An Evidence-Based Roadmap for the Provision of More Equitable Telemedicine.

OBJECTIVE: During the coronavirus disease 2019 pandemic, as a safety-net organization with a substantial percentage of patients of color and with limited English proficiency (LEP), we were wary of furthering health disparities in our community. We analyzed gaps in telemedicine (telephone and video) delivery in our communities, quantified the effects of our tests of change, and began the process of accumulating evidence to create a road map for other organizations. METHODS: We leveraged Lean problem-solving strategies to identify modifiable gaps across multiple domains that could inhibit equity in telemedicine. We implemented tests of change across domains of community engagement, technology, education, and access. We observed the proportion of telemedicine encounters across races and languages between April and November, 2020. Regression analyses tested the impact of race and language on telemedicine controlling for age, gender, insurance, and time. RESULTS: Several rounds of changes and enhancements were associated with changes in telemedicine use of +5.5% (p < 0.0001) for Hispanic, +4.0% (p < 0.0001) for Spanish-speaking, -2.1% for Black (p < 0.05), and -4.4% for White patients (p < 0.001). African-American, Hispanic, and non-English-speaking patients had between 2.3 and 4.6 times the odds of preferring telephone to video encounters (p < 0.0001), with increases in preferences for video use over time (p < 0.05). CONCLUSION: Our roadmap to improve equitable delivery of telemedicine was associated with a significant improvement in telemedicine use among certain minority populations. Most populations of color used telephone more often than video. This preference changed over time and with equity-focused changes in telemedicine delivery.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication.

STUDY OBJECTIVE: Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication. METHODS: This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations. RESULTS: We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0. CONCLUSION: Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness.

Decreased basal chloride secretion and altered cystic fibrosis transmembrane conductance regulatory protein, Villin, GLUT5 protein expression in jejunum from leptin-deficient mice.

Patients with diabetes and obesity are at increased risk of developing disturbances in intestinal function. In this study, we characterized jejunal function in the clinically relevant leptin-deficient ob/ob mouse, a model of diabetes and obesity. We measured transepithelial short circuit current (Isc), across freshly isolated segments of jejunum from 12-week-old ob/ob and lean C57BL/6J (female and male) mice. The basal Isc was significantly decreased (~30%) in the ob/ob mice (66.5±5.7 µA/cm(2) [n=20]) (P< 0.05) compared with their lean counterparts (95.1±9.1 µA/cm(2) [n=19]). Inhibition with clotrimazole (100 µM, applied bilaterally) was significantly reduced in the ob/ob mice (-7.92%±3.67% [n=15]) (P<0.05) compared with the lean mice (10.44%±7.92% [n=15]), indicating a decreased contribution of Ca(2+)-activated K(+) (KCa) channels in the ob/ob mice. Inhibition with ouabain (100 µM, applied serosally) was significantly reduced in the ob/ob mice (1.40%±3.61%, n=13) (P< 0.05) versus the lean mice (18.93%±3.76% [n=18]), suggesting a potential defect in the Na(+)/K(+)-adenosine triphosphate (ATP)ase pump with leptin-deficiency. Expression of cystic fibrosis transmembrane conductance regulatory protein (CFTR) (normalized to glyceraldehyde-3-phosphate dehydrogenase [GAPDH]) was significantly decreased ~twofold (P<0.05) in the ob/ob mice compared with the leans, whilst crypt depth was unchanged. Villi length was significantly increased by ~25% (P<0.05) in the ob/ob mice compared with the leans and was associated with an increase in Villin and GLUT5 expression. GLUT2 and SGLT-1 expression were both unchanged. Our data suggests that reduced basal jejunal Isc in ob/ob mice is likely a consequence of reduced CFTR expression and decreased activity of the basolateral KCa channel and Na(+)/K(+)-ATPase. Understanding intestinal dysfunctions in ob/ob jejunum may allow for the development of novel drug targets to treat obesity and diabetes.