The association of preoperative cardiac stress testing with 30-day death and myocardial infarction among patients undergoing kidney transplantation.

BACKGROUND: Although periodic cardiac stress testing is commonly used to screen patients on the waiting list for kidney transplantation for ischemic heart disease, there is little evidence to support this practice. We hypothesized that cardiac stress testing in the 18 months prior to kidney transplantation would not reduce postoperative death, total myocardial infarction (MI) or fatal MI. METHODS: Using the United States Renal Data System, we identified ESRD patients ≥40 years old with primary Medicare insurance who received their first kidney transplant between 7/1/2006 and 11/31/2013. Propensity matching created a 1:1 matched sample of patients with and without stress testing in the 18 months prior to kidney transplantation. The outcomes of interest were death, total (fatal and nonfatal) MI or fatal MI within 30 days of kidney transplantation. RESULTS: In the propensity-matched cohort of 17,304 patients, death within 30 days occurred in 72 of 8,652 (0.83%) patients who underwent stress testing and in 65 of 8,652 (0.75%) patients who did not (OR 1.07; 95% CI: 0.79-1.45; P = 0.66). MI within 30 days occurred in 339 (3.9%) patients who had a stress test and in 333 (3.8%) patients who did not (OR 1.03; 95% CI: 0.89-1.21; P = 0.68). Fatal MI occurred in 17 (0.20%) patients who underwent stress testing and 15 (0.17%) patients who did not (OR 0.97; 95% CI: 0.71-1.32; P = 0.84). CONCLUSION: Stress testing in the 18 months prior to kidney transplantation is not associated with a reduction in death, total MI or fatal MI within 30 days of kidney transplantation.

Patients Commonly Believe Their Heart Failure Hospitalizations Are Preventable and Identify Worsening Heart Failure, Nonadherence, and a Knowledge Gap as Reasons for Admission.

BACKGROUND: There are few data describing patient-identified precipitants of heart failure (HF) hospitalization. We hypothesized a patient's perception of reason for or preventability of an admission may be related to 30-day readmission rates. METHODS AND RESULTS: Ninety-four patients admitted with decompensated HF from July 2014 to March 2015 completed a brief questionnaire regarding circumstances leading to admission. Thirty-day outcomes were assessed via telephone call and chart review. Mean age was 58 ± 14 years, with 60% blacks (n = 56) and 41% females (n = 39). Median left ventricular ejection fraction was 30%; 27 had preserved ejection fraction. Seventy-two patients identified their hospitalization to be due to HF (± another condition). Most common patient-identified precipitants of admission were worsening HF (n = 37) and dietary nonadherence (n = 11). Readmitted patients tended to have longer time until first follow-up appointment (21 vs 8 days). Seven of the 42 patients who identified their hospitalization as preventable were readmitted compared with 21/49 who believed their hospitalization was unpreventable (P = .012). On multivariate regression analysis, patients who thought their hospitalization was preventable were less likely to be readmitted (odds ratio 0.31; 95% confidence interval 0.10-0.91; P = .04). CONCLUSION: Almost 50% of patients believe their HF hospitalization is preventable, and these patients appear to be less likely to be readmitted within 30 days. Notably, patients cite nonadherence and lack of knowledge as reasons hospitalizations are preventable. These results lend insight into possible interventions to reduce HF readmissions.

Outcomes and predictors of recovery in acute-onset cardiomyopathy: A single-center experience of patients undergoing endomyocardial biopsy for new heart failure.

BACKGROUND: About one-third of patients with unexplained acute-onset heart failure (HF) recover left ventricular (LV) function; however, characterization of these patients in the setting of contemporary HF therapies is limited. We aim to describe baseline characteristics and predictors of recovery in patients with acute-onset cardiomyopathy. METHODS: We previously described 851 patients with unexplained HF undergoing endomyocardial biopsy. In this study, 235 patients with acute-onset HF were further retrospectively examined. RESULTS: Follow-up LV ejection fraction (LVEF) was available for 138 patients. At 1 year, 48 of 138 (33%) had LVEF recovery (follow-up LVEF ≥50%), and 90 of 138 (65%) had incomplete or lack of recovery. Higher cardiac index (P=.019), smaller LV diastolic diameter (P=.002), and lack of an intraventricular conduction delay (IVCD) (P=.002) were associated with LVEF recovery. IVCD (P=.001) and myocarditis (P=.016) were independent predictors of the composite end point of death, LV assist device placement, and/or transplant at 1 year. Those with an IVCD had a significantly lower 1-year survival than those without (P=.007). CONCLUSIONS: Patients with a smaller LV end-diastolic diameter, higher cardiac index, and lack of IVCD at presentation for acute-onset HF were more likely to have LVEF recovery. IVCD was a poor prognostic marker in all patients presenting with acute cardiomyopathy.

Automatic scoring of medical students' clinical notes to monitor learning in the workplace.

BACKGROUND: Educators need efficient and effective means to track students' clinical experiences to monitor their progress toward competency goals. AIM: To validate an electronic scoring system that rates medical students' clinical notes for relevance to priority topics of the medical school curriculum. METHOD: The Vanderbilt School of Medicine Core Clinical Curriculum enumerates 25 core clinical problems (CCP) that graduating medical students must understand. Medical students upload clinical notes pertinent to each CCP to a web-based dashboard, but criteria for determining relevance of a note and consistent uploading practices by students are lacking. The Vanderbilt Learning Portfolio (VLP) system automates both tasks by rating relevance for each CCP and uploading the note to the student's electronic dashboard. We validated this electronic scoring system by comparing the relevance of 265 clinical notes written by third year medical students to each of the 25 core patient problems as scored by VLP verses an expert panel of raters. RESULTS: We established the threshold score which yielded 75% positive prediction of relevance for 16 of the 25 clinical problems to expert opinion. DISCUSSION: Automated scoring of student's clinical notes provides a novel, efficient and standardized means of tracking student's progress toward institutional competency goals.

Development and validation of the General Health Numeracy Test (GHNT).

OBJECTIVE: Because existing numeracy measures may not optimally assess 'health numeracy', we developed and validated the General Health Numeracy Test (GHNT). METHODS: An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity. RESULTS: On average, participants were 55.0 ± 13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39K with 14.4 ± 2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20=0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p<.001). Furthermore, both versions were associated with participants' understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses. CONCLUSIONS: The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy. PRACTICE IMPLICATIONS: Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients.

Filamin A mutant lacking actin-binding domain restores mu opioid receptor regulation in melanoma cells.

We have previously reported that the protein filamin A (FLA) binds to the carboxyl tail of the mu opioid receptor (MOPr). Using human melanoma cells, which do not express filamin A, we showed that receptor down-regulation, functional desensitization and trafficking are deficient in the absence of FLA (Onoprishvili et al. Mol Pharmacol 64:1092-1100, 2003). Since FLA has a binding domain for actin and is a member of the family of actin cytoskeleton proteins, it is usually assumed that FLA functions via the actin cytoskeleton. We decided to test this hypothesis by preparing cDNA coding for mutant FLA lacking the actin binding domain (FLA-ABD) and expressing FLA-ABD in the human melanoma cell line M2 (M2-ABD cell line). We report here that this mutant is capable of restoring almost as well as full length FLA the down-regulation of the human MOPr. It is similarly very effective in restoring functional desensitization of MOPr, as assessed by the decrease in G-protein activation after chronic exposure of M2-ABD cells to the mu agonist DAMGO. We also found that A7 cells, expressing wild type FLA, exhibit rapid activation of the MAP kinases, ERK 1 and 2, by DAMGO, as shown by a rise in the level of phospho-ERK 1 and 2. This is followed by rapid dephosphorylation (inactivation), which reaches basal level between 30 and 60 min after DAMGO treatment. M2 cells show normal activation of ERK 1 and 2 in the presence of DAMGO, but very slow inactivation. The rapid rate of MAPK inactivation is partially restored by FLA-ABD. We conclude that some functions of FLA do not act via the actin cytoskeleton. It is likely that other functions, not studied here, may require functional binding of the MOPr-FLA complex to actin.