Research Spotlight

Ogunfiditimi, F., S. P. Sherry, M. Foote, S. L. Christie, L. P. Shock, J. Cawley and A. Browne (2017). “How electronic health records can unmask the hidden value of pas.” Jaapa 30(6): 1-3.

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The Fee for Value (FFV) Task Force, a subgroup of the American Academy of PAs’ Research and Strategic Initiatives Commission, has examined tools and mechanisms aimed at better clarifying the volume and value of PA work and how that work contributes to improving access to high-quality care. Establishing the value of PAs has been a challenging task for many healthcare providers. Often, PA value has been defined by their clinical productivity, without any clear direction as to what constitutes value versus productivity. The objective of this article is to unmask the value of PAs through the role of electronic health records and highlight PAs’ ability to produce services that are value-oriented and quantifiably productive.

Nasir, J. M., W. Pomeroy, A. Marler, M. Hann, T. Baykaner, R. Jones, R. Stoll, K. Hursey, A. Meadows, J. Walker and S. Kindsvater (2017). “Predicting determinants of atrial fibrillation or flutter for therapy elucidation in patients at risk for thromboembolic events (predate af) study.” Heart Rhythm: 2017 May [Epub ahead of print].

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BACKGROUND: Atrial fibrillation (AF) is the most common clinically significant cardiac rhythm disorder. There is considerable interest in screening for AF, as it is a leading cause of stroke, and oral anticoagulants (OACs) have been shown to significantly reduce the risk of stroke in patients with AF. Improved screening for AF with subsequent treatment may help improve long-term outcomes, but the optimal patient population and screening intensity are unknown. OBJECTIVES: In this study, we prospectively evaluated the use of the CHA2DS2-VASc score for the prediction of new-onset AF using insertable cardiac monitors (ICMs) and examined whether this screening led to the initiation of OAC therapy. METHODS: We enrolled 245 subjects with no history of AF and CHA2DS2-VASc score >/=2 to be screened for AF with an ICM. The ICMs were programmed to record AF episodes >/=6 minutes in duration. Subjects were followed for 18 months with monthly remote interrogations and all events adjudicated by cardiologists. In subjects diagnosed with AF, medical records were reviewed to determine subsequent care. RESULTS: During a mean follow-up of 451 +/- 185 days, the incidence of AF was 22.4% (95% confidence interval 17.2%-27.7%) with a mean time to detection of 141.3 +/- 139.5 days. Among subjects newly diagnosed with AF, 76.4% were prescribed anticoagulation with either a novel OAC (n = 38) or warfarin (n = 4). CONCLUSION: In this large prospective cohort of subjects with CHA2DS2-VASc scores >/=2, 22.4% were newly diagnosed with AF and the majority of these subjects were given OACs, suggesting a potential role of ICMs in AF screening.

Miyazaki, M., K. Miyazaki, K. Chen, Y. Jin, J. Turner, A. J. Moore, R. Saito, K. Yoshida, S. Ogawa, H. R. Rodewald, Y. C. Lin, H. Kawamoto and C. Murre (2017). “The e-id protein axis specifies adaptive lymphoid cell identity and suppresses thymic innate lymphoid cell development.” Immunity 46(5): 818-834.

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Innate and adaptive lymphoid development is orchestrated by the activities of E proteins and their antagonist Id proteins, but how these factors regulate early T cell progenitor (ETP) and innate lymphoid cell (ILC) development remains unclear. Using multiple genetic strategies, we demonstrated that E proteins E2A and HEB acted in synergy in the thymus to establish T cell identity and to suppress the aberrant development of ILCs, including ILC2s and lymphoid-tissue-inducer-like cells. E2A and HEB orchestrated T cell fate and suppressed the ILC transcription signature by activating the expression of genes associated with Notch receptors, T cell receptor (TCR) assembly, and TCR-mediated signaling. E2A and HEB acted in ETPs to establish and maintain a T-cell-lineage-specific enhancer repertoire, including regulatory elements associated with the Notch1, Rag1, and Rag2 loci. On the basis of these and previous observations, we propose that the E-Id protein axis specifies innate and adaptive lymphoid cell fate.

Hargrove, L., L. Kennedy, J. Demieville, H. Jones, F. Meng, S. DeMorrow, W. Karstens, T. Madeka, J. Greene, Jr. and H. Francis (2017). “Bile duct ligation-induced biliary hyperplasia, hepatic injury, and fibrosis are reduced in mast cell-deficient kitw-sh mice.” Hepatology 65(6): 1991-2004.

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Activated mast cells (MCs) release histamine (HA) and MCs infiltrate the liver following bile duct ligation (BDL), increasing intrahepatic bile duct mass (IBDM) and fibrosis. We evaluated the effects of BDL in MC-deficient (KitW-sh ) mice. Wild-type (WT) and KitW-sh mice were subjected to sham or BDL for up to 7 days and KitW-sh mice were injected with cultured mast cells or 1x phosphate-buffered saline (PBS) before collecting serum, liver, and cholangiocytes. Liver damage was assessed by hematoxylin and eosin and alanine aminotransferase levels. IBDM was detected by cytokeratin-19 expression and proliferation by Ki-67 immunohistochemistry (IHC). Fibrosis was detected by IHC, hydroxyproline content, and by qPCR for fibrotic markers. Hepatic stellate cell (HSC) activation and transforming growth factor-beta 1 (TGF-beta1) expression/secretion were evaluated. Histidine decarboxylase (HDC) and histamine receptor (HR) expression were detected by qPCR and HA secretion by enzymatic immunoassay. To evaluate vascular cells, von Willebrand factor (vWF) and vascular endothelial growth factor (VEGF)-C expression were measured. In vitro, cultured HSCs were stimulated with cholangiocyte supernatants and alpha-smooth muscle actin levels were measured. BDL-induced liver damage was reduced in BDL KitW-sh mice, whereas injection of MCs did not mimic BDL-induced damage. In BDL KitW-sh mice, IBDM, proliferation, HSC activation/fibrosis, and TGF-beta1 expression/secretion were decreased. The HDC/HA/HR axis was ablated in sham and BDL KitW-sh mice. vWF and VEGF-C expression decreased in BDL KitW-sh mice. In KitW-sh mice injected with MCs, IBDM, proliferation, fibrosis, and vascular cell activation increased. Stimulation with cholangiocyte supernatants from BDL WT or KitW-sh mice injected with MCs increased HSC activation, which decreased with supernatants from BDL KitW-sh mice. CONCLUSION: MCs promote hyperplasia, fibrosis, and vascular cell activation. Knockout of MCs decreases BDL-induced damage. Modulation of MCs may be important in developing therapeutics for cholangiopathies.

Arpitha Chiruvolu, MD; Kimberly K. Miklis, MSN, NNP-BC; Karen C. Stanzo, MSN; Barbara Petrey, MSN; Chelsey G. Groves, MSN; Kari McCord, BSN; Huanying Qin, MS; Sujata Desai, PhD; Veeral N. Tolia, MD (2017). “Effects of Skin-to-Skin Care on Late Preterm and Term Infants At-Risk for Neonatal Hypoglycemia.” Pediatric Quality and Safety (2017) 2:4;e030.

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Objective: The objective of this study was to evaluate the effects of prolonged skin-to-skin care (SSC) during blood glucose monitoring (12–24 hours) in late preterm and term infants at-risk for neonatal hypoglycemia (NH). Study design: We conducted a retrospective pre- and postintervention study. We compared late preterm and term infants at-risk for NH born in a 1-year period before the SSC intervention, May 1, 2013, to April 30, 2014 (pre-SSC) to at-risk infants born in the year following the implementation of SSC intervention, May 1, 2014, to April 30, 2015 (post-SSC). Results: The number of hypoglycemia admissions to neonatal intensive care unit among at-risk infants for NH decreased significantly from 8.1% pre-SSC period to 3.5% post-SSC period (P = 0.018). The number of infants receiving intravenous dextrose bolus in the newborn nursery also decreased significantly from 5.9% to 2.1% (P = 0.02). Number of infants discharged exclusively breastfeeding increased from 36.4% to 45.7%, although not statistically significant (P = 0.074). Conclusion: This SSC intervention, as implemented in our hospital, was associated with a significant decrease in newborn hypoglycemia admissions to neonatal intensive care unit. The SSC intervention was safe and feasible with no adverse events.