Objective This study aimed to determine the effects of reducing the number of drug-drug interaction (DDI) alerts in an order entry system. Methods Retrospective pre–post analysis at an urban medical center of the rates of medication alerts and alert acceptance during a 5-month period before and 5-month period after the threshold for firing DDI alerts was changed from “intermediate” to “severe.” To ensure that we could determine varying response to each alert type, we took an in-depth look at orders generating single alerts. Results Before the intervention, 241,915 medication orders were placed, of which 25.6% generated one or more medication alerts; 5.3% of the alerts were accepted. During the postintervention period, 245,757 medication orders were placed of which 16.0% generated one or more medication alerts, a 37.5% relative decrease in alert rate (95% confidence interval [CI]: −38.4 to −36.8%), but only a 9.6% absolute decrease (95% CI: −9.4 to −9.9%). 7.4% of orders generating alerts were accepted postintervention, a 39.6% relative increase in acceptance rate (95% CI: 33.2–47.2%), but only a 2.1% absolute increase (95% CI: 1.8–2.4%). When only orders generating a single medication alert were considered, there was a 69.1% relative decrease in the number of orders generating DDI alerts, and an 85.7% relative increase in the acceptance rate (95% CI: 58.6–126.2%), though only a 1.8% absolute increase (95% CI: 1.3–2.3%). Conclusion Eliminating intermediate severity DDI alerts resulted in a statistically significant decrease in alert burden and increase in the rate of medication alert acceptance, but alert acceptance remained low overall.

BACKGROUND: Computerized provider order entry (CPOE) systems can warn clinicians ordering medications about potential allergic or adverse reactions, duplicate therapy, and interactions with other medications. Clinicians frequently override these warnings. Understanding the factors associated with warning acceptance should guide revisions to these systems.

Transplant recipients are highly motivated to maintain their recovered health status and are generally compliant with pharmacotherapy and medical follow-up. As well as routine blood tests and monitoring of immunosuppressant drug levels, recipients require immunization updates and regular screening for malignancy, diabetes, hypertension, hyperlipidemia, and ophthalmologic complications. Little information is available about the consistent implementation of these health maintenance strategies in this population. A telephone survey of liver transplant recipients was conducted using a 20-item questionnaire. It was designed to assess the frequency and adequacy of health maintenance screening, immunizations, and screening tests for malignancy, which are specific to the liver transplant population. We contacted 60 liver recipients transplanted at our institution between 1992 and 1996. The mean age of the patients (31 men and 29 women) was 48 years (range, 42-56 years). Before transplantation, pneumococcal and hepatitis B vaccination occurred in 13% and 18%, respectively. After transplantation, 27% had received pneumococcal vaccination and none had received primary vaccination for hepatitis B. Forty-eight percent received yearly influenza vaccination. Of 60 questioned recipients, 2 were aware of their varicella exposure status or a possible need for varicella immunoglobulin if a primary exposure to chickenpox were to occur. Two were aware of the need for the recipient's children or grandchildren who were undergoing polio vaccination to receive an inactivated intramuscular polio preparation. Yearly screening for dermatologic or oral malignancies was provided to only 40% of patients. Physician-performed breast examination or screening mammograms was done in 38% of the surveyed women. Eleven percent of the women had received a gynecologic examination with a cervical cytologic examination within the prior 2 years. Of the male recipients, 68% received either digital prostate examination or serum prostate specific antigen determinations or both. Of 60 recipients, 30 had had either flexible sigmoidoscopy or colonoscopy within the previous 2 years. Yearly dental examinations were performed on 75% of patients, and more than 90% had at least yearly blood pressure and weight determinations. Of 60 patients, 41 were aware of cholesterol and lipid profiles having been performed within the past 2 years. Ophthalmologic screening was performed in 83% of surveyed recipients. This survey suggests that routine health maintenance management is less than optimal in this population. Follow-up based on a standard protocol may improve the health care of these patients.

Background and Purpose Hypertension results in a spectrum of subcortical cerebrovascular disease. It is unclear why some individuals develop ischemia and others develop hemorrhage. Risk factors may differ for each population. We identify factors that predispose an individual to subcortical symptomatic intracerebral hemorrhage (sICH) compared with ischemia. Methods Demographic and laboratory data were prospectively collected for hypertensive patients presenting with ischemic stroke or sICH during an 8.5-year period. Neuroimaging was retrospectively reviewed for acute (subcortical lacunes [<2.0 cm] versus subcortical sICH) and chronic (periventricular white matter disease and cerebral microbleeds) findings. We evaluated the impact of age, race, sex, serum creatinine, erythrocyte sedimentation rate, low-density lipoprotein, presence of periventricular white matter disease or cerebral microbleeds, and other factors on the risk of sICH versus acute lacune using multivariate logistic regression. Results Five hundred seventy-one patients had subcortical pathology. The presence of cerebral microbleeds (adjusted odds ratio [OR], 3.39; confidence interval [CI], 2.09–5.50) was a strong predictor of sICH, whereas severe periventricular white matter disease predicted ischemia (OR, 0.56 risk of sICH; CI, 0.32–0.98). This association was strengthened when the number of microbleeds was evaluated; subjects with >5 microbleeds had an increased risk of sICH (OR, 4.11; CI, 1.96–8.59). It remained significant when individuals with only cortical microbleeds were removed (OR, 1.77, CI, 1.13–2.76). An elevated erythrocyte sedimentation rate (OR, 1.19 per 10 mm/h increase; CI, 1.06–1.34) was significantly associated with sICH, whereas low-density lipoprotein was associated with ischemic infarct (OR, 0.93 risk of sICH per 10 mg/dL increase; CI, 0.86–0.99). Conclusions Subclinical pathology is the strongest predictor of the nature of subsequent symptomatic event. Low-density lipoprotein and erythrocyte sedimentation rate may also have a role in risk stratification.

In the context of the COVID-19 pandemic, reassessing intensive care unit (ICU) use by population should be a priority for hospitals planning for critical care resource allocation. In our study, we reviewed the impact of COVID-19 on a community hospital serving an urban region, comparing the sociodemographic distribution of ICU admissions before and during the pandemic. We executed a time-sensitive analysis to see if COVID-19 ICU admissions reflect the regional sociodemographic populations and ICU admission trends before the pandemic. Sociodemographic variables included sex, race, ethnicity, and age of adult patients (ages 18 years and older) admitted to the hospital's medical and cardiac ICUs, which were converted to COVID-19 ICUs. The time period selected was 18 months, which was then dichot-

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Standard therapies for the treatment of hepatitis C are ineffective in almost 50% of patients. Amantadine is an antiviral agent that may have activity against hepatitis C virus. In this pilot study, we evaluated the efficacy of a combination of interferon, ribavirin, and amantadine in patients with chronic hepatitis C who had previously failed 6-12 months of treatment with interferon and ribavirin. In this prospective open-label study, 23 patients were treated with a combination of interferon-alpha(2b) 3 million units subcutaneously three times per week, ribavirin 1000-1200 mg daily, and amantadine 100 mg twice daily for 6-12 months. Treatment was discontinued at 6 months if the patients had detectable HCV RNA by PCR. All patients were followed for 6 months after the completion of treatment. At the end of treatment, the biochemical response was 47% and the virological response was 30%. However, the rate of sustained virological response was only 13% (3/23). There were no unexpected side effects with triple therapy. In conclusion, triple therapy with interferon, ribavirin and amantadine resulted in a low sustained viral clearance in chronic hepatitis C patients who had previously failed interferon and ribavirin combination therapy.