Don't over-complicate it

Good reminder (for some this may be new!) on overuse of an important test. Thanks to Journalwatch for this read.

Blood Cultures (Still) Not Indicated for Uncomplicated Skin Infections Daniel J. Pallin, MD, MPH Reviewing Torres J et al., Am J Emerg Med 2017 May 26; Even with selection bias and inclusion of injection drug users, this single-center study found that only 7% of blood cultures in admitted patients were positive.

Blood cultures are positive in about 4% of all comers with cellulitis. In a prospective, observational, single-center study, researchers assessed the rate of positive blood cultures in admitted patients with skin and soft tissue infections, and in the subsets with injection drug use or fever. Importantly, the investigators did not determine who would undergo blood cultures. Of 246 admitted patients with skin infection, 86 (35%) had blood cultures, and 7.0% of cultures were positive. Among the 29 blood-cultured patients who were febrile, 3.5% had positive blood cultures. Of 101 admitted patients who were injection drug users, 46% had blood cultures, and of these, 8.7% were positive. Comment This study is difficult to interpret because the investigators did not determine who underwent blood cultures, and it is likely that sicker patients were the ones who did; moreover, inclusion of only admitted patients enriched the sample for sicker patients. Therefore, the results represent upper limits for blood culture positivity. Blood cultures should never be done for patients with uncomplicated cellulitis, whether admitted or not, and fever is not an indication. For admitted patients with cellulitis and injection drug use, blood cultures may be a reasonable option. Don't forget that cellulitis complicating lymphedema often results in bacteremia, and cultures are indicated in this group. Of course, blood cultures are indicated for septic patients and those with suspected necrotizing soft-tissue infection.

Webucation 30/6/17

Webucation this month comes from the realms of trauma, cardiology. paeds and tests our "mythos" on cardiac arrest management! All credit to the original content providers.

• Pressing those veins
• Is Amiodarone dead?
• Ultrasound in paediatric trauma
• Egg white for sepsis?
• REACTing to REACT2
• The bamboo flute chest drain technique

• Is "A" really top of the treatment list?

The last link should make you wonder - are you really doing the right thing? LMAs that are inserted by ambulance personnel in the Singapore system are more than adequate. 

So things to focus on include:

• High quality CPR
• Reducing the over-oxygenation
• Using ETCO2 and U/S to guide your resuscitation
• Engaging reperfusion strategies early
• Replacing the tube when pendulum of stability has swung your way.

The New Antibiotic Mantra—“Shorter Is Better”

This is a post by Dr Ang Shiang Hu.

In line with the drive for "less is more", sometimes, "shorter is better" too.

Infections in which a shorter course of antibiotics has been shown to be equivalent to longer "standard" courses:

Reference here: JAMA Internal Medicine September 2016 Volume 176, Number 9

Webucation 7/2/16

A Happy Lunar New Year to asian readers. Wisdom from the world this edition comes from specialities of trauma to tox and even some nerd evidence thrown in at the end. Do view and credit the original content creators.

• A metric not supported by evidence - Should you be judged by the hour?
• Ultrasoundoftheweek - Great point about lung point.
• Adult educational theories - Theories for everything.
• Necrotizing fasciitis pearls n pitfalls - Air in my flesh, it must be bacteria.
• Trauma for all ages - Any country left for old men?
• Single dose activated charcoal - Not all black and white it seems

• Alarm alarm! - Alarming stats with negligible impact

The last link is once again superb dogmalysis. Tech does not solve ALL our problems. Some we bring onto ourselves.

Sepsis SMACC-down panel.

This is a long one but worth it for broad concepts which are not discussed everyday. This panel comprises of the leading minds in sepsis research and information dissemination. It also demonstrates that we don't know as much as we think we know and are far from consensus on the subject even in 2015. 
Thanks to the SMACC team for the plenary panel vid.

Webucation 10/6/14

Web wisdom this time comes from the realms of microbiology, paeds, radio and even some good ol' pharmacology. Remember to support the original content providers.

• 5 CC articles - The Rebel EM gives us his top establishment studies!
• The culture in cellulitis - ALiEM lyses a great myth regarding cultures in cellulitis. 
• Ketamine analgesia - I know, I know... Another article on ketamine? Have you read our blog title?
• DKA myths - The EM Swami on modern DKA management and the mistakes that some Drs make.
• Routine pre-op - Test yourself. Can you spot it?
• Little commotio cordis - Heart stopping hits from Paeds EM Morsels.

• Log roll finger bum ? - More dogmalysis on a topic we've been trying to bury for a decade now. Is it really necessary to rectally relieve ALL or ANY of your patients???

The last point mirrors our opinion as well. I cannot recall doing a DRE on a conscious, neurologically intact patient for years... its time we all spread the myth-busting surrounding the anal abuse in EDs! 

Webucation 29/3/14

We're happy to be back and we bring you some tasty bits of med-ed from the realms of paeds, ob/gyn, surgery and even some philosophy. Credit as always to the content creators.

• Shock in early pregnancy - Chris Cresswell's excellent pathway/guide for bleeding in early pregnancy
• Neonatal analgesia - Should children really be deprived of this based on whim?
• Abc easy as 123? - Ryan Radecki asks is ABCD3 is what you need
• Is it just culture? - Do we really need to keep doing this for everyone? ... Bug bear of mine.
• A what lesion? - The Trauma Pro shows us a lesser known disease. 
• Under the dome - Why is the dome gone?
• More TPA debate - great debate on stroke lysis. Pros and cons all laid out for you.
• Dogmalysis - Cliff Reid's homage to myth busting.

The last link is close to our hearts. We deal with such "traditions" day in/day out. We thank such innovators in bringing to light the remedies in such scientific form.

Webucation 9/3/14

Lots of kids and imaging pearls in our dive into web resources this time.

• Hit the nail on the head - Ryan Radecki asks if some hammering antibiotics are really necessary?
• Score 1 for the HEART -  Salim wonders if we should be moving on with our risk stratification tools
• No need for speed - Excellent tutorial on subtle injuries on CT in high velocity accidents
• Leave those kids alone! - Scancrit talks about the insult to injury by irradiating kids
• Imaging at Emergucate - Pop goes the weasel's hip?
• The 1-2-3 of..? - Can you spot this pathology at Radiopaedia
• Ouch it hurts down there - A great Morsel on ovarian torsion in children.

Radiation bomb - Scancrit drops the bomb on spinal immobilisation. We say about time to! We are once again grateful for such myth busting. While we are on that trail ,common sense also tells us that lying on a metal trauma board in the trauma resus bay with a collar and no neck support is NOT THE NORMAL ANATOMICAL POSITION.... so why do we persist? 

Probiotics fail the evidence triangle

I have heard seniors tell me about the use of probiotics in preventing antibiotic related complications like C.diff infection and diarrhoea. Sounds simple enough, theoretically sound, and supported by good evidence.

Several meta-analyses purported the benefits of probiotics:

• Hempel et al. JAMA. 2012 May 9;307(18):1959-69
• Johnston et al. Ann Intern Med. 2012 Dec 18;157(12):878-88
• Goldenberg et al. Cochrane Database Syst Rev. 2013 May 31;5:CD006095.

Now, meta-analyses sit right at the top of the evidence triangle; the pinnacle of evidence based medicine. Or is it?

The authors of the JAMA article noted that while probiotics are associated with a reduction in antibiotic related diarrhoea, there exists significant heterogeneity in pooled results. Similarly, the Annals of Internal Medicine article also suffers from significant clinical heterogeneity as a limitation, a caveat rightly pointed out by the folks at NNT.com.

We all know that if you take a bunch of lousy studies and pool all the results together in a meta-analysis does not make the end result any better. Listen to the folk from SmartEM talk about thrombolytics in stroke and you'll get a fair idea.

A well conducted study, randomised controlled and properly blinded, will mostly provide a better answer. Thankfully, there is just that study done, the PLACIDE trial, recently published in Lancet 2013 Aug 8 (e-pub ahead of print).

• Allen SJ et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): A randomised, double-blind, placebo-controlled, multicentre trial. 

In this UK study, 2941 older patients (age >65) who were about to start or recently were exposed to systemic antibiotics in five hospitals, were randomized to receive single capsules that contained either a multistrain preparation of Lactobacilli and Bifidobacteria, or placebo once daily for 21 days.

According to the accompanying editorial, the study was rigorous, there was central randomisation, with placebo control, good allocation concealment, and thorough follow-up was performed to identify antibiotic-related or C.diff diarrhoea. It was the largest trial to date to examine this topic in detail, the only fault of the trial being a lower than predicted event rate marring the confidence intervals.

It is then no wonder that the result of this RCT is actually negative for probiotics: the rate of antibiotic-related diarrhoea as well as C.diff diarrhoea were similar in the probiotic group versus the placebo group. So we can all say, at least in older patients > 65 years of age, probiotics given alongside antibiotic therapy, do not reduce the risk of antibiotic-related diarrhoea or C.diff diarrhoea.

For now, at least according to the Journal Watch reviewers, hand washing and antibiotic stewardship remains key.

Webucation 14/6/13

A slew of paediatrics around the web giving great advice. Also in the mix is some trauma imaging and tox for good measure. As always credit to the original authors and do visit their site.

• Digoxin-mag relations - A reminder to not only worry about K levels but Mg levels as well
• Ankle of the week- The docs at Emergucate show us a nice ankle case
• Nice-fever-guidelines-for-kids/  - Guidelines are always appreciated. Use what is relevant to your practice
• Thenar based eminence bagging - A novel way of bagging which could help you in tricky times
• Weights estimation necessary? - St Emlyn's argues that estimation is just that. Nothing preps like real weight!
• Change of CULTURE - Whats with all the culturing seriously?

The last link to Ryan Radecki's site is a must read and we fully appreciate the sentiment. It is something shared all over the world. Over investigation with no real change of management resulting from it. We understand that surveillance is warranted in some diseases by the pathologists but surely it is time to call a simple ceulluitis or chest infection (not from the middle east of course!) just that. 

We're all guilty!

We've all done it in our careers. To be fair most of  us correct our mistakes. Some learn through good mentors, some learn through reading the papers, some even learn it off TV.
The truth is that we should be wary of the greater picture of antibiotic resistance and ineffectual remedies which do not target the pathology.
Here's a great article and the links below are for people who have access.
Do the right thing folks.

Medscape link
NIH link

Over-prescribing of Antibiotics and Imaging in the Management of Uncomplicated URIs in Emergency Departments

K Tom Xu, Daniel Roberts, Irvin Sulapas, Omar Martinez, Justin Berk, John Baldwin

Abstract

Background Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers' compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US.

Methods Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age < 18 or >64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies.

Results In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors.

Conclusion Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.

Webucation 19/5

Been away for a few weeks on a course. The web has been active though and here's more than a few good articles to ponder over.

• How-marriage-works-in-medicine - interesting read for those in and around wedlock and even more interesting for those not "locked"
• Ringer's ain't great...again. - not as much volume expansion as you once thought
• FOOSH again - excellent revision on a not so common wrist injury from Emergucate
• PTX aspiration - great video by NEJM on needle aspiration of pneumothorax of you have not seen one before.
• Don't ignore naughty parts! - the trauma pro talks about not ignoring stuff down below
• Macrolides and CCBs - do they interact and cause shock?
• LUL collapse - we agree that its probably the hardest collapse to see on CXR
• Microbiology pearls - truly one of the best write-ups we have seen recently. What every hospital doc should know about those pesky microbes and what really happens. We cannot recommend this link enough.

Webucation 12/4/13

Myriad of topics ranging from social media to ultrasound to heart tracings. Enjoy and remember to credit the content originators.

• ECG of the week - new squiggly conundrum at JL's site
• All trials - a solid intiative to try and get transparency for the good of mankind.
• How-much-of-a-social-media-profile-can-doctors-have? - self explanatory
• Gentamycin dosing - something to remember next time you dose someone.
• U/S tips on the RUQ - morrison's view from the masters down under

Webucation 5/4/13

The goodness from the web this week includes excerpts from kids to ecgs to iodine dye.

1. Critical paediatric procedures  - how much to trainees really get to do?
2. Knee xray - Trevor Jackson goes through a not uncommon knee xray finding
3. Periorbital cellulitis - the ins and outs of this common paediatric condition
4. All about iv-contrast  - Rob Orman gives a comprehensive podcast on all things contrast
5. ECG of the week - as it says, get your weekly heart rhythm fix here

Remember to spread the education and support the original authors.

Primary closure for I&D of cutaneous abscesses?

In the recent issue of Acad Emerg Med, Singer et al did a randomised controlled trial of primary versus secondary closure (healing by secondary intention) of skin abscesses.

• Singer AJ, Taira BR, Chale S, Bhat R, Kennedy D, Schmitz G, Zehtabchi S. Primary versus secondary closure of cutaneous abscesses in the emergency department: A randomized controlled trial. Academic Emergency Medicine 2013, Jan;20(1):27-32.

Of note, as mentioned in the opening paragraphs of this article, this is not a new concept. There are quite a few studies which described primary closure after I&D leading to faster healing than secondary closure, and are just as safe. The caveat is, the majority of these studies are done in the OT by surgeons, under GA, and involve mainly the anogenital region.

What this latest study show, is that primary closure of garden variety skin abscesses seen in an ED, is non-inferior to secondary closure. The healing rate and treatment failure rate as defined by the authors were similar. Of note, these were small abscesses, patients with significant cellulitis (>5cm) were excluded, as well as immunocompromised patients or DM patients. Also, I&D done under procedural sedation were excluded.

The limitations described by the authors were;
- selection bias (big, angry looking abscesses were excluded).
- small study – not sufficiently powered to detect differences in primary outcome.
- small abscesses thus only small incisions were performed. If large abscesses with longer incisions were made, the difference may be significant.
- limited followup of 7 days.

Take home:
Primary closure of I&D wounds may not be as bad as you think. There is certainly a role for this, especially in larger abscesses or abscesses in areas where cosmetics is of concern. Patient selection or preference may help to select successful outcomes when primary closure is performed. The authors also note an interesting point made in an earlier study: packing may not be necessary after all in wounds left to close secondarily; less painful and heals just as well.

• O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscess is painful and probably unnecessary. Acad Emerg Med. 2009; 16:470–3.

However, it is worthy to note that in larger abscesses, there is also the loop incision and drainage technique, first described in this pediatric study.

• Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: A minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg 2010, Mar;45(3):606-9.

Anecdotal reports suggest its efficacy in adult patients as well. So there you have it, three dogma changing possibly practice changing points in therapy of skin abscesses in the ED.

1. Primary closure works just as well, possibly better than healing by secondary intention.
2. Wound packing is probably unnecessary.
3. Loop incision and drainage is a good option for large abscesses.

Finally, a youtube video of the loop I&D technique; enjoy!

Gotye medical rant

Hilarious and intellectually satisfying at the same time. Kudos to James McCormack for this.

The danger of science denial

Something different but we all need a rallying call every now and then against the forces of ignorance.
This is a talk from TEDed - the education aspect of the superb TED talks series. He is not a doctor but he puts across his well thought out medical argument very well. The highlight for me was "Big Placebo".

Maybe one day we will have critical mass to get us to the next phase of planetary evolution. Meanwhile, educate away.

Bugs below

This is a great run down by Dr Rob Orman of ERCAST on infections and abscesses of the not so palatable kind.
An essential talk on a much ignored topic.
Also interesting the evidence on antibiotics near the end.

A-primer-on-butt-pus

The Case of the Mysterious Rash

A 58 year old Chinese Missionary without any chronic co-morbidity or drug allergies, presented to our ED with an intensely itchy rash to his feet and body after recent travel to Tanzania a week ago.

His vital signs were stable and there was no fever or constitutional upset.

Morphology of the rash on his foot, as per photograph shown below -

Q1. What is the diagnosis?

Q2. What is the causative agent?

Q3. What is the commonest presentation?

Q4. What is the management ?

Q5. How can it be prevented?

Fight the bugs!

The new sepsis guidelines are out and every emergency doc worth their salt needs to know the ins and outs. Speaking of salts - the hypertonic saline debate has finally been put to rest - don't bother with it.
The energizer bunny that is Scott Weingart has already done a comprehensive summary here for those without the time to read the whole thing:
Full pdf file is here for sharing.