Assessment of readiness for clinical decision support to aid laboratory monitoring of immunosuppressive care at U.S. liver transplant centers.

BACKGROUND: Following liver transplantation, patients require lifelong immunosuppressive care and monitoring. Computerized clinical decision support (CDS) has been shown to improve post-transplant immunosuppressive care processes and outcomes. The readiness of transplant information systems to implement computerized CDS to support post-transplant care is unknown. OBJECTIVES: a) Describe the current clinical information system functionality and manual and automated processes for laboratory monitoring of immunosuppressive care, b) describe the use of guidelines that may be used to produce computable logic and the use of computerized alerts to support guideline adherence, and c) explore barriers to implementation of CDS in U.S. liver transplant centers. METHODS: We developed a web-based survey using cognitive interviewing techniques. We surveyed 119 U.S. transplant programs that performed at least five liver transplantations per year during 2010-2012. Responses were summarized using descriptive analyses; barriers were identified using qualitative methods. RESULTS: Respondents from 80 programs (67% response rate) completed the survey. While 98% of programs reported having an electronic health record (EHR), all programs used paper-based manual processes to receive or track immunosuppressive laboratory results. Most programs (85%) reported that 30% or more of their patients used external laboratories for routine testing. Few programs (19%) received most external laboratory results as discrete data via electronic interfaces while most (80%) manually entered laboratory results into the EHR; less than half (42%) could integrate internal and external laboratory results. Nearly all programs had guidelines regarding pre-specified target ranges (92%) or testing schedules (97%) for managing immunosuppressive care. Few programs used computerized alerting to notify transplant coordinators of out-of-range (27%) or overdue laboratory results (20%). CONCLUSIONS: Use of EHRs is common, yet all liver transplant programs were largely dependent on manual paper-based processes to monitor immunosuppression for post-liver transplant patients. Similar immunosuppression guidelines provide opportunities for sharing CDS once integrated laboratory data are available.

Sources of infection among persons with acute hepatitis A and no identified risk factors during a sustained community-wide outbreak.

CONTEXT: Hepatitis A is a common vaccine-preventable disease in the United States. Most cases occur during community-wide outbreaks, which can be difficult to control. Many case-patients have no identified source. OBJECTIVE: To identify foodborne and household sources of hepatitis A during a community-wide outbreak. DESIGN: Serologic and descriptive survey. SETTING: Salt Lake County, Utah. PARTICIPANTS: A total of 355 household contacts of 170 persons reported with hepatitis A during May 1996 to December 1996, who had no identified source of infection; and 730 food handlers working in establishments where case-patients had eaten. MAIN OUTCOME MEASURE: Prevalence of immunoglobulin M antibodies to hepatitis A virus (IgM anti-HAV) among household and food service contacts. RESULTS: Overall, 70 household contacts (20%) were IgM anti-HAV-positive, including 52% of children 3 to 5 years old and 30% of children <3 years old. In multivariate analysis, the presence of a child <3 years old (odds ratio [OR]: 8.8; 95% confidence limit [CL]: 2.1,36) and a delay of >/=14 days between illness onset and reporting (OR: 7. 9; 95% CL: 1.7,38) were associated with household transmission. Of 18 clusters of infections linked by transmission between households, 13 (72%) involved unrecognized infection among children <6 years old. No food handlers were IgM anti-HAV-positive. CONCLUSION: During a community-wide outbreak, HAV infection among children was common, was frequently unrecognized, and may have been an important source of transmission within and between households. Transmission from commercial food establishments was uncommon. Ongoing vaccination of children may prevent future outbreaks.

Deaths due to flash floods in Puerto Rico, January 1992: implications for prevention.

BACKGROUND: In January 1992, the Commonwealth of Puerto Rico sustained unusually heavy rainfall, which caused flash floods and deaths. METHODS: We conducted a descriptive study and a case-control study to determine the circumstances of these deaths and to identify mortality-prevention strategies. We describe the time, place, and circumstances of each death, and compare this information with water-level and rainfall data and the timing of warnings. Using controls selected from the affected population, we estimated the risk of death by age, sex, and vehicle occupancy during the flood. RESULTS: Within 7 hours, 23 people died in 17 incidents; 20 of the decedents (87%) were occupants of motor vehicles. The estimated risk of mortality was significantly elevated for motorists (odds ratio = 16, 95% confidence interval: 3.5-144). Being in a vehicle to evacuate a flash flood area was protective; however, being in a vehicle during the flood for other reasons further increased the risk of mortality. Deaths occurred early during the rapid rise of water and before official warnings were issued. CONCLUSION: We recommend improving the sensitivity of the warning system and its ability to disseminate appropriate information rapidly. We also recommend educating officials and the public about the risks of driving on flooded roads and in potential flash flood conditions; and about the unique flash flood risks associated with specific topographical features in their region.

Retrospective study of the impact of lead-based paint hazard remediation on children's blood lead levels in St. Louis, Missouri.

A retrospective follow-up study was conducted to evaluate the effectiveness of lead-based paint hazard remediation in reducing children's blood lead levels. The authors reviewed existing St. Louis, Missouri, City Health Department records, identified 185 children younger than age 6 years who had blood lead levels > or = 25 micrograms/dl during 1989 or 1990, and compared changes in blood lead levels among children whose dwellings did and those whose dwellings did not undergo remediation. Among 54 children who had not moved or received chelation therapy and whose blood lead levels were measured 10-14 months after diagnosis, the geometric mean blood lead level decreased 23% among children living in remediated dwellings (n = 37) and 12% among children in nonremediated dwellings (n = 17) (p = 0.07, t test). The estimated size of the remediation effect was similar using multiple regression (-13%; 95% confidence interval (CI) -25 to 1; p = 0.06) and an approach based on generalized estimating equations (-16%, 95% CI -25 to -7; p = 0.002), when adjusted for covariates. The effect of remediation was greater among children whose blood lead levels at diagnosis were > or = 35 micrograms/dl (-22%) than among those whose blood lead levels at diagnosis were between 25 and 34 micrograms/dl (-1%). Among lead-poisoned children in St. Louis, children whose dwellings undergo lead-based paint hazard remediation have a greater decline in geometric mean blood lead level than do children whose dwellings do not, but the effect of remediation may be influenced by the blood lead level at diagnosis.

Indigenous cases of Lyme disease diagnosed in North Carolina.

Between January 1984 and December 1989, 102 indigenous cases of Lyme disease were reported in North Carolina. Lyme disease was reported in each of the three major geographic regions of the state: mountain, piedmont, and coastal plain. One or more diagnoses were made in 42 of 100 counties. Patients ranged in age from 5 months to 78 years (median, 27 years); 58 patients (57%) reported a history of tick exposure within 1 month of the onset of symptoms. Erythema migrans was reported by 93 patients (91%). Arthritis (30%), neurologic symptoms (10%), and cardiac abnormalities (7%) were observed. Thirty of the 102 cases were confirmed serologically by indirect fluorescence microscopy or enzyme-linked immunosorbent assay.