Disseminated Nocardia nova in a child with relapsed acute lymphoblastic leukemia: a case report.

BACKGROUND: Nocardiosis is a rare infection that typically results from inhalation of or inoculation with Nocardia organisms. It may cause invasive disease in immunocompromised patients. This case describes nocardiosis with bacteremia and pulmonary involvement in a child with a hematologic malignancy. CASE PRESENTATION: A boy with testicular relapsed acute lymphoblastic leukemia with marrow involvement presented with sudden onset of fever, body aches, headaches, chills, and moderate respiratory distress during continuation 2 chemotherapy. Radiographic imaging demonstrated consolidation and ground glass opacities in bilateral lower lungs. Central line blood cultures grew Nocardia nova complex, prompting removal of the central line and initiation of triple therapy with imipenem-cilastatin, linezolid, and trimethoprim-sulfamethoxazole with rapid improvement of symptoms. Antibiotic susceptibilities showed a multidrug-susceptible isolate. The patient is anticipated to remain on trimethoprim-sulfamethoxazole for at least 12 months. CONCLUSIONS: In an immunocompromised child, blood cultures, chest imaging, and head imaging can aid in the diagnosis of disseminated nocardiosis. Long-term antibiotic therapy is necessary, guided by the organism and simplified with the results of antimicrobial susceptibility testing.

Resident Workshop Standardizes Patient Handoff and Improves Quality, Confidence, and Knowledge.

OBJECTIVES: Residency programs are required to instruct residents in handoff; however, a handoff curriculum endorsed by the Accreditation Council for Graduate Medical Education does not exist. Although curricula are available, we preferred to use a curriculum that could be taught quickly, was easy to implement, and used a mnemonic that resembled current practices at our institution. We designed and implemented a novel handoff educational workshop intended to improve resident confidence and performance. METHODS: In this observational study, pediatric residents across postgraduate training years during winter 2014-spring 2015 participated in two study segments: a handoff workshop with questionnaires and handoff observations. Co-investigators developed and led an interactive workshop for residents that emphasized a standardized approach using the SIGNOUT mnemonic (see text for definition). The effect of workshop participation on handoff abilities was evaluated using a validated, handoff evaluation tool administered before and after the workshop. Qualitative feedback was obtained from residents using pre- and postworkshop surveys. RESULTS: Forty-three residents participated in the workshop; 41 residents completed handoff observations. Improvements were noted in clinical judgment (P = 0.02) and organization/communication (P = 0.005). Pre- and postworkshop surveys demonstrated self-perceived increases in confidence, comfort, and knowledge (P < 0.001). CONCLUSIONS: Improvements in handoffs, particularly in clinical judgment and organization/communication domains, suggest that a more standardized handoff approach is beneficial, especially for postgraduate year 1 residents. The novel, interactive workshop we developed can be taught quickly, is easy to implement, is appropriate for all resident training levels, and improves resident confidence and skill. This workshop can be implemented by training programs across all disciplines, possibly leading to improved patient safety.

Perceptions of posthysterectomy cystoscopy training in obstetrics and gynecology residency programs.

OBJECTIVE: The objective of this study was to characterize the training practices of obstetrics and gynecology (OG) residency programs regarding posthysterectomy cystoscopy. METHODS: Two separate electronic surveys were sent to program directors and residents at American Council of Graduate Medical Education-accredited OG programs. Measures included the type of cystoscopy training available, estimates on indications and how often posthysterectomy cystoscopy is performed, and exposure to female pelvic medicine and reconstructive surgery (FPMRS). RESULTS: Sixty-one (26%) of 235 program directors and 394 (29.7%) of 1325 residents completed the survey. The majority of residents (95%) who received training reported having experience with cystoscopy in the operating room. Residents with FPMRS fellowships were more likely to perform routine cystoscopy after hysterectomy during their training compared with residents without fellowships (39% vs 27%, P = 0.01). Residents graduating from programs with FMPRS fellowships reported they planned to always perform routine cystoscopy more often than did those without a fellowship program (30.3% vs 17%, P = 0.01).Program directors most frequently defined competency as direct observation of the procedure (95%), followed by the number performed (53%) and a competency checklist (45%). No significant differences were noted in the reported use of routine cystoscopy by program directors after hysterectomy, with or without a fellowship program (62% vs 48%, P = 0.38). CONCLUSIONS: Residents in OG programs are receiving cystoscopy training, most commonly in the operating room, less often with simulation. Nineteen percent reported receiving no training. Graduating residents exposed to FPMRS fellowships more frequently reported planning to always perform cystoscopy after hysterectomy than did those without fellowship exposure.