bluuebunny/crossref_metadata_2025 huggingface dataset:
1083. Risk Factors Associated with Treatment of Asymptomatic Bacteriuria in the Emergency Department: A Multi-Hospital Cohort Study
Authors: Petty Lindsay A , Vaughn Valerie M , Patel Twisha S , Malani Anurag N , Pogue Jason M , Dumkow Lisa , Thyagarajan Rama , Hsaiky Lama , Osterholzer Danielle , Kaye Keith S , Ratz David , McLaughlin Elizabeth , Flanders Scott A , Gandhi Tejal N
Published: October 2019

Background

Antimicrobial stewardship interventions to decrease testing and treatment of asymptomatic bacteriuria (ASB) have primarily focused on inpatient clinicians, however emergency medicine (EM) clinicians also test and treat ASB. We identified testing attributable to EM clinicians and patient-level factors associated with EM treatment of ASB.

Methods

Between November 2017 and March 2019, data were abstracted from medical records of adult non-ICU medical patients at 43 Michigan hospitals admitted through the Emergency Department (ED) with a positive urine culture (Ucx) collected on day 1 or 2 of hospitalization. Exclusions included pregnancy, urologic surgery or abnormality, immune-compromise, severe sepsis, or concomitant infection. ASB was defined as a positive Ucx without signs or symptoms of a urinary tract infection (UTI). The treatment group included patients receiving ≥1 antibiotic dose ordered by an EM clinician. Patient factors associated with ASB treatment by EM clinicians vs. no treatment were evaluated using logistic generalized estimating equation models.

Results

Of 1,778 patients with ASB, 74.7% (N = 1328) had a Ucx ordered by an EM clinician (Figure 1), and 74.4% (N = 1323) were treated with antibiotics (Figure 2). Of those treated for ASB, 64.3% (851/1328) had the first dose ordered by an EM clinician (Figure 2). Patient variables associated with EM treatment included nonambulatory status, incontinence, presence of a urinary catheter, acutely altered mental status (AMS), leukocytosis, and positive urinalysis (Table 1). When EM initiated treatment, most patients (80%) remained on antibiotics for ≥3 days (Figure 3), with a median treatment duration of 6 days [IQR 4–9].

Conclusion

Among patients with ASB admitted through the ED with a Ucx collected on day 1 or 2 of hospitalization, most were treated with antibiotics. The majority of testing and initial treatment for ASB was by EM clinicians. The strongest predictors of EM treatment of ASB were positive urinalysis and AMS. Once started by EM, patients often received a full course for UTI. Given the burden of ASB testing and treatment, expanding stewardship into the ED is critical and should start with addressing interpretation of urinalyses in patients without specific urinary symptoms.

Disclosures

All authors: No reported disclosures.
1087. Fluoroquinolone Prophylaxis vs. No Bacterial Prophylaxis in Hospitalized Neutropenic Patients Undergoing Induction Chemotherapy for Acute Myeloid Leukemia
Authors: Buchanan Carley , Bremmer Derek N , Koget Anna , Moffa Matthew , Shively Nathan , Patel Monank , Walsh Thomas L
Published: October 2019

Background

Despite evidence to support outpatient anti-pseudomonal fluoroquinolone (FQ) prophylaxis in neutropenic patients, limited data exist to support this for inpatients undergoing induction chemotherapy for acute myeloid leukemia (AML). At our institution, we implemented an initiative to replace FQ prophylaxis with a conditional order for an anti-pseudomonal β-lactam to be given if a fever occurred.

Methods

A retrospective chart review was conducted to analyze the outcome differences between patients receiving FQ prophylaxis (pre-intervention) and those who had a conditional order for an anti-pseudomonal β-lactam in place of FQ prophylaxis (post-intervention). Patients were included if they were ≥18 years of age and were newly diagnosed with AML undergoing induction chemotherapy. The primary outcome was 90-day all-cause mortality. Secondary outcomes included the number of patients requiring ICU admission and rate of bacteremic episodes caused by any pathogen and from a Gram-negative rod (GNR). Additionally, ciprofloxacin susceptibility of these pathogens was analyzed.

Results

There were 35 and 26 patients in the pre- and post-intervention groups, respectively. Between pre- and post-intervention groups, there was no difference in 90-day mortality (20.0% vs. 15.4%; P = 0.745) or ICU admissions (25.7% vs. 23.1%, P = 1), respectively. The rate of any bacteremic episode was similar between the pre- and post-intervention groups (51.4% vs. 65.4%; P = 0.307), but more patients in the post-intervention group developed GNR bacteremia (17.1% vs. 46.2%; P = 0.023). In the patients with GNR bacteremia, the number of ciprofloxacin nonsusceptible isolates was higher in the pre-intervention group (100% vs. 30.7%; P = 0.011).

Conclusion

Replacing FQ prophylaxis with a conditional order for an anti-pseudomonal β-lactam for inpatients newly diagnosed with AML receiving induction chemotherapy is a feasible option to decrease FQ exposure. Though increased episodes of GNR bacteremia were observed, there was no difference in total bacteremic episodes or clinical outcomes, and the improved ciprofloxacin susceptibility patterns will allow for an additional treatment option in this extremely vulnerable patient population.

Disclosures

All authors: No reported disclosures.
1088. Evaluating the Timing of Antimicrobial Prophylaxis in Allogeneic and Autologous Hematopoietic Stem Cell Transplant
Authors: Gawrys Gerard , Ramirez Brittney , Horowitz Justin , Lee Grace
Published: October 2019

Background

Hematopoietic stem cell transplant (HSCT) patients develop profound neutropenia during the transplant process and often fever, which is suggestive of infection. Antimicrobial prophylaxis (AP) during anticipated neutropenia is recommended; however, data regarding when to initiate AP is limited. A local quality improvement initiative adjusted AP initiation to target the duration of severe neutropenia, defined as ANC ≤ 500 mm3 (ANC500), which is when patients are at the greatest risk of infection. This initiative aimed to reduce antimicrobial utilization and consequences of unnecessary antimicrobial exposure while not adversely affecting patient outcomes.

Methods

A retrospective study was conducted across two cohorts over a 2-year period. The pre-intervention cohort (November 2016–2017) called for the initiation of AP on Day -1 prior to transplant. The post-intervention cohort (November 2017–2018) called for initiation of AP when patients reached ANC500. The primary outcome was frequency of febrile occurrences (temperature ≥38°C). Secondary outcomes included days of antimicrobial exposure, positive blood cultures, all-cause mortality, length of stay, graft-vs.-host disease, and Clostridioides difficile rates. Patients were excluded if they received a haploidentical transplant or inappropriate AP for the specified cohort.

Results

A total of 248 patients were included in the final analysis with 130 patients in the pre-intervention cohort and 118 patients in the post-intervention cohort. The final analysis included 40 allogeneic and 208 autologous HSCT patients. There was no difference in fever occurrences between the two groups (79% pre vs. 69% post; P = 0.078). There was a significant reduction in the mean antibacterial (10.3 vs. 4.95; P < 0.001) and antifungal (13.4 vs. 7.6; P < 0.001) prophylaxis per patient-days in the pre- and post-intervention group. No significant differences in positive blood cultures (11.5% vs. 16.9%; P = 0.222), ICU admissions, length of stay or all-cause mortality were identified.

Conclusion

Delaying antimicrobial prophylaxis (AP) until severe neutropenia showed no difference in fever occurrences or other patient outcomes. This approach is associated with a drastic reduction in antimicrobial exposure.

Disclosures

All authors: No reported disclosures.
1091. An Ethnographic Approach to Interrogating Antimicrobial Stewardship at US Teaching Hospitals
Authors: Rynkiewich Katharina , Schwartz David , Won Sarah Y , Heber Mikhail , Timmireddy Kavya , Stoner Bradley
Published: October 2019

Background

Hospital antimicrobial stewardship programs (ASPs) deploy variably evidence-based interventions aimed at improving antimicrobial use and reducing antimicrobial resistance. Little is known about how ASPs are perceived by hospital clinicians or how such data might inform ASP improvement. We conducted an ethnographic study of hospital ASPs and infectious diseases (ID), surgical intensive care unit (SICU) and medical intensive care unit (MICU) practitioners to identify how ASPs are understood and integrated into everyday practice by hospital staff.

Methods

A medical anthropologist performed direct observation of patient care and semi-structured interviews with ID (N = 29), SICU (N = 10), and MICU (N = 19) practitioners at two affiliated teaching hospitals in Chicago, IL, between July 2017 and September 2018, accruing >576 hours of direct observations and 48 hours of semi-structured interview data. Data collection and analysis centered on explicating the understandings and interpretations of ASPs present in diverse practice groups. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software.

Results

Understandings and interpretations of ASPs varied greatly between the practice groups. ID practitioners commonly focused on “changing prescribing behavior” and “restricting inappropriate usage,” while MICU and SICU practitioners more often emphasized “following guidelines” and maintaining clinical “balance.” Additionally, direct observation data demonstrate that MICU and SICU practitioners are bounded by social and institutional determinants of antimicrobial prescribing (Table 1) that affect the pursuit of “appropriate antimicrobial use.”

Conclusion

Ethnographic interrogation found that practice groups understand and integrate ASPs differently according to everyday encounters with the social and institutional determinants of antimicrobial prescribing. ASP effectiveness might be enhanced by adopting a more mindful approach to accounting for and addressing the distinct understandings and interpretations of ASPs among diverse practice groups operating within the same institution.

Disclosures

All authors: No reported disclosures.
1097. An Antimicrobial Stewardship Intervention to Optimize Cefazolin Dosing for Surgical Prophylaxis
Authors: Neuner Elizabeth A , Wesolowski Jill , Rivard Kaitlyn R , Srinivas Pavithra , Pallotta Andrea , Athans Vasilios , Gordon Steven M , Fraser Thomas G
Published: October 2019

Background

Guidelines for antimicrobial prophylaxis in surgery recommend cefazolin dose be adjusted based on patient weight. Adults weighing ≥120 kg should receive a 3 g dose, all other adult patients should receive a 2 g dose pre-operatively. To promote guideline adherence, an antimicrobial stewardship pharmacist-driven dose optimization intervention was implemented.

Methods

Retrospective, pre (February 1, 2017–March 31, 2017)/post (February 1, 2018–March 31, 2018) study evaluating the impact of a pharmacist-driven cefazolin dose optimization intervention at a large health system. An alert within the electronic health record notified pharmacists during order verification when cefazolin dose from a surgical prophylaxis order set did not match weight-based recommendations. All patients with cefazolin orders for surgical prophylaxis were included; pediatric and pregnant patients were excluded.

Results

Pre-group included 9,830 patients, post-group 10,025 patients. In both groups, the mean age was 58 years, mean weight 87 kg, and 8% of patients weighed ≥120 kg. Approximately 21% of patients were seen at the academic medical center, 8% at ambulatory surgery centers, and the remainder amongst 10 community hospitals. Most common surgical procedure types were orthopedic (26%), general surgery (21%) and urologic (10%). Primary cefazolin dose was 2 g in 89.8% vs. 88.7%, followed by 3 g 6.6% vs. 6.9% and 1 g in 3.9% vs. 4.4%, pre- and post-intervention, respectively. Overall adherence to weight-based cefazolin dosing was 92.2% pre-group and 92.4% post-group. In patients weighing ≥120 kg, adherence improved from 62% (514/827) to 71% (582/817) post-intervention, P < 0.001. Adherence was better both pre- and post-intervention when an order set was used (pre: order set 95.0% vs. no order set 85.9%, P < 0.001; post: order set 96.4% vs. no order set 84.8%, P < 0.001). There were no differences between surgical services or hospital locations. Investigation of guideline nonadherent cases found order sets without updated dosing recommendations and allowed for targeted education efforts.

Conclusion

Overall adherence to cefazolin weight-based dosing recommendations for surgical prophylaxis was high, especially with the use of order sets. Pharmacist-driven dose optimization intervention improved guideline adherence in patients weighing ≥120 kg.

Disclosures

All authors: No reported disclosures.
1122. Implementation of an Outpatient Antimicrobial Stewardship Program within a Pediatric Health System
Authors: Burns Alaina , Lee Brian R , Goldman Jennifer , Myers Angela , Myers Angela , El Feghaly Rana E
Published: October 2019

Background

Over 60% of antibiotic expenditures occur in outpatient settings with at least 30% being unnecessary. In 2016, the Centers for Disease Control and Prevention (CDC) defined core elements for outpatient antimicrobial stewardship programs (ASP): commitment from all members of the healthcare team, action for policy and practice, tracking and reporting, and education and expertise. Quantifying local prescribing practices and frontline provider engagement are essential for successful outpatient ASP. We describe our outpatient ASP efforts at Children’s Mercy Kansas City (CM) emergency departments (ED) and urgent care clinics (UCC).

Methods

In March 2018, we created a report defining antibiotic prescribing patterns in 16 common pediatric infections using ICD-10 codes from ED and UCC encounters. Baseline data helped identify areas for targeted interventions and establish ED/UCC engagement, which we have maintained by ongoing review and sharing of data with leadership and frontline providers.

Results

Baseline data showed low antibiotic prescribing rates (<5%) for most viral infections, except a rate of 74% in otitis media with effusion (OME) (Figure 1). We also identified a higher rate of cefdinir use in acute otitis media (AOM), community-acquired pneumonia, and urinary tract infections (Figure 2). We developed and shared an outpatient antibiotic handbook facilitating diagnosis and treatment of common infections. Ongoing QI teams are focusing on increasing utilization of safety-net antibiotic prescriptions for eligible patients with AOM in EDs, decreasing antibiotic prescriptions of OME, and decreasing unnecessary rapid streptococcal testing in UCCs. Through these multiple interventions, in addition to email communications and newsletter articles, we observed early improvements in prescribing patterns, including OME antibiotic prescriptions and cefdinir use (Figures 1 and 2).

Conclusion

We used the CDC’s core elements for outpatient ASP to successfully develop interventions in our EDs and UCCs. We created a report defining baseline prescribing patterns and identifying opportunities for improvement. Data sharing with leadership and frontline providers facilitated widespread engagement in ASP efforts.

Disclosures

All authors: No reported disclosures
1127. Utilization of Combination Anti-fungal Therapy in Hospitalized Children and Adverse Events
Authors: Scardina Tonya , Oikonomopoulou Zacharoula , Sun Shan , Patel Sameer
Published: October 2019

Background

Combination antifungal therapy (CAF) is often prescribed to treat invasive fungal infections, despite equivocal data showing benefit. We evaluated number of CAF for treatment of proven, probable and possible invasive fungal infection (IFI) in hospitalized children, associated adverse effects (AE), and use of therapeutic drug monitoring (TDM).

Methods

Medical charts of patients ≤ 18 years old that received CAF for ≥72 hours with normal liver function test between 1/1/13 through December 31/18 were reviewed. Patients could be included for multiple episodes of CAF. Data included primary site of IFI, host risk factors, demonstration of fungal elements in tissue/sterile sites, clinical and mycological criteria for IFI (defined by European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and National Institute of Allergy and Infectious Diseases Mycoses Study Group), CAF regimen, incidence of TDM, and AE.

Results

Overall, 73 episodes of IFI were reviewed [unique patients (n) =60]. The median age was 10 years. Majority (61.6%) of patients were diagnosed with a hematological malignancy (n = 20 acute lymphoblastic leukemia, n = 12 acute myeloid leukemia, n = 5 aplastic anemia). A number of proven, possible, probable IFI were 36, 27 and 20, respectively (Table 1). Most frequent organism isolated in proven IFI was Aspergillus fumigatus (episodes=5, n = 4). Most common primary site of IFI was pulmonary (episodes=32, n = 27). Median days of CAF was 6.8 (range: 3–170). Sixty-six episodes included treatment with a triazole-containing regimen (90%). TDM was conducted in 51 (77%) episodes of triazole-containing regimens. AE were reported in 14 episodes (n = 10) (infusion-related reactions and nephrotoxicity reported in 4 episodes each, electrolyte abnormalities and skin reaction reported in 2 episodes each, and liver dysfunction and hypersensitivity reported in 1 episode each).

Conclusion

Patients diagnosed with proven or probable IFI received a longer duration of CAF in comparison to possible IFI. Voriconazole was frequently prescribed in combination with either micafungin or liposomal amphotericin B for IFI. Antifungal stewardship opportunities exist to improve TDM and reduce the incidence of AE when prescribing CAF.

Disclosures

All authors: No reported disclosures
1131. Prevalence and Characteristics of Non-β-Lactam Allergy Labeling at a Children’s Hospital
Authors: Miceli Amanda , Sun Shan , Scardina Tonya , Bhasin Ajay , Kociolek Larry , Patel Sameer
Published: October 2019

Background

Limited data are available on non-β-lactam (NBL) antibiotic allergy labeling in children. Understanding the incidence and patterns of NBL labeling is important as NBL hypersensitivity testing lacks standardization and false labeling may constrain therapeutic options and compromise antimicrobial stewardship.

Methods

We conducted a retrospective review of patients at our tertiary care pediatric facility and associated clinics who had first reported allergy to NBL antibiotics from January 1, 2015 to December 31, 2015. Demographic data, NBL subclass, severity, description of reaction, and ICD-9/10 diagnostic codes were recorded. In addition, subsequent antibiotic during the following 3 years (2016–2018) was determined. NBL allergy descriptions, when reported, were categorized based on severity and type of reaction.

Results

Of 35,796 patients with first clinical encounters in 2015, 223 patients (0.6%) had at least one NBL allergy reported, 1370 (3.8%) had a β-lactam allergy reported, and 101 (0.3%) patients had both an NBL and β-lactam allergy. There were 16 patients with two NBL allergies. The median age of patients with NBL allergy was 9.0 years. NBL classes and allergic reaction types are listed in the tables. Chronic conditions of patients with NBL allergy included gastrointestinal disease (n = 51), neurological disease (n = 37), malignancy (n = 36), bone marrow or solid-organ transplant (n = 4), and cystic fibrosis (n = 5). In the subsequent 3 years, 28 patients with NBL allergies received 129 systemic courses of antibiotics as inpatients, including 8 patients who received ≥10 courses.

Conclusion

Although not as common as β-lactam allergies, NBL allergies were noted in a substantial number of new patients. When described, the majority of patients did not have severe reactions, and were most likely nonallergic adverse reactions. As many of the patients have chronic conditions and require subsequent antibiotics, adjudication of true allergy status may be beneficial.

Disclosures

All authors: No reported disclosures.
LB15. Measles Outbreak in New York State (NYS) Outside of New York City, 2018–2019
Authors: Hoefer Dina , Ruppert Patricia S , Rausch-Phung Elizabeth , Dufort Elizabeth , Patel Manisha , Patel Manisha , Johns Dylan , Gastanaduy Paul , Gastanaduy Paul , McDonald Robert , Souto Maria , Bryant Patrick , McKay Kevin T , McNulty Lissette , McGraw Nancy , Huang Ada J , Wester Rachel E , Ahmad Nina , St. George Kirsten , Sommer Jamie N , Southwick Karen L , Carrasco Kimberly , Ostrowski Stephanie , Adams Eleanor , Adams Eleanor , Levin Toby R , Gelman Irina , Hutton Brad , Zucker Howard , Blog Debra
Published: October 2019

Background

The United States is experiencing one of the largest and longest measles outbreaks since elimination was declared in 2000 and is at risk of losing this status. Most cases occurring in NYS were reported in undervaccinated communities.

Methods

We included all confirmed NYS measles cases (excluding NYC) from outbreak counties from October 1, 2018 to July 25, 2019. We used the CSTE measles case definition requiring an acute febrile rash illness and either laboratory confirmation or direct epidemiologic linkage to a lab-confirmed case. For each case, demographic and clinical characteristics were obtained. A medical record review was completed for those reported to have an encounter at a hospital, emergency department, or urgent care center.

Results

There were 371 cases of measles reported, including 11 internationally imported cases. Most occurred in Rockland county (n = 283); followed by Orange (n = 55), Westchester (n = 18), Sullivan (n = 14) and Greene (n = 1) (Figures 1 and 2). The median age was 5.5 years; 79% of all cases occurred among children younger than 18 years of age (Figure 3). Most cases (79%) had not received any doses of measles vaccine. Of the 371 cases, 263 (71%) were children who had received 0 doses of measles, mumps, rubella vaccine (MMR), 218 (83%) of whom were over 1 year of age (Table 1). There have been no deaths or documented cases of encephalitis. Twenty-eight (8%) patients were diagnosed with pneumonia and 25 (7%) patients were hospitalized. Among 17 hospitalized children, 5 (29%) were admitted to the intensive care unit (ICU) (ages 1 day to 7 years). There were two preterm births at 34 and 25 weeks gestation to women with measles while pregnant. During October 1, 2018–July 31, 2019, providers in outbreak counties vaccinated 72,465 individuals with MMR, a 46% increase from the same period the year prior.

Conclusion

Unvaccinated children were identified as the largest group affected and experienced severe complications; nearly 30% of hospitalized children were admitted to an ICU. These data support the critical need for continued education and outreach on the risks of measles and the value of vaccination to prevent continued circulation in undervaccinated communities and potential further cases of severe disease.

Disclosures

Kirsten St. George, MAppSc, PhD, Akonni Biosystems (Other Financial or Material Support), ThermoFisher (Grant/Research Support), Zeptometrix (Other Financial or Material Support, royalty generating collaborative agreement); others, no disclosures reported..
Jasmonate Signaling during Arabidopsis Stamen Maturation
Authors: Acosta Ivan F , Przybyl Marine
Published: October 2019

The last stages of stamen development, collectively called stamen maturation, encompass pollen viability, filament elongation and anther dehiscence or opening. These processes are essential for male fertility in Arabidopsis and require the function of jasmonate signaling. There is a good understanding of jasmonate synthesis, perception and transcriptional outputs in Arabidopsis stamens. In addition, the spatiotemporal localization of jasmonate signaling components at the tissue and cellular levels has started to emerge in recent years. However, the ultimate cellular functions activated by jasmonate to promote stamen maturation remain unknown. The hormones auxin and gibberellin have been proposed to control the activation of jasmonate synthesis to promote stamen maturation, although we hypothesize that this action is rather indirect. In this review, we examine these different areas, attempt to clarify some confusing aspects found in the literature and raise testable hypothesis that may help to further understand how jasmonate controls male fertility in Arabidopsis.
Molecular Basis for Natural Vegetative Propagation via Regeneration in North American Lake Cress, Rorippa aquatica (Brassicaceae)
Authors: Amano Rumi , Nakayama Hokuto , Momoi Risa , Omata Emi , Gunji Shizuka , Takebayashi Yumiko , Kojima Mikiko , Ikematsu Shuka , Ikeuchi Momoko , Iwase Akira , Sakamoto Tomoaki , Kasahara Hiroyuki , Sakakibara Hitoshi , Ferjani Ali , Kimura Seisuke
Published: October 2019

Some plant species have a striking capacity for regeneration in nature, including regeneration of the entire individual from explants. However, due to the lack of suitable experimental models, the regulatory mechanisms of spontaneous whole plant regeneration are mostly unknown. In this study, we established a novel model system to study these mechanisms using an amphibious plant within Brassicaceae, Rorippa aquatica, which naturally undergoes vegetative propagation via regeneration from leaf fragments. Morphological and anatomical observation showed that both de novo root and shoot organogenesis occurred from the proximal side of the cut edge transversely with leaf vascular tissue. Time-series RNA-seq analysis revealed that auxin and cytokinin responses were activated after leaf amputation and that regeneration-related genes were upregulated mainly on the proximal side of the leaf explants. Accordingly, we found that both auxin and cytokinin accumulated on the proximal side. Application of a polar auxin transport inhibitor retarded root and shoot regeneration, suggesting that the enhancement of auxin responses caused by polar auxin transport enhanced de novo organogenesis at the proximal wound site. Exogenous phytohormone and inhibitor applications further demonstrated that, in R. aquatica, both auxin and gibberellin are required for root regeneration, whereas cytokinin is important for shoot regeneration. Our results provide a molecular basis for vegetative propagation via de novo organogenesis.
‘No Empty Place for Complementing Doubt’: The Spaces of Religious Toleration in Andrew Marvell’s ‘Flecknoe’
Authors: Koch Jonathan
Published: October 2019

Andrew Marvell’s ‘Flecknoe, an English Priest at Rome’ (1646) is a striking document in early modern debates over toleration and an exemplar of their rhetoric and design. Considering ‘Flecknoe’ together with Upon Appleton House (1651), I argue that Marvell uses spatial terms and satiric forms to present confessional rivalry and complementarity. Satire itself might be thought of as a practice of toleration in these poems, at once mocking the languages and gestures of opposing religious confessions and allowing the poet to draw close to—to contrive a surprising intimacy with—the convictions and practices of others. The result is a brilliant interweaving of the ideas and experiences of religious and erotic toleration: Marvell sets liberty of the spirit alongside liberty of the body in these poems’ scenes of forbearance.
Improving quality of life in vasculitis patients
Authors: Aitken M , Basu N
Published: October 2019

Systemic vasculitis are a complex cluster of diseases with high associated morbidity. As disease-related mortality diminishes, the cumulative impact of poor health-related quality of life becomes more pertinent to patients than the initial pathological insult. In this article we explore health-related quality of life in ANCA-associated vasculitis, large-vessel vasculitis and therapeutic strategies that may enhance this critical outcome.
FlgII-28 Is a Major Flagellin-Derived Defense Elicitor in Potato
Authors: Moroz Natalia , Tanaka Kiwamu
Published: October 2019

The first layer of plant immunity is deployed by recognition of pathogen-associated molecule patterns (PAMPs) and induction of early stress responses. Flagellin is the major protein component of the flagellum. Flagellin-derived peptide fragments such as Flg22, a short active peptide derived from the highly conserved part of the N-terminal region, are recognized as PAMPs by a specific perception system present in most higher plants. Some bacteria evade the plant recognition system by altering the Flg22 region in the flagellin. Instead, a small subset of plants (i.e., solanaceous plants) can sense these bacteria by recognizing a second region, termed FlgII-28. The function of FlgII-28 has been well-documented in tomato but not in potato plants. Here, we investigated the effect of FlgII-28 on several defense responses in potato. Cytosolic calcium (Ca2+) elevation is an early defense response upon pathogenic infection. We generated transgenic potato plants expressing aequorin, a nontoxic Ca2+-activated photoprotein. The results showed that FlgII-28 induced strong cytosolic Ca2+ elevation in a dose-dependent manner, whereas the response was attenuated when a Ca2+ channel blocker was added. In addition, the FlgII-28-triggered cytosolic Ca2+ elevation was shown to subsequently promote extracellular alkalinization, reactive oxygen species production, mitogen-activated protein kinase phosphorylation, and transcriptional reprogramming of defense-related genes in potato. Interestingly, all tested defense responses caused by FlgII-28 were significantly stronger than those caused by Flg22, suggesting that FlgII-28 acts as a primary flagellar PAMP to elicit multiple defense responses in potato.
Biological Characteristics and Molecular Mechanism of Fludioxonil Resistance in Botrytis cinerea From Henan Province of China
Authors: Zhou Feng , Hu Hai-Yan , Song Yu-Lu , Gao Yu-Qing , Liu Qi-Li , Song Pu-Wen , Chen Er-Yong , Yu Yong-Ang , Li Dong-Xiao , Li Cheng-Wei
Published: October 2019

The gray mold caused by Botrytis cinerea has a significant impact on tomato production throughout the world. Although the synthetic fungicide fludioxonil can effectively control B. cinerea, there have been several reports of resistance to this fungicide. This study indicated that all of the fludioxonil-resistant strains tested, including one field-resistant isolate and four laboratory strains, had reduced fitness relative to sensitive isolates. In addition to having reduced growth, sporulation, and pathogenicity, the resistant strains were more sensitive to osmotic stress and had significantly (P < 0.05) higher peroxidase activity. BOs1, a kinase in the high-osmolarity glycerol stress response signal transduction pathway, is believed to harbor mutations related to fludioxonil resistance. Sequence analysis of their BOs1 sequences indicated that the fludioxonil-resistant field isolate, XXtom1806, had four point mutations resulting in four amino acid changes (I365S, S531G, T565N, and T1267A) and three amino acids (I365S, S531G, and T565N) in the histidine kinases, adenylyl cyclases, methyl-accepting chemotaxis receptors, and phosphatases domain, which associated with fludioxonil binding. Similarly, two of the laboratory strains, XXtom-Lab1 and XXtom-Lab4, had three (Q846S, I1126S, and G415D) and two (P1051S and V1241M) point mutations, respectively. A third strain, XXtom-lab3, had a 52-bp insertion that included a stop codon at amino acid 256. Interestingly, the BOs1 sequence of the fourth laboratory strain, XXtom-lab5, was identical to those of the sensitive isolates, indicating that an alternative resistance mechanism exists. The study also found evidence of positive cross-resistance between fludioxonil and the dicarboximide fungicides procymidone and iprodione, but no cross-resistance was detected with any other fungicides tested, including boscalid, carbendazim, tebuconazole, and fluazinam.
N‐acetylaspartate availability is essential for juvenile survival on fat‐free diet and determines metabolic health
Authors: Hofer Dina C. , Zirkovits Gabriel , Pelzmann Helmut J. , Huber Katharina , Pessentheiner Ariane R. , Xia Wenmin , Uno Kyosuke , Miyazaki Toh , Kon Kanta , Tsuneki Hiroshi , Pendl Tobias , Zoughbi Wael Al , Madreiter‐Sokolowski Corina T. , Trausinger Gert , Abdellatif Mahmoud , Schoiswohl Gabriele , Schreiber Renate , Eisenberg Tobias , Magnes Christoph , Sedej Simon , Eckhardt Matthias , Sasahara Masakiyo , Sasaoka Toshiyasu , Nitta Atsumi , Hoefler Gerald , Graier Wolfgang F. , Kratky Dagmar , Auwerx Johan , Bogner‐Strauss Juliane G.
Published: October 2019

N‐acetylaspartate (NAA) is synthesized by aspartate N‐acetyltransferase (gene: Nat8l) from acetyl‐coenzyme A and aspartate. In the brain, NAA is considered an important energy metabolite for lipid synthesis. However, the role of NAA in peripheral tissues remained elusive. Therefore, we characterized the metabolic phenotype of knockout (ko) and adipose tissue‐specific (ako) Nat8l‐ko mice as well as NAA‐supplemented mice on various diets. We identified an important role of NAA availability in the brain during adolescence, as 75% of Nat8l‐ko mice died on fat‐free diet (FFD) after weaning but could be rescued by NAA supplementation. In adult life, NAA deficiency promotes a beneficial metabolic phenotype, as Nat8l‐ko and Nat8l‐ako mice showed reduced body weight, increased energy expenditure, and improved glucose tolerance on chow, high‐fat, and FFDs. Furthermore, Nat8l‐deficient adipocytes exhibited increased mitochondrial respiration, ATP synthesis, and an induction of browning. Conversely, NAA‐treated wild‐type mice showed reduced adipocyte respiration and lipolysis and increased de novo lipogenesis, culminating in reduced energy expenditure, glucose tolerance, and insulin sensitivity. Mechanistically, our data point to a possible role of NAA as modulator of pancreatic insulin secretion and suggest NAA as a critical energy metabolite for adipocyte and whole‐body energy homeostasis.—Hofer, D. C., Zirkovits, G., Pelzmann, H. J., Huber, K., Pessentheiner, A. R., Xia, W., Uno, K., Miyazaki, T., Kon, K., Tsuneki, H., Pendl, T., Al Zoughbi, W., Madreiter‐Sokolowski, C. T., Trausinger, G., Abdellatif, M., Schoiswohl, G., Schreiber, R., Eisenberg, T., Magnes, C., Sedej, S., Eckhardt, M., Sasahara, M., Sasaoka, T., Nitta, A., Hoefler, G., Graier, W. F., Kratky, D., Auwerx, J., Bogner‐Strauss, J. G. N‐acetylaspartate availability is essential for juvenile survival on fat‐free diet and determines metabolic health. FASEB J. 33, 13808‐13824 (2019). www.fasebj.org
Family Planning Training at Catholic and Other Faith-Based Obstetrics and Gynecology Programs
Authors: Guiahi Maryam , Teal Stephanie , Kenton Kimberly , DeCesare Julie , Steinauer Jody
Published: October 2019

PURPOSE:

To evaluate family planning training at obstetrics and gynecology (OB-GYN) residency programs that primarily train at restrictive religious hospitals.

BACKGROUND:

Catholic and other religious hospitals face institutional family planning care restrictions, which are in conflict with the training requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME).

METHODS:

We identified 30 ACGME accredited OB-GYN residency programs in which at least 70% of resident time is in restrictive, faith-based hospitals. We queried program representatives about training using an online survey and follow-up telephone interview.

RESULTS:

We had an 80% survey response rate. The majorities were program directors (83%), represented Catholic hospitals (75%), and completed telephone interviews (71%). Programs often relied on other sites to accomplish contraceptive (33%), sterilization (71%), and abortion (88%) training. All programs reported adequate training in reversible contraception. 58% reported inadequate sterilization training, most commonly in postpartum and hysteroscopic sterilizations. 67% reported inadequate abortion training, most commonly in D&E. Approximately half (54%) offered “routine” and 13% did not offer any abortion training. Eight programs (33%) received a total of ten Residency Review Committee citations due to insufficient family planning training, and most of these programs (71%) reported using these citations to gain institutional support for off-site training.

DISCUSSION:

While Catholic and other faith-based OB-GYN residency training programs have developed strategies in response to institutional restrictions, many report ongoing deficiencies and half remain noncompliant with abortion training requirements. Residency Review Committee citations, however, provided an opportunity for programs to leverage support for comprehensive training.
The “Clerkship Passport” Increases Student Participation in the Third-Year Medical Student Obstetrics Clerkship
Authors: Melber Dora , LaCoursiere Daphne
Published: October 2019

PURPOSE:

To develop and implement a clinical activity checklist to improve third-year medical student participation, satisfaction, and resident satisfaction on the Obstetrics Clerkship.

BACKGROUND:

The “Clerkship Passport” is a checklist of core clinical experiences that students should master. We hypothesized that its implementation would increase student participation and overall Obstetric Clerkship satisfaction.

METHODS:

The Passport was based on milestones 1 from the Ob/Gyn Milestones Project. Two student cohorts were studied before and after implementation (2/2017–3/2018). Overall participation was the primary outcome, secondary measures included task-specific participation and student and resident satisfaction. Chi-square, ANOVA, linear regression and qualitative coding were used for analysis.

RESULTS:

79 of 84 (94%) third-year medical students participated. Overall participation rates increased from 68% to 87% on nine pre-determined tasks (p < 0.001). Participation rates were higher on the Passport (96%) than on anonymous survey (p < 0.001). Academic quarter and interest were associated with participation (p=0.011 and 0.002). After controlling for both, the passport still increased participation aOR 1.7 [1.1, 2.3]. Lactation counseling, knot tying and performing sterile speculum exams increased the most. Despite increased participation, satisfaction with “amount of hands-on experience” decreased (p = 0.03). The remainder of clerkship satisfaction scores were unchanged. Residents reported the Passport defined expectations, increased teaching, encouraged feedback and was not burdensome.

DISCUSSION:

This study supports the use of a clinical activity checklist, which improves student participation. Overall clerkship satisfaction is not improved, but students report satisfaction with the Passport itself. Residents also support the use of this checklist.
Jazz up the Clinical Learning Environment in the Operating Room: The Impact of Operative Skills Checklist
Authors: Yu Pauline , Chelliah Jerome , Nelson Ashleigh
Published: October 2019

PURPOSE:

To evaluate the impact of utilizing a standardized operative skills checklist on medical student and physician-educator experience.

BACKGROUND:

As gynecological surgeries become more minimally invasive, medical students are left watching surgeries on operating room screen and may not be actively engaged in the surgery. To re-engage the medical student in the operating room, a gynecological operative skills checklist was created. The checklist outlined expectations for students on how to engage in the pre-operative, intra-operative, and post-operative setting based on our educational goals. We sought to understand the impact of utilizing the checklist on surgical engagement, clarity of expectations, and informal feedback for medical students and physician-educators.

METHODS:

Anonymous data were collected via an online survey from medical students who completed their OB/GYN clerkship in the year prior to implementation of the operative skills checklist and compared to surveys from students collected following the implementation. Similarly, physician-educators involved in surgical teaching were surveyed regarding their impression of medical student experience pre-implementation and six months post-implementation of the checklist.

RESULTS:

Ongoing data collection shows improvement of medical student rating of “above-average” and/or “excellent” in post-implementation surveys in the following categories: surgical engagement (83.3% vs 100%), clarity of expectations (62.5% vs 100%), and informal feedback (62.5% vs 80%). Physician-educator scores in these measures have shown similar improvement.

DISCUSSION:

Operative skills checklist digest educational goals into smaller action items. Implementation of such checklists in gynecology can improve medical student engagement, clarify student expectations, and improve informal feedback, thereby jazzing up the learning environment.
Bringing Basic Science to the Ob/Gyn Clerkship: Perspective from Our Learners
Authors: Liang Angela , Hammoud Maya
Published: October 2019

PURPOSE:

To evaluate medical student perceptions on whether basic science concepts were taught during patient care delivery in an Obstetrics-Gynecology clinical clerkship.

BACKGROUND:

Medical school curriculums are moving towards competency-based curricula, with an emphasis on early introduction to clinical training. These changes condense the traditional basic science curriculum, yet basic science remains critical to clinical medicine. Students who learn basic science explanations for clinical correlates have improved retention. The goal is to embed basic sciences within the clerkship.

METHODS:

At the end of each required clinical clerkship at the University of Michigan, students on their rotations were asked to evaluate their overall clerkship experiences from December 2017 to July 2018. The survey included the statement “Basic science concepts were taught during patient care delivery” with a too-little to too-much five level scale, with a score of three being “just right.” Descriptive statistics were used to analyze the results.

RESULTS:

For the OB/gyn clerkship, 102 students completed the survey. The mean score was 2.37 with a standard deviation of 0.7. Other clerkships were blinded. The same statement in other clerkships resulted in a score of 2.39 (0.69), 2.73 (0.68), 2.88 (0.56), 2.68 (0.64), 2.65 (0.63), 2.45 (0.73), and 2.66 (0.59).

DISCUSSION:

While basic science concepts are taught in the OB/gyn clerkship, there is significant room for improvement. All clerkships fell below what students considered optimal basic science teaching. Teaching scripts, basic science videos, and didactics with purposeful integration of basic science principles could be an effective, efficient method of integrating basic science content within the clerkship.
Impact of Electronic Health Records on Resident Physicians’ Off-Duty Time: A Multi-Specialty Resident Survey at a Large ACGME Accredited Institution
Authors: Grady Cynthia , Ward Sion , Lockhart Krystal , Hagan Joseph , Polite Florencia
Published: October 2019

PURPOSE:

The purpose of this study is to evaluate off-duty electronic health records (EHR) use among residents at a large multispecialty institution.

BACKGROUND:

Studies have shown that EHRs have greatly impacted the amount of time allocated to documentation of patient care. Little research has been done to investigate the extent to which residents access EHRs remotely while off-duty to complete daily clinical activities.

METHODS:

A voluntary survey was administered to LSUHSC residents to subjectively quantify EHR use in their various settings while on and off duty. Spearman’s correlation analysis was performed to assess associations between ordinal variables while the Kruskal-Wallis test was used to compare residents’ perceptions about EHR access among the top 4 largest specialties and all “other” specialties combined.

RESULTS:

A total of 200 residents (30%) completed the survey. Most residents on their inpatient rotation (60%) reported working 61-80 hours per week and nearly half of the residents accessed EHR outside of work less than 5 hours per week (49%). Among the top 4 specialties and all “other” specialties combined there were significant differences (p=0.027) in the extent of agreement regarding whether “having to access EHRs in your off-duty time negatively impacts your quality of life,” with Ob/Gyn residents having the highest agreement.

DISCUSSION:

Some residents perceive that having off-duty access to EHR negatively impacts their quality of life and this perception varies significantly across specialties. Further understanding of the impact of EHR access as a factor that affects educational and wellness implications is essential.
Improved Procedure Performance With Practice of Ultrasound Guidance Targeting Tasks
Authors: Nitsche Joshua , Conrad Sarah , Hoopes Sarah , Carrel Meredith , Bebeau Katherine , Brost Brian
Published: October 2019

PURPOSE:

To determine if repetitive practice of ultrasound guidance targeting tasks improves procedural skill in a simulated setting.

BACKGROUND:

Due to a decrease in ultrasound guided invasive procedures other training methods are required to insure all MFM fellows graduate with sufficient skill to independently perform these procedures.

METHODS:

1st year medical students either practiced the targeting tasks during 4 weekly one hour sessions (training group) or had no training (controls). Afterward all performed a simulated amniocentesis (AC) and chorionic villus sampling (CVS). Procedures were timed and the presence of the following recorded: 1) proper angle of entry, 2) excessive (>0.5 cm) needle movement during aspiration, and 3) critical errors (touching the fetus during AC, touching the opposite uterine wall or amniotic cavity during CVS).

RESULTS:

There were 22 in the training group and 15 controls. AC completion time was 140±28 seconds (sec) vs. 211±62 sec in the training and control groups, respectively (p (0.0%) vs. 1/15 (6.7%), 3/22 (13.6%) vs. 7/15 (46.7%), and 6/22 27.3%) and 8/15 (53.3%) had improper angles, excessive needle movement (p (9.1%) vs. 10/15 (66.7%), 1/22 (4.5%) vs. 8/15 (53.3%), and 3/22 (13.6%) vs. 9/15 (60.0%) had improper angles, excessive needle movement, and critical errors, respectively (all p<0.05).

DISCUSSION:

Repetitive practice of the targeting tasks improved student performance in simulated AC and CVS. There appeared to be greater benefit for CVS performance. Regular practice of the targeting tasks will likely benefit MFM fellow training.
Improved Team Climate and Increased Student Involvement With Interprofessional Learning on Labor and Delivery
Authors: Petruska Sara , Galli Angela , Burns Hadley , Jones Jeffrey
Published: October 2019

PURPOSE:

To evaluate the impact of an obstetrical interprofessional learning experience for medical students on team climate and medical student clinical involvement.

BACKGROUND:

Students often express difficulty integrating into the obstetrical team and a desire more clinical involvement on the unit. We hypothesized that an obstetrical nurse-shadowing experience for students could increase student understanding of the team’s function and that nurses who worked with students would be more willing to advocate for student involvement in deliveries. We planned to use the Team Climate Inventory to assess students’ inclusion in the team, and to use the percentage of students playing a hands-on role in a vaginal delivery to assess student clinical involvement.

METHODS:

A baseline Team Climate Inventory was administered to students in 2015. The nurse-shadowing day was introduced in 2016-2017 and these students also completed the Team Climate Inventory; student T test used for analysis. The percentages of students assisting in a vaginal delivery before and after the intervention were compared using Fisher’s Exact Test.

RESULTS:

Survey response rates were 38% for control group and 42% for intervention group. Significant improvement (p<0.05) was noted on all axes assessed by the Team Climate Inventory following the intervention with the largest change in Participative Safety. 64.25% of control group students assisted in a vaginal delivery; this increased significantly to 84.65% in the intervention group (p=0.009).

DISCUSSION:

The introduction of an interprofessional learning exercise on Labor and Delivery was associated with improvement in medical student assessment of team climate and with increased involvement of students in vaginal deliveries.