Kaiser Permanente San Leandro Medical Center

Tarsometatarsal (TMT) joint arthrodesis is essential for managing surgical management of severe bunion deformities, complex midfoot trauma, and osteoarthritis. Various fixation methods and bone grafting types have been described, but the impact of the number of joints fused on union rates remains unclear. This study aimed to evaluate whether fusing multiple joints affects arthrodesis rates and to compare union outcomes among different fixation constructs and grafting techniques. We conducted a single-center retrospective cohort study of 582 TMT fusions, comparing single- vs multiple-joint fusions involving medial and central columns. The average follow-up was 15.5 months. Two fellowship-trained foot and ankle surgeons assessed radiographs and computed tomographic (CT) scans. Radiographic union was evaluated at 8 and 12 weeks as well as the specific fixation constructs and bone graft used across each joint. Single-TMT-joint surgeries had a significantly greater proportion of fusions occurring by 12 weeks than the multiple-TMT-joint surgeries, 74.9% vs 67.0%, respectively, P = .0002. Ultimate union rates were similar for single-joint fusions (80.3%) and multiple-joint fusions (82.6%. Many nonunions were asymptomatic; the combined asymptomatic nonunion and union rate was 95.4%. The revision rate for all nonunions was 25.5%. Staple fixation was associated with higher nonunion rates in the second (46.15%) and third (37.5%) TMT joints, whereas screw fixation showed the highest nonunion at the first TMT joint (54.6%). The lowest nonunion rates were observed with combined interfragmentary screw fixation and plating across all joints. Diabetic patients and current smokers experienced higher complication and nonunion rates. Although the radiographic nonunion rate (18.2%) exceeded prior reports, symptomatic nonunion was rare (4.6%). Multiple-TMT-joint surgeries required more time to confirm radiographic union than single joint surgeries. Among the modifiable factors, implant and graft choice were associated with differences in union rates.

To investigate differences in health care utilization between immediate (within 10 minutes of placental delivery) and delayed (after 24 hours) intrauterine device (IUD) placement. This retrospective cohort study was conducted with data from Kaiser Permanente Northern California from 2017 to 2019 and included patients with an IUD placed between 0 and 63 days postpartum. The primary outcome for health care utilization was the number of obstetrician-gynecologist (ob-gyn) or women's health office visits within 1 year. Secondary outcomes included formal imaging studies, surgical intervention, and hospitalizations related to IUD complications within 1 year. An additional secondary outcome was live births at 120 days and 1 year. Among 1,543 immediate and 10,332 delayed postpartum IUD placements, the number of visits to an ob-gyn or women's health office within 1 year was slightly increased with delayed placement (mean 2.30 vs 2.47, P <.001). Imaging was increased in the immediate compared with the delayed group (10.5% vs 4.1%, P <.001). Laparoscopy was decreased in the immediate compared with the delayed group (0.0% vs 0.4%, P =.005), with no significant difference in hysteroscopy (0.2% vs 0.1%, P =.413). Hospitalizations were rare and increased in the immediate group (0.4% vs 0.02%, P <.001). Lastly, there was no difference in repeat pregnancies between groups at 120 days (both 0.2%) or at 1 year (2.9% vs 2.5%, P =.342). Compared with delayed placement, immediate postpartum IUD placement is not associated with increased office visits. Immediate placement is associated with an increase in imaging but a decrease in laparoscopic surgery to manage IUD-related complications. There was no difference in live birth rates at 6 months or 1 year between groups.

Telehealth use including secure messages has rapidly expanded since the COVID-19 pandemic, including for multidisciplinary aspects of cancer care. Recent reports described rapid uptake and various benefits for patients and clinicians, suggesting that telehealth may be in standard use after the pandemic. To examine attitudes and perceptions of multidisciplinary cancer care clinicians toward telehealth and secure messages. Cross-sectional specialty-specific survey (ie, some questions appear only for relevant specialties) among multidisciplinary cancer care clinicians, collected from April 29, 2020, to June 5, 2020. Participants were all 285 clinicians in the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation from all 21 community cancer centers of Kaiser Permanente Northern California. Clinician satisfaction, perceived benefits and challenges of telehealth, perceived quality of telehealth and secure messaging, preferred visit and communication types for different clinical activities, and preferences regarding postpandemic telehealth use. A total of 202 clinicians (71%) responded (104 of 128 medical oncologists, 34 of 37 radiation oncologists, 16 of 62 breast surgeons, 18 of 28 navigators, and 30 of 30 survivorship experts; 57% (116 of 202) were women; 73% [147 of 202] between ages 36-55 years). Seventy-six percent (n = 154) were satisfied with telehealth without statistically significant variations based on clinician characteristics. In-person visits were thought to promote a strong patient-clinician connection by 99% (n = 137) of respondents compared with 77% (n = 106) for video visits, 43% (n = 59) for telephone, and 14% (n = 19) for secure messages. The most commonly cited benefits of telehealth to clinicians included reduced commute (79%; n = 160), working from home (74%; n = 149), and staying on time (65%; n = 132); the most commonly cited negative factors included internet connection (84%; n = 170) or equipment problems (72%; n = 146), or physical examination needed (64%; n = 131). Most respondents (59%; n = 120) thought that video is adequate to manage the greater part of patient care in general; and most deemed various telehealth modalities suitable for any of the queried types of patient-clinician activities. For some specific activities, less than half of respondents thought that only an in-person visit is acceptable (eg, 49%; n = 66 for end-of-life discussion, 35%; n = 58 for new diagnosis). Most clinicians (82%; n = 166) preferred to maintain or increase use of telehealth after the pandemic. In this survey of multidisciplinary cancer care clinicians in the COVID-19 era, telehealth was well received and often preferred by most cancer care clinicians, who deemed it appropriate to manage most aspects of cancer care. As telehealth use becomes routine in some cancer care settings, video and telephone visits and use of asynchronous secure messaging with patients in cancer care has clear potential to extend beyond the pandemic period.