Desire for Residency-Provided Education and Support for Fertility Concerns: An Institutional Survey.

INTRODUCTION: Medical careers increase infertility risks and pregnancy complications. Residents often postpone pregnancy, contributing to these risks. Limited data exist regarding residents' family planning concerns. This study aims to evaluate fertility concerns and family planning during residency via a survey of residents and attending physicians. METHODS: Anonymous online surveys were distributed to all residents (n = 1030) and attending physicians (n = 1111) at a large, urban, single-campus academic hospital center. Data analysis was performed using chi-square analysis with significance at P < 0.05. RESULTS: Two hundred nine residents and 111 attendings submitted responses. Most respondents were female (74.7%). Slightly more than one-quarter of respondents were from a surgical specialty (26.6%). Residents compared to attending physicians indicated a higher concern for infertility during (57.4% versus 38.3%, P = 0.006) and after residency (68.9% versus 51.9%, P = 0.011) and a greater concern about pregnancy complications (67.8% versus 38.0%, P < 0.001). Most respondents felt pregnancy could negatively affect their training (67.3%). Surgical respondents were more concerned about the negative effects on colleagues (68.8% versus 51.1%, P = 0.045). Residents considered oocyte preservation more (57.9% versus 20.3%, P < 0.001). Respondents in surgical specialties had more concerns for fertility after residency (72.6% versus 57.9%, P = 0.033). Those in surgical fields trended for consideration of oocyte preservation (53.4% versus 39.7%, P = 0.084). Most respondents reported a need for education on oocyte preservation during residency (94.5%). CONCLUSIONS: Residents have increasing concerns about fertility and family planning related to their training. In addition to more institutional and residency program support, residents desire dedicated fertility and family planning education, such as oocyte preservation, as part of their curriculum.

The National Provider Identifier Taxonomy: Does it Align With a Surgeon's Actual Clinical Practice?

INTRODUCTION: The taxonomy code(s) associated with each National Provider Identifier (NPI) entry should characterize the provider's role (e.g., physician) and any specialization (e.g., orthopedic surgery). While the intent of the taxonomy system was to monitor medical appropriateness and the expertise of care provided, this system is now being used by researchers to identify providers and their practices. It is unknown how accurate the taxonomy codes are in describing a provider's true specialization. METHODS: Department websites of orthopedic surgery and general surgery from three large academic institutions were queried for practicing surgeons. The surgeon's specialty and subspeciality information listed was compared to the provider's taxonomy code(s) listed on the National Plan and Provider Enumeration System (NPPES). The match rate between these data sources was evaluated based on the specialty, subspecialty, and institution. RESULTS: There were 295 surgeons (205 general surgery and 90 orthopedic surgery) and 24 relevant taxonomies (8 orthopedic and 16 general or plastic) for analysis. Of these, 294 surgeons (99%) selected their general specialty taxonomy correctly, while only 189 (64%) correctly chose an appropriate subspecialty. General surgeons correctly chose a subspecialty more often than orthopedic surgeons (70 versus 51%, P = 0.002). The institution did not affect either match rate, however there were some differences noted in subspecialty match rates inside individual departments. CONCLUSIONS: In these institutions, the NPI taxonomy is not accurate for describing a surgeon's subspecialty or actual practice. Caution should be taken when utilizing this variable to describe a surgeon's subspecialization as our findings might apply in other groups.

When More Is Still Not Enough: A Case of Ceftazidime-Avibactam Resistance in a Burn Patient.

Burn patients have numerous risk factors for multidrug-resistant organisms (MDROs) and altered pharmacokinetics, which both independently increase the risk of treatment failure. Data on appropriate antimicrobial dosing are limited in this population and therapeutic drug monitoring (TDM) for beta-lactams is impractical at most facilities. Technology is available that can detect genetic markers of resistance, but they are not all encompassing, and often require specialized facilities that can detect less common genetic markers. Newer antimicrobials can help combat MDROs, but additional resistance patterns may evolve during treatment. Considering drug shortages and antimicrobial formularies, clinicians must remain vigilant when treating infections. This case report describes the development of resistance to ceftazidime-avibactam in a burn patient. The patient was a 54-year-old burn victim with a 58% total body surface area (TBSA) thermal burn who underwent multiple courses of antibiotics for various Pseudomonal infections. The initial Pseudomonal wound infection was sensitive to cefepime, aminoglycosides, and meropenem. A subsequent resistant pseudomonal pneumonia was treated with ceftazidime-avibactam 2.5 g every 6 hours due to the elevated MIC to cefepime (16 mcg/mL) and meropenem (>8 mcg/mL). Although the patient improved over 7 days, the patient again spiked fevers and had increased white blood counts (WBC). Repeat blood cultures demonstrated a multidrug-resistant (MDR) Pseudomonas with a minimum inhibitory concentration (MIC) to ceftazidime-avibactam of 16 mcg/mL, which is above the Clinical and Laboratory Standards Institute (CLSI) breakpoint of 8 mcg/mL. At first, resistance was thought to have occurred due to inadequate dosing, but genetic work demonstrated multiple genes encoding beta-lactamases.

A Cautionary Tale of Etanercept Use in Patients With Toxic Epidermal Necrolysis.

Toxic epidermal necrolysis (TEN) is a severe cutaneous reaction that can be life-threatening. In the United States, there are no established guidelines for the treatment of TEN. Supportive care including fluids and supportive therapies are the current recommendations. Research surrounding TEN involves mostly case studies or small, uncontrolled studies. Recent literature describes the use of tumor necrosis factor blockers in the treatment of TEN with positive results. These case reports describe decreased time to reepithelization, hospital length of stay, and minimal side effects. Conversely, we present three fatalities after the administration of etanercept.

Impact of inappropriate initial antibiotics in critically ill surgical patients with bacteremia.

BACKGROUND: Bloodstream infections in critically ill patients are associated with mortality as high as 60% and a prolonged hospital stay. We evaluated the impact of inappropriate antibiotic therapy (IAAT) in a critically ill surgical cohort with bacteremia. METHODS: This retrospective study evaluated adults with intensive care unit admission greater than 72 hours and bacteremia. Two groups were evaluated: appropriate antibiotic therapy (AAT) vs IAAT. RESULTS: In 72 episodes of bacteremia, 57 (79%) AAT and 15 (21%) IAAT, mean age was 54 ± 17 years and APACHE II of 17 ± 8. Time to appropriate antibiotics was longer for IAAT (3 ± 5 IAAT vs 1 ± 1 AAT days, P = .003). IAAT was seen primarily with Acinetobacter spp (33% IAAT vs 9% AAT, P = .01) and Enterococcus faecium (26% IAAT vs 7% AAT, P = .03). If 2 or more bacteremic episodes occurred, Acinetobacter spp. was more likely, 32% vs 2%, P = .001. CONCLUSIONS: AAT selection is imperative in critically patients with bacteremia to reduce the significant impact of inappropriate selection. Repeated episodes of bacteremia should receive special attention.

Hydromorphone vs fentanyl for epidural analgesia and anesthesia.

BACKGROUND: Epidural analgesia/anesthesia is used during surgery because it dramatically relieves pain and attenuates the stress response. Because limited data exist regarding the relative merits of hydromorphone (HM) and fentanyl (FENT), the objective was to determine which was more safe and effective. METHODS: Prospective case-matched, observational study evaluated elective surgery patients: 30 HM and 60 FENT. Variables were measured perioperatively. RESULTS: Of the 90 patients, mean age was 52 years; simplified acute physiology score was 26 ± 10; and American Society of Anesthesiologists score was 2.4 HM vs 2.7 FENT, P = .03. HM patients were more apt to be excessively sedated (16% HM vs 1% FENT, P = .007) and have poor mental unresponsiveness (6% HM vs 0% FENT, P = .04). The incidence of hypotension was not different, 76% HM vs 80% FENT, not significant. CONCLUSIONS: In a closely case-matched population, FENT caused less excessive sedation and unresponsiveness. FENT patients had better intraoperative urine output and tended to have less repeated episodes of hypotension.

Impact of minimizing diagnostic blood loss in the critically ill.

BACKGROUND: The use of a small-volume phlebotomy tube (SVPT) versus conventional-volume phlebotomy tube (CVPT) has led to a decrease in daily blood loss. Blood loss due to phlebotomy can lead ultimately to decreased rates of anemia and blood transfusions, which can be important in the critically ill patient. METHODS: We compared SVPT vs CVPT retrospectively in critically ill adult patients age ≥18 years admitted to a surgical intensive care unit for ≥48 hours. CVPT were evaluated from January 2011 to May 2011 and SVPT from June 2012 to October 2012. RESULTS: Amount of blood drawn for laboratory tests and transfusions were evaluated in 248 patients (116 SVPT vs 132 CVPT). When compared with CVPT, total blood volume removed (mean ± SD) with SVPT was less overall, 174 ± 182 mL vs 299 ± 355 mL, P = .001. Daily blood draws also were less, 22.5 ± 17.3 mL vs 31.7 ± 15.5 mL, P < .001. The units of packed red blood cells given were not significant, 4.4 ± 3.6 units vs 6.0 ± 8.2 units, P = .16. CONCLUSION: The use of SVPT blood sampling led to a decreased amount of blood drawn. Strategies that use SVPT in a larger cohort also may decrease the number of transfusions in selected patients. Every effort should be made to use SVPT.

Impact of evaluating antibiotic concentrations in abdominal abscesses percutaneously drained.

BACKGROUND: Appropriate antibiotic therapy and prompt drainage are essential for optimal results with abdominal abscesses. METHODS: In this prospective study, 47 abdominal abscesses from 42 patients over 2 years who had percutaneous drainage were evaluated. Antibiotic concentrations were evaluated from the abscess fluid and correlated with clinical and microbiologic cure. RESULTS: Only 23% of patients had appropriate antibiotic selection with optimal concentrations for the bacteria recovered. Piperacillin/tazobactam, cefepime, and metronidazole provided adequate concentrations in all except the largest abscesses, whereas fluconazole required higher doses in all abscesses. Vancomycin and ciprofloxacin levels were inadequate in most abscesses. With gram-negative aerobes, the use of appropriate antibiotics resulted in a relatively higher incidence of presumed eradication (100% [4 of 4] vs 75% [9 of 12], P = .26). With ≥ 3 organisms identified, clinical failure was significant (58% vs 13%, P = .01). CONCLUSIONS: For optimal treatment, abdominal abscesses require prompt drainage and properly selected antibiotics at adequate doses. Essential information can be obtained from abscess cultures and their antibiotic concentrations.

Twelve hundred abscesses operatively drained: an antibiotic conundrum?

BACKGROUND: The incidence of soft tissue infections from antimicrobial-resistant pathogens is increasing. This study evaluated the epidemiology of operatively drained soft tissue abscesses. METHODS: This retrospective study evaluated 1,200 consecutive patients from 2002 to 2008 who underwent incision and drainage (I&D) in the main operating room. Patients were excluded for perirectal or hidradenitis infections. RESULTS: Of 1,200 consecutive cases with an I&D, 1,005 patients had intraoperative cultures. The 1,817 positive isolates included gram-positive aerobes (1,180 [65%]), gram-negative aerobes (207 [11%]), anaerobes (416 [23%]), and fungi (14 [1%]). The most prevalent organism was Staphylococcus aureus, 30% (536), with 80% (431) being methicillin-resistant S aureus (MRSA). MRSA was the predominant organism in all except the breast abscesses. Anaerobes were identified primarily in the breast in diabetics, and in trunk and extremity abscesses in intravenous drug users. The most frequently prescribed empiric antibiotic was ampicillin/sulbactam (66%). The initial empiric antibiotic did not cover MRSA (82%; P < .001), resistant gram-negative aerobes (24%), and anaerobes (26%). CONCLUSION: Gram-positive aerobes plus anaerobes represented approximately 80% of the pathogens in our series, with the anaerobic rates being underestimated. Empiric antibiotics should cover MRSA and anaerobes in patients with superficial abscesses drained operatively.