Hayden T. Schwenk

Coping with college and inflammatory bowel disease: implications for clinical guidance and support.

Background:Studies have shown that young adults with chronic diseases, including inflammatory bowel disease (IBD), experience greater difficulty during the transition to college, reaching lower levels of educational attainment and reporting greater levels of perceived stress than their otherwise-healthy peers. We performed a qualitative study to better understand how underlying illness shapes the college experience for patients with IBD and how the college experience, in turn, impacts disease management. Methods:Fifteen college students with IBD were recruited from the Boston Childrens Hospital Center for IBD. We conducted an approximately 1 hour semistructured qualitative interview with each participant, and the interviews were thematically analyzed after an iterative and inductive process. Results:Four primary themes were identified: (1) The transition experience of college students with IBD is shaped by their health status, perceived readiness, and preparedness, (2) Elements of the college environment pose specific challenges to young adults with IBD that require adaptive strategies, (3) College students with IBD integrate their underlying illness with their individual and social identity, and (4) College students navigate health management by conceptualizing themselves, their families, and providers as serving particular roles. Conclusions:For young adults with IBD, college is a proving ground for demonstrating self-care and disease management practices. Future initiatives aimed at this population should recognize the evolving roles of patients, parents, and providers in disease management. Increased attention should also be paid to the promotion of patients self-management and the unique challenges of the structural and psychosocial college environment.

Progressive multifocal leukoencephalopathy in pediatric patients: case report and literature review.

Progressive multifocal leukoencephalopathy is a rare, demyelinating disease of the central nervous system caused by JC virus. Fewer than 30 cases have been reported in HIV- and non-infected children. We report the case of a 15-year-old girl with progressive multifocal leukoencephalopathy and AIDS who presented with nystagmus, dysarthria and ataxia. Following combined antiretroviral therapy, she developed immune reconstitution inflammatory syndrome, which proved fatal.

Fever and Renal Failure in a Child with DiGeorge Syndrome and Tetralogy of Fallot

The patient is a 9-year-old male with DiGeorge syndrome and tetralogy of Fallot; he underwent cardiac repair at 7 months. Seven years later, in early 2012, he underwent a pulmonary artery to right ventricle conduit replacement with a tricuspid valve repair. In November 2013, he developed increased fatigue with abdominal pain and intermittent emesis and was ultimately admitted in February 2014 with progressive cough and low-grade fevers. His initial vital signs were the following: temperature 101.7°F, blood pressure 119/66, heart rate 109, respiratory rate 13, and O2 saturation 97% on room air. Examination was notable for nontoxic appearance, III/VI holosystolic murmur at the left upper sternal border, crackles at lung bases, and 1+ edema in the bilateral lower extremities. His liver edge was 3–4 cm below the right costal margin with a palpable spleen tip. There was no lymphadenopathy or rashes or stigmata of infective endocarditis, such as Janeway lesions or Osler nodes. The patient’s white blood cell count was 7300 cells/mm (73% neutrophils, 16% lymphocytes, and 10% monocytes), his hemoglobin was 4.9 g/dL, and his platelet count was 90,000 cells/mm. Blood urea nitrogen and creatinine were 84 mg/mL and 5.3 mg/dL, respectively. Hemolysis laboratory results (haptoglobin, lactate dehydrogenase) were normal, and a reticulocyte count was elevated to 4.3% (0.5–2.3% normal). There was mild coagulopathy (international normalized ratio 1.4), hypocomplementemia with C3 47 mg/dL (93– 203 mg/dL normal), and the erythrocyte sedimentation rate was elevated to 100 mm/h (0–15 mm/h normal). Urinalysis showed 3+ blood, 1+ protein, negative nitrites and leukocyte esterase, positive casts, and crystals. A renal ultrasound scan showed enlarged echogenic kidneys and a chest radiograph revealed marked cardiomegaly with bibasilar atelectasis. A transthoracic echocardiogram showed a thickened tricuspid valve, concerning for vegetations, with moderately increased tricuspid regurgitation. Vegetations were also present in the right ventricle to pulmonary artery conduit with mild aortic insufficiency. The patient met Duke criteria for infective endocarditis (IE) with 1 major criterion, based on echocardiographic findings, and 3 minor criteria, including predisposition for endocarditis, fever 38.0°C, and evidence of immunologic phenomena as demonstrated by glomerulonephritis. Five high-volume blood cultures (including a fungal isolator) were obtained prior to initiation of antibiotics. After initiation of vancomycin, gentamicin, and cefepime, the patient quickly defervesced. No evidence of embolic events was seen on chest computed tomography scan, abdominal ultrasound, or ophthalmologic examination. On exposure history, the patient was born in the United States and lived in California before moving to Mexico at age 3. He returned briefly to the United States at age 7 for his second cardiac surgery, but otherwise was living on a farm near Guadalajara, Mexico where he had routine contact with farm animals. He denied participation in animal birthing or consuming raw meat, but frequently ate homemade queso fresco. He returned to live in California Central Valley in December 2013.

A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis

The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg−1. This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.

Allograft-Transmitted Histoplasma capsulatum Infection in a Solid Organ Transplant Recipient

Histoplasma capsulatum is a dimorphic fungus known to be endemic to the Mississippi and Ohio River valleys of North America. Infection is the result of exposure to the microconidia of the mold phase of the organism, and the degree of exposure and immunocompetency of the host are thought to be important determinants in the severity of consequent illness [1]. In most patients, histoplasmosis manifests as a self-limited respiratory illness with protean complaints that include fever, dry cough, and fatigue. The more severe form of the disease, progressive disseminated histoplasmosis, is far less common and is usually seen in very young, elderly, and immunosuppressed patients. Unfortunately, the diagnosis requires a high level of suspicion and is often delayed. We describe a case of progressive disseminated histoplasmosis in a pediatric orthotopic heart transplant recipient from a nonendemic area whose disease was acquired from the donor allograft and whose diagnosis was delayed because of an incomplete donor history.

A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries

BACKGROUND Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries. The aim of this project was to study a postoperative SSI reduction care bundle, with a goal of reducing cardiac SSIs by 50%, from 3.4 to 1.7 per 100 procedures. METHODS This project was conducted at a quaternary, pediatric academic center with a 20-bed CVICU. Historical control data were recorded from January 2013 through May 2015 and intervention/sustainment data from June 2015 through March 2017. A multidisciplinary SSI reduction team developed five key drivers that led to implementation of 11 postoperative SSI reduction care elements. Statistical process control charts were used to measure process compliance, and Pearsons chi-square test was used to determine differences in SSI rates. RESULTS Prior to implementation, there were 27 SSIs in 799 pediatric cardiac surgeries (3.4 SSIs per 100 surgeries). After the intervention, SSIs significantly decreased to 5 in 570 procedures (0.9 SSIs per 100 surgeries; p = 0.0045). CONCLUSION This project describes five key drivers and 11 elements that were dedicated to reducing the risk of SSI during prolonged CVICU recoveries from pediatric cardiac surgery, with demonstrated sustainability.

Predictors of Antimicrobial Stewardship Program Recommendation Disagreement

OBJECTIVETo identify predictors of disagreement with antimicrobial stewardship prospective audit and feedback recommendations (PAFR) at a free-standing childrens hospital.DESIGNRetrospective cohort study of audits performed during the antimicrobial stewardship program (ASP) from March 30, 2015, to April 17, 2017.METHODSThe ASP included audits of antimicrobial use and communicated PAFR to the care team, with follow-up on adherence to recommendations. The primary outcome was disagreement with PAFR. Potential predictors for disagreement, including patient-level, antimicrobial, programmatic, and provider-level factors, were assessed using bivariate and multivariate logistic regression models.RESULTSIn total, 4,727 antimicrobial audits were performed during the study period; 1,323 PAFR (28%) and 187 recommendations (15%) were not followed due to disagreement. Providers were more likely to disagree with PAFR when the patient had a gastrointestinal infection (odds ratio [OR], 5.50; 95% confidence interval [CI], 1.99-15.21), febrile neutropenia (OR, 6.14; 95% CI, 2.08-18.12), skin or soft-tissue infections (OR, 6.16; 95% CI, 1.92-19.77), or had been admitted for 31-90 days at the time of the audit (OR, 2.08; 95% CI, 1.36-3.18). The longer the duration since the attending provider had been trained (ie, the more years of experience), the more likely they were to disagree with PAFR recommendations (OR, 1.02; 95% CI, 1.01-1.04).CONCLUSIONSEvaluation of our program confirmed patient-level predictors of PAFR disagreement and identified additional programmatic and provider-level factors, including years of attending experience. Stewardship interventions focused on specific diagnoses and antimicrobials are unlikely to result in programmatic success unless these factors are also addressed.Infect Control Hosp Epidemiol 2018;806-813.