September 17, 2020

Background: Baloxavir (trade name Xofluza) was approved for the treatment of acute, uncomplicated influenza in patients > 12 years of age in October 2018. However, high-quality data has been underwhelming at best for its efficacy in treatment. Back in November of 2018, REBEL EM concluded:

Clinical Take Home Point: Consistent with every other study on anti-viral medications for influenza, baloxavir appears to decrease duration of symptoms, especially in patients treated within 24 hours of symptoms, BUT a massive exclusion list, cost of the medication, increased resistance after initiation, results only applicable to H3N2 (88% of patients with flu), no comparison to standard care (i.e. symptom based therapy), pharma sponsored study, and no patient oriented outcomes, it is hard to make an argument for the use of baloxivir in patients with confirmed influenza. This trial should be a reminder as to why an industry funded trial, without full release of data, and cherry picked endpoints should not be used to change practice.

Continued research on effective anti-influenza drugs is critically important particularly with the potential for a “double pandemic” in the coming months. While treatment results are modest at best, baloxavir has potential as a prophylactic medication as well.

September 16, 2020

Take Home Points

  • Wernicke encephalopathy is characterized by ataxia, altered mental status and ophthalmoplegia but patients are unlikely to have all these components
  • Suspect Wernicke encephalopathy in any patient that is at risk of malnutrition or malabsorption and has any one of the classic symptoms
  • Prophylactic administration of thiamine 100 mg IV/IM to at risk patients can prevent development of the disease
  • Once Wernicke encephalopathy has developed, it must be treated with high-dose, IV thiamine

September 2, 2020

Take Home Points
  • Focus on resuscitating well by focusing on the basics
  • Recognize Massive GIB (MGIB) with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
  • Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
  • Get consultants on board early
  • Give adjunctive medications that impact mortality (ie A 3rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

July 22, 2020

Take Home Points
  • Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms
  • Empiric Antibiotics should cover Staphylococcus (including MRSA) and Gram negative Bacilli
  • All patients with clinical suspicion require rapid evaluation with MRI as the diagnostic study of choice
  • Although not all patients will go to the operating room, surgical consult (Neurosurgery or Orthopedics) should be obtained emergently
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