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The Summary

Mizuho Morrison, DO and Mike Weinstock, MD
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No me gusta!

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Matt M., MD -

Well...this has been a good year - I have enjoyed UC Rap immensely, and found many, many segments specifically practice changing, and many others that supported what I have been doing as appropriate, helping me inch closer to my goal of being half as clinically savvy as Mike Weinstock. Definite progress. Two comments from this last month ...
1) Back pain - can't get too much discussion of this, it is so freaking common. I was wondering about this Amrix (basically a 24 hour, time release version of Flexeril) - it was not discussed in this segment, and I have been using it some, when the use is not precluded by the expense (which is a lot). But, in theory, I am attracted to the idea of it. Flexeril really needs to be taken three times a day, which most people won't do because of the sedation side effect. Amrix, taken around 7 pm will peak once (about 5-6 hours later - some sedation with that, but it will actually help with sleep), and provide therapeutic blood level for the 24 hour period. Sounds like a win-win, and a basic home run, except for the frequently deal-breaking expense. What does UC Rap know or think? I am thinking it might be a study that needs to be done....

2) The comment about single digit bicarb and toxicology syndromes for acidosis - this is well-taken and I understand it. But in my 15 years in the ER, I had one case of ethylene glycol toxicity (and indeed a single digit bicarb) - but for that one case I had much more than 50 cases of DKA, and many of them had a single digit bicarb. So, if the point is that toxidromes are more likely to cause the single-digit bicarb, I wholeheartedly agree. But, the caveat from my standpoint would be that of all the cases of metabolic acidosis with single-digit bicarb that we see, seems to me DKA is still the most common culprit.
Looking forward to more great stuff in 2017. Why don't we entertain the idea of soliciting ideas for clinical research in Urgent Care (Miz, you are right, there is not enough) and maybe organizing the implementation of a protocol through the UC Rap listeners??
Happy Holidays to all of the UC Rap staff,
Matt Mullen, MD

Mizuho M., DO -

Hi Matt - Thanks for your comments. Much appreciated! You make a great point about bicarb and DKA. In fact, I don't think we have covered DM emergencies yet, so thanks for the prompt to do so! Its as you say MUCH more common than ASA toxicity or toxic alcohols. Covering "Zebras" is important, but we can't forget the horses! ;)
Mike is getting Bryan's response for you. In the mean time, thanks for listening! Send us an email if you'de like to be on the program. Certainly your years of experience would add great pearls of wisdom to the show. Best, Mizuho

Mike W., MD -

Hi Matt, Weinstock here, thx for your insightful comments! I agree on the bicarb - the times I have seen single digit bicarbs are almost exclusively from DKA, just like you. Sean Nordt did really give good credence to MUD PILES, one of the few things I learned in med school which actually turns out to be true! (think post menopausal estrogen, steroid for spinal cord injury, etc). If you have an idea for clinical research for UC, I am definitely happy to help out!

Here are the comments by Bryan Hayes for Amrix:
I've never used the extended release cyclobenzaprine. The data for the immediate release product is not all that strong to begin with. There are a few small studies suggesting the ER preparation is probably equivalent to IR with a lower rate of somnolence: https://www.ncbi.nlm.nih.gov/pubmed/21424735, https://www.ncbi.nlm.nih.gov/pubmed/20675978, and https://www.ncbi.nlm.nih.gov/pubmed/19323613.

--
Bryan D. Hayes, PharmD, DABAT, FAACT
Clinical Pharmacist, Emergency Medicine & Toxicology
Massachusetts General Hospital
Twitter: @PharmERToxGuy
PharmERToxGuy.com

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Holiday Strains in the Urgent Care Full episode audio for MD edition 193:29 min - 91 MB - M4Ahippo Urgent Care RAP - December 2016 Summary 275 KB - PDF