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Background: Diagnosis and management of suspected urinary tract infection (UTI) in outpatient settings has been shown to be suboptimal. We previously developed a set of stewardship metrics for UTIs based on electronic health record (EHR) data (Antimicrobial Stewardship & Healthcare Epidemiology 2022;2 suppl 1:S5–S6. doi:10.1017/ash.2022). A tier-based approach was used to more fully capture antibiotic use associated with genitourinary (GU) symptoms and diagnoses. Herein we report a preliminary analysis of validity and reliability of these metrics based on chart abstraction. Methods: The study cohort consisted of patients who visited Veterans Affairs emergency departments or primary care clinics between 2015 and 2022 and who had a GU diagnosis based on International Classification of Disease, Tenth Revision (ICD-10) codes, divided into 3 categories: tier 1 (antibiotics always indicated), tier 2 (antibiotics sometimes indicated), and tier 3 (antibiotics not indicated). Visits related to urological procedures, nontarget settings, or concomitant non-GU infections were excluded. Cases were randomly sampled for manual review from within 8 strata based on tier, use of antibiotics, and visit type. An infectious disease physician and pharmacist abstracted charts using a standardized data-collection instrument. Clinical judgments regarding diagnosis and treatment were recorded on a Likert scale without knowledge of how the patient was managed. The intraclass correlation coefficient (ICC) was used to estimate interrater reliability. Results: To date, 148 cases have been reviewed (50 by both reviewers). Mean (SD) age was 67.5 (15.3) years and 12.2% were female. In a majority of tier 1 and 2 visits in which antibiotics were given, the reviewers found evidence for GU infection (69.7%) and favored prescribing of antibiotics (60.6%) (Table). In contrast, most patients in the tier 3 category who received antibiotics were judged to have noninfectious conditions (eg, benign prostatic hypertrophy) and to not require antibiotics. In the subset of records examined by both reviewers, the interrater reliability of judgments of whether antibiotics were warranted was good (ICC = .704). Conclusions: This preliminary validation provides support for a tier-based approach for stewardship metrics for GU conditions that relies upon electronic data to identify patients for whom antibiotics are generally not indicated.
To assess the safety and efficacy of a novel beta-lactam allergy assessment algorithm managed by an antimicrobial stewardship program (ASP) team.
One quaternary referral teaching hospital and one tertiary care teaching hospital in a large western Pennsylvania health network.
Patients or participants:
Patients who received a beta-lactam challenge dose under the beta-lactam allergy assessment algorithm.
A beta-lactam allergy assessment protocol was designed and implemented by an ASP team. The protocol risk stratified patients’ reported allergies to identify patients appropriate for a challenge with a beta-lactam antibiotic. This retrospective analysis assessed the safety and efficacy of this protocol among patients receiving a challenge dose from November 2017 to July 2021.
Over a 45-month period, 119 total patients with either penicillin or cephalosporin allergies entered the protocol. Following a challenge dose, 106 (89.1%) patients were treated with a beta-lactam. Eleven patients had adverse reactions to a challenge dose, one of which required escalation of care to the intensive care unit. Of the patients with an unknown or low-risk reported allergy, 7/66 (10.6%) had an observed adverse reaction compared to 3/42 (7.1%) who had an observed reaction with a reported high-risk or anaphylactic allergy.
Our implemented protocol was safe and effective, with over 90% of patients tolerating the challenge without incident and many going on to receive indicated beta-lactam therapy. This protocol may serve as a framework for other inpatient ASP teams to implement a low-barrier allergy assessment led by ASP teams.
We present the third data release from the Parkes Pulsar Timing Array (PPTA) project. The release contains observations of 32 pulsars obtained using the 64-m Parkes “Murriyang” radio telescope. The data span is up to 18 years with a typical cadence of 3 weeks. This data release is formed by combining an updated version of our second data release with ∼ 3 years of more recent data primarily obtained using an ultra-wide-bandwidth receiver system that operates between 704 and 4032 MHz. We provide calibrated pulse profiles, flux-density dynamic spectra, pulse times of arrival, and initial pulsar timing models. We describe methods for processing such wide-bandwidth observations, and compare this data release with our previous release.
Over the last 20 years, finite element analysis (FEA) has become a standard analysis tool for metal joining processes. When FEA tools are combined with design of experiments (DOE) methodologies, academic research has shown the potential for virtual DOE to allow for the rapid analysis of manufacturing parameters and their influence on final formed products. However, within the domain of bulk-metal joining, FEA tools are rarely used in industrial applications and limit DOE trails to physical testing which are therefore constrained by financial costs and time.
This research explores the suitability of an FEA-based DOE to predict the complex behaviour during bulk-metal joining processes through a case study on the staking of spherical bearings. For the two DOE outputs of pushout strength and post-stake torque, the FEA-based DOE error did not exceed ±1.2% and ± 1.5 Nm respectively which far surpasses what was previously capable from analytically derived closed-form solutions. The outcomes of this case study demonstration the potential for FEA-based DOE to provide an inexpensive, methodical, and scalable solution for modelling bulk-metal joining process
Diversification of the medical and cardiothoracic surgical workforce represents an ongoing need. A congenital cardiac surgery shadowing programme for undergraduate students was implemented at the University of Florida Congenital Heart Center.
Students shadowing in the Congenital Heart Center from 17 December 2020 through 20 July 2021 were sent a survey through Qualtrics to evaluate the impact of their shadowing experience. The main objectives of the survey were to determine the personal relationship(s) of the students to physicians prior to shadowing, how the presence or absence of physicians in the family of a given student related to the exposure of the student to a medical setting prior to shadowing, and the interest of the students in medicine and cardiothoracic surgery prior to and after the shadowing experience. Survey responses included “Yes/No” questions, scaled responses using a Likert scale, selection lists, and free text responses. When applicable, t-tests were utilised to assess differences between student groups.
Of the 37 students who shadowed during the study period, 26 (70%) responded. Most students were female (58%, n = 15), and the mean age was 20.9 ± 2.4 years. Students spent a mean duration of 95 ± 138 hours shadowing providers as part of the shadowing programme. Likert scale ratings of interest in the professions of medicine, surgery, and cardiothoracic surgery all increased after the shadowing experience (p < 0.01). Students with a family member in medicine had more clinical exposure prior to the shadowing programme (p < 0.01).
A surgical shadowing programme at a Congenital Heart Center may have an important formative impact on the views of undergraduate students regarding potential careers in surgery and medicine. Additionally, students without family members in medicine tend to have less prior exposure to medicine and could likely benefit more from this type of shadowing programme.
The purpose of this investigation was to expand upon the limited existing research examining the test–retest reliability, cross-sectional validity and longitudinal validity of a sample of bioelectrical impedance analysis (BIA) devices as compared with a laboratory four-compartment (4C) model. Seventy-three healthy participants aged 19–50 years were assessed by each of fifteen BIA devices, with resulting body fat percentage estimates compared with a 4C model utilising air displacement plethysmography, dual-energy X-ray absorptiometry and bioimpedance spectroscopy. A subset of thirty-seven participants returned for a second visit 12–16 weeks later and were included in an analysis of longitudinal validity. The sample of devices included fourteen consumer-grade and one research-grade model in a variety of configurations: hand-to-hand, foot-to-foot and bilateral hand-to-foot (octapolar). BIA devices demonstrated high reliability, with precision error ranging from 0·0 to 0·49 %. Cross-sectional validity varied, with constant error relative to the 4C model ranging from −3·5 (sd 4·1) % to 11·7 (sd 4·7) %, standard error of the estimate values of 3·1–7·5 % and Lin’s concordance correlation coefficients (CCC) of 0·48–0·94. For longitudinal validity, constant error ranged from −0·4 (sd 2·1) % to 1·3 (sd 2·7) %, with standard error of the estimate values of 1·7–2·6 % and Lin’s CCC of 0·37–0·78. While performance varied widely across the sample investigated, select models of BIA devices (particularly octapolar and select foot-to-foot devices) may hold potential utility for the tracking of body composition over time, particularly in contexts in which the purchase or use of a research-grade device is infeasible.
Decision-making in congenital cardiac care, although sometimes appearing simple, may prove challenging due to lack of data, uncertainty about outcomes, underlying heuristics, and potential biases in how we reach decisions. We report on the decision-making complexities and uncertainty in management of five commonly encountered congenital cardiac problems: indications for and timing of treatment of subaortic stenosis, closure or observation of small ventricular septal defects, management of new-onset aortic regurgitation in ventricular septal defect, management of anomalous aortic origin of a coronary artery in an asymptomatic patient, and indications for operating on a single anomalously draining pulmonary vein. The strategy underpinning each lesion and the indications for and against intervention are outlined. Areas of uncertainty are clearly delineated. Even in the presence of “simple” congenital cardiac lesions, uncertainty exists in decision-making. Awareness and acceptance of uncertainty is first required to facilitate efforts at mitigation. Strategies to circumvent uncertainty in these scenarios include greater availability of evidence-based medicine, larger datasets, standardised clinical assessment and management protocols, and potentially the incorporation of artificial intelligence into the decision-making process.
Changes in body composition and dietary intake occur following spinal cord injury (SCI). The Geometric Framework for Nutrition (GFN) is a tool that allows the examination of the complex relationships between multiple nutrition factors and health parameters within a single model. This study aimed to utilize the GFN to examine the associations between self-reported macronutrient intakes and body composition in persons with chronic SCI. Forty-eight individuals with chronic SCI were recruited. Participants completed and returned 3- or 5-day self-reported dietary recall sheets. Dietary intake of macronutrients (fats, proteins, and carbohydrates) were analysed. Anthropometric measures (circumferences), dual-energy x-ray absorptiometry (DXA), and magnetic resonance imaging (MRI) were used to assess whlole-body composition. Associations between all circumference measures and carbohydrates were observed. Among MRI measures, only significant associations between subcutaneous adipose tissue and protein x carbohydrate as well as carbohydrates alone were identified. Carbohydrates were negatively associated with several measures of fat mass as measured by DXA. Overall, carbohydrates appear to play an important role in body composition among individuals with SCI. Higher carbohydrate intake was associated with lower fat mass. Additional research is needed to determine how carbohydrate intake influences body composition and cardiometabolic health after SCI.
Background: Tracking antibiotic use is a core element of antimicrobial stewardship. We developed a set of metrics based on electronic health record data to support an outpatient stewardship initiative to improve management of urinary tract infections (UTIs) in Veterans’ Affairs (VA) emergency departments (EDs) and primary care clinics. Because UTI diagnostic codes only capture a portion of genitourinary (GU)-related antibiotic use, a tier-based approach was used to evaluate practices. Methods: Metrics were developed to target practices related to antibiotic prescribing and diagnostic testing (Table 1). GU conditions were divided into 3 categories: tier 1, conditions for which antibiotics are usually or always indicated; tier 2, conditions for which antibiotics are sometimes indicated; and tier 3, conditions for which antibiotics are rarely or never indicated (eg, benign prostatic hypertrophy with symptoms). Patients with visits related to urological procedures, nontarget providers, and concomitant non-GU infections were excluded. Descriptive analyses included calculation of the correlation matrix for the 7 metrics and the construction of box plots to display interfacility variability. Results: Metrics were calculated quarterly for 18 VA medical centers, including affiliated clinics, in a western VA network, from July 2018 to June 2020 (Table 1). Tier 3 GU conditions accounted for 1,276 of 11,840 (11%) of GU-related antibiotic use. Metrics 1 and 6b were strongly correlated with each other and were also positively correlated with metrics 2 and 5 (coefficients > 0.5) (Fig. 1). Substantial interfacility variation was observed (Fig. 2). Conclusions: Stewardship metrics for suspected or documented UTIs can identify opportunities for practice improvement. Broadly capturing GU conditions in addition to UTIs may enhance utility for performance feedback. Antibiotic prescribing for tier 3 GU conditions is analogous to unnecessary antibiotic use for acute, uncomplicated bronchitis and upper respiratory tract infections.
To determine the incidence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among healthcare personnel (HCP) and to assess occupational risks for SARS-CoV-2 infection.
Prospective cohort of healthcare personnel (HCP) followed for 6 months from May through December 2020.
Large academic healthcare system including 4 hospitals and affiliated clinics in Atlanta, Georgia.
HCP, including those with and without direct patient-care activities, working during the coronavirus disease 2019 (COVID-19) pandemic.
Incident SARS-CoV-2 infections were determined through serologic testing for SARS-CoV-2 IgG at enrollment, at 3 months, and at 6 months. HCP completed monthly surveys regarding occupational activities. Multivariable logistic regression was used to identify occupational factors that increased the risk of SARS-CoV-2 infection.
Of the 304 evaluable HCP that were seronegative at enrollment, 26 (9%) seroconverted for SARS-CoV-2 IgG by 6 months. Overall, 219 participants (73%) self-identified as White race, 119 (40%) were nurses, and 121 (40%) worked on inpatient medical-surgical floors. In a multivariable analysis, HCP who identified as Black race were more likely to seroconvert than HCP who identified as White (odds ratio, 4.5; 95% confidence interval, 1.3–14.2). Increased risk for SARS-CoV-2 infection was not identified for any occupational activity, including spending >50% of a typical shift at a patient’s bedside, working in a COVID-19 unit, or performing or being present for aerosol-generating procedures (AGPs).
In our study cohort of HCP working in an academic healthcare system, <10% had evidence of SARS-CoV-2 infection over 6 months. No specific occupational activities were identified as increasing risk for SARS-CoV-2 infection.
From 2014 to 2020, we compiled radiocarbon ages from the lower 48 states, creating a database of more than 100,000 archaeological, geological, and paleontological ages that will be freely available to researchers through the Canadian Archaeological Radiocarbon Database. Here, we discuss the process used to compile ages, general characteristics of the database, and lessons learned from this exercise in “big data” compilation.
To describe the epidemiology of patients with nonintestinal carbapenem-resistant Enterobacterales (CRE) colonization and to compare clinical outcomes of these patients to those with CRE infection.
A secondary analysis of Consortium on Resistance Against Carbapenems in Klebsiella and other Enterobacteriaceae 2 (CRACKLE-2), a prospective observational cohort.
A total of 49 US short-term acute-care hospitals.
Patients hospitalized with CRE isolated from clinical cultures, April, 30, 2016, through August 31, 2017.
We described characteristics of patients in CRACKLE-2 with nonintestinal CRE colonization and assessed the impact of site of colonization on clinical outcomes. We then compared outcomes of patients defined as having nonintestinal CRE colonization to all those defined as having infection. The primary outcome was a desirability of outcome ranking (DOOR) at 30 days. Secondary outcomes were 30-day mortality and 90-day readmission.
Of 547 patients with nonintestinal CRE colonization, 275 (50%) were from the urinary tract, 201 (37%) were from the respiratory tract, and 71 (13%) were from a wound. Patients with urinary tract colonization were more likely to have a more desirable clinical outcome at 30 days than those with respiratory tract colonization, with a DOOR probability of better outcome of 61% (95% confidence interval [CI], 53%–71%). When compared to 255 patients with CRE infection, patients with CRE colonization had a similar overall clinical outcome, as well as 30-day mortality and 90-day readmission rates when analyzed in aggregate or by culture site. Sensitivity analyses demonstrated similar results using different definitions of infection.
Patients with nonintestinal CRE colonization had outcomes similar to those with CRE infection. Clinical outcomes may be influenced more by culture site than classification as “colonized” or “infected.”
To assess experience, physical infrastructure, and capabilities of high-level isolation units (HLIUs) planning to participate in a 2018 global HLIU workshop hosted by the US National Emerging Special Pathogens Training and Education Center (NETEC).
An electronic survey elicited information on general HLIU organization, operating costs, staffing models, and infection control protocols of select global units.
Setting and participants:
The survey was distributed to site representatives of 22 HLIUs located in the United States, Europe, and Asia; 19 (86%) responded.
Data were coded and analyzed using descriptive statistics.
The mean annual reported budget for the 19 responding units was US$484,615. Most (89%) had treated a suspected or confirmed case of a high-consequence infectious disease. Reported composition of trained teams included a broad range of clinical and nonclinical roles. The mean number of HLIU beds was 6.37 (median, 4; range, 2–20) for adults and 4.23 (median, 2; range, 1–10) for children; however, capacity was dependent on pathogen.
Responding HLIUs represent some of the most experienced HLIUs in the world. Variation in reported unit infrastructure, capabilities, and procedures demonstrate the variety of HLIU approaches. A number of technical questions unique to HLIUs remain unanswered related to physical design, infection prevention and control procedures, and staffing and training. These key areas represent potential focal points for future evidence and practice guidelines. These data are important considerations for hospitals considering the design and development of HLIUs, and there is a need for continued global HLIU collaboration to define best practices.
We prove several different anti-concentration inequalities for functions of independent Bernoulli-distributed random variables. First, motivated by a conjecture of Alon, Hefetz, Krivelevich and Tyomkyn, we prove some “Poisson-type” anti-concentration theorems that give bounds of the form 1/e + o(1) for the point probabilities of certain polynomials. Second, we prove an anti-concentration inequality for polynomials with nonnegative coefficients which extends the classical Erdős–Littlewood–Offord theorem and improves a theorem of Meka, Nguyen and Vu for polynomials of this type. As an application, we prove some new anti-concentration bounds for subgraph counts in random graphs.
There is substantial evidence that voters’ choices are shaped by assessments of the state of the economy and that these assessments, in turn, are influenced by the news. But how does the economic news track the welfare of different income groups in an era of rising inequality? Whose economy does the news cover? Drawing on a large new dataset of US news content, we demonstrate that the tone of the economic news strongly and disproportionately tracks the fortunes of the richest households, with little sensitivity to income changes among the non-rich. Further, we present evidence that this pro-rich bias emerges not from pro-rich journalistic preferences but, rather, from the interaction of the media’s focus on economic aggregates with structural features of the relationship between economic growth and distribution. The findings yield a novel explanation of distributionally perverse electoral patterns and demonstrate how distributional biases in the economy condition economic accountability.
The Real Time Mesoscale Analysis (RTMA), a two-dimensional variational analysis algorithm, is used to provide hourly analyses of surface sensible weather elements for situational awareness at spatial resolutions of 3 km over Alaska. In this work we focus on the analysis of horizontal visibility in Alaska, which is a region prone to weather related aviation accidents that are in part due to a relatively sparse observation network. In this study we evaluate the impact of assimilating estimates of horizontal visibility derived from a novel network of web cameras in Alaska with the RTMA. Results suggest that the web camera-derived estimates of visibility can capture low visibility conditions and have the potential to improve the RTMA visibility analysis under conditions of low instrument flight rules and instrument flight rules.