ABSTRACT
STATEMENT OF PROBLEM/QUESTION: While telemedicine has been adopted in the ambulatory setting, various provider-level barriers remain DESCRIPTION OF PROGRAM/INTERVENTION: The COVID-19 pandemic prompted an exponential increase in the use of telemedicine, allowing safe and reliable access to ambulatory healthcare services for patients. RyanAdair is a federally qualified health center in New York City which also serves as the primary care practice site for our internal medicine residents. Telemedicine services were adopted and implemented at Ryan Adair in March 2020. Gradually, as in-person visits were re-introduced there was a 36% drop in televisits. We aim to identify some of the physician-perceived barriers to telemedicine use in an attempt to improve its utilization. MEASURES OF SUCCESS: This cross-sectional, single-site initiative is part of a larger effort to identify access to primary care among a medically underserved patient population. To understand the challenges and attitudes toward telemedicine, we surveyed residents in all 3 academic years (PGY1, PGY2, PGY3), preceptors, and ancillary staff at the site who provided these services. A link to an electronic survey was emailed to the physicians and a copy of the link via QR code was posted at the clinic documentation rooms with a goal to obtain a 40% response rate. The surveys are anonymous and voluntary, and all the data was devoid of any personal identifiers. FINDINGS TO DATE: 38.8% (n=61) of providers responded, with 78.7% (n= 48) of providers surveyed having conducted at least one televisit. 42.6% (n=26) of the providers surveyed were more comfortable with an in-person visit compared to a televisit. Among those who had conducted a televisit, the major barrier identified was limitations of physical exam 77% (n=47), followed by patient's inability to navigate the software for a video visit 70.5% (n=43), and provider's challenges with the software/accessories onsite 55.7% (n=34). 32.7% (n= 20) of providers mentioned that most of the time or occasionally they were not confident in their ability to conduct a video visit. 92% felt that they would like to continue telemedicine post-pandemic. KEY LESSONS FOR DISSEMINATION: Based on our survey, the main provider-perceived barriers to telemedicine use at an urban federally qualified health center were 1. limitations of the physical exam 2. inadequate patient access to needed technology, and 3. provider comfort with televisit navigation on-site. Whether these are true barriers or simply perceived barriers of the providers surveyed requires further investigation. Future directions include conducting qualitative focus groups with patients and incorporating formal telemedicine teaching and education as a part of resident training.
ABSTRACT
CASE: A 62-year-old woman presented with 4 months of sharp progressive left shoulder pain, radiating down her arm with associated weakness, numbness and tingling most pronounced at the 4th and 5th digit. Her symptoms began within hours of receiving the influenza vaccine to her left shoulder. She denied prior left shoulder or neck pain, headaches, changes in vision, other neurologic symptoms, or trauma. Exam: Left upper extremity without skin changes or deformity, normal muscle bulk, tone and DTRs, lateral upper arm tenderness to light and deep palpation, reduced sensation to light touch at the 4th and 5th left digit with loss of two-point discrimination, reduced active and passive ROM of the glenohumeral joint to flexion/extension/abduction, and restricted internal and external rotation. Cervical x-rays showed spondylosis at C5-6, C5-6 neural foramen narrowing. Normal left shoulder x-ray. Left shoulder MRI showed high grade bursal surface, full-thickness tear of the distal supraspinatus tendon at its insertion, mild subscapularis tendinosis, and small subacromial subdeltoid bursitis. She was treated with a topical NSAIDs, tramadol and cyclobenzaprine as needed and referred to physiotherapy and PM&R. Despite maximum therapy, there was only marginal improvement of left shoulder pain and function at 9 months, she is still unable to perform her ADLs or return to work, and currently receiving home care through her daughter as a caregiver. IMPACT/DISCUSSION: The MRI findings and the temporal relationship between vaccine administration and onset of symptoms, suggest Shoulder Injury Related to Vaccine Administration (SIRVA) as the most likely diagnosis. SIRVA is defined as shoulder pain with limited ROM that commences within 48 hours after vaccine receipt in individuals without prior history of pain, inflammation, or dysfunction of the affected shoulder. SIRVA occurs when a vaccine is delivered into the sub-deltoid bursa or joint space, leading to a robust inflammatory response. The single most important factor in SIRVA diagnosis is the temporal association between vaccine administration and symptom onset. Commonly reported symptoms include shoulder pain, decreased limb mobility, numbness/tingling and muscle tightness. SIRVA complications include bursitis, tendonitis, rotator cuff tear, and adhesive capsulitis. Approximately 65% of patients with SIRVA will have pain lasting more than 3 months. SIRVA is challenging to treat, but there has been some success with early corticosteroid injection within 5 days of symptom onset. Given the current increase in vaccine administration with COVID-19, this case highlights SIRVA as a diagnostic consideration for patients who present with shoulder pain post-vaccination. CONCLUSION: SIRVA should be considered in any patient with new-onset shoulder pain that began within 48 hours of vaccine administration. SIRVA is a post-vaccination complication resulting in shoulder injury that can be prevented with proper vaccine administration technique.
ABSTRACT
Background Chronic fatigue with cognitive and daily functioning decline is a major public health concern in older adults. The association between fatigue and neurodegenerative conditions (e.g., multiple sclerosis) has been studied for many years. But, it is not known the relationship between Alzheimer's pathology and perceived fatigability, a phenotype characterized by the relationship between an individual's perceived fatigue and the activity level with which the fatigue is associated. We examined the role of fatigability on the link between cognitive function and cognitive function abilities and the effect of sleep on this indirect link in older adults with mild cognitive impairment (MCI). Methods Adults age > 55 years who met the ADNI criteria for MCI were included. Depression assessed by the DSM-V criteria and a GDS>5 was exclusionary. We conducted the study with the PROMIS Cognitive Function-Abilities (CogAb), Sleep Disturbances (SD), Sleep-related Impairment (SRI), and the Neuro-QOL Cognitive Function (CogF) and Fatigue, including Fatigue symptom score (item1-3&7) and Fatigability score (item4-6&8). Linear regression models were fit to Fatigue and Fatigability included sleep outcomes and their interaction as predictors. Mediation models were fit to assess whether fatigability mediated the effect of CogF on CogAb. Results Before the COVID pandemic, 36 subjects were recruited, with the mean age= 68.8 ±9.3, 58.3% female, 78% white, and 15.2% Hispanic. The results revealed that CogF predicted CogAb (b= 0.78, t(34)=4.83, p<0.001). Analysis of the indirect effects showed CogF predicted Fatigability (b=-0.29, t(34)=-3.09, p<0.005), Fatigability predicted CogAb (b= -0.99, t(33)=-4.03, p<0.001), CogF predicted CogAb (b=0.49, t(33)=3.25, p<0.01). The indirect effect of CogF on CogAb mediated through fatigability was significant (95%CI=0.08, 0.44), even after controlling for age and education, and fatigue symptom score. Fatigability was associated with SRI (beta=0.642, t=4.73, p<0.001) but not SD (P>0.05) after controlling for age. SRI had no direct effect on CogAb. Conclusions Perceived fatigability partially mediated the link between CogF and CogAb and sleep outcomes had no significant impact on this indirect link. The results suggested that fatigability could be a biological construct of Alzheimer's pathology, independent from sleep and depression.