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do we need Evidence Based Medicine to do what is right?

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ThunderClap Headache

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Amsterdam Pediatric Wrist Rules

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Thunderclap HA

Thunderclap Headache Author: Danya Khoujah Category: Neurology Publish Date: 2015-09-23 A thunderclap headache is defined as a very severe headache that reaches its maximum intensity within 1 minute. One of the most common causes (and the one associated with this buzzword on board questions!) is subarachnoid hemorrhage, but what else can cause a it? - Reversible cerebral vasoconstriction syndrome (RCVS): suggested by recurrent thunderclap headaches (2-10) over 1 to 2 weeks. Normal CT and LP, with vasoconstriction on angiography. Can lead to SAH, ICH or ischemic stroke. - Cervical artery dissection - Cerebral venous sinus thrombosis - Spontaneous intracranial hypotension: characterized by orthostatic HAs and auditory muffling. - Intracerebral hemorrhage - “Primary”: a diagnosis of exclusion Bottom line? All patients with thunderclap HA should have a stat head CT with no contrast, then have SAH excluded with an LP, CTA or MRI/MRA. Just because you excluded SAH in a patient with thunderclap headache does not mean you’re done with the emergency workup. References: TJ Schwedt. Thunderclap Headache. Continuum 2015; 21(4): 1058-71 Keywords: SAH, cerebral venous thrombosis, head CT Favorite Share Back UMEM Pearls

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The RED MAN

Toxicological etiology of patient with flushed skin . Author: Hong Kim Category: Toxicology Publish Date: 2015-09-16 Monosodium glutamate Rapid onset 30 min and lasts about 1 hour May accompanied with headache & chest pain. No associated GI sx. History of eating Chinese fodd. AKA "Chinese restaurant syndrome" Metabisulfites (Na sulfite, Na/K bisfulfite, Na/K metabisulfite, etc.) Food preservatives found in dried fruit, wine, molasses, sauerkraut, etc. Bronchospasm – asthma like, headache, mild hypotension can occur Most significant reaction in people with asthma/allergies History of trying to eat "healthy" Tyramine reaction Mostly among patients taking MAO inhibitors Source of tyramine (food): fermented, pickled product, avocado, chocolate, etc. Niacin Burning warm sensation to body Often used for sexual enhancement, elevated cholesterol and beating drug urine screens Trichloroethylene Occupational exposure – AKA “Degreaser’s flush” Facial flushing, head pressure, lacrimation & blurred vision may occur Require several weeks of exposure prior to symptoms Scrombroids Occurs after a “fish meal” (e.g. dark meat fish - tuna) Associated with GI symptoms (nausea, vomiting, diarrhea) Histamine related reaction due to poor refrigeration after catching fish. Hydroxocobalamin Antidote for CN poisoning Skin become red after administration due to its color (red) References: Keywords: flushed skin Favorite Share Back UMEM Pearls

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May Thurner’s Syndrome - clinical case review and education

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Hemorrhoids are swollen veins in the anal canal. This common problem can be painful, but it's usually not serious.

Veins can swell inside the anal canal to form internal hemorrhoids. Or they can swell near the opening of the anus to form external hemorrhoids. You can have both types at the same time. The symptoms and treatment depend on which type you have.

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Phlegmasea Cerulea Dolens

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Mers CoV

Middle East Respiratory Syndrome (MERS) is a viral respiratory illness that is new to humans. It was first reported in Saudi Arabia in 2012 and has since spread to several other countries, including the United States. Most people infected with MERS-CoV developed severe acute respiratory illness, including fever, cough, and shortness of breath. Many of them have died.

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1. For CT-proven, uncomplicated appendicitis, antibiotic treatment was not shown to be non-inferior compared to appendectomy.

2. Most patients randomized to antibiotic treatment did not require an appendectomy in the 1-year follow-up period. Those who did require appendectomy during that time period did not experience significant complications.

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CHARCOTS JOINT - Charcot arthropathy, or neuropathic arthropathy, is a condition that affects some diabetic patients with peripheral neuropathy (loss of sensation) after eight to 10 years. Jean Martin Charcot was a French physician who in 1868 described neuropathic arthropathy primarily in patients with advanced syphilis. At that time, people with diabetes did not live very long because insulin was unavailable to treat diabetes. Once insulin was available and diabetes treatable, it was in the 1930s that neuropathic arthropathy was recognized in diabetics. It may also occur with several other diseases that affect the sensory nervous system (alcoholism, leprosy, syphilis, Charcot-Marie-Tooth Disease to name a few). In the United States, diabetes is the number-one cause.

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Oral prednisone improves function, not pain in acute lumbar radiculopathy Oral prednisone improves function, not pain in acute lumbar radiculopathy

May 20, 2015 | Jeffrey Cohen and Priyanka Vedak 1. In this randomized controlled study of acute lumbar radiculopathy, oral prednisone improved function at weeks 3 and 52 when compared to placebo.

2. In this randomized controlled study, there was no difference between oral prednisone and placebo in improvement of below the waist pain at weeks 3 or 52 or rates of spinal surgery within one year.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Acute lumbar radiculopathy, or sciatica, is pain radiating down the lower extremities due to nerve compression by a herniated spinal disk. Sciatica is common in the United States and can be managed conservatively or, when more severe, with spinal steroid injections or surgical procedures. This study randomized Kaiser Permanente of Northern California members between 18 and 70 years of age with sciatica to receive oral prednisone or placebo. At 3 weeks and 52 weeks, participants in the prednisone arm had a greater reduction in Oswestry Disability Index (ODI) scores when compared to individuals in the placebo arm. There was no difference in below the waist pain between the two study groups at 3 weeks or 52 weeks. Individuals in the prednisone group also had higher physical activity scores on the Short Form 36 (SF36) when compared to the placebo group at 3 weeks and higher mental component summary scores in the SF36 at 52 weeks.

Strengths of this study include the use of a randomized controlled methodology, high adherence to interventions and follow-up, and the utilization of several outcomes that were followed over a full 52 weeks. This study is limited by the fact that all participants were from Northern California and the use of stringent inclusion and exclusion criteria that may limit generalizability. Overall, this study found that oral prednisone for sciatica improves function but does not ameliorate pain. A larger study should be done to more completely understand the utility of oral prednisone in the management of sciatica.

In-Depth [randomized controlled study]: This study randomized 269 individuals with acute lumbar radiculopathy to receive either a 15-day oral prednisone taper or placebo and followed improvements in function and pain for 52 weeks. Study participants randomized to the intervention arm took 60 mg of prednisone daily for 5 days, followed by 40 mg of prednisone daily for 5 days, followed by 20 mg of prednisone daily for 5 days. Participants randomized to prednisone had a greater reduction in ODI scores than did individuals randomized to the placebo arm at weeks 3 (p = 0.01) and 52 (p = 0.003). There was no difference between the two groups in pain below the waist at weeks 3 (p = 0.34) or 52 (p = 0.15). Participants in the prednisone arm had a greater improvement in the physical activity score of the SF36 at 3 weeks (mean 3.3 points; 95%CI 1.3-5.2; p = 0.001) and mental component score of the SF36 at 52 weeks (mean 3.6 points; 95%CI 0.6-6.7; p = 0.02). Over the course of the one-year follow up, there was no difference in the rates of spine surgery between the two groups (9.9% vs. 9.1%; RR 1.2; 95%CI 0.5-2.6; p = 0.68).

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What's the Diagnosis? Case by Dr. Ibrahim H. Abuduruk Author: Haney Mallemat Category: Visual Diagnosis Publish Date: 2015-05-19 5 year-old with no past medical history, complains of a limp and mild left knee pain. No history of trauma. Physical exam is significant for a low-grade fever and is otherwise normal. What’s the diagnosis? Brodie's abscess a.k.a subacute osteomyelitis Form of osteomyelitis, which is difficult to diagnose, and is often mistaken for a tumor. Males are affected more than females and the range of presentation is 2-15 years. Work up is difficult as CBC, ESR, CRP, and blood cultures are inconclusive. Xrays may mimic tumors. Treatment is antibiotics if the diagnosis is obvious; if not, biopsy to make the diagnosis. Surgery an option if either the lesion is aggressive or there is pus extending into the synovial fluid.

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Coumadin Toxicity

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Bronchiolitis Updates

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CLAP for sepsis - medical minutes