Pediatric psychiatric inpatients' perspectives of aggression management: Discernment in the doorway.

PROBLEM: Aggressive behavior is common on psychiatric inpatient units. Seclusion and restraint interventions to manage patients' aggressive behavior may have the consequence of being traumatizing for patients. Pediatric psychiatric patients' perspective on the use of seclusion and restraint interventions is not present in the literature. METHODS: This hermeneutic nursing research study asked the question, "How might we understand children's experiences of seclusion and restraints on an inpatient psychiatric unit?" Four past pediatric psychiatric inpatients shared their hospitalization experiences that occurred within the previous year when they were 10 years old. The texts of the research interviews were compared to Attachment Theory for a deeper understanding of the meaning of the message. FINDINGS: Participants commonly described experiences with seclusion and restraints as feeling trapped and alone in a dark room. They recommended the nurses step into the room with them to help them heal. Interpretively, the rooms on inpatient units could be considered as actual and metaphorical spaces of possible harm or healing. CONCLUSION: The participant's voices expand understanding of nurse's use of discernment at the doorway of a patient room to ensure the most therapeutic care is provided to the patient in these spaces through a secure nurse-patient relationship.

Health-related quality of life among inpatients suffering from Traumatic brain injury in an urban setting in Vietnam.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of mortality and morbidity globally. This study aimed to measure the health-related quality of life (HRQOL) of TBI patients in Vietnam and evaluate the associated factors. METHODS: A longitudinal study was conducted in Thai Binh, Vietnam, from February to September 2020. The EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) and EQ-Visual Analog Scale (EQ-VAS) were used to measure HRQOL. Socio-demographic characteristics, including age, gender, education level, employment status, marital status, and income, as well as clinical characteristics such as injury severity, cause of injury, comorbidities, and functional status, were collected through patient interviews and medical records. Multivariate Tobit regression analysis was performed to identify variables associated with HRQOL. RESULTS: The study included 212 TBI patients. The mean scores of the VAS and EQ-5D-5L scales were 82.4/100 (SD = 14.49) and 0.9/1.0 (SD = 0.2), respectively, indicating a relatively high HRQOL. However, certain factors significantly impacted HRQOL. Unemployed patients and those with depression or higher injury severity, as measured by the Injury Severity Score (ISS), had notably lower HRQOL scores. Poor sleep quality and severe functional impairments also adversely affected HRQOL, whereas patients discharged for a longer period had slightly better HRQOL scores. CONCLUSION: This study highlights that while HRQOL is relatively high among TBI patients, mental health disorders, injury severity, and functional impairments are key factors negatively impacting their quality of life. High HRQOL was defined by mean scores on the VAS and EQ-5D-5L scales, with higher scores indicating better quality of life. Home-based interventions addressing these issues could improve HRQOL for TBI patients.

Unraveling the effects of DIP payment reform on inpatient healthcare: insights into impacts and challenges.

BACKGROUND: The Diagnosis-Intervention Packet (DIP) payment system, initiated by China's National Healthcare Security Administration, is designed to enhance healthcare efficiency and manage rising healthcare costs. This study aims to evaluate the impact of the DIP payment reform on inpatient care in a specialized obstetrics and gynecology hospital, with a focus on its implications for various patient groups. METHODS: To assess the DIP policy's effects, we employed the Difference-in-Differences (DID) approach. This method was used to analyze changes in total hospital costs and Length of Stay (LOS) across different patient groups, particularly within select DIP categories. The study involved a comprehensive examination of the DIP policy's influence pre- and post-implementation. RESULTS: Our findings indicate that the implementation of the DIP policy led to a significant increase in both total costs and LOS for the insured group relative to the self-paying group. The study further identified variations within DIP groups both before and after the reform. In-depth analysis of specific disease groups revealed that the insured group experienced notably higher total costs and LOS compared to the self-paying group. CONCLUSIONS: The DIP reform has led to several challenges, including upcoding and diagnostic ambiguity, because of the pursuit of higher reimbursements. These findings underscore the necessity for continuous improvement of the DIP payment system to effectively tackle these challenges and optimize healthcare delivery and cost management.

Incidence and related risk factors for postoperative delirium following revision total knee arthroplasty: a retrospective nationwide inpatient sample database study.

BACKGROUND: Postoperative delirium (POD) is a common surgical complication. However, the incidence and risk factors associated with postoperative delirium after revision total knee arthroplasty (rTKA) have not been comprehensively explored through extensive national databases. METHODS: Utilizing the National Inpatient Sample (NIS), the largest comprehensive U.S. hospital healthcare database, we undertook a retrospective investigation involving 127,400 patients who underwent rTKA between 2010 and 2019. We assessed various aspects, including patient demographics, hospital characteristics, pre-existing medical conditions, and perioperative complications. RESULTS: The overall incidence of postoperative delirium (POD) in patients undergoing rTKA between 2010 and 2019 was 0.97%. The highest incidence rate of 1.31% was recorded in 2013. Notably, this patient cohort demonstrated advanced age, increased burden of co-morbidities, prolonged hospital stays, increased hospitalization costs, and elevated in-hospital mortality rates (P < 0.001). Moreover, non-elective admissions, non-private insurance payments, and a preference for teaching hospitals were commonly observed among these patients. During their hospitalization, individuals who developed delirium subsequent to rTKA were more prone to experiencing certain perioperative complications. These complications encompassed medical issues like acute myocardial infarction, continuous invasive mechanical ventilation, postoperative shock, sepsis, stroke and other medical problems. Additionally, surgical complications including hemorrhage / seroma / hematoma, irrigation and debridement, prosthetic joint infection, periprosthetic fracture, and wound dehiscence / nonunion were noted. Several risk factors were found to be linked with the development of POD. These included advanced age (≥ 75 years), alcohol abuse, coagulation disorders, congestive heart failure, depression, fluid and electrolyte imbalances, and more. Conversely, female sex, having private insurance, and undergoing elective hospitalization emerged as protective factors against POD. CONCLUSION: Our findings suggest that the general prevalence of POD in rTKA is relatively low according to NIS. There was a significant connection between the POD of rTKA and advanced age, prolonged length of stay (LOS), more in-patients' costs, higher in-hospital mortality rate, increased comorbidities, postoperative medical complications and postoperative surgical complications. This study helps to understand the risk factors associated with POD to improve poor outcomes.

Integrative Korean medicine treatment for inpatients with osteoarthritis of the knee: An observational study.

The use of integrative Korean medicine treatment (IKMT) for patients with knee osteoarthritis (OA) has been reported previously; however, to date, no studies have investigated the long-term prognosis of these patients following IKMT for primary knee OA. We aimed to examine the long-term effects of IKMT in patients diagnosed with primary knee OA and receiving IKMT during hospitalization. This retrospective observational study, complemented by a follow-up survey, included patients with primary knee OA who received IKMT during hospitalization across 7 Korean medicine hospitals. The primary outcome was the Numerical Rating Scale knee-pain score, whereas the secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol-5 dimension-5 level questionnaire (EQ-5D-5L), and Patient Global Impression of Change scores. Patients were evaluated at admission, discharge, and during follow-up. Of the 180 included patients, 81 responded to the survey. Compared with the corresponding values at admission, the Numerical Rating Scale score decreased by 2.44 (2.08-2.81) points at discharge and 1.89 (1.5-2.26) points at follow-up. Additionally, compared with their scores at admission, the WOMAC score decreased by 17.20 (13.68-20.71) points at discharge and 25.74 (22.22-29.26) points at follow-up, whereas the EuroQol-5 dimension-5 level questionnaire score improved by -0.15 (-0.18 to -0.12) points at discharge and -0.12 (-0.15 to -0.09) points at follow-up. The patients expressed high satisfaction with pharmacopuncture (65.4%), acupuncture (54.03%), physical therapy (35.8%), and herbal medicine (34.6%). Regarding Patient Global Impression of Change, 96.30% of the patients reported improvement. IKMT was effective in improving pain, functional disability, and quality of life in patients with primary knee OA. Its effects were maintained throughout the long-term follow-up period, and physical functions continuously improved.

Treating Children and Adolescents with Aggressive Behaviors in the Inpatient Setting.

The mental health crisis in children and adolescents presents a unique challenge for pediatric providers in the inpatient setting. Patients are presenting to the emergency department in acute psychiatric crises, but the increased need for behavioral health services is met with an already limited supply of behavioral health services and facilities. As such, these patients are hospitalized on acute care floors, which can serve to exacerbate symptoms of aggression regardless of cause and complicates treatment and harm prevention strategies. We present a comprehensive management approach to the acutely agitated pediatric patient with aggressive behaviors, including prevention of symptoms in patients with risk factors; nonpharmacological approaches to de-escalation, including the use of restraint; and common oral and parenteral psychopharmacological agents. Such strategies are considered from a medical, ethical, and legal standpoint with the goal of maintaining safety and minimizing harm to patients, families, and staff. [Pediatr Ann. 2024;53(8):e293-e298.].

A Review of Trauma-Informed Care for Youth and Their Families in Inpatient Pediatric Settings.

Due to the pervasiveness of trauma, it is likely that many children and families seen in pediatric health settings have incurred traumatic experiences. These experiences can lead to a variety of negative medical, psychological, and social health outcomes. Therefore, a provider's focus on supporting resilience is integral. The use of trauma-informed care (TIC) is one way providers can work toward promoting a family's resilience. TIC is considered an organizational, attitudinal shift to understanding the broad impacts of trauma. This shift can contribute to changes in policies and procedures to make each system more welcoming to all those accessing the health system. This review will discuss the current pervasiveness of trauma, its associated impacts, the importance of TIC, and practical applications of TIC based on guiding principles provided by the Substance Abuse and Mental Health Services Administration. [Pediatr Ann. 2024;53(8):e299-e304.].

The Inpatient Management of Adolescents with Eating Disorders.

Eating disorders affect individuals of all ages, genders, sexual orientations, ethnicities, races, and socioeconomic statuses. They can lead to serious medical complications that require inpatient treatment. The eating disorders that are most likely to lead to medical complications requiring medical inpatient stabilization include anorexia nervosa, atypical anorexia nervosa, avoidant-restrictive food intake disorder, bulimia nervosa, and purging disorder. There are criteria that can help determine if a patient requires inpatient stabilization. Nearly all body systems may be affected. Patients are often treated by following a refeeding protocol that reduces the risk of developing refeeding syndrome, a dangerous and life-threatening state of metabolic derangements that can arise when a malnourished individual begins a renourishment process. Following stabilization, patients should receive further care through a number of different treatment options directed at their underlying eating disorder and by working with a multidisciplinary team. [Pediatr Ann. 2024;53(8):e283-e287.].

Prevalence and risk factors for extended-spectrum ß-lactamase producing antimicrobial-resistant E. coli in urinary tract infections among inpatients in the tertiary hospitals in Zanzibar (Tanzania): a prospective cross-sectional study.

Introduction: Extended-spectrum ß-lactamase (ESBL) production among Enterobacteriaceae, such as E. coli, has been increasing worldwide, which causes treatment failure for urinary tract infections. Therefore, this study aimed to determine the prevalence and risk factors for the production of ESBL in E. coli from patients with urinary tract infections (UTI) in Zanzibar. Methods: a prospective cross-sectional study was conducted from January 2018 to December 2021 in Zanzibar. Data were retrieved from a routine bacteriological laboratory culture report from urine samples of 4306 patients at the Lancet Laboratory. In addition, the patient's social demographics and clinical data were retrieved by examining the medical records in the respective hospitals. All inpatients older than fifteen years diagnosed with urinary tract infections (UTI) and requested urine culture and sensitivity were included. The Chi-square and Fischer's exact tests were used to compare antibiotic resistance. In addition, a binary logistic regression analysis was used to predict ESBL production risk factors. Results: the prevalence of E. coli-producing ESBL was 13.4% (578/4030). Infection of ESBL. E. coli was prevalent in females 52.6% (n=304) compared to male patients, 47.4% (n=274), and the majority 38.8% (n=224), were people of young age, between 16-30 years. The average age of patients was 31.5±10.2 years, with minimum age of 16 years and a maximum age of 72 years. In multivariate analysis, results shown that previously hospitalised patients aOR: 6.35, 95% Cl 3.37-11.92; p=0.001, long hospital stays aOR: 10.34, 95% Cl 3.03-22.29; p <0.001, prior use of penicillin aOR: 7.78, 95% Cl 2.99-29.11; p < 0.001, and prior use of cephalosporin drugs aOR: 4.64, 95% Cl 2.99-9.96; p=0.001, were strongly associated with the emergence of ESBL-producing E. coli in urinary tract infection patients. ESBL E. coli showed high resistance to amoxicillin 99.5% (n=575), ampicillin 97.8.% (n=570), cotrimazaxole 86.2% (n=344), ceftriaxone 73.7% (n=344), ciprofloxacin 73.2% (n=423), and ceftaxime 59.5% (n=426). There was a less resistance to ampicillin -cloxacillin 44.3% (n=256), gentamicin 22.5% (n=22.5), and norfloxacin 18.9% (n=109) respectively. Isolates were shown to be more susceptible to meropenem at 1.6% (n=9). Conclusion: the overall prevalence of ESBL-producing E. coli is 13.4%. The risk of emergence ESBL was higher in patients with previous history of hospitalisation, long hospital stay, prior use of penicillin and cephalosporin drugs. High level of antimicrobial resistance observed against most commonly used antibiotics in treatment of urinary tract infections. The clinicians should rely on microbiological diagnosis in treatment of UTIs to reduce risk of treatment failure. Further study should be carried out to assess the prevalence and resistance pattern of other uropathogens and other risk factors.

Subgroups of High-Cost Patients and Their Preventable Inpatient Cost in Rural China.

BACKGROUND: High-cost patients account for most healthcare costs and are highly heterogeneous. This study aims to classify high-cost patients into clinically homogeneous subgroups, describe healthcare utilization patterns of subgroups, and identify subgroups with relatively high preventable inpatient cost (PIC) in rural China. METHODS: A population-based retrospective study was performed using claims data in Xi county, Henan province. 32 108 high-cost patients, representing the top 10% of individuals with the highest total spending, were identified. A density-based clustering algorithm combined with expert opinions were used to group high-cost patients. Healthcare utilization (including admissions, length of stay, and outpatient visits) and spending characteristics (including total spending, and the proportion of PIC, inpatient and out-of-pocket spending on total spending) were described among subgroups. PIC was calculated based on potentially preventable hospitalizations (PPHs) which were identified according to the Agency for Healthcare Research and Quality Prevention Quality Indicators algorithm. RESULTS: High-cost patients were more likely to be older (Mean=51.87, SD=22.28), male (49.03%) and from poverty-stricken families (37.67%) than non-high-cost patients, with 2.49 (SD=2.47) admissions and 3.25 (SD=4.52) outpatient visits annually. Fourteen subgroups of high-cost patients were identified: chronic disease, non-trauma diseases which need surgery, female disease, cancer, eye disease, respiratory infection/inflammation, skin disease, fracture, liver disease, vertigo syndrome and cerebral infarction, mental disease, arthritis, renal failure, and other neurological disorders. The annual admissions ranged from 1.83 (SD=1.23, fracture) to 12.21 (SD=9.26, renal failure), and the average length of stay ranged from 6.61 (SD=10.00, eye disease) to 32.11 (SD=28.78, mental disease) days among subgroups. The chronic disease subgroup showed the largest proportion of PIC on total spending (10.57%). CONCLUSION: High-cost patients were classified into 14 clinically distinct subgroups which had different healthcare utilization and spending characteristics. Different targeted strategies may be needed for subgroups to reduce preventable hospitalizations. Priority should be given to high-cost patients with chronic diseases.

De-escalating aggression in acute inpatient mental health settings: a behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives.

BACKGROUND: De-escalation is often advocated to reduce harm associated with violence and use of restrictive interventions, but there is insufficient understanding of factors that influence de-escalation behaviour in practice. For the first time, using behaviour change and implementation science methodology, this paper aims to identify the drivers that will enhance de-escalation in acute inpatient and psychiatric intensive care mental health settings. METHODS: Secondary analysis of 46 qualitative interviews with ward staff (n = 20) and patients (n = 26) informed by the Theoretical Domains Framework. RESULTS: Capabilities for de-escalation included knowledge (impact of trauma on memory and self-regulation and the aetiology and experience of voice hearing) and skills (emotional self-regulation, distress validation, reducing social distance, confirming autonomy, setting limits and problem-solving). Opportunities for de-escalation were limited by dysfunctional risk management cultures/ relationships between ward staff and clinical leadership, and a lack of patient involvement in safety maintenance. Motivation to engage in de-escalation was limited by negative emotion associated with moral formulations of patients and internal attributions for behaviour. CONCLUSION: In addition to training that enhances knowledge and skills, interventions to enhance de-escalation should target ward and organisational cultures, as well as making fundamental changes to the social and physical structure of inpatient mental health wards. Psychological interventions targeting negative emotion in staff are needed to increase motivation. This paper provides a new evidence-based framework of indicative changes that will enhance de-escalation in adult acute mental health inpatient and PICU settings.

In-hospital mortality and its associated factors among hospitalized stroke patients at public hospitals of Eastern Ethiopia.

BACKGROUND: Stroke is rapidly developing clinical signs of focal/ global disturbance of cerebral function, with symptoms lasting more than 24 h and leading to death. Data showed that stroke deaths in Ethiopia reached nearly seven percent of total deaths. Despite this report, there is a paucity of investigations about the problem. OBJECTIVE: To determine in-hospital mortality and its associated factors among hospitalized stroke patients in Hiwot Fana Comprehensive Specialized University Hospital and Jugal General Hospital, eastern Ethiopia from September 2016-August 2022 G.C. METHODS: A retrospective cohort study was conducted among hospitalized stroke patients. A sample size of 395 medical records was selected from a total of 564 stroke patients by a simple random sampling technique. The data was analyzed by SPSS version 26 using bivariable and multivariable cox-regression models. A p-value of 0.05 and less at a 95% confidence interval was used to establish a statistically significant association. RESULTS: Of the total, 109 (27.6%) died in the hospital while 57.2% and 15.2% of them were discharged with improvement and against medical advice, respectively. Age greater than 65 (AHR = 4.71, 95% CI = 1.11-19.96), creatinine level > 1.2 mg/dl (AHR = 1.54, 95% CI = 1.0-2.39), and co-morbidity with atrial fibrillation (AHR = 1.48, 95% CI = 1.0-2.21) were significantly associated with in-hospital mortality. CONCLUSION: In-hospital mortality was found in more than a quarter of stroke patients. Mortality was more likely increased among the patients with age > 65, serum creatinine level > 1.2 mg/dl, and atrial fibrillation. Hence, these high-risk patients need to be monitored.

Epidemiology of orthopedic injuries among inpatients admitted at a tertiary teaching and referral hospital in Kenya: a retrospective cross-sectional study.

BACKGROUND: Orthopedic injuries are serious and continue to be a concern for healthcare systems worldwide. Approximately 90% of the estimated traumatic injuries occur in low- and middle-income countries. In Kenya, there is a dearth of information on orthopedic injury patterns that could be used to prioritize injury prevention measures and to help hospital management teams allocate resources appropriately. The purpose of this study was to determine the epidemiology of orthopedic injuries admitted to Kenyatta National Hospital. METHODS: This was a retrospective cross-sectional study. Overall, 720 charts were reviewed. Data were analyzed using frequency distribution, pearson chi-square test and logistic regression. RESULTS: Overall, 85% were aged 15-64 years. Approximately 80% were male, married or single. Patients with primary or secondary education composed 72%. Road traffic accidents (59.4%) and falls (24.7%) were the most common mechanisms of injury. A total of 99.9% of the inpatients were Kenyans. Open injuries were 40.1%. Lower limb (67.4%) and upper limb (26.9%) injuries were the most common. Inpatients aged 15-24 years were 74% less likely to have upper limb injuries than those aged 0-14 years (p = 0.023). However, those aged 15-24 years were 19.250 times more likely to have spine injuries than those aged 0-14 years (p = 0.008). Males were 68.6% and 51.2% less likely to have pelvic injury and comorbidities, respectively, than females (p < 0.001). Patients with secondary and tertiary education were 2.016 (p = 0.003) and 2.3 (p < 0.001) times more likely to have upper limb injuries, respectively, than those with no or preschool education. Similarly, those with tertiary education were 2.079 times more likely to have comorbidities than those with no or preschool education (p = 0.017). CONCLUSION: Most of the inpatients with orthopedic injuries were young, male involved in Road traffic accidents and therefore Kenya National Transport and Safety Authority needs to enforce road safety measures to reduce road carnage. Those with higher education and children were more likely to have upper limb injuries. Females were more likely to have pelvic injuries and co-morbidities. Lower and upper limb injuries were the most common injuries and this should guide resource allocation in management of orthopedic injuries.

Distinct enterotypes and dysbiosis: unraveling gut microbiota in pulmonary and critical care medicine inpatients.

BACKGROUND: The gut-lung axis, pivotal for respiratory health, is inadequately explored in pulmonary and critical care medicine (PCCM) inpatients. METHODS: Examining PCCM inpatients from three medical university-affiliated hospitals, we conducted 16S ribosomal RNA sequencing on stool samples (inpatients, n = 374; healthy controls, n = 105). We conducted statistical analyses to examine the gut microbiota composition in PCCM inpatients, comparing it to that of healthy controls. Additionally, we explored the associations between gut microbiota composition and various clinical factors, including age, white blood cell count, neutrophil count, platelet count, albumin level, hemoglobin level, length of hospital stay, and medical costs. RESULTS: PCCM inpatients exhibited lower gut microbiota diversity than healthy controls. Principal Coordinates Analysis revealed marked overall microbiota structure differences. Four enterotypes, including the exclusive Enterococcaceae enterotype in inpatients, were identified. Although no distinctions were found at the phylum level, 15 bacterial families exhibited varying abundances. Specifically, the inpatient population from PCCM showed a significantly higher abundance of Enterococcaceae, Lactobacillaceae, Erysipelatoclostridiaceae, Clostridiaceae, and Tannerellaceae. Using random forest analyses, we calculated the areas under the receiver operating characteristic curves (AUCs) to be 0.75 (95% CIs 0.69-0.80) for distinguishing healthy individuals from inpatients. The four most abundant genera retained in the classifier were Blautia, Subdoligranulum, Enterococcus, and Klebsiella. CONCLUSIONS: Evidence of gut microbiota dysbiosis in PCCM inpatients underscores the gut-lung axis's significance, promising further avenues in respiratory health research.

Comparison of two different frailty screening scales for predicting mortality due to all causes in older inpatients.

OBJECTIVE: This study examines the relationship between two frailty screening tools and 90-day all-cause mortality in geriatric inpatients. METHODS: The study included patients aged ≥60 years who were admitted to the geriatrics unit of a university hospital between June 2021 and August 2022 and whose mortality status and duration of hospitalization data were obtained from the Health Ministry System. During hospitalization, the patients were screened using two different frailty scales: the Simpler Modified Fried Frailty Scale (sMFS) and the Clinical Frailty Scale (CFS). Patients scoring ≥5 on the CFS and ≥3 on the sMFS were considered frail. RESULTS: A total of 84 participants with a mean age of 78.3±7.6 years were included in this study, of which 36.9% were male. Of the total, 60.7% and 89.3% were considered frail according to the CFS and sMFS, respectively, and the prevalence of all-cause mortality within 90 days was 19%. A univariate analysis using the Kaplan-Meier survival method revealed CFS scores to be statistically significantly related to 90-day all-cause mortality (p<0.001), while sMFS scores were not found to be statistically significant (p=0.849). Furthermore, a statistically significant relationship was identified between CFS score and all-cause mortality in multivariate analysis with Cox regression analysis [(p<0.001), hazard ratio (HR): 3.078; (95% confidence interval: 1.746-5.425)]. CONCLUSION: An evaluation of frailty in hospitalized older adults using two different scales revealed the CFS to be superior to the sMFS in predicting all-cause mortality within 90 days.

Antibiotic utilization at an orthopedic inpatient department in a large governmental hospital in the north of the West Bank, Palestine; a retrospective observational study.

BACKGROUND: Studies evaluating the patterns of antibiotic consumption are becoming increasingly necessary as a result of the increased use of antibiotics and development of antibiotic resistance globally. This study aimed to evaluate the use of antibiotics in in terms of both quantity and quality at the largest surgical hospital in the north of the West Bank, Palestine. METHODS: An observational retrospective study with a total population sampling method was conducted to collect data from the inpatients of the orthopedic departments of a large governmental hospital in the northern West Bank, Palestine. The data were collected from patients' files and evaluated using the anatomical therapeutic chemical and defined daily dose (ATC/DDD) methodology, and the drug utilization 90% (DU90%) index. The ATC/DDD methodology, designed by the World Health Organization (WHO), as a well-trusted and standardized tool that allows measuring and comparing antibiotic utilization across different contexts. Antibiotic prescriptions were classified using the World Health Organization Access, Watch and Reserve classification (WHO AWaRe). RESULTS: Of the 896 patients who were admitted to the hospital in the year 2020 and included in the study, 61.9% were males, and 38.1% were females. The percentage of patients who received antibiotics was 97.0%, and the overall antibiotic usage was 107.91 DDD/100 bed days. The most commonly prescribed antibiotic was cefazolin (50.30 DDD/100 bed days), followed by gentamicin (24.15 DDD/100 bed days) and ceftriaxone (17.35 DDD/100 bed days). The DU90% segment comprised four different agents. Classification of antibiotics according to the WHO AWaRe policy revealed that 75.9% of antibiotics were prescribed from the access list. CONCLUSION: This study comes as part of the efforts exerted to combat the growing problem of antibiotic resistance in Palestine. Our results showed that the consumption of antibacterial agents in the orthopedic unit at a large governmental hospital in Palestine was relatively high. The results of this study provide valuable insights for the decision-makers to create policies aimed at regulating antibiotic prescriptions. This study also aims to provide a look into the antibiotic prescription patterns, offering a clearer understanding of the current situation of antibiotic consumption in Palestine. It also emphasizes the need for antibiotic stewardship and surveillance programs.

Pseudomonas aeruginosa mucinous phenotypes and algUmucABD operon mutant characteristics obtained from inpatients with bronchiectasis and their correlation with acute aggravation.

Objective: Although the mechanism is unclear, Pseudomonas aeruginosa (PA) infection directly affects the frequency of acute exacerbations in patients with bronchiectasis. The aims of this article are to analyze the genetic mutation characteristics of the algUmucABD operon in PA, isolated from hospitalized patients with bronchiectasis, and to explore independent risk factors for frequent acute exacerbations of bronchiectasis. Methods: Based on the number of acute exacerbations that occurred in the past year, these patients with bronchiectasis were divided into those with frequent acute exacerbations (Group A) and those with non-frequent acute exacerbations (Group B). We identified the distribution of mucoid phenotypes (MPs) and alginate morphotypes (AMs) in PA, and classified them into I-IV categories based on their different AMs; otherwise, the gene mutation types (GMTs) of the algUmucABD operon were tested. Subsequently, the relationship between GMT, MP, and AM and the independent risk factors for frequent acute exacerbations in patients with bronchiectasis were explored. Results: A total of 93 patients and 75 PA strains, from January 2019 to August 2023, were included in this study. The MP and AM distributions of PA were as follows: 64 strains (85.33%) of mucoid (the AMs were 38 strains of type I, 3 strains of type II, and 23 strains of type IV) and 11 strains of non-mucoid (the AM was type III only). Mucoid PA with algU, mucA, mucB, and mucD mutations accounted for 19.61%, 74.51%, 31.37%, and 50.98%, respectively. GMT was divided into the following: mucA mutations only, mucA combined with other gene mutations, other gene mutations without mucA mutations, and without gene mutations. In 91.7% of PA with type I of AM, only mucA mutations occurred, and in both separate MP and AM, the GMT differences were statistically significant. Lastly, the number of lung lobes with bronchiectasis and the number of PA with mucA mutations only were the independent risk factors for frequent acute exacerbations. Conclusion: The mucA mutation was primarily responsible for the mucoid of MP and type I of AM in PA, and it was also an independent risk factor for frequent exacerbations of bronchiectasis.