Selection and implementation for coagulation instruments/reagents in a multiple hospital/clinic network.

Selection, standardization, and implementation of instrumentation and reagents throughout a health care facility network can often be a difficult process. However, in today's ever-changing health care setting, it is often mandated. The Veteran's Integrated Systems Network 16 (VISN 16) was faced with such a task early in 1999, with the targeted area being its coagulation laboratories. The plan outlined in this paper was drafted to help facilitate the selection, standardization and implementation of coagulation systems for 17 health care facilities that make up the VISN 16 network. The VISN, encompassing 170,000 square miles, has 10 tertiary care hospitals, six of which have close relationships with affiliate universities. There are 299,733 patients enrolled in this health delivery system. The facilities range from large institutions performing both tertiary and outpatient care to small outpatient clinics. Because of the plan's detailed, comprehensive content, which included analyses of a large number of performance parameters as well as cost-efficiency, the selection process was carried out using a checklist that could be helpful to other organizations selecting equipment and reagents for coagulation studies. An implementation process was devised, resulting in coagulation standardization across the Integrated Health Network.

American cutaneous leishmaniasis in U.S. travelers.

OBJECTIVE: To characterize the exposures and practices of U.S. travelers who acquired cutaneous leishmaniasis in the Americas and to highlight problems they encountered in seeking medical care from U.S. physicians. DESIGN: A retrospective review of Centers for Disease Control and Prevention Drug Service records and a telephone survey of patients. PATIENTS: Fifty-nine civilian U.S. travelers with American cutaneous leishmaniasis for whom the Drug Service released sodium stibogluconate between 1 January 1985 and 30 April 1990; 58 travelers (98%) were interviewed. MAIN MEASUREMENTS: Travel destination, exposure duration, knowledge about leishmaniasis, and time from noticing skin lesions to release of drug. RESULTS: Overall, travelers acquired leishmaniasis in as many as 14 countries; 33 of 59 travelers (56%) were infected in Mexico or Central America. Twenty-seven travelers (46%) were conducting field studies and 23 (39%) were tourists, visitors, or tour guides. At least 15 persons (26% of the 58 interviewed travelers) were in forested areas for 1 week or less; at least 6 of these persons had a maximum exposure of 2 days. Ten persons (17%) were home at least 1 month before they noticed skin lesions. Patients consulted from one to seven physicians (mean, 2.1 physicians) before leishmaniasis was diagnosed. Overall, the median time from noticing lesions to the release of drug was 112 days (range, 13 to 1022 days); however, the median was only 55 days for 13 patients (22%) unusually knowledgeable about leishmaniasis and was a maximum of 60 days for 16 patients (28%) (including 7 of the 13 unusually knowledgeable patients) who generally consulted physicians exceptionally knowledgeable about infectious and tropical diseases. CONCLUSIONS: Travelers to forested areas in Mexico and Central and South America and their physicians need to be educated about the risk for acquiring leishmaniasis even during short stays, as well as about effective preventive measures; and appropriate medical management [corrected].

Diloxanide furoate for treating asymptomatic Entamoeba histolytica cyst passers: 14 years' experience in the United States.

Diloxanide furoate is used for treating asymptomatic or mildly symptomatic persons who are passing cysts of Entamoeba histolytica. The Centers for Disease Control (Atlanta) released this drug for 4,371 treatment courses from 1977 through 1990. Of the 2,815 report forms (64%) returned, 656 adverse effects were reported for 390 treatment courses (14%); they included flatulence (260), diarrhea or cramping (100), nausea (93), headache (17), disorientation or dizziness (9), and diplopia (4). During 1984-1990 uniform collection of data allowed more detailed analysis of toxicity and efficacy; fewer adverse effects were reported for persons aged 20 months to 10 years than for persons aged greater than 10 years (6 of 206 [3%] vs. 89 of 763 [12%], relative risk = 0.27, 95% confidence interval = 0.12 less than relative risk less than 0.61). Parasitological cures were achieved during 497 (86%) of the 575 treatment courses (52%) administered to asymptomatic persons who were passing cysts, who had received a full 10-day treatment course, and for whom results of a follow-up stool examination (greater than or equal to 14 days post-treatment) were available. Diloxanide furoate is safe and effective for treating asymptomatic persons who are passing E. histolytica cysts and may be particularly well tolerated in children.

Waterborne-disease outbreaks, 1989-1990.

For the 2-year period 1989-1990, 16 states reported 26 outbreaks due to water intended for drinking; an estimated total of 4,288 persons became ill in these outbreaks. Giardia lamblia was implicated as the etiologic agent for seven of the 12 outbreaks in which an agent was identified. The outbreaks of giardiasis were all associated with ingestion of unfiltered surface water or surface-influenced groundwater. An outbreak with four deaths was attributed to Escherichia coli O157:H7, the only bacterial pathogen implicated in any of the outbreak investigations. An outbreak of remitting, relapsing diarrhea was associated with cyanobacteria (blue-green algae)-like bodies, whose role in causing diarrheal illness is being studied. Two outbreaks due to hepatitis A and one due to a Norwalk-like agent were associated with use of well water. Eighteen states reported a total of 30 outbreaks due to the use of recreational water, which resulted in illness for an estimated total of 1,062 persons. These 30 reports comprised 13 outbreaks of whirlpool- or hot tub-associated Pseudomonas folliculitis; 13 outbreaks of swimming-associated gastroenteritis, including five outbreaks of shigellosis; one outbreak of hepatitis A associated with a swimming pool; and three cases of primary amebic meningoencephalitis caused by Naegleria. The national surveillance of outbreaks of waterborne diseases, which has proceeded for 2 decades, continues to be a useful means for characterizing the epidemiology of waterborne diseases.