Fluconazole prophylaxis for prevention of invasive fungal infections in targeted highest risk preterm infants limits drug exposure.

OBJECTIVE: Previous reports suggest a benefit of fluconazole prophylaxis in extremely low birth weight (ELBW) infants <1000 g. Our aim was to evaluate if limiting fluconazole prophylaxis to targeted highest risk infants effectively prevents invasive fungal infections, has no undesired side effects and limits unnecessary drug exposure. STUDY DESIGN: This nonrandomized retrospective pre-post intervention study compared two groups of infants: (1) Infants <26 weeks gestation and/or <750 g birth weight, requiring central vascular access and admitted to the Monroe Carell Jr Children's Hospital at Vanderbilt neonatal intensive care unit (NICU) prior to 5 days of age, who received fluconazole prophylaxis and (2) a matched control group from the year prior to prophylaxis. This target population was selected for fluconazole prophylaxis based on prior infection control data from our institution and a number needed to treat of <15 to prevent one episode of fungemia. Following implementation and integration through the institution's computerized physician order entry (CPOE) system, provider adherence to the protocol was assessed during the prophylaxis period. RESULT: A total of 86 patients were included in the study, 44 in the no-prophylaxis group and 42 in the prophylaxis group. In the targeted prophylaxis group, no invasive fungal infections were observed as compared to nine infants with invasive infections in the no-prophylaxis group (P=0.004). No significant adverse effects were recorded. Targeting the highest risk infants reduced the number of infants <1000 g requiring prophylaxis from 80 to 42 (48% reduction) with no preventable infection missed. Provider compliance was 91% following implementation of this protocol through the CPOE system using a standardized order set. CONCLUSION: Targeting the highest risk infants for fluconazole prophylaxis through CPOE can effectively prevent invasive fungal infections and limit drug exposure with no unwanted side effects.

Care provider order entry (CPOE): a perspective on factors leading to success or to failure.

OBJECTIVE: Authors provide a perspective on factors leading to successful care provider order entry (CPOE) implementations. METHODS: Viewpoint of authors supported by background literature review. RESULTS: Authors review both benefits and challenges related to CPOE implementation using three guiding principles: (1) a clinical approach to clinical systems, which claims that CPOE implementation is analogous to a "good" clinician delivering care to a patient; (2) a commitment to quality, which advocates that no compromises should be made in implementing system functionality and clinical system content - the highest objective for CPOE implementation is to provide better quality of care and increased safety for patients; (3) a commitment to fairness, as evidenced by respect for individuals and support of local autonomy, which advocates for minimizing disruptions to clinician-users' workflows, and adequate local control over CPOE system design and evolution, including clinical content management. CONCLUSIONS: Past experiences with CPOE implementation can inform future installation attempts. Sociocultural factors dominate in determining the success of implementation, and should govern technical factors.

Analysis of vocal tract characteristics for near-term suicidal risk assessment.

OBJECTIVES: Among the many clinical decisions that psychiatrists must make, assessment of a patient's risk of committing suicide is definitely among the most important, complex and demanding. One of the authors reviewing his clinical experience observed that successful predictions of suicidality were often based on the patient's voice independent of content. The voices of suicidal patients exhibited unique qualities, which distinguished them from non-suicidal patients. In this study we investigated the discriminating power of lower order mel-cepstral coefficients among suicidal, major depressed, and non-suicidal patients. METHODS: Our sample consisted of 10 near-term suicidal patients, 10 major depressed patients, and 10 non-depressed control subjects. Gaussian mixtures were employed to model the class distributions of the extracted features. RESULTS AND CONCLUSIONS: As a result of two-sample ML classification analyses, first four mel-cepstral coefficients yielded exceptional classification performance with correct classification scores of 80% between near-term suicidal patients and non-depressed controls, 75% between depressed patients and non-depressed controls, and 80% between near-term suicidal patients and depressed patients.