Clinical Rule Research Articles

Clinical application rules of different micro needle system therapy

Different micro needle system therapies have different advantages and characteristics. However, at present, the dominant diseases for which each therapy is appropriate are positioned relatively vaguely, and even the acupoint selections for the same disease are different. The clinical application of the dominant disease and application characteristics of each micro needle system therapy is a scientific problem that needs to be explored urgently. Based on the previous data mining study of the clinical application of auricular acupuncture, scalp acupuncture, abdominal acupuncture, eye acupuncture, wrist-ankle acupuncture, hand acupuncture, the second metacarpal bone lateral needling, facial acupuncture, mouth acupuncture and nose acupuncture, the diseases reported more in the clinical literature of each therapy were extracted to find out the same symptoms applicable to different micro needle systems. The clinical application and differences of different micro needle systems for the same disease were compared horizontally, and it demonstrated that the second metacarpal bone lateral needling, facial needle, mouth acupuncture and nose acupuncture were biased towards a partial corresponding therapeutic relationship between one part and the other part, and the eye acupuncture was biased to interfere with the whole by adjusting the function of the organs, and the auricular, scalp and abdominal needles had the both characteristics, and the wrist-malleolus acupuncture and hand acupuncture were often used in various disorders of the meridian-collateral level. The differences were researched and summarized to more accurately guide clinicians in the application of different micro needle system therapies.

Reducing Inappropriate Drug Use in Older Patients by Use of Clinical Decision Support in Community Pharmacy: A Mixed-Methods Evaluation.

Older people are prone to drug-related harm. Clinical decision support systems (CDSSs) in community pharmacies may improve appropriate prescribing in this population. This study investigated (persistent) drug therapy changes and its determinants to reduce potentially inappropriate medication (PIM) in older patients based on CDSS alerts and to investigate barriers and facilitators for implementation of drug therapy changes based on these CDSS alerts. Five clinical decision rules based on national guidelines for inappropriate drugs in older patients were incorporated in a web-based CDSS in 31 community pharmacies between February and April 2017. The CDSS generated alerts for patients aged > 70years who had prescriptions for one of the following drugs: alprazolam, amitriptyline, barnidipine, duloxetine, fluoxetine, trazodone, quetiapine and olanzapine. The registered alert management data and medication dispensing histories were analysed to find potential determinants of persistent drug therapy changes. Ten pharmacists were interviewed about the barriers and facilitators for implementing drug therapy changes based on CDSS alerts. An inductive thematic analysis of the transcripts was performed. The pharmacists recorded the management of 1810 of the 2589 generated alerts, and 158 (8.7%) alerts were associated with a persistent drug therapy change. A logistic regression analysis found that the drug triggering the alert and the type of prescription [first dispensing vs. repeat; odds ratio 2.1 (95% confidence interval 1.4-3.2)] were significantly associated with persistent drug therapy changes. No association was found between persistent changes and age, sex, number of medicines in use, or recent clinical medication review. Analysis of the interviews revealed nine barriers and facilitators associated with drug therapy change. When community pharmacists implemented CDSS alerts to reduce inappropriate drug use in older patients, they registered a persistent drug therapy change in 8.7% of the cases. Alerts triggered by a first prescription were two times more likely to be associated with a persistent drug therapy change than alerts triggered by repeat prescriptions. This study found that clinical rules can be used to detect inappropriate drug use in older patients and that drug therapy can change based on the alerts. This suggests that CDSS alerts are a useful tool for implementing guidelines on PIM in older patients in daily practice.

UHPLC-Q/Orbitrap/MS/MS Fingerprinting, Free Radical Scavenging, and Antimicrobial Activity of Tessaria absinthiodes (Hook. & Arn.) DC. (Asteraceae) Lyophilized Decoction from Argentina and Chile.

The decoction of Tessaria absinthioides is used in traditional medicine of South America as hypocholesterolemic, balsamic, and expectorant; but it is also useful for the prevention of hepatitis, renal insufficiency, and diabetes, and is used as digestive. A lyophilized decoction from the aerial parts of this plant (TLD) collected in San Juan (TLDSJ) and Mendoza (TLDM) provinces (Argentina) and one collection from Antofagasta, Chile (TLDCH) were characterized regarding antioxidant and antibacterial activities, phenolics and flavonoids content, and ultrahigh resolution liquid chromatography Orbitrap MS analysis UHPLC–PDA–OT-MS/MS metabolite profiling. The antioxidant properties were carried out "in vitro" using 2,2-diphenyl-1-picrylhydrazyl (DPPH) and trolox equivalent antioxidant activity (TEAC) methods, ferric-reducing antioxidant power (FRAP), and lipoperoxidation in erythrocytes (LP). The antibacterial activity was evaluated following the Clinical and Laboratory Standards Institute (CLSI) rules. TLDSJ, TLDM, and TLDCH displayed a strong DPPH scavenging activity (EC50 = 42, 41.6, and 43 µg/mL, respectively) and inhibition of lipoperoxidation in erythrocytes (86–88% at 250 µg TLD/mL), while a less effect in the FRAP and TEACantioxidant assays was found. Additionally, the decoctions showed a content of phenolics compounds of 94 mg gallic acid equivalents (GAE)/g, 185 GAE/g, and 64 GAE/g, for TLDSJ, TLDM, and TLDCH samples, respectively. Regarding the flavonoid content, the Chilean sample was highlighted with 19 mg quercetin equivalents (QE)/g. In this work, several phenolic compounds, including sesquiterpenes, flavonoids, and phenolic acids, were rapidly identified in TLDSJ, TLDM, and TLDCH extracts by means UHPLC–PDA–OT-MS/MS for the first time, which gave a first scientific support to consider this medicinal decoction from both countries as a valuable source of metabolites with antioxidant effects, some with outstanding potential to improve human health.

A clinical rule for the prediction of meningitis in HIV patients in the era of combination antiretroviral therapy.

The diagnosis of meningitis in HIV patients is challenging due to altered immune responses. Diagnostic scoring systems were recently proposed for use in research settings to help prompt and easy differential diagnosis. The objective of this study was to create a clinical prediction rule (CPR) for meningitis in HIV-infected patients and to address the enigma of differentiating bacterial (BM), TB (TBM) and cryptococcal (CCM) meningitis based on clinical features alone, which may be enhanced by easy-to-obtain laboratory testing. We retrospectively enrolled 352 HIV patients presenting with neurological manifestations suggesting meningitis over the last 18 y (2000-2018). Relevant clinical and laboratory information were retrieved from inpatient records. The features independently predicting meningitis or its different types in microbiologically proven meningitis cases were modelled by multivariate logistic regression to create a CPR in an exploratory data set. The performance of the meningitis diagnostic score was assessed and validated in a subset of retrospective data. AIDS clinical stage, injecting drug use, jaundice and cryptococcal antigen seropositivity were equally important as classic meningitic symptoms in predicting meningitis. Arthralgia and elevated cerebrospinal fluid Lactate dehydrogenase (LDH) were strong predictors of BM. Patients with cryptococcal antigenemia had 25 times the probability of having CCM, whereas neurological deficits were highly suggestive of TBM. The proposed CPRs have good diagnostic potential and would support decision-making in resource-poor settings.

New Drugs and Clinical Trials Rules, 2019: Towards Fast-track Accessibility of New Drugs to the Indian Population

Abstract: Background: To fulfil the objective of fast-tracking the accessibility of new drugs and promoting clinical research in India, the Union Ministry of Health and Family Welfare, India has notified the “New Drugs and Clinical trials Rules, 2019” on 25th March 2019. The prime objective of the new rule is to initiate unambiguous, foreseeable and effective regulations for the clinical trials in India. Drugs Controller General of India (DCGI) affirmed that the new rules would apply to all new drugs, investigational new drugs, bioequivalence and bioavailability study (BA/BE) and ethics committees. The new rules would replace part XA and schedule Y of drugs; however, the existing rules (Drugs and Cosmetics Act, 1940; Drug and Cosmetics Rules, 1945) and licenses, orders or directions will remain valid. Purpose: This brief review aims at presenting the key highlights of the “New Drugs and Clinical Trials Rules, 2019” of India. Methods: Literature review in existing and new clinical trials rules in India was conducted by referring the articles published in the indexed journals and official websites and compared. Conclusion: The clinical trials approval timeline has moved down to 30 days for the domestic trials and 90 days for the approval of global clinical trials. This faster approval timelines in the newly amended rules have enabled approval of more number of clinical trials and as a result, India may again turn out to be the preferred centre for conducting the trials. Key words: Clinical trials, New Drugs and Clinical trials Rules 2019, DCGI, India.

In Reply: A Clinical Rule for Preoperative Prediction of BRAF Mutation Status in Craniopharyngiomas.

BACKGROUND Papillary craniopharyngiomas are characterized by BRAFV600E mutations. Targeted therapy can elicit a dramatic radiographic regression of these tumors. Therefore, prediction of BRAF mutation status before definitive surgery could enable neoadjuvant treatment strategies. OBJECTIVE To establish preoperative prediction criteria to identify patients with a BRAF mutant craniopharyngioma. METHODS Sixty-four patients with craniopharyngioma were included in this study. We determined BRAF mutation status by targeted sequencing. After scoring interobserver variability between presurgical clinical data and radiographic features, we established a diagnostic rule for BRAF mutation in our discovery cohort. We then validated the rule in an independent cohort. RESULTS The BRAFV600E mutation was detected in 12 of 42 patients in the discovery cohort. There were no patients under age 18 with BRAF mutation. Calcification was rare in tumors with BRAF mutation (P < .001), and 92% of them were supradiaphragmatic in location. Combining these 3 features-older than 18 years, absence of calcification, and supradiaphragmatic tumor location-we established a rule for predicting BRAF mutation. In cases where all 3 criteria were fulfilled, the sensitivity and specificity for the presence of BRAF mutation were 83% and 93%, respectively. In the validation cohort (n = 22), the sensitivity was 100% and specificity was 89%. CONCLUSION We propose predictive criteria for a BRAF mutation in craniopharyngioma using preoperative clinical and radiographic data. This rule may be useful in identifying patients who could potentially benefit from neoadjuvant BRAFV600E-targeted systemic therapies.

English

The present study develops the Clifford algebra Cl5,0 within a dermatological task to diagnose skin melanoma using images of skin lesions, which are modeled here by means of 5D lesion feature vectors (LFVs). The LFV is a numerical approximation of the most used clinical rule for melanoma diagnosis — ABCD. To generate the Cl5,0 we develop a new formula that uses the entries of a 5D vector to calculate the entries of a 32D multivector. This vector provides a natural mapping of the original 5D vector onto the 2-, 3-, 4-vector Cl5,0 subspaces. We use a sample set of 112 5D LFVs and apply the new formula to calculate 112 32D multivectors in the Cl5,0. Next we map the 5D LFVs onto the 2-, 3-, 4-vector subspaces of the Cl5,0. In every subspace we apply a binary support vector machine to classify the mapped 112 LFVs. With the obtained results we calculate six metrics and evaluate the effectiveness of the diagnosis in every subspace. At the end of the paper we compare the classification results, obtained in every subspace, with the results obtained by the four diagnosing rules most used in clinical practice and contemporary machine learning methods. This way we reveal the potential of using Clifford algebras in the analysis and classification of medical images.

Performance of Two Head Injury Decision Rules Evaluated on an External Cohort of 18,913 Children

BackgroundThe Pediatric Emergency Care Applied Research Network (PECARN) decision rule demonstrates high sensitivity for identifying children at low risk for clinically important traumatic brain injury (ciTBI). As with the PECARN rule, the Israeli Decision Algorithm for Identifying TBI in Children (IDITBIC) recommends proceeding directly to computed tomography (CT) in children with Glasgow Coma Score (GCS) <15. The aim was to assess the diagnostic accuracy of two clinical rules that assign children with GCS <15 at presentation directly to CT. Materials and methodsAccuracy analysis for detecting ciTBI was performed on a multicenter cohort of children used in the Australasian Pediatric Head Injury Rules Study. ResultsThe external cohort included 18,913 children; 1691 (8.9%) had CT scan, 160 had ciTBI, and 24 (0.13%) had neurosurgery. Applying IDITBIC and PECARN rules would have missed 11 and 1 ciTBI patients; respectively. All patients with missed injuries were classified as such based on a hospital stay of >2 d. None of these patients died, needed neurosurgery, or required ventilatory support. In children aged <2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 95.2%, 79.5%, 3.8%, and 99.9% and 100.0%, 59.1%, 2.0%, and 100.0%, respectively. In children ≥2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 92.4%, 75.3%, 3.1%, and 99.9% and 99.2%, 52.9%, 1.7%, and 100.0%, respectively. ConclusionsThe two decision rules demonstrated high accuracy in identifying ciTBI. As a screening tool, the PECARN rule outperformed IDITBIC. The findings suggest that clinicians should strongly consider directing children with GCS <15 at presentation to CT scan.

New Drug and Clinical Trial Rules 2019- Two Steps Forward and One Back

New Drug and Clinical Trial Rules 2019- Two Steps Forward and One Back

Development and Performance of the Pulmonary Embolism Result Forecast Model (PERFORM) for Computed Tomography Clinical Decision Support

Pulmonary embolism (PE) is a life-threatening clinical problem, and computed tomographic imaging is the standard for diagnosis. Clinical decision support rules based on PE risk-scoring models have been developed to compute pretest probability but are underused and tend to underperform in practice, leading to persistent overuse of CT imaging for PE. To develop a machine learning model to generate a patient-specific risk score for PE by analyzing longitudinal clinical data as clinical decision support for patients referred for CT imaging for PE. In this diagnostic study, the proposed workflow for the machine learning model, the Pulmonary Embolism Result Forecast Model (PERFORM), transforms raw electronic medical record (EMR) data into temporal feature vectors and develops a decision analytical model targeted toward adult patients referred for CT imaging for PE. The model was tested on holdout patient EMR data from 2 large, academic medical practices. A total of 3397 annotated CT imaging examinations for PE from 3214 unique patients seen at Stanford University hospitals and clinics were used for training and validation. The models were externally validated on 240 unique patients seen at Duke University Medical Center. The comparison with clinical scoring systems was done on randomly selected 100 outpatient samples from Stanford University hospitals and clinics and 101 outpatient samples from Duke University Medical Center. Prediction performance of diagnosing acute PE was evaluated using ElasticNet, artificial neural networks, and other machine learning approaches on holdout data sets from both institutions, and performance of models was measured by area under the receiver operating characteristic curve (AUROC). Of the 3214 patients included in the study, 1704 (53.0%) were women from Stanford University hospitals and clinics; mean (SD) age was 60.53 (19.43) years. The 240 patients from Duke University Medical Center used for validation included 132 women (55.0%); mean (SD) age was 70.2 (14.2) years. In the samples for clinical scoring system comparisons, the 100 outpatients from Stanford University hospitals and clinics included 67 women (67.0%); mean (SD) age was 57.74 (19.87) years, and the 101 patients from Duke University Medical Center included 59 women (58.4%); mean (SD) age was 73.06 (15.3) years. The best-performing model achieved an AUROC performance of predicting a positive PE study of 0.90 (95% CI, 0.87-0.91) on intrainstitutional holdout data with an AUROC of 0.71 (95% CI, 0.69-0.72) on an external data set from Duke University Medical Center; superior AUROC performance and cross-institutional generalization of the model of 0.81 (95% CI, 0.77-0.87) and 0.81 (95% CI, 0.73-0.82), respectively, were noted on holdout outpatient populations from both intrainstitutional and extrainstitutional data. The machine learning model, PERFORM, may consider multitudes of applicable patient-specific risk factors and dependencies to arrive at a PE risk prediction that generalizes to new population distributions. This approach might be used as an automated clinical decision-support tool for patients referred for CT PE imaging to improve CT use.

Sensitivity of point-of-care testing C reactive protein and procalcitonin to diagnose urinary tract infections in Dutch nursing homes: PROGRESS study protocol

IntroductionSuspected urinary tract infection (UTI) ranks among the most common reasons for antibiotic use in nursing homes. However, diagnosing UTI in this setting is challenging because UTI often presents with...

Commentary: A Clinical Rule for Preoperative Prediction of BRAF Mutation Status in Craniopharyngioma.

Commentary: A Clinical Rule for Preoperative Prediction of BRAF Mutation Status in Craniopharyngioma.

Commentary: A Clinical Rule for Preoperative Prediction of BRAF Mutation Status in Craniopharyngiomas.

Commentary: A Clinical Rule for Preoperative Prediction of BRAF Mutation Status in Craniopharyngiomas.

Population-based inference of aminoglycoside resistance mechanisms in Escherichia coli

BackgroundInterpretative reading of antimicrobial susceptibility test (AST) results allows inferring biochemical resistance mechanisms from resistance phenotypes. For aminoglycosides, however, correlations between resistance pathways inferred on the basis of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints and expert rules versus genotypes are generally poor. This study aimed at developing and validating a decision tree based on resistance phenotypes determined by disc diffusion and based on epidemiological cut-offs (ECOFFs) to infer the corresponding resistance mechanisms in Escherichia coli. MethodsPhenotypic antibiotic susceptibility of thirty wild-type and 458 aminoglycoside-resistant E. coli clinical isolates was determined by disc diffusion and the genomes were sequenced. Based on well-defined cut-offs, we developed a phenotype-based algorithm (Aminoglycoside Resistance Mechanism Inference Algorithm - ARMIA) to infer the biochemical mechanisms responsible for the corresponding aminoglycoside resistance phenotypes. The mechanisms inferred from susceptibility to kanamycin, tobramycin and gentamicin were analysed using ARMIA- or EUCAST-based AST interpretation and validated by whole genome sequencing (WGS) of the host bacteria. FindingsARMIA-based inference of resistance mechanisms and WGS data were congruent in 441/458 isolates (96·3%). In contrast, there was a poor correlation between resistance mechanisms inferred using EUCAST CBPs/expert rules and WGS data (418/488, 85·6%). Based on the assumption that resistance mechanisms can result in therapeutic failure, EUCAST produced 63 (12·9%) very major errors (vME), compared to only 2 (0·4%) vME with ARMIA. When used for detection and identification of resistance mechanisms, ARMIA resolved >95% vMEs generated by EUCAST-based AST interpretation. InterpretationThis study demonstrates that ECOFF-based analysis of AST data of only four aminoglycosides provides accurate information on the resistance mechanisms in E. coli. Since aminoglycoside resistance mechanisms, despite having in certain cases a minimal effect on the minimal inhibitory concentration, may compromise the bactericidal activity of aminoglycosides, prompt detection of resistance mechanisms is crucial for therapy. Using ARMIA as an interpretative rule set for editing AST results allows for better predictions of in vivo activity of this drug class.

Hemorragia vítrea una rara manifestación del hamartoma astrocítico retiniano: a propósito de un caso pediátrico

IntroductionRetinal astrocytic hamartoma is generally an asymptomatic benign tumour that may or may not be associated with the tuberous sclerosis complex. Haemorrhage is a rare presentation. Case reportThe case concerns a 12-year-old patient with “a black spot” vision in the upper temporal hemifield of the right eye, who referred a similar episode 2 years ago. The anterior pole was normal in the slit lamp. A mass of translucent white-yellow peri-papillary appearance and vitreous peri-papillary haemorrhage was observed in funduscopy. The autofluorescence, fluorescence angiography, and optical coherence tomography characteristics were all compatible with retinal astrocytic hamartoma. Complementary studies (serology and X-rays) and the complete clinical examination rule out associated systemic involvement. The patient was followed-up closely until the vitreous haemorrhage was reabsorbed. ConclusionVitreous haemorrhage is a rare complication of Retinal astrocytic hamartoma and funduscopic exploration is difficult. Systemic involvement should be ruled out.

Acupoint selection rules of hyperthyroidism and related exophthalmos treated with acupuncture

To explore the clinical acupoint selection rules for hyperthyroidism and related exophthalmos treated with acupuncture. By taking "hyperthyroidism" "acupuncture and moxibustion" as keywords，literature regarding acupuncture for hyperthyroidism and related exophthalmos published was collected in the Chinese Journal Full-text Database (CNKI), VIP Database (VIP) and WANFANG database. The literature was organized, the database of acupuncture prescription was established and the characteristics and rules of acupoint selection were analyzed. A total of 46 papers were included, involving 89 acupoints, the frequency of acupoint application was 449 times. The most commonly used 6 acupoints for hyperthyroidism treated with acupuncture were Sanyinjiao (SP 6), Neiguan (PC 6), Zusanli (ST 36), Shuitu (ST 10), Hegu (LI 4), Taichong (LR 3). And the most meridians of acupoints were the stomach meridian and the pericardium meridian. The most commonly used 6 acupoints for hyperthyroidism related exophthalmos treated with acupuncture were Fengchi (GB 20), Shangtianzhu (Extra), Hegu (LI 4), Sanyinjiao (SP 6), Cuanzhu (BL 2), Yangbai (GB 14). And the most meridian of acupoints was the gallbladder meridian. The most commonly used specific acupoints for hyperthyroidism treated with acupuncture were crossing points, yuan-source points and five-shu points. The most commonly used specific acupoints for hyperthyroidism related exophthalmos treated with acupuncture were crossing points, yuan-source points and five-shu points. Acupuncture masters in modern times have achieved significant therapeutic effect in the treatment of hyperthyroidism，which has showed the principles of searching for the primary cause of disease in treatment and giving consideration to both the root cause and symptoms. But there is a lack of simple and effective treatment methods that can be rapidly promoted in clinical practice.

History of malignancy and relevant symptoms may predict a positive computed tomography enterography in obscure gastrointestinal bleeds.

This study aimed to assess the clinical utility of computed tomography enterography (CTE) and identify factors associated with a diagnostic CTE for patients with obscure gastrointestinal bleeding (OGIB). A retrospective observational study was performed at a Canadian tertiary care center from 2005 to 2015. A total of 138 patients underwent a CTE for OGIB. Univariate and multivariate logistic regressions were performed to determine factors associated with a diagnostic CTE. A highly sensitive clinical rule was then developed to help identify OGIB patients for whom a CTE may be beneficial in their clinical work-up. A possible bleeding source was identified in 30 (22%) cases. The presence of abdominal or constitutional symptoms as well as history of colorectal cancer was significantly associated with a positive CTE in univariate and multivariate analyses (P<0.05). A positive CTE could be predicted based on the presence of abdominal or constitutional symptoms and history of colorectal cancer with 90% sensitivity (95% CI 74-98%) in our population. CTE identified a possible source of OGIB in one in five cases. In patients with the presence of abdominal or constitutional symptoms and a personal history of colorectal cancer, CTE may contribute to their diagnostic work-up.

Comparison of Medication Therapy Management Services and Their Effects on Health Care Utilization and Medication Adherence.

Medication therapy management (MTM) programs are designed to improve clinical outcomes and enhance appropriate medication use. Comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) are 2 broad interventions defined within MTM services. While MTM services have been extensively researched, there are few comparisons of CMR versus non-CMR interventions. Given the variability in MTM interventions and lack of a consistent TMR definition in the literature, this study sought to compare CMRs and TMRs that were clearly defined based on Centers for Medicare & Medicaid Services (CMS) criteria. To (a) compare acute inpatient admissions and emergency department (ED) visits between patients participating in MTM services (CMR, TMR, or both) and eligible nonparticipating patients and (b) examine the effect of receiving TMR services on medication adherence. This was a retrospective cohort study of patients with Medicare Part D coverage who received MTM services and a 1:1 propensity score-matched control group. Participants had to be eligible for MTM services in 2014 or 2015 based on CMS requirements. CMRs were offered to all MTM-eligible patients, while TMRs were completed based on clinical rules that helped identify medication-related problems (MRPs). The date of MTM intervention, or eligibility for the control group, was considered the index date. Participants had to be continuously enrolled in a Medicare Advantage plan that included prescription drug coverage during the study period and have at least 6 months of data before and after the index date. Medical and pharmacy claims were assessed to examine trend-adjusted inpatient admissions and ED visits from pre-index to post-index date for participants and matched controls. In 2014 and 2015, receipt of TMR interventions was associated with statistically significant reductions in acute inpatient admissions. In 2014, there were 55.2 fewer admits per 1,000 individuals (95% CI = 29-81) and 30.8 fewer admits per 1,000 individuals in 2015 (95% CI = 20-42). Receipt of CMR-only interventions was associated with fewer acute inpatient admissions only when coupled with preidentification of MRPs (36.8 [95% CI = 25-49] fewer admits per 1,000 individuals). In 2015, there were significant reductions in ED visits for participants receiving TMR-only interventions or TMR/CMR interventions (26.1 [95% CI = 11-41] and 12.0 [95% CI = 1-23] fewer ED visits per 1,000 individuals, respectively). In both years, a larger percentage (0.4% for oral diabetes medications; 7.7% for antihypertensives; 3.0% for statins) of MTM participants had greater improvements in medication adherence in the post-index period compared with controls. Receiving MTM services targeted at resolution of MRPs (TMR or CMR/TMR) resulted in positive reductions in health care utilization and increases in medication adherence. Given the importance of optimal medication utilization, this study highlights the need for additional focus on resolution of MRPs through TMRs and CMRs that can support improved clinical outcomes. No outside funding supported this study. Researchers completed the work as part of their employment with Humana. All authors are or were employees of Humana at the time of the study. There are no other conflicts of interest to disclose. This study was previously presented at AMCP Nexus 2017 on October 16, 2017, in Dallas, TX.

Sleep-Cognition Hypothesis In maritime Pilots, what is the effect of long-term work-related poor sleep on cognition and amyloid accumulation in healthy middle-aged maritime pilots: methodology of a case–control study

IntroductionEvidence indicates a bidirectional relationship between poor sleep and Alzheimer’s disease (AD). While AD may lead to disruption of normal sleep, poor sleep in itself may play a causal role...

Utility of Clinical and Laboratory Decision Rules in Identifying Bacterial Meningitis Among Children with Suspicion of Central Nervous System Infections in a Malaria-Endemic Area, Mbarara, Uganda.

Several decision rules combining clinical and biological parameters have been proposed to distinguish bacterial from aseptic meningitis, but have not been evaluated in Africa. In children hospitalized with suspected central nervous system infections in Uganda, we found that the Bacterial Meningitis Score and Meningitest showed lower performance than in European children, and that a decision rule designed specifically using parameters associated with bacterial meningitis also showed inadequate diagnostic performance for clinical use.