EMU Monthly – May 2016

  • Tako Tsubo Cardiomyopathy is generally benign but it can turn rotten and can kill image001(this is Johnny Rotten from the British Group “The Sex Pistols”). Those with co morbidities are at the highest risk. In their cohort of only 2477 patients- 19% had adverse outcomes, and unlike other studies – these patients really were sick (hypotension requiring pressors, CHF, cardiac arrest). (AJC 116(5)765)- seems kinda of high to me, and again this is a difficult diagnosis to make from the ED – since you need to know they have clear coronaries. My point is just be aware that this is not always a “well, you had cath two months ago which was clear so all is well” TBTR: Tako Tsubo can be bad- really bad.
  • Vertebral osteomyelitis-well, epidural abscesses, and osteo are definitely the rising stars of the malpractice image002show and OK – you know – or you should know that back pain and fever are not just some pylo. Think of this also with back pain and elevated CRP or ESR, or new neuro symptoms with fever even without back pain. You will need blood cultures, keeping in the back of your mind TB, Brucella, and fungi – culturing these as necessary from the blood stream as well. MRI will be necessary as well. Antibiotics need not be given immediately if the patient is stable – you can await sensitivities (I’m not sure I agree with the artyicle onthat one). Surgery is indicated if antibiotics fail. Antibiotics are continued for six weeks (CID 61(6)859). This is an executive summary of IDSA guidelines, Orthos may have other ideas. By the way – TB osteo of the spine is called? TBTR: guidelines on osteo of the spine.
  • Neck pain and stiffness? Could be dystonia- from that fluoxetine or escitalopram that you are giving the patient. This can also cause rabbit syndrome –(Psychosomatics 56(5)572) I didn’t know what that is – but I do now-go on this hyperlink and stay away from the carrots- and female rabbits image004TBTR: Cervical dystonia can be seen with some SSRIs. Here are our quotes for the month- let’s start from our favorite geeks- the Big Bang Theory

Leonard Hofstadter: We have to do this.
Sheldon Cooper: No, we have to take in nourishment, expel waste and keep our cells from dying. Everything else is purely optional


Leonard Hofstadter: [about his date with Penny] Where could I have possibly gone wrong?
Howard Wolowitz: The littlest things can set women off – like, “Hey, the waitress is hot! I bet we could get her to come home with us.” Or, “How much does your mom weigh? I want to know what I’m getting into.”


  • Odds ratios generally do not change the quality of the data – i.e. making results more or less significant – but if they are looked at as relative risks than the results will be misinterpreted – usually to the side of exaggeration. (Postgrad Med J 127(4)359) What in tarnation am I talking about and why will it interest anyone? Is anyone still reading? Well, I got another article this month which will explain these concepts and maybe it will interest you – although I doubt it will. See # 13 below. Let’s try it- and remember you must be sober to try. Raj: I don’t like bugs, okay. They freak me out.
    Sheldon: Interesting. You’re afraid of insects and women. Ladybugs must render you catatonic
  • This is not new. Nor is it a genius thing. But if you are not doing it, than be glad that you read EMU and that you have some semblance of a brain (orthopedists need not read further). They did this study with nursery songs to ease kids into the CT scanner. After all sedation can be dangerous or unpredictable depending on what you use. (AJEM 33(10)1477) It seemed to work, but they did this article on VAS scores and sedation scores and the scores were similar.  Could be that some kids may have been prepared for a CT scan or may just be naturally sedate.  I would have liked to hear parent’s opinions as well. Nevertheless, we have graduated today to iPhone and smartphones showing cartoons and soothing music (what I wouldn’t’ do to hear a little Air Supply image005or Barry Mannilowimage006( for G-d’s sake, this guy is 73 years old !!! )  before getting a head CT) but they did not study MRI where this may not be enough. They also did not head to head it with sedation but rather with nothing where of course it did better (Still, I like the idea and do use it. TBTR: Crank up those Smurfsimage007 before doing painful procedures. For adults consider thisimage008

Howard: Sheldon, don’t take this the wrong way, but, you’re insane.
Leonard: That may well be, but the fact is it wouldn’t kill us to meet some new people.
Sheldon: For the record, it could kill us to meet new people. They could be murderers or the carriers of unusual pathogens. And I’m not insane, my mother had me tested


Sheldon: Then it’s settled. Amy’s birthday present will be my genitals

  • Pancreatitis- this is one for you wine of the month guys. Is there anything new here? Actually there is- Ranson’s criteria have been updated. But here have been other new developments- some for EMU readers, some you should have known already. Pain control is important. So you were taught you should use penthidine (meperidine) since it causes less spasm of the sphincter of Oddi- but in clinical terms this effect is insignificant –in other words – this fact doesn’t lead to too much improvement in pain scores. Now the new kid on the block is epidurals for pain control – while they improve microcirculation and oxygenation – they can cause derangement of inflammation and coagulation parameters. These are a lot of disease oriented outcomes that may not be relevant- I would consider using it. Feed these people. While that will put a strain on the pancreas; not feeding these patients causes atrophy of the intestines and bacterial overgrowth. Putting feeding tubes in the jejunum has not shown that much promise. These folks need a lot of fluids but almost a quarter will develop abdominal compartment syndrome – be on the lookout. (Intens Care Med 41(11)1957)  Since this article was done by folks in Rennes France and Hamburg Germany – kind of reminded me of Mili Vanilli- remember them? They were a German and a Frenchman image009who faked their songs. Here they are if you don’t remember them.image011 TBTR: some new tidbits on pancreatitis.

Leonard: I did a bad thing.
Sheldon: Does it affect me?
Leonard: No.
Sheldon: Then suffer in silence.


  • Terrible evidence but the articles – with the few patients that they had- seem to show that lidocaine can help against seizures in 70% of the time. As Rob Orman once said – This is DD evidence- it needs a lot of support. (Seizure 31:41)

Leonard: You’ll never guess what just happened.
Sheldon: You went out in the hallway, stumbled into an inter-dimensional portal, which brought you 5,000 years into the future, where you took advantage of the advanced technology to build a time machine, and now you’re back, to bring us all with you to the year 7010, where we are transported to work at the think-a-torium by telepathically controlled flying dolphins?
Leonard: Penny kissed me.
Sheldon: Who would ever guess that?


  • And another shortee but goodee. Spiral tibia fractures are not uncommon – but can be associated with significant additional injuries .CHECK THE ANKLE! We all should be familiar with Masioneueve’s fracture, but there were also posterior malleolar fractures, anterior inferior tibiofibular ligament avulsion fractures, lateral malleolar fractures and combinations thereof. (Foot Ankle Intl 36(10)1209) They CT ed everyone, but I believe a good physical exam suffices. I thought it was kinda cool that this Korean study included a mechanical engineer in their authors- being that I was an old mech eng before I went to med school (yes ,Virginia, there were dinosaurs in those days- but then again there still are- they are called hospital administratorsimage012 TBTR: check the ankle in tibial spiral fractures.

Leonard: Our babies will be smart and beautiful.
Sheldon: Not to mention imaginary.



Sheldon: I’m exceedingly smart. I graduated college at fourteen. While my brother was getting an STD, I was getting a Ph.D. Penicillin can’t take this away

  • It is really hard for me to avoid mother in law jokes here but this article reminds of the mother in law that never leave- when we will finally stop this pendulum and come to a final decision? Patients with CAP (Community Acquired Pneumonia) who get steroids do have less need for intubation and less ARDS if they do get intubated. But it is clear that not everyone needs them, since only 1/3 of hospitalized patients get intubated (only? That seems like a lot!). So who should get them? They say check the CRP which made me sick- I for one do not believe a CRP can tell me how sick a person is- lactate yes – but CRP?? (Ann Int Med 163(7)560) I would also like to know what the ideal dose is – we can’t tell from this study. This could be a standard in the near future but the struggle continues. OK, I couldn’t contain myself. Allow me one mother in law joke. So there is this small town where there are two eligible bachelorettes with no male suitors. So a train arrives with a male (no doubt from the male order catalogue) and two women immediately pull at them, claiming that they ordered him for their unmarried daughters. Fortunately there is a wise king in this town and he hears the case and recommends they bring a large sword and he will cut the potential groom in half and give a half to each daughter. One of the mothers says- “good idea” The wise king says – stop – that is the real mother in law” image013TBTR: Steroids are back – maybe- for CAP

Penny: Oh, big deal. Not knowing is part of the fun.
Sheldon: “Not knowing is part of the fun.” Was that the motto of your community college?




Sheldon: There’s no denying that I have feelings for you that can’t be explained in any other way. I briefly considered that I had a brain parasite, but that seems even more far-fetched. The only conclusion was lov3

  • Left sided hemiparesis and a CT like this – what is your call?image014  (BMJ351:H5013)

Howard: I thought you didn’t like Facebook any more.

Sheldon: Don’t be silly, I’m a fan of anything that tries to replace actual human contact

  • OK AEM is a hoity toity journal and like all journal with the exception of EMU they reject a lot of manuscripts- what becomes of them? (on the other hand there is the Journal of Universal Rejection –look this one up). AEM in these two years of study rejected 68% of the articles of which about 2/3 were resubmitted elsewhere and accepted. It took about 16.7 months till they were accepted elsewhere. (AEM 22(10)1213) This confirms what Prof Steiner – once told me – “every paper does have its address” just most of my papers were suitable for the Mongolian Journal of Parrot Cloaca Hygiene- which basically means lining the bird cage. TBTR: Don’t be discouraged – you paper will be used – somewhere.

Howard: You gotta like this: the girlfriend, the ex-girlfriend, bonding over your rooty-tooty stinky booty? (All but Leonard laugh)
Leonard: Kill me.
Sheldon: It wouldn’t help. The human body is capable of being flatulent for hours after death


Rajesh: Why so glum, chum?
Sheldon: Apparently you can’t hack into a government supercomputer and then try to buy uranium without the Department of Homeland Security tattling to your mother.


  • I do not believe this article and when something flies in the face of accepted practice, physiology and past articles it is called a face validity problem. Here these authors- based on a meta analysis recommend liberal transfusion strategies in patients that were not critically ill in the peri operative period. (BJA 115(4)511) The key here is this was a meta analysis and therefore you can’t control for the heterogeneity of patients- maybe those lived longer because they were healthier-not because they got blood. They claimed to use the Cochrane Q and I2 tests to control for heterogeneity but I am not convinced that that is enough to make this reliable TBTR: Can giving blood help save lives in people who are well? Did I just write that??

Sheldon: A neutron walks into a bar and asks how much for a drink. The bartender replies “for you, no charge”.




Penny: Mrs. Cooper? Hey, it’s Penny. I think I broke your son. Hold on. Talk to your mother.
Sheldon: (Crying) Mommy, I love you. Don’t let Spock take me to the future


  • How many times have I written about odds ratios and relative risk and confused the hell out of you and me too? Well this guy must have heard me because he wrote an article explaining these in plain language. I am going to try and imitate him. Let’s say you have a 8.33% chance of being hit by a car crossing interstate 95 and if you are dressed like a clown – that goes up to 20%. The relative risk of being hit by a car when dressed like a clown (which includes any polyester at all) is 20 divided by 8.33 or 2.40 times more likely when you are dressed like a clown. RR is significant if less than .5 or greater than 2 (the risk is halved or doubled) but can be significant even if between those two if there is a serious side effect or a large sample size. Odds ratio is a measure of likelihood of occurrence versus nonoccurrence. In our case – there were 36 folks running across I95 and 40 dressed up as a clown. Of the first group 33 made it safely across and of the second group 32 made it across safely. So the odds ratio dressed as a clown are 8/32 divided by 3/33. – comes out to be 2.75 As I have pounded into your brains in the past – ORs are not as good as RRs. ORs can over or underestimate occurrence if the event is common.  And it ain’t easy to convert between ORs and RRs. If it includes 1 in the confidence interval the OR is meaningless (RR is as well). OR is much harder to express in plain English. RR tells you how much of a risk of the event happening. But OR is harder to express- basically if the OR is 2.75 it means that there will be 2.75 people  who get hit by a car dressed as a clown for everyone who is dressed normally (I think- this is getting confusing). This example did not take into account crossing I95 when not dressed – your odds of getting hit are probably much less. (J Clin Psych 76(7)e857) I just wanted to point out that these concepts are common but not related to hazard ratios or the star- likelihood ratios. TBTR: A little statistics came your way.image015

Sheldon: I’m sorry, coffee’s out of the question. When I moved to California I promised my mother that I wouldn’t start doing drugs.



Sheldon: Well, well, well, if it isn’t Wil Wheaton. The Green Goblin to my Spider-Man, the Pope Paul V to my Galileo, the Internet Explorer to my Firefox!


  • Here is another clinical quiz – this is for our peds guys – please do not miss this What is this?? image016–( it is a lump on the inside lip) (J Peds 167:204)

Sheldon: Good Morning your honor, Dr. Sheldon Cooper appearing in pro se – that is to say representing himself.
Judge: I know what it means, I went to law school.
Sheldon: Yet you wound up in traffic court

  • This is an odd article and its for you deviants out there who need to get a life. Legally speaking – what happens when damage occurs due to sleep walking, sexosmia(you know what is-guess what happens due to a person who is asleep) and sleep terror. These are rare although many drugs can cause this as well as stress and sleep deprivation. A big problem is that alcohol can cause sleep walking events – but alcohol alone can cause a state that looks like sleep walking – and in many places the former is not culpable whereas the latter is. Truth be told I don’t want to get any deeper into this article – I would much prefer to talk about you running across I95 unclothed –especially if you are Father Henry. (Med Sci Law 55(3)176) TBTR: Sleep walking and doing illegal things….

Amy: Acquiring a joint pet is a big step for us.
Sheldon: It’s true. It means we care so much about each other, there’s enough left over for an eight-ounce reptile


Leonard: I’m just saying, you catch more flies with honey than with vinegar.
Sheldon: You catch even more with manure, what’s your point?



Sheldon: I think that you have as much of a chance of having a sexual relationship with Penny as the Hubble telescope does of discovering at the center of every black hole is a little man with a flashlight searching for a circuit breaker

  • Shoulder dislocations – we have always featured these in EMU and if you are a long term reader (or deviant as EMU readers are called) you know we like scapular manipulation although we reported on the Spaso technique when it first came out and here is the Aufmesser technique. I will agree with them that it looks easy, the pictures look good and it seems you do not need to be image017 to do it. Naturally they report they can do this without sedation or pain control and it worked almost all the time, but all bone guys say this. What I liked about this is that it seems to work by pulling the humeral head out from under the glenoid as opposed to bringing the glenoid down or the humeral head up. ( Arch Ortho Traum Surg 135:1379) But of course I gotta try it to see. Here is a shout out to Cole- who is a tight end on my son’s team in the IFL – his team won the championship – who dislocated his shoulder in the game. I responded – did a little Hennepin, and a little Milch and that baby popped back in. I got to see the rest of the game from the sideline. TBTR: More techniques on reducing shoulders.

Sheldon: For the record, I do have genitals. They’re functional and aesthetically pleasing





Sheldon: I believe I would like to alter the paradigm of our relationship.
Amy: I’m listening.
Sheldon: With the understanding that nothing changes what so ever – physical or otherwise, I would not object to us no longer characterizing you as not my girlfriend.
Amy: Interesting, now try it without the quadruple negative


  • Two articles for Ken’s corner- For those of you who do not know Ken – Ken is former faculty at U of Arizona, and was the bio ethics guy for EM for years. He also has an MBA and has written on almost everything. He has a great book on improvised medicine and is one of EMU’s best friends (also one of EMU’s editor’s best friend) He is spending his retirement years traveling to underserved areas and has written me from assignments in a variety of countries (whose capitals I knew without even looking them up) – he is now in his second visit as the doc in Antarctica at one of the USA bases (no capital city on this continent). Curiously – and he won’t tell me why- he did not take malaria prophylaxis before he went there. I am going to present these articles but I – without a doubt – am sure he has written on these subjects as well. The first is a case report from JAMA Int Med (175(10)1606) about a med stdent who came back from Brazil where she ate a lot of a fruit that can be infested with Reduviid bug droppings. She thought she had lost some weight and had perhaps a little lymph adenopathy – so she did a test for Chagas disease which came out positive. But this parasite can lay dormant for many years if not treated within six months and can cause megacolon, and CHF. She actually took a year off and somehow got to the CDC who did a newer more reliable test which was – negative. Take home lessons here abound (TBTR) –don’t take a test that you are not prepared to know what to do with the result. Also, do not test indiscriminately. Lastly a big malpractice mistake is that people do favors and take unnecessary tests from the ED (like a PSA) and no one follows up with the result (so let’s use this a s a plug for Risk Management Monthly where you can learn how to get yourself out of a suit and get some good wine too). Also – for goodness sake – don’t be your own doctor- it was actually Osler I think who said – whoever is his own physician has a fool for a doctor. Another article deals with how to confront patients- you sometimes have to if they are in deep denial or hiding dangerous facts- there is a good way, and a bad way. There can be a good response (they acknowledge) and bad response (the silent treatment) and the ugly (I’ll sue you, bastard). Their recommendations are basically the usual- communicate clearly and sincerely, acknowledge the patient’s point of view, keep calm, eye contact – all these things that never worked for me ( I guess screaming “you Jerk” works only with Dr. House) (Psychosomat 56:556) TBTR: Confronting patients- how to do it.

Sheldon: Let’s see. What do I know about Amy? She loves medieval literature. Chaucer’s her favorite. And her eyes sparkle when she watches old French movies. And I enjoy how harp music causes her fingers to dance as if she’s playing along.
Bernadette: Wow, you really do love her.
Sheldon: I do. Now, let’s find the kind of gift that makes her feel small and worthless



Sheldon: Interesting. Sex works even better than chocolate to modify behavior. I wonder if anyone else has stumbled onto that.


  • This article speaks about q waves in LBBB –inferior wall q’s should raise suspicion of an MI. ( AJC 116:822) I think you always have to have your antennae up – but I would still advise the modified Sgarbossa criteria.

Store Clerk: Excuse me, Sir, you don’t work here.
Sheldon: Yes, well apparently neither does anyone else.



Penny: Well, she did soften your life, didn’t she?
Sheldon: Yes! She’s like the dryer sheets of my heart

  • This is not a real ED topic unless you board these types of cases in the ED, but you all know my love for ICU medicine so here it is but I won’t bore you with it too much. So you got this guy who is intubated and you want to extubate him. How do you avoid post extubation laryngeal edema and stridor? Well, first, and this is important to all ED guys – you may be very macho image018by intubating anything that will allow you to (including the pizza delivery man, the cleaning lady, and even insects) but this is a very damaging exercise. Not only does it cause edema, but it can cause ulcer to the vocal cords, not to mention all the ventilator problems such as VAP. That is the reason there is a growing body of literature pushing for the use of LMA s in pre hospital and EDs when feasible. How many have you put in? I have put in a lot – but all were on dolls. EM RAP (why do I give plugs for Risk Managements and not EM RAP? Rob Orman did use to read EMU so it is a good question) recently had some airway people pushing for this in the April EM RAP. This article can’t tell you much about incidence of edema – there are just too many bad studies. Risk factors also aren’t reliable enough-although they have traditionally been long duration of intubations, difficult intubations, female gender, higher balloon pressures and large size tubes. There are a few tests you can use to determine that the patient is ready for extubation. The easiest is the cuff leak test- I actually found it a little complicated to describe – it is the kind of thing you need to do at the bedside with the instructions before you to learn well. Ultrasound can also help by measuring air column width-that is the width of the acoustic shadow at the level of the cords. How can you prevent edema post extubation? Despite their saying that risk factors don’t predict well, they still push for modifying them- – use smaller tubes (which by the way still increases the work of breathing) and cut duration of intubation to a minimum. Killing the patient is not considered an acceptable way of achieving this goal. Cuff pressures should be kept below 25 H2O – that is not evidence based, but higher pressures will cause more ulceration. Steroids didn’t help in the past – but that is because they weren’t used correctly – recent studies do show that if started several hours before extubation – they work (Dex 5, or Methylpred 20 -40 mg). They also think nebulized steroids after intubation may work as well. NIV will not work well if you extubated the patient and they have stridor although it is another strategy to prevent intubation if used beforehand. If you do need to reintubate, consider the Ventrain– a transtracheal insufflation device – I think you should try a bougie which may work just as well and is cheaper.  Heliox and nebulized epi are great ideas with little evidence. (Critical Care 19:295) TBTR: How to prevent post extubation respiratory failure.

Penny: OK Sheldon, what can I get ya?
Sheldon: Alcohol.
Penny: Could you be a little more specific?
Sheldon: Ethyl alcohol, 40 millilitres


This next quote is for my wife

Sheldon: Under normal circumstances I’d say I told you so. But, as I have told you so with such vehemence and frequency already the phrase has lost all meaning. Therefore, I will be replacing it with the phrase, I have informed you thusly

  • This actually happened to me- let’s paint the picture here- it was a dark and stormy night image019and a lady came in obtunded. Not only that; she didn’t respond also. The paramedics found empty bottles of medications at her bedside with Chinese characters written on them, with the only English being “made in Australia”.  She was receiving medication by a practitioner of Chinese medicine for chronic pain. Now what do I do? Can’t call poison control, do know the name of the prescribing physician, the glucose is normal and Narcan didn’t’ work. What now? Well, of course you go up on to EMU, scroll down to the April/May issue and scroll down to number 21. It won’t help you too much but at least you will have a good read. And this article actually did come from Australia. Chinese medicine begins with a balanced and symbiotic function of body mind and spirit via energy that gets distributed to the destinations via meridians – if there is balance that is called Qi. If not, usually due to some blocked meridian –you have to help unblock them. What causes blockage of qui- imbalanced diet, imbalanced lifestyle, stress, excessive or repressed emotions, and lack of exercise. Kind of interesting that the Chinese knew these dangers long before western medicine did. How do you improve Qi? Easy- Tuina, Qigong and tai chi. The former is acupuncture and acupressure, the second is for balancing the state of mind- and includes medications and the latter is for exercising the body and is quite popular today. Does it work? Considering how few people who practice western medicine and do research understand Chinese medicine it is no wonder that most of it has never been studied. But Chinese medical practitioners are not witch doctors- they must have formal university education and pass a national exam to get a lisence. Their medications are under national scrutiny as well. That isn’t to say that adulterated medicines are not available – they are and are like any other medicine available on the internet- you don’t know what you are getting. That is also not to say that some medications have poisonous components- but only certain practitioners are allowed to use them and they are in doses below that which will cause untoward side effects. Now you have been waiting for what is in these medications – I could tell you, but this is where pharmacology comes in and it isn’t easy. The general headings are alkaloids, flavonoids, pyrones, and terpenes. Ones used with caution include aconitines, strychinine, pyrrolizine alkaloids, and aritstolochic acid. What these are used for is in the article and has varying levels of safety. (BJCP 80(4)834) My take on all this is that is probably merit to this form of medicine but I would not recommend it for you to try on your own- leave it to people who know what they are doing. Just like western medicine. While my med student Alex Wang has seen this article – and agrees with the content- but I will just mention our discussion of politics. It seems apparent that many people are disenchanted by the choices this time around and while I would welcome Bernie Sanders marrying Sara Palin,  image021 image020there is one thought that this is not likely to happen. So I want to tell you what you should do which would be the best for America- vote for Father- he stands for motherhood, apple pie and Gallo Chablis. He also stands for fatherhood, pierogis and Ripple. He has promised me he will bring the Edsel back providing more jobs for Detroit. And he will fix Flint’s water problems by connecting them to Finlandia. We were unable to provide a campaign picture for Father, but we did get one of his vice presidential hopefulimage008. A vote for Father is a vote for what is good in America. TBTR: Chinese medicine and voting in the upcoming election- both good reads.


Penny: Yes, I know men can’t fly.
Sheldon: No, no let’s assume that they can. Lois Lane is falling, accelerating at an initial rate of 32ft per second, per second. Superman swoops down to save her by reaching out two arms of steel. Ms. Lane, who is now traveling at approximately 120 miles per hour, hits them, and is immediately sliced into three equal pieces


Sheldon: I present to you the Relationship Agreement. A binding covenant that in its 31 pages enumerates, illuminates and codifies the responsibilities of Sheldon Lee Cooper – hereinafter referred to as the “Boyfriend” – and Amy Farrah Fowler – hereinafter referred to as the “Girlfriend.
Amy: That’s so romantic!
Sheldon: Mutual indemnification always is

  • This is a big problem – opioid constipation. Unfortunately the opposite isn’t true because if it was- getting old would be a lot more fun. (we will just mention in passing (pun intended) two other drug related bowel problems- narcotic bowel syndrome – pain due to opioid use – usually managed by more opioids which just makes things worse, and cannaboid hyperemesis syndrome- see an excellent review of the subject by an moron named Leibman) A person can develop a tolerance to opioids. He can develop an tolerance to the nausea from these meds. Ditto for sedation. But no for constipation. Often these patients have other good reasons for constipation as well (Ken what is the difference between constipation and obstipation? What about between urination and micturition? Why do we need two medical words for the same thing??) such as reduced mobility, advanced age, hypercalcemia, fissures and altered nutritional intake. The problem is that there are mu receptors in the bowel- which leads to decreased water and electrolyte movements and decreased peristalsis. This is how loperamide (Immodium) works, and as such is now being abused in the States. Increasing fiber and fruit should theoretically work but it doesn’t free up the mu receptors. Laxatives have their own problems including kidney stone development and electrolyte imbalances. For example bulking agents which can lead to bulky stool that just doesn’t move. Fiber can cause the same problem especially if not enough fluid is drunk. Stool softeners do not work. Osmotic laxatives have high salt content causing electrolyte imbalances. So do stimulant laxatives. Nalaxone is often used (Targin) but these do cross the blood brain barrier and reduce the effectiveness of the opioids. PAMORAs do exit – they are peripheral acting mu receptor antagonists. These include alvimopan, mathylnaltrexone, naloxegol, none of which I have seen used in practice. Tapentadol does have nor ep uptake inhibition which increases opioid agonist activity leading to less constipation as lower doses can be used.  And now they have oxycodone/naloxone 2:1 with better results. Other strategies include using osmotic as an adjunct (I like PEG products and pico sulfates) or opioid rotations which may lead to less constipation with other agents. (Scand J of Gastro 50(11)1331) TBTR: Some ideas on how to prevent opioid induced constipation.

Sheldon: I can’t seem to get in touch with Amy. I tried e-mail, video chat, tweeting her, posting on her Facebook wall,texting her, nothing.
Leonard: Did you try calling her on the telephone?
Sheldon: The telephone. You know, Leonard, in your own simple way, you may be the wisest of us all


Sheldon: Ah, memory impairment; the free prize at the bottom of every vodka bottle

  • Letters: Kevin – the a double boarded peds and peds EM guy and the world commander of the militant Federation Against Adult Practitioners (FAAP) actually agreed with my assertions concerning Ritalin use in adults:
    Tzion also got in touch with me- I remember him as a med student 10 years ago – he still reads EMU and has a thriving FP practice. Thanks for being in touch.
  • Number 2- TB of the spine is called Pott’s disease. There is a Pott’s Fracture and Puff’s Puffy tumor-so Pott was a pretty all around guy. And his first name was Percival – a great name for a disease naming doctor. Number 2- did you catch the dense MCA? It is an early warning sign for stroke. Here it is if you didn’t catch it. image022 Number 14 was Riga-Fede disease. This is when little kiddies lower incisors erupt and traumatize the lingual mucosa- totally benign – needs no treatment other than perhaps filling those choppers down a little.


Leonard: Have you considered telling her how you feel?
Sheldon: Leonard, I’m a physicist, not a hippie


Leonard: What makes you think she wouldn’t sleep with me? I’m a male and she’s a female.
Sheldon: Yes, but not of the same species


We will look at some antibiotics news, and some news on hamstrings (the mechanical means of killing bugs mentioned above image023) The sources for these articles are Intes Care Med 41:1950 and BJSM 49:1241

Here are ten antibiotics that will never disappear.

  • Really? Don’t the authors remember that they predicted in the sixties that with aminoglycodsides gram negative sepsis will disappear forever?
  • Polymyxin:

Myth: Why these will kill your kidneys, your nervous system and you!

Reality: Recent evidence seems to say this is less likely than once thought. These drugs work well against powerhouses such as Pseudomonas, Acinetobacter and Klebsiella (I bet they can deal with Duke, Villanova and UNC image024as well Colistin is a combo of Polymyxin A and B – so you may be familiar with this drug already.

  • Fosfomycin

Myth: Everyone knows that this is a weak antibiotic that induces resistance fairly quickly.

Reality: When given IV this med goes into a nearby phone booth and begins the fight for truth, justice and the American way. It can knock out such villains as ESBL, MDR enterobacter and in combo with other anti Klebisiella drugs- can wipe out this truant as well.

  • Aminoglycosides –well you knew I would speak about them.

Myth: Oh you are just so sixties sometimes. Genta isn’t mod anymore and really, Amikacin isn’t groovy either. There are really more psychedelic meds – so be a flower child and use what the beatniks use- – stuff that works.image025

Reality: Genta and Ami are both parts of a powerful combo to knock the stuffing out of monster Klebsiella infections. And you can give these guys once a day- an option for ESBL as an outpatient. Give them one shot of 180 a day and you will kill the ESBL without sacrificing the kidneys or their hearing. Right on, brother!

  • Vanco- native Americans are offended by the Washington Redskins football team name, but most people do not know that they were named for Vanco induced red man syndrome and not a s a derogatory reference to native Americans

Myth: Just not that effective anymore. MRSA and enterococci have figured this one out

Reality: Still the most effective treatment for C Difficile. In the field though, most MRSA strains are still susceptible.

  • Rifampin

Myth: Have you ever used this dinosaur? Once it worked for TB but this thing is so resistance inducing that the bacteria laugh every time they see itimage026

Reality: This guy has a talent for biofilm bacteria hunting. Give it with Vanco and you will knock out staph and enterococci. Give it with sulbactam and carbapenems and you will give the eight count for extreme drug resistant gram negatives. Biofilms on prosthetic valves- use this guy.  And it still works well for Leprosy.

  • Oxacillin

Myth: This baby was gorilla –cillin for a while but MSSA is really not in style anymore

Reality: But MSSA is still with us – not everything is MRSA and while Vanco is good for MRSA it is weaker against MSSA than ox. True there are meds you can use to cover both, but let’s try to be streamlined here, OK?

  • Penicillin-

Myth: Are you kidding? This stuff belongs on cheese and that’s it. What is still sensitive to it?

Reality: Strep is especially when you give this IV. And Syphillis is still scared stiff – resistance is low and you only need 0.1 mcg/ml to immobilize these worms.


Myth: The Bactrim Septra wars ended- this drug is just not the man it used to be.  Testosterone patches and Viagra aside, the drug is just not potent any more.

Reality: Well, you knew this was coming- it does kill MRSA. And it seems to work against Stenotrophomonas and Listeria too. It is and always was effective against Pneumocystis and Nocardia.

  • So where are the ten? These are only eight! Well they counted Amikacin and Genta as two and Cefazolin and Ox as two


  • We spoke about these last month, so I will only go over new things- the article does begin with a disclaimer that we still do not have a good understanding of this injury, and they recur a lot. Here is what we do know.
  • Lengthening of the muscle can lead to tears – but this is slower onset than the faster sprint type injury in runners. Nevertheless the lengthening injuries – such as in high kicking and tackling – actually take more time to rehabilitate. Anatomy of the individual may play a role as well.
  • MRI now shows hamstring mimics coming from the gluteal trigger points or the spine.
  • Return to play – they bring a number of confusing articles that US, MRI or clinical parameters do not help. When the athlete feels he can – he probably can.
  • Recurrence remains a problem probably due to – well they posit many possibilities. But those who get them usually have multiple hamstring injuries, localized discomfort and knee extension or isometric force flexion deficits.
  • As a result ,the recommend post injury PT to prevent recurrence –Nordic Hamstring Exercise, Romanian Dead Lift and Askling’s extender, diver and glider exercises- I checked all of these on you tube and they not only are easy to do, they are really cool.
  • Platelet rich plasma was being used for tendon problems but the evidence is weak and it appears that it has no role in hamstrings.
  • You can prevent hamstring injuries through the yo yo curl and NHE programs (Nordic Hamstring Exercise)
  • Why is this even called a hamstring? Well here you go – fresh from Wikipedia.- Ken did you know this? The word “ham” is derived from the Old English ham or hom meaning the hollow or bend of the knee, from a Germanic base where it meant “crooked”. It gained the meaning of the leg of an animal around the 15th century.[7] String refers to tendons, and thus, the hamstrings are the string-like tendons felt on either side of the back of the knee

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