Improvement of Inpatient Psychiatric Facility Quality Reporting program measure: Screening for metabolic disorders through pharmacy collaborative practice agreement.

BACKGROUND: Second-generation antipsychotics are associated with lower risks of extrapyramidal symptoms, including tardive dyskinesia. However, many second-generation antipsychotics are associated with metabolic adverse effects, including weight gain, impaired blood glucose control, and hyperlipidemia. Metabolic monitoring for patients prescribed antipsychotic medication is 1 of several measures of the Centers for Medicare & Medicaid Services' Inpatient Psychiatric Facility Quality Reporting program. Screening for metabolic disorders (SMD) must be obtained within the previous 365 days before the hospital discharge date. National data suggest that compliance with this measure is low. OBJECTIVE: To improve compliance of metabolic monitoring by 20% while ensuring that the quality improvement interventions did not cause any unintended adverse effects on other aspects of our system. PRACTICE DESCRIPTION: This quality initiative was conducted at a large, 2000-bed academic medical center with approximately 80 inpatient psychiatric beds. PRACTICE INNOVATION: To improve the metabolic screening rates, a pharmacist collaborative practice agreement (CPA) was established as part of a quality improvement project. Previously, there were no formal processes at the institution to ensure that appropriate laboratory tests were conducted. EVALUATION METHODS: Using an uncontrolled before-and-after design, SMD data were gathered from 6 months before and 6 months after CPA implementation. Pearson chi-square test or Fisher exact test were used to compare the pre- and postintervention groups in this quasi-experimental design. RESULTS: Compared with the preintervention period, compliance of SMD monitoring increased by 21.2% in the postintervention phase-from 69.2% to 90.4% (P < 0.001). CONCLUSION: The empowerment of clinical pharmacists with a CPA significantly improved guideline-concordant metabolic monitoring of antipsychotics. These findings may have significant impact on the approach to the safe use of these essential psychotropic medications and provide a framework for other inpatient mental health facilities to optimally use the skills of their interdisciplinary team.

Increasing Competence in Pressure Injury Prevention Using Competency-Based Education in Adult Intensive Care Unit.

BACKGROUND: There is a significant focus on pressure injury prevention to promote better patient outcomes and control health care cost. LOCAL PROBLEM: In 2016, the institution's pressure injury quarterly prevalence survey showed that two-thirds of the patients surveyed who developed unit-acquired pressure injury stage 2 and greater were in the adult intensive care units. METHODS: The quality improvement project used a pre- and postintervention design. INTERVENTIONS: The adult medical intensive care unit (MICU) executed a competency-based education project to increase staff implementation of pressure injury prevention. RESULTS: Following initiation of competency-based education, staff documentation of pressure injury prevention implementation increased, and unit-acquired pressure injury stage 2 and greater rates were reduced. CONCLUSIONS: The use of a competency-based education program may be effective in increasing pressure injury prevention in the intensive care unit.

Clozapine-induced cardiomyopathy and myocarditis monitoring: A systematic review.

The use of clozapine requires monitoring the absolute neutrophil count because of the risk of agranulocytosis, but other potentially fatal adverse events associated with clozapine (specifically, myocarditis and cardiomyopathy) do not have mandatory procedures. We performed a systematic review of English-language articles to synthesize an evidence-based approach for myocarditis and cardiomyopathy monitoring. Articles published from January 1988 through February 2017 were identified through a search of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Google Scholar. Selected articles were required to relate to myocarditis or cardiomyopathy in humans from exposure to clozapine. A total of 144 articles were included. Recommendations varied widely. Some authors recommended baseline laboratory monitoring, with or without follow-up testing, for C-reactive protein, creatine kinase MB, and troponin. Electrocardiography was commonly recommended, and echocardiography was less commonly recommended. The expense of monitoring was a consideration. A unanimous recommendation was to stop the use of clozapine and seek a cardiovascular consultation if myocarditis or cardiomyopathy is suspected. Although there is general agreement on which tests to perform for confirming myocarditis and cardiomyopathy, preemptive screening for these clozapine-induced conditions is controversial, and cost and barriers for the use of clozapine are concerns. For asymptomatic patients receiving clozapine, testing could include baseline electrocardiography, echocardiography as part of a cardiac consultation if patients have cardiac disease or risk factors, and monitoring of C-reactive protein and troponin as indicated.

Trends in Substance Use Across the Nation and South Dakota.

With the discovery of morphine in the early 1800s, substance abuse quickly followed. Next came the production of heroin and other synthetic opioids, along with increases in nonmedical use of prescription medications. In the 21st century, drug abuse and addiction continues to rise nationwide with the three most common drugs abused in adolescents being marijuana, synthetic marijuana, and hallucinogens. Among adolescents and adults nationwide, rates of alcohol, opioids, and amphetamine use have increased over the last decade. In South Dakota, the most prevalent drugs consist of alcohol, methamphetamine, heroin, and prescription opioids. Through the implementation and use of the Prescription Drug Monitoring Program (PDMP) by the South Dakota Board of Pharmacy (SDBOP), hydrocodone/acetaminophen has been identified as the most dispensed controlled substance in the state with roughly 21,000 prescriptions dispensed last November alone. While the PDMP does not necessarily encompass all controlled substances used by the patient (e.g., those purchased from illicit sources), the generation of PDMP reports by physicians and pharmacists is still beneficial. With increased use of the PDMP along with urine drug screens and patient interviews, health care professionals can continue to work collaboratively to help curb the growing epidemic of substance use.

Associations between syntax and the lexicon among children with or without ASD and language impairment.

Five groups of children defined by presence or absence of syntactic deficits and autism spectrum disorders (ASD) took vocabulary tests and provided sentences, definitions, and word associations. Children with ASD who were free of syntactic deficits demonstrated age-appropriate word knowledge. Children with ASD plus concomitant syntactic language impairments (ASDLI) performed similarly to peers with specific language impairment (SLI) and both demonstrated sparse lexicons characterized by partial word knowledge and immature knowledge of word-to-word relationships. This behavioral overlap speaks to the robustness of the syntax-lexicon interface and points to a similarity in the ASDLI and SLI phenotypes.

Proficiency with tense and aspect concordance: children with SLI and their typically developing peers.

Children with SLI have difficulty with tense and agreement morphology. This study examined the proficiency of these children and their typically developing peers with the coordination of tense and aspect markers in two-clause sentences. Scenarios designed to elicit past tense were presented to five- to eight-year-old children with SLI (n=14) and their normally developing age- and MLU-matched peers (n=24) to examine the omission of tense markers in complex sentences (Owen, 2010). Responses with overt tense/aspect morphology in both clauses were recoded for how similar the use of tense and aspect was across the two clauses. Tense and aspect concordance was high across both sentence types, but aspect-only mismatches were more common than tense mismatches. The three groups of children did not differ from each other on any comparisons. Coordination of temporal information in sentences with more than one time marker does not appear to be especially difficult for these children.

Effect of subject types on the production of auxiliary is in young English-speaking children.

PURPOSE: In this study, the authors tested the unique checking constraint (UCC) hypothesis and the usage-based approach concerning why young children variably use tense and agreement morphemes in obligatory contexts by examining the effect of subject types on the production of auxiliary is. METHOD: Twenty typically developing 3-year-olds were included in this study. The children's production of auxiliary is was elicited in sentences with pronominal subjects, high-frequency lexical noun phrase (NP) subjects (e.g., the dog), and low-frequency lexical NP subjects (e.g., the deer). RESULTS: As a group, children did not use auxiliary is more accurately with pronominal subjects than with lexical NP subjects. Furthermore, individual data revealed that although some children used auxiliary is more accurately with pronominal subjects than with lexical NP subjects, the majority of children did not show this trend. CONCLUSION: The symmetry observed between lexical and pronominal subjects supports the predictions of the UCC hypothesis, although additional mechanisms may be needed to account for the asymmetry between subject types in some individual children. Discrepant results between the present study and previous studies were attributed to differences in task formats and children's developmental levels.

Factors affecting accuracy of past tense production in children with specific language impairment and their typically developing peers: the influence of verb transitivity, clause location, and sentence type.

PURPOSE: The author examined the influence of sentence type, clause order, and verb transitivity on the accuracy of children's past tense productions. All groups of children, but especially children with specific language impairment (SLI), were predicted to decrease accuracy as linguistic complexity increased. METHOD: The author elicited past tense productions in 2-clause sentences from 5- to 8-year-old children with SLI (n=14) and their typically developing peers (n=24). The target sentences varied in the type and obligatory nature of the second clause and the number of arguments. RESULTS: On average, 85% of the responses across all groups and sentence types contained 2 clauses. Fewer 2-clause sentences were produced in the complement clause condition than in the other conditions. Sentence type and clause order, but not argument structure, influenced use of past tense. Children with SLI had a similar but less accurate profile as compared with the age-matched group. The younger mean length of utterance (MLU)-matched group reflected decreased accuracy with each additional source of linguistic complexity. CONCLUSIONS: Increased syntactic difficulty decreases use of morphology for all children, supporting the hypothesis that processing demands influence morphological accuracy. MLU-matched children, but not children with SLI, were more affected by changes in linguistic complexity. Further work on age-related changes in sentence production is necessary.

The overgeneralization of non-finite complements to finite contexts: the case of decide.

Current views on the acquisition of PRO can roughly be divided into two areas: lexical and syntactic accounts. We present data on one verb, decide, that yields data that not only differs from the data for other similar verbs with the same children, but does not lend itself easily to either type of account. Data from a sentence elicitation task conducted with 20 typically-developing children (4;o-7;11), along with 3 case studies illustrate that children may not be assigning a referent for PRO in an adult-like manner for particular verbs. Instead they may be overgeneralizing the use of non-finite complements to finite contexts.

Acoustic correlates of inflectional morphology in the speech of children with specific language impairment and their typically developing peers.

The development of the use of the third-person singular -s in open syllable verbs in children with specific language impairment (SLI) and their typically developing peers was examined. Verbs that included overt productions of the third-person singular -s morpheme (e.g. Bobby plays ball everyday; Bear laughs when mommy buys popcorn) were contrasted with clearly bare stem contexts (e.g. Mommy, buy popcorn; I saw Bobby play ball) on both global and local measures of acoustic duration. A durational signature for verbs inflected with -s was identified separately from factors related to sentence length. These duration measures were also used to identify acoustic changes related to the omission of the -s morpheme. The omitted productions from the children with SLI were significantly longer than their correct third-person singular and bare stem productions. This result was unexpected given that the omitted productions have fewer phonemes than correctly inflected productions. Typically developing children did not show the same pattern, instead producing omitted productions that patterned most closely with bare stem forms. These results are discussed in relation to current theoretical approaches to SLI, with an emphasis on performance and speech-motor accounts.

Lexical aspect and the use of verb morphology by children with specific language impairment.

PURPOSE: Many typically developing children first use inflections such as -ed with verb predicates whose meanings are compatible with the functions of the inflection (e.g., using -ed when describing events of brief duration with clear end points, such as dropped). This tendency is assumed to be beneficial for development. In this study, the authors examine whether preschool-aged children with specific language impairment (SLI) show a similar tendency. METHOD: Sixteen children in each of three groups participated-children with SLI, typically developing children matched for age (TD-A), and younger typically developing children matched for mean length of utterance (TD-MLU). The children described actions in contexts that promoted either past tense -ed or progressive aspect -ing in past contexts. Half of the verb predicates referred to events of brief duration with distinct endpoints (e.g., drop), and half referred to events of considerable duration with less distinct points of termination (e.g., play). RESULTS: Both the TD-A children and the TD-MLU children used -ed with verb predicates of the first type more consistently than they did with verb predicates of the second type. They showed the reverse pattern for -ing. The children with SLI did not show any effects according to the verb predicate type. However, although the children with SLI made less overall use of -ed than did both groups of TD children, they differed only from the TD-A children in their overall use of -ing. CONCLUSION: Difficulties with tense-related morphology may be compounded in children with SLI if they fail to make use of associations between the lexical aspect of verb predicates and the grammatical function of the accompanying inflections. The authors argue that the advantages of using these associations as a starting point in acquisition may be especially important in the case of -ed. Additional studies of children with SLI are clearly needed, including those that employ longitudinal, naturalistic data.

The production of finite and nonfinite complement clauses by children with specific language impairment and their typically developing peers.

The purpose of this study was to explore whether 13 children with specific language impairment (SLI; ages 5;1-8;0 [years;months]) were as proficient as typically developing age- and vocabulary-matched children in the production of finite and nonfinite complement clauses. Preschool children with SLI have marked difficulties with verb-related morphology. However, very little is known about these children's language abilities beyond the preschool years. In Experiment 1, simple finite and nonfinite complement clauses (e.g., The count decided that Ernie should eat the cookies; Cookie Monster decided to eat the cookies) were elicited from the children through puppet show enactments. In Experiment 2, finite and nonfinite complement clauses that required an additional argument (e.g., Ernie told Elmo that Oscar picked up the box; Ernie told Elmo to pick up the box) were elicited from the children. All 3 groups of children were more accurate in their use of nonfinite complement clauses than finite complement clauses, but the children with SLI were less proficient than both comparison groups. The SLI group was more likely than the typically developing groups to omit finiteness markers, the nonfinite particle to, arguments in finite complement clauses, and the optional complementizer that. Utterance-length restrictions were ruled out as a factor in the observed differences. The authors conclude that current theories of SLI need to be extended or altered to account for these results.

Neuropathic bladder and intermittent catheterization: social and psychological impact on families.

Clean intermittent catheterization (CIC) is the mainstay of management in neuropathic vesicourethral dysfunction, both to improve continence and, more importantly, to preserve renal function. We looked at the effects of this procedure on children, adolescents, and their families. In particular, we wished to see if there were any differences between those who successfully catheterized and those who did not. Forty families were enrolled into the study. Ages of children and adolescents (23 females, 17 males) ranged from 1 to 20 years. Most participants (n=31) had spina bifida. Other causes of bladder dysfunction included transverse myelitis, spinal cord injury, and spinal neuroblastoma. Parents were assessed using the Effects of Handicap on Parents semi-structured interview, the Socioemotional Functioning Interview, and a semi-structured interview, specifically designed for the study, which looked at family characteristics and experience related to diagnosis and catheterization. In addition, the Rutter Parental 'A' Scale Questionnaire was used to screen for emotional and behavioural disorders in the child. Results showed that CIC by carer or self-catheterization itself did not cause major emotional and behavioural problems but the bladder problem may act as a focus that puts considerable strain family relationships. Although most parents disliked CIC they complied with the suggested management. It is important that all those involved understand the aims of management and success can be achieved by combined input from medical, psychological, and specialist nursing staff. The problem is lifelong and continued support from a multidisciplinary team is essential.

Lexical diversity in the spontaneous speech of children with specific language impairment: application of D.

The lexical diversity of children with specific language impairment (SLI) (ages 3 years 7 months to 7 years 3 months) was compared to that of normally developing same-age peers and younger normally developing children matched according to mean length of utterance in words (MLUw). Lexical diversity was calculated from spontaneous speech samples using D, a measure that uses repeated calculations of type-token ratio (TTR) to estimate how TTR changes as the speech samples increase in size. When D computations were based on 250-word samples, developmental differences were apparent. For both children with SLI and typically developing children, older subgroups showed higher D scores than younger subgroups, and subgroups with higher MLUws showed higher D scores than subgroups with lower MLUws. Children with SU did not differ from same-age peers. At lower MLUw levels, children with SLI showed higher D scores than younger typically developing children matched for MLUw. The developmental sensitivity of D notwithstanding, comparisons using 100-utterance samples, in which the number of lexical tokens varied as a function of the children's MLUws, and comparisons between 250- and 500-word samples revealed the possible influence of sample size on this measure. However, analysis of the effect sizes using smaller and larger samples revealed that D is not affected by sample size to the degree seen for more traditional measures of lexical diversity.