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To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).
Design, Setting, and Participants
This 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.
Phase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication.
Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153–0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719–0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834–0·959; P=·0017).
The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.
Hospitalized influenza patients are often treated with antibiotics empirically while awaiting final diagnosis. The goal of this study was to describe the inappropriate continuation of antibiotics for influenza respiratory tract infections (RTIs).
We retrospectively studied adults admitted to our institution over 2 respiratory flu seasons with positive influenza RTIs. Inappropriate antibiotic duration (IAD) was defined as antibiotic use for >24 hours after a positive influenza test in patients presenting with <72 hours of RTI symptoms and with no other indications of bacterial infection.
During the study period, 322 patients included in this study were admitted for influenza RTI. Respiratory cultures were ordered for 50 of these patients (15.5%) and 71 patients (22%) had a positive chest x-ray, but antibiotics were prescribed to 211 patients (65.5%) on admission. Antibiotics were inappropriately continued in 73 patients (34.5%). Patients receiving IAD had a longer length of stay (LOS) (median, 6 days; range, 4–9 days) compared with those whose antibiotics were discontinued appropriately (median, 5 days; range, 3–8 days) and those who were not treated with antibiotics (median, 4 days; range, 3–6 days; P<.001). However, mortality was similar among these 3 groups: 3 patients (4.1%) from the IAD cohort died; 6 patients (4.3%) from the group with an appropriate antibiotic duration died; and 2 patients [1.8%] from the group given no antibiotics died (P=.510). The 30-day readmission rates were similar as well: 9 patients (12.3%) from the IAD group were readmitted within 30 days; 21 patients (15.2%) from the group with appropriate antibiotic duration were readmitted; and 11 patients (9.9%) from the group given no antibiotics were readmitted (P=.455). Total hospital costs were greater in patients treated with IAD ($10,645; range, $6,485–$18,035) compared with the group treated with appropriate antibiotic duration ($7,479; range, $4,866–$12,922) and the group given no antibiotics $5,961 (range, $4,711–$9,575). Thus, the hospital experienced a median loss in net hospital revenue of $2,076 per IAD patient compared with a patient for which antibiotic duration was appropriate.
The majority of patients with influenza RTI received antibiotics on admission, and 34.5% were inappropriately continued on antibiotics without evidence of bacterial infection, which led to increased LOS, loss of net revenue, and no improvement in outcome. Thus, stewardship initiatives aimed at this population are warranted.
Acute agitation is a common psychiatric emergency often treated with intramuscular (IM) medication when rapid control is necessary or the patient refuses to take an oral agent. Conventional IM antipsychotics are associated with side effects, particularly movement disorders, that may alarm patients and render them unreceptive to taking these medications again. Ziprasidone (Geodon®) is the first second-generation, or atypical, antipsychotic to become available in an IM formulation. Ziprasidone IM was approved by the Food and Drug Administration in 2002 for the treatment of agitation in patients with schizophrenia. In October 2004, a roundtable panel of physicians with extensive experience in the management of acutely agitated patients met to review the first 2 years of experience with this agent. This monograph, a product of that meeting, discusses clinical experience to date with ziprasidone IM and offers recommendations on its use in various settings.
In clinical trials, patients treated with ziprasidone IM demonstrated significant and rapid (within 15-30 minutes) reduction in agitation and improvement in psychotic symptoms, agitation, and hostility to an extent greater than or equal to that attained with haloperidol IM. Tolerability of ziprasidone IM was superior to that of haloperidol IM, with a lower burden of movement disorders. Clinical trials have also shown that ziprasidone IM can be administered with benzodiazepines without adverse consequences. Transition from IM to oral ziprasidone has been well tolerated, with maintenance of symptom control. The most common adverse events associated with ziprasidone IM were insomnia, headache, and dizziness in fixed-dose trials and insomnia and hypertension in flexible-dose trials. No consistent pattern of escalating incidence of adverse events with escalating ziprasidone doses has been observed. Changes in QTc interval associated with ziprasidone at peak serum concentrations are modest and comparable to those seen with haloperidol IM. Results of randomized clinical trials of ziprasidone IM have been corroborated in studies in real-world treatment settings involving patients with extreme agitation or a recent history of alcohol or substance abuse. In these circumstances, clinically significant improvement was seen within 30 minutes of ziprasidone IM administration, without regard to the suspected underlying etiology of agitation. Agents with a good safety/tolerability profile, such as ziprasidone IM, may be more cost effective long term than older agents, due to reduced incidence of acute adverse effects (eg, acute dystonia) that often require extended periods of observation. Additional trials of ziprasidone IM in agitated patients in a variety of clinical settings are warranted to generate comparative risk/benefit data with conventional agents and other second-generation antipsychotics.
A multi-scale investigation of twin bundles in Fe–22Mn–0.6C (wt%) twinning-induced plasticity steel after tensile deformation has been carried out by truly correlative means; using electron channelling contrast imaging combined with electron backscatter diffraction, high-resolution secondary ion mass spectrometry, scanning transmission electron microscopy, and atom probe tomography on the exact same region of interest in the sample. It was revealed that there was no significant segregation of Mn or C to the twin boundary interfaces.
The mixing of titanium overlayers with hydroxyapatite (HA) substrates via ion irradiation has been demonstrated. Analysis via secondary ion mass spectroscopy (SIMS) indicates an interfacial broadening of titanium and calcium of the implanted sample compared to that of the unimplanted sample. Attendant to the observed ion beam mixing of titanium into the HA, the oxygen signal of the titanium overlayer increases as a result of ion irradiation. It is supposed that this change is evident of diffusion through the metal layer and possibly from titania formation at the free surface and perovskite formation at the film/substrate interface. This possibility is consistent with thermodynamic predictions. Additionally, the force required to separate the film from the substrate increased as a result of ion irradiation, validating the continued study of ion beam processing of Ti/HA systems towards the improvement of long term fixation of implant devices.
Scanning force microscopy is used to study the structure of various sensing films after chemical and thermal treatments. An example chemical modification of the sensing film can be achieved by heating a Pt/Ti sensing film in an oxygen environment. 1 With Pt acting as a catalyst, the Ti can become partially oxidized, resulting in a Pt/TiOx film which has different electronic properties than a metallic film. By further oxidizing the film, an insulating layer of TiO2 may be achieved. Or as in the case of hydrogen sensing, the Pt/TiOx film may revert to a more metallic state via the reduction of TiOx. The chemical interactions of these sensing films may be associated with large scale microstructural changes. The sensing activity and the structure of Ti, Pt/Ti, and Au/Ti films to gases such as hydrogen, and propylene has been studied. These chemical and morphological changes can be monitored by measuring the resistance of the thin sensing films. Pt/Ti films were found to have the best response to hydrogen (200 ppm) and propylene (150 ppm), while Au/Ti films showed weaker response to propylene (500 ppm) and CO (1000 ppm). The Pt/Ti films also showed shifts in temperature with changing propylene concentration possibly due to catalytic combustion.
Nanophosphors correspond to nanostructured inorganic insulator materials that emit light under particle or electromagnetic radiation excitation. In this work we investigate the structure and luminescent properties of Ce-doped Lu2SiO5 (LSO) nanophosphors prepared by solution combustion synthesis with the Ce content 0.1 to 12 at. %. Samples were characterized by transmission electron microscopy (TEM), line scan electron energy-loss spectroscopy (EELS), x-ray diffraction (XRD), and electron paramagnetic resonance (EPR) spectroscopy. Photoluminescence excitation and emission spectra are composed of two major bands centered at 360 and 430 nm, respectively. These results reveal a red-shift and enhanced Stokes shift for the nanophosphors when compared to bulk. Ce content was also found to affect photoluminescence emission intensity and fluorescent lifetime. The nanophosphor concentration quenching curve presents a broad maximum centered at 1 at.%. Lifetime measurements show a continuous decrease from 34 to 21 ns as Ce content is increased.
The cognitive profile of early onset Parkinson’s disease (EOPD) has not been clearly defined. Mutations in the parkin gene are the most common genetic risk factor for EOPD and may offer information about the neuropsychological pattern of performance in both symptomatic and asymptomatic mutation carriers. EOPD probands and their first-degree relatives who did not have Parkinson’s disease (PD) were genotyped for mutations in the parkin gene and administered a comprehensive neuropsychological battery. Performance was compared between EOPD probands with (N = 43) and without (N = 52) parkin mutations. The same neuropsychological battery was administered to 217 first-degree relatives to assess neuropsychological function in individuals who carry parkin mutations but do not have PD. No significant differences in neuropsychological test performance were found between parkin carrier and noncarrier probands. Performance also did not differ between EOPD noncarriers and carrier subgroups (i.e., heterozygotes, compound heterozygotes/homozygotes). Similarly, no differences were found among unaffected family members across genotypes. Mean neuropsychological test performance was within normal range in all probands and relatives. Carriers of parkin mutations, whether or not they have PD, do not perform differently on neuropsychological measures as compared to noncarriers. The cognitive functioning of parkin carriers over time warrants further study. (JINS, 2011, 17, 1–10)