In 2017 the Society for Critical Care Medicine updated its guidelines for sepsis management. These new guidelines differ significantly from ones in the past in that they no longer recommend protocolized resuscitation and emphasize early and aggressive fluid resuscitation when patients present with septic shock. This is the first podcast in the Surviving Sepsis guideline series. The next episode discusses why the new sepsis guideline changed.
Article discussed in this episode: Management of Sepsis and Septic Shock
Speakers:
Laura Evans, MD, MSc, of Bellevue Hospital and NYU Medical Center
Andrew Rhodes, MBBS, MD, of St George’s University Hospitals NHS Trust and co-chair of the Surviving Sepsis guideline panel
Mitchell M. Levy, MD, of the Alpert Medical School of Brown University and Rhode Island Hospital
Approximately one-third of all medical school graduates report having been abused as students. Medical student and resident abuse has long been considered unacceptable behavior but still persists in the teaching environment. In this podcast we discuss how students and residents might respond to these events. We interview Geoffrey Young, MD, from the Association of American Medical Colleges and Thomas J. Nasca, MD, from the Accreditation Council for Graduate Medical Education, who discuss how they expect medical schools to respond to abusive behaviors and what resources are available to students and residents who have been abused to report those experiences without fearing retribution.
Article discussed in this episode:
As people age, loss of muscle mass is inevitable, resulting in sarcopenia. Muscle loss contributes to overall weakness, which causes frailty. Frailty, in turn, is the generalized susceptibility to disease and injury, all of which causes loss of autonomy. Because of the potential for progressive decline in physical function in very elderly patients, accurate tools are needed to predict mortality risk to individualize treatments intended to improve longevity such as chemotherapy, management of chronic diseases, and surgery. In this podcast, sarcopenia, frailty, and risk prediction are discussed in the context of major trials studying them being conducted in Europe.
Managing hypertension in elderly patients is complicated. Recent studies have shown that elderly patients may benefit from aggressive hypertension management, but other studies have shown that some are harmed by overly aggressive hypertension management. These issues were discussed in detail at the 2016 European Union Geriatric Medicine Society meeting. In this podcast we discuss how to best manage hypertension in elderly patients with Athanase Benetos, MD, PhD, a professor of internal medicine from Nancy, France, and the academic director of the European Union Geriatric Medicine Society.
Older patients tend to have multiple comorbid conditions requiring treatment with many medications. Managing polypharmacy is challenging. In this podcast we discuss 2 tools that help deal with this problem: The Beer’s list and the START/STOPP criteria. To help understand these tools we spoke with Michael Steinman, MD, a professor of medicine from University of California-San Francisco, and Denis O’Mahony from University College Cork, Ireland.
Links:
JAMA reviews on polypharmacy in the elderly: Evaluation and Treatment of Older Patients With Hypercholesterolemia (Sep 17, 2014)
Polypharmacy in the Aging Patient: Management of Hypertension (July 14, 2015)
Polypharmacy in the Aging Patient: Review of Glycemic Control in Older Adults With Type 2 Diabetes (DM article has polypharmacy podcast - Mar 8, 2016
SPRINT Trial of Hypertension Control in the Elderly: American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults or geriatricscareonline.org, click on the link for Clinical Guidelines & Recommendations–
The EU(7)-PIM list: Potentially Inappropriate Medications for Older People
STOPP/START Criteria for Potentially Inappropriate Prescribing in Older People
Workplace violence–related injuries occur disproportionately in health care settings. In this podcast, we discuss how individual clinicians should manage violent patients who might attack them. Article discussed in this episode: Ensuring Staff Safety When Treating Potentially Violent Patients
Between 8% and 10% of the population will have a seizure at one point in life. It's important to distinguish seizures from other entities that can look like them and, once a diagnosis of a seizure is established, know how to treat them. In this podcast we discuss seizures and epilepsy with Jay Gavvala, MD, author of New-Onset Seizure in Adults and Adolescents: A Review.
Article discussed in this episode:
New-Onset Seizure in Adults and Adolescents: A Review
Medicare recently developed a star rating system to help consumers determine the quality of care delivered at various hospitals. This rating system was considered controversial by many. In this podcast we discuss the rating system with one of its critics, Karl Y. Bilimoria, MD, MS, and with Kate Goodrich, MD, the Director of the Center for Clinical Standards and Quality at Medicare.
Article discussed in this episode:
The New CMS Hospital Quality Star Ratings: The Stars Are Not Aligned
Nearly all women experience some element of nausea and vomiting during their pregnancies. In this podcast we review the entire spectrum of disease all the way up to hyperemesis gravidarum and how to provide care for women experiencing these problems.
Article discussed in this episode:
Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy
When managing septic shock, passive leg raising is the best test to determine if a patient is likely to respond to a fluid bolus, better than CVP lines or even bedside ultrasound. Dr Najib Ayas, Associate professor of Critical Care Medicine at the University of British Columbia, discusses shock management from the context of his Rational Clinical examination article in the September 27, 2016 issue of JAMA, entitled “Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids?”
Drug prices continue to rise in the US. Many solutions have been proposed but few have been implemented. Drs. Janet Woodcock from the FDA and Aaron Kesselheim, author of The High Cost of Prescription Drugs in the United States from the Harvard Medical School discuss the role of brand name drugs and generics and how they influence the cost of pharmaceuticals.
Also see The Cost of US Pharmaceutical Price Reductions: A Financial Simulation Model of R&D Decisions by Thomas A. Abbott and John A. Vernon.
Edward H. Livingston, MD, discusses the British Columbia Ministry of Health’s 2015 guidelines on clinical management of opioid use disorder in adults with Keith Ahamad, MD, Evan Wood, MD, PhD, ABIM, FRCPC, Tony L. Yaksh, PhD, and Humayun J. Chaudhry, DO, MS, MACP, FACOI.
Articles and resources discussed in this episode:
Richard N. Rosenthal, MD discusses a randomized clinical trial demonstrating the efficacy of an implantable buprenorphine-releasing device for treating opioid use disorder.
Lyme disease is very common in certain regions of the country and is caused by the spirochete Borrelia bergdorferi. Lyme disease is transmitted by tick bites and in this podcast we review the discovery of Lyme disease, its major clinical features, and how to diagnose and treat it, as told by Dr Alan Steere, Dr Lyndon Hu, and Dr Paul Auerwerter.
Related article: Review of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis
Persistent diarrhea is a poorly recognized syndrome in all populations that requires proper assessment and diagnosis to ensure that affected individuals receive the treatment needed to experience improvement of clinical symptoms. Listen to Drs Herbert DuPont and Annie Feagins discuss how to diagnose and treat diarrhea. Related article: Persistent Diarrhea
Dr Allen Steere discovered Lyme disease and discusses what he saw and did when confronted early in his career with a previously undescribed disease. Late stage disease, a form not commonly seen today, is discussed in detail since that is how the disease presented before its cause was determined.
Related article:
Review of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis
Drs Stuart Spechler and Peter Kahrilis discuss GERD and esophagitis--how they occur and how they are treated. Dr Spechler also discusses a new hypothesis regarding how reflux esophagitis is caused that differs from the traditional teaching that acid and pepsin reflux into the esophagus and burn the mucosa layers.
Related articles:
Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes
Turning the Pathogenesis of Acute Peptic Esophagitis Inside Out
Attention-Deficit/Hyperactivity Disorder, or ADHD is a very common problem affecting about 10% of all adolescents. Children with ADHD have short attention spans, are hyperactive, talk a great deal, can be disruptive in the classroom etc.-features that are common in many adolescents. However, to have true ADHD, children must be significantly impaired by these problems. An array of medical and behavioral treatments can successfully help manage ADHD. These are reviewed in a series of articles appearing in the May 10, 2016, issue of JAMA. In this podcast, we discuss ADHD with the authors of some of those papers, Eugenia Chan, MD, MPH from Harvard and Philip Shaw, MD, PhD from the National Human Genome Research Institute.
Articles discussed in this episode:
Mononucleosis is a common disease of young adults manifested by lethargy, fever, pharyngitis, lymphadenopathy and splenomegaly. In this podcast, we review the clinical features of the disease and how good each of them is at establishing a diagnosis of mononucleosis. We also review how Epstein Barr virus was discovered as the cause of mononucleosis and talk to Mark H. Ebell, MD, MS, author of Does This Patient Have Infectious Mononucleosis? The Rational Clinical Examination Systematic Review.
Articles discussed in this episode:
An opioid abuse epidemic now plagues US healthcare. It was caused, in part, by overzealous advocacy for controlling chronic pain resulting in overuse of narcotics. There are now 2 million Americans addicted to opioids. The approach for treating chronic pain must change. In this podcast, we summarize recent CDC guidelines for the proper use of opioids for treating chronic pain.
Articles discussed in this episode:
Polypharmacy is a rapidly worsening problem that hits elderly patients particularly hard. As patients grow older, they need more medications but at the same time become less capable of managing the complexity of drug treatments. In order to simplify treatment regimens for older patients, it is necessary to consider the evidence supporting treatment of various conditions and when the evidence is not particularly strong, reduce or eliminate medications accordingly. Diabetes management in the elderly is highlighted in this podcast with specific attention given to deintensifying diabetes treatment in the elderly.
Articles discussed in this episode:
The American Cancer Society breast cancer screening guidelines have been changed to recommend annual screening for women older than 45 and every other year screening for women older than 55. Older women should only pursue screening if they have a more than 10 year life expectancy. These guidelines were somewhat controversial and were published in the October 15, 2015 issue of JAMA. JAMA Senior editor Mary McDermott interviews Nancy Keating, Evan Myers and Elizabeth Fontham to discuss these guidelines in detail.
Community acquired pneumonia accounts for 600,000 hospital admissions a year. Many patients with this disease are quite ill and have a very high mortality. To save lives, the appropriate antibiotics should be given in a timely basis, but it is not clear what the best antibiotics are and how long they should be given. In this podcast we interview the author of a JAMA review on community acquired pneumonia, Dr Jonathan Lee, author of Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia, who performed a systematic review of the literature to determine the best way to treat community acquired pneumonia.
The 2015-2020 US Dietary Guidelines for Americans were recently released. They are intended to provide guidance for health policy officials and clinicians regarding healthy diets and establishing goals for improving nutrition. These are important since bad eating habits are the underlying cause for a great deal of disease in the US and that these guidelines influence the operations of programs such as school lunch assistance, meals on wheels etc. Because these guidelines influence policy, they have been criticized by various investigators and special interest groups. Karen DeSalvo, MD, Acting Assistant Secretary for Health at HHS and author of Dietary Guidelines for Americans responds to some of these criticisms and explains how the guideline was created and what it is intended to do. Implementation of the guidelines dietary advice may be challenging and Deborah Clegg, RD, PhD, Professor of Internal Medicine at UCLA discusses how the various recommendations can be followed. An earlier interview with Dr DeSalvo on the guidelines is also available within the Dietary Guidelines for Americans article.
Peripheral neuropathy is a highly prevalent and morbid condition affecting 2% to 7% of the population. Patients frequently experience pain and are at risk of falls, ulcerations, and amputations. It is most commonly occurs in patients with diabetes. For most cases, the diagnosis and treatment of neuropathy can be made without complex testing or referral to specialists. Drs. Eva Feldman and Brian Callaghan from the University of Michigan Department of Neurology, authors of Distal Symmetric Polyneuropathy and Electrodiagnostic Tests in Polyneuropathy and Radiculopathy, explain how to manage neuropathy.
Constipation is one of the most frequent problems clinicians are asked to deal with. Despite how common it is, constipation is frequently not treated adequately. In this podcast, Arnold Wald, MD, explains a stepwise approach to the management of constipation ranging from very simple measures to the most novel and complicated new medical therapies.
Articles discussed in this episode: