Funtabulously Frivolous Friday Five 173

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 173.

Question 1

What arm do most people hold their babies?

  • The Left
  • The phenomenon, which is called left-side bias or left-cradling bias, encourages the right side of the brain to process emotions and ability to monitor the baby. It occurs 70-85% of the time in humans.
  • However, humans are not unique other mammals do the same including feral horses, Pacific walrus, Siberian tundra reindeer, saiga antelope, muskox, eastern grey kangaroo and red kangaroo. [Reference]

Question 2

If you were a psychiatrist what pathology might you find in 100 acre wood (Whinnie the Pooh)?

    • Shaken bear syndrome / OCD / ADHD
    • See the table below for a full list from these Canadian Authors and click on the reference for the full witty journal. [Reference]

Question 3

What are Mee’s lines?

    • White lines of discolouration across the nails, described by Dr Mees a Dutch physician in 1919 (although noted in previous years by Reynolds in 1901 and Aldrich in 1904).
    • They can appear after an episode of poisoning with arsenic, thallium or other heavy metals. They also occur in patient with renal failure and patients on chemotherapy.  [Reference]

Mee’s lines in a chemotherapy patient

Question 4

What is phonism?

  • No it’s not a prejudice against someones phone, it’s an auditory sensation produced by a stimulus of another sense e.g. taste, smell. [Reference]

Question 5

Why did Dixon of Dock Green subject himself to bee-stings?

  • As treatment for rheumatoid arthritis.
  • The actor Warner, was getting elderly and looking increasingly implausible in uniform. He had increasing difficulty moving about, which was helped slightly by a treatment involving bee stings [Reference]

Last update: Jan 20, 2017 @ 3:27 pm

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Research and Reviews in the Fastlane 169

Research and Reviews in the Fastlane

Welcome to the 169th 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 5 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!
Motov S et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2016. PMID: 27993418

  • What’s the therapeutic ceiling for ketorlac? According to this high-quality RDCT it’s just 10 mg IV, not the 30 mg that we typically use. Without added benefit at higher doses, all we’re left with is the increased risk of side effects and harm. Without any good evidence speaking to the necessity of higher doses, it’s time to drop our dose down when using this drug.
  • This well done study examined the analgesic effect of ketorolac at 3 different doses for patients presenting to the emergency department with abdominal pain, flank pain, musculoskeletal pain, or headache. Doses of 10mg, 15mg, or 30mg were administered in a convenience sample, and the authors found no difference in pain relief. In the absence of any increased benefit, all that is left is potential harm in providing doses higher than the apparent analgesic ceiling of 10mg and all practitioners should consider using that as their standard dose in the future.
  • The ceiling analgesic dose of ketorolac is 10 mg – IV or IM. This study confirms this dosage for acute pain in the ED. This was an RCT of ED patients with acute (<30 days) of musculoskeletal, flank, abdominal, or head pain rated at least 5/10. The authors set out to examine mean difference in pain scores between 10mg IV, 15 mg IV, and 30 mg IV and, unsuprisingly, they found no significant difference between mean pain scores. These results are consistent with prior literature and, given side effects of NSAIDs tend to increase in a dose related fashion, it’s a good idea to give the 10mg dose a try.
  • Recommended by: Anand Swaminathan, Jeremy Fried, Lauren Westafer

The Best of the Rest

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about thisFreund Y et al. Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department. JAMA 2016. doi:10.1001/jama.2016.20328

  • In 2016, the Sepsis-3 criteria were launched shifting our definition of sepsis to life-threatening organ dysfunction caused by a dysregulated host response to infection. Along with this shift was the change from SIRS to SOFA and qSOFA to predict mortality in septic patients. This article looks to prospectively validate the qSOFA score. Although the study is multinational, it was primarily performed in France (27 out of 30 centers) and found that patients with a qSOFA < 2 had a mortality rate of just 3% versus 24% in the qSOFA >/= 2. The article concludes that this study validates qSOFA and that this tool is more specific than SIRS without unacceptable decrease in sensitivity. However, some caution should be taken. The overall mortality rate was very low (~ 8%) and a much larger retrospective study published in the same issue from the ANZICS group showed that qSOFA was no better than SIRS but that SOFA was superior. Clearly, this isn’t the last we’ll hear on Sepsis-3.
  • Recommended by: Anand Swaminathan
  • Read more: Alfred researchers validate new sepsis criteria – with a catch (Intensive)

Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about thisStanley Adrian J, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017. PMID: 28053181

  • This paper is a comparison for the performance of the most used pre-EGD scores to predict important outcomes (mortality, rebleeding, intervention and hospital LOS) in patients with GI bleeding. The Glasgow Blatchord scale outperformed all others in all categories except on 30-day mortality. En general the disposition of patients with upper GI bleeding is straightforward, but when in doubt (close outpatient follow-up vs. admission) the use of the GBS may be helpful in determining the dispo and level of care.
  • Recommended by: Daniel Cabrera

Pediatrics
R&R Game Changer? Might change your clinical practiceMagana JN, Kuppermann N. The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med 2016. PMID: 28039943

  • An excellent commentary which examines the findings of Ide et al (PMID: 27862642) in their retrospective review validation of the PECARN head trauma decision tool. The authors remind us that the PECARN traumatic brain injury rules are not intended to be utilized in cases of suspected child abuse, and that in those cases the threshold to image should be low, as “The morbidity and mortality and social implications of abusive head trauma demand a different screening approach.”
  • Recommended by: Jeremy Fried

Systems and administration
R&R Game Changer? Might change your clinical practiceSimone JV. Understanding academic medical centers: Simone’s Maxims. Clinical cancer research 1999. PMID: 10499593

  • This is a great read for anyone hanging from the leadership chain in a complex organisation, especially so if the organisation is an academic medical center. Born from hard won experience, these are “Simone’s Maxims”: 

    INSTITUTIONS
    1. Institutions Don’t Love You Back
    2. Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.
    3. Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.
    4. Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.LEADERSHIP
    5. Leadership Does Matter
    6. Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.
    7. For Academic Leaders, the Last 10% of Job Accomplishment May Take as Much Time as the First 90% and May Not Be Worth the Effort.
    8. With Rare Exceptions, the Appropriate Maximum Term for an Academic Leader/Administrator Is 10 Years, Plus or Minus 3 Years.
    9. In Academic Institutions, Muck Flows Uphill.RECRUITING
    10. In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.
    11. Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.
    12. The Longer and More Detailed the Written Offer to a New Faculty Recruit, the More Likely Both Sides Will End Up Unhappy.
    13. Faculty Fired for Incompetence Will Almost Always Land a Better Job at Higher Pay.JOB CHANGES
    14. One Should Consider an Academic Move Only for an Improvement in Anticipated Opportunity and Environment of 50% or More.
    15. Every Job Relocation Is Due to a Combination of “Push and Pull”; However, the More “Push” Dominates the Decision, the More Unlikely the Move Will Be Satisfactory.
    16. The “Fit” in a New Job Often Is Not Apparent for at Least 18 Months.
    17. The Time Course of Academic Jobs Is Like the Classic Sigmoid Growth Curve of Bacteria in Culture, with a Lag Phase, Log Growth Phase, and Plateau.
    18. Academic Battles Are Recurring and Continuous, and No One Can Win Them All.

    SUCCESS
    19. Academic Success, Ironically, Depends on Recognizing and Adapting to the Dominant Cultural and Financial Features of One’s Academic Era.
    20. There Are Strong Temptations to Compromise One’s Academic Mission by Unhealthy Alliances with Sources of Power or Dollars
    21. Academic Medicine Is a Noble Calling.

    Read the full article to learn more about them.

    Hat tip to Daniel Cabrera for sharing this one on Twitter!

  • Recommended by: Chris Nickson

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: Jan 19, 2017 @ 5:44 am

The post Research and Reviews in the Fastlane 169 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 265

LITFL review

Welcome to the 265th 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 chunk of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick Cummins

Sergey Motov, Reuben Strayer and Lewis Nelson this week launched the first free, open-access online pain management book for acute care. It’s an absolutely monstrous undertaking with chapters to roll out serially as they become available. [AS]

 

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMed Resuscitation

  • It’s the middle of winter in northern Europe, and Scancrit gets topical by taking us through this cool review of post resuscitation hypothermia. [CC]

The Best of #FOAMus Ultrasound

The Best of #FOAMim Internal Medicine

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

Last update: Jan 16, 2017 @ 5:35 am

The post LITFL Review 265 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Funtabulously Frivolous Friday Five 172

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 172. This week we have an animal based radiology quiz sourced from radiopaedia.org. 

Question 1

What animal is winking at you?

  • An owl
  • It is in reference to an absent pedicle.
  • Differentials include, congenital absence, neurofibromatosis, radiation therapy, spinal metastases, intraspinal malignancies, TB or lymphoma. LITFL Winking Owl Reference

Question 2

What two animals are referred to here in a patient with achalasia?

  • Rats tail and Birds Beak
  • This a sign representing the tapering of the inferior oesophagus during a barium swallow.

Question 3

What snake can be seen here?

  • The cobra head sign (or spring onion sign)
  • It refers to the dilatation of the distal ureter surrounded by a thin lucent line. It indicates an uncomplicated ureterocele.
  • If there is any irregularity or loss of definition this should raise concerns for a pseudoureterocele.

Question 4

Which four legged animal is potentially referred to in this chest X-ray?

  • A stag
  • The upper lobe diversion / prominence of the pulmonary veins are said to resemble stag’s antlers, the earliest sign of pulmonary oedema (pulmonary venous hypertension). I’ve previously referred to it as “hands-up” sign, waving for help.

Question 5

What insects do orthopaedic surgeons love?

  • Butterflies
  • Butterfly fragments are large triangular fragments commonly seen in comminuted long bone fractures.

If this list has inspired you to seek out more animals in black and white while you are at work please see the full compendium on radiopaedia.org by following the link.

Last update: Jan 13, 2017 @ 12:15 am

The post Funtabulously Frivolous Friday Five 172 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 168

Research and Reviews in the Fastlane

Welcome to the 168th 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 5 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

Critical care
R&R Hall of Famer - You simply MUST READ this!
Hutchinson PJ, et al. RESCUEicp Trial Collaborators. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 2016. PMID: 27602507

  • The RESCUEicp trial looked at craniectomy as a last tier intervention in patients with severe TBI and refractory intracranial hypertension. Patients had to be between 10-65 years of age with a raised ICP of >25mmHg for 1-12 hours (different from the DECRA trial) despite stage I and II measures which were defined clearly. Patients that were not randomised to the decompressive craniectomy arm could have one later based on the discretion of the neurosurgeons or receive a barbiturate infusion.  The patients receiving a decompressive craniectomy had a lower mortality unfortunately they were more likely to be in a vegetative state with more disability compared to those randomised to medical care.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Emergency Medicine
Mitchell MA & Wartinger DD. Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association 2016. PMID: 27669068

  • I had to suggest this one in, because it contained some excellent quotes, such as “we thank Walt Disney World Resort’s Magic Kingdom theme park for allowing us to conduct this research on the park’s premises” and “seat assignment on the roller coaster was random and determined as a function of place in the waiting line.” Aside from the great quotes, I’m not sure the paper means much. They made a silicone model of a urinary collecting system containing 3 real kidney stones, and report that the stones had moved in location after the roller coaster was finished. This is clearly not ready for time prime, and I can’t imagine that people with back pain from renal colic are going to be excited to be getting on rickety old roller coasters. I will stick to suggesting sex for now.
  • Recommended by: Justin Morgenstern

Emergency Medicine
R&R Game Changer? Might change your clinical practicevan Es J, et al. A simple decision rule including D-dimer to reduce the need for computed tomography scanning in patients with suspected pulmonary embolism. J Thromb Haemost 2015. PMID: 25990714

  • This seemed to slip under the radar a little bit but this is a new decision tool for PE that aims for the sensitivity of Wells but improving the specificity. They do the usual regression on a data set to find a decision tool then apply it in a different validation set. The tricky bit is that someone had to “suspect PE” to get into any of these trials and i suspect that varies from place to place. Ultimately they get a tool that rules out those with dimer<500 and if it’s between 500 and a 1000 then you look for any of 3 things: signs of a DVT, haemoptyis and the dreaded “is PE most likely”. If any of these are ticked then get a CT. In their validation set this improved their “rule out without a CT” rate from 31% to 46% with a cost of increased false negatives from 0.5% to 1.9% (which is right around the “test threshold”). If other authors in different places can reproduce this (which they often can’t in these trials…) then this would be cool.
  • Recommended by: Andy Neill

Emergency Medicine
R&R Game Changer? Might change your clinical practiceWyman AJ, et al. The First-Time Seizure Emergency Department Electroencephalogram Study. Ann Emerg Med. 2016. PMID: 27745763

  • First-time seizures can portend real epileptic disease. These investigators performed EEGs in the ED with a surprising number of true positives.
  • Recommended by: Ryan Radecki

Critical Care
R&R Game Changer? Might change your clinical practiceR&R Hot Stuff - Everyone’s going to be talking about thisR&R Eureka - Revolutionary idea or conceptMcDonald RJ, et al. Intravenous contrast material exposure is not an independent risk factor for dialysis or mortality. Radiology 2014. PMID: 25203000

  • This paper won’t settle the ongoing debate about the real harms of IV contrast material, but it does hint that if CIN exists, it might be more of a laboratory finding than a true patient oriented condition. This is a large chart review looking at patients undergoing CT, and comparing those who received contrast material to those who didn’t. This is a relatively good topic for a chart review, as creatinine, dialysis, death, and CT scans are all objective events that are likely to be clearly recorded in the chart. They only included patients who had a Cr measured in the 25 hours before a CT and also in the period of 24-72 hours after the scan. They also excluded patients already on dialysis and those who were given multiple contrast doses. Ultimately they ended up with 21,346 patients who they matched 1:1 based on a propensity score so they had 2 groups: contrast and no contrast. Overall, the rate of acute kidney injury was 5%. The rate was the same whether you received contrast or not (4.8% versus 5.1%, p=0.38). The incidence of emergent dialysis was the same in both groups, and extremely low (0.2% vs 0.3%). The 30 day mortality rates were also similar, at 8.0% and 8.2%. Although the propensity matching done here means the results could be flawed, it highlights the important issue that led us to think contrast is dangerous: older and sicker patients tend to need contrast CTs, and they are at a high risk of developing acute renal failure in the first few days of their illness, whether or not they get the contrast. The contrast is just an easy scapegoat. This trial is not enough to demand changes in policy from radiology, but I think it fits with the bulk of the literature.
  • Recommended by: Justin Morgenstern

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: Jan 12, 2017 @ 2:23 am

The post Research and Reviews in the Fastlane 168 appeared first on LITFL: Life in the Fast Lane Medical Blog.