Another PE acquisition that dropped right after election day, hence it may have not made waves when it happened. This is the second sale and this time to a publicly held company, so I doubt another sale is in the works.

For context, Cencora used to be known as AmerisourceBergen, owns Besse. Retina is similar to oncology in that much of the medical practice revolves around buy and bill injectibles. Before the second sale, RCA was able to negotiate a bulk discount and obtain rebates to profit off the margin without having to cut physician salaries or reduce equipment significantly. However, that might change after this since there is no incentive for them to do so. Think we're about to see an exodus of senior partners retire now that they've got their bag.

https://www.reuters.com/markets/deals/cencora-buy-retina-consultants-america-46-bln-2024-11-06/

A patient with a history of Type 2 diabetes had not taken her oral meds (did not take insulin) for a long time, and she arrived in our ER with a blood glucose of 1100. She was alert and oriented. Her pH was 7.25.

After about 1.5 liters of NS and after she had been started on an insulin infusion running at just 4 units per hour (running for only 45 minutes), I rechecked her blood glucose and it had dropped to 450.

Would this rapid drop in the blood sugar be explained by her having been dehydrated, and therefore the initial blood glucose reading was so high because there was so much more glucose in relation to water in her plasma sample? I think I am fundamentally not understanding something about how blood glucose is measured.

It's been a while since I've seen an HHS patient like this, but I've seen lots of DKA ones, and I did not see such a rapid drop in their blood glucose after they were given fluid boluses.

For most of my practice/training, I have been using topical azoles for most fungal/yeast infections, but more recently when patients have rashes I’ve been asking to check their feet, and if they also have toenail fungus, which most do, I offer the option of oral lamiail, If they don’t, I offer the option of once a week fluconazole for four weeks. if patients understand the risk/benefit, why is this not offered more? The risk is super low, so why not systemically clear out the infection rather than treat it topically for it most likely to come back?

Edit: also does any one still used nystatin? 😂

TL;DR: Traditionally treated with surgery, appendicitis now has a non-surgical alternative in China called ERAT, developed by Professor Liu Bingrong, which uses endoscopy to treat the condition without removing the appendix, effectively treating thousands of patients with minimal complications. Although this method has yet to catch on in other countries.

Background: For over a century, appendicitis treatment centered on surgical removal of the appendix, or appendectomy, which became the gold standard after its introduction in the late 1800s. Initially performed as an open surgery, this was later refined into a less invasive laparoscopic method in the 1980s, reducing recovery time and complications. In recent years, however, some western countries began exploring non-surgical options using antibiotics, which can successfully treat uncomplicated cases but come with higher recurrence rates.

Alternative approach: "In 2010, inspired by the endoscopic treatment of suppurative cholangitis, Professor Liu Bingrong innovatively proposed a new method for the treatment of appendicitis, which was named Endoscopic Retrograde Appendicitis Therapy (ERAT). This method does not require laparotomy or appendectomy, but achieves the purpose of treating appendicitis by addressing the cause of acute appendicitis, while completely preserving the appendix and its functions. In 2011 and 2013, Professor Liu Bingrong introduced ERAT at the Digestive Disease Week (DDW) and published a total of 8 articles in various journals. After nearly 10 years of development, ERAT has made progress in technological advancements, changes in indications, and clinical significance.

Since December 16, 2009, when the world's first case of ERAT was completed at the Digestive Endoscopy Center of the Second Hospital of Harbin Medical University, to 2019, the ERAT technique has been in existence for 10 years. According to incomplete statistics from 2021, ERAT has been carried out in 32 provinces, municipalities, and autonomous regions in China, treating over 3,200 patients without any serious complications."

EndoNews. (2024). Endoscopic retrograde appendicitis therapy (ERAT) [Video]. YouTube

2022 - Endoscopic retrograde appendicitis therapy for acute appendicitis: a systematic review and meta-analysis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9286766/

Hi friends,

The last time IDSA published UTI guidelines (outside of ASB, which of course is not a UTI) was 2009 and 2010!

Published on Monday:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2825634

Learn more about the WikiGuideline method of guideline development in the manuscript and at WikiGuidelines.org!!

Several of my co-interns and I have had patients in our primary care clinics asking for testosterone testing, insisting they have Low T. One patient has a family member taking testosterone supplements (though it seems they didn’t have low testosterone levels either) and symptoms which could be attributed to low testosterone - or hypothyroidism or a rheumatologic disease or depression or so many other things.

What are your go-to resources for physicians to see (1) who actually needs work-up (2) list of more likely things to evaluate for in people with concerning symptoms (3) help explain why it’s not indicated to patients who don’t need testosterone testing? (For those who will listen)

Thanks in advance

Edit: spelling

As the title says, for those of you in a union, what do you wish you asked/knew going into it?

As of recently there is a union group exploring talks for our specialty(not getting to specific to dox it) form a union solely within our corporation. I have zero experience with this and hoping for some perspective from others that went through it.

Granted there are advantages to it, I am slightly skeptical as the organizer sought us out to help get the union together, talks about the fees they will take, and seem to at time use scare tactics (For example one provider was denied personal leave and they died… do you want this to happen to you?!)

I’m a transgender physician in a super specialized field. I am afraid that things are going to get worse before they get better. I think given my subspecialty I should be able to move to any country that allows DOs to practice. If anyone has any experience with this I’d love to hear it! Feel free to dm me if that is easier. I’m not putting my specific subspecialty on here because there aren’t many of us.

Basically, if you had a choice to practice in America vs. the UK or other parts of Europe, which would you choose? Why? Let's pretend family/significant others don't play a role in your decision. Obviously there are pros and cons to both healthcare systems, but if there's anyone who has experience in both countries/hospitals your input would be greatly appreciated! Salary, lifestyle, and any other aspects of medical practice are welcome in the discussion :)

I dont understand what will happen. Does anyone understand this far?

Title. I think it's completely ridiculous that any medical professional, whether it be a doctor, EMS or pharmacist; should have to think (or say) something along the lines of "I'm sorry, I can't help you. It's against the law."

I'm sure I'm not just speaking for myself when I say that a large majority of us got into medicine because we wanted to do the morally right thing to help others with their ailments, however as federal & state laws continue to change, I find myself and others in our related fields unable to effectively (or sometimes at all) do that. Which I personally do not think is fair in the slightest to myself or the patients at risk.

For context, I got a call from my long time buddy, whom is an OBGYN being hit hard by new laws in Texas. He was calling as a friend outside of the professional space and he was on the verge of falling apart. He described to me how horrible he felt as a doctor to look at young teen in the eyes and tell her she'd have to carry a child that her body would barely be able to handle. He explained that she would survive the pregnancy & be okay with only a small margin for complications, but she was mentally clearly not capable nor ready to be a parent. He was extremely troubled with the situation and it bothered me as much as it bothered him.

This post serves as a comment / opinionated short rant & safe space for anyone in medicine to share their opinion on the limitations imposed upon them at a state or federal level. My heart goes out to everyone in this situation, I hope you stay strong for us. 💙

I was sitting in the library and suddenly someone screamed: "Help!!". When I walked to what was happening I saw a women around 80 year old, pale as if she died and gasping while hanging in a chair. My first reaction was: "this woman is dying here on the spot". I asked twice while slightly shaking her shoulders if she heard me, and then I put her on the ground. While she was on the ground I couldn't see an respiratory rate anymore. I think I checked for a pulse but I couldn't feel it. Also she still looked very pale so I asked people around me to call 911 and get a defibrillator. Since I didn't see her breathing I started chest compressions. I think I did around 15 seconds (not sure) and then she gave some sign of life so I stopped. She slowly became conscious again and she was quickly also quite lucid, telling her age and stuff. She also had diabetes, but no insulin.

Afterwards I asked people around what actually happened, and they said that they saw her trying to stand up in the chair and then falling back again on the chair whlist she lost consciousness. This seems to me that she was vasovagal/orthostatic hypotension. The ambulance came and they examined her further.

People thanked me for helping, but I actually felt pretty bad since I did some chest compressions that must've damaged her ribs somewhat. Also I didn't realise that she was vasovagal, I swear she stopped breathing and she was definitely gasping when I saw her for the first time. Since she was old and also she lost consciousness in a chair I thought that there was a high chance of cardial event. But in the end I felt embarassed and I hope I didn't do more damage to her instead of helping..

My question is if anyone else has similar experiences? Any tricks to prevent doing CPR on people who just have a vasovagal collapse? What are your thoughts?

Looking into starting a longevity medicine telehealth company serving US clients with licenses in US states, a US business address, but living primarily in Finland. Has anyone done anything like this, is it possible? Any considerations?

I recall a way to get past paywalls for scholarly articles. Does anyone remember what it was? Thanks!

I'm not so hot. Just sayin'.

How are people coping?

What is competitive reimbursement in terms of % collections (or $ per RVU) for SNF work? Can be for IM/FM or PMR. 1099, no benefits. Medical directorship is not included. Admin/billing and even weekend calls are covered by this PE company. Market is HCOL part of S Florida. Any input or experience to share greatly appreciated. The offer I have is 60-70% collections, or $30/RVU. Wondering if it’s worth it to go solo, but the billing/contracts aspect and buildup is daunting.

New DM diagnosis, A1C >10%. With the intro of GLP-1 and dual agonists into the game, do providers find themselves still jumping to insulin? I have a patient with a quite- elevated A1c, only symptoms being polydipsia/polyuria- which he is trying to manage by drinking 1-2L of regular soda per day, because obviously. Started with learning to check sugars, cut down soda, start metformin, follow- up 1 month. He’s never tried any lifestyle modifications and he seems motivated. In this case, I am hesitant to jump right into insulin therapy. Thoughts and opinions welcomed!

Voted blue in a rural red area, nervous to go to work tomorrow, Ive avoided talking politics so far. Im thinking “I don’t discuss politics at the office”? Is there a way to make it more neutral / lighthearted?

As someone who’s oblivious to clearly anything related to medicine or biology, RFK Jr was promised by trump with a role in health-related cabinet position. What the future lies ahead for NIH services like public databases and search engines, since funding presumably won’t be the same and US federal government leaning against international cooperation.

I’ve hit that age where annual visits to my PCP are a must. Like most patients, I have to book months in advance to see her since she’s an MD. And here’s the twist: I also happen to be an MD, but I keep that under wraps. I’m there as a patient, after all.

Sometimes I see the practice’s PA, when I can't plan months in advance. He's fantastic, by the way. Even after I was ‘doxxed’ as a doctor, things stay professional — he’s the provider; I’m the patient.

But I can’t help imagining some potential sticky spots. For example, if my PSA came back elevated, he might suggest a urologist referral, while I’d ask for a prostate MRI first. Or, if I had a sinus infection, he might lean toward doxycycline, while I’d "suggest" Augmentin.

This might not be good for him or for me. I could be creating my own pitfalls via the Dunning-Kruger effect.

For any APPs out there, how do you navigate these situations where your physician patient has ideas about their care that differ from yours?

I just started watching it and I am genuinely obsessed with how incredibly bad it is. Not even talking about the ethics that are supposed to be bad because that's kind of the whole premise is a rouge doctor with questionable ethics who does what he has to inorder to save patients. No the actual medicine they are practicing is so bad. If I decide to play a drinking game where I took a shot everytime they would have killed a patient I'd be the dead patient by now.

Yet I constantly hear chronically ill patients talking about wanting a Dr house to come save them shudders

So is this it? Did I find the worse medical drama out there? Is there one worse, because if so I must watch it.

I think this is happening in healthcare whether we like it or not.

This is not a Noctor post against APPs. I believe they contribute valuable work to healthcare. Unfortunately, admin has realized they can be corralled far more willingly than physicians are. If I were an admin, I would think twice before refusing a physician's request for time-off or schedule change, but to the same request from a PA? you bet I'm gonna say no proud and square to their face. I would think it's no brainer to have as many APPs as patients are willing to tolerate. Hospital has to pay them far less, and given they're not a "doctor", don't have the same bargaining power as doctors do, leading to abuse, putting up to see more patients, more draconian time offs, etc.

Remember how they have you do modules about "Being a Leader", and "Speaking up"?
Well yesterday was the time to do so.
Onward my brethren!