University Medical Center Department Research Articles

Evaluating the Impact of the COVID-19 Pandemic on Late-Canceled and No-Show Appointments at the Department of Neurological Surgery.

The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented restrictions on the general public and disturbances to the routines of hospitals worldwide. These restrictions are now being relaxed as the number of vaccinated individuals increases and as the rates of incidence and prevalence decrease; however, they left a lasting impact on healthcare systems that is still being felt today. This retrospective study evaluated the total number of canceled or missed outpatient clinic appointments in a Neurological Surgery department before and after peak COVID-19 restrictions and attempted to assess the impact of these disruptions on neurosurgical clinical attendance. We also attempted to compare our data with the data from another surgical subspecialty department. We evaluated 32,558 scheduled appointments at the Loyola University Medical Center Department of Neurological Surgery, as well as 139,435 scheduled appointments with the Department of Otolaryngology. Appointments before April 2020 were defined as pre-COVID, while appointments during or after April 2020 were defined as post-COVID. Here, we compare no-show and non-attendance rates (no-shows plus late-canceled appointments) within the respective time range. Overall, we observed that before COVID-19 restrictions were put into place, there was an 8.9% no-show rate and a 17.4% non-attendance rate for the Department of Neurological Surgery. After COVID restrictions were implemented, these increased to 10.9% and 18.3%, respectively.Greater no-show and cancellation rates (9.8% in the post-COVID era vs 8.0% in the pre-COVID era) were associated with varying socioeconomic and racial demographics. African-American patients (2.56 times higher), new-visit patients (1.67 times higher), and those with Medicaid/Medicare insurance policies (1.48 times higher) were at the highest risk of no-show in the post-COVID era compared to the pre-COVID era.

One year of digital teaching in psychiatry as a response to the COVID-19 pandemic: Knowledge gain and content evaluation of medical students for two summer semesters in 2020 and 2021.

After the beginning of the COVID-19 pandemic in 2020, digital teaching had to be implemented by most universities at short notice and widely replaced classroom teaching. As a consequence, digital teaching further reduced direct social interaction for students. One year after the introduction of digital teaching formats at our university medical center (department of psychiatry and psychotherapy), teaching evaluation of students from summer semesters 2020 and 2021 (SS20, SS21) were compared. The main objective of this study was to objectify whether students evaluate digital teaching less favorably after one year of its implementation. Ratings of 311 medical students on (1) knowledge gain, (2) teaching contents and (3) subjective advantages of digital teaching were analyzed for the two separate cohorts SS20 (n = 175) and SS21 (n = 136). Students also rated their pandemic-related stress level, and if learning progress had been reduced by the pandemic in general. Significant knowledge gain was achieved for all included domains in psychiatry (all p < .001), and did not differ between SS20/SS21. Teaching contents in SS21 were rated worse in six out of eight domains compared to SS20 (p < .001 to .05). Also, subjective advantages of digital teaching vanished in most domains comparing the cohorts of SS21 and SS20 (p < .001 to .05). No differences were found for pandemic-related stress level and subjective learning progress. Limitations include the post-hoc design, possible bias from individual exam grades, and sampling bias. The present study showed that knowledge gain can be considered to be stable one year after the pandemic-related implementation of digital teaching. However, sustainability of this teaching format should be monitored critically: The subject of psychiatry and psychotherapy thrives on direct communication, which can be compromised when using digital formats only. In this light, implementation of more interactive formats in digital teaching is discussed.

Abstracts from the Seventh Annual Baylor University Medical Center Medical Education Research Forum 2021

The Baylor University Medical Center Department of Medical Education hosted its seventh annual Medical Education Research Forum on April 21, 2021, to showcase the research efforts of its medical students, residents, and fellows. Thirty-six posters were shared and 18 oral presentations were given. Here we present 17 award-winning abstracts.

Vanderbilt University Medical Center Ambulatory Teleneurology COVID-19 Experience.

Background: Telehealth has proliferated since the 1950s, but adoption and coverage of telehealth services for the U.S. public have been slow. In response to the coronavirus disease 2019 (COVID-19) pandemic, the federal government has implemented temporary policy changes that removed barriers and catalyzed the unprecedented adoption of telehealth.Methods: To assess ambulatory teleneurology satisfaction, we analyzed postvisit questionnaire data from patients and clinicians who completed teleneurology visits during the COVID-19 pandemic at Vanderbilt University Medical Center Department of Neurology (VUMC).Results: From March 18 to May 8, 2020, VUMC completed 3,935 teleneurology visits. More than 97% of patients were very highly or highly confident in the telehealth care they received, whereas almost 99% of clinicians were very likely or somewhat likely to recommend telehealth to other clinicians.Conclusions: Teleneurology satisfaction at VUMC has been positive, and going forward, we must advance upon this unprecedented adoption of telehealth and never revert to former restrictive policies.

The Change of USMLE Step 1 to Pass/Fail: Perspectives of the Surgery Program Director

ObjectiveThis study sought to evaluate the perspectives of surgical program directors regarding the change of USMLE Step 1 to pass/fail grading.DesignValidated electronic survey.SettingVanderbilt University Medical Center Department of Plastic Surgery.ParticipantsProgram directors of all ACMGE-accredited General Surgery, Integrated Vascular Surgery, Integrated Thoracic Surgery, and Integrated Plastic Surgery residency programs.ResultsThe overall response rate was 55.5%. Most PDs (78.1%) disagreed with the scoring change. Only 19.6% believe this change will improve medical student well-being. For 63.5% of PDs, medical school pedigree will become more important, and 52.7% believe it will place international medical graduates at a disadvantage. Only 6.2% believe Step 2 CK should also be pass/fail, while 88.7% will increase the weight of Step 2 CK and 88.4% will now require Step 2 CK score submission with the electronic residency application service.ConclusionsWhile well-intentioned, changing USMLE Step 1 to pass/fail may have unintended consequences and may disadvantage certain groups of applicants. The emphasis on Step 1, and resulting test-taking apprehension, will likely shift to Step 2 CK. Proponents of equitable evaluation should direct their efforts toward increasing, not decreasing, the number of objective measures available for student assessment.

Increased Time between Scheduling Date and Appointment Date Results in Increased No-Show Rates in the Academic Urology Practice.

No-show appointments can weigh heavily on a urology practice's finances and productivity. Our objective was to investigate if a relationship existed between lag time and no-show appointments at the Columbia University Medical Center department of urology. We queried adult new patient appointments from July 2017 to July 2018 and excluded rescheduled or cancelled visits. We organized appointments by subspecialty training/practice of the urologist (general urology, voiding dysfunction/female urology, male sexual dysfunction/infertility, urological oncology, endourology and reconstructive urology). We performed logistic regression analysis to determine the relationship between lag time and no-show rate. We did the same for age and gender. We also organized lag time into 4 categories (less than 3 days, 3 to 7 days, 8 to 14 days, more than 14 days) and performed a goodness of fit test for no-show rates. A total of 6,060 new patient appointments were scheduled from July 2017 to July 2018. The no-show rate was 14.3% (865 patients). Each daily increase in lag time resulted in a 2% rise in the odds of no-shows for the overall practice (OR 1.02). There were similar results for sexual dysfunction (OR 1.03), general urology (OR 1.02), oncology (OR 1.02) and voiding dysfunction (OR 1.01). There was a positive correlation with increasing lag time category and no-show rates for all subspecialties (R2 >0.80) except reconstructive urology (R2=0.68). Each increase in age resulted in a 2% rise in the odds of no-shows (OR 0.98). Lag time for new patient visits is highly correlated with no-show rates, with a 2% rise in the odds of a no-show with each daily increase in lag time. Increasing age also demonstrated a correlation with no-show rates. Practice interventions to reduce lag time will hopefully reduce no-show rates.

Erratum: Revisiting the Warnock rule.

This corrects the article DOI: 10.1038/nbt.4015.

Referral of patients with fever of unknown origin to an expertise center has high diagnostic and therapeutic value

up to 50% of patients with fever of unknown origin (FUO) remain undiagnosed despite extensive evaluation. In expertise centers, at least 25-63% of these patients are referred after evaluation in another hospital. The diagnostic and therapeutic yields of referral to an expertise center are currently unknown. To determine the diagnostic and therapeutic yield of referral of patients with fever of unknown origin (FUO) that remain undiagnosed in non-expertise hospitals. Data on workup, outcome, treatment and prognosis were extracted from medical records of all 236 patients referred to the Radboud university medical center's department of internal medicine because of FUO between January 2005 and June 2014. A final diagnosis could be made in 110 of 192 tertiary referred FUO patients. The rate of diagnosis did not differ between patients referred for first opinion or after tertiary referral (68.2 vs. 57.3%, P = 0.234). Over half of undiagnosed tertiary referred patients were treated, and fever resolved in half of these patients. Of 96 undiagnosed patients, two died (2.1)% and in both death was considered unrelated to the febrile disease. The diagnostic rate in patients with FUO does not differ between patients that are tertiary referred and patients that have not been previously evaluated in another hospital. With a total diagnostic value of 57.3% and an additional therapeutic yield of 10.9% in undiagnosed patients, tertiary referral should therefore be considered in patients that remain undiagnosed in a non-expertise center.

Fibrinolysis: A Critical Determinant in Musculoskeletal Tissue Repair

For over a century, the formation of a fibrin clot has been considered to be an initial and fundamental phase of musculoskeletal tissue repair. Following a severe injury, accumulation of fibrin clots is necessary to stop bleeding, yet recent work in our lab has demonstrated that proper healing of both bone and skeletal muscle is dependent on the temporal nature of fibrin and the fibrinolytic mechanisms rather than fibrins presence in damaged tissues.Fibrinolysis in Fracture HealingFibrin, the principle polymer protein of the coagulation system, was long believed essential to fracture healing by providing the initial scaffold for osteo‐regenerative mediators. Hence, many principles of musculoskeletal injury care and pharmaceuticals have been developed to provide a fibrin matrix in the fracture bed thought to represent the initial scaffold of fracture healing. However, we have recently demonstrated that fibrin is not essential for fracture healing, rather, persistent fibrin, which was not effectively removed via fibrinolytic mechanism, impaired fracture healing and inhibited union. Specifically, by creating a mid‐shaft femur fracture on 8 week old male mice (Wild type (WT)); n= 15, plasminogen deficient (Plg−/−) which cannot remove fibrin; n= 14, and fibrinogen deficient (Fbg−/−) which cannot make a fibrin clot; n=6) we revealed that WT and Fbg (−/−) mice formed ossified bridging callus by 3 weeks post fracture which was almost completely remodeled and all united by 6 weeks post fracture. Alternatively, Plg (−/−) mice failed to develop an organized mineralized callus and failed to unite or remodel the disorganized matrix (Figure 1A). Consistent with this finding, there was abundant avascular cartilage in Plg (−/−) mice at 2 weeks post fracture as compared to WT mice. Fibrin and CD31 immunohistochemical (IHC) staining showed abundant fibrin interposed between the avascular cartilage and vascularized bone (Figure 1B and C). Finally, reducing fibrinogen levels in Plg (−/−) mice with a targeted antisense oligonucleotide partially rescued the fracture healing in these mice. Considering that many conditions which result in pathologic fracture healing such as diabetes, smoking and aging all have impaired fibrinolysis resulting in fibrin accumulation in tissues, these results may provide valuable insight into novel means of improving fracture healing in these populations by targeting fibrin degradation.Fibrinolysis in Skeletal Muscle HealingLike bone, a fibrin meshwork forms in damaged skeletal muscle following injury, yet is resolved by the main protease of the fibrinolytic system, plasmin, to allow for timely and robust tissue regeneration. Through recent work in our lab, we have demonstrated that the protease plasmin, in addition to its canonical fibrinolytic function, also works to prevent the aberrant formation of mineralization within soft tissues. Specifically, extensive or persistent calcium phosphate deposition within soft tissues after a traumatic injury or major orthopedic surgery can result in pain and loss of joint function. The pathophysiology of soft tissue calcification, including dystrophic calcification and heterotopic ossification (HO), is poorly understood. Yet, we have demonstrated that after muscle injury, insufficient plasmin activity can lead to the formation of dystrophic calcification (Figure 2A). Additionally, we have found that if the dystrophic calcification is persistent within damaged tissues, it can become organized into mature bone, known as HO. Importantly, we determined that downregulating the primary inhibitor of plasmin (α2‐antiplasmin) pharmacologically prevented dystrophic calcification and subsequent HO in vivo (Figure 2A and Figure 2B). Since plasmin also supports bone homeostasis and fracture repair, increasing plasmin activity represents the first pharmacologic strategy to prevent soft tissue calcification without adversely affecting systemic bone physiology or concurrent muscle and bone regeneration.Together these investigations have shifted the paradigm of the role of fibrinolysis in musculoskeletal tissue repair. By utilizing animal models that effectively phenocopy different forms of human musculoskeletal injury, we aspire to translate these findings to the development of novel therapeutics aimed at improving tissue regeneration following a severe injury.Support or Funding InformationFunding for this work was provided by the Vanderbilt University Medical Center Department of Orthopaedics and Rehabilitation, The Caitlin Lovejoy Foundation, RO3 (1RO3AR065762), Orthopedic Pilot Program Award, The Musculoskeletal Transplant Fund, HHMI Student Fellowship, The Orthopaedic Trauma Association, Vascular Biology Training Grant‐Postdoctoral Funding, and the Predoctoral Pharmacology Training Grant (T32 GM007628).

Our Future Selves: Unprecedented Opportunities.

Carole B. Lewis, PT, DPT, GTC, PhD, has focused throughout her career on the continuous improvement of clinical care provided to older adults. Dr Lewis is an adjunct professor at the George Washington University Medical Center Department of Health Care Services and continues to work in private practice. She serves as president of Great Seminars and Books and Great Seminars Online and for 33 years has been editor-in-chief of Topics in Geriatric Rehabilitation , which won the Association of American Publishers' Award for the Most Outstanding Issue of a Scientific Journal. She earned a DPT from MGH Institute of Health Professions, a PhD in health education from the University of Maryland, an MS in gerontology from the University of Southern California Leonard Davis School, an MPA in health care management from the University of Southern California, and a BS in physical therapy from The Ohio State University. Dr Lewis has held 24 consultation positions in clinics and workplaces and with third-party payers. One of the first researchers to determine that older adults are able to exercise safely and can realize major improvements in outcomes when prescribed appropriate exercise, Dr Lewis has published extensively in the field of aging, with research published in journals such as Archives of Physical Medicine and Rehabilitation and the New England Journal of Medicine. She is author of more than 20 textbooks on aging, including what may be the first text on aging and rehabilitation and one of the first on functional assessment ( Aging: Health Care's Challenge: Interdisciplinary Assessment and Treatment of the Geriatric Patient , now in its fourth edition; Geriatric Clinical Strategies ; Geriatric Physical Therapy ; Orthopedic Assessment and Treatment of the Geriatric Patient ; The Geriatric Exercise Kit ; The Functional Toolbox I & II ; The Balance Book and Osteoporosis Exercise …

Cannabis: Does it help or hurt psychotic disorders and PTSD?

There is some evidence that cannabis can benefit people with psychotic disorders or post‐traumatic stress disorder (PTSD) — and some evidence that it can worsen these conditions. In light of recent policy changes on the therapeutic (as well as recreational) use of cannabis, researchers Margaret Haney, Ph.D., of the Division on Substance Abuse at Columbia University Medical Center's Department of Psychiatry, and A. Eden Evins, M.D., of the Center for Addiction Medicine at Massachusetts General Hospital and Harvard Medical School, undertook a discussion in the current issue of Neuropsychopharmacology on the benefits and harms of cannabis use: what remains unproven and what requires further testing.

Pediatric surgeons and anesthesiologists expand the dialogue on the neurotoxicity question, rationale for early and delayed surgeries, and practice changes while awaiting definitive evidence.

The Pediatric Anesthesia NeuroDevelopment Assessment team at Columbia University Medical Center Department of Anesthesiology convened its fourth biennial Symposium to address unresolved issues concerning potential neurotoxic effects of anesthetic agents and sedatives on young children and to assess study findings to date. Dialogue initiated at the third Symposium was continued between anesthesiologists, researchers, and a panel of expert pediatric surgeons representing general surgery and dermatology, orthopedic, and urology specialties. The panel explored the need to balance benefits of early surgery using improved technologies against potential anesthetic risks, practice changes while awaiting definitive answers, and importance of continued interprofessional dialogue.

Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial

ObjectiveTo determine if there is a significant difference in the infection rates of wounds irrigated with sterile normal saline (SS) versus tap water (TW), before primary wound closure.DesignSingle centre, prospective,...

Elective Procedures and Anesthesia in Children

The Pediatric Anesthesia NeuroDevelopment Assessment research group at Columbia University Medical Center Department of Anesthesiology has conducted biannual national Symposia since 2008 to evaluate study data and invigorate continued thinking about unresolved issues of pediatric anesthesia neurotoxicities. The third Symposium extended the dialogue between pediatric anesthesiologists and surgeons in panel presentations and discussions by four surgical specialists. This paper reports the prevailing opinions expressed by a pediatric general surgeon, urologist, plastic surgeon and ophthalmologist and explores factors related to delayed operative intervention, need for multiple procedures, and parental concerns.

Standardized patient identification and specimen labeling: A retrospective analysis on improving patient safety

There is an increased risk of specimen labeling errors with the generation of a high volume of pathology specimens. Measuring specimen labeling accuracy has been suggested as a possible measure for patient safety. We sought to identify operational areas for improvement around specimen handling with the institution of a standardized specimen labeling protocol in the Duke University Medical Center Department of Dermatology. The average rates of specimen labeling events before and after implementation of this protocol were analyzed to determine the efficacy of this systematic approach. We collected the monthly aggregated rates of specimen labeling events occurring with skin specimens processed through the Duke University Medical Center Department of Pathology from December 2008 through June 2011. The average monthly rates of events per 1000 cases for the time periods from December 2008 through March 2010 and June 2010 through September 2011 were compared. The data collected showed a statistically significant decline in the average monthly rate of specimen labeling errors after institution of the protocol. Before implementation, specimen labeling events occurred at a rate of 5.79 events per 1000 with a decrease to 3.53 events per 1000 after integration of this system (P= .028). Limitations of this study include possible sampling error and regression toward the mean. Low-cost, process-driven interventions are effective in the reduction of specimen handling errors.

Un modello operativo per il trattamento degli esordi di schizofrenia

Introduction Recent studies have documented an increased frequency of psychotic disorders among young persons, which carry a worse prognosis than adult-onset forms. This work highlights the potential benefits of early, integrated intervention on the global outcomes in these cases. Aim of the study In Palermo, we emphasize the integration of interventions by staff members of the University Medical Center's Department of Psychiatry, the Department of Mental Health, the Department of Neuropsychiatry for Children and Adolescents (NPIA) of the ASP (local health authority), and the University Department of Psychiatric Rehabilitation, as well as the creation of a database for patients whose care is transferred from the NPIA to the CSM (service of mental health for outpatients). Materials and methods We report our observations on the efficacy of the integrated approach in one of our patients. These observations, which cover an 8-month period, illustrate the positive effects of this strategy. We assessed the effectiveness of integrated intervention on a group of patients transferred from the NPIA to the adult psychiatric services. Results were compared with those obtained in another group of patients who did not receive integrated treatment during the same transfer. We identified the following descriptive criteria: 1) assessment tests; 2) anamnestic-observational criteria; 3) rehabilitation criteria. Conclusions Early intervention is important in attempts to reduce the number, duration, and severity of relapses, and it is associated with better functional outcomes.

Comparison of Maxillary Sinus Specimens Removed during Caldwell-Luc Procedures and Traditional Maxillary Sinus Antrostomies

The cases of 80 patients who underwent Caldwell-Luc surgery for the treatment of chronic rhinosinusitis between 2002 and 2007 at Vanderbilt University Medical Center's Department of Otolaryngology were reviewed. Data on demographics, comorbidities, details of surgery, surgical pathology, and histology were collected. These data were compared with those of 40 patients who underwent standard functional endoscopic sinus surgery in 2007. Statistically significant differences were found in terms of mean patient age, sex, mean number of sinuses surgically addressed, number of prior surgeries, and tissue eosinophil counts. Microscopic examination revealed the presence of "necrotic bone" in 2 Caldwell-Luc specimens, and "necrotic debris" in 2 other Caldwell-Luc specimens. No similar finding was seen in the control group. Caldwell-Luc is a surgery of last resort for patients who fail aggressive interventions for maxillary sinus disease. The mucosal lining of this small group of patients appears to be different from that of patients who respond favorably to functional endoscopic sinus surgery.

The Impact of Evidence-Based Education on Prescribing in a Psychiatry Residency

Recent clinical trials comparing the effectiveness of antipsychotics have found no advantage for second-generation antipsychotics over older first-generation agents. However, the former are much more commonly used despite their significantly higher cost and potential for contributing to the metabolic syndrome. To date, educational interventions have been unsuccessful in influencing this pattern. The Duke University Medical Center Department of Psy chiatry began a program based on principles of academic detailing designed to educate psychiatry residents about generic psychotropics. To encourage residents to gain experience with these medications, samples of selected generic drugs were provided. To assess the initiative's impact, the authors measured the prescribing patterns of residents. We measured the amount of generic drug use 6 months after the program began and compared it with data from a 6-month control period. The data were analyzed based on overall psychotropic use, class of medication, site, and diagnosis. We found a consistent increase in generic use across analyses. There was an increase in overall generic prescribing from 55.8% to 58.6% [X=10.37, odds ratio (OR)=1.12, P=0.0013] and a particularly large increase in prescribing of generic antipsychotic medications from 39.5% to 47.7% [X=36.12, OR=1.39, P<0.0001]. Conclusion. The implementation of this educational program was correlated with increasing use of generic medications and brought antipsychotic prescribing into concordance with the new evidence. This is the first such study in a psychiatry residency program and has implications for promoting cost-effective care while preserving patient choice in the mental health system. The findings from this study also suggest potential techniques for expanding residents' prescribing skills across specialties.

The Greenville Hospital System University Medical Center Department of Surgery

Despite its modest surgical heritage, the Greenville Hospital System University Medical Center Department of Surgery has evolved into a progressive, academic hybrid, well-suited to deliver mission-based surgical care to an expanding regional population. It not only is well positioned clinically, academically, and financially to successfully implement organized processes to improve quality and control cost, but is also well positioned to assume financial accountability for these outcomes in the future.

Value of rapid assessment cytology in the surgical management of head and neck tumors in a Nigerian mission hospital

Fine-needle aspiration (FNA) or touch preparation with rapid assessment is a valuable diagnostic tool with a reported accuracy of diagnosis similar to intraoperative frozen section consultation. The Nigeria Christian Hospital partners with health care professionals from the United States to provide surgical care for rural residents of Aba, Nigeria. Frozen section diagnosis is impractical in this setting because of very limited resources. Therefore, intraoperative rapid assessment FNA or touch preparation to guide surgical management was performed on all mass lesions, and the results were evaluated. FNA was performed just before surgery using a 22-gauge needle attached to a 10-mL syringe and/or an intraoperative touch preparation was performed on biopsies of lesions that failed to yield cellular aspirates. Smears were prepared and stained with hematoxylin and eosin, and an immediate diagnosis was rendered. Tissue samples from the same resected/biopsied cases were fixed in 10% formalin and later transported to Vanderbilt University Medical Center Department of Pathology for processing. Cytologic and histologic correlations were then performed. More than 100 patients underwent surgery for head and/or neck masses during the 2-week periods between November 2002 and November 2003. Of these patients, 98 had either preoperative FNA and/or intraoperative touch preparation performed. Twenty-seven patients were male and 71 were female; the ages ranged from 2 months to 70 years. Sites sampled included the following: thyroid (n = 40); facial/jaw area (n = 19); parotid/submandibular gland (n = 13); scalp/skull region (n = 7); cervical lymph nodes (n = 5); neck (n = 5); other (n = 4); supraclavicular lymph nodes (n = 3); and oral cavity (n = 2). On cytologic analysis, there were 79 benign diagnoses, 17 malignant diagnoses, and 2 nondiagnostic samples. A benign versus malignant cytologic diagnosis was accurate in 97 of 98 cases. In conclusion, rapid assessment cytology was invaluable in the surgical treatment of many of the patients.