How do we use electronic clinical decision support and feedback to promote good transfusion practice.

This report describes the evolution of the electronic clinical decision support system (CDSS) and feedback methods at our center and the challenges and lessons learned. The electronic blood product order with integrated CDSS ensures collection of data regarding the patient's clinical condition and the justification for the blood product order. An alert is generated in real time if the order is placed outside agreed guidelines. We have provided feedback in several ways. We began with monthly review meetings with the junior hematology clinicians responsible for ordering blood. This was successful in reducing unjustified transfusions in this setting. We expanded the feedback to the rest of our hospitals in two ways. First, a dashboard was developed allowing visualization of ordering data by clinicians. Second, these data were summarized on a quarterly basis into a report circulated to the senior clinical staff by e-mail. Finally, a daily report collates all orders placed for blood products that have triggered a CDSS alert from the previous day. A multidisciplinary team reviews these daily. If an order appears unjustified the specialist transfusion clinician contacts the prescribing clinician to ask for further information and, if necessary, provides education. The CDSS and feedback, allied with other patient blood management measures, have reduced total blood product costs for our hospitals by 26% over 6 years. The description of how we have developed and implemented CDSS and feedback to influence transfusion practice may be of particular value to others developing their own systems.

A new species of Atrimitra Dall, 1918 (Gastropoda: Mitridae) from seamounts of the recently created Nazca-Desventuradas Marine Park, Chile.

We describe Atrimitra isolata sp. n. (Gastropoda: Mitridae), collected on the summit of seamounts (~200 m water depth) in the vicinity of Desventuradas Islands, Chile insular territory. Additionally, we provide some insight into the habitat of this new species based on underwater imagery taken with a remotely operated vehicle. A. isolata sp. n. is characterized by its small size (up to 26 mm), elongate-ovate shape, solid shell and smooth appearance. It has a base brown color, with some specimens being tan or yellow. It is morphologically related to counterparts from shallow depths on the west coast of North, Central and South America (i.e., Atrimitra idae, Atrimitra orientalis and Atrimitra semigranosa), but has no affinities with species of the family reported from around Easter Island, on the far western side of the Salas y Gómez ridge (e.g., Strigatella flavocingulata, Imbricariopsis punctata and Neocancilla takiisaoi), or with other Indo-Pacific species. The present contribution adds to the knowledge of the poorly studied fauna of the seamounts in the southern portion of the Nazca ridge and easternmost section of the Sala y Gómez ridge, an area characterized by the high degree of endemism of its benthic fauna, and now protected within the large and newly created Nazca-Desventuradas Marine Park.

Mortality on Mount Everest, 1921-2006: descriptive study.

OBJECTIVE: To examine patterns of mortality among climbers on Mount Everest over an 86 year period. DESIGN: Descriptive study. SETTING: Climbing expeditions to Mount Everest, 1921-2006. PARTICIPANTS: 14,138 mountaineers; 8030 climbers and 6108 sherpas. MAIN OUTCOME MEASURE: Circumstances of deaths. RESULTS: The mortality rate among mountaineers above base camp was 1.3%. Deaths could be classified as involving trauma (objective hazards or falls, n=113), as non-traumatic (high altitude illness, hypothermia, or sudden death, n=52), or as a disappearance (body never found, n=27). During the spring climbing seasons from 1982 to 2006, 82.3% of deaths of climbers occurred during an attempt at reaching the summit. The death rate during all descents via standard routes was higher for climbers than for sherpas (2.7% (43/1585) v 0.4% (5/1231), P<0.001; all mountaineers 1.9%). Of 94 mountaineers who died after climbing above 8000 m, 53 (56%) died during descent from the summit, 16 (17%) after turning back, 9 (10%) during the ascent, 4 (5%) before leaving the final camp, and for 12 (13%) the stage of the summit bid was unknown. The median time to reach the summit via standard routes was earlier for survivors than for non-survivors (0900-0959 v 1300-1359, P<0.001). Profound fatigue (n=34), cognitive changes (n=21), and ataxia (n=12) were the commonest symptoms reported in non-survivors, whereas respiratory distress (n=5), headache (n=0), and nausea or vomiting (n=3) were rarely described. CONCLUSIONS: Debilitating symptoms consistent with high altitude cerebral oedema commonly present during descent from the summit of Mount Everest. Profound fatigue and late times in reaching the summit are early features associated with subsequent death.