Lower Gastrointestinal Bleeding Because of Kasabach-Merritt Syndrome Showing an Impressive Response to Sirolimus.

Kasabach-Merritt syndrome is a rare but life-threatening disease in which a rapidly growing vascular tumor induces localized intravascular coagulation, causing thrombocytopenia, microangiopathic hemolytic anemia, and consumption coagulopathy. It presents mainly in infants and young children. We present an adult with recurrent and severe lower gastrointestinal bleeding due to Kasabach-Merritt syndrome, treated successfully with sirolimus after multiple other failed interventions.

An Observational Study of Disparities in Telemedicine Utilization in Primary Care Patients Before and During the COVID-19 Pandemic.

Background: The rapid scale up of telemedicine due to the COVID-19 pandemic may have disadvantaged patients less able to use technology. Objectives: We tested the hypothesis that certain patient groups may have been disadvantaged in accessing primary care using telemedicine. Design: We compared visit type and patient characteristics for April-May 2019 with April-May 2020 at a large urban academic medical center. Variables of interest included age, gender, race, ethnicity, language, visit type, visit status, insurance type, and zip code to approximate average income. Results: There was a 5% increase in patient visits in the observation period from 2019 to 2020. Care shifted from 100% in person to 83% telemedicine, 60% of which occurred through video and 23% by telephone. In 2020, there was a significant increase in the percentage of older patients, patients of lower income, patients whose preferred language was not English, and patients without commercial insurance who accessed care. For patients who completed a telemedicine visit, racial minority status, Hispanic/Latino ethnicity, older age, and non-English language preference significantly increased the likelihood of a telephone visit compared with younger adult, white, non-Hispanic/Latino and English-preference patients. Conclusions: The increase in visits in 2020 and particularly visits by older, non-English preference and lower income patients, demonstrates that the telemedicine scale-up increased access and reached patients regardless of age, language, and income. However, varied usage of televideo and telephone visits for certain groups suggests the need to explore the differences between these modalities to ensure quality telemedicine care for all patients.

Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative.

OBJECTIVE: Perioperative neurocognitive disorder (PND) is now recognized as the most common postoperative complication in older surgical patients. Current multidisciplinary guidelines recommend simple cognitive screening of older adults before surgery. Patients identified at risk should have input from an interprofessional team with expertise caring for older surgical patients. Data suggest these recommendations are infrequently met. We set out to test feasibility of routine cognitive screening in a busy preoperative assessment clinic and establish a perioperative pathway with multidisciplinary support for patients identified at risk. METHODS: We undertook a prospective quality improvement study. A cohort of 1,803 older surgical patients scheduled for preoperative evaluation was screened with the Mini-Cog© test. As the project developed, we began confirmatory neurocognitive testing by occupational therapists for those patients flagged at risk. Patients confirmed at risk were referred for further evaluation by a geriatrician and geriatric pharmacist. Alerts were developed to flag patients at risk through their in-patient journey, and a multidisciplinary team developed a comprehensive care pathway. RESULTS: We demonstrated that implementing routine cognitive screening can be done in a busy clinic, regardless of prior experience. The prevalence of preoperative cognitive impairment was 21% in our older patients undergoing inpatient surgery, rising to 36% in those older than 85 years. When the Mini-Cog results were not known to providers, they were unable to identify cognitive impairment in half of the patients, supporting the use of a validated screening test. We established an interprofessional team and pooled relevant recommendations into an age-friendly perioperative care pathway for patients at increased cognitive risk. CONCLUSION: Cognitive screening must be done to reliably identify older surgical patients at risk of PND. Demonstrating the prevalence of cognitive impairment in older surgical patients can provide impetus to develop a multidisciplinary team and care pathway with the aim of reducing the incidence of PNDs. J Am Geriatr Soc 68:2359-2364, 2020.

A Bosphorus submarine passage and the reinvention of neurosurgery.

One of the major themes characterizing the emergence of modern neurosurgery has been the concept of technology transfer and the application of a broad spectrum of revolutionary elements of technology from both physical and biological science. These transference applications are now apparent in modern neurosurgery as it is practiced on all continents of the globe. More than 3 decades ago, these ideas that now have come to fruition were in states of formulation. This article describes and further documents one such fertile cauldron of ideas and practical realities--the United States Navy Nuclear Submarine Service and its role and affect on the life and professional career of an academic neurosurgeon who was active in areas of progress as modernity was established for the early 21st century.