- I promised- here is the Ian Stiell article. And in usual Ian Stiell style it asks the question no one had the testosterone to ask in the past. As we all know you can cardiovert new A fib if you do so within 48 hours of onset. But this is not exactly true. The risk is still 0.7% usually occurring within the first 48 hours after The risks are higher with older age, female gender, DM, CHF and higher CHADS scores. But they did a closer analysis of the date to dissect this risk further- and found that – like with all coagulation issues- the longer out the more danger. AF less than 12 hours- 0.3% of patients had thromboembolic events. 1.1% in patients with AF for 12-48 hours. The data seems to suggest that there is a significant higher occurrence of stroke after A fib for 12 hours. Therefore they conclude that post cardioversion is indicated in patients with the above risks who present early, and TEE if they present closer to the forty eight hour mark. (CJ of Card 31(3)239) This really shouldn’t be much of a surprise. Why when we have patients who have undergone 3 weeks of anticoagulation for an elective cardioversion – we give another three weeks of aniticoagulatiion because of our fears of a stunned heart and yet when we do one in the ED we have no fears of a stunned heart. The main problem here – other than were the thromboembolic events major? (But I assume all thromboemoblic events to be major) – is how can you really stratify patients as to when the AFib started when many do not feel it started? This study needs TEE to really help us out .TBTR: There is a subset of patients that probably should be anticoagulated after AFib cardioversion in the ED.
- An interesting idea but precious little evidence. Urticaria they claim – may be caused by bacteria. In fact – strep, staph, H pylori, M Leperae, Brucella, Salmonella, Borrelia, Chylamdia, and Yersinia can all cause urticaria (All Asth Proc 35(4)295). I am not sure how you determine this – how do you know if this is toxin induced or treatment induced? But it will change your treatment. Consider that an itchy rash with fever may not be a drug reaction to the antibiotics or an allergic reaction to the same. Or better yet- read our last essay- if you are still awake. TBTR: Uritcaria may be due to bacteria.
- Can Intravenous lidocaine help with burn pain? One study says it can but of course Cochrane says you need more studies – and they are right, but it may be worth a try (Cochrane 10:5622) TBTR: IV lido may help with pain. That’s my wife by the way – her clothing bill is causing me pain. Hey, we were thinking about Father Greg again, and Father loves law- so here are some laws that are actually still on the books: Florida: Owners of commercial establishments where alcohol is sold may be fined up to $1,000 if they participate in or permit any contest of dwarf-tossing. Iowa
Anyone trying to pass off margarine (or oleo or oleomargarine) as real butter is guilty of a misdemeanor
- This article drove me crazy. Led by the Dutch who have been doing liberal things that Father loves- we stopped using antibiotics for most cases of OM in kiddies. However this article claims that antibiotic use results in fewer effusions, less hearing loss, and less persistent effusions. Now this was only 84 patients but it was double blind and randomized and they followed these patients for 12 years. (JAMA Ped 168(7) 635) Now who do I believe? True this is not a patient oriented outcome but this study was well done. Lisa? Kevin? Itai? Eran? Can one of my Peds people set me straight? TBTR: Antibiotics for OM? No- or yes- or????
Kentucky: Every legislator, public officer, and lawyer must take an oath stating that they have not fought a duel with deadly weapons.
Maryland: A person who sells non-latex condoms by means of a vending machine is guilty of a misdemeanor and subject to a fine up to $1,000
- Sedation. Propofol is safe in kiddies. These ICU guys used it for sedation and for the X ray suite and were successful in 99.9% of the cases. They used it with lidocaine and opioids which I can understand but they used with benzos I do not understand. They had a number of useless and uninteresting adverse effects like coughing and desaturation. They did have one patient who arrested but this was a 13 month with some obscure genetic/metabolic disease that I do not think most of us would have given propofol to in any case. The amazing this is that this study was based on 91189 sedations – no beta error here, guys! (Ped CCM 16(1)11) TBTR: Propofol – it is safe for most people who do not take in the comfort of their own home. Michigan: A statute on the books since 1931 makes adultery a felony — punishable by a maximum of four years in prison and a $5,000 fine That’s Father’s home state. Happy to say that they are holding their own in Father’s neighborhood
- What is going on in the United Kingdom? ( They claim that they asked folks what they valued most in wound healing in an effort to enhance shared decision making. They said – the least chance of infection and a caring staff. Also a quick recovery. (EMJ 32(22) 153) I picked this article) to say how there are differences in cultures. My patient’s in Israel don’t care too much about shared decision making and most value the scar results. TBTR: You cannot learn anything about this study unless you look like Kate Middleton.
Nevada: In the only state where prostitution won’t get you arrested in most counties, using x-rays to determine shoe size could
New Mexico: As stated in the New Mexico Constitution, “idiots” can’t vote in state elections.
- Do your night shifts before you reach age 25. If you don’t; expect more caffeine use (duh), more likelihood to smoke and more obesity. Ergo, more cancers and CV disease. (Occup Environ Med 72(2)100) OK, but this obesity was more than a BMI of 30 which is most of us. This gives a good push to shorten night shifts, and get anchor (four hours) of sleep when you do do a night shift. TBTR: More bad newsy on night shifts.
North Dakota: All members of North Dakota’s Dry Pea and Lentil Council must be citizens.
Ohio: Every operator of an underground coal mine must provide “adequate supply” of toilet paper with each toilet
- Use of an interosseus device in the Israeli army showed dreadful results- they were unsuccessful 50% of the time and 87% of their soldiers died – meaning most were in bad shape until they decided to try the device. ( Mil Med 179(11)1254) I have heard that IO doesn’t cause terrible pain in alert adults, but I have never tried it. Let me know what your experience is. TBTR: BIG devices are not used as often as they should be.
South Carolina:A male over the age of 16 can’t seduce a woman by falsely promising to marry her. If found guilty, he’ll be charged with a misdemeanor, fined at the court’s discretion, and/or imprisoned for no longer than one year — with a decent number of exceptions.
For example, if the woman was already married or considered “lewd” or “unchaste” (which the law doesn’t define), the court can’t convict the male of the misdemeanor. The offender will also walk if no one can corroborate the woman’s testimony. And no law exists with the gender roles reversed
- Speaking of cultures, in my country LABAs are very popular- particularly the combo of formoterol and budesonide. Now is this stuff dangerous? The steroid is of course the standard of care, but does the addition of formoterol make things worse? Depends who you ask. If you ask Dave Newman, this brilliant guy who has the NNT website and is featured a lot on EM RAP- this stuff is going to kill people. If you ask Cochrane you get a toned down response that it is possible that it increase mortality – we do not know but it seems to increase the incidence of non-fatal serious reactions as well. Formoterol alone is definitely not a good idea (Cochrane 2014:CD010314). Now if you ask the folks from Palermo and Pisa in Italy they lean to (pun intended) to using LABAs and even say you can use them as needed instead of all the time, but the effects will be slightly less (Lancet Resp Med 3(2)109). If you ask me, and why you would is beyond me- I am with David on this one even though he is not an EMU reader. But that can always change. TBTR: LABAs- can they be used as needed? Should they be used at all? Alright while we are speaking about inhaling . Steroids do slow the growth rate of kids and can result in a 1-2 cm reduction of expected height. Seems this effect on growing appears even at early age-at age 2-4 do actually have a slower growth curve. This is in contrast to Ritalin that has even a greater effect on growth that seems to be reversible. However, if you have a child on steroids and Ritalin – and SSRIs which also do the same you may have worse effects.
For now try to avoid oral steroids ( J Peds 186(2)463) TBTR: Steroid do affect growth in children.
Vermont: The Vermont legislature created a law that prohibits outlawing clotheslines
Arkansas: You’re not allowed to pronounce “Arkansas” incorrectly
- I don’t have much to add here but if you do not think of this you will miss. Non convulsive status epilepticus are sick patients who do not do well even if they survive.(Seizure 24:102) The rest of the conclusions I will not report as they only had 48 cases in 5 years and I am not sure that – in view the most common cause was preexisting cerebro vascular disease- that he diagnosis was correct. TBTR: Non convulsive seizures – think of it- or just give everyone lorazepam.
Georgia: You can’t keep an ice cream cone in your back pocket on Sundays
Indiana: The value of Pi is 3
- Why is pertussis suddenly a hot item again? Well, it is true that the course in adults is relatively uncomplicated, but it really weakens people and can spread to little people where it is a lot more dangerous. The issue here is that the acellular vaccine is now in use in many countries – the USA included and this – while having fewer side effects than the whole cell vaccine – it is providing less immunity. Immunity that is as a booster – in the primary vaccination it still provides good coverage. The UK does use the whole cell vaccine – you just knew I get back to knocking the Brits – but hey go the whole route and have less pertussis(Exp Rev Anti Inf Ther 13(2)145) TBTR: Pertussis is back and it is pissed. Move to England and you can deal with it.
Massachussetts: You cannot own an explosive golf ball.
Michigan: A woman isn’t allowed to cut her own hair without her husband’s permission
- As I am writing this I just heard a compelling story of a woman who was recused from forced prostitution (the more politely correct term is human trafficking) on EM RAP. Now another article that examines the world that few of us spend much time understanding- alcoholics who presented to the ED at Bellevue. Oh sure, you can believe these people are all derelicts who willingly chose a life of alcohol and drugs and prostitution but you would be very wrong. The last human trait – that in reality makes us different than animals is hope. When that is gone – life ends. Read this article (Annals Emerg Med 65(2)178) and if you want to hear the story about the upper middle class girl who drifted by no fault of her own into he underworld of prostitution and how she got herself out- listen to July EM RAP segment or got to her site traffickfree.com or her TED talk www.youtube.com/watch?v=5qw nsAjweE TBTR: Read this whole paragraph and realize what a person is.
- Ever since Minoxidil was introduced as an anti-hypertensive and caused hair growth in women I have been interested in the multiple uses of medications for other indications. (Viagra for ICU use is another). Ketamine is a sedative. It is also being used for pain control as we have mentioned in the past. Last month we mentioned how it what used for alcoholism. Here is an article that ketamine can be used for depression and bipolar disorders. (Psych Med 45(4)693). But this is a meta analysis with few patients, and to even get that many patients they had to go back to 1962 which is only two years after the last time the Eagles won a championship which would make me depressed. But something to consider- unfortunately the correct dosage is not clear nor how to give this- I doubt it can be used acutely. TBTR: Ketamine for depression- could be.
Nebraska: Whale fishing is illegal (if you are not an American, Nebraska is landlocked and the nearest whale is about 2100 miles away)
- While we are on the subject of head shrinking. One of my favorite activities is to call a psychiatric consult in the ED and hear that they think it is delirium in any patient over the age of 60. So this article has a few pointers on delirium- Most of these pointers you probably know, but this one you may not know- benzos are out for delirium they can actually worsen the situation. Antipsychotics are better – like haloperidol and risperidal but be careful in Parkinson patients and those with Lewy body dementia (CMAJ 187(2)129) TBTR: Delirium – benzos are out. Wyoming: An ordinance in Newcastle specifically bans couples from having sex while standing inside a store’s walk-in-meat freezer. Pennsylvania: No man may purchase alcohol without written consent from his wife.
- Extensor tendon injuries – a nice review but the bottom line is we can take care of these. I just liked the way they sew em up – I always did figure eight, but they suggest a running horizontal stich. Here is a picture: . (J Hand Surg Am 40(2)391) But remember – even if the extensor tendon is 85% cut – they still do well with splinting alone. TBTR: You can – should be able to – handle extensor injuries in the hand. The state law of Pennsylvania prohibits singing in the bathtub California: It is illegal to skateboard on walls “or other vertical surfaces” in Palo Alto.
- I get these articles that I sometimes do not know what to do with them. This is a case report where they opened a kid’s abscess on his buttocks and few days later he had fever and abdominal pain with a CT showing multiple seeded abscesses in the kidneys and perinephric area. It is true that the IDSA says that you should use antibiotics after abscess incision in patients with immunosuppression, fever, cellulitis and the like but this kid had none of these.(Clin Ped 54(3)296) First of all this is a case report and I would not change practice on a rare occurrence. Secondly I would like to see evidence that antibiotics would have changed the outcome. Third of all the vast majority will do fine with just opening. I wouldn’t change my practice yet, but if a lawyer waves this at you in court and I do have a few lawyers who read EMU (“the rag”) wave EMU back at them TBTR: antibiotics for an abscess? I wouldn’t but maybe. California again: No person shall produce, test, maintain, or store within the city a nuclear weapon, component of a nuclear weapon, nuclear weapon delivery system, or component of a nuclear weapon delivery system under penalty of Chapter 9.60.030 of the Chico Municipal Code
- I liked this idea and you should too. Take your ultrasound to sporting events and you can see if the athlete has a break or just a strain and maybe can even return to the game. US is more accurate than X-rays for rib fractures and scaphoid fractures as well (although they 78% accurate –still not great compared to 50% with conventional X rays). (BJSM 49(3)143) TBTR: Bring your probe with you to wherever you go and save people from going to the ED. Kentucky, “No female shall appear in a bathing suit on any highway within this state unless she be escorted by at least two officers or unless she be armed with a club.” An amendment to the above legislation: “The provisions of this statute shall not apply to females weighing less than 90 pounds nor exceeding 200 pounds, nor shall it apply to female horses
- If you are like me- you love dentists and dentists, aside from loving pain, drills, dental floss, and sugary snacks – they also like antibiotics. Are they using them correctly? Am I making a joke? No, actually, they account for the vast majority of medications prescribed by dentists. How do they know what antibiotic to give? No one is really sure because they do not take cultures, but after reading this article you will know. But this is for sure, only 39% of dentists actually follow any guidelines. Here is the key point – antibiotics are never instead of dental interventions such as opening abscesses or surgery; they are an adjunct alone – and even in those cases it is not clear that you need antibiotics. A good example is that a lot of dental pain comes from acute and chronic pulp infections –they need surgical intervention Dry socket, pulpitis-these do not need antibiotics. OK, if there is fever and trismus, or extensive facials cellulitis – I agree but for root canal or extractions – no evidence. Not poor evidence – no evidence. Where I was wrong according to this article –they claim there are many bacteria in the mouth that are Penicillin resistant. I say – give me evidence that the penicillins are not enough- most of these bugs are very sensitive to high dose penicillins. Also in doubt is how long you do need antibiotics when you need them. Shortest duration is always best in (usually 3-5 days is enough). While we are on the subject we will speak a little on AHA endocarditis precautions- mostly antibiotics aren’t indicated if there has not been heart surgery in the last six months, nor has a history of neither endocarditis nor prosthetic heart valves. Actually prophylaxis will only prevent 5.3% of cases of endocarditis (I didn’t know that) and there is a higher likelihood of bacteremia from normal daily activities than dental procedures. (Int Dental Journal 65:4) TBTR: Wave this article in front of your dentist next time they want to complicate your root canal with diarrhea NY: A fine of $25 can be levied for flirting. This law specifically prohibits men from turning around on any city street and looking “at a woman in that way.” A second conviction for a crime of this magnitude calls for the violating male to be forced to wear a “pair of horse-blinders” wherever and whenever he goes outside for a stroll
- Exercise- we recommend this for everyone but have you noticed that a lot of fit people seem to keel lover when exercising? So what’s the deal? Well, if you are sedentary you obviously have a higher risk–for those who exercise less than once a week there is a relatives risk of 74% of a sudden cardiac death while those who do exercise five or more times a week, it was 10.9% – true that isn’t zero, but most of us die from sudden cardiac death. Here are some more numbers to crunch. Moderate exercise 30 minutes five times a week, reduced cardiovascular risk by 20% and higher levels of exercise (a difficult thing to quantitate in my opinion) can reduce risk by30-40%. Additionally, exercise reduces rates of cancer as well. We of course do not know why sudden death occurs- oh true it is arrhythmia but it may not be just ischemia but electrolyte or metabolic changes may contribute. Nevertheless the article brings some scales that can allow you to know risk, and states that stress tests may help. They recommend gradual exercise for sedentary individuals (JACC 65(5)493). This article was written by cardiologist athletes so that may be a bias. Also keep in mind that the mechanism is still not well understood. And lastly they entitled the article as “Sudden Cardiac Death in the Older Individual” but I didn’t see much in this article dedicated to this issue. TBTR: Exercise: you may drop dead but there are a lot of benefits. In Boston it is illegal to take a bath unless one has been ordered by a physician to do so Florida: Women may be fined for falling asleep under a hair dryer, as can the salon owner.
- This article was beyond me – the pathophysiology took about four pages which overwhelmed my ADD capacity but the bottom line was that we must differentiate between dilution hyponatremia like in fluid overload and depletion hyponatremia like in GI losses, diuretic use or hypovolemia. Dilution hyponatremia will not respond to normal saline as free water is not going out in the urine. Depletion will – and when it isn’t obvious you may actually find yourself given normal saline to patients with CHF (ibid 65(5)480) TBTR: Hyponatremia – sometimes you need to give saline sometimes not. Florida: If an elephant is left tied to a parking meter, the parking fee has to be paid just as it would for a vehicle. Texas: It is Texas law that when two trains meet each other at a railroad crossing, each shall come to a full stop, and neither shall proceed until the other has gone.
- Letters: Well, get some done this m onth – the mailbag has been full. John Hipskind commented way back in July: YosefAnother great month. Thanks again and keep the analysis and off center humor coming!
What sense of humor are you talking about John? This is clearly a mixed undifferentiated acute nutso disorder. Anyhow thanks for writing and tell your friend s to subscribe –w e are getting closer to being able to reach the next tier. Professor Kitai asks if I considered translating EME to other languages? The truth is we started a Primary Care edition and also have considered a patient/laymen edition but EMU is still non profit (sadly so) and a one man enterprise so I do not have the time. But we are actively searching for a solution. Alon Bar El liked the pressors review. Let me remind everyone however that no pressors have ever been proven to increase survival with the exception of epi in anaphylactic shock. Yisroel Kaplan writes: Comment: A patient I’ve begun working on nutritionally with ulcerative colitis has been on Spasmolgin for 3 years, and something similar in the US for 11 years before he made aliyah. He wants to reduce/eliminate it from his regimen due to significant symptomatic improvements and adverse reaction to the drug. He’s been taking 1/2 in the am and 1 in the evening. Today, his family doctor (MD) agreed that he should reduce it, but has no idea how to safely wean him off the medication. Are there any kind of a published protocol/guidelines he can share with his doctor?
Tolerance and addiction of sorts can happen with Spasmalgin and Donnatal use. Both have atropine and spasmlagin has a narcotic while Donantal has Phenobarbital. I do not use these medications at all basically because I am not convinced that spasm has anything to do with pain, and also a dislike for medication with multiple active ingredients. I do not know of any guidelines other than slow reduction and trying other medications that have a better safety record (In Israel that would be notensyl). Lastly,. Father Greg dropped us a line: Yosef, If it weren’t for lawyers and orthopods we would have to find some ethnic group to tell jokes about. I long for the good old days of Hungarian humor. Father Henry
In order to preserve my presidential aspirations I will not comment
EMU LOOKS AT Marmite and Dresses
The sources for the essays are Anesthesia 70(2)125, JAMA 175(2)194 and Annals of EM 65(2)147 This month we look at a medication that we use a lot in my hospital – Tramadol and also at everyone’s favorite subject in the ED- rashes.
- Let’s put things on the table. I do not like this drug. Pharmacology is boring so let’s just say that this drug works by blocking re uptake of both serotonin and nor epinephrine- just like Venlafaxine. And this is the problem. This causes the sedation, the lowering of seizure threshold (even at therapeutic dosages) and delirium. It is classified as an opioid but only 30% of its activity can be reversed by naloxone. I will give it this – it causes very little respiratory depression. But the second article above says it can also cause hypoglycemia
- In addition, it has a very potent metabolite – 200 times the affinity for pain receptors- as a result- vomiting and elimination half-life is 1/3 longer than regular tramadol- 9 hours. Ever take Tramadol? I have- wow- the dizziness and nausea was terrible.
- Want more problems? Metabolism varies widely. Ethiopians and Saudis are ultra-rapid metabolizers and therefore Tramadol may not work at regular dosages. Italians, Greeks and Portuguese are also quick metabolizers. Others are poor metabolizers and therefore have low levels of the active metabolite resulting also in a drug which doesn’t work. This is common among the Chinese.
- Metabolism is via the P450 CYP2D6 system and that brings more problems- this is a system that works variably. As a result serotonin syndrome can occur when taken with SSRIs even at low doses. Atypical anti psychotics and MAO inhibitors can also give serotonin syndrome. Ondansetron causes opposing effects and they negate each other.
- Guess what- they have never been proven to have beneficial effects for post op pain or chronic pain. It has been proven to help in neuropathic pain and in premature ejaculation; this is because of the serotonin effect and may take the patients mind off their pain.
- It is much less addictive than morphine but is still abused and the powerful metabolite we mentioned above is often sold in the street.
- Based on what we presented above – you already know that naloxone doesn’t work well but other possible antidotes can include yohimbine and as we mentioned – ondansetron.
- To quote JAMA –the analgesic effects are at best moderate, but its toxic effects are dangerous. I will say this – people poorly react to the oral form –never give this as an extended release but IV may have better results.
- What is the Marmite we mentioned above? Well it is in the article title and it refers to a paste that apparently is very popular with the Brits. It is basically Brewer’s yeast with a strong taste and they market it as “Either you like it or hate it” I hate tramadol.
The second essay is an opinion piece. My opinion. And I am pretty sure that both Donald Trump and Bernie Sanders agree with me. The Annals of EM – is usually a way stuffier journal than its impact factor indicates. So they decided to use Mel Herbert’s EM RAP as a review device for their journal (why they didn’t choose EMU is way beyond me). While I think making summary of a summary( in the Annals ) of a lecture( in EM RAP) is a bit of an exaggeration, I will give my opinion
- Rashes are always our favorite ED presentation, right after back pain, and the five kids from the same family with fever. Let me remind you – no matter what they taught you- I believe – and again this is my opinion- that it is a waste of brain hard drive bytes to know all the rashes that present to the ED and to engage in self-deprecation if you miss them. I mean missing a pityriasis rosea or lichen planus doesn’t bother me too much. Know what these are? Erythema Gyratum Repens and Erythema annulare Centrifugum- Look at this picture:
- Mel brigns 5 drug rashes you can not miss. Acute Genralized Exanthamous Pustulosis (AGEP) drug induced bullous disease, ACE angioedema, Drus reaction with eosionphilia and systemic symtohoms(DRESS syndroeme) and Stevnes Joshnson.
- ACE angioedema- let’s take that one down first. I don’t think you should ever miss this but rmember angioedema can come from many medicaitions. This may or may not repsond to steroids, usually is self limited and not dangerous but there areceptions. These people look like an allergic reaction . Fidazyr – if you can afford it- probalby works as well. The key point here is that this can occur at any time even if the patient has been taking ACEs for years
- Bullous lesions – pemphigiod is the big one and this can be caused by PCNs, and furosemide. I most often see bulla in really bad lower limb celluiltits but to tell you the truth – if there is no burn history and no obivious cellulitis – I would take bullous diesases seriously and admit most of these guys.
- SJS is something that we don’t think about a lot but you better not miss. When it goes bad it can turn into TEN with blisters but this goes back to what we said above- if it is anything fluid filled that isn’t a burn – I am admitting it and if I have it- getting a derm You want me to mention Nickolsky’s sign? Here I did. Other than remembering this for the boards it isn’t going to change things for me too much. Oh yea it will help me differentiate between Bullous Pemphigus and Pemphigus Vulgaris but as we said before – this isn’t going to change my disposition. But this brings us to our next principle – fever and unknown rashes are bad news. True it could be a garden variety viral exanthem, but you better have your antenna up (No one has antennae on their TVs anymore but that is what Ray Colbert has on his head- he was the star of an old timey TV show called My Favorite Martian) I also get worried about SJ when the patients has mucus membrane lesions and is taking meds. Also keep Kawasaki in mind for mucus membrane lesions as well
- DRESS Syndrome – to be honest – I just found out about this syndrome when I listened to EM RAP. This can be tough – the rash is morbilliform and there may be some periorbital swelling. But then again – this comes with fever. But so does Rubella and Measles which also causes the same type of rash. But this has eosinophelia and aside from some worms, you shouldn’t be seeing that too much with fever. There is often LFT elevation as well. Sometimes there is pneumonitis and myocarditis. The rash can be itchy. And to make things even peachier- it usually starts late- sometimes as much as eight weeks after the offending agent was used. It still has a10 % mortality. More on this can be garnered from the Journal of Clinical and Aesthetic Dermatology 6(6)31 -2013.
- AGEP is rare, and there a lot of pustules with edema and erythema and it likes skin folds. Mel points out the paradox that here you have a patient with fever that you would think needs antibiotics, whereas antibiotics here is the cause of the problem!. This can look like pustular psoriasis, but these AGEP patients do well, and all the need tis discontinuation of the medication. Unlike DRESS and ACE and sometimes SJ – there is no latency period.