Following a PICU admission for anaphylaxis, recurrence is high in children with food allergy compared with drug allergy. Allergic comorbidities increase the risk
Sunday 31 March 2019
Saturday 30 March 2019
ACNE MECHANICA
Acne mechanica is defined as being any acneiform eruption in areas of friction, pressure, stretching, rubbing, pinching, or occlusion of the skin in any individual, regardless of preexisting acne. Various causes have been reported, including prolonged back rest against a chair or bed, occlusive clothing, pressure from a prosthetic limb, and others. This is the first reported case of bilateral open comedones caused by inner thigh friction.
P IST UTI X MCUG INDICATED
Poor clinical appearance, presence of a uropathogen other than Escherichia coli, positive blood culture, hydroureter and thickened renal pelvic wall were all independently associated with high‐grade VUR
B NIRVANA X LET GO
Nibbana Is Giving Up, Letting Go, and Being Free
In a training program, Morpheus takes Neo out onto the roof of a building. “Let it all go, Neo,” he says. “Fear. Doubt. Disbelief. Free your mind.” Morpheus runs and jumps off of the building, landing on another roof fifty feet away. “Okie dokie,” says Neo. “Free my mind. Right. No problem.”
Ajahn Chah on letting go:
“What is nibbana all about anyway? Nibbana means not grasping. Nibbana means not giving meaning to things. Nibbana means letting go. Making offerings and doing meritorious deeds, observing moral precepts, and meditating on loving-kindness—all these are for getting rid of defilements and craving, for making the mind empty—empty of self-cherishing, empty of concepts of self and other—and for not wishing for anything, not wishing to be or become anything.”
B MATRIX CNMA 20 YRS ON
“Do we live in a ‘Matrix’-like illusion?”
The Buddha settled that question two-and-a-half millennia ago with a resounding “yes.” That’s why so many people view The Matrix as a kind of Buddhist allegory. (Spoiler alerts to follow!) The Matrix itself is humanity’s self-constructed illusory prison of the mind — a handy metaphor for the Buddhist concept of samsara. At one point the film’s villain, Agent Smith, even goes so far as to say, “I believe that, as a species, human beings define their reality through suffering and misery.”
KIPLING Words are, of course, the most powerful drug used by mankind."
Words are, of course, the most powerful drug used by mankind."
GM Those who destroy the living world should be charged with the international crime of ecocide
Those who destroy the living world should be charged with the international crime of ecocide
Friday 29 March 2019
Sometimes I look back and think my whole adult life has been underlined with a feeling of waiting – waiting for something to happen, waiting for circumstances to change, waiting for the right man or the right job or the right shoes-and-clothes-and-haircut to swoop down from above and change me, to infuse me from the outside in with a feeling of well-being and validation and peace of mind.” – Caroline Knapp, “Clearing Up: Grief in Sobriety, Confronting Loss Once More, with Feeling,”
Sometimes I look back and think my whole adult life has been underlined with a feeling of waiting – waiting for something to happen, waiting for circumstances to change, waiting for the right man or the right job or the right shoes-and-clothes-and-haircut to swoop down from above and change me, to infuse me from the outside in with a feeling of well-being and validation and peace of mind.”
– Caroline Knapp, “Clearing Up: Grief in Sobriety, Confronting Loss Once More, with Feeling,”
I have just three things to teach: simplicity, patience, compassion. These three are your greatest treasures. ~ Lao Tzu
I have just three things to teach: simplicity, patience, compassion. These three are your greatest treasures. ~ Lao Tzu 
How you handle a situation is not entirely your choice. But how you handle yourself is entirely yours.
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UMWELT
Umwelt
/ˈʊmvɛlt/
noun
- (in ethology) the world as it is experienced by a particular organism.
Thursday 28 March 2019
P TICBORNE ILLNESS
Risk Management Pitfalls for Management of Pediatric Patients With Tick-Borne Illnesses
1. “There was no history of a tick bite, so I don’t have to worry about tick-borne illnesses.”
Tick bites are often painless and may be in locations that are not easily visible. Patients may not give a history of a tick bite; therefore, a careful history to elicit risk factors for tick exposure is necessary, particularly in endemic areas. In studies of tick-borne illnesses, a history of a tick bite was not reported in 30% to 40% of confirmed cases.1,2,26,97,98
4. “I had a strong suspicion that my patient had a tick-borne illness, but I wanted to be sure, so I waited for the confirmatory tests to result before starting her on an antimicrobial.”
For most tick-borne illnesses, confirmatory testing may take days or weeks to result. In patients with a consistent history, examination, and preliminary laboratory findings, empiric treatment may be started while test results are pending. In particular, delayed treatment with doxycycline is associated with a higher mortality rate for RMSF.143 Untreated, RMSF has a case fatality rate of 10% to 25%.144
10. “I’m not in a high-risk area, so I don’t need to consider tick-borne illnesses in my differential.”
While there are areas that are highly endemic for certain diseases, tick-borne illnesses have been reported in all of the contiguous 48 states.154 A thorough travel history is critical to identifying possible tick exposures, as cases acquired during travel to endemic areas may be easily missed.155 Patients may also be exposed during international travel.156,157 Excluding a specific disease based solely on geographic location may delay diagnosis and increase the risk of developing complications.
P RMP MENINGITIS
Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis
2. “The patient has inflamed tympanic membranes. The fever and irritability are likely due to otitis media. It’s not meningitis.”
Many young children with bacterial meningitis can have concomitant inflammation in other areas on physical examination or diagnostic study. Otitis media and upper respiratory tract infections are common enough conditions that their presence can lead the emergency clinician to “explain away” the child’s more serious symptoms as being due to those pathophysiologic findings. Anchoring on a simpler, less severe diagnosis can result in missing or delaying the correct diagnosis.
6. “The patient likely has viral meningitis, so we don't need to get a lumbar puncture.”
The notion that emergency clinicians can distinguish the difference between viral and bacterial meningitis based on the history and physical examination is not supported by the available evidence. The clinical overlap of these conditions is substantial, particularly early in the course of illness. Diagnosis should not be made based on the history and physical examination alone.
8. “We need to wait for a CT scan and lumbar puncture before we can give antibiotics, as they can cause sterilization of CSF.”
When caring for a patient with a presumptive diagnosis of bacterial meningitis, do not delay administration of appropriate antibiotics for the completion of a CT scan or lumbar puncture or for the results of these studies. Although antibiotics may obscure the ultimate bacteriologic diagnosis, this is a small clinical price to pay to prevent further bacterial proliferation and inflammation within the CNS.
P X VITD INTOX
Treatment of severe hypercalcemia in vitamin D
intoxication (J Clin Res Pediatr Endocrinol. Nov 2018.
Epub ahead of print)
Vitamin D toxicity with hypercalcemia is a medical emergency.
This retrospective study pooled multicenter data regarding
clinical characteristics and management strategies using a
standardized questionnaire. A total of 74 children (median age
1.06 y) with hypercalcemia (>10.5 mg/dL) associated with
vitamin D toxicity (>150 ng/mL) were evaluated. Calcium and
25-hydroxyvitamin D showed weak positive correlation. Mild
hypercalcemia responded well to hydration alone. Other modes
of treatment included prednisolone, bisphosphonates and a
combination of these. A combination therapy was required in
severe cases, which needed prednisolone initially. Use of
pamidronate reduced the risk of recurrence of hypercalcemia
P X HFNC X 90 MIN PEWS X VENTILN
High and worsening PEWS scores 90 min after HFNC initiation may indicate non‐response
P X DPB X AZITHRO
Diffuse panbronchiolitis (DPB) is an idiopathic inflammatory disease, well recognised in Japan and principally affecting the respiratory bronchioles, causing a progressive suppurative and severe obstructive respiratory disorder. If left untreated, DPB progresses to bronchiectasis, respiratory failure and death.
P INCENSE X BAD RESP HEALTH
We found that incense burning may adversely affect children‘s respiratory health.
P INHALER BETTER THAN NEBULISER
Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial
First published: 22 January 2019
Abstract
Introduction
In moderate‐severe asthma exacerbation, salbutamol by inhaler (MDI) is superior to salbutamol delivered by nebulizer (NEB); however, to our knowledge, no studies in children with exclusively severe exacerbations were performed.
Objective
To compare the efficacy of salbutamol and ipratropium bromide by MDI versus by NEB in severe asthma exacerbations.
Methods
We performed a clinical trial enrolling 103 children (2‐14 years of age) with severe asthma exacerbations (defined by the Pulmonary Score ≥ 7) seen at the emergency room in Asuncion, Paraguay. One group received salbutamol and ipratropium (two puff every 10 min for 2 h and then every 30 min for 2 h more) by MDI with a valved‐holding chamber and mask along with oxygen by a cannula separately (MDI‐SIB); and the other received nebulization with oxygen (NEB‐SIB) of salbutamol and ipratropium (1 every 20 min for 2 h and then every 30 min for 2 h more). Primary outcome was the rate of hospitalization (Pulmonary Score ≥ 7) after 4 h and secondary outcome was oxygen saturation.
Results
Fifty two children received MDI‐SIB and 51 NEB‐SIB. After the 4th hour, children on MDI‐SIB had significantly (P = 0.003) lower rate of hospital admission than on NEB‐SIB (5.8% vs 27.5%, RR: 0.21 [0.06‐0.69], respectively). Similarly, a significant improved clinical score after 60 min and increase in oxygen saturation after 90 min of treatment was observed in MDI‐SIB versus NEB‐SIB group (4.46 ± 0.7 vs 5.76 ± 0.65, P < 0.00001; and 90.5 ± 1.7 vs 88.43 1 ± 1, P < 0.00001, respectively).
Conclusion
Even in severe asthma exacerbations administration of salbutamol and ipratropium by MDI with valved‐holding chamber and mask along with oxygen by a cannula separately was more effective than by a nebulizer.
P DKA X WHEN TO SWITCH TO SC INSULIN X NO NAUSEA X VpH7.3 OR BIC OVR 15
Is serum bicarbonate better than venous pH to predict
recovery in diabetic ketoacidosis? (J Pediatr Endocrinol
Metab. Dec 2018. [Epub ahead of print])
Resolution of acidosis is monitored closely in diabetic
ketoacidosis following which intravenous (IV) insulin is
transited to subcutaneous (SC) insulin. This study evaluated if
measurement of serum bicarbonate (target ≥15 mmol/L) was
better than venous pH (≥7.3) to shorten duration of insulin
infusion and pediatric intensive care unit (PICU) therapies.
Retrospective review of 274 case records of children was
performed. Approximately equal number had transited from IV
to SC insulin based on serum bicarbonate (n=132) and venous
pH (n=142). The duration of insulin infusion and PICU stay
were significantly shorter in bicarbonate group. The adverse
events recorded between both groups remained similar.
P SEPSIS RAPID DX TIC TEST- IL6
IL-6 is an indicator of both sepsis and bacterial meningitis, meaning the test in development could potentially help diagnose both conditions." - Linda Glennie, MRF
KG X CHILD
Khalil Gibran, from his poem “On
Children:”
“Your children are not your children.
They are the sons and daughters of Life’s
longing for itself.
They come through you but not from you,
And though they are with you yet
they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them,
but seek not to make them like you.
For life goes not backward nor tarries with yesterda
B Jhana is a meditative state of profound stillness and concentration in which the mind becomes fully immersed and absorbed in the chosen object of attention. It is the cornerstone in the development of Right Concentration.
First Jhana - Vithakka Vichara - effortlessly taking the object of meditation repeatedly
2 - Preethi - happiness (non sensual happiness)
3 - Sukha - lightness
4 -Upekkha, Ekaggatha - indiffference to any feeling or emotion
MICROAGGRESSION
The term "microaggression" was used by Columbia professor Derald Sue to refer to "brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color
IP X UVC BROKE OFF AND TRNSMIGRATED TO HEART
Umbilical venous catheterization is one of the fastest
methods of deep venous access in neonates, but may be
associated with complication [1]. A 3.5 FG size umbilical
venous catheter (UVC) was inserted in a male baby with
birthweight of 2360 g on day 1 of life for administration
of fluids for treatment of hypoglycemia. Accidentally, on
day 3, the catheter broke during removal, and part of the
catheter migrated to heart. Attempt of removal of the
broken part of UVC by laparotomy was unsuccessful.
The upper end of broken UVC was confined within both
right atrium and left atrium and lower end was lying in
IVC (Fig. 1)
. On day 5 of life, the catheter it was removed under fluoroscopic guidance by percutaneous approach under general anesthesia. It was removed by pediatric cardiology team transfemorally through a 4 Fr multipurpose
A2 catheter with help of a 5 Fr sheath and a 15 mm Gooseneck snare. The UVC was held just proximal to the tip and snared from the superior vena cava during retrieval. The baby was discharged from hospital in healthy state.
. On day 5 of life, the catheter it was removed under fluoroscopic guidance by percutaneous approach under general anesthesia. It was removed by pediatric cardiology team transfemorally through a 4 Fr multipurpose
A2 catheter with help of a 5 Fr sheath and a 15 mm Gooseneck snare. The UVC was held just proximal to the tip and snared from the superior vena cava during retrieval. The baby was discharged from hospital in healthy state.
IP X NARCOLEPSY PJ
A 4-year-8-month old school-going boy, presented
with complaints of excessive daytime sleepiness and
intense urge to sleep for last one year, and drop attacks for
last six months. There was no significant family history of
seizures or neurological disorder. In view of recurrent/
persistent symptoms, he was extensively evaluated for
seizure disorder/epilepsy syndrome/Wilson’s disease. In
view of inconclusive results and persistent symptoms, he
was started on anti-epileptics but later referred to us due
to persistence of symptoms.
On examination, he was neuro-developmentally
normal with both general physical and systemic
examination with in normal limits. During conversation
with the parents, the child not only had intense urge to
sleep but also had a drop attack. Considering the
symptoms and chronicity of presentation in otherwise
developmentally normal child, a provisional diagnosis of
narcolepsy with cataplexy was considered. Child
underwent a nocturnal polysomnography (PSG) followed
by daytime multiple sleep latency test (MSLT). Nocturnal
PSG was within normal limits and MSLT showed, a mean
sleep latency of 4 minutes with average REM latency of
1.4 minutes, thus diagnostic of Narcolepsy. A genetic test
(HLA B1*0602) to support the diagnosis was positive,
thus confirming the diagnosis. He was treated with Modafanil (50 mg/day) with good clinical response with respect to both excessive daytime sleepiness and cataplexy. Patients with narcolepsy are usually initially investigated for epilepsy, encephalopathy, and psychiatric disease [3,4]. A lack of awareness of the condition, delay in symptom recognition and absence of all the characteristic features are the primary reason for missed diagnosis of narcolepsy in children [3,4]. Administering daytime MSLT after overnight PSG is the primary modality of choice for diagnosis of narcolepsy [3,5]. Presence of both: (a) a mean sleep latency (MSL) of <8 minutes and (b) two or more sleep onset REM periods (SOREMPs) on MSLT performed after at least six hours of sleep during the previous night confirms the diagnosis [3,5]. Management of narcolepsy is multimodal and involves Sleep hygiene, frequent daytime naps, Diet recommendations, Medications, and Caregiver counseling. Though lifestyle modifications are important in management, medical treatment is the cornerstone and should be initiated as early as possible after confirming the diagnosis.
thus confirming the diagnosis. He was treated with Modafanil (50 mg/day) with good clinical response with respect to both excessive daytime sleepiness and cataplexy. Patients with narcolepsy are usually initially investigated for epilepsy, encephalopathy, and psychiatric disease [3,4]. A lack of awareness of the condition, delay in symptom recognition and absence of all the characteristic features are the primary reason for missed diagnosis of narcolepsy in children [3,4]. Administering daytime MSLT after overnight PSG is the primary modality of choice for diagnosis of narcolepsy [3,5]. Presence of both: (a) a mean sleep latency (MSL) of <8 minutes and (b) two or more sleep onset REM periods (SOREMPs) on MSLT performed after at least six hours of sleep during the previous night confirms the diagnosis [3,5]. Management of narcolepsy is multimodal and involves Sleep hygiene, frequent daytime naps, Diet recommendations, Medications, and Caregiver counseling. Though lifestyle modifications are important in management, medical treatment is the cornerstone and should be initiated as early as possible after confirming the diagnosis.
IP X SCID PT JRNY PJ
Severe combined immunodeficiency (SCID) is one of the
most severe forms of primary immunodeficiency
disorders in children. We report additional findings in the
patient of SCID reported earlier by Gupta, et al. [1]. This
was a 7-month-old boy symptomatic since 3 months of
age with recurrent pneumonia, failure to thrive, oral
thrush and oral ulcers. There was a significant family
history of death of two elder siblings during infancy due
to repeated infections. The index child died in the
hospital due to respiratory failure and acute respiratory
distress syndrome. Investigations revealed severe
lymphopenia. An autopsy performed revealed thymic
dysplasia with marked lymphoid depletion in lymphoid
organs and bone marrow consistent with the clinical
diagnosis of SCID. He also had severe Respiratory
syncytial virus pneumonia and Cytomegalovirus
inclusions in the lungs and adrenals.
P SHARP METALLIC FB
Foreign body ingestion is a common problem in children.
We share our experience of managing sharp metallic
foreign body ingestion in four children.
A 7-month-old girl was brought to us with complaints
of episodic excessive cry and blood tinged vomitus since
two days. X-ray abdomen showed a hair pin in the small
bowel loops (Fig. 1A). The baby was clinically stable
without any symptoms. After 3 hours of hospitalization
(36 hours after ingestion); baby passed the foreign body
in stools (Fig. 1B).
A 6-year-old boy presented to us with accidental
ingestion of a nail; there was no history of vomiting or
pain abdomen. X-ray revealed sharp metallic foreign
body in the stomach lying transversely (Fig. 1 C). Under
close observation, child passed the nail in the stools after
30 hours of its ingestion (Fig. 1 D).
A 9-month-old girl was brought to us with history of
accidental ingestion of an open safety pin. Serial X-rays
showed the uneventful transit of foreign body through
gastrointestinal tract (Fig. 1 E). Baby passed the foreign
body spontaneously in the stools after 36 hours of its
ingestion (Fig. 1 F).
A 13-year-old girl was brought to us with history of
accidental ingestion of a table pin. X-ray revealed a sharp
metallic foreign body in the small bowel (Fig. 1 G). Her
psychiatric evaluation was normal. She was closely
observed with daily X-rays with watchful waiting, and she
passed the foreign body in the stool after 10 days (Fig. 1
H).
Majority of foreign bodies reaching the stomach will
pass spontaneously in stools uneventfully [1]. However,
the sharp metallic foreign body may rarely migrate to
almost any intra-abdominal organ causing serious
complications such as bowel perforation, bleeding, and
obstruction [1,2]. As per Jackson’s statement “advancing
points perforate and trailing points do not”; i.e., sharp
metallic foreign body travels with its blunt end first [2,3]
Endoscopic retrieval of sharp metallic foreign bodies, even if they have reached the stomach uneventfully, is advocated by some experts, while many centers manage them with watchful waiting [3,4]. Those not amenable to endoscopic retrieval need to be followed-up with daily radiographs; surgical removal should be contemplated if it fails to progress over three days [2,3].
Endoscopic retrieval of sharp metallic foreign bodies, even if they have reached the stomach uneventfully, is advocated by some experts, while many centers manage them with watchful waiting [3,4]. Those not amenable to endoscopic retrieval need to be followed-up with daily radiographs; surgical removal should be contemplated if it fails to progress over three days [2,3].
P GLANZMANN X NEONATE
A 33-year-old woman (gravidity 2, parity 2) delivered a
male neonate at 35 weeks’ gestation via cesarean section
necessitated by premature rupture of membranes. The
neonate weighed 2350 g, and had Apgar score of 7 at 1
min, and 8 at 5 min of birth. Immediately after birth, the
baby had extensive bruising all over his body, and
developed visible jaundice on the second day of life, for
which he was referred to us. The mother had a pulmonary
embolism during the pregnancy which was treated with
enoxaparin that was continued after delivery. The
patient’s 10-year-old brother had GT, presenting with
bruises without trauma from 2 months of age, but no
history of excessive bleeding; his molecular
thrombophilia panel had not yet been assessed.
Physical examination revealed icterus and
ecchymotics patch measuring 5 × 3 cm2 on the anterior
aspect of the right thigh (the site of a vitamin K injection)
and smaller ecchymoses on his face, back, legs, and arms.
Rest of the examination was normal. Investigations
showed a white blood cell count of 7.3×109/L,
reticulocyte count 2.23% (normal 0.5-3%), platelet count
190×109/L, hemoglobin 20 g/dL (12.1-17.2 g/dL),
hematocrit 56.3% (36.1-50.3%), total bilirubin 34.19 mg/
dL, indirect bilirubin 33.45 mg/dL, G6PD enzyme level
normal, activated partial thromboplastin time (aPTT) of
23.9 s. There were no Rh, ABO, or subgroup
incompatibilities between the mother and infant. The
peripheral blood smear did not reveal any dysmorphic
erythrocytes or other findings to indicate hemolysis;
neutrophils were 40%, lymphocytes 50%, and abundant,
non-clustered, and normal-sized platelets. The abdominal
and transfontanelle ultrasonographies were also normal.
The baby underwent an exchange transfusion, after which
his total bilirubin level dropped to 23.08 mg/dL, which
was managed by phototherapy for another two days. In
view of this family history, a molecular thrombophilia
panel was tested. The results revealed that our index
patient’s mother had heterozygous factor V Leiden
G1691A and homozygous MTHFR C677T gene
mutations. The patient’s flow cytometric analysis showed
that the CD41/CD61 (anti-GPIIb–IIIa monoclonal
antibodies) levels were undetectable. In addition,
heterozygous factor V Leiden G1691A and heterozygous
MTHFR C677T gene mutations were detected.
FEEDING V EATING DISORDER P
How is This Different Than an Eating Disorder?
The difference in the psychology behind feeding and eating disorders is vast. Behaviors, however, often overlap. As previously mentioned, ARFID and anorexia nervosa are both characterized by extreme restriction. However, there are certain red flags that indicate an eating disorder is behind disordered food behaviors.
Body dysmorphia and related behaviors, such as negative body talk, body-checking, or frequent weighing, are common with eating disorders. These thoughts and behaviors are not associated with feeding disorders. The use of compensatory behaviors, including self-induced vomiting or laxative abuse, is also only found in cases of eating disorders. Despite the distinct differences between the two, feeding and eating disorders can co-occur.
FRIZNER Gambling: The sure way of getting nothing for something."
Gambling: The sure way of getting nothing for something."
According to a Ministry of External Affairs report, there are approximately 31.2 million people of Indian ancestry or origin residing outside India.
According to a Ministry of External Affairs report, there are approximately 31.2 million people of Indian ancestry or origin residing outside India.
312 LAC NRI
312 LAC NRI
Deposits in an NRE account can be repatriated without any limit, whereas those from an NRO account are restricted to a total of 1 million USD per annum.
Deposits in an NRE account can be repatriated without any limit, whereas those from an NRO account are restricted to a total of 1 million USD per annum.
COLDEST CAPITAL IN WORLD
Ulaan-Baatar (Mongolia) 29.7°F/-1.3°C
Ulaanbaatar is the largest city of Mongolia as well as its capital and is a destination for both business and pleasure trips. It is below zero for five months of the year. January and February are the coldest months with the temperature ranging between -15°C and -40°C. The average annual temperature is -1.3°C.
Do note that the earnings in an NRO account are subject to TDS and balance will be credited only after deducting all taxes.
Do note that the earnings in an NRO account are subject to TDS and balance will be credited only after deducting all taxes.
“Humor is the antidote to over thinking. It’s a way of saying that life is paradoxical. Humor contains contradictions; it does not resolve them but revels in them. It says that the right way to exist among the contradictions, paradoxes, and absurdities of life is to cope with them through laughter.” - Bob Mankoff, How About Never: Is Never Good For You
“Humor is the antidote to over thinking. It’s a way of saying that life is paradoxical. Humor contains contradictions; it does not resolve them but revels in them. It says that the right way to exist among the contradictions, paradoxes, and absurdities of life is to cope with them through laughter.”
- Bob Mankoff, How About Never: Is Never Good For You
Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship.
Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship.
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COUSTEAU "Water and air, the two essential fluids on which all life depends, have become global garbage cans."
"Water and air, the two essential fluids on which all life depends, have become global garbage cans."
Wednesday 27 March 2019
pallimed x dyspnea x eolc
Dyspnea is one of the most common symptoms that patients encounter at the end of life. In patients with terminal cancer, 70% to 80% experience dyspnea at some time during the last 6 weeks of life, and they commonly experience a significant increase in dyspnea in the last 2 weeks.17,18 In patients with non–cancer terminal diagnoses such as chronic obstructive pulmonary disease (COPD) and congestive heart failure, the severity of dyspnea is highest, but it remains relatively stable until death.18 Dyspnea ranks as one of the most distressing symptoms to the patient and the family, leading to restrictions in quality of life and an increase in anxiety and fear.1
P THYROID PROBLEMS IN ED
Risk Management Pitfalls for Management of Pediatric Patients With Tick-Borne Illnesses
1. “There was no history of a tick bite, so I don’t have to worry about tick-borne illnesses.”
Tick bites are often painless and may be in locations that are not easily visible. Patients may not give a history of a tick bite; therefore, a careful history to elicit risk factors for tick exposure is necessary, particularly in endemic areas. In studies of tick-borne illnesses, a history of a tick bite was not reported in 30% to 40% of confirmed cases.1,2,26,97,98
4. “I had a strong suspicion that my patient had a tick-borne illness, but I wanted to be sure, so I waited for the confirmatory tests to result before starting her on an antimicrobial.”
For most tick-borne illnesses, confirmatory testing may take days or weeks to result. In patients with a consistent history, examination, and preliminary laboratory findings, empiric treatment may be started while test results are pending. In particular, delayed treatment with doxycycline is associated with a higher mortality rate for RMSF.143 Untreated, RMSF has a case fatality rate of 10% to 25%.144
10. “I’m not in a high-risk area, so I don’t need to consider tick-borne illnesses in my differential.”
While there are areas that are highly endemic for certain diseases, tick-borne illnesses have been reported in all of the contiguous 48 states.154 A thorough travel history is critical to identifying possible tick exposures, as cases acquired during travel to endemic areas may be easily missed.155 Patients may also be exposed during international travel.156,157 Excluding a specific disease based solely on geographic location may delay diagnosis and increase the risk of developing complications.
P TICK BORNE ILLNESS
Risk Management Pitfalls for Management of Pediatric Patients With Tick-Borne Illnesses
1. “There was no history of a tick bite, so I don’t have to worry about tick-borne illnesses.”
Tick bites are often painless and may be in locations that are not easily visible. Patients may not give a history of a tick bite; therefore, a careful history to elicit risk factors for tick exposure is necessary, particularly in endemic areas. In studies of tick-borne illnesses, a history of a tick bite was not reported in 30% to 40% of confirmed cases.1,2,26,97,98
4. “I had a strong suspicion that my patient had a tick-borne illness, but I wanted to be sure, so I waited for the confirmatory tests to result before starting her on an antimicrobial.”
For most tick-borne illnesses, confirmatory testing may take days or weeks to result. In patients with a consistent history, examination, and preliminary laboratory findings, empiric treatment may be started while test results are pending. In particular, delayed treatment with doxycycline is associated with a higher mortality rate for RMSF.143 Untreated, RMSF has a case fatality rate of 10% to 25%.144
10. “I’m not in a high-risk area, so I don’t need to consider tick-borne illnesses in my differential.”
While there are areas that are highly endemic for certain diseases, tick-borne illnesses have been reported in all of the contiguous 48 states.154 A thorough travel history is critical to identifying possible tick exposures, as cases acquired during travel to endemic areas may be easily missed.155 Patients may also be exposed during international travel.156,157 Excluding a specific disease based solely on geographic location may delay diagnosis and increase the risk of developing complications.
P GNTL INJRY
Risk Management Pitfalls in the Management of Genital Injuries and Emergencies in Pediatric Girls
1. “This young girl has a labial laceration. She should have a surgical consult for immediate repair.”
Not every labial laceration requires surgical intervention. If the bleeding is controlled and the source of bleeding is determined to be external to the vaginal canal, the patient can be treated and given a disposition by the emergency clinician.
3. “This adolescent with hematocolpos already has a small tear in her hymen that is allowing bleeding. We can release the remainder of the blood here in the ED.”
A hymenotomy should never be performed in the ED. Due to the high risk of ascending infection, the procedure needs to be performed in the operating room under aseptic conditions.
4. “Since there are no external signs or symptoms concerning for a serious injury, I don't need to do any further workup on this child who fell on a toy.”
There are many instances in the literature where an impalement injury was missed due to lack of imaging and further investigation. Impalement injuries may be subtle, and if not treated immediately, may lead to peritonitis and bacteremia. At a minimum, further questioning regarding the appearance of the toy is warranted before making this determination.
P RMP X BACT MENINGITIS
Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis
2. “The patient has inflamed tympanic membranes. The fever and irritability are likely due to otitis media. It’s not meningitis.”
Many young children with bacterial meningitis can have concomitant inflammation in other areas on physical examination or diagnostic study. Otitis media and upper respiratory tract infections are common enough conditions that their presence can lead the emergency clinician to “explain away” the child’s more serious symptoms as being due to those pathophysiologic findings. Anchoring on a simpler, less severe diagnosis can result in missing or delaying the correct diagnosis.
6. “The patient likely has viral meningitis, so we don't need to get a lumbar puncture.”
The notion that emergency clinicians can distinguish the difference between viral and bacterial meningitis based on the history and physical examination is not supported by the available evidence. The clinical overlap of these conditions is substantial, particularly early in the course of illness. Diagnosis should not be made based on the history and physical examination alone.
8. “We need to wait for a CT scan and lumbar puncture before we can give antibiotics, as they can cause sterilization of CSF.”
When caring for a patient with a presumptive diagnosis of bacterial meningitis, do not delay administration of appropriate antibiotics for the completion of a CT scan or lumbar puncture or for the results of these studies. Although antibiotics may obscure the ultimate bacteriologic diagnosis, this is a small clinical price to pay to prevent further bacterial proliferation and inflammation within the CNS.
RMP X HYPOTHERMIA
Risk Management Pitfalls in Management of Pediatric Patients With Cold Injuries
6. “I obtained an initial temperature but did not continuously monitor it.”
Continuous temperature monitoring will indicate whether the interventions are working or more aggressive therapy is needed. Having an appropriate probe for monitoring core body temperature is imperative; the temperature measurement method may need to be changed, based on the rewarming method being used.
7. “I was 2 boluses in before I remembered to give heated IV fluids.”
Do not forget to prewarm isotonic fluids before administering a bolus. Cold IV fluids can cancel the benefits of other rewarming therapies. If there is time, prewarm the fluids so that they are ready on the patient’s arrival.
10. “I didn’t think getting the patient to an ECMO center would make a difference.”
If you identify a patient who needs ECMO and it is not available at your center, transfer the patient as early as possible. Contacting the ECMO center yourself can help facilitate the transfer and prepare the accepting hospital’s ECMO team. As a hospital system, performing in situ simulation for a critically ill patient in need of ECMO will help prepare for the infrequent times it occurs. For high-acuity, low-frequency emergencies like this, simulation can identify process and management issues in your hospital.
P RMP ADOL GYNAE
Risk Management Pitfalls in the Management of Adolescent Patients With Gynecological Emergencies
1. “The patient said she had never had sex before, so I didn’t do a pregnancy test.”
Adolescents often do not disclose sexual activity, due to concerns about confidentiality. Emergency clinicians should have a low threshold for pregnancy and STI testing in adolescent girls, regardless of the history provided by the patient.
5. “The girl came in with vaginal discharge after intercourse with a partner reporting an STI, so I tested her for gonorrhea and chlamydia. I told her to call back in 2 days for results.”
Studies have shown that adolescents have poor follow-up and can be difficult to contact after presentation to the ED. If there is clinical concern for an STI, treat empirically for both gonorrhea and chlamydia in the ED; do not wait for test results.
9. “I found out the patient was pregnant, so I updated her mom about my plan to transfer her to a hospital with obstetric services.”
Clinicians are prohibited by law from disclosing pregnancy to parents/guardians without the patient’s consent, unless there is concern that the patient will harm herself or someone else. Adolescents aged > 12 years can seek sexual health services for contraception, pregnancy care, STI treatment, and sexual assault care, as well as mental health and substance use services without parental consent. Laws vary by state, so emergency clinicians should be familiar with confidentiality regulations where they practice
P BLUNT CARDIAC TRAUMA
Risk Management Pitfalls in Blunt Chest Trauma
1. “I always wait 3 hours before obtaining a troponin as part of my BCI workup.”
It would be appropriate to send troponin as part of the initial blood draw, therefore decreasing the duration of workup in the ED. Very few patients with significant BCI will have both a negative initial ECG and troponin. The important concept is to perform both tests initially, and if both are negative, then there is very little value to serial testing.
2. “The chest x-ray was normal, so I felt comfortable ruling out a pericardial effusion.”
A significant amount of fluid may be present in the pericardium despite a normal chest x-ray. If suspicion for a BCI or pericardial effusion remains, both point-of-care ultrasound and CT have high sensitivity and should be considered.
6. “For all patients with BCI, I order a formal echocardiogram and admit them to inpatient telemetry.”
Patients with suspected BCI can be effectively ruled out while in the ED or observation unit. Formal echocardiograms are reserved for patients with hemodynamic instability, persistent new dysrhythmias, and increasing troponin levels, and in symptomatic patients with significant mechanisms of injury. In otherwise stable patients, consideration of discharge home versus observation can avoid an inpatient admission.
CELTS
The Celts were a collection of tribes with origins in central Europe that shared a similar language, religious beliefs, traditions and culture. It's believed that the Celticculture started to evolve as early as 1200 B.C. ... The existence of the Celts was first documented in the seventh or eighth century B.C.
LATIN V CYRILLIC
Cyrillic shares more similarities with Greek than Latin… ...Cyrillic was invented by two Greek monks in the Middle-Ages named Cyril and Methodius, before they created an Alphabet named Glagolitic. They created those two alphabets to convert Slavic population to Christianity and to integrate them in the Byzantine Empire.
RC V EO
The Virgin Mary is venerated in the Eastern Orthodox Church as the God-bearer, honoured in devotions. The Eastern Orthodox Church shared communion with the Roman Catholic Church untilthe East–West Schism in 1054, triggered by disputes over doctrine, especially the authority of the Pope.
Tuesday 26 March 2019
FIRST OR LAST TIME ZEN
Look at everything as though you were seeing it either for the first time or last time. Then your time on earth will be filled with glory. ~ Bette Smith 
IP The Extended Sick Neonate Score (ESNS) can predict ‘in-hospital mortality’ outcome with good sensitivity and specificity at admission in all gestational ages.
The Extended Sick Neonate Score (ESNS) can predict ‘in-hospital mortality’ outcome with good sensitivity and
specificity at admission in all gestational ages.
P INS Acute kidney injury is common in hospitalized children with nephrotic syndrome and furosemide infusion is associated with an increased risk.
Acute kidney injury is common in hospitalized children with nephrotic syndrome and furosemide infusion is
associated with an increased risk.
Any large-scale human cooperation – whether a modern state, a medieval church, an ancient city, or an archaic tribe – is rooted in common myths that exist only in people’s collective imagination” (Yuval Harari, 2014, p. 30)
Any large-scale human cooperation – whether a modern state, a medieval church, an ancient city, or an archaic tribe – is rooted in common myths that exist only in people’s collective imagination” (Yuval Harari, 2014, p. 30)
M Pregnant women who work nights may have a greater risk of miscarriage
Pregnant women who work nights may have a greater risk of miscarriage
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World Autism Awareness Day takes place every year on 2nd ApriL
World Autism Awareness Day takes place every year on 2nd ApriL
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