Effect of digital tools to promote hospital quality and safety on adverse events after discharge.

OBJECTIVES: Post-discharge adverse events (AEs) are common and heralded by new and worsening symptoms (NWS). We evaluated the effect of electronic health record (EHR)-integrated digital tools designed to promote quality and safety in hospitalized patients on NWS and AEs after discharge. MATERIALS AND METHODS: Adult general medicine patients at a community hospital were enrolled. We implemented a dashboard which clinicians used to assess safety risks during interdisciplinary rounds. Post-implementation patients were randomized to complete a discharge checklist whose responses were incorporated into the dashboard. Outcomes were assessed using EHR review and 30-day call data adjudicated by 2 clinicians and analyzed using Poisson regression. We conducted comparisons of each exposure on post-discharge outcomes and used selected variables and NWS as independent predictors to model post-discharge AEs using multivariable logistic regression. RESULTS: A total of 260 patients (122 pre, 71 post [dashboard], 67 post [dashboard plus discharge checklist]) enrolled. The adjusted incidence rate ratios (aIRR) for NWS and AEs were unchanged in the post- compared to pre-implementation period. For patient-reported NWS, aIRR was non-significantly higher for dashboard plus discharge checklist compared to dashboard participants (1.23 [0.97,1.56], P = .08). For post-implementation patients with an AE, aIRR for duration of injury (>1 week) was significantly lower for dashboard plus discharge checklist compared to dashboard participants (0 [0,0.53], P < .01). In multivariable models, certain patient-reported NWS were associated with AEs (3.76 [1.89,7.82], P < .01). DISCUSSION: While significant reductions in post-discharge AEs were not observed, checklist participants experiencing a post-discharge AE were more likely to report NWS and had a shorter duration of injury. CONCLUSION: Interventions designed to prompt patients to report NWS may facilitate earlier detection of AEs after discharge. CLINICALTRIALS.GOV: NCT05232656.

Variability in Antithrombotic Therapy Regimens Peri-TAVR: A Single Academic Center Experience.

INTRODUCTION: The aim of this study was to describe peri-procedural antithrombotic use in patients undergoing transcatheter aortic valve replacement (TAVR) at a single academic medical center. METHODS: Retrospective collection of antiplatelet and anticoagulant use during the index hospitalization for all patients undergoing TAVR at our institution from April 2009 through March 2014. RESULTS: Of a total of 255 patients undergoing the procedure, 132 (51%) had an indication for anticoagulation pre-TAVR and 92 (70% of those with an indication) were on treatment. On discharge, 106 patients (44% of total surviving to discharge, 73% of those surviving with an indication for anticoagulation) were treated with oral anticoagulation. Of these patients, 89 (84%) were discharged on aspirin and an oral anticoagulant without clopidogrel. Only 122 (51% of total patients) were discharged on the regimen of aspirin and clopidogrel alone. CONCLUSION: Peri-procedural antithrombotic regimens vary greatly following TAVR. More than half of patients have an indication for anticoagulation following the procedure. Most patients at our institution who require anticoagulation are discharged on aspirin and an oral anticoagulant, though the optimal regimen requires further investigation.

Cellular response to prosthetic wear debris differs in patients with and without rheumatoid arthritis.

OBJECTIVE: To examine whether patients with rheumatoid arthritis (RA) demonstrate patterns of prosthetic wear or cellular responses to implant wear debris different from those demonstrated by patients without inflammatory joint disease. METHODS: Thirty-eight patients who had undergone a primary revision of a total elbow arthroplasty for aseptic loosening between 1996 and 2008 were identified. Twenty-five of these patients had RA, and 13 did not have inflammatory arthritis. Clinical data, gross wear patterns of the removed prostheses, and histopathologic analyses of peri-implant tissue were compared between the patients with RA and those without RA. RESULTS: Evaluation of the retrieved prostheses showed that conformational change of the humeral polyethylene bushing was associated with the generation of polyethylene and metal particles. The amount and type of wear debris in periprosthetic tissues were similar in patients with and those without RA. Patients with RA who were not receiving anti-tumor necrosis factor (anti-TNF) therapy exhibited a histologic pattern of interstitial and sheet-like lymphocytic infiltrates associated with a high plasma cell composition, which was different from the predominantly perivascular infiltrates with few plasma cells seen in non-RA patients (P = 0.04). Patients with RA who were receiving anti-TNF therapy showed a mixed perivascular and interstitial pattern of infiltrates with variable cell composition. CONCLUSION: Patients with RA exhibited a distinct cellular response to implant wear debris compared with patients without RA. This reaction was unrelated to differences in the type or amount of wear debris and was mitigated by anti-TNF therapy. These results suggest an intrinsic alteration in immunoregulation in RA and have implications for potential immunologic treatment of osteolysis in these patients.

Protein palmitoylation by a family of DHHC protein S-acyltransferases.

Protein palmitoylation refers to the posttranslational addition of a 16 carbon fatty acid to the side chain of cysteine, forming a thioester linkage. This acyl modification is readily reversible, providing a potential regulatory mechanism to mediate protein-membrane interactions and subcellular trafficking of proteins. The mechanism that underlies the transfer of palmitate or other long-chain fatty acids to protein was uncovered through genetic screens in yeast. Two related S-palmitoyltransferases were discovered. Erf2 palmitoylates yeast Ras proteins, whereas Akr1 modifies the yeast casein kinase, Yck2. Erf2 and Akr1 share a common sequence referred to as a DHHC (aspartate-histidine-histidine-cysteine) domain. Numerous genes encoding DHHC domain proteins are found in all eukaryotic genome databases. Mounting evidence is consistent with this signature motif playing a direct role in protein acyltransferase (PAT) reactions, although many questions remain. This review presents the genetic and biochemical evidence for the PAT activity of DHHC proteins and discusses the mechanism of protein-mediated palmitoylation.