29 episodes

Host Jason Woods MD is a pediatric emergency medicine physician, interested in high-quality foamed for those taking care of children in all emergent and urgent forms. Episodes are largely interviews with experts on current topics, research, and changes in medical practice.

Little Big Med Little Big Med

    • Education

Host Jason Woods MD is a pediatric emergency medicine physician, interested in high-quality foamed for those taking care of children in all emergent and urgent forms. Episodes are largely interviews with experts on current topics, research, and changes in medical practice.

    Episode 24: Metabolic Resuscitation for Pediatric Septic Shock

    Episode 24: Metabolic Resuscitation for Pediatric Septic Shock

    On this episode, host Jason Woods speaks with Dr Nelson Sanchez-Pinto, pediatric intensivist, about an article he co-authored that was just e-published in the last week! The article concerns a retrospective analysis of the use of HAT therapy (hydrocortisone, ascorbic acid, thiamine) at a single center PICU for the treatment of pediatric septic shock. The e-pub link is below and this post will update when it is published in print. This topic has caused significant controversy and strong emotions for the last several years, and I expect that to continue. Please take a look at the additional resources below, as well as Dr. Sanchez-Pinto’s twitter feed (@nelsonspinto), for even more information.







    E-publication link: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1543LE







    The highlights:







    * Study details* Single center, retrospective, propensity score matched * 557 septic shock patients in the PICU* 43 received HAT, 181 hydrocortisone alone, 333 neither* HAT patients matched 1:1 with the other groups* Results* HAT patients had lower mortality at 30-days (9 vs 28%, P=0.03) and 90-days (14 vs 37%, P=0.01) compared to no HAT or hydrocortisone* Similar results comparing mortality in HAT to those with hydrocortisone alone – 30-day (9 vs 30%, p=0.01) and 90 day (14 vs 37%, p=0.01)* No difference at 30 days in vasoactive free days or hospital free days







    Guests







    Nelson Sanchez-Pinto MD, Assistant Professor of Pediatrics and Preventative Medicine, Northwestern University, Feinburg School of Medicine







    Pediatric Intensivist, Anne and Robert H. Lurie Children’s Hospital of Chicago







    References







    1.         Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238.







    2.         Wilson JX. Mechanism of action of vitamin C in sepsis: ascorbate modulates redox signaling in endothelium. Biofactors. 2009;35(1):5-13.







    3.         Fowler AA, 3rd, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.







    4.         Spoelstra-de Man AME, Elbers PWG, Oudemans-van Straaten HM. Making sense of early high-dose intravenous vitamin C in ischemia/reperfusion injury. Crit Care. 2018;22(1):70.







    5.         Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.







    6.        Wald EL, Sanchez-Pinto LN, Smith CM, Moran T, Badke CM, Barhight MF, Malakooti MR. Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am Journal Respr and Crit Care Med. E-pub ahead of print. PMID: 31916841. DOI: https://doi.org/10.1164/rccm.201908-1543LE







    7.        Fowler AA, Trust JD, Hite RD. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure – The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. doi:10.1011/jama.2019.11825















    Additional Resources

    • 19 min
    Episode 23: Nephritis

    Episode 23: Nephritis

    What is it and why are there so many names?















    On this episode, host Jason Woods speaks with Dr. Danielle Soranno, pediatric nephrologist, about nephritis in children. What is it, why are the terms so confusing, how do we diagnosis it, and when should we involve a nephrologist? Did the nephrologists invent terminology just to confuse us?







    Guests







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







    References







    * Floege J, Amann K. Primary glomerulonephritides. Lancet. 2016 May;387:2036-2048.* Brogan P, Eleftheriou D. Vasculitis update: pathogenesis and biomarkers. Pediatr Nephrol. 2018 Feb;33:187-198.* Chadban SJ, Atkins RC. Glomerulonephritis. Lancet. 2005 May;365:1797-1806.

    • 19 min
    Episode 22: Risk Factors for Bronchiolitis Care Escalation

    Episode 22: Risk Factors for Bronchiolitis Care Escalation

    On this episode, host Jason Woods speaks with Dr. Gabrielle Freire about her work with PERN (Pediatric Emergency Research Network) and evaluation of predictive risk factors for escalation of care in bronchiolitis.







    THE BOTTOM LINE:







    Multiple risk factors were found that predicted escalated care in infants. Infants aged 12 months old with bronchiolitis but without predictors have a low risk of receiving escalated care (1%) and may be candidates for outpatient management. Infants with increasing numbers of predictors are at a increasing risk of requiring escalated care and need consideration for in patient care with expertise in paediatric airway support.







    The highlights:







    * Background* Bronchiolitis is responsible for ~ 16% of all hospitalizations in the first year of life* The cost incurred from bronchiolitis admissions is thought to be ~ $1.78 billion every year in the US and Canada * Study methods* Retrospective cohort study of a previously collected database of infants aged 12 months with clinical diagnosis of bronchiolitis* Inclusion* Bronchiolitis defined as viral respiratory infection with respiratory distress* Age 12 months or younger* Visits from Jan – Dec 2013 collected as part of PERN* First episode of bronchiolitis only* Exclusion* Comorbidities such as chronic lung disease, congenital heart disease, immunodeficiency, renal or liver insufficiency, neuromuscular disorders* Prior episode of diagnosed bronchiolitis* Results* 2722 patients included* 261 (9.6%) required escalated care* Predictors included in the final model* O2 sats 90 (OR 8.9)* Nasal flaring/grunting (OR 3.76)* Apnea (OR 3.01)* Retractions (OR 3.02)* Age 2 months (OR 2.1)* Concomitant dehydration (OR 2.13)* Poor feeding (OR 1.85)* Discussion points (detailed in the audio)* Respiratory rate and retractions were co-linear, so RR was not included in the final model* The risk score “points” were assigned by diving the OR by 2 to give a total score of 14* Duration of illness was not found to be a significant predictor – this may be due to the lack of granularity of the data (only available in days rather than hours)* Oxygen saturation had the highest OR by a substantial margin







    Guests







    Gabrielle Freire MD, Paediatric Emergency Physician, The Hospital for Sick Children, Department of Paediatrics University of Toronto, Toronto, Ontario, CA.







    Important Resources







    * PERN website







    References







    * Freire G et. al. for the Pediatric Emergency Research Networks (PERN). Predicting Escalated CAre in Infants with Bronchiolitis. Pediatrics. 2018 Sept 142;3. PMID: 30126934.

    • 19 min
    Little Big Little: What is Vaping?

    Little Big Little: What is Vaping?

    This is the first segment in a series of “shorts” – smaller quick hit episodes on a focused topic. I’m going to affectionately call them “Little Big Littles”.







    On this Little Big Little, host Jason Woods speaks with Dr. Heather Hoch about what we might need to know about vaping to take care of our patients.







    Guests







    Heather Hoch MD – Assistant Professor, Dept. of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado







    Important Resources







    * CDC Electronic Cigarette Information* Smokefree.gov

    • 12 min
    Episode 21: HIV Screening in the Pediatric ED

    Episode 21: HIV Screening in the Pediatric ED

    On this episode, host Jason Woods speaks with Dr. Amy Grover about HIV screening in the pediatric emergency department. Dr. Grover works in both the section of emergency medicine and hospital medicine and has an interest in HIV screening.







    The highlights:







    * An estimated 50% of adolescents with HIV do not know they have contracted HIV* Acute retroviral syndrome has many non specific symptoms and can be difficult to diagnosis but includes the following* Fever* Fatigue* Myalgias* Nausea, vomiting, and/or diarrhea* Rash that can involve the hands and feed* Pharyngitis is typically not as exudative as EBV* CDC guidelines recommend that EVERY person ages 13-64 who is sexually active be screened for HIV at least once in their lives, and yearly if ongoing risk for exposure* One of the difficult aspects of setting up a screening program is deciding who is responsible for follow up of the results. Each institution will have to discuss what is appropriate for their setting* Do not forget to evaluate for risk of other STI, including Syphilis (prevalence is rising in the US)* Most rapid screening tests that do not use whole blood can not detect HIV infection until there is an antibody response (3 weeks – 3 months)* The 4th generation HIV test can detect infection starting as early as 15 days after infection. Note that there is still a latent period when detection is not possible. * One of the important reasons to screen patients is that there is evidence that knowledge of HIV infection decreases high-risk behavior.* The benefit and effect of HIV screening may depend on the regional HIV rates







    Guests







    Amy Grover MD – University of Colorado School of Medicine, Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado







    Important Resources







    * CDC HIV Resource Library







    References







    * Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatric Adolesc Med. 2000 Apr;154(4):361-5.* Kitahadta MM, et al. Effect of Early vs Deferred Antiretroviral therapy for HIV on Survival. NEJM 2009;360(18):1815-26.* Marks G, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr.2005 Aug 1;39(4):446-53. * Cohen MS, et al. Antiretroviral Therapy for the prevention of HIV-1 Transmission. NEJM 2016; 375(9):830-839.* Marks G, et al. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS.2006 Jun 26;20(10):1447-50.* Wood E, et al. Does this Adult Patient have Early HIV infection? JAMA 2014; 213 (3): 278-285.* Mehta AS, et al. Practices, Beliefs, and Perceived Barriers to Adolescent Human Immunodeficiency Virus Screening in the Emergency Department. Pediatr Emerg Care 2015; 31:621-626.* Akhter A, et al. Rapid Human Immunodeficiency Virus Testing in the Pediatric Emergency Department: A National Survey of Attitudes Among Pediatric Emergency Practitioners. Pediatr Emerg Care 2012; 28:1257-1262.

    • 24 min
    Episode 20: HIV Pre-exposure Prophylaxis (PrEP)

    Episode 20: HIV Pre-exposure Prophylaxis (PrEP)

    On this episode, host Jason Woods speaks with Martin Walker (Director of HIV Programs for Planned Parenthood of the Rocky Mountains) and Moises Munoz (Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado) about pre-exposure prophylaxis for HIV (PrEP).







    The highlights:







    * The only FDA approved PrEP regimen the combination product of emtricitabine/tenofovir (brand name Truvada) * It was approved in 2012 for PrEP* Typical dosing is one pill (200/300) once per day, for patients > 35 kg (regardless of age)* Prior to the start of PrEP, counseling and labs are suggested* Labs required before the start of PrEP include baseline creatinine and UA, negative studies for HIV and Hepatitis, pregnancy if applicable, and other STIs (all of these are included in ongoing monitoring as well)* Counseling should include discussion of risk factors, compliance, required testing, need for continued protection from other STIs* Generally not recommended to use in patients with GFR 60* From the start of use, different tissues require different amounts of time to reach effective concentrations. There is not clear data on this but Martin suggests 7 days for receptive anal intercourse and 21 days for receptive vaginal intercourse.* Some studies suggest that for penile-anal intercourse, as few as 4 doses per week may be effective.* See below for training resources







    Guests







    Martin Walker – Director of HIV Programs for Planned Parenthood of the Rocky Mountains







    Moises Munoz – Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado







    Important Resources







    * HRSA’s Aids Education and Training Center (AETC)* CDC Youth HIV 2019 Infographic







    References







    * Hosek S, Rudy B, Landovitz R, et. al. “An HIV Pre-Exposure Prophylaxis (PrEP) Demonstration Project and Safety Study for Young MSM”. J Acquir Immune Defic Syndr. 2017 Jan 1; 74(1): 21–29. PMID: 27632233* Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis 2014; 14:820. PMID: 25065857.* Krakower DS, Mayer KH. Pre-exposure prophylaxis to prevent HIV infection: current status, future opportunities and challenges. Drugs 2015; 75:243. PMID: 25673022.* Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med 2012; 4:151. PMID: 22972843.* Seifert SM, Glidden DV, Meditz AL, et al. Dose response for starting and stopping HIV preexposure prophylaxis for men who have sex with men. Clin Infect Dis 2015; 60:804. PMID: 25409469* Anderson PL, Meditz A, Zheng JH. Cellular pharmacology of TFV and FTC in blood, rectal, and cervical cells from HIV- volunteers. Presented at the Conference on Retroviruses and Opportunistic Infections 2012.

    • 21 min

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