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To evaluate whether an antimicrobial stewardship bundle (ASB) can safely empower frontline providers in the treatment of gram-negative bloodstream infections (GN-BSI).
Intervention and Method:
From March 2021 to February 2022, we implemented an ASB intervention for GN-BSI in the electronic medical record (EMR) to guide clinicians at the point of care to optimize their own antibiotic decision-making. We conducted a before-and-after quasi-experimental pre-bundle (preBG) and post-bundle (postBG) study evaluating a composite of in-hospital mortality, infection-related readmission, GN-BSI recurrence, and bundle-related outcomes.
Setting:
New York University Langone Health (NYULH), Tisch/Kimmel (T/K) and Brooklyn (BK) campuses, in New York City, New York.
Patients:
Out of 1097 patients screened, the study included 225 adults aged ≥18 years (101 preBG vs 124 postBG) admitted with at least one positive blood culture with a monomicrobial gram-negative organism.
Results:
There was no difference in the primary composite outcome (12.9% preBG vs. 7.3% postBG; P = 0.159) nor its individual components of in-hospital mortality, 30-day infection-related readmission, and GN-BSI recurrence. Vancomycin (VAN) discontinuation (DC) was done more frequently by the primary team in postBG (37.9% vs 66.7%; P < 0.001). In postBG, de-escalation done by the primary team increased by 8.8%, P = 0.310 and there was an 11.1% increase in the use of aminopenicillin-based antibiotics, P = 0.043.
Conclusions:
GN-BSI bundle worked as a nudge-based strategy to guide providers in VAN DC and increased de-escalation to aminopenicillin-based antibiotics without negatively impacting patient outcomes.
There is a paucity of data guiding treatment duration of oral vancomycin for Clostridiodes difficile infection (CDI) in patients requiring concomitant systemic antibiotics.
Objectives:
To evaluate prescribing practices of vancomycin for CDI in patients that required concurrent systemic antibiotics and to determine whether a prolonged duration of vancomycin (>14 days), compared to a standard duration (10–14 days), decreased CDI recurrence.
Methods:
In this retrospective cohort study, we evaluated adult hospitalized patients with an initial episode of CDI who were treated with vancomycin and who received overlapping systemic antibiotics for >72 hours. Outcomes of interest included CDI recurrence and isolation of vancomycin-resistant Enterococcus (VRE).
Results:
Among the 218 patients included, 36% received a standard duration and 64% received a prolonged duration of treatment for a median of 13 days (11–14) and 20 days (16–26), respectively. Patients who received a prolonged duration had a longer median duration of systemic antibiotic overlap with vancomycin (11 vs 8 days; P < .001) and significantly more carbapenem use and infectious disease consultation. Recurrence at 8 weeks (12% standard duration vs 8% prolonged duration; P = .367), recurrence at 6 months (15% standard duration vs 10% prolonged duration; P = .240), and VRE isolation (3% standard duration vs 9% prolonged duration; P = .083) were not significantly different between groups. Discontinuation of vancomycin prior to completion of antibiotics was an independent predictor of 8-week recurrence on multivariable logistic regression (OR, 4.8; 95% CI, 1.3–18.1).
Conclusions:
Oral vancomycin prescribing relative to the systemic antibiotic end date may affect CDI recurrence to a greater extent than total vancomycin duration alone. Further studies are needed to confirm these findings.
Radiocarbon (14C) is an isotopic tracer used to address a wide range of scientific research questions. However, contamination by elevated levels of 14C is deleterious to natural-level laboratory workspaces and accelerator mass spectrometer facilities designed to precisely measure small amounts of 14C. The risk of contaminating materials and facilities intended for natural-level 14C with elevated-level 14C-labeled materials has dictated near complete separation of research groups practicing profoundly different measurements. Such separation can hinder transdisciplinary research initiatives, especially in remote and isolated field locations where both natural-level and elevated-level radiocarbon applications may be useful. This paper outlines the successful collaboration between researchers making natural-level 14C measurements and researchers using 14C-labeled materials during a subglacial drilling project in West Antarctica (SALSA 2018–2019). Our strict operating protocol allowed us to successfully carry out 14C labeling experiments within close quarters at our remote field camp without contaminating samples of sediment and water intended for natural level 14C measurements. Here we present our collaborative protocol for maintaining natural level 14C cleanliness as a framework for future transdisciplinary radiocarbon collaborations.
The Subglacial Antarctic Lakes Scientific Access (SALSA) Project accessed Mercer Subglacial Lake using environmentally clean hot-water drilling to examine interactions among ice, water, sediment, rock, microbes and carbon reservoirs within the lake water column and underlying sediments. A ~0.4 m diameter borehole was melted through 1087 m of ice and maintained over ~10 days, allowing observation of ice properties and collection of water and sediment with various tools. Over this period, SALSA collected: 60 L of lake water and 10 L of deep borehole water; microbes >0.2 μm in diameter from in situ filtration of ~100 L of lake water; 10 multicores 0.32–0.49 m long; 1.0 and 1.76 m long gravity cores; three conductivity–temperature–depth profiles of borehole and lake water; five discrete depth current meter measurements in the lake and images of ice, the lake water–ice interface and lake sediments. Temperature and conductivity data showed the hydrodynamic character of water mixing between the borehole and lake after entry. Models simulating melting of the ~6 m thick basal accreted ice layer imply that debris fall-out through the ~15 m water column to the lake sediments from borehole melting had little effect on the stratigraphy of surficial sediment cores.
Aquatic subglacial habitats occur throughout the cryosphere where basal melting is sufficient to produce aqueous environments (Priscu & Christner, 2004). Heat energy for melting of basal ice is produced by frictional heating due to glacier movement and geothermal heat flux (Fisher et al., 2015). These heat sources in concert with the lowering of the pressure melting point due to the weight and insulating properties of the overlying ice all contribute to basal ice melting.
Subglacial Antarctic aquatic environments are important targets for scientific exploration due to the unique ecosystems they support and their sediments containing palaeoenvironmental records. Directly accessing these environments while preventing forward contamination and demonstrating that it has not been introduced is logistically challenging. The Whillans Ice Stream Subglacial Access Research Drilling (WISSARD) project designed, tested and implemented a microbiologically and chemically clean method of hot-water drilling that was subsequently used to access subglacial aquatic environments. We report microbiological and biogeochemical data collected from the drilling system and underlying water columns during sub-ice explorations beneath the McMurdo and Ross ice shelves and Whillans Ice Stream. Our method reduced microbial concentrations in the drill water to values three orders of magnitude lower than those observed in Whillans Subglacial Lake. Furthermore, the water chemistry and composition of microorganisms in the drill water were distinct from those in the subglacial water cavities. The submicron filtration and ultraviolet irradiation of the water provided drilling conditions that satisfied environmental recommendations made for such activities by national and international committees. Our approach to minimizing forward chemical and microbiological contamination serves as a prototype for future efforts to access subglacial aquatic environments beneath glaciers and ice sheets.
Inorganic carbon fixation, usually mediated by photosynthetic microorganisms, is considered to form the base of the food chain in aquatic ecosystems. In high-latitude lakes, lack of sunlight owing to seasonal solar radiation limits the activity of photosynthetic plankton during the polar winter, causing respiration-driven demand for carbon to exceed supply. Here, we show that inorganic carbon fixation in the dark, driven by organisms that gain energy from chemical reactions rather than sunlight (chemolithoautotrophs), provides a significant influx of fixed carbon to two permanently ice-covered lakes (Fryxell and East Bonney). Fryxell, which has higher biomass per unit volume of water, had higher rates of inorganic dark carbon fixation by chemolithoautotrophs than East Bonney (trophogenic zone average 1.0 µg C l−1 d−1vs 0.08 µg C l−1 d−1, respectively). This contribution from dark carbon fixation was partly due to the activity of ammonia oxidizers, which are present in both lakes. Despite the potential importance of new carbon input by chemolithoautotrophic activity, both lakes remain net heterotrophic, with respiratory demand for carbon exceeding supply. Dark carbon fixation increased the ratio of new carbon supply to respiratory demand from 0.16 to 0.47 in Fryxell, and from 0.14 to 0.22 in East Bonney.
OBJECTIVES/SPECIFIC AIMS: The first aim of the study is to evaluate the accuracy of serum biomarkers of acute GVHD measured after four weeks of corticosteroid therapy to predict 6 month NRM. The second aim of this study is to compare the accuracy of the biomarker algorithm to that of clinical response to corticosteroids after four weeks. The third aim of the study is to develop a novel regression model that uses weekly biomarker measurements over the first month of corticosteroid therapy to predict 6 month NRM. METHODS/STUDY POPULATION:. Patients who received HCT at one of 22 IRB-approved centers and provided blood samples to the Mount Sinai Acute GVHD International Consortium (MAGIC) biorepository and developed GVHD between January 2008 to May 2018 are included in this study. Patients were divided by time into a training set (Jan 2008-Dec 2015, n=233) for model development and a validation set (Jan 2015-May 2018, n=357) to evaluate the predictive performance of the model. The later time of the validation set was chosen deliberately to model contemporaneous GVHD treatment practices. The size of each group was designed so that there would be roughly equal numbers of deaths in both groups. RESULTS/ANTICIPATED RESULTS:. Serum concentrations of GVHD biomarkers after one month of corticosteroid therapy were measured in the validation set, and the predicted probability of NRM ($\hat{\rm p}$) was computed according to the previously published algorithm: $\log[-\log(1 - \hat{\rm p})]=-11.263 + 1.844({\rm logST}2)+ 0.577({\rm logREG}3\alpha)$. The performance of the biomarker algorithm was evaluated by creating receiver operating characteristic (ROC) curves and calculating the area under the curve (AUC) in the validation set. The AUC of the biomarker algorithm was a significantly better predictor of 6 month NRM than clinical response to treatment after four weeks of corticosteroids (0.84 vs. 0.64, p<0.001), which is a clinically relevant improvement in accuracy. To evaluate serial biomarker monitoring, serum biomarker concentrations will be measured weekly at five time points from treatment initiation to one month after corticosteroid therapy. We will use these values in the training set to develop a regression model for 6 month NRM that accounts for repeated biomarker measurements. The performance of this model will be tested in the validation set and the accuracy of the serial biomarker measurements will be compared to the accuracy of measuring biomarkers at the single time point after four weeks of corticosteroid therapy. An AUC improvement of 0.05 would be considered clinically significant. DISCUSSION/SIGNIFICANCE OF IMPACT: Clinical response to treatment after four weeks has been the standard endpoint in GVHD interventional trials for decades. If biomarkers measured at the same time more accurately predict long term mortality, this study would provide the basis for a novel endpoint in GVHD trials and enable more accurate determination of effect size of experimental interventions. An accurate biomarker algorithm will prove useful in guiding immunosuppressive treatment decisions for patients with GVHD. Patients identified by the algorithm as low-risk may benefit from reduced-dose corticosteroid therapy, potentially reducing lethal opportunistic infections. Patients identified as high-risk will be candidates for more intensive immunosuppression or investigational therapies. This precision medicine approach tailors therapy to the individual patient’s biology.
Microorganisms are the most abundant organisms on Earth, and microbial abundance records preserved in ice cores have been connected to records of environmental change. As an alternative to high resolution abundance records, which can be difficult to recover, we used culture-dependent and culture-independent methods to examine bacteria in glacier ice from the Tibetan Plateau (TP). We recovered a total of 887 bacterial isolates from ice cores of up to 164 m in depth retrieved from seven glaciers, located across the TP. These isolates were related to 53 genera in the Actinobacteria, Firmicutes, Bacteroidetes, and Proteobacteria, with 13 major genera accounting for 78% of isolates. Most of the genera were common across the geographic region covered by our sampling, but there were differences in the genera recovered from different depths in the ice, with the deepest portions of the ice cores dominated by a single genus (Sporosarcina). Because microorganisms deposited on glaciers must survive atmospheric transport under a range of temperatures, temperature tolerance should be an important survival mechanism. We tested isolate growth across a range of temperatures (0–35 °C), and found psychrotolerance to be common. Together, our results show that ice depth, and by extension age, are characterized by different types of microorganisms, providing new information about microbial records in ice.
Ethnic variations have previously been identified in the duration of untreated psychosis (DUP) and pathways into psychiatric services. These have not been examined in the context of early intervention services, which may alter these trajectories.
Aims
To explore ethnic differences in the nature and duration of pathways into early intervention services.
Method
In a naturalistic cohort study, data were collected for 1024 individuals with psychotic disorders accepted for case management by eight London early intervention services.
Results
Duration of untreated psychosis was prolonged in the White British group compared with most other ethnic groups. White British individuals were more likely to make contact with their general practitioner and less likely to be seen within emergency medical services. All Black patient groups were more likely than their White British counterparts to experience involvement of criminal justice agencies.
Conclusions
Variations continue to exist in how and when individuals from different ethnic groups access early intervention services. These may account for disparities in DUP.
The Whillans Ice Stream Subglacial Access Research Drilling (WISSARD) project will test the overarching hypothesis that an active hydrological system exists beneath a West Antarctic ice stream that exerts a major control on ice dynamics, and the metabolic and phylogenetic diversity of the microbial community in subglacial water and sediment. WISSARD will explore Subglacial Lake Whillans (SLW, unofficial name) and its outflow toward the grounding line where it is thought to enter the Ross Ice Shelf seawater cavity. Introducing microbial contamination to the subglacial environment during drilling operations could compromise environmental stewardship and the science objectives of the project, consequently we developed a set of tools and procedures to directly address these issues. WISSARD hot water drilling efforts will include a custom water treatment system designed to remove micron and sub-micron sized particles (biotic and abiotic), irradiate the drilling water with germicidal ultraviolet (UV) radiation, and pasteurize the water to reduce the viability of persisting microbial contamination. Our clean access protocols also include methods to reduce microbial contamination on the surfaces of cables/hoses and down-borehole equipment using germicidal UV exposure and chemical disinfection. This paper presents experimental data showing that our protocols will meet expectations established by international agreement between participating Antarctic nations.
The topic of 2012 can be debated and discussed from at least four different perspectives: (1) scholarly work to reconstruct authentic Maya beliefs; (2) popular writers and so-called “New Age” model-makers; (3) the mass media; (4) what contemporary Maya leaders themselves think of 2012. I have treated all four of these perspectives in detail in my recent book, The 2012 Story: The Myths, Fallacies, and Truth Behind the Most Intriguing Date in History (Jenkins 2009). These areas often overlap. For example, the media may attempt to embrace and report on all these positions. However, more often than not the mass media simply assumes and orients its reporting to the most ridiculous doomsday presentation. At best, the mass media will frame its discussion in a biased way which simply reflects modern misconceptions. For example, the one overall misconception, which I will not discuss at length here since it has been so overplayed, is that the ancient Maya predicted the end of the world in 2012. As I have been pointing out for some twenty years, there is no evidence for this assumption. It is, however, an expected talking point for a dumbed-down mass media that thrives on sensationalism.
Since the mid-1980s I have studied and written about Maya astronomy, cosmology and calendrics. I have an ancillary interest in how the 2012 topic has been increasingly appropriated by the popular imagination, including exploitative and opportunistic writers.
Thin native oxide layers can dominate the mechanical properties of metallic thin films. However, to date there has been little quantification of how such overlayers affect yield and fracture during indentation in constrained film systems. To gain insight into such processes, electrical contact resistance was measured in situ during nanoindentation on constrained thin films of epitaxial Cr and polycrystalline Al, both possessing a native oxide overlayer. Measurements during loading of the films show both increases and decreases in current, which can then be used to distinguish between various sources of plasticity. Ex situ measurements of the oxide thickness are used to provide a starting point for elasticity simulations of stress in both systems. The results show that dislocation nucleation in the metal film can be differentiated from oxide fracture during indentation.
The marginal approach to risk and return analysis compares the marginal return from a business decision to the marginal risk imposed. Allocation distributes the total company risk to business units and compares the profit/risk ratio of the units. These approaches coincide when the allocation actually assigns the marginal risk to each business unit, i.e., when the marginal impacts add up to the total risk measure. This is possible for one class of risk measures (scalable measures) under the assumption of homogeneous growth and by a subclass (transformed probability measures) otherwise. For homogeneous growth, the allocation of scalable measures can be accomplished by the directional derivative. The first well known additive marginal allocations were the Myers-Read method from Myers and Read (2001) and co-Tail Value at Risk, discussed in Tasche (2000). Now we see that there are many others, which allows the choice of risk measure to be based on economic meaning rather than the availability of an allocation method. We prefer the term “decomposition” to “allocation” here because of the use of the method of co-measures, which quantifies the component composition of a risk measure rather than allocating it proportionally to something.
Risk adjusted profitability calculations that do not rely on capital allocation still may involve decomposition of risk measures. Such a case is discussed. Calculation issues for directional derivatives are also explored.
Analyzing a single data set using multiple RNA informatics programs often requires a file format conversion between each pair of programs, significantly hampering productivity. To facilitate the interoperation of these programs, we propose a syntax to exchange basic RNA molecular information. This RNAML syntax allows for the storage and the exchange of information about RNA sequence and secondary and tertiary structures. The syntax permits the description of higher level information about the data including, but not restricted to, base pairs, base triples, and pseudoknots. A class-oriented approach allows us to represent data common to a given set of RNA molecules, such as a sequence alignment and a consensus secondary structure. Documentation about experiments and computations, as well as references to journals and external databases, are included in the syntax. The chief challenge in creating such a syntax was to determine the appropriate scope of usage and to ensure extensibility as new needs will arise. The syntax complies with the eXtensible Markup Language (XML) recommendations, a widely accepted standard for syntax specifications. In addition to the various generic packages that exist to read and interpret XML formats, an XML processor was developed and put in the open-source MC-Core library for nucleic acid and protein structure computer manipulation.