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Adherence to stewardship recommendations for antibiotic discontinuation reduces antibiotic-associated adverse drug events
- Patrick Mulligan, Nader Ismail, Nirav Shah, Jessica P. Ridgway, Urmila Ravichandran, Jennifer Grant, Mary Ellen Acree
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 4 / Issue 1 / 2024
- Published online by Cambridge University Press:
- 18 March 2024, e36
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Inappropriate antibiotic use may lead to increased adverse drug events (ADEs). This study assessed whether an antimicrobial stewardship recommendation to discontinue antibiotics in patients with low likelihood for bacterial infection reduced antibiotic duration and antibiotic-associated ADEs. At a 4-hospital system, hospitalized adult patients receiving empiric antibiotics for suspected infection were identified between May 2, 2016 and June 30, 2018. For those patients who were deemed unlikely to have a bacterial infection, a note was left by an infectious diseases physician recommending antibiotic discontinuation. Patient cases were considered “adherent” to recommendations if antibiotics were discontinued within 48 hours of the note and “non-adherent” to recommendations if antibiotics were continued beyond this. Duration of antibiotics and potential antibiotic-associated ADEs were collected retrospectively. Attribution of the adverse event to the antibiotic was decided upon by the investigators. The incidence of ADEs and duration of antibiotics between the adherent and non-adherent groups were compared. Of 253 patients deemed unlikely to have a bacterial infection, 114 (45%) treatment teams stopped antibiotics within 48 hours of the recommendation, and 139 (55%) continued antibiotics. The total number of ADEs was significantly higher in the non-adherent group compared to the adherent group (34 ADEs vs 9 ADEs, P = .001). The median number of total prescribed antibiotic days was higher in the non-adherent group than in the adherent group (5 days vs 1 day, P < .001). This study demonstrates that stewardship programs may prevent ADEs by recommending antibiotic discontinuation in patients with low suspicion for bacterial infection.
Multimodal Longitudinal Imaging of Focal Status Epilepticus
- Colin P. Doherty, Andrew J. Cole, P. Ellen Grant, Alan Fischman, Elizabeth Dooling, Daniel B. Hoch, Tessa Hedley White, G. Rees Cosgrove
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- Journal:
- Canadian Journal of Neurological Sciences / Volume 31 / Issue 2 / May 2004
- Published online by Cambridge University Press:
- 16 February 2016, pp. 276-281
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Background:
Little is understood about the evolution of structural and functional brain changes during the course of uncontrolled focal status epilepticus in humans.
Methods:We serially evaluated and treated a nine-year-old girl with refractory focal status epilepticus. Long-term EEG monitoring, MRI, MRA, SPECT, intraoperative visualization of affected cortex, and neuropathological examination of a biopsy specimen were conducted over a three year time span. Imaging changes were correlated with simultaneous treatment and EEG findings.
Results:The EEG monitoring showed almost continuous spike discharges emanating initially from the right frontocentral area. These EEG abnormalities were intermittently suppressed by treatment with anesthetics. Over time, additional brain areas developed epileptiform EEG abnormalities. Serial MRI studies demonstrated an evolution of changes from normal, through increased regional T2 signal to generalized atrophy. An MRAdemonstrated dilatation of the middle cerebral artery stem on the right compared to the left with a broad distribution of flow-related enhancement. An 18FDG-PET scan showed a dramatically abnormal metabolic profile in the same right frontocentral areas, which modulated in response to treatment during the course of the illness. A right frontotemporal craniotomy revealed a markedly hyperemic cortical focus including vascular shunting. A sample of resected cortex showed severe gliosis and neuronal death.
Conclusions:The co-registration of structural and functional imaging and its correlation with operative and pathological findings in this case illustrates the relentless progression of regional and generalized abnormalities in intractable focal status epilepticus that were only transiently modified by exhaustive therapeutic interventions. Increased flow through large vessels appeared to be shunted and did not translate into increased microvascular perfusion.
Chapter 20 - Abusive head trauma: intracranial imaging strategies
- from Section II - Abusive head and spinal trauma
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- By V. Michelle Silvera, Staff Pediatric Neuroradiologist at Boston Children’s Hospital and Assistant Professor of Radiology at Harvard Medical School, Boston, Massachusetts, USA, P. Ellen Grant, Director, Center on Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital and Associate Professor of Radiology at Harvard Medical School, Boston, Massachusetts, USA, Gary L. Hedlund, Chief of Neuroimaging at the Primary Children’s Medical Center and Adjunct Professor of Radiology at the University of Utah, Salt Lake City, Utah, USA, Paul K. Kleinman, Department of Radiology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
- Edited by Paul K. Kleinman
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- Book:
- Diagnostic Imaging of Child Abuse
- Published online:
- 05 September 2015
- Print publication:
- 03 September 2015, pp 487-493
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Summary
Introduction
How and when to image the head in infants and children with suspected abusive head trauma (AHT) has become more complex with the increasing widespread availability of robust and elegant imaging technologies. These complex decisions are generally individualized based on available resources and expertise. The evidence base is modest with respect to the comparative diagnostic performance of the various neuroimaging modalities or magnetic resonance imaging (MRI) sequences in this specific context (1–5). Based on the available literature and the expertise of a panel of experts, the American College of Radiology (ACR) has put forth “Appropriateness Criteria” for imaging AHT and the organization periodically updates their recommendations in light of new data (6, 7). The goal of this chapter is to provide guidance to imaging departments that reflects the authors’ experience in light of current knowledge. Imaging strategies with respect to the skull, scalp, and subscalp have been covered in Chapter 17 – this discussion will focus on the approach to imaging the intracranial alterations described in Chapters 18 and 19. Craniocervical junction and spinal imaging strategies are addressed in Chapter 21.
Sonography
Sonography is a valuable imaging tool used to assess children with suspected AHT. The anterior and posterior fontanels and squamosal portions of the temporal bones (transmastoid) serve as natural acoustic windows for cranial sonography in infants up to six months of age. Cranial sonography is a low-cost, noninvasive modality that can be performed at the bedside without sedation, and is particularly useful in evaluating children with severe AHT in the intensive care unit who are too unstable for transport to the radiology department and prolonged imaging in the MRI suite. This modality allows for prompt assessment of hydrocephalus, some subdural hematomas (SDHs), parenchymal abnormalities, and mass effect; and can detect small white matter lacerations (contusional tears) – lesions that may go undetected on head computed tomography (CT) and are considered highly suggestive of inflicted injury (8). Color and spectral Doppler analysis provide useful information with regard to cerebral blood flow and readily detect occlusive thrombosis of the superior sagittal venous sinus.
Chapter 19 - Abusive head trauma: parenchymal injury
- from Section II - Abusive head and spinal trauma
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- By P. Ellen Grant, Director, Center on Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children’s Hospital and Associate Professor of Radiology at Harvard Medical School, Boston, Massachusetts, USA
- Edited by Paul K. Kleinman
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- Book:
- Diagnostic Imaging of Child Abuse
- Published online:
- 05 September 2015
- Print publication:
- 03 September 2015, pp 453-486
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Summary
Overview
The most feared consequence of child abuse is brain injury. Abusive head trauma (AHT) can result in significant brain injuries that can cause death or lifelong handicap of a child, with the full consequence not truly evident until school age or later. AHT is the most common cause of traumatic death for infants with as many as one in four victims of AHT/shaken baby syndrome (SBS) dying (1). Almost all suffer serious health consequences such as sensory impairments as well as cognitive, learning, and behavioral disabilities (2).
These parenchymal brain injuries can be quite subtle initially, but the appropriate history or the presence of intracranial hemorrhage or extra-axial collections should trigger a search for subtle changes that indicate evolving brain injury. Although some parenchymal brain injuries observed in AHT are similar to those observed in accidental trauma, there are injury patterns that are more common in documented cases of abuse. The uniqueness of these injury patterns is likely due to a combination of specific mechanical forces and the vulnerability of the immature brain, particularly in infancy. Infants are more susceptible to direct mechanical brain injury from abusive shaking owing to poor neck control, larger head size, and softer brain owing to incomplete myelination. Also with shaking, indirect injuries from associated cardiac and/or respiratory compromise may occur. To further complicate matters, physiologic cascades cause the imaging appearance of abusive brain injury to evolve over time. To better understand the evolution of brain injury, we begin with an overview on cell death processes in the immature brain. Next we divide parenchymal injuries into those caused by direct mechanical forces (primary injuries) and those associated with, but not directly due to mechanical forces (secondary injuries). Also included is a discussion on mechanisms of injury for different imaging patterns of brain injury, recognizing that in some cases mechanisms are unproven or controversial. Finally, we remind the reader that it is common for severe brain injury to be present in the absence of external evidence of injury (3, 4). Therefore, brain imaging should be performed if there is a high clinical suspicion or if neurologic signs and symptoms are present, even if there are no overt signs of abuse. The recommended neuroimaging protocol is provided in Chapter 20.
16 - MR perfusion imaging in pediatrics
- from Section 2 - Clinical applications
- Edited by Peter B. Barker, The Johns Hopkins University School of Medicine, Xavier Golay, Gregory Zaharchuk
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- Book:
- Clinical Perfusion MRI
- Published online:
- 05 May 2013
- Print publication:
- 16 May 2013, pp 326-348
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Summary
Introduction
The MR perfusion techniques of dynamic susceptibility contrast (DSC; see Chapter 2) imaging and arterial spin labeling (ASL; see Chapter 3) imaging as applied to children will be discussed. While DSC perfusion is well established in the evaluation of adult neurological conditions, the use of both DSC and ASL perfusion imaging in pediatric neurological conditions remains in its infancy. While acute stroke imaging drove the adoption of DSC approaches in adults, the lack of demonstrated utility in children, the need for intravenous (IV) line placement, and the need for bolus injection has limited its adoption in children. While some groups extrapolate both DSC and ASL approaches and analysis from the adult literature in applying MR perfusion to pediatric disorders, there is still much unknown about pediatric cerebral perfusion and the changes that occur in pediatric diseases. For example, there are normal developmental changes in cerebral vasculature and cerebral perfusion as well as marked changes in body size, heart rate, vascular flow velocities, and capillary development which may impact optimization, quantification, and interpretation of both DSC and ASL. In addition, little is known about how these measures are affected by sedation, anesthesia, and hematocrit changes.
Contributors
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- By Gregory S. Aaen, Maria Pia Amato, Laura J. Balcer, Brenda Banwell, Amit Bar-Or, Khurram Bashir, Anita L. Belman, Susan Bennett, Dorothée Chabas, Tanuja Chitnis, Russell C. Dale, Angelo Ghezzi, Jin S. Hahn, Folker Hanefeld, Deborah Hertz, R. Q. Hintzen, Sunny Im-Wang, Laura J. Julian, Lauren B. Krupp, Nancy L. Kuntz, Grant T. Liu, Timothy Lotze, Andrew McKeon, Maria Milazzo, Ellen M. Mowry, Jayne Ness, Frank S. Pidcock, Immacolata Plasmati, Daniela Pohl, Christel Renoux, Moses Rodriguez, Martino Ruggieri, A. D. Sadovnick, Guillaume Sébire, Isabella Simone, Bruno P. Soares, Jonathan Strober, Esther Tantsis, Marc Tardieu, Silvia Tenembaum, Maria Trojano, Sunita Venkateswaran, Amy T. Waldman, Emmanuelle L. Waubant, Bianca Weinstock-Guttman, Max Wintermark, E. Ann Yeh
- Edited by Dorothée Chabas, University of California, San Francisco, Emmanuelle L. Waubant, University of California, San Francisco
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- Book:
- Demyelinating Disorders of the Central Nervous System in Childhood
- Published online:
- 11 April 2011
- Print publication:
- 17 March 2011, pp vii-ix
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