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OCT 2013 1) Well you got to start somewhere, and the rectum is as good of a place as any. Ah yes, the delicate pleasure of a digital rectal e am. !es the e citement, the challenge. The deep philosophical meaning of melena. "ut why do we need that cosmic message in the #$% Well, $r. &essler has what to say on this. This test has is rarely useful o'erall. (t does not help in detecting urethral tears in trauma )ha'e you e'er felt a high riding prostate% Or *etter yet+ do you ,now what this is
supposed to feel li,e%.or years we ,now it won/t help for appendicitis and it isn/t relia*le
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have a beautiful little girl who we named after my mother in law; in fact Passive Aggressive Psycho turns five tomorrow.
D- This article says that #$ physicians were good at detecting $ET *y their ultrasounds )Throm* 3aem 101)1-13:- 0ay*e, *ut this is a meta analysis and a small one to *oot. 4o this article also says that #$ physicians were good at detecting $ET *y their ultrasounds )A9#02;)3-3<D-. This one was done *y =ltrasound guru $r. "lai'as, and compared us to CTE. "ut it was a tiny study. And was done in patients with a suspicion of ?# so they may ha'e *igger clots and may *e easier to see. 4o another article says that #$ physicians were good at detecting $ET *y their ultrasounds. )A#0 1D)3-212-. "ut they
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You #now( $ome*ody a"tually "om!limented me on my driving today& They le%t a little note on the wind$"reen( it $aid 'Par#ing +ine&' ,o that wa$ ni"e& Tim 'ine again 7) >eurologists lo'e to classify headaches *ut almost e'eryone ( ,now has a headache which doesn/t really fit anyone category. 4o when they re'iew cluster headaches in this article F really all these inter'entions can help for other headaches+ so we ha'e presented in the past in #0=. 4o let/s cut to the chase, do not forget that steroids and o ygen may help and remem*er the occipital ner'e *loc,+ easy to do, and surprisingly wor,s for most headaches )C>4 $rugs 22):- <:1&eep this in your tool *o the ne t time youCre told Gnot tonight, dear, ( ha'e a headacheG TA&# 3O0# 0#44A5#6 remem*er steroids and ner'e *loc,s for headaches. 3ere is
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can ad8ust the dose and gi'e da*igatran, or gi'e the fi ed doses of ri'aro a*an or api a*an. (n se'ere renal failure, you *asically ha'e to *e careful with all anticoagulants. Api a*an may *e the safest )9 Clin ?harm <2):-12D- #y girlfriend
thin!s I$m very mature. She also thin!s I$m inca able of being faithful. #y wife% on the other hand& 'Stewart Fracis(
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?ro*iotics can reduce the amount of trauma complications+ the infectious ones that is. )Crit Care 1<)2- 1022- This is an article from China. Well, there are plenty of Chinese out there and pro*a*ly plenty of trauma *ut they only came up with 22 patients in each group. .urthermore the study was single *linded and the surrogate mar,ers were a ma8or part of the study *ut not the only outcome measure. What ( mean is F the more parameters you study the more pro*a*ility of confounders. "ut hey, if $annon wants to study this and are willing to gi'e me all the straw*erry yogurt ( can eat for a year, (/ll do the study )*ut only the 0H yogurt-. TA&# 3O0# 0#44A5#6 ?ro*iotics may
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got the )ob at #icrosoft*& they didn$t res ond to my telegram. )4tewart .rancis11) We gotta tal, a*out a sensiti'e su*8ect+ catheters. This
pro*lem is *allooning, and due the pull ( ha'e with this su*8ect, we ha'e got some wi,ilea,s to pass on to you. ( really ha'e *agged some good articles on the su*8ect. ( don/t want to lea'e you guys dangling so let me 8ust remind you what
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they now ha'e a fi*er optic catheter system so that you can a'oid false passages and *leeding from lacerated prostates. )9#> 31)1-2:- TA&# 3O0# 0#44A5# Catheters are on the way out. &eep it that way. On a related su*8ect F#4"I F that is e tended spectrum *etalactamase which is ma,ing cephalosporins and Buinolones no longer effecti'e in =T(4 s in the community and we ha'e discussed it *efore. .osfomycin still wor,s, *ut it can de'elop mutational resistance during treatment. ( still use it for garden 'ariety =T(s )"9= intl 110)3-300- #y fairy
+odmother once as!ed me if I$d rather be well endowed or have a long memory% and I forget what my answer was% butL. )4tewart .rancis-.
12) This article is all a*out cu*oid fractures which is really
e citing to people with ad'anced dementia, *ut to few others. >e'ertheless+ 8ust remem*er+ if you are going to *rea, your cu*oid, you pro*a*ly ha'e other fractures in the foot as well or a Iisfranc/s fracture@dislocation )9AA Orth 4urg 20):-D:2- .They need a CT and casting is usua y en!ugh. T"#$ %&'$ '$((")$* Cu+!id ,-actu-es a-e -a-e .ith!ut ass!ciated
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and *ilious 'omiting. 4o in order to attenuate this unfortunate response, ( throw statistics at you in small doses and sugarcoat them. ( ,now most )actually all- of you do not care and those who do would *etter understand how isotonic solutions such as normal saline can cause acidosis )4cott, are you still reading%- *ut this is a straight forward one. We ha'e spo,en a*out the inadeBuacies of the p 'alue and here is another. 7ecall that the p 'alue 8ust tells us with how much certainty you can nullify the null hypothesis. That is F a p 'alue of 0.001 says that you can say with 11.1H certainty that the null hypothesis is *ull. 3owe'er, if your sample siAe is really large then small insignificant differences in effect get magnified and the p 'alues start to loo, great. )?0M 7 D)2-DD2-. >ow we three months ago mentioned that small sample siAe lead to wide confidence inter'als which ma,e the results unrelia*le and large sample sets as we see here also ma,e the p 'alues less 'alua*le so the solution is not to use p 'alues. Or 8ust forget all this and gi'e Iactated 7ingers in dia*etes and ma,e 4cott happy. TA&# 3O0# 0#44A5#6
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sample siAes are *ig 14) Cortisporin otic drops )de otic in (srael F neomycin, polymy in and a steroid- are not oto to ic. )#>T 9 11)3-10;- Well, ( donCt hear it. They made this determination on $?AO# testing which is not a patient oriented outcome. There were only 32 children and they were all healthy *ut were undergoing tu*e placement in the T0s. We do not ,now if infected ears will do worse. The control group also underwent this testing *ut it is not clear why especially since this study was retrospecti'e.
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e terna so 8ust put in the drops. 4o why change to flora of the *ody when you can gi'e the anti*iotics 8ust where you need them+ li,e with pneumonia F send them down with inhalations% )$rugs Today D;)<-331- The authors say this wor,s well in C. patientsN ( would li,e to point out pneumonia in the elderly may *e different+ so we 8ust raised the possi*ility F ,eep it in mind TA&# 3O0# 0#44A5#6 inhaled anti*iotics may *e good for pneumonia. "ut them again, the air in .lint 0ichigan may ,ill e'erything in your lungs as well. 8!u- highness5 .hen 1 said that y!u a-e i3e a st-ea4 !, +at2s 6iss5 1 !n y 4ean that y!u shine !ut i3e a sha,t !, g! d .hen a a-!und it is da-3+ 0ore 0onty ?ython 17) ( saw this study in A#0 and it isn/t rele'ant to us *ut it mentioned ?#CA7> which is ta,ing the pediatric community *y storm. This was first mentioned in Iancet 3:D)1212-1120way *ac, in 2001 in an effort to reduce the num*er of CTs we do in ,iddies. Of course you can 8ust fry their little *rains guarantying a new generation of mutant de'iants with low (Ks or you could try this rule.
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( li,ed the fact that it was di'ided into a*o'e age 2 and *elow *ut this is still not enough in my eyes as a 3 month old is not eBual to a 2 year old and a 3 year old is not eBual to a 1: year old. "ut here is the rule. Iess than two6 n!-4a 4enta status5 n! sca 6 he4at!4a e:ce6t ,-!nta 5 n! !ss !, c!nsci!usness !- !ss !, c!nsci!usness ,!- ess than 5 s5 n!n;se<e-e in=u-y 4echanis45 n! 6a 6a+ e s3u ,-actu-e5 and acting n!-4a y acc!-ding t! the 6a-ents . A*o'e age two6 n!-4a 4enta status5 n! !ss !, c!nsci!usness5 n! <!4iting5 n!n;se<e-e in=u-y 4echanis45 n! signs !, +asi a- s3u ,-actu-e5 and n! se<e-e headache. The 6-!+ e4 is that the nu4+e-s
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serious infections in ,ids that may not *e apparent. Well you ,now the answer to this already F you/re not an idiot. Well may*e you are, *ut at least you read #0=. 4o let/s ma,e it clear. The pre'alence of serous *acterial infections that aren/t o*'ious is so low that no test can *e trusted+ the low pre'alence means the tests will *e often falsely positi'e. Chance or *est guess may do 8ust as well )ann #merg #0d 20)1-12- The only ca'eat in this re'iew is that the Americans 'accinate against 4. ?neumo, so the results may not *e the same where you practice if you are not a !an,. 4o that does it. 5o put your procalcitonin where the sun don/t shine
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TA&# 3O0# 0#44A5#6 >o *lood test in fe'erish ,ids unless it is clear they are sic,. 3ow do you decide% Ioo, at themJ .evis: 6sun 7 # cut $own
trees, # e%t my *unch, # o to the *%1%tory! 8n +e$nes$%ys #&** o sho..in , %n$ h%1e -uttere$ scones 'or te%! #ounties -hoir: 6sun 7 9e cuts $own trees, he e%ts his *unch, he oes to the *%1%tory! 8n +e$nes$%ys, he oes sho..in , %n$ h%s -uttere$ scones 'or te%! 9e&s % *um-er:%c, %n$ he&s 8;, he s*ee.s %** ni ht %n$ he wor,s %** $%y! .evis: 6sun 7 # cut $own trees, # s,i. %n$ :um., # *i,e to .ress wi*$'*owers! # .ut own womens& c*othin , %n$ h%n %roun$ in -%rs! #ounties -hoir: 6sun 7 9e cuts $own trees, he s,i.s %n$ :um.s, he *i,es to .ress wi*$'*owers! 9e .uts on womens& c*othin , %n$ h%n s %roun$< [starts to show signs of disgust] <in -%rs( [perk back up] 9e&s % *um-er:%c,, %n$ he&s 8;, he s*ee.s %** ni ht %n$ he wor,s %** $%y! .evis: 6sun 7 # cut $own trees, # we%r hi h hee*s, sus.en$ers, %n$ % -r%! # wish #&$ -een % ir*ie, :ust *i,e my $e%r =%m%4 #ountie -hoir: 6sun 7 9e cuts $own trees, he we%rs< hi h hee*s( [choir storms out in revulsion, as Bevis continues singing, to his Best Girlie's dismay]
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20!ou should ha'e ,nown this. "ut ( will *e nice+ you can ha'e appendicitis after an appendectomy+ it is called stump appendicitis.)K90 10<);-;0<21) ?atellar dislocations do 8ust as well with taping. )Arch Ortho Trauma 4urg 132);-1111- 0a,es sense *ut they compared it with cylindrical casting. We use ,nee immo*iliAers *ut that shouldn/t ma,e that much of a difference compared to cylindrical casting. .unction was done *y a ,nee scale F not sure how good it was, and there were only 1 patients in each group. 4till, to their credit+ they followed them for < years. TA&# 3O0# 0#44A5#+ Taping for patellar dislocations may do as well as casting All that was 0onty ?ython+ now for Tommy Cooper # went to the $octors! 9e s%i$ &#&$ *i,e you to *ie on the couch&!
# s%i$ &+h%t 'or(& 9e s%i$ &#&$ *i,e to swee. the '*oor& 22) Well >4A($4 do impair healing and *one formation.. *ut they
also cause angiogensis which is necessary for *one healing (s it a wash% )i*id p120<- Well, it is if you *elie'e this study. And it was done on mouse legs so who ,nows. Are >4A($4 e'il% ( thin, they are, *ut it isn/t clear if they may also *e *eneficial. TA&# 3O0# 0#4445#6 >4A($4 impair healing *ut do cause angiogneisis which is good ?o*ice %rreste$ two ,i$s yester$%y, one w%s
$rin,in -%ttery %ci$, the other w%s e%tin 'irewor,s! 2hey ch%r e$ one %n$ *et the other one o'' 23) We Buote legal *riefs of 4te'e 4el*st often and two points
that need to *e enforced )other than there are a lot of dum* physicians out there- are that do a good neuro 'ascular e am
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children must deal with )>o ( am not spea,ing a*out6 $ad, ( need money-. What is doing in that diaper% Who doesn/t ,now what diaper rash is% We all tell our patients F let them run amo, without their diaper on *ut this can lead to less than pleasant results. (nterestingly enough, the Chinese ha'e a traditional cloth diaper and they pu*lished a study showing that they get more diaper rash than these new supera*sor*ent ones. This paper says the *est way to pre'ent diaper rash is to change new*orns e'ery hour and older ,iddies e'ery three to four hours )( thin, that is a little unrealistic as well-. Anything that minimiAes waste from touching the s,in will reduce diaper rash and this is how those pastes+Ainc o ide, starches, etc+ wor,. Co'ering them with Easeline will help as well. They recommend adding hydrocortisone if there is a *ad case. ( will point out that there is no mention of using anti*iotic creams. They claim you can tell when it is Candida *ecause they ha'e *eefy red plaBues, pustules and satellite lesions ,*ut ( 8ust add some clotrimaAole to my mi )Curr Opion ?eds 2D6D:2- There are mimics li,e
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*uried in the middle. ( dou*t anyone will *e reading at this point this point. The clinical chest e am is useless. The studies supporting clinical e am are poorly done and are ancient coming from epochs that technology was minimal and we had nothing else to offer. 3e gi'es an e ample F we detect only 20H of murmurs correctly )"09 201263D<eD<21-. ( guess with practice the num*ers may *e *etter, *ut why search for creptations when you can easily ray them% ( thin, physical e am is the least important of my chart+ history and clinical decision ma,ing are way more important. >ot to say you don/t need it sometimes, *ut the lawyers who claim that you didn/t chec, *rachialradialis refle es so you are a *ad doctor is inane. !our thoughts% TA&# 3O0# 0#44A5#6 no need for chest e ams anymore. G!our mother is a TwitG 7oald $ahlI 1 d!n2t need y!u t! -e4ind 4e !, 4y age. 1 ha<e a + adde- t! d! that ,!- 4e. (te<en E-y 27) This article was way to Aussie for me+ the statistics were 8ust for $own =nder, and the phone num*ers for ?oison Control were all 'ery e pensi'e calls from where ( li'e. They also F despite *eing #?s+ recommend too often that an Ge pertG to icologist decideG *efore gi'ing certain treatments.
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nu4+e- K1 a+!<eG 3ere are 5reg/s comments. ( ha'e again *een misBuoted *ut *etter to *e misBuoted than not
Buoted at all. On #0+7A? ( said we need nurses for critical patients only. !ou should ha'e techs doing the ma8ority) 10H - of the *asic wor,. Iet nurse do real nurse wor, and not *e tied up pushing patients to the floors. We need total wor, redesign *ut are afraid to as, real Buestions. !osef, ( thin, a de*ate on this topic would *e an ideal running de*ate topic for your e ceptional readership. #ither that or the meaning of life which is eating a pastrami sandwich at &atACs $eli on 3ouston 4treet in >!C. !our choice for topics. Io'ed the issue.. 5reg With all
due respect to .ather 5reg+ ( thin, the Americans ha'e shot themsel'es in the foot. !ou ha'e a doctor shortage. 4o you train physician assistants, nurse practitioners and #$ techs. Then you see that they are all much cheaper than a doctor. 4oon you/ll need one doctor for the the whole #$ and the rest of the #$ will wor, with these other indi'iduals. >ow ( will point out that these
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i-!n 6!is!ning eithe-5 +ut the a-tic e a66ea-ed in the 6ediat-ic ite-atu-e5 s! 1 had n! ch!ice. Than3s ,!- the c!44ents; they .e-e g-eat .
307onit Ie' from =C4$ is organiAing a tour to coincide with the (sraeli Association of #0/ s scientific assem*ly in 0arch. ( was una*le to reproduce her *rochure, *ut if you are interested, please get in touch with me and ( will *ut you all together.
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E!!t.ea- is the +est 6-e<enti!n techniBue a th!ugh it .i n!t he 6 against sting-ays. Nse a shu,, ing gait .hen .ading. The !nes y!u .ish t! a<!id 4eeting inc ude -ays and sc!-6i!n,ish in the N("5 .ee<e-,ish in the N#5 st!ne,ish in (!utheast "sia and Li!n,ish in
(c!-6i!n,ish*
Li!n,ish*
8G The-e is i44ediate 6ain and s.e ing. Pi+-i! c!nta4inati!n can !ccuand in ,-esh .ate- I.atch !ut ,!- ae-!6hi us. Lea<ing s6ines in inc-ease in,ecti!n -ates. Oays ands sc!-6i!n ,ish can cause s.eating5 dia--hea5 hy6e-sa i<ati!n5 hy6!tensi!n5 and c!n<u si!ns. T-eat4ent is h!t .ate-. "nti<e-n!4 is a<ai a+ e in "ust-a ia .he-e a the g-eat
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, age ate. Tet-!t!:in is ,!und in sun,ish5 t!ad,ish and the ,a4!us 6u,,e- ,ish; 3n!.n as ,ugu in Ma6an. 1t can 3i y!u ,-!4 -e6a-at!-y 6a-a ysis .ithin thi-ty 4inutes. Che,s .h! -e4!<e the 6!is!n ,!-4 Eugu 4ust eat thei- !.n c-eati!ns as thei- ,ina e:a4 +e,!-e ce-ti,icati!n. Du,,e-,ish*
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(un,ish*
T!ad,ish*
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(he ,ish can a s! 6!is!n <ia din!, agge ates. The th-ee ty6es a-e 6a-a ytic5 neu-!t!:ic and a4nestic. The ,!-4e- is the !n y !ne that can +e dange-!us5 a th!ugh a th-ee a-e usua y su-<i<a+ e; a th!ugh n!t ,!- the 4! us3. Last y5 tuna and 4ac3e-e can a s! cause sc-!4+!id 6!is!ning. This is a hista4ine -eacti!n. This !ne is t-eated .ith the usua anti hista4ine -egi4ensF the !the-s a-e su66!-ti<e a th!ugh acti<ated cha-c!a 4ay he 6 i, y!u use it -a6id y. D-e<enti!n* the t!:ins a-e a heat sta+ e5 s! c!!3ing .i n!t he 6. (c-!4+!id 6!is!ning is a<!ided +y eating ,-esh ,ish. ?!n sca e ,ish that a-e a-ge a-e a dange- ,!- ciguate-a. ?!t in issue ,!- 4e; these ,ish a-e n!t #!she-; e<en i, Eathe- )-eg + esses the4. 1/G #8 Me y,ish a-e n! ,un eithe-. @!: Me y5 Chinese Me y5 the D!-tuguese 'an !, .a- and 1-u3and=u a sting5 and cause death5 a th!ugh 4!st d! s! -a-e y Je:ce6t ,!- the @!:G Ch-ysa!-a a-e c!44!n in ?!-ht "4e-ica5 and De agia in the "d-iatic. Het suits5 yc-a suits5 and ny !n st!c3ings a 6-!tect against 4!st =e y signs. @!:es can cause death .ithin 4inutes ,-!4 6u 4!na-y ede4a5 c!n<u si!ns and CP c! a6se. 1-u3and=i synd-!4e is se<e-e 4ya gia5 6a 6itati!ns and s.eating. 1t can 6-!ceed t! "D$ and %T?. 'an !, Ha-s can
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"na6hy a:is is a 6-!+ e4 he-e5 as it is t! the =ac3 =u46e- ant .hich +ite in I y!u guessed it; "ust-a ia. @eta + !c3e-s can 4a3e the -eacti!ns .!-se. N-tica-ia and !ca -eacti!ns I e<en i, 4assi<e d! n!t ,!-ete ana6hy a:is ne:t ti4e the-e is a +ite. Has6 stings can get in,ected +ecause they s!4eti4es ,eed !n -!tting 4eat Jyuc3G. Ta3e !ut the stinge- i, y!u see it. 13G (c!-6i!ns a-e 6-esent in "-iQ!na; J.aiting ,!- y!u- ette-5 #enG +ut deaths a-e -a-e the-e. (c!-6i!ns a-e actua y Buite c!44!n in !uc!unt-y. 1n 1ndia5 they ha<e a -ed sc!-6i!n .hich can +e etha 5 1-an has th-ee dange-!us s6ecies. 1n 1s-ae the + ac3 sc!-6i!n is 6-etty ha-4 ess5 +ut the ye !. !ne can cause a--hyth4ias and c!n<u si!ns5 a th!ugh 1 ha<en2t seen these I +ut 1 sti !+se-<e the4 ,!- 6 h!u-s. Dain is c!44!n6 ace t! a sc!-6i!n +ites. #ids a-e !+<i!us y 4!-e
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. Aeaths a-e -a-e +ut +e.a-e !, the Eunne He+ s6ide- .hich is ,!und !, c!u-se in X "ust-a ia. ?ec-!tic s6ide- +ites a-e usua y L!:!sce es s6ecies and a-e 6ain ess5 +ut .ithin h!u-s +u-ning sensati!ns de<e !6s and the .!und +ec!4es -ed .hite and + ue. " ch-!nic u ce- ensues c!<e-ed +y an escha-. ?eu-!t!:ic s6ide- +ites a-e i44ediate y 6ain,u .ith g!!se, esh and s.eating in the a-ea and then +egins the 6a-ty; ,e<e-5 %T?5 6sych!sis5 -ha+d!5 t-e4!- and 4usc e s6as4s5 -igidity !, ,ace and =a.s5 <!4iting; y!u get the 6ictu-e. E!-tunate y5 anti<en!4 is
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