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Session 1 - Live Rapid Review for BPS Exams

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Summary

Core Theme

This content is a rapid review session designed to help individuals prepare for board specialty certification exams, focusing on high-yield, core knowledge and exam-relevant concepts across various medical disciplines, particularly in endocrinology and infectious diseases.

Mind Map

انقر للتوسيع

انقر لاستعراض خريطة الذهن التفاعلية الكاملة

All right. Well, welcome everybody to uh

the first session of the rapid review

course for basically BPS exams. So,

anybody studying for one of the board

specialty certification exams um can

attend. And uh this first session is

open uh to everybody including the the

public. So, we're glad to have you. If

you are not a customer of ours, that's

okay. We're still glad to have you.

hopefully you'll benefit. If we can be

of any service to you, uh, please let us

know, but we're we're glad to have

anybody that's on, uh, people are still

logging in. And so, I'm just going to do

a quick introduction. Uh, I'll start off

with myself. If for some of those of you

that are new to us, uh, my name is

Anthony Busty. Um, I got a unique

background. I trained as a nurse, a

pharmacist, and a physician. I currently

practice in emergency medicine.

And uh my role in the company is

editor-inchief. I did also start the

company. So that was 15 years ago. Been

doing this for a long time. Bring a lot

of unique perspectives and background.

So I'm looking forward to interacting

with you guys during this series. Dr.

Koko, why don't you go next?

>> Hi, my name's uh Craig Koko. I'm a

clinical pharmacist and clinical

toxicologist. Uh also work here at High

Yield Medviews. It's been really kind of

an enjoyable process kind of continuing

my uh teaching from you know directly

just pharmacy but you know expanding it

into this realm. Uh it's been really

enjoyable especially again learning from

Dr. Bustai a lot uh myself and then kind

of carrying it forward and try to carry

on that teaching.

>> Dr. Boland.

>> I'm Dr. Cassie Boland and I come from a

unique background although all of it is

within pharmacy. So did a little a

little stint in the ER. There's fun

stories there, but that's for another

time. And uh anyway, so a little bit in

the ER, did some impatient infectious

disease work, uh went back to residency,

went into ambulatory care, been in

academia, and uh I enjoy teaching. I

love teaching and helping others grow

professionally. And so this is a

wonderful opportunity for me as Dr. Kio

uh said as well to uh kind of

carry on the torch of teaching from

here. Absolutely. So hopefully you guys

see that we've got some experts who have

have extensive amount of experience in

different backgrounds, acute care,

chronic care, outpatient, you know, uh

critical care environments. We're going

to have a number of other experts that

will join us for other sessions

specifically like oncology. We have two

clinical uh oncology pharmacists from

University of Kentucky uh Dr. Buts and

Dr. Travers who will be joining us in

that session. So, a lot of exciting

things happening here and a lot of good

people that are going to give you some

great pearls. Now, before we get started

uh with this session, I want to lay a

little bit of the uh rules and the

perspective that we're going to be

coming from. The goal at this point as

we approach exams is that this is not

meant to be primary teaching. All right?

I can't say that enough. We are not here

to dive into the minutia or details. The

goal here is to help you to keep your

mind on this on the focus of the exam.

The again, we talked about this in some

of our reviews on how to pass the test,

but you need a board exam mindset, which

are you need to know the core knowledge,

things that are facts and that are

standards of practice for everybody

across the country. you not splitting

hairs over geographic variations in

practice, not new emerging data, not

cutting edge clinical discussions.

That's not what this is about and nor is

the board exam really about that either.

And that may be surprising to you, but

that is the that is the reality. They

have to be able to an ask you questions

on on standards of care and practice

patterns that are well accepted and well

established. That's what we're going to

hit on tonight, okay? and in this series

of sessions that we're going to be doing

for you. Okay, so we're going to hit the

high points because again the assumption

is you've come in already have had done

some review probably listened to

lectures probably done some practice

test questions or practice exams and now

you just need to you know really brush

off the cobwebs make sure you got

everything as you head into this final

leg in preparation. It hopefully will

also help you to identify any areas of

weakness. Okay. And you may rec you

might want to jot down a note or so of

topics that you want to go back and look

at. For those of you that are customers

of ours, you know that you have a a lot

of material that you can access,

individual lectures on core topics even

of advanced pharmarmacology reviews, but

also disease state reviews and more

depth than what we're going to do

tonight. You have evidence-based

medicine, bioatistics, pearls, and we're

going to cover that later in another

session. But you've got access to those

things. And then of course you have the

more important thing which is practice

test questions over and over and over

again to where you develop that endurance

endurance

and the ability to maneuver from one

topic to another. Unfortunately your

questions on the exam are not going to

be categorized like the next five

questions will be on the topic of

infectious disease. I mean it's going to

be you know you got sepsis on one

question the next question is a

statistical interpretation of a a

metaanalysis you know a forest plot and

then you got to move on to practice

management question then over to you

know indocrine you've got to be able to

mentally maneuver between topics because

that's the reality of the exam that

you're going to be taking regardless of

the specialty exams either you got to

maneuver within your specialty so if

you're in the cardiology group critical

care group ID group, okay? Because I

know that some of you may be

representing different uh exams by

coming here tonight. Uh because we're

talking about endocrine and infectious

disease topics on the other days that

are listed on the website. We'll be

talking about those topics and I'll

summarize those at the end. So, it's

going to feel like a fire hydrant. This

is also not meant to be the time where

you try to jot down every little note.

Really, you should be stopping and just

listening. Think through this as we go

through it. Okay. Should be making sense

to you. You should be able to go, "Yep,

yep, yep." Now, if when we get to a

point, you go, "Yes, but

what about this scenario? We're not

going there." And the reason is is

because it's nine times out of 10 never

going to make it to a board exam. Okay?

We're hitting the most common high yield

core concepts. Okay? So again, I just

wanted to make sure that we were all on

the same page before we get started

because it's going to be a rapid review.

That's the only way we can get through

these topics. One last thing before we

start, we will have a somewhat scheduled

break. Okay, this is approximately a

2hour session. We will save about 30

minutes afterwards for Q&A. So if you

have questions or you want to go back

and hit a topic or you need some more

clarification, save it for then. Okay?

Okay, I'm not going to we're not going

to entertain questions along the way.

We're going to save it to the end. So,

we'll take about a five or 10 minute

break halfway through. Let you stretch

your legs. Make sure nobody gets a DVT

or decubinous ulcer. All right.

So, I don't want anybody claiming that,

right? If you start having a seizure,

just give yourself four milligrams of

Adaban IM. You'll be fine. Okay. All

right. I'm just kidding. Right. We got

to keep learning fun because this is

this is a lot of material and it's hard

and who wants to just have somebody just

mundane boring reading a slide to you?

That's not what we're going to do here. Okay.

Okay.

Alrighty. Well, hopefully you're excited

now and ready to go. Got your drink and

your notes. So, let let's go ahead and

jump in because we're going to hit

adrenal disorders. Okay. Both where the

adrenal gland works too much and not

enough. So Addison's disease D deficient

D deficient. So when you think about the

pathophysiology, we got a reduction in

the ability of the adrenal gland to make

enough cortisol eventually or depending

on what's causing that problem. You may

also impact the amount of aldoststerone

release, which is your mineralorticoid

activity that's really the more profound

impact on sodium and potassium. So when

we think about patients and their

clinical presentation because you got to

know some of that basics because that's

what we're treating is the underlying

problem. You need to think about they're

weak. They have weight loss because

they're deficient in the thing that

causes to retain u volume. Okay. Sodium

water reabsorption is and so they can

develop orthostasis from lack of plasma

volume. Hyperpigmentation of the skin.

Classic. Again, when you're reading a

question on a board exam, you should be

seeing a pattern of association and they

usually give you the diagnosis, but you

should it should be consistent so you

know which drugs to use. So, you measure

these levels, you see the cortisol level

is low. When you do your BMP, basic

metabolic profile or CMP, comprehensive

metabolic profile, you traditionally see

the manifestation of not having enough

mineral corticoid activity, right? So,

you're not reabsorbing enough sodium. So

your serum sodium levels are low and

you're retaining potassium by not

kicking it out when you re reabsorb the

sodium. So you have low sodium, high

potassium, low plasma volume

orthostasis. It then begins to make

sense. So then what do we want to do?

Well, correct the deficiency. Give the

very thing that you're deficient in

which is hydrocortisone. Okay,

hydrocortisone has that balance of

gluccocorticoid activities as well as

mineralocorticoid activities. Okay, we

know that they differ in the steroids,

but hydrocortisone is the drug of

choice. The reason you see plus or minus

fluocortisone has to do with whether or

not you need more potent

mineral activity. Do you need to retain

more sodium and kick out some of that

potassium? The only way you're going to

know that is by initiating the

medications and seeing what happens in

their labs. The non-farmacologic

treatment is TED hose. Those are

basically like tight panty hoes so that

when they stand up, gravity doesn't just

cause all their plasma volume to fall to

where they get laded and dizzy. Now, the

way we're going to function here is that

Dr. Cookio and and Dr. Bolan will

intermittently add to and so I'll just

pause here for a second, but as we go,

they're just going to interject. Okay.

Um, so I'm just kind of leading us

through the disease state. Is there

anything else that you guys want to add

as we move forward?

>> No. All right. Good.

>> Okay. Okay. Well, just jump in when you

do, okay? Because we we will have

moments to to pause. Okay.

>> So, let's think about the crisis level.

So, now you take an Addison's disease

>> and now you are so deficient that you

now have a s systemic problem, right? Or

you can't react to it. a situation like

a stressor, trauma, you know, infection,

particular things like sepsis, you know,

some other s major surgical procedure.

Now remember, that's a stress response.

Our body responds to it. But if you're

dependent on medication and you don't

accommodate that stressful situation,

then the patient can have more profound

basically deficiency symptoms, right? So

they become even more hypotensive, uh,

weak, more severe hypocalemia and

hyponetriia. And so in these cases, you

know, and I'm sure Dr. Kokio can jump in

on this as well, but you need to

supplement them, right? And the answer

is IV hydrocortisone, not PO, IV. Okay.

And you're going to be dosing this, you

know, around the clock. Now, Dr. Koko,

are you any comments about the dosing

based on the stressor?

>> Yeah, so I mean definitely this is

different dosing than you might see in

other indications and it's typically on

the higher end. Uh especially if you can

identify exactly what's going on, but I

mean you can see a range here being 25

to 100, but typically I mean empirically

I guess you could say it would certainly

at least start at 50 milligrams every

six hours which is certainly opposed to

other indications you're going to see

hydrocortisone use. on a clinical exam

if even if they said you know try to

paint a context it's like trying to

reconcile what exactly are they using

this hydrocodone for adrenal crisis

would immediately come to their mind to

try to consider exactly why they're

trying to consider this in in this

clinical context we might also see it in

sepsis but if you loop it back it's

actually somewhat similar considerations

we're taking in that patient population

to exactly what's going on here

>> and just so you guys know from a board

exam perspective dosing because you Dr.

Koko just mentioned that that there is

many there's no standard for like

scenario you you will have to make a you

know patient specific adjustments and

considerations but there's no like oh if

they have you know if they have like a

uh car accident and they have one broken

bone the dose is this right I mean it it

does vary why which is why you see a

range but the idea is to replace it now

let's go to the other side now you're

making too much right so your your g

your your um your adrenal glands are

doing that too much. Most commonly we

see that the the pituitary gland in the

brain is sending a message to your

adrenal glands saying hey make more of

this stuff and the feedback loop is not

really talking to itself. Remember in

all endocrine there's usually this sort

of negative feedback system where one

system talks to another and organs kind

of regulate each other. Well in this

case they're making too much. So now you

got to think of the opposite. you don't

have hypoalmia, you have hypervalmia or

to increased plasma volume where they

have increased blood pressures. Um you

have increased you know gluccocorticoite

activity happening. So of course then

their their glucose levels are high um

because of the edema and the fluid

accumulation they they have weight gain.

Um they obviously have dysipidemia and

then um high levels of steroids we know

cause uh bone mineral density decreases.

So you measure these you see elevated

cortisol uh you see um hyponetriia hypocalemia

hypocalemia

um and again that's because you know

you're excreing so much that you're

sorry that should be hyperremia I think

yes um you know you're you're

reabsorbing a too much uh sodium and

you're now kicking out more of the

potassium so most of the time this is a

tumor cancer problem and so the

treatment is treat the underlying

problem. Well, you might need to provide

them some stability before they go to

surgery. And some drugs like modane,

ketoconazol, materone, those may be used

basically to block some of the

production of those ketoconol being an

antifungal agent, but block some of the

cytochrome P450 isoenzyme systems that

produce some of those or uh hormones.

And so, um, so anyway, it's it's just

one of those treatments, but surgical is

going to obviously be the underlying,

uh, problem. So, which, uh, kind of just

changing up a little bit and and adding

another little pearl here that may

potentially show up, you know, which

sedative hypnotic, you know, some people

call it anesthetic depending on the dose

and how you use it, is known to increase

the risk of adrenal insufficiency. So,

think of it in the context of rapid

sequence intubation. The answer is

automodate. All right. So, it can block

some of that uh enzyme production that

would make uh cortisol. So, you can see

that. Just a quick few comments about

gluccocorticoids because this is a huge

drug class that extends across multiple

indications and uses. Obviously, some

agents are used for other conditions

over some other drugs. Uh I I put an

asterisk ne next to the ones that are um

have less mineral cortical activity and

are longer acting. So that's your

betamethasone and dexamethasone in

particular. Um pretty much devoid of

most mineral cortical activity but have

more they're more potent and so you

don't have to give as much and they have

a longer duration of activity. When we

look at indication, it's obviously

pretty widespread. You know, acute COPD,

uh, asthma, allergic reactions including anaphilaxis.

anaphilaxis.

Um, you got, uh, CROO, especially with

your, um, betamethasone and as well as

your uh, orbinide and and you got uh,

dexamethasone, which are sort of your

drugs of choice to reduce that subglotic

edema. U, you got gout, you got

rheumatoid, osteoarthritis, and

sometimes it's just a small dose. that's

all they need. Um even to the level of

nausea, vomiting. Okay. I mean using it

for that. I mean some like typically

outside of the norm that we think about

but it is used in space patients that

are resistant or not responding to other

anti-imetic therapies. And then

obviously also vasculitic therapies like

temporal arteritis is a classic

indication for highdose long-term use of

steroids. Well, obviously when you use

steroids, you can induce Cushings like

effects, right? And depending on which

ones have more mineral corticoid

activity like predinazone,

hydrocortisone, prediniscolone, they're

going to retain more of that sodium and

water. Um, they're going to potentially

also have an impact on the blood

pressure, which can certainly tip people

over into heart failure. Avascular

necrosis of the hip is typically seen on

higher doses around that predinazone

equivalent of 20 milligrams or more. Um

and that can be devastating and result

in the need for a hip replacement. Um

but and then you have your

gluccocorticoids like dexamethasone,

betamethasone which are going to have a

little bit more effect on those glucoses

and I'm sure Dr. Bolan can you know

comment about that but I mean I see this

stuff wreak havoc in a diabetic. In

fact, I make sure I don't really try to

use these drug drugs in that patient

population if I can, especially if

they're not well controlled.

Um, and then certainly septic shock. Um,

>> yeah, and certainly if you see somebody

who has been treated with

gluccocorticoids for a long time, it

actually presents a different treatment

scenario. So, uh, in which your oral

medications, your GLP-1s, SGLT2s,

uh, not the GLP1s are oral, but just in

general, your non-insulin therapies tend

to not work as well. So, usually these

patients who are on like long-term

gluccocorticoids will end up needing

basilbis like pretty much right out of

the gate when it starts or or fairly

quickly, more than what you would expect

for like a type two, for example.

>> Yep. Uh, another little quick pearl here

that again is board exam um relevant is

what dose of predinazone equivalent

basically is uh to the endogenous

production of cortisol every day. Uh and

and if you read the literature you'll

see a variation but but the most common

number cited is about 7 and a half

milligrams. Once you've achieved that

dose on a daily basis you are now equal

to the amount that your body makes. And

so when you exceed that 10 milligrams,

15 20 milligrams a day, you are going to

cause HPA suppression where if you've

been on it for several weeks, those are

the patients that you definitely need to

uh taper. All right, moving on to hyperlddostroneism.

hyperlddostroneism.

So now you're making too much

eldoststerone and it's usually

independent of the uh renin. Well,

that's would be primary. So like the

gland is just making it not responding

from renin release from the jxogar cells

of the nephron. Um and if you have

secondary causes that is sec uh

secondary would be things like outside

the adrenal gland that is causing

eldoststerone uh to be released in the

context of renin. So think about

hypoprofusion of their kidneys. Uh we

see this a lot in patients with cerosis.

Uh they have low onotic pressures. They

hypoprofuse the JG cells. JG cells in

the proximal renal tubule of the nephron

start releasing tons of aldoststerone

and basically that's what causes the

ascites over time. So what do we give

highdose spironolactone right? So many

of times these patients have refractory

hypertension. You start one or two

agents they don't respond very well. Uh

but many times what you're seeing is you

know their electrolytes being uh off. So

they're going to have a significant

amount of of um sodium. So they're going

to be more hyper natriic with hypocalemia.

hypocalemia.

They're not going to be responding to

anti-hypertensive medications. That

should clue you in. And then if you do

an aldoststerone renin ratio, you see

that it's pretty high, especially in

primary. Um and in those cases, uh the

treatment is straightforward. If it's a

adrenal gland problem like a tumor then

it needs to be resected right if it's

not or it's secondary and something else

is turning on like in cerosis heart

failure and these things then you have

aldoststerone antagonist so you got

anything uh there for you guys

>> yeah I think as you mentioned just kind

of reiterating it's not necessarily for

this but the the spirnolactone to

ferosomoside ratio that the patients

would actually need is somewhat again

it's a dosing question but I think

that's a unique dosing question for

these patients where it would

specifically be 100 milligrams to 40 of

spinolactone to firosomide so the doses

might increase from that perspective but

to me that would be something that could

be you know addressed or inquired upon

in that exam setting

>> absolutely he that 100 to 40 is in the

context of cerosis

>> right exactly Absolutely. Yes. So, so

just you know again the way we use these

drugs um and if you think about even

cerosis we don't use a plurinone the

data is not there it's spernolactone

whereas in heart failure it's

spernolactone and a plerone in much

lower doses >> right

>> right

>> just other little pearls make sure you

avoid uh salt substitutes with potassium

in them that's a good counseling point

for your outpatient patients on heart

failure meds where you're treating them

uh chronically uh because a lot of times

they'll replace the sodium with potassium

potassium

And then the gynecomastia with

spernolactone is clearly a problem

especially for men. All right.

Fiochromoscytoma. Now the adrenal gland

is making too much catakolamine. Okay.

Um and when you make too I we're talking

about catakolamines, norepinephrine,

epinephrine. So what do you think

they're going to present like? Well,

they're going to have palpitations. What

is epinephrine doing? It's stimulating

those beta 1, beta 2 receptors. What is

norepinephrine doing? it's it's

stimulating uh maybe some of the beta 1

receptor but predominantly hitting that

alpha receptor right so you're seeing

blood pressures going up you're seeing

uh the sweating palpitations

these types of things um and then if you

when you do an exam or evaluation you

you basically collect the urine and you

look for uh these metaneprins in the

urine and the plasma and that helps you

to get the diagnosis the part of the

problem is you go okay well they're

making too much catakolamine but where's

the tumor

So it can be not only in the adrenal

gland but some of them can be outside of

the adrenal gland. And so that's where

imaging modalities are implemented so

that you can find the tumor so that the

surgeon can go in and essentially remove

it. However, most surgeons and

anesthesiologists and the rest of the

crew, they don't want to take patients

back to the O with unstable pulses and

unstable blood pressures. And that's

where other drugs are being used to

control their blood pressure. So you got

oral phox phoxybenzamine which is

available orally uh not fenolamine which

is more your printal agent. Uh other

options that are available oral that are

commonly used are docazisonin tzisin. I

mean, you can put them on drips around

the time of surgery as they become NPO,

but you're basically treating them with

a lot of drugs that would reduce the

afterload from all the stimulation of

the alpha 1 receptors in particular. All

right, moving on to endocrine. Again,

hopefully you guys are finding that, you

know, again, we have to kind of move

through these things fast. It's rapid

fire, rapid review. So, not to insult

anybody's intelligence here. That's not

the goal. I know that most people

attending this probably have a good

understanding of type one, type two, DK,

and you know, gestational diabetes. So,

we'll kind of move through some of these

fast, but just as a reminder, uh

obviously type one is autoimmune. U just

realize that some patients can go

through a phase where as they're

autoimmune, destroying their pancreas

and beta cells, they may still make some

insulin. Um and it just depends on when

you are seeing them. Okay. Uh but

obviously a lot of times DKA's uh I'm

sorry, type ones will present and if

they don't have a diagnosis, it's

usually at the time that they develop

DKA, something gone wrong. They're they

show up with the classic findings. Um

and when you do more specific lab work

outside of the DKA, which we'll talk

about here in a minute, you clearly see

that they're, you know, fasting blood

sugars are over 126, their hemoglobin

A1C is over 6 and a half%. If you do

just do a random glucose, they're

usually over 200 with the three Ps.

Polyura, polyypsia, polyphasia. That's

usually um happening at the same time.

So our treatment for type one

chronically, Dr. Boland, walk us through

this. This is your baby, right? Hit the

high points. It's like straightforward,

but there are there's no oneizefits-all.

>> No, not at all. Um so there first of all

you're going to do basilbis and as Dr.

Busty mentioned some patients will make

some insulin so you may even have a type

one who doesn't even require insulin for

a brief period. So but in general what

you're looking for is a basilbis regimen

with about 50/50. Uh clinically you

might see 6040 one way or the other. Uh

some patients are even stable on 7030

but again that's that's thinking more

clinically. Uh but if you're trying to

figure out this out from the get-go,

you're looking at a total daily dose of

that 0.4 to one units per kilo per day

and then you divide that out 5050 and

then of course you divide your prenial

insulin usually into those three doses.

Uh pumps and CGMs should absolutely be

considered. Uh you I I can't imagine

that a board exam is going to ask you

about a specific pump. uh but they could

potentially give you some basil rates

maybe or or a correction factor or a

carb factor or something like that and

ask you you know kind of what would you

adjust uh especially with the emphasis

that they're starting to put on CGMs you

I would say you want to look at one of

those reports familiar familiarize

yourself with those numbers but with

diabetes whether it's type one or type

two kind of a test taking strategy for

you is if they start talking about

something really specific for a patient

they really this care is very patient

specific. So if they start giving you a

lot of individualized patient

characteristics, you need to start

really thinking through some of these

things and are they trying to get you

towards a pump, things like that.

>> Yeah. And that probably shows up more in

type two where you have, you know, this

insulin resistance pattern. You're

depending on what stage they're in,

their pancreas is uh and their beta

cells are pumping out like tons of

insulin. And then over time as the beta

cells burn out you begin to migrate into

basically becoming essentially insulin

dependent at some point if you don't

intervene on the underlying causes. Uh

some of these patients will have changes

in their weight weights. Obviously their

lab findings are very similar to um uh

patients with type one and then as Dr.

uh Bol and I'm going to let her like

jump in here, but what you see on here

are some of the things that guide us to

patient specific choices and there are

so many factors that go into that, but

I'll let Dr. Bolan highlight the key

points here before we move on.

>> Yeah. So, u it's sort of trending now

towards what we've or at least I've been

doing in practice for a while. A lot of

people have been doing but metformin is

still generally considered your first

line treatment, but you do have some

wiggle room there. Now again for those

patient specific factors um to choose

something different uh if it is again

good for the patient. So now we need to

consider ASCVD if they have a history of

that, if they have a history of heart

failure, they have a history of CKD, uh

you have different pathways for those.

Even considering cost initially or

access um that all of those things are

now taken into account when choosing

your initial drug therapy, which

metformin is still a great initial

choice. But again, if you start hearing

ASVD or, you know, events and heart

failure and CKD, then you need to start

thinking about uh, you know, for your

GLP1s, ASVD or CKD,

SGLT2s, ASVD, your heart failure for

sure, uh, and CKD. Um, and then weight

loss, you're going to think about your

GLP1s, SGLT2s, metformin, uh, and then

DPP4s. If you're just looking for

neutrality, um, across the board and not

to cause any additional gain. And then

if you're if they're really pushing cost

and there are some other factors in

there that are pushing you, you can go

with sulfonal uras, uh, or TZDs. So

really, you've got to if they're giving

you a case, you've got to look at the patient.

patient.

>> Yeah. I mean ghost go glaburide just kid

right I mean but here's the deal met

Metformin and some of these drugs are

cost-effective options and and they do

have some supporting data so and we're

going to come back to some of those

things here in just a few minutes we got

a few slides where we dive into a little deeper

deeper

>> uh about some of the SGLT2s as well as

the GLPS so we'll come back to this in a

second gestational diabetes obviously

during pregnancy there are obviously

changes in insulin resistance that

sometimes can be asymptomatic but you

see it. Um and so we actually screen uh

patients for this by doing oral glucose

tolerance tests. I guess some of these

patients can go on and have in a

post-natal period um gestational

diabetes uh that extends and results in

diabetes especially if the if the female

doesn't obviously lose uh their their

their weight. Now we start thinking

about um some of the agents that can be

used in um uh pregnancy that have been

studied. Metformin and glaburite

actually have been studied have been

used are some are okay to consider. Uh

clearly the preferred agent is insulin

and the whole idea behind this is to

really try to make sure that baby

doesn't get too big because it's got a

hole to come out of right and if it gets

too big it gets stuck. And I've

delivered babies many times, sometimes

emergently. Don't like to do that, but

you don't want a baby getting stuck.

Okay? Uh that's a sometimes a medical

emergency. So push you back in, just go

to the O, right? Uh but let's move on to

some of the more life-threatening

situations that you guys could be at.

For those of you doing the acute care

side, um even those of you in the

ambulatory care, you need to be able to

recognize the complications of a chronic

medical illness because they come in and

out of the hospital system. So this is

where your insufficiency of insulin is

such that now you've caused a

derangement in the metabolic u you know

factors your your biochemistry at the

cellular level where you are producing

keto acids usually in many cases um or

you get such high levels of glucose that

you not only volume deplete the patient

but you also cause electrolyte

deficiencies. both cause electrolyte

deficiencies because the kidneys just

cannot handle all of the glucose that

are is is spilling. The threshold is

exceeded which is around 180 milligrams

per diliter. You just start dumping it.

Well, what follows sod glucose water.

Well, what follows what's also in that

water in the urine filtrate?

Electrolytes. So, you start to have a

significant amount of dehydration,

electrolyte abnormalities, poly

polyipssia, polyasia. Um, and when you

do labs, then you start seeing that an

gap metabolic acidosis. And you don't

have to have, especially in DKA, blood

sugars that are, you know, 6 800. In

fact, there typically are around less

than 500. Um, you'll see them just above

250. HH um S or HS,

you don't necessarily see ketosis or

necessarily on GAP, but you can see

sugars that are 800, 900, over a

thousand. I mean, I've had patients

with, you know, 1,500 u milligrams per

deciliter of blood sugars. I mean, it

just they're so severely dehydrated uh

when they show up. And so, volume

resuscitation in both patients is very

important. Now, there's also a level of

resuscitation that you don't want to go

too high because you could cause

cerebral edema if you, you know, push

fluids too fast, especially in our

pediatric patients. But you also need to

consider electrolyte placement

especially before you ever give these

patients insulin. And that is a take-home

take-home

definitely point that must be made. >> Absolutely.

>> Absolutely.

>> Yeah. Go ahead, Craig. I mean, jump

right in.

>> Oh, yeah. No, I mean this is one of

those key things where the

differentiation here, the key therapies

for DKA or HHS is not insulin.

>> Absolutely not. That's a third like I

mean, in my mind, it's third line. So

you do fluid resuscitation, um you do

electrolyte replacement and you

absolutely have to make sure that

potassium is replaced before you start

insulin. Like those are key factors

almost guaranteed to be on the exam if

you see a a patient case in this

context. I mean almost guaranteed. Um

even still like with crystalloid uh the

selection of a crystalloid might come up

because a normal saline if you give too

much of a high volume again too quickly

you start to in introduce the you know

possibility of hypercchlormic metabolic

acidosis and you falsely eliminate that

gap before you actually clinically

eliminate the gap of the patient. So

there's you know other balanced

electrolyte or crystalloids that can be

substituted instead of normal. It seems

so simple but like def definitively

clinically relevant and also def

definitively elements on a on an exam

where that case might or the clinical

question might actually prompt you to be

able to select the the actual correct answer.

answer.

>> Yeah. And and just so you guys know, you

will you most patients are on insulin

drips in these situation and you will

start to put them on a dextrose

containing infusion around that 250

milligrams per deciliter because you're

trying to feed the cells and reverse the

system and then you won't really

actually let them start eating until

you've closed the gap.

>> Okay, that's when you know you can begin

that transition to subcutaneous insulin

and now let them uh let them eat. um

hypoglycemia. Uh you have um you know

maybe too much insulin um and not enough

glucose or the way you do the insulin

and the patient didn't eat. So their

kinetics didn't line up right. Um these

patients obviously can present in a

number of ways but classically altered

mental status. They can even have

seizures. They can even have stroke like

symptoms. And that's why when patients

come in with a stroke the one of the

first things we check is the glucose.

Okay? when they're having seizures, we

check the glucose. You just have to

treat the underlying cause. And so,

don't forget that that can happen. Uh,

Whipples triad basically is when they

come in with symptoms that are

suggestive of hypoglycemia like the

above and they're usually their glucose

levels are 55 to 60 or less. Um, and

then when you give them glucose, it's

almost like they miraculously come back

to life. It's I mean, it's amazing.

Watch it happen right in front of you.

So your treatments in mild cases as long

as they're maintaining their airway and

they're not seizing and they're not

gurgling in their saliva. Uh you can you

know do like you know glucose uh gels or

tablets. These things there's kind of

the rule of 15. Give 15 grams of oral

glucose. Check them their acue check in

15 minutes. You should see about a 25 at

least milligram per deciliter increase.

And if you don't go ahead and give them

some more. But if they're altered and

they're not controlling their airway or

secretions, it is parental dextrose like

D5 or D10 uh I'm sorry, D10 usually or

amp of D50 even uh depending how low it

is. And uh or if you have no IV access

and you can't get it in, just stab them

with glucagon.

Like literally stab them.

>> Now recognize that that you know the

glucon isn't going to last forever. Now

diabetes and cypitus, there's two types.

This is really more related to uh a

problem with anti- diiuretic hormone and

there's the central and then there's the

nephrogenic central is that the brain

from a number of reasons usually trauma

traumatic brain injury or encphylopathy

from we see this sometimes in patients

postcode if they survive with ros or

tumor uh where they're making too much

antidiuretic hormone and basically um

they're just retaining all this free

water Okay. Uh so they're having anti-diaresis.

anti-diaresis.

So it goes to the collecting tubules and

basically reabsorbs free water. Uh

nephrogenetic is when the kidney itself

is failing to respond to u the

antidiuretic hormone. So you'll see uh

variations um in the problem, right? Um

and so if you have the you know

nephrogenic where they're not responding

and and they they're just dumping free

water then they may be excessive

urination u and that's kind of typically

what we you know we'll see. So you do

plasma and urine osmolalities and look

at their uh sodiums and try to help

define what the problem is. So desmopressin

desmopressin

uh is more for central and uh uh

nephrogenic diabetes and cypitus is you

try to treat the underlying problem. Now

desmopressin is also used for other

conditions um and they're important to

recognize uh one of them being that you

might potentially see on the boards is

uremic platelet dysfunction or uremic

bleeding u is the drug of pretty much

the drug of choice in most situations uh

when you encounter that. Okay Dr. Bolan,

walk us through quickly uh some of this

emerging information that probably is

now uh testable with GLP-1 agonist and

SGLT2s that you kind of alluded to

earlier. Give us the key points here.

>> Yeah. So, just to kind of look at both

of these drug classes for CKD and we'll

talk about them for the others as well,

but first for CKD, you're looking for

reduced EGFR below 60. Um, and you know,

there may come some dosing questions

there with, you know, different

creatinin clearance, whether you're

using it for heart failure or CKD. Um,

so just be aware of that. Make sure you

kind of freshen up on those because

those can change a little bit. Um,

again, so as I'm saying that again, they

may not put that on the board because

that is somewhat inlex with the

different uh indications and things like

that. So anyway, um you're going to look

at their urine, album, and creatin.

Think about that. Your SGLT2s are

probably your go-to for CKD. Uh they

have the most evidence, but then your

GLP1s come in with some uh additional

evidence there. Uh and you can choose

those second line. Um so those trials

have really been limited by just lack of

a standard renal outcome. So that was

kind of the bold print bold print there.

really hard to compare. Uh so in

thinking about cardiovascular risk

reduction, your GLP1s,

uh they all have demonstrated safety

andor superiority. Um they uh so you've

got gelaglatide, luraglletide, and

simaglletide subq that have shown

superiority and carry indications. So

you want to know to use those for ASCBD.

Um and dulaglatide actually has a

primary prevention indication. So if

you've got a patient that's high risk

but has not had an event, dulaglatide is

the one you're going to choose. Um and

then with the SGLT2s and ASCBD,

canagloin and impagloin are the ones

that have demonstrated some superiority

with the three-point mace. So those

would be the ones that you would choose there.

there.

uh in heart failure. Um this one is

interesting in some ways, especially for

SGLT2s. With the GLP1s, it's been

secondary outcomes. So, they don't have

a primary outcome trial yet. So, that's

not going to be uh your choice. However, clinically,

clinically,

you certainly have evidence there that

you could choose one if the patient was

not a candidate for SGLT2s if they had

heart failure. Uh so for SGLT2s and

heart failure they as a class in general

they have demonstrated reductions in

heart failure hospitalizations and

death. So if you've got a patient with

heart failure you need to start thinking

SGLT2 and is it appropriate because

there are a lot of adverse effects with

these medications that could make it not

appropriate and that may be what they're

trying to get you around to as well. Um

so depacen and impactloin have primary

evidence in both patients with and

without diabetes for heart failure. So

that's also important. So if they have

heart failure, they don't have diabetes,

you could potentially still be looking

at an SGLT2 if it's appropriate.

>> Perfect. All right. Insulinoma making

too much insulin. There's a tumor and

just by the name makes sense. So these

patients present with severe usually hypoglycemia

hypoglycemia

sometimes very difficult to control.

When you measure insulin levels or

cpeptide levels they're pretty high. You

got to go looking for the tumor because

basically the treatment is surgical

resection. The one of the drugs of

choice that has been around for decades

is dazoxide. It's an old thazide

diuretic. And just as a quick side note

you know thyide diuretics we know do

increase glucose levels. And if you look

at epidemiologic data, patients on

thyide diuretics tend to have a little

higher incidence of hypoglycemia or even

diabetes. So dazoxide being in that

class is an oral option for that.

Everlymus is another option. Um it's an

mTor uh antioplastic agent. So it's

treating the cancer that's producing the

insulin itself. Obesity obviously when

you have excessive caloric intake and

not enough expenditure. By definition,

that's a BMI over 30. Remember, 25 to 29

is overweight. Um, something else to

keep in mind when you're talking about

obesity is the waist circumference

because these put patients at sort of

that higher risk of coorbidities. Um,

but a lot of times they will um show up

in a triad. you see hypertension, hyper

lipidmia, they start developing insulin

resistance or the metabolic syndrome

especially if it's that visceral

atyposity uh you know the dunlaps

disease um so treatment is the no duh

yeah yep exercise I know I know it's

hard uh but exercise and diet um now if

you start to get to where those things

are not options because it's not

necessarily the case for everybody then

there are some emerging therapies that

have come out. Um the fentamine and

fentamine com combined with the

antic-convulsant topyramate or topamax

um nal trexone bupropion combination

larglutide and then even surgical

interventions where patients you know

get lap bands and different things like

that uh which have pros and cons as

well. So none of these things in and of

themselves or by themselves are

standalone. Okay. So SIADH this is

usually a patient with uh uimmic

hyponetriia. They probably have a little

bit too much free water because of a

little bit too much excess antidiuretic

hormone. They usually present

non-specific. they're just kind of eh

don't feel well, you know, and you start

running some basic labs and you find

them to have hyponetriia with some

changes in their in their urine sodium

um and osmolerity that kind of guide you

to it. So really the treatment the

easiest first line treatment is free

water restriction. I mean slam dunk that

is it. Okay. If somebody has severe

hyponetriia, you know, whether then then

you got to start thinking outside of the

box where you need to be careful with

the correction and you might be using uh

sodium chloride, you know, replacement

therapies where you're going to be

limited by how much you can administer

over a 24-hour period to reduce the risk

of central pontine myinitis. But that is

usually in patients uh with more severe hyponatriia.

hyponatriia.

You can use the vasop prein agents like

tolvaptan for resistant cases but moving

on. All right. Thyroid disorders we have

hypo and hyper and then we have the

extreme. So in hypo that's mixedoma

uh or mixade edema. Uh this is where

they're not making enough T4. Okay. And

this may be you you know your TSH levels

are really high but there's something

wrong with the gland. And so the output

of T4 and eventually then T3 is now compromised.

compromised.

So think about low metabolic demands. Um

and these can vary on the severity or

the the amount of T4 that is not

present. But most of these patients are

tired. They feel depressed. They're

gaining weight. They have cold

intolerances. When you get to mixedadema

comomas, you start having breda cardia,

paricardial fusions, altered mental

status, severe hypothermia. The so they

vary in based on the uh levels. So when

we screen for hypothyroidism really what

we most usually screen for is TSH and it

is usually elevated. If you have an

elevated TSH but a normal T4 that is

considered subclinical hypothyroidism.

Okay. But when both the TSH is high and

the T4 is low that is clinical um or

overt hypothyroidism where patients need

to be on replacement therapy and the

drug of choice is synthetic T4

uh therapy and you recheck that at

approximately six to seven weeks. Okay,

I repeat that. It's a good question.

When will steady state for that dose be

achieved? Six to seven weeks. Um, and so

you got to be careful with making dose

adjustments too quickly because

eventually that patient will have a

steady state level that will be too

high. The halflife is about seven days.

So it makes sense. Now there's a comment

down here that says avoid T4 T3

combinations in most patients. Those are

really reserved for patients who do not

have the ability to peripherally convert

T4 to T3. Uh because when you give fixed

combinations, you're forcing the patient

and their genetic profile to that amount

of T3. Whereas when we give synthetic

T4, your body doesn't know and the and

the peripheral deodinase

doesn't know where it came from. So it

will convert what it needs from T4 to T3

and T3 is more potent or metabolically

active. So allow the body and the body's

own genetic profile metabolic demands

drive that. Dr. Koko, anything mixed

edema that we need to make sure these

guys know.

>> Yeah, absolutely. So I mean agent

selection as you were emphasizing here

would be uh T4o levothyroxine is the the

key therapy here. The the caveat that

though is that it can't be administered

uh orally or entrally uh for those

patients because in that clinical state

their GI absorption is almost absent

entirely. So although again in pharmacy

realms we often try to do a PO to or IV

to PO conversion in this situation it's

absolutely they they need parental

levothyine. Again, a dosing concept

here. Again, I don't think it's

irrational to kind of consider the

dosing because it can range quite

severely from anywhere from a 100

micrograms all the way up to essentially

a milligram. But there's clinical

evidence not to definitively say which

one is the best, but it is relatively

high compared to where you would start

somebody on hypothyroid hypothyroidism

with a relatively low levothyroxine dose

and then titrate up.

>> Excellent. Okay. So what is the average

dose increase in levothyroxine

uh dosing in women with who have known

hypothyroidism and get pregnant and

they're in the first trimester and the

answer is up to 48%.

So and it so at the time of diagnosis uh

many of the guidelines and position

statements recommend a 30% increase

almost immediately and then you may need

to further increase that all the way up

to 43 to 48% um depending on what you

read. So it is a significant increase

during pregnancy and the early that so

you reduce the risk of miscarriage and

uh you know you don't impact negatively

neuro neuro development. All right. Now,

let's go to hyperthyroid.

You make too much T4 or too too much T3.

Um, in many cases, you have the

opposite. You have weight loss, right?

You have sweating. You have

palpitations, your energy, you know,

maybe even uh increases in temperature

or fevers. Um, the extreme and

thyrotoxicosis, again, changes in mental

status. They may be even having a panic

attack, agit being agitated, they can go

into atrial fibrillation. Um, so it is

the opposite. So hopefully those two

sort of make sense. So you would see low

TSH because the brain is receiving too

much feedback from all the T4 T3. Um,

you can use some uh scoring uh

diagnostic criteria like listed here.

Um, if we're looking for thyrotoxyosis,

but a lot of times you know it based on

clinical exam and you can get some basic

labs and you can figure that out. So for

hyperthyroid states until you can remove

the thyroid gland so thyroid ectomy uh

these patients get put on uh methmosol

or PTU. Dr. Koko run us through real

quick thyrotoxicosis key points.

>> Yeah. So uh key points here again these

patients again just exists on an

extreme. So although most of the drug

therapy is actually still relatively

similar. So uh MMI or PTU they would get

started on initially. Um we're actually

trying to treat them um very acutely in

one rational state. There's a lot of

somewhat caveats that you might consider

here. But one of the the key ones at

least in terms of uh what I try to

consider is a the

iodine administration. So either SSKI or

lugalls that you have there. Um and

again they are drops. They're kind of uh

tissue toxic if you don't dilute them.

So they have to be diluted before

administration in almost every scenario.

And then propranol there's some uh

situations here where propranol has been

extensively demonstrated that it can

actually uh definitively kind of prevent

the conversion of t uh you know

producing more T43 in those clinical

scenarios. Many other beta blockers

really haven't been able to demonstrate

that. There is some emerging evidence

with ethmol as an alternative uh just

because proprrenol does have a very long

duration of action. Essol is entirely on

the opposite side. And again here also

you see uh you know cortosteroids uh

essential uh to that administration too.

So the the drug therapy does expand to

at least four of those uh key therapies.

So MMI or PTU plus SSKI or lugalls uh

and then plus beta blocker plus plus

aortic steroid. So it gets fairly

complex and then uh those patients

>> you're basically based on how they

respond you know. So just keep in mind

on the peripheral conversion of T4 to

T3, you're blocking it with PTU and propanol.

propanol.

>> And when you're inhibiting the release

of it from the uh you know stimulation

from from the gland and uh peripheral

conversion, those are your steroids. So

you're hitting it, you're trying to hit

the process from multiple angles. What

medication is known to contain high

concentrations of iodine and can cause

hypothyroid states? Amiotarone. 37% of

each dose of amiotarone is iodine and at

some point you super saturate uh the

gland and it starts to shut it down. All

right, moving on to parathyroid

or hyperarathyroid. This is remember

your parathyroid hormone depending on

the concentration can have different

effects. Um patients can um it regulates

the calcium homeostasis from the bone.

It also regulates how much is absorbed

in the GI tract, how much is released in

the in the kidneys. So you got to keep

these in mind and they the parathyroid

glands sit behind the thyroid itself and

so when you do a thyroidctomy you

actually have to dissect out the

parathyroid glands and put them back

into the body. Um so really what happens

you we got to watch out for patients who

develop hyper uh um hypercalcemia and

hypocalcemic states depending on the

level of functioning of the of the

parathyroid hormone that is is present.

Um and so you like I said you can see

persistent hypercalcemia with elevated

uh PTH which is a primary condition

where they have uh parathyroid adenomas

most commonly um and hyperlasia and then

hypocalcemia from secondary. So again

there's a it almost seems

counterintuitive at some level but you

need to recognize that it's a dose

related effect that's happening on

different organ systems. So if you have

somebody with hyper calcia and they have

that stones, bones, groans and

psychiatric overtones from too much

that's IV fluids, IV fluids, IV fluids,

that is the treatment of choice. Um if

you have a secondary cancer like a

problem that's like metastatic disease

to the bone and it's causing

hypercalcemia malignancy then in those

cases those are patients getting usually

on a bisphosphinate and it's a single

dose of pomeigronate or a single dose of

zolandronic acid because it it takes

about a week for the full effect of that

to happen. Some people will use parental

use of calcetonin if the IV fluids don't

work. But what you don't see on here is

Lasix. you can add Lasix to the regimen

of high dose of IV fluids if they need

to get rid of the extra volume. So,

people with high risk of heart failure.

Um whereas if you're hypocalcemic or you

have the secondary causes, then you may

actually need to be giving them calcium

um um replacements. Okay. So, moving on

to some infectious disease and then

we're going to take here take a break

here in a in a few minutes. Um we're

going to move on to an soft tissue

infections in this group. Okay. So

animal bites, human bites. Animal bites,

uh, bad. Human bites also bad. Uh, but

especially cat bites because they

they're fangs and they can inoculate and

puncture the wound, which we not only

have bacteria on our skin, but they have

bacteria in their oral ferings and they

basically inoculate it and they can

inoculate it pretty deep and most of the

time it's in the hand. So you're talking

about joints. Hand infections get bad

fast. Um, so be very very careful. So

the most common place is the extremity.

Next is the face and the neck because

people put their faces up next to

animals and they reach up and and bite

them. Um so high risk of infection needs

good wound irrigation and deb brement.

Um these patients need to be put on drug

of choice augment clavulonic acid is the

drug of choice for both animal and human

bites. So remember that if you have

animals, tetanus, well for animals in

Houston, tetanus is both because I mean

our mouths are dirty. Um and people that

get into certain types of bar fights and

things may be really dirty. Uh but you

also got to keep in mind rabies. So if

you don't know the uh vaccine status uh

of the animal, they can be quarantined

and monitored by a vet, but the only way

to diagnose if the animal has uh rabies

is to basically kill the animal and do a

biopsy. Uh so it's it's you know you you

got to do that because getting rabies

can result in permanent uh neurologic

damage. And so you do have a little bit

of time before you give the rabies

immune globulin and the vaccination. And

by the way, when you if you do have a

dog or an animal that is suspicious for

rabies, when you are cleaning the wound

and you know doing the repairs, you have

to inject the rabies immune globulin

literally around the bite marks all over

and then whatever is remaining you put

in the same arm or clo you know a more

proximal from away from the wound. Um,

and a lot of people don't realize that,

but you're injecting literally

antibodies all around it if you have

that high of suspicion. Humans, I can

gota be real careful with these um,

organisms. Um, most of the time it's a

fight. So you, you know, punch somebody

in the in the face, it hits the teeth,

it gets right there in the knuckle, it

gets septic joints. Bad news. Bad ruse.

That's why you see these third, fourth,

metacarpalangial joints because of the

the bar fight, the punch. That's usually

uh where it happens. And again, these

infections can be bad and the hands can

swell up and many times have to go to

surgery to have that washed out. So

wound irrigation early, clean it. We

don't always sew these up to be honest

with you because we want the ability of

the organisms to get out. If we sew them

up and suture them too tight uh then we

can trap those bacteria in and again

treatment of choice augmentin augmentin

augmentin and then tetanus. All right

moving on to feliculitis. Think of it

hair follicles. So when you look at them

these patients come in and they have

kind of red spots all over the place um

and around the hair follicles usually in

that distribution. Uh the history is

important. Uh sometimes, especially if

you're considering sudamonus, uh if

they've been exposed to lowcllorinated

uh pools or hot tubs or whirlpools, if

that's in the case, that's what they're

trying to get you to think about. But

think about what's the most common on

the skin, staff orius, strep species.

You see these red areas around the hair

follicles and they form these little

pestules. Um and so most of the findings

are based on exam alone. Sometimes you

can do wound cultures, but quite

honestly, by the time you get that

information back, the patient's going to

be, you know, have already been treated.

So with mild cases, you can get away

with topical mupin, but if it's

involving a larger area, obviously you

can't coat your whole body with mupin

ointment. I mean, you can just slip

around um all over the place. Uh but

it's also not reasonable or feasible. Um

and that's where systemic antib uh antibiotics usually things like KLEX are

antibiotics usually things like KLEX are the most common used. All right, moving

the most common used. All right, moving on to cellulitis. This is an infection

on to cellulitis. This is an infection involving the epidermis and dermis and

involving the epidermis and dermis and starts to spread within the superficial

starts to spread within the superficial fascia. So it's not going deep in the

fascia. So it's not going deep in the myofascial planes yet. Um they swelling,

myofascial planes yet. Um they swelling, inflammation, a local area of redness,

inflammation, a local area of redness, fever. Sometimes you can see streaking

fever. Sometimes you can see streaking uh or track marks going away from the

uh or track marks going away from the area of infection. You can also see

area of infection. You can also see lympadnopathy in the same extremity. Uh

lympadnopathy in the same extremity. Uh again where fluid would be draining.

again where fluid would be draining. Key differentiation from a syipolis

Key differentiation from a syipolis nonelevated lesions that would be on a

nonelevated lesions that would be on a board exam whereas irrious you're going

board exam whereas irrious you're going to see well demarcated uh level

to see well demarcated uh level elevations of the uh infection itself.

elevations of the uh infection itself. Okay, two scenarios.

Okay, two scenarios. If you have an abscess IND, many times

If you have an abscess IND, many times IND alone in a patient with no

IND alone in a patient with no co-orbidities,

co-orbidities, no significant risk factors, no known

no significant risk factors, no known colonizations of MRSA can be effectively

colonizations of MRSA can be effectively treated with IND. Period. That's it.

treated with IND. Period. That's it. Okay? No need for antibiotics in those

Okay? No need for antibiotics in those situations. If you start getting

situations. If you start getting patients with other co-orbidities that

patients with other co-orbidities that put them at higher risk, especially

put them at higher risk, especially imuninompromised states and diabetics,

imuninompromised states and diabetics, you definitely want to consider adding

you definitely want to consider adding on emperic therapy to that. And you

on emperic therapy to that. And you know, you see those listed here, clinomy

know, you see those listed here, clinomy basically being reserved for the

basically being reserved for the penicellin allergic patient. Um if you

penicellin allergic patient. Um if you um are concerned about MRSA then those

um are concerned about MRSA then those patients may need to have anti

patients may need to have anti antibiotics that cover for a

antibiotics that cover for a specifically more community- based MRSA

specifically more community- based MRSA that would be your backrum

that would be your backrum trimethropoxol

trimethropoxol or docycl

or docycl is overkill

is overkill um and you're only using venkcomy really

um and you're only using venkcomy really if the patient is being admitted because

if the patient is being admitted because they're septic uh usually from it. Now,

they're septic uh usually from it. Now, aeric syphilis is now not only the

aeric syphilis is now not only the superficial dermis, but it's now

superficial dermis, but it's now spreading and it's spreading rapidly and

spreading and it's spreading rapidly and it's going through the lymphatic system

it's going through the lymphatic system where when you look at the findings,

where when you look at the findings, they have this uh demarcation around the

they have this uh demarcation around the edge. It's like I mean you can just see

edge. It's like I mean you can just see the line. It looks like a big bully

the line. It looks like a big bully that's just moving and splitting the

that's just moving and splitting the surface of the skin. Um, and these

surface of the skin. Um, and these patients get pretty sick and it's very

patients get pretty sick and it's very painful uh for them. But the drug of

painful uh for them. But the drug of choice is penicellin. Penicellin.

choice is penicellin. Penicellin. Penicellin. Now you can also use not

Penicellin. Now you can also use not only penvk if they're if it's a mild

only penvk if they're if it's a mild case and you can treat them as an

case and you can treat them as an outpatient but also amoxicylin or even

outpatient but also amoxicylin or even kellex if they're being admitted to the

kellex if they're being admitted to the hospital

hospital ancef or spazzin

ancef or spazzin uh or uh vank and if they're especially

uh or uh vank and if they're especially if they're penicellin uh allergic neck

if they're penicellin uh allergic neck fash this is the life-threatening

fash this is the life-threatening medical emergency this is a rapidly

medical emergency this is a rapidly progressing necrosis basically of the

progressing necrosis basically of the myofascial plane pains. So, it's gone

myofascial plane pains. So, it's gone deeper and it's moving and within hours

deeper and it's moving and within hours this patient literally could be dead.

this patient literally could be dead. Um, and when you palpate this and you

Um, and when you palpate this and you look at their clinical presentation,

look at their clinical presentation, they have crepitus, which means when you

they have crepitus, which means when you push down on their skin, you can

push down on their skin, you can actually feel air like almost like ris

actually feel air like almost like ris rice krispie sensation underneath the

rice krispie sensation underneath the skin. And these patients are severely

skin. And these patients are severely toxic and basically this is a medical

toxic and basically this is a medical emergency. You can use this score here,

emergency. You can use this score here, which is a laboratory risk indicator for

which is a laboratory risk indicator for necrotizing fascia score. But quite

necrotizing fascia score. But quite honestly, if you have clinical suspicion

honestly, if you have clinical suspicion of neck basing

of neck basing stupid labs and waiting to do that test

stupid labs and waiting to do that test that you go straight for a surgeon and

that you go straight for a surgeon and you start them on empiric antibiotics.

you start them on empiric antibiotics. Uh Dr. Kio, I don't know if even Dr.

Uh Dr. Kio, I don't know if even Dr. Bolan, I know you back in the day

Bolan, I know you back in the day inatient and uh and on the antimicrobial

inatient and uh and on the antimicrobial stewardship services. I don't know if

stewardship services. I don't know if you guys have seen this but you know

you guys have seen this but you know surgery needs to be consulted emerently

surgery needs to be consulted emerently you can still start emperic antibiotics

you can still start emperic antibiotics um any thoughts

um any thoughts >> yeah this is where it comes to the order

>> yeah this is where it comes to the order of antibiotics now you can debate this

of antibiotics now you can debate this clinically but there's almost no way you

clinically but there's almost no way you can prove this in a clinical trial but

can prove this in a clinical trial but it's entirely rational in my setting

it's entirely rational in my setting where clinomy has to be administered

where clinomy has to be administered first like so the logic behind that is

first like so the logic behind that is that we're trying to inhibit the toxin

that we're trying to inhibit the toxin production toxin release and uh protein

production toxin release and uh protein synthesis from those cells cells that

synthesis from those cells cells that you're immediately going to lice with

you're immediately going to lice with the piccillant tasabactam. So you need

the piccillant tasabactam. So you need to reduce the endotoxin that's being

to reduce the endotoxin that's being released causing this essential neck

released causing this essential neck fashion. You could uh you can rapidly

fashion. You could uh you can rapidly rapidly make it worse if you don't at

rapidly make it worse if you don't at least try to inhibit those protein

least try to inhibit those protein synthesis and then lice the cells. So

synthesis and then lice the cells. So it's always clinto first which is

it's always clinto first which is deviant from or deviation from standard

deviant from or deviation from standard practice where you do betalactin first

practice where you do betalactin first in almost every situation.

in almost every situation. >> Absolutely. So moving on to fungal

>> Absolutely. So moving on to fungal cutaneous canidasis. We have not only

cutaneous canidasis. We have not only strep staff on our skin but we have

strep staff on our skin but we have Canada um and so we show we see these

Canada um and so we show we see these show up in the oral fingial area and

show up in the oral fingial area and imuninompromised patients. It can show

imuninompromised patients. It can show up on on uh patients with other

up on on uh patients with other coorbidities especially diabetics uh

coorbidities especially diabetics uh warm moist environments in the folds of

warm moist environments in the folds of skin or fat. Um and you we see this in

skin or fat. Um and you we see this in kids with diaper rashes. Many times they

kids with diaper rashes. Many times they can develop this and it just the the the

can develop this and it just the the the local uh skin is just very red and

local uh skin is just very red and extremely irritated. Um once it moves

extremely irritated. Um once it moves and disseminates into the blood

and disseminates into the blood obviously just like with bacteria they

obviously just like with bacteria they have systemic manifestation of fever,

have systemic manifestation of fever, chills can become hypotensive. Um so

chills can become hypotensive. Um so most of the time this is diagnosed based

most of the time this is diagnosed based on exam. So if you have mild cases, you

on exam. So if you have mild cases, you can get away with oral fluconazol or

can get away with oral fluconazol or even topical nestatin and there's

even topical nestatin and there's different formulations. If you're doing

different formulations. If you're doing oral fangial candidasis

oral fangial candidasis um then you can do the swish and swallow

um then you can do the swish and swallow type of mechanism. But fluconazol quite

type of mechanism. But fluconazol quite honestly is probably easier to use. But

honestly is probably easier to use. But if you're talking about topical for top

if you're talking about topical for top nestatin for like diaper rash or

nestatin for like diaper rash or cutaneous candidasis if you start

cutaneous candidasis if you start getting into systemic um you're thinking

getting into systemic um you're thinking about amplitaris B you're thinking about

about amplitaris B you're thinking about econocandons

econocandons uh antifungal agents

uh antifungal agents squirrel tracosis this is basically

squirrel tracosis this is basically where this would show up is a gardener

where this would show up is a gardener working out in their landscaping and

working out in their landscaping and with um rose bushes I mean that is the

with um rose bushes I mean that is the classic presentation they poke their

classic presentation they poke their skin with the rose bush and it

skin with the rose bush and it inoculates sporics into the skin and

inoculates sporics into the skin and basically they it can disseminate and go

basically they it can disseminate and go through multiple organs into the lungs,

through multiple organs into the lungs, bone and joint and eventually into the

bone and joint and eventually into the central nervous system. Um you can do

central nervous system. Um you can do blood in ur uh um sputum cultures

blood in ur uh um sputum cultures especially if it moves into the lungs or

especially if it moves into the lungs or a tissue biopsy but the treatment of

a tissue biopsy but the treatment of choice is itchonazol itconol

choice is itchonazol itconol or itchonazol uh especially if you're

or itchonazol uh especially if you're going to be treating it and the patient

going to be treating it and the patient is stable ampliteration B is obviously

is stable ampliteration B is obviously if they're more disseminated and have

if they're more disseminated and have CNS uh involvement

CNS uh involvement u okay I'm going to stop here after this

u okay I'm going to stop here after this thing here what this last clinical

thing here what this last clinical integration what antibiotics are known

integration what antibiotics are known to inhibit monomine oxidase case and

to inhibit monomine oxidase case and increase the risk of drug interactions.

increase the risk of drug interactions. This is important. It'll show up most

This is important. It'll show up most guaranteed on a board exam, okay?

guaranteed on a board exam, okay? Multiple board exams because we don't

Multiple board exams because we don't think about antibiotics causing a lot of

think about antibiotics causing a lot of major drug interactions, but it's

major drug interactions, but it's lenazalid and tadalid. So, be very very

lenazalid and tadalid. So, be very very careful with that. And with that, we'll

careful with that. And with that, we'll we'll pause here and we'll take a uh

we'll pause here and we'll take a uh five to 10 minute break. So, let's how

five to 10 minute break. So, let's how about this? Let's see. How about we do

about this? Let's see. How about we do about let's meet in the middle? Seven

about let's meet in the middle? Seven minutes.

minutes. Stretch your legs. Get a breather. Get

Stretch your legs. Get a breather. Get that blood circulating. We'll see you

that blood circulating. We'll see you back in seven minutes.

back in seven minutes. See what time is that going to be.

>> All right. Yeah, somewhere around there. All right. Good. All right. I'm gonna

All right. Good. All right. I'm gonna I'm gonna pause for just a second. Turn

I'm gonna pause for just a second. Turn off uh my mic. We'll I'm gonna stretch

off uh my mic. We'll I'm gonna stretch my legs as well.

right, we're going to start back here in about a minute or so. Hope everybody got

about a minute or so. Hope everybody got to stretch your legs, got a drink,

to stretch your legs, got a drink, right?

Hope everybody's uh learning something and feeling like it's,

and feeling like it's, you know, dusting off those cobwebs and

you know, dusting off those cobwebs and helping you to hit those key points. And

helping you to hit those key points. And it's a rapid review. So, uh, we

it's a rapid review. So, uh, we certainly value your feedback as well.

certainly value your feedback as well. And, um,

we're going to stay on at the end here for anybody that wants to ask any

for anybody that wants to ask any questions.

It's a lot of content. Fire hydrant.

Fire hydrant. >> Oh yeah,

>> Oh yeah, >> I wasn't lying about the fire hydrant.

I just didn't tell you how many gallons per minute it was coming out.

per minute it was coming out. It's good stuff. It's good stuff, guys.

I know it is fast, but that's why it's rapid.

Just stay with us. Don't give up. >> Absolutely.

So, don't Yeah. Don't give up, guys. Don't uh you know, feel like, okay, I

Don't uh you know, feel like, okay, I can't, you know, just let it

can't, you know, just let it just sit here and and think through it.

just sit here and and think through it. Here are the key points.

Here are the key points. Get the take-home points at minimum. Let

Get the take-home points at minimum. Let that at least set in. Right? If you feel

that at least set in. Right? If you feel like you need to go back there, you got

like you need to go back there, you got time to still study. That's our goal

time to still study. That's our goal here. All right. All right. So, um I'm

here. All right. All right. So, um I'm going to go ahead and get started

going to go ahead and get started because we still got quite a bit to go.

because we still got quite a bit to go. Fire hydrants open back up

Fire hydrants open back up and uh so hold on to your seats. All

and uh so hold on to your seats. All right. So, bone and joint osteomiitis.

right. So, bone and joint osteomiitis. Okay. So, there's many times there's a

Okay. So, there's many times there's a direct inoculation. That's what we most

direct inoculation. That's what we most commonly think of. We think about the

commonly think of. We think about the diabetic foot or maybe there's some uh

diabetic foot or maybe there's some uh wound where it's close to the bone and

wound where it's close to the bone and it directly inoculates that certainly

it directly inoculates that certainly can happen but it also can

can happen but it also can hematogenously spread UTI STDs pulmonary

hematogenously spread UTI STDs pulmonary infections it gets in the blood it can

infections it gets in the blood it can deposit in a bone period okay and that's

deposit in a bone period okay and that's sometimes sometimes we don't think about

sometimes sometimes we don't think about that um many times it's associated with

that um many times it's associated with an infection that joint if it's

an infection that joint if it's involving a bone you'll see redness and

involving a bone you'll see redness and swelling um and that's where we got to

swelling um and that's where we got to get concerned if there is like a septic

get concerned if there is like a septic joint involved or if there is a wound

joint involved or if there is a wound and the close proximity of that wound to

and the close proximity of that wound to an area. Um but once it's gotten into

an area. Um but once it's gotten into the blood then you have bacteria just

the blood then you have bacteria just like sepsis or anything else. Um now how

like sepsis or anything else. Um now how is the approach to management? We really

is the approach to management? We really need a bone biopsy. I mean that's the

need a bone biopsy. I mean that's the key. Now do you how do you know if

key. Now do you how do you know if someone has osteomiitis? Well I can look

someone has osteomiitis? Well I can look at them and see if the bone is exposed.

at them and see if the bone is exposed. The presumption is they probably do.

The presumption is they probably do. Okay. And I've seen chronic wounds with

Okay. And I've seen chronic wounds with bone exposed decubitous ulcers, foot

bone exposed decubitous ulcers, foot infections from diabetics. That can

infections from diabetics. That can happen. But you may ultimately need an

happen. But you may ultimately need an MRI to make the diagnosis. X-rays do not

MRI to make the diagnosis. X-rays do not give you the diagnosis unless it is so

give you the diagnosis unless it is so slam dunk obvious in which case they see

slam dunk obvious in which case they see perostial reaction. But it's an MRI.

perostial reaction. But it's an MRI. Okay. Now, what do we do? You want a

Okay. Now, what do we do? You want a bone biopsy so they can culture that so

bone biopsy so they can culture that so they can narrow in on the bug. You don't

they can narrow in on the bug. You don't want to swab an open wound that's

want to swab an open wound that's colonized with all kinds of stuff,

colonized with all kinds of stuff, especially if it's in the sacrum because

especially if it's in the sacrum because it's going to be polyicrobial. That

it's going to be polyicrobial. That doesn't help you. And these patients may

doesn't help you. And these patients may be on therapy for weeks depending on how

be on therapy for weeks depending on how it where it's located and how it's

it where it's located and how it's treated. Um but you need to think about

treated. Um but you need to think about the flora that's present on the skin

the flora that's present on the skin versus if it's like in a decubitous area

versus if it's like in a decubitous area then you may see more gram negatives you

then you may see more gram negatives you have to think about that if it's a

have to think about that if it's a diabetic right then you have to even

diabetic right then you have to even think of more polyicrobial even

think of more polyicrobial even sudamonus all right we'll come back to

sudamonus all right we'll come back to that in a minute now I mentioned septic

that in a minute now I mentioned septic arthritis and this is where there's

arthritis and this is where there's bacterial inoculation or spreading into

bacterial inoculation or spreading into the joint space itself so you know you

the joint space itself so you know you see a literally if a joint is swollen in

see a literally if a joint is swollen in red knee, you know, the elbow, the

red knee, you know, the elbow, the finger, any of those joints that are

finger, any of those joints that are common. If you can't prove otherwise,

common. If you can't prove otherwise, that needs to be uh treated and and

that needs to be uh treated and and handled like it's a septic joint. And

handled like it's a septic joint. And these patients have significant pain and

these patients have significant pain and swelling over that. They usually lose

swelling over that. They usually lose range of motion, uh mainly because of

range of motion, uh mainly because of the pain. And the only way you're going

the pain. And the only way you're going to know is stick a needle in it. Yep.

to know is stick a needle in it. Yep. So, make sure they don't punch you in

So, make sure they don't punch you in the face as you're sticking the needle

the face as you're sticking the needle down into the their joint because it

down into the their joint because it hurts. The other thing that you don't

hurts. The other thing that you don't want to do is you want to make sure that

want to do is you want to make sure that you do think there's joint involvement.

you do think there's joint involvement. And there are some exam findings that

And there are some exam findings that you can do like weightbearing

you can do like weightbearing assessments that if it causes pain or

assessments that if it causes pain or it's high suspicion because of a close

it's high suspicion because of a close proximity, then you want to be careful

proximity, then you want to be careful not to introduce bacteria into a joint.

not to introduce bacteria into a joint. So if you have a cellulitis that's just

So if you have a cellulitis that's just superficial and the superficial dermis

superficial and the superficial dermis but not tracking down in the joint,

but not tracking down in the joint, don't boy sticking a needle through the

don't boy sticking a needle through the red skin that's cellulitic and pushing

red skin that's cellulitic and pushing bacteria into the joint. You will now

bacteria into the joint. You will now make a septic joint. So it is a tough

make a septic joint. So it is a tough decision to do it but basically the only

decision to do it but basically the only way to diagnose septic arthritis is to

way to diagnose septic arthritis is to do a joint. So you get synovial fluid,

do a joint. So you get synovial fluid, you see these elevated white blood

you see these elevated white blood cells, PMN's in there. Many times it's

cells, PMN's in there. Many times it's cloudy and based on the location and

cloudy and based on the location and based on the patient's history if

based on the patient's history if they're colonized with MRSA then you're

they're colonized with MRSA then you're going to obviously add uh you know MRSA

going to obviously add uh you know MRSA coverage usually with venkcomyosin most

coverage usually with venkcomyosin most commonly

commonly if it's if it's uh no high-risisk

if it's if it's uh no high-risisk patient uh no histories no other

patient uh no histories no other coorbidities then you can start off with

coorbidities then you can start off with you know ANSF nefaselin those are

you know ANSF nefaselin those are certainly appropriate options If you're

certainly appropriate options If you're concerned about hematogynous and there's

concerned about hematogynous and there's perulent drainage already coming from

perulent drainage already coming from the joint, you need to cover for not

the joint, you need to cover for not only MRSA, but you need to probably

only MRSA, but you need to probably extend the spectrum, especially if

extend the spectrum, especially if there's evidence of sepsis uh going on,

there's evidence of sepsis uh going on, and that's where your sephop and

and that's where your sephop and maropenum would be great options. Now,

maropenum would be great options. Now, diabetic foots infections are typically

diabetic foots infections are typically polyicrobial because they have their

polyicrobial because they have their foot in a shoe and they're usually

foot in a shoe and they're usually dirty. I mean, let's just be honest.

dirty. I mean, let's just be honest. Anybody that's ever seen a diabetic foot

Anybody that's ever seen a diabetic foot infection can smell it from across the

infection can smell it from across the emergency department or clinic and it's

emergency department or clinic and it's very obvious that it's infected. Um but

very obvious that it's infected. Um but that so it's foul smelling. There may be

that so it's foul smelling. There may be even drainage coming from it. Uh you can

even drainage coming from it. Uh you can even see bone involvement. Uh they don't

even see bone involvement. Uh they don't feel it, right? And especially if they

feel it, right? And especially if they step on something uh because they have

step on something uh because they have diabetic neuropathy. Well, they don't

diabetic neuropathy. Well, they don't only not diabetic neuropathy, they have

only not diabetic neuropathy, they have vascular impairment. So they're not even

vascular impairment. So they're not even bringing the precursors to wound healing

bringing the precursors to wound healing necessary to fight the infection and

necessary to fight the infection and heal that wound. So that's why they tend

heal that wound. So that's why they tend to be chronic in nature. So these

to be chronic in nature. So these patients need to have surgical

patients need to have surgical debrement, wound irrigation, and then

debrement, wound irrigation, and then they try to sample the core of that to

they try to sample the core of that to get the actual bug. So many times for

get the actual bug. So many times for providers like me in the emergency

providers like me in the emergency department, I don't start emperic

department, I don't start emperic antibiotics on these patients. I get

antibiotics on these patients. I get them to orthopedic surgery. They take

them to orthopedic surgery. They take them to the O, they do the cleaning, and

them to the O, they do the cleaning, and then they get a bone biopsy from that

then they get a bone biopsy from that source so that they can discern. Now, if

source so that they can discern. Now, if they're going to do an amputation, then

they're going to do an amputation, then the treatment is much different because

the treatment is much different because you remove the infection and the source

you remove the infection and the source of the infection. But sometimes you

of the infection. But sometimes you can't always remove all the bone and so

can't always remove all the bone and so some of that bone remains. And so your

some of that bone remains. And so your treatment is guided by a number of those

treatment is guided by a number of those factors. So, I'm sorry there's no

factors. So, I'm sorry there's no one-sizefits-all answer here, but you

one-sizefits-all answer here, but you definitely need to be considering

definitely need to be considering sudamonus into that picture, especially

sudamonus into that picture, especially if the patient comes into you. And I've

if the patient comes into you. And I've seen this, I can't tell you how many

seen this, I can't tell you how many times, maybe Dr. Boland, you in your di

times, maybe Dr. Boland, you in your di your care clinics that you've been in

your care clinics that you've been in with your diabetics, but I've seen

with your diabetics, but I've seen patients come in here like, "Doc, I got,

patients come in here like, "Doc, I got, you know, I'm bleeding. My sock has got

you know, I'm bleeding. My sock has got blood on it. I don't know what the deal

blood on it. I don't know what the deal is and I like pick up the shoe and

is and I like pick up the shoe and literally like look at the bottom and

literally like look at the bottom and there's the, you know, flat part of the

there's the, you know, flat part of the nail and I look inside the shoe and like

nail and I look inside the shoe and like there's a nail sticking up literally

there's a nail sticking up literally like this and they're just literally

like this and they're just literally grinding it away.

grinding it away. >> I can't tell you how many times I've

>> I can't tell you how many times I've seen that and they're walking on it

seen that and they're walking on it without pain.

without pain. That's how bad it is,

That's how bad it is, >> right? So when you you when you have a

>> right? So when you you when you have a nail through the sole of a rubber shoe

nail through the sole of a rubber shoe that that type of um sole typically

that that type of um sole typically harbors pseudamonus and so you have to

harbors pseudamonus and so you have to keep that in in mind. Dr. Bolan, I don't

keep that in in mind. Dr. Bolan, I don't know if you have any additional

know if you have any additional things you want to say there. If you

things you want to say there. If you don't that's okay. Um,

don't that's okay. Um, >> no, I just think it's important, you

>> no, I just think it's important, you know, and and thinking about you

know, and and thinking about you clinically and for an exam, you got to

clinically and for an exam, you got to think about counseling. Uh, you know,

think about counseling. Uh, you know, what they may ask as far as counseling

what they may ask as far as counseling or what, you know, how you should

or what, you know, how you should counsel someone to take care of their

counsel someone to take care of their feet and when you should do foot exams

feet and when you should do foot exams if they're high risk, if they're not

if they're high risk, if they're not high risk, and things like that because

high risk, and things like that because it is very important to catch early. And

it is very important to catch early. And sometimes I will say they don't even

sometimes I will say they don't even present like these really nasty

present like these really nasty um you know looking wounds that are

um you know looking wounds that are already open and Sometimes they

already open and Sometimes they are kind of internal and coming out. So

are kind of internal and coming out. So it'll present like a callous that just

it'll present like a callous that just all of a sudden they look at it and

all of a sudden they look at it and they're like well it just looks a little

they're like well it just looks a little more red around the edge. Uh and then

more red around the edge. Uh and then you open that up and the you know

you open that up and the you know ulceration is underneath. So it's not

ulceration is underneath. So it's not always this gruesome kind of just you

always this gruesome kind of just you know

know >> that's true very good point.

>> that's true very good point. Hypercaratic lesions or calluses

Hypercaratic lesions or calluses build up tiss uh skin and it pushes down

build up tiss uh skin and it pushes down into it's like a pressure ulcer is

into it's like a pressure ulcer is what's happening. And so literally the

what's happening. And so literally the podiatrist if you ever send a patient to

podiatrist if you ever send a patient to a a foot specialist they'll par and

a a foot specialist they'll par and shave off literally that dead skin to

shave off literally that dead skin to reduce the pressure on that point. But

reduce the pressure on that point. But you can almost see the ulceration

you can almost see the ulceration happening just like Dr. Bolan said where

happening just like Dr. Bolan said where underneath you could transparently see

underneath you could transparently see the blood and the black spots from the

the blood and the black spots from the dead skin and dead tissue from

dead skin and dead tissue from underneath. So you know preventative

underneath. So you know preventative care is key. Dentists, vision,

care is key. Dentists, vision, opthalmologists, podiatrists,

opthalmologists, podiatrists, dieticians, I mean when you're taking

dieticians, I mean when you're taking care of a diabetic patient, it is a

care of a diabetic patient, it is a multiffactorial approach. Moving on to

multiffactorial approach. Moving on to lung infections, bronchitis,

lung infections, bronchitis, virus,

virus, do nothing. No, just kidding. Do not do

do nothing. No, just kidding. Do not do not give patients mucinx. It is

not give patients mucinx. It is absolutely the worst drug on the planet.

absolutely the worst drug on the planet. It makes people cough. It is an

It makes people cough. It is an expectctorant. And people come in all

expectctorant. And people come in all the time, man, I am coughing worse than

the time, man, I am coughing worse than I ever cough. I know because you're

I ever cough. I know because you're taking that stupid drug.

I was just joking, trying to some of you guys up, but the reality is it I

guys up, but the reality is it I everything I said was actually true. Um,

everything I said was actually true. Um, and they should take mucinex off the

and they should take mucinex off the market. It actually has zero clinical

market. It actually has zero clinical benefit, but bronchitis is almost

benefit, but bronchitis is almost guaranteed to be viral or allergen

guaranteed to be viral or allergen mediated. They're smoking. It's a virus,

mediated. They're smoking. It's a virus, right? So, they have this chronic cough.

right? So, they have this chronic cough. It can last more than even three months,

It can last more than even three months, you know, and it occurs multiple times

you know, and it occurs multiple times throughout the year for several months.

throughout the year for several months. It is symptomatic. So, you can give

It is symptomatic. So, you can give antitusive therapies, you know, um, but

antitusive therapies, you know, um, but no antibiotics. That is going to be the

no antibiotics. That is going to be the question on the test. Okay.

question on the test. Okay. Broncholitis.

Broncholitis. >> Dr. Bust, let me just throw in a

>> Dr. Bust, let me just throw in a antimicrobial stewardship point here

antimicrobial stewardship point here with the bronchitis

with the bronchitis >> and the bronchulitis even. So that is

>> and the bronchulitis even. So that is really important when we're thinking

really important when we're thinking about antimicrobial stewardship. A lot

about antimicrobial stewardship. A lot of times we're thinking about big

of times we're thinking about big interventions. Like we're thinking it's

interventions. Like we're thinking it's got to be something, you know,

got to be something, you know, earthshattering.

earthshattering. But this is the kind of question you're

But this is the kind of question you're going to get. Like if they are asking

going to get. Like if they are asking you about antimicrobial stewardship,

you about antimicrobial stewardship, it's going to be about are you choosing

it's going to be about are you choosing the right drug and the right for the

the right drug and the right for the right bug at the right time and you're

right bug at the right time and you're given the right duration. So right here

given the right duration. So right here is very important. So many patients get

is very important. So many patients get antibiotics for bronchitis. It's crazy

antibiotics for bronchitis. It's crazy to even think about. I mean, you're

to even think about. I mean, you're talking like

talking like >> Exactly.

>> Exactly. >> That's what everybody wants. They want

>> That's what everybody wants. They want an antibi an antibiotic solves

an antibi an antibiotic solves everything. Depression

everything. Depression >> solves everything.

>> solves everything. >> Uh your financial problems, um your

>> Uh your financial problems, um your marriage.

marriage. >> I mean,

>> I mean, it fixes everything. Okay.

it fixes everything. Okay. >> Well, and so exactly. And a lot of times

>> Well, and so exactly. And a lot of times we do it for convenience uh and to just

we do it for convenience uh and to just get the patient out of there and give

get the patient out of there and give them what they want. There's some

them what they want. There's some communication techniques you can use

communication techniques you can use there to actually appease the patient

there to actually appease the patient and prevent them from complaining to you

and prevent them from complaining to you versus giving them an antibiotic that

versus giving them an antibiotic that could potentially hurt them. I mean up

could potentially hurt them. I mean up to 25% of patients have GI side effects

to 25% of patients have GI side effects including cediff silk from antibiotics

including cediff silk from antibiotics period. So they're not benign. They can

period. So they're not benign. They can alter your flora for up to even two

alter your flora for up to even two years. So again, just don't. And there's

years. So again, just don't. And there's your antimicrobial stewardship question.

your antimicrobial stewardship question. I love it.

I love it. >> Point.

>> Point. >> So, and the other thing is I'll point

>> So, and the other thing is I'll point out here is a lot of times providers

out here is a lot of times providers will do it for fear because they're

will do it for fear because they're afraid they're going to miss the

afraid they're going to miss the pneumonia. But you've got to remember if

pneumonia. But you've got to remember if if you're not seeing in a patient signs

if you're not seeing in a patient signs of pneumonia, then you've treated them

of pneumonia, then you've treated them properly, you know, in sending them away

properly, you know, in sending them away with without the antibiotics. So be sure

with without the antibiotics. So be sure you do your due diligence there to make

you do your due diligence there to make sure that they don't have pneumonia.

sure that they don't have pneumonia. >> Counsel them. Give them return

>> Counsel them. Give them return precautions if you're if the diagnosis

precautions if you're if the diagnosis is vague and they're not hypoxy. We're

is vague and they're not hypoxy. We're going to talk about commu uh community

going to talk about commu uh community pneumonia here in a second. But

pneumonia here in a second. But bronchulitis is now affecting those

bronchulitis is now affecting those smaller airways and that's usually RSV.

smaller airways and that's usually RSV. An RSV is almost always in the pediatric

An RSV is almost always in the pediatric patient, usually in that two-year

patient, usually in that two-year window, and they just make tons of

window, and they just make tons of mucus, and they just sound horrible. And

mucus, and they just sound horrible. And of course, it scares the parent,

of course, it scares the parent, especially the new parent who doesn't

especially the new parent who doesn't know, you know, anything. Um, they they

know, you know, anything. Um, they they they get all freaked out about it and

they get all freaked out about it and really uh they are they can't be sick.

really uh they are they can't be sick. Um, but most of the time they're going

Um, but most of the time they're going to be fine. And it's self-limiting on

to be fine. And it's self-limiting on its own. You can do a diagnostic work up

its own. You can do a diagnostic work up on them. You can actually test for RSV.

on them. You can actually test for RSV. It helps to give the diagnosis. It all

It helps to give the diagnosis. It all help so helps with the counseling point

help so helps with the counseling point that Dr. Bolan was talking about as it

that Dr. Bolan was talking about as it relates to antimicrobial stewardship

relates to antimicrobial stewardship because again they're going to go why

because again they're going to go why are you not giving my kid an antibiotic

are you not giving my kid an antibiotic because you have a a virus does nothing

because you have a a virus does nothing to that you know and quite honestly it's

to that you know and quite honestly it's suction nasal suctioning the bulb

suction nasal suctioning the bulb syringe depending on the age of the kid

syringe depending on the age of the kid and it's just a lot of suctioning

and it's just a lot of suctioning getting rid of those secretions in the

getting rid of those secretions in the patient who's having maybe wheezing

patient who's having maybe wheezing that's resulting in

that's resulting in uh hypoxia so their pulse oxes are in

uh hypoxia so their pulse oxes are in that low 90 they're real close to 90 or

that low 90 they're real close to 90 or they're hypoxic and needing supplemental

they're hypoxic and needing supplemental oxygen then in those patients you can

oxygen then in those patients you can consider uh nebulized therapies and the

consider uh nebulized therapies and the treatment would be nebulized a

treatment would be nebulized a hypertonic saline bronco dilators really

hypertonic saline bronco dilators really don't do much uh we use them but they

don't do much uh we use them but they really don't use do much and if you got

really don't use do much and if you got sort of selected patient with bronco

sort of selected patient with bronco pulmonary dysplas pies with early you

pulmonary dysplas pies with early you know lung disorders then you can

know lung disorders then you can consider other treatments all right

consider other treatments all right moving on to communityquired pneumonia

moving on to communityquired pneumonia okay strep numo H flu um uh staff

okay strep numo H flu um uh staff klepsiella and then your atypicals

klepsiella and then your atypicals that's your myopplasma pneumonia your

that's your myopplasma pneumonia your chlamyia pneumonia and your legionella

chlamyia pneumonia and your legionella okay newilia that you would consider in

okay newilia that you would consider in those situations u you know again

those situations u you know again they're going to have fever many times

they're going to have fever many times they're going to they may usually report

they're going to they may usually report chest pain because they have an

chest pain because they have an infiltrate and it's irritating the lung

infiltrate and it's irritating the lung parankma it may even be irritating the

parankma it may even be irritating the plural tissue so that when they're

plural tissue so that when they're taking a deep breath or they're

taking a deep breath or they're coughing, it hurts. And again, that's

coughing, it hurts. And again, that's some of the differentiation from

some of the differentiation from bronchitis because bronchitis is

bronchitis because bronchitis is generalized irritation. Whereas

generalized irritation. Whereas pneumonia tends to be localized and it

pneumonia tends to be localized and it infiltrate. And so you do a chest X-ray

infiltrate. And so you do a chest X-ray and if you see no infiltrates

and if you see no infiltrates and it's wide open, looks normal, that's

and it's wide open, looks normal, that's probably viral bronchitis. It's

probably viral bronchitis. It's generalized. Um, but if you see an

generalized. Um, but if you see an infiltrate and on exam you're listening

infiltrate and on exam you're listening and you hear sort of the crackle or rail

and you hear sort of the crackle or rail in that area, okay, or it's documented

in that area, okay, or it's documented in the case, then they're basically

in the case, then they're basically telling you this is bacterial pneumonia.

telling you this is bacterial pneumonia. Okay, can a viral bronchitis turn into a

Okay, can a viral bronchitis turn into a bacterial pneumonia? Absolutely. Because

bacterial pneumonia? Absolutely. Because you set up the media, you know, dark

you set up the media, you know, dark warm space and you irritate the tissue

warm space and you irritate the tissue that can cause a secondary bacterial

that can cause a secondary bacterial infection. And usually what happens is

infection. And usually what happens is the patient with viral bronchitis ends

the patient with viral bronchitis ends up getting better, their symptoms

up getting better, their symptoms improve, but then they rebound and then

improve, but then they rebound and then they all of a sudden get worse again. So

they all of a sudden get worse again. So the history is very important. So we do

the history is very important. So we do the curb 65 or the port scores pneumonia

the curb 65 or the port scores pneumonia severity index to discern, do I need to

severity index to discern, do I need to admit this patient or can I treat them

admit this patient or can I treat them as an outpatient? That really influences

as an outpatient? That really influences the empiric therapies that I'm going to

the empiric therapies that I'm going to use. In outpatient situations you can

use. In outpatient situations you can get away with you know a zithroycin or

get away with you know a zithroycin or as you know a appropriate dose of a

as you know a appropriate dose of a zithroycin you can get away with

zithroycin you can get away with augmentatin right you can use a

augmentatin right you can use a fluoricquinolone is probably a little

fluoricquinolone is probably a little overkill but you can especially if

overkill but you can especially if there's no other uh if they have

there's no other uh if they have allergies or some unique situation but

allergies or some unique situation but if you're admitting to the hospital you

if you're admitting to the hospital you want to make sure you cover for not only

want to make sure you cover for not only those agents that I talked about but

those agents that I talked about but also your atypical so they need like

also your atypical so they need like sept trixone or sephottoxine plus a

sept trixone or sephottoxine plus a zithro or chloriththroycin depending on

zithro or chloriththroycin depending on what you have access to. So or a

what you have access to. So or a floricquinolone antibbody which would

floricquinolone antibbody which would treat all of those at the same time.

treat all of those at the same time. Okay, a respiratory floricquinolone not

Okay, a respiratory floricquinolone not cypro. Um so just keep that in mind once

cypro. Um so just keep that in mind once you get into the hospital setting you

you get into the hospital setting you know ventilator nonventilator and some

know ventilator nonventilator and some people say well hospital acquired

people say well hospital acquired pneumonia or HAP doesn't really kind of

pneumonia or HAP doesn't really kind of exist anymore compared to communicia

exist anymore compared to communicia they look starting to look very similar

they look starting to look very similar that's true but think of it as

that's true but think of it as noaccommial okay so they picked up the

noaccommial okay so they picked up the infection from within the hospital and

infection from within the hospital and so you got to now raise the level of

so you got to now raise the level of concern even though yes patients in the

concern even though yes patients in the community environment can have uh

community environment can have uh similar bugs because they're coming in

similar bugs because they're coming in and out of a lot of health care systems

and out of a lot of health care systems now. Okay? And we have to factor in

now. Okay? And we have to factor in nursing home, long-term care facilities,

nursing home, long-term care facilities, diialysis units, and those types of

diialysis units, and those types of places where they can look like and or

places where they can look like and or have basically a nocomial pneumonia. So

have basically a nocomial pneumonia. So look at that exposure. Look for a

look at that exposure. Look for a hospitalization where they came in

hospitalization where they came in without signs and symptoms of pneumonia,

without signs and symptoms of pneumonia, but two days into it, they start now

but two days into it, they start now developing symptoms of pneumonia. That's

developing symptoms of pneumonia. That's your clue. And then of course,

your clue. And then of course, ventilator associated pneumonia is duh,

ventilator associated pneumonia is duh, patient on a ventilator.

patient on a ventilator. They're usually in the ICU. Okay. Uh if

They're usually in the ICU. Okay. Uh if they're there in your emergency

they're there in your emergency department, there's something wrong

department, there's something wrong because you shouldn't be housing

because you shouldn't be housing patients in the emergency department on

patients in the emergency department on ventilators. Uh we did that through the

ventilators. Uh we did that through the pandemic, but you don't want to keep

pandemic, but you don't want to keep doing that on a long-term basis. Um but

doing that on a long-term basis. Um but again, it's the same manifestations.

again, it's the same manifestations. Um but you know, you need to consider

Um but you know, you need to consider their uh severity. Um and then you need

their uh severity. Um and then you need to factor in based on is it hospital is

to factor in based on is it hospital is it ventilator associated on how

it ventilator associated on how aggressive you need to be. Do you need

aggressive you need to be. Do you need you know obviously pseudomonus coverage

you know obviously pseudomonus coverage is certainly ranks up a little bit

is certainly ranks up a little bit higher right um in those patients um

higher right um in those patients um depending on what environment their

depending on what environment their history or their risk factors are. Uh

history or their risk factors are. Uh Dr. Kokio I don't know or even Dr. Bolan

Dr. Kokio I don't know or even Dr. Bolan I mean I know you both have worked in

I mean I know you both have worked in the inatient antimicrobial stewardship

the inatient antimicrobial stewardship services. Do you have any other comments

services. Do you have any other comments about pneumonia or hospitalacquired or

about pneumonia or hospitalacquired or VAP?

VAP? Yeah, I mean just for the the hypervap

Yeah, I mean just for the the hypervap empiric treatment uh the combination of

empiric treatment uh the combination of like a betalactin amongly I mean in

like a betalactin amongly I mean in those situations it's it's uh we have to

those situations it's it's uh we have to make sure at least for imunoglycosside

make sure at least for imunoglycosside it's like once daily dosing for those

it's like once daily dosing for those patients that you know definitely meet

patients that you know definitely meet that criteria uh rather than uh you know

that criteria uh rather than uh you know if they have renal dysfunction they

if they have renal dysfunction they still might get it once daily but that's

still might get it once daily but that's not technically they don't meet those

not technically they don't meet those criteria although you would still

criteria although you would still essentially monitor them but in a little

essentially monitor them but in a little bit more rigid format that context. So

bit more rigid format that context. So that's something at least to keep in

that's something at least to keep in mind.

mind. >> Probably a good spot to talk about

>> Probably a good spot to talk about allergies and what you can do with

allergies and what you can do with antimicrobial stewardship there too. So

antimicrobial stewardship there too. So if you have patients who are coming in

if you have patients who are coming in and you really need to pull a betalactam

and you really need to pull a betalactam or that's your preferred thing because

or that's your preferred thing because uh you know floricquinolons are not

uh you know floricquinolons are not benign either. So um you know part of

benign either. So um you know part of antimicrobial stewardship is doing some

antimicrobial stewardship is doing some investigation into the allergy and

investigation into the allergy and seeing if you can determine if it was a

seeing if you can determine if it was a true allergy or not. And then even

true allergy or not. And then even Hopefully, I mean, ideally, you would be

Hopefully, I mean, ideally, you would be able to implement some sort of allergy

able to implement some sort of allergy testing uh that the antimicrobial

testing uh that the antimicrobial stewardship team can either, you know,

stewardship team can either, you know, sponsor or do um to try and determine if

sponsor or do um to try and determine if they could actually tolerate it.

they could actually tolerate it. >> Excellent. All right. TB. Probably the

>> Excellent. All right. TB. Probably the main thing here is recognizing patients

main thing here is recognizing patients that have late high risk for TB. So,

that have late high risk for TB. So, they're homeless, they live in shelters,

they're homeless, they live in shelters, they may incarcerated,

they may incarcerated, um they come in contact with somebody.

um they come in contact with somebody. Those are in in the United States are

Those are in in the United States are predominantly going to be problem. But

predominantly going to be problem. But we have a lot of people coming from

we have a lot of people coming from other countries, refugees that you have

other countries, refugees that you have to keep in mind, especially with

to keep in mind, especially with caravans of people where infectious

caravans of people where infectious disease people are in close quarters,

disease people are in close quarters, they're sick and depending on how the

they're sick and depending on how the travel environments, these types of

travel environments, these types of things, they can bring that stuff in.

things, they can bring that stuff in. And so you have to think outside of the

And so you have to think outside of the box, right? So they have productive

box, right? So they have productive cough, uh chest pains, they have night

cough, uh chest pains, they have night sweats, weight loss, those are classic.

sweats, weight loss, those are classic. you do an X-ray, you usually see some of

you do an X-ray, you usually see some of these uh cavitations um that make raise

these uh cavitations um that make raise a concern. Um you you obviously can do

a concern. Um you you obviously can do PPD testing and these types of things or

PPD testing and these types of things or you can do sputum analysis to help you

you can do sputum analysis to help you to confirm and then it's four drug

to confirm and then it's four drug therapy uh for active infection. You got

therapy uh for active infection. You got your isized, rifamp and parazinomide

your isized, rifamp and parazinomide for active TB. So four drugs if you have

for active TB. So four drugs if you have latent TB, right? So it's just there

latent TB, right? So it's just there your immune system is keeping it at bay.

your immune system is keeping it at bay. Okay. Uh then you might need to consider

Okay. Uh then you might need to consider uh two drug therapies to uh in that

uh two drug therapies to uh in that situation especially if you're going to

situation especially if you're going to start a person on TNF alpha antagonists.

start a person on TNF alpha antagonists. So that's your adalumab your tannercept

So that's your adalumab your tannercept your infleximab for ulcerative colitis

your infleximab for ulcerative colitis Crohn's disease rheumatoid seriatic

Crohn's disease rheumatoid seriatic arthritis conditions. patients with

arthritis conditions. patients with underlying latent TB that get those

underlying latent TB that get those drugs without being adequately screened

drugs without being adequately screened have been shown to uh convert to active

have been shown to uh convert to active infections and develop uh disseminated

infections and develop uh disseminated TB and die. So because that once you

TB and die. So because that once you infuse them with antibbody you're stuck

infuse them with antibbody you're stuck with it for almost a month. All right,

with it for almost a month. All right, moving on to back men CNS infections.

moving on to back men CNS infections. We're going to talk about bacterial

We're going to talk about bacterial menitis, viral menitis and sephilitis.

menitis, viral menitis and sephilitis. Um obviously bacterial menitis a

Um obviously bacterial menitis a bacteria gets up into the menengees. um

bacteria gets up into the menengees. um into the brain and causes cerebral

into the brain and causes cerebral swelling and edema and that's what

swelling and edema and that's what causes the headaches uh phototohobias

causes the headaches uh phototohobias and all these things and they get the

and all these things and they get the nucal rigidity um they get increased

nucal rigidity um they get increased intercraanial pressure that then pushes

intercraanial pressure that then pushes on their eyes they get papalma when you

on their eyes they get papalma when you look at eye exams uh bredinsky signs are

look at eye exams uh bredinsky signs are where we sometimes do these more in our

where we sometimes do these more in our pediatric patients but you can do it in

pediatric patients but you can do it in adults too where you lift up on the head

adults too where you lift up on the head and their knees reflex up whereas kernig

and their knees reflex up whereas kernig sign is where you you know you bend

sign is where you you know you bend their leg up or you flex it at their hip

their leg up or you flex it at their hip and and then their knee is bent and then

and and then their knee is bent and then you straighten out their leg and and

you straighten out their leg and and basically it causes excruciating pain

basically it causes excruciating pain because you're stretching the meningi

because you're stretching the meningi going up the spinal column all the way

going up the spinal column all the way up into your brain and it causes it to

up into your brain and it causes it to exacerbate. So those are the classic

exacerbate. So those are the classic symptoms

symptoms patients present. So the way we when you

patients present. So the way we when you have that symptom they need a lumbar

have that symptom they need a lumbar puncture an LP. Okay. Okay. So, we're

puncture an LP. Okay. Okay. So, we're sticking now a needle into usually

sticking now a needle into usually around L3, L4 of the lumbar spine. In

around L3, L4 of the lumbar spine. In that area, we feed a needle into that

that area, we feed a needle into that space. There's no spinal cord at that

space. There's no spinal cord at that point. There are just spinal nerves that

point. There are just spinal nerves that are coming off, but we stick that needle

are coming off, but we stick that needle in there and we draw off some of the

in there and we draw off some of the CSF. And we can also do measuring

CSF. And we can also do measuring pressures. And the opening pressure

pressures. And the opening pressure helps to guide you and differentiate

helps to guide you and differentiate bacterial versus viral and fungal. So,

bacterial versus viral and fungal. So, that's why we do it. Okay. And those

that's why we do it. Okay. And those patients have to be laying on their on

patients have to be laying on their on their on the lateral side with their

their on the lateral side with their legs straight, not moving. And then we

legs straight, not moving. And then we have to measure their opening pressures.

have to measure their opening pressures. Then we draw off that CSF and we measure

Then we draw off that CSF and we measure protein, glucose, we do cultures, we do

protein, glucose, we do cultures, we do Graham stains. And that really guides

Graham stains. And that really guides us. But quite honestly, I may not know

us. But quite honestly, I may not know as the provider doing the procedure

as the provider doing the procedure whether or not they have menitis or not.

whether or not they have menitis or not. So I'm going to empirically start them

So I'm going to empirically start them on therapy. And then as I start getting

on therapy. And then as I start getting the results back, I will narrow in. So

the results back, I will narrow in. So empiric therapy is because by the nature

empiric therapy is because by the nature I don't know now obviously if the CSF

I don't know now obviously if the CSF comes back very cloudy or even perulent

comes back very cloudy or even perulent we got a problem okay um and that would

we got a problem okay um and that would be clearly a high risk for bacterial and

be clearly a high risk for bacterial and so in this case we have to think about

so in this case we have to think about getting drugs that pass through the

getting drugs that pass through the bloodb brain barrier we also need to

bloodb brain barrier we also need to factor in age okay so if they're less

factor in age okay so if they're less than one month of age or greater than 50

than one month of age or greater than 50 we need to consider lististeria those

we need to consider lististeria those patients need ain as part of their

patients need ain as part of their regimen. If they're allergic to

regimen. If they're allergic to penicellin truly, right? Then you can

penicellin truly, right? Then you can consider Bactrum in those situations.

consider Bactrum in those situations. In addition to ampeoin, it is

In addition to ampeoin, it is sephotaxine or septraxone plus

sephotaxine or septraxone plus venkcomyosin. Okay.

venkcomyosin. Okay. Now, some people think of only

Now, some people think of only septraone. They forget about

septraone. They forget about sephotaxine, but the reality is you

sephotaxine, but the reality is you could use either one. And so, be careful

could use either one. And so, be careful about choices on the test. Okay. Now the

about choices on the test. Okay. Now the big next debate is whether or not you

big next debate is whether or not you add steroids. Okay? Because if you're

add steroids. Okay? Because if you're thinking about bacterial menitis,

thinking about bacterial menitis, pre-administration of steroids in some

pre-administration of steroids in some depending on the the bacteria that's

depending on the the bacteria that's present like strep numo in particular

present like strep numo in particular may have positive benefits not only on

may have positive benefits not only on mortality but also neurologic damage and

mortality but also neurologic damage and uh effects. Uh and so if you're going to

uh effects. Uh and so if you're going to give it, you need it's best to give it

give it, you need it's best to give it before, you know, 20 minutes before or

before, you know, 20 minutes before or at the time of and that's the way it was

at the time of and that's the way it was studied. uh and so and that drug is

studied. uh and so and that drug is dexamethasone. We do not want to

dexamethasone. We do not want to facilitate cerebral edema and so when we

facilitate cerebral edema and so when we think about which one is studied

think about which one is studied dexamethasone dexamethasone

dexamethasone dexamethasone dexamethasone it has no mineralic

dexamethasone it has no mineralic corticid activity so it won't cause

corticid activity so it won't cause plasma volume to grow up which increase

plasma volume to grow up which increase which would increase cerebral edema and

which would increase cerebral edema and then we have to administer it in the

then we have to administer it in the proper dosing and context for bacterial

proper dosing and context for bacterial menitis. Okay, if you find out that it's

menitis. Okay, if you find out that it's not then just stop it. Okay. So, there's

not then just stop it. Okay. So, there's very little harm in doing that. There's

very little harm in doing that. There's a potential benefit depending on which

a potential benefit depending on which one you're seeing. All right. Viral. And

one you're seeing. All right. Viral. And again, Craig, uh, you know, you guys

again, Craig, uh, you know, you guys just jump in.

just jump in. >> You know, if you want to add anything

>> You know, if you want to add anything else to what I've said,

else to what I've said, uh, viral and sephilitis, quite

uh, viral and sephilitis, quite honestly, is going to be hard to

honestly, is going to be hard to differentiate from a a bacterial

differentiate from a a bacterial menitis.

menitis. >> Just gonna be honest with you. You

>> Just gonna be honest with you. You sometimes don't know. It's the LP. And

sometimes don't know. It's the LP. And so I underline here they have lower

so I underline here they have lower opening pressures. Their glucose levels

opening pressures. Their glucose levels tend to be higher because the bacteria

tend to be higher because the bacteria are not utilizing those uh that and

are not utilizing those uh that and their PMN's neutrfils which are more

their PMN's neutrfils which are more bacterial are going to be lower. Those

bacterial are going to be lower. Those are the primary things that are

are the primary things that are different um that help to drive that. In

different um that help to drive that. In addition you get culture. So it's

addition you get culture. So it's asycllov at 10 to 50 milligrams per

asycllov at 10 to 50 milligrams per kilogram every eight hours. That is the

kilogram every eight hours. That is the dose.

dose. >> Okay. Um

>> Okay. Um >> yeah just to jump so again echoing some

>> yeah just to jump so again echoing some of those key points which are totally

of those key points which are totally vital. One of the elements to the

vital. One of the elements to the bacterial menitis empiric therapy is

bacterial menitis empiric therapy is that you might perceive especially in

that you might perceive especially in those uh infants so 0 to one month uh

those uh infants so 0 to one month uh age and then the elderly uh patients you

age and then the elderly uh patients you might perceive the ampean plus septraone

might perceive the ampean plus septraone or amplan plus sepotaxim as a

or amplan plus sepotaxim as a unnecessary duplicate betalactam uh in

unnecessary duplicate betalactam uh in in this situation is absolutely not. But

in this situation is absolutely not. But if you're just perceiving it on a test,

if you're just perceiving it on a test, you know, that's something that might

you know, that's something that might might come up. And then uh with a

might come up. And then uh with a cycloper, again, uh just from an

cycloper, again, uh just from an administration perspective, it actually

administration perspective, it actually requires a larger volume of saline to be

requires a larger volume of saline to be administered just to make sure there

administered just to make sure there aren't any potential complications. And

aren't any potential complications. And again, these are situations that

again, these are situations that parental is definitively preferred over

parental is definitively preferred over oral and especially in empiric

oral and especially in empiric management.

management. >> All right, cavernous sinus thrombosis.

>> All right, cavernous sinus thrombosis. And a lot of people don't think about

And a lot of people don't think about this one, but when it happens, it's a

this one, but when it happens, it's a big deal. And so they want to make sure

big deal. And so they want to make sure that you know how to treat some of these

that you know how to treat some of these things. This is basically a thrombus,

things. This is basically a thrombus, infectious thrombus. Um, and so it's

infectious thrombus. Um, and so it's seating essentially the cavernous sinus

seating essentially the cavernous sinus in your brain. Um, and so I'll show you

in your brain. Um, and so I'll show you a picture of what that looks like here

a picture of what that looks like here in a minute. But they usually come in

in a minute. But they usually come in with headaches. They can have vision

with headaches. They can have vision changes, usually dipopia, uh, papadeema.

changes, usually dipopia, uh, papadeema. They even can have uh Horner syndrome

They even can have uh Horner syndrome which is where they have this unilateral

which is where they have this unilateral um uh a facial nerve problem and they

um uh a facial nerve problem and they have lid lag and they have no ability to

have lid lag and they have no ability to sweat. It's just weird. Um but when it

sweat. It's just weird. Um but when it happens it is considered a medical

happens it is considered a medical emergency. Okay. These patients need

emergency. Okay. These patients need CTS, MRIs. if you're not sure that will

CTS, MRIs. if you're not sure that will help you diagnose it. Um and the

help you diagnose it. Um and the treatment is admission to the hospital,

treatment is admission to the hospital, IV emperic antibiotics because this is a

IV emperic antibiotics because this is a basically a kind of think of like

basically a kind of think of like endocarditis in the brain essentially

endocarditis in the brain essentially and then anti-thrombotic therapy and you

and then anti-thrombotic therapy and you may say well why would I initiate

may say well why would I initiate anti-coagulants uh this is an image uh

anti-coagulants uh this is an image uh coming from our colleagues over at EBM

coming from our colleagues over at EBM consults u and when you look at this

consults u and when you look at this cross-section of the brain so there's

cross-section of the brain so there's the critical triad and so infections

the critical triad and so infections involving the ENT ear nose and throat

involving the ENT ear nose and throat and oral fairings are high risk because

and oral fairings are high risk because of the the the lymph and the drainage

of the the the lymph and the drainage from that area goes into the cavernous

from that area goes into the cavernous sitinus. Uh and again this is the kind

sitinus. Uh and again this is the kind of the cross-section of the midbrain. Um

of the cross-section of the midbrain. Um and here's your pituitary gland. Um and

and here's your pituitary gland. Um and up here you know would be somewhere you

up here you know would be somewhere you here is your hypothalammus. But this is

here is your hypothalammus. But this is the cavernous sinus. And and you look at

the cavernous sinus. And and you look at these yellow circles area these are

these yellow circles area these are these are nerves cranial nerves going

these are nerves cranial nerves going through that area. And so if you have a

through that area. And so if you have a clot forming in that area, not only is

clot forming in that area, not only is it seeding into the blood, it's also

it seeding into the blood, it's also pressing on those nerves. And that's why

pressing on those nerves. And that's why you get the neurologic manifestations

you get the neurologic manifestations that you get. And that's why it's also

that you get. And that's why it's also considered a medical emergency and why

considered a medical emergency and why you have to give both anti-thrombotic

you have to give both anti-thrombotic agents and antiquagulants while also

agents and antiquagulants while also giving because that's not intuitive to

giving because that's not intuitive to give anti-coagulants to a infectious

give anti-coagulants to a infectious disease scenario. So that's why we do

disease scenario. So that's why we do you know consider similar things like in

you know consider similar things like in endocarditis situations. All right

endocarditis situations. All right moving on to intraabdominal infections.

moving on to intraabdominal infections. So I'm going to talk about choleiccyitis

So I'm going to talk about choleiccyitis and ascending chenitis which is a more

and ascending chenitis which is a more severe case more life-threatening

severe case more life-threatening situation. Choleiccyitis is where most

situation. Choleiccyitis is where most commonly the gall stone kind of gets it

commonly the gall stone kind of gets it stuck in the cystic duct and causes

stuck in the cystic duct and causes inflammation and it can eventually get

inflammation and it can eventually get infected and that then transverses

infected and that then transverses backwards up into the liver and can then

backwards up into the liver and can then disseminate uh into the body. They

disseminate uh into the body. They usually come in with right upper

usually come in with right upper quadrant pain. They're usually also

quadrant pain. They're usually also having some nausea, vomiting especially

having some nausea, vomiting especially in the context of eating uh because that

in the context of eating uh because that gallbladder can't contract. imaging

gallbladder can't contract. imaging done. The imaging of choice is

done. The imaging of choice is ultrasound is the best imaging modality

ultrasound is the best imaging modality for diagnosing choleiccyitis. You can

for diagnosing choleiccyitis. You can use CT scans but the underlying

use CT scans but the underlying treatment is empiric antibiotics and

treatment is empiric antibiotics and many times surgeons will allow these

many times surgeons will allow these patients to cool off

patients to cool off while the inflammation decreases so they

while the inflammation decreases so they aren't going in there and just kind of

aren't going in there and just kind of pulling on necrotic tissue. Right? If

pulling on necrotic tissue. Right? If they're unstable, they'll emerently take

they're unstable, they'll emerently take them in obviously. Um, but laparoscopic

them in obviously. Um, but laparoscopic choleiccasectomy is the treatment

choleiccasectomy is the treatment underlying treatment of choice. But

underlying treatment of choice. But emperically, you're thinking about

emperically, you're thinking about intraabdominal emperic antibiotics, your

intraabdominal emperic antibiotics, your pipaso, erdipenum or something like

pipaso, erdipenum or something like cypro levo plus metronazol to get those

cypro levo plus metronazol to get those anorob coverage. Now ascending colonitis

anorob coverage. Now ascending colonitis this is now where the bacteria have now

this is now where the bacteria have now gone proximal up into the liver into the

gone proximal up into the liver into the bilary tree of the liver prankma usually

bilary tree of the liver prankma usually again resulting uh it's more severe and

again resulting uh it's more severe and these patients look sick and they can

these patients look sick and they can literally be dead within hours if you

literally be dead within hours if you don't aggressively treat these patients.

don't aggressively treat these patients. Um they usually come in with alter

Um they usually come in with alter mental status. They usually meet all the

mental status. They usually meet all the criteria for sepsis. um they already

criteria for sepsis. um they already have abnormal labs. They're they're very

have abnormal labs. They're they're very concerning perulent bile uh when they go

concerning perulent bile uh when they go in there and these patients end up

in there and these patients end up needing basically a procedure to one

needing basically a procedure to one open up the tube to drain all that pus

open up the tube to drain all that pus out of there, get rid of any stones that

out of there, get rid of any stones that are in the way and then try to clear

are in the way and then try to clear that tract and sometimes they even need

that tract and sometimes they even need a drain in place uh that stays in. And

a drain in place uh that stays in. And so again, until you can get them to the

so again, until you can get them to the O, it is empiric antibiotics, but

O, it is empiric antibiotics, but there's no delays in this situation.

there's no delays in this situation. You're not going to sit on them and let

You're not going to sit on them and let them cool off. They are getting an ERCP

them cool off. They are getting an ERCP uh emerently. Okay. Um and so start them

uh emerently. Okay. Um and so start them on something that will provide anorob

on something that will provide anorob coverage and then obviously

coverage and then obviously intraabdominal flora gram negative bugs.

intraabdominal flora gram negative bugs. Moving on to appendicitis. The appendix

Moving on to appendicitis. The appendix is this little finger-like projection in

is this little finger-like projection in the right lower quadrant of the abdomen.

the right lower quadrant of the abdomen. And when it gets blocked or clogged up,

And when it gets blocked or clogged up, that swelling and inflammation can

that swelling and inflammation can basically prevent uh blood supply to

basically prevent uh blood supply to that area. Um and because the colon and

that area. Um and because the colon and that area has a lot of bacteria, uh it

that area has a lot of bacteria, uh it can get infected. And so that can

can get infected. And so that can eventually cause not only eskeeia

eventually cause not only eskeeia to the tissue where the tissue dies and

to the tissue where the tissue dies and necrosis, but it can get infected and

necrosis, but it can get infected and then rupture. And if it ruptures then

then rupture. And if it ruptures then obviously you can develop peritonitis

obviously you can develop peritonitis where all those contents dump out into

where all those contents dump out into the peritineal space. So these patients

the peritineal space. So these patients usually come in uh with right lower

usually come in uh with right lower quadrant pain. It's rebound tenderness.

quadrant pain. It's rebound tenderness. So when we push down, let go, the

So when we push down, let go, the vibration or the bouncing effect of the

vibration or the bouncing effect of the appendix causes it to hurt. Um, if your

appendix causes it to hurt. Um, if your exam is not clear, you're not sure,

exam is not clear, you're not sure, there are some scales or risk

there are some scales or risk ratification tools that you can use, but

ratification tools that you can use, but quite honestly, uh, CT scan with

quite honestly, uh, CT scan with contrast is going to be necessary to

contrast is going to be necessary to help you with the diagnosis or if you're

help you with the diagnosis or if you're such high clinical suspicion, then you

such high clinical suspicion, then you just do send them the surgery. Um and

just do send them the surgery. Um and most of the time if the surgeon is that

most of the time if the surgeon is that high also concerned there's no need to

high also concerned there's no need to radiate the patient especially a

radiate the patient especially a pediatric patient with a lot of

pediatric patient with a lot of radiation um and you will send them to

radiation um and you will send them to the O um but obviously it's an invasive

the O um but obviously it's an invasive procedure now again just like with the

procedure now again just like with the choleiccyitis if the patient is stable

choleiccyitis if the patient is stable emperic antibiotics actually may be the

emperic antibiotics actually may be the treatment there's new emerging evidence

treatment there's new emerging evidence that is coming out and there are more

that is coming out and there are more providers doing this but from a board

providers doing this but from a board example perspective, it is a lap uh lap

example perspective, it is a lap uh lap laparoscopic appendecttomy. Um but just

laparoscopic appendecttomy. Um but just so you know, emperic antibiotics are

so you know, emperic antibiotics are started and that helps to kind of cool

started and that helps to kind of cool off if you will that tissue and again

off if you will that tissue and again very similar treatments to cholyis.

very similar treatments to cholyis. Now Dr. Boland uh very nicely brought up

Now Dr. Boland uh very nicely brought up the fact that inappropriate antibiotic

the fact that inappropriate antibiotic use can lead to complications and one of

use can lead to complications and one of those is CIFF and where the we form

those is CIFF and where the we form these toxins um and that then irritates

these toxins um and that then irritates and disrupts basically the junctions in

and disrupts basically the junctions in the intestinal flora uh and I'm sorry

the intestinal flora uh and I'm sorry the bowel integrity resulting in

the bowel integrity resulting in inflammation and irritation and it can

inflammation and irritation and it can also weaken that bowel to where they can

also weaken that bowel to where they can even perforate the bowel and now again

even perforate the bowel and now again you have a perforation that leads to

you have a perforation that leads to peritonitis that leads to disseminated

peritonitis that leads to disseminated ated infection. So these patients

ated infection. So these patients usually come in with fever, very watery,

usually come in with fever, very watery, uh diarrhea that's not usually bloody

uh diarrhea that's not usually bloody like you would see an ulcerative or

like you would see an ulcerative or Crohn's disease, ulcerative colitis,

Crohn's disease, ulcerative colitis, Crohn's disease, abdominal pain and

Crohn's disease, abdominal pain and fever, and usually have a history of

fever, and usually have a history of having been um

having been um uh on an antibiotic. So you can do stool

uh on an antibiotic. So you can do stool studies and check for this and that can

studies and check for this and that can help guide the diagnosis and then your

help guide the diagnosis and then your treatment oral venkcomy or fedaxomy and

treatment oral venkcomy or fedaxomy and it's for at least 10 days. That's the

it's for at least 10 days. That's the most common recommendation. Now

most common recommendation. Now everybody wants to jump to fidaxomy.

everybody wants to jump to fidaxomy. There's even some leaning in some of the

There's even some leaning in some of the guidelines depending on which one you

guidelines depending on which one you follow. Uh then it maybe is a little bit

follow. Uh then it maybe is a little bit more preferred. Problem is that stuff's

more preferred. Problem is that stuff's expensive like crazy expensive. Um I

expensive like crazy expensive. Um I don't know Dr. Cooko or Bolan if you

don't know Dr. Cooko or Bolan if you have any comments or you want to add

have any comments or you want to add anything in here. Uh but obviously this

anything in here. Uh but obviously this has changed where back in the day it was

has changed where back in the day it was metroniditool first but we will reserve

metroniditool first but we will reserve metroniditool

metroniditool really for severe cases.

really for severe cases. >> Yeah absolutely I mean piocomy you know

>> Yeah absolutely I mean piocomy you know although it can be compounded you can

although it can be compounded you can actually get it fairly inexpensively

actually get it fairly inexpensively outpatient if you can get to a

outpatient if you can get to a compounding pharmacy. So again to fidoxy

compounding pharmacy. So again to fidoxy discredit not necessarily clinically but

discredit not necessarily clinically but like costwise the patient I mean they're

like costwise the patient I mean they're just not going to be able to pick out

just not going to be able to pick out the prescription. So that's your

the prescription. So that's your rational choice. The other caveat again

rational choice. The other caveat again for metronidazol if uh there's a patient

for metronidazol if uh there's a patient with you know hospitalized with cediff

with you know hospitalized with cediff colitis um technically again this is not

colitis um technically again this is not an ivo conversion I would consider

an ivo conversion I would consider making because the parental is actually

making because the parental is actually going to get better uh colon uh I guess

going to get better uh colon uh I guess penetration than the than the po

penetration than the than the po metronidazol. So in those scenarios

metronidazol. So in those scenarios those are actually somewhat rational to

those are actually somewhat rational to actually consider the preferred parental

actually consider the preferred parental meisle.

meisle. >> Perfect. And you know fecal transplant

>> Perfect. And you know fecal transplant really are going to come after they

really are going to come after they failed essentially three rounds of one

failed essentially three rounds of one of those treatments. So if they're not

of those treatments. So if they're not responding then that's where you would

responding then that's where you would you know sort of give that

you know sort of give that consideration. Diverticulitis.

consideration. Diverticulitis. Well, this is basically patients with

Well, this is basically patients with diverticuli,

diverticuli, which is just think of it as, you know,

which is just think of it as, you know, in the colon you have a weakness in the

in the colon you have a weakness in the wall and you have a little out pouch

wall and you have a little out pouch diverticuli that can get filled with

diverticuli that can get filled with feces and other things and that can

feces and other things and that can basically cause bacterial overgrowth.

basically cause bacterial overgrowth. Uh, it can irritate it, get inflamed. It

Uh, it can irritate it, get inflamed. It causes left usually left lower quadrant

causes left usually left lower quadrant pain. But that just like anything else,

pain. But that just like anything else, it can perforate. And I've seen

it can perforate. And I've seen diverticulitis get perforated. I can

diverticulitis get perforated. I can also I've also seen patients develop um

also I've also seen patients develop um abscesses and so you have to do a work

abscesses and so you have to do a work up and consider this in these patients

up and consider this in these patients and usually it's a CT scan with IV

and usually it's a CT scan with IV contrast uh to help you to identify that

contrast uh to help you to identify that because if they have an abscess in place

because if they have an abscess in place you're still going to start them on

you're still going to start them on empiric antibiotics again many of them

empiric antibiotics again many of them similar to what we would use for other

similar to what we would use for other intraabdominal infections so you're

intraabdominal infections so you're seeing a trend so that hopefully makes

seeing a trend so that hopefully makes it easier to remember um but if they

it easier to remember um but if they have an abscess they have to be admitted

have an abscess they have to be admitted to the hospital and they're going to

to the hospital and they're going to have to maybe even have s perccutaneous

have to maybe even have s perccutaneous drainage of that abscess or they're

drainage of that abscess or they're never going to get better. Um, and

never going to get better. Um, and certainly if they have a bowel

certainly if they have a bowel perforation, they may even need to have

perforation, they may even need to have surgical resection uh of that. You can

surgical resection uh of that. You can get away with outpatient treatment and

get away with outpatient treatment and that's usually with augmentin or a

that's usually with augmentin or a moxicone with clavionic acid in those

moxicone with clavionic acid in those patients. You can also do oral se

patients. You can also do oral se cyproloxin with metronazol in those

cyproloxin with metronazol in those patients again that don't have evidence

patients again that don't have evidence of an abscess or don't look toxic uh in

of an abscess or don't look toxic uh in those situations. Hernas

those situations. Hernas uh basically tissue in the wrong spot.

uh basically tissue in the wrong spot. And when we think about it with uh

And when we think about it with uh intestine uh you got to make sure that

intestine uh you got to make sure that it's not strangulated. So there's

it's not strangulated. So there's incarcerated and then there's

incarcerated and then there's strangulation. And sometimes you need a

strangulation. And sometimes you need a CT scan to help you. But quite honestly,

CT scan to help you. But quite honestly, if it's strangulated, nothing's passing

if it's strangulated, nothing's passing by and the tissue is essentially dying.

by and the tissue is essentially dying. So, you either manually treat it by

So, you either manually treat it by pushing it back in. There's all these

pushing it back in. There's all these maneuvers that you can do like, you

maneuvers that you can do like, you know, make them not in a gravity

know, make them not in a gravity dependent position. Uh you may gently

dependent position. Uh you may gently put on there. Some people apply ice or

put on there. Some people apply ice or cold therapy. Um and you give anti- uh

cold therapy. Um and you give anti- uh analesics and anti-imetic therapies. But

analesics and anti-imetic therapies. But if it's strangulated, they're going to

if it's strangulated, they're going to and you can't get it back in, that is a

and you can't get it back in, that is a surgical emergency because the bowel is

surgical emergency because the bowel is going to die. So you have to send them

going to die. So you have to send them to the O. All right, moving on to ENT,

to the O. All right, moving on to ENT, ear, nose, and throat. Mastoid ititis.

ear, nose, and throat. Mastoid ititis. The mastoid bone is right here. Okay,

The mastoid bone is right here. Okay, behind your ear. Okay, behind your ear.

behind your ear. Okay, behind your ear. So mastoiditis most commonly

So mastoiditis most commonly um gets results from ear infections that

um gets results from ear infections that were untreated properly. Okay. Or left

were untreated properly. Okay. Or left untreated. Um so the masoid bone got

untreated. Um so the masoid bone got these little air cells and the basically

these little air cells and the basically the bacteria migrates through the bone

the bacteria migrates through the bone and gets into there and you're going to

and gets into there and you're going to have to actually need surgical opening

have to actually need surgical opening and drainage of that part of your skull

and drainage of that part of your skull otherwise you will form an abscess in

otherwise you will form an abscess in your brain.

your brain. So the onset typically occurs again

So the onset typically occurs again after an otitis media and many times on

after an otitis media and many times on exam their ear will stick out like this

exam their ear will stick out like this because of the swelling and the pressure

because of the swelling and the pressure coming from behind. So you look at them

coming from behind. So you look at them headon and their oracle of the ear is

headon and their oracle of the ear is deviated forward. If you press on the

deviated forward. If you press on the mastoid bone, it hurts. Um, and it's

mastoid bone, it hurts. Um, and it's very tender and many times you need a CT

very tender and many times you need a CT scan to help to verify it or at least

scan to help to verify it or at least the otoarangologist who's going to

the otoarangologist who's going to possibly do the surgery is going to need

possibly do the surgery is going to need that. But it's uh venkcomy plus

that. But it's uh venkcomy plus septraxone

septraxone very similar to you know menitis or

very similar to you know menitis or unison or amplanactam.

unison or amplanactam. Again Dr. Uh, Kokoyo, I mean if you guys

Again Dr. Uh, Kokoyo, I mean if you guys anybody has any addition to this,

anybody has any addition to this, please, you know, just jump in.

please, you know, just jump in. >> All right. Otitus externa. Sorry. Go

>> All right. Otitus externa. Sorry. Go ahead. Did you have something?

ahead. Did you have something? >> No. Yeah. No, nothing on that one.

>> No. Yeah. No, nothing on that one. >> All right. So, otitis externa and otitis

>> All right. So, otitis externa and otitis media. It's the location. They're both

media. It's the location. They're both ear infections. Otitis externa is the

ear infections. Otitis externa is the external portion of the ear, ear canal.

external portion of the ear, ear canal. Okay. So, it's basically uh not a middle

Okay. So, it's basically uh not a middle ear infection. Okay. And we usually call

ear infection. Okay. And we usually call that swimmer's ear.

that swimmer's ear. Um, and it usually causes a lot amount

Um, and it usually causes a lot amount of pain because the ear canal gets very

of pain because the ear canal gets very adeous and it can olude, it can trap

adeous and it can olude, it can trap fluids in there, ear wax, and then

fluids in there, ear wax, and then obviously it can get infected and it's

obviously it can get infected and it's not far away from the mastoid bone

not far away from the mastoid bone itself. Uh, but you can't almost even

itself. Uh, but you can't almost even pull on the ear without them wanting to

pull on the ear without them wanting to punch you. So, I mean, if you grab the

punch you. So, I mean, if you grab the ear and they come unglued, that's

ear and they come unglued, that's largely a diagnosis. You can almost even

largely a diagnosis. You can almost even just look to the side and see that the

just look to the side and see that the ear canal is swollen shut uh in these

ear canal is swollen shut uh in these patients. So it is ear drops. Okay. Um

patients. So it is ear drops. Okay. Um and analesia. So um the odic antibiotics

and analesia. So um the odic antibiotics are the ear drops and you have them, you

are the ear drops and you have them, you know, lay on the opposite side and you

know, lay on the opposite side and you apply those ear drops. You want to try

apply those ear drops. You want to try to manipulate and massage it so that it

to manipulate and massage it so that it gets down into the ear canal and you

gets down into the ear canal and you want it to sit there for at least 15

want it to sit there for at least 15 minutes so that it doesn't you know just

minutes so that it doesn't you know just sit right up and it just drains right

sit right up and it just drains right back out. Now the ear drops that you use

back out. Now the ear drops that you use like if you're going to use cyproex or

like if you're going to use cyproex or something like that u then you want to

something like that u then you want to make sure you're considering sudamonus

make sure you're considering sudamonus in certain patients. So those are your

in certain patients. So those are your diabetics and imuninompromised where

diabetics and imuninompromised where these patients have malignant otitis

these patients have malignant otitis externa uh because of their increased

externa uh because of their increased risk of infections. Now, this is an

risk of infections. Now, this is an antimicrobial stewardship one. I'm going

antimicrobial stewardship one. I'm going to let Dr. Bolan jump in here in a

to let Dr. Bolan jump in here in a minute if she has any comments, but this

minute if she has any comments, but this is one that's also overtreated um a lot

is one that's also overtreated um a lot like bronchitis. Uh this is a middle ear

like bronchitis. Uh this is a middle ear infection. Now, itis with a fusion just

infection. Now, itis with a fusion just means that somebody has fluid in the

means that somebody has fluid in the inner ear. That fluid doesn't

inner ear. That fluid doesn't necessarily mean it's infected. So, what

necessarily mean it's infected. So, what do you need to see? Well, you need to

do you need to see? Well, you need to see usually an injected red swollen eard

see usually an injected red swollen eard drum. Okay? Many many times it's it's

drum. Okay? Many many times it's it's ruptured. You'll see pus literally just

ruptured. You'll see pus literally just draining out of it like coming out of

draining out of it like coming out of the ear. Um and that's a slam dunk. You

the ear. Um and that's a slam dunk. You don't need to be a physician or provider

don't need to be a physician or provider like that to figure that out. I mean

like that to figure that out. I mean straightforward. Now vomiting sometimes

straightforward. Now vomiting sometimes happens because of pressure in the inner

happens because of pressure in the inner ear basically causing vertigo. Um so I

ear basically causing vertigo. Um so I see that a lot. Why is that matter?

see that a lot. Why is that matter? Because if you got a patient who's

Because if you got a patient who's vomiting, are you going to prescribe

vomiting, are you going to prescribe them or pick the answer choice that's an

them or pick the answer choice that's an oral option?

oral option? No. Right. Pick the dosage formulation

No. Right. Pick the dosage formulation that applies to your patient. parental

that applies to your patient. parental is probably going to be your best option

is probably going to be your best option because I want to ensure especially if

because I want to ensure especially if it's a kid that's vomiting and it's one

it's a kid that's vomiting and it's one o'clock in the morning in the emergency

o'clock in the morning in the emergency department that they're g and there's

department that they're g and there's noies open or whatever that they're

noies open or whatever that they're going to get their treatment and it's

going to get their treatment and it's going to carry them for 24 hours and I

going to carry them for 24 hours and I don't have to worry about them vomiting

don't have to worry about them vomiting it up. They may not like me after it but

it up. They may not like me after it but they're going to be treated right. So u

they're going to be treated right. So u again the air exam is the thing. Now,

again the air exam is the thing. Now, if you decide that this patient meets

if you decide that this patient meets criteria because there is a set of rules

criteria because there is a set of rules that you can consider for 72-hour

that you can consider for 72-hour observation because many times ear

observation because many times ear infections are self-limiting. If you do

infections are self-limiting. If you do nothing, they go away.

nothing, they go away. Okay, that's why it's an antimicrobial

Okay, that's why it's an antimicrobial stewardship topic.

stewardship topic. If you have patient who's, you know,

If you have patient who's, you know, febrile, starting to have nausea or, you

febrile, starting to have nausea or, you know, doesn't look well and you can see

know, doesn't look well and you can see it's very obvious. I mean, you're going

it's very obvious. I mean, you're going to treat those patients if they're less

to treat those patients if they're less than two years old. You're going to

than two years old. You're going to treat those patients. It's the it's the

treat those patients. It's the it's the stable patient who's like, yeah, I can't

stable patient who's like, yeah, I can't really tell. Maybe why don't you just go

really tell. Maybe why don't you just go home, call me back if you get worse. If

home, call me back if you get worse. If you decide you do it, then your their

you decide you do it, then your their first drug of choice is amoxicylid and

first drug of choice is amoxicylid and it's at appropriate doses 40 to 45

it's at appropriate doses 40 to 45 milligrams per kilogram twice a day.

milligrams per kilogram twice a day. Okay, at the high dose to penetrate the

Okay, at the high dose to penetrate the air. If you fail or don't improve after

air. If you fail or don't improve after really that 48 hour window, then you

really that 48 hour window, then you need to switch them probably to augment

need to switch them probably to augment or axilla clabulonic again at 40 to 45

or axilla clabulonic again at 40 to 45 milligrams per kilo. If that doesn't

milligrams per kilo. If that doesn't fail or they're vomiting,

fail or they're vomiting, then it's septra and it may require

then it's septra and it may require repeated doses. So that's come back in

repeated doses. So that's come back in the clinic and get a repeated shot. All

the clinic and get a repeated shot. All right,

right, Dr. Bolan, any comments here?

Dr. Bolan, any comments here? >> Yeah, I think you hit it. The most

>> Yeah, I think you hit it. The most important one is the watchful waiting um

important one is the watchful waiting um or the delayed prescribing, whichever,

or the delayed prescribing, whichever, you know, whichever one you want to

you know, whichever one you want to consider. Um, and it's interesting

consider. Um, and it's interesting because if you look at some data,

because if you look at some data, parents will actually listen to you and

parents will actually listen to you and do that. Um, if you explain to them, you

do that. Um, if you explain to them, you know, kind of what Dr. Busty was saying

know, kind of what Dr. Busty was saying and, you know, the, you know, the

and, you know, the, you know, the severity of it, that it will resolve,

severity of it, that it will resolve, uh, that there can be risks and things

uh, that there can be risks and things with using the antibiotics. A lot of

with using the antibiotics. A lot of times they will listen to you and they

times they will listen to you and they will wait and a lot of times they they

will wait and a lot of times they they will resolve. And if you give them the

will resolve. And if you give them the tools, then you know they're they're

tools, then you know they're they're willing to wait it out and they can

willing to wait it out and they can choose to go get it, you know, if the

choose to go get it, you know, if the patient gets worse. But if you've got

patient gets worse. But if you've got severe uh under two, bilateral, those

severe uh under two, bilateral, those types of things, then you're going to go

types of things, then you're going to go ahead and treat it. Uh and then the

ahead and treat it. Uh and then the dosing is important, too. You know,

dosing is important, too. You know, don't mess around with that and give

don't mess around with that and give them the the lower dose because that's

them the the lower dose because that's not that's not going to cut it there.

not that's not going to cut it there. >> Yeah. And this is

>> Yeah. And this is >> another important principle that kind of

>> another important principle that kind of wraps into that as well is thinking

wraps into that as well is thinking about vaccination. Vaccination is an

about vaccination. Vaccination is an important antimicrobial stewardship um

important antimicrobial stewardship um principle. So the amount of strep numo

principle. So the amount of strep numo that we've seen with otitis has really

that we've seen with otitis has really decreased since 2000 when the uh PCB

decreased since 2000 when the uh PCB vaccine started coming out. So strep

vaccine started coming out. So strep numo's really decreased. It's more H

numo's really decreased. It's more H flu. you still see some strep numo uh

flu. you still see some strep numo uh but you see a lot more um H flu as far

but you see a lot more um H flu as far as positive organisms for otitis media.

as positive organisms for otitis media. So that's an important principle when

So that's an important principle when you have it available um to help reduce

you have it available um to help reduce the need for antibiotic use and

the need for antibiotic use and >> resistance.

>> resistance. >> Absolutely.

>> Absolutely. >> All right. So guys, the again the dose

>> All right. So guys, the again the dose for those of you that may not have got

for those of you that may not have got that it's the whether it's augmentin or

that it's the whether it's augmentin or regular amoxicylin it's at a dose of 40

regular amoxicylin it's at a dose of 40 to 45 milligrams per kilogram per dose

to 45 milligrams per kilogram per dose dose twice a day. So 90 milligrams per

dose twice a day. So 90 milligrams per kilogram per day divided by two. All

kilogram per day divided by two. All right. So it's it's really important if

right. So it's it's really important if you're going to use it use it correctly.

you're going to use it use it correctly. All right. Sinocitis. Another one of

All right. Sinocitis. Another one of those antimicrobial stewardship ones.

those antimicrobial stewardship ones. Again, this is where we typically have

Again, this is where we typically have some sort of blockage of drainage and

some sort of blockage of drainage and you got a warm, dark, moist environment

you got a warm, dark, moist environment that allows for secondary bacterial

that allows for secondary bacterial overgrowth. They come in with sinus

overgrowth. They come in with sinus tenderness. So, you have your frontal

tenderness. So, you have your frontal sinuses, your sppheninoid, nethmoid

sinuses, your sppheninoid, nethmoid sinuses, your maxillary sinuses that are

sinuses, your maxillary sinuses that are the most likely to cause this. And when

the most likely to cause this. And when you palpate them, uh they can be tender.

you palpate them, uh they can be tender. So if they have facial pain or if you

So if they have facial pain or if you see swelling of the uh sinuses or

see swelling of the uh sinuses or they're starting to have perorbital

they're starting to have perorbital puffiness that is concerning especially

puffiness that is concerning especially in the context of a fever um and they

in the context of a fever um and they starting to look a little toxic because

starting to look a little toxic because again what's not far away from the

again what's not far away from the sinuses

the brain right no different than the ear. We got the mastoid you can get

ear. We got the mastoid you can get infections in the ear. So we we don't

infections in the ear. So we we don't want to just ignore it but we want to be

want to just ignore it but we want to be careful

careful uh that we're using it appropriately

uh that we're using it appropriately right and when we do it. So again for

right and when we do it. So again for the stable non sick patient really we

the stable non sick patient really we should treat no no antibiotics until

should treat no no antibiotics until their symptoms have gone beyond 10 days.

their symptoms have gone beyond 10 days. However, if their symptoms are more

However, if their symptoms are more severe, you got the facial swelling,

severe, you got the facial swelling, tenderness, fever, they're not looking

tenderness, fever, they're not looking good, then that patient, especially if

good, then that patient, especially if they have other coorbidities, risk

they have other coorbidities, risk factors, then we need to consider that.

factors, then we need to consider that. Dr. Boland, anything else on this one

Dr. Boland, anything else on this one since it's an antimicrobial stewardship?

since it's an antimicrobial stewardship? >> No, I don't think so. I think the other

>> No, I don't think so. I think the other things that we've talked about, you

things that we've talked about, you know, really hit this, you using the

know, really hit this, you using the right antibiotics as well. And so with a

right antibiotics as well. And so with a lot of these infections, sinusitis,

lot of these infections, sinusitis, otitis, um

otitis, um even pneumonia, we tend to, you know, go

even pneumonia, we tend to, you know, go to what's easy. You know, we'll go to

to what's easy. You know, we'll go to the floricquinolons. That's not with

the floricquinolons. That's not with kids, but you know, with adults,

kids, but you know, with adults, especially in thinking about sinocitis,

especially in thinking about sinocitis, you'll go to a floricquinolone because

you'll go to a floricquinolone because it's it just seems easy, but they carry

it's it just seems easy, but they carry a lot of adverse effects. So just using

a lot of adverse effects. So just using the correct things. So your augmenting

the correct things. So your augmenting for your sinusitis, your moxicylin for

for your sinusitis, your moxicylin for your otitis. Um that's really really

your otitis. Um that's really really important and will reduce the risk of

important and will reduce the risk of problems and things like that.

problems and things like that. >> Yep. Sorry, I was just checking the

>> Yep. Sorry, I was just checking the timer and uh we are clearly at the

timer and uh we are clearly at the twohour mark. Um and I'm not done.

twohour mark. Um and I'm not done. So um I will uh I'm happy to continue.

So um I will uh I'm happy to continue. Uh, but we actually I can't remember. I

Uh, but we actually I can't remember. I think we still have

think we still have maybe potentially up to 30 more minutes.

maybe potentially up to 30 more minutes. So,

So, um, I'm going to just field a few

um, I'm going to just field a few questions real quick here because the

questions real quick here because the way it was advertised that we would be

way it was advertised that we would be done. So, I'm sorry. Hopefully, this is

done. So, I'm sorry. Hopefully, this is helpful. Hopefully, it's not. Um, any

helpful. Hopefully, it's not. Um, any I'm gonna I was going to keep going. Is

I'm gonna I was going to keep going. Is there anybody and you can just type in

there anybody and you can just type in No one's going to see your name or any

No one's going to see your name or any of that kind of stuff.

of that kind of stuff. Do you anybody got any questions or it

Do you anybody got any questions or it need to go? U happy to pause for a

need to go? U happy to pause for a second and answer questions. If you want

second and answer questions. If you want me to keep going, you can certainly just

me to keep going, you can certainly just stay on and drop off as you will.

stay on and drop off as you will. Anybody? Okay.

Anybody? Okay. Uh so there's a question about what is

Uh so there's a question about what is left shift mean? So when you look at a

left shift mean? So when you look at a CBC which is a lab obviously your

CBC which is a lab obviously your complete uh blood count you'll get a

complete uh blood count you'll get a white blood cell count and then they do

white blood cell count and then they do a differential with it and with that

a differential with it and with that differential they will break down the

differential they will break down the neutrifils and the basopils and the

neutrifils and the basopils and the lymphosytes and all these things. Um,

lymphosytes and all these things. Um, and

and uh, if you see a shift to the left, it

uh, if you see a shift to the left, it has to do with the way it's normally and

has to do with the way it's normally and historically

historically presented where the neutrfils are

presented where the neutrfils are usually on the left side and the the um,

usually on the left side and the the um, uh, bands are over there as well. And so

uh, bands are over there as well. And so if there's a movement towards the left,

if there's a movement towards the left, then it's called a left shift and it

then it's called a left shift and it usually is indicative of a bacterial

usually is indicative of a bacterial infection. Um

infection. Um and so okay we're getting some just

and so okay we're getting some just positive feedback so I appreciate that.

positive feedback so I appreciate that. Um there this will be posted for our

Um there this will be posted for our customers. Uh so if you have an account

customers. Uh so if you have an account it will be in your account and you will

it will be in your account and you will have access to it. So yes um we are not

have access to it. So yes um we are not posting the slides. I think you have

posting the slides. I think you have access if you're our customer uh you

access if you're our customer uh you have the rapid review ebook that has the

have the rapid review ebook that has the fulllength

fulllength information about each of these topics

information about each of these topics there for you. Again, you you have to be

there for you. Again, you you have to be a customer for those. Um the recording

a customer for those. Um the recording will not be available tonight.

will not be available tonight. Okay. Um so there's a question or

Okay. Um so there's a question or comment here. Um

All right. So, there's a question about can we ask the future or we ask speakers

can we ask the future or we ask speakers to wear a mic

to wear a mic uh to hear? I guess maybe you guys

uh to hear? I guess maybe you guys aren't picking up some people more than

aren't picking up some people more than another. Okay, I appreciate that.

another. Okay, I appreciate that. Uh,

okay. Uh, moving on. So, why does hypertonic saline infusions cause

hypertonic saline infusions cause hypocalemia?

Um, so

Dr. Kokio. Does that I I'm not familiar. I don't really

I don't really sure

sure >> that that's a common thing.

>> that that's a common thing. Um,

Um, I've not heard that. I've never heard

I've not heard that. I've never heard that.

that. triccyclic uh antipressant o overdose. I

triccyclic uh antipressant o overdose. I mean I've never seen that. I mean they

mean I've never seen that. I mean they have acidbased disturbances.

have acidbased disturbances. >> The only one I could think of I mean

>> The only one I could think of I mean that's technically hypertonic. It's

that's technically hypertonic. It's sodium bicarbonate like you could cause

sodium bicarbonate like you could cause hypocalia with that but uh not sodium

hypocalia with that but uh not sodium chloride hypertonic.

chloride hypertonic. >> Okay. Yeah. So I'm not sure about that.

>> Okay. Yeah. So I'm not sure about that. Um new uh guidelines for CIFF is fedaxy

Um new uh guidelines for CIFF is fedaxy but if the patient can't afford it uh do

but if the patient can't afford it uh do you start venko or flagagile? Venkcomy

you start venko or flagagile? Venkcomy would be the next

would be the next uh best answer. Um I'll just say that

uh best answer. Um I'll just say that probably on the board exam they're going

probably on the board exam they're going to give you a clear scenario.

to give you a clear scenario. You know

You know >> they're not going to make you have to

>> they're not going to make you have to assume or the pay you're going to afford

assume or the pay you're going to afford it or whatever the right answer will be

it or whatever the right answer will be there. They're not going to put both.

there. They're not going to put both. there's going to be some reason if they

there's going to be some reason if they put both there's going to be a reason

put both there's going to be a reason they want you to pick one over the other

they want you to pick one over the other and it probably is going to be cost or

and it probably is going to be cost or access.

access. Um,

okay. So, there's just positive com I'm just reading through these comments

just reading through these comments though. Um,

though. Um, there's a lot of positive comments. I

there's a lot of positive comments. I know you guys can't see them. We're just

know you guys can't see them. We're just reading through them here. Something

reading through them here. Something about shift of electrolytes due to

about shift of electrolytes due to electrical neutrality.

electrical neutrality. Oh, that was that it's the same guy

Oh, that was that it's the same guy asking the question. So, I don't So,

asking the question. So, I don't So, first of all, that's not a board exam um

first of all, that's not a board exam um concept. I mean, you're not going to get

concept. I mean, you're not going to get tested on that. Period. That ain't going

tested on that. Period. That ain't going to happen. Um, and that's not a common

to happen. Um, and that's not a common clinical scenario. There's so many

clinical scenario. There's so many variables that weigh in. If you're using

variables that weigh in. If you're using hypertonic saline,

hypertonic saline, you probably have other issues going on

you probably have other issues going on as well that confound that. I'm not

as well that confound that. I'm not trying to I'm not trying to push it to

trying to I'm not trying to push it to the side, but it's just not a board exam

the side, but it's just not a board exam topic.

topic. >> Yeah.

>> Yeah. >> And that's what we're about uh tonight.

>> And that's what we're about uh tonight. So, what is the fluid of choice for DKA

So, what is the fluid of choice for DKA and HHS? I've read LR may be more

and HHS? I've read LR may be more preferred to NS products.

preferred to NS products. Well,

Well, you I mean you can use Dr. Koko. I don't

you I mean you can use Dr. Koko. I don't know. Do you want to jump in since I

know. Do you want to jump in since I >> Yeah, I mean no for sure. I mean,

>> Yeah, I mean no for sure. I mean, hypothetically, yes. I I mean, in my

hypothetically, yes. I I mean, in my clinical experience, I prefer LR or like

clinical experience, I prefer LR or like a balanced crystalalloid. Um, but uh

a balanced crystalalloid. Um, but uh from an evidence-based perspective and

from an evidence-based perspective and from a guideline perspective and then

from a guideline perspective and then from a board exam question perspective,

from a board exam question perspective, I don't think they could legitimately

I don't think they could legitimately say one is better than the other and

say one is better than the other and make you select one over the other.

make you select one over the other. What's going to matter, Jennifer, is

What's going to matter, Jennifer, is that they're going to you're going to

that they're going to you're going to use a crystaloid of some sort like

use a crystaloid of some sort like normal probably 0.9% normal second

normal probably 0.9% normal second because it's the least controversial

because it's the least controversial and you're going to uh switch it to D5

and you're going to uh switch it to D5 NS or half NS.

NS or half NS. >> Yeah. Um, and you're at that point when

>> Yeah. Um, and you're at that point when they get around 250 milligrams per

they get around 250 milligrams per deciliter and you're going to continue

deciliter and you're going to continue the IV uh uh insulin drip until their

the IV uh uh insulin drip until their gap closes. Period.

gap closes. Period. >> And you're going to keep that glucose up

>> And you're going to keep that glucose up in that 180 to 200 window until it does.

in that 180 to 200 window until it does. You're not trying to drop numbers here

You're not trying to drop numbers here quickly. And remember, just so you guys

quickly. And remember, just so you guys know, when you have an insulin drip,

know, when you have an insulin drip, you're not trying to just take them from

you're not trying to just take them from four or 500 milligrams per deciliter to

four or 500 milligrams per deciliter to 250 in an hour. That is not appropriate

250 in an hour. That is not appropriate at all. And if you do that, you have no

at all. And if you do that, you have no concept or understanding of the

concept or understanding of the underlying pathophysiology.

underlying pathophysiology. You are trying to steadily bring down

You are trying to steadily bring down the glucose at about 50 to 80 milligrams

the glucose at about 50 to 80 milligrams per deciliter per hour.

per deciliter per hour. That is the average recommended

That is the average recommended reduction. And because you're reversing

reduction. And because you're reversing biochemistry,

biochemistry, you're not treating a number. You're

you're not treating a number. You're treating a pathology.

treating a pathology. Very different mindset.

Very different mindset. >> Okay.

>> Okay. Um if recurrenc do you start bank uh

Um if recurrenc do you start bank uh Fedaxo for 10 days or 14 days? Probably

Fedaxo for 10 days or 14 days? Probably 14 days.

14 days. So the discrepancy comes from what the

So the discrepancy comes from what the manufacturers say versus the guidelines.

manufacturers say versus the guidelines. >> Remember guidelines are influenced by

>> Remember guidelines are influenced by the interpretation of a committee of

the interpretation of a committee of select number of people. You change that

select number of people. You change that committee around you can get another

committee around you can get another different recommendation. So guidelines

different recommendation. So guidelines are guides. They're not absolutes.

are guides. They're not absolutes. So you will the boards are not going to

So you will the boards are not going to get into this. We're talking about

get into this. We're talking about minutiae here. Clinical ifs, stats, the

minutiae here. Clinical ifs, stats, the others. That is not a board question.

others. That is not a board question. Board questions have to be very clear,

Board questions have to be very clear, standard of practice and well defined in

standard of practice and well defined in the literature.

the literature. All right. You're welcome. I think it's

All right. You're welcome. I think it's severe. Okay. Well, uh, I've gone

severe. Okay. Well, uh, I've gone through all the questions and comments

through all the questions and comments that have been posted to me. So, if you

that have been posted to me. So, if you have to leave, we understand. Uh, no,

have to leave, we understand. Uh, no, there's no hard feelings. I'm going to

there's no hard feelings. I'm going to continue

continue for those that want to stay on and can

for those that want to stay on and can tolerate it.

tolerate it. So, so hopefully you're not you're not

So, so hopefully you're not you're not not responding because you're having a

not responding because you're having a seizure.

seizure. All right, I'm just kidding, right? We

All right, I'm just kidding, right? We got to have fun here a little bit. Uh,

got to have fun here a little bit. Uh, as you can see in our company, we like

as you can see in our company, we like to make learning fun. All right. And but

to make learning fun. All right. And but also make it relevant. Um, so for

also make it relevant. Um, so for whatever that's worth, I'm going to keep

whatever that's worth, I'm going to keep going. Wait, there was a All right. So,

going. Wait, there was a All right. So, there's someone telling me to hurry up

there's someone telling me to hurry up and keep going.

and keep going. I'm gonna keep going. All right.

I'm gonna keep going. All right. Fingitis and peronsular abscess. What

Fingitis and peronsular abscess. What you don't want is a peronsular abscess.

you don't want is a peronsular abscess. I can promise you that. Okay. But the

I can promise you that. Okay. But the tonsular pillars, these are big lymphoid

tonsular pillars, these are big lymphoid uh uh lymph tissue. Uh they basically

uh uh lymph tissue. Uh they basically have a raging battle. There's a big

have a raging battle. There's a big fight going on, a war. And sometimes

fight going on, a war. And sometimes that tissue can die. Okay? So they're

that tissue can die. Okay? So they're fighting infection, there's

fighting infection, there's inflammation, and it can form an

inflammation, and it can form an abscess. And that abscess becomes very

abscess. And that abscess becomes very very uncomfortable. Uh in fact, it can

very uncomfortable. Uh in fact, it can be so uncomfortable they start

be so uncomfortable they start developing spasms of the muscle where

developing spasms of the muscle where they can't even open their mouth wide

they can't even open their mouth wide enough to allow you to look. because

enough to allow you to look. because they get spasms. It's called tismas. So,

they get spasms. It's called tismas. So, they have tismas on exam. That is a

they have tismas on exam. That is a peronsular abscess until proven

peronsular abscess until proven otherwise and requires incision and

otherwise and requires incision and drainage. That's right. You mean to tell

drainage. That's right. You mean to tell me you're going to put a scalpel in my

me you're going to put a scalpel in my throat or a needle? That's right. You

throat or a needle? That's right. You mean to tell me pus is going to come and

mean to tell me pus is going to come and drip out into my oral? That's right. So,

drip out into my oral? That's right. So, hopefully nobody just vomited.

I'm not kidding. It is the worst procedure that I've ever done outside of

procedure that I've ever done outside of a nasal gastric tube. It is the worst

a nasal gastric tube. It is the worst procedure to do to a patient. Absolute

procedure to do to a patient. Absolute worst. Because literally I am sticking a

worst. Because literally I am sticking a needle in the back of their throat and

needle in the back of their throat and dreading out pus or cutting it open

dreading out pus or cutting it open without hitting the corateed artery. So

without hitting the corateed artery. So this is a big deal. Why does it matter?

this is a big deal. Why does it matter? Okay. So that's where fngitis we don't

Okay. So that's where fngitis we don't want to progress and that's why people

want to progress and that's why people probably overprescribe in fngitis

probably overprescribe in fngitis because they don't want that person to

because they don't want that person to go on to develop a peratonsular abscess.

go on to develop a peratonsular abscess. So how do we discern if they have

So how do we discern if they have bacterial strep? Because fngitis can be

bacterial strep? Because fngitis can be from the cold weather. It can be from

from the cold weather. It can be from allergens. It can be from a virus. It

allergens. It can be from a virus. It can be from group A betaolytic strep.

can be from group A betaolytic strep. Well you can use the centaur criteria to

Well you can use the centaur criteria to guide you. And the centaur criteria is

guide you. And the centaur criteria is just looking for a fever. They have uh

just looking for a fever. They have uh perulent pestules on the tonsular

perulent pestules on the tonsular pillars. They have anterior chain

pillars. They have anterior chain lympadnopathy

lympadnopathy and no cough and typically less than 16.

and no cough and typically less than 16. If you have Yes. Yes. Yes. You don't

If you have Yes. Yes. Yes. You don't need to do a rapid strep. They have

need to do a rapid strep. They have strep. Okay. If they have two to three

strep. Okay. If they have two to three of the sensor criteria, rapid strep

of the sensor criteria, rapid strep testing can help you um narrow in. But

testing can help you um narrow in. But the treatment of choice is penicellin,

the treatment of choice is penicellin, penicellin, penicellin. And that could

penicellin, penicellin. And that could be amoxicylin or penk. Now if they have

be amoxicylin or penk. Now if they have per tons abscess you have to drain it.

per tons abscess you have to drain it. Okay if you can't get back there and

Okay if you can't get back there and drain it because they can't open their

drain it because they can't open their mouth that is an admission to the

mouth that is an admission to the hospital and the ear nose and throat or

hospital and the ear nose and throat or otoarangologist will do it under

otoarangologist will do it under basically a sedation and surgical

basically a sedation and surgical procedure. Uh but you don't want to go

procedure. Uh but you don't want to go down that. So what does the patient have

down that. So what does the patient have diagnosis?

diagnosis? If you start a moxicylin for a patient

If you start a moxicylin for a patient with a sore throat and they develop a

with a sore throat and they develop a whole body rash,

whole body rash, they have mono. You miss the diagnosis

they have mono. You miss the diagnosis that is caused by Epstein bar virus and

that is caused by Epstein bar virus and viruses don't respond to antibiotics.

viruses don't respond to antibiotics. Uh and if you see that diffuse rash, it

Uh and if you see that diffuse rash, it is almost always mono. Uh and if you did

is almost always mono. Uh and if you did a mono spot test, you would know if they

a mono spot test, you would know if they have active infection. Um but checking

have active infection. Um but checking making sure that you diagnose this

making sure that you diagnose this correctly. Making sure that you are

correctly. Making sure that you are using the right drug therapy and then

using the right drug therapy and then have counseling is important. Um but you

have counseling is important. Um but you don't want to label this person as

don't want to label this person as having a drug allergy to penicellin for

having a drug allergy to penicellin for the rest of their life when in fact you

the rest of their life when in fact you misdiagnosed them. Okay. All right.

misdiagnosed them. Okay. All right. Uh and again Dr. Kokan just you know

Uh and again Dr. Kokan just you know jump in. I I will say that allergy is on

jump in. I I will say that allergy is on many patients charts and we override we

many patients charts and we override we talk to the patient and get them on a

talk to the patient and get them on a betalactim and then essentially modify

betalactim and then essentially modify that we can't eliminate it but we modify

that we can't eliminate it but we modify that statement on the chart.

that statement on the chart. >> Yeah. And if they do have true

>> Yeah. And if they do have true penicellin allergy even though it's a

penicellin allergy even though it's a drug of choice it's clintomy is next.

drug of choice it's clintomy is next. Okay. Uh and clinomyin actually has good

Okay. Uh and clinomyin actually has good penetration even into some level of the

penetration even into some level of the abscessor around it uh when there's

abscessor around it uh when there's anorob anorobic environments. All right.

anorob anorobic environments. All right. So moving on to perorbital salisitis. So

So moving on to perorbital salisitis. So this is perorbital around the orbit

this is perorbital around the orbit versus orbital eyeball is infected.

versus orbital eyeball is infected. Okay. Um so you know you can get

Okay. Um so you know you can get infections from the nasop fairings area

infections from the nasop fairings area right you can certainly get it just

right you can certainly get it just being from scratching your skin. There's

being from scratching your skin. There's a number rubbing your eye too much and

a number rubbing your eye too much and you know something happens and it gets

you know something happens and it gets infected. U so any of those involvement.

infected. U so any of those involvement. Now how do you know it's perorbital

Now how do you know it's perorbital versus orbital? If I make you do your

versus orbital? If I make you do your extraocular movements up, down, left,

extraocular movements up, down, left, right, and do this, and you your eyeball

right, and do this, and you your eyeball hurts as you move it, that is very

hurts as you move it, that is very concerning for orbital cellulitis. Okay.

concerning for orbital cellulitis. Okay. You may actually need to do a

You may actually need to do a radiographic imaging or CT scan to help

radiographic imaging or CT scan to help you to see if there's any pus or

you to see if there's any pus or swelling behind the eyeball

swelling behind the eyeball uh putting pressure on the eye. Okay?

uh putting pressure on the eye. Okay? Because that changes everything. All

Because that changes everything. All right? Um so if the eyeball or there's

right? Um so if the eyeball or there's pus behind the eyeball itself that is

pus behind the eyeball itself that is concerning and requires admission to the

concerning and requires admission to the hospital and an opthalmology consult. If

hospital and an opthalmology consult. If it's just perorbital a soft tissue

it's just perorbital a soft tissue around the eyeball okay then you can get

around the eyeball okay then you can get away with usually augmentatin is the

away with usually augmentatin is the most one of the more common drugs of

most one of the more common drugs of choice that is used. I've seen report uh

choice that is used. I've seen report uh sources say Kelex uh as well, but you

sources say Kelex uh as well, but you really need something with a little bit

really need something with a little bit of H influenza coverage just in case. So

of H influenza coverage just in case. So that's why augmentan is probably used a

that's why augmentan is probably used a little bit more or a third generation

little bit more or a third generation oral sephospor like septanir or

oral sephospor like septanir or something like that. If you're admitting

something like that. If you're admitting them because you are concerned about

them because you are concerned about oral cellulitis now you're using

oral cellulitis now you're using parental agents like septraxone to get

parental agents like septraxone to get that you know gram negative coverage in

that you know gram negative coverage in addition to the gram positive or

addition to the gram positive or betalactim betalacttoase inhibitor. All

betalactim betalacttoase inhibitor. All right, moving on to our our viral

right, moving on to our our viral infections, influenza. I mean, I think

infections, influenza. I mean, I think I'm not going to insult everybody's

I'm not going to insult everybody's intelligence here, especially in the

intelligence here, especially in the context of the pandemic and stuff like

context of the pandemic and stuff like that. Um,

that. Um, but hear this. While the coldlike

but hear this. While the coldlike symptoms or flu-l like symptoms can be

symptoms or flu-l like symptoms can be similar to other viral infections,

similar to other viral infections, um, this is where testing is actually

um, this is where testing is actually helpful because the the, uh, especially

helpful because the the, uh, especially when it's collected, right? Um but the

when it's collected, right? Um but the flu test has a very good diagnostic

flu test has a very good diagnostic sensitivity. That means it has very few

sensitivity. That means it has very few false negatives. Um and it will test

false negatives. Um and it will test usually for both influenza A and

usually for both influenza A and influenza B. Why does it matter? Well,

influenza B. Why does it matter? Well, it matters because we can treat it. Um

it matters because we can treat it. Um also Tamavir or Bloxave are oral options

also Tamavir or Bloxave are oral options that that can help people um you know

that that can help people um you know with this especially if you are catching

with this especially if you are catching it early. Now I do want to make a

it early. Now I do want to make a comment because I hear it incessantly

comment because I hear it incessantly that people say that tam of flu also

that people say that tam of flu also tamir and these drugs only work in the

tamir and these drugs only work in the first 48 hours and that is just flat out

first 48 hours and that is just flat out wrong. Um so it works best in otherwise

wrong. Um so it works best in otherwise healthy patients and reduces the

healthy patients and reduces the duration of symptoms by maybe half a day

duration of symptoms by maybe half a day in the regular population. If you have

in the regular population. If you have patients with high risk factors or

patients with high risk factors or they're being admitted to the hospital,

they're being admitted to the hospital, you have a a a spreading problem. Okay?

you have a a a spreading problem. Okay? So, there's other people around you and

So, there's other people around you and it's a public health issue, especially

it's a public health issue, especially if they're going into the hospital. So,

if they're going into the hospital. So, if you're admitting to them hospital, if

if you're admitting to them hospital, if you look at the actually community

you look at the actually community acquired pneumonia guidelines, they

acquired pneumonia guidelines, they actually recommend you testing them for

actually recommend you testing them for it. And if they do have it, you treat

it. And if they do have it, you treat them because especially if you're

them because especially if you're bringing them in, you may still be

bringing them in, you may still be giving them antibiotics, but you want to

giving them antibiotics, but you want to also test them for this. So it is

also test them for this. So it is appropriate in certain patient

appropriate in certain patient populations especially if they're

populations especially if they're imunocmpromised pregnant doing really

imunocmpromised pregnant doing really bad or sick if they happen to be in the

bad or sick if they happen to be in the hospital and they can't swallow because

hospital and they can't swallow because influenza can cause nausea vomiting u

influenza can cause nausea vomiting u then and if you have to and you really

then and if you have to and you really feel strongly the patient is would

feel strongly the patient is would benefit from it paramavir which is the

benefit from it paramavir which is the IV formulation

IV formulation um basically or IV form of the

um basically or IV form of the inhibitors that you can use uh that

inhibitors that you can use uh that would be helpful in this situation. Uh

would be helpful in this situation. Uh Craig, I don't know if you've ever even

Craig, I don't know if you've ever even seen primary or you guys ever use it in

seen primary or you guys ever use it in the ICU or in the acute care

the ICU or in the acute care environment. I have not. Yeah, it was a

environment. I have not. Yeah, it was a long time ago during my PGI1 residency

long time ago during my PGI1 residency when H1N1 uh was really uh profound and

when H1N1 uh was really uh profound and they actually that was we used parameter

they actually that was we used parameter before is actually FDA approved just

before is actually FDA approved just because there was a subset of patients

because there was a subset of patients that they thought it's beneficial for um

that they thought it's beneficial for um and I I saw it on on my rotations during

and I I saw it on on my rotations during that year but other since then I haven't

that year but other since then I haven't seen it.

seen it. >> Okay.

>> Okay. Well, just keep in mind the dosage

Well, just keep in mind the dosage formulations and the indications. That's

formulations and the indications. That's what's going to be for board exam stuff.

what's going to be for board exam stuff. Now, as it relates to COVID, I mean, we

Now, as it relates to COVID, I mean, we all know that what really happens is the

all know that what really happens is the response to it. Um, and it's kind of

response to it. Um, and it's kind of like sepsis. It's a a disregulated

like sepsis. It's a a disregulated immune response and some people just do

immune response and some people just do bad and obviously they develop a lot of

bad and obviously they develop a lot of symptoms. Uh, and the respiratory ones

symptoms. Uh, and the respiratory ones especially evolve into pneumonas and the

especially evolve into pneumonas and the pneumonia can be fairly severe and

pneumonia can be fairly severe and result in severe hypoxia. Um and then

result in severe hypoxia. Um and then obviously respiratory failure and then

obviously respiratory failure and then then of all ultimately end organ

then of all ultimately end organ dysfunction. Um and so most of it is

dysfunction. Um and so most of it is clinical or based on radiographic

clinical or based on radiographic imaging. Um I don't need a stupid uh

imaging. Um I don't need a stupid uh nasal swap to tell me if someone has

nasal swap to tell me if someone has COVID. I can see it on their X-ray or I

COVID. I can see it on their X-ray or I can see it on their CT scan. It's very

can see it on their CT scan. It's very slam dunk obvious. Um but and the reason

slam dunk obvious. Um but and the reason I kind of say that and beat up the the

I kind of say that and beat up the the the testing is because we're so

the testing is because we're so hyperfocused that the diagnosis of the

hyperfocused that the diagnosis of the of COVID is by the lab test. and that is

of COVID is by the lab test. and that is absolutely inaccurate. Um, and the

absolutely inaccurate. Um, and the reason is is the diagnostic sensitivity

reason is is the diagnostic sensitivity of those tests quite honestly suck. Um,

of those tests quite honestly suck. Um, the false sensit or the false positive

the false sensit or the false positive rate uh false negative rate is up to

rate uh false negative rate is up to 30%. Depending on the assay that you're

30%. Depending on the assay that you're using. So, you know, so if I got a

using. So, you know, so if I got a patient who's clinically got it and I

patient who's clinically got it and I give this test and it says it doesn't,

give this test and it says it doesn't, I'm not going to ignore the scenario.

I'm not going to ignore the scenario. Um, so it's not as good as the flu test,

Um, so it's not as good as the flu test, but now they're at least improving some

but now they're at least improving some of the tests where the diagnostic

of the tests where the diagnostic sensitivity is improving and especially

sensitivity is improving and especially if it is collected correctly. The only

if it is collected correctly. The only thing that the boards are ever going to

thing that the boards are ever going to touch on in these situation are and for

touch on in these situation are and for your for your purposes are vaccinations,

your for your purposes are vaccinations, okay? and dexamethasone predominantly

okay? and dexamethasone predominantly because it's the only one with the

because it's the only one with the highest level of evidence with

highest level of evidence with definitive place in therapy where

definitive place in therapy where protocols are pretty much consistent and

protocols are pretty much consistent and you have guidelines that from the NIH

you have guidelines that from the NIH that basically guide it in in that

that basically guide it in in that direction. So if they come in and

direction. So if they come in and they're a hospital needing oxygen,

they're a hospital needing oxygen, they're going to probably go down the

they're going to probably go down the dexamethasone question. That's pretty

dexamethasone question. That's pretty much it. They're not going to jump into

much it. They're not going to jump into all these other treatments that are

all these other treatments that are going on. They're definitely never going

going on. They're definitely never going to no answer. if they may list

to no answer. if they may list ivormectin, they may list

ivormectin, they may list hydroxycloropin, but you better not

hydroxycloropin, but you better not choose them. You will be flat out wrong.

choose them. You will be flat out wrong. Um, so just don't do that. I don't think

Um, so just don't do that. I don't think they're going to ask you beyond this. I

they're going to ask you beyond this. I think probably it's still going to be in

think probably it's still going to be in the question validation phase. Okay,

the question validation phase. Okay, moving on to hepatitis C. Um,

moving on to hepatitis C. Um, historically, you know, we don't have a

historically, you know, we don't have a vaccine for this. Like with hepatitis B,

vaccine for this. Like with hepatitis B, we do. People get vaccinated very early

we do. People get vaccinated very early on in life, and as a result of being

on in life, and as a result of being vaccinated very early on in life, we

vaccinated very early on in life, we almost never really see it. it's the

almost never really see it. it's the people coming from other countries or

people coming from other countries or who are antivaccines who are potentially

who are antivaccines who are potentially showing up with it which makes it very

showing up with it which makes it very very hard um to deal with because the

very hard um to deal with because the risk of hepatitis B chronically is

risk of hepatitis B chronically is hepatio carcinoma. Same thing with uh

hepatio carcinoma. Same thing with uh hepatitis C. So hepatitis C doesn't have

hepatitis C. So hepatitis C doesn't have a vaccine historically didn't have great

a vaccine historically didn't have great treatments and interferon ribbon. Now we

treatments and interferon ribbon. Now we obviously have enough antiv antivirals

obviously have enough antiv antivirals that are pretty much used in a similar

that are pretty much used in a similar pattern as like HIV that allow us to

pattern as like HIV that allow us to treat it. But basically hepatitis is

treat it. But basically hepatitis is damage of the hepatosytes.

damage of the hepatosytes. So the virus replicates inside the cell.

So the virus replicates inside the cell. It replicates so much inside the cell

It replicates so much inside the cell that it basically kills the cell and so

that it basically kills the cell and so your ats

your ats go up and eventually that forms

go up and eventually that forms inflammation that leads to scar tissue.

inflammation that leads to scar tissue. That scar tissue leads to eventually

That scar tissue leads to eventually failure and they go into cerosis. Um

failure and they go into cerosis. Um um the good news is we have a lot of

um the good news is we have a lot of treatment options. You see all these you

treatment options. You see all these you know beers at the end here. Uh there's a

know beers at the end here. Uh there's a lot of them. Uh sophosphy beer has been

lot of them. Uh sophosphy beer has been around for a while. There's a lot of

around for a while. There's a lot of combinations with soft sofosphere. Uh

combinations with soft sofosphere. Uh just keep in mind that they're actually

just keep in mind that they're actually very effective. They're oral and you can

very effective. They're oral and you can actually cure somebody of many of the

actually cure somebody of many of the genotypes. So there's six genotypes of

genotypes. So there's six genotypes of hepatitis C one through six. But in a

hepatitis C one through six. But in a 12week regimen you can cure these

12week regimen you can cure these people. This is huge. I mean this is

people. This is huge. I mean this is literally

literally >> you know practice changing public health

>> you know practice changing public health issues because now we can pre slow the

issues because now we can pre slow the progression of these people or even

progression of these people or even prevent them from going on to develop

prevent them from going on to develop cerosis in a cell carcinoma whereas

cerosis in a cell carcinoma whereas rivon interferon was something you had

rivon interferon was something you had to take for like almost an entire year

to take for like almost an entire year and wasn't even still 100% curable. Um

and wasn't even still 100% curable. Um what is it? So phosphobir is the one

what is it? So phosphobir is the one that causes the brada cardia in

that causes the brada cardia in combination with amiotarone

combination with amiotarone >> right

>> right >> so right I think that's right so be very

>> so right I think that's right so be very careful um with that one if you see that

careful um with that one if you see that on the test so monucleiosis that's EBV

on the test so monucleiosis that's EBV that's mono basically it looks like

that's mono basically it looks like streput throat most people miss a

streput throat most people miss a diagnosis

diagnosis where it differs is in the posterior

where it differs is in the posterior chain of the neck of the lymph nodes and

chain of the neck of the lymph nodes and they sometimes will have spleenomegaly

they sometimes will have spleenomegaly so they'll have left upper quadrant

so they'll have left upper quadrant abdominal pain. You can do a monospot

abdominal pain. You can do a monospot test. It gives you the diagnosis. It

test. It gives you the diagnosis. It gives you a diagnosis and that's it.

gives you a diagnosis and that's it. Send them home. There is no treatment

Send them home. There is no treatment and do not give them a moxicil.

and do not give them a moxicil. All right. Moving on to HIV. Um I think

All right. Moving on to HIV. Um I think we know mostly about this and what it

we know mostly about this and what it does to the CD4 lymphocly. So I'm just

does to the CD4 lymphocly. So I'm just going to move on.

going to move on. So you know highly active

So you know highly active anti-retroviral therapy. The old

anti-retroviral therapy. The old terminology for ART anti-retroviral

terminology for ART anti-retroviral therapy is a three drug regimen. It's

therapy is a three drug regimen. It's still the case. It's mostly now with

still the case. It's mostly now with integrace inhibitors. So you know like

integrace inhibitors. So you know like dalute with himabine and tenaf but it's

dalute with himabine and tenaf but it's always two nuke backbone with again

always two nuke backbone with again initial starting a therapy integrace

initial starting a therapy integrace inhibitors. Um

inhibitors. Um you can consider in some patients other

you can consider in some patients other situations like NN NN RTI based

situations like NN NN RTI based therapies or PIs but we typically

therapies or PIs but we typically reserve those for patients who either

reserve those for patients who either have resistance from phenotypic or

have resistance from phenotypic or genotypic analysis to some of the

genotypic analysis to some of the integration inhibitors or who have

integration inhibitors or who have failed the integration inhibitor

failed the integration inhibitor pathway. Now, they're not going to go

pathway. Now, they're not going to go into on your exam unless you're a BCIDP

into on your exam unless you're a BCIDP person where you may need to be

person where you may need to be manipulating anti-retroviral therapy

manipulating anti-retroviral therapy based on the patient's history or

based on the patient's history or genotypes, those types of things. That

genotypes, those types of things. That is not the focus of this particular

is not the focus of this particular lecture. Um, most of the time we're

lecture. Um, most of the time we're talking about empiric initial therapies

talking about empiric initial therapies that we start on and we see if it causes

that we start on and we see if it causes suppression of their vital load over the

suppression of their vital load over the next four to eight weeks. Um, so just

next four to eight weeks. Um, so just keep that in mind. Now, occupational

keep that in mind. Now, occupational exposure um there the recommendation is

exposure um there the recommendation is obviously started if it's a high-risisk

obviously started if it's a high-risisk exposure like literally blood on a

exposure like literally blood on a needle goes into your body and

needle goes into your body and penetrates

penetrates those are high risk, right? If you get

those are high risk, right? If you get blood that splashes onto your skin,

blood that splashes onto your skin, that's still low risk. Okay? You really

that's still low risk. Okay? You really have to have an open wound where blood

have to have an open wound where blood and blood can have contact. That's where

and blood can have contact. That's where the high risk comes in. Uh or the

the high risk comes in. Uh or the patient who you were exposed to

patient who you were exposed to has a high viral load and is multi-drug

has a high viral load and is multi-drug resistance. You know, obviously that

resistance. You know, obviously that scares everybody. The the brittle HIV

scares everybody. The the brittle HIV patients with AIDS, you know, you get

patients with AIDS, you know, you get blood splattered on you. That actually

blood splattered on you. That actually happened to me once when I was we had a

happened to me once when I was we had a trauma come in and the guy was very well

trauma come in and the guy was very well known in the community as being a

known in the community as being a brittle AIDS patient and I mean blood

brittle AIDS patient and I mean blood was squirting everywhere and we had I

was squirting everywhere and we had I mean thankfully I had a mask but it got

mean thankfully I had a mask but it got all over my neck you know so it scares

all over my neck you know so it scares you and so the treatment is rotte and or

you and so the treatment is rotte and or do plus tenafine

do plus tenafine for four weeks we really don't know if

for four weeks we really don't know if going beyond that matters but you get

going beyond that matters but you get baseline testing and then you get your

baseline testing and then you get your viral loads tested and you or I'm sorry,

viral loads tested and you or I'm sorry, you get tested for HIV after that that

you get tested for HIV after that that that one month therapy and then it

that one month therapy and then it extends out to the uh six month and I

extends out to the uh six month and I think you even have another one at at a

think you even have another one at at a year in some patients.

year in some patients. Um Cabotra is a new newer agent with a

Um Cabotra is a new newer agent with a long acting injectable. You give it once

long acting injectable. You give it once a month times two and then after that

a month times two and then after that point it's every other oh wait a minute

point it's every other oh wait a minute that's actually this is for

that's actually this is for pre-exposure. Sorry. Duh.

pre-exposure. Sorry. Duh. I jumped too fast. So

I jumped too fast. So uh prep which is pre-exposure

uh prep which is pre-exposure prophylaxis mainly in people who have

prophylaxis mainly in people who have high-risisk behaviors you know they have

high-risisk behaviors you know they have a disconate you know um you know patient

a disconate you know um you know patient scenario where or a relationship where

scenario where or a relationship where you know maybe their spouse or their

you know maybe their spouse or their partner doesn't have HIV but they do you

partner doesn't have HIV but they do you know or they're in risky um situations

know or they're in risky um situations and the person they're you know exposing

and the person they're you know exposing theoretically um depending on what type

theoretically um depending on what type of you know activity is happening. Um

of you know activity is happening. Um you can provide them with prophylaxis to

you can provide them with prophylaxis to prevent that transmission.

prevent that transmission. So shvatada is one option and then

So shvatada is one option and then cavotegraver is another one that was the

cavotegraver is another one that was the injectable that you can put them on

injectable that you can put them on especially in somebody like in a

especially in somebody like in a relationship long term. Dr. Uh, Bolan,

relationship long term. Dr. Uh, Bolan, do you have any comments on or further

do you have any comments on or further things you may want to

things you may want to >> No, the only thing that could be kind of

>> No, the only thing that could be kind of a a thing that the boards might try

a a thing that the boards might try might try to tweeze out would be tenafir

might try to tweeze out would be tenafir would be an option for a heterosexual

would be an option for a heterosexual couple uh who had HIV serisordant

couple uh who had HIV serisordant status.

status. >> Very good point. Okay,

>> Very good point. Okay, let's move on to GU infections. Man, I I

let's move on to GU infections. Man, I I timed this bad. I'm so sorry.

timed this bad. I'm so sorry. We're at We're We're at two and a half

We're at We're We're at two and a half hours. Let's You know what? Um

hours. Let's You know what? Um Hold on one second. Let me just double

Hold on one second. Let me just double check

check real quick here.

All right. Well, let me just hit some real quick high points here so that we

real quick high points here so that we can at least stay on track. Uh, so UTI,

can at least stay on track. Uh, so UTI, here's what you need to keep in mind. If

here's what you need to keep in mind. If it's cyitis, it's just involving the

it's cyitis, it's just involving the bladder. If it's involving the kidneys,

bladder. If it's involving the kidneys, they have back pain, CVA, flank

they have back pain, CVA, flank tenderness. That's more systemic, more

tenderness. That's more systemic, more complicated, right? And that's where it

complicated, right? And that's where it can then get into the blood. So, if it's

can then get into the blood. So, if it's just localized to the to the bladder,

just localized to the to the bladder, then you can get away with drugs that

then you can get away with drugs that have good concentration in the in the

have good concentration in the in the bladder or the urine. That's your

bladder or the urine. That's your nitrintoine,

nitrintoine, single dose phosphomyin,

single dose phosphomyin, bactrum, three, you know, you can do get

bactrum, three, you know, you can do get away with three days treatment in a

away with three days treatment in a non-complicated patient, right? If you

non-complicated patient, right? If you have pyo, you need something that's

have pyo, you need something that's going to penetrate the kidney itself.

going to penetrate the kidney itself. It's going to be like floricquinolones,

It's going to be like floricquinolones, not moxy and jimmy though. Bactrum, no

not moxy and jimmy though. Bactrum, no nitrofllororent, no no phosphomyosin in

nitrofllororent, no no phosphomyosin in those situ situations. Um, you're going

those situ situations. Um, you're going to have to use things like septraone and

to have to use things like septraone and probably admitt

probably admitt or floricquinolones if they have mild

or floricquinolones if they have mild pylinritis and they're able to keep

pylinritis and they're able to keep things uh down and then you can tailor

things uh down and then you can tailor it based on the uh drive. Now I want to

it based on the uh drive. Now I want to talk about PID pelvic inflammatory

talk about PID pelvic inflammatory disease and cervicitis. This is

disease and cervicitis. This is basically your STD where patients come

basically your STD where patients come in with vag your either vaginal

in with vag your either vaginal discharge or in men penile discharge in

discharge or in men penile discharge in the context of sexual sexual

the context of sexual sexual intercourse. You need to think across

intercourse. You need to think across any of the STDs, not just cervicitis,

any of the STDs, not just cervicitis, urethritis, but syphilis, herpes, HIV,

urethritis, but syphilis, herpes, HIV, but in cervicitis or urethritis,

but in cervicitis or urethritis, um you are, you know, septraone or

um you are, you know, septraone or doxycyc is empirically used. If it's in

doxycyc is empirically used. If it's in doxycycline, it's going to be twice a

doxycycline, it's going to be twice a day for at least seven days. Now, what

day for at least seven days. Now, what is pelvic inflammatory disease? Well,

is pelvic inflammatory disease? Well, basically this is more extensive in

basically this is more extensive in expanding infection up into the uterus

expanding infection up into the uterus and going up into the fallopian tubes

and going up into the fallopian tubes and even to the ovaries where they

and even to the ovaries where they become more sick, right? They're having

become more sick, right? They're having nausea, vomiting, fever, malaise that

nausea, vomiting, fever, malaise that basically meet criteria most of the time

basically meet criteria most of the time for sepsis. They need imaging to look

for sepsis. They need imaging to look for tubo oavvarian abscesses because

for tubo oavvarian abscesses because that requires an admission and surgical

that requires an admission and surgical either drainage or um um uh

either drainage or um um uh needle basically aspiration of that. So

needle basically aspiration of that. So that's where I need gynecologic uh

that's where I need gynecologic uh consults and you start them on parental

consults and you start them on parental therapy septraone plusy with or without

therapy septraone plusy with or without metroniditool in those patients and so

metroniditool in those patients and so the anatomy here is important. So

the anatomy here is important. So cervvicitis in a female is right

cervvicitis in a female is right >> you might want to do you want to put the

>> you might want to do you want to put the slides back up.

slides back up. >> Oh dear god

man. This is just I'm sorry, guys.

I'm sorry, guys. I apologize.

I apologize. >> All right.

Crashing and burning here. >> Sorry.

>> Sorry. >> That's okay. I mean, I'm glad you said

>> That's okay. I mean, I'm glad you said something. Uh, all right. So,

something. Uh, all right. So, cervvicitis is uh right here at the

cervvicitis is uh right here at the cervix. Okay. The infection is isolated

cervix. Okay. The infection is isolated there. Whereas pelvic inflammatory

there. Whereas pelvic inflammatory disease is again the more severe where

disease is again the more severe where the infection can get up here in the

the infection can get up here in the fallopian tubes, can get up here in the

fallopian tubes, can get up here in the a uh ovaries basically just get really

a uh ovaries basically just get really sick. So just make sure I really wanted

sick. So just make sure I really wanted to make sure that we highlighted the

to make sure that we highlighted the difference between the two because if

difference between the two because if you have P your treatment is going to be

you have P your treatment is going to be more aggressive and your docycan is

more aggressive and your docycan is really for 14 days versus cervicitis is

really for 14 days versus cervicitis is seven days. All right. Bacterial

seven days. All right. Bacterial vaginosis basically they have a lot of

vaginosis basically they have a lot of vaginal discharge. It's very similar to

vaginal discharge. It's very similar to trick. The treatment is metroniditool.

trick. The treatment is metroniditool. So I'm moving past that. Okay. Herpes uh

So I'm moving past that. Okay. Herpes uh basically they get these herpetic

basically they get these herpetic lesions and it all requires is a

lesions and it all requires is a skin-to-skin contact. You don't have to

skin-to-skin contact. You don't have to have any vaginal anal penetration,

have any vaginal anal penetration, nothing like that. Uh it's just

nothing like that. Uh it's just skin-to-skin. And so if they have an

skin-to-skin. And so if they have an active herpetic outbreak, not only can

active herpetic outbreak, not only can it cause pain and itching to them, um

it cause pain and itching to them, um where you just physically on exam can

where you just physically on exam can see that they have it. Uh but the

see that they have it. Uh but the treatment is ascycllovere which is the

treatment is ascycllovere which is the cheaper option but you got to take it up

cheaper option but you got to take it up to five times a day or valycllovere

to five times a day or valycllovere which is the prod drug to ascycllovere

which is the prod drug to ascycllovere and you could take it three times a day.

and you could take it three times a day. So it's easier to take and is a little

So it's easier to take and is a little bit more compliant but is obviously more

bit more compliant but is obviously more expensive. uh syphilis still around.

expensive. uh syphilis still around. Don't forget there's primary, secondary,

Don't forget there's primary, secondary, tertiary, it can even get into the

tertiary, it can even get into the brain. Uh many times when we see these

brain. Uh many times when we see these on patients, especially men, they have

on patients, especially men, they have painless ulcers um on the penis. Um and

painless ulcers um on the penis. Um and so the treatment is penicellin.

so the treatment is penicellin. Penicellin, penicellin, even if you have

Penicellin, penicellin, even if you have neurosyphilis, it's penicellin. Now it's

neurosyphilis, it's penicellin. Now it's a different form of penicellin. Um you

a different form of penicellin. Um you know, um it's penicellin infusions, but

know, um it's penicellin infusions, but it's still the same penicellin.

it's still the same penicellin. endocarditis basically have a growth on

endocarditis basically have a growth on the valve. They're having seeding of the

the valve. They're having seeding of the blood and so they have constant fevers,

blood and so they have constant fevers, murmurss, and you're doing blood

murmurss, and you're doing blood cultures. That is going to guide you as

cultures. That is going to guide you as to what therapies you're going to be

to what therapies you're going to be giving those patients. And I'm sorry I'm

giving those patients. And I'm sorry I'm having to move past it a little bit

having to move past it a little bit here, but whether it's a native valve,

here, but whether it's a native valve, prosthetic valve, or they have IV drug

prosthetic valve, or they have IV drug abuse really kind of drives it until you

abuse really kind of drives it until you get the pathogen back from the cultures.

get the pathogen back from the cultures. Um, and so we use the modified Duke

Um, and so we use the modified Duke criteria. Sepsis, obviously a

criteria. Sepsis, obviously a high-hitting one have to have two of at

high-hitting one have to have two of at least two of the surge criteria. Usually

least two of the surge criteria. Usually that's tacoc cardia or pulse over 90, a

that's tacoc cardia or pulse over 90, a fever or hypothermia,

fever or hypothermia, elevated white blood cell above 12 or

elevated white blood cell above 12 or less than four. Um increased

less than four. Um increased respirations or you know some evidence

respirations or you know some evidence of you know loss of by carb. Um those

of you know loss of by carb. Um those are the classic ones. Um you can use the

are the classic ones. Um you can use the sofa score or sofa and they usually have

sofa score or sofa and they usually have a lactate over two. Um and so it's IV

a lactate over two. Um and so it's IV fluids, so volume resuscitation with 30

fluids, so volume resuscitation with 30 cc's per kilo. Unless they have heart

cc's per kilo. Unless they have heart failure or on diialysis, then you

failure or on diialysis, then you obviously make modifications.

obviously make modifications. Um early empiric antibiotic therapy with

Um early empiric antibiotic therapy with appropriate broadspectrum antibiotics

appropriate broadspectrum antibiotics that includes sudamonus and always

that includes sudamonus and always bacterial

bacterial acting drugs, right? So sephopene for

acting drugs, right? So sephopene for example with uh vank or levofluxin with

example with uh vank or levofluxin with you know venkcomyosin. um your goal map

you know venkcomyosin. um your goal map is 65 millimeters of mercury pressure.

is 65 millimeters of mercury pressure. If you are not able to achieve that with

If you are not able to achieve that with IV fluids and some initial treatments,

IV fluids and some initial treatments, then it's norepinephrine once the tank

then it's norepinephrine once the tank is full. Um if you still are not getting

is full. Um if you still are not getting maps of that and you are suspicious or

maps of that and you are suspicious or they are at high risk for like adrenal

they are at high risk for like adrenal insufficiency, then it's hydrocortisone.

insufficiency, then it's hydrocortisone. Surgical prophylaxis is going to be

Surgical prophylaxis is going to be obviously dependent on the type of

obviously dependent on the type of surgery that you're having and the

surgery that you're having and the location but most commonly 20 30 minutes

location but most commonly 20 30 minutes it's ANSF um to be given toxic shock

it's ANSF um to be given toxic shock syndrome these are patients with toxin

syndrome these are patients with toxin mediated disseminated disease um and

mediated disseminated disease um and they can have malaise systemic

they can have malaise systemic manifestations again staporius is

manifestations again staporius is probably the most common

probably the most common um lots of fluids because they go into

um lots of fluids because they go into shock um sephopime uh or ta piptaso with

shock um sephopime uh or ta piptaso with venkcomyosin and then IVIG therapy PJP

venkcomyosin and then IVIG therapy PJP whether it's that this is a fungus and

whether it's that this is a fungus and so we typically see it in iminompromised

so we typically see it in iminompromised patients and they can develop pneumonia

patients and they can develop pneumonia they usually become very hypoxic

they usually become very hypoxic chest x-rays show multi- uh uh patchy

chest x-rays show multi- uh uh patchy infiltrates kind of with glass brown

infiltrates kind of with glass brown glass appearance so if they are like an

glass appearance so if they are like an HIV or imuninompromised patient and

HIV or imuninompromised patient and their CD4 count less than 200 the answer

their CD4 count less than 200 the answer is spectrum

is spectrum um if they are actively infected, it's

um if they are actively infected, it's still Bactrum for 21 days. Now, you

still Bactrum for 21 days. Now, you should also consider starting uh

should also consider starting uh steroids ahead of time

steroids ahead of time and especially if they have evidence of

and especially if they have evidence of an AA gradient greater than 35 or a PCO

an AA gradient greater than 35 or a PCO a PO2 less than 70. uh because when you

a PO2 less than 70. uh because when you give the backrum to them you're

give the backrum to them you're basically going to cause licis of the

basically going to cause licis of the fungus and it's going to cause ard

fungus and it's going to cause ard basically um or oi uh basically lung

basically um or oi uh basically lung injury so it's backrum toxo is backrum

injury so it's backrum toxo is backrum so this is the one you don't want

so this is the one you don't want pregnant patients from cat feces uh

pregnant patients from cat feces uh coming in contact with that so

coming in contact with that so antimicrobial stewardship we've already

antimicrobial stewardship we've already in introduced this we do have a

in introduced this we do have a antimicrobial stewardship series um and

antimicrobial stewardship series um and a re uh uh review uh for anybody that's

a re uh uh review uh for anybody that's interested in that. Um but I'm going to

interested in that. Um but I'm going to stop right here because that was the

stop right here because that was the only really this uh last point that we

only really this uh last point that we wanted to make and we tried to introduce

wanted to make and we tried to introduce that into otitis media fngitis sinocitis

that into otitis media fngitis sinocitis bronchitis

bronchitis UTI which are high risk for

UTI which are high risk for inappropriate antimicrobial stewardship.

inappropriate antimicrobial stewardship. So make sure you're familiar with that.

So make sure you're familiar with that. Sorry we went a little long. I hope you

Sorry we went a little long. I hope you guys did learn something, found it

guys did learn something, found it enjoyable. Uh, I'm going to open up the

enjoyable. Uh, I'm going to open up the questions here.

questions here. Uh, let's see.

Um, so NCIF, when would Venko taper be the

so NCIF, when would Venko taper be the best option?

I'm not familiar with that. Do you guys, any either one of you familiar when that

any either one of you familiar when that would be the appropriate

would be the appropriate There's some different dosing regimens

There's some different dosing regimens like including that that are uh you know

like including that that are uh you know hypothetical for you know secondary or

hypothetical for you know secondary or like a secondary infe secondary

like a secondary infe secondary infection but at least a recurrence

infection but at least a recurrence definitely not empiric uh and definitely

definitely not empiric uh and definitely not the first case but I mean if they

not the first case but I mean if they haven't successfully managed it

haven't successfully managed it otherwise they can hypothetically

otherwise they can hypothetically address that at that point. So,

address that at that point. So, >> I've seen it before, but I don't know.

>> I've seen it before, but I don't know. >> I've seen it before, but I don't know.

>> I've seen it before, but I don't know. >> Okay.

>> Okay. >> Yeah, I don't think that's gonna

>> Yeah, I don't think that's gonna >> maybe for BCIDP potentially.

>> maybe for BCIDP potentially. >> I I did I do remember reading about that

>> I I did I do remember reading about that in the guidelines where they made a a an

in the guidelines where they made a a an exception for people with sort of this

exception for people with sort of this chronic situation

chronic situation >> where they may be a taper. And I thought

>> where they may be a taper. And I thought it was in the context of chronic

it was in the context of chronic recurrent. So they do a longer taper to

recurrent. So they do a longer taper to try to basically prevent them from being

try to basically prevent them from being colonized again with it. Um how do you

colonized again with it. Um how do you see COVID 19 being tested? Uh well it's

see COVID 19 being tested? Uh well it's nasoparangial

nasoparangial even though it can be in the GI tract

even though it can be in the GI tract but most places don't have a uh stool

but most places don't have a uh stool test. Um but some people there are

test. Um but some people there are saliva tests but that's not very common

saliva tests but that's not very common for most people. Uh let's see what will

for most people. Uh let's see what will they not use the brand names for heepsi

they not use the brand names for heepsi on the test? No, they won't. It'll all

on the test? No, they won't. It'll all be brand name or generic names.

be brand name or generic names. >> Sorry. Could you repeat the teasing out

>> Sorry. Could you repeat the teasing out for prep for tannophafir?

for prep for tannophafir? Uh Dr. Boland, that was you want to

Uh Dr. Boland, that was you want to mention that again?

mention that again? >> Yeah. So if you that is a tanafir

>> Yeah. So if you that is a tanafir monotherapy

monotherapy is an option for a heterosexual

is an option for a heterosexual serisordant couple. So if the if either

serisordant couple. So if the if either partner has HIV and the other doesn't

partner has HIV and the other doesn't and it's a heterosexual couple you can

and it's a heterosexual couple you can use tenophavir by itself otherwise you

use tenophavir by itself otherwise you use the trouvatada the tenafir and then

use the trouvatada the tenafir and then we have the new option with kitgrair

we have the new option with kitgrair um

um I am

I am >> so another question came up again I'm so

>> so another question came up again I'm so sorry for the pause on the on the slides

sorry for the pause on the on the slides guys um I'm sorry that happened. Um just

guys um I'm sorry that happened. Um just doing too many things and trying to move

doing too many things and trying to move it forward and so I apologize. Thanks

it forward and so I apologize. Thanks for alerting us to that. U so a question

for alerting us to that. U so a question about BC EMP emergency medicine uh and

about BC EMP emergency medicine uh and are we going to be putting out something

are we going to be putting out something and the answer is yes. uh if you want to

and the answer is yes. uh if you want to uh send us, you know, reach out to uh

uh send us, you know, reach out to uh customer service, they can put you on a

customer service, they can put you on a name, a list because we'll be rolling

name, a list because we'll be rolling out a probably a beta version of it,

out a probably a beta version of it, giving people access to things as they

giving people access to things as they are available, knowing that we may still

are available, knowing that we may still add a few things to it.

add a few things to it. I appreciate uh some of the thank yous,

I appreciate uh some of the thank yous, especially having gone long. Uh does it

especially having gone long. Uh does it really matter what order of empiric

really matter what order of empiric antibiotics you use in sepsis? And the

antibiotics you use in sepsis? And the answer is yes. You want to always use

answer is yes. You want to always use the medication that's going to provide

the medication that's going to provide the greatest coverage first most

the greatest coverage first most likelihood. So that's going to be for

likelihood. So that's going to be for let's just say it's sephop and bank. Out

let's just say it's sephop and bank. Out of the two, sephopm gets first. Why?

of the two, sephopm gets first. Why? Because it's more likely going to be a

Because it's more likely going to be a gram negative organism than it is MRSA.

gram negative organism than it is MRSA. Unless you have some reason to suspect

Unless you have some reason to suspect MRSA being the primary culprit.

MRSA being the primary culprit. Um so that's number one. Number two is

Um so that's number one. Number two is you can get sephopmia in faster than you

you can get sephopmia in faster than you can infuse fenkcomyin. Dr. Koko, any

can infuse fenkcomyin. Dr. Koko, any thoughts or comments?

thoughts or comments? >> Yeah, fully agree with that. I mean, you

>> Yeah, fully agree with that. I mean, you could Ivy push it uh get it in over

could Ivy push it uh get it in over seconds or I mean technically five

seconds or I mean technically five minutes, but uh versus being two hours

minutes, but uh versus being two hours at least. So,

at least. So, >> okay. Um there's a question about will

>> okay. Um there's a question about will we be doing anything for transplant uh

we be doing anything for transplant uh specifically for the board exam? And I'm

specifically for the board exam? And I'm sorry that we will not um it's been

sorry that we will not um it's been difficult finding enough specialists to

difficult finding enough specialists to provide enough contribution

provide enough contribution to develop that at the moment. We do

to develop that at the moment. We do have we obviously in our content cover

have we obviously in our content cover transplant but not at the level for the

transplant but not at the level for the board exam that would be necessary. So

board exam that would be necessary. So I'm sorry Cassandra for that. Uh I

I'm sorry Cassandra for that. Uh I appreciate you asking. Um if you pass

appreciate you asking. Um if you pass and you take it please reach out to us.

and you take it please reach out to us. We always we're growing our team all the

We always we're growing our team all the time. We have writers and contributors

time. We have writers and contributors all from all over the country and all

all from all over the country and all over the and different specialists and

over the and different specialists and we welcome people with transplant

we welcome people with transplant training um and they're hard to find. Um

training um and they're hard to find. Um so you're welcome. Uh would you please

so you're welcome. Uh would you please repeat the sobas

repeat the sobas phosphobir sorry uh drug interaction uh

phosphobir sorry uh drug interaction uh you mentioned and Sarah the answer is

you mentioned and Sarah the answer is amiodarone combination with it. There's

amiodarone combination with it. There's high risk of um brada cardia. In fact,

high risk of um brada cardia. In fact, you have to even monitor the patient.

you have to even monitor the patient. Um, sometimes these patients even need

Um, sometimes these patients even need to be admitted to the hospital. Um, and

to be admitted to the hospital. Um, and um they um to be monitored for it and it

um they um to be monitored for it and it and so you have to weigh the risk versus

and so you have to weigh the risk versus benefit for sure. But it's amiodarone.

benefit for sure. But it's amiodarone. Is there anything else about that Dr.

Is there anything else about that Dr. Koko or Dr. Bolan? I don't think I

Koko or Dr. Bolan? I don't think I missed it. I think that's it.

missed it. I think that's it. >> Yeah. Yeah. Not that I can add. Okay. Um

>> Yeah. Yeah. Not that I can add. Okay. Um so

so so one of you Oh yes so Cassandra please

so one of you Oh yes so Cassandra please uh email me or connect if you're on

uh email me or connect if you're on LinkedIn connect connect with us or

LinkedIn connect connect with us or connect with me or Dr. Koko uh email us

connect with me or Dr. Koko uh email us uh so we can get your contacts because

uh so we can get your contacts because you know we need more experts in some of

you know we need more experts in some of the subsp specialty areas and we'd love

the subsp specialty areas and we'd love to hire you you know if you're

to hire you you know if you're interested. Okay.

interested. Okay. Uh let's see. If no growth uh in blood

Uh let's see. If no growth uh in blood cultures and they're on empiric regimen,

cultures and they're on empiric regimen, when is it appropriate to let the

when is it appropriate to let the provider know? Any tips on AMS at work?

provider know? Any tips on AMS at work? So,

So, so if you're not having growth, you

so if you're not having growth, you know, after 48 hours and the patient,

know, after 48 hours and the patient, the patient should either be improving

the patient should either be improving clinically with what you're doing.

clinically with what you're doing. >> So, you're always treating the patient.

>> So, you're always treating the patient. >> So, follow the clinical parameters of

>> So, follow the clinical parameters of the patient first.

the patient first. Second, then when you get a lab result,

Second, then when you get a lab result, any lab result including a culture, put

any lab result including a culture, put it in context because you could even get

it in context because you could even get contaminated results or if the lab was

contaminated results or if the lab was not done correctly. What if they did the

not done correctly. What if they did the blood cultures

blood cultures in somebody that already had the

in somebody that already had the antibiotics infused or they I've

antibiotics infused or they I've actually seen this happen where the IV

actually seen this happen where the IV of the antibiotics is down here in the

of the antibiotics is down here in the hand and the lab comes in and draw while

hand and the lab comes in and draw while it's infusing they draw the blood for

it's infusing they draw the blood for the blood culture

the blood culture more proximal which means that they're

more proximal which means that they're drawing blood that has the antibiotic in

drawing blood that has the antibiotic in it.

it. [Music]

[Music] So, always put the

So, always put the context in perspective and talk to your

context in perspective and talk to your provider about why they think it's

provider about why they think it's necessary to continue this.

necessary to continue this. >> Certainly by the the fourth day and Dr.

>> Certainly by the the fourth day and Dr. Bolan and Koko, please jump in. I mean,

Bolan and Koko, please jump in. I mean, um, sometimes things aren't as black and

um, sometimes things aren't as black and white. That is not a board question.

white. That is not a board question. We're talking about

We're talking about >> clinical issues here is what we're

>> clinical issues here is what we're talking about. So this is not board

talking about. So this is not board exam. It is going to be definitive for

exam. It is going to be definitive for the board exam.

the board exam. >> Okay. So

>> Okay. So >> yeah, I I would just echo one of the

>> yeah, I I would just echo one of the things you're leading that like that

things you're leading that like that that whole discussion with and and and

that whole discussion with and and and you definitely know. So like that was a

you definitely know. So like that was a essentially a quote from Dr. Oller. You

essentially a quote from Dr. Oller. You treat the patient not the numbers. So

treat the patient not the numbers. So it's just one of those elements where

it's just one of those elements where that would incorporate where yes you

that would incorporate where yes you don't have a positive culture but let's

don't have a positive culture but let's reinccorporate it into the patient

reinccorporate it into the patient understand that whole context rather

understand that whole context rather than just you know relying on that full

than just you know relying on that full lab and then try to carry on. It has to

lab and then try to carry on. It has to be patient oriented first.

be patient oriented first. >> Yeah. And I would say you know we talk a

>> Yeah. And I would say you know we talk a lot about antimicrobial stewardship and

lot about antimicrobial stewardship and let's don't use them don't use them.

let's don't use them don't use them. Don't use them but it's when you don't

Don't use them but it's when you don't have to. So don't be overzealous with

have to. So don't be overzealous with that. So, I've seen it,

that. So, I've seen it, >> right?

>> right? >> I mean, I've seen it unfortunately go

>> I mean, I've seen it unfortunately go the other way where providers like

the other way where providers like almost killed patients because they were

almost killed patients because they were not paying attention to the patient and

not paying attention to the patient and going forward with treatments,

going forward with treatments, especially in thinking about blood

especially in thinking about blood cultures. I think about fungal, uh, you

cultures. I think about fungal, uh, you know, when you get candidia,

know, when you get candidia, um, and you know, those take a while to

um, and you know, those take a while to grow. So again, if you're looking at the

grow. So again, if you're looking at the patient and they're sick, you know, you

patient and they're sick, you know, you want to be careful and you want to start

want to be careful and you want to start thinking through some other avenues. Uh

thinking through some other avenues. Uh but again, that's clinical. You know,

but again, that's clinical. You know, they're they're going to have to give

they're they're going to have to give you something clear for an exam. But

you something clear for an exam. But clinically, just scream that from the

clinically, just scream that from the rooftops. Treat your patient. Um you

rooftops. Treat your patient. Um you know, think about what what you're

know, think about what what you're seeing. And ju and just one other little

seeing. And ju and just one other little point again probably a little bit more

point again probably a little bit more in the clinical realm than not than a

in the clinical realm than not than a board exam um is that if your patient

board exam um is that if your patient some patients you know we talk about a

some patients you know we talk about a duration 7 days 10 days

duration 7 days 10 days there are some situations in clinical

there are some situations in clinical practice that we will continue beyond

practice that we will continue beyond that because they just need it for a

that because they just need it for a longer period but if they're improving

longer period but if they're improving on it and they need a little longer then

on it and they need a little longer then you keep going uh I would suspect you

you keep going uh I would suspect you know thinking about even Dr. Cookio's

know thinking about even Dr. Cookio's practice who's in toxicologist.

practice who's in toxicologist. You know, if you've got a a liver

You know, if you've got a a liver patient or I'm sorry, a patient with

patient or I'm sorry, a patient with Tylenol overdose and they have a

Tylenol overdose and they have a penetellular damage

penetellular damage and you finish the anacettocysteine

and you finish the anacettocysteine treatment, but they're still having some

treatment, but they're still having some evidence of ongoing damage, but still

evidence of ongoing damage, but still maybe doing better. You're going to go

maybe doing better. You're going to go beyond the treatment.

beyond the treatment. >> Oh, yeah.

>> Oh, yeah. >> So, you're not stopping. So, that's

>> So, you're not stopping. So, that's where I think Dr. Boland and what we're

where I think Dr. Boland and what we're trying to you know we're teas fleshing

trying to you know we're teas fleshing out here a little bit uh the the nuances

out here a little bit uh the the nuances of clinical practice variations that are

of clinical practice variations that are patient specific.

patient specific. Uh but just please keep in mind that we

Uh but just please keep in mind that we are that is nothing to do with the board

are that is nothing to do with the board exam. Yeah. Sure. Um so and I'm not

exam. Yeah. Sure. Um so and I'm not saying board exams are clinically

saying board exams are clinically irrelevant. That is not what I'm saying.

irrelevant. That is not what I'm saying. Board exams have very appropriate

Board exams have very appropriate questions

questions >> but they have to be wellestablished as I

>> but they have to be wellestablished as I said at the very beginning. So, if

said at the very beginning. So, if you're digging into the weeds, you're

you're digging into the weeds, you're reading about class 2B recommendations

reading about class 2B recommendations and things that are being debated,

and things that are being debated, you're in the wrong content for the

you're in the wrong content for the board exam. You have got to have the

board exam. You have got to have the right mindset and play the game for the

right mindset and play the game for the board exam. So, please make sure you

board exam. So, please make sure you factor that in. Um, we're running out of

factor that in. Um, we're running out of time here. Um, and we're gonna we're

time here. Um, and we're gonna we're going to be shutting off here on us. Um,

going to be shutting off here on us. Um, but there was a question about MRSA and

but there was a question about MRSA and and like what are the risk factors for

and like what are the risk factors for MRSA and pseudomonus?

MRSA and pseudomonus? Um, Dr. Cookio or or Dr. Bolan, any

Um, Dr. Cookio or or Dr. Bolan, any comments about that? I mean, I I can

comments about that? I mean, I I can chime in here, but do you guys have

chime in here, but do you guys have anything?

anything? >> Nothing specific.

>> Nothing specific. >> Okay. So, basically what you're looking

>> Okay. So, basically what you're looking for

for obviously patients in a nose hospital

obviously patients in a nose hospital environment are higher risk for MRSA,

environment are higher risk for MRSA, right? and and it's certainly if they've

right? and and it's certainly if they've had recurrent infections or known

had recurrent infections or known history that's huge. There are people

history that's huge. There are people who are colonized with it and they get

who are colonized with it and they get recurrent infections. I see them all the

recurrent infections. I see them all the time. Okay. Um on top of that you have

time. Okay. Um on top of that you have indwelling folate catheterss or

indwelling folate catheterss or indwelling catheterss or central lines

indwelling catheterss or central lines uh pick lines those kind of things

uh pick lines those kind of things certainly put you at greater risk. Um

certainly put you at greater risk. Um when you think about sudamonus again

when you think about sudamonus again people that are in multiple healthc care

people that are in multiple healthc care environments even MRSA are high risk um

environments even MRSA are high risk um they have other imuninompromised states

they have other imuninompromised states or coorbidities that put them at risk

or coorbidities that put them at risk for sudamonis environments like you know

for sudamonis environments like you know in the ICU put them at higher risk um

in the ICU put them at higher risk um you know previous drug exposures put

you know previous drug exposures put them at risk so that's why antimicrobial

them at risk so that's why antimicrobial stewardship is so important because we

stewardship is so important because we don't want to breed resistance in a

don't want to breed resistance in a particular patient. Um, and there's more

particular patient. Um, and there's more than that and I'm sorry it's like off

than that and I'm sorry it's like off the top of my head I'm forgetting

the top of my head I'm forgetting there's a couple other ones there but um

there's a couple other ones there but um okay guys I think that's it.

okay guys I think that's it. Smoke coming out of your ears. You guys

Smoke coming out of your ears. You guys still awake some of you? All right. No,

still awake some of you? All right. No, seriously guys, I hope you found it to

seriously guys, I hope you found it to be helpful. Thank you for joining us.

be helpful. Thank you for joining us. Sorry we went a little bit long. Uh we

Sorry we went a little bit long. Uh we will uh readjust some of that for the

will uh readjust some of that for the next section. I think the actual the

next section. I think the actual the next ones are a little bit easier

next ones are a little bit easier anyway. Um but again, any feedback or

anyway. Um but again, any feedback or questions you might have, please email

questions you might have, please email us. Happy to help. If you need

us. Happy to help. If you need resources, you're not a customer and

resources, you're not a customer and you're not sure or your plans change.

you're not sure or your plans change. Please don't hesitate to reach out to

Please don't hesitate to reach out to us. Uh if you need to upgrade or you

us. Uh if you need to upgrade or you bought a different package or you ran

bought a different package or you ran out of time and you tried to change your

out of time and you tried to change your plans, we'll work with you. just reach

plans, we'll work with you. just reach out to us. Um if not, you're using

out to us. Um if not, you're using something else, best of luck to you. Uh

something else, best of luck to you. Uh the the goal here is to invest in the

the the goal here is to invest in the next generation of clinical farms who

next generation of clinical farms who are board certified to go on and

are board certified to go on and continue to do good things. So take

continue to do good things. So take care, guys.

care, guys. Okay.

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