Changes In Clinical Management Research Articles

COVID-19 infection in patients on anti-CD20 monoclonal antibodies: Changes in clinical outcomes and management over time.

e19542 Background: As the COVID-19 pandemic progressed, survival of patients in the general population with COVID-19 improved over time. It is less clear based on current data whether patients on anti-CD20 therapy experienced similar improvement in outcomes over time. Methods: We performed a retrospective study of all patients aged ≥ 18 years diagnosed with COVID-19 while receiving anti-CD20 therapy for hematologic malignancy and/or rheumatologic indications at our center from January 2020-January 2022. Our primary endpoint was median overall survival (OS) and clinical outcomes stratified by date of diagnosis (“early cohort” = 03/01/20 to 12/31/20, “later cohort” = 01/01/21 to 10/15/21, and “latest cohort” = 10/16/21 to 01/16/22”). Secondary endpoints were to describe changes in the management of patients receiving anti-CD20 agents as the pandemic progressed and to assess independent predictors of OS in this population. Results: The median OS of 186 patients in the entire group was 13 months and the case fatality rate (CFR) was 23%. The CFR of admitted patients was 84%, whereas it was 16% for those who were not admitted. To examine trends over time, we compared 71 patients in the early cohort to 69 in the later cohort, and 42 patients in the latest cohort. The median OS of patients in the early cohort was 18 months (0.1-27) compared to 9 months (0-22) in the later cohort, and 8 months (0-20) in the latest cohort (P = 0.1884). The proportion of patients who received steroids was relatively consistent as the pandemic progressed with 45% in the early vs. 41% in the latest cohort. Fewer patients received remdesivir (31% for early cohort vs 21% for latest cohort) and convalescent plasma (13% for early cohort vs 2% for latest cohort) over time. The only baseline or treatment characteristics associated with adverse outcomes were receipt of steroids and anticoagulation, both of which were associated with an increased risk of death ((HR = 5.5, p = 0.002) and (HR = 2, p = 0.043 respectively)). Conclusions: Patients receiving monoclonal anti-CD20 antibody therapy had worse clinical outcomes than previously reported outcomes for the general population. OS did not significantly improve as the pandemic progressed; the phase of the pandemic with the shortest median OS was from 01/01/21 to 10/15/21 during the Delta SARS-COV-2 wave. Our data demonstrates an increased risk of death in patients on monoclonal anti-CD20 who experienced a COVID-19 infection and were treated with steroids, consistent with other reports.

Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection

ObjectivesThe need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients. MethodsPatients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses. ResultsA total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion. ConclusionsReserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.

Long-Term Outcomes of Early Coronary Artery Disease Testing After New-Onset Heart Failure.

Coronary artery disease (CAD) testing remains underutilized in patients with newly diagnosed heart failure (HF). The longitudinal clinical impact of early CAD testing has not been well-characterized. We investigated changes in clinical management and long-term outcomes after early CAD evaluation in patients with incident HF. We identified Medicare patients with incident HF from 2006 to 2018. The exposure variable was early CAD testing within 1 month of initial HF diagnosis. Covariate-adjusted rates of cardiovascular interventions after testing, including CAD-related management, were modeled using mixed-effects regression with clinician as a random intercept. We assessed mortality and hospitalization outcomes using landmark analyses with inverse probability-weighted Cox proportional hazards models. Falsification end points and mediation analysis were employed for bias assessment. Among 309 559 patients with new-onset HF without prior CAD, 15.7% underwent early CAD testing. Patients who underwent prompt CAD evaluation had higher adjusted rates of subsequent antiplatelet/statin prescriptions and revascularization, guideline-directed therapy for HF, and stroke prophylaxis for atrial fibrillation/flutter than controls. In weighted Cox models, 1-month CAD testing was associated with significantly reduced all-cause mortality (hazard ratio, 0.93 [95% CI, 0.91-0.96]). Mediation analyses indicated that ≈70% of this association was explained by CAD management, largely from new statin prescriptions. Falsification end points (outpatient diagnoses of urinary tract infection and hospitalizations for hip/vertebral fracture) were nonsignificant. Early CAD testing after incident HF was associated with a modest mortality benefit, driven mostly by subsequent statin therapy. Further investigation on clinician barriers to testing and treating high-risk patients may improve adherence to guideline-recommended cardiovascular interventions.

Child and adolescent psychiatrists’ use, attitudes, and understanding of genetic testing and pharmacogenetics in clinical practice

The purpose of this study was to report current practices and attitudes of child and adolescent psychiatrists (CAP) regarding diagnostic genetic and pharmacogenetic (PGx) testing. We surveyed 958 US-based practicing CAP. 54.9% of respondents indicated that they had ordered/referred for a genetic test in the past 12 months. 87% of respondents agreed that it is their role to discuss genetic information regarding psychiatric conditions with their patients; however, 45% rated their knowledge of genetic testing practice guidelines as poor/very poor. The most ordered test was PGx (32.2%), followed by chromosomal microarray (23.0%). 73.4% reported that PGx is at least slightly useful in child and adolescent psychiatry. Most (62.8%) were asked by a patient/family to order PGx in the past 12 months and 41.7% reported they would order PGx in response to a family request. Those who ordered a PGx test were more likely to have been asked by a patient/family and to work in private practice. 13.8% of respondents agreed/strongly agreed that a PGx test can predict the effectiveness of specific antidepressants. Some respondents also indicated they would make clinical changes based on PGx information even if a medication was currently effective and there were no side effects. Genetic testing has become routine clinical care in child and adolescent psychiatry. Despite this, many providers rate their associated knowledge as poor/very poor. Patient requests were associated with ordering practices and providers misinterpretation of PGx may be leading to unnecessary changes in clinical management. There is need for further education and support for clinicians.

The Right Ventricular Systolic Function Assessment in Adult Respiratory Distress Syndrome: Simple. Basic. Complex.

To the Editor: We thank Dr. Dandel for his interest in our previously published article.1 We acknowledge that the pathogenicity of dominant SARS-COV-2 “variants of concern” during the second wave (Delta variant) may partially explain the higher mortality observed during the second wave. However, other factors, including steroid-resistant disease and changes in clinical management, should not be discarded.1 Dr. Dandel also suggested that right ventricular (RV) failure may be the primary cause of the high mortality rate of our ECMO patients observed during the second wave. Unfortunately, no precise and objective data supports this hypothesis in our series. However, we agree with Dr. Dandel on two essential points: First, we agree that in moderate-to-severe ARDS, the clinical impact of routinely monitoring RV systolic function with bedside echocardiography is obvious. An early diagnosis of RV systolic dysfunction to adapt medical management (ventilatory parameters, fluids, and vasopressors) is essential. However, choosing the most appropriate parameters to monitor RV systolic function is difficult. Classical parameters seem to have poor sensitivity to detect RV dysfunction2 and poor prognostic value.3 Using RV strain parameters to assess RV systolic function is promising, but the clinical significance for COVID-19-associated ARDS (C-ARDS) is still under debate.4 Nevertheless, advanced two-dimensional speckle tracking parameters, such as RV longitudinal shortening fraction (RV-LSF), seem more accurate. We recently reported in a cohort of 86 moderate-to-severe C-ARDS patients that RV dysfunction (defined by an RV-LSF < 20%) was frequent (43%) and was associated with 30-day mortality.5 Moreover, RV-LSF seems to be the most reliable parameter for assessing RV systolic function in patients with acute core pulmonale.6 The use of these parameters to choose the most appropriate support needs confirmation. Second, echocardiographic data before implementation and during ECMO therapy are, indeed, very useful. However, many factors (ultra-protective ventilation, prone positioning sessions, ventilator mode, pump/sweep gas flow...) can modify RV morphology and function under ECMO therapy. In this situation, distinguishing between RV adaptation and failure is difficult. That is why choosing relevant parameters to identify RV systolic dysfunction and the need for a standardized monitoring protocol are mandatory. Further studies are required to assess the feasibility, reproducibility, and clinical impact of the various RV parameters (conventional and advanced) that may be used during ECMO therapy. We agree that timely repeated ultrasound exams with heart/lung interaction evaluation are of utmost importance during the ECMO course.

Clinical added value of interictal automated electrical source imaging in the presurgical evaluation of MRI-negative epilepsy: A real-life experience in 29 consecutive patients

ObjectiveDuring the presurgical evaluation, manual electrical source imaging (ESI) provides clinically useful information in one-third of the patients but it is time-consuming and requires specific expertise. This prospective study aims to assess the clinical added value of a fully automated ESI analysis in a cohort of patients with MRI-negative epilepsy and describe its diagnostic performance, by evaluating sublobar concordance with stereo-electroencephalography (SEEG) results and surgical resection and outcome. MethodsAll consecutive patients referred to the Center for Refractory Epilepsy (CRE) of St-Luc University Hospital (Brussels, Belgium) for presurgical evaluation between 15/01/2019 and 31/12/2020 meeting the inclusion criteria, were recruited to the study. Interictal ESI was realized on low-density long-term EEG monitoring (LD-ESI) and, whenever available, high-density EEG (HD-ESI), using a fully automated analysis (Epilog PreOp, Epilog NV, Ghent, Belgium). The multidisciplinary team (MDT) was asked to formulate hypotheses about the epileptogenic zone (EZ) location at sublobar level and make a decision on further management for each patient at two distinct moments: i) blinded to ESI and ii) after the presentation and clinical interpretation of ESI. Results leading to a change in clinical management were considered contributive. Patients were followed up to assess whether these changes lead to concordant results on stereo-EEG (SEEG) or successful epilepsy surgery. ResultsData from all included 29 patients were analyzed. ESI led to a change in the management plan in 12/29 patients (41%). In 9/12 (75%), modifications were related to a change in the plan of the invasive recording. In 8/9 patients, invasive recording was performed. In 6/8 (75%), the intracranial EEG recording confirmed the localization of the ESI at a sublobar level. So far, 5/12 patients, for whom the management plan was changed after ESI, were operated on and have at least one-year postoperative follow-up. In all cases, the EZ identified by ESI was included in the resection zone. Among these patients, 4/5 (80%) are seizure-free (ILAE 1) and one patient experienced a seizure reduction of more than 50% (ILAE 4). ConclusionsIn this single-center prospective study, we demonstrated the added value of automated ESI in the presurgical evaluation of MRI-negative cases, especially in helping to plan the implantation of depth electrodes for SEEG, provided that ESI results are integrated into the whole multimodal evaluation and clinically interpreted.

Physical Examination in Medical Oncology Guiding the Development of a Protocol for Teleoncology Care in a Public Health Care Oncology Service.

We aimed to define clinical variables that could predict changes in physical examination (PE) findings and consequently lead to significant differences in clinical management. This knowledge is important because of the growing popularity of teleoncology consultations, in which there is no possibility of PE, aside from inspection. This prospective study was conducted in two public hospitals in Brazil. Clinical variables and findings of PE, as well as the management plan determined at the end of the medical appointment, were systematically recorded. A total of 368 in-person clinical evaluations of patients with cancer were included. PE was normal or had alterations already seen in previous consultations in 87% of the cases. Among patients with new changes in PE (n = 49), cancer treatment was maintained in 59%, complementary examinations and specialist appointments were requested in 31%, and oncological therapy was modified directly after PE in 10%. Of the total 368 visits, only 12 (3%) had a change in oncological management, five directly after PE abnormalities and 7 after complementary assessment. The presence of symptoms and reasons for consultation other than follow-up showed a positive association with alterations in PE and consequent changes in clinical management by univariate and multivariate analysis (P < .05). Considering changes in clinical management, PE on every encounter for medical oncology surveillance visits may not be necessary. We envision that teleoncology will be a safe modality in most cases, given the large percentage of asymptomatic patients with no changes in PE during face-to-face care. However, for patients with advanced disease and symptoms, however, we suggest priority for in-person care.

The Impact of Respiratory Therapist Performed Point-of-Care Lung Ultrasound on the Respiratory Care in Neonates, Manitoba Experience, Canada.

We aimed to evaluate the impact of the registered respiratory therapist (RRT) performed point-of-care lung ultrasound (POC-LUS) on patient management in the neonatal intensive care unit (NICU). This is a retrospective cohort study of neonates who had RRT performed POC-LUS in two level III NICUs in Winnipeg, Manitoba, Canada. The analysis aims mainly to describe the implementation process of the POC-LUS program. The primary outcome was the prediction of the change in clinical management. A total of 136 neonates underwent 171 POC-LUS studies during the study period. POC-LUS resulted in a change in clinical management following 113 POC-LUS studies (66%), while it supported continuing the same management in 58 studies (34%). The lung ultrasound severity score (LUSsc) was significantly higher in the group with worsening hypoxemic respiratory failure and on respiratory support than infants on respiratory support and stable or not on respiratory support, p < 0.0001. LUSsc was significantly higher in infants on either noninvasive or invasive than those not on respiratory support, p-value <0.0001. RRT performed POC-LUS service utilization in Manitoba improved and guided the clinical management of a significant proportion of patients who received the service.

Utility of endoscopic ultrasound for assessment of locoregional recurrence of pancreatic adenocarcinoma after surgical resection

Background and study aims Up to 80 % of patients with pancreatic adenocarcinoma develop locoregional recurrence after primary resection. However, the detection of recurrent pancreatic ductal adenocarcinoma (RPDAC) after pancreatic surgery can be challenging because of difficulty distinguishing locoregional recurrence from normal postoperative or post-radiation changes. We sought to evaluate the utility of endoscopic ultrasound (EUS), in detecting pancreatic adenocarcinoma recurrence after surgical resection and its impact on the clinical management of patients. Patients and methods This was a retrospective study of all pancreatic cancer patients who underwent EUS post-resection at two tertiary care centers between January 2004 and June 2019. Results Sixty-seven patients were identified. Of these, 57 (85 %) were diagnosed with RPDAC, resulting in change in clinical management of 46 (72 %) patients. EUS identified masses not seen on computed tomography, magnetic resonance imaging, or positron emission tomography in seven (14 %). Conclusions EUS is useful in detecting RPDAC after pancreatic surgery and can lead to significant impact on clinical management.

The past, present, and future of opioid prescribing: Perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021

ObjectiveTo describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates. MethodsPart one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge. Results1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients. ConclusionInpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients’ actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.

Changes in the clinical management of 5α-reductase type 2 and 17β-hydroxysteroid dehydrogenase type 3 deficiencies in France.

To examine the changes in diagnostic practices and clinical management of patients with 5α-reductase type 2 (SRD5A2) or 17β-hydroxysteroid dehydrogenase type 3 (HSD17B3) deficiency since molecular diagnoses became available. Clinical, laboratory, and therapeutic data were retrieved from the medical records of 52 patients with a molecular diagnosis of SRD5A2 (n = 31) or HSD17B3 (n = 21) deficiency. Temporal trends regarding age at assessment and initial sex assignment over 1994-2020 were qualitatively analyzed. Age at molecular diagnosis was compared between two subgroups of patients according to their year of birth. Fifty-eight percent (n = 30) patients were diagnosed during the perinatal period, 33% (n = 17) during infancy, and 9% (n = 5) during adolescence or adulthood. Over the studied period, the patients' age at initial assessment and diagnosis frankly decreased. The median (range) age at diagnostic confirmation was 10.5 (0-53.2) years for patients born before 2007 and 0.4 (0-9.3) years for those born in 2007 or later (P = 0.029). Genetic testing identified 27 different variants for the SRD5A2 gene (30% novel, n = 8) and 18 for the HSD17B3 gene (44% novel, n = 8). Before 2002, most patients were initially assigned as females (95%, n = 19), but this proportion dropped for those born later (44%, n = 14; P < 0.001). The influence of initial genital appearance on these decisions seemingly decreased in the most recent years. Therapeutic interventions differed according to the sex of rearing. Ten percent (n = 2) patients requested female-to-male reassignment during adulthood. This study showed, over the past two decades, a clear trend toward earlier diagnosis and assignment of affected newborns as males.

Effect of multimodal comprehensive communication skills training with video analysis by artificial intelligence for physicians on acute geriatric care: a mixed-methods study

ObjectivesTo quantitatively analyse by artificial intelligence (AI) the communication skills of physicians in an acute care hospital for geriatric care following a multimodal comprehensive care communication skills training programme and...

Changes in Clinical Management of Patients with Schizophrenia Treated with Long-Acting Injectable Antipsychotics (LAIs), Including Telepsychiatry Use, During the COVID-19 Pandemic.

The COVID-19 pandemic substantially impacted care of patients with schizophrenia treated with long-acting injectable antipsychotics (LAIs). This study (OASIS-MAPS) examined how clinical sites adapted operations and used telepsychiatry to maintain standard of care for these patients during the pandemic. Two online surveys (initial: October-November 2020, N = 35; follow-up: July-September 2021, N = 21) were completed by a principal investigator (PI) or PI-appointed designee at sites participating in the OASIS study (NCT03919994). Survey responses were analyzed descriptively. At the time of the initial survey, all 35 participating sites were using variants of telepsychiatry, with 20 sites adopting it after the pandemic started. Most sites reported no negative impacts of the pandemic on medication adherence, although approximately 20% of sites reported decreased adherence for LAIs. Twelve sites (34%) reported switching patients with schizophrenia from LAIs to oral antipsychotic medications, while 11 sites (31%) reported switching patients from shorter to longer injection interval LAIs during the pandemic. Most sites did not experience difficulties in implementing or expanding telepsychiatry services, although lower reimbursement rate for telepsychiatry and patients' lack of access to and training on relevant technologies were the most frequently reported barriers. Changes made by sites after the pandemic onset were viewed by almost all participants as satisfactory for maintaining standard of care. Almost all participants thought that the use of telepsychiatry services would continue after the pandemic in a hybrid manner combining telepsychiatry and office visits. Ensuring that patients have equitable access to telepsychiatry will be important in the post-pandemic future.

Frequency and Clinical Utility of Alerts for Intra-Institutional Radiologist Discrepant Opinions

ObjectiveDetermine the rate of documented notification, via an alert, for intra-institutional discrepant radiologist opinions and addended reports and resulting clinical management changes. MethodsThis institutional review board–exempt, retrospective study was performed at a large academic medical center. We defined an intra-institutional discrepant opinion as when a consultant radiologist provides a different interpretation from that formally rendered by a colleague at our institution. We implemented a discrepant opinion policy requiring closed-loop notification of the consulting radiologist’s second opinion to the original radiologist, who must acknowledge this alert within 30 days. This study included all discrepant opinion alerts created December 1, 2019, to December 31, 2021, of which two radiologists and an internal medicine physician performed consensus review. Primary outcomes were degree of discrepancy and percent of discrepant opinions leading to change in clinical management. Secondary outcome was report addendum rate compared with an existing peer learning program using Fisher’s exact test. ResultsOf 114 discrepant opinion alerts among 1,888,147 reports generated during the study period (0.006%), 58 alerts were categorized as major (50.9%), 41 as moderate (36.0%), and 15 as minor discrepancies (13.1%). Clinical management change occurred in 64 of 114 cases (56.1%). Report addendum rate for discrepant opinion alerts was 4-fold higher than for peer learning alerts at our institution (66 of 315 = 21% versus 432 of 8,273 =5.2%; P < .0001). DiscussionAlthough discrepant intra-institutional radiologist second opinions were rare, they frequently led to changes in clinical management. Capturing these discrepancies by encouraging alert use may help optimize patient care and document what was communicated to the referring or consulting care team by consulting radiologists.

Continuous glucose monitoring for children with hypoglycaemia: Evidence in 2023.

In 2023, childhood hypoglycaemia remains a major public health problem and significant risk factor for consequent adverse neurodevelopment. Irrespective of the underlying cause, key elements of clinical management include the detection, prediction and prevention of episodes of hypoglycaemia. These tasks are increasingly served by Continuous Glucose Monitoring (CGM) devices that measure subcutaneous glucose at near-continuous frequency. While the use of CGM in type 1 diabetes is well established, the evidence for widespread use in rare hypoglycaemia disorders is less than convincing. However, in the few years since our last review there have been multiple developments and increased user feedback, requiring a review of clinical application. Despite advances in device technology, point accuracy of CGM remains low for children with non-diabetes hypoglycaemia. Simple provision of CGM devices has not replicated the efficacy seen in those with diabetes and is yet to show benefit. Machine learning techniques for hypoglycaemia prevention have so far failed to demonstrate sufficient prediction accuracy for real world use even in those with diabetes. Furthermore, access to CGM globally is restricted by costs kept high by the commercially-driven speed of technical innovation. Nonetheless, the ability of CGM to digitally phenotype disease groups has led to a better understanding of natural history of disease, facilitated diagnoses and informed changes in clinical management. Large CGM datasets have prompted re-evaluation of hypoglycaemia incidence and facilitated improved trial design. Importantly, an individualised approach and focus on the behavioural determinants of hypoglycaemia has led to real world reduction in hypoglycaemia. In this state of the art review, we critically analyse the updated evidence for use of CGM in non-diabetic childhood hypoglycaemia disorders since 2020 and provide suggestions for qualified use.

Implementation and Evaluation of a Longitudinal Flipped-Classroom Point-of-Care Ultrasound Curriculum at an Internal Medicine Residency Program.

Point-of-care ultrasound (POCUS) has extensive clinical utility in internal medicine, but formal and uniform curricula in internal medicine are lacking. To determine the effectiveness of a longitudinal, flipped-classroom, academic half-day curriculum on internal medicine resident confidence, utilization, and changes in clinical management. We implemented an asynchronous, flipped-classroom, academic half-day curriculum from November 2020 to November 2021 and conducted an evaluation with a prospective, before-after cohort study. Curriculum included 4 rotating sessions comprised of 20 to 30 min of image interpretation followed by 1.5 to 2 h of image acquisition. Confidence was rated via Likert scale. Utilization was reported via indicating never, 1 to 2, 3 to 4, 5 to 6, or >6 times per month (recorded as 1-5, respectively). Image interpretation was assessed via a 6-question, multiple-choice video assessment. Nineteen of 99 potential residents (19%) completed a pre- and post-curriculum evaluation. Residents attended a median of 4 sessions. Confidence improved from 2.47 to 3.53 (P = .002). Utilization did not improve overall (2.11-2.42, P = .22), but utilization of left ventricular function assessment (1.53-2.00, P = .046) and pulmonary assessment (1.53-2.00, P = .039) increased. The percentage of residents that had ever changed their clinical management by POCUS increased from 47% to 84% after implementation of the curriculum. Cardiac, pulmonary/pleural, volume assessment, and abdominal free fluid exams were reported as the most clinically useful. Implementation of a longitudinal, academic half-day curriculum for POCUS resulted in improved confidence, increased POCUS utilization for the cardiac and pulmonary examination, and changes in clinical management based on POCUS.

Ten-Year Trends of Persistent Mortality With Gallstone Disease: A Retrospective Cohort Study in New Jersey.

Recent trends in mortality with gallstone disease remain scarce in the United States. Yet multiple changes in clinical management, such as rates of endoscopy, cholecystectomy, and cholecystostomy, and insurance access at the state level, may have occurred. Thus, we evaluated recent secular trends of mortality with gallstone disease in New Jersey. We performed a retrospective, cohort study of mortality from 2009 to 2018 using the National Center for Health Statistics, Restricted Mortality Files. The primary outcome was any death with an International Classifications of Disease, 10th Revision, Clinical Modification diagnosis code of gallstone disease in New Jersey. Simple linear regression was used to model trends of incidence of death. 1580 deaths with diagnosed gallstone disease (dGD) occurred from 2009 to 2018. The annual trend of incidence of death was flat over 10 years. The incidence of death with dGD relative to all death changed only from 0.21% to 0.20% over 10 years. These findings were consistent also in 18 of 20 subgroup combinations, although the trend of death with dGD in Latinos 65 years or older increased [slope estimate 0.93, 95% confidence limit 0.42-1.43, P = .003]. The rate of death with dGD showed little change over the recent 10 years in New Jersey. This needs to be reproduced in other states and nationally. A closer examination of the changes in clinical care and insurance access is needed to help understand why they did not result in a positive change in this avoidable cause of death.

320. Clinical Impact of Metagenomic Next Generation Sequencing in a Large Pediatric and Adult Cohort

Abstract Background Plasma metagenomic next-generation sequencing (mNGS) is an emerging diagnostic tool. As the clinical use of mNGS increases, efforts to better understand the role of mNGS in diagnosis and management of infectious diseases are essential. Current literature is limited to small retrospective reviewers and a prospective study therefore subject to institutional variability. Here, we aim to describe the use, sensitivity, time to diagnosis, clinical impact, and cost effectiveness of mNGS in the largest patient cohort to date. Methods We included pediatric and adult patients who had plasma mNGS testing as part of care from December 2017 through December 2021 at University of Minnesota (UMN). Patients were identified using the Karius database. Electronic medical records were reviewed for every mNGS test, recording patient demographics, underlying conditions, indications, and results within 30 days of mNGS. All cases were assessed by 2 reviewers including one board-certified infectious diseases doctor. Sensitivity of mNGS was determined relative to conventional tests. The primary end point was change in clinical management. Secondary end points included accuracy, time to diagnosis, and infectious disease consultation. UMN IRB approved this study as non human subjects research. Results 584 mNGS tests were ordered in the study period, with 203 reviews completed to date. Solid organ transplantation (SOT) (32%) was the most common underlying condition, followed by hemopoietic stem cell transplantation (HSCT) (28%). Fever (45.8%), then pulmonary findings (26%) were the most common indications for ordering mNGS. Conventional and mNGS tests identified an infectious cause of the clinical syndrome in 49% of cases, while a contaminant was found in 52% of cases. The sensitivity of mNGS in identification of infectious cause was 47%, approximately 7% more sensitive than conventional testing. Despite this increased sensitivity, mNGS changed clinical management in 20% of cases. Conclusion mNGS demonstrated superiority in accurate detection of infectious causes of clinical syndromes, however, changed clinical management in a minority of cases, suggesting timing of the mNGS test is critical. This study identified SOT and HSCT as high yield patient groups for implementation of a prospective study. Disclosures Beth K. Thielen, MD, PhD, Horizon: Advisor/Consultant|Horizon: Honoraria|Merck: Grant/Research Support.

2001. Clinical management changes after positive multiplex gastrointestinal pathogen panel testing for evaluation of diarrhea

Abstract Background IDSA guidelines for diarrhea include pathogen-specific management. Compared to non-molecular tests, multiplex gastrointestinal pathogen panels (GIPPs) may allow for more timely and cost-effective diagnoses and care. However, this has yet to be definitively demonstrated. Our objective was to determine the impact of positive GIPP results on clinical management, including antimicrobial use. Methods We performed a retrospective study of patients with diarrhea and a positive GIPP result (xTAG Gastrointestinal Pathogen Panel, Luminex) at an academic, tertiary-care medical center from January-December 2018. We excluded immunocompromised patients (solid organ or stem cell transplant, HIV with absolute CD4 count &amp;lt; 200 cells/µL, primary immunodeficiency, and immunosuppressive medications including biologics). We collected patient and clinical data via electronic medical record review. Our primary outcome of interest was change in antimicrobial usage. Results A total of 2,333 GIPP tests were performed of which 266 (11.4%) were positive. Of 193 patients who met inclusion criteria, 34% were tested in an emergency room, 38% in outpatient clinics, and 29% on inpatient wards. Of these, 55% were men, 65% were white, and the median age was 31 years (interquartile range, IQR 5-56). The median turnaround time from GIPP collection to result was 31 hours (IQR 24-53). The most frequently identified pathogens were norovirus, Salmonella, and Campylobacter (Figure 1). In 43% of patients, results led to one or more management changes including antibiotic discontinuation (8%) and antibiotic initiation (25%). Antibiotics were most often discontinued for norovirus (Figure 1A) and started for Campylobacter (Figure 1B). Other management changes occurred in 13% of patients, including avoidance of further diagnostic testing and isolation precaution change. The median turnaround time did not differ for GIPPs that were (30 hours; IQR 22-50) or were not (32 hours; IQR 25-56) associated with management change. Conclusion Positive GIPP results can prompt changes in antimicrobial treatment in non-immunocompromised patients with diarrhea. Future efforts will evaluate the appropriateness of these management changes. Disclosures Melissa B. Miller, PhD, Abbott Molecular: Grant/Research Support|Agena Biosciences: Board Member|ArcBio: Grant/Research Support|Cepheid: Board Member|Luminex Molecular Diagnostics: Board Member|QIAGEN: Board Member|QIAGEN: Grant/Research Support|Sherlock Biosciences: Advisor/Consultant|Talis Biomedical: Board Member|Thermo Fisher: Honoraria|Werfen: Board Member.

Drug therapy, imaging, and other aspects of clinical management change after Alzheimer’s biomarker testing in routine practice: Findings from the IMPACT‐AD BC study

AbstractBackgroundWhile previous studies have demonstrated the effect of Alzheimer’s disease (AD) CSF testing in changing diagnosis, we lack an understanding of how this testing affects clinical management. Therefore, we assessed changes in clinical management associated with AD CSF biomarker testing when ordered as part of routine clinical management.MethodThe ‘Investigating the Impact of Alzheimer’s Disease Diagnostics in British Columbia’ (IMPACT‐AD BC) study (NCT05002699) is a longitudinal study examining the impact of AD CSF testing on clinical management, personal utility and health care economics in British Columbia, Canada. After AD CSF testing was ordered as part of routine care (where the clinical scenario met the appropriate use criteria), the patient and their physician were eligible to participate in the study. The primary outcome was the change in management (pre‐ v. post‐biomarker results) in a composite measure including 1) AD drug therapy, 2) other relevant drug therapy, 3) other diagnostic procedures, and 4) referral or counselling.ResultParticipants (n = 129) had a median age of 63 (IQR:58‐68); 49% were female. Cognitive impairment at baseline consisted of 7% with subjective cognitive impairment, 53% with mild cognitive impairment, and 40% with dementia. CSF biomarker profiles were consistent with an amyloid‐beta pathology (i.e., A+) in 72% of cases. Changes in clinical management because of testing occurred in 83% of cases including: referrals and counseling (57%), imaging (47%) and other diagnostic procedures (e.g., neuropsychological testing) (42%), and use of AD drug therapies (40%). For those with a non‐AD pre‐biomarkers diagnosis, 42% were changed to AD post‐biomarkers; for those with an AD pre‐biomarkers diagnosis, 18% were changed to non‐AD post‐biomarkers.ConclusionThis study has revealed substantial changes in clinical management as a direct result of AD CSF biomarker testing in routine care. An understanding of the implications of biomarker testing will in turn help us: improve appropriate utilization, understand the broader impacts on persons living with dementia and on the health care system, and prepare for expanded use of this testing with the availability of disease‐modifying therapeutics.