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

 

Episode 15a: Nephrology Overview with Danielle Sorrano

Education, Emergency Medicine, Nephrology, Pediatric Emergency Medicine, Podcast, Uncategorized

On this episode, host Jason Woods tries to tackle all things renal. This is part 1 of a discussion with Dr. Danielle Soranno, who gives an overview of how she approaches the kidney and what things we need to know in general. She talks about common renal issues in the emergency department and what information she wants to hear when called for a consult

Part 2 will post later this week and digs into some specific illnesses such as HUS, hyperkalemia, and end-stage renal disease.

Guests

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

Important Information

  1. Fab Four – FABU
    1. Function
    2. Anatomy
    3. Blood Pressure
    4. Urine

Episode 14: UTICalc with Nader Shaikh

Calculators, Emergency Medicine, Infectious Disease, Uncategorized

On this episode, host Jason Woods speaks to Dr. Nader Shaikh about his recent paper on the development of a calculator (UTICalc) to estimate the probability of UTI in pediatric patients. The calculator itself is fantastic and easy to use (see link below) but the discussion centers on the methods behind the calculator. We dig into how these calculators are developed, how to determine if they are accurate/useful, and how to use them in clinical practice.

Important Links

  1. UTI Calculator link – UTICalc
  2. AAP UTI Guidelines, 2016 Reaffirmation of 2011 Guidelines
  3. AAP 2011 UTI Guidelines Update

References

  1. Shaikh N et al. “Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children”. JAMA Pediatr. 2018 Jun 1;172(6):550-556. doi: 10.1001/jamapediatrics.2018.0217.
  2. Roberts  KB; Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management.  Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.  Pediatrics. 2011;128(3):595-610.Lavelle  JM, Blackstone  MM, Funari  MK,  et al.  Two-step process for ED UTI screening in febrile young children: reducing catheterization rates.  Pediatrics. 2016;138(1):e20153023.
  3. Shaikh  N, Morone  NE, Bost  JE, Farrell  MH.  Prevalence of urinary tract infection in childhood: a meta-analysis.  Pediatr Infect Dis J. 2008;27(4):302-308.
  4. Hoberman  A, Wald  ER, Reynolds  EA, Penchansky  L, Charron  M.  Pyuria and bacteriuria in urine specimens obtained by catheter from young children with fever.  J Pediatr. 1994;124(4):513-519.
  5. Hoberman  A, Chao  HP, Keller  DM, Hickey  R, Davis  HW, Ellis  D.  Prevalence of urinary tract infection in febrile infants.  J Pediatr. 1993;123(1):17-23.

Guests

Nader Shaikh MD, Associate Professor, General Academic Pediatrics, Children’s Hospital of Pittsburgh

 

Episode 12: High Altitude Illness with Elaine Reno

Education, Emergency Medicine, Medical Education, Pediatric Emergency Medicine, Podcast, Uncategorized, Wilderness Medicine

On this episode, host Jason Woods speaks with Dr. Elaine Reno, an emergency medicine physician who is also a wilderness medicine expert, about high altitude illness in pediatrics. We focus on risk factors, identification of illness, and recommendations for initial treatment.

Important points

  1. Significant altitude illness is rare below 8000 feet
  2. Pre-verbal children DO experience high altitude illness but can be more difficult to diagnose given the difficulty in communication.
  3. Dr. Reno strongly prefers slow acclimatization for children, rather than prophylactic medication.

Point of Care Resources

  1. Wilderness Medical Society
  2. Colorado Wilderness Medicine
  3. Lake Louise Acute Mountain Sickness Score
  4. Children’s Lake Louise Score

Guests

Elaine Reno MD – Assistant Professor of Emergency Medicine, University of Colorado School of Medicine, Department of Emergency Medicine, Section of Wilderness and Environmental Medicine

 

Episode 11b: Acute Illness and Known Metabolic Disease with Austin Larson

Emergency Medicine, Metabolic Disorders, Pediatric Emergency Medicine, Podcast

On this episode, host Jason Woods speaks with Dr. Austin Larson, a specialist in pediatric inherited metabolic disorders (and also someone way smarter than I), about what do do with the crashing neonate if there are concerns for a metabolic disorder. We review the diagnostic approach, emergent treatment, and what resources are available to read/consult in this situation.

Important points

  1. Most children with known inherited metabolic disorder will have a letter with them, from their metabolic doc, about what to do if they show up to the with a new illness. If they do not, then the New England Consortium website is a great resource.
  2. Most protocols recommend starting D10 fluids at 1.5 x maintenance is generally the recommendation, unless there is a reason why glucose/fluids will otherwise harm the patient.
  3. Be careful with patients who are on a ketogenic diet as treatment for their seizures, as giving them glucose can cause refractory status epilepticus. In those patients, the preferred calorie support would be lipids.

Point of Care Resources

  1. New England Consortium for treatment protocols
  2. Vademecum Metabolicum handbook in book form
  3. App version of Vademecum Metabolicum – eVM

Guests

Austin Larson, MD – Assistant Professor of Pediatrics and Metabolic and Clinical Genetics, University of Colorado School of Medicine and Children’s Hospital Colorado