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Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, eight met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published Laboratory Medicine Best Practices (LMBP™) A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes., (© 2018 Society of Hospital Medicine.)

Post-analytical laboratory processes have been considered to be less prone to error than preanalytical processes because of the widespread adoption of laboratory automation and interfaced laboratory reporting. Quality monitors and controls for the post-analytical process have focused on critical result notification, meeting established turnaround time goals, and review of changed reports. The rapid increase in the adoption of electronic health records has created a new role for laboratory professionals in the management of patient test results. Laboratory professionals must interface with the clinical side of the health care team in establishing quality control for post-analytical processes, particularly in high-risk transitions of care., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Discharge summaries play a pivotal role in the transitional care of patients discharged to sub-acute care facilities, but the best ways to facilitate document completeness/quality remain unknown., Objective: To examine the relationship among clinical-work processes, provider characteristics, and discharge summary content to identify approaches that promote high-quality discharge documentation., Design: Retrospective cohort study., Subjects: All hip fracture and stroke patients discharged to sub-acute care facilities during 2003-2005 from a large Midwestern academic medical center (N = 489). Patients on hospice/comfort care were excluded., Main Measures: We abstracted 32 expert-recommended components in four categories ('patient's medical course,' 'functional/cognitive ability at discharge,' 'future plan of care,' and 'name/contact information') from the discharge summaries of sample patients. We examined predictors for the number of included components within each category using Poisson regression models. Predictors included work processes (document completion in relation to discharge day; completion time of day) and provider characteristics (training year; specialty)., Key Results: Historical components (i.e., 'patient's medical course' category) were included more often than components that directly inform the admission orders in the sub-acute care facility (i.e., 'future plan of care'). In this latter category, most summaries included a discharge medication list (99%), disposition (90%), and instructions for follow-up (91%), but less frequently included diet (68%), activity instructions (58%), therapy orders (56%), prognosis/diagnosis communication to patient/family (15%), code status (7%), and pending studies (6%). 'Future plan of care' components were more likely to be omitted if a discharge summary was created >24 h after discharge (incident rate ratio = 0.91, 95% confidence interval = 0.84-0.98) or if an intern created the summary (0.90, 0.83-0.97)., Conclusion: Critical component omissions in discharge summaries were common, and were associated with delayed document creation and less experienced providers. More research is needed to understand the impact of discharge documentation quality on patient/system outcomes.

Background: Previous studies have noted a high (41%) prevalence and poor discharge summary communication of pending laboratory (lab) tests at the time of hospital discharge for general medical patients. However, the prevalence and communication of pending labs within a high-risk population, specifically those patients discharged to sub-acute care (i.e., skilled nursing, rehabilitation, long-term care), remains unknown., Objective: To determine the prevalence and nature of lab tests pending at hospital discharge and their inclusion within hospital discharge summaries, for common sub-acute care populations., Design: Retrospective cohort study., Participants: Stroke, hip fracture, and cancer patients discharged from a single large academic medical center to sub-acute care, 2003-2005 (N = 564), Main Measures: Pending lab tests were abstracted from the laboratory information system (LIS) and from each patient's discharge summary, then grouped into 14 categories and compared. Microbiology tests were sub-divided by culture type and number of days pending prior to discharge., Key Results: Of sub-acute care patients, 32% (181/564) were discharged with pending lab tests per the LIS; however, only 11% (20/181) of discharge summaries documented these. Patients most often left the hospital with pending microbiology tests (83% [150/181]), particularly blood and urine cultures, and reference lab tests (17% [30/181]). However, 82% (61/74) of patients' pending urine cultures did not have 24-hour preliminary results, and 19% (13/70) of patients' pending blood cultures did not have 48-hour preliminary results available at the time of hospital discharge., Conclusions: Approximately one-third of the sub-acute care patients in this study had labs pending at discharge, but few were documented within hospital discharge summaries. Even after considering the availability of preliminary microbiology results, these omissions remain common. Future studies should focus on improving the communication of pending lab tests at discharge and evaluating the impact that this improved communication has on patient outcomes.

Three groups of six monkeys (Aotus nancymae) each were inoculated intragastrically with increasing doses of Campylobacter jejuni. Infection resulted in fecal colonization (100% of monkeys), dose-related diarrhea, and robust immune responses. Colonization duration and diarrhea rate were reduced upon secondary challenge. A. nancymae may be useful for studying anti-Campylobacter vaccine efficacy.

Serologic testing for antibody to monkey B virus (BV) in macaque sera is problematic due to the biohazardous nature of BV antigens. Herpesvirus papio 2 (HVP2), a herpesvirus of baboons, is nonpathogenic to humans and is genetically and antigenically more closely related to BV than is human herpes simplex virus 1. This paper describes the results of our in-house laboratory that compared a BV antigen-based enzyme-linked immunosorbent assay (ELISA) by commercial testing laboratory and an HVP2-based ELISA in our laboratory by using 447 sera from 290 rhesus monkeys. The HVP2-based ELISA identified as positive 99.11% of the sera identified as BV-positive by the BV ELISA. The BV antigen-based ELISA identified as positive 98.21% of the sera identified as BV-positive by the HVP2-based ELISA. The HVP2 ELISA also identified two BV-negative and six BV-equivocal sera as positive. Both ELISAs identified the same 85 negative and three equivocal samples as negative and equivocal, respectively. The high degree of correlation (weighted kappa coefficient, 0.94) between the two tests indicates that the HVP2 ELISA is a sensitive and reliable assay for in-house testing of the BV status of rhesus monkeys.

We investigated the etiology of acute diarrhea among Peruvian military recruits undergoing three months of basic combat training near the Amazonian city of Iquitos. From January through September 2002, 307 of 967 recruits were seen at the Health Post for diarrhea (attack rate [AR] = 31.8%, incidence = 1.28 95% confidence interval [CI] = 1.14-1.43] episodes/person-year). Shigella spp. were the most common bacterial pathogen recovered from recruits experiencing diarrhea episodes. These bacteria were isolated from 89 (40%) of 225 diarrheal stools examined (AR = 7.6%, incidence = 0.30 [95% CI = 0.24-0.38] episodes/person-year). Most (83 of 90; 92%) of the Shigella isolates were S. flexneri, of which 57 (69%) were serotype 2a. Seventy-six percent of Shigella isolates were resistant to sulfamethoxazole/trimethoprim and all were sensitive to ciprofloxacin. Peruvian soldiers may be an excellent population in which to test the efficacy of S. flexneri vaccines in advanced development.

The application of vaginal cytology in defining reproductive events is a widely accepted and applied diagnostic tool in many species. Here we present a preliminary approach to recognizing a correlation between changes in vaginal epithelial cytology and circulating plasma progesterone in the common marmoset, Callithrix jacchus, such that vaginal cytology could be diagnostically appropriate for reproductive management. We assessed six captive-born adult female common marmosets for the duration of one complete estrus cycle. Cytologic samples, collected by vaginal swab, and blood for plasma progesterone concentration were collected twice weekly. Cytologic samples were blindly assessed, and vaginal epithelial maturation was defined on the basis of the karyopyknotic index (KPI). In the three consistently cycling females (cj0328, cj0732, and cj0678), a marked increase in KPI corresponded with rising plasma progesterone levels, which subsequently decreased throughout the duration of follicular phase. The remaining three females who had previously irregular estrus cycles (cj0608, cj0680, cj0724) demonstrated irregularity in their progesterone profiles which correlated with inconsistent KPIs. Although KPI is not a very sensitive single sampling indicator of ovulation, evaluating changes in cytologic morphology over time aid in predicting the timing of an ovulatory event. Our results suggest that vaginal cytology can be an effective alternative to blood sampling for reproductive management of the common marmoset.

Campylobacter is a leading cause of traveler's diarrhea in Thailand. Since resistance to quinolones is high among Campylobacter isolates, empiric therapy with quinolones for traveler's diarrhea may be ineffective in this region. We conducted an observational study among 169 U.S. military personnel with acute diarrhea and compared their microbiologic findings to those of 77 asymptomatic personnel deployed to Thailand in May 1998. Of 146 pathogenic bacterial isolates, the most common were nontyphoidal Salmonella (n = 31), enterotoxigenic Escherichia coli (n = 24), and C. jejuni/coli (n = 23). Campylobacter was strongly associated with disease (odds ratio = 5.9; 95% confidence interval = 1.3-37.3), with a more severe clinical presentation, and with a reduced functional ability at presentation (P = 0.02). In vitro resistance to ciprofloxacin was observed in 96% of the Campylobacter isolates. Sub-optimal treatment response to ciprofloxacin was observed in 17% of the cases of Campylobacter infection versus 6% due to other causes. These results highlight the importance of Campylobacter as a cause of severe traveler's diarrhea in Thailand and illustrates the ongoing problem with antibiotic-resistant strains and associated treatment problems.

Diarrhea history questionnaires were administered to 369 U.S. military volunteers before and after deployment to Thailand. Additionally, blood samples obtained from a subset of 221 volunteers 1-3 weeks previously and 3-4 weeks after their deployment were tested by enzyme-linked immunosorbent assay for immunoglobulin A to Campylobacter jejuni. Stool samples from personnel (including volunteers) contracting diarrhea in Thailand were cultured for enteric pathogens. Overall, 35.2% (130 of 369) of questionnaire respondents reported one or more diarrhea episodes during their trip. Volunteers with pretravel anti-C. jejuni reciprocal titers < or = 450 were 1.6 times as likely to have had diarrhea during their stay in Thailand compared with those with pretravel titers > 450 (39.7% versus 25.3%; P = 0.05). The symptomatic seroconversion, or attributable Campylobacter diarrhea attack rate, for the 1-month exercise was 12.7% (28 of 221). The symptomatic seroconversion rate in nonimmune (titer < or = 450) volunteers was 17.1%, whereas that in immune volunteers was only 4.0% (P = 0.002). Campylobacter jejuni or C. coli were recovered from 32.9% (56 of 170) of stool samples cultured and were the most commonly identified enteropathogens. Campylobacter diarrhea was associated with elevated temperatures, fecal red cells, and fecal white blood cells. The results of this study show that Campylobacter continues to represent a significant health threat to Western travelers to Thailand, but many of these travelers have preexisting Campylobacter immunity that protects them from clinically significant Campylobacter enteritis.

A direct-plating method on thiosulfate citrate bile salts sucrose agar (DIR-TCBS) in conjunction with enrichment in alkaline peptone water (APW) incubated for both 6 h and 24 h followed by subculture onto TCBS (APW6h-TCBS and APW24h-TCBS, respectively) was performed on 16,034 rectal swab samples for isolating Vibrio cholerae. A total of 2,932 (18.3%) rectal swab samples were positive for V. cholerae O1 biotype El Tor, with the Ogawa serotype constituting 99.2% of the isolates. There were no significant differences in V. cholerae O1 isolation rates between the three culture systems nor between the combinations of any two systems. However, direct plating plus enrichment demonstrated a significantly higher V. cholerae O1 isolation rate than DIR-TCBS alone (P < 0.02). Conversely, enrichment procedure, alone or in combination with DIR-TCBS, yielded significantly more (P < 0.0001) V. cholerae non-O1 isolates than DIR-TCBS alone. The length of incubation time of the enrichment broth, 6 h, offers no significant advantages over 24 h for the isolation of V. cholerae O1 and non-O1. A 24-h enrichment broth incubation period has the practical advantage of being easy to integrate into a normal laboratory workday, whereas 6-h broth enrichment, although more commonly recommended, requires that arrangements be made for after-hours subculture.

Strong positive CAMP reactions were demonstrated by 121 Vibrio cholerae O139 and 504 El Tor isolates, and weak positive CAMP reactions were shown by 235 non-O1, non O139 isolates when these isolates were tested by a modified CAMP technique. Thirty-five classical biotype V. cholerae O1 isolates included in the tests were all CAMP negative.

A fiber-optic assay for amplified DNA products has been developed. Modifications of the DNA capture strategy described previously by Kemp et al. [Proc. Natl. Acad. Sci. USA 86, 2423-2427 (1989)] were made that allowed selective binding of DNA labeled during the amplification process to the sensing surface of fused silica fibers. The gene for a chimeric protein composed of the IgG-binding beta 2 subdomain of streptococcal protein G fused with the DNA binding domain of yeast GCN4 was constructed, and this PG/GCN4 protein was overexpressed in Escherichia coli. The purified protein was noncovalently bound to IgG-modified fibers utilizing strong and specific interactions between the protein G beta 2 domain and goat IgG that had been covalently immobilized on the fiber surface. Nanomolar concentrations of amplified DNA labeled with the fluorophore tetramethylrhodamine and the AP-1 consensus nucleotide sequence recognized by GCN4 (5'-ATGACTCAT) were rapidly and selectively bound within the evanescent zone of multimode laser-illuminated fibers. Signal from unincorporated fluorescent PCR primer was negligible. Individual fibers could be used for multiple sequential assays, since the fluorescent double-stranded DNA was rapidly and completely stripped from their surfaces with high salt solutions, leaving the IgG-PG/GCN4 DNA binding complex intact to accept another PCR sample.

The bacterium Vibrio parahaemolyticus was tested for its ability to internalize unmodified as well as modified DNA oligomers without attempting to permeabilize the cells. These experiments were conducted to establish whether it may be feasible to employ antisense oligomers for control of gene expression in Vibrio species without heat-shocking or electroporating the cells. The bacterium was found to bind radiolabeled synthetic oligodeoxyribonucleotides that were added to culture media. Incorporation of a phosphorothioate oligomer into subcellular regions was determined following cellular fractionation. The phosphorothioate was recovered primarily from the periplasm and peptidoglycan layer of the bacterium; however, a significant fraction was recovered from the bacterial cytosol. The extent of uptake depended on both the concentration of oligomer as well as culture medium selected. A maximum of 2.1 x 10(6) oligomers/cell was achieved when a 12-mer phosphorothioate oligomer (10 microM) was added to bacterial cultures in an artificial seawater (Instant Ocean) medium. Several terminally modified oligomers were found to become associated with bacterial cells, albeit less efficiently than the phosphorothioate. None of the oligomers tested was toxic to the bacteria at 0.1 microM, and the phosphorothioate was only marginally toxic at 10 microM. Stability of the oligomers in extracellular and cell-associated fractions was evaluated by PAGE; even after 8 hr of incubation intact phosphorothioate oligomer could be found in both components.

The epidemiology of diarrhea among Filipino pediatric patients, representing a cross-section of socioeconomic strata, was investigated over a one year period. Rotavirus was detected in 33.9% of the diarrhea stools examined and was the leading cause of diarrhea in the study population. Although proportionately more rotavirus was found during the cold season, most children became infected with rotavirus during the rainy season, when diarrheal disease was at its peak in Metropolitan Manila. Enteric adenovirus types 40 or 41 were associated with only 5.4% of the diarrhea cases. Overall, one or more etiologic agents of diarrhea were detected in 67.2% of the stools examined. Many of these positive stools (21.6%) contained multiple diarrheogenic agents. Bacterial enteric pathogens were isolated from 32.3% of the cases. Nearly 70% of these patients with bacterial gastroenteritis became ill during the rainy season. Etiology specific and general risk factors associated with diarrheal illness in the study population are discussed.

Chromosomal DNA fragments from a uropathogenic isolate of Proteus mirabilis were inserted into the cosmid vector pHC79 to construct a genomic library in Escherichia coli HB101. A urease-positive recombinant cosmid, designated pSKW1, was recovered. Sequential recombinant manipulation of pSKW1 yielded a 10.2-kilobase plasmid, designated pSKW4, which encoded three urease isozymes with electrophoretic mobilities identical to those of the donor P. mirabilis strain. Plasmid pSKW4 gene sequences encode seven proteins designated 68K (apparent molecular weight, of 68,000), 28K, 25K, 22.5K, 18.5K, 7.5K, and 5.2K within the limits of the urease gene complex. Insertion mutations in genes encoding the 68K, 28K, 25K, 22.5K, 7.5K, and 5.2K proteins resulted in complete or partial (22.5K) loss of urease activity. There was no reduction in urease activity when the gene encoding the 18.5K protein was inactivated.