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OBJECTIVE The COVID-19 pandemic led to many changes across medical organizations and graduate medical education programs nationwide including the rapid implementation of telemedicine as a modality for delivering health care. The purpose of this study was to investigate the telemedicine experiences of residents and fellows with their self-reported level of preparedness, impact on their education including precepting, skill development, and patient-physician relationships, and perceptions of telehealth platforms and curricula in the future. METHODS A total of 365 Mayo Clinic residents and fellows across three sites (Florida, Arizona, and Minnesota) were identified as trainees who conducted at least one telemedicine encounter from January 1, 2020 to June 30, 2020 and were sent an electronic survey by e-mail. RESULTS There was a total of 103 completed surveys across various specialties with 58.3% female respondents, 63.1% residents, 35.0% fellows and 77.7% of respondents who attended medical school in the United States. Most trainees reported having very little to no exposure to telemedicine in their medical careers before the pandemic. The majority were satisfied with their first telemedicine encounter and found precepting comparable to in-person visits. The trainees in this study had a favorable view with 98.1% believing telemedicine will play a more prevalent role in the future and most agreed this should be included in medical school and residency training. CONCLUSION Our survey found that after the implementation of telemedicine during the COVID-19 pandemic, the experiences of trainees at a multi-site academic center were overall positive. More research is needed on the perceptions of skill development (physical exam and history taking) during a telemedicine encounter and outlining an optimal telemedicine curriculum that can improve confidence in trainees.

AbstractThe Adult Medical Care Coordination program (“the program”) was implemented at Mayo Clinic to promote patient self‐management and improve 30‐day unplanned readmission for patients with high risk for readmission after hospital discharge. This study aimed to evaluate the impact of the program compared to usual care using a pragmatic, stepped wedge cluster randomized trial (“stepped wedge trial”). However, several challenges arose including large differences between the study arms. Our goal is to describe the challenges and present lessons learned on how to overcome such challenges and generate evidence to support practice decisions. We describe the challenges encountered during the trial, the approach to addressing these challenges, and lessons learned for other learning health system researchers facing similar challenges. The trial experienced several challenges in implementation including several clinics dropping from the study and care disruptions due to COVID‐19. Additionally, there were large differences in the patient population between the program and usual care arms. For example, the mean age was 76.8 for the program and 68.1 for usual care. Due to these differences, we adapted the methods using the propensity score matching approach that is traditionally applied to observational designs and adjusted for differences in observable characteristics. When conducting pragmatic research, researchers will encounter factors beyond their control that may introduce bias. The lessons learned include the need to weigh the tradeoffs of pragmatic design elements and the potential value of adaptive designs for pragmatic trials. Applying these lessons would promote the successful generation of evidence that informs practice decisions.

Background: The pathogenesis of human Inflammatory Bowel Disease (IBD) is a multifactorial process including interaction between immune, epithelial, and environmental factors. Growing evidence suggests that epithelial cell defects play major role in the pathogenesis of IBD. Epigenetic memory involves lasting, cell-type specific modifications to chromatin at multiple scales, which impacts transcriptional programs required for normal cell functions. A major gap in knowledge are the mechanisms involved in establishing and maintaining memory in cell types and diseases of the intestine. The objective of this study was to determine if intestinal epithelial cells (IECs) retain a memory of altered chromatin architectures and resultant regulation following inflammation. The hypothesis was that the IECs would show lasting altered chromatin structure landscapes (epigenetic memory) in response to inflammation. Methods: We have developed a multicellular model system of IBD using adult stem cell derived organoids from humans with IBD, from regions of the colon with and without active inflammation. We performed ATAC-seq, bulk RNA-seq and single cell RNA-seq on these organoids derived from the uninflamed and inflamed tissues of IBD patients, specifically Ulcerative Colitis (UC). Results: Regions of increased chromatin accessibility are enriched in organoids derived from areas of inflammation in UC patients compared to organoids from patient-matched, uninflamed regions. These open chromatin regions are associated with proinflammatory genes, with modest transcriptional alterations, pointing to an epigenetic inflammatory memory. Motif analysis for accessibly peaks in UC showed an enrichment of the AP-1 family of transcription factors and chromatin remodelers (SMARCA4). This data is consistent with other studies of inflammatory memory from other epithelial cell types, but we show this for the first time in IECs in the context of IBD. Conclusions: This study presents a novel line of investigation and development of model systems to examine epigenetic memory of IECs in human IBD. We expect that our studies will identify new chromatin-based mechanisms of IEC function that are impacted by inflammation. This research was funded by American Gastroenterological Association Research Scholar Award and KL2 Scholar Career Development Award (KL2 TR002379, National Center for Advancing Translational Science). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Abstract Introduction Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test–treatment thresholds for ED delirium screening. Methods We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta‐analysis and estimated delirium screening thresholds. Results Full‐text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta‐analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7–20.7) and rule out (pooled negative likelihood ratio [LR−] 0.18, 95% CI 0.09–0.34) delirium. We also conducted meta‐analysis of two studies that quantified the accuracy of the Abbreviated Mental Test‐4 (AMT‐4) and found that the pooled LR+ (4.3, 95% CI 2.4–7.8) was lower than that observed for the 4AT, but the pooled LR− (0.22, 95% CI 0.05–1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. Conclusions The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED‐based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM‐ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single‐center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single‐center study.

INTRODUCTION: Although hysterectomy is one of the most common surgical procedures performed in the United States, preoperative patient counseling regarding removal or preservation of the cervix, fallopian tubes, and ovaries during benign hysterectomy is far from standardized. We aimed to understand patients' preexisting values, beliefs, and preferences regarding removal or preservation of the cervix, ovaries, and fallopian tubes at the time of benign hysterectomy. METHODS: We performed a qualitative study using semistructured interview of patients referred for benign hysterectomy with a minimally invasive gynecologic surgery division. Participants were recruited according to prespecified diversity axes. The interview guide was informed by literature review, expert stakeholders, and pilot testing. Telephone interviews occurred prior to their scheduled consultation with a surgeon. Responses were analyzed for themes using Rapid and Rigorous Data Qualitative Analysis. IRB approval was obtained. RESULTS: Age of participants (n=13) ranged from 24 to 60. Participants reported their race as non-Hispanic White (n=6), non-Hispanic Black (n=3), Hispanic (n=2), and multiracial or another race (n=2). Participants reported use of commercial insurance (n=8), Medicaid/Medicare (n=2), or self-pay/financial assistance (n=3). Identified themes included knowledge, decision making, treatment goals, short- and long-term consequences, fertility, identity, and lack of concern. Many participants expressed lacking necessary knowledge of the risks and benefits of removing the cervix and adnexa. Treatment goals included symptom relief and definitive treatment. Long-term consequences included concerns about menopause and future cancer. CONCLUSION: Prior to counseling, many patients express some degree of lack of knowledge, desire to remove most or all pelvic structures, and no attachment to their reproductive organs. Many patients expressed making decisions based on how organ removal will relieve current symptoms and long-term consequences, rather than immediate surgical risk, which can inform patient-centered counseling by their surgeon.