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Background/Objectives: Healthcare-associated infections (HAIs) remain a major source of morbidity, mortality, and healthcare burden, and were profoundly affected by the COVID-19 pandemic through changes in case mix, care organization, and antimicrobial use. This study aimed to compare the epidemiology, etiology, ward distribution, risk factors, and outcomes of HAIs during the pandemic and post-pandemic periods in southeastern Romania, with particular emphasis on Clostridioides difficile infection (CDI), multidrug-resistant (MDR) pathogens, and in-hospital mortality. Methods: This retrospective observational study included 3929 patients with confirmed HAIs reported by 10 hospitals in one Romanian county between March 2020 and December 2024, divided into a pandemic period (March 2020-March 2022) and a post-pandemic period (April 2022-December 2024). Sociodemographic, clinical, ward-related, therapeutic, and microbiological variables, together with discharge status and cause of death, were analyzed using Fisher's exact test, Z-tests with Bonferroni correction, the Mann-Whitney U test, and multivariable models, applying national and ECDC-aligned surveillance definitions for HAIs. Results: Patients were predominantly older adults (median age 67 years), with a slight male and urban predominance. Hospital stays were longer during the pandemic. Immunosuppression, previous surgery, antisecretory therapy, and chemotherapy were more frequent post-pandemic. HAIs were mainly reported from medical wards, with a relative shift towards intensive care units during the pandemic; pediatric wards carried a smaller burden. CDI was the leading HAI (about half of all cases) with higher post-pandemic prevalence, whereas SARS-CoV-2 infections predominated in medical and surgical wards; Acinetobacter baumannii and Klebsiella pneumoniae clustered in intensive care units during the pandemic, and were more often associated with mortality. Overall, 59.7% of patients improved and 17.5% died, with higher mortality during the pandemic, while post-pandemic deaths were more frequently unrelated to HAIs. Conclusions: This study demonstrates a substantial and ongoing burden of healthcare-associated infections in southeastern Romania, with elderly patients with prolonged hospital stays and complex medical conditions being most affected and experiencing considerable mortality, particularly in medical and intensive care units. After the pandemic, Clostridioides difficile infections became more prevalent in the context of repeated antibiotic use and immunosuppression. Mortality among patients with HAIs was higher during the pandemic, whereas in the post-pandemic period deaths were more often unrelated to HAIs, underscoring the need to strengthen antimicrobial stewardship programs and infection prevention strategies.

This article presents a parallel analysis of Dante Alighieri's Divine Comedy and contemporary literature on moral injury to explore how Dante's journey towards enlightenment can inform the path to healing from moral injury. Described as a soul wound by those affected, moral injury is a severe psychological and spiritual trauma resulting from ethical transgressions such as abuse, betrayal, war and tyranny. Although moral injury is arguably as old as human conflict itself, its scientific study is comparatively new. The Divine Comedy is widely regarded as one of the greatest works in world literature. In this poem, moral suffering appears as a disordering of the soul: the will estranged from responsibility, love misdirected towards evil rather than good and the intellect dimmed of its light, unable to perceive truth. By comparing Dante's allegorical journey through Hell, Purgatory and Paradise with contemporary moral injury discussions and the broader literature, and by tracing connections from individual suffering to wider social and political contexts, this comprehensive narrative review uncovers underexplored dimensions of this multifaceted condition. The analysis addresses key moral injury themes, highlights routes and barriers to healing, identifies gaps in current scholarship and offers practical recommendations relevant in both peacetime and war. Dante's insights provide a symbolic framework for recognising and healing moral injury, potentially offering consolation for the affected and those who care for them, while showing how enduring cycles of violence can be interrupted through an ethic of just peace.

Background/Objectives: Respiratory dysfunction in Parkinson's disease (PD) is frequently underrecognized, particularly when resting oxygen saturation is preserved. Dynamic stress testing, however, may reveal exercise-induced oxygen desaturation, reflecting a latent functional respiratory impairment. The relationship between exertional oxygen desaturation and cognitive performance in PD remains insufficiently explored. Objective: To investigate the association between exercise-induced oxygen desaturation and global cognitive performance in patients with PD, and to explore the contribution of pulmonary gas exchange impairment assessed by diffusing capacity of the lung for carbon monoxide (DLCO). Methods: This prospective, cross-sectional, single-center observational study with consecutive enrollment included 50 patients with idiopathic Parkinson's disease undergoing multidisciplinary respiratory evaluation following neurological assessment. Participants underwent cognitive evaluation using the Romanian version of the Montreal Cognitive Assessment (MoCA), pulmonary function testing including DLCO and total lung capacity (TLC), and a supervised 6-min walk test (6MWT) with continuous pulse oximetry. Exercise-induced oxygen desaturation was defined as a decrease in SpO2 of ≥4% from baseline. Correlation analyses and multivariable regression models were applied. Results: Exercise-induced oxygen desaturation was frequent, with 60% of patients exhibiting a ≥4% decrease in SpO2 during the 6MWT. Greater desaturation was significantly associated with lower MoCA scores (Spearman's r = -0.383, p = 0.006). No significant associations were found between exertional desaturation and resting pulmonary function parameters, including DLCO and TLC. In multivariable analysis, lower MoCA score and levodopa-carbidopa intestinal gel treatment independently predicted greater oxygen desaturation during exercise. Conclusions: Exercise-induced oxygen desaturation is common in patients with PD despite preserved resting oxygenation and is associated with poorer cognitive performance. These findings suggest that exertional desaturation may reflect a dynamic functional impairment and may be associated with increased physiological vulnerability. Functional exercise testing with oxygen saturation monitoring may provide complementary information beyond resting pulmonary assessments.

BackgroundJob satisfaction influences individuals' motivation to comply with safety regulations and actively participate in safety initiatives.ObjectiveThis research aimed to investigate the influence of safety climate on job satisfaction and determine the relative importance of these variables among employees employed in a tire manufacturing organization.MethodsA descriptive-analytical cross-sectional study was conducted with a sample of 280 randomly selected individuals working in a tire manufacturing company in Tehran province, Iran. Simple random sampling was used for this study. The data collection process involved the utilization of Dante's job satisfaction questionnaire and the NOSACQ Nordic Safety climate questionnaire. Data analysis was performed using SPSS software version 29.0 and R programming language version 4.2.2, employing statistical tests including the Kruskal-Wallis test, post-hoc Dunn test, Mann-Whitney test, Spearman correlation test, and Multiple Quantile Regression.ResultsThe findings revealed that the results of the multiple regression analysis demonstrated a significant relationship between job satisfaction and factors, including the overall safety climate score, history of workplace accidents, and educational status (P&#x2009;<&#x2009;0.05).ConclusionsThese findings undeniably underscore the crucial role of safety climate in influencing employees' job satisfaction levels within the tire manufacturing industry. Future research should delve deeper into the relationship between safety climate and job satisfaction using longitudinal and qualitative methods.

Mood and anxiety disorders are leading causes of psychiatric hospitalization. However, data on real-world inpatient psychopharmacologic practices in the Philippines are limited. This study aims to describe the clinical characteristics and psychotropic medication prescribing patterns among inpatients with mood and anxiety disorders at a tertiary private hospital in the Philippines. This retrospective descriptive study reviewed medical records of patients admitted to the Section of Psychiatry at Makati Medical Center from January 1, 2014, to December 31, 2017. Patients with a primary DSM-5 diagnosis of bipolar disorder (BD), major depressive disorder (MDD), or anxiety disorder (AD) were included. Demographic and clinical characteristics, suicidality, and psychotropic prescribing patterns were summarized using descriptive statistics. A total of 705 patients were included: 350 (49.6%) with BD, 301 (42.7%) with MDD, and 54 (7.7%) with AD. Depressed mood was the most common presentation at admission (58.6%), and 72.2% of patients were euthymic at discharge. Suicide attempts were documented in more than half of patients with available data. Valproate, quetiapine, clonazepam, and aripiprazole were the most frequently prescribed medications for BD. In MDD, clonazepam, escitalopram, quetiapine, and aripiprazole predominated, while clonazepam and selective serotonin reuptake inhibitors were most commonly used in AD. Polypharmacy was frequent across diagnostic groups. Psychopharmacologic management of hospitalized patients with mood and anxiety disorders in this Philippine tertiary center largely aligns with international practice. High rates of polypharmacy and suicidality underscore the need for optimized, evidence-based prescribing and longitudinal outcome studies.

Engineering thinking has become a central goal of undergraduate engineering education, yet the psychological pathways through which it emerges in design-oriented course contexts are not well understood. This study examined how self-efficacy is associated with engineering thinking among engineering undergraduates in China and tested student engagement as a mediator of this link in courses incorporating design-based learning (DBL) activities. A cross-sectional questionnaire survey was completed by 407 students enrolled in 12 engineering-related programs at an applied university in eastern China during the second semester of the 2024-2025 academic year. The questionnaire assessed academic self-efficacy, behavioral, emotional, and cognitive engagement in course design activities, and engineering thinking. Data were analyzed using descriptive statistics, bivariate correlations, and partial least squares structural equation modeling (PLS-SEM) in SmartPLS 4.1.1.2 with 5,000 bootstrap resamples. The measurement model satisfied widely accepted criteria for indicator reliability, internal consistency, and convergent and discriminant validity. In the structural model, self-efficacy predicted higher levels of student engagement and engineering thinking, and engagement was positively related to engineering thinking. Indirect-effect estimates showed that student engagement transmitted part of the effect of self-efficacy on engineering thinking, indicating partial mediation. These findings suggest that students who feel more efficacious are more likely to invest behavioral, emotional, and cognitive resources in design-oriented learning tasks, and that this deeper involvement is linked to more advanced engineering thinking. The study highlights engagement as a key psychological mechanism connecting students' self-beliefs with complex engineering outcomes in DBL-implemented course settings.

Lung cancer remains the leading cause of cancer-related mortality, with early diagnosis critical to prognosis and survival. Histopathological confirmation is achieved through invasive or minimally invasive methods, the effectiveness of which varies according to clinical context. This study aimed to assess the diagnostic sensitivity of procedures commonly used in the evaluation of suspected bronchopulmonary neoplasms. We conducted a retrospective study of 210 patients hospitalised in two specialised centres in southeastern Romania between 2023 and 2024, all presenting with clinical and imaging findings suggestive of bronchopulmonary cancer. We analysed the diagnostic results of endobronchial biopsy, bronchial aspirate cytology, pleural fluid cytology, and surgical biopsy. Sensitivity was calculated against confirmed histopathological diagnoses and compared using the McNemar test. Surgical biopsy demonstrated the highest diagnostic performance (100% sensitivity), particularly in peripheral tumours or when minimally invasive procedures yielded inconclusive results. Endobronchial biopsy had a sensitivity of 80.2%, bronchial aspirate cytology 55.2%, and pleural fluid cytology 24.5% among patients with pleural effusion. While centrally located lesions were often accessible via bronchoscopy, minimally invasive methods were frequently insufficient when used alone. However, combining these approaches enhanced overall sensitivity in selected cases. Surgical biopsy remains the gold standard for the definitive diagnosis of bronchopulmonary cancer. A stepwise diagnostic approach-starting with minimally invasive procedures and progressing to surgical biopsy when necessary-provides an optimal balance between diagnostic accuracy and patient safety. These findings underscore the importance of tailoring diagnostic strategies according to lesion location, resource availability, and individual clinical scenarios.

The Enhanced Recovery After Surgery Society published guidelines in 2020 for minimizing physiologic stress in neonatal patients who are undergoing intestinal surgery. This study explores stakeholder perceptions of the acceptability and adoption of a neonatal enhanced recovery protocol as well as barriers and facilitators to implementation. We conducted seven semistructured focus groups, purposively selecting diverse stakeholders (N = 36) from six US hospitals. Transcripts were generated and transferred into MAXQDA for coding and analysis. We used a combined inductive and deductive approach to develop codes, followed by thematic analysis. Implementation of the guidelines was variable, with wide adoption of some components (e.g., breastmilk as preferred nutrition) and limited acceptability of others (e.g., early postoperative enteral feeds). We identified five key barriers/facilitators: (1) the heterogeneity of the neonatal surgical population (e.g., degree of prematurity); (2) competing stakeholder priorities (e.g., caregiver values versus clinician assessment of risks/benefits); (3) aligning care across teams (e.g., clinician-clinician, clinician-caregiver communication); (4) the clarity/specificity of component definitions (e.g., "goal-directed fluid management"); and (5) responsiveness to change (e.g., nursing willingness to learn and trial mucous fistula refeeding). This study provides a preimplementation assessment of an enhanced recovery protocol for neonatal intestinal surgery, highlighting the specific needs of this vulnerable population and identifying actionable refinements to existing guidelines. Broad, effective implementation will require greater consensus on the target population, alignment with stakeholder priorities, clearer care coordination strategies, refined component definitions, and increased openness to practice change.

Antibiotic overuse is harmful to patients and the health care system. Antibiotic prescribing report feedback has been described in outpatient and long-term care settings but is relatively untested in inpatient settings. To assess the association between peer comparative inpatient antibiotic prescribing feedback and changes to antibiotic prescribing rates among hospitalists in a large health care network. This quality improvement study linked data on billing and prescribing of broad-spectrum antibiotics for hospital-onset infections (BS-HO antibiotics) from hospitalists at 5 diverse acute care facilities encompassing both academic and primarily community-based hospitals within the same large health care network. Data were pooled into 12 two-month periods from January 1, 2023, through December 31, 2024, in a quality improvement intervention with a stepped-wedge cluster design. Hospitalists who contributed billed patient days for at least one 2-month period during the study period received the intervention. Observed-to-expected ratios (OERs) for days of therapy (DOT) of prescribed antibiotics were calculated for each hospitalist per period and reported back to hospitalists in a peer comparative report disseminated via email every 2 months. Hospitalists' prescribing rates for BS-HO antibiotics with activity against Pseudomonas aeruginosa were assessed, accounting for time, clustering of hospitalists, and patient characteristics including comorbidities and clinical syndrome. The study included 169 hospitalists (median per hospital, 30 [range, 24-50]) for a total of 1687 bimonthly observation periods. Per 2-month period, hospitalists had a mean (SD) of 126 (48) patient encounters. Among hospitalists at facilities receiving the intervention, the prescribing rate ratio (RR) for DOT was higher among clinicians caring for higher proportions of patients with sepsis (RR, 1.04; 95% CI, 1.00-1.08) and end-stage kidney disease (RR, 1.09; 95% CI, 1.05-1.14) and was lower for each sequential reporting period (RR, 0.99; 95% CI, 0.98-1.00). In multivariable models accounting for these variables and the trend over sequential periods, the intervention was not significantly associated with lower prescribing rates (RR, 0.97; 95% CI, 0.91-1.04). Peer comparative inpatient prescribing reports for hospitalists were not associated with a change in hospitalists' prescribing rates of BS-HO antibiotics. The findings suggest additional efforts to augment the utility of the reports are justified.

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Introduction Aggressive acts demonstrated by patients suffering from mood disorders can vary from irritability to homicidal or suicidal behavior. It has been reported that patients with affective disorder, specifically bipolar disorder, most recent episode mixed, have a higher odds of aggressive behavior compared to those with schizophrenia. The investigators were intrigued to explore how suicidality correlated with other factors and determinants of mood disorder by classifying it as an act of aggression toward oneself, giving credence to the psychopathological notion of suicidality. Methods The study was designed as a retrospective cross-sectional analytic investigation that will utilize a database previously gathered. The existing database has 705 data sets and has already been processed to be non-identifiable data. Upon processing, there were 373 data sets gathered and organized through the use of a data collection tool. The data the investigators gathered were the demographics and clinical determinants, as they have been hypothesized to have a relationship. Statistical analysis was done&#xa0;using Student's t-test for continuous variables and chi-square test or Fisher's exact test for categorical variables. Simple logistic regression was done to determine the variables that probably have significant association with aggression. Results The study showed a predominance of patients without aggression (266 from a total of 373).&#xa0;With the P-value noted to be significant if <0.20, only civil status was noted to be significant (p=0.004998) in the demographic variables.&#xa0;In the clinical determinants (p<0.20), the mood state during admission (p=2.798e-10), mood symptoms during admission (p=1.127e-12), the type of aggression (p=2.2e-16), and the total number of mood symptoms, depressed (p=3.462e-10) and manic&#xa0;(p=3.445e-11), were significant. Admitting diagnosis (p=0.004498), discharge diagnosis (p=0.001499), and comorbid psychiatric disorder (p=0.04998) were also noted to be significant in determining the presence or absence of aggression. Individuals in manic, mixed, or anxious states can expect their outcomes to be 5-6 times greater than those who are depressed. These values were also noted to be significant (p<0.20) with manic (p=1.59435e-09), mixed (p=2.60205e-04), and anxious (p=2.880880e-07). Conclusions It can be safely concluded that the factors with significant association to the absence and presence of aggression (civil status, mood state during admission, patients' mood symptoms at the time of admission, the type of aggression, the total number of symptoms for depression and mania, admitting diagnosis, discharge diagnosis, and comorbid psychiatric disorders) are also known considerations for assessing the probability of aggression, either toward&#xa0;others or of suicidal nature. The recent mood state was shown to have a positive association in terms of predicting the probability of aggression, especially manic, anxious, and mixed states. One of the primary purposes of this inquiry was to examine whether there is a change in terms of predictors of aggression if the concept of aggression includes any violence committed toward oneself.

Background: Right ventricular (RV) dysfunction is a key contributor to morbidity and mortality in systemic sclerosis (SSc), emerging from the combined effects of microvascular disease, myocardial fibrosis, interstitial lung involvement, and increasing pulmonary vascular load. Conventional echocardiography frequently fails to detect early RV impairment, prompting growing interest in deformation-based parameters such as RV free-wall longitudinal strain (RV-FWS), global longitudinal strain (RV-GLS), and RV-pulmonary artery (PA) coupling indices. Although natriuretic peptides reflect myocardial stress and are widely used in cardiopulmonary diseases, their integration with advanced RV imaging has been inconsistently reported in SSc. This systematic review synthesizes available evidence on RV strain, RV-PA coupling, and their relationship with clinical outcomes and biomarkers in SSc. Methods: A systematic search was conducted to identify clinical studies evaluating RV strain (RV-FWS, RV-GLS), right atrial strain, or RV-PA coupling indices in adult patients with SSc or SSc-associated pulmonary arterial hypertension (SSc-PAH). Eligible studies included those using speckle-tracking echocardiography or cardiac magnetic resonance feature-tracking. Study selection and data extraction were performed in accordance with PRISMA guidelines. Results: Seven studies met the eligibility criteria. Across unselected SSc cohorts, early disease without pulmonary hypertension (PH), and right-heart-catheterization-confirmed SSc-PAH, RV strain consistently detected myocardial impairment even when conventional echocardiographic indices remained normal. RV-FWS and RV-GLS were commonly reduced, and longitudinal data demonstrated progressive deterioration independent of standard measures. Strain-derived RV-PA coupling, particularly RV-FWS/PASP, significantly improved prognostic stratification when added to established PAH risk models. Two studies identified impaired RV deformation as a predictor of mortality, and CMR-derived right atrial strain provided additional prognostic value. Biomarker integration was limited, with only one study reporting an association between natriuretic peptide elevation (NT-proBNP) and impaired RV-PA coupling suggesting that biomarkers may reflect the hemodynamic load, although evidence remains limited captured by strain abnormalities. Conclusions: RV strain and RV-PA coupling indices are more sensitive than conventional echocardiography for detecting early RV dysfunction, monitoring disease progression, and predicting adverse outcomes in SSc. Although biomarker evidence remains limited, available data suggest that natriuretic peptides may provide complementary information to deformation-based assessment, although current evidence remains limited by reflecting combined myocardial and pulmonary vascular load. Standardized prospective studies including both strain imaging and biomarkers are needed to clarify the integrated diagnostic and prognostic value of advanced RV assessment in SSc.

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Refeeding ostomy effluent into the residual bowel via the mucus fistula (MFR) has been associated with decreased parenteral nutrition needs and decreased cholestasis. However, MFR is also associated with risks and the literature is not definitive. We performed a case matched comparison of neonates treated with and without MFR. All neonates who underwent enteral diversion between 2010 and 2023 were identified. Neonates who received MFR were propensity score matched with non-MFR neonates. Primary objectives included cholestasis and ability to achieve full feeds prior to enterostomy closure (EC). We also evaluated MFR complications (perforation, ostomy stricture, leak or prolapse). 262 neonates were case matched (131 MFR and 131 non-MFR). Age, height, and weight on admission were comparable. We found no difference in ability to achieve full feeds prior to EC. MFR neonates did have a lower incidence of cholestasis (p < 0.001). Complications occurred in 24 (18 %) of MFR neonates and abdominal reoperations prior to EC occurred more frequently in MFR (18 %) vs non-MFR (6.9 %) neonates, odds ratio 3.21 (1.44, 7.61). MFR is an important tool in the postoperative management of diverted neonates. However, when critically analyzed via statistical case matching, our study shows that the benefits may be more nuanced. Level III. Retrospective Chart Review.

Background and Objectives: Ward-level risk in pulmonary tuberculosis (TB) is often estimated from static admission data. This study evaluated a pragmatic composite-TRIAD-TB-integrating physiology (SpO2, respiratory rate), inflammation (systemic immune-inflammation index [SII], C-reactive protein [CRP]), and nutrition (BMI, albumin), augmented by 72 h changes in CRP and albumin, to predict 30-day mortality and hospital length of stay (LOS). Methods: A pooled prospective cohort of 126 HIV-negative adults without chronic systemic immunosuppression hospitalized with culture-confirmed pulmonary TB at two Romanian tertiary centers was analyzed. TRIAD-TB combined z-scored admission markers and 72 h deltas. The primary outcome was 30-day all-cause mortality; secondary outcomes included LOS. Associations were estimated using Firth logistic regression (mortality) and quasi-Poisson regression (LOS). Discrimination and overall performance were summarized by AUC and Brier score; internal performance used bootstrap optimism-correction. Results: Across TRIAD-TB tertiles, 30-day mortality increased from 2.4% to 16.7%, and mean LOS rose from 24.7 &#xb1; 5.8 to 32.1 &#xb1; 7.3 days. Each SD increase in TRIAD-TB was associated with higher odds of death (adjusted OR 2.4, 95% CI 1.3-4.8; p = 0.006) and longer hospitalization (adjusted IRR 1.19, 95% CI 1.09-1.30; p < 0.001). The full model discriminated mortality well (AUC 0.84; Brier 0.067) and explained 21.8% of LOS deviance. Early dynamics were informative: higher CRP ratio (72 h/0 h) and albumin decline tracked with adverse outcomes. An admission-only "mini-TRIAD" retained strong discrimination (AUC 0.79). Conclusions: A dynamic composite leveraging routine vitals and laboratory tests-plus 72 h trajectories-accurately stratified short-term risk in hospitalized pulmonary TB, while an admission-only "mini-TRIAD" retained strong discrimination. Together, these tools may support early escalation, targeted monitoring, and capacity planning. TRIAD-TB may support early escalation, targeted monitoring, and capacity planning; however, because it was derived in HIV-negative, non-immunosuppressed adults in an Eastern European setting, TRIAD-TB and the admission-only "mini-TRIAD" require external validation, including in cohorts with substantial HIV co-infection and different comorbidity profiles, before any broader implementation.

Pediatric choledocholithiasis is traditionally managed with an endoscopy-first approach, where Endoscopic Retrograde Cholangiopancreatography (ERCP) is performed before laparoscopic cholecystectomy (LC). However, ERCP carries risks such as pancreatitis, bleeding, infection, and perforation, and may even be an unnecessary procedure should stones pass spontaneously. An alternative surgery-first approach, utilizing intraoperative cholangiogram (IOC), laparoscopic common bile duct exploration (LCBDE), power flushing, and glucagon, may offer a more efficient treatment pathway. This study aims to evaluate ERCP findings in pediatric patients undergoing an endoscopy-first pathway to characterize the nature and burden of stone disease in the common bile duct. Our ultimate goal is to determine the proportion of cases that could have been successfully managed with a surgery-first approach. This retrospective, multi-center study analyzed 127 pediatric patients (&#x2264;18 years) who underwent ERCP prior to LC for suspected choledocholithiasis. Data from seven children's hospitals were reviewed, including imaging studies, ERCP findings, and stone characteristics. ERCP findings were categorized as sludge, small (<4 mm), medium (5-7 mm), large (>8 mm), or absent stones. Cases with sludge, small/medium stones, or negative ERCP findings were considered amenable to a surgery-first approach as they are known to be manageable with intraoperative techniques. 69 % of patients had ERCP findings that were amenable to transcystic surgical maneuvers without preoperative ERCP. Among those, 19 % had only sludge, 46 % had only stones, 24 % had sludge and stones, and 11 % had no evidence of obstruction. Large stones (>8 mm) were found in only 8 % of cases. The findings support a surgery-first has potential for a paradigm shift as standard of care for pediatric choledocholithiasis, with ERCP reserved for select cases where surgical clearance fails or cholangitis is present. Adoption of this approach could reduce hospital stays, procedural risks, and healthcare costs while maintaining high efficacy in duct clearance. Prospective studies are warranted to refine clinical guidelines. IV.

To evaluate potential modifications to the Centers for Disease Control and Prevention (CDC)'s Adult Sepsis Event (ASE) definition aimed at mitigating variable blood culturing practices, better-capturing cases where timely care may have prevented deterioration, and improving clinical credibility. Retrospective observational study. 5 US hospitals. Hospitalized adults, 2015-2022. We assessed the impact of potential ASE modifications on community-onset sepsis incidence and mortality and reviewed 280 charts to assess positive predictive value (PPV) for clinical sepsis. Among 1,101,252 hospitalized adults, 51,712 (4.7%) met community-onset ASE criteria (16.1% mortality). Expanding infection criteria to include present-on-admission infection codes when blood cultures were not drawn, non-blood clinical cultures, and discharge alive on antibiotic day three increased incidence by 15.0%, 12.2%, and 4.9%, respectively; all led to mild decreases in mortality rates. Expanding organ dysfunction criteria to include hypotension increased ASE incidence by 32.3% and decreased mortality by 18.5%. Broadening respiratory failure criteria to include noninvasive ventilation and high-flow oxygen had minimal impact. On chart review, original ASE criteria had 80% PPV for clinical sepsis. PPV was similar when identifying infection using present-on-admission infection codes instead of blood cultures and when including patients discharged alive on antibiotic day three. PPV decreased to 50% when using non-blood clinical cultures to identify infection, 17% when using single hypotension values alone to indicate organ dysfunction, and 30% when all ASE components occurred exactly 2 days vs within +/-1 day from the blood culture day. Our findings inform modifications to ASE to optimize its utility for national epidemiologic monitoring and quality measurement.

Healthcare-associated infections (HAIs) are a significant public health problem, having a decisive impact on the prognosis of patients hospitalized with COVID-19. In Romania, the absence of a uniform reporting system and the lack of epidemiological data comparable to European standards limit the real assessment of their incidence and consequences. In this context, the present study aimed to conduct an integrated analysis of the clinical, epidemiological, and microbiological factors involved in the mortality of patients with COVID-19 and HAIs in a county located in southeastern Romania. This research was based on a retrospective observational study that included 295 patients with a confirmed diagnosis of COVID-19 and at least one documented HAI between January 2020 and December 2022. Data were extracted from standardized reporting forms, and statistical analyses included tests (Fisher's exact test, Mann-Whitney U), ROC curves, Kaplan-Meier survival analysis, and Cox proportional hazard regression. The analysis revealed a mortality rate of 32.5%, significantly associated with advanced age, gastrointestinal surgery, and respiratory infections. Clostridioides difficile was the predominant pathogen (84.1%), and the threshold of &#x2265;63.5 years demonstrated predictive value for mortality. In multivariate models, age greater than 63 years and gastrointestinal surgery were confirmed as independent predictors of death. The findings highlight the substantial impact of HAIs on the clinical progression of COVID-19 patients, underscoring the need for comprehensive systemic interventions, including enhanced prevention and control strategies, prudent antimicrobial therapy, and standardized epidemiological monitoring. Implementing these measures is crucial to mitigating HAIs' effects and improving patient outcomes in similar situations.

Choledocholithiasis in children is commonly managed with an "endoscopy-first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)). Because ERCP availability is often limited at the end of the week (EoW), we hypothesized that a "surgery-first" (SF) approach (LC with intraoperative cholangiogram (IOC) &#xb1; transcystic laparoscopic common bile exploration (LCBDE)) would decrease length of stay (LOS) and time to definitive intervention (TTDI). A multicenter, retrospective cohort study was conducted on pediatric patients from 2018 to 2023 with suspected choledocholithiasis. Work week (WW) presentation was defined as admission between Monday to Thursday. TTDI was defined as time to LC or postoperative ERCP (if required). Among seven hospitals, there were 354 pediatric patients; 217 (61%) managed with SF (125 WW, 92 EoW) and 137 (39%) managed with EF (74 WW, 63 EoW). SF groups had a shorter LOS for both WW and EoW presentation (60.2&#xa0;h and 58.3&#xa0;h vs 88.5&#xa0;h and 93.6&#xa0;h respectively; p&#xa0;<&#xa0;0.05). TTDI decreased in SF (26.4&#xa0;h and 28.9&#xa0;h vs 61.4&#xa0;h and 72.8&#xa0;h; p&#xa0;<&#xa0;0.05). All EF patients underwent at least two anesthetics (preoperative ERCP followed by LC) while the majority (79%) of the SF group had only one procedure (LC&#xa0;+&#xa0;IOC&#xa0;&#xb1;&#xa0;LCBDE). Children who present with choledocholithiasis at EoW have a longer LOS and TTDI. These findings are amplified when children enter an EF pathway. A surgery-first approach results in fewer procedures, decreased TTDI, and shorter LOS, regardless of the time of presentation. Level III.