Mohammed Salim Al-Damluji

Integrated assessment of behavioral and environmental risk factors for Lyme disease infection on Block Island, Rhode Island.

Peridomestic exposure to Borrelia burgdorferi-infected Ixodes scapularis nymphs is considered the dominant means of infection with black-legged tick-borne pathogens in the eastern United States. Population level studies have detected a positive association between the density of infected nymphs and Lyme disease incidence. At a finer spatial scale within endemic communities, studies have focused on individual level risk behaviors, without accounting for differences in peridomestic nymphal density. This study simultaneously assessed the influence of peridomestic tick exposure risk and human behavior risk factors for Lyme disease infection on Block Island, Rhode Island. Tick exposure risk on Block Island properties was estimated using remotely sensed landscape metrics that strongly correlated with tick density at the individual property level. Behavioral risk factors and Lyme disease serology were assessed using a longitudinal serosurvey study. Significant factors associated with Lyme disease positive serology included one or more self-reported previous Lyme disease episodes, wearing protective clothing during outdoor activities, the average number of hours spent daily in tick habitat, the subject’s age and the density of shrub edges on the subject’s property. The best fit multivariate model included previous Lyme diagnoses and age. The strength of this association with previous Lyme disease suggests that the same sector of the population tends to be repeatedly infected. The second best multivariate model included a combination of environmental and behavioral factors, namely hours spent in vegetation, subject’s age, shrub edge density (increase risk) and wearing protective clothing (decrease risk). Our findings highlight the importance of concurrent evaluation of both environmental and behavioral factors to design interventions to reduce the risk of tick-borne infections.

Association of Discharge Summary Quality With Readmission Risk for Patients Hospitalized With Heart Failure Exacerbation

Patients admitted with heart failure have disproportionately high readmission rates, most recently ranging from 17.5% to 30.3% nationally.1 The Affordable Care Act penalizes hospitals with higher than average readmission rates after admissions for heart failure. However, clinicians remain uncertain, which strategies are associated with reducing readmissions in this population.2 Experts have proposed that the creation and transmission of a high-quality discharge summary to outpatient clinicians may improve the transition from hospital to home. Discharge summaries may facilitate safer transitions in care by informing outpatient clinicians about the course of hospitalization, identifying pending studies requiring follow-up, suggesting further follow-up testing, and clarifying changes in medications and treatments after discharge. Nonetheless, despite widespread enthusiasm for improving the quality of discharge summaries, there have been few studies of the effectiveness of discharge summaries in helping to avoid readmissions, and those few have found no association of timeliness,3,4 transmission,5,6 or content5 with readmission. To determine the association of discharge quality and readmission in a large national sample, we examined discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) randomized controlled trial. ### Study Cohort and Setting The Tele-HF study included patients living at home and hospitalized for heart failure in the previous 30 days.7 Patients in Tele-HF were recruited from 33 cardiology practices in 21 states and the District of Columbia. We obtained discharge summaries for the index hospitalization. Wherever possible, we obtained …

Hospital Variation in Quality of Discharge Summaries for Patients Hospitalized With Heart Failure Exacerbation

Background— Single-site studies have demonstrated inadequate quality of discharge summaries in timeliness, transmission, and content, potentially contributing to adverse outcomes. However, degree of hospital-level variation in discharge summary quality for patients hospitalized with heart failure (HF) is uncertain. Methods and Results— We analyzed discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) study. We assessed hospital-level performance on timeliness (fraction of summaries completed on the day of discharge), documented transmission to the follow-up physician, and content (presence of components suggested by the Transitions of Care Consensus Conference). We obtained 1501 discharge summaries from 1640 (91.5%) patients discharged alive from 46 hospitals. Among hospitals contributing ≥10 summaries, the median hospital dictated 69.2% of discharge summaries on the day of discharge (range, 0.0%–98.0%; P<0.001); documented transmission of 33.3% of summaries to the follow-up physician (range, 0.0%–75.7%; P<0.001); and included 3.6 of 7 Transitions of Care Consensus Conference elements (range, 2.9–4.5; P<0.001). Hospital course was typically included (97.2%), but summaries were less likely to include discharge condition (30.7%), discharge volume status (16.0%), or discharge weight (15.7%). No discharge summary included all 7 Transitions of Care Consensus Conference–endorsed content elements, was dictated on the day of discharge, and was sent to a follow-up physician. Conclusions— Even at the highest performing hospital, discharge summary quality is insufficient in terms of timeliness, transmission, and content. Improvements in all aspects of discharge summary quality are necessary to enable the discharge summary to serve as an effective transitional care tool.

New-onset versus prior history of atrial fibrillation: Outcomes from the AFFIRM trial

BACKGROUND There are limited data on prognosis and outcomes of patients with new-onset atrial fibrillation (AF) compared with those with a prior history of AF. METHODS AND RESULTS We conducted a comparison of these 2 groups in the AFFIRM trial. New-onset AF was the qualifying arrhythmia in 1,391 patients (34%). Compared with patients with prior history of AF, patients with new-onset AF were more likely to have a history of heart failure. There was no mortality difference between rate control (RaC) and rhythm control (RhC) among patients with new-onset AF (17% vs 20%, P = .152). In the univariate model, new-onset AF was associated with increased risk of mortality compared with history of prior AF (RaC unadjusted hazard ratio [HR] 1.36 [P = .010], RhC unadjusted HR 1.39 [P = .003]). However, after multivariate adjustments, new-onset AF did not carry an increased risk of mortality (RaC adjusted HR 1.14 [P = .370], RhC adjusted HR 1.16 [P = .248]). Subjects with new-onset AF randomized to the RhC arm were more likely to remain in normal sinus rhythm at follow-up (adjusted HR 0.79, P = .012) compared with patients with prior history of AF. CONCLUSIONS In a multivariable analysis adjusting for confounders, new-onset AF was not associated with increased mortality compared with prior history of AF regardless of the treatment strategy. Patients with new-onset AF treated with the rhythm control strategy were more likely to remain in normal sinus rhythm on follow-up.

Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties

Background Sign-out is the process (written, verbal or both) by which one clinical team transmits information about patients to another team. Poor quality sign-outs are associated with adverse events and delayed treatment. How different specialties approach written sign-outs is unknown. Objective To compare written sign-out practices across specialties and to determine consistency of content, format and timeliness. Methods The authors evaluated all non-Intensive Care Unit written sign-outs from five inpatient specialties on 18 January 2012, at Yale-New Haven Hospital, focusing on content elements, format style and whether the sign-outs had been updated within 24 h. In our institution, all specialties used a single standardised sign-out template, which was built into the electronic medical record. Results The final cohort included 457 sign-outs: 313 medicine, 64 general surgery, 36 paediatrics, 30 obstetrics, and 14 gynaecology. Though nearly all sign-outs (96%) had been updated within 24 h, they frequently lacked key information. Hospital course prevalence ranged from 57% (gynaecology) to 100% (paediatrics) (p<0.001). Clinical condition prevalence ranged from 34% (surgery) to 72% (paediatrics) (p=0.005). Conclusions Specialties have varied sign-out practices, and thus structured templates alone do not guarantee inclusion of critical content. Sign-outs across specialties often lacked complex clinical information such as clinical condition, anticipatory guidance and overnight tasks.

Association between anti-human heat shock protein-60 and interleukin-2 with coronary artery calcium score

Introduction Based upon evidence suggesting that concentrations of anti-heat shock protein-60 (anti-HSP60) and interleukin-2 (IL-2) are associated with atherogenesis, we tested the hypothesis that anti-HSP60 and IL-2 are associated with coronary artery calcium (CAC) score, a marker of subclinical atherosclerosis. Methods We evaluated 998 asymptomatic adults, age 45–84 years, without known coronary disease from the Multi-Ethnic Study of Atherosclerosis (MESA), who had anti-HSP60 measured at baseline. Tertiles of serum anti-HSP60 were evaluated. The associations of IL-2 and anti-HSP60 with CAC were assessed using multivariate analyses, with adjustments for coronary risk factors and Framingham risk score. Results Patients’ demographics, diabetes, hypertension, obesity, or dyslipidaemia did not show differences in levels of anti-HSP60. The median (IQR) Framingham risk score was 11 (5–22), 8 (5–16), and 9 (5–18) for the first, second, and third tertiles, respectively (p=0.043). IL-2 and tumour necrosis factor α (TNF-α) were associated with increased CAC (IL-2: OR 3.70, p<0.001; TNF-α: OR 4.63, p<0.001). In multivariate regression, the highest tertiles of anti-HSP60 and IL-2 were associated with increased risk of CAC (HSP60 T3: OR 1.49, p=0.022; IL-2: OR 2.49, p<0.001). After adjustment, significant progression of CAC was observed in patients with higher baseline levels of anti-HSP60 (estimate 31.73, p=0.016) and IL-2 (estimate 34.39, p=0.024). Conclusions Increased concentrations of inflammatory markers (IL-2 and anti-HSP60) are associated with an increased CAC at baseline and follow-up in healthy asymptomatic adults. Future studies should be carried out to assess its association with early development of atherosclerosis.

Carotid Revascularization: A Systematic Review of the Evidence

OBJECTIVE AND BACKGROUND The aim of this study is to provide an evidence-based review of the periprocedural safety and long-term effectiveness of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA), with particular attention paid to the use of embolic protection devices and patients at high risk for CEA. METHODS Electronic databases (Ovid Medline, Cochrane central register of controlled trials, Pubmed, and Embase) were searched to identify: (1) randomized controlled trials (RCT) comparing outcomes of CEA and CAS, and (2) prospective clinical trials assessing the safety of CAS in patients at high surgical risk. Pooled incidence rates and one-sided 95% confidence interval for the periprocedural and long-term composite end-point of stroke, myocardial infarction, or death among high surgical risk patients were generated and compared to objective performance criteria (OPC) reported by previous trials. RESULTS Six RCTs and 14 prospective clinical trials met our search criteria. Selected RCTs showed inconsistency in reported periprocedural and long-term outcome rates. Pooled incidence rates of the periprocedural and long-term composite end-point of stroke, myocardial infarction or death in high surgical risk candidates were 5.59% and 7.92%, respectively. These results were noninferior to selected OPCs (P-value <0.001). CONCLUSIONS CAS represents a safe and effective stroke prevention strategy in high surgical risk patients when compared with CEA. The inconsistent results from the RCTs and the improved outcomes in the prospective clinical trials are likely related to variability in operator experience, use of embolic protection devices, and patient selection strategies.