Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center.

OBJECTIVES: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. DESIGN: Retrospective chart review. SETTING: Outpatient visits (in-person, telephone, virtual-Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. INTERVENTION: Virtual visits utilizing the Doxy.me platform. MAIN OUTCOME MEASURES: Accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). METHODS: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). RESULTS: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). CONCLUSION: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

Hypercoagulability in dogs with chronic enteropathy and association with serum albumin concentration.

BACKGROUND: Dogs with protein-losing enteropathy (PLE) are at risk of developing a hypercoagulable state, but the prevalence of hypercoagulability in dogs with chronic enteropathies (CE) and normal serum albumin concentration is unknown. HYPOTHESIS: Dogs with CE are predisposed to a hypercoagulable state as assessed by thromboelastography (TEG) independent of serum albumin concentration. METHODS: Dogs with chronic gastrointestinal signs from suspected inflammatory CE between 2017 and 2019 were included. Thirty-eight were evaluated; every dog had a CBC, serum biochemistry panel, and abdominal imaging performed. The Canine Inflammatory Bowel Disease Activity Index (CIBDAI) was calculated. Thromboelastography was performed at presentation, and reaction time (R), kinetic time (K), α-angle, maximal amplitude (MA), and global clot strength (G) were recorded. Dogs were considered hypercoagulable if the G value was ≥25% above the reference interval. RESULTS: Seventeen of 38 (44.7%; 95% confidence interval [CI], 28.6-61.7%) dogs with CE were hypercoagulable. The G value did not differ between the 19 dogs with normal (≥28 g/L) serum albumin concentrations (9.05 kdyn/cm2 ; 95% CI, 7.26-10.84; SD 3.71) and 19 dogs with hypoalbuminemia (11.3 kdyn/cm2 ; 95% CI, 9.04-13.6, SD; 4.7; P = .11). The G value was negatively correlated with hematocrit, serum albumin concentration, and duration of signs and positively correlated with age. CONCLUSIONS AND CLINICAL IMPORTANCE: Dogs with CE and normal serum albumin concentration can be hypercoagulable as measured by TEG.

Utilization of Galleria mellonella larvae to characterize the development of Staphylococcus aureus infection.

Staphylococcus aureus is a human opportunistic pathogen that causes a wide range of superficial and systemic infections in susceptible patients. Here we describe how an inoculum of S. aureus activates the cellular and humoral response of Galleria mellonella larvae while growing and disseminating throughout the host, forming nodules and ultimately killing the host. An inoculum of S. aureus (2×106 larva- 1 ) decreased larval viability at 24 (80±5.77 %), 48 (55.93±5.55 %) and 72 h (10.23±2.97 %) and was accompanied by significant proliferation and dissemination of S. aureus between 6 and 48 h and the formation of nodules in the host. The hemocyte (immune cell) densities increased between 4 and 24 h and hemocytes isolated from larvae after 24 h exposure to heat-killed S. aureus (2×106 larva- 1 ) showed altered killing kinetics as compared to those from control larvae. Alterations in the humoral immune response of larvae 6 and 24 h post-infection were also determined by quantitative shotgun proteomics. The proteome of 6 h-infected larvae was enriched for antimicrobial proteins, proteins of the prophenoloxidase cascade and a range of peptidoglycan recognition proteins. By 24 h there was a significant increase in the abundance of a range of antimicrobial peptides with anti-staphylococcal activity and proteins associated with nodule formation. The results presented here indicate how S. aureus interacts with the larval immune response, induces the expression of a variety of immune-related peptides and also forms nodules which are a hallmark of soft tissue infections during human infection.

Assaults by Mentally Disordered Offenders in Prison: Equity and Equivalence.

Managing the violent behaviour of mentally disordered offenders (MDO) is challenging in all jurisdictions. We describe the ethical framework and practical management of MDOs in England and Wales in the context of the move to equivalence of healthcare between hospital and prison. We consider the similarities and differences between prison and hospital management of the violent and challenging behaviours of MDOs. We argue that both types of institution can learn from each other and that equivalence of care should extend to equivalence of criminal proceedings in court and prisons for MDOs. We argue that any adjudication process in prison for MDOs is enhanced by the relevant involvement of mental health professionals and the articulation of the ethical principles underpinning health and criminal justice practices.

Influence of body mass index on quality of life in atrial fibrillation patients undergoing catheter ablation.

BACKGROUND: Obesity increases the risk of atrial fibrillation (AF), and AF seriously impairs the quality of life (QoL). However, it is not known whether body mass index (BMI) has any direct influence on QoL in AF. OBJECTIVE: To study the association between baseline BMI and QoL improvement in patients with AF following catheter ablation. METHODS: Six hundred sixty patients with AF (62 ± 10 years, male 69%, paroxysmal AF 27%, persistent AF 31%, long-standing persistent AF 42%) made up the study population. On the basis of the baseline BMI, patients were categorized into 2 groups: normal (BMI < 25) and overweight/obese (BMI ≥ 25). The QoL survey was done at baseline and at 12-month postablation by using the Medical Outcomes Study Short Form-36 (SF-36), Beck Depression Inventory (BDI), Hospital Anxiety and Depression (HAD) scale, and State-Trait Anxiety Inventory (STAI). RESULTS: At baseline, dyslipidemia, hypertension, diabetes, coronary artery disease, and large left atrium had higher prevalence in the overweight/obese population. In addition, the preprocedure QoL scores on the SF-36, HAD scale, and STAI were significantly lower in this group than in the normal-BMI group. At the 12-month postablation assessment, no significant improvement in QoL score was noted in the normal-BMI group. However, in the overweight/obese group, QoL scores improved significantly in all scales, except the physical functioning and bodily pain categories of SF-36. Long-term ablation success was not different across the groups (69% normal BMI, 63% high BMI, log-rank P = .109). Patients with successful ablation showed significant improvement in QoL scores compared with those who failed. The multivariable analysis revealed the baseline QoL score and BMI ≥ 25 to be independent predictors of QoL improvement. CONCLUSION: Obese patients with AF tend to have a better postablation QoL outcome than do their nonobese counterparts.