Patient Outcomes With Febrile Neutropenia Based on Time to Antibiotics in the Emergency Department.

OBJECTIVE: Although bacteremia in pediatric oncology patients with febrile neutropenia (FN) is not uncommon, sepsis and mortality are rare. Because of the lack of clinically meaningful decision tools to identify high-risk patients with bacteremia, time to antibiotic administration (TTA) is increasingly considered an important quality and safety measure in the emergency department. Because little evidence exists suggesting that this benchmark is beneficial, we sought to determine whether TTA of 60 minutes or less is associated with improved outcomes. METHODS: We retrospectively reviewed patients presenting to a pediatric emergency department with FN from November 2013 to June 2016. Clinical outcomes including mortality, pediatric intensive care unit admission, imaging, fluid resuscitation of 40 mL/kg or greater in the first 24 hours, and length of stay were compared between TTA of 60 minutes or less and more than 60 minutes. RESULTS: One hundred seventy-nine episodes of FN were analyzed. The median TTA was 76 minutes (interquartile range, 58-105). The incidence of bacteremia was higher in patients with TTA of more than 60 minutes (12% vs 2%, P = 0.04), but without impact on mortality, pediatric intensive care unit admission, fluid resuscitation, or median length of stay. The median TTA was not different for those who were and were not bacteremic (91 vs 73 minutes, P = 0.11). CONCLUSIONS: Time to antibiotic administration of more than 60 minutes did not increase mortality in pediatric oncology patients with FN. Our study adds to the existing literature that TTA of 60 minutes or less does not seem to improve outcomes in pediatric FN. Further larger studies are required to confirm these findings and determine which features predispose pediatric FN patients to morbidity and mortality.

Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler.

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.

Resident perspectives on professionalism lack common consensus.

STUDY OBJECTIVE: We sought to characterize and understand the residents' perspective on how professionalism develops through pediatric emergency medicine experiences. METHODS: Qualitative methods (freelisting--listing words associated with professionalism--and semistructured interviews) were conducted with senior emergency medicine and pediatric residents about their experiences rotating in the emergency department of a large, urban, tertiary care, freestanding children's hospital. All senior residents were eligible, with purposive sampling to maximize demographic variability. Saliency (importance) of words was analyzed with Smith S scores and consensus analysis. Interviews were conducted until content saturation was achieved; transcripts were coded by independent investigators to reach thematic consensus. RESULTS: Twenty-five interviews (36% emergency, 64% pediatrics) were conducted. Common words associated with professionalism were "respect," "compassion," "empathy," and "integrity"; however, residents did not share a common consensus. The framework for how residents described the development of their professionalism includes observations, interactions, and environment. Examples include resident observation of role models; interactions with patients, families, and coworkers; self-reflection; and the unique environment of the ED. Residents believed that role modeling was the most influential factor. Few reported receiving sufficient observation by attending physicians during their interactions with patients and most reported receiving little direct feedback on their professionalism. Residents' descriptions of professionalism crossed multiple Accreditation Council for Graduate Medical Education (ACGME) competencies. CONCLUSION: Residents displayed high variability in their understanding of professionalism, which was frequently at variance with the corresponding ACGME competency definition. The resident perspective and understanding of professionalism may usefully inform refinements in ACGME milestones and entrustable professional activities.

Parental asthma education and risks for nonadherence to pediatric asthma treatments.

OBJECTIVES: Targeted parental education reduces acute visits for pediatric asthma. Whether the use of education sources readily available to parents relates to nonadherence to asthma treatments is uncertain. This study describes asthma education sources and assesses for a relationship to risks for nonadherence. METHODS: Caregivers of children with asthma completed a cross-sectional survey at 2 sites: a pediatric emergency department (ED) and an asthma clinic (AC). Measured items included the use of 7 education sources (primary care, ED, AC, friends/family, TV, internet, and printed materials), scores of child asthma morbidity, parental asthma knowledge, and risks for nonadherence, the primary outcome. Recruitment site, preferred language (English/Spanish), and demographics were recorded. Descriptive statistics, bivariate analyses, and multivariate regressions were performed. RESULTS: A total of 260 participants, 158 from ED and 102 from AC, used a variety of education sources. They reported 4.1 (2.0) of 13 risk factors for nonadherence, with more risks in ED parents than AC parents (4.8 vs 3.9, P < 0.001). The ED parents worried more about medications and had worse access to primary care. The regression did not show a significant relationship between education sources and risks for nonadherence, but ED recruitment, Spanish language, and worse morbidity contributed to higher risks. CONCLUSIONS: The use of more asthma education sources was not associated with reduced risks for nonadherence. Of the education sources, a primary care provider may benefit ED parents, who also need refills and education about medications. Spanish-speaking parents report more risks for nonadherence, warranting further study of Spanish-language asthma education.

Perspectives on preparedness for pediatric emergencies after residency: A needs assessment.

Background: General emergency physicians provide most pediatric emergency care in the United States yet report more challenges managing emergencies in children than adults. Recommendations for standardized pediatric emergency medicine (PEM) curricula to address educational gaps due to variations in pediatric exposure during emergency medicine (EM) training lack learner input. This study surveyed senior EM residents and recent graduates about their perceived preparedness to manage pediatric emergencies to better inform PEM curricula design. Methods: In 2021, senior EM residents and graduates from the classes of 2020 and 2019 across eight EM programs with PEM rotations at the same children's hospital were recruited and surveyed electronically to assess perceived preparedness for 42 pediatric emergencies and procedures by age: infants under 1 year, toddlers, and children over 4 years. Preparedness was reported on a 5-point Likert scale with 1 or 2 defined as "unprepared." A chi-square test of independence compared the proportion of respondents unprepared to manage each condition across age groups, and a p-value < 0.05 demonstrated significance. Results: The response rate was 53% (129/242), with a higher response rate from senior residents (65%). Respondents reported feeling unprepared to manage more emergency conditions in infants compared to other age groups. Respondents felt least prepared to manage inborn errors of metabolism and congenital heart disease, with 45%-68% unprepared for these conditions across ages. A heat map compared senior residents to recent graduates. More graduates reported feeling unprepared for major trauma, impending respiratory failure, and pediatric advanced life support algorithms. Conclusions: This study, describing the perspective of EM senior residents and recent graduates, offers unique insights into PEM curricular needs during EM training. Future PEM curricula should target infant complaints and conditions with lower preparedness scores across ages. Other centers training EM residents could use our findings and methods to bolster PEM curricula.

Analysis of clinical-pathologic variables, staging and prognostic groups, and therapeutic results of 106 germ-cell testicular tumors.

OBJECTIVES: Retrospective review of 106 germ-cell testicular tumors treated in our center between 1992 and 2009. METHODS: Description and analysis of several clinical-pathologic and prognostic variables and survival analysis. RESULTS: 68% of our patients were diagnosed in the last 5 years. 54.7% presented seminoma histology. The mean age at diagnosis was 33.47 for the seminoma (S) and 27.63 for non seminoma (NS), p=0,001. The median tumoral size in mm was 45.99mm (globally). 44.3% presented elevation of at least one tumor marker; Alpha-fetoprotein (AFP) or Human chorionic gonadotropin (HCG) .29.3% in the S and 60.4% in NS; p=0.02. The percentage of patients with increased HCG in S was 29.3% and 52.1% in NS; p=0.017 and AFP was elevated in 5.2% of S and 45.8% of NS; P <0.001. Accordingly to the classification of The Royal Marsden Hospital 96.5% of S and 83.2% of NS were diagnosed in stage I-II. Using the classification of the International Germ Cell Cancer Collaborative Group (IGCCG) for patients with advanced disease, 98.2% of S and 83.2% of NS belonged to the good prognostic group. Regarding the risk factors for relapse in stage I S (Rete testis invasion (RTI) and tumoral size (TS)> 4cm) 28% of our patients presented both risk factors. 18% of stage I NS presented vascular (VI) or lymphatic invasion (LI). Following the treatment protocols in consideration with the histology, stage and risk factors, 100% of stage I S with both risk factors and 100% of NS with vascular or lymphatic invasion received adjuvant therapy. Almost all the stage II-IV S and NS received different protocols of chemotherapy. In 2.8% of stage II NS a retroperitoneal lymph node dissection was performed. Residual tumor resection was documented in eight patients with stage II-IV NS. With a median follow-up of 60 months, the event free survival (EFS) was 93.3%. CONCLUSIONS: Our study has similar characteristics compared to other studies.

Predictors of severe outcomes in patients with Clostridium difficile infection from a Hispanic population.

BACKGROUND: Factors associated with complicated Clostridium difficile infection (CDI) may vary among populations, and predictors of severe outcomes in CDI have not been studied in Hispanic patients. The aim of this study was to identify factors associated with a higher risk of colectomy, all-cause mortality, and CDI-associated mortality in a Hispanic population. METHODS: We performed a retrospective study of all hospitalized patients with a diagnosis of CDI between January 1, 2011 and September 30, 2015 in a 450-bed teaching hospital in Monterrey, northeast Mexico. Three main outcomes were defined: fulminant colitis with subsequent colectomy, all-cause mortality within 30 days of diagnosis, and CDI-attributable mortality. RESULTS: Of 261 patients with diarrhea, 176 were diagnosed with CDI. For colectomy, Charlson comorbidity index, ICU stay and mechanical ventilation prior to CDI diagnosis, days with diarrhea prior to treatment, total days of hospital stay and days after CDI diagnosis, elevated ATLAS score, days of diarrhea post CDI treatment, and treatment failure significantly predicted the necessity of surgical treatment with colectomy. CONCLUSION: Treatment failure, persistent diarrhea, and a high ATLAS score were identified as risk factors for severe outcomes of CDI. A low albumin concentration and high creatinine were associated with higher overall mortality.

A case report of small bowel perforation secondary to cytomegalovirus related immune reconstitution inflammatory syndrome in an AIDS patient.

Non-traumatic small bowel perforation is rare in adults but carries a high morbidity and mortality. The diagnosis is made on clinical suspicion, and the most common causes in developing countries are infectious diseases, being cytomegalovirus infection in immunocompromised patients the main etiology. We describe a patient with a recently diagnosed advanced stage HIV infection and an intestinal perforation associated with cytomegalovirus immune reconstitution inflammatory syndrome after highly active antiretroviral therapy initiation.

Randomized clinical trial to evaluate the effect of fecal microbiota transplant for initial Clostridium difficile infection in intestinal microbiome.

OBJECTIVE: The aim of this study was to evaluate the impact of fecal donor-unrelated donor mix (FMT-FURM) transplantation as first-line therapy for C. difficile infection (CDI) in intestinal microbiome. METHODS: We designed an open, two-arm pilot study with oral vancomycin (250mg every 6 h for 10-14 days) or FMT-FURM as treatments for the first CDI episode in hospitalized adult patients in Hospital Universitario "Dr. Jose Eleuterio Gonzalez". Patients were randomized by a closed envelope method in a 1: 1 ratio to either oral vancomycin or FMT-FURM. CDI resolution was considered when there was a reduction on the Bristol scale of at least 2 points, a reduction of at least 50% in the number of bowel movements, absence of fever, and resolution of abdominal pain (at least two criteria). From each patient, a fecal sample was obtained at days 0, 3, and 7 after treatment. Specimens were cultured to isolate C. difficile, and isolates were characterized by PCR. Susceptibility testing of isolates was performed using the agar dilution method. Fecal samples and FMT-FURM were analyzed by 16S rRNA sequencing. RESULTS: We included 19 patients; 10 in the vancomycin arm and 9 in the FMT-FURM arm. However, one of the patients in the vancomycin arm and two patients in the FMT-FURM arm were eliminated. Symptoms resolved in 8/9 patients (88.9%) in the vancomycin group, while symptoms resolved in 4/7 patients (57.1%) after the first FMT-FURM dose (P = 0.26) and in 5/7 patients (71.4%) after the second dose (P = 0.55). During the study, no adverse effects attributable to FMT-FURM were observed in patients. Twelve isolates were recovered, most isolates carried tcdB, tcdA, cdtA, and cdtB, with an 18-bp deletion in tcdC. All isolates were resistant to ciprofloxacin and moxifloxacin but susceptible to metronidazole, linezolid, fidaxomicin, and tetracycline. In the FMT-FURM group, the bacterial composition was dominated by Firmicutes, Bacteroidetes, and Proteobacteria at all-time points and the microbiota were remarkably stable over time. The vancomycin group showed a very different pattern of the microbial composition when comparing to the FMT-FURM group over time. CONCLUSION: The results of this preliminary study showed that FMT-FURM for initial CDI is associated with specific bacterial communities that do not resemble the donors' sample.

Efficacy of computed tomography for the prediction of colectomy and mortality in patients with clostridium difficile infection.

AIM: To develop a CT predictor scale for the need for colectomy and to evaluate predictors of all-cause mortality within 30 days after diagnosis ofC. difficile infection (CDI). METHODS: We conducted a retrospective study of adult hospitalized patients whounderwent abdominal CT within 72 h of diagnosis of CDI. RESULTS: Presence of abnormal wall thickening in caecum (OR 8.0; CI 1.37-46.81; p = 0.021), transverse colon (OR 6.7; CI 1.15-35.60; p = 0.034), sigmoid colon (OR 12.6; CI 1.37-115.97; p = 0.025), pancolitis (OR 7.0; CI 1.36-36.01; p = 0.02) and bowel dilation (OR 16.5; CI 2.41-112.83; p = 0.004) predicted colectomy. With these values, a five parameter radiological scale from 0 to 24 was developed (sensitivity and NPV of 100%, cut-off of 6). Furthermore, wall thickening of caecum (OR 6.2; CI 1.06-35.57; p = 0.043), ascending colon (OR 12.0; CI 1.29-111.32; p = 0.029), descending colon (OR 17.0; CI 1.81-160.05; p = 0.013) and sigmoid (OR 10.2; CI 1.10-94.10; p = 0.041) independently predicted mortality within 30 days of CDI diagnosis. CONCLUSION: We designed a CT scale to predict colectomy, able to rule out the development of fulminant colitis and the need for surgical procedure. Patients with wall thickening of the caecum, ascending, descending or sigmoid colon were more likely to die within 30 days of CDI diagnosis.

Chronic rhino-orbito-cerebral mucormycosis: A case report and review of the literature.

Mucormycosis is a life-threatening disease, were rhinocerebral infection is most commonly seen in the clinical setting. Chronic mucormycosis is a rare presentation that exhibits a challenging diagnosis. We describe the case of a 47 year old diabetic man with complains of left zygomatic arch swelling of 3 months evolution. He had received previous antibiotic treatment without improvement. Biopsy of maxillary sinus revealed the presence of non-septated, 90° angle branched hyphae compatible with zygomicetes. The patient was treated with surgical debridement and amphotericin B until there was no evidence of fungi in the tissue by biopsy. We reviewed chronic rhino-orbito-cerebral mucormycosis from 1964-2014 and 22 cases were found, being this the second case of chronic mucormycosis reported in Mexico. A quarter of the cases were seen in immunocompetent hosts. As only 20% of the causal agent can be isolated by culture, the diagnosis is mainly made by biopsy. Besides treatment with amphotericin B, posaconazole as alternative, and control of the underlying comorbidities, surgical debridement represents the corner stone therapy. We recommend at least 36 month follow-up, due to the 13% risk of recurrence. A chronic presentation has a general survival rate of approximately 83%.

Bone and metabolic complications of urinary diversions.

Hyperchloremic metabolic acidosis is a complication of urinary diversion using ileum or colon. Its prevalence ranges from 25% and 46% depending on the procedure used and renal function of the patient. It is a consequence of intestinal fluid and electrolyte exchange between intestinal mucosa and urine. The main mechanism is absorption of ammonium and chloride from urine. Long-term chronic metabolic acidosis in these patients may lead to impaired bone metabolism and osteomalacia. Regular monitoring of pH, chlorine, bicarbonate, and calcium-phosphorus metabolism is therefore essential for early diagnosis and treatment.

Privatización de la seguridad social: contribución a una discusión / Privatization of social security

Contiene: 1. Marco constitucional y seguridad social; 2. Modelo neo-liberal y política social; 3. Análisis de los decretos legislativos; 4. Perspectivas