Patients In Outpatient Setting Research Articles

WEARABLE CARDIOVERTER–DEFIBRILLATORS IN CLINICAL PRACTICE IMPLEMENTATION OF THE ANMCO POSITION PAPER FOR APPROPRIATE USE OF THE WEARABLE CARDIOVERTER DEFIBRILLATOR

Abstract Introduction Wearable cardioverter–defibrillators (WCD) have emerged as a valuable tool in the management of patients at risk for life–threatening arrhythmias. These devices offer a non–invasive and temporary solution, providing continuous monitoring and the potential for prompt defibrillation when needed. In this study, we explore the indications for WCD and evaluate arrhythmic events through comprehensive monitoring. Methods From November 2022 to December 2023, we conducted an outpatient follow–up of 18 patients receiving WCD. Regular check–ups and comprehensive echocardiography were performed to optimize therapy based on specific indications for each patient. Results The average age of the patients was 59.3±17.4 years, with 79% being male. Among the cohort, 58% had hypertension, and a similar percentage comprised smokers and individuals with dyslipidemia, while 32% were diabetic. The indications for receiving WCD were: de novo diagnosis of dilated cardiomyopathy with reduced ejection fraction in 9 (50%) patients, recent acute coronary syndrome and ejection fraction < 35% in 5 (28%), cardiac electronic device infections in 3 (17%) patients and myocarditis with electrical instability in 1 (5%) patient. Patients were in optimal medical therapy (OMT) tailored to their specific comorbidities, with 84% on renin–angiotensin–aldosterone system inhibitors, 95% on beta–blockers, 53% on mineralocorticoid receptor antagonists, 53% on sodium–glucose cotransporter–2 inhibitors, and 37% on antiarrhythmics. The average follow–up was 64±45 days according to specific etiology, with a daily wearing time of 22.9±1.1 hours. No device interventions were recorded. At the end of the follow–up period, 6 (33%) patients still required implantable cardioverter–defibrillator (ICD). Among these, 4 patients (22%) underwent to ICD implantation, 3 for secondary prevention, and 1 for primary prevention, while notably, 2 (11%) patients, declined the procedure. Conclusions The use of wearable cardioverter–defibrillators in the outpatient setting for patients at risk of life–threatening arrhythmias allowed to optimize therapy and restrict the indications for ICD, in our cohort up to 67%, with a good safety profile due to the low incidence of device interventions.

A phase 3b study of venetoclax and azacitidine or decitabine in an outpatient setting in patients with acute myeloid leukemia.

Venetoclax, a highly selective BCL-2 inhibitor, combined with hypomethylating agents (HMAs) azacitidine or decitabine, is approved for the treatment of newly diagnosed acute myeloid leukemia (ND AML) in patients who are ineligible to receive intensive chemotherapy. Previous clinical studies initiated venetoclax plus HMA in an inpatient setting owing to concerns of tumor lysis syndrome (TLS). This study (NCT03941964) evaluated the efficacy and safety of venetoclax plus HMA in a United States community-based outpatient setting in patients with ND AML (N=60) who were treatment naïve for AML, ineligible to receive intensive chemotherapy, had no evidence of spontaneous TLS at screening, and were deemed as appropriate candidates for outpatient initiation of venetoclax plus HMA by the investigator. Patients received venetoclax in combination with azacitidine (75mg/m2) or decitabine (20mg/m2) for up to 6 cycles during the study. With a median time on study of 18.3weeks, the best response rate of composite complete remission was 66.7%, and the overall post-baseline red blood cell (RBC) and platelet transfusion independence rate was 55.0%, consistent with results of studies in which treatment was initiated in an inpatient setting. Key adverse events included nausea, anemia, thrombocytopenia, neutropenia, and white blood cell count decrease of any grade (≥50% of patients). The observed safety profile was generally consistent with that of venetoclax plus HMA observed in inpatient AML studies. With close monitoring, 2 cases of TLS were identified, appropriately managed, and the patients were able to continue study treatment. CLINICAL TRIALS REGISTRATION: This study is registered at ClinicalTrials.gov. The registration identification number is NCT03941964.

Application of screening tools to detect mental maladaptation in neurological patients in outpatient settings

In the practice of primary care physicians, there is a large number of patients whose somatic complaints are combined with emotional disorders or disguise them. In this regard, it is essential to identify manifestations of mental maladaptation and recommend these patients to visit a clinical psychologist or psychotherapist. In this work, screening tools were applied at the neurologist’s primary appointment in order to identify patients with anxiety and depressive states as the main markers of mental maladaptation. As a result of the study, mental maladaptation was detected in more than half of the cases, with the pain syndrome ranking first in this group. Such results provide a basis for recommending the use of screening tools for the detection of mental maladaptation during primary care visits, especially in patients with chronic pain complaints. The set of scales applied in this study is easy to use and can be utilized in an outpatient setting due to the shor t time required.

Patient-derived pathogenic microbe deposition enhances exposure risk in pediatric clinics

Healthcare-associated infections (HAIs) pose significant risks to pediatric patients in outpatient settings. To prevent HAIs, understanding the sources and transmission routes of pathogenic microorganisms is crucial. This study aimed to identify the sources of opportunistic bacterial pathogens (OBPs) in pediatric outpatient settings and determine their transmission routes. Furthermore, assessing the public health risks associated with the core OBPs is important. We collected 310 samples from various sites in pediatric outpatient areas and quantified the bacteria using qPCR and CFU counting. We also performed 16S rRNA gene and single-bacterial whole-genome sequencing to profile the transmission routes and antibiotic resistance characteristics of OBPs. We observed significant variations in microbial diversity and composition among sampling sites in pediatric outpatient settings, with active communication of the microbiota between linked areas. We found that the primary source of OBPs in multi-person contact areas was the hand surface, particularly in pediatric patients. Five core OBPs, Staphylococcus epidermidis, Acinetobacter baumannii, Pseudomonas aeruginosa, Streptococcus mitis, and Streptococcus oralis, were mainly derived from pediatric patients and spread into the environment. These OBPs accumulated at multi-person contact sites, resulting in high microbial diversity in these areas. Transmission tests confirmed the challenging spread of these pathogens, with S. epidermidis transferring from the patient's hand to the environment, leading to an increased abundance and emergence of related strains. More importantly, S. epidermidis isolated from pediatric patients carried more antibiotic-resistance genes. In addition, two strains of multidrug-resistant A. baumannii were isolated from both a child and a parent, confirming the transmission of the five core OBPs centered around pediatric patients and multi-person contact areas. Our results demonstrate that pediatric patients serve as a significant source of OBPs in pediatric outpatient settings. OBPs carried by pediatric patients pose a high public health risk. To effectively control HAIs, increasing hand hygiene measures in pediatric patients and enhancing the frequency of disinfection in multi-person contact areas remains crucial. By targeting these preventive measures, the spread of OBPs can be reduced, thereby mitigating the risk of HAIs in pediatric outpatient settings.

Interim Estimates of 2023-24 Seasonal Influenza Vaccine Effectiveness - United States.

In the United States, annual influenza vaccination is recommended for all persons aged ≥6 months. Using data from four vaccine effectiveness (VE) networks during the 2023-24 influenza season, interim influenza VE was estimated among patients aged ≥6 months with acute respiratory illness-associated medical encounters using a test-negative case-control study design. Among children and adolescents aged 6 months-17 years, VE against influenza-associated outpatient visits ranged from 59% to 67% and against influenza-associated hospitalization ranged from 52% to 61%. Among adults aged ≥18 years, VE against influenza-associated outpatient visits ranged from 33% to 49% and against hospitalization from 41% to 44%. VE against influenza A ranged from 46% to 59% for children and adolescents and from 27% to 46% for adults across settings. VE against influenza B ranged from 64% to 89% for pediatric patients in outpatient settings and from 60% to 78% for all adults across settings. These findings demonstrate that the 2023-24 seasonal influenza vaccine is effective at reducing the risk for medically attended influenza virus infection. CDC recommends that all persons aged ≥6 months who have not yet been vaccinated this season get vaccinated while influenza circulates locally.

Kinematic movement and balance parameter analysis in neurological gait disorders

BackgroundNeurological gait disorders are mainly classified based on clinical observation, and therefore difficult to objectify or quantify. Movement analysis systems provide objective parameters, which may increase diagnostic accuracy and may aid in monitoring the disease course. Despite the increasing wealth of kinematic movement and balance parameter data, the discriminative value for the differentiation of neurological gait disorders is still unclear. We hypothesized that kinematic motion and balance parameter metrics would be differently altered across neurological gait disorders when compared to healthy controls.MethodsThirty one patients (9 normal pressure hydrocephalus < NPH > , 16 cervical myelopathy < CM > , 6 lumbar stenosis < LST >) and 14 healthy participants were investigated preoperatively in an outpatient setting using an inertial measurement system (MyoMotion) during 3 different walking tasks (normal walking, dual-task walking with simultaneous backward counting, fast walking). In addition, the natural postural sway of participants was measured by pedobarography, with the eyes opened and closed. The range of motion (ROM) in different joint angles, stride time, as well as sway were compared between different groups (between-subject factor), and different task conditions (within-subject factor) by a mixed model ANOVA.ResultsKinematic metrics and balance parameters were differently altered across different gait disorders compared to healthy controls. Overall, NPH patients significantly differed from controls in all movement parameters except for stride time, while they differed in balance parameters only with regard to AP movement. LST patients had significantly reduced ROMs of the shoulders, hips, and ankles, with significantly altered balance parameters regarding AP movement and passed center-of-pressure (COP) distance. CM patients differed from controls only in the ROM of the hip and ankle, but were affected in nearly all balance parameters, except for force distribution.ConclusionThe application of inertial measurement systems and pedobarography is feasible in an outpatient setting in patients with different neurological gait disorders. Rather than defining singular discriminative values, kinematic gait and balance metrics may provide characteristic profiles of movement parameter alterations in the sense of specific ´gait signatures´ for different pathologies, which could improve diagnostic accuracy by defining objective and quantifiable measures for the discrimination of different neurological gait disorders.Trial registrationThe study was retrospectively registered on the 27th of March 2023 in the ‘Deutsches Register für Klinische Studien’ under the number DRKS00031555.

Analysis of drug provision for patients with broncho-obstructive diseases in the Russian Federation

Introduction. The article presents data from an analysis of drug provision for patients with bronchial asthma and chronic obstructive pulmonary disease, both in inpatient conditions and at the stage of outpatient treatment. The object of the study was the provision of medications to patients with broncho-obstructive diseases in the constituent entities of the Russian Federation. The purpose of our study was to study drug provision for patients with broncho-obstructive diseases. Why the following research methods were used: purchases of medicines in federal districts and some constituent entities of the Russian Federation in 2019–2022 were analyzed, the amount of funds per patient diagnosed with bronchial asthma or chronic obstructive pulmonary disease was calculated. Separately, we analyzed the purchases of short- and long-acting bronchodilators, as well as mono- and combination drugs and monoclonal antibody drugs for the treatment of patients with bronchial asthma. Data on drug purchases were analyzed using the website zakupki.gov.ru; information on the number of patients in federal districts and constituent entities of the Russian Federation was taken from statistical materials of the Russian Ministry of Health. Results. We found a multiple difference between federal districts in the amount of funds per patient in both 2019 and 2022, and differentiation between federal districts also turned out to be the case when analyzing preferential drug coverage. The dynamics of the amounts of funds spent by entities on the purchase of drugs for the treatment of patients in outpatient settings turned out to be multidirectional: some entities not only did not increase these amounts in 2012 compared to 2019, but, on the contrary, decreased them. At the same time, the difference between the subjects of the same federal district reaches tenfold values. Conclusion. Patients with broncho-obstructive diseases living in different federal districts of the country have different drug coverage both in outpatient and inpatient treatment settings. To improve the drug supply for these patients, it is necessary to introduce a unified methodology for calculating the planned need for drugs and oblige the subjects to provide patients with chronic obstructive pulmonary disease with drugs at the expense of the budgets of the subjects.

687. Zinplava Expert Retrospective Observations (ZERO) Study Findings on Clostridioides difficile Recurrence

Abstract Background Describe real world experience in the use of bezlotoxumab (BZT) for the prevention of recurrent Clostridioides difficile(CDI) infection with a 1 year follow up following administration. The original BZT studies showed approximately 16% rate of recurrence at 12 weeks with other baseline and outcome data as noted in Figure 1. Methods Retrospective study of patients administered BZT in a community based private practice infusion suite from May 2017 to October 2020. A total of 50 consecutive patients were included with background demographics, relevant medical history and CDI history obtained through chart review. In addition to the chart review, patients were contacted at least 1 year after BZT administration to see if there were any recurrences and if other treatments were required. Primary objective was to show the rate of CDI recurrence in the 1 year after BZT administration. All BZT was administered in an outpatient setting in patients who were responding to initial Standard of care (SOC) therapy. Results 50 patients were included with infusion dates from May 2017 to October 2020. Baseline patient characteristics (Figure 2) include median Age of 69 and 74% female. CDI history (Figure 3) includes an average of 2.06 episodes including the current episode at time of time treatment and median of 19.5 days to BZT administration from last positive episode (positive test or starting a new treatment course for presumed positive). SOC treatments over the course of patient’s episodes are listed in Figure 3, most patients received more than agent. In the 1 year following BZT only 4 patients had recurrence (Figure 4) with 2 going on fecal microbiota transplant. There were 3 deaths reported, all at least 3 months after BZT and none had CDI recurrence. Conclusion In our real-world use, BZT administered in an outpatient setting to patients who responded to SOC treatment resulted in only 8% recurrence after 1 year compared to 16% after 12 weeks in the trial. This supports the existing guidelines on the use of BZT in patients over 65 and with recurrent CDI to prevent further recurrence. Our data also supports administration later in the course of therapy when patients have achieved initial response. Disclosures MICAH JACOBS, Micah Jacobs, MD, FIDSA, FACP, Abbvie: Honoraria|Cumberland Pharmaceuticals: Honoraria|Merck: Grant/Research Support|Spero Pharmaceuticals: Advisor/Consultant

Abstract 14711: Prediction of Persistent High-Need High-Cost Cardiology Patients With and Without Renal Failure

Introduction: Heart failure (HF) and coronary artery disease (CAD) are increasingly complex disease entities, in particular in older patients with multiple long-term conditions. High-Need High-Cost (HNHC) patients are at risk of receiving inefficient care that does not contribute to better outcomes. Prediction models may help to identify patients at risk of becoming HNHC with potential benefit for care coordination interventions. Aim: To predict persistent HNHC status at outpatient presentation for cardiovascular populations with HF, CAD, with and without renal failure (HF&amp;RF; CAD&amp;RF). Methods: We performed a retrospective cohort study in the claims database of a large healthcare insurer in the Netherlands. We included patients with consecutive data between 2015 - 2019, at their first outpatient appointment in 2016. Potential predictors were based on the previously published Persistent High Utilizer (PHU) model and collected in the year prior to presentation. HF, CAD and RF were defined by Diagnosis Treatment Combination insurance codes. The outcome of interest was PHU status, defined as belonging to the top 10% of total annualized healthcare expenditures for three consecutive years. To account for inflation, all costs were scaled towards 2015. Predictor effects were quantified through logistic multivariable regression analysis as odds ratios. Models were validated internally by bootstrapping procedure. Model performance was assessed as discrimination, quantified by the C-statistic. Results: 219.567 patients were included, of whom 2.0% ( n =4286) became PHU. The most important predictors were chronic kidney disease diagnosis (OR 3.1 95%CI 2.4-4.1), gastroenterology involvement (OR 3.0 95%CI 2.7-3.3) and COPD diagnosis (OR 2.1 95%CI 1.8-2.5). Model performance in the overall population was good (C-statistic 0.77). Model performance varied in the more homogeneous populations with HF ( n =2261; n =157 PHU), CAD ( n =7221; n =292 PHU), HF&amp;RF ( n =163; n =40 PHU) and CAD&amp;RF ( n = 196; n =34 PHU) resulting in C-statistics of 0.74, 0.78, 0.60 and 0.67 respectively. Conclusions: Persistent HNHC status can be predicted in the outpatient setting for patients with HF and CAD. These models can be used to select cardiology patients for HNHC care coordination.

Assessment of the effectiveness of measures to improve the patient routing system in the provision of planned medical care (experience of Tomsk region)

Introduction. This article reviews the results of the development and implementation of organizational solutions aimed at reducing the time of providing routine medical care to patients in outpatient settings and increasing its availability. Among the reasons negatively affecting the waiting times for medical care are complex routing schemes and the high level of administrative overhead that accompanies each stage of the treatment and diagnostic process.Aim: To develop and evaluate the effectiveness of measures to improve the system of organization of planned medical care on the example of medical organizations of Tomsk region.Material and Methods. The study included medical organizations providing primary health care in outpatient settings (31 institutions). The study was conducted in stages: 2018–2019 the main set of measures (creation of offices of the organization of planned care) was developed and implemented, 2020–2021 – summarized interim results, 2022 – performance assessment was carried out. For comparative analysis all medical organizations were divided into 2 groups (group A and group B) depending on implementation of planned activities. Statistical processing was performed using the Statistica 10.0.228.8 software package.Results. It was found that the waiting time for a doctor’s consultation Group A reduced by 5.5% (p = 0.025) in 2019 compared with 2018, in contrast to Group B. The waiting time for a routine diagnostic examination in Group A also reduced by 16.6% in 2019 compared to 2018 (p = 0.041), while no differences were found between waiting times for routine diagnosis in Group B for the same period (p = 0.101).Summary. The study has shown that the problems of accessibility of planned medical care can be effectively solved through the creation of a patient flow management system at all stages of the treatment and diagnostic process.

Improving Pharmacist-Led Pediatric Patient Education on Oral Chemotherapy at Home.

Oral chemotherapy (OC) has been increasingly used in pediatric patients diagnosed with cancer, which is primarily managed in the outpatient setting. Different from adults, pediatric patients face unique challenges in administering these hazardous medications at home. Because of the complexity of pediatric pharmaceutical care and the hazardous nature of chemotherapy agents, comprehensive patient education is imperative to mitigate the potential safety risks associated with OC administration at home. Pharmacists play a vital role in patient education and medication consultations. However, the lack of practice guidelines and limited resources supporting OC counseling are noted. Additional barriers include insufficient knowledge and training on OC, which can be improved by continuing education. In a regional children's hospital, a comprehensive OC education checklist was developed for pediatric patients and their caregivers to standardize consultations led by pharmacists. An infographic OC handout was also formulated to improve patient knowledge and awareness. Moreover, innovative approaches such as using telepharmacy, smartphone applications, and artificial intelligence have been increasingly integrated into patient care, which can help optimize OC consultations for children and adolescents. Further studies are warranted to enhance oral chemotherapy education specifically tailored for pediatric patients in outpatient settings.

Risk Factors Associated With Polypharmacy and Potentially Inappropriate Medication Use in Ambulatory Care Among the Elderly in the United States: A Cross-Sectional Study.

Polypharmacy, defined as the concurrent use of multiple (commonly five or more) prescription drugs, is widely prevalent among the elderly. It is a preventable and significant contributor to morbidity and mortality among older people. It is linked to prescribing potentially inappropriate medications (PIMs), which have been shown to be associated with an increased risk of adverse drug interactions and reduced compliance, and in some cases result in prescribing cascades where more drugs are prescribed to manage adverse outcomes. This study aimed to examine risk factors associated with polypharmacy and PIMs among elderly patients in outpatient settings in the US. We conducted a cross-sectional analysis using the nationally representative National Ambulatory Medical Care Survey, between 2010 and 2016. We extracted data from all people aged 65 years or older and evaluated factors associated with polypharmacy and PIMs using multivariable logistic regression. Weights were applied to obtain national estimates. During the study period, there were a total of 81,295 ambulatory visits among adults 65 years and older. Being a woman (compared with a man) was more likely to be associated with greater prevalence of PIMs (OR: 1.31, 95% CI 1.23-1.40), and living in rural areas were more likely to be associated with both polypharmacy (OR: 1.15, 95% CI 1.07-1.23) and PIMs (OR: 1.19, 95% CI 1.09-1.29), compared with living in urban areas. Older age was positively associated with polypharmacy (OR: 1.08, 95% CI 1.06-1.10), but negatively associated with PIMs (OR: 0.97, 95% CI 0.95-0.99). Our study suggests age, being a woman, and living in rural areas are risk factors for both polypharmacy and PIMs usage. Aside from primary care providers' roles in managing polypharmacy, collaborative care with other specialty providers, such as clinical pharmacists, should also be considered as an approach to improving the quality of prescribing in geriatric patients. Future research should further explore reasons for polypharmacy and focus on deprescribing and quality improvement initiatives in primary care to lower polypharmacy among the elderly.

Chairside Yoga Therapy Alleviates Symptoms in Patients Concurrently Receiving Outpatient Cancer Infusions: A Promising Feasibility Study.

Purpose: To evaluate effectiveness of chairside yoga therapy on perceptions of fatigue, pain, nausea, anxiety, and distress among oncology patients concurrently receiving outpatient cancer infusion therapy. Design: This prospective pilot study used pre-/post-survey design in convenience sample of cancer patients in outpatient setting. Methods: Researchers developed and administered the Outpatient Cancer Symptom Assessment Scale (OCSAS) comprised of cancer- or treatment-related symptoms commonly reported in the oncology population (nausea, pain, fatigue, anxiety, and distress). Following IRB approval, symptoms were rated using Likert scale of 0 (not present) to 10 (severe) before and after chairside yoga therapy delivered concurrently with outpatient infusions. Qualitative data was collected related to patients' overall infusion experience. Findings: Participants (n = 82) reported positive patient experiences and statistically less pain (p < 0.001), fatigue (p < 0.001), anxiety (p < 0.001), and distress (p < 0.001) following the yoga intervention compared to baseline. Nausea was not significantly impacted by the yoga intervention. Conclusions: Yoga therapy received concurrently during outpatient cancer infusion is consistent with a holistic and integrative approach to care for the oncology population. Yoga therapy offers promise for reducing symptoms which negatively impact quality of life, including pain, fatigue, anxiety, and distress. Qualitative data suggests patients' overall infusion experience was enhanced with yoga therapy.

Advanced practice provider–led clinic for care transitions in newly diagnosed venous thromboembolism: establishment and utilization

BackgroundPatients with suspected or newly diagnosed venous thromboembolism (VTE) are often referred to the emergency department (ED) for management, where anticoagulation is initiated. However, when the patient is judged to be suitable for outpatient management, counseling and follow-up specialty care are frequently suboptimal. ObjectivesTo establish an advanced practice provider (APP)–led rapid follow-up clinic to improve transitions of care for patients with newly diagnosed deep vein thrombosis or low-risk pulmonary embolism and to provide continued specialty care and support, including management of complications and medication access issues. MethodsIn order to address this gap in transition of care, we developed an APP-led clinic with a mandate to improve quality and safety in the outpatient setting for patients with acute VTE. ResultsIn the first 2 years, a total of 234 patients were evaluated, of whom data were standardized and reviewed for 229. Utilization steadily increased over time, with at least 10% of patients requiring financial medication assistance over both years. Seventy-two percent of patients were referred from the ED in the first year and 59% in the second year, and referrals from non-ED outpatient specialties increased. Data on deviations from standard care identified in referred patients were collected in the second year and found in 19 (12.7%) of cases. These included unnecessarily prescribed or changed anticoagulants, dosing errors, misclassification of thrombosis, and other deviations. Patient demographic data also demonstrated increasing diversity of the patient population over time, with increased utilization by Hispanic and African American patients in the second year. This highlighted the need for better patient education material translations into Spanish, which is a future aim. ConclusionIn summary, the APP-led VTE Transition Clinic was feasible and grew quickly in utilization, diversity of referrals, and diversity of patients served.

P866 Skin lesions among consecutive Inflammatory bowel disease patients in outpatient setting

Abstract Background It is well known that skin lesions may be frequent extraintestinal manifestations of inflammatory bowel diseases (IBD). During literature analysis we found out that there is an obvious lack of epidemiological data regarding this issue. Therefore, the aim of our study was to establish the prevalence of skin lesions among consecutive IBD patients in outpatient department. Methods Prospective study included out-patients with IBD who were managed in the hospital of Lithuanian University of Health Sciences from January to October of 2022. Patients completed the questionnaires including the demographic and the IBD data and history or present state of cutaneous lesions. We considered skin lesions related to IBD or its treatment if they were diagnosed following the diagnosis of IBD. Skin lesions which were reported before the diagnosis of IBD were considered as not related to IBD. Results 152 patients were included, mean age (MA) – 42.0±13.9 years. There were 88 (57.9%) males and 64 (42.1%) females. Ulcerative colitis (UC) was diagnosed in 110 (72.4%) patients, Crohn’s disease (CD) – in 42 (27.6%) patients. MA of UC patients was 42.3±13.6, CD – 41.1±14.9, p&amp;gt;0.05. In total, skin lesions were indicated by 65 (42.8%) subjects. According to our criteria, in 46 (30.3%; 95% CI: 23-38%) cases, skin lesions were considered as obviously related to IBD or its treatment. We further analyzed latter cases. Among UC patients, 32 (29.1%; 95% CI: 20-38%) had skin lesions related to IBD, among CD patients – 14 (33.3%; 95% CI: 18-48%), p&amp;gt;0.05. Erythema nodosum was diagnosed in 6 (3.9%) patients, pyoderma gangrenosum – 5 (3.3%), acne – 1 (0.7%), psoriasis – 9 (5.9%), vitiligo – 2 (1.3%), epidermolysis bullosa acquisita – 1 (0.7%), hemorrhagic vasculitis – 1 (0.7%), eczema – 9 (5.9%), allergic rash – 4 (2.6%). The comparison of different skin lesions among UC and CD patients is presented in table 1. Among the patients with UC proctitis, skin lesions were reported in 2 of 15 (13.3%) patients; among left-sided colitis – in 8 of 27 (29.6%); among pancolitis – in 22 of 67 (32.8%), p=0.03 between the groups of proctitis and pancolitis. Comparing the different forms of CD, skin lesions were reported in 3 of 15 (20.0%) patients with ileitis, 4 of 10 (40.0%) patients with colitis and 7 of 17 (41.2%) patients with ileocolitis; p&amp;gt;0.05 between different groups. Conclusion In our series the prevalence of skin lesions obviously related to IBD or its treatment is 30.3%. There were no differences in the prevalence of skin lesions between the UC and CD patients. The most common skin lesions in UC were psoriasis and skin eczema, in CD – erythema nodosum and skin eczema. Cutaneous lesions were significantly more prevalent in extensive UC compared to distal disease.

890: THERAPEUTIC USE OF INHALED CORTICOSTEROIDS IN COVID-19: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction: Previous randomized trials suggest the benefit of inhaled budesonide for COVID-19 patients in outpatient settings. We evaluated available studies on the effect of the therapeutic use of inhaled corticosteroids (ICS) on mortality and pertinent clinical outcomes. Methods: A comprehensive literature search was conducted across the WHO, LitCOVID, and EMBASE databases from inception until June 30th, 2022. The primary outcome was overall mortality and secondary outcomes included symptom-based clinical improvement rates at day 14, ER visits or hospitalization, and adverse events. Data analysis was performed using Review Manager Software, version 5.2, to evaluate the combined odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model. Results: Nine studies (7 RCTs (3 budesonide, 3 ciclesonide, 1 fluticasone RCTs), & 2 observational studies) were included in the mortality meta-analysis. Of the 3,934 patients included, 103 patients died (44 out of 1925 in the ICS group and 59 out of 2009 in the non-ICS group). The odds of mortality in the therapeutic ICS use group were lower compared to the non-ICS therapy group (OR 0.78, 95% CI 0.48-1.28, p-value=0.33, I2=0%). The result was statistically insignificant, possibly due to the low mortality rate. But therapeutic ICS showed statistically significant clinical improvement rates at day 14 (5 RCTs; 3 Ciclesonide, 2 Budesonide) (OR 1.56, 95% CI 1.31-1.86, p < 0.0001, I2=0%). The number of ED visits/Hospitalization rate, and adverse events were not statistically significant between the groups (OR 0.73, 95% CI 0.32-1.70, p= 0.47 I2=75% and OR 1.10 95% CI 0.67-1.82, p=0.70, I2=28%). Conclusions: This meta-analysis shows that the therapeutic use of ICS in COVID-19 is associated with higher symptom-based clinical improvement rates. Although the reduction in mortality odds remained insignificant, as the overall mortality rates were low which increased the confidence interval overall. Early administration of ICS showed a trend towards the reduced likelihood of urgent care needs. Well-designed trials are needed to explore ICS efficacy in patients with a high risk of disease progression and in reducing the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2.

Establishment and Utilization of an Advanced Practice Provider-Led Clinic for Newly Diagnosed Venous Thromboembolism

BACKGROUND: Evidence supports treating most patients with venous thromboembolism (VTE) as outpatients. There is hesitancy among some healthcare providers to manage patients with these high-risk acute conditions, on high-risk medications, without close and reliable follow-up. In the era of direct oral anticoagulants (DOACs), the financial complications associated with appropriate anticoagulation further complicate management. The benign hematology group at the University of North Carolina (UNC) at Chapel Hill developed an Advanced Practice Provider (APP)-led clinic to address this area of need, aiming to improve efficacy and safety in the outpatient setting for patients with acute VTE. METHODS: An APP-led acute VTE clinic, "Walk-In DVT Clinic", located within Benign Hematology was established with one appointment reserved each weekday. Patients with newly diagnosed VTE can be referred by any UNC-affiliated provider. A triage system with direct pager and phone line ("1-DVT") is available during business hours. For patients referred after-hours through the Emergency Department (ED), direct scheduling is available 24 hours/day. Patients are seen by the APP (physician assistant or nurse practitioner) with hematologist oversight. Pharmacist support is available for questions about drug interactions, medication access, and other needs. Patient education and counseling on diagnosis and anticoagulation is provided. Patients are evaluated for risk factors which contributed to the VTE, and follow-up for longer-term discussion of anticoagulation plans is scheduled. Following appointment, patients have access to nurse and provider assistance for bleeding complications, anticoagulation management for surgical/procedural planning, medication access, or other complications. Here we present demographics and referral data for patients seen in the first two years. RESULTS: Since initiation, a total of 234 patients have been seen, of which data was available for 229. Specifically, 84 in the first year (8/24/20 through 7/31/21) and 150 in the second year (8/1/21 through 7/31/22). Of these, 72% were ED referrals, and 12.7% required financial assistance of some kind. In the second year, 59.3% of referrals were ED, and 10% required medication assistance of some kind. Patient demographics are listed in the table below. In the second year, significant changes in medical plan (examples: dose errors, misdiagnosis) were identified in 19 cases (12.67%). The median time to appointment in the first year was 4 days and in the second year was 5 days (including weekend days). DISCUSSION: The "Walk-In DVT” clinic grew quickly in its first year and continued to grow in the second year, nearly doubling in utilization. In the first year, time-to-visit median was 4 days, and the program's aim was to decrease this. However, with increased utilization, this metric increased to 5 days. As a consequence, a second APP has been hired to improve access. The types of providers referring to the clinic diversified, with more referrals from surgical and medicine specialties and a lower overall percentage of ED follow-ups. This finding supports progress in one goal of the clinic, to have providers who diagnose a VTE refer directly to the DVT Walk-In Clinic rather than send them to the ED. Expanding the network of outpatient providers using the clinic is a future goal. The demographics of patients showed an increase in use by African American and Hispanic patients. Importantly, the increase in Hispanic patients has highlighted the need for better patient education materials translated to Spanish, prompting efforts to produce and translate new materials. In summary, since its inception, the APP-led "DVT Walk-In Clinic” has grown in utilization, diversity of referrals, and diversity of patients served, with new focus on patient education tools and expanding access. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Professional Case Management in Outpatient Settings for Patients With Myeloproliferative Neoplasms.

Professional Case Management in Outpatient Settings for Patients With Myeloproliferative Neoplasms.

Professional Case Management in Outpatient Settings for Patients With Myeloproliferative Neoplasms.

The purpose of this discussion is to review the management and symptomatic burden of patients with myeloproliferative neoplasms (MPNs). Patients with MPNs are at increased risk for thromboembolic events; thus, cardiovascular complications are not uncommon. Professional case managers can coordinate outpatient services with the health care team and assist patients to mitigate cardiovascular complications. This discussion is relevant to professional case managers who manage patients with chronic conditions in outpatient settings. Professional case managers can intervene for patients with MPNs to improve (a) coordination of scheduled therapeutic phlebotomy procedures, and (b) education about subcutaneous injections and frequent monitoring of laboratory reports. In the outpatient setting, professional case managers can improve health care utilization for patients with MPNs and promote high-quality self-care and symptom management to prevent adverse complications. As a member of the outpatient health care team, the professional case manager can serve as a key clinician with comprehensive knowledge of the patient's experience of living with an MPN, their usual state of health and symptoms, and the factors affecting their quality of life. This article explores the role of the professional case manager in the outpatient setting and suggests specific interventions to improve delivery of care and contribute to better self-care management. Professional case managers can assess and validate symptom burden, coordinate and manage routine laboratory testing, support careful medication adjustment, and contribute to improved health outcomes.

Diagnostic Accuracy of a Bacterial and Viral Biomarker Point-of-Care Test in the Outpatient Setting

Acute respiratory infections (ARIs) account for most outpatient visits. Discriminating bacterial vs viral etiology is a diagnostic challenge with therapeutic implications. To investigate whether FebriDx, a rapid, point-of-care immunoassay, can differentiate bacterial- from viral-associated host immune response in ARI through measurement of myxovirus resistance protein A (MxA) and C-reactive protein (CRP) from finger-stick blood. This diagnostic study enrolled adults and children who were symptomatic for ARI and individuals in a control group who were asymptomatic between October 2019 and April 2021. Included participants were a convenience sample of patients in outpatient settings (ie, emergency department, urgent care, and primary care) who were symptomatic, aged 1 year or older, and had suspected ARI and fever within 72 hours. Individuals with immunocompromised state and recent vaccine, antibiotics, stroke, surgery, major burn, or myocardial infarction were excluded. Of 1685 individuals assessed for eligibility, 259 individuals declined participation, 718 individuals were excluded, and 708 individuals were enrolled (520 patients with ARI, 170 patients without ARI, and 18 individuals who dropped out). Bacterial and viral immunoassay testing was performed using finger-stick blood. Results were read at 10 minutes, and treating clinicians and adjudicators were blinded to results. Bacterial- or viral-associated systemic host response to an ARI as determined by a predefined comparator algorithm with adjudication classified infection etiology. Among 520 participants with ARI (230 male patients [44.2%] and 290 female patients [55.8%]; mean [SD] age, 35.3 [17.7] years), 24 participants with missing laboratory information were classified as unknown (4.6%). Among 496 participants with a final diagnosis, 73 individuals (14.7%) were classified as having a bacterial-associated response, 296 individuals (59.7%) as having a viral-associated response, and 127 individuals (25.6%) as negative by the reference standard. The bacterial and viral test correctly classified 68 of 73 bacterial infections, demonstrating a sensitivity of 93.2% (95% CI, 84.9%-97.0%), specificity of 374 of 423 participants (88.4% [95% CI, 85.0%-91.1%]), positive predictive value (PPV) of 68 of 117 participants (58.1% [95% CI, 49.1%-66.7%), and negative predictive value (NPV) of 374 of 379 participants (98.7% [95% CI, 96.9%-99.4%]).The test correctly classified 208 of 296 viral infections, for a sensitivity of 70.3% (95% CI, 64.8%-75.2%), a specificity of 176 of 200 participants (88.0% [95% CI, 82.8%-91.8%]), a PPV of 208 of 232 participants (89.7% [95% CI, 85.1%-92.9%]), and an NPV of 176 of 264 participants (66.7% [95% CI, 60.8%-72.1%]). In this study, a rapid diagnostic test demonstrated diagnostic performance that may inform clinicians when assessing for bacterial or viral etiology of ARI symptoms.