Regional patient transfer patterns matter for the spread of hospital-acquired pathogens.

Pathogens typically responsible for hospital-acquired infections (HAIs) constitute a major threat to healthcare systems worldwide. They spread via hospital (or hospital-community) networks by readmissions or patient transfers. Therefore, knowledge of these networks is essential to develop and test strategies to mitigate and control the HAI spread. Until now, no methods for comparing healthcare networks across different systems were proposed. Based on healthcare insurance data from four German federal states (Bavaria, Lower Saxony, Saxony and Thuringia), we constructed hospital networks and compared them in a systematic approach regarding population, hospital characteristics, and patient transfer patterns. Direct patient transfers between hospitals had only a limited impact on HAI spread. Whereas, with low colonization clearance rates, readmissions to the same hospitals posed the biggest transmission risk of all inter-hospital transfers. We then generated hospital-community networks, in which patients either stay in communities or in hospitals. We found that network characteristics affect the final prevalence and the time to reach it. However, depending on the characteristics of the pathogen (colonization clearance rate and transmission rate or even the relationship between transmission rate in hospitals and in the community), the studied networks performed differently. The differences were not large, but justify further studies.

Transmission of drug-resistant bacteria in a hospital-community model stratified by patient risk.

A susceptible-infectious-susceptible (SIS) model for simulating healthcare-acquired infection spread within a hospital and associated community is proposed. The model accounts for the stratification of in-patients into two susceptibility-based risk groups. The model is formulated as a system of first-order ordinary differential equations (ODEs) with appropriate initial conditions. The mathematical analysis of this system is demonstrated. It is shown that the system has unique global solutions, which are bounded and non-negative. The basic reproduction number ([Formula: see text]) for the considered model is derived. The existence and the stability of the stationary solutions are analysed. The disease-free stationary solution is always present and is globally asymptotically stable for [Formula: see text], while for [Formula: see text] it is unstable. The presence of an endemic stationary solution depends on the model parameters and when it exists, it is globally asymptotically stable. The endemic state encompasses both risk groups. The endemic state within only one group only is not possible. In addition, for [Formula: see text] a forward bifurcation takes place. Numerical simulations, based on the anonymised insurance data, are also presented to illustrate theoretical results.

Polarization Doping in a GaN-InN System-Ab Initio Simulation.

Polarization doping in a GaN-InN system with a graded composition layer was studied using ab initio simulations. The electric charge volume density in the graded concentration part was determined by spatial potential dependence. The emerging graded polarization charge was determined to show that it could be obtained from a polarization difference and the concentration slope. It was shown that the GaN-InN polarization difference is changed by piezoelectric effects. The polarization difference is in agreement with the earlier obtained data despite the relatively narrow bandgap for the simulated system. The hole generation may be applied in the design of blue and green laser and light-emitting diodes.

The effect of re-directed patient flow in combination with targeted infection control measures on the spread of multi-drug-resistant Enterobacteriaceae in the German health-care system: a mathematical modelling approach.

OBJECTIVE: The introduction of multi-drug-resistant Enterobacteriaceae (MDR-E) by colonized patients transferred from high-prevalence countries has led to several large outbreaks of MDR-E in low-prevalence countries, with the risk of propagated spread to the community. The goal of this study was to derive a strategy to counteract the spread of MDR-E at the regional health-care network level. METHODS: We used a hybrid ordinary differential equation and network model built based on German health insurance data to evaluate whether the re-direction of patient flow in combination with targeted infection control measures can counteract the spread of MDR-E in the German health-care system. We applied pragmatic re-direction strategies focusing on a reduced choice of hospitals for subsequent stays after initial hospitalization but not manipulating direct transfers because these are most likely determined by medical needs. RESULTS: The re-direction strategies alone did not reduce the system-wide spread of MDR-E (system-wide prevalence of MDR-E is 18.7% vs. 25.7%/29.9%). In contrast, targeted hospital-based infection control measures restricted to institutions with the highest institutional basic reproduction numbers in the network were identified as an effective tool for reducing system-wide prevalence (system-wide prevalence of MDR-E is 18.7% vs. 9.3%). If these measures were applied to the top one-third of hospitals, the system-wide prevalence could be reduced by approximately 80% (system-wide prevalence of 18.7% vs. 3.5% for one-third of patients subjected to interventions). A combination of this hospital-based intervention and patient re-direction strategies could not improve the effectiveness of the hospital-based approach (system-wide prevalence of MDR-E is 9.3% vs. 14.2%/14.3%). CONCLUSIONS: The pragmatic patient re-direction strategies were not capable of restricting the spread of MDR-E in a simulation of the German health-care system; in contrast, hospital-based interventions focusing on institutions identified based on network transmission patterns seem to be a promising approach for sustainable reduction of the spread of MDR-E through the German population.

Critical Evaluation of Various Spontaneous Polarization Models and Induced Electric Fields in III-Nitride Multi-Quantum Wells.

In this paper, ab initio calculations are used to determine polarization difference in zinc blende (ZB), hexagonal (H) and wurtzite (WZ) AlN-GaN and GaN-InN superlattices. It is shown that a polarization difference exists between WZ nitride compounds, while for H and ZB lattices the results are consistent with zero polarization difference. It is therefore proven that the difference in Berry phase spontaneous polarization for bulk nitrides (AlN, GaN and InN) obtained by Bernardini et al. and Dreyer et al. was not caused by the different reference phase. These models provided absolute values of the polarization that differed by more than one order of magnitude for the same material, but they provided similar polarization differences between binary compounds, which agree also with our ab initio calculations. In multi-quantum wells (MQWs), the electric fields are generated by the well-barrier polarization difference; hence, the calculated electric fields are similar for the three models, both for GaN/AlN and InN/GaN structures. Including piezoelectric effect, which can account for 50% of the total polarization difference, these theoretical data are in satisfactory agreement with photoluminescence measurements in GaN/AlN MQWs. Therefore, the three models considered above are equivalent in the treatment of III-nitride MQWs and can be equally used for the description of the electric properties of active layers in nitride-based optoelectronic devices.

Effects of incomplete inter-hospital network data on the assessment of transmission dynamics of hospital-acquired infections.

In the year 2020, there were 105 different statutory insurance companies in Germany with heterogeneous regional coverage. Obtaining data from all insurance companies is challenging, so that it is likely that projects will have to rely on data not covering the whole population. Consequently, the study of epidemic spread in hospital referral networks using data-driven models may be biased. We studied this bias using data from three German regional insurance companies covering four federal states: AOK (historically "general local health insurance company", but currently only the abbreviation is used) Lower Saxony (in Federal State of Lower Saxony), AOK Bavaria (in Bavaria), and AOK PLUS (in Thuringia and Saxony). To understand how incomplete data influence network characteristics and related epidemic simulations, we created sampled datasets by randomly dropping a proportion of patients from the full datasets and replacing them with random copies of the remaining patients to obtain scale-up datasets to the original size. For the sampled and scale-up datasets, we calculated several commonly used network measures, and compared them to those derived from the original data. We found that the network measures (degree, strength and closeness) were rather sensitive to incompleteness. Infection prevalence as an outcome from the applied susceptible-infectious-susceptible (SIS) model was fairly robust against incompleteness. At incompleteness levels as high as 90% of the original datasets the prevalence estimation bias was below 5% in scale-up datasets. Consequently, a coverage as low as 10% of the local population of the federal state population was sufficient to maintain the relative bias in prevalence below 10% for a wide range of transmission parameters as encountered in clinical settings. Our findings are reassuring that despite incomplete coverage of the population, German health insurance data can be used to study effects of patient traffic between institutions on the spread of pathogens within healthcare networks.

Relevance of intra-hospital patient movements for the spread of healthcare-associated infections within hospitals - a mathematical modeling study.

The aim of this study is to analyze patient movement patterns between hospital departments to derive the underlying intra-hospital movement network, and to assess if movement patterns differ between patients at high or low risk of colonization. For that purpose, we analyzed patient electronic medical record data from five hospitals to extract information on risk stratification and patient intra-hospital movements. Movement patterns were visualized as networks, and network centrality measures were calculated. Next, using an agent-based model where agents represent patients and intra-hospital patient movements were explicitly modeled, we simulated the spread of multidrug resistant enterobacteriacae (MDR-E) inside a hospital. Risk stratification of patients according to certain ICD-10 codes revealed that length of stay, patient age, and mean number of movements per admission were higher in the high-risk groups. Movement networks in all hospitals displayed a high variability among departments concerning their network centrality and connectedness with a few highly connected departments and many weakly connected peripheral departments. Simulating the spread of a pathogen in one hospital network showed positive correlation between department prevalence and network centrality measures. This study highlights the importance of intra-hospital patient movements and their possible impact on pathogen spread. Targeting interventions to departments of higher (weighted) degree may help to control the spread of MDR-E. Moreover, when the colonization status of patients coming from different departments is unknown, a ranking system based on department centralities may be used to design more effective interventions that mitigate pathogen spread.

Modelling pathogen spread in a healthcare network: Indirect patient movements.

Inter-hospital patient transfers (direct transfers) between healthcare facilities have been shown to contribute to the spread of pathogens in a healthcare network. However, the impact of indirect transfers (patients re-admitted from the community to the same or different hospital) is not well studied. This work aims to study the contribution of indirect transfers to the spread of pathogens in a healthcare network. To address this aim, a hybrid network-deterministic model to simulate the spread of multiresistant pathogens in a healthcare system was developed for the region of Lower Saxony (Germany). The model accounts for both, direct and indirect transfers of patients. Intra-hospital pathogen transmission is governed by a SIS model expressed by a system of ordinary differential equations. Our results show that the proposed model reproduces the basic properties of healthcare-associated pathogen spread. They also show the importance of indirect transfers: restricting the pathogen spread to direct transfers only leads to 4.2% system wide prevalence. However, adding indirect transfers leads to an increase in the overall prevalence by a factor of 4 (18%). In addition, we demonstrated that the final prevalence in the individual healthcare facilities depends on average length of stay in a way described by a non-linear concave function. Moreover, we demonstrate that the network parameters of the model may be derived from administrative admission/discharge records. In particular, they are sufficient to obtain inter-hospital transfer probabilities, and to express the patients' transfers as a Markov process. Using the proposed model, we show that indirect transfers of patients are equally or even more important as direct transfers for the spread of pathogens in a healthcare network.

Thermodynamic foundations of applications of ab initio methods for determination of the adsorbate equilibria: hydrogen at the GaN(0001) surface.

Thermodynamic foundations of ab initio modeling of vapor-solid and vapor-surface equilibria are introduced. The chemical potential change is divided into enthalpy and entropy terms. The enthalpy path passes through vapor-solid transition at zero temperature. The entropy path avoids the singular point at zero temperature passing a solid-vapor transition under normal conditions, where evaporation entropy is employed. In addition, the thermal changes are calculated. The chemical potential difference contribution of the following terms: vaporization enthalpy, vaporization entropy, the temperature-entropy related change, the thermal enthalpy change and mechanical pressure is obtained. The latter term is negligibly small for the pressure typical for epitaxy. The thermal enthalpy change is two orders smaller than the first three terms which have to be taken into account explicitly. The configurational vaporization entropy change is derived for adsorption processes. The same formulation is derived for vapor-surface equilibria using hydrogen at the GaN(0001) surface as an example. The critical factor is the dependence of the enthalpy of evaporation (desorption energy) on the pinning of the Fermi level bringing a drastic change of the value from 2.24 eV to -2.38 eV. In addition it is shown that entropic contributions considerable change the hydrogen equilibrium pressure over the GaN(0001) surface by several orders of magnitude. Thus a complete and exact formulation of vapor-solid and vapor-surface equilibria is presented.

Dissipation of the excess energy of the adsorbate-thermalization via electron transfer.

A new scenario for the thermalization process of adsorbates at solid surfaces is proposed. The scenario is based on the existence of an electric dipole layer in which the electron wavefunctions extend over the positive ions, creating a strong local electric field which drags the electrons into the solid interior and repels the positive ions. During adsorption the electrons tunnel into the solid interior, conveying the excess energy. The positive ions are retarded by the field, losing the excess kinetic energy, and are located smoothly into the adsorption sites. In such a scheme, the excess energy is not dissipated locally, avoiding melting or the creation of defects which is in accordance with experiments. The scenario is supported by ab initio calculation results, including density function theory of the slabs representing the AlN surface and the Schrodinger equation for the time evolution of hydrogen-like atoms at the solid surface.