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Strong, Smart, and Bold: UNMC ID Faculty Empower Young Women at Girls, Inc.

Dr. Caitlin Murphy presents to girls at Girls, Inc. Omaha.

Strep, pneumonia, microbiome, oh my! ID physicians Dr. Alison Freifeld, Dr. Andrea Zimmer, and Dr. Erica Stohs and Dr. Caitlin Murphy, Assistant Director of the Clinical Microbiology Laboratory, recently brought the world of infectious disease medicine to young women at Girls Inc. Omaha.  Girls learned about common infections and the bugs that cause them, the bacteria that inhabits the world around them, and careers in microbiology and infectious disease.

Dr. Andrea Zimmer shows girls cultures grown from dirty and clean hands and household locations

This event is one of many connections between UNMC and Girls Inc., a national nonprofit dedicated to “inspiring girls to be ‘strong, smart, and bold.’”  Dr. Freifeld started working with the Omaha chapter when she came to UNMC almost 20 years ago, when the chapter operated out of a church basement.  Since then, Girls, Inc. Omaha has grown to two dedicated locations that provide after-school enrichment activities, homework help, mentorship, and career advising to girls across the city.

Dr. Alison Freifeld is excited to talk to the girls about oral flora!

In 2016, Dr. Freifeld was instrumental in forging a partnership between UNMC/Nebraska Medicine and Girls, Inc. to open a primary care clinic at one of the chapters. The clinic is open after school and provides annual physicals, longitudinal care, well woman visits, reproductive health education, and urgent care.

As a student, I am both impressed and excited by the community outreach and impact of our physicians.  I’m proud to be at an institution with such compassionate, innovative, and altruistic clinicians, and I am hopeful, seeing their examples, that my future career can include meaningful service.

 


 

Special contributor: Dr. Shipra Goel

Dr. Shipra Goel joined us for the summer as an observer in the Infectious Disease Department.  We’re excited to include her contributions to our blog during the month she was with us!

My journey to an exciting observership at UNMC was enabled by my passion for infectious diseases (ID) which was virulent enough to infect Dr. Marcelin from 8000 miles away. Thanks to social media, which has made the world much more connected and interactions with mentors much easier, I could follow and reach out to people who inspired me. Social media in its various forms provides a means to young physicians to voice their opinions, showcase their mettle, and follow and learn from leading figures in their fields.

On one of these social media websites, when I was looking for like-minded people and luminaries in ID, a field I am extremely passionate about, I happened upon the UNMC ID Twitter account. Through this, I came across one of the most incredible and enthusiastic group of doctors working in ID.

I devoured every post and discussed and debated them with my peers. I followed Dr. Marcelin religiously while working in a land far far away. Over time, I longed for more direct learning, and I worked up the courage to reach out to her. I wrote to her that I aspire to pursue an ID fellowship in the United States and do substantial research in the field. She was enthusiastic and provided invaluable guidance, telling me about the observership opportunity, and helping me with the application process.  I could not have had this experience without her.

I have always been someone who gets really excited about opportunities to learn, and I am so glad to have the opportunity to come to UNMC for an observership.  The ID department at UNMC has gained recognition worldwide, and I have often been part of discussions of scientific papers where UNMC-ID research was referenced or referred to back in India as well.

My passion for ID has been chiefly driven by my ardent love for peace and harmony in the world and the aspiration to alleviate preventable suffering to work towards these lofty goals. I believe a better, healthier world can only be created if we recognise the multiple facets of microbes and understand that humans need not fight them but instead need to find better ways to live in harmony with them. I see this as a way to combat antibiotic resistance and prevent major outbreaks that the world faces every so often.

This is one of my favorite quotes about microbes from one of my favorite books – “Missing Microbes” by Martin Blaser:

“Microbes are invisible to our naked eye, with a few exceptions that reinforce the rule. Millions can fit into the eye of a needle. But if you were to gather them all up, not only would they outnumber all the mice, whales, humans, birds, insects, worms, and trees combined- indeed all of the visible life- forms we are familiar with on Earth- they would outweigh them as well. Think about that for a moment. Invisible microbes comprise the sheer bulk of the Earth’s biomass, more than the mammals and reptiles, all the fish in the sea, the forests. “

Here’s a brief introduction to my credentials:

I received my MBBS (equivalent to an MD in the US) from Lady Hardinge Medical College, New Delhi, one of the oldest and most prestigious medical schools in India. During my studies I discovered and developed my aptitude for ID and research by working on projects under the aegis of Indian Council of Medical Research (ICMR) . Under the tutelage of professors from my medical school I received my initial training in research methodology and had an enriching experience.

After medical school, I pursued Post Graduation training in Clinical Microbiology and ID from Maulana Azad Medical College, New Delhi, where Dr. Anita Chakravarti, a luminary in the field of virology, served as my guide and mentor over 3 years. This cemented my interest in research on infections, their diagnosis, and their management. I have experience in hepatic viruses, arboviruses, encephalitis causing viruses, and transplant virology, and I have published several research papers in these fields (you can find some of my publications here). I am keen to take on further challenges in ID, and I am really excited for my time at UNMC and looking forward to this wonderful month of opportunity and growth.


 

Journal Club – Stewardship in Community Hospitals: How should we spend our limited resources? 

Stewardship in Community Hospitals: How should we spend our limited resources? 

The following is a review by our ID Fellowship Program Director Dr. Trevor Van Schooneveld from our last Infection Control/Antimicrobial Stewardship Journal Club. He discussed the article by Anderson et al: Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals. JAMA Network Open.  2019;2(8):e199369.  

Antimicrobial stewardship is important to improving patient care and outcomes and numerous entities recommend that hospitals implement an Antimicrobial Stewardship Program (ASP).  Joint Commission requires ASPs in all settings and CMS is considering requiring all acute care facilities to have ASP.  While ASP are common at large medical centers, smaller facilities including both community hospitals (CH) and critical access hospitals (CAH) are much less likely to have an active ASP.  Additionally, the utility of strategies commonly employed in large facilities such as pre-authorization of antimicrobials (PA) and post-prescription review of antimicrobials (PPR) have not been evaluated in these smaller facilities who often lack ID trained personnel to support their program.

Anderson and colleagues set out to evaluate the feasibility and impact of implementing these two common strategies (PA and PPR) in four community hospitals.  They enrolled 4 moderately sized CH (median 305 beds) who did not previously have an ASP and trained at least one pharmacist at each location in appropriate antibiotic use and conflict resolution.  They implemented PA at 2 facilities and PPR at the other 2 for 6 months with both strategies focusing only on use of vancomycin, piperacillin/tazobactam (PT), and carbapenems.  There was then a one month washout period followed by implementation of the alternative strategy.  The local pharmacists has their stewardship time financially supported by the study site and received bimonthly feedback from the study center which has regional expertise in stewardship.  Clinical guidelines were available to assist evaluation of antibiotic appropriateness.  Local ID clinicians were only available routinely at one site and were not involved the ASP.

The primary outcome was to determine if ASP implementation was feasible which it was in each facility.  Although it should be noted that strict PA where an antibiotic is not distributed until approved was not feasible at any site and a modified PA was implemented where the first dose was distributed and then the appropriateness reviewed by local pharmacists.  Both pharmacists and physicians were somewhat skeptical about the improvement to patient care in post-implementation surveys.  While nearly 50% of clinicians said they didn’t make any changes to antibiotics based on pharmacist recommendations over 30% admitted to choosing a non-study antibiotic to avoid a pharmacist call.  The intervention was limited in scope as it only captured 30% of all study drug prescriptions.  There were significant differences in the PA and PPR group with more antibiotics judged “appropriate” in the PA group and fewer interventions.  The PPR group judged 41% of all study antibiotics inappropriate and intervened much more frequently, often with recommendations to de-escalate.  Study antibiotic use did not significantly change although this was likely confounded by a PT shortage and increases in vancomycin use at all facilities the authors hypothesized was due to the introduction of the SEP-1 quality measures.  Overall antibiotic use did not decrease during the PA portion but declined significantly with PPR.  It should be noted that while statistically significant the decline represented a 5% decrease in use.

What lessons can we take from this study?

  • Antibiotic use in CH is as high as many large facilities and there is a great opportunity to improve antibiotic use in these facilities.
  • Implementation of stewardship strategies is feasible in CH but the mechanisms used in this study did not generate major improvements in antibiotic use.
  • Pre-authorization seemed to be less effective in CH. This may be due to lack of empowerment of local pharmacists, early diagnostic and clinical uncertainty, or lack of ID involvement in PA support.  Better support for PA, particularly from ID experts, should be present if it is to be employed.
  • PPR, while showing some utility, could be improved in its effectiveness. Nearly 70% of study medications had no intervention likely due to availability factors with a single trained pharmacist at most sites, only operating during business days, and targeting PPR to 72 hours post-prescription when the median LOS was only 2 days.
  • In review of individual facility data some facilities were successful at decreasing antibiotic use while others saw only small decreases or even increases. This is likely due to local factors which may include pharmacist comfort with interventions, pharmacist communication effectiveness, clinician willingness to accept advice, and institutional prescribing culture.
  • It is likely that team-based stewardship activities supported by ID experts may be more successful. The local pharmacists received feedback from the study site but it is unclear how instructive and supportive this feedback was.  Additionally, it does not appear a local stewardship team was develop.  Multidisciplinary involvement with strong support from local leadership is essential to successful ASP development and implementation.

The authors of this study should be complimented for both addressing an oft neglected areas of ASP implementation (smaller facilities) and attempting to delineate which primary stewardship strategy is most effective in these settings.  For those who participate in ASP in CH and CAH this study provides much to learn from.

Anderson DJ, Watson S, Moehring RW, et al.  Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals.  JAMA Network Open.  2019;2(8):e199369.  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2748048

Deanna Hansen: Catalyst for Education Award Nominee

We are thrilled to announce that Deanna Hansen was among a group of elite individuals nominated for the Catalyst for Education award. This award comes from the UNMC Interprofessional Academy of Educators, and recognizes the integral role of those who serve in an educational support role on campus.

The award values the impact that nominees have made to furthering the educational mission of UNMC, promoting a premier environment, and ensuring the success of all trainees.

Here are a few quotes from her colleagues that were compiled into a touching nomination letter:

“Our entire team looks to Deanna as our leader, organizer, and motivator.”

“Deanna wears many hats…and is the administrative genius behind a number of successful endeavors including Nebraska’s AIDS Education and Training Center, the annual Update for HIV Care Providers and Educators continuing education conference, and the Comprehensive HIV Medicine Enhanced Medical Education Track (EMET).”

“Deanna always strives for the highest standards in everything she does and inspires others to be their best selves as well”

“Deanna is not afraid to face challenges and lean into discomfort when taking on new activities or roles”. 

“Deanna has a tremendous amount of empathy and takes care of all of our students and our team. Our team affectionately refers to Deanna as our “team mom””  

Deanna Hansen has worked with our group as part of the Specialty Care Center team for 28 years. She is the administrator for the SCC, but also serves as the education administrator of the HIV Enhanced Medical Education Track (EMET) program, for the last 16 years.

Congratulations to Deanna on the nomination, we appreciate you!

UNMC IDSHEAroes #RaceAgainstResistance Fundraising Milestone Unlocked!

The Society for Healthcare Epidemiology of America (SHEA) is sponsoring the Race Against Resistance for the 4th year. Money raised is used to fund educational scholarships involved in treating, and researching, ways to prevent the 2050 predictions from coming true. This is a chance to take a stand against ‘superbugs’, to support those fighting against them today, to help change the future.

Dr. Cawcutt is #RacingInRehab to gain independent ambulation after recent knee surgery. Dr. Marcelin is #RacingForWellness by focusing on active exercise every day as a reminder that we cannot provide excellent care for others, if we do not care for ourselves first.

The UNMC ID SHEAroes #RaceAgainstResistance team achieved a milestone notification (raised at least 25%), we wanted to share it with you!

In the last few months we received several generous donations bringing our total raised to $2,005. This means that we are now at 40% of our goal of $5000!

Is it a big goal? YES! Can we do it? YES!

We want to THANK all of our donors for your generosity, and encourage you to share our campaign with others, and share with us on social media how you are Racing with the UNMC ID SHEAroes!

Learn about our reasons for racing here:

If you are interested in supporting the UNMC SHEAROES in the Race Against Resistance, you can donate here.

Thank you!

Jasmine Marcelin and Kelly Cawcutt

Treatment of Osteomyelitis – What’s the Evidence for our Strategies?

New UNMC ID publication alert! #ReadUNMCID

Recently, the newest member of our Division of Infectious Diseases at UNMC/Nebraska Medicine, Dr. Nicolas Cortes-Penfield published an invited review in Open Forum Infectious Diseases entitled: The History of Antibiotic Treatment of Osteomyelitis.  Dr. Cortes-Penfield wrote this summary describing the review article, which was commissioned after he published a comprehensive blog post (on his blog IDJournalClub.com) about the history of osteomyelitis, with a robust twitter response to the topic.

What is the study about?

The impetus for this study was the recently published OVIVA trial, which showed equivalent outcomes with oral versus intravenous antibitoics for bone and joint infections.  This was a large and really well-designed randomized clinical trial – in our minds, one of the best clinical trials ever published in bone and joint infection research.  Yet, we observed that many infectious disease specialists did not feel that OVIVA represented enough evidence to change the way they treat these infections.  So we asked ourselves, “What exactly is the quality of the evidence for the way we’ve been doing things?”

In our study, we laid out some of the most commonly taught tenets of treating bone infections (osteomyelitis) and then conducted a narrative historical literature review reaching back to the beginning of the antibiotic era to try to tease out where these teachings came from and which ones were backed by high quality evidence (like clinical trials) versus simply expert opinion and tradition.

What did the study find?

As we reviewed the literature, we focused on three classical teaching points for osteomyelitis: that certain antibiotics are better for these infections because they concentrate in the bones, that intravenous antibiotics give better results than antibiotics given by mouth, and that osteomyelitis needs to be treated with antibiotics for four to six weeks.

We found that the research on antibiotic bone penetration was heterogenous, and that with the exception of the penicillins and cephalosporins there wasn’t compelling evidence that the antibiotic classes achieve different concentrations in bone.  Moreover, the studies that generated the theory that antibiotics with better bone penetration treated osteomyelitis more effectively were done in animals; we could not find any robust data in people to support this notion.

As for the universal necessity of giving antibiotics intravenously for osteomyelitis, we were surprised to find that many of the first reports of antibiotic treatment of bone and joint infections used oral penicillins and other agents, with excellent results.  Moreover, when retrospective studies and prospective clinical trials compared specific antibiotics head-to-head, the patients given antibiotics by mouth did just as well as those who received antibiotics intravenously.  This was true of multiple studies including both children and adults, and is important because it shows us that the OVIVA study is not the outlier in this body of literature, but rather an extension of what the preponderance of data in people has been telling us all along.

As for the necessary duration of therapy in osteomyelitis, we were surprised by how little evidence we could turn up on this topic.  Again, physicians in those earliest reports often used just a couple of weeks of therapy, and most often let their patients’ conditions (e.g. the presence of fever) guide the duration of antibiotic treatment.  As best we could determine, a chart study of bone and joint infections published in the New England Journal of Medicine, in which the authors reviewed 62 osteomyelitis cases at their hospital to conclude that patients who received at least a month of antibiotics were more likely to respond well to treatment, seems to have originated what is a now universal dogma.  In fact, we located more recent data showing that children with acute osteomyelitis do well with less than three weeks of antibiotic treatment, as well as studies suggest that eight or more weeks of therapy may be better for adults with osteomyelitis and certain high-risk features like ESRD, infection with Methicillin-Resistant Staphylococcus aureus, and undrained paravertebral abscess.  So, what we can say with confidence is that this question hasn’t been adequately studied, and how long a course of antibiotics a patient needs probably depends on who they are.

Why is this study interesting?

This study lays bare the scarcity of data on which several of our current traditions regarding treating osteomyelitis are based.  Medicine is a field with a lot of cultural inertia – which makes sense, in that when you’re making high-stakes decision there’s a natural bias to keep doing what you’ve seen work before and what your mentors told you worked best for them.   So, in order for us as a medical community to embrace evidence-based medicine, we need more than just better clinical science; we need a shift away from reliance on tradition and deference to hierarchies of eminence (i.e.; “That’s always how we’ve done it here”) and toward a culture of skepticism and interrogation of clinical pearls that don’t come with references cited.  We hope this study – whose narrative structure we intended to help the reader grasp the humble origins of some of the clinical dictums they were taught – will do a little to shift the infectious diseases community toward a culture of evidence-based medicine.

What about future research questions?

We could answer this question two ways.  First, with the field of osteomyelitis, some obvious next questions are whether certain antibiotic combinations might be more effective at achieving clinical cure without recurrence (i.e.; the use of adjunctive rifampin, currently undergoing a large randomized controlled trial) and what patient and infection factors identify people with osteomyelitis who will do just as well with less than four weeks of antibiotic therapy, or conversely who would really benefit from longer than six weeks of antibiotics.  Second, there are plenty of other infections with current standards of treatment based in expert opinion that would benefit from the historical narrative review treatment.


 

Meet Jessica Quick, our new ID administrator

We’re excited to welcome Jessica Quick, MBA, to our UNMC ID team as a new administrator!

Why did you choose to come work at UNMC?

UNMC has a wonderful reputation in the community for innovation and growth.  Joining the ID Division gave me the chance to expand my horizons and learn more about the academic portion of practice, along with continuing to be involved in the clinical setting through the Specialty Care Clinic and other ID clinical programs .

What makes you excited about working in ID?

The ID Division is a dynamo – clinical, research, and education.  ID has experienced amazing growth over the last few years.  The faculty numbers continue to increase and ID research is at the forefront of innovation.  We are also expanding our Fellowship and our regional, national, and international reputation.  Though the practice of medicine is very clinical in nature, I hope that I can be a valuable asset on the administrative and business side of the practice.  I expect there will be lots of great changes continuing to emerge from the ID Division over the next few and I am very excited to be part of that.

Tell us something about yourself that is unrelated to medicine.

I love spending time with my family hanging out in the back yard.  We regularly turn on a baseball game and play yard games with the kids.  Our favorite currently is Giant Jenga and Frisbie Golf.

 


 

Tenure-Track Faculty Position in Oncology-ID Open for Applications!

The University of Nebraska Medical Center (UNMC) is pleased to announce the opening of a tenure-track faculty position in Oncology-ID in the Division of Infectious Diseases, Department of Internal Medicine. Successful candidates will hold an academic appointment at the assistant or associate professor level and will be employed by UNMC and Nebraska Medicine. Candidates should be Board Eligible/Certified in Infectious Diseases. Specialized training or experience in immunocompromised host ID is desirable.

A generous compensation package with salary commensurate with experience will be offered. Candidates should have an enthusiasm for patient care, teaching, and clinical research. Generous protected time and support are available in order to conduct collaborative clinical research and achieve the goals of the program.

Opportunity Highlights:

  • Join a team of professionals – including ID Physicians, advanced practice providers, and clinical and research support personnel – dedicated to the care of patients who have infectious diseases complications associated with stem cell transplantation or treatment of underlying hematologic or solid tumor malignancies.
  • Provide care for both inpatients and outpatients in the state-of-the-art Fred & Pamela Buffett Cancer Center – newly opened in 2017; collaborate with colleagues in solid organ transplant ID.
  • Explore abundant clinical and translational research opportunities.
  • Teach medical students, residents, and ID fellows on the Oncology ID consult service

The applicant will fully participate in the clinical, teaching, and research programs of the Infectious Diseases Division – a vibrant and growing division made up of 23 ID faculty with numerous close associations with other clinical and basic science departments. The interested applicant is encouraged to learn more about UNMC ID at our website: and the UNMC ID blog.

Interested candidates should apply online.  Questions may be directed to Jessica Quick at jessica.quick@unmc.edu.


 

How Clean is the Hub?

New UNMC ID publication alert! #ReadUNMCID

Recently, several members of the Division of Infectious Diseases at UNMC/Nebraska Medicine published a study in American Journal of Infection Control (AJIC) entitled: Microbial colonization of intravascular catheter connectors in hospitalized patients. Drs. Richard Hankins (former ID fellow, class of 2019), and Kelly Cawcutt (Associate Medical Director of Infection Control) are the lead and senior authors on this study.  Dr. Hankins wrote this summary describing their study.

What is the study about?

The infection control team at Nebraska Medicine is constantly evaluating for methods to reduce central line associated blood stream infections.  In 2016 we were evaluating whether our catheter connectors could have a role contributing to central line associated blood stream infections.  At the time we were using a split septum catheter connector (Lever Lock, Becton Dickinson) and due to the open nature of the catheter connector diaphragm, we were concerned that this could become colonized, and then bacteria could spread down the IV tubing leading to a blood stream infection.

We then set out to assess the colonization of the split septum catheter connectors of both central and peripheral lines at Nebraska Medicine on active infusions.  Catheter connectors were assessed both in intensive care units as well as the general medical/surgical wards. We avoided sampling in catheter connectors with antibiotics running or what was deemed a critical infusion (pressors).  The infusion would be paused and the catheter connector diaphragm was then placed directly onto an agar place.  We would do 4 impressions onto an agar plate of the same diaphragm, and due to the size of the agar plate, we were able to do 4 separate catheter connectors on each agar plate.  After incubating each plate for 48-72 hours we assessed for microbial growth.  We found that of the 234 catheter connectors we evaluated, 98 of them had microbial growth (41.9%).  This was deemed excessively high to the point that the hospital switch from split septum catheter connectors to the luer lock catheter connector (Max Zero, Becton Dickinson) , and simultaneously instituted the alcohol infused port protector (Curos, 3M).  After the switch was made, waited three months for the nursing staff to become used to working with the new catheter connectors, and then repeated the study.

What did the study find?

We found in the first phase of the study that the split septum catheter connectors were colonized 41.9% of the time.  When we performed the second phase of the study assessing the luer lock catheter connectors with the port protector caps. In the second phase of the study with the luer lock connectors we sampled 243 catheter connectors and found that 56 of them showed microbial growth (23.1 %).  Multiple logistic regression was used and determined that that this was a significant difference, even after adjusting for the difference in locations and line type.

Why is this study interesting?

This study was fascinating given how high the rates of colonization were on active infusions in the hospital.   Given such high rates of colonization we were surprised that we didn’t have even more blood stream infections. There have been other studies regarding catheter hub colonization although this was the first to our knowledge to compare two separate catheter hubs, and more so a comparison of active infusions in a clinical setting.  The alcoholic port protectors were instituted simultaneously with the luer lock connector, so it is difficult to say whether the effect was completely from a change in the catheter connectors.  We were still shocked the rate of colonization remaining fairly high at 23.1%, even with the luer lock connectors.

What about future research questions?

There is limited data showing a correlation between catheter hub colonization and the same bacteria causing blood stream infections, but further research could evaluate this correlation.  There also remains opportunity to try to further reduce microbial colonization given that even after our intervention the microbial colonization still remained elevated, although significantly reduced from what it was prior.

Citation:

Hankins, Richard, O. Denisa Majorant, Mark E. Rupp, R. Jennifer Cavalieri, Paul D. Fey, Elizabeth Lyden, and Kelly A. Cawcutt. “Microbial colonization of intravascular catheter connectors in hospitalized patients.” American Journal of Infection Control (2019).

Tenure-Track Faculty Position in Solid Organ Transplant ID Open for Applications!

The University of Nebraska Medical Center (UNMC) is pleased to announce the opening of a tenure-track faculty position in Solid Organ Transplant Infectious Diseases in the Division of Infectious Diseases, Department of Internal Medicine. Successful candidates will hold an academic appointment at the assistant or associate professor level and will be employed by UNMC and Nebraska Medicine. Candidates should be Board Eligible/Certified in Infectious Diseases. Specialized training or experience in immunocompromised host ID is desirable.

A generous compensation package with salary commensurate with experience will be offered. Candidates should have an enthusiasm for patient care, teaching, and clinical research. Generous protected time and support are available in order to conduct collaborative clinical research and achieve the goals of the program.

Opportunity Highlights:

– Join a team of professionals – including ID Physicians, advanced practice providers, and clinical and research support personnel – dedicated to the care of patients who have infectious diseases complications associated with solid organ transplantations.

– Provide ID care for recipients of liver, kidney, heart, lung, pancreas and multi-visceral/small bowel transplants.

– Collaborate with a multi-disciplinary team in our Multi-Organ Transplant Clinic.

– Conduct clinical and translational research.

The applicant will fully participate in the clinical, teaching, and research programs of the Infectious Diseases Division – a vibrant and growing division made up of 23 ID faculty with numerous close associations with other clinical and basic science departments. The interested applicant is encouraged to learn more about UNMC ID at our website and the UNMC ID blog.

Interested candidates should apply online.  Questions may be directed to Jessica Quick at jessica.quick@unmc.edu.

 


 

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