The memoirs of Edith Nagel Eisinger continues. This podcast contains the fourth chapter of the personal memoirs of Edith Nagel Eisinger, wife of Dr. Harold Nagel. In 1936, the Nagel's founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center. Enjoy the next chapter of Edith Nagel Eisinger's story.

Ridgeview Podcast: CME Series

My Early Years in Waconia - by Edith Nagel Eisinger (CHAPTER 4)

This podcast is a reading of the third chapter from the personal memoirs of Edith Nagel Eisinger, wife of Dr. Harold Nagel. In 1936, they founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center. Enjoy the next chapter of Edith Nagel Eisinger's story.

My Early Years in Waconia - by Edith Nagel Eisinger (CHAPTER 3)

Western and Eastern medicine both offer unique perspectives fundamental to healthcare today. In this podcast, Nikki Vanecek a traditional Chinese medicine practitioner with EastWest Acupuncture, discusses different modalities of Eastern medicine, and how both Eastern and Western medicine can benefit patients. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Describe acupuncture and the different Chinese medicine treatments. Identify when to refer patients for acupuncture and Chinese medicine treatment. Determine what is best treated with acupuncture or other Chinese medicine treatment modalities. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Collaboration of Acupuncture and Chinese Medicine with Western Medicine - A unique perspective" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. Thank-you for listening to the podcast.

Collaboration of Acupuncture and Chinese Medicine with Western Medicine - A unique perspective

In this podcast,  Dr. Chris Mast, Vice President of Clinical Informatics with EPIC, discusses how electronic health medical records (EHRs) are essential to today's modern day medical world, about implementing and using an EHR for improving patient care, and  what the EHR future holds for healthcare. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Recognize the benefits that an integrated electronic health record system will bring to patients and healthcare providers. Identify steps that healthcare providers can take to maximize their efficiency and smoothly transition to new electronic systems from existing systems. List common roadblocks that prevent healthcare providers from taking full advantage of their electronic tools/resources. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "An EPIC Perspective on EHRs with Dr. Chris Mast" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: CHAPTER 1: The importance of medical records has grown in the last 100 years, starting with the first paper medical records developed in the 1920s. Even back then, standardization was important, the American College of Surgeons established an association to achieve just that. In 1965, Medicaid and Medicare were developed and pushed the development of health information systems. The 1970s brought computerized physician ordering systems. The first information system was also rolled out in the University of Vermont Medical Center's gynecology unit. In the 1980s, growth in the computer world led to new possibilities in healthcare. Personal computers became more affordable. Dragons systems developed voice recognition software and by the late 1980s, Windows software was developed. From 1990 to the late 2000s there was the boom of the World Wide Web, ICD-30 coding, and legislation for the increase of electronic health records (the HiTech Act). Between 2008 and 2015 electronic health record adoption doubled. EPIC is a privately owned company, which Dr. Mast states has allowed the company to focus on the long term, making sure that the software is a joy to use, and provide value to healthcare providers. CHAPTER 2: EPIC is an integrated comprehensive electronic health record system that offers many different functions to promote better patient and health care interactions. The features of EPIC provide a one-platform system, thereby eliminating the multiple database platforms used in the past or are still being used today. One of the big benefits of EPIC is the ability to share pertinent patient information across organizations that both work with EPIC. However, with increasing interoperability (much like cell phones bounce off other network cell towers), communication between different EHR systems increase. This interoperability will only increase as standardization of data, like how a specific diagnosis - like heart failure is coded, improves. Dr. Mast states, "playing the percentages, you will be able to connect, if not now, in the near future". The interoperability of EPIC assists in promoting care everywhere as well as the newer share everywhere features which is a limited one-time access to care everywhere for the non-EPIC health system evaluating a patient. CHAPTER 3: Connect customers, organizations that use EPIC software in partnership with another organization, benefit from a move-in ready EHR where they can start using the system immediately. The example used, is like moving into a furnished apartment, without having to find, build or organize everything. It's already there, ready to use. EPIC is not a tiered system. There is not a platinum or gold level status. However, not every organization needs every module available on the EPIC platform. What kind of support will an EPIC customer receive? In the Connect scenario, there are essentially two groups of assistance. The connect partner, with their knowledge and support as well as the support team from EPIC.  There is also personalization of EPIC systems to create the features and information important to the workflow of an individual clinician. CHAPTER 4: EPIC is more than just a documentation software. Within the system, there are algorithms and models that allow the computer to analyze data and predict, say, patients that are trending towards sepsis. This information can be used to direct resources earlier, intervene earlier, and improve outcomes. Another example of AI modeling would be a patient discharged with congestive heart failure, and submitting daily weights. Modeling can trend that data and predict those that might fail outpatient treatment, provide opportunities for early interventions, and again, improve outcomes. That is the present. The future of AI in electronic health records is endless. Ambient speech recognition is currently being trialed, providing documentation, transcription and even the possibility of cueing up orders. It is the fundamental theorem of informatics at work: clinician plus computer is greater than clinician alone. Thank-you for listening.

An EPIC Perspective on EHRs with Dr. Chris Mast

In this podcast, Dr. Scott Sharkey, senior consulting cardiologist with Minneapolis Heart Institute, provides a discussion on cardiomyopathy and more specifically Takotsubo syndrome. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Describe how Takotsubo cardiomyopathy was discovered. Differentiate the diagnostic criteria for Takotsubo cardiomyopathy from other cardiology related conditions. Identify treatment options for Takotsubo cardiomyopathy. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Achin' Breaking Hearts: Takotsubo Syndrome w/Dr. Scott Sharkey" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: CHAPTER 1: Cardiomyopathy. According to Dr. Sharkey, it is a general term for cardiac muscle disease, often times of unknown cause. Usually it refers to a dilated, poorly, contracting heart. Though it's also been called stress cardiomyopathy, Takotsubo does not behave like most cardiomyopathies. It's a microcirculatory disease, causing a stunned myocardium similar to an acute myocardial infarction, but with non-obstructive epicardial coronary arteries. Dr. Sharkey and his colleagues first noticed this phenomenon in patients with myocardial infarction that showed deep T wave inversions on EKG, and initial ECHOs with ejection fractions of 25-30%. Weeks later, these injuries would resolve, findings they attributed to a stunned myocardium. This phenomenon was then seen in a patient with a TBI, who again had a deep T wave inversion, and a large left ventricular regional wall motion abnormality with normal coronary arteries. The regional wall motion abnormality, again, resolved. These findings were noted in 20 similar cases that were then published in 1998. Though to note, this same syndrome was also present in the Japanese literature at this time. Later, it was noted patients were developing these symptoms not just from severe illness or trauma, but also from deeply emotional situations. This led to a write-up in Circulation in 2005, which received the 'Paper of the Year' award. From the early days to now, Dr. Sharkey went from seeing three to four patients per year with Takotsubo, to present day, one to two patients per week. The Minneapolis Heart Institute Foundation has done, and continues to do robust research on Takotsubo, noting that there is a subset of vulnerable patients that actually have recurrences of Takotsubo., They have also been able to study specific triggers for Takotsubo, like drug use, pheochromocytoma and critical illness in general. CHAPTER 2: Triggers for Takotsubo. As mentioned before, drug use, pheochromocytoma or critical illness are causes, but really any physical illness as well as any emotional stress are triggers for this syndrome. Death of a spouse is a good example of an emotional trigger, though as exemplified in the discussion, it can be any emotional situation. Teasing out the patient's history and the specific precipitation event is an art form. The autonomic nervous system is implicated here. Catecholamine levels are very elevated in these patients, as opposed to lower levels seen in acute MI patients. Pheochromocytoma and accidental overdose of epinephrine will cause this as well. The pathophysiology of the event is still being researched. It's postulated that this is all caused by vasospasms of the circulation or direct myocardial injury due to the catecholamine excess. It's presumed that effects occur on micro-circulatory level, and any disruption in blood flow is brief, less than 15-20 minutes, enough to raise serum troponins and cause wall motion abnormality. The involvement is circumferential, so the ECG findings are more diffuse. EKG changes include ST segment elevation in about 40% of patients. Otherwise T wave inversion is often seen, but is a later development. ST depression is not generally seen in Takotsubo, and would instead indicate a coronary artery occlusion. Echo findings show a classic, distinctive finding: poor contractility or akineses from the mid-heart to the apex, while the base of the heart is hypercontractile. Also called apical ballooning, the apex can be seen ballooning outward on echocardiograms. This is what is reminiscent of a Japanese clay pot, octopus trap, aka Takotsubo. And yes, the name is most certainly credited to the Japanese. CHAPTER 3: When a patient presents with an acute cardiac event that looks like Takotsubo, the patients still must undergo coronary angiogram to exclude a coronary occlusion. Cardiac echo and cardiac MRI are used to help diagnose this disease. Beta blockers and ACE inhibitors are used early on in treatment, but Dr. Sharkey suspects that patients would probably recover without them. The reality is, most of these patients get better. The myocardium, in the setting to Takotsubo, should recover. A process that usually takes one to two weeks. Anti-platelets do not play a role here, but anticoagulants are often given until the myocardium has recovered to prevent a small risk of left ventricular thrombus. Left ventricular outflow tract obstruction is a complicating factor in Takotsubo. Many of these patients are middle aged to older women, and have basal septal hypertrophy. This exacerbates, the outflow obstruction, which causes hypotension and shock in Takotsubo, 15-20% of the time. The left ventricular outflow obstruction should resolve with the resolution of Takotsubo. As mentioned, Takotsubo can have a recurrent phenomenon, and remarkably, these patients all recover their heart function. Curiously, the precipitating cause for these patients tends to be emotional. Though used in the initial treatment, beta blockers are not prescribed long-term for Takotsubo patients. In fact, Dr. Sharkey found that 30% of patients with a Takotsubo event were already on beta blockers, and 80% of those who have had recurrent Takotsubo were already on beta blockers and ACE inhibitors. CHAPTER 4: Patient presentation: Patients can present with chest discomfort and/or shortness of breath, much like an acute MI patient. They can also present with an acute concern of another nature. Dr. Sharkey gave the example of a patient presenting with a pasteurella multocida infection causing an airway obstruction. The patient's ongoing hypotension led to further work up and diagnosis of Takotsubo. Takotsubo patients can also be discovered during inpatient stays when incidental ECG wave form changes, troponin elevation, tachycardia, and/or hypotension are noted. About 10% of Takotsubo patient's develop cardiogenic shock. Most survive their ICU stay, even if advanced treatment, like intra-aortic balloon pumps or ECMO are required. For the critically ill, where beta blocker use is contraindicated in the light hypotension, Dr. Sharkey preferred choice of vasopressin followed by phenylephrine. Fortunately, patients recover from Takotsubo. However, malignant arrhythmias and cardiac arrest can happen. Patients are counseled to present to emergency care if their symptoms ever return. Thank-you for listening.

Achin' Breaking Hearts: Takotsubo Syndrome w/Dr. Scott Sharkey

In this podcast, Ashley Leland and Alex Ross, clinic pharmacists with Ridgeview, provide a discussion on medication therapy management, through a case study perspective.  Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Describe medication therapy management (MTM) and clinic pharmacists roles and responsibilities. Identify patients who may be candidates for a referral to a clinic pharmacist for medication therapy management (MTM) pharmacy services. Recognize the types of drug therapy problems (drug/ medication related) which a clinic pharmacist could help resolve. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Skills to Manage Your Pills: Medication Therapy Management" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: CHAPTER 1: Medication Therapy Management can also be called CMM or Comprehensive Medical Management. For the sake of this episode, it will be referred to as MTM throughout. MTM is a pharmacy service for targeted disease states like - asthma, COPD, diabetes, and/or congestive heart failure, and also for patients with polypharmacy. Really, any patient with concerns about their medications, can utilize this service. The goal is to identify drug therapy problems: side effects, medication compliance, drug interactions, and overall management of symptoms, to improve outcomes, for example, reducing hospital readmissions. CHAPTER 2:  In chapter 2, a patient was seen with a complex medical history, including heart failure, diabetes, new a-fib, and a recent hypokalemic event. MTM services identified several drug therapy problems, including drug interactions between the patient's diltiazem and atorvastatin, and between turmeric and Eliquis. Also identified was the need for diabetic management, and that the patient's over-the-counter potassium supplements were not sufficient in maintaining normal levels. In follow-up, the patient was doing well, had started taking farxiga, stopped the turmeric, and switched from diltiazem to metoprolol. In this chapter, Ashley and Alex briefly discuss natural medications and the use of the Natural Medicines Database to evaluate over-the-counter supplements and herbals. It's noted that some patients want to take a more wholesome approach to their medications, they recommend doing the research for good manufacturing practices or USP verified supplements and herbals. A great resource is your local MTM pharmacist. Another important service MTM pharmacists is helping patients navigate the financial decisions regarding medication cost. Whether suggesting alternatives or navigating the patient to assistance programs for specific mediations. CHAPTER 3:  In chapter 3, a patient who recently changed countries, had several drug therapy problems like adjusting medications to what is available here in the US, adjusting dosages of his current medications, gaining access to a glucose monitor, and updating vaccines. It's a good example of the range of things a MTM pharmacy visit can manage. Common drug interactions were touched on briefly. Highlighting the importance of knowing not just what over-the-counter medications a patient is taking, but the quantity as well. Also important, knowing the supplements and herbals being taken and how they might interact with any prescribed medications. It's noted that the structure of an MTM visit, that hour long conversation just about medication management, helps break down barriers, and hone in on the issues that patients can have with their medications. It also brings up areas for opportunity elsewhere, where that medication discussion is happening in much shorter time periods. CHAPTER 4:  The last patient case touches on an important demographic for MTM pharmacists, mental health regimens. This patient presented with a new tremor and agitation. Her drug therapy problems included duplicate therapy, suspected serotonergic complications, stimulating compounds, and an emotional attachment to her medications. The results of her MTM visit included stopping her amitriptyline and her focus supplement. Tapering off her duplicate therapy escitalopram, and then returning for follow-up. The follow-up time frame for patients depends on the complexity of drug therapy problems identified. Ashley found that setting the follow-up appointment during the current appointment, increases the follow through for patients. MTM Pharmacy is located at 7-9 Ridgeview primary and specialty clinics. They can be directly consulted by the patient's primary care provider or patient's can reach out to any of the clinics they are located in. Patients that would specifically benefit from these services include those with polypharmacy, those who are not doing well with their current medication regimen, and those with chronic disease states. Other areas where MTM pharmacy is involved, but not mentioned in depth here include - immunizations, opioid prescribing and stewardship, anticoagulation, and non-surgical weight loss programs. Thank-you for listening.

Skills to Manage Your Pills: Medication Therapy Management

In this podcast, Dr. Dennis Mohling, a board certified OB-GYN physician with Western OB-GYN, provides an insight into obstetric emergencies and how to deal with them if and when they occur. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Define each of the three stages of labor. Recognize life threatening obstetrical emergencies, and implement immediate, non-surgical treatment. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Tales of Labor: Obstetric Emergencies - with Dr. Dennis Mohling (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: CHAPTER 1: Retained PlacentaThe first stage of labor involves regular contractions affecting cervical changes up to complete cervical dilation. The next stage is the pushing and delivery of the baby, and the third stage follows delivery, ending in delivery of the placenta. The placenta is "retained" if it is still in the uterus after 30 minutes. The uterus cannot contract at this point and with approximately 500mls of blood going across the placenta-uterine interface retained placenta increases the risk for hemorrhage. Incidence is around 3%. A long list of risk factors for retained placenta include: preterm delivery, history of retained placenta, placental abnormalities, velamentous cord, and uterine abnormalities - like bicornuate uterus or septate uterus. Prior C-sections are also a risk factor, as well as intrauterine growth restrictions, and severe preeclampsia. After the 30-minute mark, preparation for manual extraction needs to begin. It's the "call for help" action step that will be a recurring theme in the discussion today. This includes the very important step of calling anesthesia. Manual extraction is a painful process, and great analgesia and sedation is a necessity. Manual extraction: using the umbilical cord as a pathway to the uterus with the dominant hand and supporting the uterine fundus with the other. Use fingers to create a dissection plan and gradually peel away the placenta from the uterus, removing it in its entirety. Post-removal the uterus will contract, but IV Pitocin, IM methergine, and TXA can be given as well. Pitocin dosing: 20 units in a liter of LR, run wide open. Average placental delivery can range from right away to 60 minutes post-delivery of the baby; but retained placenta can have a delayed presentation. This can cause prolonged bleeding requiring extraction days, to weeks postpartum. There are three stages of abnormal placental attachment. Placenta accreta: the stria layer between the placenta and uterus is absent. Placenta increta: the placenta is invading the muscle wall of the uterus. Placenta percreta: the placenta has grown through the uterus and into other organs. With uterine wall involvement, this will result in a c-section and likely a hysterectomy. CHAPTER 2: Uterine InversionUterine inversion is yet another scary presentation and can result in severe hemorrhage, shock and death. The uterus can be mildly inverted and protruding or fully inverted outside of the pelvis. Post-delivery, and in active management of the third stage, gentle cord contraction is the goal. Uterine inversion is thought to be the result of excessive cord traction, but the data on this is mixed. Incidence is 1 in 35,000, rare but still real. Larger babies, long labors and sometimes fast short fast labors, severe preeclampsia, retained placenta and other uterine abnormalities are risk factors, through these are only present in 50% of uterine inversion cases. Treatment is non-surgical. The uterus needs to be returned as soon as it's discovered. Insert that, "call for help" step. Anesthesia, more personnel, including nurses and lab techs are part of that "help" response. In order to return the uterus back inside the pelvis, pitocin should be stopped and uterine relaxant agents, like inhalation agents or nitroglycerin may be needed. The uterus is then pushed back through the vagina and cervix to its normal position. Once back in place, the placenta needs to stay intact. Uterine relaxant agents are turned off, and uterine tonic agents and TXA are started. Manual extraction of the placenta follows. As the uterus is never meant to be outside the body, antibiotics are started as well. CHAPTER 3: Cord Prolapse In delivery, the head of the baby should act as a barrier. If the umbilical cord slips in front, it will become compressed as the baby delivers, causing fetal asphyxia. Incidence is 2 in 1000.  Risk factors include: polyhydramnios, prematurity, breach, transverse lie, twin gestation, and after rupturing of membranes or other intrapartum procedures like cervical ripening with balloon catheter. Presentation is generally obvious with visualization or palpation of a pulsatile mass in the vagina or out on the bed. The fetal monitor, with normal being 120-160 bpm, will show a slowing heart rate, with variable decelerations. C-section is the eventual fix, but in preparation for that intervention, the compression on the cord must be reduced. This is accomplished by lifting or pushing the baby's head more cephalad for as long as it takes, until a C-section can be performed. The cord should not be cut, instead if it is outside the vagina, it should be covered in warm moist towels. CHAPTER 4: Shoulder Dystocia Shoulder dystocia is scary and way more common. It's the failure of the anterior shoulder to deliver after the head, and is instead stuck behind the pubic bone. Baby is at risk for brachial plexus injury as well as brain injury from asphyxia. Unfortunately, this is not a predictable dilemma. Sometimes having bigger babies does increase risk of this, but that is not always the case. Advanced maternal age, maternal age, maternal obesity and diabetes can result in bigger babies. History of shoulder dystocia in the past is also a risk factor. In the event of shoulder dystocia, a "turtle sign" may be noticed, where the baby's head comes out, then retreats between contractions. Dr. Mohling's Steps for Shoulder Dystocia: Step 1: Preparation.  Position the mother appropriately right at the edge of the bed, give gentle traction, have a stool ready for suprapubic pressure.  Step 2: Do not make it worse, by pulling harder. Step 3: McRoberts maneuver (hyperflexion of maternal legs) combined with suprapubic pressure, and of course "call for help". Usually the dystocia is relieved in less than a minute. If this doesn't work, a generous episiotomy is done to give room to maneuver. Next step is delivery of the posterior arm, by reaching in and finding the hand. If not found, press the antecubital fossa to flex the arm. Risk of humerus fracture with delivery of the posterior arm is 1 in 5. Other Manuevers: Ritgen Maneuver: Adduction of the posterior shoulders by placing the fingers behind the scapula and adducting the anterior or posterior shoulder to reduce the AP diameter. Woodscrew: Corkscrew the baby out, which sounds easier than it is. Clavicle Fracture: Pulling the bone away from the baby so as not to cause lung injury. Difficult to do with the size of the bone and slippery conditions during delivery. As last resort, the zavanelli maneuver, or attempting to return the baby back up the birth canal to the uterus for emergent c-section, may be performed. Thank-you for listening.

Tales of Labor: Obstetric Emergencies - with Dr. Dennis Mohling

In this podcast, Dr. Nicholas Deeter a Ridgeview family medicine physician, discusses how lifestyle intervention can be utilized for treatment of most chronic diseases, and how lifestyle medicine can influence one's health and nutrition. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Identify how lifestyle impacts chronic disease. Describe how the role of diet and exercise can be used as a form of  disease treatment and prevention. Develop strategies to change and improve patient lifestyles. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Lifestyle Medicine: Don't Let Perfect Get in the Way of Better - with Dr. Nick Deeter" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.    SHOW NOTES: CHAPTER 1: Heart disease, cancer, unintentional accidents, stroke and diabetes are all in the top ten leading causes of death. All of these are impacted by lifestyle. Here are the numbers: 3 out of 5 Americans have chronic disease. Half of Americans have some form of cardiovascular disruption, 38% will be diagnosed with cancer in their lifetime, and nearly 3 in 4 Americans are overweight or obese. Lifestyle modifications alone, can prevent 80% of heart disease, stroke and type 2 diabetes and 40% of cancers. Dr. Deeter referenced the EPIC study, with 20,000 participants, outlining four lifestyle modifications: refrained from smoking, moderate to no alcohol, regular physical activity, and consistently eating 5 or more servings of fruits and vegetables daily. Participants that did these four things, lived 14 years longer than those who did not. Preventable disease comes down to diet. for instance, much like smoking causes lung cancer, eating processed meats is directly linked to colon cancer. Education for our patients includes eating less processed or high sodium foods and working towards a plant based diet with an increase in fiber. "Plant based on a budget", "21-day Vegan kickstart", and nutritionfacts.org are all resources that patients can be pointed to. CHAPTER 2: Plant based diets can improve vascular health, reduce cardiovascular risks and lead to better daily performance. Briefly, proinflammatory markers were discussed in relation to meat, and how animal foods lead to Trimethylamine N-Oxide (TMAO) and advanced glycation end products. Moral of the story: less meat is better. Changing diet can be challenging, and within the current industry, food is engineered like a drug for the brain. Dr. Deeter suggests counseling patient on taking small steps in the transition to healthier eating. For those that still want to eat meat, try cutting back one day a week, controlling the portion size, and source local and organic meat when possible. Eating by stoplight colors: green is go, yellow sparingly, and avoiding red foods, is another tactic in moving towards healthier eating. Dr. Deeter points again to a couple of resources that patients can use, including an app called Dr. Gregor's Daily Dozen which has a checklist of daily foods, with the goal for an individual to gain as many check marks per day as possible. Talking about barriers, each person, patient, individual will have their own barriers. There is a psychological component to these things. Dr. Deeter suggested the book, "Never Binge Again", that he personally found helpful in understanding the reason behind personal eating habits. CHAPTER 3:  Moving on from diet to some of the other aspects of lifestyle medicine; alcohol, exercise and sleep are addressed. There is no known safe level of alcohol, and drinking any alcohol at all increases the risk of breast cancer. Current recommendations for alcohol consumption is 1 drink for females, 2 drinks for males, per day, and under limit to under four drinks in a sitting. Smoking cessation needs to address three areas: The dopamine addiction, the nicotine addiction and the habit or physical addiction. One of the first steps is to crate mindfulness: Why are you smoking? Dr. Deeter states that some individuals are able to cut back, just by introducing awareness to when and why they smoke. Exercise recommendations include 75 minutes a week of high intensity training or 150 minutes per week or moderate intensity training. The addition of weight training helps with bone density and as Dr. Deeter says, "Muscle is expensive tissue", and uses up more glucose. Even starting with 15 minutes will start to show benefits for the individual. Good sleep hygiene, a basic component to a healthy lifestyle, can help avoid things like Alzheimer's disease. The suggested level of sleep is 7-9 hours a night. Waking up tired probably means it's not enough. Many have undiagnosed sleep apnea that can contribute the decreased sleep. More tips are talked about in chapter four, but are mentioned here as well: lower the temperature in the room, and limit or stop screen time at least one hour before bedtime. CHAPTER 4:  In closing, Dr. Deeter gave us some tips and tricks for lifestyle modification. Small steps is the key, "don't let perfect get in the way of better". Practice good sleep hygiene including avoiding electronics an hour before bedtime, and turning down the thermostat so that the room is cooler. Exercise tips: park farther away, take the stairs, and get steps in where possible. A 10kg weight loss can lower blood pressure by 5-10 points. Whole and plant based were discussed extensively in this podcast, but another thing to consider is looking at caloric density. Other tricks for mealtime include drinking water before a meal, or having a bowl of soup or side salad prior to meals to help with hunger satiety. Lastly, goal setting is important. Goals need to be specific, measurable, and attainable. Finding accountability, whether it is within immediate family units or help groups is an important aspect to help an individual reach their goals. Thank-you for listening.

Lifestyle Medicine: Don't Let Perfect Get in the Way of Better with Dr. Nick Deeter

In this podcast, Dr. Cole Pueringer, a toxicology fellow with the Minnesota Poison Control System (Hennepin Healthcare), discusses various over-the-counter medications and their toxicological potential. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: List at least 3 potentially dangerous over-the-counter (OTC) medications. Discuss the basic clinical presentation and management of the following over-the-counter (OTC) medications: acetaminophen, diphenhydramine loperamide, ibuprofen, and dextromethorphan. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "The Dose Makes the Poison: Over-the-Counter (OTC) Medication" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.    SHOW NOTES: Antihistamines:  Like so many other over-the-counter medications, the dose of antihistamines makes the poison. Sedation is the most common side effect in antihistamine overdose. Some, like diphenhydramine, are more toxic and have profound anticholinergic effects. Sinus tachycardia is one of the first presentations, but remember the phrases: Tachy as a tie, dry as a bone, mad as a hatter, red as a beet, hot as a hare and blind as a bat. Excitatory toxidromes can be confusing, but urinary retention, impaired bowel motility and the absence of diaphoresis will differentiate anticholinergic toxicity from the other excitatory toxidromes. the higher the dose, the more side effects seen, leading to seizures and cardiac toxicity. Physostigmine is an antidote for anticholinergic toxicity. Delirium is the main indication for physostigmine, but it can also be given to prevent intubation and at times to get a more accurate history from the patient. Physostigmine lowers the seizure threshold, so benzodiazepines are usually given prior administration. Most likely they have already been given to treat undifferentiated delirium and excitation. Of note, physostigmine is not the cure all for the toxidrome because it has a very short half life. In the setting of seizures in overdose, very few anticonvulsants are safe. Benzodiazepines are some of the safer GABAergic agents. GABA is our main CNS inhibitory neurotransmitter, it essentially "tones down the nerves". Propofol and some other GABAergic agents can also help with tachycardia and hyperthermia. In these settings, benzodiazepines are given in very high doses. Diphenhydramine causes sodium channel blockade, subsequently decreasing action potential. lowering calcium in the cells, and causing life threatening myocardial depression. Calcium is given in this circumstance, but the mainstay of treatment is sodium bicarbonate. It works by increasing overall sodium availability and the pH. The more acidotic the patient, the more of the drug becomes unbound and available. At higher pH levels, the sodium channel blockade weakens, and more of the drug becomes protein bound. What about other antihistamines? While overdose of other antihistamines will be uncomfortable, the life threatening seizures and cardiac toxicity is unique to diphenhydramine.  Acetaminophen:  Acetaminophen is the highest nationally in morbidity and mortality of all drug overdoses. Most often taken on it's own, it's also mixed into many over-the-counter remedies. In the first 24-hours post-ingestion, the symptoms can be minimal. It's metabolized in the liver, and a small portion is metabolized by CIP 2E1, resulting in the toxic metabolite NAPQI. Normally, glutathione will detoxify NAPQI, but in acetaminophen overdose, glutathione stores are depleted and the excess NAPQI creates havoc in the liver. In a reliable historian with an acute ingestion, the Rumack-Matthew nomogram is employed, and will help guide antidote therapy. Serum acetaminophen levels will not be helpful until 4 hours post-ingestion, unless something that slows GI transit time and absorption has been taken as well. N-acetylcysteine or "NAC", is the antidote for Tylenol. If given within eight hours of ingestion it can prevent any liver toxicity. It can also be started any time a serious ingestion is suspected. Keep in mind, delayed-release Tylenol, certain populations, and conditions can obscure the diagnosis and in those settings the Rumack-Matthew nomogram can no longer be used. Chronic alcoholics who have just stopped drinking and malnourished patients are at higher risk of toxicity. Subacute and chronic ingestion is also very common. Essential lab tests include serum acetaminophen levels, ALT and AST, and INR. One would expect any or all of these to be elevated in significant toxicity. If they are, NAC is given intravenously for nearly 24 hours. NAC won't reverse hepatotoxicity that has already occurred, but will prevent more from happening. Dextromethorphan:  Dextromethorphan, referred to sometimes as "robotripping" or "robo-frying". Taken in excess causes an individual to become disassociated. It is an NMDA antagonist, like ketamine, LSD and PCP. Expect to see the same clinical signs of serotonin excess, as well as dystonia. Patients can alternate dramatically between vacant blank stares, to incredibly violent outbursts. Patient and staff safety is a crucial element in treating this toxidrome. Rotatory nystagmus, a distinctive rapid "clock ticking" of the eyes is diagnostic of this type of ingestion. Loperamide:  When Loperamide, an over-the-counter antidiarrheal, is used in abuse it can lead to death. It acts similar to opioids, slowing down the GI tract but without the central effects, because it is actively expelled from the CNS. In large doses, however, it delivers an opioid-like high. Loperamide can cause respiratory depression, but also persistent arrhythmias. The lethal effects are due to loperamide's potassium channel blocker properties causing profound QT prolongation, sinusoidal waves and can lead to cardiac arrest. Potassium channel blockade is difficult to treat. ACLS drugs, electrolyte normalization like magnesium infusions, and even Narcan can be given, but more than likely these incredibly sick patients will need ECMO. Ibuprofen:  Ibuprofen is, overall, a safe drug. Large quantities of the drug have to be taken for toxic effects. If taking over 200mg/kg if Ibuprofen, a patient is likely to have some GI symptoms and possibly an acute kidney injury. treatment would include possible admission for antiemetics and IV fluids. Ibuprofen is metabolized as a propionic acid anion. If ore than 400mg/kg are taken, it will result in an anion gap metabolic acidosis. At over 600mg/kg, a whole constellation of symptoms results: seizures, hypotension, and cardiac shock. These patients are severely ill and may require ECMO for an extended period of time. At this dosage, a 100kg patient would need to take 300 pills. Which leads to the question, "How did they fit that many pills in their stomach?"  Activated Charcoal:  Finally, a note on activated charcoal. It works great for almost everything, except alcohol ingestion and metals, by binding drugs in the GI tract. Drug absorption is decreased by 60% if given within an hour. It should be avoided if the airway is compromised or if the patient is a risk for seizure. In an intubated patient with recent ingestion, it's given via nasogastric tube. Thank-you for listening.

The Dose Makes the Poison: Over-the-Counter (OTC) Medication

In this podcast Dr. Demetri Yannopoulos, a interventional cardiologist with M Health Fairview and Interventional Cardiology Researcher Director with the University of Minnesota-Twin Cities, discusses ECPR (ECMO Cardiopulmonary Resuscitation), the recent Arrest Trial and the Mobile ECMO program. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Define the importance of time and quality of CPR on outcomes from out-of-hospital cardiac arrest (OHCA). Explain the role of ECPR and ECMO teams in the management of out-of-hospital cardiac arrest (OHCA) refractory cardiac arrest. Review the current state of the art management of cardiac arrest and the reorganization of EMS/hospital response to out-of-hospital cardiac arrest (OHCA). CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "ECPR (ECMO CPR): The Cardiac Resuscitation Frontier with Dr. Demetri Yannopoulos (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for Continuing Education (CE) and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview and Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on this presentation. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Demetri Yannopoulos, MD has received honoraria from Helmsley Charitable Trust and the National Institute of Health (NIH) within the past 24 months, as a grant for research studies. Upon an independent review of his presentation, confirms he is following ACCME guidelines, and there is no commercial tie to the named agencies and no impact on his podcast presentation. Ridgeview's Continuing Education Committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: Chapter 1: CPR was introduced in the 1960s. At the time, research at John Hopkins was being conducted on pigs in ventricular fibrillation and ventricular tachycardia who required defibrillation.  It was noted that when pushing defibrillation paddles against the chest wall, the arterial pressure of the subjects increased. It was concluded that with compression, pulsatile flow was generated. This was essentially the first iteration of closed chest CPR. Over the next 50 years or so, clinicians have been looking for better ways to improve survival outcomes. Key factors include early identification, early CPR, along with obtaining resources and assistance to improve ventilation, perfusion, and defibrillation. Poor predictors of survival for cardiac arrest include CPR for greater than 30 minutes and individuals with coronary artery blockage. With the integration of ECMO, it was found that by bypassing the heart and lungs and essentially taking on their functions, outcomes improved. Dr. Yannopoulos reiterates that CPR for greater than 30 minutes results in poor outcomes, thereby creating a goal to both normalize pressures during this time while also fixing the offending cause, such as a coronary artery occlusion.  Around 2015, in the Minnesota metro area, visionary EMS directors implemented an alternative option: If a patient fails three shocks, with ongoing CPR, the patient was transferred to a tertiary care facility with ECMO cannulation capabilities. Once on ECMO, these patients were transferred to the University of MN where they underwent PCI to evaluate for reversible causes such as occluded coronary vessels, PE, etc. Outcomes of this therapy showed 30-40% patient survival, which is a game changing result, thus the need for a randomized control trial, the ARREST Trial. Chapter 2: The ARREST Trial studied a group of patients with out-of-hospital cardiac arrest (OHCA) in ventricular fibrillation, refractory to defibrillation and initial ACLS treatment. This was a randomized control trial where one group was randomized to an ECMO intervention arm, versus a standard ACLS therapy arm. It was a phase 2, single center, open-label, adaptive, safety and efficacy randomized clinical trial.  Specific subject criteria included adults aged 18-75 with OHCA, refractory ventricular fibrillation, with no return of spontaneous circulation (ROSC) after three shocks, with an automated cardiopulmonary resuscitation device or LUCAS device and estimated transfer time shorter than 30 minutes. The primary outcome of the trial was survival to hospital discharge. Secondary outcomes included safety, survival and functional assessment at hospital discharge, at 3 months and 6 months after discharge. Results of the ACLS arm showed a 7% survivability, and zero at both three and six months, while the ECMO arm fared better with a 43% survivability. After enrolling 30 patients, the study was terminated at the first pre-planned interim analysis by the National Heart, Lung and Blood Institute after a unanimous recommendation from the Data Safety Monitoring Board, because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group compared to the standard ACLS group. No unanticipated serious adverse events were observed. Conclusion: early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation, significantly improved survival to hospital discharge compared with standard ACLS treatment. Chapter 3:  The Minnesota Mobile Resuscitation Consortium or MMRC, which was the first program to serve an entire metropolitan area in order to rapidly deliver extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation to patients with refractory ventricular fibrillation/ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA). This was an observational cohort study that analyzed consecutive patients prospectively enrolled in the MMRC's ECMO-facilitated resuscitation program. Entry criteria were identical to the ARREST Trial, adults 18-75 with an out-of-hospital cardiac arrest in VF or CT with no return of spontaneous circulation post 3 shocks, use of a LUCAS or automated cardiopulmonary resuscitation device, and an estimated transfer time of less 30 minutes. The primary endpoint was functionally favorable survival to hospital discharge with Cerebral Performance Category (CPC) 1 or 2. CPC 1 results in good cerebral performance: conscious, alert, able to work, that might have some mild neuro or psych deficits. CPC 2 results in moderate cerebral disability; conscious, sufficient cerebral function for independent activities of daily living (ADLS). Secondary endpoints included 3-month functionally favorable survival. Between the period of December 1, 2019 and April 1, 2020, 63 consecutive patients were transported, and of these 58 were treated by the mobile ECMO service. Post EMCO treatment 25 of the 58 or 43% were both discharged from the hospital and alive at 3 months with CPC 1 or 2. This first, community-wide ECMO-facilitated resuscitation program in the US demonstrated 100% successful cannulation, 43% functionally favorable survival rates at hospital discharge and 3 months. Chapter 4:  As the research continues, reaching 25-30% positive outcomes would be adequate to start a viable program. Dr. Yannopoulos speculates that with overall system improvement and refined protocols, that number can be as high as 70-80%, which is an incredible number. The future of ECPR will require a combined effort of the healthcare systems, policy makers, administrators, and communities. With a successful program in the urban and suburban areas, future research can hopefully expand access to more rural populations. Dr. Yannopoulos emphasizes that this is not a hospitalized based program, it relies on the EMS system, and those providers, especially medics, are key to the success of the program. At the time of this interview, the mobile ECMO program was on hold due to COVID, but currently the mobile ECMO program has a pending restart date of March 1st. Thanks for listening.

ECPR (ECMO CPR): The Cardiac Resuscitation Frontier with Dr. Demetri Yannopoulos

In this podcast Dr. Chris Solie, an ER physician with EMPAC, and Dr. Abby Elliott, with Lakeview Clinic, cover a variety of topic areas from six journal articles. If you like to skip to the conclusion part of the article, this podcast is for you. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Differentiate if chest pulmonary CTs are necessary when patients present with suspected venous thromboembolism (VTE). Name at least 2 benefits of nighttime antihypertensive dosing for patients. Assess when cardioversion would be deemed necessary for individuals experiencing A-fib. Identify the risks of short-term steroid use. Identify the relevance of lumbar MRI and its findings. Summarize the findings that IV contrast causing acute kidney injury is a myth. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Journal Review Day - with Drs. Chris Solie and Abby Elliott" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.    SHOW NOTES: Journal Article 1: "Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability" PEs and DVTs can be elusive. There are rising numbers of chest pulmonary CTAs being done with lower yields. These can result in increased cost and health risks. In this study, the adjusted d-dimer was looked at to see if the number of CTs being ordered can be reduced. The Wells criteria was used to place patients into low, moderate or high clinical pretest probability for venous thromboembolism of VTE. In the podcast, "clinical pretest probability" is referred to as risk. Of the entire 2000 patients enrolled, the diagnosis of VTEW was only made in 7%. Participants that qualified as low risk numbered 1742 and 1200 of these had d-dimer less than 1000. No VTWE was found in these patients for the next 90 days. For those with a d-dimer between 500 and 999, none had a VTE at 90 days. In moderate-risk groups with d-dimer less than 500, none had VTE at 90 days. Combining low-risk patients with a d-dimer less than 1000, non of these patients had evidence of VTE at 90 days. Even in the 467 patients with a d-dimer greater than 1000, only 87 had a VTE. Moderate- or high-risk patients are not applicable for this study. According to the article, if the d-dimer is greater than 1000, and the patient is low-risk, there was a 20% incidence of VTE. While it is an impressive study, it is one peice of data and should not replace clinical gestalt and decision making when truly concerned about the presence of VTE. Journal Article 2: "Bedtime Hypertension Treatment Improves Cardiovascular Risk Reduction: The Hygia Chronotherapy Trial" HTN is difficult to manage in many patients. This was a large study out of Spain of approximately twenty thousand patients. Patients were selected to take their medication either in the AM or nighttime and 48-hour blood pressure monitoring was performed. Patients were followed for 6 years. Night time dosed patients had significantly lower cardiovascular event rates than the daytime group, as well as better blood pressure management. There is little evidence to not advise nighttime antihypertensive dosing for patients, unless there would be compliance concerns. Medications that would not be tolerated, or specific medications, like diuretics, that can disrupt sleep. This was an impressive study that demonstrates a rather simple maneuver to effect a remarkable change in cardiovascular risk. Bear in mind, diet and lifestyle may also contribute to the results, but those were not assessed in this study. Journal Article 3: "Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation" A-Fib is a common presentation in primary care practice and in Emergency Departments. In this study of early cardioversion strategy vs delayed, 437 patients, aged 18 and above, were reviewed. Necessary criteria included A-fib bit less than 36-hours and hemodynamic stability. The conclusion was that neither strategy delayed or early cardioversion was an inferior approach. A large number of patients in this study spontaneously converted to normal sinus rhythm without demonstrating higher rates of stroke. However, this study was not powered to assess risk of long-term stroke, and this remains unknown. Though based on other studies referenced today, it's known that a patient cardioverted after 12-hours of A-fib has an increased risk of stroke. Psychologically, being in A-fib can be disturbing for the individual, and remaining in A-fib is not always desirable from the patient perspective. There are also potential logistical and cost considerations with delayed approach including numerous repeat clinics and ER visits for a small number of patients. Journal Article 4: "Short-term Use of Oral Corticosteroids and Related Harms Among Adults in the United States: Population-based Cohort Study" An impressive review of three hundred thousand patients was performed. Corticosteroids were given for mostly musculoskeletal, respiratory and allergic issues. Sepsis, VTE and fracture were monitored for over a 90-day time period and statistically significant higher rates of all of these were noted. Bear in mind, this was a study without true placebo, and patients essentially compared their experience on steroids to their experience not on steroids. It should probably be followed up with a prospective trial to help further validate these concerning findings. Still, this study only looked at 3 different complications and the numbers here are pretty striking, with 205 of adults receiving steroids. There are a number of studies which have shown no evidence of benefit in the use of steroids for a variety of indications, including conditions, such as urticaria and even anaphylaxis. Journal Article 5: "No Association Between MRI Changes In The Lumbar Sone and Intensity of Pain, Quality of Life, Depressive and Anxiety Symptoms in Patients With Low Back Pain" In this study, out of Poland, patients were referred for a lumbar spine MRI by neurologists, surgeons or other specialists, but not by primary care. These MRIs were graded in the study based on criteria derived from the reading radiologists. The endpoint of the study was to compare the severity of MRI findings with the patient's self-assessment and scoring of pain, quality of life, etc. The study ultimately showed there was no correlation. However, age and BMI, and total MRI scores did correlate. Physically active patients had better scores. Learning new ways of coping with pain and helping our patients with this reality can equal a more efficient use of time and money. Per this study, medications or a reassuring MRI, does not correlate to resolution of pain. Of course, MRIs are often indicated in the setting of significant neurologic findings and emergencies, but outside of those settings, some patients may not be convinced that an MRI is not necessary. Using articles like this one can assist to better counsel patients and reduce unnecessary MRIs. Journal Article 6: "Contrast Associated Acute Kidney Injury Is A Myth: Yes" IV contract is often blamed for acute kidney injury, or AKI. It turns out, like many time honored beliefs in medicine, this is not likely the case. While attempting to research and write a paper on this subject, the investigators quickly discovered that ample data already exists that shows CIN or contrast induced nephropathy, appears to be more a myth than truth. One senior author of this paper demonstrated in a pool of thousands of patients in two other separate studies that there's no association between contrast and AKI. Another investigator who is a cardiologist demonstrated actually less incidence of AKI in a cohort of patients. So, while personal clinical experience and Gestalt should not be ignored, we also must maintain a desire to debunk dogma that is unfounded time and again in the scientific literature. With regard to AKI from IV contrast, maybe there will be a prospective randomized trial looking at this, but there seems to be a preponderance of evidence already to suggest it may not be necessary. Thanks for listening.   Sources/Links:  Kearon C, de Wit K, Parpia S, et al.  Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med. 2019;381(22):2125-2134. doi:10.1056/NEJMoa1909159  Available:  https://www.nejm.org/doi/10.1056/NEJMoa1909159?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Hermida RC, Crespo JJ, Domínguez-Sardiña M, et al.   Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. Eur Heart J. 2020;41(48):4565-4576. doi:10.1093/eurheartj/ehz754 Available: https://academic.oup.com/eurheartj/article/41/48/4565/5602478 Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, et al.   Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med. 2019;380(16):1499-1508. doi:10.1056/NEJMoa1900353  Available: https://www.nejm.org/doi/full/10.1056/NEJMoa1900353 Airaksinen, K. E., Grönberg, T., Nuotio, I., Nikkinen, M., Ylitalo, A., Biancari, F., & Hartikainen, J. E. (2013).  Thromboembolic Complications After Cardioversion of Acute Atrial Fibrillation. Journal of the American College of Cardiology, 62 (13), 1187-1192. doi:10.1016/j.jacc.2013.04.089 Waljee AK, Rogers MA, Lin P, et al.   Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415. Published 2017 Apr 12. doi:10.1136/bmj.j1415 Available: https://www.bmj.com/content/357/bmj.j1415 Yao, T., Huang, Y., Chang, S., Tsai, S., Wu, A. C., & Tsai, H. (2020). Association Between Oral Corticosteroid Bursts and Severe Adverse Events. Annals of Internal Medicine, 173 (5), 325-330. doi:10.7326/m20-0432 Babińska, A., Wawrzynek, W., Czech, E., Skupiński, J., Szczygieł, J., & Łabuz-Roszak, B. (2018). No association between MRI changes in the lumbar spine and intensity of pain, quality of life, depressive and anxiety symptoms in patients with low back pain. Neurologia I Neurochirurgia Polska . doi:10.5603/pjnns.a2018.0006  Available: file:///C:/Users/E55983/Downloads/No_association_between_MRI_changes_in_the_lumbar_s.pdf Ehrmann, S., Aronson, D., & Hinson, J. S. (2018). Contrast-associated acute kidney injury is a myth: Yes. Intensive Care Medicine, 44 (1), 104-106. doi:10.1007/s00134-017-4950-6  Available: file:///C:/Users/E55983/Downloads/Ehrmann2018_Article_Contrast-associatedAcuteKidney.pdf Davenport, M. S., Perazella, M. A., Yee, J., Dillman, J. R., Fine, D., Mcdonald, R. J.,  Weinreb, J. C. (2020).   Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation. Radiology, 294 (3), 660-668. doi:10.1148/radiol.2019192094  

Journal Review Day with Drs. Chris Solie and Abby Elliott

In this podcast Dr. Todd Elftmann, a general surgeon with Lakeview Clinic and Ridgeview, discusses abdominal surgeries through a case review format. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Recognize the potential for appendicitis and/or cholecystitis. Initiate the appropriate work-up for appendicitis and/or cholecystitis. Create the appropriate referral for appendicitis and cholecystitis. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Quit Yer Belly Achin': Abdominal Surgeries with Dr. Todd Elftmann" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.    SHOW NOTES: CASE 1: The four "Elftmann criteria" include fever, elevated white blood cell count, history of pain or anorexia, and a positive physical exam. Two or more of these findings means a probable appendectomy.  Peritoneal irritation is not a subtle finding and even the most stoic patients will grimace with palpation of the abdomen. Localized pain versus diffuse pain in all four quadrants can help determine if there is a rupture. Additional work up includes, as always, a good history, plus lab work an x[ray of the abdomen in this case, and finally, a CT scan with oral contrast. The CT is the gold standard and has decreased the number of negative appendectomies to 1-2%. Ultrasound can be used, and is often for pediatric patients, but has limitations. CT scans are more sensitive and specific for appendicitis. A white blood cell count is included in the lab work-up, but a patient with appendicitis may present with a normal white count. Conservative treatment is possible, but per the literature does have a failure rate, with anywhere from 25-50% of patients still requiring an appendectomy. A perforated appendix does not guarantee an immediate OR visit. Depending on the patient and the surgeon's comfort level, treatment may include a delayed appendectomy with antibiotics, plus or minus a percutaneous drain if an abscess is present. IV piperacillin tazobactam would be given as an inpatient, and oral Augmentin as an outpatient along with very close follow-up. For patients with a penicillin allergy, a fluoroquinolone plus metronidazole is appropriate. Surgery could occur approximately 8-12 weeks later after clinical and laboratory improvement. Stump appendicitis occurs when a patient presents with a classic presentation of an appendicitis, post a previous appendectomy. It happens most commonly with patients who had an appendicolith and the entire base was not removed in the original surgery. CASE 2:  Abdominal pain for patients that are pregnant can be complicated. Initial assessment includes a fetal exam, and assuring the viability of the fetus. Further consideration would include using ultrasound instead of CT for reduced radiation exposure. In this case, a woman presented with right upper quadrant tenderness, fever, and hyperbilirubinemia indicative of cholecystitis. If she had jaundice, this would be Charcot's triad and would indicate cholangitis. Early surgical consultation, especially for a pregnant patient is important. Failed conservative treatment for these patients can have adverse outcomes. For other work-up modalities, MRCP is an option, but if the patient is already going to the operating room, a cholangiogram can be performed in the OR with GI on standby for an ERCP, thereby eliminating the need for an extra test. MRCP is for patients that are not good operative candidates, and are too acute or sick to tolerate a procedure. A HIDA scan can evaluate whether the cystic duct is open and is good for non-toxic appearing patients where ultrasound is unremarkable or with fever of unknown origin. The ongoing treatment of cholecystitis whether surgical or nonsurgical depends on the patient and the severity of their illness. It turns out, antibiotic choice for cholecystitis is similar to that of appendicitis with perforation. Antibiotics can range from cefazolin to zosyn or even meropenem. For severely penicillin allergic patients, a fluoroquinolone plus metronidazole can be used. For patients that are higher acuity, whether due to calculous or acalculous cholecystitis, and are not good surgical candidates, a percutaneous drain may be indicated. Post-cholecystectomy, 85-90% of patients will not notice a change, 10% will report a looser bowel pattern, and 1% of patients will experience severe diarrhea. These patients can be treated with a bile binding medication like cholestyramine. A key point today, the gallbladder is a surgical disease and Dr. Elftmann recommends early surgical consultation. Thanks for listening.   Sources/Links:  Evidence for an Antibiotics-First Strategy for Uncomplicated Appendicitis in Adults: A Systematic Review and Gap Analysis. Journal of the American College of Surgeons.  DOI:  http://dx.doi.org/10.1016/j.jamcollsurg.2015.01.009 Use of White Blood Cell Count and Polymorphonuclear Leukocyte Differential to Improve the Predictive Value of Ultrasound for Suspected Appendicitis in Children. Journal of the American College of Surgeons.  DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.01.039 The Scientific Forum presentation, Operative vs Nonoperative Management of Appendicitis: A Long-Term Cost-Effectiveness Analysis, was held October 22 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast, and audio information is available online at facs.org/clincon2018.  The Panel Session, The Call Bladder: Dealing with the Acute Gallbladder, was held Monday, October 28 at the American College of Surgeons Clinical Congress 2019 in San Francisco (program, webcast and audio information). Gallstone size and the risk of gallbladder cancer      https://pubmed.ncbi.nlm.hin.gov/6632129  

Quit Yer Belly Achin': Abdominal Surgeries with Dr. Todd Elftmann

This podcast is Part 2 of the Clinical COVID-19 Review podcast. In this podcast, Dr. John Litell, an intensivist with Abbott Northwestern Hospital, and Dr. Haylee Veazey, an emergency medicine physician with Hennepin Healthcare, discuss clinical management for COVID-19 patients through a case review format. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Discuss and implement fundamental critical care support for COVID-19 patients. Recite best practices for screening and managing COVID patients in the hospital setting. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Clinical COVID-19 Review (PART 2): Clinical Management" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. Thanks for listening.

Clinical COVID-19 Review (PART 2): Clinical Management

This podcast is the first of two podcasts that discusses the novel COVID-19 virus. Dr. Louis Mansky, a professor and the Director for the Institute of Molecular Virology at the University of Minnesota - Twin Cities, and Dr. Haylee Veazey, an emergency medicine physician with Hennepin Healthcare, provide an interesting discussion on the virus, testing and the COVID-19 vaccine. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Describe the pathophysiology of the COVID -19 virus. Recognize tests available for the COVID-19 virus, the methodology and efficacy of each. Describe the methodology in the development of COVID vaccines. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Clinical COVID-19 Review (PART 1): Virus, Testing, and Vaccine" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. Thanks for listening.

Clinical COVID-19 Review (PART 1): Virus, Testing and Vaccine

This podcast presents, Dr. Michael Edwards, a rheumatologist with Ridgeview Specialty Clinics, who provides a discussion some unique arthritis cases. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Identify various causes of monoarthritis. Review the evaluation and management of monoarthritis. Recognize that lower back pain may be inflammatory in nature, and how to further evaluate and manage the inflammation/pain. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Bone to Pick: Rheumatology Cases with Dr. Edwards" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: CASE 1 - Psoriatic Arthritis: For our first case, our 77 year old male ended up with psoriatic arthritis. Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerns like chronic infections, skin lesions, or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging, starting with x-rays. Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerrns like chronic infections, skin lesions or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging - starting with x-rays. To tap or not to tap? That is the question for joint complaints. Arthrocentesis through an area of cellulitis or inflamed soft tissue is generally contraindicated. However, if a tap is feasible, the three C's:  culture, WBC count, and crystals should be send. A cell count greater than 10,000 would be indicative of an inflammatory effusion. In the acute setting, the pros and cons should be weighted as to whether or not to inject steroids. If you suspect infection, though, do NOT inject corticosteroids. Long-term treatment of psoriatic arthritis is individualized to the patient. Some patients manage with methotrexate, while others might need a biologic. Cost is a barrier in prescribing biologics, requiring referrals, and prior insurance authorization. Biologics target a specific part of the immune system. Contraindications would be patients who are already immunosuppressed, have TB, hepatitis or multiple sclerosis, or are in late stages of CHF. Other contraindications include breast, lung or melanoma cancer with a high risk of recurrence. When running a fever or prior to surgery, biologic doses should be delayed or paused. CASE 2 - Ankylosing Spondylitis:  In case number 2, a young man with a long history of back pain ended up with ankylosing spondylitis. Again, the history becomes important in the diagnosis, keying us to be suspicious of this patient's chronic pain. For this case, though lab work was normal, an AP x-ray of the pelvis showed narrow and sclerotic sacroiliac joints with erosion. Like psoriatic arthritis, this diagnosis falls under the category of seronegative spondylarthropathy. When tested, the patient will not have antibodies or positive rheumatoid factor. It is a reactive condition: sacroiliitis causes inflammatory changes and therefore pain. Inflammatory bowel conditions like Crohns and Ulcerative colitis fall into this same family of reactive conditions. First line treatment for ankylosing spondylitis is NSAIDS taken on a scheduled basis to protect the joints. Long term management includes physical therapy and back education. Biologics can be used for pain refractory to NSAIDS. This pain can go undiagnosed for years, and cause irreparable fusion of the spine, otherwise known as a bamboo sign as seen on x-ray. Again, a thorough history is key to catching and diagnosing these patients early, and preventing long-term complications. CASE 3 - Gout:  Out last patient is a woman with a swollen knee, normal wbc, and elevated sed rate. Due to her history, and RA flare up would be considered in the differential, but unlikely due to a monoarthritic presentation. Following a similar work up as the first two cases, labs and imaging are obtained and the knee is tapped. The three C's mentioned earlier:  culture, WBC count  and  crystals are sent and the results are positive for needle-like crystals which are negative birefringent when examined with polarizing microscopy. The patient has gout. Treatment includes NSAIDS like Naprosyn or indomethacin. In an acute setting, oral steroids can be prescribed. Dosing for gouty monoarthritis is 20-30mg for 3-5 days. For patients already on baseline steroids, include a steroid taper back to baseline. Additional work up could include uric acid levels. While not diagnostic, a uric acid greater than 9 may help identify patients at risk for future episodes. If the patient has 2 or more gout attacks a year. Allopurinol can be prescribed. CONCLUSION:  To sum up all our cases today; a thorough history and exam are critical, keep the differential broad, and management is weighing the pros and cons of NSAIDS, steroids and whether or not to tap that joint. Septic arthritis can not be overlooked. Early recognition and diagnosis is key. Thanks for listening.

Bone to Pick: Rheumatology Cases with Dr. Edwards

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Ridgeview Podcast: CME Series

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