Medical Regiment Research Articles

Image testing based on biomedical drug loading in cardiovascular drug care simulation for coronary heart disease

Coronary heart disease is a common cardiovascular disease, and its therapeutic effect is affected by the distribution and absorption of drugs in the body. Biomedical drug-carrying image testing technology can provide a quantitative assessment of drug distribution and absorption in the body. This study aims to explore the application of biomedical drug-carrying image testing technology in the simulation of cardiovascular drug care in coronary heart disease, so as to provide reference for the optimization of drug treatment plan and individualized treatment. The study collected clinical data and medication regiments of patients with coronary heart disease. Then, the imaging examination of patients was carried out by selecting appropriate drug loading markers using the biomedical drug loading image examination technology. Then quantitative analysis was used to process the image data to quantitatively evaluate the distribution and absorption of drugs in the cardiovascular system. The quantitative data of drug distribution and absorption in patients with coronary heart disease have been obtained successfully by means of biomedical imaging. These data reveal the dynamic changes of drugs in the cardiovascular system, and help doctors optimize drug therapy, improve treatment effectiveness, and achieve personalized treatment.

Suicide, Stimulants, and Selective Serotonin Reuptake Inhibitors: A Retrospective Chart Review.

Background: Previous studies suggest that selective serotonin reuptake inhibitors (SSRIs) may increase the risk of suicide among children and youth, although the association between suicide risk and the combination of SSRIs with other medication such as stimulants in this population remains unclear. This study explored whether the combination of SSRIs with stimulants influenced suicide risk. Methods: A retrospective cohort study was conducted at a single children's hospital campus-based ambulatory psychiatric clinic between September 1, 2017, and September 30, 2020. Subjects were 6-21 years of age and prescribed either stimulants or stimulants and SSRIs only. The primary outcome was suicidal thoughts and behaviors (STB), defined by documented suicidal thoughts, plans, or behaviors. Firth logistic regression evaluated associations between medication class and STB. Results: Among 349 patients, the prevalence of STB was 5.7% (n = 20). In unadjusted model, patients prescribed SSRIs and stimulants had a 2.9-fold increase of STB compared to patients prescribed stimulants only, along with increasing age, male sex, and the diagnoses of anxiety and/or depression. In the final model adjusted for each of these factors, the observed association of medication regiment with STB was attenuated (odds ratio [OR]: 1.3, confidence interval [CI]: 0.3-4.9, p = 0.7). The magnitude of the adjusted association between depressive diagnosis and STB was notable (OR: 3.6, CI: 1.0-12.6, p = 0.049). Conclusions: Among patients followed in a children's hospital-based ambulatory psychiatric clinic, a combination medication regimen of SSRIs and stimulants after adjusting for genetic sex, age, anxiety diagnosis, and depression diagnosis, the observed association between STB and combination stimulant and SSRI treatment was attenuated. This finding suggests that other factors, including depression, may have contributed to the association between SSRI treatment and STB. Larger, prospective studies of the relationship between combination pharmacotherapy and suicide risk are warranted to guide clinical/pharmacological decision making and to better clarify these relationships.

A Trial of Adding Lung Protective Strategies to Existing Enhanced Recovery After Surgery Protocols and Its Effect on Improving Postoperative Lung Function.

With this rising popularization of enhanced recovery after surgery (ERAS) protocols, it is important to ask if the current and developing pathways are fully comprehensive for the patient's perioperative experience. Many current pathways discuss aspects of care including fluid management, pain management, and anti-emetic medication regiments, but few delineate recommendations for lung protective strategies. The hypothesis was that intraoperative lung protective strategies would results in improved postoperative lung function. One hundred patients at the Medical University of South Carolina undergoing hepatobiliary and colorectal surgeries were randomized to receive intraoperative lung protective techniques or a standard intraoperative ventilation management. Three maximum vital capacity breaths were recorded preoperatively, and postoperatively 30 min, 1 h, and 2 h after anesthesia stop time. Average maximum capacity breaths from all four data collection interactions were analyzed between both study and control cohorts. There was no significant difference in the preoperative inspiratory capacity between the control and the ERAS group (2,043.3 ± 628.4 mL vs. 2,012.2 ± 895.2 mL; P = 0.84). Additional data analysis showed no statistically significant difference between ERAS and control groups: total average of the inspiratory capacity volumes (1,253.5 ± 593.7 mL vs. 1,390.4 ± 964.9 mL; P = 0.47), preoperative oxygen saturation (97.76±2.3% vs. 98.04±1.7%; P = 0.50), the postoperative oxygen saturation (98.51±1.4% vs. 96.83±14.2%; P = 0.40), and change in inspiratory capacity (95% confidence interval (CI) (-211.2 - 366.6); P = 0.60). No statistically significant difference in postoperative inspiratory capacities were seen after the implementation of intraoperative lung protective strategies. The addition of other indicators of postoperative lung function like pneumonia incidence or length of inpatient stay while receiving oxygen treatment could provide a fuller picture in future studies, but a higher power will be needed.

Managing atrial fibrillation: The intersection of cardiology, health psychology, and the patient experience.

Atrial fibrillation (AF) is the most common cardiac dysrhythmia and is an accelerating public health challenge. Challenges related to detection, management, and prevention of disability and dysfunction secondary to AF are increasingly apparent. The subspecialty of cardiology, cardiac electrophysiology, is primarily tasked with the treatment of AF. Patients with AF are often ambushed by the condition with approximately 28% to 38% of patients experiencing significant anxiety or depressive symptoms. Behavioral risk reduction can be targeted by achieving and maintaining a healthy BMI, abstaining from smoking, avoiding alcohol consumption, and sustaining regular physical activity. AF patients are also tasked with considering possible treatment options, adhering to medication regiments & lifestyle changes, utilizing wearable technologies, and managing emotional distress, to minimize health risks and optimize quality of life. Major medical organizations have called for integrated, multidisciplinary management as the treatment of choice for AF patients. Health psychologists bring valuable expertise but are not uniformly involved in the care of AF patients. The purposes of this article are to (a) review the existing research on the medical, psychological, and behavioral aspects of contemporary management of AF, (b) highlight the intersections between cardiac electrophysiology and clinical health psychology in managing AF, and (c) call for more health psychologists in this specialized area of cardiac electrophysiology. This opportunity for health psychologists may challenge the profession to further specialize as "cardiac psychologists" and mirror our medical colleagues. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A multi-class drug and metabolite screen of 231 analytes by LC-MS/MS

The use of pain management drugs has been steadily increasing. As a result, labs are seeing an increase in patient samples that must be screened for a wide variety of drugs to prevent drug abuse and to ensure patient safety and adherence to their medication regiment. Therapeutic drug monitoring can be challenging due to the low cut-off levels, potential matrix interferences and isobaric drug compounds. To address these challenges, many drug testing facilities are turning to liquid chromatography coupled with mass spectrometry (LC-MS/MS) for its increased speed, sensitivity, and specificity. In this example, a method was developed for a multi-class drug and metabolite screen containing 231 compounds. There are many challenges one must consider when developing a large screening assay. Experiments performed included mobile phase considerations, sample diluent, isomer resolution, drug interferences, and instrumentation capabilities. Analytes were diluted in water and injected into a Shimadzu Nexera UHPLC equipped with an AB SCIEX API 4500™ MS/MS. Detection was performed using electrospray ionization in positive and negative ion modes using scheduled multiple reaction monitoring (MRM). During mobile phase investigations, it was found that methanol provided the best retention of early eluting analytes, such as morphine, oxymorphone, nicotine and norcotinine. Sample diluent was optimized to improve the peak shape of the early eluting compounds. Scan rates and retention time windows were optimized to ensure enough data points per peak were collected. 231 compounds with a final optimized separation gradient run time of 10 minutes, with a total cycle time of 12 minutes.

A new day, a new treatment. A case report

IntroductionWe present the case of a 21 year-old male, with history of a psychotic episode, currently with monthly follow-up in an outpatient facility, with a favorable clinical evolution after one year of intensive follow-up. In the context of abandonment of his medication and a problematic family situation, the patient starts to show suspicious, with insomnia and a progressive social isolation. Despite an attempt of ambulatory treatment with oral aripiprazole, showing good tolerance, the patient refuses such treatment, showing active clinical psychotic with great distress and behavioral repercussion, finally requiring hospital admission.ObjectivesTo perform a literature review about the treatment initiation with two vials of aripiprazole long-acting injection.MethodsLiterature review of scientific articles using Pubmed as search engine. We considered articles published both in English and Spanish.ResultsDuring hospital stay, treatment with 2 intramuscular injections of 400mg of aripiprazole is started, combined with a single dose of oral aripiprazole 20mg on day 1, assuring correct dosing, with good tolerance and favoring therapeutic adherence. Progressively, the patient starts to feel calmer, adequate, collaborative and emotionally stable, recuperating chronobiological rhythms, with remission of the hallucinations and appearing more distant from delusions.ConclusionsAccording to the currently available studies, the use of this posology could avoid the potential impact that lack of adherence to oral treatment could have in the therapeutic outcome, assuring a correct dosing and favoring adherence from day 1. Furthermore, this would help simplify the medication regiment for patients, physicians and caregivers.DisclosureNo significant relationships.

Acute Pain Management for a Tibial Plateau Fracture Shortly After a Buprenorphine XR Depot Injection: A Case Report

Acute pain management of patients on buprenorphine for opioid use disorder remains a challenge. The buprenorphine extended-release depot injection which lasts for 1 month and has a higher plasma concentration of buprenorphine compared to the sublingual formulation is increasingly being used in patients. Acute pain management of patients on buprenorphine depot remains a challenge because waiting for the washout of the medication is not feasible and discontinuation is challenging because it requires surgical excision. We describe here the pharmacokinetics of the buprenorphine depot formulation and the clinical implications of its long duration of action. A 39-year-old woman with a history of alcohol and opioid use disorder, on buprenorphine depot, was admitted to the hospital with a left tibial plateau fracture. Acute pain service managed her pain by utilizing a multimodal analgesia plan including femoral and popliteal nerve catheters, intravenous patient-controlled analgesia and oral opioid and nonopioid medications. The patient had a prolonged length of stay of 11 days but was successfully weaned off nerve catheters and intravenous medications and converted to an oral medication regiment such that she could be discharged from the acute care hospital.

P676 Burden of depression and anxiety among inflammatory bowel disease patients in a national cohort in Israel – Data from the EPI-IIRN

Abstract Background Depression and anxiety in inflammatory bowel disease (IBD) patients have been receiving much deserved attention in recent years, as consecutive studies demonstrated that these emotional disorders are both common and detrimental for IBD patients. The aim of the current study was to examine the prevalence of depression and anxiety in a national cohort of IBD patients in Israel. Methods The epi-IIRN is a validated cohort of all IBD patients in Israel, ensured in four health maintenance organizations (HMOs). In this historical cohort study we included data from three HMOs, encompassing ~85% of Israeli population, between December 1997 [TD1] [UM2] and December 2019. Data included demographic data (age, sex and socioeconomic status), medical data (diagnosis type, time of diagnosis, medical regiments) and mental health status (a diagnosis of depression / anxiety defined by the relevant ICD9 codes or use of antidepressants / anxiolytics for at least two year quarters). For each IBD patient identified, three non-IBD subjects were allocated. Patients younger than 18 years or with a diagnosis of depression / anxiety preceding the diagnosis of IBD were excluded. Using cox regression and Kaplan Meier survival curve, we evaluated the prevalence of comorbid depression / anxiety at 5, 10 and 15 years following the diagnosis of an IBD. Results A total of 31340 IBD patients (48.1% females, mean age at diagnosis 38.6±15.9) and 91535 controls (48.7% females, mean age 39.9±16.1) were identified. The risk of depression / anxiety comorbidity was higher in IBD patients in comparison to controls at all evaluated timepoints: At 5 years following a diagnosis of IBD the hazard risk ratio (HR) was 1.48 (95% CI 1.43 – 1.53, p < 0.001, 15.5% vs 10.6%,); at 10 years HR was 1.38 (95% CI 1.34 – 1.42, p < 0.001, 22.9% vs. 17.0%) and at 15 years 1.37 (95% CI 1.33 – 1.40, p < 0.001, 27.5% vs 21.0%). For all analyses, female gender was a risk factor for development of depression/anxiety (HR~1.5, p < 0.001). IBD type (Crohn’s disease / ulcerative colitis) was not significantly associated with the risk of comorbid depression / anxiety. Conclusion Our national study highlights the substantial burden of depression and anxiety in IBD patients that is persistent for up to 15 years after diagnosis. Our findings emphasize the need to monitor for potential symptoms of depression and anxiety among our patients, as well as the need for prompt intervention and follow-up by a mental health care provider when such symptoms are identified.

Opiate vs non-opiate prescription medication for pain control after endoscopic sinus surgery for chronic rhinosinusitis

PurposeResearch indicates that most providers give opiates after endoscopic sinonasal surgery. The effectiveness of non-opiate medications after sinonasal surgery is poorly understood and most studies do not assess medication failure. This study compares oral opiate, oral opiate and topical steroid, and oral non-opiate pain control. Patient call-backs are used as a proxy for pain medication failure. Materials and methodsThis study compares three medication regiments after sinonasal surgery for 180 adults with chronic rhinosinusitis. Patients were instructed to take acetaminophen for mild pain. For moderate/severe pain, patients used: 1) oxycodone-acetaminophen, 2) oxycodone-acetaminophen + budesonide nasal rinses, or 3) meloxicam + acetaminophen. Patients were instructed to call clinic if pain was not controlled. Descriptive statistics compared cohorts. Chi-square tests compared call-backs between cohorts. Logistic regression adjusted for baseline differences in covariates, comorbidities, and operative sites. ResultsCohorts had similar age, sex distribution, disease features, and extent of surgery. The meloxicam cohort had less subjects with pain disorders. The oxycodone cohort had less subjects with diabetes, septoplasty, and turbinate reduction. After adjusting for baseline differences and using oxycodone as the reference group (n = 50), the odds of calling clinic for poorly controlled pain was 0.18 (95% Confidence Interval (CI): 0.05–0.6) in the meloxicam cohort (n = 45) and 0.19 (95% CI:0.07–0.5) in the oxycodone + budesonide rinses cohort (n = 85). ConclusionIn this study, both meloxicam and oxycodone + budesonide rinses were more effective at controlling pain after sinonasal surgery than oxycodone alone.

Multidisciplinary team led by internists improves diabetic foot ulceration outcomes a before-after retrospective study

Study objectiveDiabetic foot ulceration (DFU) is associated with high mortality and morbidity. A multidisciplinary approach has been suggested, but as these patients usually present with various comorbidities, leadership of a multidisciplinary team by internists was initiated. Our aim was to evaluate the impact of the leadership of the multidisciplinary team by internists on the outcomes of patients with DFU. MethodsOutcomes of patients with salvable DFU admitted pre and post introduction of the multidisciplinary team were compared, i.e., a major amputation (above or below the knee), blood stream infection, major medical complications, 30 day mortality, vascular interventions, diabetes control, medication regiments and laboratory results. ResultsThe cohort included 315 patients, 207 - multidisciplinary pre-period and 108 - multidisciplinary period. During the multidisciplinary period, the rates of major amputations, blood stream infections were found significantly lower than the pre-multidisciplinary period (10% vs. 14%; p = 0.01 and 2% vs. 13%, p = 0.04, respectively). The 30 day mortality rates tended to be lower (5% vs. 11%, p = 0.08). Vascular interventions increased significantly (18% vs. 1%, p<0.01). The diabetes control significantly improved (median glucose levels 163 vs. 185 mg/dl, p = 0.03). Treatment consisting of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, statins) were updated and laboratory results at discharge (albumin, CRP) showed improved disease control. ConclusionThe treatment of hospitalized DFU patients by a multidisciplinary team led by internists using a holistic therapeutic approach demonstrated improved clinical outcomes.

Potent protective effects of polysaccharide peptide on vascular endothelium and cardiac remodelling in post myocardial infarction patients: A prospective double-blind randomized controlled trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Indonesia"s Ministry of Research and Technology/National Research and Innovation Agency grants Background Inflammation and oxidative stress contribute to endothelial dysfunction leading to progression of atherosclerosis and myocardial infarction (MI). Purpose To evaluate the effect of polysaccharide peptide of Ganoderma lucidum mycelium extracts (β-1,3/1,6-D-Glucan) as protective vascular endothelium and cardiac reverse remodelling in post MI. Methods This is a prospective, randomized double-blind clinical trial in 45 post MI patients. Treated group (TG) was given 3 divided dose of 540 mg β-1,3/1,6-D-Glucan daily for 90 days, and control group (CG) received placebo. Variable measured were EPC,CEC,IL-1,IL-6,TNF-α,hsCRP,NO,SOD,MDA and echocardiography parameters. Results β-1,3/1,6-D-Glucan administration significantly increased EPCs (P = 0.000), but not significantly reduced CECs (P = 0.069). Significant suppression was found in IL-1, IL-6 and TNF-α (all P &amp;lt; 0.05), but not in hsCRP (P = 0.064). TG exhibited significant elevation of NO (P = 0.02) and SOD (P = 0.023), and reduction of MDA (P = 0.001). TG revealed significant improvement of LVEF, LVMI, LVIDd, RWT, RWMA and LV diastolic dysfunction (all P &amp;lt; 0.05); but not in FS and TAPSE (P = 0.24, P = 0.20; respectively). Conclusions Polysaccharide peptide exhibits potent protective vascular endothelium and cardiac reverse remodelling in post MI patients, hence promising as add-on medication on top of standard medical regiment. Result comparison between study groupsVariableMeanPretestMean Difference Post-testP valuePolysaccharide peptide (β-1,3/1,6-D-Glucan)PlaceboVascular Endothelium BiomarkersCECsEPCs87.99 ± 76.7398.32 ± 44.52-48.01 ± 64.0714.90 ± 24.05-13.84 ± 58.67-17.65 ± 27.870.0690.000Oxidative Stress MarkersSODMDANitric Oxide2.93 ± 0.5419.68 ± 9.9737.98 ± 14.440.26 ± 0.74-5.52 ± 10.756.04 ± 9.27-0.23 ± 0.685.75 ± 10.29-0.62 ± 3.300.0230.0010.02Proinflammatory BiomarkershsCRPTNF-αIL-1IL-62512.90 ± 1332.11348.58 ± 85.0392.14 ± 29.62259.40 ± 125.52-6.78 ± 1099.60-44.98 ± 100.94-15.77 ± 27.06-29.63 ± 104.30-1.42 ± 795.35-1.34 ± 104.893.42 ± 33.1475.77 ± 130.830.0640.0060.0420.005Echocardiographic ParametersLVEFFSLVMITAPSELVIDdRWT57.20 ± 11.3930.85 ± 7.07114.07 ± 59.612.14 ± 0.354.86 ± 0.820.54 ± 0.352.30 ± 9.770.73 ± 7.59-4.55 ± 14.460.99 ± 0.49-0.49 ± 0.45-0.14 ± 0.29-2.08 ± 3.353.74 ± 9.2711.48 ± 23.94-0.17 ± 0.340.23 ± 0.430.03 ± 0.040.0080.2480.0430.2020.0000.017Abstract Figure. Comparison among pre- and post-treatment

The Royal Army Dental Corps today.

The Royal Army Dental Corps (RADC) provides dental care to the British Army both in barracks and on deployment While a significant proportion of most RADC dental officers' careers is spent working in permanent military primary care dental clinics, it is the ability of all RADC dental officers to provide dental care when deployed that provides unique challenges only seen in the military environment. All RADC dental officers are able to deliver high quality care in temporary facilities. During a career the majority of RADC dental officers will have at least one job in a medical regiment providing the dental component of the British Army's rapidly deployable medical capability. This article covers some of the issues faced when delivering dental care outside the UK using portable equipment on a recent exercise.As RADC officers gain experience they are expected to lead increasingly large teams, both within primary care dentistry and some in the wider Army Medical Services, with the appropriate professional and military training to support their development.Working under pressure can be developed through the use of adventurous training and sport and the authors have pushed themselves well beyond their comfort zones in the air, on land and under the sea.

Construction and Validation of Claims‐Based Medication Regimen Complexity Index

Research ObjectivePopulation health management programs often use administrative claims to measure medication refills (eg, medication possession ratio); however, claims‐based indexes lack measuring medication complexity and adherence together.Medication Regimen Complexity Index (MRCI) is a validated measure of medication complexity and adherence levels and has been originally developed using nonclaims data sources. A claims‐based version of MRCI is lacking.This study aimed to create and validate a claims‐based version of MRCI (ie, cMRCI).Study DesignRetrospective cross‐sectional analysis of administrative claims data (QuintileIMS).MRCI consists of components A, B, and C, but the input for component C was unavailable in claims. For each pharmacy record, we used the route and dose information to calculate component A while the quantity and days of supply to calculate component B. We then computed an individual’s 2014 cMRCI by aggregating components A and B associated with an individual’s entire pharmacy records in 2014. We also assigned an individual to one of three medication complexity levels based on the tertiles of cMRCI among enrollees with the same number of active ingredients.We evaluated the impact of adding two types of cMRCI (continuous or categorical) to three baseline models in explaining health care costs and utilization: (1) demographics only, (2) demographics plus the count of active ingredients, and (3) demographics, the count of active ingredients, and a JHU‐ACG‐based morbidity measure. We adopted generalized linear models with a log link and gamma distribution for costs (total, pharmacy, and medical costs) and logistic regression for binary utilization markers (any hospitalization, any 30‐day readmission, and any ER visit). Both costs and utilization variables were derived from the concurrent (2014) and prospective (2015) year. We reported adjusted cost ratios for costs and adjusted odds ratio for utilization.Population StudiedWe included 1,541,873 eligible enrollees aged 1 to 63 with continuous medical and pharmacy enrollment in 2014 and 2015. Older adults (65+) were excluded due to missing Medicare claims.Principal FindingsStudy subjects were 47.1% male with mean age of 42.6 years.Across all models and costs, a higher cMRCI was statistically significantly associated with higher costs both concurrently and prospectively, with the exception in concurrent total costs; such increases were the highest for pharmacy costs.Alternatively, compared to those with low cMRCI level, enrollees with high or medium cMRCI level consistently had higher costs across all models and costs.As for utilization, a higher cMRCI was statistically significantly associated with higher odds of prospective utilization but not concurrently; compared to those with low cMRCI level, enrollees with high or medium level generally had higher odds of utilization across all models, with the exception in high vs. low comparison of the concurrent utilization from the most complex model.ConclusionscMRCI is a valid measure of medication complexity given its associations with health care costs and utilization. Categorical cMRCI may be a better format to be used than continuous cMRCI.Implications for Policy or PracticePopulation health analytics using insurance claims data lack a mixed medication complexity and adherence measure. cMRCI can be used as a claims‐based medication regiment complexity index, to measure adherence and improve utilization prediction.

SUN-114 Successful Long-Term Medical Management of Insulinomas

Background: Insulinomas are usually benign, solitary tumors. Surgical resection is the treatment of choice and only method of cure. Surgical cure is not possible with unresectable metastatic disease, unlocalizable disease, or contraindications to surgery. Long-term medical management may be required. Clinical Cases: Patient 1: A 57-year-old female was diagnosed at age 42 when imaging confirmed a 2.4cm insulinoma in the pancreatic tail and two lesions in the right hepatic lobe. She underwent distal pancreatectomy with splenectomy, and hepatic wedge resection. Follow-up imaging showed two new hepatic lesions. She underwent chemoembolization with resolution of her symptoms. By age 48, her symptoms returned. Imaging showed new lesions in the liver, not amenable to embolization. She was placed on Octreotide 20mg IM monthly and her symptoms resolved soon after initiation of therapy. She has since had an unremarkable clinical course. Additional therapies have been deferred as follow-up imaging has not shown disease progression. Patient 2: A 48-year-old female was diagnosed at age 37. CT and MRI did not find a source. A DOPA-PET showed increased uptake in head and tail of the pancreas. An 8-hour ex-laparotomy with EUS and palpation of the pancreas did not localize a mass. A second surgery, with 75% removal of the distal pancreas, including the tail and body, did not relieve her symptoms. She had unsuccessful trials of verapamil, verapamil with low-dose diazoxide, and octreotide. She started diazoxide 300mg daily, but had fluid retention and tachycardia. Her dose was decreased to 200mg daily and HCTZ 25mg daily was started. Due to persistent symptoms, prednisone was started at 5mg in the morning and 2.5mg in the afternoon, which gave symptom relief. At her request it was decreased to 5mg daily. By age 42 she had self-decreased it to 2.5 mg daily, but continued her other meds. She endorsed the return of symptoms, but felt she could manage them without increasing her dose. At age 44, as part of a clinical trial, an MRI and nuclear medicine study showed a 9mm lesion in the head of the pancreas. Another exploratory surgery did not find a lesion. Currently, she is on the same medication regiment with strict diet and frequent meals. She endorses only rare hypoglycemic episodes. Conclusion: The patients have been managed with medical therapy for 15 and 11 years respectively. Long-term survival data of patients with metastatic insulinoma indicates that prolonged survival is unlikely; however, most data is from the 1990s or earlier. It does not incorporate new medical treatments, or advancements in technology and the field of medicine. Patients who are not candidates for surgical cure, may have better survival rates and undergo longer courses of medical management. Additionally, while oral prednisone is not standard therapy for insulinoma, there are cases of its use to control hypoglycemia when other treatments are exhausted.

Decisions for Medication Nonadherence: Stories from Older Adults with Heart Failure

Background More than half of all heart failure (HF) patients do not take medications as prescribed, resulting in substantial negative health outcomes. Research has shown that medication adherence may be more a consequence of individual decisions rather than the ability to follow prescribed regimens, yet very little is known about decision-making regarding nonadherence to medications for HF. Purpose The purpose of this study was to gain understanding and insight into older adults' decision-making experiences and perceptions in choosing to take or not take medications for HF in the community setting. Methods Using a narrative inquiry approach, the personal narratives of eleven adults aged 65 and older who took at least two daily medications for HF were gathered using in-depth, semi-structured interviews. The data in this study were organized and analyzed using Riessman's framework for narrative analysis. Results This study suggests that medication nonadherence in older adults with HF is primarily attributed to intentional decisions, based on personal values, to deviate from the prescribed regimen. When study participants felt that the effects of a medication interfered with their lifestyles, they coped by individualizing their prescribed medication regiment to try and live as comfortably as possible. Although participants made decisions to take medications differently than prescribed, they did not perceive themselves to be nonadherent. Conclusions Participants perceived their decisions for medication nonadherence as logical and necessary to maintain their health which could be seen as practicing self-care as opposed to nonadherent behavior. Thus, assessments should aim to understand actual medication-taking routines. Participants described consulting the Internet and resources other than providers for medication information. The development of interventions that utilize resources that are readily accessible to patients may promote decisions for medication adherence.

Our Experience with Transcatheter Aortic Valve Replacement Medication Outcomes from 2013 to 2016.

BackgroundAortic stenosis is classified as stenosis that can be caused by a congenital disability in infants and children but is more commonly produced by a degenerative process of calcification and scarring of the valve in the later decades of life. High systemic pressure and hemodynamic disturbances characteristic of this area of the cardiovascular system makes the aortic valve susceptible to plaque and cholesterol buildup over time, similarly to atherosclerosis, contributing to the pathology of aortic stenosis. Thus, this study aims to assess the short and long-term clinical outcomes of risk factor reduction, post transcatheter aortic valve replacement (post-TAVR), and results of tested medication outcomes.MethodsData were obtained from Charleston Area Medical Center, which is a tertiary care 800-bed community teaching facility and was examined using STATA 11.4 (StataCorp LLC, College Station, Texas, USA), a Cox proportional hazards model to test for clinical significance. This study examined the medications aspirin, clopidogrel, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. Additional medications analyzed included statin, anticoagulant, aspirin with clopidogrel, and beta-blocker with ACE inhibitor and statin following the procedure of transcatheter aortic valve replacement (TAVR) and the overall risk of a hazard event of mortality.ResultsResults suggest that clopidogrel by itself had the lower rate of mortality at one year with hazards of 0.6906, a p-value of 0.221 and a 95% confidence interval of 0.3677 - 1.259; and at three years with hazards of 0.4845, a p-value of 0.027 and a 95% confidence interval of 0.2552 - 0.9201. Statins had the second-lowest rate at one year with hazards of 0.7299 and a p-value 0.215 and a 95% confidence interval of 0.4438 - 1.200; and at three years with hazard of 0.8529 and a p-value of 0.530 and a 95% confidence interval of 0.5192 - 1.401. Both of these medications had a consistent lower hazard and/or risk of death compared to other standard medication regiments. Within our center's data, clopidogrel had the best clinical outcome. ConclusionsThis study showed that therapy with aspirin and clopidogrel alone did not demonstrate a significant increase in mortality versus alternative anticoagulation therapy in patients post aortic valve replacement. Clopidogrel and statin usage post-aortic valve revascularization may have a trend towards a reduction in mortality.

Cancer Pain Management in the Emergency Department: A Retrospective Cohort Study

Background: Cancer pain has historically been very difficult to manage. Despite targeted initiatives by oncologists aimed at increasing the awareness of cancer pain, improving the documentation of pain, and improving pain medication regiments, some patients continue to have significant breakthrough symptoms and therefore seek additional care in the emergency department (ED). Unfortunately, the ED has classically struggled with providing appropriate pain management in the general population. Therefore, patients with cancer who are already at risk for inadequate analgesia may be at particular risk for poor pain management when they present to the ED.

3022 Barriers to Accessing Follow-up Care and Changes in Medical Needs after Childhood Injury

OBJECTIVES/SPECIFIC AIMS: The objective of this study was to prospectively assess caregiver-perceived barriers to accessing post-acute care for their injured child and determine if caregivers report ongoing, unmet health needs for their children after trauma. METHODS/STUDY POPULATION: This was a prospective cohort study that followed 50 participants for 6 months and administered surveys to parents of children who are admitted to a pediatric level 1 trauma center for injury. Surveys were given bi-weekly regarding care children received after hospital discharge. At 3 months, parents were surveyed over the phone on whether they were able to access all needed health services and if there were any perceived barriers to obtaining or providing at-home care. At 6 months, parents were given the Child &amp; Family Follow-up Survey to assess ongoing physical, mental, social, and scholastic needs. Free responses and transcribed interviews were analyzed using thematic content analysis and frequencies are reported for discrete data. RESULTS/ANTICIPATED RESULTS: Out of 50 families recruited, 47 completed follow-up assessments. At 3 months, common themes regarding challenges after hospital discharge included difficulty scheduling specialist care; uncertainty in managing their child’s pain; transitioning home without enough knowledge to meet their child’s medical needs; lack of communication between multiple providers; distress at having providers release children to full activities before caregivers were comfortable. At 6 months, approximately 24% of parents reported children had ongoing cognitive limitations, 29% reported emotional problems, 19% reported physical limitations, 33.3% reported difficulty in school, and 15% reported play/social difficulties. DISCUSSION/SIGNIFICANCE OF IMPACT: Evidence suggests families face significant barriers in accessing follow-up care, despite nearly universal health insurance coverage for children. Further, a large percentage of parents report ongoing health needs, despite the majority of the cohort having only mild or moderate severity injuries. Making follow-up care more patient-centered for families of traumatically injured children may improve compliance with medical regiments and reduce the likelihood of future disability. Examples of this may be coordinating care among multiple specialty providers, so that patients with multiple injuries can schedule multiple follow-up appointments on the same day. Additionally, more caregiver education on administering pain medication, caring for wounds, and safe practices for returning to full activities would be beneficial for families.

A Randomized Controlled Trial of Intensive Case Management (Project Bridge) for HIV-Infected Probationers and Parolees.

Individuals on probation and parole are disproportionately at high risk for HIV infection and experience significant barriers to accessing health care. This study was a two-group randomized controlled trial conducted at a community corrections office and was designed to link HIV positive probationers/parolees to HIV treatment in the community. HIV positive participants were assigned to one of the two treatment conditions: (1) Project Bridge (PB), an intensive case-management intervention; or (2) treatment as usual (TAU), involving standard referral to treatment. We hypothesized that PB would be more effective than TAU in terms of initiating individuals in community HIV treatment. We found no difference in rates of, or time to, treatment initiation when comparing the PB to TAU (all ns>0.05). Additionally, there was no statistically significant difference between HIV medication regiment initiation by treatment condition (p>0.05). Despite limitations, we found that probationers and parolees were willing to be screened and linked to treatment.

Group O low titre only emergency donor panels for small combat teams

IntroductionMilitary elements increasingly operate in small teams in remote areas with no immediate blood product support. Planners and operators may endorse collection of fresh whole blood from pretested donors in...