From Clinic to Kitchen to Electronic Health Record: The Background and Process of Building a Culinary Medicine eConsult Service.

Diet plays a pivotal role in health outcomes, influencing various metabolic pathways and accounting for over 20% of risk-attributable disability adjusted life years (DALYs). However, the limited time during primary care visits often hinders comprehensive guidance on dietary and lifestyle modifications. This paper explores the integration of electronic consultations (eConsults) in Culinary Medicine (CM) as a solution to bridge this gap. CM specialists, with expertise in the intricate connections between food, metabolism, and health outcomes, offer tailored dietary recommendations through asynchronous communication within the electronic health record (EHR) system. The use of CM eConsults enhances physician-patient communication and fosters continuous medical education for requesting clinicians. The benefits extend directly to patients, providing access to evidence-based nutritional information to address comorbidities and improve overall health through patient empowerment. We present a comprehensive guide for CM specialist physicians to incorporate CM eConsults into their practices, covering the historical context of eConsults, their adaptation for CM, billing methods, and insights from the implementation at UT Southwestern Medical Center. This initiative delivers expanded access to patient education on dietary risks and promotes interprofessional collaboration to empower improved health.

What you eat significantly impacts your health, affecting various aspects including weight, blood sugar, and inflammation. This paper highlights how health-related issues are linked to diet and presents one solution to help doctors guide patients more effectively. Often, the limited time during medical visits makes it challenging for doctors to provide detailed advice on lifestyle changes. Additional common barriers are that many doctors lack nutrition expertise, and access to nutrition experts such as registered dietitian nutritionists can be limited geographically and financially. This paper introduces the concept of electronic consultations (eConsults) in Culinary Medicine (CM) to help overcome this challenge. CM specialists are licensed healthcare professionals who understand how food influences the body and can use eConsults to offer personalized dietary recommendations. EConsults occur via a secure electronic medical record system that connects doctors and specialists, ensuring efficient communication. Patients benefit by gaining access to reliable nutritional information tailored to their specific health needs. This innovative approach also enhances communication between doctors and patients and helps doctors stay updated on the new research about how nutrition and food impact health. The paper provides a practical guide for doctors to integrate CM eConsults into their practices, making it easier to give valuable advice on dietary risks and promote healthier lifestyles. Overall, this initiative represents a significant step in improving patient nutrition education and fostering positive changes in health through the power of informed dietary choices.

The Supportive Role of Provocative Maneuvers and Impedance Clearance in Detecting Ineffective Esophageal Motility.

Background: Ineffective esophageal motility (IEM) is one of the most common esophageal motility disorders. However, the definition of IEM has evolved. Chicago classification version 4.0 (CCv4.0) made IEM parameters more stringent with greater than 70% of ineffective wet swallows (WS) necessary to diagnose conclusive IEM. Of the ineffective swallows, 50-70% are deemed "inconclusive cases". This study sought to determine whether provocative maneuvers, including multiple rapid swallows (MRS) and apple viscous swallows (AVS), and impedance clearance can provide supportive information for inconclusive IEM disorders based on CCv4.0. Methods: Esophageal motility data on 100 patients were analyzed. All patients completed WS and at least one additional swallow test (MRS and/or AVS). Patients were classified as having conclusive IEM, inconclusive IEM, or normal motility. IEM features detected on MRS/AVS and incomplete bolus clearance were recorded. Percentage of agreement between IEM features and incomplete bolus clearance was calculated for each motility group. Results: Ten patients had conclusive IEM, nine had inconclusive IEM, and 32 had normal motility. There was 70% agreement between IEM features and incomplete bolus clearance with conclusive IEM, 33% agreement with inconclusive IEM, and 9% agreement with normal motility. There was significantly more agreement in the conclusive and inconclusive IEM groups than in the normal motility group (P = 0.0003). Conclusions: Combinational follow-up testing with provocative maneuvers and impedance clearance may assist with risk stratification of IEM patients and assist in further management of inconclusive IEM. MRS and AVS can detect unique IEM features that may help with preoperative management of inconclusive IEM.

Advancing high-resolution manometry: evaluating the use of multiple rapid swallows versus apple viscous swallows in clinical practice.

BACKGROUND: High-Resolution Manometry (HRM) with provocative maneuvers, such as Multiple Rapid Swallows (MRS) and Apple Viscous Swallows (AVS), is commonly utilized to diagnose esophageal disorders. Increasing standardization in HRM protocol can help save time and reduce patient discomfort. This study assesses AVS and MRS to determine their respective benefits and limitations. METHODS: Retrospective reviews were performed on 100 patients to analyze their AVS and/or MRS results. Parameters included abnormal motility patterns, tolerance, and DCI. Diagnostic benefits from MRS and AVS were assessed. Based on the previous studies, additional benefit from MRS was defined as detection of good peristaltic reserve, weak peristaltic reserve, or an abnormal motility/pressurization pattern. Additional benefit from AVS was defined as detection of IEM features or abnormal motility/pressurization pattern. RESULTS: When patients completed both MRS and AVS (n = 70), MRS provided additional benefit in assessing 36% of patients, while AVS provided additional benefit in 19% of patients (p < 0.0001). Furthermore, MRS detected significantly more abnormal motility/pressurization patterns than AVS (27% MRS; 8% AVS; p = 0.0005). Two unique strengths of AVS were higher tolerance for test completion (p = 0.009) and better detection of severe hypokinetic disorders in 4% of patients, which were missed by MRS. CONCLUSIONS: MRS may uniquely identify abnormal motility/pressurization patterns, such as paradoxical LES response, distal pressurization, hypercontractile, and spasm patterns. These findings argue for a tailored approach when selecting provocative testing. MRS may be more useful for patients with abnormal pathophysiology, while AVS may help to supplement MRS in detecting severe hypokinetic disorders in preoperative management.

Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing.

Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient's peristaltic reserve prior to surgery.