Identifying and enhancing risk thresholds in the detection of elder financial abuse: a signal detection analysis of professionals’ decision making

Background

Financial abuse of elders is an under acknowledged problem and professionals’ judgements contribute to both the prevalence of abuse and the ability to prevent and intervene. In the absence of a definitive “gold standard” for the judgement, it is desirable to try and bring novice professionals’ judgemental risk thresholds to the level of competent professionals as quickly and effectively as possible. This study aimed to test if a training intervention was able to bring novices’ risk thresholds for financial abuse in line with expert opinion.

Methods

A signal detection analysis, within a randomised controlled trial of an educational intervention, was undertaken to examine the effect on the ability of novices to efficiently detect financial abuse. Novices (n?=?154) and experts (n?=?33) judged “certainty of risk” across 43 scenarios; whether a scenario constituted a case of financial abuse or not was a function of expert opinion.Novices (n?=?154) were randomised to receive either an on-line educational intervention to improve financial abuse detection (n?=?78) or a control group (no on-line educational intervention, n?=?76). Both groups examined 28 scenarios of abuse (11 “signal” scenarios of risk and 17 “noise” scenarios of no risk). After the intervention group had received the on-line training, both groups then examined 15 further scenarios (5 “signal” and 10 “noise” scenarios).

Results

Experts were more certain than the novices, pre (Mean 70.61 vs. 58.04) and post intervention (Mean 70.84 vs. 63.04); and more consistent. The intervention group (mean 64.64) were more certain of abuse post-intervention than the control group (mean 61.41, p = 0.02). Signal detection analysis of sensitivity (A´) and bias (C) revealed that this was due to the intervention shifting the novices’ tendency towards saying “at risk” (C post intervention -.34) and away from their pre intervention levels of bias (C-.12). Receiver operating curves revealed more efficient judgments in the intervention group.

Conclusion

An educational intervention can improve judgements of financial abuse amongst novice professionals.

     

Ceftriaxone-induced pseudolithiasis in children treated for perforated appendicitis

Purpose

Ceftriaxone has been associated with development of pseudolithiasis. In our institution, it is used for treatment of perforated appendicitis in children. This study evaluated the occurrence of ceftriaxone-related pseudolithiasis in this population.

Methods

After obtaining IRB approval, we performed a retrospective chart review over 51 months. We included patients undergoing laparoscopic appendectomy for perforated appendicitis. All patients were treated with ceftriaxone post-operatively. Patients without initial or post-treatment gallbladder imaging available for review were excluded.

Results

There were 71 patients who met inclusion criteria with a mean (±SD) age of 10.8 ± 3.8 years. Of these, 14 % (n = 10) developed stones or sludge in the gallbladder. The mean duration of ceftriaxone therapy was 8.7 ± 3.8 days. The average time to post-antibiotic imaging was 11.5 ± 10.3 days from initiation of antibiotics. There was no significant difference in duration of ceftriaxone therapy in the children that developed pseudolithiasis or sludge (10.0 ± 4.9 days) compared to those that did not (8.5 ± 3.6, p = 0.26). One child (10 %) with pseudolithiasis went on to become symptomatic, requiring a laparoscopic cholecystectomy.

Conclusions

In our experience, ceftriaxone use for perforated appendicitis is associated with a significant incidence of biliary pseudolithiasis, and is unrelated to duration of ceftriaxone therapy.     

Postnatal management and long-term outcome for survivors with congenital diaphragmatic hernia

Significant advances in the postnatal management of patients with congenital diaphragmatic hernia (CDH) have resulted in a remarkable improvement in survival rates over the past two decades. The success of current postnatal management of CDH patients has rendered fetal intervention to be limited to the most severe cases, and the role for prenatal treatment of CDH patients remains unclear. The adoption of lung-preserving strategies including high-frequency oscillatory ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) have improved CDH outcomes especially in those patients with significant ventilatory or circulatory compromise. Survival rates of up to 90% are being reported in some high-volume centers. However, the increased survival in CDH patients has been accompanied by an increase in neurological, nutritional and musculoskeletal morbidity among the long-term survivors. This has resulted in the need to provide resources for the long-term follow-up and support of this patient population. In this article, the postnatal management strategies and primary and secondary outcomes of high-volume international pediatric surgical centers will be reviewed. Finally, the role of a multidisciplinary management team for the follow-up of long-term CDH survivors will be discussed.