Overall Number Of Patients Research Articles

MONDEP: A unified SpatioTemporal MONitoring Framework for National DEPression Forecasting

Depression has become a prevalent mental disorder that significantly affects a person's emotions, behaviors, physical health, ability to perform daily tasks, and ability to maintain healthy relationships. Untreated depression can escalate the risk of suicide, making the situation even worse. Despite an abundance of models previously proposed for forecasting depression, the issue of foretelling the overall number of patients at each administrative level remains under-investigated. Therefore, in this paper, we propose a simple but effective SpatioTemporal Monitoring Framework for National Depression Forecasting (MONDEP). In particular, we analyze national depression statistics data in Thailand as a case study and create prediction models for a real-time depression forecasting system using machine learning and deep learning approaches. In order to forecast the prevalence of depression at various administrative levels, we use the hierarchical structure of depression aggregation. The proposed framework consists of three modules: Data Pre-processing to extract and pre-process the raw data, Exploratory Data Analysis (EDA) to visualize and analyze the data to get insight, and Model Training and Testing to predict future depression cases. The objective of our research is to construct a comprehensive MONDEP framework that utilizes machine learning and deep learning to predict depression profiles at the district and national levels using multivariate time series across various administrative levels. Our study illustrates the considerable association between a spatial-temporal component and demonstrates how depression profiles may be represented by employing lower administrative-level data to estimate the general level of mental health across the nation. Additionally, the best performance across all criteria is obtained when a deep learning model is used to exploit multivariate time series, showing a 13% improvement in MAE measure compared to the SARIMAX baseline. We believe the proposed framework could be used as a point of reference for decision-making regarding the management of depression and has the potential to be incredibly helpful for policymakers in successfully managing mental health services on time.

Management of Distal Tibial Deformity Secondary to Traumatic Physeal Arrest: Systematic Review and Meta-Analysis

Abstract Background Injuries of the ankle growth plate are the second most common physeal injury of the childhood and comprises 6% of all fractures of the tibia. These injuries are typically observed among children 10 to 12 years of age, usually as Salter-Harris (SH) Type 1 and Type 2 fractures followed by Type 3 and Type 4 fractures. Objective To review modalities of treatment for distal tibia deformity secondary to physeal arrest post traumatic and to perform a systematic review and meta- analysis of the outcome for different methods of treatment. Methodology The included studies published between 2000 and 2021. Regarding the type of included studies, 8 studies (out of 10 studies) were retrospective; while 2 studies were prospective. Results Meta-analysis study was done on 6 studies which described Epiphysiodesis technique for distal tibial deformities secondary to post-traumatic physeal arrest; with overall number of patients (N = 215). We calculated efficacy for each technique through (Bone union ―success rate‖) and (Excellent functional outcome). We calculated safety for each technique through (Revision rate) and (Complication’s rate). Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2022. Conclusion Ilizarov technique for corrections of post-traumatic physeal arrest ankle deformities showed better efficacy and safety profiles, compared to Epiphysiodesis. Which also, showed relatively good efficacy and safety especially in children with post-traumatic physeal arrest ankle deformities.

Improving ambulatory patient access through strategic reorganisation and implementation of innovative ambulatory care best practices

John Muir Health, a large health system in northern California, struggled with a complex practice management structure that lacked role clarity and core positions, making it difficult to bring about positive change within the ambulatory setting. As part of a broader, strategic partnership to improve operations and deliver healthcare, health system leaders partnered with Optum Advisory to reorganise the practice management structure and optimise primary care patient access. Across its duration, the partnership improved access within primary care while reducing the administrative burden on providers through care team redesign, and with a new structure, physicians received administrative clarity and practice managers have leaders providing support for access, project management and innovation. These changes led to greater innovation and efficiency, resulting in higher satisfaction for patients, providers and staff. Optimising access and productivity, John Muir Health primary care practices have decreased the amount of time it takes for patients to get into the practice, increasing the overall number of patients they have been able to see. In addition, centralised prescription refills have allowed patients to receive their medications quicker while enabling physicians to concentrate on direct patient care. The overall result has been less administrative burden for providers and staff, allowing for more top-of-licence work and time with patients.

Depression Screening in Pediatric Orthopedic Surgery Clinics and Identifying Patients At-Risk.

Up to 25% of youth experience a depressive episode by 18 years of age, leading the US Preventive Services Task Force to recommend depression screening within this population. This study aimed to understand the prevalence of depression identified within pediatric orthopedic clinics compared with primary care clinics after the implementation of a screening program and present data on the prevalence of moderate-severe depression across specific pediatric orthopedic clinics, characterizing and identifying specific populations at higher risk. A retrospective review was performed to identify all patients screened using the 2-item and 9-item versions of the Patient Health Questionnaire (PHQ-2/PHQ-9) and the Columbia-Suicide Severity Rating Scale over a 2-year period (October 2018 to January 2021) within pediatric primary care and orthopaedic clinics. Demographic and clinical characteristics were collected. Statistical analysis was performed to compare scores between orthopedic and primary care clinics, as well as between the different pediatric orthopedic subspecialties and included χ 2 test, ANOVA, and logistic regression. There were 32,787 unique adolescent patients screened in primary care clinics, with an additional 14,078 unique adolescent patients screened in orthopaedic clinics, leading to a 30% increase in the overall number of patients receiving depression screening. 5.2% of patients in primary care pediatric clinics screened positive for moderate-severe depression versus 2.0% in pediatric orthopaedic clinics ( P <0.001). 2.7% of primary care patients were at risk of self-harm compared with 0.8% of orthopedic patients ( P <0.001). Within orthopaedic subspecialty clinics, the spine patients were at the highest risk of moderate-severe depression (3.5%), significantly higher than both the sports (1.4%, P =0.006) and patients with acute fracture (1.3%, P <0.001). This study demonstrates the high incidence of patients screening positive for depression in pediatric and adolescent orthopaedic clinics. By identifying high-risk clinics and patient groups, health care systems can apply a more practical approach and appropriately deploy behavioral health specialists for timely counseling and treatment discussions. Level-III.

Venous Thromboembolism in Burn Patients: A 5-Year Retrospective Study.

Background and Objectives: Burn patients manifest all components of Virchow's triad, amplifying the concern for venous thromboembolism (VTE). Routine prophylaxis for VTE remains a subject of debate, with the central concern being the occurrence of associated adverse events. Materials and Methods: We conducted a five-year retrospective study on burn patients admitted to our burn center. Demographic data, comorbidities, burn lesions characteristics, surgical interventions, anticoagulant medication, the need for transfusions, the presence of a central venous catheter, length of stay, complications, and mortality were recorded. Results: Of the overall number of patients (494), 2.63% (13 patients) developed venous thromboembolic complications documented through paraclinical investigations. In 70% of cases, thrombosis occurred in a limb with central venous catether (CVC). Every patient with VTE had a Caprini score above 8, with a mean score of 12 points in our study group. Conclusions: Considering each patient's particularities and burn injury characteristics, individualized approaches may be necessary to optimize thromboprophylaxis effectiveness. We suggest routinely using the Caprini Risk Assessment Model in burn patients. We recommend the administration of pharmacologic thromboprophylaxis in all patients and careful monitoring of patients with Caprini scores above 8, due to the increased risk of VTE. Additionally, ongoing research in this field may provide insights into new strategies for managing thrombotic risk in burn patients.

Immune landscape of the kidney allograft in response to rejection.

Preventing kidney graft dysfunction and rejection is a critical step in addressing the nationwide organ shortage and improving patient outcomes. While kidney transplants (KT) are performed more frequently, the overall number of patients on the waitlist consistently exceeds organ availability. Despite improved short-term outcomes in KT, comparable progress in long-term allograft survival has not been achieved. Major cause of graft loss at 5 years post-KT is chronic allograft dysfunction (CAD) characterized by interstitial fibrosis and tubular atrophy (IFTA). Accordingly, proactive prevention of CAD requires a comprehensive understanding of the immune mechanisms associated with either further dysfunction or impaired repair. Allograft rejection is primed by innate immune cells and carried out by adaptive immune cells. The rejection process is primarily facilitated by antibody-mediated rejection (ABMR) and T cell-mediated rejection (TCMR). It is essential to better elucidate the actions of individual immune cell subclasses (e.g. B memory, Tregs, Macrophage type 1 and 2) throughout the rejection process, rather than limiting our understanding to broad classes of immune cells. Embracing multi-omic approaches may be the solution in acknowledging these intricacies and decoding these enigmatic pathways. A transition alongside advancing technology will better allow organ biology to find its place in this era of precision and personalized medicine.

Impact of COVID-19 lockdown on hospital admissions for epistaxis in Germany.

Reports of a decrease in hospital admissions during the coronavirus disease 2019 (COVID-19) lockdown period have raised concerns about delayed or missed diagnoses and treatments for non-COVID-19-related illnesses. To investigate the impact of the COVID-19 pandemic-induced lockdown and its end on hospital admissions of patients with epistaxis in Germany. A retrospective analysis based on the national database of the Hospital Remuneration System was used to compare hospital admissions during defined time periods between 2019 and 2022 with the lockdown period as the reference period. This was done on a weekly basis before, during, and after the lockdown. An Interrupted Time Series was used as the analysis method. In our analysis, we included 26183 patients. The implementation of the lockdown led to a substantial reduction in the overall occurrence of epistaxis among patients (P < 0.05). This effect was most pronounced in the age group of 0-39 years, where the decrease was highly significant (P < 0.001). However, there was no change observed in patients aged 80 years and older (not significant). With the end of the lockdown period, the overall number of patients, especially in the youngest age group, increased abruptly and significantly (P < 0.01). During the lockdown period, there was a decrease in hospital admissions for younger patients with epistaxis, possibly due to the fear of COVID-19 exposure. We also conclude that the severity of epistaxis was not underestimated in the elderly during the pandemic.

Examining the Effectiveness of Telephone Clinics: A Review of a Telephone Foot and Ankle Orthopaedic Clinic in a District General Hospital in the United Kingdom.

Since the outbreak of COVID-19, significant value has been placed on preventative methods for pathogen spread.One suchmethod is the use of telemedicine via telephone clinics (TC). This article is designedto study TCin a District General Hospital in the United Kingdom. This clinical audit aims to evaluate the use of a TC in the United Kingdom and assess its effectiveness. It also aims to assess the use of a clinician-led triaging system to select patients who would receive subsequent telephone follow-ups (TFU). Two cycles were conducted. The first cycle was conducted in 2020 and the second cycle in 2022. Inbetween the two cycles, a clinician-led triage system was implemented to reduce the number of patients being called back for a face-to-face (FTF) appointment. Data was collected regarding the outcomes of the appointments and compared between the two cycles. Chi-squared test statistical test was employed with a p-value < 0.05 deeming significance. Overall, more discharges were made for 2022 outcomes compared to 2020 outcomes (30% vs 19%; p = 0.03) after employing the clinician-led triage. The number of patients listed for a TFU increased when comparing the 2020 versus 2022 datasets (21% vs 12%; p = 0.026), and the overall number of patients not attending appointments decreased when comparing the 2020 versus 2022 datasets (9% vs 17%; p = 0.033). This articleshows that for this particular clinic, an orthopaedic clinician-led triaging system allows for a greater number of patients to be discharged, lessened need for FTF consultations, and increased adherence to appointments by patients. However, much work is yet to be done concerning the long-term consequences and issues of rolling out nationwide telemedicine.

Effect of dapagliflozin on outpatient worsening heart failure in patients with mildly reduced or preserved ejection fraction: the DELIVER trial

Abstract Background Hospitalization is recognized as a sentinel event in the disease trajectory of patients with heart failure (HF), but not all patients experiencing decompensation are hospitalized. Outpatient intensification of diuretics is common in response to worsening symptoms suggestive of HF, yet its prognostic and clinical relevance is less certain. Purpose To evaluate the prognostic importance of outpatient oral diuretic intensification and assess the treatment effect of dapagliflozin across the spectrum of worsening HF events. Methods DELIVER was a global, randomized clinical trial of dapagliflozin vs. placebo in 6,263 participants with HF with mildly reduced or preserved ejection fraction. In this prespecified landmark analysis, we assessed the association between various non-fatal worsening HF events (those requiring hospitalization, urgent outpatient visits requiring intravenous HF therapies, and outpatient oral diuretic intensification) and rates of subsequent mortality. Diuretic intensification was defined as new initiation (among those not on diuretics at baseline) or dose uptitration sustained for at least 30 days (among those on diuretics at baseline). We also examined the treatment effect of dapagliflozin on an expanded composite endpoint of CV death, HF hospitalization, urgent HF visit, or outpatient oral diuretic intensification. Results In DELIVER, 4,532 (72%) patients experienced no worsening HF event, while 789 (13%) had outpatient oral diuretic intensification, 86 (1%) required an urgent HF visit, 585 (9%) had a HF hospitalization, and 271 (4%) died of CV causes as a first manifestation of worsening HF. Patients with a first presentation manifesting as outpatient oral diuretic intensification experienced rates of subsequent mortality that were higher (10 per 100py) than those without a worsening HF event (4 per 100py) but similar to rates of subsequent death following urgent HF visit (10 per 100py). Patients with a HF hospitalization as a first presentation of worsening HF had the highest rates of subsequent death (35 per 100py); Figure 1. The addition of outpatient diuretic intensification to the adjudicated DELIVER primary endpoint (CV death, HF hospitalization, or urgent HF visit) increased the overall number of patients experiencing an event from 1,122 to 1,731. Dapagliflozin reduced the need for outpatient diuretic intensification alone (HR 0.72; 95% CI: 0.64-0.82; P&amp;lt;0.001) and when analyzed as a part of an expanded composite endpoint of worsening HF (HR 0.76; 95% CI: 0.69-0.84; P&amp;lt;0.001); Figure 2. Conclusions Even in patients with HF with mildly reduced or preserved ejection fraction, hospitalization as a first presentation of worsening HF is associated with significant subsequent mortality. Moreover, oral diuretic intensification in ambulatory care was frequent, adversely prognostic, and significantly reduced by dapagliflozin.Figure 1Figure 2

Optimizing Acute Sickle Cell Care at Community Health Partners Medical Center

CONCLUSION Sickle cell disease (SCD) is an inherited disease affecting more than 100,000 Black and Hispanic patients in the US. An adult with SCD has an average life expectancy of 54 years compared to 76 years in a typical US adult. This poor survival rate can be attributed to disease and race-related biases, a lack of standardized procedures and dedicated care providers, and delayed or insufficient pain management in the acute care setting. Delays and disparities in care, particularly pain management in acute care setting, have been identified as one of the key deficiencies leading to a decreased quality of care and patient reported outcomes. This SCD quality improvement project seeks to improve the quality and timeliness of acute sickle cell vaso-occlusive care by utilizing an ED pain pathway, SCD-specific inpatient order sets, and educating providers on care-related biases for patients seeking acute care at Community Health Partners Medical Center (CHP). The primary objective is to improve efficacy, timeliness and patient-centered care in order to optimize health outcomes for patients with SCD seeking acute care at CHP. This is a collaborative effort between ED, Hospitalist and Pain Management teams. By identifying areas of strength and areas for improvement, we can work towards delivering more efficient, effective, and patient-centered care, ultimately leading to better health outcomes for patients with SCD disease in need of emergency services. Using the Epic EMR, a metric dashboard was created for SCD patients to measure time from arrival to ED order placement, time from arrival to medication administration, number of inpatient admissions, and length of stay. We focused on crucial time metrics and patient outcomes to gauge the department's efficiency and quality of care for SCD Vaso-occlusive pain crisis. Our intervention included delivering an educational presentation to the ED providers regarding appropriate recognition and treatment of SCD pain episodes, and by creating ED and inpatient SCD-specific order sets. The baseline data was evaluated from 3/1/2021-2/28/2022, and metrics were followed for one year after implementation of the intervention from 3/1/22-2/28/23. After implementation, the average time from arrival to ED order placement improved from 94.9 minutes to 69.4 minutes, a difference of 25.5 minutes or 27%. The average time from arrival to medication administration improved from 158.5 minutes to 135.3 minutes, a difference of 23.2 minutes or 14.6%. The average length of stay increased from 5.7 days to 8.4 days, an increase of 2.7 days or 32.2%. By providing education and SCD-specific order sets, we were able to significantly decrease the total amount of time to medication administration for SCD patients experiencing acute pain crises. While our methods were aimed at ED providers to simplify the input of orders, it did not address the time for nursing to obtain and administer the medication; future improvements could be made towards educating nursing staff to help administer medications sooner. One complicating factor is that these metrics were evaluated during the COVID pandemic, which was responsible for an overall increase in patient admissions and length of stay during this time period. These additional burdens have strained the ability of providers and nurses to provide timely care to SCD patients, though this will hopefully continue to improve as the pandemic recedes. Additionally, the proportion of ED patients who were admitted for further management decreased marginally from 25/39(61%) to 36/63(57%) though the overall number of patients seeking care in our acute care setting has increased. This increase in the number of patients utilizing our acute care may be partly due to an expanding Sickle Cell program at our facility. This analysis shows that by providing appropriate education and using a standardized order set and pathway, we observed a significant decrease in time to order placement to facilitate a faster administration of medications. While the results indicate positive changes in the acute setting, there are opportunities for continued improvement, particularly in reducing the time from order placement to medication administration to ensure more efficient, effective, and patient-centered care.

Retrospective chart analysis to determine the impact of a patient-facing digital risk stratification tool combined with a clinical screener for hereditary cancer genetic risk assessment triage in a community oncology clinic.

The purpose of this study was to evaluate the utility of adding a clinical screener to the patient-facing digital risk stratification tool triage process for the identification of patients eligible for a genetic risk assessment for hereditary cancer. Digital risk stratification entries were retrospectively reviewed to determine the overall number of patients eligible for genetic risk assessment. These were also analyzed to determine how many patients were re-contacted by the clinical screener, and how many of those recontacted patients met criteria after their personal and family history was revised by the clinical screener. There was an 89.9% digital risk stratification triage tool completion rate, with 22.6% requiring contact from the clinical screener. Of the 640 patients who completed the digital tool, 5.9% met criteria for testing after their personal and/or family history was revised by the clinical screener. Overall, 51.1% of patients met criteria for a genetic risk assessment. The addition of a clinical screener further increased identification of patients eligible for genetic risk assessment. About half of patients who met criteria after being contacted by the clinical screener met criteria based on their personal diagnosis of cancer alone. Incorporation of a clinical screener to the digital screening process may serve to reduce barriers to patient completion of the tool and increase rates of patient identification for cancer genetic services.

FRI081 Quality Improvement Initiative To Improve Management Of Obesity In A Primary Care Resident Continuity Clinic

Abstract Disclosure: M.G. Fernandez: None. M. Hillhouse: None. D. Ozimek: None. M. Salvo: None. Background: Obesity is a leading health concern in the US and a growing epidemic worldwide. Despite the substantial evidence on weight management interventions, it remains the least commonly addressed medical problem. Physicians also document obesity infrequently in medical records. It has been well established that increasing documentation of obesity improves its management as a chronic disease. Objective: The main aim of our project was to increase the percentage of patients with a body mass index (BMI) ≥30kg/m2 with documented obesity in the electronic medical record (EMR) from 42% to 70%. The second aim was to increase the percentage of patients with a BMI ≥30kg/m2 prescribed weight loss pharmacotherapy from 10% to 40%. The project was performed in an Internal Medicine residency program continuity clinic over six months. Methods: We used three cycles of the Plan-Do- Study-Act methodology; all included education in obesity medicine, distribution of a hard copy list of the patients who met inclusion criteria, and EMR message reminders to address obesity by the following medical appointment. The EMR was used to generate reports to track outcomes. The first report listed all the resident clinic patients with a documented BMI ≥30kg/m2. The following list the number of patients with BMI ≥30kg/m2 and a corresponding diagnosis of obesity in their chart. The last report listed the number of patients with BMI ≥30kg/m2 on weight loss pharmacotherapy. Reports were generated bi-monthly, and percentages were used to determine the efficacy of each cycle. Results: There were 25% of residents’ patients who met project inclusion criteria. Of this, 11% were prescribed pharmacotherapy at baseline. Of those receiving treatment, 98% had type 2 diabetes. After the interventions, the documentation of obesity in the EMR increased from 42% to 60%. As a result, the overall number of patients on weight loss pharmacotherapy increased from 10.53% to 12.68%. Conclusion: The overall goal of the interventions was successful. There was an increase in both EMR documentation of obesity and increased weight loss pharmacotherapy prescribing; however, both were lower than anticipated. It was also found that the resident physicians responded more to printed metrics of their population of patients. In addition, physicians were more susceptible to treating patients when obesity was documented as a chronic disease. However, this project emphasizes that more efforts should be made to engage residents in multidisciplinary training to improve the management of obesity and increase tools to navigate through barriers to obesity treatments. Presentation: Friday, June 16, 2023

Can guidelines rein inoxygen use? A retrospective cross-sectional study using routinely collected data.

Oxygen is one of the most commonly used emergency therapies. Like other therapies, oxygen can cause harm if used inappropriately. During the COVID-19 pandemic, guidelines were released to optimize oxygen and medication use. In the current study, we examine whether oxygen and medication use during the first wave of the COVID-19 pandemic was in concordance with new guidelines. A retrospective cross-sectional study was conducted using routinely collected data from University of Birmingham NHS Foundation Trust in England. Patients were admitted between April 2020 and September 2020, were over the age of 18 years, and had a confirmed diagnosis of COVID-19. To assess adherence to the oxygen guidelines (i.e. SpO2 adherence), the percentage of times oxygen therapy was administered within, over, and under guideline specifications were calculated for patients overall, and then for patients with and without chronic obstructive pulmonary disease (COPD)/pulmonary disease separately. Next, two multinomial regression analyses were conducted to assess whether clinical processes, pre-admission diagnoses, and other demographic factors were related to oxygen use. Analysis 1 included patients not diagnosed with COPD/pulmonary disease. Analysis 2 included patients diagnosed with COPD/pulmonary disease. Results are reported as tallies, percentages, and odds ratios with 95% confidence intervals. To assess adherence to a new medication guideline, the percentage of patients administered oxygen and dexamethasone was calculated for those admitted after 25 June 2020. The overall number of patients included in our SpO2 adherence analyses was 8751 (female = 4168). Oxygen was used within guideline specifications less than half the time, i.e. 41.6% (n = 3638/8751); non-adherence involving under-administering (3.5%, n = 304/8751) was markedly lower than over-administering (55.0%, n = 4809/8751). Adherence was higher for patients without COPD (43.7%, n = 3383/7741) than with COPD (25.2%, n = 255/1010). Under-administering was low across groups (non-COPD 3.5%, n = 274/7741 and COPD 2.9%, n = 30/1010). Over-administering was markedly lower for non-COPD (52.3%, n = 4084/7741) than COPD (71.8%, n = 725/1010) patients. Diagnoses associated with over-administering varied across the groups. Regarding the dexamethasone guidelines, of the 6397 patients admitted after the 24th of June, only 12.6% (n = 805) received dexamethasone. Suboptimal use of oxygen and medication were common during the first wave of the COVID-19 pandemic. As found in previous studies, over-administering was more common than under-administering. The new guidelines issued during the COVID-19 pandemic were not by themselves sufficient to optimize oxygen use. Behavioural strategies are explored which may help policymakers optimize oxygen use.

Outpatient Worsening Among Patients With Mildly Reduced and Preserved Ejection Fraction Heart Failure in the DELIVER Trial.

Hospitalization is recognized as a sentinel event in the disease trajectory of patients with heart failure (HF), but not all patients experiencing clinical decompensation are ultimately hospitalized. Outpatient intensification of diuretics is common in response to symptoms of worsening HF, yet its prognostic and clinical relevance, specifically for patients with HF with mildly reduced or preserved ejection fraction, is uncertain. In this prespecified analysis of the DELIVER trial (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure), we assessed the association between various nonfatal worsening HF events (those requiring hospitalization, urgent outpatient visits requiring intravenous HF therapies, and outpatient oral diuretic intensification) and rates of subsequent mortality. We further examined the treatment effect of dapagliflozin on an expanded composite end point of cardiovascular death, HF hospitalization, urgent HF visit, or outpatient oral diuretic intensification. In DELIVER, 4532 (72%) patients experienced no worsening HF event, whereas 789 (13%) had outpatient oral diuretic intensification, 86 (1%) required an urgent HF visit, 585 (9%) had an HF hospitalization, and 271 (4%) died of cardiovascular causes as a first presentation. Patients with a first presentation manifesting as outpatient oral diuretic intensification experienced rates of subsequent mortality that were higher (10 [8-12] per 100 patient-years) than those without a worsening HF event (4 [3-4] per 100 patient-years) but similar to rates of subsequent death after an urgent HF visit (10 [6-18] per 100 patient-years). Patients with an HF hospitalization as a first presentation of worsening HF had the highest rates of subsequent death (35 [31-40] per 100 patient-years). The addition of outpatient diuretic intensification to the adjudicated DELIVER primary end point (cardiovascular death, HF hospitalization, or urgent HF visit) increased the overall number of patients experiencing an event from 1122 to 1731 (a 54% increase). Dapagliflozin reduced the need for outpatient diuretic intensification alone (hazard ratio, 0.72 [95% CI, 0.64-0.82]) and when analyzed as a part of an expanded composite end point of worsening HF or cardiovascular death (hazard ratio, 0.76 [95% CI, 0.69-0.84]). In patients with HF with mildly reduced or preserved ejection fraction, worsening HF requiring oral diuretic intensification in ambulatory care was frequent, adversely prognostic, and significantly reduced by dapagliflozin. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03619213.

Impact of the COVID-19 Pandemic on the Severity and Early Postoperative Outcomes of Acute Appendicitis.

Background The coronavirus disease 2019 (COVID-19) pandemic caused changes in surgical practice. For acute appendicitis (AA), measures to control the pandemic might hinder patients from seeking medical care timely, resulting in increasing severity, postoperative complications, and mortality. This study aimed to investigate whether the COVID-19 pandemic had a negative impact on the severity and postoperative outcomes of patients with AA. Methodology We retrospectively reviewed medical records of AA patients treated operatively at Nhan Dan Gia Dinh Hospital hospital from June 1st to September 30th in three consecutive years: pre-pandemic (2019)/Group 1,minor waves (2020)/Group 2, and major wave (2021)/Group 3 (2021). Data were collected focusing on the duration of symptoms, severity of AA, time from admission to operation,postoperative complications, and mortality. Results There were 1,055 patients, including 452 patients in Group 1, 409 in Group 2, and 194 in Group 3. The overall number of patients decreased mainly in non-complicated AA. The percentages of hospital admission after 24 hours gradually increased (20.8%, 27.9%, and 43.8%, p < 0.05). The percentages of complicated AA in Group 2 and Group 3 were statistically higher than in Group 1 (39% and 55% vs. 31%, p < 0.05). Waiting time for operation increased to five hours during the major wave. Laparoscopic appendectomy was performed in 98-99% of AA patients during the pandemic, with an early postoperative complication rate of 5-9% and a mortality rate of 0.2-1%. Conclusions Although the percentages of hospital admission after 24 hours and complicated AA increased, laparoscopic appendectomy was still feasible and effective and should be maintained as the standard management for AA during the COVID-19 pandemic.

Which Patients Do We Need to Test for BRCA1/2 Mutation? Feasibility of Adjuvant Olaparib Treatment in Early Breast Cancer-Real-World Data from Two Large German Breast Centers.

Approximately 6% of women with breast cancer carry pathogenic germline variants in predisposition genes such as BRCA1 and BRCA2. Depending on personal and family cancer history, it is therefore recommended to test for hereditary breast cancer. Moreover, as shown by the phase III OlympiA trial, olaparib significantly improves overall survival in patients with HER2 negative (HER2-) early breast cancer who (1) carry a BRCA1 or BRCA2 germline mutation (gBRCA1/2-positive), (2) have received (neo)adjuvant chemotherapy and (3) are at high clinical risk. The objective of the current analysis was to determine the number of patients with early HER2- breast cancer who are at high clinical risk, according to the inclusion criteria of OlympiA, and to estimate how many of these patients would meet the criteria for hereditary cancer testing in a real-world analysis. All patients included in this retrospective analysis were treated for early breast cancer (eBC) at the Department of Gynecology and Obstetrics, Ulm University Hospital, Germany, and the Department of Women's Health at Tuebingen University Hospital, Germany, between January 2018 and December 2020. Patients were identified as high risk, in line with the clinicopathological determiners used in the OlympiA trial. The criteria of the German Consortium for Hereditary Breast and Ovarian Cancer were used to identify patients who qualify for hereditary cancer testing. Of 2384 eligible patients, 1738 patients (72.9%) showed a hormone receptor positive (HR+)/HER2- tumor biology, 345 patients (14.5%) displayed HER2+ breast cancer and 301 patients (12.6%) suffered from HR-/HER2- breast cancer (TNBC). Of 2039 HER2- breast cancer patients, 271 patients (13.3%) were at high clinical risk. This cohort encompassed 130 of the 1738 patients with HR+/HER2- breast cancer (7.5%) and 141 of 301 patients with TNBC (46.8%). A total of 121 of 271 patients (44.6%) with high clinical risk met the criteria for hereditary cancer testing (34 of 130 (26.2%) HR+/HER2- patients and 87 of 141 (61.7%) patients with TNBC). Approximately one in ten patients with HR+/HER2-, and half of the patients with TNBC, meet the high-risk criteria according to OlympiA. Half of these patients do not meet the criteria for hereditary cancer testing and should therefore be tested for the presence of gBRCA1/2 mutations, irrespective of their own or family cancer history. The overall number of patients with early breast cancer benefiting from olaparib needs to be investigated in future studies.

The Impact of the SARS-COV-2 pandemic on the Prevalence of Injuries among Children and Adolescents at the Upper Silesian Child Health Center in Katowice

Background: Maxillofacial injuries quite often relate to children. The etiology of injuries occurring among children and adolescents differs in different age groups. In December 2019, the new SARSCoV-2 coronavirus was identified. Pandemic and the preventive actions had a significant impact on the epidemiology and etiology of injuries in children and adults. The aim of this analysis is assessing the impact of the SARSCoV-2 pandemic and the social restrictions on the frequency and type of maxillofacial injuries among children and adolescents treated at the Children’s Trauma Center in Katowice and the Upper-Silesian Child Health Center. Material and Methods: A retrospective analysis of the medical records of patients with craniofacial fractures is based on six periods of time: February-May 2019 [Spring 2019], February-May 2020 [Spring 2020], JuneSeptember 2019 [Summer 2019], June-September 2020 [Summer 2020], October-January 2019 [Autumn 2019], October-January 2020 [ Autumn 2020]. Results: Craniofacial injuries were the most common in the age group of 10-18 years (65.2%) in March-May 2019 while in March-May 2020 injuries were as well common in the both age group. Violence, sports and traffic accidents were the cause of injuries in 27.3% each in June-September 2019, but playing sport was the main cause of injury in June-September 2020 (42.9%). Differences in the overall number of patients with craniofacial trauma were observed in every period of time. Conclusion: There were differences in the number of patients reporting to the Upper Silesian Child Health Center. In the peak periods of COVID-19 in the spring and autumn, the number and variety of cases of injuries were significantly different from the previous norms.

PD09 A prospective study of outcomes of narrowband ultraviolet B for the treatment of paediatric atopic dermatitis, with additional breakdown by ethnicity/skin type

Abstract Narrowband UVB (NBUVB) phototherapy is regarded as a second-line treatment for atopic dermatitis (AD) when response to first-line treatment is ineffective. We undertook a prospective study evaluating response to NBUVB treatment in paediatric AD to assess changes to pretreatment Eczema Area and Severity Index (EASI) score immediately postphototherapy and 12 months later. We subanalysed response in different skin types. All patients had NBUVB treatment three times weekly up to a maximum of 40 exposures. Follow-up was every 3 months for 1 year postphototherapy. In total, 58 patients were recruited for NBUVB phototherapy treatment [37 (64%) men, 21 (36%) women, mean age 10.6 years (range 4.1–16.9 years)]. Skin types/ethnicity were as follows: White, n = 22 (38%); South Asian (Pakistani/Indian/Bangladeshi), n = 17 (29%); Black African/Caribbean, n = 9 (16%); other, n = 10 (17%). The immediate post-treatment mean EASI reductions vs. pretreatment baseline scores were 10.0 (entire cohort), 12.4 (White), 8.6 (South Asian), 2.5 (Black African/Caribbean) and 7.5 (other). A ≥ 75% increase in EASI (EASI 75) was achieved in the 49% of the entire cohort, in 48% of White people, in 50% of South Asians, in 44% of Black African/Caribbean people and in 56% of others. A ≥ 90% increase in EASI (EASI 90) was achieved in 15% of the whole group, 14% of White people, 13% of South Asians, 22% of Black African/Caribbean people and 11% of others. At 12 months post-treatment, mean EASI reduction vs. pretreatment baseline score was 7.6 in the whole cohort, 9.0 in White people, 8.6 in South Asians, −2.1 (i.e. worsening) in Black African/Caribbean people and 8.0 in others. At 12 months post-treatment, EASI 75 was achieved in 28% of the whole group, 33% of White people, 40% of South Asians, 14% of Black African/Caribbean people and 13% of others. For those who responded, there were a similar proportion of those achieving EASI 75 across the different skin types. However, there was more variation in the reduction in EASI score in those with skin colour. We acknowledge that existing scoring systems may lead to underscoring of the severity of erythema and therefore overall EASI score in darker skin types. Although the mean EASI reduction was highest in the group of White patients, there was a higher proportion of Black/Caribbean patients achieving EASI 90 at the end of the NBUVB treatment; however, the overall number of patients in this group was small. Our study showed that White and South Asian paediatric patients had a more sustained response to NBUVB phototherapy up to 1 year after stopping treatment. Black African/Caribbean patients had a greater risk of relapse.

264-OR: Incorporating Shared Decision-Making to Facilitate Equitable Insulin Pump Use among Pediatric Patients with Type 1 Diabetes

Background: Insulin pumps, CGMs, and other technologies have shown to improve outcomes for patients with T1D. However, various obstacles prevent some patient groups from utilizing these technologies. This was evident by the discrepancy in non-Hispanic black patients on insulin pumps (9%) vs non-Hispanic white patients (23%) in our clinic. Our goal is to identify and overcome these obstacles in order to safely increase the total number of patients that utilize insulin pumps while also creating equity in pump use between groups. Methods: We identified a group of non-Hispanic black patients who were not candidates for starting insulin pumps based on our clinic’s “typical” practice, but showed interest in pumps. By focusing on this group, we continued to adjust pump prescriptions and processes. After demonstrating efficacy and safety of pump use in this group, we began expanding to all patients as appropriate. Beyond continued education for nurse educators and changing pump start criteria, we also started using shared decision-making to be sure all patients were learning about technology on a regular basis. Results: As of December 2022, we have helped &amp;gt;35% of our interested patients navigate the process of obtaining an insulin pump. Equity was also improved, with 20% of our non-Hispanic black patients now using pumps vs 25% of non-Hispanic white patients. Some of these patients would not typically be candidates for pumps but were able to safely begin using this technology because of the interventions we initiated. Conclusions: Utilizing shared decision-making can help to identify patients who might not initially be considered for insulin pumps and other technology. We have demonstrated that many interested patients can safely initiate pumps which will help improve management of their diabetes. We are continually adjusting our processes to improve equity in pump use and increase the overall number of patients utilizing pumps in our clinic. Disclosure J.Turner: None. G.Nelson: None. B.V.Adams: None.

INR VALUES WITH PATIENTS ON ORAL ANTICOAGULANT THERAPY DURING COVID-19 PANDEMICS

Introduction: Oral anticoagulant therapy (OAT) is widely used for preventing and treating vein and arterial thrombosis. The OAT drug that is most commonly used is warfarin.Aim of the paper: assess the effect of anti-pandemic measures on the frequency of disorders in INR values with patients who use warfarin.Material and methods: This study includes 89 patients who use warfarin and who controlled their INR values University Clinical Center Tuzla. The available data base gave information about the patients including age, gender, diagnosis and INR values during 2019 and 2020 and these were compared.Results: Among 89 examinees there were 57.3% (51) male patients and 42.7% (38) female patients. From the overall number of patients during 2019 51.7% (46) patients had recommended INR values while in 48.3% (43) patients there were INR oscillations outside the therapeutic range of warfarin effect. The average INR value in 2019 was 2.6 while in 2020 it was 1.7. The disorders of INR outside therapeutic range (INR&lt;2.0 i INR&gt;3.5) during 2019 was noticed in 21.3% (19), and in 2020 in 35.9% (32) patients. The results showed that 68.5% patients during pandemics didn’t regulate INR values.Conclusion: The results of the examinations showed that the appearance of the COVID-19 pandemics resulted in the disorder of INR values with 61 (68.5%) patients who use warfarin regardless of the indication for usage, which is 20.2% higher in comparison to 2019.Key words: warfarin, acenocoumarol, COVID-19 pandemics