BackgroundWe define electronic consultations (“e-consults”) as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults.MethodsWe searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based.ResultsOur final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers.DiscussionE-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.

AIMTo reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors.METHODSWe performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013 (n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariate analyses were performed to describe variables associated with readmission.RESULTSOne hundred thirty-two patients (59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit.CONCLUSIONReadmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.

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Pulmonary valve (PV) infective endocarditis (IE) is an extremely rare disease that involves normal as well as abnormal valves. This condition mostly occurs in patients with underlying predisposing factors. It could be missed if patients do not present with typical features of right-sided endocarditis or in the absence of classic risk factors. The case presented here did not have any known risk factors for IE until surgery and presented mainly with fever, weight loss, and musculoskeletal symptoms.

Introduction: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal (GI) system. Most GISTs originate from the interstitial cells of Cajal (ICC), the pacemaker cell situated between the circular and longitudinal layers of the muscularis propria along the GI tract. In this population-based study using the SEER database, we sought to identify demographic, clinical, and pathologic factors that affect the prognosis and survival of patients with this neoplasm. Molecular genetic advances, current management guidelines, and advances in targeted therapy are discussed. Methods: Demographic and clinical data from GIST patients were retrieved from the SEER research plus database for the period 2000–2018. Statistical analysis was performed with IBM SPSS® v20.2 software using the Chi-square test, paired t-test, multivariate analysis, and Kaplan–Meier functions. Results: A total of 10,833 patients with GIST were identified. Most patients were between 60–74 years of age: 40%, Caucasian: 68%, and the male to female ratio was 1.1:1. The most common primary tumor sites were stomach: 63%, small intestine: 30%, rectum: 3%, and esophagus: 0.7%. When reported, the grade of differentiation was well: 38%, moderately: 32%, undifferentiated: 19%, poorly: 12%. The size of most tumors ranged between 6–10 cm: 36% and they were treated by surgical intervention: 82% and/or chemotherapy/targeted therapy: 39%. The stage was localized: 66%, advanced: 19%, and regional: 15%. The 5-year survival was 74% (95% confidence interval (95% CI) = 72.6–74.7), and the 5-year cause-specific survival 82% (95% CI = 80.7–82.6). The 5-year cause-specific survival by treatment included surgery at 86% (95% CI = 85.4–87.3), chemotherapy/targeted therapy with or without surgery at 77% (95% CI = 75.7–78.9), and radiation at 75% (95% CI = 74.5–80). On multivariable analysis tumor size > 5 cm, poorly and undifferentiated grade, age > 60, and distant metastases at presentation were associated with worse overall survival. Conclusion: GISTs comprise 1–2% of malignancies of the GI tract, usually affect male Caucasians between the ages of 60 and 74 years, most tumors occur in the stomach and small intestine, and are usually >5 cm, but still localized, at the time of diagnosis. Most tumors receive multimodality surgical and chemotherapy/targeted therapy treatment, with a 5-year overall survival of 74% and cause-specific survival of 82%. GIST patients would benefit from enrollment in large clinical trials to establish better therapy guidelines for unresectable, treatment-refractory, and recurrent tumors.