Patient Experiences and Outcomes of a Telehealth Clinical Care Pathway for Postoperative Inflammatory Bowel Disease Patients.

Background:Despite advancements in treatment for inflammatory bowel disease (IBD), surgery remains inevitable for patients and IBD management is costly.Introduction:Frequent postoperative monitoring is needed for early detection of both short-term complications and long-term disease recurrence. We developed a care pathway for postoperative home monitoring of IBD patients using telehealth applications.Materials and Methods:We performed a retrospective cohort study with a matched control group to assess the efficacy of the Tight Control Surgery Scenario (TCSS), a 4-week postoperative care pathway. IBD patients aged 18 or older who underwent an IBD-related intestinal operation between October 2013 and December 2015 were eligible. Enrolled participants submitted postsurgical questionnaires and wound photos through e-mail. We measured patient satisfaction with the care pathway and assessed its impact on 30-day postoperative hospital readmission rates, emergency department (ED) visits, and gastroenterologist (GI)-related office visits.Results:Sixty-four (n) cases were enrolled in TCSS and matched to 64 historic controls. Patients who completed the additional evaluation survey expressed overall satisfaction. Readmissions, 30-day ED rates, and GI visits were numerically higher in cases compared with controls, but this difference was not statistically significant.Discussion:TCSS demonstrates the feasibility of implementing a telehealth care coordination platform for postsurgery IBD management. Patients with more complications may have sent in more photos due to greater concern for maintaining their health.Conclusions:Implementation of TCSS for easy home monitoring is feasible. While we did not see reductions in ED visits, GI follow-up visits, or readmissions, patient satisfaction was high, thus demonstrating its feasibility for telehealth applications.

CDH1 is essential for endometrial differentiation, gland development, and adult function in the mouse uterus.

CDH1 is a cell-cell adhesion molecule expressed in the epithelium to coordinate key morphogenetic processes, establish cell polarity, and regulate epithelial differentiation and proliferation. To determine the role of CDH1 in the mouse uterus, Cdh1 was conditionally ablated by crossing Pgr-Cre and Cdh1-flox mice, and the phenotype was characterized. We found that loss of Cdh1 results in a disorganized cellular structure of the epithelium and ablation of endometrial glands in the neonatal uterus. Cdh1(d/d) mice lost adherens junctions (CTNNB1 and CTNNA1) and tight junctions (claudin, occludin, and ZO-1 proteins) in the neonatal uterus, leading to loss of epithelial cell-cell interaction. Ablation of Cdh1 induced abnormal epithelial proliferation and massive apoptosis, and disrupted Wnt and Hox gene expression in the neonatal uterus. Although the uteri of Cdh1(d/d) mice did not show any myometrial defects, ablation of Cdh1 inhibited expression of epithelial (cytokeratin 8) and stromal (CD10) markers. Cdh1(d/d) mice were infertile because of defects during implantation and decidualization. Furthermore, we showed in the model of conditional ablation of both Cdh1 and Trp53 in the uterus that interrupting cell cycle regulation through the loss of Cdh1 leads to abnormal uterine development. The uteri of Cdh1(d/d) Trp53(d/d) mice exhibited histological features of endometrial carcinomas with myometrial invasion. Collectively, these findings suggest that CDH1 has an important role in structural and functional development of the uterus as well as adult uterine function. CDH1 has a capacity to control cell fate by altering directional cell proliferation and apoptosis.

WNTs in the neonatal mouse uterus: potential regulation of endometrial gland development.

The WNTs are secreted proteins that control essential developmental processes, such as embryonic patterning, cell growth, migration, and differentiation. In mice, three members of the Wnt gene family (Wnt4, Wnt5a, and Wnt7a) have been studied extensively in the female reproductive tract. The present study determined effects of postnatal day and exposure to diethylstilbestrol (DES) on Wnt and Fzd gene expression in the mouse uterus as well as the biological role of Wnt11 in postnatal mouse uterine development and function. Wnt4, Wnt5a, Wnt7a, Wnt7b, Wnt11, Wnt16, Fzd6, and Fzd10 were detected by in situ hybridization in the neonatal mouse uterus. In situ hybridization analyses revealed that Wnt4, Wnt5a, and Wnt16 were localized in the endometrial stroma, whereas Wnt7a, Wnt7b, Wnt11, Fzd6, and Fzd10 were in the uterine epithelia of neonatal mice. Exposure of mice to estrogen or estrogen receptor agonists during critical development periods inhibits endometrial adenogenesis. In the present study, DES-induced disruption of endometrial gland development was associated with reduction or suppression of Wnt4, Wnt5a, Wnt7a, Wnt11, Wnt16, and Fzd10. Ablation of Wnt11, an epithelial-expressed, DES-regulated gene, in the neonatal uterus did not affect endometrial adenogenesis or expression of other Wnt genes. Interestingly, Wnt11-deleted uteri had more endometrial glands on Postnatal Day 10. Although CTNNB1 expression was not affected by ablation of Wnt11, Vangl2 was inhibited in the uteri of Wnt11(d/d) mice. These results support the idea that a number of different Wnt genes are potential regulators for uterine morphogenesis; however, Wnt11 does not have a direct effect on uterine development.

Sustaining Improvement: Implementation and Spread of a Surgical Site Infection Bundle.

Surgical site infections (SSIs) are considered a quality metric across surgical specialties and are a major cause of increased readmissions and overall costs to surgical patients. Bundled interventions have demonstrated efficacy in reducing SSIs in various surgical fields, yet the ability to sustain and spread interventions while continuing to reduce infection rates is a significant challenge. This study assessed the implementation and sustainability of an SSI bundle, which was initially piloted within the colorectal surgery division and then spread to additional general surgery services. Outcomes (risk-adjusted ACS-NSQIP odds ratio and observed to expected (O:E) SSI rates) and process measures were monitored on run charts throughout the course of the intervention. By the end of the study period, ACS-NSQIP risk-adjusted odds ratios for SSIs decreased from 1.22 to 0.95 for colorectal procedure targeted and 1.32 to 1.04 for all general surgery procedures (P < 0.05). O:E ratios showed similar reductions. SSI reductions were associated with process measure compliance. This study demonstrates that effective implementation within a single surgical division provides the foundation for spread of a SSI bundle, which results in continued and sustained reductions in SSI rates.

Wireless Technology to Track Surgical Patients after Discharge: A Pilot Study.

Failure to detect changes in patients' postoperative health status increases the risk of adverse outcomes, including complications and readmission. We sought to design and implement a real-time surveillance system for postoperative colorectal surgery patients using wireless health technology. Participants were assigned a preprogrammed tablet computer during their inpatient hospitalization, and asked to complete a daily survey regarding their postoperative health status until their first clinic visit. Surveys were transmitted wirelessly to a secure database for review. As a pilot study, we report on our first 20 consecutively enrolled patients, monitored for 265 patient days. Overall compliance was 63 per cent (data available for 166 of the 265 days), but varied by patient from 26 to 100 per cent. We were able to reliably collect basic data on postoperative health status as well as patient-reported outcomes not previously captured by standard assessment techniques. Qualitative data suggest that the experience strengthened patients' relationship with their surgeon and aided in their recovery. Postoperative remote monitoring is feasible, and provides more detailed and complete information to the clinical team. Wireless health technology represents an opportunity to close the information gap between discharge and first clinic visit, and, eventually, to improve patient-provider communication, increase patient satisfaction, and prevent unnecessary readmissions.