Pre Protocol Research Articles

Implementation and Interim Analysis of a Standardized Renal Trauma Imaging and Urinary Extravasation Management Protocol.

The AUA recommends delayed-phase imaging (DPI) in renal injuries to evaluate the collecting system. A renal trauma imaging protocol for early conservative management of urinary extravasation (UE) was implemented to improve guideline adherence. We aimed to determine if increased adherence led to changes in outcomes. Patients with American Association for the Surgery of Trauma III to V renal injury presenting from January 2018 to September 2022 were identified from an institutional trauma registry. Patients were included if a contrasted CT scan of the abdomen was obtained on admission. Frequency of DPI and patient outcomes were compared before and after protocol implementation. Of 223 included patients, 131 (58.7%) were pre protocol and 92 (41.3%) were post protocol. Following protocol implementation, the rate of DPI on admission nearly doubled from 32.8% to 58.7% (P < .001). The rate of follow-up cross-sectional imaging increased from 18.3% to 58.7% (P < .001). Although there were no significant differences in rates of immediate or delayed interventions following protocol implementation, the postprotocol immediate intervention rate did decrease to 0%. Readmissions due to symptomatic UE were unchanged after protocol implementation (0.0% vs 0.0%). Implementation of a multidisciplinary renal trauma early imaging and management protocol improved AUA guideline adherence. With protocol adherence, there was also an elimination of immediate interventions for UE. Despite decreases in early intervention, there was no significant increase in interval interventions or UE-related readmissions. More research is needed to determine the role for routine follow-up imaging in conservative management of high-grade renal trauma.

Outcomes of a same day discharge protocol in patients undergoing mastectomy and implant reconstruction.

Finite hospital resources has required a closer look at resource allocation. This has prompted a shift toward same day surgeries and a focus on reducing hospital readmissions. Following the institution of a same day discharge protocol for mastectomy and mastectomy with immediate reconstruction, we sought to assess differences in the length of stay and readmission rates. This retrospective review evaluates all cases of mastectomy with or without immediate reconstruction performed at a single high-volume center between June 2019 and March 2021. Average length of stay, 30-day readmission rates, Anesthesia Society Assessment class, and type of immediate reconstruction were assessed. Autologous reconstructions were excluded. A total of 413 patients underwent mastectomy with or without reconstruction (n=148 pre protocol and n=265 during protocol) between June 2019 and March 2021. Of those 413 patients, 180 underwent reconstruction (n=62 pre protocol and n=118 during protocol). The average length of stay after mastectomy following the implementation of the same day discharge protocol was decreased at 0.6days (n=265) compared to preimplementation at 1.02days (n=148), p<0.001. The 30-day readmission rate was not significant between the groups, p=0.13. A total of 180 patients underwent immediate reconstruction after mastectomy. The average length of stay after mastectomy with immediate reconstruction following implementation of the same day discharge protocol was shorter than preimplementation at 1.05days preimplementation (n=62) versus 0.58days following implementation (n=118), p<0.001; this finding was significant for both prepectoral and subpectoral implants, p<0.001. There was no significant difference in 30-day readmission rates between the groups with immediate reconstruction, p=0.34. Same day discharge for mastectomy with reconstruction is as safe as the more widely recognized same day discharge practice for patients with mastectomy alone.

Clinical utility of methicillin-resistant Staphylococcus aureus nasal PCR to streamline antimicrobial use in treatment of diabetic foot infection with or without osteomyelitis

BackgroundDiabetic Foot Infection (DFI) guidelines recommend empiric methicillin-resistant Staphylococcus aureus (MRSA)-targeted therapy in settings where there is high prevalence of MRSA infections or in cases of severe infection; however, they do not provide recommendations for de-escalation. This approach has the potential to increase unnecessary use of broad-spectrum antibiotics; therefore, additional strategies are needed to optimize appropriate antibiotic use. This study evaluates the effect of MRSA nasal PCR testing on MRSA-targeted antibiotic use and clinical outcomes in patients with DFI.MethodsThis was a retrospective quasi-experimental study of patients admitted to South Texas Veterans Health Care System for DFI, with or without osteomyelitis (OM), who had an MRSA nasal PCR and culture data. Eligible patients were identified from the Corporate Data Warehouse and reviewed via electronic health record. Patients were allocated into two groups: PRE (5/1/2019-4/30/2020) and POST (12/1/2020-11/30/2021) protocol implementation for de-escalation or avoidance of MRSA-targeted antibiotics. The primary outcome was median (interquartile range [IQR]) hours of empiric inpatient MRSA-targeted antibiotic therapy. A Wilcoxon Rank Sum test was used to assess the difference between the groups for the primary outcome. Secondary outcomes included the proportion of patients needing MRSA coverage added back for MRSA after de-escalation, hospital readmission, length of hospital stay (LOS), patient mortality, and acute kidney injury.ResultsA total of 151 patients were included (83 PRE; 68 POST). Most patients were male (98% PRE; 97% POST) with a median age of 64 (IQR, 56–72) years. Incidence of MRSA in DFI in the cohort was 14.7% overall (12% PRE and 17.6% POST). MRSA was detected via nasal PCR in 12% of patients 15.7% PRE and 7.4% POST). After protocol implementation, there was a significant decrease in empiric MRSA-targeted antibiotic therapy use, from a median of 72 (IQR, 27–120) hours in the PRE group, to 24 (IQR, 12–72) hours in the POST group (p < 0.01). No significant differences were found for other secondary outcomes.ConclusionThis study of patients presenting to a Veterans Affairs (VA) hospital with DFI identified a statistically significant decrease in median duration of MRSA-targeted antibiotic use post-protocol implementation. This suggests a favorable effect of MRSA nasal PCR for de-escalation or avoidance of MRSA-targeted antibiotics in DFI.

894. Clinical utility of methicillin resistant Staphylococcus aureus (MRSA) nasal PCR to streamline antimicrobial use in the treatment of diabetic foot infection (DFI) with or without osteomyelitis (OM)

Abstract Background DFI guidelines recommend empiric MRSA-targeted therapy in settings of high prevalence or severe infection; however, they do not provide recommendations for de-escalation. This approach has the potential to increase unnecessary use of broad-spectrum antibiotics; therefore, additional strategies are needed to optimize appropriate antibiotic use. This study evaluates the effect of MRSA nasal PCR testing on MRSA-targeted antibiotic use and clinical outcomes in patients with DFI. Methods This was a retrospective quasi-experimental study of patients &amp;gt; 18 years admitted to South Texas VA for DFI, with or without OM, who had an MRSA nasal PCR and culture data. Eligible patients were identified from the Corporate Data Warehouse and reviewed via electronic health record. Patients were allocated into two groups: PRE (5/1/2019-4/30/2020) and POST (12/1/2020-11/30/2021) protocol implementation for de-escalation or avoidance of MRSA-targeted antibiotics. The primary outcome was median (interquartile range [IQR]) days of inpatient MRSA-targeted antibiotic therapy. A Wilcoxon Rank Sum test was used to assess the difference between the groups for the primary outcome. Secondary outcomes included the proportion of patients needing MRSA coverage added back after de-escalation, hospital readmission, length of hospital stay (LOS), patient mortality, and acute kidney injury. Results A total of 151 patients were included (83 PRE; 68 POST). Most patients were male (98% PRE; 97% POST) with a median age of 64 (IQR, 56-72) years. There was a significant decrease in MRSA-targeted antibiotic therapy use, from a median of 72 (IQR, 27-120) hours in the PRE group, to 24 (IQR, 12-72) hours in the POST group (p &amp;lt; 0.01). There was also a significant decrease in hospital readmission from 17% in the PRE group to 5% in the POST group (p = 0.02). No significant differences were found for other secondary outcomes. Conclusion This study of patients presenting to a VA hospital with DFI identified a statistically significant decrease in median duration of MRSA-targeted antibiotic use post-protocol implementation. This suggests a favorable effect of MRSA nasal PCR for de-escalation or avoidance of MRSA-targeted antibiotics in DFI. Disclosures All Authors: No reported disclosures.

Efficacy of Implementing Pre and Postoperative Protocol of Nursing Care on Postthyroidectomy Patients' Clinical Outcomes

Efficacy of Implementing Pre and Postoperative Protocol of Nursing Care on Postthyroidectomy Patients' Clinical Outcomes

Evaluating the Efficacy of a Screening Protocol for Severe Acute Respiratory Syndrome Coronavirus 2 Virus in Asymptomatic Preoperative/Preprocedural Patients at a Military Hospital.

ABSTRACTIntroductionFacing the COVID-19 pandemic, many hospitals implemented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening protocols before aerosol-generating procedures (AGPs) in an effort to protect patients and health care workers. Given the limited prior evidence on the effectiveness of such protocols, we report the process improvement experience at a military treatment facility.Materials and MethodsWe evaluated the outcomes of patients undergoing AGPs from March to September 2020, divided into three cohorts: a preprotocol (PP) cohort who did not receive screening, an early testing (ET) cohort representing the early months of the screening protocol, and a late testing (LT) cohort managed under adaptive modifications to the screening protocol. We recorded identifiable post-procedure COVID-19 diagnoses. The study was approved as a process improvement protocol and was determined not to meet criteria for human subject research through an institutional approval process.ResultsAcross the three cohorts, 4520 procedures were performed: 422 PP, 1297 ET, and 2801 LT. Among 4098 procedures in the ET and LT cohorts, 12 asymptomatic patients tested positive for SARS-CoV-2 (0.29% positivity rate). One left the health system before completing the procedure and another proceeded urgently under COVID precautions, while 10 were rescheduled and completed at a later date; 7 were cleared using a test-based strategy, while 3 were cleared using a time-based strategy. Of 445 patients who had SARS-CoV-2 tests performed within 30 days following their procedures, three patients with negative preoperative tests had a positive test within 30 days, all in the LT cohort but had evidence of acquiring the infection after the procedure or had a false-positive test.ConclusionsOur strategy of preprocedural SARS-CoV-2 testing successfully identified asymptomatic infected patients before surgery. Care was delayed for most of these patients without apparent detriment. Adaptation to a time-based strategy for clearance might reduce such delays, but other considerations may still influence how soon procedures should be completed after a positive test.

Reliability of 2D kinematics during landing of volleyball athletes after exhaustion

IntroductionIt is possible to quantify changes in movement patterns through kinematic analysis of landing, especially to quantify changes in pre and post exhaustion situations, however the reliability of this post exhaustion analysis is not known. ObjectiveTo verify the inter and intra-examiner reliability of two-dimensional kinematic analysis during the landing of a vertical jump of volleyball athletes, pre and post exhaustion protocol. ExperimentalThirty volleyball athletes were recruited, and kinematic analysis was performed during landing, pre and post exhaustion protocol. The angular measurements analyzed were: 1) frontal plane: knee valgus and 2) sagittal plane: anterior trunk inclination, knee flexion and tibiotarsal angle, performed by two examiners. The reliability calculation used the intraclass correlation coefficient (ICC), in addition to the error of measurement (SEM), the coefficient of variation (CV) and the minimum detectable difference (MDD). ResultsRegarding reliability: ICC = 0.95–0.98 (pre) and ICC = 0.83–0.98 (post exhaustion). The CV presented heterogeneous values for the knee valgus and the inclination of the trunk, both pre and post protocol. The SEM from all angles presented values that varied from 0.74°-2.33° and the MDD ranged from 2.55°-5.54° pre protocol and 2.05°-6.45° post protocol. Conclusion2D kinematic evaluation can be used during landing, before and after the application of an exhaustion protocol, but professionals should pay attention to the angles of the knee valgus and the inclination of the trunk, as they have a large CV.

A preoperative standardized feeding protocol improves human milk use in infants with complex congenital heart disease.

To evaluate the hypothesis that implementation of a preoperative standardized feeding protocol increases human milk use in infants with complex congenital heart disease (CHD). Single-center, quasi-experimental study of infants with complex CHD. A cohort of 546 infants pre protocol was compared to 55 patients post protocol. Feeding regimen and peri-operative outcomes information were collected. Human milk use increased significantly (58.4% versus 100%, p < 0.01) and there was no formula use post protocol (18.7% versus 0%, p < 0.01). Preoperative necrotizing enterocolitis occurred in 18/546 (3.3%) infants pre protocol versus 1/55 (1.8%) post protocol, p = 1.00. Days to full feeds and length of hospital stay in both cohorts were not significantly different. Successful implementation of a preoperative standardized feeding protocol can increase human milk and decrease formula use in infants with complex CHD without significant adverse outcomes. A larger study is needed to evaluate the association of human milk use with peri-operative outcomes.

Exposure-Based Methadone and Lorazepam Weaning Protocol Reduces Wean Length in Children.

Determine if a standardized methadone and lorazepam weaning protocol that is based on dose and duration of exposure can reduce the length of opioid and benzodiazepine weaning and shorten hospital stay. Retrospective cohort study performed in a 24-bed medical/surgical PICU. A total of 177 patients on opioid and/or benzodiazepine infusions for >3 days were included; 75 patients pre protocol (June 2012- June 2013) were compared with 102 patients post implementation of a standardized weaning protocol of methadone and lorazepam (March 2014-March 2015). The recommended wean was based on duration of infusions of >3 days up to 5 days (no wean), 5 to 13 days (short wean), and ≥14 days (long wean). Median number of days on methadone for patients on opioid infusions for 5 to 13 days was reduced from 8.5 to 5.7 days (p = 0.001; n = 45 [pre], n = 68 [post]) and for patients on opioid infusions for ≥14 days, from 29.7 to 11.5 days (p = 0.003; n = 9 [pre], n = 9 [post]) after protocol implementation. The median number of days on lorazepam for patients on benzodiazepine infusions for 5 to 13 days was reduced from 8.1 to 5.2 days (p = 0.020; n = 43 [pre], n = 55 [post]) and for patients on benzodiazepine infusions for ≥14 days, from 27.4 to 9.3 days (p = 0.011; n = 9 [pre], n = 8 [post]). There was no difference in methadone or lorazepam wean length for patients on 3 to 5 days of infusions. There was no difference in adverse events or hospital length of stay. A methadone and lorazepam weaning protocol based on patient's exposure to opioids and benzodiazepines (dose and duration) reduces weaning length.

Clinical and microbiological profile of Hansen’s diseases in a tertiary care centre of southwest Bihar

Leprosy or Hansen’s disease is a slowly progressive infection caused by mycobacterium Lepra. It has been reported from Bihar that false positive diagnosis is a major issue and decline in false positive diagnosis is not statistically significant. Present study has been designed primarily to study the clinical presentation and microbiological profile of patients presenting with symptoms of Hansen disease and secondarily to know the smear positivity of patients with clinical manifestation of leprosy. After enrolment of patients a detail clinical examination was done and demographic information of patient was recorded on predesigned Performa. After taking consent from enrolled patients slit skin smear was obtained as pre standard protocol. All patients below 20 years of age were slit smear staining smear negative for AFB. In our study 55(38.19%) patients with clinical manifestation were from 31 to 50 years of age among them 18(30 % of total AFB positive) was AFB positive. Among 30 patients with 16 (53.34%) patients have bacteriological index 6+ and 8 patients have bacteriological index 1+. From present study we can conclude that there was male predominance and in most of the patients who were smear staining positive have bacteriological index more than 6+. Most common age group presented with clinical symptom and AFB positive were in 3 and 4 decade of life. Hypopigmented macules were common presentation and AFB positive was most frequent in them.

The effects of aerobic exercise on biochemical parameters in individuals with CKD on hemodialysis: A longitudinal study

Background: Chronic kidney disease is directly related to cardiovascular disorders. Guided physical exercises significantly improve the adverse effects of dialytic treatment.&#x0D; Objective: To analyze changes in biochemical parameters of subjects with chronic kidney disease undergoing moderate exercise during hemodialysis.&#x0D; Methods: This is an experimental study composed of 54 subjects submitted to hemodialysis, split into a control group and a group with intervention. The experimental group underwent three weekly sessions of aerobic exercise, performed during hemodialysis sessions, with a duration of 30 minutes, for 12 weeks. The blood parameters of both groups were compared.&#x0D; Results: Statistically significant differences were observed between pre (p=0.001) and post-exercise protocol for urea (p=0.006), calcium (p=0.001), alanine aminotransferase (p=0.020) and sodium (p=&lt;0.001). In the control group, we observed significant differences for the calcium variable (p&lt;0.001), alanine aminotransferase (p=0.024), hematocrit (p=0.015), calcium vs phosphorus (p=0.018), and sodium (p=0.023), before and after the period.&#x0D; Conclusion: Aerobic training during hemodialysis was able to maintain blood level stability in patients with chronic kidney disease, both during and at the end of the protocol, even considering increased blood flow. This trial is registered in the Brazilian registry of clinical Trials - number RBR-7354r6. Registration date: July 5, 2018 at 12:59 PM. Last Update: July 24, 2018 at 10:24 AM. Identification of the test - UTN Number: U1111-1216-8272.

Enhancing patient mobility following cesarean-delivery \u2013 the efficacy of an improved postpartum protocol assessed with pedometers

BackgroundThe incidence of thromboembolic complications is highest in the immediate postpartum period, especially following caesarean delivery (CD). Ambulation following CD is important in their prevention. We examined the effect of an educational protocol on patients’ mobility following CD, with the use of digital step counters (pedometers).MethodsStarting February 2018, we implemented an educational protocol at the maternity ward, which included nurses’ tutoring and subsequent patients’ education, regarding the importance of early ambulation. Following CD, ambulation was initiated 4 h following surgery (as compared to 6 h prior). Scheduled IV acetaminophen was administered at six-hour intervals for 48 h (as compared to only 24 h prior), while additional analgesics were given upon patient request. We compared maternal demographics, delivery and postpartum course between the pre-protocol group (n = 101) and the post-protocol group (n = 100). All patients were asked to wear pedometers for 48 h following the delivery to assess ambulation.ResultsPatients’ demographics, surgical and post-partum course were non-significant between the groups, except for surgical length (48.5 ± 14.6 vs. 53.5 ± 15.3 min in the pre and post protocol groups, respectively, p = 0.02). The pre-protocol group was treated with more additional analgesics (p = 0.02). A higher number of steps was taken in the post-protocol group as compared to the pre-protocol group (4394 ± 2985 vs.3551 ± 2931, respectively p = 0.04). In a linear regression analysis in which the number of steps served as the dependent variable, this educational protocol was independently associated with a higher number of steps [coefficient 988 steps, 95% CI 137–1838, p = 0.02], as was smoking, after adjustment for surgical length, emergent surgery, maternal age and body mass index.ConclusionAn educational protocol which included earlier ambulation and regular interval pain control was associated with improved ambulation following CD.

Evaluation of Universal versus Preemptive Antifungal Prophylaxis in Lung Transplantation

Infections from various fungi are increasingly recognized in the setting of lung transplant and guidelines do not distinguish one superior strategy between universal or preemptive. Limited studies exist comparing the two approaches and this study aims to evaluate the incidence mold infections post lung transplant (LTx) before and after the implementation of a protocol change. Our institution's PRE-protocol (PRE) included a pre-emptive prophylaxis for high risk IMI (invasive mold infection) with positive donor or recipient mold colonizations. POST-protocol implementation, a universal prophylaxis approach using itraconazole 200mg PO BID for lifetime post-transplant was employed. A single-center, retrospective chart review was conducted on adult LTx recipients. Patients receiving LTx between 1/2012-5/2016 were included in the PRE cohort and those between 8/2016-5/2019 were included in the POST cohort. A total of 150 patients were included in the PRE cohort and 127 in the POST cohort. Baseline demographics were similar among the cohorts in regards to mean age, gender, bilateral transplant and race. Incidence of IMI or disseminated fungal disease was n=13 (9%) vs n=1 (1%) in the PRE vs POST cohort; p=0.002. A total of 94/150 (63%) vs 51/127 (40%); p=.001 patients developed post LTx fungal colonization. The distribution of types of mold (Table 1) show that there was significantly less BAL colonization with aspergillus with the universal prophylaxis protocol (POST) 33 vs 64%. Median time to first fungal colonization was similar in both groups 108 vs 109 days in the respective PRE and POST groups. Discontinuation rates of itraconazole was n=28 (22%) among the POST cohort. While fungal colonization is ubiquitous, invasive and disseminated fungal infections can result in detrimental outcomes post lung transplant. The strategy of lifelong universal prophylaxis for molds may confer decreased colonization rates and in turn lower incidence if invasive and disseminated disease.

Abstract WP297: Impact of the Extended Thrombectomy Window on a Large, Comprehensive Stroke Center Run Telestroke Network

Background: The Wake Forest (WF) Telestroke Network, founded in 2009, is the largest in North Carolina serving 20 hospitals. WF Baptist Medical Center is a Comprehensive Stroke Center (CSC) and referral site for endovascular therapy from many regional hospitals, including 11 within our telestroke network. In December 2017, following dissemination of the DAWN and DEFUSE trial results, we adopted a 24 hour thrombectomy window at WF. In January 2018, education was provided at telestroke sites to facilitate identification of candidates for extended thrombectomy (ET). It has been unclear how the extended window will impact CSC systems. We evaluated the impact of ET on telestroke calls, transfers, and thrombectomy volumes within our state and regional telestroke network. Method: Telestroke activations and consultations within our state network for the months pre and post ET protocol implementation were compared (July -December 2017 vs January - May 2018). Stroke transfers from regional telestroke hospitals and resultant thrombectomy procedures conducted at WF were compared (July - November 2017 vs December 2017-June 28 2018). Patients transferred for primary hemorrhage were excluded. Monthly volumes were compared using the Kruskal-Wallis Test. Results: Monthly network activations increased, though not significantly, following education on ET window (median 109.5 vs 153 p = 0.07). Monthly consultations remained steady (median 50.5 vs 54 p= 0.20). Stroke transfers per month remained steady (median 28 vs 27 p= 0.74) while thrombectomies increased (median 1 vs 4 p=0.03). Conclusions: Though thrombectomy volumes increased, the impact on telestroke consultations and transfer volumes at our institution has not been substantial since adoption of the 24 hour thrombectomy window. While the ET window has led to more calls to our 20 site telestroke network, likely for triage of later presenting patients, it was not significant in this small sample. Further evaluation will examine this trend. Regional transfers to WF have remained stable, as the majority of patients with large stroke are transferred for inpatient stroke care. With a previously established transfer arrangement, the extended window has not led to overtriage from our regional hospitals.

A Standardized Oxytocin Administration Protocol After Delivery to Reduce the Treatment of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a leading cause of maternal death, and its rate and severity have been increasing. Oxytocin is widely recommended for PPH prophylaxis, but consensus is lacking on the dose or duration, leading to disparate and subjective practices. In this study, clinical outcomes were compared before and after introduction of a quality measure: a standardized oxytocin protocol for PPH prophylaxis. A retrospective cohort study was conducted of postpartum women ≥24 weeks' gestation delivered from 2010 to 2015. Women were grouped according to delivery pre-protocol (PREP) or post-protocol (POSTP) then subgrouped by specified criteria indicating low risk for PPH. The protocol was standardized for all POSTP women: 60 units of oxytocin over 5.25 hours postdelivery. The primary outcome was a composite: defined treatment for hemorrhage or uterine atony. Of 16,811 women included, 46.3% were PREP (n = 7,791), and 53.7% were POSTP (n = 9,020). A total of 2,315 subjects (13.8%) met low risk for PPH criteria. The primary outcome rate was lower after protocol introduction for all subjects (7.0% vs. 4.6%; p <0.001) and low-risk subset women (3.8% vs. 1.4%; p <0.001). Delivery after protocol introduction was associated with a decreased risk of the primary outcome among all subjects women (adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI] = 0.55-0.72) and low-risk subset women (AOR, 0.33; 95% CI = 0.19-0.57). Standardized, higher-dose postpartum oxytocin may be associated with less PPH treatment in this cohort. These findings support standardization and set the stage for a randomized controlled trial.

Efficacy of bismuth containing quadruple therapies on Helicobacter pylori eradication in patients with history of antibiotic treatment

To investigate the efficacy of bismuth containing quadruple therapies on Helicobacter pylori (Hp) eradication in patients with history of antibiotic treatment. Methods: Hp infected patients (n=327) were allocated into 3 groups. Group A (n=52), patients had no antibiotic history and they took medicine of proton pump inhibitors (PPI) and livzon triple (clarithromycin, tinidazole, and bismuth); group B (n=80), patients had the antibiotic history except for amoxicillin and clarithromycin, and they were treated with PPI, amoxicillin, clarithromycin, and bismuth; group C (n=195), patients suffered failures of Hp therapy or with history of antibiotic abuse, and they were treated with PPI, doxycycline, furazolidone, and bismuth. Results: Both the intention-to-treat (ITT) analysis (group A 63.5%, group B 76.2%, group C 82.6%, P<0.05) and the pre-protocol (PP) analysis (group A 76.7%, group B 92.4%, group C 96.4%, P<0.05) showed significant difference among the 3 groups, revealing higher elimination in group B and C. The side-effects (20.2%) were mild and tolerable (group A, 28.0%; group B, 10.7%; group C, 22.0%). Conclusion: Proton pump inhibitors together with the livzon triple regimen have a low rate of Hp eradication and a higher incidence of adverse reactions. The quadruple therapy containing clarithromycin and metronidazole drugs can achieve the satisfactory outcomes based on patient's antibiotic history. For patients with multiple antibiotics, the quadruple therapy containing furazolidone and doxycycline may achieve the satisfactory outcomes, but the adverse resction would be relatively higher.

Nurse titrated analgesia and sedation in intensive care increases the frequency of comfort assessment and reduces midazolam use in paediatric patients following cardiac surgery

BackgroundPain and sedation protocols are suggested to improve the outcomes of patients within paediatric intensive care. However, it is not clear how protocols will influence practice within individual units. ObjectivesEvaluate a nurse led pain and sedation protocols impact on pain scoring and analgesic and sedative administration for post-operative cardiac patients within a paediatric intensive care unit. MethodsA retrospective chart review was performed on 100 patients admitted to a tertiary paediatric intensive care unit pre and post introduction of an analgesic and sedative protocol. Stata12 was used to perform Chi-squared or Student’s t-test to compare data between the groups. ResultsPost protocol introduction documentation of pain assessments increased (pre protocol 3/24h vs post protocol 5/24h, p=0.006). Along with a reduction in administration of midazolam (57.6mcg/kg/min pre protocol vs 24.5mcg/kg/min post protocol, p=0.0001). Children’s pain scores remained unchanged despite this change, with a trend towards more scores in the optimal range in the post protocol group (5 pre protocol vs 12 post protocol, p=0.06). ConclusionsIntroducing a pain and sedation protocol changed bedside nurse practice in pain and sedation management. The protocol has enabled nurses to provide pain and sedation management in a consistent and timely manner and reduced the dose of midazolam required to maintain comfort according to the patients COMFORT B scores. Individual evaluation of practice change is recommended to units who implement nurse led analgesic and sedative protocols to monitor changes in practice.

Influence of Trunk Extensor Muscles Fatigue on the Postural Control and Sensorimotor Integration

This study aimed to investigate the effect of trunk extensor muscles fatigue, through a submaximum and time-limited isometric task, on the postural control and sensorimotor integration of young healthy adults. Previously and after a submaximum and time-limited isometric fatigue protocol of trunk extension muscles, 30 s stabilometric recordings were taken in both conditions: eyes opened and closed. The center of pressure (CoP) displacement in the anteroposterior (AP) and mediolateral (ML) directions, as well as the total displacement (TD) of CoP were analyzed from the recordings with both conditions (eyes opened and closed) and moments (PRE and POST fatigue protocol). Additionally, the Romberg Index was calculated for CoP displacement in the AP and ML directions, as well as for TD PRE and POST fatigue protocol. Significant differences between the studied parameters of pre- and post-fatigue protocol were not observed. The applied fatigue protocol was not able to modify the postural control, as well as the capacity of integrating sensorial information in the absence of vision, of young healthy subjects. These results indicate that proprioceptive information remains reliable after the used fatigue protocol, allowing subjects to keep a satisfactory straight posture.

Efficacy of Doxycycline in the Treatment of Syphilis.

Doxycycline is an alternative antibiotic drug for the treatment of syphilis, but data on its efficacy, especially data on its efficacy against late latent syphilis, are limited. A retrospective study was conducted to evaluate the effectiveness of doxycycline for the treatment of patients with different stages of syphilis. Patients who received doxycycline treatment between June 2011 and June 2014 were involved. The serological response to doxycycline was defined as either a negative toluidine red unheated serum test (TRUST) result or a ≥4-fold decrease in titer at 12 months following the treatment. Univariate and multivariate logistic regression analyses were performed to identify factors associated with the serological response. During the study period, a total of 163 syphilis patients were treated with doxycycline, and 118 patients completed doxycycline treatment and the 12-month follow-up. Among the 118 patients, the serological response rate at 12 months was 100.0% (7/7) in patients with primary syphilis, 96.9% (62/64) in patients with secondary syphilis, 91.3% (21/23) in patients with early latent syphilis, and 79.2% (19/24) in patients with late latent syphilis. The total serological response rates were 92.4% (109/118) for preprotocol (PP) patients and 66.9% (109/163) for all intention-to-treat (ITT) patients. In multivariate analysis, patients who serologically responded at 12 months following treatment were positively associated with a higher baseline TRUST titer and an earlier syphilis stage than nonresponders. Our study showed excellent treatment outcomes in patients with different stages of syphilis. Our data, along with those from other reports, support the usage of doxycycline as a good alternative therapeutic option in the treatment of syphilis.

Preoperative Antibiotic Orders: Protocol-Initiated Pharmacist Order Entry.

OBJECTIVE: To evaluate the antibiotic selection of preoperative orders before and after a pharmacist order entry protocol for patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization. METHODS: A retrospective chart review of orthopedic surgery procedures on patients with MRSA colonization at a free-standing, academic pediatric hospital, between February 2010 and February 2012. RESULTS: Procedures that were performed pre protocol (n = 27) implementation had a 63% rate of appropriate antibiotic selection compared to 81% in the postprotocol group (n = 32; p = 0.1155). The preprotocol group dose accuracy was 96% compared to 97% in the postprotocol group (p = 0.81). Two procedures, 1 in each group, were redosed appropriately for extended surgery duration. Correct timing of antibiotic administration occurred in 82% of cases pre protocol versus 68% post protocol (p = 0.42). CONCLUSIONS: Patients with MRSA colonization had a greater rate of appropriate drug selection after the implementation of a pharmacist-initiated preoperative protocol. Correct antibiotic dose and redose remained consistent between the study groups. Most of the orthopedic procedures performed included patients on antibiotic coverage at steady state for ongoing infections, which impacted the analysis of preoperative timing. Further studies should be conducted to assess whether the increase in the number of appropriate antibiotic selections decreases the rate of postoperative MRSA infections.