This topic is full of clinical pearls, interesting pharmacology, practical decision tools and my favorite…pseudoaxioms!

Quick Pimps: Acute GI Bleeding PDF Preview

Disclaimer: this cartoon is meant to say NG tubes are safe. Their efficacy is up for debate.

Our goal in medicine is to gather and organize data, interpret that data and ultimately make decisions in the prevention, diagnosis, and management of disease.  The initial part of this system is to ensure that adequate and correct data is collected and interpreted with knowledge of the process and shortcomings that the data was collected with.

Discussion includes vital signs, pulse oximetry, blood gases, capnography/end-tidal C02 (ETC02) and more.  It is important to recognize where vital signs can trick you, how to deal with pulse oximetry latency and how blood gases and ETC02 can be interpreted in the setting of shock.

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Monitoring Critically Ill Patients PDF

Assali AR, Herz I, Vaturi M, Adler Y, Solodky A, Birnbaum Y, Sclarovsky S. Electrocardiographie criteria for predicting the culprit artery in inferior wall acute myocardial infarction. Am. J. Cardiol. 84(1); 87-9

Ding ZN, Shibata K, Yamamoto K, Kobayashi T, Murakami S. Decreased circulation time in the upper limb reduces the lag time of the finger pulse oximeter response. Can J Anaesth. 1992 Jan;39(1):87-9.

Goldberg AL. Electrocardiogram in the diagnosis of myocardial ischemia and infarction. In: UpToDate, Ganz, LI (Ed , UpToDate, Waltham, MA, 2013.

Goldberger AL, Stein PK. Evaluation of heart rate variability. In: UpToDate, Ganz, LI (Ed), UpToDate, Waltham, MA, 2013.

Elert, Glenn (2005). “Temperature of a Healthy Human (Body Temperature)”. The Physics Factbook. Retrieved 2007-08-22.

Ellender TJ, Skinner JC. The use of vasopressors and inotropes in the emergency medical treatment of shock. Emerg Med Clin N Am. 26 (2008) 759-786

Jin x, Weil MH, Tang W, Povoas H, Pernat A, Xie J, Bisera J. End-tidal carbon dioxide as a noninvasive indicator of cardiac index during circulatory shock. Crit Care Med. 2000 Jul;28(7):2415-9.

Kelly G (December 2006). “Body temperature variability (Part 1): a review of the history of body temperature and its variability due to site selection, biological rhythms, fitness, and aging”. Altern Med Rev 11 (4): 278–93. PMID 17176167.

Levin T, Goldstein JA. Right ventricular myocardial infarction. UpToDate

Mackay MH, Ratner PA, Johnson JL, Humphries KH, Buller CE. Gender differences in symptoms of myocardial ischaemia. Eur Heart J 2011;32:3107-3114.

Mackowiak, P. A.; S. S. Wasserman, M. M. Levine (1992-09-23). “A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich”. JAMA 268 (12): 1578–1580. doi:10.1001/jama.268.12.1578. PMID 1302471. Retrieved 2007-08-22.

Marino, Paul. The ICU Book, 3rd Edition. Ovid Technologies, Inc. 2006

Mateer, J.R., et al. Continuous pulse oximetry during emergency endotracheal intubation. Ann Emerg Med 1993;22(4):675-9.

Meyers CM, Weingart SD. Critical Care Monitoring In The Emergency Department. Emergency Medicine Practice. 2007;(9)7:1-23.

Reeder GS, Kennedy HL, Rosenson RS. Overview of the acute management of ST elevation myocardial infarction. UpToDate

Ryan TJ, Reeder GS. Initial evaluation and management of suspected acute coronary syndrome in the emergency department. UpToDate

Prause G, Hetz H, Lauda P, Pojer H, Smolle-Juettner F, Smolle J. A comparison of the end-tidal-CO2 documented by capnometry and the arterial pCO2 in emergency patients. Resuscitation. 1997 Oct;35(2):145-8

Polielinicio SD. Use of inhaled nitric oxide in the treatment of right ventricular myocardial infarction. Am. J. or Emerg. Med. 29;473.e3-473.e5

Spalding MB, Ala-Kokko TI, Kiviluoma K, et al. Inhaled nitric oxide effectively decreases right heart afterload following right heart infarct in pigs. Scand Cardiovasc J 2001;35(1):45-9

Weingart S. Physiology of oxygenation. Emcrit audio podcast

ARDS PDF

ARDS Podcast

No matter how many times I have memorized these syndromes I feel like the information is gone after a week.  I looked around for helpful study tips but since most use a combination of “this many Ps and that many Ms”…yet everything is a P or M, I was lost.

I made this diagram because I am a visual learner and it only seemed right to point out that there are only a few differences.  I hope this helps for boards.  This seems to show up on every USMLE and COMLEX.

Multiple Endocrine Neoplasias

OMT In Hospice and Palliative Care PDF

Approach to Rheumatic Patient

Criteria and Rules Sheet

DidacticsOnline is growing thanks to its great followers.  Thank you for the comments and support!  Please email with any comments or suggestions.

Stats from 2012:

4,329 films were submitted to the 2012 Cannes Film Festival. This blog had 18,000 views in 2012. If each view were a film, this blog would power 4 Film Festivals

The busiest day of the year was November 20th with 348 views.

How did they find you?

The top referring sites in 2012 were:

1. facebook.com
2. youtube.com
3. reddit.com

Some visitors came searching, mostly for didactics online, didacticsonline, didacticsonline.com, brandon masi parker, and prolotherapy.

Where did they come from?

• Ws mnemonic
  • POD 1-2: Wind– Pneumonia, Aspiration, PE (NOT ATELECTASIS…listen to podcast for more details)
  • POD 3-5: Water– UTI
  • POD ~5: Walking– DVT, PE
  • POD ~7: Wound– Surgical Site Infection
  • POD >7: What we did– Line infections of drug/blood product reactions at any time
  • POD >10: Wonder Where?- Deep Abcess

Causes of Postoperative Fever Podcast

Postoperative fever notes

Evaluating postoperative fever: A focused approach. By James C. Pile MD

How to Present a Patient Podcast

Approach to the Oral Presentation PDF

Article by Greeen et al on the SOAPS method for OCPs

Treatment of Hyperkalemia Podcast

Treatment of Hyperkalemia Powerpoint

Please subscribe to our podcast and youtube channel and follow us on facebook and Google+.

COPD Podcast

To Join via Webcam: Follow DidacticsOnline on Google+ and send an email to didacticsonline@gmail.com prior to Monday night to let us know you want to join via webcam chat live OR,

To Watch Review Live: Go to YouTube.com/didacticsonline to watch the review live.

We encourage you to email didacticsonline@gmail.com with OPP questions prior to the review. Watch the review live to see your question answered. We will also be monitoring emailed questions throughout the review.

If you will be joining us via webcam make sure to sign on by 6:45 PM to make sure everything is working correctly.  Also you can not join via iPad.

This review is not affiliated with Nova Southeastern University and the review does NOT represent the views or opinions of Nova Southeastern University.

Cranial Intro Video

Cranial Strain Patterns

There are also some great videos from another user on YouTube at http://www.youtube.com/user/jvh981/videos.  DidacticsOnline has no affiliation with this person.

Stroke and TIA podcast

Stroke and TIA Powerpoint

des Anges Cruser, Couglad Maurer, Kendi Hensel, Sarah K Brown, Kathryn White, Scott T Stoll in the Journal of Manual & Manipulative Therapy,  Volume 20, Number 1, 2012 , pp. 5-15(11).

This article is a crucial randomized and controlled study analyzing the effectiveness of Osteopathic Manipulative Treatment (OMT) for acute low back pain (LBP) in active military personnel.  The article analyzes pain, functionality and a few other parameters.  I make the assertion that this unique subset of population may provide a model for other LBP patients that have physically demanding lifestyles with limited possibility for rest.

OMT for acute LBP in military personnel; journal review podcast

Prostate Disease podcast

On April 21 from 10am-3pm at the Westin Diplomat on 3555 South Ocean Drive in Hollywood, Fl 33019.

Symposium Flyer

Back pain interview with Dr Fossum

Interview with Dr. Danto on Muscle Function

Please stay tuned and come say hi if you see us walking around in our stylish DidacticsOnline shirts.

Anemia Podcast

Diabetes Podcast

Diabetes mellitus Powerpoint

Cranial’s Effect on Cerebral Tissue Oxygenation Journal Review Podcast

Cranial Article Journal Review Powerpoint

Xiangrong Shi, PhD; Seth Rehrer, OMS IV; Parna Prajapati, MBBS, MPH; Scott T. Stoll, DO, PhD; Russell G. Gamber, DO, MPH; and H. Fred Downey, PhD. (2011). Effect of Cranial Osteopathic Manipulative Medicine on Cerebral Tissue Oxygenation. Journal of the American Osteopathic Association 111(12), 660-666.

Irritable Bowel Syndrome Podcast

IBS Powerpoint

Prolotherapy Interview Podcast

In the interview we discuss a case where prolotherapy is used on a young male with an ACL tear.  Below are the MRI images from before and after a prolotherapy regimen.

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HAPPY MARDI GRAS POST

Effects of Manipulation Podcast

Peripheral Vascular Disease Podcast

Peripheral Vascular Disease Powerpoint

Coronary Artery Disease Podcast

Migraine Interview Podcast

American Headache Society

American Headache Society Committee on Headache Education (ACHE)

Dr. Winner’s website

Osteoporosis podcast

Tara Nowakhtar reviews the article by Donald Noll et al, Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial published in Osteopathic Medicine and Primary Care in 2010.

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial.

Asthma Podcast

Asthma Powerpoint

Dizziness and Vertigo podcast

Dizziness and Vertigo Powerpoint Presentation

Carpal Tunnel Syndrome podcast

Video for Provocative Maneuvers in CTS diagnosis

Carpal tunnel syndrome (CTS) is the most commonly diagnosed and treated nerve entrapment syndrome, affecting approximately 3-6% of the population.¹ CTS can present as an acute form caused by a major trauma, or more often as a chronic condition.²  Although the etiology of CTS varies, the most common cause is repetitive stress injury to the wrist, leading to flexor tenosynovitis.³  The symptoms of CTS are caused by compression of the median nerve at the wrist, with ischemia and impaired axonal transport of the median nerve across the wrist.⁴  The standard first line treatment for CTS is rest, immobilization, avoiding aggravating activities and modifying physical activities, and nonsteroidal anti-inflammatory drugs (NSAIDs).  Conservative treatment is effective in approximately 80% of patients but if these modalities fail, positive results ranging from 56-73% of patients treated has been seen with local anesthetics and corticosteroid injections.⁵  If these treatment options are unsuccessful then surgery is indicated.  Studies comparing surgical versus non-surgical patients have shown symptoms improving in both groups but with surgical treatment leading to a better outcome than current nonsurgical.⁶  Complications among these surgical procedures are uncommon. Approximately 1-2% of patients, experience nerve, tendon, and blood vessel laceration, infection, scar tenderness, damage to the median nerve, pain, hematoma, reflex sympathetic dystrophy, and potential repeat surgery if the procedure is unsuccessful.^7,8

Among the non-surgical techniques available is osteopathic manipulative treatment (OMT), which was shown to be a safe and effective method of treatment for mild to moderate CTS.⁹  The goal of OMT in the treatment of CTS is to stretch soft tissues, release tissue adhesions, free restricted metacarpal and carpal bones, increase range of motion, strengthen the muscles, and remove edematous fluid, resulting in improvement in circulation and nerve function.³  Sucher was able to show through MRI measurements that manipulation is capable of increasing the transverse and AP dimensions of the carpal canal.  Sucher also showed improvement in nerve conduction studies within 1-3 months of manipulative treatment.⁹  Median sensory and motor nerve conduction studies have been shown as valid and reproducible clinical laboratory studies that confirm a clinical diagnosis of CTS with a high degree of sensitivity and specificity.¹⁰  However, Sucher’s studies were conducted with small sample sizes, with test groups ranging from 4-9 patients and a control group of 13 patients.  Although multiple studies have shown the effectiveness of osteopathic manipulative medicine for CTS, future research to enhance the clinical efficacy is still warranted.³

1)      Atroshi, I., et al. Prevelance of carpal tunnel syndrome in a general population. Jama 282, 153-158 (1999)

2)      Naranjo A, Ojeda S, MendozaD, et al. What is the diagnositc value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome?. Clin /exp Rheumatol. Nov-Dec 2007; 25(6): 853-9.

3)      Siu, G. Osteopathic Manipulative Medicine for Carpal Tunnel Syndrome. AOCPMR.

4)      Lundborg G, Dahlin LB. The pathophysiology of nerve compression. Hand clin. May 1992; 8(2): 215-27

5)      Dammers, J.W., Roos, Y., Veering, M.M. &Vermeulen, M. Injection with methylprednisolone in patients with carpal tunnel syndrome: a randomized double blind trial testing three different doses. J. Neurol 253, 574-577 (2006)

6)      Jarvik JG, Comstock BA, Kliot M, Turner JA, Chan L, Haegerty PJ, et al. Surgery bersus non-surgical therapy for carpal tunnel syndrome: a randomized parallel-group trial. Lancet. Sep 26 2009; 374 (9695): 1074-81

7)      Gerritsen, A.A., et al. Splinting vs surgery in the treatment of carpal tunnel syndrome : a randomized controlled trial. JAMA 288, 1245-1251 (2002)

8)      Boeckstyns, M.E.& Sorensen, A.I. Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? An analysis of published series. J Hand surgery 24, 9-16 (1999)

9)      Sucher BM. Palpatory diagnosis and manipulation management of carpal tunnel syndrome. Journal of American Osteopathic Association 1994; 94;647-663

10)  Jablecki CK, AndaryMT, So YT, WilkinsDE, Williams FH. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. AAEM Queality Assurance Committee. Muscle Nerve 1994. Dec; 17 (12): 1490-1

Osteopathic Medicine and Surgery Podcast

Below are some cited resources:

Jarski RW et al. The effectiveness of osteopathic manipulation treatment as complementary therapy following surgery: a prospective, match-controlled outcome study. September 2000 77-81

O-Yurvati, A. et al. Hemodynamic Effects of Osteopathic Manipulation Treatment Immediately After Coronary Artery Bypass Graft Surgery. J Am Osteopath Assoc. October 2005 10:105

Stiles, EG. Osteopathic manipulation in a hospital environment. J Am Osteopath Assoc.  December 1, 1976 76:243

Sleszynski & Kelso. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. J Am Osteopath Assoc. August 1, 1993 93:834

The knee is the largest joint in the human body when considering volume and surface area of articular cartilage and the size and complexity of the articulation lend to susceptibility to acute injury, chronic wear and tear and arthritis (inflammatory and septic).  It is important to recognize the various etiologies of knee pain.  This podcast aims to provide an overview of the topic of knee pain and help you develop a differential diagnosis.  We also have a section at the end specifically discussing the somatic dysfunctions of the knee.

Video for Orthopedic Exam of the Knee

Scott Sandilands OMS III discusses a pediatric case study with us on Bell’s Palsy.  We also discuss some etiologies, approach to diagnosis and treatment of both adult and pediatric Bell’s Palsy cases as well as some success that Osteopathic manipulation has had with these patients.

John Gentile OMS III discusses Venous Thromboembolism.  In this podcast the etiologies, clinical management and risks of Deep Venous Thrombosis and Pulmonary Embolisms will be discussed.  Please join in the discussion with any questions or comments.  We hope to act as a source for review and summary on these topics as well as a catalyst for further discussion on these very pervasive and dangerous pathologies.