Presentation and outcomes of necrotizing soft tissue infections.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) are aggressive infections associated with significant morbidity, including amputation and organ failure, and high mortality. The rapid progression and significant risk of morbidity and mortality associated with NSTIs makes quick diagnosis and treatment critical. The objective of this study was to determine the presentation of patients diagnosed with NSTIs and their in-hospital outcomes. METHODS: This was a retrospective review of adult (>17 years) patients with a discharge diagnosis of necrotizing fasciitis at London Health Sciences Centre (annual census 125,000) over a 5-year period (April 2008-March 2013). RESULTS: Sixty patients with confirmed NSTI were included in this study. Common comorbidities at presentation included immunocompromise (58.3%), diabetes mellitus (41.7%), vascular disease (45.0%), and obesity (24.6%). Initial presentations included swelling (91.7%), erythema (86.7%), bullae (28.3%), petechiae (8.3%), and bruising (45.0%). Fifty (83.3%) underwent surgery, with a median (interquartile range) time from initial emergency department presentation to surgery of 15.5 hours (7.8, 74.9). In-hospital mortality among those who had surgical intervention was 14.0%, compared to 60.0% for patients who did not have surgery (Δ46.0%; 95% CI: 14.8% to 70.2%). CONCLUSION: Diabetes mellitus, immune-compromise, vascular disease, and obesity are common comorbidities of NSTIs. Survival is higher among patients who receive surgical treatment. Patients presenting with this clinical picture warrant a high degree of suspicion.

Residents as teachers: survey of Canadian family medicine residents.

OBJECTIVE: To examine Canadian family medicine residents' perspectives surrounding teaching opportunities and mentorship in teaching. DESIGN: A 16-question online survey. SETTING: Canadian family medicine residency programs. PARTICIPANTS: Between May and June 2011, all first- and second-year family medicine residents registered in 1 of the 17 Canadian residency programs as of September 2010 were invited to participate. A total of 568 of 2266 residents responded. MAIN OUTCOME MEASURES: Demographic characteristics, teaching opportunities during residency, and resident perceptions about teaching. RESULTS: A total of 77.7% of family medicine residents indicated that they were either interested or highly interested in teaching as part of their future careers, and 78.9% of family medicine residents had had opportunities to teach in various settings. However, only 60.1% of respondents were aware of programs within residency intended to support residents as teachers, and 33.0% of residents had been observed during teaching encounters. CONCLUSION: It appears that most Canadian family medicine residents have the opportunity to teach during their residency training. Many are interested in integrating teaching as part of their future career goals. Family medicine residencies should strongly consider programs to support and further develop resident teaching skills.

Knowledge of CanMEDS-Family Medicine roles: survey of Canadian family medicine residents.

OBJECTIVE: This study evaluates the self-perceived awareness of the new CanMEDS-Family Medicine (CanMEDS-FM) roles by family medicine residents. DESIGN: A 22-question online survey. SETTING: Canadian family medicine residency programs. PARTICIPANTS: All residents enrolled in a Canadian family medicine residency as of September 2010 received the survey between May and June 2011. A total of 568 residents participated. MAIN OUTCOME MEASURES: Survey respondents indicated their awareness of, their exposure to, and the perceived importance of the CanMEDS-FM roles. RESULTS: The survey response rate was 25.1%. In total, 88.9% (463 of 521) of family medicine residents were aware of the CanMEDS-FM roles; there was no statistically significant difference in awareness between first- and second-year residents. Family medicine expert and communicator were most frequently chosen as the most important CanMEDS-FM roles, while manager and scholar were selected the least often. Overall, 76.4% of family medicine residents thought that their core family medicine teaching was guided by CanMEDS-FM, while 41.8% thought the same about off-service rotations. CONCLUSION: It appears that most family medicine residents are aware of the CanMEDS-FM roles. While core family medicine training and evaluation seem to be grounded in CanMEDS-FM, residency program directors should endeavour to ensure that the same principles apply during off-service rotations.

Challenges of multisite surgical teaching programs: a review of surgery clerkship.

OBJECTIVE: As the enrollment in medical schools increases, the need for affiliated sites to participate in clerkship teaching will continue. The aim of this literature review was to provide a summary of measures that have been used to compare the training in affiliated community hospital sites with the tertiary teaching hospitals. METHODS: An extensive literature search was conducted using PubMed, MEDLINE, and EMBASE. A total of 386 articles were identified, of which 20 were found to be relevant to this topic. The references of those articles were also consulted and were included in the preparation of this manuscript when deemed appropriate. RESULTS: A significant difference does not seem to exist in either written examination or clinical performance evaluations among medical students who receive training at either tertiary care teaching hospitals or affiliated community hospital sites. Positive role models are important in influencing the choice of a surgical career, regardless of where clerkship training takes place. CONCLUSIONS: Although more research is merited in this area, the current evidence suggests that affiliated sites are comparable in their ability to train medical students during their surgical clerkship.

Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature.

INTRODUCTION: The shoulder joint is the most commonly injured major joint in patients who present to the hospital emergency department today. In the community the incidence of shoulder joint injuries is 11.2 cases per 100,000 person-years. Traditionally, procedural sedation and analgesia (PSA) has been used to facilitate the reduction of anterior shoulder dislocations. However, there are risks of complication, such as respiratory depression, particularly in certain populations. As such, the use of intra-articular lidocaine (IAL) has been suggested as an alternative method of analgesia. METHODS: We searched EMBASE (Ovid) and MEDLINE (PubMed) databases using the keywords "shoulder, dislocation, and/or reduction" from the respective start dates of the databases until October 2008. RESULTS: Based on the current literature, it appears that the IAL method provides, at a minimum, the same level of pain control and reduction success as the procedural sedation method, while markedly reducing the time spent by the patient in the emergency department and the cost of treatment. The likelihood of complications is arguably less with the use of IAL. CONCLUSION: Although more research is this area is merited, physicians may consider IAL as an alternative to PSA in the management of anterior shoulder dislocations.

Can food banks sustain nutrient requirements? A case study in Southwestern Ontario.

BACKGROUND: Concerns about adequate food supply is a mounting problem in Canada, making food bank visits a necessity for over 820,000 Canadians. Given this reliance, the purpose of this study was to compare contents of food hampers with Canadian guidelines, at a large urban food bank in Southwestern Ontario that intends to provide 3 days worth of food per person. METHOD: Thirty hampers of each available size (for 1-6 people) were sampled (N = 180). Food items were recorded and analyzed for caloric value, food group, and macro- and micro-nutrient values. Results were compared to Dietary Reference Intakes (DRI) and Canada's Food Guide to Healthy Eating. RESULTS: 99% of hampers did not provide 3 days worth of nutrients. Grains and cereals met the lower range of Canada's Food Guide recommendations, and fruits and vegetables, meats and alternatives, and dairy products were below recommended levels, as were numerous vitamins and minerals, including vitamins A, D, B12, C, riboflavin, niacin, calcium, magnesium and zinc. Carbohydrates were slightly above recommended DRI, and energy from fat and protein scarcely met the minimums recommended. Hampers contained 1.6 days worth of energy per person. DISCUSSION: The energy available per person was below recommendations for most Canadians. Nutrients missing from the hampers can come from fresh fruits, vegetables, dairy products, and meats and alternatives. However, many low-income families have limited finances to purchase these foods which are relatively more expensive than processed foods. Encouraging more perishable food donations and storage facilities to maximize the nutritional intake for clients is imperative.

Competing with Crohn's disease: management issues in active patients.

Crohn's disease is a chronic inflammatory bowel disorder that has genetic and environmental risk factors. Although moderate physical activity seems to reduce the risk of developing Crohn's disease, some high-performance athletes live with the disease. Uncontrolled Crohn's disease predisposes patients to numerous nutrient deficiencies and associated health issues such as anemia and osteoporosis. Low-intensity exercise has been shown to decrease flare-ups in sedentary patients; however, high-intensity exercise may lead to increased symptoms. Physicians play a crucial role in coordinating a team approach among the athlete, parents, coach, and athletic trainers to provide the best possible management of diet, training schedule, and treatment.