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A Retrospective Analysis of Provider-to-Patient Secure Messages: How Much Are They Increasing, Who Is Doing the Work, and Is the Work Happening After Hours?

North, Frederick; Luhman, Kristine E; Mallmann, Eric A; Mallmann, Toby J; Tulledge-Scheitel, Sidna M; North, Emily J; Pecina, Jennifer L
BACKGROUND:Patient portal registration and the use of secure messaging are increasing. However, little is known about how the work of responding to and initiating patient messages is distributed among care team members and how these messages may affect work after hours. OBJECTIVE:This study aimed to examine the growth of secure messages and determine how the work of provider responses to patient-initiated secure messages and provider-initiated secure messages is distributed across care teams and across work and after-work hours. METHODS:We collected secure messages sent from providers from January 1, 2013, to March 15, 2018, at Mayo Clinic, Rochester, Minnesota, both in response to patient secure messages and provider-initiated secure messages. We examined counts of messages over time, how the work of responding to messages and initiating messages was distributed among health care workers, messages sent per provider, messages per unique patient, and when the work was completed (proportion of messages sent after standard work hours). RESULTS:Portal registration for patients having clinic visits increased from 33% to 62%, and increasingly more patients and providers were engaged in messaging. Provider message responses to individual patients increased significantly in both primary care and specialty practices. Message responses per specialty physician provider increased from 15 responses per provider per year to 53 responses per provider per year from 2013 to 2018, resulting in a 253% increase. Primary care physician message responses increased from 153 per provider per year to 322 from 2013 to 2018, resulting in a 110% increase. Physicians, nurse practitioners, physician assistants, and registered nurses, all contributed to the substantial increases in the number of messages sent. CONCLUSIONS:Provider-sent secure messages at a large health care institution have increased substantially since implementation of secure messaging between patients and providers. The effort of responding to and initiating messages to patients was distributed across multiple provider categories. The percentage of message responses occurring after hours showed little substantial change over time compared with the overall increase in message volume.
PMID: 32673238
ISSN: 2291-9694
CID: 4848822

Review of cardiovascular outcomes trials of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists

North, Emily J; Newman, Jonathan D
PURPOSE OF REVIEW/OBJECTIVE:In recent years, there have been several cardiovascular outcomes trials (CVOT) of two new classes of glucose-lowering medications: sodium-glucose cotransporter-2 inhibitors (SGLT2-i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA). It is important examine their potential for cardiovascular benefit and possible side effects among patients with type 2 diabetes (T2D) mellitus. RECENT FINDINGS/RESULTS:The current article reviews the findings of recent CVOT of SGLT2-i and GLP-1 RA, including their impact on cardiovascular events and relevant side effects. SUMMARY/CONCLUSIONS:For all T2D patients, with or without established cardiovascular disease, the SGLT2-i have demonstrated impressive reductions in hospitalization for heart failure and renoprotection. For T2D patients with established cardiovascular disease, SGLT2-i demonstrated an additional benefit of reduced major adverse cardiac events, on top of reductions in hospitalizations for heart failure, renoprotection, and in some instances, mortality. Similarly, all GLP-1 RA CVOTs demonstrated noninferiority compared with placebo for safety. In comparison, GLP-1 RA appear to preferentially reduce ischemic events (stroke or myocardial infarction) over hospitalization for heart failure, and demonstrated renoprotection in several of the CVOTs.
PMID: 31436559
ISSN: 1531-7080
CID: 4046912

Long-term clinical and visual outcomes after surgical resection of pediatric pilocytic/pilomyxoid optic pathway gliomas

Hidalgo, Eveline Teresa; Kvint, Svetlana; Orillac, Cordelia; North, Emily; Dastagirzada, Yosef; Chang, Jamie Chiapei; Addae, Gifty; Jennings, Tara S; Snuderl, Matija; Wisoff, Jeffrey H
OBJECTIVEThe choice of treatment modality for optic pathway gliomas (OPGs) is controversial. Chemotherapy is widely regarded as first-line therapy; however, subtotal resections have been reported for decompression or salvage therapy as first- and second-line treatment. The goal of this study was to further investigate the role and efficacy of resection for OPGs.METHODSA retrospective chart review was performed on 83 children who underwent surgical treatment for OPGs between 1986 and 2014. Pathology was reviewed by a neuropathologist. Clinical outcomes, including progression-free survival (PFS), overall survival (OS), and complications, were analyzed.RESULTSThe 5- and 10-year PFS rates were 55% and 46%, respectively. The 5- and 10-year OS rates were 87% and 78%, respectively. The median extent of resection was 80% (range 30%-98%). Age less than 2 years at surgery and pilomyxoid features of the tumor were found to be associated with significantly lower 5-year OS. No difference was seen in PFS or OS of children treated with surgery as a first-line treatment compared with children with surgery as a second- or third-line treatment. Severe complications included new disabling visual deficit in 5%, focal neurological deficit in 8%, and infection in 2%. New hormone deficiency occurred in 22% of the children.CONCLUSIONSApproximately half of all children experience a long-term benefit from resection both as primary treatment and as a second-line therapy after failure of primary treatment. Primary surgery does not appear to have a significant benefit for children younger than 2 years or tumors with pilomyxoid features. Given the risks associated with surgery, an interdisciplinary approach is needed to tailor the treatment plan to the individual characteristics of each child.
PMID: 31100719
ISSN: 1933-0715
CID: 3920122

Time to Resolution of Symptoms After Suboccipital Decompression with Duraplasty in Children with Chiari Malformation Type I

Hidalgo, Eveline Teresa; Dastagirzada, Yosef; Orillac, Cordelia; Kvint, Svetlana; North, Emily; Bledea, Ramona; McQuinn, Michelle W; Redel-Traub, Gabriel; Rodriguez, Crystalann; Wisoff, Jeffrey H
OBJECTIVE:Duraplasty is one technique successfully used to treat Chiari malformation type I (CM-I). This study describes the timely manner of clinical outcomes and the postoperative course after craniectomy and duraplasty for the treatment of symptomatic CM-I in pediatric children. METHODS:A retrospective chart review was done on 105 consecutive children who underwent surgical decompression of symptomatic CM-I with dural opening by a single surgeon between 1999 and 2015. RESULTS:In 16 of 28 children (57%) with typical Valsalva-related/tussive and mixed headaches, the symptoms resolved before discharge; by 6 months all children were headache free. Two of 28 children (7%) had recurrent headaches 9 months after surgery. In 78 children with syrinx, syrinx resolved or decreased in 68 children (87%), recurred in 8 children (10%), and was stable in 2 children (3%). In 51 children (65%), syrinx resolved or decreased by 3 months and in 62 children (79%) by 6 months. Complications included aseptic meningitis requiring reoperation in 3% and infection in one child (1%). Twelve reoperations occurred, none within the first 30 days. No child had a major morbidity or mortality. CONCLUSIONS:In carefully selected children with CM-I, a high success rate can be achieved with suboccipital decompression and duraplasty. Valsalva-related/tussive headaches resolved in the majority of children at discharge from the hospital; syrinx resolved or decreased in two thirds of the children by 3 months. By 6 months, headaches were resolved in all cases, and syrinx was resolved or decreased in 79% of cases.
PMID: 29933088
ISSN: 1878-8769
CID: 3158372

Betweenness centrality of intracranial electroencephalography networks and surgical epilepsy outcome

Grobelny, Bartosz T; London, Dennis; Hill, Travis C; North, Emily; Dugan, Patricia; Doyle, Werner K
OBJECTIVE:We sought to determine whether the presence or surgical removal of certain nodes in a connectivity network constructed from intracranial electroencephalography recordings determines postoperative seizure freedom in surgical epilepsy patients. METHODS:We analyzed connectivity networks constructed from peri-ictal intracranial electroencephalography of surgical epilepsy patients before a tailored resection. Thirty-six patients and 123 seizures were analyzed. Their Engel class postsurgical seizure outcome was determined at least one year after surgery. Betweenness centrality, a measure of a node's importance as a hub in the network, was used to compare nodes. RESULTS:The presence of larger quantities of high-betweenness nodes in interictal and postictal networks was associated with failure to achieve seizure freedom from the surgery (p < 0.001), as was resection of high-betweenness nodes in three successive frequency groups in mid-seizure networks (p < 0.001). CONCLUSIONS:Betweenness centrality is a biomarker for postsurgical seizure outcomes. The presence of high-betweenness nodes in interictal and postictal networks can predict patient outcome independent of resection. Additionally, since their resection is associated with worse seizure outcomes, the mid-seizure network high-betweenness centrality nodes may represent hubs in self-regulatory networks that inhibit or help terminate seizures. SIGNIFICANCE/CONCLUSIONS:This is the first study to identify network nodes that are possibly protective in epilepsy.
PMID: 29981955
ISSN: 1872-8952
CID: 3192372

Elevated intracranial pressure and reversible eye-tracking changes detected while viewing a film clip

Kolecki, Radek; Dammavalam, Vikalpa; Bin Zahid, Abdullah; Hubbard, Molly; Choudhry, Osamah; Reyes, Marleen; Han, ByoungJun; Wang, Tom; Papas, Paraskevi Vivian; Adem, Aylin; North, Emily; Gilbertson, David T; Kondziolka, Douglas; Huang, Jason H; Huang, Paul P; Samadani, Uzma
OBJECTIVE The precise threshold differentiating normal and elevated intracranial pressure (ICP) is variable among individuals. In the context of several pathophysiological conditions, elevated ICP leads to abnormalities in global cerebral functioning and impacts the function of cranial nerves (CNs), either or both of which may contribute to ocular dysmotility. The purpose of this study was to assess the impact of elevated ICP on eye-tracking performed while patients were watching a short film clip. METHODS Awake patients requiring placement of an ICP monitor for clinical purposes underwent eye tracking while watching a 220-second continuously playing video moving around the perimeter of a viewing monitor. Pupil position was recorded at 500 Hz and metrics associated with each eye individually and both eyes together were calculated. Linear regression with generalized estimating equations was performed to test the association of eye-tracking metrics with changes in ICP. RESULTS Eye tracking was performed at ICP levels ranging from -3 to 30 mm Hg in 23 patients (12 women, 11 men, mean age 46.8 years) on 55 separate occasions. Eye-tracking measures correlating with CN function linearly decreased with increasing ICP (p < 0.001). Measures for CN VI were most prominently affected. The area under the curve (AUC) for eye-tracking metrics to discriminate between ICP < 12 and >/= 12 mm Hg was 0.798. To discriminate an ICP < 15 from >/= 15 mm Hg the AUC was 0.833, and to discriminate ICP < 20 from >/= 20 mm Hg the AUC was 0.889. CONCLUSIONS Increasingly elevated ICP was associated with increasingly abnormal eye tracking detected while patients were watching a short film clip. These results suggest that eye tracking may be used as a noninvasive, automatable means to quantitate the physiological impact of elevated ICP, which has clinical application for assessment of shunt malfunction, pseudotumor cerebri, concussion, and prevention of second-impact syndrome.
PMID: 28574312
ISSN: 1933-0693
CID: 2591872


Hidalgo, Eveline Teresa; Kvint, Svetlana; Thomas, Cheddhi; Orrilac, Cordelia; North, Emily; Dastagirzada, Yosef; Snuderl, Matija; Wisoff, Jeffrey H.
ISSN: 1522-8517
CID: 2964242

Plastics and environmental health: the road ahead

North, Emily J; Halden, Rolf U
Plastics continue to benefit society in innumerable ways, even though recent public focus on plastics has centered mostly on human health and environmental concerns, including their endocrine-disrupting properties and the long-term pollution they represent. The benefits of plastics are particularly apparent in medicine and public health. Plastics are versatile, cost-effective, require less energy to produce than alternative materials like metal or glass, and can be manufactured to have many different properties. Due to these characteristics, polymers are used in diverse health applications like disposable syringes and intravenous bags, sterile packaging for medical instruments as well as in joint replacements, tissue engineering, etc. However, not all current uses of plastics are prudent and sustainable, as illustrated by the widespread, unwanted human exposure to endocrine-disrupting bisphenol A (BPA) and di-(2-ethylhexyl)phthalate (DEHP), problems arising from the large quantities of plastic being disposed of, and depletion of non-renewable petroleum resources as a result of the ever-increasing mass production of plastic consumer articles. Using the health-care sector as example, this review concentrates on the benefits and downsides of plastics and identifies opportunities to change the composition and disposal practices of these invaluable polymers for a more sustainable future consumption. It highlights ongoing efforts to phase out DEHP and BPA in the health-care and food industry and discusses biodegradable options for plastic packaging, opportunities for reducing plastic medical waste, and recycling in medical facilities in the quest to reap a maximum of benefits from polymers without compromising human health or the environment in the process.
PMID: 23337043
ISSN: 0048-7554
CID: 4848812

Base-catalyzed direct conversion of dipyrromethanes to 1,9-dicarbinols: a [2 + 2] approach for porphyrins

Terazono, Yuichi; North, Emily J; Moore, Ana L; Moore, Thomas A; Gust, Devens
A variant of the MacDonald approach was devised for the synthesis of porphyrins. A new base-catalyzed one-step synthesis of 1,9-dipyrromethane-dicarbinols was achieved by Friedel-Crafts alkylation of dipyrromethanes using commercially available ethyl glyoxylate solution in toluene. This method avoids the use of acid chlorides, Grignard reagents, borohydride reductions, and acidic conditions. The [2 + 2] condensation of dipyrromethanedicarbinols and dipyrromethanes yielded 5,15-di(ethoxycarbonyl)porphyrins.
PMID: 22420376
ISSN: 1523-7052
CID: 4848802