Risk Of Inappropriate Use Research Articles

A Reassessment of Ignorance from the Perspective of the New Meanings of Rationality

In this article, we take a view of ignorance in relation to the new meaning of rationality, including the specific perspectives of limited rationality. We begin by suggesting that the problem of ignorance is far from the implied clarity of everyday expression, and there is a risk of inappropriate use of the concept. We show that not understanding what ignorance is, is part of ignorance, trying to avoid the situation of ignorance over ignorance. We propose a definition of ignorance by reference to the possible accessible and useful knowledge at a given time, suggesting that the understanding of ignorance is dependent on three variables: time, knowledge accessible at each moment of the present and utility. We analyze some asymmetries, including the one caused by the fact that we are often rigorous (but, nevertheless, interested) judges of others ignorance and very biased (that is, somewhat ignorant) about ourselves. We assess responsibility for our own ignorance by suggesting some limitations to the forms of ignorance for which we are responsible. We suggest that some variants of the unknown meet the definition of ignorance, and if we consider that most human decisions are made in conditions of information poverty, we can find that ignorance is frequently part of our cognitive strategies. Ignorance can be intentionally included in some of our cognitive strategies, one of which is provided by the principle of cognitive economics. The article can be one of the starting points for a set of recommendations on what can be ignored, what should and should not be ignored, when we are ignorant with no considerable effect and where/when we should not be

Identifying Outpatient-Specialized High-Volume Prescribers of Antibiotics in Older Adult Populations – Philadelphia, PA 2021

Background: Inappropriate antibiotic use promotes antibiotic resistance which poses a threat to public health. Outpatient settings are responsible for 80-90% of all antibiotic use, yet up to 50% of these prescriptions may be inappropriate and at least 33% completely unnecessary. To promote outpatient antibiotic stewardship (AS), the Philadelphia Department of Public Health (PDPH) identified outpatient high-volume prescribers (HVPs) in Philadelphia and provided them with peer comparison letters along with evidence-based AS educational resources. Method: We identified HVPs using overall and drug specific antibiotic volume and rates from the Centers of Medicare and Medicaid Services (CMS) Part D Prescribers by Provider and by Provider and Drug publicly available datasets for 2021. We restricted analyses to Philadelphia prescribers specializing in internal medicine, family practice, or general practice with antibiotic and beneficiary claim counts ≥ 11. We further restricted the Provider and Drug dataset to prescribers of high-consequence drugs: levofloxacin, ciprofloxacin, and azithromycin. Prescribers with subspecialities where these three drugs are commonly used appropriately were excluded from letter distribution. We analyzed U.S. Census Bureau American Community Survey (ACS) data for overall HVPs on census tract-level to describe health equity demographic characteristics. Result: A total of 1,001 prescribers with 67,145 total antibiotic claims, and 306 unique prescribers (77 levofloxacin, 176 ciprofloxacin, and 250 azithromycin) with 37,057 total antibiotic claims met the inclusion criteria in the Provider and the Provider and Drug datasets, respectively. There were 101 overall HVPs, and 89 unique drug-specific HVPs (20 levofloxacin, 45 ciprofloxacin, and 63 azithromycin) based on the highest 10% and 25% of prescribers by antibiotic volume, respectively. The overall HVPs contributed 42.0% of all antibiotic claims. The drug-specific HVPs contributed 60.5% of all antibiotic claims and 55.5% of levofloxacin, ciprofloxacin, and azithromycin claims. These 3 drugs contributed 45.1% of all antibiotic claims. Among the overall and drug-specific HVPs, we sent peer comparison letters to the top 10 by rate per 1,000 beneficiaries (overall) and per 1,000 antibiotic claims (drug-specific), who fell within the following prescribing rates: overall 954-2,714, levofloxacin 84-396, ciprofloxacin 288-723, and azithromycin 496-1,000. Conclusion: This initiative identified prescribers at risk for inappropriate use of antibiotics, and empowered these same prescribers to self-reflect on how they prescribe antibiotics. Efforts by local health departments to provide HVPs with peer comparison feedback and AS educational resources may improve the provider knowledge and prescribing habits across different healthcare systems, targeting prescribers at highest risk for misuse or overuse of antibiotics.Disclosure: Jane Gould: Spouse receives salary support- Incyte

Observational evidence linking psychotropic medicines to the dispensing of opioid agents in later life.

The use of opioid medicines is common in developed countries, particularly among older adults and those with mental health disorders. It is unclear if the association between mental disorders and opioid medicines is causal, or is due to reverse causality or confounding. We used a 10% random sample of the Australian Pharmaceutical Benefits Scheme (years 2012-2022) to examine the cross-sectional, case-control and longitudinal association between the dispensing of antidepressants, anxiolytics, hypnotics, antipsychotics and lithium, and opioid medicines. We used logistic regression, structural equation models (SEM), and Cox regression to analyze the data. Analyses were adjusted for age (years), sex, and number of non-psychotropic medicines dispensed during the year. The 2022 file contained 804 334 individuals aged 50 years or over (53.1% women), of whom 181 690 (22.6%) received an opioid medicine. The adjusted odds ratio of being dispensed opioid medicines was 1.44 (99% CI = 1.42-1.46) for antidepressants, 1.97 (99% CI = 1.92-2.03) for anxiolytics, 1.55 (99% CI = 1.51-1.60) for hypnotics, 1.32 (99% CI = 1.27-1.38) for antipsychotics, and 0.60 (99% CI = 0.53-0.69) for lithium. Similar associations were noticed when we compared participants who were or not dispensed opioid medicines in 2022 for exposure to psychotropic agents between 2012 and 2021. SEM confirmed that this association was not due to reverse causality. The dispensing of antidepressants was associated with increased adjusted hazard (HR) of subsequent dispensing of opioid medicines (HR = 1.29, 99% CI = 1.27-1.30). Similar associations were observed for anxiolytics, hypnotics and antipsychotics, but not lithium. The dispensing of opioid medicines is higher among older individuals exposed to antidepressants, anxiolytics, hypnotics and antipsychotics than those who are not. These associations are not due to reverse causality or study design. Preventive strategies seeking to minimise the risk of inappropriate use of opioid medicines in later life should consider targeting this high-risk population.

Prevalence of inappropriateness of elemene injection for hospitalized cancer patients: a multicenter retrospective study.

Background: Elemene injection could provide clinical benefit for the treatment of various cancers, but the clinical evidence is weak. Thus, its wide use in China has raised concerns about the appropriateness of its use. Methods: This was a multicenter retrospective study to evaluate the prevalence of inappropriateness of elemene injection for hospitalized cancer patients. Patients who met the inclusion criteria were retrospectively included, and demographic characteristics were extracted from the hospital information systems. The inappropriateness of elemene injection use was assessed using the preset criteria, and the prevalence was calculated. Multivariate logistic analysis was applied to identify any factors associated with inappropriate use. Results: A total of 275 patients were included in the analysis. The median age was 62years, and 30.9% were females. The most common cancer was lung cancer (24.0%), and 68.2% of the patients were receiving chemotherapy. The overall prevalence of inappropriateness was 61.8%. The most common reason for inappropriateness was inappropriate indications, and the second was inappropriate doses. Age and oncological department were significant risk factors associated with inappropriate use, while lung cancer, liver cancer and admission to cardiothoracic surgery were associated with a low risk of inappropriate use. Conclusion: The prevalence of inappropriateness among hospitalized elemene injection users was high. More efforts, especially those to improve the appropriateness of indications, should be made to improve the rational use of elemene, as well as other complementary medicines. Physicians should take caution to avoid inappropriate use when prescribing drugs with limited clinical evidence.

Brief Intervention as a Method to Reduce Z-Hypnotic Use by Older Adults: Feasibility Case Series.

Z-hypnotics or z-drugs are commonly prescribed for insomnia and sleep difficulties in older adults. These drugs are associated with adverse events and dependence and are not recommended for long-term use. Despite evidence of older adults being more sensitive to a wide array of adverse events and clinical guidelines advocating limiting use, inappropriate use in this population is still prevalent. Previous intervention studies have focused mainly on prescriber information. Simple, individually focused intervention designs are less studied. Brief intervention (BI) is a simple, easily transferable method mainly used to treat patients at risk of alcohol overuse. Our objective was to design and test the feasibility and acceptability of a BI intervention adapted to address individual, inappropriate use of z-hypnotics among older adults. This preparatory study aimed to optimize the intervention in advance of a quantitative randomized controlled trial investigating the treatment effect in a larger population. This feasibility case series was conducted at Akershus University Hospital, Norway, in autumn 2021. We included 5 adults aged ≥65 years with long-term (≥4 weeks) use of z-hypnotics and 2 intervening physicians. Additionally, 2 study investigators contributed with process evaluation notes. The BI consists of information on the risk of inappropriate use and individualized advice on how to reduce use. The focus of the intervention is behavioral and aims, in cooperation with the patient and based on shared decision-making, to change patient behavior regarding sleep medication rather than physician-based detoxification and termination of z-hypnotic prescriptions. Qualitative and descriptive quantitative data were collected from intervening physicians, study investigators, and participants at baseline, immediately after the intervention, and at the 6-week follow-up. Data were obtained from 2 physicians, 2 study investigators, and 5 participants (4 women) with a median age of 84 years. The average time spent on the BI consultation was 15 minutes. All 5 participants completed the intervention without problems. The participants and 2 intervening physicians reported the intervention as acceptable and were satisfied with the delivery of the intervention. After the intervention, 2 participants stopped their use of z-hypnotics completely and participated in the follow-up interview. Study investigators identified logistical challenges regarding location and time requirements. Identified aspects that may improve the intervention and reduce dropouts included revising the intervention content, focusing on rebound insomnia, adding an information leaflet, and supporting the patient in the period between the intervention and follow-up. The notion that the intervention should best be located and conducted by the patient's own general practitioner was supported by the participants. We identified important aspects to improve the designed intervention and found that the BI is feasible and acceptable for incorporation into a larger randomized trial investigating the treatment effect of BI for reducing z-hypnotic use by older adults. ClinicalTrials.gov NCT03162081; http://tinyurl.com/rmzx6brn.

Generative AI in the Australian education system: An open data set of stakeholder recommendations and emerging analysis from a public inquiry

The launch of new tools in late 2022 heralded significant growth in attention to the impacts of generative AI (GenAI) in education. Claims of the potential impact on education are contested, but there are clear risks of inappropriate use particularly where GenAI aligns poorly with learning aims. In response, in mid-2023, the Australian Federal Government held an inquiry, calling for public submissions. This inquiry offers a lens onto the policy framing of GenAI in education and provides the object of investigation for this paper. We use the inquiry submissions, extracting structured claims from each. This extraction is provided as an open data set for further research, while this paper focuses on our analysis of the policy recommendations made. Implications for practice or policy For practitioners, policymakers, and researchers. the paper provides an overview and synthesis of submission recommendations and their themes, by source type. For respondents to the inquiry (sources), the paper supports reflection regarding synergies and gaps in recommendations, pointing to opportunity for collaboration and policy development. For stakeholders with responsibility for aspects of policy delivery and/or those applying a critical lens to the inquiry and recommendation framing(s), the paper offers actionable insight.

Police Realistic Tactical Training Is Not Risk-Free: Stress-Induced Wide-QRS Paroxysmal Tachyarrhythmia in a Healthy Police Officer and Professional Athlete

The reported case, a spin-off of a wider ongoing national study investigating the individual stress reactions of police officers during realistic police tactical training, highlights the eventuality that stress-induced paroxysmal arrhythmias might occur and remain undetected without ECG monitoring as a standard practice. The ECG of a 41-year-old frontline police officer (and professional athlete of the State Police’s rugby team) was monitored with a wireless, textile-based, wearable device during stressful scenarios implying the use of force. ECG data were processed with the Kubios software to assess training-induced time-varying changes of heart rate variability parameters and of the parasympathetic, sympathetic, and stress indices. Multiparametric analysis of the heart rate variability quantified remarkable stress-induced increment of vagal withdrawal and of sympathetic dominance, with exceptionally high-stress index and sudden occurrence of a wide-QRS paroxysmal tachyarrhythmia (240 bpm) with concomitant operational failure. Subsequent exhaustive mandatory clinical assessment excluded any structural and arrhythmogenic cardiac abnormality. Although exceptional and to the best of our knowledge so far unique, the recording of a stress-induced paroxysmal wide-QRS arrhythmia occurring during realistic tactical training in a healthy police officer and highly fit athlete is worth to be shared as a caveat about the potential risk if eventually occurring in officers with unknown cardiovascular risk factors (e.g., for ischemic heart disease). Moreover, the demonstration that such a high level of stress may occur even in an experienced, healthy, and highly fit officer altering the physiologic dynamicity of brain–heart interaction with a negative consequence on the operational outcome strongly suggests that individual emotional reactions induced by stressful duty events must be safely experienced and assessed with realistic training, to adopt preventive coping strategies, to improve police officers’ efficiency in front of threats, and to lower the risk of inappropriate use of force with dramatic consequences on the street.

Effects of self-medication reasons, television advertisements, and pharmaceutical professionals' roles on self-medication practices

Self-medication has become increasingly common in society, and it is crucial to provide reliable information and emphasize the role of pharmacists in dispensing information to ensure that self-medication is carried out safely. This study aimed to analyse the reasons for self-medication, the influence of television advertisements, and the role of pharmacists in self-medication. The research used a descriptive-analytic approach with a cross-sectional design. The study involved 350 adult participants who were purposively selected in Tegal City, Central Java, Indonesia. Data were collected using a questionnaire and analysed using SPSS, employing univariate and bivariate analyses. The Chi-Square test was used to investigate the relationship between variables, with a significance level of 0.05. The findings showed that the primary reasons for self-medication were minor illnesses (63.1%), complete TV advertisements (86.3%), active involvement of pharmacists (68.9%), and good self-medication practices (73.1%). The study revealed that there was a significant relationship between the reasons for self-medication (p=0.032) and the role of pharmacists (p=0.002) in self-medication practices. In conclusion, the study found that self-medication practices were good, but pharmacists should be more active in providing information to clients to enhance the quality of self-medication. To achieve this, pharmacists need to play a more significant role in promoting appropriate self-medication practices by providing appropriate information on the safe use of medications. Moreover, health authorities should develop policies to regulate the advertising of over-the-counter drugs, emphasizing the risks of inappropriate use of medications through the media.

Uticaj socijalnih mreža na razvoj zavisnosti kod adolescenata

With the development of civilization the rate of adoption of new technologies has been increased drastically, and the researches show that media are generally adopted faster than other forms of new technologies. In this sense, the Internet has become a global phenomenon in a short period of time. A significant place in the variety of interactive communications on the Internet is occupied by social networks. They become an inevitable way to communicate, make contact, follow events and connect with the environment. Social networks such as Tik Tok, Instagram, Snapchat, Facebook, Twitter, YouTube and many others have escalated into imperative usage, especially among young people. These are specific online communities, where users (especially young people) try to create their profiles in a creative and fun way, start communication, and some individuals also try to make money. In the last few years, the question of the real consequences of computer usage and the Internet usage especially by children, has become a new and very dynamic area of research. A large number of documents are being written about the consequences of using these innovations on the intellectual, emotional and social development of children, adolescents and adults. The work of a nurse as a member of a team in the prevention of addiction to the Internet and social networks is extremely important, especially in the field of counseling, which refers to a wide range of technically simpler psychological therapies, from giving advice, through compassionate listening to young people struggling with depressive disorders, to structured ways encouraging young people to solve problems. The aim of this paper is to consider the influence of social networks on the development of depression in adolescents, as well as the importance of nurses as educators of young people in the prevention of depressive disorders. A descriptive method is used in the paper in order to consider the influence of social networks on the development of depression in adolescents, as well as the role and importance of the nurse in educating young people about the risks of inappropriate use of social networks.

Appropriateness of alert antibiotics measured by repeated prevalence surveys and impact of direct prescriber interaction and feedback

ABSTRACT Objectives Hospital point prevalence surveys (PPS) are shown to help identifying determinants for inappropriate antimicrobial therapy (AMT) and create feedback opportunities to optimize AMT. Methods PPS were performed at the AZNikolaas hospital, on four wards with high consumption rates of three alert antibiotics (AB) to judge their appropriateness. The impact of a multidisciplinary interaction between a medical microbiologist, a clinical pharmacist and the prescriber on inappropriate AMT, hospital costs and intravenous AMT days, was analyzed. Results During this survey, 7,39% of hospitalized patients in the selected wards received one or more of three alert antibiotics. Out of 78 prescriptions, 35.90% were judged appropriate, 39.74% inappropriate and 24.36% had insufficient data for judgment. Only the oncology ward was associated with more frequent appropriate use of alert AB. In case of an unknown infection focus or a catheter-related infection, the relative risk of inappropriate use was the highest. Multidisciplinary interaction improved inappropriate AMT in 59% of cases. It resulted in a 2478€ healthcare AMT cost saving and a reduction of 30 intravenous AMT days. Conclusions This survey shows high consumption rates and a high rate of inappropriate use of three alert AB in the observed wards. It revealed the lack of a local guideline concerning treatment of neutropenic fever of unknown origin and the need for more diagnostic information in electronical medical records. The survey demonstrated that direct feedback on inappropriate AMT to clinicians can be of added value, cost-saving and reducing length of intravenous AMT days. However, more studies are needed to confirm this.

Findings From Implementation of the EIT-4-BPSD Trial

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, depression, anxiety, apathy and hallucinations and are exhibited by up to 90% of nursing home (NH) residents with dementia. BPSD result in negative health outcomes, functional decline, high care costs, increased risk for inappropriate use of antipsychotic medications and social isolation. Behavioral approaches are endorsed as the first line of treatment for BPSD. Despite regulatory requirements, less than 2% of nursing homes consistently implement these approaches. The EIT-4-BPSD Trial was done to test a novel implementation approach to assure that staff in nursing homes use non-pharmacologic, behavioral approaches for the management of BPSD. EIT-4-BPSD is a theoretically-based four-step approach that includes: 1. Assessment of the environment and policies; 2. Education of staff; 3. Establishing person-centered care plans; and 4. Mentoring and motivating staff. Implementation of the four-step approach was guided by the Evidence Integration Triangle (EIT). The EIT brings together evidence and key stakeholders from the NH and uses a participatory implementation processes, practical evidence-based interventions, and pragmatic measures of progress toward goals. A total of 55 nursing homes from two states and 553 residents were included in this study. Nursing homes were randomized to EIT-4-BPSD or education only. This symposium will describe the utility of the EIT as an implementation framework based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance model, report detailed effectiveness outcomes of EIT-4-BPSD at the setting and resident levels, and address recruitment and measurement challenges and future solutions to these challenges.

Pattern of prescription of psychotropics (antipsychotics, antidepressants and benzodiazepines) in Western Australian residential aged care facilities.

Behavioural and psychological symptoms of dementia are exhibited by up to 90% of residents in aged care facilities and are associated with a risk of inappropriate use of psychotropic drugs. This study examined the prevalence pattern of psychotropic drug use in 409 residents from 11 residential aged care facilities in Western Australia. Sixty-four (n = 64; 15.6%) residents were not prescribed any psychotropic drug, 345 (84.4%) were prescribed at least one psychotropic drug and between 4 and 10% were prescribed high doses, depending on the class of psychotropic. Despite increasing awareness of inappropriate psychotropic drug use in this population, targeted and effective interventions are required to improve psychotropic prescribing practices.

Point of care testing for infectious disease: ownership and quality.

Traditionally, diagnosis of acute infections has been organism-growth based, which makes timely and actionable infection diagnosis a major challenge. In addition, traditional microbial detection methods, including direct microscopy, are not suited for outsourcing to clinical, non-laboratory-educated personnel. Optimal management of patients with known or suspected clinical infections, such as targeted (or no) antimicrobial treatment and correct use of single room contact isolation facilities, requires rapid identification of the causative infectious microorganism. We are now facing a new disruptive paradigm shift in diagnostic microbiology. The availability of small-footprint robust instruments with easy-to-use assay kits allows non-laboratory-trained nurses and physicians to perform high-quality molecular diagnostics in a near-patient setting with results available in <30 minutes. This technology is currently breaking the centralized laboratory monopoly on the delivery of gold-standard clinical microbiology diagnostics. There is clear potential for huge positive impacts on clinical patient management and antibiotic stewardship, especially in settings where access to timely laboratory test results is not possible, but there are also potentially huge risks. Moving diagnostic testing away from the controlled diagnostic laboratory environment will lead to risks such as increased risk of inappropriate use of the diagnostic tests, insufficient training of staff performing the tests, incorrect interpretation of the test results, lack of quality control procedures, failure to capture test results in electronic patient records and compromised local as well as national surveillance. To reap the upside and avoid the downside of point-of-care infectious disease testing, the diagnostic laboratory needs to maintain oversight, and each institution must have a clear strategy for implementation and execution. If we fail, the risks could outweigh the benefits.

Outpatient Prescription Practices in Patients with Atrial Fibrillation (From the NCDR PINNACLE Registry)

This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present.

Implementation and Impact of a Multidisciplinary Coagulation Factor Stewardship Program

Introduction: Coagulation factor products are costly and can cause adverse outcomes when used inappropriately. Active stewardship may reduce the risk of inappropriate use, increase the likelihood of safe and effective use, and help control costs. Such goals may be met when these products are dispensed from an inpatient pharmacy. After multidisciplinary discussions of unmet clinical needs and pharmacoeconomic concerns, coagulation factor product guidelines for use were established at our institution and a multidisciplinary stewardship program was implemented.Objective: The purpose of this quality improvement initiative was to implement a multidisciplinary coagulation factor stewardship program and ascertain its impact on the use of coagulation factor products after dispensing them from inpatient pharmacy instead of the blood bank.Methods: We compared the utilization of 4-Factor prothrombin complex concentrate (4F-PCC) and recombinant factor VIIa (rVIIa) from the period of 7/1/16 to 5/31/17, 6 months prior to and 6 months after implementation of the stewardship program. Prior to implementation, pharmacists, hematologists, surgeons, anesthesiologists, and intensivists met to develop hospital-wide guidelines and order sets for 4F-PCC and rVIIa. The guidelines include indications for which 4F-PCC can be dispensed without hematology consultation and the requirement for hematology consultation for approval of requests outside of these guidelines. The Pharmacy & Therapeutics Committee approved all guidelines, order sets and the hematology service stewardship. Data about approval, administration, cost, and outcomes were obtained retrospectively for the 6 months prior and prospectively for the 6 months after implementation of the stewardship program.Results: Pre-implementation, 30 patients received 4F-PCC and 7 received rFVIIa. Warfarin reversal prior to emergent surgery (n=18, 60%) was the most common indication for 4F-PCC, followed by warfarin reversal for major bleeding (n=9, 30%) and direct oral anticoagulant (DOAC) reversal (n=3, 10%). Vitamin K was administered to 78% of the patients requiring warfarin reversal. The indications for rFVIIa included FVII deficiency (n=3, 42%), hemophilia with inhibitors (n=2, 29%), and refractory major bleeding (n=2, 29%). Of all patients, 7 (19%) died before discharge, but not within 72 hours and 1 (3%) had a thrombotic event within 72 hours. The cost of 4F-PCC and rFVIIa during the 6 months preceding the stewardship program was $261,880.After stewardship was implemented, 34 patients received 4F-PCC and 3 received rFVIIa. Indications for 4F-PCC included warfarin reversal prior to emergent surgery (n=21, 62%), warfarin reversal for major bleeding (n=5, 15%), DOAC reversal (n=4, 12%), and peri-operative management of other coagulopathies (n=4, 12%). Vitamin K was administered to 88% of patients requiring warfarin reversal. The pharmacy dispensed the products according to institutional guidelines in 88% of cases, and without hematology consultation when it should have been obtained in 12% of cases. Hematology was consulted for stewardship in 6 cases; 2 were approved and 4 were denied for disseminated intravascular coagulation (DIC) (n=2), factor V deficiency without active bleeding (n=1), and surgical bleeding (n=1). Of all patients, 10 (24%) died before discharge, including the 2 with DIC who were denied product. Three (7%) died within 72 hours and 2 (5%) had thrombotic events within 72 hours. The cost for 4F-PCC and rFVIIa was $160,144 after stewardship was implemented.Conclusions: Dispensing 4F-PCC and rFVIIa from the inpatient pharmacy with stewardship has resulted in similar utilization and efficacy as existed in the pre-implementation period but with cost savings of $101,000 during the first 6 months of stewardship. Furthermore, implementation of a multidisciplinary coagulation factor stewardship program with standardized institutional guidelines, streamlined dispensing from the inpatient pharmacy, as well as use of expert hematologic consultation when indicated, has enhanced the culture of safety in our institution. The experience has also enriched the training of hematology fellows, residents and pharmacists. DisclosuresFongemie:Bristol Myers Squibb: Speakers Bureau. Comenzo:Janssen: Consultancy, Research Funding; Prothena: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Karyopharm: Research Funding.

Environmental and Health Risks of Pesticide Use in Ethiopia.

Background.There are frequent reports of unsafe pesticide use in many parts of Africa. Ethiopia is the second most populous nation in Africa with around 80% of the population still depending on agriculture which intensively uses pesticides. A number of studies have examined pesticide-related health and environmental risks in Ethiopia. However, most of these studies have been small in scale and it is therefore challenging to get a general overview of the extent of health risks and level of environmental contamination in the country.Objectives.The aim of the present study was to synthesize and summarize contemporary knowledge on pesticide-related risks and relevant gaps in Ethiopia.Methods.An electronic database search and gathering of grey literature were done to collect information on the risks of pesticide use in Ethiopia. The electronic search was conducted using MEDLINE (via PubMed) without any publication date or language specifications. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) checklist was used as guide in the creation of this review.Discussion.A synthesis of the reviewed studies showed evidence of health risks due to occupational pesticide exposure, surface water pollution with pesticides that could cause chronic health risks to the public, evidence of pesticide contamination of the environment (e.g., soil organisms, fish, bee colonies and wildlife) and local as well as international consumer risks due to pesticide residues in food items. In addition, there have been frequent reports of health and environmental hazards in association with cut-flower farms. There is also evidence of direct use of DDT (dichlorodiphenyltrichloroethane) on food crops and detection of DDT residues in surface water, soil and human breast milk. Those reported risks might be due to lack of knowledge among farm workers, negligence of farm owners, absence of post-registration monitoring systems and poor implementation of both national and international regulations in Ethiopia due to poor institutional capacity.Conclusions.The health and environmental risks of inappropriate use of pesticides requires action by all concerned bodies. Improved institutional arrangements for enforcement of regulations, awareness and further intervention studies could lessen the high risks of pesticide misuse.Competing Interests.The authors declare no competing financial interests.

Effectiveness of pregabalin and gabapentin in patients with neuropathic pain

Effective and safe treatment of patients with neuropathic pain (NP), despite the emergence of new clinical trials, remains a challenge for clinicians. A review of epidemiological data from around the world suggests the prevalence of NP at the level of 6.9–10% in the entire population, more often in women and in the elderly [1, 2]. Chronic NP is associated with a reduced quality of life of patients. In this group of patients, anxiety, and depressive disorders as well as sleep disorders are more common [3]. Hence, effective management of patients with NP is an important problem that requires further research. The aim of the article is to present the current knowledge about pregabalin and gabapentin, their mechanisms of action, effectiveness in patients with NP, the potential risk of side effects and the risk of inappropriate use, as well as to indicate their place in the standards of neuropathic pain treatment in the light of current clinical trials.

Toward an Integrated Policy Framework

Policymakers often face difficult tradeoffs in pursuing domestic and external stabilization objectives. The paper reflects staff’s work to advance the understanding of the policy options and tradeoffs available to policymakers in a systematic and analytical way. The paper recognizes that the optimal path of the IPF tools depends on structural characteristics and fiscal policies. The operational implications of IPF findings require careful consideration. Developing safeguards to minimize the risk of inappropriate use of IPF policies will be essential. Staff remains guided by the Fund’s Institutional View (IV) on the Liberalization and Management of Capital Flows.

A predictive model of inappropriate use of medical tests and medications in Bronchiolitis.

Few studies have identified predictors of inappropriate use of medications and medical tests in bronchiolitis. This study aimed to look for potential factors associated with the inappropriate use of medications and tests in bronchiolitis. A retrospective study that included all infants under two years of age in tertiary center admitted due to Bronchiolitis from January 2015 to December 2018. We defined a composite score as the main outcome variable. 1930 patients were included. The most prescribed medications were nebulized hypertonic saline in 1789 patients (92.6%), albuterol (56%), and β-lactam antibiotics (26.4%). The medical tests more commonly ordered were hemogram (95.9%), chest X-rays (92.2%) and C-reactive protein (79.8%). After controlling for potential confounders, it was found that the length of hospital stay increases the risk of the inappropriate use of medications and tests (OR 1.29; CI 95% 1.01-1.65), whereas fever (OR 0.22; CI 95% 0.06-0.71) and leukocytosis (> 15,000/μL) (OR 0.09; CI 95% 0.03-0.32) at admission decrease the risk of the inappropriate use of medications and tests. Inappropriate use of diagnostic tests and drugs for bronchiolitis was a highly prevalent outcome in our population. Patients with longer hospitalizations, absence of fever and a normal white blood cell count at admission, were at increased risk of inappropriate use of medications and medical tests.

A pharmacist-led pilot using a performance dashboard to improve psychotropic medication use in a skilled nursing facility

ObjectivesInappropriate use of psychotropic medications in the elderly, particularly those with dementia, is a critical safety and quality concern. This pilot quality improvement study used a novel Department of Veterans...