Background: International Classification of Diseases, Tenth Edition (ICD-10) data help track outpatient antibiotic prescribing but lack validation in immunocompromised populations or subspecialty clinics for this purpose. Asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are important stewardship targets in renal transplant (RT) patients, but they may require alternative metrics to best monitor prescribing patterns. We describe ICD-10 utilization for RT clinic encounters in which antibiotics were prescribed. We developed a metric classifying “acute urinary antibiotics” (AUA) to track antibiotic use for ASB and UTI, and we validated systematic identification of AUA to enable practical implementation. Methods: We examined RT clinic visit and telemedicine encounters from 2018 to 2021 conducted 1 month after transplant. This project was deemed non–human-subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The analytic cohort included 420 antibacterial prescriptions from 408 encounters (Fig. 1). Of 238 patients, 136 (57%) were male and 112 (47%) were Hispanic or Latino. The most common primary ICD-10 code was Z94.0 (kidney transplant status) (N = 302 of 408 encounters, 75%); 26 encounters (6%) were coded for UTI (eg, N39.0, urinary tract infection, site not specified); and 214 encounters (53%) had multiple ICD-10 codes. The R82.71 code (bacteriuria) was never used. However, 215 prescriptions (51%) were classified as AUA (Fig. 2). The validation cohort included 130 prescriptions; 59 (45%) were classified as AUA and 51 (39%) had documented intent to treat ASB or UTI (positive percent agreement, 83%; negative percent agreement, 97%) (Table 1). For patients >1 month after transplant, the positive percent agreement was 95% and the negative percent agreement was 98%. Of 51 patients receiving AUA, 32 (63%) were asymptomatic despite frequently having a code for UTI (Fig. 3). Conclusions: ICD-10 coding may not be helpful in monitoring antibiotic prescribing in RT patients. The AUA metric offers a practical alternative to track antibiotic prescribing for urinary syndromes and reliably correlates with physician intent. Monitoring AUA prescribing rates could help identify opportunities to optimize antibiotic use in this complex outpatient setting.

Disclosures: None

Background: Using patient data from the electronic health record (EHR) and computer logic, an “electronic phenotype” can be created to identify patients with community-acquired pneumonia (CAP) in real time to assist with syndrome-specific antimicrobial stewardship efforts.1 We adapted and validated the performance of an inpatient CAP electronic phenotype for antimicrobial stewardship interventions. Methods: An automated scoring system was created within the EHR (Epic Systems) to identify hospitalized patients with CAP based on the variables and logic listed in Fig. 1B. We adapted a score used by the Michigan Hospital Medicine Safety Consortium (HMS) to identify patients with CAP, with additions made to improve sensitivity (Fig. 1).1 The score can be displayed in a column within the EHR patient list (Fig. 2). We validated the electronic phenotype via chart review of all hospitalized patients on systemic antimicrobials admitted to a medicine team consecutively between November 8 and 18, 2021. Patients who were readmitted within the validation time frame were excluded. We assessed the performance of the electronic phenotype by comparing the score to manual chart review, where “CAP diagnosis” was defined as (1) mention of “pneumonia” or “CAP” as part of the differential diagnosis in the admission documentation, (2) antimicrobials were started within 48 hours of admission, and (3) radiographic findings were suggestive of pneumonia. After initial evaluation, the scoring system was adjusted, and performance was re-evaluated during prospective audit and feedback performed on EHR CAP–positive patients over 13 days between July 2022 and December 2022. Results: We included 191 patients in our initial validation cohort. The CAP score had high sensitivity (95.83%), specificity (92.2%), and negative predictive value (99.35%), though lower positive predictive value (63.89%) was noted (Table 2). The rules were further refined to include bloodstream infection only with Haemophilus influenza or Streptococcus pneumoniae in rule 2B, and azithromycin was removed from “CAP antibiotics.” After these changes, repeated evaluation of 88 patients with positive CAP EHR score was performed, and only 20 (23%) were considered false-positive results. Conclusions: Electronic phenotypes can be used to create automated tools to identify patients with CAP with reasonable performance. Data from this tool can be used to guide more focused antimicrobial stewardship interventions and clinical decision support in the future. Reference: Vaughn VM, et al. A statewide collaborative quality initiative to improve antibiotic duration and outcomes in patients hospitalized with uncomplicated community-acquired pneumonia. Clin Infect Dis 2022;75:460–467.

Disclosures: None

Background: Billing data have been used in the outpatient setting to identify targets for antimicrobial stewardship. However, COVID-19 ICD-10 codes are new, and the validity of using COVID-19 ICD-10 codes to accurately identify COVID-19 encounters is unknown. We investigated COVID-19 ICD-10 utilization in our urgent care clinics during the pandemic and the impact of using different COVID-19 encounter definitions on antibiotic prescribing rates (APRs). Methods: We included all telemedicine and office visits at 2 academic urgent-care clinics from January 2020 to September 2021. We extracted ICD-10 encounter codes and testing data from the electronic medical record. We compared encounters for which COVID-19 ICD-10 codes were present with encounters for which SARS-CoV-2 nucleic acid amplification testing (NAAT) was performed within 5 days of and up to 2 days after the encounter (Fig. 1). We calculated the sensitivity of the use of COVID-19 ICD-10 codes against a positive NAAT. We calculated the APR as the proportion of encounters in which an antibacterial drug was prescribed. This quality improvement project was deemed non–human-subjects research by the Stanford Panel on Human Subjects in Medical Research.

Funding: None

Disclosures: None

Background: Emerging evidence supports the use of billing data to identify stewardship targets in primary care. Standardizing an approach to antibiotic prescribing rate (APR) calculations could facilitate external benchmarking. Methods: Using methodology and an ICD-10 dictionary validated in urgent care clinics,1 we created an expanded ICD-10 dictionary to incorporate additional ICD-10 codes from primary care associated with antibiotic prescriptions (Fig. 1). We then compared antibiotic prescribing rates using the urgent care and expanded dictionaries. We included all primary care visits from 2019 to 2020 and extracted ICD-10 codes and antibiotic order data. Using the urgent care and expanded ICD-10 dictionary, we classified each encounter by prescribing tier based on whether antibiotics are almost always (tier 1), sometimes (tier 2), or almost never (tier 3) indicated. For encounters with ICD-10s in multiple tiers, we chose the lowest tier. For multiple ICD-10 codes within the same tier, we chose the first extracted ICD-10 code. We calculated antibiotic prescribing rates as the proportion of encounters associated with ≥ 1 antibacterial prescription. This quality improvement project was deemed non–human subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The urgent care dictionary has 1,400 ICD-10 codes. We added 1,439 ICD-10 codes derived from primary care encounters to create the expanded ICD-10 dictionary (8.5% tier 1, 9.1% tier 2, and 82.4% tier 3) (Fig. 1). We identified 177,531 encounters; 74% had ≥ 2 associated ICD-10 codes (Fig. 2). In total, 147,085 encounters (82.9%) were classified into a tier using the urgent care dictionary. An additional 22,039 encounters were classified with the expanded dictionary (Table 1). Most added encounters were tier 3 with low 0.7% APR (Tables 1 and 3). In total, 41,473 (28.2%) encounters were classified differently depending on the ICD-10 dictionary used, most commonly changing from tier 3 to tier 2 without an increase in overall tier 2 antibiotic prescribing rate (Tables 2 and 3). Overall antibiotic prescribing rates were similar when using either the urgent care or expanded ICD-10 dictionary (Table 2). Conclusions: The expanded ICD-10 dictionary allowed for classification of more encounters in primary care; however, it did not meaningfully change antibiotic prescribing rates. Antibiotic prescribing rates were likely diluted by classifying more encounters without identifying an associated increase in antibiotic prescribing. A more sophisticated classification system may help to accommodate the diversity and volume of ICD-10 codes used in primary care.

1. Stenehjem E, et al. Clin Infect Dis 2020;70:1781–1787.

Funding: None

Disclosures: None

Band contrast (BC) is a qualitative measure of electron back-scattered diffraction (EBSD), which is derived from the intensity of the Kikuchi bands. The BC is dependent upon several factors including scanning electron microscope measurement parameters, EBSD camera setup, and the specimen itself (lattice defect and grain orientation). In this study, the effective factors for BC variations and the feasibility of using BC variations for the quantification of microstructure evolutions have been investigated. In addition, the effects of the lattice defect and the grain orientation on the BC variations are studied. Next, a shear-deformed microstructure of 316L stainless steel, which contains nanosized grains and a large portion of twin boundaries, is revealed by BC map and histogram. Recovery and recrystallization of shear-deformed 316L stainless steel are displayed by BC variations during isothermal annealing at 700 and 800°C, respectively. It is observed that the BC turns bright as the shear-deformed crystal structure is recovered or recrystallized.

Contrary to concerns that fructose may have adverse metabolic effects, there is evidence that small, ‘catalytic’ doses ( ≤ 10 g/meal) of fructose decrease the glycaemic response to high-glycaemic index meals in human subjects. To assess the longer-term effects of ‘catalytic’ doses of fructose, we undertook a meta-analysis of controlled feeding trials. We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library. Analyses included all controlled feeding trials ≥ 7 d featuring ‘catalytic’ fructose doses ( ≤ 36 g/d) in isoenergetic exchange for other carbohydrates. Data were pooled by the generic inverse variance method using random-effects models and expressed as mean differences (MD) with 95 % CI. Heterogeneity was assessed by the Q statistic and quantified by I2. The Heyland Methodological Quality Score assessed study quality. A total of six feeding trials (n 118) met the eligibility criteria. ‘Catalytic’ doses of fructose significantly reduced HbA1c (MD − 0·40, 95 % CI − 0·72, − 0·08) and fasting glucose (MD − 0·25, 95 % CI − 0·44, − 0·07). This benefit was seen in the absence of adverse effects on fasting insulin, body weight, TAG or uric acid. Subgroup and sensitivity analyses showed evidence of effect modification under certain conditions. The small number of trials and their relatively short duration limit the strength of the conclusions. In conclusion, this small meta-analysis shows that ‘catalytic’ fructose doses ( ≤ 36 g/d) may improve glycaemic control without adverse effects on body weight, TAG, insulin and uric acid. There is a need for larger, longer ( ≥ 6 months) trials using ‘catalytic’ fructose to confirm these results.

Previous research on personality traits and political attitudes has largely focused on the direct relationships between traits and ideological self-placement. There are theoretical reasons, however, to suspect that the relationships between personality traits and political attitudes (1) vary across issue domains and (2) depend on contextual factors that affect the meaning of political stimuli. In this study, we provide an explicit theoretical framework for formulating hypotheses about these differential effects. We then leverage the power of an unusually large national survey of registered voters to examine how the relationships between Big Five personality traits and political attitudes differ across issue domains and social contexts (as defined by racial groups). We confirm some important previous findings regarding personality and political ideology, find clear evidence that Big Five traits affect economic and social attitudes differently, show that the effect of Big Five traits is often as large as that of education or income in predicting ideology, and demonstrate that the relationships between Big Five traits and ideology vary substantially between white and black respondents.

We report on a direct epitaxial growth approach for the heterogeneous integration of high speed III-V devices with Si CMOS logic on a common Si substrate. InP-based heterojunction bipolar transistor (HBTs) structures were successfully grown on patterned Si-on-Lattice-Engineered-Substrate (SOLES) substrates using molecular beam epitaxy. DC and RF performance similar to those grown on lattice-matched InP were achieved in growth windows as small as 15×15μm2. This truly planar approach allows tight device placement with InP-HBTs to Si CMOS transistors separation as small as 2.5 μm, and the use of standard wafer level multilayer interconnects. A high speed, low power dissipation differential amplifier was designed and fabricated, demonstrating the feasibility of using this approach for high performance mixed signal circuits such as ADCs and DACs.

Nanoporous electrodes, such as those made from carbon or gold, can capture and release ionic analytes at concentrations near 1 mole per liter of pore volume through capacitive charging or electrochemically reversible adsorption. In vitro studies suggest that this phenomenon can be the basis for a noninvasive, precise, and programmable drug delivery method. It would eliminate the need for bulk fluid delivery to target tissue and require only a thin electrical connection, minimizing pain and tissue disruption. We have designed effective gold electrode assemblies and observed the depletion and release phenomena using electrochemical methods and charged dyes.

Our direct growth approach of integrating compound semiconductors (CS) and silicon CMOS is based on a unique silicon template wafer with an embedded CS template layer of Germanium (Ge). It enables selective placement of CS devices in arbitrary locations on a Silicon CMOS wafer for simple, high yield, monolithic integration and optimal circuit performance. HBTs demonstrate a peak current gain cutoff frequency ft of 170GHz at a nominal collector current density of 2mA/μm2. To the best of our knowledge this represents the first demonstration of an InP-based HBT fabricated on a silicon wafer.

self-injury is a defining feature of lesch–nyhan disease (lnd) but does not occur in the less severely affected lesch–nyhan variants (lnv). the aim of this study was to quantify behavioral and emotional abnormalities in lnd and lnv. thirty-nine informants rated 22 patients with lnd (21 males, 1 female), 11 males with lnv, and 11 healthy controls (hc; 10 males, 1 female) using two well-validated rating scales. the age of patients with lnd ranged from 12 years 7 months to 38 years 3 months (mean 22y 11mo; sd 7y 8mo), whereas the age range of those with lnv was 12 years 9 months to 65 years (mean 30y 7mo; sd 15y 2mo), and the healthy controls were aged 12 years 4 months to 31 years 3 months (mean 17y 10mo; sd 5y 7mo). behavioral ratings were based on the child behavior checklist and the american association on mental retardation's adaptive behavior scale – residential and community, 2nd edition. statistical analyses revealed that patients with lnd showed severe self-injury together with problematic aggression, anxious-depressed symptoms, distractibility, motor stereotypes, and disturbing interpersonal behaviors. patients with lnv were rated as being intermediate between the hc and lnd groups on all behavior scales. although the lnv group did not differ from hcs on most scales, their reported attention problems were as severe as those found in lnd. we conclude that self-injurious and aggressive behaviors are nearly universal and that other behavioral abnormalities are common in lnd. although patients with lnv typically do not self-injure or display severe aggression, attention problems are common and a few patients demonstrate other behavioral anomalies.