Impact of New Diagnostic Approaches for Invasive Candidiasis on Antifungal Stewardship

Background

Invasive candidiasis (IC) including candidemia and deep-seated candidiasis is associated with up to 50 % overall mortality and up to $80,000 in attributable cost (2015 US$). Rapid diagnostic tests (RDTs) for Candida have been developed. However, whether RDTs along with real-time decision support translate to better attainment of stewardship goals—improve clinical outcomes, minimize unintended consequences of antifungal use, and reduce healthcare costs—is unknown. The purpose of this systematic review was to provide an up-to-date review of recently published studies that have assessed how RDTs for IC impact attainment of these goals.

Methods

Three electronic bibliographic databases were searched using a pre-defined search strategy evaluating the impact of RDTs for IC on attainment of antifungal stewardship goals. Quality assessments were performed by two reviewers using established study methodology metrics.

Results and Conclusions

Eight studies were identified of which five had sufficient information to be included in the review. Despite the limitations of the various studies and the different methodologies employed, the studies all produced similar conclusions. Compared to conventional methods and baseline stewardship activities, the integration of RDTs for IC and real-time decision support, mainly through antifungal stewardship, was associated with decreased mortality, more optimal use of antifungals, and reduced healthcare costs. However, larger clinical studies are needed to confirm these trends.

     

Antifungal Penetration into the Nail and New Topicals for Onychomycosis

Onychomycosis is a common and difficult to treat infection, owing predominately to the limited penetration of topical drugs to the site of infection. Systemic drugs are not an option for all patients due to adverse events and drug-drug interactions. In this article, we review the nail penetration and clinical efficacy data of topical drugs, including older agents such as ciclopirox and amorolfine, as well as the newer agents, efinaconazole and tavaborole. Additionally, we describe some unresolved questions in the management of onychomycosis.     

Species Composition Changes in Conservation Reserve Program (CRP) Grassland When Managed for Biomass Feedstock Production

Grasslands enrolled in the Conservation Reserve Program (CRP) serve as one of the potential national herbaceous resources for use as a dedicated bioenergy feedstock. The goal of this project was to assess the yield potential and suitability of CRP grassland as a bioenergy feedstock source across the USA in regions with significant CRP land resources. In addition to that goal, one major objective of this project was to assess vegetation composition changes that also occurred on these different CRP grasslands over time with different harvest and fertilization management strategies. Three levels of nitrogen fertilization (0, 56, and 112 kg ha^?1) and two harvest timings [peak standing crop (PSC) or end of growing season (EGS)] were evaluated for effects on biomass production and resulting species composition changes. Three sites in regions containing concentrated tracts of CRP grassland and representing variable climatic parameters were analyzed for vegetation composition trends over the course of six growing seasons (2008–2013). Specifically, a mixture of warm-season perennial grasses was evaluated in Kansas (KS), while a cool-season mixture was evaluated in Missouri (MO). North Dakota (ND) contained a mixture of both warm- and cool-season grasses. At the MO and KS sites, nitrogen fertilization significantly altered the grass and legume composition over time by lowering the legume percentage in the stand. In KS and ND, the two sites with warm-season grasses, harvesting in mid-summer at PSC, greatly reduced warm-season grass composition over time in favor of annual cool-season grass invaders or perennial cool-season grasses. Any shift to less desirable or less productive species limits the ability of these lands to provide a sustainable or reliable feedstock for bioenergy production.     

Patient admission planning using Approximate Dynamic Programming

Tactical planning in hospitals involves elective patient admission planning and the allocation of hospital resource capacities. We propose a method to develop a tactical resource allocation and patient admission plan that takes stochastic elements into consideration, thereby providing robust plans. Our method is developed in an Approximate Dynamic Programming (ADP) framework and copes with multiple resources, multiple time periods and multiple patient groups with uncertain treatment paths and an uncertain number of arrivals in each time period. As such, the method enables integrated decision making for a network of hospital departments and resources. Computational results indicate that the ADP approach provides an accurate approximation of the value functions, and that it is suitable for large problem instances at hospitals, in which the ADP approach performs significantly better than two other heuristic approaches. Our ADP algorithm is generic, as various cost functions and basis functions can be used in various hospital settings.     

A note on the selection of priority rules in software packages for project management

Various software packages for project management include a procedure for resource-constrained scheduling. In several packages, the user can influence this procedure by selecting a priority rule. However, the resource-allocation methods that are implemented in the procedures are proprietary information; therefore, the question of how the priority-rule selection impacts the performance of the procedures arises. We experimentally evaluate the resource-allocation methods of eight recent software packages using the 600 instances of the PSPLIB J120 test set. The results of our analysis indicate that applying the default rule tends to outperform a randomly selected rule, whereas applying two randomly selected rules tends to outperform the default rule. Applying a small set of more than two rules further improves the project durations considerably. However, a large number of rules must be applied to obtain the best possible project durations.     

Impact of Different Lignin Fractions on Saccharification Efficiency in Diverse Species of the Bioenergy Crop Miscanthus

Lignin is a key factor limiting saccharification of lignocellulosic feedstocks. In this comparative study, various lignin methods—including acetyl bromide lignin (ABL), acid detergent lignin (ADL), Klason lignin (KL), and modified ADL and KL determination methods—were evaluated for their potential to assess saccharification efficiency. Six diverse accessions of the bioenergy crop miscanthus were used for this analysis, which included accessions of Miscanthus sinensis, Miscanthus sacchariflorus, and hybrid species. Accessions showed large variation in lignin content. Lignin estimates were different between methods, but (highly) correlated to each other (0.54?≤?r?≤?0.94). The strength of negative correlations to saccharification efficiency following either alkaline or dilute acid pretreatment differed between lignin estimates. The strongest and most consistent correlations (?0.48?≤?r?≤??0.85) were obtained with a modified Klason lignin method. This method is suitable for high throughput analysis and was the most effective in detecting differences in lignin content (p?<?0.001) between accessions.     

Ecosystem Services of Woody Crop Production Systems

Short-rotation woody crops are an integral component of regional and national energy portfolios, as well as providing essential ecosystem services such as biomass supplies, carbon sinks, clean water, and healthy soils. We review recent USDA Forest Service Research and Development efforts from the USDA Biomass Research Centers on the provisioning of these ecosystem services from woody crop production systems. For biomass, we highlight productivity and yield potential, pest susceptibility, and bioenergy siting applications. We describe carbon storage in aboveground woody biomass and studies assessing the provision of clean and plentiful water. Soil protection and wildlife habitat are also mentioned, in the context of converting lands from traditional row-crop agriculture to woody production systems.