Catheter-associated urinary tract infections: patient characteristics, treatment, and clinical outcomes in one South Texas acute care hospital

Background: Catheter-associated urinary tract infections (CA-UTIs) account for 40 percent of nosocomial infections worldwide. Their elimination is at the forefront of quality improvement in one South Texas acute care hospital. Methods: Over a period of 6 months, five CA-UTIs occurred in one South Texas acute care hospital. These cases were identified via regular surveillance by Infection Prevention staff and the Laboratory Department of the hospital. This research reviews patient age, sex, length of stay, bacteria contracted, appropriate antibiotic use, patient characteristics, and overall outcomes. Results: Between the months of July and December 2021, 5 CAUTIs were contracted. Patients ranged in age from 44 to 71 years old with a mean age of 68.8 years old; 2 were male and 3 were female; the average length of stay ranged from 19 to 59 days with an average stay of 32.2 days. All patients had severe illness on presentation and multiple comorbidities. Organisms isolated included klebsiella oxytoca, carbapenem-resistant Enterobacteriaceae, extended-spectrum beta-lactamase E. coli and klebsiella pneumoniae. Susceptibility studies were conducted on all 5 patients. Antibiotics used include piperacillin-tazobactam, ceftriaxone, levofloxacin, and meropenem. CAUTIs resolved in 4 patients; two of them were discharged to skilled nursing facilities, one was discharged home, and one died due to complications from COVID-19. Conclusions: Among these cases, factors such as local rates of COVID-19 cases (the cases happened when hospital census was unusually high), extended length of stay, use of mechanical ventilation, Foley catheter placement in the Emergency Department, severe illness, and comorbid health conditions should be considered when assessing risk of CA-UTI and treatment outcome. While antibiotics that were prescribed appropriately corresponded with sensitivity studies, sustainability of infection prevention processes for the prevention of CA-UTIs is difficult to sustain during periods of crisis as exemplified in this project

Predicting USMLE Step 2 Scores Using Results from the NBME Shelf Exams

Background In February of 2020 the sponsors of the USMLE examinations, which includes the NBME and the Federation of State Medical Boards (FSMB) decided to change the scoring system of the USMLE Step 1 from a three-digit numeric score to a Pass/Fail outcome1. The basis of this change was made to “address concerns about Step 1 scores impacting student well-being and medical education”2. Historically, the three-digit numeric score from Step 1 has been one of the top determining factors for admission into residency3. This change will cause a shift in the priority of objective and subjective factors about applicants that residency program directors use to assess medical students. The purpose of this study is to further assess the correlation between core clerkship NBME Shelf exam scores with performance on the USMLE Step 2. Predicting performance on the USMLE Step 2 is of more importance now that the Step 1 scoring system was changed to a Pass/Fail outcome. We expect that the scores on the NBME shelf exams will be correlated to the overall performance on USMLE Step 2, further supporting the conclusions of the previous study by Zahn et al4. Methods Data containing students’ performance on the USMLE Step 2 and NBME Shelf exams was obtained from Blackboard and One45. In order to protect student confidentiality, data will be de-identified at the point of collection by supervising faculty. From the clerkship assessment score (professionalism, clinical knowledge, shelf exam, etc.) each component will be standardized and converted into a z-score. The NBME Shelf Exams and USMLE Step 2 score will also be converted into a standardized z-score. Standardized USMLE Step 2 T-scores will be substituted in place of NBME Shelf T-scores and final grading computation will analyze the frequency of each grade type (Honors, High Pass, Pass, Fail). Linear regression will be used to determine the correlation between USLME Step 2 scores and performance on the Clerkship Shelf Exams. To assess the effect size of the regression equation, a squared correlation coefficient (R2) will be computed between scores of the USLME Step 2 and NBME Shelf Exams. Results Data collection complete after update to IRB research proposal was approved. Data analysis underway with preliminary results expected in early Spring 2021. Conclusion Further analysis of the data is required for proper conclusions to be drawn

The Infectious Headache- A Case of Neurocysticercosis

A 50-year-old Hispanic female presented to her primary care physician with a progressively worsening headache over a week, associated with visual disturbances, prosopagnosia and episodes of disorientation. Outpatient workup with head CT showed abnormality in the ventral aspect of the left thalamus showing 1.2 × 1 cm low density cyst with approximately 2-3 mm right-left midline shift locally. Left basal ganglia showed multiple well-defined foci of low density measuring up to 3 mm reflecting edema. On admission, pertinent physical exam findings were left sided nystagmus, positive deep tendon reflexes (DTRs) in the right lower extremity (RLE), positive Babinski on the right foot, and mild endpoint tremor dysmetria. MRI showed multiple cystic structures (Figure 1) with eccentric nodularity suggesting a scolex, with calcifications and surrounding edema (Figure 2). The largest was localized near the left anterior aspect of the third ventricle measuring 15 mm with vasogenic edema extending to left temporal lobe (Figure 3). EEG showed focal cortical disturbance (transient triphasic sharp morphology) on the left hemisphere localizing to the central temporal region, corresponding with the area of vasogenic edema and potential for epileptogenesis (Figure 4). Travel history was significant for a family vacation in Punta Cana 3 years prior, where they ate at local restaurants and street vendors. Family members also lived in close proximity, often preparing meals together. Serum antibody detection ELISA assays for Taenia solium cysticercosis (T. solium) was negative. Serum testing for Toxoplasmosis, HIV and CMV were also unrevealing. A diagnosis [1] of Neurocysticercosis (NCC) was established based on 2 Major Neuroimaging criteria: presence of cystic lesions and enhancing lesions paired with 1 Minor criteria: Clinical presentation. Treatment [2] was started as per IDSA guidelines with albendazole, praziquantel (though delayed due to lack of supply in hospital), anti-epileptic and dexamethasone. Recommendation was given for family members to be evaluated and treated upon discharge. Repeat MRI brain after one month of treatment initiation, showed a decrease to 13 mm for the largest cyst. Patient was instructed to follow up with her PCP and ID specialist for monitoring

Without a rash! A diagnostic dilemma for VZV vasculopathy

Varicella zoster virus vasculopathy is a condition that can classically present with a dermatomal zoster rash followed by a neurological deficit. The possible neurological manifestations and disease range are extensive. Diagnosis becomes more challenging in patients whose presentation does not include a rash, often causing cognitive errors and delay in treatment. We present a case of an 85-year-old patient, who developed stroke-like symptoms, initially with normal MRI, to later progress to multiple evolving enhancing lesions seen in subsequent MRIs. This case also represents the anchoring, that we as physicians can have when a patient with risk factors for stroke or TIA, presents to the emergency department complaining of unilateral weakness

Quality Improvement in a Hospital Setting: Central Line-Associated Bloodstream Infections at an Acute Care Hospital in South Texas

Background: Central line-associated infections (CLABSI) are life-threatening nosocomial infections that are associated with significant increase in healthcare expenditure, prolonged stays, and risk of mortality. Objective: To identify outcome trends and risk factors that contribute to incidence of CLABSI at an 866-bed acute care hospital in South Texas. Methods: A retrospective chart review was conducted on 38 patients who met the National Healthcare Safety Network criteria for CLABSI during the period of January 2021 to March 2022 Results: There was a total of thirty-two CLABSIs in 2021. Hospital-wide CLABSI rate was 1.76 hospital-wide per 1,000-line days. Half of cases were COVID-19 positive with 59% of the infections occurring between August and October. Overall mortality rate for CLABSI in 2021 was 56%. COVID-19 positive patients with CLABSI had a mortality rate of 87.5% vs 25% in COVID-19 negative patients. From January to March 2022, there was six CLABSIs. Hospital-wide CLABSI incidence rate was 1.09 per 1,000-line days. Half were COVID-19 positive. Overall mortality rate for CLABSI in 2022 is 50%. COVID-19 positive patients with CLABSI had a mortality rate of 66.7% vs 33.3% in COVID-19 negative patients. Conclusions: The COVID-19 pandemic has had a significant impact on incidence of CLABSI this South Texas Hospital. The peak of CLABSI incidence correlates with the trends of COVID cases within the U.S

Antibiotic Stewardship in Skin and Soft Tissue Infections

Introduction: Skin and soft tissue infections (SSTIs) are characterized by microbial invasion of the skin layers and are common in various healthcare settings. A study conducted between 2005-2010 in the United States, found a combined total of 2.3 million cases of SSTIs in ambulatory and inpatient settings. This was higher than the rates of pneumonia and urinary tract infections during the same time period. Another study found that between 2000 and 2012, there was a 40% increase (2.4 million to 3.3 million) in cases of SSTIs. Our aim is to study the primary uses of vancomycin and piperacillin/tazobactam and their average days of therapy in the treatment of SSTIs. Objective: Our aim is to study the primary uses of vancomycin and piperacillin/tazobactam and their average days of therapy in the treatment of SSTIs. Methods: Data was collected for during January of 2019 of all administrations of antimicrobial use in a local hospital, which included the emergency department, inpatient admissions, and intensive care unit. These data points were sorted by antimicrobial, dates administered, and then by their indicated use. Indicated uses were then tallied on a histogram and an average days on therapy was calculated per patient. Discussion: Our analysis illustrates that the top three indicated uses of vancomycin was other, sepsis, and SSTIs, in descending order. The average days of therapy per patient for use of vancomycin in the treatment of SSTIs was 2.97 days. Piperacillin/tazobactam similarly was used primarily for sepsis, gastrointestinal/intra-abdominal infections, and SSTIs, in descending order. Conclusion: Our analysis shows that the average days of therapy for use of vancomycin in the treatment of SSTIs was 2.97. Study limitations include the limited, one-month duration of the data set. Our plan is to expand this work using data from a 12-month period on use of antimicrobials in the same hospital. We intend to compare the average days of therapy for different indications (i.e sepsis) and compare to national averages. We hope to interpret these data in the context of guideline recommendations on duration of intravenous therapy for SSTIs, so as to surmise what differences may exist between guidelines and clinical practice

Prevalence of Liver Cirrhosis and Its Association with Obesity Among Hispanics and Mexican Americans: An Evidence Synthesis

INTRODUCTION The obesity epidemic is a growing public health concern. In addition to the already known complications and comorbidities associated with obesity, data suggest that obesity is an independent risk factor for the development of liver disease.1,2 However, there is a paucity of data regarding the clinical correlation of obesity and cirrhosis in a predominantly Hispanic population of South Texas. The aim of this systematic literature review is to investigate the prevalence of cirrhosis stratified by obesity in Hispanic populations. MATERIALS AND METHODS PubMed was used to perform a thorough literature search. The terms liver cirrhosis and obesity were combined with the subheading\u27s epidemiology, genetics, and complications. The articles generated were then filtered by human species, full text, and date range 2000-2020. RESULTS Obesity is an independent risk factor for developing cirrhosis in Hispanic populations and increases the morbidity and mortality burden in this demographic. Therefore, it is reasonable to extrapolate and estimate similar trends in American towns across the US-Mexican border. Studies have found that an increased prevalence of cirrhosis in Hispanics in South Texas compared to the general US population. DISCUSSION There is an increased prevalence of cirrhosis in Hispanics compared to other races/ethnicities in the United States. Moreover, obesity increases the risk of developing liver fibrosis and cirrhosis. It is important to establish the relationship between obesity and liver cirrhosis in Hispanics living in South Texas to properly allocate resources to further alleviate the burden of disease

Follow Up Care For Heart Failure Patients And Association With Hospital Readmission

Background: The CDC reports 6.5 million adults in the US have Heart failure (HF) with yearly costs topping 30 billion. HF patients admitted to Valley Baptist (VB) are readmitted 26% of the time, which is close to the national average of 23% [1]. Standard of care for HF patients is remote nursing care for 30 days from discharge. A hospitalization for any reason within 30 days is considered a “readmission”. On October 1, 2019 at VB remote nursing care changed from weekly house visits to weekly phone calls. The aim of the study is to evaluate the effectiveness of this policy change on readmission rates. Methods: We performed a retrospective chart review using all patients admitted with HF from August 1, 2019 to January 31, 2020 at VB. A final sample of 170 patients was collected. Variables considered for the study were readmission, time to readmission (days), age (yrs), length of stay (LOS), in hospital education and follow up care (FU). Descriptive statistics [mean (SD) and n (%)] were created overall and stratified by readmission. Binary logistic regression was used to assess the association with readmission and time to admission. Final adjusted ORs are reported to explore how FU care is associated with readmission. Results: The average age of patients was 68.8 (yrs) with the mean LOS 5.5 days. During hospital stay, 54.1% (92/170) of all patients received education; 29.3 % (27/92) of them received it through a skilled nurse in the Progressive Coronary Care Unit (PCCU) while 70.7% received it from the primary nurse. Readmission rates were 31.7 % before nursing care changed from weekly house visits to weekly phone calls and 19.3% afterwards (p = 0.0633). There was no evidence FU Care produces a disparity in readmission rates after adjustment (in-home visits vs phone calls) OR = 1.75 (95% CI 0.84 – 3.66, p = 0.1363). Conclusions: Our study supports the change in FU care produced no disparity in readmission rates, which may result in lower costs to FU care with new policy. In-home visits were more prevalent with readmissions than phone calls; As a limitation for our analysis, we were unable to determine if CHF severity determined what patients received hospital education from skilled nursing staff which could have introduced selection bias. 1. Khera, R., et al., Evaluation of 30-day hospital readmission and mortality rates using regression-discontinuity framework. Journal of the American College of Cardiology, 2019. 74(2): p. 219-234

Impact of Academic Golden Weekend Initiative on Academic Success for an Internal Medicine Clerkship

Background: COVID-19 precautions led to a change in the number of protected weekends for the UTRGV Internal Medicine Clerkship, going from 2 protected weekends to none. The aim of Academic Golden Weekends during a fully inpatient clerkship has been to maximize the student experience by providing enough time to balance all the necessary components of the student experience. Starting April 26, 2021, all cohorts completing their Internal Medicine Clerkship as third-year medical students had 3 protected weekends. Methods: Two surveys were created to compare the pre-intervention and post-intervention cohorts. The surveys focused on student satisfaction regarding the time they had for self-study, accomplishing clerkship requirements, and overall well-being. Furthermore, IM Clerkship NBME grade and clerkship final grade data have been retrieved and deidentified, later analyzed by a blinded party to assess the impact of the Academic Golden Weekend Initiative on academic performance. Results: Prior survey analysis has shown that prior to the implementation of Academic Golden Weekends, students had a higher rate of dissatisfaction regarding time available for self-study, accomplishing clerkship requirements, and self-care. The leading cause for overall dissatisfaction was lack of protected weekends.100% of students in the post-intervention cohort reported feeling that Academic Golden Weekends had a positive impact on their academic performance and self-care and reported increased levels f satisfaction across all categories. However, the preliminary analysis of the impact that this initiative had on academic performance, did not show a significant improvement on average NBME, and clerkship grades. Conclusions: While the Academic Golden Weekends initiative has led to improved student satisfaction for academic performance and self-care, the limited data collected thus far does not reveal a significant improvement in academic performance in terms of NBME and clerkship grades. Once more data is gathered these variables will be re-analyzed for statistical differences

Intoxication With Endogenous Angiotensin II: A COVID-19 Hypothesis

Severe acute respiratory syndrome coronavirus 2 has spread rapidly around the globe. However, despite its high pathogenicity and transmissibility, the severity of the associated disease, COVID-19, varies widely. While the prognosis is favorable in most patients, critical illness, manifested by respiratory distress, thromboembolism, shock, and multi-organ failure, has been reported in about 5% of cases. Several studies have associated poor COVID-19 outcomes with the exhaustion of natural killer cells and cytotoxic T cells, lymphopenia, and elevated serum levels of D-dimer. In this article, we propose a common pathophysiological denominator for these negative prognostic markers, endogenous, angiotensin II toxicity. We hypothesize that, like in avian influenza, the outlook of COVID-19 is negatively correlated with the intracellular accumulation of angiotensin II promoted by the viral blockade of its degrading enzyme receptors. In this model, upregulated angiotensin II causes premature vascular senescence, leading to dysfunctional coagulation, and immunity. We further hypothesize that angiotensin II blockers and immune checkpoint inhibitors may be salutary for COVID-19 patients with critical illness by reversing both the clotting and immune defects (Graphical Abstract)