Inappropriate Cases Research Articles

2015 개정 교육과정 중학교 기술·가정 교과서의 건설기술 관련 단원에 대한 내용학적 분석

Objectives The purpose of this study is to prevent the same writing errors in the future by analyzing problems in the description of the construction technology section of the 2015 revised curriculum technology and home eco-nomics textbook from a content perspective and suggesting appropriate alternatives.
 Methods In this study, an analysis framework was constructed based on the achievement standards of the 2015 revised curriculum and the content system of technology and home economics textbooks. In addition, this study reviewed the content validity and presented alternatives in five areas: the concept and characteristics of con-struction technology, the production process of construction structures, the construction technology system, the development process of construction technology, and future construction technology.
 Results In this study, civil engineering technology is a concept that encompasses the concepts of social overhead capital, natural power, energy utilization, and sustainability, and the characteristics of construction technology are sole production, immobility, complexity, costliness, and publicness. Most descriptions of the production process of construction structures focused on architectural structures, and there appeared to be no textbooks explaining the differences between architectural structures and civil structures at the planning and design stage. The devel-opment process of construction technology was mostly divided into four stages, and many inappropriate cases were found in the period classification of buildings, descriptions of styles, structures, and example buildings.
 Conclusions The construction technology section of current technology and home economics textbooks contains many problems and errors from a content perspective. These problems and errors can be fully reviewed and cor-rected by content experts. It is expected that the same problems can be improved in new textbooks through this study.

Patients cancelled after initial activation for suspected STEMI via the ODiSEA APP, what happens to them?

Abstract Introduction The use of technological innovation in STEMI care networks has been shown to be effective in sharing diagnostic ECG tracing and clinical information with the cardiology department, reducing the number of inappropriate cases transferred to the cathlab. These inappropriate cases have been shown to be more likely to die than those undergoing urgent coronary angiography, but data on incidence, cause of cancellation and prognosis are limited1. Objective Our aim was to investigate the characteristics and prognosis of patients in whom transfer to the cathlab was cancelled, compared with those who underwent emergent coronary angiography (EC). Material and Methods Prospective study analysing all STEMI alert activations during the year 2022. Information on ECG pattern and clinical history was transmitted using an APP (ODiSEA2,3). Based on the ECG pattern and clinical history, cancellations were made. Patient characteristics, myocardial infarction, ECG activation pattern, angiography results and in-hospital mortality were studied. Results A total of 406 infarction codes were activated through the ODISEA APP, of which 284 (70%) underwent EC and 122 (30%) were cancelled. The cancelled patients had a higher comorbidity than the transferred patients. The reasons for cancellation based on ECG patterns are shown in Figure 1. The most common were ST depression (23%), concave ST elevation (18.8%) and intraventricular conduction disturbances (22.9%). In addition, coronary angiography was performed in 33% of the cancelled patients compared to 99% of the transferred patients (p<0.001). The number of patients with coronary arteries without lesions was significantly higher in the cancelled group (31.7% vs. 9.6% p<0.001). In the EC group, 90.5% of patients presented with a final diagnosis of ACS, whereas in the cancelled group this was 32.8% (final diagnosis of STEMI 2.5% in the cancelled group vs. 83.5% in the CE group, p<0.001). Discharge from the emergency department was 46% in the cancellation group versus 2.7% in the transfer group (p<0.001). Finally, the in-hospital mortality rate was significantly higher in the cancelled group: 14 patients (11.4%) vs. 12 patients (4.2%) in the transferred group (p<0.001). Discussion Compared to patients who are transferred to a centre with cathlab, the subgroup of patients initially activated as STEMI alerts and eventually cancelled have a high comorbidity, a low probability of a final diagnosis of ACS and a high in-hospital.Table 1.Patients characteristicsFigure 1.ECG pattern

Cancelled STEMI patients: what happen to them?

Abstract Introduction In the STEMI care network, the number of inappropriate cases sent to cathlab remains high 1. The use of technological innovations to share the diagnostic ECG tracing with the cardiology department has been shown to be effective in improving patient discrimination. Objective Our aim was to study the characteristics and prognosis (at discharge and 1-year follow-up) of patients whose transfer to the cathlab was cancelled. Material and Method Prospective study analysing all STEMI alert activations in 2022. Information on ECG pattern and clinical history was transmitted using an APP (ODiSEA 2-3) and used for cancellation. Patient characteristics, myocardial infarction, ECG activation pattern, angiography results, final diagnosis and clinical events during admission and 1-year follow-up were recorded. Patients who underwent urgent coronary angiography were excluded from the study. Results A total of 406 infarction codes were activated through the ODISEA APP. 122 (30%) of these were cancelled. The characteristics of the patients are shown in Table 1. Reasons for cancellation based on ECG pattern are shown in Figure 1.B. The most common were ST depression (23%) and intraventricular conduction disturbances (22.9%). The final diagnosis was ACS in 32.8% (STEMI 2.5%, NSTEMI 27% and unstable angina 3.3%). In the remaining 67.2%, the final diagnosis was atypical chest pain with negative biomarkers in 22.9%, arrhythmia in 17.2%, pericarditis in 9%, gastrointestinal pathology in 4.9%, heart failure in 4.9%, aortic dissection in 3.2%, PTE in 1.6% and other pathologies in 3.5%. (Figure 1.A). Coronary angiography was performed in 41 patients (33.6%). There were 36.6% with one vessel, 9.8% with two vessels and 22% with three vessels. Percutaneous revascularisation was required in 70% of patients. Discharge from the emergency department occurred in 46% of the patients. Hospital mortality occurred in 14 patients (11.4%). Of these, 3 (2.4%) were due to cardiac causes. Regarding events at 12 months, 6 (4.9%) were deaths (5 natural deaths and 1 due to cancer). 5 patients (4%) had ACS, 3 patients (2.4%) had stroke and 1 patient (0.8%) had digestive bleeding. Conclusions STEMI alert cancelled transfer patients are older, have more comorbidities and are less likely to have a final diagnosis of ACS or to have coronary lesions. They have a high rate of non-cardiovascular in-hospital mortality and a low rate of cardiovascular events at one year of follow-up.A.Final diagnosis. B. ECG patternTable 1.Patients characteristics

Clinical pharmacist-initiated assessment and amelioration of appropriate antibiotic use in surgical units at a South Indian tertiary care hospital - A handshake approach

Studies on the appropriateness of antibiotic use among surgical patients are limited in developing countries, notably in India. Therefore, we aimed to evaluate the inappropriateness of antibiotic use, demonstrate the impact of clinical pharmacist interventions and determine the predictors of inappropriate use of antibiotics in the surgical units of a South Indian tertiary care hospital. This was a 1-year prospective interventional study on in-patients of the surgical wards to determine the appropriateness of the prescribed antibiotics by reviewing medical records using available antimicrobial susceptibility test reports and medical evidence. When inappropriateness in antibiotic prescriptions was identified, the clinical pharmacist discussed and conveyed apt suggestions to the Surgeon. Bivariate logistic regression analysis was applied to evaluate its predictors. Among the 660 antibiotic prescriptions of 614 patients that were followed and reviewed, about 64% were inappropriate. Most inappropriate prescriptions were witnessed in the cases that involved the gastrointestinal system (28.03%). Among the inappropriate cases, 35.29% were attributed to an excessive regimen of antibiotic use which marked the highest. Based on the category of use, most of the antibiotics were used inappropriately as prophylaxis (76.7%) followed by empirical (71.31%). The increase in the percentage of the appropriate use of antibiotics resulting from pharmacist intervention was 95.06%. There was a significant link between inappropriate antibiotic use and the presence of two or three comorbid conditions, the use of two antibiotics, and length of hospital stay of 6-10 days and 16-20 days (p < 0.05). An antibiotic stewardship program in which the Clinical pharmacist is an integral part along with well-framed institutional antibiotic guidelines must be implemented to assure appropriate antibiotic use.

The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting.

Anticoagulation treatment is routinely underused in patients with atrial fibrillation (AF), particularly in settings with limited resources. The current study is aimed at evaluating the appropriateness of oral anticoagulation treatment among AF patients at the Yekatit 12 Hospital Medical College (Y12HMC), Addis Ababa, Ethiopia. Institutional-based retrospective cross-sectional study conducted in Y12HMC from November 2019 to March 2020. During the study period, 256 patients' medical records were found; 231 of them met the eligibility criteria and were included in the study. The data were analyzed using SPSS version 25, descriptive statistics were used to summarize the data, and binary logistic regression was performed to identify predictors of inappropriate anticoagulation management. The majority of study participants were males (55.8%), and over half of them (57.6%) had a nonvalvular type of AF. The majority of patients (61.9%) were receiving anticoagulant treatment, and of them, warfarin was prescribed to most of the study subjects (71.3%). Nearly half (47.6%) of the study participants had inappropriate anticoagulation treatment; among these, the majority of them (69.1%) were from a valvular type of AF. Patients with a valvular type of AF and having the diagnosis of congestive heart disease as comorbidity showed a statistically significant association towards inappropriate anticoagulation management. According to the study, a significant portion of AF patients received inappropriate anticoagulant treatment, which may play a significant role for the increased risk of stroke in these groups of patients. All of the inappropriate cases were due to failure to start anticoagulant treatment.

False negative bronchial artery caliber on multi-detector computed tomography in predicting outcome of bronchial artery embolization in patient with haemoptysis

Bronchial artery embolization was first performed in 1973 by Remy et al with widespread acceptance since then. Multi-detector computed tomography (MDCT) CT angiography (CTA) is currently the gold standard imaging modality used to identify the site and cause of bleeding in patient presented with haemoptysis. Bronchial artery anatomies and precise location can be obtained by scrutinizing CTA prior to interventional procedures. CTA has the advantage of not only can preclude the need of digital subtraction angiography (DSA) in inappropriate cases, but also can shorten the intervention procedure timing. We present a case of false negative bronchial artery caliber seen on MDCT which was abnormal in DSA.

S280 Appropriateness of Scheduled 5-Year Colorectal Cancer Surveillance Colonoscopies at an Academic Medical Center

Introduction: Prudent adenoma detection and family history assessment results in increased surveillance colonoscopies for colorectal cancer screening (CRC), where recommended intervals for follow-up colonoscopies are based on prior colonoscopy findings (i.e., polyp number, size, pathology) as well as family history. Previous studies based on retrospective electronic health data determined that surveillance colonoscopies are often performed earlier than recommended intervals based on guidelines. These procedures expose patients to procedural risks, inconvenience with scheduling and unnecessary preps, and add to healthcare costs, as well as increase caseload for endoscopy centers that often have limited capacity. In the context of updated surveillance guidelines that lengthen follow-up intervals for some adenomas, we sought to assess the proportion of 5-year surveillance colonoscopies scheduled without appropriate indication. Methods: We conducted a retrospective cohort study of all outpatient endoscopic procedures scheduled in a tertiary, academic medical center over a 4-week period (4/25/22-5/20/22). We screened for cases that had an active Electronic Health Record (EHR) flag for 5-year screening colonoscopy and were classified by the ordering provider as having a screening, non-diagnostic indication, and then confirmed the EHR flag and indication with chart review. Two physicians conducted chart review of last colonoscopy and ordering provider documentation to evaluate indication and appropriateness for 5-year screening based on US Multi-Society Task Force February 2020 guidelines. Results: The 4-week period included 2,222 total procedures scheduled, of which 149 were colonoscopies scheduled for 5-year surveillance. Of these, 57% (85/149) were inappropriate based on current guidelines, which accounts for 4% (85/2,222) of total cases. 74% (63/85) of inappropriate cases were due to not meeting polyp-based guidelines, where 65% (55/85) was due to the 2020 change in guidelines. 24% (20/85) were based on inappropriately applied family history. (Figure) Conclusion: A majority of cases scheduled for 5-year surveillance were not indicated, where most were inappropriate based on updated polyp-based guidelines. Interventions targeting these cases and assessing overall appropriateness of cases may reduce patient harm and increase the capacity for necessary procedures.Figure 1.: (a) Appropriateness of Scheduled 5-Year Surveillance Colonoscopies (b) Reasons for Inappropriate Colonoscopy Scheduling

Evaluating the Impact of COVID-19 on a Regional Primary Percutaneous Coronary Intervention Service During the First Wave of COVID-19.

Background: Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy in ST-segment elevation MI (STEMI). This study evaluates the impact of COVID-19 on the authors' pPCI service. Methods: A retrospective study of referrals to the Belfast pPCI service between 23 March and 9 June 2020 – the period of the first full lockdown in the UK – was performed. All ECGs were reviewed alongside patient history. A pPCI turndown was deemed inappropriate if the review demonstrated that the criteria to qualify for pPCI had been met. The number of pPCIs was compared with 2019. Results: The unit had 388 referrals in 78 days, from which 134 patients were accepted for pPCI and 235 referrals were turned down. Of these, nine (4%) were deemed inappropriate. No referrals were turned down because of COVID-19. Of the nine inappropriate cases, six had pPCI following re-referral, two had routine PCI and one had takotsubo syndrome. From the accepted cohort, 85% had pPCI. In the appropriate turndown cohort, there was a final cardiovascular diagnosis in 53% (n=127) of patients, 1-year mortality was 16% (n=38), 55% (n=21) of which were due to a cardiovascular death. There was a 29% reduction in the number of pPCIs performed compared with 2019. Conclusion: During the first wave of COVID-19 there was a significant reduction in the number of pPCIs performed at the Department of Cardiology at Royal Victoria Hospital in Belfast. This was not due to an increase in referrals being inappropriately turned down. The majority of the cohort who had their referral turned down had a final cardiovascular diagnosis unrelated to STEMI; 1-year mortality in this group was significant.

ロングパイル人工芝における水平方向衝撃力の検討

The purpose of this study is to consider the two-dimensional impact force applied to the artificial turf with spike studs, especially focused on the horizontal impact force. The shock attenuation properties of sports surfaces are usually evaluated by reduction of maximum input force, for example, WA (World Athletics) adopted the EN14808 as the vertical force attenuation test. Otherwise, the horizontal impact attenuation has not been treated as the regulation of impact, although the most of impact in sports activities performed with diagonal impact force, including horizontal impact forces. In previous studies, we developed the two-dimensional impact test device with parallelogram structure which divide the vertical impact force to two-dimensional impact forces simultaneously. The impact test device can be set the various impact weights to generate the impact forces resembled to the ground reaction force in human running. And proposed the method for two-dimensional impact attenuation, named DFR (dynamic force reduction) because the horizontal impact forces were very dependent to the initial impact angle. Although the proposed method could evaluate the attenuation of various impact forces, there are some inappropriate cases especially in horizontal impact force attenuation. As the results, the horizontal impact force is very dependent to the impact angle and is independent to the vertical impact attenuation properties. Additionally, rubber chip as an infill material may cause increasing of horizontal impact force because it makes larger horizontal displacement in diagonal impact.

DEMESTIFYING THE EFFECTS OF SEXUAL ABUSE ON EMPLOYEE PRODUCTIVITY WORKING IN THE HOSPITALITY INDUSTRY: A SURVEY OF SELECTED HOTELS IN ELDORET KENYA

Inappropriate sexual advances has been documented as a widespread and damaging phenomenon yet the specific patterns of behaviour reported in alleged inappropriate sexual advances cases and the factors influencing the lodging of formal, legal complaints have received little attention. The extent of inappropriate sexual advances in the hospitality industry has become a serious problem nationwide. As one of the nation's largest employment sector, the hospitality industry is particularly susceptible to this problem this is based on the long hours often at night, the pressure and intimacy of hospitality service that makes inappropriate sexual advances is a problem with the industry. The purpose of this research paper was to assess hospitality workers (both male and female) perception and attitudes on inappropriate sexual advances and the influence that inappropriate sexual advances has on their work. By analyzing the responses of the employees and employers, a better understanding of the issues brought about by inappropriate sexual advances was obtained. This research paper provides some useful information when it comes to inappropriate sexual advances in the hospitality industry and what policies should be implemented. The target population was 55 individuals aged 18years and above both male and female. A sample size of 48 respondents was selected, 20, 13, 15 from the three hotels picked through simple random sampling. Data analysis involved descriptive statistics. From the findings 75% of the respondents claimed to be aware of inappropriate sexual advances existing and that it affected their productivity in general. This paper will go way in assisting hoteliers to handle this grave issue and therefore establish a conducive working environment where employees will be more productive, the government will also benefit in coming up with laws that will protect their key clients.

Evaluation of Appropriateness of the Reimbursement Criteria of Korean Health Insurance Review and Assessment Service for Total Knee Arthroplasty.

We evaluated and compared South Korea's total knee arthroplasty (TKA) reimbursement criteria set by Health Insurance Review and Assessment Service (HIRA) with other TKA appropriateness criteria to find additional criterion to improve its appropriateness by reviewing TKA inappropriate cases. Two TKA appropriateness criteria and HIRA's reimbursement criteria for TKA were adapted for use on patients undergoing TKA in one institute from December 2017 to April 2020. Preoperative data including 9 validated questionnaires on knee joint-specific parameters, age, and radiography were used. We categorized cases into appropriate, inconclusive, inappropriate groups and analyzed each group. Data on 448 cases that underwent TKA were examined. According to the HIRA's reimbursement criteria, 434 cases (96.9%) were appropriate and 14 cases (3.1%) were inappropriate; superior to other TKA appropriateness criteria. The inappropriate group had Knee Injury and Osteoarthritis Outcome score (KOOS) pain, KOOS symptoms, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, and Korean Knee score total score with worse symptoms compared to the appropriate group classified by HIRA's reimbursement criteria. In terms of insurance coverage, HIRA's reimbursement criteria was more effective in providing healthcare access to patients who had the most pressing need for TKA compared to other TKA appropriateness criteria. However, we found the lower age limit and patient-reported outcome measures of other criteria as useful tools in improving appropriateness of the current reimbursement criteria.

104. Improving Efficiency of Antimicrobial Stewardship Reviews Using Artificial Intelligence Modelling

BackgroundAntimicrobial stewardship programs (ASP) in hospitals improve antibiotic prescribing, slow antimicrobial resistance, reduce hospitalisation duration, mortality and readmission rates, and save costs. However, the strategy of prospective audit and feedback is laborious. In Singapore General Hospital (SGH), 10 reviews are required to identify 2 inappropriate cases. Limited manpower constraints ASP audits to only about 30% of antibiotics prescribed. This proof-of-concept study explored the feasibility of developing a predictive model to prioritise inappropriate antibiotic prescriptions for ASP review. MethodsASP-audited adult pneumonia patients from January 2016 to December 2018 in SGH were included. Patient data e.g., demographics, allergies, past medical history, and relevant laboratory investigations at each antibiotic use episode were extracted from electronic medical records and re-assembled through linking for analysis. Ground truth for model training was based on ASP-defined appropriateness for each encounter. The dataset was split into 80% and 20% for training and testing respectively. Three modelling techniques, XGBoost, decision tree and logistic regression, were assessed for their relative performance in terms of precision, sensitivity and specificity. ResultsThere were 12471 unique patient encounters. Training was done on 10459 encounters and 39 data elements were included. When tested on 2012 encounters, the logistic regression model performed the best (86.7% sensitivity, 71.4% specificity). The model correctly classified 1377 out of 1388 (99.2%) encounters as “appropriate” (do not require ASP intervention). 624 antibiotic use encounters were classified as “inappropriate”, of which only 72 were truly inappropriate (positive predictive value for ASP intervention, PPV 11.5%). The low PPV was likely due to inadequate representation of “inappropriate” cases in the training dataset (4.1%). Applying this model would prioritise the number of immediate ASP reviews needed to identify cases for intervention by two-thirds, from 2012 to 624 (Figure 1). Figure 1. Illustration of AI benefits in ASP ConclusionASPs can leverage on machine learning capabilities to improve audit efficiency. This can increase ASP’s productivity and staff’s job satisfaction as they are freed up to perform other work. Disclosures All Authors: No reported disclosures

Will blue hydrogen lock us into fossil fuels forever?

Will blue hydrogen lock us into fossil fuels forever?

Efilter: An effective fault localization based on information entropy with unlabelled test cases

Automatic fault localization is essential to intelligent software system. Most fault localization techniques assume the test oracle is perfect before debugging, which is hard to exist in practice. In fact, the test suite would contain a number of unlabelled test cases which have been proved to be useful in fault localization. However, due to the execution diversity, not all unlabelled test cases are suitable for fault localization. Selecting inappropriate unlabelled test cases can even weaken the fault localization efficiency.

Antibiotic Resistance, Still a Global Challenge.

The use of antibiotics represents a major health problem worldwide because they are often administered without medical prescription. This has led to different situations starting from a large use in inappropriate cases without medical recommendation, to a major issue that represents antimicrobial resistance. Our aim was to identify the opinion of healthcare workers (physicians and pharmacists) about the most effective solution at reducing antimicrobial resistance, helping the policy makers to take a decision. The present study was conducted from March 15th, 2021 to April 15th, 2021, using a virtual questionnaire. A total of 397 respondents provided a complete response to our questionnaire: 313 physicians and 84 pharmacists. Our results provided valuable insights that can be used to inform the development of a national health policy, resulting in population health gains. Our work provided an indication of physicians’ preferences toward solutions as “A tax on antibiotic consumption, which could be used to fund innovation strategies.” (41.53%) and “An educational program for patients that highlights the causes and effects of antimicrobial resistance.” (42.49%). The pharmacists preferred the solutions as “An educational program for patients that highlights the causes and effects of antimicrobial resistance.” (52.38%) and “Elimination of antibiotics from the list of the emergency pharmaceutical services.” (42.86%). A small number of physicians (2.24%) and pharmacists (3.57%) recommended as the most effective solution at reducing antimicrobial resistance “Restrain antibiotic use in the food industry.”

Indefensión y sobrecarga procesal en la Nueva Ley Procesal del Trabajo

El presente trabajo pretende hacer un análisis respecto a la problemática detectada en la aplicación de la Nueva Ley Procesal del Trabajo, así como aportar propuestas para contribuir con la eficiencia en el sistema, uno de los objetivos del proceso de reforma procesal laboral. El hechode aceptar que solo excepcionalmente se pueden efectuar precisiones o aclaraciones respecto de una pretensión, en tanto no la altere sustancialmente, ha instaurado una mala práctica, porque, bajo este argumento, los litigantes siguen modificando su pretensión en materia laboral; luego, algunos juzgados la rechazan, en casos evidentemente improcedentes, mientras que otros juzgados la amparan. Ahora, si bienes cierto que existen aún abogados que no cumplen adecuadamente con una práctica responsable y diligente al momento de plantear la demanda, esto se puede solucionar con criterios uniformes en cada distrito judicial para evitar la sobrecarga procesal y expedir resoluciones bajo el argumento de la aplicación de los principios.

3. Research Misconduct and Research Integrity: Based on Actual Inappropriate Cases

3. Research Misconduct and Research Integrity: Based on Actual Inappropriate Cases

An analysis of the descriptors of acute myocardial infarction used by South Africans when calling for an ambulance from a private emergency call centre.

IntroductionAcute myocardial infarction (AMI) is a time sensitive emergency. In resource limited settings, prompt identification and management of patients experiencing AMI in the pre-hospital setting may minimise the negative consequences associated with overburdened emergency medical and hospital services. Expedited care thus, in part, relies on the dispatch of appropriate pre-hospital medical providers by emergency medical dispatchers. Identification of these patients in call centres is challenging due to a highly diverse South African society, with multiple languages, cultures, and levels of education. The aim of this study was therefore, to describe the terms used by members of the South African public when calling for an ambulance for patients suffering an AMI.MethodsIn this qualitative study, we performed content analysis to identify keywords and phrases that callers used to describe patients who were experiencing an advanced life support (ALS) paramedic-diagnosed AMI. Using the unique case reference number of randomly selected AMI cases, original voice recordings between the caller and emergency medical dispatcher at the time of the emergency were extracted and transcribed verbatim. Descriptors of AMI were identified, coded and categorised using content analysis, and quantified.ResultsOf the 50 randomly selected calls analysed, 5 were not conducted in English. The descriptors used by callers were found to fall into three categories; Pain: Thorax, No pain: Thorax and Ill- health. The code that occurred most often was no pain, heart related (n = 16; 23.2%), followed by the code describing pain in the chest (n = 15; 21.7%).ConclusionSouth African callers use a consistent set of descriptors when requesting an ambulance for a patient experiencing an AMI. The most common of these are non-pain descriptors related to the heart. These descriptors may ultimately be used in developing validated algorithms to assist dispatch decisions. In this way, we hope to expedite the correct level of care to these time- critical patients and prevent the unnecessary dispatch of limitedly available ALS paramedics to inappropriate cases.

P0971IDENTIFICATION OF HUB GENES ASSOCIATED WITH THE DEPOSITION OF EXTRACELLULAR MATRIX AND SPECIFIC FOR DIABETIC NEPHROPATHY BY WEIGHTED GENE CO-EXPRESSION NETWORK ANALYSIS

Abstract Background and Aims Diabetic nephropathy (DN) and its most severe manifestation, end-stage renal disease (ESRD), remains one of the leading causes of reduced lifespan in people with diabetes. Identifying novel molecules that are involved in the pathogenesis of DN has both diagnostic and therapeutic implications. The gene co-expression network analysis (WGCNA) algorithm represents a novel systems biology approach that provide the approach of association between gene modules and clinical traits to find the module involvement into the certain phenotypic trait. The goal of this study was to identify hub genes and their roles in DN from the aspect of whole gene transcripts analysis. Method Various types of chronic kidney diseases (CKD), including DN, microarray-based mRNA gene expression data, listed in the Gene Expression Omnibus (GEO) database, were analyzed. Next, we constructed a weighted gene co-expression network and identified modules distinguishing DN from normal or other types of CKD by WGCNA. Functional annotations of the genes in modules specialized for DN were analyzed by Gene Ontology (GO) enrichment analysis. Through protein-protein interaction (PPI) analysis and hub gene screening, the hub genes specific for DN were obtained. Furthermore, we drew ROC curves to determine the diagnosis and differential diagnosis value to DN of hub genes. Finally, another study of microarray in the GEO database was selected to verify the expression level of hub genes and in the “Nephroseq” database, the correlation between the gene expression level and eGFR was analyzed. Results “GSE99339”, glomerular tissue microarray in 187 patients with a total of 10947 genes, was selected for analysis. After excluding the inappropriate cases, a total of 179 specimens were analyzed, including 14 cases of DN, 22 cases of focal segmental glomerulosclerosis (FSGS), 15 cases of hypertensive nephropathy (HT), 26 cases of IgA nephropathy (IgAN), 13 cases of minimal change disease (MCD), 21 cases of membranous nephropathy (MGN), 23 cases of rapidly progressive glomerulonephritis (RPGN), 30 cases of lupus nephritis (LN) and 14 cases of kidney tissue adjacent to tumor. Co-expression network analysis by WGCNA identified 23 distinct gene modules of the total 10947 genes and revealed “MEsaddlegreen” module was strongly correlated with DN (r=0,54), but not with other groups. GO functional annotation showed that these 64 genes in the “MEsaddlegreen” module mainly enriched in the deposition of extracellular matrix, which represents the specific and diagnostic pathophysiological process of DN. Further PPI and hub gene screening analysis revealed that LUM, ELN, FBLN1, MMP2, FBLN5 and FMOD can be served as hub genes, which had been proved to play an important role in the deposition of extracellular matrix. Furthermore, we found that the expression of hub genes was the highest in DN group and for the diagnosis value of DN by each gene, the area under the ROC curve is about 0.75∼0.95. The external verification of another study showed that compared with the normal control group, the expression of these hub genes was the highest in the DN group, and their expression level was negatively correlated with eGFR. Conclusion Using WGCNA and further bioinformatics approach, we identified six hub genes that appear to be identical to DN development. As such, they may represent potential diagnostic biomarkers as well as therapeutic targets with clinical utility.

How Does Antimicrobial Stewardship Affect Inappropriate Antibiotic Therapy in Urological Patients?

Antimicrobial stewardship teams (ASTs) have been well-accepted in recent years; however, their clinical outcomes have not been fully investigated in urological patients. The purpose of this study was to evaluate the outcomes of intervention via a retrospective review of urological patients, as discussed in the AST meetings, who were treated with broad-spectrum antibiotics between 2014 and 2018 at the Department of Urology, Kobe University Hospital in Japan. Interventions were discussed in AST meetings for patients identified by pharmacists as having received inappropriate antibiotic therapy. The annual changes in numbers of inappropriate medications and culture submissions over five years at the urology department were statistically analyzed. Among 1,033 patients audited by pharmacists, inappropriate antibiotic therapy was found in 118 cases (11.4%). The numbers of inappropriate antibiotic use cases and of interventions for indefinite infections had significantly decreased during the study period (p = 0.012 and p = 0.033, respectively). However, the number of blood and drainage culture submissions had significantly increased (p = 0.009 and p = 0.035, respectively). Our findings suggest that urologists have probably become more familiar with infectious disease management through AST intervention, leading to a decrease in inappropriate antibiotic use and an increase in culture submissions.