Robert Enberg

Watermelon and ragweed share allergens.

A biotin-avidin amplified ELISA was used to measure antigen-specific IgE for ragweed, representative members of the gourd family (watermelon, cantaloupe, honeydew melon, zucchini, and cucumber), and banana in the sera of 192 allergic patients, each with an IgE greater than or equal to 180 microns/ml. Sixty-three percent (120/192) of the sera contained antiragweed IgE, and of these patients, 28% to 50% contained IgE specific for any single gourd family member. In contrast, no greater than 11% of the sera positive for a given gourd or banana were negative for ragweed. Correlations between ragweed and gourd-specific IgE levels were significant (p less than 0.001), and correlation coefficients between any two gourds exceeded 0.79. In an ELISA system, the extracts of watermelon and ragweed inhibited each other in a dose-dependent manner; the resulting nonparallel inhibition curves indicate that some, but not all, of the allergens in the two extracts are cross-reactive. Isoelectric focusing of watermelon and ragweed extracts in narrow range gel (pH 4 to 6) followed by immunoblotting demonstrated six watermelon allergen bands with isoelectric points identical to those of ragweed allergens. Several remaining bands in the two extracts had differing isoelectric points, however. Six of 26 patients interviewed with watermelon-specific IgE reported developing oropharyngeal symptoms (itching and/or swelling of the lips, tongue, or throat) after ingesting at least one of the study foods, whereas only one of 25 patients interviewed without detectable watermelon-specific IgE reported similar symptoms (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A cluster-randomized trial to provide clinicians inhaled corticosteroid adherence information for their patients with asthma

BACKGROUND Inhaled corticosteroid (ICS) nonadherence is common among patients with asthma; however, interventions to improve adherence have often been complex and not easily applied to large patient populations. OBJECTIVE To assess the effect of supplying patient adherence information to primary care providers. METHODS Patients and providers were members of a health system serving southeast Michigan. Providers (88 intervention; 105 control) and patients (1335 intervention; 1363 control) were randomized together by practice. Patients were age 5 to 56 years, had a diagnosis of asthma, and had existing prescriptions for ICS medication. Adherence was estimated by using prescription and fill data. Unlike clinicians in the control arm, intervention arm providers could view updated ICS adherence information on their patients via electronic prescription software, and further details on patient ICS use could be viewed by selecting that option. The primary outcome was ICS adherence in last 3 months of the study period. RESULTS At the study end for the intention-to-treat analysis, ICS adherence was not different among patients in the intervention arm compared with those in the control arm (21.3% vs 23.3%, respectively; P = .553). However, adherence was significantly higher among patients whose clinician elected to view their detailed adherence information (35.7%) compared with both control arm patients (P = .026) and intervention arm patients whose provider did not view adherence data (P = .002). CONCLUSIONS Overall, providing adherence information to clinicians did not improve ICS use among patients with asthma. However, patient use may improve when clinicians are sufficiently interested in adherence to view the details of this medication use.

The morningside initiative: collaborative development of a knowledge repository to accelerate adoption of clinical decision support.

The Morningside Initiative is a public-private activity that has evolved from an August, 2007, meeting at the Morningside Inn, in Frederick, MD, sponsored by the Telemedicine and Advanced Technology Research Center (TATRC) of the US Army Medical Research Materiel Command. Participants were subject matter experts in clinical decision support (CDS) and included representatives from the Department of Defense, Veterans Health Administration, Kaiser Permanente, Partners Healthcare System, Henry Ford Health System, Arizona State University, and the American Medical Informatics Association (AMIA). The Morningside Initiative was convened in response to the AMIA Roadmap for National Action on Clinical Decision Support and on the basis of other considerations and experiences of the participants. Its formation was the unanimous recommendation of participants at the 2007 meeting which called for creating a shared repository of executable knowledge for diverse health care organizations and practices, as well as health care system vendors. The rationale is based on the recognition that sharing of clinical knowledge needed for CDS across organizations is currently virtually non-existent, and that, given the considerable investment needed for creating, maintaining and updating authoritative knowledge, which only larger organizations have been able to undertake, this is an impediment to widespread adoption and use of CDS. The Morningside Initiative intends to develop and refine (1) an organizational framework, (2) a technical approach, and (3) CDS content acquisition and management processes for sharing CDS knowledge content, tools, and experience that will scale with growing numbers of participants and can be expanded in scope of content and capabilities. Intermountain Healthcare joined the initial set of participants shortly after its formation. The efforts of the Morningside Initiative are intended to serve as the basis for a series of next steps in a national agenda for CDS. It is based on the belief that sharing of knowledge can be highly effective as is the case in other competitive domains such as genomics. Participants in the Morningside Initiative believe that a coordinated effort between the private and public sectors is needed to accomplish this goal and that a small number of highly visible and respected health care organizations in the public and private sector can lead by example. Ultimately, a future collaborative knowledge sharing organization must have a sustainable long-term business model for financial support.

Antibody responses in watermelon sensitivity

Watermelon-specific IgE (WM-IgE) appears to mediate the oropharyngeal symptoms after watermelon ingestion. However, less than one fourth of watermelon-sensitive individuals (i.e., those with detectable WM-IgE) develop such symptoms after watermelon ingestion. In an attempt to separate symptomatic from asymptomatic persons, we measured watermelon-specific-IgE and IgG4 concentrations in the sera of 29 watermelon-sensitive patients, 6 of whom were symptomatic. Although the mean WM-IgE level of the symptomatic group exceeded that of the asymptomatic group (p = 0.04), individual WM-IgE values failed to distinguish symptomatic from asymptomatic persons. No differences in WM-IgG4 levels between the two groups could be found. Watermelon extract proteins were separated by isoelectric focusing and blotted to nitrocellulose membranes. The membranes were reacted with the individual sera of 14 watermelon-sensitive patients and then stained for IgE, IgG1, and IgG4 binding. Great variations in IgE, IgG1, and IgG4 binding patterns were found, but no subtype restrictions were discovered. Although the pattern of IgE-stained bands in the absence of corresponding IgG1-stained bands was seen more frequently in symptomatic individuals, immunoblot patterns failed to separate symptomatic from asymptomatic persons. We conclude that the pattern of IgE, IgG1, and IgG4 responses to separated watermelon allergens was not predictive of clinical symptoms in a group of watermelon-sensitive patients.

Transforming growth factor beta (TGFβ1) in breast milk and indicators of infant atopy in a birth cohort.

The infant guts ability to suppress immunologic reactions to food proteins could be influenced by levels of TGFβ in breast milk. We hypothesized that lower levels of TGFβ1 in the breast milk (BM) of mothers in the WHEALS birth cohort are associated with atopy at infant age 2–3 yrs.

Requirements for guidelines systems: implementation challenges and lessons from existing software-engineering efforts

BackgroundA large body of work in the clinical guidelines field has identified requirements for guideline systems, but there are formidable challenges in translating such requirements into production-quality systems that can be used in routine patient care. Detailed analysis of requirements from an implementation perspective can be useful in helping define sub-requirements to the point where they are implementable. Further, additional requirements emerge as a result of such analysis. During such an analysis, study of examples of existing, software-engineering efforts in non-biomedical fields can provide useful signposts to the implementer of a clinical guideline system.MethodsIn addition to requirements described by guideline-system authors, comparative reviews of such systems, and publications discussing information needs for guideline systems and clinical decision support systems in general, we have incorporated additional requirements related to production-system robustness and functionality from publications in the business workflow domain, in addition to drawing on our own experience in the development of the Proteus guideline system (http://proteme.org).ResultsThe sub-requirements are discussed by conveniently grouping them into the categories used by the review of Isern and Moreno 2008. We cite previous work under each category and then provide sub-requirements under each category, and provide example of similar work in software-engineering efforts that have addressed a similar problem in a non-biomedical context.ConclusionsWhen analyzing requirements from the implementation viewpoint, knowledge of successes and failures in related software-engineering efforts can guide implementers in the choice of effective design and development strategies.

Using a physician panel to estimate food allergy prevalence in a longitudinal birth cohort

The incidence of immunoglobulin E-mediated food allergy (IgE-FA) has increased in the US and Europe, likely due to a complex interplay between biologic, genetic and environmental factors.1-4 The estimated prevalence (95% Confidence Interval) of allergy to milk, egg, and peanut among US 0-2 year olds is 2.0% (1.6-2.4), 1.0% (0.7, 1.3), and 1.4% (1.1-1.8), respectively.5 Determining the prevalence of IgE-FA status for epidemiologic studies is challenging.6 Self-report may result in overestimates due to the inability of respondents to distinguish food intolerance from IgE-FA.7, 8 The double-blind placebo controlled food challenge (DBPCFC), while a gold standard for diagnosis of IgE-FA, is seldom feasible for large, epidemiologic studies. It is costly in terms of materials and staff and there is risk to the patient.9-11 The use of predictive decision points for specific IgE (sp-IgE) and skin prick tests (SPT) that predict clinical reactivity with > 95% certainty also have limitations and do not incorporate patient symptoms.12, 13 Even using sp-IgE as an outcome in research is problematic, since only 40% of persons who are sensitized to food allergens will respond to a DBPCFC.14 The challenge for advancing epidemiologic investigations in IgE-FA is to combine physician expertise with clinical assessments, medical history and self-report of symptoms. We describe the process of establishing a physician panel to systematically review data from infants enrolled in a birth cohort. Physicians then classified them according to the presence of IgE-FA.

Improving the Documentation of Vital Signs: A Business Reengineering Efficiency Study

By upgrading its electronic medical record to include a Quick Vitals screen, the Henry Ford Health System increased the mean rate of entry of vital signs from 0.7% to 58.5%.