Outpatient Testing Research Articles

385. Impact of the COVID-19 Pandemic First Wave on Clostridioides difficile Infection

Abstract Background Clostridioides difficile infection (CDI) is the leading cause of nosocomial diarrhea and a costly burden on the healthcare system. The COVID-19 pandemic brought enhanced infection control measures that could hypothetically decrease CDI transmission. Nonetheless, diarrhea secondary to COVID-19 and increased usage of broad-spectrum antibiotics could potentially increase testing for or frequency of CDI. We aimed to assess variations in CDI testing and frequency during the first surge of the COVID-19 pandemic in a tertiary community medical center in the Southern United States. Methods Records from adult patients were retrospectively reviewed at Princeton Baptist Medical Center, Birmingham, AL. Three groups spanning equal time periods were created based on the CDC COVID-19 rate curves for Alabama: PPG (pre-pandemic, 03/01/2020 to 05/31/2020), PG (pandemic, 06/01/2020 to 08/31/2020), and SCG (seasonal control, 06/01/2019 to 08/31/2019). We included patients ≥ 18 years old and excluded readmissions and follow-up visits. We determined the frequency, testing rates, and positivity rates for CDI in each group to assess their differences. Also, we measured the rate of coinfection between C. difficile and SARS-CoV-2. CDI cases were defined as positive toxin enzyme-linked immunosorbent assay (EIA) and glutamate dehydrogenase (GDH), or positivity of either in addition to positive nucleic acid amplification test (NAAT). Differences in frequencies and rates across groups were compared with Fisher exact test. Results Overall, 7,252 hospitalized patients and 29,671 outpatients were included (Figure 1). No outpatient CDI cases were detected. Outpatient testing rates were: PPG 3 (0.05%), PG 4 (0.05%), and SCG 9 (0.06%). Among inpatients, 3,912 (53.9%) were female with a mean ± SD age of 61.2 ± 17.5 years. Overall, CDI frequency, testing rates, and positivity rates did not vary significantly among all groups (Table 1). Among those tested, the only case of C.difficile/SARS-CoV-2 coinfection corresponded to PPG. Figure 1:Patient distributionTable 1:Frequency of CDI and COVID-19 infection in inpatients Conclusion There were no statistically significant differences in CDI frequency, or positivity rate between the pre-pandemic, pandemic, and seasonal control groups for inpatients. No CDI cases were detected in outpatients. This is likely due to a low testing rate in our population. Disclosures All Authors: No reported disclosures.

Implementing American College of Obstetricians and Gynecologists Outpatient Antepartum Testing Recommendations: Can Your Clinic Handle It?

This study was conducted to determine the difference in the number of pregnancies that would qualify for outpatient fetal testing between our current academic practice and that of the 2021 American College of Obstetricians and Gynecologists (ACOG) antepartum recommendations. We performed a retrospective study of all pregnancies that delivered and received prenatal care at our institution between January 1, 2019, and May 31, 2021. The timing and amount of outpatient antepartum testing was determined for each patient. Our current antepartum testing guidelines (clinic protocol) were compared with the 2021 ACOG recommendations (ACOG protocol). Statistical analysis was performed with descriptive statistics and z scoring to compare the total amount of antepartum testing utilized with each protocol. A total of 1,335 pregnancies were included in the study. With the ACOG protocol, an additional 310 (23.2%) of pregnancies would qualify for antepartum testing (57.8% with ACOG protocol vs. 34.6% with clinic protocol). Most of the increased testing was due to maternal age with additional risk factors, hypertensive disorders, diabetes, prepregnancy body mass index ≥ 35, and complex fetal anomalies or aneuploidies. Overall, the ACOG protocol would require an additional 570 antepartum tests (z-score = 4.04, p = 0.000005) over the study period, which is equivalent to 19 additional tests per month and 5 per week. Only nine stillbirths occurred during this time, of which two would have had antepartum testing with both protocols, one would have only had testing per ACOG, and two would have had testing individualized per ACOG. More pregnancies would require outpatient antenatal testing with adoption of the ACOG protocol. A 23% increase in testing would equate to five additional antepartum tests per week. Although this study cannot assess the clinical impact of additional testing, minimal scheduling resources are needed to accommodate this increase. · Most pregnancies have risk factors for stillbirth.. · Most pregnancies qualify for fetal testing per ACOG.. · More resources are needed for this increased testing..

Kneeling tolerance following intramedullary nailing or plate fixation of uncomplicated distal tibia fractures

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 preoperative 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 44years. Mean overall follow-up was 13.3months (range 8–25, SD 3.6). All fractures had completely healed without postoperative 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.

Resource Utilization and Cost Analysis of a Chromogenic Factor X Assay for Anticoagulation Monitoring and Management

Introduction High risk venous thrombotic states such as heparin-induced thrombocytopenia (HIT) and antiphospholipid antibody syndrome (APLS) contribute to significant patient morbidity and mortality, and financial toxicity. Traditional coagulation assays (prothrombin time [PT], activated partial thromboplastin time [aPTT], and international normalized ratio [INR]) guide anticoagulation but are unreliable in the presence of a lupus anticoagulant and/or disseminated intravascular coagulation (DIC). Further, some agents used for treatment, such as direct thrombin inhibitors (DTI), elevate the PTT, PT, and INR. Collectively, this highlights the challenge of maintaining a therapeutic index with aberrant PTT values. The chromogenic factor X (CFX) assay depends on an enzymatic reaction that generates photometrically (colorimetric) distinct signals that are proportional to factor X levels and therapeutic INR levels. Rationale for the use of CFX assay is to abrogate difficulty in guiding treatment decisions in HIT with DIC, APLS, and with DTI use. It remains unclear how the use of CFX testing and need for hematology consultation impacts clinical and financial resources at an institutional level seeking to incorporate novel coagulation tests. Here we aim to understand how involving a hematologist in decision-making when using this test can improve healthcare utilization and expenditure associated with thrombotic disease and its complications. Methods This study design was reviewed by the Institutional Review Board and met the criteria for exempt review. This is a single institution retrospective cohort analysis. All patients who had CFX assays performed between July 1, 2019 and June 30, 2021 were included. Each encounter was categorized by location (inpatient vs. outpatient), the indication prompting use of the CFX assay, and if hematology was consulted. Costs were aggregated by evaluating individual decentralized de-identified patient accounts. In particular, variable costs were evaluated to capture all costs from services rendered directly related to the anticoagulation management of the patient (i.e. cost of operations). Descriptive analysis was done for aggregated variable costs and expenditures relevant to the CFX-guided anticoagulation treatment episode. A two-sample t-test was used to identify association between numbers of tests ordered when hematology was consulted in patient care. Statistical analysis to identify differences was set at α=0.05 or less. Maximum type I error rate of p<0.05 was used. Results In total, 179 patient charts were analyzed, of which 90 patients met inclusion criteria (Table 1). The majority of patients had the CFX assay performed inpatient; 33 had the test as an outpatient. A breakdown of testing indication is presented in Table 1, with the majority of tests ordered for APLS, HIT, and recurrent thrombosis. As show in Table 2, for inpatients, fewer tests per patient were ordered when hematology is consulted compared (3.4 vs. 5.4 tests/patient, p=0.005 [α = 0.05]). The mean direct variable cost (DVC) was not statistically different, however there was a median $1800 cost savings when hematology was consulted. There is no difference in length of stay (LOS). All outpatient tests were ordered by a hematologist. In total, 40 tests were ordered for 33 patients (1.2 tests/patient) with a mean DVC of $602.75. Conclusion Our study highlights that there was a statistically significant decrease in tests ordered when a hematologist is involved. For institutions adopting novel coagulation testing, expert hematology consultation helps improve fiscal resource utilization and clinical practice. The discordance of mean and median DVC suggest that variation is not normally distributed. This is often seen in healthcare finance where macro-economic or supply-side factors dictate variation in medically ill patients. Further, the wide ranges in DVC and in LOS suggest a possibly more complex patient population for whom hematology was consulted. Therefore, we highlight that consultation with a hematologist should be considered in complex patients, particularly for anticoagulation given the significant implications inadequate treatment can have. Hematologist can help with anticoagulation management, and their involvement appears to correlate with decreased testing and improved overall savings even with the cost incurred of the consultant. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Ordering Patterns, Cost, and Utility of Factor V Leiden Testing in an Academic Medical Center

Factor V Leiden (FVL) is one of the most common inherited thrombophilias. It is an autosomal dominant condition, and 99% of individuals with FVL are heterozygous for the variant. Heterozygotes have a mildly increased risk of venous thromboembolism (VTE) compared to non-carriers, with an estimated lifetime risk of 10%. An association between FVL and arterial thromboembolism remains controversial and is likely to be relatively small if present. Although anticoagulation guidelines for VTE published by the American College of Chest Physicians are not affected by the presence or absence of thrombophilia, testing is commonly ordered. FVL in particular is one of the most frequently ordered molecular genetic tests. This testing is costly and may represent an unnecessary healthcare expenditure if it does not affect clinical decision making. This was a retrospective chart review of FVL testing performed at the University of Kansas Medical Center from 7/6/21-7/5/2022. The purpose of the study was to determine FVL testing patterns, cost, impact on clinical decision making, and potential opportunities for quality improvement. FVL screening was obtained in 192 patients during the study period; 21% of testing was obtained inpatient, and 79% outpatient. Hematology ordered testing most frequently overall (46% of the time), followed by cardiology (13%), neurology (12%), and internal medicine (8%). Nineteen (10%) tests were positive, all of which were heterozygous on subsequent gene testing. Additional thrombophilia testing was performed 89% of the time, which was positive in 6 patients (3 with lupus anticoagulant, 3 with heterozygous prothrombin G20210A mutation). Of the 41 tests performed inpatient, 88% were ordered by non-hematology services, and hematology was consulted only 11% of the time prior to testing. Inpatient testing was ordered most frequently by neurology (42%), internal medicine (20%), cardiology and intensive care units (7% each). The most frequent indications for inpatient testing were arterial thrombosis (56%), first venous thrombosis (24%), and recurrent venous thrombosis (10%). Neither anticoagulation type nor duration was change based on results in any of the patients. Regarding outpatient testing, hematology ordered the majority of tests (55%), followed by cardiology (15%), internal medicine, family medicine and surgery (5% each). The most frequent indications were first venous thrombosis (39%), recurrent venous thrombosis (15%), family history without any personal history of thrombosis (11%), and arterial thrombosis (9%). When provoked or unprovoked venous thrombosis was the testing indication, neither duration nor type of anticoagulation was changed in any of the 86 patients. The average charge for FVL testing from hospitals in the Kansas City Area is $119, totaling an estimated $22,848 in charges for the time period reviewed. Given the lack of impact test results had on the duration or type of anticoagulation, the utility of FVL testing appears to be limited in our sample. In particular, FVL testing of inpatients, most often performed for arterial thrombosis by non-hematology services, had no notable impact on patient care. These results suggest that a quality improvement project restricting testing to the outpatient setting and to indications where results would change clinical decision making, would result in significant cost savings. The additional thrombophilia work-up often performed with FVL screening is even more costly, with an average charge of $2500 for protein c, protein s, prothrombin, and anti-thrombin III testing. In addition, given only 3.5% of those tested for additional thrombophilias were found to be positive, investigation into the utility of these tests may also be warranted. This analysis is limited by its retrospective nature and limited follow-up. Future studies based on this data will include quality improvement measures with subsequent re-analysis to determine the effect on test reduction and cost savings.

High Prevalence of Iron Deficiency and Socioeconomic Disparities in Laboratory Screening of Non-Pregnant Females of Reproductive Age

BACKGROUND Iron deficiency anemia (IDA) is one of the most prevalent medical conditions in the world. Iron deficiency (ID) and IDA are common among females of reproductive age, with health consequences both during and outside of pregnancy. However, screening for ID and IDA is variable, and often screening is performed with a complete blood count (CBC) alone, which is neither sensitive nor specific for IDA, in contrast to ferritin. OBJECTIVES The primary objective was to determine the prevalence of screening for ID and IDA over a 3-year period in non-pregnant females of reproductive age who had tests performed at outpatient laboratories in Ontario, Canada. Secondary objectives were to determine the prevalence and severity of ID and IDA, and to identify demographic and provider characteristics that influence the likelihood of screening. METHODS This was a retrospective cohort study of non-pregnant females ages 15-54 in Ontario, Canada. Laboratory data was provided by Dynacare, the second-largest laboratory company in the province, performing around 30% of annual non-hospital outpatient laboratory testing. Tests between January 2017 and December 2019 were retrieved. Tests ordered by providers other than physicians, midwives, or nurse practitioners were excluded. As this was a study of non-pregnant patients, records from patients who had a beta-hCG test of 5 IU or greater, explicitly defined antenatal laboratory testing, or who fulfilled criteria of a previously published laboratory definition of pregnancy were excluded. ID was defined as ferritin < 30 µg/L and severe ID ferritin < 15 µg/L. Anemia was defined as hemoglobin < 120 g/L, and IDA defined as a ferritin < 30 µg/L and hemoglobin < 120 g/L measured within 90 days of each other. Annual household income was estimated using the patient's postal code and Statistics Canada census data. Research ethics board approval was obtained. Dynacare was not involved in study design or analysis. RESULTS 6,652,487 records were retrieved from the Dynacare database. 4,623,284 records representing 784,132 non-pregnant females were eligible for inclusion (Figure 1). Of this cohort, 644,066 patients (82.1%) had a ferritin checked at least once during the study period, with a mean ferritin of 60.7 µg/L (SD 86.9 µg/L). 245,953 (38.3%) were iron deficient with a < 30 µg/L at least once, with 14.4% of patients having severe ID with ferritin < 15 µg/L. Family physicians or general practitioners ordered most ferritin tests (74.1%). 709,434 patients (90.5%) had a CBC checked at least once, with a mean hemoglobin of 130.1 g/L (SD 12.9 g/L). Of those who had a CBC checked, 134,265 (19%) had anemia (hemoglobin < 120 g/L) at least once. 633,396 patients (80.8%) were screened for and 82,655 (13.1%) had IDA. The proportion of ferritin testing increased with increasing anemia severity (Table 1), ranging from 40.2% of patients with normal hemoglobin levels having a ferritin test, to 66.4% of patients with hemoglobin < 70 g/L having a ferritin checked. Median annual household income was CAD$89,387.80 (IQR 69178.8, 107037.5) at the first service date. Compared to patients in the lowest household income quintile (Q1, <CAD$60,000 per year), the odds of ever having a normal hemoglobin generally increased with increasing income quintiles, with odds ratio (OR) 1.08 (95% CI 1.05-1.11), 1.07 (95% CI 1.04-1.10), 1.36 (95% CI 1.30-1.43), and 1.47 (95% CI 1.25-1.72) for Q2-5 respectively. Compared to patients in Q1, the odds of having a ferritin checked was also greater with higher income quintiles with OR for Q2-5 1.20 (95% CI 1.18-1.23), 1.56 (95% CI 1.53-1.60), 1.67 (95% CI 1.61-1.73), and 1.21 (95% CI 1.09-1.34) respectively (Figure 2). CONCLUSION: This was a large study of non-pregnant females of reproductive age in Ontario, Canada, a high-income province within a publicly funded health services system. Our cohort had a high median household income ($89,387.80, compared to a province-wide median of $65,285 in 2016). A large proportion of patients were screened for ID - yet even in this relatively privileged population, ID affected nearly 40% and IDA 13% of those screened. Screening for ID was more likely with increasing anemia severity. Despite low household income being associated with the greatest odds of anemia, low income was associated with lower odds of having a ferritin check. These findings highlight socioeconomic disparities in screening and inequitable diagnosis of ID and IDA in this population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Utility of Von Willebrand Testing during Acute Bleeding Episodes

Background: The diagnosis of mild bleeding disorders such as von Willebrand disease (VWD) poses many diagnostic challenges. Several patient-specific factors including physiologic, inflammation, anemia and medications can affect VWD testing and lead to falsely elevated values. Given that the physiologic stress may cause falsely normal levels of VW factor and associated tests, determining the appropriate timing for testing remains an area of debate. Testing is often performed during inpatient or emergency department (ED) visits when patients present for bleeding complaints, although these results may be skewed by stress or illness. Initial normal results may falsely reassure a patient and their health care provider, preventing them obtaining repeat testing or pursuing outpatient hematological evaluation. Further study is needed to determine the reliability of VWD evaluation when obtained during episodes of acute bleeding. Methods: This single-center retrospective cohort study included subjects who were evaluated for acute bleeding complaints in the UPMC Children's Hospital of Pittsburgh ED or inpatient units who had VWD testing sent during that visit over a five-year period. Bleeding complaints included were epistaxis, heavy menstrual bleeding, spontaneous ecchymosis, post-procedural hemorrhage or intracranial hemorrhage. VWD test results including von Willebrand antigen (VWF:Ag), factor VIII (FVIII) and ristocetin co-factor (VWF:RCo) levels obtained at the time of ED or inpatient care were compared with those obtained in outpatient follow-up visits. T-tests and Wilcoxon rank sum tests were used to compare VWD test levels across the two time points. Results: Over a 5-year period, 144 patients had VWD testing completed during ED or inpatient evaluations for acute bleeding complaints. The population was primarily Caucasian (71%) with a median age of 9 years old. Fifty-two percent of the population was male. Epistaxis and post-tonsillectomy/adenoidectomy bleeding were the most common presenting complaints, making up 47 and 22% of the population, respectively. Other presenting bleeding complaints included spontaneous bruising (18%), menorrhagia (6%), post-procedural hemorrhage of a digestive organ (4%), and nontraumatic intracranial hemorrhage (3%). Six subjects (4%) met laboratory criteria for a diagnosis of VWD during an acute bleeding episode. Twenty-four percent of the total population was evaluated subsequently by outpatient hematology, and 23% of patients had repeat VWD testing performed. Median levels of VWD tests obtained at initial presentation were 116% for VWF:Ag, 112% for FVIII, and 85% for VWF:RCo, and were not statistically different from those obtained on repeat testing in outpatient follow up. An additional two patients that were not initially diagnosed with VWD met laboratory criteria for VWD on repeat outpatient testing. Conclusions: Among children presenting for emergency or inpatient care for acute bleeding episodes, VWD testing was unlikely to be diagnostic. Interestingly, our study did not find that median VWF:Ag and FVIII levels were higher during acute bleeding as has been suggested in other studies. A minority of patients who were evaluated in the hospital for acute bleeding were subsequently evaluated by hematology, which may have limited these findings. It is possible that obtaining VWD testing at the time of an acute bleeding episode may provide false reassurance to a patient, thus decreasing hematology referrals and follow up. Based on these results, we recommend that for patients evaluated in the ED with mild mucocutaneous bleeding who warrant a bleeding disorder evaluation, VWD testing be postponed until the patient is seen in steady-state by hematology.

WHAT TO GIVE NEXT? THE CHALLENGE OF SEVERE PERIOPERATIVE DRUG REACTIONS IN PEDIATRIC PATIENTS

<h3>Introduction</h3> Perioperative drug reactions (PODR) are rare, occurring in∼ 1:10,000 cases. For patients with ongoing surgical needs, it is challenging to select safe alternatives. <h3>Case Description</h3> An 11 yr old male with history of food allergy, environmental allergy, and well-controlled mild intermittent asthma required surgical reduction of a forearm fracture. Prior to presentation, he was clinically well. Anesthesia induction was performed with propofol, rocuronium, and morphine. Within minutes, the patient had severe bronchospasm, without hives/angioedema, leading to bradycardic arrest requiring intubation, resuscitation with epinephrine and ICU admission. Serum tryptase drawn at 30 minutes after the event was 62.5 ug/mL (normal: <10.9 ug/mL).. The following day, he tolerated vecuronium and rocuronium while intubated. He has tolerated multiple opiates since the event. The initial injury still requires surgical repair. <h3>Discussion</h3> His PODR was most likely triggered by a medication received during anesthesia induction, and clinically, rocuronium was most suspected. Mast cell depletion may explain his tolerance immediately after the event. Propofol is a rare cause of anaphylaxis but remains a possibility. Opioids are less likely as the patient has since tolerated multiple opioids. An underlying mast cell disorder must be considered. It was recommended the patient avoid rocuronium, vecuronium, and propofol until a full evaluation is completed. Cisacuronium was offered as an alternative agent to use for his acutely needed surgical repair due to the low cross-reactivity (5%) with rocuronium. Outpatient SPT testing was recommended when well. This case highlights the differential for perioperative anaphylaxis and the importance of further evaluation to determine the inciting agent.

PSAT040 Bilateral Adrenal Infarcts: Initial Presentation in Concurrent Myelodysplastic Syndrome and Anti-Phospholipid Syndrome

Abstract Introduction Bilateral adrenal hemorrhage (BAH) has been noted in several conditions. Bilateral adrenal infarcts (BAI) are rarer but have been seen in anti-phospholipid syndrome (APS). Adrenal insults are not commonly associated with myelodysplastic syndrome (MDS). We present a patient who developed BAI as initial presentation of APS in the setting of MDS and discuss management considerations. Case A 58-year-old female with MDS diagnosed one month prior presented with abdominal pain, present for one year but acutely worse in the past week. CT A/P showed nodularity of bilateral adrenal glands. She was treated conservatively but continued to experience nausea, vomiting, and abdominal pain – repeat CT A/P one month later was suspicious for bilateral peri-adrenal hemorrhages. MRI with adrenal protocol demonstrated bilateral non-hemorrhagic adrenal infarcts. VS were negative for hypothermia or hypotension. Labs showed Na 136 (135-145 mmol/L), K 3.5 (3.4-5.1 mmol/L), BG 108 (mg/dL), DHEA-S 9.3 (8.0-391 mcg/dL), renin 6.7 (0.5-4.0 ng/mL/hr), aldosterone 6.2 (&amp;lt;31.0 ng/dL), 60-minute cortisol after ACTH stimulation test 34.3 (5.2-22.5 mcg/dL), plasma metanephrines &amp;lt;0.10 (0.00-0.49 nmol/L), plasma normetanephrines 0.34 (0.00-0.89 nmol/L), Hgb 11.8 (12.0-15.5 g/dL), and plts 129K (140-450 K/mcL). No history of anticoagulant use, trauma, or VTE. COVID-19 PCR was negative on two separate tests. Hypercoagulability testing noted positive lupus anticoagulant. Anticoagulation was deferred due to underlying bone marrow abnormalities and thrombocytopenia; aspirin was recommended instead by hematology. Outpatient testing revealed 12pm cortisol of 12.6 (5.2-22.5 mcg/dL), ACTH 108.3 (7.2-63.0 pg/mL), and DHEA-S 6.2 (8.0-391 mcg/dL). Patient was empirically started on hydrocortisone for glucocorticoid replacement therapy. Conclusion BAI is not typically associated with MDS but can occur in the setting of a concurrent hypercoagulable process such as APS. The adrenal glands are the most commonly involved glands in APS. Patients often present in adrenal crisis but can present in stable condition as in this case. The adrenal glands are particularly vulnerable due to the "vascular dam" near the zona reticularis. Imaging and laboratory investigation can clarify the nature of the adrenal insult and guide management. Treatment strategy may include anticoagulation to prevent further VTE events, but bleeding risk must be considered. Both glucocorticoid and mineralocorticoid replacement should be considered until residual adrenal reserve can be fully elucidated, which may take several months from initial diagnosis. References Rao RH. Bilateral massive adrenal hemorrhage. Med Clin North Am 1995; 79(1): 107-29. Aron DC, Findling JW, Tyrrell JB. Glucocorticoids and adrenal androgens. In: Greenspan's Basic and Clinical Endocrinology. Gardner DG, Shoback D (eds). Mc Graw Hill 2007; pp 367-378. Caron P, Chabannier MH, Cambus JP, Fortenfant F, Otal P, Suc JM. Definitive adrenal insufficiency due to bilateral adrenal hemorrhage and primary antiphospholipid syndrome. J Clin Endocrinol Metab 1998; 83(5): 1437-9. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A study of adverse drug reactions in tuberculosis patients in a tertiary care hospital

Background: Tuberculosis is the most rambling communicable infectious disease on earth. It is the single most common cause of death in individuals aged 15-49 years. Adverse drug reactions to antitubercular drugs causing significant morbidity, mortality, incurring substantial additional costs because of added outpatient visits, tests, and hospitalizations. Study was carried out with objectives of assessing the rate and type of adverse drug reactions (ADRs) and detecting serious and preventable ADRs with collection of demographic details of patients taking antitubercular drugs and developing ADRS.Methods: A cross sectional, prospective, observational study conducted in department of chest and TB of a tertiary Health care and teaching hospital in both IPD and OPD patients for a period of 18 months. 480 patients monitored.Results: Among 480 patients 120 i.e., 25% developed ADR. frequency being significantly higher in males (58%) and adult age group (&gt;18 years) amongst hospitalized comparing to outdoor patients the gastrointestinal tract [GIT] (39%) followed by, generalized body disorders (19%) hepatobiliary system (17%) were organ systems most affected Majority (56%) ADRs reported in 0-2 month of starting therapy (63%) of cases were in “probable according to Naranjo causality assessment (37%) being possible. 55% ADRs were moderate in severity followed by 36% mild and 9% severe. 30% of ADRs were definitely preventable followed by 20% of probably prevented according to schumock thronstone preventability scaleConclusions: Study highlights the importance of routine monitoring and robust pharmacovigilance system for success of national tuberculosis programmes in India as well as worldwide.

Factors Analysis of the Compliance Rate of Hypertension Detection Control and Self-Assessment Control in Community Outpatient Clinics.

Objective To understand the related influencing factors of outpatient hypertension detection and control and self-test control compliance rate. Methods A total of 637 hypertensive patients who visited the outpatient clinic of our hospital from January 2021 to December 2021 were selected for investigation and research, and the relevant information such as blood pressure, treatment detection, and other related information of the patients were counted, and the detection and control of outpatient hypertension were explored through regression analysis and the related factors of the self-test control compliance rate. Results There was no statistically significant difference in the number of patients who met the standard or not under the gender difference (P > 0.05), and it can be found that there was no statistically significant difference in the age of patients who met the standard and those who did not (P > 0.05). The proportion of patients with self-test hypertension control at home was 64.68%, and the compliance rate of self-test blood pressure was 42.54%. The compliance rate of blood pressure control in outpatient testing was 61.85%. Heart rate, exercise, smoking, medication compliance, and other factors are important factors affecting the control of hypertension. Knowing hypertension-related knowledge, regular follow-up, office blood pressure compliance, smoking, excessive salt intake, and hypertension complications are important factors affecting the self-test control of hypertension in the family. Conclusion By urging patients to do daily physical exercise, admonishing patients to quit smoking, and improving patients' medication compliance, the control rate of hypertension in outpatient clinics can be effectively improved. Understanding the knowledge of hypertension, controlling the salt content in the diet, and receiving regular follow-up surveys from doctors can effectively improve the effect of self-measurement and control of blood pressure at home and further improve the control rate of hypertension.

Gestational diabetes mellitus in the COVID-19 pandemic: A retrospective study from Hangzhou, China.

AimsOur study aimed to investigate changes in the prevalence of gestational diabetes mellitus (GDM) in the COVID‐19 pandemic and postpandemic era and the risk of adverse pregnancy outcomes in pregnant women diagnosed with GDM during the blockade period.MethodsFirst, we investigated changes in the prevalence of GDM and the population undergoing oral glucose tolerance tests (OGTT) after the COVID‐19 pandemic. We then collected clinical information from pregnant women diagnosed with GDM to explore the risk of adverse pregnancy outcomes in pregnant women with GDM during the COVID‐19 pandemic.ResultsAfter the COVID‐19 pandemic, the proportion of pregnant women in the total number of outpatient OGTT tests decreased yearly. The ratio was 81.30%, 79.71%, and 75.48% from 2019 to 2021, respectively, with the highest proportion of pregnant women in February 2020 (92.03%). The prevalence of GDM was higher in March 2020 compared to the same period in 2019. However, from 2019 to 2021, the prevalence decreased year by year with 21.46%, 19.81%, and 18.48%, respectively. The risk of adverse pregnancy outcomes for pregnant women diagnosed with GDM during the most severe period of the COVID‐19 pandemic did not differ from before the COVID‐19 pandemic.ConclusionsAfter the COVID‐19 pandemic, the prevalence of GDM increased during the most severe period of the epidemic, but the overall prevalence of GDM decreased year by year. In addition, the pandemic did not change the risk of adverse pregnancy outcomes in pregnant women with GDM.

S501 High Burden of Disease and Associated Costs for Eosinophilic Gastrointestinal Diseases: Results From an Online Patient-Centered Research Network

Introduction: Data regarding health care-related costs and the burden of disease for non-EoE eosinophilic gastrointestinal diseases (EGIDs) are lacking, particularly from the patient perspective. We aimed to determine the patient-reported health care burden of disease and costs related to care for non-EoE EGIDs. Methods: We performed a retrospective cohort study based in EGID Partners (egidpartners.org), an online patient-centered research network designed and launched in 2020 by patient advocacy groups (PAGs) and researchers. Subjects were recruited via informational emails, social media, directed messages through patient healthcare portals, webinars, and by physicians. Adult (≥18 years) EGID patients and caregivers of children < 18 years with EGIDs could join and complete surveys which included a burden of disease questionnaire. This instrument recorded patient-reported healthcare utilization over the prior year related to heath care visits and procedures, as well as out-of-pocket costs/payments. We calculated the median total costs and number of visits. Results: Of 58 non-EoE EGID patients with health care utilization data (mean (SD) age 29 (19) years; 69% female; 95% white; 88% with an atopic condition; mean (SD) 7.4 (9.9) years of symptoms prior to diagnosis), 13 had eosinophilic gastritis (EoG), 17 had eosinophilic enteritis (EoN), 6 had eosinophilic colitis (EoC), and 22 had multiple areas of overlap; additionally, 27 had esophageal involvement. The median number of health care visits over the prior year was 12 (IQR: 5-33; range 1-90), with a median of 5 outpatient doctor visits, 3 urgent care/ED visits or hospitalizations, and 2 endoscopy visits; results were similar for adult patient report (n=42) or caregiver report for pediatric patients (n=16) (Table). The annual median costs were $1000 (IQR: $100-$3570; range: 0-$100,400). Median costs for outpatient visits, testing, and medications were $250, $400, and $325, respectively. Costs were similar for adult patients and caregivers (Table). Conclusion: Patients with non-EoE EGIDs experience a high health care burden, with frequent health care encounters (median of 1 encounter/month) and substantial out-pocket costs (median of $1000/year). Both adult and pediatric providers must maintain awareness of the substantial burden in costs to EGID patients, including challenges for patients to manage their disease given these costs.

Symptom-based vs asymptomatic testing for controlling SARS-CoV-2 transmission in low- and middle-income countries: A modelling analysis

BackgroundDiagnostic testing plays a critical role in the global COVID-19 response. Polymerase chain reaction (PCR) tests are highly accurate, but in resource-limited settings, limited capacity has led to testing delays; whereas lateral flow assays (LFAs) offer opportunities for rapid and affordable testing. We examined the potential epidemiological impact of different strategies for LFA deployment. MethodsWe developed a deterministic compartmental model of SARS-CoV-2 transmission, parameterised to resemble a large Indian city. We assumed that PCR would be used to test symptomatic individuals presenting to outpatient settings for care. We examined how the second epidemic wave in India could have been mitigated by LFA deployment in its early stages by comparing two strategies: (i) community-based screening, using LFAs to test a proportion of the population, irrespective of symptoms (in addition to symptom-driven PCR), and (ii) symptom-driven outpatient testing, using LFAs to replace PCR. ResultsModel projections suggest that a stock of 25 million LFAs, used over a 600-day period in a city of 20 million people, would reduce the cumulative symptomatic incidence of COVID-19 by 0.44% if used for community-based screening, and by 13% if used to test symptomatic outpatients, relative to a no-LFA, PCR-only scenario. Sensitivity analysis suggests that outpatient testing would be more efficient in reducing transmission than community-based screening, when at least 5% of people with symptomatic COVID-19 seek care, and at least 10% of SARS-CoV-2 infections develop symptoms. Under both strategies, however, 2% of the population would be unnecessarily isolated. InterpretationIn this emblematic setting, LFAs would reduce transmission most efficiently when used to test symptomatic individuals in outpatient settings. To avoid large numbers of unnecessary isolations, mass testing with LFAs should be considered as a screening tool, with follow-up confirmation. Future work should address strategies for targeted community-based LFA testing, such as contact tracing.

Tracking changes in SARS-CoV-2 transmission with a novel outpatient sentinel surveillance system in Chicago, USA

Public health indicators typically used for COVID-19 surveillance can be biased or lag changing community transmission patterns. In this study, we investigate whether sentinel surveillance of recently symptomatic individuals receiving outpatient diagnostic testing for SARS-CoV-2 could accurately assess the instantaneous reproductive number R(t) and provide early warning of changes in transmission. We use data from community-based diagnostic testing sites in the United States city of Chicago. Patients tested at community-based diagnostic testing sites between September 2020 and June 2021, and reporting symptom onset within four days preceding their test, formed the sentinel population. R(t) calculated from sentinel cases agreed well with R(t) from other indicators. Retrospectively, trends in sentinel cases did not precede trends in COVID-19 hospital admissions by any identifiable lead time. In deployment, sentinel surveillance held an operational recency advantage of nine days over hospital admissions. The promising performance of opportunistic sentinel surveillance suggests that deliberately designed outpatient sentinel surveillance would provide robust early warning of increasing transmission.

Complement activation products vs standard ANA testing: Treatment outcomes, diagnosis, and economic impact (CAPSTONE) in systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus (SLE) is a complex clinical diagnosis historically aided by imperfect biomarkers. The advent of a multianalyte assay panel incorporating innovative cell-bound complement activation markers necessitates a comparison of its clinical utility to conventional autoantibodies for the diagnosis and treatment of SLE. OBJECTIVES: To compare the likelihood of SLE diagnosis, SLE treatment initiation, and the downstream impact on health care utilization among patients tested with AVISE Lupus (AVISE) vs standard-of-care laboratory testing with the traditional antinuclear antibody (ANA) testing strategy cohort (tANA). METHODS: An observational retrospective cohort study was conducted using electronic health record (EHR) data from the Illumination Health registry, which integrates EHR records from more than 300 rheumatologists across the US. Health records from January 2016 to December 2020 and administrative claims with cost data for a subset of patients linkable to the HealthCore Integrated Research Database and Medicare data were analyzed. The AVISE and tANA test results were classified as positive, negative, or indeterminate, and outcomes were stratified based on test results. Two cohorts were established: AVISE testing strategy and the tANA approach. Analyses included test impact on SLE diagnosis, treatment initiation, patterns of repeat testing, and downstream health care utilization. Multivariable logistic regression was used to estimate odds ratios (ORs) comparing the likelihood of SLE medication initiation and SLE diagnosis between the AVISE and tANA cohorts. RESULTS: The main cohort included 21,827 AVISE testing episodes and 22,778 tANA testing episodes. A total of 2,437 (11.2%) patients tested positive by AVISE compared with 5,364 (23.6%) of tANA positive patients. Among patients with no baseline prescription for SLE medication(s), patients with a positive AVISE test result were more likely to initiate SLE medications compared with tANA positive patients (43% vs 32%; OR = 1.57; 95% CI = 1.41-1.76). The treatment effect was larger in patients new to the practice within the preceding year (55% vs 33%; adjusted OR = 2.77; 95% CI = 2.31-3.32). AVISE positive patients were more than 5-fold more likely to be diagnosed with SLE, as compared with the tANA patients (31% vs 8%; OR = 5.11; 95% CI = 4.43-5.89), and similar in the new patient cohort (30% vs 6%; OR = 6.34; 95% CI = 5.12-7.86). Linked EHR-Medicare data revealed a greater decrease in posttest vs pretest mean annualized outpatient laboratory testing in AVISE negative (-$985; P < 0.0001) vs tANA negative (-$356; P < 0.0001) patients. A similar analysis in the EHR-HealthCore linked data revealed similar numerical trends as the Medicare data for outpatient laboratory testing but did not reach significance (P > 0.05). Cost comparisons in the categories of hospitalization, emergency department, outpatient imaging, and pharmacy costs did not yield significant differences. CONCLUSIONS: The significantly greater likelihood of SLE diagnosis and SLE medication initiation in AVISE positive vs tANA positive patients is consistent with improved clinical actionability, potentially shortening time to diagnosis. AVISE negative patients experienced a greater decrease in outpatient laboratory testing posttest relative to tANA negative patients, supporting the improved negative predictive value of AVISE vs tANA. DISCLOSURES: Mr O'Malley and Dr Zack are employed by Exagen Inc. Drs Curtis and Xie, Ms Su, and Ms Clinton are affiliated with the University of Alabama at Birmingham. Mr Haechung and Dr Grabner are employees of HealthCore, Inc., which received funding from Bendcare (owner of the Illumination Health Registry) for the conduct of parts of the study on which this manuscript is based. Exagen Inc. provided funding to Bendcare for the conduct of the study. Dr Grabner is also a shareholder of Anthem, Inc.

Strategies to shorten turnaround time in outpatient laboratory.

BackgroundTurnaround time (TAT) is one of the most important indicators of laboratory quality. For the outpatient routine chemistry tests whose results are checked by clinicians on the same day, we set a quality goal that >90% of these samples should be reported within 60 min. As more than 20% of the samples failed to achieve this goal in 2020, we introduced an additional autoanalyzer and a real‐time monitoring system to improve this rate.MethodsAs the TAT of the pre‐analytical phase is the greatest contributor to TAT, we divided it into sampling, sample transport, and sample preparation times. An additional autoanalyzer was introduced, and its effect on TAT improvement was evaluated with the TAT data of June and July 2020. A real‐time monitoring system was introduced to sort delayed samples, and its effect was assessed with the TAT data of June and July 2021. TAT data from December 2019 to January 2020 were set as baseline controls.ResultsThe preparation time comprised the largest proportion of TAT. Although there was a slight decrease in overall TAT after the introduction of the above two strategies, the target TAT achievement rate increased significantly from 78.5% to 88.7% (p < 0.001).ConclusionsWe checked the cause of TAT prolongation and introduced new strategies to improve it. The addition of an autoanalyzer per se was not so effective but was better when combined with the real‐time monitoring system. Such strategies would increase the quality of the laboratory services.

Scanning the medical phenome to identify new diagnoses after recovery from COVID-19 in a US cohort.

ObjectiveCOVID-19 survivors are at risk for long-term health effects, but assessing the sequelae of COVID-19 at large scales is challenging. High-throughput methods to efficiently identify new medical problems arising after acute medical events using the electronic health record (EHR) could improve surveillance for long-term consequences of acute medical problems like COVID-19.Materials and MethodsWe augmented an existing high-throughput phenotyping method (PheWAS) to identify new diagnoses occurring after an acute temporal event in the EHR. We then used the temporal-informed phenotypes to assess development of new medical problems among COVID-19 survivors enrolled in an EHR cohort of adults tested for COVID-19 at Vanderbilt University Medical Center.ResultsThe study cohort included 186 105 adults tested for COVID-19 from March 5, 2020 to November 1, 2021; of which 30 088 (16.2%) tested positive. Median follow-up after testing was 412 days (IQR 274–528). Our temporal-informed phenotyping was able to distinguish phenotype chapters based on chronicity of their constituent diagnoses. PheWAS with temporal-informed phenotypes identified increased risk for 43 diagnoses among COVID-19 survivors during outpatient follow-up, including multiple new respiratory, cardiovascular, neurological, and pregnancy-related conditions. Findings were robust to sensitivity analyses, and several phenotypic associations were supported by changes in outpatient vital signs or laboratory tests from the pretesting to postrecovery period.ConclusionTemporal-informed PheWAS identified new diagnoses affecting multiple organ systems among COVID-19 survivors. These findings can inform future efforts to enable longitudinal health surveillance for survivors of COVID-19 and other acute medical conditions using the EHR.

Clinical Features and Burden of Postacute Sequelae of SARS-CoV-2 Infection in Children and Adolescents

The postacute sequelae of SARS-CoV-2 infection (PASC) has emerged as a long-term complication in adults, but current understanding of the clinical presentation of PASC in children is limited. To identify diagnosed symptoms, diagnosed health conditions, and medications associated with PASC in children. This retrospective cohort study used electronic health records from 9 US children's hospitals for individuals younger than 21 years who underwent antigen or reverse transcriptase-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 between March 1, 2020, and October 31, 2021, and had at least 1 encounter in the 3 years before testing. SARS-CoV-2 positivity by viral test (antigen or RT-PCR). Syndromic (symptoms), systemic (conditions), and medication PASC features were identified in the 28 to 179 days following the initial test date. Adjusted hazard ratios (aHRs) were obtained for 151 clinically predicted PASC features by contrasting viral test-positive groups with viral test-negative groups using proportional hazards models, adjusting for site, age, sex, testing location, race and ethnicity, and time period of cohort entrance. The incidence proportion for any syndromic, systemic, or medication PASC feature was estimated in the 2 groups to obtain a burden of PASC estimate. Among 659 286 children in the study sample, 348 091 (52.8%) were male, and the mean (SD) age was 8.1 (5.7) years. A total of 59 893 (9.1%) tested positive by viral test for SARS-CoV-2, and 599 393 (90.9%) tested negative. Most were tested in outpatient testing facility settings (322 813 [50.3%]) or office settings (162 138 [24.6%]). The most common syndromic, systemic, and medication features were loss of taste or smell (aHR, 1.96; 95% CI, 1.16-3.32), myocarditis (aHR, 3.10; 95% CI, 1.94-4.96), and cough and cold preparations (aHR, 1.52; 95% CI, 1.18-1.96), respectively. The incidence of at least 1 systemic, syndromic, or medication feature of PASC was 41.9% (95% CI, 41.4-42.4) among viral test-positive children vs 38.2% (95% CI, 38.1-38.4) among viral test-negative children, with an incidence proportion difference of 3.7% (95% CI, 3.2-4.2). A higher strength of association for PASC was identified in those cared for in the intensive care unit during the acute illness phase, children younger than 5 years, and individuals with complex chronic conditions. In this large-scale, exploratory study, the burden of pediatric PASC that presented to health systems was low. Myocarditis was the most commonly diagnosed PASC-associated condition. Acute illness severity, young age, and comorbid complex chronic disease increased the risk of PASC.

Healthcare resource utilization among patients receiving non-invasive testing for coronary artery disease in an outpatient setting: A cohort study reflecting daily practice trends

BackgroundAccurate, early diagnosis and the initiation of appropriate treatment is central to reducing the clinical burden of coronary artery disease (CAD); however, real-world evidence characterizing healthcare resource utilization (HCRU) associated with testing for CAD is lacking. Methods and ResultsUsing a non-interventional, retrospective, secondary database analysis, patients aged ≥18 years who underwent outpatient non-invasive cardiac diagnostic testing were identified. The primary objective was to gain an understanding of pre- and post-assessment care pathways and the associated interventions for patients who underwent non-invasive testing for CAD in either an outpatient or emergency department setting. Overall, chest pain was the primary reason for the index visit (54.8%), followed by shortness of breath (23.7%), myocardial infarction (MI), coronary artery disease (CAD) or congestive heart failure (CHF) (3.8%), and other (46.8%); 3.0% of patients had no apparent reason for testing in the last 45 days. Single-photon emission computed tomography (SPECT) was the dominant diagnostic testing modality (40.3%). During the 90-day follow-up, 7.3% (n = 22,083) of patients were diagnosed with CAD; among these patients, 19.4% had repeat diagnostic testing, 26.0% of patients had a revascularization procedure, and 65.6% underwent cardiac catheterization. These rates varied by testing modality. ConclusionsIn this study of a large real-world data sample, variability in the use of non-invasive tests and HCRU were evident. These results may assist efforts to optimize system-wide care/diagnostic pathways and value-based treatment decisions for patients.