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Background: Antibiotic use was common in patients with suspected or confirmed COVID-19 infection; however, data emerged demonstrating low rates of bacterial coinfection (6%–10%). Antimicrobial stewardship best practice was challenged during this time, requiring new strategies and education to limit the inappropriate use of antibiotics. At the Veterans’ Affairs Maryland Healthcare System, we evaluated the use of community acquired pneumonia (CAP) specific antibiotics in COVID-19–positive patients after successive interventions. Methods: We conducted a pre–post evaluation of common CAP antibiotics (ceftriaxone IV/IM, cefpodoxime PO, azithromycin PO/IV, ampicillin/sulbactam IV, amoxicillin-clavulanate PO, levofloxacin) during the COVID-19 pandemic. The preintervention period was April–October 2020 and the postintervention period was November 2020–April 2021. During the preintervention period, intervention A was carried out as follows: (1) inpatient weekly virtual interdisciplinary COVID-19 rounds were led by an antimicrobial stewardship champion, (2) χprocalcitonin was implemented in clinical decision making, and (3) inpatient audit and feedback of active antibiotics was conducted by the antimicrobial stewardship team. In the postintervention period, intervention B was added as follows: (1) weekly educational COVID-19 virtual seminars were conducted for providers, and (2) targeted education was provided to emergency department and hospitalist directors. Comparisons of the proportions of antibiotics prescribed were made between the pre- and postintervention periods using X2 statistic, and data were stratified by location. The rates of CAP antibiotic prescription per 100 COVID-19–positive patients were also compared using Poisson distribution. Results: During the study period, 814 unique patients had COVID-19 infection: 182 (22.4%) patients admitted to the acute-care center, 66 (8.1%) long-term care residents, and 566 (69.5%) were managed outside the hospital. Of these 814 patients, 211 (25%) were prescribed a CAP antibiotic. Of the antibiotics prescribed, 223 (61%) were ceftriaxone, cefpodoxime, amoxicillin-clavulanate, or ampicillin-sulbactam; 123 (34%) were azithromycin; and 16 (4.4%) were levofloxacin. We observed a decrease in the frequency of all antibiotic prescriptions after intervention B was added: 32% (86 of 273) vs 23% (125 of 541) (P = .01). Decreases in antibiotic prescriptions were observed in all locations: acute care (57% vs 44%), long-term care (53% vs 41%) and outpatient care (19% vs 15%). The rates of CAP antibiotic prescribing per 100 COVID-19–positive patients were 114 in the preintervention period and 45 in the postintervention period, a rate difference of −70 antibiotics per 100 COVID-19–positive patients (pConclusions: Curbing antibiotic use for CAP indication during the COVID-19 pandemic was a challenge. A multifaceted approach focusing on education was an impactful intervention leading to significant decreases in antibiotic prescribing despite COVID-19 cases increasing.
The launch of the Sentinel-1B satellite in April 2016 completed the two-satellite synthetic aperture radar (SAR) constellation of the European Copernicus Sentinel-1 mission. The European Space Agency executed the calibration of this sensor during the commissioning phase and an independent calibration by the German Aerospace Center (DLR) in 2016. The calibration parameters must be monitored to assess the stability of the instrument. This study reports the temporal stability assessment of radiometric calibration and image quality parameters of Sentinel-1B SAR data using the corner reflector (CR) array, Surat Basin, Australia. Impulse response functions generated from the CRs in the satellite images were used to derive the image quality parameters. The average radar cross-section difference between estimated and theoretical values (38.40 dB m2) was 0.53 dB m2 for 1.5 m CRs, which is accordant with the absolute radiometric accuracy specified for the Sentinel-1 SAR system. Derived image quality parameters viz. the mean peak-to-side lobe ratio, mean integrated side lobe ratio, and spatial resolutions in the range and azimuth directions were found to be accordant with the specified value for the Sentinel-1 SAR system. The results indicate the excellent quality of the Sentinel-1B data.
Arched magnetized structures are a common occurrence in space and laboratory plasmas. Results from a laboratory experiment on spatio-temporal evolution of an arched magnetized plasma ($\beta \approx 10^{-3}$, Lundquist number $\approx 10^{4}$, plasma radius/ion gyroradius $\approx 20$) in a sheared magnetic configuration are presented. The experiment is designed to model conditions relevant to the formation and destabilization of similar structures in the solar atmosphere. The magnitude of a nearly horizontal overlying magnetic field was varied to study its effects on the writhe and twist of the arched plasma. In addition, the direction of the guiding magnetic field along the arch was varied to investigate its role in the formation of either forward- or reverse-S shaped plasma structures. The electrical current in the arched plasma was well below the current required to make it kink unstable. A significant increase in the writhe of the arched plasma was observed with larger magnitudes of overlying magnetic field. A forward-S shaped arched plasma was observed for a guiding magnetic field oriented nearly antiparallel to the initial arched plasma current, while the parallel orientation yielded the reverse-S shaped arched plasma.
Niemann-Pick disease type C (NPC), is a rare lysosomal storage disorder, which has a variable presentation based on the age of onset. We describe five adult/adolescent-onset NPC cases presenting with a range of movement disorders along with vertical supranuclear gaze palsy as part of the clinical presentation. A diagnostic delay of 4–17 years from the symptom onset was found in this case series. A high index of clinical suspicion in adult/adolescent patients presenting with vertical supranuclear gaze palsy along with various movement disorder phenomenology can help in the early diagnosis of NPC.
Substance abuse has traditionally been considered as a disease of men. Women were believed to have some kind of immunity in terms of “social inoculation”. However, due to change in societal norms and beliefs, substance use is currently increasing among women also.
Objectives
To focus on female substance use in India
Methods
In India, traditional use of various substances by women during religious festivals is not unknown. Chewing tobacco is a common practice among many women across the country. Cultural use of alcohol has been known in some tribal populations but gradually the use is increasing. There is major difference in pattern of male and female substance use including initiation, progression, recovery and relapse. Women experience greater medical, physiological and psychological impairment and experience loss of control sooner than males. Teatment needs of female substance users is different and requires a gender specific comprehensive strategy which will require medical services, mental health services, services for family and child and employment opportunities.
Results
Currently, there is no Indian policy for women substance use. However, Government of India has started a convergence program which includes National AIDS Control program (NACP), National rural health mission (NRHM) and reproductive or sexually transmitted infection (RTI/STI) to combat some aspects.
Conclusions
India is in great need of a policy or at least a standard operative protocol for management of female substance use disorder which may include screening for substance use disorder for all females accessing health sector, counselling, referral to addiction services, formation of a treating team and after –care.
Opioid dependent individuals frequently complain of sleep problems in withdrawal and during abstinence.
Objectives
The objectives were to assess the subjective sleep parameters among buprenorphine-maintained opioid-dependent patients and to correlate it with socio-demographics, concomitant drug use and treatment related variables
Methods
Using a cross-sectional study design, 106 hundred six opioid-dependent patients maintained on buprenorphine for at least six months and on same dose in past month were interviewed. Sleep was assessed by Pittsburgh sleep quality index (PSQI) and Epworth sleepiness scale. Association between subjective sleep parameters, socio-demographics, concomitant drug use and treatment related variables was also studied.
Results
All participants were males. Their mean age was 41.1 years (SD:14.3). The mean duration of illicit opioid use was 10 years (IQR: 5,22). About 63.2% (n=67) had PSQI scores more than 5 denoting sleep problem. The scores obtained in Epworth Sleeping Scale were in normal range. Mean subjective total sleep time of the sample was 403.5 (SD 94.8) minutes and median sleep latency was 35 (IQR 18.8, 62.5) minutes. Subjective total sleep time was significantly higher in participants who had use tobacco in the past three months (p value=0.03) and who were in moderate ASSIST risk category (p value=0.04). Subjective sleep latency was significantly higher (p value=0.04) in participants who had used opioids in last three months. It was observed that age was a significant predictor of subjective total sleep time and OST compliance was a significant predictor of sleep latency.
Conclusions
A sizeable proportion of opioid dependent patients on buprenorphine have sleep problems
A prospective randomised study was undertaken to compare the results of type 1 tympanoplasty with and without middle-ear packing with gelfoam.
Method
Eighty patients undergoing type 1 tympanoplasty were randomised into two groups according to packing in the middle ear: with gelfoam and without gelfoam. The data in terms of graft uptake rate, hearing gain and subjective improvement were analysed at one and three months.
Results
The graft uptake rate between both groups did not show a statistically significant difference. There was conductive hearing loss in the gelfoam group in the early post-operative period. Subjectively, patients were more comfortable with respect to heaviness and hearing gain than in the non-gelfoam group.
Conclusion
Gelfoam use in middle-ear packing is not an essential step and causes more discomfort in patients during the early post-operative period. It should be a surgeon's choice to use it when and where it is necessary.
Our understanding of major depression is complicated by substantial heterogeneity in disease presentation, which can be disentangled by data-driven analyses of depressive symptom dimensions. We aimed to determine the clinical portrait of such symptom dimensions among individuals in the community.
Methods
This cross-sectional study consisted of 25 261 self-reported White UK Biobank participants with major depression. Nine questions from the UK Biobank Mental Health Questionnaire encompassing depressive symptoms were decomposed into underlying factors or ‘symptom dimensions’ via factor analysis, which were then tested for association with psychiatric diagnoses and polygenic risk scores for major depressive disorder (MDD), bipolar disorder and schizophrenia. Replication was performed among 655 self-reported non-White participants, across sexes, and among 7190 individuals with an ICD-10 code for MDD from linked inpatient or primary care records.
Results
Four broad symptom dimensions were identified, encompassing negative cognition, functional impairment, insomnia and atypical symptoms. These dimensions replicated across ancestries, sexes and individuals with inpatient or primary care MDD diagnoses, and were also consistent among 43 090 self-reported White participants with undiagnosed self-reported depression. Every dimension was associated with increased risk of nearly every psychiatric diagnosis and polygenic risk score. However, while certain psychiatric diagnoses were disproportionately associated with specific symptom dimensions, the three polygenic risk scores did not show the same specificity of associations.
Conclusions
An analysis of questionnaire data from a large community-based cohort reveals four replicable symptom dimensions of depression with distinct clinical, but not genetic, correlates.
ABSTRACT IMPACT: Laying the groundwork for better predictive algorithms to inform clinical decisions and planning. OBJECTIVES/GOALS: Frailty scores predict poor patient outcomes. Validated against highly relevant outcomes, such scores can be used to inform clinical and resource utilization decisions. We generated and validated an electronic Frailty Index (EFI) from real-world EHR data using the Rockwood deficit-accumulation framework to predict patient safety events. METHODS/STUDY POPULATION: To assure that the research approach reflected perspectives of multiple stakeholders, our multidisciplinary group included an implementation scientist, a geriatrician, an internist, and an informatician. From our large academic health center, we accessed EHR data for 14,844 patients randomly sampled from the data warehouse underlying our ACT/SHRINE node. The per-visit EFI scores were calculated using EHR codes in a rolling 2-year time window. EFI was used as the predictor variable in the analytic design. The primary outcomes were preventable patient-safety events derived from ICD-10 codes including hospital-acquired infections, non-operative hospital-acquired trauma, and cardiac complications. Cox proportional hazard models were used to estimate risk for each outcome. RESULTS/ANTICIPATED RESULTS: We found statistically significant associations of EFI with clinically meaningful outcomes from EHR data. For most outcomes, we found significant correlation with EFI and c-statistics indicating good calibration of the models. The EFI was a strong predictor of clinically relevant outcomes without relying on any data other than diagnoses, vital signs, and laboratory results from the EHR. In contrast to previous studies, we treated EFI as a time-varying predictor with multiple follow-ups per patient, which is more realistic than relying on one static time-point. We used a representative sample of the adult patient population rather than limiting it to older individuals and found EFI to be a useful metric even at relatively young ages. DISCUSSION/SIGNIFICANCE OF FINDINGS: The EFI predicted safety events in adult patients using only routine, structured EHR data and can offer a low-effort, scalable method of risk assessment, valuable to clinical decisions. The capability to harness EHR data and rapidly generate clinical knowledge can be transformative for complex care and contributes to Learning Health Systems.
Background: Healthcare-associated infections (HAIs) are a major global threat to patient safety. Systematic surveillance is crucial for understanding HAI rates and antimicrobial resistance trends and to guide infection prevention and control (IPC) activities based on local epidemiology. In India, no standardized national HAI surveillance system was in place before 2017. Methods: Public and private hospitals from across 21 states in India were recruited to participate in an HAI surveillance network. Baseline assessments followed by trainings ensured that basic microbiology and IPC implementation capacity existed at all sites. Standardized surveillance protocols for central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) were modified from the NHSN for the Indian context. IPC nurses were trained to implement surveillance protocols. Data were reported through a locally developed web portal. Standardized external data quality checks were performed to assure data quality. Results: Between May 2017 and April 2019, 109 ICUs from 37 hospitals (29 public and 8 private) enrolled in the network, of which 33 were teaching hospitals with >500 beds. The network recorded 679,109 patient days, 212,081 central-line days, and 387,092 urinary catheter days. Overall, 4,301 bloodstream infection (BSI) events and 1,402 urinary tract infection (UTI) events were reported. The network CLABSI rate was 9.4 per 1,000 central-line days and the CAUTI rate was 3.4 per 1,000 catheter days. The central-line utilization ratio was 0.31 and the urinary catheter utilization ratio was 0.57. Moreover, 3,542 (73%) of 4,742 pathogens reported from BSIs and 868 (53%) of 1,644 pathogens reported from UTIs were gram negative. Also, 1,680 (26.3%) of all 6,386 pathogens reported were Enterobacteriaceae. Of 1,486 Enterobacteriaceae with complete antibiotic susceptibility testing data reported, 832 (57%) were carbapenem resistant. Of 951 Enterobacteriaceae subjected to colistin broth microdilution testing, 62 (7%) were colistin resistant. The surveillance platform identified 2 separate hospital-level HAI outbreaks; one caused by colistin-resistant K. pneumoniae and another due to Burkholderia cepacia. Phased expansion of surveillance to additional hospitals continues. Conclusions: HAI surveillance was successfully implemented across a national network of diverse hospitals using modified NHSN protocols. Surveillance data are being used to understand HAI burden and trends at the facility and national levels, to inform public policy, and to direct efforts to implement effective hospital IPC activities. This network approach to HAI surveillance may provide lessons to other countries or contexts with limited surveillance capacity.
There is a paucity of scientific analysis that has examined spatial heterogeneities in the socioeconomic vulnerabilities related to coronavirus disease 2019 (COVID-19) risk and potential mitigation strategies at the sub-national level in India. The present study examined the demographic, socioeconomic, and health system-related vulnerabilities shaping COVID-19 risk across 36 states and union territories in India.
Methods:
Using secondary data from the Ministry of Health and Family Welfare (MoHFW), Government of India; Census of India, 2011; National Family Health Survey, 2015-16; and various rounds of the National Sample Survey, we examined socioeconomic vulnerabilities associated with COVID-19 risk at the sub-national level in India from March 16, 2020, to May 3, 2020. Descriptive statistics, principal component analysis, and the negative binomial regression model were used to examine the predictors of COVID-19 risk in India.
Results:
There persist substantial heterogeneities in the COVID-19 risk across states and union territories in India. The underlying demographic, socioeconomic, and health infrastructure characteristics drive the vulnerabilities related to COVID-19 in India.
Conclusions:
This study emphasizes that concerted socially inclusive policy action and sustained livelihood/economic support for the most vulnerable population groups is critical to mitigate the impact of the COVID-19 pandemic in India.
Economic progress in India over the past three decades has not been accompanied by a commensurate improvement in the nutritional status of children, and a disproportionate burden of undernutrition is still focused on socioeconomically disadvantaged populations in the poorest regions. This study examined the nutritional status of children under 3 years of age using data from the fourth round of Indian National Family Health Survey conducted in 2015–2016. Child undernutrition was assessed in a sample of 126,431 under-3 children using the anthropometric indices of stunting, underweight and wasting (‘anthropometric failure’) across 640 districts, 5489 primary sampling units and 35 states/UTs of India. Descriptive statistics were used to examine the regional pattern of childhood undernutrition. Multilevel logistic regression models were fitted to examine the adjusted effect of social group (tribal vs non-tribal) and economic, demographic and contextual factors on the risks of stunting, underweight and wasting accounting for the hierarchical nature of the data. Interaction effects were estimated to model the joint effects of socioeconomic position (household wealth, maternal education, urban/rural residence and geographical region) and social group (tribal vs non-tribal) with the likelihood of anthropometric failure among children. The burden of childhood undernutrition was found to vary starkly across social, economic, demographic and contextual factors. Interaction effects demonstrated that tribal children from economically poorer households, with less-educated mothers, residing in rural areas and living in the Central region of India had elevated odds of anthropometric deprivation than other tribal children. The one-size-fits-all approach to tackling undernutrition in tribal children may not be efficient and could be counterproductive.
In this paper, a new design configuration has been proposed in which a prototype of resonant inductive power transfer-based contactless power transfer to wound rotor has been developed which provides field power to brushless alternating current (BLAC) or brushless direct current (BLDC) motors without the use of permanent magnets in the rotor. Further, wound field in the rotor of DC motor can be powered without carbon brushes. The proposed design facilitates motor performance improvement by adding an extra dimension of field flux control, while the armature circuit is conventionally fed from position detection and commutation schemes. It contains a primary multilayer concentrated coil fed with high-frequency resonating AC supply or switched mode supply. A single layer helical secondary coil coaxially fixed on the shaft receives high frequency wireless AC power transmitted from primary coil. Fast rectifier inside the hollow shaft and DC filter provides the transferred DC power to field terminals in the rotor. It has been verified that rotor power can be varied linearly with linear variation in input DC power with the highest efficiency at the resonant frequency. Available power to the rotor remains invariable with rotational speed and angle, which is a necessary requirement for rotor field. DC voltage on the rotor terminals can be effectively controlled during standstill as well as during rotation at any speed.