Kenneth W. Scully

The development of health care data warehouses to support data mining.

Clinical data warehouses offer tremendous benefits as a foundation for data mining. By serving as a source for comprehensive clinical and demographic information on large patient populations, they streamline knowledge discovery efforts by providing standard and efficient mechanisms to replace time-consuming and expensive original data collection, organization, and processing. Building effective data warehouses requires knowledge of and attention to key issues in database design, data acquisition and processing, and data access and security. In this article, the authors provide an operational and technical definition of data warehouses, present examples of data mining projects enabled by existing data warehouses, and describe key issues and challenges related to warehouse development and implementation.

Mycobacterial infections in a large Virginia hospital, 2001-2009

BackgroundIn areas where both tuberculosis (TB) and nontuberculous mycobacteria (NTM) are prevalent, descriptive studies of the clinical features of individual mycobacteria are needed to inform clinical triage.MethodsWe queried the University of Virginia Clinical Data Repository for all mycobacterial infections from 2001-2009.ResultsOf 494 mycobacterial infections in 467 patients there were 22 species. Patients with pulmonary Tb were more likely to be reported as immigrants (p < 0.001) and less likely to have a predisposing risk factor for NTM (pre-existing lung disease or host predisposition; p = 0.002). Review of chest CT scans revealed that TB infection was more likely to exhibit cavities and pleural effusion than NTM infection (p < 0.05). Among NTM infections M. kansasii, M. xenopi, and M. fortuitum were more likely than MAC to have cavities. There were at least 83 patients that met criteria for NTM lung disease and these were caused by 9 species. M. abscessus infection was associated with cystic fibrosis and M. xenopi infection was associated with male gender.ConclusionsIn our center mycobacterial infections were common and of diverse species. Immigrant status, cavities, and effusion were associated with TB vs. NTM.

Role of Leptin-Mediated Colonic Inflammation in Defense against Clostridium difficile Colitis

ABSTRACT The role of leptin in the mucosal immune response to Clostridium difficile colitis, a leading cause of nosocomial infection, was studied in humans and in a murine model. Previously, a mutation in the receptor for leptin (LEPR) was shown to be associated with susceptibility to infectious colitis and liver abscess due to Entamoeba histolytica as well as to bacterial peritonitis. Here we discovered that European Americans homozygous for the same LEPR Q223R mutation (rs1137101), known to result in decreased STAT3 signaling, were at increased risk of C. difficile infection (odds ratio, 3.03; P = 0.015). The mechanism of increased susceptibility was studied in a murine model. Mice lacking a functional leptin receptor (db/db) had decreased clearance of C. difficile from the gut lumen and diminished inflammation. Mutation of tyrosine 1138 in the intracellular domain of LepRb that mediates signaling through the STAT3/SOCS3 pathway also resulted in decreased mucosal chemokine and cell recruitment. Collectively, these data support a protective mucosal immune function for leptin in C. difficile colitis partially mediated by a leptin-STAT3 inflammatory pathway that is defective in the LEPR Q223R mutation. Identification of the role of leptin in protection from C. difficile offers the potential for host-directed therapy and demonstrates a connection between metabolism and immunity.

Dialysis Requirement and Long-Term Major Adverse Cardiovascular Events in Patients with Chronic Kidney Disease and Superimposed Acute Kidney Injury

Background: Chronic kidney disease (CKD) patients who experience superimposed acute kidney injury (AKI) have been shown to be at higher risk of long-term sequelae of AKI when compared to those who do not experience AKI. It remains unclear whether the need for temporary dialysis intervention following superimposed AKI in patients with CKD has any effect on the long-term major adverse cardiovascular events (MACE). This study examines the relationship between temporary dialysis therapy following AKI and long-term major cardiovascular events in patients with background CKD. Methods: The study population consists of adults who developed AKI while on admission at the University of Virginia Medical Center between January 1, 2002 and December 31, 2012, and who had preadmission estimated glomerular filtration rate (eGFR) between 20 and 60 mL/min/1.73 m2 and survived beyond 30 days of AKI. Demographic and baseline clinical variables were used to generate propensity score. Survivors who had temporary dialysis were matched to those managed conservatively according to the propensity score in a ratio of 1:3. Results: Overall, 6,634 (n = 381 and 6,253 in the temporary dialysis-requiring AKI and non-dialysis AKI groups respectively) met entry criteria for the full cohort. Of these, 381 (5.7%) received temporary dialysis. There were 3,147 (47.4% of all patients) MACE events during the study period. The crude incidence for MACE after 30 days of AKI was similar in both dialyzed and non-dialyzed patients. After the propensity score matching, the adjusted hazard ratio for MACE in dialyzed versus non dialyzed patients was 1.162 (95% CI 0.978-1.381). Conclusions: Treatment of AKI with temporary dialysis in hospitalized patients with baseline eGFR between 20 and 60 mL/min/1.73 m2 was not associated with an increased risk for subsequent admission for MACE. If confirmed by prospective studies, clinicians may not need to worry that the dialysis procedure may contribute to additional risk for long-term MACE in CKD patients with superimposed AKI.

COST ANALYSIS OF HEART FAILURE READMISSION INTERVENTION PROGRAM

Dedicated heart failure (HF) clinics have been established to improve HF care. The Hospital-to-Home (H2H) program at our institution is a rapid clinic follow-up program for patients with recent HF admissions. We evaluated the real world costs of health care delivery with H2H after a HF admission

Development and Validation of a Prediction Model for Mortality and Adverse Outcomes Among Patients With Peripheral Eosinopenia on Admission for Clostridium difficile Infection

Importance Recent evidence from an animal model suggests that peripheral loss of eosinophils in Clostridium difficile infection (CDI) is associated with severe disease. The ability to identify high-risk patients with CDI as early as the time of admission could improve outcomes by guiding management decisions. Objective To construct a model using clinical indices readily available at the time of hospital admission, including peripheral eosinophil counts, to predict inpatient mortality in patients with CDI. Design, Setting, and Participants In a cohort study, a total of 2065 patients admitted for CDI through the emergency department of 2 tertiary referral centers from January 1, 2005, to December 31, 2015, formed a training and a validation cohort. The sample was stratified by admission eosinophil count (0.0 cells/&mgr;L or >0.0 cells/&mgr;L), and multivariable logistic regression was used to construct a predictive model for inpatient mortality as well as other disease-related outcomes. Main Outcomes and Measures Inpatient mortality was the primary outcome. Secondary outcomes included the need for a monitored care setting, need for vasopressors, and rates of inpatient colectomy. Results Of the 2065 patients in the study, 1092 (52.9%) were women and patients had a mean (SD) age of 63.4 (18.4) years. Those with an undetectable eosinophil count at admission had increased in-hospital mortality in both the training (odds ratio [OR], 2.01; 95% CI, 1.08-3.73; P = .03) and validation (OR, 2.26; 95% CI, 1.33-3.83; P = .002) cohorts in both univariable and multivariable analysis. Undetectable eosinophil counts were also associated with indicators of severe sepsis, such as admission to monitored care settings (OR, 1.40; 95% CI, 1.06-1.86), the need for vasopressors (OR, 2.08; 95% CI, 1.32-3.28), and emergency total colectomy (OR, 2.56; 95% CI, 1.12-5.87). Other significant predictors of mortality at admission included increasing comorbidity burden (for each 1-unit increase: OR, 1.13; 95% CI, 1.05-1.22) and lower systolic blood pressures (for each 1-mm Hg increase: OR, 0.99; 95% CI, 0.98-1.00). In a subgroup analysis of patients presenting without initial tachycardia or hypotension, only patients with undetectable admission eosinophil counts, but not those with an elevated white blood cell count, had significantly increased odds of inpatient mortality (OR, 5.76; 95% CI, 1.99-16.64). Conclusions and Relevance This study describes a simple, widely available, inexpensive model predicting CDI severity and mortality to identify at-risk patients at the time of admission.

Major Depression and Long-Term Outcomes of Acute Kidney Injury

Background: The prevalence of depression and its relationship to poor outcomes in chronic kidney disease are established facts. Such prognostic impact in acute kidney injury (AKI) is not known. This study determines the prognostic implication of a diagnosis of depression on renal recovery and major adverse cardiovascular events (MACE), a new diagnosis of myocardial infarction, cerebrovascular disease (CVD, stroke or transient ischemic attack) or congestive heart failure (CHF) after hospitalization with AKI. Methods: The study population comprises adults admitted to the University of Virginia Medical Center between January 1, 2002 and December 31, 2012 who suffered AKI during admission. Long-term outcomes, MACE and all-cause mortality, were compared between 2 groups; patients with preexisting diagnosis of major depression and those without. Risk adjusted multivariable Cox proportional hazards regression examined the association between major depression and these outcomes. Results: Patients with AKI numbering 11,425 survived beyond 90 days and had data available. Of these patients, 2,519 (22%) were majorly affected by depression; more often, younger patients, females, African Americans, and those with more comorbid conditions, especially CHF, CVD, diabetes, peptic ulcer disease, chronic pulmonary disease and liver disease were found to be affected with depression. Crude hazard ratio for MACE was 1.245, 95% CI 1.150-1.348 and for all-cause mortality 1.186, 95% CI 1.091-1.290; p < 0.001, that is, the cohort with major depression had a long-term risk for MACE and all-cause mortality increased by 24 and 18%, respectively. Conclusion: Patients who develop AKI in hospital and have preexisting major depression are at greater long-term risk of MACE and all-cause mortality.

IMPACT ON READMISSIONS AND MORTALITY OF HEART FAILURE READMISSION INTERVENTION PROGRAM

Heart failure (HF) readmissions are a quality measure for health outcomes. The Hospital-to-Home (H2H) program is an institutional rapid clinic follow-up program for patients with HF admission. We sought to determine the impact of this intervention on HF readmissions and mortality during the first 30