1 00:00:05,190 --> 00:00:05,890 Sara Dong: Hi, everyone. 2 00:00:05,930 --> 00:00:10,089 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:10,569 --> 00:00:15,420 We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. 4 00:00:16,040 --> 00:00:18,939 I'm Sara Dong, your host and a MedPeds ID doc. 5 00:00:19,179 --> 00:00:22,300 Welcome to the very first Febrile StAR episode. 6 00:00:22,310 --> 00:00:28,990 These will feature topics and authors from the CID, so Clinical Infectious Diseases Journal State of the Art Reviews. 7 00:00:29,740 --> 00:00:38,690 You can listen to our last episode, number 97, to hear from the editors of these reviews, and we'll be bringing you four straight weeks of star episodes to kick this off. 8 00:00:39,530 --> 00:00:41,510 I'll introduce our guest stars today. 9 00:00:41,800 --> 00:00:42,200 Dr. 10 00:00:42,200 --> 00:00:50,350 Meghan Brennan is an infectious diseases physician and health services researcher at the University of Wisconsin with a joint appointment at the VA hospital. 11 00:00:50,430 --> 00:00:52,050 Meghan Brennan: Hi, my name is Meghan Brennan. 12 00:00:52,740 --> 00:00:53,410 Nice to be here. 13 00:00:53,830 --> 00:00:54,170 Sara Dong: Dr. 14 00:00:54,170 --> 00:00:59,960 Marcos Schechter is an infectious diseases physician and assistant professor at Emory University School of Medicine. 15 00:01:00,585 --> 00:01:02,214 Marcos Schechter: Hi, my name is Marcos Schechter. 16 00:01:02,515 --> 00:01:07,604 I'm an infectious disease at Emory, practice at Grady in downtown Atlanta and good to be here with the crew. 17 00:01:07,925 --> 00:01:08,264 Sara Dong: Dr. 18 00:01:08,264 --> 00:01:18,285 Tze-Woei Tan is an Associate Professor of Clinical Surgery and Director of the Limb Salvage Research Program at Keck Medicine of the University of Southern California, USC. 19 00:01:18,664 --> 00:01:22,045 He is double board certified in vascular surgery and general surgery. 20 00:01:22,335 --> 00:01:23,775 Tze-Woei Tan: Hi, my name is Tze-Woei. 21 00:01:24,475 --> 00:01:26,755 I am a vascular surgeon at USC. 22 00:01:26,875 --> 00:01:27,605 Happy to be here. 23 00:01:28,385 --> 00:01:28,685 Sara Dong: Dr. 24 00:01:28,685 --> 00:01:41,695 David Armstrong is professor of surgery with tenure also at Keck Medicine at the University of Southern California, and he is an internationally recognized leader in the field of podiatry, diabetic foot, limb preservation, tissue repair, and wound healing. 25 00:01:42,115 --> 00:01:59,225 David Armstrong: I'm David Armstrong, I am a professor of surgery, a toe doctor at the Keck School of Medicine of University of Southern California in beautiful, sunny Southern California where even when it's not sunny, oh it's sunny, it's sunny. 26 00:01:59,680 --> 00:02:03,080 Sara Dong: Uh, well, thank you guys all for joining. 27 00:02:03,090 --> 00:02:08,989 Before we talk about medical things, though, uh, Febrile is everyone's favorite cultured podcast. 28 00:02:09,160 --> 00:02:15,800 So we always ask our guests to share a little piece of culture that brings you happiness, basically just something, uh, non medical. 29 00:02:16,180 --> 00:02:17,259 So I'd love to hear it. 30 00:02:17,954 --> 00:02:19,575 What, what kind of interest do you guys have? 31 00:02:21,495 --> 00:02:27,565 Meghan Brennan: It's spring here in Wisconsin, so I was thrilled to see my first robin last week. 32 00:02:28,384 --> 00:02:28,885 Sara Dong: Very nice. 33 00:02:29,315 --> 00:02:46,605 Marcos Schechter: Um, it's funny, in the era of podcasts, I stopped listening to music for a while, but I've rediscovered music recently, and I've been listening a lot to an album called 1988 by a pianist called Michel Camillo, who is a jazz guy, and I used to listen to that album from my dad's records. 34 00:02:47,215 --> 00:02:51,075 Just listening to that guy has been really good and getting myself back into music's been nice. 35 00:02:51,625 --> 00:03:04,574 David Armstrong: Well, I've loved podcasts since they were actually on Short Wave, and actually one of my favorite podcasts is still one of the oldest and it's with a guy named Melvyn Bragg, uh, and I would tell everyone to go out and grab this. 36 00:03:04,784 --> 00:03:06,764 It's called "In Our Time" and it's on BBC. 37 00:03:06,764 --> 00:03:17,424 It used to be on the BBC home service, Radio 4, and I used to listen to it way back in the day in the 90s and 2000s, um, and, uh, they've had over 1, 000 podcasts now. 38 00:03:17,884 --> 00:03:22,934 And the last one just yesterday, every Thursday at 9 a. 39 00:03:22,934 --> 00:03:23,264 m. 40 00:03:23,354 --> 00:03:25,904 Greenwich Mean Time, they broadcast them. 41 00:03:26,534 --> 00:03:35,884 It could be anything from, uh, particle physics to yesterday was Alice's Adventures in Wonderland, talking about Charles Dodgson. 42 00:03:36,304 --> 00:03:44,194 Uh, also known as Lewis Carroll, uh, and he has one of my favorite quotes, which is, uh, don't just do something, stand there. 43 00:03:44,524 --> 00:03:52,344 And I think when we stand there and we regard what we do, a lot of what we do is pretty good, but some of the things we do, we could probably improve on. 44 00:03:52,969 --> 00:03:57,439 That's why it is the practice of medicine and surgery and nursing. 45 00:03:57,439 --> 00:04:09,439 And that's why, Sara, you put all these really smart and some of us less smart characters to try to mix it up in the Petri dish, uh, or at least the sonic Petri dish. 46 00:04:09,479 --> 00:04:10,219 So here's to that. 47 00:04:11,149 --> 00:04:12,189 Sara Dong: Excellent references. 48 00:04:12,189 --> 00:04:15,389 And closing us out, Tze-Woei. 49 00:04:15,939 --> 00:04:17,379 Tze-Woei Tan: I enjoy traveling. 50 00:04:18,079 --> 00:04:20,129 Uh, I enjoy experience different cultures. 51 00:04:20,879 --> 00:04:24,849 And I actually also, uh, enjoy listening to Dr. 52 00:04:24,849 --> 00:04:28,019 Armstrong talking so that all of us don't have to talk too much. 53 00:04:30,299 --> 00:04:34,789 David Armstrong: Tze-Woei, why say it in two words? 54 00:04:35,479 --> 00:04:35,749 Dr. 55 00:04:35,749 --> 00:04:37,659 Tan, when you can say it in 200, that's what I say. 56 00:04:40,599 --> 00:04:41,639 Sara Dong: Oh, well, thank you. 57 00:04:41,649 --> 00:04:43,749 We got some good recommendations. 58 00:04:43,849 --> 00:04:44,909 So you all are on the show. 59 00:04:44,909 --> 00:04:57,839 I want to thank you for creating this article, so State of the Art Review: evaluation and management of diabetes related foot infections, which I know brings together ID, endocrinology, podiatry and vascular surgery. 60 00:04:57,919 --> 00:05:08,519 And I have sort of a representative case, but I wanted to just start by having you share a little introduction or some perspective of the, I'm going to say DFI throughout the podcast. 61 00:05:08,699 --> 00:05:12,829 So everyone knows and the goals that you had when you were writing this review. 62 00:05:13,009 --> 00:05:35,839 Meghan Brennan: Well, I think a big selling point for me was to try to write a review that was more all encompassing and taking a step back from any one specific facet, because it really is like a puzzle piece and infectious disease and antibiotics is just one small part, uh, you can't treat the whole thing just from one discipline. 63 00:05:36,699 --> 00:05:40,099 Marcos Schechter: I was just excited to spend December at my mom's house. 64 00:05:40,099 --> 00:05:49,029 I was in Brazil sitting, you know, eating food over Christmas and I would log in and Nico, Jonathan, Megan, everybody would be there just typing and I would see their little thing that they were typing there. 65 00:05:49,569 --> 00:05:49,969 It's beautiful. 66 00:05:50,159 --> 00:05:53,409 David Armstrong: Oh man, you're making me wax nostalgic about churrascarias. 67 00:05:53,869 --> 00:06:01,029 I think that this problem is often a lemon on everyone's 10 most important things, you know. 68 00:06:01,419 --> 00:06:14,654 We have this problem that's often covered by a shoe at the end of the body, you know, the end of the anatomic peninsula, and folks often just ignore it until it's too often, too difficult to ignore. 69 00:06:15,104 --> 00:06:18,784 Coming together like this in an interdisciplinary way, I think, is really life affirming. 70 00:06:19,544 --> 00:06:24,784 Tze-Woei Tan: All of the people in this podcast talk about how much they hate amputation. 71 00:06:25,404 --> 00:06:34,314 I think I'm the only one that get to do the amputation, so I think, uh, if I don't have to do another amputation in my career, they'll be great. 72 00:06:35,044 --> 00:06:35,544 Sara Dong: Love it. 73 00:06:36,864 --> 00:06:44,854 So, I put together a sort of made up case, but just something to give us a chance to talk about a lot of the concepts that you covered in the review. 74 00:06:44,984 --> 00:06:46,804 So, we'll meet our patient. 75 00:06:46,814 --> 00:06:48,384 He's a 50 year old male. 76 00:06:48,714 --> 00:06:55,969 Has a long standing history of insulin dependent diabetes, hypertension, coronary artery disease, and CKD. 77 00:06:56,609 --> 00:07:00,789 He presents with about one week of left foot swelling and discoloration. 78 00:07:01,249 --> 00:07:03,779 You know, he says, I might've stubbed my toe in the past. 79 00:07:03,779 --> 00:07:04,899 I'm not really sure. 80 00:07:05,389 --> 00:07:16,809 His physical exam today shows cellulitis in his left foot extending to about the ankle, as well as an ulcer on the plantar surface of the fifth toe around the metatarsal head. 81 00:07:16,849 --> 00:07:19,789 And there is a small amount of purulent discharge. 82 00:07:20,814 --> 00:07:22,004 His vitals are stable. 83 00:07:22,224 --> 00:07:25,024 He is afebrile with a temp of 37. 84 00:07:25,044 --> 00:07:25,724 8 Celsius. 85 00:07:26,554 --> 00:07:28,994 The initial x ray is unrevealing. 86 00:07:29,384 --> 00:07:38,514 The initial peripheral pulses were not appreciated due to foot swelling, but a Doppler did show signal in the dorsalis pedis and posterior tibial arteries. 87 00:07:39,274 --> 00:07:50,804 On his labs, we have a leukocytosis with a white count of 17, 000, a sedimentation rate of 92, that's the millimeters per hour, CRP 200 milligrams per liter. 88 00:07:50,914 --> 00:07:55,484 His blood glucose is 200 and his A1c is 12.5%. 89 00:07:56,144 --> 00:07:59,354 And then I mentioned that he had CKD, his creatinine is 1. 90 00:07:59,404 --> 00:07:59,644 6. 91 00:08:00,514 --> 00:08:15,224 Uh, so I'm going to pause here first because you provide information in the article about how diabetic foot ulcers are classified and specifically the Society for Vascular Surgery's Wound Ischemia Foot Infection Classification System and really sort of framing it, 92 00:08:15,414 --> 00:08:18,674 particularly for, I think, us in ID. 93 00:08:18,674 --> 00:08:22,334 And so most of the Febrile audience is probably ID trainees and docs. 94 00:08:22,334 --> 00:08:28,584 And I would love sort of an introduction or perspective on using that classification system and any other thoughts you might have. 95 00:08:28,714 --> 00:08:32,994 David Armstrong: Well, since I'm farthest away from the center of the body, I'll get started. 96 00:08:33,064 --> 00:08:33,654 In the toes. 97 00:08:33,974 --> 00:08:39,614 So the reason that we use something like wound ischemia and foot infection or WIfI. 98 00:08:40,044 --> 00:08:44,619 People thought when we came up with that, uh, acronym that it was me that actually came up with the acronym, right? 99 00:08:44,619 --> 00:08:45,049 It wasn't. 100 00:08:45,089 --> 00:08:50,629 It was my flo-migo prime, Joe Mills, uh, who's now the President of the Society for Vascular Surgery. 101 00:08:51,149 --> 00:09:00,394 It was a real stroke of brilliance, but we often will compare this problem unfavorably, unfortunately, to cancer. 102 00:09:01,134 --> 00:09:03,724 Morbidity and mortality is similar to cancer. 103 00:09:03,904 --> 00:09:09,174 Cost, believe it or not, is more expensive than the five most expensive cancers in the United States. 104 00:09:09,524 --> 00:09:13,664 But we don't really talk about this problem, which can be profoundly life shortening like cancer. 105 00:09:13,664 --> 00:09:18,234 And so to do that, we wanted to try to create a common language, common language of risk. 106 00:09:18,234 --> 00:09:22,244 So with cancer, you know, you have tumor, node, metastasis, TNM. 107 00:09:22,484 --> 00:09:31,664 And you grade those, you know, a mild, moderate, severe for tumor node metastasis, and then you come up with your stage, um, and you can have some modicum of predictability. 108 00:09:32,154 --> 00:09:34,324 Same thing with WIfI. 109 00:09:34,524 --> 00:09:38,594 It's just wound, that's tissue loss, ischemia, and then foot infection. 110 00:09:38,594 --> 00:09:46,459 And so for the foot infection portion of it, this is the IDSA's classification that has been around now for a long time. 111 00:09:46,499 --> 00:09:59,349 Um, my friend Larry Lavery and I, we, we worked on about 20 years ago, validating that, um, after it was first described by Ben, my old long time buddy, Ben Lipsky et al, uh, a few years earlier. 112 00:09:59,559 --> 00:10:02,419 So that classification's in there, none, mild, moderate, severe. 113 00:10:02,479 --> 00:10:04,799 For the wound, it's just none, mild, moderate, severe. 114 00:10:04,969 --> 00:10:19,694 And for ischemia, it's none, mild, moderate, and severe, based on Uh, hemodynamics or tissue perfusion, take your pick, and each of those individually is predictive, but when you combine all of them, it's super predictive. 115 00:10:20,384 --> 00:10:26,244 And the other cool thing about it is that it helps us say, okay, what is dominant? 116 00:10:26,634 --> 00:10:30,239 Is this just a tissue loss dominant, just a wound dominant condition? 117 00:10:30,449 --> 00:10:31,589 If that's the case, great. 118 00:10:32,019 --> 00:10:33,109 Just take care of the wound. 119 00:10:33,179 --> 00:10:34,609 Patient doesn't need to be in hospital. 120 00:10:34,799 --> 00:10:35,739 We can protect the wound. 121 00:10:35,769 --> 00:10:36,659 We can offload it. 122 00:10:36,729 --> 00:10:37,549 We can debride it. 123 00:10:37,619 --> 00:10:39,609 We can skin graft it as we need to. 124 00:10:40,269 --> 00:10:45,449 If it is an ischemia dominant condition, well, that is the purview of Professor Tan. 125 00:10:45,779 --> 00:10:47,349 Uh, one improves the flow. 126 00:10:47,539 --> 00:10:49,309 Um, and then of course the patient can be discharged. 127 00:10:49,709 --> 00:10:55,419 Or if it's a foot infection, an infection dominant condition, then that needs to be taken care of. 128 00:10:55,644 --> 00:11:08,934 Typically, the infection, you'll be happy to know all of you in ID, culturally, it typically supersedes all of the other problems like tissue loss and ischemia, generally speaking. 129 00:11:10,104 --> 00:11:15,784 But the complicating part of this is that they're all together, like a big Venn diagram of bad. 130 00:11:16,164 --> 00:11:18,334 And it's always changing. 131 00:11:18,774 --> 00:11:28,499 And the key is to be able to communicate this to your flo-migos, and your toe-migos, uh, as, uh, as infectious disease doctors, uh, with your entire team and the family. 132 00:11:29,009 --> 00:11:30,629 Um, and that's kind of the big enchilada. 133 00:11:30,779 --> 00:11:36,799 Tze-Woei Tan: I think there's a lot of adoption from vascular and podiatry for the WIfI classification. 134 00:11:37,189 --> 00:11:47,649 Since this is a podcast for the ID doctor, and I want to ask, you know, whether the system is used widely in the ID world and what are the, some of the barrier of using it? 135 00:11:48,104 --> 00:11:52,624 Meghan Brennan: So, I used to use Wagner and I did morph over to WIfI. 136 00:11:52,884 --> 00:12:01,924 I think Wagner was pretty easy from an infectious disease standpoint because it was so infectious centric. 137 00:12:02,324 --> 00:12:12,754 I like WIfI a lot because it helps me in particular pay attention to the ischemic portion that was definitely missing in Wagner. 138 00:12:12,774 --> 00:12:18,699 You know, they had a little bit of wound, but definitely wasn't taking into as much account for ischemia. 139 00:12:19,219 --> 00:12:41,699 And the way I kind of overcame it is I kind of looked a little geeky for a while, but I put that, you could almost cut out these tables and just post it above your, your computer screen or bring it up on a screen and figure out an image really quickly to reference and then just run through it and it's pretty, it's pretty self explanatory and pretty quick. 140 00:12:42,189 --> 00:12:46,209 And then it really does help create that, you know, as Dr. 141 00:12:46,209 --> 00:12:53,499 Armstrong would say, lingua franca between all the services so that everybody's on the same page much more quickly. 142 00:12:54,219 --> 00:12:59,449 Marcos Schechter: I, I would take even of a more proximal step about what Tze-Woei is asking. 143 00:12:59,839 --> 00:13:03,999 I think a lot of us don't even use the IDSA infection classification system. 144 00:13:04,009 --> 00:13:05,229 Let's just start from there. 145 00:13:05,739 --> 00:13:10,269 People look at an ulcer and they're like, bad, good, medium, right? 146 00:13:10,309 --> 00:13:12,279 And they say vanc[omycin] and zosyn (piperacillin-tazobactam) vs. 147 00:13:12,639 --> 00:13:15,869 IV versus oral, like, as if that meant anything. 148 00:13:15,929 --> 00:13:22,949 So I would say, even as a step back, if we just use the IDSA system to decide if something is infected or not, that would be so wonderful. 149 00:13:23,199 --> 00:13:27,699 And I actually have just a plugin for the Society of Vascular Surgery app. 150 00:13:27,709 --> 00:13:28,779 I have it on my phone. 151 00:13:29,359 --> 00:13:30,599 Has a WIfI calculator. 152 00:13:30,599 --> 00:13:31,679 I use it all the time. 153 00:13:31,739 --> 00:13:35,589 And here at Grady, we built it into Epic, too, so people can use it. 154 00:13:35,679 --> 00:13:37,269 Not that they do, but it's there. 155 00:13:37,609 --> 00:13:40,169 David Armstrong: Well, yeah, but you can also use a dot phrase. 156 00:13:40,634 --> 00:13:44,164 I can't believe I'm getting dot phrases into a podcast now. 157 00:13:44,424 --> 00:13:47,194 It's almost like, that must be a sign of the apocalypse. 158 00:13:47,699 --> 00:13:49,469 Or toe-pocalypse. 159 00:13:51,299 --> 00:13:57,619 Okay, but the point is the, uh, yeah, we just have a quick dot, dot wifi and it, uh, it puts it all out there. 160 00:13:57,619 --> 00:13:59,309 And then what we do is super easy. 161 00:13:59,429 --> 00:14:05,829 We just bold none, mild, moderate, severe for wound ischemia and foot infection. 162 00:14:05,859 --> 00:14:17,909 And by the way, you know, Marcos, if you're saying none, you were saying bad, medium, good, uh, well you have three quarters of the IDSA system there, it's none, mild, moderate, severe. 163 00:14:18,529 --> 00:14:23,499 So, just like, just like the ischemia and the foot infection, it's just 0,1,2,3 for all these. 164 00:14:23,509 --> 00:14:26,304 It actually is really simple and elegant. 165 00:14:26,504 --> 00:14:29,974 When you start using this kind of thing, you just want to ask, like, what's dominant? 166 00:14:30,064 --> 00:14:31,324 Like, what's the dominant problem? 167 00:14:31,624 --> 00:14:33,894 And so that's the way that our trainees communicate. 168 00:14:33,894 --> 00:14:35,884 They say, this is an ischemia dominant condition. 169 00:14:36,244 --> 00:14:38,264 This is an infection dominant condition. 170 00:14:38,304 --> 00:14:39,704 Oh, this is just tissue loss. 171 00:14:40,004 --> 00:14:47,384 Great, we can discharge the patient, but that's the kind of conversations that we see happening between ID, between vascular, between podiatry. 172 00:14:47,494 --> 00:14:57,444 Marcos Schechter: To your point, I think what I see the most in the hospital is ischemia and wound dominant conditions all become bad, and bad means vanc[omycin] and zosyn (piperacillin-tazobactam) right? 173 00:14:58,014 --> 00:15:01,894 Which in a patient with CKD is creating problems. 174 00:15:01,895 --> 00:15:20,360 David Armstrong: We just finished grand rounds that Tze-Woei just gave, and we had M& M before that, and in M& M, Uh, there were, there were several, I mean, obviously with vascular, there can be some real flow-tastrophes, as we say, and, uh, and one of the big ones that we were looking at was, uh, patients that ultimately had C. 175 00:15:20,360 --> 00:15:22,209 diff that was completely avoidable, right? 176 00:15:22,210 --> 00:15:32,780 If, uh, if there was a consistent interdisciplinary approach to looking after this patient's antimicrobial regime or no antimicrobial regime. 177 00:15:32,780 --> 00:15:51,785 And I think what a lot of people, especially non ID doctors, don't appreciate is that you can really hurt people with antibiotics and having respect for these things and don't just prescribe them to treat yourself, treat your patient, I think is the order of the day and, this is the way forward. 178 00:15:52,075 --> 00:15:54,595 Can I ask a quick question to you guys on the ID side? 179 00:15:54,685 --> 00:15:57,075 You know, why are we still using vanc? 180 00:15:58,025 --> 00:15:59,025 Marcos Schechter: It's great, man. 181 00:15:59,055 --> 00:16:00,435 It takes an hour and a half to infuse. 182 00:16:00,445 --> 00:16:07,755 Gotta check levels, causes AKI, and it, it's worse than any other antibiotic for bone and joint infections, how could I not use it? 183 00:16:10,065 --> 00:16:16,045 Sara Dong: Well, you guys are making the transitions very easy because I actually was going to throw it to our ID group. 184 00:16:16,115 --> 00:16:19,845 Obviously, we're going to talk about the different components of care here. 185 00:16:19,895 --> 00:16:24,515 So antibiotics, when indicated, surgery, other aspects of care. 186 00:16:24,515 --> 00:16:29,895 Meghan and Marcos, can you talk a little bit about, you know, we get the call on the ID side. 187 00:16:29,915 --> 00:16:31,935 Maybe you hear this patient scenario. 188 00:16:31,945 --> 00:16:33,935 What are you thinking about for infection? 189 00:16:34,195 --> 00:16:37,755 What should we reach for in, in empiric therapy? 190 00:16:37,805 --> 00:16:45,645 And kind of, I guess I should say your, your framework as the ID person and maybe ways that we could improve upon that, 191 00:16:45,695 --> 00:17:05,980 Meghan Brennan: well, the first thing I was gonna ask is whether or not this wound probed to bone, because I think a good, solid, physical exam is underappreciated, and especially in so many of these patients who are insensate, you know, you don't have to really pussyfoot around. 192 00:17:05,990 --> 00:17:13,220 You can go for it, um, and get in there with some sort of a probe and tell me, hey, does it hit bone or not? 193 00:17:13,720 --> 00:17:17,640 And right then we'll have a really good idea of whether this is osteomyelitis. 194 00:17:18,825 --> 00:17:30,565 Marcos Schechter: Yeah, I think this is a pretty interesting prompt because, you know, there's flirtations here that this patient has a significant cellulitis, which generally means we want to start antibiotics sooner than later. 195 00:17:30,565 --> 00:17:41,545 But there's also a hint that they may have osteo[myelitis] based on this ESR of 92, which also means that maybe we don't want to muddle the diagnostics if we ever want to get a bone biopsy. 196 00:17:41,795 --> 00:17:42,445 So I'm with Meghan. 197 00:17:42,445 --> 00:17:48,025 I think this is a case of, you know, let's, let's get a little more, the probe to bone is pretty important in this case. 198 00:17:48,025 --> 00:17:51,150 And as far as antibiotics, these are the ones that I find hard curbsiding. 199 00:17:51,150 --> 00:17:54,370 I don't curbside skin and soft tissue infection consults. 200 00:17:54,370 --> 00:17:55,210 I go and see them. 201 00:17:55,880 --> 00:17:57,530 I can curbside pneumonia all day. 202 00:17:57,630 --> 00:18:00,850 Uh, cellulitis, I need to go see this patient. 203 00:18:01,160 --> 00:18:05,590 And if they look okay, you know, I might want to do a probe to bone and hear a little bit more. 204 00:18:05,590 --> 00:18:08,290 If they don't look okay, I would start antibiotics right away. 205 00:18:08,290 --> 00:18:12,600 And then you need to know if your area where MRSA worries you or not as a first step. 206 00:18:12,780 --> 00:18:13,670 Meghan Brennan: I agree. 207 00:18:13,820 --> 00:18:32,490 David Armstrong: I'm just kind of fangirling for infectious disease because, you know, and again, not to blow sunshine here on an ID centric kind of podcast, but there are very few specialties that I see externally that, that doctor that really looked after their patients, uh, you know, from stem to stern like ID do. 208 00:18:32,680 --> 00:18:46,085 I know Marcos was complaining to the opposite, uh, but, uh, in my experience over a long time at a lot of different hospitals, ID has been, you know, just uniformly the doctor's doctor. 209 00:18:46,275 --> 00:18:47,085 So there's that. 210 00:18:47,575 --> 00:18:56,835 So you start from there, but just to kind of bring it out there to talk about osteomyelitis, you know, I think in the foot, people tend to make a big deal about osteomyelitis. 211 00:18:57,475 --> 00:19:01,145 But, you know, I would ask everyone here, is it really a big deal? 212 00:19:01,165 --> 00:19:03,605 I mean, it doesn't wake us up at night. 213 00:19:04,015 --> 00:19:06,835 It's not like some urgent surgical imperative. 214 00:19:07,225 --> 00:19:12,705 And generally speaking, in the foot, most of the time, uh, osteomyelitis. 215 00:19:13,210 --> 00:19:18,430 is, is actually there because of, because of a wound. 216 00:19:18,650 --> 00:19:31,115 So you have a continuous source, contiguous source, uh, and that wound is there, not because of an infection, that wound is there because of, generally speaking, repetitive stress and a deformity. 217 00:19:31,645 --> 00:19:37,775 So I would argue, usually, uh, osteomyelitis is really a mechanical problem in the foot. 218 00:19:37,935 --> 00:19:43,625 In other places it's obviously different, especially, and also in kids, but in the foot it's generally a mechanical problem. 219 00:19:43,635 --> 00:20:06,345 So very often this can be treated, especially if it's fulminant, uh, surgically, and one could get back to a clean margin, just like one would do in cancer, um, one can rapidly de escalate from all of this poly antimicrobial to just oral, if someone has a functioning gut, and then stop antibiotics. 220 00:20:06,835 --> 00:20:19,215 Sara Dong: Since it is Febrile, I'm going to ask, uh, Megan and Marcus, just to, for especially earlier learners, thinking about microbiology, not necessarily this patient, but microbiology of diabetic foot infections. 221 00:20:19,525 --> 00:20:23,055 Meghan Brennan: I think over 80 percent of them are polymicrobial. 222 00:20:23,765 --> 00:20:27,315 So, you are kind of trying to potentially cover a zoo. 223 00:20:27,675 --> 00:20:33,545 I think the things that come up are, do you need MRSA coverage and do you need pseudomonal coverage? 224 00:20:33,745 --> 00:20:44,790 And in cases where the patient is not septic, uh, I would argue that I think depending on where you are in the region, about 10 percent of them have Pseudomonas. 225 00:20:44,830 --> 00:20:55,400 I'm not sure you need the pseudomonal coverage, um, right off the bat for somebody that's hemodynamically stable, and maybe I'll leave MRSA to Marcos. 226 00:20:55,510 --> 00:21:08,050 Marcos Schechter: Yeah, just to, also in the microbiology, I think one of the things where the, um, infection classification helps is it also has a correlation with microbiology, or mild infections are generally only gram positives. 227 00:21:08,645 --> 00:21:14,015 And then as you go to moderate, severe, start adding gram negatives to the mix and anaerobes once you become severe. 228 00:21:14,165 --> 00:21:18,175 At Grady, we have lots of community acquired MRSAs, so it's something we worry about. 229 00:21:18,275 --> 00:21:25,405 I should mention there is a big, I think, VA study out there where they did nasal swabs for MRSA and checking the wounds. 230 00:21:25,645 --> 00:21:32,105 If you read the abstract, it'll say there are, great negative predictive value, positive predictive value, but you need to get it to fine print. 231 00:21:32,675 --> 00:21:36,305 Because predictive values, of course, depend on your local prevalence, right? 232 00:21:36,805 --> 00:21:44,115 So the sensitivity and specificity was not that great depending on where you are and how cautious you want to be about it. 233 00:21:44,255 --> 00:21:48,935 And the whole issue of Pseudomonas, I think, depends a lot where you are in the world. 234 00:21:49,065 --> 00:21:56,985 Uh, in case there are international people here, there's, you know, in Turkey and other warmer places, found a lot of Pseudomonas in feet. 235 00:21:57,610 --> 00:22:01,270 Uh, and also prior antibiotic exposure is something that I think about a lot. 236 00:22:01,270 --> 00:22:04,590 Is this somebody who received IV antibiotics in the last 30 to 90 days? 237 00:22:04,720 --> 00:22:12,060 Sara Dong: And also trying to think of this more broadly, we are really lucky to have our surgical friends on this call. 238 00:22:12,060 --> 00:22:13,340 Thank you guys for joining. 239 00:22:13,340 --> 00:22:25,500 And I'm wondering if if you could talk a little bit about, what are the surgical options for treatment for diabetic foot infection, what does that spectrum look like? 240 00:22:25,500 --> 00:22:30,020 What important pieces of information play into your decision making for how to manage these patients? 241 00:22:30,110 --> 00:22:46,430 David Armstrong: Well, maybe I could touch on the infection portion, maybe the incision and debridement, and then Tze-Woei could pop in and talk about the latest and greatest data for endo(vascular) and open options for improving folks runoff on the anatomic peninsula for their blood flow. 242 00:22:46,800 --> 00:22:54,080 So for the I&D (incision and debridement), I, I think I'm preaching to the converted when I say that, uh, time, um, is tissue here. 243 00:22:54,140 --> 00:23:01,235 This is one of the few places I think in medicine and surgery, where the most conservative approach actually is a surgical one. 244 00:23:01,715 --> 00:23:04,265 I think it depends on the patient obviously. 245 00:23:04,455 --> 00:23:20,245 There are some patients where it pays to be very, very cautious, but if you're really wondering about is there an abscess there or am I missing it, I think not doing something can be just as problematic as doing something. 246 00:23:20,245 --> 00:23:28,360 So if you have a question about whether that thing probes the bone or not or whether that streaking up the leg, um, is, uh, concerning. 247 00:23:28,360 --> 00:23:30,840 I would take that person to the operating room and open it up. 248 00:23:31,360 --> 00:23:38,490 Now, there are set approaches to opening up the diabetic foot and doing a good quality consistent incision and debridement. 249 00:23:38,490 --> 00:23:43,740 It's almost like approaching a compartment syndrome where you would, uh, where you would release, uh, different compartments of the leg. 250 00:23:43,990 --> 00:23:45,000 Same thing in the foot. 251 00:23:45,300 --> 00:23:51,780 And the foot is, a small, discreet area with a lot of complex bones and joints, like 20 percent of the whole body down there. 252 00:23:52,110 --> 00:24:01,730 So, there's a lot of little nooks and crannies and knowing that and understanding that implicitly is important for the she or he that's going to be going in there and doing the I&D. 253 00:24:02,050 --> 00:24:04,860 But doing that sooner rather than later, I think, is important. 254 00:24:05,210 --> 00:24:25,050 Once one has done a good quality incision and debridement, you've taken good quality cultures, one has altered their course of antimicrobials based on those cultures, then that this problem kind of moves away from being an infection dominant condition and moves toward being, uh, an ischemia dominant condition. 255 00:24:25,350 --> 00:24:26,290 Tze-Woei Tan: Thank you for the setup. 256 00:24:26,580 --> 00:24:35,180 I think before moving into the blood flow, there are some patients with extensive infection, especially if the infection extends above the ankle. 257 00:24:36,170 --> 00:24:54,135 I think those patients would benefit from urgent or emergent open amputation, where we do a guillotine and cut just above the ankle to get rid of the infection and then leave the wound open and come back to revise to a higher below knee amputation once all the infection is resolved. 258 00:24:55,595 --> 00:25:14,115 Going into the blood flow issue after the infection has been addressed, I think the main thing to know is inpatient PAD and we think that they need blood flow for healing, those patients will benefit from some type of procedure to improve the blood flow. 259 00:25:14,755 --> 00:25:17,705 And nowadays we do open or endovascular. 260 00:25:17,745 --> 00:25:31,165 Where open is we use um, bypass using a vein or prosthetic for a bypass versus an endovascular where we use stent or balloon or arterectomy and different techniques to resolve the issue. 261 00:25:31,905 --> 00:25:49,125 I think a recent randomized trial, which is the best endovascular versus open revascularization trial for people with critical limb ischemia, which is PAD with a wound loss or tissue loss and open procedure in a good surgical candidate. 262 00:25:49,510 --> 00:25:54,310 Especially those with a good vein for bypass is better than endovascular. 263 00:25:55,010 --> 00:26:04,020 Uh, for those who is not a surgical candidate or they don't have good vein, that endovascular is acceptable procedure to improve the blood flow. 264 00:26:04,340 --> 00:26:17,920 Marcos Schechter: Just take a step back if you, if you guys, cause I know we're talking about a hypothetical patient and it's hard to visualize, but I just think like in somebody that I'm hearing has, yes, has an extensive cellulitis yes, has leukocytosis. 265 00:26:18,770 --> 00:26:34,530 But otherwise seems stable, you know, I don't know that I would be in a hurry to chop a whole lot off, I think I want to clean things up, I just want to make sure that's absolutely clear to, to everybody listening, and I think cooling them off with antibiotics, and if you can clean things up surgically, great, right? 266 00:26:35,080 --> 00:26:41,540 Uh, and I'm here looking at David and Tze-Woei, see if they disagree, because minor amputations, it's, it's just a terrible name. 267 00:26:42,285 --> 00:26:51,215 Like, there's nothing minor about, you know, losing a toe or whatever, and I think a lot of times I see a lot of hurry. 268 00:26:51,690 --> 00:27:03,000 When the patient, they're there, they're not septic, you know, they're gonna, they're gonna survive, just slow down, so I just, I don't know, this sounds like a slow down type case based on the, as I heard the case that Sara described. 269 00:27:03,610 --> 00:27:05,260 Meghan Brennan: So can I say something though? 270 00:27:06,140 --> 00:27:10,900 Cause he, cause Tze-Woei did say something really cool and I was like, oh, I should mention this part. 271 00:27:10,920 --> 00:27:14,610 And that was about amputating and then coming back for a revision. 272 00:27:15,230 --> 00:27:24,380 Because one thing I think for our ID colleagues don't consider enough is the fact that you guys surgically need good tissue to flap. 273 00:27:24,970 --> 00:27:36,279 And so if we can generate good, healthy tissue, get rid of infection there so that you guys can flap and have a more distal amputation. 274 00:27:36,580 --> 00:27:42,919 That is a very legitimate use of antibiotics to get you guys the tissue that you need. 275 00:27:43,280 --> 00:27:48,780 And also it speaks to this idea that Marcos had of slowing down, right? 276 00:27:49,240 --> 00:28:03,140 If you needed to amputate higher and immediately close, um, that's different, right, than taking a measured approach where you might do a couple different stages with everyone on board together. 277 00:28:03,690 --> 00:28:04,620 David Armstrong: I, I'm, I'm with you. 278 00:28:04,620 --> 00:28:11,360 I think the order of the day here is moderation, but I don't know if I would call it slowing down. 279 00:28:11,570 --> 00:28:16,280 I would say be aggressively, surgically conservative in that. 280 00:28:17,525 --> 00:28:27,585 You are, uh, marrying your antimicrobial therapy with rapid, aggressively tissue conservative debridement of the foot. 281 00:28:27,905 --> 00:28:49,340 This is why, when we look at success or failure kind of over a large scale, we look at limb sparing procedures, like partial foot amputations or just incisions and drainage procedures of the foot over high level amputations like below knee and above knee amputations. 282 00:28:49,370 --> 00:29:03,370 And so we actually use what we call a high to low amputation ratio just to get a little idea about the level of acuity of management of diabetic foot complications in a region or in a hospital. 283 00:29:03,649 --> 00:29:19,745 And different hospitals can be very, very different, but that also shows you if you're talking about what Marcos was just talking about, which is that different clinicians can have dramatic impacts here where there might be a woman or a man that just says, you know what, Ms. 284 00:29:19,745 --> 00:29:21,515 Garcia, she just has that problem. 285 00:29:21,795 --> 00:29:22,945 She's going to get another one. 286 00:29:23,275 --> 00:29:25,294 Let's just cut off her foot and be done with it. 287 00:29:26,315 --> 00:29:35,885 And you know, for some patients, that's probably the best therapy, but I think most of us agree that the data are very strong, suggesting that's an extremely small number of patients. 288 00:29:36,135 --> 00:29:52,445 And the great news is, nowadays, thanks to all you characters, we can reduce dramatically the rate of high level amputations to only a small fraction of all the ones that are done collectively in a unit. 289 00:29:53,025 --> 00:30:02,275 Because usually, those things are not emergency procedures, they're almost semi elective in some cases. 290 00:30:02,705 --> 00:30:03,045 Right? 291 00:30:03,105 --> 00:30:05,195 I mean, not the one that Tze-Woei mentioned. 292 00:30:05,305 --> 00:30:24,524 That's source control for someone that is where there is the life over limb issue, but for a lot of the other issues, when you just have the tissue loss now, and maybe some result in the infection, that is almost semi elective to where a person, she or he can make that decision with her or his clinicians and team around them and family. 293 00:30:25,120 --> 00:30:26,390 Tze-Woei Tan: Yeah, I think I agree with Dr. 294 00:30:26,390 --> 00:30:26,770 Armstrong. 295 00:30:26,770 --> 00:30:30,060 I think team is the great approach or the right approach, right? 296 00:30:30,060 --> 00:30:34,459 I think, uh, we don't take everyone with a severe infection to the OR. 297 00:30:34,955 --> 00:30:45,415 In general, we talk to the podiatry or toe colleague to see whether there's any option for limb salvage and especially to drain the infection. 298 00:30:45,895 --> 00:30:50,065 And we will try our best not to go for major amputation if possible. 299 00:30:50,414 --> 00:30:50,744 Sara Dong: Yeah. 300 00:30:50,744 --> 00:30:56,145 So I tried to intentionally make this case a little bit challenging and sort of in the gray area. 301 00:30:56,175 --> 00:31:18,714 So let's just say for this patient, they ended up being started on the classic vanc piptazo combo, you know, they rolled in through the ED, and so this patient does go for debridement of this ulcer and has some pretty significant necrosis and actually an abscess cavity that tracks to the head of that fifth metatarsal and through to the midfoot. 302 00:31:18,774 --> 00:31:27,374 So he ultimately does require an amputation of his third, fourth, and fifth toe and needed a couple subsequent debridements to gain control of his infection. 303 00:31:27,464 --> 00:31:36,614 From a vascular standpoint, he has an assessment completed after the infection is more under control and ultimately undergoes endovascular intervention for revascularization. 304 00:31:37,214 --> 00:31:40,644 Um, so it has some balloon angioplasties of a couple stenoses. 305 00:31:40,844 --> 00:31:44,564 His labs are improving from a white blood cell count standpoint. 306 00:31:44,574 --> 00:31:48,834 His inflammatory markers are dropping and we have some bone cultures that are growing E. 307 00:31:48,834 --> 00:31:49,354 coli. 308 00:31:49,574 --> 00:31:54,794 I am going to open it back up to talk a little bit about clinical response in these patients. 309 00:31:55,044 --> 00:32:02,644 What should we do with their antimicrobials now and any other thoughts that you may have on my, uh, made up case. 310 00:32:03,509 --> 00:32:10,569 Meghan Brennan: Well, I would made up ask you where, where were the cultures taken from, because I would just give a call out to Dr. 311 00:32:10,569 --> 00:32:15,769 Armstrong and be like, Hey, is that the stuff that was going in the trash or was that a clean margin? 312 00:32:16,609 --> 00:32:32,239 Sara Dong: So let's say we don't know, or, or maybe I'll just throw it back and say, what if we talk through the what if of either scenario of if you had gotten information that it is from proximal or sort of, as you said, the stuff that goes in the trash. 313 00:32:32,389 --> 00:32:38,054 Marcos Schechter: So just one parenthesis there about inflammatory markers in particular. 314 00:32:38,374 --> 00:32:41,244 I don't know about you guys, but I don't trend those at all. 315 00:32:41,364 --> 00:32:44,594 For esr ESR, CRPs diabetic foot infections. 316 00:32:44,594 --> 00:32:46,004 Like, I, I don't, I don't trend that. 317 00:32:46,004 --> 00:32:47,054 I don't know if anybody does. 318 00:32:47,054 --> 00:32:50,824 It's something that people get hung up a lot on, uh, just putting that out there. 319 00:32:50,854 --> 00:32:53,224 Do you follow them, Megan, David, Tze-Woei? 320 00:32:54,164 --> 00:32:55,454 Meghan Brennan: I'm trying not to. 321 00:32:55,454 --> 00:32:57,314 It's a hard habit to break. 322 00:32:57,784 --> 00:33:00,694 I will say sometimes I think there's utility. 323 00:33:00,814 --> 00:33:09,104 If we are in a scenario where we're using a PICC line, especially, not so much to worry about the infection down in the foot, but to catch. 324 00:33:09,204 --> 00:33:11,464 like a line related complication. 325 00:33:12,054 --> 00:33:14,254 So it's a different purpose. 326 00:33:15,104 --> 00:33:19,994 I have found it's, it's, I know I should stop and it's so darn hard to, you know. 327 00:33:21,024 --> 00:33:25,049 David Armstrong: Yet another reason, um, Meghan, to pull that PICC line out. 328 00:33:26,059 --> 00:33:26,729 Marcos Schechter: That is amazing. 329 00:33:26,729 --> 00:33:32,849 The only patient I have ever seen an ESR bump high, this is years ago when we were doing PICC lines all the time. 330 00:33:33,069 --> 00:33:34,149 It's like, what the hell is this about? 331 00:33:34,149 --> 00:33:36,909 Took the PICC line out, two days she came back with a line infection. 332 00:33:36,909 --> 00:33:39,529 I'm like, ah, that was that ESR. 333 00:33:39,699 --> 00:33:40,629 So glad I had it. 334 00:33:40,630 --> 00:33:42,707 David Armstrong: We make a lot of jokes in our unit. 335 00:33:42,707 --> 00:33:44,999 We always say, we have a bone to PICC with you. 336 00:33:45,539 --> 00:33:52,990 Uh, yeah, I think sometimes the first thing that someone wants to do is to throw a PICC in an arm and send someone out for six to eight weeks of, of antimicrobials. 337 00:33:53,249 --> 00:33:59,440 And if they're a little sophisticated, maybe they're culture directed antimicrobials, but, but, we see this frequently. 338 00:33:59,440 --> 00:34:17,229 We've been trying for a really long time to adhere to work that's done by, you know, many different clinicians, but one of my good friends here, about 500 yards in this direction from me is, uh, Brad Spellberg, uh, who will preach the mantra that, you know, shorter is better. 339 00:34:17,229 --> 00:34:25,920 And if someone has a functioning gut, oral, um, is in many cases as good as IV and as long as you have coverage. 340 00:34:26,130 --> 00:34:27,570 And I think there's times for both. 341 00:34:28,195 --> 00:34:35,875 But we like to really adhere to that mantra, especially if we feel like we have a clean margin for this patient population. 342 00:34:36,215 --> 00:34:57,795 I'll also say that I, I might follow a white count while someone's in hospital and we'll look if someone has a, you know, sky high SED rate or CRP, you know, so many of our patients are just pan inflammatory anyway, by the way, they're just, but, um, I won't follow the SED rate for trending, although it's kind of a nice idea, 343 00:34:57,795 --> 00:35:18,085 you know, I might watch the white count drop, because even though half of our patients that we take to the operating room have a normal white count, you know, we published that back in the 90s, still, we might see a little drop in the white count, and maybe if we have an undulating white count or a persistently raising one, 344 00:35:18,085 --> 00:35:26,205 maybe that means we did not get as good source control as we could, or maybe it means that there's another source, right, that we're missing collectively as a family. 345 00:35:26,634 --> 00:35:34,619 Um, but, uh, so I might track that as we're thinking about, as rapidly as possible moving towards discharge. 346 00:35:35,000 --> 00:35:39,800 Marcos Schechter: I think you, you, you picked a really cool case, Sara, because there's all the uncertainties here, right? 347 00:35:39,819 --> 00:35:46,840 So I think what you're trying to get us to talk about is, does this patient have residual cellulitis? 348 00:35:46,860 --> 00:35:48,779 Does this patient have residual osteo? 349 00:35:49,135 --> 00:35:49,825 Or nothing. 350 00:35:50,565 --> 00:36:00,475 And this patient probably has residual cellulitis because you told us that they had cellulitis above the level of the ankle and we left their ankle there, right? 351 00:36:00,745 --> 00:36:03,205 So odds are we need to treat some of that. 352 00:36:03,915 --> 00:36:10,495 The issue of residual osteo is, I find one almost impossible to understand for the reasons that Meghan pointed out. 353 00:36:10,525 --> 00:36:13,435 It's really hard to know what came from where. 354 00:36:14,265 --> 00:36:27,544 Also, we don't really know what osteomyelitis is because the agreement between path and culture is a flip of a coin, and we don't know what it means prognostically to have residual positive margins by culture, path, or both. 355 00:36:27,805 --> 00:36:37,035 We do have now that recommendation to do three weeks for residual osteomyelitis, and that is one recommendation that I really struggle with. 356 00:36:37,985 --> 00:36:45,185 In part because it's based on a pilot trial of 92 patients with a non inferiority margin of 25 percent. 357 00:36:46,125 --> 00:36:49,495 And I think something we don't talk a lot about is what's at risk here. 358 00:36:49,975 --> 00:36:57,825 So is this somebody who is really not mobile and may have a little bit of osteo of the pinky and if that comes back I cut the pinky and we're good? 359 00:36:58,394 --> 00:37:07,055 Or is this a 50 year old person who is working providing for their family, and if this thing comes back, we're talking BKA, right? 360 00:37:07,085 --> 00:37:13,174 And, and I think that's what I take into account of how aggressive I want to, how much understanding I know nothing about this problem, right? 361 00:37:13,175 --> 00:37:14,375 Cause I don't know what osteo is. 362 00:37:14,854 --> 00:37:16,495 I don't know what residual margins mean. 363 00:37:16,774 --> 00:37:17,795 I don't know anything. 364 00:37:18,064 --> 00:37:21,974 So based on all that knowledge, what I do is based on some sort of risk assessment. 365 00:37:22,404 --> 00:37:22,774 David Armstrong: Wow. 366 00:37:22,775 --> 00:37:24,295 What great discussions here, man. 367 00:37:24,345 --> 00:37:31,860 I mean, the other thing is about, you know, we think that our buddies, That are down there, they're always down there in the basement of the hospital. 368 00:37:31,860 --> 00:37:39,280 You know, you, it's either micro, both are basement people, uh, micro or a path, right? 369 00:37:39,590 --> 00:37:42,979 You know, you go down there and you see them and they're like, struggle for the light. 370 00:37:43,020 --> 00:37:50,295 And, you know, you, uh, and you walk down with, sometimes you walk down with a culture or path, and then they're so happy to see you. 371 00:37:50,295 --> 00:37:53,715 It's like they haven't seen someone, it's like they've been, they've been isolated for so, so long. 372 00:37:54,075 --> 00:37:58,705 And you go and you see them and uh, you pay 'em a little respect and then they're your best friend forever. 373 00:37:58,705 --> 00:38:04,415 But I'll tell you what, we think that that is the final word, pathology, because it is the final word. 374 00:38:04,415 --> 00:38:18,940 I mean, these guys are brilliant, but yet there is so much variability in, in assessment histologically for, for many things, for cancer and for bone infection. 375 00:38:19,460 --> 00:38:29,819 Just as you said, Marcos, I think there was that paper this was like a few years ago where there's like 33 percent variability depending on different clinicians, uh, at teaching hospitals. 376 00:38:29,949 --> 00:38:30,189 Right? 377 00:38:30,799 --> 00:38:32,912 Uh, so it's, it, it really is wild. 378 00:38:33,039 --> 00:38:36,599 Wow, so I think there's an element of subjectivity for all of us. 379 00:38:37,179 --> 00:38:39,829 Speaking of that, could I ask a quick question to everyone else? 380 00:38:39,929 --> 00:38:55,939 How do you all feel, Meghan, Marcus, specifically, about delivering a high level of antimicrobials locally, like through maybe, um, a polymethylmethacrylate or a calcium sulfate bead media for calcium phosphate. 381 00:38:56,089 --> 00:39:05,719 So something that is absorbable on the calcium sulfate, phosphate bit or the non-absorbable on the, the string of pearls, kind of cement sort of thing. 382 00:39:05,839 --> 00:39:07,519 What's the feeling in the infection? 383 00:39:07,549 --> 00:39:13,744 I, I kind of know what the feeling, what's, what's the feeling in your, uh, community about, uh, about this and should I keep doing this or not? 384 00:39:14,659 --> 00:39:18,389 And maybe how can I figure out whether this is really helping my patients or not. 385 00:39:19,859 --> 00:39:22,569 Sara Dong: For those who can't see, Marcos just shaking his head. 386 00:39:22,569 --> 00:39:26,079 Marcos Schechter: Meghan, I'll let you take that one. 387 00:39:26,259 --> 00:39:29,679 Meghan Brennan: It's like you see the bus coming and you're like, jump in front of it. 388 00:39:30,499 --> 00:39:31,489 This is not fair. 389 00:39:35,039 --> 00:39:43,029 Well, I would say, quite frankly, that I think that sort of topical antimicrobial, Dr. 390 00:39:43,029 --> 00:39:46,389 Armstrong, is treating yourself more than the patient. 391 00:39:46,959 --> 00:39:49,919 I don't think it's going to make or break the case. 392 00:39:50,059 --> 00:39:56,459 It's also not the molehill that I'm willing to die on in terms of antimicrobial stewardship. 393 00:39:57,009 --> 00:40:13,569 So, but I will also caution, you know, the, the thing that I have seen a few times become a problem are sometimes those, those antimicrobial beads tend to work themselves out the suture line and then everybody gets confused as to what they might be like, is that pus? 394 00:40:13,569 --> 00:40:14,919 Are those gout crystals? 395 00:40:15,279 --> 00:40:21,829 And so I think that is a potential, so, keep in mind as a, as a con. 396 00:40:22,279 --> 00:40:23,149 Marcos Schechter: What Megan said. 397 00:40:25,629 --> 00:40:25,949 David Armstrong: Great. 398 00:40:26,939 --> 00:40:28,709 Marcos Schechter: No, it's really an unknown, right? 399 00:40:28,709 --> 00:40:30,229 And how do you study these things? 400 00:40:30,229 --> 00:40:36,989 And being in a trauma center, we see a lot of the more classical use impregnated antibiotic nails, right? 401 00:40:37,119 --> 00:40:44,744 I find that so fascinating because, like, are they good in the beginning, but do they eventually themselves become anitis for infection? 402 00:40:44,744 --> 00:40:46,574 What grows biofilm, what doesn't? 403 00:40:47,094 --> 00:40:48,314 We don't know the first thing. 404 00:40:48,424 --> 00:40:57,654 Sara Dong: And the other, uh, controversial is maybe not the best word, but discussed point about antimicrobials is whether or not we should add rifampin. 405 00:40:58,144 --> 00:40:58,854 Who would like to 406 00:40:59,264 --> 00:40:59,614 Marcos Schechter: take a 407 00:40:59,654 --> 00:40:59,894 Sara Dong: stab at 408 00:40:59,894 --> 00:41:00,044 Marcos Schechter: that? 409 00:41:00,044 --> 00:41:01,754 Does the patient have tuberculosis? 410 00:41:02,894 --> 00:41:08,469 David Armstrong: For those of you that don't know, Marcos Twitter handle is Limbs and Lungs. 411 00:41:10,049 --> 00:41:12,719 So this is like the perfect tuberculosis sort of thing. 412 00:41:12,929 --> 00:41:16,069 Meghan Brennan: Well, I'm gonna wait for VA INTREPID to come out. 413 00:41:16,079 --> 00:41:27,149 I think we are within a couple years of having a very solid, well informed data with which to answer your questions. 414 00:41:27,174 --> 00:41:33,754 So, uh, I am politely going to pass for the next few years until that data is available. 415 00:41:34,504 --> 00:41:40,534 Marcos Schechter: Yeah, and I also 100 percent with Megan there, I think for those who read that retrospective paper. 416 00:41:40,904 --> 00:41:48,204 A lot of the outcome difference there is not carried by limb salvage, it's carried by survival and patients who got rifampin were younger and less medications. 417 00:41:48,974 --> 00:42:00,535 Which brings me to, oh my god, how much I wish VA INTREPID was testing rifabutin instead of rifampin, right, just because of the DDIs, which are, which can be a pain in the butt to manage. 418 00:42:00,535 --> 00:42:07,574 Meghan Brennan: But, well, I, Tze-Woei, I'm gonna put you on the spot here though, because let's play the future game. 419 00:42:08,104 --> 00:42:16,044 What's going to happen if VA VA INTREPID says, Hey, we need to use rifampin, it improves outcomes as an adjuvant. 420 00:42:16,994 --> 00:42:21,444 And you've got all these patients on Xa inhibitors that interact. 421 00:42:21,754 --> 00:42:29,724 Is this something where we can think about potentially pausing them for the time of rifampin or is that risk benefit? 422 00:42:30,094 --> 00:42:31,294 How do you see that risk benefit? 423 00:42:31,295 --> 00:42:35,904 Tze-Woei Tan: I think those are for long term patency. 424 00:42:36,184 --> 00:42:42,869 I don't think, uh, You know, we can always hold antiplatelet or anti Xa unless there's a reason. 425 00:42:43,629 --> 00:42:48,309 If they are going on for PAD outcome, that's long term. 426 00:42:48,309 --> 00:42:56,769 So I think there's no reason not to pause it and, uh, you know, continue the antibiotics if that is what the patient need. 427 00:42:57,229 --> 00:43:03,064 I think it'd be different if patient is on anticoagulation for heart valve where you can't really stop them. 428 00:43:03,714 --> 00:43:09,964 Sara Dong: As we've talked about, you know, oversimplified a little bit with the case, just to give us something to have conversation. 429 00:43:09,974 --> 00:43:15,714 But we focus significantly on antibiotics and then surgical management. 430 00:43:15,724 --> 00:43:34,509 And I think an important message of your review is that there are a lot of other components of multidisciplinary, not necessarily diabetic foot infection, but diabetic foot care that we should be thinking about as either obviously preventative, but after the fact, you know, after they've been in the hospital and are on their way home. 431 00:43:34,509 --> 00:43:37,119 And I was wondering if you could talk about some of those other components. 432 00:43:37,569 --> 00:43:40,539 Marcos Schechter: Is the patient gonna go home on the same shoe that they came in? 433 00:43:42,049 --> 00:43:42,409 Sara Dong: Perfect. 434 00:43:43,174 --> 00:43:44,224 . David Armstrong: That, that was beautiful. 435 00:43:44,494 --> 00:43:44,984 Perfect. 436 00:43:45,259 --> 00:43:46,219 That's what I was looking for. 437 00:43:46,589 --> 00:43:49,549 Marcos Schechter is an honorary podiatrist. 438 00:43:49,549 --> 00:43:52,224 In fact, I will call you a PPE . You are. 439 00:43:52,874 --> 00:43:54,954 The podiatry physician extender right there, man. 440 00:43:55,034 --> 00:43:56,234 I just have to throw that. 441 00:43:56,514 --> 00:43:58,184 So listen, that is great. 442 00:43:58,554 --> 00:44:04,904 It is not what we put on these wounds that that heals them once we've sorted out the flow and once we've sorted out the infection. 443 00:44:04,914 --> 00:44:07,324 It is what we, as you heard, is what we take off. 444 00:44:07,724 --> 00:44:13,394 If we Uh, and this is a term for, for, for ID trainees, the term is called offloading. 445 00:44:13,624 --> 00:44:19,664 Uh, it's not offloading the responsibility onto the, uh, onto something, it is offloading the pressure. 446 00:44:19,674 --> 00:44:23,244 So you're spreading force out over a large unit area. 447 00:44:23,434 --> 00:44:26,084 And this sounds like something that is super easy. 448 00:44:26,134 --> 00:44:28,989 And FYI, it is so hard. 449 00:44:29,629 --> 00:44:30,119 Why? 450 00:44:30,559 --> 00:44:35,489 Because our patients are, right, why our patients may look like us and they may dress like us. 451 00:44:35,989 --> 00:44:46,700 They are not going to act like us because they have lost what one of my mentors, Paul Brand, used to call the gift of pain. 452 00:44:47,689 --> 00:45:10,660 And so they will behave differently because that hole in their foot You're having more of a reaction viscerally to that than they are, and they, just as Marcos said, may skip out of the hospital, leap out of the chair, leap out of the room, maybe Tze-Woei did a gorgeous endoheroic limb sparing procedure and there were all these other sorts of things happening and but then they leap out 453 00:45:10,660 --> 00:45:24,135 and bound out of the hospital to the bus stop or to their car in the same shoes that caused the wound in the first place so this has to be protected but people don't focus on this very well. 454 00:45:24,485 --> 00:45:30,365 Fewer than 2 percent of people get kind of the gold standard offloading therapy that they're supposed to get. 455 00:45:30,385 --> 00:45:33,245 It's amazingly un golden, that gold standard. 456 00:45:33,355 --> 00:45:52,430 That's why now we have an NIH sponsored study, this R01 that we're running now called the Smart Boot Study, where we're randomizing people into removable and irremovable boots, but also the boots that can maybe make up for some of that lack of pain, and give people some feedback, uh, of maybe a smart watch that can say, Hey, Mr. 457 00:45:52,430 --> 00:45:55,580 Jones, great job, you're wearing your boot, or Hey, Ms. 458 00:45:55,590 --> 00:46:05,700 Smith, that's not so hot, that boot's sitting next to your sofa, acting like a beer cozy, not acting like a, uh, offloading device. 459 00:46:05,720 --> 00:46:10,080 So this sort of thing, doing things with our patients and not to them is really important. 460 00:46:10,120 --> 00:46:15,905 So that's the offloading bit, um, that I think is really critically important. 461 00:46:16,125 --> 00:46:28,955 Could I ask another ID tangential question, because I tend to be on one side of this argument, but I'm kind of becoming in between this argument that my friend, longtime friend, Ben Lipsky, I hope Ben listens to this podcast. 462 00:46:28,975 --> 00:46:34,605 For those of you who don't know Ben Lipsky, please just, you guys, ID folks, Google him. 463 00:46:34,615 --> 00:46:36,485 He's the ID hero. 464 00:46:36,885 --> 00:46:40,055 Uh, and he's one of my longest standing friends in this area. 465 00:46:40,340 --> 00:46:49,010 Ben was very much against giving people with a little bit of redness or something or stalled wounds, antibiotics. 466 00:46:49,430 --> 00:46:50,960 That makes sense, obviously, doesn't it? 467 00:46:52,170 --> 00:46:54,670 You don't want to give someone that doesn't have an infection antibiotics. 468 00:46:54,700 --> 00:46:59,240 That's the, it goes against every tenet that one might believe in their training. 469 00:47:00,460 --> 00:47:04,620 Another really good friend of mine, actually, I would say equally good, is a guy named Mike Edmonds. 470 00:47:04,800 --> 00:47:07,340 This is another guy for you, uh, for everyone to Google. 471 00:47:07,360 --> 00:47:16,760 Mike's at King's [College Hospital NHS], strategically several thousand miles away from Ben, who is in Washington state, um, and Mike Edmonds is a diabetologist. 472 00:47:17,190 --> 00:47:24,780 And Mike often said, you know, sometimes these people kind of have something that's like sort of infected, but really not infected. 473 00:47:25,050 --> 00:47:32,559 I'm going to give these people a little bit of antibiotics and see if it helps their wounds heal, even though I'm doing a good job of debriding and offloading them. 474 00:47:33,120 --> 00:47:35,190 And he showed some of these patients would heal a little bit better. 475 00:47:35,530 --> 00:47:41,710 I always felt like this was the most dumb idea in the universe, and I still feel that way, for sure. 476 00:47:42,030 --> 00:47:45,500 I do not want to give non infected wounds antibiotics. 477 00:47:48,240 --> 00:47:50,380 I'm going to say this, and it sounds heretical. 478 00:47:51,000 --> 00:47:52,810 Maybe they're both right. 479 00:47:53,540 --> 00:48:19,820 Uh, and maybe these wounds that are not infected clinically and classically, have some colonization that's inhibitory, um, and so some, last year I think we came up with a term that we called Chronic Inhibitory Bacterial Load, or CIBL, C I B L, kind of like chronic limb threatening ischemia, or or CLTI. 480 00:48:20,280 --> 00:48:24,790 That patient population we think probably needs to be addressed in some fashion. 481 00:48:24,800 --> 00:48:35,970 Maybe not with antibiotics, but maybe with just a really good quality debridement and serial assessments of load there, or maybe something clever locally. 482 00:48:36,500 --> 00:48:43,640 I wonder what you guys think, because I think the data are emerging that some of these bacteria can inhibit healing, 483 00:48:44,125 --> 00:48:45,945 even though they're not frank infections. 484 00:48:46,465 --> 00:48:53,345 Just like you can have a glandular hyperplasia before you get a low grade prostate cancer, you know? 485 00:48:53,345 --> 00:48:59,805 Meghan Brennan: I think what you're getting at is like the role of the microbiome within the wound bed itself. 486 00:49:00,655 --> 00:49:25,295 And so, I don't think that there is enough data for me to make clinical decisions yet, but I really hope that my microbiology colleagues start exploring this and start exploring this amazing communication that can happen between bacteria, between fungi, between human hosts, all within this milieu. 487 00:49:26,265 --> 00:49:36,905 I think the tools are there to make these good studies possible, but we really have to back up and wait for the science to catch up to our eagerness to apply it. 488 00:49:37,925 --> 00:49:43,275 David Armstrong: Let me tell you, we have been working with whole genome shotgun and 16S, as you know, forever. 489 00:49:43,315 --> 00:49:45,755 We called it from, I'll tell you how we're dating it. 490 00:49:45,785 --> 00:49:49,565 We had a paper called from Louis Pasteur to CSI. 491 00:49:49,735 --> 00:49:51,005 That's how long we've been doing this. 492 00:49:51,005 --> 00:49:53,605 That's when CSI is now like Louis Pasteur. 493 00:49:53,645 --> 00:49:58,115 So, so yes, but usually it's a paralysis of analysis, isn't it? 494 00:49:58,555 --> 00:50:06,505 I'll tell you something that's fun that we're doing now, actually, is we're using kind of image based debridement where we're using basically blacklight. 495 00:50:06,770 --> 00:50:26,554 No joke, like you'd see in a club, we're doing it on like feet, and we're imaging the porphyrin in bacteria, and we are then debriding the patients in our clinic, and my friend Stephanie Wolfel, who's a physical therapist, or if you're British, a physiotherapist, for those of you listening, she's doing some of this as well. 496 00:50:26,554 --> 00:50:41,749 There, there are companies that make these devices both in a phone kind of form factor and then in a, uh, actually loupes on your, uh, like L O U P E S that you can put on your glasses so that's a fun thing that's giving you semi quantitative assessments. 497 00:50:43,129 --> 00:50:46,189 I love your comments here. 498 00:50:46,189 --> 00:50:49,054 I think it's a really rich area for inquiry. 499 00:50:49,274 --> 00:50:53,284 Marcos Schechter: I'm gonna quote two great foot people. 500 00:50:53,674 --> 00:51:06,664 First, Ben himself, who is like, I think, the godfather of all ID doctors interested in feet, where he says, In diabetic foot ulcers, antibiotics are to cure the infection and not to heal the wound, which I think is a great saying. 501 00:51:07,224 --> 00:51:15,104 And then there's this David guy, he wrote somewhere something like, We should be more worried about what we take off from wounds than what we put on them. 502 00:51:15,754 --> 00:51:22,754 And when it comes to the bacteria, I would argue that, David, removing them is probably more important than any antibiotic I can sprinkle. 503 00:51:23,334 --> 00:51:26,484 I'm glad he, that guy is here to confirm or deny that he said that. 504 00:51:26,484 --> 00:51:26,544 Um, 505 00:51:28,394 --> 00:51:31,604 , David Armstrong: I I can both, I I can definitely confirm that I said that. 506 00:51:31,604 --> 00:51:33,434 I think I said that more than 20 years ago. 507 00:51:34,849 --> 00:51:35,089 I idea. 508 00:51:35,609 --> 00:51:36,714 Marcos Schechter: I, I, I read it. 509 00:51:36,774 --> 00:51:37,194 I read it. 510 00:51:37,194 --> 00:51:38,844 At that time my dad used to read it to me. 511 00:51:38,844 --> 00:51:42,024 David Armstrong: Uh, but I think at that thing is fraying at the edges, man. 512 00:51:42,029 --> 00:51:43,494 That thing on some wall. 513 00:51:43,494 --> 00:51:45,444 A wall or on some hard drive somewhere. 514 00:51:45,684 --> 00:51:47,124 But yes, that is true. 515 00:51:47,394 --> 00:51:51,704 I think though that there are probably a lot of subtleties, uh, in this area now. 516 00:51:51,954 --> 00:51:56,724 I think Graham Green said, life's not black and white, it's black and gray. 517 00:51:57,094 --> 00:51:59,544 And I think there's just a lot of complexities in this area. 518 00:51:59,554 --> 00:52:04,314 The more of this stuff you do, the more of those black and grays you start seeing. 519 00:52:04,644 --> 00:52:06,014 But you are absolutely correct. 520 00:52:06,014 --> 00:52:09,004 I think we need to debride and offload well. 521 00:52:09,034 --> 00:52:25,049 And then we need to have, just like Meghan said, and you said, we need to have companion diagnostics and theranostics that are going to help us say, if this, then this, and we don't quite have that as well as we could yet, but it's getting better. 522 00:52:25,049 --> 00:52:25,799 It's a fun time. 523 00:52:25,809 --> 00:52:26,619 Like I said, to be doing this, 524 00:52:26,739 --> 00:52:30,659 Marcos Schechter: Sara, can I ask a, since we're just like, I don't even know that we're doing a podcast anymore. 525 00:52:30,659 --> 00:52:31,969 We're just asking each other's questions. 526 00:52:31,969 --> 00:52:34,899 I actually want to, I actually want to ask a question. 527 00:52:36,369 --> 00:52:47,054 It's like, I think it might be useful for what you're getting to, but I've been more and more bothered by the follow up part of the patients? 528 00:52:47,594 --> 00:52:53,544 Because just like nobody can diagnose an infection based on validated systems, are they getting better or worse? 529 00:52:54,284 --> 00:52:56,144 That's even worse than the weathermen. 530 00:52:56,694 --> 00:53:13,844 So I'm just curious, because at here, you know, we photograph the wound, we measure it, we put it on the chart, but at your institutions, what, how are you guys tracking wounds to see if people are progressing as they should, or, you know, any MR tricks, phones, like how are you guys keeping track of 531 00:53:13,844 --> 00:53:15,614 Tze-Woei Tan: I think we, we follow them clinically. 532 00:53:15,634 --> 00:53:23,994 I don't think we take any, other than pictures, and we want to make sure that they come back to see the surgeon who did the surgery, for sure. 533 00:53:24,644 --> 00:53:25,834 And hopefully Dr. 534 00:53:25,834 --> 00:53:31,054 Armstrong is not away giving some talk somewhere, and we have to cover his clinic. 535 00:53:31,854 --> 00:53:36,854 But I think we follow them quickly, and as long as they're progressing and not getting worse, I think that's all we base on. 536 00:53:37,504 --> 00:53:38,714 Marcos Schechter: But by size alone? 537 00:53:38,714 --> 00:53:42,334 Tze-Woei Tan: Size and the wound appearance, I think you know pretty fast. 538 00:53:42,374 --> 00:53:47,874 It's not a subtle thing if, for example, if the stent goes down or bypass goes down, that's a big difference. 539 00:53:47,904 --> 00:53:58,704 If, uh, they are not progressing, so like in a month they still look the same, uh, then something, so obviously I'm thinking more from the vascular perspective and you guys are thinking more from ID perspective. 540 00:53:59,224 --> 00:54:12,569 David Armstrong: Yeah, let me also add to that by indicating that actually in Tze-Woeis superb grand rounds that he just gave a couple hours ago, he talked about a friend of ours, Chris Lynch, who's a physician here in L. 541 00:54:12,569 --> 00:54:12,889 A. 542 00:54:13,109 --> 00:54:13,729 County and L. 543 00:54:13,729 --> 00:54:13,849 A. 544 00:54:13,859 --> 00:54:19,439 General Hospital, and he helps to run, uh, a program called Safer at Home. 545 00:54:19,999 --> 00:54:24,654 Safer at Home started during, uh, the pandemic. 546 00:54:24,774 --> 00:54:27,044 So it was very ID centric kind of start. 547 00:54:27,684 --> 00:54:35,424 Um, but now it has evolved to where some of the most common patients treated are not upper respiratory or cardiopulmonary kind of things. 548 00:54:35,874 --> 00:54:52,224 Um, it's actually diabetic foot, far and away the most common treated patients, and those patients are now getting a phone if they don't have a phone, um, or, but they're also getting nurses to visit them at home for assessments, and they're getting, uh, photographs. 549 00:54:52,664 --> 00:55:00,344 We also have a program called the foot selfie program, where we have our patients send us photos, no joke, of their feet. 550 00:55:00,584 --> 00:55:08,644 Um, I, I'm, I'm not kidding, when I was on this, I literally just got one right now from Chennai in India from a patient. 551 00:55:08,864 --> 00:55:18,044 Um, that had come to visit us some weeks earlier . We then put all those into one set area, and then every Monday at seven, we have what we call foot selfie rounds. 552 00:55:18,494 --> 00:55:22,724 And, you know, not a week goes by where we don't catch something and stop a hospitalization. 553 00:55:22,734 --> 00:55:25,214 And that's done almost entirely manually. 554 00:55:25,584 --> 00:55:31,884 What this grant is trying to do is to create kind of an AI based Sherpa to help improve that throughput. 555 00:55:32,469 --> 00:55:49,709 Some of this is already happening thanks to, and no kidding, NVIDIA and the Diabetic Foot Grand Challenge, uh, Johnny Hancox in NVIDIA and Moi Hoon Yap in Manchester did this Foot Grand Challenge to identify wounds autonomously in under 10 seconds using a standard cell phone picture. 556 00:55:49,989 --> 00:56:04,194 That's already published, that library is already online, but now we can take these data and use them and make them better and iterate them for our own place, whether that's at Grady, whether it's in Madison, or whether it's here in LA or all around the world. 557 00:56:04,194 --> 00:56:12,214 So it's an exciting time because this stuff that is outside the hospital is, as you said, is way more important than what's inside the hospital. 558 00:56:12,284 --> 00:56:14,644 Our goal is to maximize the Holy Trinity. 559 00:56:15,214 --> 00:56:16,064 Ulcer free days. 560 00:56:16,924 --> 00:56:18,074 Hospital free days. 561 00:56:19,134 --> 00:56:20,314 Activity rich days. 562 00:56:20,984 --> 00:56:23,324 And maybe antibiotic free days too, if you want to add a few. 563 00:56:23,834 --> 00:56:32,534 Sara Dong: Uh, well, you guys have been very, uh, kind to be on the podcast and spend a little bit of time asking each other and answering, uh, my questions. 564 00:56:32,774 --> 00:56:40,099 I will just leave it open at the last section here to see if there's any point that you want to make before we wrap up. 565 00:56:40,189 --> 00:56:44,069 Or, you know, a take home summary point just as closing thoughts. 566 00:56:44,409 --> 00:56:57,079 Meghan Brennan: Well, in the spirit of multidisciplinary, I want to make sure that we all emphasize each other's disciplines when we're talking to the patient, because it means a whole lot when I say, stay off your foot. 567 00:56:57,514 --> 00:57:19,794 The patient knows it's not just coming from, you know, the podiatrist, um, and the same thing, you know, we didn't even get to touch on glycemic control at all, but as an ID doc or a podiatrist saying, hey, you know, lower your glucose, stop smoking, is re reinforcing the same message consistently is, is very important. 568 00:57:20,534 --> 00:57:23,174 Marcos Schechter: I, I think for the trainees who listen to this. 569 00:57:23,749 --> 00:57:25,449 This is a very important disease. 570 00:57:25,709 --> 00:57:31,689 It's much more nuanced and complicated than we learned during ID fellowship and internal medicine residency. 571 00:57:32,529 --> 00:57:35,159 And there's so much of it in the U. 572 00:57:35,159 --> 00:57:35,349 S. 573 00:57:35,559 --> 00:57:36,249 and globally. 574 00:57:36,249 --> 00:57:42,489 I think it's scientifically interesting and there is a big room to make a big impact. 575 00:57:42,969 --> 00:57:45,449 And we don't think about it enough as a cool thing to do an ID. 576 00:57:45,449 --> 00:57:46,899 It doesn't have the glamour it should. 577 00:57:47,939 --> 00:57:49,649 Tze-Woei Tan: And I think we all get along. 578 00:57:49,799 --> 00:57:51,899 Surgeon, non surgeon, ID doctor. 579 00:57:53,079 --> 00:57:57,619 endocrine, toe and flow, glycemic control, primary care, 580 00:57:59,349 --> 00:58:00,359 David Armstrong: and metabolic jump. 581 00:58:00,924 --> 00:58:15,389 Toe, flow and the metabolic know, and the ID know, K N O W, uh, listen, my dad used to say that, I can think of two great gifts at working at the end of the body, you know, my dad was a foot doctor too, and my daughter, Uh, is now going to be a third generation. 582 00:58:15,389 --> 00:58:20,269 She's a PGY 1 in Texas now, UT, uh, but she's going to be a third generation foot doc. 583 00:58:20,879 --> 00:58:28,099 Back in the day, I would say I could think of two great gifts at working at the end of the body, but the most important one is when you're, uh, looking after the foot. 584 00:58:28,634 --> 00:58:36,634 Immediately, um, in this era of chest thumping, uh, and testosterone, you know, fueled kind of chatter. 585 00:58:36,764 --> 00:58:41,704 I can't think of anything that's more of an expression of humility than looking after someone's feet. 586 00:58:41,774 --> 00:58:44,374 And this is a humble little area. 587 00:58:45,774 --> 00:58:50,064 It may be humble though, and I said little, but you know what, the trouble is it's not so little anymore. 588 00:58:50,094 --> 00:58:55,074 This is a big area and it's interdisciplinary and, and with a little bit of humility and perspective. 589 00:58:55,644 --> 00:59:02,354 Um, I think we can make a really, really big difference by just realizing it's not one individual. 590 00:59:02,354 --> 00:59:05,874 No one is unto him or herself an island here. 591 00:59:06,254 --> 00:59:17,154 When you put yourself together like you have here on this podcast amongst friends, I think we can affect big change, um, and we can eliminate preventable amputations over the next generation. 592 00:59:17,174 --> 00:59:19,724 So listen, thanks for doing this and here's to that. 593 00:59:20,949 --> 00:59:21,859 Sara Dong: Oh, thank you guys. 594 00:59:21,899 --> 00:59:25,279 And I have to say, this may be a record for most puns. 595 00:59:25,279 --> 00:59:30,889 So I'll give you an extra congratulation for that. 596 00:59:33,189 --> 00:59:35,099 A huge thank you to our guest stars today. 597 00:59:35,389 --> 00:59:42,989 You can find their article, Evaluation and Management of Diabetes Related Foot Infections from CID linked in the episode info and in the Consult Notes. 598 00:59:44,119 --> 00:59:45,939 We'll be back next week with another StAR episode. 599 00:59:47,249 --> 00:59:49,299 Don't forget to check out the website, febrilepodcast. 600 00:59:49,339 --> 00:59:54,059 com, where you can find the Consult Notes, our library of ID infographics, and a link to our merch store. 601 00:59:54,529 --> 00:59:58,959 Febrile is produced with support from the Infectious Diseases Society of America, IDSA. 602 00:59:59,179 --> 01:00:03,029 Please reach out if you have any suggestions for future shows or want to be more involved with Febrile. 603 01:00:03,339 --> 01:00:04,059 Thanks for listening. 604 01:00:04,359 --> 01:00:05,679 Stay safe, and I'll see you next time.