Time Of Initial Assessment Research Articles

WP5.15 - A review of emergency general surgery (EGS) admissions via the direct access pathway (DAP) in a district general hospital in United Kingdom

Abstract Aims Emergency surgical presentations require urgent attention by surgeons to ensure appropriate treatment, However, increased waiting time in A&E often leads to delayed diagnosis and subsequently delayed management. A direct access pathway (DAP) to Surgical Emergency Assessment Unit (SEAU) helps minimize these delays and subsequently improve patient outcome. Methods A retrospective observational study of Emergency General Surgery (EGS) admissions from May 2023 to December 2023 was performed. Structured DAP referral proforma was implemented for patients to be directly referred to SEAU from A&E triage. Factors taken into consideration were - initial presentation, source of referral, time of initial assessment and patient outcome. Results A total of 265 patients were channeled through DAP referrals during the study period, of which 96.6% were appropriate referrals. The main source of the referral the A&E (52.4%), while the UTC-GP and GP constituted the remaining (47.6%). The most common clinical presentations were abdominal pain (32.4%), followed by subcutaneous abscess (17.3%). The median watiting time for initial assessment by the surgical team was 60 minutes. In terms of outcomes - 15 % patients were admitted, 14.7% were discharged after intervention, 35.8 % were discharged without intervention and 28.6% were planned to return for investigations or interventions. Conclusion The DAP for EGS admissions has enabled surgical emergencies to be addressed more promptly, and thus seen to have improved patient outcome as a result of avoiding unnecessary steps and delays before being reviewed by the surgical team through A&E pathway.

Impact of the integration of remote clinical oncology pharmacists into routine precision medicine workflows on biomarker testing rates within The US Oncology Network community-based practices.

e13813 Background: The US Oncology Network implemented a centralized, remote clinical oncology pharmacist review program (ClinReview) into select community-based practices. Initially, pharmacists were integrated into a precision medicine workflow process to increase biomarker testing rates among patients receiving adjuvant treatment for non-small cell lung cancer, with recommendations achieving a 100% acceptance rate. Following this success, metastatic prostate cancer patients were incorporated into the established workflow, following updated guideline recommendations for both germline and somatic testing and the 2023 approvals of PARP inhibitors in the first-line treatment setting. With previously reported testing rates only reaching 60%, we sought to evaluate the impact of the pharmacist integration into the precision medicine workflow on biomarker testing in metastatic prostate patients. Methods: Over a 4-month period, ClinReview remotely identified patients with metastatic prostate cancer during normal order review. The EMR was reviewed to assess germline and somatic testing status. If testing was not ordered, the pharmacist sent a recommendation to the treating provider. Initial testing rates for germline and somatic testing, BRCA+ status and provider acceptance rates for testing recommendations were collected. Additional data was collected utilizing a de-identified database. While additional data collection is ongoing, descriptive statistics were utilized to analyze data and the impact of the pharmacists’ interventions. Results: Across 9 practices, 142 patients were initiated on treatment for metastatic prostate cancer. At the time of initial assessment, germline and somatic testing was not ordered in 50% and 37% of patients, respectively. Pharmacists recommended additional testing in 61 patients (43%) with a 73% provider acceptance rate. Findings showed equitable testing rates across racial demographics. Pharmacist workflow integration enhanced combined germline and somatic testing rates, demonstrating an improvement from a baseline of 57% up to 77% currently. Conclusions: Community oncology practices seek to provide high-value care, including offering the most current evidence-based precision medicine testing. These findings highlight the continued need for improved somatic and germline testing in metastatic prostate cancer. However, the implemented precision medicine pharmacist workflow demonstrates the positive impact a clinical pharmacist can have on both testing rates and the potential to improve therapeutic offerings within this growing treatment space. [Table: see text]

Development of a Prediction Model for Surgery or Early Mortality at the Time of Initial Assessment for Necrotizing Enterocolitis.

No available scale, at the time of initial evaluation for necrotizing enterocolitis (NEC), accurately predicts, that is, with an area under the curve (AUC) ≥0.9, which preterm infants will undergo surgery for NEC stage III or die within a week. This is a retrospective cohort study (n = 261) of preterm infants with <33 weeks' gestation or <1,500 g birth weight with either suspected or with definite NEC born at Parkland Hospital between 2009 and 2021. A prediction model using the new HASOFA score (Hyperglycemia, Hyperkalemia, use of inotropes for Hypotension during the prior week, Acidemia, Neonatal Sequential Organ Failure Assessment [nSOFA] score) was compared with a similar model using the nSOFA score. Among 261 infants, 112 infants had NEC stage I, 68 with NEC stage II, and 81 with NEC stage III based on modified Bell's classification. The primary outcome, surgery for NEC stage III or death within a week, occurred in 81 infants (surgery in 66 infants and death in 38 infants). All infants with pneumoperitoneum or abdominal compartment syndrome either died or had surgery. The HASOFA and the nSOFA scores were evaluated in 254 and 253 infants, respectively, at the time of the initial workup for NEC. Both models were internally validated. The HASOFA model was a better predictor of surgery for NEC stage III or death within a week than the nSOFA model, with greater AUC 0.909 versus 0.825, respectively, p < 0.001. Combining HASOFA at initial assessment with concurrent or later presence of abdominal wall erythema or portal gas improved the prediction surgery for NEC stage III or death with AUC 0.942 or 0.956, respectively. Using this new internally validated prediction model, surgery for NEC stage III or death within a week can be accurately predicted at the time of initial assessment for NEC. · No available scale, at initial evaluation, accurately predicts which preterm infants will undergo surgery for NEC stage III or die within a week.. · In this retrospective cohort study of 261 preterm infants with either suspected or definite NEC we developed a new prediction model (HASOFA score).. · The HASOFA-model had high discrimination (AUC: 0.909) and excellent calibration and was internally validated..

A review of emergency general surgery (EGS) admissions via the direct access pathway (DAP) in a district general hospital

Abstract Aims Patients presenting with emergency general surgical (EGS) conditions require urgent management - however, increased waiting time in A&amp;E often leads to delayed diagnosis and subsequently delayed management. Having a direct access pathway (DAP) to Surgical Emergency Assessment Unit (SEAU) helps minimize these delays - leading to better outcome in management of these patients. Methods A retrospective observational study of EGS admissions in May 2023 was performed. Structured DAP referral proforma was implemented for patients to be directly referred to SEAU from A&amp;E triage. Factors taken into consideration were - initial presentation, source of referral, time of initial assessment and patient outcome. Results A total of 188 referrals were made to SEAU, of which 46 (24.5%) were DAP referrals. The average number was 18 over weekdays and 10 over weekends - of these, 97.8% of referrals were appropriate with correctly filled out proforma, whereas 2.2% were inappropriate referrals. 33% patients were discharged, 10% were admitted, and 10% were planned to return for investigations the following day. The median waiting time for initial assessment was 1.5hours. The most common presentations were RUQ Pain, subcutaneous abscess and RLQ pain which correlated with the final diagnosis. It was also noticed that when compared with May 2022 (176patients during the same 2-week period), there was 6.8% increased referral since commencement of DAP. Conclusion The DAP for EGS admissions has been seen to have improved patient outcome as a result of avoiding unnecessary steps and delays before being reviewed by the surgical team through A&amp;E pathway.

Detection of Left Ventricular Systolic Dysfunction From Electrocardiographic Images.

Left ventricular (LV) systolic dysfunction is associated with a >8-fold increased risk of heart failure and a 2-fold risk of premature death. The use of ECG signals in screening for LV systolic dysfunction is limited by their availability to clinicians. We developed a novel deep learning-based approach that can use ECG images for the screening of LV systolic dysfunction. Using 12-lead ECGs plotted in multiple different formats, and corresponding echocardiographic data recorded within 15 days from the Yale New Haven Hospital between 2015 and 2021, we developed a convolutional neural network algorithm to detect an LV ejection fraction <40%. The model was validated within clinical settings at Yale New Haven Hospital and externally on ECG images from Cedars Sinai Medical Center in Los Angeles, CA; Lake Regional Hospital in Osage Beach, MO; Memorial Hermann Southeast Hospital in Houston, TX; and Methodist Cardiology Clinic of San Antonio, TX. In addition, it was validated in the prospective Brazilian Longitudinal Study of Adult Health. Gradient-weighted class activation mapping was used to localize class-discriminating signals on ECG images. Overall, 385 601 ECGs with paired echocardiograms were used for model development. The model demonstrated high discrimination across various ECG image formats and calibrations in internal validation (area under receiving operation characteristics [AUROCs], 0.91; area under precision-recall curve [AUPRC], 0.55); and external sets of ECG images from Cedars Sinai (AUROC, 0.90 and AUPRC, 0.53), outpatient Yale New Haven Hospital clinics (AUROC, 0.94 and AUPRC, 0.77), Lake Regional Hospital (AUROC, 0.90 and AUPRC, 0.88), Memorial Hermann Southeast Hospital (AUROC, 0.91 and AUPRC 0.88), Methodist Cardiology Clinic (AUROC, 0.90 and AUPRC, 0.74), and Brazilian Longitudinal Study of Adult Health cohort (AUROC, 0.95 and AUPRC, 0.45). An ECG suggestive of LV systolic dysfunction portended >27-fold higher odds of LV systolic dysfunction on transthoracic echocardiogram (odds ratio, 27.5 [95% CI, 22.3-33.9] in the held-out set). Class-discriminative patterns localized to the anterior and anteroseptal leads (V2 and V3), corresponding to the left ventricle regardless of the ECG layout. A positive ECG screen in individuals with an LV ejection fraction ≥40% at the time of initial assessment was associated with a 3.9-fold increased risk of developing incident LV systolic dysfunction in the future (hazard ratio, 3.9 [95% CI, 3.3-4.7]; median follow-up, 3.2 years). We developed and externally validated a deep learning model that identifies LV systolic dysfunction from ECG images. This approach represents an automated and accessible screening strategy for LV systolic dysfunction, particularly in low-resource settings.

Flow through the Emergency Department for Patients Presenting with Substance Use Disorder in Alberta, Canada.

Since 2016 the province of Alberta, Canada, has seen a significant increase in substance use disorder (SUD) presentations to the emergency department (ED) with a large surge during the COVID-19 pandemic. In this retrospective study we deconstruct the total length of stay (LOS) in the ED into stages for patients presenting with SUD and estimate the effects of covariates on the time to transition between stages. Using the Canadian Coding Standards for International Classification of Diseases, 10th Modification, codes F10.0-F19.9 and T36.0-T50.9, we extracted data from the National Ambulatory Care Reporting System between April 1, 2019-March 31, 2020 on all ED presentations for SUD by Alberta residents. We used a multistate model to deconstruct the EDLOS into eight mutually exclusive states and determine which factors affected the time spent in each state. We analyzed 66,880 presentations (37,530 patients). The mean age was 37.2 years, and 61% were male. The median total LOS in the ED was 6 hours 13 minutes. Patients presenting with methamphetamines (METH) intoxication and patients from low-income neighborhoods had significantly increased transition times between all states. Opposite this, opiate use was associated with faster transition times between almost all states. Metro EDs experienced slower transitions when attempting to discharge or admit patients when compared to urban or rural EDs. Emergency department crowding also had a dramatic effect on physician initial assessment times, while discharge and admission times in patients presenting with SUD were also significantly affected. Patients with SUD experience a variety of delays during their ED stay. Those with METH intoxication and those from the lowest income neighborhoods were most likely to experience slower transitions from state to state in the ED and may benefit from a focused approach to improve ED flow.

Factors Associated With Restarting Androgenic Anabolic Steroids After Cessation in Men With Infertility: A Retrospective Analysis.

Introduction The use of androgenic anabolic steroids (AAS) negatively affects male fertility by disrupting hormone release and reducing testosterone levels. Despite this, many men using steroids are unaware of fertility-related consequences. We aimed to determine the factors associated with AAS resumption during fertility treatment, specifically focusing on the duration, age, and dosage of AAS use prior to treatment. Our study, the first of its kind, investigated risk factors for resuming AAS following fertility assessment. Methods We conducted a retrospective review of adult men diagnosed with infertility due to chronic AAS use between 2012 and 2022 at the University of Miami. The study included men with azoospermia or severe oligospermia who were instructed to stop using AAS. Excluded were those who underwent orchiectomy for benign or malignant conditions. We collected data on demographic characteristics, AAS route details, fertility treatments, and AAS resumption. We hypothesized that risk factors for restarting AAS would include duration of AAS use, type of AAS, pre-treatment testosterone levels, and increased age. Results We identified 94 men with infertility caused by AAS use. Among them, 31 (33.0%) resumed AAS therapy within eight months after cessation. The median age of men who restarted AAS was 40 years. Those who resumed AAS had used it for a longer duration prior to fertility assessment compared to those who did not (60 months vs. 17 months, respectively). However, we found no statistically significant differences in age, duration of AAS use, AAS administration details, or serum testosterone levels at the time of initial assessment. Conclusion In conclusion, most men seeking fertility assessment due to AAS abuse did not resume testosterone therapy. However, those who did restart AAS had a longer history of AAS use. Future high-quality prospective studies are needed to better understand the risk factors associated with resuming AAS in male infertility caused by anabolic steroids.

Implementation of clinical recommendations from the geriatric oncology clinic

IntroductionWhile evidence on the value of routine geriatric assessment (GA) in cancer care for older patients is growing, there is limited data on the geriatric oncology (GO) clinic's specific recommendations and how they are implemented. In this study, we aimed to assess and evaluate the implementation of recommendations from the GO clinic at Princess Margaret Cancer Center, Toronto, Canada, within six months of the initial visit. Materials and MethodsA retrospective chart review was conducted on 100 consecutive adults age 65+ visiting the GO clinic from 2018 to 2019. For each patient, we evaluated the number and type of recommendations from the GO clinic. Recommendations were grouped based on clinical judgement. Of the recorded recommendations, we measured the rate of implementation within six months of the initial visit including who implemented the recommendations and why recommendations were not implemented. Data were analyzed using descriptive statistics. ResultsOne hundred patients visiting the GO clinic (mean age of 80.5 years, 62% male, 52% with planned curative intent, with the genitourinary site being most common) received a median of six recommendations (range of 2–12), regardless of sex, cancer stage, cancer site, and treatment intent. Medication optimization (27%), patient education (26%), and referral to allied health (14%) were the top recommendations from the GO clinic. At six-month follow-up, 83% of all recommendations were implemented, of which 94% were performed by the GO clinic team. Patient education was implemented at a 100% rate by the GO clinic at the time of initial assessment. GO follow-up visit and other diagnostic tests (hearing test, vision test) were the recommendations with the lowest implementation rates, at 51% and 31%, respectively. The most common reasons for recommendations not being implemented were patient transfer to palliative care/death and patient declining recommendations due to busy appointment schedules. DiscussionA median of six recommendations were made per patient. The vast majority of recommendations were implemented, predominantly by the GO team. Overall, the study helps evaluate recommendations provided to patients visiting GO clinics, identify potential gaps, and assist with resource planning for optimal cancer care for older adults.

Effect of chained one-stop emergency nursing combined with optimized triage path nursing on the rescue effect of chest pain patients in emergency department

ABSTRACT This study aimed to investigate the effect of chained one-stop emergency nursing combined with optimized triage path nursing on emergency chest pain patients. Data of 142 patients with chest pain in emergency department of our hospital were retrospectively analyzed, and from March to May 2022,71 patients with optimized triage route nursing were treated as control group, from June to August 2022, 71 patients with chain one-stop emergency care combined with optimized triage route care were selected as the observation group. Data of completion time of the first electrocardiogram (ECG) completion, troponin result giving time, door to balloon (D to B) time, length of hospital stay and rescue time (disease condition initial assessment time, preliminary examination time, first medical contact time of balloon dilation, D to B dilation time) were collected. The complication rate, adverse event rate and nursing satisfaction were compared between the two groups. The completion time of the first ECG, troponin result giving time, D to B time, initial condition assessment time, hospital stay and rescue time in the observation group were shorter than those in the control group, (all P<0.05). The incidence of complications and adverse events in the observation group were lower than control group (both P<0.05). The scores of nursing satisfaction in the observation group were evidently higher than those in the control group, (P<0.05). Chained one-stop emergency nursing combined with optimized triage path nursing has a good effect on emergency chest pain patients.

Characterizing changes in tumor mutational burden (TMB) by serial circulating tumor DNA (ctDNA) testing in patients with advanced prostate cancer (aPC).

239 Background: In part, TMB guides therapeutic decisions on the use of immune checkpoint inhibitors (ICIs) in aPC. Most patients (pts) with aPC do not have high TMB (TMB-H) at the time of initial assessment. However, TMB changes over time (from treatment pressure) as pts progress through lines of therapy (LOT) has not been extensively explored in aPC. We describe real world data on changes to blood TMB (bTMB) in pts with aPC exposed to several LOT. Methods: Genomic results from pts with aPC who had ≥1 ctDNA test(s) with TMB analyzed (Guardant360, Guardant Health, Inc) as part of clinical care from Oct 2020 – Jun 2022 were retrospectively queried. Clinical factors were extracted from test requisition forms; pts from Mayo Clinic had additional factors, including intervening treatment, extracted from medical records. High bTMB (TMB-H) was defined as ≥13.4 mut/Mb, as previously reported. Proportions were compared using Fisher’s Exact Test. Results: 316 patients with a median age of 72 (range: 44-91) were analyzed. Initial median TMB for the entire cohort was 8.18 mut/Mb (range: 0.01-268.3). On subsequent test, TMB decreased in 122(40%), increased in 173(55%), of whom 29 (17%) became TMB-H; 21 (7%) had unchanged TMB. Median time between tests was 182 days (range: 21-578). 101 patients with 262 tests and a median age of 71 years (range: 46-87) were clinically annotated in the Mayo cohort of whom 58 had &gt;2 consecutive TMB scores: 25 (43%) had TMB increase, of whom 4 (16%) became TMB-H, 23 (40%) had TMB decrease, 10 (17%) had dynamic changes with increases and decreases. Numeric but not statistically significant differences in clinical factors were observed between groups (p&gt;0.05). Conclusions: In this real world cohort, variation in TMB is seen with increasing LOT. Importantly, nearly 1 in 5 patients with increasing tumor mutational burden develop TMB-H, which may be a clinically actionable finding as these pts become eligible for ICI. Findings underscore the importance of repeat genetic testing with time and LOT. [Table: see text]

The multicenter impacts of an emergency physician lead on departmental flow and provider experiences.

Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences. Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact. The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18min (p < 0.001) and at Foothills ED length of stay increased by 8min (p < 0.001). EMS length of stay at Lougheed decreased by 20min (p < 0.001), and at Foothills length of stay increased by 17min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations. In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.

Increase Mortality Rate in Sepsis Patients with qSOFA Score Greater than Two

Objective: To look for patients of sepsis with a qSOFA score of more than two and an association of a high qSOFA score with mortality and other socio-demographic factors.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Department of Medicine, Combined Military Hospital, Sialkot Pakistan, from Nov 2021 to May 2022.&#x0D; Methodology: All baseline and relevant investigations were carried out at the time of initial clinical assessment, and the qSOFA score was calculated by a consultant medical specialist for all the patients diagnosed with the septic condition. Patients were followed up for two weeks to look for mortality.&#x0D; Results: A total of 500 patients, managed for sepsis during the study period were included in the study. Of them, 298(59.6) were males, while 202(40.4) were females. Out of all the patients in the study, 379(75.8) had a qSOFA score of two or less than two, while 121(24.2) had a qSOFA score of more than two. Increased mortality, patients with more than 50 years and comorbid illnesses were found statistically significantly more in the group having a qSOFA score of more than two (p-value&lt;0.001).&#x0D; Conclusion: Mortality was significantly high in patients with sepsis who had a qSOFA score greater than two at the time of initial assessment compared to those with a score of two or less.

Validation of MATCH Score: A Predictive Tool for Identification of Patients With Kelch-Like Protein-11 Autoantibodies

Objective To validate performance of the MATCH score using an independent paraneoplastic neurological syndrome (PNS) cohort. Background Kelch-like protein 11 (KLHL11)-IgG is a high-risk paraneoplastic antibody associated with rhombencephalitis. MATCH score is a composite clinical model recently developed to predict KLHL11-IgG positivity Design/Methods Retrospective review of cases with definite or probable PNS who underwent neural specific autoantibody evaluation at Mayo Clinic Neuroimmunology laboratory between January 2001 and December 2021 was performed. MATCH score was calculated for all patients to assess the score's discriminative ability Results 186 patients who met the definite or probable PNS criteria were identified. The MATCH score was = 4 in 31/36 patients who were KLHL11-IgG positive and in 17/150 patients who were KLHL11-IgG negative but positive for other high-risk autoantibodies including CRMP5, ANNA1, PCA1 and amphiphysin, among others, or seronegative to all antibodies. MATCH Score's sensitivity, specificity, positive and negative predictive value were 86%, 89%, 65% and 96%, respectively. The score showed an excellent discriminative ability with an AUC of 0.924 [95% CI 0.885-0.962]. Conclusions MATCH score is a sensitive and specific tool to identify patients likely to be KLHL11-IgG positive. Utilization of MATCH score can improve pre-test probability. However, some KLHL11-IgG cases with motor neuronopathy or limbic encephalitis presentation or those without a detectable testicular cancer at the time of initial assessment may potentially be missed.

Abstract 14057: Detection of Left Ventricular Systolic Dysfunction From Electrocardiographic Images

Background: Left ventricular systolic dysfunction (LVSD) is associated with an over 8-fold risk of heart failure and 2-fold risk of premature death. Echocardiographic screening is limited by access to the technology, and artificial intelligence-based tools have been limited to ECG signals, precluding access by end users. Methods: A total of 393,910 12-lead ECGs from patients undergoing echocardiography at Yale were used to develop a model identifying LV ejection fraction &lt; 40% in printed ECG images, using a EfficientNet-B3 convolutional neural network with transfer learning. The algorithm was validated using real-world ECG images. To allow interpretability, gradient-weighted class activation mapping (Grad-CAM) was used to localize class-discriminating signals in the images. Results: A total of 60,293 ECGs (15.3%) were performed in patients with LVSD. The ECG-based image identified LVSD accurate across multiple image formats in the held-out test set (AUROC 0.91, AUPRC 0.69), and in two external sets of real-world ECG images from an outpatient academic center (AUROC 0.93, AUPRC 0.69) and a rural hospital system (AUROC 0.91, AUPRC 0.89). An ECG suggestive of LVSD portended over 24-fold higher odds of LVSD in the held-out set (OR 24.4, 95% CI, 22.4-26.6). Regardless of the ECG layout, class-discriminative patterns from Grad-CAM localized to leads V2 and V3, corresponding to the left ventricle. Moreover, a positive ECG screen in individuals with LV ejection fraction &gt; 40% at the time of initial assessment was associated with 4-fold increased risk of developing incident LV systolic dysfunction in the future (HR 4.3, 95% CI 3.9-4.7, median follow up 2.3 years). Conclusions: We developed and validated a layout-independent deep learning model that identifies LVSD from images of ECGs. This approach represents an automated and accessible screening strategy for LVSD, particularly in low resource settings.

PSAT030 A Clinically Dormant Adrenal Incidentaloma Evolving to A Cortisol Secreting Adenoma, A Ten Year Follow Up Experience

Abstract Intro Adrenal incidentalomas (AIs) are found in approximately 3–4% of abdominal computed tomography (CT) scans performed for other reasons. Most of these masses are found to be nonfunctioning. Studies showed that subtle cortisol secretion in AIs and disruption in the hypothalamic-pituitary-adrenal axis are more frequent than expected. Here we report a case of a small AI progressing to a hormone-secreting adrenal mass causing Cushing's syndrome (CS) after a period of a decade, in which dexamethasone suppression test was the confirmatory diagnostic procedure. Case 66-year-old woman was referred to Endocrinology in 2007 for assessment of abnormal abdominal CT finding indicating minimal nodularity of the right adrenal gland followed by an MRI performed 2 years later with suspicion of a small adenoma measuring 1.4 cm. Patient's past medical history included coronary artery disease, impaired glucose tolerance controlled by diet. No reported family history of relevant endocrine tumors. At time of initial assessment, functional hormonal baseline workup was normal including ACTH: 23 pg/mL [5-27 pg/mL], AM Cortisol level: 13.6 mcg/dL [4-22 mcg/dL], 24h U-Cortisol: 16.4 mcg/24h/1g Cr [4-50 mcg/24h/1g], and DHEAS: 30 mcg/dL [&amp;lt;185 mcg/dL] Patient was re-evaluated annually. Over the course of the follow-up, she was found to have poor healing after surgical repair of ankle fracture in 2012, as well as depression necessitating medical therapy in 2015. Her previously diet-controlled diabetes significantly progressed, requiring combination therapy and ultimately basal/bolus insulin. Moreover, patient developed hypertension with antihypertensive medication doses increased from Valsartan 40mg to Valsartan/HCT 80/12.5 in a 5-year period. The patient was found to have normal ACTH, serum, and urine cortisol levels throughout her follow-up period. Annual CT imaging demonstrated no change in right adrenal mass. In 2017, overnight low dose dexamethasone suppression test was found to be 16.2 mcg/dL[&amp;lt;1.8 mcg/dL], which is significantly increased from 0.9 mcg/dL in 2011. In 2018, CT abdomen showed a marked increase in the adrenal mass size to 2.8 cm. In 2020, she underwent right-sided adrenalectomy with no complications. Both blood pressure and glucose levels improved postoperatively. The preoperative use of mifepristone therapy controlled her blood sugar and pressure and eliminated the need for postoperative glucocorticoid replacement. She is currently controlled on diet and lifestyle modifications alone. Discussion Our case highlights the limitations of current guidelines in the management of AIs that recommend discontinuing annual follow-up if no significant growth occurs after 5 years. Careful long-term follow-up of AIs provides an opportunity to detect the subclinical hormonal alterations, development of new hormonal abnormalities, or any change in mass size. These findings indicate the need for good communication between radiology, primary care, and endocrine providers to assure periodic hormonal and morphological evaluation. This case also suggests that the dexamethasone suppression test may be useful in the evaluation of CS in patients without significant hypercortisolemia. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

4 The Impact of the COVID-19 Pandemic on Number and Severity of New Diagnoses of Restrictive Eating Disorders During Prolonged Lockdown in Ontario, Canada

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic has had a disproportionate impact on the well-being of adolescents and young adults. Worldwide, eating disorder (ED) experts have observed worsening symptoms in youth with pre-existing EDs and an escalation in the number of new cases compared to prior years. Disruption of routine, work and school closures, as well as social isolation are potential contributing factors. The Canadian province of Ontario (specifically the most highly populated cities) experienced one of the most prolonged lock downs worldwide with approximately 20 weeks of face-to-face school closure and/or restriction to virtual learning. Objectives We sought to better understand the impact of COVID-19 on new pediatric ED presentations, patient characteristics and hospital admissions in a tertiary care Children’s Hospital. Design/Methods We completed a retrospective chart review of patients presenting for new ED assessments at a single centre pediatric ED program within a tertiary care children’s hospital between January 1st, 2015 and June 1st 2021. Patients aged 9-18 years old with a new diagnosis of Anorexia Nervosa (AN) restrictive type or binge/purge type or Other Specified Feeding and Eating Disorder (OSFED) - Atypical Anorexia Nervosa (AAN) were included. Demographic and clinical variables for pre and post pandemic were analyzed using Chi-Square and T-Tests. Interrupted time series regression was used to examine pre-pandemic and post-pandemic monthly summary data over time. Results Overall, 425 youth were newly diagnosed with AN or AAN (N=329 pre-pandemic, N=96 pandemic) during the study period (Jan 1 2015 – December 31 2020). Average age was 14.7 years (SD 1.8, range 8.1 – 17.9). Most youth were diagnosed with DSM-5 AN-restrictive type (65.6%). The number of new diagnoses of AN and AAN during the pandemic more than doubled when compared to pre-pandemic years. In the 5-year period preceding the pandemic, mean number of newly diagnosed cases was 5.1/month (ßcoeff=0.043, p=0.33), increasing to 10.6/month (p=&amp;lt;0.001) during the pandemic and demonstrating an upward trend coinciding with onset of lockdown measures (ßcoeff=5.95, p&amp;lt;0.001). At the time of initial assessment, more youth presented with medical instability and increased illness severity. Hospitalization increased from an average of 2.2/month to 6.3/month (ßcoeff -0.008 vs. 3.23, p&amp;lt;0.0001). Average heart rate also decreased from 58.6 bpm (SD 16.6) pre-pandemic to 53.3 bpm (SD 16.3), p&amp;lt;0.008. Conclusion With this study, we found a significant increase in both new diagnoses and admissions for medical instability for AN and AAN among youth at our institution during the COVID-19 pandemic. Our study contributes to the growing body of global evidence tracking the unanticipated surge of eating disorder diagnoses and severity in already under-resourced health systems. It is unclear how long the effects of the pandemic may last. Further research is required to better understand the illness trajectory and treatment outcomes of pandemic-triggered EDs in adolescents.

Comparison of two Specialized Cleft Palate Feeders.

To evaluate feeding efficiency and weight gain in infants with cleft palate fed using 1 of the 2 specialty feeders. Retrospective cohort study. Cleft palate clinic in a tertiary pediatric hospital. Infants with cleft palate (with or without cleft lip) fed using the Medela SpecialNeeds® Feeder (n = 39) or the Dr. Brown's® Specialty Feeding System (n = 16) and who had documented feeding and growth data available from the time of initial assessment in the first month of life and at subsequent follow-up between 2 and 4 months. Feeding velocity (mL/min). Calorie velocity (kcal/min), weight gain, and complications associated with poor feeding. No statistically significant differences in feeding or calorie velocities were identified between infants with cleft palate fed with the Medela SpecialNeeds® feeder and those fed with the Dr. Brown's® feeder. Mean weight z-scores by month did not differ significantly between the 2 bottle groups at the time of initial assessment (P = .84) and follow-up (P = .20). Mean weight z-scores by month for the infants included in this study fell below the 50th percentile. The proportion of infants who developed otitis media, reflux requiring treatment, or who required hospital admission for nasogastric (NG) feeds did not differ significantly between the 2 groups. Despite being adequately powered for the primary outcome, no significant differences were identified between infants fed with the Medela or the Dr. Brown's feeders in terms of feeding velocity, calorie velocity, weight gain, or complications.

Factors Associated With Additional Clinic Visits in the Treatment of Sports-Related Concussion.

To evaluate the variables associated with additional concussion clinic visits before discharge to athletic trainer (AT). Retrospective cohort study. Multidisciplinary Sports Concussion Center. Patients ages 12 to 23 years presenting with a sport-related concussion between January 11, 2017, and January 10, 2020, and were discharged to an AT. Our main outcome variable was being discharged to AT after the initial clinic visit versus those who attended additional clinic visits before AT discharge. We examined the influence of age, sex, initial visit symptom score, family and personal history of psychiatric disorders and migraines, history of prior concussions, and other variables on this outcome. Of 524 patients, 236 were discharged to AT after the initial clinic visit, while 288 patients required additional clinic visits. The additional visit group had higher initial visit symptom scores ( P = 0.002), head imaging performed more frequently ( P < 0.02), a family history of psychiatric disorders and/or migraines ( P < 0.001, P < 0.001), more often reported a prior concussion ( P = 0.02), and was younger ( P = 0.014) compared with the one visit group. In a multiple variable model, the family history of psychiatric disorders [odds ratio (OR), 3.12 (95% CI, 1.531-6.343), P = 0.002], prior concussions [OR, 1.39 (95% CI, 1.020-1.892), P = 0.037], greater initial symptom score [OR, 1.05 (95% CI, 1.031-1.058), P < 0.001], and younger age [OR, 0.87 (95% CI, 0.773-0.979), P = 0.021] were strongly associated with additional visits. Among athletes treated at a regional sports concussion center, family history of psychiatric disorders, increased symptom score at initial visit, prior concussions, and younger age were each uniquely associated with needing additional clinic visits at the time of initial assessment. Understanding these variables may guide treatment protocols for optimal care.

Paediatric forearm fractures: assessment and initial management.

The forearm is the most common site of fracture in children. At the time of initial assessment, a thorough examination and neurovascular assessment of the limb is necessary. X-rays allow evaluation of the fracture location and type, in addition to the degree of displacement. With the help of intranasal opiates, manipulation of fracture fragments can be performed in the emergency department. Immobilisation in plaster is the gold standard treatment for paediatric forearm fractures where the degree of displacement is within acceptable parameters. Manipulation and casting should be followed by orthogonal radiographs and a repeated neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge and the child should be reviewed in fracture clinic within a week of the injury. This article reviews the British Orthopaedic Association Standards for Trauma and Orthopaedics for the early management of paediatric forearm fractures that do not require operative management.

A Study on the Clinical Profile, Blood Profile and Culture Sensitivity Pattern of Salmonella Typhi in Paediatric Patients

Objective: To study clinical profile, blood profile and culture sensitivity patterns of Salmonella typhi in paediatric patients and factors associated with multi-drug resistant pattern.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Paediatrics and Microbiology Department, Combined Military Hospital Peshawar from Jan 2021 to Jan 2022.&#x0D; Methodology: A total of 97 paediatric patients with a confirmed diagnosis of Salmonella typhi were included in the study. A detailed clinical proforma was designed to document all the symptoms this patient had since admission. In addition, all baseline blood investigations and culture sensitivity analysis were requested during clinical evaluation. Basic demographic factors were associated with the presence of multi-drug resistant disease patterns in study participants.&#x0D; Results: Out of 97 children in the study, 65 (67.1%) were males, while 32 (22.9%) were females The mean age of the children in our study was 9.82±3.26 years. 61 (62.8%) patients had Salmonella typhi, which was not multi-drug resistant, while 36 (37.2%) had multi-drug resistant disease. Fever was the commonest symptom reported by our study participants. No organism was found resistant to Meropenem. Statistical analysis revealed that raised C-reactive protein levels at the time of assessment had a statistically significant relationship with the presence of multi-drug resistant disease (p-value=0.001).&#x0D; Conclusion: A considerable number of pediatric patients with typhoid had multi-drug resistant illnesses in our study participants. Therefore, special attention should be paid to children who had raised C-reactive protein levels at the time of initial assessment.