[This corrects the article DOI: 10.1371/journal.pone.0160748.].

Objective

To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population.

Methods

The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care.

Results

There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets.

Conclusion

Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.

Purpose

This case report discusses an atypical case of cytomegalovirus (CMV) retinal necrosis with panretinal occlusive vasculopathy in a 77-year-old man who was immunosuppressed following treatment for giant cell arteritis (GCA).

Methods

A case report is presented.

Results

Clinical examination demonstrated a central retinal artery occlusion and pale disc suspicious for arteritic ischemic optic neuropathy in the right eye. Biopsy-proven GCA prompted treatment with oral prednisone. While on glucocorticoid immunosuppression, the patient suffered vision loss in the left eye from CMV-necrotizing retinitis with occlusive vasculopathy. Treatment controlled the CMV infection but tapering of his steroids resulted in worsening GCA, requiring a steroid-sparing treatment, tocilizumab.

Conclusions

Corticosteroid immunosuppression for GCA may lead to immune dysfunction allowing for an atypical occlusive vasculitis with retinal necrosis from CMV. Early identification and treatment are essential to adjust the level of immunosuppression and consider alternate therapies to control the GCA and prevent worsening of this opportunistic infection.

Background

Short telomere length independently predicts mortality in patients with coronary heart disease. Whether 5-year change in telomere length predicts subsequent mortality in patients with coronary heart disease has not been evaluated.

Methods

In a prospective cohort study of 608 individuals with stable coronary artery disease, we measured leukocyte telomere length at baseline and after five years of follow-up. We divided the sample into tertiles of telomere change: shortened, maintained or lengthened. We used Cox survival models to evaluate 5-year change in telomere length as a predictor of mortality.

Results

During an average of 4.2 years follow-up, there were 149 deaths. Change in telomere length was inversely predictive of all-cause mortality. Using the continuous variable of telomere length change, each standard deviation (325 base pair) greater increase in telomere length was associated with a 24% reduction in mortality (HR 0.76, 95% CI 0.61-0.94; p = 0.01), adjusted for age, sex, waist to hip ratio, exercise capacity, LV ejection fraction, serum creatinine, and year 5 telomere length. Mortality occurred in 39% (79/203) of patients who experienced telomere shortening, 22% (45/203) of patients whose telomere length was maintained, and 12% (25/202) of patients who experienced telomere lengthening (p<0.001). As compared with patients whose telomere length was maintained, those who experienced telomere lengthening were 56% less likely to die (HR 0.44, 95% CI, 0.23-0.87).

Conclusions

In patients with coronary heart disease, an increase in leukocyte telomere length over 5 years is associated with decreased mortality.