Ordering Patterns and Costs of Specialized Laboratory Testing by Hospitalists and House Staff in Hospitalized Patients With HIV at a County Hospital: An Opportunity for Diagnostic Stewardship.

BACKGROUND: Inpatient HIV care often requires specialized laboratory testing with which practitioners may not be familiar. In addition, computerized physician order entry allows for ordering tests without understanding test indications, but it can also provide a venue for education and diagnostic stewardship. METHODS: All charts of HIV-positive patients hospitalized at a tertiary care public safety net hospital in Houston, Texas, between January 1, 2014, and June 30, 2014, were reviewed for a set list of laboratory tests. Appropriateness of test ordering was assessed by 2 providers. Cost estimates for each test were obtained from Medicaid and a national nonprofit health care charge database. RESULTS: A total of 274 HIV-positive patients were admitted 429 times in the 6-month study period. During the study period, 45% of the study laboratory tests ordered were not indicated. A total of 532 hepatitis serologies were ordered, only 52% of which were indicated. Overall, 71 serum qualitative cytomegalovirus (CMV) polymerase chain reactions (PCRs) and eight CMV quantitative PCRs were ordered, with most (85%) qualitative PCRs ordered for nonspecific signs of infection (eg, fever). Other tests ordered without clear indications included Aspergillus IgE (7), serum Epstein-Barr virus (EBV) PCR (5), parvovirus serology (7), and Toxoplasma IgM (18). Overall, the estimated laboratory cost of inappropriate testing over the study period was between $14 000 and $92 000, depending on which cost database was used. CONCLUSIONS: Many tests ordered in HIV-positive inpatients do not have indications, representing a substantial source of health care waste and cost and potentially leading to inappropriate treatment. Opportunities exist to decrease waste through education of trainees and hospitalists and through implementation of diagnostic stewardship via the electronic medical record.

Are we prepared to help low-resource communities cope with a severe influenza pandemic?

Recent research involving lab-modified H5N1 influenza viruses with increased transmissibility and the ongoing evolution of the virus in nature should remind us of the continuing importance of preparedness for a severe influenza pandemic. Current vaccine technology and antiviral supply remain inadequate, and in a severe pandemic, most low-resource communities will fail to receive adequate medical supplies. However, with suitable guidance, these communities can take appropriate actions without substantial outside resources to reduce influenza transmission and care for the ill. Such guidance should be completed, and support provided to developing countries to adapt it for their settings and prepare for implementation.

Imaging Analysis of Carbohydrate-Modified Surfaces Using ToF-SIMS and SPRi.

Covalent modification of surfaces with carbohydrates (glycans) is a prerequisite for a variety of glycomics-based biomedical applications, including functional biomaterials, glycoarrays, and glycan-based biosensors. The chemistry of glycan immobilization plays an essential role in the bioavailability and function of the surface bound carbohydrate moiety. However, the scarcity of analytical methods to characterize carbohydrate-modified surfaces complicates efforts to optimize glycan surface chemistries for specific applications. Time-of-Flight Secondary Ion Mass Spectrometry (ToF-SIMS) is a surface sensitive technique suited for probing molecular composition at the biomaterial interface. Expanding ToF-SIMS analysis to interrogate carbohydrate-modified materials would increase our understanding of glycan surface chemistries and advance novel tools in the nascent field of glycomics. In this study, a printed glycan microarray surface was fabricated and subsequently characterized by ToF-SIMS imaging analysis. A multivariate technique based on principal component analysis (PCA) was used to analyze the ToF-SIMS dataset and reconstruct ToF-SIMS images of functionalized surfaces. These images reveal chemical species related to the immobilized glycan, underlying glycan-reactive chemistries, gold substrates, and outside contaminants. Printed glycoarray elements (spots) were also interrogated to resolve the spatial distribution and spot homogeneity of immobilized glycan. The bioavailability of the surface-bound glycan was validated using a specific carbohydrate-binding protein (lectin) as characterized by Surface Plasmon Resonance Imaging (SPRi). Our results demonstrate that ToF-SIMS is capable of characterizing chemical features of carbohydrate-modified surfaces and, when complemented with SPRi, can play an enabling role in optimizing glycan microarray fabrication and performance.

Testing species boundaries in an ancient species complex with deep phylogeographic history: genus Xantusia (Squamata: Xantusiidae).

Identification of species in natural populations has recently received increased attention with a number of investigators proposing rigorous methods for species delimitation. Morphologically conservative species (or species complexes) with deep phylogenetic histories (and limited gene flow) are likely to pose particular problems when attempting to delimit species, yet this is crucial to comparative studies of the geography of speciation. We apply two methods of species delimitation to an ancient group of lizards (genus Xantusia) that occur throughout southwestern North America. Mitochondrial cytochrome b and nicotinamide adenine dinucleotide dehydrogenase subunit 4 gene sequences were generated from samples taken throughout the geographic range of Xantusia. Maximum likelihood, Bayesian, and nested cladogram analyses were used to estimate relationships among haplotypes and to infer evolutionary processes. We found multiple well-supported independent lineages within Xantusia, for which there is considerable discordance with the currently recognized taxonomy. High levels of sequence divergence (21.3%) suggest that the pattern in Xantusia may predate the vicariant events usually hypothesized for the fauna of the Baja California peninsula, and the existence of deeply divergent clades (18.8%-26.9%) elsewhere in the complex indicates the occurrence of ancient sundering events whose genetic signatures were not erased by the late Wisconsin vegetation changes. We present a revised taxonomic arrangement for this genus consistent with the distinct mtDNA lineages and discuss the phylogeographic history of this genus as a model system for studies of speciation in North American deserts.

Ti Foyer (Hearth) community-based nutrition activities informed by the positive deviance approach in Leogane, Haiti: a programmatic description.

This paper details the steps to design and implement a positive deviance-informed, "Hearth" approach for the nutritional rehabilitation of malnourished children in the district of Leogane, Haiti. Groups of four to five children met daily for two weeks at the home of a local volunteer mother for nutritional and health messages and a well-balanced meal. Health messages and meal components were determined using information gathered from interviews with the mothers of positive deviant children in the community who are well nourished despite their family's limited economic resources. Hearth participants were then followed for six months in their own home by the program "monitrices," women hired from each village and intensively trained to supervise the Hearth program, periodically weigh the children to evaluate their progress, and liaise between the hospital and the community. Monitoring from the first cycle indicated that 100% of children in eight villages and 66% of children in the remaining five villages continued to gain weight as fast or faster than the international standard median six months after participating in a Hearth program. At the conclusion of this cycle, programmers interviewed participant and non-participant families and made six modifications to the model, including the addition of a microcredit option for participating mothers.