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We examined the impact of microbiological results from respiratory samples on choice of antibiotic therapy in patients treated for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP).
Four-year retrospective study.
Veterans’ Health Administration (VHA).
VHA patients hospitalized with HAP or VAP and with respiratory cultures between October 1, 2014, and September 30, 2018.
We compared patients with positive and negative respiratory culture results, assessing changes in antibiotic class and Antibiotic Spectrum Index (ASI) from the day of sample collection (day 0) through day 7.
Between October 1, 2014, and September 30, 2018, we identified 5,086 patients with HAP/VAP: 2,952 with positive culture results and 2,134 with negative culture results. All-cause 30-day mortality was 21% for both groups. The mean time from respiratory sample receipt in the laboratory to final respiratory culture result was longer for those with positive (2.9 ± 1.3 days) compared to negative results (2.5 ± 1.3 days; P < .001). The most common pathogens were Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin and β-lactam/β-lactamase inhibitors were the most commonly prescribed agents. The decrease in the median ASI from 13 to 8 between days 0 and 6 was similar among patients with positive and negative respiratory cultures. Patients with negative cultures were more likely to be off antibiotics from day 3 onward.
The results of respiratory cultures had only a small influence on antibiotics used during the treatment of HAP/VAP. The decrease in ASI for both groups suggests the integration of antibiotic stewardship principles, including de-escalation, into the care of patients with HAP/VAP.
Background: Transmission of carbapenemase-producing organisms (CPO) threatens patient safety in healthcare facilities. As a result of a 2011 outbreak of blaKPC+ Klebsiella pneumoniae, the NIH Clinical Center (NIHCC) has prioritized early detection and isolation of CPO carriers, using point-prevalence surveys and targeted high-risk ward surveillance since 2011 and admission surveillance since 2013. We describe our experience over 6 years of admission surveillance. Methods: The NIHCC is a 200-bed research hospital that provides care for a highly immunocompromised patient population. From September 2013 to September 2019, perirectal swabs were ordered automatically for all patients on admission to nonbehavioral health wards. Swabs were ordered twice weekly for ICU patients, weekly in other high-risk wards, and monthly for hospital-wide point prevalence (excluding behavioral health). Patients hospitalized in the United States in the previous week or abroad in the previous 6 months were considered high risk for carriage and isolated pending results from 2 swabs. Most swabs (n = 37,526) were cultured onto HardyCHROM CRE. If gram-negative bacilli (GNB) were present, a molecular screen for carbapenemases was performed on a sweep of cultured material (day 1) pending organism isolation. GNB were identified by MALDI-TOF MS. Prior to June 2019, isolates were screened by blaKPC/blaNDM PCR. Starting in June 2019, Enterobacteriaceae and Pseudomonas aeruginosa were screened using the phenotypic modified carbapenem inactivation method (mCIM), reflexing to the GeneXpert CARBA-R molecular assay if positive; other GNB were tested directly with CARBA-R. Selected GNB underwent susceptibility testing (Sensititre). Whole-genome sequencing was used to assess relatedness among CPO isolates. Swabs from high-risk patients were tested directly by blaKPC PCR (n = 699) until August 2019 (most in parallel with culture) and thereafter by CARBA-R (n = 13). Results: Among 54,188 orders for perirectal swabs, 38,238 were collected from 14,497 patients (compliance 71%). Among 33 CPO-colonized patients identified from September 2013 through September 2019, 15 were identified on admission, 6 were identified in point-prevalence surveys, 8 were identified from high-risk ward surveillance, and 4 were identified from clinical cultures. Sequencing demonstrated no relatedness among CPO isolates. Although only 1.4% of patients sampled on admission were colonized with CPO, those meeting high-risk criteria were 21 times as likely to be colonized. Conclusion: Admission surveillance for CPO identified a low rate of colonization, but it detected nearly half of known CPO-colonized NIHCC patients over the past 6 years. Modest compliance with swab collection leaves room for improvement and likely results in missed instances of colonization. Although we cannot determine its effectiveness, we view our strategy as one of several key safety measures for our highly vulnerable patient population.
Hot liquid metal drops impacting onto a cold substrate solidify during their subsequent spreading. Here we experimentally study the influence of solidification on the outcome of an impact event. Liquid tin drops are impacted onto sapphire substrates of varying temperature. The impact is visualised both from the side and from below, which provides a unique view on the solidification process. During spreading, an intriguing pattern of radial ligaments rapidly solidifies from the centre of the drop. This pattern determines the late-time morphology of the splat. A quantitative analysis of the drop spreading and ligament formation is supported by scaling arguments. Finally, a phase diagram for drop bouncing, deposition and splashing as a function of substrate temperature and impact velocity is provided.
The Hamilton Depression Rating Scale (HAMD) and the Beck Depression Inventory (BDI) are the most frequently used observer-rated and self-report scales of depression, respectively. It is important to know what a given total score or a change score from baseline on one scale means in relation to the other scale.
We obtained individual participant data from the randomised controlled trials of psychological and pharmacological treatments for major depressive disorders. We then identified corresponding scores of the HAMD and the BDI (369 patients from seven trials) or the BDI-II (683 patients from another seven trials) using the equipercentile linking method.
The HAMD total scores of 10, 20 and 30 corresponded approximately with the BDI scores of 10, 27 and 42 or with the BDI-II scores of 13, 32 and 50. The HAMD change scores of −20 and −10 with the BDI of −29 and −15 and with the BDI-II of −35 and −16.
The results can help clinicians interpret the HAMD or BDI scores of their patients in a more versatile manner and also help clinicians and researchers evaluate such scores reported in the literature or the database, when scores on only one of these scales are provided. We present a conversion table for future research.
This chapter consolidates findings on student assessment, plagiarism and academic misconduct of interest to computing researchers and instructors. This builds on the literature recommendation that savvy assessment design can reduce the opportunities for student plagiarism. Despite this recommendation, it is uncommon for assessment research and plagiarism research to be considered on an equal footing. Computing courses are unusual in that they include both technical situations, such as computer programming classes, alongside more general activity, such as writing reports. This requires instructors to use of a diverse range of assessments. Many traditional assessment practices are susceptible to plagiarism and cheating, including contract cheating, the behaviour where students engage a third party to complete their assessments for them. The chapter provides practical suggestions for designing robust assessments and promoting academic integrity. It also identifies technical solutions that can be deployed to reduce the threat of academic misconduct. The chapter concludes by exploring opportunities for future computing research in the assessment and plagiarism areas.
This chapter is an introduction to the Handbook of Computing Education Research. It argues that computing education is an important field, due to the growing impact of computing in society and the workforce, and a timely field, as computing topics make their way into school curricula around the world. It discusses the organisation of the book, introducing the sections (and the themes running through the sections). The Foundations section serves a "textbook" function, intended to set our field in context, and to be a practical guide for new researchers. The Topics section contains chapters which explore the “state of the art”, illustrating the kind of problems that researchers trying to address, and why they matter. The chapter concludes with a discussion of the open and collaborative process by which the Handbook was written. The editors hope that the Handbook will serve as a useful resource for some time to come, as instruction for the novice, a guide for the curious, and a companion for the experienced.