Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BackgroundAbscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.ObjectiveThis review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.DiscussionUltrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.ConclusionsThis review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.     

Catheter Ablation of Atrial Fibrillation: An Overview for Clinicians

Catheter ablation (CA) of atrial fibrillation (AF) is currently one of the most commonly performed electrophysiology procedures. Ablation of paroxysmal AF is based on the elimination of triggers by pulmonary vein isolation (PVI), while different strategies for additional AF substrate modification on top of PVI have been proposed for ablation of persistent AF. Nowadays, various technologies for AF ablation are available. The radiofrequency point-by-point ablation navigated by electro-anatomical mapping system and cryo-balloon technology are comparable in terms of the efficacy and safety of the PVI procedure. Long-term success of AF ablation including multiple procedures varies from 50 to 80%. Arrhythmia recurrences commonly occur, mostly due to PV reconnection. The recurrences are particularly common in patients with non-paroxysmal AF, dilated left atrium and the "early recurrence" of AF within the first 2–3 post-procedural months. In addition, this complex procedure can be accompanied by serious complications, such as cardiac tamponade, stroke, atrio-esophageal fistula and PV stenosis. Therefore, CA represents a second-line treatment option after a trial of antiarrhythmic drug(s). Good candidates for the procedure are relatively younger patients with symptomatic and frequent episodes of AF, with no significant structural heart disease and no significant left atrial enlargement. Randomized trials demonstrated the superiority of ablation compared to antiarrhythmic drugs in terms of improving the quality of life and symptoms in AF patients. However, nonrandomized studies reported additional clinical benefits from ablation over drug therapy in selected AF patients, such as the reduction of the mortality and stroke rates and the recovery of tachyarrhythmia-induced cardiomyopathy. Future research should enable the creation of more durable ablative lesions and the selection of the optimal lesion set in each patient according to the degree of atrial remodeling. This could provide better long-term CA success and expand indications for the procedure, especially among the patients with non-paroxysmal AF.     

Training Clinicians to be Preceptors: An Application of Kolb's Theory

The use of adult learning theory can provide advanced practice registered nurses (APRNs) with concrete strategies for developing skills as preceptors in clinical settings. These same principles can also strengthen continuing education programs. We present ways in which the Clinical Training Center for Family Planning uses Kolb’s Adult Learning Theory to structure a preceptor training curriculum and assist APRNS in precepting clinical settings.     

Chronic Disease and Mobile Technology: An Innovative Tool for Clinicians

Chronic disease is common, costly and the epidemic of the 21st century. Primary care providers seek new and innovative approaches to prevent chronic illness. Since the majority of chronic illness management occurs outside a physician's office, providers must use different techniques to support daily self‐management of any chronic illness. Assisting the individual to develop life skills to support self‐management is one way to improve patient outcomes. Technology, that is easily accessed, may provide an additional method to develop and individual's self‐management skills to prevent diabetes.     

An Introduction to Search Engines

Scientific Inquiry provides a forum to facilitate the ongoing process of questioning and evaluating practice, presents informed practice based on available data, and innovates new practices through research and experimental learning.     

An Introduction to Patient Safety

A brief historical background of today's patient safety movement helps us to understand how the leap was made from safety in other industries to that in health care. Although comparing studies on adverse events in various countries is difficult, an attempt is made to emphasize both their scope and cost in the United States, Australia, the United Kingdom, and Canada. Sources of error are then examined and a variety of concepts are introduced, namely, human and systemic error; active failures and latent conditions; the Swiss cheese model; and normalization of error. A human versus a system approach to adverse events is also examined.The four basic building blocks or the four Cs of patient safety are reviewed. They are: changing the culture of safety, collecting the data through incident reporting systems, calculating the risk to patients, and clinical audits. This is followed by a review of the three essential supporting activities, namely human factors engineering, effective communication, and staff education on patient safety. Current patient safety initiatives are summarized, along with high reliability organizing concepts and system barriers to health care safety. The article concludes that many adverse events are preventable and that they happen in all areas of health care, and calls for an orderly and comprehensive approach to patient safety. It also concludes that the four Cs of patient safety must be supported by the other three patient safety activities.     

Quick Reference Guide for Clinicians

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline on Management of Cancer Pain , which was developed by a private-sector panel of health care providers and consumers. Selected aspects of evaluating and managing pain in adults with cancer pain are presented. Topics covered include initial assessment, pharmacologic treatment, administration of medications, side effects of medications, adjuvant medications, cognitive-behavioral interventions, and discussion of other more invasive palliative techniques, A flowchart is included that shows the sequence of events in evaluating and managing cancer pain, as well as drug dosing tables and forms to assist the clinician and patient to adequately describe and assess pain.
The Clinical Practice Guideline , a critical synthesis of research and knowledge in the field, is designed to help any clinician working with cancer patients in any setting. The Guideline presents a thorough discussion of ways to manage procedure-induced pain and invasive modalities of pain control therapy, for use when simpler methods do not control pain. It also devotes considerable attention to pain control in special populations, including patients with concurrent medical and substance abuse problems, those with psychiatric problems related to pain and cancer, and members of minority and ethnic groups. Because pain problems in patients with HIV/AIDS are often assessed and treated using the same approaches as those used for cancer pain, HIV/AIDS pain is described as well. Practitioners should review the Clinical Practice Guideline carefully to become familiar with the various options for management of cancer pain and then use the Quick Reference Guide to help them remember the major points in managing cancer pain.