We developed the Shell Game Task (SGT) as a novel Performance Validity Test (PVT). While most PVTs use a forced-choice paradigm with “memory” as the primary domain being assessed, the SGT is a face-valid measure of attention and working memory. We explored the accuracy of the SGT to detect noncredible performance using a simulatordesign study.

Ninety-four university students were randomly assigned to either best effort (CON) (n=49) or simulating traumatic brain injury (TBI) (SIM) (n=45) conditions. Participants completed a full battery of neuropsychological tests to simulate an actual evaluation, including the Test of Memory Malingering (TOMM) and the SGT. The SGT involves three cups and a red ball shown on the screen. Participants watch as the ball is placed under one of the three cups. Cups are then shuffled. Participants are asked to track the cup that contains the ball and correctly identify its location. We created two difficulty levels (easy vs hard, 20 trials each) by changing the number of times the cups were shuffled. Participants were given feedback (correct vs incorrect) after each trial. At the conclusion of the study, participants were asked about adherence to study directions they were given.

Participants with missing data (CON=1; SIM=2) or who reported non-adherence to study directions (CON=2; SIM=1) were removed from analyses. Twenty-five percent in SIM and 0% in CON failed TOMM

Trial 2 (<45) suggesting adequate manipulation of groups. Groups were not different in age, gender, ethnicity, or education (all p’s>.05). There were 9 participants in each group with concussion/TBI history. TBI history was not significantly related to performance on the SGT in either group, although participants with TBI history tended to do better. Average performances on TOMM Trial 1 (36.62 vs 47.91, p<.001) and TOMM Trial 2 (37.50 vs 49.71, p<.001) were significantly lower in the SIM group. Performance on SGT was also significantly lower in the SIM group across SGT Total Correct (20.17 vs 24.65 of 40, p=.008), SGT Easy (10.60 vs 13.52 of 20, p=.002), and SGT Hard (9.57 vs 11.13 of 20, p=.068). Mixed ANOVA showed a trend towards significant group by SGT difficulty interaction (F(1,86)=3.41, p=.052, np2=.043). There was steeper decline in performance on SGT Hard compared to SGT Easy for CON. ROC analyses suggested adequate but not ideal sensitivity/specificity: scores <8 on SGT Easy (sensitivity=26%; false positive=11%), <7 on SGT Hard (sensitivity=26%; false positive=7%), and <15 on SGT Total (sensitivity=24%; false positive=9%).

These preliminary data indicate the SGT may be able to detect malingered TBI. However, additional development of this measure is necessary. Further refinement of difficulty level may improve sensitivity/specificity (e.g., CON mean performance for SGT Easy trails was 13.52, suggesting the items may be too difficult). This study was limited to an online administration due to COVID, which could have affected results; future studies should test inperson administration of the SGT. In addition, performance in clinical control groups (larger samples of individuals with mild TBI, ADHD) should be tested to better determine specificity for these preliminary cutoffs.

One common concern amongst the aging population is that of worsening memory. Speed of processing and executive functions are also areas of age-related decline that affect daily living. Lifestyle modifications such as diet, exercise, and sleep have garnered intense interest as potential methods to prevent or delay cognitive decline. Among dietary factors, omega-3 fatty acids (FAs) have been documented as containing a myriad of health benefits, including neuroprotective effects. The aim of this study is to examine the associations between omega-3 FAs, cognitive function, and neuroanatomical regions of interest in a healthy aging population.

Adults aged 65 and older (n=40, 48.9% Female) were recruited for the Loma Linda University Adventist Health Study-2 Cognitive and Neuroimaging Substudy. Participants had a mean age of 76.25 years (SD=8.29), 16.78 years of education (SD=2.53), and were predominantly White (85.0%). Participants received a two-hour neurocognitive battery, including measures of immediate and delayed memory (Rey Auditory Verbal Learning Test, RAVLT; WMS-IV Logical Memory, LM), processing speed (Stroop), and executive functions (Stroop Color/Word). Participants underwent brain imaging on a 3T Siemens MRI, including a 3D T1-weighted MPRAGE sequence. Cortical reconstruction and volumetric segmentation were performed using FreeSurfer software. Blood samples were collected for fatty acid analysis. Individual FAs were expressed as a percent of total FAs. An omega-3 index was constructed as the sum of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) FAs. Correlational analyses, controlling for age, sex, and education, investigated relationships between omega-3 levels (individual and index) and (a) cognitive function (immediate and delayed memory, processing speed, executive functions), and (b) brain volumes in specific regions of interest (hippocampus, entorhinal cortex, frontal pole, white matter).

EPA was significantly positively correlated with Stroop Color (r=.34, p=.048). Although not statistically significant, trends were observed between the omega-3 index and Stroop Color (r=.30, p=.08), and between both DHA and the omega-3 index with RAVLT – delayed recall (r=.29, p=.095; r=.30, p=.08, respectively). With regards to regional brain volumes, EPA and the omega-3 index were both significantly positively correlated with the entorhinal cortex (r=.34, p=.041; r=.41, p=.01, respectively) and white matter volume (r=.36, p=.028; r=.34, p=.038, respectively). DHA was significantly positively correlated with white matter volume (r=.34, p=.044).

Blood levels of EPA were positively correlated with a measure of processing speed, and trends were observed between DHA, the omega-3 index and[GN1] verbal memory, and between the omega-3 index and processing speed. We also found that omega-3 FA values were associated with greater brain volume in the entorhinal cortex and white matter in our sample of healthy older adults. Atrophy of the entorhinal cortex has been associated with pathological processes. Additionally, white matter is known to effect processing speed. These findings may offer support for the idea that omega-3 FAs exert their neuroprotective effects by fortifying areas of the brain, specifically the entorhinal cortex and white matter, that promote maintenance of cognitive function in late life.

To assess the proportion of inpatients who received guideline-concordant antibiotics for community-acquired bacterial pneumonia (CABP) in special populations of the All of Us database.

CABP contributes significantly to healthcare burden worldwide. The American Thoracic Society and Infectious Disease Society of America jointly published guidelines for the treatment of CABP. Guideline-concordant antibiotics for CABP are associated with better patient and cost outcomes.

This was a retrospective cohort study of patients with pneumonia (n = 1608; SNOMED 233604007) from 10/1/2018 to 1/01/22 in the All of Us database. Cases were excluded for treatment setting other than inpatient, prior (within 90 days) pneumonia, receipt of intravenous antibiotics, respiratory isolation of methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa, and/or other non-community-acquired types of pneumonia. Patients were grouped based on patient age, sex, race, and ethnicity. The proportion of patients on guideline-concordant therapy was compared within groups using chi-square statistics. Significant associations were assessed using multivariate logistic regression models.

A total of 1608 cases were included, and 45% of these patients received guideline-concordant antibiotics. Non-Hispanic White (NHW) patients vs. Black patients were associated with a 36% higher likelihood for receiving guideline-concordant antibiotics (adjusted OR, 1.36; 95% CI 1.02–1.81), whereas NHW vs. Hispanic patients were associated with a 34% lower likelihood for receiving guideline-concordant antibiotics (aOR 0.66; 0.48–0.91).

Black patients with CABP in the All of Us database were less likely to receive guideline-concordant antibiotics, and Hispanic patients were more likely to receive guideline-concordant antibiotics, than NHW patients.

To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States.

We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017.

Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics.

Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (P < .001).

Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.

To characterize the current state of antifungal stewardship practices and perceptions of antifungal use among pediatric antimicrobial stewardship programs (ASPs).

We developed and distributed an electronic survey, which included 17 closed-ended questions about institutional antifungal stewardship practices and perceptions, among pediatric ASPs.

ASP physicians and pharmacists of 74 hospitals participating in the multicenter Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative.

We sent surveys to 74 hospitals and received 68 unique responses, for a response rate of 92%. Overall, 63 of 68 the respondent ASPs (93%) reported that they conduct 1 or more antifungal stewardship activities. Of these 68 hospital ASPs, 43 (63%) perform prospective audit and feedback (PAF) of antifungals. The most common reasons reported for not performing PAF of antifungals were not enough time or resources (19 of 25, 76%) and minimal institutional antifungal use (6 of 25, 24%). Also, 52 hospitals (76%) require preauthorization for 1 or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals, 80%) and posaconazole (39 of 52 hospitals, 75%). Furthermore, 33 ASPs (48%) agreed or strongly agreed that antifungals are inappropriately used at their institution, and only 25 of 68 (37%) of ASPs felt very confident making recommendations about antifungals.

Most pediatric ASPs steward antifungals, but the strategies employed are highly variable across surveyed institutions. Although nearly half of respondents identified inappropriate antifungal use as a problem at their institution, most ASPs do not feel confident making recommendations about antifungals. Future studies are needed to determine the rate of inappropriate antifungal use and the best antifungal stewardship strategies.

To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs).

Descriptive retrospective cohort with nested case-control study.

Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.

Children≤18 years ventilated for≥1 calendar day.

We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria.

Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20–67%; PICU, 0–70%; and NICU, 0–43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test.

Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.

In 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for hospital-acquired conditions (HACs) not present on admission (POA). We sought to understand why this policy did not impact central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) trends.

Retrospective cohort study.

Acute-care hospitals in the United States.

Fee-for-service Medicare patients discharged January 1, 2007, through December 31, 2011.

Using inpatient Medicare claims data, we analyzed billing practices before and after the HAC policy was implemented, including the use and POA designation of codes for CLABSI or CAUTI. For the 3-year period following policy implementation, we determined the impact on diagnosis-related groups (DRG) determining reimbursement as well as hospital characteristics associated with the reimbursement impact.

During the study period, 65,205,607 Medicare fee-for-service hospitalizations occurred at 3,291 acute-care, nonfederal US hospitals. Based on coding, CLABSI and CAUTI affected 0.23% and 0.06% of these hospitalizations, respectively. In addition, following the HAC policy, 82% of the CLABSI codes and 91% of the CAUTI codes were marked POA, which represented a large increase in the use of this designation. Finally, for the small numbers of CLABSI and CAUTI coded as not POA, financial impacts were detected on only 0.4% of the hospitalizations with a CLABSI code and 5.7% with a CAUTI code.

Part of the reason the HAC policy did not have its intended impact is that billing codes for CLABSI and CAUTI were rarely used, were commonly listed as POA in the postpolicy period, and infrequently impacted hospital reimbursement.

In 2012, the Centers for Medicare and Medicaid Services expanded a 2008 program that eliminated additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) to include Medicaid. We aimed to evaluate the impact of this Medicaid program on mediastinitis rates reported by the National Healthcare Safety Network (NHSN) compared with the rates of a condition not targeted by the program, deep-space surgical site infection (SSI) after knee replacement.

Interrupted time series with comparison group.

We included surveillance data from nonfederal acute-care hospitals participating in the NHSN and reporting CABG or knee replacement outcomes from January 2009 through June 2017. We examined the Medicaid program’s impact on NHSN-reported infection rates, adjusting for secular trends. The data analysis used generalized estimating equations with robust sandwich variance estimators.

During the study period, 196 study hospitals reported 273,984 CABGs to the NHSN, resulting in 970 mediastinitis cases (0.35%), and 294 hospitals reported 555,395 knee replacements, with 1,751 resultant deep-space SSIs (0.32%). There was no significant change in incidence of either condition during the study. Mediastinitis models showed no effect of the 2012 Medicaid program on either secular trend during the postprogram versus preprogram periods (P=.70) or an immediate program effect (P=.83). Results were similar in sensitivity analyses when adjusting for hospital characteristics, restricting to hospitals with consistent NHSN reporting or incorporating a program implementation roll-in period. Knee replacement models also showed no program effect.

The 2012 Medicaid program to eliminate additional payments for mediastinitis following CABG had no impact on reported mediastinitis rates.

Infect Control Hosp Epidemiol 2018;39:694–700

The objective of this study was to assess determinants of poor sleep quality which is an under-diagnosed and under-treated problem in elderly patients with diabetes mellitus, hyperlipidemia and hypertension.

Poor sleep quality is linked to decreased quality of life, increased morbidity and mortality. Poor sleep quality is common in the elderly population with associated cardiometabolic risk factors such as diabetes, hyperlipidemia and hypertension.

This is a cross-sectional study undertaken in the primary healthcare setting (Singhealth Polyclinics-Outram) in Singapore. Singaporeans aged 65 years and above who had at least one of the three cardiometabolic risk factors (diabetes, hypertension and hyperlipidemia) were identified. Responders’ sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire and were divided into those with good quality sleep and those with poor quality sleep, based on the PSQI score. Information on demographics, co-morbidities and lifestyle practices were collected. Descriptive and multivariate analyses of determinants of poor sleep were determined.

There were 199 responders (response rate 88.1%). Nocturia (adjusted prevalence rate ratio 1.54, 95% confidence interval 1.06–2.26) was found to be associated with an increased risk of poor sleep quality in elderly patients with diabetes mellitus, hypertension and hyperlipidaemia. Nocturia, a prevalent problem in the Asian elderly population, has been found to be associated with poor sleep quality in our study. Hence, it is imperative to identify and treat patients with nocturia to improve sleep quality among them.

Adult ventilator-associated event (VAE) definitions include ventilator-associated conditions (VAC) and subcategories for infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (PVAP). We explored these definitions for children.

Retrospective cohort

Pediatric, cardiac, or neonatal intensive care units (ICUs) in 6 US hospitals

Patients ≤18 years old ventilated for ≥1 day

We identified patients with pediatric VAC based on previously proposed criteria. We applied adult temperature, white blood cell count, antibiotic, and culture criteria for IVAC and PVAP to these patients. We matched pediatric VAC patients with controls and evaluated associations with adverse outcomes using Cox proportional hazards models.

In total, 233 pediatric VACs (12,167 ventilation episodes) were identified. In the cardiac ICU (CICU), 62.5% of VACs met adult IVAC criteria; in the pediatric ICU (PICU), 54.2% of VACs met adult IVAC criteria; and in the neonatal ICU (NICU), 20.2% of VACs met adult IVAC criteria. Most patients had abnormal white blood cell counts and temperatures; we therefore recommend simplifying surveillance by focusing on “pediatric VAC with antimicrobial use” (pediatric AVAC). Pediatric AVAC with a positive respiratory diagnostic test (“pediatric PVAP”) occurred in 8.9% of VACs in the CICU, 13.3% of VACs in the PICU, and 4.3% of VACs in the NICU. Hospital mortality was increased, and hospital and ICU length of stay and duration of ventilation were prolonged among all pediatric VAE subsets compared with controls.

We propose pediatric AVAC for surveillance related to antimicrobial use, with pediatric PVAP as a subset of AVAC. Studies on generalizability and responsiveness of these metrics to quality improvement initiatives are needed, as are studies to determine whether lower pediatric VAE rates are associated with improvements in other outcomes.

Infect Control Hosp Epidemiol 2017;38:327–333