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To describe and evaluate the impact of primary and specialty care integration via asynchronous communication at a large integrated healthcare system.In January 2014, Geisinger's primary care providers (PCPs) were given access to an asynchronous communication tool, Ask-a-Doc (AAD), that enabled direct communication with specialists in 14 medical specialties and 5 surgical specialties. Internal data were collected to assess PCPs' acceptance and use of the tool, as well as satisfaction. Insurance claims data were obtained to assess the impact on healthcare utilization and cost.A retrospective analysis of health plan claims data was conducted among those patients who had at least 1 specialist visit with 1 of the participating specialties between January 2014 and December 2016. A set of difference-in-differences multivariate linear regression models with patient fixed effects was estimated, in which those who were not exposed to AAD served as the comparison group.Acceptance and use of AAD among PCPs gradually increased over time but varied by specialty. AAD was associated with an approximately 14% reduction in total cost of care during the first month of follow-up and a 20% reduction (P.001) during the second month. These reductions in cost of care appeared to be driven by reductions in emergency department visits and physician office visits.Geisinger's AAD experience suggests that the integration of primary and specialty care via the use of a highly reliable and efficient asynchronous communication system can potentially lead to reductions in avoidable care and more efficient use of specialty care.

Terrence E Murphy,1 Gail J McAvay,1 Heather G Allore,1 Jason A Stamm,2 Paul F Simonelli2 1Department of Internal Medicine, Section of Geriatrics, Yale University School of Medicine, New Haven, CT, USA;2Department of Internal Medicine, Section of Thoracic Medicine, Geisinger Medical Center, Danville, PA, USA Background: Among persons with obstructive airway disease, the relative contributions of chronic obstructive pulmonary disease (COPD), asthma, and common comorbid conditions to health care utilization and patient-centered outcomes (PCOs) have not been previously reported.Methods: We followed a total of 3,486 persons aged ≥40 years with COPD, asthma, or both at baseline, from the Medical Expenditure Panel Survey (MEPS) cohorts enrolled annually from 2008 through 2012 for 1year. MEPS is a prospective observational study of US households recording self-reported COPD, asthma, and ten medical conditions: angina, arthritis, cancer, coronary heart disease, cognitive impairment, diabetes, hypertension, lung cancer, myocardial infarction, and stroke/transient ischemic attack. We studied the separate contributions of these conditions to health care utilization (all-cause and respiratory disease hospitalization, any emergency department [ED] visit, and six or more outpatient visits) and PCOs (seven or more days spent in bed due to illness, incident loss of mobility, and incident decline in self-perceivedhealth).Results: COPD made the largest contributions to all-cause and respiratory disease hospitalization and ED visits, while arthritis made the largest contribution to outpatient health care. Arthritis and COPD, respectively, made the greatest contributions to the PCOs.Conclusion: COPD made the largest and second largest contributions to health care utilization and PCOs among US adults with obstructive airway disease. The twelve medical conditions collectively accounted for between 52% and 61% of the health care utilization outcomes and between 53% and 68% of the PCOs. Cognitive impairment, diabetes, hypertension, and stroke also made significant contributions. Keywords: average attributable fraction, AAF, chronic obstructive pulmonary disease, COPD, patient-centered outcomes, health care utilization

Background CT scan measures of emphysema and airway disease have been correlated with lung function in cohorts of subjects with a range of COPD severity. The contribution of CT scan-assessed airway disease to objective measures of lung function and respiratory symptoms such as dyspnea in severe emphysema is less clear. Methods Using data from 338 subjects in the National Emphysema Treatment Trial (NETT) Genetics Ancillary Study, densitometric measures of emphysema using a threshold of −950 Hounsfield units (%LAA-950) and airway wall phenotypes of the wall thickness (WT) and the square root of wall area (SRWA) of a 10-mm luminal perimeter airway were calculated for each subject. Linear regression analysis was performed for outcome variables FEV 1 and percent predicted value of FEV 1 with CT scan measures of emphysema and airway disease. Results In univariate analysis, there were significant negative correlations between %LAA-950 and both the WT ( r = −0.28, p = 0.0001) and SRWA ( r = −0.19, p = 0.0008). Airway wall thickness was weakly but significantly correlated with postbronchodilator FEV 1 % predicted (R = −0.12, p = 0.02). Multivariate analysis showed significant associations between either WT or SRWA (β = −5.2, p = 0.009; β = −2.6, p = 0.008, respectively) and %LAA-950 (β = −10.6, p = 0.03) with the postbronchodilator FEV 1 % predicted. Male subjects exhibited significantly thicker airway wall phenotypes (p = 0.007 for WT and p = 0.0006 for SRWA). Conclusions Airway disease and emphysema detected by CT scanning are inversely related in patients with severe COPD. Airway wall phenotypes were influenced by gender and associated with lung function in subjects with severe emphysema.

Objectives: We hypothesized that lung-volume reduction surgery for pulmonary emphysema would improve body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) index, a multidimensional predictor of survival in chronic obstructive pulmonary disease. We also aimed to identify preoperative predictors of improvement in the BODE index. Methods: In a prospective cohort study of patients undergoing lung-volume reduction surgery at our center, with the methodology of the National Emphysema Treatment Trial, we compared clinical characteristics before and 1 year after surgery with the Wilcoxon signed rank test. Changes in the BODE index were correlated with preoperative variables with the Spearman correlation coefficient. Results: Twenty-three patients with predominantly upper-lobe pulmonary emphysema underwent lung-volume reduction surgery (14 by video-assisted thoracoscopic surgery, 9 by median sternotomy). There were no postoperative or follow-up deaths. The BODE index improved from a median of 5 (interquartile range 4-5) before surgery to 3 (interquartile range 2-4) 1 year after surgery (P .0001). Improvements were seen in the lung function and dyspnea components of the BODE index. Lower preoperative 6-minute walk distance and lower postwalk Borg fatigue scores were each associated with greater improvement in the BODE index after 1 year. Conclusion: Lung-volume reduction surgery for pulmonary emphysema improved the BODE index in patients with predominantly upper-lobe disease. Lower preoperative 6-minute walk distance correlated with greater improvement in the BODE index.

To determine whether human immunodeficiency virus type 1 (HIV-1) strains in the lungs of infected individuals are derived from proviral forms contemporaneously present in the peripheral blood or whether they evolve independently as an autonomous pool of viral quasispecies, HIV-1 envelope V3 domain structures at these sites were analyzed and compared. The V3 loop proviral nucleotide and inferred amino acid sequences from lung bronchoalveolar lavage, where HIV-1 is primarily found in macrophages, were more homogeneous within individuals than those from unseparated peripheral blood mononuclear cells, where virus is predominantly in T cells. Comparison between individuals revealed that strains from bronchoalveolar lavage, but not from peripheral blood mononuclear cells, contained V3 domain nucleotide sequences with a great degree of homogeneity in the C-terminal region and a highly conserved, negatively charged amino acid motif. This V3 loop C-terminal structure could be important in the ability of HIV-1 to infect alveolar macrophages. Phylogenetic analyses of V3 domain nucleotide sequences in cells of monocyte/macrophage lineage at both sites revealed the strains in lung macrophages to have evolved further from a presumed ancestral species than those in blood monocytes and to differ considerably in the inferred V3 loop amino acid structures. These results show that, as disease progression occurs, viral strains in monocyte/macrophage lineage cells within the lung and blood microenvironments are not in a state of unrestricted bidirectional traffic but, instead, evolve independently.

A 79-year-old Asian man was admitted with community-acquired pneumonia. Antimycobacterial therapy was initiated when sputum smears revealed acid fast bacilli. The patient was, however, diagnosed to have pneumonia secondary to Tsukamurella spp. This is an exceedingly rare cause of pneumonia, especially in immunocompetent individuals. Clinical presentation, diagnosis and treatment strategies of Tsukamurella pneumonia are discussed with a literature review.

Publisher Summary Adenosine 5'-O-(γ-thio)-triphosphate (ATPγS) can replace ATP as an effective substrate of many kinases, particularly protein kinases. On the other hand, ATPγS is hydrolyzed very slowly by phosphatases and by most ATPases in comparison with ATP. Similarly, proteins thiophosphorylated by ATPγS are also resistant to protein phosphatases. Thus, thiophosphorylation of phosphorylase b by phosphorylase kinase leads to its conversion to the activated a form that is resistant to dethiophosphorylation and inactivation by phosphorylase phosphatase activity. The metabolic stability of thiophosphorylated proteins has also been demonstrated for myosin light chain in smooth muscle contraction, and for the receptor of epidermal growth factor in the epidermal carcinoma cell line A431. Therefore, thiophosphorylation of protein by ATPγS can serve as a powerful tool for investigating the regulatory mechanism of enzymes and metabolic processes that are controlled by a cycle of protein phosphorylation and dephosphorylation.