In this podcast, Dr. Riddell Scott, a dermatologist with Ridgeview Medical Center and Clinics, leads the discussion about skin cancer. Dr. Scott discusses changes to our DNA, what dermatology office visits look like, types of skin cancer and treatments available, as well as prevention efforts. 

Enjoy the podcast.

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

• Explain the 3 main types of skin cancer and how they differ from each type.
• State how most skin cancers are treated.
• Identify how sun exposure contributes to the onset of skin cancer.
• Describe 3 activities that help to reduce skin cancer incidence.
• Counsel patients about skin cancer prevention efforts.

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  [email protected].

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 show information.
  
What happens to our DNA
- Ultraviolet light hits skin and energy is transferred
- Melanocytes & Melanin
- Skin cancer risk factors

Office visits
- Family history
- Dermatology: pattern recognition
- Dermatoscope
- Patient education
- Repeat exams & recommendations
- ABCDE (asymmatry, border irregularity, color variation, diameter, evolution) 

Types of skin cancer: Squamous , Basal Cell Carcinoma, Melanoma
- Cell physiology
- Metastatic rate
- Presentation
- Primary vs secondary sources
- Diagnosis
- Stages (0,1,2)
- Treatment (biopsy, MOHS, surgery, radiation, medication)

Skin Cancer Prevention:
- 3 Big Things:
      - Wear a wide brimmed hat
      - Wear sun protective clothing
      - Wear sun screen daily
- Sunscreen recommendations

* For more information - see attached "Show Notes".

Thanks for listening.

In this podcast, Edith Nagel Eisinger continues entertaining us with the seventh chapter (and final chapter) of her memoirs in Waconia, MN. 

Edith Nagel Eisinger, was the wife of Dr. Harold Nagel and nurse in the hospital she talks about in her memoirs. In 1936, the Nagel's founded the first hospital in Waconia - Nagel Hospital - which later became Waconia Hospital, and eventually Ridgeview Medical Center.

Enjoy this chapter of Edith Nagel Eisinger's story.

In this podcast, Dr. Andraya Huldeen, an obstetrician and gynecologist with  Western OB/GYN, a division on Ridgeview Clinics will discuss several obstetrical myths; including medication safety profiles for pregnant women, epidurals, COVID vaccinations and induction of labor. Also joining in this podcast is Dr. Nate Beerling, an anesthesologist with Ridgeview, who will add to the discussion of epidurals. Enjoy the podcast!

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

• Assess timing for induction of labor.
• Recognize there is lack of evidence of COVID vaccines causing infertility.
• Describe the different medication classes in pregnancy and how to balce risk/benefit in prescribing some medications.
• Summarize the role epidurals play in labor.

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  [email protected].

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 show information.
  
Medications in Pregnancy:
- Current, but not standard system
    - Risks vs outweighing benefits
- Old system: ABCD & X
    - A: studied extensively, no risk
    - B: used extensively & very few problems
    - C: "waste baskeet garbage world"
    - D: can cause increase risk of birth defects but benefit outweighs the risk
    - X: Never use, serious side effects or defects

MYTH: All medications cause birth defects if taken during pregnancy
- Cold medicines
- NSAIDs
- Acetaminophen
- Narcotics
- Ondansetron

MYTH: Cervical exam has to be less than 4 to get epidural
MYTH: Epidurals slow down labor and cause c-sections
- History of epidurals
- Epidural at what stage of labor
- Epidural placement
- Combined Spinal Epidural
- Intrathecal: Spinal block
- Contraindications for epidurals/spinal blocks
- Complications:
     - Epidural hematomoa
     - Postural puncture headache

MYTH: COVID vaccinations are not safe for pregnant women
MYTH: COVID vaccine cause infertility
- Concerns & live attenuated vaccines
- Pertussis vaccination
- COVID vaccination & infection & pregnancy outcomes
- IVF & Fertility Outcomes

MYTH: Induction of labor causes more c-sections
- Previously: induction at 41 weeks unless medical reason to be induced earlier
- With higher primary C-section & repeat C-sections - morbidity & mortaility
- Prevent 1st C-section
- 39th week is  lowest risk week to deliver
- "Arrival Trial"
- Induction of labor
     - Bishop scale
     - No specific order for starting induction - provider dependent

* For links and resources - see attached "Show Notes".

Thanks for listening.

In this podcast,Dr. Greg Giese, an internal medicine physician with Ridgeview talks about diabetic ketoacidosis (DKA). More specifically Dr. Giese will discuss the pathophysiology, initial assessment findings and diagnosis of DKA, along with addressing the differences between diabetic ketoacidosis (DKA) and hypersmolar hyperglycemic state (HHS), and treatment options for DKA patients.

Enjoy the podcast!

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

• Define diabetic ketoacidosis.
• State the differences between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
• Summarize how to diagnose and treat diabetic ketoacidosis.

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  [email protected].

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 show information.
  
DKA: Deficit of insulin
- Typical scenario
    - Insulin deficienty + counterregulatory hormones
    - Catabolic state
    - Gluconeogensis
    - Glycogenolysis
    - Elevated blood sugar causes concomitant osmotic
      diuresis

DKA: 3 Parts
- Ketones (ketonemia)
- Hyperglycemia (lack of insulin)
- Acidosis (Anion gap Metabolic Acidosis)

Presentation
- Critically ill individual on set in 24-48 hours
- Kussmaul respirations
- Other causes (infections, UTI, pneumonia, skin
   infections, MI, drugs,)
- Altered mental status
- HHS: Hyperosmolar hyperglycemic state

Work-up
- Basics
CBC with differential; metabolic panel, serum ketones, blood gas, urine analysis, plasma osmolality
- Evaluation:
Elevated WBC;  elevated anion gap;  electrolyte abnormalities;  Chest x-ray

Results
- Potassium (hold insulin if K was 3.4 or below)
- Hyponatremia
- Bicarb
- Anion gap
- Normal to elevated calcium
- BUN greater than creatinine ration
- Elevated creatinine
- Elevated WBC due to catecholamines and stress response
- Hgb/platelets
- Urine

Treatment
- Fluids
- Potassium
- Insulin

Transition to baseline
- Discontinue insulin when anion gap metabolic acidosis closed and able to take oral nutrition
- Bridge, start subcutaneous long acting insulin, stop insulin drip 1-2 hours later.

Thanks for listening.

In this podcast, Dr. Kim Thielen, a nephrologist/kidney specialist with Minnesota Kidney Specialists joins us today to continue part 2 of our discussion on acute kidney injury, as we wade further "into the weeds" 
discuss intrinsic renal disease. This episode will break down hallmark urinary findings and
further subdivide intrinsic concerns into bland, nephrotic and nephritic, various causes, and
treatment.

Enjoy the podcast!

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

• State the 3 types of urinary analysis findings related to instrinic acute kidney injury.
• Describe etiology of presentation of each type of intrinsic acute kidney injury.

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  [email protected].

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 show information.
  
Intrinsic Kidney Injuries: Urinary analysis findings
- Bland Urine: no protein
- Nephrotic: protein
- Nephritic: protein and blood

Hallmark Urinary Findings: Casts
- Tamm Horsfall Protein : Mucoprotein made by tubular epithelial cells that precipitate out and congeal
   to form casts on whatever is in the cells at the time.  (i.e. RBCs, WBCs, tubular debris)

Bland Urine States
- Crystalline Induced Renal Injury: obstruction and infllamatory response
      - Uric Acid Neuropathy (Most common)
             - Cancers, lymphomas, etc.
             - Drugs: acyclovir, methotrexate, protease inhibitors, etc.
             - Toxins: Ethylene glycol
- Bland Urine Disease states: results from injury to tubules, instertim or pre glomerular blodd vessels, not
   the filters of the kidney
      - Interstital Nephritis
             - Hallmark: pyuria and WBC casts
                     - Biopsy: inflammatory infiltrate
             - Causes:  viral, PPIs, Adenover, mizalamin, etc., Checkpoint inhibitors
      - Acute Tubular Necrosis
             - Hallmark: tubular epithelial cell cast
                     - Granular: (course or fine) diagnostic of ATN
             - Biopsy: denuded dilated tubular cells
             - Causes: #1: Ischemia;  toxins, drugs, contrast dye;  pigment injury. myoglobin
             - What about contrast dye?
                     - Categorized under ATN
                     - Per Dr. Thielen, plays a role, but injury is not solely dependent on dye alone.
      - Hepatorenal Syndrome: ischemic injury to the kidney due to unopposed vasocontstriction
              - Ace inhibitors cause unopposed efferent vasoconstriction + nonsteroidals cause
                unposed afferent vasoconstriction = no glomerular perfusion pressure
      - Multiple Myeloma
             - Hallmark: Light chain cast nephropathy or myeloma kidney 
                    - Light chains precipitate  out causing obstruction, inflammatory response and causes
                       tubular damage
             - Presentation: older possibly with anemia, bone pain and elevated creatinine with a bland urine.
             - Protein to creatinine ratio: + for protein (non albumin)
             - Dipstick: (which measures for albumin and not light chains) will be negative for protein aka
                bland urine
      - Hypertensive Nephrosclerosis
             - Small vessel vascular disease
                    - Blood vessels prematurely atherosclerosis causing glomerular drop out and scarring of the
                       interstim
      - Scleroderma
               - Limited cutaneous systemic sclerosis
               - Diffuse cutaneous systemic sclerosis: 60-80% have renal injury from disease state itself
                          - FANA positive
                          - Concern for Scleroderma Renal Crisis = medical emergency
                                  - AKI, moderate to severe HTN and bland urine
                                  - Uncontrolled accumulation of collage, thickens vascular walls, narrowing and renal
                                      ischemia
                         - Occurs in 10-15% of those with Diffuse Cutaneous Systemic sclerosis and happens early
                             in disease
                                    - Left untreated: renal failure in 1-2 months and death in 1 year
                         - Treatment: ACE Inhibitor

Nephrotic Urine States
- Urine protein: albumin excretion greater than 3.5g in 24 hours
- Nephrotic Syndrome:
     - Present with 3 things (nephrotic range protein, hypoalbuminemia, peripheral edema)
      - Hyperlipidemia: due to increased hepatic lipogenesis
               - Increased risk of renal disease and arthroscleratic
      - Venous thrombotic disease:
                - Loose proteins other than albumin and develop a hypercoagulale state
                - Renal and peripheral venous thrombosis
      - Lipiduria (forms fatty casts,  looks like a latese cross under microscope)
 -Pathophysiology or nephrotic syndrome
   - Glomerular capillary wall
          - 3 layers that work as a glomerular filtration and responsible in the filtration between blood and
            urine
                 - Fenestrated Capillary Enothelial cells (fenestrations allow plasma through to the basement
                    membrane)
                - Glomerular Basement Membrane (maintains glomerular filtration barrier; negatively charged,
                    repels albumin)
                - Epithelium: Podocytes (Have highly specialized foot processes that connect and form slit
                    diaphragms; Slit diaphragm important for the efficient flow of small solute and water)
         - Anything that messes with any of these layers: nephrotic proteinuria
- Nephrotic Disease States:
    - Biopsy: anyone with nephrotic proteinuria (besides diabetics)
         1) Light microscopy: high overview
         2) Immunofluorescens: looks for nephritic component and identif immunce complexes
         3) Electron microscopy: (EM) helps look at the ultrastructure and better identify immune deposits
    - Diabetic nephropathy
          - Leading cause of kidney disease in U.S. and western society
          - Responsible for 30-40% of all ESRD causes
          - Hyperglycemia: produces inflammatory responses, oxidative stress, and injures the podocytes and
            deposits that charge and affect the ability of the kidney to filter.
    - Amyoidosis
           - Organize into betapleted sheets and produce spikes of the capillary uniion and poke through the
              GF membrane
           - Easily identified by apple green birefringence on congo red
           - Terminal illness
           - Present with HTN, cardiac effects and elevated creatine
 - Nephrotic Disease states based of histologic appearance
     - Diagnosed by histologic appearance but does not determine the etiology
     - Minimal Change Disease
             - Fairly common
             - Minimal change under light microscope
             - EM: podocytes are abnormal, fused, no unique cell-cell junction
             - Primary: Immune generated circulating facture;  alters the cytoskeleton of the podocytes
      - Secondary
              - Nonsteriodal - most common cause of secondary minimal change disease
              - Gama interferon
              - Hodgkin's lymphoma
              - Allergy: 30% of minimal change have associate allergy (mechanism unknown) 
     - Presentation
              - Sudden onset (days to weeks)
              - Marked edema and hypoablbuminemia
              - 60% have normal blood pressure,    82% have normal creatinine
- Focal Segmental Glomerulosclerosis (FSGS) - primary and secondary 
       - Most common cause idopathic nephrotic syndrome in adults
       - Primary glomerulonephritis in the US that causes ESRD
       - Widespread podocyte injury
    - Primary: circulating factor that messes with regulation of foot process and adhesion to the
        glomerular basement membrane (afffect all podocytes)
         - Present with nephrotic syndrome and rapid progression
         - HTN and elevated creatinine
   - Secondary: the visceral epithelial cells don't replicate
         - Nephron loss or obesity or direct foot process injury
         - Cannot replicate (podocytes), leads to decreased to podo denisty at specific areas (focal injury)
         - 2/3 of all cases FSGS
         - Present: with slowly increasing proteinuria and kidney impairment over time
         - Causes: interferon, bisphosphonates, talc, anabolic steroids
   - Genetics: gene mutations that encode for the slit diaphragms of the podocytes (affect all podocytes)
           - Present in Childhood: full blown nephrotic and progress rapidly to ESRD

Membranous Nephropathy
- Most common cause of nephrotic syndrome in caucasion adults
- 80% present with nephrotic but develops more slowly to ESRD
- Primary: Major antigen identified
     - antibody to trans-membrane receptor that is highly expressed on the glomerular podocyte
- Secondary: Cancers (lung, breast, GI), Lupus, Thyroiditis, Hep B, Syphilis, Nonsteroidals, Monoclonal
   Antibodies

Nephritic Syndrome
- Hematuria and proteinuria
   - Hematuria: blood from kidney or outside the kidney
            - Outside the kidney: look the same
            - Inside the kidney: dysmorphic red cells
   - Present:
            - Renal impairment for days to weeks
            - Edmatous, HTN and look critically ill 
            - Vasculitis, sinusitis, oral ulcers
            - Pulmonary renal syndrome: short of breath or hemoptysis
            - Skin changes: bruising , bleeding, purpura
            - Myalgias and arthritis
    - Urine:
            - Hallmark: red blood cell casts (polymorphic red cells)
            - dipstick + for blood
            - elevated proteinuria
   - Biopsy: nephritic and + urine

Nephritic Disease States (based on immunofluorescence staining)
- Pauci Immune Disease
        - Ankle vasculitis, common
        - A paucity (little amount) of immune complexes
        - See black on imaging
        - Lab work: check on ANCA and peripheral eosinophils
- Anti-GBM Disease
        - Renal limited, or classic pulmonary renal: Good Pasture's
         - linear staining of the glomerular basement with anti IGG (looks like a ribbon on a package)
         - Treat with cytotoxic agents
 - Immune Complex
         - Starry sky pattern
         - Glomerulus looks dotted with stars
               - Stars = immune complex definition
         - Diseases:  Lupus (FANA), Post Infectious GN, Membranous Proliferative GN
 - IGA Nephropathy 
         - Most common cause of glomerulonephritis in the world
         - Presentation:
                - Peak incidence is the 2nd and 3rd decades of life
               - 40-50% gross hematuria with upper respiratory and GI illness
         - Risk Factors for Progression:
               - younger age or hypertension at time of presentation
               - > 1g proteinuria
               - Elevated creatinine at time of presentation

Thanks for listening.

In this podcast, we are joined by Dr. Kim Thielen, a nephrologist/kidney specialist with Minnesota Kidney Specialists. This episode is part one of a two part series dealing with acute kidney injuries. During this episode Dr. Thielen will discuss pre and post acute kidney injury etiologies. Included with the podcast is additional shownotes that Dr. Thielen references throughout the podcast.  Also check out the next podcast/episode on intrinsic kidney injuries.

Enjoy the podcast!

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

• Describe how to work up a patient who presents with kidney injury.
• State the 3 types of kidney injury etiologies.
• Identify various causes of kidney injury.
• Choose treatment options for the specific types of kidney injury.

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  [email protected].

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 show information.
  
Acute Kidney Injury
- Abrupt decrease in kidney function
- Suspected with oliguria, elevated creatinine, proteinuria, and hematuria

Oliguria
- Less than 500mls of urine in 24 hour period.

PreRenal
- Anything that decreases circulating volume or disruption of blood flow to the kidney, causing ischemic kidney
- Causes:
    - Total body salt and water depletion
    - Dehydration
    - Hemorrhage
    - Decompensated right or left ventricular failure
    - Renal arterial stenosis or renal vasospasm

Signs and Symptoms
- Orthostatic, hypotensive, tachycardiac
- Most sensitive indicator of ischemic kidney: Urinary sodium concentration

Urinary Sodium Concentration
- Distinguishes between prerenal and instrinsic causes
- Urine sodium less than 20 in oliguria is indicator of ischemic kidney

Fractional Excretion of Sodium
- Fractional excretion of less than 1% is indicative of ischemic kidney or a prerenal state
- Fractional excretion of 2% is indicative of tubulules not working or ATN

Fractional Excretion of Urea
- For patients on diuretics
- Urea not affected by water concentrating effect of kidney
- Prerenal state: fractional excretion of urea less than 35
- Intrinsic: fractional excretion of urea greater than 35

Classic Presentation of Prerenal
- BUN to Creatinine Ratio greater than 20.1 signifies dehydration
      - Variables: GI bleed can increase BUN
- Elevated bicarb

Post Renal Etiologies
- Anything that interfers with the drainage of the urine from the renal pelvis out to the urethra.
- Causes:
      - Intraluminal obstruction: stones or tumors
      - Dysfunctional bladder: spinal injury, diabetes
             - Dysfunction with bladder drainage
      - Extrinsic compression on ureter
               - Ruptured AAA: edema
               - Retroperitoneal fibrosis
               - Prostate
               - Urethral strictures

Post Renal Presentation
- Can present with pain or not
- Decreased urine output or outflow
- Hypertensive
- Volume overload

Treatment
- Foley distal obstructions of urethra
- Imaging: ultrasound
       - Horizontal view:
              - Normal: (bright white) collecting system is collapsed due to normal drainage of pelvis
              - Post renal obstruction
                      - Dilated (dark pools) collecting system
- Chronic obstruction
       - Functional dilatation
       - Further testing: functional lasix radiograph
       - Kidney transplant: functional dilated picture
              - Changed physiology of the ureter, and can get flow both ways and thus chronic dilation

Thanks for listening.

In this podcast, Dr. Lioudmila Sitnikova, a urologist with Minnesota Urology, discusses micturition, pathology of incontinence including stress, urge and neurological, as well as various treatments available.

Enjoy the podcast!

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

• Describe the normal function of the bladder.
• List the different types of incontienence.
• Describe how female urinary incontinence is diagnosed.
• Identify treatment options for each type of urinary incontinence.

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  [email protected].

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 atachment for the full chapter summaries.
  
Phases of Micturition
- Storage
- Evacuation

Risk Factors
- BMI, smoking, caffiene, spicy food, heavy lifting, child-bearing, diabetes, pelvic surgeries.

Hormone Replacement Therapy (HRT)
- Oral estrogen/progesterone vs placebo

Prevalence
- 1 out of 4 women over age 80 suffer incontinence.

Types & identification
- Stress incontinence
- Urge incontinence
- Overflow incontinece
- Bladder outlet obstruction

Evaluation for incontinence
- Questionnaires
- Voiding diaries
- Assess quality of life
- Physical assessment and pelvic exam

Treatment
- Stress incontinence: physical therapy, surgical, bulking agents, Burch procedure
- Urge incontinence: biofeedback, antimuscarinics and Beta 3 agonists, Botox, nerve stimulator
- Hypotonic bladder (non-obstructive urinary retention): nerve stimulator

*For links to reference materials please see the full show notes.

In this podcast,three great physicians come to gether to discuss colon cancer. Dr. Sabina Khan, a gastroenterologist with Rigeview, Dr. Dawn Stapleton , a general surgeon with Lakeview Clinic, and Dr. Purvi Gada, an oncologist and hemotologist with Minnesota Oncology; together they cover history, screening, staging and treatment for colon and colorectal cancer.

Enjoy the podcast!

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

• Summarize colonoscopy screening guidelines.
• Recognize symptoms of colon cancer in order to make a cancer diagnosis.
• Describe surgical and adjuvant therapies available for colon cancer diagnoses.

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  [email protected].

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 the full chapter summaries. 

Statistics
- Colon cancer is the 3rd leading cause of cancer death in the U.S.
- USPSTF recommendation states approximately 10.5% of new colorectal cancer occurs in individuals younger than 50 years old.
- Incidence of colorectal cancer has increased by almost 15% from the early 2000s to 2016.
- Recommended age to start colon screening is now at 45 years, down from 50 years old.

Screening Recommendations:
- screening tests and intervals are fecal immunochemical testing or high-sensitivity guaiac-based fecal occult blood testing every 2 years
- Colonoscopy every 10 years
- Flexible sigmoidoscopy every 10 years - plus fecal ummunochemical testing every 2 years.

Systematic Review: Post-Colonoscopy Complications & Review of Enhanced Recovery Programs in Colon Surgeries
- Complications post-colonoscopy
- ERAS: Enhanced Recovery After Surgery
- Fast track surgery protocols - shortened hosptial length of stay
- Adjuvant therapies
- Targeted therapies
- Treatment side effects

*For links to reference materials please see the full show notes.

In this podcast, Dr. Ron Tarrel, a Stroke Neurologist with Allina Health, discusses everything stroke. Dr. Tarrel walks through recognition, evaluation, and management of stroke. He also discusses current guidelines, as well as the future of stroke medicine. Enjoy the podcast!

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

• Identify and describe warning signs of stroke and its initial presentation.
• Assess when initial urgent/emergent evaluation, imaging, coordination of care and decision making needs to occur in regards to stroke.
• Discuss treatment options and indications in regards to stroke care.

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  [email protected].

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.

ADDENDUM TO SHOW NOTES:
Please note the Dr. Tarrel refers to TPA as a blood thinner at one point throughout the podcast. He would like the listerner to know that this medication (TPA) is a clot dissolving medication and not a blood thinner. Dr. Tarrel does not wish to confuse the listner on the nomenclature of TPA vs blood thinners (i.e. anticoagulants).

SHOW NOTES: 
FAST
The American Heart Association (AHA) put forth an initative for the lay person to recognize signs and symptoms of stroke and that was the FAST assessment which is (Facial asymmetry or weakness, Arm weakness, Speech difficulties, and Time), but now it has moved to the BE-FAST screening test. the BE portion of the FAST exam is assessment of Balance and Eyes to determine if there are posterior circulation findings.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.116.015169

HINTS Exam
The HINTS exam is a bit more specific and sensitve, looking for posterior circulation strokes in the correct patient population. Briefly, HINTS is a Head Impulse test direction-changing Nystagmus in eccentric gaze, or skew deviation.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.109.551234

Common Deficits
The majority of strokes are going to occur in the anterior circulation which would be the carotid distribution, then into MCA (M1, M2, M3, M4, M5). Most of the deficits are going to be unilateral weakness, sensory or cognitive symptoms - example: aphasia/ neglect (cortical symptoms). Whereas, posterior circulation (vertebrobasilar) may have more devastating qualities. Symptoms for posterior stroke can include dizziness, nausea and vomiting, nystagmus, coordination, ataxia. However, see the article linked below where posterior cirulation vs anterior crculation infarcts can sometimes be difficult to determine on a clinical exam alone. Therefore, neuroimaging is recommended to accurately determine stroke distribution.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.112.652420

This study indicates that the symptoms/signs considered typical of posterior circulation infarcts occur far less often than was expected. Inaccurate localization would occur commonly if clinicians relied on the clinical neurological deficits alone to differentiate posterior circulation infarcts from anterior circulation infarcts. Neuroimaging is vital to ensure acurate localization of cerebral infarction.

Hemorrhagic vs Ischemic Stroke
Which one is it? According to Dr. Tarrel, intracranial hemorrhage appears to exhibit more headache symptoms, such as this is the "worst headache of my life" , whereas ischemic stroke appears to be more painless, usually. Blood pressure and loss of consciousness can closely mimic hemorrhagic vs ischemic.

Telestroke Guidelines
Telestroke guidelines are generally insitution specific. Refer to the linked article below, on the current guidelines in telestroke medicine.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802246/pdf/tmj.2017.0006.pdf

BP / 1st Line Agent
For hemorrhagic strokes, the neurosurgeons and neurologist like the systolic blood pressure to be in the 140-160 range. BP is usually controlled with Nicardipine as a 1st line agent.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.117.020058

Last Known Well (LKW)
Last Known Well (LKW) is extremely important especially since we know that we are working against the closk for the use of lytic therapy (currently 4.5 hour window).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630074/pdf/nihms699406.pdf

https://www.ahajournals.org/doi/epub/10.1161/CIRCULATIONAHA.116.023336

Imaging
Imaging modalities for stroke workup can often include an initial non-contrast CT of the head to rule out ICH, but hen what happens? Generally, it is recommended to work in concert with the stroke neurologist to then determine the next line of imaging studies. If it is determined the patient looks to have a high NIHSS and concerns for LVOT (Large Vessel Occulusion) a CTA of the head and neck can be considered. Perfusion studies and advanced MR imaging should be discussed with consulting neurologists. Clinicians should also remember to follow their specific institutional guidelines for imaging studies if the stroke neurologist is unavailable or there is a delay in consultation.

LKW along with CTA and CT perfusion of the head in ischemic stroke patients can sometimes give us a picture of the infarct core with surrounding penumbra (ratio). If circumstances are faborable, it may allow the pursuit of a thrombectomy. The current guidelines are for thrombectomy within 6 hours, but consideration upwards of 24 and beyond in the right patient population. Please see the DAWN and DIFFUSE 3 trials.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.119.027974

Thrombectomy
Generally the neurointerventionalist does not pursue thrombectomy beyond the MCA (M2 region), sometimes depending on anatomy.

ASPECT Score
The ASPECT Score (Alberta Stroke Program Early CT Score) determines the volume of subcortical and cortical infarct involvement via perfusion study. Generally the score provided is 1-10. Anything less than a 6 portends a poor outcome. More early changes seen on CT suggest poorer outcomes from stroke. Patients with scores >8 have a better chance for an independent outcome.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.117.016745

IV TPA
IV TPA with thrombectomy is safe.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.109.568451

TNK appears to have the same efficacy as TPA. Single dose IV push over 5 minute infusion. Easier and faster delivery of TNK.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.119.025080

Institutions may have different absolute and relative contraindications to TPA. Practice should be guided by institutional protocol and consultation with neurology.
https://www.ahajournals.org/doi/epub/10.1161/STR.0000000000000086

Secondary Prevention
Secondary prevention of stroke with the aid of DAPT (Dual Antiplatelet Therapy) - usually Plavix and Aspirin. Patients with cerebra ischemia are at high risk for early recurrent stroke, and use of DAPT for secondary prevention is reflected in current guidelines. Good BP and lipid management is paramount for 2nd stroke prevention.
https://www.ahajournals.org/doi/epub/10.1161/STROKEAHA.119.028400

Scoring Systems
HAS-BLED score for major bleeding risk.
CHA2DS2-VASc Score for artrial fibrillation stroke risk.

Anti-thrombotic Therapy & Elderly Patients
Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/484991

Fall risk and anticoagulatoin for atrial fibrillation in the elderly: A delicate balance.
https://www.ccjm.org/content/ccjom/84/1/35.full.pdf

 

In this podcast, Dr. Laura Mohling, a pediatrician with Lakeview Clinic, talks about pathogens that infect children, childhood immunizations, current guidelines regarding vaccine scheduling, and vaccine hesitancy.

Enjoy the podcast!

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

• Name at least 3 pathogens mentioned in the podcast children/adolescents were/are susceptible to.
• Distinguish between the two different meningococcal vaccines available.
• Summarize Human Papilloma Virus (HPV) recommendations for adolescents.

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  [email protected].

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 the full chapter summaries. 

Vaccines
- Biggest impact on public health
- Vaccine safety continues to improve.
- No causation of autism from MMR or other vaccines. (Andrew Wakefield debunking, Thimerosal-free).
- ACIP Schedule for Childhood Immunization

Meningococcus
- Causation - Neisseria meningitidis
- Incidence declining
- Case fatality approximately 15%, with 10-20% survivor have serious sequelae.
- Serogroups 
     - Serogroup B and C - most frequent cause of disease in U.S.
     - Meningitis type B accounts for about 1/3 of cases in adolescents.
     - Serogroup A is rare in U.S.
- Meningococcal Vaccine
     - Meningococcal B vaccines (Trumenba and Bexsero) developed in 2014.
     - Vaccine short duration of protection (1-2 years) based on antibody response
     - Trumenba (2 doses 6 mos apart) \ Bexero (2 doses at least 1 mo apart)
    - MenACWY vaccine in 2005 primary dose at age 11, booster at age 16.

HPV
- HPV vaccine is the cancer prevention vaccine!
- Statistics
- Vaccine - Gardasil 9
     - ACIP recommendation of vaccine at age 11 or 12
     - dosing schedule of HPV vaccine

COVID-19 (SARS-CoV2)
- Approved vaccine for age 12 and above. (Pfizer-BioNTech)
- RNA vaccines
- Antigentic target  - how the vaccine works
- Co-administering with other vaccines
- ACIP, UpToDate, FDA statements regarding vaccine in adolescents

*For links to reference materials please see the full show notes.