Fungemia Associated with Left Ventricular Assist Device Support

Objective: Infections remain an important complication of left ventricular assist device (LVAD) support. While relatively uncommon, fungal infections present a serious concern given a high association with adverse events including death. We sought to further characterize the epidemiology of fungemias during LVAD support. Methods: Retrospective review of 292 patients receiving LVAD support from October 1996 to April 2009 at the University of Michigan Health System was done. Results: Seven cases of LVAD-associated fungemia were observed during the study period (0.1 infections/1000 days of device support). Five patients had infection with Candida species and two with Aspergillus species. The two patients with Aspergillus infection presented with disseminated disease, quickly dying of multiorgan failure, and sepsis. All five patients with Candida infections were successfully treated with systemic antifungal therapy along with transplantation in four of five patients. The fifth patient is receiving mechanical support as destination therapy. He remains on long-term suppression with high-dose fluconazole. Conclusions: Fungal infections appear to be a rare but serious complication of LVAD support. Future studies should aim to improve our understanding of risk factors for fungal infection during mechanical support, especially disseminated Aspergillus . Short-term perioperative antifungal prophylaxis with fluconazole appears to be an effective and reasonable approach to prevention. (J Card Surg 2009;24:763–765)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78694/1/j.1540-8191.2009.00919.x.pd

Relapsing cytomegalovirus infection in solid organ transplant recipients

Efforts to prevent relapsed cytomegalovirus (CMV) disease among solid organ transplant (SOT) recipients present clinical challenges. Historically, SOT recipients treated with short courses of ganciclovir, without documented clearance of viremia, had relapse rates of 23–33%. Current treatment often includes much longer courses of valganciclovir, and persistence of viremia at the end of treatment is rare. We sought to determine the rate and risk factors for relapse under those treatment conditions. Records of 1760 SOT recipients from January 2003 to June 2007 were reviewed; 105 cases of CMV viremia were identified. Relapse occurred in 20/105 (19%); 50% had end-organ disease at the time of relapse. Most patients received approximately 3 months of valganciclovir. Clearance of viremia was documented in 19/20 patients with relapse. Multivariable analysis identified receipt of a thoracic organ and diabetes mellitus as risk factors for relapse. Despite long treatment courses with valganciclovir and documented clearance of viremia, CMV relapse remains common among SOT recipients. Better understanding of the epidemiology of CMV among SOT recipients and validation of risk factors for disease relapse should be the focus of future prospective trials. Such trials should include different treatment durations and extended monitoring for relapse.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73013/1/j.1399-3062.2009.00443.x.pd

Surgical Infection Prophylaxis for Left Ventricular Assist Device Implantation

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/86804/1/j.1540-8191.2011.01262.x.pd

Risk Factors for Arthralgias or Myalgias Associated with Quinupristin‐Dalfopristin Therapy

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90134/1/phco.23.2.159.32078.pd

Experience with Community‐Based Amphotericin B Infusion Therapy

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90368/1/phco.25.5.690.63591.pd

Promoting medical students’ reflection on competencies to advance a global health equities curriculum

Abstract Background The move to frame medical education in terms of competencies – the extent to which trainees “can do” a professional responsibility - is congruent with calls for accountability in medical education. However, the focus on competencies might be a poor fit with curricula intended to prepare students for responsibilities not emphasized in traditional medical education. This study examines an innovative approach to the use of potential competency expectations related to advancing global health equity to promote students’ reflections and to inform curriculum development. Methods In 2012, 32 medical students were admitted into a newly developed Global Health and Disparities (GHD) Path of Excellence. The GHD program takes the form of mentored co-curricular activities built around defined competencies related to professional development and leadership skills intended to ameliorate health disparities in medically underserved settings, both domestically and globally. Students reviewed the GHD competencies from two perspectives: a) their ability to perform the identified competencies that they perceived themselves as holding as they began the GHD program and b) the extent to which they perceived that their future career would require these responsibilities. For both sets of assessments the response scale ranged from “Strongly Disagree” to “Strongly Agree.” Wilcoxon’s paired T-tests compared individual students’ ordinal rating of their current level of ability to their perceived need for competence that they anticipated their careers would require. Statistical significance was set at p < .01. Results Students’ ratings ranged from “strongly disagree” to “strongly agree” that they could perform the defined GHD-related competencies. However, on most competencies, at least 50 % of students indicated that the stated competencies were beyond their present ability level. For each competency, the results of Wilcoxon paired T-tests indicate – at statistically significant levels - that students perceive more need in their careers for GHD-program defined competencies than they currently possess. Conclusion This study suggests congruence between student and program perceptions of the scope of practice required for GHD. Students report the need for enhanced skill levels in the careers they anticipate. This approach to formulating and reflecting on competencies will guide the program’s design of learning experiences aligned with students’ career goals.http://deepblue.lib.umich.edu/bitstream/2027.42/109541/1/12909_2013_Article_919.pd

A multidisciplinary approach to improving women’s health in semi‐urban Ecuador

ObjectiveTo examine women’s reasons for seeking care at The Quito Project (TQP), a student‐led organization that aims to improve the health, education, and well‐being of a semi‐urban community in Quito, Ecuador, and to explore the need for additional preventative interventions.MethodsAn oral survey was administered to 86 adult patients in 2008. We also completed a chart review to evaluate patient demographics and medical conditions.ResultsSixty‐three (73.3%) survey respondents were female. Nearly three‐quarters of the women reported an income below the minimum wage; 60% reported that the cost of medical care posed a burden. Fifty‐two percent sought care at TQP because the services were free. Additionally, 77% of women reported going to the doctor only when ill and did not access preventative services.ConclusionsBy offering medical, dental, and tutoring services, along with preventative health workshops, TQP addresses established barriers to achieving adequate women’s health. Survey results have reinforced TQP’s focus on prevention.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135173/1/ijgo70.pd

Poor Functional Status as a Risk Factor for Severe Clostridium difficile Infection in Hospitalized Older Adults

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/112304/1/jgs12442.pd

Real-Time Identification of Serious Infection in Geriatric Patients Using Clinical Information System Surveillance

To develop and characterize an automated syndromic surveillance mechanism for early identification of older emergency department (ED) patients with possible life-threatening infection. DESIGN : Prospective, consecutive-enrollment, single-site observational study. SETTING : A large university medical center with an annual ED census of 75,273. PARTICIPANTS : Patients aged 70 and older admitted to the ED and having two or more systemic inflammatory response syndrome (SIRS) criteria during their ED stay. MEASUREMENTS : A search algorithm was developed to screen the census of the ED through its clinical information system. A study coordinator confirmed all patients electronically identified as having a probable infectious explanation for their visit. RESULTS : Infection accounted for 28% of ED and 34% of final hospital diagnoses. Identification using the software tool alone carried a 1.63 relative risk of infection (95% confidence interval CI=1.09–2.44) compared with other ED patients sufficiently ill to require admission. Follow-up confirmation by a study coordinator increased the risk to 3.06 (95% CI=2.11–4.44). The sensitivity of the strategy overall was modest (14%), but patients identified were likely to have an infectious diagnosis (specificity=98%). The most common SIRS criterion triggering the electronic notification was the combination of tachycardia and tachypnea. CONCLUSION : A simple clinical informatics algorithm can detect infection in elderly patients in real time with high specificity. The utility of this tool for research and clinical care may be substantial.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66036/1/j.1532-5415.2008.02094.x.pd