Personalized Telehealth: Redesigning Complex Care Delivery for the 65+ During the COVID Pandemic: a Survey of Patients, Caregivers, and Health-care Providers

Background

In the context of the ongoing COVID-19 pandemic, rapid transitions have been made towards telehealth. Optimal use of telehealth in elderly patients remains poorly understood and adaptation challenges persist. Our study aimed at identifying perceptions, barriers, and possible facilitators to telehealth use amongst elderly patients with comorbidities, their caregivers, and health-care providers (HCPs).

Methods

Health-care providers, patients 65 years and older with multiple comorbidities, and caregivers were recruited from outpatient clinics and invited to complete an electronic self-administered or telephone-administered survey on their perceptions of telehealth and of barriers to its implementation.

Results

A total of 39 health-care providers, 40 patients, and 22 caregivers responded to the survey. Most patients (90%), caregivers (82%), and HCPs (97%) had experienced telephone visits, but few were conducted via videoconference platforms. Patients and caregivers showed interest in pursuing some future telehealth visits (68%, 86%, respectively), but felt they lacked access to technology and skills (n=8, 20%), and some felt that telehealth visits may be inferior to in-person visits (n=9, 23%). HCPs showed interest in incorporating telehealth visits into practice (n=32, 82%), but identified challenges in lack of administrative support (n=37), lack of HCP (n=28) and patient (n=37) technological skills, and limited infrastructure (n=37)/internet access (n=33).

Conclusions

Older patients, caregivers, and HCPs show interest in pursuing future telehealth visits but elucidate similar barriers. Facilitating access to technology, as well as to administrative and technology support guides, could promote high quality and equal access to virtual care for the older adult.

Benefits of implementing a rapid access clinic in a high-volume inflammatory bowel disease center: Access, resource utilization and outcomes

BACKGROUND

Emergency situations in inflammatory bowel diseases (IBD) put significant burden on both the patient and the healthcare system.

AIM

To prospectively measure Quality-of-Care indicators and resource utilization after the implementation of the new rapid access clinic service (RAC) at a tertiary IBD center.

METHODS

Patient access, resource utilization and outcome parameters were collected from consecutive patients contacting the RAC between July 2017 and March 2019 in this observational study. For comparing resource utilization and healthcare costs, emergency department (ED) visits of IBD patients with no access to RAC services were evaluated between January 2018 and January 2019. Time to appointment, diagnostic methods, change in medical therapy, unplanned ED visits, hospitalizations and surgical admissions were calculated and compared.

RESULTS

488 patients (Crohn’s disease: 68.4%/ulcerative colitis: 31.6%) contacted the RAC with a valid medical reason. Median time to visit with an IBD specialist following the index contact was 2 d. Patients had objective clinical and laboratory assessment (C-reactive protein and fecal calprotectin in 91% and 73%). Fast-track colonoscopy/sigmoidoscopy was performed in 24.6% of the patients, while computed tomography/magnetic resonance imaging in only 8.1%. Medical therapy was changed in 54.4%. ED visits within 30 d following the RAC visit occurred in 8.8% (unplanned ED visit rate: 5.9%). Diagnostic procedures and resource utilization at the ED (n = 135 patients) were substantially different compared to RAC users: Abdominal computed tomography was more frequent (65.7%, P < 0.001), coupled with multiple specialist consults, more frequent hospital admission (P < 0.001), higher steroid initiation (P < 0.001). Average medical cost estimates of diagnostic procedures and services per patient was $403 CAD vs $1885 CAD comparing all RAC and ED visits.

CONCLUSION

Implementation of a RAC improved patient care by facilitating easier access to IBD specific medical care, optimized resource utilization and helped avoiding ED visits and subsequent hospitalizations.

Identification of patients with recent-onset psychosis in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic instruments

PURPOSE

There is considerable variation in epidemiology and clinical course of psychotic disorders across social and geographical contexts. To date, very little data are available from low- and middle-income countries. In sub-Saharan Africa, most people with psychoses remain undetected and untreated, partly due to lack of formal health care services. This study in rural South Africa aimed to investigate if it is possible to identify individuals with recent-onset psychosis in collaboration with traditional health practitioners (THPs).

METHODS

We developed a strategy to engage with THPs. Fifty THPs agreed to collaborate and were asked to refer help-seeking clients with recent-onset psychosis to the study. At referral, the THPs rated probability of psychosis ("maybe disturbed" or "disturbed"). A two-step diagnostic procedure was conducted, including the self-report Community Assessment of Psychic Experiences (CAPE) as screening instrument, and a semi-structured interview using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Accuracy of THP referrals, and test characteristics of the THP rating and the CAPE were calculated.

RESULTS

149 help-seeking clients were referred by THPs, of which 44 (29.5%) received a SCAN DSM-IV diagnosis of psychotic disorder. The positive predictive value of a THP "disturbed" rating was 53.8%. Test characteristics of the CAPE were poor.

CONCLUSION

THPs were open to identifying and referring individuals with possible psychosis. They recognized "being disturbed" as a condition for which collaboration with formal psychiatric services might be beneficial. By contrast, the CAPE performed poorly as a screening instrument. Collaboration with THPs is a promising approach to improve detection of individuals with recent-onset psychosis in rural South Africa.

Harmonization of quality of care in an IBD center impacts disease outcomes: Importance of structure, process indicators and rapid access clinic

BACKGROUND AND AIMS

We aimed to evaluate the quality of care at a tertiary inflammatory bowel disease (IBD) center using quality of care indicators (QIs) including patient assessment strategy, monitoring, treatment decisions and outcomes.

METHODS

We retrospectively reviewed the quality of care pre- and post-referral and during follow-up at the at the McGill University Health Center (MUHC) IBD center. Consecutive patients were included presenting with an outpatient visit ('index visit') between July and December 2016. Disease characteristics, biochemistry, imaging and endoscopy data, changes in medications, and vaccination profiles were captured.

RESULTS

1357 patients were included. At referral, a large proportion of patients were objectively re-evaluated (ileocolonoscopy: 79%, cross-sectional imaging: 39.3%, biomarkers: 89.9%, 81.9%). Therapeutic strategy was changed in 53.6% with 22.5% of patients starting biologics. Tight objective patient monitoring was applied during follow-up (colonoscopy: 79%, cross-sectional imaging: 61.8% were available at index visit; C-reactive protein: 78%, Faecal calprotectin: 37.6%, therapeutic drug monitoring: 16.3% were performed additionally). Maximum therapeutic step was biologicals in 48.8% of the patients, while only 6.6% of all patients were steroid dependent. Implementation of a rapid access clinic improved healthcare delivery.

CONCLUSIONS

Our data support that tight monitoring was applied at the MUHC IBD center with a high emphasis on objective patient (re)evaluation, timely access and accelerated treatment strategy at referral and during follow-up.

Exposure to thrombus diminishes endothelial derived relaxation in the rabbit carotid artery

PURPOSE

Thrombus is believed to be deleterious to intimal function. However, few studies have directly examined this effect. This study examines the effect of thrombus on endothelial-dependent and -independent vasorelaxation in the rabbit carotid artery.

METHODS

Twelve male New Zealand white rabbits (3.5-4.5 kg) were divided into two groups of six. Thrombosis was induced in group I by segmental right carotid artery ligation. Group II underwent segmental right carotid ligation immediately followed by removal of thrombus with normal saline flush through an arteriotomy. The left carotid arteries were exposed in both groups and served as internal controls. After 4 h, left and right carotid arteries were harvested, sectioned into 6-mm rings, and mounted on isometric force transducers in a physiologic bath. Thrombus was removed from the arteries in group I during the ring preparation process. Neither group I nor group II had thrombus in contact with endothelium during ex vivo testing. The arterial rings were constricted with norepinephrine (1 x 10(-4) M). Endothelium-dependent and -independent vasorelaxation to acetylcholine (Ach) and s-nitrosoacetylpenicillamine, respectively, were measured in a dose-response manner. Results were expressed as a percentage of vasorelaxation. Statistical analysis was performed using an analysis of variance.

RESULTS

Endothelial-dependent vasorelaxation, which tests for endothelial cell function, was decreased in the thrombus and endothelial ischemia group (I) compared to control as noted by vasorelaxations of 22% vs 34% at 1 x 10(-4) molar concentration Ach, and 33% vs 48% at 1 x 10(-3) molar concentration Ach, respectively (P = 0.05). By comparison, there was no difference in the endothelial-dependent vasorelaxation of the endothelial ischemia group (II) versus control. Endothelial-independent vasorelaxation, which tests for smooth muscle function, was not affected by either the thrombus and endothelial ischemia group (I) or the endothelial ischemia group (II) compared to the control group. The controls in group I and group II were slightly different. When this difference was removed, the resulting comparison of treatments in group I and group II approached significance at molar concentrations of 1 x 10(-4), 1 x 10(-5), and 1 x 10(-6) (P = 0.07, 0.06, 0.06).

CONCLUSIONS

The presence of thrombus within the rabbit carotid artery for a period of 4 h decreases endothelial-dependent relaxation. Four hours of endothelial ischemia without thrombus did not change endothelial-dependent vasorelaxation. Neither thrombus nor ischemia alone had any effect on the endothelium-independent vasorelaxation. We conclude that thrombus is deleterious to endothelial function independent of smooth muscle function in the acute setting as measured by endothelial-dependent vasorelaxation.

The role of patch angioplasty in prevention of early recurrent carotid stenosis

The aim of this study was to determine the effect of primary closure versus patch angioplasty on the incidence of early recurrent stenosis after carotid endarterectomy in the hands of a single surgeon, and to analyze the risk factors associated with early recurrent stenosis after carotid endarterectomy. A retrospective review was performed of 178 consecutive patients who underwent 200 carotid endarterectomies-100 done consecutively with primary closure and 100 done consecutively with patch angioplasty. Of these patients, 126 qualified for analysis by having had at least 18 months of follow-up by serial duplex scanning. Of this group, the first 65 patients underwent 75 routine primary closures, while the last 61 underwent 67 routine patch angioplasties. All patients underwent a completion angiogram at the end of the case. Recurrent stenosis was defined as luminal diameter narrowing >60% on duplex scan. A multifactorial analysis was performed to analyze the effect of age, sex, tobacco use, diabetes, hypertension, peripheral vascular disease, coronary artery disease, and contralateral stenosis on recurrent stenosis. The results of this study showed that in a single surgeon's experience with carotid endarterectomy, varying only the method of closure between primary closure versus patch angioplasty, there is no statistically significant difference in the rate of early restenosis. No difference was noted in the perioperative morbidity and mortality between groups.

Cigarette smoking increases endothelial-derived vasorelaxation in the rat carotid artery in a dose-dependent manner

While there is clear-cut epidemiologic, morphologic, and functional evidence to suggest that cigarette smoking is deleterious to the cardiovascular system and endothelium, previous experiments with regard to the effect of cigarette smoking on endothelial-derived vasorelaxation are not conclusive. This study examines the effect of cigarette smoking on endothelium-derived vasorelaxation and its relationship to serum nitric oxide concentrations. Fourteen Sprague-Dawley rats (350-500 g) were divided into two groups (N = 7). The experimental group was exposed to six cigarettes (Kentucky 1R4F) per day for 50 days using a Griffith snout exposure method. The two groups were sacrificed and the carotid arteries were mounted on isometric force transducers in a physiologic bath. The arteries were constricted with norepinephrine (1 x 10(-4) M). Vasorelaxation to acetylcholine (Ach) was measured in a dose response manner. Vasorelaxation to nitroglycerin was measured at 10(-4) M. After the rats were sacrificed, blood samples from each rat were examined for total nitrate/nitrite concentration with serum chemiluminescence on a vanadium column. The results were analyzed with ANOVA and the Student's t test. Vasorelaxation to nitroglycerin was 17.42% +/- 0. 44 versus 16.25% +/- 0.42 in the control and smoke exposure groups, respectively (P = 0.19). This experiment counterintuitively demonstrates that cigarette smoking augments endothelial-derived vasorelaxation. No effect was noted in the endothelium-independent vasorelaxation to nitroglycerin. Alternative mechanisms including the presence of hypoxia and exogenous nitric oxide, which lead to endothelial-dependent and -independent vasorelaxation secondary to cigarette smoking, may serve to explain the apparent augmentation of endothelial-derived vasorelaxation. Further experiments with isolated components of smoke will need to be done to resolve the debate.

Chemoenzymatic synthesis of D(-)phenylglycine using hydantoinase of Pseudomonas desmolyticum resting cells

We screened 125 Pseudomonas strains from our culture collection for the production of hydantoinase activity using DL-phenylhydantoin as a substrate. Pseudomonas desmolyticum NCIM 2112 was found to be the best hydantoinase (dihydropyrimidinase E.C. 3.5.2.2) producer. The enzymatic reactions were carried out using 18-20-h grown cells in nutrient broth and 5-phenylhydantoin as the substrate. Optimization studies for the biotransformation reaction were performed to increase product yield. The optimum pH and temperature for D(-)N-carbamoylphenylglycine production were 9.5 and 30 degrees C, respectively. Biotransformation under these alkaline conditions allowed the complete conversion of 27.0 g l-1 of DL-phenylhydantoin to 26.5 g l-1 of N-carbamoylphenylglycine within 24 h, with a molar yield of 90%. The hydantoinase involved in this biotransformation process was strictly D-stereospecific, because the product isolated was pure D(-)N-carbamoylphenylglycine. This pure product was further chemically converted to D(-)phenylglycine using nitrous acid with an 80% chemical yield. Thus, the overall conversion efficiency of DL-5-phenylhydantoin to D(-)phenylglycine was found to be 65-68%.

Multiparametric Evaluation of Retinoic Acid-Induced Terminal Differentiation of Blastoid Cells from Acute Non-Lymphocytic Leukemia Patients in Vitro

Recent findings that retinoic acid (RA) induces terminal granulocytic differentiation of the human promyelocytic leukemia cell line HL-60 in vitro and blast cell maturation in patients suffering from acute non-lymphocytic leukemia (ANLL) prompted an investigation on the ability of this agent to induce terminal maturation in blast cells from ANLL patients in vitro. We tested the ability of RA at 3×10–6 M, 3×10–7 M and 3×108– M concentrations to induce differentiation in blastold cells from 16 patients with ANLL using cytochemical and cytologic parameters, in addition to cytofluorometric methods. Leukemic cells in primary culture from all the patients underwent cytochemical and biochemical changes after treatment with RA. However, the extent of differentiation-positive cell clones (D+ clones) varied from patient to patient. Morphologic maturation was observed in a significant number of bone marrow samples. Leukocyte alkaline phosphatase and NBT reduction ability of cells, which are biochemical markers of granulocytic differentiation, were also significantly increased with a simultaneous decrease in DNA and RNA synthesis (which was estimated using a Phywe ICP-11 impulse flow cytometer).