A potential cost savings analysis of a penicillin de-labeling program

IntroductionOver 95% of patients documented as penicillin allergic can tolerate a penicillin without a reaction. Inaccurate documentation of penicillin allergy leads to more expensive alternative antibiotic prescriptions and an increased incidence of resistant infections.ObjectiveTo understand the potential drug cost savings of a penicillin de-labeling program to a healthcare system.MethodsWe evaluated patient visits with documented penicillin allergy who presented to the pediatric Emergency Department (PED) and 22 associated primary care clinics. Patients were included if they were discharged home with a non-penicillin antibiotic when the first-line treatment for the diagnosis would have been a penicillin. The potential cost savings were the sum of all visit-level cost differences between the non-penicillin prescription(s) and a counterfactual penicillin prescription. To factor in a 95% successful patient de-labeling rate, we repeatedly sampled 95% from the patients with the eligible visits 10,000 times to produce an estimate of the potential cost savings.ResultsOver the 8-year period, 2,034 visits by 1,537 patients to the PED and 12,349 visits by 6,073 patients to primary care clinics satisfied eligibility criteria. If 95% of the patients could have been successfully de-labeled, it would have generated a cost saving of $618,653 (95$618,617—$618,689) for all the corresponding payers in the system.ConclusionsImplementing a penicillin de-labeling program across a healthcare system PED and its associated primary care clinics would bring significant cost savings. Healthcare systems should rigorously evaluate optimal methods to de-label patients with reported penicillin allergy

The AROME-WMED reanalyses of the first special observation period of the Hydrological cycle in the Mediterranean experiment (HyMeX)

To study key processes of the water cycle, two special observation periods (SOPs) of the Hydrological cycle in the Mediterranean experiment (HyMeX) took place during autumn 2012 and winter 2013. The first SOP aimed to study high precipitation systems and flash flooding in the Mediterranean area. The AROME-WMED (western Mediterranean) model (Fourrié et al., 2015) is a dedicated version of the mesoscale Numerical Weather Prediction (NWP) AROME-France model, which covers the western Mediterranean basin providing the HyMeX operational center with daily real-time analyses and forecasts. These products allowed for adequate decision-making for the field campaign observation deployment and the instrument operation. Shortly after the end of the campaign, a first reanalysis with more observations was performed with the first SOP operational software. An ensuing comprehensive second reanalysis of the first SOP, which included field research observations (not assimilated in real time) and some reprocessed observation datasets, was made with AROME-WMED. Moreover, a more recent version of the AROME model was used with updated background error statistics for the assimilation process. This paper depicts the main differences between the real-time version and the benefits brought by HyMeX reanalyses with AROME-WMED. The first reanalysis used 9 % additional data and the second one 24 % more compared to the real-time version. The second reanalysis is found to be closer to observations than the previous AROME-WMED analyses. The second reanalysis forecast errors of surface parameters are reduced up to the 18 and 24 h forecast range. In the middle and upper troposphere, fields are also improved up to the 48 h forecast range when compared to radiosondes. Integrated water vapor comparisons indicate a positive benefit for at least 24 h. Precipitation forecasts are found to be improved with the second reanalysis for a threshold up to 10 mm (24 h)-1. For higher thresholds, the frequency bias is degraded. Finally, improvement brought by the second reanalysis is illustrated with the Intensive Observation Period (IOP8) associated with heavy precipitation over eastern Spain and southern France

Changing classroom culture, curricula, and instruction for proof and proving: how amenable to scaling up, practicable for curricular integration, and capable of producing long-lasting effects are current interventions?

This paper is a commentary on the classroom interventions on the teaching and learning of proof reported in the seven empirical papers in this special issue. The seven papers show potential to enhance student learning in an area of mathematics that is not only notoriously difficult for students to learn and for teachers to teach, but also critically important to knowing and doing mathematics. Although the seven papers, and the intervention studies they report, vary in many ways—student population, content domain, goals and duration of the intervention, and theoretical perspectives, to name a few—they all provide valuable insight into ways in which classroom experiences might be designed to positively influence students’ learning to prove. In our commentary, we highlight the contributions and promise of the interventions in terms of whether and how they present capacity to change the classroom culture, the curriculum, or instruction. In doing so, we distinguish between works that aim to enhance students’ preparedness for, and competence in, proof and proving and works that explicitly foster appreciation for the need and importance of proof and proving. Finally, we also discuss briefly the interventions along three dimensions: how amenable to scaling up, how practicable for curricular integration, and how capable of producing long-lasting effects these interventions are

Bridging knowing and proving in mathematics An essay from a didactical perspective

Text of a talk at the conference "Explanation and Proof in Mathematics: Philosophical and Educational Perspective" held in Essen in November 2006International audienceThe learning of mathematics starts early but remains far from any theoretical considerations: pupils' mathematical knowledge is first rooted in pragmatic evidence or conforms to procedures taught. However, learners develop a knowledge which they can apply in significant problem situations, and which is amenable to falsification and argumentation. They can validate what they claim to be true but using means generally not conforming to mathematical standards. Here, I analyze how this situation underlies the epistemological and didactical complexities of teaching mathematical proof. I show that the evolution of the learners' understanding of what counts as proof in mathematics implies an evolution of their knowing of mathematical concepts. The key didactical point is not to persuade learners to accept a new formalism but to have them understand how mathematical proof and statements are tightly related within a common framework; that is, a mathematical theory. I address this aim by modeling the learners' way of knowing in terms of a dynamic, homeostatic system. I discuss the roles of different semiotic systems, of the types of actions the learners perform and of the controls they implement in constructing or validating knowledge. Particularly with modern technological aids, this model provides a basis designing didactical situations to help learners bridge the gap between pragmatics and theory

Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City

<p>Abstract</p> <p>Background</p> <p>Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland.</p> <p>Methods</p> <p>The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services.</p> <p>Results</p> <p>After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter.</p> <p>Conclusions</p> <p>The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.</p

The French Didactic Tradition in Mathematics

This chapter presents the French didactic tradition. It first describes theemergence and development of this tradition according to four key features (role ofmathematics and mathematicians, role of theories, role of design of teaching andlearning environments, and role of empirical research), and illustrates it through two case studies respectively devoted to research carried out within this traditionon algebra and on line symmetry-reflection. It then questions the influence of thistradition through the contributions of four researchers from Germany, Italy, Mexicoand Tunisia, before ending with a short epilogue

Cilostazol Inhibits Accumulation of Triglyceride in Aorta and Platelet Aggregation in Cholesterol-Fed Rabbits

Cilostazol is clinically used for the treatment of ischemic symptoms in patients with chronic peripheral arterial obstruction and for the secondary prevention of brain infarction. Recently, it has been reported that cilostazol has preventive effects on atherogenesis and decreased serum triglyceride in rodent models. There are, however, few reports on the evaluation of cilostazol using atherosclerotic rabbits, which have similar lipid metabolism to humans, and are used for investigating the lipid content in aorta and platelet aggregation under conditions of hyperlipidemia. Therefore, we evaluated the effect of cilostazol on the atherosclerosis and platelet aggregation in rabbits fed a normal diet or a cholesterol-containing diet supplemented with or without cilostazol. We evaluated the effects of cilostazol on the atherogenesis by measuring serum and aortic lipid content, and the lesion area after a 10-week treatment and the effect on platelet aggregation after 1- and 10-week treatment. From the lipid analyses, cilostazol significantly reduced the total cholesterol, triglyceride and phospholipids in serum, and moreover, the triglyceride content in the atherosclerotic aorta. Cilostazol significantly reduced the intimal atherosclerotic area. Platelet aggregation was enhanced in cholesterol-fed rabbits. Cilostazol significantly inhibited the platelet aggregation in rabbits fed both a normal diet and a high cholesterol diet. Cilostazol showed anti-atherosclerotic and anti-platelet effects in cholesterol-fed rabbits possibly due to the improvement of lipid metabolism and the attenuation of platelet activation. The results suggest that cilostazol is useful for prevention and treatment of atherothrombotic diseases with the lipid abnormalities

Feasibility and impact of providing feedback to vaccinating medical clinics: evaluating a public health intervention

<p>Abstract</p> <p>Background</p> <p>Vaccine coverage (VC) at a given age is a widely-used indicator for measuring the performance of vaccination programs. However, there is increasing data suggesting that measuring delays in administering vaccines complements the measure of VC. Providing feedback to vaccinators is recognized as an effective strategy for improving vaccine coverage, but its implementation has not been widely documented in Canada. The objective of this study was to evaluate the feasibility of providing personalized feedback to vaccinators and its impact on vaccination delays (VD).</p> <p>Methods</p> <p>In April and May 2008, a one-hour personalized feedback session was provided to health professionals in vaccinating medical clinics in the Quebec City region. VD for vaccines administered at two and twelve months of age were presented. Data from the regional vaccination registry were analysed for participating clinics. Two 12-month periods before and after the intervention were compared, namely from April 1^st, 2007 to March 31^st, 2008 and from June 1^st, 2008 to May 31^st, 2009.</p> <p>Results</p> <p>Ten medical clinics out of the twelve approached (83%), representing more than 2500 vaccinated children, participated in the project. Preparing and conducting the feedback involved 20 hours of work and expenses of $1000 per clinic. Based on a delay of one month, 94% of first doses of DTaP-Polio-Hib and 77% of meningococcal vaccine doses respected the vaccination schedule both before and after the intervention. Following the feedback, respect of the vaccination schedule increased for vaccines planned at 12 months for the four clinics that had modified their vaccination practices related to multiple injections (depending on the clinic, VD decreased by 24.4%, 32.0%, 40.2% and 44.6% respectively, p < 0.001 for all comparisons).</p> <p>Conclusions</p> <p>The present study shows that it is feasible to provide personalized feedback to vaccinating clinics. While it may have encouraged positive changes in practice concerning multiple injections, this intervention on its own did not impact vaccination delays of the clinics visited. It is possible that feedback integrated into other types of effective interventions and sustained over time may have more impact on VD.</p