Funtabulously Frivolous Friday Five 103

Funtabulously Frivolous Friday Five 103

Question 1

Who was de Musset, and why do we still refer to him?

  • Alfred de Musset (1810-1857) was a French romantic poet and playwright.
  • His brother remarked to him that his head regularly nodded and de Musset reportedly stopped it temporarily by placing his thumb and forefinger on his neck.
  • de Musset’s sign is one of the clinical findings of aortic regurgitation.

Question 2

In Britain Hoover this is a common brand of vacuum cleaner and the Americans have a dam with the same name, but what does ‘Hoover’s sign‘ mean to neurologists?

  • Hoover’s sign is used to help determine if leg paresis is organic or not.
  • Placing a hand under the heel of the non-affected leg, the examiner asks the patient to raise the weak leg.
  • With a genuine (organic) deficit, you would expect to feel the normal heel push down as the weak leg attempts to rise.
  • In functional (non-organic) weakness, there is no movement of the normal heel.
  • Dr Charles Franklin Hoover (1865–1927), a physician in Cleveland, Ohio, described his useful principle and two tests in the Journal of the American Medical Association in 1908
  • Read full description by Jon Stone and Michael Sharpe. Hoover’s Sign. Practical Neurology 2001.[PDF]

Hoover Sign

Question 3

What is erythema ab igne and why is it making a comeback?

  • The translation of this dermatological term is “redness from fire“.
  • It was most commonly associated with an older population applying hot water bottles to the skin to reduce pain.
  • However, there are an increasing number of case reports in a younger demographic secondary to heat exposure from laptops and other electronic device (toasted skin syndrome)
  • Laptop-induced erythema ab igne: Report and review of literature. Riahi RR, Cohen PR
  • Arnold AW, Itin PH. Laptop Computer–Induced Erythema ab Igne in a Child and Review of the Literature
Hot water bottle induced erythema ab igne

Hot water bottle induced erythema ab igne

Laptop induced erythema ab igne

Laptop induced erythema ab igne

Question 4

Your elderly patient is concerned that she is going crazy because she keep seeing “little people” scurrying around the house. Given that she lives alone, what might this be?

  • Charles Bonnet Syndrome
  • A form of visual hallucination that relates to severely impaired vision rather than mental illness.
  • Typically patients will describe seeing small people or objects and be aware that they are not real.
  • Charles Bonnet (1720-1793) first noted this phenomenon in his elderly grandfather who suffered from bilateral cataracts and regularly claimed to witness ‘men, women, birds, physically impossible circumstances and scaffolding patterns
  • C. Bonnet: Essai analytique sur les facultés de l’âme. Copenhagen, 1760

Question 5

What is the Will Rogers phenomenon?

  • The Will Rogers phenomenon is an epidemiological paradox that occurs when moving an element from one set to another set raises the average values of both sets.
  • The best example is Sir Robert Muldoon’s (former Prime Minister of New Zealand) response to a query about trans-Tasman migration:
“New Zealanders who emigrate to Australia raise the IQ of both countries.”
  • The ‘Will Rogers phenomenon‘ is named after a remark made by the humorist Will Rogers who had similar views to Muldoon about migration from Oklamhoma to California during the American economic depression of the 1930′s.
  • The name was proposed in 1985 by Alvan Feinstein to describe the ‘stage migration’ he observed in patients with cancer. It has since been described as occurring ina many conditions, including multiple sclerosis with the advent of the imaging-assisted McDonald criteria.
  • The phenomenon is dangerous as improvements in prognosis over time may be spuriously attributed to treatments rather than stage migration.

 

…and always remember

depression

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TechTool Thursday 057 iNIV

TechTool review iNIV by Gecod s.r.l Apps on iOS

iNIV was developed by a team of Emergency Doctors in an Italian hospital. It aims to guide acute care staff in managing non-invasive ventilation effectively, and to provide practical education around NIV use in general

Website: – iTunes

Design

The app icon and overall graphics work well. The font style and colour make the text very easy to read. However there is something very un-Apple about the design. There are buttons and navigation in unusual places, so it’s not immediately intuitive to use on the iPhone. It’s hard to pinpoint the issue here, but when using the app, it feels like you are jumping around the content and that it doesn’t flow smoothly.

User Interface

iNIV 1

iNIV 2

iNIV 3

Clinical Content

The app contains a large volume of educational material and covers iNIV in detail.

  • NIV basics including physiology, indications, oxygen therapy, and equipment
  • Practical advice on setting up and starting NIV
  • How to troubleshoot and problem-solve
  • Case histories with quizzes and images

Cost

  • $9.99 – this is a reduced price until the end of September.
  • …pricey, but you are paying for a lot of material, so not unreasonable

Room for improvement

  • A rethink of the navigation could make it a simpler user experience
  • A search function would be useful

Overall

This is a great comprehensive handbook on NIV in emergency situations and it is a useful reference app to have on your phone. With just a few changes to the navigation and flow of the app, it would be well worth its price tag.

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The LITFL Review 150

LITFL review

The LITFL Review is 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.

Welcome to the 150th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerThe ripper this week is taken out by EMRAP crew offers up a mini episode on ebola via their free Hippo EM blog and podcast. It gives us the nuts and bolts about what we need to know about ebola! [MG] [KG]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

#FOAMTox Toxicology

#FOAMPed Paediatrics

  • Croup season is just a couple months away (at least in the US). Great review of the diagnosis and management of croup from Don’t Forget the Bubbles. [AS]
  • A succinct summary of the evidence on clearing c-spines in children at Clinical Monster. [TRD]
  • Sean Fox at Pediatric EM Morsels covers a difficult topic for paediatric doctors – eating disorders. [TRD]
  • All things pediatric asthma in one place. Andy Sloas finishes up his asthma series reviewing EtCO2, BiLevel, Intubation and Vent Strategies in sick asthmatics. [AS]

News from the Fast Lane

Reference Sources and Reading List

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Research and Reviews in the Fastlane 045

Research and Reviews in the Fastlane

Welcome to the 45th 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 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan 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, Education

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

Scott KR et al. Integration of Social Media in Emergency Medicine Residency Curriculum. Ann Emerg Med 2014 PMID: 24957931

  • Social media and FOAM have changed and influenced our clinical practice. This paper highlights the basics as well as the barriers and challenges. It’s an outstanding look at the cutting edge of how residencies are using social media and FOAM content in their curriculum. The revolution is happening!
  • Recommended by: Sa’ad Lahri, Jeremy Fried

The Best of the Rest

Wilderness Medicine, Infectious Diseases

R&R Game Changer? Might change your clinical practice

Nadelman RB et al. Tick Bite Study Group. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001 Jul 12;345(2):79-84. PMID: 11450675. (OPEN ACCESS ARTICLE)

  • The RCT that showed you can prophylax people with a single dose of doxycycline after removal of a deer tick.
  • Recommended by: Justin Hensley
  • Read more: So You’ve Pulled Off A Deer Tick (Justin Hensley)

Resuscitation, Critical Care

R&R Landmark paper that will make a difference
R&R Game Changer? Might change your clinical practice

Guerin C et al. Prone positioning in severe acute respiratory distress syndrome. NEJM 2013; 368: 2159-68. PMID: 23688302 (OPEN ACCESS ARTICLE)

  • In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality.
  • Recommended by: Salim Rezaie

Resuscitation, Critical Care

R&R Game Changer? Might change your clinical practice
R&R Hot Stuff - Everyone’s going to be talking about this
Beitler JR. Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis. Intensive Care Med 2014;40(3):332-341 PMID: 24435203

  • Overall, prone positioning was not associated with a lower mortality rate. However, in low baseline tidal volume subset, there was a reduced mortality rate. With longer and longer waiting times for ICU patients to go to an ICU bed, is this intervention ready for incorporation into ED practice?
  • Recommended by: Anand Swaminathan

Psychiatry, Emergency Medicine
R&R Eureka - Revolutionary idea or concept

Olfson M et al. Focusing suicide prevention on periods of high risk. JAMA. 2014; 311(11):1107-8. PMID: 24515285.

  • In this opinion piece in JAMA, Dr. Olfson laments the rising rate of suicide deaths, and, because of the shortage of mental health professionals, calls on emergency practitioners to augment their skillset in recognizing and managing patients at risk for self-harm. He is specifically concerned that when consultant psychiatry services are not available, emergency providers will focus on the medical aspects of care (trauma, ingestion, etc) and not adequately address the psychiatric/social concerns that in one study led to death in 0.9% of patients who presented to the ED with self-harm within three months.
  • Recommended by: Reuben Strayer

Critical Care
R&R Boffintastic - High quality research

Clay AS. Hyperammonemia in the ICU. Chest 2007; 132(4): 1368-78. PMID: 17934124

  • So the ammonia level is elevated …. What do I do with that nugget of information? Well, you could read this review article and become the resident hyperammonaemia guru for a little while. It’s an easy read and quite practical.
  • Recommended by: Matt MacPartlin

Resuscitation, Cardiology

R&R Game Changer? Might change your clinical practice
Littmann L et al. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Med Princ Pract. 2014; 23(1): 1-6. PMID: 23949188.

  • Wow – an actual practical algorithm for dealing with PEA in the Resus room. Easy decision points with ECG and bedside US.
  • Recommended by: Casey Parker

Critical Care, Respiratory

R&R Eureka - Revolutionary idea or concept
Costa EL et al. Electrical impedance tomography. Curr Opin Crit Care. 2009 Feb;15(1):18-24. Review. PMID: 19186406.

  • Electrical impedance tomography. (EIT) is seriously cool. If you look after mechanically ventilated patients you’ll be amazed at the potential this technology has for real-time assessment of lung ventilation and perfusion. Time will tell if use becomes widespread.
  • Recommended by: Chris Nickson

Emergency Medicine

R&R Hot Stuff - Everyone’s going to be talking about this
Shanafelt TD et al. Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population. Arch Int Med 2012: 172: 1377-85. PMID: 22911330.


Emergency Medicine, Gastroenterology

R&R Game Changer? Might change your clinical practice

Coxib and traditional NSAID Trialists’ (CNT) Collaboration, Bhala N et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analysis of individual participant data from ranomised trials. Lancet 2013; 382: 769-79 PMID: 23726390

  • When compared to placebo, coxibs (COX-2 inhibitors), diclofenac and ibuprofen all increased the risk of major coronary events but naproxen did not. While none of these medications are “safe” from a gastrointestinal bleeding standpoint, is this evidence that we should move away from ibuprofen and towards naproxen?
  • Recommended by: Anand Swaminathan
  • Read More: All NSAIDs are created equally . . . right? (Anand Swaminathan)

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.

The post Research and Reviews in the Fastlane 045 appeared first on LITFL.

The LITFL Review 149

LITFL review

The LITFL Review is 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.

Welcome to the 149th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerMRI when applied to patients with cervical spine tenderness and negative CT scans finds abnormalities but it’s unclear if these findings are clinically significant. Rory Spiegel delves into the issue in his latest post A Secondary Analysis of the Adventure of the Crooked Man. [AS]From SMACC Gold, “Punk Rock, Top Gun, and the Resus Room” discusses the parallels between music, combat aviation, and emergency medicine. (direct) [MG]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

#FOAMTox Toxicology

  • Obsessed by spiders, snakes and sharks??  Don’t forget the lowly scorpion.  The Poison Review discuss a recent review article on Scorpion Envenomation, with an unforgettable video showing the effects of neuromuscular toxicity.  [CC]

News from the Fast Lane

Reference Sources and Reading List

The post The LITFL Review 149 appeared first on LITFL.

Research and Reviews in the Fastlane 044

Research and Reviews in the Fastlane
Welcome to the 44th 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 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan 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, Cardiology
R&R Hall of Famer - You simply MUST READ this!
Nuotio I, Hartikainen JE, Grönberg T, Biancari F, Airaksinen KE. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA. 2014 Aug 13;312(6):647-9. PMID: 25117135

  • This is an interesting research letter suggesting that we might be a little bit “button happy” with our defibs in the case of new onset AF. I’ve always been a big fan of DCC for new AF and assumed that the “within 48hrs” was a useful protection against stroke. This small research letter (with 5000 cardioversions) suggests the rate of thromboembolism might be as high as 1% in the first 30 days following unanticoagulated DCC. As it’s only a research letter there’s not much details in the way of methods but gives pause to think before you charge. Especially considering that rate control and anticoagulation seems to produce the same outcomes. Hat tip to @drjohnm for the link
  • This retrospective review challenges the widely accepted concept that patients with recent onset atrial fibrillation of less than 48 hours duration are safe for cardioversion without preceding anticoagulation. The authors report a 1.1% risk of thromboembolism after symptoms have been going for greater than 12 hours (vs 0.3% in the < 12 hour group). Before practice is completely changed, though, it should be noted that the rate of CVA after cardioversion in anticoagulated patients (3 weeks of therapeutic anticoagulation) may be as high as 0.8%. Additionally, this study suffers from the standard flaws of all retrospective studies. More research is needed to help answer this question and guide management.
  • Recommended by: Andy Neill, Anand Swaminathan
  • Read More: Shocking AF — What’s the rush? (Dr John M), Should the 48-hour Cardioversion Window Be Revised? (EM Literature of Note)

The Best of the Rest

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about this
Courtney DM et al. Prospective multicenter assessment of interobserver agreement for radiologist interpretation of multidetector computerized tomographic angiography for pulmonary embolism. J Thromb Haem 2010; 8: 533-9. PMID 20015156

  • This study looks at the agreement between radiologists in reading CTPAs for pulmonary embolism. They found that more than 10% of studies initially read as positive were later read as either negative or indeterminate. Many of the change in read occurred in subsegmental embolisms. This study throws further doubt on starting patients on long term anticoagulation based on the presence of a subsegmental pulmonary embolism.
  • Recommended by: Anand Swaminathan

Education

Raemer DB. Ignaz semmelweis redux? Simul Healthc. 2014 Jun;9(3):153-5. PMID: 24401925

  • As a rabid in situ simulationist it is good to be tempered now an then by a brilliant article. Dan Raemer, one of the many sim gurus from the Center for Medical Simulation and Harvard Medical School, writes about the pros and cons of in situ simulation. The cons provide food for thought.
  • Recommended by: Chris Nickson

Critical Care

R&R Hot Stuff - Everyone’s going to be talking about this


Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care. 2014 PMID: 25110606

  • If the author doesn’t make you want to read this, then the title will. Paul Marik’s talk on EMCrit took the FOAMiverse by storm – this article is really the distillation of his ideas about over-resuscitation, chloride toxicity and the uselessness of the CVP for assessing euvolaemia. IT is typically iconoclastic and persuasive. A word of caution, ideas like chloride being toxic are far from proven and though they may well turn out to be true we should guard against creating new dogma before the truth is really known.
  • Recommended by: Chris Nickson
  • Listen to more: Fluids in Sepsis, A New Paradigm – Paul Marik (EMCrit)

Resuscitation

R&R Hot Stuff - Everyone’s going to be talking about this

Driver BE, Debaty G, Plummer DW, Smith SW. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014 PMID: 25033747

Critical Care, Cardiology


Antonucci E, et al. Myocardial depression in sepsis: from pathogenesis to clinical manifestations and treatment. J Crit Care. 2014 Aug;29(4):500-11. PMID 24794044

  • An awesome bench to bedside review, summarizing the basics of the pathogenesis, diagnosis, and treatment of myocardial depression in sepsis.
  • Recommended by: Sa’ad Lahri

Resuscitation


Heradstveit BE, Heltne JK. PQRST – A unique aide-memoire for capnography interpretation during cardiac arrest. Resuscitation 2014 PMID 25063372

  • End tidal CO2 monitoring has become a mainstay in resuscitation. This article gives a mnemonic device for applying capnography during resuscitation. This tool can help bridge the gap from theory to application for many practitioners.
    P – Position of the tube
    Q – Quality of compressions
    R – Return of spontaneous circulation
    S – Strategy for further treatment
    T – Termination of resuscitation
  • Recommended by: Anand Swaminathan

Critical Care, Haematology, Infectious Disease


Rohde JM, et al. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA. 2014 PMID: 24691607

  • A meta analyses providing further evidence for a restrictive PRBC transfusion policy as those patients in liberal groups were more likely to acquire hospital associated infections. A goal of Hb <7 provided a NNT of 20 to reduce infection.
  • Recommended by: Jeremy Fried

Haematology

Sezik S, Aksay E, Kılıç TY. The Effect of Fresh Frozen Plasma Transfusion on International Normalized Ratio in Emergency Department Patients.  J Emerg Med. 2014 Jul 26. pii: S0736-4679(14)00636-2. doi: 10.1016/j.jemermed.2014.04.042. [Epub ahead of print] PMID 25074780

  • Fresh frozen plasma (FFP) is commonly used to reverse elevated international normalized ratios (INRs) in patients with coagulopathy and trauma or anticipated procedures.  While prior studies and recommendations have demonstrated that FFP does not reduce the iNR below 1.7, FFP is often given to patients with minimally elevated INRs.  This cross-sectional retrospective study of 87 patients who received FFP and had their INR re-checked within 6 hours found that the degree of improvement in INR is greatest in those with the most elevated INRs. They found the following reductions in INR per unit of FFP:
    INR <2:  0.03
    INR 2-5: 0.77
    INR 5-9: 2.14
    INR 9-12: 4.63
    The study has limitations and correcting numbers isn’t the same as fixing patients, but it’s good to know the gains of an intervention, especially as transfusions have associated risks.
  • Recommended by: Lauren Westafer

Emergency Medicine, Imaging


Carpenter CR, et al. Adult scaphoid fracture. Acad Emerg Med 2014; 21: 102-121. PMID 24673666

  • In this systematic review, only the absence of snuff box tenderness to palpation had an adequate negative likelihood ratio (- LR = 0.15) to affect management. MRI was found to be better than bone scan, CT or ultrasound for the diagnosis. This is in stark contrast with traditional teaching that only MRI can rule out occult scaphoid fractures in the acute setting.
  • Recommended by: Anand Swaminathan

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.

The post Research and Reviews in the Fastlane 044 appeared first on LITFL.