Early experience with focused telemedicine implementation in an academic colorectal surgery practice.

BACKGROUND: The need to continue providing care to patients during the corona virus disease 2019 pandemic facilitated telemedicine's rapid adoption, including in surgical clinic settings. Our purpose was to evaluate integration of telemedicine into an academic colorectal surgery practice and assess physician experiences providing telemedicine care. METHODS: Patients seen in colorectal surgery clinic by telemedicine and in person from March 31, 2020 to August 31, 2020 were evaluated. Demographic and clinical outcomes were assessed for patients. Physician responses to a survey were collected. RESULTS: Two hundred and thirty-one telemedicine visits were performed by 4 physicians, comprising 20% of visits during the study period. Patients were 47.6% male and 90.9% Caucasian. In addition, 85.7% were established patients and 21.2% were postoperative visits. Diagnoses evaluated by telemedicine included benign and malignant anorectal and colorectal disease as well as inflammatory bowel disease. All providers reported being able to provide adequate care via telemedicine and were planning to continue providing telemedicine. Patients seen via telemedicine were more likely to be Caucasian and less likely to be African American (P < .001) and more likely to be established patients than those seen in person (P < .001). CONCLUSION: During the COVID-19 pandemic, telemedicine was most successfully used to facilitate care for established patients, particularly the long-term care of colorectal cancer and inflammatory bowel disease. We identified significant differences in ethnicity between patients seen via telemedicine and those seen in person. Telemedicine represents an exciting advancement in patient care, although ongoing study is required regarding providing access to this technology to all colorectal surgery patients, particularly minority populations.

Vagal Nerve Stimulator Placement by a Vascular Surgeon.

BACKGROUND: Refractory seizure activity represents a difficult problem for both patients and practitioners. Implantation of the vagal nerve stimulator has been posited as an effective treatment for refractory seizure activity. These devices are inserted by placing leads into the carotid sheath along the vagus nerve. We evaluated a vascular surgeon's experience placing vagal nerve stimulators. METHODS: We examined all patients treated with placement of vagal nerve stimulator by a single surgeon from October 2016 to October 2018. Data collected included demographics, medical and surgical history, intraoperative variables, and complications. RESULTS: Thirty-four patients underwent placement of a vagal nerve stimulator. About 29.4% had a previous vagal nerve stimulator placed on the ipsilateral side. Intraoperative bradycardia was seen in 1 patient. Postoperative complications were identified in 5 patients, all of which were transient dysphagia or changes in voice quality which did not require intervention. There was no significant difference between patients with the previous operation and those without for developing postoperative complications (P = .138). Average blood loss was higher in patients who had undergone previous stimulator placement than those who had not (P = .0223), and the operative time was longer (P ≤ .0001). DISCUSSION: Given the anatomical location of placement, vascular surgeons may be called upon to place these devices. In our single surgeon series, we found that the placement was safe, with minimal complications. Intraoperatively, this case appears to be more difficult (with higher blood loss and longer operative time) in patients who have had previous device placement, but this does not appear to lead to increased complications.

Energy Expenditure and Protein Requirements Following Burn Injury.

Severe burn injuries have long been known to have a profound effect on metabolic equilibrium that can persist after resolution of the cutaneous injuries. Following burn injury, metabolism is a dynamic state resulting in the need for frequent interval reassessment over the course of the care continuum. The acute phase of injury transitions to chronic alterations in macronutrient utilization characterized by futile energy cycling and disproportionate catabolism of skeletal muscle. Protein supplementation appears to be preferentially distributed to the burn wound rather than the skeletal muscle pool. Accurate assessment of caloric and protein requirements is extremely difficult in these patients but is an essential step in efforts to attenuate functional impairment. Indirect calorimetry should be utilized to determine caloric requirements, but trophic feeding strategies are preferred in the initial resuscitative phase to prevent overfeeding while maintaining enteric and immune function. Controversy persists regarding optimal protein targets, and weight-based estimates remain the norm. Exogenous protein and caloric provision performed in isolation is insufficient to optimize outcomes and should be incorporated within a multidisciplinary approach to include muscle loading and pharmaceutical adjuncts.