Jennifer Sartorius

Hydroxychloroquine use associated with improvement in lipid profiles in rheumatoid arthritis patients

Cardiovascular disease (CVD) is the leading cause of death in patients with rheumatoid arthritis (RA). Disease‐modifying therapies that improve risk factors for CVD, such as dyslipidemia, are desired. This study used an electronic health record to determine if hydroxychloroquine (HCQ) use was associated with an improvement in lipid levels in an inception RA cohort.

Door-to-Balloon Times Under 90 Min Can Be Routinely Achieved for Patients Transferred for ST-Segment Elevation Myocardial Infarction Percutaneous Coronary Intervention in a Rural Setting

OBJECTIVES The purpose of this study was to demonstrate the feasibility of routine transfer of ST-segment elevation myocardial infarction (STEMI) patients to achieve percutaneous coronary intervention (PCI) in less than 90 min from presentation. BACKGROUND Many PCI hospitals have achieved routine door-to-balloon times under 90 min for patients with STEMI presenting directly to the hospital. However, few patients transferred from a non-PCI center undergo PCI within 90 min of presentation. METHODS Our rural PCI hospital implemented a program in 2005 for rapid triage, transfer, and treatment of STEMI patients and made additional improvements in 2006 and 2007. Intervals between milestones in the STEMI triage/transfer/treatment process were assessed before and after implementation of the program. RESULTS During the 5-year study period, 676 patients with 687 STEMIs were transferred from 19 community hospitals and underwent PCI. Median door-to-balloon time decreased from 189 min to 88 min (p < 0.001). The time intervals reflecting efficiency of the referring hospitals, transfer services, and PCI hospital all significantly improved. In 2008, median door-to-balloon times were <90 min for 6 of the 7 most frequently referring hospitals. Delays during off-hours presentation in 2004 were abolished after the program was implemented in 2005. In-hospital mortality decreased from 6% before to 3% after implementation of the program. In multivariate modeling, presentation before initiation of the STEMI program predicted increased risk of in-hospital mortality (odds ratio: 3.74, 95% confidence interval: 1.22 to 11.51, p = 0.021). CONCLUSIONS A program of rapid triage, transfer, and treatment of STEMI patients presenting to non-PCI hospitals can reduce in-hospital mortality and produce progressive improvements in door-to-balloon time such that median door-to-balloon times under 90 min are feasible.

Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert

OBJECTIVE To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications. METHODS A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fishers exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites. RESULTS PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001). CONCLUSION The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.

Diabetes mellitus risk in rheumatoid arthritis: reduced incidence with anti-tumor necrosis factor α therapy.

To examine the association of tumor necrosis factor α (TNFα) inhibitor use and the risk of developing diabetes mellitus in a rheumatoid arthritis (RA) inception cohort.

PTSD and Alcohol Use After the World Trade Center Attacks: A Longitudinal Study

Research suggests that posttraumatic stress disorder (PTSD) is associated with increased alcohol use, but the findings have not been consistent. We assessed alcohol use, binge drinking, and psychotropic medication use longitudinally in 1,681 New York City adults, representative of the 2000 census, 2 years after the World Trade Center attacks. We found that, with the exception of a modified CAGE Questionnaire index for alcohol, alcohol use showed a modest increase over time and was related to PTSD symptoms, with an increase of about 1 more drink per month for those with PTSD, even though overall levels appeared to be within the National Institute on Alcohol Abuse and Alcoholisms safe range. Psychotropic medication use followed a similar trend; those with PTSD used psychotropics about 20 more days over the past year than those without. Because the study analyses adjusted for key psychosocial variables and confounders, it is not clear if the increased alcohol use following trauma exposure is associated with self-medication of PTSD symptoms, whether increased alcohol use prior to exposure is a risk for delayed-onset PTSD, or whether a third unmeasured variable is involved. Further research is warranted.

A brief screening tool for assessing psychological trauma in clinical practice: development and validation of the New York PTSD Risk Score.

OBJECTIVE The objective was to develop a brief posttraumatic stress disorder (PTSD) screening instrument that is useful in clinical practice, similar to the Framingham Risk Score used in cardiovascular medicine. METHODS We used data collected in New York City after the World Trade Center disaster (WTCD) and other trauma data to develop a new PTSD prediction tool--the New York PTSD Risk Score. We used diagnostic test methods to examine different clinical domains, including PTSD symptoms, trauma exposures, sleep disturbances, suicidal thoughts, depression symptoms, demographic factors and other measures to assess different PTSD prediction models. RESULTS Using receiver operating curve (ROC) and bootstrap methods, five prediction domains, including core PTSD symptoms, sleep disturbance, access to care status, depression symptoms and trauma history, and five demographic variables, including gender, age, education, race and ethnicity, were identified. For the best prediction model, the area under the ROC curve (AUC) was 0.880 for the Primary Care PTSD Screen alone (specificity=82.2%, sensitivity=93.7%). Adding care status, sleep disturbance, depression and trauma exposure increased the AUC to 0.943 (specificity=85.7%, sensitivity=93.1%), a significant ROC improvement (P<.0001). Adding demographic variables increased the AUC to 0.945, which was not significant (P=.250). To externally validate these models, we applied the WTCD results to 705 pain patients treated at a multispecialty group practice and to 225 trauma patients treated at a Level I Trauma Center. These results validated those from the original WTCD development and validation samples. CONCLUSION The New York PTSD Risk Score is a multifactor prediction tool that includes the Primary Care PTSD Screen, depression symptoms, access to care, sleep disturbance, trauma history and demographic variables and appears to be effective in predicting PTSD among patients seen in healthcare settings. This prediction tool is simple to administer and appears to outperform other screening measures.

Bisphosphonate Therapy, Death, and Cardiovascular Events Among Female Patients With CKD: A Retrospective Cohort Study

BACKGROUND Accelerated vascular calcification contributes to cardiovascular disease burden in patients with chronic kidney disease (CKD). We hypothesized that bisphosphonate therapy would reduce the risk of mortality and cardiovascular events in this population. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adult women with stage 3 or 4 CKD receiving primary care in a large rural integrated health care system in 2004-2010. EXPOSURE Time-dependent exposure status based on outpatient prescription for any medication within the bisphosphonate class, obtained from electronic health records. OUTCOMES Time to death and first cardiovascular event (composite of myocardial infarction, heart failure, or stroke). RESULTS Data from 9,604 eligible female patients with CKD were analyzed; 3,234 were treated with bisphosphonate therapy. During a median follow-up of 3.9 (25th-75th percentile, 2.3-5.4) years, there were 286 versus 881 deaths and 206 versus 571 cardiovascular events (treated vs not-treated groups, respectively). In a multivariate Cox proportional hazard model, the adjusted HR for death (treated vs not treated) was 0.78 (95% CI, 0.67-0.91; P = 0.003). In Cox modeling adjusted for similar baseline covariates, treatment with bisphosphonates was not associated with a lower risk of the composite cardiovascular outcome (adjusted HR, 1.14; 95% CI, 0.94-1.39; P = 0.2). LIMITATIONS Residual confounding by unidentified factors, exclusion of male patients, and lack of information about longitudinal drug adherence. CONCLUSIONS For female patients with CKD, treatment with bisphosphonates is associated with a lower risk of death, but not cardiovascular events. Confirmatory studies and investigations of potential causal mechanisms are warranted.

A survey of clinicians addressing the approach to the management of severe sepsis and septic shock in the United States

PURPOSE Mortality in severe sepsis and septic shock (SS/SS) remains high. Surviving Sepsis Campaign (SSC) guidelines were published in 2004 with the goal of improving outcomes in SS/SS. We tested the hypothesis that adherence to SSC guidelines and management of patients with SS/SS were influenced by physician specialty. MATERIALS AND METHODS A survey was mailed to 4998 randomly selected physicians, 1666 each for emergency medicine (EM), critical care medicine (CCM), and internal medicine (IM) from the American Medical Association database. Demographics, compliance with SSC guidelines, and approaches to management of patients with SS/SS were analyzed by specialty. RESULTS Four hundred ninety-nine respondents were included for final analysis. There were no differences between 3 specialties in obtaining blood cultures and in administering intravenous fluids, pressors, and antibiotics. The CCM physicians were more likely to measure serum lactate and central venous pressure, use corticosteroids and drotrecogin α, and aim for normoglycemia and plateau pressures less than 30 cm H(2)O in mechanically ventilated patients (all P < .001). CONCLUSIONS We observe that adherence with SSC guidelines continues to be a challenge for CCM, IM, and EM physicians. Significant differences in management of SS/SS exist for the 3 specialties. Because guideline implementation impacts patient outcomes, further evaluation of these differences is warranted.

The New York PTSD Risk Score for Assessment of Psychological Trauma: Male and Female Versions

We previously developed a new posttraumatic stress disorder (PTSD) screening instrument-the New York PTSD Risk Score (NYPRS). Since research suggests different PTSD risk factors and outcomes for men and women, in the current study we assessed the suitability of male and female versions of this screening instrument among 3298 adults exposed to traumatic events. Using diagnostic test methods, including receiver operating characteristic (ROC) curve and bootstrap techniques, we examined different prediction domains, including core PTSD symptoms, trauma exposures, sleep disturbances, depression symptoms, and other measures to assess PTSD prediction models for men and women. While the original NYPRS worked well in predicting PTSD, significant interaction was detected by gender, suggesting that separate models are warranted for men and women. Model comparisons suggested that while the overall results appeared robust, prediction results differed by gender. For example, for women, core PTSD symptoms contributed more to the prediction score than for men. For men, depression symptoms, sleep disturbance, and trauma exposure contributed more to the prediction score. Men also had higher cut-off scores for PTSD compared to women. There were other gender-specific differences as well. The NYPRS is a screener that appears to be effective in predicting PTSD status among at-risk populations. However, consistent with other medical research, this instrument appears to require male and female versions to be the most effective.

Frequency of Coronary Angiography and Revascularization among Men and Women with Myocardial Infarction and Their Relationship to Mortality at One Year: An Analysis of the Geisinger Myocardial Infarction Cohort

OBJECTIVES To determine sex bias in the selection of strategies to evaluate patients with acute myocardial infarction (AMI), and determine if the choice of strategy influences survival. BACKGROUND Controversy exists regarding the role of female sex in the use of invasive evaluation for AMI and its possible effect on adverse outcomes. METHODS Electronic health record data from the Geisinger Acute Myocardial Infarction Cohort (GAMIC) was analyzed which included 1,968 men and 1,047 women admitted to the Geisinger Medical Center between January 2001 and December 2006 with acute myocardial infarction (AMI).Multivariate logistic regression analyses were used to determine independent correlates of an invasive evaluation. Multivariate logistic regression modeling stratified on sex was used to determine when invasive evaluation was done and whether there was a correlation with mortality. RESULTS In unadjusted analyses, male sex was a significant predictor for the use of invasive evaluation (odds ratio = 1.71, 95% CI = [1.46, 2.00]). Adjusted for baseline differences (like age, renal function, co-morbid conditions) multivariate analyses found no significant relationship between male sex and invasive evaluation (OR = 1.02, 95% CI = [0.82, 1.23]). Females in the STEMI group were found to be less revascularized. No difference was observed in the one-year mortality between women and men regardless of invasive evaluation or revascularization. CONCLUSIONS Sex was not independently associated with the occurrence of an invasive evaluation of a MI. Females in the STEMI group were less revascularized. There was no strong gender effect on survival irrespective of the performance on an invasive evaluation or revascularization.