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In the era of widespread resistance, there are 2 time points at which most empiric prescription errors occur among hospitalized adults: (1) upon admission (UA) when treating patients at risk of multidrug-resistant organisms (MDROs) and (2) during hospitalization, when treating patients at risk of extensively drug-resistant organisms (XDROs). These errors adversely influence patient outcomes and the hospital’s ecology.
Design and setting:
Retrospective cohort study, Shamir Medical Center, Israel, 2016.
Adult patients (aged >18 years) hospitalized with sepsis.
Logistic regressions were used to develop predictive models for (1) MDRO UA and (2) nosocomial XDRO. Their performances on the derivation data sets, and on 7 other validation data sets, were assessed using the area under the receiver operating characteristic curve (ROC AUC).
In total, 4,114 patients were included: 2,472 patients with sepsis UA and 1,642 with nosocomial sepsis. The MDRO UA score included 10 parameters, and with a cutoff of ≥22 points, it had an ROC AUC of 0.85. The nosocomial XDRO score included 7 parameters, and with a cutoff of ≥36 points, it had an ROC AUC of 0.87. The range of ROC AUCs for the validation data sets was 0.7–0.88 for the MDRO UA score and was 0.66–0.75 for nosocomial XDRO score. We created a free web calculator (https://assafharofe.azurewebsites.net).
A simple electronic calculator could aid with empiric prescription during an encounter with a septic patient. Future implementation studies are needed to evaluate its utility in improving patient outcomes and in reducing overall resistances.
Widespread testing for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) is necessary to curb the spread of coronavirus disease 2019 (COVID-19), but testing is undermined when the only option is a nasopharyngeal swab. Self-collected swab techniques can overcome many of the disadvantages of a nasopharyngeal swab, but they require evaluation.
Three self-collected non-nasopharyngeal swab techniques (saline gargle, oral swab and combined oral-anterior nasal swab) were compared to a nasopharyngeal swab for SARS-CoV-2 detection at multiple COVID-19 assessment centers in Toronto, Canada. The performance characteristics of each test were assessed.
The adjusted sensitivity of the saline gargle was 0.90 (95% CI 0.86-0.94), the oral swab was 0.82 (95% CI, 0.72–0.89) and the combined oral–anterior nasal swab was 0.87 (95% CI, 0.77–0.93) compared to a nasopharyngeal swab, which demonstrated a sensitivity of ˜90% when all positive tests were the reference standard. The median cycle threshold values for the SARS-CoV-2 E-gene for concordant and discordant saline gargle specimens were 17 and 31 (P < .001), for the oral swabs these values were 17 and 28 (P < .001), and for oral–anterior nasal swabs these values were 18 and 31 (P = .007).
Self-collected saline gargle and an oral–anterior nasal swab have a similar sensitivity to a nasopharyngeal swab for the detection of SARS-CoV-2. These alternative collection techniques are cheap and can eliminate barriers to testing, particularly in underserved populations.
A case–case–control investigation (216 patients) examined the risk factors and outcomes of carbapenem-resistant Enterobacter (CR-En) acquisition. Recent exposure to fluoroquinolones, intensive care unit (ICU) stay, and rapidly fatal McCabe condition were independent predictors for acquisition. Acquiring CR-En was independently associated with discharge to a long-term care facility after being admitted from home.
Background: Carbapenemase-producing Enterobacterales (CPE) have rapidly become a global health concern and are associated with substantial morbidity and mortality due to limited treatment options. Travel to endemic areas, especially healthcare exposure in these areas, is an important risk factor for acquisition. We describe the evolving epidemiology, molecular features, and outcomes of CPE in Canada through surveillance by the Canadian Nosocomial Infection Surveillance Program (CNISP). Methods: CNISP has conducted surveillance for CPE among inpatients and outpatients of all ages since 2010. Participating acute-care facilities submit eligible specimens to the National Microbiology Laboratory for detection of carbapenemase production, and epidemiological data are collected. Incidence rates per 10,000 patient days are calculated based on inpatient data. Results: In total, 59 CNISP hospitals in 10 Canadian provinces representing 21,789 beds and 6,785,013 patient days participated in this surveillance. From 2010 to 2018, 118 (26%) CPE-infected and 547 (74%) CPE-colonized patients were identified. Few pediatric cases were identified (n = 18). Infection incidence rates remain low and stable (0.02 per 10,000 patient days in 2010 to 0.03 per 10,000 patient days in 2018), and colonization incidence rates have increased by 89% over the surveillance period. Overall, 92% of cases were acquired in a healthcare facility: 61% (n = 278) in a Canadian healthcare facility and 31% (n = 142) in a healthcare facility outside Canada. Of the 8% of cases not acquired in a healthcare facility, 50% (16 of 32) reported travel outside of Canada in the 12 months prior to positive culture. The distribution of carbapenemases varied by region; New Delhi metallo-B-lactamase (NDM) was dominant (59%) in western Canada and Klebsiella pneumoniae carbapenemase (KPC) (66%) in central Canada. NDM and class D carbapenemase OXA-48 were more commonly identified among those who traveled outside of Canada, whereas KPC was more commonly identified among patients without travel. In addition, 30-day all-cause mortality was 14% (25 of 181) among CPE infected patients and 32% (14 of 44) among those with bacteremia. Conclusions: CPE rates remain low in Canada; however, national surveillance data suggest that the increase in CPE in Canada is now being driven by local nosocomial transmission as well as travel and healthcare within endemic areas. Changes in screening practices may have contributed to the increase in colonizations; however, these data are currently lacking and will be collected moving forward. These data highlight the need to intensify surveillance and coordinate infection control measures to prevent further spread of CPE in Canadian acute-care hospitals.
Susy Hota reports contracted research for Finch Therapeutics. Allison McGeer reports funds to her institution for projects for which she is the principal investigator from Pfizer and Merck, as well as consulting fees from the following companies: Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.
Administration of antimicrobials to patients with asymptomatic bacteriuria (ASB) is a common error that can lead to worse outcomes. However, controlled analyses quantifying the commonality and impact of this practice are lacking. We analyzed the independent predictors for antimicrobials misuse in ASB and quantified the impact of this practice on clinical outcomes.
Retrospective case-control and cohort analyses for calendar year 2017.
Tertiary-care, university-affiliated medical center.
The study included adult (>18 years) patients with positive urine culture. Pregnant women, renal transplant recipients, and patients who underwent urologic procedures were excluded.
ASB was determined according to US Centers for Disease Control and Prevention (CDC) criteria. Multivariable logistic regression models were constructed to analyze predictors and outcomes associated with antimicrobial use for patients with ASB.
The study included 1,530 patient-unique positive urine cultures. Among these patients, 610 patients (40%) were determined to have ASB. Of the 696 isolates, 219 (36%) were multidrug-resistant organisms (MDROs). Also, 178 (29%) patients received antimicrobials specifically due to the ASB. Independent predictors for improper administration of antimicrobials were dependent functional status (adjusted odds ratio [aOR], 2.3; 95% CI, 1.4–3.6) and male sex (aOR, 2; 95% CI, 1.25–2.6). Use of antimicrobials was independently associated with re-hospitalizations (aOR, 1.7; 95% CI, 1.1–2.6) and later, acute Clostridioides difficile infections (CDI) in the following 90 days (aOR, 4.5; 95% CI, 2–10.6).
ASB is a common condition, frequently resulting from an MDRO. Male sex and poor functional status were independent predictors for mistreatment, and this practice was independently associated with rehospitalizations and CDI in the following 90 days.
A case–case-control investigation (N = 255 patients) explored the epidemiology of carbapenem-resistant Pseudomonas aeruginosa (CRPA). Recent exposure to carbapenems and a rapidly fatal condition should prompt practitioners to shorten delays in initiating appropriate therapy, which can adversely impact CRPA outcomes, as opposed to the isolated impact of the carbapenem resistance determinant.
Certain geological features have been interpreted as evidence of channelized magma flow in the mantle, which is a compacting porous medium. Aharonov et al. (J. Geophys. Res., vol. 100 (B10), 1995, pp. 20433–20450) developed a simple model of reactive porous flow and numerically analysed its instability to channels. The instability relies on magma advection against a chemical solubility gradient and the porosity-dependent permeability of the porous host rock. We extend the previous analysis by systematically mapping out the parameter space. Crucially, we augment numerical solutions with asymptotic analysis to better understand the physical controls on the instability. We derive scalings for the critical conditions of the instability and analyse the associated bifurcation structure. We also determine scalings for the wavelengths and growth rates of the channel structures that emerge. We obtain quantitative theories for and a physical understanding of, first, how advection or diffusion over the reactive time scale sets the horizontal length scale of channels and, second, the role of viscous compaction of the host rock, which also affects the vertical extent of channelized flow. These scalings allow us to derive estimates of the dimensions of emergent channels that are consistent with the geologic record.
This work is part of the interlaboratory collaboration to study the stability of organic solar cells containing PCDTBT polymer as a donor material. The varieties of the OPV devices with different device architectures, electrode materials, encapsulation, and device dimensions were prepared by seven research laboratories. Sets of identical devices were aged according to four different protocols: shelf lifetime, laboratory weathering under simulated illumination at ambient temperature, laboratory weathering under simulated illumination, and elevated temperature (65 °C) and daylight outdoor weathering under sunlight. The results generated in this study allow us to outline several general conclusions related to PCDTBT-based bulk heterojunction (BHJ) solar cells. The results herein reported can be considered as practical guidance for the realization of stabilization approaches in BHJ solar cells containing PCDTBT.
To measure transmission frequencies and risk factors for household acquisition of community-associated and healthcare-associated (HA-) methicillin-resistant Staphylococcus aureus (MRSA).
Prospective cohort study from October 4, 2008, through December 3, 2012.
Seven acute care hospitals in or near Toronto, Canada.
Total of 99 MRSA-colonized or MRSA-infected case patients and 183 household contacts.
Baseline interviews were conducted, and surveillance cultures were collected monthly for 3 months from household members, pets, and 8 prespecified high-use environmental locations. Isolates underwent pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec typing.
Overall, of 183 household contacts 89 (49%) were MRSA colonized, with 56 (31%) detected at baseline. MRSA transmission from index case to contacts negative at baseline occurred in 27 (40%) of 68 followed-up households. Strains were identical within households. The transmission risk for HA-MRSA was 39% compared with 40% (P=.95) for community-associated MRSA. HA-MRSA index cases were more likely to be older and not practice infection control measures (P=.002–.03). Household acquisition risk factors included requiring assistance and sharing bath towels (P=.001–.03). Environmental contamination was identified in 78 (79%) of 99 households and was more common in HA-MRSA households.
Household transmission of community-associated and HA-MRSA strains was common and the difference in transmission risk was not statistically significant.
The goal of the present study was to apply experimental economic methods in an online supermarket to examine the effects of nutrient profiling, and differential pricing based on the nutrient profile, on the overall diet quality, energy and macronutrients of the foods purchased, and diet cost.
Participants were provided nutrient profiling scores or price adjustments based on nutrient profile scores while completing a hypothetical grocery shopping task. Prices of foods in the top 20 % of nutrient profiling scores were reduced (subsidized) by 25 % while those in the bottom 20 % of scores were increased (taxed) by 25 %. We evaluated the independent and interactive effects of nutrient profiling or price adjustments on overall diet quality of foods purchased as assessed by the NuVal® score, energy and macronutrients purchased and diet cost in a 2×2 factorial design.
A large (>10 000 food items) online experimental supermarket in the USA.
Seven hundred and eighty-one women.
Providing nutrient profiling scores improved overall diet quality of foods purchased. Price changes were associated with an increase in protein purchased, an increase in energy cost, and reduced carbohydrate and protein costs. Price changes and nutrient profiling combined were associated with no unique benefits beyond price changes or nutrient profiling alone.
Providing nutrient profile score increased overall NuVal® score without a reduction in energy purchased. Combining nutrient profiling and price changes did not show an overall benefit to diet quality and may be less useful than nutrient profiling alone to consumers who want to increase overall diet quality of foods purchased.
THIS book is a team effort, driven by a shared desire to illuminate and celebrate the world's great classical traditions. Its ancestry as a piece of crosscultural musical analysis goes back a thousand years, to the ‘science of music’ of the medieval Arab theorists. Its European precursors include the sixteenthcentury Swiss theologian Jean de Léry, who notated antiphonal singing in Brazil, and the Moldavian polymath Prince Dimitrie Cantemir (1673–1723) who was enslaved by the Ottomans in Istanbul, became a de facto Turkish composer, and created the first notation for Turkish makam; also Captain James Cook, who made detailed descriptions of the music and dance of Pacific islanders in 1784. Meanwhile Chinese music was being admiringly analysed by French Jesuit missionaries – Chinese theorists had beaten their European counterparts in the race to solve the mathematics of equal temperament – and other Frenchmen were investigating the music of the Arab world. While serving on Napoleon Bonaparte's Egyptian campaign, Guillaume-André Villoteau made studies of Arab folk and art music, before going on to contrast those with the music of Greece and Armenia; his theories were then contested by the French composer Francesco Salvador-Daniel, who after a twelve-year musical sojourn in Algeria concluded, among other things, that Arab and Greek modes were one and the same. Long before ‘ethnomusicology’ was born in academe, the game was well established.
In recent years the ethnomusicologists’ findings have been magisterially presented in two great publications: in the ten massive volumes of the Garland Encyclopedia of World Music, and scattered through the twenty-nine volumes of the New Grove Dictionary of Music and Musicians. But our book is, we believe, the first panoptic survey of the world's classical musics (I explain in the Introduction why we have settled on that somewhat contentious adjective). Although much of its information may also be found in Grove and Garland – many of its writers were contributors to, or editors on, those projects – its tight focus permits presentation in a single volume, rather than scattered through a six-foot shelf of tomes.
As editor I am deeply indebted to my writers, who have patiently put their chapters through numerous drafts in pursuit of non-academic accessibility, while in no way traducing their (often very complicated) subject-matter. I must particularly thank Terry Miller, whose resourceful problem-solving assistance has extended far beyond his own signed contributions; also his colleague Andrew Shahriari, for additional information on Persian classical music.