Acknowledging the predominantly hubbed traffic profile in the metro, we apply digital subcarrier multiplexing techniques to 400Gb/s coherent pluggable optics, enabling a point-to-multipoint ...architecture which shows TCO savings of 76% over a five-year period compared to a traditional architecture based on ROADMs and point-to-point transponder
The various topologies, traffic patterns and cost targets of optical networks have prevented the deployment of end-to-end solutions across multi-domains, and the optimization of the network as a ...whole. The consequent limitations in flexibility, scalability, and adaptability of optical networks will become increasingly important with new applications, such as 5G/6G. Coherent transceivers based on digital subcarrier multiplexing (DSCM) are proposed to address these current constraints. In particular, DSCM allows (i) the design of high-capacity point-to-point (P2P) and -multipoint (P2MP) optical networks; (ii) simplified aggregation with passive optics; and (iii) connections between low- and high-speed transceivers. Furthermore, DSCM-based networks reduce the number of opto-electro-opto stages, halve the number of bookended transceivers, and provide a better match for existing hub-and-spoke (H&S) traffic patterns in fast-growing and dynamic access/metro segments. A DSCM-based transceiver will pave the way for the deployment of next-generation flexible, adaptable, and scalable software-configurable optical networks. Key steps and elements to realize this solution are laid out, and promising applications outlined. The first real-time experimental results of coherent P2MP transceivers are presented.
Purpose:
The medication regimen complexity-intensive care unit (MRC-ICU) score was developed prior to the existence of COVID-19. The purpose of this study was to assess if MRC-ICU could predict ...in-hospital mortality in patients with COVID-19.
Methods:
A single-center, observational study was conducted from August 2020 to January 2021. The primary outcome of this study was the area under the receiver operating characteristic (AUROC) for in-hospital mortality for the 48-hour MRC-ICU. Age, sequential organ failure assessment (SOFA), and World Health Organization (WHO) COVID-19 Severity Classification were assessed. Logistic regression was performed to predict in-hospital mortality as well as WHO Severity Classification at 7 days.
Results:
A total of 149 patients were included. The median SOFA score was 8 (IQR 5-11) and median MRC-ICU score at 48 hours was 15 (IQR 7-21). The in-hospital mortality rate was 36% (n = 54). The AUROC for MRC-ICU was 0.71 (95% Confidence Interval (CI), 0.62-0.78) compared to 0.66 for age, 0.81 SOFA, and 0.72 for the WHO Severity Classification. In univariate analysis, age, SOFA, MRC-ICU, and WHO Severity Classification all demonstrated significant association with in-hospital mortality, while SOFA, MRC-ICU, and WHO Severity Classification demonstrated significant association with WHO Severity Classification at 7 days. In univariate analysis, all 4 characteristics showed significant association with mortality; however, only age and SOFA remained significant following multivariate analysis.
Conclusion:
In the first analysis of medication-related variables as a predictor of severity and in-hospital mortality in COVID-19, MRC-ICU demonstrated acceptable predictive ability as represented by AUROC; however, SOFA was the strongest predictor in both AUROC and regression analysis.
Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity ...(as measured by the Medication Regimen Complexity-ICU MRC-ICU scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population.
This was a multicenter, observational cohort study.
Twenty-eight ICUs in the United States.
Adult ICU patients.
Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay LOS) were recorded retrospectively.
A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (β coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (β coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (β coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (β coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (β coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (β coefficient, -0.05; 95% CI, -0.09 to -0.01).
Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes.
Abstract
Background
Central line-associated bloodstream infections result in thousands of deaths and billions of dollars annually. At the Augusta University Medical Center (AUMC), it was identified ...that ~50% of peripherally inserted central venous catheters (PICCs) that were placed for intravenous (IV) antibiotic administration were unnecessary. A novel initiative was implemented, which required antimicrobial stewardship/infectious diseases approval for PICC insertions if the indication was for IV antibiotic administration only. The objective of this study was to determine the impact of this initiative.
Methods
A retrospective observational study was conducted at the AUMC. All adult patients with a PICC line insertion order for IV antibiotic administration, between December 2017 and May 2019 were included. The vascular access team would forward requests for PICC insertions to the antimicrobial stewardship pharmacist. The pharmacist would approve/disapprove the PICC or recommend an infectious diseases consult. The variables collected were: infection types, infectious diseases consultation, reason for PICC denial and 30-day PICC-related complications.
Results
A total of 215 requests for PICC insertion (for IV antibiotics) were placed. Of these, 54% of the requests were denied, while 46% were approved. The reasons for PICC denial included: midline catheter preferred (47%), switched to oral antibiotics (33%), further work-up required (10%), or no antibiotics needed (7%). The types of infections treated were: bone and joint infections (28%), urinary tract infections (13%), intra-abdominal infections (12%), endocarditis/endovascular infections (11%), skin soft tissue infections (9%), pneumonia (7%), catheter-related bloodstream infections (6%), central nervous system infections (6%), bacteremia (4%) and others (4%).The infectious diseases consult team was involved in the care of 79% of the patients. Of those that received a PICC line, only 5% experienced any PICC-related complications. The overall cost savings for PICCs that were denied was ~ $294,000.
Conclusion
Mandatory antimicrobial stewardship/infectious diseases approval for PICC insertion can decrease healthcare cost and reduce the number of unnecessary PICC lines placed.
Disclosures
All Authors: No reported disclosures
Purpose
High-dose methotrexate (HD-MTX) requires urine alkalinization to pH ≥ 7 for adequate excretion to prevent toxicity. Due to shortages of IV sodium bicarbonate (IV-NaHCO3), few reports have ...demonstrated utility of oral bicarbonate (PO-NaHCO3); however, the addition of acetazolamide (Acet) has not been well described. Our study compares outcomes between alkalinization methods of IV-NaHCO3 monotherapy versus IV-NaHCO2 + Acet and PO-NaHCO3 + Acet.
Methods
A single-center, IRB exempt, retrospective review was conducted from Jan 2016 to Sept 2019 of adults receiving HD-MTX ≥ 500 mg/m
2
. The primary outcome was time from start of alkalinization to pH ≥ 7. Secondary outcomes included time from start of alkalinization to initiation of HD-MTX, time to MTX clearance, length of stay (LOS), percentage of urine pH assessments < 7, and incidence of MTX toxicity. Statistical analysis was performed using SAS9.4 with alpha 0.05.
Results
Overall demographics (
n
= 196 HD-MTX cycles for 55 patients) include a mean age 55 years, HD-MTX dose ~ 5400 mg/m
2
, and 69% with a diagnosis of lymphoma. Adjusting for baseline demographic differences among groups, median time from first dose alkalinization to pH ≥ 7 and to start of HD-MTX was longer for those receiving IV-NaHCO3 (
n
= 41) vs either IV-NaHCO3 + Acet (
n
= 70) or PO-NaHCO3 + Acet (
n
= 76) (
p
= 0.0001). HD-MTX clearance to a level < 0.1 μmol/L was not improved with the addition of Acet. No difference existed among groups for pH results < 7, LOS, or incidence of MTX toxicity (
p
> 0.05).
Conclusions
Addition of Acet to NaHCO3 reduces time to pH ≥ 7 and initiation of HD-MTX but does not appear to improve LOS, MTX toxicities, or time to MTX clearance.
Metro aggregation is one of the fastest growing segments in telecommunications in terms of data traffic. At the intersection of core and access, where coherent modules compete with direct detection ...technology, high capacity must be provided at low cost and low power, with enhanced scalability and flexibility. Real-life Telecom Italia Mobile metro aggregation networks are examined and their design and planning optimized. The analysis is supported by techno-economics, which compares two coherent solutions: traditional point-to-point (P2P) and digital subcarrier (DSC)-based coherent modules for P2P and point-to-multipoint transmission. We demonstrate that the greater flexibility of DSC-based coherent modules leads to significant cost savings over a three-phase network deployment.
Introduction: The position paper on critical care pharmacy services describes two tiers of responsibilities: essential and desirable activities. Activities are categorized into five domains: patient ...care, quality improvement, research and scholarship, training and education, and professional development. Documentation of these activities can be important for justifying pharmacist positions, comparing pharmacy practice models, conducting performance evaluations, and tracking individual workload; however, limited recommendations are provided for standardized productivity tracking, and national practices remain largely uncharacterized. Objectives: The purpose of this survey was to describe documentation practices of critical care pharmacist activities. Methods: A cross-sectional survey was distributed via email to 1694 members of the ACCP critical care practice research network. The survey asked respondents to describe the methods used to document productivity as it relates to the 5 domains. Results: Seventy-nine (4.7%) critical care pharmacists from 63 institutions completed the survey. Intervention documentation was used for position justification and annual reviews among 54.4% and 44.1% of pharmacists, respectively. Pharmacists were routinely expected to perform additional responsibilities beyond patient care that contribute to overall productivity, but the percentage of institutions that track these activities as a measure of pharmacist productivity was relatively low: quality improvement (46%), research/scholarship (29%), training/education (38%), and professional development (27%). Documentation of these additional responsibilities and activities was primarily used for annual evaluations, but the majority of respondents answered that no standardized method for tracking activities existed. In multivariate regression, dedicated ICU pharmacists was a significant predictor for increased satisfaction (Exp(ß) 4.498, 95% CI 1.054-19.187, P = .042). Conclusion: Practice variation exists in how and for what intent critical care pharmacists track productivity. Further evaluation and standardization of productivity tracking may aid in position justification and practice model evaluation for dedicated ICU pharmacists in today’s value-based era.
Full depth reclamation (FDR) is a flexible pavement recycling technique that has not been explored in the state of Arkansas. FDR is unique in that it incorporates the entire flexible pavement section ...as well as a predetermined portion of the underlying base and sub-base materials with a stabilizer to create a new, stronger stabilized base course. Common stabilization techniques include the addition of asphalt emulsion, asphalt foam, or cement. Using the North Carolina emulsion FDR mix design, the Wirtgen foam FDR mix design, and the Portland Cement Association cement FDR mix design, field materials from four Arkansas highways in the Fayetteville Shale and Brown Dense Shale areas were gathered and used to produced laboratory stabilized FDR samples to determine the potential future use of these mix designs in Arkansas. Initial testing to determine mix properties were performed, which included determination of gradation, Atterberg limits, and sand equivalency testing. Optimal stabilizer contents were determined using the indirect tensile strength test for asphalt emulsion and asphalt foam stabilization and the unconfined compressive strength test was used for the cement stabilized samples. Once the mix designs were validated and optimal contents were determined, performance testing began on new samples produced at optimal stabilization contents from two of the highways to determine material characteristics and to determine if the performance tests are valid for use with FDR materials. For the asphalt emulsion and asphalt foam samples, performance testing included dynamic modulus in indirect tension mode, creep compliance, semi-circular bend, and indirect tensile strength. The cement stabilized samples were tested using the tube suction test and the semi-circular bend test. Results indicated dynamic modulus is a viable testing indicator for rutting and low temperature cracking, while creep compliance may not be suitable for FDR materials. The semi-circular bend test indicated that it is a testing option when using asphalt stabilized materials but another option may be needed for cement stabilization. The indirect tensile strength and tube suction tests are quantifiable moisture susceptibility tests that worked well with the FDR materials.
PDF
