Publications

OBJECTIVE

With increasing oversight of postoperative outcomes with the Patient Protection and Affordable Care Act, the reduction of readmissions is necessary to avoid financial penalties. This article provides a multi-institutional, multivariate analysis of the pre- and postoperative patient factors associated with readmission after carotid endarterectomy (CEA).

METHODS

Using the National Surgical Quality Improvement Program from 2011, we considered 8456 patients. The primary outcome variable was 30-day unplanned readmission. Multiple logistic regression was used, and we controlled for preoperative demographic variables, comorbidities and clinical characteristics, and postoperative medical and surgical complications.

RESULTS

Patients with CEA had a 6.0% unplanned readmission rate. The most common comorbidities in the readmitted patients included hypertension, diabetes, and bleeding disorder. Risk-adjusted multiple regression indicated that preoperative bleeding disorder (odds ratio [OR] 1.62), diabetes (OR 1.46), history of a cerebrovascular accident/stroke (OR 1.46), and increasing age (OR 1.01) were statistically significant predictors for readmission. Postoperatively, surgical-site infection (OR 21.90), myocardial infarction (OR 10.35), sepsis/septic shock (OR 7.79), cerebrovascular accident/stroke (OR 6.58), pneumonia (OR 4.37), and urinary tract infection (OR 3.21) were associated with a greater rate of readmission.

CONCLUSIONS

Readmission after CEA occurs at a comparatively high rate. Preoperative bleeding disorders, diabetes, cerebrovascular accidents, and age and postoperative surgical-site infection, myocardial infarction, sepsis/septic shock, pneumonia, and cerebrovascular accident were associated with readmission. These findings may help guide the surgical management of patients and prevent costly readmissions.

RATIONALE, AIMS AND OBJECTIVES

To describe primary care providers' (PCP) attitudes about the impact of a mature, commercial electronic health records (EHR) on clinical practice in settings with experience using the system and to evaluate whether a provider's propensity to adopt new technologies is associated with more favourable perceptions.

METHOD

We surveyed PCPs in 11 practices affiliated with three health systems in Texas. Most practices had greater than 5 years of experience with the Epic EHR. The effect of early adopter of technology status was evaluated using logistic regression.

RESULTS

One hundred forty-six PCPs responded (70%). Most thought the EHR had a positive impact on routine tasks, such as prescription refills (94%), whereas fewer agreed for complex tasks, such as delivery of guideline-concordant care for chronic illnesses (51%). Two-thirds (62%) thought it interfered with eye contact with patients, and 40% reported that it interfered with in-visit communication. Early adopters of technology reported greater positive effects of the EHR, even after adjusting for age, ranging from 2% to 15% higher on satisfaction ratings.

CONCLUSION

PCPs practicing in settings with considerable experience using a common commercial EHR identified many positive effects, as well as two key areas for improvement - patient centredness and intelligent decision support. Providers with a propensity to adopt new technologies have more favourable perceptions of the EHR.

BACKGROUND

The pathogenic mechanisms underlying pulmonary arterial hypertension resulting from schistosomiasis, one of the most common causes of pulmonary hypertension worldwide, remain unknown. We hypothesized that transforming growth factor-β (TGF-β) signaling as a consequence of Th2 inflammation is critical for the pathogenesis of this disease.

METHODS AND RESULTS

Mice sensitized and subsequently challenged with Schistosoma mansoni eggs developed pulmonary hypertension associated with an increase in right ventricular systolic pressure, thickening of the pulmonary artery media, and right ventricular hypertrophy. Rho-kinase-dependent vasoconstriction accounted for ≈60% of the increase in right ventricular systolic pressure. The pulmonary vascular remodeling and pulmonary hypertension were dependent on increased TGF-β signaling, as pharmacological blockade of the TGF-β ligand and receptor, and mice lacking Smad3 were significantly protected from Schistosoma-induced pulmonary hypertension. Blockade of TGF-β signaling also led to a decrease in interleukin-4 and interleukin-13 concentrations, which drive the Th2 responses characteristic of schistosomiasis lung pathology. Lungs of patients with schistosomiasis-associated pulmonary arterial hypertension have evidence of TGF-β signaling in their remodeled pulmonary arteries.

CONCLUSION

Experimental S mansoni-induced pulmonary vascular disease relies on canonical TGF-β signaling.