Asynchronous Telepsychiatry: A Component of Stepped Integrated Care.

OBJECTIVE: Integrated behavioral healthcare models typically involve a range of consultation options for mental healthcare. Asynchronous telepsychiatry (ATP) consults may be an additional potential choice, so we are conducting a 5-year clinical trial comparing ATP with synchronous telepsychiatry (STP) consultations. METHODS: Patients referred by primary care providers are randomly assigned to one of the two treatment groups, ATP or STP. Clinical outcome, satisfaction, and economic data are being collected from patients for 2 years at 6-month intervals. RESULTS: Baseline characteristics for the first 158 patients and case examples of ATP are presented. CONCLUSION: Implementing ATP in existing integrated behavioral healthcare models could make mental healthcare more efficient.

Transcultural psychiatry made simple--asynchronous telepsychiatry as an approach to providing culturally relevant care.

OBJECTIVE: To examine the feasibility and diagnostic reliability of asynchronous telepsychiatry (ATP) consultations in Spanish and ATP consultation with Spanish-to-English translation. SUBJECTS AND METHODS: Twenty-four interviews of Spanish-speaking patients were videorecorded by a bilingual clinician who also collected patient history data and gave the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to each patient. The ATP data (video of the interview and patient history) were forwarded for psychiatric consultation and a diagnostic assessment by the investigators. The ATP data were then examined separately by two Spanish-speaking psychiatrists, before being translated into English and then re-examined by two English-speaking psychiatrists. Agreement between the expert diagnoses of the investigators and the diagnoses from the Spanish consultations, the Spanish-to-English translated consultations, and the SCID-I results was assessed using kappa statistics. RESULTS: We found acceptable levels of agreement for major diagnostic groupings among the Spanish- and English-speaking psychiatrists. Kappa values for diagnostic agreement between the expert and the translated consultations, the original language consultations, and the SCID-I were at least 0.52 (percentage agreement, 79%) and higher. CONCLUSIONS: ATP consultations in Spanish, and those translated from Spanish to English, are feasible, and broad diagnostic reliability was achieved. The ATP process allows for rapid language translation. This approach could be useful across national boundaries and in numerous ethnic groups. Cross-language ATP may also offer significant benefits over the use of real-time interpreting services and has the potential to improve the quality of care by allowing for the addition of culturally relevant information.

The P3-model of perioperative psychological preparation: Pre-surgical and pre-medical procedural psychological preparation and psychophysiological interventions.

Applied psychophysiological and psychological interventions can support successful post-surgical outcomes among patients who undergo surgical or medical procedures. However, more translational research is needed to extend the current understandings and practices of evidence-based and evidence-informed behavioral interventions to improve the outcomes of surgical and medical procedures. As healthcare becomes increasingly integrative, biopsychosocial oriented practitioners (e.g., health psychologists, neuropsychologists, pain psychologists, psychiatrists, nurses) will play an integral role with surgical and interventional professionals (e.g., neurosurgeons, bariatric surgeons, anesthesiologist, transplant surgeons, interventionalist, radiologist). These roles include pre-surgical evaluations, identifying pre-emptive concerns and implementing behavioral interventions, which ultimately act to improve the outcome of the surgery or medical procedure. In this paper, the authors 1) review the status of the broader practice of perioperative behavioral interventions; 2) review the pre-surgical and pre-procedural behavioral risk factors and translate psychophysiological and behavioral interventions to optimize post-surgical and post-procedural outcomes; and 3) provide a general framework (P3-Model) that can be used in a perioperative practice to carry out pre-surgical and pre-procedural behavioral interventions. Specifically, the role of behavioral and biofeedback interventions in the preparation of patients who are undergoing surgeries and medical procedures will be detailed. Psychological preparation that addresses pre-surgical and pre-medical procedure behavioral risk factors help perioperative healthcare providers and patients to have maximal post-operative success.

PsychVACS: a system for asynchronous telepsychiatry.

OBJECTIVE: To describe the technical development of an asynchronous telepsychiatry application, the Psychiatric Video Archiving and Communication System. METHODS: A client-server application was developed in Visual Basic.Net with Microsoft(®) SQL database as the backend. It includes the capability of storing video-recorded psychiatric interviews and manages the workflow of the system with automated messaging. RESULTS: Psychiatric Video Archiving and Communication System has been used to conduct the first ever series of asynchronous telepsychiatry consultations worldwide. A review of the software application and the process as part of this project has led to a number of improvements that are being implemented in the next version, which is being written in Java. CONCLUSIONS: This is the first description of the use of video recorded data in an asynchronous telemedicine application. Primary care providers and consulting psychiatrists have found it easy to work with and a valuable resource to increase the availability of psychiatric consultation in remote rural locations.

Disruptive innovation: the future of healthcare?

The traditional face-to-face doctor-patient relationship is the core of conventional medical practice. One key aspect of this changing relationship is the increasing dependency on asynchronous data collection in clinical consultations. Such electronic communications and data streams may be numeric, text-based, audio, digitized still pictures, video and radiologic, as well as emanating from multiple medical devices. While asynchronous medicine may be established in specialties like radiology and dermatology, there is little research regarding the use of asynchronous medicine in areas of medicine that traditionally rely on the physical doctor-patient interaction such as primary care, internal medicine, geriatrics, and psychiatry. The practice of psychiatry stands out as a discipline that is highly dependent on the quality of the physical meeting between the doctor and the patient, yet even in this specialty it is possible to utilize asynchronous medicine for some types of psychiatric consultations. Asynchronous medicine has the potential to be significantly disruptive to our current healthcare processes, as well as more clinically and economically efficient.

Comparing the 5-Year Diabetes Outcomes of Sleeve Gastrectomy and Gastric Bypass: The National Patient-Centered Clinical Research Network (PCORNet) Bariatric Study.

Importance: Bariatric surgery can lead to substantial improvements in type 2 diabetes (T2DM), but outcomes vary across procedures and populations. It is unclear which bariatric procedure has the most benefits for patients with T2DM. Objective: To evaluate associations of bariatric surgery with T2DM outcomes. Design, Setting, and Participants: This cohort study was conducted in 34 US health system sites in the National Patient-Centered Clinical Research Network Bariatric Study. Adult patients with T2DM who had bariatric surgery between January 1, 2005, and September 30, 2015, were included. Data analysis was conducted from April 2017 to August 2019. Interventions: Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Main Outcome and Measures: Type 2 diabetes remission, T2DM relapse, percentage of total weight lost, and change in glycosylated hemoglobin (hemoglobin A1c). Results: A total of 9710 patients were included (median [interquartile range] follow-up time, 2.7 [2.9] years; 7051 female patients [72.6%]; mean [SD] age, 49.8 [10.5] years; mean [SD] BMI, 49.0 [8.4]; 6040 white patients [72.2%]). Weight loss was significantly greater with RYGB than SG at 1 year (mean difference, 6.3 [95% CI, 5.8-6.7] percentage points) and 5 years (mean difference, 8.1 [95% CI, 6.6-9.6] percentage points). The T2DM remission rate was approximately 10% higher in patients who had RYGB (hazard ratio, 1.10 [95% CI, 1.04-1.16]) than those who had SG. Estimated adjusted cumulative T2DM remission rates for patients who had RYGB and SG were 59.2% (95% CI, 57.7%-60.7%) and 55.9% (95% CI, 53.9%-57.9%), respectively, at 1 year and 86.1% (95% CI, 84.7%-87.3%) and 83.5% (95% CI, 81.6%-85.1%) at 5 years postsurgery. Among 6141 patients who experienced T2DM remission, the subsequent T2DM relapse rate was lower for those who had RYGB than those who had SG (hazard ratio, 0.75 [95% CI, 0.67-0.84]). Estimated relapse rates for those who had RYGB and SG were 8.4% (95% CI, 7.4%-9.3%) and 11.0% (95% CI, 9.6%-12.4%) at 1 year and 33.1% (95% CI, 29.6%-36.5%) and 41.6% (95% CI, 36.8%-46.1%) at 5 years after surgery. At 5 years, compared with baseline, hemoglobin A1c was reduced 0.45 (95% CI, 0.27-0.63) percentage points more for patients who had RYGB vs patients who had SG. Conclusions and Relevance: In this large multicenter study, patients who had RYGB had greater weight loss, a slightly higher T2DM remission rate, less T2DM relapse, and better long-term glycemic control compared with those who had SG. These findings can help inform patient-centered surgical decision-making.

High Resolution 3D Models for the Teaching of American Sign Language.

Millions of Americans in all age groups are affected by deafness and impaired hearing. They communicate with others using the American Sign Language (ASL). Teaching is tutorial (person-to-person) or with limited video content. We believe that high resolution 3D models and their animations can be used to effectively teach the ASL, with the following advantages over the traditional teaching approach: a) signing can be played at varying speeds and as many times as necessary, b) being 3-D constructs, models can be viewed from diverse angles, c) signing can be applied to different characters (male, female, child, elderly, etc.), d) special editing like close-ups, picture-in-picture, and phantom movements, can make learning easier, and e) clothing, surrounding environment and lighting conditions can be varied to present the student to less than ideal situations.

The State of Open Source Electronic Health Record Projects: A Software Anthropology Study.

BACKGROUND: Electronic health records (EHR) are a key tool in managing and storing patients' information. Currently, there are over 50 open source EHR systems available. Functionality and usability are important factors for determining the success of any system. These factors are often a direct reflection of the domain knowledge and developers' motivations. However, few published studies have focused on the characteristics of free and open source software (F/OSS) EHR systems and none to date have discussed the motivation, knowledge background, and demographic characteristics of the developers involved in open source EHR projects. OBJECTIVE: This study analyzed the characteristics of prevailing F/OSS EHR systems and aimed to provide an understanding of the motivation, knowledge background, and characteristics of the developers. METHODS: This study identified F/OSS EHR projects on SourceForge and other websites from May to July 2014. Projects were classified and characterized by license type, downloads, programming languages, spoken languages, project age, development status, supporting materials, top downloads by country, and whether they were "certified" EHRs. Health care F/OSS developers were also surveyed using an online survey. RESULTS: At the time of the assessment, we uncovered 54 open source EHR projects, but only four of them had been successfully certified under the Office of the National Coordinator for Health Information Technology (ONC Health IT) Certification Program. In the majority of cases, the open source EHR software was downloaded by users in the United States (64.07%, 148,666/232,034), underscoring that there is a significant interest in EHR open source applications in the United States. A survey of EHR open source developers was conducted and a total of 103 developers responded to the online questionnaire. The majority of EHR F/OSS developers (65.3%, 66/101) are participating in F/OSS projects as part of a paid activity and only 25.7% (26/101) of EHR F/OSS developers are, or have been, health care providers in their careers. In addition, 45% (45/99) of developers do not work in the health care field. CONCLUSION: The research presented in this study highlights some challenges that may be hindering the future of health care F/OSS. A minority of developers have been health care professionals, and only 55% (54/99) work in the health care field. This undoubtedly limits the ability of functional design of F/OSS EHR systems from being a competitive advantage over prevailing commercial EHR systems. Open source software seems to be a significant interest to many; however, given that only four F/OSS EHR systems are ONC-certified, this interest is unlikely to yield significant adoption of these systems in the United States. Although the Health Information Technology for Economic and Clinical Health (HITECH) act was responsible for a substantial infusion of capital into the EHR marketplace, the lack of a corporate entity in most F/OSS EHR projects translates to a marginal capacity to market the respective F/OSS system and to navigate certification. This likely has further disadvantaged F/OSS EHR adoption in the United States.

Intraoperative incidents and complications in primary arthroscopic anterior cruciate ligament reconstruction.

PURPOSE: To analyze intraoperative incidents and complications in primary arthroscopic anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) and quadruple hamstring semitendinosus and gracilis (STG) grafts. METHODS: From January 1999 to June 2004, we performed 330 BPTB and 96 STG procedures. Intraoperative incidents and complications were recorded for each case. RESULTS: Our overall intraoperative incident and complication rate was 9.6% and was higher in the STG group (13.5%) than in the BPTB group (8.7%). In the BPTB group, combined incidents and complications according to stage of the procedure consisted of graft harvesting, 4 cases (1.21%); tunnel placement, 9 cases (2.7%); and graft fixation, 15 cases (4.5%). In the STG group, combined incidents and complications included graft harvesting, 8 cases (8.3%); tunnel placement, 1 case (1%); graft fixation, 3 cases (3.1%); and others, 1 case (1%). In 4 patients (0.9%), we had to change the technique from BPTB to STG and vice versa. In 2 STG cases, conversion of the technique was required because of graft-related problems; in the third case, it was necessary because of fixation. One BPTB was converted to STG because the graft was completely transected as a result of improper screw fixation technique. CONCLUSIONS: None of the encountered incidents and complications had an adverse effect on final stability or on range of motion in operated knees. All incidents and complications were due to technical errors that occurred during graft harvesting, tunnel placement, or graft fixation. It is known that technical errors are preventable if careful surgical technique is followed. The surgeon must be well versed in various reconstruction techniques to be able to detect and resolve forthcoming incidents or complications. Backup implants are mandatory. LEVEL OF EVIDENCE: IV, therapeutic case series.

A software communication tool for the tele-ICU.

The Tele Intensive Care Unit (tele-ICU) supports a high volume, high acuity population of patients. There is a high-volume of incoming and outgoing calls, especially during the evening and night hours, through the tele-ICU hubs. The tele-ICU clinicians must be able to communicate effectively to team members in order to support the care of complex and critically ill patients while supporting and maintaining a standard to improve time to intervention. This study describes a software communication tool that will improve the time to intervention, over the paper-driven communication format presently used in the tele-ICU. The software provides a multi-relational database of message instances to mine information for evaluation and quality improvement for all entities that touch the tele-ICU. The software design incorporates years of critical care and software design experience combined with new skills acquired in an applied Health Informatics program. This software tool will function in the tele-ICU environment and perform as a front-end application that gathers, routes, and displays internal communication messages for intervention by priority and provider.

A feasibility study of the use of asynchronous telepsychiatry for psychiatric consultations.

OBJECTIVE: This study examined the feasibility of conducting psychiatric consultations using asynchronous, or store-and-forward, video-based telepsychiatry. METHODS: Video-recorded 20- to 30-minute assessments of 60 nonemergency, English-speaking adult patients in a medically underserved county in California were uploaded along with other patient data to a Web-based record. Two psychiatrists then used the record to provide psychiatric consultations to the referring primary care providers. RESULTS: Eighty-five percent of patients received diagnoses of mood disorders, 32% diagnoses of substance use disorders, 53% diagnoses of anxiety disorders, and 5% other axis I diagnoses. Psychiatrists recommended short-term medication changes for 95% of the patients and provided guidelines for possible future changes. CONCLUSIONS: This study-the first study of asynchronous telepsychiatry to be published-demonstrated the feasibility of this approach. This type of assessment should not replace the face-to-face psychiatric interview, but it may be a very helpful additional process that improves access to care and expertise.

Método indirecto para calcular la masa renal: su aplicación en la determinación de la filtración glomerular por gramo de masa renal / An indirect method to calculate mass: its application to the determination of glomerular filtration rate per gram of renal tissue

En ratas se ha demostrado que la abllación renal ocasiona hiperfiltración glomerular, hipertensión arterial y finalmente insuficiencia renal. Raij demostró que al calcular la filtración glomerular por gramo de masa renal, dicha hiperfiltración es menor. En seres humanos con un solo riñón seguidos a largo plazo no se han demostrado alteraciones significativas en la función renal o en la tensión arterial, aunque tambien presentan hiperfiltración. Con el objetivo de investigar la FG por gramo de masa renal en el ser humano se diseño un método no invasor utilizando ultrasonografía para calcular la masa renal. Se encontró un coeficiente de correlación entre el peso calculado y el renal de menos de 0.50 (p < 0.005). La correlación entre la FG por gramo de masa renal calculado y la FG por gramo de masa renal fue de más de 0.85 (p < 0.005)

Selección de receptores para transplante utilizando una computadora personal / Selection of transplantation recipients utilizing a personal computer

El trasplante de órganos a partir de donadores cadavéricos requiere de la participación de múltiples instituciones y una organización compleja para la obtención y óptimo aprovechamiento de los órganos. Para ello se ha creado la Coordinación de Centros de Referencia para Trasplante con sede en el Instituto Nacional de la Nutrición "Salvador Zubirán". Con el fin de lograr que dicha coordinación funcione lo más eficientemente posible, se desarrolló un programa para una computadora personal que ayuda a identificar en forma rápida (dos minutos), imparcial y certera a los mejores receptores de los 50 existentes en las 16 instituciones participantes. Dicho programa puede ser ejecutado por cualquier persona capaz de encender el equipo, cargar el programa y los discos necesarios en la computadora. El único dato que el usuario tiene que aportar es el grupo sanguíneo del potencial donador. Usando 6 criterios mayores de selección, sin ninguna otra intervención, la computadora proporciona listados de los potenciales receptores, sus domicilios y forma de localizarlos, su hospital de origen con los números telefónicos y extensiones necesarias y los nombres de sus médicos tratantes y la manera de localizarlos. Los criterios mayores de selección usados son: 1) compatibilidad por grupo sanguíneo, 2) tiempo de espera (antigüedad), 3) disponibilidad, 4) pruebas cruzadas con el donador, 5) grado de sensibilización, y 6) número de pruebas cruzadas previas

Efecto de la combinación de benzoato de sodio con lactulosa en la hiperamonemia experimental / Effect of sodium benzoate plus lactulose combination in experimental hyperammonemia

El benzoato de sodio se ha utilizado en el tratamiento de la encefalopatía hepática hiperamonémica con buenos resultados. Con el objeto de investigar si la combinación de benzoato de sodio con un disacárido (lactosa, lactulosa) tiene un efecto aditivo sobre la disminución de amonio plasmático, se estudió el efecto de la combinación de benzoato de sodio con lactulosa en el modelo de anastomosis portocava en la rata, ya que éste es el modelo experimental que produce mayores elevaciones de amonio en sangre. Se utilizaron ratas Wistar de 250-300 g de peso en las que se practicó una anastomosis porto-cava terminolateral. Diez días después de la operación se inició tratamiento experimental por un periodo de siete días, dividiendo a los animales en cuatro grupos: a) solución salina, b) B.S. 500 mg/kg/día, c) lactulosa 4 g/kg/día, d) benzoato de sodio más lactulosa (dosis anotadas). También se incluyeron un grupo de ratas normales y un grupo con operación ficticia como controles. Se tomaron muestras de sangre arterial al final del periodo de estudio y se determinó amonio por el método enzimático. Resultados. El benzoato de sodio y la lactulosa disminuyeron significativamente las concentraciones de amonio plasmático (437ñ50, 433ñ85 ug/dl, respectivamente) en comparación con el grupo control (638 ñ 50 ug/dl, p = 0.05), tal como se esperaba. La combinación de benzoato de sodio con lactulosa produjo una disminución de amonio aún mayor (264 ñ 17 ug/dl, p<0.001), lo cual apoya la existencia de un efecto aditivo entre ambos fármacos. Estos hallazgos parecen reproducirse en la clínica de acuerdo a estudios clínicos preliminares en los que se ha utilizado la combinación de lactosa con benzoato de sodio. Estos resultados sugieren que puede haber un efecto aditivo entre el benzoato de sodio y disacáridos como la lactulosa, lo cual podría aumentar la eficiencia del tratamiento e incluso disminuir la dosis total de medicamentos y aumentar la tolerancia a cada uno de los fármacos. Finalmente, se plantea la posibilidad de emplear otros fármacos derivados del benzoato de sodio