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1265. Penicillin Allergy Delabeling: A Quality Improvement Project
(Oxford University Press, 2023-11-27) Shah, Ibrahim; Sheraz, Sana; Ali, Marriam; Graduate Medical Education, School of Medicine
Background: 15% of all hospitalized patients report a penicillin allergy, and greater than 90% of them are not truly allergic. Penicillin allergy labels are associated with worse clinical outcomes, increasing in-hospital mortality, and increasing hospital stays. Historically, penicillin allergies were delabeled by either allergists or infectious disease specialists. Pharmacy-led delabeling programs are emerging but are limited due to pharmacists not having provider status in all states. Also, after successful delabeling, a significant number of patients were relabeled for penicillin allergies on subsequent hospital visits. Methods: We conducted an internal medicine resident-driven quality improvement project in a 350 bed community hospital. Fifty-six patients with a penicillin allergy label in the electronic medical record (EMR) were randomly selected from the inpatient service. If the patient had a non-allergic reaction or had prior exposure to penicillin without a reaction, they were directly delabeled. The remainder underwent risk stratification using the PENFAST scoring tool. Very low-risk and low-risk patients underwent an oral challenge after obtaining written consent. Following this, a hospital-wide pharmacist-triggered physician-driven delabelling protocol was established. Results: We assessed 56 patients between 04/2022 and 09/2022. Thirty-eight patients were delabeled: 18 by direct delabeling and 20 via oral penicillin challenge. One patient who underwent the oral challenge had an adverse reaction (nausea and vomiting). Seven months later, we conducted a secondary survey to assess the durability of our delabeling. Thirteen percent of patients (n=5) had the penicillin allergy label re-added to their chart on subsequent hospital admissions. Conclusion: Delabeling patients on the inpatient service is effective, carries little risk, and requires minimal resources. Additionally, it does not require specialist services. However, the durability of delabeling needs to be reinforced with a robust hospital delabeling protocol, continuous patient education, and EMR alerts to prevent allergy labels from being added back on subsequent visits.
1340. Yield of Repeat Blood Cultures beyond 48 Hours after Negative Initial Cultures in Patients Hospitalized on a Pediatric Hematology/Oncology Unit
(Oxford University Press, 2022-12-15) Prather, Cassandra S.; Alali, Muayad; Graduate Medical Education, School of Medicine
Background: Repeat blood cultures (BCxs) beyond 48 hours are often obtained despite negative initial BCxs in hospitalized pediatric hematology/oncology patients. This study seeks to determine the yield of repeat BCxs after negative initial cultures in these patients and to characterize new positive BCxs beyond 48 hours and the clinical contexts in which they were obtained. Methods: A retrospective review utilizing MedMined Inc. Data Mining Surveillance database was conducted on all BCxs obtained on hospitalized patients on the pediatric hematology/oncology unit at Riley Hospital for Children in Indianapolis, IN from January 2015 to February 2021. Exclusion criteria are shown in Fig. 1. Patient episodes in which a new pathogen (or commensal treated by the primary team as a pathogen) was identified on a repeat BCx more than 48 hours after negative initial BCxs were further investigated via electronic medical record review. Results: A total of 1,362 BCx sets were obtained beyond 48 hours in 792 patient hospitalizations, resulting in 303 positive BCxs (Fig. 2). Of these positive cultures, 193 were the same pathogen cultured on day 0 and 74 were contaminant cultures (in 4.0% (23/573) of patient hospitalizations without a positive BCx before 48 hours). Only 36 (2.6%) of positive BCxs beyond 48 hours were determined to be new pathogens, or commensals treated as pathogens, that were not cultured before 48 hours, corresponding to seven patient hospitalizations (1.2% (7/573) of patient hospitalizations without a positive BCx before 48 hours). The majority (6/7) of these patients were neutropenic and on broad spectrum antibiotics when the new positive BCxs were obtained. Fever pattern was prolonged in one patient and recurrent in six. No deaths occurred in these seven patients. All patients with new, true pathogens on BCxs beyond 48 hours (n=5) were either hemodynamically unstable (n=3) or had clinical changes (n=2, mucositis, diarrhea) the day the new positive BCx was drawn. Conclusion: The yield of repeat BCxs beyond 48 hours in hospitalized pediatric hematology/oncology patients with negative initial BCxs is low, while the associated costs are high. Repeat BCxs beyond 48 hours after negative initial cultures need not be obtained in febrile patients that remain hemodynamically stable and without clinical changes.
506 Review of Empiric Voriconazole Dosing in Large TBSA Burn Patients – A Case Series
(Oxford University Press, 2023-05-15) Lautenslager, Lauren; Boyd, Allison; Hartman, Brett; Spera, Leigh; Graduate Medical Education, School of Medicine
Introduction: Burn patients are significantly immunocompromised and susceptible to opportunistic fungal infections. Treatment includes aggressive surgical debridement with topical and systemic anti-fungal agents. Voriconazole (VCZ) is a systemic anti-fungal and an approved first line treatment of invasive Aspergillus and Fusarium species. Standard dosing is a 6 mg/kg loading dose twice followed by 200 mg enterally twice daily. Therapeutic drug monitoring is recommended to confirm a goal trough concentration of >1 mcg/mL, once steady state is reached, approximately 4-7 days after initiation. At our institution, VCZ levels are a send out lab, averaging 4-7 days for results. We reviewed a series of three patients with invasive fungal infections and their VCZ treatment dosing to assess impact of altered pharmacokinetics and time delays with drug monitoring. Methods: Three patients with significant burn injury (TBSA >40%) and invasive fungal wound infections were reviewed. Two were treated with standard dosing of VCZ (200 mg BID). The %TBSA, weight, albumin at time of VCZ initiation, initial VCZ dosing, initial trough concentration, time from initiation to trough result and final VCZ dose was reviewed. Consideration of the subtherapeutic drug level of prior patients led to initiation of VCZ treatment at an increased initial empiric dose (300 mg BID) for a third patient, followed by assessment and review of the same variables. Results: For the two patients treated with standard VCZ dosing, initial trough concentrations were subtherapeutic (0.4 mcg/mL and 0.9mcg/mL) and took 13 and 10 days from initiation to trough result, respectively. The albumin concentrations for these patients were 2.1 and 1.6 g/dL. Initial trough concentration for the third patient started on increased empiric dosing was therapeutic (4.9 mcg/mL), despite an albumin of < 1 g/dL. (Table 1). Conclusions: Fungal infections significantly increase the morbidity and mortality of burn patients. The time lapse from initial dose to steady state plus turnaround time of send out labs may result in 1-2 weeks of subtherapeutic treatment. Results from our case series demonstrate that standard VCZ dosing could be inadequate for large TBSA burn patients ( >40%) and higher empiric doses should be considered. Applicability of Research to Practice: Consider use of increased initial VCZ dosing for large burn patients to reach therapeutic serum levels more expeditiously.
A Pilot Study of a Mobile Intervention to Support Mental Health and Adherence Among Adolescents Living with HIV in Western Kenya
(Springer, 2022) Chory, Ashley; Callen, Grant; Nyandiko, Winstone; Njoroge, Tabitha; Ashimosi, Celestine; Aluoch, Josephine; Scanlon, Michael; McAteer, Carole; Apondi, Edith; Vreeman, Rachel; Graduate Medical Education, School of Medicine
Mobile technologies represent potentially novel and scalable intervention delivery platforms for adolescents living with HIV (ALWH) in low- and middle-income countries. We conducted a prospective, mixed methods pilot study to evaluate the acceptability and feasibility of the WhatsApp® platform to deliver individual counseling services and facilitate peer support for ALWH in western Kenya. Thirty ALWH (17 female, mean age 15.4) on ART, engaged in HIV care and aware of their status, were enrolled. After 6 months, participants described their experiences with the intervention. Treatment adherence, stigma, and mental and behavioral health were assessed prospectively. Participants reported overall positive experiences and indicated that the platform encouraged peer network development. They endorsed potential benefits for treatment adherence, stigma reduction, and mental and behavioral health. All participants supported intervention expansion. In western Kenya, WhatsApp® was an acceptable and feasible platform for mobile counseling and peer support for ALWH.
A Roadmap to Surgical Education: A Scoping Review of Educational Needs in Surgery
(2024-04-26) Yan, Yichuan; Krusing, Madeline; Awad, MIchael; Stefanidis, Dimitrios
Purpose: Understanding the educational needs can help organizations like the Association for Surgical Education to develop relevant solutions. However, relevant literature is limited to know the needs. Thus, the aim of this study was to identify the educational needs in surgical education literature. Methods: Following the PRISMA Statement guideline, we performed a scoping review with three search terms in two databases in tandem with three inclusion criteria to identify the literature pertinent to educational needs in surgery. Through content analysis of the abstracts of the identified literature, we inquired about the objectives, methods, data sources, and conclusions in each identified article to tease out the trends, specialties, participants, and topics of educational needs in surgical education literature. Descriptive statistics of frequency were used to present the data. Results: The PRISMA article selection procedures resulted in 212 peer-reviewed journal articles in the scoping review. The content analysis identified the trends of the needs in four areas including the trends of educational needs, surgical specialties, participants, and topics of educational needs. To synthesize the results of the data analysis, a heat map was created with the cross-section of the trends and topics of educational needs showing the hot topics and potential gaps in surgical education literature. Conclusions: The scoping review provides surgical educators and trainees an overview of the educational needs in the literature that can serve as a roadmap of educational needs to be taken into consideration by organizations like the ASE to help address the needs and advance the field.
An Abscessed Tooth that Wasn't: An Unusual Case of Mumps in an Elderly Patient
(2020-03) Lin, Jenny; Willhite, Sydney; Moore, Hannah; Smith, Maddie; Duncan, Francesca
Case: A 62-year-old African American female with history of self-resolving parotitis initially presented with progressive neck and bilateral facial swelling. She attributed this to an abscessed tooth. CT revealed parotitis with inflammatory changes and mass effect on the hypopharynx and larynx, although the patient denied breathing difficulty. Antibiotics were administered for two days, discontinuing due to lack of abscess. Six days later, the patient presented with worsening facial swelling, sore throat, and dysphagia. She remained afebrile but with a WBC count of 12.8. Antibiotics and steroids were given. MRI displayed retropharyngeal space involvement of 2.6 cm in thickness. ENT performed surgical debridement and culture collection. Upon return from the OR, respiratory distress and inability to manage secretions resulted in intubation via an upright awake fiberoptic approach given concern for impending airway compromise. Finally, a positive IgM antibody to mumps virus was detected from the debridement culture. Discussion: The differential for nonsuppurative parotitis includes viruses, autoimmune disorders, and granulomatous inflammation. Paramyxovirus, specifically mumps, is the most common viral cause, with EBV, HSV, CMV, and HIV as other concerns. Autoimmune causes are Sjogren syndrome and SLE. Mycobacterium species are the likely granulomatous culprit. Though mumps is the most common viral cause of parotitis, it typically occurs in children and young adults, not fitting of the patient described. However, mumps cases have increased recently. MMR vaccination began in 1967 and cases decreased more than 99%; yet, since 2006 there have been outbreaks. Vaccine-induced protection may wane over time. Mumps is highly contagious and complications include meningitis, encephalitis, pancreatitis, and deafness, occurring more commonly in elderly patients. Patients with nonsuppurative parotitis should thus be surveyed for vaccination history and examined for MMR titers.
Acknowledging Racial and Ethnic Health Disparities in Mass Incarceration
(Indiana State Medical Association, 2022-06-06) Brown, Lucy; Clark, Sydney; Nunge, Rebecca A; Fazle, Trilliah; Cooper, Siena; Robinson, Peyton; Darroca, Roberto
Whereas, the United States incarcerates more people per capita than any country in the world, where the U.S. comprises only 4% of the world’s population, yet is home to nearly 16% of all incarcerated people in the world; and Whereas, in Indiana, the total jail population increased by 526% between 1970 and 2015, while rates of pretrial detainees have increased by 72% in the state’s 48 rural counties, 43% in the state’s 21 small/medium counties, 40% in the state’s 22 suburban counties, and 268% in Marion County alone since 2000; and Whereas, in 2015 in Indiana, when including jail, prison, immigration detention, and juvenile facilities, the incarceration rate was 765 per 100,000 people, well above the rate of the United States as a whole, which was 665 per 100,000 people; and Whereas, Black residents make up 10% of Indiana’s population, but represent 24% of people in jail and 34% of people in prison; additionally, pretrial populations, disproportionately Black and Hispanic, more than doubled from 2002 to 2017; and Whereas, in 2019, Native people made up 2.1% of all federally incarcerated people, larger than their share of the total U.S. population, which was less than one percent; additionally, Native women are particularly overrepresented in the incarcerated population, making up 2.5% of women in prisons and jails and only 0.7% of the total U.S. female population; and Whereas, populations of color are more impacted by the use of money bail, where Black defendants often receive higher bail amounts, even when controlling for legal factors such as offense severity; and Whereas, Black and brown defendants are 10-25% more likely to be detained pretrial or to receive financial conditions of release; and Whereas, significant racial and ethnic disparities exist among policing, arrests, and incarceration rates, which further exacerbate disparate health outcomes for Black communities, including, but not limited to, Black individuals disproportionately being stopped by the police, experiencing use of force and repeated arrests, serving sentences of life and life without parole, being sent to solitary confinement, and receiving convictions that place them on death row; and Whereas, nearly one in three Black men will ever be imprisoned, and nearly half of Black women currently have a family member or extended family member who is in prison; and Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; however, ISMA has no policy acknowledging the inequitable burden of incarceration and policing on minoritized individuals and communities of color; and Whereas, the AMA (H-65.954) recognizes police brutality as a manifestation of structural racism which disproportionately impacts Black, Indigenous, and other people of color; therefore, be it RESOLVED, that ISMA recognize that unjust and disproportionate racial and ethnic disparities exist in policing, sentencing, and mass incarceration among Black, indigenous, and other people of color (BIPOC) and have devastating impacts on BIPOC communities; and be it further, RESOLVED, that ISMA refer to the Committee on Diversity, Equity and Inclusion for study on what policies would be germane for ISMA to act on regarding racial and ethnic disparities in mass incarceration.
Activation of the oncogene ERG by the Ras/ERK and PI3K/AKT pathways
(2019-08) Willhite, Sydney; Strittmatter, Brady; Hollenhorst, Peter
Background and Hypothesis: The TMPRSS2-ERG re-arrangement occurs in ~50% of prostate cancers and results in aberrant expression of the transcription factor ERG in the prostate. ERG is known to be activated by the Ras/ERK and PI3K/AKT pathways, however, the exact mechanism of this activation is not fully understood. The aim of this project is to identify how activation of these signaling pathways differentially effect transcription of ERG target genes. Experimental Design or Project Methods: In order to test how the Ras/ERK and PI3K/AKT pathways effect ERG target gene transcription, normal prostate epithelial cells (RWPE1) were transfected with constitutively active AKT in combination with phospho-mutants of ERG. These cell lines were then used to conduct Quantitative Reverse Transcription PCR and Western blotting of known downstream ERG target genes to identify how the activation status of these signaling pathways affected transcription and protein production. Results: Overall, our results demonstrate that ERG mediated transcription of the VIM gene, a marker of EMT, was activated by the Ras/ERK pathway and was repressed by the PI3K/AKT pathway. In addition, we found that ERG expression decreased FOXO1 protein expression in our cell lines regardless of Ras/ERK and PI3K/AKT status. Transcription and protein quantification was also measured for ERG target gene VEGFA, a critical regulator of angiogenesis. Conclusion and Potential Impact: This project helps identify the molecular mechanisms by which a common oncogene in prostate cancer is activated. Our results demonstrate how upstream signaling pathways differentially regulate oncogenic transcription and cell transformation. Overall, this project will provide insight to the molecular mechanisms of possible therapeutic targets in prostate cancer, the most common cancer amongst men.
Acute Heart Failure in the Setting of Post-Covid MIS-C: A Case Report
(2023-03-24) Luster, Taylor; Sloat, Brittany; Mederos, Alexa; Karam, Marie; Pavlik, Lauren; Duncan, Francesca
Introduction: Multi-inflammatory Syndrome in Children (MIS-C) has emerged as a rare, but severe complication of SARS-CoV-2 infection. Patients present with persistent fever, abdominal pain, diarrhea, vomiting, rash, mucocutaneous lesions, and in severe cases, shock. The diagnostic criteria are age < 21, fever, laboratory evidence of inflammation, multi-organ involvement, and a positive COVID-19 test or known exposure 4 weeks prior to symptoms onset. Case Description: A 17-year-old female with a history of prior COVID-19 infection presented complaining of chest pain, shortness of breath, headache, and fevers with a Tmax of 105F for 4 days. The patient was hypotensive, tachycardic, tachypneic, and hypoxic. Pertinent labs included: Na 126, BUN 48, Creatinine 2.1, ALT 62, AST 86, WBC 27.4, Hg 10.5, Troponin 0.96, Lactate 3.3, CRP 60, ESR 85, Procalcitonin 75, D-dimer 2.02, Fibrinogen >1000, COVID PCR negative, and COVID Ig-G reactive. CT chest was notable for bibasilar pulmonary opacites, cardiomegaly, and bilateral pleural effusions. Echocardiogram showed left ventricular ejection fraction of 21% and global hypokinesis. She was ultimately intubated due to respiratory failure and started on milrinone and vasopressors. She was treated with IVIG, aspirin, and methylprednisolone for MIS-C. She clinically improved and repeat echo showed an improved EF of 57% and was discharged after 10 days with a prolonged prednisone taper. Clinical Significance: The incidence of MIS-C is 316 per 1 million pediatric SARS-CoV-2 infections. This case demonstrates need for increased awareness of potential acute cardiac failure in adolescents with a recent history of COVID-19 infection, elevated inflammatory markers, and signs of multi-organ failure so that IVIG, aspirin and corticosteroids can be started immediately to avoid progression of MIS-C into acute cardiac failure. Conclusion: Pediatric presentation of SARS-CoV-2 infection can be mild, but there is a subset of patients that have been reported to develop MIS-C, a more severe post viral syndrome.
Acute psychosis and serotonin syndrome in the setting of "Triple-C" overdose: a case report
(BMC, 2021-11) Bachar, Roudi; Majewski, John Robert; Shrack, Christopher; El-Khoury, Anthony; Graduate Medical Education, School of Medicine
BACKGROUND: Over-the-counter medication overdose is a difficult diagnostic challenge for many physicians as common drug screening assays cannot detect these substances. We present a case of acute psychosis, serotonin syndrome, and anticholinergic overdose-like properties in the setting of Coricidin HBP Cough & Cold tablets, known by their street name Triple-C. This is the first case report we are aware of involving a patient presenting with these symptoms and requiring critical-care-level support. CASE PRESENTATION: A 31-year-old African American female with a past medical history of anxiety, childhood asthma, previous methamphetamine abuse, and coronavirus disease 2019 infection in August 2020 was brought to the emergency department by the local police department with altered mental status. Initial blood work, including extended drug screens, were unremarkable for a definitive diagnosis. This patient required critical-care-level support and high sedation because of her symptoms. Collateral history revealed the patient regularly consumed Triple-C daily for the 6 weeks prior to admission. A trial off sedation was attempted after 24 hours with no complications. The patient admitted to regular Triple-C consumption and auditory hallucinations since adolescence. She was discharged safely after 48 hours back into the community. She was lost to follow-up with psychiatry and internal medicine; however, she was evaluated in the emergency room 1 month later with a similar psychiatric presentation. CONCLUSION: Overdose of Triple-C should be kept in the differential diagnosis of patients presenting with a triad of psychosis, serotonin syndrome, and anticholinergic overdose, in the setting of unknown substance ingestion.

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