bluuebunny/crossref_metadata_2025 huggingface dataset:
Trends in the Co-occurrence and Association Between Heavy Episodic Drinking and Generalized Anxiety Among Adolescents Between 2013 and 2023 in Finland
Authors: Berg Noora , Kiviruusu Olli
Published: September 2024

The diverging trends of decreasing alcohol use and increasing anxiety symptoms among adolescents raise a question, has the strength of the well-known association between these issues also changed. This study examined changes in the co-occurrence and associations between heavy episodic drinking (HED) and generalized anxiety (GA) among Finnish adolescents between 2013 and 2023. From the repeated cross-sectional Finnish School Health Promotion Study (N = 874 110, age 13–20 years) we estimated self-reported GA symptoms and HED. The proportion of those with both HED and moderate to severe GA increased from 2.9% in 2013 to 3.6% in 2023, indicating a 21.5% relative difference. The association between GA symptoms and HED was stable during the study period (ORs 1.06–1.07). Although the association has been stable, there has been a rise in the proportion of adolescents experiencing both conditions concurrently over the past decade. This calls for strengthening the integration of mental health and substance use prevention and services.
Percutaneous thermal segmentectomy for liver malignancies over 3 cm: mid-term oncological performance and predictors of sustained complete response from a multicentric Italian retrospective study
Authors: Lucatelli Pierleone , Rocco Bianca , Argirò Renato , Semeraro Vittorio , Lai Quirino , Bozzi Elena , Crociati Sara , Barone Michele , Posa Alessandro , Catalano Carlo , Crocetti Laura , Iezzi Roberto
Published: September 2024

Introduction

Percutaneous thermal segmentectomy is a single-step combination of microwave ablation, performed during arterial occlusion obtained with a balloon micro catheter, followed in the same session by balloon-occluded TACE. The aim of this multicenter retrospective study is to report the mid-term oncological performance of this technique for liver malignancies > 3.0 cm and to identify risk factors for the loss of sustained complete response.

Methods

Oncological results were evaluated with CT or MRI according to m-RECIST (HCC) and RECISTv1.1 (metastasis/intra-hepatic cholangiocarcinoma, iCC) at 1-month, 3–6-month and then at regular-6-month intervals. To identify predictive variables associated with not achieving or losing complete response two mixed-effects multivariable logistic regression models were constructed.

Results

Sixty-three patients (40/23, male/female) with primary liver malignancies (HCC = 49; iCC = 4) and metastasis (n = 10) were treated. Median diameter of target lesion was 4.5 cm (range 3.0–7.0 cm). The median follow-up time was 9.2 months. At one-month follow-up, 79.4% of patients presented with a complete response and the remaining 20.6% were partial responders. At the 3–6-month follow-up, reached by 59 of the initial 63 patients, 83.3% showed a sustained complete response, while 10.2% had a partial response and 8.5% a local recurrence. At the last follow-up, 69.8% of the lesions showed a complete response. The initial diameter of the target lesion ≥ 5.0 cm was the only independent variable associated with the risk of failure in maintaining a complete response at 6 months (OR = 8.58, 95% CI 1.38–53.43; P = 0.02).

Conclusion

Percutaneous thermal segmentectomy achieves promising oncological results in patients with tumors > 3.0 cm, with tumor dimension ≥ 5.0 cm being the only risk factor associated with the failure of a sustained complete response.
Autonomous countertraction for secure field of view in laparoscopic surgery using deep reinforcement learning
Authors: Iyama Yuriko , Takahashi Yudai , Chen Jiahe , Noda Takumi , Hara Kazuaki , Kobayashi Etsuko , Sakuma Ichiro , Tomii Naoki
Published: September 2024

Purpose

Countertraction is a vital technique in laparoscopic surgery, stretching the tissue surface for incision and dissection. Due to the technical challenges and frequency of countertraction, autonomous countertraction has the potential to significantly reduce surgeons’ workload. Despite several methods proposed for automation, achieving optimal tissue visibility and tension for incision remains unrealized. Therefore, we propose a method for autonomous countertraction that enhances tissue surface planarity and visibility.

Methods

We constructed a neural network that integrates a point cloud convolutional neural network (CNN) with a deep reinforcement learning (RL) model. This network continuously controls the forceps position based on the surface shape observed by a camera and the forceps position. RL is conducted in a physical simulation environment, with verification experiments performed in both simulation and phantom environments. The evaluation was performed based on plane error, representing the average distance between the tissue surface and its least-squares plane, and angle error, indicating the angle between the tissue surface vector and the camera’s optical axis vector.

Results

The plane error decreased under all conditions both simulation and phantom environments, with 93.3% of case showing a reduction in angle error. In simulations, the plane error decreased from $$3.6 \pm 1.5{\text{ mm}}$$

3.6
±
1.5

mm

to $$1.1 \pm 1.8 {\text{mm}}$$

1.1
±
1.8
mm

, and the angle error from $$29 \pm 19 ^\circ$$

29
±

19
∘

to $$14 \pm 13 ^\circ$$

14
±

13
∘

. In the phantom environment, the plane error decreased from $$0.96 \pm 0.24{\text{ mm}}$$

0.96
±
0.24

mm

to $$0.39 \pm 0.23 {\text{mm}}$$

0.39
±
0.23
mm

, and the angle error from $$32 \pm 29 ^\circ$$

32
±

29
∘

to $$17 \pm 20 ^\circ$$

17
±

20
∘

.

Conclusion

The proposed neural network was validated in both simulation and phantom experimental settings, confirming that traction control improved tissue planarity and visibility. These results demonstrate the feasibility of automating countertraction using the proposed model.
MRI-compatible and sensorless haptic feedback for cable-driven medical robotics to perform teleoperated needle-based interventions
Authors: Vogt Ivan , Eisenmann Marcel , Schlünz Anton , Kowal Robert , Düx Daniel , Thormann Maximilian , Glandorf Julian , Yerdelen Seben Sena , Georgiades Marilena , Odenbach Robert , Hensen Bennet , Gutberlet Marcel , Wacker Frank , Fischbach Frank , Rose Georg
Published: September 2024

Purpose

Surgical robotics have demonstrated their significance in assisting physicians during minimally invasive surgery. Especially, the integration of haptic and tactile feedback technologies can enhance the surgeon’s performance and overall patient outcomes. However, the current state-of-the-art lacks such interaction feedback opportunities, especially in robotic-assisted interventional magnetic resonance imaging (iMRI), which is gaining importance in clinical practice, specifically for percutaneous needle punctures.

Methods

The cable-driven ‘Micropositioning Robotics for Image-Guided Surgery’ (µRIGS) system utilized the back-electromotive force effect of the stepper motor load to measure cable tensile forces without external sensors, employing the TMC5160 motor driver. The aim was to generate a sensorless haptic feedback (SHF) for remote needle advancement, incorporating collision detection and homing capabilities for internal automation processes. Three different phantoms capable of mimicking soft tissue were used to evaluate the difference in force feedback between manual needle puncture and the SHF, both technically and in terms of user experience.

Results

The SHF achieved a sampling rate of 800 Hz and a mean force resolution of 0.26 ± 0.22 N, primarily dependent on motor current and rotation speed, with a mean maximum force of 15 N. In most cases, the SHF data aligned with the intended phantom-related force progression. The evaluation of the user study demonstrated no significant differences between the SHF technology and manual puncturing.

Conclusion

The presented SHF of the µRIGS system introduced a novel MR-compatible technique to bridge the gap between medical robotics and interaction during real-time needle-based interventions.
How Can Genetically Informative Research Contribute to Life Course Research?
Authors: Diewald Martin
Published: September 2024

Genetically informative studies have established a new research field that crosscuts disciplinary boundaries within the social sciences, as well as between social science and biology, with proprietary aims and research questions. This happens, however, at the cost of appropriate integration into the current theoretical and conceptual streams in the social sciences, e.g., sociology. That such a fruitful integration is possible is demonstrated for the case of life course research. The focus in dominantly, though not exclusively, on sociological concepts of the life course. This article first introduces central concepts of genetically informative research and life course research and then discusses possible ways to integrate genetic information into the life course research agenda, giving a brief overview of the main methodological tools available.
Adverse childhood experiences and coping strategies: do they make a difference in psychopathic traits and altruism for young adults?
Authors: Lacomba-Trejo Laura , Quezada-Gaibor Katherine , Gomis-Pomares Aitana , Prado-Gascó Vicente , Villanueva Lidón
Published: September 2024

Adverse Childhood Experiences (ACEs) have been frequently associated with the presence of psychopathic traits and low levels of altruism. However, there are psychological factors such as coping strategies and demographic variables (sex and socioeconomic status) that can also influence psychopathic and altruistic traits. This study explored the impact of ACEs on psychopathic and altruistic traits, considering participants’ coping strategies, in an underexplored population. A total of 420 young Spanish adults (18–20 years old, M = 18.92; SD = 0.77) completed the Adverse Childhood Experiences Questionnaire, the Youth Psychopathic Inventory, the Altruistic Scale, and the Brief Coping Scale. Linear regression and comparative qualitative (fsQCA models) analyses indicated that total ACEs and avoidant emotion-focused coping (especially among males) were associated with higher psychopathic traits. Conversely, total ACEs and problem-focused coping (particularly among females) were linked to altruism. FsQCA models extended these findings, incorporating high SES to these previous profiles when predicting psychopathy and altruism. Thus, it is crucial to promote secure environments in childhood that facilitate the development of adaptive coping strategies. These strategies can mitigate the long-term effects of ACEs, reducing the likelihood of developing psychopathic traits while simultaneously increasing altruism.
Next day sentinel node biopsy for melanoma after lymphoscintigraphy using 99mTc-labelled nanocolloid does not adversely affect long-term outcomes
Authors: Roshan Amit , Pasha Terouz , Kounidas Georgios , Murphy Suzanne , Aloj Luigi , Buscombe John , Patel Animesh , Durrani Amer
Published: September 2024

Objective

Sentinel Lymph Node Biopsy (SLNB) is an important management tool for early-stage melanoma. Different radiopharmaceuticals are used internationally to localise the sentinel node using lymphoscintigraphy (LSG) before surgery. Recent reports have suggested that a delayed interval between LSG and SLNB using 99mTc-labelled nanocolloid tracer has an adverse survival impact, but not with 99mTc-labelled antimony sulphide colloid. This study aims to analyse survival outcome in a prospective cohort of melanoma patients undergoing same day or next day SLNB after LSG using 99mTc-labelled nanocolloid.

Methods

Outcome data were reviewed for patients undergoing SLNB, stratified by time interval between LSG and SLNB at a single UK academic centre. Kaplan–Meier survival analysis was used to assess overall survival (OS), melanoma-specific survival (MSS) and progression-free survival (PFS). Cox multivariable regression analysis identified independent risk factors.

Results

925 patients had LSG using the 99mTc-nanocolloid tracer between 2009 and 2019, with a median follow-up of 6.36 years. No difference was seen on univariate analysis in OS, MSS, PFS, or nodal recurrence between patients undergoing same day or next day SLNB (Log-rank P = 0.437, 0.293, 0.587, 0.342 respectively). In addition, nodal recurrence as first site or anytime site of recurrence in SLNB negative patients was similar between the groups (Log-rank P = 0.093 and 0.457 respectively). Stratified analysis of time did not demonstrate an outcome difference (MSS Log-rank P = 0.938). Cox multivariable regression did not show time interval to independently influence OS, MSS or PFS.

Conclusions

We do not find a significant effect on long-term outcomes when SLNB is performed the day after LSG with 99mTc-labelled nanocolloid tracer. We infer that tracer migration is not clinically significant within 24 h of injection based on long term clinical outcome data.
„Importierter Antisemitismus“? Differenzierende Wahrnehmungen in Deutschland lebender Jüdinnen und Juden zum politisch-islamischen Antisemitismus als Problem und Debatte
Authors: Beyer Heiko , Goldkuhle Bjarne , Herrberg Niklas , Reddig Melanie
Published: September 2024

Die vorliegende Mixed-Methods-Studie untersucht die unterschiedlichen Perspektiven in Deutschland lebender Jüdinnen und Juden zum Thema des politisch-islamischen Antisemitismus sowie zur gesellschaftlichen Debatte um „importierten Antisemitismus“. Anhand eines Survey-Experiments (n = 295) zeigt der Beitrag zunächst, dass die Bedrohung als weniger gravierend wahrgenommen wird und die Differenzierung zwischen „Muslimen“ und „radikalen Muslimen“ zunimmt, je stärker die konkrete persönliche Betroffenheit im Vergleich zur allgemeinen Problemwahrnehmung angesprochen wird. Insbesondere links eingestellte und höher gebildete Befragte unterscheiden hinsichtlich der Bedrohungswahrnehmungen stärker zwischen „Muslimen“ und „radikalen Muslimen“. Die qualitativen Interviews offenbaren eine kritische Haltung gegenüber der Debatte um „importierten Antisemitismus“, weisen jedoch gleichzeitig auf das reale Problem des politisch-islamischen Antisemitismus hin. Die gesellschaftliche Debatte wird oft als moralische Selbstvergewisserung rechter und linker Gruppen betrachtet, wobei rechte Gruppen ihren eigenen Antisemitismus auf Muslimas und Muslime projizieren und linke Gruppen Antisemitismus nur als rechtsextremes Phänomen betrachten, wodurch der politisch-islamische Antisemitismus ausgeblendet werde. Die Befragten assoziieren Antisemitismus unter Muslimas und Muslimen und die davon ausgehende Bedrohung eher mit einer radikalen Auslegung des Islam als mit der islamischen Religion oder der muslimischen Gemeinschaft als solcher.
Large scale structure-aware pronoun resolution using quantum natural language processing
Authors: Wazni Hadi , Lo Kin Ian , McPheat Lachlan , Sadrzadeh Mehrnoosh
Published: September 2024

Natural language consists of words, sentences, and larger units. Guided by grammatical structure, words compose with each other to form sentences. Similarly, guided by discourse structure, sentences compose with each other to form dialogues and documents. Classical machine learning algorithms have achieved significant success in learning the meanings of words. When it comes to meanings of sentences and discourse units, they however fall short of being compositional. The DisCoCat model of meaning, introduced by Clark, Coecke, and Sadrzadeh in 2010, provides a solution—at the sentence level—using higher-order tensors, the learning of which has been a challenge. A recent initiative known as Quantum Natural Language Processing (QNLP) introduces a translation between the DisCoCat tensors and Variational Quantum Circuits (VQC). This offers the potential of learning these higher-order tensors more efficiently when the circuits are executed on quantum computers. In previous work, we lifted the DisCoCat framework from the sentence level to the discourse level using a Fock space semantics. In this paper, we extend the DisCoCat-VQC translation to this semantics and experiment with it in a discourse task. We develop a massive dataset with 16,400 entries inspired by a major coreference resolution task, known as the Winograd Schema Challenge, proposed as a test of machine intelligence. Noisy and noiseless simulations were executed on IBMQ software, and the parameters of the discourse VQCs were learnt. The model converged to 77.5% accuracy, surpassing a Bag-of-Words model that neglects any structure. It also outperformed 2 out of 3 state-of-the-art classical coreference resolution architectures. These findings highlight the significant potential of quantum machine learning in advancing discourse analysis and structured natural language processing.
User-Centered Education for Patients/Caregivers about Urinary Tract Infections, Asymptomatic Bacteriuria, and Antibiotics
Authors: Thorpe Alistair , Fong Karen , Hardin Hannah , Muller Brandi , Szymczak Julie , White Andrea , Vaughn Valerie
Published: September 2024

Background: Older adults (aged ≥65) are at high risk of harm from overdiagnosis and overtreatment of urinary tract infections (UTIs) with antibiotics. Involving patients/caregivers in their antibiotic treatment decisions has potential to improve prescribing. To engage effectively, patients/caregivers must have sufficient knowledge about UTIs, asymptomatic bacteriuria (ASB: bacteria in the urine without signs of UTI), and antibiotics and opportunities to share their concerns and treatment preferences with healthcare staff. Patient education is one of the core elements of antibiotic stewardship recommended by the Centers for Disease Control and Prevention but, there are few resources for patients/caregivers about UTIs and antibiotics, leaving a knowledge gap as to what effective patient/caregiver antibiotic education for UTIs looks like. We sought to better understand the perspectives of patients/caregivers at high-risk of antibiotic overuse for UTIs and create an educational leaflet on UTIs, antibiotics, and ASB. Method: Between 11/2022 and 03/2023, we conducted virtual semi-structured interviews with patients ≥65yrs who had experienced UTI and caregivers about their needs, experiences, and preferences for educational support. Interviews lasted ~1 hour. Audio recordings were transcribed verbatim. NVivo software managed the data, which we analyzed using thematic analysis. Results: We conducted 9 interviews (5 patients, 4 caregivers). Interviewees expressed desire to be involved in their treatment decisions and learn more about antibiotics and alternative strategies (themes shown in Figure 1). Reported reasons for limited involvement in decisions included lacking the knowledge and confidence to ask questions, emotional factors (e.g., embarrassment/stress), deference to healthcare staff, and time constraints. Healthcare staff behaviors were described both as barriers (e.g., assertive treatment decisions) and facilitators (e.g., effective communication) of patient/caregiver engagement. Interviewees were eager for printed and digital educational support that could provide tailored content to help improve their knowledge and prepare for future conversations with healthcare staff. From this feedback we developed an educational leaflet (Figure 2). Conclusions: Involving patients/caregivers in antibiotic treatment decisions represents an opportunity to intervene before patients experience antibiotic overuse. Our findings offer important insights on patient/caregiver’ educational needs and preferences as well as perceived barriers to engaging in antibiotic treatment decisions for UTI. We used these insights to inform the development of educational materials about UTIs, ASB, and antibiotics for patients/caregivers and plan to test their use through multiple mediums with tailoring for unique patient needs, experiences, and backgrounds.
Implementing an Antimicrobial Stewardship Lecture Series for Family Medicine Residency Programs in South Carolina
Authors: Antosz Kayla , Bailey Pamela , Al-Hasan Majdi , Bookstaver Brandon , Winders Hana , Battle Sarah
Published: September 2024

Background: Family medicine physicians are one of the leading prescribers of antimicrobials in both the inpatient and ambulatory setting, however appropriate education on antimicrobial stewardship (AS) is lacking. The Antimicrobial Stewardship Collaborative of South Carolina (ASC-SC) created a family medicine AS lecture series to increase awareness of stewardship, improve antimicrobial prescribing throughout the state, and ultimately combat antimicrobial resistance. Methods: All family medicine residency programs in South Carolina (n=17) were contacted to determine interest in a four 1-hour long lecture series regarding various AS topics provided by infectious diseases physicians and pharmacists. The introductory AS lecture included topics such as interpreting minimal inhibitory concentrations, utilizing antibiograms, guidelines for diagnosing and treating common infections, and antibiotic essentials. Lectures were given on-site, and eight identical pre- and post-lecture questions were asked to assess baseline knowledge and efficacy of the introductory lecture. Not all the attendees answered all the pre- and post-lecture questions. A Chi-square analysis was used to determine statistical significance. Results: To date, 7 family medicine residency programs were given the introductory antimicrobial stewardship lecture and were included in the total analysis. Respondents included 1st year (25 of 99 responses, 25%) and 2nd year family medicine residents (17 of 99 responses 17%). When asked “How familiar are you with the concept of antimicrobial stewardship?”, 43 of 106 (41%) respondents were at least familiar or very familiar prior to the lecture compared to 81 of 93 (87%) after the lecture (p < 0.001). When asked “How confident are you in using antibiograms for antimicrobial decisions?”, 41 of 107 (38%) were confident or very confident pre-lecture and 83 of 101 (82%) post-lecture (p < 0.001). When given a case-based question on using an antibiogram to determine an appropriate empiric agent for inpatient pyelonephritis, 59 of 107 (55%) respondents were able to answer the question correctly pre-lecture compared to 85 of 99 (86%) post-lecture (p < 0.001). Among those who answered the question incorrectly, 60% selected the agent with the highest percentage susceptible rate in the antibiogram, despite it being an inappropriate agent for pyelonephritis. Conclusion: The ASC-SC lecture series was an effective tool to increase awareness and knowledge of antimicrobial stewardship to family medicine providers. This lecture series survey data helps determine what family medicine residents commonly misunderstood in AS concepts and helps guide future initiatives.
Capturing MRSA Diversity by Integrating Genomic and Epidemiological Data of Patients and their Spaces
Authors: Clement Tasmine , Panson Kristen , Cassone Marco , Mohammed Pirani Ali , Snitkin Evan , Mody Lona
Published: September 2024

Background: Methicillin-resistant S. aureus (MRSA) is known to cause frequent and severe infections in community living centers, potentially resulting in significant mortality for elderly patients. More research is needed to understand how to utilize genomic and epidemiological data to understand characteristics that may lead to increased transmission. We hypothesized that combining genomic and epidemiological information to sample patients and their environments during long-term stays, we will be able to capture a diverse set of MRSA strains. Method: This work included genome sequencing of patient and environmental samples from 11 patients within the VA Ann Arbor Healthcare System from May 4, 2021- November 16, 2022. All 11 patients tested positive for MRSA during their stay (mean days = 31). Patient and environmental samples were taken throughout their stays, screened for MRSA, and whole-genome sequenced. Single nucleotide variants (SNVs) were identified by mapping reads and calling variants against strain-specific reference genomes. We used ape v5.6-2 in R v4.2.2 to analyze and infer evolution, acquisition, and transmission events based on pairwise SNV distances. Genomic clusters were determined using stats v3.6.2, with a SNV distance threshold of 20. Result: Samples that were collected from patient bodily sites were able to reveal 20 distinct genomic clusters of MRSA (patient hands: n = 10, nares: n = 7, groin: n = 3). Environmental samples from patient environments also revealed distinct genomic MRSA clusters (tv remote: n = 9, toilet seat and bed rail: n = 6, table top, bed control, and call button: n = 5, bed curtain: n = 4, pulse ox = 2, cell phone, tray, pulse ox, mat, body hoist wrap, and bed: n = 1). Conclusion: The identification of various genomic clusters from patients and their environmental reservoirs suggests intrahost variation that can only be captured by using a more holistic approach of integrating epidemiology and genomic sequencing. Developing studies that incorporate genomic data, various environmental sources, and multiple isolates over time within community living centers can increase our understanding of strains that are more likely to transmit, survive on living and non-living surfaces and therefore lead to improved recommendation for infection prevention interventions and drivers of endemicity.

Disclosure: Lona Mody: NIH, VA, CDC, Kahn Foundation; Honoraria: UpToDate; Contracted Research: Nano-Vibronix
Health Equity Factors and Healthcare-Associated Infections in Louisiana Facilities, 2022
Authors: Dixon Tamia , Lee Grace , Ramirez Alexa
Published: September 2024

Background: Health equity is a critical consideration in public health research, emphasizing the importance of fair and just access to healthcare resources. This study explores the impact of health equity factors on the incidence rates of Central Line-Associated Bloodstream Infections (CLABSI) and Methicillin-Resistant Staphylococcus aureus (MRSA) across diverse healthcare facilities in Louisiana. Methods: We conducted a comprehensive analysis utilizing 2022 data from the National Healthcare Safety Network (NHSN). Fourteen healthcare facilities were randomly selected from nine regions in Louisiana, with guidance from the 2022 NHSN external validation toolkit. Key health equity factors from Health Resources and Service Administration (HRSA) were assessed, including urbanicity, MUA/P, and HPSA_Primary Care. Risk ratios were calculated to quantify the association between these health equity factors and the incidence rates of CLABSI and MRSA. Results: The findings reveal intriguing insights into the relationship between health equity factors and infection rates. In urban settings, the risk of CLABSI was lower (Risk Ratio: 0.634, 95% CI: 0.2442–1.646), contrasting with a significantly higher risk of MRSA (Risk Ratio: 1.7, 95% CI: 1.119–2.582). This suggests a complex interplay between urbanicity and the specific infection types. For MUA/P, no significant impact on CLABSI rates was observed (Risk Ratio: 0.963, 95% CI: 0.4225–2.195), but an increased risk of MRSA emerged (Risk Ratio: 1.652, 95% CI: 1.029–2.652). In healthcare professional shortage areas for primary care (HPSA_Primary Care), both CLABSI (Risk Ratio: 1.37, 95% CI: 0.5854–3.204) and MRSA (Risk Ratio: 2.098, 95% CI: 1.305–3.372) exhibited elevated risks, though only MRSA risk was statistically significant. Conclusions: This research underscores the nuanced relationship between health equity factors and infection rates in healthcare facilities. Urban settings may contribute to a lower risk of CLABSI but a higher risk of MRSA, emphasizing the need for tailored preventive strategies. Living in medically underserved areas appears to heighten the risk of MRSA, warranting targeted interventions. Additionally, healthcare professional shortage areas for primary care demonstrate potential associations with increased risks for both CLABSI and MRSA. These findings provide valuable insights for public health practitioners, policymakers, and healthcare administrators aiming to address health disparities and enhance infection control measures in diverse healthcare settings. Further research is encouraged to unravel the multifaceted dynamics influencing infection rates and to inform targeted interventions for improved health outcomes.
An Examination of Racial/Ethnic Differences in the Antibiotic Treatment of Community Acquired Pneumonia
Authors: Burrowes Shana , Barlam Tamar , Drainoni Mari-Lynn
Published: September 2024

Background: Community Acquired Pneumonia (CAP) is the most common reason for antibiotic treatment in hospitalized adults. Some prior studies have found treatment differences by race/ethnicity but research on the topic is limited, results are mixed, and it is unclear if clinical outcomes are affected. We sought to examine whether guideline-concordant CAP care and patient outcomes varied by race/ethnicity. Methods: Using the Vizient clinical database, we conducted a cross sectional analysis of all hospitalized patients > = 18 years of age with a primary diagnosis of pneumonia (ICD10 codes: J12-J18) from 2018-2021. Univariate and bivariate analyses examined the distribution of demographic, clinical and hospital characteristics across race/ethnicity. The primary outcome was receipt of therapy concordant with ATS/IDSA Clinical Practice Guideline for CAP. Final models included only patients with bacterial pneumonia and examined the relationship between race/ethnicity and guideline-concordant antibiotic treatment. Secondary analysis examined the interaction between race/ethnicity and concordant antibiotic treatment with length of stay >7 days, 30-day hospital readmission, adverse events or complications in separate models. We used hierarchical multivariable regression models accounting for clustering within patients and among patients hospitalized at the same facility. Due to sample size, significance was assessed with an OR > = 1.2 and p≤ 0.05. All analyses used SAS (v.9.4, SAS Institute Inc. Cary, NC). Results: There were 1,277,770 admissions with a primary diagnosis of bacterial CAP. Sixty-nine percent of the sample was White, 18% Black, 8% Hispanic, 2% Asian and 3% identified as other. 56% of the sample received concordant care. In adjusted models Black patients had greater odds of overall concordant care (OR 1.22; p 7 days (OR 0.67 p <.0001), complication or adverse event (OR 0.75 p <.0001), but not readmission within 30 days. Conclusion: We observed differences between Black and White patients in the receipt of concordant treatment. Hospital bed size, CMI and region played an important role in both antibiotic treatment decisions and clinical outcomes, indicating that hospital and regional prescribing cultures may play in role in treatment inequities.
Implementing an Internal CLABSI Validation Program
Authors: DiBiase Lauren , Teal Lisa , Sickbert-Bennett Vavalle Emily , Stancill Lisa , Culbreth Cyndi , Croyle Karen , Schnell Natalie , Schultz Katherine , Sotak Tara , Wiley Jessica , Graham Karen
Published: September 2024

Background: The National Healthcare Safety Network (NHSN) provides detailed surveillance case definitions for healthcare-associated infections (HAI), including central line-associated bloodstream infections (CLABSI). CLABSI data are used for several purposes, including improving patient safety, value-based purchasing, and comparing hospitals’ performance. Our Infection Prevention (IP) team conducts house-wide HAI surveillance. To ensure that our hospital CLABSI reporting is accurate and that staff are implementing case definitions consistently and systematically, we conducted an internal validation of CLABSI. This undertaking allowed us to identify educational opportunities for IPs and improve surveillance data consistency. Methods: At UNC Hospitals, data on all positive blood cultures collected in the inpatient setting from July 2022 – June 2023 were obtained from electronic medical records. A random number generator was used to select 16 records per quarter. Each record was then randomly assigned to two different IPs (out of 8 total inpatient IPs) for review. Concordance of CLABSI classification was summarized across the two reviews and compared to the initial review. Discordant cases were then reviewed by the Associate IP Director (a certified IP with 15 years of experience) for final adjudication. A summary of findings and discordant cases details were discussed at regular IP educational meetings. Results: From July 2022-June 2023, there were 1658 positive blood cultures collected in the inpatient setting. Of the 64 randomly selected blood cultures, total concordance amongst all reviewers occurred 65.6% of the time. Concordance improved in the 2nd half of FY23 compared to the 1st half (72% vs, 59%, p>0.05). Amongst the 33% of blood culture results with reviewer discrepancy, the most common reasons were related to distinction of a bloodstream infection secondary to another infection site (32%) and application of the repeat infection timeframe (18%). Importantly, there was only one instance where a blood culture result was categorized by all 3 reviewers as present on admission, but upon Associate Director review, actually represented a CLABSI (i.e., false negative). Conclusions: Standardized case definitions remain open to interpretation. At our hospital, we experienced discordance in approximately one-third of instances during review of blood culture data amongst trained infection preventionists. Reviewing all blood culture data is key for validation so that both false positives and false negative CLABSIs can be identified. Identifying the most common reasons for discordance and using specific examples when case disagreement occurred for educational purposes may lead to improved reliability and accuracy of application of the NHSN surveillance defintions.
Barriers and Facilitators to Optimal Antibiotic Prescribing on Discharge from the Hospital to Nursing Homes
Authors: Furuno Jon , Zhou Michelle , Crnich Christopher , Chan Dominic , McCracken Caitlin , Jolles Sally , Noble Brie , McGregor Jessina , Ham YoungYoon , Shephard Emily , Izumi Seiko
Published: September 2024

Background: Up to half of antibiotics used in nursing homes (NHs) are initiated in acute care hospitals prior to nursing home admission. Optimizing antibiotic prescribing on hospital discharge presents an opportunity to improve NH antibiotic use. We aimed to identify barriers and facilitators to optimal antibiotic prescribing on discharge from the hospital to NHs. Methods: This was a qualitative thread of a convergent parallel mixed methods study to identify high-value targets to optimize antibiotic prescribing on discharge from the hospital to NHs. We conducted 32 qualitative interviews: 16 with prescribers (9), pharmacists (6), and a care manager (1) from 3 acute care hospitals and 16 with advanced practice providers (12) and registered nurses/nurse managers (4) from 7 NHs in Oregon and Wisconsin. Interview participants were asked to describe their typical practice for prescribing antibiotics on discharge to NHs or admitting patients with antibiotic prescriptions from hospitals, and about barriers and facilitators for optimal antibiotic prescribing during these transitions. Interviews were audio recorded, transcribed verbatim, and analyzed by 3 investigators using the qualitative descriptive analysis Results: Hospital healthcare workers described that there are different practice flows for oral and intravenous (IV) antibiotic prescribing. IV antibiotic orders are typically routed to the infectious diseases (ID) specialists and ID pharmacists to review and verify appropriateness. There were minimal established workflows to review and verify oral antibiotic orders. Pharmacists appeared integral to optimal antibiotic prescribin; however, the high frequency of oral prescriptions and short turnaround times from discharge orders to transportation limited pharmacists’ abilities to review these orders. With limited pharmacist involvement, the quality of oral antibiotic prescription relied on the prescribers’ knowledge, and there was no systematic oversight for inexperienced prescribers or specialists who may not be familiar with the adequacy of antibiotic use for NH residents. NH participants perceived that most antibiotics prescribed from hospitals were appropriate. Yet, some commented that they occasionally observe inadequate or unusual prescriptions from newer prescribers or specialists. NH participants most common concern related to antibiotic prescriptions was missing information including unclear or lack of antibiotic indications or stop dates. NH participants also stated that the frequent need to contact the hospital to obtain missing information is challenging and burdensome. Conclusions: Qualitative interviews identified several barriers and facilitators to optimal antibiotic prescribing on discharge to NHs. These results will be used to develop an intervention to improve antibiotic prescribing during these transitions.
Evaluation of a Sepsis Alert System at a Veterans Affairs Medical Center
Authors: Roberts Grace , Akbar Bushra , Bennett Jessica , Mitchell Anna , Thomas-Gosain Neena
Published: September 2024

Background: Automated sepsis alerts have become a widely implemented screening tool aimed at early detection of clinically unstable patients. Prior research has shown mixed results depending on the type of screening tools used and the patient population studied. This study aimed to evaluate the predictive value of an alert system created for identifying patients with sepsis to determine utility in clinical practice prior to implementation. Additionally, clinical management of those with and without sepsis was compared to measure potential added benefit of this system in clinical decision making. Methods: A TheraDoc® software sepsis alert was generated for non-ICU patients meeting >2 SIRS criteria within a 24-hour time period (temperature >38°C or 90, respiratory rate >20 or partial pressure CO2 12,000 or 10% bands/immature cells) during March 2023. Alerts were excluded if they were duplicates (using identical criteria or a second alert within 24 hours), triggered by labs collected >48 hours prior, or death or discharge occurred before the time of alert. The primary outcome was positive predictive value (PPV) of sepsis identification, confirmed by ICD-10 codes and diagnostic studies (cultures, imaging). Secondary outcomes included clinical management (antibiotic utilization [AU] and choice, infectious disease [ID] consultations and culture collection). Antibiotics were categorized as broad-spectrum using National Healthcare Safety Network (NSHN) criteria. Secondary outcomes were compared between sepsis and SIRS without infection groups (SIRS) by chi-square analysis. Results: After applying exclusion criteria, 116 of 166 alerts were analyzed; 55 of 116 alerts had confirmed sepsis (PPV 47.4%). Patients with sepsis were more likely to have an ID consult (16% [9/55] vs 7% [4/61]) and cultures collected (70.9% [39/55] vs 39.3% [24/61]) compared to SIRS patients, however these differences were not statistically significant. AU was higher with confirmed infections compared to SIRS patients (94.5% [52/55] vs 32.8% [20/61], p < 0 .05) along with use of broad-spectrum antibiotics (73% [38/52] vs 40% [ 8/20] p < 0 .05). Conclusions: While automated alerts may enable early identification of sepsis, use of SIRS criteria alone has poor specificity, which was borne out by the low PPV in this study. Our study found that management of sepsis patients (as measured by AU and culture ordering) was better than expected and combined with the low PPV of this alert system resulted in our team rejecting widespread adoption of SIRS-based sepsis alerts.
Timing Is Everything: Recognizing the Importance of Infusion Duration in Preoperative Antimicrobial Prophylaxis
Authors: Oakes Peter , Donohue Lindsay , Chiao Sunny , Ketcham Susan , Terenyi James , Hedrick Traci , Mathers Amy
Published: September 2024

Background: For preoperative antimicrobials to be most effective in preventing surgical site infection, they must be administered early enough to reach a minimum tissue concentration that is specific to each drug. However, antibiotics have widely ranging infusion durations, from intravenous push over a few minutes to slow infusion over two hours. Heterogeneity in recommended infusion administration instructions, importance of infusion completion prior to incision, and complexity of healthcare systems present just some of the barriers to achieving appropriate preoperative antibiotic prophylaxis. We compared the percentage of infusion completion prior to case start before and after a multidisciplinary intervention. Methods: We performed a retrospective analysis of all patients undergoing a colorectal surgical procedure as defined by the National Healthcare Safety Network at a single university hospital from 10/19/22-10/18/23. A recognition that some antimicrobials were not finished infusing prior to surgery start prompted a multidisciplinary group including antibiotic stewardship, colorectal surgery, perioperative nursing, and anesthesiology to create and deploy an order set shortening metronidazole infusion duration from 60 to 30 minutes and initiating infusion in the preoperative area instead of the operating room. No change to the cefazolin intravenous push over 3-5 minutes was made. Goal antimicrobial infusion was defined as completed infusion within 120 minutes prior to incision, and calculations were made based on infusion start time and case start times. Rate of infusion completion was compared from the pre-intervention period to a post-intervention period from 10/19/23 through the end of the year. Results: For all colorectal surgeries in the pre-intervention period, 95% (n=418/440) of cefazolin doses and 0.002% (n=1/427) doses of metronidazole met goal infusion timing. At-goal infusion timing increased to 99% (n=84/85) of cefazolin doses and 68% (n=56/82) of metronidazole doses in the post-intervention period, resulting in a statistically significant improvement for metronidazole (Fischer’s exact test p < 0 .00001). The average time to metronidazole infusion completion changed from 45 minutes after procedure start to 58 minutes before procedure start. Conclusions: Multidisciplinary team engagement and deployment of an order set incorporating changes in duration and workflow for metronidazole infusion improved all antimicrobial preoperative infusions for colorectal procedures. Increased awareness of completing antimicrobial infusion prior to the incision may improve preoperative antimicrobial administration.

Disclosure: Lindsay Donohue: Advisor - Abbvie
Clinician Interpretation and Management of Discordant PCR+/Toxin- Clostridioides difficile Testing Results Post-COVID
Authors: Boton Noah , Mehrotra Preeti , Lee Matthew
Published: September 2024

Background: Our institution utilizes a two-step algorithm consisting of an initial polymerase chain reaction (PCR) test with positive results reflexed to an enzyme immunoassay (EIA) for toxin. Institutional guidelines implemented during the COVID-19 pandemic recommended applying clinical judgment to patients with PCR+/Toxin- (discordant) results when determining if treatment is indicated. Pre-pandemic, we found that clinicians continued CDI-directed therapy in 56% of patients following the Toxin- result. Our study aims to identify how clinicians interpret PCR+/Toxin- results and reasons for management decisions post-pandemic. Methods: At an academic medical center, we conducted a retrospective cohort study of the first 50 inpatient charts with PCR+/Toxin- results from August to October 2022. Data was abstracted from clinical, pharmacy, and microbiology databases. The primary outcome was the proportion of patients continued on CDI-directed therapy for ≥24 hours after the Toxin- result became available. Secondary outcomes included the proportion of patients prescribed a full treatment course for CDI and the reasons for continuing treatment. Results: There were 37 patients (74%) who started CDI-directed treatment after initial PCR+ Results: Of these patients, 59% (22/37) were continued on treatment for ≥24 hours after the Toxin- result (primary outcome). 77% (17/22) of these patients who met the primary outcome completed full treatment courses. Three patients were transitioned to prophylaxis dosing after the Toxin- result. The most common reason for continuing treatment after discordant results was high clinical suspicion for CDI (Figure). There were no CDI-related complications in this 50-patient cohort. In immunocompromised patients, 70% (16/23) started treatment after initial PCR+ results and 81% (13/16) met the primary outcome. In patients admitted specifically to immunocompromised inpatient services, 90% (9/10) started treatment after initial PCR+ results and 100% (9/9) met the primary outcome. Conclusion: The majority of patients started on treatment after the PCR+ result were continued on treatment following the Toxin- result, though several of these patients did not complete full treatment courses. Treatment rates were similar to our pre-pandemic baseline. When patients were continued on treatment after discordant results, clinicians cited appropriate high clinical suspicion. Notably, every patient admitted to an immunocompromised service was continued on treatment after Toxin- Results: Overall, clinicians are following institutional guidelines by applying clinical judgement when interpreting discordant Results: Further research will help identify what variables affect clinician interpretation and management practices for discordant results, which will help shape institutional guideline updates, clinician education, and additional stewardship interventions.
The Next Target for Readmission Reporting? Exploring Readmission Rates of Patients with CLABSI
Authors: Crews-Stowe Caitlin , Sklar Elliot
Published: September 2024

Background: Multi-drug resistant organisms (MDROs) are a common cause of healthcare-associated infections, particularly central line-associated bloodstream infections (CLABSIs). Prior research has shown that MDROs cause up to 67% of CLABSIs and have up to a 37% increase in 30 day readmission, which is higher than readmission rates for other conditions reported to the Centers for Medicare and Medicaid Services (CMS). The objective of the study was to determine overall 90-day readmission rates, and if there was a difference in readmission rate within 90 days post discharge for patients who had a MDRO as the causative pathogen of their CLABSI compared to patients who did not have an MDRO. Methods: A retrospective analysis of patient data from a nine-hospital system was performed on patients who had a CLABSI and were discharged alive between January 1st, 2018, and December 31st, 2019. Basic descriptive statistics were performed, and the potential differences in readmission rates were examined using Chi-square analyses. Results: The overall readmission rate for all CLABSIs was 46.9%. The chi-square analysis determined there was not a significant difference in readmission rates in patients who had a MDRO CLABSI compared to patients with a non-MDRO CLABSI (59.1% vs. 44.6%, x2= 1.564 , p= 0.211). Conclusion: There was not a significant difference in readmission rates between patients with an MDRO CLABSI compared to a non-MDRO CLABSI. However, the overall readmission rate for this patient population was much higher than seen in previous literature and other publicly reported readmission rates. Additional research is recommended to explore if the increased CLABSI readmission rates seen are a unique finding to this health system.