Inappropriate Initiation Research Articles

Brain abscess caused by Nocardia farcinica in a person living with HIV

Nocardia farcinica is the most pathogenic Nocardia, which is easy to disseminate. It can be caused by trauma, and even lead to severe lung or central nervous system infection. This report covers a case of Nocardia brain abscess in an HIV patient, who underwent resection of the brain abscess, followed by anti-infective therapy with sulfamethoxazole and meropenem, and eventually made a good recovery. The mortality rate of Nocardia farcinica brain abscess has been attributed to the severity of the underlying disease, the difficulty in identifying the pathogen, and its inherent resistance to antibiotics, leading to inappropriate or late initiation of treatment. Medication should follow the principle of sufficient dosage and sufficient course of treatment.

Wilder rangelands as a natural climate opportunity: Linking climate action to biodiversity conservation and social transformation

Rangelands face threats from climate and land-use change, including inappropriate climate change mitigation initiatives such as tree planting in grassy ecosystems. The marginalization and impoverishment of rangeland communities and their indigenous knowledge systems, and the loss of biodiversity and ecosystem services, are additional major challenges. To address these issues, we propose the wilder rangelands integrated framework, co-developed by South African and European scientists from diverse disciplines, as an opportunity to address the climate, livelihood, and biodiversity challenges in the world’s rangelands. More specifically, we present a Theory of Change to guide the design, monitoring, and evaluation of wilder rangelands. Through this, we aim to promote rangeland restoration, where local communities collaborate with regional and international actors to co-create new rangeland use models that simultaneously mitigate the impacts of climate change, restore biodiversity, and improve both ecosystem functioning and livelihoods.

Inappropriate antibiotic initiation for suspected urinary tract infection: a multicenter study comparing psychiatric vs. nonpsychiatric hospital admissions

Differentiating between urinary tract infection (UTI) and asymptomatic bacteriuria is challenging in patients with altered mental status (AMS) and/or decompensated psychiatric illness. The purpose of this multicenter, retrospective cohort study was to identify the extent, patterns, and predictors of inappropriate antibiotic initiation for UTI (IAI-U) within an 18-hospital health system comprising of behavioral health units. Patient-specific factors were evaluated as predictors for IAI-U using descriptive, bivariate and multivariate regression with two-tailed alpha= 0.05. A total of 150 patients were included for data analysis, half of which were admitted for psychiatric evaluation. Almost half of patients (42.7%) had IAI-U, with a nearly even split between IAI-U occurring in the emergency department vs. following hospital admission. There was no statistical difference in IAI-U between patients admitted primarily for a psychiatric diagnosis compared to those with a non-psychiatric diagnosis (46.7% vs. 38.7% respectively, p = 0.32). Factors associated with IAI-U were female sex (OR 5.83, 95% CI: 1.73–19.71; p = 0.005) and being discharged to skilled nursing facilities (OR 11.77, 95%: CI 2.11–65.48; p = 0.005). This exploratory analysis suggests IAI-U occurs frequently in the various subgroups evaluated, even those where no association was found. These findings demonstrate an ongoing urgent need for interventions to reduce IAI-U across all sectors of inpatient health systems. Future large-scale studies are needed to fully evaluate these findings across health care systems and specialty acute care settings.

Positive thinking about negative studies.

The non-reporting of negative studies results in a scientific record that is incomplete, one-sided and misleading. The consequences of this range from inappropriate initiation of further studies that might put participants at unnecessary risk to treatment guidelines that may be in error, thus compromising day-to-day clinical practice.

Development of explicit definitions of potentially inappropriate prescriptions for antidiabetic drugs in patients with type 2 diabetes: A multidisciplinary qualitative study.

The management of type 2 diabetes mellitus patients has changed over the past decade, and a large number of antidiabetic drug treatment options are now available. This complexity poses challenges for healthcare professionals and may result in potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus which can be limited using screening tools. The effectiveness of explicit tools such as lists of potentially inappropriate prescriptions has been widely demonstrated. The aim was to set up nominal groups of healthcare professionals from several disciplines and develop a list of explicit definition of potentially inappropriate prescriptions of antidiabetic drugs. In a qualitative, nominal-groups approach, 30 diabetologists, general practitioners, and pharmacists in France developed explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus. A nominal group technique is a structured method that encourages all the participants to contribute and makes it easier to reach an agreement quickly. Each meeting lasted for two hours. The three nominal groups comprised 14 pharmacists, 10 diabetologists, and 6 general practitioners and generated 89 explicit definitions. These definitions were subsequently merged and validated by the steering committee and nominal group participants, resulting in 38 validated explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs. The definitions encompassed four contexts: (i) the temporary discontinuation of a medication during acute illness (n = 9; 24%), (ii) dose level adjustments (n = 23; 60%), (iii) inappropriate treatment initiation (n = 3; 8%), and (iv) the need for further monitoring in the management of type 2 diabetes mellitus (n = 3; 8%). The results of our qualitative study show that it is possible to develop a specific list of explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus by gathering the opinions of healthcare professionals caring for these patients. This list of 38 explicit definitions necessitates additional confirmation by expert consensus before use in clinical practice.

Comparison of Children’s Communication Checklist Between Deaf and Hard of Hearing, and Hearing Adolescents

Background and Objectives: The present research compared pragmatic abilities between deaf and hard-of-hearing (DHH), and hearing adolescents using the children’s communication checklist (CCC). Methods: In this study, 16 hearing adolescents aged 11–16 and 16 deaf and DHH adolescents with similar chronological ages participated. The CCC was completed with parents of DHH and hearing adolescents. Results: The study’s results revealed that DHH and hearing adolescents had a significant difference in pragmatic composite scores (PCS) and the score of all CCC subscales. The results showed that in all subscales of the CCC, DHH adolescents received lower scores from their parents than hearing adolescents. The inappropriate initiation and stereotyped language subscales of the CCC had the highest correlation rates. Also, the pragmatic composite score showed the highest correlation with the stereotyped language subscale. Conclusion: DHH adolescents showed weaker performance in pragmatic skills than hearing adolescents.

Impaired communication ability in SOX11 syndrome.

Speech and language skills are important for social interaction and learning. This study characterised the communication abilities of verbal individuals with SOX11 syndrome using a standardised parent/carer questionnaire, the Children's Communication Checklist (CCC-2). Thirteen parent/carers of verbal individuals (aged 5-19years) diagnosed with SOX11 syndrome completed the CCC-2. In order to contextualise findings, responses were compared to norms and to data from Noonan syndrome, a relatively well-known genetic diagnosis associated with communication impairment. For all individuals, the CCC-2 composite score indicated significant communication difficulties. Language structure (speech, syntax, semantics and coherence), pragmatic language (inappropriate initiation, stereotyped language use of context and non-verbal communication) and autistic features (social relations and interests) scores were lower than typically developing norms. Subscale comparisons revealed relative difference in use of context compared to other pragmatic domains (stereotyped language and inappropriate initiation). Individual scores showed substantial variation, particularly in regard to language structure profile. Differences were more pronounced than for Noonan syndrome, specifically in domains of speech, syntax, non-verbal communication and social relations. SOX11 syndrome is associated with communication impairment. It is important to assess communication abilities as part of the management of individuals with SOX11 syndrome and understand individual strengths and difficulties in order to provide targeted support.

Reducing inappropriate oxygen use in hospitalized medicine patients

ABSTRACT Introduction Evidence suggests inappropriate oxygenation may be harmful to patients. To improve oxygen use in our hospital, we initiated a quality improvement project with a goal to reduce the percentage of inappropriate utilization of oxygen by 50% within a year. Methods Nasal cannula (NC) oxygen use data for medicine inpatients was abstracted weekly for chart review. A multidisciplinary team developed a guideline for use. Initiation of NC O2 with a baseline SPO2 > 92% was deemed inappropriate and 3+ consecutive SPO2 > 96% was defined as over-supplementation. Formal interventions included an oxygen use guideline, updated EMR order, unit-specific feedback, and magnetic placards. Progress was tracked by control charts. Results Baseline data revealed 40% of patients were inappropriately placed on oxygen and 55% of patients had one instance of excessive supplementation. Only half of all improper uses of oxygen had charted medical reasoning, and 30% had a corresponding order. Instances of proper oxygen use had orders 48% of the time. Run charts revealed inappropriate initiation was significantly reduced to 27.1% (p < 0.0001) and excessive oxygenation decreased significantly to 34.4% (p < 0.0001) following interventions with no effect on other variables. Conclusions Our interventions significantly decreased improper oxygen initiation and excessive supplementation.

PO-04-057 ATRIAL FIBRILLATION CURED BY PACEMAKER REPROGRAMMING

Atrial fibrillation (AF) is commonly detected by remote monitoring of implanted devices. A common question is whether to start anticoagulation in patients with detected AF at risk of stroke. However, the cause of AF is rarely able to be diagnosed or corrected. Repetitive non-reentrant ventriculoatrial synchrony (RNRVAS) is a pacemaker mediated arrhythmia that can occur in patients with intact ventriculoatrial (VA) conduction. Ventricular pacing with retrograde atrial activation that falls within the PVARP is followed by atrial pacing, often delivered while the atrium is refractory. Retrograde atrial activation from the next ventricular paced beat facilitates a repetitive (but non-reentrant) process. Atrial arrhythmias may occasionally result. To highlight the importance of recognizing and correcting RNRVAS as a cause of device-mediated arrhythmia. NA A 68-year-old man with hypertension and sinus node dysfunction underwent dual chamber pacemaker implant (Abbott Assurity). Device interrogation 5-years later showed repetitive episodes of AF that might warrant anticoagulation. Device tracings revealed RNRVAS: retrograde atrial activation falling in PVARP, followed by competitive sensor driven atrial pacing with non-capture, until a captured atrial event initiated AF (Figure, red arrow). Anticoagulation was deferred in favor of device reprogramming, including: 1) reduction in the lower rate; 2) reduction in paced AV delay; and 3) disabling of rate-response. The patient had no further AF episodes. RNRVAS is largely benign but may facilitate initiation of AF or other supraventricular arrhythmias that lead to symptoms or inappropriate therapy. Both RNRVAS and device-triggered AF may be underrecognized. Current devices do not have automatic diagnostic or treatment algorithms. Therefore, it is important to be aware of RNRVAS triggered AF in patients with a dual-chamber device and newly diagnosed AF. RNRVAS tends to occur with a long programmed AV delay (such as is often used to avoid ventricular pacing) and a relatively fast lower rate. Reprogramming to shorten the AV delay, decrease the lower rate or decrease the PVARP are the primary methods of correction. Awareness of pacemaker triggered AF may help avoid inappropriate initiation of anticoagulation or other therapies.

Effect of a pharmacist-based toxicology consult service on appropriate use of intravenous N-acetylcysteine for acetaminophen toxicity: A retrospective cohort study.

Incorporating clinical pharmacists on the medical team has been associated with fewer medication errors and increased error interception. Due to the logistical complexities of the intravenous (IV) N-acetylcysteine (NAC) regimen for acetaminophen toxicity, many opportunities for medication errors exist. A pharmacist-based toxicology consultation service was implemented at our institution, allowing pharmacists to formally aid in the management of toxicology patients throughout their hospital admission, including those with acetaminophen toxicity. The purpose of this study was to evaluate the effect of a house-wide pharmacist-based toxicology consult service on errors associated with IV NAC treatment for patients admitted with acetaminophen toxicity. A retrospective, pre-post cohort study was conducted on patients who received IV NAC for acetaminophen toxicity. The intervention evaluated was the implementation of a pharmacist-based toxicology consult service, known as the pharmacy toxicology team. The primary end point was the incidence of an error associated with IV NAC. An error was defined as the composite of inappropriate dose, administration rate, initiation, continuation, or discontinuation. Eighty-four patients were included; 30 patients in the pregroup, and 54 patients in the postgroup. Fewer patients experienced an error in the postgroup compared to the pregroup (30% vs 63%, P = 0.003). The implementation of this unique pharmacist-based toxicology consult service was associated with fewer patients experiencing an error related to IV NAC therapy for acetaminophen toxicity. Application of this data may aid in the justification for development of clinical pharmacist-based toxicology consult services at other institutions.

Artificial Intelligence in Continuous Kidney Replacement Therapy.

Artificial Intelligence in Continuous Kidney Replacement Therapy.

Technology Matters: Digital micro interventions to support parenting: Evaluating time out apps.

Digital interventions to support parenting skills are popular but engagement can be low. Digital micro interventions such as apps targeting specific aspects of parenting are a novel development with the potential to overcome this challenge. Time out is an evidence-based component of many parenting skills training programmes and is an appropriate target for digital micro intervention. We describe the eight requirements of high-quality time out according to the literature and how these can be supported by an app. Searches of the App Store, Google Play, and Alexa Skills in the UK identified six apps designed to support time out. Current time out apps all promoted consistency, but they all risked low-quality time out through inappropriate initiation, duration, and termination. Professionals in child and adolescent mental health should explore the details of any digital micro interventions being used by parents for time out and provide appropriate counselling. We recommend that all future digital micro interventions in this area should incorporate evidence-based guidance.

An Endorsement of the Removal of Race From GFR Estimation Equations: A Position Statement From the National Kidney Foundation Kidney Disease Outcomes Quality Initiative

An Endorsement of the Removal of Race From GFR Estimation Equations: A Position Statement From the National Kidney Foundation Kidney Disease Outcomes Quality Initiative

Communication abilities in children with hearing loss – views of parents and daycare professionals

IntroductionToday, children with hearing loss (HL) are diagnosed and fitted with hearing devices at an early age. However, HL may still influence their communicative development. Thus, we need up-to-date research on how children perform in their everyday environments, such as at home or daycare. This study provides an overview of the communication abilities of early-diagnosed children with HL reported by parents and daycare professionals. The first aim of the study is to compare the results of children with bilateral hearing aids (BiHAs) or bilateral cochlear implants (BiCIs) with those of children with normal hearing (NH) and with each other. The second aim of the study is to compare the views of the two respondents, parents and the daycare professionals. In addition, the effects of gender and nonverbal intelligence quotient (IQ) on the responses are explored. MethodsThe participants, aged 4;0–6;9, were 25 children with BiHAs, 29 children with BiCIs, and 64 children with NH. The Finnish version of the Children's Communication Checklist-2 (CCC-2) was used to assess the communication skills of the participants. ResultsGroup and nonverbal IQ had a significant effect on the General Communication Composite (GCC) score. Both groups of children with HL had poorer GCC scores than the children with NH, apart from the respondent. The BiHA-group had significantly lower scores than the NH-group on Speech, Syntax, Semantics, and Coherence subscales. The BiCI-group had significantly lower scores than the NH-group across all subscales of the CCC-2. The parents rated the participants significantly higher than the daycare professionals in Speech and Social Relations. In contrast, the daycare professionals rated the participants higher than the parents in Coherence, Inappropriate Initiation, Stereotyped Language, and Use of Context. Furthermore, gender influenced Coherence, Nonverbal Communication, Social Relations, and Interests, for which the girls performed better than the boys. The nonverbal IQ had an effect on Syntax, Semantics, and Use of Context, for which higher nonverbal IQ was associated with better performance. ConclusionsOn average the children with HL had poorer communication skills than the children with NH. Pragmatic difficulties were more common in the BiCI-group than in the BiHA-group. The respondents were not completely unanimous, which may be because of the different demands of different environments.

Pulmonary Tuberculosis and Lung Cancer: A Case Report

Lung cancer and pulmonary tuberculosis (TB) are two major public health problems associated with similar clinical and radiological presentations thus leading to misdiagnosis and inappropriate initiation of treatment. We investigated the case of a patient presenting symptoms for Tuberculosis and who was finally diagnosed as having probable lung cancer. Lung cancer may be the cause of some of the symptoms in TB suspected patients and this calls for vigilance on clinicians to know what appropriate tests are needed for patients presenting symptoms suspicious of TB in order to differentially diagnose TB and /or lung cancer.

Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners.

To examine relationships between changing general practitioner after entering residential aged care and overall medicines prescribing (including polypharmacy) and that of psychotropic medicines in particular. Retrospective data linkage study. 45 and Up Study participants in New South Wales with dementia who were PBS concession card holders and entered permanent residential aged care during January 2010 - June 2014 and were alive six months after entry. Inverse probability of treatment-weighted numbers of medicines dispensed to residents and proportions of residents dispensed antipsychotics, benzodiazepines, and antidepressants in the six months after residential care entry, by most frequent residential care GP category: usual (same as during two years preceding entry), known (another GP, but known to the resident), or new GP. Of 2250 new residents with dementia (mean age, 84.1 years; SD, 7.0 years; 1236 women [55%]), 625 most frequently saw their usual GPs (28%), 645 saw known GPs (29%), and 980 saw new GPs (44%). The increase in mean number of dispensed medicines after residential care entry was larger for residents with new GPs (+1.6 medicines; 95% CI, 1.4-1.9 medicines) than for those attended by their usual GPs (+0.7 medicines; 95% CI, 0.4-1.1 medicines; adjusted rate ratio, 2.42; 95% CI, 1.59-3.70). The odds of being dispensed antipsychotics (adjusted odds ratio [aOR], 1.59; 95% CI, 1.18-2.12) or benzodiazepines (aOR, 1.69; 95% CI, 1.25-2.30), but not antidepressants (aOR, 1.32; 95% CI, 0.98-1.77), were also higher for the new GP group. Differences between the known and usual GP groups were not statistically significant. Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. Facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.

Preliminary psychometric properties of the Autism Classification System of Functioning: Social Communication (ACSF: SC) in Farsi speaking children

Background Autism Classification System of Functioning: Social Communication (ACSF: SC) assesses typical performance and capacity of communication. Farsi version of ACSF: SC was developed and its psychometric properties investigated. Material and methods The English version of ACSF: SC was translated into Farsi and cultural adaptation was completed. The content validity of the adapted version was evaluated by experts and parents. The back-translated version was approved by www.canchild.ca. Therapists and parents assessed face validity. Correlation between ACSF: SC and the Children’s Communication Checklist (CCC) was analyzed to determine concurrent validity. For inter-rater reliability, 5 speech and language pathologists, 5 occupational therapists, and 35 parents participated to assess the communication level of 35 autistic children aged 3–6. The test–retest reliability was performed at the interval of 14 days. Result The results of analyses for typical performance and capacity showed the communication levels of children in ACSF: CS were directly related to subscales of CCC including inappropriate initiation (r ≥ 0.46) and stereotypical conversation (r ≥ 0.45). The weighted kappa inter-rater reliability ranged from good (0.54) to excellent (0.77); and the test–retest reliability varied from good (0.63) to excellent (0.85). Conclusion Adapted version of ACSF: CS is able to estimate the communication function of Farsi- speaking autism spectrum disorder children.

Individualized prescribing portraits to reduce inappropriate initiation of opioid analgesics to opioid naïve patients in primary care: Protocol for a randomized controlled trial

BackgroundOpioid analgesics are frequently initiated for chronic and acute pain despite weak evidence of benefit, although prescribing rates of some analgesics decreased in the context of the epidemic. In some populations, up to a quarter of opioid naïve persons prescribed opioids for non-cancer pain develop prescription opioid use disorder (OUD). Audit and feedback interventions rely on constructive use of routinely collected data to align professional behaviours and clinical practice with best evidence. These interventions have been shown to help reduce inappropriate initiation. However, effectiveness and acceptability of individualized “portraits” of physicians' prescribing patterns, to reduce inappropriate initiation of opioid analgesics to opioid naïve persons, have not been evaluated.MethodsREDONNA is a mixed-methods randomized study testing the effectiveness of individualized prescribing Portraits to reduce inappropriate initiation of opioid analgesics. This intervention to improve safety of opioid prescribing in primary care in British Columbia (BC), Canada involves mailing individual prescribing portraits to an ‘early group’ of 2604 family physicians, followed in 6 months by a mailing to 2553 family physicians in the ‘delayed group’. Primary outcome is number of new opioid prescriptions initiated in opioid naïve people, measured using administrative data from a centralized medication monitoring database covering all prescription opioids dispensed from BC community pharmacies. Secondary endpoints will compare prescribing impact between the two groups. A qualitative sub-study will examine feasibility among a purposive sample of physicians and patients.DiscussionThis trial provides important evidence on the intervention's potential to steer policy and practice on inappropriate opioid analgesics initiation.Trial registration: The study was registered prospectively on 30 March 2020 at the ISRCTN Register (https://www.isrctn.com/ISRCTN34246811).

The profile of pragmatic language impairments in children with ADHD: A systematic review.

This systematic review synthesizes the empirical literature examining pragmatic language in children diagnosed with attention-deficit/hyperactivity disorder (ADHD). Using a taxonomy of pragmatic language, we compared the pragmatic language profiles of children with ADHD to those of typically developing (TD) children and children with autism. Three databases were searched up to October 2019: PsychInfo; PubMed; and CSA Linguistics and Language Behavior Abstracts. We included 34 studies reporting on 2,845 children (ADHD = 1,407; TD = 1,058; autism = 380). Quality and risk of bias assessments included sample size and representativeness; measure reliability and validity; and missing data management. Children with ADHD were found to have higher rates of pragmatic difficulties than their TD peers. Specific difficulties were identified with inappropriate initiation, presupposition, social discourse, and narrative coherence. Children with ADHD appear to differ from those with autism in the degree of their pragmatic language impairments. General language skills contribute to, but do not explain, pragmatic difficulties in samples of children with ADHD. Though the extant evidence is limited, a preliminary profile of the pragmatic language impairments in children with ADHD is indicated. This supports a call for evidence-based interventions that include pragmatic language skills training.

Immune Regulation in Time and Space: The Role of Local- and Long-Range Genomic Interactions in Regulating Immune Responses.

Mammals face and overcome an onslaught of endogenous and exogenous challenges in order to survive. Typical immune cells and barrier cells, such as epithelia, must respond rapidly and effectively to encountered pathogens and aberrant cells to prevent invasion and eliminate pathogenic species before they become overgrown and cause harm. On the other hand, inappropriate initiation and failed termination of immune cell effector function in the absence of pathogens or aberrant tissue gives rise to a number of chronic, auto-immune, and neoplastic diseases. Therefore, the fine control of immune effector functions to provide for a rapid, robust response to challenge is essential. Importantly, immune cells are heterogeneous due to various factors relating to cytokine exposure and cell-cell interaction. For instance, tissue-resident macrophages and T cells are phenotypically, transcriptionally, and functionally distinct from their circulating counterparts. Indeed, even the same cell types in the same environment show distinct transcription patterns at the single cell level due to cellular noise, despite being robust in concert. Additionally, immune cells must remain quiescent in a naive state to avoid autoimmunity or chronic inflammatory states but must respond robustly upon activation regardless of their microenvironment or cellular noise. In recent years, accruing evidence from next-generation sequencing, chromatin capture techniques, and high-resolution imaging has shown that local- and long-range genome architecture plays an important role in coordinating rapid and robust transcriptional responses. Here, we discuss the local- and long-range genome architecture of immune cells and the resultant changes upon pathogen or antigen exposure. Furthermore, we argue that genome structures contribute functionally to rapid and robust responses under noisy and distinct cellular environments and propose a model to explain this phenomenon.