Academic Health Care Center Research Articles

Effectiveness of Osteopathic Manipulative Medicine vs Concussion Education in Treating Student Athletes With Acute Concussion Symptoms.

Concussion, a type of mild traumatic brain injury, is a disruption in normal brain function due to head injury. New-onset symptoms from concussion vary, likely depending on the areas of the head and neck affected; they can be severe and debilitating. Current treatment options are limited and difficult to individualize. Osteopathic manipulative medicine (OMM) can aid musculoskeletal restrictions that can potentially improve concussion symptoms. To assess concussion symptom number and severity in participants with concussion who received either OMM or an educational intervention. A randomized controlled trial was conducted at the New York Institute of Technology Academic Health Care Center. Patients presenting to the center with concussion-like symptoms due to recent head injury within the previous 7 days provided consent and were randomized into 2 intervention groups, receiving either 1 OMM treatment (n=16) or 1 concussion education intervention (n=15). Participants were assessed before and after the intervention with the validated Symptom Concussion Assessment Tool fifth edition (SCAT-5) for quantification of number of symptoms and their severity. Collected data were analyzed using the Mann-Whitney U test and the repeated-measures analysis of variance. Thirty-one participants were enrolled in the study; after 1 control participant was excluded due to incomplete data, 30 patient records were analyzed. The OMM intervention group had a significant decrease in symptom number (P=.002) and symptom severity (P=.001) compared with the concussion education group. When used in the acute setting, OMM significantly decreased concussion symptom number and severity compared with concussion education. This study demonstrates that integration of OMM using a physical examination-guided, individualized approach is safe and effective in the management of new-onset symptoms of uncomplicated concussions. (Clinicaltrials.gov No. NCT02750566).

Investigating the incidence, nature, severity and potential causality of medication errors in hospital settings in Qatar

Background Medication errors are a major public health concern that negatively impact patient safety and health outcomes. Effective and efficient medication error reporting systems and practices are imperative in reducing error incidence and severity. Objective The objectives were to quantify the incidence, nature and severity of medication errors, and to explore potential causality using a theoretical framework. Setting The study was conducted at Hamad Medical Corporation, the largest public funded academic healthcare center in the state of Qatar. Methods A retrospective review of medication error reports submitted to the Hamad Medical Corporation incident reporting system during 2015 to 2017. Data related to number of reports, reporter, medication, severity and outcomes were extracted. Reason’s Accident Causation Model was used as a theoretical framework for identifying potential causality. Two researchers independently categorized errors as: active failures (e.g. forgetting to administer medication at scheduled time); error provoking conditions (e.g. medication prescribed by an unauthorized physician and administered to the patient); and latent failures (e.g. organizational factors, lack of resources). Main outcome measures Incidence, classes of medications, reporter, error severity and outcomes, potential causality. Results A total of 5103 reports provided sufficient information to be included in the study giving an estimated error incidence of 0.044% of prescribed medication items. Most of the reports (91.5%, n = 4667) were submitted by pharmacists and majority (87.9%, n = 4485) were prescribing errors. The most commonly reported medications were anti-infectives for systemic use (22.0%, n = 1123) followed by medications to treat nervous system disorders (17.2%, n = 876). Only three errors reported to have caused temporary harm requiring intervention while one contributed to or resulted in temporary harm requiring initial or prolonged hospitalization. In terms of potential causality of medication errors, the majority (91.5%, n = 4671) were classified as active failures. Conclusion Almost all reports were submitted by pharmacists, indicating likely under-reporting affecting the actual incidence. Effort is required to increase the effectiveness and efficiency of the reporting system. The use of the theoretical framework allowed identification of potential causality, largely in relation to active failures, which can inform the basis of interventions to improve medication safety.

A Pilot Study Comparing Aortic Valve Area Estimates Derived from Fick Cardiac Output with Estimates Based on Cheetah-NICOM Cardiac Output

Cardiac output during cardiac catheterization is often estimated using the modified Fick method (COFick). In this proof-of-concept, prospective non-randomized study carried out in a single academic healthcare centre, we examined whether replacing COFick in the Gorlin formula with Cheetah-NICOM monitor cardiac output (COCheetah) could produce an accurate and precise estimate of aortic valve area in patients with severe aortic stenosis. In twenty-six subjects, COFick and COCheetah were obtained concurrently. A spot and 3-minute running average of COCheetah was used. Bland and Altman analysis was used to derive bias, 95% limits of agreement (LOA) and confidence intervals (CI). The mean difference (bias) between AVACheetah (average) and AVAFick was 0.11 cm2 and the 95% LOA were ±0.42 cm2. The 95% CI of the bias was 0.02–0.2 cm2. The bias and 95% LOA of AVACheetah (spot value) were 0.14 ± 0.42cm2, with a 95% CI of 0.06–0.23 cm2. No proportional bias was present. AVACheetah thus appears to be a reasonably accurate measure of AVA in patients with severe aortic stenosis compared to AVAFick measured using a modified Fick CO. However, the limits of agreement were not narrow enough to consider AVACheetah and AVAFick interchangeable.

Informing the Model of Care for an Academic Integrative Health Care Center: A Qualitative Study of Primary Care Stakeholder Views.

Objectives: To engage with local primary care stakeholders to inform the model of care for a proposed academic integrative health care center incorporating evidence-informed traditional, complementary, and integrative medicine (TCIM) in Sydney, Australia. Design: In-depth semistructured interviews, informed by community-based participatory research principles, were conducted to explore primary care stakeholder preferences and service requirements regarding the proposed Western Sydney Integrative Health (WSIH) center in their local district. Setting: Telephone and face-to-face interviews at primary care clinics in Sydney. Subjects: Thirteen participants took part in the study: eight general practitioners (GPs) and five primary care practice managers (PMs). Methods: GPs were recruited through local GP newsletters, closed GP Facebook groups, and snowballing. PMs were recruited through a national PM newsletter. The semistructured interviews were audiorecorded and transcribed verbatim before conducting a thematic analysis. Results: Three main themes emerged: (1) the rationale for "why" the WSIH center should be established, (2) "what" was most important to provide, and (3) "how" the center could achieve these goals. Participants were willing to refer to the service, acknowledging the demand for TCIM, current gaps in chronic disease care, and negligible Government funding for TCIM. They endorsed a model of care that minimizes out-of-pocket costs for the underserved, incorporates medical oversight, integrates evidence-informed TCIM with conventional health care, builds trust through interprofessional communication and education, and provides sound clinical governance with a strong focus on credentialing and risk management. It was proposed that safety and quality standards are best met by a GP-led approach and evidence-based practice. Conclusions: Our findings demonstrate that participants acknowledged the need for a model of care that fits into the local landscape through integrating conventional health care with TCIM in a team-based environment, with medical/GP oversight to ensure sound clinical governance. Findings will be used with input from other stakeholder groups to refine the WSIH model of care.

Informing the model of care for an academic integrative healthcare centre: a qualitative study exploring healthcare consumer perspectives

BackgroundIn response to high demand and the growing body of evidence for traditional and complementary therapies, the practice of integrative medicine and integrative healthcare has emerged where these therapies are blended with conventional healthcare. While there are a number of academic integrative healthcare centres worldwide, there are none in Australia. Western Sydney University will soon establish an academic integrative healthcare centre offering evidence-informed traditional and complementary therapies integrated with conventional healthcare in a research-based culture. The aim of this study was to explore healthcare consumers’ views about the perceived need, advantages, and disadvantages of the proposed centre and its relevance to community-defined problems and health and service needs.MethodsQualitative methods, informed by community-based participatory research, were used during 2017. Focus groups supplemented with semi-structured interviews were conducted with healthcare consumers. Participants were recruited through paid advertisements on Facebook. Thematic coding, informed by an integrative healthcare continuum, was used to analyse and organise the data. Analysis was augmented with descriptive statistics of participant demographic details.ResultsThree main themes emerged: (i) the integrative approach, (i) person-centred care, and (iii) safety and quality. Participants proposed a coordinated healthcare model, with perspectives falling along a continuum from parallel and consultative to fully integrative models of healthcare. The importance of multidisciplinary collaboration and culturally appropriate, team-based care within a supportive healing environment was emphasised. A priority of providing broad and holistic healthcare that was person centred and treated the whole person was valued. It was proposed that safety and quality standards be met by medical oversight, evidence-informed practice, practitioner competency, and interprofessional communication.ConclusionsOur findings demonstrate that participants desired greater integration of conventional healthcare with traditional and complementary therapies within a team-based, person-centred environment with assurances of safety and quality. Findings will be used to refine the model of care for an academic integrative healthcare centre in Western Sydney.

Association of Acculturation With Adverse Pregnancy Outcomes.

To evaluate the relationship between acculturation and adverse pregnancy outcomes, and whether these relationships differ across racial or ethnic groups. This is a planned secondary analysis of the nuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be), a prospective observational cohort study of 10,038 pregnant women at eight academic health care centers in the United States. Nulliparous pregnant women with singleton gestations were recruited between 6 0/7 and 13 6/7 weeks of gestation from October 2010-September 2013. Acculturation was defined by birthplace (United States vs non-United States), language used during study visits (English or Spanish), and self-rated English proficiency. The adverse pregnancy outcomes of interest were preterm birth (less than 37 weeks of gestation, both iatrogenic and spontaneous), preeclampsia or eclampsia, gestational hypertension, gestational diabetes, stillbirth, small for gestational age, and large for gestational age. Multivariable regression modeling was performed, as was an interaction analysis focusing on the relationship between acculturation and adverse pregnancy outcomes by maternal race or ethnicity. Of the 10,006 women eligible for this analysis, 8,100 (80.9%) were classified as more acculturated (eg, born in the United States with high English proficiency), and 1,906 (19.1%) were classified as having less acculturation (eg, born or not born in the United States with low proficiency in English or use of Spanish as the preferred language during study visits). In multivariable logistic regression modeling, more acculturation was significantly associated with higher frequency of preterm birth (odds ratio [OR] 1.46, adjusted odds ratio [aOR] 1.50, 95% CI 1.16-1.95); spontaneous preterm birth (OR 1.54, aOR 1.62, 95% CI 1.14-2.24); preeclampsia or eclampsia (OR 1.39, aOR 1.31, 95% CI 1.03-1.67); preeclampsia without severe features (OR 1.44, aOR 1.43, 95% CI 1.03-2.01); and gestational hypertension (OR 1.68, aOR 1.48, 95% CI 1.22-1.79). These associations did not differ by self-described race or ethnicity. In a large cohort of nulliparous women, more acculturation, regardless of self-described race or ethnicity, was associated with increased odds of several adverse pregnancy outcomes. ClinicalTrials.gov, NCT01322529.

Knee Flexion Contracture Associated With a Contracture and Worse Function of the Contralateral Knee: Data From the Osteoarthritis Initiative

ObjectivePatients at risk of developing knee osteoarthritis (OA) or those already diagnosed with knee OA may present with a knee flexion contracture (FC). A knee FC can cause pain and can decrease function. By altering lower extremity biomechanics, the effect of a knee FC goes beyond the affected joint. Compensatory movements during gait can chronically affect other joints in both lower limbs. Few studies describe the effect of a knee FC on, or direct assessment toward, the contralateral knee. We investigated the associations between knee FC with range of extension, function, pain, and stiffness of the contralateral knee. DesignCross-sectional, using the Osteoarthritis Initiative Database. ParticipantsOutpatient cohort study, recruiting from 4 United States academic health care centers (N=4796). Two groups were included: those at risk of developing OA (n=3284 knees), and those already with radiographic OA (n=1390 knees). Main Outcomes MeasuresMaximum contralateral knee extension and Western Ontario and McMaster Osteoarthritis Index (WOMAC) scores. Statistical analysis included a mixed linear model evaluating for independent associations between the index knee FC and contralateral knee outcome measures. ResultsA knee FC was associated with a contralateral knee FC (P<.001) with contralateral FC severity dependent on severity of the index knee FC (P<.001). Participants at risk of developing OA with moderate FC showed worse function in the contralateral knee than those with mild FC (WOMAC functional subscale ± SD: 7.6±10.1 vs 5.5±8.8; P=.036). Mixed linear analysis confirmed an independent association between knee FC severity and contralateral WOMAC function. ConclusionsHaving an FC in 1 knee was associated with an FC in the contralateral knee for participants who were at risk of developing OA and for those with a current diagnosis of OA. For those at risk of developing OA, the severity of knee FC was an independent predictor for loss of contralateral knee function. Rehabilitation of patients with or at risk of developing OA should consider the restoration of extension and function for both knees.

Extent of the association between self-rated health and place of birth: a cross-sectional study among people at high risk of developing pre-diabetes and diabetes in Sweden

ObjectiveThe first aim was to determine the extent of the relationship between place of birth and self-rated health (SRH) in primary healthcare patients born outside Sweden and those born in...

550 Discordance in Colorectal Polyp Size Determination Between Colonoscopy and Pathology Reporting

INTRODUCTION: National guidelines recommend that patients with colorectal adenomas ≥1cm undergo surveillance colonoscopy to prevent colorectal cancer. Polyp size is often assessed twice, once during colonoscopy and again during pathology examination. It remains unclear whether these measurements vary and which should govern surveillance intervals. METHODS: We retrospectively analyzed a random sample of primary care patients who underwent polypectomy between January 1, 2013 and January 1, 2016 in a large academic healthcare center. Chart abstractors reviewed electronic health record data for colonoscopic polyp descriptors and measurements, corresponding pathology measurements, and histology. We excluded cases with normal histology, missing pathology, fragments, unreliable polyp matches between reports, and &gt;5 polypectomies. We performed a paired t-test to assess polyp size discordance between reports and calculated Cohen's kappa coefficient to assess agreement whether the size was ≥1 cm. RESULTS: We reviewed 1,528 patient charts, and 831 (54.4%) met inclusion criteria, representing 1,532 polyps. Sizes ranged from 0.1-3.0cm on colonoscopy and 0.1-2.7cm on pathology reports. On colonoscopy report, the majority (881, 57.5%) used only a descriptive term rather than a numeric value to describe size (Table 1). Descriptive size terms were diminutive (513), tiny (39), small (328), and large (1). Only 2.8% of polyps described as diminutive, small, or tiny on the colonoscopy report were ≥1cm on the corresponding pathology report. Among the 367 (24.0%) polyps with discrete numeric sizes on both reports, size discordance varied by &gt;0.2 cm for 50% of polyps (Figure 1). More of these polyps were ≥1 cm on colonoscopy (70) than on pathology (51) report, and there was remarkable clustering at 1 cm by colonoscopy report estimation (Figure 2). There was moderate agreement (kappa = 0.52) on size ≥1 cm. Among tubular adenomas (TA) ≥1 cm on colonoscopy or pathology report (36), 10 (27.8%) were ≥1 cm on both, 18 (50.0%) were ≥1 cm on colonoscopy only, and 8 (22.2%) were ≥1 cm on pathology only. CONCLUSION: There is considerable discordance between colonoscopic and pathology polyp size measurements, with more polyps sized as ≥1 cm by colonoscopic estimation compared to pathology, which has implications for surveillance frequency. Future studies should investigate the implications of discordant measurements on clinical outcomes and inform guidelines on surveillance intervals.

66 High Cost Drug Policies in Canadian Children’s Hospitals

Over the past decade a number of highly promising new therapeutic entities have become available. Many of these new treatments are biologicals or antibodies rather than conventional small molecules. These drugs offer great promise but come with the potential for potent adverse effects as well as creating challenges for access. Many of these new treatments are very expensive and are frequently not on hospital formularies. There is no comprehensive pan-Canadian strategy on how to best provide access to these drugs for the children at most need and how to address the rapidly evolving world of novel therapeutics for children. To evaluate how this issue is being addressed nationally we conducted a survey among the 17 Departments of Paediatrics across Canada. In Paediatrics high cost drugs are most commonly used in academic child health care centres. Our objectives were to; I) Determine what the policies as to provision of high cost drugs in Canada’s academic child health care centres, ii) Determine what the challenges facing Canada’s academic health care centres were in providing access to novel therapies to children at most need and iii) Explore possible solutions to these challenges. To explore these questions we conducted a survey of the 17 Departments of Paediatrics across Canada through the Paediatric Chairs of Canada and faciliated through Childrens Healthcare Canada. A questionnaire was sent to all Department Chairs asking the following four questions; 1) Does your hospital have a policy for how to deal with high cost drugs that are not covered by provincial health insurance or are not on the hospital formulary? 2) If so, how does this policy work? 3) If not, how are these therapies addressed? 4) What do you think is the best approach to provide access to high cost drugs for children? Department Chairs agreed to voluntarily participate in the survey. After completion of the survey areas of uncertainty were followed up by interviews with the respective Department Chairs. The issue of high cost drugs for children was noted to be a growing issue by all Departments of Paediatrics across Canada. There was a wide variability in how requests for high cost drugs were dealt with, ranging from a somewhat ad hoc case-specific response to a formal process involving decision making groups representing physicians, hospital administration and hospital pharmacy. No single best practice was identified. There was a concensus that this has emerged as a major problem in terms of access having a significant impact on hospital budgets with no end in sight as the therapeutic revolution in biological, factor and molecular therapy continued. It was acknowledged that traditional payment measures have failed to address this and some changes in provincial policy towards drugs for children may have negatively impacted access to these therapies. There was also a wide concensus that a pan-Canadian approach was needed, with suggestions including a national formulary for drugs for children that could provide evidence and recommendations to provincial funders as well as the suggestion of a pan-Canadian pharmacare plan for children. An urgent need for national leadership on this issue was also identified. Historically the per capita expenditure for pharmaceuticals for a Canadian child was in the range of $450. With the advent of new therapies that cost in the tens of thousands of dollars new approaches to drug evaluation and drug access for Canada’s children are urgently needed. This is a concern for all Departments of Paediatrics across Canada and pan-Canadian solutions are needed to address how to best treat Canada’s children at highest need.

Assessment of Job Satisfaction and Feeling Valued in Academic Medicine

This cross-sectional survey study examines the factors associated with satisfaction at work in academic health care centers.

Refining the model of care for Australia's first University-based academic integrative healthcare centre

Refining the model of care for Australia's first University-based academic integrative healthcare centre

Clinical utility of genomic analysis in adults with idiopathic liver disease

Adult patients suffering from liver disease of unknown cause represent an understudied and underserved population. The use of whole-exome sequencing (WES) for the assessment of a broader spectrum of non-oncological diseases, among adults, remains poorly studied. We assessed the utility of WES in the diagnosis and management of adults with unexplained liver disease despite comprehensive evaluation by a hepatologist and with no history of alcohol overuse. We performed WES and deep phenotyping of 19 unrelated adult patients with idiopathic liver disease recruited at a tertiary academic health care center in the US. Analysis of the exome in 19 cases identified 4 monogenic disorders in 5 unrelated adults. Patient 1 suffered for 18 years from devastating complications of undiagnosed type 3 familial partial lipodystrophy due to a deleterious heterozygous variant in PPARG. Molecular diagnosis enabled initiation of leptin replacement therapy with subsequent normalization of liver aminotransferases, amelioration of dyslipidemia, and decreases in daily insulin requirements. Patients 2 and 3 were diagnosed with MDR3 deficiency due to recessive mutations in ABCB4. Patient 4 with a prior diagnosis of non-alcoholic steatohepatitis was found to harbor a mitochondrial disorder due to a homozygous pathogenic variant in NDUFB3; this finding enabled initiation of disease preventive measures including supplementation with antioxidants. Patient 5 is a lean patient with hepatic steatosis of unknown etiology who was found to have a damaging heterozygous variant in APOB. Genomic analysis yielded an actionable diagnosis in a substantial number (∼25%) of selected adult patients with chronic liver disease of unknown etiology. This study supports the use of WES in the evaluation and management of adults with idiopathic liver disease in clinical practice. We performed whole-exome sequencing in 19 adult patients with unexplained liver disease after an unrevealing conventional work-up performed by a hepatologist. In 5 cases, genomic analysis led to a diagnosis and informed treatment and management of the disease. Therefore, we suggest using whole-exome sequencing in the evaluation and management of adults with unexplained liver disease.

Independent Research as a Resident Physician: Novel Methods for Data Collection, Teaching, and Collaboration During Graduate Medical Training

Since the mid-1990s, the US has seen a decline in research activities in medical education and academic health care centers. Our goal was to offer a multi-disciplinary experience for undergraduates to participate in a practical, hands-on research experience to increase the likelihood of entering STEM research careers. The authors structured a collaborative teaching environment to lead a group of over 25 undergraduate and graduate students in clinical research activities as part of the resident author’s research program during psychiatry graduate training. A particularly innovative component of this work, making the timeline and technical analysis possible, was the partnership with an industry sponsor. Much of the teaching program’s structure was inspired by the analogous program of the industry sponsor. This provided a structured clinical research experience for undergraduates, providing opportunities to participate in the study design, patient recruitment and enrollment, data collection and analysis phases of the project with more autonomy than typically available at this level of training. Students favored the experience with generally positive ratings of the program. Students gained skills and felt more comfortable in practical aspects of research and stated they were more likely to pursue a research career after this experience. This method may be a solution for other clinical trainees given their limited time and funding while serving to increase exposure to STEM research earlier in life to reverse the trend of declining research activity. This method can be used across other training institutions at different scales to achieve similar goals.

Can the Federal Baldrige Survey Measure Workforce Well-being in an Academic Health Center?

Experts suggest health care institutions switch focus from measuring burnout to measuring positive organizational psychology. Concerns include burnout being a late sign of organizational decline. The Baldrige survey is promoted by the U.S. Department of Commerce to measure positive worksite conditions (e.g., workforce wellbeing of industries, including health care and education). For years, the survey has been completed by managers within organizations, but now the same survey is promoted for completion by an organization's workforce. We tested the structure of the Baldrige survey when completed by an academic health care workforce. In addition, we tested whether the results in an academic worksite correlate with an example metric of an organizational mission. In 2015, our academic health center surveyed faculty and staff with the Baldrige survey. The validity of the Baldrige was tested with confirmatory factor analyses. Within the School of Medicine, responses for the Baldrige's concepts were correlated against a measure of organizational outcome: graduates' assessments of Departmental educational quality. The structure of the Baldrige survey did not validate when assessed by a workforce (RMSEA = 0.086; CFI = 0.829; TLI = 0.815). None of its concepts correlated with learner reported educational quality. The Baldrige survey, when administered to a workforce rather than managers, did not appear to measure workforce well-being within an academic health care center. We discourage use of the current survey for this purpose.

Elevated Pulse Pressure in Anesthetized Subjects Before Cardiopulmonary Bypass Is Associated Strongly With Postoperative Acute Kidney Injury Stage

To investigate whether pulse pressure (PP) in anesthetized patients undergoing cardiac surgery before and after cardiopulmonary bypass (CPB) is associated with higher postoperative acute kidney injury (AKI) stage. Retrospective cohort of 597 patients undergoing cardiac surgery. Single academic health care center. Adult patients undergoing cardiac surgery requiring CPB (coronary artery bypass grafting, valve, aortic, or combined surgery). Pulse pressure was assessed during 3 time periods: pre- and post-CPB, and in the first postoperative hour in the intensive care unit. Pulse pressure, patient characteristics, and intraoperative variables were evaluated using univariable generalized estimating equation analysis for a relationship with AKI stage. Significant risk factors from the univariable analysis then were evaluated in a multivariable generalized estimating equation analysis. Acute kidney injury stage was defined using the Acute Kidney Injury Network criteria. Stage of postoperative AKI. Intraoperative prebypass PP was associated independently and significantly with postoperative AKI stage (odds ratio 1.0107; 95% Confidence Interval, 1.0046-1.0168; p = 0.0005). For every 1-mmHg increase in PP, the odds of a higher AKI stage increased 1.07%. The 2 other periods were not found to be significant predictors of AKI stage. During general anesthesia prior to initiation of CPB, elevated PP is significantly predictive of postoperative AKI stage. This finding merits further research.

Interprofessional Education Among Occupational Therapy Programs: Faculty Perceptions of Challenges and Opportunities.

We investigated occupational therapy faculty beliefs about and perceptions of interprofessional education (IPE) and to identify differences in faculty positions on IPE between programs affiliated with an on-campus academic health care center (AHC) and programs not affiliated with an on-campus AHC. Online surveys were distributed by email to 1,466 faculty at programs accredited by the Accreditation Council for Occupational Therapy Education. The results were described using descriptive statistics and cross-tabulations. Faculty responses supported the need for IPE. Ethics was ranked as the most important IPE competency among both the AHC and the non-AHC groups. IPE was more commonly included in the curriculum of programs with an on-campus AHC than in the curriculum of those without an AHC. The majority of occupational therapy faculty supported the need for IPE; however, many reported limitations with faculty or time constraints as barriers to IPE.

The Use of a Self-Administered Questionnaire to Reduce Consultation Wait Times for Potential Elective Lumbar Spinal Surgical Candidates: A Prospective, Pragmatic, Blinded, Randomized Controlled Quality Improvement Study.

In a public health-care system, patients often experience lengthy wait times to see a spine surgeon for consultation, and most patients are found not to be surgical candidates, thereby prolonging the wait time for those who are. The aim of this study was to evaluate whether a self-administered 3-item questionnaire (3IQ) could reprioritize consultation appointments and reduce wait times for lumbar spinal surgical candidates. This prospective, pragmatic, blinded, randomized controlled quality improvement study was conducted at a single Canadian academic health-care center. This study enrolled 227 consecutive eligible participants with an elective lumbar condition who were referred for consultation with a spine surgeon. All participants were mailed the 3IQ after their referral was received. Patients were randomized into the intervention group, in which leg-dominant pain reported on the 3IQ resulted in an upgrade in priority to be seen, or into the control group, in which no change to wait-list priority occurred. The main outcome measured was time to consultation for participants who were deemed surgical candidates following consultation. There were no significant differences between groups with regard to demographics, overall group wait times, proportion of surgical candidates, or disability. A total of 33 patients were deemed surgical candidates after consultation. The median wait from referral to consultation was shorter for the 16 surgical candidates in the intervention group (2.5 months; interquartile range [IQR]: 2.0 to 4.8 months) compared with the 17 surgical candidates in the control group (4.5 months; IQR: 3.4 to 6.9 months; p = 0.090). The odds of seeing a surgical candidate within the acceptable time frame of 3 months were 5.4 times greater (95% confidence interval: 1.2 to 24.5 times; p = 0.024) in the intervention group. The use of a simple, self-administered questionnaire to reprioritize referrals resulted in shorter consultation wait times for patients who required a surgical procedure and significantly increased the number of surgical candidates seen within the acceptable time frame. It may be valuable to consider adding the 3IQ to clinical care practices to better triage these patients on waiting lists.

1027. Outpatient Parenteral Antimicrobial Therapy (OPAT) in Injection Drug Users (IDUs): Is It Safe?

BackgroundOPAT is widely implemented in the United States. However, there are concerns surrounding discharge of IDU with a peripherally inserted central catheter (PICC). The objective of this study was to evaluate the characteristics and treatment outcomes of IDUs discharged on OPAT.MethodsThis is a retrospective observational study conducted on patients discharged from an Infectious Diseases unit at a quaternary academic healthcare center in Detroit. Charts of all IDUs discharged on OPAT between 2011 and 2017 were reviewed. Current or former IDU were discharged on OPAT if they met the following criteria: self-reported history of IDU, stable living conditions, controlled psychiatric illness (if present), and willingness to sign a discharge agreement to refrain from using the PICC as a route for illicit drugs. Patients were categorized based on clinic follow-up vs. no clinic follow-up. Outcomes evaluated were: cured (completed treatment and symptom free for 1 month after completion), improved (symptoms were improved but there was no confirmation of treatment completion); and relapsed (readmitted within 30 days for the same infection or sequela). Outcomes of patients with no clinic follow-up were based on chart review of subsequent emergency department visits or admissions.ResultsPatient characteristics are shown in Table 1. Of the 61 patients evaluated, 33 (54.1%) attended clinic follow-up and 28 (45.9%) did not. Outcomes based on clinic follow-up are shown in Table 2. Of the 18 patients who were cured, 16 attended clinic follow-up vs. two who did not.ConclusionThis study demonstrates that some IDUs can be discharged safely on OPAT. Patients with clinic follow-up had improved outcomes compared with those who did not. Further studies are needed to look at other predictors of outcome in this patient population.Table 1: Patient CharacteristicsPatientsN = 61 (%)Age (mean ± SD)±12.4Male33 (54.1)Length of stay (days)mean ± SD± 10.9IVDU statusActive49 (80.3)Former10 (16.4)Unknown2 (3.3)Psychiatric illness12 (19.7)DispositionHome37 (60.6)Nursing facility24 (39.3)Table 2. Outcome Based on Clinic Follow-upClinic Follow-upN = 33 (%)No Clinic Follow-upN = 12 (%) P valueCured16 (48.5)2 (16.7)0.086Improved14 (42.4)6 (50)0.74Relapsed3 (9)4 (33.3)0.069Sixteen patients were excluded from the analysis because their outcome was unknown.Disclosures All authors: No reported disclosures.

Diabetes and the Link between Plasticity and Glutamate Metabolism in the Human Motor Cortex

Background: Type-2 diabetes mellitus (T2DM) can affect the brain leading to cognitive deficits and impaired neuroplastic mechanisms. The objective of this study was to assess glutamate metabolism and its relationship with cortical plasticity in older adults with impaired glucose intolerance and insulin resistance. Methods: Forty adults (50-87 years) participated, including 17 with T2DM, 14 with pre-diabetes (PreDM), and 9 controls. All subjects underwent magnetic resonance spectroscopy to quantify glutamate and other key metabolites within a 2cm3 region around the hand knob of the left primary motor cortex. Thirty-six participants underwent a separate transcranial magnetic stimulation (TMS) assessment of cortical plasticity, defined as the change in the average amplitude of motor evoked potentials (MEPs) following intermittent theta-burst TMS (iTBS). Group differences in cortical plasticity and metabolism were assessed with one-way analyses of variance (ANOVAs) and related to each other by linear regression. Findings: The ANOVAs yielded significant group variance in relative concentrations of glutamine (p=.028), glucose (p=.008), total cholines (p=.048), and the glutamine/glutamate ratio (p=.024). Cortical plasticity was reduced in both T2DM and PreDM (p's<.05). As a possible mechanism of action, there was a significant association in T2DM between glutamate concentration and facilitation of MEPs (r=.56, p=.030). Interpretation: The current findings indicate impaired mechanisms of plasticity may be present at the earliest stages of glucose intolerance and that in T2DM, cortical plasticity may depend in part on the availability of free glutamate at the synapse. Funding Statement: This study was primarily funded by the National Institutes of Health (NIH R21 NS082870). A.P.-L. was also supported in part by the Sidney R. Baer Jr. Foundation, the NIH (R01HD069776, R01NS073601, R21 MH099196, R21 NS085491, R21 HD07616), and Harvard Catalyst | The Harvard Clinical and Translational Science Center (NCRR and the NCATS NIH, UL1 RR025758). The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, the National Institutes of Health, or the Sidney R. Baer Jr. Foundation. Declaration of Interests: A.P.-L. serves on the scientific advisory boards for Nexstim, Neuronix, Starlab Neuroscience, Neuroelectrics, Cognito, Constant Therapy, and Neosync; and is listed as an inventor on several issued and pending patents on the real-time integration of transcranial magnetic stimulation with electroencephalography and magnetic resonance imaging. The authors declare no competing interests. Ethics Approval Statement: The manuscript details research conducted on human participants. All provided written informed consent consistent with the Declaration of Helsinki. All forms and procedures were approved by the Institutional Review Board at Beth Israel Deaconess Medical Center, where the research took place.