Cerebrospinal Fluid (CSF) - Pathway of Flow 1) CSF is produced and secreted by the choroid plexus of each lateral ventricle 2) CSF flows through interventricular foramina into the third ventricle 3) Choroid plexus of the third ventricle adds more CSF 4) CSF flows down cerebral aqueduct into the fourth ventricle 5) Choroid plexus of the fourth ventricle adds more CSF 6) CSF flows out the two lateral apertures and one median aperture 7) CSF fills the subarachnoid space and bathes the external brain & spinal cord 8) At the arachnoid villi, CSF is reabsorbed into the venous blood of the dural venous sinuses By @rev.med #Cerebrospinal #Fluid #CSF #Pathway #Flow #Ventricles #neurology

Perioperative IBD Pharmacotherapy Management Immunomodulators: • Stop MTX one week prior to elective surgery • Stop AZA/6MP the day of surgery and resume post op day 1 Biologics: • Do not delay urgent/emergent surgery • Time elective surgery with drug trough • Resume in CD patients at high risk of recurrence 2-4 weeks after surgery • Discontinue in UC patients undergoing colectomy Steroids: • Reduce dose as much as possible prior to surgery • Rapid taper (goal dose mg per day of prednisone) & intraoperative stress dose Gastroenterology Review @GIreview #Perioperative #IBD #Pharmacotherapy #medication #Management #preoperative #gastroenterology

ZSFG Inpatient Management of Opioid Use Disorder: Buprenorphine #Management #Addiction #Buprenorphine #Inpatient #Opioid #Withdrawal #COWS #Algorithm

Acute Pain Control In Patients On Medication Assisted Treatment (MAT) Methadone - µ-opioid receptor agonist: 1) Continue maintenance dose 2) Try non-opioid analgesics 3) Try increase dose or frequency of dosing - go slowly given long half-life 4) Add short-acting opioids Buprenorphine - Partial µ-opioid receptor agonist 1) Continue maintenance dose 2) Try non-opioid analgesics 3) Try increase dose or frequency of dosing 4) Add PRN doses of buprenorphine 5) Add short-acting opioids Naltrexone - µ-opioid receptor Acute pain control can be challenging as naltrexone has high binding affinity for the µ-opioid receptor 1) Try non-opioid analgesics 2) Add high-potency opioids 3) Try regional nerve blocks by Alyssa Mancini, MD @AlyssaManciniMD via @iMedEducation #MAT #PainControl #management #Buprenorphine #methadone #addiction #opiate

Quick Guide: Acute Pain and Perioperative Management in Opioid Use Disorder The following applies to patients already on a medication for opioid use disorder. Patients who have opioid use disorder but are not on a medication should be managed according the accompanying guidelines “Inpatient Management of Opioid Use Disorder: Buprenorphine” and “Inpatient Management of Opioid Use Disorder: Methadone.” Methadone: Before Surgery - Continue full dose After Surgery - Continue full dose, consider splitting TID Buprenorphine: Before Surgery - Continue full dose - Rarely, decrease to 12 mg 2-3 days prior to surgery After Surgery - Continue full dose, consider splitting TID Naltrexone: Before Surgery - Hold oral for at least 72 hours - Hold IM for at least 30 days After Surgery - Resume when no further need for opioids Support for Hospital Opioid Use Treatment (SHOUT) #Perioperative #Pain #Management #Opioid #UseDisorder #Addiction

Buprenorphine Initiation for the Uninitiated 1) WAIT FOR MODERATE WITHDRAWAL SYMPTOMS - Precipitated withdrawal can be caused by buprenorphine displacing a full opioid agonist. To avoid precipitated withdrawal, begin initiation during moderate withdrawal. - Moderate withdrawal symptoms: e.g. COWS Score 6-10 or substantial patient discomfort. - Consider the BUP Home Induction app for guidance. 2) START LOW DOSE BUPRENORPHINE - Begin with a first dose of 4mg for patients in moderate withdrawal. - Consider starting with 2mg for patients at higher risk of precipitated withdrawal. - Pro tip: Rx 8mg BID, then have the patient cut the film in half for the first day's doses. 3) WAIT 4 HOURS, GIVE 4MG - If the first dose is well tolerated, the patient can take a second 4mg dose later that day. 4) UPTITRATE & REASSESS - The following day, start 8mg BID - reassess adequacy after 7 days. - A majority of patients do well on a total dose of 16mg buprenorphine daily for maintenance therapy. #Buprenorphine #Initiation #Prescribing #Addiction #Management

Emergency Department Initiation of Buprenorphine for Opioid Use Disorder - r. strayer & e. ketcham (@emupdates) #Management #Opioid #Buprenorphine #Algorithm #Addiction #Initiation #Emergency #Prescribing

Inherited Qualitative Platelet Defects Bernard-Soulier Syndrome • Defect of adhesion due to a lack of GP Ib/IX/V [vWF receptor] • Thrombocytopenia, Large platelets on smear Glanzmann Thrombasthenia • Defect of aggregation due to a lack of GP IIb/IIIa [fibrinogen receptor] • Normal platelet count, Single isolated platelets without platelet clumping on smear MYH9-Related Disorder • Defect of cytoplasmic structure and cell mobility due to mutation in non-muscle myosin heavy chain IIA • Thrombocytopenia, Large platelets on smear, as well as granulocyte inclusions called Döhle-like bodies. May also present with sensorineural hearing loss, cataracts, and renal failure Grey Platelet Syndrome (an example of a storage pool deficiency) • Absence of platelet α-granules (contains vWF, factor V, and fibrinogen) • Thrombocytopenia, Large, grey colored platelets on smear, Associated with myelofibrosis and splenomegaly - Dr. Eric Strong @DrEricStrong - Strong Medicine https://www.youtube.com/c/EricsMedicalLectures/ #Inherited #Platelet #Defects #comparison #table #differential #diagnosis #hematology

Ground Glass Opacities on Lung CT - Pathophysiology Ground glass opacity lung is denser (whiter) than normal lung, but as compared to consolidation, not dense enough to obscure vessels within the area of GGO. Most often, GGO is caused by the partial replacement of air within alveoli with something that normally does not belong there. Unfortunately, there are many things that can partially fill alveoli, so the finding is non-specific. History, physical exam and other findings are key! Dr. Stefan Tigges @StefanTigges #Ground #Glass #Opacities #Lung #pulmonary #ChestCT #Pathophysiology #Radiology

Global Alliance algorithm to improve outcomes in acne. †With small nodules (>0.5–1 cm). ‡Consider physical removal of comedones. §Second course in case of relapse. ¶There was not consensus on this alternative recommendation; however, in some countries, azelaic acid prescribing is appropriate practice. For pregnancy, see text. ††See text. alt.: Alternative; BPO: Benzoyl peroxide. #Management #Dermatology #PrimaryCare #Acne #Treatment #Algorithm