IMPORTANCE Video or telephone telemedicine can offer patients access to a clinician without arranging for transportation or spending time in a waiting room, but little is known about patient characteristics associated with choosing between telemedicine or office visits.OBJECTIVE To examine patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study included data from 1 131 722 patients who scheduled a primary care appointment through the Kaiser Permanente Northern California patient portal between January 1, 2016, and May 31, 2018. All completed primary care appointments booked via the patient portal were identified. Only index visits without any other clinical visits within 7 days were included to define a relatively distinct patient-initiated care-seeking episode. Visits for routine physical, which are not telemedicine-eligible, were excluded. Data were analyzed from July 1, 2018, to December 31, 2019. MAIN OUTCOMES AND MEASURESPatient choice between an office, video, or telephone visit.Relative risk ratios (RRRs) for patient sociodemographic characteristics (age, sex, race/ethnicity, neighborhood socioeconomic status, language preference), technology access (neighborhood residential internet, mobile portal use), visiting the patient's own personal primary care clinician, and in-person visit barriers (travel-time, parking, cost-sharing), associated with choice of video or telephone telemedicine (vs office visit). RESULTSOf 2 178 440 patient-scheduled primary care visits scheduled by 1 131 722 patients, 86% were scheduled as office visits and 14% as telemedicine visits, with 7% of the telemedicine visits by video. Choosing telemedicine was statistically significantly associated with patient sociodemographic characteristics. For example, patients aged 65 years and over were less likely than patients aged 18 to 44 years to choose telemedicine (RRR, 0.24; 95% CI, 0.22-0.26 for video visit; RRR 0.55; 95% CI, 0.54-0.57 for telephone visit). Choosing telemedicine was also statistically significantly associated with technology access (patients living in a neighborhood with high rates of residential internet access were more likely to choose a video visit than patients whose neighborhoods had low internet access: RRR, 1.10; 95% CI, 1.06-1.14); as well as in-person visit barriers (patients whose clinic had a paid parking structure were more likely to choose a telemedicine visit than patients whose facility had free parking: RRR, 1.70; 95% CI, 1.41-2.05 for video visit; and RRR, 1.73, 95% CI, 1.61-1.86 for telephone visit). CONCLUSIONS AND RELEVANCEIn this cross-sectional study, patients usually chose an in-person visit when scheduling an appointment online through the portal. Telemedicine may offer the (continued) Key Points Question Which patient characteristics are associated with choosing either a telemedicine visit or an office visit with the same primary care clinician? Findings In this cross-...
Maple syrup urine disease (MSUD) is an inherited disorder of branched chain amino acid metabolism presenting with neonatal encephalopathy, episodic metabolic decompensation, and chronic amino acid imbalances. Dietary management enables survival and reduces risk of acute crises. Liver transplantation has emerged as an effective way to eliminate acute decompensation risk. Psychiatric illness is a reported MSUD complication, but has not been well characterized and remains poorly understood. We report the prevalence and characteristics of neuropsychiatric problems among 37 classical MSUD patients (ages 5-35 years, 26 on dietary therapy, 11 after liver transplantation) and explore their underlying mechanisms. Compared with 26 age-matched controls, MSUD patients were at higher risk for disorders of cognition, attention, and mood. Using quantitative proton magnetic resonance spectroscopy, we found lower brain glutamate, N-acetylaspartate (NAA), and creatine concentrations in MSUD patients, which correlated with specific neuropsychiatric outcomes. Asymptomatic neonatal course and stringent longitudinal biochemical control proved fundamental to optimizing long-term mental health. Neuropsychiatric morbidity and neurochemistry were similar among transplanted and nontransplanted MSUD patients. In conclusion, amino acid dysregulation results in aberrant neural networks with neurochemical deficiencies that persist after transplant and correlate with neuropsychiatric morbidities. These findings may provide insight into general mechanisms of psychiatric illness.
Depressed people perform poorly on cognitive tasks -it is unclear whether these deficits are due to decreased devotion of task-related resources or increased attention to non-task-related information. We examined the degree to which depressed and healthy adults displayed pupillary motility which varied at the frequency of presented stimuli on a cognitive task, which we interpreted as task-related processing, and at other frequencies which we interpreted as reflecting intrinsic processing. Depressed participants made more consecutive errors compared to controls. More pupillary motility at other frequencies was associated with poorer performance whereas more pupillary motility at the frequency of presented stimuli was associated with better performance. Depressed participants had more pupillary motility at other frequencies which partially mediated observed deficits in cognitive performance. These findings support the hypothesis that allocating cognitive resources to intrinsic processing, contributes to observed cognitive deficits in depression.
This cohort study evaluates whether rates of treatment or follow-up office or emergency visits associated with telemedicine visits differ from those associated with in-person visits in a large integrated health system.
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