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Peridomestic exposure to Borrelia burgdorferi-infected Ixodes scapularis nymphs is considered the dominant means of infection with black-legged tick-borne pathogens in the eastern United States. Population level studies have detected a positive association between the density of infected nymphs and Lyme disease incidence. At a finer spatial scale within endemic communities, studies have focused on individual level risk behaviors, without accounting for differences in peridomestic nymphal density. This study simultaneously assessed the influence of peridomestic tick exposure risk and human behavior risk factors for Lyme disease infection on Block Island, Rhode Island. Tick exposure risk on Block Island properties was estimated using remotely sensed landscape metrics that strongly correlated with tick density at the individual property level. Behavioral risk factors and Lyme disease serology were assessed using a longitudinal serosurvey study. Significant factors associated with Lyme disease positive serology included one or more self-reported previous Lyme disease episodes, wearing protective clothing during outdoor activities, the average number of hours spent daily in tick habitat, the subject’s age and the density of shrub edges on the subject’s property. The best fit multivariate model included previous Lyme diagnoses and age. The strength of this association with previous Lyme disease suggests that the same sector of the population tends to be repeatedly infected. The second best multivariate model included a combination of environmental and behavioral factors, namely hours spent in vegetation, subject’s age, shrub edge density (increase risk) and wearing protective clothing (decrease risk). Our findings highlight the importance of concurrent evaluation of both environmental and behavioral factors to design interventions to reduce the risk of tick-borne infections.

Background Single-site studies have demonstrated inadequate quality of discharge summaries in timeliness, transmission and content, potentially contributing to adverse outcomes. However, degree of hospital-level variation in discharge summary quality for patients hospitalized with heart failure (HF) is uncertain. Methods and Results We analyzed discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) study. We assessed hospital-level performance on timeliness (fraction of summaries completed on the day of discharge), documented transmission to the follow-up physician, and content (presence of components suggested by the Transitions of Care Consensus Conference (TOCCC)). We obtained 1,501 discharge summaries from 1,640 (91.5%) patients discharged alive from 46 hospitals. Among hospitals contributing 10 or more summaries, the median hospital dictated 69.2% of discharge summaries on the day of discharge (range: 0.0–98.0%, p<0.001); documented transmission of 33.3% of summaries to the follow-up physician (range: 0.0–75.7%, p<0.001); and included 3.6/7 TOCCC elements (range: 2.9–4.5, p<0.001). Hospital course was typically included (97.2%), but summaries were less likely to include discharge condition (30.7%), discharge volume status (16.0%) or discharge weight (15.7%). No discharge summary included all seven TOCCC-endorsed content elements, was dictated on the day of discharge, and was sent to a follow-up physician. Conclusions Even at the highest performing hospital, discharge summary quality is insufficient in terms of timeliness, transmission and content. Improvements in all aspects of discharge summary quality are necessary to enable the discharge summary to serve as an effective transitional care tool.

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Background: This study was designed to estimate the costs of index hospitalizations after cardiac arrest in the United States. Methods and Results: We used the US Nationwide Inpatient Sample (2003–2012) to identify patients with cardiac arrest. Log transformation of inflation-adjusted cost was determined for care to patient outcomes. Overall, an estimated 1 387 396 patients were hospitalized after cardiac arrest. The mean age of the cohort was 66 years, 45% were women, and the majority were white. Inpatient procedures included coronary angiography (15%), percutaneous coronary intervention (7%), intra-aortic balloon pump (4.4%), therapeutic hypothermia (1.1%), and mechanical circulatory support (0.1%). The rates of therapeutic hypothermia increased from zero in 2003 to 2.7% in 2012 ( P <0.001). Both hospital charges and inflation-adjusted cost increased linearly over time. In a multivariate analysis, predictors of inflation-adjusted cost included large hospital size, urban teaching hospital, and length of stay. Among comorbidities, atrial fibrillation or fluid and electrolytes imbalance was most associated with cost. Among selected interventions, the cost was significantly increased with automatic implantable cardioverter defibrillators (odds ratio, 1.83; P <0.001), intra-aortic balloon pump (odds ratio, 1.50; P <0.001), hypothermia (odds ratio, 1.28; P <0.001), and extracorporeal membrane oxygenation (odds ratio, 2.38; P <0.001). Conclusions: In the period between 2003 and 2012, postcardiac arrest hospitalizations resulted in a steady rise in associated health care cost, likely related to increased length of stay, medical procedures, and systems of care. Although targeted cost containment for postarrest interventions may reduce the finance burden, there is an increasing need for funding research into prediction and prevention of cardiac arrest, which offers greater societal benefit.

Increased concentrations of inflammatory markers (IL-2 and anti-HSP60) are associated with an increased CAC at baseline and follow-up in healthy asymptomatic adults. Future studies should be carried out to assess its association with early development of atherosclerosis.

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Background Hospitalists are key providers of care to medical inpatients, and sign-out is an integral part of providing safe, high quality inpatient care. There is little known about hospitalist-to-hospitalist sign-out. Objective To evaluate the quality of hospitalist/physician-extender sign-outs by assessing how well the sign-out prepares the night team for overnight events and to determine attributes of effective sign-out. Design Analysis of a written-only sign-out protocol on a non-teaching hospitalist service using prospective data collected by attending physician survey during overnight shifts. Setting Yale-New Haven Hospital (YNHH), a 966-bed, urban, academic medical center in New Haven, CT with approximately 13,700 hospitalist discharges annually. Results We recorded 124 inquiries about 96 patients during 6 days of data collection in 2012. Hospitalists referenced the sign-out for 89 (74%) inquiries, and the sign-out was considered sufficient in isolation to respond to 27 (30%) of these inquiries. Hospitalists physically saw the patient for 14 (12%) of inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety-five (77%) of inquiries were considered to be “somewhat” or “very” clinically important by the hospitalist. Conclusions Overall, we found that attending hospitalists rely heavily on written sign-out to address overnight inquiries, but that those sign-outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign-out is needed to help improve the safety of overnight care.