1 00:00:07,560 --> 00:00:08,370 Sara Dong: Hello everyone. 2 00:00:08,400 --> 00:00:12,510 Welcome to Febrile - a cultured podcast about all things infectious disease. 3 00:00:12,630 --> 00:00:13,570 My name is Sara Dong. 4 00:00:13,590 --> 00:00:15,629 I'm your host and a Med-Peds ID fellow. 5 00:00:15,770 --> 00:00:19,210 In today's Febrile Digest, I'm joined by Jeremey Walker. 6 00:00:19,210 --> 00:00:20,970 Jeremey, can you say hello and introduce herself. 7 00:00:21,030 --> 00:00:21,480 Jeremey Walker: Yes. 8 00:00:21,480 --> 00:00:22,020 Hello. 9 00:00:22,020 --> 00:00:23,660 Thank you so much for having me on Sara. 10 00:00:23,660 --> 00:00:24,960 I'm really excited to be here. 11 00:00:25,200 --> 00:00:26,100 My name is Jeremey Walker. 12 00:00:26,100 --> 00:00:29,130 I'm an Assistant Professor in Infectious Disease at UAB. 13 00:00:29,220 --> 00:00:42,670 Um, my clinical interests are in transplant and hospital epidemiology, but what I'm here and what I really, uh, I guess is my passion is medical education and specifically making that fun, uh, through some elements of gamification. 14 00:00:42,910 --> 00:00:43,960 Sara Dong: Yeah, love it. 15 00:00:44,050 --> 00:00:56,465 Um, and so today we're going to chat a little bit about ID Fellows Cup, which I suspect a lot of our listeners already know about or heard of, but for those who haven't, can you just give a quick overview of what ID Fellows Cup is? 16 00:00:56,735 --> 00:00:57,485 Jeremey Walker: Absolutely. 17 00:00:57,545 --> 00:01:05,555 So the Fellows Cup is really based out of, uh, an app, the Kaizen education app, which was created by one of my mentors, James Willig. 18 00:01:05,885 --> 00:01:10,565 And what that does is it's really a tool to help educators deliver content. 19 00:01:10,895 --> 00:01:17,585 And so it allows you to create multiple choice board style questions and deliver that through a mobile app. 20 00:01:17,585 --> 00:01:19,105 So it's really crisp and clean. 21 00:01:19,435 --> 00:01:22,195 Um, but what separates it a bit from a question bank? 22 00:01:22,345 --> 00:01:33,025 It actually releases the content rather than just a large bank of questions, it releases it daily at a certain pattern, and then it also has some additional game elements to help keep it fun and engaging. 23 00:01:33,445 --> 00:01:40,075 Um, so we, my first experience with that was actually within microbiology for our first-year medical students. 24 00:01:40,465 --> 00:01:45,625 And so the story of the Fellows Cup is that we had this experience and found that our learners really enjoyed it. 25 00:01:45,625 --> 00:01:49,655 And we were able to actually present it as an abstract at ID week. 26 00:01:49,985 --> 00:01:56,465 And then through that ended up meeting some of the people from the ID Fellows Networks, specifically Nathan Nolan and Miguel Chavez. 27 00:01:56,705 --> 00:02:03,845 And then we just started dreaming about what that could look like, um, in fellows education, and thus came the ID Fellows Cup. 28 00:02:03,905 --> 00:02:09,205 And so for last year, what we actually were able to do is we had two competitions. 29 00:02:10,080 --> 00:02:13,080 Uh, one was in the spring and one was in the fall. 30 00:02:13,130 --> 00:02:14,990 Each was three to four weeks. 31 00:02:14,990 --> 00:02:17,780 And so it ended up being a total of about a hundred questions. 32 00:02:18,110 --> 00:02:23,120 And then in January of 2022, we actually had what we called a consolidation game. 33 00:02:23,390 --> 00:02:28,250 And so we revisited some of the questions that hit in that 60 to 70% accuracy. 34 00:02:28,460 --> 00:02:38,150 And we released those right before the in-training exam, just as an opportunity for some spaced learning, um, and to get everyone kind of geared up for that upcoming in-training experience. 35 00:02:38,584 --> 00:02:51,275 So really our goals with the Fellows Cup have been to provide a platform to engage fellows in both creation, as well as review of board relevant ID content, and then to connect learners to useful online med ed resources. 36 00:02:52,635 --> 00:02:53,235 Sara Dong: Love it. 37 00:02:53,565 --> 00:02:57,035 And it perfectly aligns with what I hope Febrile can do. 38 00:02:57,035 --> 00:03:12,300 And I think all of us as fellows probably have those, um, talks where you go over the most commonly missed questions on your in training exam, so we're going to kind of do the same thing today and chat about commonly missed questions or topics in the recent competition. 39 00:03:12,300 --> 00:03:13,410 So I'm excited. 40 00:03:13,770 --> 00:03:15,510 Um, and I actually have the first question. 41 00:03:15,540 --> 00:03:25,320 We have a young carnival worker who presented with progressive right arm symptoms after sustaining an injury on the arm, repairing a macaque monkey habitat. 42 00:03:25,380 --> 00:03:31,320 A few days after the injury, he has a local vesicular rash, and it's followed by some regional numbness. 43 00:03:31,350 --> 00:03:36,660 And now it's been about three weeks later and he has lymphadenopathy, parasthesias, and fever. 44 00:03:37,195 --> 00:03:40,795 And so the way this actually was created originally, it was a two-step question. 45 00:03:40,795 --> 00:03:44,605 But the first thing we're asking ourselves is what infection is this? 46 00:03:44,815 --> 00:03:46,525 What is the monkey to blame for? 47 00:03:47,375 --> 00:03:52,055 Jeremey Walker: Exactly to be honest, I probably should have stuck with the first step. 48 00:03:53,705 --> 00:03:58,715 You know, our goal in creating these questions is to hit it about 60 to 80% accuracy. 49 00:03:58,715 --> 00:04:00,875 That's where you're kind of flexing your muscles. 50 00:04:01,205 --> 00:04:06,545 Um, but yet not just kind of getting blown away the difficulty. 51 00:04:06,875 --> 00:04:12,485 And so I think if you are approaching this question and you have no association with monkeys necessarily. 52 00:04:13,065 --> 00:04:16,095 The question, stem itself, screams zoonotic exposure. 53 00:04:16,515 --> 00:04:29,355 And if you're thinking in that zone, and you're thinking about a regional syndrome with lymphadenopathy and fevers, some things like Bartonella or tularemia may come to mind, and that was what some of the distractor choices were getting at. 54 00:04:29,375 --> 00:04:36,935 The progressive neurologic features probably brought to mind rabies, and that was another one of the distractor choices, but none of those fit perfectly. 55 00:04:37,565 --> 00:04:40,505 And in particular, because you said something about a vesicular rash. 56 00:04:40,565 --> 00:04:48,664 And so that brings up to the association that you do need to have, which is herpes B virus, which is associated with macaque monkey exposure 57 00:04:49,085 --> 00:04:49,445 Sara Dong: Yeah. 58 00:04:49,475 --> 00:04:58,835 And I know most of us don't get called too frequently about monkey bites, but it's really important to recognize herpes B virus because it can be fatal without treatment. 59 00:04:58,835 --> 00:05:00,635 And so how is this treated? 60 00:05:00,785 --> 00:05:00,935 Jeremey Walker: Yeah. 61 00:05:01,025 --> 00:05:05,255 So in this example, actually the answer would be, IV ganciclovir. 62 00:05:05,575 --> 00:05:11,435 Because uh, they were already demonstrating neurologic involvement, so that is the agent that is gone to at that time. 63 00:05:11,465 --> 00:05:16,805 Really in an ideal world, they would receive prophylaxis before they got to that stage. 64 00:05:16,805 --> 00:05:21,475 And so the prophylactic answer is actually valacyclovir. 65 00:05:21,975 --> 00:05:25,965 And that was actually the most commonly chosen distractor choice as well. 66 00:05:25,965 --> 00:05:30,705 So I think in retrospect, I should have just asked what prophylaxis could have prevented this. 67 00:05:30,705 --> 00:05:32,535 And I think a lot of people were right on there. 68 00:05:32,925 --> 00:05:43,145 Um, but there was a nice paper in the notes, which kind of addresses when prophylaxis should be considered, but I think the most important takeaway is this is something that's truly unique to macaque monkey exposure. 69 00:05:43,675 --> 00:05:44,065 Sara Dong: Yeah. 70 00:05:44,515 --> 00:05:44,755 Yeah. 71 00:05:44,755 --> 00:05:49,675 And I think it's a association that once you have a question like this, it, it probably sticks. 72 00:05:49,675 --> 00:05:53,485 The same way, I think of, uh, that picture of orf virus. 73 00:05:53,725 --> 00:06:01,045 I suspect I'll never see that, but I feel like because I've done questions on it, I'm going to remember it somewhere wedged in my brain forever. 74 00:06:01,525 --> 00:06:08,370 And you know, you've referenced a little bit about the writing process and things that you learn as you go through these iterations of the game. 75 00:06:08,430 --> 00:06:13,419 How do you feel like question writing has changed since you guys had that first game in April? 76 00:06:13,659 --> 00:06:16,750 Jeremey Walker: So the biggest change is this the number of people involved. 77 00:06:16,780 --> 00:06:25,930 So it really began with just five fellows and five attendings kind of reviewing that initial question set, but on our second game, we're actually able to open it up. 78 00:06:25,960 --> 00:06:29,110 Uh, and fellows from around the world submitted questions. 79 00:06:29,110 --> 00:06:32,140 And then we had a team of mentors that helped develop them. 80 00:06:32,500 --> 00:06:42,250 And so for our upcoming game in April, this year, we actually have 47 separate fellows that are writing questions and 12 question mentors, helping to develop. 81 00:06:43,155 --> 00:06:44,025 Sara Dong: Which is so cool. 82 00:06:44,025 --> 00:06:48,254 I mean, just another way to build community amongst ID fellows. 83 00:06:48,674 --> 00:06:52,484 Are there any other impacts from opening it up that you have noticed? 84 00:06:52,814 --> 00:06:55,874 Jeremey Walker: I mean, I think the first is just, the questions are so much better. 85 00:06:56,804 --> 00:07:02,924 So initially when we approached or developed this, a lot of it was for community building and to help collaborate. 86 00:07:03,104 --> 00:07:09,614 Also to provide an opportunity to get some feedback, which is so rare in medical education, to help develop better question writers. 87 00:07:09,914 --> 00:07:11,594 And I do hope we are doing that. 88 00:07:11,944 --> 00:07:23,760 But in addition, we're just getting this variety in clinical experience and exposures and interests, and people are asking questions in ways that we could have never envisioned on our own or as individual creating them. 89 00:07:24,060 --> 00:07:26,580 And so it's been really interesting to learn from one another. 90 00:07:26,790 --> 00:07:29,700 So the next question I'll share is actually an example of this. 91 00:07:29,700 --> 00:07:35,190 It's about a topic that I think is near to both of our hearts, rashes in immunocompromised patients. 92 00:07:35,280 --> 00:07:35,850 Sara Dong: Yes. 93 00:07:35,880 --> 00:07:36,210 Okay. 94 00:07:36,210 --> 00:07:36,690 I'm ready. 95 00:07:37,455 --> 00:07:48,945 Jeremey Walker: So the stem is a middle-aged person with myelodysplastic syndrome on azacitadine for several months with severe neutropenia and who presents with progressive skin lesions for two weeks. 96 00:07:49,905 --> 00:07:53,625 So the first lesion appeared on the right arm and grew to three centimeters. 97 00:07:53,865 --> 00:07:57,705 And now she has innumerable lesions across torso and upper extremities. 98 00:07:58,005 --> 00:08:01,575 They all begin as red nodules, but then grow to be bullous in the center. 99 00:08:01,965 --> 00:08:06,435 She's had no fevers or chills and her vitals are normal on presentation. 100 00:08:06,705 --> 00:08:15,920 She lives in Appalachia, hikes on cultivated trails, but no concerning exposures of note and, I've actually rewrote this again so it's a single step. 101 00:08:16,580 --> 00:08:19,640 But what is your differential when you're approaching cases like this. 102 00:08:20,140 --> 00:08:20,420 Sara Dong: Yeah. 103 00:08:20,420 --> 00:08:34,890 I mean, I think the one we worry about or sort of one of the scarier ones is ecthyma or ecthyma gangrenosum , which we classically think of Pseudomonas, but can definitely be a variety of other bacteria or molds even such as Fusarium. 104 00:08:35,340 --> 00:08:46,235 And then I think anytime you think of echythma in an immunocompromised host, you're also probably thinking about disseminated fungal infection in general, whether that's candidiasis or Crypto. 105 00:08:46,295 --> 00:08:52,685 And so you're kind of stuck biopsying these to rule out infection because it's really hard to know just from looking at it. 106 00:08:53,065 --> 00:08:58,605 But in this stem it's been around for a little while and has been relatively stable. 107 00:08:58,665 --> 00:09:12,985 And it makes you think about non ID etiologies of rashes that look like this , so leukemia cutis, and I have the benefit of seeing the picture, but what looks like neutrophilic dermatosis or sweet syndrome. 108 00:09:13,165 --> 00:09:14,305 Jeremey Walker: That's exactly right. 109 00:09:14,365 --> 00:09:21,955 Uh, we seem to have a new case of rash in a neutropenic patient every week that I'm on the IC service, and that differential is just so important. 110 00:09:21,955 --> 00:09:29,305 And so it is challenging to write a question that incorporates that because ultimately so many things do come back, uh, to the biopsy. 111 00:09:29,605 --> 00:09:42,100 But the mobile app will use Kaizen can actually embed content such as pictures and, uh, which will allow you to be able to see some of these components of the physical exam or micro content as we'll discuss later. 112 00:09:42,400 --> 00:09:50,260 Um, and then it also has links that you can link out to other resources, which is really part of my favorite component of this. 113 00:09:50,500 --> 00:09:55,510 And so you can include a succinct explanation, uh, for each question. 114 00:09:56,235 --> 00:10:00,375 On top of that, you can have these various links that they can go to to learn more. 115 00:10:00,555 --> 00:10:08,855 And we usually try to have one link that's a little bit easier to digest, something quick and simple, like a Twitter post, another question, a tweetorial. 116 00:10:09,075 --> 00:10:16,215 And then we like to have something that's a little bit more detailed and robust, like a nice review article or an excellent podcast, such as Febrile. 117 00:10:16,755 --> 00:10:17,125 Sara Dong: Nice. 118 00:10:17,145 --> 00:10:18,195 A very nice plug. 119 00:10:18,795 --> 00:10:29,035 And, you know, as reminder, we're going to put these question samples on the Consult Notes for the Febrile website, and also I will remember to put them out on Twitter. 120 00:10:29,365 --> 00:10:32,005 Um, but I have our third question. 121 00:10:32,405 --> 00:10:39,085 So, in this scenario, we had a middle-aged patient with diabetes who came into the ED with severe sepsis. 122 00:10:39,475 --> 00:10:47,640 And so she had just returned from a rafting trip in Northern Australia and had acute onset of fever, chills, productive cough, and dyspnea. 123 00:10:47,670 --> 00:10:56,400 Her workup then reveals a left upper lobe consolidation as well as hypotension and hypoxia that unfortunately required transfer to the ICU. 124 00:10:56,490 --> 00:11:05,970 And so a CT scan shows splenic abscesses and the blood cultures are now growing aerobic gram-negative rods with bipolar staining. 125 00:11:06,000 --> 00:11:08,460 And so in this scenario, there was a picture of that. 126 00:11:08,520 --> 00:11:10,790 So Jeremey, what's our most likely diagnosis here? 127 00:11:10,930 --> 00:11:14,600 Jeremey Walker: So I love a question that allows a couple routes to the answer, right? 128 00:11:14,900 --> 00:11:20,060 So you can approach this by thinking about the clinical history and epidemiology. 129 00:11:20,060 --> 00:11:24,350 So you have severe sepsis with pneumonia and multiorgan abscesses. 130 00:11:24,590 --> 00:11:28,070 You layer in that epi history of rafting in Northern Australia. 131 00:11:28,310 --> 00:11:30,830 And you've probably arrived at your correct answer. 132 00:11:31,040 --> 00:11:44,585 We could have changed the stem a bit to be someone from the U S who's an avid user of essential oil aromatherapy sprays, um, although thankfully uh that has, that outbreak has been found and addressed. 133 00:11:44,945 --> 00:11:47,345 But the micro picture tells you a lot as well. 134 00:11:47,345 --> 00:11:50,345 There's only a few organisms that are known for bipolar staining. 135 00:11:50,675 --> 00:11:50,945 Sara Dong: Yes. 136 00:11:50,975 --> 00:11:55,415 This is one of those buzzwords that I think all of us probably have a little note scratched somewhere. 137 00:11:55,745 --> 00:12:01,695 The list I have is - there are, you know, a couple of things in the genital ulcer realm. 138 00:12:01,695 --> 00:12:06,055 So Klebsiella granulomatosis and Haemophilus ducreyi. 139 00:12:06,195 --> 00:12:20,305 And then when I think about systemic illness, which is a better fit for this patient, the ones that stand out in particular are Yersinia pestis, which I feel like is usually an answer we think of, but in this scenario, Burkholderia pseudomallei. 140 00:12:20,525 --> 00:12:21,605 Jeremey Walker: Yes exactly. 141 00:12:21,605 --> 00:12:25,470 And, you know, it's a perfect example of why it's always worth a trip to the micro lab. 142 00:12:25,830 --> 00:12:30,540 Um, you know, as I stated, I, this started for me, at least with our micro course. 143 00:12:30,780 --> 00:12:39,800 And so one of the fun things from this past year is I actually took, uh, some of the ID Fellows Cup questions that had a significant microbiology component. 144 00:12:40,020 --> 00:12:52,665 And I did it as part of a trivia round with some of our, with our med students that were first years and despite not having any of the clinical context, they were able to get several of these questions just by knowing those key micro components. 145 00:12:52,665 --> 00:12:56,085 So it's really, it's nice to see those two things play together. 146 00:12:56,085 --> 00:13:11,095 And I, I think it's an important thing for us still to know, cause it comes up, you know, at least once a week on rounds, especially on the immune compromised service where we need to go down to the micro lab and talk about some things, but the original stem actually it took us to, um, treatment. 147 00:13:11,095 --> 00:13:20,125 And so it, it implied that the patient was on a broad coverage with Vanc and Zosyn, everyone's favorite, um, and that just wasn't doing the trick. 148 00:13:20,275 --> 00:13:20,755 Sara Dong: All right. 149 00:13:20,755 --> 00:13:23,155 So what are we thinking about for drug of choice then? 150 00:13:23,185 --> 00:13:32,620 Jeremey Walker: Given this as critical illness, the answer is meropenem, but ceftazidime would also work for those with moderate disease and Bactrim or doxy has activity as well. 151 00:13:33,020 --> 00:13:38,060 Sara Dong: You know, we've picked, obviously we're reviewing some of the most missed questions that are a little bit more challenging. 152 00:13:38,520 --> 00:13:45,750 How do you strike that balance between making the questions difficult, but also trying to keep it a bit more fun and entertaining. 153 00:13:45,870 --> 00:13:47,890 Jeremey Walker: It's an excellent question, Sara. 154 00:13:48,170 --> 00:13:53,570 Gamification is a little different than serious gaming, which I know you've had some, some serious gamers on as well. 155 00:13:53,570 --> 00:13:56,570 So at the heart of a serious game is a game. 156 00:13:56,600 --> 00:14:01,730 It's a game that's designed to learn, but it's, it's the activity itself as a game. 157 00:14:02,120 --> 00:14:09,685 And the difference with gamification is at the heart of it is an educational activity with game elements added in. 158 00:14:09,685 --> 00:14:17,755 And so at the heart of Kaizen is truly a question bank and we all know that question banks are incredibly effective for learning. 159 00:14:17,755 --> 00:14:25,085 It's how we have learned medicine, essentially since we began studying for step one, but we also know it can be kind of challenging. 160 00:14:25,265 --> 00:14:28,115 And the reason it works is because it is challenging, right? 161 00:14:28,115 --> 00:14:34,835 It's forces you to pull up and retrieve prior information to form new connections and all of that takes work. 162 00:14:35,135 --> 00:14:44,185 And it's hard to get yourself geared up, to do that extra work day in and day out to kind of have that frequent exposure that's most helpful to really learn. 163 00:14:44,915 --> 00:14:51,905 And so what, um, the game elements help us to do is it just helps to keep you coming back to help make it a little bit fun. 164 00:14:52,175 --> 00:15:07,805 And it's really not unlike what a lot of fitness apps or gyms or other things will kind of utilize to help getting people to come back day in and day out, um, to continue an activity they know is good, um, but also can sometimes be a little bit, uh, taxing. 165 00:15:08,790 --> 00:15:09,210 Sara Dong: Yeah. 166 00:15:09,330 --> 00:15:11,790 And what are some of those things that you guys do? 167 00:15:11,820 --> 00:15:17,670 I I'm already thinking of some from, from thinking about playing the game, but maybe you can point out a couple. 168 00:15:17,850 --> 00:15:18,210 Jeremey Walker: Yeah. 169 00:15:18,210 --> 00:15:22,020 So the obvious are those that really play off those who are competitive at heart. 170 00:15:22,050 --> 00:15:22,440 Right. 171 00:15:22,440 --> 00:15:26,850 And so you have each question answered correct gives you points. 172 00:15:26,850 --> 00:15:30,240 And so there's a leaderboard and you can see where you fall on that. 173 00:15:30,300 --> 00:15:40,085 Um, uh, really across everyone who's playing and then there's also badges that you get for answering so many questions correct in a row, et cetera. 174 00:15:40,475 --> 00:15:45,275 But then there's, there's more, um, subtle things that play off people's intrinsic motivation. 175 00:15:45,275 --> 00:15:51,995 So ability to complete a task, you can get the badges for reaching a certain level of, for playing for so many days in a row. 176 00:15:52,355 --> 00:15:56,345 And then I think one of the most important aspects really is the team component. 177 00:15:56,375 --> 00:16:00,695 That many people were playing as a group, as part of an institution. 178 00:16:00,935 --> 00:16:05,520 And they felt like they were competing together as a team, uh, through these questions. 179 00:16:05,940 --> 00:16:06,330 Sara Dong: Yeah. 180 00:16:06,630 --> 00:16:09,720 And you guys did a couple versions of teams right. 181 00:16:09,720 --> 00:16:17,490 Where sometimes it was by institution and sometimes it was sort of a group of others that didn't necessarily come in as a program. 182 00:16:17,760 --> 00:16:19,240 How does that sort of team play work? 183 00:16:19,260 --> 00:16:24,300 Jeremey Walker: Yeah, so each person, I mean, practically each person receives the same questions. 184 00:16:24,300 --> 00:16:45,470 And so you're answering each question as an individual, but then your group score is the average of those, uh, and so for those who are playing as an institution, I think it's really helpful because generally you have someone on the ground that was excited that signed the team up so they can kind of help rally the troops if you will, and get people, you know, engaged in playing. 185 00:16:45,470 --> 00:16:52,580 Oftentimes what I've seen, at least at UAB, is after the questions are answered, there's kind of review of some of the question contents. 186 00:16:52,580 --> 00:16:56,120 Things will come up in other lecture platforms and other places. 187 00:16:56,810 --> 00:16:58,790 Sometimes that's a helpful learning thing. 188 00:16:58,790 --> 00:17:04,820 Sometimes that's just a well spirited grumble, but both are helpful, right, for team building. 189 00:17:05,704 --> 00:17:15,845 Um, and then the people who, uh, were joining as individuals for them, we just put them on teams with people, for other people from around the world who wanted to join as an individual. 190 00:17:15,845 --> 00:17:21,365 And we did try to separate, especially for the second game, we realized that there was different levels of competitiveness. 191 00:17:21,665 --> 00:17:26,675 So we had to ask, so we said, you know, how competitive are you? 192 00:17:26,974 --> 00:17:33,745 And we tried to put people on similarly competitive teams so that everyone would have a good time. 193 00:17:34,215 --> 00:17:34,575 Sara Dong: Yeah. 194 00:17:34,865 --> 00:17:40,835 Jeremey Walker: So I think we have time for one more question and we're back to skin rashes and immune compromised hosts. 195 00:17:40,865 --> 00:17:45,815 And this one I think is really fair to ask you because you helped to develop this question as one of the mentors. 196 00:17:46,325 --> 00:17:48,425 So, but we have a different host this time. 197 00:17:48,425 --> 00:17:56,645 So it's a kidney transplant patient, or a recipient, who is from Texas and presents with two weeks of subcutaneous nodules. 198 00:17:56,935 --> 00:18:03,785 Her immune suppression has been stable and her exam is only notable for these multiple tender brown to purple nodules on extremities. 199 00:18:04,265 --> 00:18:11,255 A punch biopsy reveals granulomatous inflammation and acid fast bacilli are found, which grow after four days. 200 00:18:11,465 --> 00:18:15,285 So the question again, takes you to the second step and asks how you would treat. 201 00:18:15,725 --> 00:18:27,045 Sara Dong: Oh, well, I'm thinking about rapid growers and I will plug when we had Ruvandhi on way back in like episode seven, thinking about NTMs. 202 00:18:27,215 --> 00:18:27,575 Jeremey Walker: Yes. 203 00:18:27,575 --> 00:18:33,335 You had some great infographics there for both breaking NTMs down by lab ID techniques, but also clinical centers. 204 00:18:34,040 --> 00:18:34,520 Sara Dong: Yeah. 205 00:18:34,550 --> 00:18:42,710 So I'm thinking about a Mycobacterium chelonae or maybe abscessus here since it's rapid growing. 206 00:18:43,070 --> 00:18:51,620 Um, those also are the ones that you sort of keep in mind, as you think about syndromes with multiple skin lesions in someone who's immunocompromised. 207 00:18:52,090 --> 00:19:00,625 Fortuitum is also a rapid grower, and I feel like we classically get the stem that they've had some sort of procedure, cosmetic procedure, like a pedicure. 208 00:19:00,895 --> 00:19:03,565 Um, but often they have more localized disease. 209 00:19:03,955 --> 00:19:11,005 But for chelonae and abscessus, you would need at least two antibiotics, if not a third. 210 00:19:11,465 --> 00:19:19,035 And so I think amino glycosides and linezolid and macrolides would be our common initial agents. 211 00:19:19,395 --> 00:19:24,795 Uh, but I always have to look up the issue with using macrolides and maybe you'll tell me. 212 00:19:25,590 --> 00:19:32,850 Jeremey Walker: Yes, um well the erm gene, uh, is an inducible resistance to macrolides that several of our rapid growers have. 213 00:19:33,240 --> 00:19:37,710 And this is primarily fortuitum, but it's seen an abscessus as well. 214 00:19:38,030 --> 00:19:40,630 Chelonae however, is safer. 215 00:19:40,965 --> 00:19:48,525 Sara Dong: The other thing that we have to think about if it's a transplant, patient is macrolides can interact with calcineurin inhibitors. 216 00:19:48,555 --> 00:19:50,865 And so it's going to bump up those drug levels. 217 00:19:51,225 --> 00:19:56,595 And I think azithro does this less than clarithromycin. 218 00:19:56,955 --> 00:19:59,235 And so I'd probably pick that as part of my regimen. 219 00:19:59,265 --> 00:20:04,205 I feel like we're really shifting towards azithro in general for most cases anyways., 220 00:20:04,295 --> 00:20:05,285 Jeremey Walker: You're absolutely right. 221 00:20:05,315 --> 00:20:10,505 And this question actually emphasized that by having both macrolides as options with appropriate regimens. 222 00:20:10,745 --> 00:20:13,045 And so the best choice would have been as azithro. 223 00:20:13,385 --> 00:20:14,165 Sara Dong: Oh, I love it. 224 00:20:14,195 --> 00:20:17,635 We're just sprinkling in a little bit of fun of transplant as well. 225 00:20:18,115 --> 00:20:29,760 And so, you know, we are approaching the end of time for the episode and I, I just wanted to end by asking how do you see ID Fellows Cup growing and expanding this coming year? 226 00:20:30,120 --> 00:20:34,860 Jeremey Walker: Yeah, I think I'm most excited about having gained so many new question writers. 227 00:20:35,130 --> 00:20:39,690 The question we just reviewed actually was from the October game from Suha Khalaf at Missouri. 228 00:20:40,080 --> 00:20:46,620 And I've just been amazed by the quality and varied perspective that has been generated by having all these different contributors. 229 00:20:46,890 --> 00:20:58,740 And the ID Fellows Network has actually allowed us to incorporate these former questions on their websites, which gives us a place to backlog these questions, as well as allow our question writers a place to point towards their questions in the future. 230 00:20:59,010 --> 00:21:15,680 And so I'm just excited to see where these ongoing collaborations take us, and hope that we can add to the grow in a kind of fountain of ID Med Ed resources that are being developed, um, as well as just have some fun through our questions and build some of those bridges with other resources. 231 00:21:15,890 --> 00:21:16,310 Sara Dong: Yeah. 232 00:21:16,370 --> 00:21:22,320 I think, I think that's our end goal is to make this mega ID Med Ed collaboration or force. 233 00:21:22,645 --> 00:21:27,175 But yeah, as you kind of mentioned connecting resources, is there anything else that you had in mind? 234 00:21:27,565 --> 00:21:29,695 Jeremey Walker: And there's just so much great content out there. 235 00:21:29,785 --> 00:21:35,305 Um, but it's so hard to stay up to date and I'm, I'm honestly incredibly impressed by people like yourself. 236 00:21:35,305 --> 00:21:41,695 I feel like you just are always just like have your finger on the pulse of what's going on and all these different resources. 237 00:21:41,965 --> 00:21:58,350 And I find myself often like getting a case or having something come up on the wards and I'm having to go through looking for tweetorials or, you know, other sorts of resources that will help point me to this, people who have dealt with this question previously. 238 00:21:58,620 --> 00:22:19,185 And so what we found actually is that because people are signing up as groups, a lot of times we're reaching people initially who have, um, a lot of exposure to online MedEd, but about a third to half of our players end up being recruited from those people at their institution and don't use a lot of online med ed resources. 239 00:22:19,185 --> 00:22:29,985 And so we're hopeful we can kind of collate some helpful resources for the question at hand that they're seeing, um, so that they could visit that or maybe save it for the future if a desired. 240 00:22:30,255 --> 00:22:32,645 Sara Dong: So I'm super excited about the upcoming game. 241 00:22:32,695 --> 00:22:40,550 We're going to post the link for everyone to sign up, but you can also follow ID Fellows Cup on Twitter to make sure that you stay updated. 242 00:22:40,760 --> 00:22:41,420 Jeremey Walker: Absolutely. 243 00:22:41,450 --> 00:22:44,390 And just wanted to thank you again so much for having me on Sara. 244 00:22:44,390 --> 00:22:58,895 It's really been a pleasure and I do want to thank everyone that's been involved, um, with ID Fellows Cup, which has included both our question writers and mentors, the people who have rallied their institution, as you said, the kind of team captains at each individual institution. 245 00:22:59,105 --> 00:23:09,175 But most importantly, my co game managers, Nico Herrera, Mauricio Kahn, they've really done an incredible job, and it's been so fun to partner with so many incredible people like yourself. 246 00:23:09,205 --> 00:23:09,675 Sara Dong: Yeah. 247 00:23:09,675 --> 00:23:10,825 Yeah, no, likewise. 248 00:23:10,825 --> 00:23:28,935 And I'm very grateful for everyone who participates in projects like this, because, you know, you didn't really talk about this necessarily, but it takes a lot of effort to make a good question, in the same way that it can be difficult or time-consuming to make a podcast episode or a quality tweetorial. 249 00:23:29,695 --> 00:23:48,215 And I think these skillsets, although they remain a little bit under appreciated, all of us would benefit from knowing how to create and educate in these different formats, but also as learners and test-takers, there really are multiple benefits for working on projects like this. 250 00:23:48,995 --> 00:23:51,365 Well, with that all wrap us up for the day. 251 00:23:51,425 --> 00:23:53,645 Uh, thank you so much, Jeremy, for coming on the show. 252 00:23:53,675 --> 00:23:55,035 Jeremey Walker: Thank you for having me. 253 00:23:56,475 --> 00:23:56,835 Sara Dong: All right. 254 00:23:56,860 --> 00:24:01,690 So we will have links to the signups for the upcoming ID Fellows Cup game. 255 00:24:02,290 --> 00:24:08,920 Remember that you can find ID Fellows Cup as well as Febrile on Twitter and the website febrilepodcast.com. 256 00:24:09,340 --> 00:24:15,670 I can't wait to have you back next week and we'll have our next episode of Curious Congenital Conundrums, featuring Drs. 257 00:24:15,760 --> 00:24:18,430 Ella Dzora and Jason Brophy. 258 00:24:18,820 --> 00:24:19,690 Thanks for listening. 259 00:24:19,870 --> 00:24:21,910 Stay safe, and we'll see you next time.