Point-of-Care Synchronous Virtual Radiology Consultations for Atherosclerotic Disease in Primary Care: A Cluster-Randomized Study.

PURPOSE: Synchronous virtual visits are an emerging model of care, and their feasibility has been demonstrated in radiology. The purpose of this study was to assess the value of point-of-care virtual radiology primary care consultations for atherosclerotic vascular disease management. METHODS: In this institutional review board-approved study, 107 age- and gender-matched patients were assigned to control (n = 62) and intervention (n = 45) arms with the following inclusion criteria: (1) age > 45 years, (2) consult with a primary care physician (PCP), and (3) recent CT of the chest or abdomen demonstrating atherosclerotic calcification. In the intervention arm, virtual real-time radiology consultation with referring PCPs and patients was conducted, with review of CT images focused on the extent of vascular atherosclerosis. Patients in the control arm followed the current standard of care of PCPs' discussing relevant imaging results, if any. RESULTS: Thirty-one patients in the intervention arm and 31 patients in the control arm completed the study (control: 64.5% women; mean age, 68 years; intervention: 67.7% women; mean age, 67 years). Discussion of imaging findings occurred with all patients in the intervention arm (discussion with PCP and virtual consultation with radiologist) and with 45% of patients in the control arm (PCP only; P < .001). All patients in the intervention arm indicated that seeing or discussing their images improved their understanding of their disease, compared with 85% of patients in the control arm (P = .04). In the intervention arm, 10 of 31 patients (32.2%) left the visit with changes in prescriptions for statins or antihypertensive medications, compared with only 4 of 31 patients (13%) in the control arm (P = .04). CONCLUSIONS: Point-of-care radiology virtual visits enhance patient understanding and may influence the longitudinal management of atherosclerotic disease in primary care.

Point-of-Care Virtual Radiology Consultations in Primary Care: A Feasibility Study of a New Model for Patient-Centered Care in Radiology.

BACKGROUND: The goal of this study is to assess the value of point-of-care virtual consultations in radiology. METHODS: We conducted an institutional review board-approved feasibility study of video-based radiology consultations in an internal medicine primary care clinic at a quaternary academic medical center. The study included 3 primary care providers (PCPs) and enrolled 43 patients. Inclusion criteria consisted of the following: age > 18 years, English speaking, recent radiology examination at our institution, and patient consenting to participate. Patients completed a pre- and postvisit survey. PCPs completed a postvisit survey. Primary study end points included the effect on patient and provider satisfaction, effect on patient experience and understanding of medical condition, and impact on PCP's management decisions. Statistical significance was assessed using Fisher's exact test. RESULTS: Of the enrolled patients, 93% (n = 40 of 43) indicated that they were satisfied with the virtual consultation visit. The PCPs were satisfied with the virtual consultation in 97% of consultations (n = 42 of 43). In addition, 88% (n = 38 of 43) of patients indicated improved understanding of their medical condition as a result of the virtual consultation, and 91% of patients (n = 39 of 43) were interested in similar consultations in the future. The participating PCPs indicated that the consultation was helpful in their management decisions in 83% of visits. Patient's interest in receiving their imaging results from radiologist increased from 56% to 88% when comparing pre- and post-virtual consultation survey results (P = .03). CONCLUSION: Initial experience with virtual radiology consultations show high rates of patient and provider satisfaction. Virtual radiology consultations have the potential to advance radiology's value in care delivery.

Practice, Preferences, and Practical Tips From Primary Care Physicians to Improve the Care of Cancer Survivors.

PURPOSE: There is a need to improve the coordination of care and communication between primary care physicians (PCPs) and oncology after completion of initial cancer treatment. We sought to evaluate PCP experiences and perspectives in cancer survivorship and to identify practical opportunities to improve care within an integrated health care system with a shared electronic health record (EHR). METHODS: We conducted a self-administered, anonymous, electronic survey of PCPs in practices affiliated with an academic medical center to evaluate practices, the sense of preparedness, and preferences in the delivery of survivorship care and communication with oncology. RESULTS: One hundred seventeen of 225 PCPs responded (response rate, 52%). A majority were engaged in survivorship care, with 94% reporting managing psychological sequelae of cancer, 84% managing chronic physical complications, 71% screening for cancer recurrence, and 60% screening for late complications. However, few PCPs felt prepared to manage these issues: 65% felt unprepared to screen for late complications, and 36% felt unprepared to screen for recurrence. Common barriers to survivorship care were uncertainty about delegation of responsibility (73%) and a lack of training (72%). PCPs expressed strong interest in survivorship care plans, preferring active tracking of ongoing care needs and delegation of care responsibility in the EHR active problem list over traditional summary documents. CONCLUSION: Most PCPs are engaged in cancer survivorship care but report barriers to optimal care delivery. Opportunities to improve care could include targeted education to increase preparedness to deliver survivorship care, and optimization of communication among providers, including active survivorship care plans in the EHR.

Cluster Analysis Demonstrates the Need to Individualize Care for Cancer Survivors.

BACKGROUND: In efforts to inform clinical screening and development of survivorship care services, we sought to characterize patterns of health care needs among cancer survivors by (a) identifying and characterizing subgroups based on self-reported health care needs and (b) assessing sociodemographic, clinical, and psychosocial factors associated with these subgroups. METHODS: We conducted a cross-sectional self-administered survey among patients presenting for routine follow-up care for early-stage cancer at our academic medical center. Latent class cluster analysis was used to identify clusters of survivors based on survivorship care needs within seven domains. Multiple logistic regression analyses were used to assess factors associated with these clusters. RESULTS: Among 292 respondents, the highest unmet needs were related to the domains of side effects (53%), self-care (51%), and emotional coping (43%). Our analysis identified four clusters of survivors: (a) low needs (n = 123, 42%), (b) mainly physical needs (n = 46, 16%), (c) mainly psychological needs (n = 57, 20%), and (d) both physical and psychological needs (n = 66, 23%). Compared with cluster 1, those in clusters 2, 3, and 4 were younger (p < .03), those in clusters 3 and 4 had higher levels of psychological distress (p < .05), and those in clusters 2 and 4 reported higher levels of fatigue (p < .05). CONCLUSION: Unmet needs among cancer survivors are prevalent; however, a substantial group of survivors report low or no health care needs. The wide variation in health care needs among cancer survivors suggests a need to screen all patients, followed by tailored interventions in clinical care delivery and research. IMPLICATIONS FOR PRACTICE: The characterization of patients as having few needs, predominantly physical needs, predominantly psychological needs, or substantial needs that are both physical and psychological provides a productive framework for clinical care of cancer survivors and to guide further research in this field. Further research is needed to define the tailored information and services appropriate for each group of patients and to define optimal screening tools to efficiently identify the needs of individuals in oncology practice.

A Comparative Study Between Smartphone-Based Microscopy and Conventional Light Microscopy in 1021 Dermatopathology Specimens.

CONTEXT: The incorporation of high-resolution cameras into smartphones has allowed for a variety of medical applications including the use of lens attachments that provide telescopic, macroscopic, and dermatoscopic data, but the feasibility and performance characteristics of such a platform for use in dermatopathology have not been described. OBJECTIVE: To determine the diagnostic performance of a smartphone microscope compared to traditional light microscopy in dermatopathology specimens. DESIGN: A simple smartphone microscope constructed with a 3-mm ball lens was used to prospectively evaluate 1021 consecutive dermatopathology cases in a blinded fashion. Referred, consecutive specimens from the community were evaluated at a single university hospital. The performance characteristics of the smartphone platform were calculated by using conventional light microscopy as the gold standard. The sensitivity and specificity for the diagnosis of melanoma, nonmelanoma skin cancers, and other miscellaneous conditions by the phone microscopy platform, as compared with traditional light microscopy, were calculated. RESULTS: For basal cell carcinoma (n = 136), the sensitivity and specificity of smartphone microscopy were 95.6% and 98.1%, respectively. The sensitivity and specificity for squamous cell carcinoma (n = 94) were 89.4% and 97.3%, respectively. The lowest sensitivity was found in melanoma (n = 15) at 60%, although the specificity was high at 99.1%. The accuracy of diagnosis of inflammatory conditions and other neoplasms was variable. CONCLUSIONS: Mobile phone-based microscopy has excellent performance characteristics for the inexpensive diagnosis of nonmelanoma skin cancers in a setting where a traditional microscope is not available.

Conscientiousness is modified by genetic variation in catechol-O-methyltransferase to reduce symptom complaints in IBS patients.

BACKGROUND: Attention to and perception of physical sensations and somatic states can significantly influence reporting of complaints and symptoms in the context of clinical care and randomized trials. Although anxiety and high neuroticism are known to increase the frequency and severity of complaints, it is not known if other personality dimensions or genes associated with cognitive function or sympathetic tone can influence complaints. Genetic variation in catechol-O-methyltransferase (COMT) is associated with anxiety, personality, pain, and response to placebo treatment. We hypothesized that the association of complaint reporting with personality might be modified by variation in the COMT val158met genotype. METHODS: We administered a standard 25-item complaint survey weekly over 3-weeks to a convenience sample of 187 irritable bowel syndrome patients enrolled in a placebo intervention trial and conducted a repeated measures analysis. RESULTS: We found that complaint severity rating, our primary outcome, was negatively associated with the personality measures of conscientiousness (ß = -0.31 SE 0.11, P = 0.003) and agreeableness (ß = -0.38 SE 0.12, P = 0.002) and was positively associated with neuroticism (ß = 0.24 SE 0.09, P = 0.005) and anxiety (ß = 0.48 SE 0.09, P < 0.0001). We also found a significant interaction effect of COMT met alleles (ß = -32.5 SE 14.1, P = 0.021). in patients genotyped for COMT val158met (N  = 87) specifically COMT × conscientiousness (ß = 0.73 SE 0.26, P = 0.0042) and COMT × anxiety (ß = -0.42 SE 0.16, P = 0.0078) interaction effects. CONCLUSION: These findings potentially broaden our understanding of the factors underlying clinical complaints to include the personality dimension of conscientiousness and its modification by COMT.

The ageing phenome: caloric restriction and hormones promote neural cell survival, growth, and de-differentiation.

The phenome represents the observable properties of an organism that have developed under the continued influences of both genome and environmental factors. Phenotypic properties are expressed through the functions of cells, organs and body systems that operate optimally, close to equilibrium. In complex organisms, maintenance of the equilibrium is achieved by the interplay of several regulatory mechanisms. In the elderly, dynamic instability may lead to progressive loss of normal function, failure of adaptation and increased pathology. Extensive research (reported elsewhere in this journal) has demonstrated that genetic manipulations of endocrine signaling in flies, worms and mice increase longevity. Another effective strategy for prolonging the lifespan is caloric restriction: in data presented here, the persistence of estrogen-sensitive cells in the hypothalamus of caloric restricted 22-month-old female mice, may explain the persistence of reproductive function at an age, when reproductive function has long ceased in ad libitum fed controls. Still another strategy utilizes the effects of epidermal growth factor (EGF) to promote in vitro proliferation of neuroglia, astrocytes and oligodendrocytes. Their subsequent de-differentiation generates immature precursor cells potentially capable of differentiating into neuroblasts and neurons. These and other examples suggest that, in terms of functional outcomes, "the genome proposes but the phenome disposes".