Evaluation of Telemedicine Consultations Using Health Outcomes and User Attitudes and Experiences: Scoping Review.

BACKGROUND: Despite a recent rise in adoption, telemedicine consultations retention remains challenging, and aspects around the associated experiences and outcomes remain unclear. The need to further investigate these aspects was a motivating factor for conducting this scoping review. OBJECTIVE: With a focus on synchronous telemedicine consultations between patients with nonmalignant chronic illnesses and health care professionals (HCPs), this scoping review aimed to gain insights into (1) the available evidence on telemedicine consultations to improve health outcomes for patients, (2) the associated behaviors and attitudes of patients and HCPs, and (3) how supplemental technology can assist in remote consultations. METHODS: PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guided the scoping review process. Inclusion criteria were (1) involving adults with nonmalignant, noncommunicable chronic conditions as the study population; (2) focusing on health outcomes and experiences of and attitudes toward synchronous telemedicine consultations between patients and HCPs; and (3) conducting empirical research. A search strategy was applied to PubMed (including MEDLINE), CINAHL Complete, APA PsycNet, Web of Science, IEEE, and ACM Digital. Screening of articles and data extraction from included articles were performed in parallel and independently by 2 researchers, who corroborated their findings and resolved any conflicts. RESULTS: Overall, 4167 unique articles were identified from the databases searched. Following multilayer filtration, 19 (0.46%) studies fulfilled the inclusion criteria for data extraction. They investigated 6 nonmalignant chronic conditions, namely chronic obstructive pulmonary disease, diabetes, chronic kidney disease, ulcerative colitis, hypertension, and congestive heart failure, and the telemedicine consultation modality varied in each case. Most observed positive health outcomes for patients with chronic conditions using telemedicine consultations. Patients generally favored the modality's convenience, but concerns were highlighted around cost, practical logistics, and thoroughness of clinical examinations. The majority of HCPs were also in favor of the technology, but a minority experienced reduced job satisfaction. Supplemental technological assistance was identified in relation to technical considerations, improved remote workflow, and training in remote care use. CONCLUSIONS: For patients with noncommunicable chronic conditions, telemedicine consultations are generally associated with positive health outcomes that are either directly or indirectly related to their ailment, but sustained improvements remain unclear. These modalities also indicate the potential to empower such patients to better manage their condition. HCPs and patients tend to be satisfied with remote care experience, and most are receptive to the modality as an option. Assistance from supplemental technologies mostly resides in addressing technical issues, and additional modules could be integrated to address challenges relevant to patients and HCPs. However, positive outcomes and attitudes toward the modality might not apply to all cases, indicating that telemedicine consultations are more appropriate as options rather than replacements of in-person visits.

High-precision inversion of dynamic radiography using hydrodynamic features.

While radiography is routinely used to probe complex, evolving density fields in research areas ranging from materials science to shock physics to inertial confinement fusion and other national security applications, complications resulting from noise, scatter, complex beam dynamics, etc. prevent current methods of reconstructing density from being accurate enough to identify the underlying physics with sufficient confidence. In this work, we show that using only features that are robustly identifiable in radiographs and combining them with the underlying hydrodynamic equations of motion using a machine learning approach of a conditional generative adversarial network (cGAN) provides a new and effective approach to determine density fields from a dynamic sequence of radiographs. In particular, we demonstrate the ability of this method to outperform a traditional, direct radiograph to density reconstruction in the presence of scatter, even when relatively small amounts of scatter are present. Our experiments on synthetic data show that the approach can produce high quality, robust reconstructions. We also show that the distance (in feature space) between a testing radiograph and the training set can serve as a diagnostic of the accuracy of the reconstruction.

Estimating and examining the costs of inpatient diabetes care in an Irish Public Hospital.

AIM: To estimate and examine hospitalisation costs of Type 1 and Type 2 diabetes in an Irish public hospital. METHODS: A retrospective audit of hospital inpatient admissions over a 5-year period was undertaken, and a wide range of admission-related data were collected for a sample of 7,548 admissions. Hospitalisations were costed using the diagnosis-related group methodology. A series of descriptive, univariate and multivariate regression analyses were undertaken. RESULTS: The mean hospitalisation cost for Type 1 diabetes was €4,027 and for Type 2 diabetes was €5,026 per admission. Sex, admission type and length of stay were significantly associated with hospitalisation costs for admissions with a primary diagnosis of Type 1 diabetes. Age, admission type, diagnosis status, complications status, discharge destination, length of stay and year were significantly associated with hospitalisation costs for admissions with a primary diagnosis of Type 2 diabetes. Length of stay was associated with higher mean costs, with each additional day increasing Type 1 diabetes costs by €260 (p = 0.001) and Type 2 diabetes by €216 (p < 0.001). Unscheduled admissions were associated with significantly lower costs than elective admissions; €1,578 (p = 0.035) lower for Type 1 diabetes and €2,108 (p < 0.001) lower for Type 2 diabetes. CONCLUSIONS: This study presents estimates of the costs of diabetes care in the Irish public hospital system and identifies the factors which influence costs for Type 1 and Type 2 diabetes. These findings may be of interest to patients, the public, researchers and those with influence over diabetes policy and practice in Ireland and internationally.

Sodium-glucose cotransport-2 inhibitor induced ketoacidosis following coronary artery bypass surgery: implications for management.

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) improve cardiovascular outcomes in patients with type 2 diabetes (T2D). Diabetic ketoacidosis (DKA) is an uncommon, but well recognised, life-threatening complication of SGLT2i. In a retrospective study of patients with T2D undergoing cardiac surgery at our institution, DKA occurred in 15.3% of patients taking SGLT2i at the time of surgery, compared with 0.47% of non-SGLT2i-treated patients. Intravenous insulin in the first 24 h after surgery was associated with a significantly lower risk of DKA in SGLT2i patients. Use of an insulin infusion should be considered in these patients, especially in those who are unable to cease their SGLT2i pre-operatively.

Clinical and operational insights from data-driven care pathway mapping: a systematic review.

BACKGROUND: Accumulated electronic data from a wide variety of clinical settings has been processed using a range of informatics methods to determine the sequence of care activities experienced by patients. The "as is" or "de facto" care pathways derived can be analysed together with other data to yield clinical and operational information. It seems likely that the needs of both health systems and patients will lead to increasing application of such analyses. A comprehensive review of the literature is presented, with a focus on the study context, types of analysis undertaken, and the utility of the information gained. METHODS: A systematic review was conducted of literature abstracting sequential patient care activities ("de facto" care pathways) from care records. Broad coverage was achieved by initial screening of a Scopus search term, followed by screening of citations (forward snowball) and references (backwards snowball). Previous reviews of related topics were also considered. Studies were initially classified according to the perspective captured in the derived pathways. Concept matrices were then derived, classifying studies according to additional data used and subsequent analysis undertaken, with regard for the clinical domain examined and the knowledge gleaned. RESULTS: 254 publications were identified. The majority (n = 217) of these studies derived care pathways from data of an administrative/clinical type. 80% (n = 173) applied further analytical techniques, while 60% (n = 131) combined care pathways with enhancing data to gain insight into care processes. DISCUSSION: Classification of the objectives, analyses and complementary data used in data-driven care pathway mapping illustrates areas of greater and lesser focus in the literature. The increasing tendency for these methods to find practical application in service redesign is explored across the variety of contexts and research questions identified. A limitation of our approach is that the topic is broad, limiting discussion of methodological issues. CONCLUSION: This review indicates that methods utilising data-driven determination of de facto patient care pathways can provide empirical information relevant to healthcare planning, management, and practice. It is clear that despite the number of publications found the topic reviewed is still in its infancy.

Local models for scatter estimation and descattering in polyenergetic X-ray tomography.

We propose a new modeling approach for scatter estimation and descattering in polyenergetic X-ray computed tomography (CT) based on fitting models to local neighborhoods of a training set. X-ray CT is widely used in medical and industrial applications. X-ray scatter, if not accounted for during reconstruction, creates a loss of contrast in CT reconstructions and introduces severe artifacts including cupping, shading, and streaks. Even when these qualitative artifacts are not apparent, scatter can pose a major obstacle in obtaining quantitatively accurate reconstructions. Our approach to estimating scatter is, first, to generate a training set of 2D radiographs with and without scatter using particle transport simulation software. To estimate scatter for a new radiograph, we adaptively fit a scatter model to a small subset of the training data containing the radiographs most similar to it. We compared local and global (fit on full data sets) versions of several X-ray scatter models, including two from the recent literature, as well as a recent deep learning-based scatter model, in the context of descattering and quantitative density reconstruction of simulated, spherically symmetrical, single-material objects comprising shells of various densities. Our results show that, when applied locally, even simple models provide state-of-the-art descattering, reducing the error in density reconstruction due to scatter by more than half.

Impact of adherence to surgical and non-surgical components of infective endocarditis guidelines and recommendations.

BACKGROUND: Infective endocarditis (IE) is associated with significant morbidity and mortality. Non-adherence to IE guidelines and recommendations is frequent, and may adversely impact patient outcomes. AIM: To assess the impact of non-adherence to components of existing IE guidelines and recommendations on a composite outcome consisting of any of the following: mortality, unplanned cardiac surgery, embolic event or relapse of positive blood culture within six months of diagnosis. METHODS: A single centre, retrospective cohort study. RESULTS: Amongst 157 patients, there was inconsistent adherence to: initial diagnosis of an infective condition (87%), timely administration of antimicrobial therapy (82%), appropriateness of predominant antimicrobial regime (94%), appropriate management of the portal of entry (86%), multidisciplinary input (75%), end of antimicrobial therapy repeat echocardiography (60%) and adherence to indications for surgery (76%). Inpatient mortality was 12.1% (n = 19) and the composite adverse outcome occurred in 36 (22.9%) patients. In multivariate logistic regression analysis, infection of prosthetic device (adjusted odds ratio [95% confidence interval]; 2.43 [1.07-5.50]) and non-adherence to surgical guidelines (aOR 3.67 [1.60-8.47]) were significantly associated with an adverse outcome. CONCLUSIONS: Our data suggests that adherence to differing components of IE management guidelines and recommendations varies and that non-adherence to surgical aspects of guidelines has the biggest impact in determining outcomes.

Patient perceptions of treatment with medication treatment for opioid use disorder (MOUD) in the Vermont hub-and-spoke system.

In 2013, Vermont leaders implemented the "hub-and-spoke" (H & S) system to increase access to medication treatment for opioid use disorder (MOUD). "Hubs" are licensed specialty opioid treatment programs (OTPs) with the authority to dispense buprenorphine/naloxone and methadone. "Spokes" are primary care practices that provide office-based opioid treatment, primarily with buprenorphine/naloxone. This report describes the qualitative component of an evaluation of the H&S system, conducted in 2016. The qualitative data collection assessed patient perspectives about the positive and negative aspects of treatment in the H & S system. The data collected included 80 responses to five open-ended questions and 24 in-depth interviews. Five open-ended questions were completed with hub (n = 40) and spoke (n = 40) participants. In-depth qualitative interviews were conducted with different hub (n =12) and spoke (n =12) participants. Findings from both data collection approaches suggest positive perceptions about treatment overall by patients treated in both settings. Participants treated in spokes reported a positive treatment environment, minimal stigma, and few obstacles to treatment and a strong positive relationship with their prescriber. Hub patients valued the MOUD and expressed gratitude for having access to MOUD, but reported the treatment environment was somewhat challenging, with long lines and drug talk in the clinic, high staff turnover and "cookie cutter" treatment. There appear to be some differences in patient perceptions of MOUD treatment between patients treated in primary care settings and specialized OTP settings.

Cardiac Prehabilitation.

The care of patients undergoing cardiac surgery is becoming more complex, in part owing to the increasing burden of comorbid disease, frailty, and psychosocial issues. Many risk factors for postoperative morbidity and mortality are potentially modifiable if identified and treated in a timely fashion before surgery. Cardiac prehabilitation, draws from strategies currently undertaken in cardiac rehabilitation but implements them proactively rather than reactively. There is substantial evidence that in multiple domains, including aerobic conditioning, respiratory muscle training, lifestyle modification, diabetic control, sleep, and psychoeducation, selected interventions before cardiac surgery may improve outcomes. However, the optimal preoperative program remains unclear and there is an unmet need for a comprehensive evaluation of the range of interventions specifically targeted at modifiable perioperative risk factors that may reduce adverse outcomes after cardiac surgery.

No Fever, No Murmur, No Problem? A Concealed Case of Infective Endocarditis.

BACKGROUND: Infective endocarditis is associated with significant morbidity and mortality, despite advances in diagnosis and treatment strategies. Injecting drug users are particularly at risk of endovascular infections, especially with multi-resistant and virulent microorganisms. Typically, patients with endocarditis present with constitutional symptoms, such as high fever and malaise combined with cardiorespiratory symptoms of valvular failure or emboli, such as septic pulmonary embolism. CASE REPORT: A 33-year-old female with a history of peptic ulcer disease presented to the emergency department with 3 days of increasing unilateral calf pain and swelling. There was no history of trauma or immobilization, no fever or clinical signs of sepsis or cardiopulmonary symptoms. A history of recent i.v. amphetamine injection in the forearm was elicited and empiric treatment for endovascular infection was commenced. Workup revealed methicillin-resistant Staphylococcus aureus mitral papillary endocarditis with gastrocnemius pyomyositis, multi-joint septic arthritis, and brain abscesses. After a 60-day inpatient stay, including intensive care admission for septic shock, the patient made a good recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The incidence of injecting drug use is increasing, and these patients are at risk of severe invasive infections with multi-resistant organisms. The emergency physician is most often responsible for the initial workup and treatment of patients with suspected infective endocarditis, with timely collection of blood cultures and appropriate antibiotics being essential interventions. This case highlights that even without fever, murmurs, or constitutional symptoms, severe multisystem infections from endocarditis can occur.

Ustilago maydis, the corn smut fungus, has an unusual diploid mitotic stage.

Ustilago maydis causes common smut disease in maize. Although pathogenic diploid strains of the fungus have been known for many years, the normal life cycle was thought to involve an extended dikaryotic stage, with nuclear fusion occurring in immature teliospores. However, microscopic examination of both living and fixed tumor material showed that nuclei fuse long before sporulation begins and that tumors are filled with uninucleate cells undergoing mitosis. Quantification of DNA in the nuclei confirmed these observations. Additionally, fungal cells from tumor material placed on nutrient agar produced colonies of diploid budding cells. Time-lapse observations showed that at least some of these colonies arose from thin-walled fungal cells rather than from immature spores. Ultrastructural examination of developing teliospores from tumors confirmed that they were uninucleate. Condensed chromatin and other structures characteristic of nuclei in prophase I of meiosis were observed. These observations support revising the U. maydis life cycle to include a diploid mitotic stage that corresponds with rapid tumor enlargement and conversion of plant to fungal biomass. Because mitotic division of diploid nuclei is so unusual as a life cycle feature in the fungi, it will be interesting to explore the consequences of its presence in U. maydis.

Right Coronary Dissection and Left Anterior Descending Thrombus: Dual Dilemma in a Young Cardiac Arrest Survivor.

BACKGROUND: ST-elevation myocardial infarction (STEMI) leading to cardiac arrest is an exceptionally rare occurrence in young adults. Those affected tend to abuse sympathomimetic drugs, have strong family histories, or have a significant burden of cardiac risk factors. Another uncommon cause of STEMI is coronary artery dissection, which overwhelmingly affects middle- and older-aged women with few cardiac risk factors. CASE REPORT: A 22-year-old athlete with no medical history was admitted to our institution post-cardiac arrest with an anterior STEMI and concomitant right coronary dissection. To our knowledge, this represents the first documented case of these simultaneous pathologies in a young cardiac arrest survivor. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Myocardial infarction is rare in young adults, and a diverse range of etiologies must be considered promptly to prevent delays in time-sensitive therapies, such as antiplatelet agents and revascularization. The emergency physician is most often the first point of contact in patients with acute coronary syndromes, and the failure to recognize it in young adults threatens them with premature death and potentially life-long disability.

Non-nearest-neighbor dependence of stability for group III RNA single nucleotide bulge loops.

Thirty-five RNA duplexes containing single nucleotide bulge loops were optically melted and the thermodynamic parameters for each duplex determined. The bulge loops were of the group III variety, where the bulged nucleotide is either a AG/U or CU/G, leading to ambiguity to the exact position and identity of the bulge. All possible group III bulge loops with Watson-Crick nearest-neighbors were examined. The data were used to develop a model to predict the free energy of an RNA duplex containing a group III single nucleotide bulge loop. The destabilization of the duplex by the group III bulge could be modeled so that the bulge nucleotide leads to the formation of the Watson-Crick base pair rather than the wobble base pair. The destabilization of an RNA duplex caused by the insertion of a group III bulge is primarily dependent upon non-nearest-neighbor interactions and was shown to be dependent upon the stability of second least stable stem of the duplex. In-line structure probing of group III bulge loops embedded in a hairpin indicated that the bulged nucleotide is the one positioned further from the hairpin loop irrespective of whether the resulting stem formed a Watson-Crick or wobble base pair. Fourteen RNA hairpins containing group III bulge loops, either 3' or 5' of the hairpin loop, were optically melted and the thermodynamic parameters determined. The model developed to predict the influence of group III bulge loops on the stability of duplex formation was extended to predict the influence of bulge loops on hairpin stability.

Fast 3D reconstruction method for differential phase contrast X-ray CT.

We present a fast algorithm for fully 3D regularized X-ray tomography reconstruction for both traditional and differential phase contrast measurements. In many applications, it is critical to reduce the X-ray dose while producing high-quality reconstructions. Regularization is an excellent way to do this, but in the differential phase contrast case it is usually applied in a slice-by-slice manner. We propose using fully 3D regularization to improve the dose/quality trade-off beyond what is possible using slice-by-slice regularization. To make this computationally feasible, we show that the two computational bottlenecks of our iterative optimization process can be expressed as discrete convolutions; the resulting algorithms for computation of the X-ray adjoint and normal operator are fast and simple alternatives to regridding. We validate this algorithm on an analytical phantom as well as conventional CT and differential phase contrast measurements from two real objects. Compared to the slice-by-slice approach, our algorithm provides a more accurate reconstruction of the analytical phantom and better qualitative appearance on one of the two real datasets.

Access to properly fitting personal protective equipment for female construction workers.

BACKGROUND: Previous literature suggests that most personal protective equipment (PPE) for construction is designed for males and does not accommodate female anthropometry. We conducted a pilot study to identify whether female construction workers currently have adequate access to properly fitting PPE. METHODS: Semi-structured focus group interviews were conducted with union female carpenters, laborers, and ironworkers. Researchers coded focus group transcriptions and extracted major themes using thematic framework analysis. RESULTS: Participants (n = 23) had a mean of 15.1 years of construction experience (range 3-34.5 years). A majority reported fit problems for many types of PPE (gloves, harnesses, safety vests, work boots, outerwear), generally noting that the equipment provided by contractors was too large. Other emergent themes included female workers purchasing their own PPE, exposure to various safety hazards from poorly fitted PPE, and perceived indifferent safety culture. CONCLUSIONS: Female construction workers continue to have difficulty accessing properly fitting PPE. Am. J. Ind. Med. 59:1032-1040, 2016. © 2016 Wiley Periodicals, Inc.

The Association of Race, Socioeconomic Status, and Insurance on Trauma Mortality.

BACKGROUND: Although race, socioeconomic status, and insurance individually are associated with trauma mortality, their complex interactions remain ill defined. METHODS: This retrospective cross-sectional study from a single Level I center in a racially diverse community was linked by socioeconomic status, insurance, and race from 2000 to 2009 for trauma patients aged 18-64 years with an injury severity score more than 9. The outcome measure was inpatient mortality. Multiple logistic regression analyses were performed to investigate confounding variables known to predict trauma mortality. RESULTS: A total of 4,007 patients met inclusion criteria. Individually, race, socioeconomic status, and insurance were associated with increased mortality rate; however, in multivariate analysis, only insurance remained statistically significant and varied by insurance type with age. Odds of death were higher for Medicare (odds ratio [OR] = 3.63, p = .006) and other insurance (OR = 3.02, p = .007) than for Private Insurance. However, when grouped into ages 18-40 years versus 41-64 years, the insurance influences changed with Uninsured and Other insurance (driven by Tricare) predicting mortality in the younger age group, while Medicare remained predictive in the older age group. CONCLUSIONS: Insurance type, not race or socioeconomic status, is associated with trauma mortality and varies with age. Both Uninsured and Tricare insurance were associated with mortality in younger age trauma patients, whereas Medicare was associated with mortality in older age trauma patients. The lethality of the Tricare group warrants further investigation.

Stability of single-nucleotide bulge loops embedded in a GAAA RNA hairpin stem.

Forty-six RNA hairpins containing combinations of 3' or 5' bulge loops and a 3' or 5' fluorescein label were optically melted in 1 M NaCl, and the thermodynamic parameters ΔH°, ΔS°, ΔG°(37), and T(M) for each hairpin were determined. The bulge loops were of the group I variety, in which the identity of the bulge is known, and the group II variety, in which the bulged nucleotide is identical to one of its nearest neighbors, leading to ambiguity as to the exact position of the bulge. The fluorescein label at either the 3' end or 5' end of the hairpin did not significantly influence the stability of the hairpin. As observed with bulge loops inserted into a duplex motif, the insertion of a bulge loop into the stem of a hairpin loop was destabilizing. The model developed to predict the influence of bulge loops on the stability of duplex formation was extended to predict the influence of bulge loops on hairpin stability. Specifically, the influence of the bulge is related to the stability of the hairpin stem distal from the hairpin loop.

Non-nearest-neighbor dependence of the stability for RNA group II single-nucleotide bulge loops.

Thirty-one RNA duplexes containing single-nucleotide bulge loops were optically melted in 1 M NaCl, and the thermodynamic parameters ΔH°, ΔS°, ΔG°(37), and T(M) for each sequence were determined. The bulge loops were of the group II variety, where the bulged nucleotide is identical to one of its nearest neighbors, leading to ambiguity as to the exact position of the bulge. The data were used to develop a model to predict the free energy of an RNA duplex containing a single-nucleotide bulge. The destabilization of the duplex by the bulge was primarily related to the stability of the stems adjacent to the bulge. Specifically, there was a direct correlation between the destabilization of the duplex and the stability of the less stable duplex stem. Since there is an ambiguity of the bulge position for group II bulges, several different stem combinations are possible. The destabilization of group II bulge loops is similar to the destabilization of group I bulge loops, if the second least stable stem is used to predict the influence of the group II bulge. In-line structure probing of the group II bulge loop embedded in a hairpin indicates that the bulged nucleotide is the one positioned farther from the hairpin loop.

An analysis of relapse prevention factors and their ability to predict sustained abstinence following treatment completion.

BACKGROUND & OBJECTIVES: This study assessed the role of 14 specific relapse-prevention activities and their underlying factors in maintaining abstinence among subjects (N = 302) completing outpatient treatment for stimulant dependence. METHODS: We examined what broader dimensions might subsume the 14 items constituting the Drug Avoidance Activities checklist (Farabee et al. J Subst Abuse Treat 2002;23:343-350), and how well these derived factors predicted concurrent drug use at baseline and again 3 and 12 months later. RESULTS: Although four factors were identified consistently for the three time points, only avoidance strategies had sufficient internal consistency to be retained for further analysis. Controlling for age, gender, and ethnicity, the avoidance subscale was a significant predictor of UA results at all time periods: a one-point increase in the avoidance strategies scale was associated with an 86% increase in odds of a negative UA at baseline (OR = 1.86, 95% CI = 1.37-2.53, p < .001), a 77% increase at 3-month follow-up (OR = 1.77, CI = 1.37-2.29, p < .001), and a 37% increase at 12-month follow-up (OR = 1.37, CI = 1.04-1.81, p = .026). CONCLUSIONS: Although correlations of individual items with UA results showed statistically significant (p < .05) results for 8 of 14 items at one or more observation points, avoidance-related behaviors showed the strongest associations with sustained abstinence.