medstudents

We often get asked about student engagement and campus life while living in Barbados. In this episode, we hear more about our Office of Student Affairs from the time students arrive at the airport, through events, clubs and community connections.

Dr. Jeremy Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada and ARVD.

Lumps and Bumps: Can't-Miss Diagnoses in Syncope 

Host: Alex Kaminsky

Guest: Jeremy Berberian, MD

• Associate Director of Resident Education, ChristianaCare
• Editor-in-chief: EMRA EKG Guide, EMRA Ortho Guide, and the upcoming Emergency ECGs: Case-Based Review and Interpretations, with Amal Mattu and William Brady
• Faculty editor: EM Resident Monthly ECG Challenge
• Creator: ECG Greeting Cards©, a collaboration with MPP and JerBer Productions

EPISODE OVERVIEW
Residents are well-programmed to recognize cardiovascular emergencies such as STEMIs at a glance. However, during a busy shift it can be easy to overlook dysrhythmias and other electrophysiologic urgencies and emergencies. Syncope is a prime example of a chief complaint that may be uncovered with an EKG alone -- however, syncopal emergencies are often subtle and nuanced. Dr. Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada, ARVD and more.

KEY POINTS

Wolff-Parkinson-White (WPW)

Prevalence: 0.7 to 1.7 per 10000

Overview
Accessory Pathway Connecting the atria to the ventricle. In some instances, this can cause the accessory pathway to travel FASTER than through the AV node.

 

Courtesy of CardioNetworks: Free use image

Key Features:

 Image: Courtesy of EMRA EKG Guide

Most common presentation is SVT. But also can present as atrial fibrillation.

Treatment
Orthodromic (Narrow): Treat like SVT

Key Point: Procainamide is the most safe chemical cardioversion in WPW as it does not directly affect the AV node. Use of AV-nodal blockers in WPW (including Amiodarone) increases the risk of VT/VF.

***Blocking the AV node in a WPW patient in Atrial Fibrillation can precipitate bad ventricular rhythms. If you see A-fib GREATER than 220 minus age -- consider WPW.***

Antidromic (Wide): Treat Like V-Tach

Brugada Syndrome
Prevalence: 5 in 10,000. Traditionally taught more common in Southeast Asian populations.

Overview
Sodium Channelopathy, which can lead to unstable dysrhythmias and ultimately cardiac death

Key Features

Diagnosis is made both by EKG and clinical criteria

   

Images: Courtesy of EMRA EKG Guide

Type 1:

• “Coved” ST-Elevation >2mm with a negatively deflected T in right precordial leads (V1-V3)
• Potentially diagnostic as isolated EKG finding.

Type 2:

 

• Not completely diagnostic but concerning fr workup.

 

Clinical Criteria (EKG Findings PLUS one or more):

• SYNCOPE
• Nocturnal Agonal Respirations
• • Brugada gets WORSE with parasympathetic stimuli.
• Family member with known Type 1
• Observed/Documented VT/VF
• Sudden cardiac death in family member <45 (Take that history!)

 

Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD)

Prevalence: Unknown, likely more than we thought. Mean age is 31. Also we don't have great clinical criteria to full encompass this -- yet. Multiple genes linked to disease process. Variable inheritance patterns.

Overview
Fibro-Fatty infiltration of the myocardium that replaces good "conductive" tissue with fibrinous infiltrates. Think: "Kinda like cirrhosis of the heart."

Causes paroxysmal ventricular rhythms. Can present as CHF.

Key Features

Image: Courtesy of EMRA EKG Guide

 

• Epsilon wave -- AKA "The Ditzle or Nubbin" (only in 30% of patients)

• T-wave inversions in right precordial leads (V1-V3) -- (85% of patients)

• Long S-wave repolarization delay >55ms (in 95% of patients)

• Slightly prolonged QRS >110ms (Right precordial leads)

• VT looks more like a Left-bundle morphology -- Appreciate that AFTER the patient is out of VT.

 

Key Resources: *If needed and/or different than references*

• EMRA EKG Guide
• Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope: Huff J.S., Decker W.W., Quinn J.V., Perron A.D., Napoli A.M., Peeters S., Jagoda A.S.( 2007)  Annals of Emergency Medicine,  49 (4) , pp. 431-444.
• Epidemiological profile of Wolff-Parkinson-White syndrome in a general population younger than 50 years of age in an era of radiofrequency catheter ablation. Lu C.-W., Wu M.-H., Chen H.-C., Kao F.-Y., Huang S.-K. (2014)  International Journal of Cardiology,  174  (3) , pp. 530-534.
• Reference, G. (2019). Brugada syndrome. [online] Genetics Home Reference. Available at: https://ghr.nlm.nih.gov/condition/brugada-syndrome#statistics [Accessed 14 Feb. 2019].
• McNally E, MacLeod H, Dellefave-Castillo L. Arrhythmogenic Right Ventricular Cardiomyopathy. 2005 Apr 18 [Updated 2017 May 25]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1131/

Nick Andrews and Emi Okamoto, MD, talk about how to decrease the number of phone calls to your office, how more and more people view mental illness as a threat, and how to handle it when your family and friends ask for medical advice. 

The interview this week is Taylor Brana, DO, the founder, producer, and host of the Happy Doc Podcast. 

Timestamps:

• Is mental illness threatening? (01:58)
• Preview gender empowerment conversation (06:08)
• How to decrease your office phone calls (06:58)
• Should you charge your friends for medical advice? (09:25)
• Meet the guest (14:15)
• Interview (18:50)

Links:

• People view mental illness as a threat (Medscape)
• #MyFirstNameIsDoctor (MDedge)
• Decreasing office phone calls (reddit)
• Charging your family and friends for medical advice? (reddit)
• The Happy Doc Podcast

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: podcasts@mdedge.com

 

In this masterclass, Philip D. Harvey, PhD, professor of psychiatry and behavioral sciences at the University of Miami, discusses the relationships between aging, neurocognition, and functional outcomes.

And in a new segment from MDedge, called This Week in Psychiatry, we’d like to share a Current Psychiatry evidence-based review on using antidepressants for pediatric patients (PDF) by Jennifer B. Dwyer, MD, PhD, and Michael H. Bloch, MD, MS.

Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Introduction to normal aging

• Changes in cognitive abilities are part of normal aging.
• Crystalized intelligence, the storage of information learned throughout life, does not change over time in normal, healthy aging.
• Fluid intelligence, the ability to learn new information, solve problems, concentrate, and rapidly process information, starts changing at age 65 or so.
• Episodic memory performance, the ability to learn new verbal information, declines 30% between ages 65 to 80, followed by another equivalent decline from ages 80 to 90.
• Alzheimer’s disease and amnestic mild cognitive impairment are characterized by signature memory loss called rapid forgetting, which occurs in cases in which a person is unable to remember information right after being told.
• Older people who are self-aware and sensitive to their age-related cognitive changes have a better prognosis.

Technology and aging

• Individuals in their 80s to 90s might have retired before the advent of technological advances such as ATMs, cell phones, the Internet, smartphones, and other touch screen devices.
• For these individuals, vital aspects of daily living, such as accessing finances online, requires using Internet navigation skills, and those skills were not acquired at a younger age.
• A direct connection exists between cognitive abilities and learning how to use technology for the first time.
• Healthy older people will be challenged by new technology the first time because of their lack of exposure. Yet, their ability to learn how to use technology is comparable to that of younger people.

Embracing technology to prevent normative cognitive decline

• The ACTIVE study, sponsored by the National Institute on Aging, enrolled 2,800 older healthy adults, with a mean age of 75, to evaluate the effectiveness of cognitive interventions in maintaining cognitive health and functional independence in older adults.
• Participants were randomized to either computerized speed training, memory training, problem solving training, or psychosocial intervention.
• The computerized speed training produced the most significant benefit in cognitive functioning. Participants randomized to computerized speed training sustained their functioning of instrumental daily activities of living and had a 50% lower rate of at-fault motor vehicle collisions, compared with controls, over a 6-year follow-up period.
• The ACTIVE study results suggest that age-related changes might be reversible with 14 1-hour sessions of brain training. Normative age-related cognitive decline can be attenuated through the use of affordable, accessible technology.

In summary, not all age-related cognitive complaints are pathological

• Clinicians must ask specifically about memory loss and rapid forgetting of information to differentiate normative age-related changes from Alzheimer’s dementia.
• Patients should be empowered to use technology to intervene for their cognition.
• Both brain and physical fitness are paramount to preventing dementia.
• Physical fitness is essential to prevention, because chronic illnesses such as type 2 diabetes are primary risk factors for dementia, and being overweight in middle age is a major predictor for developing type 2 diabetes.
• Physical exercise, brain exercise, and embracing technology are essential to preventing social isolation and subsequent dementia.

References

Antidepressants for pediatric patients
by Jennifer B. Dwyer, MD, PhD; Michael H Bloch, MD, MD

An evidence-based review from Current Psychiatry: 2019 September:18(9):26-30,32-36,41-42,42A-42F

• Click here for the webpage
• Click here for the downloadable PDF

Tennstedt SL and FW Unverzagt. The ACTIVE study: Study overview and major findings. J Aging Health. 2013 Dec;25(8 0):3S-20S. doi: 10.1177/0898264313118133.

Rebok GW et al. Ten-year effects of the ACTIVE cognitive training trial on cognition and everyday functioning of older adults. J Am Geriatr Soc. 2014 Jan;62(1):16-24.

Harvey PD and MT Strassnig. Cognition and disability in schizophrenia: Cognition-related skills deficits and decision-making challenges add to morbidity. World Psychiatry. 2019 Jun;18(2):165-7.

Brem AK and SL Sensi. Towards combinational approaches for preserving cognitive function in aging.  Trends Neurosci. 2018 Dec;41(2):885-97.

This week in cardiology:

1. PCSK9 inhibition cuts events in very-high-risk groups
   ODYSSEY OUTCOMES analyses peg prior CABG and polyvascular disease as targets for alirocumab.
2. Cardiovascular cost of smoking may last up to 25 years
   Past smokers face an elevated cardiovascular risk for up to 25 years after they quit.
3. Impact of climate change on mortality underlined by global study
   This may be the largest study ever to assess the effects of inhalable particulate matter around the world.
4. HCV coinfection adds to the cardiovascular risk in HIV-infected patients
   Hepatitis C virus and other injections were independently linked to the risk of having a cardiovascular event in HIV-infected patients.

You can contact the MDedge Cardiocast by emailing us at podcasts@mdedge.com or following us on Twitter at @MDedgeTweets.