The role of increasing synchronous telehealth use during the COVID-19 pandemic on disparities in access to healthcare: A systematic review.

INTRODUCTION: The COVID-19 public health emergency led to an unprecedented rapid increase in telehealth use, but the role of telehealth in reducing disparities in access to care has been questioned. The objective of this study was to conduct a systematic review to summarize the available evidence on how telehealth during the COVID-19 pandemic was associated with telehealth utilization for minority groups and its role in health disparities. METHODS: We conducted a systematic review focused on health equity and access to care by searching for interventional and observational studies using the following four search domains: telehealth, COVID-19, health equity, and access to care. We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, telehealth.hhs.gov, and the Rural Health Research Gateway, and included any study that reported quantitative results with a control group. RESULTS: Our initial search yielded 1970 studies, and we included 48 in our final review. The most common dimensions of health equity studied were race/ethnicity, rurality, insurance status, language, and socioeconomic status, and the telehealth applications studied were diverse. Included studies had a moderate risk of bias. In aggregate, most studies reported increased telehealth use during the pandemic, with the greatest increase in non-minority populations, including White, younger, English-speaking people from urban areas. DISCUSSION: We found that despite rapid adoption and increased telehealth use during the public health emergency, telehealth did not reduce existing disparities in access to care. We recommend that future work measuring the impact of telehealth focus on equity so that features of telehealth innovation can reduce disparities in health outcomes.

Telehealth Use and Health Equity for Mental Health and Substance Use Disorder During the COVID-19 Pandemic: A Systematic Review.

Background: As a result of the COVID-19 public health emergency (PHE), telehealth utilization accelerated to facilitate health care management and minimize risk. However, those with mental health conditions and substance use disorders (SUD)-who represent a vulnerable population, and members of underrepresented minorities (e.g., rural, racial/ethnic minorities, the elderly)-may not benefit from telehealth equally. Objective: To evaluate health equality in clinical effectiveness and utilization measures associated with telehealth for clinical management of mental health disorders and SUD to identify emerging patterns for underrepresented groups stratified by race/ethnicity, gender, age, rural status, insurance, sexual minorities, and social vulnerability. Methods: We performed a systematic review in PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL through November 2022. Studies included those with telehealth, COVID-19, health equity, and mental health or SUD treatment/care concepts. Our outcomes included general clinical measures, mental health or SUD clinical measures, and operational measures. Results: Of the 2,740 studies screened, 25 met eligibility criteria. The majority of studies (n = 20) evaluated telehealth for mental health conditions, while the remaining five studies evaluated telehealth for opioid use disorder/dependence. The most common study outcomes were utilization measures (n = 19) or demographic predictors of telehealth utilization (n = 3). Groups that consistently demonstrated less telehealth utilization during the PHE included rural residents, older populations, and Black/African American minorities. Conclusions: We observed evidence of inequities in telehealth utilization among several underrepresented groups. Future efforts should focus on measuring the contribution of utilization disparities on outcomes and strategies to mitigate disparities in implementation.

Predictors of Survival After Emergent Surgical Decompression for Acutely Presenting Spinal Metastasis.

BACKGROUND: Metastatic spinal tumors represent 90% of spinal masses and present variably with slow progression and/or rapid symptomatic worsening. Several prognostic scoring systems have been proposed. However, patients presenting acutely and requiring emergent surgery represent a unique subset of patients with different prognostic indicators. METHODS: All cases of symptomatic spinal metastases requiring emergent surgery between 2010 and 2021 at our institution were retrospectively reviewed. Survival time from date of surgery to death or last follow-up was calculated. Patients were stratified on the basis of survival for more or less than 6 months after surgery. Multivariate logistic regression was used to develop a model predicting probability of mortality at 6 months. RESULTS: Forty-four patients satisfied inclusion criteria. Mean age at presentation was 60.4 ± 11.8 years with a median survival time of 6.5 [1.9-19.5 interquartile range] months. On univariate analysis, higher Tokuhashi score, Karnofksy performance scale (KPS), and lower modified McCormick scale were significantly associated with 6-month survival (P = 0.018, P < 0.001, P = 0.002, respectively). Preoperative American Spinal Injury Association grade and Spine Instability Neoplastic Score scores were not associated with survival. Multivariate analysis found KPS significantly correlated with survival (0.91 odds ratio, 0.85-0.98, 95% confidence interval, P = 0.011) at 6 months and that a stepwise regression model derived from KPS and Tokuhashi score demonstrated the highest predictive accuracy for 6-month survival (area under the curve = 0.843, Akaike information criterion = 37.1, P = 0.0039). CONCLUSIONS: KPS and Tokuhashi scores most strongly correlated with 6-month survival in patients presenting with acutely symptomatic spinal metastases. These findings underscore the importance of baseline functional status and overall tumor burden on survival and may be useful in preoperative evaluation and surgical decision making for acutely presenting spinal metastases.

The Challenges to Advancing Induced Pluripotent Stem Cell-Dependent Cell Replacement Therapy.

Induced pluripotent stem cells (iPSC) represent a potentially exciting regenerative-medicine cell therapy for several chronic conditions such as macular degeneration, soft tissue and orthopedic conditions, cardiopulmonary disease, cancer, neurodegenerative disorders and metabolic disorders. The field of iPSC therapeutics currently exists at an early stage of development. There are several important stakeholders that include academia, industry, regulatory agencies, financial institutions and patients who are committed to advance the field. Yet, unlike more established therapeutic modalities like small and large molecules, iPSC therapies pose significant unique challenges with respect to safety, potency, genetic stability, immunogenicity, tumorgenicity, cell reproducibility, scalability and engraftment. The aim of this review article is to highlight the unique technical challenges that need to be addressed before iPSC technology can be fully realized as a cell replacement therapy. Additionally, this manuscript offers some potential solutions and identifies areas of focus that should be considered in order for the iPSC field to achieve its promise. The scope of this article covers the following areas: (1) the impact of different iPSC reprogramming methods on immunogenicity and tumorigenicity; (2) the effect of genetic instability on cell reproducibility and differentiation; (3) the role of growth factors and post-translational modification on differentiation and cell scalability; (4) the potential use of gene editing in improving iPSC differentiation; (5) the advantages and disadvantages between autologous and allogeneic cell therapy; (6) the regulatory considerations in developing a viable and reproducible cell product; and (7) the impact of local tissue inflammation on cell engraftment and cell viability.

Virus-free and oncogene-free induced pluripotent stem cell reprogramming in cord blood and peripheral blood in patients with lung disease.

AIM: A virus- and oncogene-free induced pluripotent stem cell (iPSC) reprogramming method was developed with cord blood-derived mononuclear cells (CBDMNC) and peripheral blood mononuclear cells (PBMNC) from patients with genetic lung diseases. METHOD: iPSC reprogramming used small molecules, hematopoietic stem cell (HSC) expansion media and episomal vectors that lacked Myc and Lin28. RESULTS: All iPSC colonies were fully reprogrammed based on SSEA4 expression. A total of 300,000 CBDMNC was the optimal cell number for cell reprogramming, which was associated with a 13-fold increase in CD34+ cells upon exposure to HSC media. Cell reprogramming was not observed in the absence of HSC expansion media. The method also reprogrammed PBMNC in patients with cystic fibrosis or α-1 antitrypsin deficiency. Oncogene-free iPSC cell lines differentiated into all three germ cell lineages. CONCLUSION: This iPSC reprogramming approach satisfies an important regulatory requirement for iPSC-based cell therapies with lower clinical risk from CBDMNC and PBMNC.

Efficient method to create integration-free, virus-free, Myc and Lin28-free human induced pluripotent stem cells from adherent cells.

AIM: Nonviral induced pluripotent stem cell (IPSC) reprogramming is not efficient without the oncogenes, Myc and Lin28. We describe a robust Myc and Lin28-free IPSC reprogramming approach using reprogramming molecules. METHODS: IPSC colony formation was compared in the presence and absence of Myc and Lin28 by the mixture of reprogramming molecules and episomal vectors. RESULTS: While more colonies were observed in cultures transfected with the aforementioned oncogenes, the Myc and Lin28-free method achieved the same reprogramming efficiency as reports that used these oncogenes. Further, all colonies were fully reprogrammed based on expression of SSEA4, even in the absence of Myc and Lin28. CONCLUSION: This approach satisfies an important regulatory pathway for developing IPSC cell therapies with lower clinical risk.