Cefepime extended infusion versus intermittent infusion: Clinical and cost evaluation.

Background: Extended infusion cefepime (1 gram every 6 hours administered over 3 hours) achieves pharmacodynamic efficacy against bacteria with a MIC of ≤8 mg/L in Monte Carlo simulations. This regimen has not been evaluated in clinical practice. Objective: Compare clinical and economic outcomes for cefepime by intermittent infusion and by extended infusion in the acute-care setting. Design: Single-center, retrospective cohort study. Setting: Tertiary-care academic medical center. Patients: Hospitalized adults who received cefepime between August 2016 and July 2018 with a diagnosis of sepsis or pneumonia. Methods: Clinical and economic outcomes were compared for patients who received empiric cefepime via intermittent infusion (30-minute infusion of 2 g every 8 hours) or extended infusion (3-hour infusion of 1 g every 6 hours). Clinical outcomes analyses were carried out using appropriate statistical methods. Results: Overall, 111 patients received intermittent infusion and 93 patients received extended infusion. Approximately half of the included patients had a positive culture for a bacterial pathogen (intermittent infusion 45.9% vs extended infusion 47.3%). Median hospital length of stay (intermittent infusion 6 days vs extended infusion 6 days; P = .67) and 90-day readmission rates (intermittent infusion 61.3% vs extended infusion 67.7%; P = .34) did not differ between the groups. Mortality was infrequent in both groups (intermittent infusion 2.9% vs extended infusion 1.5%; P = .45). Cefepime cost per patient was lower with cefepime by extended infusion: average total daily cost $86.06 for intermittent infusion versus $43.39 for extended infusion. Conclusions: Cefepime via extended infusion (4 grams/day) did not differ in clinical outcomes compared to intermittent infusion (6 grams/day) but reduced drug expenditure. Prospective, multicenter, high-quality studies should be conducted to evaluate a mortality difference between these regimens.

Chronic toxicity of technical atrazine to the fathead minnow (Pimephales promelas) during a full life-cycle exposure and an evaluation of the consistency of responses.

Fathead minnows (Pimephales promelas) were continuously exposed to the herbicide atrazine (0.15, 0.25, 0.46, 0.99, and 2.0 mg a.i./L, plus dilution water and solvent controls) for a complete life cycle (274 days). Concentrations of atrazine up to 2.0 mg a.i./L did not significantly reduce hatching success, larval survival at 30 or 60 days post-hatch, or reproduction (eggs/spawn, total eggs, spawns/female, or eggs/female) in the F0 generation. However, at 60 days of exposure, total length and total survival to study completion were significantly reduced in ≥0.46 mg a.i./L and ≥ 0.99 mg a.i./L treatments, respectively. In the F1 generation, hatchability of embryos at ≥0.25 mg a.i./L (range 74-82%) was significantly less than that of pooled control organisms (86%). Following 30 days' post-hatch exposure, F1 survival was not significantly different from pooled control for any treatment. Finally, tissues representing major life stages had bioconcentration factors ranging from 3.7× (F1 embryos, <24 h) to 8.5× (F0 adults), indicating little to no evidence of bioconcentration. We developed a series of questions to assess the consistency of observed responses in order to place the data in context with the wider available and relevant literature (e.g., Observed between studies? Observed between species? Observed at lower levels of biological organization?). The analysis for consistency supports the conclusion that atrazine does not pose a significant chronic risk to freshwater fish in terms of growth, reproduction, or survivorship at concentrations of up to at least 100 µg/L.

Teaching future providers about dementia: the impact of service learning.

In this article, we describe an innovative approach for providing speech-language pathology graduate students with exposure to long-term care settings and clinical training in service delivery for persons with dementia. Our pedagogical approach emphasizes leading learners through distinct stages of creating awareness and a foundation of knowledge, teaching clinical skills, hands-on practice via service learning, and ongoing self-reflection. Outcome data presented in this article are derived from learner evaluations and written reflections as well as social validation data provided by dementia patients in a long-term care setting. Our findings reveal that a combination of high-impact practices, community-based service learning, and ongoing reflection can result in transformative learning and attitude shifts for speech-language pathology graduate students toward serving persons with dementia. This is a key finding given that a majority of our learners had little exposure to long-term care environments or had any prior interaction with persons with dementia.

Best practice updates for pediatric/adolescent weight loss surgery.

The objective of this study is to update evidence-based best practice guidelines for pediatric/adolescent weight loss surgery (WLS). We performed a systematic search of English-language literature on WLS and pediatric, adolescent, gastric bypass, laparoscopic gastric banding, and extreme obesity published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. In light of evidence on the natural history of obesity and on outcomes of WLS in adolescents, guidelines for surgical treatment of obesity in this age group need to be updated. We recommend modification of selection criteria to include adolescents with BMI >or= 35 and specific obesity-related comorbidities for which there is clear evidence of important short-term morbidity (i.e., type 2 diabetes, severe steatohepatitis, pseudotumor cerebri, and moderate-to-severe obstructive sleep apnea). In addition, WLS should be considered for adolescents with extreme obesity (BMI >or= 40) and other comorbidities associated with long-term risks. We identified >1,085 papers; 186 of the most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in pediatric/adolescent WLS are required to address advances in technology and the growing evidence base in pediatric WLS. Key considerations in patient safety include carefully designed criteria for patient selection, multidisciplinary evaluation, choice of appropriate procedure, thorough screening and management of comorbidities, optimization of long-term compliance, and age-appropriate fully informed consent.

ICON rice seed treatment toxicity to crayfish (Procambarus clarkii) in experimental rice paddies.

Outdoor pools (2.3 x 2.3 m) were used to simulate typical rice agricultural practices in Louisiana, USA, to evaluate the toxicity of ICON (active ingredient [a.i.] fipronil) and its degradates to crayfish (Procambarus clarkii). Six paddies were planted with seed treated with ICON 6.2 FS at an exaggerated application rate of 0.05 kg a.i./ha (recommended rate, 0.042 kg a.i./ha), simulating three rice-planting scenarios. Two reference paddies were planted with untreated seed. Crayfish were exposed to tail water within 24 to 48 h after seeding, simulating standard Louisiana agricultural and water management practices. At 50 d after planting, a separate group of crayfish was caged in situ for 14 d to evaluate toxicity. An additional 50 crayfish were added to two paddies approximately 100 d after rice planting and held for 29 weeks to evaluate bioaccumulation. Residues of fipronil and its degradates in water and soil were similar to residue concentrations measured from rice fields in Louisiana. Tail water from the treated paddies was not toxic to crayfish. The fipronil 96-h median lethal concentration (LC50) for adult crayfish was 180 microg/L, which would provide at least a sixfold safety factor between the maximum fipronil concentration in tail water and the crayfish LC50. In situ exposures of crayfish also were not toxic. Concentrations of fipronil and its degradates after 29 weeks of exposure were less than 5 microg/kg in crayfish tail muscle tissue. These results demonstrate that label instructions adequately protect crayfish in a rice-crayfish cropping scenario when ICON is applied at maximum application rates as a seed treatment.