Seasonal Vibes {Volume 2}: Winter 2018

Seasonal Vibes - Volume 2 - What's happening in Winter 2018 with The Healthy Maven and general life updates from Davida and the THM crew.

I’ll be honest, this picture feels kind of deceiving since it’s the furthest thing from winter here in San Francisco. The weather has been beautiful (70s and sunny) and I’m certainly not complaining about it. I feel like I paid my dues in my 27 years of living on the East Coast…but alas it’s Seasonal Vibes so it felt much more fitting to include a picture of me in the snow, which was in fact an accurate depiction of what my January looked like. More on that in a bit…

Seasonal Vibes - Volume 2 - What's happening in Winter 2018 with The Healthy Maven and general life updates from Davida and the THM crew.

All of you seemed to really enjoy my last Seasonal Vibes post so here I am again for a little life update. It’s funny because I think a lot of people feel that social media has allowed everyone to minute-by-minute stalk another person’s life. While I certainly share elements of my life on social media (Instagram in particularly), there’s actually a lot you don’t see. Social media is a highlight reel and while I definitely don’t shy away from sharing those uncurated moments, it’s also just a small version of my reality. Most of the time I’m sitting in my PJs on the couch, writing or editing a podcast. Sometimes I’ve put on real clothes and I’m shooting a video or some photos. And even more realistically, I’m binge-watching a TV show with Curt or hanging in the park with Bodhi. Most of these moments don’t get shared. Partially because they’re not the most glamorous, but also because we all need a bit of privacy in our lives. It’s been so nice to take the pressure off sharing everything and really just live in the moment. Ironically, I think it was the best decision I could have made for THM too. I feel so much more present and productive in my work because I’m so much more compassionate in my personal life.

Of course, I do kind of miss the days of weekend recaps and life lately posts. To me they’re so much better than a quick Instagram image because there’s such a story there. I’m a write by nature and by now you know I don’t like be limited in characters. As a result, blogging will always be at the heart of what I do. Social media platforms and algorithms may come and go, but THM is all mine. I can be 100% myself here and that is something I deeply value. So with that, here’s what’s been happening lately:

A trip (or two) to Minnesota 

A few days after returning home from Grand Cayman C and I got the call we had long dreaded. I haven’t talked about it on here but C’s dad was diagnosed with pancreatic cancer in April 2016. It was one of the motivating factors behind our two months of living in Minnesota in Fall 2016 and besides just general visits back to MN it also explains our frequent visits. In January Frank passed away and while it wasn’t unexpected, it was still shocking in the moment.

There’s so much more I want to say about this and the lessons Frank taught me but I just don’t even know where to begin. What I know for certain is that I’m feeling so lucky to have both mine and C’s families and our dear friends who provided so much support during this challenging time. I’m obviously deeply saddened by this loss and especially to not have him at our wedding in a couple months but knowing the support we have from our incredible community makes it so much easier.

We managed to get a warm spell (by Minnesota standards) and were able to spend more time outside than expected. Minneapolis really is so beautiful in the winter. I never thought I’d say this but it really does feel like a home away from home.

A Life-Altering Trip to Sonoma and Santa Cruz

Last week I had the privilege of attending a trip to Sonoma (and then a quick jaunt down to Santa Cruz) with Stonyfield. What was cool and unique about this trip was that its sole purpose was the educate us and share knowledge about organics and the sustainable food movement. I’m working on this post but it was a lot of information to take in so I’m needing a little more time to digest it all.

What I can say is that it completely opened my mind to how to food system is broken in North America, but also where our points of entry are for making change. Whether it be on the policy side, reducing food waste, improving our soil or voting with our wallet, there is an opportunity for so many improvements and I’m eager to be a part of this change. Stay tuned!

I Started Yoga Teacher Training!

This was a big one that I’ve actually been sitting on for months. I signed up for YTT in November and have been eagerly waiting for it to begin this month. So far it’s been challenging, intense and inspiring. At first I was going to document the process but I’m now thinking I’ll capture my feelings at the end (I wrote down my thoughts before starting it for comparison). In many ways, the conversations we’re having in class feel very personal and private and I want to respect that. However, I also know a lot of people are curious about what the training is like so I’ll share that once it’s done. I’m only just beginning but I have a feeling this is going to be a life-changing experience that goes far beyond teaching yoga.

Let’s Talk About The Wedding…

Ahhhhh the wedding. I feel like I get the most questions about this and I provide such vague and uninspiring answers! I’ll put it to you this way: I am so looking forward to having all my favorite people in one room. I’m also so looking forward to it being over. Nothing about wedding planning has been particularly fun for me. Mainly because if I had it my way we’d all be drinking in the park in yoga clothes. When I went to go buy my dress, I went in by myself on my way to yoga. The sales associate didn’t know what to do with herself. She tried to give me a bottle of champagne to celebrate but I thought it would be weird walking into yoga with a full bottle of champagne haha. I think I’m a major disappointment to anyone who works in the wedding industry!

So far we have a venue, a dress, a DJ, photographer, invites and some other random knick-knacks. Still working on a few other pieces. I’m confident it will all get down and I’m trying to have a positive attitude about everything since there’s no point in being stressed. I’ll keep you posted…though to be honest the next Seasonal Vibes post may come after the wedding!

Los Angeles Folks – Let’s Hang!

Speaking of events, I’ll be in LA on February 27th to host an event with my favorite clean beauty company, Credo Beauty. By now you all know my love for Credo and I’m so excited to be throwing this Green Beauty Happy Hour with them on Feb 27th from 5:00-7:00 and would love to see you there! P.S. It’s totally free! SIGN-UP HERE.

If you want to stay up-to-date on future events that are coming to your city, make sure you sign-up HERE.

Credo Beauty LA Event details with The Healthy Maven

* * * * *

That’s all I’ve got for you today but I hope this helped raise the veil (somewhat) on what life has been like around here. Alright, back to snuggling Bodhi…

What’s new in your life? Fill me in!

The post Seasonal Vibes {Volume 2}: Winter 2018 appeared first on The Healthy Maven.

Article source here:The Healthy Maven


Research and Reviews in the Fastlane 195

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog


Research and Reviews in the Fastlane

Welcome to the 195th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Justin Morgenstern and Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

R&R Hall of Famer - You simply MUST READ this!

Weiser et al. Initial Electrical Frequency Predicts Survival And Neurological Outcome in Out Of Hospital Cardiac Arrest Patients with Pulseless Electrical Activity. Resuscitation. 2018. PMID: 29408228

  • Maybe PEA isn’t all ‘doom and gloom’. There is already emerging awareness that ‘pseudo-PEA’ may have a better prognosis, now this observational study from Vienna suggests that OOHCA patients and a heart rate >60/min may do better. In this study, this group “showed a 30-days-survival rate of 22% and a good neurological outcome in 15% of all patients – comparable to shockable cardiac arrest rhythms”.
  • Recommended by: Chris Nickson

The Best of the Rest

PediatricsR&R Game Changer? Might change your clinical practice
Babl FE, et al. Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study Annals of Emergency Medicine. 2018.

  • Personally, I love when clinical decision tools are compared to physician judgement. It’s rarely done, and helps us determine if these tools are helping or hurting us take care of our patients. In this setting of low CT utilization, the use of decision tools did not perform as well as physician judgement. Clinicians had better specificity and positive predictive value, and similar sensitivity and negative predictive value.
  • One caveat, this was done in a setting where head CTs are performed at a low baseline rate (unlike the U.S.), so be sure to take your own baseline utilization rate into consideration when applying these findings to your practice.
  • Recommended by: Jeremy Fried

Emergency Medicine
R&R Game Changer? Might change your clinical practiceR&R Hot Stuff - Everyone’s going to be talking about this
Keijzers G, et al. Don’t just do something, stand there! The value and art of deliberate clinical inertia. Emergency medicine Australasia : EMA. 2018; PMID: 29327445

  • This one is hot off the press, and the first of a three part series – look out for the rest… The article discusses the concept of ‘deliberate clinical inertia’, which is “the art of doing nothing as a positive response”. In particular, it talks about the barriers and strategies to overcome them. That’s right the 13th Law of the House of God wasn’t just a joke, often the best medicine really does involve doing as much nothing as possible. Should ‘doing nothing’ be a KPI?… A caveat is that the sicker the patient, the more likely intervention will be appropriate.
  • Recommended by: Chris Nickson

R&R Game Changer? Might change your clinical practice
Hughes PG, et al. Ten Tips for Maximizing the Effectiveness of Emergency Medicine Procedure Laboratories. The Journal of the American Osteopathic Association. 2016; 116(6):384-90. PMID: 27214775

  • The world would be a better place if (1) we all had regular procedure labs and (2) we all followed the 10 tips in this article.
  • Recommended by: Chris Nickson

R&R Hot Stuff - Everyone’s going to be talking about this
Kawano et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2018 PMID: 29310869

  • IO or IV in arrest? This study finds an association between IO use and worse neuro outcomes but, the data is extremely limited due to a host of biases. It’s unclear why IO was chosen as the route and the IO group was sicker overall. Additionally, with no evidence for benefit of any meds in cardiac arrest, there isn’t even a physiologic basis for why IO would be worse than IV. Ultimately, only a randomized trial can give us any useful information. We should continue to de-emphasize the importance of obtaining access in arrest.
  • Recommended by: Anand Swaminathan

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: Feb 15, 2018 @ 9:46 am


Research and Reviews in the Fastlane 195
Jeremy Fried

Article source here:Life in the Fast Lane

5 Yoga Workouts for Beginners to Improve Balance

Balance is often overlooked by yoga newbies because flexibility and weight loss are often the top two goals. These yoga workouts for beginners to improve balance will help you shift your perspective! There are so many reasons why we love yoga. It’s a yummy exercise practice that increases strength, supports weight loss, and relaxes you […]

The post 5 Yoga Workouts for Beginners to Improve Balance appeared first on Avocadu.

Article source here:Avocadu

Episode #49: Curt Lederle (aka my Fiancé!)

This week on the That's So Maven podcast we have Curt Lederle (aka my fiance!) and probably the wisest person I know...although I'm biased!

Happy Valentine’s Day lovers!

Today I have a very special guest on the podcast…its someone you might be familiar with. I’m welcoming my fiancé, known around here as “C” onto the show to chat about love. Well, we get into more than just love but in honor of Valentine’s Day, I thought I would share the hot seat with my love.

Now I may be biased, but I’m pretty sure Curt might be the wisest person we’ve ever had on the show. I’ve never met anyone who is so deeply content with their life but also strives for so much more. He’s a dreamer by nature and his taught me so much about what it means to create the life you want to live.

This week on the That's So Maven podcast we have Curt Lederle (aka my fiance!) and probably the wisest person I know...although I'm biased!

I could not be more honored (or thankful!) to have Curt on the show today.

Here are a few things we covered in today’s episode:

  • Curt’s own journey and how we met
  • What he does for a living and how we make it work living and working under the same roof
  • Long distance and how we did 2.5 years of it!
  • Being in a relationship with someone who is more emotional and extreme than you
  • His involvement with THM and what he thought when I first started a blog
  • His best tips for training a dog
  • His version of self-care and how he takes care of himself daily
  • His favorite and least favorite things about me
  • Random facts you may not know about me

LISTEN HERE:  iTunes | Stitcher | Google Play | Player.FM | Podbean

This week on the That's So Maven podcast we have Curt Lederle (aka my fiance!) and probably the wisest person I know...although I'm biased!

What questions do you have for Curt?

The post Episode #49: Curt Lederle (aka my Fiancé!) appeared first on The Healthy Maven.

Article source here:The Healthy Maven

Medmastery: The biliary system and Cholecystitis

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog

The team at Medmastery are providing LITFL readers with a series of FOAMed courses from across their website.

Dr Nikolaus Mayr from the Abdominal Ultrasound Essentials course demonstrates ultrasound examination of the biliary system.

Dr Mayr provides strategies to help identify the biliary system especially the gallbladder with the help of ultrasound imaging. Clinical examples of acute and chronic cholecystitis as well as the porcelain gallbladder.

Further reading:

Guest post: Nikolaus Mayr, MD. Chief Resident of Radiology, Department of Radiology, and Nuclear Medicine at the Hospital of the Brothers of St. John of God in Salzburg.

Last update: Feb 14, 2018 @ 8:52 am

Medmastery: The biliary system and Cholecystitis
Mike Cadogan

Article source here:Life in the Fast Lane

Jellybean 90 with Jessica Stokes-Parish – Simulationist

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog

Over simulated? Simulation; surely one of the fastest growing parts of health education in recent times. There is much more to simulation than a plastic mannequin and healthcare is but a small part of the bigger picture. Matt McPartlin went along to the Australasian Simulation Congress and spoke to ICU nurse and co-convenor Jessica Stokes-Parish.

We sent Matt MacPartlin off to pretend to be a submariner, a jet pilot and an ICU Nurse. He wasn’t qualified for any of these difficult tasks but he is qualified to talk about it. Here is Matt’s report:

“War, video games and virtual hospital beds. There are links. Many links. The ever present threat and application of war in various parts of the world have throughout history led to advances in healthcare. (Some see this as a benefit but arguably, at best war has pressed the need rather than generated the the benefit itself, but that’s not the point of this particular podcast.)

One of those links is training. And simulation has been an integral part of training. The military uses simulation in many forms – tabletop exercises, part task trainers, in situ simulation and more recently virtual reality. Video gaming is essentially entertainment through simulation. Industries such as engineering, logistic supply chains and motorsport use simulation too. And so does healthcare.

So it would seem that each of these areas might be able to contribute something to each other’s development. A group of simulation enthusiasts certainly think so. They organised a big simulation congress to help that process along. And they threw in research themes, expert-led workshops and DIY self help sessions.

It’s called the Australasian Simulation Congress and it happened for the third year over 4 days at the end of August in Sydney’s International Conference Centre on Darling Harbour.

Jessica Stokes-Parish is a critical care nurse who has spent time running and developing simulation training at both Newcastle and Tamworth Hospitals in New South Wales. She is also one of the convenors of the Australasian Simulation Congress – check out the Australasian Simulation Congress 2017 program.

We talk about the origins of the Congress, the development of simulation based training, take a peek into the near future and try to solve the lack of surfing opportunities in Tamworth.” MMacP

For more information or to get involved in a simulation community, check out Simulation Australia

Please check out the excellent podcast on all things health and Simulation; “Simulcast” starring @inject_orange and @SocraticEM. You can find it on iTunes and all good purveyors of podcastery. Have a listen to their special shows from September 2017 which were the “Official Broadcasts” from the Congress that Matt and Jessica mention during their chat.

Thanks to Matt for going along and playing with the expensive toys. More thanks to Jessica for taking the time to talk to us. She was very busy and we are very appreciative.

Thanks also to Róisín Murphy, formerly of Moloko, for the clips from her solo disco throwback “Simulation” from 2012. This is the Mano Le Tough remix. You can find that on iTunes and somewhere out there is the 12 inch EP on vinyl.

Further Listening

JellyBean Large

Last update: Feb 13, 2018 @ 12:56 pm

Jellybean 90 with Jessica Stokes-Parish – Simulationist
Mike Cadogan

Article source here:Life in the Fast Lane

Eponymythology: Graves orbitopathy

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog

Having recently reviewed the chronology of diffuse toxic goitre (Parry-Graves-Basedow disease) we tackle the chronological descriptions behind Graves orbitopathy (GO).

Why? Well, I’m still working that out. But I think that in our KPI-driven quest for diagnostic certainty, we have forgotten the descriptive pioneers – the clinical diagnosticians.

Time to review the descriptions and eponymythology of the forgotten signs associated with Graves orbitopathy  – the signs of Dalrymple, Stellwag, von Graefe, Möbius and Joffroy…


It is no surprise that historically, semantic confusion reigns regarding Graves orbitopathy. ..

An interchangeable array of terms ranging from thyroid eye disease (TED) and thyroid-related ophthalmopathy (TRO) to dysthyroid/euthyroid/infiltrative/Graves ophthalmopathy; thyrotoxic/malignant/endocrine exophthalmos; exophthalmos of endocrine origin; and thyroid ophthalmopathy/orbitopathy have been used to describe ophthalmic signs that may accompany Graves disease, hypothyroidism, or Hashimoto thyroiditis.

Graves orbitopathy, thyroid dermopathy (pretibial myxedema) and acropachy are the extrathyroidal manifestations of Graves disease. They occur in 25%, 1.5% and 0.3% of patients with Graves disease respectively.

Graves orbitopathy is the commonest extrathyroidal manifestation of Graves disease and signs include proptosis or exophthalmos, eyelid retraction, eyelid lag, restrictive extraocular myopathy and optic neuropathy. GO is a noninfectious, inflammatory disorder of the orbit mostly associated with hyperthyroidism. However, this constellation of signs may also occur on patients without objective evidence of thyroid dysfunction (euthyroid Graves disease) and in patients who are hypothyroid secondary to chronic autoimmune (Hashimoto) thyroiditis.

Thyroid Eye Signs

Upwards of 40 eye signs have been described over the past two centuries. The most enduring of these are outlined.

John Dalrymple (1803–1852) [Dalrymple sign]

The most common clinical sign in Graves orbitopathy, is eyelid retraction. Dalrymple is associated with the description of ‘a widened lid opening in exophthalmus with sclera revealed above the upper margin of the cornea‘ better known as lid retraction.

1849 – The first published description was by Sir William White Cooper (1816-1886) in ‘On protrusion of the eyes in connexion with anemia, palpitation, and goitre‘. Cooper described Dalrymple’s extensive experience and pathophysiologic explanation for this ophthalmologic sign. Cooper provides Dalrymple’s explanation thus:

An absence of the proper tonicity of the muscles by which the eyes are retained in their natural positions in the orbit; and some amount of venous congestion of the tissues forming the cushion behind the globes. Dalrymple relates a case of a gentleman whose eyes were so protruded that they were nearly denuded of the protection of the upper lid by a constant and powerful spasm of the levator palpebrae *superioris, which drew the lids, so far upwards and backwards, that much of the sclera above the cornea was visible.’  WW Cooper 1849

1852 – The eponym ‘Dalrymple sign‘ may have originated after the publication of his book, ‘The Pathology of the Human Eye‘ in 1852. Cooper does not specifically use the eponym, suggesting it manifested later, probably posthumously. No separate accounts or case reports were published by Dalrymple on this topic.

Albrecht von Graefe (1828-1870) [Graefe sign]

1864 – Friedrich Wilhelm Ernst Albrecht von Graefe first described the finding now given his name at the Berlin Medical Society on March 9, 1864.

Von Graefe noted that in exophthalmos, the upper eyelid fails to follow the downward movement of the eye. He believed it was present even in very slight exophthalmos, was most likely due to involvement of Müller’s muscle, and was pathognomonic of Basedow disease.

When normal individuals elevate or lower their glance, the upper eyelid makes a corresponding movement. In patients suffering from Basedow disease, this is entirely abolished or reduced to the minimum. That is, as the cornea looks down, the upper eyelid does not follow.’ [1864;16:158-160]

1932 – Ruedemann applied the more commonly used term ‘lid lag‘ in his chapter on ‘Ocular changes associated with hyperthyroidism

Karl Stellwag von Carion (1823–1904) [Stellwag sign]

1869 – Stellwag von Carion reported his sign of ‘infrequent and incomplete blinking’ in patients with Basedow disease

The palpebral fissure was open very widely, so that thin slivers of sclera remained visible directly above and below the cornea, when the patient looked straight ahead, even under very bright conditions. Blinking became less frequent and incomplete. At various times over many days, I witnessed how both eyelids would not move for several minutes. At other times, only a marginal twitching of the eyelids was visible over several minutes. In no way was a full closure of the eyelids observed over this period of time. The immobility of the lids came to become ‘normal’ during quiet, undisturbed conditions or when the patient was staring / fixating on something.

Within a short period of time of becoming agitated or excited, the patient’s blinking would increase in frequency, yet the closure remained incomplete. Voluntary blinking however remained unaffected. Upon asking the patient to blink, they would do so lightly and with normal power. However, I discovered that the voluntary movement was followed by several involuntary complete blinks in rapid succession. Gradually, the blinking became less frequent and incomplete as to stop altogether.Stellwag 1869;25:40.

Paul Julius Möbius (1853-1907) [Möbius sign]

1883 – Paul Julius Möbius first drew attention to finding of ‘incomplete convergence’ in cases of Basedow disease [1883;CC:100]

1886 – Möbius went on to discuss “…the sign in more detail on the basis of the examination of 10 patients, 8 of whom demonstrated a varying severity of the finding“. [1886;CCXII:136-138]

1891 – Möbius reviewed the clinical signs, symptoms and related pathology since the original description of diffuse toxic goitre and added further to his original description of the insufficiency of convergence [1891;1 (5-6):400-444]

All other movements of the eyeballs are normal, but if the patient is to look at a nearby object (such as the tip of his nose or a finger held in front of his face), the eyes look to the right or to the left, and only one eye sees the object. This is seen most prominently when the patient is asked to first look at the ceiling and then at his own nose.

On looking at a finger moved toward the patients nose, the eyes converge to a point that varies between patients and at different times for the same patient. After this point, only one of the eyes fixates onto the object, whilst the other abducts to align in parallel with the adducted eye’s axis.

Whilst the eyes converge, the patient complains of eye strain. They are not however aware of the abnormal movements, nor do they suffer with double vision. The inability to converge is not directly related to the degree of exophthalmos. It also occurs without Basedow disease.

Charcot et al, corroborate my findings but have described them as ‘rare’ occurrences. In my experience over the past years, its incidence is less frequent than I had originally thought, however it does occur in most cases of Basedow’s disease, if only to a mild degree.

The insufficiency is not a real paralysis, neither is it caused by the exophthalmos. Exophthalmos does limit eye movements. Eye movements are also weakened at the onset of Basedow disease. The weakness is seen at the earliest during convergence, the most strenuous of the eye movements.Möbius 1891;1(5-6):402 Translation: Ercleve T. 2018

Alix Joffroy (1844-1908) – [Joffroy sign]

1893 –  Alix Joffroy presented a lecture at the Hospice de la. Salpêtrière on the ‘epidemiology and treatment of exophthalmic goitre’ by request of Jean-Martin Charcot.

Along with general observations of clinical signs in Graves Ophthalmopathy, Joffroy made particular mention of a new sign ‘Paralasie des muscles de la partie supérieure de la face‘. He described ‘absence of of wrinkling of the forehead‘ when a patient with Graves Ophthalmopathy looks upwards with the head bent forwards.

In our patient, these muscles are affected in a rather unique way that I have already encountered in three other cases, without this particularity having been so far reported. When the eyes are rotated upwards, normally there occurs a synergistic contraction of the elevator of the lids, and a contraction of the frontalis with concomitant wrinkling of the skin of the forehead. However in these cases, the synergistic action is disturbed, the frontalis does not contract and there is an absence of wrinkling of the skin of the forehead. The frontalis that is paralyzed, as the patient can perform voluntary eyebrow movements.’ [Joffroy 1893:479]

In modern summary…

  • Graves orbitopathy (ophthalmopathy) is considered to be present if eyelid retraction occurs in association with objective evidence of thyroid dysfunction or abnormal regulation; exophthalmos; optic nerve dysfunction or extraocular muscle involvement.
  • The ophthalmic signs may be unilateral or bilateral, and confounding causes must be excluded.
  • If eyelid retraction is absent, then Graves orbitopathy may be diagnosed only if exophthalmos; optic nerve involvement; or restrictive extraocular myopathy is associated with thyroid dysfunction or abnormal regulation and if no other cause for the ophthalmic feature is apparent.


LITFL Related Links

Last update: Feb 12, 2018 @ 10:24 pm

Eponymythology: Graves orbitopathy
Mike Cadogan

Article source here:Life in the Fast Lane

LITFL Review 318

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 318th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsJanuary is National Slavery and Human Trafficking month. Listen to this insightful podcast from EM Pulse on a topic EM physicians need to dive into deeper. [MMS]


The Best of #FOAMed Emergency Medicine

  • Know your MALA??  EMdocs have a new posting in their Educator series–with a new look, so ensure you click the educatory link to get the wonderful FOAM-y good stuff. [CC]
  • Dr Smith is a frequent LITFL Review favorite, but he has a particularly interesting case this week. [MG]

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

  • Intubation during cardiac arrest in notoriously difficult, but this post from The Airway Jedi will show you the tricks you need to remember. [MG]
  • Nice post by Ryan Radecki on the utility of the qSOFA score as a screening tool.  This is a meta-analysis that has recently been published reviewing the utility of qSOFA in the ICU, hospital, and ED. [SR]
  • A 2015 post on Deranged Physiology on an important (and still controversial) topic was updated this week:  clearing the C-Spine in the unconscious patient. [SO]
  • More goodness from the 2017 Australian College of Intensive Care Medicine Annual Scientific Meeting: Paul Young talks on the future of GI bleeding in the ICU. [SO]
  • Zach Shinar, from ED ECMO, interviews French ECMOlogist Lionel Lamhaut and ethicist Cyrus Olsen about ECMO and organ transplantation. Ethics, money, organs, and ECMO… What more do you need in a podcast? [CN]

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

The Best of #FOAMpeds Pediatrics

  • This review of atrial fibrillation in kids is a must-read, if only for Sean Fox’s reminder that pediatric exceptionalism “engenders fear of caring for kids instead of empowering providers for staying abreast of the issues that make caring for kids unique and special.” A powerful message from the best at Pediatric EM Morsels! [RP]
  • There’s a quick review of bronchiolitis basics by John Cafaro at EMDaily. [RP]

The Best of #FOAMim Internal Medicine

  • The Methods Man, F. Perry Wilson, sacrifices his body for science in his review of the Annals of Internal Medicine study suggesting a link between hot tea ingestion and esophageal cancer. If you’re interested in statistical quirks, this is your cup of tea! [RP]
  • A U of Louisville EM resident identifies what to look for in cardiac syncope as well as how to identify rare manifestations of serious and potentially fatal heart conditions in Syncope and ECGs at the Louisville Lectures. [ML]

The Best of #MedEdFOAM and #FOAMsim

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Last update: Feb 12, 2018 @ 10:23 pm

LITFL Review 318
Marjorie Lazoff, MD

Article source here:Life in the Fast Lane

The ALiEM Faculty Incubator

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog

A project I’m excited about this year is the ALiEM Faculty Incubator programme. I’m going to join the team as a guest mentor, and I anticipate learning far more than I teach!

This is what it’s about:

The ALiEM Faculty Incubator is a year-long professional development program for educators, which enrolls members into a mentored digital community of practice. This small, 30-person, exclusive community will stoke the fires of creative engagement through mentorship and collaboration. We aim to strengthen your educational skills and produce tangible works of scholarship. Our goal is to construct a curriculum, delivered to you in a closed digital platform, and help you launch and accelerate your career development.

If you want to be a successful, scholarly leader in health professions education, we hope to work with you to acquire the skills and knowledge required to be a superstar educator in the 21st century.

So far, the programme has been remarkably successful. Succesful at developing the skills, knowledge, and attitudes needed by a modern Clinician Educator (regardless of specialty). Successful at producing tangible, scholarly output. Successful at creating a real community that works. The latter, in particular, is no mean feat.

Applications for joining the 2018-2019 ALiEM Faculty Incubator programme are still open – but if this sounds like the thing for you, you need to be quick and get your application in by February 18th 2018. Follow @ALiEMFac on Twitter.

facubator logo

The ALiEM Faculty Incubator
Chris Nickson

Article source here:Life in the Fast Lane

Funtabulously Frivolous Friday Five 225

LITFL • Life in the Fast Lane Medical Blog
LITFL • Life in the Fast Lane Medical Blog – Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 225.

Question 1

Who Wrote:“Scepticaemia, an uncommon generalised disorder of low infectivity. Medical school likely to confer lifelong immunity”?


  • Prof Petr Skrabanek in 1989
  • Written in Follies and Fallacies in Medicine he also wrote a stream of scientific papers and articles exposing the claims of public health doctors, epidemiologists, dietary evangelists and others that many diseases were preventable. [Reference]

Question 2

Where would you see this stained glassed window?


  • Liverpool School of Tropical Medicine
  • Ship owners Alfred Lewis Jones (first benefactor) and John Holt could see their profits disappearing as slaves became sick on their ships. Liverpool had an extensive slave trade which overtook London and eventually accounted for 10% of all the slave trade. Alfred Jones donated 350 pounds per annum for the first 3 years once the school was developed.
  • The Liverpool School of Tropical Medicine was formally inaugurated (as the Liverpool School of Tropical Diseases) by Lord Lister (of antiseptic and aspetic fame) on the 22nd April 1899. It was the first institution in the world dedicated to research and teaching in tropical medicine and parasitology.
  • Major Ronald Ross was the school’s first lecturer and won the Nobel prize in 1902 for Medicine for his work demonstrating the link between mosquitoes and malaria. [Reference]

Question 3

A woman in her third trimester presents with a swollen leg on the triage screen. You make a bet with your resident that she has a DVT on the left side. If she does indeed have a DVT, what are the odds it will be on the left side?


  • 88%
  • In one review article, for 124 pregnant women with a diagnosis of deep vein thrombosis. Overall, involvement of the left leg was reported in 84 (88%) of the 96 patients for which the side affected was known.
  • As for the pathophysiology… “We might speculate that among pregnant women, a May–Thurner-like syndrome brought on by compression of the left iliac vein by the gravid uterus (at the point where it crosses the right iliac artery) plays a major role in the increased incidence of iliofemoral deep vein thrombosis in late pregnancy. However, given that deep vein thrombosis occurs with equal frequency in all three trimesters of pregnancy, this hypothesis would presumably not apply to deep vein thrombosis observed in early pregnancy. [Reference]
  • Regardless of the pathophysiology, you win the bet!


Question 4

What animal was the source of the most cases of rabies in the USA since 1997?


  • Bats
  • Among the 19 naturally acquired cases of rabies in humans in the United States from 1997-2006, 17 were associated with bats.
  • Among these, 14 patients had known encounters with bats. Four people awoke because a bat landed on them and one person awoke because a bat bit him. In these cases, the bat was inside the home. [Reference]


Question 5

Marathon runners have an increased rate of gastric emptying, true or false?


  • True
  • Gastric emptying rates of radiolabeled beef stew meals were measured in 10 healthy, young male subjects. The subjects either (1) stood at rest, (2) walked on an exercise treadmill at 3.2 km/hr, or (3) at 6.4 km/hr during the study while gastric emptying was being monitored by externally positioned gamma cameras. Compared to the standing at rest study, exercise significantly increased gastric emptying (at rest emptying half-time (t1/2)=72.6 (sem) min; 3.2 km/hr t1/2=44.5 min, P=0.0051; 6.4 km/hr t1/2=32.9 min, P=0,0051). The 6.4 km/hr emptying time was significantly (P=0.0249) faster than the 3.2 km/hr emptying time. Thus, the amount of exercise is a physiological factor that alters solid meal gastric emptying rates. [Reference]
  • Bill Rodgers, marathon legend, with four victories in both the Boston marathon and the New York City marathon in the late 1970s said, “More marathons are won or lost in the porta-toilets than at the dinner table.”

…and finally

Academia Obscura Bagpipes

Funtabulously Frivolous Friday Five 225
Neil Long

Article source here:Life in the Fast Lane