Appropriateness vs value: Echocardiography in primary care.

BACKGROUND: Despite efforts targeting the growth of healthcare spending within the United States, the current increase in expenditures remains a widespread systemic issue. The overuse of healthcare testing has previously been identified as a modifiable contributing factor. One such test, echocardiography, has seen a continuous increase in its rate of use. This test is frequently ordered by primary-care physicians. HYPOTHESIS: In the setting of a low likelihood of disease, echocardiography does not substantially change cardiac therapy, even if appropriately ordered. METHODS: We randomly identified 500 patients who received an echocardiogram ordered by a primary-care physician between January 1, 2014, and December 31, 2014. Of these, 239 patient charts were reviewed and the following extracted: primary indication for the test, echocardiogram results, and changes in patient medical management. In addition, appropriateness of the test was assessed using the appropriate use criteria guidelines for echocardiography. RESULTS: Nearly 97% of the studies within the ambulatory primary-care setting were appropriately ordered according to the appropriate use criteria. Among the 239 patients studied, only 52 had abnormalities and only 6 (2.5%) experienced a change in management that corresponded with the initial suspected diagnosis and echocardiographic findings. CONCLUSIONS: To ensure the greatest value and optimize use of diagnostic testing, it may be necessary to develop a more comprehensive set of guidelines to assist clinicians to readily identify patient populations at low, moderate, and high risk for the presence of disease and provide educational interventions, including feedback regarding individual ordering behaviors.

Impact of troponin testing in noncardiac admissions.

BACKGROUND: There is little data to support Troponin I (TNI) use in the management of noncardiac patients. We studied the use of TNI in patients on our gastroenterology service, to determine whether there was a change in management as a result of TNI testing. METHODOLOGY: Patients admitted from September 2011 to June 2012 to our gastroenterology service who had TNI performed were included. Data collected included symptoms, cardiovascular risk factors, medical treatment, and testing. RESULTS: Sixty-three of 295 patients had a positive TNI. The mean length of stay was significantly longer with a positive troponin (180 vs. 108 hours, P<0.001). Age, hypertension, diabetes, coronary artery disease, and chronic kidney disease were associated with a positive TNI. Cardiac consultation and echocardiography were performed in a higher proportion of TNI positive patients (P<0.0001). There were no statistically significant changes in treatment with clopidogrel, beta-blockers, angiotensin converting enzyme inhibitors, or statins between both groups. CONCLUSIONS: TNI testing in patients admitted to the gastroenterology service was associated with increased length of stay and echocardiography, without any change in management. This study supports adherence to national guidelines for the use of TNI, to reduce TNI testing and length of hospital stay.

The use of transthoracic echocardiography and adherence to appropriate use criteria at a regional hospital.

BACKGROUND: The sharp increase in health care costs over the past decade has prompted health care providers to reevaluate how diagnostic imaging is utilized. In response to the need for more rational use of imaging services, the American College of Cardiology Foundation and the American Society of Echocardiography have developed appropriate use criteria (AUC) for transthoracic echocardiography to guide its utilization. Although community and regional hospitals, such as Danbury Hospital, account for 85% of registered hospitals in the United States, very little is known about adherence to the AUC at these institutions. METHODS: The electronic medical records of 1,205 patients who underwent inpatient transthoracic echocardiography from January 1 to June 30, 2008, were retrospectively examined to determine the reasons for ordering the studies. The 2007 and 2011 AUC were used to classify indications as appropriate, inappropriate, or uncertain. RESULTS: Using the 2007 AUC, 86% of echocardiographic examinations were classified as appropriate. One percent had indications that were inappropriate, and there were no uncertain indications. Thirteen percent of studies were ordered for reasons not defined by the 2007 AUC. The most common appropriate indications were symptoms due to suspected cardiac etiology, initial evaluation after acute myocardial infarction, and acute chest pain with suspected myocardial ischemia. When evaluated using the 2011 AUC, appropriate and inappropriate indications increased to 97% and 2%, respectively. Ninety-three percent of undefined studies, using the 2007 AUC, could be classified using the 2011 guidelines. CONCLUSIONS: Consistent with studies conducted at university hospitals, Danbury Hospital, a regional hospital, showed good adherence to the AUC. This suggests that the AUC are valuable across a large continuum of inpatient settings and can serve as an excellent guide for utilization and appropriateness.

UV sensitive mutations in histone H3 in Saccharomyces cerevisiae that alter specific K79 methylation states genetically act through distinct DNA repair pathways.

Chromatin serves as a regulator of various nuclear processes, with post-translational modifications of histone proteins serving as modulators to influence chromatin function. We have previously shown that histone H3 K79 methylation is important for repair of UV-induced DNA damage in Saccharomyces cerevisiae, acting through multiple repair pathways. To evaluate the potential role of distinct K79 methylation states in DNA repair, we identified four mutations in histone H3 that confer sensitivity to UV, each of which also has a distinct effect on specific K79 methylation states. Epistasis analyses indicate that each mutation exerts its phenotypic effects through distinct subsets of the various DNA damage response pathways, suggesting the existence of discrete roles for histone H3 in DNA damage checkpoint and repair pathways. Furthermore, we find that the distribution of K79 methylation states is altered by mutation of the acetylatable N terminal lysines in histone H4. The combined results suggest that K79 methylation states may be modulated in response to UV damage via a trans-histone regulatory pathway, and that distinct methylation states may provide a means of coordinating specific DNA repair and damage checkpoint pathways.

Methylation of histone H3 lysine-79 by Dot1p plays multiple roles in the response to UV damage in Saccharomyces cerevisiae.

Various proteins have been found to play roles in both the repair of UV damaged DNA and heterochromatin-mediated silencing in the yeast Saccharomyces cerevisiae. In particular, factors that are involved in the methylation of lysine-79 of histone H3 by Dot1p have been implicated in both processes, suggesting a bipartite function for this modification. We find that a dot1 null mutation and a histone H3 point mutation at lysine-79 cause increased sensitivity to UV radiation, suggesting that lysine-79 methylation is important for efficient repair of UV damage. Epistasis analysis between dot1 and various UV repair genes indicates that lysine-79 methylation plays overlapping roles within the nucleotide excision, post-replication and recombination repair pathways, as well as RAD9-mediated checkpoint function. In contrast, epistasis analysis with the H3 lysine-79 point mutation indicates that the lysine-to-glutamic acid substitution exerts specific effects within the nucleotide excision repair and post-replication repair pathways, suggesting that this allele only disrupts a subset of the functions of lysine-79 methylation. The overall results indicate the existence of distinct and separable roles of histone H3 lysine-79 methylation in the response to UV damage, potentially serving to coordinate the various repair processes.