Cessation of Antibiotics for Complicated Appendicitis at Discharge Does Not Increase Risk of Post-operative Infection.

PURPOSE: The utilization of home antibiotic therapy following surgery for complicated pediatric appendicitis is highly variable. In 2019, we stopped home antibiotic therapy in this cohort at our institution. We sought to evaluate our outcomes following this protocol change. METHODS: We queried our institutional NSQIP Pediatrics data for all children undergoing appendectomy for complicated appendicitis between January 2015 and May 2022. We identified two cohorts: those discharged with home antibiotics (1/1/15-4/30/19) and those discharged with no home antibiotics (5/1/19-4/30/22). Both groups were treated with response based parenteral antibiotics while hospitalized and discharged when clinically well. Our primary outcome was postoperative deep organ space infection requiring intervention (drainage, aspiration, reoperation, or antibiotics). Secondary outcomes included length of stay, superficial site infection, Clostridium difficile colitis, ER visits, post-operative CT imaging, and readmission. RESULTS: There were 185 patients in the home antibiotic group (83% discharged with antibiotics) and 121 patients in the no home antibiotic group (8.3% discharged with antibiotics). There were no significant differences in deep organ space infection requiring intervention (7% vs. 7.4%, p = 1.0). Our length of stay was not different (4.5 days vs. 3.95 days, p = 0.32), nor were other secondary outcomes or patient characteristics. All patients had documented follow-up. CONCLUSIONS: We did not identify differences in deep organ space infections, length of stay or other events after eliminating home antibiotic therapy in our complicated appendicitis cohort. The use of home antibiotics following surgery for complicated appendicitis should be reconsidered. LEVEL OF EVIDENCE: III.

Deeper Pathways for Recruitment Efforts: Identifying Opportunities for Undergraduate and Medical Student Involvement in Infectious Diseases.

Background: Only 74% of infectious diseases (ID) training positions were filled in the 2022 fellowship match, indicating a need to find increasingly novel and creative solutions for ID recruitment and outreach. Methods: The websites of 2321 universities and 181 medical schools across the United States were manually searched for the presence of undergraduate clubs and interest groups, respectively, for multiple medical specialties and subspecialties, including ID. Geographic data were used to compare the proximity of ID fellowships to undergraduate institutions. Results: ID student groups were extremely rare among the categories studied throughout undergraduate institutions (6 out of 2048, or 0.29%). Only 58 of 163 (35.6%) medical schools nationwide included an ID student group. Geographic comparison found that every adult ID fellowship is in the same county and/or city as at least 1 undergraduate institution and 28.5% of adult ID fellowships are in the same zip code as at least 1 undergraduate institution. Conclusions: The relative paucity of ID student interest groups presents an opportunity for the ID community to begin outreach and recruitment at the undergraduate and medical student levels, specifically through student groups.

The impact of beta-lactam allergy labels on hospitalized children.

BACKGROUND AND OBJECTIVES: Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that ß-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of ß-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes. METHOD: This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with ß-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children's hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs. RESULTS: In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with ß-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients. CONCLUSIONS: Hospitalized pediatric patients with ß-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.

The impact of antibiotic allergy labels on antibiotic exposure, clinical outcomes, and healthcare costs: A systematic review.

OBJECTIVE: A growing body of evidence suggests that antibiotic allergy labels as documented in medical records are a risk factor for poor clinical outcomes. In this systematic review, we aimed to determine how antibiotic allergy labels influence 3 domains: antibiotic use and exposure, clinical outcomes, and healthcare-related costs. DESIGN: We performed a systematic review to identify studies reporting outcomes in patients with antibiotic allergy labels compared to nonallergic counterparts. The search included PubMed, EMBASE, Cochrane CENTRAL, EBSCO, Cochrane Database of Abstracts of Reviews of Effects and Web of Science. Two reviewers independently screened studies for inclusion and abstracted data. Studies were graded using the Newcastle-Ottawa quality assessment scale. Study outcomes included antibiotic use, clinical outcomes, and economic outcomes. RESULTS: In total, 41 studies met our criteria for inclusion. These studies varied in medical specialty, patient population, healthcare delivery system, and design, but most were conducted among adults age >18 years (85%) in the inpatient setting (82.5%). Among 34 studies examining antibiotic exposure, 32 (94%) found that patients with antibiotic allergy labels received more broad-spectrum antibiotics. Moreover, 31 studies examined clinical outcomes such as length of hospitalization, ICU admission, hospital readmission, multidrug-resistant or opportunistic infection, or mortality, and 27 (87%) found that allergy-labeled patients had at least 1 negative outcome. Of 9 studies examining healthcare costs, 7 (78%) found that allergy-labeled patients incurred significantly higher drug or hospital-related costs. CONCLUSIONS: Antibiotic allergy labels have negative effects on antibiotic use, clinical outcomes, and economic outcomes in a variety of clinical settings and populations.

Utility of three-dimensional models in resident education on simple and complex intracardiac congenital heart defects.

OBJECTIVE: Applications of three-dimensional (3D) printed models in medicine include preprocedure planning, patient education, and clinical training. Reproducing complex anatomy as a 3D printed model can be useful for understanding congenital heart defects (CHD). We hypothesized that using 3D printed models during didactic sessions with resident physicians will improve trainees' understanding of CHD. DESIGN AND INTERVENTION: We performed a prospective, randomized educational intervention for teaching pediatric and pediatric/emergency medicine residents about simple (ventricular septal defect [VSD]) and moderately complex (tetralogy of Fallot [ToF]) CHD. Residents were divided into two groups: intervention and control. Each group completed a subjective survey about their comfort with the anatomy, evaluation, and treatment of VSD and ToF and took an objective test on VSD and ToF. They separately received the same 20 min lecture, including projected two-dimensional digital images of VSD and ToF; the intervention group was given 3D printed models created using the same imaging data. After the lecture, the groups repeated the survey and test questions. RESULTS: Twenty-six residents participated in the VSD session, 34 in the ToF. There were no differences in demographics between control and intervention groups. All residents had higher subjective comfort with VSD and ToF after the lectures. There was no difference in baseline test scores for VSD or ToF groups. The control group scored higher on the VSD postlecture test. The intervention group scored higher on the ToF postlecture test. CONCLUSION: Incorporation of 3D printed models into lectures about CHD imparts a greater acute level of understanding, both subjective and objective, for pediatric and combined pediatric/emergency medicine residents. There does not seem to be an added benefit for understanding ventricular septal defects, but there is for tetralogy of Fallot, likely due to increased complexity of the lesion and difficulty visualizing spatial relationships in CHD with multiple components.

Use of 3D models of vascular rings and slings to improve resident education.

OBJECTIVE: Three-dimensional (3D) printing is a manufacturing method by which an object is created in an additive process, and can be used with medical imaging data to generate accurate physical reproductions of organs and tissues for a variety of applications. We hypothesized that using 3D printed models of congenital cardiovascular lesions to supplement an educational lecture would improve learners' scores on a board-style examination. DESIGN AND INTERVENTION: Patients with normal and abnormal aortic arches were selected and anonymized to generate 3D printed models. A cohort of pediatric and combined pediatric/emergency medicine residents were then randomized to intervention and control groups. Each participant was given a subjective survey and an objective board-style pretest. Each group received the same 20-minutes lecture on vascular rings and slings. During the intervention group's lecture, 3D printed physical models of each lesion were distributed for inspection. After each lecture, both groups completed the same subjective survey and objective board-style test to assess their comfort with and postlecture knowledge of vascular rings. RESULTS: There were no differences in the basic demographics of the two groups. After the lectures, both groups' subjective comfort levels increased. Both groups' scores on the objective test improved, but the intervention group scored higher on the posttest. CONCLUSIONS: This study demonstrated a measurable gain in knowledge about vascular rings and pulmonary artery slings with the addition of 3D printed models of the defects. Future applications of this teaching modality could extend to other congenital cardiac lesions and different learners.

Factitious disorder-by-proxy simulating fetal growth restriction.

BACKGROUND: Although a variety of presentations have been described in the literature, the true prevalence of factitious disorder, also commonly known as Münchausen syndrome, and factitious disorder-by-proxy in pregnancy is unknown. The authors present a unique case in which intrauterine fetal growth restriction was simulated through fabrication of prenatal records. CASE: A 30-year-old woman, gravida 6 para 3113, was transferred at 38 4/7 weeks of gestation for severe fetal growth restriction. The clinic listed in the patient-provided prenatal record was contacted to obtain original ultrasonographic reports for verification of gestational age; however, further investigation revealed the patient had never attended this clinic nor was the ostensible treating physician ever employed there. The initial prenatal record subsequently was determined to be entirely fabricated. CONCLUSION: In this era of extensive technologic resources, health care providers should consider the possibility of factitious disorder when patient-provided medical record-derived information is inconsistent with the clinical presentation.

Honoring our donors: a survey of memorial ceremonies in United States anatomy programs.

Many anatomy programs that incorporate dissection of donated human bodies hold memorial ceremonies of gratitude towards body donors. The content of these ceremonies may include learners' reflections on mortality, respect, altruism, and personal growth told through various humanities modalities. The task of planning is usually student- and faculty-led with participation from other health care students. Objective information on current memorial ceremonies for body donors in anatomy programs in the United States appears to be lacking. The number of programs in the United States that currently plan these memorial ceremonies and information on trends in programs undertaking such ceremonies remain unknown. Gross anatomy program directors throughout the United States were contacted and asked to respond to a voluntary questionnaire on memorial ceremonies held at their institution. The results (response rate 68.2%) indicated that a majority of human anatomy programs (95.5%) hold memorial ceremonies. These ceremonies are, for the most part, student-driven and nondenominational or secular in nature. Participants heavily rely upon speech, music, poetry, and written essays, with a small inclusion of other humanities modalities, such as dance or visual art, to explore a variety of themes during these ceremonies.

Creating a longitudinal environment of awareness: teaching professionalism outside the anatomy laboratory.

Anatomy educators have long understood the role that professionalism education plays in the dissection laboratory. The process of dissecting human material forces students to address such issues as human mortality, their responsibility to the vulnerability of the deceased, their privileged position in society, and their commitment to scientific ideals. Educators have offered a wealth of opinions and curricula dedicated to teaching professionalism in first-year anatomy courses. That they have risen to this challenge is laudable. However, professionalism education is a longitudinal process of acculturation. What happens, then, to students after they leave the anatomy classroom? As it is not taught in other basic science courses, professionalism education effectively becomes a null curriculum, teaching students to compartmentalize professionalism questions so that they can be addressed in anatomy courses or during dedicated professionalism course work. In their training, medical students spend 4 to 12 years navigating this shifting environment of hidden, null, or explicit curricula, which have a significant impact on their attitudes and character.In this perspective, the author highlights, from his experience as a medical student, specific professionalism challenges in anatomy--such as encountering mortality, enacting contracts with society and those who are most vulnerable, and upholding scientific excellence--and discusses how these challenges are addressed by anatomy educators. He then provides analogous examples of opportunities to teach professionalism in other basic science courses, such as pathology, microbiology, and pharmacology. He concludes by describing the goal of incorporating professionalism into all basic science courses--a longitudinal, cohesive environment of awareness.

Students as resurrectionists--A multimodal humanities project in anatomy putting ethics and professionalism in historical context.

Because medical students have many different learning styles, the authors, medical students at Mayo Clinic, College of Medicine researched the history of anatomical specimen procurement, reviewing topic-related film, academic literature, and novels, to write, direct, and perform a dramatization based on Robert Louis Stevenson's The Body-Snatcher. Into this performance, they incorporated dance, painting, instrumental and vocal performance, and creative writing. In preparation for the performance, each actor researched an aspect of the history of anatomy. These micro-research projects were presented in a lecture before the play. Not intended to be a research study, this descriptive article discusses how student research and ethics discussions became a theatrical production. This addition to classroom and laboratory learning addresses the deep emotional response experienced by some students and provides an avenue to understand and express these feelings. This enhanced multimodal approach to"holistic learning" could be applied to any topic in the medical school curriculum, thoroughly adding to the didactics with history, humanities, and team dynamics.