Using Computerized Physician Order Entry to Ensure Appropriate Vaccination of Patients with Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) is a disorder in which an aberrant immune response in a genetically susceptible host, with influences from environmental factors, leads to intestinal inflammation. Vaccines against influenza and pneumococcal pneumonia are indicated for all patients with IBD, while vaccines such as hepatitis A and B, human papillomavirus, and meningococcal meningitis are only indicated for patients with specific risk factor profiles. Some vaccines are contraindicated for patients receiving immunosuppressive medications; typically, these are live or live attenuated vaccines such as measles-mumps-rubella, varicella zoster, and herpes zoster. Given the importance of ensuring patients with IBD are properly vaccinated, we designed a quality improvement project to determine the perceived barriers to ordering these vaccines and to make the process easier. METHODS: At the outset of the study, providers in our gastroenterology department who treat patients with IBD received a survey about vaccinations. Based on the preintervention survey responses, we created an order panel in our electronic medical record (Epic Systems Corporation) to facilitate vaccination ordering. This order panel prompted physicians to order the vaccinations and informed them of contraindications. At the end of the 2-month implementation period, we distributed a second survey to assess the utility of the order panel. RESULTS: Respondents generally agreed that the Epic SmartSet order panel made vaccinations easier to order, ensured physician confidence in ordering vaccinations, was helpful for use in practice, made the clinic more efficient, and reminded physicians which vaccinations are contraindicated because of immunosuppression. Respondents were divided regarding whether a greater number of patients with IBD were actually receiving vaccinations after the order panel was implemented. CONCLUSION: We used the order entry function in Epic to facilitate vaccination ordering for patients with IBD. Our results indicate that the order panel we built made ordering vaccinations easier and more efficient compared to the previous process. We hope this order panel promotes improved patient care and becomes a future area of study for how Epic and other electronic health records may be used.

Intraoperative parathyroid hormone assay: a necessary tool for multiglandular disease.

OBJECTIVES: The aims were to: (1) evaluate whether failure of intraoperative parathyroid hormone (ioPTH) to decrease by the Miami criterion is a more specific indicator of multiglandular disease (MGD) than sestamibi scan and (2) determine an adequate cutoff value for decrease in ioPTH in MGD. STUDY DESIGN: Case series with chart review. SETTING: Louisiana State University Health Sciences Center- Shreveport. SUBJECTS AND METHODS: Review of subjects undergoing parathyroidectomy using ioPTH and sestamibi for suspected parathyroid adenoma between 2005 and 2009. Patients with MGD were identified by pathology and operative reports. RESULTS: Eighty-three subjects were identified (68 single adenomas, 11 double adenomas, and 4 multiple-gland hyperplasias). Sestamibi predicted MGD in only 4 of 15 cases (27%). Five of the 11 double adenomas (DAs) were identified during initial surgery; the rest required reoperation for cure. ioPTH was useful in predicting MGD in 7 of 10 cases (70%) when a postexcisional value was drawn after removal of the first enlarged gland. Using the Miami criterion of 50% decrease in ioPTH over 15 minutes would have resulted in 1 unnecessary neck exploration and 3 missed DAs. Requiring both a 50% decrease in ioPTH over 15 minutes and normalization of the postexcisional value would have missed only 1 DA and resulted in a single unnecessary neck exploration. CONCLUSION: Sestamibi alone fails to identify MGD 73% of the time, but the success rate increases significantly when combined with ioPTH. The "50% and normal" criterion worked best to increase the success rate in our study population, but larger trials are needed to confirm the utility of this criterion.

Viability of an enzymatic mannitol method to predict sugarcane deterioration at factories.

The delivery of consignments of deteriorated sugarcane to factories can detrimentally affect multiple process units, and even lead to a factory shut-down. An enzymatic factory method was used to measure mannitol, a major degradation product of sugarcane Leuconostoc deterioration in the US, in press (consignment) and crusher juices collected across the 2004 processing season at a Louisiana factory. Weather conditions varied markedly across the season causing periods of the delivery of deteriorated sugarcane to the factory. A strong polynomial relationship existed between mannitol and haze dextran (R(2)=0.912) in press and crusher juices. Mannitol concentrations were usually higher than haze and monoclonal antibody dextran concentrations, which indicates: (i) the usefulness and higher sensitivity of mannitol to better predict sugarcane deterioration from Leuconostoc and other bacteria than dextran, and (ii) the underestimation by sugar industry personnel of the relatively large amounts of mannitol present in deteriorated sugarcane that can affect processing. Greater than ∼2500ppm/%Brix mannitol in juice predicts downstream processing problems. The enzymatic method is quantitative and could be used in a sugarcane payment formula. Approximately >300ppm/%Brix haze dextran in raw sugar indicated that the majority of the crystals were elongated. Approximately >600ppm/%Brix antibody dextran indicated when elongated crystals were predominant in the raw sugar. The enzymatic mannitol method underestimates mannitol in raw sugars.