Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital.

BACKGROUND: Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections. METHODS: In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making. RESULTS: Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice. CONCLUSIONS: Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.

Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: A Prospective Cluster-Randomized Crossover Study.

BACKGROUND: Few groups have formally studied the effect of dedicated antibiotic stewardship rounds (ASRs) on antibiotic use (AU) in intensive care units (ICUs). METHODS: We implemented weekly ASRs using a 2-arm, cluster-randomized, crossover study in 5 ICUs at Duke University Hospital from November 2017 to June 2018. We excluded patients without an active antibiotic order, or if they had a marker of high complexity including an existing infectious disease consult, transplantation, ventricular assist device, or extracorporeal membrane oxygenation. AU during and following ICU stay for patients with ASRs was compared to the controls. We recorded the number of reviews, recommendations delivered, and responses. We evaluated change in ICU-specific AU during and after the study. RESULTS: Our analysis included 4683 patients: 2330 intervention and 2353 controls. Teams performed 761 reviews during ASRs, which excluded 1569 patients: 60% of patients off antibiotics, and 8% complex patients. Exclusions affected 88% of cardiothoracic ICU (CTICU) patients. The AU rate ratio (RR) was 0.97 (95% confidence interval [CI], .91-1.04). When CTICU was removed, the RR was 0.93 (95% CI, .89-.98). AU in the poststudy period decreased by 16% (95% CI, 11%-24%) compared to AU in the baseline period. Change in AU was differential among units: largest in the neurology ICU (-28%) and smallest in the CTICU (-2%). CONCLUSIONS: Weekly multidisciplinary ASRs was a high-resource intervention associated with a small AU reduction. The noticeable ICU AU decline over time is possibly due to indirect effects of ASRs. Effects differed among specialty ICUs, emphasizing the importance of customizing ASRs to match unit-specific population, workflow, and culture.

Current state of antimicrobial stewardship in organ transplantation in Singapore.

BACKGROUND: Antibiotic stewardship programs (ASPs) are well established in the public hospitals in Singapore, but they are not mandatory for transplant programs. Given the positive impact of ASPs in non-organ transplant patients (improved use of broad-spectrum antibiotics, reduced length of stay, and lower healthcare costs), stewardship principles are likely to benefit transplant recipients. METHODS: We reviewed the progress made in ASPs in the Asia Pacific region as well as the progress of our ASP over the last decade since it was established. We also described how stewardship strategies have evolved for the purposes of our transplant program. RESULTS: Currently, pressing stewardship issues for our transplant program include high antibiotic consumption, as well as the burden, morbidity, and mortality associated with drug-resistant bacterial infections. Transplanting the model of stewardship onto a transplant program ignores the intricacies of transplant patients; the bespoke form of stewardship, "handshake stewardship", is more appropriate. CONCLUSION: To advance the cause of ASP in the transplant unit in Singapore, stakeholder buy-in is key; empowering transplant physicians to be stewardship-focused would be more sustainable in the long run. In addition, expanding our diagnostic armamentarium, optimizing existing therapeutics and multi-disciplinary team involvement (including stakeholders from microbiology, and infection prevention teams) are vital.

Magnetic handshake materials as a scale-invariant platform for programmed self-assembly.

Programmable self-assembly of smart, digital, and structurally complex materials from simple components at size scales from the macro to the nano remains a long-standing goal of material science. Here, we introduce a platform based on magnetic encoding of information to drive programmable self-assembly that works across length scales. Our building blocks consist of panels with different patterns of magnetic dipoles that are capable of specific binding. Because the ratios of the different panel-binding energies are scale-invariant, this approach can, in principle, be applied down to the nanometer scale. Using a centimeter-sized version of these panels, we demonstrate 3 canonical hallmarks of assembly: controlled polymerization of individual building blocks; assembly of 1-dimensional strands made of panels connected by elastic backbones into secondary structures; and hierarchical assembly of 2-dimensional nets into 3-dimensional objects. We envision that magnetic encoding of assembly instructions into primary structures of panels, strands, and nets will lead to the formation of secondary and even tertiary structures that transmit information, act as mechanical elements, or function as machines on scales ranging from the nano to the macro.

The QQUIC Transport Protocol: Quantum-Assisted UDP Internet Connections.

Quantum key distribution, initialized in 1984, is a commercialized secure communication method that enables two parties to produce a shared random secret key using quantum mechanics. We propose a QQUIC (Quantum-assisted Quick UDP Internet Connections) transport protocol, which modifies the well-known QUIC transport protocol by employing quantum key distribution instead of the original classical algorithms in the key exchange stage. Due to the provable security of quantum key distribution, the security of the QQUIC key does not depend on computational assumptions. It is possible that, surprisingly, QQUIC can reduce network latency in some circumstances even compared with QUIC. To achieve this, the attached quantum connections are used as the dedicated lines for key generation.

DDoS Flood and Destination Service Changing Sensor.

In this paper, we aim to detect distributed denial of service (DDoS) attacks, and receive a notification of destination service, changing immediately, without the additional efforts of other modules. We designed a kernel-based mechanism to build a new Transmission Control Protocol/Internet Protocol (TCP/IP) connection smartly by the host while the users or clients not knowing the location of the next host. Moreover, we built a lightweight flooding attack detection mechanism in the user mode of an operating system. Given that reinstalling a modified operating system on each client is not realistic, we managed to replace the entry of the system call table with a customized sys_connect. An effective defense depends on fine detection and defensive procedures. In according with our experiments, this novel mechanism can detect flooding DDoS successfully, including SYN flood and ICMP flood. Furthermore, through cooperating with a specific low cost network architecture, the mechanism can help to defend DDoS attacks effectively.

Comparison between laryngeal handshake and palpation techniques in the identification of cricothyroid membrane: a meta-analysis.

Because the use of conventional digital palpation technique for the identification of cricothyroid membrane (CTM) has been widely believed to be unreliable, the 'laryngeal handshake' technique (LH) has been introduced for CTM identification in the event of cricothyroidotomy. To provide evidence for clinical practice, this pilot meta-analysis aimed at investigating whether identification of CTM with the LH is superior to that with the palpation technique. Studies that evaluated the accuracy of CTM identification by using LH or palpation techniques (i.e., LH group vs. Palpation group) were identified from electronic databases including PubMed, Embase, Medline, google scholar, Cochrane Central Register of Controlled Trials from inception to July 5, 2020. The primary outcome was the accuracy of both techniques. Four studies published from 2018 to 2020 were considered relevant and were read in full. We found no significant difference in success rate of CTM identification [Risk Ratio (RR) 1.09, 95% CI 0.89-1.34, p = 0.41] between the two groups. These preliminary results of the current study demonstrated no significant differences in success rate between the laryngeal handshake and conventional palpation techniques in cricothyroid membrane identification.

Sustainability of Handshake Stewardship: Extending a Hand Is Effective Years Later.

BACKGROUND: Children's Hospital Colorado created a unique method of antimicrobial stewardship, called handshake stewardship, that effectively decreased hospital anti-infective use and costs in its pilot year (2013). Handshake stewardship is distinguished by: (1) the lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to supporting providers. We sought to reevaluate the outcomes of the program after 5 years of experience, totaling 8 years of data. METHODS: We retrospectively measured anti-infective (antibiotic, antiviral, antifungal) use hospital-wide by unit and by drug for an 8-year period spanning October 2010 to October 2018. Aggregated monthly use was measured in days of therapy per thousand patient days (DOT/1000 PD). The percentage of children admitted ever receiving an anti-infective was also measured, as well as severity-adjusted mortality, readmissions, and lengths of stay. RESULTS: Hospital-wide mean anti-infective use significantly decreased, from 891 (95% confidence interval [CI] 859-923) in the pre-implementation phase to 655 (95% CI 637-694) DOT/1000 PD in post-implementation Year 5; in a segmented regression time series analysis, this was a rate of -2.6 DOT/1000 PD (95% CI -4.8 to -0.4). This is largely attributable to decreased antibacterial use, from 704 (95% CI 686-722) to 544 (95% CI 525 -562) DOT/1000 PD. The percentage of children ever receiving an anti-infective during admission likewise declined, from 65% to 52% (95% CI 49-54). There were no detrimental effects on severity adjusted mortality, readmissions, or lengths of stay. CONCLUSIONS: The handshake method is an effective and sustainable approach to stewardship.

SARS-CoV-2 Transmission from Presymptomatic Meeting Attendee, Germany.

During a meeting in Munich, Germany, a presymptomatic attendee with severe acute respiratory syndrome coronavirus 2 infected at least 11 of 13 other participants. Although 5 participants had no or mild symptoms, 6 had typical coronavirus disease, without dyspnea. Our findings suggest hand shaking and face-to-face contact as possible modes of transmission.

Object-Based Attention on Social Units: Visual Selection of Hands Performing a Social Interaction.

Traditionally, objects of attention are characterized either as full-fledged entities or either as elements grouped by Gestalt principles. Because humans appear to use social groups as units to explain social activities, we proposed that a socially defined group, according to social interaction information, would also be a possible object of attentional selection. This hypothesis was examined using displays with and without handshaking interactions. Results demonstrated that object-based attention, which was measured by an object-specific attentional advantage (i.e., shorter response times to targets on a single object), was extended to two hands performing a handshake but not to hands that did not perform meaningful social interactions, even when they did perform handshake-like actions. This finding cannot be attributed to the familiarity of the frequent co-occurrence of two handshaking hands. Hence, object-based attention can select a grouped object whose parts are connected within a meaningful social interaction. This finding implies that object-based attention is constrained by top-down information.

How good are doctors at introducing themselves? #hellomynameis.

BACKGROUND: This explorative study was triggered by the '#hellomynameis' campaign initiated by Dr Kate Granger in the UK. Our objectives were twofold: first, to measure rates of introduction in an Irish hospital setting by both consultant and non-consultant hospital doctors. Second to establish whether such practices were associated with patient perceptions of the doctor/patient interaction. METHOD: A patient 'exit' survey was undertaken following doctor-patient consultations in both acute (surgical and medical assessment units) and elective settings (outpatient clinics). The survey was carried out over a 5-month period by three trained clinical observers. RESULTS: A total of 353 patients were surveyed. There were 253 outpatients and 100 inpatients surveyed. There were 121 outpatients (47.8%) who attended a surgeon, 73 were medical (28.8%), while 59 (23.3%) were divided between obstetrics, gynaecology and ophthalmology. One hundred acute presentations were surveyed: 52% in the emergency department, 20% to the acute medical assessment unit, 21% attended the acute surgical assessment unit and 7% attended other specialties/departments. CONCLUSION: According to the returned forms, 79% of doctors (n=279) introduced themselves to patients. Eleven per cent (39) of doctors did not introduce themselves, and 8.5% of patients (30) were unsure whether the doctor had introduced themselves. Five patients left their response blank.Consultants were significantly more likely (P=0.02) to introduce themselves or shake hands than non-consultant hospital doctors. Gender had no bearing (P=0.43) on introductions or handshakes regardless of grade of doctor.Three hundred and seventeen patients (89.7%) felt that an introduction had made a positive difference to their healthcare visit. Thirty patients (8.5%) felt it did not make a difference and 8 patients (2.2%) were unsure or failed to answer.This study has highlighted the importance of introductions to patients. Definite evidence of an introduction was documented in 79% of patients with 14.5% either not receiving or could not recall whether an introduction had been made on repeat visits. 6.5% stated that they did not receive an introduction.

A Hybrid Sender- and Receiver-Initiated Protocol Scheme in Underwater Acoustic Sensor Networks.

In this paper, we propose a method for sharing the handshakes of control packets among multiple nodes, which we call a hybrid sender- and receiver-initiated (HSR) protocol scheme. Handshake-sharing can be achieved by inviting neighbors to join the current handshake and by allowing them to send their data packets without requiring extra handshakes. Thus, HSR can reduce the signaling overhead involved in control packet exchanges during handshakes, as well as resolve the spatial unfairness problem between nodes. From an operational perspective, HSR resembles the well-known handshake-sharing scheme referred to as the medium access control (MAC) protocol using reverse opportunistic packet appending (ROPA). However, in ROPA the waiting time is not controllable for the receiver's neighbors and thus unexpected collisions may occur at the receiver due to hidden neighbors, whereas the proposed scheme allows all nodes to avoid hidden-node-induced collisions according to an elaborately calculated waiting time. Our computer simulations demonstrated that HSR outperforms ROPA with respect to both the throughput and delay by around 9.65% and 11.36%, respectively.

Status and Challenge of Antifungal Stewardship at the Osaka Metropolitan University Hospital.

Antifungal stewardship (AFS), compared with antimicrobial stewardship (AS), requires more advanced knowledge, skills, and multidisciplinary collaboration in its implementation. Therefore, fewer facilities are performing AFS compared with AS. At our hospital, we started AS and AFS in 2014. Our AFS programs include the following: i) interventions for patients with yeast-positive blood cultures, ii) introduction of a conditional antifungal notification system, and iii) commencement of AS team rounds. AFS for filamentous fungi includes bronchoscopy and microbial identification, including genetic and drug susceptibility testing. These AFS activities have improved several processes and outcome measures. However, our AFS team has faced several problems owing to the impact of COVID-19. This review introduces the practice of AFS, which we initiated at our hospital in 2014, and presents the current problems.

Embodied, visible, and courteous: exploring robotic social touch with virtual idols.

In recent years, virtual idols have garnered considerable attention because they can perform activities similar to real idols. However, as they are fictitious idols with nonphysical presence, they cannot perform physical interactions such as handshake. Combining a robotic hand with a display showing virtual idols is the one of the methods to solve this problem. Nonetheless a physical handshake is possible, the form of handshake that can effectively induce the desirable behavior is unclear. In this study, we adopted a robotic hand as an interface and aimed to imitate the behavior of real idols. To test the effects of this behavior, we conducted step-wise experiments. The series of experiments revealed that the handshake by the robotic hand increased the feeling of intimacy toward the virtual idol, and it became more enjoyable to respond to a request from the virtual idol. In addition, viewing the virtual idols during the handshake increased the feeling of intimacy with the virtual idol. Moreover, the method of the hand-shake peculiar to idols, which tried to keep holding the user's hand after the conversation, increased the feeling of intimacy to the virtual idol.

Carbapenem Use in the Last Days of Life: A Nationwide Korean Study.

The appropriate use of carbapenem is a critical concern for patient safety and public health, and is a national priority. We investigated the nationwide status of carbapenem prescription in patients within their last 14 days of life to guide judicious-use protocols from the previous study comprised of 1350 decedents. Carbapenem use was universally controlled through computerised authorisation system at all centres during the study period. Carbapenem prescribing patterns and their optimality were evaluated. A total of 1201 patients received antimicrobial agents within the last two weeks of their lives, of whom 533 (44.4%) received at least one carbapenem. The median carbapenem treatment duration was seven days. Of the 533 patients receiving carbapenems, 510 (95.7%) patients had microbiological samples drawn and 196 (36.8%) yielded carbapenem-resistant pathogens. A total of 200 (37.5%) patients were referred to infectious disease (ID) specialists. Of the 333 patients (62.5%) who did not have ID consultations, 194 (58.2%) were assessed as "not optimal", 79 (23.7%) required escalation, 100 (30.0%) required de-escalation, and 15 (4.5%) were discontinued. Notwithstanding the existing antibiotic restriction program system, carbapenems are commonly prescribed to patients in their last days of life.

Antimicrobial Stewardship in the Hospital Setting: A Narrative Review.

The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.

Guidelines for Robot-to-Human Handshake From the Movement Nuances in Human-to-Human Handshake.

The handshake is the most acceptable gesture of greeting in many cultures throughout many centuries. To date, robotic arms are not capable of fully replicating this typical human gesture. Using multiple sensors that detect contact forces and displacements, we characterized the movements that occured during handshakes. A typical human-to-human handshake took around 3.63 s (SD = 0.45 s) to perform. It can be divided into three phases: reaching (M = 0.92 s, SD = 0.45 s), contact (M = 1.96 s, SD = 0.46 s), and return (M = 0.75 s, SD = 0.12 s). The handshake was further investigated to understand its subtle movements. Using a multiphase jerk minimization model, a smooth human-to-human handshake can be modelled with fifth or fourth degree polynomials at the reaching and return phases, and a sinusoidal function with exponential decay at the contact phase. We show that the contact phase (1.96 s) can be further divided according to the following subphases: preshake (0.06 s), main shake (1.31 s), postshake (0.06 s), and a period of no movement (0.52 s) just before both hands are retracted. We compared these to the existing handshake models that were proposed for physical human-robot interaction (pHRI). From our findings in human-to-human handshakes, we proposed guidelines for a more natural handshake movement between humanoid robots and their human partners.

The Current State and Future Directions of Inpatient Pediatric Antimicrobial Stewardship.

Antibiotic use in hospitalized children is highly variable and often unnecessary, which puts children at risk of antibiotic-associated harms including adverse drug events, antibiotic resistance, and long-term chronic health problems. Antimicrobial stewardship programs reduce unnecessary antibiotic use through antimicrobial review, the development of guidelines and clinical decision-support tools, diagnostic stewardship, and other targeted interventions. Future directions for inpatient stewardship include increased collaboration with nurses, utilization of implementation science to close the gap between evidence-based recommendations and practice changes, and the extension of stewardship from large academic centers to smaller hospitals.

Extending the Reach of Antimicrobial Stewardship to Pediatric Patients.

Guidance for developing and implementing antimicrobial stewardship programs for children is lacking. This review article describes unique considerations for planning antimicrobial management of children that may impact stewardship strategies. A variety of methods and training tools are described along with metrics specific to measuring antibiotic use and outcomes in children. Handshake stewardship is specifically explained and is considered a best practice. Information on stewardship in unique settings, including the neonatal intensive care unit and outpatient settings, are included.

Nurses' and Physicians' Responses to a New Active Antimicrobial Stewardship Program: A Two-Phase Study of Responses and Their Underlying Perceptions and Values.

BACKGROUND: Successful implementation of an antimicrobial stewardship program (ASP) depends on staff members' response to it. We introduced at the Hadassah Medical Center in Israel a significant change to our long-standing handshake ASP. As before, the new ASP involved a dialogue between the treating physician and the infectious disease physician over the appropriate antibiotic therapy. The main change was that the infectious disease physician's decision was now integrated into the patient's electronic medical record (EMR). Our purpose in this study was to uncover the concerns and expectations of physicians and nurses towards the new ASP, before and after its implementation, and link these with their basic perceptions of the ASP and their personal values. METHODS: We used open-ended questions and Likert-type scales to study staff members' personal values, basic perceptions of the new system, and attitudes towards it, both before (N = 143), and one year after (N = 103) the system's implementation. Relationships of the system's perceptions and personal values with attitudes toward the system were tested using correlations and multiple regression analyses. RESULTS: Prior to its implementation, physicians and nurses had multiple concerns about the new ASP's demandingness and inefficiency and its threat to physicians' autonomy and expertise. They also had positive expectations for benefits to the hospital, the patients and society. A year later, following the system's implementation, concerns dissipated, whereas the perceived benefits remained. Moreover, staff members' attitudes tended to be more positive among those who value conformity. CONCLUSION: Introducing new ASPs is a challenging process. Our findings suggest that hospital staff's initial concerns about the new ASP were primarily about its ease of use and demandingness. These concerns, which diminished over time, were linked with perceived satisfaction with the system. Conformity values had an indirect effect in predicting satisfaction with the system, mediated by perceptions of the system as straightforward.