Medical and social determinants of health as predictors of adverse outcomes in patients with inflammatory bowel disease.

There is a growing recognition that social determinants of health (SDOH) influence outcomes in patients with chronic diseases. This study aimed to investigate the influence of SDOH on outcomes in patients with inflammatory bowel disease (IBD). We conducted a retrospective cohort study of adult patients with IBD from 1996 to 2019. Patients were identified using ICD-10 codes for ulcerative colitis and Crohn's disease, and chart review was performed to validate the diagnosis and extract clinical information. SDOH factors including food security, financial resources, and transportation were self-reported by the patient. Random forest models were trained and tested in R to predict either IBD-related hospitalization or surgery. A total of 175 patients were studied, and the majority reported no financial resource, food security, or transportation concerns. For the model using clinical predictors, the sensitivity was 0.68 and specificity was 0.77 with an area under the receiver operating characteristic curve (AUROC) of 0.77. The model's performance did not significantly improve with the addition of SDOH information (AUROC of 0.78); however, model performance did vary by phenotype (AUROC of 0.86 for patients with Crohn's disease and AUROC of 0.68 for patients with ulcerative colitis). Further research is needed to understand the role of SDOH factors and IBD-related outcomes.

Electronic health records and resident workflow: a time-motion study of otolaryngology residents.

OBJECTIVES/HYPOTHESIS: To evaluate the impact of electronic health records (EHRs) on the workflow of otolaryngology residents. STUDY DESIGN: Prospective, time-motion study. METHODS: A time-motion study was conducted both in the 2009 to 2010 and 2012 to 2013 postgraduate years. Eight otolaryngology residents were directly observed on both operative and clinic days, with resident activities categorized by way of a database program. Comparisons were made to the same data collected in the same setting prior to and following integration of an EHR system. RESULTS: Residents spent their day on direct patient care (41.1%), indirect patient care (35.3%), didactic education (14.0%), personal activities (6.9%), and transit (3.1%). The primary activity during operative days was direct patient care, and during clinic days it was indirect patient care. Activities of marginal educational value comprised a considerable component of their time (16.5%). Compared to data collected prior to use of an EHR, time was spent similarly. However, residents using an EHR devoted significantly more time to indirect patient care on clinic days (P < .05). CONCLUSIONS: This is the first study to evaluate EHR integration on otolaryngology resident workflow. Overall resident efficiency was not significantly altered by the implementation of an EHR. However, more time was shifted from directly caring for patients to documenting on the EHR in the clinic setting. These findings provide an important objective insight into EHRs, especially given the looming mandate for their use and the need to streamline resident curriculum in the duty hours era.

Prostaglandin E2 protects lower airways against bronchoconstriction.

Prostaglandin E2 (PGE2), similar to beta-adrenergic receptor agonists, can protect airways from bronchoconstriction and resulting increase in airway resistance induced by a number of agents, including cholinergic receptor agonists and antigen. We examined the impact of sustained alterations in PGE2 pathways on changes in airway resistance. Genetic methods were utilized to alter PGE2 metabolism and signal transduction in the murine lung. PGE2 levels were elevated by generating mice lacking 15-hydroxyprostaglandin (Hpgd-/-), the major catabolic enzyme of PGE2, and by generating a transgenic line in which mouse PGE2 synthase (Ptges) expression is driven by a human lung-specific promoter, hSP-C. Conversely, to determine the impact of loss of PGE2 on airway reactivity, we examined mice lacking this synthase (Ptges-/-) and receptors that mediate the actions of PGE2, particularly the PGE2 EP2 receptor (Ptger2). Diminished capacity to produce and respond to PGE2 did not alter the response of mice to cholinergic stimuli. In contrast, the responsiveness to cholinergic stimulation was dramatically altered in animals with elevated PGE2 levels. The Hpgd-/- and hSP-C-Ptges transgenic lines both showed attenuated airway responsiveness to methacholine as measured by lung resistance. Thus, whereas compromise of the Ptges/PGE2/Ptger2 pathway does not alter airway responsiveness, genetic modulation that elevates PGE2 levels in the lung attenuates airway responsiveness.

Transcellular biosynthesis contributes to the production of leukotrienes during inflammatory responses in vivo.

Leukotrienes are lipid mediators that evoke primarily proinflammatory responses by activating receptors present on virtually all cells. The production of leukotrienes is tightly regulated, and expression of 5-lipoxygenase, the enzyme required for the first step in leukotriene synthesis, is generally restricted to leukocytes. Arachidonic acid released from the cell membrane of activated leukocytes is rapidly converted to LTA(4) by 5-lipoxygenase. LTA(4) is further metabolized to either LTC(4) or LTB(4) by the enzyme LTC(4) synthase or LTA(4) hydrolase, respectively. Unlike 5-lipoxygenase, these enzymes are expressed in most tissues. This observation previously has led to the suggestion that LTA(4) produced by leukocytes may, in some cases, be delivered to other cell types before being converted into LTC(4) or LTB(4). While in vitro studies indicate that this process, termed transcellular biosynthesis, can lead to the production of leukotrienes, it has not been possible to determine the significance of this pathway in vivo. Using a series of bone marrow chimeras generated from 5-lipoxygenase- and LTA(4) hydrolase-deficient mice, we show here that transcellular biosynthesis contributes to the production of leukotrienes in vivo and that leukotrienes produced by this pathway are sufficient to contribute significantly to the physiological changes that characterize an ongoing inflammatory response.