Overtreatment Research Articles

Multimodal Migraine Management and the Pursuit of Migraine Freedom: A Narrative Review.

Migraine is a neurologic disease with a complex pathophysiology that can be controlled with current treatment options but not cured. Therefore, treatment expectations are highly variable. The concept of migraine freedom was recently introduced and can mean different things, with some, for example, expecting complete freedom from headache and associated symptoms and others accepting the occasional migraine attack if it does not impact functioning. Therefore, migraine management should be optimized so that patients can have the best opportunity to achieve their optimal treatment goals. With migraine freedom as a goal and, given the complex pathophysiology of migraine and the high incidence of comorbidities among individuals with migraine, treatment with a single modality may be insufficient, as it may not achieve migraine freedom in those with more frequent or disabling attacks. In this clinical perspective article, we have identified four key, partially overlapping principles of multimodal migraine treatment: (1) manage common comorbidities; (2) control modifiable risk factors for progression by addressing medication and caffeine overuse; (3) diagnose and treat secondary causes of headache, if present; and (4) individualize acute and preventive treatments to minimize pain, functional disability, and allodynia. There are many barriers to pursuing migraine freedom, and strategies to overcome them should be optimized. Migraine freedom should be an aspirational goal both at the individual attack level and for the disease overall. We believe that a comprehensive and multimodal approach that addresses all barriers people with migraine face could move patients closer to migraine freedom.

A Brief Review of Gepants.

Gepants are small molecules that antagonize calcitonin gene-related peptide (CGRP) receptors. Due to their favorable side effect profile and versatility in treating headaches acutely and preventively, gepants are preferred over triptans. We will cover the indications for the four FDA-approved gepants in adults: rimegepant, atogepant, ubrogepant, and zavegepant. This review will illustrate how gepants will continue to revolutionize the acute and preventive treatment of headaches. Gepants are now available in oral tablet, dissolving tablet, and intra-nasal spray formulations. Recent studies have shown promising utility in treating the pre-headache or prodromal phase. They have favorable tolerability, no evidence for association with medication overuse, and remain a safer alternative in those who have cerebrovascular risk factors. Additional research is needed to explore occurrence of Raynaud's phenomenon in participants treated with gepants, as it has been associated with CGRP monoclonal antibodies, but are not extensively studied in gepants. Gepants are expected to play a significant role in the next generation of migraine treatments.

Reliability of the Single-Arm and Double-Arm Jobe Test for the Diagnosis of Full-Thickness Supraspinatus Tendon Tear.

The Jobe test is commonly used to diagnose full-thickness (FT) supraspinatus (SSP) tendon tear. The original Jobe test used single-arm testing, although the double-arm Jobe test has also been used in clinical practice. To evaluate the reliability, accuracy, and diagnostic value of the single-arm and double-arm Jobe test for diagnosis of FT SSP tear. Cohort study (diagnosis); Level of evidence, 2. Patients with shoulder pain requiring magnetic resonance imaging (MRI) of the shoulder between March 1, 2021, and March 31, 2022, were enrolled. Each patient underwent both single-arm and double-arm Jobe tests by 2 orthopaedic surgeons independently, and the presence of pain, weakness, or both during the test was documented. Diagnosis of FT SSP tear on MRI scan was used as the gold standard to compare the diagnostic value of the Jobe test. The interrater reliability of the Jobe test, and the inter- and intrarater reliability of the MRI evaluation (patients with vs without FT SSP tear) was performed using the kappa (κ) coefficient. A total of 80 patients (57 females [71%]; mean age, 61.46 ± 9.61 years) were included. MRI scans revealed FT SSP tears in 32 (40%) of the patients. Both single- and double-arm Jobe tests had low diagnostic values (accuracy, 46.25% to 60%; sensitivity, 46.9% to 84.4%; specificity, 25% to 66.7%). The single-arm test with weakness revealed the highest sensitivity (84.4%). The double-arm test with weakness plus pain revealed the highest specificity (66.7%). Double-arm testing with pain had the highest accuracy (60%), with the highest positive likelihood ratio (1.5). The interrater reliability of the Jobe test indicated substantial agreement (double-arm vs single-arm, κ = 0.771 and 0.716, respectively, agreement 85%; P < .05). The interrater reliability of MRI scan evaluation of the FT SSP tear indicated substantial agreement (κ = 0.750, agreement 85%; P < .05), while the intrarater reliability indicated almost perfect agreement (κ = 0.917, agreement 96%; P < .05). The Jobe test, either single- or double-arm, had low accuracy and diagnostic value in diagnosing FT SSP tear. The concern with a single-arm examination for weakness is that it may be an inappropriate diagnostic test for ruling out FT SSP with 84% sensitivity, while a double-arm examination provides a higher specificity.

Effect of delivery mode on Chinese women’s maternal satisfaction: a moderated mediation model of support from medical staff and women’s self-assessment of health

Purpose In recent years, the Chinese government has implemented measures to address the rising rate of cesarean deliveries and promote vaginal births, with the aim of improving women’s childbirth experience. However, non-medically necessary cesarean sections and repeated cesarean sections remain prevalent. This study seeks to explore the correlation between mode of delivery and childbirth experiences. Additionally, it examines the moderating and mediating effects of support from medical staff and women’s self-assessment of health on maternal satisfaction across different delivery methods. Material and Method This cross-sectional survey was conducted with 140 Chinese mothers who were 1–10 days post-partum at three tertiary hospitals. The mothers were asked to fill out a socio-demographic data form and questionnaires related to women’s maternal satisfaction, mode of delivery, self-assessed health, and perception of medical staff support while they were in the hospital after delivery. The data from the questionnaires were analyzed and compared using SPSS 24.0 and PROCESS 3.2. Results This study discovered that the mode of delivery (vaginal birth or C-section) and the perception of support from medical staff significantly influenced maternal satisfaction (β = 0.82, t = 3.42; β = 0.82, t = 10.23). Specifically, women who had a vaginal birth reported higher levels of satisfaction compared to those who had a C-section. The study also found that the perception of medical staff support played a mediating role in this relationship, indicating its influence on women’s satisfaction (β = 0.78, t = 9.58; indirect effect = 0.43, Boot SE = 0.15; 95% CI= [.12–.73]). Furthermore, women’s self-assessed health acted as a moderator in the relationship between the mode of delivery and medical staff support (β = −0.53, t = −2.39; indirect effect = −0.41, Boot SE = 0.19; 95% CI= [–.80–.05]). Conclusion The childbirth experience of Chinese women is greatly influenced by factors such as vaginal birth, their perception of care support from medical staff, and their self-assessment of health. This highlights the importance of healthcare professionals providing women-centered maternity services and childbirth education, which can help reduce unnecessary medical intervention and the need for tertiary obstetric care.

Diagnosis of neurosyphilis in HIV-negative patients with syphilis: development, validation, and clinical utility of a suite of machine learning models

The ability to accurately identify the absolute risk of neurosyphilis diagnosis for patients with syphilis would allow preventative and therapeutic interventions to be delivered to patients at high-risk, sparing patients at low-risk from unnecessary care. We aimed to develop, validate, and evaluate the clinical utility of simplified clinical diagnostic models for neurosyphilis diagnosis in HIV-negative patients with syphilis. We searched PubMed, China National Knowledge Infrastructure and UpToDate for publications about neurosyphilis diagnostic guidelines in English or Chinese from database inception until March 15, 2023. We developed and validated machine learning models with a uniform set of predictors based on six authoritative diagnostic guidelines across four continents to predict neurosyphilis using routinely collected data from real-world clinical practice in China and the United States (through the Dermatology Hospital of Southern Medical University in Guangzhou [659 recruited between August 2012 and March 2022, treated as Development cohort], the Beijing Youan Hospital of Capital Medical University in Beijng [480 recruited between December 2013 and April 2021, treated as External cohort 1], the Zhongshan Hospital of Xiamen University in Xiamen [493 recruited between November 2005 and November 2021, treated as External cohort 2] from China, and University of Washington School of Medicine in Seattle [16 recruited between September 2002 and April 2014, treated as External cohort 3] from United States). We included all these patients with syphilis into our analysis, and no patients were further excluded. We trained eXtreme gradient boosting (XGBoost) models to predict the diagnostic outcome of neurosyphilis according to each diagnostic guideline in two scenarios, respectively. Model performance was measured through both internal and external validation in terms of discrimination and calibration, and clinical utility was evaluated using decision curve analysis. The final simplified clinical diagnostic models included neurological symptoms, cerebrospinal fluid (CSF) protein, CSF white blood cell, and CSF venereal disease research laboratory test/rapid plasma reagin. The models showed good calibration with rescaled Brier score of 0.99 (95% CI 0.98-1.00) and excellent discrimination (the minimum value of area under the receiver operating characteristic curve, 0.84; 95% CI 0.81-0.88) when externally validated. Decision curve analysis demonstrated that the models were useful across a range of neurosyphilis probability thresholds between 0.33 and 0.66 compared to the alternatives of managing all patients with syphilis as if they do or do not have neurosyphilis. The simplified clinical diagnostic models comprised of readily available data show good performance, are generalisable across clinical settings, and have clinical utility over a broad range of probability thresholds. The models with a uniform set of predictors can simplify the sophisticated clinical diagnosis of neurosyphilis, and guide decisions on delivery of neurosyphilis health-care, ultimately, support accurate diagnosis and necessary treatment. The Natural Science Foundation of China General Program, Health Appropriate Technology Promotion Project of Guangdong Medical Research Foundation, Department of Science and technology of Guangdong Province Xinjiang Rural Science and Technology（Special Commissioner）Project, Southern Medical University Clinical Research Nursery Garden Project, Beijing Municipal Administration of Hospitals Incubating Program.

Serologic Testing for Rocky Mountain Spotted Fever in a Low-Incidence Region.

Tick-borne diseases have grown in incidence over recent decades. As a result, diagnostic testing has become more common, often performed as broad antibody-based panels for multiple tick-transmitted pathogens. Rocky Mountain spotted fever (RMSF) is rare in our region yet may cause severe morbidity, leading to diagnostic screening in low-risk patients. We sought to describe trends in RMSF diagnostic testing, rate of IgG seropositivity, and clinical features of those tested. We performed a retrospective chart review of patients ≤21 years old undergoing testing for RMSF and/or with an ICD-9/10 code for RMSF. Patients were categorized by infection likelihood based on clinical and laboratory criteria adapted from Centers for Disease Control and Prevention's (CDC) case definition of spotted fever rickettsioses. Clinical data were collected and analyzed with descriptive statistics. One hundred and seventy patients were included. 5.8% met CDC criteria for rickettsial infection, 6.5% had an elevated IgG titer but lacked suggestive symptoms, and 87.6% had a negative IgG titer. Many patients tested were unlikely to have RMSF, including 50% lacking fever, 20% lacking any RMSF "classic triad" symptoms, 13% without acute illness, and 22% tested during months with low tick activity. Convalescent serology was performed in 7.6% of patients and none underwent Rickettsia rickettsii polymerase chain reaction (PCR) testing. Diagnostic testing was frequently performed in patients unlikely to have RMSF. We identified many opportunities for improving test utilization. Reserving testing for those with higher pretest probability, performing convalescent serology, and utilizing PCR may improve the accuracy of RMSF diagnosis and reduce clinical challenges stemming from inappropriate testing.

Impact of an Intervention to Reduce Bronchodilator Use in Bronchiolitis - A Time Series Analysis.

International guidelines recommend against the use of bronchodilators in bronchiolitis. Despite attempts to address low value care practices in pediatrics, the literature is still evolving regarding which interventions are most effective in low value care reduction. We aim to assess the impact of a multifaceted intervention on rates of bronchodilator prescription in bronchiolitis. With electronic medical record (EMR) data over a 76- month period, we evaluated changes in bronchodilator prescription among infants aged 1 to 12 months diagnosed with bronchiolitis, using interrupted time series analysis, controlling for preintervention prescribing trends. The setting was the emergency department of a large teaching pediatric hospital. The intervention included education, clinician audit-feedback, and an EMR alert, implemented February 2019. The main outcome measure was rate of bronchodilator prescription per month. There were 9576 infants, aged 1 to 12 months, diagnosed in the emergency department with bronchiolitis over the study period. Bronchodilator ordering reduced from 6.9% to 3.2% after the intervention. Once underlying trends were accounted for, the multifaceted intervention was associated with a reduction in the rate of prescribing (inter-rater reliability 0.98, 95% confidence interval 0.96 to 0.99, P = .037). We found that the multifaceted intervention, including an EMR alert, may be an effective method of reducing low value care prescribing in bronchiolitis, accelerating the reduction of unnecessary care and supporting sustainable change.

Pre-Hospital Emergency Medical Services Utilization Amid COVID-19 in 2020: Descriptive Study Based on Routinely Collected Dispatch Data in Bavaria, Germany.

The COVID-19 pandemic affected the utilization of health care services and posed organizational challenges. While many previous studies focused on the misuse of pre-hospital EMS for low-urgency health problems, the pandemic has put more emphasis on the avoidance of medically necessary calls. To compare the utilization of pre-hospital emergency medical services before and after specific pandemic periods. This was a retrospective, descriptive analysis of routine data from 26 dispatch centers in Bavaria, Germany. We investigated the number of emergencies per 100,000 population, as well as the relative change in the emergency rates and transport rates in 2020, compared to the two previous years. Boxplots showed the distributions across the Bavarian districts per calendar week. The mean rates and standard deviations as well as the relative changes were presented for the specific periods. A paired samples t-test was used to compare the rates. Compared to the average of the two previous years, the emergency rates in 2020 were lower in 35 out of 52 calendar weeks. The strongest reductions were observed during the first wave, where the average emergency rate declined by 12.9% (SD 6.8, p < 0.001). There was no statistically significant difference in the overall emergency rate during the summer holidays. Lower transport rates were observed throughout the year, especially during the first wave. Utilization of pre-hospital emergency medical services decreased in 2020, especially during the periods with strict measures. This could be due to the lower morbidity from the behavioral changes during the pandemic, but also to the avoidance of medical services for both less urgent and severe conditions. While a reduction in unnecessary care would be beneficial, patients must be encouraged to seek necessary urgent care, even during a pandemic.

The role of a photographic atlas in reducing unanticipated healthcare utilization following circumcision

Circumcision is a common procedure that can evoke caregiver anxiety in the postoperative period due to unfamiliarity with the healing process. To mitigate unnecessary healthcare utilization such as phone calls and unanticipated clinic or emergency department (ED) visits, photographic atlases have been developed to better prepare caregivers for the recovery process. The objective of our study is to further investigate the efficacy of a photographic atlas in its ability to decrease postoperative healthcare utilization using an increased sample size and extended study period compared to previous studies. In this study, we compared a prospective intervention cohort of patients undergoing circumcision at our institution who received a photographic atlas during postoperative teaching to a retrospective cohort of patients who had not received it. Our primary outcome was unanticipated healthcare utilization, defined as postoperative telephone calls and unanticipated presentations to the urology clinic or ED. The retrospective no-atlas cohort included 105 patients, and the prospective intervention atlas cohort included 80 patients. Both groups were similar with respect to age (p=0.47) and other demographics. There was no statistically significant difference in healthcare utilization between the no-atlas and atlas cohort. Specifically, we identified no difference in the number of phone calls to clinic staff (12 [11.4%] vs. 11 [13.8%], p=0.64) or unanticipated postoperative clinic or ED visits (2 [1.9%] vs. 4 [5.0%], p=0.41). The use of a photographic atlas as part of caregiver support for circumcision patients did not demonstrate a statistically significant reduction in either postoperative phone calls or clinic/ED visits. The decrease in absolute number of caregiver phone calls was minimal (12-11), with a small increase in follow-up presentations (2-4). The lack of significant change may be due to the already infrequent occurrence of these events following circumcision, as demonstrated by the no-atlas cohort. Other potential advantages of the atlas, such as improved caregiver confidence and satisfaction, may have been present, but were not measured in this study. Adding to the mixed results of previous studies, these findings do not support that photographic atlases decrease unanticipated healthcare utilization in children undergoing a circumcision. However, utilization was found to be low. Additionally, further studies are needed to determine other significant benefits of this form of education, such as improved caregiver confidence and satisfaction.

Distinguishing Keratoacanthoma from Well-Differentiated Cutaneous Squamous Cell Carcinoma Using Single-Cell Spatial Pathology

Keratoacanthoma (KA) is a common keratinocyte neoplasm that is regularly classified as a type of cutaneous squamous cell carcinoma (cSCC) despite demonstrating benign behavior. Differentiating KA from well-differentiated cSCC is difficult in many cases due to the substantial overlap of clinical and histological features. Currently, no reliable discriminating markers have been defined, and consequently, KAs are often treated similarly to cSCC, creating unnecessary surgical morbidity and healthcare costs. In this study, we used RNA sequencing to identify key differences in transcriptomes between KA and cSCC, which suggested divergent keratinocyte populations between each tumor. Imaging mass cytometry was then used to identify single-cell tissue characteristics, including cellular phenotype, frequency, topography, functional status, and interactions between KA and well-differentiated cSCC. We found that cSCC had significantly increased proportions of Ki67+ keratinocytes among tumor keratinocytes, which were dispersed significantly throughout non-basal keratinocyte communities. In cSCC, regulatory T-cells were more prevalent and held greater suppressive capacity. Furthermore, cSCC regulatory T-cells, tumor-associated macrophages, and fibroblasts had significant associations with Ki67+ keratinocytes as opposed to avoidances with KA, indicating a more immunosuppressive environment. Our data suggest that multicellular spatial features can serve as a foundation to enhance the histological discrimination of ambiguous KA and cSCC lesions.

Imaging features of peritoneal inclusion cysts

Abstract Peritoneal inclusion cysts (PICs) are well-known medical conditions typically observed in the female pelvis, with occasional occurrences in males. These cysts can present with diverse imaging characteristics, sometimes resembling other adnexal masses in the female pelvis. However, establishing a confident diagnosis of a PIC relies on the correlation between imaging findings and the patient’s medical history and clinical presentation. This review explores the underlying causes and various imaging features of PICs. It also discusses distinguishing them from other adnexal pathologies using different imaging techniques, as accurate diagnosis is crucial for ruling out malignancy and avoiding unnecessary medical interventions.

Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients

ObjectiveTo characterise the extent of unnecessary care in general surgery inpatients using a triple bottom line approach.DesignPatients with uncomplicated acute surgical conditions were retrospectively evaluated for unnecessary bloodwork according to...

Evaluation of tumour marker utilisation and impact of electronic gatekeeping in the province of KwaZulu-Natal, South Africa.

Inappropriate testing remains a high healthcare cost driver. Tumour marker tests are more expensive than routine chemistry testing. Implementing test demand management systems like electronic gatekeeping (EGK) has reportedly decreased test requests. This study aimed to describe the appropriateness of tumour marker tests, carcinoembryonic antigen, alpha foetal protein, prostate-specific antigen, carbohydrate antigen 19-9, cancer antigen 15-3, cancer antigen 125, and human chorionic gonadotropin, and determine the effectiveness of the EGK used in the public health sector in KwaZulu-Natal, South Africa. Tumour marker test data for the KwaZulu-Natal province were extracted from the National Health Laboratory Service Central Data Warehouse for 01 January 2017 - 30 June 2017 (pre-EGK) and 01 January 2018 - 30 June 2018 (post-EGK implementation). Questionnaires were sent to the clinicians in the regional hospitals ordering the most tumour marker tests to assess ordering practices. In addition, we assessed monthly rejection reports to determine the effect of the EGK. The EGK minimally reduced tumour marker requests or associated costs (1.4% average EGK rejection rate). An overall 18% increase in the tumour marker tests occurred in 2018. The data suggest inappropriate tumour marker test utilisation, particularly for screening. The introduction of EGK as a test demand management had little impact on tumour marker test requests and costs. Continuous education and reiteration of indications for tumour marker test use are required. This study demonstrates the ineffectiveness of EGK in tumour marker orders, and provides some insight as to why these markers are being ordered, which is important in trying to decrease inappropriate ordering of these tests.

Optimal symptom control in last days of terminally ill patients

Death is a biological imperative and inevitable. Adequate control of symptoms of a terminally ill patient is a challenging task for most end-of-life care professionals. The sole aim to provide comfort till the end of life with a holistic approach is necessary. In keeping with Liverpool Care Pathway as a guide, care of the terminally ill in their last days should be individualized from a more humanistic perspective. It should not be a ‘Tick Box Exercise’ and never a ‘One Size Fits All’ type. Once a ‘diagnosis of dying’ is made, spending on unnecessary medical interventions should be curtailed and natural death process should be allowed to continue. If available, it is always desirable to seek the opinion of specialist palliative care service team in the management of terminally ill patients. Shared decision making and open communications with all concerned are of paramount importance in end-of-life care. This mini review attempts to identify common physical symptoms and an appropriate intervention.

Sustainment of continuous pulse oximetry deimplementation: Analysis of Eliminating Monitor Overuse study data from six hospitals.

Using continuous pulse oximetry (cSpO2 ) to monitor children with bronchiolitis who are not receiving supplemental oxygen is a form of medical overuse. In this longitudinal analysis from the Eliminating Monitor Overuse (EMO) study, we aimed to assess changes in cSpO2 overuse before, during, and after intensive cSpO2 -deimplementation efforts in six hospitals. Monitoring data were collected during three phases: "P1" baseline, "P2" active deimplementation (all sites engaged in education and audit and feedback strategies), and "P3" sustainment (a new baseline measured after strategies were withdrawn). Two thousand and fifty-three observations were analyzed. We found that each hospital experienced reductions during active deimplementation (P2), with overall adjusted cSpO2 overuse decreasing from 53%, 95% confidence interval (CI): (49-57) to 22%, 95% CI: (19-25) between P1 and P2. However, following the withdrawal of deimplementation strategies, overuse rebounded in all six sites, with overall adjusted cSpO2 overuse increasing to 37%, 95% CI: (33-41) in P3.

The impact of headache disorders: a prospective analysis of headache referrals to outpatient and inpatient neurology and emergency services in an Irish University teaching hospital

BackgroundHeadache represents a significant proportion of disability globally in general practice, neurology outpatient settings, and emergency departments. There is scant literature regarding the impact of headache on healthcare services in Ireland.AimsWe aimed to investigate headache burden across the emergency department, inpatient stays, and neurology outpatient department referrals in an Irish University teaching hospital.MethodsWe prospectively collected data regarding emergency department presentations, inpatient neurology consultations, and neurology outpatient referrals for patients with headache between 13th January and 8th March 2020. Data were analyzed using descriptive statistics.ResultsThere were 180 emergency department attendances, 50 inpatient consultations, and 76 outpatient referrals with headache. Neurological examinations were often incomplete; neuroimaging was commonly employed. Migraine was the most frequent headache diagnosis at discharge in the emergency department and among inpatients after neurology review. Diagnostic uncertainty was identified—33% of patients left the emergency department with no diagnosis, and “unknown/unspecified headache” was recorded on 49% of outpatient referrals and 30% of inpatient consult requests. Medication overuse headache coexisted with migraine in nine patients in the inpatient group. Prophylaxis had been trialed in 56% of patients with migraine referred to outpatients.ConclusionsPrimary headache disorders have a large impact on hospital services. Diagnostic uncertainty is common; neuroimaging is relied upon. Appropriate care pathways, education, and resource allocation should be prioritized.

Managing Migraine: Medication Overuse Headache and Treatment with Eptinezumab.

Medication overuse headache (MOH) places both a physical and emotional burden on patients. MOH may occur as a consequence of a negative spiral of events comprising an increasing number of headache days while taking frequent or excessive amounts of medications for acute treatment of headaches or migraine. Despite acute and prophylactic treatment options, there remains a complex subset of patients who fail first-line oral prophylactic therapies due to insufficient response or failure to tolerate, and require access to new prophylactic treatment options, including calcitonin gene-related peptide (CGRP) inhibitors such as eptinezumab. In this article I present a series of clinical scenarios in which the use of eptinezumab may be beneficial, based on the extensive experience I have gained using the treatment, in more than 25 patients, (and over 40 infusions), over a 2-year period. Eptinezumab provides an additional therapeutic modality for patients who are refractory to other migraine medications, including other CGRP pathway monoclonal antibody (mAb) therapies. I discuss within this article the potential role for eptinezumab in various clinical scenarios such as refractory migraine, including MOH, in which the rapid bioavailability of the preparation may be of particular utility. It is important to tailor treatment plans to the individual patient needs and provide other lifestyle and non-drug-based recommendations when treating patients with MOH, who may be appropriate for treatment with eptinezumab.

Medication Overuse Headache, Chronic Migraine and Monoclonal Antibodies Anti-CGRP: A Real-World Study.

Medication overuse headache (MOH) in chronic migraineurs may be a cause or consequence of the overuse of symptomatic medications for headache attacks. It is highly prevalent in tertiary centers. We compared the efficacy of 3 anti-CGRP monoclonal antibodies with traditional pharmacological agents in patients with chronic migraine (CM) and MOH. A randomized, cross-sectional, prospective, and open trial with real-world comparison groups was carried out. The sample consisted of 100 consecutive patients having CM and MOH. Eighty-eight patients (65 women and 23 men) were included in the study and divided into 4 groups: those having used erenumab (19.3%), galcanezumab (29.6%), fremanezumab (25%) and conventional medications, and the control group (26.1%). Ages ranged from 18 to 78 years (mean, 44.1 ± 13.6 years). In the 6 months of follow-up, there was a significant reduction in the number of headache days in the 3 groups when compared with the control (P < 0.0001). The small number of patients included in each group and the open design do not allow definitive conclusions, but the use of anti-CGRP monoclonal antibodies in patients with CM and MOH may result in lessening the number of headache days when compared with conventional treatment with drugs.

713-P: The Concomitant Health Needs and Health Care Utilization Patterns of U.S. Women with Lifetime Criminal Legal Involvement and Diabetes, 2015–2019

Background: Over 100 million Americans have a history of criminal legal involvement (CLI), which is increasingly recognized as a risk for poor disease outcomes. Women with diabetes and CLI may have unique needs and utilization patterns, but this population has not been studied. Methods: Using nationally representative data, we examined a sample of respondents with lifetime CLI and self-reported diabetes. We compared rates by gender of physical conditions, mental health conditions, and substance use disorders using multivariate logistic regression considering relevant sociodemographic confounders. We then estimated the adjusted odds of outpatient, emergency department and inpatient hospitalization using similar models. Stata 16.1 was used. Results: In our sample of US adults with diabetes and CLI (N=2,742), 28% were women. Women were generally of lower socioeconomic status but more likely to have insurance. Compared to men, women reported higher rates of comorbid physical conditions, including having ≥2 conditions (aOR 1.5, 95% CI 1.2-1.9); higher rates of serious mental illness (aOR 2.5, 95% CI 1.8-3.6), any mental illness (aOR 2.1, 95% CI 1.6-2.6), and past year major depression (aOR 2.1, 95% CI 1.6-2.8). They were less likely to have a substance use disorder (aOR 0.7, 95% CI 0.5-0.9). Compared to men, women were more likely to use the emergency department (aOR 1.2, 95% CI 1.1-1.3) with a trend towards increased hospitalizations (aOR 1.2, 95% CI 0.9-1.5). They were also more likely to use outpatient care (aOR 2.1, 95% CI 1.3-3.5). Conclusions: Women with diabetes and CLI have higher rates of chronic disease and mental illness, but lower rates of substance use disorders, a pattern which is distinct. Additional research should consider if addressing the unique needs of this marginalized population could improve diabetes outcomes and decrease unnecessary acute care utilization. Disclosure L.Hawks: None. R.J.Walker: None. L.E.Egede: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1K23DK132505-01A1)

The incidence and factors of inappropriate rapid antigen test usage for group A streptococcus

IntroductionAlthough rapid antigen tests (RADTs) for group A streptococcus (GAS) can help diagnose group A streptococcal pharyngitis, little is known about the inappropriate use of these RADTs. MethodsThis retrospective observational study compared the appropriate vs. inappropriate use of RADTs in patients who had a RADT between January 2019 and August 2022. RADTs for patients with a low Centor score of 0–1 point were deemed inappropriate. ResultsOf the 1015 patients, 380 (37.4%) had inappropriate RADTs. Patients with asthma were associated with an increased risk of inappropriate testing. In contrast, during the coronavirus 2019 pandemic, outpatients and residents were associated with a reduced risk of inappropriate testing. Consequent to the inappropriate use of RADTs, 162 (16.0%) patients received potentially inappropriate antibiotics. ConclusionsOur results suggest that diagnostic stewardship for pharyngitis, including education for healthcare workers, is needed to reduce inappropriate test ordering and prevent unnecessary care.