Evidence for multiple historical colonizations of an endoreic drainage basin by an Australian freshwater fish

The contemporary and historical colonization capacity of an Australian freshwater fish, north-west glassfish Ambassis sp., was tested using mtDNA sequence data and six newly developed microsatellite loci in an endoreic basin in central Australia. Overall, Ambassis sp. exhibited weak genetic structure within catchments, suggesting some capacity to recolonize extirpated waterholes after disturbance. Genetic structure revealed that the historical pattern of connectivity among catchments in the Lake Eyre Basin was dramatically different from other species studied in this region. Two highly divergent clades were detected in separate catchments in the basin. mtDNA from individuals sampled in catchments north of the Lake Eyre Basin suggest that Ambassis sp. has colonized on two separate occasions from catchments in northern Australia, subsequently generating two highly divergent lineages.

Multiple incursions and putative species revealed using a mitochondrial and nuclear phylogenetic approach to the Trogoderma variabile (Coleoptera: Dermestidae) trapping program in Australia

The Warehouse beetle, Trogoderma variabile (Coleoptera: Dermestidae), is an internationally significant invasive pest of packed goods and stored grain. When it was first documented in Australia at Griffith, New South Wales, in 1977, an eradication campaign was initiated. After several years and considerable effort, the eradication campaign was abandoned. To monitor the presence and spread of T. variabile, surveys were carried out by government agencies in 1992 and 2002. When survey data was compared, it was concluded that the distribution of morphologically identified T. variabile had doubled in most Australian states. Here, we used samples from the 2002 survey to conduct a phylogenetic study using partial sequences of mitochondrial genes Cytochrome oxidase I and Cytochrome B, and the nuclear gene 18S, to examine the distribution and dispersal of T. variabile and detect the presence of misidentified species. Based on our molecular results, we show that only 47% of the samples analysed were T. variabile, and the remaining were a mixture of six putative species. In addition, T. variabile was found in only 78% of the trapping sites. We discuss the importance of correct diagnosis in relation to the eradication campaign.

Systematics and biogeography of the Gondwanan Orthocladiinae (Diptera: Chironomidae)

Restrictions to effective dispersal and gene flow caused by the fragmentation of ancient supercontinents are considered to have driven diversification and speciation on disjunct landmasses globally. Investigating the role that these processes have played in the development of diversity within and among taxa is crucial to understanding the origins and evolution of regional biotas. Within the chironomid (non-biting midge) subfamily Orthocladiinae (Diptera: Chironomidae), a group of genera that are distributed across the austral continents (Australia, New Zealand, South America) have been proposed to represent a relict Gondwanan clade. We used a molecular approach to resolve relationships among taxa with the aim to determine the relative roles that vicariance and dispersal may have played in the evolution of this group. Continental biotas did not form monophyletic groups, in accordance with expectations given existing morphological evidence. Patterns of phylogenetic relationships among taxa did not accord with expected patterns based on the geological sequence of break-up of the Gondwanan supercontinent. Likewise, divergence time estimates, particularly for New Zealand taxa, largely post-dated continental fragmentation and implied instead that several transoceanic dispersal events may have occurred post-vicariance. Passive dispersal of gravid female chironomid adults is the most likely mechanism for transoceanic movement, potentially facilitated by West Wind Drift or anti-cyclone fronts. Estimated timings of divergence among Australian and South American Botryocladius, on the other hand, were congruent with the proposed ages of separation of the two continents from Antarctica. Taken together, these data suggest that a complex relationship between both vicariance and dispersal may explain the evolution of this group. The sampling regime we implemented here was the most intensive yet performed for austral members of the Orthocladiinae and unsurprisingly revealed several novel taxa that will require formal description.

Teacher-student relationship climate and school outcomes: implications for educational policy initiatives

In recent discussions regarding concerns about the academic achievement of US students, educational policy makers have suggested the implementation of certain teacher policies. To address the limited empirical research on the putative educational impact of such policies, this study used multilevel structural equation models to investigate the longitudinal associations between teacher evaluation and reward policies, and student mathematics achievement and dropout with a national sample of students (n = 7,779) attending one of 431 public high schools. The student sample included an equal number of boys and girls averaging 16 years of age, and included a White (53%) majority. This study examined whether associations between teacher policies and student achievement were mediated by the teacher-student relationship climate. Results of this study were threefold. First, teacher evaluation policies that allowed students to evaluate their teachers were associated with more positive student reports of the classroom teaching climate. Second, schools with teacher reward policies that included assigning higher performing teachers with higher performing students had a negative association with student perceptions of the teaching climate. Lastly, schools with better student perceptions of the teaching climate were associated with lower student dropout rates by students' senior year. These findings are discussed in light of their educational policy implications.

Population subdivision in Siamese mud carp Henicorhynchus siamensis in the Mekong River basin: implications for management

A molecular approach was employed to investigate stock structure in Siamese mud carp Henicorhynchus siamensis populations collected from 14 sites across mainland south-east Asia, with the major focus being the lower Mekong River basin. Spatial analysis of a mitochondrial DNA fragment (ATPase 6 and 8) identified four stocks in the Mekong River basin that were all significantly differentiated from a population in the nearby Khlong River, Thailand. In the Mekong River basin, populations in northern Lao People's Democratic Republic and northern Thailand represent two independent stocks, and samples from Thai tributaries group with those from adjacent Mekong sites above the Khone Falls to form a third stock. All sites below the Khone Falls constituted a single vast stock that includes Cambodia and the Mekong Delta in Vietnam. While H. siamensis is considered currently to undertake extensive annual migrations across the Mekong River basin, the data presented here suggest that natural gene flow may occur over much more restricted geographical scales within the basin, and hence populations may need to be managed at finer spatial scales than at the whole-of-drainage-basin level.

Pleistocene refugia in an arid landscape: analysis of a widely distributed Australian passerine

While many studies have documented the effect that glacial cycles have had on northern hemisphere species, few have attempted to study the associated effect of aridification at low latitudes in the southern hemisphere. We investigated the past effects that cyclic aridification may have had on the population structure and history of a widespread endemic Australian bird species, the Australian magpie (Gymnorhina tibicen). One thousand one hundred and sixty-six samples from across its native range were analysed for mitochondrial control region sequence variation and variation at six microsatellite loci. Analysis of mitochondrial control region sequence data indicated monophyletic clades that were geographically congruent with an eastern and western region. The contemporary distribution of east and west clades is nonoverlapping but in close proximity. Populations were estimated to have diverged in the Pleistocene around 36,000 years ago. The putative Carpentarian and Nullarbor arid barriers appear to be associated with the divergence between east and west mainland populations. Nested clade analysis indicated a signature of range expansion in the eastern region suggesting movement possibly inland and northward subsequent to the last period of aridity. The island population of Tasmania was of very recent origin, possibly since sea levels rose 16,000 years ago. Given the east-west structure, there was no congruence between morphology and recent history of this species indicating a lack of support for morphological taxa. Overall mitochondrial DNA and microsatellite variation suggest that increasing aridity and Pleistocene refugia played a role in structuring populations of the Australian magpie; however, the dispersal ability and generalist habitat requirements may have facilitated the movement of magpies into an almost contiguous modern distribution across the continent. This study supports the idea that Pleistocene aridification played an important role in structuring intraspecific variation in low latitudinal southern hemisphere avian species.

Fentanyl concentrations in 23 postmortem cases from the hennepin county medical examiner's office

The purpose of this study was to compare blood fentanyl concentrations in fentanyl-related deaths with fentanyl concentrations found incidentally at autopsy, as well as with fentanyl concentrations found in hospitalized patients receiving fentanyl. Between the years 1997 to 2005, 23 fentanyl-positive postmortem cases were identified. Nineteen of 23 (82.6%) cases were deemed to be drug overdoses. Fentanyl alone was responsible for 8 of the 19 (42.1%) overdose deaths. Mean and median fentanyl concentrations were 36 (SD 38) microg/L and 22 microg/L, respectively, range 5-120 microg/L. Seven of the cases were accidental, one undetermined. The remaining 11 of the 19 (57.9%) cases were mixed drug overdoses. Fentanyl concentrations in these cases were 31 (SD 46) microg/L, range 5-152 microg/L. All of the mixed drug overdoses were determined to be accidental. Four cases where fentanyl was considered an incidental postmortem finding were determined to be natural deaths. In hospitalized inpatients (n = 11) receiving fentanyl 2 of the patients receiving fentanyl for chronic pain for more than 3 months had concentrations of 8.5 microg/L and 9.9 microg/L. The other nine inpatient concentrations were less than 4 microg/L. In conclusion, blood fentanyl concentrations found in cases where fentanyl alone was determined to be the cause of death were similar to cases where fentanyl was part of a mixed drug overdose. There was also considerable overlap between fentanyl concentrations in fentanyl-related overdose deaths compared to hospitalized patients being treated for chronic pain. Fentanyl concentrations in postmortem cases must be interpreted in the context of the deceased's past medical history and autopsy findings.

Phylogenetic diversity (PD) and biodiversity conservation: some bioinformatics challenges

Biodiversity conservation addresses information challenges through estimations encapsulated in measures of diversity. A quantitative measure of phylogenetic diversity, "PD", has been defined as the minimum total length of all the phylogenetic branches required to span a given set of taxa on the phylogenetic tree (Faith 1992a). While a recent paper incorrectly characterizes PD as not including information about deeper phylogenetic branches, PD applications over the past decade document the proper incorporation of shared deep branches when assessing the total PD of a set of taxa. Current PD applications to macroinvertebrate taxa in streams of New South Wales, Australia illustrate the practical importance of this definition. Phylogenetic lineages, often corresponding to new, "cryptic", taxa, are restricted to a small number of stream localities. A recent case of human impact causing loss of taxa in one locality implies a higher PD value for another locality, because it now uniquely represents a deeper branch. This molecular-based phylogenetic pattern supports the use of DNA barcoding programs for biodiversity conservation planning. Here, PD assessments side-step the contentious use of barcoding-based "species" designations. Bio-informatics challenges include combining different phylogenetic evidence, optimization problems for conservation planning, and effective integration of phylogenetic information with environmental and socio-economic data.

Biogeographic history of an Australian freshwater shrimp, Paratya australiensis (Atyidae): the role life history transition in phylogeographic diversification

The widespread distribution of the freshwater shrimp Paratya australiensis in eastern Australia suggests that populations of this species have been connected in the past. Amphidromy is ancestral in these shrimps, although many extant populations are known to be restricted to freshwater habitats. In this study, we used a fragment of the cytochrome c oxidase I mitochondrial DNA (mtDNA) gene to examine diversity within P. australiensis and to assess the relative importance of amphidromy in its evolutionary history. We hypothesized that if transitions from an amphidromous to a freshwater life history were important, then we would find a number of divergent lineages restricted to single or groups of nearby drainages. Alternatively, if amphidromy was maintained within the species historically, we expected to find lineages distributed over many drainages. We assumed that the only way for divergence to occur within amphidromous lineages was if dispersal was limited to between nearby estuaries, which, during arid periods in the earth's history, became isolated from one another. We found nine highly divergent mtDNA lineages, estimated to have diverged from one another in the late Miocene/early Pliocene, when the climate was more arid than at present. Despite this, the geographic distribution of lineages and haplotypes within lineages did not support the notion of a stepping-stone model of dispersal between estuaries. We conclude that the extensive divergence has most likely arisen through a number of independent amphidromy-freshwater life history transitions, rather than via historical isolation of amphidromy populations. We also found evidence for extensive movement between coastal and inland drainages, supporting the notion that secondary contact between lineages may have occurred as a result of drainage rearrangements. Finally, our data indicate that P. australiensis is likely a complex of cryptic species, some of which are widely distributed, and others geographically restricted.

Central penetration and stability of N-terminal tripeptide of insulin-like growth factor-I, glycine-proline-glutamate in adult rat

Insulin-like growth factor-I is a neurotrophic factor and can prevent neurons from ischemic brain injury. However, the large molecular weight and metabolic effects can be problematic in its central delivery. Glycine-proline-glutamate (GPE) is the N-terminal tripeptide of insulin-like growth factor-I, which is naturally cleaved in the plasma and brain tissues. GPE reduces neuronal loss from hypoxic-ischemic brain injury following central administration. Central penetration and the stability of GPE in the plasma and central nervous system were examined in rats using radioimmunoassay and HPLC. GPE was rapidly metabolised in the plasma (8 min) after intraperitoneal administration. Despite having a short half-life in plasma, GPE was detected in the cerebrospinal fluid up to 40 min after intraperitoneal administration. With present of peptidase inhibitors, GPE existed in the brain tissue up to 3 h after intracerebroventricular administration, suggesting a role for peptolysis in its stability. The endopeptidase inhibitors 4- (2-aminoethyl) benzenesulfonyl fluoride hydrochloride (AEBSF) reduced GPE metabolism in the brain tissue while acid peptidase inhibitor pepstatin-A decreased GPE metabolism in the plasma. GPE reduced neuronal loss in the CA1-2 sub-region of the hippocampus given (intraperitoneally) after 30 min of hypoxic-ischemic injury in adult rats, further suggested the effectiveness of GPE central uptake. These results indicated that GPE crosses the blood-CSF and the functional CSF-brain barriers. The longer half-life of GPE in the CNS may be due to its unique enzymatic stability.

Past and present patterns of connectivity among populations of four cryptic species of freshwater mussels Velesunio spp. (Hyriidae) in central Australia

We examined genetic structure and levels of connectivity among subpopulations within each of four cryptic species belonging to the freshwater mussel genus Velesunio. We used allozymes and a fragment of the mitochondrial cytochrome c oxidase I gene to examine genetic variation in populations from isolated waterholes, belonging to four major inland drainages in eastern Australia. Based on evidence from other invertebrates in the region we predicted that, in each species, we would find evidence of historical connectivity among populations from different drainages. This was clearly not the case, as for the two species that occurred in more than one drainage there was evidence of both current and past restriction to gene flow. Moreover, given the potential for extensive dispersal of these mussels through the river systems during flood times via their fish hosts, we predicted low levels of genetic variation among populations from waterholes in the same drainage. Contrary to our expectations, all four species showed some evidence of restricted gene flow among waterholes within drainages. This suggests that either (a) mussel larvae are not produced during flood times, when their fish hosts would be free to move between waterholes, or (b) mussel larvae are attached to their hosts at these times, but the fish movement is limited between waterholes.

Mitochondrial DNA phylogenetic structuring suggests similarity between two morphologically plastic genera of Australian freshwater mussels (Unionoida: Hyriidae)

In the Lake Eyre Basin, the Australian hyriid genus Velesunio is represented by three undescribed species, each of which are highly divergent genetically, but morphologically similar to Velesunio wilsonii (Lea 1859). A fourth species, Velesunio ambiguus (Philippi 1847), occurs not only in the Lake Eyre Basin but throughout much of eastern Australia, including the Murray-Darling Basin. In this study, we show that another hyriid, Alathyria jacksoni (Iredale 1934), which is sympatric with V. ambiguus, is genetically deeply nested within the Velesunio species complex, such that the genus Velesunio is paraphyletic with respect to A. jacksoni. Moreover, our mitochondrial phylogenetic reconstructions indicate that A. jacksoni is closely allied to one of the cryptic Velesunio species occurring in the Lake Eyre Basin, but distinct from V. ambiguus and the two other Velesunio species. These data suggest that the genera Alathyria and Velesunio are in need of revision. The shells of A. jacksoni and Velesunio spp. vary with local conditions and sometimes are difficult to distinguish. Our analyses also show that shell characters of these taxa do not closely match the phylogenetic data, and it appears that the traditional taxonomic emphasis on these plastic characters has obscured evolutionary relationships between these, and possibly other, Hyriidae.

Mitochondrial DNA signatures of restricted gene flow within divergent lineages of an atyid shrimp (Paratya australiensis)

We measured spatial genetic structure within three previously described mitochondrial lineages of the atyid shrimp, Paratya australiensis, occurring in upland streams of two major catchments within the Sydney Water Supply Catchment, New South Wales, Australia. In all three lineages, there was significant spatial structuring of genetic variation between catchments. In two lineages, recurrent but restricted maternal gene flow has apparently predominated in shaping within-catchment genetic structure, although this framework may be overlaid with episodic contiguous/long-distance expansion events. In the third lineage, there was no evidence of spatial genetic structuring within one of the catchments, because one haplotype was both common and widespread throughout the sampled area. High-frequency haplotypes were also shared among subcatchments in the other two lineages, and we discuss both historical and contemporary processes that may have left these genetic signatures. Our results are generally concordant with previous reports of significant population structuring in P. australiensis, occurring in upland river reaches elsewhere in eastern Australia. We propose that restricted dispersal and gene flow among upland populations of P. australiensis is linked to dramatic architectural structuring within and among mountain streams.

Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and case management

Medical examiners and coroners (ME/Cs) are essential public health partners for terrorism preparedness and response. These medicolegal investigators support both public health and public safety functions and investigate deaths that are sudden, suspicious, violent, unattended, and unexplained. Medicolegal autopsies are essential for making organism-specific diagnoses in deaths caused by biologic terrorism. This report has been created to 1) help public health officials understand the role of ME/Cs in biologic terrorism surveillance and response efforts and 2) provide ME/Cs with the detailed information required to build capacity for biologic terrorism preparedness in a public health context. This report provides background information regarding biologic terrorism, possible biologic agents, and the consequent clinicopathologic diseases, autopsy procedures, and diagnostic tests as well as a description of biosafety risks and standards for autopsy precautions. ME/Cs' vital role in terrorism surveillance requires consistent standards for collecting, analyzing, and disseminating data. Familiarity with the operational, jurisdictional, and evidentiary concerns involving biologic terrorism-related death investigation is critical to both ME/Cs and public health authorities. Managing terrorism-associated fatalities can be expensive and can overwhelm the existing capacity of ME/Cs. This report describes federal resources for funding and reimbursement for ME/C preparedness and response activities and the limited support capacity of the federal Disaster Mortuary Operational Response Team. Standards for communication are critical in responding to any emergency situation. This report, which is a joint collaboration between CDC and the National Association of Medical Examiners (NAME), describes the relationship between ME/Cs and public health departments, emergency management agencies, emergency operations centers, and the Incident Command System.

Patterns of spatial genetic structuring in a hydropsychid caddisfly (Cheumatopsychesp. AV1) from southeastern Australia

We assessed levels of mitochondrial genetic spatial structuring in the hydropsychid caddisfly Cheumatopsyche sp. AV1 in southeastern New South Wales, Australia. No significant spatial structuring was detected within or between catchments using analysis of molecular variance, and nested clade contingency analysis suggested no strong relationship between haplotypes and geographical location, at any clade level. However, tests for association among haplotypes incorporating geographical distance in the nested clade analysis, revealed patterns of historical range expansion and recent restricted gene flow. Most likely, population fragmentation preceded range expansion, although subsequent recontact and gene flow among the previously sundered populations has apparently obscured the geographical signature of the former fragmentation. Taken together, our analyses suggest that a number of populations fragmented during the Pleistocene evolved in isolation for a time and subsequently expanded into secondary contact. Since expansion, there has apparently been substantial (albeit somewhat restricted) dispersal and gene flow of adult female Cheumatopsyche sp. AV1, throughout the study area.

Cryptic species and morphological plasticity in long-lived bivalves (Unionoida: Hyriidae) from inland Australia

Molecular (mitochondrial DNA, isozyme) and morphological diversity of freshwater mussels (Family Hyriidae) was examined at 21 sites encompassing four large river systems, across southwest Queensland, Australia. Evidence was found for two major morphological groups. One group, which occurred in every river system, closely matched a recognized species (Velesunio ambiguus) both morphologically and in a well-supported lineage within a mitochondrial phylogeny generated from partial cytochrome c oxidase subunit I (COI) sequences. The second group most closely matched Velesunio wilsonii in shell morphology but formed three deeply divergent mitochondrial DNA lineages. All four lineages occurred sympatrically in some areas and displayed corresponding fixed differences at nuclear allozyme loci, which suggests an absence of recent hybridization and the presence of separate species.

From the archives of the AFIP. Child abuse: radiologic-pathologic correlation

In the United States, roughly one of every 100 children is subjected to some form of neglect or abuse; inflicted injury is responsible for approximately 1,200 deaths per year. Child physical abuse may manifest as virtually any injury pattern known to medicine. Some of the injuries observed in battered children are relatively unique to this population (especially when observed in infants) and therefore are highly suggestive of nonaccidental, or inflicted, injury. Worrisome injuries include rib fracture, metaphyseal fracture, interhemispheric extraaxial hemorrhage, shear-type brain injury, vertebral compression fracture, and small bowel hematoma and laceration. As noted, however, virtually any injury may be inflicted; therefore, careful consideration of the nature of the injury, the developmental capabilities of the child, and the given history are crucial to determine the likelihood that an injury was inflicted. The majority of these injuries are readily detectable at imaging, and radiologic examination forms the mainstay of evaluation of child physical abuse. Detection of metaphyseal fracture (regarded as the most specific radiographically detectable injury in abuse) depends on high-quality, small field-of-view radiographs. The injury manifests radiographically as a lucent area within the subphyseal metaphysis, extending completely or partially across the metaphysis, roughly perpendicular to the long axis of the bone. Acute rib fractures (which in infants are strongly correlated with abuse) appear as linear lucent areas. They may be difficult to discern when acute; thus, follow-up radiography increases detection of these fractures. For skull injuries, radiography is best for detecting fractures, but computed tomography and magnetic resonance imaging best depict intracranial injury.

Fatal diphenhydramine intoxication in infants

Diphenhydramine is an antihistamine available in numerous over-the-counter preparations. Often used for its sedative effects in adults, it can cause paradoxical central nervous system stimulation in children, with effects ranging from excitation to seizures and death. Reports of fatal intoxications in young children are rare. We present five cases of fatal intoxication in infants 6, 8, 9, 12, and 12 weeks old. Postmortem blood diphenhydramine levels in the cases were 1.6, 1.5, 1.6, 1.1 and 1.1 mg/L, respectively. Anatomic findings in each case were normal. In one case the child's father admitted giving the infant diphenhydramine in an attempt to induce the infant to sleep; in another case, a daycare provider admitted putting diphenhydramine in a baby bottle. Two cases remain unsolved; one case remains under investigation. The postmortem drug levels in these cases are lower than seen in adult fatalities. We review the literature on diphenhydramine toxicity, particularly as it pertains to small children, and discuss the rationale for treating these cases as fatal intoxications.

Homicidal commotio cordis: the final blow in a battered infant

OBJECTIVE

This report describes in detail the occurrence of inflicted commotio cordis (cardiac concussion) in a previously abused 7-week-old. Though inflicted commotio cordis has been reported in three toddlers, this is the first report in a young infant.

METHOD

Following documentation of abuse in a living child, the case of a death of a prior sibling--previously regarded as natural--was re-opened for further investigation. Original autopsy materials were reviewed, and the body of the deceased child was exhumed.

RESULTS

Exhumation and second autopsy documented more than 50 fractures in the deceased child. When re-interviewed, the children's father admitted to causing the injuries in both children, and gave a textbook description of commotio cordis as the mechanism of death in the fatal case.

CONCLUSIONS

Commotio cordis is a rare event in which a fatal dysrhythmia--usually ventricular fibrillation--is precipitated by a blow to the precordial chest. Previous reports have indicated that homicidal commotio cordis can occur in small children. This report demonstrates that commotio cordis can occur even in the very young, previously abused infant.

Estimation of body exposure to explosion

An ordnance-disposal expert was killed while disposing of a cache of explosives. The likely position of the body was reconstructed by modeling the explosion as an omnidirectional emission of particles from a model of the explosion site and noting the distribution of particles on a model of a human. The applications and limitations of this method in reconstructing the events and correlation with the injuries noted at autopsy are discussed.

A novel hunting accident. Discharge of a firearm by a hunting dog

The authors report the case of a 21-year-old man who was killed while duck hunting when a shotgun accidentally discharged, shooting him in the head. The loaded weapon, which had been lying on the ground with the safety off and the muzzle pointed toward a river a few feet away, discharged when a hunting dog stepped on the trigger. Scene investigation confirmed that the victim had been standing in the river, planting decoys, with his head approximately level with the adjacent bank. Autopsy examination and ballistic testing confirmed a range of fire consistent with the witness' statements. Examination of the weapon in question documented a light trigger pull but no mechanical defects. The authors review the epidemiology and causality of hunting accidents and discuss the various safety rules that were violated in this highly unusual case. The importance of a complete death investigation, including autopsy, when dealing with a firearm death is emphasized.

A Web-based diabetes care management support system

BACKGROUND

Because of the often asymptomatic nature of diabetes and the long period between sustained hyperglycemia and observable complications, appropriate diabetes care relies on a long-term program of secondary prevention. Yet routine monitoring and screening among patients with diabetes is less than optimal. To support the provision of routine care to patients with diabetes, the Center for Health Services Research, Henry Ford Health System (Detroit), developed a Web-based Diabetes Care Management Support System (DCMSS). A nonrandomized, longitudinal study was conducted (January 1, 1998-October 31, 1999) with 13,325 health maintenance organization patients with diabetes who were aligned to 190 primary care providers practicing in 31 primary care clinics.

RESULTS

Three DCMSS features--clinical practice guidelines, patient registries, and performance reports--were made available via a corporate intranet within an existing electronic medical record. The effect of DCMSS usage frequency was evaluated on the likelihood of a patient's receipt of glycated hemoglobin testing, lipid profile testing, and retinal examinations. Logistic regression models controlling for patient sociodemographic and clinical characteristics, and the testing history of the patient, the primary care physician, and the primary care clinic, were fit using generalized estimating equation methods. The more often a physician used DCMSS, the more likely his or her patients were to receive lipid profile testing (OR [odds ratio] = 1.01, 95% CI [confidence interval] = 1.01-1.02). Compared with patients of physicians who never used the system, patients of physicians who initiated 12 sessions were an estimated 19% more likely (95% CI = 7%-33%) to receive lipid profile testing. The analyses also suggested that the likelihood of a patient receiving a retinal exam was associated with system usage (OR = 1.01, 95% CI = 1.01-1.01). No relationship was found between system use and glycated hemoglobin testing.

CONCLUSIONS

Computerized systems of clinical practice guidelines, patient registries, and performance feedback may help improve the rate of routine testing among patients with diabetes.