Funtabulously Frivolous Friday Five 156

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 155

Question 1

What is the story behind the Cochrane logo?
cochrane

    • The forest plot within the logo shows one of the first meta analyses done by Cochrane. It was showing the benefit of corticosteroids given to women who are about to give birth prematurely.
    • Despite several trials showing the benefit of corticosteroids, adoption of the treatment among obstetricians was slow. The originally systematic review published by Crowley et al (and subsequently updated) was influential in increasing use of this treatment. This simple intervention has probably saved thousands of premature babies. [Reference]

cochrane logo 2

Question 2

You are doing some home decorating and decide to paint the north wing of your house red. You partner pulls out a colour chart from your bag but what is this chart really used for?
colour chart

  • It is a bed side colour chart to detect the level of methaemoglobin (%)
  • Classically the blood drawn is of a chocolate brown colour.
  • You should match a sample of the blood on tissue or filter paper within 5 minutes of taking the sample. [Reference]

Question 3

What dermatological condition gives you the seven year itch?

  • Okay, arguably a lot of dermatological things might make you itch for 7 years but it has been classically been associated with scabies. [Reference]

Question 4

What is scrivener’s palsy?

  • Otherwise known as writers cramp, a neurological condition caused by frequent handwriting. [Reference]

Question 5

What metabolic disorder couldn’t Hannibal Lecter have had?
Hannibal

  • Glucose-6-phosphate dehydrogenase deficiency; he has a liking for liver with Fava beans!

Last update: Aug 26, 2016 @ 5:39 pm

The post Funtabulously Frivolous Friday Five 156 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 148

Research and Reviews in the Fastlane

Welcome to the 148th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Emergency Medicine
R&R Hall of Famer - You simply MUST READ this!

Taylor RA et al. Determination of a Testing Threshold for Lumbar Puncture in the Diagnosis of Subarachnoid Hemorrhage after a Negative Head CT: A Decision Analysis. Academic emergency medicine. 2016. PMID: 27378053

  • Test thresholds are an essential concept in emergency medicine, but have really only taken hold in PE workups so far. This group attempts to weigh the harms and benefits of LP after negative CT for subarachnoid haemorrhage and come up with a test threshold of 4.3%. This means that we are doing more harm than good by testing anyone with a pre-LP likelihood of disease less than 4.3% – which is almost everyone after a negative CT. (Look at figure 3 in the paper for more detail.) That being said, there are a lot of assumptions that go into a number like this, so don’t expect it to be exact. Interestingly, another team published on the same topic in the same issue, and also came up with a test threshold of 5%:
    Carpenter CR et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and Lumbar Puncture with an Exploration of Test Thresholds. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2016. PMID: 27306497
  • Recommended by Justin Morgenstern

The Best of the Rest

Emergency Medicine
R&R Game Changer? Might change your clinical practiceRubin LG, Schaffner W. Clinical practice. Care of the asplenic patient. The New England journal of medicine. 371(4):349-56. 2014. PMID: 25054718

  • A great review and reminder to us all that asplenic patients (whether surgical, functional, or congenital) are at VERY high risk when they present with fever. According to the authors, they should ALL be antibiosed and brought into the hospital as their presenting symptoms may be isolated to fever alone, or otherwise mild. These are the well appearing patients who can deteriorate rapidly. The authors also remind us that sickle cell patients are functionally asplenic after age 1 and anatomically asplenic due to autoinfarction after age 6-8.
  • Recommended by Jeremy Fried

Quirky, weird and wonderfulR&R Hot Stuff - Everyone’s going to be talking about this
Berg R. The hardships of being a Sith Lord: implications of the biopsychosocial model in a space opera. Advances in Physiology Education 2016 Vol. 40 no. 2, 234-236 PMID: 27105743

  • Have you ever wondered about the cause of Darth Vader’s progressive decline in pulmonary function? In this paper the authors consider the mental and physical impact of the severe psychosocial stress that Darth Vader is exposed to as a high-ranking official in the Galactic Empire. Just wonderful nerdy reading….by the way, did you know that the estimated cost of the Death Star is at least $850 quadrillion in steel alone!
  • Recommended by Soren Rudolph

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about this
Chauny JM et al. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Emerg Med 2016. PMID: 27473443

  • Do we need to observe and re-scan patients with minor head trauma on anticoagulants who have negative initial NCHCTs? This systematic review and meta-analysis says probably not. The authors identified 7 studies with about 1600 patients and found that the incidence of new ICH 24 hours later was 0.60% with resulting neurosurgical intervention occurring in just 0.13% of patients. Admitting and observing all these patients doesn’t make sense but consider it in patients who can’t get back to the hospital quickly if they get worse, those who are over-anticoagulated, those with multiple comorbidities and those on multiple antiplatelet/anticoagulant medications.
  • Recommended by Anand Swaminathan

Research and Critical AppraisalR&R Eureka - Revolutionary idea or concept
Kaplan RM, Irvin VL. Likelihood of Null Effects of Large NHLBI Clinical Trials Has Increased over Time. PLoS ONE. 2015;10(8):e0132382. PMID: 26244868


Education
R&R Eureka - Revolutionary idea or concept
Morrow DS et al. Versatile, Reusable, and Inexpensive Ultrasound Phantom Procedural Trainers. Journal of ultrasound in medicine. 35(4):831-41. 2016. PMID:26969595

  • Medical training equipment is often ridiculous expensive, but hands on training is important and real patients are in short supply. This is a great paper that describes the use of ballistic gel to cheaply create a ultrasound trainers for vascular access, lumbar puncture, and abscess I&D
  • Recommended by Justin Morgentern

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: Aug 25, 2016 @ 3:43 am

The post Research and Reviews in the Fastlane 148 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 245

LITFL review

Welcome to the 245th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick Cummins

Kidney-directed resuscitation. A flood of wisdom and evidence appraisal from Pulmcrit. Enter the world of renoresuscitation. [JS]

Matthew Mac Partlin gives his own brief take on the VANISH trial on the Intensive Care Network, and asks the question: What will you do? [SO]

 The Best of #FOAMed Emergency Medicine

  • More on the fragility index. This time, Emergency Medicine PharmD takes a look at the ECASS III trial. [AS]
  • REBEL EM reviews the very real and likely underdiagnosed euglycemic DKA. [AS]
  • The Bottom Line review the Subtle STEMI trial, helping us all better differentiate between early depolarisation and true ST elevation. [SO]
  • Emdocs put up a great summary on Non-invasive ventilation, explaining CPAP, BiLevel, and their indications. Nice work! [SO]

The Best of #FOAMed Resuscitation

The Best of #FOAMus Ultrasound

  • A great podcast from CRACKcast on Major Trauma, covering everything from primary survey to investigations, management and disposal [SL]

The Best of #FOAMped Paediatrics

The Best of #FOAMim Internal Medicine


The Best of Medical Education and Social Media

  • Rich Carden gives a short primer on Bayesian thinking and it’s relevance to EM over on St. Emlyn’s this week. [AS]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

Last update: Aug 22, 2016 @ 8:01 am

The post LITFL Review 245 appeared first on LITFL: Life in the Fast Lane Medical Blog.

JellyBean 046 with Ruth Bird

A sports mad yet sensible woman. It’s @DrRuthBird from #SMACCdub
(She turned down free beer, paid for by @precordialthump, in order to talk to me and thus talk to you.)

Sport! More sport! The Rio Olympics are in full flow. The European Football season has started. That means thousands and thousands of people all crammed into stadia all over England, Spain, Italy and so on. (Mostly men & not necessarily the fittest blokes.)

If you put thousands and thousands of people in a big concrete bowl and get them stressed things happen. Ruth Bird has been the Crowd Doctor at Fulham FC for 4 years. She is not responsible for the team and thus not even slightly responsible for them getting relegated in 2014. So whats that like? And how? And why?

Turns out this sport mad doctor has a far from mad plan. She has been building her contacts and experience in the Pre-Hospital Medicine world. Ruth has branched out into the motorsport world. She has been mixing business and pleasure by finding ways to use her skills in many different poorly controlled environments. It is all much more sensible than you might think. Ruth gives us a bit of an insight into the fun things she does and the very serious things that she is hoping to do. Ruth is applying for one of the very few UK Pre-Hospital Emergency Medicine Specialty Training Posts in one of the many great Aeromedical/Pre-Hospital Medical Services across the country traditionally known as the United Kingdom.

Coming to a major event near you and possibly by helicopter; it’s a bird, it’s a plane… it’s… no I was right the first time its a Bird. Dr Ruth Bird.

P.S. The on field doctor that I refer to in this Jellybean is Eva Carneiro (Sorry for my mispronunciation of her Portuguese name.) There’s another interesting woman in a male dominated world. Dr Carneiro was abused by Jose Mourinho for doing her job at Chelsea Football Club and the rest is history. Eventually Jose climbed down. Eva didn’t. There is a lot to that case but heres my take home message; don’t behave like a sexist pig and you won’t have to apologise and hand over millions of ponds/euros/dollars.

P.P.S. Anyone who remembers the infamous Diastole and Systole medical student houses out behind the old Royal London Hospital please feel free to share any stories. (Perhaps change the names to protect the innocent?) (If there were any innocents?)

JellyBean Large

Last update: Aug 19, 2016 @ 2:25 pm

The post JellyBean 046 with Ruth Bird appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 147

Research and Reviews in the Fastlane

Welcome to the 147th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Trauma
R&R Hall of Famer - You simply MUST READ this!

Carrick MM et al. Intraoperative hypotensive resuscitation for patients undergoing laparotomy or thoracotomy for trauma: Early termination of a randomized prospective clinical trial. J Trauma Acute Care Surg. Volume 80, Number 6 PMID: 27015578

  • Hypotensive resuscitation is one of the pillars of damage control resuscitation in the bleeding trauma patient. Maintaining a just sufficient mean arterial pressure (MAP) with limited fluid resuscitation until hemorrhage control is considered standard of care although this practice is largely based on animal studies with no high level evidence other than a non-blinded semi-randomized study by Bickell et al in 1994 (also known as the “Mattox trial”). In a single-institution RCT the Mattox group extended the limited fluid resuscitation beyond the trauma bay into the OR. The study was originally including both blunt and penetrating trauma patients, but at interim analysis concerns were raised about a disproportionate number of blunt trauma patients being randomized. To eliminate this confounding effect, the decision was made to stop enrolling blunt trauma patients.  A total of 168 patients undergoing laparotomy or thoracotomy for penetrating trauma with SBP of 90 mm Hg or lower were randomized to either a minimum MAP of 50 mmHg (LMAP) or MAP of 65 mmHg (HMAP) at which further specific resuscitative interventions (e.g., fluids, transfusions or vasopressors) were administered. Primary outcome was 30-day mortality.  The trial was terminated early and therefore was underpowered and failed to demonstrate that a MAP of 50 mmHg could significantly improve 30-day mortality. Despite the lack of statistical significance there was a 5% difference in mortality favoring the hypotensive group. Furthermore the study suggests that maintaining a MAP of greater than 50mmHg is far easier than to maintain one that is greater than 65 mm Hg supporting the theory of autoregulation as proposed by Dutton.  The authors concluded that hypotensive resuscitation is safe in the penetrating trauma population and it does not increase end organ damage, infectious complications or coagulopathy.
  • Recommended by Soren Rudolph

The Best of the Rest

Emergency Medicine
R&R Eureka - Revolutionary idea or conceptSchou-Jensen K et al. [An ordinary condom can be used for removing encircling metallic objects around penis]. Ugeskrift for laeger. 178(32):. 2016. PMID: 27507030

  • Self- insertion of the penis in various ring shaped foreign bodies, usually for sexual gratification and auto-eroticism especially during male masturbation, is an unusual but important condition which EM docs and urologists will encounter. In this report two cases where a new method for removing encircling objects from the penis using a ordinary condom was applied. The article in danish with a short abstract, but sufficient self explanatory images are provided.
  • Recommended by Soren Rudolph

ResuscitationR&R Game Changer? Might change your clinical practiceR&R Hot Stuff - Everyone’s going to be talking about this
Laina A et al. Amiodarone and cardiac arrest: Systematic review and meta-analysis. Internat J Cardiol 2016; 221: 780-8. PMID: 27434349

  • Amiodarone is dead in the dead! The recent ALPs trial in the NEJM grabbed headlines showing that there was no difference in survival to discharge in OHCA patients who got amiodarone versus lidocaine versus placebo. This systematic review and meta-analysis looked at 4 RCTs and 6 observational studies and found that while amiodarone increases survival to hospital admission, it doesn’t change survival to discharge or good neurologic outcomes. Another nail in the coffin for amiodarone.
  • Recommended by Anand Swaminathan

Toxicology
R&R Game Changer? Might change your clinical practice
Coorg et al. Clinical presentation and outcomes associated with different treatment modalities for pediatric back scorpion envenomation. J Med Tox 2016. PMID: 27487782

  • The high cost of scorpion antivenom has led some PEM physicians to treat with supportive care alone or to use off label dosing in single vial increments instead of the recommended three vial loading dose. This retrospective review showed no difference in outcomes between these strategies. Significant differences in envenomation severity between the groups, however, suggests that this most likely reflects the ability of experienced PEM physicians to select the appropriate patient for each strategy.
  • Recommended by Meghan Spyres

TraumaR&R Hot Stuff - Everyone’s going to be talking about this
Sheridan RL. Fire-Related Inhalation Injury. N Engl J Med. 375(5):464-469. 2016.

  • A great review of all things related to fire inhalation injury, for both the clinician in the emergency department as well as the ICU.  Key points included:
    • Remember to consider concomitant carbon monoxide and cyanide exposure
    • And contrary to what I was often told early in training, “The presence of inhalation injury does not mandate intubation.” The authors instead remind us that intubation should be immediately considered in patients “who have facial edema, hoarseness, or stridor or in patients with large cutaneous burns in whom facial edema is likely to develop with resuscitation.”
  • Recommended by Jeremy Fried

Emergency Medicine
R&R Game Changer? Might change your clinical practice
Welch JL, Cooper DD. Should I Use Lidocaine With Epinephrine in Digital Nerve Blocks? Annals of emergency medicine. 2016. PMID:27125816

  • By now, most people have heard that epinephrine is safe in digital blocks – but a common question is why would you want to use it? In this systematic review, they found that using epinephrine resulted in longer anaesthesia and less bleeding. Although not critical, those advantages have me routinely reaching for the epi when working with digits.
  • Recommended by Justin Morgentern

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: Aug 18, 2016 @ 1:21 am

The post Research and Reviews in the Fastlane 147 appeared first on LITFL: Life in the Fast Lane Medical Blog.