Demographic and technological factors influencing virtual seizure clinic visit satisfaction before and during the Covid-19 pandemic in rural Hawaii.

BACKGROUND: Telemedicine clinic visits traditionally originated from spoke clinic sites, but recent trends have favored home-based telemedicine, particularly in the time of Covid-19. Our study focused on identification of barriers and factors influencing perceptions of care with use of home-based telemedicine in patients with seizures living in rural Hawaii. We additionally compared characteristics of patients using telemedicine versus in-person clinic visits prior to the Covid-19 pandemic. METHODS: For the retrospective portion of our study, we queried charts of adult outpatients treated by the two full-time epileptologists at a Level 4 epilepsy center accredited by the National Association of Epilepsy Centers between November 2018 and December 2019. We included patients who live on the neighbor islands of Hawaii but not on Oahu, i.e., patients who would require air travel to see an epileptologist. There had been no set protocol at the epilepsy center for telemedicine referral; our practice had been to offer telemedicine visits to all neighbor island patients when felt to be appropriate. We collected demographic and clinic visit data. For the prospective portion we surveyed neighbor island patients or their caregivers, seen via home-based telemedicine between March 2020 and December 2020. We obtained verbal consent for study participation. Survey questions addressed satisfaction with clinical care, visit preferences, and potential barriers to care. RESULTS: In a 14-month period prior to the Covid-19 pandemic, 75 (61%) neighbor island patients were seen exclusively in-person in seizure clinic while 47 (39%) had at least one telemedicine visit. 39% of patients seen only in-person were female whereas 38% of patients seen by telemedicine were female. Patients seen in-person had an older median age (47.2 years) compared to those seen at least once by telemedicine (42.4 years). The no-show rate was 13% for in-person visits versus 4% for telemedicine visits. Among patients seen in person, 17% were Asian, 32% Native Hawaiian, and 47% White, whereas patients seen by telemedicine were 15% Asian, 23% Native Hawaiian, and 57% White. Patients who were seen in person lived in zip codes with median household income of $68,516 and patients who were seen by telemedicine lived in zip codes with median household income of $67,089. Patients who were seen in person lived in zip codes in which 78% of the population had access to broadband internet, whereas patients who were seen by telemedicine lived in zip codes in which 79% of the population had access to broadband internet. During the Covid-19 pandemic, we surveyed 47 consecutive patients seen by telemedicine, 45% female with median age of 33 years. Telemedicine connection was set up by the patient in 74% of cases, or by the patient's mother (15%), other family member (9%), or other caregiver (2 %). Median patient satisfaction score was 5 ("highly satisfied") on a 5-point Likert scale with mean score of 4.6. Telemedicine visit was done using a smartphone by 62% of patients, a computer by 36% of patients, and a tablet by 2% of patients. A home WiFi connection was used in 83% of patients. CONCLUSIONS: Home-based telemedicine visits provide a high-satisfaction method for seizure care delivery despite some obstacles. Demographic disparities may be an obstacle to telemedicine care and seem to relate to race and possibly age, rather than to sex/gender, household income, or access to broadband internet. Additionally, despite high satisfaction overall, more patients felt the physical exam was superior at in-person clinic visits and more patients expressed a preference for in-person visits. During the Covid-19 pandemic when there may be barriers to in-person clinic visits, home-based telemedicine is a feasible alternative.

A Type II Split Cord Malformation in an Adult Patient: An Operative Case Report.

BACKGROUND AND IMPORTANCE: Split cord malformations (SCMs) are rare conditions in which the spinal cord is split into two hemicords within either a single thecal sac or two separate thecal sacs. The hemicords are typically split by a bony or fibrous structure. We present an adult patient who presented with a type II SCM with tethered cord. This is the first case of such a presentation with an accompanying intraoperative video. Unusual features of the case were the presence of an incomplete fibrous septum and lack of a discrete filum terminale. CLINICAL PRESENTATION: A 50-yr-old woman presented with back pain, radiculopathy, urinary urgency, and episodic fecal incontinence. Her exam was notable for weakness of the right extensor hallicus longus. Imaging showed an SCM extending from L3 to S1, a fibrous septum located at L4-5, and a low-lying conus at S4. She was treated with a decompressive L3-S4 laminectomy and disconnection of all the dural attachment points. She required lumbar drain placement postoperatively and reoperation for wound dehiscence and persistent pseudomeningocele. At the time of last follow-up, she was neurologically intact with improvement in bowel/bladder function. CONCLUSION: SCM is an uncommon presentation in adults and is often accompanied by findings of skin stigmata, tethered cord, and other central nervous system/skeletal anomalies. Obtaining full multimodal imaging is critical to understanding subtle anatomic variations that can pose operative challenges. We report the treatment of an adult patient with type II SCM, and provide an intraoperative video demonstrating the removal of an incomplete midline fibrous septum.

Industry payments to physician journal editors.

BACKGROUND: Open Payments is a United States federal program mandating reporting of medical industry payments to physicians, increasing transparency of physician conflicts of interest (COI). Study objectives were to assess industry payments to physician-editors, and to compare their financial COI rate to all physicians within the specialty. METHODS AND FINDINGS: We performed a retrospective analysis of prospectively collected data, reviewing Open Payments from August 1, 2013 to December 31, 2016. We reviewed general payments ("… not made in connection with a research agreement") and research funding to "top tier" physician-editors of highly-cited medical journals. We compared payments to physician-editors and physicians-by-specialty. In 35 journals, 333 (74.5%) of 447 "top tier" US-based editors met inclusion criteria. Of these, 212 (63.7%) received industry-associated payments in the study period. In an average year, 141 (42.3%) of physician-editors received any direct payments to themselves including general payments and research payments, 66 (19.8%) received direct payments >$5,000 (National Institutes of Health threshold for a Significant Financial Interest) and 51 (15.3%) received >$10,000. Mean annual general payments to physician-editors was $55,157 (median 3,512, standard deviation 561,885, range 10-10,981,153). Median general payments to physician-editors were mostly higher compared to all physicians within their specialty. Mean annual direct research payment to the physician-editor was $14,558 (median 4,000, range 15-174,440). Mean annual indirect research funding to the physician-editor's institution (highly valued by academic leaders such as departmental chairs and deans) was $175,282 (median 49,107, range 0.18-5,000,000). The main study limitation was difficulty identifying physician-editors primarily responsible for making manuscript decisions. CONCLUSIONS: A substantial minority of physician-editors receive payments from industry within any given year, sometimes quite large. Most editors received payment of some kind during the four-year study period. Given the extent of editors' influences on the medical literature, more robust and accessible editor financial COI declarations are recommended.

Toxoplasma gondii-Induced Long-Term Changes in the Upper Intestinal Microflora during the Chronic Stage of Infection.

Toxoplasma gondii is an obligate intracellular parasite with worldwide distribution. Felines are the definitive hosts supporting the complete life cycle of T. gondii. However, other warm-blooded animals such as rodents and humans can also be infected. Infection of such secondary hosts results in long-term infection characterized by the presence of tissue cysts in the brain and other organs. While it is known that T. gondii infection in rodents is associated with behavioral changes, the mechanisms behind these changes remain unclear. Alterations of the host intestinal microflora are recognized as a prominent role player in shaping host behavior and cognition. It has been shown that acute T. gondii infection of mice results in microflora changes as a result of gastrointestinal inflammation in inbred mouse models. The long-term effects of chronic T. gondii infection on microbial communities, however, are unknown. In this study, after we verified using our model in terms of measuring microflora changes during an acute episode of toxoplasmosis, we assessed the microbiome changes that occur during a long-term infection; then we further investigated these changes in a follow-up study of chronic infection. These analyses were performed by constructing and sequencing 16S rRNA amplicon DNA libraries from small intestine fecal specimens. We found that acute infection with the GT1 strain of T. gondii caused an enrichment of Bacteroidetes compared with controls in CD1 mice. Strikingly, this enrichment upheld throughout long-term chronic infection. The potential biological consequences of this alteration in rodents and humans should be subjected to further exploration.