Introduction: Hand hygiene compliance in healthcare settings is significantly influenced by the acceptability and skin tolerability of hand sanitisers. Conventional alcohol-based hand rubs have been associated with increasing incidences of skin dryness, irritation, and contact dermatitis with repeated application, leading to reduced compliance and limited alternatives for staff with skin sensitivities. This challenge has become more prominent with the convergence of occupational skin health and environmental sustainability goals in healthcare settings worldwide, underscoring the need for alternative hand hygiene solutions that protect skin integrity whilst supporting compliance targets and staff well-being. Objectives: To assess healthcare workers' acceptance and tolerability of an organic bioethanol-based hand rub as a potential alternative to conventional alcohol-based hand sanitisers. Methods: A non-blinded study was conducted over one-month with 41 healthcare workers (29 nurses, 4 doctors, 6 ancillary staff, and 2 allied health workers) recruited through convenience sampling at Singapore General Hospital. Participants received a bioethanol-based hand rub (Saniswiss Sanitizer H1) containing bioethanol (72% concentration), moisturising agents, and super-fatting agents (perfume- and fragrance-free) in 100mL or 500mL bottles with ongoing replenishment. Data collection occurred at three time points: baseline (initial skin integrity assessment), 3-5 days post-implementation (follow-up questionnaire), and one month (final questionnaire and hand rub consumption calculation). Questionnaires were administered via FormSG platform with data analysed using Microsoft Excel. Results: Average consumption was 380mL per participant, with nurses demonstrating highest usage at 400mL. Initial skin assessment identified 17 participants with pre-existing dry skin and/or redness, which decreased to 6 participants reporting mild symptoms by study completion. User acceptance was high: 98% rated colour as pleasant or very pleasant, 95% approved of smell, 76% reported no sticky residue, 95% experienced no stinging sensation, 71% found the hand rub non-drying, and 90% rated drying speed as fast or very fast. Overall satisfaction reached 98% after 3-5 days and maintained 92% after one month. Notably, 82% believed the product could enhance hand hygiene compliance, and 68% preferred the bioethanol-based hand rub over conventional sanitiser. Conclusion: Bioethanol-based hand rub demonstrated excellent user acceptance and skin tolerability among healthcare workers. The significant reduction in skin-related complaints, combined with high satisfaction rates and improved skin condition despite frequent use, supports its potential implementation as an effective alternative hand hygiene solution for healthcare workers, particularly those with contact dermatitis. Figure 1: Progression of skin scale scores during study period Figure 2: Breakdown of Product Preferences Across Professional Group

Background: Carbapenemase-producing (CP) organisms (CPOs), including Enterobacterales (CRE), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPA), harbor carbapenemase genes that confer resistance and cause transmissible, difficult-to-treat infections, particularly in healthcare settings. In September 2022, California expanded reporting from CP-CREs to all CPOs. Through 2023, the state noted rising cases, multiple gene mechanisms, and rare combinations like NDM CRAB spreading statewide. However, recent data on all reportable CPOs remain limited. This analysis examines organism and gene distribution and annual trends in San Francisco (SF) following reporting expansion. Methods: We reviewed CPO cases, defined as isolates with a specific organism-carbapenemase gene combination, reported by SF healthcare facilities from January 1, 2023 to September 30, 2025. Clinical isolates were genetically characterized by local/state public health laboratories. Demographics, clinical, and epidemiological characteristics were analyzed. Crude incidence rates (IR) were calculated using SF population estimates, and temporal trends assessed using Poisson regression. Result: A total of 126 cases from 101 patients were included. Among these patients, median age was 64 years; 59 (58%) were male, and 68 (67%) resided outside SF. Of 126 cases, most were identified in short-term (70%) and long-term (18%) acute care hospitals (STACH and LTACH); 93% were healthcare-associated. CPO cases included 79 (63%) CP-CRE, 32 (25%) CP-CRAB, 5 (4%) CP-CRPA, and 10 (7.9%) unknown/other. Among the CP-CREs, Klebsiella pneumoniae (33%), Escherichia coli (32%), and Enterobacter cloacae (11%) predominated. Common specimen sources included urine (25%), respiratory (25%), and rectal (screening, 19%). CP-CREs were mainly associated with KPC (41%) and NDM (35%), while CP-CRAB frequently harbored OXA-variants (31%) and multiple mechanisms (31%, all NDM plus OXA-variant). Crude IR increased in 2024 to 6.3 cases/100,000 persons, driven by CP-CRE (4.5 cases/100,000 persons). NDM predominated in 2024 (2.4 cases/100,000 persons) before declining below KPC in 2025 (NDM: 1.3; KPC: 1.5 cases/100,000 persons). Incidence was highest among males and adults aged 65-79 years. No significant monthly trend was observed (IRR = 1.00, p = 0.74). Conclusion: Cases in SF increased from 2023 to 2024, with monthly trends through partial 2025 data suggesting stabilization. Our data showing 7% of cases with no/unknown healthcare-association align with estimates of 6-10% community-association from previous studies, reinforcing healthcare settings as the primary context for transmission. CP-CRE were predominantly KPC and NDM, consistent with recent reports; however, CP-CRAB showed greater multi-mechanistic resistance, with NDM/OXA-variant combinations as common as OXA-variants alone. Ongoing local surveillance and healthcare collaboration is critical to monitor evolving organism–gene patterns.

Introduction: In the setting of the BACTEC BCx bottle shortage in 8/2024, we established a clinical standard for BCx stewardship using evidence-based best practices. Specifically, we implemented clinical decision support (CDS) within the electronic medical record (EMR) across the health system to prompt reflection on the indication for BCx collection and discourage low-yield testing. Our primary objective was to compare blood culture event (BCE) rates before (8/2022-7/2024) and after (8/2024-8/2025) CDS implementation. Secondary objectives included comparing all-cause mortality, 30-day readmission, BCx contamination rates, antimicrobial use, central line–associated bloodstream infection rates, and hospital-onset Clostridioides difficile infection rates before and after CDS implementation. Methods: This study was conducted within an academic health system comprising 3 inpatient hospitals. In 8/2024, we integrated CDS into the EMR (Epic Systems, Verona, WI). (Figure 1) CDS was displayed whenever a provider ordered a BCx set. Providers were prompted to document the clinical indication for the BCx, stratified as high-, medium-, or low-yield based on the algorithm developed by Fabre et al. in the DISTRIBUTE study. If the selected indication was categorized as low-yield, the CDS displayed a message noting the likelihood of low-diagnostic yield and required additional justification documentation. Providers retained discretion to proceed with the order. We used an interrupted time series (ITS) analysis to compare BCE rates in the pre- versus post-intervention periods. Results: The preintervention period had a rate of 52.8 BCE per 1000 inpatient days compared to 46.5 BCE per 1000 inpatient days in the postintervention period (0.88 95% CI 0.87-0.89 p< 0.01). (Figure 2) ITS analysis demonstrated a significant decrease in BCE rate by 17.5% (95% CI -20.7%, 014.2%, P-value < 0.01) at the time of the intervention, but a significant increase in BCE rate of 1.0%% (95% CI 0.6%, 1.4%, p-value <0.01) in the post-intervention period. (Figure 3) We also saw a significant increase in days of antibiotic therapy and BCx contamination rates. (Figure 2) 37,418 BCEs were placed when the CDS was active. Of these, 22,994 BCE (61.5%) were ordered for sepsis. Of the remaining 14,424 BCE, 3,127 (22.0%) occurred for low-risk clinical scenarios. (Figure 4) Conclusions: We implemented hospital systemwide CDS during a critical BCx bottle shortage. While we saw an initial decrease in BCE rates, BCE rates increased following implementation. Specifically, many BCE occurred for low-risk clinical scenarios. Thus, while electronic CDS can be helpful, additional feedback mechanisms are necessary for persistent change in BCx stewardship practices.

Background: Antibiotic overuse is common at hospital discharge. Antibiotic stewardship [ASP] metrics that capture antibiotic-prescribing at discharge can identify opportunities to optimize prescribing. We conducted a qualitative analysis of clinician perceptions of a novel risk-adjusted metric that shows the frequency and duration of oral antibiotics prescribed at discharge at Veterans Health Administration (VHA) hospitals. Methods: We conducted 91 semi-structured interviews with clinicians (e.g., ASP champions, hospitalists, pharmacists) from nine VHA facilities. Facilities represented three performance groups on the metric [Figure 1]: Group 1: less frequent antibiotic prescribing at discharge and shorter duration; Group 3: less frequent and longer duration; Group 4: more frequent and longer duration. During the interview, we presented the metric and explained its design and the facility's placement on the metric. Our interview guide prompted responses concerning clarity, fairness, utility of the metric for stewardship goals, and thoughts on the metric broadly. We conducted thematic analysis on interview transcripts. Results: The majority of clinicians from each performance group reported that the metric made sense and conveyed results clearly, expressing that the metric could support stewardship practices by reinforcing appropriate prescribing and identifying areas for improvement. Yet, many clinicians highlighted that they needed additional granular data to inform effective interventions, including service-specific prescribing, which infections are being overtreated, and how close their hospital is to being categorized in a different performance group. Clinicians often proposed a potential explanation for why their facility was in a specific performance group, including descriptions of strong ASP programs or reflections on patient complexity or services that may drive more frequent or longer prescribing. Responses on fairness varied across performance group and clinician role. Clinicians voiced concerns about the possible punitive use of the metric without considering whether it aligned with the appropriateness of antibiotic prescribing. Clinicians wanted more information about how the metric accounted for differences in patient case-mix. Conclusions: Our study found that clinicians generally considered the novel metric for comparing antibiotic prescribing at VHA hospital discharges to be clear and useful. This metric has potential to strengthen antibiotic stewardship by identifying areas needing improvement. However, clinicians emphasized the need for more granular data and raised concerns about fairness and potential punitive use. Addressing these points and clearly framing the metric as a tool for quality improvement will be essential for successful implementation.

Background: Daily toothbrushing is recommended for all hospitalized patients and long-term care facility (LTCF) residents because it has been associated with significantly lower rates of healthcare-associated pneumonia. However, limited information is available on effective strategies to improve education of patients on oral hygiene. Methods: We surveyed a convenience sample of 60 patients hospitalized on medical/surgical or rehabilitation wards at a Veterans Affairs medical center regarding oral hygiene education and practices. Medical records were reviewed to determine if education on oral hygiene was documented by nursing staff as is recommended by facility protocols. Based on the initial survey results, we piloted an intervention in which educational posters were placed beside the mirror in patient bathrooms and small educational placards were placed on meal trays. Patients were surveyed to determine the impact of the intervention. Results: Of the 60 patients completing the initial survey, 55 (92%) practiced oral hygiene at home, and 19 (32%) had partial or complete dentures. Nursing notes documented oral hygiene education for 39 (65%) patients, but only 18 (30%) recalled receiving education, and none were aware that oral hygiene reduces the risk for pneumonia. After the intervention, 35% of patients were aware of the sign by the sink, 62% were aware of the reminder on meal trays, and 35% were aware that oral hygiene reduces the risk for pneumonia (Figure). Conclusions: Simple visual educational tools can improve awareness of oral hygiene and its role in reducing the risk for hospital-acquired pneumonia. Studies are needed to determine if interventions using these tools will improve oral hygiene practices by patients.

Background: During outbreaks of emerging infectious diseases, healthcare personnel (HCP) safety depends not only on PPE availability but also on correct donning and doffing. In real-world isolation care, inconsistent guidance, product variability, and workflow constraints contribute to self-contamination risk. Human-factors–driven PPE ensembles were developed and their performance was evaluated through a series of standardized, simulation-based randomized crossover studies. Methods: Three randomized crossover simulation studies were performed among HCP to evaluate PPE performance. The first study compared existing Level C/D PPE ensembles with prototype PPE ensembles during simulations (n=40). Participants performed two donning–simulation–doffing sequences with randomized PPE order, and self-contamination was assessed using fluorescent markers and ultraviolet light. Based on findings from the first study, the PPE ensembles were iteratively refined and re-evaluated in a second randomized crossover simulation focused on post-refinement performance among returning participants (n=29). A third randomized crossover simulation assessed the effect of structured donning/doffing education and brief coached practice when using the refined PPE ensembles compared with existing PPE among PPE-na HCP (n=20). Outcomes included objective self-contamination events, perceived protection, usability (donning, working, doffing), overall satisfaction, confidence, and intention to use. Results: In the initial randomized crossover simulation (n=40), self-contamination after doffing was observed in 42.5% of participants using existing PPE and 52.5% using the prototype PPE ensembles, despite higher perceived convenience with these ensembles (mean scores, 10-point scale: working 7.5 vs 5.9, doffing 6.6 vs 5.5). Following iterative refinement, the second simulation (n=29) demonstrated improved performance of the developed PPE ensembles, with self-contamination reduced to 37.9% compared with the initial prototype evaluation, and no severe contamination events observed. Usability ratings further improved (donning 8.0 vs 7.1, working 8.1 vs 7.5, doffing 7.8 vs 6.6), and intention to use was high (8.9/10). In the third randomized crossover simulation among PPE-na HCP (n=20), structured education and coached practice reduced self-contamination from 50% with existing PPE to 35% with the developed PPE ensembles and substantially improved usability (donning 8.6 vs 6.1, working 9.0 vs 6.4, doffing 8.4 vs 5.2) and confidence. Conclusions: Across three randomized crossover simulation studies, human-factors–driven PPE ensembles demonstrated improvements in usability and reductions in self-contamination. Importantly, early identification of increased self-contamination risk during prototype evaluation enabled design optimization, resulting in safer performance. Standardized simulation-based evaluation can identify early risks, guide PPE optimization, and support safer adoption of improved PPE ensembles in high-risk isolation care settings.

Background: In patients with cyanotic congenital heart disease (CHD), aortopulmonary collateral arteries (APCAs) commonly develop as a compensatory source of pulmonary blood flow. However, APCAs increase pulmonary vascular resistance and ventricular preload, potentially complicating the establishment of Fontan circulation. Coil embolisation of APCAs is routinely performed before Fontan completion, but post-procedural fever is frequently observed and may delay subsequent surgery. This study aimed to identify factors associated with post-embolisation fever, with a particular focus on the influence of coil type. Methods and Results: We retrospectively reviewed 97 paediatric patients who underwent APCA coil embolisation between 2007 and 2023. Patients were categorised according to coil type: platinum coils only (P group, n = 52), both platinum and hydrogel coils (P–H group, n = 29), or hydrogel coils only (H group, n = 16). The incidence of post-embolisation fever (≥38°C) and inflammatory markers were compared among groups. Histopathological characteristics of embolised vessels were also assessed. Overall, post-embolisation fever occurred in 64% of patients. The incidence of fever was significantly lower in the H group (25.0%) than in the P group (73.0%) and P–H group (68.9%) (p < 0.01). C-reactive protein levels increased significantly after fever onset, whereas white blood cell counts showed no meaningful change. Histopathological evaluation demonstrated prominent fibrin deposition and inflammatory cell infiltration in vessels embolised with platinum coils, while vessels treated with hydrogel coils exhibited only mild inflammatory changes. Conclusions: Hydrogel coils were associated with a lower incidence of post-embolisation fever and a milder inflammatory response than platinum coils. These findings suggest that coil selection may play an important role in minimising post-procedural inflammation and facilitating perioperative management in children preparing for the Fontan procedure.

Background: Gram-negative bacteremia (GNB) accounts for a substantial proportion of both community-onset and nosocomial bloodstream infections and carries significant morbidity and mortality. The utility of follow-up blood cultures(FUBC) for GNB remains unclear. Prior studies have demonstrated associations with prolonged hospitalization and antibiotic duration without clear reinfection or mortality benefit. Methods: We conducted a retrospective cohort study of adults (<18 years) admitted to a three-hospital healthcare system with GNB from 4/1/2024 to 1/31/2025. Patients who died within 24 hours of the initial positive culture or had hospital stays < 35 days were excluded. Clinical variables including organism, infection source, presence of indwelling catheters or other devices, immunocompromising conditions, severity scores (qSOFA, PITT), as well as intensive care unit admission (ICU) were also collected. Primary outcomes were 30-day mortality and 90-day reinfection. We used chi-square and Fisher’s exact test to compare categorical variables and Mann-U Whitney to compare continuous variables based on repeat blood cultures. We used the univariate screen (p<0.1) and prespecified variables that we thought might impact repeat blood cultures in an inverse probability of treatment-weighted models using propensity scores. Results: There were 372 identified eligible patients with GNB. These patients were split based on whether they had FUBC or not. There were no significant differences in immunocompromised status, co-morbidities, or age between the two groups. The most common organisms detected were Enterobacterales, followed by Pseudomonas. The most common source of infection was overwhelmingly genitourinary, followed by gastrointestinal and hepatobiliary. There were no significant differences between those who did and did not undergo FUBC for odds of 30-day mortality (OR 0.74 (0.36-1.55)) or 90- day reinfection (OR 0.86 (0.16-4.47)). However, FUBC were associated with significantly longer median hospital stay (7 days vs 5 days, p < 0.001) and higher odds of receiving <7 days of antibiotics (OR 2.28, (1.23-4.25), p = 0.009). Persistent bacteremia despite appropriate therapy occurred more frequently among patients with ICU admission, though clinical impact could not be fully assessed. Additionally, patients with an Infectious Diseases consult were more likely to have FUBC. No other subgroup was significantly more likely to have blood cultures repeated. Conclusions: The use of FUBC in GNB did not demonstrate improvement in mortality or reinfection rates. Instead, FUBC correlated with prolonged hospitalization and extended antibiotic therapy. It remains unclear whether FUBC offers significant clinical benefit in higher-risk groups. Further research is needed to clarify the role of FUBC in critically ill patients.

Background: Clostridioides difficile infection (CDI) has been diagnosed with a variety of test methods that vary in their sensitivity and specificity. Because of concerns over potential overdiagnosis of clinical CDI, a single step method was adopted in May 2023 with glutamate dehydrogenase (GDH) and toxin enzyme immunoassay (EIA) with nucleic acid amplification test (NAAT) only to be ordered by clinicians who had ongoing clinical suspicion of CDI despite indeterminate test results. We aimed to describe the physician response to indeterminate test results, evaluate the percentage of people who had re-admission within 90 days for all-cause mortality and those with re-admission for diarrhea Methods: A multicenter historical cohort study was conducted among patients who were found to have GDH+/toxin- C. difficile results from 6/1/2023 to 12/31/24. Data were collected by retrospective chart review on the initial hospitalization and subsequent episodes of CDI in the following 90 days based on receipt of treatment for the initial episode of GDH+/toxin-. Data were analyzed using Student’s t-test, the Mann-Whitney U test, and the chi-squared test, using SPSS v. 31.0. Results: Of 382 patients, 380 had complete information on treatment history. Of these patients, 25% were treated (95/380). Among 285 patients with indeterminate C.difficile tests who were untreated and had re-admission in 90 days for diarrhea, only 2.1% were diagnosed with C.difficile colitis on the follow up admission. Patients who received vancomycin alone had the highest percentage of re-admission among other treatment options. Patients with chronic steroid use (p=0.05), other immunosuppressive agents (p=0.02) and with inflammatory bowel disease (IBD) (p=0.002) were significantly more likely to be readmitted for diarrhea within 90 days. Conclusion: A physician-based approach reduces overtreatment of indeterminate C. difficile results using a single step reporting method with only a small number of patients readmitted with CDI within 90 days.

Background: A resilient healthcare epidemiology workforce is essential to preventing healthcare-associated infections (HAIs), mitigating antimicrobial resistance, supporting antibiotic stewardship, and responding to emerging pathogens. To address statewide gaps in training and preparedness, the Texas Epidemic Public Health Institute (TEPHI) developed a virtual Infection Prevention and Control (IPC) education program. The IPC 300 Series—the third tier of this initiative—focuses on clinical and systems-level applications that strengthen surveillance, outbreak response, environmental risk assessment, and epidemiologic capacity. This evaluation assesses the reach, learning outcomes, and workforce impact of the 300 Series. Methods: The 10-module 300 Series (2025) was delivered via Zoom and Microsoft Teams, with recordings available on YouTube for asynchronous access. Registration, attendance, and CE participation were tracked across platforms. Knowledge checks (?80% required) and post-module surveys assessed comprehension and intended practice change using the Kirkpatrick Model (Levels 1–3). Mid- and end-of-series evaluations identified epidemiology training needs, barriers to implementation, and perceived impact on outbreak and stewardship readiness. Descriptive statistics and pairwise t-tests for 2023–2025 trends were conducted in Stata/BE 18.0. Results: The 300 Series registered 5,230 individuals, including 1,685 live attendees and 2,070 asynchronous learners—contributing to more than 13,000 learning encounters across three years. Participation represented 49 states and over 20 countries, with 61% from Texas. Continuing education engagement was high (n=325). Knowledge assessment scores (n=511) averaged 92%, exceeding competency thresholds. Modules addressing emerging pathogens, outbreak investigation, environmental risk management, and stewardship-related decision-making generated the highest engagement, reflecting healthcare epidemiology priorities. Post-module surveys demonstrated strong satisfaction (mean 4.7/5.0), with 88% reporting improved understanding and 91% planning to apply epidemiologic principles in surveillance, risk assessment, preparedness, and stewardship-related practices. End-of-series evaluations highlighted persistent gaps in epidemiology and stewardship capacity, including limited staffing, time, and analytic resources. Monthly networking forums (n=323) supported peer learning, case discussion, and practical application of epidemiologic methods. Across 2023–2025, registration doubled and live attendance increased by 55%, demonstrating rising demand for statewide epidemiology-focused IPC training. Conclusions: The TEPHI IPC 300 Series strengthens healthcare epidemiology capacity by delivering accessible, competency-based education aligned with surveillance, outbreak response, environmental risk management, and antimicrobial resistance prevention. Light integration of stewardship principles further supports comprehensive infection prevention practice. Strong participation, high learning outcomes, and widespread intent to apply concepts demonstrate the program’s value as a scalable workforce model that advances public health preparedness across healthcare systems.

This work is the second in a series, following Part I [Kwa24] (Algebra Number Theory 18.10 (2024)) and preceding Part III [Kwa25] (Math. Ann. 391.1 (2025)). We continue our investigation of spectral moments of $\text {GL}(3)\times \text {GL}(2)\ L$-functions from the perspective of period integrals. Using an identity between two distinct periods for the $\text {GL}(3)$ Eisenstein series, we establish an exact Motohashi-type identity linking the shifted cubic moment of $\text {GL}(2)\ L$-functions to the shifted fourth moment of $\text {GL}(1) L$-functions. In addition, we offer a novel, intrinsic and automorphic account for the sources and symmetries of the full set of main terms for both moments, in agreement with the CFKRS Moment Conjectures (Proc. Lond. Math. Soc. (3) 91 (2005)).

Background: Recurrent urinary tract infections (rUTIs), especially catheter-associated UTIs (CA-UTIs), are common complications in people with neurogenic bladder (NB). The Recurrent UTI Impact Questionnaire (RUTIIQ) includes 5 domains assessing patient-reported quality of life (QoL) impacts from rUTIs: 1.) personal wellbeing, 2.) social wellbeing, 3.) sexual wellbeing, 4.) work and activity interference, and 5.) satisfaction with medical care. The RUTIIQ has only been validated in young women without NB. Our objective was to use cognitive interviews to determine initial adaptations to the RUTIIQ optimizing content validity for people with NB. Methods: This study included adult (age < 18) Veterans from two tertiary care Veterans Affairs Medical Centers who had NB due spinal cord injury/disorder (SCI/D) or multiple sclerosis. Virtual cognitive interviews were conducted between June-September 2025 with patients with rUTI, defined as ≥ 2 face-to-face encounters with a UTI diagnosis in the prior 6 months or ≥ 3 in the prior 12 months. Purposeful sampling was used to recruit from both SCI/D and MS groups. Participants were asked to complete the RUTIIQ using “think aloud” technique to evaluate comprehension, understanding and appropriateness. Results: Out of 55 eligible patients, 10 interviews were completed. One participant was female (10%), 9 were male (90%). Two participants had MS (20%), 6 had SCI/D (60%). Nine (90%) participants used indwelling or intermittent catheterization. Several participants struggled to focus on UTI-specific impacts, instead responding to items based on QoL and functional impacts from their disability in general. In response, we changed the survey instructions to emphasize that respondents should think about UTI-related impacts and broadened the recall timeframe from 2 weeks to 4 weeks to capture more UTI episodes. The term ‘work’ in the Work and Activity Interference domain was poorly applicable to nearly all participants, whose disability precludes traditional employment. This term was revised to ‘daily activities.’ Finally, several participants noted that the sexual wellbeing domain was not relevant for them, given that sexual dysfunction related to their disability prevented sexual activity. Thus, we added a ‘not applicable’ option to bypass that domain. Conclusions: Cognitive interviews with Veterans with NB revealed unique themes primarily related to their underlying disability that affected how rUTIs impact their QoL and functioning. Using these themes, we made substantive changes to the RUTIIQ to adapt it to the NB population. Future work will test the validity and reliability of this adapted RUTIIQ in a national cohort of Veterans with NB.

In this article, we obtain uniform effective upper bounds for the projective dimension and the Castelnuovo–Mumford regularity of homogeneous ideals inside a standard graded polynomial ring S over a field. Such bounds are independent of the number of variables of S, in the spirit of Stillman’s conjecture and of the Ananyan–Hochster’s theorem, and depend on partial data extracted from the beginning or the end of the resolution. The main result is an extension of a theorem due to McCullough from 2012. Namely, we bound the projective dimension and the regularity of an ideal in terms of the regularity of a fraction of the syzygies.

Background: We queried long term acute care hospitals (LTACHs) within the NALTH network regarding facility characteristics, C. auris prevention practices, and perceived barriers to C. auris prevention. Methods: Participating facilities completed a REDCap survey of multiple choice, free response, and ranked choice questions. Quantitative and descriptive analyses were performed for completed surveys. Perceived barriers and important tools for C. auris prevention were assessed with ranked choice questions and analyzed by non-weighted counts. Results: Among 33 responses from 56 eligible LTACHs (Figure 1, Table 1), 23 (70%) had ever identified at least one case of C. auris infection or colonization. Eighteen of 33 (54%) reported identifying cases of C. auris within the past 3 months (Figure 2) and 9 of 33 (27%) had experienced suspected within-facility transmission. All facilities employed multimodal approaches for C. auris infection prevention (Table 2). More than half of LTACHs reported routine C. auris screening programs (21, 64%), including in response to a known C. auris case (n=15) and/or screening for asymptomatic colonization at the time of LTACH admission (n=12). The most frequently reported barriers to effective C. auris infection prevention included lack of communication between healthcare facilities at the time of patient transfer (n=16), lack of training and education for frontline staff (n=15), and lack of compliance with personal protective equipment (n=12). The most impactful methods anticipated to support future C. auris prevention included improved communication between facilities at the time of patient transfer (n=15), standardized protocols for C. auris decolonization (n=15), and standardized protocols for C. auris screening and isolation (n=14). Conclusion: Most participating LTACHs within the NALTH network reported firsthand experience with C. auris. Universally, responding facilities employed multimodal evidence-based infection prevention and control methods targeted against C. auris. Future research should focus on improving inter-facility communication of C. auris colonization or infection status, development of novel decolonization strategies, and standardization of surveillance practices.

Background: Diarrhea is common among patients with cancer, and rapid diagnosis of gastrointestinal (GI) infections using a multiplex stool enteric pathogen panel (EPP) may expedite clinical decision-making and inform infection prevention measures. However, the diagnostic yield of EPPs in patients with cancer with hospital-onset diarrhea is not well defined. At our center, inpatient diarrhea testing guidelines recommend EPP testing primarily in those with community-onset diarrhea. We aimed to assess adherence to these EPP testing guidelines and describe EPP diagnostic yield in hospitalized patients with cancer to identify opportunities for diagnostic stewardship. Methods: We retrospectively reviewed EPP and stand-alone C. difficile (SACD) tests ordered between July 1, 2021 – May 23, 2025 among hospitalized patients (age ≥18 years) with a malignancy diagnosis. Our center recommends EPP testing (BIOFIRE® FILMARRAY® GI Panel) for community-onset diarrhea (on or before hospital day [HD] 3) and SACD testing for hospital-onset diarrhea (after HD 3). EPPs may be ordered after HD 3 for patients with unexplained prolonged or bloody diarrhea. Results: A total of 3338 stool tests (1433 EPP, 1905 SACD) were performed among 2131 patients. Among EPPs, 468 (33%) were ordered after HD 3 whereas 1621 (85%) SACD tests were ordered after HD 3 (Figure 1). The proportion of EPPs ordered after HD 3 was highest among patients with hematologic malignancies (44%) compared to other cancer types and higher among hematopoietic cell transplant (HCT) recipients versus non-HCT recipients (54% vs. 22%; Figure 2). Among EPPs ordered after HD 3, 102/468 (22%) were positive for ?1 pathogen compared to 288/965 (30%) EPPs ordered on HD 1-3. At least 1 non-C. difficile pathogen was detected in 49/468 (10%) EPPs ordered after HD 3 compared to 146/965 (15%) on HD 1-3 (Table 1). Among EPPs with non-C. difficile pathogens detected after HD 3, norovirus was most frequent (26/468; 6%; Table 1). Conclusion: EPP detection of non-C. difficile pathogens among hospitalized patients with cancer was lower in patients with hospital-onset diarrhea compared to those with community-onset diarrhea. Most EPP orders after HD 3 at our center occurred in HCT recipients and patients with hematologic malignancies. Additional studies are needed to determine the clinical significance of positive EPP results beyond HD 3 and understand which patients may benefit most from EPP testing beyond HD 3.

Background: Less than 25% of adults in the United States are up-to-date on all age-appropriate vaccinations. Primary care providers (PCPs) may defer routine vaccine discussions due to insufficient time to access and review vaccination records. The Virtual Vaccine (ViVa) clinic was implemented to reduce time and cognitive burden on PCPs by offloading the tasks of vaccine history review and patient-specific recommendations to other clinicians, with the goal to improve adult vaccination rates. Methods: From January to October 2025, ViVa clinicians reviewed the charts of Veterans aged ?vs. vs. without (ViVa-) a ViVa note. Patients seen in non-intervention primary care clinics at the same facility served as controls. Results: During the study period, 654 and 2488 Veterans aged ?Table 1). The proportion of up-to-date patients increased across all studied vaccines in all groups. Among ViVa+ patients, 36% received one or more recommended vaccines compared to 27% in the ViVa- and 23% in the control patients. The largest gains were for RSV and pneumococcal vaccines among ViVa+ patients (Figure 1). The median number of vaccines for which ViVa+ patients were up-to-date increased from 3 (IQR 2-4) at baseline to 4 (IQR 2-5) at follow-up. Median values did not change from baseline vs. follow-up for patients in the ViVa- (3, IQR 2-4 vs. vs. Conclusions: A succinct note entered into the electronic health record successfully augmented adult vaccination rates for patients seen in primary care clinics. The ViVa clinic was more effective for vaccines with recent schedule changes compared to those with more established schedules, including seasonal vaccines. Comparing outcomes among ViVa- and control patients suggests a positive spillover effect for PCPs in the intervention clinics.

The John Day Formation of central Oregon preserves a diversity of Oligo-Miocene caniform carnivorans, many of which were first described from the formation. However, many historically important specimens lack detailed locality or stratigraphic information, complicating any analysis of faunal change through time. Here, we describe 16 new specimens of caniforms from the John Day Formation, most with precise stratigraphic information. We report multiple specimens of the amphicyonids Daphoenus Leidy, 1853, Paradaphoenus cuspigerus (Cope, 1878), and Temnocyon altigenis (Cope, 1878), all previously known from the formation. We also report the first definitive occurrence of the hesperocyonine canid Osbornodon Wang, 1994 from the John Day Formation and the first occurrence of the borophagine canid Otarocyon Wang, Tedford, and Taylor, 1999 from west of the Rocky Mountains. Two isolated postcranial elements are consistent in size and morphology with large amphicyonines but we cannot confidently assign them to this subfamily. Biostratigraphic trends in these taxa parallel those seen elsewhere in North America, although the turnover in large carnivorans observed at the Oligocene-Miocene boundary on the Great Plains might begin somewhat earlier in Oregon. The possible presence of a large amphicyonine would, however, mark a major temporal range extension for the subfamily and would be the oldest occurrence of this Eurasian taxon in North America.

Background: Carbapenemase-producing organisms (CPO) are a serious public health threat. The Centers for Disease Control and Prevention (CDC) guidelines for combating CPO includes a recommendation to screen selected high risk patients. We describe a program to identify and screen patients at risk for CPO. Setting: An academic, tertiary care center with 2,059 licensed beds and 74,359 admissions a year. Methods: A report was created in the electronic medical record (EMR) to identify adult patients admitted in the previous 24 hours who were from countries and states with known CPO transmission based on address and zip code. A nursing protocol was subsequently developed in the EMR to facilitate CPO screening for eligible patients at admission. After the CPO order is placed, an electronic communication is sent via the EMR alerting the patient care team of the order, the rationale for screening, details on swab collection, and links to a toolkit with resources to help answer patient questions. A single perirectal swab is obtained by the patient’s primary nurse and is tested for Klebsiella pneumoniae Carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), oxacillinase-48 (OXA-48), and Verona integron-encoded metallo-β-lactamase (VIM) by polymerase chain reaction (PCR). Patients may refuse testing. Results: From May 2018 through November 2025, 6,039 patients were identified for CPO screening using case-finding report. Of these patients, 2,424 had CPO swabs completed. Eighteen patients with CPO were identified with an overall yield of 0.75% on admission screening. There was one patient who tested positive for KPC, 10 patients who tested positive for NDM, and 5 patients who tested positive for OXA-48. Two patients were identified to have both NDM and OXA-48. Conclusions: The EMR can be leveraged for early identification and screening of patients with epidemiologically significant pathogens. Use of the nursing protocol has enabled IPAC to complete timely CPO surveillance and prevent transmission to other patients. Protocols within the EMR can be effectively replicated for a timely response to emerging infections.