Vulvar Aphthous Ulcers in Perimenarchal Adolescents after COVID-19 Vaccination: A Multicenter Case Series.

This case series from 3 academic hospital-based pediatric and adolescent gynecology services outlines the temporal association between vulvar ulcers in female adolescents and COVID-19 vaccination. We identified 8 cases and describe each patient's presentation, differential diagnosis, diagnostic workup, complications, treatment modalities, and overall course of illness. All cases seek to illustrate the clinical experiences of patients and providers interfacing with vulvar aphthous ulcers and contribute to the emerging literature exploring the novel association between vulvar aphthous ulcers and COVID-19 vaccination. To date, this is the largest described case series of this association in the literature. Key Words: COVID-19, Vaccine, Aphthous ulcers, Vulva, Adolescent.

AuduBon-Bons: Bite-Sized Learning for Residents in the Ambulatory Obstetrics and Gynecology Clinic.

Background: While most medical education happens in the inpatient setting, the vast majority of medicine is practiced in the outpatient setting. Graduates from our obstetrics and gynecology (OB/GYN) program consistently report lower confidence and comfort in the ambulatory, as opposed to inpatient, setting. Objective: To describe and evaluate a novel curriculum, delivered in an ambulatory clinic covering ambulatory care topics, and to assess its feasibility in a single site OB/GYN residency program. Methods: We created an ambulatory curriculum, comprising short modules delivered in the ambulatory clinic during the first 15 minutes of every half-day clinic session. Modules were delivered using a flipped classroom format with pre-session assignments during the 2019-2020 academic year. Outcomes were residents' pre- and post-session comfort and confidence and module developers' time to create the curriculum. Time tracking was performed. Results: On average, 11 residents were present for the teaching session weekly. Twenty-four residents and 6 faculty were eligible to complete pre- and post-session surveys. For every weekly session, the average resident comfort level and the average resident confidence level with the module's topic increased from the pre-module survey to the post-module survey. Residents completed pre-module assignments 64.8% (236 of 364) of the time, and of residents who completed the pre-work, 89.4% (211 of 236) reported it was useful. Average survey completion rate was 70.5% (1398 of 1984). Conclusions: We showed that it is feasible to create and implement an ambulatory curriculum for residents in OB/GYN, and this curriculum increased resident's comfort and confidence with ambulatory practice.

An Analysis of 400 Sternal Wound Reconstructions at a Single Institution: Bacterial Pathogens Vary With Time.

BACKGROUND: Sternal wound (SW) infection and dehiscence after median sternotomy from cardiac surgery remain challenging complications with high morbidity. Knowledge of common pathogen types and variance with time from cardiac surgery can simplify the choice of antibiotics while awaiting definitive culture results. METHODS: Records of 505 patients undergoing SW reconstruction by the senior author from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. The most common indications for reconstruction were SW infection and dehiscence. At surgery, all patients underwent removal of sternal hardware, thorough debridement, and closure with bilateral pectoralis major myocutaneous advancement flaps. Deep tissue and bone cultures were sent in nearly all cases. Patients were split into group 1 or group 2 based on timing of flap reconstruction after initial cardiac surgery: 0 to 30 days and longer than 30 days, respectively. RESULTS: Complete data were available for 400 SW procedures performed during this period. Group 1 included 203 patients, and group 2 had 197 patients, with a mean time to SW surgery of 16.3 and 138.1 days, respectively. Intraoperative cultures were positive in 147 of 203 (72.4%), and 122 of 197 (61.9%) patients, respectively. Forty-four patients grew polymicrobial cultures. There was a significant difference in culture positivity rates in the 2 groups (P = 0.0004). The most common bacteria cultured in group 1 was Staphylococcus epidermidis (54 of 203 vs 21 of 197; P < 0.0001), whereas methicillin-sensitive Staphylococcus aureus was most common in group 2 (15 of 203 vs 22 of 197; P = 0.23). Methicillin-resistant S. aureus was relatively common in both groups (17 of 203 vs 21 of 197; P = 0.50). Although not statistically significant, Pseudomonas, Klebsiella, and Candida were all found in a higher percentage of patients in group 2 (p = 0.11, 0.20, 0.20). CONCLUSIONS: Microbial species cultured in SW flap reconstruction vary over time. Staphylococcus epidermidis is the most common infectious agent in patients having reconstruction within 30 days of cardiac surgery, whereas methicillin-sensitive S. aureus is most common after 30 days. The trend toward a higher incidence of Gram-negative and fungal organisms after 30 days may indicate a need for broader initial anti-infective coverage in this patient group. Awareness of these pathogen patterns can better inform antibiotic selection while awaiting culture data.

An Outcomes Review of 330 Sternal Wound Reconstructions: Timing of Closure Does Make a Difference.

BACKGROUND: Sternal wound infection and dehiscence following cardiac surgery remain difficult clinical problems with high morbidity. Older classification systems regarding timing to reconstruction do not take into account recent improvements in critical care, wound vacuum-assisted closure use, or next-generation antibiotic therapies, which may prolong time to reconstruction. METHODS: Records of patients undergoing sternal wound reconstruction performed by the senior author (J.A.A.) from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. Indications included sternal wound infection or dehiscence. All patients underwent single-stage removal of hardware, débridement, and flap closure. Patients were divided into two groups based on timing of wound closure after cardiac surgery: less than 30 days or greater than or equal to 30 days. RESULTS: Of the 505 patients identified during the study period, 330 had sufficient data for analysis. Mean time to sternal wound surgery was 15.7 days in the early group compared to 64.4 days (p < 0.01) beyond 30 days. Postdébridement cultures were positive in 72 percent versus 62.5 percent of patients (p = 0.11), whereas rates of postoperative infection were significantly higher in the delayed group: 1.9 percent versus 9.5 percent (p < 0.01). Partial wound dehiscence rates were also higher after 30 days (1.9 percent versus 11.3 percent; p < 0.01), whereas total length of stay was decreased. Use of wound vacuum-assisted closure was significantly associated with reconstruction beyond 30 days (p < 0.01). CONCLUSIONS: Although performing sternal wound reconstruction more than 30 days after initial cardiac surgery was associated with a shorter overall hospital length of stay and higher extubation rates in the operating room, these patients also had elevated postoperative infection and wound complication rates. The authors thus recommend not delaying definitive surgical reconstruction when possible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.