The Digital Transformation of a Metropolitan New York Health System

SUMMARY

Digital transformation strategies in healthcare are presenting unique ways to support patient acquisition and retention efforts. Montefiore Health System is on a multiyear, multipronged digital transformation journey with interventions centered on improving access to care.Our patients can search for a provider, schedule a visit, get details about their visit, and check in through a welcoming digital front door. Asynchronous e-communication and video visits have also been implemented, and these added options are optimized by technologies including a new provider data management tool to support an enhanced provider directory, electronic health record system integration with online scheduling, telehealth/virtual care, and text message communications. Combined, these tactics support a positive patient experience. Happier patients are more likely to return for the care they need to improve their health and maintain wellness. In addition, digital solutions can alleviate administrative burdens, which can improve employee engagement and satisfaction.While the lack of access to technology as a social determinant of health can present challenges in our diverse market, Montefiore has developed a respectful process to meet patients where they are in an era of consumer-driven healthcare. The process sets forth various approaches to bridge healthcare's digital divide. The route is sequenced in a digital transformation road map to ensure that Montefiore remains competitive, provides value with operational efficiencies, and delivers the innovative care that is necessary in today's healthcare landscape.

Electronic Health Record Usage Patterns: Assessing Telemedicine's Impact on the Provider Experience During the COVID-19 Pandemic

Telemedicine has been widely implemented during the coronavirus disease 2019 (COVID-19) pandemic; however, its impact on those providing care remains largely understudied. Provider documentation data collected by the electronic health record (EHR) represents an underutilized tool for assessing the provider experience. Through Epic Signal, we collected data regarding the actions logged in the EHR by health care providers of the Montefiore Health System (Bronx, NY) before and after the implementation of telemedicine during the pandemic. Focusing on five metrics (appointments per day, visits closed same day, time spent outside 7 AM-7 PM, time spent on unscheduled days, and pajama time), we performed a preliminary analysis of providers across the institution, by specialty, and according to demographic characteristics such as gender and years since graduation. We observed that after telemedicine implementation, a greater proportion of providers had fewer appointments per day, closed more notes same day, and spent less time in the EHR outside of normal working hours for each of the time-related metrics. We additionally found that providers who graduated longer ago as well as female providers spent more time documenting in the EHR after hours. This brief analysis highlights the potential of using EHR data to inform decisions based on provider well-being, specifically in the setting of telemedicine implementation.

THU0343 AUTOANTIBODIES CAN PARTLY PREDICT SEVERITY OF DAMAGE BUT NOT EXTENT IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOSITIS

Background:

Patients with idiopathic inflammatory myopathies (IIM) might suffer from irreversible damage once inflammation has decreased. Autoantibodies are found in up to 80% of patients with IIM and are coupled with specific clinical features. Whether autoantibodies can be used as biomarkers to predict patterns of damage in IIM remains unknown.

Objectives:

To investigate the association between autoantibodies and organ damage in patients with IIM using longitudinal national register data.

Methods:

Data were retrieved from the electronic Swedish Rheumatology Quality Register (SRQ). Patients (n=302) with a clinical diagnosis of IIM (2017 EULAR/ACR criteria) were included. Autoantibody status was tested by either line blot or RNA- and protein immunoprecipitation; HMGCR and FHL-1 autoantibodies were tested by ELISA. Patients were grouped into six categories of autoantibodies (Table 1). TheMyositis Damage Index(MDI) score was applied to measure organ damage using both components (extentandseverity) as a continuous variable and were analyzed using generalized estimating equations (GEE). A categorical variable for each time point of MDI assessment since diagnosis was created to adjust for time (Table 2). A base model which included autoantibody group and time was fit. Other potential predictors included age at diagnosis, sex, disease duration from diagnosis to inclusion to SRQ, arthritis, Raynaud, mechanics’ hands and heart involvement at registry; core set measures at each MDI time point allowing multiple longitudinal observations were also tested.

Table 1.

Clinical diagnosis and autoantibody groups.

DiagnosisN (%)Polymyositis119 (38)Dermatomyositis (DM)99 (33)Inclusion body myositis35 (12)Amyopathic DM9 (3)Juvenile DM8 (3)Low probability myositis32 (11)Autoantibody286 (%)Antisynthetase (AS)74 (26)Necrotizing myopathy NM)20 (7)DM- specific44 (15)FHL-118 (6)Associated antibodies AA)50 (18)Negative to any80 (28)

AS: Jo1, PL7, PL12, EJ, OJ;NM: SRP, HMGCR;DM-specific: TIF1γ, Mi2, MDA5, SAE;AA: Ro52, PmScl, U1RNP, KU.

Table 2.

Predictors of damage severity and extent.

EstimateP valueSeverityTime#0.20NSAutoantibody group1Negativereference--Antisynthetase-0.6NSIMNM1.6NSDM- specific-2.6**FHL-10.4NSAssociated0.7NSMMT score1-0.1***ExtentTime#0.33NSCK, mkat/L2-0.006*

#Time from diagnosis to MDI. *<0.05**<0.01***<0.001

1. Adjusted for gender + disease duration + time.

2. Adjusted for disease duration + time.

Results:

Mean age at diagnosis was 54 years (SD 16), 205 were female (68%), median disease duration was 4 months (IQR 1-39). Clinical diagnosis and the autoantibody groups are shown in Table 1. The median time from diagnosis to the first MDI assessment was 2.2 years (IQR 1.2 – 5.5), 227 patients had a second MDI assessment at median 4.5 years (3.3-8.6 years) and 114 patients had a third assessment at 7.8 (5.8-9.9) years.Severity of damage:Only the DM-specific autoantibodies (P = 0.01) and manual muscle test score (MMT) (P = 0.007) were independent negative predictors; disease duration was a positive predictor (P = 0.01).Extent of damage: Autoantibodies were not significant predictors; creatine kinase (CK) levels were negative predictors (P = 0.01) (Table 2).

Conclusion:

Presence of DM-specific autoantibodies, a high MMT score over time and short disease duration seem to predict less damage severity whereas high CK levels seem to predict of less extent of damage. These findings indicate that some myositis specific autoantibodies may serve as predictors of damage along with other clinical measures.

References:

[1]Sultan SM, et al. Interrater reliability and aspects of validity of the myositis damage index. Annals of the Rheumatic Diseases. 2011;70:1272-6.

Disclosure of Interests:

Fabricio Espinosa-Ortega: None declared, Marie Holmqvist: None declared, Maryam Dastmalchi: None declared, Andrew Mammen: None declared, Ingrid E. Lundberg Grant/research support from: Bristol Meyer Squibb, Corbus Pharmaceuticals, Inc and Astra Zeneca, Helene Alexanderson: None declared

Effect of hypoxia on expression of selected proteins involved in regulation of apoptotic activity in striatum of newborn piglets

The levels of selected neuroregulatory proteins that inhibit or promote apoptotic cell death were measured in the striatum of piglets subjected to precisely controlled 1 h hypoxic insult followed by 0, 2 and 4 h recovery and compared to sham operated animals. The anti-apoptotic proteins: there were increases in Survivin at 0 (157%, P = 0.031) and 4 h (171%, P = 0.033), in Bcl-XL at 0 (138%, P = 0.028) and 4 h (143%, P = 0.007), in VEGF at 4 h (185%, P = 0.019) and Hsp27 at 2 h (144%, P = 0.05) and 4 h (143%, P = 0.05). The pro-apoptotic proteins: caspases-1 and 7 increased at 4 h (135%, P = 0.05) and (129%, P = 0.038), respectively. Bim increased after 4 h (115%, P = 0.028), Apoptosis Inducing Factor after 2 h (127%, P = 0.048) and Calpain after 4 h (143% of control, P = 0.04). Hypoxia causes increase in levels of both anti- and pro-apoptotic proteins. Their relative activity determines the outcome in terms of cell damage and neuronal deficit.

Early regional response of apoptotic activity in newborn piglet brain following hypoxia and ischemia

Responses of selected neuroregulatory proteins that promote (Caspase 3 and Bax) or inhibit (Bcl-2, high Bcl-2/Bax ratio) apoptotic cell death were measured in the brain of piglets subjected to precisely controlled hypoxic and ischemic insults: 1 h hypoxia (decreasing FiO₂ from 21 to 6%) or ischemia (ligation of carotid arteries and hemorrhage), followed by 0, 2 and 4 h recovery with 21% FiO₂. Protein expression was measured in cortex, hippocampus and striatum by Western blot. There were no significant differences in expression of Caspase-3 between sham operated, hypoxic and ischemic groups. There were significant regional differences in expression of Bcl-2 and Bax in response to hypoxia and ischemia. The changes in Bcl-2/Bax ratio were similar for hypoxia and ischemia except for striatum at zero time recovery, with ischemia giving lower ratios than hypoxia. The Bcl-2/Bax ratio was also lower for the striatum than for the other regions of the brain, suggesting this region is the more susceptible to apoptotic injury.

Infant mortality in an urban slum

OBJECTIVE

Infant and child mortality are important indicators of the level of development of a society, but are usually collected by governmental agencies on a region wide scale, with little local stratification. In order to formulate appropriate local policies for intervention, it is important to know the patterns of morbidity and mortality in children in the local setting.

METHODS

This retrospective study collected and analyzed data on infant mortality for the period 1995 to 2003 in an urban slum area in Vellore, southern India from government health records maintained at the urban health clinic.

RESULTS

The infant mortality rate over this period was 37.9 per 1000 live births. Over half (54.3%) of the deaths occurred in the neonatal period. Neonatal deaths were mainly due to perinatal asphyxia (31.9%), pre-maturity (16.8%) and aspiration pneumonia or acute respiratory distress (16.8%), while infant deaths occurring after the first mth of life were mainly due to diarrheal disease (43%) and respiratory infections (21%).

CONCLUSION

These results emphasize the need to improved antenatal and perinatal care to improve survival in the neonatal period. The strikingly high death rate due to diarrheal illness highlights the requirements for better sanitation and water quality.

Nipple aspirate cytology and pathologic parameters predict residual cancer and nodal involvement after excisional breast biopsy

We previously demonstrated that abnormal nipple aspirate fluid (NAF) cytology predicted residual breast cancer (RC) and tumour size after excisional biopsy (EB), although normal NAF cytology did not exclude RC. Tumour size correlates with the risk of lymph node (LN) metastases. LN metastases provide prognostic information allowing medical and radiation oncologists to determine the need for adjuvant therapy. We hypothesized that pathologic factors known after EB, combined with NAF cytology, would predict with a high degree of accuracy the presence of RC and LN spread. NAF cytology and pathologic parameters: tumour distance from biopsy margins, multifocal and multicentric disease, sub-type of ductal carcinoma in situ (DCIS) or invasive cancer (IC), grade of DCIS or IC, tumour and specimen size, tumour and biopsy cavity location, presence or absence of extensive DCIS, and biopsy scar distance from the nipple were evaluated bivariately and then by logistic regression (LR) for their association with RC and involved LN (> or = 1 (+) LN, useful to determine chemotherapy need, and > or = 4 (+) LN, useful to determine radiation need to the chest and axilla). Data were analysed using NAF cytology alone, pathologic parameters alone, and NAF cytology and pathologic parameters combined. The combined LR model was superior in predicting residual cancer (94%) to LR models using NAF cytology (36%) or pathologic parameters (75%) alone. When only subjects with normal NAF cytology were evaluated by LR, the model was 92% sensitive in predicting RC. Tumour size and NAF cytology predicted which patients had > or = 1 (+) LN, whereas tumour and specimen size predicted which patients had > or = 4 (+) LN. We propose an algorithm which, if confirmed in a larger study, may allow clinicians to be more selective in their recommendations of re-excision breast biopsy or mastectomy.

Rare pancreatic tumours in children (other than nesidioblastosis)

BACKGROUND

The rarity of pancreatic tumours other than nesidioblastosis in children is such that the experience of any one surgeon or institution is small. As a consequence, there is limited information on the appropriate management and outcome of these tumours. For this reason a review was conducted of the experience of a large paediatric surgical institution.

METHODS

During a 23-year period, six patients with pancreatic tumours other than nesidioblastosis were treated at the Royal Children's Hospital, Melbourne.

RESULTS

Despite the varied modes of presentation and surgery undertaken, all six patients with surgery alone, with follow-up from 1 to 18 years. Two of the tumours were malignant; the remaining four being islet cell adenomata. No form of adjuvant treatment (chemotherapy or radiotherapy) was used.

CONCLUSION

These rare paediatric tumours appear to have a good prognosis, even when malignant, and respond well to radical surgical ablation. Adjuvant therapy appears to be unnecessary.

[Change in corneal sensitivity after topical dorzolamide administration. A comparative study]

BACKGROUND

The new antiglaucoma drug, dorzolamide, mainly evokes local side effects like eye burning, pruritus, blurred sight and a foreign-body sensation. A clinical study was conducted to determine it dorzolamide has any influence on corneal sensitivity.

SUBJECTS AND METHODS

We examined three different groups of substances. We used sodium chloride solution 0.9% and the local anesthetic oxybuprocaine 0.4% as control groups, each in two subgroups aged 23-40 years or 60-86 years. Corneal sensitivity was measured in the corneal center with Draeger's electronic optic aesthesiometer. We took the measurements directly before and 1,5,10,15 and 20 min after applying one eye drop.

RESULTS

The control groups with sodium chloride solution showed no significant (P > 0.05) corneal hyposensitivity. The local anesthetic caused corneal asensitivity (P < 0.05) until the 10-min measurement. Twenty minutes after giving the anesthetic, with 12.10(-5) N corneal sensitivity nearly reached the starting value. At this time corneal sensitivity in the older subgroup was still decreased with 627.10(-5) N. In the younger subgroup dorzolamide only caused slight, but significant (P < 0.05), hyposensitivity of the cornea 1 and 5 min after application of the eye drop.

CONCLUSION

Although dorzolamide decreases corneal sensitivity only a little, people with glaucoma using contact lenses should not insert them until at least 15 min after applying the dorzolamide.

Interaction of the N-methyl-D-aspartate receptor complex with a novel synapse-associated protein, SAP102

Ionotropic glutamate receptors are known to cluster at high concentration on the postsynaptic membrane of excitatory synapses, but the mechanism by which this occurs is poorly understood. Studies on the neuromuscular junction and central inhibitory synapses suggest that clustering of neurotransmitter receptors requires its interaction with a cytoplasmic protein. Recently, in vitro studies have shown that members of the N-methyl--aspartate (NMDA) class of glutamate receptors interact with a synapse-associated protein, SAP90 (PSD-95). However, evidence for the in vivo interaction of NMDA receptors with SAPs is still lacking. In the present study, we demonstrate the specific interaction between SAP102, a novel synapse-associated protein, and the NMDA receptor complex from the rat cortical synaptic plasma membranes using co-immunoprecipitation techniques. No association was observed between SAP102 and GluR1, a member of the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate class of glutamate receptors. To identify the domain on the NMDA receptor responsible for this interaction, we constructed hexahistidine fusion proteins from different regions of the NR1a and NR2 subunits of the NMDA receptor. Immunoblot overlay experiments showed that while the C-terminal domain of the NR2 subunit displayed strong binding, the NR1a intracellular C-terminal tail did not interact with SAP102. The site of interaction was more precisely located to the last 20 amino acids of the NR2 subunit as indicated by the interaction of the synthetic peptide with SAP102. In summary, we demonstrate here for the first time an in vivo interaction between the native NMDA receptor complex and a synapse-associated protein. These results suggest that SAP102 may play an important role in NMDA receptor clustering and immobilization at excitatory synapses.

Combination syndrome in relation to osseointegrated implant-supported overdentures: a survey

Thirteen patients who had worn a maxillary conventional denture and mandibular osseointegrated implant-supported overdenture for at least 3 years were evaluated for subjective assessment of fit of the maxillary denture, occlusal integrity, and the status of the anterior maxillary residual ridge. The findings of this study support the view that this combination of prostheses can result in perceived loosening of the maxillary denture, loss of posterior occlusion, increased anterior occlusal pressure, and anterior maxillary bone loss, similar to the effects seen in Combination Syndrome. It is therefore important to ensure that where an implant-supported mandibular overdenture is planned for the edentulous patient, some form of stabilisation of the maxillary arch is also considered.

Neurotransmitter release regulated by nitric oxide in PC-12 cells and brain synaptosomes

BACKGROUND

Nitric oxide is a messenger molecule of the nervous system, which is produced by the enzyme nitric oxide synthase, which may regulate cyclic guanosine monophosphate levels and which has been implicated in the control of neurotransmitter release. PC-12 pheochromocytoma cells differentiate to form neuronal cells in culture when they are exposed to nerve growth factor. The levels of cyclic guanosine monophosphate in the cells and their ability to release acetylcholine in response to K(+)-depolarization are both maximal after eight days of treatment with nerve growth factor. We set out to assess a possible role for nitric oxide in the processes that occur in differentiating PC-12 cells.

RESULTS

Nitric oxide synthase is first evident in differentiating PC-12 cells eight days after beginning treatment with nerve growth factor, coinciding with the marked increase in K(+)-depolarization-induced release of acetylcholine. The release of both acetylcholine and dopamine in response to K(+)-depolarization is blocked by inhibitors of nitric oxide synthase and by hemoglobin, which binds nitric oxide. Providing l-arginine, a precursor required for nitric oxide synthesis, reverses the effects of the inhibitors. In synaptosomal preparations from the corpus striatum, inhibitors of nitric oxide synthase prevent the release of glutamate in response to the glutamate derivative N-methyl-d-aspartate but not in response to K(+)-depolarization.

CONCLUSION

Nitric oxide may mediate the release of acetylcholine and dopamine in response to K(+)-depolarization in PC-12 cells and the release of glutamate in response to N-methyl-d-aspartate in striatal synaptosomes. Nitric oxide synthase expression is induced after eight days of treating PC-12 cells with nerve growth factor, coinciding with a marked enhancement of the release of neurotransmitters in response to K(+)-depolarization.