POTD: Superficial Thrombophlebitis (feat. Dr. Doge Pologe)

Today's POTD is inspired by resident extraordinaire Dr. Doge Pologe. As usual, TL;DR is below the main text. 

Thrombophlebitis is essentially a composite of two diagnoses: phlebitis, which is a clinical diagnosis in the setting of an erythema and pain overlying a vein and an identified thrombus. In the lower extremities, this is most likely to occur in varicose veins. 

In general, risk factors for thrombophlebitis are the same as for DVT (think Virchow's Triad of hypercoagulability, hemodynamic changes (stasis/turbulence), and endothelial injury/dysfunction). These include pregnancy, history of vein excision/ablation, history of prior thrombosis, malignancy, and prior IV catheter placement. 

Special cases:

• "Mondor": thrombophlebitis of a breast vein, anterior chest vein, or of the dorsal penile vein. The two former should prompt a search for breast cancer and the later is usually due to repetitive trauma

• "Trousseau's sign of malignancy": migratory thromboembolism, has a strong association with adenocarcinoma of the pancreas and lung

Diagnosis:
Diagnosis of phlebitis is clinical. Ultrasound should be used to identify a thrombus to distinguish between phlebitis and thrombophlebitis. Patients should also have duplex ultrasound to identify a DVT especially if the area of concern is above the knee. This is important because the rate of concurrent DVT in all cases is 25% and the rate of concurrent PE is 5%. 

Thrombophlebitis on ultrasound will demonstrate heterogeneous internal echoes within a superficial vein. Unlike an abscess or a lymph node, this will not be discrete and you should be able to trace it out. in the words of the Doge:

"it looks like a weird continuous twisty spaghetti
abscess thing; 
but it's not to be feared, 
mostly superfluous, so get frisky and ultrasound that biddy, 
color doppler, diagnosis, ka-ching". 

There may be flow present (which can help distinguish an abscess from thrombophlebitis; abscess = no flow). Some examples (by the Doge Pologe and myself):

Treatment:
As with treatment of below the knee VTE, the treatment of superficial thrombophlebitis is controversial. Patients can be considered low risk (for VTE) if they meet these criteria:

• Affected vein segment < 5cm

• Remote from the saphenofemoral/saphenopopliteal junction

• Low risk for VTE

**Repeat duplex should be obtained in 7-10 days or for worsening symptoms to check for propagation!

NB: thrombophlebitis post-ablation are always low risk and do not require treatment

For these uncomplicated cases, treatment is aimed at alleviating symptoms and prevention of propagation. This includes the following:

• NSAIDs

• Warm/cool compresses

• Elevation of the extremity

• Compression stockings

Patients that do not qualify as low risk or if they have recurrent thromboembolism should be considered for anticoagulation. Although studies looking at anticoagulation for SVT are small and flawed, NSAIDs, LMWH, and fondaparinux have all been shown to decrease incidence of DVT. Patients can also be discharged on Xarelto (this is the only NOAC to be studied for this indication). 

In addition, thromboembolism can become suppurative. Signs and symptoms include high fever (as opposed to the low-grade fever that accompany simple thrombophlebitis) and purulent drainage (duh). In these cases, consider antibiotics. 

TL;DR

• Thrombophlebitis = phlebitis (redness/pain along vein) + thrombus

• Find the thrombus on ultrasound! Look for internal echoes.

• Low risk patients = below the knee, affected vein < 5cm, distance remove from saphenofemoral/saphenopopliteal junction can be managed with NSAIDs, compression stockings, warm/cool compresses, elevation

• Low risk patients should get repeat study in 7-10 days to check for propagation

• High risk patients: consider anticoagulation with LWMH, fondaparinux, or Xarelto

• Antibiotics for suppurative thrombophlebitis

Special thanks to Dr. Jonas Pologe, Dr. Lawrence Haines, and Dr. Leily Naraghi Bagher Pour. 

Sources:
http://www.emdocs.net/core-em-superficial-venous-thrombosis-svt/
https://www.bmj.com/rapid-response/2011/10/31/superficial-thrombophlebitis-not-straightforward-we-may-think
https://emedicine.medscape.com/article/463256-overview
https://www.uptodate.com/contents/phlebitis-and-thrombosis-of-the-superficial-lower-extremity-veins
https://radiopaedia.org/cases/superficial-thrombophlebitis-1?lang=us

Sunday Funday POTD: Priapism - a hard problem to solve?

Background:

Named after the Greek god of fertility, Priapus, priapism is defined as an erection that lasts for longer than 4 hours that is not associated with sexual stimulation. Why do we care? Because 90% of men with persistent erections > 24 hours will have permanent erectile dysfunction. There are three types: non-ischemic, ischemic, and recurrent. 

Non-Ischemic ("high flow"):
The less common type, this is due to an excess of blood via a fistula between the cavernosal artery and the corpus cavernosum, usually in the setting of trauma. 

Ischemic ("low flow"):
The more common type, this is due to obstruction of venous outflow as a result of impaired relaxation of cavernosal smooth muscle. This is a urological emergency. 

Recurrent ("stuttering"):
A form of ischemic priapism that occurs in men with sickle cell disease. It's characterized by initially short erections that progressively worsen. 

Workup:
History should include: duration of current erection, prior episodes, any medications used (legal or otherwise), history of hematological disorders (specifically sickle cell), history of trauma, how severe the pain is. 

Your entire workup is used to distinguish between ischemic and non-ischemic priapism. The table below summarizes the characteristics. 

Treatment:

Call urology!! (if available)
If unavailable, believe it or not, high flow or non-ischemic priapism, can resolve spontaneously, actually does not require treatment, and can be managed as an outpatient by urology. 

First of all, analgesia should be provided. An easy way to do this is to perform a dorsal penile nerve block.

Steps:

1. Obtain consent, grab your materials (lidocaine), syringe, needle, alcohol/iodine, cleanse the area

2. Insert a small needle at the 2 o'clock and 10 o'clock position at the base of the penis

3. Feel for the pop of scarpa's (superficial) fascia

4. Aspirate and inject 2mL anesthesia in each position

This can also be done under ultrasound guidance!
Second, the American Urological Association recommends primary aspiration of cavernosal blood. To do this, insert an 18 gauge needle to the lateral aspect of the penis one in each corporal body. 30-60ccs of blood should be removed. 

If this is sufficient, stop here. If tumescence persists, phenylephrine injection may be attempted. This should be given in 1mL aliquots of a 100-500mcg/mL concentration. To mix this, take a vial of phenylephrine (10mg/mL) and take out 1mL, mix this in a 100mL bag of NS. To make it easier, don't take the needle out of the penis and simply attach a syringe with the medication to the needle. This may be repeated every 3-5 minutes for an hour until resolution. 

Fun fact: epinephrine can be used as well based on several case series. The dosing: 2mL of a 1:100,000 (10mcg/mL) concentration. This is essentially your push-dose dose (ie. 1mL of code cart epi in 9mL NS)

If this fails, the patient will need urological surgery... won't bore you with the details here!

What about sickle cell disease?

Priapism in sickle cell disease should be managed in the same way as ischemic priapism. It is rare that standard therapies do not work, but if they do not, exchange transfusion or simple transfusion can be considered. Don't forget to get a retic level in these patients!

TL;DR

• Ischemic priapism is painful and is a urological emergency

• Call urology consult!

• Provide analgesia/perform a dorsal nerve block

• Aspirate with two needles laterally

• Phenylephrine if this fails

• Further management with urology if this fails

• Consider exchange transfusion in patients with sickle cell disease with priapism that doesn't resolve with these measures

Sources:

https://www.uptodate.com/contents/priapism
http://www.emdocs.net/priapism-ed-pearls-pitfalls/
http://www.nuemblog.com/blog/priapism
https://www.uptodate.com/contents/priapism-and-erectile-dysfunction-in-sickle-cell-disease
https://www.asra.com/asra-news/article/151/peripheral-nerve-blocks-for-urologic-pro
https://www.ncbi.nlm.nih.gov/books/NBK535389/
https://www.ncbi.nlm.nih.gov/pubmed/11416834

Wellness Wednesday POTD: Imposter Syndrome

As the academic year is coming to and we all adjust to our new roles within our residency programs or as new attendings or fellows, I thought this would be a good time to talk about this.

Imposter Syndrome

Originally described by psychologists Suzanne Imes, PhD and Pauline Rose Clance, PhD in the 1970s, it is defined as an "internal experience of intellectual phoniness". Essentially, this means that people with imposter syndrome feel that their achievements are undeserved and worry about being "found out"that they are less than adequate despite evidence indicating success and/or competence. 

Dr. Clance described six potential characteristics:

1. The imposter cycle
   The cycle starts with a task, which is then met with anxiety, lead to either over-preparation for the task or procrastination (which is over-compensated with frenzied preparation). When the task is completed, there is relief, but this is short-lived despite positive feedback. Instead, the person believes that their success is either due to their hard work or luck, but not due to their ability. 

   The result is a feeling of self-doubt, depression, and anxiety and a tendency to overwork. 

2. The need to be special or the very best
   Those with imposter syndrome are secretly comparing themselves to others, which leads to a feeling of inadequacy.  

3. Super(wo)man aspects
   Related to the need to be the best, people with imposter syndrome set unrealistic goals for themselves. 

4. Fear of failure
   This can also be identified as the main motivational factor for most people with imposter syndrome. 

5. Denial of competence and discounting praise
   Adding onto feelings of inadequacy, those with imposter syndrome have difficulty internalizing success and will even make excuses about why praise is not deserved. 

6. Fear and guilt about success
   Although people with imposter syndrome crave success, they also fear it because it makes them feel isolated in their success. They also fear taking on more responsibilities as they're more likely to be "found out" with higher expectations. 

This was further elucidated by Dr. Valerie Young who broke down the syndrome into five different personality types in her book The Secret Thoughts of Successful Women:

1. Perfectionists: people who set unrealistic goals and feel like failures despite the level of completion of these goals

2. Experts: people who need to know every piece of information and will overeducate themselves. They are also afraid of looking stupid and will hesitate to assert themselves

3. Natural geniuses: people that are used to achieve success effortlessly, which leads to feelings of inadequacy when any effort is needed

4. Soloists: people who feel that asking for help is a sign of failure

5. Super(wo)men: people who need to work harder than everyone else around them in order to succeed in all aspects of life
   

How to deal with imposter syndrome

As with any problem, the first step is identifying and recognizing the problem. From there, overcoming imposter syndrome requires a lot of self-reflection and much of this comes from reframing your mindset on what qualifies as success. Some potential methods:

• Seek help: this can be found in a mentor, a friend, or a therapist. Vocalizing feelings and concerns can help in several ways. First, it can help identify characteristics that are typical of imposter syndrome, which can lead to increased self-awareness. Talking can also help with the realization that imposter syndrome is not an uncommon occurrence, which helps to normalize the condition. 

• Lean to internalize validation: people with imposter syndrome tend to dismiss positive feedback. Learning to reframe your mindset by resisting this response to positive feedback can help put things into perspective.  

• Be realistic about expectations: the expectations that those with imposter syndrome set for themselves are unrealistic. It is important to realize that nobody is perfect and to properly reflect on one's own successes. Likewise, it's important to recognize that everyone has strengths and weakness and to reflect on one's strengths and not to see weaknesses as failures. 

• Figure out your true goals: it's possible the goals that you've set for yourself would not actually ones that would make you happy. Take stock in what really matters and that may also help to redirect your ambitions. 

Sources:
Abrams A. Yes, Imposter Syndrome is Real. Here’s How to Deal With It. Time Website. http://time.com/5312483/how-to-deal-with-impostor-syndrome/
Roche J. 10 Ways to Overcome Imposter Syndrome. The Shriver Report Website. http://shriverreport.org/10-ways-to-overcome-impostor-syndrome-joyce-roche/
Sakulku J, Alexander J. The imposter phenomenon. International Journal of Behavioral Science. 2011;6(1):75-97.
Weir K. Feel Like a Fraud?. American Psychological Association Website. https://www.apa.org/gradpsych/2013/11/fraud
Wilding M. 5 Different Types of Imposter Syndrome (and 5 Ways to Battle Each One). The Muse Website. https://www.themuse.com/advice/5-different-types-of-imposter-syndrome-and-5-ways-to-battle-each-one