Background: Up to 33% of methicillin-resistant Staphylococcus aureus (MRSA) colonized patients will subsequently develop an invasive MRSA infection. Intranasal treatment is necessary to eliminate MRSA in the nose, which is recognized as a primary carriage site. In our 542 bed, community, teaching hospital, we had implemented CHG daily bathing for targeted patient populations (patients in ICU and with central lines), but struggled to reduce MRSA bacteremia rates. We proposed adding nasal decolonization and expanding the target population to include MRSA-positive patients, as a method of reducing MRSA bloodstream infections. Methods: On July 21, 2025, a formal MRSA decolonization protocol, including twice daily mupirocin for five days, and daily CHG bathing was recommended for all ICU patients, regardless of MRSA history, and MRSA positive patients, on any inpatient unit. A MRSA decolonization order set went live on October 27th, 2025, and was automatically added to pre-existing ICU admission and central line maintenance order sets. Pre-and post-intervention National Healthcare Safety Network (NHSN) hospital-onset MRSA bacteremia standardized infection ratios (SIR) were compared, in addition to a monthly review of MRSA bacteremia rates per 1000 patient days and mupirocin administration. NHSN antimicrobial resistance module standardized resistant infection ratios (SRIRs), were also compared between 2024 and 2025. Result: The pre-intervention (January-June 2025) MRSA bacteremia SIR was 0.853, compared to a post-intervention (August-December 2025) MRSA bacteremia SIR of 0.405. This represents a 53% reduction in SIR (p=0.398). The outpatient MRSA BSI prevalence rate from emergency department visits stayed steady between the pre and post-intervention periods, at 0.095 and 0.094. Figure 1 shows the inverse relationship between the increase in mupirocin administration (utilizing a threshold of < 5 administered doses) and decrease in hospital-onset MRSA bacteremia. Figures 2 and 3 show the prior years’ variation and current decline in SRIRs for both MRSA bacteremia and lower respiratory tract specimens. A decreasing trendline was not observed for other organisms’ SRIRs, including vancomycin-resistant Enterococcus. Conclusion: MRSA bacteremia contributes to significant morbidity, mortality, and financial penalties for hospitals. CHG bathing alone for ICU and central line patients was inadequate to reduce MRSA bacteremia rates. A default order set for MRSA decolonization, including nasal mupirocin, added to all ICU admissions and central line maintenance orders, improved compliance with the recommended protocol. Our hospital experienced a reduction in MRSA bacteremia following the implementation of a standardized decolonization protocol, including the nares, for all ICU, central line, and MRSA positive patients.

Background: After three decades of declining tuberculosis (TB) incidence in the United States, case counts have increased annually since 2020, including an 8% rise in 2024. Undiagnosed TB poses a risk in healthcare settings because its clinical overlap with other respiratory illnesses can delay diagnosis and expose unprotected healthcare workers (HCWs) to active TB during routine job duties. Despite this risk, there is no standardized CDC definition of TB exposure for HCWs, resulting in variability in exposure investigations, notification, and follow-up. Safety-net hospitals such as Cambridge Health Alliance (CHA), a 300-bed health system, are increasingly affected by complex exposure events. Over the past year, seven patients with active pulmonary TB potentially exposed nearly 250 staff across six clinical areas, requiring multiple notification rounds despite prompt protocols, highlighting gaps in follow-up and uncertainty about actionable exposure definitions. Objective: Using the definition of employee exposure as ?15 minutes within 6 feet of a source case without mask/respirator, this study aimed to evaluate the effectiveness of post-exposure investigation protocols, determine TB screening test conversion rates among exposed employees, and assess the incidence of active TB disease during the study period. Methods: We reviewed email outreach to HCWs, employee communications, and TB testing records, and compared institutional practices with CDC and National Tuberculosis Controllers Association (NTCA) guidance. Analysis focused on accurate identification of exposed employees and completion of recommended follow-up testing using IGRA or TST. Results: Key barriers included incomplete exposure lists, fragmented interdepartmental communication, and inconsistent documentation of TB history,necessitating additional outreach efforts and contributing to a more time intensive notification process. The audit identified 243 potentially exposed staff, of whom 238 were contacted. 189 (79.4%) responded; non-responders included former employees, staff on leave, and those who did not reply. Among respondents, 87 (46%) met exposure criteria. Twenty-five (28.7%) had prior positive TB tests and were excluded from retesting. Of the 62 eligible for follow-up testing, 48 (77.4%) completed testing. No new TB infections or active TB cases were identified. Conclusions: Despite logistical challenges, the investigation achieved a high response rate with no new TB cases detected. Our study identified opportunities for improvement in data management, communication, and exposure classification. Standardizing TB exposure definitions and implementing centralized tracking systems may improve efficiency, consistency, and HCW protection. These findings support the effectiveness of current infection prevention measures while underscoring the need for a standardized national or regional approach.

Background: Inappropriate urine cultures without a clinical indication are sent frequently. Previous work has demonstrated that clinical decision support (CDS) requiring an indication for culture can reduce the number of unnecessary urine cultures. Our multi-campus VA facility implemented requirement of an indication for urine culture orders and evaluated the rate of urine cultures over time as well as the indications. Methods: We implemented a previously developed CDS menu across inpatient and outpatient services within VA Boston healthcare system. The CDS implementation required assistance and approval from our laboratory and clinical applications coordinators. Clinicians were notified about the change in ordering process through email and focused educational sessions. We captured rates of urine cultures by location and by indication and compared rates before and after implementation. A run-in period was allowed for full roll-out of the intervention, which was set at 98% of urine cultures being ordered through the CDS menu. This was a quality improvement initiative. Result: The study period included a 5-month pre-intervention period and a 5-month post-intervention period that followed a 2 month run-in period. A total of 2955 urine cultures were ordered preintervention compared with 2028 cultures postintervention. The average rate of monthly urine cultures decreased from 591/month to 406/month (P Conclusion: We demonstrated a significant reduction in urine culture orders using a clinical decision support intervention that required the ordering clinician to indicate a reason for the order. This intervention only required a targeted modification in our lab orders and was simple for clinicians to comply with given a drop down click menu. One limitation is that we did not capture clinical outcomes - but we did have continuous feedback from clinicians that did not indicate any adverse events, either in efficiency of practice or in outcomes among patients. This approach has been more successful at our hospital compared with other approaches that require system wide changes in urine culture processing or resulting. It has the added benefit of direct clinician education regarding appropriate urine culture indications in different settings.

Background: Invasive Staphylococcus aureus (SA) infections are a common cause of sepsis in premature infants admitted to the neonatal intensive care unit (NICU). While a quality improvement team effectively reduced methicillin resistant (MRSA) invasive infections, methicillin susceptible (MSSA) infections remained problematic. As a result, there was a renewed effort to understand MSSA infection transmission and reduce invasive MSSA infections. Methods: The primary outcome was invasive MSSA infection, most commonly bacteremia, in the NICU. Environmental cultures identified MSSA on high touch point areas and whole genome sequencing (WGS) confirmed there were both endemic strains and independently introduced strains. New interventions to reduce invasive SA infections included additional environmental cleaning of clinical workstations with effectiveness measured by fluorescent marking and a start of shift chlorhexidine (CHG) /alcohol (Avaguard) below the elbow wash for NICU staff. Babies were screened weekly for MSSA/MRSA colonization. Results: In 2023 and 2024 when there were no MRSA infections, there were nine MSSA infections (Figure 1). WGS confirmed that environmental MSSA strains were recovered from infants. Increased screening for MSSA with selective decolonization with mupirocin for high risk infants did not temporally change invasive infection rates and the mupA gene for high level mupirocin resistance was identified in a subset of colonizing strains. There were no significant changes in rates of new colonization for either MSSA or MRSA in 2025. After 1697 days there was one MRSA infection in September 2025. Introducing enhanced environmental cleaning and below the elbow disinfection for staff was temporally associated with a reduction in invasive MSSA infections with only two MSSA infections in 2025, most recently in March. As of January 1, 2026 the NICU has gone nine months without a MSSA infection. Conclusions: Increased environmental cleaning of clinical workstations with a start of shift below the elbow staff disinfection has resulted in a sustained reduction in invasive MSSA infection without a significant reduction in colonization rates. Additional work is ongoing to further understand if SA environmental colonization is reduced and whether current strains colonizing infants are identical to those that have caused invasive infection in the past.

Background: Hospital-acquired infections remain a significant challenge for healthcare systems despite well-established infection prevention (IP) strategies, with ventilator-associated infections (VAI) being particularly challenging. This is especially true for pediatric patients, who often require mechanical ventilation for extended periods, increasing the risk of infection. Gram-negative bacteria, primarily Pseudomonas aeruginosa, are the leading causes of VAI. Traditional IP strategies are often reactive and may miss potential transmissions within the hospital, particularly for pathogens that are endemic to the hospital environment. Whole-genome sequencing (WGS) and genomic epidemiology have demonstrated value in identifying such events in adult hospitals, but their application in pediatric facilities remains limited. Here, we conduct a retrospective analysis to determine how this technology could be utilized in a pediatric facility. Methods: We conducted a retrospective genomic surveillance study of Gram-negative isolates collected between 2020 and 2024 at a pediatric tertiary hospital. Briefly, clones were selected by colony morphology, cultured, and DNA was extracted. DNA libraries were prepared and sequenced on the Illumina NextSeq 1000 platform. Phylogenetic analyses were performed using core-genome alignment pipelines. Likely transmission events were defined as bacterial clones differing by fewer than 10 single-nucleotide polymorphisms, based on previously described literature. Genetically related clones were evaluated with patient location and temporal hospital metadata to assess epidemiologic linkage. Results: A total of 687 clones from roughly 500 clinical samples were sequenced. We identified over 50 groups of genetically related isolates from multiple Gram-negative species. P. aeruginosa accounted for most of the genetically related groups, with over 40 discovered. Additional pathogens suspected to have genetic relatedness include Serratia marcescens, Klebsiella pneumoniae, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans. These groups range in size from 2 to 15 patients. Pairwise genomic analysis confirmed at least 16 groups consistent with likely transmission events. To date, epidemiologic review has confirmed that 2 of these groups were plausible based on temporal and geographic relationships between patients. The remaining 14 groups are under investigation. Conclusion: WGS-based surveillance identified multiple transmission events that were not recognized by conventional IP methods, highlighting the added value of WGS for hospital surveillance. This is especially true in the case of pathogens that are commonly found in hospitals. Integrating WGS with genomic epidemiology and hospital metadata can enhance patient safety and reduce healthcare costs. These findings indicate that reliance on traditional surveillance alone may underestimate the true burden of hospital outbreaks, particularly those caused by common Gram-negative respiratory pathogens in pediatric populations.

Auxinic herbicides (Group 4) are a crucial tool for maintaining effective weed management in modern agronomic systems. Palmer amaranth has evolved resistance to multiple herbicides, including auxinic herbicides. With documentation of auxin resistance in Palmer amaranth, new strategies should be implemented to improve management. Field studies were conducted in Tennessee during the summers of 2024 and 2025 to evaluate the efficacy of different herbicide application methods for managing auxin-resistant Palmer amaranth. The research compared tank-mixed applications of 2,4-D and glufosinate with split-applied (split-boom; herbicides applied simultaneously through separate spray booms as independent solutions) applications across multiple Palmer amaranth populations. Results demonstrated that in populations exhibiting high auxinic resistance, the split-boom application method was more effective than the conventional tank-mix approach. However, control levels were still below those typically considered acceptable for effective Palmer amaranth contol. Sequential split-boom applications were required to achieve acceptable levels of control in these populations. A second study evaluated whether carrier volume influenced the performance of these applications by comparing mixtures of 140 L ha-1 and 280 L ha-1. The results indicated that carrier volume did not significantly affect Palmer amaranth control at these volumes.

The “shape bias” – the tendency to generalize new nouns by their shape rather than features like colour or texture – is considered a cornerstone of early noun learning. However, the magnitude, development, and cross-cultural generality of this bias remain debated. We conducted a pre-registered meta-analysis and meta-regression of 71 studies to synthesize the evidence base. Our analysis revealed a robust overall effect, confirming the existence of a shape bias. However, this effect was characterized by extreme between-study heterogeneity (I2 = 0.95). Critically, meta-regression analyses failed to support hypothesized developmental changes, with a constant model across ages providing the most parsimonious fit. The literature is overwhelmingly dominated by studies of English-speaking children, preventing meaningful tests of cross-linguistic or cross-cultural variation. Diagnostic tests were also consistent with the possibility of publication bias, though these patterns can also arise from methodological heterogeneity and should be interpreted with caution. Together, these findings indicate that procedural variation, and potentially publication bias, more than currently testable theoretical moderators, account for the variability in the literature, severely limiting the ability to distinguish between theories of the shape bias’s origins.

Authors and Affiliations: Frank Frankovsky III, Thane Thomas, Mark Sigler, MD, Joshua Preator, DO, James Morris, MD, MPH, FACEP, Jennifer Clary, MSN, RN, CIC, Stephanie Stroever, PhD, MPH Background: Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline 2.2.11 recommends replacement of central venous catheters inserted emergently under non-sterile conditions as soon as possible and ideally within 48 hours. The extent of compliance with this recommendation and associated outcomes in emergency department (ED)–placed central lines remains unstudied. Methods We conducted an observational study of adult patients admitted following central line placement in the ED at two hospitals in West Texas between June 2024 and August 2025. Patients who died in the ED were excluded. The primary outcome was time to central line removal or replacement after admission. Central lines were classified as emergent (non-sterile) if placed without maximal sterile barrier precautions and documented as such in a standardized ED log. Conditions of line placement were verified by investigator chart review and, when necessary, direct discussion with the team involved in placement. Patient demographics, indications for line placement, and clinical outcomes were abstracted from the medical record. Median time to removal or replacement was calculated for sterile and non-sterile lines and compared using the Wilcoxon rank-sum test; p-values <0.05 were considered statistically significant. Sensitivity analyses excluded patients who died after hospital admission. Results A total of 284 patients were included, of whom 121 (42.6%) had non-sterile central lines placed. Mean age was 64.5 years, with similar distribution by sex. Common indications for line placement included altered mental status (24.3%), cardiac arrest (19.0%), and shortness of breath (14.8%). Median time to removal/replacement was shorter for non-sterile lines than sterile lines (56.2 vs 90.7 hours; p = 0.038). This difference was not observed in sensitivity analyses excluding patients who died after admission (p = 0.775), suggesting survivorship or competing risk bias. No central line–associated bloodstream infections (CLABSI) were identified. Conclusion No CLABSI events were observed despite median central line dwell times exceeding the 48-hour threshold referenced in HICPAC guidance. Early mortality among patients with emergently placed lines may have limited the opportunity for infection to occur. These findings emphasize the role of concurrent infection prevention measures and highlight the need for multidisciplinary strategies to support timely replacement of emergently placed central lines.

Background: In response to mounting antibiotic resistance and overuse, antimicrobial stewardship continues to serve as a major evolving initiative within healthcare institutions. Handshake stewardship utilizes in-person feedback to help facilitate intervention communication, in hopes of fostering clinician-ASP relationships and providing real-time education. This “face-to-face” approach has been demonstrated to improve antibiotic days of therapy (DOT) while also being perceived by treating teams as more favorable when compared to written feedback. Methods: Integrated ID/Pharmacy rounds occurred daily Monday – Friday, excluding holidays during the months of December 2024 to March 2025. The current hospital admitting structure separates individual hospitalist teams and internal medicine teaching resident teams. Teaching and hospitalist teams each have their own designated floors. To assess the long-lasting impact of ongoing antimicrobial stewardship education and intervention, an alternating checker box design was utilized, where ID/pharmacy rounds alternated between both designated teaching floors and used a hospitalist floor as control, where routine ASP review occured daily. Primary endpoints were antibiotic discontinuation, antibiotic deescalation and intravenous to oral conversion. Patients with an Infectious Diseases consultation were excluded. Results: Primary endpoints were antibiotic discontinuation, antibiotic deescalation and intravenous to oral conversion. Secondary endpoints included impact on length of stay and associated hospital acquired infections (C difficile). Overall: 196/388 patients (50.5%). Hospitalist control floor: 69/190 (36.3%). Teaching: 127/198 (64.6%); for the active teaching rounding group (75/106 (70.8%)) vs ASP education only (52/92 (57.6%)). For Hospitalist control floor vs teaching floor: p < 0.00001. Active teaching rounds vs ASP education: p = 0.037 Conclusion: Active participation and strong presence of ID pharmacy and ID physicians in daily medicine rounds, posiively impacts antibiotic utilization. It secures a direct line of communication and fosters strong relationships between departments, that ultimately benefits patient care, reduces lenght of stay and optimizes antibiotic utilization in terms of deescalation, duration of treatment and targeted antibiotic selection. Limitations include low availability of ID physicians for daily rounds, limited number of ID pharmacists for dailys ASP review and occasional disregard of recommendations by medicine teams.

Background: Genomic surveillance detects healthcare-associated outbreaks that are often missed by traditional methods, offering substantial benefits for infection prevention. However, its use introduces complex ethical dilemmas regarding patient notification and disparities in outbreak detection between institutions with and without genomic capabilities. Methods: We applied the Centers for Disease Control and Prevention's 2020 ethical considerations regarding patient notification and the Ethical Infection Prevention and Control (EIPAC) framework to two hypothetical scenarios involving genomic surveillance programs. Our analysis was informed by qualitative research reporting the types of harm experienced by patients across detected and undetected outbreaks. Results: We identified ethical justifications for patient notification when both genomic and epidemiologic evidence suggest transmission, as well as considerations militating for and against notification when epidemiologic evidence supporting genomic findings is absent (Figure). We also demonstrated ethical concerns arising from institutional disparities in genomic capability such that patients in hospitals without genomic surveillance may suffer preventable harm and remain uninformed due to lack of detection. A harms matrix illustrates physical, psychological, and ethical harms depending on detection and disclosure status. Conclusion: Hospitals adopting genomic surveillance face new ethical duties to disclose transmission events, while those that do not engage in such surveillance risk perpetuating inequities in patient safety and transparency. National guidance is urgently needed to ensure consistency in notification and promote ethical adoption of genomics. Coordinated frameworks from professional societies should define genetic thresholds warranting disclosure, address disparities in pathogen genomic detection methods, and uphold patient trust in the genomic era.

We give a method to produce faithful representations of the groups $G(n,m)=\langle X, Y \ \vert \ X^m = Y^n \rangle $ in $\mathrm {GL}_2(\mathbb {C}[t^{\pm 1}, q^{\pm 1}])$. These groups are Garside groups and the Garside normal forms of elements of the corresponding monoid can be explicitly recovered from the matrices, in the spirit of Krammer’s proof of the linearity of Artin’s braid groups. We use this method to construct several explicit faithful representations of the above groups, among which a representation which generalizes the reduced Burau representation of $B_3 \cong G(2,3)$ to a large family of groups of the form $G(n,m)$ with n, m coprime (which are torus knot groups). Like the Burau representation, this representation specializes to a representation of a reflection-like quotient that we previously introduced, called 2-toric reflection group. As a byproduct, we get a “Burau representation” for some exceptional complex braid groups, which also shows that the latter embed into their Hecke algebra.

Background: Socio-economic factors may play a role in patients’ risk for healthcare associated infections (HAI), including surgical site infections (SSI). The Area Deprivation Index (ADI) is a mapping tool that characterizes neighborhood-level socioeconomic disadvantage based on income, education, employment, and housing quality. A higher ADI score indicates a greater disadvantage. ADI has been studied extensively as a predictor for various patient outcomes. The purpose of this study was to establish whether an association exists between the national ADI score and SSI following abdominal hysterectomy at a 1400-bed academic center in northeast Ohio. Methods: At the Cleveland Clinic, SSIs are identified by Infection Preventionists using NHSN surveillance definitions. Using our surveillance software (EPIC, Bugsy, Verona, Wisconsin), we extracted all NHSN-defined inpatient abdominal hysterectomy procedures in adult patients between January 1, 2023 and December 31, 2024, including those with and without an SSI. We queried our electronic medical record data warehouse for the national ADI score recorded closest to the surgical procedure. Patients without an ADI score were excluded. Characteristics of patients with and without a SSI were summarized. Categorical variables were compared using a chi-square test and a two-tailed t-test was used to compare mean ADI scores. Results: During the study period 682 patients met criteria that underwent an inpatient abdominal hysterectomy, 26 developed an NHSN-defined SSI, including 15 superficial incisional SSI and 11 organ space SSI. Counts and attack rates of SSI, stratified by relevant factors are shown in the Table. Patients with an SSI had an average ADI of 71.81 while patients with no SSI had an average ADI of 62.29 (p=0.0573). Conclusion: In this study, the mean ADI trended higher for patients who developed a SSI following an abdominal hysterectomy, indicating a possible association between socio-economic factors and risk of a SSI. Although the test for difference in mean ADI did not achieve statistical significance, it highlights ADI as a readily obtainable patient characteristic that may contribute to post-operative infection risk. Further exploration of obtainable patient characteristics, including ADI score, is beneficial to inform best practice for optimal outcomes following an abdominal hysterectomy procedure.

Van der Auwera and Plungian’s map of possibility and necessity paths, the main topic of the workshop from which this special issue emerged, offers a rearrangement of Bybee et al.’s data on grammaticalization paths in the domain of modality along three dimensions: necessity vs. possibility, pre-modal vs. modal vs. post-modal, and participant-internal vs. participant-external. In this article, I will argue for a different interpretation of ‘post-modality’ and a different model for dealing with the data. With respect to the pre-modal/modal/post-modal distinction, I will point out that most of the ‘post-modal’ functions are in fact still modal. Furthermore, I will point out that the overall direction of change is not towards ‘non-modal’ but rather an increase in discourse orientation. At the late stages in the development of modal meaning, dubbed as ‘post-modal’ in van der Auwera and Plungian, it signifies a shift toward meanings and functions that contribute to the construction of discourse. Additionally, in various hierarchical models of grammar, modal expressions unidirectionally shift into higher positions that correspond to a higher degree of discourse orientation, thus providing independent confirmation for the model of change proposed here.

Background: Building water systems are known reservoirs for Legionella species, which can lead to healthcare-acquired infections, particularly among immunocompromised patients. Ice machines present complex internal surfaces and components that can support biofilm formation, which makes remediation challenging. This study evaluated the number of mitigation cycles required to eliminate Legionella from hospital water sources, with a focus on ice machines. Methods: A retrospective review of environmental Legionella testing from 2024-2025 was conducted. This included positive results identified from ice machines, sinks, and showers through routine surveillance and outbreak investigations. For each contaminated source, the number of mitigation cycles required for each source to achieve negative results was assessed. A total of 18 ice machines and 25 sinks and showers that tested positive for Legionella species were included in the analysis. Results: A total of 367 water sources were sampled during the study period, including 55 ice machines and 312 sinks and showers. 25 sinks and showers tested positive (8% of total samples) over a two-year period and required a mean of 1.66 mitigation cycles, with no fixture requiring more than five cycles to achieve negative results. In comparison, 18 positive ice machines (33% of total samples) required a mean of 2.67 mitigation cycles to achieve negative Legionella results, with one machine requiring eight cycles. Overall, the ice machines required, on average, one additional mitigation cycle to achieve negative results compared to the sinks and showers. ANOVA testing revealed no statistically significant differences in the number of cycles to clear Legionella between the different sources (F(2,40)=2.65, p=0.083). Conclusion: Ice machines demonstrated a higher frequency of persistent Legionella positivity and required more remediation cycles compared with sinks and showers. While the results were not statistically significant, additional data may demonstrate clearer differences in Legionella clearance across different sources. The persistent positive ice machines prompted implementation of an enhanced sanitization process beyond manufacturer recommendations. This highlights the challenges associated with biofilm control in these devices. Standard cleaning practices based on ice machine manufacturer’s instructions for use (MIFU) may be insufficient at eliminating contamination. These findings support the need for enhanced mitigation strategies and routine environmental surveillance.

Background: Appropriate implementation of Transmission-Based Precautions (TBP) are necessary to decrease the risk of exposure to infectious pathogens and hospital-acquired infections (HAI). Through routine auditing, gaps were identified in the appropriateness of TBP orders within our institution. A multi-disciplinary quality improvement team was convened to implement a TBP stewardship pilot program with aim to increase TBP compliance and optimize use of personal protective equipment (PPE). Methods: Preintervention planning: A key-driver diagram (Figure 1) was created for the pilot program following multiple meetings with infectious diseases (ID) physicians, healthcare epidemiologists, infection preventionists (IP), and nursing leadership. Patients admitted to the ID ward and under the management of the ID service, consisting of 3 pediatrics residents, an ID Pharmacist, and the ID attending physician, were selected for the pilot program starting in October 2025. Protocol Design: Education materials were developed and distributed to members of the ID service, including nursing staff. The stewardship pilot program team, consisting of 4 IPs and 2 healthcare epidemiologists, conducted twice weekly chart reviews of ID ward patients to determine the appropriateness of TBP orders. The pilot program team would interface in-person to review the admitted patients with the ID service once weekly. To determine the impact of the pilot program, baseline and post-intervention TBP-appropriateness was compared using the chi-square test of proportions. Results: At baseline, 60% of patients were on appropriate TBP (n = 249). Following the implementation of the pilot program, the percentage of patients on appropriate TBP increased to 73% (n = 162), p < 0.01. During the interim analysis period, there were no noted outbreaks or documented HAIs on the ID ward. Conclusion: An interim analysis of the TBP stewardship pilot program demonstrated an improvement in the appropriateness of TBP applied to hospitalized patients. Based on qualitative comments from the physicians and nursing staff, the pilot program was well-received. Strengths of the program include real-time feedback, education, and review as well as increased visibility of the Infection Prevention & Control team. Future efforts will focus on increasing TBP-appropriateness to the 80% goal and quantifying the impact on PPE utilization.

Background: Candida growth in organ preservation fluid (OPF) is uncommon, with reported incidence ranging up to 4% of OPF. Its clinical significance is unclear, as many recipients remain asymptomatic, while on rare occasions, transmission can lead to severe donor-derived infections, most notably mycotic aneurysms, graft loss, and fatal hemorrhage. The current American Society of Transplantation (AST) guidance recommends prompt antifungal therapy when Candida is identified; however, real-world practice patterns and outcomes are not well described. Methods: We conducted a retrospective cohort study of adult solid organ transplant recipients at a tertiary academic center from January 2020 through October 2025. Patients with Candida-positive OPF cultures were identified through the medical record. We collected recipients' and donors' demographics, microbiological profiles, antifungal management, and clinical outcomes. Invasive candidiasis was defined as Candida isolated from blood or deep tissue/fluid within 90 days of transplant. Results: We identified 55 solid organ transplant recipients with Candida-positive OPF cultures (34 Kidney, 9 Liver, 12 Kidney-Pancreas). The most common isolates (37 patients) were C. albicans and C. glabrata. Treatment patterns and outcomes varied by organ type. Among Kidney recipients, 20.5% (7/34) received no antifungal therapy; notably, none of these untreated patients developed invasive candidiasis, graft loss, or vascular complications. All Liver recipients (n=9) received antifungal therapy, predominantly for <7 days (n=8). Despite treatment, Liver recipients had high morbidity: 22% (2/9) progressed to invasive candidiasis (peritonitis and vascular arteritis), and 67% (6/9) demonstrated vascular Doppler abnormalities. Median length of hospital stay was similar across treatment durations (p < 0.05) and similarly no increased readmission rate among all transplant groups. Conclusion: Our findings suggest that the risk of Candida-positive OPF is not uniform across organ types, indicating that current universal treatment recommendations may lead to over-treatment in some populations. Kidney recipients demonstrated favorable outcomes even without antifungal therapy. In contrast, liver recipients remained at risk for significant vascular morbidity and invasive infection regardless of treatment. Shifting to an organ-specific, risk-stratified management strategy can improve antifungal stewardship while ensuring safety for higher-risk recipients.

This article examines how Asianism was locally reconfigured and politically mobilized in late Qing China through the activities of Tang Caichang (1867–1900). Rather than treating Asianism as a coherent ideology of regional unity, it shows how Tang transformed it into a flexible political language that linked racial survival, Sino-Japanese cooperation, and revolutionary action. Drawing on the concepts of tongzhong (racial fusion) and qiangzhong (racial strengthening), Tang recast Asianism as a Han-centred project of national revitalization and articulated a ‘Yellow Race Alliance’ as both an anti-Western and anti-Qing strategy. Through his leadership in the Promoting Asia Righteousness Association, the Shanghai Asia Association, the Zhengqi Society, and, ultimately, the Zili Army Uprising, Asianist discourse was progressively embedded in organizational and military structures that enabled its translation into transnational outreach, on the one hand, and domestic revolutionary mobilization, on the other. Unlike Japan’s state-led deployments of Asianism or Southeast Asia’s anti-colonial appropriations, Chinese Asianism was shaped by a dual imperative: resisting Western imperialism while simultaneously challenging the Qing dynasty’s legitimacy. By tracing this process of ideological vernacularization, the article demonstrates how Asianism acquired political life only when rewritten to fit China’s fractured institutional landscape. It thereby situates Tang’s practice within the broader history of Asian regionalism, highlighting how transnational ideas gained mobilizational force when recalibrated into locally resonant forms during China’s transition from empire to nation-state.

We make the case for incorporating a notion of time into causal directed acyclic graphs (DAGs). We demonstrate that nontemporal causal DAGs are ambiguous and obstruct justification of the acyclicity assumption. Assuming that causes precede effects, causal relationships are relative to the time order, and causal DAGs require temporal qualification. We propose a formalization via composite causal variables that refer to quantities at one or multiple time points. We emphasize that the acyclicity assumption requires different justifications depending on whether the time order allows cycles. We conclude by discussing implications for the interpretation and applicability of DAGs as causal models.