bluuebunny/crossref_metadata_2025 huggingface dataset:
Safety and efficacy of the new modified technique for c2 nerve root resection in 3d fluoroscopy navigated instrumentation in the cranio-cervical junction
Authors: Bobinski Lukas , Sandberg Linda , Bylander Frida , Hållberg Hampus , Berglund Anders , Duff John M.
Published: September 2024

Purpose

Instrumentation of the C1 vertebra requires either mobilization or transection of the C2 nerve root. This study investigates clinical and radiological outcomes and incidences of C2 neuropathic pain after posterior instrumented fusion in the cranio-cervical junction with or without division of the C2 nerve roots.

Methods

This retrospective study compared two cohorts of patients who underwent instrumented fusion in the cranio-cervical junction. Fifty patients (22 males and 28 females) were operated with complete resection of C2 nerve root ganglion (Ex group), and fifty-one patients (30 men, 21 women) with C2 nerve roots preservation (No group).

Results

The incidence of postoperative C2 neuropathy was eight times lower in the Ex group compared to the No group that was statistical significant, p = 0.039. Surgical time was significantly shorter in the No group (p = 0.001). The fusion rates were very high for both groups, without difference between groups (p = 1.0). Autografting from the iliac crest (p = 0.001) as well as postoperative immobilisation with a hard collar (p < 0.001) were required in fewer patients in the Ex group. Also, patients in the Ex group were mobilised faster after surgery (p = 0.49). Overall, complication rates were similar between groups, but the Ex group demonstrated fewer major medical complications (16% vs 31%). Male sex and iliac bone harvesting demonstrated significantly higher OR for development of postoperative complications (p = 0.023 and p = 0.034 respectively) and postoperative mobilization demonstrated significant higher OR for development of postoperative major complications (p = 0.042).

Conclusions

Resection of the C2 nerve root ganglion during posterior instrumented fusion of the cranio-cervical junction is safe and rarely leads to C2 neuropathy. The technique tends to mitigate the odds of developing postoperative complications.
Comparison of eTEP and IPOM for ventral hernia surgery in the early postoperative period: a retrospective cohort study of a tertiary university centre
Authors: Wieland Lukas , Alfarawan Fadl , Bockhorn Maximilian , El-Sourani Nader
Published: September 2024

Purpose

The extended totally extraperitoneal technique (eTEP) is a relatively new laparoscopic approach to address ventral hernias. Since this technique is not widely used yet, the literature regarding its efficacy and safety is limited, especially when compared to more established surgical techniques like intraperitoneal onlay mesh (IPOM). This study aimed at contributing to the expanding body of evidence for eTEP, by comparing the early outcomes of eTEP and IPOM surgeries for ventral hernias.

Methods

This monocentric, retrospective cohort study compared patients with ventral hernias that were treated with eTEP or IPOM from 2019 to 2023.

Results

A total of 123 patients were analysed. 92 underwent eTEP and 31 IPOM respectively. Both groups were overall comparable. The IPOM group had a higher proportion of incisional hernias (61,29% vs. 21,74%, p < 0,001). This was taken into account for in a subgroup analysis of only primary hernias. The IPOM group had a significantly longer admission time (eTEP: 3 days, IPOM: 4 days, p < 0,001). The subgroup analysis revealed a statistically significant shorter surgery time in IPOM (median of 66,5 min vs. 106,5 min; p = 0,043) and a lower rate of postoperative complications in eTEP (eTEP: 4,17%, IPOM: 25%. p = 0,009). The eTEP group reported lower postoperative pain, yet without statistical significance.

Conclusion

eTEP for ventral hernia repair appears to be non-inferior to IPOM. Compared to IPOM it leads to shorter postoperative hospital stay and a potentially lower complication rate, despite a longer operation time.
Reaching China’s fertilizer reduction goals through nitrogen and phosphorus recovery: a substance flow analysis case study
Authors: Santolin Julia , Larsen Oliver Christopher , Fritze Albrecht , Xue Bing , Yang Zheng , Rotter Vera Susanne
Published: September 2024

Linear agricultural nutrient regimes are the principal cause for perturbation of the geochemical cycles for nitrogen (N) and phosphorus (P) and other planetary boundaries. Nutrient cycles are characterized by high spatial disparity and China is a hotspot due to high fertilizer application rates. Using substance flow analysis, this study identified and quantified nutrient flows from agricultural production to residue management of Huangyan tangerines (Citrus reticulata) and water bamboo (Zizania latifolia) in a case study of Huangyan district (Taizhou City, Zhejiang province). About 754 Mg/a of N and 105 Mg/a of P can theoretically be recovered in the tangerines and water bamboo systems from currently untapped material flows. This could replace 59% of the N and 15% of the P currently applied as chemical fertilizer, reducing environmental impacts. Combining the nutrient recovery of both systems and upscaling the results to Taizhou City, the goal from the 14th Five-Year Plan for Agricultural and Rural Modernization to save 1182 Mg of nutrients per year could be exceeded by almost 12 times. This study’s data have varying degrees of uncertainty. The analysis of data representativeness shows potential for improvements, especially in the agricultural production of water bamboo and the nutrient contents of material flows.
Dietary differences in males and females of a strongly sexually dimorphic ungulate
Authors: Brambilla Alice , Bal Xavier , Lusetti Maria Letizia , Colombo Mattia , Mainetti Andrea , Keller Lukas , Bassano Bruno
Published: September 2024

Detailed knowledge of dietary preferences in wild species are important both for understanding evolutionary processes as well as for their conservation. By means of DNA metabarcoding analysis of faecal samples, we investigated the diet of Alpine ibex (Capra ibex), a mountain ungulate characterised by strong sexual dimorphism and segregation, and analysed differences between male and female diet. Despite a low level of selectivity, we found differences in the diet of males and females that consumed different plant in different quantities. Differences were maintained during both spring and summer. Males tended to feed more on plants richer in fibres (i.e., grasses and sedges) and showed stronger seasonal differences while females consumed more digestible plant families (i.e., forbs). Differences in diet between male and female Alpine ibex are compatible with the strong sexual dimorphism and segregation typical of the species and with female reproductive constraints. These results also show that conservation actions have to take into account different ecological needs of males and females in species characterized by sexual dimorphism and segregation.
Characterization of the floral traits, pollen micromorphology and DNA barcoding of the edible flowers from three basil taxa (Lamiaceae)
Authors: Bazzicalupo Miriam , Betuzzi Federica , Frigerio Jessica , Nissim Werther Guidi , Rapallo Fabio , Ruffoni Barbara , Cornara Laura , Copetta Andrea
Published: September 2024

The edible flowers sector is expanding due to the popularity and uses in culinary recipes of different species. In particular, flowers of Ocimum basilicum L. and related taxa are increasingly used for their aromas and nutritional value. However, there is limited information regarding their morphological characteristics and molecular profiles, which are both important to perform a quality control of food, and to avoid contaminations. Hence, our aim was the study of three basil taxa (O. basilicum ‘Cinnamon’, O. basilicum ‘Blue Spice’, and the hybrid O. × africanum Lour.) to obtain data useful for taxa identification and to understand which traits could be linked to their chemodiversity. The plants were grown in a greenhouse starting from seeds. Flowers were collected at anthesis; the morphology of calyxes, corolla and pollen grains was characterized; DNA barcoding analyses were performed. All taxa were identified only as O. basilicum by molecular analyses, but two haplotypes were distinguishable. All taxa were identifiable due to the presence/absence of specific glandular trichomes, and by pollen size and number of colpi. ‘Cinnamon’ and O. × africanum showed more morphological affinities to each other, but histochemical analyses suggested the separation of the three taxa. Pollen grains from ‘Cinnamon’ had the smallest diameter in polar view and were hexacolpate, while ‘Blue Spice’ pollen showed the highest diameter with grains being hexacolpate/octacolpate, similarly to O. × africanum. Our interdisciplinary study provides the first information for authenticating these basil cultivars in packaged products for human consumption.
Quantum geodesic flows on graphs
Authors: Beggs Edwin , Majid Shahn
Published: September 2024

We revisit the construction of quantum Riemannian geometries on graphs starting from a hermitian metric compatible connection, which always exists. We use this method to find quantum Levi-Civita connections on the n-leg star graph for $$n=2,3,4$$

n
=
2
,
3
,
4

and find the same phenomenon as recently found for the $$A_n$$

A
n

Dynkin graph that the metric length for each inbound arrow has to exceed the length in the other direction by a multiple, here $$\sqrt{n}$$

n

. We then study quantum geodesics on graphs and construct these on the 4-leg graph and on the integer lattice line $$\mathbb {Z}$$
Z
with a general edge-symmetric metric.
Desıgn of quantum-dot semiconductor optical amplifiers wıth near-zero linewidth enhancement factor
Authors: Aşırım Özüm Emre , Jirauschek Christian
Published: September 2024

The linewidth enhancement factor (LWEF) of a semiconductor optical amplifier (SOA) quantifies refractive index fluctuations in the gain medium, which induce phase distortion in the amplified optical signal. Optoelectronic systems employing SOAs with high LWEFs often exhibit poor device stability and beam coherence. Thus, designing SOAs with low LWEF is imperative. Recently, Quantum-Dot (QD) SOAs have emerged as a solution for LWEF suppression due to quantum-confinement effects enabling tunability of the QD carrier density and emission frequency. In this study, we aim to design a composite active region comprised of a host medium and the embodied QDs, to explore the corresponding LWEF variation and propose the ultimate design strategy to achieve near-zero LWEF in QD SOAs for enhancing device stability and beam coherence. Our approach entails modeling the refractive index of the composite active region using effective medium approximation via Maxwell–Garnett mixing formulation. We then extensively tune key SOA parameters, including QD carrier density, QD emission frequency, and the collision-time constant of the carriers to uncover the optimal configuration for minimizing the LWEF. Based on empirical values, we have developed and validated a simple yet effective algorithm that precisely simulates LWEF behavior in response to changes in key QD SOA parameters. This approach offers a straightforward model for estimating LWEF variation, and its corresponding minimization in QD SOAs without requiring complex experimental measurement techniques.
Adaptability, stability, and productivity of potato breeding clones and cultivars at high latitudes in Europe
Authors: Ortiz Rodomiro , Reslow Fredrik , Huicho José , Vetukuri Ramesh , Crossa José
Published: September 2024

The aim of potato breeding is to release cultivars that exhibit high and stable performance across the target population of environments. The objective of this research was therefore to investigate the use of various methods (site regression [SREG], coefficient of variation and regression deviation [σ2δ]) for determining the adaptability and stability of productive and quality traits in the Nordic region of Europe. The multi-environment trials included 256 breeding clones and released cultivars grown by EU farmers at three distinct testing sites over two years in Sweden. There was significant (P < 0.001) variation in tuber yield, starch percentage and reducing sugars in the tuber flesh among the breeding clones and cultivars, testing environments and the genotype by environment interaction (GEI). The environments were very diverse, as revealed by the SREG biplots and particularly for the GEI patterns noted in terms of their productive and quality characteristics. The percentage of stable high-tuber yielding germplasm was greater for breeding clones (23%) than for released European cultivars (2%), thus revealing the advantage of potato breeding in the target population of environments. SLU 1415001 and SLU 1314015 were the most promising breeding clones due to their stable high tuber yield. This characteristic was best for the starch potato cultivars, although none of them exhibited a significant different σ2δ. ‘Talent’ shows an almost stable good performance among low reducing sugar cultivars and breeding clones, which are often unstable in terms of their scoring across environments. Neither a breeding clone nor a cultivar was at the top for stable tuber yield, tuber flesh starch or reducing sugars in the tuber flesh, which shows the challenge faced by potato breeding while addressing the needs of different markets.
Equivalent Error Based Modelling for Prediction and Analysis of Measuring Accuracy in 3-Axis FXYZ Coordinate Measuring Machines from Position, Repeatability and Reversibility Errors
Authors: Jodar J. , Franco P.
Published: September 2024

The measuring accuracy of coordinate measuring machines (CMMs) will be affected by the different geometrical and dynamic errors, including the deviations associated to the axis displacement, the working table and the part to be measured. This work is focused on the analysis of the influence of the position errors, repeatability errors and reversibility errors in 3-axis FXYZ coordinate measuring machines, and it will be developed by a numerical model that is known as EE-based stochastic model. This model implements a new error index that is named equivalent error (EE), which will integrate the totality of machine errors of the CMMs and will allow a global description of all these error sources by means of a unique error parameter. The results obtained by this numerical model have been compared with the application of a traditional method, and it was probed that the EE-based model makes possible an increase of a 13.29% in the linear modelling of the performance of CMMs from the machine errors considered in this work, which implies a relevant improvement for the analysis and description of the effect of the distinct error sources on the achievable measuring accuracy of CMMs. For this reason, the EE-based model will be of special interest for industrial applications such as the quality control to be applied inside the production systems dedicated to manufacture mechanical components of high dimensional accuracy.
A simplified rare earth element mining project cost estimator - a new tool for evaluating future mine supply
Authors: O’Brien Tim M. , Alonso Elisa
Published: September 2024

Rare earth elements (REE) are essential for the future of electric vehicles and renewable energy production, but currently there is limited REE production outside of China. Forecasting global future supplies of REE often relies on the valuation of advanced mining projects to assess if projects will initiate production. Classical valuation methods, such as net present value (NPV), require knowledge of initial capital and operating expenditures to assess the economic feasibility of a given project. Typical industry unit expenditure projections are highly precise but are extremely project dependent and require detailed knowledge of a site that is far beyond the level that a domestic and/or global supply-demand model can obtain. To model future REE supplies we developed a new globally representative, simplified, mining project cost model that can be used to approximate the capital and operating expenditures of greenfield REE mining projects. Results from this model allow users to estimate expenses of open-pit and underground mines with mineral processing operations that range from solely beneficiation to individual REE separation. Using our new model and an estimate of NPV, we evaluate several REE mining projects and assess the economic variables impacting the likelihood for these projects to advance to the production stage. Of 12 assessed projects located outside of China, in the early to advanced development stages, nine had positive NPV at 2011 peak REE prices, but none had positive NPV when prices reached bottom in 2016. Two projects yielded positive NPV’s using 2022 and projected 2028 prices. The viability of these projects given the impact of the volatility in REE prices explains the high uncertainty in the future supply for these mineral commodities.
Exogenous Application of Selenium Nanoparticles (Se-NPs) to Mitigate Salt Stress in Soybean-Evaluation of Physiological, Molecular and Biochemical Processes
Authors: Desouky Abeer F. , Desoukey S. F. , Abdel-Aziz Hend S. M. , EL-kholy Ragab I. , Hanafy Moemen S.
Published: September 2024

Salt stress is identified as a significant abiotic stress that hampers agricultural sustainability globally. The study was carried out to investigate the potential mitigating effects of selenium nanoparticles (Se-NPs) on salt stress in soybean. Two weeks old grown soybean seedlings were subjected to salt stress conditions (4000 mg L− 1 of sea salts). The plants were foliar sprayed with Se-NPs at concentrations of 0.0, 0.5, 1.0 and 1.5 mg L− 1 twice. The first application was applied at four weeks from sowing and the second application was added after two weeks from the first application. Compared to control, Se-NPs application mitigates the negative effect of salinity on plant growth to a variable extent. This improvement may be attributed to several factors such as increased the concentrations of photosynthetic pigments, total soluble sugars and total protein. In addition, Se-NPs alleviated the adversely effect of oxidative stress by increasing the antioxidant activities and potassium contents without markedly increase in the sodium content of the soybean leaf tissues. Also, Se-NPs enhanced the biosynthesis of secondary metabolites such as total phenolic content under salinity. Moreover, Se-NPs spray significantly reinforced the development of conducting secondary tissues in the leaves and roots of the treated plants. GmHKT1 gene transcription was markedly up-regulated in salinized soybean and foliar sprayed with Se-NPs as a molecular strategy to cope with the salinity. Based on the obtained results, among the different doses of Se-NPs, soybean plants sprayed with 1.0 mg L− 1 Se-NPs showed better salt tolerance. The foliar spray of Se-NPs may be considered as a promising approach to enhance salt tolerance in soybean plants, which could have significant implications for improving agricultural sustainability in salt-affected regions.
Spatial dynamics and drivers of recent changes in grass and shrub cover in submontane grassland plant communities
Authors: Hua Xiaobin , Ohlemüller Ralf , Sirguey Pascal
Published: September 2024

Shrub encroachment into grassland ecosystems has been increasingly observed and documented worldwide in recent years. A grass–shrub transition can affect the diversity, abundance and functional integrity of grassland plant communities and understanding the drivers behind these processes is therefore crucial. While potential environmental drivers are often investigated, the role of spatial patterns of neighbouring shrub density in local shrub encroachment has been less well studied. The aim of this study is to investigate the relative role of neighbouring shrub density and topography as potential key drivers of shrub encroachment in a typical montane grassland ecosystem in New Zealand. We used the SPOT (Satellite Pour l’Observation) 6/7 multispectral imagery captured on one day in 2013 and in 2017 to calculate recent changes in shrub/grass cover during this period. Using the Normalised Difference Vegetation Index (NDVI), we classified the study area into grassland and shrubland and quantified the extent and change in these two land-cover types over the study period. We then investigated the relationships between changes in land cover and neighbourhood shrub density, elevation and aspect. Between 2013 and 2017, there was an overall shrubland increase of + 0.35% of the study area per year, and grassland decrease of −0.43% per year. Locations at which any change in vegetation type occurred were more likely to be at mid-elevation (c. 600–1,000 m a.s.l.) and on west-facing slopes. Highest shrub expansion rates were observed on areas that were on warmer, north-facing slopes and at elevations below 900 m a.s.l.; this is consistent with areas below the pre-human, natural treeline which is estimated to be at very similar elevations. We found a marked threshold in the degree to which neighbourhood shrub density correlated with local shrub encroachment: local shrub encroachment only occurred when shrub cover in the neighbourhood exceeded 40% and peaked at c. 60% indicating the potential for a sudden grass–shrub regime shift once shrub cover reaches a certain level. Our study provides new evidence from the Southern Hemisphere of a measurable and interacting effect of topography and neighbourhood shrub density on recent shrub encroachment rates in montane grasslands even over short time periods.
A simple model for the estimation of turbofan engine performance in all airborne phases of flight
Authors: Poll D.I.A. , Schumann U.
Published: September 2024

The overall efficiency of a turbofan engine may be expressed as a function of the Mach number, flight level and one other parameter. This may be either the net thrust, the turbine entry temperature or the fuel flow rate. Using basic aero-thermodynamic principles, dimensional analysis, normalisation and curve fitting, five approximate and “near universal” relations have been identified for engines having bypass ratios between 1 and 13. These relations contain five independent characteristic engine parameters. When these parameters are known, the relations form the basis of an estimation method for engine overall efficiency that is simple, fast, open source, completely transparent and, as new information appears, capable of further refinement. Since the empirical relations presented in this analysis are valid for Mach numbers greater than 0.2, the method is applicable to all airborne phases of flight. For a given aircraft, if the flight trajectory is specified in sufficient detail for the variation of net thrust with Mach number and flight level to be determined, only three of the five relations, together with the value of engine overall efficiency at a single reference condition, are needed to estimate the overall efficiency at every point on the trajectory. Comparisons with the data used in this analysis suggest that the accuracy is better than ±5% in most cases. In the completely general case, two additional engine characteristic parameters, one a total temperature ratio and the other a Mach number, are introduced. If these are known, both engine overall efficiency and net thrust can be expressed as functions of Mach number, flight level and turbine entry temperature. This allows the method to be used for the estimation of operating limits in the various phases of flight and in simplified optimisation studies, e.g. finding the environmentally optimum flight trajectory.

In previous work, estimates of engine overall efficiency at the “design optimum” condition have been estimated for 53 aircraft and engine combinations. It is shown that the ‘design optimum’ condition is an appropriate choice for the engine reference condition. Updated and revised values for the relevant parameters for these 53 examples, together with estimates for the two additional engine characteristic parameters, are given in tabular form.
Natural Language Processing (NLP) Accurately Identifies LTCF Exposure from Clinical Notes: A Proof-of-Principle Study
Authors: Goodman Katherine , Resnik Philip , Taneja Monica , Magder Laurence , Sutherland Mark , Sorongon Scott , Klein Eili , Tamma Pranita , Harris Anthony
Published: September 2024

Background: Residence or recent stay in a long-term care facility (LTCF) is one of the most important risk factors for multidrug-resistant organism (MDRO) carriage and infection, making reliable identification of LTCF-exposed inpatients a critical priority for infection control day-to-day practice and research. However, because most hospital electronic health records (EHRs) do not include a dedicated field for documenting LTCF exposure, absent manual review of patient charts, identifying LTCF-exposed inpatients is challenging. We aimed to develop an automated, natural language processing (NLP)-based classifier for identifying LTCF exposure from clinical notes. Methods: We randomly sampled 1020 adult admissions from 2016-2021 across the 12-hospital University of Maryland Medical System and manually reviewed each admission’s history & physical (H&P) note for mention of LTCF exposure (Figure 1). After H&P pre-processing, we calculated feature representations for documents based on term frequencies and visually explored between-group (LTCF-exposed vs. LTCF-unexposed) feature differences. To predict LTCF status from the H&P notes, we trained and tuned a LASSO regression-based classifier on 70% of the data with 3-fold cross-validation and 1:1 up-sampling to address class imbalance. The final classifier was evaluated on the 30% held-out sample (not up-sampled), with calculation of the C-statistic (area-under-the-curve, AUC) with bootstrapped 95% confidence intervals, and construction of receiver-operating-characteristic and variable importance plots (R Version 4.3.2). Results: 7% (n=76 cases) of H&P notes documented LTCF exposure. In our visual analysis, the H&P words and phrases that were over-represented among LTCF patients had high face validity (Figure 2). The final LASSO-regression-based classifier achieved a C-statistic of 0.89 (95% CI: 0.80–0.98) on the held-out data for identifying LTCF exposure from the H&P notes (Figure 3). The most important model predictors (i.e., words) for distinguishing LTCF-exposed from LTCF-unexposed patients are reflected in Figure 4. The most important predictor-words of LTCF-exposure were “rehab,” “place,” “status,” “egd,” and “dementia.” Conclusion: In this multi-center study, even a simple NLP classifier demonstrated very strong discrimination for identifying LTCF exposure status from H&P notes, which could substantially reduce the manual review time required to identify LTCF-exposed inpatients. If automated in the electronic health record, it could also inform real-time MDRO screening decisions. Future research is planned to build more sophisticated classifiers using machine learning best practices, to build classifiers for additional MDRO risk factors, and to externally validate NLP classifiers on notes from an external healthcare system.
Burden of Healthcare-Associated Infections in a Pediatric Intensive Care Setting Before, During, and After the Pandemic
Authors: Engbretson Meghan , Schaffzin Josh , McNally Dayre , Gubb George , Thampi Nisha
Published: September 2024

Background: Adult rates of non-COVID-19-related healthcare-associated infection (HAI) initially decreased and subsequently increased during the COVID-19 pandemic. Little is known about pediatric HAI rates during this period. Methods: A retrospective review of HAIs was conducted for patients admitted to the intensive care unit (PICU) at a pediatric tertiary care hospital between January 1, 2019 and November 30, 2023. Patients who spent ≥48 hours in the PICU were included. Surgical site infections were excluded. Data were obtained from infection surveillance reports; each HAI was reviewed for validity and attribution based on National Healthcare Safety Network definitions. HAIs were grouped into 3 time periods: pre-pandemic (January 2019-February 2020), pandemic (March 2020- February 2022), and post-pandemic (March 2022-November 2023). Infection rate ratios were calculated for pre-pandemic and post-pandemic periods. Results: Among 2,959 PICU patients admitted during the study period, there were 60 HAI events (4.78 per 1,000 patient days). Rates generally remained steady throughout with slight increases and decreases between time periods (Table 1). There was no significant difference in CAUTI, CLABSI, or HAVRI rates noted in the PICU between pre-pandemic and post-pandemic periods despite a significantly higher device utilization ratio in the post-pandemic period for both urinary catheters and central lines (IRR, 0.89; p < 0 .05; 95% CI, 0.82-0.97). The most frequent HAI in all time periods was CAUTI. Conclusion: Unlike reports from adult centers, no significant variation between time periods was noted for HAIs in our pediatric center. Despite numerous COVID-19-related changes in infection prevention and control measures and contexts throughout the study period, HAI rates remained stable. This may be due in part to the lower burden of critically ill COVID-19 pediatric patients compared to adult populations. Additionally, this could indicate resiliency and consistency in practice among pediatric providers throughout the pandemic. Further evaluation of pediatric HAIs in the context of the COVID-19 pandemic may reveal practices that could be replicated elsewhere to control HAI rates.
Intervention Targets to Optimize Antibiotic Prescribing on Discharge from the Hospital to Nursing Homes
Authors: Furuno Jon , Noble Brie , Chan Dominic , Nguyen Thuan , Hildebrand Andrea , McGregor Jessina , Shephard Emily , Jolles Sally , Ham YoungYoon , Bearden David , McCracken Caitlin , Izumi Seiko , Crnich Christopher
Published: September 2024

Background: Approximately half of antibiotics used in nursing home (NHs) are initiated in acute care hospitals prior to NH admission. Optimizing antibiotic prescribing on hospital discharge to these facilities presents an opportunity to improve NH antibiotic use. We aimed to identify intervention targets to optimize antibiotic use on discharge from the hospital to NHs. Methods: This was a multicenter, cross-sectional study across 9 acute care hospitals in Oregon, Wisconsin, and Washington. We selected a 20% random sample of adult (age >18) inpatients prescribed at least one antibiotic on discharge from the hospital to a NH between 2016-2018. We excluded patients discharged from the emergency department or an intensive care unit. Study data were electronically extracted from patients’ electronic health records and supplemented with manual chart review. Antibiotic optimization opportunities were determined by an infectious diseases (ID) physician or ID pharmacist and classified as definitely, possibly, or unlikely. Expert reviewers also recorded the type of optimization opportunity and the rationale for each determination. A gamma lasso algorithm was used to identify patient-level characteristics associated with definite optimization opportunity, which were then included in a logistic regression model. Results: There were 2761 antibiotic prescriptions among 2215 patients. Mean (standard deviation) age was 71.9 (14.3) years and 48.8% were male. Most discharges (83.1%) were prescribed one antibiotic, 15.2% were prescribed two antibiotics, and 1.8% were prescribed three antibiotics. The most frequently prescribed antibiotics were cephalexin (10.4%), vancomycin (9.8%), and amoxicillin clavulanate (8.4%). Among the 2761 antibiotic prescriptions, expert reviewers determined that 18.4% could definitely be optimized, 36.0% could possibly be optimized, and 45.3% unlikely could have been optimized. Among the 508 definite antibiotic optimization opportunities, 25.2% were to subtract the antibiotic, 56.3% were to change the antibiotic, 11.0% were to change the dose, 25.0% were to change the duration, 0.8% were to change the route, and 1.8% were to change the schedule. Patient-level characteristics found to be associated with definite antibiotic optimization opportunity included age over 80 years (odds ratio (OR)=1.44, 95% confidence interval (CI): [1.14, 1.82]), length of stay < 8 days (OR=1.40, 95% CI: [1.09, 1.81]), discharge with multiple antibiotic prescriptions (OR=1.92, 95% CI: [1.39, 2.63]), and discharge with prescription for oral vs intravenous (IV) antibiotics (OR=2.08, 95% CI: [1.49, 2.95]). Conclusion: We identified several patient and antibiotic characteristics which may serve as intervention targets to optimize antibiotic prescribing on discharge from the hospital to nursing homes.
Infection prevention making a difference on statewide standardized infection ratios for device-associated HAIs from 2015-2022
Authors: Pranathi Bingi Sai , Stroever Stephanie
Published: September 2024

Background: Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) cause significant morbidity and mortality among hospitalized patients. Over the last 10 to 20 years, hospital accountability for the prevention of device-associated infections increased at the state and national levels. For example, the Centers for Medicare & Medicaid Services implemented the Hospital Inpatient Quality Reporting Program in 2015. The objective of this study was to assess the impact of increased federal attention on infection prevention using longitudinal data from the National Healthcare Safety Network (NHSN). We hypothesize that there was a significant decrease in statewide standardized infection ratios (SIRs) for CLABSI and CAUTI over the last 8 years. Methods: We collected SIRs for CLABSI and CAUTI in acute care hospitals for all 50 states and Washington D.C. from the NHSN database from 2015 to 2022. For CLABSI, we performed unique analyses for critical care units, wards, and neonatal intensive care (NICU) locations. For CAUTI, we stratified by critical care units and wards. We included all states with more than 5 hospitals reporting data. Those with fewer than 5 were excluded by listwise deletion in the corresponding analysis. We tested trends over time using linear mixed effect models with year as fixed effect and state as random effect. We also included an indicator variable representing the influence of SARS-CoV-2 (Covid-19) on healthcare-associated infections (HAIs). We elected an alpha of 0.05 as the threshold for statistical significance. Results: Overall, CLABSI and CAUTI SIRs exhibited significant negative slopes (Figures 1-5) after controlling for the influence of Covid-19. Each analysis revealed progressively lower SIRs compared to the previous year except for the 2019-2020 interval. Interestingly, the linear trend resumed after 2020 with subsequently lower SIRs in 2021 and 2022. Covid-19 had a greater influence on CLABSI SIRs in critical care settings compared to ward or NICU locations. The slope of CAUTI SIRs were impacted less by Covid-19 in wards compared to critical care settings. Conclusion: The results of the analysis demonstrate that CLABSI and CAUTI are trending in the desired direction despite the HAI spike during Covid-19. Government and hospital stakeholders in the United States should be encouraged by the reported trends and continue to prioritize the funding and use of resources for evidence-based device-associated infection prevention.
Quantity versus Quality: Chlorhexidine Bathing Adequacy Assessments in 3 High-Risk Units
Authors: Doll Michelle , Rittmann Barry , Ching Patrick , Cooper Kaila , Major Yvette , Bearman Gonzalo
Published: September 2024

Background: Chlorhexidine gluconate bathing (CHGB) prevents healthcare associated infections (HAIs). CHGB quality is rarely assessed; prior studies identified that concentrations of CHG can be suboptimal, particularly at the neck, and if rinsed after application. In the setting of increased HAI rates on 3 high-risk units, we evaluated CHG skin concentrations, comparing results to bathing documentation and patient reports as part of a quality improvement initiative. Methods: All patients admitted to 3 high-risk units were swabbed for CHG concentration testing at the neck, bilateral upper arms, and groin. Swabs were processed using a semi-quantitative colorimetric CHG assay. A threshold of 0.001875% CHG was used to determine adequacy based on prior studies. Adequacy was assessed by body site, timing of bath, and patient-reported skin care activities using Chi-square tests in SAS 9.4. Per hospital policy, all admitted patients are bathed daily with 2% CHG pre-packed wipes. Patients without a documented CHGB for the duration of the admission were excluded. Results: CHG testing was completed on 63 patients: 23 on medical ICU, 18 surgical ICU, 22 oncology ward, yielding 249 samples. Only ward patients could report the time of last CHGB, which agreed with nursing documentation for 12/21(57%) Adequacy by sample was no different across units: 59/88(67%) Oncology, 68/90(76%) MICU, 56/71(79%) SICU, p=0.2091. Site adequacy was different by site: neck 36/63(57%), left arm 49/62(79%), right arm 50/62(81%), groin 48/62(77%), p=0.0083. Samples taken from the 11 patients with > = 24 hours since last CHGB were more likely to be below threshold concentration: 19/47(40%) versus 47/202(23%) not adequate in the recent treatment grouping. Three patients reported showering soon after the CHGB and 8 patients used moisturizing lotion. The percent of samples below threshold for the showering patients (6/12, 50%) and lotion-users (11/32, 34%) were not significantly different from the non-showering or non-lotion using patient samples (p=0.0588 and 0.2800 respectively). Conclusion: In a facility with longstanding daily CHGB policies in place, 66/249 samples from 63 patients lacked adequate concentrations of CHG for optimal HAI prevention. Even in patients with recent CHGB, 23% of sites tested revealed inadequate levels of CHG, while 60% of those overdue for CHGB kept adequate concentrations. Reliable implementation strategies are required for CHGB so as to ensure maximal infection prevention impact.
Extended-Spectrum Beta-Lactamase Producing Enterobacterales Infections in the United States, 2012-2021
Authors: Maillis Alexander , McCarthy Natalie , Wolford Hannah , Baggs James , Reddy Sujan , Lutgring Joseph
Published: September 2024

Background: The 2022 Special Report: COVID-19 U.S. Impact on Antimicrobial Resistance identified continued increases in the rate of extended- spectrum beta-lactamase producing (ESBL) infections in the United States from 2017 through 2020. Using similar data sources and methodology, we examined the trends of species-specific ESBL infections from 2012-2021. Methods: We identified a cohort of patients from the PINC AI and BD Research Insights databases with a clinical culture yielding a Klebsiella pneumoniae or Escherichia coli isolate with accompanying susceptibility testing. E. coli or K. pneumoniae isolates non-susceptible to ceftriaxone, cefotaxime, ceftazidime, or cefepime were considered suggestive of ESBL production. Isolates from patients with no culture yielding the same resistance phenotype of interest in the previous 14 days were counted as an incident case. Community-onset (CO) cultures were obtained ≤ day 3 of hospitalization; hospital-onset (HO) cultures were obtained ≥ day 4. We used a raking procedure to determine weights for extrapolating the number of discharges included in our sample to match the distribution of discharges, stratified by bed size, U.S. census division, urban/rural designation, and teaching status, for U.S. hospitals included in the American Hospital Association survey. We evaluated rates over time due to the changes in number of hospitalizations during the COVID-19 pandemic. Results were stratified by HO and CO, and sterile and non-sterile specimen sources. Results: In 2021, there were 48,936 ESBL K. pneumoniae and 153,112 ESBL E. coli infections among approximately 32 million discharges. Overall, most infections were CO and from non-sterile specimens. From 2012-2021, the rate of ESBL K. pneumoniae increased from 9.54 to 15.28 per 10,000 discharges. ESBL E. coli infections increased from 2012-2020 (30.18 to 51.32 per 10,000 discharges), then declined in 2021 (47.81 per 10,000 discharges) (Table 1, Figure 1). The proportion of non-sterile ESBL E. coli declined from 88% in 2012 to 83% in 2021, and the proportion of non-sterile ESBL K. pneumoniae was 85-87% over the study period (Figure 2). Conclusion: ESBL E. coli and K. pneumoniae infections increased from 2012-2021, although the CO ESBL E. coli rate decreased between 2020 and 2021. Understanding changes in culturing practices over time may provide insights into the increased proportion of ESBL E. coli from sterile sites. Additionally, further investigation into differences in organism trends, particularly in 2021, may inform prevention strategies.
Fluoroquinolones in Focus: Unraveling Prescription Trends among Clinician Specialties in Washington State
Authors: Evans David , Zering Jessica , Stohs Erica , D’Angeli Marisa , Katarina Kamenar
Published: September 2024

Background: An overall decrease of prescriptions for outpatient fluoroquinolones (FQs) following the FDA’s release of boxed warnings in 2016 was shown in a previous analysis1. An additional study found that this decline held true when further broken down by specialty 2. We sought to determine which different clinician specialties in Washington State (WA) continue to prescribe FQs and if these rates are congruent with previously conducted national analyses. Methods: We conducted a comprehensive analysis of Medicare Part D data from 2021. We identified specialty types contributing the highest proportions of FQ claims from the total volume of claims in 2021. Subsequently, we calculated the average FQ claims per 1,000 Medicare Part D beneficiaries for each specialty. The analysis excluded providers with missing beneficiary data. All dosage formulations were included (i.e. topical & oral). We repeated this process for each year from 2021 to 2013 to assess changes in the average FQ prescription rate for each specialty over time. Results: Our analysis encompassed 99,250 FQ prescriptions involving 976,209 Medicare Part D beneficiaries from January 1 to December 30, 2021. Among the specialties, urologists emerged as the highest prescribers of FQs to Medicare Part D beneficiaries, closely followed by ophthalmologists and family practitioners (Table 1). Notably, 72.4% of urologists prescribed FQs, while only 12.4% of family practitioners did so in 2021. Trend analysis indicated that the average FQ claims per 1,000 beneficiaries for urologists decreased from 251 claims per 1,000 beneficiaries (SD = 177.98) in 2013 to 130 claims per 1,000 beneficiaries (SD = 122.50) in 2021 (Figure 1A). In contrast, the only specialty types that had positive trends in average FQ claims per 1,000 beneficiaries from 2013 to 2021 included ophthalmologists, optometrists, and otolaryngologists (Figure 1A). Conclusion: Throughout the years leading up to 2021, most prescriber specialties contributing high volumes of FQ claims experienced a decline in FQ prescriptions. The positive trend noted amongst ophthalmologists, optometrists, and otolaryngologists could be due to the limited ability to differentiate between oral & topical FQ formulations within the dataset. These findings underscore the importance of understanding specialist prescribing behaviors and partnering with them to formulate tailored antibiotic stewardship guidance. By doing so, we can further promote patient safety and well-being in the context of FQ usage. Public health departments can promote more holistic antibiotic stewardship interventions and better patient safety outcomes with FQs. Ambulatory Fluoroquinolone Use in the United States 2015–2019 Outpatient Fluoroquinolone Prescription Fills.

Disclosure: Erica Stohs: Contracted research - Merck; Contracted research – bioMerieux
Antimicrobial Use Rates by Patient Care Units using NHSN Antimicrobial Use Option in TN Reporting Facilities, 2015–2023
Authors: Patel Dipen M , Mutamba Glodi , Wren Callyn , Evans Christopher
Published: September 2024

Background: Tracking antimicrobial use (AU) is a Core Element of Hospital Antimicrobial Stewardship Programs and important to help curb the public health threat of antimicrobial resistance. The National Healthcare Safety Network’s (NHSN) AU Option serves as a way for facilities, healthcare systems, and health departments to track and report AU rates within their jurisdictions. Many analyses at the state and national levels do not assess unit-level AU rates. This study investigates AU rates among patient care units in Tennessee reporting facilities from 2015 to 2023 and the most frequently used antimicrobial agents based on AU rates within select unit types. Methods: A retrospective analysis was conducted utilizing data obtained from the NHSN AU Option for inpatient units in Tennessee acute care hospitals. Units were defined as critical care (including neonatal), ward, oncology ward, stepdown, operating room (OR), and mixed acuity and specialty care areas, termed ‘other’. Unit types with fewer than five facilities represented were excluded. AU rates were determined by Antimicrobial Days of Therapy (DOT) per 1000 Days Present (DP). Statistical analyses , including descriptive statistics and comparison among the units by ANOVA test , were calculated using SAS Version 9.4. Results: Eighty-three facilities reported at least one month of data into the NHSN AU Option between 2015–2023. Among 70 facilities reporting inpatient units, the highest AU rate was observed in oncology ward units (n=12, 1114.6 DOT/1000 DP). A significant difference in AU rates was observed between oncology ward units compared to different unit types (p < 0 .001). Vancomycin, ceftriaxone, and piperacillin/tazobactam were the most used antimicrobials with AU rates of 83, 76, and 65 DOT/1000 DP, respectively. Vancomycin AU rates were significantly higher in oncology ward units compared to stepdown, ward, other, and OR units (p < 0 .0001). Ceftriaxone AU rate was significantly higher in stepdown units compared to oncology ward, other, and OR units (p < 0 .0001). Piperacillin/tazobactam AU rate was significantly higher in critical care units compared to different unit types (p < 0 .0001). Conclusion: During the study period, the AU rate varied across hospital inpatient units in Tennessee, with the highest AU rate in oncology wards. This unit-specific approach is critical to address the diverse antimicrobial prescribing behaviors observed, indicating that interventions should be customized to each unit’s distinct antimicrobial usage patterns for successful stewardship efforts. Targeted strategies focused on individual wards rather than facility-wide initiatives appear essential for effective reduction in antibiotic usage.