Use of Pulmonary Rehabilitation After COPD Hospitalization: An Analysis of Statewide Patient and Hospital Data.

RATIONALE: Pulmonary rehabilitation (PR) is a clinically and cost-effective outpatient treatment for COPD that remains highly underutilized. Existing analyses of PR utilization patterns have been largely focused on patient characteristics, however hospital level analysis is lacking, and is needed to inform interventions aimed at improving utilization after COPD hospitalization. OBJECTIVE: To evaluate PR utilization across hospitals after COPD hospitalization in the state of Michigan, with the goal of characterizing hospital level variation and identifying the characteristics of high-performing hospitals. METHODS: This is a retrospective study of patients with a COPD hospitalization between 1/1/18 and 12/31/21 using claims data from the Michigan Value Collaborative (MVC) and hospital data from the American Hospital Association annual survey. Our primary outcome was initiation of PR within 30 days of discharge. Chi-square tests and ANOVA were used to test for differences in patient and hospital covariates. Multilevel logistic regression was used to analyze associations between patient covariates and the primary outcome, and to characterize hospital level variation. RESULTS: A total of 36,389 patients and 99 hospitals were included in the analysis. The majority of patients were older than 65 years of age, female, White, and Medicare fee-for-service insured. The rate of PR initiation within 30 days after hospitalization was 0.8%. Adjusted rates of PR initiation by hospital ranged from 0.4-2.0%. Compared to the set reference groups, being female, in the 5th Distressed Community Index quintile, and being older than 85 years of age independently decreased the odds of initiating PR. Some variation in initiation rate was attributed to the hospital level (7% ICC 0.07, 95% CI 0.03-0.15). The median odds ratio was 1.6 for PR initiation by hospital. CONCLUSIONS: Rates of PR initiation after COPD hospitalization are universally low across all hospitals, though there is some variation. Interventions targeted at patients alone are not sufficient to improve utilization. Hospital-based strategies to improve PR utilization after discharge, adapted from those being successfully used with cardiac rehabilitation, should be further explored.

Repeat crossclamp after failed initial degenerative mitral valve repair is safe and successful.

Objective: Surgical risk and long-term outcomes when re-crossclamp is required during degenerative mitral valve repair are unknown. We examined the outcomes of patients who required re-crossclamp for mitral valve reintervention. Methods: Adults undergoing mitral valve repair for degenerative mitral valve disease at a single center from 2007 to 2021 who required more than 1 crossclamp for mitral valve reintervention were included. Outcomes including major morbidity and 30-day mortality were collected. Kaplan-Meier analysis characterized survival and freedom from recurrent mitral regurgitation. Results: A total of 69 patients required re-crossclamp for mitral valve reintervention. Of those, 72% (n = 50) underwent successful re-repair and the remaining underwent mitral valve replacement (28%, n = 19). Major morbidity occurred in 23% (n = 16). There was no 30-day mortality, and median long-term survival was 10.9 years for those undergoing re-repair and 7.2 years for those undergoing replacement (P = .79). Midterm echocardiography follow-up was available for 67% (33/50) of patients who were successfully re-repaired with a median follow-up of 20 (interquartile range, 7-37) months. At late follow-up, 90% of patients had mild or less mitral regurgitation. Of those re-repaired, 2 patients later required mitral valve reintervention. Conclusions: Patients requiring re-crossclamp for residual mitral regurgitation had low perioperative morbidity and no mortality. Most patients underwent successful re-repair (vs mitral valve replacement) with excellent valve function and long-term survival. In the event of unsatisfactory repair at the time of mitral valve repair, attempt at re-repair is safe and successful with the appropriate valvar anatomy.

Subpopulations of M-MDSCs from mice infected by an immunodeficiency-causing retrovirus and their differential suppression of T- vs B-cell responses.

Monocytic (CD11b(+)Ly6G(±/Lo)Ly6C(+)) myeloid derived suppressor cells (M-MDSCs) expand following murine retroviral LP-BM5 infection and suppress ex vivo polyclonal T-cell and B-cell responses. M-MDSCs 3 weeks post LP-BM5 infection have decreased suppression of T-cell, but not B-cell, responses and alterations in the degree of iNOS/NO dependence of suppression. M-MDSCs from LP-BM5 infected mice were sorted into four quadrant populations (Ly6C/CD11b density): all quadrants suppressed B-cell responses, but only M-MDSCs expressing the highest levels of Ly6C and CD11b (Q2) significantly suppressed T-cell responses. Further subdivision of this Q2 population revealed the Ly6C(+/Hi) M-MDSC subpopulation as the most suppressive, inhibiting T- and B-cell responses in a full, or partially, iNOS/NO-dependent manner, respectively. In contrast, the lower/moderate levels of suppression by the Ly6C(+/Lo) and Ly6C(+/Mid) M-MDSC Q2 subpopulations, whether versus T- and/or B-cells, displayed little/no iNOS dependency for suppression. These results highlight differential phenotypic and functional immunosuppressive M-MDSC subsets in a retroviral immunodeficiency model.