Ridgeview Podcast: CME Series

In this podcast, Dr. Nick Schneeman, a geriatrican and the Chief Medical Officer for LifeSpark, brings his passion and expertise to discuss the state of care in geriatrics, along with how current delivery in care and payment models effect the geriatric population.

Disclosure note: Dr. Nick Schneeman , speaker for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Describe what is meant by "value-based care".
• Describe current barriers to delivering high value care to a senior population.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All of the relevant financial relationships for the individuals listed above have been mitigated.

Thank-you for listening to the podcast.

SHOW NOTES:  
*See the attachment for additional information. 

PODCAST OVERVIEW
- Geriatric care delivery and quality has not evolved significiantly.
- Pockets of excellence exist in academic centers.
- Social support systems is integral, but lacking in many parts of the country.
- Fee for service (FFS) system is not a sustainable model per Dr. Schneeman for complex senior patients.
- Training and exposure to the 'business platforms' in medicine is lacking with providers
- FFS = paying for a specific service, procedure, treatment, etc.

Value Based Care (VBC)
- Value based care = outcomes/cost
        - Clinical outcomes
        - Experience outcomes of patient/family and caregiving team
- How is VBC measured?
        - Medical loss ratio (cost containment)
- How does VBC work?
        - Organization contracts with payor
        - VBC organization takes on risk
        - Money savings opportunity
- Half of seniors in USA are already in a VBC model
        - Medicare (CMS)
        - ACO (group of doctors, health care organization, etc.)
        - Medicare advantage (CMS product that insurance companies contract with federal government)
- Cost Product (Medicare advantage product)
        - Introduced in MN with assumption that this state will do such a good job with cost containment, but this wasn't how it worked out.
        - For-profits don't participate in Medicare advantage products which keep the non-profits more accountable, although there are also disadvantages with for-profit programs.
- How does the care delivery work in VBC organizations (Nick's viewpoint)?
        - Step 1: Journey from simple problems into complexity
        - Step 2: What is the current reality and quality of life?  (When people hear you restating their story, trust goes up immensily.)
        - Step 3: What are you hoping for? (patient, family, etc.)
        - Step 4: Acute care planning
        - Step 5: Chronic care planning
        - Outcomes:  POLST (physician orders for life-sustaining treatment) form that is comprehensive;
           Chronic care plans that are clear and purposeful and match goals of care
- Well done POLST forms require intential discussion with patient and advocates who have decision making capacity and understanding of the patient's reality and values

Palliative Care
- How it's integrated and its controversy
- All practitioners should be able to make palliative decisions with and for their patients who they know intimately
- Palliative care as a specialty exists largely due to a FFS model
- Often this is a clinican the patient has never met before and is a one time consult
- Private equity had created palliative care 'cold call' business models in recent years

Value Based Care (VBC) - continued
- How does a practitioner go about doing this?
- Make sure the organization you join actually values the primacy of primary care
- Clinicians need TIME with their complex patients and to be paid for this time
- FFS can work well for simple problems
- Who does this well? Small pockets, mostly senior care (i.e. clinic-based, homebased healthcare etc.)
- Nurse, APP, physician - are assigned to each patient and continue to follow their care, avoid overprescribing, inappropriate abx
- Private equity and Big insurance is getting into the game, but their approaches tend to be siloed and perhaps less humanistic
- Recruiting quality providers to this care delivery model is imperative
- Improved patient outcomes and costs exisst (i.e. geriatric assessment before cancer care)
- Value Based Care really has to be an "all in" experience for a clinic or organization for it to work

Training
- Training typically happens in house, as opposed to a training program or course
- Subspecialists will still be very much part of the care team, although decision making about proceeding with advanced therapies will be oriented around the VBC  medical home team
- Pharmacy is a valuable team member as well, especially if part of the "goals of care" as opposed to merely looking up medications
- Challenge: SNFs and long term care facilities often have significant staff turnover, care quality issues, and these can lead to unnecessary care, ED visits and hospitalizations

Evidence Based Moment (EBM) 
Resources
Magill MK. Time to Do the Right Thing: End Fee-for-Service for Primary Care. Ann Fam Med. 2016 Sep;14(5):400-1. doi: 10.1370/afm.1977. PMID: 27621155; PMCID: PMC5394371.
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394371/pdf/0140400.pdf

Basu S, Phillips RS, Song Z, Landon BE, Bitton A. Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model. Ann Fam Med. 2016 Sep;14(5):404-14. doi: 10.1370/afm.1960. PMID: 27621156; PMCID: PMC5394379.
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.annfammed.org/content/annalsfm/14/5/404.full.pdf

Thanks to Dr. Nick Schneeman for his expert knowledge and contribution to this podcast.

In this podcast, Dr. Nedaa Skeik, a vascular surgeon with Minneapolis Heart Institute, brings his knowledge and experience in regards to vascular insufficiency, and the importance of a timely diagnosis and management options.

*Disclosure note: Dr. Nedaa Skeik, speaker for this educational event, has disclosed that he received honorarium from Medtronic.  All relevant financial relationships for Dr. Skeik have been mitigated.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Summarize the pathophysiology of different venous disorders.
• Recognize and confidently diagnose venous insufficiency.
• Identify the risks and benefits of different interventions for venous conditions.
• Differentiate medical management (conservative and interventional) for venous insufficiency.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All of the relevant financial relationships for the individuals listed above have been mitigated.

Thank-you for listening to the podcast.

SHOW NOTES:  
*See the attachment for additional information. 

PODCAST OVERVIEW

Wide Range of Venous Disorders and Presentations
- Morphologic (spider, reticular, varicose), skin discoloration, ulceration
- Functional (venous reflux +/- loss of pumping mechanism
- Anatomic (thrombosis, congenital anomalies)
- Presentation (asymptomatic vs symptomatic)
Anatomy
Pathophysiology
Epidemiology
- Chronic vein abnormalities
- Prevalence (venous insufficiency)
- Varicose veins & prevalence
- Presence of symptoms
Risk factors
- Family component
- Other 
Clinical features
- Correlation - severity of venous reflux, age
- Asymptomatic
- General symptoms
- Vein appearance
- Severity
Disease Severity - Classification Scales
- CEAP calssification scale
- Venous Clinial Severity Score 
Disease Progression
- Correlation
- pregression of disease not well understood
Diagnosis
- History
- Symptoms
- Exam findings - including venous ultrasound
- Differential diagnoses (edema, skin manifestations, vein engorgement)
- Pre-management considerations (severity, superficial and/or deep, proximal/distal, multiple or single, comorbidities)
Management
Asymptomatic
- visual sclerotherapy
- surface laser therapy
- complications
Symptomatic
- compression therapy
- exercise
- leg elevation
- skin care
Conserative Therapy
- leg elevation
- exercise
- compression stockings
Pharmacologic Therapy and Skin Care
- vasoactive drugs
- rheologic agents
- skin care
Interventional Options
- Preintervention measures (venous anatomy, preop medications, anesthesia)
- Sclerotherapy (visual, US guided)
- Vein closure procedures (thermal - RFA/EVLA, chemical, MOCA, PEM, EHIT)
- Surgical (phlebectomy, ligation, stripping)
Post Intervention Care
- pain management
- ambulation
- leg elevation
- compression
- return to normal activity/work
- post procedural US
- follow up appointment

Thanks to Dr. Nedaa Skeik for his expert knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Gabi Hester, a pediatric hospitalist and Quality Improvement (QI) medical director for Children's Hospitals of Minnesota and St. Luke's Hospital in Duluth. Dr. Hester brings her knowledge and experience in  everything related to croup and bronchiolitis (specifically pertaining to in-patients and to frontline healthcare providers).

*Dr. Gabi Hester, speaker for this educational event, has disclosed that she is a consultant who provides content recommendations to AvoMed. All relevant financial relationships for Dr. Hester have been mitigated. 

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• State at least 2 challenges in the recognition of and treatment of acute respiratory illnesses in children.
• Describe potential interventions for bronchiolitis that have not been shown to provide significant benefit to most patients.
• Recognize common "mimickers" of croup.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All of the relevant financial relationships for the individuals listed above have been mitigated.

Thank-you for listening to the podcast.

SHOW NOTES:  
*See the attachment for additional information. 

PODCAST OVERVIEW

CROUP (layngotracheitis)
Overview
- 400,000 approx. ER visits/year in U.S.
- Costly, approx. $53 million/year
- Scary disease due to airway obstruction
- Para-influenza most common
- Classically, kids are admitted after 2 racemic epinephrine nebulizers
        - Dr. Hester studied croup and hospitalization (see resources below)
        - Kids admitted, and no further treatment or intervention (observed)
Presentation and treatment
- Rhinorrhea, low grade fever, barky cough (seal bark)
- Inspiratory stridor, usually worse when agitated
- Rarely insp and exp stridor (if progressed disease state)
- Dexamethason 0.6 mg/kg (max dose of 12-16 mg)
- Nebulized racemic epinephrine (RA)
      - bridge for steroid to kick in
      - reserved for stridulous patient
- Think about croup mimics
      - not responding to racemic epinephrine
      - older kids (i.e. 7 yr old), think about other diagnoses
      - Epiglottitis
           - cough is less barky
           - respiratory distress and tripoding
           - thumb print sign
      - Bacterial tracheitis
           - can be complication of viral croup
           - can quickly decompensate
- Foreign body, airway anomalies, etc.
TREATMENT:
- cool outdoor air can be soothing, no good studies to support
- humidified air
- imaging can be done (steeple sign on AP neck) but not routinely required
        - Worried about foreign body? Epiglottitis?
        - not responding to racemic epi
        - CXR if hypoxia. Not typical of croup to be hypoxia.
Research (links below)
- Most kids don't need further treatment after ED course.
- <1% needed adanced airway, heliox, etc.
- 1:5 hospitalized kids needed further racemic epi
- Some limitations (included pre-ER racemic epi)
       - Study was done at a Children's, tertiary hospital, not a community or small hospital
- Follow-up QI study (2022) evaluating croup guidelines showed 60% relative reduction in admissions to hospital (4-5% hospitalization rate)
     - 3 RA nebs before admission was found to be safe 
Croup Guidelines at Children's Hospital
- '3 is the new 2' re: racemic epi nebs
- Good H&P, dexamethasone and up to 3 doses of RA, hen admit
- 2 hour obsrervation after each dose of RA
- Repeating steroids is controversial. If repeated, give in 48 hours, but rarely needed
- Dexamethasone tastes terrible
COVID impact
- Seasonal presenation shift occurred
- Omicron related croup more common
- No difference in serverity with COVID-19, but increased volumes

Resources:
Hester, G., Barnes, T., O'Neill, J., Swanson, G., McGuinn, T., & Nickel, A. (2019). Rate of Airway Intervention for Croup at a Tertiary Children's Hospital 2015-2016. The Journal of emergency medicine, 57(3), 314–321. https://doi.org/10.1016/j.jemermed.2019.06.005

Hester, G., Nickel, A. J., Watson, D., Maalouli, W., & Bergmann, K. R. (2022). Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup. Pediatrics, 150(3), e2021053507.  doi.org/10.1542/peds.2021-053507
https://publications.aap.org/pediatrics/article/150/3/e2021053507/188776/Use-of-a-Clinical-Guideline-and-Orderset-to-Reduce?autologincheck=redirected

Lefchak, B., Nickel, A., Lammers, S., Watson, D., Hester, G. Z., & Bergmann, K. R. (2022). Analysis of COVID-19-Related Croup and SARS-CoV-2 Variant Predominance in the US. JAMA network open, 5(7), e2220060. https://pubmed.ncbi.nlm.nih.gov/35796213/

BRONCHIOLITIS
Overview
- Leading cause of hospitalization in kids < 1 year old in U.S.
- Cold sx, fever, runny nose at first
- Several days into URI, increased work of breathing, wheezing, reatractions
- Typically at its worst on day 5
- Cough can persist up to 2 weeks
Diagnosis and treatment
- Most interventions and tests don't have a significant impact on patient outcome
- Consider albuterol nebulizer trial after intial therapies (suctioning, hydration)
- Nasal suctioning imperative
- consider socioeconomic factors
- Hydration staus important
- Respiratory therapy is a resource (consider this if albuterol is not really working)
- Be mindful of exlusion criteria for the guideline (cardiac and other underlying co-morbidities, etc.)
- Oxygen (low flow)
- High flow nasal cannula is helpful in respiratory distress
        - no reduction in hospital length of stay
        - may increase PICU use (some institutions only use this in the ICU)
- Scoring systems for bronchiolitis severity not very useful
- Respiratory rate, work of breathing (WOB), agitation, coloration, heart rate - all factor into asssessment
- Infants may be tricky - be sure to examine well with baby unclothed, watch carefully for retractions and nasal flaring
COVID impact
- Seasonal variation/timing and severity of illness changes were seen
Testing and CXR
- Will testing change treatment?
- Routine RSV testing not needed
- Apnea and RSV: any respiratory virus can cause apnea in susceptible and very young infants
- Routinely, CXR not required, unless worried about bacterial pneumonia
          - high fever late in illness
- When and who to admit?
          - Significant WOB, hypoxia, dehydration, very young infants, apnea
          - Consider family resources and barriers to care
Treatment and Vaccines
- On the way!
- Vaccine gibven to mothers in 3rd trimester
- Nirsevimab given to infants 
Research (links below)
- Forthcoming treatment (Nirsevimab) specifically for RSV
- Improved outcomes, less hospitalizations
- Race, ethnicity and socioeconomics impact outcomes

Resources:
Hammitt, L. L., Dagan, R., Yuan, Y., Baca Cots, M., Bosheva, M., Madhi, S. A., Muller, W. J., Zar, H. J., Brooks, D., Grenham, A., Wählby Hamrén, U., Mankad, V. S., Ren, P., Takas, T., Abram, M. E., Leach, A., Griffin, M. P., Villafana, T., & MELODY Study Group (2022). Nirsevimab for Prevention of RSV in Healthy Late-Preterm and Term Infants. The New England journal of medicine, 386(9), 837–846. https://doi.org/10.1056/NEJMoa2110275
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.nejm.org/doi/pdf/10.1056/NEJMoa2110275?articleTools=true

Hester, G., Nickel, A. J., Watson, D., & Bergmann, K. R. (2021). Factors Associated With Bronchiolitis Guideline Nonadherence at US Children's Hospitals. Hospital pediatrics, 11(10), 1102–1112. https://doi.org/10.1542/hpeds.2020-005785
https://publications.aap.org/hospitalpediatrics/article/11/10/1102/181172/Factors-Associated-With-Bronchiolitis-Guideline

Thanks to Dr. Gabi Hester for her expert knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Robert Steffen, a cardiac surgeon with Minneapolis Heart Institute. Dr. Steffen brings his knowledge and experience regarding the prevalence of aortic valve disease, advancements in technology, as well as treatment modalities for patients who suffer with this problematic disorder.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• State the prevalence of aortic valve disease.
• Identify when patients with aortic valve disease need intervention.
• Describe the different therapeutic options for patients with aortic valve disease and when to use them.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

In this podcast, Dr. Michael Maddaus, a retired thoracic surgeon, but currently a physician coach with a special interest in helping surgeons.  Dr. Maddaus brings his knowledge and experience around burnout, wellness, resiliency and other healthcare provider challenges.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Define reslience and identify how it applies to adversities encountered in medicine.
• Identify behaviors that promote resilience, including managing expectations, setting realistic goals and finding gratitude.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES:  
*See the attachment for additional information. 

PODCAST NOTES & REFERENCES

1. Resilience Bank Account scientific paper: https://www.annalsthoracicsurgery.org/article/S0003-4975(19)31352-9/fulltext
2. Podcast by Dr. Maddaus: https://www.sts.org/topics/resilient-surgeon
3. Authors and Sites Referenced
   1. Love + Work by Marcus Buckingham
   2. www.principlesyou.com  (Ray Dalio)
   3. www.jocko.com  (Jocko Willink)
   4. Dark Horse by Todd Rose
   5. The End of Average by Todd Rose
   6. Waking Up and www.wakingup.com by Sam Harris
4. www.michaelmaddaus.com

Thanks goes out to Dr. Michael Maddaus for his expert knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Matt Weber, a podiatrist with Ridgeview Specialty Clinics, brings his knowledge and experience around the causes of ankle instability, how common it is, and the different approaches for therapy and management.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Recognize ankle ligament instability from a patient's clinical history and exam.
• Diagnose ankle problems (pathology) assiciated with ankle instability, including acute injury vs. chronic conditions.
• Choose appropriate treatment protocols for an ankle instability condition.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES:  
*See the attachment for additional information. 

PODCAST OVERVIEW

Ankle Sprains
- 25% go on to further sprains.
- Graded 1-3
- Anatomy
- Ottawa ankle rules
- Physical therapy
- Acute vs chronic

Ankle Surgery
- Brostrom Gold (pants over vest)
- Attenuated Gracilis Repair
- Following surgery - 3-4 weeks immobilized, then boot for 2-3 weeks, then physical therapy.
- 4 months post injury - back to activity

Thanks to Dr. Matt Weber for his expert knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Nicole Roeder, a pulmonologist with Ridgeview Specialty Clinics, brings her knowledge and experience to discuss how to properly diagnose and manage asthma and chronic obstructive pulmonary disease (COPD) in patients exhibiting signs and symptoms of these chronic conditions.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Identify signs and symptoms of asthma and chronic obstructive pulmonary disease (COPD).
• Review methods for diagnosing asthma and COPD.
• Select treatment options for asthma and COPD.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES:  
*See the attachment for additional information. 

PODCAST OVERVIEW

COPD
- Major contributor - tobacco use
- Environmental exposures
- Types (chronic bronchitis, emphysema, mixed)
- Symptoms and exam
- Exacerbation red flag -  more frequent use of rescue inhaler use, more cough and wheeze
- Tests (imaging - CXR, CT, pulmonary function testing, spirometry, BODE screening test, alpha antitrypsin)
- Inpatient COPD management
- Outpatient COPD management
- Prevention (immunizations, vaccines, smoking cessation, daily maintenance medication/compliance)
- Severe COPD considerations (lung transplant, endobronchial valves)
- Pulmonary Rehab (9-week program, multidisciplinary team, baseline assessment, exercise/education sessions)
- Pulmonary Function Testing (PFT) including spirometry, lung volume testing, lung diffusion capacity, and
   methachoine challenge testing

ASTHMA
- Prevalence
- Work-up (CXR, PFTs, CT chest, Allergy testing, referral to pulmonary)
- Theophylline (bronchodialiator, antiinflammatory)
- Differential Dx - consider other conditions if not improvment (CHF, PE, pneumothorax, etc.)
- Peak flow testing
- Action plans (Green, Yellow, Red)
- Treatment - for mild, moderate and severe cases

Thanks to Dr. Nicole Roeder for her expert knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Bill Roberts - a family medicine physician and Professor Emeritus with the University of Minnesota. Dr. Roberts brings his vast expertise of sports medicine to discuss a potpourri of sports medicine topics.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Summarize the evolution of changes to sports medicine.
• Identify common sports related injuries and treatment modalities.
• Describe how supplements, substances and proformance enhancing drugs (PEDs) impact athletes and the environment of sports medicine.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES:  
*See the attachment for additional information. 

Pre-participation Evaluation (sports qualifying exam)
- Better screening questions and techniques
- Mental health screening incorporation
- Sudden Cardiac Death dilemma

"Weekend Warrior"
- Activity level and training for things (marathons, etc.) - when to check in with your provider.
- More CAD in older marathoners who started training later in life
- CAD, not long distance running, associated with Sudden Cardiac Arrest (SCA/SCD).

Youth Athletes
- Young children (pre-teen) should experience a wide variety of motor activities.
- Life sports - throwing sports, running, biking, skiing

"The Runner"
- Start slow, build slow.
- Overuse injuries

Environmental
- Heat and cold injuries

"We've got an athlete down!"
- SCA - sudden cardiac arrest
- heat stroke
- hypthermia
- concussion/head injury
- stroke or ICH (intracranial hemorrhage)
- electrolytes (hyponatremia due to overhydration)

Supplements, Substances and Performance Enhancement for Athletes
- legal vs "illegal"
- supplement use
- "Eat well, sleep well, study well...."
- peer and social pressure

Pearls of Wisdom
- pearls from Dr. Roberts

Thanks to Dr. Bill Roberts for his expert knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Steve Smith - an emergency medicine physician with Hennepin Healthcare and full faculty professor of Emergency Medicine at the University of Minnesota, discusses OMI (occlusion myocardial infarction) and NOMI (non-occlusion myocardial infarction) matrix, along with the importance of proper ECG interpretation and how this impacts the management of acute coronary syndrome. Dr. Smith also talks about STEMI and NSTEMI and the use (or the replacement) of these terms.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Express that acute coronary occlusion must be diagnosed and treated emergently.
• Recognize that ST elevation on the EKG is a very poor way of diagnosing occlusion myocardial infarction (OMI).
• Recognize that the entire QRST wave on the EKG is important for the diagnosis of occlusion mycardial infarction (OMI).
• Identify when other modalities (other than the EKG) may be needed to make a diagnosis of acute coroanary occlusion (OMI).
• Recognize that deep convolutional neural networks are the future of EKG diagnosis of acute coronary occlusion.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Steve Smith, MD has disclosed a personal financial relationship with Cardiologs, Heartbeam, Powerful Medical, Rapid AI, and Wlech Allyn. Upon an independent review of his podcast presentation confirms he is only utilizing AI ECG algorithms (from stated companies) to teach  how to diagnose occlusion myocardial infarction. Dr. Smith does NOT endorse any products and has NO commercial ties to the above company's products, therefore has NO impact on his Ridgeview CME presentation, and is following CME guidelines.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

Links:
Steve Smith ECG Blog
OMI Manifesto

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Kelly Lemieux - a pediatrician with Wayzata Children's Clinic brings some insight into pediatric ADHD, specifically around the history, symptoms and treatment options.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Define the differential diagnosis for children presenting with academic difficulties.
• Utilize the DSM-5 criteria when diagnosing ADHD in children.
• Identify common co-morbidities for children with ADHD.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

ADHD History
- 1902 - British pediatrician definition of ADHD
- Evolution
- 1990s - increase in diagnosis
- 2013 - Change in age range for diagnosis

Diagnosis
- Symptoms
- Comorbidities
- Concerns for learning disabilities
- Diagnostic tools

Prevalence
- CDC estimates 6 million children (ages 3 to 17) with ADHD (approx. 9.8%)

Assessment
- Three key symptoms (inattention, hyperactivity, impulsivity)
- How ADHD is explained to parents
- Standarized tools (including listening to parents)
- Neuropsychological testing & Vanderbilts

Nonpharmocologic strategics
At school
- ADHD coach
- Therapy
- Bounce ball chairs
- special study halls
- other resources

At home
- Daily schedules 
- reducing disctractions (minimize)
- noise cancelling
- exercise 

Pharmacologic interventions
- Risk benefits
- Prescribing age
- 2 broad categories of medications (stimulants v. non-stimulants)
- other medications
- limitations

Thanks to Dr. Kelly Lemieux for her knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Daniel Marek - an orthopedic hand surgeon with Twin Cities Orthopedics, brings pearls and wisdom of how to better manage various injuries of upper extremity fractures in adults.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Summarize various types of upper extremity injuries that can occur in adults.
• Describe how to diagnose and treat common hand injuries that present to an urgent or emergency healthcare setting.
• Evaluate when a referral is needed to an orthopedist and/or orthopedic surgeon.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

The Hand
- Alignment
- Fractures
- Splinting

The Wrist
Scaphoid
- The most commonly missed fracture
- How to diagnose injury
- Treatment = 6 to 10 weeks of treatment

Lunate
- Rare fracture
- Slow healing injury (6 to 10 weeks)
- Requires splint and cast 
- Scapholunate ligament ter - 10 weeks of cast and surgery bookended
- Lunate/Perilunate dislocation - needs immediate reduction and surgery
- Triquetral Fracture - treatment with removable splint

Distal Radius and Ulna
- Fall onto outstretched hand - most common
- Colles' Fracture -       ncbi.nlm.nih.gov/books/NBK553071/
- Smith's Fracture -      ncbi.nlm.nih.gov/books/NBK547714/
- Barton's Fracture -     ncbi.nlm.nih.gov/books/NBK499906/
- Ulnar styloid fracture 
- Median nerve symptoms
- Volar displaced fractures very hard to maintain reduction - will likely need surgery.
- What needs to be reduced?  3 radiographic angles (length, radial inclination, tilt)
- Closed fracture complications
- Splinting issues

The Forearm
- Monteggia
- Galeazzi
- Radial head fracture (very common)
- Radial neck fracture
- Proximal ulna (olecranon)

The Humerus
- Mid humerus
- Proximal humerus
- Distal humerus

Describing Fracture to Orthopedist
- Looking at correct film/correct patient
- Open or closed fracture
- Location of fracture
- Involvment of articular surface?
- Simple or comminuted fracture and what direction? (transverse, oblique, spiral, avulsed)
- Displaced? if so which direction
- Angulation
- Rotation
- Impaction

Future horizon for Upper Extremity and Hand Surgery
- Awake surgery
- Hand transplant

Thanks to Dr. Daniel Marek for his knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Natalie Stoltman - a primary care physician with Lakeview Clinic, brings pearls and highlights around the topics of: behavior weight loss interventions in older adults, falls risk and increasing medications, chronic pain management in older adults, and current concepts of diabetes management in the post-acute and long-term care setting.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Summarize the latest standards in regards to care in geriatric medicine.
• Identify and review interventions targeting geriatric obesity.
• Identify falls risk enhancing drugs and ways for deprescribing.
• Summarize the updates provided related to chronic pain management in geriatrics.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

Major Themes:  deprescribing medications, poly pharmacy, individualization of care and a tailored approach, and the need for a multidisciplinary team.

Beyond Behavior Weight Loss Intervention in Older Adults
- Impact and Impairments
- How to begin: "diet takes on new connotation in the elderly"
- Weight loss interventions/behavior modifiations
- Weight loss interventions - medications
- Weight loss surgeries (Roux-n-y/Sleeve gastrectomy)
- Multidisciplinary team

Getting Rid of "FRIDS" or Fall Risk Increasing Drugs
-  More than 30% of older adults fall
- Deprescribing

Managing Chronic Pain in Older Adults
- Classification of pain (nociceptive /neuropathic /nociplastic)
- Pain evaluation
- Nonpharmocologic interventions
- Pharmacological

Current Concepts of Diabetes Management in the Post-Acute and Long-term Care Setting
- Patient goals and change in goals
- Goals of care
- Life expectancy

Thanks to Dr. Natalie Stoltman for her knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Jon Cole - an emergency medicine physician with Hennepin Healthcare and medical director with Minnesota Poison Control Center and Samantha Lee, PharmD - managing director with Minnesota Poison Control Center discuss the poison control system - past and present; along with a disscusion around toxicology - the big, the bad, and the ugly.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Describe the purpose of the Minnesota Poison Control Center, and how it works.
• Name the most common call types coming into MN Poison Control Center.
• Summarize the management of toxicological exposures for APAP, bupropion and calcium channel blockers.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

HISTORY of MN POISON CONTROL CENTER

TOXICOLOGY
Calcium Channel Blockers
- Diltiazem, Verapamil, Amlodipine
- Causes bad distributive shock
- Pulmonary edema is an issue
- Norepinephrine infusion is recommended in setting of shock with high dose insulin simultaneously
- "Red, white and blue" therapy for refractory Ca++ blocker overdose
- Activated charcoal - not for all patients, give if patient not at risk of aspiration for potentially lethal ingestions

Bupropion
- Chemical structure similar to amphetamine and bath salts
- Sympathomimetic effects (tachycardia, agitation, seizures, ultimately cardiogenic shock)
- Treatment with benzodiazepines - usually high dose - may need intubation
- Norepinephrine for cardiogenic shock
- ECMO may be needed

Sodium Nitrite
- Salt used to cure meats
- Internet suicide phenomenon
- Effect: Life threatening methemoglobinemia (chocolate colored blood, pallor, low O2 sats)
- Very rapid onset of symptoms
- Methylene Blue use

N-acetylcysteine (NAC) for acetaminophen poisoning
- Transitioning from 3 bag Prescott regimen to a 2 bag regimen
- Rumack-Matthew nomogram is the same

Article Resources:
Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila). 2022 Nov;60(11):1205-1213. doi: 10.1080/15563650.2022.2131565. Epub 2022 Oct 25. PMID: 36282196.  

Cole JB, Olives TD, Ulici A, Litell JM, Bangh SA, Arens AM, Puskarich MA, Prekker ME. Extracorporeal Membrane Oxygenation for Poisonings Reported to U.S. Poison Centers from 2000 to 2018: An Analysis of the National Poison Data System. Crit Care Med. 2020 Aug;48(8):1111-1119. doi: 10.1097/CCM.0000000000004401. PMID: 32697480.

Coralic Z, Kapur J, Olson KR, Chamberlain JM, Overbeek D, Silbergleit R. Treatment of Toxin-Related Status Epilepticus With Levetiracetam, Fosphenytoin, or Valproate in Patients Enrolled in the Established Status Epilepticus Treatment Trial. Ann Emerg Med. 2022 Sep;80(3):194-202. doi: 10.1016/j.annemergmed.2022.04.020. Epub 2022 Jun 17. PMID: 35718575.

Kline JA, Tomaszewski CA, Schroeder JD, Raymond RM. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. J Pharmacol Exp Ther. 1993 Nov;267(2):744-50. PMID: 8246150.

Thanks to Dr. Jon Cole and Samantha Lee, PharmD for their knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this podcast, Dr. Michelle Haroldson, a hospitalist and a sleep medicine physician with Ridgeview's Sleep Clinic, talks about sleep and why it is important, specific sleep conditions and various treatments.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Summarize the importance of sleep for physical health and wellness
• Identify barriers to (impacts upon) sleep
• Identify treatment options for sleep disorders.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

How do we break the cycle of burnout? Approximately 50% of burnout is present with clinicians prior to COVID.

Why sleep is important
- 1/3 of an individual's life is spent sleeping.
- Sleep is when the body resets, restores, and heals
- Higher mortality rates may occur with those who sleep less than 6 hrs a night.
- Optimal sleep window is 6.5 to 8.5 hours a night.

Stages of Sleep
- 4 stages (Light sleep, slow wave, dream sleep)
- Sleep architecture
-Shift work

REM sleep
- what happens during this sleep stage

Sleep conditions/disorders
- Narcolepsy
- Sleep walking
- Dream enactment
- Sleep apnea
- Sleep talking
- Snoring
- Kleine-Levin

Why see a sleep specialist
- People are paying attention to their sleep
- Sleep study

Impacts upon sleep
- Society's values on sleep
- Blue wave light
- Lack of sleep associated with major accidents

How to improve sleep
- Decide sleep is a priority
- Appropriate bedtime
- Decreasing exposure to blue wavelength light
- Remove light from sleeping environment
- Sleep temperature
- White noise
- Sleep zone

Medications that affect sleep (for better or worse)
- Mental health or psychiatric meds
- Vistaril, Benadryl
- Beta blockers
- Melatonin
- antidepressants

Thanks to Dr. Michelle Haroldson for her knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

In this special podcast, discussions occur around the impact of physician burnout. Dr. Michelle LeClaire, a critical care physician with Minnesota VA Medical Center, discusses her first hand account of provider burnout, how burnout is measured, how we can affect change with physician champions and wellness programs, moral distress, residue, injury and gender discrepancies in medicine, and discussions occur around the culture, healthcare organizations, patient complexity, and how a pandemic can affect and lead to burnout. 

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Identify hallmarks of burnout and implications of burnout in clinicians.
• Define moral distress and moral injury.
• Describe gender discrepancies in medicine and burnout rates among gender.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

How do we break the cycle of burnout? Approximately 50% of burnout is present with clinicians prior to COVID.

Mini Z
Asks 10 questions:
1.  Overall  "I am satisfied with my current job."
2. "I feel a great deal of stress because of my job."
3. "Using your own definition of 'burnout', please circle one of the following answers below:
      a) I enjoy my work. I have no symptoms of burnout.
      b) I am under stress and don't always have as much energy as I did, but I don't feel burned out.
      c) I am definately burning out and have one or more symptoms of burnout (e.g. emotional exhaustion).
      d) the symtpms of burnout that I am experiencing won't go away. I think about work frustrations a lot.
      e) I feel completly burned out. I am at the point where I may need to seek help.
4. My control of my workload is?
5. Sufficiency of time for documentation is:
6. Which number best describes the atmosphere in your primary work area?
7. My professional values are well aligned with those of my department leaders.
8. The degree to which my care team works efficiently together is:
9. The amount of time I spend on the electronic health record at home is:
10. My proficiency with the electronic health record is:

- Predisposed providers get burned out if you can predict it - you can prevent it.

Predictor factors include the three C's : Control, Chaos, Culture
1.) work control
2) chaos
3) culture which include time pressure and work control
4) controlling our schedule
5) chaos in the workplace
6) teamwork

Maslach burnout inventory/emotional exhaustion. These include reduced personal accomplishment, depersonalization and lack of compassion.

The control model of a job is the teeter-totter that demands control/support. You need to prevent burnout by offsetting the demands with control and support.
- Burnout leas to more intent of leaving the job that is three times the odds of leaving. In addition, there are poor patient outcomes.  Patient disenrollment, destabilzation of groups on the indiviual side - there is a high rat of alcoholism, suicide, broken relationships and substance abuse.

Items that help with burnout include physician champions, wellness programs and measuring burnout.

Culture is massive. Organizations job is to provide a benue for healthcare providers to treat and help patients.

External and internal factors of the "mini z" include teamwork, work control, sufficient time for documentation, stress, job satisfaction

Gender discrepancies 
Women have a 60% burnout over their male counterparts. Gender expectations for listening, a phenomenon of attracting more complicated patients, faster work pace, less values alignment with leadership.

Moral distress
Situation troubling providers where they know the right thing to do and they cannot. Compromises and patient care due to staffing. Resources and administrative support not in place. This also secondary to social determinants, healthcare disparities, abusive families and patients, not being able to alleviate suffering.

Unresolved moral distress becomes moral injury. Moral injury is a more pervasive issue which leads to cognitive dissidents, depersonalization, bad ethical decision making.

Moral residue leads to unresolved moral distress.

EDM or ethical decision making is dealing with moral injury. Generally secondary to self-reflective providers, empowerment, having a practice - culture - open to multi-disciplinary and reflection, teamwork, mutual respect within the multi-disciplinary team, active involvement of the bedside nurses with end-of-life care, providers active in decision-making, practicing culture of ethical awareness.

Article:
Trends in Clinician Burnout With Associated Mitigating and Aggravating Factors During the COVID-19 Pandemic 

Thanks to Dr. Michelle LeClaire for her knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

This podcast, Dr. Lucas Dingman and Dr. Cady Welch, emergency medicine physicians with EMPAC and Ridgeview, discuss six articles on various topics related to emergency medicine, as part of this first ED journal review.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Identify emergency medicine journal articles that may be potentially practice-changing
• Describe how to rule out a pulmonary embolism (PE) in the emergency department using the YEARS criteria and age adjusted d-dimer.
• Differentiate when antibiotics for treating diverticulitis is warranted.
• Describe the benefits of using a small percutaneous catheter chest tube for treating a traumatic hemothorax.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

Study #1: 
Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study) A Multicentre, Randomised, Open-label, Noninferiority Trial

- DINAMO study & diverticulitis
- Multicenter, randomized, open label, non-inferiority trial (Nov.2016 - Jan.2020)
- 480 randomized participants  and put into two groups
- Results: admission to hospitals, ED revisits, no complications, no major significant findings
- Nonantibiotic outpatient treatment of mild acute diverticulitis is safe and effective and is not inferior to current standard treatment.

Study #2: 
Anterior–Lateral Versus Anterior–Posterior Electrode Position for Cardioverting Atrial Fibrillation

- EPIC Atrial Fibrilation ( EPIC AF)
- Two positions for pad placement for cardioverting patients
- Multicenter, randomized, open label trial
- 467 randomized patients, scheduled for elective cardioversion
- Results: 50% successful conversion to normal sinus rhythm after one biphasic shock, many patients needed multiple shocks to cardioconvert (4-5 shocks).
- AHA Guidelines: pad placement for AF and VF, treatment recommendations
- Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome.

Study #3: 
The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial

- Poiseuille's law and chest tubes - and involves components of rate of flow, radius of the tube, change in pressure and viscosity.
- 120 participants - 8 years and older, traumatic hemothorax or pneumothorax, hemodynamically stable patient only
- Treatment arm: 14 Fr cook catheter used (seldinger techique, anterior axillary or midaxillary line)
- Control arm: 28-32 Fr. chest tube placed (standard way - 4th-5th intercostal, midaxillary line)
- Results: Failure rate of the tube, repeat hemothorax requiring intervention, drainage outputs at different designated times, total chest tube days, insertion complications, ventilator days, ICU length of days, hospital length of stay
- Patients had better experience with percutaneous catheter
- Hemlich valve
- Study discussed looks specifically at hemothoraces which require drainage of blood and chest tubes connected to traditional pleuro vac chamber
- Small caliber 14 Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.

Study #4: 
Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial - ScienceDirect

- Single center, placebo controlled, blinded, randomized trial
- Sample: 120 healthy adults, median age 40 years old presenting to ED with chief complaint of nausea/vomiting
-  Change in nausea score at 30 min. (drop in mm on VAS)
- Mean nausea baseline = 50
- Limitations: fairly young healthy participants, difficult to blind (can smell difference)
- Among ED patients with acute nausea and not requiring immediate IV access, aromatherapy with or without ondansetron provides greater nausea relief than oral ondansetron alone.

Study #5: 
Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial

- YEARS criteria with age adjusted vs only age adjusted
- Cluster, randomized, crossover, non-inferiority trial to determine if YEARS plus age-adjusted could be used to rule out PE, age 18 or older, not pregnant
- Sample size: 1414 patients within 18 EDs, PERC positive
- Outcome: PE diagnosed in 100 patients, no missed PEs with patients with YEARS score of "0",
- Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a concential diagnostic strategy, did not result in an inferior rate of thromboembolic events.

Study #6: 
Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial

- Randomized, single masked study (providers were masked), controlled clinical trial, non-inferiority study design, single center study
- Participants: children - aged 8 weeks to 3 years, moderately dehydrated (dehydration score greater than 3, but less than 7)
- Outcomes: Successful rehydration at 4 hours, hospitalization rate, time to initiation of treatment, repeat ED visits within 72 hrs
-Results: no difference between the groups with succesful rehydration at 4 hours
- Limitations: small sample size
- Oral rehydration therapy (ORT) is as good as intravenous fluid therapy (IVF) in rehydration of moderately dehydration children due to gastroenteritis. In addition, the study found that less time was required to intiate ORT when compared with IVF in the ED. Patients treated with ORT had fewerer hospitalizations. Results of the study suggested that ORT be the initial treatment of choice for moderately dehydrated children less than three years old with gastroeneritis.

Thanks to Dr. Lucas Dingman and Dr. Cady Welch for their knowledge and contribution to this podcast.

Please check out the additional show notes for more information/resources.

This podcast, Dr. Peter Eckman, a cardiologist and heart failure specialist, with Minneapolis Heart Institute, discusses heart failure and why it is an extensive medical issue.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Recognize heart failure as a problematic clinical disease and its morbidity and mortality that leads to comprehensive medical management.
• Identify and describe optimal contemporary medical therapy for heart failure.
• Describe novel options for heart failure.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Dr. Eckman has disclosed a financial relationship with Abbott Labortories, Edwards Life Science, Ancora, and Daxor, and there are no conflicts of interest with this podcast presentation. No other individuals in control of content have disclosed any financial relationships, thus no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

Heart Failure (HF)
- Can occur without congestion or fluid retention
- Characterized by fatigue, fluid retention, SOB, PND, orthopnea
- We should consider the same urgency for heart failure as patients with CAD and CA.

Heart Failure Preserved/Reduced Ejection Fraction (HFpEF/HFrEF)
- HFpEF is a Preserved Ejcetion Fraction over about 50%
- HFpEF - congestive phenotype more of a fluid retention
      - an exercise intolerant phenotupe where the patient becomes intolerant of exercise induced dyspnea.
      - Pulm HTN phenotype
      - Increased pressure in the heart that gets transmitted to the lungs
- HRrEF is Reduced EF is usually below 40%

Medications
- 4 classes of medications (MRAs, BB, SGLT2, ARNIs)
- Treatment with mineralocorticoid receptor antagonists (MRAs) has been demonstrated to improve clinical outcomes in patients with HFrEF with mild to severe symptoms and also in patients with left ventricular dysfunciton after myocardial infarction.
- SGLT2 inhibitors reduced the risk of cardiovascular death and hospitalizations for heart failure in a broad range of patients with heart failure, supporting their role as a foundational therapy for heart failure, irrespective of ejection fraction or care setting.
- ARNI (angiotensin receptor/neprilysin inhibitor) medication is a newer treatment for heart failure. The combination of sacubitril and valsartan has helped people live longer and have a better quality of life.
- Comprehensive EF therapy involves BB, ARNI, MRAs, angiotensin receptor/neprilysin inhibitors. Spironolactone, SGLT2 inhibitors.

Treatment
- Traditional therapy usually involves a BB and ACE inhibitor.
- Currently we should be looking at comprehensive therapy when it comes to HF treatment.
      - STOP USING LISINOPRIL.
- SGLT2 inhibitors contraindicated ketoacidosis, amputation UTI, weight loss
      - (SGLT2 inhibitors) DAPA-HF trial showed that dapagliflozin was superior to placebo at preventing cardiovascular deaths and heart failure events among patients with heart failure.  (Source: https://www.nejm.org/doi/full/10.1056/NEJMoa1911303#article_citing_articles )
- Catheterization - a vast majority of HF patients will need a right heart catheterization.
- Cardiac pulmonary pressure monitoring Cardio MEMS - same day outpatient surgery which helps with medication adjustments and hospitalization in half. Works regardless of EF.
- CardioVere laser spectroscopy which uses different wavelengths to detect light characteristics to determine the level of edema/fluid present wihin someone's tissues. Currently in development.
- Casana is a toilet seat with certain sensors that detect and monitor impedance that check levels between different tissues, monitors HR and weight.
- Cardiac contractility modulation causing electrical stumulation during a particular contraction of the myocyets it will augment potential (like a pacemeaker).
-CORCHINCH - HF trial catheter based device that cinches up the heart, thereby making it smaller. It works more efficiently.  (Source: Clinical Evaluation of the AccuCinch® Ventricular Restoration System in Patients Who
Present With Symptomatic Heart Failure With Reduced Ejection Fraction (HFrEF): The
CORCINCH-HF Study)

Novel Treatments
- Atrial shunting procedure is investigational trials. Potentially impactful in exercise capacity and pressures but stay tuned as the verdict is not out. HfPEF exercise induced intolerance may be the best candidate.
- SVC trial feasibility trial more durable effects of cardiac output.  Stay tuned.
- LVAD for advanced therapies. Sometimes a bridge for candidacy as well as recovery.
- Biventricular pacing has shown promise.

*Heart failure is a problematic clinical disease entity with significant morbidity and mortality often leading to comprehensive medical management. It is often beneficial to enlist the help of our heart failure colleagues for these complicated patients. 

Thanks to Dr. Peter Eckman - MHI heart failure specialist for his knowledge and contribution to this podcast.

Please check out the additonal show notes for additional information/resources.

This podcast, Elizabeth Hopfenspirger, DNP, a psychiatric and family practice nurse practitioner with Lakeview Clinic, discusses various mental health topics, primarily in the adult patient, but also touches on some pediatric issues. Today's discussion will focus on the following areas of mental health - depression, anxiety, mixed disorders, ADHD and psychosis.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Describe different implemention stratgies in how to better establish a therapeutic relationship with the patient.
• Recognize how many psychotropics medications are on a "spectrum".
• Realize that treatment choice depends on several variables - including presenting symptoms and underlying organic issues.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information. 

The state of mental health care in the US is not ideal
- Lack of resources
- Lack of practitioners
- social, physical, economic and environmental challenges

CASE REVIEW #1
- 18 year old female with predominantly anxiety
- Respectful curiosity: listening and asking questions without judgement
- Medication for generalilzed anxiety disorder
- High intensity aerobic exercise can improve anxiety symptoms.
- Trauma? ADHD/Learning difficulties? Sleep? Appette and restriction of food/eating disorders? Substance use/abuse?
- SSRI: bupropion>fluoxetine?Sertaline?escitalopram>fluvoxamine>paxil (most activating to least activating)
- For pure anxiety - Elizabeth prefers escitalopram, citalopram and sertaline
- Trauma and trauma therapy: Trauma can be anything (death of a loved one, MVC, etc.)
     - Trauma therapy (EMDR: eye movement desensitization reprocessing)
     - IFS (internal family systems - recognizing and connecting with your own history and younger self)
    - ART (acceleraed resolution therapy)
- Substance use: What is the substance doing for the patient? Why are they using? Helps to direct therapy and arrive at diagnosis.
- ADHD (attention deficit hyperactivity disorder)
    - sometimes missed or ignored
    - PCPs have discomfort treating at times
    - trial of stimulant may be beneficial
- Suicide ideation and other adverse effects while first starting certain meds is real, but rare
- Article resources: 
      Walkup, et.al   (https://pubmed.ncbi.nlm.nih.gov/18974308/)
      Wetherell, et.al  (https://pubmed.ncbi.nlm.nih.gov/23680817/)
      Critz-Christoph, et.al  (https://pubmed.ncbi.nlm.nih.gov/21840164/)
     Trauma therapy : https://www.emdria.org/

CASE REVIEW #2
- 32 year old male with depression
- Labs? Physical activity? Testosterone concerns?
- Lifestyle and sexual function
- Post-retirement? (identity and purpose has changed/gone)
- Consider bupropion if no seizures or other contraindications. Consult with neurologist if significant history
- Sexual dysfunction an issue? Vortioxetine can be an option wich may help enhance libido
- Physical activity (natural endorphins) and exposure to nature are improtant
- Screen time? Smart phone and other screen time has dopaminergic effects; too much 'negative' screen time can be detrimental  (If AHDH is poorly treated, screen addiction may increase.)

CASE REVIEW #3
- 65 year old male with mixed depression and anxiety, off meds for many months
- Find as many of patient's historical records as possible
- Meeting a patient "where they are at". How motivates is the patient to get better?
- Are they coasting (teenagers)? Are they taking an active role in getting better?
      - may need to wait to push/empower patient until after giving medication and psychotherapy some time
       - where is the patient in their willingness to change and get better? 
- Meds in this ager group (and many others) to avoid:  TCAs and MAOIs
- IF DM, HTN, CAD and other co-morbidities, fluoxetine is less likely to have interactions and adverse effects
- Article resources: 
      Prochasa and DiClemente - Stages of Change https://www.ncbi.nlm.nih.gov/books/NBK556005/)

Psychosis
- Caplyta (stimulating) if more depressed with psychotic features
- Zyprexa (sedating) if more manic/psychotic

Genetic testing for optimization of medications is an option 
- Serves as a 'guide' for medication choice
- SLC6A4 gene, for instance, is responsible for serotonin reuptake into the presynaptic neuron

What to do while waiting for SSRI and SNRI to "work"?
- Hydroxyzine, benzodiazepine
- Sleep medication:
     - Doxylamine, Trazadone or Remeron (older patients)
     - Sleep medication: lunesta, sonata

Polypharmacy
- Is polypharmacy present and patients feeling poorly with persistent symptoms? May need thoughtful/ careful deprescribing.

Nontraditional/novel treatment options
- Nontraditional/novel options for treatment resistant depression, PTSD treatment, chronic pain, etc.
- Ketamine
- Psilocybe

Psychiatry & Primary Care
- Incorporating psychiatry into our own primary care practices is anxiety provoking but inevitable in this day and age of healthcare
- We can learn new things and leverage our existing resources to better help our patients
- Time with our patients is a barrier
- Ask the patient: what is the most pressing issue for you today? What is the most distressing thing for the patient? Then consider Maslow's Hierarchy of Needs and build up from there.
- Article resources: 
      Maslow Hierarcy of Needs (https://www.simplypsychology.org/maslow.html)

Please check out the additonal show notes for additional information/resources.

This podcast, Dr. Abby Elliott returns and the debut of Dr. Natalie Stoltman, both primary care physicians with Lakeview Clinic. They are both here for the third episode of Ridgeview Podcast CME Series: Journal Review. This is the episode where our speakers talk through new, practice changing and/or just interesting journal articles. In this episode we have six articles addressing subjects related to primary care, including antibiotic prescribing, weight loss modalities, intermittent fasting, non-alcoholic fatty liver disease, LDL levels in relation to coronary plaque, and proton pump inhibitors. The articles referenced in this podcast are linked in the attached show notes.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Identify when antibotics are warranted for pediatric infections.
• Compare the differences in weight change between individuals who participated in a commercial weight management program to those who participated in a "do-it-yourself (DIY)" approach.
• Explain intermittent fasting and its correlation to health outcomes.
• Define nonalcoholic fatty liver disease and explain the different treatment modalities.
• Explain the correlation between LDL levels and calcium scores/CTA and cardiac outcomes.
• Describe the best practice approach to proton-pump inhibitors (PPI) de-prescribing in ambulatory patients.
• Name significant/relevant findings of the journal articles being reviewed and discussed.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians. 

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org.

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for article discussion summaries. 

Journal Article 1: "Association of Inappropriate Outpatient Pediatric Antibiotic Prescriptions with Adverse DRug Events and Health Care Expenditures"

CITATION:  Butler AM, Brown DS, Durkin MJ, et al. Association of Inappropriate Outpatient Pediatric Antibiotic Prescriptions With Adverse Drug Events and Health Care Expenditures [published correction appears in JAMA Netw Open. 2022 Jun 1;5(6):e2221479]. JAMA Netw Open. 2022;5(5):e2214153. Published 2022 May 2. doi:10.1001/jamanetworkopen.2022.14153.  Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792723

Journal Article 2: "Efficacy of a Commercial Weight Management Program Compared With a Do-It-Yourself Approach: A Randomized Clinical Trial"

CITATION:  Tate DF, Lutes LD, Bryant M, et al. Efficacy of a Commercial Weight Management Program Compared With a Do-It-Yourself Approach: A Randomized Clinical Trial [published correction appears in JAMA Netw Open. 2022 Sep 1;5(9):e2235316]. JAMA Netw Open. 2022;5(8):e2226561. Published 2022 Aug 1. doi:10.1001/jamanetworkopen.2022.26561  Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2795182

Journal Article 3: "Intermittent Fasting and Obesity-Related Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials"

CITATION:  Patikorn C, Roubal K, Veettil SK, et al. Intermittent Fasting and Obesity-Related Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials. JAMA Netw Open. 2021;4(12):e2139558. Published 2021 Dec 1. doi:10.1001/jamanetworkopen.2021.39558.  Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787246

Journal Article 4: "Clinical Care Pathway for the Risk Stratification and Management of Patiemts with Nonalcholic Fatty Liver Disease"

CITATION:  Kanwal F, Shubrook JH, Adams LA, et al. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2021;161(5):1657-1669. doi:10.1053/j.gastro.2021.07.049.  Available: https://www.gastrojournal.org/article/S0016-5085(21)03384-9/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F

Journal Article 5: "Association of Coronary Plaque With Low-Density Lipoprotein Cholesterol Levels and Rates of Cardiovascular Disease Events Among Symptomatic Adults"

CITATION:  Mortensen MB, Caínzos-Achirica M, Steffensen FH, et al. Association of Coronary Plaque With Low-Density Lipoprotein Cholesterol Levels and Rates of Cardiovascular Disease Events Among Symptomatic Adults. JAMA Netw Open. 2022;5(2):e2148139. Published 2022 Feb 1. doi:10.1001/jamanetworkopen.2021.48139.  Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788975

Journal Article 6: "AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review"

CITATION:  Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022;162(4):1334-1342. doi:10.1053/j.gastro.2021.12.247.  Available: https://www.gastrojournal.org/article/S0016-5085(21)04083-X/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F

Please check out the additonal show notes for additional information/resources.

For this podcast, we don't just have one but two guests. Returning to the show is Dr. Tara McMichael, an Internal Medicine Physician with Lakeview Clinic and Internist for Ridgeview, and Stacy Jepsen, an advanced practice nurse/clinical nurse specialist with Ridgeview. During this podcast, Dr. McMichael and Stacy will be discussing Post Intensive Care Syndrome, also known as PICS. They will both bring unique perspectives from the initial critical illness and care in the ICU to the patient's outpatient visits and long term prognosis.

Enjoy the podcast.

Objectives:
Upon completion of this podcast, participants should be able to:

• Define post intensive care syndrome (PICS) and post intensive care syndrome-family (PICS-F).
• Identify risk factors for devcelopment of PICS and PICS-F.
• Summarize prevention and treatment strategies for PICS and PICS-F
• Interpret the prevalence of PICS within the community.
• Utilize available resources to support patients/families with PICS symptoms.
• Describe how patients and their families can be supported who are struggling with PICS.

CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at  Education@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: 
*See the attachment for additional information.
  
CLINICAL NURSE EDUCATOR
- Advance practice RN who operates as an expert clinician, educator, researcher or consultant.
- Masters or doctorate degree
- Role had been around the US for over 60 years.

POST INTENSIVE CARE SYNDROME (PICS)
- New or worsening cognitive, psychological, physical limitation, post survival of critical illness and stay in ICU.
- Post intensive care syndrome - family (PICS): family memvers who have mental limiations from the experience of having a loved on eiwth a critical illness.
- First defined by Society of Critical Crea Medicine in 2010.
- Remains difficult to diagnose for coding and reimbursement. ICD-10 code does not exsist.

RISK FACTORS
- critical illness with stay in ICU
- Delirium
- Sedataion during hostpital stay
- Diagnosis of sepsis, ARDS, etc.

DIAGNOSIS
- Cognitive: short term memory loss, slow cognition, mental disorganization
- Physical: changes in balance and gait
- Psychological: anxiety, depression, insomnia, PTSD

TESTING
- no specific tests available for PICS
          - MoCa
          - Mini mental status
          - PHQ9 (in setting of depression)
          - GAD7 (in setting of anxiety)
- two or more symptoms in any category - cognitive, physical and psychological 4-6 weeks post hspitalization.

PREVALENCE
- Of 5.8 ICU admissions, 4.8 million survive
- Of the 4.8 million survivors, 50-80% will beet diagnostic criteria
- COVID has brought PICS to forefront.

PREVENTION
- Prevention tips (multidisciplinary rounds, ABCDEF bundle, checklists for goals, support groups)
- ABCDEF Bundle
    A - Assess, precent and manage pain
    B - Sedation reduction and vent weaning
    C - Choice of analgesic and sedation 
    D - delirium prevention, recognition and treatment
    E - Early mobility
    F - Family

BARRIERS
- Communication, not true barrier, but requires effort

PICS RESOURCES & TREATMENT
- PICS clinics (pros & cons)
- For primary care physician (it exists, dont; have to solve it one go; there are online resources available)
- Addition PICS resources (listed in show notes).

Thanks for listening.
Please check out the additonal show notes for additional resources.