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Background: Traditional blood cultures for gram-negative bacteremia can take up to 72 hours or more to return results, prolonging the duration of empiric broad-spectrum intravenous antibiotics. The Accelerate Pheno system provides rapid identification and susceptibilities for blood cultures in gram-negative bacteremia. Current data on its clinical utility are mixed overall, so the system requires further research., Methods: A multicenter, retrospective quasi-experimental study was conducted comparing the Accelerate Pheno rapid diagnostic system with antimicrobial stewardship intervention and traditional blood cultures alone., Results: A total of 264 patients with blood cultures with gram-negative bacteria growth were included in the final analysis (102 pre-intervention, 162 post-intervention). The antimicrobial stewardship team made 364 recommendations in 152/162 (93.8%) patients in the post group. Duration of intravenous therapy was shorter ( P < .001) for the post-intervention group (median, 4.0 days) compared with the pre-intervention group (median, 7.5 days). Hospital length of stay was also shorter ( P < .001) for the post-intervention group (median, 5.1 days) compared with the pre-intervention group (median, 7.0 days). Readmission rates within 30 days were reduced ( P = .042) post-intervention (13.0%) compared with pre-intervention (22.6%). In the post-intervention group, a larger proportion of patients were transitioned to oral therapy at any point (126/162, 77.8%) compared with pre-intervention (62/102, 60.8%; P < .001)., Conclusions: These results suggest that the Accelerate Pheno system, with active review and intervention by a multidisciplinary antimicrobial stewardship team, is a useful tool in improving both patient-centric and antimicrobial stewardship outcomes., Competing Interests: Potential conflicts of interest. A.M.B. reports receiving honoraria to serve as a speaker for bioMerieux and receiving research grants and contracts from bioMerieux, Becton Dickinson, QuidelOrtho, and TECHLAB. All other authors: no relevant disclosures., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

We describe a case of relapsing babesiosis in an immunocompromised patient. A point mutation in the Babesia microti 23S rRNA gene predicted resistance to azithromycin and clindamycin, whereas an amino acid change in the parasite cytochrome b predicted resistance to atovaquone. Following initiation of tafenoquine, symptoms and parasitemia resolved., Competing Interests: Potential conflicts of interest. P. J. K. reports payments to Yale School of Public Health from Gold Standard Diagnostics; payments made to self for a chapter that addresses the modalities available for treatment of human babesiosis and that mentions tafenoquine as a promising therapeutic approach from UpToDate, Inc; and serving on the board of directors for the American Lyme Disease Foundation (received no monetary compensation). E. V. reports payments made to Tufts Medical Center from the Global Lyme Alliance; payments for a chapter that addresses the modalities available for treatment of human babesiosis and that mentions tafenoquine as a promising therapeutic approach from UpToDate, Inc; and patent PCT/US2020/062315, Compositions and Methods for the Prophylaxis and Treatment of Babesiosis (pending). All remaining authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Liposomal amphotericin B (LAmB) is used for various fungal infections, but it is unclear which dosing weight to use in obese patients. The purpose of this study was to compare clinical outcomes of adjusted body weight (adjBW) versus total body weight (TBW) dosing of LAmB. This single-center, retrospective cohort study included patients who received LAmB for definitive therapy and whose TBW exceeded 120% of their ideal body weight (IBW). Analyses were conducted for 3 mg/kg for adjBW versus TBW and 5 mg/kg for adjBW versus TBW. A total of 238 patients were included. For the 68 patients who received LAmB at 3 mg/kg, there were no differences in safety or efficacy outcomes. For the 170 patients who received LAmB at 5 mg/kg, significantly more patients in the TBW group experienced the primary outcome of nephrotoxicity (57% versus 35% [ P value of 0.016]) and had significantly higher rates of early discontinuation of LAmB due to toxicity (33% versus 17% [ P  = 0.030]). There was a trend toward increased 90-day mortality in the adjBW group (60% versus 45% [ P  = 0.079]); however, adjBW dosing was not associated with increased mortality in an adjusted model. Given the lower rates of nephrotoxicity but a possible trend toward increased mortality in patients whose TBW exceeds 120% of their IBW, dosing LAmB by adjBW may be reasonable in patients who are not critically ill and who have lower-risk infections. In critically ill patients or those with fungal pathogens or sites of infection associated with higher mortality risk, dosing by TBW can be considered.

Background: Organism susceptibilities for trauma-associated pneumonia (TAP) differ from those in other patient populations, including the critically ill. The purpose of this study was to identify common organisms and their susceptibilities in the respiratory isolates of trauma patients diagnosed with pneumonia within the first 7 days of hospital admission, and to create a TAP-specific disease-state antibiogram to guide empiric antibiotic therapy in this patient population., Methods: This study was a retrospective review of adult trauma patients with pneumonia admitted between September 1, 2015 and August 31, 2018. Patients included were diagnosed with and treated for pneumonia, with respiratory cultures drawn within the first 7 hospital-days; both culture-positive and culture-negative patients were included. Subgroup antibiograms were made for diagnosis made on days 1-3, 4-5, and 6-7., Results: There were 131 patients included with a median age of 45; 85% were male, and 31% were illicit drug users. Most patients (63%) had ventilator-associated pneumonia, and most respiratory samples (77%) were obtained via bronchoalveolar lavage. Cultures were positive in 109 patients and negative in 22. There were 144 total isolates; 54% were Gram-negative bacteria. The most common Gram-negative pathogens were Haemophilus influenzae (16%) and Klebsiella pneumoniae (15%). The most common Gram-positive pathogen was Staphylococcus aureus ; methicillin-resistant S. aureus (MRSA) constituted 8% of all isolates. With culture-negative patients counted as susceptible, ceftriaxone monotherapy and ceftriaxone+vancomycin susceptibilities were 85% and 94%, respectively. Susceptibilities to cefazolin, ampicillin/sulbactam, cefepime, piperacillin/tazobactam, and levofloxacin were 49%, 69%, 91%, 90%, and 92%, respectively. Illicit drug use and day of pneumonia diagnosis did not appreciably affect antibiotic susceptibilities., Conclusions: For TAP diagnosed within the first 7 days of hospital admission, ceftriaxone monotherapy is adequate as empiric therapy, including in ventilated patients. The addition of vancomycin can be considered in patients with MRSA risk factors or who are critically ill., Level of Evidence: Level III, prognostic and epidemiological., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Life Goals Programme (LGP) was developed as a psychological intervention for bipolar disorder, with its structured 6-session psychoeducation phase (Phase 1) targeting understanding of the disorder, medication adherence, early warning signs, and coping with symptoms and triggers. The present study tested the efficacy of Phase 1 of the LGP on symptom recovery and moment-by-moment mood stability, as well as medication adherence and quality of life., Methods: Adults with bipolar disorder were randomly allocated to the LGP condition (six weekly group sessions) or the waitlist condition (six weeks of standard care, followed by the same LGP intervention). Participants were assessed before and after treatment, and at 6-month follow up. Waitlist participants were additionally assessed at baseline. Assessment included a clinical interview (SCID, MADRS, YMRS, and HAM-A), self-reported questionnaires, and 6-day experience sampling assessment on a mobile device., Results: 64 out-patients with bipolar disorder (44 Bipolar I and 20 Bipolar II subtypes) participated in this study. LGP was well received and attended. Following LGP, there were significant improvements in knowledge about illness and level of anxiety, which were of large effect sizes and sustained at 6-month follow-up. Experience sampling assessment revealed small but significant improvements in moment-by-moment mood stability. Improvement in medication adherence was significant at 6 months and was of a moderate-to-large effect size. Changes in anxiety and mood stability were significantly greater following LGP than standard care., Limitations: Our results warrant further testing against active control., Conclusions: There was a robust improvement in emotional regulation following the 6-week LGP., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Individuals with bipolar disorder respond to affective symptoms with a range of coping behaviours, which may further maintain the symptoms., Aims: To examine moment-to-moment dynamics between affective states and coping behaviours, and to evaluate the role of cognitive appraisals of internal states as moderators., Method: Forty-six individuals with bipolar disorder completed a clinical interview and an experience sampling assessment over 6 days. Time-lagged analyses were conducted by multilevel regression modelling., Results: A total of 1807 momentary entries were analysed. Negative affect predicted an increase in rumination at the subsequent time point (β = 0.21, s.e. = 0.08, P = 0.009, 95% CI 0.05-0.36), and vice versa (β = 0.03, s.e. = 0.01, P = 0.009, 95% CI 0.01-0.05). Positive affect predicted an increase in adaptive coping (β = 0.26, s.e. = 0.11, P = 0.018, 95% CI 0.04-0.47), and vice versa (β = 0.02, s.e. = 0.01, P = 0.019, 95% CI 0.00-0.03). Positive affect also predicted a decrease in rumination (β = -0.15, s.e. = 0.06, P = 0.014, 95% CI -0.26 to -0.03), and vice versa (β = -0.03, s.e. = 0.01, P = 0.016, 95% CI -0.06 to -0.01). Extreme cognitive appraisals predicted stronger associations between affective states and coping behaviours., Conclusions: Feedback loops between affective states and coping behaviours were revealed in the daily life of individuals with bipolar disorder, which were moderated by extreme cognitive appraisals., Declaration of Interest: None.

Summary: Offender rehabilitation seeks to minimise recidivism. Using their experience and actuarial-type risk assessment tools, probation officers in Singapore make recommendations on the sentencing outcomes so as to achieve this objective. However, it is difficult for them to maximise the utility of the large amounts of data collected, which could be resolved by using predictive modelling informed by statistical learning methods., Findings: Data of youth offenders ( N  = 3744) referred to the Probation Service, Ministry of Social and Family Development for rehabilitation were used to create a random forests model to predict recidivism. No assumptions were made on how individual predictor values within the risk assessment tool and other administrative data on an individual's socio-economic status such as level of education attained and dwelling type collected in line with organisational requirements influenced the outcome. Sixty per cent of the data was used to develop the model, which was then tested against the remaining 40%. With a classification accuracy of approximately 65%, and an Area under the Curve value of 0.69, it outperformed existing models analysing aggregated data using conventional statistical methods., Application: This article identifies how analysis of administrative data at the discrete level using statistical learning methods is more accurate in predicting recidivism than using conventional statistical methods. This provides an opportunity to direct intervention efforts at individuals who are more likely to reoffend.

Objectives: There were two aims to this study: firstly, to identify family subtypes of Singaporean youth offenders based on eight family variables. Secondly, the associations of these family subtypes with youth offending outcomes were tested., Methods: With a sample of 3,744 youth, a latent class analysis was first conducted based on eight family variables. Multivariate analyses and a Cox regression were subsequently performed to analyze the associations of the family classes with age at first arrest, age at first charge, and recidivism., Results: A three-class solution was found to have the best fit to the data: (1) intact functioning families had little family risk; (2) families with criminality had higher probabilities of family criminality, of drug/alcohol abuse, and of being nonintact; and (3) poorly managed families received the poorest parenting and were more likely to be nonintact. Youth offenders from the latter two classes were arrested and charged at younger ages. Additionally, they reoffended at a quicker rate., Conclusions: Family backgrounds matter for youth offending outcomes. Interventions have to be multifaceted and targeted at the family in order to mitigate the risk of young offenders from developing into pathological adult criminals., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Children's soft toys are known to harbour house dust mite (HDM) allergens, but little is known whether they harbour cat or dog allergens. The objective of the study was to measure cat (Fel d 1), dog (Can f 1) and HDM allergens on children's soft toys., Methods: Dust was collected from 40 children's soft toys and their mattresses. Data were collected on pet ownership. Dust samples were analysed for Fel d 1, Can f 1, Der p 1 and Der f 1 by enzyme-linked immunosorbent assay (ELISA) and results are expressed as median levels with inter-quartile ranges., Results: Thirty-five (87.5%) soft toys had detectable Fel d 1 levels (median: 0.73 µg/g; inter-quartile range: 0.26-2.56 µg/g) while 34 (85%) had detectable Can f 1 levels (1.20 µg/g; 0.53-2.68). Correspondingly, 32 (80%) mattresses had detectable Fel d 1 levels (0.18 µg/g, 0.07-1.01) while 34 (85%) had detectable Can f 1 levels (0.50 µg/g; 0.33-1.06). All mattresses and soft toys had detectable HDM allergen (Der p 1 + Der f 1) levels with soft toys containing about three times higher levels than mattresses. In homes with cats (n = 10) Fel d 1 levels were higher on soft toys than homes without cats (2.49 versus 0.48 µg/g; p = 0.0009). In homes with dogs (n = 25) Can f 1 levels were generally higher on soft toys (1.38 versus 0.63 µg/g; p = 0.10)., Conclusions: This study has shown that soft toys can harbour cat and dog allergen as well as HDM allergens, some with very high levels. Cat and dog ownership resulted in higher Fel d 1 and Can f 1 levels on soft toys and mattresses. The levels of Fel d 1, Can f 1 and HDM allergens on soft toys could be of importance to sensitized asthmatic children.

Here we present a rare case of an isolated trapezoid dislocation secondary to a high-speed motor vehicle injury. In this case we highlight that the fact that these injuries are commonly missed on standard radiographs and management invariably requires open reduction and internal fixation.

We determined the incidence of percutaneous (needlestick and sharps) injuries among emergency medical technicians (EMTs) in one county in Taiwan, compared this with the official reporting rate, and sought reasons for non-reporting. An anonymous questionnaire was distributed to all EMTs in that county, eliciting percutaneous injuries occurrences, reasons why, and reporting data. Data were analyzed by logistic regression. A total of 329 out of 353 EMTs completed the questionnaire, giving a response rate of 93.2%. Thirty-nine EMTs (11.9%) experienced at least one percutaneous injury in the preceding 12 months. Older, less experienced EMTs were at greater risk of percutaneous injuries. None of the EMTs officially reported their percutaneous injuries primarily because they thought reporting was not mandatory and that the reporting process was too complicated. About one in eight EMTs had experienced at least one percutaneous injury in the preceding year. None of these injuries was officially reported to their organization. Ways to make reporting more user friendly are required, along with resources to minimize percutaneous injuries among EMTs in Taiwan.