Episode 23: Nephritis

Education, Emergency Medicine, Medical Education, Nephrology, Pediatric Emergency Medicine

What is it and why are there so many names?

On this episode, host Jason Woods speaks with Dr. Danielle Soranno, pediatric nephrologist, about nephritis in children. What is it, why are the terms so confusing, how do we diagnosis it, and when should we involve a nephrologist? Did the nephrologists invent terminology just to confuse us?

Guests

Danielle Soranno MD,  Assistant Professor, Pediatrics, Bioengineering & Medicine
University of Colorado and Children’s Hospital Colorado

References

  1. Floege J, Amann K. Primary glomerulonephritides. Lancet. 2016 May;387:2036-2048.
  2. Brogan P, Eleftheriou D. Vasculitis update: pathogenesis and biomarkers. Pediatr Nephrol. 2018 Feb;33:187-198.
  3. Chadban SJ, Atkins RC. Glomerulonephritis. Lancet. 2005 May;365:1797-1806.

Episode 22: Risk Factors for Bronchiolitis Care Escalation

Bronchiolitis, Emergency Medicine

On this episode, host Jason Woods speaks with Dr. Gabrielle Freire about her work with PERN (Pediatric Emergency Research Network) and evaluation of predictive risk factors for escalation of care in bronchiolitis.

THE BOTTOM LINE:

Multiple risk factors were found that predicted escalated care in infants. Infants aged < 12 months old with bronchiolitis but without predictors have a low risk of receiving escalated care (<1%) and may be candidates for outpatient management. Infants with increasing numbers of predictors are at a increasing risk of requiring escalated care and need consideration for in patient care with expertise in paediatric airway support.

The highlights:

  • Background
    • Bronchiolitis is responsible for ~ 16% of all hospitalizations in the first year of life
    • The cost incurred from bronchiolitis admissions is thought to be ~ $1.78 billion every year in the US and Canada
  • Study methods
    • Retrospective cohort study of a previously collected database of infants aged < 12 months with clinical diagnosis of bronchiolitis
    • Inclusion
      • Bronchiolitis defined as viral respiratory infection with respiratory distress
      • Age 12 months or younger
      • Visits from Jan – Dec 2013 collected as part of PERN
      • First episode of bronchiolitis only
    • Exclusion
      • Comorbidities such as chronic lung disease, congenital heart disease, immunodeficiency, renal or liver insufficiency, neuromuscular disorders
      • Prior episode of diagnosed bronchiolitis
  • Results
    • 2722 patients included
    • 261 (9.6%) required escalated care
    • Predictors included in the final model
      • O2 sats < 90 (OR 8.9)
      • Nasal flaring/grunting (OR 3.76)
      • Apnea (OR 3.01)
      • Retractions (OR 3.02)
      • Age < 2 months (OR 2.1)
      • Concomitant dehydration (OR 2.13)
      • Poor feeding (OR 1.85)
  • Discussion points (detailed in the audio)
    • Respiratory rate and retractions were co-linear, so RR was not included in the final model
    • The risk score “points” were assigned by diving the OR by 2 to give a total score of 14
    • Duration of illness was not found to be a significant predictor – this may be due to the lack of granularity of the data (only available in days rather than hours)
    • Oxygen saturation had the highest OR by a substantial margin

Guests

Gabrielle Freire MD, Paediatric Emergency Physician, The Hospital for Sick Children, Department of Paediatrics University of Toronto, Toronto, Ontario, CA.

Important Resources

  1. PERN website

References

  • Freire G et. al. for the Pediatric Emergency Research Networks (PERN). Predicting Escalated CAre in Infants with Bronchiolitis. Pediatrics. 2018 Sept 142;3. PMID: 30126934.

Little Big Little: What is Vaping?

Adolescent Medicine, Education, Emergency Medicine, Podcast, Pulmonology, Uncategorized

This is the first segment in a series of “shorts” – smaller quick hit episodes on a focused topic. I’m going to affectionately call them “Little Big Littles”.

On this Little Big Little, host Jason Woods speaks with Dr. Heather Hoch about what we might need to know about vaping to take care of our patients.

Guests

Heather Hoch MD – Assistant Professor, Dept. of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado

Important Resources

  1. CDC Electronic Cigarette Information
  2. Smokefree.gov

Episode 21: HIV Screening in the Pediatric ED

Adolescent Medicine, Emergency Medicine, Infectious Disease, Uncategorized

On this episode, host Jason Woods speaks with Dr. Amy Grover about HIV screening in the pediatric emergency department. Dr. Grover works in both the section of emergency medicine and hospital medicine and has an interest in HIV screening.

The highlights:

  • An estimated 50% of adolescents with HIV do not know they have contracted HIV
  • Acute retroviral syndrome has many non specific symptoms and can be difficult to diagnosis but includes the following
    • Fever
    • Fatigue
    • Myalgias
    • Nausea, vomiting, and/or diarrhea
    • Rash that can involve the hands and feed
    • Pharyngitis is typically not as exudative as EBV
  • CDC guidelines recommend that EVERY person ages 13-64 who is sexually active be screened for HIV at least once in their lives, and yearly if ongoing risk for exposure
  • One of the difficult aspects of setting up a screening program is deciding who is responsible for follow up of the results. Each institution will have to discuss what is appropriate for their setting
  • Do not forget to evaluate for risk of other STI, including Syphilis (prevalence is rising in the US)
  • Most rapid screening tests that do not use whole blood can not detect HIV infection until there is an antibody response (3 weeks – 3 months)
  • The 4th generation HIV test can detect infection starting as early as 15 days after infection. Note that there is still a latent period when detection is not possible.
  • One of the important reasons to screen patients is that there is evidence that knowledge of HIV infection decreases high-risk behavior.
  • The benefit and effect of HIV screening may depend on the regional HIV rates

Guests

Amy Grover MD – University of Colorado School of Medicine, Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado

Important Resources

  1. CDC HIV Resource Library

References

  1. Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatric Adolesc Med. 2000 Apr;154(4):361-5.
  2. Kitahadta MM, et al. Effect of Early vs Deferred Antiretroviral therapy for HIV on Survival. NEJM 2009;360(18):1815-26.
  3. Marks G, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr.2005 Aug 1;39(4):446-53.
  4. Cohen MS, et al. Antiretroviral Therapy for the prevention of HIV-1 Transmission. NEJM 2016; 375(9):830-839.
  5. Marks G, et al. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS.2006 Jun 26;20(10):1447-50.
  6. Wood E, et al. Does this Adult Patient have Early HIV infection? JAMA 2014; 213 (3): 278-285.
  7. Mehta AS, et al. Practices, Beliefs, and Perceived Barriers to Adolescent Human Immunodeficiency Virus Screening in the Emergency Department. Pediatr Emerg Care 2015; 31:621-626.
  8. Akhter A, et al. Rapid Human Immunodeficiency Virus Testing in the Pediatric Emergency Department: A National Survey of Attitudes Among Pediatric Emergency Practitioners. Pediatr Emerg Care 2012; 28:1257-1262.
  9. Haines CJ, et al. Pediatric emergency department – based rapid HIV testing: adolescent attitudes and preferences. Pediatr Emerg Care.2011 Jan;27(1):13-6.

Episode 20: HIV Pre-exposure Prophylaxis (PrEP)

Adolescent Medicine, Emergency Medicine, HIV, Pediatric Emergency Medicine, Sexual Health

On this episode, host Jason Woods speaks with Martin Walker (Director of HIV Programs for Planned Parenthood of the Rocky Mountains) and Moises Munoz (Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado) about pre-exposure prophylaxis for HIV (PrEP).

The highlights:

  • The only FDA approved PrEP regimen the combination product of emtricitabine/tenofovir (brand name Truvada)
  • It was approved in 2012 for PrEP
  • Typical dosing is one pill (200/300) once per day, for patients > 35 kg (regardless of age)
  • Prior to the start of PrEP, counseling and labs are suggested
    • Labs required before the start of PrEP include baseline creatinine and UA, negative studies for HIV and Hepatitis, pregnancy if applicable, and other STIs (all of these are included in ongoing monitoring as well)
    • Counseling should include discussion of risk factors, compliance, required testing, need for continued protection from other STIs
    • Generally not recommended to use in patients with GFR < 60
  • From the start of use, different tissues require different amounts of time to reach effective concentrations. There is not clear data on this but Martin suggests 7 days for receptive anal intercourse and 21 days for receptive vaginal intercourse.
  • Some studies suggest that for penile-anal intercourse, as few as 4 doses per week may be effective.
  • See below for training resources

Guests

Martin Walker – Director of HIV Programs for Planned Parenthood of the Rocky Mountains

Moises Munoz – Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado

Important Resources

References

  1. Hosek S, Rudy B, Landovitz R, et. al. “An HIV Pre-Exposure Prophylaxis (PrEP) Demonstration Project and Safety Study for Young MSM”. J Acquir Immune Defic Syndr. 2017 Jan 1; 74(1): 21–29. PMID: 27632233
  2. Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis 2014; 14:820. PMID: 25065857.
  3. Krakower DS, Mayer KH. Pre-exposure prophylaxis to prevent HIV infection: current status, future opportunities and challenges. Drugs 2015; 75:243. PMID: 25673022.
  4. Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med 2012; 4:151. PMID: 22972843.
  5. Seifert SM, Glidden DV, Meditz AL, et al. Dose response for starting and stopping HIV preexposure prophylaxis for men who have sex with men. Clin Infect Dis 2015; 60:804. PMID: 25409469
  6. Anderson PL, Meditz A, Zheng JH. Cellular pharmacology of TFV and FTC in blood, rectal, and cervical cells from HIV- volunteers. Presented at the Conference on Retroviruses and Opportunistic Infections 2012.

Episode 19: In-flight Emergencies

Emergency Medicine, Podcast

On this episode, host Jason Woods speaks with Dr. TJ Doyle, medical director of the communicaton center at the University of Pittsburgh Medical Center (UPMC) and medical director for STAT-MD, a ground based consulting group for airlines. The discussions encompasses that frequency and types of in-flight medical emergencies (IME), what is in the medical kit on airplanes, what resources are available in-flight, and the legal ramifications for medical vounteers.

The highlights:

  • Worldwide ~ 2.75 billion persons fly annually.
  • IME occur in roughly 1 per 604 US flights, or 24-130 IME per 1 million passengers.
    1. 69% had EMS requested, 25% transported to hospital, 8.6% admitted, 0.3% died.
    2. Aircrafts divert in about 4$ of IME
  • Airplane cabins are pressurized to between 5000 and 8000 ft altitude
  • Minimum equipment in the US (see graphic)
  • AED
    • Hemorrhage control
    • IV line
    • Gloves
    • Medications to treat “basic conditions”
      1. Pain
      2. Allergic reactions
      3. Bronchoconstriction
      4. Hypoglycemia
      5. Dehydration
      6. “Some” cardiac conditions
    • Equipment for initial assessment
  • Most common IME
    • Syncope or near 32.7%
    • GI 14.8%
    • Resp 10.1%
    • CV 7.0 %
  • Medical volunteer role
    • Individual airline policies may have different guidance
    • Not generally required to carry proof of medical license
    • Primary role is to gather info, provide assessment, and communicate with ground support. May need to admin medicines or perform procedures but direction of care is by ground medical.
  • Legal and ethical issues
    • US Aviation Medical Assistance Act
      1. Protects passengers who provide medical assistance from liability except in cases of negligence or willful misconduct.
      2. Medical volunteers who seek compensation for this service may jeopardize their protections under this law, though now lawsuit of such has been filed
    • Duty to respond
      1. In US, Canada, England, Singapore, no legal duty
      2. In Australia, many European countries, physicians are required to render assistance.
    • Other countries may have different protections or no protections at all

Guests

Thomas J. Doyle, Clinical Assistant Professor of Emergency Medicine, University of Pittsburgh Medical Center; Associate Medical Director, STAT MedEvac; Medical Director, Command Center, STAT-MD.

References

  1. Christian Martin-Gill, MD, MPH; Thomas J. Doyle, MD, MPH; Donald M. Yealy, MD. In-Flight Medical Emergencies: A Review. JAMA. 2018;320(24):2580-2590. doi:10.1001/jama.2018.19842
  2. Peterson DC, Martin-Gill C, Guyette FX, et all. Outcomes of Medical Emergencies on Commercial Airline Flights. NEJM. 2013:368(22):2075-2083. doi:10.1056/NEJMoa1212052

Episode 18b: Anti-trafficking and the role of the ED

Adolescent Medicine, Emergency Medicine, Pediatric Emergency Medicine, Sexual Health, Trafficking

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 2 of a 2 part discussion. The highlights:

  1. Definition of trafficking
    1. recruitment, harboring, transportation, provision, and/or obtaining of a person
    2. By the use of force, fraud, and/or coercion
    3. For purposes of labor and/or sexual exploitation
  2. Numbers and general info
    1. Overall labor trafficking is most common
    2. Under age 18 “survival” sex considered victim of trafficking
    3. US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.
    4. On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked
  3. There is no comprehensive trafficking screening tool in existence
    1. The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking
  4. Quotes from Makini’s published work that I loved
    1. It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience.
    2. We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve.

Guests

Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System

Other Resources

  1. HEAL Trafficking
  2. Training for providers that Dr. Chisolm-Straker mentioned
  3. Human trafficking hotline:
    1. Phone: 1-888-373-7888
    2. SMS:233733 text HELP or INFO
    3. Humantraffickinghotline.org
  4. HumantraffickingED.com

References

1.     Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52. 

2.     Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7. 

3.     Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33. 

4.     Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1. 

5.     Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D. Acad Emerg Med 2018.  doi: 10.1111/acem.13552 

Episode 18a: Anti-trafficking and the role of the ED

Adolescent Medicine, Emergency Medicine, Pediatric Emergency Medicine, Trafficking, Uncategorized

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 1 of a 2 part discussion. The highlights:

  1. Definition of trafficking
    1. recruitment, harboring, transportation, provision, and/or obtaining of a person
    2. By the use of force, fraud, and/or coercion
    3. For purposes of labor and/or sexual exploitation
  2. Numbers and general info
    1. Overall labor trafficking is most common
    2. Under age 18 “survival” sex considered victim of trafficking
    3. US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.
    4. On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked
  3. There is no comprehensive trafficking screening tool in existence
    1. The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking
  4. Quotes from Makini’s published work that I loved
    1. It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience.
    2. We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve.

Guests

Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System

Other Resources

  1. HEAL Trafficking
  2. Training for providers that Dr. Chisolm-Straker mentioned
  3. Human trafficking hotline:
    1. Phone: 1-888-373-7888
    2. SMS:233733 text HELP or INFO
    3. Humantraffickinghotline.org
  4. HumantraffickingED.com

References

1.     Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52. 

2.     Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7. 

3.     Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33. 

4.     Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1. 

5.     Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D. Acad Emerg Med 2018.  doi: 10.1111/acem.13552 

Episode 17: Teeny Weeny Problems – Pediatric Urology

Emergency Medicine, Pediatric Emergency Medicine, Urology

On this episode, host Jason Woods speaks with Dr. Tanya Davis, pediatric urologist and all around superstar, about common pediatric urology problems that present to the emergency department. The highlights:

  1. Testicular torsion is an emergency, and ultrasound should be performed when this is suspected. If the symptoms are highly suggestive call urology even with a normal ultrasound
  2. It is suggested that urology is contacted before performing any repair of a laceration that is more than superficial.
  3. Pediatric patients that develop epididymitis in the absence of sexual activity should be referred to urology, as this is unusual and may indicate an anatomic abnormality.
  4. Dr. Davis feels that any patient with complex urogenital anatomy, indwelling catheters, or a surgically created catheterizable tract should NOT have antibiotics started for UTI without contacting their primary urologist.

Guests

Tanya Davis MD, Clinical Instructor, Department of Urology, Children’s National Health System

Pediatric Urologist, Mid-Atlantic Permanente Medical Group

Episode 16: Transgender Health Care

Emergency Medicine, Podcast

First, apologies for the delay in this episode! We’ve got a 2-month-old at home and it turns out, those little amazing terrorists take a lot of time!

On this episode, host Jason Woods speaks to Dr. Natalie Nokoff, a pediatric endocrinologist who works with transgender patients. The discussion centers on the health care needs of these patients, preferred language, safety, and how to approach the discussion of gender in our population.

Important Links

  1. Human Rights Campaign
  2. National LGBT Health Education Center
  3. GLAAD
  4. World Professional Association for Transgender Health
  5. Transgender Law Center

References

  1. Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet 2016; 388:401.
  2. Turban J, Ferraiolo T, Martin A, Olezeski C. Ten Things Transgender and Gender Nonconforming Youth Want Their Doctors to Know. J Am Acad Child Adolesc Psychiatry 2017; 56:275.
  3. Olson-Kennedy J and Forcier M. Management of transgender and gender-diverse children and adolescents. UpToDate. Last Update Nov 2018. Accessed Nov 2018.
  4. Olson-Kennedy J and Forcier M. Gender development and clinical presentation of gender diversity in children and adolescents. Last Update Nov 2018. Accessed Nov 2018.

Guests

Natalie Nokoff MD, Assistant Professor of Pediatrics, Section of Endocrinology, Children’s Hospital Colorado and the University of Colorado