scholarly journals Risk factors for Clostridium difficile infection in C. difficile colonized ICU patients

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S403-S403
Author(s):  
Yuan Zhou ◽  
Larissa Lewis ◽  
Michelle McIntosh ◽  
Ferric C Fang ◽  
Ronald Pergamit ◽  
...  
Keyword(s):  
Risk Factors ◽  
Clostridium Difficile ◽  
Disease Transmission ◽  
Significant Risk ◽  
Retrospective Chart Review ◽  
Signs And Symptoms ◽  
Significant Risk Factor ◽  
Antibiotic Use ◽  
Research Support ◽  
Icu Patients

Abstract Background Clostridium difficile is a major cause of healthcare-associated infections leading to significant morbidity and mortality; however, data-driven interventions to decrease C. difficile infections (CDI) are lacking due to an incomplete understanding of disease transmission and risk factors. Asymptomatic C. difficile carriers may be an important source of nosocomial transmission and disease but few studies have examined colonized patients who later develop CDI. We describe risk factors for the development of CDI in a critical care population screened for C. difficile colonization. Methods All patients admitted to our medical or trauma ICUs were screened for toxigenic C. difficile by PCR via rectal swab. Colonized patients were placed in contact enteric precautions for their entire hospitalization and monitored for signs and symptoms of CDI. Retrospective chart review assessed risk factors associated with development of CDI. Results 868 rectal swabs were collected from 4/01/16 to 10/31/16. 40 patients were colonized with C. difficile on ICU admission and 20 developed symptomatic CDI (Table 1). Risk factors for CDI in colonized patients include enteral feeding and exposure to antibiotics (Table 2). Conclusion 50% of C. difficile colonized ICU patients progressed to symptomatic CDI during their hospitalization. Antibiotic use was a significant risk factor for CDI. C. difficile carriers may be a particularly vulnerable population for CDI, warranting further investigation for early identification of colonized patients and strategies for infection prevention. Disclosures F. C. Fang, BioFire: Collaborator, Consultant and Scientific Advisor, Consulting fee, Research support and Speaker honorarium; Cepheid: Collaborator, Consultant and Scientific Advisor, Consulting fee, Educational grant, Research support and Speaker honorarium

Evaluation of Hospital Room Assignment and Acquisition of Clostridium difficile Infection

2011 ◽  
Vol 32 (3) ◽  
pp. 201-206 ◽  
Author(s):  
Megan K. Shaughnessy ◽  
Renee L. Micielli ◽  
Daryl D. DePestel ◽  
Jennifer Arndt ◽  
Cathy L. Strachan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Clostridium Difficile ◽  
Tertiary Care ◽  
Significant Risk ◽  
Extended Period ◽  
Significant Risk Factor ◽  
Antibiotic Use ◽  
Care Hospital ◽  
Icu Discharge

Background and Objective.Clostridium difficile spores persist in hospital environments for an extended period. We evaluated whether admission to a room previously occupied by a patient with C. difficile infection (CDI) increased the risk of acquiring CDI.Design.Retrospective cohort study.Setting.Medical intensive care unit (ICU) at a tertiary care hospital.Methods.Patients admitted from January 1, 2005, through June 30, 2006, were evaluated for a diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge. Medical, ICU, and pharmacy records were reviewed for other CDI risk factors. Admitted patients who did develop CDI were compared with admitted patients who did not.Results.Among 1,844 patients admitted to the ICU, 134 CDI cases were identified. After exclusions, 1,770 admitted patients remained for analysis. Of the patients who acquired CDI after admission to the ICU, 4.6% had a prior occupant without CDI, whereas 11.0% had a prior occupant with CDI (P = .002). The effect of room on CDI acquisition remained a significant risk factor (P = .008) when Kaplan-Meier curves were used. The prior occupant's CDI status remained significant (P = .01; hazard ratio, 2.35) when controlling for the current patient's age, Acute Physiology and Chronic Health Evaluation III score, exposure to proton pump inhibitors, and antibiotic use.Conclusions.A prior room occupant with CDI is a significant risk factor for CDI acquisition, independent of established CDI risk factors. These findings have implications for room placement and hospital design.

scholarly journals Neisseria meningitidis carriage and risk factors among teenagers in Suizhou city in China

2020 ◽  
Vol 148 ◽  
Author(s):  
Fei He ◽  
Hong mei Yang ◽  
Guo ming Li ◽  
Bing qing Zhu ◽  
Yating Zhang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Population Density ◽  
Neisseria Meningitidis ◽  
Old Age ◽  
Age Groups ◽  
Significant Risk ◽  
Epidemiological Data ◽  
Significant Risk Factor ◽  
Antibiotic Use ◽  
Carriage Rate

Abstract Teenagers are important carriers of Neisseria meningitidis, which is a leading cause of invasive meningococcal disease. In China, the carriage rate and risk factors among teenagers are unclear. The present study presents a retrospective analysis of epidemiological data for N. meningitidis carriage from 2013 to 2017 in Suizhou city, China. The carriage rates were 3.26%, 2.22%, 3.33%, 3.53% and 9.88% for 2013, 2014, 2015, 2016 and 2017, respectively. From 2014 to 2017, the carriage rate in the 15- to 19-year-old age group (teenagers) was the highest and significantly higher than that in remain age groups. Subsequently, a larger scale survey (December 2017) for carriage rate and relative risk factors (population density, time spent in the classroom, gender and antibiotics use) were investigated on the teenagers (15- to 19-year-old age) at the same school. The carriage rate was still high at 33.48% (223/663) and varied greatly from 6.56% to 52.94% in a different class. Population density of the classroom was found to be a significant risk factor for carriage, and 1.4 persons/m2 is recommended as the maximum classroom density. Further, higher male gender ratio and more time spent in the classroom were also significantly associated with higher carriage. Finally, antibiotic use was associated with a significantly lower carriage rate. All the results imply that attention should be paid to the teenagers and various measures can be taken to reduce the N. meningitidis carriage, to prevent and control the outbreak of IMD.

scholarly journals Epidemiological characterization and risk factors associated with lentiviral infection of small ruminants at animal fairs in the semiarid Sertão region of Pernambuco, Brazilian semiarid

2017 ◽  
Vol 38 (4) ◽  
pp. 1875
Author(s):  
José Romero Alexandre Alves ◽  
Clécio Henrique Limeira ◽  
Geilson Manoel de Souza Lima ◽  
Raymundo Rizaldo Pinheiro ◽  
Francisco Selmo Fernandes Alves ◽  
...  
Keyword(s):  
Risk Factors ◽  
Traffic Control ◽  
Disease Transmission ◽  
Significant Risk ◽  
Small Ruminants ◽  
Significant Risk Factor ◽  
Disease Diagnosis ◽  
Serum Samples ◽  
Western Blots ◽  
Factors Associated

Animal agglomerations at commercial events such as trade fairs represent an important facilitator in infectious disease transmission. Thus, it is crucial to understand the epidemiology of infectious diseases in small ruminants. The objective of this study was to examine lentiviral presence in goats and sheep traded at the animal fair of Tabira city (Sertão region of Pernambuco) and identify possible risk factors associated with infection. We collected serum samples from 233 crossbred goats and 119 crossbred sheep, belonging to 12 breeders, at the Tabira livestock fair from November 2014 to June 2015. An epidemiological questionnaire was used to analyze the risk factors. Agar gel immunodiffusion (AGID) and western blotting (WB) were performed to diagnose small ruminant lentivirus (SRLV) infection. In the AGID test, we used maedi-visna virus (MVV) antigens for sheep and caprine arthritis/encephalitis virus (strain Cork) (CAEV-Co) antigen for goats. The WB analysis used CAEV-Co antigen for both species. Variables from the questionnaire were analyzed with univariate and multivariate statistics. One seropositive goat but no sheep was identified via AGID. According to the WB results, 15/233 goats (6.44%; CI95% = 3.94 - 10.35%) and 8/119 sheep (6.72%; CI95% = 3.45 - 12.71%) were seropositive, totaling 23/352 reactive animals (6.53%; CI95% = 4.39 - 9.61%) from 12 herds. Annual vermifugation of the animals was a significant risk factor (odds ratio = 5.9; CI95% = 1.7-19.8; p = 0.04) for disease in goats, but no variables associated with infection risks were identified in sheep. We concluded that SRLV was present in goats and sheep at the animal fair. Western blots were more sensitive than AGID for SRLV diagnosis. Practices aiming to improve sanitary management may reduce the risk of infection in goats. All studied herds included animals identified as seropositive for SRLV. Therefore, we recommend adopting measures that increase disease diagnosis while intensifying traffic control and surveillance of animal agglomerations.

scholarly journals Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S1-S1 ◽  
Author(s):  
Maria Bye ◽  
Tory Whitten ◽  
Stacy Holzbauer
Keyword(s):  
Risk Factors ◽  
Clostridium Difficile ◽  
Medical Record ◽  
Significant Risk ◽  
Healthcare Facility ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Emerging Infections ◽  
Active Population ◽  
Dental Procedures

Abstract Background Clostridium difficile infections (CDIs) are the leading cause of healthcare-associated diarrhea. Two of the most significant risk factors for CDI are antibiotic use and healthcare exposure. Dentists write approximately 10% of all outpatient prescriptions in the USA; however, limited data are available regarding dental prescribing’s impact on CDI. We described characteristics of community-associated (CA) CDI cases following antibiotics for dental procedures. Methods The Minnesota Department of Health (MDH) performs active population- and laboratory-based surveillance for CDI as part of the CDC’s Emerging Infections Program (EIP). A case was defined as a positive C. difficile toxin or molecular assay on a stool specimen from a person >1 years old without a positive test in the prior 8 weeks, living in one of the five EIP catchment counties. Cases were classified as CA if stool was collected ≤3 days of admission or as an outpatient, with no overnight stay in a healthcare facility in the past 12 weeks. Medical records were reviewed and interviews performed to assess CDI risk factors and potential exposures. Differences in antibiotic prescribing and documentation among CA CDI cases receiving dental procedures were explored. Results During 2009–2015, 2176 presumptive CA CDI cases were reported to MDH; 1626 (75%) were confirmed as CA and interviewed. In total, 926 (57%) were prescribed antibiotics and 136 (15%) for dental procedures. Cases prescribed antibiotics for dental procedures were significantly older (median age: 57 vs. 45 years, P < 0.001), more likely to be prescribed clindamycin (50% vs. 10%, P < 0.001), and less likely to be prescribed fluoroquinolones (6% vs. 19%, P < 0.001) and cephalosporins (7% vs. 30%, P < 0.001) than those prescribed antibiotics for other indications. Among cases who received antibiotics for a dental procedure, 31 (23%) reported antibiotics on interview which were also documented in the medical record and 46 (34%) reported antibiotics for any reason on interview without documentation in the medical record. Conclusion Dental antibiotic prescribing rates are likely underestimated. Stewardship programs should address dental prescribing and alert dentists to CDI subsequent to antibiotics prescribed for dental procedures. Disclosures All authors: No reported disclosures.

Risk Factors for the Development of Clostridium difficile-Associated Diarrhea During a Hospital Outbreak

1991 ◽  
Vol 12 (6) ◽  
pp. 345-348 ◽  
Author(s):  
Alain Thibault ◽  
Mark A. Miller ◽  
Christina Gaese
Keyword(s):  
Risk Factors ◽  
Clostridium Difficile ◽  
Systemic Disease ◽  
Gastrointestinal Surgery ◽  
Significant Risk ◽  
Antibiotic Use ◽  
Surgical Patients ◽  
Convenience Sample ◽  
Significant Difference ◽  
Clostridium Difficile Associated Diarrhea

AbstractObjective:To evaluate the risk factors associated with a nosocomial outbreak of Clostridium difficile-associated diarrhea.Design:Case-control study with two control groups.Setting:University-affiliated urban hospital.Patients:A convenience sample of 26 patients was chosen out of a total of 78 hospitalized patients with C difficile-associated diarrhea, defined as the presence of diarrhea and a positive C difficile cytotoxin assay or stool culture. Twenty-six controls were matched for age, gender, ward, and date of admission; 18 additional controls were matched to surgical patients for date and ward of admission, as well as for the type of surgical procedure performed.Results:Significant risk factors for the development of C difficile-associated diarrhea were gastrointestinal surgery (exposure odds ratio [EOR] = 7.9, p= .004, 95% confidence interval [CI]= 1.9, 35), use of neomycin (EOR= 15.6, p=.012, 95% CI=1.7, 92), clindamycin (EOR=15.6, p=.005, 95% CI=1.7, 92), metronidazole (EOR=5.7,p=.02,95%CI= 1.4, 25), and excess antibiotic use (mean number of antibiotics = 4.2 versus 1.4, p<.00005). The presence of systemic disease and the use of antacids or immunosuppressive drugs were similar in cases and controls. In surgical patients, no specific antibiotic could be linked to C difficile-associated diarrhea because of uniform perioperative antibiotic use. There was a significant difference in the number of antibiotics administered to cases and controls (mean = 3.1 versus 1.9, p< .005).Conclusions:The results suggest that control of nosocomial C difficile-associated diarrhea may be attained by minimizing the administration of antibiotics, avoidance of high-risk antibiotics, and having a high index of suspicion of C difficile-associated diarrhea in patients who develop diarrhea after gastrointestinal surgery. Perioperative administration of metronidazole, when given with other antibiotics, failed to protect against the development of C difficile-associated diarrhea.

scholarly journals Etiological  characteristic  and risk factors of ESBL-Urinary Tract Infections: A nomogram had been built and Urologist should act in time

2020 ◽  
Author(s):  
Yi Wei ◽  
Chengjun Yu ◽  
Tianxing Zhao ◽  
Tao Lin ◽  
Dawei He ◽  
...  
Keyword(s):  
Risk Factors ◽  
Antibiotic Resistance ◽  
Urinary Tract ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Antibiotic Use ◽  
Clinical Microbiology Laboratory ◽  
Neurologic Disorder ◽  
Extended Spectrum Beta Lactamase ◽  
Tract Infections

Abstract Background: The presence of urinary tract infection (UTI) due to Extended-Spectrum Beta-Lactamase (ESBL)-producing bacteria is reported increased. Aim to study the most frequent uropathogens and the antibiotic susceptibility patterns of them in children and identify whether urodynamic change, underlying neurologic disorders and undernourishment were independent risk factors for ESBL positive UTI which is unclear. Methods: We retrospectively reviewed microbial etiologies and antimicrobial resistance among patients experiencing UTI events in the urology ward of Chongqing Medical University Afflicated Chlidren's Hospital from January 1994 and December 2019. All strains were cultured and identified by the Clinical Microbiology Laboratory. Results: A total of 854 patients with UTI over a 26-years period were evaluated and Escherichia coli was the most common pathogen. During the study period, the proportion of UTI cases attributed to Enterococci increased significantly. Susceptibilities to carbapenems and amikacin decreased significantly, indicating increased antibiotic resistance of pathogens associated with UTI. Interestingly, the susceptibilities to piperacillin/tazobactam have increased. 72.64% were caused by ESBL bacteria and ESBL-producing bacteria increased significantly. ESBL (+) and ESBL (-) UTI were compared and there were no significant differences in the clinical presentation between gender, side of the lesion and urodynamic results. Significant potential risk factors of ESBL-UTI were presence of congenital urological abnormalities, vesicoureteral reflux, neurologic disorder, age <12months, fever and previous use of antibiotics in the last 3 months. On logistic regression analysis, underlying neurologic disorder (OR =8, CI 1.845-34.695) and history of previous antibiotics administration in the last 3 months (OR =4.764, CI 3.114-7.289) were identified as an independent significant risk factor for ESBL- UTI. The nomogram generated was well calibrated for all predictions of ESBL+ probability, and the accuracy of the model nomogram measured by Harrell’s C statistic (C-index) was 0.741. Conclusions: The current situation of multiple bacterial antibiotic resistance has become a worrisome issue in UTI, and urologist should act timely. Our data will greatly assist physicians recognizing the risk factors of ESBL-UTI and optimising antibiotic use.

scholarly journals Rates and risk factors for nephrotoxicity and ototoxicity among tuberculosis patients in Tbilisi, Georgia

2019 ◽  
Vol 23 (9) ◽  
pp. 1005-1011 ◽  
Author(s):  
M. Buziashvili ◽  
V. Mirtskhulava ◽  
M. Kipiani ◽  
H. M. Blumberg ◽  
D. Baliashvili ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Multinomial Logistic Regression ◽  
Significant Risk ◽  
Retrospective Chart Review ◽  
Significant Risk Factor ◽  
Multidrug Resistant ◽  
Disease Classification ◽  
Second Line ◽  
Multinomial Logistic Regression Analysis

SETTING: Treatment of multidrug-resistant tuberculosis (MDR-TB) is lengthy and utilizes second-line anti-TB drugs associated with frequent adverse drug reactions (ADRs).OBJECTIVE: To evaluate the prevalence of and risk factors for ADRs among patients with MDR- and extensively drug-resistant TB (XDR-TB).DESIGN: A retrospective chart review of patients initiating treatment for M/XDR-TB in 2010–2012 in Tbilisi, Georgia.RESULTS: Eighty (54%) and 38 (26%) of 147 patients developed nephrotoxicity per RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification and ototoxicity, respectively. Twenty-five (17%) patients required permanent interruption of injectables due to an ADR. Median hospital stay, total treatment duration and number of regimen changes were higher among those with nephrotoxicity and/or ototoxicity, compared to those without (P < 0.01). Multinomial logistic regression analysis identified increasing age (per year) as a risk factor for nephrotoxicity (aOR 1.08, 95%CI 1.03–1.12) and for both, nephro- and ototoxicity (aOR 1.11, 95%CI 1.05–1.17). Low baseline creatinine clearance (CrCl) was a significant risk factor for developing nephrotoxicity (aOR 1.05, 95%CI 1.02–1.07).CONCLUSION: Second-line injectable drug-related ADRs are common among M/XDR-TB patients. Patients with increasing age and low baseline CrCl should be monitored closely for injectable-related ADRs. Notably, our findings support WHO's latest recommendations on introduction of injectable free anti-TB treatment regimens.

scholarly journals Risk factors of poor prognosis and impairment of activities of daily living in patients with hemorrhagic gastroduodenal ulcers

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Junya Arai ◽  
Jun Kato ◽  
Nobuo Toda ◽  
Ken Kurokawa ◽  
Chikako Shibata ◽  
...  
Keyword(s):  
Risk Factors ◽  
Activities Of Daily Living ◽  
Daily Living ◽  
Poor Prognosis ◽  
Significant Risk ◽  
Care Facility ◽  
Significant Risk Factor ◽  
Advanced Age ◽  
Gastroduodenal Ulcers ◽  
Poor Outcomes

Abstract Background Impairment of activities of daily living (ADL) due to hemorrhagic gastroduodenal ulcers (HGU) has rarely been evaluated. We analyzed the risk factors of poor prognosis, including mortality and impairment of ADL, in patients with HGU. Methods In total, 582 patients diagnosed with HGU were retrospectively analyzed. Admission to a care facility or the need for home adaptations during hospitalization were defined as ADL decline. The clinical factors were evaluated: endoscopic features, need for interventional endoscopic procedures, comorbidities, symptoms, and medications. The risk factors of outcomes were examined with multivariate analysis. Results Advanced age (> 75 years) was a significant predictor of poor prognosis, including impairment of ADL. Additional significant risk factors were renal disease (odds ratio [OR] 3.43; 95% confidence interval [CI] 1.44–8.14) for overall mortality, proton pump inhibitor (PPIs) usage prior to hemorrhage (OR 5.80; 95% CI 2.08–16.2), and heart disease (OR 3.05; 95% CI 1.11–8.43) for the impairment of ADL. Analysis of elderly (> 75 years) subjects alone also revealed that use of PPIs prior to hemorrhage was a significant predictor for the impairment of ADL (OR 8.24; 95% CI 2.36–28.7). Conclusion In addition to advanced age, the presence of comorbidities was a risk of poor outcomes in patients with HGU. PPI use prior to hemorrhage was a significant risk factor for the impairment of ADL, both in overall HGU patients and in elderly patients alone. These findings suggest that the current strategy for PPI use needs reconsideration.

Comorbidity and severity-of-illness risk adjustment for hospital-onset Clostridioides difficile infection using data from the electronic medical record

2020 ◽  
pp. 1-7
Author(s):  
Stephanie M. Cabral ◽  
Katherine E. Goodman ◽  
Natalia Blanco ◽  
Surbhi Leekha ◽  
Larry S. Magder ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Risk Adjustment ◽  
Community Hospital ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Bivariate Analysis ◽  
Patient Admissions ◽  
Clostridioides Difficile ◽  
Risk Adjustment Model

Abstract Objective: To determine whether electronically available comorbidities and laboratory values on admission are risk factors for hospital-onset Clostridioides difficile infection (HO-CDI) across multiple institutions and whether they could be used to improve risk adjustment. Patients: All patients at least 18 years of age admitted to 3 hospitals in Maryland between January 1, 2016, and January 1, 2018. Methods: Comorbid conditions were assigned using the Elixhauser comorbidity index. Multivariable log-binomial regression was conducted for each hospital using significant covariates (P < .10) in a bivariate analysis. Standardized infection ratios (SIRs) were computed using current Centers for Disease Control and Prevention (CDC) risk adjustment methodology and with the addition of Elixhauser score and individual comorbidities. Results: At hospital 1, 314 of 48,057 patient admissions (0.65%) had a HO-CDI; 41 of 8,791 patient admissions (0.47%) at community hospital 2 had a HO-CDI; and 75 of 29,211 patient admissions (0.26%) at community hospital 3 had a HO-CDI. In multivariable regression, Elixhauser score was a significant risk factor for HO-CDI at all hospitals when controlling for age, antibiotic use, and antacid use. Abnormal leukocyte level at hospital admission was a significant risk factor at hospital 1 and hospital 2. When Elixhauser score was included in the risk adjustment model, it was statistically significant (P < .01). Compared with the current CDC SIR methodology, the SIR of hospital 1 decreased by 2%, whereas the SIRs of hospitals 2 and 3 increased by 2% and 6%, respectively, but the rankings did not change. Conclusions: Electronically available patient comorbidities are important risk factors for HO-CDI and may improve risk-adjustment methodology.

scholarly journals Designing a bed-side system for predicting length of stay in a neonatal intensive care unit

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Harpreet Singh ◽  
Su Jin Cho ◽  
Shubham Gupta ◽  
Ravneet Kaur ◽  
S. Sunidhi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intensive Care ◽  
Length Of Stay ◽  
Neonatal Intensive Care ◽  
Financial Burden ◽  
Significant Risk ◽  
Model Performance ◽  
Significant Risk Factor ◽  
Validation Dataset ◽  
Patient Records

AbstractIncreased length of stay (LOS) in intensive care units is directly associated with the financial burden, anxiety, and increased mortality risks. In the current study, we have incorporated the association of day-to-day nutrition and medication data of the patient during its stay in hospital with its predicted LOS. To demonstrate the same, we developed a model to predict the LOS using risk factors (a) perinatal and antenatal details, (b) deviation of nutrition and medication dosage from guidelines, and (c) clinical diagnoses encountered during NICU stay. Data of 836 patient records (12 months) from two NICU sites were used and validated on 211 patient records (4 months). A bedside user interface integrated with EMR has been designed to display the model performance results on the validation dataset. The study shows that each gestation age group of patients has unique and independent risk factors associated with the LOS. The gestation is a significant risk factor for neonates < 34 weeks, nutrition deviation for < 32 weeks, and clinical diagnosis (sepsis) for ≥ 32 weeks. Patients on medications had considerable extra LOS for ≥ 32 weeks’ gestation. The presented LOS model is tailored for each patient, and deviations from the recommended nutrition and medication guidelines were significantly associated with the predicted LOS.

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