1244. Evaluation of Antibiotic Prescribing Practices for Geriatric Patients in the Outpatient Setting in a Veterans Affairs Hospital: Identification of Stewardship Targets

Abstract Background Antibiotics are frequently overused in the outpatient setting, however it is unknown how antibiotic use differs with age. Infections are a leading cause of hospitalization in elderly patients. Prescribing appropriateness for patients less than 65 years old was compared with patients at or above ≥65 years old in order to identify targets for antimicrobial stewardship in this population. Methods A retrospective review of all outpatient antibiotic prescriptions between June and September of 2017. Prescriptions were reviewed based on alerts in the electronic medical record when orders for antibiotics were signed by the provider. Appropriateness of antibiotics was assessed based on clinical practice guidelines. Retreatment and hospital admissions were documented. Those aged <65 were compared with those ≥65 years of age using Student’s t-test and chi-squared tests. A multivariate logistic regression model was constructed to identify risk factors for inappropriate use of antibiotics between the two age groups. Results The study period yielded 1,700 prescriptions after exclusions 1,063 were included in the analysis. Patients aged ≥65 comprised 51% of the population. Older patients had significantly more comorbidities than the younger population. No significant difference was observed for antibiotic indicated (60%), correct drug (50%), or correct duration (75%) between the two age groups. Patients in the ≥65 cohort were statistically significantly more likely to receive an inappropriate dose (86% vs. 76%, P < 0.002). In the multivariable analysis, patients with COPD were more likely to be appropriately with antibiotics OR 1.4 (95% CI: 1.03–1.9) compared with those without COPD. Older patients were not more likely to be retreated or admitted for the same indication within 30 days. Conclusion Antibiotics were frequently overused in the outpatient setting; however, they were not more frequently used in elderly patients. However, older adults were more likely to be prescribed an antibiotic at an inappropriate dose highlighting the need for increased caution with dosage selection in this population. Stewardship teams caring for elderly patients should be cognizant of dosing in this population. Disclosures All authors: No reported disclosures.

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Older Patients Are Less Affected by Radiochemotherapeutic Treatment than Younger

BioMed Research International ◽

10.1155/2018/5471054 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8

Author(s):

Max J. Weiling ◽

Wencke Losensky ◽

Katharina Wächter ◽

Teresa Schilling ◽

Fabian Frank ◽

...

Keyword(s):

Quality Of Life ◽

Elderly Patients ◽

Cancer Patients ◽

Older Patients ◽

Normative Data ◽

Age Groups ◽

German Population ◽

Younger Patients ◽

Significant Difference

Purpose. The general assumption is that cancer therapy impairs the quality of life in elderly patients more than in younger ones. We were interested in the effects of radiochemotherapeutic treatment on the quality of life of elderly patients compared to younger patients and compared to normative data of a general German population. Methods and Materials. A total of 465 patients completed the EORTC QLQ-C30 questionnaire. Repetitive completion of the questionnaire over time led to 1407 datasets. Our patient cohort contained 197 (42.4%) patients with colorectal cancer followed by 109 (23.4%) patients with head and neck cancer, 43 (9.2%) patients with lung cancer, and 116 (25%) with other types of cancer. Patients were categorized into five age groups, the respective cut-offs being 40, 50, 60, and 70 years. Normative data were drawn from a population study of a general German population. Results. Functional scores and symptom scores were approximately stable between the different age groups. Our data does not suggest a significant difference between the investigated age groups. Advancing age evened out the differences between the normative data of the general German population and the cancer patients in 11 of 15 scores. Conclusions. The general belief about younger patients having fewer physical and psychological problems related to radiochemotherapy needs to be reconsidered. Overall resilience of older patients is apparently underestimated.

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Evaluation of Antibiotic Prescribing in a Veterans Affairs Outpatient Setting: Identification of Stewardship Targets

The Senior Care Pharmacist ◽

10.4140/tcp.n.2019.268 ◽

2019 ◽

Vol 34 (4) ◽

pp. 268-278

Author(s):

Collin M. Clark ◽

Alexis T. White ◽

John A. Sellick ◽

Kari A. Mergenhagen

Keyword(s):

Multivariable Analysis ◽

Outpatient Setting ◽

Veterans Affairs ◽

Chronic Obstructive ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Obstructive Pulmonary Disease ◽

Significant Difference ◽

Observational Prospective Cohort Study ◽

Va Health Care System

OBJECTIVE: To evaluate antibiotic prescribing practices for geriatric outpatients in a Veterans Affairs (VA) health care system. DESIGN: This is a single-center, observational, prospective cohort study. SETTING: Veterans Affairs Healthcare System. PATIENTS: Outpatients treated with oral antibiotics between June and September 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Appropriate therapy was assessed based on clinical practice guidelines. Multivariable logistic regression was used to identify predictors of appropriate treatment. RESULTS: This study yielded 1,063 prescriptions for analysis. No significant difference was observed for antibiotic indicated (60%), correct drug (50%), or correct duration (75%). Patients older than 65 years of age were more likely to receive an inappropriate dose (86% vs. 76%; P < 0.002). In the multivariable analysis, patients with chronic obstructive pulmonary disease (COPD) were more than 1.4 times likely to be treated appropriately (95% confidence interval 1.03-1.9) versus those without COPD. Older patients were not more likely to be re-treated or admitted within 30 days. CONCLUSION: Antibiotics are often inappropriately used in the outpatient setting; but not more frequently in elderly patients. Older adults were more likely to be prescribed an antibiotic at an inappropriate dose. Opportunities exist for stewardship teams to provide value in the outpatient setting to ensure appropriate antibiotic prescribing with a focus on dosing.

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Cisplatin-based combination chemotherapy in elderly patients with metastatic urothelial cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.6_suppl.269 ◽

2013 ◽

Vol 31 (6_suppl) ◽

pp. 269-269

Author(s):

Aristotelis Bamias ◽

Susanne Krege ◽

Chia-Chi Lin ◽

Noah M. Hahn ◽

Thorsten Ecke ◽

...

Keyword(s):

Elderly Patients ◽

Urothelial Carcinoma ◽

Combination Chemotherapy ◽

Age Groups ◽

First Line ◽

Significant Difference ◽

Visceral Metastases ◽

Metastatic Urothelial Carcinoma ◽

Baseline Characteristics ◽

Two Age Groups

269 Background: Cisplatin-based combination chemotherapy is considered standard first-line treatment for patients with metastatic urothelial carcinoma. However, cisplatin-based chemotherapy is frequently avoided in elderly patients due to concerns regarding treatment-related toxicities. We analyzed the efficacy, and tolerability, of cisplatin-based chemotherapy in two age groups (< 70 versus ≥ 70 years old). Methods: Individual patient data was pooled from eight phase II and III trials evaluating cisplatin-based first-line chemotherapy in patients with metastatic urothelial carcinoma. Toxicities, treatment delivery, response proportions, and survival outcomes were compared between patients < 70 versus ≥ 70 years old. Results: Of the 543 patients included in the analysis, 162 patients (30%) were ≥ 70 years old. Patients ≥ 70 years old had a significantly lower baseline calculated creatinine clearance (57 vs. 73 ml/min, p<0.0001). All other baseline characteristics, including PS and visceral metastases were well balanced between the two age groups. Patients ≥ 70 years received a median of 1 cycle less of chemotherapy compared with younger patients (median cycles 5 versus 6; p = 0.004). There was no significant difference in the proportions of patients experiencing Grade 3-4 renal failure, febrile neutropenia, or treatment-related death. Response rate among patients ≥ 70 years old was 50% compared to 52% for patients < 70 years old (p=0.65). There was no significant difference in survival between the age groups (p=0.91). The median survival of the patients ≥ 70 years old was 12.1 months compared to 12.8 months for patients < 70 years old. There was no significant difference in survival between age groups when controlling for baseline performance status and/or the presence of visceral metastases. Conclusions: Elderly patients, with adequate renal function and other baseline characteristics suitable for clinical trial enrollment, tolerate cisplatin-based chemotherapy similarly, and achieve comparable clinical outcomes, compared with their younger counterparts. Cisplatin-based therapy need not be withheld from such patients.

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Dose Intensity and Hematologic Toxicity in Older Cancer Patients Receiving Systemic Chemotherapy.

Blood ◽

10.1182/blood.v106.11.3124.3124 ◽

2005 ◽

Vol 106 (11) ◽

pp. 3124-3124

Author(s):

Michelle Shayne ◽

Eva Culakova ◽

Marek S. Poniewierski ◽

Debra Wolff ◽

David C. Dale ◽

...

Keyword(s):

Elderly Patients ◽

Cancer Patients ◽

Older Patients ◽

Age Groups ◽

Dose Intensity ◽

Disease Stage ◽

Severe Neutropenia ◽

Hematologic Toxicity ◽

Significant Difference ◽

Older Cancer Patients

Abstract Introduction: Controlled clinical trials have provided limited data on hematologic toxicity and dose intensity of chemotherapy in the elderly. This study evaluated patient and treatment characteristics that contributed to hematologic toxicity in older cancer patients. Methods: A prospective study of 115 randomly selected U.S. community oncology practices was undertaken between March 2002 and March 2005 that included 999 consecutive patients age 70 and older. Major malignancies included cancers of lung (26%), colorectal (15%), lymphoma (13%), breast (13%), ovary (9%), genitourinary (7%), other gastrointestinal (6%), other gynecologic (3%) and head and neck (2%). Primary outcome measures included: anemia (Hgb <10 gm/dL), thrombocytopenia (plts <75k/mm3), severe neutropenia (SN) (neutrophils <500 cells/mm3, or WBC count <1000/mm3), febrile neutropenia (FN) and both planned and actual relative dose intensity (RDI) compared to standard regimens. Univariate and multivariate logistic regression analyses were performed to compare the difference among patients age 70–74 (45%), 75–79 (34%), ≥ 80 (21%). Results: Increasing age was associated with lower actual RDI (P<001), although planned RDI did not differ among age groups. Along with reduced actual RDI in elderly patients, progressively fewer SN or FN events (25%, 24%, and 16%, respectively) occurred across chemotherapy cycles (P=0.036). More advanced stage of disease at the time of treatment was associated with fewer SN or FN events in all cycles (35%, 27%, 21%, and 19% for stages 1–4, respectively) (P=0.017) along with lower RDI (P=.041). Use of taxane-containing regimens decreased with advancing age (37%, 34%, 27%, respectively) (P=0.034). Among the 50% of patients receiving ≥ 85% RDI, there was no significant difference in SN or FN based on age group or stage. Use of anthracycline-containing regimens was associated with development of SN or FN compared to non-anthracycline regimens (P<0.001). Older patients who received ≥ 85% actual RDI experienced more frequent SN or FN in all cycles of chemotherapy (27%) compared with patients who received <85% (22%) (P=.041) although no significant increase with age was observed. There was no statistically significant difference in anemia or thrombocytopenia among the different age groups. Anemia and thrombocytopenia were more prevalent in older patients receiving an anthracycline or platinum-containing regimen. In multivariate analysis, lower risk of SN or FN remained significantly associated with increasing age (P=.044) after adjustment for stage (P=.115) and actual RDI (P=.066). Prophylactic colony-stimulating factor was used in 5% of patients with no significant difference observed among the age groups. Conclusion: This report represents one of the largest studies to date of elderly cancer patients receiving chemotherapy. Neutropenic events increased with actual RDI while decreasing with age and disease stage. Advancing age alone does not appear to increase the risk of hematologic toxicity in older patients receiving full dose intensity chemotherapy. Nevertheless, half of elderly patients in this study received major reductions in actual dose intensity. More information is needed on the impact of reduced dose intensity chemotherapy on long term clinical outcomes in this population.

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ACUTE KIDNEY INJURY IN ELDERLY PATIENTS

Wiadomości Lekarskie ◽

10.36740/wlek201908109 ◽

2019 ◽

Vol 72 (8) ◽

pp. 1466-1472

Author(s):

Grażyna Kobus ◽

Jolanta Małyszko ◽

Hanna Bachórzewska-Gajewska

Keyword(s):

Acute Kidney Injury ◽

Renal Failure ◽

Acute Renal Failure ◽

Elderly Patients ◽

Older Patients ◽

Age Groups ◽

Kidney Injury ◽

The Elderly ◽

Younger Patients ◽

Common Cause

Introduction: In the elderly, impairment of kidney function occurs. Renal diseases overlap with anatomic and functional changes related to age-related involutionary processes. Mortality among patients with acute renal injury is approximately 50%, despite advances in treatment and diagnosis of AKI. The aim: To assess the incidence of acute kidney injury in elderly patients and to analyze the causes of acute renal failure depending on age. Materials and methods: A retrospective analysis included medical documentation of patients hospitalized in the Nephrology Clinic during the 6-month period. During this period 452 patients were hospitalized in the clinic. A group of 77 patients with acute renal failure as a reason for hospitalization was included in the study. Results: The prerenal form was the most common cause of AKI in both age groups. In both age groups, the most common cause was dehydration; in the group of patients up to 65 years of age, dehydration was 29.17%; in the group of people over 65 years - 43.39%. Renal replacement therapy in patients with AKI was used in 14.29% of patients. In the group of patients up to 65 years of age hemodialysis was 16.67% and above 65 years of age. -13.21% of patients. The average creatinine level in the group of younger patients at admission was 5.16 ± 3.71 mg / dl, in the group of older patients 3.14 ± 1.63 mg / dl. The size of glomerular filtration GFR in the group of younger patients at admission was 21.14 ± 19.54 ml / min, in the group of older patients 23.34 ± 13.33 ml / min. Conclusions: The main cause of acute kidney injury regardless of the age group was dehydration. Due to the high percentage of AKI in the elderly, this group requires more preventive action, not only in the hospital but also at home.

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Comparison of esophageal motility impairment caused by Chagas' disease in two age groups

Arquivos de Gastroenterologia ◽

10.1590/s0004-28032006000300008 ◽

2006 ◽

Vol 43 (3) ◽

pp. 196-200 ◽

Cited By ~ 3

Author(s):

Roberto Oliveira Dantas ◽

Lilian Rose Otoboni Aprile

Keyword(s):

Chagas Disease ◽

Esophageal Motility ◽

Older Patients ◽

Aging Process ◽

Age Groups ◽

Upper Esophageal Sphincter ◽

Control Group ◽

Younger Patients ◽

Lower Amplitude ◽

Two Age Groups

BACKGROUND: Chagas' disease and the aging process cause loss of neurons of the esophageal myenteric plexus. AIM: To evaluate the esophageal motility impairment caused by Chagas' disease in two age groups. Our hypothesis was that the aging process may cause further esophageal motility impairment in patients with Chagas' disease. METHODS: We studied the esophageal motility of 30 patients with Chagas' disease and dysphagia, with esophageal retention of barium sulfate and an esophageal diameter within the normal range. Fifteen were 34 to 59 years old (younger group, median 51 years) and 15 were 61 to 77 years old (older group, median 66 years). As a control group we studied 15 subjects aged 33 to 58 years (median 42 years) and 7 subjects aged 61 to 73 years (median 66 years). The esophageal contractions were measured by the manometric method with continuous perfusion after five swallows of a 5 mL bolus of water at 2, 7, 12 and 17 cm below the upper esophageal sphincter. RESULTS: Patients with Chagas' disease had lower amplitude of contractions and fewer peristaltic, more simultaneous, and more non-conducted contractions than controls. Older patients with Chagas' disease had lower amplitude of contractions in the distal esophagus (mean ± SE: 30.8 ± 4.3 mm Hg) than younger patients (51.9 ± 8.6 mm Hg). From 12 to 17 cm, older patients had more non-conducted (41%) and fewer peristaltic (8%) contractions than younger patients (non-conducted: 16%, peristaltic: 21%). CONCLUSION: Older patients with Chagas' disease with clinical and radiological examinations similar to those of younger patients had motility alterations suggesting that the aging process may cause further deterioration of esophageal motility.

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Abstract 13197: Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Outpatient Setting

Circulation ◽

10.1161/circ.132.suppl_3.13197 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Krishna Patel ◽

Laura Young ◽

Erik H Howell ◽

Bo Hu ◽

Shannon J Morrison ◽

...

Keyword(s):

Hospital Admissions ◽

Outpatient Setting ◽

Uncontrolled Hypertension ◽

Office Visits ◽

Hypertensive Urgency ◽

Admission Rates ◽

Coronary Syndrome ◽

Asymptomatic Patients ◽

Significant Difference ◽

Hypertensive Urgencies

Background: Hypertensive urgency is a commonly encountered outpatient problem. Prevalence and short term outcomes of this condition are unknown. JNC VII recommends aggressive BP control over several days. However, a small percentage of patients are sent to the emergency department. It is unknown whether hospital management of these patients is better than outpatient BP management. Methods: Retrospective cohort study of all patients presenting to an office in a large health care system from 2008-2013 with SBP ≥180mmHg or DBP ≥ 110mmHg. We excluded pregnant women and patients referred to the hospital for symptoms or treatment of other conditions. Patients were divided into 2 groups: those sent home and those referred to hospital. We recorded baseline demographic and clinical data. Propensity matched outcomes recorded included MACE (acute coronary syndrome, stroke/TIA) uncontrolled hypertension (≥140/90 mmHg) and hospital admissions. Results: Of 2,199,019 office visits, 58,583 (5%) had hypertensive urgency. Mean age was 63±15 yrs, 58% were females, 76% Caucasian, mean BMI was 31±8 kg/m2 and mean SBP and DBP were 182±16 and 96±16 mmHg. Only 426 (0.7%) patients were referred to the ED/hospital. On propensity matched analysis between the patients referred to the hospital and sent home, there was no significant difference in MACE events at 7 days (0% vs. 0.13%, p=1), 30 days (0.25% vs. 0%, p=1) or 6 months (0.5% vs. 0.13%, p=0.26). Compared to patients sent home, patients referred to the hospital had less uncontrolled hypertension at 1 month (81% vs. 88%, p=0.001) but not at 6 months (65% vs 69%, p=0.16). They also had higher 7- and 30-day hospital admission rates (8.5% vs. 4.9%, p=0.01; 11.8% vs 7.6%, p=0.02). Conclusion: Hypertensive urgency occurs commonly, but the rate of MACE in asymptomatic patients is very low. ED visits increased hospitalizations, but did not improve outcomes. Most patients with hypertensive urgencies still had uncontrolled hypertension at 6 months.

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Prescribing of different antibiotics, rates of sepsis-related mortality and bacteremia in the US and England, and the utility of antibiotic replacement vs. reduction in prescribing: a cross-sectional study

10.21203/rs.2.10944/v1 ◽

2019 ◽

Cited By ~ 1

Author(s):

Edward Goldstein

Keyword(s):

Bacterial Infections ◽

Multivariable Analysis ◽

Age Groups ◽

Epidemiological Data ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Limited Information ◽

Cross Sectional ◽

E Coli ◽

The Us

Abstract Background Antibiotic use contributes to the rates of bacteremia, sepsis and associated mortality, particularly through lack of clearance of resistant infections following antibiotic treatment. At the same time, there is limited information on the effects of prescribing of some antibiotics vs. others on the rates of outcomes related to severe bacterial infections. Methods We looked at associations between the proportions (state-specific in the US; Clinical Commissioning Group (CCG)-specific in England) of different antibiotic types/classes among all prescribed antibiotics in the outpatient setting (oral antibiotics in the US), and rates of outcomes (mortality with sepsis, ICD-10 codes A40-41 present as either underlying or contributing causes of death on a death certificate in different age groups of US adults; E. coli as well as MSSA bacteremia in England) per unit of antibiotic prescribing (defined as the rate of outcome divided by the rate of outpatient prescribing of all antibiotics). Results In the US, prescribing of penicillins was associated with rates of mortality with sepsis for persons aged 75-84y and 85+y between 2014-2015. In England, prescribing of penicillins other than amoxicillin/co-amoxiclav was associated with rates of both MSSA and E. coli bacteremia for the period between financial years 2014/15 through 2017/18. Additionally, multivariable analysis for the US data has also shown an association between the percent of individuals aged 50-64y lacking health insurance, as well as the percent of individuals aged 65-84y who are African-American and rates of mortality with sepsis in the corresponding age groups. Conclusions Our results suggest that prescribing of penicillins is associated with rates of E. coli and MSSA bacteremia in England, and rates of mortality with sepsis in older US adults. Those results, as well as the related epidemiological data suggest that replacement of certain antibiotics, particularly penicillins in the treatment of certain syndromes should be considered for reducing the rates of outcomes related to severe bacterial infections.

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Differences in Treatment Outcomes and Prognosis between Elderly and Younger Patients Receiving Definitive Radiotherapy for Cervical Cancer

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17124510 ◽

2020 ◽

Vol 17 (12) ◽

pp. 4510

Author(s):

PeiYu Hou ◽

ChenHsi Hsieh ◽

MingChow Wei ◽

ShengMou Hsiao ◽

PeiWei Shueng

Keyword(s):

Cervical Cancer ◽

Prognostic Factors ◽

Elderly Patients ◽

Treatment Outcomes ◽

Clinical Outcomes ◽

Age Groups ◽

Definitive Radiotherapy ◽

Regional Control ◽

Group 2 ◽

Two Age Groups

The aim was to compare the clinical outcomes and prognostic factors of cervical cancer between elderly and younger women, and to explore which treatment strategy is more appropriate for elderly patients. We retrospectively reviewed patients with cervical cancer receiving definitive radiotherapy (RT) between 2007 and 2016, and divided them into two age groups: age < 70 vs. age ≥ 70. The clinical outcomes were compared between the two age groups. The median follow-up was 32.2 months. A total of 123 patients were eligible, 83 patients in group 1 (age < 70), and 40 patients in group 2 (age ≥ 70). Patients in group 2 received less intracavitary brachytherapy (ICRT) application, less total RT dose, and less concurrent chemoradiotherapy (CCRT), and tended to have more limited external beam radiotherapy (EBRT) volume. The treatment outcomes between the age groups revealed significant differences in 5-year overall survival (OS), but no differences in 5-year cancer-specific survival (CSS), 66.2% vs. 64.5%, and other loco-regional control. In multivariate analyses for all patients, the performance status, pathology with squamous cell carcinoma (SCC), International Federation of Gynecology and Obstetrics (FIGO) stage, and ICRT application were prognostic factors of CSS. The elderly patients with cervical cancer had comparable CSS and loco-regional control rates, despite receiving less comprehensive treatment. Conservative treatment strategies with RT alone could be appropriate for patients aged ≥ 70 y/o, especially for those with favorable stages or histopathology.

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Character introductions in oral narratives of Swedish–German bilingual preschoolers

First Language ◽

10.1177/0142723719897440 ◽

2020 ◽

pp. 014272371989744

Author(s):

Josefin Lindgren ◽

Valerie Reichardt ◽

Ute Bohnacker

Keyword(s):

Language Proficiency ◽

Language Skills ◽

Age Groups ◽

Age Group ◽

Morphological Form ◽

Information Status ◽

Significant Difference ◽

Old Swedish ◽

As Effects ◽

Two Age Groups

Closely related Swedish and German both mark information status of referents morphologically, though little is known about its acquisition. This study investigates character introductions in the narratives of 4- and 6-year-old Swedish–German bilinguals ( N = 40) in both languages, elicited with MAIN Cat/Dog. We analyse effects of age group, language and animacy (human vs nonhuman characters) on the type of referring expression (indefinite NP and pronoun), as well as effects of language proficiency and exposure on the use of indefinite NPs for each language. We also explore which syntactic constructions indefinite NPs occur in. A significant difference was found between the two age groups, but not between languages. No effect was found of language skills or exposure. Four-year-olds used more pronouns and a lower proportion of indefinite NPs than 6-year-olds. Pronouns were more frequent for the human character than for nonhuman animate characters. Whilst animacy (humanness) promoted the use of pronouns, it did not affect the choice of morphological form for lexical NPs (indefinite/definite). The age groups differed in how indefinite NPs were used. Four-year-olds produced fewer narrative presentations (where a character is introduced as part of a typical story opening, e.g. Once upon a time there was a cat) than 6-year-olds, and more labellings (with only an NP, or a clausal predicative, e.g. That’s a cat). Qualitative analyses suggest that the children’s indefinite NPs in labelling constructions can be both referential (when setting the narrative scene), and type-denoting (when naming referents in individual pictures). Whilst the children’s abilities to introduce story characters develop measurably from 4 to 6 years in Swedish and German, appropriateness of character introductions not only depends on whether an indefinite NP is chosen, but also on the syntactic construction this indefinite NP is used in.

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