Comparison of Patient Satisfaction Between Face-to-Face and Telehealth Modalities in Nephrolithiasis Nutritional Counseling.

INTRODUCTION: Following the COVID-19 pandemic, telehealth usage increased. Virtual visits minimize exposure risk while also addressing barriers to care. Telehealth offers the ability to increase patient access and provider efficiency. However, patient satisfaction with telehealth has not been fully determined. This study evaluated patient-perceived quality and satisfaction of virtual vs face-to-face visits during consultation with a dietician in the management of nephrolithiasis. METHODS: Ninety-six patients with previous diagnosis of nephrolithiasis underwent an initial, in-person nutrition consultation between May 2019 to February 2021. A follow-up with a dietician was randomized to in-person or telehealth. The telehealth group used an application called MDLive. The telehealth group used MDLive on a hospital computer during their follow-up with the urologist, whereas the in-person group had a separate appointment scheduled at a different location. Patient satisfaction following telehealth visits was assessed by the Telemedicine Satisfaction Questionnaire. Patient satisfaction following in-person visits was assessed with an 8-question modified Telemedicine Satisfaction Questionnaire, which lacked technology-related questions. RESULTS: Fifty patients were randomized to in-person follow-up and 46 to virtual follow-up. Within the virtual follow-up group more than 90% "agreed" or "strongly agreed" that they were satisfied with the quality of service provided through telemedicine. Greater than 82% reported intention to use telemedicine services again. There was no significant difference in patient satisfaction between telemedicine and face-to-face visits. Sixty-seven percent of patients in the telemedicine group reported better access to health care services and time saved and 89% reported independence accessing the telehealth system without assistance. CONCLUSIONS: This study supports the idea that telemedicine may be a successful alternative in the follow up of patients undergoing nutritional counseling for stone prevention. Future studies regarding telehealth use should evaluate which other urologic conditions are amenable to virtual management.

Can the marshmallow esophagram replace high-resolution manometry as an appropriate screening for esophageal motility prior to anti-reflux surgery?

BACKGOUND: The purpose of our study was to evaluate the use of minimally invasive Marshmallow Swallow Study (MSS) as a preoperative screening technique for patients and correlate marshmallow results with High Resolution Manometry (HRM) results and post-operative dysphagia following antireflux surgery. METHODS: A retrospective electronic chart review of data on 61 adult patients undergoing MSS was completed. Patients were included if they completed the MSS as well as: HRM and/or antireflux surgery. RESULTS: Sixty-one patients completed MSS. Of the 37 patients that completed HRM, 27 had abnormal results. 23 of these 27 patients who had abnormal results also failed MSS. The NPV for a failure on the MSS and abnormal HRM results is 0.767(p-value = 0.360). The PPV for a pass on the MSS and no post-operative dysphagia is 0.833 (p-value = 0.656). CONCLUSIONS: MSS is an effective screening tool for ruling out major esophageal motility disorders and can prevent need for invasive HRM.

Effect of near real-time feedback tool in the electronic medical record on protocol compliance during laparoscopic cholecystectomy: a single-center retrospective analysis.

Implementation of evidence-based medicine has proved difficult across medical fields. Leveraging the electronic medical record may improve clinician compliance to published best practices. Our hypothesis was that the use of a near real-time feedback tool would improve compliance to the protocol steps. In order to test this hypothesis, we performed a retrospective chart review to compare compliance to a proprietary enhanced recovery protocol for patients undergoing laparoscopic cholecystectomy with and without a near real-time feedback tool embedded in the electronic medical record. Deviations to the care pathway were quantified and classified as allowable or as errors of commission, omission, or dose. During the study period, 2625 laparoscopic cholecystectomies were performed. A total of 16,972 protocol steps were evaluated. Complete protocol compliance improved from 10.3 to 61.5% (p < 0.001) with the use of the feedback tool. Individual protocol component compliance increased from 4994/8418 (59.3%) to 7669/8554 (89.7%) (p < 0.001). The near real-time feedback tool reduced the number of cases with every number of deviations (except zero) at p < 0.001. The near real-time feedback tool significantly improved protocol compliance for patients undergoing laparoscopic cholecystectomy.

Isolated Rib Fractures in Elderly Falls: Not As Deadly As We Think.

BACKGROUND: Rib fractures in elderly patients have been associated with high morbidity and mortality; however, many of these patients had substantial mechanisms of injury, which may have contributed to these high rates. OBJECTIVE: The purpose of this study was to determine the morbidity and mortality of elderly patients with isolated rib fractures who fell from standing. METHODS: A single-institution retrospective study was conducted in a Level I trauma center using the trauma registry and a separate elderly fall from standing database. Admitted patients 65 years or older who presented with rib fractures after a fall from January 2013 to June 2017 were included. Patients with a nonthoracic Abbreviated Injury Scale score greater than 2 were excluded from the study. RESULTS: Of 129 patients with isolated rib fracture, 94% (n = 121) had comorbidities and 71% (n = 92) had two or more comorbidities. Almost half (41.9%; n = 54) were taking antiplatelet and anticoagulant medications, 78.3% (n = 101) were caused by a mechanical fall, and 7% (n = 9) were caused by syncope. Data showed 72.9% (n = 94) had three or more rib fractures. The mortality rate of patients was 3.9% (n = 5). Three patients had dementia at death, four had do-not-resuscitate order, and only two deaths were directly related to pulmonary status. Patients who developed pneumonia (14.7%; n = 19) and required mechanical ventilation for a median of 11 days (3.9%; n = 5) were fewer than those in in previous studies. CONCLUSION: The morbidity and mortality associated with rib fractures are significantly less than reported in the literature when additional injuries are excluded.

Design and implementation of a clinic-to-community, physical activity health promotion model for healthcare providers.

Due to the worldwide burden of noncommunicable disease, the American College of Sports Medicine (ACSM) launched a global health awareness initiative in 2007 called Exercise is Medicine® (EIM®) to create awareness in healthcare providers in promoting physical activity to their patients. To transition awareness into action, Exercise is Medicine Greenville® (EIMG®) launched in 2016 through a first-of-its-kind partnership between a medical school, large healthcare system, and community organization to comprehensively integrate physical activity as a primary prevention strategy into their health system. The EIMG® model connects patients referred by their healthcare provider due to diagnosis of a physical inactivity and/or noncommunicable disease to community partners who provide evidence-based physical activity programs as a population health management strategy. The EIMG® program is inclusive of all patients referred and provides an "open door policy" through the YMCA scholarship fund. Through 2019, 210 patients completed the program (>60% graduation rate). Patients receiving usual care by their healthcare provider decreased body weight (p < 0.001) and systolic blood pressure (p = 0.042). Patients receiving usual care by their healthcare provider who were referred with hypertension decreased body weight (p = 0.001), and both systolic and diastolic blood pressure (p < 0.001). Graduating patients were highly satisfied with the program and program personnel (>4 on a 5-point Likert scale). Aligning healthcare and community partners to implement a clinic-to-community model for patients with noncommunicable disease may be a beneficial population health promotion strategy. Future efforts will be to refine the referral process, scale the model, and continue to inform national health promotion strategies.

Current Outcomes of Blunt Vertebral Artery Injuries.

BACKGROUND: There is no consensus on the treatment of blunt vertebral artery injuries, and studies are limited to small case series. We assessed the natural history and current management of these injuries. METHODS: We performed a retrospective study of a prospectively collected registry at a level I trauma center over a 5-year period. Additional information was gathered from patient charts and imaging review from electronic medical records. We analyzed demographics, mechanism of injury, Glasgow Coma Score, mortality, length of stay, associated injuries, Denver grading scale, neurological findings, level and laterality of injury, delay in diagnosis, treatment, and follow-up imaging. RESULTS: There were 13,080 trauma admissions during this time period yielding 141 patients with blunt vertebral artery injuries from 2013 to 2018 (1.1% incidence). Mean injury severity score (ISS) was 22 with a 30-day mortality of 14 (9.9%). An ISS of greater than 15 is associated with polytrauma and increased mortality. There were 112 (79.4%) associated cervical fractures. C6 and C7 were both equally the most common locations. There was one symptomatic injury manifesting as a cerebellar ischemic infarct. The degree of arterial injury was classified by the Denver grading scale. There were 61 (43.3%) instances of Denver grade I injuries, followed by grade IV at 36 (25.5%), grade II at 34 (24.1%), grade III at 8 (5.7%), and grade V at 1 (0.7%). The level of injury was recorded as follows: V2 = 67 (47.5%), V3 = 56 (39.7%), V1 = 48 (34%), V4 = 14 (9.9%). Medical therapy included aspirin in 93 patients (66%), 31 patients (22%) received systemic anticoagulation with heparin drip, and 2 patients (1%) were administered therapeutic Lovenox. A total of 15 patients (11%) received no medical treatment. There was one intervention in our series. Our only grade V injury was coil embolized. A total of 118 patients (84%) had follow-up imaging. Seventy-eight patients (96%) with grade I and grade II injuries did not worsen, and complete radiographic resolution was found in 50 patients (62%). Grade IV injuries persisted in 22 patients (75.9%). Median time to resolution for grade I and grade II injuries was 7 and 8 days, respectively. Most follow-up scans for grade I and II injuries occurred within 50 days. CONCLUSIONS: Posterior circulation stroke due to blunt vertebral artery injury is rare. In our experience, the natural course of blunt vertebral artery injury was benign and neither delay in medical treatment nor choice of antithrombotic had a significant impact on outcomes. In our series, only 3 (3.7%) grade I and II injuries worsened and were without any clinical sequelae. We suggest that routine serial imaging in grade I and II blunt vertebral injuries is not warranted.

Robotic Versus Laparoscopic Approach to Hiatal Hernia Repair: Results After 7 Years of Robotic Experience.

INTRODUCTION: Robotic hiatal hernia repair offers potential advantages over traditional laparoscopy, most notably enhanced visualization, improved ergonomics, and articulating instruments. The clinical outcomes, however, have not been adequately evaluated. We report outcomes of laparoscopic and robotic hiatal hernia repairs. METHODS: A retrospective observational cohort study was performed of all hiatal hernia repairs performed from 2006 through 2019. Operative, demographic, and outcomes data were compared between laparoscopic and robotic groups. Discrete variables were analyzed with Chi-square of Fisher's exact test. Continuous variables were analyzed with Student's t test (mean) or Wilcoxon rank sum (medians). All analyses were performed using R statistical software. RESULTS: Laparoscopic repair was performed in 278 patients and robotic repair in 114. More recurrent hernias were repaired robotically (24.5% vs 12.9%, P = .08). Operative times were no different between groups (175 vs 179 minutes; P = .681). Robotic repair resulted in significantly shorter length of stay (LOS; 2.3 vs 3.3 days; P = .003). Rate of readmission was no different, and there were no differences in acute complications. For patients with at least 1 year of follow-up, recurrence rates were lower after robotic repair (13.3% vs 32.8%; P = .008); however, mean follow-up is significantly longer after laparoscopic repair (23.7 ± 28.4 vs 15.1 ± 14.9 months; P < .001). DISCUSSION: Robotic hiatal hernia repair offers technical advantages over laparoscopic repair with similar clinical outcomes.

Screening and socioeconomic associations of dyslipidemia in young adults.

BACKGROUND: The Southern region of the United States is home to substantial populations with obesity, dyslipidemia, and hypertriglyceridemia, while also housing a large percentage of America's minority, rural, and low socioeconomic status (SES) peoples. Adult-onset cardiovascular disease (CVD) research may be informed by investigating associations(s) between late adolescent demographic variables and lipid values. Our objective was to investigate lipid parameter associations with college-age socioeconomic status, which may improve age-specific screening algorithms for management or prevention of adult-onset CVD. METHODS: Using an Analysis of Variance test and a general linear model, associations between gender, race/ethnicity, SES, and athletic participation on lipid parameters (VLDL-C, LDL-C, TG, TC, and HDL-C) were analyzed in 4423 private liberal arts college students enrolled in freshman-level wellness courses at Furman University in Greenville, SC. Comparative data were collected from an age-matched sample (National Health and Nutrition Examination Survey: NHANES 2003-2016). Our main outcomes were statistically significant relationships between any lipid values (TC, HDL-C, LDL-C, TG) and any demographic variables (gender, SES, ethnicity, athlete status). RESULTS: Males demonstrated lower TC and LDL-C, and higher HDL-C values. HDL-C was highest in athletes. African-American students demonstrated healthier VLDL-C, TG, and HDL-C values. With similar distributions, the age-matched NHANES comparison group showed unhealthier values in nearly all categories. CONCLUSIONS: College students may have better lipid health than the general population. African-Americans may have seemingly healthier lipid values than age-matched individuals independent of athletic or college enrollment which has already been demonstrated in other studies. Future research should include SES relationships in lipid screening paradigms along with other appropriate risk factors for cardiovascular disease. Based on our comparative data, pediatric health providers and researchers may consider education as a potential protective factor against poor lipid health when considering lipid screening protocols for students.

Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago-gastric junction outflow obstruction.

BACKGROUND AND AIMS: Idiopathic Esophago-gastric outflow obstruction (EGJOO) is a new clinical entity resulting in delayed esophageal emptying secondary to a poorly relaxing lower esophageal sphincter. Little is known about treatment outcomes of idiopathic EGJOO patients. The aim of this study was to investigate the clinical response of pneumatic dilation (PD) in idiopathic EGJOO patients with a standing barium column and/or with pill arrest on timed barium esophagram (TBE) before and after undergoing PD. METHODS: Idiopathic EGJOO patients with retained liquid barium on TBE at 1 minute and/or with pill arrest in esophagus at 5 minutes were included. Patients were treated with PD and evaluated with post-procedural TBE. RESULTS: A total of 33 patients with Idiopathic EGJOO and poor esophageal emptying on TBE were treated with PD. 67% of Idiopathic EGJOO patients reported subjective symptom relief, 18% improved and symptoms later recurred, 6% were lost to follow up, and 9% reported no change. TBE results of pre-PD showed 1 minute average barium column height of 11.0 cm and 1 minute barium column width of 1.7 cm. There was significant decrease in 1 minute liquid barium column height and width (P < 0.001 and <0.001, respectively) as well as significant improvement in pill passing (P < 0.006) after undergoing PD. No complications occurred after PD. CONCLUSION: PD is an effective initial treatment for Idiopathic EGJOO patients with abnormal TBE. Pneumatic dilation relieved symptoms and improved esophageal emptying in Idiopathic EGJOO patients on TBE.

FibroSURE and elastography poorly predict the severity of liver fibrosis in Fontan-associated liver disease.

OBJECTIVE: As the population of patients with Fontan circulation surviving into adulthood increases, hepatic cirrhosis has grown to be a significant cause of morbidity and mortality. Early detection of advanced hepatic fibrosis is imperative for proper intervention and consideration for heart or combined heart/liver transplantation. Noninvasive biomarkers and elastography have been evaluated for their diagnostic utility with variable results in the Fontan population. DESIGN: The cohort included 14 patients age 26.4 SD 7.5 who underwent Fontan surgery. All patients were evaluated with FibroSURE, shear wave elastography (SWE), hepatic duplex sonography, and liver biopsy. Liver fibrosis on biopsy was evaluated according to the congestive hepatic fibrosis system. RESULTS: In our cohort, 100% of patients had fibrosis with 36% demonstrating advanced fibrosis. FibroSURE agreed with liver biopsy in only 5 out of 14 cases (36%): underestimating in 7 and overestimating in 2 individuals. SWE agreed with liver biopsy in 0% of cases: overestimating in 10 and underestimating in 4 cases. None of the duplex sonography indices predicted the presence or severity of liver fibrosis. CONCLUSION: This study demonstrates that children who have undergone a Fontan procedure universally develop some hepatic fibrosis and a significant number have advanced fibrosis by adulthood. The FibroSURE blood test, SWE, and hepatic duplex sonography were unable to accurately predict the presence or severity of hepatic fibrosis when compared with liver biopsy. Further studies are needed to investigate novel noninvasive methods and/or biomarkers that can adequately detect advanced hepatic fibrosis before the development of cirrhosis and hepatic decompensation.

Seasonality in the adverse outcomes in weight loss surgeries.

BACKGROUND: Weight loss surgery is a common procedure in the United States. OBJECTIVE: As weight loss surgery is largely an elective procedure for which patients and physicians can choose the timing, it could be helpful to explore the seasonality pattern of its perioperative adverse outcomes to help decide the timing of this surgery. SETTING: United States. METHODS: We used an obese adult sample (age ≥20 yr) of patients who underwent weight loss surgeries from the Premier Healthcare Database from 2011 to 2014. The International Classification of Diseases, Ninth Revision Clinical Modification procedure codes were used to identify weight loss surgery cases. Binary variables are used for 4 adverse outcomes, including hospital mortality, sepsis, deep vein thrombosis (DVT), and pulmonary embolism. The associations between the adverse outcomes and season of surgery were examined using logistic regressions, adjusting for age, sex, race, marital status, surgery types, body mass index, the Charlson co-morbidity index, and region. RESULTS: A total of 69,365 weight loss surgeries were identified for the analytic sample. The overall rate was .27% for hospital mortality, .16% for DVT, .10% for pulmonary embolism, and .20% for sepsis. For DVT, adjusted odds ratio for the fall was 2.68 (95% confidence interval: 1.39-5.19) and the odds ratio for the winter was 2.26 (95% confidence interval: 1.09-4.27) compared with the summer. For sepsis, adjusted odds ratio for the spring was 1.83 (95% confidence interval: 1.07-3.12) compared with that of the summer. The seasonality pattern was not statistically significant for hospital mortality and pulmonary embolism. CONCLUSION: DVT and sepsis are more likely to occur in colder seasons compared with the summer season, although the crude rates of these adverse events were low.

The impact of diagnosis: measuring the psychological response to being diagnosed with serious or potentially lethal cardiac disease in young competitive athletes.

AIM: To determine the psychological impact of athletes diagnosed with cardiac disease. METHODS AND DESIGN: Athletes diagnosed with cardiovascular disorders were recruited to complete the Impact of Event Scale (IES), a validated tool measuring responses to a traumatic event. IES scoring =0-88 (<12= normal, 12-32=recommend monitoring, >33=significant stress reaction). Subscales include: intrusion, avoidance and hyperarousal. RESULTS: 30 athletes (53% male, 83% Caucasian, median age 18.0, median age at diagnosis 15.7) participated. Diagnoses included: 6 hypertrophic cardiomyopathy, 9 Wolff Parkinson White, 4 Long QT syndrome, 3 atrial septal defect, 2 supraventricular tachycardia and 6 other. For the group, the mean IES-Revised (IES-R) score=16.6 (SD=12.1), subscales: intrusion 6.6 (SD=4.3), avoidance=7.4 (SD=6.5), hyperarousal=2.7 (SD=3.5). Higher risk individuals included: permanently disqualified athletes (p<0.01), athletes requiring daily medication (p<0.01), those with genetically inheritable conditions (p<0.01), and athletes undergoing medical management instead of definitive therapy (p<0.01). No differences were reported by gender (male=16.6, female=16.6). Higher IES-R scores were reported in more competitive athletes (college=17.8, high school=13.3; p=0.369) and African-American individuals (African-American=25.8, Caucasian=14.8 p=0.061), although not statistically significant. Athletes with cardiomyopathy (IES-R=24) and channelopathy (IES-R=28) reported the highest IES results. Athletes with high IES-R scores were most likely to psychologically respond through avoidance of feelings/situations/ideas. CONCLUSIONS: Athletes diagnosed with potentially lethal cardiac disorders are at risk for significant psychological distress. These athletes tend to avoid thoughts, feelings and conversations associated with their diagnosis and should be offered consistent emotional support to mitigate psychological morbidity. SIGNIFICANCE: Currently, there are no recommendations to guide physicians on how to support an athlete that is newly diagnosed with a potentially career altering heart condition. Proper planning and use of appropriate support mechanisms can be useful for emotionally vulnerable athletes.