Cook, David J.

INTRODUCTION: Chronic gastrointestinal (GI) conditions, including irritable bowel syndrome and other disorders of gut-brain interaction, are prevalent and costly, and fragmented care contributes to suboptimal outcomes. Virtual and multidisciplinary care models may improve outcomes. Objectives: We aimed to (i) characterize patients receiving virtual GI care, (ii) report patient engagement with and patient-reported outcomes after virtual multidisciplinary care, and (iii) report healthcare utilization and costs from a payer perspective among patients vs propensity score-matched controls identified from claims data. METHODS: We collected descriptive data on patient demographics, clinic provider visits, symptoms, and patient-reported outcomes from 3/2021 to 9/2022. To evaluate healthcare utilization and costs, we conducted difference-in-difference analyses using claims data compared with a propensity score-matched control group. RESULTS: Among 234 patients (71% women, mean age 45.4 ± 13.2 years), 51% received a new GI diagnosis, predominately disorders of gut-brain interaction (63%). Engagement criteria were met by 80% (n = 187), who completed a mean of 10 visits and median time-to-first appointment of 6 days. Dietitians (93%), psychologists (76%), and health coaches (64%) were frequently used. Engaged patients exhibited significant improvements from preclinic to postclinic in irritable bowel syndrome severity (226.7–145.6), symptom control (20.2%–86.6%), quality-of-life dysphoria (27.5–32.8), missed workdays (1.0–0.7), and satisfaction (37.4%–96.3%) (all P < 0.05). Compared with matched controls, a significantly smaller percent of patients had imaging (15% vs 44%; P < 0.0001) and GI-related emergency department visits (4% vs 10%; P = 0.0028), which contributed to reductions in GI-related costs ($443 per member per month; P = 0.047) and all-cause costs ($676 per member per month; P = 0.043), equating to annualized savings of $5,316 and $8,112, respectively. DISCUSSION: Virtual multidisciplinary GI care was associated with high engagement, improved clinical outcomes, and reduced healthcare utilization and costs.

BACKGROUND Myofibromas are benign mesenchymal tumors, classically presenting in infants and young children in the head and neck region. Perineural involvement, especially in peripheral nerves within the upper extremity, is extremely rare in myofibromas. OBSERVATIONS The authors present the case of a 16-year-old male with a 4-month history of an enlarging forearm mass and rapidly progressive dense motor weakness in wrist, finger, and thumb extension. Preoperative imaging and fine needle biopsy confirmed the diagnosis of a benign isolated myofibroma. Given the dense paralysis, operative management was indicated, and intraoperative exploration showed extensive involvement of tumor within the radial nerve. The infiltrated nerve segment was excised along with the tumor, and the resulting 5-cm nerve gap was reconstructed using autologous cabled grafts. LESSONS Perineural pseudoinvasion can be an extremely rare and atypical feature of nonmalignancies, resulting in dense motor weakness. Extensive nerve involvement may still necessitate nerve resection and reconstruction, despite the benign etiology of the lesion.

Objectives: To evaluate the epidemiology of hyperammonemia unrelated to liver failure in the critical care setting. Design: Retrospective case series. Setting: Critically ill patients admitted to ICUs at Mayo Clinic, Rochester, MN (medical ICU, two mixed medical-surgical ICUs, coronary care unit, or the cardiosurgical ICU) between July 1, 2004, and October 31, 2015. Patients: Adult critically ill patients with hyperammonemia not related to acute or chronic liver failure. We excluded patients with diagnosis of moderate or severe liver disease, hyperbilirubinemia, and patients who denied the use of their medical records. Interventions: None. Measurements and Main Results: Of 3,908 ICU patients with hyperammonemia, 167 (4.5%) had no evidence of acute or chronic liver failure. One-hundred one patients (60.5%) were male with median age of 65.7 years (interquartile range, 50–74.5 yr) and median serum ammonia level of 68 µg/dL (interquartile range, 58–87 µg/dL). Acute encephalopathy was present in 119 patients (71%). Predisposing conditions included malnutrition 27 (16%), gastric bypass six (3.6%), total parenteral nutrition four (2.4%); exposure to valproic acid 17 (10%); status epilepticus 11 (6.6%), high tumour burden 19 (11.3%), and renal failure 82 (49.1%). Urea cycle defects were diagnosed in seven patients (4.1%). Hospital mortality was high (30%), and median ammonia level was higher among the nonsurvivors (74 vs 67 µg/dL; p = 0.05). Deaths were more likely in hyperammonemic patients who were older (p = 0.016), had greater illness severity (higher Acute Physiology and Chronic Health Evaluation III score, p < 0.01), malignancy (p < 0.01), and solid organ transplantation (p = 0.04), whereas seizure disorder was more common in survivors (p = 0.02). After adjustment, serum ammonia level was not associated with increased mortality. Conclusions: Hyperammonemia occurs in a substantial minority of critically ill patients without liver failure. These patients have a poor prognosis, although ammonia level per se is not independently associated with mortality. Serum ammonia should be measured when risk factors are present, such as nutritional deficiencies and protein refeeding, treatment with valproic acid, high tumour burden, and known or suspected urea cycle abnormalities.

Aims Total hip arthroplasty (THA) has well known subjective benefits, but little is known objectively about the recovery of mobility in the early post-operative period. Patients and Methods A total of 33 patients aged > 60 years who underwent elective primary THA had their activity monitored for 30 days post-operatively using an at-home (Fitbit) ankle accelerometer. Their mean age was 70.7 years (61 to 86); 15 (45.5%) were female. The rate of compliance and the mean level of activity were determined. Comparisons between subgroups based on age, body mass index (BMI), surgical approach, and the destination of the patients when discharged were also performed. Results The mean compliance over the 30 days was 26.7 days (16 to 30; 89%) of use. The mean number of steps increased from 235 (5 to 1152) to 2563 (87 to 7280) (p < 0.001) between the first and the 30th post-operative day. Age < 70 years and an anterior surgical approach were significantly associated with higher levels of activity (1600 to 2400 (p = 0.016 to 0.031) and 1000 to 1800 (p = 0.017 to 0.037) more steps per day, respectively) between the second and the fourth week post-operatively. There was also a trend towards higher levels of activity in those who were discharged to their home rather than to a nursing facility (a mean of 1500 more steps per day, p = 0.02). BMI greater or less than 30 kg/m 2 was not predictive of activity (p = 0.45 to 0.98). Conclusion At-home remote mobility monitoring using existing commercially available technology is feasible in patients who have undergone THA. It showed a clear trend towards increased activity with the passage of time. Additionally, the remote device was able to detect differences in levels of activity clearly between patients in relation to variables of interest including age, BMI, surgical approach, and the destination of the patient at the time of discharge from hospital. Such monitoring may allow for the early identification and targeted intervention in patients who recover slowly. Cite this article: Bone Joint J 2016;98-B:1450–4.

Objective: The objective of this investigation was to assess whether a new electronic health (e-health) platform, combining mobile computing and a content management system, could effectively deliver modular and “just-in-time” education to older patients following cardiac surgery. Subjects and Methods: Patients were provided with iPad ® (Apple ® , Cupertino, CA) tablets that delivered educational modules as part of a daily “to do” list in a plan of care. The tablet communicated wirelessly to a dashboard where data were aggregated and displayed for providers. Results: A surgical population of 149 patients with a mean age of 68 years utilized 5,267 of 6,295 (84%) of education modules delivered over a 5.3-day hospitalization. Increased age was not associated with decreased use. Conclusions: We demonstrate that age, hospitalization, and major surgery are not significant barriers to effective patient education if content is highly consumable and relevant to patients' daily care experience. We also show that mobile technology, even if unfamiliar to many older patients, makes this possible. The combination of mobile computing with a content management system allows for dynamic, modular, personalized, and “just-in-time” education in a highly consumable format. This approach presents a means by which patients may become informed participants in new healthcare models.

There is no single optimal set of conditions for cardio pulmonary bypass. What is optimal is determined by patient factors, surgical need, and the mechanics of perfusion. Additionally, the best way to manage bypass typically varies over its course.

Background— Renal insufficiency is associated with increased morbidity and mortality after cardiopulmonary bypass cardiac surgery. B-type natriuretic peptide is a cardiac hormone that enhances glomerular filtration rate and inhibits aldosterone. Cystatin has been shown to be a better endogenous marker of renal function than creatinine. Methods and Results— We performed a double-blinded placebo-controlled proof of concept pilot study in patients (n=40) with renal insufficiency preoperatively (defined as an estimated creatinine clearance of <60 mL/min determined by the Cockroft-Gault formula), undergoing cardiopulmonary bypass cardiac surgery. Patients were randomized to placebo (n=20) or IV low dose nesiritide (n=20; 0.005 μg/Kg/min) for 24 hours started after the induction of anesthesia and before cardiopulmonary bypass. Patients in the nesiritide group had an increase of plasma B-type natriuretic peptide and its second messenger cGMP with a decrease in plasma cystatin levels at the end of the 24-hour infusion. These changes were not observed in the placebo group. There was a significant activation of aldosterone in the placebo group at the end of the 24-hour infusion, but not in the nesiritide group. At 48 and 72 hours, there was a decrease in estimated creatinine clearance and an increase in plasma cystatin as compared with end of the 24-hour infusion in the placebo group. In contrast, renal function was preserved in the nesiritide group with no significant change in estimated creatinine clearance and a trend for plasma cystatin to increase as compared with end of the 24-hour infusion. Conclusion— This proof of concept pilot study supports the conclusion that perioperative administration of low dose nesiritide is biologically active and decreases plasma cystatin in patients with renal insufficiency undergoing cardiopulmonary bypass cardiac surgery. Further studies are warranted to determine whether these physiological observations can be translated into improved clinical outcomes.

Oncology services have been provided by telemedicine from the University of Kansas Medical Center (KUMC) for almost 10 years. We have analysed the costs associated with providing tele-oncology clinics to a rural Kansas town for two fiscal years, 1995 and 2000. The aim was to compare recent tele-oncology costs with those of the first year of tele-oncology practice. A study conducted in 1995 showed that the average cost was $812 per telemedicine consultation. Data from fiscal year 2000 showed that the average cost was $410 per telemedicine consultation, a decrease of almost 50%. As the tele-oncology practice in Kansas continues to grow, it can be expected that the costs associated with providing tele-oncology services will continue to decline.