bluuebunny/crossref_metadata_2025 huggingface dataset:
Revision and complication rates in adult shunt surgery: a single-institution study
Authors: Mansoor Nadia , Solheim Ole , Fredriksli Oddrun A. , Gulati Sasha
Published: October 2020

Background

CSF diversion with shunt placement is frequently associated with need for later revisions as well as surgical complications. We sought to review revision and complication rates following ventriculoperitoneal, ventriculoatrial and cystoperitoneal shunt placement in adult patients, and to identify potential risk factors for revision surgery and postoperative complications.

Method

Included patients were adults (≥ 18 years) who underwent primary shunt insertion at St. Olavs Hospital in Trondheim, Norway, from 2008 through 2017. The electronic medical records and diagnostic imaging from all hospitals in our catchment area were retrospectively reviewed. Follow-up ranged from 1 to 11 years. Complications were graded according to the Landriel Ibañez classification system.

Results

Of the 227 patients included, 47 patients (20.7%) required revision surgery during the follow-up. In total, 90 revision surgeries were performed during follow-up. The most common cause for the first revision was infection (5.7%) and for all revisions proximal occlusion (30.0%). A total of 103 patients (45.4%) experienced ≥ 1 complication(s). Mild to moderate complications (grade I and II) were detected in 35.0% of all procedures. Severe or fatal complications (grade III and IV) were observed in 8.2% of all procedures. Urinary tract infections and pneumonia were common postoperatively (13.9% and 7.3%, respectively), and the most common IIb complication was shunt misplacement (proximally or distally). Two out of fourteen deaths within 30 days were directly associated with surgery. We did not find that aetiology/indication, age or gender influenced the occurrence of revision surgery or a grade III or IV complication.

Conclusions

Shunt surgery continues to be a challenge both in terms of revision rates and procedure-related complications. However, the prediction of patients at risk remains difficult. A multidimensional focus is probably needed to reduce risks.
Numerical modelling of land subsidence related to groundwater withdrawal in the Firenze-Prato-Pistoia basin (central Italy)
Authors: Ceccatelli Mattia , Del Soldato Matteo , Solari Lorenzo , Fanti Riccardo , Mannori Gaddo , Castelli Fabio
Published: October 2020

The Tuscany region of Italy is widely affected by subsidence, landslides and floods, which severely impact buildings and infrastructure. In particular, Firenze-Prato-Pistoia basin has a long experience of ground deformation related to groundwater withdrawal. European remote-sensing satellite (ERS) data collected since 1992 have revealed the presence of several subsiding areas in the basin such as the south-eastern portion of the city of Pistoia. Sentinel-1 persistent scatterer interferometry (PSI) measurements for 2015–2018 confirmed the long-term subsidence of this area, associated with intense horticulture (plant nurseries). At the same time, Sentinel-1 data revealed the unexpected movement of Pistoia historic center, which has always been considered stable in the past. To identify the complex relationship between aquifer conditions and ground displacement, a hydrogeologic model of the Pistoia aquifers was developed, applying an integrated modelling procedure. Hydrodynamic-parameter distributions, calibrated and validated by means of Sentinel-1 PSI measurements, suggest that subsidence in Pistoia area is probably related with the combined impacts of groundwater extraction and highly compressible aquitards. To evaluate the potential evolution of ground displacement, numerical simulations were extended until 2050, using regional and global climate model data, analyzing three different pumping-rate scenarios. This led to the development of several subsidence hazard maps of the city of Pistoia that display the influence of groundwater extraction in controlling land subsidence in the area. This study emphasizes the importance of developing proper groundwater management policies, especially in alluvial aquifers made of fine compressible sediments, in order to sustainably utilize underground freshwater resources and to avoid related side effects.
Mechanical Properties of Long Leaves: Experiment and Theory
Authors: Jakubska-Busse A. , Janowicz M. W. , Ochnio L. , Jackowska-Zduniak B. , Ashbourn J. M. A.
Published: October 2020

The static properties of leaves with parallel venation from terrestrial orchids of the genus Epipactis were modelled as coupled elastic rods using the geometrically exact Cosserat theory and the resulting boundary-value problem was solved numerically using a method from Shampine, Muir and Xu. The response of the leaf structure to the applied force was obtained from preliminary measurements. These measurements allowed the Young’s modulus of the Epipactis leaves to be determined. The appearance of wrinkles and undulation characteristics for some leaves has been attributed to the small torsional stiffness of the leaf edges.
Gamification of health professions education: a systematic review
Authors: van Gaalen A. E. J. , Brouwer J. , Schönrock-Adema J. , Bouwkamp-Timmer T. , Jaarsma A. D. C. , Georgiadis J. R.
Published: October 2020

Gamification refers to using game attributes in a non-gaming context. Health professions educators increasingly turn to gamification to optimize students’ learning outcomes. However, little is known about the concept of gamification and its possible working mechanisms. This review focused on empirical evidence for the effectiveness of gamification approaches and theoretical rationales for applying the chosen game attributes. We systematically searched multiple databases, and included all empirical studies evaluating the use of game attributes in health professions education. Of 5044 articles initially identified, 44 met the inclusion criteria. Negative outcomes for using gamification were not reported. Almost all studies included assessment attributes (n = 40), mostly in combination with conflict/challenge attributes (n = 27). Eight studies revealed that this specific combination had increased the use of the learning material, sometimes leading to improved learning outcomes. A relatively small number of studies was performed to explain mechanisms underlying the use of game attributes (n = 7). Our findings suggest that it is possible to improve learning outcomes in health professions education by using gamification, especially when employing game attributes that improve learning behaviours and attitudes towards learning. However, most studies lacked well-defined control groups and did not apply and/or report theory to understand underlying processes. Future research should clarify mechanisms underlying gamified educational interventions and explore theories that could explain the effects of these interventions on learning outcomes, using well-defined control groups, in a longitudinal way. In doing so, we can build on existing theories and gain a practical and comprehensive understanding of how to select the right game elements for the right educational context and the right type of student.
Strategies to Cope with Phases of Spiritual Dryness in Seventh-Day Adventists
Authors: Büssing Arndt , Starck Lorethy , van Treeck Klaus
Published: October 2020

In Adventists (n = 603) 45% were less effective and 55% more effective in coping with phases of spiritual dryness, particularly those with leading roles in the church. Strategies such as devotion/trust in God, private prayer/meditation/scripture reading, openness, talks with close others, and self-care were most often utilized. Their ability to cope was predicted best by low Acedia, Living from the Faith, low emotional exhaustion, well-being and having a duty in the church (R2 = .24). When these phases were overcome, several perceived spiritual depth and were able to help others all the more. Helpful strategies should be made available to support persons struggling with spiritual dryness.
Autonomous demand, multiple equilibria and unemployment dynamics
Authors: Ferri Piero , Tramontana Fabio
Published: October 2020

The paper presents a medium-run growth model driven by autonomous demand, where aggregate demand and supply interact and unemployment is present and plays different roles. In particular, it generates a feedback from supply to aggregate demand rooted in the presence of heterogeneous consumers and an uncertain environment. Two are the main consequences of this approach. The first is that multiple equilibria can be generated. The second is that equilibria may have different stability properties. In this perspective, growth becomes a dynamic process where initial conditions matter and history plays an important role.
Public Health Messaging and Strategies to Promote “SWIFT” Lung Cancer Detection: a Qualitative Study Among High-Risk Individuals
Authors: Saab Mohamad M. , Kilty Caroline , Noonan Brendan , FitzGerald Serena , Collins Abigail , Lyng Áine , Kennedy Una , Hegarty Josephine
Published: October 2020

Lung cancer (LC) is the most common cancer and the leading cause of cancer mortality globally. A positive association between LC incidence and socioeconomic deprivation exists. High-risk individuals are less likely to be aware of LC and to correctly appraise LC symptoms and seek medical help accordingly. This qualitative study explored strategies to promote early detection of LC among at-risk individuals living in high-incidence areas in Ireland. Five semi-structured focus groups were conducted with 46 individuals. Data were collected face-to-face in community centres and organisations in high-incidence areas in two Irish counties and analysed using inductive qualitative content analysis. Participants believed that there was insufficient information regarding LC and recommended promoting LC awareness at a young rather than old age. They favoured public health messages that are Simple, clear, and honest; Worded positively; Incorporating a shock element; Featuring a celebrity, healthcare professional, or survivor; and Targeted (SWIFT). Most participants reported becoming immune to messages on cigarette packaging and recommended using a combination of broadcast and print media within national government-run campaigns to promote LC awareness and early detection. Study findings suggest that promoting LC awareness, help-seeking, early presentation, and diagnosis can be achieved by developing and testing targeted interventions. Promoting LC awareness requires a multi-sectoral policy network, or a whole systems approach. Such approaches ought to consider the multifactorial drivers of LC risk behaviours; involve coordinated, collective actions across various stakeholders; operate across multiple agencies; and take a life course perspective.
Time-lapse electrical resistivity investigation of seawater intrusion in coastal aquifer of Ibeno, Southeastern Nigeria
Authors: Inim Iniemem J. , Udosen Ndifreke I. , Tijani Moshood N. , Affiah Uduak E. , George Nyakno J.
Published: October 2020

Saltwater intrusion, erosion, and periodic flooding during severe storms are some of the critical problems bedeviling the precarious coastal environment of Nigeria. A time-lapse study aimed at monitoring the dynamics of saltwater intrusion within the coastland surrounding Ibeno, southeastern Nigeria is presented. Three (3) vertical electrical soundings (VES) and four time-lapse electrical resistivity tomography (ERT) profiles with minimum and maximum electrode spacing of 5 m and 40 m and profile lengths of 120 m and 150 m respectively were acquired in 2016 and 2017 using the Wenner and Schlumberger arrays. Data acquired from the field surveys were modeled with WINRESIST and RES2DINV software to generate 1D and 2D resistivity images of the subsurface. The VES results with a maximum survey length of AB = 300 m revealed a four-layer KH curve. The 2D geo-electrical sections delineated contrast between the high resistivity values obtained for the saturated freshwater zones and the low resistivity values obtained for the saturated saltwater zone. Expectedly, the intrusion was dominant nearer the coastline than inland. The salinity changes are believed to have been caused by both incremental tides passing through highly porous materials in the active-salinity change area and over-pumping of groundwater. The time-lapse resistivity measurements showed significant, active lateral salinity changes rapidly intruding the freshwater aquifers. The study demonstrates the application of time-lapse 2D ERT and vertical electrical sounding in identifying the spatial and temporal changes of saltwater intrusion in the coastal aquifer.
Further phenotypic delineation of the auriculocondylar syndrome type 2 with literature review
Authors: Bukowska-Olech Ewelina , Sowińska-Seidler Anna , Łojek Filip , Popiel Delfina , Walczak-Sztulpa Joanna , Jamsheer Aleksander
Published: October 2020

Auriculocondylar syndrome (ACS) is an ultra-rare disorder that arises from developmental defects of the first and second pharyngeal arches. Three subtypes of ACS have been described so far, i.e., ACS1 (MIM: 602483), ACS2 (MIM: 600810), and ACS3 (MIM: 131240). The majority of patients, however, are affected by ACS2, which results from the mutations in the PLCB4 gene. Herein, we have described an 8-year-old male patient presenting with ACS2 and summarized the molecular and phenotypic spectrum of the syndrome. We have also compared the clinical features of our case to three other previously described cases (one sporadic and two familial) harboring the same heterozygous missense variant c.1862G>A, p.Arg621His in the PLCB4 gene. The mutation was detected using whole-exome sequencing (WES). Due to low coverage of WES and suspicion of somatic mosaicism, the variant was additionally reassessed by deep targeted next-generation sequencing panel of genes related to the craniofacial disorders, and next confirmed by Sanger sequencing. ACS2 presents high intra- and interfamilial phenotypic heterogeneity that impedes reaching an exact clinical and molecular diagnosis. Thus, describing additional cases, carrying even the known mutation, but resulting in variable phenotypes, is essential for better understanding of such orphan Mendelian diseases.
Analysis and Prioritization the Effective Factors on Increasing Farmers Resilience Under Climate Change and Drought
Authors: Javadinejad Safieh , Dara Rebwar , Jafary Forough
Published: October 2020

California is severely exposed to drought and damage due to the climate change and drought belt, which has a major impact on agriculture. So, after the drought crisis, there are various reactions from farmers. The extent of the damage caused by the socioeconomic, environment and the extent of the resistance of farmers to this crisis is manifested in a variety of ways. Recognizing the population’s resilience and the involved human groups is a tool for preventing a catastrophe-based increase in life-threatening areas in high-risk areas. Sometimes the inability to manage this phenomenon (especially under the climate change) leads to farmers’ desertification and agricultural land release, which itself indicates a low level of resilience and resilience to the crisis. The recent drought under the climate change condition in California and the severity of the damage sustained by farmers continue to be vulnerable. The present study seeks to prioritize and prioritize resilience of farmers to the crisis under the climate change. This study simulated drought condition with using PDSI value for current and future time period. In order to calculate PDSI values, the climatic parameters extracted from CMIP5 models and downscaled under the scenario of RCP 8.5. Also in order to understand the resilience of the agriculture activities under the climate change, this study was performed using statistical tests and data from the questionnaire completed in the statistical population of 320 farmers in the Tulare region in California. The findings of the research by t test showed that the average level of effective factors in increasing the resilience of farmers in the region is low. This is particularly significant in relation to the factors affecting government policies and support. So that only the mean of five variables is higher than the numerical desirability of the test and the other 15 variables do not have a suitable status for increasing the resilience of the farmers. Also, the results of the Vikor model showed that most of the impact on their resilience to drought and climate change was the development of agricultural insurance, the second important impact belongs to drought monitoring system, climate change and damage assessment, and variable of attention to knowledge is in third place of the important factor.
Wave-induced loads on a lock gate provided with an opening through the ballast tank
Authors: Cavallaro Luca , Iuppa Claudio , Scandura Pietro , Foti Enrico
Published: November 2020

The wave loads on a navigation lock gate provided with an opening in the ballast tank are analyzed using a mathematical model based on the linear wave theory. The analysis focuses on the influence of the wave number and the geometrical characteristics of the structure on the applied load. It is shown that the maximum value of the vertical force mainly depends on the height of the ballast tank and on the width of the opening. The wave number for which the maximum load occurs significantly depends on the geometric characteristics of the structure except for the water depth above the ballast tank which has a negligible effect. An increase in the height of the ballast tank causes an increase in the wave load while an increase in the width of the opening causes a decrease in the wave load. Based on the results of the mathematical model an easy to use regression model has been developed which can be employed to evaluate the wave load.
Economic fish production inventory model for perishable fish items with the detoriation rate and the added value under pentagonal fuzzy number
Authors: Kuppulakshmi V. , Sugapriya C. , Nagarajan D.
Published: October 2020

In marine fishing, a considerable planning is required for developing socio-economic value of fishermen. This research explores the discussion in optimal fish manufacturing quantity for perishable fish items in the vessel during yachting. The rate of deterioration is treated as a Pentagonal Fuzzy Number (PFN) to obtain the optimal total cost. The convexity of the model is proved by satisfying the constraint equation in a fuzzy environment. An efficient procedure is applied to find the annual fish production quantity and the production in a single period to avoid the faulty measurement in the demand for fish items and the supply to the retailers. In addition, a few sensitivity analyses are carried out for the repair cost and the added value cost to indicate the existence of the total cost in the least possible range. Some managerial discrimination is also included.
Correction to: High-Index-Faceted Ni3S2 Branch Arrays as Bifunctional Electrocatalysts for Efficient Water Splitting
Authors: Deng Shengjue , Zhang Kaili , Xie Dong , Zhang Yan , Zhang Yongqi , Wang Yadong , Wu Jianbo , Wang Xiuli , Fan Hong Jin , Xia Xinhui , Tu Jiangping
Published: October 2020

In the original publication Figure S4 is an ancillary image to compare the specific surface areas of TiO2/Ni3S2 and Ni3S2 samples was incorrectly published.
Characterization of Lysine Monomethylome and Methyltransferase in Model Cyanobacterium Synechocystis sp. PCC 6803
Authors: Lin Xiaohuang , Yang Mingkun , Liu Xin , Cheng Zhongyi , Ge Feng
Published: October 2020

Protein lysine methylation is a prevalent post-translational modification (PTM) and plays critical roles in all domains of life. However, its extent and function in photosynthetic organisms are still largely unknown. Cyanobacteria are a large group of prokaryotes that carry out oxygenic photosynthesis and are applied extensively in studies of photosynthetic mechanisms and environmental adaptation. Here we integrated propionylation of monomethylated proteins, enrichment of the modified peptides, and mass spectrometry (MS) analysis to identify monomethylated proteins in Synechocystis sp. PCC 6803 (Synechocystis). Overall, we identified 376 monomethylation sites in 270 proteins, with numerous monomethylated proteins participating in photosynthesis and carbon metabolism. We subsequently demonstrated that CpcM, a previously identified asparagine methyltransferase in Synechocystis, could catalyze lysine monomethylation of the potential aspartate aminotransferase Sll0480 both in vivo and in vitro and regulate the enzyme activity of Sll0480. The loss of CpcM led to decreases in the maximum quantum yield in primary photosystem II (PSII) and the efficiency of energy transfer during the photosynthetic reaction in Synechocystis. We report the first lysine monomethylome in a photosynthetic organism and present a critical database for functional analyses of monomethylation in cyanobacteria. The large number of monomethylated proteins and the identification of CpcM as the lysine methyltransferase in cyanobacteria suggest that reversible methylation may influence the metabolic process and photosynthesis in both cyanobacteria and plants.
MPR rewind
Authors: Nickels Liz
Published: October 2020

Liz Nickels leafs through past issues of Metal Powder Report to find out what was happening in the PM industry of the past.
Crime, Deviance and Society
Authors: Rodas Ana , Simpson Melanie , Rawlinson Paddy , Kramer Ronald , Ryan Emma , Taylor Emmeline , Walters Reece , Beckley Alan , Cunneen Chris , Gore Ashlee , Porter Amanda , Poynting Scott , Russell Emma
Published: October 2020

Crime, Deviance and Society: An Introduction to Sociological Criminology offers a comprehensive introduction to criminological theory. The book introduces readers to key sociological theories, such as anomie and strain, and examines how traditional approaches have influenced the ways in which crime and deviance are constructed. It provides a nuanced account of contemporary theories and debates, and includes chapters covering feminist criminology, critical masculinities, cultural criminology, green criminology, and postcolonial theory, among others. Case studies in each chapter demonstrate how sociological theories can manifest within and influence the criminal justice system and social policy. Each chapter also features margin definitions and timelines of contributions to key theories, reflection questions and end-of-chapter questions that prompt students reflection. Written by an expert team of academics from Australia, New Zealand and the United Kingdom, Crime, Deviance and Society is a highly engaging and accessible introduction to the field for students of criminology and criminal justice.
Creative Research as Story-Telling: An Indigenous visual culture course from the perspectives of a librarian, a professor and students
Authors: Munroe Howard , Payne Daniel
Published: November 2020

Located on Treaty #13 (Toronto Purchase) territory, OCAD University offers an Indigenous Visual Culture (INVC) program that leads to a Bachelor of Fine Arts degree or an interdisciplinary minor. The curriculum combines courses in the cultural, social and political history of Indigenous peoples, preparing students to engage in global discourses in contemporary art practice through a profound understanding of story-telling as the foundation of visual culture.

A narrative framework is used to present an information literacy interaction with an INVC course from the perspectives of a librarian from the Canadian settler population and an assistant professor, who is a member of the Métis Indigenous nation. Research and evaluation models are presented; ones that emerged from traditional information literacy concepts informed and transformed by Indigenous knowledge systems. Finally, student learning outcomes from the course are presented through an exhibition of artworks and artist statements that display their visual story-telling skills.
Surgical Site Infection Trend Analysis Following Abdominal Hysterectomy, National Healthcare Safety Network, 2009–2018
Authors: Li Qunna , Soe Minn , Nkwata Allan , Russo Victoria , Dudeck Margaret , Edwards Jonathan
Published: November 2020

Background: Surveillance data for surgical site infections (SSIs) following abdominal hysterectomy (HYST) have been reported to the CDC NHSN since 2005. Beginning in 2012, HYST SSI surveillance coverage expanded substantially as a result of a CMS mandatory reporting requirement as part of the Hospital Inpatient Quality Reporting Program. A trend analysis of HYST SSI using data submitted to the NHSN has not been previously reported. To estimate the overall trend of HYST SSI incidence rates, we analyzed data reported from acute-care hospitals with surgery performed between January 1, 2009, and December 31, 2018. Methods: We analyzed inpatient adult HYST procedures with primary closure resulting deep incisional primary and organ-space SSIs detected during the same hospitalization or rehospitalization to the same hospital. SSIs reported as infection present at time of surgery (PATOS) were included in the analysis. Due to the surveillance definition changes for primary closure in 2013 and 2015, these were tested separately as interruptions to HYST SSI outcome using an interrupted time-series model with a mixed-effects logistic regression. Because the previously described changes were not significantly associated with changes in HYST SSI risk, mixed-effects logistic regression was used to estimate the annual change in the log odds of HYST SSI. The estimates were adjusted for the following covariates: hospital bed size, general anesthesia, scope, ASA score, wound classification, medical school affiliation type, procedure duration and age. Results: The number of hospitals and procedures reported to NHSN for HYST increased and then stabilized after 2012 (Table 1). The unadjusted annual SSI incidence rates ranged from 0.60% to 0.81%. Based on the model, we estimate a 2.58% decrease in the odds of having a HYST SSI annually after controlling for variables mentioned above (Table 2). Conclusions: The volume of hospitals and procedures for HYST reported to NHSN increased substantially because of the CMS reporting requirement implemented in 2012. The overall adjusted HYST SSI odds ratio decreased annually over 2009–2018, which indicates progress in preventing HYST SSIs.

Funding: None

Disclosures: None
Toward a Change Among the Epidemiology of Catheter-Related Bloodstream Infections in Catalonia
Authors: Gasch Oriol , Andrés Marta , Camara Jordi , Llobregat L’Hospitalet de , Domenech Dolors , Jimenez Emili , Llobregat L'Hospitalet de , Marrón Anna , Meije Yolanda , Pomar Virginia , Saliba Patrick , Calbo Esther
Published: November 2020

Background: Catheter-related bloodstream infections (CRBSIs) are one of the most frequent causes of heathcare-associated infections and an important cause of preventable death. Central venous catheters (CVC) have been considered the most worrisome origin of CRBSI. Implemented preventive measures at most hospitals and published guidelines for the prevention of vascular catheter infections have focused mostly on CVCs. However, peripherally inserted venous catheters (PIVC)–related bloodstream infections have increased in recent years and are currently among the top 10 patient safety concerns for 2019. Objective: We describe the changes in the epidemiology of catheter-related bloodstream infections among acute-care hospitals reporting at the VINCat program (Infection Control and Antimicrobial Stewardship Catalan Program) from 2008 to 2018. Methods: Data on 55 hospitals in Catalonia reporting all the episodes of CRBSI diagnosed according to standardized definitions during 2008–2018 were used for the analysis. Participating hospitals were classified into 3 groups according to size: group 1 (>500 beds), 9 hospitals; group 2 (500–200 beds), 17 hospitals; and group 3 (<200 beds), 29 hospitals. Catheters were classified in 3 categories: CVCs, PICVCs, and short peripheral venous catheters (PVCs). Rates of catheter-related bloodstream infection (CR-BSI) were obtained by adjusting the total number of episodes by 1,000 hospital stays. Simple linear regressions were performed. Values of P ≤ .05 were considered statistically significant. Results: During the study period, 8,221 nosocomial episodes of CRBSI were diagnosed among the 55 participating hospitals. In total, 37,587,967 hospital stays were counted. The CRBSI rate was 0.22 episodes per 1,000 hospital stays (group 1, 0.28; group 2, 0.15; and group 3, 0.16), following a downward trend from 2008 to 2018 from 0.28 to 0.21 per 1,000 hospital stays (P < .005). Among them, CVC-BSI showed a downward trend (from 610 annual episodes in 2008 to 312 in 2018), and PICVC and PVC showed an upward trend (from 51 and 120 annual episodes in 2008 to 130 and 312 in 2018, respectively). Annual rates of PICVCs and PVCs showed an upward trend, but CVCs showed a downward trend in 2018 (P < .05): 0.09 per 1,000 hospital stays for PICVCs; 0.07 per 1,000 hospital stays for PVCs, and 0.04 episodes per 1,000 hospital stays for CVCs (Fig. 1). Conclusions: PIVC-related bloodstream infections have increased in recent years, whereas bloodstream infections related to CVC have followed a downward trend. Our hospitals should implement preventive measures to specially address the prevention of PICVC infections.

Funding: None

Disclosures: None
Decreasing Blood Culture Contamination Rates Using A Specimen Diversion Device: A Quasi-Experimental Study
Authors: Babiker Ahmed , Ramakrishnan Aditi , Howard-Anderson Jessica , Holdsworh Jill , Jacob Mini , Jacob Jesse
Published: November 2020

Background: Blood culture contamination rates are frequently higher than the ≤3% standard in the emergency department (ED). Objective: We sought to determine whether the implementation of a blood diversion device that mechanically sequesters the initial aliquot of the blood culture sample decreased blood culture contamination rates. Methods: We performed a quasi-experimental study in two 500-bed hospitals. The blood-diversion device was implemented in the ED in hospital A, but not in hospital B, starting in January 2018. Preintervention data were collected over a 29-month baseline period, and postintervention data were collected for 20 months. Both hospitals provided ongoing feedback on contamination rates. Blood culture contamination was defined as presence of common skin microbiota (eg, coagulase-negative staphylococci) in only 1 of ≥2 blood culture sets collected within 24 hours. Preintervention and postintervention blood culture contamination rates were calculated based on total blood cultures collected and were compared within and between hospitals using the Wilcoxon rank-sum test. Changes in preintervention and postintervention total and ED contamination rates within hospitals were calculated as rate ratios (RRs) using interrupted time series (ITS) analysis with segmented Poisson regression. Results: Among 212,789 total blood cultures (hospital A, 70,005; hospital B, 142,784), 4,025 (1.8%) were contaminated. In hospital A, the intervention resulted in a decrease in overall median blood culture contamination rates (2.4% vs 1.4%; P < .001) and ED median blood culture contamination rates (4.7% vs 2.6%; P < .001), whereas in hospital B there was no significant change during the same period in overall (2.3% vs 2.0%) or ED (5.0% vs 5.0%) median blood culture contamination rates. In the ITS analysis, the intervention was associated with an immediate decrease in hospital A’s contamination rate by 21.3% (level change RR, 0.79; 95% CI, 0.63–0.98; P = .04) overall and 21.0% (level change RR, 0.79; 95% CI, 0.62–1.0; P =.06) in the ED. After the intervention, there was a continued decrease in hospital A’s overall (trend change RR, 0.95; 95% CI, 0.93–0.97; P < .001) and ED (trend RR, 0.94; 95% CI, 0.92–0.96; P < .001) blood culture contamination rates, but not in hospital B’s overall (trend change RR, 1.02; 95% CI, 1.00–1.02; P = .01) or ED (RR, 1.00; 95% CI, 0.99–1.02; P = .30) blood culture contamination rates during the same period. Conclusions: Implementation of the blood diversion device in the ED resulted in a >20% relative reduction from a baseline of 5% of ED blood culture contamination rates. Continued improvement after implementation suggests ongoing efforts to address the workflow and the culture of safety are needed to optimize the use of this device.

Funding: None

Disclosures: None
Epidemiology of Positive Blood Cultures due to Multidrug-Resistant Organisms From an Academic Center and Community Hospitals
Authors: Boly Frances , Olsen Margaret , Stwalley Dustin , Burnham Jason , Kwon Jennie
Published: November 2020

Background: Multidrug-resistant organisms (MDROs) are a threat to public health. The objective of this study was to define risk factors and outcomes of patients with positive blood cultures due to MDROs in 2 rural community hospitals as compared to a tertiary-care academic center. Methods: Retrospective cohort study with IRB approval from 1 tertiary-care academic center and 2 rural community hospitals (Barnes-Jewish [BJH], Parkland Health Center, and Missouri Baptist Sullivan Hospital) from July 1, 2013, to August 1, 2018. Demographics, comorbidities, procedures, outcomes, and blood and urine culture data were collected from the BJH informatics database for hospitalized patients with positive blood cultures due to MDROs. MDROs were defined according to European and US CDC standards. Results: Of the patients with positive blood cultures growing organisms with the potential to be MDR, 1,065 (55%) blood cultures grew MDROs from the academic center and 157 (33%) grew MDROs from the 2 community hospitals (P < .0001). Among these, methicillin-resistant Staphylococcus aureus (35% at BJH and 37% at community hospitals) and MDR Enterobacteriaceae (29% at BJH and 36% at community hospitals) were the most common organisms grown from blood cultures at all hospitals. Among patients with positive MDRO blood cultures, 60% were males and 69% were white, with a mean age of 58 years at BJH. At the community hospitals, 47% were male and 99% were white, with a mean age of 66 years. The most common comorbidity in patients with MDRO bacteremia at BJH was cancer, compared to diabetes at the community hospitals. At all hospitals, >33% of patients with MDRO bacteremia required an ICU stay. Also, 17% of patients with MDRO bacteremia at BJH died during hospitalization compared to 4% at the community hospitals. Among individuals with positive MDRO blood cultures, 9% had a matching isolate from a urine culture at BJH and 46% had a matching urine isolate at the community hospitals. Conclusions: At an academic medical center, the most common organisms identified in MRDO-positive blood cultures included MRSA, MDR Enterobacteriaceae, and VRE. However, at the community hospitals, MRSA, MDR Enterobacteriaceae, and ESBL Enterobacteriaceae were most common. Patients with a positive MDRO blood culture were more likely to have a matching isolate from urine culture at a community hospital compared to the academic center. Further research is needed regarding risk factors and interventions to prevent, detect, and treat MDRO infections.

Funding: None

Disclosures: Margaret A. Olsen reports consulting fees for contract research from Pfizer, Merck, and Sanofi Pasteur.
Inpatient and Discharge Fluoroquinolone Prescribing in Veterans’ Affairs Hospitals Between 2014 and 2017
Authors: Vaughn Valerie M. , Prescott Hallie C. , Seelye Sarah M. , Rubin Michael A. , Wang Xiao Q. , Wiitala Wyndy
Published: November 2020

Background: Between 2007 and 2015, inpatient fluoroquinolone use declined in US Veterans’ Affairs (VA) hospitals. Whether fluoroquinolone use at discharge has also declined, in particular since antibiotic stewardship programs became mandated at VA hospitals in 2014, is unknown. Methods: In this retrospective cohort study of hospitalizations with infection between January 1, 2014, and December 31, 2017, at 125 VA hospitals, we assessed inpatient and discharge fluoroquinolone (ciprofloxacin, levofloxacin, and moxifloxacin) use as (1) proportion of hospitalizations with a fluoroquinolone prescribed and (2) fluoroquinolone days per 1,000 hospitalizations. After adjusting for illness severity, comorbidities, and age, we used multilevel logit and negative binomial models to assess for hospital-level variation and longitudinal prescribing trends. Results: Of 560,219 hospitalizations meeting inclusion criteria as hospitalizations with infection (Fig. 1), 209,602 of 560,219 (37.4%) had a fluoroquinolone prescribed either during hospitalization (182,337 of 560,219, 32.5%) or at discharge (110,003 of 560,219, 19.6%) (Fig. 1). Hospitals varied appreciably in inpatient, discharge, and total fluoroquinolone use, with 71% of hospitals in the highest prescribing quartile located in the southern United States. Nearly all measures of fluoroquinolone use decreased between 2014 and 2017, with the largest decreases found in inpatient fluoroquinolone and ciprofloxacin use (Fig. 2). In contrast, there was minimal decline in fluoroquinolone use at discharge (Fig. 2), which accounted for 1,433 of 2,339 (61.3%) of hospitalization-related fluoroquinolone days by 2017. Between 2014 and 2017, fluoroquinolone use decreased in VA hospitals, largely driven by a decrease in inpatient fluoroquinolone (especially ciprofloxacin) use. Fluoroquinolone prescribing at discharge, and levofloxacin prescribing overall, remain prime targets for stewardship.

Funding: This work was funded by a locally initiated project grant from the Center for Clinical Management Research at the VA Ann Arbor Healthcare System.

Disclosures:Valerie M. Vaughn reports contract research for Blue Cross and Blue Shield of Michigan, the Department of Veterans’ Affairs, the NIH, the SHEA, and the APIC. She also reports fees from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and The Hospital and Health System Association of Pennsylvania.

Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
Staphylococcal Decolonization to Prevent Surgical Site Infection: Is There a Role in colorectal surgery?
Authors: Raslan Rasha , Doll Michelle Elizabeth , Albert Heather , Shah Hirsh , Cooper Kaila , Godbout Emily , Stevens Michael , Bearman Gonzalo
Published: November 2020

Background: Colorectal surgery is associated with a high risk of surgical site infections (SSIs), with an incidence ranging from 16.9% to 20%, and SSIs are associated with significant morbidity and mortality, prolonged length of hospitalization, and increased health care costs. Staphylococcal decolonization is an attempt to alter the microbiome to prevent staphylococcal and other skin flora from accessing the surgical site, and This practice effectively reduces SSIs in orthopedic, neurologic, and cardiac surgeries. A staphylococcal decolonization protocol was enacted in colorectal surgeries at our institution beginning in October 2016. We compared patient outcomes between patients who did and did not undergo preoperative staphylococcal decolonization. Methods: All patients undergoing nonemergent NHSN-defined colorectal procedures from July 2015 until June 2019 at a tertiary-care medical center were included in this retrospective study. Staphylococcal decolonization was performed using chlorhexidine 2% body wash solution, mupirocin nasal ointment, and chlorhexidine 0.12% oral rinse all twice daily for 5 days prior to surgery. All SSIs were defined by NSHN criteria. The primary outcome was SSI, and secondary outcomes were superficial wound infection (SIP) and organ-space infection (IAB). Predictive variables included decolonization status (yes or no), age, gender, body mass index, procedure duration, American Society of Anesthesiologists (ASA) score, diabetes, smoking, and surgical oncology service. Surgical antimicrobial prophylaxis with cefazolin and metronidazole OR cefoxitin, and chlorhexidine skin preparation were standard throughout the study period. Univariate analysis was performed using a χ2 or t test. Multivariable logistic regression was performed to control for all clinically important variables above. All statistical analyses were done using SAS version 9.4 software (Cary, NC). Results: In total, 1,139 patients underwent nonemergent colorectal surgery from July 2015 to June 2019. There were 74 SSIs: 42 IABs and 32 SIPs. Decolonization was performed in 332 of 1,139 cases (29%). There was no difference in overall SSIs between those decolonized and not decolonized (P = .50). However, SIPs were reduced in the group receiving decolonization: 1.2% (4 of 332) versus 3.5% (28 of 807) (P = .04. When controlling for known SSI risk factors, those not receiving decolonization remained at increased risk of SIPs (OR, 3.79; 95% CI, 1.14–12.61; P = .03. Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.

Funding: None

Disclosures: Michelle Doll reports a research Grant from Molnlycke Healthcare.
The Importance of Environmental Screening in a Methicillin-Resistant Staphylococcus aureus (MRSA) Outbreak Investigation in a Transplant Unit
Authors: Sim Xiang Ying Jean , Ling Moi Lin , Venkatachalam Indumathi
Published: November 2020

Background: Methicillin-resistant Staphylococcus aureus (MRSA) colonization conveys a higher risk of invasive infection. The transplant cohort is a group of immunocompromised patients who are at higher risk of infection. We conducted an outbreak investigation of hospital-acquired MRSA colonization within the transplant unit, which led to the discovery of positive isolates within our environment and to changes in our hospital disinfection policies. Methods: Our transplant unit consists of 8 single, positive-pressure rooms housed separately at the side of a larger ward. Staffing from this unit differs from the rest of the shared ward that houses up to 60 patients. As part of hospital screening, we found that a patient admitted for a stem-cell transplant had acquired nosocomial MRSA colonization. Given the unusual occurrence of such an event, a root-cause analysis was conducted. Results: A meeting was convened together with nursing, medical staff, and ancillary staff. Identified areas of potential transmission were deemed equipment, staff, and patients, and screening was performed. Shared equipment included the portable electrocardiogram (ECG) machines and portable x-ray machines and boards. In particular, ECG machines were shared with the adjoining nontransplant oncology ward. The usual practice was to clean the machine after use but not prior to the next use. This was deemed a possible exposure risk in view of a recent MRSA outbreak in a separate section of the ward. Positive isolates were found on both the x-ray and ECG machines. All healthcare workers were screened and were negative for MRSA. Furthermore, 7 patients admitted during the same time period were also screened for MRSA and were negative. Given the concurrent outbreak within the ward, pulsed-field gel electrophoresis was performed for all MRSA isolates obtained and the outbreak strain. These were found to be nonclonal (Table 1). Work processes for both the cleaning of ECG and x-ray machines were enhanced and modified. Hand hygiene measures to ward and radiology staff were reinforced. Thus far, no further cases have been detected. Conclusions: The environment is an important part of outbreak investigation. Shared equipment is often overlooked during day to day processes but should not be neglected. This can result in changes to hospital disinfection policy.

Funding: None

Disclosures: Indumathi Venkatachalam reports receiving honoraria for speaking engagements for bioMérieux and Pfizer and serving on an expert panel for MSD Pharma.
Large Multisite Clinical Field Study Characterizing Contamination Levels in Patient Used Endoscopes After Manual Cleaning
Authors: Bommarito Marco , Meyer Mark
Published: November 2020

Background: Multiple outbreaks multidrug-resistant organisms (MDROs) have been associated with flexible endoscopes resulting in unacceptable patient mortality and morbidity. Evidence highlights the importance of effective cleaning to achieve effective high-level disinfection (HLD). This study presents an analysis of >700,000 measurements of adenosine-triphosphate (ATP) contamination levels found in flexible endoscopes after manual cleaning. Method: This 2018–2019 study consists of 702,768 measurements of ATP levels found in the suction/biopsy channel of instruments used on patients after manual cleaning: gastroscopes (267,533 measurements from 223 sites), duodenoscopes (123,697 measurements from 161 sites), colonoscopes (252,249 measurements from 229 sites), and bronchoscopes (59,289 measurements from 107 sites). Sites were located across the United States and employed protocols that included routine cleaning verification performed by the reprocessing technicians using a handheld luminometer and the associated ATP water test (3M Clean-Trace). Results: Figure 1 shows a boxplot analysis of the ATP levels by endoscope type. Upper gastrointestinal (GI) endoscopes (gastroscopes and duodenoscopes) show a significantly (P < .005) greater level of ATP contamination after manual cleaning. The pairwise mean differences are all significant (P < .005) except for colonoscopes when compared to bronchoscopes (P = .203). Also shown on Fig. 1 is a literature supported adequate cleanliness value of 200 RLUs [=2.3log(RLUs)] (MJ Alfa et al.; Am J Infec Control 2013;41:245–253 and ANSI/AAMI ST91; 2015). A 95% confidence interval analysis performed against this literature value (Table 1) showed that a high number of gastroscopes (12%) and duodenoscopes (10%) are not adequately clean. Figure 2 shows a box-plot analysis of the data set by endoscope type and by site. There is significant (P < .005) site-to-site variability for all endoscope types as demonstrated by variation in mean values, box size, and many outliers. Conclusions: This study highlights the importance of using a quantitative cleaning verification method to better understand process capability and to provide more robust quality assurance for manual cleaning. Significant differences were detected in the level of cleanliness between upper GI scopes and lower GI scopes and bronchoscopes. When compared to a literature-supported level for adequate cleanliness, upper GI scopes exhibited failure rates in excess of 10%. Furthermore, significant site-to-site variability occurred, and many outliers fell well beyond the normal process envelope, representing significant cleaning lapses. Root causes to these concerning findings could range from inadequate execution of the cleaning protocol, to device design, to age and existing damage that could prevent achieving adequate cleaning and possibly impair the effectiveness of HLD.

Funding: None

Disclosures: Marco Bommarito, 3M (salary)