Clinician Impression Research Articles

Screening for depression, anxiety, and psychological distress associated with low back pain by musculoskeletal and spinal clinicians. A scoping review.

A biopsychosocial assessment of a person with low back pain (LBP) should include the detection of psychological risk factors. Pragmatically, clinicians often use their clinical impression rather than questionnaires to screen for psychological risk factors. This scoping review explores how accurately depression, anxiety, and psychological distress can be identified by musculoskeletal (MSK) or spinal clinicians using clinical impression alone. The study protocol was pre-registered on Open Science Framework (OSF) https://osf.io/pt3a6/ . A comprehensive search strategy using five databases (MEDLINE, CINAHL, Academic Search Complete, APA PsycInfo, APA PsycArticles) was conducted by two independent reviewers, with additional searching of references. Studies must have included adults with LBP, who were assessed by MSK or spinal clinician for depression, anxiety or psychological distress using their clinical impression as well as a reference standard questionnaire. Data were synthesised descriptively and thematically for each psychological factor separately. Eight studies involving MSK clinicians (n = 4) and spinal clinicians (n = 4) were eligible. Four different reference standard questionnaires were used. Overall MSK and spinal clinicians were not accurate at identifying depression, anxiety or psychological distress in adults with LBP using only clinical impression. Mean sensitivity for accurate identification of high reference standard questionnaire scores for depression, anxiety, and psychological distress ranged between 12.0% and 40.0%. Mean sensitivity was marginally higher when the threshold was reduced to analyse clinician ability to accurately capture any abnormal psychological state (34.0% to 54.1%). Mean specificity values acrosshigher thresholds ranged from 88.7% to 93.6%. Overall, clinician impression alone is insufficient for MSK and spinal clinicians to accurately identify depression, anxiety and psychological distress in adults with LBP. The general tendency of the clinicians was to underestimate their presence. Without formal assessment of the psychological status of patients with LBP, clinicians will have an incomplete understanding of concordant psychological factors, and may fail to notice the requirement to refer on for appropriate psychological management.

Subjective and objectives measures of frailty among adults with advanced chronic kidney disease: a cross-sectional analysis of clinician misclassification.

Frailty is a recognisable clinical measure of impaired physiological reserve and vulnerability to adverse outcomes that is validated among patients with kidney disease. Practice patterns reveal inconsistent use of objective frailty measures by nephrologists, with clinicians prioritising subjective clinical impressions, possibly risking misclassification and discrimination. The aim of this study was to examine correlations between subjective and objective measures of frailty in a cohort of patients attending routine nephrologist review. Eighty-nine participants attending scheduled review with their primary treating nephrologist (n = 6) were included in cross-sectional analysis. Measured frailty based on Fried phenotype and subjective clinician impression were assessed for congruence using Pearson's correlation analysis and ĸ statistic. Ordinal logistic regression examined patient demographics associated with perceived frailty. Misclassification was explored using descriptive statistics and contingency table analysis. Frailty and prefrailty were prevalent by both objective and subjective means of assessment with minimal correlation between clinician impression and measured Fried phenotype (r = 0.50, P = 0.00, ĸ = 0.25, P = 0.00). Subjective clinician impression misclassified half of participants, influenced by surrogate frailty measures including female sex, comorbidity and reliance on a walking aid. Clinicians were equally likely to over-classify prefrailty as to under-recognise established frailty, with no evidence of systemic misclassification bias. Subjective clinican impression of frailty had a positive predictive value of 19.1% and a negative predictive value of 56.2%. Nephrologists' reliance on subjective clinical impressions that overlook or misclassify prefrailty offers incomplete prognostic assessment and potentially misses opportunities for early intervention.

State-Level Helmet Use Laws, Helmet Use, and Head Injuries in EMS Patients Involved in Motorcycle Collisions

ABSTRACT OBJECTIVES Motorcycle helmets save lives and reduce serious injury after motorcycle collisions (MCC). In 2022, 18 states had laws requiring helmet use by motorcyclists aged ≥21 years. Our objective was to compare helmet use and head trauma in emergency medical services (EMS) patients involved in MCC in states with and without helmet use laws. METHODS We conducted an analysis of the 2022 ImageTrend Collaborate national EMS dataset. We included 9-1-1 responses where the patient was a motorcyclist in a transport accident (ICD-10 V20-V29) and aged ≥21 years. Patient demographics, incident urbanicity, helmet use, presence of state helmet use law, patient disposition, Glasgow Coma Scale (GCS) score, and trauma team activations were examined. Our primary outcome of interest was EMS documentation of helmet use (yes/no). Our secondary outcome was the presence of a head injury. We examined EMS-documented head injury, defined using clinician impressions and chief complaint anatomical location. Chi-square tests were used to assess differences in proportions, and a multivariable logistic regression model was used to estimate odds of moderate/severe head injury adjusted for covariates of interest. RESULTS A total of 15,891 patient encounters were included, 10,738 (67.6%) occurred in states without helmet use laws. States without helmet use laws had higher proportions of unhelmeted patients (56.8% vs 24.2%, p < 0.001), encounters in non-metro/rural areas (19.7% vs 13.3%, p < 0.001), and GCS-defined moderate/severe head injuries (4.6% vs 2.3%, p < 0.001). In a multivariable model that included 10-yr age groups, sex, race, urbanicity, and documented helmet use, the adjusted odds of moderate/severe head injury were lower for females (0.47, 95%CI, 0.35-0.65) and Black patients (0.47, 95%CI 0.32-0.70), and were higher for incidents in nonmetro/rural areas (1.58, 95%CI 1.28-1.95) and when EMS had not documented helmet use (3.17, 95%CI 2.56-3.92) CONCLUSIONS In this retrospective cross-sectional study, a higher proportion of patients involved in MCCs in states without helmet laws were not wearing helmets at the time of injury, and unhelemted patients had increased likelihood of sustaining a head injury. Emergency medical services agencies in states without helmet laws should prepare their systems and clinicians for an increased incidence of head injuries after MCCs.

Association between behavioral parameters of men in psychiatric emergency department video recording and subsequent violence in the psychiatric ward

Violence risk is a major challenge among acute psychiatric inpatients. The study aimed to predict violent behavior risk in an acute psychiatric ward using video recordings from the emergency department. 69 videos of the emergency department recording the first ten minutes following patients’ arrivals were included. Psychiatrists watched the videos, completed relevant Brief Psychiatric Rating Scale items and answered intuitive questions about each patient’s risk of violence. Demographic and clinical data were also collected. Motoric mannerisms as rated in the BPRS significantly differed between violent and non-violent patients (p < 0.05). Additionally, we found a significant correlation between intuitive prediction of violence and actual violence (p = 0.008). Violent behavior was predicted in 42.1% of the cases by the intuitive evaluation compared to 11.5% mistakenly evaluated patients. Logistic regression revealed that the intuitive question and the BPRS items regarding tension and motoric mannerism created a successful model for predicting violence with 88.2% sensitivity and 72.5% specificity. We sought to define the factors that most accurately predict violence in the acute psychiatric ward, based solely on behavior in the emergency department. Intuitive impressions of clinicians and motoric mannerisms should be considered when evaluating patients for potential violent behavior.

Viral Determinants of Childhood Asthma Exacerbation Severity and Treatment Response

Although respiratory viruses are common triggers of asthma exacerbations, the influence of viral infection characteristics on exacerbation presentation and treatment response in the pediatric emergency department (ED) is unclear. To assess viral infection characteristics of children experiencing ED asthma exacerbations and to test their associations with severity and treatment response. This is a prospective study of children, aged 4 to 18 years, who received standard ED asthma exacerbation treatment with inhaled bronchodilators and systemic corticosteroids. Nasal swabs collected for viral metagenomic analyses determined virus presence, load, and species. Outcomes included exacerbation severity (Pediatric Asthma Severity [PAS] score, clinician impression, and vital signs) and treatment response (discharge home without needing additional asthma therapies). Of 107 children, 47% had moderate/severe exacerbations by PAS and 64% demonstrated treatment response. Viral metagenomic analysis on nasal swabs from 73 children detected virus in 86%, with 10 different species identified, primarily rhinovirus A (RV-A), RV-C, and enterovirus D68. Exacerbations involving RV-A were milder (odds ratio [OR]= 0.25; 95% confidence interval [CI]= 0.07-0.83) and tended to be more responsive to treatment than non-RV-A infections, whereas exacerbations involving enterovirus D68 were more severe (OR= 8.3; 95% CI= 1.3-164.7) and had no treatment response association. Viral load was not associated with treatment response but exhibited a strong linear relationship with heart rate (rpartial= 0.48), respiratory rate (rpartial= 0.25), and oxygen saturation (rpartial= -0.25), indicative of severity. The majority of ED asthma exacerbations are triggered by respiratory viruses. Viral species are associated with severity and treatment response, suggesting that early pathogen detection could inform ED treatment decisions. Additional studies are needed to identify differences in pathobiology underlying exacerbations triggered by different viral species, and how to effectively treat these heterogeneous exacerbations.

Mapping Prehospital Clinician Impression to Hospital-Based Diagnoses in Children Transported to the Hospital by Emergency Medical Services

Objectives Emergency medical services (EMS) serves a critical role in the delivery of services to children with out-of-hospital emergencies. The EMS clinicians’ initial field diagnoses, termed “impressions,” facilitate focused patient assessments, guide the application of prehospital treatment protocols, and help determine transport destination. We sought to evaluate the concordance of the EMS clinician impression to a child’s hospital-based diagnosis. Methods We retrospectively studied de-identified pediatric (<18 years old) scene runs transported to the hospital and with available linked hospital data from the 2021 ESO Data Collaborative, a multi-agency prehospital electronic health record dataset. EMS impressions and primary emergency department or admission-based diagnoses were categorized into one of twenty-one major groups in the Diagnosis Grouping System. We identified the most common hospital-based discharge diagnoses and evaluated for the agreement between EMS impression and hospital-based diagnosis using Cohen’s Kappa statistic. Results We included 35,833 pediatric transports from the scene with linked prehospital and in-hospital data (median age 11 years, interquartile range, 3-15 years; 50.9% male). The most common categories for both EMS impressions and hospital-based diagnoses were as follows respectively: trauma (26.1%; 24.6%), neurologic diseases (18.9%; 16.4%), psychiatric and behavioral diseases and substance use disorder (11.8%; 11.6%), and respiratory diseases (11.1% and 9.5%). A total of 23,224 out of 35,833 patients, or 64.8%, had concordant EMS impressions and hospital-based diagnoses. There was high agreement between common EMS impression and in-hospital diagnoses (trauma 77.3%; neurologic diseases 70.3%; respiratory diseases 64.5%; and psychiatric, behavioral disease and substance use disorder 73.9%). Hospital-based diagnoses demonstrated moderate concordance with prehospital data (Cohen’s κ = 0.59). Conclusions We found moderate concordance between EMS primary impression and hospital diagnoses. The EMS encounter is brief and without capabilities of advanced testing, but initial impressions may influence the basis of the triage assignment and interventions during the hospital-based encounter. By evaluating EMS impressions and ultimate hospital diagnoses, pediatric protocols may be streamlined, and specific training emphasized in pursuit of improving patient outcomes. Future work is needed to examine instances of discordance and evaluate the impact on patient care and outcomes.

Development of antibiotic metrics for hospitalists via multi-institutional modified Delphi survey.

Closing the gap between evidence-supported antibiotic use and real-world prescribing among clinicians is vital for curbing excessive antibiotic use, which fosters antimicrobial resistance and exposes patients to antimicrobial side effects. Providing prescribing information via scorecard improves clinician adherence to quality metrics. We aimed to delineate actionable, relevant antimicrobial prescribing metrics extractable from the electronic health record in an automated way. We used a modified Delphi consensus-building approach. Our study entailed two iterations of an electronic surveydisseminated to hospital medicine physicians at 10 academic medical centers nationwide. Main outcomes comprised consensus metrics describing the quality of antibiotic prescribing to hospital medicine physicians. Twenty-eight participants from 10 United States institutions completed the first survey version containing 38 measures. Sixteen respondents completed the second survey, which contained 37 metrics. Sixteen metrics, which were modified based on qualitative survey feedback, met criteria for inclusion in the final scorecard. Metrics considered most relevant by hospitalists focused on the appropriate de-escalation of antimicrobial therapy, selection of guideline-concordant antibiotics, and appropriate duration of treatment for common infectious syndromes. Next steps involve prioritization and implementation of these metrics based on quality gaps at our institution, focus groups exploring impressions of clinicians who receive a scorecard,and analysis of antibiotic prescribing patterns before and after metric implementation. Other institutions may be able to implement metrics from this scorecard based on their own quality gaps to provide hospitalists with automated feedback related to antibiotic prescribing.

A cytomics-on-a-chip platform and diagnostic model stratifies risk for oral lichenoid conditions

ObjectivesA small fraction of oral lichenoid conditions (OLC) have potential for malignant transformation (MT). Distinguishing OLCs from other oral potentially malignant disorders (OPMD) can help prevent unnecessary concern or testing, but accurate identification by non-expert clinicians is challenging due to overlapping clinical features. In this study, the authors developed a cytomics-on-a-chip tool and integrated predictive model for aiding the identification of OLCs. Study DesignAll study subjects underwent both scalpel biopsy for histopathology and brush cytology. A predictive model and OLC Index comprising clinical, demographic, and cytologic features was generated to discriminate between subjects with lichenoid (OLC+) (N=94) and non-lichenoid (OLC−) (N=237) histologic features in a population with OPMDs. ResultsThe OLC Index discriminated OLC+ and OLC− subjects with area under the curve (AUC) of 0.76. Diagnostic accuracy of the OLC Index was not significantly different from expert clinician impressions, with AUC of 0.81 (p=0.0704). Percent agreement was comparable across all raters, with 83.4% between expert clinicians and histopathology, 78.3% between OLC Index and expert clinician, and 77.3% between OLC Index and histopathology. ConclusionThe cytomics-on-a-chip tool and integrated diagnostic model have the potential to facilitate both the triage and diagnosis and risk stratification of patients presenting with OPMDs and OLCs.

Retrospective analysis of the standardized BARD criteria for acute cholangitis in biliary atresia patients.

In 2022, the Biliary Atresia and Related Diseases (BARD) community reached a consensus for the definition of suspected and confirmed cholangitis for biliary atresia (BA) patients after hepatoportoenterostomy (HPE). This study assessed the new standardized BARD definition in a retrospective, multicenter cohort study. We included BA cases managed between 2010 and 2020 at the Hannover Medical School and Geneva University Hospitals'Swiss Pediatric Liver Center. The standardized BARD cholangitis definition assesses fourclinical items and fourimaging/laboratory items to define cholangitis. The definition was retrospectively applied to all BA cases having presented, according to their physician, cholangitis within the first year after the HPE. The diagnosis defined by the standardized BARD definition was compared with the final clinical diagnosis made by physicians. The Spearman's correlation coefficient was used to test for correlation between diagnoses made by standardized and clinical appreciation. Of 185 consecutive BA patients, 59 (32%) had at least one episode of cholangitis within the first year after HPE. The correlation between the clinician's impression and the standardized BARD definition was very strong (r = 0.8). Confirmed cholangitis definition coincided with the clinician's impression (2.5 [±0.7]/4 clinical items, 2.6 [±0.5]/4 imaging/laboratory items). For suspected cholangitis, the threshold for diagnosis was lower within the standardized BARD definition (1.1 [±0.3]/4 clinical items, 2.2 [±0.8]/4 laboratory/imaging items). This first retrospective application of the standardized BARD cholangitis definition reveals a very strong correlation with the physician's assessment before standardization. A prospective study is needed to further refine the standardized definition for cholangitis in BA patients.

Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers

ObjectiveNational efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, emphasizing the need to maintain pediatric readiness in these settings. We aimed to characterize emergency medical services (EMS) utilization from outpatient offices and urgent care centers to better understand pediatric readiness needs. MethodsWe performed a retrospective cross-sectional analysis of EMS encounters using the National Emergency Medical Services Information System, a nationally representative EMS registry (2019–2022). We included four years of EMS encounters of children (<18 years old) that originated from an outpatient office or urgent care center. We described characteristics, including patient demographics, prehospital clinician impression, therapies, and procedures performed. ResultsOf 179,854,336 EMS encounters during the study period, 164,387 pediatric encounters originated at an outpatient setting. Most EMS encounters originated from outpatient offices. Evening and weekend EMS encounters more frequently originated from urgent care centers. The most common impressions were respiratory distress (n = 60,716), systemic illness (n = 23,583), and psychiatric/behavioral health (n = 13,273). Ninety-four percent of EMS encounters resulted in transportation to a hospital. ConclusionsEMS encounters from outpatient settings most commonly originate from outpatient offices, relative to urgent care settings, where pediatric emergency readiness may be limited. It is important that outpatient settings and providers are ready for varied emergencies, including those occurring for a behavioral health concern, and that readiness guidelines are updated to address these needs.

Association of midazolam route of administration and need for recurrent dosing among children with seizures cared for by emergency medical services.

National guidelines in the United States recommend the intramuscular and intranasal routes for midazolam for the management of seizures in the prehospital setting. We evaluated the association of route of midazolam administration with the use of additional benzodiazepine doses for children with seizures cared for by emergency medical services (EMS). We conducted a retrospective cohort study from a US multiagency EMS dataset for the years 2018-2022, including children transported to the hospital with a clinician impression of seizures, convulsions, or status epilepticus, and who received an initial correct weight-based dose of midazolam (.2 mg/kg intramuscular, .1 mg/kg intravenous, .2 mg/kg intranasal). We evaluated the association of route of initial midazolam administration with provision of additional benzodiazepine dose in logistic regression models adjusted for age, vital signs, pulse oximetry, level of consciousness, and time spent with the patient. We included 2923 encounters with patients who received an appropriate weight-based dose of midazolam for seizures (46.3% intramuscular, 21.8% intranasal, 31.9% intravenous). The median time to the first dose of midazolam from EMS arrival was similar between children who received intramuscular (7.3 min, interquartile range [IQR] = 4.6-12.5) and intranasal midazolam (7.8 min, IQR = 4.5-13.4) and longer for intravenous midazolam (13.1 min, IQR = 8.2-19.4). At least one additional dose of midazolam was given to 21.4%. In multivariable models, intranasal midazolam was associated with higher odds (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.10-1.76) and intravenous midazolam was associated with similar odds (OR = 1.00, 95% CI = .80-1.26) of requiring additional doses of benzodiazepines relative to intramuscular midazolam. Intranasal midazolam was associated with greater odds of repeated benzodiazepine dosing relative to initial intramuscular administration, but confounding factors could have affected this finding. Further study of the dosing and/or the prioritization of the intranasal route for pediatric seizures by EMS clinicians is warranted.

Evaluating the safety and efficacy of the addition of liver radiation (RT) to atezolizumab and bevacizumab (A/B) in advanced hepatocellular carcinoma (HCC): A retrospective cohort analysis.

481 Background: Recently, the addition of stereotactic body RT to sorafenib in patients (pts) with advanced HCC demonstrated improved overall survival. However, A/B is the current standard of care for pts with advanced HCC based on IMBrave150. For these pts, RT may potentiate the antitumor immune response of A/B but carries the risk of bowel toxicity and impaired liver function. To date, there are limited data regarding safety and outcomes with the addition of liver RT to A/B in pts with advanced HCC. Here, we describe our single-center experience of adding RT to A/B for pts with advanced HCC. Methods: This single-center retrospective cohort study was conducted at the University of Pennsylvania. We identified all pts with HCC naïve to systemic therapy who received infusions of A/B and those who received RT to the liver within 30 days of starting A/B until discontinuation from 1/1/2020 until 2/2/2023. We assessed the real-world response rate (rwRR) determined from clinician impression after initiating A/B, safety outcomes, overall survival (OS), and time-to-progression (TTP) from initiation of A/B. Time-to-event outcomes were analyzed by the Kaplan-Meier method with log-rank test and Cox proportional hazards modeling. Results: We identified 49 pts (n=34 control, n=15 RT) with advanced HCC receiving first-line A/B. Those who received RT were more likely to have alcoholic liver disease (p=0.013) and were less likely to have ascites (p=0.04) but were otherwise balanced regarding demographics, prior locoregional therapies, presence of macrovascular invasion and extrahepatic spread, and baseline laboratories. The median RT dose was 63 Gy. The rwRR in the RT group was 73.3% (11/15) compared to 17.6% (6/34) in the control group (Risk Ratio (RR) 3.9, 95% CI 1.7-8.6, p&lt;0.001). Two pts in the control group (5.8%) and one patient in the RT group (6.7%) experienced clinically significant bleeding (RR=1.1 95% CI 0.1-11.6). In the RT group, three pts (20%) developed worsening liver dysfunction after completing RT, concerning for possible radiation-induced liver disease. Six pts in the control group and one patient in the RT group developed immune-related adverse events leading to discontinuation of A/B. The median OS in the RT group was 14.4 mos and 10.8 mos in the control group (Hazard Ratio (HR) death 0.49 (95% CI 0.20-1.22, p=0.12)). Median TTP was 6.4 months (mos) with RT compared to 5.8 mos in the control group (HR progression 0.72 (95%CI 0.35-1.46, p=0.36. Conclusions: In our retrospective cohort, the addition of liver RT to standard A/B resulted in increased responses and a non-significant improvement in outcomes without an increased risk of bleeding. An assessment of changes in liver dysfunction by Child-Pugh and ALBI score is ongoing. Overall, these data support prospective trials to evaluate the addition of RT to A/B.

Transport Rates and Prehospital Intervals for an EMS Telemedicine Intervention

Introduction Emergency medical services (EMS) facilitated telemedicine encounters have been proposed as a strategy to reduce transports to hospitals for patients who access the 9-1-1 system. It is unclear which patient impressions are most likely able to be treated in place. It is also unknown if the increased time spent facilitating the telemedicine encounter is offset by the time saved from reducing the need for transport. The objective of this study was to determine the association between the impressions of EMS clinicians of the patients’ primary problems and transport avoidance, and to describe the effects of telemedicine encounters on prehospital intervals. Methods This was a retrospective review of EMS records from two commercial EMS agencies in New York and Tennessee. For each EMS call where a telemedicine encounter occurred, a matched pair was identified. Clinicians’ impressions were mapped to the corresponding category in the International Classification of Primary Care, 2nd edition (ICPC-2). Incidence and rates of transport avoidance for each category were determined. Prehospital interval was calculated as the difference between the time of ambulance dispatch and back-in-service time. Results Of the 463 prehospital telemedicine evaluations performed from March 2021 to April 2022, 312 (67%) avoided transports to the hospital. Respiratory calls were most likely to result in transport avoidance (p = 0.018); no other categories had statistically significant transport rates. Four hundred sixty-one (99.6%) had matched pairs identified and were included in the analysis. When compared to the matched pair, telemedicine without transport was associated with a prehospital interval reduction in 68% of the cases with a median reduction of 16 min; this is significantly higher than telemedicine with transport when compared to the matched pair with a median interval increase in 27 min. Regardless of transport status, the prehospital interval was a median of 4 min shorter for telemedicine encounters than non-telemedicine encounters (p = 0.08). Conclusion In this study, most telemedicine evaluations resulted in ED transport avoidance, particularly for respiratory issues. Telemedicine interventions were associated with a median four-minute decrease in prehospital interval per call. Future research should investigate the long-term effects of telemedicine on patient outcomes.

A Quantitative Three-Dimensional Tear Trough Deformity Assessment and Its Application in Orbital Septum Fat Transposition.

Existing evaluation tools of tear trough deformity are based on subjective impression of clinicians. More accurate quantitative assessment methods are needed. This study aimed to propose a quantitative three-dimensional assessment method for the tear trough deformity in comparison with the Barton's grading system and apply it to the efficacy evaluation of orbital septum fat transposition. 117 healthy Chinese adults (234 eyes) were enrolled and divided into four groups according to the Barton's grading system. Three-dimensional facial images were captured using Vectra H1 handheld camera. 6 anthropometric landmarks were identified on each eye and 8 linear measurements were generated accordingly. Intra-observer reliability was determined and measurements were compared between groups. Pre- and post-operative three-dimensional measurements were compared in 19 patients who received lower blepharoplasty with orbital septum fat transposition. The severity of tear trough was positively correlated with age (P < 0.001) but not BMI (P = 0.145) or gender (P = 0.280). Intra-rater reliability of the 8 linear measurements was excellent except for the vertical distance between the palpebrale inferioris margin and the tear trough below the pupillary center. Intergroup comparison showed that the horizontal distance between the lateral end of tear trough (P < 0.001) and medial canthus and the sagittal vector from tear trough point toward eyelid bag point (P = 0.009) increased with grade, while the vertical distance from mid-pupil to palpebrale inferioris margin decreased gradually (P = 0.001). Orbital septum fat transposition significantly improved the tear trough deformity as assessed by these three-dimensional measurements. We demonstrated a novel quantitative evaluation method of the tear trough deformity using three-dimensional stereophotogrammetry and proved it to be valid and reliable. It showed good value of clinical application and might help with periorbital rejuvenation planning and outcome assessment. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictive value of clinician impression for readmission and postdischarge mortality among neonates and young children in Dar es Salaam, Tanzania and Monrovia, Liberia

BackgroundThere are no validated clinical decision aids to identify neonates and young children at risk of hospital readmission or postdischarge mortality in sub-Saharan Africa, leaving the decision to discharge a...

E086 Comparing ankylosing spondylitis disease activity during the COVID-19 pandemic using patient-reported outcome measures with face-to-face clinical evaluation of disease scores pre-pandemic

Abstract Background/Aims During the COVID-19 pandemic, asynchronous consultations were introduced for patients with ankylosing spondylitis (AS). To assess disease activity in the absence of face-to-face clinical review and blood testing, patients submitted patient-reported outcome measures (PROMs) via electronic survey forms which were subsequently triaged by clinicians. We compared pre-pandemic clinician-reported scores with intra-pandemic self-reported scores and assessed clinical outcomes including allocation of follow-up and further management/treatment escalation. Methods Clinician-reported scores were obtained in-person pre-pandemic (defined as 01/01/2019-01/03/2020). Self-reported BASDAI scores were submitted by patients via electronic forms sent out during-pandemic (defined as 01/12/2020-31/03/22). The responses were stored and analysed in a secure database. These scores are analogous to disease activity scores completed by clinicians during outpatient appointments. Score comparison was performed using Wilcoxon Sign Rank testing. We used the need for a follow-up within 3 months as target for those with severe disease. Data analysis was performed in Microsoft Excel and R (version 4.2.1). Results We noted a significantly higher overall level of patient-reported disease activity during the pandemic. In the total cohort of AS patients, the median BASDAI Score collected during-pandemic increased from 5.30 (n = 124, range 0-10) compared to 2.80 pre-pandemic (n = 590, range 0-12) (p &amp;lt; 0.001). The proportion of patients with severe/active disease (defined as BASDAI &amp;gt;4) increased from 36% pre- to 65% during pandemic. In a smaller cohort of 34 patients for whom we had both pre- and during-pandemic scores, all patient parameters worsened during the pandemic. Notably, median BASDAI increased from 2.65 to 5.62 (p &amp;lt; 0.0001). Patients with severe AS increased from 10 (29.4%) to 21 (61.8%) intra-pandemic. Follow-up data was available for 12/21 patients with severe AS during-pandemic. 7/12 patients (58%) received a follow-up appointment within one month; 11/12 (91%) were seen within three months. On subsequent clinician assessment, only 7 (58%) of patients with self-reported severe AS were felt to have active disease; treatment was escalated for 3 patients. Conclusion There was a significantly higher reported level of AS disease activity during the COVID-19 pandemic, with 62 % of patients qualifying for biologic therapy (BASDAI &amp;gt;4). In a focussed sample, 91% of patients with new severe disease during-pandemic were followed up within the target of 3 months. The BASDAI score is independent from clinical examination and inflammatory markers, and therefore self-reported score should reliably reflect a patient’s perception of disease activity. Further work is required to determine the reason for the increased disease activity observed during pandemic, and for the disparity between clinician impression and score results. Disclosure D.A. Kurzeja: None. K. Song: None. M. Mirza: None. M. Ashraf: None. L. James: None. A. Verdiyeva: None. R. Luqmani: None.

Prehospital Fluid Administration for Suspected Sepsis in a Large EMS System: Opportunities to Improve Goal Fluid Delivery

Objectives Despite EMS-implemented screening and treatment protocols for suspected sepsis patients, prehospital fluid therapy is variable. We sought to describe prehospital fluid administration in suspected sepsis patients, including demographic and clinical factors associated with fluid outcomes. Methods A retrospective cohort of adult patients from a large, county-wide EMS system from January 2018-February 2020 was identified. Patient care reports for suspected sepsis were included, as identified by EMS clinician impression of sepsis, or keywords “sepsis” or “septic” in the narrative. Outcomes were the proportions of suspected sepsis patients for whom intravenous (IV) therapy was attempted and those who received ≥500 mL IV fluid if IV access was successful. Associations between patient demographics and clinical factors with fluid outcomes were estimated with multivariable logistic regression adjusting for transport interval. Results Of 4,082 suspected sepsis patients identified, the mean patient age was 72.5 (SD 16.2) years, 50.6% were female, and 23.8% were Black. Median (interquartile range [IQR]) transport interval was 16.5 (10.9–23.2) minutes. Of identified patients, 1,920 (47.0%) had IV fluid therapy attempted, and IV access was successful in 1,872 (45.9%). Of those with IV access, 1,061 (56.7%) received ≥500mL of fluid from EMS. In adjusted analyses, female (versus male) sex (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69–0.90), Black (versus White) race (OR 0.57, 95% CI 0.49–0.68), and end stage renal disease (OR 0.51, 95% CI 0.32–0.82) were negatively associated with attempted IV therapy. Systolic blood pressure (SBP) <90 mmHg (OR 3.89, 95% CI 3.25–4.65) and respiratory rate >20 (OR 1.90, 95% CI 1.61–2.23) were positively associated with attempted IV therapy. Female sex (OR 0.72, 95% CI 0.59–0.88) and congestive heart failure (CHF) (OR 0.55, 95% CI 0.40–0.75) were negatively associated with receiving goal fluid volume while SBP <90 mmHg (OR 2.30, 95% CI 1.83–2.88) and abnormal temperature (>100.4 F or <96 F) (OR 1.41, 95% CI 1.16–1.73) were positively associated. Conclusions Fewer than half of EMS sepsis patients had IV therapy attempted, and of those, approximately half met fluid volume goal, especially when hypotensive and no CHF. Further studies are needed on improving EMS sepsis training and prehospital fluid delivery.

A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids

Objective/Introduction Ketamine is an opioid-alternative used for analgesia in the prehospital setting. There are knowledge gaps regarding its use during emergency medical services (EMS) encounters for pediatric patients. Our objective was to compare pain reduction, adverse events, and prehospital deaths between ketamine and opioids when used for analgesia administered by any route among pediatric patients. Methods This was a retrospective review of 9-1-1 EMS records of injured pediatric patients (≤17 years of age) who received ketamine or opioids for analgesia using the ESO Data Collaborative (calendar years 2019-2020). We excluded interfacility transfers, patients receiving both medications, those with EMS clinician impressions indicating behavioral disorders, and those who received medication to facilitate advanced airway placement. EMS narrative review was performed to confirm ketamine use was for analgesia and to identify any unplanned airway placements. We assessed pain score reduction (0–10 ordinal scale) and clinician-documented patient response (improved, unchanged, worsened, unknown). Adverse events were defined as change in vital signs (GCS, SBP, RR, SpO2), bag valve mask ventilation alone, or death. Descriptive statistics were calculated to compare outcomes between groups. Results Overall, 9,223 patients were included, 190 (2.1%) received ketamine and 9,033 (97.9%) received opioids. Mean age in years was 12.8 [SD 4.0] for ketamine and 12.7 [SD 4.0] for opioids. Patients in both groups experienced pain reduction, and more patients receiving ketamine had EMS clinician reported improvement (93.2% vs. 87.9%, p = 0.03). Ketamine was associated with a greater average reduction in pain score than opioids (mean difference: −4.4 [SD 3.5], and −3.1 [SD 2.8], p < 0.001). Adverse events were rare with few patients receiving ventilatory support following the use of ketamine or opioids, (0, [SD 0.0%] vs. 6 [SD 0.1%], p = 1). There were no unplanned airway placements or prehospital deaths identified. Conclusion We identified similar high rates of pain reduction and rare adverse events among pediatric patients who received ketamine or opioids. A greater pain reduction was noted among patients administered ketamine. Intubation as a result of medication administration did not occur and need for ventilatory assistance was rare.

Factors that influence the quality of final impressions for fixed dental prostheses in Nairobi, Kenya

Background:Good quality dental impressions free of air bubbles, voids, steps, drags, streaks and tears are a pre-requisite for the fabrication of well-fitting fixed dental prostheses (FDP). The quality of impressions is dependent on clinician and material factors.Aim:To evaluate factors that influence the quality of final impressions for FDP in Nairobi, Kenya. Methods:In this cross-sectional study, 234 impressions received by five dental laboratories were analyzed. The study collected information on the type of tray, impression material, technique, type of prostheses, and clinically detectable errors, including voids, inadequate material at margins, tears, steps, drags, and streaks. Impression quality was the outcome assessed as good, fair, or poor by two investigators. The independent variables influencing impression quality included clinician specialty, experience, impression material, technique, and tray type.Results: Inter-rater agreement was 96.8% (p&lt;0.001). Clinician experience ranged between 1-45yrs, median 13.5yrs and mean 8.39±11.96yrs. The majority were GPs, 80.8% while restorative dentists were 11.5% and other specialists, 7.7%. Most impressions were non-aqueouselastomers, 97.9% employing dual-viscosity technique, 75.6%. Impression trays included stock metal, 60.3%, stock plastic, 34.2%, and custom, 5.5%. Impression quality was good, 24.8%, fair, 37.2% or poor, 38.0%. Cumulatively, 74.5% impressions hadbubbles/voids, 53.0% tears and 43.2% poor margins. Clarity of margins was associated with clinician specialty, (Fisher’s exact=9.372, p=0.047), and impression technique with impression quality, (Pearson’s χ2 = 6.385, p=0.041). Compared to restorative specialists, estimated odds of other specialists producing poor margins was 5.71, 95%CI 1.55,21.06, Wald χ2=5.24, p=0.009 while for GPs, the estimated odds was 2.19, 95%CI 0.88, 5.43, Wald χ2 = 2.86, p=0.09. Compared to dual viscosity, estimated odds of monophase giving a poor-quality impression was 1.52, 95%CI 0.83,2.78, Wald χ2 = 1.52, p=0.18.Conclusion:Most impressions were good or fair hence acceptable. Quality of impressions was influenced by clinician specialty and impression technique

Can fluconazole be used for inpatient re-treatment of coccidioidomycosis among patients with past fluconazole exposures?

Coccidioides spp. may cause significant disease requiring hospitalisation, but optimal antifungal therapy among inpatients following outpatient fluconazole exposures is unknown. The objective of this study is to describe the effectiveness of fluconazole among patients hospitalised for coccidioidomycosis despite recent outpatient fluconazole treatment. Patients were admitted to an academic medical center in Phoenix, Arizona from 1 January 2013 through 31 December 2020 for coccidioidomycosis following at least 30 days of outpatient treatment and re-initiation of fluconazole upon admission. The primary outcome was the proportion of patients with an improved response per the change in the modified Mycosis Study Group (MSG) score (a composite of symptoms, serology and radiographic findings) and clinician impressions. Sixty-seven patients were included, with most (54%) admitted to the intensive care unit. Meningitis was the most common infectious presentation (55%), 17 patients (25%) had multiple infection sites, and 23 (34%) were culture-positive for Coccidioides. Upon admission, the median (IQR) MSG score was 11 (9-14), which dropped to 4 (1-7) at end of therapy or last follow-up. Overall, after initiation of fluconazole therapy at a median daily dose of 800 mg, 48 patients (72%) improved in overall status, 10 (15%) showed stable disease and 9 (13%) were unresponsive. Improved response rates were high across all infection sites, including meningitis (68%) and bone infection (71%). There was no significant difference in response rates between patients with and without reported outpatient fluconazole nonadherence. The majority of patients admitted to the hospital for coccidioidomycosis appeared responsive to fluconazole therapy despite past outpatient exposures.