The impact of antibiotic stewardship interventions and patient related factors on antibiotic prescribing in a vascular surgical department

PURPOSE

The development of guidelines tailored to the departments' needs and counselling during ward rounds are important antibiotic stewardship (AS) strategies. The aim was to analyse the impact of AS ward rounds and institutional guidelines as well as patient-related factors on antibiotic use in vascular surgical patients.

METHODS

A retrospective prescribing-analysis of 3 months (P1, P2) before and after implementing weekly AS ward rounds and antimicrobial treatment guidelines was performed. Choice of systemic antibiotics, days of antibiotic therapy and clinical data were obtained from electronic patient records.

RESULTS

During P2, the overall antibiotic consumption as well as the use of last-resort compounds like linezolid and fluoroquinolones decreased distinctly (overall: 47.0 days of therapy (DOT)/100 patient days (PD) vs. 35.3 DOT/100PD, linezolid: 3.7 DOT/100PD vs. 1.0 DOT/100PD, fluoroquinolones: 7.0 DOT/100PD vs. 3.2 DOT/100PD) while narrow-spectrum beta-lactams increased by 48.4%. Courses of antibiotics were de-escalated more often during P2 (30.5% vs. 12.1%, p = 0.011). Only in P2, an antibiotic therapy was initiated in patients suffering from more comorbidities (i.e. higher Charlson Comorbidity Index) more frequently. Other patient factors had no distinct impact on antibiotic prescribing.

CONCLUSION

Weekly AS ward rounds improved adherence to institutional antibiotic treatment guidelines and antibiotic prescribing in vascular surgical patients. Clear patient-related determinants affecting choice of antibiotic therapies could not be identified.

Analysis of transmission-related third-generation cephalosporin-resistant Enterobacterales by electronic data mining and core genome multi-locus sequence typing

BACKGROUND

To contain intra-hospital transmission of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), contact isolation precautions are recommended.

AIM

To quantify transmissions of 3GCR Escherichia coli and 3GCR Klebsiella pneumoniae within a hospital.

METHODS

An automated outbreak detection system (AODS) was used to identify clusters (N≥2) of 3GCR Enterobacterales for the years 2016, 2018 and 2020. Clusters were defined by phenotypic agreement of microbiological results and spatial and temporal relationship. Core genome multi-locus sequence typing (cgMLST) was used to confirm whether the cluster isolates were transmitted between patients.

FINDINGS

A total of 4343 3GCR E. coli and 1377 K. pneumoniae isolates were analysed. Among the 3GCR E. coli isolates, the AODS identified 304 isolates as cluster isolates, the median cluster size was two (range: 2-5). The cgMLST analysis revealed that a total of 23 (7.5%) 3GCR E. coli cluster isolates were transmission-associated, of which 20 isolates (87%) were detected in intensive care patients. Among the 3GCR K. pneumoniae isolates, the AODS identified 73 isolates as cluster isolates, the median cluster size was two (range: 2-4). CgMLST revealed that 35 (48%) 3GCR K. pneumoniae cluster isolates were transmission associated, of which 27 isolates (77%) were detected in intensive care patients.

CONCLUSION

For 3GCR K. pneumoniae, cgMLST confirmed the AODS results more frequently than for 3GCR E. coli. Therefore, contact isolation precautions for 3GCR K. pneumoniae may be appropriate on intensive care units, but only in certain circumstances, such as outbreaks, for Enterobacterales with lower transmissibility, such as E. coli.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Enhancement of awareness through feedback does not lead to interlimb transfer of obstacle crossing in virtual reality

Locomotor skill transfer is an essential feature of motor adaptation and represents the generalization of learned skills. We previously showed that gait adaptation after crossing virtual obstacles did not transfer to the untrained limb and suggested it may be due to missing feedback of performance. This study investigated whether providing feedback and an explicit goal during training would lead to transfer of adaptive skills to the untrained limb. Thirteen young adults crossed 50 virtual obstacles with one (trained) leg. Subsequently, they performed 50 trials with their other (transfer) leg upon notice about the side change. Visual feedback about crossing performance (toe clearance) was provided using a color scale. In addition, joint angles of the ankle, knee, and hip were calculated for the crossing legs. Toe clearance decreased with repeated obstacle crossing from 7.8 ± 2.7 cm to 4.6 ± 1.7 cm for the trained leg and from 6.8 ± 3.0 cm to 4.4 ± 2.0 cm (p < 0.05) for the transfer leg with similar adaptation rates between limbs. Toe clearance was significantly higher for the first trials of the transfer leg compared to the last trials of the training leg (p < 0.05). Furthermore, statistical parametric mapping revealed similar joint kinematics for trained and transfer legs in the initial training trials but differed in knee and hip joints when comparing the last trials of the trained leg with the first trials of the transfer leg. We concluded that locomotor skills acquired during a virtual obstacle crossing task are limb-specific and that enhanced awareness does not seem to improve interlimb transfer.

Measurement of the α-Particle Monopole Transition Form Factor Challenges Theory: A Low-Energy Puzzle for Nuclear Forces?

We perform a systematic study of the α-particle excitation from its ground state 0_{1}^{+} to the 0_{2}^{+} resonance. The so-called monopole transition form factor is investigated via an electron scattering experiment in a broad Q^{2} range (from 0.5 to 5.0  fm^{-2}). The precision of the new data dramatically supersedes that of older sets of data, each covering only a portion of the Q^{2} range. The new data allow the determination of two coefficients in a low-momentum expansion, leading to a new puzzle. By confronting experiment to state-of-the-art theoretical calculations, we observe that modern nuclear forces, including those derived within chiral effective field theory that are well tested on a variety of observables, fail to reproduce the excitation of the α particle.

Resolving colistin resistance and heteroresistance in Enterobacter species

Species within the Enterobacter cloacae complex (ECC) include globally important nosocomial pathogens. A three-year study of ECC in Germany identified Enterobacter xiangfangensis as the most common species (65.5%) detected, a result replicated by examining a global pool of 3246 isolates. Antibiotic resistance profiling revealed widespread resistance and heteroresistance to the antibiotic colistin and detected the mobile colistin resistance (mcr)-9 gene in 19.2% of all isolates. We show that resistance and heteroresistance properties depend on the chromosomal arnBCADTEF gene cassette whose products catalyze transfer of L-Ara4N to lipid A. Using comparative genomics, mutational analysis, and quantitative lipid A profiling we demonstrate that intrinsic lipid A modification levels are genospecies-dependent and governed by allelic variations in phoPQ and mgrB, that encode a two-component sensor-activator system and specific inhibitor peptide. By generating phoPQ chimeras and combining them with mgrB alleles, we show that interactions at the pH-sensing interface of the sensory histidine kinase phoQ dictate arnBCADTEF expression levels. To minimize therapeutic failures, we developed an assay that accurately detects colistin resistance levels for any ECC isolate.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

A81 TRANSITION PRACTICES FROM PEDIATRIC TO ADULT CARE OF CHILDREN LIVING WITH CROHN’S DISEASE IN QUEBEC

Background

Nearly 25% of Crohn’s disease cases are diagnosed during childhood. Among them, several adolescents may have extensive or complex disease implying specific needs during transition to adult care.

Aims

The primary aim was to describe current transition practices from pediatric to adult care in patients diagnosed with Crohn’s disease at CHU Sainte-Justine. The secondary aim was to determine factors that influenced the type of adult health centers (academic vs non-academic) to which patients were referred.

Methods

This single center study included patients diagnosed with Crohn’s disease at CHU Sainte-Justine between 2009 and 2019. Adult centers were separated into five categories: academic centers in Montreal (CHU-Mtl) and outside of Montreal (CHU), non-academic centers in Montreal (CHG-Mtl) and outside of Montreal (CHG), and other centers. The following factors influencing the transfer to an academic center were analyzed in a multivariate logistic regression model: age at diagnosis, gender, disease location, disease activity: relapses, hospitalizations, emergency room (ER) visits, and place of residence.

Results

A total of 366 patients were included: 44% female, median (IQR) age at transfer 18.0 (17.9–18.4). Among them, 169 (48%) were transferred to CHU-Mtl, 144 (39%) to CHG, 22(6%) to CHU, 4 (1%) to CHG-Mtl, 27 (7%) to other centers. There was a significant increase in the annual number of patients referred to CHG and CHU-Mtl across the decade, compared to other centers. Patients transferred to CHU-Mtl had more relapses per year (mean (SD) 0.8 (0.5) versus patients transferred to CHU, CHG and CHG-Mtl, p=0.0348), and 57% (N=97) of patients sent to CHU-Mtl had already visited the ER, as compared to 54%, 40% and 25% for CHU, CHG and CHG-Mtl respectively (p=0.0258). However, gender, age at diagnosis, maintenance treatment, number and duration of hospitalisations, extraintestinal manifestations, perianal inflammation or extensive disease location did not correlate with the type of adult center. Place of residence played a role in the choice of adult center: 56% (N= 95) of patients transferred to CHU-Mtl lived in Montreal (p<0.0001).

Conclusions

Clinical evolution and disease burden have an impact on the type of adult center. Efforts should be put to understand patient factors associated with the transfer to an academic vs non-academic center, for a better utilization of healthcare resources and adequate patient quality of life during transition.

Funding Agencies

NonePrincipal researcher funds

Kombinierter Suizid: Methode nach Kusch und Kopfschuss – ein Fallbericht

Die gleichzeitige Anwendung mehrerer Methoden beim Suizid wird als „kombinierter Suizid“ bezeichnet. Vorgestellt wird ein Fall, bei dem zunächst alles auf einen Suizid mittels Schusswaffe hindeutet. Die chemisch-toxikologische Analyse ergibt den Nachweis von Benzodiazepinen und einer potenziell letalen Chloroquinkonzentration im Blutserum, was als Methode nach Kusch bezeichnet wird und mit einer Handlungsunfähigkeit einhergehen kann. Die Kombination von Chloroquin mit Diazepam kann aber, in Abhängigkeit von der Dosierung, auch dazu führen, dass die Handlungsfähigkeit erhalten bleibt und auch hohe Chloroquinkonzentrationen überlebt werden. Der vorgestellte Fall soll die potenziellen Wechselwirkungen dieser Wirkstoffe verdeutlichen.

Comparative analysis of antibody responses to outer surface protein (Osp)A and OspC in dogs vaccinated with Lyme disease vaccines

Lyme disease (LD), the most common tick-borne disease of canines and humans in N. America, is caused by the spirochete Borreliella burgdorferi. Subunit and bacterin vaccines are available for the prevention of LD in dogs. LD bacterin vaccines, which are comprised of cell lysates of two strains of B. burgdorferi, contain over 1000 different proteins and cellular constituents. In contrast, subunit vaccines are defined in composition and consist of either outer surface protein (Osp)A or OspA and an OspC chimeritope. In this study, we comparatively assessed antibody responses to OspA and OspC induced by vaccination with all canine bacterin and subunit LD vaccines that are commercially available in North America. Dogs were administered a two-dose series of the vaccine to which they were assigned (3 weeks apart): Subunit-AC, Subunit-A, Bacterin-1, and Bacterin-2. Antibody titers to OspA and OspC were determined by ELISA and the ability of each vaccine to elicit antibodies that recognize diverse OspC proteins (referred to as OspC types) assessed by immunoblot. While all of the vaccines elicited similar OspA antibody responses, only Subunit-AC triggered a robust and broadly cross-reactive antibody response to divergent OspC proteins. The data presented within provide new information regarding vaccination-induced antibody responses to key tick and mammalian phase antigens by both subunit and bacterin LD canine vaccine formulations.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

A simple method for preconditioning radial forearm flaps in the case of an insufficient ulnar vascular supply: a retrospective clinical analysis

Due to its versatile applicability, many reconstructive surgeons use the radial forearm flap (RFF) as the first choice for soft tissue replacement. Donor site limitations of the flap arise with an insufficient blood supply along the ulnar artery. This study presents a simple and safe method for RFF preconditioning by recruitment of the deep palmar arch via the ulnar artery. Fourteen patients scheduled for RFF surgery between 2013 and 2018 showed an insufficient vascular supply according to the Allen test, which was confirmed by digital subtraction angiography (DSA). These 14 patients underwent temporary ligature of one or both radial arteries with elastic vessel loops under local anaesthesia and continuous pulse oximetry. A control DSA was performed about 24hours later in 10 of the 14 patients. Recruitment of the blood supply along the enlarged ulnar artery or reanimated collaterals was confirmed in all 10 patients. No local complications such as ischemia of the hand were seen. All flaps could be harvested regularly and were used for different reconstructive purposes. This simple technique may help to overcome vascular limitations of the RFF via the rapid, efficient, and reliable recruitment of the biological vascular reserve. Within the limits of a case series, this procedure appears practicable and safe.

A pilot study evaluating GSK1070806 inhibition of interleukin-18 in renal transplant delayed graft function

INTRODUCTION

Delayed graft function (DGF) following renal transplantation is a manifestation of acute kidney injury (AKI) leading to poor long-term outcome. Current treatments have limited effectiveness in preventing DGF. Interleukin-18 (IL18), a biomarker of AKI, induces interferon-γ expression and immune activation. GSK1070806, an anti-IL18 monoclonal antibody, neutralizes activated (mature) IL18 released from damaged cells following inflammasome activation. This phase IIa, single-arm trial assessed the effect of a single dose of GSK1070806 on DGF occurrence post donation after circulatory death (DCD) kidney transplantation.

METHODS

The 3 mg/kg intravenous dose was selected based on prior studies and physiologically based pharmacokinetic (PBPK) modeling, indicating the high likelihood of a rapid and high level of IL18 target engagement when administered prior to kidney allograft reperfusion. Utilization of a Bayesian sequential design with a background standard-of-care DGF rate of 50% based on literature, and confirmed via extensive registry data analyses, enabled a statistical efficacy assessment with a minimal sample size. The primary endpoint was DGF frequency, defined as dialysis requirement ≤7 days post transplantation (except for hyperkalemia). Secondary endpoints included safety, pharmacokinetics and pharmacodynamic biomarkers.

RESULTS

GSK1070806 administration was associated with IL18-GSK1070806 complex detection and increased total serum IL18 levels due to IL18 half-life prolongation induced by GSK1070806 binding. Interferon-γ-induced chemokine levels declined or remained unchanged in most patients. Although the study was concluded prior to the Bayesian-defined stopping point, 4/7 enrolled patients (57%) had DGF, exceeding the 50% standard-of-care rate, and an additional two patients, although not reaching the protocol-defined DGF definition, demonstrated poor graft function. Six of seven patients experienced serious adverse events (SAEs), including two treatment-related SAEs.

CONCLUSION

Overall, using a Bayesian design and extensive PBPK dose modeling with only a small sample size, it was deemed unlikely that GSK1070806 would be efficacious in preventing DGF in the enrolled DCD transplant population.

TRIAL REGISTRATION

NCT02723786.

A119 THE LOCATION-BASED RESECT AND DISCARD STRATEGY FOR DIMINUTIVE COLORECTAL POLYPS: A PROSPECTIVE CLINICAL STUDY

Background

Replacing histopathology evaluation of diminutive polyps with optical polyp diagnosis is considered a cost-effective approach. However, the widespread use of optical diagnosis is limited due to concerns about making incorrect optical diagnoses and the requirements of training, credentialing and auditing of performance.

Aims

This prospective study aimed to evaluate a simplified resect and discard strategy that is not operator dependent.

Methods

The study evaluated a resect and discard strategy that uses anatomical polyp location to classify colon polyps into non-neoplastic or low-risk neoplastic. All rectosigmoid diminutive polyps were considered hyperplastic and all polyps located proximally to the sigmoid colon were considered neoplastic. Surveillance interval assignments based on these a priori assumptions were compared with those based on actual pathology results and optical diagnosis, respectively. The primary outcome was ≥90% agreement with pathology in surveillance interval assignment.

Results

Overall, 1117 patients undergoing complete colonoscopy were included and 482 (43.1%) had at least one diminutive polyp. Surveillance interval agreement between the location-based resect and discard strategy and pathological findings using the 2020 US Multi-Society Task Force guideline was 97.0% (95% CI = 0.96 - 0.98), surpassing the ≥90% benchmark. Optical diagnoses using NICE and Sano classifications reached 89.1% and 90.01% agreement, respectively (p &lt;0.0001), and were inferior to the location-based strategy. The location-based resect and discard strategy allowed a 69.7% (95% CI = 0.67 - 0.72) reduction in pathology examinations compared with 55.3% (95% CI = 0.52 - 0.58) (NICE and Sano) and 41.9% (95% CI = 0.39 - 0.45) (WASP) with optical diagnosis.

Conclusions

The location-based resect and discard strategy achieved very high surveillance interval agreement with pathology-based surveillance interval assignment, surpassing the ≥90% quality benchmark and outperforming optical diagnosis in surveillance interval agreement and the number of pathology examinations avoided.

Funding Agencies

None

Obstacle avoidance training in virtual environments leads to limb-specific locomotor adaptations but not to interlimb transfer in healthy young adults

Obstacle avoidance is one of the skills required in coping with challenging situations encountered during walking. This study examined adaptation in gait stability and its interlimb transfer in a virtual obstacle avoidance task. Twelve young adults walked on a treadmill while wearing a virtual reality headset with their body state represented in the virtual environment. At random times, but always at foot touchdown, 50 virtual obstacles of constant size appeared 0.8 m in front of the participant requiring a step over with the right leg. Early, mid and late adaptation phases were investigated by pooling data from trials 1-3, 24-26 and 48-50. One left-leg obstacle appearing after 50 right-leg trials was used to investigate interlimb transfer. Toe clearance and the anteroposterior margin of stability (MoS) at foot touchdown were calculated for the stepping leg. Toe clearance decreased over repeated practice between early and late phases from 0.13 ± 0.05 m to 0.09 ± 0.04 m (mean ± SD, p < 0.05). MoS increased from 0.05 ± 0.02 m to 0.08 ± 0.02 m (p < 0.05) between early and late phases, with no significant differences between mid and late phases. No differences were found in toe clearance and MoS between the practiced right leg for early phase and the single trial of the left leg. Obstacle avoidance during walking in a virtual environment stimulated adaptive gait improvements that were related in a nonlinear manner to practice dose, though such gait adaptations seemed to be limited in their transferability between limbs.

Performance of a Novel Handheld Bioelectrical Impedance Device for Assessing Muscle Mass in Older Inpatients

Objectives: To investigate practicality and repeatability of a handheld compared to a state-of-the-art multisegmental bioelectrical impedance analysis (BIA) device to facilitate screening of sarcopenia in older inpatients. Design and setting: Cross-sectional study in a geriatric rehabilitation hospital. Participants: 207 inpatients aged 70+. Measurements: In a first phase, appendicular skeletal muscle mass index (ASMI) was measured using the handheld Biody xpertZm II BIA device (n=100). In a second phase, ASMI was obtained using the multisegmental Biacorpus RX 4004M device (n=107). Repeatability of BIA devices was compared in subgroups of patients (handheld BIA device: n=36, multisegmental BIA device: n=46) by intra-class correlation (ICC) and Bland-Altman plots. Results: Overall, measurement failure was seen in 31 patients (31%) tested with the handheld BIA device compared to one patient (0.9%) using the multisegmental BIA device (p<0.001). Main reasons for measurement failure were inability of patients to adopt the position necessary to use the handheld BIA device and device failure. The mean difference of two ASMI measurements in the same patient was 0.32 (sd 0.85) using the handheld BIA device compared to 0.02 kg/m2 (sd 0.07) using the multisegmental device (adjusted mean difference between both groups -0.35, 95% confidence interval (CI) -0.61 to -0.09 kg/m2). Congruently, Bland-Altman plots showed poor agreement with the handheld compared to the multisegmental BIA device. Conclusion: The handheld BIA device is neither a practical nor reliable device for assessing muscle mass in older rehabilitation inpatients.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.