Faculty Bibliography

Background: Avoidable hospital readmissions may be reflective of poor quality of inpatient healthcare and may be used as a metric to guide reimbursement rates to hospitals. Most existing risk prediction models rely on administrative databases and have poor predictive ability. Physician chart reviews are necessary to identify both the cause and preventability of a readmission. Methods: We performed a retrospective chart review of 135 patients with an unplanned (Table presented) readmission to Bellevue Hospital within 7 days of discharge from the medicine service during a six month period. Each chart was reviewed independently by two experienced attending physicians. Using an algorithm developed via a pilot study, each readmission was classified into one of five categories: (1) not medically necessary (medical necessity), (2) following a discharge against medical advice (AMA), (3) related to a deficiency in the discharge process, (4) related to poor patient adherence (patient behavior) to the discharge plan, or (5) related to a condition that was difficult to predict. The latter three categories were further subcategorized to allow for more detailed analysis. Discrepancies in classification were resolved by consensus of the four authors. Baseline demographic information was obtained for the same time frame for patients who were not readmitted within 7 days. Results: During the study period there were 265 patients who were readmitted within seven days of discharge and 3,411 patients who were not. The gender ratio was not significantly different between groups (65% male in the readmitted group versus 62% male in the not readmitted group, P = 0.47). Age was significantly lower in the readmitted group (mean = 52.9 years) as compared to the not readmitted group (56.3; P = 0.001). Median length of stay (LOS) for the initial hospitalization was longer in the readmitted group (5 days vs 3 days; P = 0.0002). For the 135 readmitted cases, there was good agreement between reviewers (84%; j 0.776). The most common category of readmission was "unpredictable" (37.8%), followed by patient behavior (22.2%), discharge process (21.5%), medical necessity (9.6%), and AMA (8.9%). Conclusions: Our novel algorithm efficiently and reproducibly classified 7-day readmissions into discreet categories. Compared to all other patients, those who were readmitted within 7 days were more likely to be younger and have a longer initial LOS. We found 62% of readmissions were attributable to physician or patient behaviors, or system failures. This categorization algorithm can be used to guide creation of risk prediction models and allows for detailed analysis of individual groups that will assist development of individualized interventions to reduce rates of avoidable readmissions

Translational informatics (TI) is extremely important for the pharmaceutical industry, especially as the bar for regulatory approval of new medications is set higher and higher. This paper will explore three specific areas in the drug development lifecycle, from tools developed by precompetitive consortia to standardized clinical data collection to the effective delivery of medications using clinical decision support, in which TI has a major role to play. Advancing TI will require investment in new tools and algorithms, as well as ensuring that translational issues are addressed early in the design process of informatics projects, and also given higher weight in funding or publication decisions. Ultimately, the source of translational tools and differences between academia and industry are secondary, as long as they move towards the shared goal of improving health.

Case Presentation: A 65-year-old female with metastatic breast cancer, glioblastoma multiforme, bilateral pulmonary emboli diagnosed 4 days prior to admission started on enoxaparin, presented with syncope. On the day of admission the patient collapsed on the street suddenly without any prodrome. She reported abdominal pain for the prior 2-3 days, no other new symptoms, and no change in her baseline fatigue. On presentation to the emergency department (Figure presented) she was afebrile with a blood pressure of 105/72, and a heart rate of 92. Her physical exam was notable for conjunctival pallor and a firm, very tender 6 centimeter mass right of the midline slightly inferior to the umbilicus. Fothergill's sign was present. Her hemoglobin was 5.7 gm/dl (it was 12 gm/dl 4 days prior to admission). On CT scan of the abdomen and pelvis a large rectus sheath hematoma (RSH) was found that extended into the preperitoneal space inferiorly, as well as into the pelvis. The patient was transfused, enoxaparin was stopped and she had a retrievable inferior vena cava (IVC) filter placed. Upon further questioning, the patient reported that she had been injecting herself with enoxaparin intramuscularly rather than subcutaneously. Discussion: RSH is an uncommon cause of abdominal pain and is usually not associated with hemodynamically significant hemorhage. It is caused by rupture of the epigastric arteries or trauma to smaller vessels in the rectus muscle often due to vigorous contraction of the abdominal wall muscles from coughing, retching or straining from constipation. In this case, repeated direct intramuscular trauma from needles as well as the effect of the enoxaparin caused the hematoma. Mortality is reported at 4% for RSH but increases to 25% when anticoagulation plays a role. The patient presented with Fothergill's sign which is a painful abdominal mass that does not cross the midline and remains palpable with rectus muscle contraction thus differentiating it from an intra-abdominal mass. In light of her short term contraindication to receiving anticoagulation, an IVC filter was placed (supported by ACC/AHA guidelines issued in April 2011). The indications for placement of IVC filters are not robustly supported by evidence with only one prospective randomized study and a large populationbased retrospective analysis serving as the basis for recommendations. Because the RSH was caused by incorrect injection of enoxaparin, I recommended attempting to reinitiate anticoagulation in a monitored setting and if tolerated, removal of the retrievable IVC filter. The patient remained hemodynamically stable with an unfluctuating hemoglobin level and was transferred to the hospital where she was receiving her oncological treatment. Conclusions: RSH is often associated with the use of anticoagulation and on occasion can cause significant hemorrhage. IVC filters have a role in protecting patients with known proximal deep venous thrombosis or pulmonary embolism who have a contraindication against the use of anticoagulation

We have reported results from the formative stage of a community health worker intervention designed to improve diabetes management among Bangladeshi patients in New York City. Trained community health workers conducted focus groups (n = 47) and surveys (n = 169) with Bangladeshi individuals recruited from community locations. Results indicated that participants faced numerous barriers to care, had high rates of limited English proficiency, and had low levels of knowledge about diabetes. Most participants expressed interest in participating in a community health worker intervention.

Telephone medicine is often preferred by patients to meet primary care needs and may be associated with high patient satisfaction. This article presents findings about incoming patient calls to primary care for medically based reasons during office hours and reports factors independently associated with telephone encounter satisfaction, considering patient characteristics, call reasons, and staff responsiveness, for a national cohort of primary care users. Interviews were conducted with patients from 18 nationwide primary care clinics during the fall of 2009. Calling for an urgent medical issue was associated with dissatisfaction. Odds of call satisfaction were greater when patients thought staff was friendly (10×), call answer was timely (5×), and needed medical information was provided (7×). These findings can be used for interventions to optimize telephone access and patient satisfaction which is beneficial because satisfactory telephone encounters reduce primary care use and satisfied patients are more likely to be engaged in their health care.

OBJECTIVE:It is unclear whether coronary artery calcium (CAC) is effective for risk stratifying patients with diabetes in whom treatment decisions are uncertain. RESEARCH DESIGN AND METHODS/METHODS:Of 44,052 asymptomatic individuals referred for CAC testing, we studied 2,384 individuals with diabetes. Subjects were followed for a mean of 5.6 ± 2.6 years for the end point of all-cause mortality. RESULTS:There were 162 deaths (6.8%) in the population. CAC was a strong predictor of mortality across age-groups (age <50, 50-59, ≥60), sex, and risk factor burden (0 vs. ≥1 additional risk factor). In individuals without a clear indication for aspirin per current guidelines, CAC stratified risk, identifying patients above and below the 10% risk threshold of presumed aspirin benefit. CONCLUSIONS:CAC can help risk stratify individuals with diabetes and may aid in selection of patients who may benefit from therapies such as low-dose aspirin for primary prevention.

In the United States, the decision of whether to withdraw or continue to provide artificial nutrition and hydration (ANH) for patients in a permanent vegetative state (PVS) is placed largely in the hands of surrogate decision-makers, such as spouses and immediate family members. This practice would seem to be consistent with a strong national emphasis on autonomy and patient-centered healthcare. When there is ambiguity as to the patient's advanced wishes, the presumption has been that decisions should weigh in favor of maintaining life, and therefore, that it is the withdrawal rather than the continuation of ANH that requires particular justification. I will argue that this default position should be reversed. Instead, I will argue that the burden of justification lies with those who would continue artificial nutrition and hydration (ANH), and in the absence of knowledge as to the patient's advanced wishes, it is better to discontinue ANH. In particular, I will argue that among patients in PVS, there is not a compelling interest in being kept alive; that in general, we commit a worse violation of autonomy by continuing ANH when the patient's wishes are unknown; and that more likely than not, the maintenance of ANH as a bridge to a theoretical future time of recovery goes against the best interests of the patient.

Since their recent discovery, miRNAs have been shown to play critical roles in a variety of pathophysiological processes. Such processes include pathological angiogenesis, the oxidative stress response, immune response and inflammation, all of which have been shown to have important and interdependent roles in the pathogenesis and progression of age-related macular degeneration (AMD). Here we present a brief review of the pathological processes involved in AMD and review miRNAs and other noncoding RNAs involved in regulating these processes. Specifically, we discuss several candidate miRNAs that show promise as AMD therapeutic targets due to their direct involvement in choroidal neovascularization or retinal pigment epithelium atrophy. We discuss potential miRNA-based therapeutics and delivery methods for AMD and provide future directions for the field of miRNA research with respect to AMD. We believe the future of miRNAs in AMD therapy is promising.

A total of 299 nares and 194 blood isolates of methicillin-resistant Staphylococcus aureus (MRSA), each recovered from a unique patient, were collected from 23 U.S. hospitals from May 2009 to March 2010. All isolates underwent spa and staphylococcal cassette chromosome mec element (SCCmec) typing and antimicrobial susceptibility testing; a subset of 84 isolates was typed by pulsed-field gel electrophoresis (PFGE) using SmaI. Seventy-six spa types were observed among the isolates. Overall, for nasal isolates, spa type t002-SCCmec type II (USA100) was the most common strain type (37% of isolates), while among blood isolates, spa type t008-SCCmec type IV (USA300) was the most common (39%). However, the proportion of all USA100 and USA300 isolates varied by United States census region. Nasal isolates were more resistant to tobramycin and clindamycin than blood isolates (55.9% and 48.8% of isolates versus 36.6% and 39.7%, respectively; for both, P < 0.05). The USA300 isolates were largely resistant to fluoroquinolones. High-level mupirocin resistance was low among all spa types (<5%). SCCmec types III and VIII, which are rare in the United States, were observed along with several unusual PFGE types, including CMRSA9, EMRSA15, and the PFGE profile associated with sequence type 239 (ST239) isolates. Typing data from this convenience sample suggest that in U.S. hospitalized patients, USA100 isolates of multiple spa types, while still common in the nares, have been replaced by USA300 isolates as the predominant MRSA strain type in positive blood cultures.

Staphylococcus aureus infections are a significant cause of morbidity and mortality in health care settings. S. aureus clinical isolates vary in the function of the accessory gene regulator (agr), which governs the expression of virulence determinants, including surface and exoproteins, while agr activity has been correlated with patient outcome and treatment efficiency. Here we describe a duplex real-time nucleic acid sequence-based amplification (NASBA) detection and quantification platform for rapid determination of agr functionality in clinical isolates. Using the effector of agr response, RNAIII, as the assay target, and expression of the gyrase gene (gyrB) as a normalizer, we were able to accurately discriminate agr functionality in a single reaction. Time to positivity (TTP) ratios between gyrB and RNAIII showed very good correlation with the ratios of RNAIII versus gyrB RNA standard inputs and were therefore used as a simple readout to evaluate agr functionality. We validated the assay by characterizing 106 clinical S. aureus isolates, including strains with genetically characterized agr mutations. All isolates with dysfunctional agr activity exhibited a TTP ratio (TTP(gyrB)/TTP(RNAIII)) lower than 1.10, whereas agr-positive isolates had a TTP ratio higher than this value. The results showed that the assay was capable of determining target RNA ratios over 8 logs (10(-3) to 10(4)) with high sensitivity and specificity, suggesting the duplex NASBA assay may be useful for rapid determination of agr phenotypes and virulence potential in S. aureus clinical isolates.