National Pediatrician-Scientist Collaborative Workgroup comment on new ACGME requirements' impact on pediatric physician-scientists

BACKGROUND

The ACGME recently released its recommendation for updates to the program requirements for pediatrics. These updates proposed changes to allocation of resident clinical time and a greater emphasis on individualization. The potential impact of these changes on the training of physician-scientists is discussed.

METHODS

Discussion of the proposed changes was held within the members of the National Pediatrician-Scientist Collaborative Workgroup, a group that represents scientists, trainees, program directors, chairs, and physician-scientist educators at nearly 30 residency programs from across the US with a focus on understanding and developing optimal approaches to physician-scientist training. Consideration was given to the both the personal and institutional impact of the proposal for physician-scientist development.

RESULTS

Both threats and opportunities were identified. Key opportunities include the enhanced individualized training time that could be used to explore research. Threats include re-allocation of clinical training time that may strain institutions financially, expand clinical service requirements for other early career stage individuals, and alter exposure to a broad range of pediatric specialists and sub-specialists that impact career development.

CONCLUSION

The NPSCW encourages consideration of the impact of changing program requirements on physician-scientist development to include ongoing discussion amongst mentors, programs, and trainees to understand and mitigate impact of new program requirements on the development of pediatrician-scientists.

1322. Infectious Complications Following Pediatric Lawn Mower Injury: A Case Series

Background

According to the National Electronic Injury Surveillance System, there are an estimated 9,400 riding lawn mower injuries in the United States in pediatric patients per year. Previous case series report a 7-12.5% infection rate after injury. We report our experience of lawn mower injury-related infections over a 4-year period.

Methods

Cases of lawn mower injury at our center were identified by the ICD-10 code W28.XXXA for contact with a powered lawn mower between 2017-2020. Patient demographics, injury background, microbial results, and antimicrobial use were collected via manual chart review.

Results

During the 4-year period, 25 patients presented to UPMC Children’s Hospital of Pittsburgh who had a diagnosis of lawn mower injury. The median age of the patients was 6.5 years old. Most cases sustained foot injury (68%, 17/25), followed by leg (24%, 6/25), and hand or arm (24%, 6/25). Perioperative antibiotics depended on the extent of the damage, intent to amputate or salvage a limb, and extent of obvious contamination. These included 24-48 hours of piperacillin-tazobactam for 44% (11/25) of patients, ampicillin/sulbactam for 32% (8/25) of patients, and cefazolin for 24% (6/25) patients. Four of the 25 patients (16%) had infection after the initial injury as defined as growth of organisms from a wound culture collected more than 48 hours after the initial injury and debridement. Antimicrobials for the treatment of infection were further tailored to the culture results. From the four patients with infection after initial debridement or amputation, pathogens included: Serratia marcescens, Staphylococcus aureus, Myroides odartus, Stenotrophomonas, Prevotella, Aeromonas, Coagulase negative Staphylococcus, Enterobacter cloacae, Sphingomonas, Bacillus species, Pseudomonas aeruginosa, Candida albicans, Rhizopus, and Trichosporon.

Conclusion

Infections after lawn mower injures are infrequent with early, aggressive surgical debridement. However, infections following lawn mower injuries are frequently polymicrobial and involve a wide variety of pathogens. Obtaining repeat cultures during subsequent surgical debridements can be useful to track persistent growth and identify new and uncommon pathogens.

Disclosures

All Authors: No reported disclosures.

Gonococcal Infection and Ventriculoperitoneal Shunts

ABSTRACT

Neisseria gonorrhoea e and Chlamydia trachomatis are pathogens commonly isolated in pelvic inflammatory disease. Neisseria gonorrhoea e may uncommonly spread outside the urogenital tract to cause complications. We present 2 cases of adolescents with ventriculoperitoneal shunt infection due to N. gonorrhoea e, requiring shunt externalization.

The Impact of Operative Intervention in Pediatric Lyme Arthritis

BACKGROUND

Lyme arthritis often presents as acute monoarticular arthritis challenging to distinguish from septic arthritis. Typical management for Lyme arthritis entails antibiotic therapy, while septic arthritis usually warrants operative debridement. During the period when Western Pennsylvania transitioned to a Lyme-endemic region, many children underwent operative intervention who were ultimately diagnosed with Lyme arthritis due to diagnostic ambiguity. We examined the impact of the operative intervention on pediatric Lyme arthritis outcomes.

METHODS

We conducted a retrospective cohort study of patients admitted to a tertiary care children's hospital who were diagnosed with Lyme arthritis from 2008 to 2018 using chart review. Inclusion criteria were positive Lyme serology by Centers for Disease Control and Prevention (CDC) definition, clinical arthritis, and negative bacterial cultures. We recorded clinical presentation, laboratory data, details of hospitalization, costs, and outcomes after therapy to compare the impact of antibiotics alone (nonoperative group) versus antibiotics plus operative debridement (operative group).

RESULTS

A total of 149 patients met the inclusion criteria. Overall, 47 (32%) patients underwent orthopaedic intervention. Operative management was associated with increased length (3.17 vs. 1.40 d) and cost ($27,850 vs. $10,716) of admission. The clinical resolution was documented in 57/58 patients (98%) in the nonoperative group and 41/42 patients (98%) in the operative group. The median duration to resolution was 21 days for both groups.

CONCLUSIONS

Operative management of pediatric patients with Lyme arthritis is associated with increased resource utilization and costs while being similarly efficacious to nonoperative management. As the US Lyme epidemic expands, improved diagnosis and management of acute undifferentiated arthritis may prevent unneeded operative intervention.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Pediatric decision limits for serologic screening of Lyme disease

BACKGROUND

Laboratory diagnosis of Lyme disease (LD) relies on a two-tier protocol. We have observed disproportionate equivocal serologies in children requiring reflex western blot (WB) using manufacturer-provided ranges based on adult studies. We aimed to determine appropriate ranges for our pediatric population.

METHODS

We performed a one-year retrospective institutional review of all 2755 children with LD testing with the Vidas® Lyme IgM II/IgG II immunoassays with reflex to WB for equivocal/positive serologies. Results were assessed by frequency distributions, optimization via percent agreement analysis, and clinical adjudication.

RESULTS

The proposed ranges for IgM (negative ≤0.20, equivocal ≥0.21 to <0.32, positive ≥0.32) and IgG (negative ≤0.50, positive >0.50) allowed for a decrease in the IgM equivocal rate (7% to 2%) and IgG positive rate (15% to 13%). There was a decrease in the positive percent agreement between tiers (95% to 83% and 98% to 95%) with increase in the negative (32% to 63% and 70% to 81%) and overall (65% to 73% and 85% to 88%) percent agreements for IgM and IgG, respectively. Of 15 IgM serologies reclassified as negative with a positive WB and not positive for IgG, 8 were clinically negative, 5 were clinically positive, and two had insufficient history. Of the 10 IgG serologies reclassified as negative with a positive WB 3 were clinically positive, 6 were clinically negative and one had insufficient history.

CONCLUSIONS

Our modified ranges are more suitable for our pediatric population while reducing overdiagnosis, unnecessary treatment, diagnostic uncertainty, and turnaround time.

Pediatric Faculty and Trainee Attitudes Toward the COVID-19 Pandemic

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented event in modern medicine. In this study, we evaluate pediatric faculty and trainee attitudes and perspectives related to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their roles in the COVID-19 pandemic.

METHODS

We surveyed a pediatric hospital's faculty and trainees (n = 701) in April 2020 about their concerns related to SARS-CoV-2, trust in current recommendations, and attitudes toward trainee roles. We used descriptive statistics to analyze results and compared across sex and roles using logistic regression.

RESULTS

Among 320 respondents (46% response rate), 73% were concerned with personal risk of SARS-CoV-2 infection and 88% were concerned with loved ones' risk. Twenty-four percent were concerned because of personal risk factors. Nearly half expressed concerns as their family's major provider and about salary changes (48% and 46%). Seventy-nine percent were concerned about lack of personal protective equipment and 43% about redeployment. Respondents endorsed varying levels of trust in recommendations related to COVID-19. Nearly three-fourths (72%) felt trainees are essential personnel. The majority were receptive to returning to usual patient care and training as the pandemic progresses. Significant differences exist across sex and roles related to levels of concern, trust, and trainee roles.

CONCLUSIONS

In this study, we assess the concerns and perspectives of pediatric faculty and trainees related to the COVID-19 pandemic. Most view trainees as essential personnel and recognize the importance of direct patient care in their training. These results can be used to inform policy changes and trainee roles as the COVID-19 pandemic progresses.

Host and Bacterial Markers that Differ in Children with Cystitis and Pyelonephritis

OBJECTIVE

To determine whether treatment for urinary tract infections in children could be individualized using biomarkers for acute pyelonephritis.

STUDY DESIGN

We enrolled 61 children with febrile urinary tract infections, collected blood and urine samples, and performed a renal scan within 2 weeks of diagnosis to identify those with pyelonephritis. Renal scans were interpreted centrally by 2 experts. We measured inflammatory proteins in blood and urine using LUMINEX or an enzyme-linked immunosorbent assay. We evaluated serum RNA expression using RNA sequencing in a subset of children. Finally, for children with Escherichia coli isolated from urine cultures, we performed a polymerase chain reaction for 4 previously identified virulence genes.

RESULTS

Urinary markers that best differentiated pyelonephritis from cystitis included chemokine (C-X-C motif) ligand (CXCL)1, CXCL9, CXCL12, C-C motif chemokine ligand 2, INF γ, and IL-15. Serum procalcitonin was the best serum marker for pyelonephritis. Genes in the interferon-γ pathway were upregulated in serum of children with pyelonephritis. The presence of E coli virulence genes did not correlate with pyelonephritis.

CONCLUSIONS

Immune response to pyelonephritis and cystitis differs quantitatively and qualitatively; this may be useful in differentiating these 2 conditions.

279. A Decision Tree Using Clinical Characteristics to Predict a Hospitalized Child’s Risk of a Multidrug-Resistant Gram-Negative Bloodstream Infection

Background

As the threat of multidrug-resistant Gram-negative (MDRGN) bacteria rises, recognizing children at high risk of bloodstream infections with bacteria resistant to commonly prescribed empiric antibiotics is critical. We developed a decision tree to predict which pediatric bloodstream infections were due to MDRGN bacteria resistant to cefepime or piperacillin–tazobactam, commonly prescribed empiric antibiotics.

Methods

We conducted a longitudinal retrospective cohort study at the Children’s Hospital of Pittsburgh including all admitted patients with a Gram-negative bloodstream infection from June 2009 to June 2015. Episodes of bloodstream infection were considered unique if at least 30 days had elapsed since the previous bloodstream infection. Logistic regression was performed to identify notable risk factors. A decision tree describing the risk of an MDRGN infection was developed using recursive partitioning based on clinical characteristics available at the time of presentation.

Results

Six hundred eighty-nine episodes of Gram-negative bloodstream infections occurred during the study period among 387 patients. Twenty-eight percent of infections were multidrug-resistant (MDR). The decision tree separated patients into higher or lower risk groups based on history of prior carbapenem treatment for seven or more days, having a prior MDR infection within 6 months, intestinal transplant status, age 3 years or older, and seven or more prior episodes of bacteremia. The sensitivity to classify high risk of MDR was 46% and the specificity was 92% based on leave one out cross validation. For patients who had more than one episode, 30% of initially non-MDR infections were subsequently MDR.

Conclusion

A decision tree using readily available clinical characteristics may be helpful to identify pediatric patients at higher risk of bloodstream infection due to an MDRGN organism resistant to common empirical antibiotic therapy.

Disclosures

All authors: No reported disclosures.

Hypersensitivity Pneumonitis and Acute Respiratory Distress Syndrome From E-Cigarette Use

Electronic cigarette (e-cigarette) use, or "vaping," is gaining widespread popularity as an alternative to conventional cigarettes among adolescents. Little is known of the health risks of e-cigarette use, especially in children and adolescents. We present a Case Report of a previously healthy 18-year-old woman who presented with dyspnea, cough, and pleuritic chest pain after e-cigarette use. She developed respiratory failure with hypoxia and was intubated, and ultimately met diagnostic criteria for acute respiratory distress syndrome. Chest tubes were placed to drain worsening pleural effusions. Computed tomography of the chest revealed dependent opacities in both lung bases, superimposed smooth interlobular septal thickening, and pleural effusions. Bronchoalveolar lavage revealed cellular debris and reactive mononuclear cells, and cell counts were remarkable for elevated mononuclear cells and eosinophilia. After the results of a workup for an infectious etiology came back negative, the patient was diagnosed with hypersensitivity pneumonitis and intravenous methylprednisolone therapy was initiated. After this the patient rapidly improved, was weaned off vasopressor support, and was extubated. This is the first reported case of hypersensitivity pneumonitis and acute respiratory distress syndrome as a risk of e-cigarette use in an adolescent, and it should prompt pediatricians to discuss the potential harms of vaping with their patients. Hypersensitivity pneumonitis, lipid pneumonia, and eosinophilic pneumonia should be included in the differential diagnosis of patients who exhibit respiratory symptoms after the use of an e-cigarette.

Lyme disease-related intracranial hypertension in children: clinical and imaging findings

Lyme disease (LD) is a tick-borne infection that is endemic to multiple areas of the United States. Patients with LD may present with sign and symptoms of intracranial hypertension (IH). The objective of this study is to evaluate the history, clinical findings, CSF analysis, and brain imaging results in pediatric patients with increased intracranial pressure secondary to LD. A retrospective database search was performed using the International Classification of Diseases (ICD) 9/10 codes to identify patients diagnosed with LD and IH between 2004 and 2014 at a tertiary referral pediatric hospital. Clinical, laboratory and neuroimaging data for each patient were reviewed. Seven patients met inclusion criteria; mean age was 9.6 years (standard deviation 4.0 years); 4/7 patients were male. Average body mass index was 18.8 kg/m(2) (standard deviation 3.0 kg/m(2)). Fever was present in four patients. Four had a history of LD related erythema migrans. All had elevated CSF opening pressure with leukocytosis and lymphocytic predominance. MRI obtained in six patients showed contrast enhancement of various cranial nerves. Tentorial enhancement was noted in all patients. In addition, patients had widening of the optic nerve sheath (ONS), optic nerve protrusion, and flattening of the posterior globe consistent with increased intracranial pressure. All patients had resolution of their symptoms after initiation of antibiotic therapy. In endemic areas, LD should be included in the differential of IH. MRI can help distinguish IH due to LD from its idiopathic form due to the presence of tentorial and cranial nerve enhancement in the former in addition to abnormal CSF showing leukocytosis with lymphocyte predominance.

Outbreak of KPC-3 Producing Carbapenem-Resistant Klebsiella pneumoniae in a US Pediatric Hospital

BACKGROUND

The increase in carbapenem-resistant Enterobacteriaceae (CRE) infections is a critical public health issue. We recently experienced the largest single-center pediatric outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) at our hospital. The objective of this study was to describe the molecular epidemiology of this outbreak before and after infection-prevention interventions.

METHODS

All positive cultures and associated clinical conditions were reviewed to determine whether health care-associated infections (HAIs) exist. HAIs were defined using Centers for Disease Control and Prevention guidelines. CRKP isolates were collected and screened for the presence of β-lactamase genes. Strain relatedness of CRKP isolates was determined by field-inversion gel electrophoresis (FIGE) and multilocus sequence typing (MLST). Polymerase chain reaction (PCR) amplification and sequencing of blaTEM, blaSHV, and blaKPC genes were performed on representative isolates.

RESULTS

During March-July 2010, 18 CRKP isolates were recovered from 15 unique patients. Six isolates were considered HAIs; all were central-line-associated bloodstream infections. All isolates testing positive by PCR for blaKPC were found to carry KPC-3 in transposon Tn4401 isotype "b." FIGE revealed 2 prevalent patterns (accounting for 10 and 3 CRKP isolates, respectively) that MLST demonstrated to consist entirely of strains from ST730; the remaining FIGE types corresponded to ST14, ST15, and ST1559 (a single-locus variant of ST730), with these alternate backgrounds appearing later in the outbreak. New CRKP cases decreased after the implementation of infection-control interventions. All isolates were ciprofloxacin sensitive.

CONCLUSIONS

Molecular analyses document the introduction of a KPC-3-producing CRKP clone into our hospital setting, though some isolates appear to have other mechanisms of carbapenem resistance. The transition to a polyclonal epidemiology suggests that the initial outbreak was due to nosocomial spread of a single ST730 clone, while latter isolates may have been secondary to the introduction of a blaKPC-3/Tn4401 isotype "b"-containing plasmid into other K pneumoniae strain backgrounds versus new carbapenemase-producing bacteria.

Comparison of two educational interventions on pediatric resident auscultation skills

OBJECTIVE

Multiple cross-sectional physician surveys have documented poor cardiac auscultation skills. We evaluated the impact of 2 different educational interventions on pediatric resident auscultation skills.

METHODS

The auscultation skills of all first-year (PGY1; n = 20) and second-year pediatric residents (PGY2; n = 20) were evaluated at the beginning and end of the academic year. Five patient recordings were presented: atrial septal defect, ventricular septal defect, pulmonary valve stenosis, bicuspid aortic valve with insufficiency, and innocent murmur. Residents were asked to classify the second heart sound, identify a systolic ejection click, describe the murmur, and provide a diagnosis. All PGY1 and most PGY2 (14 of 20) participated on the inpatient cardiology service for 1 month. PGY2 on the cardiology service also attended outpatient clinic. PGY1 did not attend outpatient clinic but were allotted 2 hours/week to use a self-directed cardiac auscultation computer teaching program.

RESULTS

Resident auscultation skills on initial evaluation were dependent on training level (PGY1: 42 +/- 15% correct; PGY2: 53 +/- 13% correct), primarily as a result of better classification of second heart sound (PGY1: 45%; PGY2: 63%) and diagnosis of an innocent murmur (PGY1: 35%; PGY2: 65%). There was no difference in the ability to identify correctly a systolic ejection click (20% vs 23%) or to arrive at the correct diagnosis (35% vs 40%). At the end of the academic year, the PGY1 scores improved by 21%, primarily as a result of improved diagnostic accuracy of the innocent murmur (35% to 65%). PGY2 scores remained unchanged (53% vs 51%), regardless of participation in a cardiology rotation (cardiology rotation: 50%; no cardiology rotation: 51%). Combined, diagnostic accuracy was best for ventricular septal defect (55%) and innocent murmur (60%) and worst for atrial septal defect (18%) and pulmonary valve stenosis (15%). However, 40% identified the innocent murmur as pathologic and 21% of pathologic murmurs were diagnosed as innocent.

CONCLUSIONS

Pediatric resident auscultation skills were poor and did not improve after an outpatient cardiology rotation. Auscultation skills did improve after the use of a self-directed cardiac auscultation teaching program. These data have relevance given the American College of Graduate Medical Education's emphasis on measuring educational outcomes and documenting clinical competencies during residency training.

The Interdisciplinary Generalist Curriculum (IGC) project: an overview of its experience and outcomes

The Interdisciplinary Generalist Curriculum (IGC) Project was a competitive, seven-year demonstration project funded by the Health Resources and Services Administration (HRSA). It was established to determine whether specific interdisciplinary innovations in preclinical medical school curricula could affect students' selection of careers in family medicine, general internal medicine, or general pediatrics. Through collaboration among the three generalist disciplines, the IGC innovation exposed all preclinical students in ten demonstration schools to a new or significantly enhanced preclinical curriculum that included a direct supervised clinical experience with a generalist physician preceptor. The project was managed by an interdisciplinary executive committee that was codirected by one representative each from family medicine, general internal medicine, and general pediatrics. A national advisory committee with representation from the academic and professional organizations of family medicine, internal medicine, pediatrics, and osteopathy provided input to the executive committee in guiding the project. The project was externally evaluated. Major outcomes of the IGC Project include sustained curricular changes in ten institutions, prompted by relatively few dollars and demonstration of models for collaboration at institutional and national levels. This supplement describes the IGC Project's experience and outcomes so that others may draw pertinent information to apply to their own efforts in medical education.

Curricular change: recommendations from a national perspective

Recommendations on future directions, funding, and organizational and curricular issues have emerged from the complexity of the Interdisciplinary Generalist Curriculum (IGC) Project. For example, future demonstration projects aimed at innovations in medical education that are funded through the contracting mechanism are recommended, and funding intended to serve as institutional leverage for demonstrating desired curricular innovations in medical education is encouraged. Funding provided to entities that can maximize influence within the institutions is recommended. Also, the period of time over which funds are provided needs to take into consideration the breadth of the impact of the funded program on the larger curriculum and the length of time needed to measure desired outcomes. Organizational findings are that multi-site projects with administrative oversight bodies should be governed by representatives of concerned disciplines who have stakes in the demonstration of the innovations in medical education, and roles of the executive and advisory committees involved in the effort need to be made explicit at the onset and revisited over time. Similarly, the role of the funder needs to be explicit. Curricular recommendations are that medical schools are encouraged to develop longitudinal generalist preceptorship experiences early in medical education for all students, regardless of their eventual career choices. Schools should anticipate that curricular innovations in the preclinical years may require modifications of the educational process in the clinical years.

What did we learn about student and faculty "backlash" to the Interdisciplinary Generalist Curriculum Project?

There was student and faculty backlash against the Interdisciplinary Generalist Curriculum (IGC) Project innovations at all ten schools involved. Students may react strongly to requirements and experiences they find onerous, and often reacted to being "preached at" and being told what they should value and believe. Backlash was not limited to students. A complaint heard in virtually all schools was that the basic science faculty barely had enough time to adequately cover their topics as it was, and now they were being asked to give up time for clinical experiences and topics. Despite the backlash, the authors point out that the vast majority of students endorsed the value of the preceptorship experience and that reaction to the IGC Project did not necessarily translate into negative perceptions of primary care medicine. Each IGC Project school made strategic decisions in response to backlash. Among the various efforts undertaken were enhanced communication and clarification, persistence and "watchful waiting," programmatic changes, and elimination of program components that were not working. These various efforts appear to have paid off, as most schools reported that backlash diminished over time. Lessons learned about backlash against new curricular innovations were that (1) backlash, however defined, is inevitable; (2) communication, coordination, and cooperation are essential; (3) flexibility, compromise, and willingness to change are essential; and (4) "watchful waiting" can be an effective response to some forms of backlash.