Bilateral lower extremity swelling: black pearl.

Iatrogenic pneumothorax secondary to thoracentesis is relatively uncommon but does present to the emergency department (ED). Iatrogenic pneumothoraces developing tension physiology are rare. We report a case of an elderly female patient presenting to the ED with an isolated chief complaint of bilateral leg swelling, beginning the day after a thoracentesis, which was performed 3 days prior for pleural effusions secondary to lung cancer. Given that the patient was hemodynamically stable, not hypoxic, and had a history of chronic obstructive pulmonary disease and recent history of pleural effusions with diminished lung sounds throughout, this was a radiologic diagnosis. Immediately upon diagnosis, a 10F intrapleural catheter was inserted at the second intercostal space in the midclavicular line with successful resolution of the tension phenomenon. The patient tolerated the procedure well, and the catheter was removed on hospital day 2 without recurrence of the pneumothorax. She experienced resolution of her lower extremity swelling and was discharged from the hospital 2 days later. Isolated inferior vena cava syndrome secondary to a subacute tension pneumothorax was likely the cause of the patient's symptoms. This presentation is very rare and is undocumented in the literature. A high degree of suspicion for acute chest pathology should exist in every patient presenting to the ED with history of recent pleural violation.

Impact of Nasal Swabs on Empiric Treatment of Respiratory Tract Infections (INSERT-RTI).

Methicillin-resistant Staphylococcus aureus (MRSA) polymerase-chain-reaction nasal swabs (PCRNS) are a rapid diagnostic tool with a high negative predictive value. A PCRNS plus education "bundle" was implemented to inform clinicians on the utility of PCRNS for anti-MRSA therapy de-escalation in respiratory tract infections (RTI). The study included patients started on vancomycin with a PCRNS order three months before and after bundle implementation. The primary objective was the difference in duration of anti-MRSA therapy (DOT) for RTI. Secondary objectives included hospital length of stay (LOS), anti-MRSA therapy reinitiation, 30-day readmission, in-hospital mortality, and cost. We analyzed 62 of 110 patients screened, 20 in the preintervention and 42 in the postintervention arms. Mean DOT decreased after bundle implementation by 30.3 h (p = 0.039); mean DOT for patients with a negative PCRNS decreased by 39.7 h (p = 0.014). Median cost was lower after intervention [USD$51.69 versus USD$75.30 (p < 0.01)]. No significant difference in LOS, mortality, or readmission existed. The bundle implementation decreased vancomycin therapy and cost without negatively impacting patient outcomes.

Use of continuous infusion ceftolozane-tazobactam with therapeutic drug monitoring in a patient with cystic fibrosis.

PURPOSE: The safe and effective use of ceftolozane-tazobactam delivered via continuous infusion in a cystic fibrosis (CF) patient with reduced body weight and presumed augmented renal clearance is reported. SUMMARY: A 30-year-old woman with CF was admitted for acute pulmonary exacerbations with positive respiratory cultures for Pseudomonas aeruginosa and extended-spectrum ß-lactamase-producing Escherichia coli. Susceptibility testing confirmed multidrug resistance, and the patient was transitioned to ceftolozane-tazobactam for definitive therapy. A novel strategy of administering ceftolozane-tazobactam 6 g by continuous i.v. infusion over 24 hours was initiated during hospitalization and continued at discharge for a total of 10 days. Therapeutic drug monitoring over the first 36 hours of the continuous infusion confirmed adequate exposure. The patient had clinical resolution with return to baseline of pulmonary function tests and no noted adverse drug events. CONCLUSION: A continuous infusion regimen of ceftolozane-tazobactam was successfully used in a CF patient with augmented renal clearance.

Survey of residency program directors' perceptions of nontraditional pharmacy residency applicants.

PURPOSE: The attitudes and expectations of residency program directors (RPDs) regarding nontraditional residency applicants (NTAs) were evaluated. METHODS: This was a cross-sectional, survey-based study targeting RPDs of American Society of Health-System Pharmacists-accredited residency programs. A 14-question survey requesting information related to demographics, perceptions of NTAs compared with traditional applicants, advantages and disadvantages of NTAs, and advice for NTAs was administered electronically to RPDs. The primary outcome of this study was to determine RPDs' perceptions of NTAs as suitable residency candidates. The secondary outcome evaluated the rate of NTA acceptance into residency programs and a qualitative assessment of RPDs' advice for NTAs. RESULTS: Of the 1,414 RPDs contacted to participate, 328 (23%) completed the survey. RPDs were primarily affiliated with postgraduate year 1 pharmacy practice (52%) or postgraduate year 2 specialty residencies (30%), and 35% reported having an NTA in their program. Most respondents (87%) reported that NTAs are given equal consideration relative to traditional residency applicants. RPDs rated work experience as the most important quality of an NTA, followed closely by the ability to work with others and teachability. Most (277 [85%]) RPDs agreed that NTAs should possess experiences beyond work experience, such as research, leadership, and community service. The biggest concern regarding NTAs was significant time since graduation prior to application. CONCLUSION: The majority of RPDs did not perceive NTAs differently from traditional applicants in the selection process of prospective candidates.

An Interactive Session to Help Faculty Manage Difficult Learner Behaviors in the Didactic Setting.

Introduction: The transition to more active learning during residency didactics has made the skill of managing difficult learner behaviors essential: Just one learner exhibiting difficult behavior can derail the educational experience for the room. Many educators feel uncomfortable handling these learners in real time and after the session. Methods: We created an interactive session for a mixed group of educators at a medical education boot camp. After learning about a framework for addressing difficult learner behaviors, participants were paired and presented with the case of a withdrawn learner. For each pair, the cause of the behavior was different. With one of the pair role-playing the learner, they were asked to identify the problem and solutions together. Multiple etiologies for the identical behavior reinforced the need to address underlying causes to create an effective plan for behavior change. Strategies to address difficult behaviors in real time were also discussed in large-group format. Results: Participants gave the session a mean score of 4.5 out of 5, indicating a high likelihood of changing their teaching practice. Free-response comments remarked on the role-play's educational value and the enjoyability of the session overall. Discussion: This session was effective in giving participants a framework for dealing with difficult learner behaviors, as well as hands-on practice with these skills. While this was a short (30-minute), single session, its success with participants with a wide variety of experience levels suggests it would be highly adaptable to other settings and may benefit from future expansion into the clinical setting.