Citations

Background: As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities. Methods: Using the National Inpatient Sample (NIS) database, all anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (RSA) procedures from 2011 to 2017 were analyzed. The patients were divided into the Black, Hispanic, and White groups. Results: Overall, 91.4% of the patients undergoing any shoulder arthroplasty procedure were White, 4.75% were Black, and 3.85% were Hispanic. Age and sex-standardized RSA utilization rates (per 100,000) in White patients increased by 139% from 6.94 in 2011 to 16.60 in 2017. The disparity for Black patients, compared with White patients, was 118% in 2011 and 124% in 2017; the disparity for Hispanic patients was 112% in 2011 and 103% in 2017. Similar disparities in aTSA utilization rates were seen; when compared with White patients, there was a 150% disparity in 2011 and a 197% disparity in 2017 for Black patients, and a 169% disparity in 2011 and a 262% disparity in 2017 for Hispanic patients. Finally, Blacks had a higher rate of non-home discharge, longer length of stay, and higher overall costs, while Hispanics had a longer length of stay and higher cost than Whites. Conclusions: Despite many efforts to reduce racial disparities in health-care utilization, the chasm in shoulder arthroplasty in the United States appears to be large and widening further. The exponential increase in utilization of shoulder arthroplasty has not been shared equally among races, and the disparities are larger than those reported in lower-extremity arthroplasty.

AbstractBackgroundGastrostomy tubes placed radiologically, endoscopically or surgically facilitate long‐term home enteral nutrition (HEN). Patient‐specific clinical factors may affect placement techniques, confounding direct comparisons between radiologically inserted gastrostomy (RIG) and percutaneous endoscopic gastrostomy (PEG) outcomes. This study sought to evaluate the differences in clinical outcomes in patients undergoing gastrostomy tube placement by interventional radiologists or gastroenterologists.MethodsA single‐center prospective trial randomizing patients initiating HEN to RIG or PEG was conducted between March 2018 and June 2021. Patients were followed until the time of gastrostomy removal or until 9 months after tube placement. Tracked complications included peritonitis, abscess, bleeding, bowel perforation, and tube occlusion, malposition, or damage. Periprocedural pain rating and quality of life (QoL) surveys were collected.ResultsForty‐two patients were randomized to RIG or PEG. Twenty patients underwent RIG (mean age, 63.0 ± 11.7 years; 85% male; 95% with head and neck cancer) and 22 patients underwent PEG (mean age, 66.3 ± 10.9 years; 81.8% male; 90.9% with head and neck cancer). RIG and PEG groups had 4.18 ± 5.49 and 2.80 ± 5.82 complications per 1000 HEN days, respectively (P = 0.357). The most frequent complications were tube malposition and abscess formation for the RIG and PEG groups, respectively. No major complications occurred in either group. There was no difference in the average of pain ratings in all pain inventory components across both groups. Both groups reported improvement in overall QoL after gastrostomy tube placement (P = 0.532).ConclusionRIG is noninferior to PEG regarding complication rates, pain, and QoL when compared in a prospective randomized fashion.

A previously healthy and active middle-aged woman acquired COVID-19 as an occupational exposure with subsequent persistent post-COVID-19 symptoms including headache, dyspnoea on exertion, chest pressure, tachycardia, anosmia, parosmia, persistent myalgia, vertigo, cognitive decline and fatigue. She presented to a tertiary medical centre for further evaluation after 9 months of persistent symptoms and had a largely unremarkable workup with the exception of a persistently elevated monocyte chemoattractant protein 1, blunted cardiovagal response and non-specific scattered areas of low-level hypometabolism at the bilateral frontal, left precuneus, occipital and parietal regions on PET scan.

Objective: The purpose of this pilot study was to evaluate the safety and use of a nature-based virtual reality (VR) experience among health care providers (HCP) during a pandemic. Methods: Twenty-four frontline HCP participated in this crossover pilot where the viewing order of the experiences were randomized. All participants attended in-person consent, baseline, and end-of-study visits. The intervention consisted of viewing 2 nature-based scenes (“walk in the woods” and “forest of focus”) through 3-D VR and with computer 4K graphic imagery. Randomization took place with regards to the viewing order (VR vs 4K computer video, scene 1 and 2). Outcomes measured were safety, acceptability and changes in intensity of anxiety feelings, resilience, emotional distress, cognitive function, and self-efficacy. Results: Among the 26 HCP expressing interest in the study, 24 enrolled in this study. The majority were male (58.3%), white (66.7%) and of an average age of 46.3 ± 10.5 years (standard deviation (SD)). End of the study survey showed that almost all participants (96%) would participate in the study again and recommend it to others. Twenty-three of the 24 participants also felt relaxed after seeing the imagery. With respect to anxiety (as measured by the STAI Y1), the VR “walk in the woods” had the greatest reduction from pre to post (6.4 points, SD = 5.98) followed by VR “forest of focus” (5.8 points, SD = 9.29), computer screen “forest of focus” (5.0 points, SD = 8.89), and computer screen “walk in the woods” (4.1 points, SD = 6.22). All 4 sessions had a significant decrease in score from pre to post (P-values ≤.005), but there was no significant difference in the change from pre- to post-session between the 4 groups (P-value = .5835). Conclusion: The use of the VR among HCP has promise for reducing stress among health care providers during a high stress period, such as a pandemic but much larger studies are needed.

Objective: To evaluate the performance of an Electronic Health Record (EHR) integrated risk score for COVID-19 positive outpatients to predict 30-day risk of hospitalization. Patients and Methods: A retrospective observational study of 67 470 patients with COVID-19 confirmed by polymerase chain reaction (PCR) test between March 12, 2020 and February 8, 2021. Risk scores were calculated based on data in the chart at the time of the incident infection. Results: The Mayo Clinic COVID-19 risk score consisted of 13 components included age, sex, chronic lung disease, congenital heart disease, congestive heart failure, coronary artery disease, diabetes mellitus, end stage liver disease, end stage renal disease, hypertension, immune compromised, nursing home resident, and pregnant. Univariate analysis showed all components, except pregnancy, have significant ( P < .001) association with admission. The Mayo Clinic COVID-19 risk score showed a Receiver Operating Characteristic Area Under Curve (AUC) of 0.837 for the prediction of admission for this large cohort of COVID-19 positive patients. Conclusion: The Mayo Clinic COVID-19 risk score is a simple score that is easily integrated into the EHR with excellent predictive performance for severe COVID-19. It can be leveraged to stratify risk for severe COVID-19 at initial contact, when considering therapeutics or in the allocation of vaccine supply.

AbstractBackgroundMalnutrition is underrecognized and underdiagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high‐risk patients with malnutrition remains low despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models.MethodsThis survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth.ResultsOf 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p < .0001). Most responding physicians (46/57; 80.7%) reported being a member of NSTs, compared with 56.5% (88/156) of dietitians. Of those not practicing in NSTs (N = 81/235, 34.4%), 12.3% (10/81) reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (115/235; 48.9%), followed by leadership (72/235; 30.6%), and healthcare professional (HCP) interest (55/235; 23.4%). A majority (173/235; 73.6%) of all respondents wanted additional training in nutrition but reported insufficient protected time, ability to travel, or support from administrators or other HCPs.ConclusionCore actions resulting from this survey focused on formalizing physician roles, increasing interdisciplinary nutrition support expertise, utilizing cost‐effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.

AbstractAs the prevalence of smoking continues to decline, dietary factors are rapidly becoming the leading preventable cause of disease. Diet and obesity are also leading to a shift in cancer prevalence with increases noted in breast, liver, pancreas, and uterine cancers. Once cancer is detected, obesity is also associated with poorer outcomes with therapy as well as higher morbidity and mortality. Key factors are associated with the link between obesity and cancer including chronic inflammation, change in sex hormones, alteration in insulin‐IGF‐1 axis, alteration in adipokines, as well as cancer stem cells that are derived from adipose tissue. Because of these associations, a great deal of effort is being placed in implementing lifestyle changes that mitigate obesity‐associated factors that contribute to development of cancer, reduce side effects of treatment, and improve survival. Ketogenic diet is emerging as an attractive option in countering obesity‐related tumor‐promoting factors, as it is associated with weight loss as well as a reduction in insulin resistance and inflammation. Ketogenic diet can also deprive cancer cells of glucose, a fuel source that is predominantly used by many cancer lines through aerobic glycolysis in the setting of dysregulated mitochondria. Current manuscript reviews the theoretical benefits for use of ketogenic diet in cancer as well as the data available from clinical trials.

AbstractBackgroundPatients with headand neck cancer (HNC) are at high risk for malnutrition before and during chemoradiation treatment. Many will also require tube feeding to address declines in energy intake, weight, and quality of life (QOL) caused by the impact of treatment on gastrointestinal (GI) symptoms. Blenderized tube feeding (BTF) may ameliorate these adverse conditions.MethodsIn this open‐label, prospective pilot study, 30 patients with HNC who required feeding tube placement were recruited to switch from standard commercial formula after 2 weeks to a commercially prepared BTF formula. Weight, body mass index (BMI), GI symptoms, and QOL scores were tracked for 6 weeks from the first week of feeding tube placement.ResultsOf the 16 patients who completed the 6‐week assessment period, weights and BMI scores for 15 patients trended upward. For most patients, QOL and oral intake increased and GI symptoms decreased over the 6‐week period, particularly during weeks 3 and 4, when the impact of treatment is particularly exacting on patients with HNC.ConclusionBTF effectively mitigated weight loss, GI symptoms, QOL scores, and total energy intake in this group of patients with HNC who received tube feeding for 6 weeks.

Abstract Coronavirus disease 2019 (COVID‐19), after initially being detected in Wuhan, China in late 2019, quickly spread to most regions of the world, meeting World Health Organization criteria for a pandemic. Social distancing along with other measures implemented to control spread had a drastic impact on the provision of healthcare including deferred elective procedures and surgeries as well as delayed care and evaluation for emergent diagnoses such as heart attacks and strokes. In the home nutrition practice, patients began to delay routine laboratory tests and were canceling or deferring annual visits. Our group soon began to rapidly deploy telehealth to meet the needs of the home nutrition patients. Telehealth is not a new concept with descriptions of healthcare being provided at a distance with the use of telephone in the 1870s. However, widespread adoption has been limited because of regulation (licensure, prescriptions, credentialing, and privileges), lack of reimbursement, as well as adoption and availability of technology needed to carry out telehealth visits. As regulations and limits on reimbursements were waived during COVID‐19 pandemic, our home nutrition practice began to evaluate core components of the care we provide for our patients and assess which could be successfully transitioned to telehealth. In addition to the history and regulation of telehealth, the current manuscript provides details regarding successful implementation of telehealth visits such as change management, selection of telehealth platform, scheduling and logistics, as well as carrying out the virtual visit including history and physical exam.