Prescriptive Protocol Research Articles

Antibiotic-Prescribing Habits in Dentistry: A Questionnaire-Based Study.

A ten-question survey was administered to a group of Italian dentists. The participants were asked about their preferences for antibiotic administration for the prevention of infective endocarditis, the administration of antibiotics to patients allergic to penicillin, the insertion of implants, and the extraction of third molars. The retrieved data were screened and analyzed. A total of 298 surveys were filled out. The most-prescribed antibiotic was amoxicillin or amoxicillin with clavulanic acid or macrolides for allergic patients. The administration of two grams of amoxicillin one hour before surgery was the most widely used prescriptive protocol for prophylaxis. International guidelines on antibiotic prophylaxis for infective endocarditis were only partially followed. The most heterogeneous results emerged for prophylaxis associated with dental implants or provided prior to surgical third-molar extraction. The present study shows widespread antibiotic prescriptive heterogeneity among the sample of dentists analyzed, especially in conditions where international guidelines are lacking. An evidence-based consensus on prescriptive modalities in dentistry would be desirable in the near future.

Safe(r) by design guidelines for the nanotechnology industry

Expectations for safer and sustainable chemicals and products are growing to comply with the United Nations and European strategies for sustainability. The application of Safe(r) by Design (SbD) in nanotechnology implies an iterative process where functionality, human health and safety, environmental and economic impact and cost are assessed and balanced as early as possible in the innovation process and updated at each step. The EU H2020 NanoReg2 project was the first European project to implement SbD in six companies handling and/or manufacturing nanomaterials (NMs) and nano-enabled products (NEP).The results from this experience have been used to develop these guidelines on the practical application of SbD. The SbD approach foresees the identification, estimation, and reduction of human and environmental risks as early as possible in the development of a NM or NEP, and it is based on three pillars: (i) safer NMs and NEP; (ii) safer use and end of life and (iii) safer industrial production. The presented guidelines include a set of information and tools that will help deciding at each step of the innovation process whether to continue, apply SbD measures or carry out further tests to reduce uncertainty. It does not intend to be a prescriptive protocol where all suggested steps have to be followed to achieve a SbD NM/NEP or process. Rather, the guidelines are designed to identify risks at an early state and information to be considered to identify those risks. Each company adapts the approach to its specific needs and circumstances as company decisions influence the way forward.

An uncertainty-based protocol for the setup and measurement of soot–black carbon emissions from gas flares using sky-LOSA

Abstract. Gas flaring is an important source of atmospheric soot–black carbon, especially in sensitive Arctic regions. However, emissions have traditionally been challenging to measure and remain poorly characterized, confounding international reporting requirements and adding uncertainty to climate models. The sky-LOSA optical measurement technique has emerged as a powerful means to quantify flare black carbon emissions in the field, but broader adoption has been hampered by the complexity of its deployment, where decisions during setup in the field can have profound, non-linear impacts on achievable measurement uncertainties. To address this challenge, this paper presents a prescriptive measurement protocol and associated open-source software tool that simplify acquisition of sky-LOSA data in the field. Leveraging a comprehensive Monte Carlo-based general uncertainty analysis (GUA) to predict measurement uncertainties over the entire breadth of possible measurement conditions, general heuristics are identified to guide a sky-LOSA user toward optimal data collection. These are further extended in the open-source software utility, SetupSkyLOSA, which interprets the GUA results to provide detailed guidance for any specific combination of location, date–time, and flare, plume, and ambient conditions. Finally, a case study of a sky-LOSA measurement at an oil and gas facility in Mexico is used to demonstrate the utility of the software tool, where potentially small regions of optimal instrument setup are easily and quickly identified. It is hoped that this work will help increase the accessibility of the sky-LOSA technique and ultimately the availability of field measurement data for flare black carbon emissions.

Implementation of a Prescriptive Extracorporeal Circuit and Its Effect on Hemodilution and Blood Product Usage during Cardiac Surgery.

The use of cardiopulmonary bypass (CPB) contributes significantly to intraoperative anemia. The use of a prescriptive circuit that is tailored to the patient size could significantly reduce priming volumes, resulting in less hemodilution. The purpose of this study was to determine whether a prescriptive circuit resulted in decreased hemodilution, reduced blood product usage, and improved outcomes. In total, 204 patients prospectively received the prescriptive protocol between March 2019 and November 2019. This protocol was composed of three circuit sizes: small [body surface area (BSA) ≤ 1.85 m2], medium (BSA 1.86-2.30 m2), and large (BSA ≥ 2.31 m2). Data for CPB and post-bypass transfusions were collected, along with postoperative outcomes. These patients were then 1:2 propensity score matched to 401 patients who were retrospectively reviewed who had undergone cardiac surgery using a one-sized CPB circuit. The prescriptive protocol cohort had more patients with renal disease, whereas the conventional cohort had more history of hypertension. Intraoperative results show the prescriptive circuit had lower mean prime volume and total prime volume after reverse autologous prime (1,084 mL vs. 1,798 mL, p < .0001; 725 mL vs. 1,181 mL, p < .0001). Ultrafiltration was higher in the prescriptive group (872 vs. 645 mL, p < .0001), which likely balanced the increased use of del Nido cardioplegia in the prescriptive group (1,295 vs. 377 mL, p < .0001). The drop in hematocrit (HCT) from baseline was less in the prescriptive group (15.1 ± 4.91 vs. 16.2 ± 4.88, p = .0149), whereas the postoperative HCT was higher (32.79 ± 4.88 vs. 31.68 ± 4.99, p = .0069). Transfusion of packed red cells did not change between the two groups. Implementation of a prescriptive circuit did not reduce on-bypass or intraoperative blood product usage. However, there was a significant reduction in on-bypass hemodilution and increased postoperative HCT.

Implementation of a Prescriptive Extracorporeal Circuit and Its Effect on Hemodilution and Blood Product Usage during Cardiac Surgery

The use of cardiopulmonary bypass (CPB) contributes significantly to intraoperative anemia. The use of a prescriptive circuit that is tailored to the patient size could significantly reduce priming volumes, resulting in less hemodilution. The purpose of this study was to determine whether a prescriptive circuit resulted in decreased hemodilution, reduced blood product usage, and improved outcomes. In total, 204 patients prospectively received the prescriptive protocol between March 2019 and November 2019. This protocol was composed of three circuit sizes: small [body surface area (BSA) ≤ 1.85 m2], medium (BSA 1.86–2.30 m2), and large (BSA ≥ 2.31 m2). Data for CPB and post-bypass transfusions were collected, along with postoperative outcomes. These patients were then 1:2 propensity score matched to 401 patients who were retrospectively reviewed who had undergone cardiac surgery using a one-sized CPB circuit. The prescriptive protocol cohort had more patients with renal disease, whereas the conventional cohort had more history of hypertension. Intraoperative results show the prescriptive circuit had lower mean prime volume and total prime volume after reverse autologous prime (1,084 mL vs. 1,798 mL, p &lt; .0001; 725 mL vs. 1,181 mL, p &lt; .0001). Ultrafiltration was higher in the prescriptive group (872 vs. 645 mL, p &lt; .0001), which likely balanced the increased use of del Nido cardioplegia in the prescriptive group (1,295 vs. 377 mL, p &lt; .0001). The drop in hematocrit (HCT) from baseline was less in the prescriptive group (15.1 ± 4.91 vs. 16.2 ± 4.88, p = .0149), whereas the postoperative HCT was higher (32.79 ± 4.88 vs. 31.68 ± 4.99, p = .0069). Transfusion of packed red cells did not change between the two groups. Implementation of a prescriptive circuit did not reduce on-bypass or intraoperative blood product usage. However, there was a significant reduction in on-bypass hemodilution and increased postoperative HCT.

Modifications to the PREEMPT Protocol for OnabotulinumtoxinA Injections for Chronic Migraine in Clinical Practice.

To assess the PREEMPT protocol modifications that have developed in clinical practice over time. The United States Food and Drug Administration approved the 155-unit fixed-dose, fixed-site PREEMPT protocol of onabotulinumtoxinA (BoNT-A) injections for migraine prevention 9 years ago. This is an anonymous survey with free text response options of Headache Medicine clinicians. Out of the 878 contacted Headache Medicine clinicians, 182 (20.7%) completed the survey. Of the 182 respondents, 141 (77.5%) reported that they did not always follow the PREEMPT protocol. Of the 182 respondents, 128 (70%) changed the number of injections, 115 (63%) changed the total units of BoNT-A injected, 105 (57.7%) altered the location of injection sites (58%); 101 (55.5%) do not aspirate to ensure the absence of blood return; 22 (12.1%) changed the dilution; and 4 (2.2%) added lidocaine. The main reported reasons for changes in number, dose, and location of injections included adapting to the patients' pain, anatomy, and preferences. The wide inter- and intra-personal variations in BoNT-A injections for chronic migraine prevention seen in this survey raise concerns about the standardization of the procedure and suggest that an advisory protocol containing more evidence and discussion of the reasoning behind the recommendations might be more helpful than the current prescriptive protocol.

Effects of manual therapy and exercise targeting the hips in patients with low-back pain-A randomized controlled trial.

The benefits of providing manual therapy and exercise targeting the hips in individuals with mechanical low-back pain (LBP) are not well established. The objective in this study is to determine whether a formal prescriptive treatment protocol for the hips improves outcomes in patients with a primary complaint of mechanical LBP. Eighty-four (84) subjects (50 males, 46.1±16.2years) were randomized to 1 of 2 groups: pragmatic treatment of the lumbar spine only (LBP) (n=39) or pragmatic treatment of the lumbar spine and prescriptive treatment of bilateral hips (LBP+HIP) (n=45). Pragmatic treatment of the lumbar spine was based upon published clinical guidelines. Prescriptive treatment of the hips involved the use of 3 hip exercises targeting the gluteal musculature and 3 mobilization techniques targeting the hips. Subjects were assessed at baseline, 2weeks, and at discharge with the following measures: Modified Oswestry Disability Index, Numeric Pain Rating Scale, a global rating of change (GRoC) score, the patient acceptable symptom state (PASS), and patient satisfaction. At 2weeks, significant differences between groups differences were found in GRoC and patient satisfaction (P<.05) favoring the LBP+HIP group. At discharge, there were significant differences on the Modified Oswestry Disability Index, numeric pain rating scale, GRoC, and patient satisfaction favoring the LBP+HIP group (P<.05). Effect sizes were small to medium. Our findings suggest that a prescriptive treatment of the hips may be of clinical value to individuals presenting with the primary complaint of mechanical LBP.

The New York State Collaborative Care Initiative: 2012–2014

We report on a partnership between the NYS Department of Health and Office of Mental Health that delivered the full integration of depression care into primary medical care. Called the NYS Collaborative Care Initiative (NYS-CCI), nineteen NYS academic medical centers participated. Based on principles of chronic illness care, Collaborative Care detects and manages depression in primary care using a highly prescriptive protocol (University of Washington AIMS Center website: http://uwaims.org/ ). Fidelity was ensured by measuring screening rates, diagnosis, enrollment, and improvement among those in treatment for 16 weeks. There was significant, progressive performance improvement in sites that served over 1 million patients over the course of the two and a half year grant. Clinics also reported satisfaction with the CC model. Based on the experience gained, we recommend a number of critical actions necessary for the successful implementation and scaling-up of CC throughout any state undertaking this endeavor.

Ventilator versus Manual Hyperinflation in Clearing Sputum in Ventilated Intensive Care Unit Patients

The aim of hyperinflation in the ventilated intensive care unit patient is to increase oxygenation, reverse lung collapse and clear sputum. The efficacy and consistency of manual hyperventilation is well supported in the literature, but there is limited published evidence supporting hyperventilation utilising a ventilator. Despite this, a recent survey established that almost 40% of Australian tertiary intensive care units utilise ventilator hyperinflation. The aim of this non-inferiority cross-over study was to determine whether ventilator hyperinflation was as effective as manual hyperinflation in clearing sputum from patients receiving mechanical ventilation using a prescriptive ventilator hyperinflation protocol. Forty-six patients received two randomly ordered physiotherapy treatments on the same day by the same physiotherapist. The efficacy of the hyperinflation modes was measured by sputum wet weight. Secondary measures included compliance, tidal volume, airway pressure and PaO2/FiO2 ratio. There was no difference in wet weight of sputum cleared using ventilator hyperinflation or manual hyperinflation (mean 3.2 g, P=0.989). Further, no difference in compliance (P=0.823), tidal volume (P=0.219), heart rate (P=0.579), respiratory rate (P=0.929) or mean arterial pressure (P=0.593) was detected. A statistically significant difference was seen in mean airway pressure (P=0.002) between techniques. The effect of techniques on the PaO2/FiO2 response ratio was dependent on time (interaction P=0.024). Physiotherapy using ventilator hyperinflation cleared a comparable amount of sputum and was as safe as manual hyperinflation. This research describes a ventilator hyperinflation protocol that will serve as a platform for continued discussion, research and development of its application in ventilated patients.

Interpreting the large fish indicator for the Celtic Sea

AbstractShephard, S., Reid, D. G., and Greenstreet, S. P. R. 2011. Interpreting the large fish indicator for the Celtic Sea. – ICES Journal of Marine Science, 68: 1963–1972. The large fish indicator (LFI) was developed in the North Sea as a size-based indicator of fish community state. It is now established as OSPAR's fish community Ecological Quality Objective (EcoQO) metric and will be applied across all OSPAR regions. To produce a protocol for use when developing regional LFIs, the North Sea experience is interpreted using data from the Celtic Sea. Differences in fish community species composition and size distribution were reflected in a different species complex and large fish threshold (50 cm) for the Celtic Sea LFI. However, a lag of 12–14 years in the relationship between assemblage-averaged fishing mortality Fcom,y and the LFI suggested similar underlying ecological mechanisms to the North Sea. The indicator responded to changes in small fish biomass that follow fishing-induced changes in the level of predation by large demersal piscivores. The Celtic Sea LFI showed maximum observed values &gt;0.40 before 1990, and 0.40 is here proposed as an EcoQO. Development of regional LFIs demands a flexible process rather than a strictly prescriptive protocol.

EDITORIAL

There have been few more public and controversial chapters in the still relatively brief history of the National Institute for (Health and) Clinical Excellence (NICE) than in relation to recommendations concerning drugs for dementia. In 2001 an unusually prescriptive protocol (NICE, 2001) was drawn up limiting the initiation of acetylcholinesterase inhibitors for Alzheimer's disease to ‘appropriate specialists’, in practice old age psychiatrists and a few geriatricians. This advice was broadly accepted by the then newly established Health Technology Board for Scotland with a minimum of ‘tartanisation’ to protect the needs of more isolated and rural communities by defining a role for suitably interested and experienced GPs.

MULTIDISCIPLINARY APPROACH FOR PRESCRIPTIVE MANAGEMENT OF MINERAL AND BONE METABOLISM IN CHRONIC KIDNEY DISEASE: DEVELOPMENT OF A DIETETIC LED PROTOCOL

A number of mineral metabolism abnormalities occur as kidney function declines, these include hyperphosphatemia, hyperparathyroidism and altered vitamin D metabolism. These derangements are associated with increased morbidity and mortality amongst the chronic kidney disease patient group. Treatment requires a multidisciplinary team approach in which the dietitian plays a pivotal role. The development of protocols to aid implementation of various international, national and local treatment strategies is described. Audit the protocol to evaluate their clinical effectiveness. A prescriptive Protocol for the management of mineral and bone metabolism abnormalities in chronic kidney disease was developed and implemented. Initial audit findings suggest the protocol has had a positive effect on the control of phosphate, corrected calcium and parathyroid (PTH) levels. The development and implementation of a dietetic-led prescriptive therapy protocol allows dietitians and clinicians to adopt an integrated approach for the diagnosis and timely management of these complicated conditions.

A communication model for structural design objects. II: Performatives and protocols

In the companion paper, communication channels and medium have been proposed. These communication channels and medium are used here to define object communication protocols based on certain object and agent communication performatives. Specifically, this paper presents a conceptual underpinning for identifying, classifying and defining object communication protocols. Three communication protocols have been identified, namely: (1) the Prescriptive protocol; (2) the Conversational protocol; and (3) the Meditative protocol. Features of each protocol are presented using UML notations. The Meditative protocol, which is based on a Mediator Agent, is adopted due to its versatility and viability. Implementation details of the Mediator Agent are presented. Key communication performatives are defined to execute the steps of the mediative protocol. The performatives and protocols, together with the channels and medium, define the communication model for structural design objects. Examples that show how the defined protocols help in enhancing the design of modular objects and in facilitating the communication of data and information among design objects of the integrated structural engineering system are shown.

Inter‐ and intralaboratory variation of in vitro diffusion cell measurements: An international multicenter study using quasi‐standardized methods and materials

In vitro measurements of skin absorption are an increasingly important aspect of regulatory studies, product support claims, and formulation screening. However, such measurements are significantly affected by skin variability. The purpose of this study was to determine inter‐ and intralaboratory variation in diffusion cell measurements caused by factors other than skin. This was attained through the use of an artificial (silicone rubber) rate‐limiting membrane and the provision of materials including a standard penetrant, methyl paraben (MP), and a minimally prescriptive protocol to each of the 18 participating laboratories. “Standardized” calculations of MP flux were determined from the data submitted by each laboratory by applying a predefined mathematical model. This was deemed necessary to eliminate any interlaboratory variation caused by different methods of flux calculations. Average fluxes of MP calculated and reported by each laboratory (60 ± 27 μg cm−2 h−1, n = 25, range 27–101) were in agreement with the standardized calculations of MP flux (60 ± 21 μg cm−2 h−1, range 19–120). The coefficient of variation between laboratories was approximately 35% and was manifest as a fourfold difference between the lowest and highest average flux values and a sixfold difference between the lowest and highest individual flux values. Intralaboratory variation was lower, averaging 10% for five individuals using the same equipment within a single laboratory. Further studies should be performed to clarify the exact components responsible for nonskin‐related variability in diffusion cell measurements. It is clear that further developments of in vitro methodologies for measuring skin absorption are required. © 2005 Wiley‐Liss, Inc. and the American Pharmacists Association J Pharm Sci 94:632–638, 2005

Implementing intensive insulin therapy: development and audit of the Bath insulin protocol.

Intensive insulin therapy to control blood glucose has been found to reduce mortality among critically ill patients in a surgical intensive care unit, though a simple prescriptive insulin infusion protocol to achieve this has not been published previously. This study documents the development and routine use of a simple prescriptive intravenous insulin infusion protocol for critically ill patients and compares the results with previous practice. During development the protocol was optimized and practical issues of implementation addressed. The optimized protocol was then used for all ICU admissions, and a prospectively defined retrospective chart audit performed for the first month of use. Results were compared with a similar time period the previous year. In September 2002, 27 admissions were started on the protocol. Blood glucose for the time on the protocol had a median value of 6.2 (IQR 5.9-7.1) mmol/l compared with 9.2 (IQR 8.1-10.2) mmol/l for those on insulin in 2001. Blood glucose for the whole ICU stay for those on the protocol in 2002 had a median value of 6.6 (IQR 6.0-7.4) mmol/l compared with 8.6 (IQR 8.0-9.4) mmol/l in 2001. Blood glucose for all ICU patients in 2002 had a median value of 6.5 (IQR 6.0-7.3) mmol/l compared with 7.2 (IQR 6.3-8.3) mmol/l in 2001. Three blood glucose recordings were less than 2.2 mmol/l in September 2002. This study provides initial effectiveness and safety data for the Bath Insulin Protocol Further audits in a larger patient population are now needed.

Best management practice turnip production: how to target a 14 tonne/ha crop on a central North Island dairy farm

A best management protocol for growing a turnip crop was developed from published information and provided to dairy farmers intending to grow the crop. On the basis of information returned by farmers in the 2002/2003 and 2003/2004 growing seasons, the validity of the assumptions underlying the protocol were tested. Many of the returned forms were incomplete and could not be used in the analysis. Adherence to the protocol was variable as farmers interpreted the prescriptive protocol differently and applied components of the protocol as they saw fit on their property. Protocol directions for nitrogen application, soil phosphorus content and sowing rate were applied the most uniformly, providing little variation for testing the impact of these factors. Farmers who applied post-emergence herbicide and insecticide as prescribed achieved a higher (P

Resurfacing the care in nursing by telephone: Lessons from ambulatory oncology

The practice of providing telephone mediated advice and assistance is often described as “telephone triage” in relevant literature. The decision-making processes required for priority-setting and the provision of advice have been found to be complex and multifaceted. Conceptualization of this valuable patient care activity as a linear “triage” function serves to make invisible the nursing care provided. This article explores the current practice of providing telephone mediated advice and assistance in the following 2 distinct nursing care settings: emergency departments and ambulatory oncology centers. Examination of this activity in these 2 settings provides a forum to discuss and critique legally and fiscally driven prescriptive protocol use to inform decision-making. The effectiveness of experiential knowledge coupled with the strengths of nurse-patient relationships suggests that a need exists to highlight the caring aspects of telephone mediated assistance.Nurs Outlook 2002;50:160-4.