bluuebunny/crossref_metadata_2025_split huggingface dataset:
Evaluation of Procalcitonin Use in Patients Discharged from the Emergency Department with Acute Respiratory Infection
Authors: Fontaine Garrett , Banach David , Aeschlimann Jeffrey 
Published: November 2021

Background: Acute respiratory infections (ARIs) contribute significantly to inappropriate antimicrobial prescription. The rate of such prescriptions in US emergency departments (EDs) has remained stable over time. The use of procalcitonin (PCT) testing has been shown to lower risk of mortality and to reduce antibiotic consumption. It also has the potential to aid ED physicians in stratifying ARI patients who may require antibiotics but do not require hospital admission. In this study, we described the characteristics and proportion of antibiotic prescription in patients evaluated in and discharged from the ED with ARI. Methods: We performed a retrospective chart review of patients diagnosed with ARI and discharged from a single academic ED between January 2018 and January 2020. We compared those for whom a PCT test was ordered to those without a PCT test ordered at ARI diagnosis. Charts were reviewed until there were 110 subjects in each of the 2 study groups. The main outcome variable was receipt of an antibiotic prescription. The χ2 test was used to compare the proportion of patients who received an antibiotic prescription, demographics, and clinical characteristics between the 2 groups. The Mann-Whitney U test was used to compare the distribution of ages between the 2 groups. Results: Among patients in the PCT group, 87 (79.0%) received antibiotics versus 69 (62.7%) in the non-PCT group (P ± 18.8 vs 52.7 years ± 17.6; P = .0002); more likely to have preexisting heart and lung disease (28.2% vs 15.5%; P = .02); more often male (58.2% vs 40%; p < 0.01); had more subjective fevers (47.3% vs 33.6%, p=0.04), sputum production (49.1% vs 28.2%, p < 0.01), and nausea (17.3% vs 8.2%, p=0.04). PCT results were low (≤0.25) in 82.7% (91) of patients, of whom 70.3% (64) received antibiotics. Conclusions: Patients for whom PCT testing was ordered were older, had more underlying conditions and increased severity of illness. This finding may reflect that PCT testing was more likely to be ordered in patients at risk of severe infection but not requiring admission. The proportion of antibiotics prescriptions was higher for patients who had a PCT test. For patients with a low PCT result, the proportion of patients prescribed antibiotics was high. This finding may suggest that clinical characteristics were more influential than PCT result in the decision to prescribe antibiotics. More research is needed on the role of PCT testing in antibiotic prescription decisions for patients presenting to the ED with ARI.Funding: NoDisclosures: None
Evaluation of Penicillin Allergy Prevalence and Antibiotic Prescribing Patterns for Patients within the Emergency Department
Authors: Norris Ashlyn , Daniels Lindsay , Mavrogiorgos Nikolaos , Northam Kalynn , Kwan Mildred , Burke Gary , Boerneke Renae 
Published: November 2021

As the point of entry into healthcare for many patients, the emergency department (ED) is an ideal setting in which to assess penicillin (PCN) allergies. An estimated 10% of the United States population has a reported PCN allergy; however, few studies have evaluated the prevalence and impact of PCN allergies on antibiotic selection within the ED. Patients with a documented PCN allergy are more likely to be exposed to costly alternative broad-spectrum antibiotics that have higher rates of adverse events, including C. difficile infections. We sought to determine the prevalence of PCN allergies within the UNC Medical Center ED. Key secondary outcomes included the percentage of patients with a documented PCN allergy who (1) received alternative antibiotics (carbapenems, aztreonam, fluoroquinolones, clindamycin, vancomycin), (2) received β-lactam antibiotics and experienced an allergic reaction during their ED visit, and/or (3) had received a β-lactam antibiotic during a past hospitalization or ED visit without their chart being appropriately updated. A retrospective evaluation included patients aged >18 years with a documented PCN allergy who were discharged from the ED between January 1, 2017, and December 31, 2019. Over the study period, there were 14,635 patient encounters with a documented PCN allergy that comprised 8,573 unique patients. The prevalence of PCN allergies was 14.3% for all ED encounters. PCN allergy–labeled patients received alternative antibiotics in 59.4% of ED encounters in which antibiotics were prescribed. Of the 454 β-lactam antibiotics (62 penicillins, 380 cephalosporins, 12 carbapenems) administered to PCN allergy-labeled patients within the ED, there were zero allergic reactions. Also, 18.6% of PCN allergy-labeled patients had received and tolerated a β-lactam antibiotic during prior hospitalizations or ED visits (1.7% penicillins, 14.4% cephalosporins, 2.6% carbapenems) without appropriate updated documentation to reflect β-lactam antibiotic tolerance. These findings confirm the utilization of non–β-lactam antibiotics in PCN allergy-labeled patients, highlighting the importance of accurate and updated allergy documentation in the electronic medical record. These findings also demonstrate the need for improved allergy documentation and protocols to proactively assess penicillin allergy labels while in the ED.Funding: NoDisclosures: None
Associations Between Patient Neighborhood Characteristics and Inappropriate Antimicrobial Use
Authors: Engeda Joseph , Kriengkauykiat Jane , Epson Erin 
Published: November 2021

Background: Antimicrobials are among the most commonly prescribed medications in US hospitals; an estimated 50% of hospitalized patients receive an antimicrobial. Research has shown that antimicrobial prescriptions to vary by patient- and hospital-level factors; however, disparities by patient neighborhood characteristics have not been examined. We evaluated associations between hospital and neighborhood indicators of socioeconomic status (SES) and antimicrobial use (AU) for gram-positive bacterial infections (GPBs), and broad-spectrum use for community-acquired infections (BSCAs) and hospital-onset infections (BSHOs). Methods: This analysis was conducted among 86 acute-care hospitals in California that submitted AU data via the NHSN in 2019. Hospital-level AU was measured as standardized antimicrobial administration ratios (SAARs) calculated by dividing observed antimicrobial use by risk-adjusted predicted antimicrobial use for GPB, BSCA, and BSHO antimicrobial groupings and categorized as binary (>1 or <1); SAARs >1 indicate potential inappropriate prescribing. California Office of Statewide Health Planning and Development 2018 data were used to obtain hospital characteristics and patient age, race or ethnicity, insurance, and comorbidities (defined by Charlson comorbidity index) for hospitalizations where AU may have been indicated, based on International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes. The California Healthy Places Index (HPI) was used to obtain composite neighborhood SES indicators for each patient at the ZIP code level, measured as tertiles. Covariates were aggregated to the hospital level. Poisson regressions were used to evaluate the association between hospital and neighborhood SES indicators and SAAR scores, controlling for potential hospital-level confounders. Results: Among 86 hospitals included in the analysis, the mean patient age for hospitalizations where AU may have been indicated was 66 years, the proportion of white patients was 55%, and the mean proportion of Medi-Cal users was 19%. After adjusting for confounders including age, race or ethnicity, insurance status, comorbidities, and number of hospital beds; higher median values of patient SES had a protective effect against hospitals having GP SAAR scores > 1 (relative risk [RR], 0.68; 95% CI, 0.50–0.93) but was not significantly associated with hospitals having BSCA SAAR scores >1 (RR, 0.79; 95% CI, 0.62–1.02) or BSHO SAAR scores >1 (RR, 0.80; 95% CI, 0.61–1.04). Conclusions: Considering SES in addition to summary antimicrobial use scores such as SAARs may help identify populations potentially at risk for inappropriate AU; however, patient-level information is still necessary to evaluate appropriateness of antimicrobial prescribing.Funding: NoDisclosures: None
Clinical Characteristics and Fecal Microbiome in Recurrent Versus Nonrecurrent Clostridioides difficile Infection
Authors: Lanjewar Swapnil , Kates Ashley , Watson Lauren , Safdar Nasia 
Published: November 2021

Background: Up to 30% of patients with Clostridioides difficile infection (CDI) develop recurrent infection, which is associated with a 33% increased risk of mortality at 180 days. The gut microbiome plays a key role in initial and recurrent episodes of CDI. We examined the clinical characteristics and gut microbial diversity in patients with recurrent (rCDI) versus nonrecurrent CDI at a tertiary-care academic medical center. Methods: Stool samples were collected from 113 patients diagnosed with CDI between 2018 and 2019. Clinical and demographic data were extracted from the electronic medical record (Table 1), and 16S rRNA sequencing of the v4 region was carried out on the Illumina MiSeq using 2×250 paired-end reads. Sequences were binned into operational taxonomic units (OTUs) using mothur and were classified to the genus level whenever possible using the ribosomal database project data set version 16. Alpha diversity was calculated using the Shannon diversity index. Β diversity was calculated using the Bray-Curtis dissimilarity matrix. Differential abundance testing was done using DESeq to assess taxonomic differences between groups. A P value of .05 was used to assess significance. Results: In total, 55 patients had rCDI (prior positive C. difficile polymerase chain reaction in last 7–365 days) and 58 had nonrecurrent CDI (Table 1). Patients with rCDI had a higher frequency of organ transplant and comorbidity. No differences in α not β diversity were observed between groups. Also, 4 OTUs were more abundant in those with rCDI: Ruminococcus (n = 2), Odoribacter, and Lactobacillus. Patients with rCDI had microbiomes with greater proportions of Bacteroidetes (27% of OTUs) compared to the nonrecurrent group (18%) as well as fewer OTUs belonging to the Firmicutes phyla compared to the nonrecurrent patients (56% vs 59%). Among the rCDI patients, those experiencing 2 or more recurrences had greater abundances of Bacteroides and Ruminococcus, while those experiencing only 1 recurrence had significantly greater abundances of Akkermensia, Ruminococcus, Streptococcus, Roseburia, Clostridium IV, and Collinsella compared to those with only 1 recurrence (Table 2). Conclusions: Patients with rCDI had a more impaired microbiome than those with initial CDI. Ruminococcus OTUs have been previously indicated as a risk factor for recurrence and treatment failure, and they were significantly more abundant in those with rCDI and among those with multiple recurrences. The greatest differences in the microbiome were observed between those with 1 recurrence compared to those with multiple recurrences. Interventions for gut microbiome restoration should focus particularly on those with recurrent CDI.Funding: NoDisclosures: None
Did Clostridioides difficile Testing and Infection Rates Change During the COVID-19 Pandemic?
Authors: Hawes Armani , Patel Payal , Desai Angel 
Published: November 2021

Background: The COVID-19 pandemic has underscored the importance of ongoing infection prevention efforts. Increased adherence to infection prevention recommendations, increased antibiotic use, improved hand hygiene, and correct donning and doffing of personal protective equipment may have influenced healthcare-associated infections (HAIs) in the United States during the pandemic. In this study, we investigated testing for Clostridioides difficile infection (CDI) and incidence during the initial surge of the pandemic. We hypothesized that strict adherence to contact precautions may have resulted in a decreased incidence of CDI in hospitalized patients during the first peak of the COVID-19 pandemic and that CDI testing may have increased even in the absence of directed diagnostic stewardship efforts. Methods: We conducted a single-center, retrospective, observational study at the Veterans’ Affairs (VA) Hospital in Ann Arbor, Michigan, between January 2019 and June 2020. We compared data on CDI tests from January 2019 through February 2020 to data from March 2020 (the admission of the first patient with COVID-19 at our institution) through June 2020. Pre-peak and peak periods were defined by confirmed cases in Washtenaw County. No novel diagnostic or CDI-focused stewardship interventions were introduced by the antimicrobial stewardship program during the study period. An interrupted time series analysis was performed using STATA version 16.1 software (StataCorp LLC, College Station, TX). Results: There were 6,525 admissions and 34,533 bed days between January 1, 2019, and June 30, 2020. Also, 900 enzyme immunoassay (EIA) tests were obtained and 104 positive cases of CDI were detected between January 2019 and June 2020. A statistically significant decrease in EIA tests occurred after March 1, 2020 (the COVID-19 peak in our region) compared to January 1, 2019–March 1, 2020 (Figure 1). After March 1, 2020, the number of EIA tests obtained decreased by 10.2 each month (95% CI, −18.7 to −1.7; P = .02). No statistically significant change in the incidence of CDI occurred. The use of antibiotics that were defined as high risk for CDI increased in the months of April–June 2020 (Figure 2). Conclusions: In this single-center study, we observed a stable incidence of CDI but decreased testing during the first peak of the COVID-19 pandemic. Understanding local HAI reporting is critical because changes in HAI reporting structures and exemptions during this period may have affected national reporting. Further research should be undertaken to investigate the effect of COVID-19 on other HAI reporting within the US healthcare system.Funding: NoDisclosures: None
The COVID-19 Pandemic and Antibiotic Use on the United States–Mexico Border
Authors: Khan Sana , Ellingson Katherine , Parra Gemma , Villanueva Juan , Garrido Carlos 
Published: November 2021

Background: The US–Mexico border represents a unique region of the country where antibiotics are more accessible and nonprescription treatment with antibiotics is deeply enculturated. Currently, both the United States and Mexico are experiencing widespread community transmission of SARS-CoV-2, which may have implications for antibiotic seeking and use. The objective of this study was to examine antibiotic seeking behavior as it relates to COVID-19 in the border region relative to the greater US and Mexico populations. Methods: An interdisciplinary team at The University of Arizona developed a survey to assess knowledge, attitudes, and beliefs about antibiotics along the US–Mexico border region (defined as 100 km from the border) and to compare findings from the border region to the broader US and Mexico populations. The team recruited survey participants through Amazon’s MTurk survey platform and through the distribution of recruitment flyers to community partners in Arizona and Mexico border regions from October 2020 to January 2021. Targeted recruitment was 750 through March 2021. We report here on findings from the first round of recruitment (n = 116). These participants were asked whether they had sought out antibiotics specifically as a treatment for COVID-19, as well as their general beliefs and behaviors on self-seeking antibiotics for illness. Results: As of January 24, 2021, we surveyed 116 participants: 82 (70.7%) from the United States and 34 (29.3%) from Mexico. Most participants (71.2%) were aged 25–44 years; 56.9% were male; and 50% reported Hispanic ethnicity. Of these, 13.8% lived within 100 km of the US–Mexico border. Overall, 21.6% of participants reported taking antibiotics to fight COVID-19–like illness. Of these participants, 28% obtained the antibiotics directly from a pharmacy, without a physician prescription, and 16% obtained them from an online vendor. Additionally, 33% of US respondents reported that they would be willing to travel to Mexico to obtain antibiotics if they were too difficult to obtain in the United States. Of these respondents, 55% said they would be willing to travel for >1 hour to obtain antibiotics. Conclusions: Preliminary data suggest that the COVID-19 pandemic will have widespread ramifications on antibiotic seeking behavior and could propagate antibiotic resistance. Targeted intervention strategies in the border region are necessary to mitigate the unique factors that contribute to antibiotic use in this area.Funding: NoDisclosures: None
Prevalence of SARS-CoV-2 Antibody in Healthcare Workers in Central Pennsylvania
Authors: Kwon Taesung , Kenyon Stacy , Kilheeney Kimberly , Martin Stanley , Shelly Mark 
Published: November 2021

Background: Determining the incidence of SARS-CoV-2 in healthcare workers (HCW) is important in assessing the safety of the work environment. Though of limited use in acute illness, serologic testing can detect some infections that occur undetected. We compared the prevalence of antibodies to SARS-CoV-2 to a place of work, exposure by role and department, and use of various prevention methods. Methods: Healthcare workers (HCWs) working in Geisinger Health System were offered voluntary serology through Employee Health. Before they had blood taken, they completed a brief questionnaire. Testing was conducted from June 15 to September 4, 2020. Blood was analyzed for SARS-CoV-2 immunoglobulin G (IgG) (Roche and Diasorin platforms). Results: In total, 2,295 employees and contract workers providing care at Geisinger facilities were tested. Most of this group, 2,037 (88.8%), were involved in direct patient care. In total, 101 tests returned positive, a rate of 4.4% (95% CI, 3.6%–5.3%). Of 54 HCWs with a positive NAAT for SARS-CoV-2, positive serology results were found in 48, a sensitivity of 89% (95% CI, 78%–95%). Those involved in patient care were slightly more likely to become infected, 91 of 2,037 (4.6%) compared to 10 of 258 who were not involved in patient care (3.9%; P = .68). Those with unprotected exposure to a known case of COVID-19 were more likely than those not exposed to be positive for SARS-CoV-2, 51 of 792 (6.4% vs 3.3%; P = .0008). This risk was highest for those exposed outside work (7 of 33; 21%; P = .003). HCWs working in COVID-19 units were positive at a rate of 4.0% (95% CI, 3.8%–5.4%), no more than other inpatient areas, which were 5.0% positive (95% CI, 3.8%–6.4%). HCWs working with outpatients were at slightly lower risk, 2.8% positivity (95% CI, 1.9%–4.1%). The rates of infection ranged between 3.3% and 5.0% by job category. Employees were asked about symptoms experienced since March 2020. Positive serology occurred in 39 (2.8%) of 1,414 employees who did not recall any symptoms. Symptoms related to COVID-19, except sore throat, were strongly correlated with positive serology. Conclusions: When provided a safe work environment, the risk of COVID-19 in employees is comparable to that in the surrounding communities. Persons with patient care responsibilities have an absolute risk that is marginally higher.Funding: NoDisclosures: None
From curves to currents
Authors: Martínez-Granado Dídac , Thurston Dylan P. 
Published: November 2021

Abstract
Many natural real-valued functions of closed curves are known to extend continuously to the larger space of geodesic currents. For instance, the extension of length with respect to a fixed hyperbolic metric was a motivating example for the development of geodesic currents. We give a simple criterion on a curve function that guarantees a continuous extension to geodesic currents. The main condition of our criterion is the smoothing property, which has played a role in the study of systoles of translation lengths for Anosov representations. It is easy to see that our criterion is satisfied for almost all known examples of continuous functions on geodesic currents, such as nonpositively curved lengths or stable lengths for surface groups, while also applying to new examples like extremal length. We use this extension to obtain a new curve counting result for extremal length.
Perinatal mental healthcare in Northern Ireland: challenges and opportunities
Authors: Mongan D. , Lynch J. , Anderson J. , Robinson L. , Mulholland C. 
Published: November 2021

AbstractPerinatal mental health is a vital component of public mental health. The perinatal period represents the time in a woman’s life when she is at the highest risk of developing new-onset psychiatric disorders or relapse of an existing mental illness. Optimisation of maternal mental health in the perinatal period is associated with both short- and long-term benefits not only for the mother, but also for her infant and family. However, perinatal mental health service provision remains variable across the world. At present in Northern Ireland, 80% of women do not have access to specialist community perinatal mental health services, and without access to a mother and baby unit, mothers who require a psychiatric admission in the postnatal period are separated from their baby. However, following successful campaigns, funding for development of specialist perinatal mental health community teams has recently been approved. In this article, we discuss the importance of perinatal mental health from a public health perspective and explore challenges and opportunities in the ongoing journey of specialist service development in Northern Ireland.
FUJITA DECOMPOSITION AND MASSEY PRODUCT FOR FIBERED VARIETIES
Authors: RIZZI LUCA , ZUCCONI FRANCESCO 
Published: November 2021

AbstractLet$f\colon X\to B$be a semistable fibration whereXis a smooth variety of dimension$n\geq 2$andBis a smooth curve. We give the structure theorem for the local system of the relative$1$-forms and of the relative top forms. This gives a neat interpretation of the second Fujita decomposition of$f_*\omega _{X/B}$. We apply our interpretation to show the existence, up to base change, of higher irrational pencils and on the finiteness of the associated monodromy representations under natural Castelnuovo-type hypothesis on local subsystems. Finally, we give a criterion to have thatXis not of Albanese general type if$B=\mathbb {P}^1$.
Kymlicka’s Alignment of Mill and Engels: Nationality, Civilization, and Coercive Assimilation
Authors: Beaumont Tim 
Published: November 2021

AbstractJohn Stuart Mill claims that free institutions are next to impossible in a multinational state. According to Will Kymlicka, this leads him to embrace policies kindred to those of Friedrich Engels, aimed at promoting mononational states in Europe through coercive assimilation. Given Mill’s harm principle, such coercive assimilation would have to be justified either paternalistically, in terms of its civilizing effects upon the would-be assimilated, or non-paternalistically, with reference to the danger that their non-assimilation would pose to others. However, neither possible interpretation is plausible; Mill takes Europe’s civilized status to shield Europeans from paternalistic coercion, and he opposes coercive assimilation where it could conceivably be justified in the name of defense. Although this much suggests that Kymlicka misinterprets Mill by ignoring his definition ofnationality, it leaves scope for Kymlicka to argue that Mill favors policies that promote mononationality through neglecting the languages and cultures of national minorities.