Vasopressine: une nouvelle cible pour la prévention ou le traitement de certaines maladies rénales ?

Voici l’excellente présentation de Madame le Pr Lise Bankir sur Vasopressine: une nouvelle cible pour la prévention ou le traitement de certaines maladies rénales ?

Elle parle de la vasopressine et de ses effets sur la maladie polykystique rénale, sur la maladie rénale chronique, sur l’albuminurie dans la néphropathie diabétique et sur l’hypertension artérielle.

Cliquer sur l’image pour télécharger la présentation au format PDF (5.2 Mo)

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Conclusion:

  • On devrait prêter plus d’attention au taux de vaopressine (ou de copeptine) et/ou au volume et à la concentration des urines dans les études chez l’humain.
  • Une augmentation volontaire de la prise liquidienne, ou un traitement par antagoniste des récepteurs V2 de la vasopressine pourrait devenir une nouvelle stratégie thérapeutique pour la prévention de l’insuffisance rénale chronique, de la néphropathie diabétique et pour certaines formes d’hypertension artérielle sel-dépendante.

Source

2 excellents articles de revue, toujours par Madame le Pr Lise Bankir

Vasopressin V2 receptors, ENaC, and sodium reabsorption: a risk factor for hypertension ? Am J Physiol Renal Physiol 2010

Vasopressin: a novel target for the prevention and retardation of kidney disease ? Nat Rev Nephrol 2013

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Does this single lead show a wide complex tachycardia?

A woman in her 50's had a v fib arrest and required defibrillation 10 times before resuscitation to an organized rhythm.

Here was the monitored rhythm:
ventricular tachycardia?








There are two clues that it is not:

1) The rhythm is irregularly irregular, which strongly suggests atrial fibrillation
2) There is a "shelf" on the upslope of the S-wave.  This suggests that it is ST segment, not part of the QRS.

Here is the 12-lead:
Here you can see in leads V4-V6 that the QRS is indeed narrow.  All of the apparent width is really ST segment depression, as well as ST elevation in aVR and V1.

Here I have placed lines to demonstrate the end of the QRS in all leads, using lead II across the bottom for orientation:


After resuscitation, her ECG normalized:


She was found to have an 80% LAD lesion, with open artery and good flow.  This was not definitely a culprit, and not definitely the etiology of arrest.

Lessons:

1. In the presence of ST deviation, the rhythm strip may deceive you into believing there is a wide complex.
2. ST depression is often seen immediately after resuscitation from cardiac arrest.  After a short period of stabilization, it will resolve if there is no underlying acute ischemia

Highly Sensitive Troponins – False Positive Bonanza

The “highly sensitive” troponin has received a great deal of publicity, hyped ad nauseum, see: “Simple test could help rule out heart attacks in the ER.”

But, as sensitivity increases – invariably, specificity decreases.  However, that is not the fault of the test – it is a failure of clinicians to ask the correct question of the test.  When asking “does this patient have an acute myocardial infarction?”(most commonly Type 1 MI in the ED), our training and education has been outpaced by assay technology – the test no longer provides a dichotomous “yes” or “no”.

This publication provides a lovely window into precisely the added value of the hsTnI compared with conventional TnI, both assays by Abbott Laboratories.  In this study, the authors simultaneously drew research samples of blood any time a cTnI was ordered.  The sample was frozen, and then analyzed at least 1 month following presentation.  Authors performed hospital records review, telephone follow-up, and vital records search to evaluate adverse events in patients with hsTnI or cTnI elevation.

Overall, they enrolled 808 patients, 40 of which received an adjucated diagnosis of “acute coronary syndrome” – 26 with AMI and 14 with unstable angina.  61 patients had acute heart failure, 7 had volume overload, 7 had pulmonary emboli, and 41 had other non-ACS cardiac diagnoses.

All told, there were 105 elevated cTnI samples – and 164 elevated hsTnI samples.  This means, essentially – in the acute setting, asking our question of interest – there were 50% greater false positives associated with hsTnI.  No patients would have been reclassified as nSTEMI based on the hsTnI result.  The authors sum this up nicely in their discussion:
“The preponderance of novel elevations (roughly 10% in this study) will be observed mainly in subjects with non-ACS conditions.”
The authors go on to note the value in detecting these novel or detectable troponin levels – essentially, non-ACS, subclinical disease – with a much poorer long-term prognosis.  This is almost certainly the case, although it will require further investigation to reliably demonstrate cost-effective management strategies based on these results.

“Troponin Elevations Only Detected With a High-sensitivity Assay: Clinical Correlations and Prognostic Significance”
http://www.ncbi.nlm.nih.gov/pubmed/25112512

POCUS and recurrent abdominal pain in the elderly

A 82 yr. old patient came in for chronic recurrent epigastric pain. A CT was done on the previous admission which showed pancreatic calcifications, consistent with chronic pancreatitis. On this visit the patient had a similar presentation. She looked well, with a pretty benign abdomen and normal labs. I was pressed for time and didn’t really feel like getting the U/S out, figuring that it wouldn’t likely add anything to a diagnosis of chronic pancreatitis. However I decided to POCUS and sure enough the GB was full of stones/distended and tender. At surgery later in the day she had a necrotic GB. Gallstones

EM Match Advice: The EM Rotation, ERAS, and Am I Competitive?

EM Match iconToday launches a series of Google Hangout videos, which was created and expertly facilitated by Dr. Michael Gisondi (@MikeGisondi) from Northwestern. In this series, he recruited an amazing panel of program directors from around the country, who have kindly volunteered their time to share their insights and expertise. In these videos, you get a sense of each panelist’s personalities while they outdo each other with behind-the-scenes advice and stories, which would normally be shared only at the institutional level. Our videocasts are a unique must-see for medical students, interested in and applying into Emergency Medicine (EM). Keep a look out for more videos in the future!

The EM Rotation

Dr. Gisondi facilitates a great discussion featuring esteemed residency program directors Dr. Lainie Yarris (Oregon Health Sciences University), Dr. Maria Moreira (Denver Health), and Dr. Jan Schoenberger (LAC-USC), with the occasional outburst/question by Dr. Michelle Lin (UCSF-SFGH).

Timestamps

  • 00:00  Dr. Mike Gisondi introduces the series and talks about 3 key publications to review for the EM medical student and how to succeed in the EM rotation
  • 05:11  Dr. Lainie Yarris discusses “what defines an honors level performance?”
  • 08:23  Dr. Maria Moreira discusses the differences between an away and a home rotation?
  • 11:24  Dr. Maria Moreira discusses the art of getting a Standardized Letter of Evaluation (SLOE) from their EM rotation
  • 13:43  Dr. Jan Schoenberger discusses how to be a stellar stand-out in a rotation with only a pass-fail system in the EM rotation.
  • 14:45  Dr. Michelle Lin poses the question to the PD’s about — “I didn’t get an honors, now what?”
  • 16:28  Dr. Schoenberger addresses advising/counseling approaches
  • 17:35  Dr. Lin asks about the “departmental SLOE” letter
  • 18:10  Dr. Schoenberger talks about her departmental SLOE
  • 18:45  Dr. Yarris talks about her departmental SLOE and the value of intangible, behavioral characteristics in applicants
  • 19:45  Dr. Moreira talks about her department’s SLOE approach and reminds us that programs want diversity in the program
  • 22:48  Dr. Yarris – pearls and pitfalls
  • 24:05  Dr. Moreira - pearls and pitfalls
  • 26:36  Dr. Schoenberger – pearls and pitfalls
  • 29:18  Dr. Gisondi wraps things up by asking the 3 program directors to share something awesome back their program and something that we might not know about their program.

References

  1. Mahadevan S, Garmel GM. The outstanding medical student in emergency medicine. Acad Emerg Med. 2001 Apr;8(4):402-3. PMID: 11282680.
  2. AAEM Rules of the Road for Medical Students (2003), a free PDF.
  3. Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008 Jul;15(7):683-7. PMID: 18691216.

 

Electronic Residency Application Service (ERAS)

Dr. Gisondi (Northwestern) facilitates a great discussion featuring star residency program directors Dr. Gene Hern (Highland-Alameda), Dr. Laura Hopson (Univ of Michigan), and Dr. Josh Broder (Duke), with an occasional question by Dr. Michelle Lin (UCSF-SFGH).

Timestamps

  • 00:00  Dr. Gisondi introduces the series and talks about 3 key publications to review about what are important in the ERAS application
  • 09:37  Dr. Hern talks about his perspectives about the ERAS and what matters to him and his program at Highland
  • 15:00  Dr. Hern discusses what parts of the ERAS the student should focus more time on.
  • 16:25  Dr. Hern reviews what doesn’t matter as much on the ERAS.
  • 17:41  Dr. Hopson drops pearls about what to do and where to focus your time on the ERAS application.
  • 21:38  Dr. Hopson shares her perspectives about looking for the well-rounded, multitasking applicant.
  • 22:15  Dr. Hopson talks about red-flags in filling out the ERAS application.
  • 26:00  Dr. Broder shares his thoughts about how a non-superstar applicant can shine on his/her application.
  • 28:37  Dr. Gisondi and Dr. Hern talk about how some red flags in the application can be addressed.
  • 31:20  Dr. Hopson recommends teaming up with your mentor/advisor in addressing any red flags in the SLOE.
  • 32:10  Dr. Broder shares his comments how he approaches thinks about any red-flag candidates.
  • 33:07  Dr. Lin shares her thoughts about the personal statement and concerns about honesty on the application.
  • 34:58  Dr. Hern talks about his 2005 BMJ Med Educ study about errors/omissions on the ERAS applications (BMJ Med Educ 2005).
  • 36:16  Dr. Hopson talks about poor integrity, in the form of inconsistent information within the application packet, being a huge red flag in applications.
  • 37:33  Dr. Broder and Dr. Gisondi banter about application misrepresentation.
  • 39:04  Dr. Hene talks about final thoughts – pearls and pitfalls
  • 41:38  Dr. Hopson talks about final thoughts – pearls and pitfalls. In a nutshell: Be yourself.
  • 42:11  Dr. Broder talks about final thoughts – pearls and pitfalls.
  • 43:13  Dr. Lin talks about final thoughts – pearls and pitfalls.
  • 44:16  The panel talks about the “drop dead” deadline for the ERAS application.
  • 45:10  Dr. Lin challenges the panel by asking about the few programs who may offer interviews before the Dean’s letter comes out.
  • 47:46  Dr. Hern shares why one should apply to Highland.
  • 49:28  Dr. Hopson shares why one should apply to University of Michigan.
  • 50:22  Dr. Broder shares why one should apply to Duke.

References

  1. Hayden SR, Hayden M, Gamst A. What characteristics of applicants to emergency medicine residency programs predict future success as an emergency medicine resident? Acad Emerg Med. 2005 Mar;12(3):206-10. PMID: 15741582.
  2. Breyer MJ, Sadosty A, Biros M. Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List. West J Emerg Med. 2012 Dec;13(6):458-62. PMID: 23359215. Free PDF.
  3. Green M, Jones P, Thomas JX Jr. Selection criteria for residency: results of a national program directors survey. Acad Med. 2009 Mar;84(3):362-7. PMID: 19240447.
  4. Katz ED, Shockley L, Kass L, Howes D, Tupesis JP, Weaver C, Sayan OR, Hogan V, Begue J, Vrocher D, Frazer J, Evans T, Hern G, Riviello R, Rivera A, Kinoshita K, Ferguson E. Identifying inaccuracies on emergency medicine residency applications. BMC Med Educ. 2005 Aug 16;5:30. PMID: 16105178. Free article link.

 

Mirror Mirror on the Wall: Am I Competitive?

Dr. Gisondi (Northwestern) kicks off a great conversation and debate about the knowing how competitive you are, as an applicant. This panel features star residency program directors Dr. Andrew Perron (Maine Medical Center), Dr. Madonna Fernandez (Harbor-UCLA), and Dr. Kevin Biese (UNC Chapel Hill), with comments by Dr. Michelle Lin (UCSF-SFGH).

Timestamps

  • 00:00  Dr. Gisondi launches this panel discussion on determining your competitiveness in the application process. He
  • 03:19  Dr. Gisondi delves right into a great PDF that summarizes some recent statistics about How Competitive is the EM Match that he and Jill Craig compiled. FYI, “SOAP” in the document means Supplemental Offer and Acceptance Program. For a more full listing see the NRMP website [1].
  • 07:26  Dr. Lin discusses what her take-away points after looking at the trends.
  • 09:08  Dr. Biese follows up with his take-away points from these trends.
  • 09:31  Dr. Gisondi weighs in on these trends as well. “There’s a home for (almost) every EM applicant.”
  • 11:00  Dr. Gisondi discusses relevant papers [2-4].
  • 15:58  Dr. Lin fields the first question about — how many programs should I apply to?
  • 18:00  Dr. Perron makes a grand entrance and stresses the importance of a knowledgeable advisor.
  • 19:03   Dr. Perron shares stories about application numbers.
  • 21:32   The panel debates about how many programs to interview at. What is the interview-canceling etiquette? What about couples matching? Tax-break tips?
  • 26:40  Dr. Biese talks about how applications are screened once their submitted into ERAS.
  • 30:09  Dr. Gisondi shares on his perspectives on the numbers game (i.e. USMLE scores).
  • 32:40  The panel rapid-fires about how to address stumbling blocks in one’s application (e.g. below average scores or poor shelf exam scores).
  • 37:34  Dr. Biese shares a story about why a “creative” personal statement that stands out maybe isn’t a good idea.
  • 40:04  Dr. Fernandez shares how to find a great advisor about matching into EM, especially if there’s no home EM residency department to help advise. Think about SAEM/CDEM’s e-Advisor system (application system).
  • 43:40  Dr. Fernandez and Dr. Biese describe what makes a quality advisor.
  • 47:30  Dr. Gisondi and Dr. Fernandez share who/what might be questionable resources for advice and why.
  • 51:18  Dr. Lin summarizes it all to the bottom line – Get a good advisor.
  • 52:43  Dr. Biese clarifies that there are two games afoot – get an interview vs get ranked highly on rank day.
  • 54:27  The panel each leaves a short take-away pearl/pitfall.
  • 57:30  The panel shares something that one might not know about their residency program.

References

  1. NRMP Match Results and Data 2014 (PDF)
  2. Crane JT, Ferraro CM. Selection criteria for emergency medicine residency applicants. Acad Emerg Med. 2000 Jan;7(1):54-60. PubMed PMID: 10894243.
  3. Girzadas DV Jr, Harwood RC, Delis SN, Stevison K, Keng G, Cipparrone N, Carlson A, Tsonis GD. Emergency medicine standardized letter of recommendation: predictors of guaranteed match. Acad Emerg Med. 2001 Jun;8(6):648-53. PMID: 11388941.
  4. Lotfipour S, Luu R, Hayden SR, Vaca F, Hoonpongsimanont W, Langdorf M. Becoming an emergency medicine resident: a practical guide for medical students. J Emerg Med. 2008 Oct;35(3):339-44. PMID: 18547776.

 

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief

Editorial Board Member, Annals of Emergency Medicine

UCSF Academy Endowed Chair for EM Education

UCSF Associate Professor of Emergency Medicine

San Francisco General Hospital

The post EM Match Advice: The EM Rotation, ERAS, and Am I Competitive? appeared first on ALiEM.

Code of Ethics: Nurses value quality nursing care for all people.

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The Code of Ethics for Nurses in Australia is an incredibly empowering document.
It is a call to uphold your questioning. A call to protect the value of quality nursing care. It is a call for accountability. A call for action.

The code has been developed and supported by the Australian Nursing and Midwifery Board of Australia, Australian College of Nursing, and the  Australian Nursing & Midwifery Federation. It is intended to “provide nurses with a reference point from which to reflect on the conduct of themselves and others” as well as acting as a guide in our ethical decision making and practice.

Many of you are probably aware of the code and some may have read through it. But in my opinion it is really worth taking some time to read through these value statements carefully,  reflecting on how this code relates to the clinical environment we work in.
How does this code speak to us with respect to our own experiences of quality care delivery within the hospital system?
What issues does it raise for us?
How does it guide our response?

 

“Nurses who value quality nursing care recognise that they are accountable for the decisions they make regarding a person’s care; accept their moral and legal responsibilities for ensuring they have the knowledge, skills and experience necessary to provide safe and competent nursing care; and practise within the boundaries of their professional role. Nurses who value quality nursing care ensure the professional roles they undertake are in accordance with the agreed practice standards of the profession. Nurses are also entitled to conscientiously refuse to participate in care and treatment they believe on religious or moral grounds to be unacceptable (‘conscientious objection’).

Nurses recognise that people are entitled to quality nursing care, and will strive to secure for them the best available nursing care. In pursuit of this aim, nurses are entitled to participate in decisions regarding a person’s nursing care and are obliged to question nursing care they regard as potentially unethical or illegal. Nurses actively participate in minimising risks for individuals.

Nurses take steps to ensure that not only they, but also their colleagues, provide quality nursing care. In keeping with approved reporting processes, this may involve reporting, to an appropriate authority, cases of unsafe, incompetent, unethical or illegal practice. Nurses also support colleagues whom they reasonably consider are complying with this expectation.

Nurses, individually and collectively, participate in creating and maintaining ethical, equitable, culturally and socially responsive, clinically appropriate and economically sustainable nursing and health care services for all people living in Australia. Nurses value their role in providing health counselling and education in the broader community. Nurses, individually and collectively, encourage professional and public participation in shaping social policies and institutions; advocate for policies and legislation that promote social justice, improved social conditions and a fair sharing of community resources; and acknowledge the role and expertise of community groups in providing care and support for people. This includes protecting cultural practices beneficial to all people, and acting to mitigate harmful cultural practices.”

[Note: sections in bold highlighted by me]

 


Reference: Code of Ethics for Nurses in Australia (pdf).
Developed under the auspices of Australian Nursing and Midwifery Board of Australia, Australian College of Nursing, and the  Australian Nursing & Midwifery Federation.

Original featured image via: COD newsroom.