{"version":"1.0.0","segments":[{"startTime":0.47,"endTime":3.24,"body":"[upbeat intro music]"},{"startTime":3.24,"endTime":5.64,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.24,"endTime":5.64,"body":"to Harrison's Podclass,"},{"startTime":5.64,"endTime":8.78,"body":"where we discuss important"},{"startTime":5.64,"endTime":8.78,"body":"concepts in internal medicine."},{"startTime":8.78,"endTime":9.91,"body":"I'm Cathy Handy."},{"startTime":9.91,"endTime":11.803,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.91,"endTime":11.803,"body":"Wiener, and we're coming to you"},{"startTime":11.803,"endTime":13.78,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.87,"endTime":16.9,"body":"Welcome back."},{"startTime":16.9,"endTime":20.8,"body":"Today's patient is a 45-year-old"},{"startTime":16.9,"endTime":20.8,"body":"with lethargy and confusion."},{"startTime":20.8,"endTime":23.976,"body":"Okay Cathy, today we're"},{"startTime":20.8,"endTime":23.976,"body":"seeing a 45-year-old man"},{"startTime":23.976,"endTime":26.828,"body":"with a history of alcoholism"},{"startTime":23.976,"endTime":26.828,"body":"and presumed cirrhosis"},{"startTime":26.828,"endTime":28.51,"body":"who is brought to the emergency department"},{"startTime":28.51,"endTime":31.03,"body":"by his friend complaining"},{"startTime":28.51,"endTime":31.03,"body":"of two to three days"},{"startTime":31.03,"endTime":33.66,"body":"of increasing lethargy and confusion."},{"startTime":33.66,"endTime":36.11,"body":"His friend reports that the"},{"startTime":33.66,"endTime":36.11,"body":"patient has stayed in bed"},{"startTime":36.11,"endTime":38.61,"body":"and has been sleepy for the past two days,"},{"startTime":38.61,"endTime":40.13,"body":"and when they talk sports,"},{"startTime":40.13,"endTime":41.92,"body":"which is one of their favorite topics,"},{"startTime":41.92,"endTime":43.461,"body":"he's been repeating himself"},{"startTime":43.461,"endTime":46.22,"body":"and repeating things from many years ago."},{"startTime":46.22,"endTime":49.56,"body":"The patient has not consumed"},{"startTime":46.22,"endTime":49.56,"body":"alcohol for the past two years."},{"startTime":49.56,"endTime":51.75,"body":"He currently takes zero medications"},{"startTime":51.75,"endTime":54.42,"body":"and works at home as"},{"startTime":51.75,"endTime":54.42,"body":"a video game designer."},{"startTime":54.42,"endTime":56.26,"body":"He was referred by his"},{"startTime":54.42,"endTime":56.26,"body":"primary care physician"},{"startTime":56.26,"endTime":58.193,"body":"for liver transplant evaluation"},{"startTime":58.193,"endTime":61.26,"body":"and is scheduled to begin"},{"startTime":58.193,"endTime":61.26,"body":"his evaluation next month."},{"startTime":61.26,"endTime":63.085,"body":"[Dr. Handy] All right, so"},{"startTime":61.26,"endTime":63.085,"body":"we have a man with presumed"},{"startTime":63.085,"endTime":65.57,"body":"cirrhosis with a change in mental status."},{"startTime":65.57,"endTime":67.3,"body":"Now, there's a very broad differential"},{"startTime":67.3,"endTime":68.93,"body":"for altered mental status,"},{"startTime":68.93,"endTime":70.66,"body":"but can narrow it a little bit in someone"},{"startTime":70.66,"endTime":73.24,"body":"with cirrhosis and a more acute change."},{"startTime":73.24,"endTime":75.7,"body":"Infection, worsening"},{"startTime":73.24,"endTime":75.7,"body":"renal or liver function,"},{"startTime":75.7,"endTime":78.56,"body":"and toxicity would be"},{"startTime":75.7,"endTime":78.56,"body":"high on that differential."},{"startTime":78.56,"endTime":80.42,"body":"A physical examination in this patient"},{"startTime":80.42,"endTime":81.93,"body":"would also be very helpful."},{"startTime":81.93,"endTime":84.9,"body":"[Dr. Wiener] Okay, so his"},{"startTime":81.93,"endTime":84.9,"body":"blood pressure is 90/60,"},{"startTime":84.9,"endTime":89.541,"body":"his heart rate is 105, his"},{"startTime":84.9,"endTime":89.541,"body":"temperature is 38.5 centigrade,"},{"startTime":89.541,"endTime":91.13,"body":"his respiratory rate is 10,"},{"startTime":91.13,"endTime":94.15,"body":"and his room air saturation is 97%."},{"startTime":94.15,"endTime":96.81,"body":"He's somnolent but he's"},{"startTime":94.15,"endTime":96.81,"body":"oriented a little bit,"},{"startTime":96.81,"endTime":99.55,"body":"he's able to answer simple"},{"startTime":96.81,"endTime":99.55,"body":"questions accurately."},{"startTime":99.55,"endTime":102.07,"body":"But he gets confused with"},{"startTime":99.55,"endTime":102.07,"body":"complicated questions"},{"startTime":102.07,"endTime":105.71,"body":"and is not able to do"},{"startTime":102.07,"endTime":105.71,"body":"serial seven subtractions."},{"startTime":105.71,"endTime":109.03,"body":"His skin is notable for"},{"startTime":105.71,"endTime":109.03,"body":"many spider telangiectasias,"},{"startTime":109.03,"endTime":110.938,"body":"and he has palmar erythema."},{"startTime":110.938,"endTime":114.28,"body":"His lungs are clear and his"},{"startTime":110.938,"endTime":114.28,"body":"cardiac examination is normal."},{"startTime":114.28,"endTime":117.57,"body":"His jugular veins are flat"},{"startTime":114.28,"endTime":117.57,"body":"at 45 degrees, though."},{"startTime":117.57,"endTime":120.22,"body":"He has distended diffusely tender abdomen"},{"startTime":120.22,"endTime":122.2,"body":"with a positive fluid wave."},{"startTime":122.2,"endTime":126.22,"body":"There's no peripheral edema"},{"startTime":122.2,"endTime":126.22,"body":"and he has no asterixis."},{"startTime":126.22,"endTime":128.29,"body":"[Dr. Handy] So he's febrile"},{"startTime":126.22,"endTime":128.29,"body":"with a borderline blood pressure"},{"startTime":128.29,"endTime":130.54,"body":"and some tachycardia with a flat JVP"},{"startTime":130.54,"endTime":133.48,"body":"suggesting intravascular volume depletion,"},{"startTime":133.48,"endTime":135.84,"body":"but he has a distended"},{"startTime":133.48,"endTime":135.84,"body":"abdomen with a fluid wave"},{"startTime":135.84,"endTime":137.36,"body":"which is from ascites."},{"startTime":137.36,"endTime":140.118,"body":"You mentioned in the history"},{"startTime":137.36,"endTime":140.118,"body":"that he has presumed cirrhosis,"},{"startTime":140.118,"endTime":141.46,"body":"but he clearly has the quality"},{"startTime":141.46,"endTime":144.4,"body":"of chronic liver disease"},{"startTime":141.46,"endTime":144.4,"body":"and decompensated cirrhosis"},{"startTime":144.4,"endTime":146.06,"body":"with the spider telangiectasias,"},{"startTime":146.06,"endTime":148.28,"body":"the palmar erythema and ascites."},{"startTime":148.28,"endTime":149.88,"body":"[Dr. Wiener] Okay, well, what"},{"startTime":148.28,"endTime":149.88,"body":"would you do at this point"},{"startTime":149.88,"endTime":152.1,"body":"for more treatment or diagnostics?"},{"startTime":152.1,"endTime":153.533,"body":"[Dr. Handy] To begin, I would start with"},{"startTime":153.533,"endTime":156.67,"body":"some fluid resuscitation"},{"startTime":153.533,"endTime":156.67,"body":"in addition to basic labs,"},{"startTime":156.67,"endTime":158.61,"body":"but he definitely needs a paracentesis"},{"startTime":158.61,"endTime":160.1,"body":"to rule out infection."},{"startTime":160.1,"endTime":161.843,"body":"[Dr. Wiener] Okay, let's"},{"startTime":160.1,"endTime":161.843,"body":"jump to the paracentesis"},{"startTime":161.843,"endTime":164.363,"body":"because the question is"},{"startTime":161.843,"endTime":164.363,"body":"going to relate to that."},{"startTime":164.363,"endTime":167.1,"body":"A paracentesis reveals"},{"startTime":164.363,"endTime":167.1,"body":"slightly cloudy fluid"},{"startTime":167.1,"endTime":170.33,"body":"with a white blood cell"},{"startTime":167.1,"endTime":170.33,"body":"count of 1,000 per microliter"},{"startTime":170.33,"endTime":173.32,"body":"and 40% neutrophils on the differential."},{"startTime":173.32,"endTime":177.005,"body":"His blood pressure increases"},{"startTime":173.32,"endTime":177.005,"body":"to 100/65 and his heart rate"},{"startTime":177.005,"endTime":180.871,"body":"decreases to 95 after"},{"startTime":177.005,"endTime":180.871,"body":"one liter of IV fluids."},{"startTime":180.871,"endTime":182.449,"body":"So the question asks,"},{"startTime":182.449,"endTime":185.06,"body":"which of the following statements"},{"startTime":182.449,"endTime":185.06,"body":"regarding his condition"},{"startTime":185.06,"endTime":187.348,"body":"and treatment is true?"},{"startTime":187.348,"endTime":191.9,"body":"Option A says, fever is present"},{"startTime":187.348,"endTime":191.9,"body":"in greater than 50% of cases;"},{"startTime":191.9,"endTime":195.359,"body":"option B says, initial"},{"startTime":191.9,"endTime":195.359,"body":"empiric antibiotic therapy"},{"startTime":195.359,"endTime":199.86,"body":"should include metronidazole"},{"startTime":195.359,"endTime":199.86,"body":"or clindamycin for anaerobes;"},{"startTime":199.86,"endTime":202.68,"body":"option C says, the diagnosis of primary"},{"startTime":202.68,"endTime":205.03,"body":"or spontaneous bacterial peritonitis"},{"startTime":205.03,"endTime":207.36,"body":"is not confirmed because the percentage"},{"startTime":207.36,"endTime":211.277,"body":"of neutrophils in the peritoneal"},{"startTime":207.36,"endTime":211.277,"body":"fluid is less than 50%;"},{"startTime":211.277,"endTime":214.6,"body":"option D says, the most"},{"startTime":211.277,"endTime":214.6,"body":"likely causative organism"},{"startTime":214.6,"endTime":217.25,"body":"for his condition is enterococcus;"},{"startTime":217.25,"endTime":220.64,"body":"and option E says, the yield"},{"startTime":217.25,"endTime":220.64,"body":"of peritoneal fluid cultures"},{"startTime":220.64,"endTime":223.501,"body":"for diagnosis is greater than 90%."},{"startTime":223.501,"endTime":225.426,"body":"[Dr. Handy] All right, so"},{"startTime":223.501,"endTime":225.426,"body":"this question is asking about"},{"startTime":225.426,"endTime":227.26,"body":"spontaneous bacterial peritonitis"},{"startTime":227.26,"endTime":230.694,"body":"or SBP in a patient with"},{"startTime":227.26,"endTime":230.694,"body":"cirrhosis, good topic."},{"startTime":230.694,"endTime":232.26,"body":"[Dr. Wiener] Okay, tell me more about it."},{"startTime":232.26,"endTime":235.38,"body":"[Dr. Handy] So primary or"},{"startTime":232.26,"endTime":235.38,"body":"spontaneous bacterial peritonitis,"},{"startTime":235.38,"endTime":238.45,"body":"which is often referred to as SBP or PBP,"},{"startTime":238.45,"endTime":241.04,"body":"occurs when the peritoneal"},{"startTime":238.45,"endTime":241.04,"body":"cavity becomes infected"},{"startTime":241.04,"endTime":243.453,"body":"without an apparent"},{"startTime":241.04,"endTime":243.453,"body":"source of contamination."},{"startTime":243.453,"endTime":246.691,"body":"In adults, it most commonly"},{"startTime":243.453,"endTime":246.691,"body":"occurs in conjunction with"},{"startTime":246.691,"endTime":249.423,"body":"cirrhosis of the liver, but"},{"startTime":246.691,"endTime":249.423,"body":"it has also been described"},{"startTime":249.423,"endTime":251.91,"body":"in patients with metastatic"},{"startTime":249.423,"endTime":251.91,"body":"malignant disease,"},{"startTime":251.91,"endTime":254.943,"body":"chronic active hepatitis,"},{"startTime":251.91,"endTime":254.943,"body":"acute viral hepatitis,"},{"startTime":254.943,"endTime":258.635,"body":"congestive heart failure,"},{"startTime":254.943,"endTime":258.635,"body":"systemic lupus, and lymphedema,"},{"startTime":258.635,"endTime":261.634,"body":"as well as in patients"},{"startTime":258.635,"endTime":261.634,"body":"with no underlying disease."},{"startTime":261.634,"endTime":263.57,"body":"Now, although it mostly"},{"startTime":261.634,"endTime":263.57,"body":"develops in patients"},{"startTime":263.57,"endTime":265.17,"body":"with pre-existing ascites,"},{"startTime":265.17,"endTime":268.05,"body":"it is in general an uncommon"},{"startTime":265.17,"endTime":268.05,"body":"event occurring in fewer"},{"startTime":268.05,"endTime":270.32,"body":"than 10% of cirrhotic patients."},{"startTime":270.32,"endTime":271.44,"body":"[Dr. Wiener] So how does the peritoneum"},{"startTime":271.44,"endTime":273.09,"body":"get infected in these cases?"},{"startTime":273.09,"endTime":274.01,"body":"[Dr. Handy] The cause of SBP"},{"startTime":274.01,"endTime":275.76,"body":"has not been established definitively,"},{"startTime":275.76,"endTime":278.11,"body":"but is believed to involve"},{"startTime":275.76,"endTime":278.11,"body":"hematogenous spread"},{"startTime":278.11,"endTime":280.77,"body":"of organisms in a patient"},{"startTime":278.11,"endTime":280.77,"body":"in whom a diseased liver"},{"startTime":280.77,"endTime":282.81,"body":"and altered portal circulation results"},{"startTime":282.81,"endTime":285.7,"body":"in a defect in the usual"},{"startTime":282.81,"endTime":285.7,"body":"filtration function."},{"startTime":285.7,"endTime":287.59,"body":"Organisms multiply in ascites,"},{"startTime":287.59,"endTime":289.69,"body":"which is a good medium for growth."},{"startTime":289.69,"endTime":291.026,"body":"[Dr. Wiener] So this"},{"startTime":289.69,"endTime":291.026,"body":"question is also asking"},{"startTime":291.026,"endTime":292.21,"body":"about the physical findings."},{"startTime":292.21,"endTime":294.372,"body":"[Dr. Handy] Yeah, so to"},{"startTime":292.21,"endTime":294.372,"body":"answer the question, it's A,"},{"startTime":294.372,"endTime":297.184,"body":"so fever is present in"},{"startTime":294.372,"endTime":297.184,"body":"up to 80% of patients"},{"startTime":297.184,"endTime":299.465,"body":"and it is the most common sign."},{"startTime":299.465,"endTime":302.26,"body":"Some other signs, abdominal"},{"startTime":299.465,"endTime":302.26,"body":"pain and acute onset"},{"startTime":302.26,"endTime":304.29,"body":"of symptoms and peritoneal irritation"},{"startTime":304.29,"endTime":307.55,"body":"during physical examination"},{"startTime":304.29,"endTime":307.55,"body":"can be helpful diagnostically,"},{"startTime":307.55,"endTime":310.514,"body":"but the absence of any of"},{"startTime":307.55,"endTime":310.514,"body":"these findings does not exclude"},{"startTime":310.514,"endTime":312.67,"body":"this often subtle diagnosis."},{"startTime":312.67,"endTime":314.02,"body":"In an at-risk patient,"},{"startTime":314.02,"endTime":317.43,"body":"non-localizing symptoms"},{"startTime":314.02,"endTime":317.43,"body":"such as malaise, fatigue,"},{"startTime":317.43,"endTime":320.53,"body":"or encephalopathy without"},{"startTime":317.43,"endTime":320.53,"body":"any other clear etiology,"},{"startTime":320.53,"endTime":324.104,"body":"as in this patient, should also"},{"startTime":320.53,"endTime":324.104,"body":"prompt consideration of SBP."},{"startTime":324.104,"endTime":326.08,"body":"[Dr. Wiener] I assume"},{"startTime":324.104,"endTime":326.08,"body":"the diagnosis is made"},{"startTime":326.08,"endTime":327.4,"body":"with paracentesis."},{"startTime":327.4,"endTime":330.53,"body":"What are the exact criteria"},{"startTime":327.4,"endTime":330.53,"body":"to make the diagnosis?"},{"startTime":330.53,"endTime":332.91,"body":"[Dr. Handy] Yeah, it is vital"},{"startTime":330.53,"endTime":332.91,"body":"to sample the peritoneal fluid"},{"startTime":332.91,"endTime":335.67,"body":"of any cirrhotic patient"},{"startTime":332.91,"endTime":335.67,"body":"with ascites and a fever."},{"startTime":335.67,"endTime":337.77,"body":"The diagnosis requires the exclusion"},{"startTime":337.77,"endTime":340.2,"body":"of an intra-abdominal source of infection."},{"startTime":340.2,"endTime":342.71,"body":"Blood cultures are seldom"},{"startTime":340.2,"endTime":342.71,"body":"positive and in fact,"},{"startTime":342.71,"endTime":345.66,"body":"peritoneal cultures are"},{"startTime":342.71,"endTime":345.66,"body":"also seldom positive."},{"startTime":345.66,"endTime":348.09,"body":"The yields of peritoneal"},{"startTime":345.66,"endTime":348.09,"body":"cultures may be increased"},{"startTime":348.09,"endTime":350.74,"body":"by inoculating into blood culture bottles."},{"startTime":350.74,"endTime":353.18,"body":"[Dr. Wiener] So in that sense,"},{"startTime":350.74,"endTime":353.18,"body":"how do we make the diagnosis?"},{"startTime":353.18,"endTime":357.131,"body":"[Dr. Handy] The findings of"},{"startTime":353.18,"endTime":357.131,"body":"over 250 PMNs per microliter is"},{"startTime":357.131,"endTime":361.46,"body":"diagnostic, so in this"},{"startTime":357.131,"endTime":361.46,"body":"case he had 40% of 1,000"},{"startTime":361.46,"endTime":365.62,"body":"white blood cells so that"},{"startTime":361.46,"endTime":365.62,"body":"would be 400, so he has SBP."},{"startTime":365.62,"endTime":367.969,"body":"[Dr. Wiener] Okay, I know that"},{"startTime":365.62,"endTime":367.969,"body":"getting a definitive organism"},{"startTime":367.969,"endTime":370.094,"body":"is not common, but what are thought to be"},{"startTime":370.094,"endTime":372.775,"body":"the most common organisms"},{"startTime":370.094,"endTime":372.775,"body":"to direct therapy?"},{"startTime":372.775,"endTime":374.34,"body":"[Dr. Handy] Entero Gram negative bacilli,"},{"startTime":374.34,"endTime":376.84,"body":"such as E. coli are most"},{"startTime":374.34,"endTime":376.84,"body":"commonly encountered,"},{"startTime":376.84,"endTime":379.847,"body":"however, Gram positive"},{"startTime":376.84,"endTime":379.847,"body":"organisms such as streptococci,"},{"startTime":379.847,"endTime":383.23,"body":"enterococci, or even"},{"startTime":379.847,"endTime":383.23,"body":"pneumococci are sometimes found."},{"startTime":383.23,"endTime":386.67,"body":"Anaerobes are almost never"},{"startTime":383.23,"endTime":386.67,"body":"thought to be causative in SBP"},{"startTime":386.67,"endTime":388.7,"body":"whereas in an intra-abdominal source,"},{"startTime":388.7,"endTime":390.61,"body":"such as a perforated viscus,"},{"startTime":390.61,"endTime":392.78,"body":"anaerobes are an important pathogen."},{"startTime":392.78,"endTime":393.64,"body":"[Dr. Wiener] Okay, that gets us"},{"startTime":393.64,"endTime":395.62,"body":"to the optimal empiric therapy."},{"startTime":395.62,"endTime":398.38,"body":"The question mentioned"},{"startTime":395.62,"endTime":398.38,"body":"metronidazole, clindamycin,"},{"startTime":398.38,"endTime":400.52,"body":"but you already mentioned"},{"startTime":398.38,"endTime":400.52,"body":"that anaerobes are not common"},{"startTime":400.52,"endTime":402.03,"body":"so we know that that is wrong."},{"startTime":402.03,"endTime":403.89,"body":"[Dr. Handy] Third"},{"startTime":402.03,"endTime":403.89,"body":"generation cephalosporins,"},{"startTime":403.89,"endTime":406.738,"body":"such as cefotaxime or ceftriaxone,"},{"startTime":406.738,"endTime":408.97,"body":"or piperacillin/tazobactam provide"},{"startTime":408.97,"endTime":412.32,"body":"reasonable initial coverage"},{"startTime":408.97,"endTime":412.32,"body":"in moderately ill patients."},{"startTime":412.32,"endTime":415.31,"body":"Interestingly, the etiology"},{"startTime":412.32,"endTime":415.31,"body":"of infections in patients"},{"startTime":415.31,"endTime":417.65,"body":"with cirrhosis has"},{"startTime":415.31,"endTime":417.65,"body":"changed in recent years,"},{"startTime":417.65,"endTime":419.679,"body":"with more Gram positive bacteria"},{"startTime":419.679,"endTime":423.971,"body":"and ESBL-producing gut bacteria"},{"startTime":419.679,"endTime":423.971,"body":"being the causative agents."},{"startTime":423.971,"endTime":427.624,"body":"And this is probably because"},{"startTime":423.971,"endTime":427.624,"body":"of widespread use of quinolones"},{"startTime":427.624,"endTime":429.47,"body":"that have been used to prevent SBP"},{"startTime":429.47,"endTime":431.34,"body":"in high-risk subgroups of patients,"},{"startTime":431.34,"endTime":432.78,"body":"frequent hospitalizations,"},{"startTime":432.78,"endTime":435.589,"body":"and more exposure to broad"},{"startTime":432.78,"endTime":435.589,"body":"spectrum antibiotics."},{"startTime":435.589,"endTime":438.14,"body":"Risk factors for multi-drug"},{"startTime":435.589,"endTime":438.14,"body":"resistant infections"},{"startTime":438.14,"endTime":440.53,"body":"include nosocomial origin of infection,"},{"startTime":440.53,"endTime":443.2,"body":"long term norfloxacin prophylaxis,"},{"startTime":443.2,"endTime":445.97,"body":"recent infection with"},{"startTime":443.2,"endTime":445.97,"body":"multi-resistant bacteria,"},{"startTime":445.97,"endTime":448.68,"body":"and recent use of beta-lactam antibiotics."},{"startTime":448.68,"endTime":450.4,"body":"So the empiric choice should be tailored"},{"startTime":450.4,"endTime":452.452,"body":"to your patient in the clinical situation."},{"startTime":452.452,"endTime":454.037,"body":"[Dr. Wiener] Okay, great."},{"startTime":454.037,"endTime":456.5,"body":"So the teaching points"},{"startTime":454.037,"endTime":456.5,"body":"here are that in a patient"},{"startTime":456.5,"endTime":457.9,"body":"with underlying cirrhosis"},{"startTime":457.9,"endTime":459.88,"body":"and particularly those with ascites,"},{"startTime":459.88,"endTime":461.86,"body":"primary bacterial peritonitis"},{"startTime":461.86,"endTime":463.91,"body":"or spontaneous bacterial peritonitis"},{"startTime":463.91,"endTime":467.14,"body":"can present subacutely"},{"startTime":463.91,"endTime":467.14,"body":"with subtle clinical signs."},{"startTime":467.14,"endTime":470.18,"body":"Paracentesis is important"},{"startTime":467.14,"endTime":470.18,"body":"and the diagnosis"},{"startTime":470.18,"endTime":471.17,"body":"is made by the presence"},{"startTime":471.17,"endTime":474.05,"body":"of greater than 215"},{"startTime":471.17,"endTime":474.05,"body":"neutrophils per microliter,"},{"startTime":474.05,"endTime":475.96,"body":"even if cultures are negative."},{"startTime":475.96,"endTime":479.23,"body":"Broad empiric antibiotics"},{"startTime":475.96,"endTime":479.23,"body":"should be started promptly."},{"startTime":479.23,"endTime":480.59,"body":"[Dr. Handy] And you can"},{"startTime":479.23,"endTime":480.59,"body":"read more about this"},{"startTime":480.59,"endTime":483.603,"body":"in Harrison's chapter on"},{"startTime":480.59,"endTime":483.603,"body":"intra-abdominal infections."},{"startTime":483.603,"endTime":487.786,"body":"[outro music]"},{"startTime":487.786,"endTime":490.547,"body":"[Dr. Shanahan] This is Jim"},{"startTime":487.786,"endTime":490.547,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":490.547,"endTime":492.37,"body":"Harrison's Podclass is brought to you"},{"startTime":492.37,"endTime":494.23,"body":"by McGraw Hill's Access Medicine,"},{"startTime":494.23,"endTime":496.217,"body":"the online medical resource that delivers"},{"startTime":496.217,"endTime":499.567,"body":"the latest trusted content from"},{"startTime":496.217,"endTime":499.567,"body":"the best minds in medicine."},{"startTime":499.567,"endTime":502.103,"body":"Go to accessmedicine.com to learn more."}]}