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29 Jul 13:00

These Amazing Fantasy Creature Sculptures Will Blow You Away

by Amy Ratcliffe

fantasy creatures 1

Lee Cross has skills. The talented artist has a knack for being able to sculpt life-like fantastical creatures that are breathtaking. The handmade critters appear to be armature wire covered in fabric, stuffing, and fur, and they come in a wide variety of sizes. They’re also fully posable! It’s like having an adorable, exotic pet without any of the work.

While she doesn’t take commissions or have an Etsy shop, Lee does offer her creatures on eBay from time to time.

See more of Lee’s work after the break.

fantasy creatures 2

fantasy creatures 3

fantasy creatures 4

fantasy creatures 5

fantasy creatures 6

fantasy creatures 7

fantasy creatures 8

fantasy creatures 9

fantasy creatures 10

(Wood-Splitter-Lee via GxG)

29 Jul 13:10

Salmon Sandwich with Creamy Dill Sauce

by Meghan B.

Getting back into the healthy eating routine is not so easy…

Salmon Sandwich_3

I have been trying to get inspired with new healthy recipes and lately fish has been the only way for me to start climbing back up on that diet bandwagon. Salmon in particular has been a welcome healthy (re)addition to my diet. I never seem to know what to make myself for lunch, so I thought, why not make a fresh salmon sandwich? 

This salmon sandwich is the ultimate lunch, particularly because it test just as heavenly warm as it does cold. It’s perfect for me to take to the office or to have as a casual lunch. Deceivingly simple to make AND it makes you feel somewhat elegant/sophisticated when you are eating it!

Salmon Sandwich_2

Unless you are me and end up with oh-so adorable dribbles of dill sauce running down your face (I hope you heard the sarcasm dripping from “oh-so adorable” there…). I might not be the most elegant of eaters, but I can’t possibly begin to care when a sandwich tastes as gosh darn good as this one does!

I rub the top of my salmon with a simple mixture of garlic powder, salt, and pepper which pairs perfectly with the slightly tangy creamy dill sauce and the peppery mixture of micro greens.

Salmon Sandwich_1

If only I could pair it with a glass of chilled white wine when I am at work… ;)

Recipe Tip: Any leftover creamy dill sauce can be kept in an airtight container for up to a week. 

Salmon Sandwich with Creamy Dill Sauce
My favorite fresh lunch packed with light and summery flavors. Perfect for taking with you to work or enjoying on a leisurely weekend.
Serves: 2
  • 2 salmon filets
  • ¼ tsp garlic powder
  • ¼ tsp kosher salt
  • ¼ tsp freshly cracked black pepper
  • Ciabatta
  • Micro greens
  • 1 cup light mayonnaise
  • ¼ cup reduced fat sour cream
  • ¾ tsp white wine vinegar
  • ¾ cup fresh dill
  • ¼ tsp kosher salt
  • 3 tsp capers, drained
  1. Turn your oven’s broiler to high. Line a small baking sheet with aluminum foil. Place the salmon filets side by side on the lined baking sheet.
  2. In a small bowl, mix together the ¼ tsp salt, pepper, and garlic powder. Rub the spice mixture evenly over the top of the two salmon filets. Place the baking sheet in the upper third section of the oven and broil on high for approximately 6 to 7 minutes, or until salmon reaches desired doneness. Remove from oven and set aside.
  3. In the bowl of a food processor, add mayonnaise, sour cream, white wine vinegar, dill, salt, and capers. Process until the mixture is well combined.
  4. Add approximately 1 tablespoon of the creamy dill sauce to one side of each slice of ciabatta. Add each salmon filet to the sauced side of two slices of prepared bread. Top with micro greens and the other slices of bread (sauce-side down). Enjoy immediately!


The post Salmon Sandwich with Creamy Dill Sauce appeared first on Cake 'n' Knife.

24 Jul 15:00

Tiny Tips: Non-Cardiogenic Pulmonary Edema / ARDS

by Teresa Chan

When you see a pulmonary edema on chest x-ray (CXR), the knee jerk reaction is to attribute it to heart failure.  But what might you be missing?

Not all the glitters is gold. And not all that is wet on CXR is just plain ol’ CHF.

Non-Cardiogenic Pulmonary Edema (NCPE) is better known to the world when it it is at its most severe form – i.e. ARDS (Acute Respiratory Distress Syndrome) or ALI (Acute Lung Injury).[1] However, for the purposes of linking the concept to the mnemonic (and the CXR findings), I have chosen to file it as a Tiny Tip under NCPE.

First recognized in military casualties in the first and second World Wars, NCPE is a commonly discussed entity in critical care.  In fact, an international group of experts has met in Berlin recently to redefine the definition of ARDS/ALI (see the post by the LIFTL guys on this topic for a great primer). [2,3] NCPE can be caused by direct insults to the lung tissue or indirect mechanisms such as systemic inflammation.

Mnemonic  for Causes for Non-Cardiogenic Pulmonary Edema


I nhaled Toxins (Ammonia, Chlorine, Phosgene, Nitrous oxide)
S IRS / Sepsis / Septic Shock

N eurogenic (seizure, strangulation, trauma)
O verdose (Heroin, methadone, cocaine)
T hyrotoxicosis

T rauma
H eat (Smoke! Remember to also consider carbon monoxide!)
E lectrocution

H igh altitude pulmonary edema
E mbolism (Pulmonary Embolism, Acute Gas Embolism, Amniotic Fluid Embolism)
A SA toxicity
R eperfusion or Re-expansion pulmonary edema (or Rocky Mountain Spotted Fever – This one is in here for the PGY5s: May the Force be with you until your quiz next year)
T ransfusion

Remember, this is NOT a comprehensive list, but it is a list that can help you think through alternative causes of a “wet” CXR.  Causes that it does not contain include Uremia, Cardiopulmonary bypass, DIC (RMSF is in the above list mostly due to this), other coagulopathies, pancreatitis… and more.

The mnemonic for this Tiny Tip, as well as a bunch of others, can be accessed and memorized using spaced repetition through Boring Cards as outlined here.


1.  Perina DG.  Noncardiogenic pulmonary edema.  Emerg Med Clin N Am ;21 (2003) 385–393. PMID: 12793620.

2. Nickson C.  Acute Respiratory Distress Syndrome (ARDS) Definitions. Life in the Fast Lane. Revised April 16, 2014.  Accessed July 13, 2014.  Available at:

3. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33. doi: 10.1001/jama.2012.5669. PubMed PMID: 22797452.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Tiny Tips: Non-Cardiogenic Pulmonary Edema / ARDS appeared first on BoringEM and was written by Teresa Chan.

28 Jul 17:00

That’s No Moon [Comic]

by Sean Fallon
25 Jul 12:31

Star Wars Darth Vader Lightsaber Barbecue Fork With a Hilt Modeled After the Sith Lord’s Iconic Weapon Design

by Justin Page

Star Wars Darth Vader Lightsaber BBQ Fork

ThinkGeek released an officially licensed Star Wars Darth Vader Lightsaber Barbecue Fork that has a hilt modeled after the feared Sith Lord‘s iconic weapon design. It is available to purchase online. This force-filled utensil would go great with the Star Wars Lightsaber BBQ Tong from The Fowndry.

Darth Vader loves nothing more than a grilled weenie, and the brand he likes best is Coruscant National (hey, they answer to a higher power: the Emperor). When Vader grills, he insists on using his favorite BBQ fork. You know, the one that looks like his lightsaber hilt? The one that we’re calling the Star Wars Darth Vader Lightsaber BBQ Fork.

Star Wars Darth Vader Lightsaber BBQ Fork

Star Wars Darth Vader Lightsaber BBQ Fork

images via ThinkGeek

via foodiggity

25 Jul 21:21

Survey Results for America’s Favorite ‘Star Wars’ Film and Character

by Rollin Bishop

538 Best Star Wars

FiveThirtyEight has posted some interesting survey results from a survey they recently ran based on the Star Wars films. The survey was run through SurveyMonkey Audience and collected 1,186 responses from June 3rd to June 6th. As it turns out, people still really hate Jar Jar Binks. More on the survey results is available at FiveThirtyEight.

538 Star Wars Characters

538 Star Wars Han or Greedo

images via FiveThirtyEight DataLab

26 Jul 16:44

Finding Rover, An App That Uses Facial Recognition to Help Reunite Lost Dogs with Their Humans

by Lori Dorn

Finding Rover is a handy free app that helps to reunite lost dogs with their frantic humans through the use of canine facial recognition.

Here’s how it works. If you ever lose your dog, the app will do an instant facial recognition search of all lost dogs in your area. Within seconds you’ll see a list of dogs’ photos with the contact information of the kind person (or shelter) who has the dog. Contact the person or shelter, and a blissful scene of face licking and tummy rubbing will follow. On the flip side, Finding Rover revolutionizes the process of helping lost dogs…Simply snap a photo and the app instantly shows you photos of matching dogs with the owners’ contact info.

The app is available via iTunes, Google Play or via the Finding Rover site.


Finding Rover Instructions

Finding Rover

Registering Your Dog

images via Finding Rover

via SF Gate, The Daily Dot

23 Jul 14:19

Shiba Inu Brownies

by Clockwork Lemon

Shiba Inu Brownies-1-2

This weekend, whilst baking a birthday treat for my Brother's 30th, I realized a slab of brownies could be decorated just like a cake or a batch of sugar cookies. Perhaps this fact was already obvious to everyone else seeing as it IS a flat, frostable surface.. but I thought I'd share the revalation just in case it wasn't. Think about it! Who wouldn't welcome a platter of fudgy, chocolate frosted brownies adorned with adorable decorations at their next party? Why should sugar cookies get all the decoration glory?

Since these particular brownies were for my brother, I made a design partly inspired by the hilarious doge meme (because my brother is my go-to technology guru and enjoys all things internet),  partly by some cute cartoons of shibas, but it was mostly inspired by.....



Shiba Inu Brownies-24

 .. my brother and his wife's new Shiba, Laika. They adopted her shortly before my brother's bday and THE CUTENESS.. how can so much cuteness exist within one tiny animal?

 I'll be sharing how to make the brownies, but first: more Laika photos. Feel free to scroll past them to get to the brownie instructions (if your heart is made of stone..)

Shiba Inu-11Just look at her back legs: tiny adorable drumsticks!


Shiba Inu-2That face! Pure puppy joy.

Shiba Inu-13and that belly.. oh my god the puppy belly.

Ok. Puppy quota filled. Brownie time!


Shiba Inu Brownies-1

The process began by drawing out the icing design along with some doge inspired captions. The best part about making royal icing transfers is you don't need to have mad piping skills to make a cute design. If you're good at drawing, draw a design out, then trace over it with icing. If you're NOT good at drawing simply print out a design or have someone else draw one for you. It's the poor-bakers version of a kopykake projector.

Royal Icing Transfer-1-2I like to photocopy the drawing, tape the copies to a table, place a piece of wax paper over top, tape it down, then lightly grease the wax paper with shortening.

Then, I use a wilton #1 tip to outline the drawing in black royal icing, and a #2 to fill in first the white details followed by the tan and red details. Once the transfers have dried I use a food colouring marker to add eyes, although a #1 tip and black royal icing works well too.

Two tips for royal icing transfers:

1. Make extra. These babies are delicate and it's better to have a few left over than is it to break a bunch and come up short. I often pipe out 4 - 5 extras because I'm clumsy and tend to snap them in half.

2. Give them day or two (or more if they are bigger/thicker) to dry completely. If you can, set up on a surface where you can leave them untouched for an entire day. If I know I'll be needing my table, I usually pipe them onto cookie trays that can be easily moved.


Shiba Inu Brownies-5For the brownies, I made a double batch of the fudgiest  of brownie recipes and once it was cool, spread a thick, even layer of chocolate frosting made with unsalted Stirling butter.

To decorate, I carefully peeled the Shiba transfers from the wax paper and placed them gently onto the frosting. Next, I piped out the doge captions then stuck the pan in the fridge to firm up the frosting.


Shiba Inu Brownies-17Once we got to my brother's house I sliced up the brownies and served them chilled.

And by "sliced up the brownies" I mean "was hopelessly distracted by Laika", it was a miracle that they came out even remotely square shaped.

  Shiba Inu Brownies-21But it's not my fault.

Happy 30th Chris!

(I've included recipes/instructions for the brownies and the royal icing transfers, but not for the chocolate icing. I like to make my icing free-hand/to taste and this one was a combo of salted butter, cocoa powder, icing sugar, and a splash of cream. Just mix butter, cocoa powder, and icing sugar and adjust to taste to find the right balance of chocolaty and sweet. Then (if it needs it) add a splash of cream or milk to smooth it out.)

Fudgy Brownies


Brownies (barely) adapted from The Patent and the Pantry

1 cup unsalted Stirling butter

1 cup cocoa powder, sifted

2 cup sugar

1/4  tsp salt

1 cup all purpose flour

1/2 cup milk

2 egg

2 tsp vanilla

1. Preheat the oven to 350 degrees and line an 9x13 baking pan with parchment paper

2. Melt the butter in a medium pot, then stir in the cocoa powder until smooth. Stir in the sugar and salt, followed by the flour, milk, egg, and vanilla. The batter will be very thick.  Use a spatula to spread the batter in an even layer in the baking pan. 

3. Bake at 350 for 25 - 30 minutes until the center is just set and the edges are starting to pull away from the pan. Use the parchment paper to pull the slab of brownies out of the pan and cool on a wire rack. I like mine to be slightly underbaked and served chilled for maximum fudginess. If you want them to be more chewy and firm, bake an additonal 5 minutes or so.


Royal icing for icing transfers

4 cups  icing sugar (powdered sugar)

3 tbsp meringue powder (available at stores that sell decorating supplies)

½ tsp lemon juice

½ cup warm water

1. In mixer bowl, stir icing sugar and meringue power until combined. Add lemon juice and warm water. Using the whisk attachment, mix on low to dissolve the sugar. Turn the mixer on high and whip until thick and glossy. Continue to whip on high until icing holds stiff peaks when you lift the whisk up. This should take about 3-5 minutes.

2. Tint the icing using gel food colouring (available at most craft/cake supply stores) then transfer them into piping bags fitted with a #1 tip for the black outline and any small coloured details and #2 tips for the larger areas of colour.

3. Carefully outline each drawing with royal icing.. Keep the piping tip a few centimetres higher than the cookie to prevent squished or smudged borders. Allow to dry 15-20 minutes. Then fill in the drawings with the appropriate colours. Allow the transfers to dry completely (1 - 3 days depending on how big/thick they are) before moving.

4 cups  icing sugar (powdered sugar)

3 tbsp meringue powder (available at stores that sell decorating supplies)

½ tsp lemon juice

½ cup warm water

1. In mixer bowl, stir icing sugar and meringue power until combined. Add lemon juice and warm water. Using the whisk attachment, mix on low to dissolve the sugar. Turn the mixer on high and whip until thick and glossy. Continue to whip on high until icing holds stiff peaks when you lift the whisk up. This should take about 3-5 minutes.

2. Tint the icing using gel food colouring (available at most craft/cake supply stores) then transfer them into piping bags fitted with a #1 tip for the black outline and any small coloured details and #2 tips for the larger areas of colour.

3. Carefully outline each drawing with royal icing.. Keep the piping tip a few centimetres higher than the cookie to prevent squished or smudged borders. Allow to dry 15-20 minutes. Then fill in the drawings with the appropriate colours. Allow the transfers to dry completely (1 - 3 days depending on how big/thick they are) before moving.

25 Jul 04:05

One-Pot French Onion Pasta

by joythebaker

one pot french onion pasta

I’m already anticipating Sunday.

Talk about putting the cart before the horse.  We haven’t even hopped around the weekend enough to make it to Sunday.

Sundays, I would argue, are the worst.  Actually… they’re the BEST but only between the hours of 8am and noon when we’re sleeping in, churching, brunching, or napping after pancakes.  After noon on a Sunday I find myself in the unfortunate task of pretending to be relaxed while stressing about the week to come.  We’ve talked about this before.  It’s called The Sunday Stresses, and it’s more real that we deserve.

Luckily there’s PASTA.  All healing, all comforting, all filling PASTA.  Thank you, Lord.  For real.

I have pasta every Sunday night.  I spoon myself an embarrassingly large bowl, sit cross-legged on the couch, watch Comedians In Cars Getting Coffee and just tear through a bowl.  I’m trying to fill the pit of Sunday Stresses and pasta usually works, until it doesn’t… but even still.

One Pot French Onion Pasta

This One-Pot pasta comes together easily and makes the house smell like an onion dream.  There’s just something so right about the smell of cooking onions.

While the onions, thyme, and chicken broth flavors have more of a Fall feel to them… well, The Sunday Stresses know no season.   Let’s just get some quality couch time in.  Let’s make out with pasta, just a little.


One Pot French Onion Pasta

Fat spaghetti pasta, chicken broth and water, onions halved and sliced, butter and olive oil, thyme and cheese and arugula and seasoning.  Everything! Let’s go!

One Pot French Onion Pasta

The onions.  Oh the onions.  They actually cook longer than the pasta itself.  The onions need a bit of caressing with butter and olive oil and low heat.

One Pot French Onion Pasta

Progress.  It’s hard not to hover and stir, but the onions do need quality time with the heat.  They need to sit and simmer a bit.

One Pot French Onion Pasta

This is about when I get super impatient and start to think of worms.

One Pot French Onion Pasta

Golden brown, studded with fresh thyme, seasoned with salt and pepper rather aggressively.

One Pot French Onion Pasta

Deglazing the hot pan with water and chicken broth.  The steam!  The best part.

One Pot French Onion Pasta

Welcome to the party, pasta!  We need you.

One Pot French Onion Pasta

We do a little dance on the stovetop.  Simmer with the lid on for a bit.  Stir with the lid off for a bit.  Simmer with the lid on again.  Fluff with the lid off.

It’ll all come together in about 10 magical minutes.

Related:  I need more magical minutes in all of my days.  RIGHT!?

One Pot French Onion Pasta

Taste and most likely add:  salt and pepper, way too much parmesan cheese, and handfuls of fresh arugula.

One Pot French Onion Pasta

By now your neighbors are likely knocking on the door because you made the world smell AMAZING! Share the pasta, not the stresses.

This pasta is both slightly sweet and salty.  As the onions cook down, they take on a tender and sweet quality.  It’s lovely, but you may find yourself adding a bit more salt and parmesan cheese than you might expect.  I love the spice that fresh arugula adds to the pasta.  Red pepper flakes are also divine.  You want to add cooked sausage too!?  Heck yes!

Happy Weekend!

One-Pot French Onion Pasta

serves 4

Print this Recipe!

3 medium yellow onions, peeled and sliced

3 tablespoons olive oil

1 tablespoon unsalted butter

salt and fresh cracked black pepper

3 teaspoons fresh thyme

2 cups water

2 1/2 cups chicken broth

12 ounces uncooked spaghetti

salt and fresh cracked black pepper, to taste

parmesan cheese

fresh arugula

Place a large heavy bottom sauce pan over medium heat.  Add the olive oil and butter and stir until butter is melted.  Add the sliced onions all at once.  Stir to coat the onions in the fat.  Allow onions to cook, undisturbed, for about 4 minutes.  Add salt, pepper and thyme and stir.  Allow the onions to cook for about 4 minutes at a time.  Lower the heat if the onions are browning too quickly.    The onions will begin to brown, break down, and resemble an onion jam.

When onions are entirely browned and completely soft (about 15 minutes), add the water and chicken broth to the pan.  Using a wooden spoon, scrape any burned bits off the bottom of the pan.  Add the pasta all at once.

Return to medium heat and bring to a simmer.  Place the lid on the pan and allow to simmer for 5 minutes.  Remove the lid to toss and stir the pasta for about 3 minutes.  Return the lid and allow to cook for another 5 minutes.  Remove the lid and taste the pasta for doneness.  There will still be just under an inch of liquid in the pot.  Allow the pasta to cook more (if it was still crunchy), or allow some of the liquid to cook off.  It’s about your preference.  I like a bit of the broth remaining.  Plus, the pasta will absorb more of the liquid as it sits.

To serve, spoon into large bowls, top with parmesan cheese and fresh arugula.  



22 Jul 10:00

Diagnose on Sight: Bilateral Leg Rash

by Jeff Riddell, MD

Erythema Nodosum

Case: A pre-teen girl, living in central California, recently started on fluconazole, now presenting with a bilateral leg rash. What is your diagnosis? Click on the image for a larger view.


Take Our Poll



Erythema nodosum, secondary to coccidioidomycosis


Erythema nodosum is a cutaneous reaction consisting of inflammatory, tender erythematous subcutaneous nodular lesions. The classically painful rash is located on the lower extremities and usually regresses spontaneously. It is associated with a wide variety of disease processes [1,2] including:

  • Most common cause: Streptococcal infections
  • Other causes:
    • Behcet’s syndrome
    • Oral contraceptive use
    • Pregnancy
    • Sarcoidosis
    • Tuberculosis
    • Viral infections

Coccidioidomycosis is endemic to certain arid parts of the Southwest United States. Erythema nodosum is the most characteristic reactive cutaneous manifestation of coccidioidomycosis. It presents 1-3 weeks after onset of illness and is usually self-limited [3]. While strep infections are the most common cause of erythema nodosum, in a patient who has recently visited the American southwest, suspect coccidioidomycosis.


Master Clinician Bedside Pearls

Stuart Swadron, MD




Stuart Swadron, MD – Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California (provided to ALiEM and recorded by Swadron, 2014)



  1. Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol. 2000;19(3):212-6. PMID: 10870657.
  2. Schwartz R, Nervi S. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007 Mar 1;75(5):695-700 PMID: 17375516.
  3. DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol. 2006 Dec;55(6):929-4.2 PMID: 1711021.

Author information

Jeff Riddell, MD
Jeff Riddell, MD
Chief Resident
UCSF-Fresno Emergency Medicine Residency

The post Diagnose on Sight: Bilateral Leg Rash appeared first on ALiEM.

30 Jun 22:22

Update on Age-Adjusted D-Dimer

by Salim Rezaie

burns was talking about this at a journal club a while ago...

Update on Age-Adjusted D-DimerD-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. The result of this would be that older patients would often have more diagnostic imaging or downstream testing, but on the other hand, maybe a higher cut-off d-dimer value may lead to increased false negative cases (i.e. missed venothromboembolism) and make this strategy less safe. Recently, I wrote a post on age-adjusted d-dimer testing on REBEL EM, but since that post there was a new article that was published in Chest 2014. This post, will specifically focus on an update of age-adjusted d-dimer testing based on the above article.

What article will we be discussing?

Woller SC et al. Assessment of the Safety and Efficiency of Using an Age-Adjusted D-Dimer Threshold to Exclude Suspected Pulmonary Embolism. Chest 2014. [Ahead of Print] PMID: 24831769

What is the clinical question we are trying to answer?

Is the use of age-adjusted d-dimer testing in patients ≥ 50 years of age safe for clinical practice?

What did they do:

  • A retrospective review of 923 patients, age > 50 years evaluated for suspected PE
  • All patients had a Revised Geneva Score (RGS) calculated, a d-dimer performed, and a computed tomography pulmonary angiography (CTPA)
  • A 64-slice CT scanner was used and high sensitivity d-dimer test (Stago latex agglutination)
  • Compared false negative rate for PE of a conventional d-dimer threshold with an age-adjusted d-dimer threshold



  • 104 patients had a negative CONVENTIONAL d-dimer and RGS ≤ 10, with NO PEs observed within 90 days (False Negative Rate = 0%)
  • 273 patients had a negative AGE-ADJUSTED d-dimer and RGS ≤ 10, with 4 PEs observed within 90 days (False Negative Rate = 1.5%)
  • AGE-ADJUSTED d-dimer resulted in 18.3% absolute reduction in patients age > 50 years who would undergo CTPA vs CONVENTIONAL d-dimer
  • In a subcohort evaluation a negative AGE-ADJUSTED d-dimer and RGS≤ 10 was seen in:
    • Age > 50 years: 273/923 pts with 4 (1.5%) missed PEs at 90d (95% CI 0.4 – 3.7)
    • Age 51 – 65 years: 130/480 pts with 1 (0.8%) missed PEs at 90d (95% CI 0.02 – 4.2)
    • Age 66 – 74 years: 66/186 pts with 0 (0.0%) missed PEs at 90d (95% CI 0.0 – 5.4)
    • Age ≥ 75 years: 77/257 pts with 3 (3.9%) missed PEs at 90d (95% CI 0.8 – 11.0)


  • If you look at each of the sub cohorts in the results section, the maximum confidence interval ranged from 3.7 – 11.0% increasing with age, which means we are potentially missing more PEs in older patients (i.e. upto 11.0% at the maximum CI in patients 75 years and older)
  • LimitationsThe prevalence of PE in this study was 10.6%.  In the US prevalence has been reported as 5.1% [1], but in contrast in European studies the prevalence for PE ranges from 24 – 31% [2] [3] [4].
  • This study was a retrospective chart review, so if hemoptysis or leg edema were not recorded they were considered negative, and actually underestimate RGS.  Also how may patients don’t go to doctors and have not had their initial malignancy diagnosed?  This will also reduce the RGS, when it is well known that malignancy risk increases with age
  • All patients in this study received a CTPA, which is not what is done in clinical practice, and excluded all patients who did not receive imaging.  Therefore this study population differs from an unselected patient population, making this a higher risk population for PE

Authors’ Conclusion: Using an age-adjusted d-dimer threshold reduces imaging among patients age > 50 years with a RGS ≤ 10, but at the cost of missing an additional 1.5% of PEs and requires a prospective study before this practice can be adopted into routine clinical care

Take Home Message

Take Home Message

Using an age-adjusted d-dimer strategy in patients age > 50 years would result in 18.3% fewer scans, but would miss up to 3.7 – 11.0% of PEs at 90 days of follow up based on the highest confidence intervals.  Therefore a prospective, randomized control trial with narrower confidence intervals would be needed before implementing this strategy into clinical practice



  1. A. Penaloza, P. Roy, J. Kline, F. Verschuren, G. LE Gal, S. Quentin-Georget, N. Delvau, and F. Thys, "Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism.", Journal of thrombosis and haemostasis : JTH, 2012.
  2. R.A. Douma, G. le Gal, M. Söhne, M. Righini, P.W. Kamphuisen, A. Perrier, M.J.H.A. Kruip, H. Bounameaux, H.R. Büller, and P. Roy, "Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts.", BMJ (Clinical research ed.), 2010.
  3. M. Jaffrelot, F. Le Ven, P. Le Roux, V. Tissot, E. Rame, P. Salaun, and G. Le Gal, "External validation of a D-dimer age-adjusted cut-off for the exclusion of pulmonary embolism.", Thrombosis and haemostasis, 2012.

The post Update on Age-Adjusted D-Dimer appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

21 Jul 14:21

Two Skydivers Jump From 5,000 Feet and Successfully Land on a Slip ‘N Slide

by Brian Heater

In this footage by Caters News, skydivers Niklas Daniel and Brianne Thompson leap from a plane at 5,000 feet above Arizona and manage to successfully land on a Slip ‘N Slide, traveling the length of the backyard toy at 50MPH.

21 Jul 08:30

Mushroom Gouda Quinoa Bake

by Annie

It all started with an omelette.  That tends to be my go-to meal on the nights when I get home late after barre class.  I’m famished, Ben and the kids have already eaten, and I’m looking for quick and healthy fare.  I make them a bit differently every depending on what veggies and cheeses we happen to have in the fridge at the moment. One evening a few months ago, I added some sautéed mushrooms and shredded gouda to my omelette and I don’t know if I was having an exceptionally good cooking night or if I was just incredibly hungry, but it was just soooo good.

Since then, I’ve been looking for every opportunity to combine mushrooms and gouda. I made them into burgers. I continue to put them in omelettes. And now, I baked them with quinoa. It’s a bit reminiscent of mac and cheese, but it’s really all about the mushrooms here. I included three of my favorite varieties, but feel free to use whatever you like best.  I also included a bit of greek yogurt to add a bit of creaminess, but if you don’t have it on hand, not to worry. It’s still pretty great even without it.  I know this meal will be on heavy rotation here, since this mushroom gouda thing doesn’t seem to be just a phase anymore.

16 Jul 12:18

The LITFL Review 144

by Kane Guthrie

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.

Welcome to the 144th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

The Best of #FOAMed Emergency Medicine

  • Stephen Smith reposts on a Certain Pattern of PseudoSTEMI to remind us that WPW can cause STEMI-like findings on the 12-lead ECG. Patients with chest pain and this finding should be considered for cardiac catherization or thrombolytics but caution is advised. [AS]
  • Audio from NYU/Bellevue Grand Rounds in June 2014 featuring Jerry Hoffman on Over-diagnosis and David Newman on Chest Pain posted this week to the All NYC EM Conference site. Great talks from a couple legends in Emergency Medicine on topics critical to us all. [AS]
  • Richard Body at St Emlyns uses his own research to answer the question How accurate is clincal judgement for acute coronary syndromes? He highlights the relative uselessness of historical features and risk factors – but interestingly the combination of clinician gestalt, normal ECG and negative troponin looks very promising… more studies needed, but a must read all the same. [CN]
  • TTL Podcast 1. Getting to CT in 30 mins is a St. Emlyns podcast examining what aspects of initial trauma managment are really needed before going for a scan, when you have to have the scan done within 30 minutes of arrival. This sparked
  • Hippo EM present a videocast on pus and stones discussing how you can diagnoses UTI in patients with ureteric calculi. Or rather, how you can’t. [CN]
  • Are topical anesthetics dangerous in the treatment of corneal abrasions or is withholding them simply evil? Ken Milne and Salim Rezaie discuss on The Skeptics Guide to Emergency Medicine. Ken even brings in an opthalmologist who says it’s “okay” to give topical anesthetics! [AS]

The Best of #FOAMcc Critical Care

  • Speak up! on INTENSIVE focusses on speaking up, an obligation of all healthcare professionals to ensure that patients are not harmed. It can be difficult, requires skill, and requires courage – but is essential. [CN]
  • Cliff Reid has looked into the options for rewarming when you are faced with profound hypothermia and no ECMO. [CN]
  • PulmCCM highlight a recent meta-analysis showing that Prone positioning reduces ARDS mortality by 26%. Is your ICU proning yet? [CN]

The Best of #FOAMPed Paediatrics

  • In yet another superb smaccGOLD talk, Paediatric INtensivist and Palliative Care physician Greg Kelly tells us what to do when children die. [CN]

#FOAMTox Toxicology

News from the Fast Lane

LITFL Review EM/CC Educational Social Media Round Up

Show Reference list

Emergency Medicine and Critical Care Blogroll — Emergency Medicine and Critical Care Podcasts — — Academic Life in Emergency Medicine — A Life at Risk — Bedside Ultrasound - BIJC — Boring EM — Broome Docs — CCM-L — Critical Care Perspectives in EM — Dave on Airways — Dont Forget the Bubbles — Dr Smith’s ECG Blog — ECG Academy — ECG Guru — ECG of the Week — ED ECMO — ED Exam — ED-Nurse — EDTCC — EKG Videos — EM Basic — EMCrit — EM CapeTown — EMCases — EMDocs — EMDutch — EMin5 — Emergency Medical Abstracts — EM Journey — EmergencyLondon — Emergency Medicine Cases — Emergency Medicine Education — Emergency Medicine News — Emergency Medicine Ireland — Emergency Medicine Tutorials — Emergency Medicine Updates — EM on the Edge — Emergucate  — EM Journey —  EM IM Doc — EM Literature of Note — — EMpills — Emergency Physicians Monthly — EM Lyceum —EM nerd— EMProcedures — EMRAP — EMRAP: Educators’ Edition — EMRAP.TV — EM REMS — ER CAST — EXPENSIVECARE — Free Emergency Medicine Talks — Gmergency! — Got Resuscitation— Greater Sydney Area HEMS — — Impactednurse —Injectable Orange  — INTENSIVE — Intensive Care Network — iTeachEM — IVLine — KeeWeeDoc — KI Docs— ER Mentor — MDaware — MD+ CALC — bone tumours — Medical Education Videos — Medical Evidence Blog — MedEmIt — Micrognome — Movin’ Meat — Paediatric Emergency Medicine — Pediatric EM Morsels — PEM ED — PEMLit — PEM Cincinnati — PHARM — Practical Evidence — Priceless Electrical Activity — Procedurettes — — Radiology Signs — Radiopaedia — REBEL EM - — Resus.ME — Resus Review — RESUS Room — Resus Room Management — Richard Winters’ Physician Leadership — ruralflyingdoc — SCANCRIT — SCCM Blogs — SEMEP — SinaiEM — SinaiEM Ultrasound — SMART EM — SOCMOB — SonoSpot — StEmylns — Takeokun — thebluntdissection — The Bottom Line — The Central Line — The Ember Project —The Emergency Medicine Resident Blog — The Flipped EM Classroom — thenursepath — The NNT — The Poison Review — The Sharp End — The Short Coat — The Skeptics Guide to Emergency Medicine — The Sono Cave - The Trauma Professional’s Blog —  — ToxTalk — tjdogma — Twin Cities Toxicology — Ultrarounds — UMEM Educational Pearls —Ultrasound Podcast

LITFL Review

The post The LITFL Review 144 appeared first on LITFL.

18 Jul 09:02

China – Men’s Group – Acro Worlds

by coach Rick

Very impressive.

… 24th Acrobatic Gymnastics World Championships – Levallois (FRA), July 10 – 12, 2014. China (Zhou Yi, Wang Lei, Tang Jian, Wu Yeqiuyin). Men’s Groups Dynamic, Qualification …

Click PLAY or watch it on YouTube.

(via GymCastic)

15 Jul 22:10

The Ancient Kaiju Project, Classic Paintings Augmented with Skillfully Inserted Pop Culture Monsters and Objects

by EDW Lynch

Classic Works of Art with Monsters by Oliver Wetter

In his ongoing digital illustration series “The Ancient Kaiju Project,” German artist Oliver Wetter skillfully augments classic paintings with the addition of fearsome creatures and objects from pop culture like Godzilla, a Star Wars AT-AT, and Howl’s Moving Castle. According to Wetter he is using the project as a way improve his ability at replicating classic painting styles. He has posted process images and making-of videos on his blog.

Classic Works of Art with Monsters by Oliver Wetter

Classic Works of Art with Monsters by Oliver Wetter

Classic Works of Art with Monsters by Oliver Wetter

Classic Works of Art with Monsters by Oliver Wetter

images by Oliver Wetter

via DesignTAXI, Archie McPhee’s Endless Geyser of Awesome

16 Jul 01:06

French Supermarket Chain Launches Food Waste Reduction Campaign that Celebrates Ugly Fruits and Vegetables

by Lori Dorn

The French supermarket chain Intermarché has launched “Inglorious Foods“, a unique campaign developed by Marcel Worldwide as a way to highlight the enormous amount of food wasted due to imperfect appearance. Instead the store celebrated the ugly fruits and vegetables and put them on shelves, either in their natural form or in soup or juice, and sold them at a significant discount to shoppers.

Intermarché launched the Inglorious Fruits & Vegetables, a film, print, poster and radio campaign, celebrating the beauty of the Grotesque Apple, the Ridiculous Potato, the Hideous Orange, the Failed Lemon, the Disfigured Eggplant, the Ugly Carrot, and the Unfortunate Clementine to call attention to our problem with food waste.

Inglorious Foods Group

Inglorious Orange and Carrot

Moches in Store

Soup and juice

images via Marcel Worldwide, Intermarché

via Good, Design Taxi

15 Jul 18:11

‘Marvels of Nature’, A Series of Animal Body Paintings Created on Contortionist Models

by EDW Lynch

Marvels of Nature Animal Body Paintings by Emma Fay

“Marvels of Nature” is a series of beautiful animal-themed body paintings by artist Emma Fay featuring contortionists as models.

Marvels of Nature Animal Body Paintings by Emma Fay

Marvels of Nature Animal Body Paintings by Emma Fay

Marvels of Nature Animal Body Paintings by Emma Fay

photos by Jonathan Macauley

11 Jul 15:23

A Dad Makes His Six-Year-Old Son a LEGO ‘Star Wars’ Boba Fett Minifigure Costume

by Justin Page

LEGO Boba Fett

The Dented Helmet member and father CGS1 recently made his six-year-old son an awesome LEGO Star Wars Boba Fett minifigure costume to wear at a local ToyCon. You can view more “making of” photos on the The Dented Helmet forums.

We took the costume for a trial run at a local toycon this past Sunday. I still have to finish building the arms and blaster, as well as tweaking a few things such as the cape fabric. I approached the components of this project as if they were actual Lego elements. In doing so, I created the jetpack to be removable as it appears in the actual minifigure as well as the range finder stalk. The entire costume is built from scratch using photo references and scans I took myself. The costume is built primarily out of sintra with pink insulation foam used to carve the helmet dome and a small amount of plastazote foam used on the tips and base of the jetpack rockets. Torso and leg graphics are printed on adhesive vinyl while a custom green was used to colour match the helmet and jetpack.

LEGO Boba Fett

photos via The Dented Helmet\

via reddit, Fahionably Geek, Archie McPhee’s Endless Geyser of AWESOME!

11 Jul 20:30

LEGO Sculptures That Portray Iconic Superheroes and Movie Characters as Lazy Couch Potatoes

by Justin Page

Bat Couch

Pixar director and LEGO fan Angus MacLane has built a great series of LEGO sculptures that portray iconic superheroes and movie characters as lazy couch potatoes. More characters from MacLane’s collection can be viewed online at Flickr.

Optimus Couch

Iron Couch

Robo Couch

Kane Couch

photos by Angus MacLane

via Geek Art, DesignTAXI

27 Jun 20:42

Goodnight Darth Vader, A ‘Star Wars’ Children’s Book by Jeffrey Brown Filled With Bedtime Stories for Future Jedi

by Justin Page

Goodnight Darth Vader

Goodnight Darth Vader is a fun new Star Wars children’s book created by cartoonist Jeffrey Brown and published by Chronicle Books that is filled with bedtime stories for future Jedi. The book is a follow-up to Brown’s children’s stories, Darth Vader and Son and Vader’s Little Princess. Hardcover editions of Goodnight Darth Vader are available to purchase from Chronicle Books and Amazon.

It’s bedtime in the Star Wars galaxy, and Darth Vader’s parenting skills are tested anew in this delightful follow-up to the breakout New York Times bestsellers Darth Vader™ and Son and Vader’s™ Little Princess. In this Episode, the Sith Lord must soothe his rambunctious twins, Luke and Leia—who are not ready to sleep and who insist on a story. As Vader reads, the book looks in on favorite creatures, droids, and characters, such as Yoda, R2-D2, Han Solo, Chewbacca, Darth Maul, Admiral Ackbar, Boba Fett, and many others as they tuck in, yawn, and settle down to dream. As ever, Jeffrey Brown’s charming illustrations and humor glow throughout, playing on children’s book conventions to enchant adults and kids alike.

Goodnight Darth Vader

Goodnight Darth Vader

Goodnight Darth Vader

images via Chronicle Books

submitted via Laughing Squid Tips

30 Jun 22:30

A Delicious Life-Size Chocolate Replica of a Human Skull

by EDW Lynch

Life-Size Chocolate Replica of a Human Skull

UK-based chocolatier BlackChocolate uses a mold based on an actual human skull to cast a life-size, anatomically correct Belgian chocolate human skull.

Life-Size Chocolate Replica of a Human Skull

Life-Size Chocolate Replica of a Human Skull

photos via BlackChocolate

via Joanne Manaster, Boing Boing

06 Jul 16:30

Bunday Morning Comix

by Brinke

1959217_10152179505267549_6270182706573710006_nAs seen on the Hundeurlaub FB page, original artwork by “Ayka.” We think. Thanks to Aunt Bonnie P.

Filed under: Uncategorized Tagged: Bunday Morning Comix
03 Jul 16:00

Dogs of the World Illustration Series by Lili Chin

by Katherine Becker

Dogs of the World Illustration Series by Lili Chin

We love keeping up with what the fabulous Lili Chin is up to, and her newest collection of illustrations totally rocks our world. Lili’s been compiling a massive Dogs of the World illustration collection – a breakdown of dog breeds by the region of their provenance, all rendered in Lili’s distinctive, adorable style. Check out the full collection on tumblr as well as prints, tees, and other goodies for sale!

Dogs of the World Illustration Series by Lili Chin in other for humans

Dogs of the World Illustration Series by Lili Chin in other for humans

Dogs of the World Illustration Series by Lili Chin in other for humans

Dogs of the World Illustration Series by Lili Chin in other for humans

Share This: Twitter | Facebook | Don't forget that you can follow Dog Milk on Twitter and Facebook.
© 2014 Dog Milk | Posted by Katherine in For Humans, Other | Permalink | 4 comments
18 Jun 19:02

A Knife Holder Shaped Like an X-Wing Starfighter From ‘Star Wars’

by Justin Page

Star Wars X-Wing Knife Block

The officially licensed Star Wars X-Wing Starfighter Knife Holder from The Fowndry will “give your regular old kitchenware a rebellious kick in the vegetables.” Their chrome-effect plastic knife holder comes loaded with five stainless steel knives and is available to purchase online.

Chrome finished and standing over 20cm high, the X-Wing Knife Block raises the status of the humble knife holder. Heck, with this in the kitchen even Aunt Beru would be signing up to give the Empire one in the eye. And as for the Force? Well… it’s useful. But can it chop an onion, dice peppers, and slice a loaf? Can it? We’ll ask George, as soon as he picks up.

Star Wars X-Wing Knife Block

Star Wars X-Wing Knife Block

Star Wars X-Wing Knife Block

images via The Fowndry

submitted via Laughing Squid Tips

19 Jun 14:44

How to Cut a Cake Using Scientific Principles in Order to Best Maintain Freshness

by Brian Heater

Math writer Alex Bellos demonstrates a more scientific alternative to cake cutting which better maintains the moistness of the innards in the latest episode of the Mathematical Science Research Institute series Numberphile. The method dates back to a 1906 letter to Nature by renowned British scientist Francis Galton, entitled, “Cutting a Round Cake on Scientific Principles”, detailing a method that involves removing thin slices from the cake’s center. Galton also suggested employing a rubber band to help keep the segments together.

via The Presurfer

19 Jun 17:11

Future Lifelong Companions Ruuxa the Baby Cheetah and Raina the Puppy Meet For First Time at San Diego Zoo

by Lori Dorn

Ruuxa the baby cheetah and Raina the Rhodesian ridgeback puppy meet for the very first time, clumsily climbing all over each other, biting each other and cementing their lifelong friendship through the San Diego Zoo’s Ambassador program in this adorable video posted by the San Diego Zoo.

A 6-week-old cheetah cub at the San Diego Zoo Safari Park is spending lots of time with his new dog companion. The young cheetah, Ruuxa, was chosen to be raised as an animal ambassador at the Safari Park after he was rejected by his mother and had to be hand raised by keepers…Safari Park cheetahs selected for training as ambassadors are paired early in life with a domestic dog. As the two companions grow up together, the dog’s body language will communicate to the cheetah that there’s nothing to fear in new or public surroundings, which relaxes and calms the cheetah. The Safari Park currently has four cheetah ambassadors all of which are trained to participate in the Park’s Cheetah Run experience.

Raina the Puppy

Raina the Puppy

Raina the Puppy

via Daily Picks and Flicks

19 Jun 18:50

A Behind the Scenes Look at Sophie Gamand’s ‘Wet Dog’ Photo Shoot

by Lori Dorn

Photographer Sophie Gamand goes behind the scenes of her imaginative award-winning photo series “Wet Dog” to talk about how she framed and styled the shots (with the help of pet stylist Ruben Santana), what camera equipment she used and the book she has planned for the future in this video posted by Sony. We previously wrote about this photo series in November 2013.

via PictureCorrect, PetaPixel

20 Jun 20:55

Soldier Comes Home to an Exuberant Greeting at the Door by His Cat

by Lori Dorn

An Army Reserve soldier, returning home from drills, was exuberantly greeted at the door by Finn, his beautiful and very vocal ragdoll cat in this video posted by wildlimeyogi

via reddit

17 Jun 16:29

SoundWorks Collection Interviews the Sound Team Behind ‘Maleficent’

by Brian Heater

For their latest video, “The Sound of Maleficent,” SoundWorks Collection talks to Tim Nielsen of Skywalker Sound, the sound designer for the Disney film Maleficent.

The one sound reoccurring moment that we refer to the original is the classic Maleficent laugh — the deep, bellowing evil laugh. A lot of work was done to pay homage to it.

submitted via Laughing Squid Tips