More Specialties, Fewer Problems: Using Collaborative Competency Between Infectious Diseases, Podiatry, and Pathology to Improve the Care of Patients with Diabetic Foot Osteomyelitis.

BACKGROUND: Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking. METHODS: Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses. RESULTS: A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients. CONCLUSIONS: This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.

Bridging the Gap Between "Do One" and "Teach One": Impact of a Procedural Objective Structured Teaching Encounter on Resident Procedural Teaching Proficiency.

PROBLEM: Minimal formal training exists in teaching invasive bedside procedures during Internal Medicine (IM) residency despite the large role trainees have in instructing junior colleagues. OBJECTIVE AND METHODS: We investigated if using a Procedural Objective Structured Teaching Encounter (PrOSTE) to disseminate a novel method for teaching procedures would improve supervising residents' (n = 7) ability to teach ultrasound-guided peripheral IV's (USGIV) to incoming interns (n = 67) at a single, large academic IM residency. Supervising residents were assigned to receive the PrOSTE training versus standard procedure training, and then, both groups instructed incoming interns. The impact of the PrOSTE was measured by participant surveys, observed changes in teacher behavior, and performance of incoming interns on a USGIV blinded assessment station. MEASUREMENT AND MAIN RESULTS: PrOSTE-trained residents reported high levels of satisfaction with the session and demonstrated increased desirable behaviors when teaching procedures. There was no statistical difference in incoming intern performance when placing USGIVs between intervention and standard groups (81.0% vs 74.8% items correct; difference 6.2; SD = 12.4; p = 0.22). CONCLUSION: The PrOSTE is a feasible, well-received tool for training supervising residents in our novel teaching framework, as demonstrated in this pilot study. Despite not showing a difference in learner performance, qualitative data suggests the impact of the PrOSTE would be even greater in a more controlled teaching environment. Using a PrOSTE to deliver this teaching framework has broad applicability to any IM residency, and the tenets can be used with any bedside invasive procedure with an effective task trainer.

Surgical cure of clarithromycin resistant Mycobacterium chelonae breast implant infection: A case report and review of the literature.

Clusters of patients who obtain cosmetic surgeries abroad have developed surgical site infections due to rapid growing non-tuberculous mycobacteria (NTM). These are usually treated with a combination of surgery and months of anti-mycobacterial therapy, but poor outcomes, including permanent scarring are common. We present a case of a 36-year-old female who developed a clarithromycin-resistant M. chelonae (CRMC) infection after undergoing breast augmentation in the Dominican Republic. She underwent debridement and explant of her silicone implants, but due to a series of complications including discordant antimicrobial susceptibility testing profiles, GI side effects, and then pregnancy, she was unable to receive typical multidrug anti-mycobacterial therapy after surgery. She received close clinical follow up and demonstrated full recovery without any evidence of recurrence of infection at 9 months of follow up. We searched the literature for cases of NTM surgical site infection after breast surgery. To our knowledge, this is the first case report of confirmed NTM breast implant infection being cured with surgery alone, and only the second report of clarithromycin resistant M. chelonae in a patient without disseminated infection or pre-exposure to macrolides. The increasing prevalence of drug resistant NTM infections is an emerging concern for clinicians treating patients with complications related to medical tourism.

Beyond the Superficial: Disseminated Trichophyton rubrum Infection in a Kidney Transplant Recipient.

Superficial dermatophyte infections are common in the general population and are readily treated with topical antifungals. Deeper invasion is rare, and dissemination to visceral organs is extremely uncommon. We describe a 66-year-old renal transplant recipient who developed disseminated Trichophyton rubrum infection while undergoing treatment for acute humoral rejection. The infection presented as a facial rash with subsequent dissemination to the lungs and chest wall. All sites of infection improved with combination administration of oral posaconazole and terbinafine. In this work, we review the available literature regarding management of disseminated Trichophyton infection and discuss therapeutic interventions for disseminated dermatophytosis in immunosuppressed hosts.

Invasive Ureaplasma Infection in Patients Receiving Rituximab and Other Humoral Immunodeficiencies-A Case Report and Review of the Literature.

Ureaplasma species are small, fastidious bacteria that frequently colonize the lower reproductive tract of asymptomatic hosts. These organisms have been well described to cause chorioamnionitis, neonatal infection, and urethritis, and to a lesser degree surgical site infection and infection in transplant recipients. Outside of these settings, invasive Ureaplasma infections are rare. We describe the case of a young woman receiving rituximab for multiple sclerosis who presented with fever and bilateral renal abscesses due to Ureaplasma spp., which was successfully treated with oral doxycycline. We searched the literature for cases of invasive Ureaplasma infection and found a patient population that predominates with humoral immunodeficiency, either congenital or iatrogenic. Diagnostic and therapeutic interventions are discussed.

Angiotensin type 1 receptor antagonist losartan, reduces MPTP-induced degeneration of dopaminergic neurons in substantia nigra.

BACKGROUND: Recent attention has focused on understanding the role of the brain-renin-angiotensin-system (RAS) in stroke and neurodegenerative diseases. Direct evidence of a role for the brain-RAS in Parkinson's disease (PD) comes from studies demonstrating the neuroprotective effect of RAS inhibitors in several neurotoxin based PD models. In this study, we show that an antagonist of the angiotensin II (Ang II) type 1 (AT1) receptor, losartan, protects dopaminergic (DA) neurons against 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) toxicity both in primary ventral mesencephalic (VM) cultures as well as in the substantia nigra pars compacta (SNpc) of C57BL/6 mice (Fig. 1). RESULTS: In the presence of exogenous Ang II, losartan reduced MPP+ (5 muM) induced DA neuronal loss by 72% in vitro. Mice challenged with MPTP showed a 62% reduction in the number of DA neurons in the SNpc and a 71% decrease in tyrosine hydroxylase (TH) immunostaining of the striatum, whereas daily treatment with losartan lessened MPTP-induced loss of DA neurons to 25% and reduced the decrease in striatal TH+ immunostaining to 34% of control. CONCLUSION: Our study demonstrates that the brain-RAS plays an important neuroprotective role in the MPTP model of PD and points to AT1 receptor as a potential novel target for neuroprotection.