Disparities in telemedicine utilization among kidney transplant patients during the COVID-19 pandemic: Barriers and opportunities.

INTRODUCTION: The COVID-19 pandemic allowed for the rapid implementation of telemedicine for kidney transplant patients; however, widespread adoption may worsen existing health care inequities among vulnerable populations. This study aimed to characterize telemedicine utilization by kidney transplant patients during the early pandemic with particular attention to healthcare equity. METHODS: A retrospective analysis of kidney transplant patients interacting with telemedicine was performed. Patient demographic data and distance to the transplant center were obtained. The National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties and Brokamp Neighborhood Deprivation Index (NDI) score were used to characterize patients' counties of residence. Multivariable logistic regression evaluated associations between patient and community characteristics and the likelihood of an encounter being telemedicine. RESULTS: This study included 1033 patients who participated in 3727 encounters from March 11 through October 2020. Characteristics associated with decreased likelihood of telemedicine use were increased age (OR = .993; 95% CI = .986-.999, P = .022), non-White vs. White race (OR = .826, 95% CI = .697-.979; P = .028), male vs. female sex (OR = .746, 95% CI = .632-.880; P < .001), and a higher Brokamp Neighborhood Deprivation Index score (OR = .159; 95% CI = .029-.873; P = .034). The effect of distance to the transplant center on the likelihood of a telemedicine encounter differed by NCHS Urban-Rural designation (interaction P = .018), with its likelihood increasing by 2%-3% with each 10-mile increment among persons residing in medium-, small-, and non-metropolitan counties compared to those residing in the most rural counties. CONCLUSIONS: Telemedicine visits were less often completed by patients of older age, non-white race, male sex, and those residing in counties having higher NDI scores. While telemedicine has the potential to improve healthcare access and decrease costs, proactive efforts need to be taken to mitigate disparities in vulnerable populations.

Associations between social determinants of health and abdominal solid organ transplant wait-lists in the United States.

BACKGROUND: Societal factors that influence wait-listing for transplantation are complex and poorly understood. Social determinants of health (SDOH) affect rates of and outcomes after transplantation. METHODS: This cross-sectional study investigated the impact of SDOH on additions to state-level, 2017-2018 kidney and liver wait-lists. Principal components analysis, starting with 127 variables among 3142 counties, was used to derive novel, comprehensive state-level composites, designated (1) health/economics and (2) community capital/urbanicity. Stepwise multivariate linear regression with backwards elimination (n = 51; 50 states and DC) tested the effects of these composites, Medicaid expansion, and center density on adult disease burden-adjusted wait-list additions. RESULTS: SDOH related to increased community capital/urbanicity were independently associated with wait-listing (starting models: B = .40, P = .010 Kidney; B = .36, P = .038 Liver) (final models: B = .31, P = .027 Kidney, B = .34, P = .015 Liver). In contrast and surprisingly, no other covariates were associated with wait-listing (P ≥ .122). CONCLUSIONS: These results suggest that deficits in community resources are important contributors to disparities in wait-list access. Our composite SDOH metrics may help identify at-risk communities, which can be the focus of local and national policy initiatives to improve access to organ transplantation.

Population and risk assessment of sympatric pheasant species in Palas Valley, Pakistan.

Pheasants are declining everywhere in the world and therefore updated information about their population and habitats are important for conservation and management. The present study was conducted in the Palas Valley, District Kohistan, Pakistan in late spring (May and June) 2020 and early spring (March and April) 2021 to assess the population and anthropogenic stress. The major focus was on three sympatric pheasant species, including Western Horned Tragopan (Tragopan melanocephalus), Himalayan Monal (Lophophorus impejanus), and Koklass Pheasant (Pucrasia macrolopha). We used the "Call Count Method" for the population assessment in the field, and a questionnaire survey was conducted to document the risk assessment of local residents of the valley. The population assessments revealed that the Koklass Pheasant is more adapted to increasing anthropogenic activities and its population appeared more or less similar as 22 years ago. In the past 22 years, Western Tragopan and Himalayan Monal have lost about 40-50% of their populations. Human interference in the form of illegal hunting, deforestation, and overgrazing was found to be common in the valley. The study concludes that the Palas Valley habitat is ideal for pheasant species; however, human interference in the form of urbanization, habitat fragmentation, illegal hunting, and deforestation is occurring at a rapid pace, causing havoc in the pheasant population.

Take 10: A Resident Well-Being Initiative and Burnout Mitigation Strategy.

OBJECTIVE: Physician training is associated with stressors which contribute to burnout. Individual and institutional level strategies can be employed to address resident burnout; however, time is an often-reported barrier in initiating recommended well-being activities. We hypothesize that brief bursts of well-being activities that are conducive to a resident schedule can mitigate burnout. DESIGN: This is a prospective observational study following burnout after implementation of an institution-wide, well-being initiative called "Take 10." SETTING: In the present study, the "Take 10" initiative, meditating or exercising for a minimum of 10 minutes per day 3 times a week, was encouraged at Vanderbilt University Medical Center, a tertiary care center in Nashville, Tennessee. PARTICIPANTS: Following implementation of the initiative, 254 residents from surgical, procedural, and non-procedural specialties were invited to complete surveys assessing compliance with encouraged "Take 10" activities as well as rates of burnout over a 5-month period. A total of 201 surveys were completed during the study period. RESULTS: Overall, burnout rates were worse for females (Odds Ratio [OR] = 3.7 | Confidence Interval [CI] = 1.57, 9.05), better for those living with others (OR = 0.22 | CI = 0.07, 0.64), and better for those participating in "Take 10" initiatives (OR = 0.71 | CI = 0.58, 0.86). There was a significant difference in resident-reported burnout (Control = 85.3% vs Intervention = 58.2% | p < 0.01) and Resident Well-Being Index score (Control = 3.73 vs Intervention=2.93 | p < 0.01), when "Take 10" initiatives were employed. CONCLUSIONS: "Take 10" is a low cost and low intensity initiative for individuals and programs to use to mitigate burnout.

Large Bowel Obstruction.

Nearly one-quarter of bowel obstructions occur in the large bowel. As with all bowel obstructions, large bowel obstructions have three defining characteristics: partial or complete, intrinsic or extrinsic, benign or malignant. The work-up for a large bowel obstruction should focus on the etiology of the obstruction as well as severity. Management strategy is contingent on the previous characteristics and can include endoscopy, diversion, or resection. This chapter will discuss common and rare etiologies of large bowel obstructions as well as management strategies for clinical guidance.

Is a fixed low-dose protamine better at reducing postoperative bleeding in off pump coronary artery bypass grafting?

CONTEXT: Protamine is used ubiquitously in all cardiac surgeries for reversal of heparin. Risk of postoperative bleeding is increased with inadequate heparin reversal or due to anticoagulant side effects of protamine; hence, it is important to dose protamine properly. This study compares 80% protamine dose with full dose on postoperative bleeding and transfusion needs in OPCAB. AIMS: The aim of our study was to find whether lower dose of protamine could reduce postoperative bleeding and need for blood product transfusions in off pump coronary artery bypass grafting as compared to the regular dose of protamine. SETTINGS AND DESIGN: This was a double-blinded randomised controlled trial where patients posted for off pump CABG meeting the inclusion criteria were included in the study. METHODS AND MATERIAL: Ninety patients were randomised to two groups, group F receiving full dose of protamine of 1 mg per mg heparin used, and group L received 0.8 mg per mg. Postoperative activated clotting time, bleeding at 1 h, 4 h, 24 h and total drainage till drains removal and blood product transfusion requirements were noted.Statistical analysis used: SPSS software. RESULTS: Both groups were matched in demographics, preoperative cessation of heparin and aspirin and platelet counts. Both groups received equal heparin dose, activated clotting time before protamine, activated clotting time post protamine in OT and ICU were equal as were the conduits used. There was no significant difference between the groups in post-operative drainage over time or in the need for blood product transfusions. CONCLUSIONS: Eighty per cent of the dose of protamine can adequately reverse the heparin used during off pump cardiac surgery without any increase in incidence of postoperative bleeding or need for blood product transfusions.

Extracorporeal Membrane Oxygenation in Pediatric Liver Transplantation: A Multicenter Linked Database Analysis and Systematic Review of the Literature.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) can be used to maintain oxygen delivery and provide hemodynamic support in case of circulatory and respiratory failure. Although the role of ECMO has emerged in the setting of adult liver transplantation (LT), data in children are limited. We aimed to describe the characteristics and outcomes of children receiving ECMO support at the time of or following LT. METHODS: All pediatric LT recipients (≤20 y) requiring ECMO support peri-/post-LT were identified from a linked Pediatric Health Information System/Scientific Registry of Transplant Recipients dataset (2002-2018). The Kaplan-Meier method and Cox regression analysis were used to assess post-ECMO survival. A systematic literature review was conducted in accordance with the PRISMA statement. RESULTS: Thirty-four children required ECMO peri-/post-LT. The median time from LT to ECMO was 5 d (interquartile range, 0.0-12.3), and the median ECMO duration was 1 d (interquartile range, 1.0-6.3). Children started on ECMO within 1 d of LT exhibited superior survival compared with those started on ECMO later (P = 0.03). When adjusting for recipient weight, increasing time from LT to ECMO initiation was associated with increased risk of mortality (hazard ratio, 1.03; 95% confidence interval, 1.00-1.06; P = 0.049). Overall, 55.9% (n = 19 of 34) of the patients survived. Twenty-two children receiving ECMO in the peri-/post-LT period were systematically reviewed, and 15 of them survived (68.2%). CONCLUSIONS: With an encouraging >55% patient survival at 6 mo, ECMO should be considered as a viable option in pediatric LT recipients with potentially reversible severe respiratory or cardiovascular failure refractory to conventional treatment.

Prevalence and risk factors of domestic violence in women attending the National Guard Primary Health Care Centers in the Western Region, Saudi Arabia, 2018.

BACKGROUND: Domestic violence (DV) is considered a public health issue in Saudi Arabia as well as a violation of a fundamental human right. DV causes many acute and chronic physical and mental health consequences. Cultural taboos and lack of awareness regarding the appropriate support services can increase the number of cases annually. The objective of the study was to assess the prevalence and risk factors of DV in women attending the National Guard Primary Health Care Clinics in the Western Region of Saudi Arabia. METHODS: A cross-sectional study was conducted with patients attending five Primary Health Care Centers in Jeddah from August 2017 to February 2018. A convenient sampling method was used. In total, 1845 participants were invited to complete a self-report validated Arabic version of the Norvold Domestic Abuse Questionnaire (NORAQ) to determine the prevalence and risk factors of DV. All women between 18 and 65 years who met the inclusion criteria were included. The data were analyzed using SPSS (Statistical Package Social Sciences) version 24.0. RESULTS: The lifetime prevalence of DV in the study sample was 33.24%, with psychological abuse the most prevalent (48.47%), followed by physical abuse (34.77%) and sexual abuse (16.75%). A small proportion (4.1%) suffered from all three types of abuse. Risk factors for being a victim of abuse include being single or divorced, having a postgraduate level of education, employed, and being financially independent of the husband. CONCLUSION: DV is prevalent in Saudi Arabia. Modernization has shifted the risk factors, identifying the risk factors and victim characteristics would support the development and implementation of preventive and screening programs to facilitate the early identification of cases as well as the initiation of empowerment programs for Saudi women.

Patient satisfaction with the implementation of electronic medical Records in the Western Region, Saudi Arabia, 2018.

BACKGROUND: The implementation of the Electronic Medical Record (EMR) system initiated a significant transition in the healthcare system from traditional paper-based medical records to a digital version. Though EMR offers several benefits compared to Paper Medical Records (PMR), patient satisfaction with the EMR has been an area of concern. The objective of this study is to explore patient satisfaction with the EMR compared to the PMR of patients attending five Primary Healthcare Centers in the Western Region of Saudi Arabia. METHODS: A cross-sectional survey was conducted with patients who attended five Primary Health Care centers (PHCs) in the Western Region during 2018. A sample of 377 participants was invited to complete a self-developed structured questionnaire with multiple choice and Likert Scale questions. The questionnaire was distributed to participants in the PHC waiting areas. RESULTS: The sample size realized as (n = 377) participants, the majority (65.0%) were female. The overall patient satisfaction was 3.708. Patient satisfaction with the EMR was statistically significant compared to the PMR (3.7241 vs. 3.6919, p < 0.001). Several factors provided evidence of the overall satisfaction with the implementation of the EMR, including an increase in physician attention during the clinical consultation (82.3%), increased explanation of tests and medication (85.8%), increased time spent with the patient during the consultation (80.4%) and increased active listening by the physician (77.3%). Besides, the patients felt confident to ask the physician question related to health during clinical consultation (84.0%). CONCLUSION: Patient satisfaction during the clinical consultation and overall satisfaction with various PHC services improved with the implementation of EMR.

Acute Neurological Illness in a Kidney Transplant Recipient Following Infection With Enterovirus-D68: An Emerging Infection?

We report the first case of enterovirus-D68 infection in an adult living-donor kidney transplant recipient who developed rapidly progressive bulbar weakness and acute flaccid limb paralysis following an upper respiratory infection. We present a 45-year-old gentleman who underwent pre-emptive living-donor kidney transplantation for IgA nephropathy. Eight weeks following transplantation, he developed an acute respiratory illness from enterovirus/rhinovirus that was detectable in nasopharyngeal (NP) swabs. Within 24 h of onset of respiratory symptoms, the patient developed binocular diplopia which rapidly progressed to multiple cranial nerve dysfunctions (acute bulbar syndrome) over the next 24 h. Within the next 48 h, asymmetric flaccid paralysis of the left arm and urinary retention developed. While his neurological symptoms were evolving, the Centers for Disease Control reported that the enterovirus strain from the NP swabs was, in fact, Enterovirus-D68 (EV-D68). Magnetic resonance imaging of the brain demonstrated unique gray matter and anterior horn cell changes in the midbrain and spinal cord, respectively. Constellation of these neurological symptoms and signs was suggestive for postinfectious encephalomyelitis (acute disseminated encephalomyelitis [ADEM]) from EV-D68. Treatment based on the principles of ADEM included intensive physical therapy and other supportive measures, which resulted in a steady albeit slow improvement in his left arm and bulbar weakness, while maintaining stable allograft function.

Introducing new tuberculosis diagnostics: the impact of Xpert(®) MTB/RIF testing on case notifications in Nepal.

SETTING: The Xpert(®) MTB/RIF assay is a highly sensitive molecular test with the potential to improve tuberculosis (TB) case detection. However, evidence supporting this potential at a programme level is minimal. METHODS: Xpert testing following smear microscopy and chest X-ray was implemented as part of routine case finding in 16 districts of Eastern Nepal. Changes in TB case notification were evaluated based on a pre/post analysis, as were expected notifications based on linear trend. RESULTS: A total of 9723 Xpert tests were performed, resulting in the identification of 1662 Mycobacterium tuberculosis-positive patients. Despite a previous declining trend in notifications, annual bacteriologically positive TB notifications increased by 15.2% during the intervention, from 3390 to 3906. However, annual notifications of pulmonary TB dropped by 8.5% overall, from 5123 to 4688. Both observations were significantly different from expected notifications based on historical trends. Treatment initiation for drug-resistant TB almost doubled. DISCUSSION: Xpert testing significantly increased bacteriologically positive TB notifications, but large reductions in empiric treatment of smear-negative disease reduced the number of pulmonary TB notifications overall. While better diagnostics remain critical, focusing solely on superior test sensitivity may not increase TB case notifications. Additional interventions are required to reach the millions of people with TB who are missed by routine services.

Evaluation of bacteria-induced enamel demineralization using optical profilometry.

OBJECTIVES: Streptococcus mutans is considered a major causative of tooth decay due to its ability to rapidly metabolize carbohydrates such as sucrose. One prominent excreted end product of sucrose metabolism is lactic acid. Lactic acid causes a decrease in the pH of the oral environment with subsequent demineralization of the tooth enamel. Biologically relevant bacteria-induced enamel demineralization was studied. METHODS: Optical profiling was used to measure tooth enamel decay with vertical resolution under one nanometer and lateral features with optical resolution as a result of S. mutans biofilm exposure. Comparison measurements were made using AFM. RESULTS: After 72h of biofilm exposure the enamel displayed an 8-fold increase in the observed roughness average (R(a)), as calculated over the entire measured array. Similarly, the average root mean square (RMS) roughness, R(RMS), of the enamel before and after biofilm exposure for 3 days displayed a 7-fold increase. Further, the direct effect of chemically induced enamel demineralization using biologically relevant organic acids was shown. Optical profiles of the enamel surface after addition of a 30% lactic acid solution showed a significant alteration in the surface topography with a corresponding increase in respective surface roughness statistics. Similar measurements with 10% citric acid over seconds and minutes give insight into the demineralization process by providing quantitative measures for erosion rates: comparing surface height and roughness as metrics. SIGNIFICANCE: The strengths of optical profilometry as an analytical tool for understanding and analyzing biologically relevant processes such as biofilm induced tooth enamel demineralization were demonstrated.

Optimizing immunosuppression with sirolimus in the first year posttransplantation: experience in the United States.

Early and late kidney graft survival has improved considerably due to advances in clinical care, particularly immunosuppression. Many of the kidney transplants functioning today should serve their new owners for their life expectancy. What challenges this viewpoint and the main cause of late kidney function deterioration remains allograft nephropathy. Often this reflects an influence of the immunosuppression. Subclinical rejection, chronic nephrotoxicity, recurrent disease, infections, or diabetes may also contribute to this process. Optimal early and late immunosuppression is required, which provides efficacy without attendent risk for graft dysfunction due to nephrotoxicity. Since 1-year serum creatinine level often provides an indication of long-term graft function, early evaluation of subtle degrees of graft dysfunction should prompt a graft biopsy to identify treatable causes.

Early withdrawal of calcineurin inhibitors and rescue immunosuppression with sirolimus-based therapy in renal transplant recipients with moderate to severe renal dysfunction.

Mammalian Target-of-Rapamycin inhibitors (mTOR inhibitors) can be used to replace the calcineurin inhibitors (CNIs) to prevent progression in chronic kidney disease (CKD) following organ transplantation. Discontinuation of tacrolimus in 136 recipients of kidney transplants with progressive renal dysfunction significantly decreased the rate of loss of estimated glomerular filtration rate (eGFR, mL/min/1.73 m(2)) (pre-intervention vs. post-intervention slopes, -0.013 vs. -0.002, p < 0.0001). Discontinuation of tacrolimus was associated with a sustained and significant improvement in graft function (pre-eGFR vs. post-eGFR; 26.0 +/- 1.1 vs. 47.4 +/- 2.1, p < 0.0001) in 74% of patients. This intervention was ineffective if the mean and (median) values of creatinine (mg/dL) and eGFR were 3.8 +/- 0.2 (3.4) and 18.4 +/- 1.9 (22.4), respectively, at the time of conversion therapy. During the follow-up (range, 1.5-34.6, months), a total of 13 patients had their first acute rejection following the conversion therapy, an annual incidence of less than 10% and none of these episodes resulted in graft loss. The salutary effects of sirolimus therapy following discontinuation of tacrolimus in patients with moderate to severe graft dysfunction due to allograft nephropathy even in high-risk patients improves kidney function and prevents acute rejection.

Increased microvascular blood content is an early event in colon carcinogenesis.

BACKGROUND: Increased premalignant epithelial microvascular blood content is a common theme in neoplastic transformation; however, demonstration of this phenomenon in colon carcinogenesis has been stymied by methodological limitations. Our group has recently developed a novel optics technology, four dimensional elastic light scattering fingerprinting (4D-ELF), which allows examination of the colonic mucosal architecture with unprecedented accuracy. In this study, we utilised 4D-ELF to probe the preneoplastic colonic microvasculature. METHODS: Colonic mucosal blood content was assessed by 4D-ELF at serial preneoplastic time points from azoxymethane (AOM) treated Fisher 344 rats and age matched control animals. We also examined the pretumorigenic intestinal mucosa of the MIN mouse, and compared with wild-type mice. Finally, in a pilot study, we examined superficial blood content from the endoscopically normal mid transverse colon in 37 patients undergoing screening colonoscopy. RESULTS: In the AOM treated rat model, augmentation of superficial mucosal and total mucosal/superficial submucosal blood supply preceded the appearance of aberrant crypt foci (ACF) and temporally and spatially correlated with future ACF occurrence. These findings were replicated in MIN mice. The 4D-ELF based results were corroborated with immunoblot analysis for haemoglobin on mucosal scrapings from AOM treated rats. Moreover, 4D-ELF analysis of normal human colonic mucosa indicated that there was a threefold increase in superficial blood in patients who harboured advanced adenomas. CONCLUSION: We report, for the first time, that blood content is increased in the colonic microvasculature at the earliest stages of colon carcinogenesis. These findings may provide novel insights into early biological events in colorectal carcinogenesis and have potential applicability for screening.

Improved outcome of polyoma virus allograft nephropathy with early biopsy.

Polyoma virus allograft nephropathy often results in accelerated graft loss despite reduction of immunosuppression and/or treatment with antiviral agents. Irreversible renal fibrosis due to late diagnosis is likely to be one of the important causes of treatment failure. Early biopsy in 14 patients resulted in stable graft function after a mean follow-up of 22 months.