Ron C. Li

Abnormal lipoprotein particles and cholesterol efflux capacity in patients with psoriasis

OBJECTIVES Psoriasis is a Th-1/17 mediated inflammatory disease associated with increased risk of cardiovascular disease (CVD). Inflammation may modulate lipoprotein particle number and directly impair HDL functions, in particular reverse cholesterol transport (RCT). We sought to study how chronic in vivo inflammation modulates lipoprotein particle composition using nuclear magnetic resonance spectroscopy (NMR) and HDL efflux in psoriasis. METHODS AND RESULTS We prospectively enrolled a consecutive sample of patients with psoriasis (n = 122) and compared lipoprotein and metabolic risk factors to patients without psoriasis (n = 134). Fasting lipids, insulin, glucose were measured by standard assays, and lipoprotein concentration and size were measured by NMR. In a random subset (n = 100 each group), HDL efflux capacity was quantified using a validated ex vivo system involving the incubation of macrophages with apolipoprotein B-depleted serum from patients. Traditional lipid concentrations were similar in both groups except for HDL concentration which was lower in psoriasis (43 mg/dl (36-58) vs 50 (42-62), p < 0.01). However, NMR showed an atherogenic profile in psoriasis similar to that observed in diabetes, with significant increase in LDL particle concentration [1210.5 (1002-1498) vs 1115 (935-1291), p = 0.02] with decrease in LDL size [20.6 (20.3-21.1) vs 21.3 (20.6-21.1), p < 0.001] beyond CV risk factors and HOMA-IR (p = 0.001). Finally, HDL efflux capacity was lower in psoriasis compared to controls in fully adjusted models (beta -0.14, p = 0.001). CONCLUSIONS These data support a more atherogenic lipoprotein profile by NMR and decreased HDL efflux capacity in psoriasis patients compared to controls beyond CVD risk factors. The abnormal lipoprotein particle composition and HDL efflux capacity in psoriasis may provide a link between psoriasis and CVD.

Dietary vitamin K intake and anticoagulation control during the initiation phase of warfarin therapy: A prospective cohort study

Dietary vitamin K intake and anticoagulation control during the initiation phase of warfarin therapy: A prospective cohort study -

Validation of test performance and clinical time zero for an electronic health record embedded severe sepsis alert

BACHGROUND Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management. OBJECTIVE To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR. METHODS The sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis. RESULTS Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen. CONCLUSION We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems.

The Impact of Big Data on the Physician

Over the past few years technology has evolved to integrate itself into a myriad of aspects of every day life, including healthcare access and delivery. One way in which technology has begun to truly transform healthcare is with big data and big data analytics. Using sophisticated tools to capture, aggregate, and translate data across multiple sources, ranging from traditional electronic health records to non-traditional consumer devices, big data has the potential to transform the practice of medicine at both the level of the patient-physician relationship as well as in clinical decision-making and treatment. Already apparent are intriguing examples of increased patient engagement, improved evidence-based physician decision-making, and multi-faceted tools for more individualized patient care. As big data becomes more and more incorporated into the practice of medicine, issues regarding systems interoperability, privacy and security, and legal and regulatory boundaries will need to be resolved. This chapter is intended to be an overview of big data applications and potential challenges as they relate to the patient and physician.

Impact of problem-based charting on the utilization and accuracy of the electronic problem list

Objective Problem-based charting (PBC) is a method for clinician documentation in commercially available electronic medical record systems that integrates note writing and problem list management. We report the effect of PBC on problem list utilization and accuracy at an academic intensive care unit (ICU). Materials and Methods An interrupted time series design was used to assess the effect of PBC on problem list utilization, which is defined as the number of new problems added to the problem list by clinicians per patient encounter, and of problem list accuracy, which was determined by calculating the recall and precision of the problem list in capturing 5 common ICU diagnoses. Results In total, 3650 and 4344 patient records were identified before and after PBC implementation at Stanford Hospital. An increase of 2.18 problems (>50% increase) in the mean number of new problems added to the problem list per patient encounter can be attributed to the initiation of PBC. There was a significant increase in recall attributed to the initiation of PBC for sepsis (β = 0.45, P < .001) and acute renal failure (β = 0.2, P = .007), but not for acute respiratory failure, pneumonia, or venous thromboembolism. Discussion The problem list is an underutilized component of the electronic medical record that can be a source of clinician-structured data representing the patients clinical condition in real time. PBC is a readily available tool that can integrate problem list management into physician workflow. Conclusion PBC improved problem list utilization and accuracy at an academic ICU.

ELEVATED ENDOTHELIAL CELL, PLATELET AND T-CELL MICROPARTICLES IN PSORIASIS MAY PROVIDE NOVEL LINK TO ATHEROSCLEROSIS

Severe psoriasis is a risk factor for cardiovascular (CV) disease beyond traditional risk factors; however, the mechanism remains unknown. Recent findings suggest that cell membrane vesicles, or microparticles, which are released upon cell activation or apoptosis, are associated with CV disease and