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  Bipolar Androgen Therapy for Prostate Cancer
Posted by: dbrosnahan - 12-01-2016, 02:45 AM - Forum: General Discussion - No Replies


The trial involved three cycles of "bipolar androgen therapy" (BAT) which involves alternately flooding and starving the body of the male hormone testosterone.  Levels of Prostate Specific Antigen (PSA) fell in the majority of the 47 participants.  One individual had PSA levels drop to zero after three months and 22 cycles of treatment.

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  Antibiotic Activity of Black Mustard
Posted by: dbrosnahan - 10-15-2016, 07:09 AM - Forum: General Discussion - No Replies


Jesus Christ said mustard was the greatest of herbs.

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Posted by: dbrosnahan - 10-07-2016, 04:17 AM - Forum: General Discussion - Replies (1)

A Cavernoma or Cavernous malformations are a vascular abnormality of the central nervous system involving clusters of abnormal, tiny blood vessels, and larger, stretched-out, thin-walled blood vessels filled with blood in the brain. These blood vessel malformations can also occur in the spinal cord, the covering of the brain (dura), or the nerves of the skull. Pathologically, it is red to purple in color, appearing as a raspberry. Cavernomas contain blood products at various stages of evolution and are usually less than 3 centimetres in size.

Some individuals are born with a tendency to develop cavernous malformations. They are not a cancer, which means they cannot spread to other parts of the body. Occasionally, people can have multiple cavernomas.  Cavernous malformations occur in people of all races and sexes. The male-female ratio is about equal. Family history may be positive especially in patients of Hispanic descent. Recent work has linked the predisposition to cavernous malformation to the seventh human chromosome. Cavernomas can be found in any region of the brain, be of varying size, and present with varying clinical disorders. In a general population of 1,000,000 - .5% or 5000 people may be found to have a cavernous malformation, although many are not symptomatic.

Patients with cavernomas may have associated seizures, progessive or transient neurologic deficits, bleeding, and headaches.   Approximately 12% of patients at our clinic are asymptomatic. Headaches accompany a cavernous malformation in many patients and may have even precipitated the diagnostic evaluation uncovering the lesion. 6-10% of patients with a cavernoma will report headaches as an accompanying symptom.  Patients may present with double vision, unsteadiness, sensory disturbances, and weakness or paralysis on one side of the body. These complaints are closely related to where the lesion is located. 20% of patients will complain of these when they present to the physician.  36% of patients with a cavernous malformation will present with seizures. Up to 25% of patients will present with a hemorrhage. This is the most serious complication of a cavernoma. If the cavernoma does bleed, it usually, but not always, starts with a headache. The headache starts suddenly and may be followed by nausea, neurological problems or a decreasing level of consciousness. Sometimes a bleed may be very small and produce very mild or no symptoms at all.  Bleeding risk depends on where the malformation is located. Deep lesions in the brainstem bleed and cause problems at a rate of 10% per year, whereas symptomatic hemorrhage from a superficial lesion is very uncommon. The risk with a superficial lesion is much lower (less than 1% year). 

There are two main tests that are used to diagnose cavernomas. These are: Computerized Axial Tomography (CAT Scan), Magnetic Resonance Imaging (MRI).  There are two possible options available for patients who are found to have a cavernous malformation: Surgery, or No treatment.  The following are indications to consider treatment of a cavernous malformation: Neurological dysfunction, An episode of bleeding, Intolerable symptoms, Uncontrolled seizures.


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  Automatic Blogger Posting
Posted by: dbrosnahan - 09-15-2016, 04:06 AM - Forum: General Discussion - Replies (1)

I am hoping to set up the Emergcity forum to automatically upload new threads from the General Discussion forum to the Emergcity blog at http://emergcity.blogspot.com.  This way, new content will be easily found at both locations.  This is accomplished by without 3rd-party software or another plugin by creating an account for the emergcity blog, and then subscribing to the thread or forum of interest.  MyBB should automatically forward any new threads and posts to the subscriber email.  Posts to the Blogger website can then be made via email.  If this works, I will try to accomplish something similar with Facebook, Instagram, and Twitter.

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  tPA Contraindictions
Posted by: dbrosnahan - 09-14-2016, 05:45 AM - Forum: General Discussion - No Replies

Absolute Contraindications

Acute Intracranial Hemorrhage
History of ICH
Severe Uncontrolled Hypertension
Serious Head Trauma or Stroke in Previous 3 Months
Thrombocytopenia and Coagulopathy
Low-Molecular-Weight Heparin
Direct Thrombin Inhibitors
Factor Xa Inhibitors
Severe Hypoglycemia or Hyperglycemia
Early Radiographic Ischemic Changes

Relative Contraindications (Judgment)

Advanced Age (Rare Contraindication)
Mild or Improving Stroke Symptoms (NIH<4)
Severe Stroke and Coma (NIH>25)
Recent Major Surgery (3 months)
Arterial Puncture of Noncompressible Vessel
Recent Gastrointestinal or Genitourinary Hemorrhage (21 days)
Seizure at Onset
Recent Myocardial Infarction (3 months)
Central Nervous System Structural Lesions
Dementia (Rare Contraindication)


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  Emetrol (Phosphorated Carbohydrate) for Nausea
Posted by: dbrosnahan - 08-31-2016, 01:08 AM - Forum: General Discussion - No Replies

Emetrol is a phosphoric acid glucose mixture available over-the-counter for control of nausea. It is believed to work by relaxing gastric smooth muscle and decreasing gastric motility. Studies show that it is most effective for "functional" nausea (morning sickness, gastroenteritis, migraine, etc) over "organic" nausea (gallbladder disease, cancer, etc). 


Notes from:

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  Isopropyl Alcohol Inhalation for Nausea
Posted by: dbrosnahan - 08-31-2016, 12:33 AM - Forum: General Discussion - No Replies

A recent randomized, double-blinded, placebo-controlled trial by Beadle et al. was performed in an ED population complaining of nausea and/or emesis comparing saline versus isopropyl alcohol inhalation. This study found that isopropyl alcohol provided significantly greater relief from nausea in the first 10 minutes of aromatherapy compared to saline (p <0.001).  The mechanism of action is unknown.  Treatment involves three nasal inhalations of a standard ED alcohol wet wipe every 15 minutes, repeated two times as needed.

[*]Cotton JW, Rowell LR, Hood RR, Pellegrini JE. A comparative analysis of isopropyl alcohol and ondansetron in the treatment of postoperative nausea and vomiting from the hospital setting to the home. AANA J. 2007; 75(1): 21-6. PMID: 17304779
[*]Winston AW, Rinehart RS, Riley GP, Vacchiano CA, Pellegrini JE. Comparison of inhaled isopropyl alcohol and intravenous ondansetron for treatment of postoperative nausea. AANA J. 2003; 71(2): 127-32. PMID: 12776641
[*]Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Ann Emerg Med. 2014; 64(5): 526-532.e1. PMID: 24818542
[*]Pellegrini J, DeLoge J, Bennett J, Kelly J. Comparison of inhalation of isopropyl alcohol vs promethazine in the treatment of postoperative nausea and vomiting (PONV) in patients identified as at high risk for developing PONV. AANA J. 2009; 77(4): 293-9. PMID: 19731848
[*]Merritt BA, Okyere CP, Jasinski DM. Isopropyl alcohol inhalation: alternative treatment of postoperative nausea and vomiting. Nurs Res. 2002; 51(2): 125-8. PMID: 11984383
[*]Smiler BG, Srock M. Isopropyl alcohol for transport-related nausea. Anesth Analg. 1998; 87(5): 1214. PMID: 9806717
[*]Hines S, Steels E, Chang A, Gibbons K. Aromatherapy for treatment of postoperative nausea and vomiting. Cochrane Database Syst Rev. 2012; 4: CD007598. PMID: 22513952
[*]Wang SM, Hofstadter MB, Kain ZN. An alternative method to alleviate postoperative nausea and vomiting in children. J Clin Anesth. 1999; 11(3): 231-4. PMID: 10434220
[*]Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015; DOI: http://dx.doi.org/10.1016/j.annemergmed.2015.09.031

Notes from https://www.aliem.com/2015/trick-trade-i...-vomiting/

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  Infant Colic (Fussy and Gas Pain)
Posted by: dbrosnahan - 08-27-2016, 08:40 AM - Forum: General Discussion - No Replies

Not uncommonly, first-time Moms will bring their babies into the ED wanting help with a crying or fussy baby with report of gas pain.  If the baby is inconsolable it may be important to consider a corneal abrasion and checking for a hair tourniquet around a finger or toe. If the pain is episodic, and the infant is feeding well and consolable, then it may an intolerance to formula or swallowing too much air while feeding. So, I will routinely give reflux precautions to the Mother to burp the baby after every 1 oz feeding and to have the baby put on their back to sleep on an incline. In fact, allowing the baby to sleep in their car seat next to the bed wrapped in a swaddle (baby burrito) works rather well.  Additionally, I have suspected that the choice of pacifier may contribute to colic.  I prefer the Soothie pacifier over the Gerber Nook and think some infants swallow air with the Nook. Also, Mylicon infant drops (Simethicone) can be used.  Ultimately, these are issues for the pediatrician.

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  Thrombolytic Dosing
Posted by: dbrosnahan - 08-19-2016, 09:07 AM - Forum: General Discussion - No Replies

Alteplase (Activase, tPA)
Acute MI: (>67kg): 15 mg IV bolus over 1-2 minutes, then 50 mg over 30 minutes, then 35 mg over next 60 minutes. (<67kg): 15 mg IV bolus, followed by 0.75 mg/kg (maximum 50mg) over 30 minutes, then 0.5 mg/kg (maximum 35mg) over the next 60 minutes. Note: Concurrently, begin heparin 60 units/kg bolus (maximum: 4000 units) followed by continuous infusion of 12 units/kg/hour (maximum: 1000 units/hour) and adjust to aPTT target of 1.5-2 times the upper limit of control. Infuse remaining 35 mg of alteplase over the next hour.

Acute PE: 100mg IV over 2 hours, then restart heparin when PTT < twice normal.

Acute ischemic stroke: Doses should be given within the first 3 hours of the onset of symptoms. Recommended total dose: 0.9 mg/kg (maximum dose should not exceed 90 mg) infused over 60 minutes. Load with 0.09 mg/kg (10% of the 0.9 mg/kg dose) as an IV bolus over 1 minute, followed by 0.81 mg/kg (90% of the 0.9 mg/kg dose) as a continuous infusion over 60 minutes. Heparin should not be started for 24 hours or more after starting alteplase for stroke.

Central venous catheter clearance: Intracatheter (Cathflo™ Activase® 1 mg/ml): Patients <30 kg: 110% of the internal lumen volume of the catheter, not to exceed 2 mg/2 ml. Retain in catheter for 0.5-2 hours. May instill a second dose if catheter remains occluded. Patients >30 kg: 2 mg/2ml- retain in catheter for 0.5-2 hours - may instill a second dose if catheter remains occluded.

Acute peripheral arterial occlusive disease (unlabeled use): Intra-arterial: 0.02-0.1 mg/kg/hour for up to 36 hours. The most common indications for thrombolysis were peripheral arterial occlusion and venous thrombosis. Preparation: Continuous infusion of alteplase (50 mg of alteplase reconstituted in 50 mL of sterile water and diluted with 0.9% normal saline solution to a concentration of 0.1 to 0.2 mg/mL). Infusion rate: 0.5 to 2 mg/hr x 6 to 72 hours depending on location.

Supplied: 50 mg, 100 mg vial ( powder for reconstitution). Cathflo: 2 mg.

Tenecteplase (TNKase)
Acute MI: Treatment should be initiated as soon as possible after the onset of AMI symptoms. The recommended total dose should not exceed 50 mg and is based upon patient weight. A single bolus dose should be administered over 5 seconds based on patient weight.

Patient Wt (kg)  TNKase (mg)   Volume (ml) over 5 seconds
< 60                            30mg                   6ml 
60 to < 70                    35                       7 
70 to < 80                    40                       8 
80 to < 90                    45                       9 
Over 90                       50                      10  

Preparation: dilute 50mg vial with 10ml sterile water (packaged with diluent and syringe).

All patients received 150-325 mg of aspirin as soon as possible and then daily. Intravenous heparin was initiated as soon as possible and aPTT was maintained between 50-70 seconds.  Tenecteplase is incompatible with dextrose solutions.

Supplied: 50 mg vial ( powder for reconstitution).

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  Contract Management and EM Reimbursement
Posted by: dbrosnahan - 08-19-2016, 04:02 AM - Forum: General Discussion - No Replies

Emergency Medicine is being taken over by contract management groups.  The private democratic physician group is being pushed out by pressures from the federal government and private insurance which gives unequal reimbursement to contract groups over private groups due to their so-called negotiating power.  Also, it is suspected that the federal government has been targeting private physician groups with billing audits.

In the short term, EM reimbursement has been up due to basic Friedman economics.  (Doctor Supply) M . (Velocity) V = (Pay) P . (Productivity) G.  In this simple relationship, the supply of doctors, and their productivity is relatively unchanged. But because doctor's tend to have less invested with a contract management group, as opposed to a private group, they tend to move around more.  This increased velocity (V) of physicians will inflate pay (P) as doctors as contract management groups compete for a limited supply of EM physicians.   The same trend can be seen in professional sports.

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