Outpatient Testing Research Articles

Clinical Testing Guidance for Coccidioidomycosis, Histoplasmosis, and Blastomycosis in Patients With Community-Acquired Pneumonia for Primary and Urgent Care Providers.

Coccidioidomycosis, histoplasmosis, and blastomycosis are underrecognized and frequently misdiagnosed fungal infections that can clinically resemble bacterial and viral community-acquired pneumonia. This guidance is intended to help outpatient clinicians test for these fungal diseases in patients with community-acquired pneumonia to reduce misdiagnoses, unnecessary antibacterial use, and poor outcomes.

THU624 Opioid Induced Adrenal Insufficiency (OIAI) Presenting With Altered Mental Status

Abstract Disclosure: D. Bondarenko: None. M. Ahmad: None. G.A. McGrath: None. Background: Opioid suppression of the hypothalamic-pituitary-adrenal (HPA) axis via inhibition of corticotropin releasing hormone secretion leading to secondary adrenal insufficiency (AI) has been described in literature. Biochemical secondary AI is evident in 6-50% of patients on chronic opioids; fewer cases are reported presenting with clinical AI.1 We present a rare case of symptomatic opioid-induced AI (OIAI) with clinical improvement on initiation of hydrocortisone. Clinical Case: A 49-year-old female on daily buprenorphine (20 mg) and naltrexone (5 mg) presented to the hospital with syncope and hypotension (79/49 mmHg). AM cortisol was 6.2 mcg/dL, a cosyntropin stimulation test was performed, but there was technical difficulty with the results. She was started on midodrine 2.5 mg three times daily and referred to outpatient endocrinology for follow up. Weeks later, outpatient cosyntropin stimulation test showed baseline cortisol of 18 mcg/dL with increase to 26 mcg/dL. Simultaneous adrenocorticotrophic hormone (ACTH) was 16.9 pg/mL. AI was ruled out. Seven years later she presented with acute lethargy, confusion, and memory loss over several days. AM cortisol was 1.6 mcg/dL and cosyntropin stimulation test increased cortisol to 15.1 mcg/dL (normal response being 18 mcg/dL or greater). ACTH was 24 pg/mL. The abnormal cosyntropin stimulation test results are consistent with AI, and lack of elevation of morning ACTH is consistent with secondary AI.2 Hydrocortisone therapy was started and midodrine was held due to elevated blood pressure after initiation of steroids. She was discharged on hydrocortisone 15 mg each morning and 5 mg each afternoon. Within 10 days of initiation of glucocorticoid replacement therapy her neurologic symptoms improved and midodrine discontinued. Prescription Drug Monitoring Program (PDMP) review shows reduction of buprenorphine (16 mg) and naltrexone (4 mg). Conclusion: Data on management of OIAI and recovery of the HPA axis with or without cessation of opioid therapy is limited. This case highlights that opioids should be considered as a potential cause of secondary AI. Further follow-up of this case and other OIAI cases would provide insight into management of opioid therapy, continuation of glucocorticoid therapy, and recovery of HPA axis. This data could provide basis for OIAI management recommendations. Reference: (1) Fountas, A., Prof, S.V.U., Karavitaki, N. Opioid-induced endocrinopathies. Lancet Diabetes Endocrinol. 2020;8(1);68-80. (2) Bornstein, S.R., Allolio, B., Arlt, W., et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocr. 2016;101(2);364-389. Presentation: Thursday, June 15, 2023

FRI400 A Rare Case Of Acute Sheehan's Syndrome In An Antepartum Patient

Abstract Disclosure: E. Jalal: None. C. Baldwin: None. Sheehan’s syndrome (SS) is a known complication of postpartum hemorrhage. It is typically diagnosed several years after birth given slow symptom onset related to hypopituitarism. We report a rare case of life-threatening antepartum pituitary ischemia secondary to hypotension, representing an acute presentation of SS. A 19-year-old primigravid woman at 31 weeks of gestation was admitted to the intensive care unit for septic shock secondary to Klebsiella pneumoniae pyelonephritis. Despite appropriate treatment, persistent hypotension prevented weaning of vasopressor support. Due to concurrent mild hyponatremia, the following studies were obtained: morning cortisol (2.46 mcg/dL [4.5-23 mcg/dL]), thyroid stimulating hormone (TSH) (0.379 IU/L [0.47-4.7 IU/L]), free triiodothyronine (2.1 pg/mL [2.8-5.3 pg/mL]), and free thyroxine (0.77 ng/dL [0.7-1.8 ng/dL]). Endocrinology was consulted for evaluation of adrenal insufficiency and abnormal thyroid function tests. Her prolactin was measured at 10.3 ng/mL, far below the expected range in a 3rd trimester pregnancy (35-600 ng/mL). Her remaining anterior pituitary hormone panel was unremarkable. MRI brain without contrast showed no evidence of an acute stroke or hemorrhage and commented that the prominence of the pituitary gland was likely related to current pregnancy. Stress dose hydrocortisone 100mg thrice daily and levothyroxine 50 mcg daily were initiated, allowing for weaning of vasopressor support. By discharge, she was titrated to levothyroxine 75mcg daily and hydrocortisone 20mg in the morning and 5mg in the afternoon. Repeat outpatient pituitary function testing found increase of prolactin to 397 ng/mL (35-600 ng/mL) and of IGF-1 to 486 ng/mL (113-408 ng/mL) as well as normalization of TSH to 3.210 (0.45-4.5IU/L), indicating likely recovery of pituitary axis. When readmitted at 38 weeks gestation for scheduled induction, she was given stress dose hydrocortisone 100mcg for labor. On discharge, she was tapered to prednisone 10mg daily and levothyroxine 50mcg daily. Appropriate hormone replacement and stress dose hydrocortisone resulted in an uncomplicated delivery and signs of clinical pituitary recovery postpartum as she was able to breastfeed without need for supplementation and maintain normotension after self-discontinuing prednisone and levothyroxine. The leading diagnosis to explain this patient’s hypopituitarism is acute SS, which is defined as symptom onset within 6 weeks postpartum. In our case, septic shock caused an abrupt onset of persistent hypotension leading to hormone levels suggestive of panhypopituitarism while the patient was pregnant at 31 weeks of gestation, which has not been reported in prior literature. While known as a chronic diagnosis in the postpartum population, further research should explore possible stunning effect of acute hypotension manifesting as acute SS in peripartum patients. Presentation: Friday, June 16, 2023

SAT529 An Uncommon Case Report Of A Paraaortic Paraganglioma

Abstract Disclosure: E. Askar: None. J.R. Fredrick: None. S. Anantha: None. K.G. Reddy: None. Background: Extraadrenal pheochromocytomas, also known as paragangliomas are uncommon neuroendocrine tumors that develop from sympathetic ganglia chromaffin cells. These tumors rarely cause hypertension, in less than 0.2% of patients. Although pheochromocytomas are known to be secreting catecholamines, paragangliomas are less likely to be functional. Here we report a rare case of Catecholamine secreting Paraganglioma presenting with hypertension. Clinical Case: A 28 -year-old female with past medical history of Goldenhar syndrome presented to our outpatient institution complaining of headache, palpitations and high blood pressure measurements at home with systolic blood pressure ranging between 160-200 mm Hg for a few months prior to presentation. Her only medication was propranolol for hypertension. At presentation, blood pressure was 126/72 mm Hg, heart rate was 76 beats per minute. Physical examination revealed no significant findings. Abdominal exam did not reveal any palpable masses. The patient denied any history of substance, tobacco, or alcohol abuse. No family history was found for any similar masses or hypertension. Laboratory findings were significant for elevated normetanephrines at 785 pg/mL (18 to 111) with normal metanephrines level. CT abdomen was significant for 2.5 cm enhancing left paraaortic mass separate from kidneys and adrenal glands. The patient was started on doxazosin and propranolol was switched to atenolol. After her blood pressure was adequately controlled with the alpha and beta blockade, she was referred to a tertiary facility for excision of the mass. Robotic excision of the mass was performed successfully without any significant blood pressure variations noted intraoperatively. The diagnosis of a well differentiated extraadrenal pheochromocytoma was confirmed by pathology, and the patient was referred for outpatient genetic testing and endocrinology follow up. Conclusion: This is an extremely rare case of paraganglioma given its presentation and location of the mass. The previously reported paragangliomas usually present as ER visits with severe sympathetic symptoms but it is uncommon to present as an outpatient for secondary hypertension workup. In the literature, we have found case reports of catecholamine secreting paragangliomas which guided the management of this uncommon case as mentioned above. Clinicians must be aware of this rare presentation of paraganglioma in order to properly diagnose and manage the condition.

FRI165 BIUXX

Abstract Disclosure: A. Haider: None. M. Sadiq: None. J. Shakesprere: None. G.K. Sidhu: None. Background: Syndrome of inappropriate anti-diuretic hormone (ADH) secretion (SIADH) is characterized by inappropriate ADH secretion causing hyponatremia due to free water retention. Plasma volume expansion leads to renin inhibition by the renal juxtaglomerular complex, resulting in decreased aldosterone secretion with inappropriate natriuresis. However, when autonomous renin-independent aldosterone production is present, natriuresis can be suppressed, causing normal sodium levels despite inappropriately high ADH. Case: 58-year-old male with history of resistant hypertension & bipolar disorder on Oxcarbazepine presented with dizziness, lightheadedness, and severe hypokalemia (2.7 mmol/L, n 3.5-5.0 mmol/L). CT Adrenals revealed an incidental 1.2 cm left-sided adrenal adenoma [HU 6, 40% washout]. Serum aldosterone and plasma renin activity (PRA) were obtained in the supine position via LC/MS/MS assay; concurrent serum K+ was 3.4 mmol/L. Spironolactone was started and titrated to 50 mg BID for blood pressure control due to high suspicion of hyperaldosteronism. The patient was continued on Oxcarbazepine 900 mg BID. A 3 mg Dexamethasone suppression test showed suppressed morning cortisol (1.0 μg/dL, n <1.8 μg/dL). Urine catecholamines and metanephrines were obtained and normal. 3-4 days after starting Spironolactone, the patient developed severe subacute hyponatremia (119 mmol/L, n 135-145 mmol/L) from an admission level of 137 mmol/L. No active renal or GI losses, diuretic use, or untreated hypothyroidism were documented. Serum osmolality was low (262 mOsm/kg, n 275-295 mOsm/kg) with urine osmolality of 357 mOsm/kg (n 50-1200 mOsm/kg) and urine sodium of 92 mEq/L (n >20 mEq/L). Serum aldosterone and PRA levels returned with normal aldosterone (7 ng/dL, n 2-9 ng/dL) but suppressed PRA (0.07 ng/mL/hr, n 0.7-3.3 ng/mL/hr) and elevated aldosterone-renin ratio (100 ng/dL per ng/mL/hr, n ≤ 30 ng/dL per ng/mL/hr). As renin was very low despite mild hypokalemia and active Losartan use at the time of testing, these findings were suggestive of primary aldosteronism. In-hospital 24-hour urine aldosterone collection showed urine aldosterone of 29.3 mcg/24 h (n 5-19 mcg/24 h) with urine sodium of 93 mmol/ 24 h (n 40-220 mmol/24 h). Oxcarbazepine was subsequently tapered off; Spironolactone was intermittently held until complete discontinuation. Fluid restriction and oral salt repletion were started and the patient’s sodium ultimately normalized. Outpatient saline suppression testing and adrenal vein sampling were scheduled. Conclusion: Oxcarbazepine was likely causing high ADH release but co-occurring untreated hyperaldosteronism inhibited natriuresis. Use of Spironolactone unmasked natriuresis by blocking aldosterone activity on the intercalated cells of the renal nephron. Stopping Oxcarbazepine ultimately resulted in hyponatremia resolution. Presentation Date: Friday, June 16, 2023

FRI360 A Protracted Course Of Worsening Adrenergic And Neuroglycopenic Symptoms Due To Delay In Diagnosis Of Insulinoma

Abstract Disclosure: A. Karca: None. W. Lai: None. S. Naidoo: None. L.N. Saladi: None. B.C. Jameson: None. A 33-year-old Hispanic male presented with altered mental status, witnessed seizure and hypoglycemia (capillary BG 40mg/dL). Patient and family reported multiple episodes of symptomatic hypoglycemia and progressively worsening adrenergic and neuroglycopenic episodes with altered mental status requiring hospital admissions and evaluation for endogenous hyperinsulinemia in the past several months prior to admission. Patient was admitted to the ICU. Laboratory workup revealed documented hypoglycemia (venous BG 45mg/dL) and inappropriate insulin (17uU/mL, n3-25uU/mL), c-peptide (2.7ng/mL, n0.8-4.2 ng/mL) and pro-insulin (38.3 pmol/L, n<18.8 pmol/L) levels. Sulfonylurea and meglitinide screens were negative. Patient required continuous dextrose infusion as well as octreotide, with enteral feeding, to maintain BG >70mg/dL. Abdominal US, multiple CT scans, endoscopic US failed to locate source of endogenous hyperinsulinemia. Multi-discipline discussion among ICU team, Endocrinology, Interventional Radiology (IR), and Surgery considered MRI versus IR-guided selective arterial calcium stimulation (SACS) vs PET-CT NETSPOT with Ga-68 Dotatate, which had been ordered, but unable to be arranged prior to this admission. Ultimately, MRI with pancreatic protocol revealed 3.5cm exophytic solid mass arising from the tail of the pancreas and patient underwent laparoscopic hand-assisted distal pancreatectomy and splenectomy, with intraoperative ultrasound to confirm the location of the mass. Histologic examination revealed a well-differentiated neuroendocrine tumor. Chart review revealed documented hypoglycemia as far back as eight years prior to this admission, although no further results were available from that time to confirm endogenous source. Possible explanations for delay in diagnosis include patient health literacy, inaccessibility of outpatient testing, limitations of testing modalities, and access to staff skilled in more specialized testing, like PET-CT NETSPOT and SACS. Localizing techniques are divided into pre-operative and intra-operative, with pre-operative techniques further divided into non-invasive and invasive modalities. First line pre-operative testing includes US and CT, which have widely varying sensitivity depending on size and location of the tumor. MRI can have better sensitivity for smaller and distal tumors. PET-CT NETSPOT with Ga-68 Dotatate, has very high sensitivity and specificity in limited studies. If not localized with non-invasive modalities, SACS is an invasive modality with high sensitivity and specificity. Although insulinomas are a rare neuroendocrine tumor with challenging diagnostic workup, higher clinical suspicion with early biochemical workup, patient education, referral to endocrinology, better accessibility of diagnostic testing will help lead to timely diagnosis and management. Presentation: Friday, June 16, 2023

Evaluation of Hepatitis B Vaccination Status and Factors Affecting Response to Vaccination in HIV/AIDS Patients

Objective: Chronicity of acute HBV infection is higher in people living with HIV (PLWH) than in the general population. HIV/HBV coinfection has a higher risk of rapid progression to cirrhosis and liver-related death than in solely HBV-infected patients. Therefore, vaccination against HBV is recommended. In this study, we aimed to evaluate hepatitis B vaccination rates and the factors affecting response to the vaccine in PLWH. Methods: Outpatient follow-up files and laboratory test results at the hospital information system of 1394 patients aged >18 years diagnosed with HIV/AIDS and followed between January 1, 2007, and January 1, 2022, were evaluated retrospectively. Results: Of the PLWH, 81 (5.8%) had chronic hepatitis B infection, 114 (8.2%) had isolated anti-HBc IgG positivity, and 274 (19.6%) had a previous condition. 248 (17.7%) of the PLWH had been vaccinated before HIV/AIDS diagnosis. HBsAg, anti-HBc IgG and anti-HBs were negative in 673 PLWH. A total of 352 (44.7%) PLWHs were vaccinated, consisting of 63 (55.2%) of 114 PLWHs with isolated anti-HBc IgG positivity and 289 (42.9%) of 673 PLWHs with negative HBV serology. Immunity developed in 282 (84.1%) of those vaccinated. We found that the main factor determining the immune response was the CD4+ T lymphocyte count at the time of diagnosis, and there was a significant increase in immune response since 2015 when the recommendation of antiretroviral therapy independent of the CD4+ T lymphocyte level was implemented. We observed that comorbidities, age, gender, and sexual orientation did not significantly affect the vaccine response. Conclusion: Vaccination is critical in PLWH, and we observed that the ideal time for vaccination in those with negative HBV serology is when the CD4+ T lymphocyte count is >200 cells/mm³ and the viral load is suppressed. It should be considered that the vaccination rate and immune response will increase with the support of vaccination outpatient clinics, where vaccination status is closely monitored by healthcare personnel. Keywords: HIV/AIDS, hepatitis B vaccine, vaccination, vaccine respons

Real-World Treatment Effectiveness of Disease-Modifying Antirheumatic Drugs by Serostatus Among Patients With Rheumatoid Arthritis.

The objective of this study was to compare the clinical effectiveness of biologic disease-modifying antirheumatic drugs (bDMARDs) or Janus kinase inhibitors (JAKi) among seropositive versus seronegative patients with rheumatoid arthritis (RA) in a real-world setting. We used Optum's deidentified Clinformatics Data Mart Database (January 1, 2004, to March 31, 2021) linked with outpatient laboratory test results. The study population was adult patients with RA who initiated a bDMARD or JAKi. The index date was the dispensing of the first-ever study drug. At least 1-year continuous enrollment before and after the index date was required. Disenrollment due to death after the index date was allowed. Serostatus was defined using laboratory test results or the International Classification of Diseases, 10th Revision code M05x or M06.0x any time prior to the index date. Treatment effectiveness was measured based on a claims-based composite endpoint at 1-year post index, including nonoccurrence of any of the following: addition of conventional synthetic DMARDs, addition of or switching tonew bDMARDs/JAKi, initiation of glucocorticoids, increased glucocorticoid dose, or death. Log-binomial regression models were constructed to estimate the risk ratio (RR) with 95% confidence interval (CI) comparing seropositive patients with seronegative patients, adjusting for more than 60 baseline covariates. We identified a total of 7813 seropositive patients and 4202 seronegative patients. The mean (±SD) age was 56.7 (±14.0) years; 77.9% were female. The risk of 1-year treatment effectiveness was 70.2% among seropositive patients and 69.8% among seronegative patients. The adjusted RR (95% CI) was 1.00 (0.98-1.02). In this real-world cohort study, seropositive and seronegative patients with RA had similar 1-year treatment effectiveness after initiating a bDMARD/JAKi.

273 Improving frail care—is there a role for the geriatrician in elective waiting lists?

Abstract Background The perfect storm of an ageing population and recent pandemic has hugely impacted waiting lists. There is evidence for frailty assessment at point of referral as per the traditional Peri-Operative Care of Older People undergoing Surgery (POPS) model however our concern was for all those patients already on lengthy waiting lists. We obtained funding via the Bevan commission to look at whether a geriatrician had a role in reviewing need for surgery, intervening in medical issues and the best way to select the patients who would benefit. Methods We chose the cholecystectomy list to start as the ‘least frail’. We contacted all patients completing a modified CRANE (Comprehensive Risk Assessment and Needs Evaluation) questionnaire and frailty scoring. We offered a clinic appointment to any patient with a CFS (Clinical Frailty Score) over 4 or who triggered for frailty. Primary outcome was patients removed from the list, secondary outcomes included cost savings through avoiding further outpatient tests and consults, diagnoses made and patient feedback collected. Results Over 20% of patients were removed from the waiting list with a cost saving of around £250,000. 54 patients were offered clinic appointments, over 25 tests were ordered minimising delays in pre-operative assessment and diagnoses including dementia and hyponatraemia were made. Patient feedback was excellent. They felt there was an improvement in the health and social care needs being met following an outpatient appointment and raised the importance of good communication whilst waiting a procedure. The HFRS (Hospital Frailty Risk Score) showed the greatest specificity in selecting patients for clinic while the CRANE questionnaire was more sensitive. Conclusion Clearly geriatricians have a huge role to play in perioperative medicine. We have suggested a modified POPS model with a six monthly CFS score and CRANE questionnaire to identify patients who are becoming frailer while waiting. The project shows cost savings and decreased waits but more importantly improvement in patient care and satisfaction.

Using a Modified Delphi Panel to Estimate Health Service Utilization for Patients with Advanced and Non-Advanced Systemic Light Chain Amyloidosis.

Patients with diagnosed with systemic light chain (AL) amyloidosis at advanced Mayo stages have greater morbidity and mortality than those diagnosed at non-advanced stages. Estimating service use by severity is difficult because Mayo stage is not available in many secondary databases. We used an expert panel to estimate healthcare utilization among advanced and non-advanced AL amyloidosis patients. Using the RAND/UCLA modified Delphi method, expert panelists completed 180 healthcare utilization estimates, consisting of inpatient and outpatient visits, testing, chemotherapy, and procedures by disease severity and organ involvement during two treatment phases (the 1 year after starting first line [1L] therapy and 1 year following treatment [post-1L]). Estimates were also provided for post-1L by hematologic treatment response (complete or very good partial response [CR/VGPR], partial, no response or relapse [PR/NR/R]). Areas of disagreement were discussed during a meeting, after which ratings were completed a second time. During 1L therapy, 55% of advanced patients had ≥1 hospitalization and 38% had ≥2 admissions. Rates of hematopoietic stem cell transplant (HSCT) in advanced patients were 5%, while pacemaker or implantable cardioverter defibrillator (ICD) placement were 15%. During post-1L therapy, rates of hospitalization in advanced patients remained high (≥1 hospitalization: 20-43%, ≥2 hospitalizations: 10-20%), and up to 10% of advanced patients had a HSCT. Ten percent of these patients underwent pacemaker/ICD placement. Experts estimated advanced patients, who would not be good candidates for HSCT, would have high rates of hospitalization (traditionally the most expensive type of healthcare utilization) and other health service use. The development of new treatment options that can facilitate organ recovery and improve function may lead to decreased utilization.

Deferred Testing in Stable Outpatients With Suspected Coronary Artery Disease

Guidelines recommend deferral of testing for symptomatic people with suspected coronary artery disease (CAD) and low pretest probability. To our knowledge, no randomized trial has prospectively evaluated such a strategy. To assess process of care and health outcomes in people identified as minimal risk for CAD when testing is deferred. This randomized, pragmatic effectiveness trial included prespecified subgroup analysis of the PRECISE trial at 65 North American and European sites. Participants identified as minimal risk by the validated PROMISE minimal risk score (PMRS) were included. Randomization to a precision strategy using the PMRS to assign those with minimal risk to deferred testing and others to coronary computed tomography angiography with selective computed tomography-derived fractional flow reserve, or to usual testing (stress testing or catheterization with PMRS masked). Randomization was stratified by PMRS risk. Composite of all-cause death, nonfatal myocardial infarction (MI), or catheterization without obstructive CAD through 12 months. Among 2103 participants, 422 were identified as minimal risk (20%) and randomized to deferred testing (n = 214) or usual testing (n = 208). Mean age (SD) was 46 (8.6) years; 304 were women (72%). During follow-up, 138 of those randomized to deferred testing never had testing (64%), whereas 76 had a downstream test (36%) (at median [IQR] 48 [15-78] days) for worsening (30%), uncontrolled (10%), or new symptoms (6%), or changing clinician preference (19%) or participant preference (10%). Results were normal for 96% of these tests. The primary end point occurred in 2 deferred testing (0.9%) and 13 usual testing participants (6.3%) (hazard ratio, 0.15; 95% CI, 0.03-0.66; P = .01). No death or MI was observed in the deferred testing participants, while 1 noncardiovascular death and 1 MI occurred in the usual testing group. Two participants (0.9%) had catheterizations without obstructive CAD in the deferred testing group and 12 (5.8%) with usual testing (P = .02). At baseline, 70% of participants had frequent angina and there was similar reduction of frequent angina to less than 20% at 12 months in both groups. In symptomatic participants with suspected CAD, identification of minimal risk by the PMRS guided a strategy of initially deferred testing. The strategy was safe with no observed adverse outcome events, fewer catheterizations without obstructive CAD, and similar symptom relief compared with usual testing. ClinicalTrials.gov Identifier: NCT03702244.

Monitoring Practices After Pediatric Liver Transplantation.

This study sought to understand the current monitoring practices after pediatric liver transplantation (LT), specifically regarding follow-up clinic visits, outpatient laboratory testing, protocol biopsies, and diagnostic imaging, and to identify potential center and provider characteristics associated with such practices. A cross-sectional survey of pediatric LT providers at centers participating in the Society of Pediatric Liver Transplantation (SPLIT) registry was conducted from February 2020 to April 2021. The overall response rate was 79% (38/48 SPLIT centers), with the majority representing large volume centers (>10 LTs per year). Frequency of clinic visits and laboratory monitoring varied by center, but all centers decreased frequency after the first post-transplant year. The most common practice included an annual clinic visit and laboratory sampling every 2-3 months. Surveillance liver biopsy is seldom done during the first post-transplant year, while being routinely performed by 50% of centers after this time period. Centers forgoing surveillance biopsies assert that the results would likely not change management. Only 39% of centers have a hepatologist perform the liver biopsy while the remaining centers consult interventional radiology. Most diagnostic imaging is obtained only as needed. Routine abdominal ultrasounds were obtained by only 50% of responding centers after the first year post-transplant. SPLIT centers vary widely in the routine management of LTs after the first year post-transplant. While common themes emerge, future studies will be needed to connect protocols to outcomes to determine best practice.

An Effective Malignancy Prediction Model for Incidentally Detected Pulmonary Subsolid Nodules Based on Current and Prior CT Scans

IntroductionIt is challenging to diagnose and manage incidentally detected pulmonary subsolid nodules due to their indolent nature and heterogeneity. The objective of this study is to construct a decision tree-based model to predict malignancy of a subsolid nodule based on radiomics features and evolution over time. Materials and MethodsWe derived a training set (2947 subsolid nodules), a test set (280 subsolid nodules) from a cohort of outpatient CT scans, and a second test set (5171 subsolid nodules) from the National Lung Cancer Screening Trial (NLST). A Computer-Aided Diagnosis system (CADs) automatically extracted 28 preselected radiomics features, and we calculated the feature change rates as the change of the quantitative measure per time unit between the prior and current CT scans. We built classification models based on XGBoost and employed 5-fold cross validation to optimize the parameters. ResultsThe model that combined radiomics features with their change rates performed the best. The Areas Under Curve (AUCs) on the outpatient test set and on the NLST test set were 0.977 (95% CI, 0.958-0.996) and 0.955 (95% CI, 0.930-0.980), respectively. The model performed consistently well on subgroups stratified by nodule diameters, solid components, and CT scan intervals. ConclusionThis decision tree-based model trained with the outpatient dataset gives promising predictive performance on the malignancy of pulmonary subsolid nodules. Additionally, it can assist clinicians to deliver more accurate diagnoses and formulate more in-depth follow-up strategies.

Journey to STEEEP healthcare: A focus on systems through a patient's experience

Healthcare systems continue to struggle with providing safe, timely, effective, efficient, equitable and patient-centered (STEEEP) care. Upon audit by clinicians, treatment processes such as those completed following clinical pathways appear to manage care safely. However, when reviewing the treatment process through the patient and/or their family's lens, the experience is quite different. This article will use a vignette detailing care provided in a primary care physician's office along with the patient's outpatient testing experience to reveal opportunities for improvement, a glimpse into the patient's experience and share methods for achieving STEEEP healthcare.

Point-of-Care Ultrasound of Post-acute COVID-19 Syndrome: A Prospective Cohort Study.

Introduction Acute COVID-19 patients can suffer from chronic symptoms known as post-acute sequelae of SARS-CoV-2 infection (PASC). Point-of-care ultrasound (POCUS) is established in acute COVID, but its utility in PASC is unclear. We sought to determine the incidence of cardiac and pulmonary abnormalities with POCUS in patients with PASC in a COVID-19 recovery clinic. Methods This prospective cohort study included adults (>18 years old) presenting with cardiopulmonary symptoms to the COVID-19 recovery clinic. A lung ultrasound and standard bedside echocardiogram were performed by ultrasound-trained physicians. Images were interpreted in real time by the performing sonographer and independently by a blinded ultrasound faculty member. Discrepancies in interpretation were addressed by consensus review. A modified Soldati score was calculated by the sum of the scores in each of the 12 lung zones, with each zone score ranging from 0 to 3 (maximum score of 36). The score was then compared to clinical outcomes and outpatient testing. Results Between April and July 2021, 41 patients received POCUS examinations, with 24 of those included in the study. In all, 15 out of 24 (62.5%) had a normal lung ultrasound. Of the nine subjects with lung abnormalities, the median modified Soldati score was 2. Three patients had trivial pericardial effusions, and all had normal left and right ventricular size and function. Conclusion The majority (62.5%) of patients presenting to the PASC clinic had a normal pulmonary ultrasound, and the vast majority (87.5%) had normal cardiac ultrasounds. These findings suggest that cardiopulmonary symptoms in PASC may be from etiologies not well evaluated by POCUS.

Innovation, Automation and Informatics Improves Quality in Lerdsin Hospital, Thailand.

This paper describes a planned, continuous improvement journey, of a laboratory that has installed a system with a single sample touch from blood draw to result. To achieve this, physical connectivity of systems from phlebotomy through pre-analytical to the analytical phase were paired with informatics connectivity from the patient's national identity card to the hospital and laboratory informatics management systems (LIMS) and associated middleware. This allowed accurate time stamps to track turnaround time (TAT). TAT metrics were collected from the LIMS for inpatient, emergency room and outpatient samples and tests over a period of 7months. This time span incorporated the 2-month period before automation was implemented. The results for all tests and specific tests are shown and the results of an analysis of the outpatient phlebotomy workflow are given. The implemented solution has improved outpatient TAT by over 54% and has shown that samples can be collected, and results obtained without touching the sample. Improving intra-laboratory TAT is an important quality goal for all laboratories. The implementation of automation is important in achieving this albeit more about obtaining predictable TAT. Automation does not necessarily improve TAT it removes variation which leads to predictable TAT (PTAT). Automation should only be considered with a strategic vision for the future as it is important to have clear goals and objectives based on the individual laboratories process and needs. Automating a poor process leads to an automated poor process. Here, an innovative use of automation, hardware and software has resulted in marked improvement in TAT across all samples processed in the central laboratory.

#4126 LONG-TERM VISIT TO VISIT VARIABILITY IN HBA1C AND KIDNEY RELATED OUTCOMES IN PERSONS WITH DIABETES

Abstract Background and Aims Glycated hemoglobin (HbA1c) is central to the routine monitoring of glycemic control in persons with diabetes, and poor glycemic control is an established contributor to the occurrence and progression of CKD, but whether long-term visit-to-visit variability in glycemic control predicts kidney outcomes is not well studied. Method We included all adults with type 1 or type 2 diabetes in Stockholm, Sweden, during 2006–2019, who had at least one annual outpatient HbA1c test in three consecutive years. We evaluated associations between baseline and time-varying HbA1c variability score (HVS, the percentage of total HbA1c measures that vary by >0.5% [5.5 mmol/mol] during a 3-year window), with the risk of CKD progression (composite of >30% eGFR decline and kidney failure), acute kidney injury (AKI, by clinical diagnosis or increase in creatinine ≥0.3 mg/dL over 48 h or 1.5 times creatinine over 7 days), and worsening of albuminuria. Results We included 93,598 adults with diabetes undergoing 891,536 routine HbA1c tests (median 8 tests per person) during a median follow-up of 5.2 years. Compared with persons showing low HbA1c variability (HVS 0–20%), any increase in variability was associated with a higher risk of adverse kidney outcomes. For example, for patients with a baseline HbA1c variability of 81–100%, the adjusted HR was 1.47 (95% CI, 1.38-1.56) for CKD progression, 1.27 [1.19-1.36] for AKI, and 1.28 [1.21-1.36] for worsening of albuminuria. Results were robust across subgroups (diabetes subtypes, baseline eGFR or albuminuria categories) and in sensitivity analyses including time-weighted average HbA1c or alternative metrics of variability. Conclusion A higher long-term visit-to-visit HbA1c variability is robustly associated with the risks of CKD progression, AKI and worsening of albuminuria.

NUTRISCORE Compared to NRS-2002 for Detection of Malnutrition in Hospitalized Cancer Patients; A Cross Sectional Study

The most commonly recommended screening test for determining the nutritional status of hospitalized cancer patients is Nutrition Risk Screening-2002 (NRS-2002). NUTRISCORE, on the other hand, is an outpatient cancer patient-specific nutritional screening test that is easier to administer than NRS-2002 and queries tumor location and treatment information received from the patient. We aimed to investigate the validity of NUTRISCORE, in hospitalized cancer patients. In total, 112 patients were enrolled in this study. The NRS 2002 and NUTRISCORE screening tests were performed. The data obtained with NUTRISCORE were compared to the reference test NRS-2002 using the κ test and ROC curve analysis. The NRS-2002 identified 45.5% of patients as being at risk of malnutrition, while the NUTRISCORE test identified 48.2% (k = 0.516, p < 0.005). The AUC value was 0.759 (95% CI:0.67-0.85) as shown in the ROC analysis. Using the NRS-2002 as a reference test, the sensitivity (S), specificity (SP), Positive Predictive (PPD), and Negative Predictive (NPD) values for the NUTRISCORE test were 76.5% (95% CI:63.7-86.6), 75.4% (95.CI:63.7–85), 72.2% (95% CI:59.4–83), 79%, (95% CI:67.7-88.3) respectively. NUTRISCORE can be used for screening of malnutrition in hospitalized cancer patients.

Tolérance de la position à genoux après enclouage centromédullaire ou fixation par plaque sans complications

IntroductionDistal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee function in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following distal tibia fracture to assist in the pre-operative consent process. HypothesisThere is no difference in kneeling tolerance following either tibial nailing or plate fixation of distal tibia fractures. Material and methodsRetrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome measure was the Kneeling Test (KT). Secondary outcome measures were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. There were 28 patients recruited (18 IMN and 10 ORIF) with a mean age of 44 years. Mean overall follow-up was 13.3 months (range 8–25, SD 3.6). All fractures had completely healed without post-operative complication. ResultsThe IMN affected limb had a significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs 94.9 respectively, p<0.005) Additionally, the IMN group performed significantly worse when compared to the ORIF group (mean KT 70.4 vs 92.5 respectively, p<0.005). No significant differences (p>0.05) in kneeling function existed for the ORIF group when comparing affected to non-affected limbs. Secondary outcome analysis showed significantly worse overall WOMAC and FJS in the IMN group compared to the ORIF group (mean WOMAC 19.3 vs 6.9 respectively, p=0.040; mean FJS 38.3 vs 75.9 respectively, p=0.005). DiscussionThe use of intramedullary nailing for the treatment of distal tibia fracture results in a mean reduction of 20% in kneeling tolerance in comparison to ORIF. The resulting kneeling tolerance is comparable to that of patients post-total knee arthroplasty. The present findings should assist in the consent process for patients with high kneeling demands in sportive, professional or cultural pastimes. Level of evidenceIV; retrospective cohort study with quantitative outcome measurement.

Disparities in Delivery of Ambulatory Surgical Care for Children

This cross-sectional study characterizes the delivery of ambulatory surgical care for children across freestanding ambulatory surgery centers and hospital-based outpatient centers and tests for differences in patient characteristics and features of procedures being performed.