Curriculum and Competency Guidelines for the Advanced Care Practitioner in Infectious Disease.

Background: Changes in the health care delivery system have altered the way internal medicine (IM) is practiced, with inclusion of subspecialty advanced care practitioners (ACPs) as vital members of the health care team. Methods: ACPs are provided the clinical settings and educational resources within an academic center to become competent in recognizing and managing common and complicated infectious diseases (ID). The ID ACP will be given progressive responsibility with expectations for achievement of milestones as they develop into competent practitioners. We seek to ensure quality, cost-effective, and comprehensive patient-centered care on the ID service in the inpatient and ambulatory settings in compliance with national standards and scope of practice recommendations and regulations. Results: In recognition of the expanding role of ACPs, we developed a curriculum and guidelines in the subspecialty of ID. Conclusions: Our proposal greatly adds to the available literature for ACPs to provide the full spectrum of ID practice.

Vitamin D Supplementation in COVID-19 Patients: A Clinical Case Series.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has infected more than 4.4 million people and caused more than 300,000 deaths partly through acute respiratory distress syndrome with propensity to affect African American and Hispanic communities disproportionately. Patients with worse outcomes have exhibited higher blood plasma levels of proinflammatory cytokines. Activation of the vitamin D receptor expressed on immune cells has been shown to directly reduce the secretion of inflammatory cytokines, such as interleukin-6, and indirectly affect C-reactive protein. AREAS OF UNCERTAINTY: The significance of the vitamin D pathway in patients diagnosed with COVID-19. THERAPEUTIC INNOVATION: Vitamin D supplementation in patients after diagnosis of COVID-19. PATIENTS AND PHARMACOLOGICAL INTERVENTIONS: We report 4 vitamin D deficient patients diagnosed with COVID-19 in April 2020 who were provided with either cholecalciferol of 1000 IU daily (standard dose) or ergocalciferol 50,000 IU daily for 5 days (high dose) as part of supplementation. CLINICAL OUTCOMES: Patients that received a high dose of vitamin D supplementation achieved normalization of vitamin D levels and improved clinical recovery evidenced by shorter lengths of stay, lower oxygen requirements, and a reduction in inflammatory marker status. CONCLUSIONS: Vitamin D supplementation may serve as a viable alternative for curtailing acute respiratory distress syndrome in patients in underserved communities where resources to expensive and sought-after medications may be scarce. Randomized clinical trials will serve as an appropriate vessel to validate the efficacy of the therapeutic regimen and dissection of the pathway.

A unique approach to faculty development using an Observed Structured Teaching Encounter (OSTE).

We have challenges with poor patient satisfaction scores (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]) and internal medicine resident (IMR) evaluations of voluntary attending physicians. Using an Observed Structured Teaching Encounter (OSTE), we designed a faculty development project that focused on attendings' teaching and feedback skills. To assess attending communication with interns and improve attending teaching and feedback skills. All IM attendings on the Long Island Jewish Forest Hills (LIJFH) Emergency Department (ED) call schedule participated. OSTE simulation sessions included two clinical scenarios, standardized patients (SPs), fourth-year medical students trained as 'interns,' OSTE checklists, and debriefing. We analyzed 'intern' ratings of communication with attendings and attending self-assessment during the OSTE, and attending HCAHPS scores and IMR evaluations of attendings pre- and post-OSTE. Twenty-nine of 29 attendings completed the OSTE. Although an increase was demonstrated pre- to post- for 'intern' OSTE ratings of attendings and LIJFH attending self-assessment ratings, there was no statistically significant difference. Mean HCAHPS scores and resident evaluations of attendings also increased from pre- (22% and 3.59) to post-OSTE (30% and 3.87) but did not reach statistical significance. A statistically significant difference for both cases was demonstrated when comparing mean attending self-assessment ratings with 'intern' evaluation of attendings. Attending teaching/feedback skills improved between cases, attending self-ratings were higher than 'intern' ratings of attendings. HCAHPS and IMR evaluations of attendings improved post-OSTE. Regular intervention utilizing an OSTE may provide a sustained benefit for enhancing attendings' skills, patient satisfaction, and resident training.

Do medical residents perform patient-centered medical home tasks? A mixed-methods study.

BACKGROUND: Increasingly, residents are being trained in Patient-centered Medical Home (PCMH) settings. A set of PCMH entrustable professional activities (EPAs) for residents has been defined but not evaluated in practice. OBJECTIVE: To understand whether residents trained at PCMH sites reported higher likelihood of engaging in PCMH tasks than those training in non-PCMH sites. DESIGN: Survey and nominal group data from post-graduate trainees at three residency programs. RESULTS: A total of 179 residents responded (80% response). Over half (52%) cared for patients at PCMH sites. Residents at PCMH sites were more likely to report engaging in tasks in the NCQA domains of enhancing access and continuity (p < 0.01 for 4/11 tasks), planning and managing care (p < 0.01 for 3/4 tasks), providing self-care and community support (p < 0.01 for 3/5 tasks), and identifying and managing patient populations (p < 0.01 for 1/6 tasks), but were not more likely to report tracking and coordinating care or measuring and improving performance. Residents at PCMH sites were more likely to report working with medical assistants (p < 0.01), but not other healthcare professionals. Qualitative data showed staff teamwork and continuity of care as facilitators of patient-centered care, and technological problems and office inefficiencies as barriers to care. CONCLUSIONS: Residents trained at PCMH sites were more likely to engage in tasks in several NCQA domains, but not care coordination and quality assessment. Similar facilitators and barriers to trainee provision of patient-centered care were cited regardless of PCMH status. Curricula on PCMH principles and workflows that foster continuity and communication may help to inform residents on PCMH tenets and incorporate residents into team-based care. ABBREVIATIONS: EPA: Entrustable professional activity; GIM: General Internal Medicine; NCQA: National Center for Quality Assurance; PCMH: Patient-centered medical home.

Antimicrobial Resistant Streptococcus pneumoniae: Prevalence, Mechanisms, and Clinical Implications.

BACKGROUND: Streptococcus pneumoniae is a major cause of pneumonia, meningitis, sepsis, bacteremia, and otitis media. S. pneumoniae has developed increased resistance to multiple classes of antibiotics. STUDY DESIGN: Systematic literature review of prevalence, mechanisms, and clinical implications in S. pneumoniae resistance. AREAS OF UNCERTAINTY: Since S. pneumoniae resistance to penicillin was first reported with subsequent development of resistance to other classes of drugs, selection of appropriate antibiotic treatment is challenging. DATA SOURCES: We searched PubMed (English language) for citations to antibiotic resistance in S. pneumoniae published before March 1, 2016. RESULTS: We present a review of S. pneumoniae resistance to beta-lactams, macrolides, lincosamides, fluoroquinolones, tetracyclines, and trimethoprim-sulfamethoxazole (TMP-SMX). There has been a steady decline in susceptibility of S. pneumoniae to commonly used beta-lactams. Phenotypic expression of penicillin resistance occurs as a result of a genetic structural modification in penicillin-binding proteins. Between 20% and 40% of S. pneumoniae isolates are resistant to macrolides. Macrolide resistance mechanisms include ribosomal target site alteration, alteration in antibiotic transport, and modification of the antibiotic. Approximately 22% of S. pneumoniae isolates are resistant to clindamycin. Similar to macrolide resistance, clindamycin involves a target site alteration. The prevalence of fluoroquinolone resistance is low, although increasing. S. pneumoniae resistance to fluoroquinolones occurs by accumulated mutations within the bacterial genome, increased efflux, or acquisition of plasmid-encoded genes. S. pneumoniae resistance has also increased for the tetracyclines. The primary mechanism is mediated by 2 genes that confer ribosomal protection. The prevalence of TMP-SMX resistance is around 35%. As with fluoroquinolones, resistance to TMP-SMX is secondary to mutations in the bacterial genome. CONCLUSIONS: Effective treatment of resistant S. pneumoniae is a growing concern. New classes of drugs, newer formulations of older drugs, combination antibiotic therapy, nonantibiotic modalities, better oversight of antibiotic usage, and enhanced preventive measures hold promise.

Preschool children's vision screening in New Zealand: a retrospective evaluation of referral accuracy.

OBJECTIVES: To assess the accuracy of preschool vision screening in a large, ethnically diverse, urban population in South Auckland, New Zealand. DESIGN: Retrospective longitudinal study. METHODS: B4 School Check vision screening records (n=5572) were compared with hospital eye department data for children referred from screening due to impaired acuity in one or both eyes who attended a referral appointment (n=556). False positive screens were identified by comparing screening data from the eyes that failed screening with hospital data. Estimation of false negative screening rates relied on data from eyes that passed screening. Data were analysed using logistic regression modelling accounting for the high correlation between results for the two eyes of each child. PRIMARY OUTCOME MEASURE: Positive predictive value of the preschool vision screening programme. RESULTS: Screening produced high numbers of false positive referrals, resulting in poor positive predictive value (PPV=31%, 95% CI 26% to 38%). High estimated negative predictive value (NPV=92%, 95% CI 88% to 95%) suggested most children with a vision disorder were identified at screening. Relaxing the referral criteria for acuity from worse than 6/9 to worse than 6/12 improved PPV without adversely affecting NPV. CONCLUSIONS: The B4 School Check generated numerous false positive referrals and consequently had a low PPV. There is scope for reducing costs by altering the visual acuity criterion for referral.

Assessment of adherence to atovaquone-proguanil prophylaxis in travelers.

BACKGROUND: Malaria continues to be a serious, world-wide infection. Atovaquone-proguanil is one of the prophylactic agents recommended for travelers to endemic regions. However, little information is available regarding adherence with this medication. A large proportion of malaria cases reported from travelers is due to non-adherence to prescribed regimens. This study was undertaken to analyze adherence with atovaquone-proguanil prophylaxis and specific factors contributing to non-adherence. METHODS: Men and non-pregnant women > or = 18 years of age were eligible for inclusion. Enrolled travelers received a prescription for atovaquone-proguanil prophylaxis and were contacted by telephone within 3 weeks of return to the United States. A questionnaire was prepared by the authors to determine if subjects were adherent with the medication. Additional data included demographics, duration of malarious travel, previous use of prophylactic agents, underlying medical conditions, concurrent medications, and reasons for non-adherence. RESULTS: Complete data were available for 104/124 (84%) participants: 49 (47%) men, 55 (53%) women. Average duration of malarious travel was 12 days, and 19 (18%) travelers reported previous travel to a malarious region. Ninety-two (89%) subjects were completely adherent with their prophylactic atovaquone-proguanil course. Adverse effects were seen in 6 (5%) travelers. CONCLUSIONS: Adherence with atovaquone-proguanil malaria prophylaxis is high among travelers from a non-endemic region. Adverse effects are minimal. Non-adherence was primarily attributable to travelers' perception of need.

Neurotoxicity in patients treated with intravenous polymyxin B: Two case reports.

PURPOSE: Two cases of reversible neurotoxicity associated with the administration of intravenous polymyxin B are described. SUMMARY: In the first case, a 60-year-old, obese, white woman with a medical history of recurring urinary tract infections, nephrolithiasis, and chronic renal insufficiency was admitted for parenteral antibiotics for dysuria and hematuria despite outpatient management with oral antibiotics. Her urinalysis revealed pyuria and large blood content. The corresponding urine culture contained >or=100,000 colony-forming units/mL of multidrug-resistant (MDR) Klebsiella pneumoniae. The patient was treated with polymyxin B at 20,000 units/kg i.v. as a loading dose and then 10,000 units/kg i.v. daily based on her renal function. The patient experienced oral paresthesia that resolved upon discontinuation of the infusion with no further complications. In the second case, a 57-year-old white man with hypertension and ascending cholangitis was admitted. He required percutaneous drainage of an infected pancreatic cyst and received polymyxin B at 25,000 units/kg i.v. as a loading dose and then 15,000 units/kg i.v. daily in addition to imipenem-cilastatin based on the sensitivities of two organisms (Escherichia coli and MDR K. pneumoniae) isolated from the abdominal drainage. For his pancreatic abscess, the patient received a prolonged course of polymyxin B, which was well tolerated for the first four weeks. On day 30 of the polymyxin B, the patient reported oral and lower extremity paresthesias. The symptoms resolved upon discontinuation of the polymyxin B. CONCLUSION: Two patients developed symptoms of neurotoxicity after receiving intravenous polymyxin B for the treatment of MDR gram-negative infections.

Development, impact, and measurement of enhanced physical diagnosis skills.

Evidence suggests that the quality and frequency of bedside clinical examination have declined. We undertook the study to (1) determine whether intensive instruction in physical examination enhances medical student skills and (2) develop a tool to evaluate those skills using a modified observed structured clinical examination (OSCE). This was a randomized, blinded, prospective, year-long study involving 3rd year students at the Albert Einstein College of Medicine. Students were randomized to receive intensive instruction in physical examination [study group (n = 46)] or usual instruction [control group (n = 75)] and evaluated by a modified OSCE. The OSCE consisted of 6 real patient stations: Head, ears, eyes, neck, throat; pulmonary; cardiovascular; gastrointestinal; neurology; musculoskeletal; and 2 computer imaging stations: genitourinary and dermatology. A faculty member present at each patient station evaluated student performance. Data were analyzed using t-tests for comparison of the mean scores between the two groups for each station and for average scores across stations. A total of 121 students were tested. The study group performed significantly better than the control group in the gastrointestinal station (p = 0.0004), the combined average score across the six real patient stations (p = 0.0001), and the combined average score across all eight stations (p = 0.0014). Intensive physical diagnosis instruction enhances physical examination skills of 3rd year medical students. The modified OSCE is a useful tool to evaluate these skills.

Variables impacting an academic pharmacy career choice.

OBJECTIVES: To identify the variables associated with an academic pharmacy career choice among the following groups: final professional-year doctor of pharmacy (PharmD) students, pharmacy residents, pharmacy faculty members within the first 5 years of academic employment, and clinical pharmacy practitioners. METHODS: A cross-sectional design Web-based survey instrument was developed using the online tool SurveyMonkey. The survey link was distributed via e-mail and postcards, and data were collected anonymously. Quantitative analyses were used to describe the 2,494 survey respondents and compare their responses to 25 variables associated with an academic pharmacy career choice. Logistic regression models were used to predict the motivators/deterrents associated with an academic pharmacy career choice for each participant group. RESULTS: Across all participant groups, the potential need to generate one's salary was the primary deterrent and autonomy, flexibility, and the ability to shape the future of the profession were the primary motivators. Final-year pharmacy students who considered a career in academic pharmacy were significantly deterred by grant writing. The overall sample of participants who considered an academic pharmacy career was more likely to be motivated by the academic environment and opportunities to teach, conduct professional writing and reviews, and participate in course design and/or assessment. CONCLUSIONS: This study demonstrates specific areas to consider for improved recruitment and retention of pharmacy faculty. For example, providing experiences related to pharmacy academia, such as allowing student participation in teaching and research, may stimulate those individuals' interest in pursuing an academic pharmacy career.

Cervical osteomyelitis caused by Burkholderia cepacia after rhinoplasty.

Burkholderia cepacia, previously known as Pseudomonas cepacia, has been implicated in vertebral osteomyelitis in patients who are intravenous drug abusers. We report a case of acute vertebral osteomyelitis in a non-intravenous drug user, following an elective rhinoplasty.

Adherence to the Infectious Diseases Society of America guidelines in the treatment of uncomplicated urinary tract infection.

BACKGROUND: Uncomplicated urinary tract infection (UTI) is one of the most common infections encountered and treated in outpatients. A set of guidelines published in 1999 by the Infectious Diseases Society of America recommends trimethaprim-sulfamethoxazole as first-line therapy. METHODS: We undertook a study of cross-sectional data describing the use of ambulatory medical services in the United States by women > or = 18 years of age who had uncomplicated UTI. Data from 1996 to 2001 were obtained from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to (1) examine the prescribing practices for the treatment of uncomplicated UTI and (2) determine whether these practices were influenced by the recommendation in the Infectious Diseases Society of America guidelines. The major outcomes measurement was to evaluate whether antibacterial selection was influenced by the Infectious Diseases Society of America guidelines. Data were analyzed by year, treatment in private offices vs. hospital clinics, race, geographic location, the specialty of the prescribing health care provider, and the payment method of the patient. RESULTS: We identified 2339 cases of uncomplicated UTI. Trimethaprim-sulfamethoxazole and ciprofloxacin were the most commonly prescribed drugs. Despite the Infectious Diseases Society of America guidelines, the use of trimethaprim-sulfamethoxazole did not change significantly (odds ratio, 0.89; 95% confidence interval, 0.60-1.30; P = .53), whereas the use of ciprofloxacin increased significantly (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P < or = .016). Similar results were obtained after adjusting for age, geographic region, race, physician specialty, payment method, and whether the visit was by a new or returning patient. CONCLUSIONS: Despite the Infectious Diseases Society of America recommendation of trimethaprim-sulfamethoxazole as first-line therapy for uncomplicated UTI, physicians in the United States have not altered their prescribing practices. Adjustment for age, geographic region, race, physician specialty, and payment method confirmed a lack of adherence to this recommendation.

Susceptibilities of Propionibacterium acnes ophthalmic isolates to ertapenem, meropenem, and cefepime.

We investigated the in vitro susceptibilities of 23 Propionibacterium acnes ophthalmic isolates to ertapenem, meropenem, and cefepime by utilizing the Etest. The MICs ranged from 0.094 microg/ml to 0.75 microg/ml, 0.094 microg/ml to 1.5 microg/ml, and 1 microg/ml to 12 microg/ml for ertapenem, meropenem, and cefepime, respectively. Based on our excellent in vitro carbapenem susceptibility results, in vivo studies using ertapenem and meropenem in a rabbit model of P. acnes endophthalmitis are warranted.

Updating the pharmacy technician certification examination: a practice analysis study.

OBJECTIVE: To update the Pharmacy Technician Certification Examination based on analysis of pharmacy practice elements (functions, responsibilities, and knowledge). DESIGN: Cross-sectional study. SETTING: United States in spring 2005. INTERVENTIONS: Web-based survey. PARTICIPANTS: Random sample of 4,000 Certified Pharmacy Technicians (CPhTs). MAIN OUTCOME MEASURES: Respondents' ratings of each of the practice analysis elements, the time spent performing each function, and the frequency of performance of each responsibility and use of each knowledge base. RESULTS: The survey return rate was 26%, and while the number of CPhTs practicing in community pharmacies was increased substantially over the 1999 practice analysis survey, non-respondent analysis suggested under-representation of this group. The distribution of primary responsibilities of CPhTs (63%, assisting the pharmacist in serving patients; 23%, maintaining medication and inventory control systems; 14%, participating in pharmacy management and administration) was almost identical to the 1999 survey. In community, hospitals/health systems, and other pharmacy practice settings, pharmacy technicians were more typically involved in compounding medications and coordinating communications throughout the practice setting than in previous practice analyses. In community settings, pharmacy technicians were more frequently contacting prescribers for clarification of prescriptions and participating in quality assurance activities. CONCLUSION: Using results of this practice analysis, the Pharmacy Technician Certification Board revised the content outline for its Pharmacy Technician Certification Examination, and the new test specifications are being used for all tests administered during 2006.