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Importance: Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients. Objectives: To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers. Design, Setting, and Participants: In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022. Exposure: Use of the patient portal during ED visit. Main Outcomes and Measures: The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use. Results: The study included 1 280 924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes. Conclusions and Relevance: These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.

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Revision lumbar discectomy, given the disruption of anatomic planes, can be a more technically complicated operation. Historically, it may have higher complication rates than first-time microdiscectomy. Recently, minimally invasive tubular discectomy (MITD) has been reported as an equivalent treatment to traditional approaches and may have better utility for revision surgery. A retrospective review of MITDs performed by the senior surgeon (F.A.S.) on 42 patients with single-level, recurrent disk herniation was analyzed. Surgical technique, preoperative and postoperative visual analogue score, modified Macnab criteria, and complication rate were compared with similar patient series in the literature. One case is reviewed and the technique is described in detail. There were no significant differences across age (49.5±14.1), sex, or obesity status. Visual analogue scores improved significantly from 7.24±1.75 to 2.45±2.12 (P<0.001). Successful clinical outcome (excellent or good Macnab score) was reported in 83.3% of patients. There were no postoperative complications, including dural tears or wound infections: fewer than any reported series of this size to date. MITD can be safely performed for revision discectomies with low morbidity. A paramedian approach helps to decrease the exposure to preexisting scar tissue and may offer a significant advantage over the traditional midline approach to treat recurrent disk herniation.

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Acute kidney injury (AKI) is the rapid onset of decreased kidney function that ultimately increases mortality and morbidity. Stem cell research is a promising avenue for curative and preventative therapies of kidney injury, however, there are many types of stem cells under investigation. Currently there is no research to compare the value of one stem cell method over another. Induced pluripotent stem cells (iPSCs) and spermatogonial stem cells (SSCs) have been shown to differentiate into renal cells, though further clinical research is needed to fully explore potential therapeutic strategies. Mesenchymal stem cells (MSCs) have long been investigated in the preclinical setting and have recently been successful in Phase I clinical trials. MSCs may represent a promising new therapeutic approach to treat AKI as they demonstrate renoprotective effects post-injury via the secretion of promitotic, anti-apoptotic, anti-inflammatory, and immunomodulatory factors. Given the most current research, MSCs appear to offer a promising course of treatment for AKI.

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Objective Traditional techniques for resection of lumbar plexus tumors have been associated with approach-related morbidity. We describe a case utilizing a minimally invasive transpsoas lateral access approach to resect a retroperitoneal tumor of the lumbar plexus. Methods We report a case with an extradural retroperitoneal schwannoma of the L4 nerve root that was treated with a minimally invasive direct lateral transpsoas approach using atraumatic tissue dilators and an expandable tubular retractor. The use of directional and continuous electromyographic monitoring was critical in locating the plexus and positioning the retractor immediately anterior to the tumor. Results The patient tolerated the procedure well without postoperative complications. The operative approach was direct and intraoperative blood loss was negligible. The patient demonstrated improved left leg strength and ambulation and resolution of paresthesias. Conclusions A minimally invasive direct lateral transpsoas access approach is an effective technique to safely and adequately resect extradural retroperitoneal lumbar plexus tumors.