Triage Of Patients Research Articles

Overall Staging Prediction for Non-Small Cell Lung Cancer (NSCLC): A Local Pilot Study with Artificial Neural Network Approach

Background: Non-small cell lung cancer (NSCLC) has been the most common cancer globally in the recent decade. CT is the most common imaging modality for the initial diagnosis of NSCLC. The gold standard for definitive diagnosis is the histological evaluation of a biopsy or surgical sample, which usually requires a long processing time for the confirmation of diagnosis. This study aims to develop artificial intelligence models to predict overall staging based on patient demographics and radiomics retrieved from the initial CT images, so as to prioritize later-stage patients for histology evaluation to facilitate cancer diagnosis. Method: Two cohorts of NSCLC patient datasets were utilized for this study. The NSCLC-radiomics dataset from The Cancer Imaging Archive (TCIA) was divided into 70% for the training group and 30% for the internal testing group. Another cohort from a local hospital was collected for the an external testing group. Patient demographics and 107 radiomic features were retrieved from the gross tumor volume delineated by clinical oncologists on CT images. Artificial neural networks were used to build models for NSCLC overall staging (stage I, II, or III) prediction. Four traditional classifiers were also adopted to build models for comparison. Result: The proposed feed-forward neural network (FFNN) model showed good performance in predicting overall staging with an accuracy of 88.84%, 76.67%, and 74.52% in overall accuracies in validation, internal cohort testing, and external cohort testing, respectively. The sensitivity and specificity are balanced in all the stages, with average precision and F1 score in each of the stages. Conclusion: The FFNN demonstrated good performance in overall staging prediction for NSCLC patients. It has the benefit of predicting multiple overall stages in a single model. The software required and the proposed model are simple. It can be operated on a general-purpose computer in the radiology department. The application will eventually be used as a prediction tool to prioritize the biopsy or surgery sample for histological analysis and molecular investigation, thus shortening the time for diagnosis by pathologists, which supports the triage of patients for further testing.

Non-invasive prediction of atrial cardiomyopathy characterized by multipolar high-density contact mapping.

Atrial cardiomyopathy (AC) establishes links between atrial fibrillation (AF), left atrial (LA) mechanical dysfunction, structural remodeling, and thromboembolic events. Early diagnosis of AC may impact AF treatment and stroke risk prevention. Modern endocardial contact-mapping provides high-resolution electro-anatomical (EA) maps of the LA, thus allowing to display the myocardial substrate based on impaired signal amplitude and to characterize AC. Correlation of invasively assessed AC using a novel, multipolar mapping catheter (OCTARAY™, Biosense Webster, limited market release) and LA echocardiographic parameters could form the basis for a set of echo parameters for non-invasive prediction of AC. We retrospectively identified 50 adult patients who underwent primary pulmonary vein isolation (PVI) for paroxysmal or persistent AF between 08/22 and 05/23 fulfilling the selection criteria: (i) EA mapping with a novel multipolar mapping catheter (Octaray®); (ii) acquisition of voltage maps in sinus rhythm (SR) with ≥ 5000 points/map; and (iii) transthoracic echocardiography acquired in SR ≤ 48h before PVI. Exclusion criterion was previous LA ablation. We generated EA maps with two sets of upper voltage thresholds (0.2-0.5mV and 0.2-1.0mV) and assessed total LA low voltage area (LVA). As LVA thresholds for the classification of AC are not yet established, an unsupervised machine learning cluster analysis was performed using a Gaussian mixture model (GMM), and two groups of patients with mild and severe AC were identified. Based on these two groups, we selected echo parameters for further analysis by applying the Boruta algorithm. The predictive capacity of the selected parameters was evaluated using a support vector machine. The mean age of the studied sample (n = 50) was 63 ± 11years, 62% were men, 64% showed persistent AF, median CHA2DS2-VASc score was 2 (quartiles 1, 3), and NT-proBNP was 190 (71, 391) pg/ml. A median of 5771 (5217, 6988) points/map were acquired. GMM yielded clusters of mild AC (n = 28) and severe AC (n = 22). Median LVA was 0.6 cm2 (< 0.5mV) resp. 4.1 cm2 (< 1.0mV) in group mild AC and 6.9 cm2 (< 0.5mV) resp. 27.2 cm2 (< 1.0mV) in group severe AC. Several echocardiographic parameters differed between the groups of mild and severe AC: dynamic LA parameters (end diastolic LA reservoir strain: 24.5% (22, 29) vs 15% (12, 19), p < 0.001; LA reservoir strain at atrial contraction: 22% (19, 25) vs 15% (11, 18), p < 0.001, end diastolic LA contraction strain: 13% (8, 15) vs 7.5% (3, 13), p < 0.01) as well as LA end-systolic volume index to a´ ratio (LAVI/a': 297 (231,365) vs 510 (326,781), p < 0.01). Consistent distribution of NT-proBNP (mild AC: 125 (48,189) pg/ml, severe AC: 408 (254,557) pg/ml, p < 0.0001) and CHA2DS2-VASc score (mild AC: 1 (1-2), severe AC: 3 (3-4), p < 0.0001) served as proof of concept. Applying the selected echocardiographic parameters, the machine learning algorithm correctly identified both subgroups with a mean AUC of 0.9 (95% CI 0.83-0.99). At 12months, AF recurrence rate was 10.7% in mild AC and 40.9% in severe AC (p < 0.05). Among patients qualifying for PVI, machine learning analysis of high-resolution LA maps allowed to identify subgroups with mild and severe AC avoiding the use of arbitrary LVA thresholds. The subgroups were predicted non-invasively with good accuracy using a machine learning approach that incorporated a set of echocardiographic markers. This data could advance the clinical triage of patients with AF.

Diagnostic accuracy of point-of-care ultrasound in detecting clavicle fractures

Diagnostic accuracy of point-of-care ultrasound in detecting clavicle fractures

Abstract TMP65: Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients with Intracranial Hemorrhage

Background: We aimed to evaluate whether the implementation of regional prehospital transport to comprehensive stroke center (CSC) protocol has any impact on inter-hospital transfer rate and neurologic outcomes of intracranial hemorrhage (ICH) patients. Methods: We performed a retrospective multicenter study comparing outcomes in patients with ICH arriving at 15 Primary Stroke Centers (PSC) and 8 CSC in Chicago, Illinois via emergency medical services transport from January 1 2017 and December 31 2023 - before and after implementation of a prehospital transport protocol in September 2018 which uses a 3-item stroke scale to identify patients with more severe stroke types and &lt;6 hours from onset for transport to the closest CSC rather than closest PSC. Outcomes of interest included inter-hospital transfer rates, arrival to CT times, in-hospital mortality rate, favorable disposition location (discharged to home or acute rehabilitation) and favorable neurologic outcome at discharge (modified Rankin score [mRS] of 0-3). Results: Pre-implementation included 853 patients (mean age=63 [SD 15.0], 54% male, and 45% black), of which 232 (27%) were transported to PSCs (mean NIHSS=13 [SD 11.4]) and 621 patients (73%) to CSCs (mean NIHSS=13 [SD 9.3]). Post-implementation included 3506 patients (mean age=63 [SD 15.3], 63% male, 45% black), of which 891 (25%) went to PSCs (mean NIHSS=13 [SD 11.4]) and 2615 (75%) went to CSCs (mean NIHSS=15 [SD 10.5]). Initial NIHSS score was higher post-implementation compared to pre-implementation (13 [SD 9.9] vs. 14 [SD 10.7]), p=0.04). There were similar rates (41% pre-implementation vs 43% post-implementation) of inter-hospital transfer (p=0.39). Time from hospital arrival to CT imaging was significantly faster post-implementation (86 min vs 36 min, p&lt;0.0001). Rates of favorable discharge disposition (49% pre-implementation vs. 47% post-implementation, p=0.28) and neurologic outcome (29% pre vs 26% post, p=0.13) were similar after adjusting for age, sex, time to CT, and initial NIHSS. However, in-hospital mortality was significantly higher post-implementation (15% pre vs. 20% post, odd ratio=1.4, 95% CI[1.1-1.8], p=0.02) after adjusting for initial NIHSS score. Conclusion: Implementation of a regional prehospital transport protocol to stroke center was associated with a shorter time to CT scanner but higher mortality. Our findings do not support prehospital policies to transport ICH patients directly to CSCs.

Pragmatic evaluation of point of care lung ultrasound for the triage of COVID-19 patients using a simple scoring matrix: Intraclass-classification and predictive value

The value of routine bedside lung ultrasound (LUS) for predicting patient disposition during visits to the Emergency Department (ED) is difficult to quantify. We hypothesized that a simplified scoring of bedside-acquired LUS images for the triage of acute respiratory symptoms in the ED would be associated with patient disposition. For this observational pragmatic study, we reviewed prospectively-collected bedside LUS images from patients presenting to the ED with acute respiratory symptoms. We agreed on a simplified LUS scoring approach (0-3). At least three reviewers blindly assessed the available LUS images for each patient and determined the worst score for each patient and the presence of individual LUS findings. The worst LUS score was used to classify patients' LUS-suggested hospital admission risk. We evaluated the agreement between reviewers and the predictive value of LUS findings for patient disposition. 204 patients were eligible, and 126 sets of images were available and scored. The most common LUS finding were isolated B-lines (63.5% of LUS images), pleural thickening/irregularity (48.4%), and diffuse B-lines (43.7%). The patients' worst LUS score were 2 (43.5%), 3 (26.1%), 1 (20.7%), and 0 (9.8%). There was good agreement among reviewers on the worst LUS score (intra-class correlation coefficient 0.830, 95% confidence interval (0.772-0.875)) and the LUS-suggested disposition (ICC 0.882, 95% CI (0.846, 0.911)). A simplified scoring of bedside-acquired LUS images from patients with acute respiratory symptoms at the emergency department reliably predicts patient disposition.

High-Field-Blinded Assessment of Portable Ultra-Low-Field Brain MRI for Multiple Sclerosis.

MRI is crucial for multiple sclerosis (MS), but the relative value of portable ultra-low field MRI (pULF-MRI), a technology that holds promise for extending access to MRI, is unknown. We assessed white matter lesion (WML) detection on pULF-MRI compared to high-field MRI (HF-MRI), focusing on blinded assessments, assessor self-training, and multiplanar acquisitions. Fifty-five adults with MS underwent pULF-MRI following their HF-MRI. Two neuroradiologists independently assessed pULF-MRI images in an evaluation process, including initial assessment blinded to HF-MRI, self-training with reference to HF-MRI and evaluation of 20 cases with additional T2-fluid-attenuated inversion recovery in an additional plane. A third rater conducted cross-referenced analysis with HF-MRI data to determine true-positive lesions, false-positive areas, and case-level sensitivity and positive predictive value. The mean age of participants was 50 years (standard deviation: 11; 74% women). Initially, Rater 2 marked more false-positive areas than Rater 1 (p = 0.003). After self-training, both raters embraced a conservative approach, with Rater 2 marking fewer false-positive areas (p = 0.01). Both raters maintained 100% case-level sensitivity and positive predictive value for detecting at least one WML, particularly in periventricular areas. Multiplanar acquisitions reduced both false-positive areas and true-positive lesions. True-positive lesions and false-positive areas had similar contrast-to-noise ratios in the juxtacortical region (p = 0.73) but not in periventricular, deep parenchymal regions (p = 0.004, p = 0.01). With adequate training, radiological interpretation of pULF-MRI has high sensitivity and positive predictive value for MS lesions but should be approached conservatively. These results suggest utility for patient triage, potentially reducing diagnostic delay, and screening high-risk individuals.

Streptococcus agalactiae infection of a reconstructed human respiratory epithelium revealed infection and host response characteristics by different serotypes.

Streptococcus agalactiae poses a significant threat to neonatal health, causing morbidity and mortality when transmitted from the maternal vagina to the newborn's respiratory tract. Among its various strains, serotype III is predominant in severe neonatal infections in Asia. However, the mechanisms of pathogenesis and host responses underlying serotype-specific disease outcomes remain poorly understood. This study employed 2D airway epithelial organoids as a host model to investigate the progression of S. agalactiae respiratory tract infections across four serotypes. RNA and ATAC analyses were used to identify differentially expressed genes and related pathways. S. agalactiae infection triggered inflammatory responses in differentiated airway epithelia, particularly increasing the expression of genes linked to innate immunity. Serotype III elicited stronger immune responses compared to other serotypes. The SLC2A3 gene demonstrated upregulated expression and increased chromatin accessibility specific to serotype III infection. Neonates predominantly clear S. agalactiae infections through immune detection and opsonophagocytosis. These findings highlight the importance of patient triage based on serotype variations. Developing therapeutic candidates targeting invasive serotypes to enhance OPK titers may be crucial. Furthermore, serotype III infection may induce apoptosis via Ferroptosis.

Critical Time Intervals in Door-to-Balloon Time Linked to One-Year Mortality in ST-Elevation Myocardial Infarction

Background: Timely activation of primary percutaneous coronary intervention (PCI) is crucial for patients with ST-segment elevation myocardial infarction (STEMI). Door-to-balloon (DTB) time, representing the duration from patient arrival to balloon inflation, is critical for prognosis. However, the specific time segment within the DTB that is most associated with long-term mortality remains unclear. In this study we aimed to identify the target time segment within the DTB that is most associated with one-year mortality in STEMI patients. Methods: We conducted a retrospective cohort study at a tertiary teaching hospital. All patients diagnosed with STEMI and activated for primary PCI from the emergency department were identified between January 2013–December 2021. Patient demographics, medical history, triage information, electrocardiogram, troponin-I levels, and coronary angiography reports were obtained. We divided the DTB time into door-to-electrocardiogram (ECG), ECG-to-cardiac catheterization laboratory (cath lab) activation, activation-to-cath lab arrival, and cath lab arrival-to-balloon time. We used Kaplan-Meier survival analysis and multivariable Cox proportional hazards models to determine the independent effects of these time intervals on the risk of one-year mortality. Results: A total of 732 STEMI patients were included. Kaplan-Meier analysis revealed that delayed door-to-ECG time (&amp;gt;10 min) and cath lab arrival-to-balloon time (&amp;gt;30 min) were associated with a higher risk of one-year mortality (log-rank test, P &amp;lt; .001 and P = 0.01, respectively). In the multivariable Cox models, door-to-ECG time was a significant predictor for one-year mortality, whether it was analyzed as a dichotomized (&amp;gt;10 min vs ≤10 min) or a continuous variable. The corresponding adjusted hazard ratios (aHR) were 2.81 (95% confidence interval [CI] 1.42–5.55) for the dichotomized analysis, and 1.03 (95%CI 1.00–1.06) per minute increase, respectively. Cath lab arrival-to-balloon time also showed an independent effect on one-year mortality when analyzed as a continuous variable, with an aHR of 1.02 (95% CI 1.00–1.04) per minute increase. However, ECG-to-cath lab activation and activation-to-cath lab arrival times did not show a significant association with the risk of one-year mortality. Conclusion: Within the door-to-balloon interval, the time from door-to-ECG completion is particularly crucial for one-year survival after STEMI, while cath lab arrival-to-balloon inflation may also be relevant.

P-1930. Absence of Booster Vaccination and Low Cycle Threshold Values Predict Severe and Critical COVID-19 in Fully Vaccinated Individuals: A Multi-Center Retrospective Cohort Study

Abstract Background The development of severe/critical Coronavirus Disease 2019 (COVID-19) infection in fully vaccinated individuals is an incompletely defined area of research and lacks clinical scoring tools. Most scoring systems were assessed with unvaccinated patients, making it less clinically applicable in today’s global landscape. Our study validated an existing clinical prediction tool using data from vaccinated individuals and created a new model that could provide improved prediction accuracy. Methods Adults fully vaccinated against COVID-19 and admitted to two Philippine tertiary hospitals from March 2021 to August 2022 for breakthrough infections were enrolled. Clinical characteristics, type and number of vaccine doses, and rt-PCR cycle threshold (CT) values were collected. The primary outcome of interest was the development of severe/critical COVID-19. An existing severe/critical COVID-19 prediction tool was validated using the study data, while a new and simpler scoring system was developed from the multiple logistic regression analysis of significant variables.Table 2:Final Model with Significant Factors Results Among 803 adults with COVID-19, 138 (17%) received at least one booster dose, and 139 (17%) progressed to severe/critical disease. The existing prediction tool had a sensitivity (Sn) of 96.5%, specificity (Sp) of 11.7%, and area under the receiver-operator curve (AUROC) of 0.54. Multivariable logistic regression showed that age &amp;gt;75y (OR 2.86; 95% CI 1.56 - 5.21), diabetes mellitus (OR 1.76, 95% CI 1.10-2.80), CT value &amp;lt; 20 (OR 1.90; 95% CI: 1.19 - 3.03), suspicion of bacterial co-infection (OR 2.85, 95% CI 1.60-5.07), and non-receipt of a booster dose (OR 0.32; 95% CI: 0.15 - 0.72) were independent risk factors for developing severe/critical COVID-19. The developed scoring system showed a Sn of 89.4%, Sp of 62.7%, and AUROC of 0.76. Conclusion A simplified scoring tool using five variables may help predict the progression to severe/critical COVID-19 in fully vaccinated individuals. Although the tool has modest Sn and Sp, it can help triage patients and guide initial therapy. Validation of this tool in larger studies is recommended. Disclosures Karl Evans R. Henson, MD, FIDSA, BSV Biosciences: Honoraria|Cathay Drug Company, Inc: Grant/Research Support|MSD: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria

P-140. A Quality Improvement (QI) Project to Increase Chagas Disease Screening Rates in an At-Risk, Underserved Patient Population Living in Houston, Texas

Abstract Background Chagas disease (CD), caused by Trypanosoma cruzi, is a neglected disease of poverty affecting &amp;gt;6 million people in the Americas, including &amp;gt;200,000 in the US. While many are asymptomatic, 20-30% develop end-organ damage like Chagas cardiomyopathy. Early diagnosis and treatment are essential to reduce this risk; however, US clinicians generally are unaware of for whom CD screening is recommended (Table 1) and how to order it. &amp;gt;1.5 million people born in continental Latin America live in Harris County, TX, making this an important region in which to establish systematic CD screening. This QI project seeks to improve CD screening rates using electronic medical record (EMR) tools.Figure 1A:HHS Chagas disease testing protocol, Figure 1B: Outpatient clinic visit flow diagram incorporating PDSA Cycle Phase 1 and Phase 2 Methods This project is set in the Harris Health System (HHS), a public safety-net healthcare system serving &amp;gt;1 million outpatients annually; 52.9% are Hispanic and 45.9% are uninsured. Previous studies support a CD prevalence of ∼1%, suggesting that &amp;gt;5,000 outpatients/year present to HHS with undiagnosed CD. Our HHS CD screening protocol (Figure 1A) is based on US screening recommendations. We assembled a team of stakeholders and identified a HHS primary care clinic (MLK Clinic) as the pilot location. We used Epic Systems EMR tools to evaluate the patient population presenting to MLK Clinic over a 9 month period and develop corresponding QI interventions. The primary outcome is CD screening rate; see Table 2 for secondary outcomes.Figure 2:Plan, Do, Study, Act (PDSA) cycle structure Results 1,443 patients presented to MLK Clinic between 7/1/2023-4/30/2024, average age 26 years (range 0-95). A sample of 158 showed that 40% were eligible for CD screening based on birth country. Of those, only 12 T. cruzi IgG tests were ordered (2% of eligible patients). Together with stakeholders, we developed 2 interventions to improve CD screening rates (Figure 1B): 1) single-question Epic SmartPhrase used by nursing staff during patient triage and 2) physician CD educational session and Epic SmartPhrase. These will be applied in 2 PDSA cycle phases (Figure 2). We trained nursing staff on 4/2024 and began PDSA Phase 1 on 5/1/24. Conclusion Early CD diagnosis and treatment reduce the risk of progression to devastating end-organ damage. This QI project will contribute to improved identification of at-risk patients through use of EMR tools for systematic screening. Disclosures All Authors: No reported disclosures

P-1881. Don't Know Much About Geography? Decision Support for Frontline Clinicians Evaluating Patients with Suspected High Consequence Infectious Diseases

Abstract Background High Consequence Infectious Diseases (HCIDs) are acute infectious diseases characterized by high case-fatality rates, few (if any) rapidly accessible treatments, and person-to-person spread in the absence of appropriate transmission-based precautions. Rapid identification and isolation of suspected cases is critical, however, diagnosis is challenging because HCIDs can manifest with nonspecific symptoms and specialized knowledge about the geography of current outbreaks, as well as HCID-specific exposure risk factors and incubation periods, are not uniformly known to healthcare personnel (HCP) performing patient evaluations. Clinical Decision Support Systems (CDSS) embedded within the electronic health record (EHR) may facilitate assessment.Figure 1:EvalHCID Clinical Decision Support System DemonstrationFrom top to bottom, EvalHCID automatically imports travel information from the routine travel screening conducted during initial patient triage. Additional travel can be manually entered, with an itinerary of up to 4 countries. By cross-referencing a system-wide database of circulating HCIDs, EvalHCID automatically loads an interface to evaluate HCIDs relevant to the patient’s travel history. By subtracting symptom onset date from the last day in country, symptom development outside the relevant incubation period can be identified. Methods We describe the design and development of an EHR-embedded CDSS tool, linked to a travel and symptom screening, and referencing a regularly updated worldwide HCID Watch List, to assist HCP in the evaluation of a returning traveler with infectious symptoms. Performance and user experience of the tool are described.Figure 2:EvalHCID Clinical Decision Support System DemonstrationFrom top to bottom, EvalHCID facilitates collection of epidemiological history that would place a traveler at high risk for the development of an HCID (in this case, the Middle East Respiratory Syndrome). Based on the data entered into EvalHCID, a recommendation regarding risk stratification and next steps is given. Relevant resources are also provided. Results The Evaluate for High Consequence Infectious Disease (EvalHCID) CDSS facilitates identification of patients with travel, symptom, and epidemiological risk factors warranting Person Under Investigation (PUI) status for viral hemorrhagic fevers (including Lassa Fever, Crimean-Congo Hemorrhagic Fever, Marburg Virus Disease, and Ebola Virus Disease) as well as Novel Influenza and the Middle East Respiratory Syndrome (Figures 1 and 2). Using integrated, adaptable logic concordant with public health guidance, EvalHCID can be deployed to rapidly identify patients who meet PUI criteria, while allowing patients who do not meet PUI criteria to proceed with an otherwise appropriate clinical evaluation (Figure 3).Figure 3:EvalHCID Clinical Decision Support System LogicBy incorporating travel history, the dates of travel and symptom onset, relevant symptoms, and epidemiological risk factors, EvalHCID assists frontline healthcare personnel in risk-stratifying returning travelers for HCIDs. Conclusion With highly specialized and accessible HCID expertise embedded within the EHR, HCP identification of patients at high risk for HCIDs is augmented, enabling rapid initiation of appropriate isolation when indicated for PUIs. At the same time, through speeding the evaluation of low-risk patients, care can be improved by allowing diagnosis of more likely clinical conditions. Disclosures All Authors: No reported disclosures

Post COVID glaucoma service redesign utilising electronic patient triage and community optometry clinics (Fife, Scotland 2020—2022)

BackgroundCOVID-19 caused a huge backlog of patients in glaucoma clinics. This study describes redesign of an entire glaucoma service with electronic patient triage to three levels and utilisation of the Scottish optometry infrastructure of upskilled optometrists.Methods2276 patients in glaucoma clinics were identified and triaged to three levels in keeping with Glauc-strat-fast guidance with local amendments. Every patient detail was entered into a bespoke glaucoma database to include demographics, clinical findings and social deprivation scores. The database generated automatic patient, GP and optometrist letters. Level one patients (482) were discharged within the Scottish general optometry service contract. Level two patients (714) were discharged to glaucoma accredited community optometry clinics. The glaucoma consultants would discuss the optometry decision making through screen share once a week. Level three patients (1080) were retained in hospital. All outcomes were audited and analysed 24 months after the new service.ResultsStatistically significant parameters were found between the three groups, to include more normal eyes, less mean deviation on visual fields and less social deprivation in level one patients. After 24 months level one patients had a return rate of 40.2%, mainly for other diseases with only 20.4% retained within hospital or level two. 9.4% of level two patients returned to hospital with retention of only 2.7% in hospital at 24 months.ConclusionGlaucoma patients in Scotland can be appropriately triaged to glaucoma accredited community optometry clinics. This frees capacity within hospital to see patients with moderate and severe disease in a timely fashion, for best visual outcomes.

Accuracy of a Rapid-Response EEG's Automated Seizure-Burden Estimator: AccuRASE Study.

The use of rapid response EEG (rr-EEG) has recently expanded in limited-resource settings and as a supplement to conventional EEG to rapidly detect and treat nonconvulsive status epilepticus. The study objective was to test the accuracy of an rr-EEG's automated seizure burden estimator (ASBE). This is a retrospective observational study using multiple blinded reviewers. All consecutive clinical rr-EEG procedures performed between November 2019 and February 2021 at Yale New Haven Hospital, one affiliated community hospital, and one affiliated inner-city regional hospital were included. Three reviewers blindly reviewed each EEG. The reference standard was 2/3 agreement. The co-primary outcome measures were the negative predictive value (NPV) of the ASBE for the detection of electrographic status epilepticus (ESE) or possible ESE (ESE/pESE) (to be used as a screening method to exclude ESE without the need for urgent expert review) and the positive predictive value (PPV, to be used for immediate treatment without requiring urgent expert review). These were assessed using a variety of seizure burden cutoffs determined by the algorithm (>1%, >10%, >20%, >50%, and >90%). In the first 2 hours, a >10% burden cutoff detected 86% (95% CI 42%-100%) of studies with ESE alone and 88% (68%-97%) with ESE/pESE; this >10% cutoff had a NPV of 99% (97%-100%) for ESE and 98% (95%-100%) for ESE/pESE. The specificity at this threshold was 79% (73%-84%) for ESE and 84% (79%-89%) for ESE/pESE, but the PPV was low at 11% (4%-23%) for ESE and 39% (26%-53%) for ESE/pESE. A >90% burden cutoff was 97% (94%-99%) specific for detecting ESE (PPV 33% [7%-70%]) and 99% (97%-100%) specific for detecting ESE/pESE [PPV 78% (40%-97%)], although the sensitivity dropped significantly to 29% (13%-51%) for ESE/pESE and 43% (10%-82%) for ESE at the >90% threshold. The ASBE has high specificity at >90% seizure burden threshold for detecting ESE and ESE/pESE, with good PPV for ESE/pESE, though with only low-to-moderate sensitivity; at this threshold, it can be used to help triage patients for immediate treatment/transfer, urgent expert review, and additional CEEG. A >10% threshold has a high sensitivity, detecting approximately 85% of patients with ESE; at this lower cutoff, it can be used as a screening tool to exclude ESE with >95% NPV. This study provides Class II evidence that ASBE software can reliably exclude ESE (98% negative predictive value using a <10% burden cutoff) without expert review in most patients requiring rapid response EEG.

Multi-center evaluation of the Alinity m HR HPV assay with liquid-based cytology cervical specimens in the United States.

Incorporating molecular testing for human papillomavirus (HPV) into the screening of cervical specimens can improve risk stratification and, in turn, patient management. Infection with a high-risk (HR) HPV genotype is associated with greater risk for persistent infection, viral integration, and progression of cervical neoplasia. Current guidelines consider HPV 16 or HPV 18 clinically actionable with referral to colposcopy; however, 12 Other HR HPV genotypes have been associated with cervical cancer risk, suggesting a benefit of extended genotyping. In this multi-center study, we evaluated the performance of the Alinity m HR HPV assay, which reports HPV 16, 18, and 45 individually and aggregates of HPV 31/33/52/58 and HPV 35/39/51/56/59/66, compared with cobas HPV and Aptima HPV assays, across a variety of cytology result categories. A total of 746 de-identified residual cervical specimens, collected as part of routine cervical cancer screening programs, were tested using Alinity m HR HPV and at least one comparator assay. The overall percent agreement was ≥90.7% for results from the Alinity m HR HPV assay and cobas HPV assays and 90.5% for results from the Alinity m HR HPV and Aptima HPV assay. In patients with any abnormal cytology result, Alinity m identified 78 specimens with non-HPV 16/18 results, underscoring the benefit of detecting additional HR HPV genotypes to guide patient management more accurately. Among specimens with normal cytology, Alinity m detected 14 additional specimens with non-HPV 16/18 genotypes. Extended HR HPV testing can provide additional information to triage patients for appropriate testing and follow-up.IMPORTANCEExtended genotyping for high-risk human papillomavirus (HPV) types enhances diagnostic precision by identifying additional oncogenic HPV types beyond 16 and 18 therefore offering a more nuanced risk profile. This more comprehensive detection may aid in identifying persistent infections that are more likely to progress, thereby supporting future risk-based patient management strategies.

Prediction of mortality and prioritisation to tertiary care using the 'OUR-ARCad' risk score gleaned from the second wave of COVID-19 pandemic-A retrospective cohort study from South India.

Judicious utilisation of tertiary care facilities through appropriate risk stratification assumes priority, in a raging pandemic, of the nature of delta variant-predominated second wave of COVID-19 pandemic in India. Prioritisation of tertiary care, through a scientifically validated risk score, would maximise recovery without compromising individual safety, but importantly without straining the health system. De-identified data of COVID-19 confirmed patients admitted to a tertiary care hospital in South India, between April 1, 2021 and July 31, 2021, corresponding to the peak of COVID-19 second wave, were analysed after segregating into 'survivors' or 'non-survivors' to evaluate the risk factors for COVID-19 mortality at admission and formulate a risk score with easily obtainable but clinically relevant parameters for accurate patient triaging. The predictive ability was ascertained by the area under the receiver operator characteristics (AUROC) and the goodness of fit by the Hosmer-Lemeshow test and validated using the bootstrap method. Of 617 COVID-19 patients (325 survivors, 292 non-survivors), treated as per prevailing national guidelines, with a slight male predilection (358/617 [58.0%]), fatalities in the age group above and below 50 years were (217/380 [57.1%]) and (75/237 [31.6%]), p<0.001. The relative distribution of the various parameters among survivors and non-survivors including self-reported comorbidities helped to derive the individual risk scores from parameters significant in the multivariable logistic regression. The 'OUR-ARCad' risk score components were-Oxygen saturation SaO2<94%-23, Urea > 40mg/dL-15, Neutrophil/Lymphocytic ratio >3-23, Age > 50 years-8, Pulse Rate >100-8 and Coronary Artery disease-15. A summated score above 50, mandated tertiary care management (sensitivity-90%, specificity-75%; AUC-0.89), validated in 2000 bootstrap dataset. The OUR-ARCad risk score, could potentially maximize recovery in a raging COVID-19 pandemic, through prioritisation of tertiary care services, neither straining the health system nor compromising patient's safety, delivering and diverting care to those who needed the most.

Pre-hospital Identification of a Giant Bladder Calculus through Screening Sonography: A Case Report

Introduction: Screening ultrasound proves to be remarkably beneficial in pre-hospital settings, particularly in geographically remote areas with technological constraints and no medical specialties. Urological pathology has a high frequency of occurrence in the emergency department and is part of the wide range of occurrences that can benefit from this ultrasound screening as a clinical guide for patients. Case Presentation: In this case, a patient experiencing lower abdominal pain and symptoms of renal colic sought assistance at a basic emergency service facility. Utilizing a renal screening ultrasound executed by a sonographer, the clinical team identified images indicative of a significant bladder calculus. Subsequently, the patient was referred to a referral hospital for a comprehensive evaluation by medical specialties. Conclusion: The images obtained in both health units exhibited congruence, indicating that the screening ultrasound, while not intended to replace the specialized orthodox ultrasound executed by a radiologist, served as a crucial tool for diagnostic presumption, providing consistency in clinical decision-making for referring patients. This capability allowed emergency physicians to promptly transfer a patient requiring urgent further investigation to a referral hospital with compelling and substantiated data. This shift in the approach to patient triage in a remote setting could enhance patient safety.

Innovative telehospitalist model optimizes medical triage in collaboration with community emergency departments: A cross-sectional study.

Optimal hospital bed utilization requires innovative patient care models. We studied a novel hospitalist model utilizing telemedicine to facilitate collaboration with affiliated emergency departments (EDs) and support medical triage and care of ED patients with high likelihood of hospital admission. Telehospitalists based at a tertiary care facility collaborated with four community EDs in the same healthcare network between January 1, 2022, and April 30, 2023. Telehospitalists supported ED clinicians in medical care decisions and facilitated patient disposition. Emergency department length of stay (LOS) and disposition were evaluated, as were hospital LOS, 30-day readmission, and in-hospital mortality. For patients discharged from the ED, 7-day ED readmission and subsequent hospitalization were evaluated. Telehospitalists discussed 550 "admit-likely" patients with ED clinicians: 105 patients (19.1%) discharged from the ED and avoided admission; 322 patients (58.5%) were admitted to local or nearby community hospitals; 123 patients (22.4%) transferred to the tertiary care facility. Emergency department LOS differed significantly among disposition groups, including patients discharged home (10.2 h), admitted to local hospitals (12.6 h), and transferred to tertiary care hospitalist services (14.9 h; p < 0.001). Hospital LOS and in-hospital mortality were not significantly different among disposition groups. Patients admitted locally had lower 30-day readmission compared to those transferred to tertiary care facility (odds ratio = 0.59 [0.36, 0.99], p = 0.048). Telehospitalists as triage clinicians is an innovative approach to support local ED clinicians and patients. Telehospitalists optimized hospital bed utilization and healthcare system resources by facilitating safe discharges to home and expediting tertiary care transfers when necessary.

Diagnostic accuracy of point-of-care ultrasound of the posterior fatpad in elbow fractures

BackgroundPoint-of-care ultrasound (POCUS) can potentially be used in the triage of patients with elbow injuries. However, the diagnostic accuracy of POCUS performed by non-radiologists for the exclusion of elbow fractures...

Using a Hypotheticodeductive Reasoning Approach to Identify Coronary Artery Stenosis and Myocardial Ischemia in a Patient with Upper Arm, Scapular, and Wrist Pain

BACKGROUND: A 58-year-old male with left upper extremity pain presented for second opinion via video teleconferencing secondary to his physician’s recommendation for potential rotator cuff surgery. CASE PRESENTATION: He reported subacute variable left upper extremity pain. He denied questioning targeting the cardiopulmonary symptoms but also denied movement-based aggravating factors of the cervical spine and shoulder. OUTCOME: A movement-based exam targeting potential cervical and shoulder differential diagnoses failed to elicit symptoms. The physical therapist advocated for referral by the primary care provider to a cardiologist to rule out an underlying cardiac etiology. Per-recommendation stress EKG testing reproduced his symptoms and caused abnormal EKG behavior, leading to angiography and stenting. FOLLOW-UP: At follow-up forty-eight hours, one week, and four weeks after stent placement, the patient reported complete resolution of symptoms. DISCUSSION: This case underscores the importance of ruling out competing differential diagnoses, the role the physical therapist can have in entry-point care, and the value that telehealth-based services can have in patient triage.

P0683 Is it time to move away from malnutrition screening as a gateway to a dietitian referral in patients with Inflammatory Bowel Disease? An investigation into nutritional Issues in Crohn’s Disease Remission

Abstract Background Conventional methods of triaging patients with Crohn’s Disease (CD) to see a dietitian mainly focus on generic risk scores for identifying overt malnutrition and do not consider dietary-impact factors more specific to CD, such as food-related gastrointestinal (GI) symptoms, bowel strictures or food avoidance. The INTICO-2 study characterised the nutritional state of adults in CD remission and included a novel patient-completed questionnaire of nutritional risk factors and symptoms, which would warrant a referral to a dietitian. Methods The INTICO2 study recruited adults with CD in confirmed clinical (HBI &amp;lt;5) and biochemical remission (faecal calprotectin &amp;lt;250 mg/g) from a single UK outpatient IBD Centre for nutritional assessment. Participants completed a dietetic-developed questionnaire that addressed signs and symptoms likely to limit dietary intake or indicate nutritional risk, including weight, weight loss, appetite (SNAQ)1, food restriction, CD phenotype (strictures, previous surgery), GI symptoms and physical symptoms associated with nutritional deficiencies. Results The median BMI in the cohort was 26.1 kg/m2 (18.0-48.9), and only one reported recent weight loss. Only one patient was assessed as at risk of malnutrition by MUST criteria. Nevertheless, most patients (92%; 180/196) reported at least one sign or symptom with a mean of 4 (SD 3) signs or symptoms for the cohort. About a third (34%, 67/196) reported food restriction; dairy, wheat, red meat, pulses, garlic, and onion were the most avoided. On average, patients avoided two foods, with 47 different foods reported across the cohort. About a third of patients (30%, 57/192) reported impaired appetite (SNAQ≤14); the mean SNAQ score was 15.5 (SD 2.3). Gastrointestinal symptoms after eating and signs and symptoms that suggest micronutrient deficiencies were evident (Table 1). Participants who answered ‘yes’ to the presence of strictures or previous CD surgery had significantly more signs and symptoms than those who did not: Mean(SD) strictures 6.32 (2.9) versus no strictures 3.66 (2.7) P&amp;lt;0.001 and surgery 5.4(2.8) versus no surgery 3.8 (2.9) P&amp;lt;0.05). Conclusion Patients with CD in remission may experience significant symptoms impacting their nutritional intake. Patients in remission do not routinely see a dietitian. Triage based on low BMI or weight loss may be insufficient to identify those who might benefit from further dietetic assessment and advice. A move towards dietetic triage that also considers GI signs, symptoms, and prior surgery might improve the identification of those who would benefit from dietetic advice by improving nutritional intake and tailoring advice to relieve symptoms (e.g. texture modification advice for those with strictures).