively can lead to resistance, but we simply don't know whether this is a fact.
Candida iris is widely resistant to almost all antifungals. Middle eastern acinetobacter also have significant resistance and increased pseudomonas resistance nationwide. Not a lot of this is seen in our local/metro area, but it's likely to happen.
Testing for infectious organisms with PCR will give us faster answers and provide for rapid deescalation, but is not likely to immediately have impact on drug resistance.
Biologics are an emerging therapeutic as well in the infectious disease world. These will target specific organisms, and effectively use the human immune system to do the work of killing the organism. This is way off on the horizon, though.
Dr. Francke states that people should keep their vaccines up to date, and for the public to take an active interest in their health, use antibiotics, their own gut flora, and the public health issues that relate to antimicrobials. Ask questions of your providers, and your colleagues to help guide what to take and what to prescribe.
CONCLUSION: A huge thanks to Dr. Francke for his time with us, as well as his many years of practice and dedication to the field of infectious disease. And to all of us practicing, let's keep an eye on those guidelines and do our part in this. Buy-in essential and ambivalence is no longer an option.
Thanks for tuning into Antibiotic Stewardship, and we'll see you in a couple weeks here at Ridgeview Podcast CME Series!
This podcast is a reading of the second chapter from the personal memoirs of Edith Nagel Eisinger, wife of Dr. Harold Nagel. In 1936, they founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center.
Enjoy chapter 2 of Edith Nagel Eisinger's story.
In this podcast, Dr. Josh Stein, an adult and child psychiatrist with PrairieCare medical group, and Joe Waller, Operations Director and a licensed graduate social worker with PrairieCare medical group, presented at Ridgeview Medical Center's Live Friday CME Series on January 10, 2020. At this event, Dr. Stein and Joe discussed different treatment levels and modalities that PrairieCare medical group is able to offer. While much of this talk deals specifically with the Ridgeview locale and PrairieCare, it is a good overview of where we are at in our day and age with child and adolescent psychiatric treatment.
Enjoy the podcast!
OBJECTIVES: Upon completion of this podcast, participants should be able to:
- Describe the various effects that trauma has on one's health.
- Identify current trends occurring in mental health.
- Explain at least 3 barriers/challenges to accessing mental health care.
- Identify a minimum of 3 treatment options available in Minnesota.
To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.
CME Evaluation
Note: CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks. You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org.
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SHOW NOTES:
CHAPTER 1: Accessing psychiatric care for our pediatric patients presents a number of challenges. There are many acronyms for our patients receiving care or in need of care. We mention this because it is important to better define these services so that we can navigate the system more appropriately for our patients.
With regard to PrairieCare, the first stage in care is the needs assessment, which really helps to define the level of care our patients will require. As mentioned, this process can be started simply by picking up the phone and calling PrairieCare's number to discuss cases and essentially immediately obtain a psychiatric consultation from Dr. Stein or his partner(s). The triage portion of this consultation is handled by a social worker, such as Joe Waller, who assesses the often complex needs of our child psychiatry patients.
Dr. Stein discusses an average, fairly typical patient he treats in the child psychiatry world. While general psychiatry looks at biologic illness, in the child psychiatry world, much of the diagnoses are quite directly linked to exposure and environment these children are actively experiencing. This particular 9 yo patient he presents to us has experienced exposure in utero, violence at home and witnessing abuse, divorce, limited paternal relationship, differences in parenting, education challenges, living environment changes, and video game overuse to placate behaviors. To further complicate matters, the patient threatens to kill himself, but does demonstrate empathy for others as well. His step-father is of SE Asian descent and the patient experiences barriers to psychotropic medication use and care due to some first generation cultural beliefs. So does this sound like something you can properly manage in the primary care clinic, let alone in an emergency department without resources?
Irritability and agitation tend to be fundamental qualities in child psychiatry. Bronfenbrenner's Ecological theory helps us understand the various systems that make us who we are. We are informed by a microsystem that spreads out from the self. the Chronosystem makes up the outer sphere and informs us based on the time and ear in which we accept things to be "the way they are". We are informed by what is happening in front of us, but also what we have experienced in the past. The Macrosystem is composed of overarching beliefs and values to help inform us as well. For instance, being gay is now accepted as who we are, as opposed to a psychiatric condition, as it was in the 1950s. The exosystem consists of economical, governmental, educational and political systems which tend to also inform us of who we are. For instance, the push for equality in these systems informs us that we are equally capable and worthy. The meso and microsystems involve family, school, peer, and religious affiliation. Finally we get to the "you" part of this system - that is defined by our biology and genetics.
ACEs are adverse childhood events. Parental issues, abuse, assault, medical concerns, etc. all tend to lead to early death from all causes. Impairments increase when ACEs are present. Carious untoward behaviors ensue, such as addiction, promiscuity and eating disorders. Therefore, positive childhood experiences are remedies for these kids, such as participation in sports or activities, having other adult figures who offer positive experiences that an otherwise positive parent would ordinarily provide. As Dr. Stein alluded to in the CDC study, the more ACEs a child has, the more risks (factors) they will take on. Overcoming periodic markers of stress in our childhood helps us to have success in future life stressors or obstacles. From positive stressors like passing a spelling test, to one's first crush on a girl or boy, to writing college essays. Then we have tolerable stressors like job loss, health problems and loss of a loved one. Next are the more dysfunctional, toxic stressors like physical abuse, living with violence, etc. Our ability to maturely handle each of these more minor, typical as well as tolerable life stressors depends on our ability to handle previous lesser positive stressors and so on. In other words, kids who have never learned how to move past and cope with these more basic stressors because of continuous toxic stressors like neglect, poor support, abuse, chemical dependency, violence and a variety of other dysfunctions, will continue to struggle. Many of Dr. Stein's patients are living in a chronically stressed state and therefore agitation and aggression is easily triggered with minimal provocation. Medication often is implemented in order to get a child to a state of being able to learn to address these markers of stress.
Stay tuned for the next chapter, where we will go through some statistics of childhood mental illness, and how we even begin to approach these issue in our patients.
CHAPTER 2: 1/5 of all adults experience mental illness. 20% of all youth live with a mental health condition from ages 13 to18. 70% of kids in the juvenile justice system have at least one mental health condition. At least 20% live with a serious MHD. Less than half of these kids will receive treatment that they actually need. Over 1/3 of students served by special education end up dropping out of school. Suicide is the 2nd leading cause of death between ages 10 and 24. Earlier diagnosis leads to earlier appropriate treatment for children. Approximately 160 people are directly affected by suicide, but a youth suicide will often directly affect hundreds or more.
We are doing a better job than before in schools now of recognizing mental illness. The stigma is gradually being erased and remedied. While social media can and does affect emotional well being, there is ironically an almost therapeutic or empathetic aspect to it. Dr. Stein gives the example of "meme" culture, which offers emotional context and description that is easily recognized and identified with by patients.
Kids are talking more about suicide, and there is evidence of influencing others to consider suicide as well, similar to couples experiencing divorce. Suicide will be of great concern in our suburbs and exurbs. The Native American population in particular will continue to see a rise in this for many of the reasons mentioned in chapter 1 relating to the microsystem discussed.
So what is the goal? We need to connect kids and adults with care when it is needed. An important step is referring for evaluation when we've identified there may be a problem We in the primary care or emergency department setting often are even afraid to ask some of the questions to help identify if there is a mental illness problem, because we have limited time and resources. In general though, we're doing a much better job of screening for mental illness. For instance the schools are actually really doing a great job here. However, problems arise after we've identified an issue. The question is what do we do now? We all have experienced this, right? We want to help our patients but we are challenged by limited access to mental health resources, closed clinics, limitations on the part of the psychiatrist, etc. Sometimes kids are in a vicious cycle of crisis, and crisis aversion, which gets in the way of making progress or even getting them into the system.
Stay tuned for chapter three, where we'll take a deeper dive into what we do next and what actual options we may have for our child and adolescent psych patients. And we'll immerse into the alphabet soup of acronyms in this field. So hold on and tune back in!
CHAPTER 3: Acronyms are abundant in child psychology. CTSS or children's therapeutic services and supports are a great tool for helping to assess and deescalate in the home. But there are many other programs as mentioned by Dr. Stein. Outpatient treatment is of course for patients who are otherwise stable and sage, but need regular visits for therapy and support. Intensive outpatient programs (IOP) are group based therapy programs for ongoing support and transitioning. Partial hospitalization (PHP) is a service that provides care for patients who no longer need to be fully hospitalized (or inpatient care), but they receive during the day intensive therapy, and they're not actually attending their school either, but still doing classwork in the facility. PHP of course is staffed by nurses and physicians. These patients don't meet the safety needs or criteria for impatient care. And they do go home at night with self-support skills, and there is an emphasis on supporting families of the patient. Inpatient hospitalization is fairly self-explanatory and reserved for patients who are unsafe and not thriving with the other mentioned modalities. Finally, residential treatment or RTC, is provided for patients who are well-regulated on medications but still need intensive therapy. PRTF, psychiatric residential treatment facility, is a place for patients to live while they're getting intensive outpatient therapy, but not a hospital, thereby allowing for a more independence and normalcy not found in the hospital.
Residential treatment is actually very difficult to access. These are reserved for patients who are in the vicious cycle of crisis, crisis intervention by police, emergency department visits and repeating this experience over and again. Unfortunately, after inpatient care or partial hospitalization and stabilization patients can sometimes fall between the cracks and not have important outpatient ongoing care and follow-up, therefore the same dysfunctional responses to crises happen, leading the patient right back to where they were just a few weeks ago. Primary care providers must continue to advocate for their mental health patients, and this involves transparency with what was done and planned for regarding their most recent mental health hospitalization. Case management services through the county are also quite valuable for us.
CHAPTER 4: So who are typical patients. Inpatient care's goal is to have a short stay, avert the crisis at hand, and deescalate to other care options. At PrairieCare, a typical inpatient stay is 7 to 10 days. Residential treatment is for children or adults with chronic suicidality, severe biologic illness sand general unsafe existence, and it offers and opportunity to build them up with better coping skills. Partial hospitalization duration of care varies, but remember it is a step down from inpatient care and often with the same physician. With intensive outpatient treatment, there aren't usually the same safety or morbidity concerns as with the aforementioned modalities. It tends to be more common in the adult population. eating disorders as an example are commonly addressed with IOP. IOPs are fairly specific services for patients. Outpatient services are classically 1 or 2 days per week. There may be resistance to this on the part of our patients, but it's important that we push for this. A lot of changes occur in teens' live on a weekly basis as opposed to an adults. 911 for crises is always available, especially when there is risk of harm to self or others. County crisis services are also helpful and available. Also, there is the option of walking in for an appointment. The medical aspect of this service at PrairieCare and Ridgeview is helpful, but so is the social work aspect. The needs assessment of patient care is paramount, and the social workers are instrumental in heading this up. They will often provide resources for specific parental and patient concerns, such as stressors from screen overuse, LGBTQ specific needs, etc. From a medical aspect, we will be supported by the psychiatrist dosing changes, titration, etc. Fast tracker is an important tool that is sponsored by DHS that is updates and provides links and recommendations to services for some's specific locale. It is updated regularly by major and some smaller institutions.
One of the issues of our day is bullying and it's abundance in society now. But it does present a unique challenge for caregivers and providers. In many cases, bullying does not represent toxic or ongoing dysfunctional stress, because many bullied kids have other healthy releases and coping mechanisms. Nonetheless, it can be quite traumatic, especially if not addressed. It is also important to understand the difference between teasing and bullying.
Dr. Stein addresses the concern for access to the system. Essentially, the number is at our disposal, and there are many modalities available to our patients. While it is wonderful to have these options, driving distance must be considered, and we as referring providers have to advocate for our patients with regard to this. Driving 50 to 80 miles round trip for an appointment is not always desirable.
How does the primary care provider address mental health during a well visit? Dr. Stein mentions screening options which will offer some talking points. Discussing social media and its inherent struggles within this subject is also important. Bottom line is that a follow-up appointment may be necessary to address lingering concerns.
This podcast is a reading of the first chapter from the personal memoirs of Edith Nagel Eisinger, wife of Dr. Harold Nagel. In 1936, they founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center.
Enjoy the podcast.