KT Evidence Bite: Colchicine for Pericarditis

Editor’s note: This is a series based on work done by three physicians (Patrick ArchambaultTim Chaplin, and our BoringEM Managing editor Teresa Chan)  for the Canadian National Review Course (NRC). You can read a description of this course here.

The NRC brings EM residents from across the Canada together in their final year for a crash course on everything emergency medicine. Since we are a specialty with heavy allegiance to the tenets of Evidence-Based Medicine, we thought we would serially release the biggest, baddest papers in EM to help the PGY5s in their studying via a spaced-repetition technique. And, since we’re giving this to them, we figured we might as well share those appraisals with the #FOAMed community! We have kept much of the material as drop downs so that you can quiz yourself on the studies.

Paper: A Randomized Trial of Colchicine for Acute Pericarditis

Citation: 

Imazio, Massimo, et al. “A randomized trial of colchicine for acute pericarditis.”New England Journal of Medicine 369.16 (2013): 1522-1528. PMID: 23992557

Summarized by: Patrick Archambault
Reviewed by: Teresa Chan & Tim Chaplin

Clinical Question

Is colchicine effective in treating a first attack of acute pericarditis and in the prevention of recurrent symptoms?

Population18 years of age or older with a first episode of acute pericarditis* (idiopathic, viral, after cardiac injury, or associated with connective-tissue disease).

Exclusion criteria: tuberculous, neoplastic, or purulent pericarditis; severe liver disease or current aminotransferase levels of more than 1.5 times the upper limit of the normal range; a serum creatinine level of more than 2.5 mg per deciliter (221 μmol per liter); skeletal myopathy or a serum creatine kinase level above the upper limit of the normal range; blood dyscrasia; inflammatory bowel disease; hypersensitivity to colchicine or other contraindication to its use
InterventionColchicine was administered at a dose of 0.5 to 1.0 mg daily for 3 months. Dose was based on weight: 0.5mg BID if >70kg, 0.5mg ID if < 70kg

All patients also received: (1) NSAIDS (ASA 800 mg TID or ibuprofen 600mg TID) for 7-10 days tapered over 3-4 weeks OR (2) prednisone (0.2-0.5 mg/kg daily if NSAIDS were contraindicated) for 2 weeks with gradual tapering AND a PPI for gastrointestinal prophylaxis.
Controlplacebo AND NSAIDS (or prednisone) AND PPI
Outcome1) Incessant (recurrence < 6 weeks after first attack) or recurrent pericarditis (after a 6-week symptom free period)

2) Symptom persistence at 72 hours, remission within 1 week, number of recurrences, the time to the first recurrence, disease-related hospitalization, cardiac tamponade, and constrictive pericarditis

Methods

This was a randomized, double-blind trial, with intention-to-treat analysis

Results

n=240

Primary outcome (rate of incessant/recurrent pericarditis)

  • Colchicine: 20 patients (16.7%) vs. Placebo: 45 patients (37.5%)
  • RRR in the colchicine group, 0.56; 95%CI, 0.30 to 0.72  (P<0.001)
  • NNT=4

Secondary outcomes

  • Lower rate of symptom persistence at 72 hours in the colchicine group (19.2% vs. 40.0%, P = 0.001)
  • Lower number of recurrences per patient in the colchicine group (0.21 vs. 0.52, P = 0.001)
  • Reduced hospitalization rate in the colchicine group (5.0% vs. 14.2%, P = 0.02)
  • Higher remission rate at 1 week in the colchicine group (85.0% vs. 58.3%, P<0.001)
  • No serious adverse events were observed

Conclusions

Colchicine in addition to conventional antiinflammatory therapy significantly reduced the rate of incessant or recurrent pericarditis, reduced the number of recurrences of pericarditis, and prolonged the time to recurrence, as compared with placebo.

Take Home Point

Colchicine is safe and effective to use in acute pericarditis (of idiopathic, viral and autoimmune etiologies).

EBM Considerations

  • Sample size: Small study with 240 patients (120 in each arm), that was however adequately powered to detect a large reduction in incessant and recurrent pericarditis
  • Side effects: Although there were no differences in rates of adverse events, diarrhea was the major limiting side effect associated with colchicine and was reported in less than 10% of patients, and no serious adverse events were recorded.
  • Generalizability: Colchicine was not used in bacterial or neoplastic pericarditis so use cannot be easily extrapolated to use in these disease conditions.

For a pdf version of this summary click NRC – BoringEM – Colchicine for Pericarditis

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post KT Evidence Bite: Colchicine for Pericarditis appeared first on BoringEM and was written by Eve Purdy.

Chalk Talk: Skin and Soft Tissue Infections

Editor’s note: This BoringEM Chalk Talk on skin and soft infections and accompanying was created as part of a joint Digital Scholarship Elective between the University of Toronto and McMaster University. This video is a great and quick review of the must-knows on the topic.  The accompanying case questions can be accessed here

 

As part of a Digital Scholarship elective at The University of Toronto, Alia Dharamsi (@alia_dh), R1 in Emergency Medicine created a series of pocket cards, cases and a Chalk Talk to guide initial learning of the management of Skin and soft tissue infections, as well as Diabetic Foot Infections in the ED.

Skin and soft tissue infections (SSTIs) account for a large portion of ambulatory presentations to the ED. With respect to infection management in the ED, currently there is greater attention to antibiotic stewardship—that is the appropriate use of antibiotics, when and if they are warranted based on clinical presentation and investigations. Understanding the classification of SSTIs  can guide ED treatment. There will be differences between centers and local antibiograms, these SSTI pocket cards have been created as a guideline for the classification of SSTIs, and ED management. This Chalk Talk  is also available to help learners develop an approach to antibiotic choices.

For specific information and resources for Diabetic Foot Infections, refer to this blog post.

You can also download a summary card by click on this link here: SSTI pocket card

Alia Picture

Author information

Alia Dharamsi
Alia Dharamsi

The post Chalk Talk: Skin and Soft Tissue Infections appeared first on BoringEM and was written by Alia Dharamsi.

BoringEM CaRMS | Life after CaRMS

Editor’s note:  Another version of this piece previously appeared on Luckett’s own blog (“This Liminal Space“).  We asked her to revise and add to it so that it might become a permanent part of the BoringEM CaRMS advice section.  – TC

 

I remember submitting my CaRMS rank order list all too well. I remember pacing my apartment, biting my lips until they were raw while I talked through its ordering and re-ordering with my best non-medical friends. I remember the grumbling, low-level anxiety of the intervening weeks while I waited for Match Day, and the nail-biting anticipation of the day before the match was released.

Deciding on a rank order list was a matter of optimising specialty, opportunity, geography, and feel. I had kept careful notes on programs as I’d interviewed. Ultimately, I settled on a list that felt, if not right, then at least okay. Knowing that the CaRMS process is imperfect, I intellectually, if not quite emotionally, accepted that checks and balances existed to ensure I ended up in a program that was a good fit.

On Match Day, I took my computer into a stairwell at the hospital, sat on the steps, and logged into the CaRMS website. I discovered that I had not matched to my first choice program, nor to my second. It was a blow to my ego. I berated myself for my many failings. I now knew that I was not smart enough, not savvy enough, not interesting, charismatic, or talented enough to match to my first choice.

In my PGY1 year, I was honoured to meet CaRMS applicants to our program. It was fun and exciting to tell them all about my program and how much I love it.

That’s right; I love my program even though it wasn’t my first choice.

So, how do you get there? What do you do when you find yourself in a program that isn’t your first choice? How do you deal with the disappointment and turn it into excitement?

Here are a few things I found helpful:

1. Talking it out.

After the match, it seemed that each of my classmates had matched to his or her first choice programs and was filled with unmitigated joy at what lay ahead. I felt isolated and alone in my disappointment. Moreover, I knew I had matched to a competitive specialty, and felt guilty that I wasn’t happier about my good fortune.

There were a few notable exceptions. A few of my classmates looked glazed when I ran into them shortly after the match, and revealed their shock or uncertainty about their placements. With these peers, and with my close friends, I tentatively disclosed my disappointment at not matching to my first-choice program. As my feelings were validated, I began to be more open. In openly talking about my experience, I began to feel less isolated. Speaking with others made me realise both that I was not alone in my situation and that there were definite positives to matching to a program other than my first choice. Slowly, I began to adjust to the idea.

The feelings that come with matching to a program – even your first choice program – can be complex and difficult to deal with on your own. One of the most important things you can do is to talk out all the conflict and angst with someone you trust. This can help you gain clarity and perspective.

2. Learning my community.

I moved to my new community a month before starting residency. During that first month, I tried new restaurants, ran new routes, and got comfortable driving to surrounding areas (which was quite the feat, as the first time I was ever alone in a car was the day I moved to my new city!). I swam at recreation centres, and walked around in my neighbourhood. Eventually, I began to feel both comfortable with, and optimistic about, my new surroundings.

Putting down roots can help you feel at home in your new environment. Many people find exploring restaurants and local attractions, joining clubs, or getting involved in community organisations helps them feel happy and optimistic about their surroundings, and gives them an all-important sense of home.

3. Creating a home.

The first task I attacked after match day was finding somewhere to live. With the help of a great real estate agent, I began looking at properties for rental or purchase. I ultimately settled on renting a really lovely apartment in a converted school building, and I set about making it my home.

I hung photographs and art on my walls. At the head of my bed is a typographic exhortation to bloom where I am planted, a reminder that my location for the coming years is decided, and all that remains is for me to decide to be excellent exactly where I am. At the foot of my bed is encouragement to wake up and be awesome so that I remember to greet the day with enthusiasm. Over my couch are reminders to work hard and be brave, since I know that nothing will be asked of me so much as a dedication to hard work and bravery during this residency. In creating an environment that reflected my personality and was comfortable to come home to, I made a commitment to my new city and my new program. That made it easier to let go of the things that could have been and embrace exactly what was.

Settling into a comfortable home, organised and decorated to your tastes, is an essential part of starting a new residency. It lends a sense of ownership and permanence, but also gives you a space to host friends, be creative, reflect, and relax.

4. Meeting my fellow residents and getting involved.

Immediately upon my arrival, I met friendly co-residents and staff (and also some who are really, really intimidating!). Soon, I was offered an opportunity at BoringEM.org, and I became junior resident editor. Shortly thereafter, I began casually helping out with the Medical Education in Cases (MEdIC) series at ALiEM.com, and later began more seriously working on the series in editing, hosting, and writing roles. I began a research project. I sought out teaching and feedback and began to feel part of the community in my new program.

Seeing friendly faces, having purpose, and learning about the brilliant minds around you can help you settle into a new environment faster than just about anything else.

5. Staying connected with friends.

After the match, I was tempted to withdraw from friends both within and outside medicine. My closest friends outside medicine were well-acquainted with my goals for the match, and I was embarrassed that they knew I had failed. My friends within medicine were all so excited with their match prospects that I felt removed from them, and worried that my disappointment would taint their high spirits. I was fortunate that my friends would not take no for an answer. They reached out in the days following the match, and I was soon feeling positive and excited about my new program, largely due to their congratulations, encouragement, and positivity about my prospects.

Though we tend to withdraw when we are disappointed, ashamed, or upset, friends (and family, for some) are your best resource. Whether they are commiserating, encouraging, or just distracting you, the positive people in your life can help you get through matching to a second, third, or lower choice residency. Often, they are also the people most likely to kick your butt and adjust your attitude. A common refrain was, ‘Yeah, Luckett, you didn’t match to your first choice, but you are going to be an emergency physician! That’s what you wanted!’

I started my time in this new city with a commitment to making the coming five years productive, exciting, and fun. I dedicated myself to becoming an excellent clinician through practise, through welcoming feedback, and through embracing all that my program has to offer. I now cannot imagine myself anywhere but in this program. I cannot imagine what life would have been like in my first-choice program. I cannot imagine choosing any program over the very program where I am now. I have taken advantage of opportunities that I would never have been offered anywhere else. I have met co-residents, support staff, and attendings unlike anyone else I know. I am grateful that this program felt that I would be a good fit and welcomed me into their home.

Matching to a program that is not your first choice is a painful and disappointing experience, and one that can make you question your worthiness. It takes tenacity, optimism, and an open mind to make the best of a disappointing situation, but your tenacity, optimism, and open mind have already brought you this far; they can take you right across the finish line. Remember, life is 10% what happens to you, and 90% what you make of it.

 

Reviewing with the Staff  |  Dr. Teresa Chan, BoringEM.org Managing Editor

Luckett’s piece brings up some good points – the CaRMS match is built to optimize a best fit.  Funny thing is, our own personal desires don’t always reveal the best possible path.  Sometimes fate (or the CaRMS match computer) has a funny way of helping you along your way towards being a great and amazing emergency physician.  To be honest, I perseverated quite a bit with my top 3 choices (won’t say which schools or programs they were), but in the end I matched to McMaster… And now looking at where I am and what I’ve accomplished, I can truly attest that it was the best fit for me.  I have been given career-making opportunities, met life-changing mentors, and all of this is largely due to the Great Wizardry of CaRMS.

And even after the match goes through, statistics suggest that roughly 10% of residents switch programs by the end of PGY1… So as they say, “it’s not too late to change”.  At every postgraduate medical education office in Canada there is always someone you can talk to if you are not sure if you’ve made the right career choice.  In the end, you remain the master of your fate, and you can choose to use your powers and resilience to problem solve, wherever life leads you!

Author information

Sarah Luckett-Gatopoulos
Sarah Luckett-Gatopoulos
Junior Resident Editor at BoringEM
Luckett is a resident at McMaster University. Newbie to the #FOAMed world. Interested in literacy, health advocacy, creative writing, and near-peer mentorship.

The post BoringEM CaRMS | Life after CaRMS appeared first on BoringEM and was written by Sarah Luckett-Gatopoulos.

Medical Concepts: Diabetic Foot Infections

Editor’s note: In this post we are going back to some BoringEM basic content, a case-based approach to classifying diabetic foot infections. It is designed to follow the introductory Chalk Talk: An approach to skin infections, available HERE. This awesome series was created by Alia Dharamsi (@alia_dh) a PGY1 in EM at the University of Toronto. 

A fantastic quick reference pocket card is available for download.  Click on the picture or link below.

Screenshot 2015-04-11 14.00.17

Diabetic Foot Reference Card

Objectives

  1. Classify diabetic foot infections into uninfected, mild, moderate, severe
  2. Name the most likely pathogens causing diabetic foot infections of varying severity
  3. Prescribe an antibiotic regimen for mild, moderate, severe diabetic foot infections

 

The Cases

Case 1 (Click to reveal case)

You are working in an urban ED when Unna, a 55 year old female, presents to the ED to ask about a lesion that her husband found on the bottom of her right foot yesterday.

History

It has never been painful, there is no warmth to the area, erythema, or any purulent drainage. She has no fever or chills. Her foot is mostly insensate secondary to a 20 year history of diabetes, which is poorly controlled (on insulin, sugars range from 10-20 on any given day).

  • PMHx: diabetes mellitus type 2
  • Medicationsinsulin, metformin, ramipril, rosuvastatin, pantoprazole
  • Allergies: none
  • Social History1 PPD smoking, social alcohol consumption (2 drinks/month), no drug use, works as a mail clerk in an office building

Exam

BP 132/86, HR 78, RR 14, O2 98% RA, Temp 36.7

1×1 cm ulcer on the plantar aspect of the heel of her left foot. There is no ulceration, drainage, erythema, or rubor (warmth)Her peripheral pulses are present, but she has decreased sensitivity to light touch and pinprick on her R and L soles.

Questions

1. How would you classify this ulcer in terms of severity? (Click to reveal answer)

Since this ulcer is not showing any local signs of infection, there is no history of purulent drainage, and there is no sign of deeper involvement to bone or soft tissue, this ulcer is uninfected. 

2. Does Unna require antibiotics at this time? (click to reveal answer)

No. Uninfected ulcers do not require antibiotics

Management

  • In the emergency department: Since this wound is not infected, and she is not systemically unwell, she does not require hospital admission. You decide to discharge her home: recommend reduced weight bearing and elevating foot to facilitate healing follow up with family doctor for assessment of the wound.
  • Referrals: Diabetic foot care team for coordinated management: she will need to have the wound re checked, as well as peripheral vascular assessments, and possibly fitting for offloading boot. The fact that she is a smoker and has Diabetes puts her at increased risk of peripheral vascular disease. May also consider an endocrinology consult for closer monitoring of diabetes, and optimal management of complications. 

Case 2 (Click to reveal case)

Your next patient that night is Cam, a 68 year old obese male with pain in his left foot.

History

The area has been painful for quite some time, “probably weeks.” He has previously been seen by his GP for this problem, and has been told he has an “ulcer on the side of my foot.” He has never been on antibiotics for this problem. On history the area has a throbbing pain, although his feet are mostly insensate and have been for years. He thinks his foot feels warm to touch, and he noted that his socks have a green-yellow discharge on them from his foot. He is unable to see the soles of his feet due to osteoarthritis of his joints prohibiting appropriate flexion.

  • PMHx: Type 2 diabetes, CHF, HTN, OA, OSA, asthma
  • MedicationsInsulin, furosemide, metoprolol, atorvastatin, ramipril, atrovent, ventolin
  • Allergies: none
  • Social Hx: 1ppd smoking, social alcohol consumption (10/week), works occasionally for a contracting company

Exam

BP 134/72, HR 66, RR 14, O2 96% RA, Temp 36.9

There is a 2cm x 2cm ulcer on his left foot. The area is surrounded by 1-2 cm of cellulitis and erythema, and there is some discharge from the wound. You probe gently and do not detect any involvement to bone (and since you dont probe to bone you have a lower suspicion of osteomyelitis). His peripheral pulses are present, but he has decreased sensitivity to light touch and pinprick on his R and L soles.

Questions

1. How would you classify  Cam’s ulcer? (Click to reveal answer)

Cam’s foot ulcer is mild, and although there are local signs of infection, there does not seem to be any extension to bone or deeper soft tissue, and he is systemically well

Mild- 2 or more signs of inflammation (below) AND infection limited to skin and superficial dermis, with no local complications or systemic illness

  • purulent secretions
  • erythema <2cm
  • pain
  • tenderness
  • warmth
  • induration
2. Does Cam require antibiotics at this time? (Click to reveal answer)

Yes, he is beginning to show signs of local infection.

3. What microbes should you consider in the differential of his infection? (Click to reveal answer)

In mild diabetic foot infections, most likely causes are Streptococci, and Methicillin-Susceptible Staph Aureus.

4. Does Cam have risks for community acquired or hospital acquired methicillin resistant staphylococcus aureus infection? (Click to reveal answer)

Cam does have a risk factor for CA-MRSA but none for HA-MRSA. His diabetes should trigger you to think about CA-MRSA and should make turn to your local guidelines to determine the appropriate treatment. In Cam’s case, based on local antibiograms empiric coverage of MRSA is not recommended, and this is a first time DFI therefore empiric CA-MRSA coverage was not initiated. . The risk factors are:

  • Hospital acquired: hospitalization, long-term care, recent antibiotic therapy, hemodialysis
  • Community acquired*: HIV infection, men who have sex with men, injection drug use, unsanitary/cramped living conditions, incarceration, military service, sharing sports equipment,  diabetes

*avoid clindamycin if suspected CA-MRSA due to inducible resistance

5. What antibiotics are recommended for mild diabetic foot infections? (Click to reveal answer)

Mild infections, without MRSA Coverage, choose 1 of:

  • Cephalexin 500mg PO QID
  • Dicloxacillin 500mg PO QID
  • Amox-Clav 875/125mg PO BID
  • Levofloxacin 750mg PO Daily
  • Clindamycin 450mg PO TID

Mild infections, with MRSA coverage, choose 1 of

  • Clindamycin 450mg PO TID
    • Avoid Clindamycin in suspected CA-MRSA due to inducible resistance
  • Cephalexin OR Dicloxacillin WITH TMP/SMX (DS) 2 tabs PO BID
  • Cephalexin OR Dicloxacillin WITH Doxycycline 100mg PO BID

Duration of treatment for Mild DFIs is 7-14 days

Management

  • In the emergency department: You do not think that Cam requires admission at this time, and you plan to discharge him home.
    • You send a swab for C&S.
    • Since Cam does not have risk factors for CA-MRSA or HA-MRSA, you provide him with a prescription for antibiotics: Cephalexin 500mg PO QID x 14 days
    • Instructions for follow up with GP
    • Instructions to offload pressure to the area: an offloading boot is fitted for him
    • Home care nursing for dressing changes
  • Referrals: Wound care team is contacted for coordinated approach to diabetic foot ulcers. Will need peripheral vascular assessment, as well as close monitoring and possibly fitting for shoes that prevent excoriation of ulcerated area. Consider consulting endocrinology for diabetes management.

Case 3 (Click to reveal case)

Recall Cam, a 68 year old obese male with pain in his left foot who returns to your ED 4 months later.

History

He completed the previous round of antibiotics, and had complete resolution of the erythema and pain, as well as no purulent drainage for at least 2 months. This wound was initially healing but has been deteriorating for the past 6 weeks. Since his last visit to the ED he has been followed by Endocrinology, however has been non compliant with new insulin recommendations and a special shoe that he was fitted with by the wound care team. The area is now more painful, and he feels there is a pocket of fluid on the bottom of his foot that drains significant amounts of yellow-green pus.

  • PMHx: Type 2 diabetes (insulin), CHF, HTN, OA, OSA, asthma
  • Medications: Insulin, furosemide, metoprolol, tylenol arthritis, atrovent, ventolin
  • Allergies: none
  • Social Hx: 1PPD smoking, social alcohol consumption (10/week), unemployed due to foot pain

Exam

BP 138/86, HR 77, RR14, O2 95% RA, Temp 36.8

There is a 2cm x 2cm ulcer on the lateral aspect of his left foot. The area is surrounded by 4 cm of cellulitis and erythema, and there is significant discharge from the wound. There is a central area of fluctuance. You probe gently and do not see any involvement to bone. His peripheral pulses are present, but he has decreased sensitivity to light touch and pinprick on his R and L soles.

Labs and Imaging

Due to the significant appearance of this wound, you get labs and ask for an ultrasound of the foot to assess for a deeper infection as well as an Xray to assess for any osteomyelitis. Significant results:

  • WBC: 12.8 (elevated)
  • ESR: 8 (normal)
  • CRP: normal
  • U/S: 5x5x6cm  deep abscess extending from plantar fascia deep towards calcaneous
  • X-ray: no fractures or evidence of OM noted

Questions

1. How would you classify Cam’s ulcer now?  (Click to reveal answer)

Moderate diabetic foot infection. Cam’s ulcer has both evidence of deep tissue abscess, and significant cellulitis.

Moderate diabetic infections have at least 1 of:

  • cellulitis > 2 cm
  • spread beneath fascia (fasciitis)
  • deep tissue abscess
  • gangrene
  • osteomyelitis, septic arthritis, involvement of muscle
2. Does Cam require antibiotics? (Click to reveal answer)

Yes. Moderate infections require antibiotic treatment.

3. Which microbes should you consider in the differential of this infection? (Click to reveal answer)

In Moderate diabetic foot infections consider a broader differential, including Staph (MSSA AND MRSA), Streptococci., Enterobacter, Enterococcus, obligate anaerobes.

4. What antibiotics are recommended for moderate diabetic foot infections? (Click to reveal answer)

Moderate infections, if you do not suspect MRSA

  • Clindamycin 300-45 mg PO QID with a Fluoroqinolone like Levofloxacin 750mg PO q24h or Ciprofloxacin 750mg PO q12h
  • You can start also with IV Clindamycin 600-900mg q8h with an IV Fluoroquinolone, then step down to PO.

Moderate infections, if you suspect MRSA (avoid Clindamycin in suspected CA-MRSA due to the possibility of inducible resistance)

  • TMP/SMX 2 tabs PO BID + Amoxicillin-Clavulanate 875/125 PO BID x 2-4 weeks
  • Clindamycin 300-450mg q 6-8 hours WITH a Fluoroquinolone (egMoxifloxacin 400mg PO q24hours OR Levofloxacin 750 mg PO q 24hours OR Ciprofloxacin 750mg PO q12hours)

Duration of Treatment for Moderate DFIs is 2-4 weeks.

Management

  • In the emergency department: The abscess is complex and quite deep, and you do not feel that you would get adequate drainage with an ED I&D, and consider the need for surgical management. You consult orthopaedics, and they see him in the ED and perform an I&D. Orthopaedics agrees with your choice of antibiotics, and you write him a prescription for Levofloxacin and Clindamycin. He still does have the CA-MRSA risk factor of diabetes and although deceiving his antibiotic use does not qualify as a risk for HA-MRSA since he had complete resolution of his symptoms for > 2 months. So, as was the case above, based on local guidelines you determine MRSA coverage is not necessary. Follow-up in clinic is arranged, with the wound care team, and they will consider further operative I&D pending repeat ultrasound. A swab is sent to microbiology for C&S.
  • Referrals: You refer him back to Endocrinology, and ask him to follow up with his GP.

Case 4 (Click to reveal case)

What if Cam had presented to the ED with the exactly the story as Case 3 but showed systemic signs of infection including fever of 38.4 degrees, chills, and tachycardia (115 bpm)?

Questions

1. How do you classify his infection with respect to his new symptoms? (Click to reveal answer)

Cam now has a severe infection. Severe infection have evidence of local infection as in moderate, AND signs of systemic toxicity (SIRS), i.e. at least 1 of

  • Temp >38 or <36
  • Pulse >90bpm
  • Tachypnea >20 breaths/minute or PaCO2< 32
  • WBC >12 or <4, or >10% bands
2. Does Cam require antibiotics? (Click to reveal answer)

Yes, severe infections require antibiotic treatment

3. Which microbes should you consider in the differential of this infection? (Click to reveal answer)

In severe diabetic foot  infections consider a broader differential, including Staph (MSSA AND MRSA), Streptococci, Enterobacter, Enterococcus, obligate anaerobes.

4. What antibiotics are recommended for severe diabetic foot infections? (Click to reveal answer)

Severe infections with no MRSA risk factors

  • Moxifloxacin 400mg IV q24 hours
  • Ertapenem 1gm IV q24 hours
  • Imipenem-cilastatin 500mg IV q6 hours
  • Pip/tazo 4.5g IV q8 hours

Severe infections, with MRSA risk factors or high clinical suspicion for MRSA, ADD

  • Linezolid 600mg PO q12 hours
  • Daptomycin 4-6mg/kg IV q24 hours
  • Vancomycin 15-20mg/kg IV BID

Duration of Treatment for Severe DFIs depends on symptomatology. Monitor patient and step down to PO antibiotics as soon as clinically indicated.

 References

1. Gemechu, Fassil W., Fnu Seemant, and Catherine A. Curley. “Diabetic foot infections.” American family physician 88.3 (2013): 177-184.

2. Lipsky, Benjamin A., et al. “2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.” Clinical infectious diseases 54.12 (2012): e132-e173.

3. Lipsky, B., Berendt, A., Cornia, P., Pile, J., Peters, E., & Armstrong, D. et al. Executive Summary: 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases54(12), (2012): 1679-1684. doi:10.1093/cid/cis460

4. Weintrob, A., Sexton, D., (2014). Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. Retrieved 31 December 2014, from uptodate.

This piece was created as part of a joint Digital Scholarship Elective between the University of Toronto and McMaster University.  This piece has been reviewed for content by Drs. Andrew Petrosoniak and Teresa Chan.  The piece was peer reviewed by (soon-to-be-Dr.) Eve Purdy

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post Medical Concepts: Diabetic Foot Infections appeared first on BoringEM and was written by Eve Purdy.

EMSimCases.com | A not-so-boring take on Simulation

In the spirit of true FOAM-y collaboration, we are taking some time to feature a recent #FOAMed initiative that has been lead by two Canadian PGY4 residents.  As depicted in Eve Purdy’s post earlier this week, however, these two actually collaborated at a distance to bring this initiative to life.  Kyla Caners is a co-Chief Resident at McMaster University (Hamilton, ON, Canada) and Martin Kuuskne is a senior resident at McGill University (Montreal, QC, Canada).

Funny enough, I have known both of them separately for quite some time (Martin was once-upon-a-time a medical student who helped me on a paper; and Kyla is only a few years behind me in residency here at Mac), and only just realized that they were working on this project together. :D

We caught up recently to chat about their EMSimCases.com project:

 

TC:  So, Kyla & Martin, could you explain the inspiration/need for an online sim case repository? Who is the intended audience?

MK: Generally speaking, simulation is a resource heavy teaching method. It requires a high instructor-to-learner ratio, a dedicated space, specialized equipment, and time for running the simulations. Planning for and creating quality cases that run smoothly also takes a significant amount of time. Every site needs their own instructors, but not all sites need to have unique cases. If we learn from similar resources and complete common exams across Canada, why can’t we collaborate to create shared simulation resources?

KC: We’ve talked to a lot of different simulation educators along the way and we each took a look online to see if there was anything like this. We weren’t very impressed by the databases we did find. Simulation educators want something that is searchable and has a variety of cases in a wide range of topic areas and skill levels. Further, educators want to be able to modify a case so it can suit their specific educational needs. Some cases are specifically designed for a certain type of mannequin. The trick isn’t programming your mannequin. It’s ensuring that the case progression is logical and anticipates most likely learner actions. Mannequin sellers also sell pre-made cases…but that’s expensive! Clearly, EM simulation educators are keen to find easier ways to create and use new high-quality cases!

MK: The blog is intended for simulation educators in the field of EM. However, many of the cases would also be relevant to other critical care specialties (trauma, ICU, anesthesia). Similarly, we feel that EM residents and medical students could learn a lot by reviewing the case content. Finally, we will be featuring a biweekly segment on medical education & simulation theory, tips, and tricks. This could apply to anyone involved in simulation or medical education.

TC:  It says on your website that your resources are peer reviewed.  What is your peer review process?

MK: All submitted cases are first vetted by Kyla and I for face validity. They are then reviewed and initially edited by a senior emergency medicine resident member of our associate editor team. They are then reviewed by two members of our advisory board. The board member’s job is to ensure that the medical content is accurate, that the case has clear learning objectives, and that the learning objectives align with the case and its progression. Lastly, Kyla and I incorporate any improvements derived from the peer review process before it is published.

KC: Our advisory board consists of leaders in simulation and medical education who are spread across the country. The goal was to ensure a wide and expert perspective on the cases.

TC: So, that’s great that the content is vetted and reviewed a prioi.  But with simulation cases, reviewing them on paper is one thing…. But, tell me, are your cases tested before they are posted? If so, how?

KC: Absolutely! It’s incredibly important that cases work in real time with real learners. Some cases look great on paper or in theory, but fall flat when used in real life. So we make sure all cases are tried before publication by either Martin, myself, or one of our advisory board members in a simulated environment. We incorporate the cases into our simulation curriculum that we provide to our own residents.

TC: I’ll be honest with you, there are a LOT of other repositories for educational resources.  How is your site different than the other simulation repositories online? (e.g. MedEdPORTAL, SAEM case library)?

MK: We worked really hard to ensure that all the cases are formatted in the same way for consistency and ease of use. We created the EMSimCases template for this reason. Many existing sites have unstructured requirements for case publication; cases are presented in different and sometimes confusing formats. We thought we could improve on this and also create a platform for posts on simulation medical education – or simeducation as we call it – and to highlight innovative efforts in simulation happening across the country.

KC: We also wanted to ensure that all cases had gone through a peer review process. The sites you mentioned have a peer review process, but for some sites, it’s not explicit or hasn’t been completed for every case before they are published for use. Our goal was to front load that process, like a journal does, to ensure quality content.

MK: And it was most important to us that this would serve as a free, open access, collaborative project. We want contributions from across the country! And we want it to be clear who wrote the cases. We want the cases to be clearly organized by content area. Ultimately, our blog will be searchable and will serve as a great way to look for a new version of a case you may have already run or to look for ideas for new cases.

TC: Can tell us a bit of the origin story for EMsimcases?

KC: I’ve spent the past year doing a fellowship in medical education and simulation. As a large part of my fellowship project, I’ve been designing a simulation component for our curriculum at the Royal College EM program at McMaster. Throughout the process, I’ve written a full curriculum of simulation cases for our residents. Writing cases is time-intensive. In fact, simulation is a very time-intensive way to teach. I kept thinking that if we couldn’t offload the amount of instructor time required for quality simulation, there should be a way that educators across the country could offload the case writing process. And hence, the idea of case repository was born.

MK: I had gone through a similar process at McGill; I developed and was leading the EM residency simulation curriculum with a resident colleague of mine, Wayne Choi. During my fellowship year in medical education and simulation, I thought about how incredible it would be for simulation educators to share their work to enhance the variety of cases that could be incorporated into their respective programs. I knew Jonathan Sherbino from my medical school training at McMaster and was aware of his expertise as a clinician educator. I contacted him regarding ideas about simulation based learning objectives and brought up the idea of creating a national repository of cases; he put me in contact with Kyla and the rest is history!

TC:  You two are at different universities and hundreds of kilometres away… How did you find it working on creating this project together?

KC: Right after we were put in contact by our mutual mentor, we both happened to be at the 2014 Simulation Summit in Toronto. It was so helpful to meet each other in person. The more we talked, the bigger and better the idea became. Our goal transformed from a small case book to a collaborative, FOAMed inspired blog! Having had that initial brainstorming session in person was such a great way to get things started.

MK: It’s surprisingly easy to collaborate via skype, email and even texting! Also, the fact that we both have access to editing the blog and have predetermined roles in terms of taking charge on selected blog posts is really helpful. Lastly, I think that being transparent and honest with our goals and opinions has made the process both successful and fulfilling.

KC: We also made a point of having regular meetings. We record minutes and action items after each meeting. And we always set the date for our next meeting before we end our current meeting. Setting clear timelines and goals also made our expectations of each other really clear.

TC:  What are your tips to med students doing sim for the first time?

MK: My advice would be to dive into the simulated environment as much as you can, regardless of the level of fidelity or realism! Treat the mannequin like a real patient. Talk to it; ask it questions. If you have to start compressions, give it your all and don’t be afraid to work up a sweat. Go through the motions of listening for breath sounds or putting in an IV. The more realistic learners treat the scenario, the more realistic the scenario becomes and the more it can mimic learning from a real patient encounter. Also, I think if you make the experience memorable, it will be easier to remember the learning points that you took away from the case.

KC: Remember that simulation is, above all else, a teaching modality. Just like a lecture is designed to deliver content, simulation is designed to teach a specific objective. Sometimes it feels like simulation is set up to make you fail. Particularly because any gaps in your knowledge feel like they are on display. But it’s actually the exact opposite. Why not jump in and make use of an excellent opportunity to realize what concepts you don’t fully understand? The point of simulation education is to help you learn content without needing to compromise patient care. The process of not knowing an answer is always uncomfortable. But in simulation, you should be happy to fail. And I bet you $10 that you’ll remember exactly what to do the next time you’re faced with a similar situation!

MK: I can vouch for that: I will NEVER forget about giving stress dose steroids for suspected adrenal insufficiency to a septic patient not responding to fluids or vasopressors after missing it in a simulated scenario during the CAEP Simulation Olympics 2 years ago!!

TC:  Okay, one last What’s your favourite flavour of ice cream?

KC: Mint chocolate chip. No question.

MK: I know its boring… but vanilla all the way!

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 EMSimCases.com | A not-so-boring take on Simulation appeared first on BoringEM and was written by Teresa Chan.

Behind the Scenes: doing research at a distance

Editor’s note: In this article Eve Purdy discusses lessons learned while performing, writing and publishing research with a team spread across the country. The final product “The use of free educational  resources by Canadian emergency medicine residents and program directors” was published in CJEM in March 2015.  Of note, she (and some of here colleagues) will be available to answer questions via the new CJEM Facebook page in the coming weeks!  – TC

 

“Hi, I’m Eve Purdy,” I said as introduced myself to a physician at the CaRMS social in Winnipeg.

“Nice to meet you, I’m Joeseph Bednarcyzk,” the doc responded.

And then we both started laughing.

You see, Joe and I had been working together on a paper that was about to be published… Yet, we had never actually met.

Welcome to academic publishing in the 21st century!

***

Flashback to 2013 where Brent Thoma and I conceived a project over coffee  at CAEP 2013. We knew we shared an interest in how online and open access resources (#FOAMed) affect education and we were “nerding out”. We lamented that despite our gut feeling, there was little empiric support for our gestalt, and no one really knew if these resources were being used as ubiquitously amongst EM learners as we suspected. Being people of action, we decided to tackle the problem…

But first we needed to draft a dream team.

Drafting Your Dream Team

As we sat sipping our lattes, we thought up the best possible roster for our team. What did this project need for success and who could help. Like any team the research unit has multiple roles that need to be filled. The needs we saw and recruited for were:

  • Communicator: to make it a truly Canadian project we needed to include French-speaking physicians/programs and we needed someone who could translate the survey but who could also help to increase the response rate among residents.
  • Methodology Expert: If you are going to do a project, do it right. Neither of us felt perfectly comfortable with our desired methodology so we recognized that recruiting somebody with expertise in the area would be extremely helpful.
  • Passion generators/work horses: We figured that we had these roles covered.
  • Coach: We all need help seeing the bigger picture. We wanted someone who could help us turn a good project, into a great project.

Fortunately, everyone on our short list said yes! David Migneault (communicator), Joseph Bednarczyk (methods expert) and Jonathan Sherbino (coach) were drafted and the dream team was formed, but there was only one problem….none of us lived in the same city!

 

Collaborating at Distance

When working at a distance you are not going to run into each other in the hallway or in the department, so there might not be that immediate feeling of necessity to complete tasks. Learning to work in geographically disparate teams, however, is likely the future of academic success.  (NB: BoringEM managing editor, Teresa Chan, has recently written about this phenomenon for the ICE blog.)

Collaborating with people you are far from requires an extra bit of discipline. These strategies and use of technology allowed us to be efficient. The publishing date is 2015 which makes it seem like this was a 2 year project however, the actual time from idea conception to completion (acceptance to CJEM) was about 9 months…coincidence? ;)   I think not.

Team Management

  • Clear expectations: Every contributor knew what their role was. All had a job and everyone was aware at the outset that this project was going to maintain momentum. All involved bought into that approach.
  • Hard deadlines: Whether it be survey creation, data analysis, paper writing or editing deadlines for completion/feedback were set and respected (see clear expectations above). There were no cases of manuscripts sitting in inboxes for months just waiting to be “gotten to”.
  • Structure: We largely communicated by email with individuals responding in a very timely fashion. The few times (three maybe?) that we we met virtually as a group  it was with purpose and structured. We all came prepared and left with tasks. Follow up for tasks was performed by email.

Harnessing Technology

To employ these team management strategies we leveraged a number of technologies to improve communication to facilitate working at a distance.

  • Email: Our primary method of communication was email with a group thread. It was alright, but maybe not the best group messaging system (see next section).
  • Conferencing: we used Skype but again I think there are better options like Google Hangouts.
  • Google docs: We used this at the beginning for brain storming but found that once we were making more complex edits to surveys and manuscripts that the review functions on Word were better. I do believe the functionality of track changes has improved since we were using this google docs.
  • Shared dropbox folder: Here we stored pdf references, draft manuscript versions and images.

For Next Time

When considering working on a project at a distance again, there are many things that I would do exactly the same. The team structure and function was gold but some aspects of our workflow could be improved. I would:

  • Consider using Slack for communication. This app allows teams to communicate efficiently and if you are managing multiple projects with multiple teams the advantage becomes having all of those centralized in one place!
  • Use Google Hangouts instead of Skype. It has easily accessible features that allow sharing of a desktop view to multiple people, which could have allowed us to review the manuscript/images in real time. If we had used Hangouts I also probably would have recognized Joeseph at the CaRMS social because it allows videoconferencing with multiple users, instead of the voice-only functionality of Skype when in a group.

I would also suggest that budding academicians consider the publishing time of the journal to which you submit. Our project was completed within six months of starting, accepted within nine months but not published until about two years after we began. Given the nature of the subject matter we studied, this delay compromises the validity of our findings.  We are hopeful, however, that given CJEM’s recent transition to online publication this lag time will be reduced!

I really look forward to sharing a beer with these awesome team members at CAEP 2015 to celebrate our completed work! We hope that this post might clarify what working with a geographically distanced team looks like. So go out, find your dream team and keep progressing the field!

Have questions please ask below!  You can also reach me via the CJEM Facebook page (www.facebook.com/cjemonline) where I will be answering questions about this article in the coming weeks.

 

NB: The project described in this blog post has been recently published in the Canadian Journal of Emergency Medicine.  

The citation is:  

Purdy E, Thoma B, Bednarcyzk J, et al. The use of free online educational resources by Canadian emergency medicine residents and program directors. 2015 CJEM 17(2):101-106.

Read the article here.

View the official CJEM infographic for this paper below!

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post Behind the Scenes: doing research at a distance appeared first on BoringEM and was written by Eve Purdy.