Implementation of indication-based antibiotic order sentences improves antibiotic use in emergency departments.

INTRODUCTION: Prior data have suggested that suboptimal antibiotic prescribing in the emergency department (ED) is common for uncomplicated lower respiratory tract infections (LRTI), urinary tract infections (UTI), and acute bacterial skin and skin structure infections (ABSSSI). The objective of this study was to measure the effect of indication-based antibiotic order sentences (AOS) on optimal antibiotic prescribing in the ED. METHODS: This was an IRB-approved quasi-experiment of adults prescribed antibiotics in EDs for uncomplicated LRTI, UTI, or ABSSSI from January to June 2019 (pre-implementation) and September to December 2021 (post-implementation). AOS implementation occurred in July 2021. AOS are lean process, electronic discharge prescriptions retrievable by name or indication within the discharge order field. The primary outcome was optimal prescribing, defined as correct antibiotic selection, dose, and duration per local and national guidelines. Descriptive and bivariate statistics were performed; multivariable logistic regression was used to determine variables associated with optimal prescribing. RESULTS: A total of 294 patients were included: 147 pre-group and 147 post-group. Overall optimal prescribing improved from 12 (8%) to 34 (23%) (P < 0.001). Individual components of optimal prescribing were optimal selection at 90 (61%) vs 117 (80%) (P < 0.001), optimal dose at 99 (67%) vs 115 (78%) (P = 0.036), and optimal duration at 38 (26%) vs 50 (34%) (P = 0.13) for pre- and post-group, respectively. AOS was independently associated with optimal prescribing after multivariable logistic regression analysis (adjOR, 3.6; 95%CI,1.7-7.2). A post-hoc analysis showed low uptake of AOS by ED prescribers. CONCLUSIONS: AOS are an efficient and promising strategy to enhance antimicrobial stewardship in the ED.

Evaluation of Guideline-Recommended Pain Management in Acute Sickle Cell Crisis and Its Effect on Patient Outcomes.

This was a retrospective, multi-site observational cohort of 233 encounters of patients with Sickle Cell Disease (SCD) who received analgesia for acute pain crisis related to SCD from January 1, 2019 to December 31, 2019. Patient encounters were categorized based on whether they received analgesia within guideline directed 60 minutes of emergency department (ED) arrival. The primary outcome was time to a pain score reduction of ≥30% on the numerical rating scale. Assessments were also conducted for potential disparities leading to suboptimal care. Time to pain score reduction of ≥30% was significantly less in those receiving analgesia within 60 minutes of arrival compared to delayed analgesia [3.5 hours (2.5-10) vs 8.0 hours (4.5-22.5), p < 0.001]. Patients receiving timely analgesia also saw a faster time to ED disposition and achieved pain reduction goals more frequently at hospital discharge. We found that patients with a history of substance use disorder documented in their chart were less likely to receive timely analgesia. Our study indicated that when patients with SCD received analgesia in accordance with guideline recommendations, pain goals were achieved faster with an improvement in outcomes. Providing optimal care can be difficult, but education and standardized policies may help mitigate this gap.

Improving pediatric pharmacy services in a primarily adult emergency department.

PURPOSE: The American Society of Health-System Pharmacists (ASHP) and Pediatric Pharmacy Advocacy Group (PPAG) guidelines for providing pediatric pharmacy services in hospitals and health systems can be used to improve medication safety wherever pediatric patients receive care, including in the emergency department (ED). The purpose of this initiative was to improve compliance with these guidelines in a primarily adult ED. METHODS: This quality improvement initiative was conducted in a level 1 trauma center ED between October 2019 and March 2020. The ASHP-PPAG guidelines were used to create practice elements applicable to the ED. An initial compliance assessment defined elements as noncompliant, partially compliant, fully compliant, or not applicable. Investigators identified interventions to improve compliance for noncompliant or partially compliant elements and then reassessed compliance following implementation. Data were expressed using descriptive statistics. This initiative was exempt from institutional review board approval. RESULTS: Ninety-three ED practice elements were identified within the 9 standards of the ASHP-PPAG guidelines. At the initial compliance assessment, the majority (59.8%) of practice elements were fully compliant; however, various service gaps were identified in 8 of the standards, and 16 interventions were implemented to improve compliance. At the final compliance assessment, there was a 19.5% increase in full compliance. Barriers to achieving full compliance included technology restrictions, time constraints, financial limitations, and influences external to pharmacy. CONCLUSION: This quality improvement initiative demonstrated that the ASHP-PPAG guidelines can be used to improve ED pediatric pharmacy services in a primarily adult institution. The initiative may serve as an example for other hospitals to improve compliance with the guidelines.

Experience in an Urban Level 1 Trauma Center With Tranexamic Acid in Pediatric Trauma: A Retrospective Chart Review.

BACKGROUND: Evidence for tranexamic acid (TXA) in the pharmacologic management of trauma is largely derived from data in adults. Guidance on the use of TXA in pediatric patients comes from studies evaluating its use in cardiac and orthopedic surgery. There is minimal data describing TXA safety and efficacy in pediatric trauma. The purpose of this study is to describe the use of TXA in the management of pediatric trauma and to evaluate its efficacy and safety end points. METHODS: This retrospective, observational analysis of pediatric trauma admissions at Hennepin County Medical Center from August 2011 to March 2019 compares patients who did and did not receive TXA. The primary end point is survival to hospital discharge. Secondary end points include surgical intervention, transfusion requirements, length of stay, thrombosis, and TXA dose administered. RESULTS: There were 48 patients aged ≤16 years identified for inclusion using a massive transfusion protocol order. Twenty-nine (60%) patients received TXA. Baseline characteristics and results are presented as median (interquartile range) unless otherwise specified, with statistical significance defined as P < .05. Patients receiving TXA were more likely to be older, but there was no difference in injury type or Injury Severity Score at baseline. There was no difference in survival to discharge or thrombosis. Patients who did not receive TXA had numerically more frequent surgical intervention and longer length of stay, but these did not reach significance. CONCLUSIONS: TXA was utilized in 60% of pediatric trauma admissions at a single level 1 trauma center, more commonly in older patients. Although limited by observational design, we found patients receiving TXA had no difference in mortality or thrombosis.

Reduced levels of dopamine and altered metabolism in brains of HPRT knock-out rats: a new rodent model of Lesch-Nyhan Disease.

Lesch-Nyhan disease (LND) is a severe neurological disorder caused by loss-of-function mutations in the gene encoding hypoxanthine phosphoribosyltransferase (HPRT), an enzyme required for efficient recycling of purine nucleotides. Although this biochemical defect reconfigures purine metabolism and leads to elevated levels of the breakdown product urea, it remains unclear exactly how loss of HPRT activity disrupts brain function. As the rat is the preferred rodent experimental model for studying neurobiology and diseases of the brain, we used genetically-modified embryonic stem cells to generate an HPRT knock-out rat. Male HPRT-deficient rats were viable, fertile and displayed normal caged behaviour. However, metabolomic analysis revealed changes in brain biochemistry consistent with disruption of purine recycling and nucleotide metabolism. Broader changes in brain biochemistry were also indicated by increased levels of the core metabolite citrate and reduced levels of lipids and fatty acids. Targeted MS/MS analysis identified reduced levels of dopamine in the brains of HPRT-deficient animals, consistent with deficits noted previously in human LND patients and HPRT knock-out mice. The HPRT-deficient rat therefore provides a new experimental platform for future investigation of how HPRT activity and disruption of purine metabolism affects neural function and behaviour.

Is BodyThink an efficacious body image and self-esteem program? A controlled evaluation with adolescents.

This study aimed to evaluate the efficacy of BodyThink, a widely disseminated body image and self-esteem program. Participants were 277, grade 7 students from 4 secondary schools in Australia. The intervention group (62 girls, 85 boys) participated in BodyThink during four 50-min lessons, while the control group (65 girls, 65 boys) received their usual classes. All participants completed baseline, postintervention and 3-month follow-up questionnaires. For girls, the intervention group reported higher media literacy and lower internalization of the thin ideal compared to the control group. For boys, the intervention group reported higher media literacy and body satisfaction than the control group. Although some positive outcomes were observed, it would be valuable to find ways to enhance the impact of BodyThink, especially in light of its wide dissemination. Suggestions for improving BodyThink are presented.

Theme analysis of narratives produced by children with and without Specific Language Impairment.

Theme is defined within the Systemic-Functional Linguistics framework as the point of the departure for the clause and therefore important for text organisation. Aspects of theme are examined in the elicited narratives and story retells from a group of 25 5-8 year-old children with Specific Language Impairment (SLI) and a group of 25 age-matched children with Typically Developing Language. The analysis indicated that subjects with SLI used less variety and complexity in themes with more than one element but this is suggested to reflect localised lexicogrammatical problems. Analysis of the aspects of theme which are more reliant on text-level resources, namely marked theme and theme progression patterns, yielded equivocal results. No significant inter-group difference was found in the subjects' representation of marked Theme and only one of the two progression patterns showed a significant difference. These findings are discussed in relation to the theoretical implications for the description of narrative abilities in SLI.

Age-dependent cardiovascular, renal and endocrine responses to furosemide in conscious lambs.

1. The present study was performed to investigate some of the physiological responses to furosemide during postnatal maturation. 2. In 1- (n = 8) and 6-week old (n = 10) conscious, chronically instrumented lambs at least 3 days after surgery, three experiments were performed at intervals of 24-48 h and in random order. Various parameters of cardiovascular and endocrine function, as well as cumulative urinary flow rates, were measured before and after intravenous injection of 0 mg/kg (experiment one), 0.25 mg/kg (experiment two; low dose) and 5 mg/kg (experiment three; high dose) furosemide. 3. After high-dose furosemide, mean venous pressure decreased and there was a transient increase in mean arterial pressure in lambs aged 6 weeks. At 1 week of age, heart rate increased after high-dose furosemide and renal blood flow decreased. After high-dose furosemide, plasma renin activity increased in both groups of lambs, although the effects were greater in 1-week-old lambs. Plasma levels of arginine vasopressin increased after high-dose furosemide in lambs aged 1 but not 6 weeks. Cumulative urinary flow rate responses to furosemide were similar in 1- and 6-week-old lambs. 4. These data provide new information that cardiovascular and endocrine responses to furosemide are developmentally regulated.