Improving Emergency Department Use of Safety-Net Antibiotic Prescriptions for Acute Otitis Media

OBJECTIVES

Acute otitis media (AOM) is the most common reason for pediatric antibiotic prescriptions. The 2013 American Academy of Pediatrics' AOM guidelines recommend observation for nonsevere AOM. Our aim was to increase the percentage safety-net antibiotic prescription (SNAP) offered to patients 6 months of age or older diagnosed with AOM in 2 pediatric emergency departments (EDs) from a baseline of 0.5% to 15% in 20 months.

METHODS

This is a quality improvement study at a quaternary pediatric medical center with 2 locations, both with EDs. A random chart review revealed that 27.5% of patients diagnosed with AOM in the ED would qualify for a SNAP, but only 0.5% were offered it. Quality improvement interventions were designed to improve safety-net antibiotic prescribing. Both EDs conducted multiple interventions, including algorithm development, provider education, and electronic medical record aids. The primary outcome measure was the percentage of patients offered a SNAP for AOM.

RESULTS

A total of 8226 children 6 months of age or older were diagnosed with AOM in our 2 EDs during the 20-month intervention period. The percentage offered a SNAP increased at both EDs. One ED had a single shift in the mean to 7.9%, whereas the other had 2 shifts in the mean, an initial shift to 5.1% and a second to 7.3%. Providers consistently used the algorithm and electronic medical record aids.

CONCLUSIONS

Safety-net antibiotic prescriptions in conjunction with parent education was effective in reducing the use of immediate antibiotic prescriptions in children with AOM in 2 pediatric EDs. Offering a SNAP can reduce unnecessary use of antibiotics, which in turn may decrease antibiotic-related adverse events and antibiotic resistance.

Characterising the nutritional status of children with primary ciliary dyskinesia

INTRODUCTION

Primary ciliary dyskinesia (PCD) is a rare, heterogeneous genetic disorder where impaired mucociliary clearance is caused by dysfunctional motile cilia leading to bronchiectasis. There is limited evidence characterising the nutritional status of children with PCD, although lower body mass index (BMI) z-score has been associated with worse lung function (FEV₁).

METHODS

All children (n = 43) with PCD, aged <16 years, from a single tertiary centre were prospectively enrolled. Information on clinical phenotype and nutritional status including bioelectrical impedance spectroscopy (BIS) phase-angle was collected.

RESULTS

There was a weak positive association between height-for-age z-score (HAZ) and FEV₁ z-score (n = 28, r = 0.4, p = 0.049). Those with a low fat free mass index (<-2 z scores) had a lower BMI z score (-1.3 ± 1.2 vs. 0.8 ± 0.7, p = 0.0002). BIS phase angle identified more patients at nutritional risk than using moderate malnutrition cut-offs of either HAZ or BMI ≤ -2 z scores alone (21% vs. 4.6% vs. 6.9% respectively). PCD patients had a higher incidence of vitamin D insufficiency (<50 nmoL/L) (54%) and deficiency (<30 nmoL/L) (26%) than healthy children.

CONCLUSIONS

We have characterised the nutritional phenotype of a cohort of children with PCD. Monitoring vitamin D levels is important in PCD patients. There is a weak association between lung function and nutritional status, and measures of BIS phase-angle. The use of BIS phase-angle may allow for early identification of at risk children and may therefore be of benefit for nutritional assessments in the clinical setting. These findings will help inform a future nutritional intervention strategy in children with PCD.

Total hip replacement for the treatment of acute femoral neck fractures: results from the National Joint Registry of England and Wales at 3-5 years after surgery

INTRODUCTION

This paper describes, for the first time, the outcomes of patients undergoing total hip replacement for acute fractured neck of femur (#NOF) as recorded by the National Joint Registry of England and Wales (NJR).

METHODS

In the NJR we identified 1,302 of 157,232 Hospital Episode Statistics linked patients who had been recorded as having a total hip replacement for acute #NOF between April 2003 and November 2008.

RESULTS

The revision rate at five years for fully uncemented components was 4.1% (95% confidence interval [CI]: 2.2-7.3%), for hybrid it was 2.2% (95% CI: 0.9%-5.3%) and for fully cemented components 0.9% (95% CI: 0.4-2.0%). Five-year revision rates were increased for those whose operations were performed via a posterior versus a lateral approach. The Kaplan-Meier estimate of 30-day mortality was 1.4% (95% CI: 1.0-2.4%), which is over double the 30-day mortality rate for total hip replacement identified by the Office for National Statistics. The mean length of stay was also increased for those undergoing total hip replacements for #NOF compared with non-emergency indications.

CONCLUSIONS

Our data suggest that total hip replacements for acute #NOF give comparable results with total hip replacements for other indications.

The genetic characterisation of stripe rust resistance in the German wheat cultivar Alcedo

Stripe rust resistance in the German winter wheat cv. Alcedo has been described as durable, the resistance having remained effective when grown extensively in Germany and Eastern Europe between 1975 and 1989. Genetic characterisation of field resistance in a cross between Alcedo and the stripe rust susceptible UK winter wheat cv. Brigadier identified two major QTL in Alcedo located on the long arms of chromosomes 2D (QPst.jic-2D) and 4B (QPst.jic-4B). Stripe rust resistance was evaluated by measuring the extent of fungal growth, percentage infection (Pi) and the necrotic/chlorotic response of the plant to infection, infection type (IT). Both QPst.jic-2D and QPst.jic-4B contributed significantly to the reduction in stripe rust infection (Pi), with QPst.jic-2D explaining up to 36.20% and QPst.jic-4B 28.90% of the phenotypic variation measured for Pi. Both QTL were identified by the IT phenotypic scores, with QPst.jic-2D in particular being associated with a strong necrotic phenotype (low IT), QPst.jic-2D explaining up to 53.10% of IT phenotypic variation and QPst.jic-4B 22.30%. In addition, two small effect QTL for field stripe rust resistance were identified in Brigadier, QPst.jic-1B on the long arm of chromosome 1B and QPst.jic-5A on the short arm of chromosome 5A. The influence of QPst.jic-1B was primarily seen with the Pi phenotype, contributing up to 13.10% of the explained phenotypic variation. QPst.jic-5A was only detected using an approximate multiple-QTL model and selecting markers linked to the major effect QTL, QPst.jic-2D and QPst.jic-4B as co-factors. Seedling stripe rust resistance was also mapped in the cross, which confirmed the location of Yr17 from Brigadier to the short arm of chromosome 2A. A seedling expressed QTL was also located in Alcedo that mapped to the same location as the field stripe rust resistance QPst.jic-2D.

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery

BACKGROUND

The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited.

AIMS

To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology.

METHOD

101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined.

RESULTS

There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive.

CONCLUSIONS

The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

QTL identification and microphenotype characterisation of the developmentally regulated yellow rust resistance in the UK wheat cultivar Guardian

Yellow rust (causal agent: Puccinia striiformis f.sp. tritici) resistance in the UK wheat cultivar Guardian is developmentally regulated, resistance increasing as the plant matures. Yellow rust resistance was assessed under field conditions on plants after ear emergence to ensure maximum expression of resistance. Three quantitative trait loci (QTL) for yellow rust resistance were identified, being located on chromosomes 1B (QPst.jic-1B), 2D (QPst.jic-2D) and 4B (QPst.jic-4B). The largest resistance effect, QPst.jic-1B located to the same position on the long arm of chromosome 1B as the known durable source of yellow rust resistance, Yr29. Microscopic studies were carried out to determine what effect the resistance in Guardian had on the development of P. striiformis f.sp. tritici. While the adult plant resistance in Guardian did not prevent germinated urediniospores from establishing an effective infection site, the growth of hyphae within flag leaf tissue was significantly inhibited, slowing the development of microcolonies. 3,3-diaminabenzadine (DAB) and trypan blue staining indicated that this inhibition of hyphal growth was not associated with hydrogen peroxide accumulation or extensive plant cell death.

Influence of plant development and environment on transgene expression in potato and consequences for insect resistance

Clonal replicates of different transformed potato plants expressing transgene constructs containing the constitutive Cauliflower Mosaic Virus (CaMV) 35S promoter, and sequences encoding the plant defensive proteins snowdrop lectin (Galanthus nivalis agglutinin; GNA), and bean chitinase (BCH) were propagated in tissue culture. Plants were grown to maturity, at first under controlled environmental conditions, and later in the glasshouse. For a given transgene product, protein accumulation was found to vary between the different lines of clonal replicates (where each line was derived from a single primary transformant plant), as expected. However, variability was also found to exist within each line of clonal replicates, comparable to the variation of mean expression levels observed between the different clonal lines. Levels of GNA, accumulated in different parts of a transgenic potato plant, also showed variation but to a lesser extent than plant-plant variation in expression. With the majority of the clonal lines investigated, accumulation of the transgene product was found to increase as the potato plant developed, with maximum levels found in mature plants. The variation in accumulation of GNA among transgenic plants within a line of clonal replicates was exploited to demonstrate that the enhanced resistance towards larvae of the tomato moth, Lacanobia oleracea L., caused by expression of this protein in potato, was directly correlated with the level of GNA present in the plants, and that conditions under which the plants were grown affect the levels of GNA expression and subsequent levels of insect resistance.

Economic rationalism and the cost efficiency of hospital chaplaincy: an Australian study

Health care reform is also occurring in Australia and effects hospital chaplaincy programs. "Economic rationalism" is the philosophic foundation of this effort and its contrast with the values inherit in hospital chaplaincy are highlighted. Selected research results from the Australian system are described and the authors offer a perspective on the cost efficiency of hospital chaplaincy.

Biomedicine, genetics and disability: reflections on nursing and a philosophy of holism

This article critically explores the notion of those sociopolitical spaces that are 'disability', 'holism' and 'genetics', arguing from the perspectives of someone who identifies as having a disability. Medical genetics is seen to reflect the ideology and dominant biomedical reductionist thought. In contrast with this, it is proposed that disability and health are inherently social. A nursing approach is seen to recognize the social and holistic nature of the human person and to present a critical reflection on the reductionistic applications of medical genetics.

The social nature of disability, disease and genetics: a response to Gillam, Persson, Holtug, Draper and Chadwick

The dominance of the biomedically informed view of disability, genetics, and diagnosis is explored. An understanding of the social nature of disability and genetics, especially in terms of oppression, adds a richer dimension to an understanding of ethical issues pertaining to genetics. This is much wider than the limited question of whether or not such technology discriminates. Instead, it is proposed that such technology will perpetuate the oppression and control of people with disability, especially if the knowledge of people with disability is not utilised in bioethical debates.

The ethics of narrative ethics: some teaching reflections

Narrative is reemerging as a teaching tool. Narrative ethics is being seen as a rich endeavour both for clinical practice and academic teaching and research. Narrative helps put ethics into context. However, the use of narrative increasingly raises issues in teaching and research: for instance, how do we do justice to the people and narratives we utilise, and what does our practice reveal about our ethics? In this article examples are drawn from clinical practice, teaching and case notes to draw out some lessons to help further critical understanding.

The CAT-CAM socket and quadrilateral socket: a comparison of energy cost during ambulation

Twenty unilateral trans-femoral amputees fitted with either the Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM) socket (n = 10) or the quadrilateral (QUAD) socket (n = 10), and a "non-amputee" control group (n = 10) participated in the study. Subjects meeting the following criteria were studied: healthy males between the ages of 18 and 55 years, amputation due to non-vascular pathology, an unaffected sound limb, at least six months use of the test prosthesis, and a minimal stump length of 15 cm. Subjects ambulated in two randomized trials separated by 20 minutes of rest at 2 assigned speeds: a pace reflecting normal walking speed (97 m/min = 2.5 mph) or a slower speed (48.5 m/min = 1.25 mph). Heart rate (HR) and Oxygen uptake (VO2) measured during steady state walking were analyzed via two-way ANOVA. Differences among means were further analyzed using Tukey post hoc and simple effects tests. Significant differences were observed between the control group and CAT-CAM subjects with respect to VO2 (p < 0.05) and HR (p < 0.01) at the slower speed. The control group and subjects using the QUAD socket also differed with respect to VO2 (p < 0.01) and HR (p < 0.01) at the slower pace. Faster pace required more energy expenditure (p < 0.01) and produced higher HR (p < 0.01) than slower speeds. At faster pace, a significantly higher energy expenditure in the QUAD than the CAT-CAM group was observed (p < 0.01). It is concluded that ambulating at normal pace using the CAT-CAM socket design uses less energy than when using a QUAD socket design.

Stable transformation via particle bombardment in two different soybean regeneration systems

The Biolistics(®) particle delivery system for the transformation of soybean (Glycine max L. Merr.) was evaluated in two different regeneration systems. The first system was multiple shoot proliferation from shoot tips obtained from immature zygotic embryos of the cultivar Williams 82, and the second was somatic embryogenesis from a long term proliferative suspension culture of the cultivar Fayette. Bombardment of shoot tips with tungsten particles, coated with precipitated DNA containing the gene for β-glucuronidase (GUS), produced GUS-positive sectors in 30% of the regenerated shoots. However, none of the regenerants which developed into plants continued to produce GUS positive tissue. Bombardment of embryogenic suspension cultures produced GUS positive globular somatic embryos which proliferated into GUS positive somatic embryos and plants. An average of 4 independent transgenic lines were generated per bombarded flask of an embryogenic suspension. Particle bombardment delivered particles into the first two cell layers of either shoot tips or somatic embryos. Histological analysis indicated that shoot organogenesis appeared to involve more than the first two superficial cell layers of a shoot tip, while somatic embryo proliferation occurred from the first cell layer of existing somatic embryos. The different transformation results obtained with these two systems appeared to be directly related to differences in the cell types which were responsible for regeneration and their accessibility to particle penetration.

Documenting smoking Status: Trial of three strategies

A randomized trial at a family medicine center compared three ways of improving the rates of recording patients' smoking behavior: letter, telephone, and reminding physicians to inquire at visits. Telephone produced the highest rate of recordings, while physician reminder was most cost-effective. We recommend physician reminder with telephone calls from the practice nurse for patients who do attend.

Use of reminders to increase compliance with tetanus booster vaccination

OBJECTIVE

To assess the effect of three computerized reminder systems on compliance with tetanus vaccination.

DESIGN

Prospective randomized controlled trial.

SETTING

Ottawa Civic Hospital Family Medicine Centre.

PARTICIPANTS

Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were randomly assigned, by family, to a control group, a physician reminder group, a telephone reminder group or a letter reminder group. The remaining 2480 patients were not included in the randomized portion of the study but were monitored. Results are presented for the 5242 randomized patients and the 2369 nonrandomized patients for whom there was no up-to-date record of tetanus vaccination at the start of the trial.

INTERVENTIONS

For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient's tetanus vaccination status and to recommend vaccination; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose.

MAIN OUTCOME MEASURE

Proportion of patients who received tetanus toxoid during the study year or who had a claim of vaccination in the previous 10 years.

MAIN RESULTS

The rate of recorded tetanus vaccination in the randomized control group was 3.2%. The difference between that rate and those for the three reminder groups was 19.6% in the physician reminder group (95% confidence interval [CI] 17.1% to 22.2%, p less than 0.00001), 20.8% in the telephone reminder group (95% CI 18.3% to 23.5%, p less than 0.00001) and 27.4% in the letter reminder group (95% CI 24.8% to 30.2%, p less than 0.00001)). The letter reminders were more effective than either the telephone reminders (p = 0.00013) or the physician reminders (p less than 0.00001) in improving compliance. The cost to the practice per additional vaccination recorded was 43 for the physician reminders, $5.43 for the telephone reminders and $6.05 for the letter reminders.

CONCLUSIONS

Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage. More intensive interventions would be required to approach that goal. However, such interventions do not appear to be justified given the rarity of tetanus.

Use of reminders for preventive procedures in family medicine

OBJECTIVE

To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice.

DESIGN

Prospective, randomized, controlled study.

SETTING

Ottawa Civic Hospital Family Medicine Centre.

PARTICIPANTS

Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were randomly assigned, by family, to a control group, a physician reminder group (passive) or a telephone or letter reminder group (active). The remaining 2619 patients were not included in the randomized portion of the study but were monitored.

INTERVENTION

During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service.

OUTCOME MEASURE

Rates of completion of the preventive procedures required.

MAIN RESULTS

All three reminder systems significantly improved the delivery of preventive services (p less than 0.001). The procedure completion rates were 42.0% in the letter reminder group, 42.0% in the telephone reminder group, 33.7% in the physician reminder group and 14.1% in the randomized control group. The use of a letter was more cost-effective than the telephone system, but the physician reminder system was the most cost-effective.

CONCLUSION

Computerized reminder systems do improve the delivery of preventive services in family practice.

A follow-up study of patients advised to obtain influenza immunizations

Computers have been used in general practice to issue reminders to patients overdue for preventive procedures. Although effective, issuing reminders may be inconsistent with the belief that patients should take responsibility for their own health. To assess the effect of a reminder on subsequent use of influenza prevention services, this study examined the three-year immunization behavior of 1,175 patients 65 years or older who were part of a randomized controlled trial. During the middle year only, reminders were issued to patients in the experimental group. A comparison of immunization patterns over the three years in experimental and control groups indicated that the reminder both promoted independent action and engendered dependency on the reminder. The former, favorable effect was more frequent among younger patients; the latter, adverse effect was more common among older patients who visited the practice more frequently.

Engineering Resistance to Mixed Virus Infection in a Commercial Potato Cultivar: Resistance to Potato Virus X and Potato Virus Y in Transgenic Russet Burbank

Potato virus X (PVX) and potato virus Y (PVY) infection in potato may result in the loss of certification of seed potatoes and affect quality and yield of potatoes in commercial production. We transformed a major commercial cultivar of potato, Russet Burbank, with the coat protein genes of PVX and PVY. Transgenic plants that expressed both CP genes were resistant to infection by PVX and PVY by mechanical inoculation. One line was also resistant when PVY was inoculated with viruliferous green peach aphids. These experiments demonstrate that CP protection is effective against mixed infection by two different viruses and against mechanical and aphid transmission of PVY.

Comparative analysis of the structures of the outer membrane protein P1 genes from major clones of Haemophilus influenzae type b

P1 outer membrane proteins from Haemophilus influenzae type b are heterogeneous antigenically and with respect to apparent molecular weight in sodium dodecyl sulfate-polyacrylamide gel electrophoresis. For determination of the molecular basis for the differences in the P1 proteins, the genes for the P1 proteins from strain 1613, representative of outer membrane protein subtype 3L, and strain 8358, representative of outer membrane protein subtype 6U, were cloned, sequenced, and compared with the previously reported gene for the P1 protein from strain MinnA, a strain with the outer membrane protein subtype 1H. These prototype strains are representatives of the three major clonal families of H. influenzae type b responsible for invasive disease in diverse areas of the world. The nucleotide sequences of the P1 genes from strains 1613 and 8358 were 94 and 90% identical to the MinnA sequence, respectively. The derived amino acid sequences were 91 and 86% identical, respectively. Heterogeneity between the MinnA and 1613 proteins was largely localized to two short variable regions; the protein from strain 8538 contained a third variable region not observed in the other P1 proteins. Thus, the outer membrane protein P1 genes are highly conserved; the variable regions may code for the previously demonstrated strain-specific antigenic determinants.

A randomized trial of computerized reminders for blood pressure screening in primary care

In a randomized, controlled trial (N = 8,298) the authors compared three ways of encouraging patients in a large family practice to obtain a blood pressure check. Working from computerized medical records at a teaching family-medicine center, the study included patients aged 18 years and over who had not had a blood pressure measurement during the previous year. In a normal-care control group, 21.1% of those due for a blood pressure reading obtained one during the trial year. In one intervention group, a computer-generated message reminded the doctor to check the blood pressure of patients who happened to visit the center for an appointment; 30.7% of patients allocated to this group were checked. In the second group, the nurse contacted patients by telephone and encouraged 24.1% of those who were due for a check to obtain one. Sending a letter to patients in the third group yielded a 35.7% compliance rate. Considering the costs of the three interventions, the physician reminder was the most cost effective, followed by the letter reminder. Although statistically significant, the impact of the reminders was modest. A better approach might involve a combination of routine reminders to the physician, followed by letters to noncompliant patients.

Comparison of three methods of recalling patients for influenza vaccination

Despite recommendations supporting annual influenza vaccination for people aged 65 years or older, vaccination rates remain low. Several studies have evaluated the effect of sending mailed reminders, but few have compared alternative ways of reminding patients to receive the vaccine. In a randomized trial of 939 patients aged 65 years or older in four family practices carried out between Oct. 23 and Dec. 31, 1984, we compared three ways of reminding elderly patients to receive the vaccine: personal reminder by the physician, telephone reminder by the nurse and reminder by letter. The vaccination rates for the three groups were 22.9%, 37% and 35.1% respectively. No reminder was issued to a control group, and the rate was 9.8%. Some patients could not be reached by telephone, and some did not see the physician during the specified time. Among the patients whom the nurse actually contacted, the vaccination rate was 43.5%; the rate for patients whom the doctor actually saw was 45.1%. Overall, a telephone reminder by the nurse was the most effective method, and at an hourly salary of $16 or less this method would also be the most cost-effective. The reminders used in this study were automatically generated from a computerized medical record system. The study shows how a computerized system can be used to identify patients for whom preventive procedures are due.

Sequence and evolution of rhesus monkey alphoid DNA

Analysis of rhesus monkey alphoid DNA suggests that it arose by tandem duplication of an ancestral monomer unit followed by independent variation within two adjacent monomers (one becoming more divergent than the other) before their amplification as a dimer unit to produce tandem arrays. The rhesus monkey alphoid DNA is a tandemly repeated, 343-bp dimer; the consensus dimer is over 98% homologous to the alphoid dimers reported for baboon and bonnet monkey, 81% homologous to the African green monkey alpha monomer, and less than 70% homologous to the more divergent human alphoid DNAs. The consensus dimer consists of two wings (I and II, 172 and 171 bp, respectively) that are only 70% homologous to each other, but share seven regions of exact homology. These same regions are highly conserved among the consensus sequences of the other cercopithecid alphoid DNAs. The three alpha-protein binding sites reported for African green monkey alpha DNA by F. Strauss and A. Varshavsky (Cell 37: 889-901, 1984) occur in wings I and II, but with one site altered in wing I. Two cloned dimer segments are 98% homologous to the consensus, each containing 8 single-base-pair differences within the 343-bp segment. Surprisingly, 37% of these differences occur in regions that are evolutionarily conserved in the alphoid consensus sequences, including the alpha-protein binding sites. Sequence variation in this highly repetitive DNA family may produce unique nucleosomal architectures for different members of an alphoid array. These unique architectures may modulate the evolution of these repetitive DNAs and may produce unique centromeric characteristics in primate chromosomes.

A double-blind comparison of clovoxamine and amitriptyline in the treatment of depressed outpatients

Forty-two outpatients with major depression were treated in a 4-week double-blind parallel-group comparison of the new antidepressant clovoxamine--a member of oximethers of aralkylketones--with amitriptyline. The two drugs were comparable in efficacy, although because of the small sample size a moderate clinical difference between treatments may not have been detected. The magnitude of unwanted effects also was comparable, but clovoxamine produced fewer "anticholinergic" effects; this was determined by patient complaints of typical anticholinergic symptoms, by decreased salivary flow, and by a new signal detection memory test.