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Do What You Do and Get Published, Too – Key Take Home Points!

 

This morning, a fantastic Faculty Development panel was held to a full house of attendees,  focused on how to maximize your productivity within your career and life. Our Division is incredibly productive and this is reflected in that two of the three panelists were from within our ranks: Dr. Hewlett and Dr. Scarsi were joined by Dr. Schenarts in providing insight and expertise in this area.

Missed the session? Here are a few of the key suggestions from that session:

  • Decide when and where you want to write – Where can you focus? What time of day are you productive?
  • Schedule the time – Block your calendar
  • Close the door
  • Find your team AND bring others up to your level when you can. Ask junior colleagues or trainees to work with you and delegate roles.
  • Set deadlines for when this will be done.
  • Do not forget downtime. It is critical to rest.
  • Write down possible research ideas to bring for possible future use.
  • Be an opportunist. When you have an experience that can teach others, capitalize on that.
    • Building a new clinical model? Write it up! If you do not, someone else will.
  • Sometimes the practical and simple clinical questions are well worth printing.
  • Choose a way to write and edit documents as a team IN ADVANCE so that roles are very clear.
  • Consider editing live together as opposed to constant track changes if possible as then your final draft will be done once and in real-time.
  • Not sure if you can publish your project because you hadn’t planned on it at the onset? Perhaps it was a quality improvement project? Call the IRB and ask. This is usually not an insurmountable situation.
  • Consider WHO you think will want to read this and submit to that journal.
    • “Not everything has to be a RCT published in The Lancet”
  • How do you get the expertise to do this?
    • Find a good mentor.
    • Reach out beyond your division.
    • Consider a national course or masters program for additional training.
    • Send your publication/grant/proposal to your WORST critic to focus on improvement.

 

Interested in learning more about faculty development opportunities at UNMC? Read more here.


 

IDWeek 2017 – The Official UNMC ID Guide of Where We Will Be!

IDWeek is upon us and we want to be sure YOU know where to find us! Below is the list of faculty presentations and posters from our Division. Please come visit us at IDWeek –  We would LOVE to meet you! 

Content courtesy of Sandy Nelson and the entire UNMC ID Division. 

 

Tuesday Oct 3

10:15-10:45 a.m.   Van Schooneveld TC.  Best Practices for Antimicrobial Stewardship Programs – Syndrome-specific interventions: Combining Interventions to Improve Care

4:10 p.m. Friefeld A. Transplant Infections. *at Vincent T. Andriole Board Review Course

Wednesday October 4

1:30-3:30 p.m.  Rupp ME. Controversies in Infection Prevention: Pro/Con

Thursday October 5

12:30-2:00 p.m.   Rupp ME, Olson C, Cavalieri RJ, Lyden E, Carling P. How Clean are the Clinics?

Assessment of Environmental Cleanliness in Ambulatory Care. Poster 481

12:30-2:00 p.m. Fitzgerald T, Nailon R, Tyner K, Beach S, Drake M, Lyden E, Rupp ME, Schwedhelm M, Tierney M, Ashraf MS. Infection Control in Long-Term Care Facilities: Frequently Identified Gaps in Infrastructure, Surveillance and Safety. Poster 413

12:30-2:00 p.m. Tyner K, Nailon R, Beach S, Drake M, Fitzgerald T, Lyden E, Rupp ME, Schwedhelm M, Tierney M, Ashraf MS. Environmental Cleaning and Disinfection in Long-Term Care Facilities: Opportunities for Improvement. Poster 485

12:30-2:00 p.m. Chung P, Nailon R, Tyner K, Beach S, Bergman S, Drake M, Fitzgerald T, Lyden E, Rupp ME, Schwedhelm M, Tierney M, Van Schooneveld, T, Ashraf MS. Frequently Identified Gaps in Antimicrobial Stewardship Programs in Critical Access Hospitals. Poster 701

12:30-2:00 p.m. Chung P, Nailon R, Tyner K, Beach S, Bergman S, Drake M, Fitzgerald T, Lyden E, Rupp ME, Schwedhelm M, Tierney M, Van Schooneveld, T, Ashraf MS. Frequently Identified Gaps in Antimicrobial Stewardship Programs in Long-Term Care Facilities. Poster 702

12:30-2:00 p.m. Uriel Sandkovsky, Michelle Schwedhelm, Shonelle Grayer, Emily Adelgren, and Mark E. Rupp. Small Changes Make a Big Difference in the Fit of N95 Respirators. Poster 435

 

Friday, October 6

12:30-2:00 p.m.  Green Hines A, Zwiener J, Stec R, Heybrock B, Hegemann L, Simonsen K. Cost Analysis of an Antimicrobial Stewardship Program (ASP) Protocol for Adherence to the 2014 American Academy of Pediatrics (AAP) Palivizumab Prophylaxis Recommendations in a Freestanding Children’s Hospital. Poster 1608

12:30-2:00 p.m. Bares SH and Sandkovsky U. Development and Assessment of an HIV-focused E-learning Flipped Classroom Curriculum in an Infectious Diseases Fellowship Program. Poster 1446

12:30-2:00 p.m. Tyner K, Nailon R, Beach S, Drake M, Fitzgerald T, Lyden E, Rupp ME, Schwedhelm M, Tierney M, Ashraf MS. Frequently Identified Infection Control Gaps Related to Hand Hygiene in Long-Term Care Facilities. Poster 1322

 

Saturday October 7

12:30-2:00 p.m.  Rupp ME, Tandon HK, Danielson PW, Cavalieri RJ, Sayles H. Peripheral Intravenous Catheters – “They Don’t Get No Respect”. Poster 2160

12:30 -2:00 p.m.  Uriel Sandkovsky, Fang Qiu, Andre C. Kalil, Ada Florescu, Natasha Wilson, Christa Manning, and Diana F. Florescu. Risk factors for development of cytomegalovirus resistance in solid organ transplantation: a retrospective nested case control study. Poster 2448

12:30 -2:00 p.m.  Uriel Sandkovsky, Fang Qiu, Andre C. Kalil, Adriana Weinfeld-Massaia, Joong Kwon, Cynthia Schmidt, and Diana F. Florescu. Epidemiology of Bloodstream Infections in Kidney Transplant Recipients: A Systematic Review and Meta-analysis. Poster 2375

12:30 -2:00 p.m.  Signorelli J, Liewer S, Zimmer A, Freifeld AG Incidence of Febrile Neutropenia in Autologous Hematopoietic Stem Cell Transplant (HSCT) Recipients on Levofloxacin Prophylaxis at a Single Center Midwest Cancer Center Poster 2390

12:30 -2:00 p.m.  Richard Hankins, Denisa Majorant, , R Jennifer Cavalieri, , Elizabeth Lyden, Paul D. Fey, Mark E. Rupp,  and Kelly Cawcutt, Microbial Colonization of Intravenous Luer Lock Connector During Active Infusions Among Hospitalized Patients Poster 2155

 

Find us on Twitter @UNMC_ID; #UNMCID


 

Twitter Here We Come!!

Thank you for ALL of the AMAZING support for our blog! We are thrilled to continue our venture into social media to provide more content, and commentary, on what is happening in the world of Infectious Diseases – particularly here at UNMC. With that goal in mind, we have officially launched our Twitter account @UNMC_ID. We encourage you to join us on Twitter and engage in the conversations, particularly given the increasing utilization of Twitter for academic medicine,  faculty development, promotion of publications, access to journal articles via links and Twitter chats and the opportunity to engage in conversations with colleagues both near and far. IDWeek is almost here(October 4-8th) and is a great time to get involved! Tag #IDWeek2017 AND #UNMCID to follow the conference virtually.

See you on Twitter!


 

 

Welcoming Our New Fellows – Focus on Dr. Hankins

Tell us about the position you are starting?

I think it’s a little difficult to fully describe the position that I am starting.  I don’t fully know all the ins and outs of what the Infectious Disease fellow does, but I’m excited to get into the position and learn.

Tell us about your background?

When people ask me where I’m from, I always find that to be a difficult question to answer.  I was born in the south, where most of my family is from, and my extended family still lives, but grew up in Omaha, so I usually answer that partly from Nebraska and partly from Mississippi.  After finishing high school in Nebraska I went to Ole Miss for undergrad, before returning to Nebraska for medical school.

Why UNMC?

I have ended up staying at UNMC for both internal medicine residency and infectious disease fellowship.  When ever I have thought about leaving UNMC, I seem to be drawn back to how much I enjoy working with the people here.

What about ID makes you excited?

I’m excited to be able to start focusing on just treating infections.  I noticed as I was going through residency that it always seemed the patient’s that had infections were the most interesting to me.  I was always astounded how quickly and much people can improve from getting anti-microbial therapy. I’m also excited about the interesting differentials that occurs in patients being seen by the infectious disease service, and the history and clues that contribute to the infectious disease work up.

Tell us something about yourself UNRELATED to medicine? 

Outside of medicine, I have found that I really enjoyed Mock Trial, an activity that I was able to compete in during high school and college, and that since I have been in Omaha have been able to coach a collegiate team.

Learn more about the UNMC Division of Infectious Diseases and ID fellowship here.


 

What’s Hot in Infection Control?

Here are some fantastic take-home points from our Infection Preventionists who attended APIC 2017 – the national meeting of the Association for Professionals in Infection Control and Epidemiology. 

Water management Legionella  – Building water safety & Management

Legionella is endemic to overall water systems, not just the cooling towers, therefore infection control programs need to be concerned about the sporadic nosocomial risk, not just outbreak risk. Even portable risks, such as patients bringing in personal equipment that may have biofilm due to poor cleaning and disinfection at home.

Urine antigen test is inadequate for water related testing as only one serotype is detected, therefore Legionella cultures are required instead.

When is Legionella considered a nosocomial infection?  At  >10 days, but 2-10 days may still be nosocomial, so think about performing an environmental investigation. Finally, don’t necessarily chase zero;  zero legionella contamination is not the goal and may be impossible in some cases, zero patient cases is the goal. There are MANY waterborne pathogens with potential risk of infection. A water safety & management plan is the key component, not focus on mitigation and eradication of a single pathogen.

 

Central Line Insertion Site Assessment (CLISA Score)

There is a lot of focus on insertion, but maintenance is critical. Standardize criteria & expectations for early risk detection. At what point of site assessment, can you intervene and prevent a CLABSI? Beyond asking if you need the line, assess the site for signs of erythema and if progressing beyond 3mm radius of erythema, documentation of the scoring would prompt providers to starting looking toward removing the line BEFORE a CLABSI occurred.  Multidisciplinary approach – daily site assessment & documentation, communication with providers when results warrant further assessment/intervention. Read more here.

 

Disinfectants used in the hospital and what should we use? Are we thoughtful enough in our choices?

There are many critical pieces of information to consider when choosing a disinfectant, but one piece that often has been overlooked is the consideration of the end-user – are we also considering the patients, nursing and environmental service staff?

 

3 Fatal Flaws – Hand Hygiene

The three Fatal Flaws of Bias are: 1) Sampling bias; 2) Observer bias; 3) Hawthorne Effect.  Many Hand Hygiene programs across the country suffer from these Fatal Flaws. Due to lack of resources and competing priorities many Hand Hygiene programs are based on individual observations.

A successful Hand Hygiene program needs appropriate resource allocation, as well as an elevated design and reporting process. Particular attention needs to be given to the statistical design of the program to ensure meaningful data is shared across the organization.  The design must highlight the link between clean hands and a reduction of all hospital-acquired infections. The most successful programs are embraced by each layer of leadership; linking hand hygiene scores to leadership goals/rewards have been successful to garner appropriate support and resources

 

Learn more about Infection Prevention and Control at UNMC here.

Content courtesy of Terry Micheels, Kim Hayes and Joleen Strosahl.


 

New Faculty Spotlight – Dr. El-Ramahi

Background:

I am Jordanian but grew up in Riyadh, Saudi Arabia where my dad used to work. I moved back to attend medical school at the Jordan University of Science and Technology. After graduation, I worked in Jordan for two years before moving to the United States. We recently moved to Omaha and before that we lived in Tucson, Arizona for more than 6 years.

Why UNMC:

I decided during my training that I wanted to work in an academic institution because I wanted to teach and be a part of educating our medical students and residents/fellows. I also realized that working in a tertiary referral center offers the clinician the opportunity to take care of a variety of disease processes and a good number of intriguing cases. The other appealing quality is that there is a lot of support for research.

UNMC is well-renowned for offering high quality patient care and medical education along with exceptional research opportunities. The infectious diseases division here is unique in that it offers different service teams tailored to different patient populations which I believe enables the ID physicians to focus their interests and provide better care for the patients.

What about ID makes you excited?

When evaluating patients as infectious diseases physicians we are doing a detective’s work trying to gather as many clues as we can. What is also appealing to me is that it is a very intellectual specialty rather than procedure-driven. In addition to using our infectious diseases analytical skills, we also utilize a lot of our internal medicine knowledge trying to decide if what is making the patient sick is an infection or not. What is rewarding at the end of this hard work and after identifying a specific infection, is that we get to see patients improve and feel better with the treatment(s) we provide.

Something interesting about me not related to medicine:

I like outdoor activities such as hiking and riding my bike. I recently started to learn how to play the piano.

See more about the UNMC ID Division here.


 

Dr. Paul Fey on “Why I Love Clinical Microbiology”

 

Dr. Paul Fey on “Why I Love Clinical Microbiology:

“I love clinical microbiology because each pathogen that invades a human host has a different strategy. Our job is to determine how these processes occur mechanistically but also practically utilize this information to find new diagnostic strategies for our patients and clinical colleagues. ”

 

See more about UNMC Clinical Microbiology here.

Seeking a Full-time Physician to Join UNMC’s HIV Program

We are looking for a board-eligible/board-certified ID physician to join our HIV team.

As the largest provider of care to patients living with HIV in the Omaha area, the HIV clinic provides quality health care in a truly integrated system wherein medical care, case management and advocacy are provided via a multidisciplinary approach. Alongside the clinical care, the UNMC HIV program actively participates in both clinical and translation research and has a team of research nurses and support staff and a culture that is fully supportive of research. Finally, the HIV team is involved in education both in the community and in UNMC’s colleges of medicine, nursing, and pharmacy.

We are looking for an Infectious Diseases physician with a passion for HIV care to join our group and look forward to hearing from anyone who is interested in the position.

If you are interested, please submit your application here.


 

Do the Right Thing and Get a Flu Vaccine

Content courtesy of Dr. Mark Rupp.

As the days shorten and there is a bit of fall nip in the morning air, it is a reminder that the respiratory virus season will be here soon.

Although the flu vaccine is not perfect (about 50% protection), it remains our best means to prevent influenza.  We are not able to predict with accuracy whether this will be a mild or severe flu season.  However, it was a worse than average flu season in Australia (remember their winter season is our summer) and this may mean we are in store for a severe flu season.  In any case, it is wise to prepare for the worst.

This year’s quadrivalent vaccine will again contain two “A” strains and two “B” strains and will hopefully match up well with the circulating strains in the community.  The flu vaccine is highly recommended by the CDC for all persons aged greater than six months of age.   Flu vaccination is particularly important for healthcare providers because we are in close contact with vulnerable patients who can experience serious complications or death if they contract the flu.  As healthcare providers, we have a moral and ethical responsibility to provide safe care to our patients.  At Nebraska Medicine, we take this responsibility seriously.  Last year, 92% of our providers received the flu vaccine without a mandate.  We are doing the right thing for the right reason- to protect ourselves, our patients and our families.

However, our high rate of influenza vaccination acceptance does not happen by accident.  Months in advance, our colleagues in the pharmacy make sure we order an adequate supply of vaccine.  Each unit and clinic has a “Flu Vaccine Champion” who undergoes special training and then promotes and administers flu vaccine to colleagues. We routinely provide, free of charge, quadrivalent vaccine for most persons.  A high dose vaccine is provided for our co-workers over the age of 65 and a recombinant “egg-free” vaccine is available for those with serious allergy to eggs. The Employee Health Department holds over a dozen open clinics that are conveniently located and scheduled to allow our workers, students, and volunteers to receive the vaccine.

Vaccine status is conveniently tracked and reported via an online database that is constructed and maintained by our experts in Information Technology.  Finally, the whole program is supported by administration at the highest levels.  It truly takes a village to pull this off every year-but it pays off with >90% voluntary vaccine acceptance.

In addition, there are other features to our campaign to prevent the spread of respiratory viruses.  We post signs throughout the hospital to alert visitors to not visit if they are sick.  Similarly, we try to avoid “presenteeism” and we urge our healthcare providers to stay home if they are ill.  We aggressively promote hand hygiene, environmental cleanliness, and respiratory etiquette (e.g. “cover your cough”).

So, do the right thing and get your flu vaccine.

See more about influenza and vaccinations at UNMC here.

Vitamin C and Sepsis – Miracle, Madness or Still Murky?

Experimental and emerging data suggest intravenous ascorbic acid may be a potential therapy in patients presenting with septic shock, but more evidence is needed to confirm or refute the clinical utility of ascorbic acid (vitamin C). Proposed mechanisms of this essential water-soluble vitamin include anti-inflammatory effects, reduction in oxidative damage, and preservation of endothelial function and microcirculatory flow.1 Additionally, ascorbic acid is a cofactor in the enzymes required for synthesizing endogenous norepinephrine and vasopressin.2 Intravenous administration may be required to achieve normal serum levels in these patients due to saturable intestinal absorption.3 Findings indicate serum levels of ascorbic acid are lower in critically ill patients due to the increased metabolic turnover in this acute inflammatory response and are associated with severity of illness.4,5 Low plasma levels of ascorbic acid have been shown to be inversely correlated with multiple organ failure incidence and directly correlated with survival.6

A randomized controlled trial of intravenous ascorbic acid in patients with severe sepsis in a medical ICU in the United States showed no study-related adverse events (i.e., tachycardia, hypotension, hypernatremia, nausea/vomiting), a faster reduction in Sequential Organ Failure Assessment (SOFA) scores, and improved inflammatory markers.7 A total of 24 patients were assigned to placebo, low dose ascorbic acid (50 mg/kg/day), or high dose ascorbic acid (200 mg/kg/day) for 96 hours.7

Further, Zabet et al. conducted a randomized double blind trial in Iran and evaluated the effect of ascorbic acid 25 mg/kg IV q6h on 28 critically ill surgical patients with septic shock requiring vasopressor support.8 Mean norepinephrine dose (7.44 ± 3.65 vs. 13.79 ± 6.48 mcg/min, p=0.004) and duration of use (49.64 ± 25.67 vs. 71.57 ± 1.60 h, p=0.007) were significantly lower in patients treated with ascorbic acid than placebo. There were no differences in length of ICU stay; however, patients in the treatment group had a significantly lower 28-day mortality (14.28% vs. 64.28%, p=0.009) and no adverse effects were found during the study.8

The most recently published study was a retrospective review comparing the clinical course of 47 septic patients with a procalcitonin > 2 ng/ml treated with thiamine 200 mg IV q12hr, ascorbic acid 1.5 g IV q6hr, and hydrocortisone 50 mg IV q6hr.9 Hospital mortality was significantly reduced in the treatment group (8.5% vs. 40.4%, 95% CI 0.04-0.48). A reduction in SOFA scores, requirement for RRT, and duration of vasopressor use were also shown. The authors believe ascorbic acid and hydrocortisone act synergistically by restoring glucocorticoid function, improving transport of ascorbic acid into the cell, and preserving endothelial integrity.  A concern with high doses of ascorbic acid is the metabolic conversion to oxalate. Although oxalate is excreted through the kidneys, patients with renal impairment may have increased serum levels resulting in crystallization in the kidney. However, within the small sample size, Marik et al. reported improvement in renal function.9  There were many scientific limitations in Marik et al study which are highlighted within a letter to the editor of CHEST written by Drs. Kalil, Johnson and Cawcutt. Click here to read the letter.

The optimal dose and time of administration are still to be determined. The safety concerns of oxalate accumulation and pro-oxidant effects should also be considered with high-dose ascorbic acid. Although recent and very limited evidence suggests potential benefits with intravenous ascorbic acid, further studies are needed to confirm these preliminary findings. A large double-blind placebo-controlled randomized clinical trial is necessary to confirm or refute the efficacy and safety of ascorbic acid in patients with septic shock.

 

References

  1. Oudemans-van Straaten HM, Spoelstra-de Man AM, de Waard MC. Vitamin C revisited. Crit Care. 2014;18(4):460.
  2. Carr AC, Shaw GM, Fowler AA, et al. Ascorbate-dependent vasopressor synthesis: a rationale for vitamin C administration in severe sepsis and septic shock? Crit Care. 2015;19:418.
  3. Padayatty SJ, Sun H, Wang Y, et al. Vitamin C pharmacokinetics: implications for oral and intravenous use. Ann Intern Med. 2004;140(7):533-7.
  4. Long CL, Maull KI, Krishnan RS, et al. Ascorbic acid dynamics in the seriously ill and injured. J Surg Res. 2003 Feb;109(2):144-8.
  5. Schorah CJ, Downing C, Piripitsi A, et al. Total vitamin C, ascorbic acid, and dehydroascorbic acid concentrations in plasma of critically ill patients. Am J Clin Nutr. 1996;63(5):760-5.
  6. Borrelli E, Roux-Lombard P, Grau GE, et al. Plasma concentrations of cytokines, their soluble receptors, and antioxidant vitamins can predict the development of multiple organ failure in patients at risk.Crit Care Med. 1996;24(3):392–397.
  7. Fowler AA, Syed AA, Knowlson S, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.
  8. Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.
  9. Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2016.S0012-3692(16)62564-3.

Content courtesy of Stephanie Willis, Scott Bergman and Dr. Andre Kalil. Commentary and opinions reflect those of the authors and may not reflect the opinions of the Division or UNMC as a whole.


 

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