Common Clinical Questions Research Articles

Trends in CT examination utilization in the emergency department during and after the COVID-19 pandemic.

The increasing use of CT imaging in emergency departments, despite efforts of reducing low-value imaging, is not fully understood, especially during and after the COVID-19 pandemic. The aim of this study was to investigate the impact of COVID-19 pandemic related measures on trends and volume in CT examinations requested in the emergency department. CT examinations of the head, chest, and/or abdomen-pelvis (n = 161,008), and chest radiographs (n = 113,240) performed at our tertiary care hospital between 01/2014 and 12/2023 were retrospectively analyzed. CT examinations (head, chest, abdomen, dual-region and polytrauma) and chest radiographs requested by the emergency department during (03/2020-03/2022) and after the COVID-19 pandemic (04/2022-12/2023) were compared to a pre-pandemic control period (02/2018-02/2020). Analyses included CT examinations per emergency department visit, and prediction models based on pre-pandemic trends and inpatient data. A regular expressions text search algorithm determined the most common clinical questions. The usage of dual-region and chest CT examinations were higher during (+ 116,4% and + 115.8%, respectively; p < .001) and after the COVID-19 pandemic (+ 88,4% and + 70.7%, respectively; p < .001), compared to the control period. Chest radiograph usage decreased (-54.1% and - 36.4%, respectively; p < .001). The post-pandemic overall CT examination rate per emergency department visit increased by 4.7%. The prediction model underestimated (p < .001) the growth (dual-region CT: 22.3%, chest CT: 26.7%, chest radiographs: -30.4%), and the rise (p < .001) was higher compared to inpatient data (dual-region CT: 54.8%, chest CT: 52.0%, CR: -32.3%). Post-pandemic, the number of clinical questions to rule out "pulmonary infiltrates", "abdominal pain" and "infection focus" increased up to 235.7% compared to the control period. Following the COVID-19 pandemic, chest CT and dual-region CT usage in the emergency department experienced a disproportionate and sustained surge compared to pre-pandemic growth.

Using multi-level regression to determine associations and estimate causes and effects in clinical anesthesia due to patient, practitioner and hospital or health system practice variability.

In this research methods tutorial of clinical anesthesia, we will explore techniques to estimate the influence of a myriad of factors on patient outcomes. Big data that contain information on patients, treated by individual anesthesiologists and surgical teams, at different hospitals, have an inherent multi-level data structure (Fig.1). While researchers often attempt to determine the association between patient factors and outcomes, that does not provide clinicians with the whole story. Patient care is clustered together according to clinicians and hospitals where they receive treatment. Therefore, multi-level regression models are needed to validly estimate the influence of each factor at each level. In addition, we will explore how to estimate the influence that variability-for example, one anesthesiologist deciding to do one thing, while another takes a different approach-has on outcomes for patients, using the intra-class correlation coefficient for continuous outcomes and the median odds ratio for binary outcomes. From this tutorial, you should acquire a clearer understanding of how to perform and interpret multi-level regression modeling and estimate the influence of variable clinical practices on patient outcomes in order to answer common but complex clinical questions. Fig.1 Infographics.

When IBD Patients Require an Ostomy: Evidence-based Answers to 10 Common Clinical Questions in IBD Surgery

When IBD Patients Require an Ostomy: Evidence-based Answers to 10 Common Clinical Questions in IBD Surgery

Practice Pearls for Stimulant Treatment of Attention-Deficit/Hyperactivity Disorder in Youth.

Over half of youth with attention-deficit/hyperactivity disorder (ADHD) have co-occurring psychiatric or medical conditions that present treatment challenges. Stimulants are the most effective pharmacologic treatment of ADHD for preschoolers to adults but questions about safety with co-occurring conditions frequently arise. In addition, stigma surrounding diagnosis and treatment can negatively impact care. This manuscript presents evidence-based practice pearls to guide treatment decisions for youth with ADHD and common coexisting psychiatric and medical conditions. Recommendations address specific stimulant adverse effects (i.e., anxiety, cardiac, growth, mania, psychosis) along with management strategies. Pearls were developed for the most common clinical questions, controversial topics, or therapeutic issues that may not be widely known. The goals of this manuscript are to: 1) provide a detailed resource for interprofessional teams regarding stimulant use in youth with ADHD, 2) improve therapeutic outcomes for youth with ADHD and co-occurring psychiatric and/or medical conditions through evidence-based recommendations, and 3) decrease stigma associated with stimulant use through education.

(109) Assessment of Artificial Intelligence and ChatGPT Quality in the Management of Erectile Dysfunction

Abstract Introduction Since November 2022, Artificial Intelligence (AI) chatbots have grown in popularity including urologic conditions. However, its accuracy and quality has not been evaluated systematically. In this study, we sought to assess the accuracy and quality of AI chatbots in the management of Erectile Dysfunction (ED). Objective We aim to evaluate the accuracy and quality of open-source language models in fielding common clinical questions pertaining to ED compared to board certified urologists. Methods Two AI open-source language models, ChatGPT and Google Bard, were fielded 15 standard questions related to ED some of which included causes, risk factors and treatment options of ED. Two board certified urologists were given the same questions on a standard survey. A third blinded board-certified urologist served as a grader using the AUA guidelines for ED on a Likert scale to assess the accuracy, robustness, and bias of each response. Urologist and AI responses were graded and aggregated using Likert scales. Results Overall AI responses were significantly more accurate (p&amp;lt;0.01), robust (p&amp;lt;0.01), and unbiased (p&amp;lt;0.01). Additionally, Google Bard had the highest scores all around followed by ChatGPT. The urologists’ responses were approximately 38% lower compared to the AI responses. Conclusions This study suggests that AI responses were superior compared to urologists in the areas of accuracy, robustness, and bias pertaining to the management of ED. Albeit, the chatbots have promising role in urologic conditions including ED, its widespread clinical use and adoption warrants further evaluation in the context of clinical decision making and enhancing patient care. Disclosure No.

(165) Assessing Artificial Intelligence Quality in the Evaluation and Treatment of Erectile Dysfunction

Abstract Introduction Since November 2022, Artificial Intelligence (AI) chatbots have grown in popularity including in urologic conditions. However, their accuracy and quality has not been evaluated systematically. In this study, we sought to assess the accuracy and quality of AI chatbots in the management of Erectile Dysfunction (ED). Objective We aim to evaluate the accuracy and quality of open-source language models in fielding common clinical questions pertaining to ED compared to board certified urologists. Methods Two AI open-source language models, ChatGPT and Google Bard, were fielded 15 standard questions related to ED some of which included causes, risk factors and treatment options of ED. Two board certified urologists were given the same questions on a standard survey. A third blinded board-certified urologist served as a grader using the AUA guidelines for ED on a Likert scale to assess the accuracy, robustness, and bias of each response. Urologist and AI responses were graded and aggregated using Likert scales. Results Overall AI responses were significantly more accurate (p&amp;lt;0.01), robust (p&amp;lt;0.01), and unbiased (p&amp;lt;0.01). Additionally, Google Bard had the highest scores all around followed by ChatGPT. The urologists’ responses were approximately 38% lower compared to the AI responses. Conclusions This study suggests that AI responses were superior compared to urologists in the areas of accuracy, robustness, and bias pertaining to the management of ED. Albeit, the chatbots have promising role in urologic conditions including ED, its widespread clinical use and adoption warrants further evaluation in the context of clinical decision making and enhancing patient care. Disclosure No.

Association between implanted cardioverter-defibrillator and mortality for patients with left ventricular ejection fraction near 35%

Abstract Background Consensus guidelines support the use of implanted cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death in patients with either non-ischemic or ischemic cardiomyopathy with left ventricular ejection fraction ≤ 35%. Despite that class 1 recommendation, evidence from trials for efficacy specifically for patients with left ventricular ejection fraction (LVEF) near 35% is weak. Past trials are underpowered for this population and future trials are unlikely to be performed. As such, we aimed to use a large longitudinal echocardiography database linked to mortality to assess the comparative effectiveness of ICD therapy near the conventional primary prevention LVEF threshold. Methods Patients with lowest LVEF between 33-38% without an ICD prior to the lowest-LVEF echo (defined as "time zero") were identified by querying echocardiography data from November 28, 2001 until July 9, 2020 at large general hospital-based echocardiography registry linked to ICD treatment status. These data were then linked to mortality and comorbidity data. After inclusion and exclusion criteria were applied, 6,144 patients remained for the analytic cohort. Given evidence of covariate imbalance around the LVEF = 35% threshold, fuzzy regression discontinuity methods were considered but not used. Instead, to assess the association between ICD and mortality, multiple propensity score methods including matching and inverse probability of treatment weighting (IPTW) were used to create synthetic reference groups. Survival was then assessed with Cox proportional hazards models considering treatment status as a time-dependent covariate. Results In bivariate unadjusted comparisons, patients who received ICDs were substantially more often male (85.6% vs. 64.9%, p &amp;lt; 0.0001), more often white (87.3% vs. 82.9%, p &amp;lt; 0.048), and more often had a history of ventricular tachycardia (41.1% vs. 12.1%, p &amp;lt; 0.0001) and myocardial infarction (42.1% vs. 34.7%, p = 0.008). In the propensity matched sample, after accounting for time-dependence, there was no association between ICD and mortality (HR 1.09, 95% CI 0.86-1.39, p = 0.474). In the IPTW analysis, there also was no association between ICD and mortality (HR 1.09, 95% CI 0.91-1.30, p = 0.3672). Conclusions ICD therapy was not associated with reduced mortality near the conventional LVEF threshold of 35%. Although this treatment design cannot definitively demonstrate lack of efficacy, our results are concordant with available prior trial data. A definitive, well-powered trial is needed to answer the common and important clinical question of primary prevention ICD efficacy near the threshold of LVEF = 35%.

1069 Radiological Diagnosis of Groin Hernia - The New Norm?

Abstract Aim Ultrasound is an effective means for diagnosis of groin hernia however, RCS England and The British Hernia Society recommend that herniae should be diagnosed clinically and ultrasound should not be arranged at a primary care level. Following an increase in radiologically-diagnosed herniae referred to the general surgery department, we sought to determine whether ultrasound was used as a primary diagnostic tool. Method Ultrasound requests received from primary care between January and December 2021 were identified using radiology department records. Exclusion of incomplete, follow up and paediatric scans (&amp;lt;16 years old) was ensured. Electronic records were reviewed for clinical history, examination, radiology request and imaging report. Results 342 patients were included. 193 patients had the right groin scanned and 149, the left. The predominant symptoms for which scans were requested were “lump/swelling” (46%) and “pain” (36%). 13% were for suspected recurrence. 27% had a hernia on examination and 45% had no documented examination findings. The most common clinical question on imaging requests was “?hernia” (63%). 143 (42%) of ultrasound scans positively identified a hernia. Of these, 52% had a documented hernia on examination. Conclusions Ultrasound imaging is commonly used to diagnose or confirm diagnosis of groin hernia in the primary care setting. This study was conducted during the COVID-19 pandemic; reduced access to face-to-face consultations may have resulted in increased use of imaging and absence of clinical examination in the assessment of these patients. Patients with suspected hernia should be reviewed by a secondary care specialist prior to diagnostic imaging.

Application of estimand framework in ICH E9 (R1) to vaccine trials

ABSTRACT Over the past decades, the primary interest in vaccine efficacy or immunogenicity evaluation mostly focuses on the biological effect of immunization in complying with the vaccination schedule in a targeted population. The safety questions, which are essential for vaccines as they are generally given to large healthy populations, need to be clearly defined to reflect the risk assessment of interest. ICH E9 (R1) provides a structured framework to clarify the clinical questions and formulate the treatment effect as an estimand. This paper applies the estimand framework to vaccine clinical trials on common clinical questions regarding efficacy, immunogenicity, and safety.

Letting Tourette's be: The importance of understanding lived experience in research and the clinic.

The most common clinical research question regarding Tourette syndrome focuses on tic reduction, which follows from classical 'lack of inhibition' models. Rooted in views about brain deficits, this model suggests that with higher severity and frequency, tics are necessarily disruptive and should therefore be inhibited. However, emerging calls from people with lived experience of Tourette syndrome suggest that this is too narrow a definition. This narrative literature review analyses issues with brain deficit views and qualitative research on tic context and feelings of compulsion. The results suggest the need for a more positive and encompassing theoretical and ethical position on Tourette's. The article puts forward an enactive analytical approach of 'letting be', that is, approaching a phenomenon without forcing preconceived reference structures onto it. We suggest using the identity-first term 'Tourettic'. Prioritizing the perspective of the 'Tourettic patient', it urges attentiveness to the everyday issues diagnosed people encounter and how these are embedded in further life. This approach highlights the strong relationship between the Tourettic persons' felt impairment, their adoption of an outsider's perspective, and feeling under constant scrutiny. It suggests that this felt impairment of tics can be reduced by creating a physical and social environment in which the person is 'let be' but not 'let go of'. WHAT THIS PAPER ADDS: Its theoretical position allows a more holistic view of Tourette's, integrating tics with oft-overlooked complex compulsions. The 'letting be' position also allows us to view why the presentation of Tourette's is likely to vary with gender and age of onset. 'Letting be' is a promising approach to improve a clinical understanding of Tourettic well-being over and above tic severity and frequency. It integrates quantitative research on Tourette syndrome in the neurosciences with qualitative neurodiversity literature in the medical humanities. It integrates ethical frameworks as developed in enactive philosophy with the conceptualization and treatment of tics and compulsions.

A Brief Review of a Common Clinical Question: Intravenous Diltiazem or Metoprolol for Atrial Fibrillation with Rapid Ventricular Response?

A Brief Review of a Common Clinical Question: Intravenous Diltiazem or Metoprolol for Atrial Fibrillation with Rapid Ventricular Response?

S1548 GI Dysmotility Symptoms Are Not Associated With Increased L-Dopa Requirements in Parkinson’s Disease Patients

Introduction: Gastrointestinal (GI) motility disorders like gastroparesis or small bowel bacterial overgrowth are thought to impair efficacy of L-dopa, which is absorbed in the proximal small intestine, resulting in motor fluctuations among Parkinson’s Disease (PD) patients that prompt dosage increases. While symptoms of dysmotility are frequently reported in PD, results are mixed concerning their effect, if any, on L-dopa pharmacokinetics. In this study, we compare L-dopa equivalent daily dose (LEDD) and motor function among patient with 5 upper GI symptoms to study the possible relationship between dysmotility symptoms and increased L-dopa requirement. Methods: Two hundred PD patients evaluated by outpatient neurology at Mass General Brigham Healthcare between 2018-2019 were included. History of 5 upper GI symptoms (dysphagia, nausea, vomiting, epigastric pain, and bloating), as well as LEDD were obtained from the medical record. Unified PD Rating Scale (UDPRS) part III motor exam scores off medication were extracted from clinical notes. Differences between LEDD and UDPRS motor scores among patients with and without a history of each of the 5 GI symptoms were calculated via Student t-tests. Results: Dysphagia was significantly associated with increased LEDD (230mg, P=0.0067) as well as increased motor severity (4.6 UDPRS, P=0.036). In contrast, nausea was associated with decreased LEDD (-187 mg, P=0.030) despite similar motor severity (1.1 UDPRS, P=0.63) to those without nausea (Table). There were no differences in LEDD and UDPRS scores among patients with and without vomiting, epigastric pain, and bloating. Conclusion: Except dysphagia, we found that GI dysmotility symptoms were not associated with increased LEDD nor increased motor severity. This suggests that symptomatic GI dysmotility may not be directly related to poor L-dopa absorption, a common clinical question for PD patients referred to GI. While dysphagia was linked with higher LEDD, this may have stemmed from higher UDPRS scores in this population. Interestingly, those with nausea required lower LEDD despite comparable motor severity. Nausea, a frequent symptom of delayed intestinal transit, may extend absorption time leading to better motor outcomes on less L-dopa. However, further studies are needed to discern any underlying mechanism. Our results nonetheless indicate that clinical management of dysmotility may not reduce motor fluctuations and the need for increased L-dopa as previously presumed. Table 1. - Changes in L-dopa Requirements and Motor Severity in the Presence of Dysmotility Symptoms GI Symptom ΔLEDD, mg (SD) P value ΔUDPRS III (SD) P value Nausea -187 (86) 0.03 1 (2) 0.633 Vomiting 11 (95) 0.91 -2 (2) 0.343 Dysphagia 230 (84) 0.007 5 (2) 0.036 Epigastric pain 101 (104) 0.33 0 (3) 0.881 Bloating 62 (99) 0.533 1 (2) 0.764 LEDD—L-dopa equivalent daily dose UDPRS—Unified Parkinson's Disease Rating Scale.

Body MRI: Imaging Protocols, Techniques, and Lessons Learned.

Body MRI has evolved from a niche subspecialty to a standard modality in the practice of abdominal radiology. However, the practicing radiologist may feel uncomfortable interpreting body MRI studies owing to a lack of case volume and inconsistent exposure. The authors highlight teaching points and subtleties central to better acquisition and interpretation of body MRI studies. Appropriate contrast agent selection and arterial phase acquisition timing provide greater diagnostic certainty in answering common clinical questions at liver MRI, such as assessing cirrhosis and evaluating focal liver lesions. Clinically relevant artifacts and physiologic phenomena, such as magnetic susceptibility and transient hepatic intensity difference, must be recognized and appropriately used when reading a study. Fat within organs and lesions is commonly encountered at body MRI. The authors discuss the nuances of common and uncommon entities, how to address fat suppression failure, assessment of bone marrow at body MRI, and an organized approach to fat-containing renal and adrenal masses. Motion artifacts are more commonly encountered at body MRI than at MRI of other anatomic regions, and understanding the various techniques, their benefits, and trade-offs will aid the body imager in protocol design and moving beyond "nondiagnostic" examinations. Challenging anatomic sites to evaluate at body MRI are reviewed. Finally, the authors offer tips for accurate interpretation of diffusion-weighted imaging, hepatobiliary phase imaging, and posttreatment imaging studies. By reviewing this article, the abdominal imager will be better prepared to perform and interpret body MRI studies confidently and accurately. An invited commentary by Kalb is available online. Online supplemental material is available for this article. ©RSNA, 2022.

SER-SEPAR recommendations for the management of rheumatoid arthritis-related interstitial lung disease. Part 1: Epidemiology, risk factors and prognosis

ObjectiveTo develop multidisciplinary recommendations to improve the management of rheumatoid arthritis-related interstitial lung disease (RA-ILD). MethodsClinical research questions relevant to the objective of the document were identified by a panel of rheumatologists and pneumologists selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Specific recommendations were made. ResultsSix PICO questions were selected, three of which analysed the incidence and prevalence of RA-ILD, associated risk factors, and predictors of progression and mortality. A total of 6 specific recommendations on these topics, structured by question, were formulated based on the evidence found and/or expert consensus. ConclusionsWe present the first official SER-SEPAR document with specific recommendations for RA-ILD management developed to resolve some common clinical questions and facilitate decision-making for patients.

SER-SEPAR recommendations for the management of rheumatoid arthritis-related interstitial lung disease. Part 2: Treatment

ObjectiveTo develop multidisciplinary recommendations to improve the management of rheumatoid arthritis-related interstitial lung disease (RA-ILD). MethodsClinical research questions relevant to the objective of the document were identified by a panel of rheumatologists and pneumologists selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Specific recommendations were made. ResultsSix PICO questions were selected, three of which analysed the safety and effectiveness of glucocorticoids, classical synthetic disease-modifying anti-rheumatic drugs (DMARDs) and other immunosuppressants, biological agents, targeted synthetic DMARDs, and antifibrotic therapies in the treatment of this complication. A total of 12 recommendations were formulated based on the evidence found and/or expert consensus. ConclusionsWe present the first official SER-SEPAR document with specific recommendations for RA-ILD management developed to resolve some common clinical questions, reduce clinical healthcare variability, and facilitate decision-making for patients.

Screening criteria for interstitial lung disease associated to rheumatoid arthritis: Expert proposal based on Delphi methodology

ObjectiveTo develop a joint proposal for screening criteria of interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) and vice versa, which serves as a guidelines in patient referral between the Rheumatology and Pneumology departments to early detection of these patients. MethodsA systematic literature review was carried out on the risk factors for the development of ILD in RA patients, and for the referral criteria to Rheumatology for suspected early RA. Based on the available evidence, screening criteria were agreed using the Delphi method by a panel of pneumologists and rheumatologists with expertise in these pathologies. ResultsScreening criteria for ILD in patients with RA and for the early detection of RA in cases with ILD of unknown etiology have been developed. In both cases, a detection strategy was based on clinical risk factors. Recommendations also included the complementary tests to be carried out in the different clinical scenarios and on the periodicity that screening should be repeated. ConclusionA selective screening strategy is recommended for the first time in the early diagnosis of patients with ILD-RA. This multidisciplinary proposal aims to solve some common clinical questions and help decision-making, although its usefulness to identify these patients with good sensitivity must be confirmed in a validation study.

Hypertensive Disorders of Pregnancy: Common Clinical Conundrums.

Hypertensive complications of pregnancy comprise 16% of maternal deaths in developed countries and 7.4% of deaths in the United States. Rates of preeclampsia increased 25% from 1987 to 2004, and rates of severe preeclampsia have increased 6.7-fold between 1980 and 2003. The aim of this study was to review current and available evidence for common clinical questions regarding the management of hypertensive disorders of pregnancy. Original research articles, review articles, and guidelines on hypertension in pregnancy were reviewed. Severe gestational hypertension should be managed as preeclampsia with severe features. Serum uric acid levels can be useful in predicting development of superimposed preeclampsia for women with chronic hypertension. When presenting with preeclampsia with severe features before 34 weeks, expectant management should be considered only when both maternal and fetal conditions are stable. In the setting of hypertensive disorders of pregnancy, oral antihypertensive medications should be initiated when systolic blood pressure is greater than 160 mm Hg or when diastolic blood pressure is greater than 110 mm Hg, with the most ideal agents being labetalol or nifedipine. Furthermore, although risk of preeclampsia recurrence in future pregnancy is low, women with a history of preeclampsia should be managed with 81 mg aspirin daily for preeclampsia prevention. Despite the frequency with which hypertensive disorders of pregnancy are encountered clinically, situations arise frequently with limited evidence to guide providers in their management. An urgent need exists to better understand this disease to optimize outcomes for impacted patients.

Clinical Management of Prostate Cancer in High-Risk Genetic Mutation Carriers.

Simple SummaryMen with certain genetic differences are at much higher risks of developing metastatic and lethal prostate cancer. With the recent introduction of a new class of medications specifically targeted to these gene repair pathways (PARP inhibitors), it is critical to review the state of the literature surrounding the management of men with prostate cancer who have these genetic differences. We review the existing literature to address common clinical questions pertaining to this population. There is an urgent need for further research regarding clinical management in these scenarios as patients are increasingly seeking out genetic testing and consulting healthcare professionals for guidance.Background: Prostate cancer is a leading cause of death. Approximately one in eight men who are diagnosed with prostate cancer will die of it. Since there is a large difference in mortality between low- and high-risk prostate cancers, it is critical to identify individuals who are at high-risk for disease progression and death. Germline genetic differences are increasingly recognized as contributing to risk of lethal prostate cancer. The objective of this paper is to review prostate cancer management options for men with high-risk germline mutations. Methods: We performed a review of the literature to identify articles regarding management of prostate cancer in individuals with high-risk germline genetic mutations. Results: We identified numerous publications regarding the management of prostate cancer among high-risk germline carriers, but the overall quality of the evidence is low. Conclusions: We performed a review of the literature and compiled clinical considerations for the management of individuals with high-risk germline mutations when they develop prostate cancer. The quality of the evidence is low, and there is an immediate need for further research and the development of consensus guidelines to guide clinical practice for these individuals.

30-minute CMR for common clinical indications:\xa0a\xa0Society for Cardiovascular Magnetic Resonance white paper

BackgroundDespite decades of accruing evidence supporting the clinical utility of cardiovascular magnetic resonance (CMR), adoption of CMR in routine cardiovascular practice remains limited in many regions of the world. Persistent use of long scan times of 60 min or more contributes to limited adoption, though techniques available on most scanners afford routine CMR examination within 30 min. Incorporating such techniques into standardize protocols can answer common clinical questions in daily practice, including those related to heart failure, cardiomyopathy, ventricular arrhythmia, ischemic heart disease, and non-ischemic myocardial injury.BodyIn this white paper, we describe CMR protocols of 30 min or shorter duration with routine techniques with or without stress perfusion, plus specific approaches in patient and scanner room preparation for efficiency. Minimum requirements for the scanner gradient system, coil hardware and pulse sequences are detailed. Recent advances such as quantitative myocardial mapping and other add-on acquisitions can be incorporated into the proposed protocols without significant extension of scan duration for most patients.ConclusionCommon questions in clinical cardiovascular practice can be answered in routine CMR protocols under 30 min; their incorporation warrants consideration to facilitate increased access to CMR worldwide.

66.1 PREPARATION BEFORE PRESCRIBING BUPRENORPHINE: WHAT DO I NEED TO DO?

Clinician questions and concerns about prescribing buprenorphine for opioid use disorder in adolescents, especially minors, prevent many from actually taking the leap to accepting patients, even after finishing the federally mandated buprenorphine waiver training. This overview will review common clinical questions and answers before starting treatment to improve feelings of readiness. A vignette of a typical treatment course will be used to give an overview of what buprenorphine treatment looks like before and during long-term treatment, with emphasis on common issues that arise for prescribers and how adequate preparation ahead of time can make dealing with these situations much easier. The scientific literature (and gaps within) about patient and clinician experiences and published guidelines will be reviewed. Psychiatrists can make slight modifications to their current practice to accommodate requirements for prescribing buprenorphine. Release of health information forms currently in use can be modified to allow for discussion of opioid use disorder treatment with parents. Labs used to check lithium levels or monitor antipsychotic medications can also process drug tests. Networks for referrals to a higher level of care can be cultivated just as is done for mental health needs. Treatment agreements can facilitate thorough discussion of risks and benefits and clearly outline clinician and patient responsibilities and improve the quality of treatment. Child and adolescent psychiatrists are well positioned to use buprenorphine to treat adolescents with opioid use disorder using many familiar clinical tools. Preparing for common problems ahead of time improves clinician confidence and willingness to start treatment.