• We evaluated a cohort of ARL samples for known and novel tumor viruses, revealing the oncogenic herpesvirus EBV as the sole detected infectious agent.• Heterogeneous viral gene expression suggests that variable host immunosurveillance of EBV latency may influence lymphomagenesis.Immunodeficiency dramatically increases susceptibility to cancer as a result of reduced immune surveillance and enhanced opportunities for virus-mediated oncogenesis. Although AIDS-related lymphomas (ARLs) are frequently associated with known oncogenic viruses, many cases contain no known transforming virus. To discover novel transforming viruses, we profiled a set of ARL samples using whole transcriptome sequencing. We determined that Epstein-Barr virus (EBV) was the only virus detected in the tumor samples of this cohort, suggesting that if unidentified pathogens exist in this disease, they are present in <10% of cases or undetectable by our methods. To evaluate the role of EBV in ARL pathogenesis, we analyzed viral gene expression and found highly heterogeneous patterns of viral transcription across samples. We also found significant heterogeneity of viral antigen expression across a large cohort, with many patient samples presenting with restricted type I viral latency, indicating that EBV latency proteins are under increased immunosurveillance in the post-combined antiretroviral therapies era. Furthermore, EBV infection of lymphoma cells in HIV-positive individuals was associated with a distinct host gene expression program. These findings provide insight into the joint host-virus regulatory network of primary ARL tumor samples and expand our understanding of virus-associated oncogenesis. Our findings may also have therapeutic implications, as treatment may be personalized to target specific viral and virus-associated host processes that are only present in a subset of patients. (Blood. 2015;125(20):e14-e22)
ImportancePosthospital contact with a primary care team is an established pillar of safe transitions. The prevailing model of telephone outreach is usually limited in scope and operationally burdensome.ObjectiveTo determine whether a 30-day automated texting program to support primary care patients after hospital discharge is associated with reductions in the use of acute care resources.Design, Setting, and ParticipantsThis cohort study used a difference-in-differences approach at 2 academic primary care practices in Philadelphia from January 27 through August 27, 2021. Established patients of the study practices who were 18 years or older, were discharged from an acute care hospitalization, and received the usual transitional care management telephone call were eligible for the study. At the intervention practice, 604 discharges were eligible and 430 (374 patients, of whom 46 had &gt;1 discharge) were enrolled in the intervention. At the control practice, 953 patients met eligibility criteria. The study period, including before and after the intervention, ran from August 27, 2020, through August 27, 2021.ExposurePatients received automated check-in text messages from their primary care practice on a tapering schedule during the 30 days after discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox.Main Outcomes and MeasuresThe primary study outcome was any emergency department (ED) visit or readmission within 30 days of discharge. Secondary outcomes included any ED visit or any readmission within 30 days, analyzed separately, and 30- and 60-day mortality. Analyses were based on intention to treat.ResultsA total of 1885 patients (mean [SD] age, 63.2 [17.3] years; 1101 women [58.4%]) representing 2617 discharges (447 before and 604 after the intervention at the intervention practice; 613 before and 953 after the intervention at the control practice) were included in the analysis. The adjusted odds ratio (aOR) for any use of acute care resources after implementation of the intervention was 0.59 (95% CI, 0.38-0.92). The aOR for an ED visit was 0.77 (95% CI, 0.45-1.30) and for a readmission was 0.45 (95% CI, 0.23-0.86). The aORs for death within 30 and 60 days of discharge at the intervention practice were 0.92 (95% CI, 0.23-3.61) and 0.63 (95% CI, 0.21-1.85), respectively.Conclusions and RelevanceThe findings of this cohort study suggest that an automated texting program to support primary care patients after hospital discharge was associated with significant reductions in use of acute care resources. This patient-centered approach may serve as a model for improving postdischarge care.
Objective To examine the effect of the COVID-19 pandemic on post-acute care utilization and spending. Design We used a large national multi-payer claims dataset from January 2019 through October 2020 to examine trends in post-hospital-discharge location and spending Setting and participants We identified and included 975,179 hospital discharges who were 65 years or older. Methods We summarized post-discharge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for selfcare and to the three common post-acute care locations: home with home health, skilled nursing facility (SNF) and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the three post-acute care settings. Results The percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic while the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the three post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31% while the percentage of post-acute care spending on home health and inpatient rehabilitation both increased. Conclusions and Implications Changes in post-hospital-discharge location of care represent a significant shift in post-acute care utilization, which persisted nine months into the pandemic. These shifts could have profound implications on the future of post-acute care.
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