{"version":"1.0.0","segments":[{"startTime":0.0,"endTime":3.2,"body":"[intro music]"},{"startTime":3.2,"endTime":5.6,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.2,"endTime":5.6,"body":"to Harrison's Podclass"},{"startTime":5.6,"endTime":8.73,"body":"where we discuss important"},{"startTime":5.6,"endTime":8.73,"body":"concepts in internal medicine."},{"startTime":8.73,"endTime":9.89,"body":"I'm Cathy Handy."},{"startTime":9.89,"endTime":11.733,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.89,"endTime":11.733,"body":"Wiener and we're coming to you"},{"startTime":11.733,"endTime":13.74,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.83,"endTime":17.286,"body":"[Dr. Handy] Welcome to episode 59,"},{"startTime":17.286,"endTime":20.11,"body":"a 65-year-old with fever and cough."},{"startTime":20.11,"endTime":21.85,"body":"[Dr. Wiener] Okay Cathy, here we go."},{"startTime":21.85,"endTime":24.47,"body":"A 65-year-old woman is"},{"startTime":21.85,"endTime":24.47,"body":"admitted to the hospital"},{"startTime":24.47,"endTime":27.29,"body":"in the United States in"},{"startTime":24.47,"endTime":27.29,"body":"January with a two-day history"},{"startTime":27.29,"endTime":30.38,"body":"of fevers, myalgias, headache and cough."},{"startTime":30.38,"endTime":32.74,"body":"She has a history of"},{"startTime":30.38,"endTime":32.74,"body":"stage 3 kidney disease,"},{"startTime":32.74,"endTime":35.3,"body":"diabetes mellitus and hypertension."},{"startTime":35.3,"endTime":38.52,"body":"Upon admission her blood"},{"startTime":35.3,"endTime":38.52,"body":"pressure is 138 over 65,"},{"startTime":38.52,"endTime":42.35,"body":"her heart rate is 122,"},{"startTime":38.52,"endTime":42.35,"body":"her temperature is 39.4,"},{"startTime":42.35,"endTime":44.44,"body":"her respiratory rate is 24 per minute"},{"startTime":44.44,"endTime":48.83,"body":"with a resting room air"},{"startTime":44.44,"endTime":48.83,"body":"oxygen saturation at 85%."},{"startTime":48.83,"endTime":51.46,"body":"On physical examination"},{"startTime":48.83,"endTime":51.46,"body":"you notice diffuse crackles"},{"startTime":51.46,"endTime":54.66,"body":"in both lungs and a chest"},{"startTime":51.46,"endTime":54.66,"body":"radiograph confirms the presence"},{"startTime":54.66,"endTime":57.73,"body":"of bilateral lung infiltrates"},{"startTime":54.66,"endTime":57.73,"body":"concerning for pneumonia."},{"startTime":57.73,"endTime":59.36,"body":"So what are your initial thoughts?"},{"startTime":59.36,"endTime":61.24,"body":"[Dr. Handy] Well, this"},{"startTime":59.36,"endTime":61.24,"body":"woman likely has pneumonia"},{"startTime":61.24,"endTime":64.683,"body":"with the fever, diffuse"},{"startTime":61.24,"endTime":64.683,"body":"crackles, hypoxemia on room air"},{"startTime":64.683,"endTime":66.8,"body":"and the radiographic abnormalities."},{"startTime":66.8,"endTime":68.86,"body":"I'm going to assume also that"},{"startTime":66.8,"endTime":68.86,"body":"her white blood cell count"},{"startTime":68.86,"endTime":71.59,"body":"is elevated even though you"},{"startTime":68.86,"endTime":71.59,"body":"haven't given us labs yet."},{"startTime":71.59,"endTime":73.45,"body":"I would like to know"},{"startTime":71.59,"endTime":73.45,"body":"what she is coughing up,"},{"startTime":73.45,"endTime":74.75,"body":"but in any event I'm worried"},{"startTime":74.75,"endTime":76.41,"body":"because she has multiple risk factors"},{"startTime":76.41,"endTime":79.82,"body":"for severe bacterial pneumonia,"},{"startTime":76.41,"endTime":79.82,"body":"plus you specified January"},{"startTime":79.82,"endTime":81.82,"body":"and that's right in the"},{"startTime":79.82,"endTime":81.82,"body":"middle of flu season"},{"startTime":81.82,"endTime":83.32,"body":"in the United States."},{"startTime":83.32,"endTime":84.42,"body":"[Dr. Wiener] You mentioned risk factors,"},{"startTime":84.42,"endTime":86.05,"body":"what got your attention there?"},{"startTime":86.05,"endTime":88.1,"body":"[Dr. Handy] Well, we know that"},{"startTime":86.05,"endTime":88.1,"body":"patients with renal disease"},{"startTime":88.1,"endTime":90.57,"body":"and diabetes are at risk"},{"startTime":88.1,"endTime":90.57,"body":"for a host of infections,"},{"startTime":90.57,"endTime":94.15,"body":"including pneumonia, plus her"},{"startTime":90.57,"endTime":94.15,"body":"age is another risk factor."},{"startTime":94.15,"endTime":96.91,"body":"I'm hoping she's been diligent"},{"startTime":94.15,"endTime":96.91,"body":"with her pneumonia vaccines."},{"startTime":96.91,"endTime":99.22,"body":"She should have received"},{"startTime":96.91,"endTime":99.22,"body":"pneumococcal vaccination"},{"startTime":99.22,"endTime":101.61,"body":"as well as the annual flu vaccine by now."},{"startTime":101.61,"endTime":103.3,"body":"But we know that the seasonal flu vaccine"},{"startTime":103.3,"endTime":105.99,"body":"is typically about 50-75% effective"},{"startTime":105.99,"endTime":108.1,"body":"at preventing seasonal infection,"},{"startTime":108.1,"endTime":110.87,"body":"but even when not fully"},{"startTime":108.1,"endTime":110.87,"body":"protective it may ameliorate"},{"startTime":110.87,"endTime":113.36,"body":"the severity of infection when acquired."},{"startTime":113.36,"endTime":115.84,"body":"[Dr. Wiener] Okay, we don't know"},{"startTime":113.36,"endTime":115.84,"body":"about her vaccination status"},{"startTime":115.84,"endTime":117.35,"body":"but the question asks,"},{"startTime":117.35,"endTime":119.35,"body":"all of the following could be included"},{"startTime":119.35,"endTime":122.58,"body":"in the initial management"},{"startTime":119.35,"endTime":122.58,"body":"of this patient, except?"},{"startTime":122.58,"endTime":124.321,"body":"A. amantadine;"},{"startTime":124.321,"endTime":126.237,"body":"B. oseltamivir;"},{"startTime":126.237,"endTime":128.642,"body":"C. droplet precautions;"},{"startTime":128.642,"endTime":131.099,"body":"D. nasal zanamivir;"},{"startTime":131.099,"endTime":133.241,"body":"or E. peramivir."},{"startTime":133.241,"endTime":134.22,"body":"[Dr. Handy] Well first off,"},{"startTime":134.22,"endTime":137.46,"body":"absolutely she should be placed"},{"startTime":134.22,"endTime":137.46,"body":"under droplet precautions."},{"startTime":137.46,"endTime":140.46,"body":"This is flu season and any"},{"startTime":137.46,"endTime":140.46,"body":"patient with suspected pneumonia"},{"startTime":140.46,"endTime":142.51,"body":"should be on droplet precautions."},{"startTime":142.51,"endTime":145.16,"body":"In the COVID era we've"},{"startTime":142.51,"endTime":145.16,"body":"actually upped the precautions"},{"startTime":145.16,"endTime":147.62,"body":"for patients like this"},{"startTime":145.16,"endTime":147.62,"body":"to aerosol precautions."},{"startTime":147.62,"endTime":149.5,"body":"So in the coming years that recommendation"},{"startTime":149.5,"endTime":152.04,"body":"will be dependent on the"},{"startTime":149.5,"endTime":152.04,"body":"prevalence of COVID-19"},{"startTime":152.04,"endTime":154.45,"body":"or other emerging viral diseases."},{"startTime":154.45,"endTime":155.92,"body":"But if you're thinking influenza"},{"startTime":155.92,"endTime":157.87,"body":"or the common bacterial pneumonia"},{"startTime":157.87,"endTime":160.46,"body":"then droplet precautions"},{"startTime":157.87,"endTime":160.46,"body":"are the least to impose,"},{"startTime":160.46,"endTime":162.06,"body":"and she needs oxygen immediately"},{"startTime":162.06,"endTime":163.71,"body":"in attention to her volume status,"},{"startTime":163.71,"endTime":165.98,"body":"I suspect she's dry"},{"startTime":163.71,"endTime":165.98,"body":"given her acute illness"},{"startTime":165.98,"endTime":167.74,"body":"even with her kidney disease."},{"startTime":167.74,"endTime":169.27,"body":"[Dr. Wiener] Okay well,"},{"startTime":167.74,"endTime":169.27,"body":"the other options mentioned"},{"startTime":169.27,"endTime":170.58,"body":"were medications,"},{"startTime":170.58,"endTime":173.53,"body":"which of those is not recommended"},{"startTime":170.58,"endTime":173.53,"body":"for initial management?"},{"startTime":173.53,"endTime":174.86,"body":"[Dr. Handy] So of the"},{"startTime":173.53,"endTime":174.86,"body":"choices you mentioned,"},{"startTime":174.86,"endTime":178.87,"body":"the answer is A. amantadine,"},{"startTime":174.86,"endTime":178.87,"body":"that is not recommended anymore."},{"startTime":178.87,"endTime":181.48,"body":"[Dr. Wiener] Why? I thought it"},{"startTime":178.87,"endTime":181.48,"body":"was an influenza medication?"},{"startTime":181.48,"endTime":183.71,"body":"[Dr. Handy] Amantadine"},{"startTime":181.48,"endTime":183.71,"body":"and its cousin rimantadine"},{"startTime":183.71,"endTime":185.67,"body":"are M2 blockers that have activity"},{"startTime":185.67,"endTime":188.04,"body":"against influenza A but not B."},{"startTime":188.04,"endTime":190.21,"body":"If we were discussing this"},{"startTime":188.04,"endTime":190.21,"body":"patient some years ago"},{"startTime":190.21,"endTime":192.0,"body":"it may have been an okay answer."},{"startTime":192.0,"endTime":194.74,"body":"However, widespread resistance"},{"startTime":192.0,"endTime":194.74,"body":"has currently relegated"},{"startTime":194.74,"endTime":197.51,"body":"these compounds to"},{"startTime":194.74,"endTime":197.51,"body":"historical interest only."},{"startTime":197.51,"endTime":199.22,"body":"[Dr. Wiener] Okay, what about the others?"},{"startTime":199.22,"endTime":201.64,"body":"[Dr. Handy] In general, in"},{"startTime":199.22,"endTime":201.64,"body":"patients with influenza treatment"},{"startTime":201.64,"endTime":204.32,"body":"with antiviral medications"},{"startTime":201.64,"endTime":204.32,"body":"has been demonstrated"},{"startTime":204.32,"endTime":206.19,"body":"to decrease the duration of symptoms"},{"startTime":206.19,"endTime":208.95,"body":"by one to one and a"},{"startTime":206.19,"endTime":208.95,"body":"half days when initiated"},{"startTime":208.95,"endTime":212.71,"body":"within the first 48 hours"},{"startTime":208.95,"endTime":212.71,"body":"after the onset of symptoms."},{"startTime":212.71,"endTime":214.67,"body":"Most currently available"},{"startTime":212.71,"endTime":214.67,"body":"drugs for treatment"},{"startTime":214.67,"endTime":218.66,"body":"of influenza A and B viruses"},{"startTime":214.67,"endTime":218.66,"body":"are neuraminidase inhibitors."},{"startTime":218.66,"endTime":220.17,"body":"The use of these is recommended"},{"startTime":220.17,"endTime":222.35,"body":"for complicated influenza infections"},{"startTime":222.35,"endTime":225.36,"body":"in hospitalized patients in"},{"startTime":222.35,"endTime":225.36,"body":"the absence of formal proof"},{"startTime":225.36,"endTime":228.44,"body":"of efficacy and when diagnosis"},{"startTime":225.36,"endTime":228.44,"body":"may have been delayed."},{"startTime":228.44,"endTime":230.63,"body":"They define risk groups of who can benefit"},{"startTime":230.63,"endTime":232.747,"body":"from neuraminidase inhibitors to include"},{"startTime":232.747,"endTime":236.65,"body":"children less than two years"},{"startTime":232.747,"endTime":236.65,"body":"of age, adults over age 65,"},{"startTime":236.65,"endTime":238.36,"body":"patients with chronic conditions,"},{"startTime":238.36,"endTime":240.88,"body":"immunosuppressed"},{"startTime":238.36,"endTime":240.88,"body":"individuals, pregnant women"},{"startTime":240.88,"endTime":243.69,"body":"or women who have delivered"},{"startTime":240.88,"endTime":243.69,"body":"infants within two weeks,"},{"startTime":243.69,"endTime":246.33,"body":"and patients who are"},{"startTime":243.69,"endTime":246.33,"body":"younger than 19-years-old"},{"startTime":246.33,"endTime":249.02,"body":"who are receiving"},{"startTime":246.33,"endTime":249.02,"body":"long-term asthma treatment."},{"startTime":249.02,"endTime":250.84,"body":"Also included are native Americans,"},{"startTime":250.84,"endTime":254.05,"body":"including Alaska natives,"},{"startTime":250.84,"endTime":254.05,"body":"morbidly obese individuals"},{"startTime":254.05,"endTime":257.3,"body":"and residents of nursing homes"},{"startTime":254.05,"endTime":257.3,"body":"or chronic care facilities."},{"startTime":257.3,"endTime":258.98,"body":"[Dr. Wiener] Wow, so it"},{"startTime":257.3,"endTime":258.98,"body":"sounds like a lot of people"},{"startTime":258.98,"endTime":260.63,"body":"are eligible for these medications"},{"startTime":260.63,"endTime":262.95,"body":"in patients with suspected influenza."},{"startTime":262.95,"endTime":264.27,"body":"In that case, why don't you tell me more"},{"startTime":264.27,"endTime":266.16,"body":"about the neuraminidase inhibitors?"},{"startTime":266.16,"endTime":267.31,"body":"[Dr. Handy] As their name implies,"},{"startTime":267.31,"endTime":270.86,"body":"these drugs act by inhibiting"},{"startTime":267.31,"endTime":270.86,"body":"the influenza neuraminidase"},{"startTime":270.86,"endTime":273.7,"body":"and thus limiting the"},{"startTime":270.86,"endTime":273.7,"body":"egress of influenza virus"},{"startTime":273.7,"endTime":275.4,"body":"from an infected cell."},{"startTime":275.4,"endTime":277.02,"body":"They are most effective in patients"},{"startTime":277.02,"endTime":279.54,"body":"whose influenza illness"},{"startTime":277.02,"endTime":279.54,"body":"is recognized early"},{"startTime":279.54,"endTime":282.13,"body":"and confirmed by rapid antigen detection"},{"startTime":282.13,"endTime":285.41,"body":"or on the basis of clinical"},{"startTime":282.13,"endTime":285.41,"body":"and epidemiologic evidence."},{"startTime":285.41,"endTime":287.314,"body":"[Dr. Wiener] So the"},{"startTime":285.41,"endTime":287.314,"body":"neuraminidase inhibitors work"},{"startTime":287.314,"endTime":289.86,"body":"against influenza A and influenza B."},{"startTime":289.86,"endTime":292.47,"body":"I know that influenza A is more common"},{"startTime":292.47,"endTime":293.8,"body":"during this flu season,"},{"startTime":293.8,"endTime":295.45,"body":"but I know every year at Hopkins"},{"startTime":295.45,"endTime":298.15,"body":"we get notable numbers of influenza B."},{"startTime":298.15,"endTime":300.42,"body":"[Dr. Handy] Right, and you"},{"startTime":298.15,"endTime":300.42,"body":"could use these with both."},{"startTime":300.42,"endTime":302.687,"body":"[Dr. Wiener] What are the"},{"startTime":300.42,"endTime":302.687,"body":"common neuraminidase inhibitors?"},{"startTime":302.687,"endTime":304.27,"body":"[Dr. Handy] So the ones that are available"},{"startTime":304.27,"endTime":308.05,"body":"are oral oseltamivir,"},{"startTime":304.27,"endTime":308.05,"body":"nasal spray zanamivir"},{"startTime":308.05,"endTime":311.735,"body":"and intravenous peramivir and zanamivir."},{"startTime":311.735,"endTime":313.91,"body":"Oseltamivir, which is most widely used,"},{"startTime":313.91,"endTime":316.45,"body":"is an orally absorbed"},{"startTime":313.91,"endTime":316.45,"body":"drug that is converted"},{"startTime":316.45,"endTime":319.6,"body":"to its active component,"},{"startTime":316.45,"endTime":319.6,"body":"oseltamivir carboxylate"},{"startTime":319.6,"endTime":320.717,"body":"in the liver."},{"startTime":320.717,"endTime":324.025,"body":"Gastrointestinal symptoms,"},{"startTime":320.717,"endTime":324.025,"body":"especially nausea may accompany"},{"startTime":324.025,"endTime":326.515,"body":"the administration of oseltamivir."},{"startTime":326.515,"endTime":329.438,"body":"Because zanamivir is"},{"startTime":326.515,"endTime":329.438,"body":"not orally bioavailable,"},{"startTime":329.438,"endTime":332.216,"body":"it's given as an inhaled"},{"startTime":329.438,"endTime":332.216,"body":"dry powder disperse"},{"startTime":332.216,"endTime":333.933,"body":"through a descaler device."},{"startTime":333.933,"endTime":336.687,"body":"[Dr. Wiener] Yeah, and I've"},{"startTime":333.933,"endTime":336.687,"body":"not heard of baloxavir."},{"startTime":336.687,"endTime":339.58,"body":"[Dr. Handy] Baloxavir is a newly"},{"startTime":336.687,"endTime":339.58,"body":"approved selective inhibitor"},{"startTime":339.58,"endTime":342.263,"body":"of influenza cap-dependent endonuclease"},{"startTime":342.263,"endTime":345.27,"body":"for treatment of acute"},{"startTime":342.263,"endTime":345.27,"body":"uncomplicated flu within two days"},{"startTime":345.27,"endTime":348.23,"body":"of illness onset in"},{"startTime":345.27,"endTime":348.23,"body":"people 12 years and older"},{"startTime":348.23,"endTime":350.78,"body":"who are otherwise healthy or at high risk"},{"startTime":350.78,"endTime":353.62,"body":"of developing flu related complications."},{"startTime":353.62,"endTime":355.46,"body":"The CDC does not recommend use"},{"startTime":355.46,"endTime":358.41,"body":"of baloxavir in pregnant"},{"startTime":355.46,"endTime":358.41,"body":"women, breastfeeding mothers,"},{"startTime":358.41,"endTime":361.28,"body":"outpatients with complicated"},{"startTime":358.41,"endTime":361.28,"body":"or progressive illness,"},{"startTime":361.28,"endTime":364.44,"body":"severely immunocompromised"},{"startTime":361.28,"endTime":364.44,"body":"people or hospitalized patients"},{"startTime":364.44,"endTime":367.2,"body":"because of the lack of"},{"startTime":364.44,"endTime":367.2,"body":"information on use of baloxavir"},{"startTime":367.2,"endTime":368.95,"body":"for these groups to date."},{"startTime":368.95,"endTime":371.17,"body":"[Dr. Wiener] Okay, so the"},{"startTime":368.95,"endTime":371.17,"body":"teaching points in this case"},{"startTime":371.17,"endTime":373.38,"body":"are that patients with suspected influenza"},{"startTime":373.38,"endTime":376.81,"body":"based on seasonality,"},{"startTime":373.38,"endTime":376.81,"body":"presentation and risks"},{"startTime":376.81,"endTime":378.91,"body":"should be started on a"},{"startTime":376.81,"endTime":378.91,"body":"neuraminidase inhibitor"},{"startTime":378.91,"endTime":380.53,"body":"as soon as possible."},{"startTime":380.53,"endTime":381.47,"body":"These agents will cover"},{"startTime":381.47,"endTime":384.87,"body":"both seasonal influenza A and influenza B."},{"startTime":384.87,"endTime":386.35,"body":"Amantadine and rimantadine"},{"startTime":386.35,"endTime":388.66,"body":"are no longer first-line therapies."},{"startTime":388.66,"endTime":390.44,"body":"And remember, the patients who did receive"},{"startTime":390.44,"endTime":392.891,"body":"the seasonal flu vaccine remain at risk"},{"startTime":392.891,"endTime":394.69,"body":"for developing disease."},{"startTime":394.69,"endTime":396.01,"body":"[Dr. Handy] And to read more about this,"},{"startTime":396.01,"endTime":398.83,"body":"you can check out the"},{"startTime":396.01,"endTime":398.83,"body":"Harrison's chapter on influenza"},{"startTime":398.83,"endTime":401.88,"body":"but I'll also refer you to the CDC website"},{"startTime":401.88,"endTime":403.67,"body":"on just influenza generally,"},{"startTime":403.67,"endTime":406.68,"body":"but then they also have"},{"startTime":403.67,"endTime":406.68,"body":"a webpage on baloxavir."},{"startTime":406.68,"endTime":409.065,"body":"That general webpage is www.cdc.gov/flu"},{"startTime":409.065,"endTime":412.581,"body":"That general webpage is www.cdc.gov/flu"},{"startTime":416.63,"endTime":419.5,"body":"[Mr. Shanahan] This is Jim"},{"startTime":416.63,"endTime":419.5,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":419.5,"endTime":421.138,"body":"Harrison's Podclass is brought to you"},{"startTime":421.138,"endTime":423.1,"body":"by McGraw Hill's Access Medicine,"},{"startTime":423.1,"endTime":425.22,"body":"the online medical resource that delivers"},{"startTime":425.22,"endTime":428.43,"body":"the latest trusted content from"},{"startTime":425.22,"endTime":428.43,"body":"the best minds in medicine."},{"startTime":428.43,"endTime":430.973,"body":"Go to accessmedicine.com to learn more."}]}