Medical Team Research Articles

Automated mental health screening in pediatric lupus: associations with disease features and treatment.

Patients with childhood-onset systemic lupus erythematosus (c-SLE) have higher rates of depression than their peers, which has been associated with worse medical outcomes. Therefore, it is imperative that their mental health be addressed. We utilized quality improvement (QI) methodology to automate mental health screening for patients with lupus within a pediatric rheumatology clinic. The retrospective cohort study aims to evaluate the association between mental health screening outcomes and demographics, medications, and disease activity measures in patients with childhood lupus. The mental health QI team at a quaternary pediatric rheumatology center implemented an automated process for mental health screening in patients with c-SLE. Patients seen between 2017 and June 2023 with a diagnosis of c-SLE were identified using International Classification of Disease -Clinical Modification (ICD-CM) codes. Disease activity was assessed with the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI 2K). Medications were identified on outpatient and inpatient orders for conventional synthetic and biologic disease-modifying anti-rheumatic drugs, hydroxychloroquine, corticosteroids, and aspirin. Mental health screening was accomplished with the Patient Health Questionnaire (PHQ). Descriptive statistics, univariate and multivariate linear regression were used. Between January 2017 and June 2023, 117 patients with c-SLE (41% with lupus nephritis) completed 534 total screenings. Each patient completed PHQ screenings, a median of 5 [interquartile range 2, 6] times. Screening increased when the screening process was automated. Those who were Black, female, or prescribed leflunomide, mycophenolate, and corticosteroids had higher PHQ scores. Mental health support is essential for patients with chronic rheumatologic diseases such as SLE. Sustainable processes for quickly identifying depression are needed for optimal care of patients with SLE. Our process of automated, streamlined mental health screening successfully increased the screening of patients with SLE at every visit and led to timely interventions for positive PHQ scores. Higher PHQ scores were correlated with patients on leflunomide, mycophenolate, and corticosteroids. Future research should identify modifiable risk factors for high PHQ scores that the medical team can target.

STORMS: A Pilot Feasibility Study for Occupational TeleRehabilitation in Multiple Sclerosis.

Digital solutions in the field of restorative neurology offer significant assistance, enabling patients to engage in rehabilitation activities remotely. This research introduces ReMoVES, an Internet of Medical Things (IoMT) system delivering telemedicine services specifically tailored for multiple sclerosis rehabilitation, within the overarching framework of the STORMS project. The ReMoVES platform facilitates the provision of a rehabilitative exercise protocol, seamlessly integrated into the Individual Rehabilitation Project, curated by a multidimensional medical team operating remotely. This manuscript delves into the second phase of the STORMS pilot feasibility study, elucidating the technology employed, the outcomes achieved, and the practical, professional, and academic implications. The STORMS initiative, as the genesis of digital telerehabilitation solutions, aims to enhance the quality of life for multiple sclerosis patients.

12586 A Case Of Ventricular Fibrillation In Thyroid Storm

Abstract Disclosure: A.A. Luzuriaga Chavez: None. N. Aamir: None. J.P. Hidalgo: None. A. Rao: None. N. Patel: None. Thyrotoxicosis is a life-threatening condition caused by an excessive level of circulating thyroid hormones. It can lead to high mortality and morbidity, even if diagnosed and treated in its early stages. Symptoms can include fever, irritability, tachycardia, diarrhea, and seizures. Levothyroxine is a medication commonly used for hypothyroidism, but cases of acute overdose have been reported worldwide. This is a case of a 55-year-old woman who was admitted after a cardiac arrest caused by a possible overdose of 8 mg of levothyroxine. Case presentation:A 55-year-old woman with a history of major depressive disorder was found unconscious by her boyfriend next to a bottle of levothyroxine (which contained a 3-month supply) and was rushed to the emergency department (ED) by EMS. According to the patient's medical chart and family, she did not have a history of hypothyroidism. In the field, she suffered a V-fib cardiac arrest but was successfully resuscitated and brought to the ED. However, she had another cardiac arrest upon arrival but was revived again after 20 minutes. During the physical examination, the patient did not exhibit any signs of thyroid enlargement, exophthalmos, or jaundice. The initial electrocardiogram showed concerning signs of ST-elevation myocardial infarction so the patient was started on heparin drip and continuing amiodarone. The patient was then transferred to the ICU for post-arrest care. Bloodwork revealed TSH <0.005, T3 15.74, and T4 1.57. The Burch-Wartofsky point scale indicated a score of 55, which is consistent with a high suspicion of thyroid storm. The patient's condition continued to worsen, with increasing vasopressor requirements and hyperthermia. Despite the amiodarone drip, the patient's heart rate continued to be less than 100 beats per minute, propranolol could not be started. Furthermore, the patient started bleeding from the nasogastric tube, and the medical team was unable to start any oral propylthiouracil or methimazole. Consequently, they administered hydrocortisone 300 mg, followed by 100mg every 8 hours. The patient was transitioned to comfort care measures. Discussion:Massive ingestion of levothyroxine can lead to excessive thyroid hormone levels and cause sympathetic excitation.Reports of adults ingesting levothyroxine are rare, and those who do generally experience more severe symptoms such as cardiac arrhythmias, malignant hyperthermia, and renal failure. Excessive thyroid hormone levels lead to increased beta adrenergic receptors within the myocardium, rendering it more susceptible to both vagal and sympathetic stimulation. A few isolated case reports show thyrotoxicosis was associated with ventricular fibrillation. Thyroid storm can occur a few days after an overdose of levothyroxine. However, in this case, the patient developed thyrotoxicosis within 6 to 8 hours of ingestion, making it an interesting case to study. Presentation: 6/1/2024

7148 Fake Fingerstick: Artifactual Hypoglycemia in a Hospitalized patient with Systemic Sclerosis

Abstract Disclosure: S. Shteyman: None. F. Mirza: None. Introduction: Artifactual hypoglycemia is a problem in hospitalized patients. It often leads to unnecessary use of resources and creates anxiety for the patient and medical team. We describe a case of a 60-year-old female with history of systemic sclerosis (Raynaud, telangiectasias, esophageal dysmotility, interstitial lung disease, pulmonary hypertension), rheumatoid arthritis, autoimmune hepatitis and hypothyroidism who initially presented to the hospital emergency department with bilateral lower extremity radiculopathy, and new onset urine incontinence. She underwent spine surgery initially, followed by emergent left upper extremity thrombectomy two days later. Postoperatively, she was noted to have fingerstick glucose of 34 mg/dL. Dextrose and juice were given, and endocrinology service was consulted. The patient was monitored with 2 hourly fingerstick glucose and was noted to have frequent hypoglycemia on fingerstick monitoring. Serum glucose in AM labs was consistently within normal limits. Patient denied both adrenergic and neuroglycopenic symptoms during periods of “hypoglycemia”. She was asked to fast till fingerstick glucose was noted to be at 43 mg/dl, when blood was drawn for serum glucose, insulin, proinsulin, C-peptide, B-hydroxybutyric acid, IGF-2, insulin AB, and sulfonylurea panel, prior to giving her any dextrose. She was asymptomatic at the time. All labs were within normal limits, with serum glucose at 119 mg/dL. At that point, artifactual hypoglycemia was suspected. Serum glucose was checked twice again when fingerstick glucose was noted to be <45mg/dL, and corresponding serum glucose was noted to be normal at both times (>100 mg/dL). Decision of artifactual hypoglycemia was made and fingerstick glucose monitoring was discontinued in this non-diabetic patient, with recommendation to check serum glucose only if symptoms of hypoglycemia occur, as fingerstick glucose values were not reliable. Fasting serum glucose continued to be normal for the remainder of the hospitalization. Discussion: There have been a handful cases of artifactual hypoglycemia reported in patients with CREST, systemic sclerosis, and Raynaud’s disease. It is thought to be due to abnormal small vasculature causing delayed transit of blood through capillaries, and increased uptake of glucose into the interstitial tissue. Some recommend using earlobe sticks as a replacement for fingerstick glucose monitoring in these patients. Future research can explore if continuous glucose monitoring can be used reliably in these patients. Presentation: 6/1/2024

8652 Real World Impact of Cushing’s Syndrome: A Shared Global Story

Abstract Disclosure: L. Edwin: None. G. Jordan: None. Introduction: Cushing's Syndrome creates short- and long-term challenges to physical and mental health. Clinical and surgical outcome statistics have improved over time, but patients continue to report diagnosis delays, confusion about treatments, and the feeling of being “dropped” once cortisol is normalized. White matter is damaged by persistent high cortisol, and a return to eucortisol often unmasks new or worsened autoimmune, neuropsychological, physical, and other conditions. Hypothesis: Patients have been sharing best practices and supporting each other through patient networks for decades on topics that are misunderstood, dismissed, and under-treated in the clinical setting. Improvements to care will come faster if this kind of patient-created data is made widely available, and advocacy groups must establish an acceptable method to accomplish this. Methodology: A committee of patients reviewed the design and content of two large Quality of Life surveys conducted in recent years, then built a new survey for a larger international patient cohort. SurveyMonkey was used for layout and response collection. Spanish and French translations were done with DeepL then cleaned up by native speakers. The survey was then promoted within global patient advocacy organizations and on social media. The survey comprised over 150 questions and received 438 responses from 38 countries. Results: Respondents answered questions about their daily lives including physical, emotional, mental and social well-being. Examples: •75% of respondents are still trying to determine their “new normal”.•Over 80% report memory problems that did not exist before.•Almost 90% took much longer than six weeks to return to work in any capacity.•A third of male patients and a fifth of female patients report that their marriage or long-term relationship ended because of Cushing’s.•Almost half of respondents felt that their medical team was unable to support them beyond cortisol issues.•More than 50% who answered this survey have experienced suicidal thoughts due to the overwhelming nature of Cushing’s. Conclusion: Dr. Harvey Cushing, namesake of the disease, identified the most underrated element of the patient experience when he made his famous statement: “A physician is obligated to consider more than a diseased organ, more than even the whole man—he must view the man in his world.”The man in his world. The results of our study paint a picture of the ongoing burden of hypercortisolism that often starts seven or more years before an official diagnosis is made and continues indefinitely. Patients can help fast-track the identification of areas where more work needs to be done. It is therefore incumbent on a group of well-organized advocates to develop a structure that translates the patient voice into datasets that are useable by all doctors, researchers, and stakeholders in the Cushing’s community. Presentation: 6/3/2024

7815 Pembrolizumab-Induced Autoimmune Hypophysitis with “Isolated” ACTH Deficiency: Need for Heightened Awareness and Action Among Medical Fraternity

Abstract Disclosure: S. Shankar: None. S.S. Sundar: None. M.S. Vaishnav: None. L. Lekkala: None. K. Thummala: None. S. Srikanta: None. T. Deepak: None. R.B. Vijay: None. K. Muniraj: None. V. Nath: None. C. Siddlingappa: None. P. Ravikumar: None. M.D. Chitra: None. Introduction: Autoimmune hypophysitis caused by immune checkpoint inhibitors [ICIs; anti-CTLA-4 (Ipilimumab alone 7.9%), anti-PD-1 (Pembrolizumab alone 1.7%; nivolumab alone 0%)] are being increasingly documented, with anterior hypopituitarism affecting corticotrophs more commonly than thyrotrophs and gonadotrophs (large time span of onset; different recovery patterns). Clinical Case 2021 Sep Age 65 years (type 2 diabetes, hypertension). Renal Cell Carcinoma S/P radical nephrectomy. 2023 Jul PET-CT= Metastatic pleuropulmonary nodules. Four admissions to Specialist Oncology Hospital [Four 2 weekly cycles of Inj Pembrolizumab 200 mg (with Tab Axitinib 10 mg/day)]. After first cycle: progressive fatigue, body aches, drowsiness. S Sodium= Pre-pembrolizumab= 137 mEq/L (135-145); Post-pembrolizumab= 124, 134, 132, 124; T3= 1.63 to 0.60 to 1.24 to 1.35 ng/mL (0.97-1.69); T4= 6.83 to 4.93 to 10.44 to 11.44 mcg/dL (5.53-11); TSH= 10.46 to 6.28 to 5.39 to 9.48 mIU/mL (0.46-4.68); S Cortisol 8 am= 1.54 mcg/dL (5-25); S Potassium= 4.59 mEq/dL (3.5-5.1)]. One episode of loss of consciousness; EEG= abnormal; MRI Brain= normal. During every hospital admission, oncology, medical, endocrinology and nephrology teams attributed the same to “illness” (no specific diagnosis) and provided symptomatic treatment (IV 3% saline, tolvaptan and sodium bicarbonate tablets).2023 Nov Medicine: Very severe nausea, anorexia, generalised weakness, myalgia, hiccoughs, and inability to walk. Frustrated family members sought admission in “new” General Hospital. S Sodium= 119, 120; S Potassium= 4.8; S Creatinine= 1.67 mg/dL (0.7-1.3); S Uric acid= 4.5 mg/dL (4.40-7.60); Urine spot Sodium= 84 mmol/L; ESR= 144 mm. Endocrinology: S Cortisol 8 am= 0.09 mcg/dL;S Cortisol post 250 mcg Inj Synacthen= 3.76 (>20);Plasma ACTH= 5.4 pg/ml (9-52). S T3= 1.35; S T4= 11.44; S TSH= 9.48; LH= 3.61mIU/mL (1.5-9.3); FSH= 1.4mIU/mL (1.4-18.1); PRL= 30.1 (2.6-13.3); Testosterone total= 314 ng/dL (241-827); TPO antibodies negative. MRI-Pituitary: Partial empty sella; infundibulum neurohypophysis normal; mild asymmetric enhancement (5.5 mm) left cavernous sinus. Treatment: Tab Hydrocortisone 25 mg/day, with complete clinical and biochemical response [Suggestion of gonadotroph dysfunction and partial recovery of thyrotrope dysfunction/ injury. Hence, not on thyroxine replacement]. Clinical Lessons: Mechanisms for differential cellular vulnerability for ICI induced autoimmune pathologies [thyroid (destructive versus stimulatory), islet beta cells, adrenal cortical cells, various anterior pituitary cells (corticotrophs vs thyrotrophs and gonadotrophs] need elucidation. Specific molecular and cellular immunopathogenic pathways in different autoimmune endocrinopathies appear distinct and disparate. Presentation: 6/2/2024

A “rotating menu” of medical uncertainty for families affected by telomere biology disorders: A qualitative interview study

BackgroundMedical uncertainty may cause distress and challenge medical decision-making for patients with rare diseases and their caregivers. Few studies have examined the experience and management of medical uncertainty in rare disease and the dynamics of multiple medical uncertainty sources, issues, and management strategies. ObjectiveWe explored the experience and management of uncertainty in individuals with telomere biology disorders (TBDs), a set of rare cancer-prone bone marrow failure syndromes, and their caregivers. DesignParticipants (N = 32) in this qualitative-descriptive study were individuals with a TBD (n = 17) and/or their caregivers (n = 15). We thematically analyzed transcripts to describe the presence and dynamics of medical uncertainty in TBDs using categories from a previously published taxonomy. ResultsIndividuals with TBDs and caregivers described medical uncertainty as a chronic burden embodied amidst a range of interrelated sources and issues. Scientific uncertainty included diagnostic and prognostic ambiguity. Practical uncertainty focused on logistical challenges of building and maintaining medical care teams. Personal uncertainty included difficulty realigning self-identity, goals, and relationship expectations post-diagnosis. Scientific, practical, and personal uncertainty issues were entangled. The rarity of TBDs resulted in limited scientific knowledge, which gave rise to practical and personal uncertainties affecting medical decision-making and relationship formation (e.g., creating trusted care teams where patient knowledge of TBDs may exceed that of clinicians). Participants used multiple strategies for uncertainty management, particularly information-seeking and community-building. However, these management strategies could intensify, rather than resolve, participants’ medical uncertainty. ConclusionIn TBDs, medical uncertainty manifests as a network of multiple, interrelated, sources and issues, which require evolving management strategies. Researchers must be mindful that complex, synergistic uncertainty networks contribute to psychosocial challenges in TBDs. Additional research is warranted to address scientific uncertainty in TBDs, including clinical manifestations and underlying biology, and to develop psychosocial interventions that recognize and anticipate evolving uncertainty.

Consensus statements for the establishment of medical intensive care in low-resource settings: international study using modified Delphi methodology

BackgroundThe inadequacy of intensive care medicine in low-resource settings (LRS) has become significantly more visible after the COVID-19 pandemic. Recommendations for establishing medical critical care are scarce and rarely include expert clinicians from LRS.MethodsIn December 2023, the National Association of Intensivists from Bosnia and Herzegovina organized a hybrid international conference on the topic of organizational structure of medical critical care in LRS. The conference proceedings and literature review informed expert statements across several domains. Following the conference, the statements were distributed via an online survey to conference participants and their wider professional network using a modified Delphi methodology. An agreement of ≥ 80% was required to reach a consensus on a statement.ResultsOut of the 48 invited clinicians, 43 agreed to participate. The study participants came from 20 countries and included clinician representatives from different base specialties and health authorities. After the two rounds, consensus was reached for 13 out of 16 statements across 3 domains: organizational structure, staffing, and education. The participants favored multispecialty medical intensive care units run by a medical team with formal intensive care training. Recognition and support by health care authorities was deemed critical and the panel underscored the important roles of professional organizations, clinician educators trained in high-income countries, and novel technologies such as tele-medicine and tele-education.ConclusionDelphi process identified a set of consensus-based statements on how to create a sustainable patient-centered medical intensive care in LRS.

A-185 Impact Assessment of Centrifugation During Transportation on Examination Results

Abstract Background Laboratories are increasingly challenged to seek solutions to expedite the collection process and provide more convenience to patients. This study aims to validate the centrifugation of samples in transport cars for home collections without need to return to the basic unit after each sample collection for centrifugation using the traditional method for up to 2 hours, as recommended in the literature, providing an increase in the number of patient appointments and a greater portfolio of exams. Methods The study was carried out evaluating measurands that represent different methodologies and sample stability challenges, namely, PTH, free T4, testosterone, CA19.9, anti-HBS, anti-transglutaminase, LDH, potassium, glucose, sodium and alkaline phosphatase( FAL). The centrifuge used during sample transport was the Drucker, model Horizon - 6 Flex, calibrated and monitored during the study. Forty samples from volunteer patients were analyzed, with one tube centrifuged in the equipment installed in the car and a second tube in the basic unit's centrifuge within 2 hours of collection, both respecting the 30-minute clot retraction period. All tubes were sent to the same laboratory for execution. Results Throughout the study period, the calibration of the car's centrifuge remained stable. In the correlation, the variance, calculated by the F Test, showed an adequate result, below 1.69. The difference between the means of the test method and the comparative method calculated through the T Test was below the Critical T. The Pearson correlation for the mensurands Free T4, CA19.9, anti-transglutaminase, LDH, potassium, sodium and glucose was lower than the accepted limit of 0.950. Agreement analysis and Kappa index were performed and the data were evaluated from a qualitative point of view by the medical team, who considered the differences to have no clinical impact on the patient. PTH, CA19.9 and FAL were approved by the difference graph.In relation to glucose, the correlation between the serum-gel tube and fluoride was also evaluated, where we obtained lower results with the fluoride tube due to hemolysis caused by the additive. During the analysis of LDH results, a tendency to decrease the concentration of its dosages over time can be observed, and in this case there were lower results in samples centrifuged in the basic unit, due to the longer interval between collection and centrifugation. Conclusions After evaluation from a pre-analytical, quality and medical point of view, centrifugation from home samples collection directly in the car will allow a greater number of patients to be served, as there will be no need to return to the basic unit for centrifugation every 2 hours. It will also bring greater safety in centrifuging the sample at the correct time, avoiding any delays that may occur, mitigating potential deviations in results and greater process efficiency as the collector will not need to return to the basic unit for centrifugation, right during During the collection route, the samples will already be prepared for sending directly to the execution site. For glucose and LDH tests, it was possible to observe efficiency gains due to centrifugation 30 minutes after collection.

Physiotherapy advanced clinical practitioners in an inpatient medical team: opportunities and challenges

Physiotherapy advanced clinical practitioners in an inpatient medical team: opportunities and challenges

A-045 Analytical and Clinical Evaluation of A1c Test by HPLC - Lifotronic™ H100Plus Analyzer - in a Brazilian Clinical Laboratory

Abstract Background Over the years, the measurement of Glycated Hemoglobin (A1c) has solidified as an important risk marker for pre-diabetic patients and for the diagnosis and control of diabetic patients. The High-Performance Liquid Chromatography (CLAE) method has been adopted in prospective studies such as the DDCT, and international certification by the NGSP is available. In this study, analytical performance metrics including imprecision, correlation, linearity, carryover, and detection of hemoglobin variants were evaluated for the Lifotronic® H100 Plus analyzer from China. Methods The results were evaluated following CLSI guidelines on samples within stability, collected according to standardized procedures. For the comparative method, 40 patient samples ranging from 4 to 15.4% were analyzed, and two concentrations of internal quality control material were used for intra-assay (5 repetitions per day) and inter-assay (over five days) imprecision testing. Linearity was assessed using samples at two concentrations, one low (4.5%) and another high (17.2%). For carryover evaluation, low (4.98%), intermediate (9.97%), and high (14.96%) concentrations were assayed in an interleaved manner. Hemoglobin variants found in the studied population were determined using the same method employed in correlation tests (HbS, HbF, HbC, HbE, and HbD). Results The method comparison study revealed a Total Error for decision levels of 5.6%: 2.23% and 6.5%: 1.70%, which were lower than the maximum allowable Total Error of 3.3% (EFLM - EuBIVAS). The difference plot showed that 95% of the results fell within acceptable limits. Positive bias was observed in 7 out of 40 tested samples, predominantly in samples with concentrations above 6,5%, although the medical team assessed it as having no clinical impact. For intra-assay imprecision, the obtained result was 0.86%, and for inter-assay imprecision, it was 0.87%, both deemed acceptable according to the 3.0 % specification proposed by the supplier for the two tested levels.Linearity tests were approved for concentrations proposed by the manufacturer between 3 and 18%, and no carryover was found between samples. All hemoglobin variants previously detected in the comparative method were also identified in the test method without exception, although the specific type of Hb variant was not identified. Conclusions The Lifotronic™ H100Plus analyzer demonstrated approved analytical performance with some notable observations: positive bias was observed in samples with concentrations above 6,5%, though it was not considered clinically relevant, the throughput of 58 tests per hour could be a limitation for laboratories with high testing volumes and the analyzer detected the presence of Hb variants, although it did not identify their specific types.

A-192 Effectiveness in Communicating Critical Results: impact of technology and consultive actions on improving performance indicators in a laboratory in Northeast Brazil

Abstract Background Critical results consist of laboratory test results that require immediate intervention or decision-making by the responsible medical team, as they pose a risk to the patient's life. To manage the process of communicating critical results, it is also necessary to define the indicators, goals and systematic comparability through benchmarking. Methods The performance of the indicators measuring the critical results process for the year 2023 was analyzed. Performance indicators such as resolution time, success and failure rate in communication, delay rate in communication and the rate of open incidents related to the communication of critical results were monitored using a Business Intelligence tool. Results In the first two months of 2023 the results reflected the absence of parameters in the LIS for effective communication of critical results. September and October there was a high turnover rate in the laboratory in addition to the change in the hospital care profile in which the laboratory medicine service was inserted. These causes culminated in a number of 122 (1.48%) communication failures, representing an increase of 1,120% compared to the first two months of the year. On the other hand, there was a significant improvement in the average communication time for critical results, decreasing from approximately 736 hours to 184 hours(reduction of around 75%). There was also a reduction in communication delay of approximately 67%. These numbers corroborate the parameterization actions in the system aimed at speeding up the process. As a continuation of the improvement actions, the laboratory implemented goal setting for the resolution time indicator and also the periodic meeting for critical analysis of the results.In addition to these actions, the laboratory approached the hospital's clinical staff, making it possible to provide clarity on the difference between compulsory notification and critical results. This clarification allowed for the establishment of a list of exams considered critical, in order to meet the hospital profile, as well as to define the communication flow. For the success indicator in communicating critical results, there was a 22% improvement when comparing the last two months of 2023 with the first two months of the same year. In the last two months of the year, this indicator performed at 99.4%, corroborating the study published by Noronha et al., (2016), where the effectiveness rate in critical results communication was 96.1%. Comparing with the study by Noronha et al., (2016), where the biochemistry sector had the highest rate of critical results communication failures (73.8%), followed by the Emergency Room (78.6% ) and ICU (16.7%), the findings of this study highlighted the top 3 detracting sectors: Biochemistry (68%), “UPA” - Emergency Care Unit (42.1%) and ICU (21.4%), making data superimposable. Conclusions The communication of critical results has challenges related to its effectiveness, especially in hospital contexts. As a critical and high-impact activity, constant actions are necessary to continuously improve the process. Actions should take into account: interactions with attending physicians, the development and training of the internal team, and constant checks of the LIS, as technology can support the process management.

Understanding the causes of nonadherence to chronic medications among patients with cancer and multimorbidity: A qualitative study.

252 Background: Patients with active cancer and multimorbidity (≥2 chronic conditions) are at increased risk of disease progression, hospitalization and death compared to patients without concomitant chronic conditions. Adherence to chronic medications is imperative in this patient population, but frequently declines after the initial cancer diagnosis. Reasons for this declining adherence are not well understood. We aimed to explore barriers and facilitators of chronic medication adherence among patients with multimorbidity and a recent cancer diagnosis. Methods: We conducted a qualitative study of patients with active solid organ cancer and multimorbidity receiving care at one academic health system in March-November 2023. We used purposive sampling to include balanced numbers of advanced (stage 3-4) and non-advanced (stage 1-2) cancers and perceived change in chronic medication adherence after cancer diagnosis (same/better vs worse). We asked participants to describe their perceptions of and experiences with balancing their cancer and non-cancer symptoms, medications, and medical appointments, as well as barriers to adherence and strategies used to help with adherence. We analyzed transcripts using thematic analysis. Results: We interviewed 20 patients aged ≥50 who had an average of 3 chronic conditions and took an average of 3 chronic medications. Three themes emerged. First, patients made decisions about which diseases, medications, and medical appointments to prioritize. Many focused their energy on their cancer treatment and appointments, putting management of their chronic conditions on pause. In contrast, patients with severe chronic conditions (e.g., heart failure, diabetes) prioritized avoiding hospitalizations for their chronic conditions so that they could continue their cancer treatment uninterrupted. Patients based their decisions on prior experience, as well as advice from caregivers and clinicians. Second, adherence fluctuated in response to drug side effects (e.g., nausea/vomiting), drug-disease interactions (e.g., weight loss reducing need for antihypertensives), drug-drug interactions, and conflicting recommendations from cancer and non-cancer care teams. Patients often most closely followed the recommendations of the clinician they viewed as being “in charge” of their care. Third, patients’ trust in caregivers, medical teams, and their own self-efficacy influenced their motivation to adhere to medications. Conclusions: Patients with cancer and multimorbidity must balance competing priorities, interactions between their cancer and non-cancer conditions, relationships with care teams and caregivers, and their own sense of self-efficacy. Further work is needed to devise strategies to address barriers to chronic medication adherence in this population and thus improve short- and long-term health outcomes.

Patient experiences in high-grade gliomas: from symptoms to radiotherapy

ObjectivesLittle is known in the literature about felt experience and supportive care needs of patients with new diagnosis of adult-type diffuse gliomas Central Nervous System WHO grades 3 and 4....

Digitizing community resources and closed-loop referral system to identify top sought health-related social needs (HRSN) in a community cancer center.

154 Background: Prior to implementation of a digital closed-loop referral system, community resources were not centralized, and knowledge of resources varied between clinic staff within a community cancer center treating patients throughout the Willamette Valley of Oregon. Referrals to community-based organizations (CBO) were found in the electronic health record as unstructured data and were difficult to track manually. As an organization, the medical care team needed to identify top sought HRSNs to better understand health equity needs in our community. Methods: 2023 Q1: Partnered with Findhelp, a social needs closed-loop referral platform. 2023 Q2-4: Attended Findhelp train-the-trainer education and began building a customized oncology database of local, regional, and national resources. Developed a process to log community-based referrals, update the referral status, and close the referral loop within Findhelp for individual patients. Educated and trained support services staff. 2024 Q1: Utilized Findhelp data analytics to review and evaluate closed-loop referral system and top sought HRSNs. Results: We describe our results to date (Table). Conclusions: Digitizing community resources and establishing a closed-loop referral process between the community cancer center and CBOs allowed accurate data tracking and increased access to data to ensure patients’ needs were met. After eight months, financial toxicity, housing insecurity, and food insecurity were identified as the top three sought HRSNs. In the future, increased data will help evaluate gaps in resources and leverage stronger relationships with CBOs to meet patients’ HRSNs in a community cancer center. Month % Closing the Referral Loop (patients with closed-loop referrals/total patient referrals) Top Sought HRSN Needs July 2023 74% (50/68) Help pay for healthcare August 2023 68% (51/75) Help pay for healthcare September 2023 80% (59/74) Housing October 2023 67% (66/98) Help pay for healthcare November 2023 78% (51/65) Food December 2023 86% (55/64) Support/Counseling January 2024 83% (52/63) Help pay for healthcare February 2024 65% (56/86) Food

Severe Salicylate Poisoning Due to Teaberry Flavoring Ingestion: A Case Report

BackgroundCurrently there are many commercial uses of methyl salicylate including fragrances, flavoring, topical pain relief, and polymer restoration. Most recorded instances of human toxicity due to methyl salicylate are the result of topical or accidental exposures. However, this is a previously unreported case of an adult patient who intentionally ingested teaberry flavoring causing life-threatening salicylism. Case ReportA 22-year-old man presented to the Emergency Department with the chief complaint of nausea, vomiting and abdominal pain. Triage nursing noted the patient's vomit smelled strongly of wintergreen. Further history indicated the patient had ingested approximately 40 mL of teaberry oil while using it to make ice cream. The initial serum salicylate concentration was 111 mg/dL. The medical toxicology team was consulted, and the patient was given a singular dose of activated charcoal by mouth. He was also administered both an intravenous sodium bicarbonate bolus and sodium bicarbonate infusion. He was admitted to the intensive care unit while the nephrology service was consulted to initiate emergent hemodialysis (hD). After the single hD treatment with concomitant serum and urine alkalization, the patient had progressive improvement of salicylate concentrations. He was discharged on hospital day three in normal condition. Why should an emergency physician be aware of this?Emergency physicians should be aware of novel etiologies of life-threatening salicylate poisoning.

Aging well with diabetes

The care of elderly people with diabetes has become a real public health issue due to the growing number of patients. In these patients, the complications of the pathology are often combined with more particularly gerontological manifestations. It is therefore essential to adapt the therapeutic objectives according to the clinical presentation of each of them. If the new drug classes are promising because they are effective in terms of cardiovascular and renal protection, it is crucial to evaluate their benefit-risk balance for each individual. The quality of care for these elderly patients relies on a well-trained multidisciplinary medical and paramedical team.

Spontaneous Umbilical Cord Vascular Rupture during Labor: A Retrospective Analysis of 12 Cases.

Umbilical cord vascular rupture is a rare and severe condition that can occur during labor, leading to adverse outcomes for the fetus before as well as after delivery. Prompt diagnosis and intervention are crucial for improving the chances of a successful outcome. We aimed to analyze cases of umbilical cord vascular rupture during labor to provide insights into this challenging condition. This retrospective study evaluated the medical records of patients diagnosed with umbilical cord vessel rupture or umbilical cord hematoma at Fujian Maternity and Child Health Hospital from January 1, 2015, to May 31, 2023. The inclusion criteria included gestational age of ≥28 weeks, occurrence during labor, and availability of complete delivery data. Data on fetal heart rate (FHR) changes, delivery intervals, intraoperative findings, placental pathology, and neonatal outcomes were collected and analyzed. A total of 12 cases were analyzed. The incidence of umbilical cord vascular rupture during childbirth was 0.08%. The FHR patterns in umbilical cord rupture during delivery included baseline tachycardia, minimal or absent variability, variable or late deceleration, prolonged deceleration, and undetectable heart rate. The bradycardia-to-delivery interval (BDI) ranged from 6 to 26 minutes. Among the 12 neonates, 9 were discharged well, 2 were stillbirths, and there was 1 neonatal death. Hemorrhagic shock was common in live births. Our study highlights the significance of continuous FHR monitoring during labor and the urgent need for medical teams to respond quickly in cases of umbilical cord vascular rupture. Despite advancements in neonatal resuscitation techniques, managing cases with undetectable fetal heart activity remains clinically challenging, and even with immediate pregnancy termination, poor neonatal outcomes may still occur. · Umbilical cord vascular rupture during labor is a rare event.. · Its clinical management presents significant challenges.. · Advances in neonatal resuscitation have improved rescue success rates.. · In such cases, hemorrhagic shock is common in live births..

Psychological Assessment and Intervention at the Boston Marathon.

The Boston Marathon is a highly regarded event in the running world, not just for its prestige and challenging course, but also for its implementation of a psychology team to support runners. The 2013 Boston Marathon bombings underscored the essential role that mental health support plays at this event, prompting the development and expansion of its innovative care model. This review critically outlines, evaluates, and analyzes the approach and effectiveness of the psychological care model provided to runners on race day as part of the Boston Marathon medical team, including the standard of care, how it functions, and best practices for other marathons. The implications for this review contribute to the increasing trend of providing psychological care in marathon and other athletic settings, and to provide a framework for standardizing assessment and intervention procedures for both elite and novice runners.

Going in Blind: A Common Scenario in an Uncommon Situation.

Medical students, interns, junior resident physicians, senior resident physicians. Power outages have been increasing in frequency in the past few years, therefore becoming an increased threat to healthcare delivery.1 While most studies related to the effects of power outages are focused on outpatient care, such as acute exacerbations of chronic lung conditions and the lack of chargeable equipment, with the increasing number of power outages, hospitals must be prepared for this situation as well.2,3 Although agencies such as the Federal Emergency Management Agency (FEMA) and the US Department of Health and Human Services (HHS) have provided guidelines for the response of hospitals to temporary loss of power,12,13 hospitals generally rely on institutional policies in response to the event of a power outage. Given the relative rarity but increasing frequency of power outages in hospital settings, this medical simulation was created to present a common occurrence in the emergency department (eg, cardiac arrest) in an uncommon setting of a power outage. Simulation has been shown to improve learner self-efficacy, confidence, and leadership skills among resuscitation teams.4,5 The role of simulation also helps learners identify latent safety threats, in this case a power outage.6 The goal of this simulation is to improve the skills of healthcare professionals with regards to managing cardiac arrest and to encourage these practitioners to consider their own hospital guidelines in response to a power outage. By the end of this simulation, learners will be able to (1) evaluate and treat a patient experiencing myocardial infarction and subsequent cardiac arrest during a power outage, (2) describe the local protocols for managing patient care during a power outage, (3) demonstrate the ability to coordinate a medical team during a simulated power outage in an emergency department with limited resources, (4) manage a cardiac arrest patient by following Advanced Cardiac Life Support (ACLS) protocols for bradycardia and ventricular fibrillation, and (5) justify the urgency of transfer to a certified ST segment elevation myocardial infarction center/cardiac intensive care unit, referencing the recommended 120-minute door-to-balloon time. This simulation was conducted with a high-fidelity mannequin. A total of six residents of various post-graduate year (PGY) levels participated in the simulated patient encounter as part of the simulation competition at the Western Regional meeting of the Society for Academic Emergency Medicine. This case was assessed for educational content and piloted by emergency medicine attendings from several institutions prior to running the case for the Western Regional meeting. The efficacy of the content was assessed by oral feedback. The case was well-received by both the attending physicians who evaluated the case prior to running the scenario at the Western Regional meeting and the emergency medicine residents who participated in the case at the Western Regional meeting. Overall, this simulation was well received by both the learners and the debriefers. General feedback was positive, with the perception of increased confidence among learners and reflection upon individual hospital policy in the event of a power outage. Simulation, acute myocardial infarction, cardiac arrest, power outage.