Emergency Room Visits Research Articles

Health care utilization at the end of life in Parkinson’s disease: a population-based register study

BackgroundKnowledge of health care utilization at the end of life in Parkinson’s disease (PD) is sparse. This study aims to investigate end of life health care utilization, characterized by emergency room (ER) visits, receipt of specialized palliative care (SPC), and acute hospital deaths in a Swedish population-based PD cohort.MethodsWe conducted a retrospective cohort study on deceased patients (≥ 18 years) with a PD diagnosis during their last year of life (n = 922), based on health care-provider data from Region Stockholm´s data warehouse, for the study period 2015–2021. Univariable and multivariable logistic regression analyses tested associations and adjusted Odds ratios (aORs) were calculated.ResultsDuring the last month of life, approx. half of the cohort had emergency room (ER) visits and risk of frailty (measured by Hospital Frailty Risk Score) significantly predicted these visits (aOR, 3.90 (2.75–5.55)). In total, 120 people (13%) received SPC during their last three months of life, which positively associated with risk for frailty, (aOR, 2.65 (1.43–4.94, p = 0.002). In total, 284 people (31%) died in acute hospital settings. Among community-dwellers, male gender and frailty were strongly associated with acute hospital deaths (aOR, 1.90 (1.15–3.13, p = 0.01) and 3.70 (1.96–6.98, p < 0.0001)).ConclusionsRates of ER visits at end of life and hospital deaths were relatively high in this population-based cohort. Considering a high disease burden, referral to SPC at end of life was relatively low. Sex-specific disparities in health care utilization are apparent. Identifying people with high risk for frailty could assist the planning of optimal end-of-life care for people with PD.

A nurse-led intervention improves quality of life and reduces arrhythmic recurrences in patients undergoing atrial fibrillation ablation. Results of the NURSECAT-AF randomized clinical trial

Abstract Background/Introduction Atrial fibrillation (AF) is a prevalent condition that can lead to a decrease in quality of life and frequent re-hospitalizations. Some data suggest that integrated care nurse-led may blunt these consequences in unselected patients with AF, but not all studies support this. While AF ablation is becoming a cornerstone treatment for symptomatic patients with AF, it is unclear what impact a nurse-led intervention would have on these, quite likely, more receptive patients. Purpose To assess the impact of nurse-led intervention on quality of life among AF patients undergoing ablation. Methods We conducted a single-centre prospective randomised clinical trial to test the effect of an expert nurse-based intervention consisting of an educational programme on AF, support for the patient undergoing cardiac ablation to ensure its success, and management of risk factors associated with this arrhythmia. The control group underwent standard medical follow-up. Patient selection was based on chronological order. Only patients who underwent their first ablation and did not have heart failure were included. The primary endpoint was quality of life at 12 months post-ablation using the Arrhythmia-Specific Scale in Tachycardia and Arrhythmia (ASTA) questionnaire (higher values denote impaired quality of life). Secondary endpoints were AF knowledge and satisfaction at 15 days post-ablation using validated instruments, symptoms using the ASTA questionnaire as well, and readmissions rates, emergency room visits, and AF recurrence rates over a one-year period. Results 116 patients were screened (50 were excluded mostly because were re do). A total of 66 patients were eventually included and randomized (33 per arm; mean age [mean±SD] 63±10 years; 44 men [67%]). At 12 months, quality of life was significantly better in the intervention group than in the control group (4.5 ± 6.1 vs 0.57 ± 2.3, respectively, p=0.001)(Figure). Furthermore, satisfaction levels (17 ± 4.1 vs 12.7 ± 5.4, p&amp;gt;0.001) and disease knowledge (20.5 ± 5.1 vs 15.9 ± 4.5, p&amp;lt;0.001) were higher in the intervention group. Patients in the control group experienced a higher symptom burden during the first year (0.6 ± 1.5 vs 3.8 ± 4.5, p&amp;lt;0.001. Relevant clinical endpoints such as readmissions (3% vs 18.2%, p=0.046), emergency room visits (21.2% vs 57.5%, p=0.021), and arrhythmia recurrences (15.2% vs 45.5%, p=0.02) were all significantly lower in the intervention group. Conclusion(s) Nurse-led integrated care for patients undergoing AF ablation yields substantial improvements in quality of life and symptomatic relief at one year post-procedure. Additionally, it enhances patient knowledge of AF and satisfaction levels, and reduces readmissions, emergency room visits, and arrhythmia recurrences.

Quality of life measures with etripamil self-administration for acute episodes of paroxysmal supraventricular tachycardia in a medically unsupervised setting: patient-reported outcomes from NODE-303

Abstract Background Etripamil nasal spray (NS) is a fast-acting, self-administered calcium-channel blocker in development for the conversion of AV-nodal dependent paroxysmal supraventricular tachycardia (PSVT) in a medically unsupervised setting. Prior studies show favorable safety and efficacy in converting single episodes of PSVT to sinus rhythm (SR). Purpose In NODE-303, patient-reported outcome (PRO) instruments assessed quality of life (QoL) over multiple etripamil-treated episodes of PSVT. Methods NODE-303 was an event-driven, multi-center, open-label Phase 3 study in North and South American patients with documented PSVT that evaluated the safety and efficacy of etripamil in PSVT termination, over multiple episodes and without the need for prior test dosing. Enrolled patients who perceived PSVT symptoms applied an ambulatory ECG cardiac monitoring system (CMS), performed a pre-trained vagal maneuver and, if symptoms persisted, self-administered etripamil NS 70 mg. A study amendment allowed a repeat dose (etripamil NS, 70 mg) if symptoms persisted 10 min after the first dose. Each patient could self-treat up to 4 episodes. Safety was assessed through adverse events, clinical data, and ECG CMS recordings. The Treatment Satisfaction Questionnaire for Medication (TSQM; validated for acute episodic assessments) and other PROs were administered, and healthcare utilization data were acquired. Patients completed PROs at baseline (BL), monthly, and per PSVT episode, which collected information on symptoms, episode characteristics, rescue medications, and emergency room visits. Additional PROs were the Brief Illness Perception Questionnaire (BIPQ), Cardiac Anxiety Questionnaire (CAQ), and 36-Item Short Form Health Survey (SF-36). Results There were higher proportions of patients reporting mild, minimal or no disease severity, every 6 months, than at BL; extremely severe, severe, and moderate disease severity was reported by smaller proportions of patients than at BL, though incomplete surveys at later visits may limit this analysis. Anxiety and stress about future PSVT episodes were consistently reduced from BL. Measures of treatment satisfaction, effectiveness, and convenience were consistent across multiple episodes, and were at levels considered favorable for the TSQM instrument (Table 1). Rates of emergency-room visits and hospital admissions across multiple, treated PSVT episodes were similar to those observed in trials assessing single episodes (Table 2). The BIPQ, CAQ or SF-36 had no notable changes from BL. Conclusions Etripamil self-administration was associated with patient-reported improvements in degree of disease severity, decreased anxiety and stress over future PSVT episodes, and levels of treatment satisfaction, effectiveness, and convenience considered favorable for respective PRO instrument. Using a symptom-prompted, self-administered treatment for PSVT could potentially improve QoL measures and reduce healthcare resource utilization.

Value-based versus usual care for heart failure patients leads to reduction in cost, hospital admissions and improved survival

Abstract Background OptumCare (OC) in our city, Nevada established a heart failure (HF) program comprised of a team of outpatient cardiologists including two who are board certified in advanced heart failure. Referred patients are enrolled in the HF program once HF is diagnosed by a cardiologist. Patients are managed by an interdisciplinary team of cardiologists, advanced practice clinicians (APC), registered nurse case managers (RNCM), and a social worker. Patients at higher risk for HF admissions are enrolled in remote patient telemonitoring. In contrast, OC in Arizona utilizes a "usual" care approach of fee-for-service contracted cardiology groups to manage HF patients in outpatient and in-patient settings. Purpose A head-to-head comparison was performed between the cohort of patients enrolled in HF program in OC Nevada (treatment group) and patients with HF diagnosis in OC Arizona (control group). The groups were compared on the following measures: medical cost, hospital admissions, and survival rates. Methods In this retrospective study, a 1:1 iterative propensity score (PS) matching was performed to closely approximate patient demographics and comorbidities, which resulted in 818 matched pairs (total n=1,636) of the patients with program enrollment or 1st HF diagnosis between March 1, 2019 and June 30, 2022. For Difference-in-Difference Analysis (Diff-in-Diff), generalized linear models were used on PS matched data to test the difference in difference in medical cost and utilizations changes between control and treatment group over a six month period. Log-Binomial regression was used to estimate the relative risk of post period 30-day readmission and hospice enrollment. Kaplan Meier Estimator was used to test the difference in survival rates over time. Results Average age of patients was 77.6 years old, and 49% were female. The treatment group resulted in significantly lower overall medical costs per member per month (PMPM), significantly less emergency room (ER) visits, less acute hospital and skilled nursing facility (SNF) admissions, and shorter overall hospital length of stays. The control group was twice as likely to be readmitted to the hospital. Lastly, the treatment group had a significantly better survival rate than the control group. 19% of the patients in the control group expired within 12 months of enrollment vs. 10% of the patients in the treatment group expired during the same time period. Average survival was 142 days in the control group vs. 200 days in the treatment group. Conclusions A value-based care approach involving a multidisciplinary team in an outpatient-based cardiology HF program resulted in statistically significant improvement in medical costs, acute care visits/admissions, and survival rates compared to "usual" care approach for HF patients.

Rationale and design of the SHASTA-3 and SHASTA-4 studies: randomized, double-blind, placebo-controlled, phase 3 studies of plozasiran in patients with severe hypertriglyceridemia

Abstract Severe hypertriglyceridemia (sHTG) confers an increased risk of atherosclerotic cardiovascular disease (ASCVD) and acute pancreatitis (AP). sHTG-associated AP is a substantial source of morbidity, mortality, reduced quality of life and financial burden to health care systems. Currently available therapeutic approaches for sHTG are often insufficient to reduce triglyceride (TG) levels and prevent AP. Plozasiran, an investigational siRNA therapeutic, inhibits hepatic production of apolipoprotein C3 (APOC3), a key regulator of lipoprotein lipase-mediated TG metabolism and clearance. In a phase 2 study of sHTG patients [TG ≥500 mg/dL (≥5.65 mmol/L)], plozasiran demonstrated durable reductions in TG levels of up to -80%, 12 weeks after the last dose, and decreased TG below 500 mg/dL (5.65 mmol/L), a threshold of increased risk for AP in most participants. The SHASTA-3 and SHASTA-4 trials will evaluate safety and efficacy of plozasiran, including AP rates, in patients with sHTG. SHASTA-3 and SHASTA-4 are phase 3, randomized, double-blind, placebo-controlled, multi-center trials. Key inclusion criteria are prior sHTG and fasting TG ≥500 mg/dL (≥5.65 mmol/L), at screening. Key exclusion criteria include use of any hepatocyte targeted siRNA treatments that target lipids and/or TGs within 1 year (except inclisiran at least 4 weeks prior to enrollment), siRNA or ASO within 60 days, known FCS diagnosis, and AP within 4 weeks of screening. 700 adults with sHTG will be enrolled in these two trials in several sites across multiple countries. Patients will be randomized 2:1 to receive 4 quarterly subcutaneous injections of plozasiran 25 mg or matching placebo over a 1-year double-blinded period, followed by post-treatment evaluation or entry into the open-label extension study. The randomization will be stratified based on TG levels (≥880 mg/dL vs &amp;lt;880 mg/dL [≥ vs &amp;lt;10 mmol/L]) and prior history of AP, within 5 years of screening. The primary efficacy endpoint of the studies is placebo-adjusted percent change in fasting TG from baseline to month 12 with plozasiran. Secondary endpoints include percent change in fasting TG from baseline to month 10 compared to placebo, percent of patients achieving fasting TGs of &amp;lt;500 mg/dL (&amp;lt;5.65 mmol/L) and TGs of &amp;lt;150 mg/dL (&amp;lt;1.69 mmol/L) at month 10 and 12 compared to placebo, and event rate of adjudicated abdominal clinical events including ER visits and hospitalization for abdominal pain attributed to HTG and events of documented pancreatitis. The effect of plozasiran on other lipids and lipoproteins, inflammatory biomarkers, and liver fat content using magnetic resonance imaging-proton density fat fraction will be assessed. Adjudicated major adverse cardiovascular event rates, safety and tolerability will be assessed. SHASTA-3 and SHASTA-4 are designed to determine whether the quarterly-dosed APOC3 siRNA plozasiran, added to standard of care, safely reduces TG levels and the rate of AP in patients with sHTG.

Cost-Related Medication Behaviors for Patients With and Without Systemic Autoimmune Rheumatic Diseases.

Medication nonadherence challenges the management of systemic autoimmune rheumatic diseases (SARDs). We investigated cost-related medication behaviors among patients with SARDs, and compared them to those of patients without SARDs, in a large diverse cohort across the United States. As part of the All of Us (version 7), a nationwide diverse adult cohort with linked electronic health records begun in 2017, participants completed questionnaires concerning cost-related medication behaviors. Chi-square tests compared responses between patients with SARDs, by disease and medication type, and to those without SARDs. Logistic regression analyses were used to calculate odds ratios (95% confidence intervals [CIs]). We analyzed data from 3,997 patients with SARDs and 73,990 participants without SARDs. After adjustment, patients with versus without SARDs had 1.56 times increased odds of reporting unaffordability of prescription medicines (95% CI 1.43-1.70), 1.43 times increased odds of cost-related medication nonadherence (95% CI 1.31-1.56), and 1.23 times increased odds of using cost-reducing strategies (95% CI 1.14-1.32). Patients with SARDs who reported unaffordability were 16.5% less likely to receive a disease-modifying drug (95% CI 0.70-0.99) but 18.1% more likely to receive glucocorticoids (95% CI 0.99-1.42). In addition, unaffordability of prescription medicines was likely to have 1.27 times increased odds of one to two emergency room visits per year (95% CI 1.03-1.57) and 1.38-fold increased odds of three or more emergency room visits per year (95% CI 0.96-1.99). In this large diverse cohort, patients with versus without SARDs had more self-reported cost-related medication behaviors, and those who reported medication unaffordability received fewer disease-modifying drugs and had more emergency room visits.

Clinical burden and healthcare resource utilization associated with managing sickle cell disease with recurrent vaso-occlusive crises in France

Objective This retrospective, real-world claims database analysis described the clinical burden and healthcare resource utilization (HCRU) among patients with sickle cell disease (SCD) with recurrent vaso-occlusive crises (VOCs) in France. Methods The French National Health Data System database (système national des données de santé) was used to identify eligible patients from January 1, 2012, to March 1, 2019. Inclusion criteria were a SCD diagnosis, ≥2 VOCs/year for ≥2 consecutive years following the diagnosis, and ≥1 year of follow-up data to March 1, 2020. Patients with hereditary persistence of fetal hemoglobin or hematopoietic stem cell transplant in their medical records were excluded. Clinical complications, mortality, treatment use, and HCRU were evaluated during follow-up. Results Overall, 4602 patients with SCD with recurrent VOCs were eligible; their mean (standard deviation [SD]) age was 19.8 (13.5) years, and 51.8% were female. Patients experienced a mean (SD) of 3.82 (3.57) VOCs per patient per year (PPPY). Prevalent complications were anemia or leukocytosis (44.1%), infections (42.0%), and organ failure (38.2%). In total, 101 (2.2%) patients died during follow-up (mean age of death [SD]: 39.3 [17.5] years; mortality rate: 0.64 deaths per 100 person-years). Most patients received opioids (89.1%) and hydroxycarbamide (72.8%). Patients had a mean of 5.7 inpatient hospitalizations, 6.0 emergency room visits, 6.6 outpatient visits, and 13.4 outpatient prescriptions PPPY. Conclusions Patients with SCD with recurrent VOCs in France have substantial clinical complications, mortality, and HCRU despite currently available treatment options. Innovative treatments that reduce frequency of or eliminate VOCs are needed to alleviate the burden associated with SCD.

The potential to prevent unnecessary emergency department visits by timely diagnosis of migraine-A prospective observational study.

Successful acute migraine treatment potentially prevents emergency room (ER) consultations but requires that the diagnosis of migraine was given earlier. The aim of this study is to quantify the problem of missed migraine diagnosis prior to ER visits. Inclusion criterion for this single-center prospective study was the presentation at the ER for acute headache. Patients with acute migraine attacks were assessed for previous migraine attacks, and whether they were given a diagnosis of migraine in the past. Of 137 patients with migraine diagnosis at discharge, 108 (79%) had previous headache attacks fulfilling the criteria for migraine according to The International Classification of Headache Disorders 3rd edition (ICHD-3). Of those, 54 (50%) received the diagnosis for the first time. Half of the migraine patients (50%) presenting in the ER for headache could have been diagnosed earlier. This highlights the need for better detection and treatment of migraine by pre-hospital healthcare providers, as earlier diagnosis and specific acute treatment could have prevented the ER visit.

Postpartum readmission after unscheduled cesarean delivery in patients with class 3 obesity.

Identify risk factors for postpartum readmission in class 3 obese patients undergoing unscheduled cesarean deliveries. Retrospective cohort study of patients with BMI ≥ 40 kg/m2 undergoing unscheduled cesarean delivery from 2017-2020 comparing patients with and without postpartum readmission (unexpected admission, emergency room/overnight observation visit, unscheduled outpatient visit, or ambulatory surgery within 30 days). Medical history, operative data, and postpartum outcomes were compared between the cohorts. "The electronic medical record was queried to identify cesarean deliveries documented as 'unscheduled'". 255 of 1273 identified patients (20.0%) had a postpartum readmission. Median BMI was similar between the cohorts (44.2 kg/m2, IQR [41.8, 47.9] vs. 44.8 kg/m2 [42.0, 48.9], p= 0.066). Readmitted patients were more likely to have a history of smoking during or prior to pregnancy (p= 0.046). A sub-group exploratory analysis excluding outpatient and emergency room visits demonstrated higher rates of type II diabetes mellitus in patient's with postpartum readmission (11.5% vs 4.6%, p= 0.030). Patients with readmission in comparison to those without readmissions were less likely to receive cefazolin prophylaxis (78.0% vs 84.3%, p= 0.014) in comparison to gentamicin/clindamycin prophylaxis. Patients with readmission were less likely to have had vaginal preparation (56.9% vs 64.3%, p= 0.027). On multivariable logistic regression analysis, smoking history (OR 1.44, 95% CI 1.06-1.96, p= 0.0220) and hypertensive disease (OR 1.57, 95% CI 1.18-2.09, p 0.002) were associated with readmission. Cefazolin preoperative prophylaxis (OR 0.59, 95% CI 0.41-0.84, p= 0.004) and vaginal sterile preparation (OR 0.72, 95% CI 0.54- 0.95, p= 0.022) were associated with decreased risk of readmission. In class 3 obese patients, a history of smoking and a diagnosis of hypertensive disease associate with increased risk of postpartum readmission. Perioperative antibiotic prophylaxis with cefazolin along with vaginal sterile preparation associate with decreased risk of postpartum readmission.

Risk score model for predicting mortality among patients with lung cancer

BackgroundTo develop an accurate mortality risk predictive model among patients with lung cancer.MethodsThe development cohort included 96,255 patients with lung cancer aged ≥19 years, who underwent a Korean National Health Insurance Service health check-up from 2005 to 2015. The validation cohort consisted of 18,432 patients (≥19 years) with lung cancer from another region. The outcome was all-cause mortality between January 1, 2005, and December 31, 2020.ResultsApproximately 60.5% of the development cohort died within a median follow-up period of 2.32 (0.72–5.00) years. Risk score was highest in participants aged ≥65 years, followed by those who underwent treatment, had a history of emergency room visits, and were current smokers. Participants treated by surgery had the lowest risk score, followed by combined surgery and chemotherapy, combined surgery and radiation therapy, women, and regular exercisers. The C statistic in the development and validation cohorts was 0.78 (95% confidence interval, 0.77–0.78) and 0.81 (95% confidence interval, 0.78–0.84), respectively.ConclusionAdvanced age, lung cancer stage, and treatment type were strong risk factors of mortality in lung cancer patients, while being a woman and exercise were preventive factors. These will aid in the prediction of mortality and management of lung cancer patients.

Outcomes and Healthcare Resource Utilization in Patients with COVID-19 Treated with Nirmatrelvir-Ritonavir: Real-World Data Analysis.

Background: Nirmatrelvir-ritonavir was granted emergency use authorization in Israel in January 2022 to treat high-risk patients with mild-to-moderate COVID-19. The aim of the study was to assess the association between nirmatrelvir-ritonavir treatment and COVID-19-related hospitalization and healthcare resource utilization (HCRU) in a country with a high level of vaccinations compared to patients who were offered treatment and declined. Methods: The Maccabi Healthcare Services dataset was used to identify high-risk SARS-CoV-2-positive adults from January to February 2022 who received nirmatrelvir-ritonavir within 5 days of symptom onset (treatment group) or who were offered nirmatrelvir-ritonavir treatment and declined it (reference group). COVID-19-related hospitalizations and all-cause mortality and HCRU within 30 days were compared between treatment and reference groups using inverse probability of treatment weighting. Results: Treatment and reference groups included 3460 (median age, 68.4 years) and 1654 (70.2 years) patients, respectively. Patients with ≥1 dose of COVID-19 vaccine accounted for 89.5% (treatment group) and 72.1% (reference group) of the total. Treatment was associated with a lower risk of COVID-19-related hospitalization (adjusted OR, 0.59 [95% CI, 0.41,0.83]). Results were similar by age group (18-64/≥65 years) and among patients with/without vaccination in the prior 180 days. There were 11 (0.3%) versus 11 (0.7%) deaths in the treatment and reference groups, respectively. Treated patients had lower inpatient HCRU and greater less intensive outpatient HCRU (e.g., telemedicine and emergency room visits). Conclusions: Nirmatrelvir-ritonavir treatment was associated with a reduced risk of COVID-19-related hospitalization and a shift to less intensive outpatient HCRU. Comparison with a reference group of nirmatrelvir-ritonavir-eligible patients who declined treatment enabled an unbiased outcome assessment. Real-world data gathered during the Omicron BA.1 variant wave of COVID-19 in Israel support the continued use of nirmatrelvir-ritonavir for high-risk adults of all ages, regardless of previous vaccinations.

Post Artesunate Delayed Hemolysis in Pediatric Patients in the United States

Abstract Background Malaria continues to pose a major threat to global public health, causing millions of infections and hundreds of thousands of deaths each year. Intravenous artesunate is the current first line therapy for severe malaria and has substantially reduced its mortality. Some patients develop severe delayed hemolysis after artesunate therapy, a phenomenon termed post artesunate delayed hemolysis (PADH). A recent study of U.S. adults treated with artesunate found that 2.7% of patients experienced PADH and 56% of those patients required blood transfusion. Thus, the U.S. Food and Drug Administration recommends that patients treated with artesunate receive weekly post-treatment monitoring of hemoglobin and hemolytic markers for four weeks after therapy. While PADH in adults frequently requires blood transfusion, the frequency and severity of PADH in pediatric patients in non-endemic countries is not known. Understanding the risk of PADH in pediatric patients is essential to determine appropriate monitoring for this condition. Methods Multicenter Retrospective Chart Review To estimate rates of PADH in pediatric patients (0-18 years of age), we used ICD-10 diagnosis codes to identify patients treated for malaria at seven hospitals (The Children’s Hospital of Philadelphia, Riley Hospital for Children, Texas Children’s Hospital, Seattle Children’s Hospital, UCSF Benioff Children’s Hospital, NYU Langone Medical Center, and Bellevue Hospital), between April 2017 and July 2022. We reviewed post-discharge laboratory values and clinic visits to identify patients with laboratory findings of PADH and determine clinical outcomes. Pediatric Health Information System (PHIS) Database Review To estimate rates of severe PADH requiring repeat emergency room visit or hospitalization, we used ICD-10 diagnosis codes to identify patients who were treated for malaria with artesunate between January 2019 and July 2023 in a database of 49 children’s hospitals (PHIS). We reviewed patient visits within eight weeks of treatment to identify patients with repeat presentations related to anemia or hemolysis. Results In our retrospective chart review, four of seventeen patients (25%) treated with artesunate had laboratory evidence of PADH. None of these patients were symptomatic and none required readmission or medical intervention. Haptoglobin levels remained low in most patients up to four weeks after treatment, regardless of the presence of PADH, and lactate dehydrogenase (LDH) levels slowly declined over this period. We identified 92 patients in the PHIS database who were treated with artesunate. Of these, three patients (3.3%) had a repeat presentation within four weeks with one or more diagnosis suggestive of new onset anemia. Repeat presentations occurred 5-13 days after initial admission for malaria. Conclusion PADH is common in US pediatric patients treated with artesunate for severe malaria. However, severe hemolysis requiring repeat emergency room visit or readmission is rare. We find that haptoglobin and LDH levels were not useful as initial screening labs for PADH in pediatric patients. Together, our findings call into question the utility of weekly laboratory monitoring, as opposed to symptom-based monitoring, to identify pediatric patients at risk of readmission for PADH. Additional studies are necessary to determine which patients would benefit from weekly laboratory monitoring and which can be monitored clinically.

Inpatient zoledronic acid in older hip fracture patients is well tolerated and safe.

According to the 2022 Dutch 'Osteoporosis and fracture prevention' guideline, zoledronic acid (ZA) is the preferred osteoporosis treatment for hip fracture patients. Less than 25% of hip fracture patients visit the outpatient fracture liaison service, therefore inpatient administration of ZA during the hip fracture hospitalization is now recommended in patients > 75years. In the OLVG Hospital, inpatient administration of ZA during hospitalization for hip fracture in older patients has been standard of care since 2020. This single center retrospective observational follow-up study included hip fracture patients > 75years admitted to the orthogeriatric ward of the OLVG Hospital, and treated with 5mg of ZA intravenously on the day of hospital discharge between June 2020 and December 2022. Life expectancy estimated < 12months, creatinine clearance < 35ml/min, hypocalcemia, and high risk of osteonecrosis of the jaw were contra-indications. During three months of follow-up (FU) adverse events, emergency room visits, hospital readmissions, and death were recorded. In 161 consecutive hospitalized hip fracture patients (mean age 86 ± 6years, 65% female, 18% nursing home) ZA was administered and no adverse events were recorded. During 3months of FU, 8 patients (5%) visited the emergency room, 19 patients (12%) were re-admitted to the hospital, 3 with a new fracture (2 contralateral hip, 1 radius), and 17 patients (11%) died of reasons unrelated to ZA. This study shows that inpatient administration of zoledronic acid during hip fracture hospitalization is safe and feasible to prevent future fragility fractures in older hip fracture patients.

A prospective, observational, multi-center, post-marketing safety surveillance study of the GSK combined vaccine against diphtheria, tetanus, pertussis, poliomyelitis, and Haemophilus influenzae type b invasive infections (DTaP-IPV/Hib) in South Korean infants

ABSTRACT In South Korea, a combined vaccine against diphtheria, tetanus, pertussis, poliomyelitis, and Haemophilus influenzae type b invasive infections (DTaP-IPV/Hib) is available since 2018 for vaccination of infants from the age of 2 months. This prospective, observational, non-comparative, post-marketing study evaluated the real-world safety of DTaP-IPV/Hib primary vaccination in eligible South Korean infants from the age of 2 months between 2018 and 2022. Infants were followed up for 30 days after each vaccine dose to assess the proportion of infants experiencing any adverse event (AE), including adverse drug reactions (ADRs), unexpected AEs, and serious AEs/serious ADRs (SAEs/SADRs). Of 660 infants vaccinated during the study period, 646 were included in the total safety cohort. A total of 194 AEs were reported in 143 (22.1%) infants; 158 AEs occurred after the first dose in 130 (20.1%) infants, 21 after the second dose in 20 (13.4%) infants, and 11 after the third dose in ten (8.1%) infants. The most frequent AEs by Medical Dictionary for Regulatory Activities Preferred Terms terminology were pyrexia (13.3%), injection site swelling (5.1%), and irritability (1.7%). Most of the AEs were mild, resolved without a medical visit, and were classified as possibly related to vaccination. The incidence proportions of ADRs, unexpected AEs, and SAEs/SADRs were 19.4%, 4.3%, and 0.9%, respectively. All SAEs/SADRs resolved after hospitalization or emergency room visit, and one event was possibly related to vaccination. These results are in line with the approved label and other national/international studies, confirming the acceptable safety profile of DTaP-IPV/Hib in the South Korean pediatric population.

Self-reported Health Service Utilization and Barriers to Care Among US Adults with a History of Post COVID-19 Condition.

Millions of US adults continue to experience symptoms of post COVID-19 condition (PCC). More data on health service utilization patterns and barriers to care in this population are needed to understand how to care for people with PCC. To evaluate health service utilization and barriers to medical care among individuals with a history of PCC compared with other US adults. Data were analyzed from the 2022 National Health Interview Survey (NHIS), a nationally representative, cross-sectional survey of the US population. US adults. Health service utilization and the presence of financial and nonfinancial barriers to care in the preceding 12 months. There were 24,905 individuals included in the analysis, representing approximately 230 million US adults. The weighted prevalence of those with a history of PCC was 6.9% (95%CI, 6.5-7.3). Compared to other US adults, participants with a history of PCC were more likely to have had an urgent care visit (adjusted odds ratio (aOR) 1.52 [95%CI, 1.34-1.72]), emergency room visit (aOR 1.94 [95%CI 1.71-2.21]), hospitalization (aOR 1.48 [95%CI, 1.24-1.77]), rehabilitation services (aOR 1.35 [95%CI, 1.14-1.60]), home care (aOR 1.55 [95%CI, 1.66-2.26]), mental health counseling (aOR 1.39 [95%CI, 1.17-1.65]), and complementary and integrative medicine services (aOR 1.29 [95%CI, 1.13-1.49]). Furthermore, respondents with a history of PCC were more likely to report at least one financial barrier to care (aOR 1.71 [95%CI, 1.48-1.97]) and at least one nonfinancial barrier (aOR 1.77 [95%CI, 1.56-2.00]). A greater proportion of participants with a history of PCC reported a financial barrier and nonfinancial barrier than adults with most other chronic conditions captured by NHIS. Individuals with a history of PCC were more likely to use a variety of health services and report barriers to medical care. Health systems should consider developing accessible, multidisciplinary care pathways for this population.

Effect of frail phenotype on cardiorenal risk and healthcare utilization in older patients with chronic kidney disease.

Introduction Limited data have addressed frailty's role in cardiorenal risk among older adult patients with chronic kidney disease (CKD). We investigated whether frailty could predict major renal and cardiovascular events, healthcare utilization, and mortality in these patients. Methods We conducted a prospective cohort enrolling patients ≥ 75 years with a stable estimated glomerular filtration rate (eGFR) &lt; 60 mL/min/1.73 m2. Frailty phenotype consists of shrinking, low activity, exhaustion, weakness, and slowness, scored 0 to 5. The primary composite renal outcome was a ≥ 25 % decrease in eGFR concurrent with CKD stage progression or dialysis initiation. Secondary outcomes included major adverse cardiovascular events (MACE), emergency room (ER) visits, all-cause mortality, and hospitalization. Using multivariate Cox models with/without competing risk analyses, we explored frailty's impact on these outcomes. Results Among 203 older CKD patients (mean age 81.6 ± 5.0 years, female 40.9 %, diabetes 33.0 %, body mass index 24.9 ± 3.7 kg/m2), 67.9% were frail. Over 3.47 years, 38.9% faced composite renal outcomes, 13.3% MACE, 15.3% mortality, and more than half utilized healthcare. Every one-point frailty elevated composite renal outcome risk by 28.0 % (HR: 1.28, 95% CI:1.03-1.59) and significantly increased secondary outcomes (hospitalization [HR: 1.24, 95% CI: 1.06-1.46], unexpected ER visit [HR: 1.20, [95% CI:1.03-1.39], and mortality [HR: 1.51, 95% CI: 1.06-2.16]) but not for MACE [HR: 1.43, 95% CI: 0.99-2.08]. Results were consistent across subgroups and competing risk analysis. Conclusion In CKD patients ≥ 75 years, frailty was associated with progressive kidney disease, increased mortality and healthcare utilization.

7298 Hyperventilation Associated Hypophosphatemia, Hypocalcemia, Hypokalemia And Paralysis

Abstract Disclosure: S. Afreen: Research Investigator; Self; Tandem Diabetes Care, Yes. N. Afreen: None. Introduction: Hyperventilation is over-breathing in excess of the metabolic needs of the body, which can result in respiratory alkalosis and a wide range of electrolyte abnormalities. Case: A 38 year old male with a past history of hypertension, OSA and cholecystectomy reported having episodes of palpitations, tachypnea with respiratory rate as high as 80 breaths/ minute, associated with facial numbness and tingling, tetany, progressing to paralysis of his extremities. These episodes started 7 years ago but gradually became more frequent. He denied anxiety or stressors prior to these episodes. The episodes almost always result in emergency room visits. During one of these episodes he was found to have the following labs: ionized calcium-1 mmol/l, serum phosphorus- 0.8 mg/dl, serum potassium- 2.7 mmol/l, 1.25(OH)2D- 44pg/ml, alkaline phosphatase- 60 IU/l, glucose- 94 mg/dl and GFR- 90 ml/min/1.73m2. VBG during this episode: pH - 7.59, PCO2- 23 mm Hg, and bicarbonate - 22 mmol/l. Of note, the electrolytes are normal in between the episodes. Thyroid labs are normal. Off of phosphate supplementation for 3 days, in between episodes, his serum phos- 4.2mg/dl, cr - 0.84 mg/dl. Second morning urine phos - 84 mg/dl and urine cr - 206.81 mg/dl. Tubular phosphate reabsorption was 91.9%. He had negative Holter, nuclear stress testing and MRI of the brain. No mutations were identified on genetic analysis of CACNA15, KCNJ2, RYR1, SCN4A. During his recent endocrine clinic visit, on physical exam: height- 5 feet 11 inches, weight- 366 lbs weight, BMI- 51.1 kg/m2, BP- 129/89 mm Hg, heart rate- 81 bpm and respiratory rate- 18 breaths/minute. He did have one palpable 1.5 cm left thyroid nodule. Otherwise, the exam was unremarkable. The patient was referred to pulmonology to be evaluated for potential diaphragmatic and lung causes of his tachypnea. He was also referred to psychiatry for evaluation of underlying anxiety. Since these episodes of hyperventilation associated electrolyte abnormalities lead to paralysis, he was started on calcitriol 0.25mcg daily along with 1250 mg potassium phosphate daily. Discussion: Hyperventilation can lead to a respiratory alkalosis and corresponding increase in intracellular pH. High intracellular pH can lead to increased phosphofructokinase activity and glycolysis, resulting in increased intracellular phosphate shift. Acute respiratory alkalosis can also result in ionized calcium binding to albumin. Moreover, acute respiratory alkalosis results in reduction in hydrogen ion in the intracellular fluid with extracellular potassium ion shift into cells leading to hypokalemia.These electrolyte abnormalities can cause myopathies, cardiac arrhythmias, respiratory failure, paralysis, seizures, coma and death. Physicians should be aware of the possibility of electrolyte imbalance due to hyperventilation to prevent the development of life threatening complications. Presentation: 6/1/2024

7564 Adrenal Pheochromocytoma In A Clinically Inapparent Adrenal Mass

Abstract Disclosure: L. Medina Mora: None. S. Htoo: None. A. Sanchez Ruiz: None. M. Harshan: None. A. Busta: None. Introduction: Pheochromocytomas (PCC) are rare tumors that arise from the adrenal medulla, with an estimated annual incidence of 0.8 per 100,000 person-years. These tumors have been associated with significant morbidity and mortality and are considered among the most life-threatening endocrine diseases, particularly if left undiagnosed. Its symptoms can be related to the tumor's mass effect or catecholamine excess. As a result, they can mimic other conditions, often leading to delayed or incorrect diagnosis. A study conducted on 296 patients with PCC treated from 2005 to 2016 found that 61% were discovered incidentally through cross-sectional imaging (CSI). The widespread use of CSI in recent years has led to the identification of asymptomatic cases that would have otherwise gone undetected. In this case, we present a middle-aged female who was incidentally found to have a PCC. Case Report: A 59-year-old female with a history of hypertension, cerebrovascular accident, pulmonary hypertension, systolic heart failure, mitral valve replacement, and asthma presented to the clinic for evaluation of a right adrenal lesion measuring 4.2 x 3.5 cm found during an emergency room visit during the evaluation of chest pain. She had no known family history of brain or endocrine disorders. Her lab results showed elevated plasma metanephrine and normetanephrine to 578.4 (reference range: 0-88) and 459.9 (reference: 0-244), respectively. Additionally, her 24-hour urine metanephrine was elevated to 984 mcg (normal range: 36-209), and Chromogranin A was 164.3 (reference range: 0-101). The rest of her labs, including cortisol, renin, aldosterone, and DHEA-S were unremarkable. A CT with and without contrast revealed a 3.0 x 3.5 x 5.1 cm solid non-calcified right adrenal mass measuring 39 Hounsfield units (HU). In addition, it measured 53 HU in the venous phase and 61 HU in the 15-minute delayed phase (relative washout of &amp;lt;1%; absolute washout of &amp;lt;7%). The patient was treated with alpha-blockers and underwent a robotic-assisted right adrenalectomy. The pathology was significant for a 5.4 cm well-differentiated PCC. The tumor had extended into but not beyond the adrenal capsule. The postoperative course of the patient was uncomplicated. Discussion: After a PCC is detected, the most effective treatment option is to surgically remove it. This procedure necessitates a combination of alpha and beta-blockade to regulate blood pressure and prevent a hypertensive crisis. Despite the success of surgery, there is still uncertainty about the optimal follow-up after the procedure, which often leads to many patients being lost during the process. Furthermore, even a decade after the initial surgery, there remains a substantial likelihood of illness reoccurrence or metastasis, making the situation even more complex. Therefore, it is crucial to adhere to a lifelong follow-up plan that includes annual biochemical testing. Presentation: 6/2/2024

The economic burden of varicella among children in France: a caregiver survey.

A substantial economic burden is associated with pediatric varicella in France, primarily due to the productivity loss among caregivers. •Although varicella is considered a mild disease, it poses a significant burden on caregivers and society. Our study aimed to estimate the economic burden of varicella among children in France from family and societal perspectives to support policymakers in understanding the value of UVV in France. • We conducted an online survey of caregivers of 185 French children (≤17 years) diagnosed with varicella and collected data on varicella-related healthcare resource use, missed school days and workdays. Our study estimated annual societal burden of pediatric varicella in France. Out of 185 children with varicella, most (95.1%) had at least one outpatient visit, 10.3% had at least one emergency room visit, and 2.2% were hospitalized. 61.1% of parents with sick child, missed work and median productivity loss was 2.0 workdays. Additionally, 170 children who attended school or preschool missed a median of 5.0 school days. • The societal burden of pediatric varicella in France was estimated to be €450,427,578 (95% CI, €357,144,618 - €543,710,538), with indirect costs accounting for 85%. Pediatric varicella is associated with a substantial economic burden in France, primarily due to high productivity losses among parents and caregivers.

7618 Thyroid Nodules, Normal Thyroid Levels, and Chronic Anxiety: A Case for Sub-Clinical Toxic Multinodular Goiter

Abstract Disclosure: C.M. Barrera: None. Introduction: Chronic anxiety and panic disorders, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), are the most common psychiatric conditions. Hyperthyroidism is a known cause of both chronic anxiety and panic disorder. Case 1: A 36-year-old overweight Latin female is referred for evaluation of multiple thyroid nodules. The thyroid ultrasound was heterogeneous, with multiple bilateral nodules. In her history, the patient has chronic anxiety with panic attacks resulting in frequent emergency room visits. The TSH and T4 levels were TSH 0.59 mIU/L (0.40-4.5) and T4 10.7 mcg/dL (5.1-11.9). An I[1]23- Thyroid Scan showed a hot nodule with mild suppression and an uptake of 31.8% (The top limit is 35%). The patient started methimazole 2.5 mg daily, and after two months, her chronic anxiety and panic attacks resolved. Post-methimazole TSH rose to 1.18 mIU/L, and T4 10.0 mcg/dL and she has weaned off anxiety medications. Case 2: A 49-year-old overweight Latin female is referred for increased thyroid nodules. She complained of six months of tachycardia and anxiety. The TSH and T4 levels were TSH of 0.828 mIU/L (0.40-4.5) and T4 of 7.9 mcg/dl (4.5-12.0). An I[1]23-Thyroid Scan showed no dominant hot or cold nodules, with an uptake of 36.4% (The top limit is 35%, within normal error limits). She started methimazole 5 mg daily, resolving her tachycardia and anxiety within five weeks. Post-methimazole TSH was 1.64 mIU/L (0.45-4.5), and T4 6.7 mcg/dL (4.5-12.0). Case 3: A 60-year-old overweight Latin female is referred for evaluation of multiple thyroid nodules of ten years. She complained of chronic anxiety and panic attacks for two years. The TSH and T4 were normal at TSH 0.36 mIU/L (0.35- 5.50) and T4 9.7 mcg/dL (4.5-10.9). The thyroid ultrasound showed multiple bilateral nodules. An I[1]23-Thyroid Scan showed a suspected hot nodule without appreciable suppression and an uptake of 33% (The top limit is 35%). The patient started methimazole 5 mg daily. After eight weeks, she reported the resolution of most of her chronic anxiety with post-methimazole TSH 2.39 mIU/L and T4 7.1 mcg/dL (4.5-12.0). Discussion: The normal range of TSH, typically from 0.4-4.5 mIU/L, is calculated by measuring the TSH levels among a normal population. The group range then determines the laboratory reference range. This contrasts with individual values, which have a narrower range, suggesting that each person has a unique thyroid level. This suggests that TSH levels at the extremum, associated with hyperfunctioning nodules contributing to a rise in uptake, may not be normal for that patient and may explain the anxiety and other symptoms. Learning Points: Evolving multiple autonomous thyroid nodules lowers TSH levels while raising thyroid uptake. Symptoms of chronic anxiety and panic attacks can predate abnormal thyroid levels and resolve with low-dose methimazole. Presentation: 6/1/2024