Herpes Zoster in Kidney Transplant Recipients: A Series of Three Cases.

Kidney transplant recipients require lifelong immunosuppression to prevent organ rejection. The need for this intervention, however, leads to decreased cellular immunity and, in turn, increased risk of developing herpes zoster (HZ) from reactivation of latent varicella zoster virus. HZ commonly presents as a painful rash in a dermatome presentation followed by post-herpetic neuralgia. In immunosuppressed individuals, the presentation can be atypical and vary in severity depending on degree of immunosuppression and host immune response. We present the clinical course of 3 kidney transplant recipients who developed HZ after transplantation at different times post-transplant with varying clinical manifestations. The balance between maintaining immunosuppression and preventing or subsequently treating disseminated disease is discussed.

Clinical relevance of automated drug alerts from the perspective of medical providers.

The authors used a real-time survey instrument and subsequent focus group among primary care clinicians at a large healthcare system to assess usefulness of automated drug alerts. Of 108 alerts encountered, 0.9% (n = 1) represented critical alerts, and 16% (n = 17) were significant drug interaction alerts. Sixty-one percent (n = 66) involved duplication of a medication or medication class. The rest (n = 24) involved topical medications, inhalers, or vaccines. Of the 84 potentially relevant alerts, providers classified 11% (9/84), or about 1 in 9, as useful. Drug interaction alerts were more often deemed useful than drug duplication alerts (44.4% versus 1.5%, P < .001). Focus group participants generally echoed these results when ranking the relevance of 15 selected alerts, although there was wide variance in ratings for individual alerts. Hence, a "smarter" system that utilizes a set of mandatory alerts while allowing providers to tailor use of other automated warnings may improve clinical relevance of drug alert systems.

Leptospirosis, water sports, and chemoprophylaxis.

Recreational activities, such as water sports and adventure travel, are emerging as an important risk factor for leptospirosis, a potentially fatal zoonosis. We report the clinical course of 2 patients who acquired leptospirosis through participation in water sports. Physicians caring for patients who participate in adventure travel involving water sports should be familiar with the risk factors for and diagnosis, prevention, and treatment of leptospirosis.