A Symposium on the Clinic of the Future and Telehealth: Highlights and Future Directions

Children’s National Hospital held a virtual symposium on “The Clinic of the Future and Telehealth” in December 2020. The goal of the symposium was to explore future trends in these domains. We also discussed how the coronavirus disease 2019 (COVID-19) pandemic accelerated ongoing changes in healthcare. We explored what is on the horizon in these fields and how these changes might affect care delivery in the future. Specifically, we discussed the “Clinic of the Future” with clinical teams from genetics and metabolism, orthopedic surgery, and primary care while our telehealth discussion involved genetics and metabolism, psychiatry, and telerehabilitation. As one example, wearable technology could be adopted among primary care practices and drive a shift in outpatient care from center-based care to patient-based care. We also examined technological innovations in physical exam instruments, gait analysis, imaging integration, and cast technology that could modernize the orthopedic surgery clinic. Telemedicine has rapidly expanded among all fields of medicine, especially since the COVID-19 pandemic, and has spurred innovation to improve the effectiveness of virtual physician visits. The development of technology to improve the virtual physical exam, during a telemedicine visit, further increases the utility of online appointments and increases access to care in all specialties. The incorporation of photogrammetry technology, in genetics and metabolism dysmorphology exams, will offer standardized tracking of patients that could improve diagnosis and treatment. Psychiatry has found nearly equal efficacy in diagnosis and treatment with telehealth visits and the additional benefit of gaining insight in the setting of the patients’ home. Robotics has become increasingly common in rehabilitation, which can now incorporate a gaming experience that can be remotely updated and increase engagement and adherence in pediatric patients. The continued exploration of new ideas promises to improve both in-person and virtual care options.

A Unique "Reverse" Crescent Fragment in an Anterior-Posterior Compression Fracture: A Case Report

CASE

We describe a patient with an anterior-posterior compression type pelvic fracture sustained after a motorcycle crash, with pubic symphysis disruption and a "reverse" crescent fragment. The injury force ruptured the anterior sacroiliac ligaments and travelled posterior medially, creating a complete Denis zone 2 sacral fracture, rather than rupturing the posterior sacroiliac ligaments as would be expected. The patient underwent open reduction and internal fixation of the pubic symphysis and closed reduction and percutaneous pinning of the right sacroiliac joint.

CONCLUSIONS

This case presents a unique "reverse" crescent fragment not previously described in the literature as an anterior-posterior compression type III variant.

The Introduction of a Preoperative MRI Protocol Significantly Reduces Unplanned Return to the Operating Room in the Treatment of Pediatric Osteoarticular Infections

BACKGROUND

Pediatric osteoarticular infection can cause severe morbidity. Some infectious loci may be difficult to identify clinically, and there may be more than one. There is little agreement regarding the appropriate use of preoperative magnetic resonance imaging (MRI) in this setting. After noting an unacceptably high rate of unplanned returns to the operating room for recurrent infection, clinicians at a tertiary care children's hospital noticed many patients had adjacent foci of infection on postoperative MRI. As a result, patients experienced prolonged treatment courses and multiple surgeries. An interdisciplinary team instituted practice guidelines whereby all patients with suspected osteoarticular infection underwent MRI for planned debridement during a reserved morning slot with a surgical suite on hold to proceed directly to surgery if indicated. Images were reviewed in real time to form the surgical plan. Young patients that required sedation for MRI were taken to surgery under the same anesthetic used for MRI without being awakened. The purpose of our retrospective study is to determine if implementing the practice guidelines for acute management of osteoarticular infection reduced unplanned returns to the operating room.

METHODS

A total of 93 patients with osteoarticular infection were included in this study. A total of 40 cases, group A, were treated before implementing practice guidelines; 53 cases, group B, were treated after implementing practice guidelines. Our primary outcomes of interest were the identification of adjacent infections prior to surgery and need for repeat surgery, either planned or unplanned.

RESULTS

Implementation of these guidelines reduced repeat surgery from 50% of patients to <27% (P=0.0099). Of patients requiring repeat surgery, 85% (n=17) were unplanned in group A versus 60% (n=9) in group B (P=0.0099). Adjacent infections were identified in 47.5% (n=19) of patients in group A, versus 60% (n=32) in group B. Adjacent infections were known before surgery in 32% (n=6) of patients in group A versus 72% (n=23) in group B. There were no statistically significant differences in initial patient characteristics or sites of infection.

CONCLUSIONS

Implementing these guidelines reduced the need for repeat surgery in this population. It is difficult to predict with sufficient accuracy which patients need preoperative MRI. While resource intensive, preoperative MRI appears to offer substantial benefit in preoperative planning.

The superiority of antidepressant medication to cognitive behavior therapy in melancholic depressed patients: a 12-week single-blind randomized study

OBJECTIVE

To pursue the previously long-standing but formally untested clinical view that melancholia is preferentially responsive to antidepressant medication in comparison with psychotherapy [specifically Cognitive Behavior Therapy (CBT)]. Second, to determine whether a broader action antidepressant medication sequencing regimen is superior to a Selective Serotonin Reuptake Inhibitor (SSRI) alone.

METHOD

We sought to recruit a large sample of participants with melancholic depression for a 12-week trial but inclusion criteria compromised recruitment and testing the second hypothesis. The first hypothesis was evaluated by comparing 18 participants receiving antidepressant medication to 11 receiving CBT. Primary study measures were the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Endogenous Subscale (HES), rated blindly, while several secondary measures also evaluated outcome.

RESULTS

Participants receiving medication had a superior 12-week outcome to those receiving CBT, with significant differences present on primary measures as early as 4 weeks. At trial conclusion, the percentage improvement in HAM-D scores was 61.1% vs. 34.4%, respectively [Number Needed to Treat (NNT) = 3.7] and with those in receipt of medication returning non-significantly higher HAM-D responder (66.6% vs. 36.4%, NNT = 2.8) and remission (66.7% vs. 45.4%, NNT = 4.7) rates.

CONCLUSION

As the sample size was small and participants evidenced only moderate levels of depression severity, the study risked being underpowered and idiosyncratic. Despite the small sample, the superiority of antidepressant medication to CBT in those with a melancholic depression was distinctive in this pilot study.

Social networking profiles and professionalism issues in residency applicants: an original study-cohort study

OBJECTIVE

To determine the frequency of social networking, the degree of information publicly disclosed, and whether unprofessional content was identified in applicants from the 2010 Residency Match.

BACKGROUND

Medical professionalism is an essential competency for physicians to learn, and information found on social networking sites may be hazardous to the doctor-patient relationship and an institution's public perception. No study has analyzed the social network content of applicants applying for residency.

METHODS

Online review of social networking Facebook profiles of graduating medical students applying for a residency in orthopedic surgery. Evidence of unprofessional content was based upon Accreditation Council for Graduate Medical Education guidelines. Additional recorded applicant data included as follows: age, United States Medical Licensing Examination part I score, and residency composite score. Relationship between professionalism score and recorded data points was evaluated using an analysis of variance.

RESULTS

Nearly half of all applicants, 46% (200/431), had a Facebook profile. The majority of profiles (85%) did not restrict online access to their profile. Unprofessional content was identified in 16% of resident applicant profiles. Variables associated with lower professionalism scores included unmarried relationship status and lower residency composite scores.

CONCLUSION

It is critical for healthcare professionals to recognize both the benefits and risks present with electronic communication and to vigorously protect the content of material allowed to be publically accessed through the Internet.

Children with a history of atypical febrile seizures show abnormal steady state visual evoked potential brain responses

Atypical febrile seizures (FSs) are considered a risk factor for the onset of epilepsy in later life as well as for potential cognitive impairment. However, distinctive characteristics defining the group of children at risk for negative outcomes are not well established. In the following study, children from 6 to 59 months with a history of atypical FSs were investigated using steady state visual evoked potentials (ssVEP), a brain response known to increase with age. Abnormally, low theta and alpha ssVEP brain responses were found in children with a history of atypical FSs.

Metformin directly inhibits ghrelin secretion through AMP-activated protein kinase in rat primary gastric cells

The antidiabetic drug Metformin causes weight loss in both diabetic and non-diabetic individuals. Metformin treatment is also associated with lower circulating levels of the orexigenic hormone ghrelin. To test whether Metformin directly affects ghrelin cells, rat primary stomach cells were treated with Metformin and the levels of ghrelin secretion, proghrelin gene expression and activation of adenosine monophosphate-activated protein kinase (AMPK) were examined. Metformin significantly reduced ghrelin secretion and proghrelin mRNA production and both these effects were blocked by co-incubation with the AMPK inhibitor compound C. Furthermore, the AMPK activator 5-amino-1-β-D-ribofuranosyl-imidazole-4-carboxamide (AICAR) significantly inhibited ghrelin secretion. Additionally, ghrelin cells were shown to express AMPK. Finally, Metformin treatment caused a significant increase in the level of phosphorylated (active) AMPK. Our results show that Metformin directly inhibits stomach ghrelin production and secretion through AMPK. This reduction in ghrelin secretion may be one of the key components in Metformin's mechanism of weight loss.

GIS-based measures of environmental equity: exploring their sensitivity and significance

In order to determine whether principles of environmental justice have been violated, a large number of empirical studies have been carried out to ascertain whether minority and low-income populations are disproportionately exposed to industrial pollution. This study provides a comparative evaluation of two commonly employed proximity measures in GIS-based environmental equity assessment, examining their influence on the results of the analysis, and proposes a methodology for evaluating the significance of these results. 1990 census data on population characteristics and data from the 1995 EPA's toxic release inventory (TRI) for the City of Minneapolis, MN are used. These results also allow a preliminary assessment of environmental equity/inequity in potential exposure to airborne toxic chemicals for racial minorities, poor people and children in Minneapolis. In the third part of the paper we develop and employ a geographic randomization methodology for assessing the significance of these results.

City size distributions and spatial economic change

"The concept of the city size distribution is criticized for its lack of consideration of the effects of interurban interdependencies on the growth of cities. Theoretical justifications for the rank-size relationship have the same shortcomings, and an empirical study reveals that there is little correlation between deviations from rank-size distributions and national economic and social characteristics. Thus arguments suggesting a close correspondence between city size distributions and the level of development of a country, irrespective of intranational variations in city location and socioeconomic characteristics, seem to have little foundation." (summary in FRE, ITA, JPN, )

Thematic analysis of dreams: inter-scorer reliabilities

Psychoanalytically-based scales for the analysis of emotional and cognitive contents of dreams are described. Data for inter-scorer reliability and agreement are presented for each of three series of dreams. Prior to scoring each set, the raters underwent extensive training with the Dream Scales. The data indicate that inter-scorer reliability may decrease over time, but that with training, reliabilities and coefficients of agreement are sufficiently high to warrant further exploration of the utility of the scales.